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PECOS Edits Officially Coming in January – Will Your Claims Deny?

Thursday, November 7th, 2013

Anglea Hayden


After nearly four years of operating under Phase I of the PECOS project, CMS has officially released the implementation date for Phase II edits via MLN Matters Article SE1305. Phase II was originally set to go into effect on May 1st of this year, however an eleventh hour delay published on April 29th pushed the implementation to an unspecified future date.  Medicare Contractors have now been officially instructed to deny claims that are linked to an ordering or referring physician that is not PECOS enrolled as of January 6, 2014.


DME providers have seen PECOS Phase I warning messages dating back to October 1, 2009, when the project was first initiated.   Providers initially received warning messages via claim status reports. Those warning messages were then migrated to the Medicare Remittances in the form of remark code N544 after the 5010 conversion, where they are currently still reported.  The N544 remark code is an indicator that future claims tied to the same non-PECOS enrolled ordering or referring physician will deny.  Once the edits take effect in January, these claims cannot be reprocessed until that physician is officially enrolled, and providers risk an unnecessary hold on reimbursement for these claims.


With the PECOS surrogate program now underway, providers have a better chance at getting busy physicians properly enrolled with PECOS to mitigate claim denials.  The surrogate program allows physicians to delegate the enrollment process to employees or third parties.  When working with overwhelmed referral sources, DME providers certainly understand just how valuable this tool can be.


While getting non-enrolled physicians to enroll in PECOS is an important part of the compliance process, most denials will be a result of non-matching records.  The PECOS Phase II edits require that the physician’s record match exactly to what is being submitted on the claim, which means that any typographical errors  in the spelling of the physician’s name, or transpositions of the NPI number within your records will cause the claim to deny.  Providers that have not already begun to scrub their files for these errors should do so immediately to ensure all records are clean prior to January 6, 2014.


The key to this process is to be proactive.  The majority of the denials that will result from the implementation of Phase II can be avoided by taking action now to scrub your physician records. Providers have enough uncertainty in the current market; don’t let the implementation of Phase II be another barrier between you and your Medicare reimbursement.


For more information on the steps to take to avoid claims denials and to better understand how the PECOS project will impact your business join us for our special webinar PECOS Revisited conducted by Reimbursement Consultant Andrea Stark on December 12, 2013 at 3pm (see details on registration here) or contact our office to schedule a consult with Andrea at 803-462-9959 ext. 246


The End of April Brings Big Changes: PECOS Delay & MPP

Friday, May 3rd, 2013

Angela Hayden & Andrea Stark


Originally set to go into effect on May 1st, PECOS Phase 2 has been delayed…again. CMS issued word of the delay via their website citing technical issues with the claim processing side for correctly applying the PECOS edits that would have caused erroneous rejections.  Specific information was not released regarding a timeframe for when the new deadline would be set.  So for now, providers have an opportunity to complete their internal review process and avoid immediate claim denials.


Providers are familiar with the many delays that have affected the PECOS project.  Due to repeated delays, Phase 1 has essentially been in effect for 3.5 years in one form or another;  represented to providers via GEN response rejections (pre-5010) then as N544 remark codes on remittance advices (post-5010).


In March 2013, CMS announced that May 1st would be the Phase 2 implementation date.   Yet five days prior to implementation, we have another delay.  What does that mean to providers?  At MiraVista we are advising providers “Don’t get too comfortable”.  The delay is due to a technical issue and is not intended to offer providers a substantial break.  We have no way to officially determine when a resolution will occur, but these types of minor issues can be fixed in as little as 30 days. As such, providers should continue to review their records and ensure accuracy to be prepared for implementation.


Another important announcement took place on April 24th, which was the introduction of HR 1717 by Congressman Tom Price of Georgia.  Price kept to his word and introduced new legislation to repeal and replace the current Competitive Bidding Program with the Market Pricing Program (MPP).  The bill text was released by Congressman Price’s office and proposes an end to Round 1 pricing effective December 31, 2013.  The legislation also calls for an immediate cease to both Round 2 implementation and National Mail Order, suggesting the termination of any awarded contracts under these programs.  These are hefty requests that are accompanied by a detailed plan of action for the transitional period between the termination of Competitive Bidding and the implementation of MPP.  This transitional plan is an important part of the legislation in order to gain a budget neutral score by the Congressional Budget Office (CBO).  We will keep you up-to-date as we continue to review the legislation and monitor its progress.


Providers are encouraged to reach out to their Representatives to gather support for the new legislation. AAHomecare has provided a template letter to assist in this process which can be accessed here: http://action.aahomecare.org/9244/stop-medicare-bidding-program-home-medical-equipment/.   The bill was introduced with a total of 25 co-sponsors, so be sure to reach out and thank those congressional members who are in support of this pivotal piece of legislation.  Providers can also show their support by joining AAHomecare on Capitol Hill for the Washington Legislative Conference on May 22-23rd to lobby on behalf of the DME industry (Register here: https://www.aahomecare.org/events/2013/5/washington-legislative-conference)


Bill Text: http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%201717.pdf


The Clock is Ticking: PECOS Phase 2 Implementation Date Released

Friday, March 8th, 2013

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:


  1. 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.
  2. 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.
  3. 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.
  4. 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.

PECOS Revalidation Application Not Printing Correctly?

Thursday, May 10th, 2012

When revalidating through the electronic provider enrollment chain and ownership system (PECOS), you are highly encouraged to print a paper copy of your reenrollment application for your records. However, if you tried to do this recently, you may have noticed that not all of the information you entered into PECOS successfully printed. In fact, the form that prints may look somewhat different than the CMS-855S you are accustomed to seeing.


We have confirmed with CMS that there is a glitch in the PECOS system that occurs when suppliers try to print paper copies of their electronic reenrollment applications. Suppliers should note that this does NOT impact the information that is sent to the NSC. The information you enter into PECOS will still be successfully transmitted to the NSC, once your electronic application is submitted.


On one of the last screens displayed in the PECOS revalidation process, suppliers are given the opportunity to view and print a copy of the completed application. Clicking the print link should produce a prepopulated paper copy of the CMS-855S form that you may keep for your records. However, as of May 1, 2012, a glitch in the system is resulting in applications printing with incomplete fields and missing information. As previously mentioned, while this does create a bit of a headache for suppliers trying to print hard copies, if you can see the information in PECOS and everything looks correct online, it is safe to submit your electronic application to the NSC.


After a little digging, MiraVista was able to confirm that the glitch is the result of PECOS trying to print information to a new, draft version of the CMS-855S form that has not yet been released. You can identify whether PECOS incorrectly printed the draft copy of the CMS-855S by looking for an 04/12 revision date in the lower left-hand corner of each page. This version of the CMS-855S is not yet active, and it is our understanding that PECOS is not set to populate the revised fields in this form.


The active version of the CMS-855S form that should be linked to in PECOS (and that suppliers should use if they opt to submit a paper application) was last updated on July 2011 and can be identified by an 07/11 revision date in the lower left-hand corner of each page. This is the form PECOS is set to populate when printing hard copies of electronic revalidation applications.


We have informed CMS of the issue and have received confirmation that they are looking into a fix. A date has not yet been released for the implementation of the 04/12 draft version of the CMS-855S form. Look for full details on revisions made to the draft form in the June 2012 issue of Vista Notes.

PECOS Rejections Delayed, Not Repealed

Wednesday, November 24th, 2010

CMS will delay the implementation of PECOS rejections until after January 3, 2011. Due to the current physician enrollment backlog, automated edits will not begin until Contractors are caught up and the PECOS system is current.


While denials will no longer begin on January 3, 2011, suppliers should not take their foot off the gas when it comes to pursuing physician enrollments. The edits are not being repealed, and there is no way of knowing how long (or short) of a time it will take to resolve enrollment issues.


CMS has stated that they will provide an advanced notice to suppliers before automatic rejections are implemented. While the delay is indefinite, we expect CMS will implement rejections no later than July 5, 2011, if not much sooner. July 5, 2011 was recently given as the PECOS enforcement date for Home Health Agencies (see MM6856). While this date does NOT apply to DMEPOS suppliers, reason stands that CMS will want the system fully functioning prior to this next implementation deadline.

PECOS Enrollment Open to DMEPOS Suppliers!

Monday, October 11th, 2010

The long awaited mysterious “Fall” deadline is finally here! As of October 4, 2010 DMEPOS suppliers may take full advantage of the online Provider Enrollment Chain and Ownership System (PECOS).


Suppliers were first given a glimpse of PECOS on July 13, 2010, but at that time the system was not ready to process DMEPOS enrollments. Now that the system is fully functional, you may begin utilizing PECOS to quickly:

  • Review, validate and make changes to your enrollment records,
  • Submit new enrollment applications,
  • Complete the re-enrollment process,
  • Track the status of your applications,
  • Voluntarily terminate your billing number(s), and
  • Reactivate an inactive (but not terminated) billing number.

All of the same functions that are performed with the paper CMS-855S may be performed online using PECOS. While PECOS does not replace the paper 855S form (suppliers may still opt to use it over the online system), it does offer an alternative way for you to update your information. Suppliers who submit their applications online will notice that PECOS offers a much quicker processing time – just 45-days, versus the 60-day processing time for paper submissions.  However, the system does not eliminate the need for paperwork entirely. When submitting an application via PECOS, you will be required to print, sign, date and mail a Certification Statement to the NSC. It’s important to do this immediately after submitting your application (no later than 7-days), as the NSC will not process online enrollments until a Certification Statement is received.

Unlike mail sent via the postal service, PECOS also offers suppliers the ability to track their applications. Beginning 15 days after submission, suppliers may log into PECOS and check to see if their application is:

  • Submitted – Sent to the NSC,
  • In Process – Being reviewed by the NSC,
  • Returned for Corrections – Errors have been found and corrections must be made within 30-days,
  • Resubmitted – You have made corrections and resubmitted the application, or
  • Approved, Denied, or Rejected - Final status.

The NSC recently completed a transfer of all DMEPOS enrollment information into PECOS. So chances are you will already be in system. We highly recommend that suppliers take a moment to log into the system and validate the information uploaded by the NSC. At a minimum, you should ensure that the owners, address(es) and product accreditations listed for your business are current and correct. You may immediately log into PECOS and check on your information using your NPPES user ID and password (created when you applied for your NPI). Just visit : https://pecos.cms.hhs.gov/pecos/login.do.


However, as with physician enrollments, if your billing number has become inactive, or if you have not enrolled, reenrolled, or made changes to your information since November of 2003, you will not be in the PECOS system and will need to submit a new enrollment application.


For more information, a PECOS Getting Started Guide for DMEPOS supplier is available at: http://www.cms.gov/MedicareProviderSupEnroll/downloads/Internet-basedPECOS–GettingStartedGuideforDMEPOSSuppliers.pdf.

Which is the Greater Risk: Retroactive Recoupments or Alienating Referral Sources?

Friday, July 30th, 2010

By: Andrea Stark, DMEPOS Consultant


The July 6th PECOS enrollment deadline established in CMS’ May 5th interim final rule created quite a stir among suppliers in the DME community, and left many looking for direction on what to do in the muddy water of PECOS validations. While CMS has confirmed that PECOS rejections of DME claims will not begin until January 3, 2011, they have not issued any specific statements regarding the potential for retroactive recoupments.


The goal of this article is to help you make intelligent decisions about the impending consequences of various options available to you. While we are often presented with black and white scenarios that give us only two options, neither of which are desirable, in the case of PECOS I don’t see it so starkly. Instead, I believe there is a middle of the road approach that can be more suitable to those suppliers worried about the possibility of retroactive recoupments.


After taking a close look at specific language in the Patient Protection and Affordable Care Act (PPACA or ACA) in conjunction with the press release issued by CMS on June 30th, it is my professional opinion that continuing to accept orders from physicians who are not yet in PECOS (but are otherwise legitimate, Medicare enrolled providers) is an acceptable risk, provided you’ve done your homework.


Sec. 6405 of the ACA specifically requires all physicians who order items or services under Medicare “to be Medicare enrolled physicians or other eligible professionals.” In terms of DME, the ACA requires that certifications and written orders only be made by “enrolled physicians” effective July 1, 2010, and that the ordering physician’s name and NPI be included on all claims. The ACA does NOT specifically reference the PECOS database. However, CMS is choosing to use this system as a tool to verify physician enrollment and maintain compliance with ACA requirements.


On May 5th CMS issued an interim final rule mandating that physicians who order DMEPOS have an approved enrollment record in PECOS effective July 6, 2010. This enrollment requirement was also extended to physicians who order home health services and other covered Part B services (laboratories, imaging suppliers, specialists).


One June 30th CMS issued a press release to reiterate and clarify that PECOS rejections will not begin until January 3, 2011, specifically stating that:


“Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation. These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.”


“Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.”


What this says to me, is that CMS understands suppliers and physicians are making “good faith efforts” to comply with the law. Additionally, CMS is admitting that PECOS is not ready to be relied upon solely, and they are resorting to a “contingency plan” to stay in compliance with ACA requirements. This most likely means they will reference the Part B contractor’s enrollment database to verify a physician’s enrollment in Medicare while the PECOS database is brought up to speed.


Based on this information and my experience in the field, it is my belief that unless there is a true issue with improper payments, claims submitted for legitimate referral sources are not likely to be retroactively recouped. At this point, those physicians resulting in PECOS warning messages are predominantly well established physicians who have been practicing for 10+ years and are otherwise legitimate, Medicare enrolled providers. As long as you’ve done your homework and are able to verify that the physician is a legitimate provider with the proper credentials to order DMEPOS, then it should present a minimal risk to continue accepting orders from that physician.


While there is always the potential that a claim could be audited or recouped down the road, whether or not to accept an order ultimately comes down to assessing the risks. Is the risk of alienating an established referral source (and permanently losing those referrals and revenue) greater to your company than the potential that you may be audited down the road?


At this time, the best thing you can do is establish a risk policy for your company. Have a set of guidelines in place to help you decide whether you will ultimately continue taking orders from individual physicians not yet enrolled in PECOS. At a minimum, you should work to ensure that each referral source:


1. Understands the PECOS enrollment requirement and has recently enrolled or plans to enroll in the system (sooner rather than later).

2. Is licensed to practice in the state.

3. Is enrolled in the Medicare program and is otherwise eligible to order/refer DMEPOS (has the appropriate credentials and has a Medicare provider number).


Bottom line, you must do your homework and make sure you can validate that the referral source is a legitimate provider prior to accepting an order. By taking these steps, your claims will be in compliance with federal ACA requirements that ordering physicians be enrolled in Medicare by July 1, 2010.


It is my expectation that CMS will modify the interim final rule before publishing the final version. The comments submitted to CMS have already seen press coverage in their June 30 release on the matter (even CMS acknowledges that they cannot rely on PECOS exclusively right now). To further support this position, neither the CEDI contractor nor the DME MACs have received any indication that the January 3, 2011 rejection date is going to change.


Have questions about this content? Andrea Stark offers on-call consulting services for DMEPOS suppliers. Visit our Services page to learn more.


A digital recording of Andrea’s 7/29/10  ”Have PECOS Questions? Get Straight Answers!” webinar is also available for purchase on our Products page.

Receiving Conflicting PECOS Enrollment Information?

Monday, July 19th, 2010

Some suppliers may be receiving rejection warnings for physicians otherwise identified as enrolled in PECOS. MiraVista recently learned that CEDI’s list of PECOS enrolled physicians is incomplete, which may result in the incorrect firing of warning messages for enrolled physicians. CEDI is aware of the issue and is working to update their records as quickly as possible.


Bottom line, if you are able to match the physician’s NPI and exact spelling of their first and last name in CMS’ list of PECOS enrolled physicians, then they should not result in rejections beginning January 3, 2011. CMS last updated the .csv ordering/referring PECOS file on July 15, 2010.

New List Identifies Physicians with Pending PECOS Applications

Tuesday, July 13th, 2010

A new PECOS list posted by CMS eliminates almost all of the guesswork when it comes to checking on the status of enrolling physicians. As of July 12, 2010, suppliers can now check to see whether their physicians’ applications are pending contractor review.


CMS has posted two new lists to the Medicare Provider and Supplier Enrollment section of their website: 

ClaraVista’s Maureen Bacon was able to confirm with CMS that the lists are exactly as the titles imply; they include the names and NPIs of those physicians and non-physician practitioners whose PECOS applications have been submitted for review.


The publication of these lists follows a recent series of positive breaks for DME suppliers, who are now able to easily identify PECOS enrolled physicians via a frequently updated .csv data file (for more information see CMS Updates CSV PECOS List More Frequently; Twice per Week). Rather than calling a physician’s office directly, suppliers now have an alternate resource to confirm whether a physician has at least submitted their PECOS or CMS-855 enrollment application.


As applications are processed, physicians will be removed from the pending review list and added to the Medicare Ordering and Referring File, which was also updated on July 12, 2010. We expect the two review lists will be updated with the enrollment file simultaneously. As of late, the .csv file is being updated twice per week. You may download the latest version of all three lists by visiting:



We recommend suppliers note the date a physician first appears on the pending review list. If a particular physician’s name remains on the list for an extended period of time, it may be a sign that their Certification Statement has not yet been submitted. At the end of the online enrollment process, physicians are required to print, sign and mail in a paper Certification Statement, and contractors will not process a PECOS application until that statement is received. For physicians whose applications linger on as pending, a phone call may be warranted to confirm whether their Certification Statement was mailed in.


With the establishment of the July 6th physician enrollment deadline, a recent surge in applications may have contributed to processing back-logs for some contractors.

CMS Updates CSV PECOS List More Frequently; Twice per Week

Wednesday, June 30th, 2010

Recently, MiraVista was contacted by a concerned supplier who found differences between the .csv and .pdf PECOS files they downloaded from CMS. The number of physicians in the .csv version didn’t match those in the .pdf. Naturally, we wanted to know why. So we rolled up our sleeves and did a little digging.


On June 29th, Maureen Bacon, the controller for our sister billing company ClaraVista, went back to CMS’ website and downloaded the zipped .csv file. As it turns out, CMS modified the file after we first informed you about it on the 24th. Here’s what we found: 

  • The original file that was made available on June 24th was named OrderReferringJune2010.csv. It was 18.0MB in size, and contained 687,819 lines. (Note: This is the one we first wrote about and is likely the one you downloaded.)
  • The file that is now on the site was created by CMS on June 25th at 8:41am and is named OrderReferring_June2010v2.csv. It is 18.1 MB in size and contains 719,024 lines.

Based on these findings, Bacon sent an inquiry to CMS asking if the .csv file, which now contains an additional 31,205 lines, would continue to be updated more frequently. CMS confirmed that the file will indeed be updated on a regular basis.


“If we don’t have any issues CMS plans to put a new file up twice per week,” wrote one CMS official.


Long story short, it looks like the .csv PECOS file will be updated more frequently than the monthly updates originally scheduled for the .pdf version. To our knowledge, CMS is not yet releasing announcements to let suppliers know each time a new file is posted.


The new .csv Zip file may be downloaded the same way as the previous version, by visiting:



Please be sure to bookmark this site, www.miravistallc.com/blog, and check back regularly for future PECOS news alerts and announcements!


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