MLN Matters Number: MM6023
Related Change Request (CR) #: 6023
Related CR Release Date: May 30, 2008
Effective Date: May 23, 2008
Related CR Transmittal #: R1519CP
Implementation Date: June 30, 2008

Instructions for Institutional Providers and Suppliers Billing Self-Referred Mammography Claims Regarding the Attending/Referring Physician National Provider Identifier (NPI)

Provider Types Affected
Institutional providers and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FI), and/or Part A/B Medicare Administrative Contractors (A/B MAC)) for self-referred mammography services provided to Medicare beneficiaries

Provider Action Needed
Impact to You
This article is based on Change Request (CR) 6023 which provides National Provider Identifier (NPI) instructions for institutional providers and suppliers billing for self-referred mammography services. Do not use the surrogate unique physician identification number (UPIN) of “SLF000” on claims effective May 23, 2008.

What You Need to Know
Providers of mammography services are instructed to report their own facility NPI in the attending physician NPI field in cases where the service is self-referred by the patient (beneficiary) and no attending/referring physician NPI is available.

What You Need to Do
See the Background and Additional Information sections of this article for further details regarding these changes.

Background
Effective May 23, 2008, covered health care providers, suppliers and health plans (other than small plans) are required to use National Provider Identifiers (NPI). In reviewing the Medicare program’s business needs in preparation for the implementation of the NPI, the Centers for Medicare & Medicaid Services (CMS) identified that clarifying instructions are needed for institutional and supplier billing of self-referred mammography services.

The Medicare Claims Processing Manual (Pub. 100-04, Chapter 18 (Preventive and Screening Services), Section 20 (Mammography Services) indicates that a doctor’s prescription or referral is not necessary for screening mammography services to be covered. In self-referral cases, an NPI for an attending/referring physician is not available to the institution or supplier providing the mammography service. CR6023 modifies that instruction to alleviate this in self-referral cases.
In the past, Medicare fiscal intermediaries (FI) instructed providers to use the surrogate UPIN of “SLF000” in the Attending Physician UPIN field on the institutional claim form. Since UPINs will no longer be accepted on Medicare claims after May 23, 2008, an alternate means of identifying self-referral is needed.

Therefore, CR 6023 clarifies how providers and suppliers will reflect this situation on Medicare claims submitted on or after May 23, 2008, as follows:

• Institutional providers submitting claims for self-referred mammography services will duplicate the institution’s own NPI in the attending physician NPI field on their claims; and
• Suppliers submitting claims for self-referred mammography services will duplicate the supplier’s own NPI in the attending/referring physician NPI field on their claims.

Additional Information
The official instruction, CR 6023, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1519CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.