PECOS Ordering/Referring Edit Put on Hold

With the implementation of Section 6405 of the Patient Protection and Affordable Care Act (Affordable Care Act), some physicians will need to enroll in the Medicare program for the sole purpose of certifying or ordering services for Medicare beneficiaries. Rumors of when this policy goes into effect, however, are greatly exaggerated.

The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning Jan. 3, 2011, claims for certain ordered/referred Part B items and services will not be paid if the ordering/referring provider on the claim does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).

In the process of implementing the provisions contained in the Affordable Care Act, however, CMS discovered several unique enrollment issues for certain physicians and non-physician practitioners (NPPs) who are permitted to order or certify items or services for Medicare beneficiaries. As a result, the agency has modified the enrollment process to accommodate the special circumstances of the following physicians and NPPs:

  • Physicians/practitioners employed by the Department of Veterans Affairs (DVA)
  • Physicians/practitioners employed by the Public Health Service (PHS)
  • Physicians/practitioners employed by the Department of Defense (DoD) TRICARE program
  • Physicians/practitioners employed by Medicare-enrolled federally qualified health centers (FQHCs), rural health clinics (RHCs), or critical access hospitals (CAHs)
  • Physicians in a fellowship
  • Dentists, including oral surgeons

The automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS will not be turned on effective Jan. 3, 2011. No date has been announced yet as to when ordering/referring edits will be turned on. CMS is reportedly working to resolve enrollment backlogs and other system issues and will notify providers before beginning any automatic non-payment actions.

Until CMS advises otherwise, claims for ordered or certified items and services will not be rejected due to the lack of the ordering/referring provider having an approved enrollment record in PECOS.

If you are concerned or uncertain about whether you have an enrollment record in PECOS, you can review the Ordering and Referring Report, which is available at on the CMS website under the Downloads section.

Source: MLN Matters article SE1011 Revised

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