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When does a Medicare Claim need to have a Referring Provider?

Sadna Posted Thu 06th of March, 2014 17:54:25 PM

Please see the information below. The second sentence states that All Claims for Medicare needs to have a Referring or Ordering Provider Name, but we are not whether it is also for an office visit. If the Dr. is a PCP and he is seeing a Medicare patient for an office visit (ex: 99214), does he still need to enter himself as a Referring Provider? Can you please let us know when we need to enter the Referring Provider on a Medicare claim.

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.

• 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);

Jen Godreau, CPC, CPMA, CPEDC

SuperCoder Answered Tue 11th of March, 2014 09:58:12 AM


I am waiting for my editor to respond.


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