CMS-Announcement

PECOS Edits Going Live in January

HEALTHCAREfirst Offers Free PECOS Provider Validation Tool.

CMS announced on November 7th that the PECOS Ordering and Referring Denial Edits will finally be implemented on January 6, 2014. The edits had previously been delayed due to technical issues. The edits will check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid:

  • Claims from Part A Home Health Agencies (HHAs)
  • Claims from clinical laboratories for ordered tests
  • Claims from imaging centers for ordered imaging procedures
  • Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS

HEALTHCAREfirst’s free PECOS lookup tool is available to all providers regardless of whether they use our software or not, to verify a referring physician against the most recent CMS public-use file.  Home Health claims that fail the edits will display the following reason codes:

Reason Code 37236 will display when:

  • The statement “From” date on the claim is on or after May 1, 2013.
  • The type of bill is ’32’ or ’33’
  • Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

Reason Code 37237 will display when:

  • The statement “From” date on the claim is on or after May 1, 2013.
  • The type of bill is ’32’ or ’33’
  • The type of bill frequency code is ‘7’ or ‘F-P’
  • Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

Click here for the full Medlearn Matters article.

November 11, 2013
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