New Requirements for Documenting Imaging Orders

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imageCMS published an interim final rule (with a comment period) on May 5, implementing several changes to the Medicare and Medicaid programs mandated by the Patient Protection and Affordable Care Act (PPACA). In the interim final rule, CMS exercised its discretion in expanding the requirements of the legislation in ways significant to imaging centers and radiology practices across the country. Notably, the rule places new burdens on providers to maintain written orders for imaging services and to indicate the legal name and national provider identifier (NPI) of the ordering physician or practitioner on the claim.

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The interim final rule represents one of the first efforts by CMS to issue rules implementing the requirements of the PPACA. In this effort, CMS addressed three separate issues. First, the new rule requires both the furnishing and ordering provider or supplier of Medicare Part B services to maintain documentation of the (apparently written) order or referral for seven years. Second, it requires providers and suppliers to include their NPIs on all Medicare enrollment applications, as well as on all claims submitted to the Medicare and Medicaid programs. Third, the rule requires physicians and other eligible professionals who order services for Medicare beneficiaries to be enrolled in the Medicare program or to maintain a valid opt-out record.

The PPACA requires physicians who prescribe durable medical equipment (DME) or home health services to enroll in the Medicare program. It also gave CMS the authority to extend this requirement, by regulation, to other services, which CMS did by applying the requirement to imaging and other Part B services.

The final rule requires physicians and eligible professionals who order (or refer patients for) any Part B items and services, excluding Part B drugs, to maintain an approved Medicare enrollment record or a valid opt-out record. Further, claims submitted for Part B items or services must contain the legal name and NPI of the physician or eligible professional who ordered, or referred the patient for, the item or service. If the item or service is ordered (or the patient is referred for it) by a resident or intern, the claim must indicate the teaching physician’s legal name and NPI as those of the ordering or referring supplier.

According to CMS, Medicare administrative contractors will be instructed to reject claims from providers and suppliers for Part B items and services (excluding Part B drugs) if the legal name and NPI are not reported in the claim or if the ordering/referring physician or eligible professional does not have an approved enrollment record or valid opt-out. In the preamble to the final rule, CMS indicates that it reserves the right to apply these enrollment and ordering requirements to Part B drugs within the next year.

Documentation Requirements

The PPACA authorizes CMS to revoke, for up to one year, the Medicare enrollment of any provider or supplier who fails to maintain (and to provide access to) written orders or requests for payment for DME, certification for home health services, or referrals for other items and services, effective January 1, 2010.

A requirement to maintain and to provide access to such documentation also is added to the general Medicare provider enrollment requirements of the Social Security Act. Moreover, the PPACA extends the OIG's authority to exclude individuals or entities from the Medicare program if they order, refer for, or certify the need for health-care services, but fail to provide adequate documentation to verify payment.

The final rule implements these documentation requirements by requiring providers and suppliers who furnish DME, prosthetics, orthotics, and supplies (DMEPOS); home health services; and laboratory, imaging, or specialist services to maintain ordering and referring documentation for seven years from the date of service, including the NPIs received from physicians or eligible nonphysician practitioners.

In addition, the final rule requires providers and suppliers who order DMEPOS; home health services; and laboratory, imaging, or specialist services to maintain ordering and referring documentation for seven years from the date of order, referral, or certification. The documentation of the order or referral must be supplied to CMS or the Medicare contractor upon request.

It is unclear whether the final rule’s documentation requirements apply only to the technical-component provider/supplier