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Medicine Seeks to Halt to Mandatory PECOS Enrollment
On Oct. 5, Medicare implemented the first phase of a new policy requiring physicians who order or refer services to be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) database. Physicians will not be paid by CMS if the physician who refers a patient to the billing physician is not enrolled in PECOS by January (when the new policy is fully implemented). Currently, billing physicians receive a warning edit that makes it appear a claim has been denied. A major flaw in this new system is that the billing physician has no control over whether the referring physician is in PECOS. Physicians who enrolled in Medicare prior to 2003, when PECOS was created, need to re-enroll through PECOS before January 2010. As of now, more than 10,000 ophthalmologists have taken this step, but as many as 8,000 more could face problems if appropriate action is not taken. The Academy is working with the AMA and other groups to urge CMS to delay the policy because it could bog down the enrollment system and present significant workflow challenges for physicians and other health care practitioners. More information about PECOS is on the CMS Web site.
PECOS Phase Two Deadline Delayed (CMS Update, Nov. 23, 2009)
The Centers for Medicare & Medicaid Services (CMS) will delay, until April 5, 2010, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)). CRs 6417 and 6421 are applicable to Part B claims only.
The delay in implementing Phase 2 of these CRs will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.
Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non-physician practitioner’s National Provider Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.
CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.
For physicians and non-physician practitioners who order or refer— - If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs.gov/MedicareProviderSupEnroll.
- If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.
- If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
- If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
- If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.
CMS actions to mitigate the number of informational messages:
Since many Part B providers and suppliers are receiving a high volume of informational messages in their Remittances, CMS is taking the following actions to reduce the number of informational messages being generated: - Prior to the implementation of Phase 2, CMS will systematically add the NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose enrollment records are in PECOS but do not contain their NPIs. Because the NPI is one of the matching criteria used in implementing the two new edits on the Ordering/Referring Provider, it is essential that the NPI be in the PECOS enrollment record. Because the data file used to implement the two edits contains only the eligible physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will add many more physicians and non-physician practitioners to that data file.
- Prior to the implementation of Phase 2, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program. The name displayed will be that of the physician or non-physician practitioner as it appears in his or her PECOS enrollment record. This will allow Part B providers and suppliers who furnish and bill for items or services based on orders or referrals to determine if the Ordering/Referring Provider being identified in their claims will pass the two new edits prior to submitting the claims to Medicare.
- Prior to the implementation of Phase 2, CMS will issue instructions to carriers and A/B MACs that will assist them in processing enrollment applications from physicians who are employed by the Department of Veterans Affairs, the Public Health Service, and the Department of Defense Tricare program. The instructions will also state that the teaching physician should be reported as the Ordering/Referring Physician in situations where a resident orders or refers items or services for Medicare beneficiaries. The instructions will also note that dentists and pediatricians, who sometimes order or refer items or services for Medicare beneficiaries, may be enrolling in Medicare in order to continue to order and refer.
- CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters Article on the implementation of these two new edits. This MLN Matters Article will expand upon the information currently available in MLN Matters Articles MM 6417 and MM 6421.
Practice Expense Update Phase-in
CMS has decided to phase-in implementation of the new Practicing Physician Information Survey (PPIS), which will rescale the practice expense (PE) payments for most specialties. Rather than fully implement the new data in 2010, CMS decided to phase in the updates due to the dramatic swing in payments and to pressure from specialties adversely impacted by the changes proposed in PE allocations. Ophthalmology will now see an increase in its PE values of 11 percent over the next four years. Three percent of ophthalmology’s increase comes in 2010. The compromise is not expected to satisfy specialties that are adversely impacted, and they are expected to continue their push to derail implementation of the PPIS data. Academy intelligence indicates the Senate is considering legislation that restores those specialties to their current rates, without penalizing specialties (including ophthalmology) that are due the PE payment increase. The one-year agreement, costing about $1 billion, is to allow specialties facing cuts to work out issues with CMS. The Academy will remain vigilant to ensure that further erosion in ophthalmology’s rates is not included in Medicare and health care reform legislation.
Academy Interprets Necessity of DMEPOS Surety Bond
Ophthalmologists who have optical shops within their practice should not need the bonds unless the shop is purely a dispensary and does not provide typical services for Medicare beneficiaries who come in for post-cataract glasses with an outside prescription. The Academy believes such patients are your patient for the provision of the DMEPOS item (post-cataract eyeglasses) if you treat them as your other surgical patients and provide the normal course of services, including: - Reviewing the prescription;
- Fabricating the lenses and fit them into the selected frames;
- Fitting the frames to the patient; and
- Checking visual acuity.
Recently, the National Supplier Clearinghouse posted language on its Web site stating that it believes patients who are not given an “exam or test” are not the patients of your practice, thus necessitating a bond if such individuals are seen in your optical shop. Academy questions to CMS to clarify the meaning of “exam or test” have gone unanswered.
CMS Releases Final 2010 Medicare ASC Payment Rule
In addition to releasing its Final 2010 Physician Fee Schedule on Oct. 30, CMS also released its 2010 ASC payment rates and policies. Although Medicare continues to transition in its new payment methodology for 2010, and payments are migrating to a larger percentage of the new method, rates are variable due to several factors. ASCs, which have not seen an update in payments since 2004, will see a 1.1 percent increase in their conversion factor, with a 2010 factor set at $41.873 (a 50-cent increase from last year). CMS continues to base any update on the Consumer Price Index rather than the Academy-advocated hospital market basket. CMS is also still using two budget neutrality adjustments which the Academy, in coordination with the Outpatient Ophthalmic Surgery Society and the Ambulatory Surgery Center Association, has been opposing.
CMS continues to refuse to allow unlisted codes (including eye codes) to be added to the ASC list, despite a detailed explanation of why such eye procedures are safe and appropriate for ASCs. One eye procedure is being removed from the ASC list, 21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (e.g., microophthalmia). Medicare has again delayed requiring ASCs to report quality data. Therefore, ASCs will not be required by Medicare to report quality data in 2010. Further, because CMS disagrees with Medicare Payment Advisory Commission recommendations.
The revised Ambulatory Surgical Center Fee Schedule Fact Sheet (January 2010), which provides general information about the Ambulatory Surgical Center (ASC) Fee Schedule, ASC payments, and how ASC payment amounts are determined, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network.
Academy, AOA Call on FTC to Reinstate Contact Complaint Process
The Fairness to Contact Lens Consumers Act (FCLCA) mandates that eye care practitioners, including ophthalmologists, release contact lens prescriptions to their patients. It also requires contact lens sellers to verify the validity of prescriptions before releasing lenses to consumers. When online sellers neglect to verify each prescription with a patient’s provider, the provider can file a complaint with the Federal Trade Commission (FTC). In the past, an FCLCA complaint form was available on the FTC Web site. Recently, however, the Academy learned that the FTC eliminated the FCLCA complaint form and providers are being directed to the general FTC consumer “complaint assistant.” The new process has proved insufficient to handle prescriber complaints about contact lens sellers who are not following the requirements of the FCLCA. The Academy and the American Optometric Association have sent a joint letter (PDF 56K) to FTC Chairman William E. Kovacic, urging him to make the FCLCA complaint form accessible again.
AMA Clarifies Medicare Advantage Fraud Training
The AMA has clarified fraud-compliance training requirements (PDF 59K) for physicians who participate in Medicare Advantage (MA). Several Academy members have received notices from MA plans, saying fraud-compliance training was required. CMS clarifies that MA plans may provide training directly or may provide appropriate training materials. The clarification does not say MA plans must certify physicians in its network. It is up to a practice to determine if it wants to participate in the MA fraud compliance training. The Academy will work with the AMA on further clarification. TOP
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