OPBS News

PECOS REJECTIONS DELAYED

2010-02-19T09:14:00.006-06:00

CMS has just announced a new implementation date for PECOS rejections of January 3, 2011. CMS announced this delay yesterday. Prior to this announcement CMS maintained that implementation of rejections would begin to occur on April 4, 2010 for any services ordered by physicians who are not in PECOS. Suppliers will continue to get warnings on their remittance notices when your referring physician is not in PECOS, but claim rejections will not happen until next year. At some point during 2010, CMS will send letters directly to any physician not in PECOS, telling them that they must reenroll or they will not be able to make referrals. CMS staff also has indicated that the PECOS system will become available for DMEPOS supplier enrollment some time in 2010. We will notify you of any new information as it is announced.

Medicare 2010 Claim Alert

2010-01-06T09:47:00.001-06:00

CMS has issued a notice stating that claims submitted between January 1, 2010, and January 15, 2010, for 2010 dates of service will be held pending final review of the Medicare Physician Fee Schedule (MPFS). CMS will release claims for payment on January 19, 2010.

Claims for dates of service on or before December 31, 2009, will be processed and paid under normal procedures.

PECOS REQUIREMENT

2009-12-15T09:08:00.002-06:00

CMS' January 4, 2010 deadline requiring physicians to be registered with PECOS in order to write a valid prescription. No registration would result in no reimbursement to the O and P facility providing services under the unregistered physician's prescription. CMS agreed to delay implementaion until April 1, 2010 and promised that the PECOS physician regisrty will be on line before the program goes into effect.
The effective date was postponed to provide time to educate physicians and facilities the requirements.

CMS/PECOS REQUIREMENTS FOR ALL DME MACs

2009-11-04T11:30:00.016-06:00

This article was revised on September 14, 2009, to add clarifying language to emphasize that billed services requiring an ordering/referring provider on the claim must contain the ordering/referring provider under both phases of this change or the claim will not be paid.

This article is based on change request which requires Medicare implementation of system edits to assure that DMEPOS suppliers bill for items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services.Physician and non-physician practitioners must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and of the type/specialty eligible to order/refer services for Medicare beneficiaries. Be sure billing staff are aware of these changes that will impact DMEPOS claims received and processed on or after October 5, 2009.

The two phases are list below:

During Phase 1 (October 5, 2009-January 3, 2010):
If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard
electronic claim, the DMEPOS supplier will receive a warning
message on the Common Electronic Data Interchange (CEDI)
GenResponse Report.
2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the
DMEPOS supplier will not receive a warning and will not know that
the claim did not pass these edits.

During Phase 2, (January 4, 2010 and thereafter):
If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

Below is a link found that might help in checking if a physician is enrolled in PECOS? it looks like this is a list of providers who accept assignment. Please play around with it and see what you find.
We suggest that you select a few with the green symbol beside them and personally call and ask if they are PECOS enrolled. Please let us know your feedback and the results from your phone calls. CLICK HERE TO FIND OUT IF YOUR PHYSICIANS IS ENROLLED IN PECOS

Upcoming Changes to the Orthopedic Shoe Policy

2009-10-07T11:04:00.001-05:00

Beginning October 1 each claim line for orthopedic shoes must include the KX or the GY modifier. If the items you are providing meet the coverage criteria set forth in the policy, each claim line would include a KX modifier. If an item does not meet the coverage criteria or is a non-covered item (i.e. shoes not attached to a brace) the claim line must include the GY modifier and this claim line will be denied. Therefore, each shoe, insert or modification must include either the KX or the GY modifier. If a claim line doesn't include a modifier, then that line will be rejected and you will have to resubmit that claim line with the appropriate modifier.

Medicare/Consignment Closets

2009-09-04T14:29:00.003-05:00

The Centers for Medicare & Medicaid Services (CMS) has announced changes to the compliance standard for consignment closets and stock and bill arrangements. In such arrangements, ?an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather, owned by a physician, non-physician practitioner or other health care professional for the purpose of distribution,? according to CMS. The changes are effective March, 2010.

Although most consignment closet or stock and bill arrangements do not satisfy the DMEPOS supplier standards, CMS has identified a limited arrangement that may be permissible. This scenario involves a DMEPOS supplier selling DMEPOS items to the practice of the physician or other non-physician practitioner, and the billing and furnishing of a DMEPOS item(s) would be done by the physician or non-physician practitioner, each arrangement will be evaluated on a case by case basis. The CMS wants to ensure that beneficiaries are aware that the enrolled supplier who has billed Medicare on their behalf has furnished their DMEPOS item(s).

New Prothetics Bill signed in Iowa

2009-07-30T13:05:00.005-05:00

Governor Chet Culver of Iowa signed a bill that prosthetic devices must be covered by insurance, if they are medically necessary. The health insurance mandate affects only state-regulated health insurance policies - which means plans held typically by smaller businesses and individuals. Larger companies' insurance plans are typically regulated by the federal government.

Protect your Practice from Recovery Audit Contractor's (RAC).

CMS will continue with the implementation of the RAC( Recovery Audit Contractors) program. By 2010, CMS plans to have 4 RAC's in place. Each RAC will be responsible for identifying overpayment and underpayments in approximately 1/4 of the country. The RAC demonstration program has proven to be successful in returning dollars to the Medicare trust funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments. You may visit CMS website at http://www.cmshhs.gov/ for more information.

Confused About Billing?

2009-06-18T10:12:00.010-05:00

Billing & Coding Workshop Designed Specifically for O & P Facilities

This Workshop is Presented by CARIS Innovation, Inc.
&
O & P Billing Solutions, Inc.

Date of Workshop: November 18, 2009
Session 1: 8:30 am - 12:00 pm
Session 2: 1:00 pm - 4:30 pm

Continuing Education Credits: 3.5

Location:
Holiday Inn Express and Suites
309 St. Hwy 114 West
Grapevine, TX 76051

Click link below to download your register form for this Workshop!

Workshop Registration Form

Accreditation Mandatory

2009-05-05T15:51:00.003-05:00

Effective May 4, 2009

Medicare liability insurance requirments, which currently are $300, 000. This clarification would change that to 300,000 per incident and would require that such liability insurance be obtained prior to submitting an enrollment application. Since Medicare requires that it be able to verify the insurance not only with the insurance agent but also with the underwriter, it means that there may be a significant delay between the time the insurance application is approved and the time that the supplier may submit a Medicare enrollment application. There is often a lag of several months between insurance and notification of the underwriter.

Effective Oct 2, 2009

The mandatory accreditation date for individual facilities will vary, depending on whether or not your facility already has an NPI number and is enrolled to provide Medicare services. For DME facilities that already have an NPI and Medicare TPAN number, accreditation is not required until October 2, 2009. New DME facilities, including new branch offices of existing facilities, must become accredited before they can submit their application for a PTAN number to the National Suplier Clearinghouse.

Changes in DME MAC Medical Policy

2009-04-08T09:37:00.021-05:00

The DME MAC's have announced and released the following changes .

AFO/KAFO, KO, TLSO/LSO Policy
Medicare made the decision that the elastic braces and code L2770 are no longer a covered benefit. Medicare has added the following new diagnosis codes ICD-9 844.2 and 996.40 - 996.49, these codes will be acceptable for the following braces L1830, L1832, L1834, and L1843-L1846. KX modifier will need to be added to the base code and any additional codes used. The new CG Modifier should only be used when providing a flexible LSO/TLSO made of non-elastic material or it should have a solid posterior panel.