Monday, October 18, 2010

Referring physician and ordering physician of CMS 1500

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, Medicare Benefit Policy Manual, 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 nonphysician practitioner's service.

The ordering/referring requirement became effective January 1, 1992, and is required by Section 1833(q) of the Social Security Act. 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 result from 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 nonphysician practitioner, the name of the physician or non-physician
practitioner who performs the initial service and orders the nonphysician 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.

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