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February 14, 2018

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Medical Coding News Archives

CMS Expands Editing for Ordering/Referring Providers

May 12, 2009:

The Centers for Medicare and Medicaid Services has indicated that, as of October 5, 2009, claims will be edited to determine that the ordering/referring provider identified by the national provider identifier (NPI) on a claim is enrolled in Medicare and is eligible to order or refer services. The edits will be phased in in two parts. 

During phase 1 implementation (beginning October 5, 2009), if the claim does not pass the ordering/referring provider edit, Medicare will continue to process the claim and will include an informational message on the remittance advice.

In phase 2 (implementation date not determined by CMS at this time), if the billed service requires an ordering/referring provider and none is present, the claim will not be paid.

If the ordering/referring provider is on the claim, Medicare will verify the ordering/referring provider’s NPI and name reported on the claim against Medicare’s provider enrollment records to ensure the ordering/referring provider is enrolled in Medicare and practices a specialty eligible to order or refer.

Sections 1861 (r) and 1842 (b) (18) (C) of the Social Security Act specify that only the following types of providers may order or refer a patient for services:

  • Doctor of medicine or osteopathy
  • Dentist
  • Dental surgeon
  • Podiatrist
  • Optometrist
  • Chiropractor
  • Physician assistant
  • Certified clinical nurse specialist
  • Nurse practitioner
  • Clinical psychologist
  • Certified nurse midwife
  • Clinical social worker

Deborah C. Hall
Clinical/Technical Editor


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