Last month, CMS again announced that Phase II of their troubled PECOS program would be activated beginning on January 6, 2014. Earlier this week, CMS finally got around to releasing updated guidance to physicians informing them of the requirements they must fulfill in order to refer their patients for orthotics and prosthetics, and for associated claims to be paid.
Phase II 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. After delaying Phase 2 implementation indefinitely multiple times, most recently on May 1, 2013, CMS announced this week that the troubled PECOS system will begin denying durable medical equipment, orthotic and prosthetic supplies (DMEPOS), Part B, and Part A home health agency claims if the referring physician is not enrolled to refer for that particular category beginning on January 6, 2014. CMS is required to provide 60 days notice prior to implementing Phase 2.
Phase I 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, or rather, the 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 II, only to delay it on multiple occasions because of 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. You may access that at:
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 the referring physicians are properly registered, meaning your physicians checked the box on their 855s enrollment form to refer for orthotics and prosthetics. Orthotic and prosthetic providers should also ensure they submit claims using the individual clinician NPI number, rather than the organization.
Additional information on the PECOS program and information that can be provided to your local referring physicians can be found here: