PECOS Automatic Edits on Hold

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 FAQ on the system.