Billing for a specialist how do I show there is a referral?

[dmaney]

After family practice billing I am now billing for a neurologist.  We recently had an HMO patient that brought in a referral from her PCP.  When I create the claim, where do I indicate that there is a referral for the apt?  Do I need the PCP's NPI?  Do I mail in the claim with the referral as supporting documentation?  Any directions on how to do this would be much appreciated!

Thank you!!

[Merry]

The name of the referring physician should go in box 17 and the NPI in 17b (I am looking at the revised 02-12 form). But recent comments from CMS states that only the name should be in box 17; no titles such as MD etc.
But since this is an HMO, I would check with them to make sure that this is what they want. They may want the title.



Merry

[shanbull]

First name, last name, and NPI is all you should need.

Medicare also maintains a list of NPI's by name. If a provider is not in the list, that provider cannot refer services for Medicare patients, but since this is for an HMO the list is not exhaustive:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html

Click the "Medicare Ordering and Referring File - CSV [ZIP, 9MB]" to download the files, there are so many names that CMS put the first half of the alphabet by last name in the first file, and the other half in the second. It's fantastic to have to deal with. Also, there are a lot of duplicate names, which is frustrating, so you may have to call the provider to verify you have the correct NPI.

To find an NPI, hit Ctrl+F and enter the last name of the person you're looking for.


Edited post to remove some info, it's looking like some of the issues we're having with this new requirement are not with Medicare.

[Merry]

If you use the site HIPAAspace.com it is easier I think to look up NPI's.

[Merry]

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1305.pdf

Great resource re referring, ordering and supervising providers. Note new changes.

[dekenn]

You can also go to NPI registry search and type in last name and state, or whatever info you have, and it will give you address and NPI number.
https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistrySearch.do?subAction=reset&searchType=ind

[dmaney]

 thank you!