Ordering Physician Related Denials Set to Increase

CMS has instructed contractors to turn on new ordering/referring denial edits on January 6, 2014. Medicare contractors will begin denying claims made by providers who furnish services not meeting CMS ordering and referring criteria, namely not properly enrolling with the Medicare program.   

For diagnostic tests for which there are separate claims for the Technical (TC) and Professional (PC) components, the denial will only be for the Technical Component.  However, CMS has also announced that if the TC and PC are billed using a global code, then the ordering/referring policy will apply to both the TC and PC.

Break Away from the Static

This requirement was originally scheduled to go into effect in 2010, but HBMA and other organizations successfully convinced CMS to delay this so that more time could be given for physicians to enroll.

As always, ADVOCATE will keep you updated as more details about the CMS denial edits and all issues impacting radiology become available.

Best regards,
Kirk Reinitz, CPA