Down to the Wire on NPI Compliance
By Devon Bernard, AOPA Government Affairs Department

Medicare tells us: The NPI is here. The NPI is now.

Are you using it?

Since the introduction of the National Provider Identifier (NPI) in May 2005, O&P practitioners have navigated many obstacles to become NPI-compliant. We are heading into the final stretch of full NPI implementation.

While March 1 was the deadline for mandatory use of NPI numbers on Medicare claims, you still had the safety blanket of recording legacy pairs on your Medicare claims. However, starting May 23, you will no longer be able to submit claims with legacy pairs. Claims will only be accepted with NPI numbers.

With this final deadline around the corner, it is the perfect time to review the use of NPIs on the CMS-1500 form.

Placing NPIs on the CMS-1500 form
Here are different places where you should fill in NPIs on the CMS-1500 form.

Box 17b.
This is the field relating to the ordering/referring physician. The information should match the prescription. The ordering/referring physician may also be a nurse practitioner, clinical nurse specialist or physician assistant, if he or she is authorized to write prescriptions and meets Medicare’s criteria for dispensing and signing orders. The ordering/referring physician may also be a podiatrist, if the referral is in the scope of his or her practice.

It is your responsibility to obtain the NPI from the ordering/referring physician, and your first source should be the referring entity. However, if the referrer does not give you his or her NPI, you may look up an NPI number on the National Plan and Provider Enumeration Systems (NPPES) Web site, www.nppes.cms.hhs.gov. If you are unable to retrieve this information, don’t leave the field blank—that will result in your claim not being processed. If you don’t have the referrer’s NPI, enter your own name and NPI number in this field.

Box 24J.
This space is reserved for the NPI number of the rendering provider. O&P practitioners are not required to have an individual NPI number, but rather a number for each physical location where they see patients (other than facilities such as SNFs or hospitals). Fill in Box 24J with the NPI of the office where you saw the patient. Since NPIs are attached to a location, each of your patient care offices must have a unique NPI number.

Box 32a.
Box 32 indicates where the items or services were delivered. Medicare doesn’t require an NPI to be entered in this box even though there is a box provided for one. Since an NPI is not required, all you need to fill in is the address to where the items were furnished. If the items were delivered to a hospital or SNF, enter the address of the hospital or SNF. If the items were furnished to a satellite office, enter the address of the satellite office, not the address of your central billing office.

Box 33a.
Enter the billing information here. If your practice is structured so that all billing flows to and from one central location, then enter that address and NPI in box 33 and 33a. If your billing office doesn’t have an NPI, and no patients are seen there, then enter the address and NPI of the office where the item or service was delivered. This also applies if the device was delivered to a patient in a SNF. 

If you have multiple facilities, be sure to submit at least one claim a year from each location and NPI
number. If Medicare doesn’t see billing activity for four straight quarters from a single location, they will assume the facility is no longer in use. If this occurs, Medicare will deactivate that number and it will no longer be valid on claim submissions. That facility will then have to be reenrolled with Medicare, which can take several months.

How to test your NPI
If you have submitted claims with NPI/legacy pairs, submit a handful with only NPI numbers. If they are not rejected, increase the amount of claims to be sure that your NPI is correct before the May 23rd deadline. It will save you time and frustration later!

If you have submitted claims with only NPI numbers, and they were rejected, you need to verify that your NPI information is accurate. Here’s how to verify whether your information on record is up to date.

First, go to the NPPES Web site, www.nppes.cms.hhs.gov.  Once you have accessed the Web site, click on the link for National Provider Identifier. You will then click on the link for “Login.” If you enrolled for your NPI via EFI (Electronic File Interchange) or paper application, you may have to click the link for “Create a login.” You will then be asked to enter your user ID and password, and then click on “Login.”

You will now be able to view all the information that is on file with the NPPES. Review the following information and make sure it is accurate.

First, check your numbers. Are you using the correct NPI number? Does your legacy number match the one on file with the NPPES? If the legacy number is incorrect or missing, edit it or add it to the online record.

Second, verify that the Legal Business Name is correct, if you are an organization. If you are a sole proprietorship, make sure the Legal Name is correct.

Lastly, you will want to double-check that you have selected the proper Entity Type, either Type 1 or Type 2. If you operate as an organization, you must select Entity Type 2. If you are the sole proprietor, you own the business and you accept all financial liability, you must select Entity Type 1.

If you have any questions about the information on the NPPES site, contact NPPES directly. It may be reached by phone at (800) 465-3203, or by e-mail at customerservice@npinumerator.com.

If the information on the NPPES site is correct, or has been corrected, print out a copy of your information. Keep a copy for your records. It will be needed for the next step.

If all the information on the NPPES site was correct, and your claims are still being rejected, you should contact your DME MAC customer service representative.

• Jurisdiction A: (866) 419-9458
  9:00 a.m.-5:00 p.m. EST
• Jurisdiction B: (888) 897-7541
  6:00 a.m.-7:00 p.m. EST
• Jurisdiction C: (866) 270-4909
  8:00 a.m.-5:00 p.m. EST
• Jurisdiction D: (866) 243-7272
  8:00 a.m.-5:30 p.m. CT

When you contact your appropriate DME MAC, have the following information ready:

• Name and location of your organization
• Claim tracking number, if available. The number may be found on the Remittance Advice, next to the letters “ICN”
• The month and year you submitted your Medicare Provider Enrollment form, CMS-855
• Your provider/supplier Tax Identification Number (EIN or SSN)
• Your NPI
• Your Medicare legacy identifier (NSC Number)

The customer service representative will then be able to decide if your claim is being rejected because of faulty information on record with Medicare. Be prepared to provide contact information if further
deliberation is needed.

With this last-minute tutorial on using NPIs on your Medicare claims, and how to verify your NPI, you are ready for the May 23 deadline. You will also avoid seeing the dreaded rejection code “N257––Missing,
incomplete, billing provider primary identifier.”

You may now say, “The NPI is here. The NPI is now. And I am using my NPI.”

Devon Bernard is reimbursement services coordinator for AOPA. Questions? Call (571) 431-0876, ext. 254, or e-mail dbernard@AOPAnet.org.