Part B Insider (Multispecialty) Coding Alert

Six month reprieve gives you extra time to ensure that you're in the system.

CMS has offered Part B practices a late holiday gift with the news that MACs won't institute ordering/referring PECOS edits until July, thanks to a new transmittal on the topic.

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 announced that MACs would start denying these claims on Jan. 3, but CMS announced on Dec. 16 that claim denials won't begin until July 5.

Part B reminder: In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected starting this July.

Act now: Even though CMS won't reject your claims this month, you should still take this time 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, said National Government Services' Andrea Freibauer during a Nov. 9 webinar on ordered and referred services.

To read the updated CMS transmittal, visit http://www.cms.gov/transmittals/downloads/R825OTN.pdf.

CMS Also Delays Hospices' Face-to-Face Requirement

Hospices benefited from a separate holiday gift that CMS delivered just before Christmas -- a delay of the enforcement date for the new face to face encounter requirement.

For weeks, hospices, home care providers, and their representatives had been giving CMS the full court press about the burdensome new physician visit requirement. In a Dec. 15 letter to CMS Administrator Donald Berwick, more than 25 senior and long-term care organizations joined the National Association for Home Care & Hospice (NAHC) in calling for a delay to the FFE requirement.

Victory: CMS sent instructions to its Medicare contractors to push back the FFE enforcement date from Jan. 1 to April 1. "Beginning with the second quarter of CY2011 ... CMS will expect appropriate documentation of the encounter," regional home health intermediary Cahaba GBA said in a Dec. 27 e-mail to providers.

While it isn't the six-month delay NAHC was asking for, "NAHC appreciates that CMS has taken this responsible action," the trade group says.

The Visiting Nurse Associations of America "is grateful that CMS recognized the significant implementation challenges facing home health agencies, physicians, hospitals, and patients in adapting to the new requirements," VNAA's Andy Carter says. "The additional three months to spread the word and finalize preparations will make a smooth implementation much more likely. Moving aggressively to curb abuse does not mean we have to put patient access to care at risk, which a Jan. 1 enforcement date would have done."

Background: Under the new FFE requirement finalized in the 2011 PPS final rule published in the Nov. 17 Federal Register, certifying physicians must see the home care patient 90 days prior to start of care or 30 days after care begins for the reason the patient is requiring home care. And the certifying physician must document the encounter as part of the certification itself or as a signed addendum to it. The documentation must include the date when the encounter occurred and a brief narrative that describes how the clinical findings of the encounter support the patient's homebound status and need for skilled services. HHAs and hospices can't bill for the patients if the FFE isn't performed.

Keep at it: While the three-month enforcement delay is good news, it doesn't mean HHAs and hospices are off scot-free until April. Providers must still work diligently on the FFE requirement, the message from Cahaba makes clear.

"CMS is concerned that some home health agencies and physicians may need additional time to establish operational protocols necessary to comply with this new law," the message says. "As such, CMS expects that during the first quarter of CY 2011, home health agencies and physicians who order home health services will collaborate and establish internal processes to ensure compliance."

Start now: "This announcement from CMS does not eliminate the requirement that hospice providers implement the face to face requirement on January 1, 2011," NHPCO stresses.

NAHC urges providers "to implement face-to-face encounters as soon as possible," the trade group says. "Doing so will enable us to collect information about provider and beneficiary problems and pitfalls related to this regulation that need to be addressed with CMS."