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Healthcare by the Numbers: ID Codes Providers and Practices Need

Healthcare by the Numbers: ID Codes Providers and Practices Need

When the Health Insurance Portability and Accountability Act (HIPAA) first mandated that all healthcare providers have a single unique provider number to be used in all administrative and financial transactions by providers and health plans, it seemed like the end of a panoply of lots of other ID numbers currently in use. 

While the creation of the NPI did simplify some administrative headaches, it didn’t entirely rid the healthcare industry of the many ID numbers still in use. Sound confusing? It can be. But this simple Healthcare by the Numbers Guide should help you sort it all out.

NPI

Let’s start with the number that was supposed to, and in some cases has, made healthcare easier. 

The National Provider Identifier (NPI) is a HIPAA Administrative Simplification Standard. It’s a unique, intelligence-free identification number for covered health care providers and is required for all health plans and health care clearinghouses for administrative and financial transactions adopted under HIPAA.

Individuals are assigned individual NPI numbers that follow them throughout their careers, and practices are assigned separate group NPI numbers that remain with the practice as long as it exists.

PTAN/CCN/OSCAR

The PTAN (Provider Transaction Access Number) is assigned to providers by Medicare Administrative Contractors (MACs). It’s not required for claims (only the NPI is needed for those transitions), but the PTAN is used to authenticate the provider when using the local MAC self-help tools like the IVR, internet portal, on-line application status, etc. 

Medicare maintains a record of both the NPI and PTAN in their Provider Enrollment Chain & Ownership System (PECOS), and uses the NPI/PTAN combination to identify providers in their programs and revalidate enrollment information. While an individual provider will only ever have one individual NPI, he may be assigned a different PTAN for every practice, group, or MAC he is affiliated with. 

According to Noridian, the Medicare Part A MAC for Jurisdiction F, the CCN (CMS Certification Number) and the OSCAR (Online Survey Certification and Reporting) are now synonymous with PTAN.

Taxonomy Codes

A taxonomy code is a unique 10-character code that designates a provider’s classification and specialization. Providers are required to designate a taxonomy code when applying for a NPI. 

That National Uniform Claim Committee (NUCC) maintains a code set list of all taxonomy codes.

TIN/EIN

A TIN is a tax ID number used by the Internal Revenue Service (IRS) in the administration of tax laws. There are several types of TINs, including the following:

  • Social Security Number (SSN)
  • Employer Identification Number (EIN)
  • Individual Taxpayer Identification Number (ITIN)
  • Taxpayer Identification Number for Pending U.S. Adoptions (ATIN)
  • Preparer Taxpayer Identification Number (PTIN)

While healthcare providers personally will have an SSN, which is used to report individual income, healthcare practices will have an EIN, which is a federal tax identification number used to identify a business entity. According to Medicare, sole proprietor physician practices may also choose to apply for an EIN to “protect the sole proprietor’s SSN from being disclosed on W-2s and in transactions, such as claims sent to health plans.”

DEA Number

A DEA number is a 9-digit identifier assigned to a health care provider by the United States Drug Enforcement Administration allowing them to write prescriptions for controlled substances.

A valid DEA number consists of:

  • 2 letters, 6 numbers, and 1 check digit
  • The first letter is a code identifying the type of registrant (see below)
  • The second letter is the first letter of the registrant’s last name, or “9” for registrants using a business address instead of name.
  • Of the seven digits that follow, the seventh digit is a “checksum” that is calculated similarly to the Luhn algorithm.

According to Meditec, the following providers are eligible to register for a DEA number and the related code is used in the first digit of their number:

  • B = Hospital/Clinic
  • C = Practitioner (i.e., a physician, dentist, veterinarian)
  • D = Teaching Institution
  • E = Manufacturer
  • F = Distributor
  • G = Researcher
  • H = Analytical Lab
  • J = Importer
  • K = Exporter
  • L = Reverse Distributor (an entity that collects expired or unwanted drugs for disposal)
  • M = Mid-Level Practitioner (i.e., nurse practitioners, physician’s assistants)
  • P, R, S, T, U = Narcotic Treatment Program
  • X = Suboxone/Subutex Prescribing Program

CLIA Certification Number

CLIA is the Clinical Laboratory Improvement Amendments passed in 1988 establishing authority to create standards for certain laboratory testing to ensure the accuracy, reliability and timeliness of test results regardless of where or by whom the test was performed. 

All facilities that perform even one applicable test on “materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings,” including physician practices, is considered a laboratory under CLIA and generally must apply for and obtain a certificate from the CLIA program that corresponds to the complexity of tests performed. 

Once certified, each laboratory is assigned an individual and unique CLIA number that consists of ten alphanumeric positions and must be included on all claims for laboratory services.

According to the Centers for Medicare and Medicaid Services (CMS), there are five types of certificates, and each is generally effective for two years. They include the following:

  • Certificate of Waiver (COW): Issued to a laboratory that performs only waived tests.
  • Certificate for Provider-performed Microscopy (PPM) procedures: Issued to a laboratory in which a physician, midlevel practitioner or dentist performs specific microscopy procedures during the course of a patient’s visit. A limited list of provider-performed microscopy procedures is included under this certificate type, which are categorized as moderate complexity testing.
  • Certificate of Registration: Issued to a laboratory to allow the laboratory to conduct nonwaived (moderate and/or high complexity) testing until the laboratory is surveyed (inspected) to determine its compliance with the CLIA regulations. Only laboratories applying for a certificate of compliance or a certificate of accreditation will receive a certificate of registration.
  • Certificate of Compliance (COC): Issued to a laboratory once the State Agency or CMS surveyors conduct a survey (inspection) and determine that the laboratory is compliant with the applicable CLIA requirements. This type of certificate is issued to a laboratory that performs nonwaived (moderate and/or high complexity) testing.
  • Certificate of Accreditation (COA): Issued to a laboratory on the basis of the laboratory’s accreditation by an accreditation organization approved by CMS. This type of certificate is issued to a laboratory that performs nonwaived (moderate and/or high complexity) testing.

A March 2019 CLIA publication lists seven CMS-approved accreditation organizations:

  • AABB
  • American Association for Laboratory Accreditation (A2LA)
  • Accreditation Association for Hospitals and Health Systems/ Healthcare Facilities Accreditation Program (AAHHS/HFAP)
  • American Society for Histocompatibility and Immunogenetics (ASHI)
  • COLA
  • College of American Pathologists (CAP)
  • The Joint Commission

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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