CMS Tightens Rules for Physicians Who Order, Refer

Effective Oct. 5, physicians who participate in Medicare must include their names and National Provider Identifiers, or NPIs, when ordering prescriptions, medical supplies or medical services or when making patient referrals for service. And enrollment in Medicare will be checked against the Medicare Provider Enrollment, Chain and Ownership System, PECOS.

According to an article in CMS' MLN Matters (4-page PDF; About PDFs), Medicare claims that lack the proper information will continue to be processed if they are received by Jan. 3. However, the provider or supplier will receive a warning on the remittance advice.

The grace period ends on Jan. 4. From that point forward, Medicare claims will be rejected if the ordering physician's NPI and active status in Medicare cannot be verified.

Cynthia Hughes, C.P.C., an AAFP coding specialist, said the change likely will most affect physicians who are semi-retired or retired but who maintain prescribing privileges.

"I've heard from some of our semi-retired members recently who were asked to provide an NPI number when they prescribed medication or ordered medical supplies. These members had not attained an NPI number and may not be actively enrolled in Medicare," said Hughes.

"If a physician orders anything for a patient who has Medicare coverage, even if the patient is a family member or personal friend, the supplier will request the physician's NPI number. If the physician is not enrolled as a Medicare provider, the supplier's bill will be denied by Medicare in early 2010," Hughes added.

It's also important for physicians to update their Medicare enrollment information if they haven't done so during the past five years, said Hughes. Physicians can verify their enrollment in PECOS at any time at the same Web site.