PECOS Ordering/Referring Edit Reset

The Centers for Medicare & Medicaid Services (CMS) has rescinded its previous announcement that, beginning Jan. 3, 2011, claims for certain ordered/referred Part B items and services will not be paid if the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). The new “placeholder” implementation date for this Patient Protection and Affordable Care Act (PPACA) provision—known as Phase 2—is July 5, 2011.

Update: On Jan. 12, 2011, CMS issued revised CR 6417 to clarify that a date has not been set as to when it will begin to reject claims if an ordering/referring provider does not have a PECOS record.

“This placeholder date is being issued [for business requirements only] to give CMS more flexibility to determine the appropriate date for nonpayment of claims that fail the ordering/referring provider edits,” CMS announced Dec. 16, 2010.

Phase 2 completes the expansion of the current scope of editing for ordering and referring providers for Medicare claims. Once Phase 2 is officially implemented, providers can no longer use their National Provider Identifier (NPI) as the NPI of the ordering/referring provider. Physicians and nonphysician practioners (NPPs) will not only need to be uniquely identified on claims for ordered/referred services provided to Medicare patients but will need to be uniquely identified with their own NPI and be Medicare-enrolled.

Until an official implementation date is established, however, 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. Rather, contractors will continue with Phase 1, which is to process these claims and add remark messages N264 Missing/incomplete/invalid ordering physician provider name and N265 Missing/incomplete/invalid ordering physician primary identifier to the remittance advice.

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: Transmittal 825, Change Request (CR) 6417

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