CMS Pub. 100-04, ch. 5, § 10.3.5

Therapy plans of care must be certified by a physician or non-physician practitioner

(NPP), per the requirements in the Pub. 100-02, Medicare Benefit Policy Manual, chapter

15, section 220.1.3. Further, the National Provider Identifier (NPI) of the certifying

physician/NPP identified for a therapy plan of care must be included on the therapy

claim.

For the purposes of processing professional claims, the certifying physician/NPP is

considered a referring provider. At the time the certifying physician/NPP is identified for

a therapy plan of care, private practice therapists (PPTs), physicians or NPPs, as

appropriate, submitting therapy claims, are to treat it as if a referral has occurred for

purposes of completing the claim and to follow the instructions in the appropriate ASC

X12 837 Professional Health Care Claim Technical Report 3 (TR3) for reporting a

referring provider (for paper claims, they are to follow the instructions for identifying

referring providers per chapter 26 of this manual). These instructions include

requirements for reporting NPIs.

Currently, in the 5010 version of the ASC X12 837 Professional Health Care Claim TR3,

referring providers are first reported at the claim level; additional referring providers are

reported at the line level only when they are different from that identified at the claim

level. Therefore, there will be at least one referring provider identified at the claim level

on the ASC X12 837 Professional claim for therapy services. However, because of the

hierarchical nature of the ASC X12 837 health care claim transaction, and the possibility

of other types of referrals applying to the claim, the number of referring providers

identified on a professional claim may vary. For example, on a claim where one

physician/NPP has certified all the therapy plans of care, and there are no other referrals,

there would be only one referring provider identified at the claim level and none at the

line levels. Conversely, on a claim also containing a non-therapy referral made by a

different physician/NPP than the one certifying the therapy plan of care, the billing

provider may elect to identify either the nontherapy or the therapy referral at the claim

level, with the other referral(s) at the line levels. Similarly, on a claim having different

certifying physician/NPPs for different therapy plans of care, only one of these

physician/NPPs will be identified at the claim level, with the remainder identified at the

line levels. These scenarios are only examples: there may be other patterns of

representing referring providers at the claim and line levels depending upon the

circumstances of the care and the manner in which the provider applies the requirements

of the ASC X12 837 Professional Health Care Claim TR3.

For situations where the physician/NPP is both the certifier of the plan of care and

furnishes the therapy service, he/she supplies his/her own information, including the NPI,

in the appropriate referring provider loop (or, appropriate block on Form CMS 1500).

This is applicable to those therapy services that are personally furnished by the

physician/NPP as well as to those services that are furnished incident to their own and

delivered by “qualified personnel” (see section 230.5 of this manual for qualifications for

incident to personnel).

Contractors shall edit to ensure that there is at least one claim-level referring provider

identified on professional therapy claims, and shall use the presence of the therapy

modifiers (GN, GP, GO) to identify those claims subject to this requirement.

For the purposes of processing institutional claims, the certifying physician/NPP and their

NPI are reported in the Attending Provider fields on institutional claim formats. Since

the physician/NPP is certifying the therapy plan of care for the services on the claim, this

is consistent with the National Uniform Billing Committee definition of the Attending

Provider as “the individual who has overall responsibility for the patient’s medical care

and treatment” that is reported on the claim. In cases where a patient is receiving care

under more than one therapy plan of care (OT, PT, or SLP) with different certifying

physicians/NPPs, the second certifying physicians/NPP and their NPI are reported in the

Referring Physician fields on institutional claim formats.