Home Health & Hospice Week

Suppliers have a few more months to get up to speed on physician number edits that will hit in April, but that won't help if ordering physicians don't bother to register in PECOS.

Starting April 5, the Medicare claims system will begin editing the referring/ordering physician field on Part B claims to make sure physicians are enrolled with their National Provider Identifier (NPI) number in the Medicare Provider Enrollment Chain and Ownership System (PECOS). The Centers for Medicare & Medicaid Services originally set the edits to begin Jan. 4, but pushed back the date.

The problem: Suppliers can't dictate whether ordering physicians enroll in PECOS, but their claims will be rejected if the physicians don't. "Absent any change, suppliers will see huge disruption in cash flow unless their physicians are registered," the National Association of Independent Medical Equipment Suppliers warns.

"I don't have control over my physicians," Carey Jinright, general manager of Precision Medical Systems in Montgomery, Ala. told CMS in a Jan. 20 home health Open Door Forum. Physician office managers who are already overwhelmed with other reimbursement concerns and regulatory burdens aren't too interested in signing up for PECOS when it doesn't affect their Medicare billing, Jinright related in the forum.

"Many of them are much more interested in their own benefits than mine," Jinright noted. "Why is there not any feedback toward the physician?" Multiple other suppliers on the call echoed the sentiment, noting the unfairness of having their Medicare reimbursement affected by the physician's actions when the physician sees no reimbursement consequences.

CMS has been encouraging physicians to enroll in PECOS, including a November letter sent to docs, a CMS official said. Many suppliers expect to be deeply affected by this issue, based on the informational edit messages they are already receiving on the topic, said Bruce Rodman with the National Home Infusion Association on the call.

Those informational edit messages should have gone down, thanks to CMS manually entering the NPIs of many physicians last month, a CMS official noted. But suppliers say they haven't seen much of a decrease, if any.

"Suppliers are very frustrated with the process," NAIMES notes. The trade group's members report about 70 percent of their claims still getting the PECOS edit flag and about 80 percent of active ordering physicians still going un-registered in PECOS.

"The PECOS denial issue could be the first of many threats to cash flow this year," NAIMES cautions suppliers.

Suppliers can take these steps to reduce their payment disruptions due to the new edits, CMS said in the forum:

Next month CMS will post on its Web site a file containing the NPI and legal name of every physician who is authorized to order or refer for Medicare. Suppliers can use the file to look up their physicians to see if they are in PECOS and if not, encourage them to enroll. CMS will post the file at www.cms.hhs.gov/medicareprovidersupenroll.

2. Give applications time to process. Don't panic if your doc says he is enrolled, but you are still receiving informational edit messages saying he's not. "Just because somebody submits an enrollment application over the Web or mails it in to the contractor ... does not mean that 'bingo,' you have a record in PECOS," CMS's Pat Peyton told forum attendees. That's especially true when the physician has submitted it online.

The contractor has to review and verify that information, Peyton pointed out. "It can take them 45, maybe even 60 days to do all that. It's not instantaneous like getting an NPI, [which] is really a pretty quick thing."

3. Use teaching physicians' NPIs. When residents order DME, suppliers can use the teaching physician and her NPI on claims, CMS instructs.

4. Check your claims. When a claim fails the edit, it's not always the physician's fault. Check to make sure you are entering the physician's name in all caps and that you aren't using the doc's nickname, CMS said in the forum. The system will recognize the PECOS system match only if the first letter of the physician's name matches the record.

For example: You can't use "Bob Smith" as the doctor's name if he is listed as "Robert" in PECOS. Also don't enter "Doctor" or other titles.

5. Use individual NPIs. Suppliers also must use the physician's individual or "Type 1" NPI rather than the physician clinic or "Type 2" NPI on the claim, CMS added.

Suppliers attending the forum were skeptical that many of their ordering physicians would complete the necessary PECOS enrollment by the April 1 deadline. "If my physicians do not follow through, as I expect them not to ... if a patient comes into my facility with an order from a doctor that is not PECOS-registered, what are my options to provide service to that patient?" Jinright asked CMS in the call. "Do I have an ABN option? Do I have a cash option? Or can I not provide service to this patient because she went to a doctor who is not enrolled in PECOS?"

This is a question many suppliers are vitally interested in, Rodman added.

CMS promised to consider the question and issue an answer by the next home health Open Door Forum, if not sooner.