CMS Pub. 100-04, ch. 2, § 90.3

The hospital’s registration process must distinguish whether the referral source for this

registration/admission is from:

• Its own inpatient hospital;

• An encounter in another hospital (see §90.6 for definition of encounter); or

• Any other source - See chapter 25.

Hospitals must determine the appropriate source of admission from internal records or by

asking the patient who referred him/her, and whether the referral took place as a result of

an encounter in the servicing hospital, another hospital, or elsewhere.

The following coding must be used on the outpatient claim. Therefore

admission/registration processes must obtain the information.

1. Physician Referral - The patient was referred to this facility for outpatient or

referenced diagnostic services by his/her personal physician, or the patient

independently requested outpatient services (self-referral).

2. Clinic Referral - The patient was referred to this facility for outpatient or

referenced diagnostic services by this facility’s clinic or other outpatient

department physician.

3. HMO Referral - The patient was referred to this facility for outpatient or

referenced diagnostic services by an HMO physician.

4. Transfer from a Hospital - The patient was referred to this facility for outpatient

or referenced diagnostic services by a physician of another acute care facility.

5. Transfer from a SNF - The patient was referred to this facility for outpatient or

referenced diagnostic services by a physician of the SNF where the patient is an

inpatient.

6. Transfer from Another Health Care Facility - The patient was referred to this

facility for outpatient or referenced diagnostic services by a physician of another

health care facility where the patient is an inpatient.

7. Emergency Room - The patient was referred to this facility for outpatient or

referenced diagnostic services by this facility’s emergency room physician.

8. Court/Law Enforcement -The patient was referred to this facility for outpatient or

referenced diagnostic services upon the direction of a court of law, or upon the

request of a law enforcement agency representative.

9. Information not available.

10. Transfer from a CAH - The patient was referred to this facility for outpatient or

referenced diagnostic services by (a physician of) the CAH were the patient is an

inpatient.

The hospital must determine the proper source of admission code based on the patient’s

response and/or any other information the hospital may have available from its

preregistration records or scheduling data. The hospital must enter the proper source of

admission code on the claim.

NOTE: Information regarding the form locator number that corresponds to the source of

admission code and a table to crosswalk its CMS-1450 form locator to the 837

transaction is found in Chapter 25.

If the patient was referred for services by a physician at:

• This hospital, the hospital enters codes 2 or 7;

• Another hospital, the hospital enters code 4; or

• Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate.

If the hospital is sure the admission source is not from its hospital or another hospital but

cannot determine which of the codes apply, the hospital will enter code 1 on Medicare

claims. However, incorrect reporting where services were referred by staff at its own

hospital or another hospital (codes 2, 4, or 7 are applicable) is considered program abuse

and subject to applicable sanctions.