The Centers for Medicare & Medicaid Services will implement edits on providers ordering/referring Part B, durable medical equipment and Part A home health agency claims effective January 6, 2014.

Effective January 6, 2014, the Centers for Medicare & Medicaid Services (CMS) will deny Part B clinical laboratory and imaging, durable medical equipment prosthetics, orthotics and supplies (DMEPOS) and Part A home health agency (HHA) claims, unless the ordering/referring physician or non-physician practitioner: (1) has a current Medicare enrollment record with a valid National Provider Identifier and (2) is of a type that is eligible to order/refer items or services for Medicare beneficiaries.

Providers and suppliers affected by this requirement include clinical laboratories, independent diagnostic testing facilities, portable x-ray facilities, radiation therapy centers, DMEPOS suppliers and HHAs.  Providers and suppliers may check the Ordering/Referring Report, available on CMS’ website, to determine whether physicians and non-physician practitioners who order/refer Part B DME and/or Part A HHA items and services have current Medicare enrollment records and are of a type that is eligible to order/refer.

Physicians, physician assistants, clinical nurse specialists, nurse practitioners, clinical psychologists, interns, residents, fellows, certified nurse midwives and clinical social workers may order/refer certain items or services for Medicare beneficiaries.  However, HHA services may only be ordered/referred by a physician with an M.D., D.O. or D.P.M.  Optometrists may only order/refer certain DMEPOS products and services and laboratory and x-ray services payable under Part B.  Chiropractors are not eligible to order/refer items or services for Medicare beneficiaries.

The edits are effective for claims with dates of service on or after January 6, 2014.  Claims denied because they failed the ordering/referring edit cannot be billed to a Medicare beneficiary. As a result, CMS advises that an Advance Beneficiary Notice is not appropriate.  Providers and suppliers whose claims are denied as a result of the edits may file an appeal through the standard claims appeals process or work with their A/B or DME Medicare Administrative Contractor.

The original implementation date of the ordering/referring practitioner edits was April 2, 2010.  The implementation date has been postponed multiple times and, while further delays are possible, it appears that the systems are now in place to implement the edits as of the January 6, 2014, effective date.