Modifications to ordering and certifying rules for physicians

The Centers for Medicare & Medicaid Services (CMS) recently published a final rule that makes improvements to the requirements set forth in an interim final rule from 2010 related to the ordering and certification of certain Medicare items and services. This final rule implements a provision of the Affordable Care Act (ACA).*†

A major modification in the final rule that benefits surgery eliminates the requirement that physicians be enrolled in Medicare to order, certify, or refer the services of physician specialists. This article provides details regarding this modification and other changes in the final rule, as well as what surgeons should know about the current requirements.

How will the elimination of the requirement that physicians must be enrolled in Medicare to order, certify, or refer specialist services affect my practice?

Because CMS no longer requires physicians to be enrolled in Medicare to order or refer patients for specialist services, surgeons can rest assured that their claims will be paid, even when they provide services to patients who were referred by nonenrolled physicians. Furthermore, if nonenrolled surgeons refer patients to other specialists, those physicians’ claims will be paid as well.

However, if surgeons order or certify durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), or home health, imaging, or clinical laboratory items and services, the surgeon should be enrolled in Medicare or validly opt out in order for Medicare to pay the claims submitted by those entities.

What changes does the final rule make regarding ordering and certifying items and services for Medicare beneficiaries?

The ACA requires that Medicare claims for DMEPOS and home health services be paid only if the items or services were ordered or certified by a physician (or if permitted, a nonphysician [NPP]) who is enrolled in Medicare. Such claims must include the National Provider Identifier (NPI) of the ordering or certifying physician. The ACA authorized the extension of these policies to all other categories of items or services under Medicare.

The interim final rule in 2010 implemented these policies and extended identical policies to imaging, laboratory, and specialist items and services.

The final rule, however, limited the affected items or services only to DMEPOS and home health, imaging, and clinical laboratory items and services. Specialist services were specifically removed from this list in the final rule, meaning that a physician or NPP who refers to specialists will not be required to be enrolled in Medicare.

CMS also points out that the ordering and certification requirements do not apply to Part B or Part D drugs.

In addition, the interim final rule specified that if any of the affected items or services were ordered or certified by a resident or intern, claims for such services would be required to identify the teaching physician (by legal name and NPI) as the ordering or certifying supplier. In contrast, the final rule allows interns and residents, if permitted by the state to be licensed to order and certify services, to enroll in Medicare to order and certify. This makes it unnecessary for the teaching physician’s legal name and NPI to be included on claims for items or services ordered or certified by residents or interns.

It is important to note that physicians and NPPs should use their Type 1 NPI (issued to individual practitioners) when certifying or ordering, even if they are being reimbursed under a Type II NPI (issued to an organization, facility, or practice).

How can a physician or NPP meet the ordering and certifying requirements?

An ordering or certifying physician can meet the ordering and certifying requirements one of four ways.

A physician or NPP must fall into one of these four categories to order or certify DMEPOS and home health, imaging, or clinical laboratory items and services for Medicare payment.

Notably, although the interim final rule specified that all ordering or certifying physicians or NPPs must have approved enrollment records or valid opt-out records in PECOS, the final rule modifies this policy to recognize enrollment and opt-out records in Medicare legacy systems. As such, any Medicare enrollment record, not just PECOS, satisfies the ordering and certifying requirement. The final rule, however, notes that the legacy systems are being phased out and will no longer be used in the near future.

When will the requirement to have the ordering or certifying physician’s or NPP’s NPI on claims become effective?

The effective date of the ordering and certifying policies in the final rule dates back to July 6, 2010, but CMS has not yet turned on the automated edits that would deny claims due to lack of an enrollment record. Currently, noncompliant claims are only flagged with a note that the claim may not be paid in the future. In the final rule, CMS also clarifies that the ordering or certifying practitioner must be enrolled at the time the service is performed, not the date of written orders or certifications.

When will CMS turn on the automated edits, and will such edits result in claim denials or rejections?

CMS repeatedly stresses in the final rule that the agency would provide advance notice to physicians before turning on the edits. CMS specifically states that the automated edits will be turned on only after all physicians and eligible professionals have been asked to revalidate their Medicare enrollment and have been given the opportunity to complete that process through their respective Medicare Administrative Contractors. CMS further states that edits will only apply to those claims with a date of service on or after the date the edits are activated. According to the final rule, CMS plans to conduct outreach using CMS listservs, Medicare Learning Network® articles, and open-door forums to inform providers of the date when the edits will be turned on. The American College of Surgeons (ACS) will monitor these channels in order to rapidly update Fellows of the date that CMS will turn on the automated edits.

Whereas the interim final rule stated that claims failing to meet the ordering and certifying requirements would be rejected, the final rule states that claims will instead be denied, thereby providing affected providers and suppliers with the usual Medicare appeals rights.

How long must documentation of orders or certifications be maintained, and who must keep track of such documentation?

Under the final rule, both the individual who orders or certifies and the provider or supplier that furnishes the ordered or certified items or services must maintain documentation for seven years from the date of the service.

Where can I find additional information?

The final rule is available at this website

This article follows a previous Bulletin article related to billing Medicare for orders and referrals

A provider or supplier can look up an NPI in the NPI registry

If you have additional questions concerning modifications to ordering and certifying rules for physicians, contact Vinita Ollapally, JD, in the Division of Advocacy and Health Policy at 202-337-2701.


*Medicare and Medicaid Programs. Changes in provider and supplier enrollment, Ordering and referring, and documentation requirements; and changes in provider agreements. 2012. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-04-27/pdf/2012-9994.pdf. Accessed July 23, 2012.

†Medicare and Medicaid programs. Changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. 2010. Available at: http://www.gpo.gov/fdsys/pkg/FR-2010-05-05/pdf/2010-10505.pdf. Accessed July 23, 2012.

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