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October 20, 2020

Home Health Ordering/Referring Requirements

This article serves as a reminder for home health providers about the ordering/referring billing requirements. Please share this information with your appropriate staff.

Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). The physician who orders/refers a patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS).

Note: Section 3708 of the CARES Act allows a nurse practitioner, clinical nurse specialist, or physician assistant who is working in accordance with State law to order or refer home health services. This applies to claims with a claim through date on or after March 1, 2020.

To ensure this requirement is met, the Fiscal Intermediary Standard System (FISS) edits home health claims to verify the attending physician's and referring physician's National Provider Identifier (NPI) is valid and that the attending physician and referring physician is enrolled in Medicare and is in the PECOS file. Providers enter the ordering/referring physician's NPI and name on FISS Claim Page 03 as shown below.

FISS Claim Page 03

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Before submitting your claims, follow the steps below to help avoid denial of your home health claims.

Step 1: Access the Order and Referring dataset fileExternal Website to verify the physician's NPI, last name, and first name. Select "View Data" and search by name or NPI. This file does not include the physician's specialty code. To verify the specialty code, refer to Step 2.

Screenshot

Ordering and Referring Example: If the Order and Referring dataset file shows the physician's name as Willy Wonka, enter the last name as "Wonka" in the "L" field and the first name as "Willy" in the "F" field. FISS will only verify the first initial of the first name. In this example, the first initial was entered as "W." in the "F" field. Since the period was entered after the first initial, the claim was denied because it did not match the Order and Referring dataset file.

Screenshot

Things to note:

  • The NPI for the ordering/referring physician must be for an individual physician, not a group or organizational NPI.
  • In addition, middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields.
  • The Order and Referring dataset file is updated weekly.

Step 2: Access the NPPESExternal Website website and search the NPI record by using the NPI, first or last name. The results will display showing the NPI, Name, NPI Type, Primary Practice Address, Phone, and Primary Taxonomy (see below example). To determine if the physician's specialty is a valid home health ordering/referring specialty, review the information under the "Primary Taxonomy" field. In the example shown below the Primary Taxonomy field is Internal Medicine. By reviewing the Ordering/Referring Physician Checklist for Home Health AgenciesExternal PDF quick reference tool, which includes a list of specialty codes, Internal Medicine (11), indicates that this physician is a valid home health ordering/referring physician. Click on the NPI number to access additional information.

NPPES Example:

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Step 3: Prior to submitting your claim, follow Steps 1 and 2, and enter the following information on FISS Claim Page 03, ensuring that it matches exactly as shown on the Order and Referring dataset.

  • The NPI of the physician
  • The first four letters of the physician's last name
  • The physician's first name or the first letter of the physician's first name

Denial Reason Codes

If the above information is not entered exactly as shown on the Order and Referring dataset, your home health claim will deny with reason code 37236 (claim), or 37237 (adjustments) when:

  • The attending physician NPI on the claim is not found in the eligible attending physician file from PECOS; or
  • The attending physician NPI on the claim is found in the eligible attending physician file from PECOS but the name on the claim does not match the name in the PECOS file; or
  • The specialty code is not a valid eligible code (see below for a list of valid home health ordering/referring specialty codes).

If the PECOS physician file includes a termination date that falls within the dates of service on the claim, the claim will deny with reason code 32072.

NOTE: There may be times when a physician has an enrollment record in PECOS, but they are not located on the ordering/referring data file. This is often due to the physician not completing the necessary information in PECOS which allows them to be included in the ordering/referring data file. You may need to contact the physician and ask that they complete the necessary information in PECOS.

Requesting a Reopening

If your claim denies with one of the above reason codes, you may appeal the decision by submitting an Ordering/Referring Denial Reopening. Complete the Medicare HHH Reopenings Adjustment Request FormPDF along with a hardcopy UB-04 claim form the Type of Bill (XX7), appropriate condition code, Document control Number (DCN) and an explanation in the REMARKS field. Refer to the Ordering/Referring Denial Reopenings information located on the Reopenings web page for additional information. Do not submit a first level of appeal Redetermination request.

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