Billing/Reimbursement

PECOS Automatic Edits on Hold

Good news for HME providers: CMS has indefinitely postponed automatic PECOS edits that would deny claims for equipment or services

BALTIMORE — A burst of good news for home medical
equipment providers: CMS has postponed indefinitely its automatic
PECOS edits that would deny claims for equipment or services
ordered by physicians or other eligible professionals who do not
have approved files in the online Medicare enrollment program.

The edits were to have been implemented Jan. 3.

The Centers for Medicare and Medicaid Services "is working
diligently to resolve backlog and other systems issues and will
provide ample advance notice to the provider and beneficiary
communities before CMS begins any such automatic denials," the
agency said in a Nov. 24 note to providers. The message added that
CMS did not yet have a date as to when the ordering/referring edits
would be turned on.

Under the Affordable Care Act, only Medicare-enrolled physicians
or eligible professionals can certify or order such services as
home health, home medical equipment, prosthetics, orthotics and HME
supplies for beneficiaries. But to be considered enrolled, they
must be in PECOS; those who have not updated their information
since 2003 are not listed in the system. The enrollment deadline
was July 6, 2010, and CMS left it up to providers to push
physicians and other professionals to register in the agency
database.

Physician enrollment has remained spotty, however; earlier this
year, two pharmacy groups faxed 62,000 physicians about enrolling
in the system, and the American Association for Homecare estimates
that some 18 to 25 percent of those who refer HME are not yet
registered in PECOS. Along with HME providers, both pharmacy and
physician groups had worried not only that claims submitted from
July 6 to Jan. 3 would be rejected but also that they would be
subject to recoupment if the certifying or ordering physician was
not enrolled in the online system.

AAHomecare applauded the agency's action, saying it had been
working for more than a year to inform CMS "of the disruption that
would occur if the edit, which would result in a front-end claim
rejection, went into effect with [the] current backlog of PECOS
enrollees along with those physicians who had not enrolled
yet."

In its statement, CMS encouraged physicians and other eligible
professionals who are not enrolled to do so "sooner than later" and
referred them to an target="_blank">FAQ on the system.



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