March 30, 2017
Home Health Ordering/Referring Requirements
This article serves as a reminder for home health providers about the ordering/referring billing requirements. Please share this information with your billing staff.
Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). In addition, the physician who orders/refers a patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS).
The Fiscal Intermediary Standard System (FISS) edits home health claims to ensure the attending physician’s National Provider Identifier (NPI) is valid and that the attending physician is enrolled in Medicare, and is in the PECOS file. Providers enter the ordering/referring physician’s NPI and name on FISS Claim Page 03 as shown below.
FISS Claim Page 03
Taking the following step will help to avoid denial of your home health claims.
Step 1: Access the “Order and Referring” data file at https://data.cms.gov/ to verify the physician’s NPI, last name, and first name. This file does not include the physician’s specialty code.
Step 2: Access the NPPES website at https://npiregistry.cms.hhs.gov/ to verify the physician’s specialty is a valid home health ordering/referring specialty. Use the information under the “Primary Taxonomy” field to cross reference the list (found below) of valid home health ordering/referring specialty codes. In the example below, the specialty code is 11 for Internal Medicine.
Step 3: Prior to submitting your claim, verify that the following matches the ordering/referring data file at https://data.cms.gov/ exactly.
- The NPI of the physician
- The first four letters of the physician’s last name
- The first letter of the physician’s first name
Your home health claim will deny with reason code 37236, or 37237 (adjustments) when:
- The attending physician NPI on the claim is not found in the eligible attending physician file from PECOS; or
- The attending physician NPI on the claim is found in the eligible attending physician file from PECOS but the name on the claim does not match the name in the PECOS file; or
- The specialty code is not a valid eligible code (see below for a list of valid home health ordering/referring specialty codes).
NOTE: There may be times when a physician has an enrollment record in PECOS, but they are not located on the ordering/referring data file. This is often due to the physician not completing the necessary information in PECOS which allows them to be included in the ordering/referring data file. You may want to contact the physician and ask that they complete the necessary information in PECOS.
Valid Home Health Ordering/Referring Physician Specialty Codes
Code |
Physician Specialty |
Code |
Physician Specialty |
---|---|---|---|
02 |
General Surgery |
36 |
Nuclear Medicine |
03 |
Allergy/Immunology |
37 |
Pediatric Medicine |
04 |
Otolaryngology |
38 |
Geriatric Medicine |
05 |
Anesthesiology |
39 |
Nephrology |
06 |
Cardiology |
40 |
Hand Surgery |
07 |
Dermatology |
44 |
Infectious Disease |
08 |
Family Practice |
46 |
Endocrinology |
09 |
Interventional Pain Management |
48 |
Podiatry |
10 |
Gastroenterology |
66 |
Rheumatology |
11 |
Internal Medicine |
72 |
Pain Management |
12 |
Osteopathic Manipulative Therapy |
76 |
Peripheral Vascular Disease |
13 |
Neurology |
77 |
Vascular Surgery |
14 |
Neurosurgery |
78 |
Cardiac Surgery |
16 |
Obstetrics/Gynecology |
79 |
Addiction Medicine |
17 |
Hospice and Palliative Care |
81 |
Critical Care (Intensivists) |
20 |
Orthopedic Surgery |
82 |
Hematology |
22 |
Pathology |
83 |
Hematology/Oncology |
24 |
Plastic and Reconstructive Surgery |
84 |
Preventive Medicine |
25 |
Physical Medicine and Rehabilitation |
85 |
Maxillofacial Surgery |
26 |
Psychiatry |
86 |
Neuropsychiatry |
27 |
Geriatric Psychiatry |
90 |
Medical Oncology |
28 |
Colorectal Surgery (Formerly Proctology) |
91 |
Surgical Oncology |
92 |
Radiation Oncology |
||
29 |
Pulmonary Disease |
93 |
Emergency Medicine |
30 |
Diagnostic Radiology |
94 |
Interventional Radiology |
33 |
Thoracic Surgery |
98 |
Gynecological/Oncology |
34 |
Urology |
C6 |
Hospitalist |
Additional Resources:
- CGS Ordering/Referring Physician Checklist for Home Health Agencies Quick Resource Tool (QRT)
- SE1305 – Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)
- SE1413 – Certifying Physicians and the Phase 2 Ordering and Referring Denial Edits for Home Health Agencies (HHAs)
Please share this information with your billing staff.