Update on PECOS Implementation
Update: In an email to provider community dated January 2011, CMS stated "Due to recent inquiries, the Centers for Medicare & Medicaid Services (CMS) is clarifying its policy regarding expanded ordering/referring provider claim edits. CMS has not yet decided when it will begin to reject claims if an ordering/referring provider does not have a record in the Provider Enrollment, Chain, and Ownership System (PECOS). CMS will give providers ample notice before claim rejections begin. Recent revisions to Change Requests (CRs) #6417 and #6421 require Medicare Administrative Contractors to delay rejecting claims until receiving further direction from CMS."
CR 6417
CR 6421
Referring and ordering physicians were supposed to be registered in the Provider Enrollment, Chain and Ownership System (PECOS) by July 6, 2010 (see CMS’ interim final rule). There is no penalty for physicians who are not registered. CMS has not yet determined a date when DMEPOS claims where the referring/ordering provider is not registered in PECOS will be automatically denied. CMS is working on edits to implement the new deadline and will notify providers when the edits will begin. CMS reserves the right to go back and reprocess claims.
At this time CMS has not turned on the automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS. CMS is working diligently to resolve backlog and other systems issues and will provide ample advance notice to the provider and beneficiary communities before CMS begins any such automatic denials. While there are some rumors that the edits will be turned on in January, CMS reiterated that CMS has not announced any date (January 3, 2011 or otherwise) as to when ordering/referring edits will be turned on.
What This Means for OTs
If you are an occupational therapist who bills L Codes for orthotics, you should check that the referring provider is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS). If the referring provider is not registered with PECOS, encourage them to register. Medicare Administrative Contractors (MACs) may begin to reject claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items and services provided by
DMEPOS suppliers as early as July 6, 2010. ‘Referring providers’ may include physicians or eligible non-physician practitioners (physician assistants, certified clinical nurse specialists, nurse practitioners, clinical psychologists, certified nurse midwives, and clinical social workers).
To verify that a provider has an enrollment record in PECOS, check the Ordering Referring Report on the CMS website, available at Ordering Referring Report. If a provider is listed on that report, they have a current enrollment record in PECOS.
DMEPOS suppliers were required to include the legal name and NPI of the ordering/referring provider on each claim starting July 6, 2010.
Note: To ensure accurate claims processing, it is critically important for DMEPOS suppliers to submit each claim using the Provider Transaction Access Number (PTAN) of the location that furnished the item or service being billed. This has been a long standing CMS policy. If you submit a claim using a PTAN for a location that is not the location that furnished the item or service, your claim may be denied. This is particularly important in competitive bidding areas, where only contract suppliers, grandfathered suppliers, and suppliers furnishing competitively bid items under a program exception are eligible to furnish and be paid for competitively bid items. OTs in private practice are exempt from competitive bidding and accreditation requirements.
Additional Resources
For information on Medicare enrollment and Internet-based PECOS, visit the CMS Provider/Supplier Enrollment web page at: http://www.cms.gov/MedicareProviderSupEnroll.
MLN Matters MM6417
MLN Matters MM6421
MLN Matters SE1011
CMS News Release 6/30/10: CMS to Review PECOS Enrollment Process
Transmittal 710 (CR 6566)
MLN Matters MM6566
Transmittal 328 (CR 6696)
Background Information
