CMS announces start date of PECOS edits

Thursday, November 7, 2013

BALTIMORE – CMS will start editing DME claims to determine whether or not the ordering or referring physician has enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) on Jan. 6, 2014, according to a new bulletin.

Claims that don’t pass muster will be denied, and the billing provider will not be paid for the items or services that were furnished based on the order or referral.

CMS had planned to start editing claims on May 1, but it held off due to technical reasons. The agency has delayed the edits going as far back as 2010.

Physicians and other professionals who order and refer items and services must establish a record in PECOS and a valid national provider identifier (NPI), CMS says.

If a claim identifies the ordering or referring provider but does not include a matching NPI, the claim will still be rejected, the agency says.

The edits will verify provider enrollment by comparing the first four letters of the last name. CMS cautions providers to leave out middle names or initials and suffixes.