Internal Medicine Coding Alert

New CMS Directive

You may -- or may not -- face claims denials in January due to PECOS edits, depending on which CMS announcement you read.

Background: Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you know that the practitioner's information is missing from the system. It was previously believed that CMS would start denying these claims on Jan. 3, but now that's up in the air.

On Nov. 29, CMS distributed an email that the agency referred to as an "Important Update on PECOS and Ordering/Referring," in which the agency noted, "While there are some rumors that the edits will be turned on in January, we want to reiterate that CMS has not announced any date (January 3 or otherwise) as to when ordering/referring edits will be turned on."

In black and white: Although CMS now clearly denies ever announcing that claim rejections would start on Jan. 3, MLN Matters article MM6417, which CMS distributed on Feb.26, 2010, stated, "Effective January 3, 2011, if the ordering/ referring provider is not in PECOS, the carrier or Part B MAC will search its claims system for the ordering/referring provider. If the ordering/referring provider is not in PECOS and is not in the claims system, the claim will not be paid. It will be rejected."

Which CMS statement to believe? At this point, CMS seems to be indicating that you may not face ordering/referring denials next month, despite the previous MLN Matters article to the contrary. Your best bet is to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality.