CMS recently announced that they will move forward with Phase 2 of the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) program, creating more headaches for those filing orthotic and prosthetic claims for Medicare patients. Beginning May 1, 2013, CMS will deny durable medical equipment, orthotic and prosthetic supplies (DMEPOS), Part B, and Part A home health agency claims if the referring physician is not enrolled in the PECOS system.
Phase 1 of the PECOS system began in October 2009. At that time, CMS started warning DMEPOS providers who were submitting claims ordered by clinicians who were not yet enrolled in PECOS. Due to the high number of warnings, IE, high number of referring physicians and providers that had not signed up on PECOS, CMS was forced to delay the implementation. This gave physicians and providers additional time to register on PECOS and delayed the direct denial of claims due to a lack of physicians signing up. CMS has since attempted to implement Phase 2, only to delay it on multiple occasions due to a lack of physician involvement.
CMS now estimates that less than 1% of physicians and providers who order and refer DMEPOS patients have not enrolled in PECOS as of February 2013. CMS has provided a tool to search if your referring physicians are currently enrolled in PECOS, or if you should approach them with more information. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html
I must reiterate, if your referring physicians/providers are not properly registered for PECOS you will not be paid for any claims submitted from that physician. Much like our problems on documentation requirements and medical necessity audits, CMS has again put the onus on orthotic and prosthetic providers, by withholding payments, to ensure our referring physicians are properly registered. Orthotic and prosthetic providers should also ensure they submit claims using the individual clinician NPI number, rather than the organization.
If one of your local physicians is not listed in the search tool above, consider sending them a “Dear Physician” letter to inform them of the changes to billing for DMEPOS referrals.