Part B Insider (Multispecialty) Coding Alert

Published on Wed Nov 04, 2009 PDF

Your MAC will begin denying claims in April.

CMS wants to make sure that the PECOS system is entirely up to date -- and if your records aren't on file, you have until April 5 to make sure they get there -- after that date, claim denials will result.

If your physician performs a service as a result of an order or referral, your claim must include the referring or ordering practitioner's national provider identifier (NPI) and that number must be in the PECOS system. What many practices don't realize, however, is that even if the physician has an NPI, he may not necessarily be in the PECOS system,and starting in April, you'll face denials if you perform services referred or ordered by doctors that are not part of PECOS or the MAC's claims system.

How this happens: If the referring/ordering doctor has a valid NPI but has not updated his enrollment in the last five or six years, he may not be in the PECOS system, says coding consultant Jay Neal in Atlanta.

On Nov. 23, CMS announced that ordering/referring providers must be enrolled in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) by April 5 or they'll face claim denials. Previously, CMS had indicated that the deadline for PECOS enrollment would be Jan. 4, but the new directive delays the deadline by 3 months.

Currently, if you submit a claim and the ordering/referring provider does not have a current enrollment record in the Medicare system (or is not of a specialty eligible to order/refer), your MAC will send you a message noting that the provider is not in PECOS. But in April, the claim will be denied.

Don't delay: Carriers are reminding practices not to wait until April to take action.

"Although CMS has delayed the implementation of Phase 2 until April 5, 2010, we continue to urge physicians and nonphysician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment since November 2003 to update their enrollment record now," says a Dec. 1 release by NGS Medicare.

Some physicians have expressed the belief that the directive does not apply to them because they don't order durable medical equipment, but providers ordering DME are just a fraction of who is affected by this  rule, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions.

In actuality, the deadline applies to Part B providers (both physician and non-physician) who order items or services, or refer Medicare patients to other providers.