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Tuesday Apr 30, 2013

Medicare delays penalties for claims with invalid or missing NPIs

In a recent post, I referenced that the day of reckoning was finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification. As it turns out, that day has been pushed back.

The Centers for Medicare & Medicaid Services (CMS) announced late last week that, due to technical issues, implementation of phase 2 of the ordering and referring(www.cms.gov) denial edits is being delayed from May 1 to an unspecified future date. As a reminder, these edits would have denied certain claims from physicians and other eligible professionals who lacked a valid individual National Provider Identifier. Those claims include Medicare Part-B claims involving laboratories, imaging centers, durable medical equipment, orthotics, and supplies that have an ordering or referring physician/nonphysician provider as well as Part-A home health agency claims that require an attending physician. 

CMS will advise physicians and other qualified health professionals of the new implementation date in the near future. In the interim, the agency will continue to attach warnings to those claims that would have been denied had the edits been in place.

All of this means that if you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you have a little more time to submit an enrollment application to Medicare using the Internet-based Provider Enrollment, Chain, and Ownership System(www.cms.gov). As noted previously, physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare for this purpose; CMS has a special, shorter enrollment form, known as the CMS-855O(www.cms.gov), for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly.

More information on the new edits can be found here(www.cms.gov).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 03:15PM Apr 30, 2013 by David Twiddy

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