Physicians

Physician means any of the following entities legally authorized to practice by a State in which he/she provides their services. The services performed by a physician within these definitions are subject to any limitations posed by the State on the scope of practice.

• Doctor of medicine;
• Doctor of osteopathy (including osteopathic practitioner) – must be licensed to practice medicine and surgery;
• Doctor of dental surgery or dental medicine;
• Chiropractor (see below);
• Doctor of podiatric medicine; and
• Doctor of optometry.

The term physician does not include practitioners such as a Christian Science practitioner or naturopath. There is no Medicare benefit for DMEPOS items ordered by these entities.

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Medicare coverage for all items and services furnished or ordered by chiropractors, with the exception of treatment by means of manual manipulation of the spine to correct a subluxation, is statutorily excluded. Therefore, all DMEPOS items ordered by chiropractors are denied.

Medicare coverage for all items and services furnished or ordered by podiatrists is limited by State statutes governing the scope of practice for podiatry. DMEPOS suppliers should be familiar with the limitations imposed by the statutes of the state(s) in which they operate and dispense DMEPOS items. Claims submitted to the DME MAC, when furnished or ordered by podiatrists practicing outside the limits of their licensures, will be denied as statutorily noncovered. Podiatrists are excluded by statute from ordering a power operated vehicle (POV) or power wheelchair.

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Physician assistants, nurse practitioners and clinical nurse specialists may also order DMEPOS (see below for more information).

Nurse Practitioners or Clinical Nurse Specialist Rules Concerning Orders

A nurse practitioner or clinical nurse specialist may provide the Standard Written Order in the following situations:

• They are treating the beneficiary for the condition for which the item is needed;
• They are practicing independently of a physician;
• They bill Medicare for other covered services using their own provider number; and
• They are permitted to do all of the above in the State in which the services are rendered.

Resource: CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.5

Physician Assistant Rules Concerning Orders

Physician assistants may provide the Standard Written Order if they satisfy all the following requirements:

• They meet the definition of physician assistant as found in Section 1861(aa)(5)(A) of the Act;
• They are treating the beneficiary for the condition for which the item is needed;
• They are practicing under the supervision of a Doctor of Medicine or Doctor of Osteopathy;
• They have their own NPI; and
• They are permitted to perform services in accordance with State law.

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Resource: CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.6

PECOS Ordering Physician Edits

CMS implemented ordering physician Provider Enrollment, Chain and Ownership (PECOS) edits for claims with dates of service on/after on January 6, 2014. The PECOS ordering physician edits will do the following:

• Verify that the ordering/referring provider is in PECOS and eligible to order and refer. If not, the claim will not be paid.
• If the name submitted on the claim does not match the provider’s name in PECOS, the claim will not be paid.

Additional information can be found on the CMS Provider Enrollment and Certification Ordering & Certifying webpage.

Noridian information regarding claim processing of the ordering and referring edits is available on the Noridian Medicare website.

Resources

• Social Security Act Sections 1834(a)(11)(B) and 1861(s)(2)(K)(iii)
• Standards for Electronic Prescribing – 42CFR 423.160
• Title 42 C.F.R. Section 410.38
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2 & 5.3
• CMS IOM, Publication 100-08, Medicare Benefit Policy Manual, Chapter 15, Section 30.5

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