Assist physicians with their enrollment to provide payments rather than denials
by Sarah Hanna

Our industry has been aware of the impending Medicare Provider Enrollment, Chain and Ownership System (PECOS) implementation. With the implementation of Phase 2 that began on Jan. 6, 2014, suppliers will no longer receive a warning. During Phase 1, suppliers received a warning notification. Staff should have been working with referral sources to help them enroll in PECOS so that when Phase 2 was deployed the denial would not be realized. This denial could occur if the referring/ordering provider name on the claim does not match what is stored in PECOS. The following are the American National Standards Institute (ANSI) denial and remark codes:

  • CO16 - Claim/service lacks information which is needed for adjudication
  • N264 - Missing/incomplete/invalid ordering provider name
  • N575 - Mismatch between the submitted ordering/referring provider name and records

To qualify for coverage by Medicare, DMEPOS must be ordered by a physician or a practitioner who is eligible to order such an item. To be eligible:

  • Physicians or practitioners must be enrolled in PECOS
  • Must be registered in the system
  • Practice a specialty that is eligible to order DMEPOS items for Medicare beneficiaries

The provider specialties eligible to order DMEPOS items include:

  • Doctor of Medicine or Osteopathy
  • Doctor of Dental Medicine or Dental Surgery
  • Doctor of Podiatric Medicine
  • Physician Assistant Certified Clinical Nurse Specialist
  • Nurse Practitioner
  • Doctor of Optometry

Chiropractors are not eligible to order and refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied. If the CO16 denial with the N264 or N575 remark code is received, the following remedies can assist in denial reduction in future and payments in the bank. Check the Ordering Referring Report—This file contains the NPI and names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer. CMS updates the report on a periodic basis, and each document includes a create date. This file is available at Claim submission—If the physician or non-physician practitioner appears on the file, follow these tips to avoid denials for invalid format of ordering physician and non-physician practitioner names. File a new claim. No need to file an appeal if you received a claim denial. Ensure you are correctly spelling the ordering/referring provider’s name. Use the name and NPI exactly as it appears on the Ordering Referring Report which comes directly from PECOS. Edits will compare the first four letters of the last name. Do not use nicknames on the claim, as they could cause the claim to fail the edits. Do not enter a credential (e.g., Dr.) in a name field. Special characters, such as apostrophes or hyphens, appear in some names on the PECOS list and should be submitted on the claim as such. Spaces must also be present as depicted on the CMS PECOS list. Enter the last name in the last name field and first name in the first name field. On paper claims (CMS-1500), enter the ordering provider’s first name first, and last name second (e.g., John Smith), in Item 17. On electronic claims, ensure that you are not submitting the last name in the first name field or vice versa. Ensure that the name and the NPI you enter for the ordering/referring provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral. Make sure that the qualifier in the electronic claim 2420E NM102 loop is a one (person). Qualifier two (organizations) cannot order and refer. CMS Ordering Referring Report—Any applications processed after the create date will not appear on the report until it is next updated. Services ordered by a physician who is not enrolled in Medicare will be denied. Check the report weekly for newly enrolled providers.