Medicare Ordering/Referring Physician Updates

Many changes have been implemented recently as part of the Affordable Healthcare Act.  One of these items is the passing of  the “Pathway to SGR Reform Act”, which affects Medicare payments and ordering/referring physicians. The law has been delayed for several years, but was passed and became effective 1/6/14. Medicare released the following statement: On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides for a 0.5 percent update for such services through March 31, 2014…The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of the Affordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming. The new law provides for a 0.5 percent update on claims with dates of service on or after 1/16/14 through 3/31/14. CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements. The 2014 conversion factor is $35.8228. The existing 1.0 floor on the physician work geographic practice cost index is extended through 3/31/14, and will be reflected in the revised 2014 MPFS. An additional key part of the new law is that claims submitted by providers who render services which do not meet the agency’s “ordering and referring criteria” beginning on 1/6/14 will be denied. The “Ordering and Referring Physician Fact Sheet” was written in conjunction with the American Medical Association, and outlines key issues practices need to know in order to avoid claim denials. Some of those key criteria are: 1. Claims submitted for the ordering/referring provider, which do not accurately list the matching NPI will continue to be rejected 2. Physicians and other providers who are eligible to order and refer items or services, need to ensure that they are correctly enrolled with  Medicare to reflect their specialty, and ensure their specialty is one which is eligible to order and refer services. 3. The ordering/referring provider name on the claim must match what Medicare has on record. (Middle names, initials and suffixes, such as MD, APRN etc., should not be listed in the ordering/referring fields). For more information, please refer to the CMS website at: