Medicare's Wrong... No Willy Nilly NPIs

We wanted to know whether Medicare's demand that an NPI be placed in secondary provider slot, even if it's the wrong one, was really the right thing to do. Our question to the official standards body was dead simple:

In Medicare's guidance to its billers, it states:

"If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields."  (MLN Matters Number MM5890)

Using an ID/name other than that of the actual referring/ordering/etc. provider in the data element so designated seems a clear violation of the standard.  Please advise.

Also, if a secondary provider does not have an NPI (and is not required by law or contract to obtain one), what should the biller use instead?

X12's Response:

The 837 Implementation Guides contain usage and content requirements for the listed provider roles in conjunction with the services reported on a given claim; for example, Attending Physician. Name and Identification Code data elements are for the reporting of information pertaining to the person or entity performing the provider role designated by the Entity Identifier (NM101) qualifier in that loop.

The Trading Partner Agreements section of the Implementation Guide’s Purpose and Overview (Frontmatter section 1) states that trading partner requirements may not modify the requirements in the Implementation Guides. It further states that trading partner requirements may not modify the definition, meaning, or intent of the Implementation Guide.

Regarding the usage of NPI, when the Implementation Guide requires a provider ID, the use of NPI is required when mandated by the NPI rule. Other identifiers are available in the guide when NPI is not required by the rule.

What does X12 recommend? Read on...

X12's Recommendation:

For those provider roles that require the reporting of an identifier, when that provider does not have an NPI we recommend that the submitter report an alternate, non-NPI identifier. The Implementation Guide conditions for requiring an identifier have not changed with the implementation of NPI. Therefore, submitters must have reported an identifier for these provider roles prior to NPI. It would be reasonable for trading partner requirements to specify which identifier is preferred by the health plan.

Note that some of the provider roles listed in this question only require an identifier if known by the submitter. In those cases, it is valid to report the provider name and no identifier when the submitter can not obtain that identifier.

Status: Final

Nuff said? Here's the link.

The reference for this is X12 HIR #632. It says, quite simply, that Medicare's instructions to billers for representing non-enumerated providers is a violation of the 837 standard. My colleagues at X12 would be quick to add that this does not mean it's a HIPAA violation. They are not in charge of assessing HIPAA violations. And they did a great job and showed a lot of courage in fulfilling their assigned responsibility.

Quick! Call the cops!?
Medicare's secondary provider kluge does, however, seem inconsistent with the language in regulatory text that states that data elements can't be repurposed (I'm away from my office now, and unable to pull the numerous cites I quoted previously -- check my post Medicare to Plug NPI Hole with HIPAA Violation for authoritative citations). It's also worth noting that the standards are incorporated into the regs by reference.

But we aren't as optimisitic for a favorable, much less public, much less timely, opinion from the body that is responsible for interpreting the regulation. It's not that I'm skeptical of the integrity of involved, I just think that the time to get it right before May 23 no longer exists.

Fix It Before You Break It
Medicare should withdraw their misdirections -- and announce it soon and timely -- before they put them in place. No falsification of claims for the sake of satisfying ill-conceived edits.

And here's the link to our analysis of the rather timely NPI Contingency Status Survey for the big picture.

Comments

[Darrell Pruitt]

Until all this mess is cleared up, here is an idea for something to put into the ten-digit slot: The provider's phone number.

If things get really screwed up on the crosswalks, someone might just think to use it. Darrell Pruitt DDS