Lab Claims With Incomplete NPI Info at Risk for Denial

Laboratory claims with missing or incorrect National Provider Identifier (NPI), or missing or incorrect identification information about the referring or ordering provider, are at risk of denial effective Jan. 6, 2014, according to a Nov. 6 announcement from the Centers for Medicare and Medicaid Services (CMS). The Affordable Care Act requires physicians or other eligible providers to be enrolled in the Medicare program to order or refer items or services for Medicare beneficiaries. Physicians and suppliers that bill Medicare must show their NPI on a claim. CMS implemented edits on ordering and referring providers when they are required to be identified in certain Part B claims, including those for clinical laboratory services. In Phase 1, which began Oct. 5, 2009, providers received an information message alerting them that the identification of the referring provider is missing, incomplete, or invalid. During this phase, claims were not denied but certain specific reason and remark codes were included to help providers or suppliers identify claims that were problematic. In Phase 2, which becomes effective Jan. 6, 2014, CMS will turn on the edits to deny Part B claims that fail to identify the ordering provider and that fail to have the required NPI. If the referring provider is listed on the claim, the edits will verify that the provider is enrolled in Medicare and will compare the first four letters of the last name. Claims from billing providers and suppliers that are denied because they failed the ordering or referring edit will not expose a Medicare beneficiary to liability. Therefore, an advance beneficiary notice is not appropriate in this situation. Details on Phase 2 are contained in a revised MLN Matters article, SE1305, released Nov. 6, 2013. The article is available at www.cms.gov. Takeaway: Laboratory claims must contain correct national provider identifiers and correct information about referring providers in order to be paid beginning Jan. 6, 2014.