Certifying Physician: Identify for Claim Processing - JE Part A
Certifying Physician: Identify for Claim Processing
Conditions of coverage and payment for outpatient physical therapy (PT), occupational therapy (OT) or speech-language pathology (SLP) services rely on the certification of the plan of care (POC). The National Provider Identifier (NPI) of the certifying physician or non-physician practitioner (NPP) must be included on the therapy claim.
Institutional Claim Processing: UB-04 Form
- Certifying physician/NPP is individual who has overall responsibility for patient's medical care and treatment
- NPI is reported on claim in Attending Provider fields (form location 76)
- Care provided under more than one POC with different certifying physicians/NPPs, report second NPI in Referring Physician field (form locations 78-79)
In a Comprehensive Outpatient Rehabilitation Facility (CORF), NPPs cannot certify the plan of care.
Professional Claim Processing: CMS-1500 Claim Form
- Certifying physician/NPP is considered a referring provider
- Claim edits to ensure one claim-level referring NPI is present
- Follow instruction for ASC X12 837 Professional Health Care Claim Technical Report 3 (TR3) reporting referring provider
- Paper submission: Report NPI in Item 17/17A
- CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 10.3.5
Last Updated Thu, 27 Oct 2022 15:20:52 +0000