Posts Tagged ‘PECOS’

Important Reminder: PECOS Edit begins Monday, January 6th

January 3, 2014

January 6, 2014 is the date for activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) edits that will result in denial of home health claims if the ordering physician is not enrolled in PECOS or officially opted-out of Medicare. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians.

Beneficiary Notification

The Centers for Medicare & Medicaid Services (CMS) clarified in their most  recent communication (MLN Matters Article SE 1305)  that claims  denied because they failed the ordering/referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. CMS also informed HCAF and the National Association for Home Care & Hospice (NAHC) that since the beneficiary can not be held liable for services ordered by a provider who is not registered in PECOS,  no notice is to be given because the beneficiary can not be charged.

CMS’ position would prohibit the beneficiary from choosing to privately pay for services even if informed of Medicare non-payment in advance of the initiation of care. HCAF advises that home health agencies should not initiate services for beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after January 6.

PECOS Verification Tips

Below are several important tips about PECOS operational consideration:

  1. Physicians approved to order home health services are limited to doctors of medicine, osteopathy, and podiatry.
  2. The NPI must be that of the individual physician, not a group or organization.
  3. Home health agencies must report the name of the physician who ordered services on the RAPs and claims – i.e. the physician who signs the plan of care.
  4. The edit will compare the physicians NPI and the first four letters of the last name as they appear in PECOS.
  5.  Information such as middle initial, nicknames, credentials, or titles may be included on electronic claims as long as they do not appear in first or last name fields on the claims, and must never appear on paper claims.
  6. If the PECOS information differs from that in NPES or licensure files, agencies should verify and document that identity was confirmed but only use PECOS information on claims.
  7. Enrollment status should be verified upon referral – at the start of care – and on the date of all subsequent episodes.
  8. Retain documentation of verified PECOS enrollment. If you have a claim denied due to the Ordering/Referring provider edits, you must file an appeal. An adjustment cannot be submitted
  9. Check a physician’s enrollment status either:
  • Individually in the CMS Medicare Ordering Referring File download available here:

OR

  • For multiple physician names, by importing the agency’s ordering physician list into the NAHC PECOS toolkit, which contains the latest CMS PECOS enrolled, and pending datasets. Note: a new file must be downloaded twice a week when CMS updates the Ordering Referring File.

NAHC has developed the NAHC PECOS Toolkit, which contains the latest PECOS dataset along with the latest PECOS Pending dataset available to NAHC as supplied by CMS. The toolkit allows NAHC members to check a physician’s existence in the PECOS database.

Please Note: A new file must be downloaded every time CMS updates the dataset.

You may also individually check if a physician is in PECOS by using this free search tool at oandp.com.

Impact of Edits on Payment

In response to home health agencies’ questions about the dates of service and application of PECOS edits to claims, NAHC has learned from CMS that:

  • Edits are based on the “from” date on the claims
  • If the “from” date of a claim is prior to January 6, then it will not hit the denial edits and the episode will be paid in full.
  • Claims will always be paid in full if the ordering physician is enrolled in PECOS as if the “from” date of claims – i.e. the start of episode – even if the physician dis-enrolls prior to the end of the episode.
  • RAPs are not subject to the edits and will continue to process as they do now.

The effective date of enrollment in PECOS for physicians is determined by CMS by the later of the two following criteria:

  • The date the physician filed an enrollment application that was subsequently approved. For PECOS applications, this is the date that the contractor received an electronic version of the enrollment application and a signed certification statement submitted via paper or electronically.

OR

  • The date the physician first began furnishing services at a new practice location.

Please click here to view MLN Matters Article SE 1305 which provides more details on the PECOS edits.

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Palmetto GBA Releases Updated Provider Q&As

July 2, 2013

MedicarePalmetto GBA this week released questions from a convening of the Home Health Coalition that took place in Charlotte, NC on June 10. The coalition is made up of state association executives including HCAF’s Bobby Lolley. HCAF requested questions from Medicare providers last month to submit to Palmetto representatives.

Questions and answers cover topics such as the face-to-face encounter requirement, an update on RAP suppression activity, PECOS, Negative Pressure Wound Therapy G-Codes, ADRs, billing, Q-code requirements, medical review and more. (more…)

CMS Announces Temporary Delay in PECOS Implementation

April 25, 2013

CMS issued the following message this morning announcing delay of PECOS edits that would result in denial of home health claims when the ordering/referring physician is not enrolled in PECOS.

Temporary Delay in Implementing Ordering and Referring Denial Edits

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny. (more…)

PECOS Tips as Edits Draw Near

April 19, 2013

May 1, 2013 is the date for activation of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) edits that will result in denial of home health claims if the ordering physician is not enrolled in PECOS or officially opted-out of Medicare. In order to protect against non-payment by Medicare, home health agencies must verify enrollment of all ordering physicians.

Beneficiary Notification

The Centers for Medicare & Medicaid Services (CMS) has not issued final guidance about beneficiary notices and liability. However, home health agencies should begin to notify both physicians who are not enrolled in PECOS and their patients who will be affected by nonpayment by Medicare as a result of the activation of edits. For beneficiaries who are unable to identify a PECOS-enrolled physician to assume ordering responsibilities for episodes of care beginning on and after May 1, discharge planning should begin immediately in accord with State regulations and agency policy. (more…)

Palmetto GBA: Analysis of Phase 1 HHA Ordering/Referring Edits

April 11, 2013

Phase one of the ordering/referring edits began on October 5, 2009, with informational messaging (remark code N272) on the remittance advice (RA) to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. (more…)

NAHC Participates in Call with CMS on Phase II of PECOS Edits

April 5, 2013

The National Association for Home Care & Hospice participated in a conference call with the Centers for Medicare & Medicaid Services on April 3, 2013 to discuss Phase II of the PECOS edit activation. During the call, NAHC reported on the information collected from home health agencies about ongoing physician enrollment problems, the findings of one CMS contractor that as many as 4 percent of claims could be subject to denial, and the large number of Veteran’s Administration and military hospitals that have failed to enroll physicians who order and refer for Medicare home health services. (more…)

Medicare Providers: Participate in Nationwide PECOS Survey

April 1, 2013

In the industry’s efforts to collect and share with the Centers for Medicare & Medicaid Services information about ongoing problems with PECOS enrollment, every home health agency is encouraged to visit the National Association for Home Care & Hospice website at www.nahc.org and complete the survey at the bottom right hand corner of the home page.

The survey asks how many of the physicians that ordered home health services for patients during March were not enrolled in PECOS. Click here to take the survey, and stay tuned to HCAFeHighlights for survey results when they’re available.

CMS Announces PECOS Activation for May 1, 2013

February 27, 2013

The following information was excerpted from a Centers for Medicare & Medicaid Services MedLearn Matters article that was posted early yesterday, but later pulled back. The National Association for Home Care & Hospice has since learned that the article was posted sooner than intended. It will be reposted by CMS on Friday, March 1, 2013. Home health agencies must ensure that all ordering/referring (for home health certifying) physicians are enrolled in PECOS since failure to do so will result in denial of any claim submitted on or after May 1, 2013 that does not pass the edit.

Note: This Special Edition MLN Matters® Article is a consolidation and update of prior articles SE1011, SE1201, SE1208, and SE1221. 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. (more…)

WEDNESDAY: CMS Home Health Open Door Forum

August 20, 2012

This month’s CMS Home Health, Hospice, & DME Open Door Forum is scheduled for Wednesday, August 22, 2012 at 2:00pm ET. Please call at least 15 minutes prior to the forum start time.

The agenda is as follows: (more…)

Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A HHA Claims

June 25, 2012

MLN Matters® Special Edition Article #SE1011, “Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A HHA Claims (Change Requests 6417, 6421, 6696, and 6856),” was revised and is now available in downloadable format.

This article is designed to provide education on phases 1 and 2 of the edits CMS will perform on certain claims submitted by providers who order/refer services to Medicare beneficiaries. It includes a list of questions and answers related to the edits and how they will impact providers. (more…)