PECOS Registration Scramble Resumes

BALTIMORE — Earlier this year, HME providers heaved a sigh of relief when CMS announced it would delay implementation of the PECOS edits — which require verification of a referral source's Medicare enrollment — until Jan. 3, 2011. But regulations related to the Patient Protection and Affordable Care Act have put them right back in the hot seat on making sure their referring physicians are registered in the Internet-based system.

The Provider Enrollment, Chain and Ownership System allows physicians and other practitioners to enroll in Medicare, check on the status of an application or make a change in their enrollment information. Under the edits in question, if ordering/referring physicians or other non-physician practitioners listed on DMEPOS claims are not in PECOS, those claims will reject.

CMS had originally set Jan. 4, 2010, as the effective date for the system edits, but later pushed that date out to April 5 and then to Jan. 3, 2011. Following passage of the new health care reform law, however, on May 5, CMS published an interim final rule stipulating that physicians and other eligible professionals who order items and/or services for Medicare beneficiaries must have an approved enrollment in PECOS by July of this year.

On a Special Open Door Forum May 19, CMS' Jim Bossenmeyer noted that the new regulation would become effective July 6. Confused callers wondered: If they submitted claims for items and/or services ordered after July 6 by a physician who was not enrolled in PECOS, would the claims reject?

In an exchange with one caller, Bossenmeyer seemed to indicate the edits' implementation date would remain Jan. 3, 2011. (See "New PECOS Chapter to Begin for HME Providers, May 24.)

But last week on a May 26 call, Bossenmeyer said CMS is developing the system edits now to check whether order/referring physicians or non-physician practitioners are enrolled in PECOS. The edits may not be active by July 6, but  "we reserve the right to go back and reprocess claims," Bossenmeyer said.

"When we implement those edits … if we don't have the correct name and NPI combination on the claim for the ordering and referring [physician] or the individual is not enrolled in the Medicare program, your claim will be rejected," he said, adding that CMS would notify providers in advance of when the edits will be implemented.