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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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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

Screen Shot

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/External Website 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/External Website 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.

Screen Shot

Step 3: Prior to submitting your claim, verify that the following matches the ordering/referring data file at https://data.cms.gov/External Website 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:

Please share this information with your billing staff.

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