PECOS Edits - JA DME

PECOS is the online Medicare enrollment management system for providers and suppliers which allows:

• Enrollment as a Medicare provider or supplier
• Revalidating (renew) enrollment
• Withdrawing from the Medicare program
• Review and update provider or supplier information
• Report changes to enrollment record
• Electronically sign and submit information

Only physicians and certain types of non-physician practitioners are eligible to order or refer items or services for Medicare beneficiaries. They are as follows:

• Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry),
• Physician Assistants,
• Clinical Nurse Specialists,
• Nurse Practitioners,
• Clinical Psychologists,
• Interns, Residents, and Fellows,
• Certified Nurse Midwives, and
• Clinical Social Workers.

Medicare will only reimburse for specific items or services when ordered by providers or suppliers authorized by Medicare statute and regulation to do so. Claims that a billing provider or supplier submits in which the ordering provider is not authorized by statute and regulation will be denied as a non-covered service. The denial will be based on the fact that neither statute nor regulation allows coverage of certain services when ordered or referred by the identified supplier or provider specialty. This means that if they are not registered through PECOS, they are unable to order or refer to Medicare beneficiaries.

Interns or residents who have been assigned an NPI must also be registered and active in PECOS for their NPI to be used on Medicare claims and for the claim to be paid. See more guidance below:

Orders or referrals by interns or residents: The IFC (interim final rule with comment period) mandated that all interns and residents who order and refer specify the name and NPI of a teaching physician (i.e., the name and NPI of the teaching physician would have been required on the claim for service(s)). The final rule states that State-licensed residents may enroll to order and/or refer and may be listed on claims. Claims for covered items and services from un-licensed interns and residents must still specify the name and NPI of the teaching physician. However, if States provide provisional licenses or otherwise permit residents to order and refer services, CMS will allow interns and residents to enroll to order and refer, consistent with State law.

• Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.
• Optometrists may only order and refer DMEPOS products/services, and laboratory and x-ray services payable under Medicare Part B.

Claim Submission - Ordering/Referring Provider on Claim

• Medicare will verify that the ordering/referring provider
• NPI is in PECOS and eligible to order and refer
• Is in PECOS and is the specialty to order or refer 
• Name submitted on the claim matches the provider's name in PECOS

• When these edits are not met, the claim will be denied

Claim Denial

If claim denies, the remittance advice will display the following codes when due to an error in the ordering physician NPI:

• Reason code 16, Remark code N265 - Missing/incomplete/invalid ordering provider primary identifier
• Reason code 16, Remark code N276 - Missing/incomplete/invalid other payer referring provider identifier

Correct claim and resubmit with a valid ordering physician NPI registered in PECOS.

Take the following steps in the order listed to correct the claim and avoid claim rejections:

1. Check to see whether the provider is a specialty that can order DMEPOS.
• Noridian has seen claims ordered by physical and occupational therapists, massage therapists, opticians and others who are enrolled in PECOS or may have an NPI, but these heath care personnel are not allowed by statute to order DME for Medicare purposes.
2. Verify that the ordering physician NPI is on the list of physicians and other non-physician practitioners enrolled in PECOS. This can be done by:
• Checking the CMS PECOS NPI Look-Up File containing the NPI, first name, and last name of providers enrolled in PECOS.
• Note: This file contains approximately 2,600,000 records. A new file will be made available quarterly that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be viewed online or be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Additional notes about this list:
• Records are in alphabetical order based on the surname of the physician or non-physician practitioner.
• Name suffixes (e.g., Jr.), if they exist, are not displayed.
• There are no "duplicates" in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness.
• Deceased physicians and non-physician practitioners are not included in the file.
• If a user is unsure of a physician or non-physician practitioner's NPI, he or she can look it up in the NPI Registry.
3. Ensure you are correctly entering the Ordering/Referring Provider's name on the claim as listed in PECOS.
4. Do not use "nicknames" on the claim, as their use could cause the claim to fail the edits.
5. Do not enter a credential (e.g., "Dr.") in a name field.
6. On paper claims (CMS-1500), in item 17, enter the ordering provider's first name first, and last name second (e.g., John Smith).
7. Special characters, such as ' or - appear in some names on the PECOS list and should be submitted on the claim as such. Spaces must also be present as depicted on the CMS PECOS list.
8. Ensure that the name and the NPI entered for the ordering provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner.
• Ensure that the qualifier in the electronic claim (2310A NM102 loop) is a 1 (person). Organizations (qualifier 2) cannot order and refer.
• Make sure on electronic and paper claims that you are not submitting the last name in the first name field and vice versa.
9. If name is corrected on claim, ensure physician/practitioner information is updated/corrected in billing software for future claims.

When receive denial, correct claim and resubmit with a valid ordering physician NPI registered in PECOS.

DME Ordering Physician Deactivated

• Physician is deactivated from PECOS
• Capped rental items will process up to total of 13 months after deactivation
• Rentals not completed in that timeframe will require a new ordering physician
• This only applies to items in capped rental category, all other items will be denied after the deactivation date and a new ordering physician would be required for all other items.
• i.e., Prosthetics and Orthotics, Oxygen and Oxygen Equipment, Inexpensive and Routinely Purchased Items, and supplies

Top Ordering/Referring Submission Errors

• Supplier interchanging first and last name of referring physician
• Supplier submitting the organizational NPI of referring physician
• Nurse Practitioners/Interns not enrolled in Medicare
• Supplier submitted last name not matching PECOS

The following table are examples which would fail the PECOS ordering/referring physician edits. The table includes:

• Physician's name as submitted by the supplier
• Physician's name on the PECOS file
• First four characters of the last name the DME MAC would be comparing
• First four characters of the last name as listed in the PECOS file

In the first example, the supplier submitted the ordering physician's name as MACIE DE LUNA; the name is listed as MACIE DELUNA in the PECOS file with a space between the second and third character. This claim would fail the edits due to the first four letters on the last name submitted on the claim does not match the first four letters of the last name in the PECOS file.

Resources

• CMS Change Request (CR) 6421
• MLN Matters Number: SE1305
• Become a Medicare Provider or Supplier | CMS