Identifying the Certifying Physician(s) on a Claim Form

July 15, 2019
Rick Gawenda

I am often asked by providers of outpatient therapy services how to identify who the certifying physician/non-physician practitioner (NPP) or physicians/NPPs are on the claim form. The answer depends on whether you are a private practice submitting claims on the paper 1500 claim form or the electronic equivalent (i.e. 837P) or you are an institutional provider (i.e. skilled nursing facility, rehabilitation agency, CORF, or hospital outpatient department) submitting claims on the UB-04 electronic claim form (837I). In this article, I will provide the answers to the above including how to identify multiple physicians/NPPs on the claim form when one physician/NPP is certifying for one diagnosis/condition and a second physician/NPP is certifying for a separate diagnosis/condition.

If you are a private practice submitting claims via the paper version 1500 claim form, the physician or NPP who is certifying the outpatient therapy plan of care is referred to as the

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  1. when submitting a UB -04 form for a hospital based outpatient therapy practice under direct access, who is placed in the attending provider section?

    1. The physician who signed the plan of care since the Medicare program does not recognize direct access.

  2. from my understanding you can see a Medicare patient without a referral, but the PCP must certify the POC prior to treatment. Is that correct?

    1. The Medicare program does not require a physician order for payment of outpatient therapy services. What is required is a signed and dated plan of care by the evaluating therapist and the physician or nonphysician practitioner who is responsible for the oversight of the therapy services.

  3. in the instance of an insurance provider, other then medicare/Medicaid, recognizing direct access, who would be placed on the claim form under the attending provider? As a hospital based system, we are struggling between the utilization of UB-04 or 1500 when billing under direct access due to not having a referring provider.

    Jus tto clarify, if we saw a medicare patient without an order for the eval and then got the provider to certify the plan of care, we would place that provider on the UB-04?

    1. 1. For your first question, you would need to check with the insurance carrier.
      2. For Medicare, whoever signs the plan of care is the referring physician.