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Resolve claim return reason code 34963 for outpatient therapy services
Last Modified: 6/7/2024
Location: FL, PR, USVI
Business: Part A
Outpatient therapy services billed on institutional claims have been receiving reason code 34963 indicating the attending provider on claim page 03 is invalid or the attending provider NPI is present, but the first four digits of the last name do not match PECOS. This article provides you with guidance to resolve your claim returns.
CMS implemented a new consistency system edit in April 2023 that validates the attending provider NPI on institutional claims. This new edit was communicated in
MLN Matter Article (MM) 12889 
and First Coast’s
FAQ article. As a reminder, an attending provider is the individual who has overall responsibility for the patient's medical care and treatment reported on institutional claims. Institutional providers can’t use an organizational NPI in place of individual NPI, unless conditions for exception are met.
Institutional providers must indicate the attending provider name and NPI for the patient’s medical care and treatment on institutional claims for any services other than nonscheduled transportation claims. Also, on outpatient claims, institutional providers must send the referring provider NPI and name when the referring provider for the services is different from the attending provider.
Refer to MM12889 for a list of physician and non-physician practitioner (NPP) specialties eligible as an attending physician and who must be enrolled in PECOS in an approved status.
“For the purposes of processing institutional claims, the certifying physician or non-physician practitioner (NPP) and their NPI are reported in the attending provider fields on institutional claim formats. Since the physician or NPP is certifying the therapy plan of care for the services on the claim, this is consistent with the National Uniform Billing Committee definition of the attending provider as “the individual who has overall responsibility for the patient’s medical care and treatment” that is reported on the claim. In cases where a patient is receiving care under more than one therapy plan of care (OT, PT, or SLP) with different certifying physicians/NPPs, the second certifying physicians/NPP and their NPI are reported in the Referring Physician fields on institutional claim formats.”
“Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions apply.
• Services are or were required because the individual needed therapy services;
• A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP;
• Services are or were furnished while the individual is or was under the care of a physician;
• In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met (42 CFR 424.24(c)). Certification is required for coverage and payment of a therapy claim.
Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the NPI of the certifying physician identified for a PT, OT, and SLP plan of care.”
To resolve reason code 34963, follow the steps below:
1. Confirm the attending provider’s name is the physician or NPP who certified the plan of care for the services on the claim and then validate the provider’s name and NPI in PECOS.
2. If you don’t have PECOS access, you can use the order and referring data set at
data.cms.gov 
to verify the physician’s name and spelling as seen in PECOS. It is recommended to search by the provider’s NPI to correctly display the information.
• Use PECOS or data.cms.gov only for validation to obtain the correct information for editing.
3. Correct the reported physician information and resubmit your institutional claim.
Note: If you want to include the physician or NPP who rendered the service (therapist), report their name and NPI in the rendering provider field. This is optional.
Example of FISS MAP1713 page 3
ATT PHYS = physician or NPP who certified the plan of care
REN PHYS = physician or NPP (therapist) who rendered the service (optional)
Review our articles for more guidance.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
