Home Health & Hospice Week

MAC makes PECOS RAP correction.

There’s no doubt that home care providers were starting to see Phase 2 of the PECOS edits as realistic as Bigfoot — but CMS surprised many agen-cies by actually switching on the edits last month.

Background: In today’s Medicare environment, you certainly can’t afford to have payments denied, but effective Jan. 6, your claim must include the ordering or referring practitioner’s NPI, and that number must be in the Medicare Provider Enroll-ment, Chain, and Ownership System (PECOS) or the payer’s computer system.

Now, if the ordering or referring physician’s information is not in PECOS, you will find those claims denied.

If you want to ensure your claims continue to process smoothly, follow these steps that can lead you to payment success.

1. Know Who Is Affected: These edits apply not only to physicians who submit claims to Medicare, but even to "physicians … who do not and will not send claims to a MAC for the services they furnish," CMS says in its document, Medicare Enrollment Guidelines for Ordering/Referring Pro-viders. "CMS permits such physicians … to enroll for the sole purpose of ordering/referring items or services for Medicare beneficiaries."

2. Don’t Count on RAPs as Indicators. Contrary to what some MACs had told providers, Requests for Anticipated Payment aren’t affected by the PECOS edits (see Eli’s HCW, Vol. XXIII, No. 1). A provider education article from MAC CGS "incorrectly indicated that no payment would be made on Requests for Anticipated Payment (RAPs) if the attending physician name submitted does not exactly match the name in the PECOS file," the MAC says on its website. "Please note that the ordering/referring physician edits discussed in Medicare Learning Network (MLN) Matters® article SE1305 do not apply to home health RAPs. RAPs will continue to process and pay as usual."

3. Don’t Add Credentials: When you enter the name of the ordering/referring physician on your paper or your electronic claim, do not include titles such as "doctor" or "MD," CMS stresses. In addition, "Do not enter ‘nicknames’ or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits," CMS says in article SE1305.

4. Make ‘Caps Lock’ Your Friend: Be sure to use all uppercase letters when reporting the ordering/referring provider’s name on electronic claims. "The information from PECOS is provided to the Common Electronic Data Interchange (CEDI) using only upper case characters," said MAC NHIC Corp. in a notification to providers. "The alpha character on the claim for the ordering/referring provider must be in upper case in order to validate the name against the PECOS file."

5. Don’t Rely on ABNs: 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 for the service. "Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability," CMS says in SE1305. "There-fore, an advance beneficiary notice is not appropriate in this situation."

6. Bookmark the List: To ensure that referring physicians are of the type and specialty eligible to order and refer under Medicare, and that they have current enrollment records in PECOS, check the PECOS file at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html.