Andrea Stark & Angela Hayden
Almost four years after the public implementation of the PECOS project, CMS started the clock on the countdown to Phase 2. This second phase will implement edits to deny claims dated on or after May 1, 2013 for claims with physician data that does not link to a valid PECOS record. Claims for DME, Home Health and Part B lab and similar services prescribed by a referring physician will be affected by the new edits. This has been in the works for quite some time; however, because of the repeated delays to implementation, the call to action has waned. With larger scale issues on the docket such as Competitive Bidding, PECOS seems to have been all but forgotten. As previously reported on our blog and in several editions of our signature Vista Notes publication, we believed it to be imminent that suppliers would be given a 60 day window, for the Phase 2 announcement. Now that we are proceeding to implementation, suppliers must ensure that physician records match the PECOS database before the edits go into place. Don’t expect any more delays… the official countdown has begun.
Phase 1 (the informational messaging phase) began in October of 2009 using claim rejection, warning messages to communicate that the ordering/referring provider submitted on a given claim was not PECOS certified. This front-end warning system was used until the implementation of Version 5010 when these claims were allowed to proceed past the front-end system and warnings are now reflected in the form of a remark code N544 on Medicare remittance advices. Until now, these N544 remark codes have served only as a warning to providers of denials to come if action is not taken on these flagged physicians. Beginning May 1, under Phase 2, these remittance warnings will become actual denials on future EOBs.
Providers need to act swiftly to identify which physicians in their billing system are problematic and cannot be validated in the PECOS database. Affected claims will be denied and cannot be reprocessed until the data is corrected or the physician has been certified. At this stage of the game, most of the N544 remark codes are likely tied to typographical errors, transposed NPI numbers, or incorrect use of group NPI numbers instead of individual practitioner NPI numbers. There are still a select number of practitioners that are either new or not linked to PECOS, and these will be a bit more difficult to resolve.
Here are a few steps to help you identify which records can be fixed in your billing software and which physicians will require contact:
- Start by verifying that the NPI from the physician record in your billing system ties back to the individual physician and not a group practice or facility by looking up the NPI in your system on the NPPES website. Make sure there are no spelling errors in the first or last name and that the NPI is correct for the doctor.
- Next, compare your physician record to the PECOS database located here (in the Downloads section click the CSV version of the Medicare Ordering and Referring File) to verify that this physician is confirmed as PECOS certified.
- When you do find a match (based on NPI), ensure that the first letter of the first name and the first four letters of the last name match exactly to the PECOS record. If your record does not match the PECOS file, claims will be denied.
- Identify and parse out those physicians that do not have a match in the PECOS database and begin contacting them to encourage the completion of the enrollment process. In the case of long standing physicians they may need to send in a renewal of their Medicare enrollment information, so the PECOS record can be created. Remind the doctor that none of their referrals for DME, Home Health or lab referrals will be payable after May 1 until this issue is resolved.
While it is in the hands of the physician to complete the enrollment process, there are some resources that providers can use to explain what PECOS is and why this update or enrollment is necessary. The most recent piece of information is provided in an MLN Matters article released by CMS (#SE1305), which is a consolidation of previous instruction and can be found here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf. Physicians should also be reminded that the PECOS database is used to populate the www.medicare.gov website and without enrollment, Medicare beneficiaries will not be able to validate or locate them for new business.
The bottom line is that real revenue is at stake if providers are not mindful of this deadline. By taking these steps and utilizing the resources available, PECOS Phase 2 Implementation can be a smooth transition for providers, but action must be taken now. For additional guidance on navigating through this process you can attend our webinar on April 10th @2pm EST (registration details here) or contact our office to schedule a consult with reimbursement consultant, Andrea Stark at 803-462-9959 ext.246.