New Requirement for Ordering/Referring Information on Ambulatory Surgical Center (ASC) Claims for Diagnostic Services
MLN Matters Number: MM6129 Revised
Related Change Request (CR) #: 6129
Related CR Release Date: August 8, 2008
Effective Date: January 1, 2009
Related CR Transmittal #: R1572CP
Implementation Date: January 5, 2009
Note: This article was revised on September 24, 2008, to change the reference in the 'Impact on Providers' section to data loop 2310A, instead of 2310B. All other information is the same.
Provider Types Affected
Providers (ASCs) who submit claims to Medicare Administrative Contractors (A/B ACs) or carriers for services provided to Medicare beneficiaries.
Impact on Providers (ASCs)
This article is based on Change Request (CR) 6129 which states that the Centers for Medicare & Medicaid Services (CMS) has determined that beginning January 1, 2009, the ordering/referring physician needs to be reported on claims for diagnostic radiology services submitted by ASCs, as it is for other Part B claims for diagnostic services (modifier TC). The name of the ordering/referring physician needs to be present in block 17 and the National Provider Identifier (NPI) of the physician needs to be present in block 17B of the CMS-1500 (or in Data Element Loops 2420E and 2310A of the 837P).
Key Points of CR 6129
· Effective for dates of service on or after January 1, 2009 for allowed ASC claims, if modifier = TC, the ordering/referring physician name needs to be included in block 17 and ordering/physician NPI in block 17B of the CMS-1500 for paper claims.
· Effective for dates of service on or after January 1, 2009 for allowed ASC claims, if modifier = TC, the ordering physician name and NPI needs to be present in
Loop 2420E NM1 (NM101=DK, NM102=1, NM103=provider’s last name, NM104=provider’s first name, NM108=XX, NM109=provider’s NPI).
· Effective January 1, 2009 for allowed ASC claims, if modifier = TC, the referring physician name and NPI needs to be present in
Loop 2310A/2420F NM1 (NM101=DN, NM102=1, NM103=provider’s last name, NM104=provider’s first name, NM108=XX, NM109=provider’s NPI).
· Claims will be returned as unprocessable (using Claim Adjustment Reason Code 16-Claim/service lacks information which is needed for adjudication) for the above services without the ordering/referring physician name or NPI on the claim.
· When returning claims as unprocessable, your Medicare Carrier or A/B MAC will use Remittance Advice Remark codes:
o N264 - Missing/incomplete/invalid ordering provider name;
o N265 - Missing/incomplete/invalid ordering provider primary identifier;
o N285 - Missing/incomplete/invalid referring provider name; or
o N286- Missing/incomplete/invalid referring provider primary identifier.
· If the NPI of the ordering/referring provider cannot be obtained by the billing provider and it cannot be found on the NPI Registry, the billing provider (in X12N 837 transactions) or the service provider (in NCPDP 5.1 transactions) may be used in the ordering/referring field on a temporary basis and such use is subject to post-payment review.
Background
Prior to January 1, 2008, ASCs could not be paid for diagnostic radiology services since these services were not included on the list of ASC-approved procedures. Effective for services on or after January 1, 2008 several radiology codes were added to the list of payable ASC procedures. Since ASCs can now bill for these services with the TC modifier, claims from ASCs for these services must be in compliance with Section 1883 (q) of the Social Security Act, which requires that physician ordering/referring information be included on all claims for payable services when there had been a referral by a referring physician.
Additional Information
To see the official instruction (CR6129) issued to your Medicare Carrier or AB/MAC, refer to www.cms.hhs.gov/Transmittals/downloads/R1572CP.pdf.
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