August 12, 2008
New requirement for ordering/referring information on ASC claims for diagnostic services
Effective Date: January 1, 2009
Implementation Date: January 5, 2009
Summary
Beginning January 1, 2009, the ordering/referring physician must be reported on claims for diagnostic radiology services submitted by ambulatory surgical centers (ASCs), as it is for other Part B claims for diagnostic services (modifier TC).
Key points
• Effective for dates of service on or after January 1, 2009, for allowed ASC claims, if modifier = TC, the ordering/referring physician name needs to be included in block 17 and ordering/physician NPI in block 17B of the CMS-1500 for paper claims.
• Effective for dates of service on or after January 1, 2009, for allowed ASC claims, if modifier = TC, the ordering physician name and NPI needs to be present in Loop 2420E NM1 (NM101=DK, NM102=1, NM103=provider’s last name, NM104=provider’s first name, NM108=XX, NM109=provider’s NPI).
• Effective January 1, 2009, for allowed ASC claims, if modifier = TC, the referring physician name and NPI needs to be present in Loop 2310A/2420F NM1 (NM101=DN, NM102=1, NM103=provider’s last name, NM104=provider’s first name, NM108=XX, NM109=provider’s NPI).
• Claims will be returned as unprocessable (using Claim Adjustment Reason Code 16- Claim/service lacks information which is needed for adjudication) for the above services without the ordering/referring physician name or NPI on the claim.
• If the NPI of the ordering/referring provider cannot be obtained by the billing provider and it cannot be found on the NPI Registry, the billing provider (in X12N 837 transactions) or the service provider (in NCPDP 5.1 transactions) may be used in the ordering/referring field on a temporary basis and such use is subject to postpayment review.
Additional information is available on the CMS Web site. Here is the link to the MLN Matters article MM6129 
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.Source: CMS MLN Matters Article MM6129
