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Last Modified: 9/12/2024 Location: FL, PR, USVI Business: Part A

New Fiscal Intermediary Shared System (FISS) consistency edit to validate attending physician NPI

Effective with claims received on or after April 1, a new consistency edit was implemented in FISS that validates the attending provider’s NPI. Organizational NPIs cannot be used in place of individual NPIs, unless exception conditions 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 April 1, First Coast 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 the NPI/physician name does not match PECOS. Information has been added to MM12889 explain how the attending physician information on a claim is verified.
If you don’t have PECOS access, you can use the order and referring data set at data.cms.gov external link 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.
Note: For the purposes of processing institutional claims for outpatient therapy services, the attending provider field must contain the NPI of the certifying physician or NPP for a therapy plan of care. For additional information review the article Resolve claim return reason code 34963 for outpatient therapy services.
Please review these resources for more guidance:
MLN Matters Article MM12889 external pdf file
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.