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Medicare Order and Referring API

Source: vignettes/articles/mcr-ord-referring.Rmd
mcr-ord-referring.Rmd


Providers That are Legally Eligible to Order and Refer in the Medicare Program and Have Current Enrollment Records in Medicare.


The Order and Referring dataset provides information on all physicians and non-physician practitioners, by their National Provider Identifier (NPI), who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare. This dataset is based on information gathered from the Provider Enrollment, Chain and Ownership System (PECOS).

Ordering providers can order non-physician services for patients. Referring providers can request items or services which Medicare may reimburse on behalf of Medicare beneficiaries. To qualify as an ordering and certifying/referring provider, a provider must have an individual National Provider Identifier (NPI), be enrolled in Medicare in either an “approved” or an “opt-out” status, and be of an eligible specialty type. Providers currently enrolled as a Medicare Part B provider can already order and certifyand do not need to re-enroll in Medicare.

In the event a provider does not want to bill Medicare for their services, they can still order and refer/certify by opting out of Medicare or enrolling solely to order and certify. Medicare coverage will then apply when ordering or certifying:

  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
  • Clinical Laboratory Services
  • Imaging Services
  • Home Health Services


Example Searchs

By NPI:

order_refer(npi = 1083879860)
#> # A tibble: 1 × 7
#>   npi        first_name  last_name partb hha   dme   pmd  
#>   <chr>      <chr>       <chr>     <lgl> <lgl> <lgl> <lgl>
#> 1 1083879860 CHRISTOPHER AARON     TRUE  TRUE  TRUE  TRUE


By Name, as well as filtering for certain privileges:

order_refer(last_name = "Smith", 
            partb = FALSE,
            hha = TRUE,
            pmd = FALSE)
#> ✖ No results for last_name: Smith, partb: N, hha: Y, and pmd: N


order_refer(last_name = "Smith", 
            partb = FALSE,
            hha = FALSE,
            pmd = FALSE)
#> # A tibble: 151 × 7
#>    npi        first_name last_name partb hha   dme   pmd  
#>    <chr>      <chr>      <chr>     <lgl> <lgl> <lgl> <lgl>
#>  1 1063535672 AARON      SMITH     FALSE FALSE TRUE  FALSE
#>  2 1891210431 ALAINA     SMITH     FALSE FALSE TRUE  FALSE
#>  3 1962830570 ALESHA     SMITH     FALSE FALSE TRUE  FALSE
#>  4 1922655521 ALLISON    SMITH     FALSE FALSE TRUE  FALSE
#>  5 1942778188 ALYSSA     SMITH     FALSE FALSE TRUE  FALSE
#>  6 1467902791 AMANDA     SMITH     FALSE FALSE TRUE  FALSE
#>  7 1992203582 AMANDA     SMITH     FALSE FALSE TRUE  FALSE
#>  8 1023475761 AMY        SMITH     FALSE FALSE TRUE  FALSE
#>  9 1609219773 AMY        SMITH     FALSE FALSE TRUE  FALSE
#> 10 1063878056 ANNA       SMITH     FALSE FALSE TRUE  FALSE
#> # ℹ 141 more rows


Visualizations 

order_refer(last_name = "Smith", 
            first_name = "Aaron") |> 
  provider:::gt_prov(divider = c("last_name"), 
                     checkmark = c("partb", 
                                   "dme", 
                                   "hha", 
                                   "pmd"),
                     title = "Medicare Order & Referring Eligibility",
                     source = "Source: data.cms.gov")
Medicare Order & Referring Eligibility
Npi First Name Last Name Partb Hha Dme Pmd
1013342567 AARON SMITH
1023540655 AARON SMITH
1033614821 AARON SMITH
1053714196 AARON SMITH
1063535672 AARON SMITH
1104200609 AARON SMITH
1134834948 AARON SMITH
1245673557 AARON SMITH
1285157347 AARON SMITH
1346644812 AARON SMITH
1417159625 AARON SMITH
1497109037 AARON SMITH
1598242018 AARON SMITH
1649998667 AARON SMITH
1659582005 AARON SMITH
1659650166 AARON SMITH
1679758346 AARON SMITH
1689124802 AARON SMITH
1700383007 AARON SMITH
1710563317 AARON SMITH
1740785922 AARON SMITH
1760018618 AARON SMITH
1780028993 AARON SMITH
1780079459 AARON SMITH
1780099481 AARON SMITH
1851753537 AARON SMITH
1871614149 AARON SMITH
1942314885 AARON SMITH
Source: data.cms.gov


Data Dictionary

Variable Description

npi
NPI
National Provider Identifier (NPI) of the Order and Referring Provider

last_name
Last Name
Last Name of the Order and Referring Provider

first_name
First Name
First Name of the Order and Referring Provider

partb
Part B
Indicates if Provider can refer to Medicare Part B

dme
DME
Indicates if Provider can order Durable Medical Equipment (DME)

hha
HHA
Indicates if Provider can refer to a Home Health Agency (HHA)

pmd
PMD
Indicates if Provider can order Power Mobility Devices (PMDs)