Medicare Ordering/Referring Edits Extended to Certifying Physicians

Beginning July 1, the certifying physician reported on a Medicare home health agency (HHA) claim must be enrolled in Medicare. If not, the claim will be denied under Medicare's ordering and referring denial edits.

Previously, these edits applied only to the attending physician on an HHA claim. Starting with home health episodes that begin on or after July 1, the edits will check to ensure both the attending and certifying physicians (when they are different people) have valid national provider identifiers (NPIs) and are eligible to order and refer the HHA items and services. Both physicians must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) — or have validly opted out — as of the date of service. You can verify if a physician is listed in PECOS on the Centers for Medicare & Medicaid Services (CMS) website.

An attending physician signs a patient's plan of care, while a certifying physician certifies or recertifies a patient's eligibility to receive services under the Medicare home health benefit. 

  • If the certifying and attending physicians are different, both physicians are subject to the ordering and referring denial edits. These edits apply to the "Attending" and "Referring Provider" fields in electronic claims. In paper claims, the "Other Provider" field identifies the certifying physician.
  • If the certifying and attending physicians are the same, the edits apply only to the "Attending" field.  

For more information, see the following from CMS: 

Action, July 1, 2014

Last Updated On

May 13, 2016

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