Outpatient Facility Coding Alert - 2013 Issue 9
Denial Management: CMS Confirms Ordering/Referring Edits Will Start May 1
Subscribe or sign in to view the full article.
Article Overview
This article covers CMS guidance on the start date for ordering and referring edits affecting Medicare Part B, DME, and Part A HHA claims. It explains the operational impact for practices that rely on physician orders or referrals, including the importance of maintaining accurate provider identification and enrollment information, and it points readers to CMS resources used to verify provider identifiers and participation status. The piece is aimed at billing, coding, and revenue cycle staff who manage claim submission, denial prevention, and referral/order workflows.
Why This Topic Matters
Practices that submit claims tied to physician orders or referrals need to understand when CMS edits take effect and how that can affect claim acceptance. The article helps readers identify the administrative preparation needed to reduce denials and avoid delays in payment.
Article Sections
-
Ordering/Referring Edits Take Effect
Introduces CMS’s planned activation of edits tied to Medicare claims and the expected impact on claims processing. It frames the denial-management issue for practices that depend on ordered or referred services.
-
Preparing for Denials Before the Deadline
Discusses the need to confirm that ordering and referring physicians are properly enrolled and identifiable in the relevant systems. It also explains why practices should review provider information before the edits are turned on.
-
Phase 1 and Phase 2 Enforcement
Summarizes the staged implementation approach described in the article and the transition from informational messages to claim denials. It also notes the role of specialty eligibility in the processing outcome.
-
Tracking NPIs and Using CMS Resources
Covers operational steps for maintaining provider identifier records and references CMS tools for locating provider information. It emphasizes ongoing workflow readiness for practices that receive frequent referrals or orders.
What You Will Learn
- What CMS’s ordering and referring edits are intended to affect
- How claim processing changes can influence denial management workflows
- Why provider identification and enrollment status matter to Medicare claims
- Which operational steps practices may use to prepare for the edit rollout
- What CMS resources are referenced for checking provider information
Who Should Read This
- Medical billing staff
- Coding professionals
- Revenue cycle managers
- Practice administrators
- Compliance staff
- Specialty practices that receive referrals or orders
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com