Part B Insider (Multispecialty) Coding Alert

Published on Thu Jul 12, 2007 PDF

Watch out for common NPI billing problems

Many physician claims could soon get lost in the ether because of a basic error. Are your claims safe?

Check this: Many group practices are combining their National Provider Identifiers (NPIs) and legacy numbers incorrectly, warned officials from the Centers for Medicare & Medicaid Services (CMS) at an Aug. 2 Q&A session on -Common Billing Errors- involving NPIs.

Example: A group practice bills Medicare using the practice's group NPI, but adds the rendering or individual provider's legacy identifier instead of the group's legacy number. Some practices are also doing the opposite, billing the individual provider's NPI but adding the group practice's legacy number in the rendering field.

Right now, if you-re wrongly using a group NPI and an individual legacy number, your claims are still getting paid. But this will soon change, CMS officials warned. Already, CMS is returning hospital claims with -incorrect provider combinations- as unprocessable.

-The reason your Part B claims are not rejecting today is because Medicare claims processing systems are using bypass logic that does not validate the NPI/legacy pair against the Medicare crosswalk,- one official said. But the Part B carriers will turn off this -bypass logic- and start rejecting claims in a -staggered schedule,- from Sept. 3 to Oct. 29.

For now, physician offices that are confusing group and individual NPIs and legacy numbers are receiving -an informational edit,- officials added. But in some cases, this edit is going to the clearinghouse instead of your practice. CMS has heard that some clearinghouses aren't passing these edits back to providers. If you-re worried that you might be mixing up NPIs and legacy numbers and not hearing about it, contact your clearinghouse.

Other common billing problems you could face:

- If your referring physician refuses to get an NPI because he or she works on a cash-only basis, then you could be unable to bill for patients that doctor sends you, once Medicare starts requiring the referring physician's NPI next year.

- If a Canadian physician refers a patient to you, that foreign doctor can't obtain an NPI. But CMS will issue instructions on how to handle this. The same goes for patients referred by residents, and self-referred patients.

- If you-re still rebilling claims from 18 months ago, and some providers have since left without obtaining an NPI, you should bill those claims right away. Medicare has not yet decided when it will start requiring an NPI on all claims.