On May 1, 2013, Phase two of Medicare’s ordering physician PECOS enrollment status audit will go into full effect. This enrollment audit, and PECOS– Provider Enrollment Chain and Ownership System, is part of the Affordable Care Act, section 6405.

Beginning May 1, 2013, Home Health claims that are audited and DO NOT have a PECOS-enrolled ordering physician or non-physician provider for dates of service May 1 and after WILL BE DENIED. The audit will use the physician’s NPI, the first four letters of the last name and first letter of the first name to verify enrollment. The physician’s name on the claim MUST MATCH exactly the name in the PECOS system.

The Medicare Administrative Contractors (e.g. Palmetto GBA, NGS and CIGNA) will deny payment if any of the following is found upon audit:

1. The NPI of the physician is not found in the PECOS enrollment look up system
2. The NPI and name on the claim IS FOUND but does not match the name in the PECOS enrollment  look up system
3. The specialty code is not a valid eligible code

When accepting a referral, it is imperative that agencies confirm that the ordering physician or non-physician provider is a type or specialty that is eligible to refer to home health. These specialties include MD (Medical Doctor), DO Doctor of Osteopathy, or DPM (Doctor of Podiatric Medicine). It is also imperative that you ensure the physician is enrolled in PECOS and the name matches in PECOS and on your claim.  You can look this information up here: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html

In cases where several physicians who have the same name listed are found, use the NPI to confirm which physician is correct for your patient’s claim. Also, avoid the use of Prefixes such as “Mr. or Mrs.”, suffixes such as “Sr. or MD”, or nicknames for your physicians or non-physician providers.

Because claims that fail the audit for PECOS are denied, you will not be able to submit an adjustment, or simply resend a corrected bill. Once the claim is denied for PECOS audit failure, you must file an appeal through the usual Medicare Appeals process and provide a corrected NPI and attending physician name. Information on the Medicare Appeals process can be found at: https://www.cgsmedicare.com/hhh/appeals/overview.html .

Agencies should prepare NOW by checking all ordering physician’s NPI and PECOS status and ensure that they are enrolled or will be finalized by May 1. Be sure also that the physician’s name you have on file matches exactly the name in the Medicare PECOS enrollment system. Because the PECOS system has been in place since October 5, 2009 (Phase 1), and agencies and physicians have had adequate time to be informed on and enroll in the PECOS system, Medicare will not be pushing back the May 1, 2013 date.

Axxess Agencycore software customers already enjoy an automatic PECOS enrollment lookup that determines a Physician’s PECOS status before the physician is added as a certifying physician in the software.  The feature will be further enhanced to ensure that Medicare claims cannot be submitted when the physician is not PECOS-enrolled to meet the new PECOS guidelines. This feature will be added well in advance of the deadline of May 1, 2013.

You can learn more about the new PECOS guideline at:

www.federalregister.gov/articles/2010/05/05/2010-10505/medicare-and-medicaid-programs-changes-in-provider-and-supplier-enrollment-ordering-and-referring

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf

www.cgsmedicare.com/hhh/pubs/news/2013/0313/cope21705.html