Reporting the National Provider Identifier (NPI) on Claims for Reference Laboratory and Purchased Diagnostic Services Performed Outside the Billing Jurisdiction
MLN Matters Number: MM6362
Related Change Request (CR) #: 6362
Related CR Release Date: February 27, 2009
Effective Date: March 27, 2009
Related CR Transmittal #: R1690CP
Implementation Date: March 27, 2009
Provider Types Affected
Physicians and other providers who bill Palmetto GBA for reference laboratory or purchased diagnostic services.
What You Need to Know
CR 6362, from which this article is taken, establishes an exception to the standard reporting of the National Provider Identifier (NPI) on Medicare fee-for-service claims for reference laboratory and purchased diagnostic services performed by a provider located outside the jurisdiction of Palmetto GBA. When you bill for either of these services (reference laboratory services listed on the Clinical Laboratory Fee Schedule or purchased diagnostic services) and the services were performed by a provider located in another Medicare contractor’s jurisdiction, you must report your own NPI on the Medicare claim as the performing provider and annotate the claim with the performing provider’s name, address and ZIP code. Be sure to record the performing provider’s NPI in the clinical records for auditing purposes. You should make sure that your billing staff has been made aware of this NPI documentation requirement.
Background
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for health care providers; and the January 23, 2004, final rule establishes the NPI as this standard.
All entities covered under HIPAA must comply with the requirements of the final rule (45 CFR Part 162, CMS-0045-F), which requires that (effective May 23, 2008) covered health care providers, suppliers, and health plans (other than small plans) must use the NPI on paper or electronically-submitted Medicare fee-for-service claims.
If you, as the billing provider, outsource Medicare-covered services to another Medicare-enrolled provider you are 'purchasing' these services and ordinarily would report, on the claim, both your own NPI (as the billing provider) and also the performing provider’s NPI. However, when the performing provider is geographically located in a different Medicare contractor’s jurisdiction, Palmetto GBA will not have a record of the performing provider’s NPI. CR 6362 clarifies billing instructions on using the NPI in these situations.
CR 6362 requires that when you submit paper or electronic Medicare claims for reference laboratory or purchased diagnostic services that are performed by a provider outside of your billing jurisdiction; you should report your own NPI in the performing provider’s NPI data field and annotate the claim with the performing provider’s name, address and ZIP code. The billing provider must keep the performing provider’s NPI in the clinical records for auditing purposes.
You should be aware that Palmetto GBA will return as unprocessable your claims for reference laboratory or purchased diagnostic services that are performed outside the billing jurisdiction. Claims must be submitted with your NPI in Item 32a and the name, address and ZIP code of the performing provider in Item 32 of the CMS-1500 form or on the ANSI X12 837P electronic claim form in the appropriate data field.
Note: CR 6362 establishes this previously discretionary requirement as mandatory and supplements and manualizes CR 5289, which was issued October 27, 2006, as Transmittal 243. (You might want to review the related MLN Matters article MM 5289, Reporting the National Provider Identifier (NPI) on Physician Claims for Clinical Diagnostic Services Purchased Outside of the Local Carrier’s Jurisdiction, which you can find at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5289.pdf.
Additional Information
You can find more information about reporting your NPI on claims for reference laboratory and purchased diagnostic services performed outside of your billing jurisdiction by going to CR 6362, located at
As an attachment to that CR you will find the updated Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Sections 40.1.1.1 (Paper Claim Submission to Carriers/B MAC) and 40.1.1.2 (Electronic Claim Submission to Carriers/B MAC).
If you have any questions, please contact our Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
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Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.