Medicare Compliance & Reimbursement

CMS is offering conditional "ordering/referring only" PECOS enrollment status -- for a select few. If your physician performs a service as the result of an order or referral, your claim must include the ordering or referring practitioner's National Provider Identifier (NPI), and that number must be in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or the payer's computer system. But in some cases, the ordering or referring physician is not in PECOS because he works for a VA hospital, the Dept. of Defense (DOD), or a Public Health System (PHS).

Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the Medicare Area Contractor's (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. But starting next January, CMS will deny claims lacking this information.

How to avoid these denials: If you treat Medicare patients, you should enroll in PECOS as soon as possible. If you don't do business with Medicare because you work for a PHS, Veteran Affairs (VA) program, or DOD Tricare provider, you may still order/refer services to Medicare providers or suppliers. For instance, a VA clinic might refer a patient to an otolaryngologist for surgery or a hearing aid, says Candice Ruffing, CPC, CENTC with South Coast Ear Nose and Throat in Port St. Lucie, Fla.

In these situations, the VA clinic will need a PECOS record and resultant NPI so that the otolaryngologist can report the ordering/referring physician's information.

Here's how: CMS will accept Internet-based PECOS applications or paper 855I forms from these public health providers, with a cover letter stating that "the provider is only enrolling to order and refer services to beneficiaries,"according to CMS Transmittal 328, issued on March 19.

"Basically, these physicians will have a restricted NPI which they can use for referring/ordering, but not for billing their own services to Medicare,"says Barbara J.Cobuzzi, MBA, CPC, CPC-H,CPCP,CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, NJ.

If physicians who have restricted NPIs ever decide that they want to work in private practice and bill Medicare directly, they would have to reapply to get their PECOS enrollment record changed, Cobuzzi says.

(Editor's note: To read Transmittal 328, visit: www.cms.hhs.gov/transmittals/downloads/R328PI.pdf.)