Revenue Cycle Management Blog | GroupOne Health Source

Medicare PECOS Edits Begin May 1, 2013 - Claim Denials Possible

Written by Kaitlyn Houseman | April 6, 2013
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 and make sure that your billing staff is aware of these updates.

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.