Avoid Denials for Provider Enrollment, Chain and Ownership System (PECOS) Ordering/Referring Physician Edits

Posted December 19, 2013

Claims that fail the Ordering/Referring physician edits with dates of service on or after January 06, 2014 will be denied.

Prior to dates of service January 06, 2014 suppliers received the informational N544 message on their remittance advice for claims that failed the Ordering/Referring physician edits.

N544 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.

Medicare will only reimburse for specific items or services when those items or services are ordered by providers or suppliers authorized by Medicare statute and regulation to do so. Claims from billing providers and suppliers that are denied because they failed the Ordering/Referring edit will not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation.

If the claim did not initially pass the Ordering/Referring provider edits and is denied:

  • Verify the ordering/referring information submitted was an exact match with the PECOS record.
    • If the information submitted did not match the PECOS record, correct and resubmit the claim.
    • If the exact information was submitted, file an appeal through the standard claims appeals process.

CMS has highlighted the following limitations:

  • 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.

To avoid claim denials

  1. Confirm the provider is a specialty that can order DMEPOS. The following is a list of those eligible to order and refer items/services for Medicare beneficiaries:
    • 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
  2. Verify that the ordering physician's National Provider Identifier (NPI) is on the list of physicians and other non-physician practitioners enrolled in PECOS. This can be done by:
    1. Checking the CMS ordering/referring provider downloadable report which contains the NPI, first name, and last name of providers enrolled in PECOS located on the CMS Web site at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring
    2. Calling the NHIC, Corp. DME MAC IVR, 866-419-9458 and select Option 8; enter the NPI, first and last name of the referring provider. The IVR will respond if the individual is or is not enrolled in PECOS.
  3. Ensure that the Ordering/Referring Provider's name is entered correctly on the claim. The edits will compare the first four letters of the last name.
    • Do not use "nicknames" on the claim, as this could cause the claim to fail the edits.
    • Do not enter a credential (e.g., "Dr.") in a name field.
    • On paper claims (CMS-1500), enter the ordering provider's first name first, and last name second (e.g., John Smith), in Item 17 and only include the first and last name as it appears on the ordering and referring file.
    • Ensure that the name and the NPI 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 who generated the order.
    • On electronic claims, ensure that you are not submitting the last name in the first name field and vice versa.
    • Confirm the ordering physician's name is spelled correctly as listed in the PECOS listing and that the qualifier in the 2310A NM102 loop is a 1 (person). Organizations (qualifier 2) cannot order and refer.

Example:

The following are examples which would fail the PECOS ordering/referring physician edits. The table includes the physician's name as submitted by the supplier, the physician's name on the PECOS file, the four characters of the last name the DME MAC would be comparing and the 4 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. This claims 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.

Supplier Submitted PECOS File Last Name: 4 Character Match - DME MA Last Name: 4 Character Match - PECOS
MACIE DE LUNA MACIE DELUNA DELU DELU
JANE TAM PARRO JANE PARRO TAM PARR
BRIANNE TAPAS BRIANNE TAPES TAPA TAPE
LEE KYING KYING LEE KYIN LEE

 

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

Additional information is available at:

 

            Last Updated Thu, 19 Dec 2019 11:00:27 +0000