American Speech-Language-Hearing Association

Correction for Physician NPI Requirement on Medicare Claims

(May 20, 2013)

In April, the Centers for Medicare and Medicaid Services (CMS) released instructions for a claims processing edit to deny claims beginning May 1, 2013, when the physician listed on the claim as referring, ordering, or certifying physician for Part B services and Part A Home Health Services is not enrolled in Medicare's Provider Enrollment, Chain, and Ownership System (PECOS). ASHA learned in conversations with CMS officials, and in an announcement which indefinitely postponed the claims edit, the Medicare enrollment requirement applies specifically to claims from

  • laboratories for ordered tests;
  • imaging centers for ordered imaging procedures;
  • suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for ordered DMEPOS;
  • Part A Home Health Agencies (HHAs).

For audiologists and speech-language pathologists (SLPs), this requirement affects claims for cochlear implants and supplies, speech generating devices, and tracheoesophageal voice prostheses and supplies, as well as claims for Part A home health services.

Audiologists and SLPs must continue to include the NPI of the referring, ordering, or certifying physician on the claim form for diagnostic services and therapy services, but at this time do not need to ensure that the physician is enrolled in PECOS.

Background

The Patient Protection and Affordable Care Act (ACA) included requirements for referring providers-physicians, nurse practitioners, and physician's assistants-to be enrolled in Medicare. The implementation of the mandate has been left to the discretion of CMS and has been rolled out in phases. The last phase, requiring physician enrollment-without which claims will be denied, was originally scheduled for May 1, but has since been postponed due to "technical issues." Because the mandate allows for open implementation, it is feasible that the requirement of enrolled referring, ordering, and certifying providers be extended to all Part B services in the future.

ASHA Resources

For more information on claims instructions, see the Medicare Part B Claims Checklist or contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at lsatterfield@asha.org.


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