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New Fiscal Intermediary Shared System Consistency Edit to Validate Attending Physician National Provider Identifier

Effective 5/16/2023, CMS implemented a new FISS consistency edit to validate the attending provider NPI. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported on an institutional claim/encounter and is entered in Form Locator 76 (refer to claim page 3 in the FISS Direct Data Entry System).

Institutional providers are required to report the attending provider name and identifiers for the patient’s medical care and treatment on institutional claims for any services other than claims for nonscheduled transportation. Additionally, institutional providers are required on outpatient claims to send the referring provider NPI and name when the referring provider for the services is different from the attending provider. Institutional providers must not use an organizational NPI in place of individual NPIs, unless conditions for an exception are met. Refer to MLN article MM12889 for the exceptions and additional information.

Effective for claims received on or after 5/16/2023, NGS will edit for institutional claims to ensure that the institutional provider has not used any other organizational NPI in the Attending Provider NPI Data Element.

Reason code 34963 is validating the provider to the NPI and if there is a mismatch on the last name, the claim is returned to the provider (RTP) with this edit. The issue is that the NPI/provider name does not match the information in PECOS.

For additional information review Medlearn Matters article MM12889 “New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI” that was revised on 4/27/2023 to provide additional provider education relevant to this consistency edit.

Revised 5/23/2023
Posted 4/7/2023