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J Posted Fri 28th of September, 2012 13:07:37 PM

We are a Podiatrist that sees patinet only in nursing homes part B stay
Does CMS require a referring physician for our routine foot care ?
We have started to get denials for no referring and I do not see a CMS policythat states we need one ?

SuperCoder Answered Fri 28th of September, 2012 17:53:39 PM

Enter the performing provider as the referring provider. Item 17 represents the referring physician or other source. The line 17 description and below final bullet suggest that when the ordering physician is also the performing physician, you can use the ordering physician in item 17.

From Instructions on how to fill out the CMS 1500 Form:

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. Use the physician’s last name and as much of the first name as will fit in item 17. Do not use “self,” “friend,” etc.

The ordering/referring requirement became effective January 1, 1992, and is required by Section 1833(q) of the Social Security 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. See items 17a and 17b below for further guidance on reporting the referring/ordering provider’s UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:

• Medicare covered services and items that result from 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);

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