In a Lab setting, Ancillary claims for Blue Cross/Anthem are filed to the plan where the specimen is drawn or where the ordering provider is located. If the ordering provider also works in another practice/hospital (non ancillary) at the same time in 2 states bordering each other, when physicians services claims are billed (non ancillary) for the same provider will they be effected by the Ordering Provider location (NPI ) or this Rule only applies to Independent Lab services? Any information or links about non ancillary claims i.e physicians services will be appreciated . Thank you
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Physician practicing in 2 bordering states
- Thread starter Louke
- Start date
mikhaila
Contributor
Hello,
I may be misunderstanding your question so forgive me if I am but the question seems to be emphasizing the ordering provider working in two states and not the specimen.
I cannot tell if you are referring to just a blood draw, on-site testing or reference lab testing.
Where was the specimen retrieved (blood draw at doc's office) or did the patient go to a 'LabCorp or Quest' type of facility)?
Who tested the specimen (on-site testing or sent out to a reference lab)?
I believe the snips below with accompanying scenarios may be able to answer your question.
This was taken from the book, 'Procedural Coding and Reimbursement for Physician Services', authored by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA.
I may be misunderstanding your question so forgive me if I am but the question seems to be emphasizing the ordering provider working in two states and not the specimen.
I cannot tell if you are referring to just a blood draw, on-site testing or reference lab testing.
Where was the specimen retrieved (blood draw at doc's office) or did the patient go to a 'LabCorp or Quest' type of facility)?
Who tested the specimen (on-site testing or sent out to a reference lab)?
I believe the snips below with accompanying scenarios may be able to answer your question.
This was taken from the book, 'Procedural Coding and Reimbursement for Physician Services', authored by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA.
https://archive.org/details/proceduralcoding0000kueh_p1g9/page/240/mode/2up?q=pathology&view=theater
Thank you for your response and here is a better explanation for my question: The provider is licensed in 2 neighboring states and practicing in 2 clinics respectively. At clinic1/State1 he orders a lab test for a patient (blood/urine drawn at clinic 1) the specimen get sent to an independent lab and the lab would run the test & bill claim (ancillary claim) to the BCBS plan where specimen was drawn which is determined where the Ordering/Referring Provider is located (NPI Primary practice address). At Clinic 2 the same provider in the neighboring State 2 bills for an E/M office visit for example & claim (non-ancillary) is filed to the BCBS in State 2, would this claim to BCBS be effected/denied if the provider’s NPI on the NPPES shows state 1 address? Would BCBS be using the provider individual NPI address to validate this type of service, or this claim would be based on another factor like the NPI of the practice group in state 2? Any information or links would be appreciated. Thank you.
mikhaila
Contributor
Okay, I think I understand your question better.
One provider with two locations in different states:
Clinic 1:
Provider orders a blood draw which is done at clinic 1.
Specimen is sent out for testing to independent lab.
Lab performs test and bills.
Clinic 2:
Provider bills E/M office visit.
Questions:
Would claim at clinic 2 be denied due to NPI showing address of clinic 1?
Factors used to pay claim and does NPI address matter?
Answer to both these questions is: It isn't the address necessarily but the NPI entity type.
To clarify the address thing - how many times have you heard of doctors participating in health fairs?
These providers go to malls, conference centers, community centers, schools and religious institutions and conduct exams as a service to the community.
Now to the NPI entity type issue:
See highlighted info from the CMS website:
Also, you stated BCBS/Anthem and I found the following link which has claims submission guidelines regarding NPI for facilities and professionals.
The info coincides with the CMS info.
Is your provider acting as a:
sole proprietor?
part of a larger organization that allows physicians to also act independently?
individual provider who is incorporated?
There are three types of entities that can be assigned an NPI.
If he is practicing as a sole proprietor who happens to have multiple locations then billing with that one NPI should not be an issue.
If he is acting as part of an organization (for example clinic 2) then he needs to use the organization's NPI unless of course he is conducting business separate from the parent organization. If he is conducting business separate from the parent company then he has to use his NPI for billing services.
If he is an individual provider who is incorporated then he may have two NPIs. I have seen it where a provider has more than one location and he acts as a sole proprietor in location 1 and bills with their respective sole proprietor NPI. However, for services he conducts in location 2 he uses the incorporated NPI.
One provider with two locations in different states:
Clinic 1:
Provider orders a blood draw which is done at clinic 1.
Specimen is sent out for testing to independent lab.
Lab performs test and bills.
Clinic 2:
Provider bills E/M office visit.
Questions:
Would claim at clinic 2 be denied due to NPI showing address of clinic 1?
Factors used to pay claim and does NPI address matter?
Answer to both these questions is: It isn't the address necessarily but the NPI entity type.
To clarify the address thing - how many times have you heard of doctors participating in health fairs?
These providers go to malls, conference centers, community centers, schools and religious institutions and conduct exams as a service to the community.
Now to the NPI entity type issue:
See highlighted info from the CMS website:
Also, you stated BCBS/Anthem and I found the following link which has claims submission guidelines regarding NPI for facilities and professionals.
The info coincides with the CMS info.
Is your provider acting as a:
sole proprietor?
part of a larger organization that allows physicians to also act independently?
individual provider who is incorporated?
There are three types of entities that can be assigned an NPI.
If he is practicing as a sole proprietor who happens to have multiple locations then billing with that one NPI should not be an issue.
If he is acting as part of an organization (for example clinic 2) then he needs to use the organization's NPI unless of course he is conducting business separate from the parent organization. If he is conducting business separate from the parent company then he has to use his NPI for billing services.
If he is an individual provider who is incorporated then he may have two NPIs. I have seen it where a provider has more than one location and he acts as a sole proprietor in location 1 and bills with their respective sole proprietor NPI. However, for services he conducts in location 2 he uses the incorporated NPI.