Home Health & Hospice Week

Tip: Check for extra spaces in your doc names.

You have only a few weeks to get your act together for the next phase of referring physician edits, or you’ll face major reimbursement woes.

Background: Back in 2009, the Centers for Medicare & Medicaid Services implemented edits for home health agencies, durable medical equipment suppliers, and physicians detecting when claims contained an invalid ordering or referring provider. Under the edits, the ordering physician for HHA services must have a valid National Provider Identifier (NPI) number and be enrolled in Medicare’s Internet-based Provider Enrollment, Chain, and Ownership System (PECOS).

But the first phase of edits has been informational only, so claims still pay even if the physician information is incorrect. In those cases, home care claims process with this message: N272 — Missing/incomplete/invalid other payer attending provider identifier.

Now: After numerous delays, CMS is finally implementing the edits May 1 (see Eli’s HCW, Vol. XXII, No. 9).

If you haven’t researched your PECOS edit status, you should get on it pronto, urges HHH Medicare Administrative Contractor CGS in a message to providers. "If your billing transactions fail the ordering/referring physician edits they will be fully denied," CGS stresses. "NO Medicare payment will be made to the billing home health agency."

This edit will deny — not return — claims, so you’ll be unable to submit an adjustment, or resubmit the billing transaction to correct the edit, CGS reminds providers. "For Medicare payment, you must file an appeal through the usual Medicare Appeals process and provide a corrected NPI and attending physician name."

Chances are the edits will impact your bottom line. From September 2012 to February 2013, about "3 out of every 4 home health agencies (HHAs) have filed claims which would have been denied for the upcoming physician editing," CGS warns.

Submitting a claim with an incorrect ordering/referring physician name for the NPI submitted was a common error, CGS explains.

Another common misstep: "There were extra spaces in the physician’s name that were not present in the PECOS file," the MAC says.

Remember, the physician information on your claim must match the information in the PECOS file exactly, CGS warns.

Do this: "Check the ‘Ordering Referring Report’ … to ensure the information submitted exactly matches the information as it appears in PECOS," CGS instructs. "Do not use nicknames or enter credentials (e.g., ‘Dr.’) or suffixes (e.g., Jr., M.D.)."

The doctor’s specialty code has to be valid as well to pass the edit, CGS adds. But a technical glitch may derail some legit claims. Specialty Code ‘01’ (General Practice) "was not included in the logic when determining an appropriate ordering/referring physician," the MAC explains. "As a result, the Remark Code N272 appears on the RA if the attending physician’s specialty code is a ‘01’."

Stay tuned: "This issue has been reported to ... CMS for additional research and clarification," CGS says.

Note: Links to the ordering/referring report and other PECOS edit-related resources are in the article at www.cgsmedicare.com/hhh/pubs/news/2013/0413/cope21869.html.