Wiki Medicare rejection message PLEASE HELP!

[AshleyCRPM]

I keep getting this message, after billing a spinal cord stim TRIAL. I called medicare and they say the referring provider (who is a neurosurgeon) is not enrolled with PECOS. We are a pain management company so the patient was referred to us by the neurosurgeon. The neurosurgeon believes they are completely enrolled and doesnt understand either. Here is the message:

Missing/incomplete/invalid procedure code(s) and/or dates.; Procedure code billed is not correct/valid for the services billed or the date of service billed.; Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.; The referring provider is not eligible to refer the service billed.

I've used the same codes to bill this procedure for the past year and have never had a rejection on it. PLEASE HEP! THANK YOU IN ADVANCE!!

 

[MarcusM]

Looks like an issue with the referring doc's NPI/Mcare provider # so you would need to research the correct number. If the neurosurgeon is getting paid by Medicare, you will need to input that number so Medicare can correctly identify the referring doctor. Maybe they gave you his group number so it is a mis-match.

 

[AshleyCRPM]

Yea it is strange because we work with this referring provider all the time and his info has been put in our system (Athena) for about the past 2 years. I will def look into it tho, thanks for the idea!

 

[taandrews]

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf

Here is a helpful link regarding PECOS. Medicare just began enforcing the PECOS requirement in January, so it is possible that the doc was in your system but was not ever certified but no one knew it. We had a few claims reject because the number did not match the name exactly as they had it in their system, ex. using a middle initial or not; married vs. maiden name, suffix. (One name was changed after immigrating but registered under the previous name; it was so different the staff kept sending documentation requests back to us very angry, because no doctor by that name works there!) A few were newer docs that had not completed their certification, and a few that were certified through the group or even a previous group that they are no longer part of. Good luck playing detective!

 

[AshleyCRPM]

Thank you for your help everyone. that was exactly the problem. A new doctor in their practice and his last name is something I cant even pronounce and I think their NEW office manager had made an error. She said its fixed and medicare says its now pending, so im just crossing my fingers now.