Author Topic: CPT 93000 denied for absence of Ordering physician information (Read 4813 times)

Sriram_Sub · « **on:** January 24, 2013, 11:52:44 AM »

Hi,

I work for a family practice provider now and she has done EKG's (CPT 93000) to patients at the time of their office visit itself. I have received denials from Medicare stating N265 and N286 (Missing / Invalid Ordering / referring physician identifier). I am thinking of resubmitting all such denied claims with the rendering provider's name added as referring provider as she was the one who ordered it. Will that work? If not, what else should I do?

Regards
Sriram

RichardP · « **Reply #1 on:** January 24, 2013, 02:27:08 PM »

The following is true for us, so I assume it is true for you:

For Medicare billing, for every Medicare patient - every HCFA form must have the referring doctor's name in Box 17 and that doctor's NPI number in Box 17b. That is, even if there is no outside referral, and even if it is just an uncomplicated office visit, the name and NPI number of the doctor who saw the patient must go in those boxes. The NPI number in Box 17b must be the same number that is in Box 24J.

Some background follows, in case it is useful to you. From here: http://www.medicalbillinglive.com/members/index.php?topic=7045.msg21031#msg21031

Doctors groups may hire physicians and pay them a salary. A doctor who has incorporated may hire physicians and pay them a salary. A doctor acting as a sole proprietorship may hire physicians and pay them a salary. All work done is billed under the name of the hiring group or physician. The hiring group or physician gets paid and then pays the hireling(s) a salary.

One of the points of the NPI numbers was to make this relationship more clear to CMS. Hence the Type 1 (who did the work) and Type 2 (who gets paid) NPI numbers. Both must be used on the CMS 1500 form that is submitted to Medicare. One tells CMS who did the work, and the other tells CMS who gets paid. In the case of a solo practitioner, both of the NPI numbers provided on the CMS 1500 form belong to him. In the case where the work was actually performed by a hireling, the CMS 1500 form must contain the Type 1 NPI number for who did the work (the hireling), plus the Type 2 NPI number for who gets paid (the hirer).

On the CMS 1500 Form, the Type 2 NPI number for who gets paid goes in Box 33. The Type 1 NPI number for who did the work goes in Box 24J. The Type 1 NPI number for the referring doctor goes in Box 17a. This is how we do it and we have no problems getting paid.

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