Update on Ordering/Referring Physician PECOS Mandate and Claim Denial Phase

As reported over the past few months, CMS published 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)” on February 26, 2010 with an implementation date of January 3, 2011. 

This was the instruction to begin denying claims for physicians who were listed as Ordering/Referring Physicians on the claim form who had not set up a record in the Provider Enrollment Chain Ownership System (PECOS) as of January 3, 2011.

In the meantime, there was confusion generated due to the publication of an interim final rule “CMS-6010-IFC Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements” on May 5, 2010 that set the effective date of the claim denial phase for the Ordering/Referring Physician PECOS mandate to July 6, 2010.

However, this interim final rule is still in a comment period and CMS has not released any change to the January 3, 2011 implementation date. 

This means that without additional instruction from the CMS, Medicare will not begin rejecting Part B claims that fail the Ordering/Referring Provider edits until January 3, 2011. 

In any event, physicians are urged to set up a record in the PECOS system.

For guidance on this issue, contact us through the Third Party Insurance Help Program.

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James A. McNally, CPC

Health Care Consultant Services