Home Health & Hospice Week

Edits are based on Jan. 6 ‘From’ dates.

You may have some extra weeks before newly enforced PECOS edits impact your bottom line, but now is the time to take steps to mitigate the damage.

After delaying for years the edits which will require an ordering or referring physician to be en-rolled in PECOS, the Centers for Medicare & Medicaid Services was set to implement them Jan. 6 at press time.

However: The edits affect claims with a "From" date of Jan. 6 or later. That means your end of episode claims for episodes that began before Jan. 6 will not be affected by the newly enforced requirement.

How the edits will affect Requests for Antic-ipated Payment (RAPs) for episodes starting Jan. 6 or later is still unclear. HHH Medicare Administra-tive Contractor CGS says that "if the attending physician name submitted on the [RAP] does not exactly match the name in the PECOS file, no RAP payment will be made." But the National Associa-tion for Home Care & Hospice says that CMS has indicated "RAPs are not subject to the edits and will continue to process as they do now."

The CGS statement "is in direct conflict with what CMS stated to me in an email," NAHC’s Mary Carr tells Eli. Confusion may have stemmed from an initial, erroneous CMS explanation that RAPs would pay at zero if the RAP didn’t pass the edit, Carr suggests.

Remember: To pass PECOS edits, be sure to use the physician’s individual NPI, not her group or organization number, CGS reminds providers. (For more PECOS edit tips, see Eli’s HCW, Vol. XXII, No. 40.)

While physician enrollment in PECOS has improved markedly since the Affordable Care Act mandated the edits, home health agencies should still prepare to see denials for docs who haven’t jumped on the PECOS bandwagon. "The VA physicians are particularly deficient — apparently because they still, mistakenly, believe that they do not need to enroll as they are not paid by Medicare for physician services," NAHC observes.

Warning: Remember that you can’t merely adjust claims that fail the edit. Instead, you have to file an appeal.

The good news is that CMS will consider a physician’s PECOS enrollment effective from the date he submits an enrollment application to his carrier, NAHC relates.

Advice: Check a physician’s PECOS status upon referral and before each subsequent episode, NAHC counsels.

Bitter pill: If the doc is not enrolled in PECOS, you’ll need to turn down his referral, NAHC advises.

Another option: You also may help the patient find a new physician who is enrolled in PECOS, NAHC suggests.