PECOS Warnings Are Back on DME Claims

Starting Jan. 1, the four DME MACs once again began attaching warning messages related to physicians who are not registered in Medicare's Provider Enrollment, Chain, and Ownership System (PECOS).

The warnings will be attached, according to a National Government Services (NGS) bulletin, "if the ordering or referring provider on the claim is not eligible to order or refer DME supplies as determined from PECOS."

In those cases, DME suppliers and complex rehab technology providers can expect to see Remittance Advice Remark Code N544, which states, "Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected, this will not be paid in the future."

The messages will be returned on Electronic Remittance Advice and Standard Paper Remits and will apply to 4010A1 and 5010A1 formatted claims, the bulletin noted.

The bulletin added that the Common Electronic Data Interchange (CEDI) "will continue to return the PECOS warning edits for 4010A1 claims on the GenResponse report" through Jan. 29 of this year.

But there was no indication of when those warnings would become actual denials.

"CMS and the DME MACs will communicate when the edits will become denials when that date is determined," the bulletin said.

The PECOS saga started in earnest in late 2009 and has already gone through multiple implementation delays...albeit not before causing multiple headaches for suppliers.

In October 2009, CMS began notifying suppliers when claims for DME had been prescribed by a physician or practitioner who was not enrolled in PECOS. The long-term plan: Starting in January 2010, CMS would stop issuing warnings and start denying claims if prescribers weren't in PECOS.

When suppliers expressed concern for the large percentage of claims that contained PECOS-related warnings, CMS urged suppliers to educate prescribers about the PECOS requirement.

CMS also reached out to prescribing physicians - as well as to non-physician practitioners, such as nurse practitioners, physician assistants and clinical social workers - to tell them they needed to register in PECOS to retain their DME-prescribing authority.

Suppliers also pointed out that the PECOS registration process was time consuming and lengthy, easily taking 60 days or more to complete. That would make it difficult for the many thousands of physicians who wanted to retain their Medicare DME-prescribing privileges to register in such a short timeframe. And since Medicare planned to continue to pay physicians' own claims regardless of whether they registered in PECOS or not, suppliers worried that physicians would not feel motivated to register in PECOS in a timely fashion.

The PECOS January 2010 implementation was postponed till April 5, 2010; a second postponement then pushed the implementation date to Jan. 3, 2011.

But in November 2010, CMS indicated implementation would not happen on Jan. 3 and did not give a new implementation date.

In June 2011, CMS sent out a reminder saying no implementation date had been set, but that it would give providers "ample notice before the ordering/referring provider claim edit is applied."

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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