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October 11, 2023

Entering the Correct Ordering Practitioner on Claims

Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) have noted an increase in Comprehensive Error Rate Testing (CERT) program denials when the name and National Provider Identifier (NPI) of the referring practitioner, listed in Item 17 and Item 17b of the CMS-1500 claim form and electronic equivalent do not match the name and NPI of the practitioner who completed the order. Title XVIII §1833(q) of the Social Security Act requires the referring/ordering physician information be submitted on a Medicare claim when the billing provider/supplier has received a referral or order for the referred/ordered service(s) or item.

This type of error can occur as the result of Medicare beneficiaries who are under the care of multiple physicians or the death, reassignment, or retirement of their primary care provider, resulting in a change in providers. Suppliers are strongly encouraged to check their documentation from referring practitioners and ensure that the information listed in Item 17 and Item 17b on the CMS-1500 form or electronic equivalent for the referring provider matches the information on the order for any item of durable medical equipment, orthotics, prosthetics, or supplies (DMEPOS).


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