CMS Pub. 100-04, ch. 4, § 250.18

For Critical Access Hospital (CAH) billing under Method II (the optional payment

method), CMS and the Medicare Administrative Contractors (MACs) require the

rendering practitioner’s National Provider Identifier (NPI) to be reported at the line

level if it differs from the rendering NPI submitted at the claim level.

CMS implemented Change Request (CR) 7578, “Fiscal Intermediary Shared System

(FISS) and Common Working File (CWF) System Enhancement for Storing Line Level

Rendering Physicians/Practitioners National Provider Identifier (NPI) and Physician

Specialty Code Information.” This change enabled the display and storage of line-level

NPIs for combined billing of professional and institutional services on the CMS-1450

(UB-04) institutional claim form and was implemented to support HIPAA-compliant

processing.

Medicare must be able to determine the line level rendering professional for each

outpatient service on a combined billing claim submitted to Medicare and store this

information in our databases for data analysis purposes. The primary rendering

professional is also used to support standard claims processing, medical review, fraud

detection, Health Insurance Portability and Accountability Act (HIPAA) compliance,

identifying revoked practitioners, Office of Inspector General (OIG)

audits/overpayments, supporting program planning and capturing potential practitioner-

level incentives tied to the NPI.

As previously instructed, HIPAA requires that if the claim level rendering provider is

different from the attending provider, that a claim level rendering provider be reported.

HIPAA also requires that if the line level rendering provider is different than the claim

level rendering provider for combined claims that contain both facility and professional

charges, the line level rendering provider must be reported. Please ensure these

guidelines are followed. Affected Medicare providers are CAHs billing under Method II

and Federally Qualified Health Centers/ Rural Health Clinics (FQHCs/RHCs).

Prior to the implementation of the 5010 version of the 837I transaction, rendering

provider information could only be captured at the claim level. However, since 2012,

line-level rendering provider reporting has been required to ensure more accurate

tracking.

Line-level rendering provider editing applies to Type of Bill (TOB) 085X and revenue

codes 096X, 097X, and 098X, following the hierarchy below:

• Line Level "Rendering Physician" field when populated, or

• Claim level “Rendering Physician" field where a line level "Rendering Provider" field

is blank, or

• Claim level "Attending Physician” field if the claim level “Rendering Provider" field is

blank.

NOTE: Blank NPI line level rendering provider information indicates the claim level

rendering provider performed the professional services. Blank NPI claim level rendering

provider information indicates the attending provider performed the professional

services.

Please read the situational rule for Loop: 2420C — RENDERING PROVIDER NAME in

the current version of the HIPAA 837I.

“Required when Rendering Provider is different than the Attending Provider reported in

the 2310A loop of this claim.

AND

State or federal regulatory requirements call for a “combined claim,” that is, a claim

that includes both facility and professional components (for example, a Medicaid clinic

bill or Critical Access Hospital Claim.)

AND

The Rendering Provider for this line is different than the Rendering Provider reported in

Loop ID 2310D (claim level).

If not required by this implementation guide, do not send.

For information on the enrollment policy rules and how to reassign your benefits see

IOM 100-08, Chapter 10.

For all these examples assume the NPI for the Professional service provider is

1111111111.

Example 1 – The Professional service revenue code provider has reassigned benefits to

the CAH and is the claim level attending.

In this example if the professional service revenue code provider has not reassigned their

benefits in PECOS with an effective date that is prior to the from date on the claim, the

claim will receive reason code 31007.

Revenue Code Line Level

Rendering Provider

NPI in paper FL 43

or electronic Loop

2420C

Claim level

Attending Provider

NPI in paper FL 76

or electronic Loop

2310A

Claim level

Rendering Provider

NPI in paper FL

78-79 or electronic

Loop 2310D

1111111111

096x

Example 2 – The Professional service revenue code provider has reassigned benefits to

the CAH but is not the claim level attending but is the claim level rendering provider.

In this example if the professional service revenue code provider has not reassigned their

benefits in PECOS with an effective date that is prior to the from date on the claim, the

claim will receive reason code 31006.

Revenue Code Line Level

Rendering Provider

NPI in paper FL 43

or electronic Loop

2420C

Claim level

Attending Provider

NPI in paper FL 76

or electronic Loop

2310A

Claim level

Rendering Provider

NPI in paper FL

78-79 or electronic

Loop 2310D

2222222222 1111111111

096x

Example 3 – Professional has reassigned benefits to the CAH but is not the claim level

attending or rendering provider.

In this example if the professional service revenue code provider has not reassigned their

benefits in PECOS with an effective date that is prior to the from date on the claim, the

claim will receive reason code 31006.

Revenue Code Line Level

Rendering Provider

NPI in paper FL 43

or electronic Loop

2420C

Claim level

Attending Provider

NPI in paper FL 76

or electronic Loop

2310A

Claim level

Rendering Provider

NPI in paper FL

78-79 or electronic

Loop 2310D

2222222222 3333333333

096x 1111111111