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January 12, 2015

Billing Reminder: Home Health Ordering/Referring Edits

Billing transactions and adjustments for home health services with the "FROM" date of service on or after January 6, 2014, are denied if the attending physician National Provider Identifier (NPI) and name do not exactly match the NPI and the name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file. Therefore, as a reminder, before submitting your home health billing transactions, check the "Ordering Referring FileExternal website" to verify the physician's National Provider Identifier (NPI), last name and first name.

Submit your home health billing transactions and adjustments with the first and last name as it appears on the "Ordering Referring File". The attending physician NPI and name that you submit, must exactly match the NPI and name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file and displays in the "Ordering and Referring File."

Providers may submit a Reopening request when claims are denied when the NPI and/or physician's last name does not match the physician's information on the PECOS file. For additional information, refer to the Ordering/Referring Denial Reopenings information on the Reopenings Web page on the CGS website.

As an additional reminder, the Centers for Medicare & Medicaid Services (CMS) issued the article, "Home Health Agency Reporting Requirements for the Certifying Physician and the Physician Who Signs the Plan of Care" (MM8441External PDF), requiring that for episodes beginning on or after July 1, 2014, home health agencies must report the NPI of the physician who certifies/recertifies the patient's eligibility for home health services, if different than the attending physician.

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