CMS Issues New Enrollment, Ordering and Referring and Documentation Requirements - Effective July 6, 2010
By: KATHERINE B. ILTEN
July 19, 2010
CMS recently published a final rule implementing provisions of the Patient Protection and Affordable Care Act (PPACA) that sets forth new requirements for ordering, referring and furnishing certain Part B items and services. Effective July 6, 2010, ordering and referring physicians and other “eligible professionals” must be registered in the Provider Enrollment, Chain and Ownership System (PECOS) as enrolled or opted out of Medicare in order for certain Part B items or services to be covered. In addition, claims for the Part B items and services must contain the legal name and National Provider Identifier (NPI) of the ordering or referring physician or eligible professional. Failure to comply with these new rules could result in claim denials.
The final rule also clarifies PPACA provisions requiring providers and suppliers to maintain documentation related to the order or referral of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and other Part B items and services. Failure to properly maintain documentation could result in a revocation of billing privileges.
In a recently released MLN Matters issue (Number SE1011), CMS indicated that these new requirements would be effective January 3, 2011. However, the effective date of the final rule is July 6, 2010. All indications from CMS suggest that the agency is adhering to the earlier July 6, 2010, effective date. Medicare providers and suppliers should look carefully at the new requirements and seek advice from legal counsel if necessary.
Enrollment or Opt-Out Record in PECOS
Effective July 6, 2010, physicians and “eligible professionals” who order Part B items and services (excluding Part B drugs) for Medicare beneficiaries, or who refer beneficiaries to providers or suppliers for such items or services, must be enrolled in PECOS in order for Medicare to pay for the items or services. “Eligible professionals” include physician assistants, certified clinical nurse specialists, nurse practitioners, clinical psychologists, certified nurse midwives, clinical social workers, physical therapists, occupational therapists, speech language pathologists and audiologists.
The ordering or referring physician or eligible professional must be able to show an “approved enrollment record” in PECOS as of the date of the order or referral. The rule clarifies that physicians who have opted out of Medicare can still order items and services, but the Medicare contractor must be able to verify the opt out in PECOS to pay for the items and services. (It is important to remember Medicare’s general rule that the treating physician must be the one to order or refer the items or services.)
Claims Requirements / Grounds for Denying Claims
In addition to the PECOS enrollment requirement, beginning July 6, 2010, all claims for Part B items and services (excluding Part B drugs) must contain both the legal name and the NPI of the ordering or referring physician or eligible professional.
Beginning July 6, 2010, Medicare contractors may deny claims for the Part B items or services if the claims do not contain the legal name and NPI, or if PECOS does not show an approved enrollment or opt out record for the physician or eligible professional.
Maintaining Documentation for DMEPOS, Home Health, Laboratory and Specialist Services
Providers and suppliers who furnish DMEPOS and home health services, and physicians or practitioners who order, certify, or refer such items and services, must maintain written documentation for seven years from the date of the order, certification or referral. Under PPACA, the documentation requirement for DMEPOS and home health services was effective January 1, 2010.
CMS’s new rule expands the documentation requirement to those who furnish, order or refer laboratory, imaging and specialist services under Medicare. Beginning July 6, 2010, any person or entity that orders, refers or furnishes lab, imaging or specialist services covered by Medicare must maintain written documentation for those services for seven years.
The documentation must include all electronic and written communications relating to the order or request for payment. It must also include the NPI of the physician or eligible professional who ordered or referred the items or services. In addition, the party maintaining the documentation must provide access to the documentation upon the request of CMS or a Medicare contractor.
Failure to adhere to this documentation requirement could result in revocation of the supplier or provider’s Medicare enrollment for up to one year for each act of non-compliance. This means that multiple documentation failures could result in an extended period of disenrollment from Medicare, which could have serious consequences for many providers and suppliers.