By Christopher P. Young, Editor, G2 Compliance Advisor
Contractors sent all Medicare Part B providers a notice on Feb. 16 reminding them that effective April 1, laboratories submitting claims for reference laboratory or anti-markup tests will no longer include the National Provider Identifier (NPI) of their own laboratory but must include the NPI of the laboratory actually performing the test. Today, laboratories include the name, address and ZIP code of the performing provider in item 32 and their own NPI in item 32a on the Centers for Medicare and Medicaid Services (CMS) 1500 claim form or its electronic equivalent. After April 1, the NPI in item 32a must be the NPI of the laboratory actually performing the tests.
Importantly, the change will affect claims submitted with a “receipt date” on or after April 1, not the date of service. It does not matter if the testing laboratory is in another jurisdiction because changes to the Provider Enrollment Chain and Ownership System or PECOS, allows contractors to verify the NPI of any laboratory provider.
According to the business requirements on the originating transmittal, R3103CP, change request 8806, contractors will identify affected claims by finding a “yes” in item 20 on a professional claim or a 90 modifier on a service line of a reference lab claim.
The reason codes for claims denied based on these changes are always preceded by CO (contractual obligation):
- In all cases, the reason code will be CO-16 – Claim/service lacks information which is needed for adjudication.
- For reference lab claims, the remark code will be N270 – Missing/incomplete/invalid other provider primary identifier
- For anti-markup claims, the remark code will be N283 – Missing/incomplete/invalid purchased service provider identifier
These claims will be returned as unprocessable which means that the provider may simply correct and resubmit the claim; no appeal is necessary. Laboratories receiving CO-16 denials after April 1 with either of these remark codes should first check to insure they have included the correct NPI in item 32a and all demographic information in the CMS data base matches that on the claim. Any provider can check the NPI of a laboratory using basic identifying information by searching on the National Plan and Provider Enumeration System (NPPES) website.