PECOS Clarification

The previous announcement made by the Centers for Medicare & Medicaid Services (CMS) that beginning January 3, 2011, claims for certain ordered/referred Part B items and services will not be paid if the ordering/referring provider on the claim does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), has been rescinded.  The new "placeholder" implementation date for this Patient Protection and Affordable Care Act (PPACA) provision-known as Phase 2-is July 5, 2011.

CMS Issues Revised CR 64117

However, on January 12, 2011 CMS issued a revised CR 6417 to clarify that a date has not been set as to when it will begin to reject claims if an ordering/referring provider does not have a PECOS record.

"This placeholder date is being issued [for business requirements only] to give CMS more flexibility to determine the appropriate date for nonpayment of claims that fail the ordering/referring provider edits," CMS announced on December 16, 2010.

Phase 2

Phase 2 would complete the current scope of editing for ordering and referring providers for Medicare claims. Once this phase is officially implemented, providers can no longer use their National Provider Identifier (NPI) as the NPI of the ordering/referring provider. Physicians and non-physician practitioners (NPPs) need to be uniquely identified with their own NPI and be Medicare enrolled and also be uniquely identified on claims for ordered/referred services provided to Medicare patients.

Awaiting Official Implementation Date

Until an official implementation date is established, claims for ordered or certified items and services will be not be rejected due to the lack of the ordering/referring provider having an approved enrollment record in PECOS. Contractors will continue with Phase 1, which is to continue processing claims  but adding remark messages N264 Missing/incomplete/invalid ordering physician provider name and N265 Missing/incomplete/invalid ordering physician primary identifier to the remittance advice.

You can refer to the Ordering and Referring Report on the CMS website if you are concerned or uncertain about whether you have been enrolled in PECOS.

http://www.cms.gov/MedicareProviderSupEnroll/06_
MedicareOrderingandReferring.asp

Source: AAPC Industry News