Medical billing physician definition and terms

Physician/Supplier Specialties 

Medicare Part B enrolls physicians/suppliers based on their credentials or specialties. Medicare rec- ognizes many specialties. Physicians may have a primary and a sub-specialty. Since a physician ’ s specialty may be used to determine peer utilization comparisons, physicians should notify the carrier of their practice ’ s predominant specialty for annotation in Medicare records. No payment differential is applied to a service based on specialty.

Physician and specialist

A health care provider who is responsible for examining and diagnosing patients and treating diseases. Doctors may be put in two classifications: a general physician or expert. A general practitioner is a doctor who conducts routine examinations and normal disease check up. A doctor who focuses on a specific group of diseases is called specialist.

For instance, if he has a persistent cough, a patient visits his primary care doctor. The patient will be examined by the primary care physician and the chest X ray may be taken. When unexpected results appear in X-rays, the patient shall be referred to a doctor who specializes in respiratory disabilities, where a further examination is performed and tests are conducted to reduce diagnosis and therapy.

Physician Identification 

Physicians receive several different identifying numbers: Provider Identification Number (PIN) – used as a provider billing number to receive reimburse- ment Unique Physician/Practitioner Identification Number (UPIN) – used only when a service requires a referring or ordering physician; never used as a provider billing number

Provider Identification Number 

The PIN is the individual provider number issued by the local Medicare carrier. It identifies who provided the beneficiary ’ s service and allows the physician/supplier or patient to receive reimburse- ment for claims filed to the Medicare carrier. The PIN format is unique and varies from carrier to carrier. All Medicare claims filed to the carrier require a PIN; if a provider fails to show a PIN in the appropriate paper claim block or electronic claim field, an “ unprocessable ” claim denial will result.

Unique Physician/Practitioner Identification Number (UPIN) 

The UPIN is assigned by CMS. It is a six-character alphanumeric code identifying the Medicare pro- vider. This number is assigned to physician, nonphysician practitioners, groups/clinics, and suppliers (excluding those billing to the DMERC) to identify the referring or ordering physician on the Medi- care claim. Each individual practitioner (physicians and nonphysician practitioners only) receives one UPIN, re- gardless of the number of practice settings.

The individual practitioner keeps the UPIN throughout his or her Medicare affiliation, regardless of the state he or she practices in. CMS uses the UPIN to identify the ordering and referring physician, to aggregate payment and utilization information for individual practitioners, to ensure compliance with contractor recommendations for sanctions, and to validate duplicate services.

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