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Medicare Enrollment and Ordering/Referring Update

Updated November 2013

After numerous delays, the Centers for Medicare and Medicaid Services (CMS) announced that implementation for Phase 2 ordering and referring denial edits for services ordered or referred by providers not enrolled in the Medicare program will begin on Jan. 6, 2014. The policy was first announced in 2009 and has been delayed several times amid numerous concerns raised by the ACC, the American Medical Association and others. 

Under the new policy, providers must have their information contained within CMS’ provider database, but they are not required to be participating in the Medicare program. 

To accommodate practitioners who are not interested in enrolling in Medicare or traditionally do not do so, such as those who work for the Department of Defense and Veterans Administration, CMS has created a new enrollment form, the CMS-855O. This form is designed to allow ordering and referring practitioners to enroll in the Medicare program strictly for that purpose. Individuals interested in becoming a Medicare participating provider must complete separate applications.

Types of services affected

This policy applies to all services involving an order or referral. Typically, this includes:

  • Imaging services

  • Laboratory tests

  • Durable medical equipment (DME)

Recommendations

The ACC recommends that cardiologists check their Medicare provider enrollment information to ensure it is current and accurate. You can verify that you are currently eligible to order and refer patients for Medicare services by visiting the CMS website. If not, enrollment applications should be submitted as soon as possible. Referral sources should be encouraged to do the same.

Additionally, you will need to ensure that your typical referral sources are properly enrolled in Medicare. The ACC has drafted a sample letter that you can send to those frequent referral sources to remind them of the need to enroll in the Medicare program, so you can continue accepting their referrals. You will need to periodically check the list of practitioners eligible to order/refer against your list of traditional referral sources. The CMS list is updated on a monthly basis to include any practitioners who are enrolled and eligible to refer Medicare patients for services or to order tests for those patients.

The ACC also continues to recommend that members review remittances for edits indicating that services they provided were ordered or referred by a provider not properly enrolled in Medicare. Specifically, these messages are:

  • N264: Missing/incomplete/invalid ordering physician provider name

  • N265: Missing/incomplete/invalid ordering physician primary identifier

For adjusted claims, the Claims Adjustment Reason Code (CARC) code 16, claim/service lacks information which is needed for adjudication, is used.

These edits will be informational in nature until Jan. 6, 2013. Their appearance on claims after Jan. 6 will indicate a payment denial.

If you do observe these messages on your claims remittances, the College recommends contacting the referring or ordering provider and explaining the new policy to them using the sample letter referenced above. You can refer them to the information here, as well as CMS educational materials.

How do you know if you need to be enrolled? 

The enrollment requirement applies not only to individuals who are participating or non-participating providers, but also to individuals who have formally opted out of the Medicare program but may refer patients for covered services from a participating provider. It also applies to professionals employed by the Public Health Service, the Department of Defense, the Department of Veterans Affairs and pediatricians who refer any patients for Medicare services.

The rules regarding interns and residents will be determined based on state licensure rules. Where states allow for the licensing of interns and/or residents, CMS will allow interns and residents to enroll for the purposes of ordering and referring patients for services, consistent with state law. Where state law does not allow for this, the name and NPI of the relevant teaching physician should be used.

How do you know if you are enrolled?

Enrollment in Medicare, in this case, refers to having an enrollment record in the Medicare provider enrollment database. If you enrolled in Medicare before 2003 and have not updated your record since that time, you likely do not have an enrollment record in the Medicare provider enrollment database. To ensure that one is created, you must either complete a Medicare provider enrollment application (CMS-855 form) or use the Internet-based system to submit your information to your Medicare contractor. For additional instructions on using the Internet-based system, CMS has created “Getting Started Guides” for individual practitioners and organizations to assist.

How can you tell if you will be affected by non-enrolled referral sources?

CMS added new remark codes that practitioners should see on the claims remittances that they receive. This remark code appears on remittances that include claims for services where the ordering or referring practitioner is not permitted to order and refer for Medicare services. While those claims are currently still being paid, this will change when CMS implements the new policy, as will the remark codes. Thus, it is important for physician practices to carefully review the remittances that they receive from Medicare. Physician practices can use this information to target their enrollment education efforts to referral sources that are not currently enrolled in Medicare.

 

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