10/2/02

Section 1833(q) of the Social Security Act requires that all physicians who meet the §1861(r) definition of a physician must have a UPIN. All claims for services ordered or referred by a physician must include the name and UPIN of the ordering/referring physician.

A physician or supplier who bills Medicare for a service or item must show the name and UPIN of the ordering/referring physician on the claim form, if that service or item was the result of an order or referral from a physician. If the ordering physician is also the performing physician, the physician must enter his/her name and assigned UPIN as the ordering physician. If the ordering/referring physician is not assigned a UPIN, the biller may use a surrogate UPIN.

A physician or supplier who submits a claim for a service or item is responsible for ensuring that the name and UPIN of the ordering/referring physician is obtained and submitted on Form CMS-1500. Physician names and UPINs can be found in the UPIN directory. If the physician's UPIN has not yet been issued, a surrogate UPIN is to be used only until an individual UPIN has been assigned. Surrogate UPINs are used under these conditions:

• OTH000: To be used when the ordering/referring physician has not yet been assigned and does not qualify for one of the other surrogate UPINs. When OTH000 is used, ensure that it is not being over utilized. Notify the suppliers, physicians, or billers if their use of surrogates is excessive. If surrogate UPINs are over utilized, the Part B contractor via the UPIN Registry will confirm that a UPIN has not been assigned to the ordering/referring physician. If a UPIN has been assigned, the physician will be notified of the assigned UPIN. If a UPIN has not been assigned, the physician will be notified of the need to file an application for a UPIN and sent an application form.
• RES000: To be used by physicians meeting the description of "intern," "resident," or "fellow."
• VAD000: To be used by physicians serving on active duty in the United States military and those employed by the Department of Veterans Affairs.
• PHS000: To be used by physicians serving in the Public Health Service, including the Indian Health Service.
• RET000: To be used by retired physicians who have not been issued a UPIN. (Retired physicians who have been assigned a UPIN must use the assigned UPIN.)

It is CMS's goal to assign a UPIN to every physician/health care practitioner and group practice that meets the Medicare definition.

1009. UPINs for Ordering/Referring Physicians

Section 1833(q) of the Act requires that all physicians that meet the §1861(r) definition of a physician must have a UPIN and all claims for services ordered or referred by one of these physicians include the names and UPINs of the ordering/referring physician.

• Effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and UPIN of the ordering/referring physician on the claim form, if that service or item was the result of an order or referral from a physician.
• If the ordering physician is also the performing physician, the physician must enter his/her name and assigned UPIN as the ordering physician.
• If the ordering/referring physician is not assigned a UPIN, the biller may use a surrogate UPIN, e.g., OTH000, until an application for a UPIN is processed and a UPIN assigned. (See §1009.2.)

The following guidelines apply to those services that are edited by CWF (common working file):

• If the service is a diagnostic laboratory or radiology service, the assigned UPIN of the ordering/referring physician must be shown in item 17a on Form CMS-1500.
• If the service was referred by a physician assistant or other limited licensed practitioner, the name and UPIN of the physician supervising the limited licensed practitioner must be shown on Form CMS-1500 in items 17 and 17a.
• If the ordering/referring physician is not assigned a UPIN, the biller may use OTH000 until a UPIN is assigned, or a surrogate may be used.
• Residents.--Billers are to use the six (6) character surrogate UPIN RES000 for a physician meeting the description of "intern, resident", or "fellow" in MCM, Part 3, §2020.8A, if the individual does not have a UPIN. However, if a resident already obtained a UPIN, that number is to be used instead of the resident surrogate. If a physician leaves the hospital for private practice and did not receive a UPIN, the physician may continue to use the surrogate used in the hospital until a UPIN is assigned.
• Physician with Military, Department of Veterans Affairs and Public Health Service. --Physician/health care practitioners serving in the military or with the Department of Veterans Affairs or the Public Health Service are not exempt from the requirement to obtain a UPIN, particularly if they expect to provide services to Medicare beneficiaries or refer beneficiaries for other services. Until a UPIN is assigned, they are to use the following surrogate UPINs:VAD000 (Physicians serving on active duty in the military of the United States and those employed by the Department of Veterans Affairs), PHS000-(Physicians serving in the Public Health Service, including the Indian Health Service)
• Retired Physicians.--These physicians are not issued UPINs and are to use the surrogate RET000. Retired physicians who are assigned a UPIN must use the assigned UPIN.