Home Health & Hospice Week

Use the next three months wisely to make sure your Medicare payments will remain intact come January.

The problem: Starting Oct. 4, informational edits checking for ordering/referring physicians' PECOS enrollment status will begin. Starting Jan. 3, edits will begin rejecting claims that don't have information for PECOS-enrolled ordering physicians.

"It's critical that agencies monitor this matter now, while there is no penalty to cash flow," stresses consultant M. Aaron Little with BKD in Springfield, Mo. Taking action on the issue now will "hopefully minimize [payment] delays in the new year," Little says.

The solution: Smart home health agencies will take these key steps to head off PECOS editrelated cash flow problems in January:

1. Check all your physicians. Don't wait on edit results to head off claims errors. If you haven't already done so, check all your ordering physicians' PECOS enrollment status, recommends Lynn Olson with billing company Astrid Medical Services in Corpus Christi, Texas. You can do this in the Centers for Medicare & Medicaid Services' ordering and referring physician report, which it says it updates twice a week (for steps on how to check, see box, this page). CMS also posts a file of initial physician PECOS applications that are pending review.

2. Monitor N272 claims. After Oct. 4, the Medicare payment system will pay claims that lack physicians' PECOS information, but the remittance advice will include remark code N272. First, check to make sure you have listed the physician's information

correctly on the claim -- verify the National Provider Identifier number and the spelling of the doc's first and last name, Little advises.

Remember: You should be listing the Type 1 (individual) NPI for the physician, says the National Association for Home Care & Hospice. If the physician's information is incorrect, correct it in your billing system so the N272 errors don't continue, Little says.

If the physician's information is correct, then check her PECOS enrollment status, Little counsels.

3. Reach out to docs. For physicians who do not show up in CMS's PECOS files, check with their offices to determine their Medicare enrollment and PECOS status.

You might want to start with an informalc verbal inquiry, Olson recommends. If physicians are in the process of enrolling in PECOS, document that information. If they are not enrolling, send a "Concerned Provider" letter requesting that they enroll, Olson says.

Resource: For a sample letter you can use, see Eli's HCW, Vol. XIX, No. 24, p. 188.

4. Document. Don't forget to document your PECOS activities thoroughly in the patient's chart, billing file, and electronic medical records, Little recommends. That documentation might save your payments if you get audited later.

5. Settle on a PECOS strategy. The rub for HHAs will be how to deal with patients whose docs simply won't participate in PECOS. Agencies must "accept the fact that some physicians are not going to enroll," Olson says.

Hopefully that number will be lower now that CMS has instituted a simplified enrollment option for physicians who want to order and refer only, not receive Medicare payments, observers say.

When HHAs in Open Door Forums asked if they should discharge patients whose physicians aren't in PECOS, the CMS rep replied that they shouldn't jump the gun on discharges.

Instead: Providers should try to verify physician's eligibility to order Medicare services by checking things like state licensure and HHS Office of Inspector General exclusions. "If [orderingphysicians] do not have a state license and you do some type of an onsite review afterwards, then we will be looking at that particular issue," CMS's Jim Bossenmeyer said in a forum this July.

HHAs should "be reluctant to start an episode if it ends in 2011" when the physician isn't enrolled in PECOS, Olson says. But agencies also should carefully examine their legal and ethical responsibilities when considering discharge. Industry veterans hope to see CMS issue more detailed guidance about the situation before the rejection edits start in January.