Enroll in Provider Enrollment Chain and Ownership System by January 3 for CMS payments; documentation aids in claims payments and appeals

December 3, 2010

Learn of new PECOS regulations to ensure reimbursement in 2011.

Q: The physicians in our practice order lab tests that are conducted in-house. To date, our claims have been paid, but we have received messages on our remittance advice that claims failed the ordering/referring provider edits. What does this mean?

The first phase of the 2-phase process began October 5, 2009, when the agency required that the ordering or referring provider be reported on Medicare claims. If the ordering/referring provider is not listed, then the claim will not be paid.

Beginning January 3, however, CMS will reject Part B claims that fail the ordering/referring provider edits and will not pay these claims unless the providers have enrolled in PECOS.

To ensure that the providers in your practice are enrolled in PECOS, visit http://www.cms.gov/Medicare ProviderSupEnroll and click on "OrderingReferringReport." The national provider identifiers and names of providers who have current PECOS enrollment records will be listed. Providers in your practice who are not listed will need to be enrolled at the aforementioned Web address (click on "Internet-based PECOS") or via the paper form that can be downloaded at http://www.cms.gov/cmsforms (click on "Provider Enrollment"). CMS can take 45 to 60 days-and sometimes longer-to process enrollment applications, so time is of the essence.

DOCUMENTATION AIDS IN CLAIMS PAYMENTS, APPEALS

Q: Recently, a claim I sent to Medicare was denied. The claim had 2 lines: 1) 99213 with the 25 modifier and diagnosis codes 919.8 (excoriation skin) and 881.00 (open wound of elbow, forearm), and 2) 11043 (debride tissue/muscle) with diagnosis code 881.00 (open wound of elbow, forearm). What can I do?

A: Without the denial reason listed on your remittance advice, I am not able to give you specifics, but we can examine this claim to highlight the questions you can answer to bill a clean claim or to ensure a solid basis for an appeal.

The author is a medical consultant based in Indianapolis, Indiana. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to medec@advanstar.com