Health Information Management

ASCs to include ordering/referring physician names, NPIs on claims for diagnostic radiology services

HIM-HIPAA Insider, September 15, 2008

CMS has issued MLN Matters 6129 (based on Transmittal R5172CP), which clarifies changes affecting ambulatory surgery centers (ASC) that submit claims to Medicare Administrative Contractors or carriers for services provided to Medicare beneficiaries.
 
Effective January 1, 2009, ASCs must report the ordering/referring physician on claims for diagnostic radiology services, similarly to other Part B claims for diagnostic services. The ordering/referring physician’s name must appear in block 17 and the physician NPI must appear in block 17B of the CMS-1500 on paper claims, and must be similarly present on electronic claims.
 
CMS will return claims without the ordering/referring physician’s name or NPI with claim adjustment reason code 16 (Claim/service lacks information necessary for adjudication) and one of the following remittance advice remark codes:
  • N264—Missing/incomplete/invalid ordering provider name
  • N265—Missing/incomplete/invalid ordering provider primary identifier
  • N285—Missing/incomplete/invalid referring provider name
  • N286—Missing/incomplete/invalid referring provider primary identifier
If the billing provider cannot obtain the ordering/referring provider’s NPI, and cannot find it on the NPI Registry, enter the billing provider in X12N 837 transactions or the service provider in NCPDP 5.1 transactions in the ordering/referring field as a temporary solution. This entry is subject to postpayment review.
 
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