Home Health & Hospice Week

PECOS edits for ordering physicians may not hit home health agency claims until next July, but you need to start getting your PECOS ducks in a row now to avoid big reimbursement hits when the deadline arrives.

Because the Centers for Medicare & Medicaid Services has suspended its Medicare Provider Enrollment, Chain, and Ownership System (PECOS) edits for physicians' claims, home care providers will have even more work to do to make sure the edits don't take a big bite out of their Medicare reimbursement come July. Referring physicians won't have peer pressure in advance from other docs to make sure they're enrolled in PECOS.

Background: When the edits begin next summer, the Medicare system will reject your claim if it doesn't include the ordering or referring practitioner's NPI, which must be in the PECOS computer system. Currently, if you submit claims where the ordering or referring physician's information is not in PECOS, you will get an informational message letting you know that the practitioner's information is missing from the system.

The following tips, offered by National Government Services'Andrea Freibauer during a recent provider education call, can help you stave off rejections next year:

1. Know what the edit covers. Freibauer reminded providers that the inclusion of the referring doctor's NPI does not guarantee payment -- you'll also have to meet the other requirements based on Medicare guidelines.

2. Don't add credentials. "I want to stress that when entering the name of the ordering or referring physician ... on your paper or your electronic claim, do not include titles such as 'doctor' or 'MD,' as these will cause problems with your claim," Freibauer said. In addition, you don't want to include name suffixes such as "Jr."

3. Avoid nicknames. If you report the ordering/referring doctor's name as "Bob" but the PECOS system has him listed as "Robert," the claim will fail the edit.

4. Remove apostrophes, periods, and commas. If the doctor's last name is O'Connell, "Remove the apostrophe and don't leave a blank space between the O and the C," Freibauer said. The same goes for periods or commas that you would normally add to a physician's name.

5. Keep that 'caps lock' key pressed. Be sure to use all uppercase letters when reporting the ordering/referring provider's name on electronic claims. "I verified with our EDI department and our claims processing department that claims that are not in all uppercase letters will result in claim denials," Freibauer said.

6. Don't look to ABNs as a safety net. If you can't get the referring/ordering physician's NPI, you should not simply ask the patient to sign an advance beneficiary notice (ABN) and expect the patient to pay. "Using an ABN to shift responsibility to the beneficiary is not an appropriate practice and it's not an acceptable practice," Freibauer said.

7. Prepare now. Get ready for the edits before the deadline is on you by ensuring that physicians from whom you accept orders and referrals are of the type and specialty eligible to order and refer under Medicare, and have current enrollment records in PECOS.

Tip: You can check the PECOS enrollment file, which contains about 800,000 practitioner records, on the CMS website online at www.cms.hhs.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.