CMS Implementing Ordering/Referring Edit

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Topic CMS Implementing Ordering/Referring Edit
Background The enrollment requirement for ordering/referring physicians is part of the Patient Protection and Affordable Care Act (PPACA). The provision was included in the PPACA to address multiple issues including combating fraud and abuse by making sure only those physicians who are appropriately enrolled in Medicare are providing services to Medicare beneficiaries, making sure that nonphysician providers were not ordering/referring services that they’re not allowed to order under the Medicare rules, and making sure that physicians maintain updated enrollment records with Medicare. Since January 1992, physicians have been required to list the ordering/referring physician on a claim if the service provided was the result of an order/referral.
Regulating Body CMS
Compliance Date 1/6/2014
Consequences Starting on Jan 6, 2014, claims submitted by the physician who has received the referral will be denied if the ordering/referring physician is not in the PECOS system.
Next Steps ​Physicians should check to make sure physicians who order/refer services to them are in PECOS. Physicians can check by using the TMA look up tool at
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