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ASCs in the news: CMS discusses ASC requirements for physician names and NPIs on claims for diagnostic services

Ambulatory Surgery Reimbursement Update, September 23, 2008

CMS has issued MLN Matters 6129, based on Transmittal R5172CP. The article clarifies changes affecting ASCs who submit claims to Medicare Administrative Contractors (MAC) or carriers for services provided to Medicare beneficiaries.

Beginning January 1, 2009, ASCs must report the ordering/referring physician on claims for diagnostic radiology services, the same as for other Part B claims for diagnostic services, technical component (modifier -TC). The ordering/referring physician’s name needs to appear in block 17 and the physician National Provider Identifier (NPI) needs to appear block 17B of the CMS-1500 on paper claims, and 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.

To read the complete article, click here.

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