Home Health & Hospice Week

If you choose to ignore the PECOS requirement for your ordering physicians on your Medicare claims, you'll be playing Russian roulette with your reimbursement starting next month.

In an April transmittal, the Centers for Medicare & Medicaid Services said it would be implementing Medicare Provider Enrollment Chain and Ownership System (PECOS) edits for HHAreferring physicians starting in October. At first the edits will be informational only, then in January claims will reject if referring docs aren't in the PECOS system (see Eli's HCW, Vol. XIX, No. 18, p. 140).

The HHA deadline matches the alreadypushed-back PECOS edit deadline for durable medical equipment claims.

Home care providers were glad that they seemed to get a little breathing room on the troubled PECOS edit initiative. DME PECOS edits were delayed due to difficulty getting referring physicians to enroll in the system, since docs' Medicare reimbursement isn't affected by their PECOS status.

But now CMS is telling providers they need to adhere to the PECOS requirements by July 6, even if the official edits aren't yet in place. "DMEPOS suppliers and home health agencies should submit claims that include the legal name and the associated national provider identifier of the ordering and referring physicians who are eligible professionals ... beginning on July 6, 2010,"

CMS's Jim Bossenmeyer said in the May 26 Open Door Forum for home care providers. CMS may use "administrative review" to ensure claims are in compliance after that date, Bossenmeyer warned the more than 700 forum attendees. And CMS isn't ruling out applying edits to claims retroactively, he said.

Unanswered questions: Don't count on having until January for the systemic PECOS edits to kick in, either. Despite the current transmittals setting that deadline, Bossenmeyer was cryptic about exactly when the PECOS edits would take effect. "We'll be making decisions about whether or not there will be a change in those implementation dates," Bossenmeyer said of the current PECOS edit timelines.

CMS has told the American Association for Homecare it won't start rejection edits on July 6, the trade group reports. Instead CMS will wait until it receives comments on its interim final rule 6010, which addresses the issue, AAHomecare tells its members. But that still may be sooner than the current Jan. 1 deadline.

This leaves home care providers unsure of when to launch their PECOS efforts. Home health agencies won't even be getting informational edits on which physicians aren't PECOS-enrolled until October. (DME claims already receive such edits.) "Suppliers are once again left to second guess CMS," protests the National Association of Independent Medical Equipment Suppliers.

"Regardless of what they do, [providers] could still have claims previously paid recouped if the retroactive application of the edits is applied." Providers should get started on PECOS compliance by downloading the file of PECOSenrolled physicians at www.cms.hhs.gov/medicareprovidersupenroll -- click on "OrderingReferring Report" and scroll down to the file in the "Downloads" section. Then they should check the list for their ordering docs.

The file, which is updated monthly, contains the names of physicians who will pass the edits. "If you see their name, you know they are enrolled and have approved status within PECOS," Bossenmeyer said.

Tip: The PDF file has a search function to help you find your ordering physician's information. Although this list is updated only monthly, the claims system is updated nightly with newly enrolled physician information, Bossenmeyer explained. CMS is encouraging physicians to enroll, he added. Many docs are in the enrollment process now.

Limitations: The informational edits that currently apply to DME claims and that are scheduled to start applying to HHA claims in October won't be as much help as you might like. They will flag a claim, but not tell you exactly what's wrong -- a name problem, the wrong specialty for the physician, etc. CMS may include that information in edits in the future, Bossenmeyer allowed. Reaching out to physicians to try to figure out exactly what's wrong with their PECOS file will be "a real heavy lift workload for us," one pharmacy caller told CMS.

Providers will be able to resubmit claims once physicians correct their PECOS information or enroll in the system, Bossenmeyer explained.