NAHC Participates in Call with CMS on Phase II PECOS Edits

The National Association for Home Care & Hospice participated in a conference call with the Centers for Medicare & Medicaid Services on April 3, 2013 to discuss Phase II of the PECOS edit activation. During the call, NAHC reported on the information collected from home health agencies about ongoing physician enrollment problems, the findings of one CMS contractor that as many as 4 percent of claims could be subject to denial, and the large number of Veteran’s Administration and military hospitals that have failed to enroll physicians who order and refer for Medicare home health services.

CMS asked NAHC to remind providers that they must submit the physician’s name with his/her individual NPI, rather than a group NPI. According to CMS, about 1 percent or the errors found during Phase I were the result of home health claims submitted with the physician’s group NPIs.

Below are responses provided by CMS to several outstanding PECOS questions. NAHC will continue to provide additional answers and updates about the May 1 PECOS edit activation as soon as they are received.

Will the edits be against PECOS only or will they be applied to other files of Medicare enrolled physician (i.e. legacy files)? CMS will edit home health claims against PECOS. However, since there are still “a couple of thousand” physicians who have not been transitioned to PECOS, the PECOS edits will be supplemented by a check of legacy files. Note: PECOS edits refer to edits against both PECOS files and legacy files from this point forward

Where are opt-out physicians listed? In enforcing the statutory requirement that physicians be enrolled in Medicare to order or refer services, physicians who have validly opted out of Medicare are treated as if they were enrolled – for purposes of the ordering and referring edits. If the physician has validly opted out of Medicare, his/her certifications for home health care will not be denied for lack of an approved enrollment record in Medicare.

CMS has made the Ordering Referring Report, containing the NPIs and legal names of physicians and other eligible professionals who have approved enrollment or valid opt-out records in PECOS available, and are encouraging providers and suppliers to view this report at

Can you explain the reason physicians are dropping off the Ordering and Referring File? Could these physicians still be receiving payment from Medicare using a group NPI? Physicians who fail to respond to revalidation notices or provide requested information (e.g. license number, IRS information, etc.) will be considered to have “voluntarily withdrawn” from Medicare. Their names will be removed from the Ordering and Referring File. Also, opt-out physicians who fail to renew their opt-out status every two years will be removed. Medicare payments will not be made for any physician that that has withdrawn or been terminated regardless of whether their claims are submitted using an individual or group number.

Will home health agencies be paid for services ordered by a physician who has had a gap in their enrollment? Medicare payments will be made only for those dates of home health services provided while the ordering physician is actively enrolled in Medicare. Physicians who failed to respond to revalidation notices within the 60-day timeline will have their provider number deactivated. If deactivated, but respond by day 120, they will be retroactively reactivated without a gap (i.e. ordering and referring authority retroactively restored). However, if they fail to respond by day 120, they must reenroll and will be assigned a new date of enrollment (ordering and referring authority terminated as of day 60).

The PECOS Ordering and Referring files do not include the date of physician enrollment. Since home health payments will be based on whether the ordering physician was enrolled in PECOS at the time services were provided, rather than at the time claims were submitted, how will home health agencies identify and track the effective dates of physicians’ PECOS enrollment? CMS will not provide this information to providers. Physicians’ date of enrollment is in both physicians’ effective date for billing Medicare notification letters and in the physicians’ PECOS files. Home health agencies must contact the physicians for this information in cases where they have concerns about an initial effective date or a gap in enrollment.

Will home health episodes that begin prior to but end subsequent to May 1 be paid in full? CMS will get back to NAHC with the answer to this question.

Must physicians that order additional visits be enrolled? The PECOS edits will look at whether the primary ordering physician is enrolled only. Determination of coverage of services by secondary physicians who are not enrolled in PECOS is the responsibility of other groups at CMS.

If an HHA receives a $0.00 payment on a RAP because the ordering physician is not enrolled in PECOS, should the agency cancel and resubmit the RAP with new information – i.e. corrected physician name and/or NPI, or the name of a different (enrolled) physician? Yes, if a RAP is paid at $0.00 because the physician is not enrolled or validly opted out of Medicare, home health agencies may cancel these RAPs and resubmit them once correct information is available.

The HHABN issue remains puzzling since this is not a notice of non-coverage. Should agencies use Option Box 2-business reasons? May home health agencies hold beneficiaries financially liable? Internal discussions are underway about beneficiary liability and beneficiary notices with the appropriate parties at CMS. CMS will get back to NAHC with the answers.

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April 9TH, 2013