Medicare Compliance & Reimbursement

CMS intends to help your transition to using the PECOS system, even if it means additional legwork on their part. Providers who order/refer many services and supplies must be enrolled in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) by April 5, 2010, or the entity billing the claim will face denials.

Previously, CMS had indicated that the deadline for PECOS updates by ordering/referring providers would be Jan. 4, 2010 but a Nov. 23, 2009 directive delayed the deadline by three months "to try to give the physicians and non-physician practitioners who can order and refer an opportunity to get their enrollment records into PECOS," said CMS's Pat Peyton during a Dec. 16, 2009 CMSsponsored Open Door Forum.

If you bill an item or perform a service that was ordered or referred by another practitioner, your claim must include the referring or ordering practitioner's National Provider Identifier (NPI) and that number must be in the PECOS system.

"A lot of them [the providers] are in Medicare but have not updated their records in six or more years, and they need to revalidate their information in order to get them into PECOS," Peyton said on the call.

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, you'll get an informational message letting you know that the practitioner's information is missing from the system -- but come April, 2010, that message will be in the form of a denial. Even if the record is in PECOS, if the NPI is not recorded, you'll get that informational error message, Peyton said. Therefore, the weekend of Dec. 12, 2009, CMS input the NPIs of over 230,000 practitioners into the PECOS system on providers' behalf, "so many of those informational messages should not be going out anymore," Peyton said.

Internet listing coming: CMS also intends to create an internet based list of physicians and non-physician practitioners who can order and refer within Medicare. The listing will include the practitioners; with their legal names and NPIs, Peyton said. "We still are going to do that, it's probably going to be January, but we will let you know when that is going to be there and how to access it at the appropriate time," Peyton said.

With 2010 just around the corner, CMS officials want to stress that 2013 isn't that far behind. And with 2013, comes a slew of new diagnosis codes that your systems will have to accept.

"The transition date for ICD-10 codes is Oct 1, 2013," said CMS's Stewart Streimer during the call. "That's really the drop-dead date for those of you that have familiarized yourselves with the Final Rule regarding ICD-10, but there are a lot of things that must happen before then and I expect many of the payers may even require ICD-10 codes before then so a sufficient amount of testing can take place," he suggested.

Vendors are already working to prepare their systems to accommodate ICD-10 codes, Streimer said. "A lot has to be done not only from the systems perspective, but also a lot has to be done from practitioner offices in terms of how to bill a claim or how to send information onto your vendors for your clearinghouses."

Editor's note: The CMS Web site offers resources for preparing for ICD-10 at: www.cms.hhs.gov/icd10.