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

Effective 4/1/2023, CMS implemented a new consistency edit to validate that the attending physician NPI. An Attending Provider is the individual who has overall responsibility for the patient’s medical care and treatment reported on institutional claims. Organizational NPIs cannot be used in place of individual NPIs, unless conditions for exception are met.

Institutional providers are required to indicate the Attending Provider Name and Identifiers for the patient’s medical care and treatment reported on institutional claims for any services other than nonscheduled transportation claims. 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.

Effective for claims received on or after 4/1/2023, 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 physician to the NPI and if there is a mismatch on the last name, it hits this edit. The issue is that the NPI/Physician name does not match PECOS.

Reason code 34963 will be bypassed for hospice claims. The A/B MACs will pull back all hospice claims that were returned for reason code 34963 and adjust them for processing.

Revised 4/11/2023
Posted 4/7/2023