PECOS update: CMS to add more physicians to list

Monday, November 2, 2009

BALTIMORE – A bulletin published by CMS this week may contain some relief for HME providers that are struggling to get ordering/referring physicians listed in CMS’s Provider Enrollment, Chain and Ownership System (PECOS).

Much is at stake: Starting Jan. 4, 2010, CMS will begin rejecting claims that include the names and NPI numbers of physicians and non-physician practitioners that aren’t listed in the system. Last month, the agency began sending providers “informational messages”—not denials—to alert them of such claims.

The bulletin states that CMS is taking the following actions to reduce the number of informational messages prior to Jan. 4:

•    CMS will systematically add to the PECOS enrollment records the NPIs of all physicians and non-physician practitioners whose PECOS records do not contain their NPIs. This action will result in the addition of many more physicians and non-physician practitioners to the PECOS list.

•    CMS will make publicly available on the Internet a national file of Medicare physicians and non-physician practitioners who are eligible to order/refer. The file will contain the NPI and the legal name (from the Medicare PECOS enrollment record). This will allow DMEPOS suppliers to determine if the ordering/referring provider has a current Medicare enrollment record and is eligible to order or refer.

•    An MLN Matters article (MM6421) about CR 6421 is available on the CMS Web site (Search for MM6421 at To supplement that article, CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters article.

•    CMS's Medicare contractors have also initiated a revalidation effort (via CR 6574, Transmittal 557), which is designed to update the Medicare enrollment record for 2,500 physicians and non-physician practitioners (50 practitioners per state). We expect that this revalidation effort will be complete or nearing completion by Jan. 4.

The bulletin also offered HME providers the following tips:

•    Beginning Jan. 4, only accept and fill orders from eligible Medicare providers.

•    If you submit electronic claims, ensure that the ordering/referring provider name is reported in all uppercase letters.

•    Do not report a nickname in the ordering/referring provider name. For example, a reported first name of "BOB" will result in a non-match to the first name of "ROBERT" (editing includes the comparison of the first initial of the first name), causing the claim to fail the two new edits.

•    Do not use commas, periods or apostrophes within the ordering/referring provider's name. For example, "O'CONNELL" should be reported as "OCONNELL".

•    Ensure that names are reported correctly. For example, do not include credentials in a name field in the name segment for the ordering/referring provider (e.g., do not report a first name as "DR JOHN.")

•    Use of the Advance Beneficiary Notice of Noncoverage (ABN) is not appropriate on a rejected claim. An ABN is appropriate only when a provider/supplier expects Medicare to deny coverage for an item or service under the limitation on liability provisions of Section 1879 of the Social Security Act.

•    After Jan. 4, a DMEPOS claim may identify an ordering/referring provider who now has a current enrollment record (i.e. in PECOS with the NPI in the record), but the date of service precedes the date the ordering/referring provider's information was effective in PECOS. Medicare is not comparing the date of service on the claim to the date the ordering/referring provider was effective in PECOS. The claim would not be rejected.