Yes, A physician who is supervising could be the lab’s referring physician for billing when they are involved in the care of the patient and the tests are required by medical necessity. For instance, in the case where a person suffering from diabetes sees a nurse frequently and the nurse is able to order blood tests to track the patient’s glucose levels, the supervising physician could be named as the referring physician to bill the patient.
Enrollment Required for Billing:
If a physician isn’t registered with Medicare or PECOS, the supervising physician can’t be considered the primary provider to receive reimbursement. Medicare will require that the referring provider already be enrolled in Medicare. Reference: Medicare Claims Processing Manual, Chapter 16, Section 60.4.1.
Private Insurance:
Private insurance companies could have their own eligibility requirements along with guidelines on referring businesses. It is recommended to check with the insurance plan you have chosen to learn their policies on the usage of unenrolled referrer providers for billing labs.
Medicare Claims Processing Manual
CMS Chapter 26 – Completing and Processing (Form CMS-1500 Data Set)
CMS-1500 Form Item 17:
If a doctor ordered or recommended the item or service, provide the name of the ordering or referring physician. All doctors who refer Medicare beneficiaries or place service orders are required to report this information. Similarly, enter information about a supervising physician in item 17 if the Medicare regulation requires you to report one. Use a different CMS-1500 claim form for each ordering, referring, or supervising physician when a claim involves many of these medical professionals.
Please choose one of the following qualifiers to specify the role that this physician or non-physician practitioner is performing:
| Qualifier | Provider Role |
| DN | Referring Provider |
| DK | Ordering Provider |
| DQ | Supervising Provider |
Frequently Asked Questions (FAQ):
Is the ordering provider the same as the referring provider?
The term “ordering provider” refers to a healthcare professional who orders specific services, tests, or treatments for patients. A referring provider, however, is a healthcare professional who is well-qualified and sends the patient to a different specialist or doctor for further treatment or evaluation. Although, in many instances, the person who is ordering the treatment and the person who refers the patient to them may be the same person, particularly in healthcare settings that integrate, they do not need to be. The roles vary primarily depending on the context and necessity of the patient’s treatment.
Can the rendering and referring provider be the same?
Yes, the render service provider (the one who actually provides or supervises the procedure or service) and the one who refers patients to (the one who refers the patient to a specialist or provider) could have the same name. This is often the case when a physician recommends a patient for an area of expertise within their practice or when the provider is a member of many areas of expertise.
How does lab billing work?
Lab billing involves several key steps:
- Ordering: A health professional requires the patient to undergo lab tests.
- Performing: The laboratory conducts the tests requested.
- Coding: Every test has a specific code that explains the test to ensure billing accuracy.
- Billing: The lab will send an invoice either directly to the patient or to the patient’s insurance company, depending on the test results. The bill will include all testing costs, as well as any administrative or handling fees.
- Reimbursement: The insurance company processes the claim and pays for labs that are compatible with the patient’s coverage and policy.
Can a physician bill an incident to another physician?
Yes, in certain situations physicians may bill for services “incident to” another physician’s services. To bill purposes “incident to” services are the ones offered by a non-physician doctor with the guidance of a physician. They are an element of the normal treatment regimen where the physician has completed an initial treatment and continues to be a part of continuing treatment plans. These services should be performed in a non-hospital environment and must meet the specific guidelines established by the payer (often Medicare or Medicaid). The physician who supervises the service must be present at the office and readily accessible to offer assistance and guidance all the time the service is offered.
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