Navigating the NPI final rule

Residency Program Insider, May 8, 2007

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Navigating the NPI final rule

The Centers for Medicare & Medicaid Services (CMS) recently undertook a project to develop and subsequently revise a national identification system for all healthcare providers. As a result of the project and before the Health Insurance Portability and Accountability Act of 1996 (HIPAA), CMS has required the adoption and use of a standard unique identifier-or National Provider Identifier (NPI)-for health care providers. Because NPIs are needed for reimbursement and CMS compliance, medical staff and residency program personnel must be aware of the rules and regulations regarding this sea change. However, there has been recent confusion over who must obtain an NPI, the use of the NPI, and the deadline for programs and providers to comply.

What is an NPI?

According to CMS, the NPI is a 10-digit number that does not carry other information about healthcare providers, such as the state in which they live or their medical specialty. Beginning May 23, 2007, the NPI must be used in lieu of legacy provider identifiers, such as:

  • Online Survey Certification and Reporting (OSCAR) system numbers

  • National Supplier Clearinghouse (NSC) numbers

  • Provider Identification Numbers (PINs)

  • Unique Physician Identification Numbers (UPINs) used by Medicare

Although the deadline for NPI implementation was May 23, 2007, CMS announced in April 2 that the deadline would not be enforced as long as covered entities "demonstrate good faith efforts and employ contingency plans," allowing for the continued use of the old identifiers until May 23, 2008.

On that date, physicians who bill electronically, as required under HIPAA, are required to use their new NPI numbers. While not required by law, Medicare has decided to require physicians who bill on paper to obtain and use their NPI as well.

Relation to residents

The new rules have left many residency program personnel wondering if the NPI rule applies to resident physicians.

According to the NPI final rule, medical students, interns, residents, and fellows are eligible for NPIs because they are healthcare providers. If they transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are "covered" healthcare providers under HIPAA and are required by the NPI Final Rule to obtain NPIs.

Because most residents do not bill for their services, the thinking is that they do not need NPI numbers, says Eric Sandhusen, MPH, CHC, CPC, director of reimbursement, HIPAA and Fiscal Compliance at the Columbia University department of surgery in NY.

However, residents should get an NPI number because they are often considered the referring physician for consultation requests and orders. This referral is necessary for the billing physicians (attending physicians) to report when submitting claims for these services, and so residency programs should have a system in place to share resident NPI numbers with billing physicians, adds Sandhusen.

Residents will eventually need the NPI when they become certified, and should have one now because Medicare will no longer accept a generic resident claim form from a consulting physician, adds Sandhusen. Medicare wants to know which particular resident was the referring physician for a consultation by an attending physician, and will need an NPI to identify these residents individually.

"The end result is that physicians will have a hard time getting paid if applicable residents do not have NPI numbers," says Sandhusen.

Obtaining an NPI

While administrators and coordinators can give residents information on the rules and on how to obtain an NPI, they should not register for residents, and instead have residents register themselves, stresses Sandhusen.

"If a director or coordinator is doing an application for a resident, they have to create a password that residents may not remember or receive," says Sandhusen. "Then when residents have to update their NPI information, they may be stuck having to figure out who has the information they need to log on to the system."

According to the NPI Application tips on the National Plan & Provider Enumeration System (NPPES) Web site, once a user ID has been selected it cannot be changed.

In addition, they are supposed to maintain this information throughout their career, says Sandhusen. If they are the ones that are going to be using the NPIs, they should be able to give feedback on how the system works.

Residents can apply on-line at:

The application is free and should take about 20 minutes to complete and 10 business days to process, according to CMS.

Residents will need to enter the following information on the application:

  • Contact person for CMS to contact for questions or changes regarding NPI
  • Taxonomy (specialty)
  • Tax identification/social security number
  • Mailing address
  • Practice location

For frequently asked questions and answers on the NPIs, go to: Click on "Questions" and enter "NPI" as a search term.

Editor's note: This is an excerpt of a longer article. For tips and additional information, see the complete article on NPI numbers in the June 2007 issue of Residency Program Alert newsletter.

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