Thursday, June 24, 2010

Who is Referring physician and ordering physician Box 17

Item 17

Enter the name of the referring or ordering physician if the service or item was ordered or  referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring service.

Referring physician is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician is a physician or, when appropriate, a non-physician practitioner, who orders non-physician services for the patient. See Pub. 100-02, Chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

Ordering/Referring Terms

Medicare Part B claims use the term “ordering/referring provider” to denote the person who ordered, referred, or certified an item or service reported in that claim. To view the comments to the Final Rule, visit 2012-04-27/pdf/2012-9994.pdf on the Internet. Use the following technically correct terms:

1. A provider “orders” non-physician items or services for the beneficiary, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), clinical laboratory services, or imaging services; and

2. A provider “certifies” home health services for a beneficiary. The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. CMS uses the term “ordered/referred” on its website and in educational materials directed to a broad provider audience.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of 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 NPI.

The following services/situations require the submission of the referring/ordering provider
  •  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;

Ordering/Referring Services

If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office). While a physician order is not required to be signed, the physician must clearly document in the medical record his or her intent that the test be performed.

Providers who order diagnostic services for Medicare patients must also maintain documentation of the order/intent to order and medical necessity of the service(s) in the patient’s medical record. Keep this information available and submit it, along with the test results, upon request for a Medicare claim review. For information on “access to documentation,” refer to MLN Matters® Article MM9112 Clarification of Ordering and Certifying Documentation Maintenance Requirements.

Cooperation among ordering/referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials

Laboratory Billing – Referring Provider 

The ordering or referring provider’s name should be included on all CMS-1500 claims submitted with laboratory services in boxes 17, 17a, 17b or its electronic equivalent.

Laboratory Billing – Referring Provider NPI BOX 17

1. What are the ordering and referring edits?

The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B clinical laboratory and imaging, DME, and Part A HHA claims) (1) has a current Medicare enrollment record and contains a valid NPI (the name and NPI must match), and (2) is of a provider type that is eligible to order or refer for Medicare beneficiaries (see list above).

2. Why did Medicare implement these edits?

These edits help protect Medicare beneficiaries and the integrity of the Medicare program. 

3. How and when will these edits be implemented* 

These edits were implemented in two phases:

Phase 1 -Informational messaging: Began October 5, 2009, to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:

For Part B providers and suppliers who submit claims to carriers:

N264 Missing/incomplete/invalid ordering provider name
N265 Missing/incomplete/invalid ordering provider primary identifier

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

DME suppliers who submit claims to carriers (applicable to 5010 edits):


Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future For Part A HHA providers who order and refer, the claims system initially processed the claim and added the following remark message: 

N272 Missing/incomplete/invalid other payer attending provider identifier

For adjusted claims the CARC code 16 and/or the RARC code N272 was used.

CMS has taken actions to reduce the number of informational messages. In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physicians and non-physician practitioners who are eligible to order and refer but who had not updated their PECOS enrollment records with their NPIs.1 On January 28, 2010, CMS made available to the public, via the Downloads section of the “Ordering Referring Report” page on the Medicare provider/supplier enrollment website, a file containing the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer. The file, called the Ordering Referring Report, lists, in alphabetical order based on last name, the NPI and the name (last name, first name) of the physician or non-physician practitioner. To keep the available information up to date, CMS will replace the Report twice a week. At any given time, only one Report (the most current) will be available for downloading. To learn more about the Report and to download it, go to on the CMS website.

Phase 2: Effective January 6, 2014, CMS will turn on the Phase 2 edits. In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.

Below are the denial edits for Part B providers and suppliers who submit claims to Part A/B MACs, including DME MACs:
254D or 001L

Referring/Ordering Provider Not Allowed To Refer/Order

255D or 002L

Referring/Ordering Provider Mismatch

CARC code 16 or 183 and/or the RARC code N264, N574, N575 and MA13 shall be used for denied or adjusted claims.

Claims submitted identifying an ordering/referring provider and the required matching NPI is missing (edit 289D) will continue to be rejected. CARC code 16 and/or the RARC code N265, N276 and MA13 shall be used for rejected claims due to the missing required matching NPI.

Below are the denial edits for Part A HHA providers who submit claims: 37236 This reason code will assign when:

* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on

* The type of bill is '32' or '33'

* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from EPCOS or the specialty code is not a valid eligible code

37237 This reason code will assign when:

* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on

* The type of bill is '32' or '33'

* The type of bill frequency code is '7' or 'F-P'

* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

Effect of Edits on Providers

I order and refer. How will I know if I need to take any sort of action with respect to these two edits*
In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you, the ordering/referring provider, need to ensure that:

a . You have a current Medicare enrollment record.

* If you are not sure you are enrolled in Medicare, you may:

i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in Medicare and it contains your NPI;

ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in Medicare and it contains the NPI; or

iii . Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do not have an enrollment record in Medicare). 

iv . If you choose iii, please read the information on the Medicare provider/supplier enrollment web page about Internet-based PECOS before you begin.

b . If you do not have an enrollment record in Medicare.

* You need to submit either an electronic application through the use of internet-based PECOS or a paper enrollment application to Medicare.

i. For paper applications - fill it out, sign and date it, and mail it, along with any required supporting paper documentation, to your designated Medicare enrollment contractor.

ii. For electronic applications – complete the online submittal process and either e-sign or mail a printed, signed, and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor.

iii . In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement.

iv . If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web page to learn more about the web-based system before you attempt to use it. Go to, click on “Internet-based PECOS” on the left-hand side, and read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and non-physician practitioners. A link to Internet-based PECOS is included on that web page.

v. If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS or by completing the paper enrollment application (CMS-855O). Enrollment applications are available via internet-based PECOS or .pdf for downloading from the CMS forms page (

c. You are an opt-out physician and would like to order and refer services. What should you do*
If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit). Note, however, that prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician/practitioner opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If physicians and practitioners that file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.

d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries. When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order or refer in the Medicare program.

e . I bill Medicare for items and services that were ordered or referred. How can I be sure that my claims for these items and services will pass the Ordering/Referring Provider edits?

* You need to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program. 

If you are not sure that the physician or non-physician practitioner who is ordering or referring items or services meets those criteria, it is recommended that you check the Ordering Referring Report described earlier in this article.

* Ensure you are correctly spelling the Ordering/Referring Provider’s name.

* If you furnished items or services from an order or referral from someone on the Ordering Referring Report, your claim should pass the Ordering/Referring Provider edits.

* The Ordering Referring Report will be replaced twice a week to ensure it is current. It is possible that you may receive an order or a referral from a physician or non-physician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next Report.

f. Make sure your claims are properly completed.

* On paper claims (CMS-1500), in item 17, only include the first and last name as it appears on the Ordering and Referring file found on

* On paper claims (CMS-1450), you would capture the attending physician’s last name, first name and NPI on that form in the applicable sections. On the most recent form it would be fields in FL 76.

* On paper claims (CMS-1500 and CMS-1450), do not enter “nicknames”, credentials (e.g., “Dr.”, “MD”, “RPNA”, etc.) or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits.

* Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral.

* Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1 (person). Organizations (qualifier 2) cannot order and refer.

If there are additional questions about the informational messages, Billing Providers should contact their local A/B MAC, or DME MAC.

Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services including home health, DMEPOS, imaging and clinical laboratory.

g. What if my claim is denied inappropriately?

If your claim did not initially pass the Ordering/Referring provider edits, you may file an appeal through the standard claims appeals process or work through your A/B MAC or DME MAC.

h. How will the technical vs. professional components of imaging services be affected by the edits* Consistent with the Affordable Care Act and 42 CFR 424.507, suppliers submitting claims for imaging services must identify the ordering or referring physician or practitioner. Imaging suppliers covered by this requirement include the following: IDTFs, mammography centers, portable x-ray facilities and radiation therapy centers. The rule applies to the technical component of imaging services, and the professional component will be excluded from the edits. However, if billing globally, both components will be impacted by the edits and the entire claim will deny if it doesn’t meet the ordering and referring requirements. It is recommended that providers and suppliers bill the global claims separately to prevent a denial for the professional component.

i. Are the Phase 2 edits based on date of service or date of claim receipt* The Phase 2 edits are effective for claims with dates of service on or after January 6, 2014.

j. A Medicare beneficiary was ordered a 13-month DME capped rental item. Medicare has paid claims for rental months 1 and 2. The equipment is in the 3rd rental month at the time the Phase 2 denial edits are implemented. The provider who ordered the item has been deactivated. How will the remaining claims be handled*

Claims for capped rental items will continue to be paid for up to 13 months from the physician’s date of deactivation to  allow coverage for the duration of the capped rental period.

Ordering/Referring Physician Checklist for Home Health Agencies

To receive Medicare reimbursement for home health services, the physician that ordered/ referred the patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS). Fiscal Intermediary Standard System (FISS) edits are in place to ensure that the attending and certifying physician information reported on a home health claim meets this requirement. To avoid claim denials, follow the steps below.

Step 1: Verify the physician’s NPI, last name, and first name using the “Medicare Ordering and Referring File” available at

NOTE: This file is updated by CMS twice a week, so it is important to verify the physician information prior to submitting each billing transaction.

Step 2: Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). To verify the credentials of the ordering/referring physician, search the physician’s NPI using the NPPES website, Refer to Page 3 of this tool for a list of valid home health ordering/referring specialty codes.

Step 3: Prior to submitting the Request for Anticipated Payment (RAP) and claim, verify the following information matches the Ordering/Referring File exactly.

• The NPI of the physician.
• The first four letters of the physician’s last name
• The first letter of the physician’s first name


The majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were due to insufficient documentation. Insufficient documentation means that something was missing from the medical records. For example, the medical record was missing:

** Documentation to support intent to order, such as a signed progress note, signed office visit note, or signed physician order

** Documentation to support the medical necessity of ordered services The Medicare Learning Network® (MLN) and the CERT Part A and Part B (A/B) Medicare Administrative Contractor (MAC) Outreach & Education Task Force developed this publication. The CERT Program estimates improper payments in the Medicare FFS Program. The CERT Program reviews a random sample of all Medicare FFS claims to determine if they met Medicare coverage, coding, and billing rules. Once the CERT Program identifies a claim as part of the sample, it requests the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim. Medical review professionals review the submitted documentation to see if the claim was paid or denied appropriately.

Document Requirements

For more information about signature requirements and attestation statements, refer to Complying with Medicare Signature Requirements.

** The physician who is treating the beneficiary must order all diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests. The physician who treats the beneficiary is the physician who furnishes a consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician are not reasonable and necessary.

** When completing progress notes, the physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself does not support intent to order).

** Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records in response to a request for medical records.

** Keep these records available upon request: Progress notes or office notes

Physician order/intent to order Laboratory results

Attestation/signature log for illegible signature(s) Signature Requirements

** Unsigned physician orders or unsigned requisitions alone do not support physician intent to order.

** Physicians should sign all orders for diagnostic services to avoid potential denials.

** If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. For an example of a signature attestation statement, visit the CERT Provider website. If the signature is illegible, an attestation statement or signature log is acceptable.

** Attestation statements are not acceptable for unsigned physician orders/requisitions.

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