(Medicare Claims Processing Manual)

The term "physician" when used within the meaning of 1861(r)  of the Act and used in connection with performing any function or action refers to:   1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;   2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;   3. A doctor of podiatric medicine for purposes of (k), (m), (p)(1), and (s) and 1814(a) , 1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;   4. A doctor of optometry, but only with respect to the provision of items or services described in 1861(s)  of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or   5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets  uniform minimum standards specified by the Secretary, but only for purposes of 1861(s)(1) and 1861(s)(2)(A)  of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).  For the purposes of 1862(a)(4)  of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referr ed to in 1862(a)(4) of the Act) are furnished.   Referring physician  - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.   Ordering physician  - is a physician or, when appropriate, a non -physician practitioner who orders non- physician services for the patient.  See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15 for non- physician practitioner rules.  Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physicians or non- physician practitioners service.  The ordering/referring requirement became effective January 1, 1992, and is required by 1833(q)  of the Act.  All claims  for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name.  The following services/situations require the submission of the referring/ordering provider information:    Medicare covered services and items that are the result of a physician's order or referral;    Parenteral and enteral nutrition;    Immunosuppressive drug claims;    Hepatitis B claims;   Diagnostic laboratory services;    Diagnostic radiology services;    Portable x -ray services;    Consultative services;    Durable medical equipment;    When the ordering physician is also the performing physician (as often is the case with in -office clinical laboratory tests);    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;   When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;   Effective for claims with dates of service on or after October 1, 2012, all claims for physical therapy, occupational therapy, or speech- language pathology services, including those furnished incident to a physician or nonphysician practitioner, require that the name and NPI of the certifying physician or nonphysician practitioner of the therapy plan of care be entered as the referring physician in Items 17 and 17b.  Item 17a -  Leave blank.   Item 17b -  Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17.  All physicians and non- physician practitioners 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.   Item 18 -  Enter either an 8 -digit (MM | DD | CCYY) or a 6 -digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.   Item 19  - Enter either a 6 -digit (MM | DD | YY) or an 8 -digit (MM | DD | CCYY) date patient was last seen and the NPI of his/her attending physician when a physician providing routine foot care submits claims.  NOTE:   Effective May 23, 2008, all provider identifiers submitted on the CMS -1500 claim form MUST be in the form of an NPI.   Enter either a 6 -digit (MM | DD | YY) or an 8 -digit (MM | DD | CCYY) x -ray date for chiropractor services (if an x -ray, rather than a physical examination was the method used to demonstrate the subluxation).  By entering an x -ray date and the initiation da te for course of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of subluxation) of Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, is on file, along with the appropriate x -ray and all are available for A/B MAC (B) review.   Instructions for Not Otherwise Classified (NOC) Codes  Any unlisted services or procedure code.  Note: When reporting NOC codes, this field must be populated as specified below.   Enter the drug's name and dosage when submitting a claim for NOC drugs.   Enter a concise description of an "unlisted procedure code" or a NOC code if one can be given within the confines of this box.  Otherwise an attachment shall be submitted with the claim.     When billing for unlisted laboratory tests using a NOC code, this field MUST  include the specific name of the laboratory test(s) and/or a short descriptor of the test(s).  Claims for unlisted laboratory tests that are received without this information shall be treated according to the requirements found in Pub. 100- 04, Medicare Cl aims Processing Manual, Chapter 1, Section 80.3.2 and returned as unprocessable. Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA) requires reporting entities to report private payor payment rates for laboratory tests and the corresponding volumes of tests.   In compliance with PAMA, CMS must collect private payor data on unique tests currently being paid as a NOC code, Not Otherwise Specified (NOS) code, or unlisted service or procedure code.   Enter all applicable modifiers when modifier - 99 (multiple modifiers) is entered in item 24d.  If modifier - 99 is entered on multiple line items of a  single claim form, all applicable modifiers for each line item containing a - 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.   Enter the statement "Homebound" when an independent laboratory obtains a specimen from a homebound or institutionalized patient.  (See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Me dicare Claims Processing Manual, Chapter 16, "Laboratory Services, and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively, for the definition of "homebound" and a more complete definition  of a medically necessary laboratory service to a homebound or an institutional patient.)   Enter the statement, "Patient refuses to assign benefits," when the beneficiary absolutely refuses to assign benefits to a non- participating physician/supplier who accepts assignment on a claim.  In this case, payment can only be made directly to the benef iciary.   Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.   When dental examinations are billed, enter the specific surgery for which the exam is being performed.   Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.   Enter a 6 -digit (MM | DD | YY) or an 8- digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share post -operative care.   Enter demonstration ID number "30" for all national emphysema treatment trial claims.   Enter demonstration ID number 56 for all national Laboratory Affordable Care Act Section 113 Demonstration Claims.   Enter the NPI of the physician who is performing the technical or professional component of a diagnostic test that is subject to the anti -markup payment limitation.  (See Pub. 100- 04, chapter 1, section 30.2.9 for additional information.)   NOTE:   Effective May 23, 2008, all provider identifiers submitted on the CMS -1500 claim form MUST be in the form of an NPI.   Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis.  (See Pub. 100- 04, chapter 8, section 60.7.2.)   Individuals and entities who bill A/B MACs (B) for administrations of ESAs or Part B anti-anemia drugs not self -administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results.  The test results s hall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point [xx.x]).  Example for hemoglobin tests: TR/R1/9.0, Example for Hemat ocrit tests: TR/R2/27.0.  Item 20 -  Complete this item when billing for diagnostic tests subject to the anti- markup payment limitation.  Enter the acquisition price under charges if the "yes" block is checked.  A "yes" check indicates that an entity other than the entity billing for the service performed the diagnostic test.  A "no" check indicates "no anti -markup tests are included on the claim."  When "yes" is annotated, item 32 shall be completed.  When billing for multiple anti- markup tests, each test shall be submitted on a separate clai m form CMS -1500.  Multiple anti -markup tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different service facility locations.  See chapter 1.   NOTE:  This is a required field when billing for diagnostic tests subject to the anti -markup payment limitation.   Item 21 -  Enter the patient's diagnosis/condition.  With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service.  Enter the diagnoses in priority order.  All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.   Reminder:  Do not report ICD -10-CM codes for claims with dates of service prior to implementation of ICD -10-CM, on either the old or revised version of the CMS -1500 claim form.   For form version 08/05, report a valid ICD -9-CM code.  Enter up to four diagnosis codes.   For form version 02/12, it may be appropriate to report either ICD -9-CM or ICD -10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).    The ICD Indicator identifies the ICD code set being reported.  Enter the applicable ICD indicator according to the following:   Indicator  Code Set  9 ICD-9-CM diagnosis  0 ICD-10-CM diagnosis   Enter the indicator as a single digit between the vertical, dotted lines.