Thursday, June 3, 2010

Service required referring physician - BOX 17 A

All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:

• Medicare covered services and items that are the result of a physician's order or referral;
• Parenteral and enteral nutrition;
• Immunosuppressive drug claims;
• Hepatitis B claims;
• Diagnostic laboratory services;
• Diagnostic radiology services;
• Portable x-ray services;
• Consultative services;
• Durable medical equipment;

• When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);

• When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;
• When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;
Item 17a – Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Item 17b Form CMS-1500 – Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

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