Home Health & Hospice Week

Home care providers will soon see serious claims problems if their ordering physicians aren't enrolled in PECOS, but now they can get more docs signed up.

Background: Starting in January 2011, durable medical equipment claims will get rejected if ordering physicians don't have a Medicare Provider Enrollment, Chain, and Ownership System (PECOS) record. And thanks to the recently enacted health care reform package, home health agencies are scheduled to go under the same edit this summer, although observers expect that date to get pushed back.

Suppliers have had a terrible time getting  ordering docs to sign up for PECOS, which bodes ill for home care providers' claims under the new rule.

One problem has been physicians who aren't even enrolled in Medicare. In some cases, the ordering or referring physician is not in PECOS because he works for a Veterans Administration hospital, the Department of Defense (DOD), or a Public Health System (PHS).

But now the Centers for Medicare & Medicaid Services is offering conditional "ordering/referring only" PECOS enrollment status -- for a select few. If your ordering physician treats Medicare patients, he should enroll in PECOS as soon as possible. If he doesn't do business with Medicare because he works for a PHS, VA program, or DOD Tricare provider, he may still order/refer services to Medicare providers or suppliers.

For example, a VA clinic doctor may order Medicare-covered home care or medical equipment for a patient. In these situations, the VA clinic will need a PECOS record and resultant NPI so that the home care provider can report the ordering/referring physician's information.

Here's how: CMS will accept Internet based PECOS applications or paper 855I forms from these public health providers, with a cover letter stating that "the provider is only enrolling to order and refer services to beneficiaries," according to March 19 CMS Transmittal No. 328.

"Basically, these physicians will have a restricted NPI which they can use for referring/ ordering, but not for billing their own services to Medicare," explains Barbara J. Cobuzzi of CRN Healthcare Solutions in Tinton Falls, N.J. If physicians who have restricted NPIs ever decide that they want to work in private practice and bill Medicare directly, they would have to reapply to get their PECOS enrollment record changed, Cobuzzi adds.