decisionhealth Newsletters, Coder Pink Sheets - 2013 Issue 4 (April)
Getting paid: CMS begins denials May 1 when ordering provider isn’t enrolled in Medicare
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Article Overview
This article covers CMS’s move from claim-edit warnings to denials when ordering or referring provider information does not meet Medicare requirements. It is relevant to billing staff, coders, compliance teams, and providers who submit Part B, durable medical equipment, imaging, lab, and home health claims. The discussion focuses on provider enrollment, claim data accuracy, eligible ordering/referring practitioners, and where to check official Medicare resources.
Why This Topic Matters
Organizations that bill Medicare for services ordered or referred by another provider need to understand the enrollment and credentialing requirements that can affect payment. The article helps readers identify the general compliance issues involved and the types of claims most likely to be impacted.
What You Will Learn
- How Medicare claim edits affect ordering and referring provider information
- Which types of claims are impacted by the policy change
- Why provider enrollment status matters for Medicare payment
- How official Medicare resources can be used to verify ordering/referring provider eligibility
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Compliance teams
- Healthcare providers
- Non-physician practitioners
Codes Discussed
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