Wiki Group NPI or Physical Therapist NPI on claims?

[MSCPCNG]

I am having a difficult time finding resolution on how to bill for our physical therapists
services. We are a specialist office who hires PT and MT who work between 10 to 40 hours a week. They are licensed with the state. We bill our claims using the group tax and NPI number with the ordering physician listed as the referring and rendering physician with the doctor's NPI number.

Some of our PT's have their own NPI because they work at other offices in town or have their own office. We were billing "incident to" for all payers. Since some of our PT's do not have an NPI, we were not billing with any of the PT's or MT's NPI (box 24J) or as the rendering provider (box 31) on the claims. We have not had any problems until recently.

Federal BCBS advised that we are suppose to bill with the PT's name and NPI number as the rendering provider because patients claim they have to pay the copay of a Specialist office not their PCP copay. We are not a gereral physician office.

We are contracted with CMS, Medicaid, Tricare, and Premera only. I have gone to the OIG site, AAPC, APTA, Google, CMS, and our state insurance commissioners office and still cannot find a direct answer. I am hoping some of my fellow coders and billers can please assist me. Thank you.

 

[airart]

Medicare Benefit Policy Manual, Chapter 15

Have you read Chapter 15? Either the group NPI or individual NPI may be used on health care claims. However, there are situations where an individual NPI is specifically needed by some health plans to process claims. I used to work for Aetna processing insurance claims and some individual doctors in the practice would not be participating in an Aetna plan, but the group would be. This really wouldn't matter if the group billed and they were participating, but if the non-participating provider was also listed as the referring phyician for say like a well woman visit, then the claim would be denied. The health insurance plans are wanting more specific information from providers on who exactly rendered services so that the benefits can be applied correctly to the claim. It also sounds like they are wanting to track the PT services for those plans who may have a maximum on their plan. Hope the info below helps or at leasts helps point you in the right way.

Here is the link: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

I would review:

60.1 - Incident To Physician's Professional Services
230.4 - Services Furnished by a Therapist in Private Practice (TPP)
230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)
230.6 - Therapy Services Furnished Under Arrangements With Providers and Clinics

There is lots of good information on what is covered and how to bill. Also, found this on the CMS1500 site.

Box 17 - The following services/situations require the submission of the referring/ordering provider information: When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;

Item 17b Form CMS-1500 – Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Box 24J - Rendering Provider ID

�� This box is only required when clinics or group practices use a specific billing provider number in box 33. This identifies who rendered the service.

�� Non-shaded - Enter the ten-digit NPI of the rendering provider.

Enter the rendering provider's NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion. (CMS Manual)

NOTE: Effective May 23, 2008, the shaded portion of 24J is not to be reported.

Box 33 - Required - Billing Provider Information

�� Box 33 - (Billing provider info & phone number) Enter the name and address of the provider that is requesting to be paid for the services rendered.
�� 33a - (NPI) Enter the ten-digit NPI of the billing provider.
�� 33b - (Other ID) Enter the six (6)-or nine (9)-digit provider number of the billing provider.
Note: Non-medical services do not require NPI (e.g., taxis).

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

NOTE: This is a required field; however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.