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.
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.
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.
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