Whether you’re just beginning your physical therapy career or are a seasoned veteran, having your NPI number should be a priority.
This 10-digit identifier is the number that must be used on claim forms submitted to payers by individual and organization health care providers who meet a broad definition of a “covered entity” under the Health Insurance Portability and Accountability Act, or HIPAA. An NPI also is required for all providers enrolled in Medicare. The NPI replaces any legacy or billing numbers for all health insurance plans, both public and private.
Who Can Get an NPI
All health care providers who are HIPAA-covered entities, whether individuals or organizations, must obtain an NPI. A “covered entity” is defined as a health care provider that transmits any health information in electronic form, such as submitting a claim. This includes:
- Health care providers that conduct certain transactions in electronic form.
- A health care clearinghouse.
- A health plan (including commercial plans, Medicare, and Medicaid).
If you electronically transmit health information in connection with a HIPAA standard transaction, you are considered a “covered entity” — even if you use a business associate to do so.
There are two categories of health care providers for NPI purposes: Type 1 (Individual) and Type 2 (Organization).
Type 1 entities include physical therapists, physicians, chiropractors, dentists, nurses, and pharmacists. Type 2 entities include ambulance companies, clinics, group practices, health maintenance organizations, home health agencies, hospitals, laboratories, nursing homes, pharmacies, residential treatment centers, and suppliers of durable medical equipment.
Group practices, in addition to the individual physical therapists working in the practices, are each required to obtain an NPI.
With solo incorporated practices, the corporation and the individual therapist each should have an NPI. You must apply for each NPI. Your state physical therapy license number should appear on the individual application, and the corporate application should include the number associated with the corporate entity, such as the tax identification number. It’s not necessary to include your state license number on the application for the corporate NPI.
According to CMS, all health care providers are eligible to apply for an NPI, even if your services may be billed by the facility and not individually. Also worth noting: Settings such as nursing facilities and hospitals may want you to obtain your NPI for administrative purposes.
It’s not mandatory for health care providers who are not “covered entities” under HIPAA to apply for an NPI, but we encourage all PTs and PTAs to have one.
Applying for NPI
You may apply for an NPI number through CMS’ web-based application process, a file interchange system, or regular mail.
We recommend CMS’ web-based application — it’s the most efficient. For details, see CMS’ wepage on how to apply for an NPI number. Under Related Links at the bottom of the webpage is a link to the National Plan and Provider Enumeration System. This online application takes fewer than 30 minutes once you have assembled the required documents such as your social security number and state license information. If you apply by mail, factor in turnaround time for processing and mailing.
NPI and Medicare Enrollment
You must have an NPI in order to enroll in Medicare. Without it, your enrollment application will be rejected.
Tip: When enrolling in Medicare, make sure the information you include on your Medicare enrollment application (such as the CMS-855 form) matches with the information you submitted with your NPI application. If there are any differences between the two applications, CMS may reject your claims. You can update your NPI profile online fairly quickly.