Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 44

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attaChMent 2: indePendent diagnoStiC teSting f aCilitieS
(Continued)
C. interpreting Physician information
Check here
if this section does not apply because the interpreting physician will bill separate from the IDTF.
All physicians whose interpretations will be billed by this IDTF with the technical component (TC) of the
test (i.e., global billing) must be listed in this section. If there are more than three physicians, copy and
complete this section as needed. All interpreting physicians must be currently enrolled in the Medicare
program.
If you are billing for interpretations as an individual reassigning benefits, the interpreting physician must
complete the Reassignment of Benefits Form (CMS 855R). Note: Both the IDTF and individual physician
must be enrolled with the fee-for-service contractor where the IDTF is located.
If you are billing for purchased interpretations, all requirements for purchased interpretations must be met.
When a mobile unit of the IDTF performs a technical component of a diagnostic test and the interpretive
physician is the same physician who ordered the test, the IDTF cannot bill for the interpretation. Therefore,
these interpreting physicians should not be reported since the interpretive physician must submit his/her
own claims for these tests.
1
interpreting Physician information
St
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy) (Required)
Medicare Identification Number (if issued)
NPI
2
interpreting Physician information
nd
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy) (Required)
Medicare Identification Number (if issued)
NPI
CMS-855B (07/11)
43

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