Medicare PECOS Edits Begin May 1, 2013 – Claim Denials Possible
Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.
The Affordable Care Act, Section 6405, “Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals,” requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries. Some physicians or other eligible professionals do not and will not send claims to a Medicare contractor for the services they furnish and therefore may not be enrolled in the Medicare program. Also, effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and referring providers when they are required to be identified in Part B, DME, and Part A HHA claims from Medicare providers or suppliers who furnished items or services as a result of orders or referrals.
This means that starting May 1, Medicare will deny claims for Medicare-covered services ordered/referred by a physician for durable medical equipment, prosthesis, orthotics and services (DMEPOS), clinical lab, radiology services and certification of home health if the physician does not have a Medicare profile in the Medicare enrollment system, PECOS. The Centers for Medicare & Medicaid Services (CMS) says physicians who order such services and are not enrolled should do so immediately, or the applications may not be processed before May 1.
So if you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). Review the background and additional information below and make sure that your billing staff is aware of these updates.
The Ordering and Referring Files
The downloads below contain the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners 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 (i.e., they have enrollment records in PECOS).
A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file.
There are two file formats for the Medicare Ordering and Referring File below. The first is a PDF format. This file will allow a user to verify that an individual physician or eligible professional has an approved enrollment record in PECOS using Adobe Acrobat Reader. The second file is a ZIP file. The ZIP file contains the same information as the PDF, however, the file is a CSV format. The CSV file will allow users to open the Ordering and Referring data in Excel, Notepad and other software formats that could be easier for users to search/sort.
In order to use the CSV file, please left-click on the “Medicare Ordering and Referring File [ZIP, 64400KB]” and save the CSV document contained in the zipped download. Right-click on the saved CSV file, select “Open With” on the task bar and select the program through which you would like open the Medicare Ordering and Referring File.
Users must have the most recent version of Adobe Acrobat Reader and/or Excel in order to open the PDF and/or CSV file.
The new Initial Physician and Non-Physician Applications Pending Contractor Review files are lists of applications pending contractor review. These pending applications have NOT been processed by the CMS contractors. These lists have been compiled to allow individuals the ability to verify that an application has been submitted and is awaiting processing.
The downloads below are the most recent versions of the O&R file. For a specific create date, please review each document individually.
Educational Material MLN Matters® article #SE1305 Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A Home Health Agency (HHA) Claims.
Medicare Enrollment Guidelines for Ordering/Referring Providers
The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement
Medicare Ordering and Referring File – PDF [ZIP, 32MB]
Medicare Ordering and Referring File – CSV [ZIP, 9MB]
Initial Physician Applications Pending Contractor Review [ZIP, 228KB]
Initial Non Physician Applications Pending Contractor Review [ZIP, 92KB]
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Source: www.envoynews.com; April 3, 2013.