No Clarity in NPI Adoption

June 24, 2011
Any institutional providers or group practices confused about the best way to apply for national provider identifiers (NPI) are probably in the

Any institutional providers or group practices confused about the best way to apply for national provider identifiers (NPI) are probably in the majority.

Under HIPAA, providers must have and use NPIs in most electronic claims and other HIPAA-related transactions by May 23, 2007.

But representatives of a host of providers went to Washington recently to tell the Department of Health and Human Services (HHS) that the process is behind schedule, and, in some aspects, almost blocked by unanswered questions.

A prominent question is whether and how providers, including hospitals, should assign numbers to the subparts of their organization. For example, if a hospital has two campuses across town from each other, should it bill with one number or two?

Hurry up and wait

James Whicker, chair-elect of the Workgroup on Electronic Data Interchange (WEDI), said, "The industry is at a stand-still on this issue, with providers waiting for commercial payers and Medicaid programs to state their subpart enumeration expectations, and all expecting further clarifications on the 'Medicare Subpart Enumeration Expectations,' policy document recently released by CMS (Centers for Medicare and Medicaid Services)."

There is a "Medlearn" educational article on NPIs and applying for them on the HHS site: WEDI has resources on NPIs at

Whicker and others note that although HIPAA rules say payers cannot tell providers how to enumerate themselves, most providers are worried they will not be paid, or paid accurately, if they don't submit claims the way payers want them.

As of this spring, only about 400,000, or about 15 percent of the total expected number of providers, according to WEDI, had gotten the numbers.

Extensive testimony on the issues came at a meeting of the standards and security subcommittee of the National Committee on Vital and Health Statistics (NCVHS), the major advisory body to HHS on HIPAA.

Another question

A closely related question is how much access will be allowed to the database of provider numbers. As of late spring, CMS had not published the rules on that issue, although it said they should be out shortly. George Arges, chair of the National Uniform Billing Committee and senior director of health data management at the American Hospital Association, says, "Providers, payers and vendors are really struggling to determine whether the NPI information that will be made available will be information that would be helpful to the way business is conducted with one another." That in turn, he said, is causing confusion on how to build a strategy to load, validate and use NPIs.

The American Health Care Association, representing long-term care organizations, told the subcommittee, "In most instances when submitting a claim, institutional providers must identify the 'human provider' (e.g., doctors) who rendered the services," and they cannot do that without the NPIs of the individual providers. Without that kind of access to the NPI database, said the group, the "industry will be forced to 'scramble' (e.g., phone calls, faxes, e-mails, letters, etc.) to be able to submit claims at all."

Whicker said the delay on the database rules has already put the industry at high risk of not being in compliance by May 2007.

He also complained that CMS, as of early April, had not started the bulk enumeration system (Electronic File Interchange) through which larger organizations can apply for NPIs for their providers. He said a number of institutions were waiting to apply until that is done.

Author Information:Kathryn Foxhall Kathryn Foxhall is a contributing writer based in Hyattsville, Md.

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