Podiatry Coding & Billing Alert

If your providers have enrolled in PECOS, you may think your job is done, right? Wrong. If your podiatrist performs a service as a result of an order or referral, the doctor of medicine or osteopathy hat the podiatrist lists as referring must also be enrolled in PECOS, says Paul Fehring, owner of Drs. Billing Inc., a podiatry-specific billing service in Fairfield, Ohio.

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. You may start to see warnings to this effect on your explanation of benefits (EOBs). If this happens, advise the referring physicians that they need to get up to date with the PECOS system, advises Fehring.

What many practices don't realize, however, is that even if the physician has a national provider identifier (NPI), he may not necessarily be in the PECOS 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 three 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 non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment since November 2003 to update their enrollment record now," states a Dec. 1 release by NGS Medicare. "It literally takes less than 20 minutes online," comments John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates Inc. in Tampa, Fla. "If they don't register, they may not ever get paid ... or at least not in a timely fashion."

Some physicians have expressed the belief that the directive does not apply to them because they don't order durable medical equipment (DME), 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.

Note: To read more about requirements for ordering/referring providers, visit the CMS Web site at www.cms.hhs.gov/OpenDoorForums/Downloads/CR6421PhysiciansODFfollowup111709.pdf.