Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 25, 2013 PDF

If a new CMS podcast is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date when the denials would start.

However, a Dec. 13 CMS podcast indicates that CMS "will soon begin denying Part B, DME, and Part A Home Health claims that fail the ordering/referring provider edits." Although CMS notes in the podcast that the agency "does not have a date at this time," it warns providers that once it does, it will offer at least 60 days’ notice before the edits are turned on, so you should prepare now.

Background: Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system.

Part B reminder: MACs will take two steps before denying your Part B claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected once the edits are turned on.

To listen to the complete podcast, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2012-12-17Phase-2-of-Ordering-Referring-Requirement-Podcast.html.