LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-01 Ordering/Referring Physician Documentation Responsibility

Ordering/Referring Physician Documentation Responsibility
  • As the Zone 5 Zone Program Integrity Contractor (ZPIC), AdvanceMed Corporation, LLC performs benefit integrity activities aimed to reduce fraud, waste, and abuse in the Medicare (Part A, B, DME, Home Health and Hospice) Program. Provider/supplier education is part of the ZPIC activities. In this educational article Zone 5 will highlight the responsibilities of the referring/ordering physician.
  • Title XVIII §1833(q) of the Social Security Act requires the referring/ordering physician information be submitted on a Medicare claim when the billing provider/supplier has received a referral or order for the referred/ordered service(s) or item1. Section 1842 (p)(4) of the Act requires the referring/ordering physician provide documentation to the billing provider/supplier based on a referral/order:
  • In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861(s) ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
  • Pursuant to 42 Code of Federal Regulations (CFR) § 424.535, a referring/ordering physician’s failure to provide the above required documentation that referring/ordering physician’s Medicare number may result in revocation. The revocation of enrollment and billing privileges in the Medicare program:
    (a) Reasons for revocation. CMS may revoke a currently enrolled provider or supplier’s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons:
    (10) Failure to document or provide CMS access to documentation. (i) The provider or supplier (as described in section 1866(j) of the Act) did not comply with the documentation or CMS access requirements specified in §424.516(f) of this subpart.
  • Regulation 42 CFR § 424.516 sets forth the types of documentation that are required to be provided by impacted provider/suppliers: Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program. (f) Maintaining and providing access to documentation.
    (1) A provider or a supplier who furnishes covered ordered DMEPOS or referred home health, laboratory, imaging, or specialist services is required to maintain documentation for 7 years from the date of service and, upon the request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders and requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.
    (2) A physician who ordered home health services and a physician and an eligible professional who ordered or referred items of DMEPOS or laboratory, imaging, and specialist services is required to maintain documentation for 7 years from the date of the order, certification, or referral and, upon request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders or requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.
  • The Office of the Inspector General (OIG) U.S. Department of Health and Human Services provides physician educational resources on physician relationships with payers and vendors. These resources are found here. The educational information discusses maintaining and providing documentation as well as the importance of legitimate prescriptions for patients.
  • As a billing provider/supplier, if you are asked and/or required to pay for or refused documentation by a referring/ordering physician, please report the incident as potential fraud and/or abuse. As a referring/ordering physician, if you are asked to sign or write prescriptions for Medicare beneficiaries by a provider/supplier for unnecessary services/items or for patients you do not know, please report the incident.
You can also call the OIG Hotline at 1-800-HHS-TIPS (1-800-447-8477).

1The definition of physician is found at.

last updated on 01/26/2012