Home Health Ordering, Referring, Attending Physician or Allowed Practitioner Claim Edits

Claims denied because the identification of the ordering, referring, attending physician or allowed practitioner does not match the physician's or practitioner’s information on the internet-based Provider Enrollment, Chain and Ownership System (PECOS), or because the physician or practitioner is not eligible to order and refer home health (HH) services, may be either be adjusted or qualify for an appeal using the redetermination process. 

Claims denied for these reasons will appear in status/location D B9997. Claim reason codes 37236, 37237, 37247, 37248, 32072 or 32092 may be assigned to the denials.

Referring physicians/practitioners shall only be reported on admission/start of care HH claims. If the referring physician/practitioner is reported on a sequential claim and causes one of the denials in this article, adjust the claim and remove the referring physician/practitioner using the “Adjustment Requirements” information within this article.

Denials that Are Not Reversible

• The ordering/referring/attending physician/practitioner has not established a Medicare enrollment record in PECOS
• The PECOS physician/practitioner file has a termination date present and it is equal to or less than the claim from date
• His/her specialty is not eligible to order and refer HH services. HH services may only be ordered or referred by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatric Medicine (DPM), or an allowed practitioner
  • Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at § 484.2 as a physician assistant, nurse practitioner, or clinical nurse specialist.

If the ordering/referring/attending physician/practitioner meets one of the above criteria, the claim is not payable. Therefore, do not submit an adjustment or appeal.

Reason Codes 37236, 37237, 37247 and 37248
If a claim edits for reason code 37236, 37237, 37247 or 37248, it means one of the following issues has occurred:

• The physician/practitioner on the claim is not present in eligible physician/practitioner file from PECOS
• The physician/practitioner NPI on the claim is present in files from PECOS but the first four letters of the last name or the first initial of the first name on the claim do not match first four letters on the PECOS file
  • Do not use “nicknames” on the claim
  • Do not enter a credential (e.g., “Dr.”) in a name field
  • Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or practitioner and not to an organization
• The physician’s/practitioner’s specialty code is not a valid eligible code

An adjustment should be submitted when an input error (e.g., incorrect NPI, incorrect name spelling) is being corrected, or the physician’s/ practitioner’s PECOS record has been updated. 

If your claim did not initially pass the ordering/referring/attending provider edits, you also may file an appeal through the standard claims appeals process. If an appeal is submitted to remove, add or change the NPI and physician/practitioner name, you must provide a corrected UB-04 (XX7) along with supporting documentation, such as the home health certification/plan of care, the face-to-face information, etc.

Home Health Agencies (HHA) are required to report the NPI of the physician/practitioner who certifies or recertifies the patient's eligibility (certifying physician). This is in addition to reporting the NPI and name of the physician/practitioner who signs the patient's plan of care (attending) when the attending physician/practitioner is not the same physician/practitioner who certified/recertified the patient’s eligibility to receive services under the Medicare HH benefit.

• If the certifying and attending physicians/practitioners are different, both physicians are subject to the ordering and referring denial edits
•  If the certifying and attending physicians/practitioners are the same, the edits will only be applied to the "Attending" field

In addition, the physician/practitioner must have an active PECOS enrollment record prior to the period start date

Reason Codes 32072 and 32092
If a claim edits for reason code 32072 and 32092, it means the physician’s/practitioner’s PECOS file has a termination date present and it is equal to or less than the claim from date. If you disagree and the physician/practitioner is active in PECOS, you may submit an appeal through the redetermination process.

Adjustment Requirements
An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Providers shall initiate an adjusted claim through their electronic billing software (Direct Data Entry) cannot be used). PC-ACE Pro32 software does allow for submission of adjusted claims. If your software does not allow you to adjust non-medical claim denials, you may download the PC-ACE Pro32 software or contact you software vendor.

• Enter bill type XX7
• Condition code "D9" (FL 18–28)
• Ensure the claim number of the denied final claim is entered in the cross-reference (X-Ref) Document Control Number field
• Correct ordering/referring/attending physician’s or practitioner’s NPI and name, if applicable
• Enter remarks (FL80) indicating the reason for the adjustment 
  • Correction to ordering/referring/attending physician’s or practitioner’s NPI and/or name or the physician’s/practitioner’s PECOS record has been updated
  • Removed referring physician/practitioner on a HH sequential claim

Do not submit an adjustment to the final claim unless there is a correction to the ordering/referring/attending physician’s/practitioner’s PECOS record, or the HHA is correcting an input error. The physician/practitioner must work with their Part B Medicare Administrative Contractor (MAC) to update errors in their PECOS record, if applicable. Once the Part B MAC corrects the PECOS file, they must “retrigger” the record, which will update the PECOS file that is used HH claims processing.

Reference: CMS Ordering & Certifying Homepage.