Medicare to deny claims with no NPI

The day of reckoning is finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification.

On May 1, the Centers for Medicare & Medicaid Services (CMS) will begin instructing its contractors to deny Medicare claims from individuals who don't include a valid National Provider Identifier (NPI).

Section 6405 of the Affordable Care Act requires physicians or other eligible professionals to be enrolled in the Medicare program to order or refer items or services for Medicare beneficiaries. Also, Medicare requires that a physician or supplier that bills Medicare for a service or item show the name and unique identifier (i.e., the NPI) of the attending physician on the claim if that service or item was the result of an order or referral.

Beginning in October 2009, Medicare contractors began alerting billing providers if the identification of the ordering/referring provider was missing, incomplete, or invalid, or if the ordering/referring provider was not eligible to order or refer. The alerts were merely warnings, however, that the claims lacked the required information, and the claims were paid anyway. Beginning next month, however, CMS will deny Part B, durable medical equipment, and Part A home health agency claims that fail the ordering/referring provider edits.

Physicians and others who want to continue ordering and referring items and services need to establish their Medicare enrollment record and make sure they're of a specialty that is eligible to order and refer. You can enroll in the Medicare program here: Internet-Based Provider Enrollment, Chain, and Ownership System (PECOS). Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a shorter enrollment form, known as the CMS-855-0, for use by physicians and other health professionals who refer and order services but do not bill Medicare directly.

More information on the new edits can be found in this Medicare bulletin.

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