NHIC CR6421-PECOS-Part I
Andrea Couture
Description
Collection
Title:
NHIC CR6421-PECOS-Part I
Creator:
Andrea Couture
Date:
11/2/2009
Text:
The following information was sent out last week from NHIC - It explains the
process pretty well - Part II to follow - If you compare your current
physician database against the national file of Medicare
physicians/non-physician practitioners CMS will be providing, you should be
able to proactively contact the non-PECOS physicians and give them a heads
up that you cannot provide services to their Medicare patients after January
4, 2010 until their role in this process is completed - Also,
physicians/non-physician practitioners are going to be going through this
same process with their claims - Unfortunately, their warning period BEGINS
January, 2010 - It would have been nice to have the warning periods of the
physicians and DMEPOS suppliers line up so that the physicians would be
motivated to make sure they were enrolled/registered in PECOS and we
wouldn't need to worry about this, but that's asking a lot when government
efficiency experts are running the show.By the way, we're not members of
AOPA either -
TO: DMEPOS suppliers and their billing agents/clearinghouses
Physicians/non-physician practitioners and their
group practice offices
SUBJECT: Change Request 6421-Editing the Ordering/Referring Provider in
DMEPOS Claims
This message is directed at Medicare suppliers of durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS), their billing agents and
clearinghouses, and the physicians and non-physician practitioners who order
items of DMEPOS for their Medicare patients. We refer to those physicians
and non-physician practitioners as ordering/referring providers.
Background:
To implement Section 1833(q) of the Social Security Act that requires all
physicians and non-physician practitioners that meet the definitions at
section 1861(r) and 1842(b)(18)(C) be uniquely identified for all claims for
services that are ordered or referred and to address concerns raised by
Congress, the public, and Government agencies for paying claims for DMEPOS
that were ordered by physicians or non-physician practitioners who were not
permitted by the Medicare program to do so.
As a first step in addressing these concerns, the Centers for Medicare &
Medicaid Services (CMS) is verifying that the ordering/referring provider on
a DMEPOS claim (1) has a current enrollment record in Medicare (i.e., the
ordering/referring provider enrolled or updated his/her enrollment record
within the past 5 years and the NPI is in the record) and (2) is of a
specialty that is eligible to order and refer.
This verification is being implemented in two phases:
* In Phase 1 (October 5, 2009 through January 3, 2010), DMEPOS
suppliers who report ordering/referring providers who do not pass both edits
will receive an informational message on their remittance. (Paper billers
will not receive an informational message.) The claims will be paid.
* In Phase 2 (January 4, 2010 and thereafter), DMEPOS suppliers who
report ordering/referring providers who do not pass both edits will have
their claims rejected.
The following physicians and non-physician practitioners may order/refer in
the Medicare program:
Physicians (doctors of medicine or osteopathy-all specialties, and doctors
of dental medicine, dental surgery, podiatric medicine, optometry, and
chiropractic medicine)
Physician assistants,
Certified Clinical Nurse Specialists,
Nurse Practitioners,
Clinical Psychologists,
Certified Nurse Midwives, and
Clinical Social Workers.
How the new edits are being implemented:
CMS has furnished the DME claims processing system with a national file that
was generated from the CMS' national provider enrollment repository,
Provider Enrollment, Chain and Ownership System (PECOS). We refer to this
file as the PECOS List. PECOS maintains Medicare enrollment information for
all providers and suppliers (including physicians and the non-physician
practitioners shown above), except DMEPOS suppliers; however, it is
important to note that PECOS only maintains enrollment information for
physicians and non-physician practitioners if they have enrolled or updated
their enrollment information since November 2003.
Medicare transmits updates to the PECOS List daily to the claims processing
system. The PECOS List contains only the physicians and non-physician
practitioners who are enrolled in the above specialties and who have current
enrollment records (i.e., they have enrollment records in PECOS that contain
their NPIs). CEDI (the front-end claims processing system for electronic
DMEPOS claims) compares the NPI and the first letter of the first name and
the first four letters of the last name of the ordering/referring provider
as reported on the claim to that same information in the PECOS List. If a
match is found, no informational message is sent to the DMEPOS supplier in
the Remittance. If a match is not found, an informational message is sent
to the DMEPOS supplier in the Remittance. Beginning January 5, 2010 and
thereafter, if a match is not found, the claim will be rejected.
CMS actions to mitigate the number of information messages:
Since many DMEPOS suppliers are receiving informational messages in their
Remittances, CMS is taking the following actions to reduce the number of
informational messages:
1. Prior to the implementation of Phase 2, CMS will systematically add
the NPIs to the PECOS enrollment records of all physicians and non-physician
practitioners whose PECOS records do not contain their NPIs. Because the
NPI is one of the matching criteria used in implementing the edits, it is
essential that the NPI be in the PECOS enrollment record. Because the PECOS
List contains only physicians and non-physician practitioners who are in
PECOS with NPIs in their enrollment records, this action will result in the
addition of many more physicians and non-physician practitioners to the
PECOS List.
2. Prior to the implementation of Phase 2, CMS will make publicly
available on the Internet a national file of Medicare physicians and
non-physician practitioners who are eligible to order/refer. The file will
contain the NPI and the Legal Name (from the Medicare PECOS enrollment
record). This will allow DMEPOS suppliers to determine if the
ordering/referring provider has a current Medicare enrollment record and is
eligible to order or refer.
3. Prior to the implementation of Phase 2, CMS will issue instructions
that will assist Medicare contractors in enrolling licensed residents,
Department of Veterans Affairs physicians, and Public Health Service
physicians. These physicians continue to order DMEPOS but have not enrolled
in Medicare because they are not eligible for payments from Medicare. The
instructions will also state that the teaching physician should be reported
as the ordering/referring physician in situations where a resident orders
DMEPOS but is not licensed by the State and thus cannot enroll in Medicare.
Note that dentists and pediatricians, who may sometimes order DMEPOS for
Medicare beneficiaries but who have not enrolled in Medicare because they
see so few Medicare patients or most of their services are not covered by
Medicare, are considered physicians in terms of eligibility to
order/refer, have been and continue to be eligible to enroll in the Medicare
program.
4. An MLN Matters Article (MM6421) about CR 6421 is available on the
CMS web site. To supplement that Article, CMS will be preparing a Special
Edition Medicare Learning Network (MLN) Matters Article about CR 6421.
5. CMS's Medicare contractors have also initiated a revalidation effort
(via CR 6574, Transmittal 557) which is designed to update the Medicare
enrollment record for 2,500 physicians and non-physician practitioners (50
practitioners per State). We expect that this revalidation effort will be
complete or nearing completion by the time that Phase 2 is implemented.
Andrea Deshaies-Couture
Business Coordinator
Next Step O & P, Inc.
155 Dow Street #200
Manchester, NH 03101
603.668.3831
603.668.4032 (Fax)
< <URL Redacted>> www.nextstepoandp.com
If you want total security, go to prison. There you're fed, clothed, given
medical care, and so on. The only thing lacking ... is freedom. --5-Star
General and U.S. President Dwight D. Eisenhower (1890-1969)
process pretty well - Part II to follow - If you compare your current
physician database against the national file of Medicare
physicians/non-physician practitioners CMS will be providing, you should be
able to proactively contact the non-PECOS physicians and give them a heads
up that you cannot provide services to their Medicare patients after January
4, 2010 until their role in this process is completed - Also,
physicians/non-physician practitioners are going to be going through this
same process with their claims - Unfortunately, their warning period BEGINS
January, 2010 - It would have been nice to have the warning periods of the
physicians and DMEPOS suppliers line up so that the physicians would be
motivated to make sure they were enrolled/registered in PECOS and we
wouldn't need to worry about this, but that's asking a lot when government
efficiency experts are running the show.By the way, we're not members of
AOPA either -
TO: DMEPOS suppliers and their billing agents/clearinghouses
Physicians/non-physician practitioners and their
group practice offices
SUBJECT: Change Request 6421-Editing the Ordering/Referring Provider in
DMEPOS Claims
This message is directed at Medicare suppliers of durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS), their billing agents and
clearinghouses, and the physicians and non-physician practitioners who order
items of DMEPOS for their Medicare patients. We refer to those physicians
and non-physician practitioners as ordering/referring providers.
Background:
To implement Section 1833(q) of the Social Security Act that requires all
physicians and non-physician practitioners that meet the definitions at
section 1861(r) and 1842(b)(18)(C) be uniquely identified for all claims for
services that are ordered or referred and to address concerns raised by
Congress, the public, and Government agencies for paying claims for DMEPOS
that were ordered by physicians or non-physician practitioners who were not
permitted by the Medicare program to do so.
As a first step in addressing these concerns, the Centers for Medicare &
Medicaid Services (CMS) is verifying that the ordering/referring provider on
a DMEPOS claim (1) has a current enrollment record in Medicare (i.e., the
ordering/referring provider enrolled or updated his/her enrollment record
within the past 5 years and the NPI is in the record) and (2) is of a
specialty that is eligible to order and refer.
This verification is being implemented in two phases:
* In Phase 1 (October 5, 2009 through January 3, 2010), DMEPOS
suppliers who report ordering/referring providers who do not pass both edits
will receive an informational message on their remittance. (Paper billers
will not receive an informational message.) The claims will be paid.
* In Phase 2 (January 4, 2010 and thereafter), DMEPOS suppliers who
report ordering/referring providers who do not pass both edits will have
their claims rejected.
The following physicians and non-physician practitioners may order/refer in
the Medicare program:
Physicians (doctors of medicine or osteopathy-all specialties, and doctors
of dental medicine, dental surgery, podiatric medicine, optometry, and
chiropractic medicine)
Physician assistants,
Certified Clinical Nurse Specialists,
Nurse Practitioners,
Clinical Psychologists,
Certified Nurse Midwives, and
Clinical Social Workers.
How the new edits are being implemented:
CMS has furnished the DME claims processing system with a national file that
was generated from the CMS' national provider enrollment repository,
Provider Enrollment, Chain and Ownership System (PECOS). We refer to this
file as the PECOS List. PECOS maintains Medicare enrollment information for
all providers and suppliers (including physicians and the non-physician
practitioners shown above), except DMEPOS suppliers; however, it is
important to note that PECOS only maintains enrollment information for
physicians and non-physician practitioners if they have enrolled or updated
their enrollment information since November 2003.
Medicare transmits updates to the PECOS List daily to the claims processing
system. The PECOS List contains only the physicians and non-physician
practitioners who are enrolled in the above specialties and who have current
enrollment records (i.e., they have enrollment records in PECOS that contain
their NPIs). CEDI (the front-end claims processing system for electronic
DMEPOS claims) compares the NPI and the first letter of the first name and
the first four letters of the last name of the ordering/referring provider
as reported on the claim to that same information in the PECOS List. If a
match is found, no informational message is sent to the DMEPOS supplier in
the Remittance. If a match is not found, an informational message is sent
to the DMEPOS supplier in the Remittance. Beginning January 5, 2010 and
thereafter, if a match is not found, the claim will be rejected.
CMS actions to mitigate the number of information messages:
Since many DMEPOS suppliers are receiving informational messages in their
Remittances, CMS is taking the following actions to reduce the number of
informational messages:
1. Prior to the implementation of Phase 2, CMS will systematically add
the NPIs to the PECOS enrollment records of all physicians and non-physician
practitioners whose PECOS records do not contain their NPIs. Because the
NPI is one of the matching criteria used in implementing the edits, it is
essential that the NPI be in the PECOS enrollment record. Because the PECOS
List contains only physicians and non-physician practitioners who are in
PECOS with NPIs in their enrollment records, this action will result in the
addition of many more physicians and non-physician practitioners to the
PECOS List.
2. Prior to the implementation of Phase 2, CMS will make publicly
available on the Internet a national file of Medicare physicians and
non-physician practitioners who are eligible to order/refer. The file will
contain the NPI and the Legal Name (from the Medicare PECOS enrollment
record). This will allow DMEPOS suppliers to determine if the
ordering/referring provider has a current Medicare enrollment record and is
eligible to order or refer.
3. Prior to the implementation of Phase 2, CMS will issue instructions
that will assist Medicare contractors in enrolling licensed residents,
Department of Veterans Affairs physicians, and Public Health Service
physicians. These physicians continue to order DMEPOS but have not enrolled
in Medicare because they are not eligible for payments from Medicare. The
instructions will also state that the teaching physician should be reported
as the ordering/referring physician in situations where a resident orders
DMEPOS but is not licensed by the State and thus cannot enroll in Medicare.
Note that dentists and pediatricians, who may sometimes order DMEPOS for
Medicare beneficiaries but who have not enrolled in Medicare because they
see so few Medicare patients or most of their services are not covered by
Medicare, are considered physicians in terms of eligibility to
order/refer, have been and continue to be eligible to enroll in the Medicare
program.
4. An MLN Matters Article (MM6421) about CR 6421 is available on the
CMS web site. To supplement that Article, CMS will be preparing a Special
Edition Medicare Learning Network (MLN) Matters Article about CR 6421.
5. CMS's Medicare contractors have also initiated a revalidation effort
(via CR 6574, Transmittal 557) which is designed to update the Medicare
enrollment record for 2,500 physicians and non-physician practitioners (50
practitioners per State). We expect that this revalidation effort will be
complete or nearing completion by the time that Phase 2 is implemented.
Andrea Deshaies-Couture
Business Coordinator
Next Step O & P, Inc.
155 Dow Street #200
Manchester, NH 03101
603.668.3831
603.668.4032 (Fax)
< <URL Redacted>> www.nextstepoandp.com
If you want total security, go to prison. There you're fed, clothed, given
medical care, and so on. The only thing lacking ... is freedom. --5-Star
General and U.S. President Dwight D. Eisenhower (1890-1969)
Citation
Andrea Couture, “NHIC CR6421-PECOS-Part I,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 22, 2024, https://library.drfop.org/items/show/230924.
