Optometry Coding & Billing Alert

Hint: You'll need the system's electronic funds transfers in order to get paid.

If your physicians are not enrolled in Medicare's Provider Enrollment, Chain, and Ownership System (PECOS), you stand to lose out big time on reimbursement opportunities. Even though the deadline to enroll or update  was extended to January 2011, you can't afford to put off enrollment. We'll show you how to take advantage of the extra time to get organized and get in the system.

Enrolling your physicians and non-physician practitioners in PECOS is essential if you want to get paid by Medicare for covered services, says Cyndee Weston, executive director of the American Medical Billing Association in Sulpher, Okla.

There are other reasons which would require your practice to enroll. For example, if your provider orders or refers services and supplies, he must be enrolled in the system.

Important: 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). The referring physician's NPI must also be enrolled in PECOS. If it's not, you will face denials as the providing physician.

Beware: If your physician or non-physician PECOS did not exist prior to that date, what date?? CMS's Pat Peyton said during a February 17 Open Door Forum. "You would have to submit a full-blown enrollment application, either using the paper CMS 855-I and the 855-R if you reassign benefits to a group or claim, or the Internet-based PECOS enrollment system."

Good news: If your practice has been scrambling to make the April deadline for PECOS enrollment, you'll be happy to hear that CMS is buying you more time. During the Open Door Forum, CMS announced they would be delaying PECOS Phase II enforcement from April 2010 until January 3, 2011.

"We will be stepping up our outreach efforts to all physicians and nonphysician practitioners who do not have current Medicare enrollment records, because all of them -- not just those who are eligible to order and refer --- need to take action to get their enrollment data into PECOS," Peyton said.

Tip: Don't let the deadline delay make you complacent, however. Your effective date of application is the date the Medicare contractor receives the signed certification statement. This could take up to 45 days, which is one reason your practice shouldn't wait until the last minute to enroll.

A frequent question about PECOS is whether there is any way around electronic funds transfer (EFT) process if your medical practice chooses not to accept its Medicare reimbursement electronically.

In the CMS forum, Peyton noted that electronic funds transfer is mandatory by federal law. Practices are welcome to discuss the issue with their Medicare Administrative Contractor (MAC), but all federal agencies are required to use EFT.

Bonus: Ultimately, the EFT process works in your favor, because it provides your practice use of your money quicker than waiting for a check in the mail.

Before you enroll, "be sure to go to the NPI registry first and check all the information for that provider iscorrect in the registry before going to PECOS," says Weston. The information you submit on the main log-in page should match the registry. Once verified, CMS offers three steps to complete the process:

1. Create a National Plan and Provider Enumeration System (NPPES) user ID and password -- or use the NPPES user ID and password you created when you created your NPI electronically.

2. Go to the Internet-based PECOS application page on the CMS website (https://pecos.cms.hhs.gov/pecos/login.do).Complete, review, and submit the electronic application.

3. Print, sign, and date the two-page certification statement and mail the statement and all supporting paper documentation to the Medicare contractor within seven days of electronic submission.

Good practice: Consider having another person added to the application aside from the provider. CMS will only answer phone questions from people listed as contacts, Weston says.

To view the full instructions from CMS, go here: www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.