May 1, 2013 Departments

Policy Analysis: No Physician Referral Equals No Medicare Payment

Audiologists and speech-language pathologists, beware. As of May 1, any Medicare claim that lacks an appropriate referring physician will be automatically denied.

Under the Affordable Care Act, physicians—and nonphysician practitioners, such as physician assistants, clinical nurse specialists and nurse practitioners—who order items or services for Medicare beneficiaries must be enrolled as Medicare providers.

On May 1, the Centers for Medicare and Medicaid Services activated a process that automatically denies payment for three categories—Part B services, durable medical equipment and Part A home health claims—if the referring physician's National Provider Identification number is not recognized in the Medicare enrollment system, known as PECOS (Provider Enrollment, Chain, and Ownership System). The physician must be enrolled prior to the date of the provided procedure. All Part B claims, except those submitted by hospital outpatient departments or critical access hospitals, are subject to this rule.

Audiology regulations

Under previous regulations for audiology services—in effect since 2009—if the NPI of the ordering/referring physician was missing, incomplete or invalid, an informational message was included with the claim.

Audiologists must have a physician order prior to the evaluation. The evaluation must be conducted to obtain information necessary to diagnose a medical condition or determine the appropriate medical or surgical treatment for a hearing loss. (Hearing tests conducted as part of a hearing aid evaluation are not a covered benefit.) The physician order may be a signed written document, a documented telephone call or an encrypted e-mail. The order must be documented in the medical records maintained by the physician and the audiologist, but does not need to specify which tests the audiologist is to administer.

Speech-language pathology regulations

Payment for speech-language pathology services is based on the plan of care certified by a physician, rather than on a physician order. SLPs have been required to include the certifying physician on the claim form since October 2012. For billing purposes, the certifying physician is considered a "referring provider," and the physician's NPI is documented in box #17 of the CMS 1500 claim form.

Denials

If you receive a denial with one of the codes below, it is likely that your referring physician is not in the provider system or the physician's name or NPI is incorrect on the claim:

  • 254D, Referring/ordering provider not allowed to refer.
  • 255D, Referring/ordering provider mismatch.
  • 289D, Referring/ordering provider NPI required.
  • 37236, Attending physician NPI is not eligible/not in PECOS.
  • 37237, Attending physician NPI is not present/not in PECOS.

The CMS website has the most current ordering/referring list in a PDF format, sorted alphabetically by last name (select "Medicare Provider-Supplier Enrollment"). Make sure the information on your claim matches the spelling on the ordering/referring list. Do not include the middle initial, credential or title. If the physician is not on the list, the physician needs to contact the Medicare contractor to determine if an enrollment application is necessary.

Services ordered by unlicensed interns or residents must specify the name and NPI of the teaching physician. Residents in states that have provisional licenses may enroll in Medicare consistent with state laws.

If the referring physician has opted out of Medicare, but wants to continue to order and refer for services, the physician must submit an opt-out affidavit with his or her NPI to the Medicare contractor every two years.

For a full explanation, see the CMS publication "MLN Matters" [PDF].

Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. lsatterfield@asha.org

cite as: Satterfield, L. (2013, May 01). Policy Analysis: No Physician Referral Equals No Medicare Payment. The ASHA Leader.

  

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