CMS in 2010 issued changes requiring an individual ordering or referring an imaging or laboratory service to be a physician or other health care professional able to enroll in Medicare and permitted to order or refer for the service. According to CMS, claims that did not contain the name of an enrolled ordering or referring provider would not be paid beginning in January 2010. However, based on concerns raised by the ACC and others, CMS agreed to push the implementation date to January 2011.
On December 16, 2010, CMS revised CR 6417 to set a placeholder date of July 5, 2011. This placeholder date is being issued to give the Centers for Medicare & Medicaid Services more flexibility to determine the appropriate date for nonpayment of claims that fail the ordering/referring provider edits.
The rule requires that individuals ordering or referring patients for “specialist services” be enrolled. While it is unclear at this time what is meant by specialist services and whether this changes which services now require orders or referrals, practitioners that traditionally have not billed Medicare for services but may have ordered or referred Medicare patients for services (including practitioners working for the Department of Defense and Veterans Administration) must now be enrolled. Additionally, in the original ordering and referring policy, practitioners who were not in the Medicare provider enrollment database but were in the contractor’s master file were allowed to continue to order and refer for Medicare imaging and laboratory services. Under the new regulation, practitioners must be in the Medicare provider enrollment database in order to order and refer for Medicare services.
How do you know if you're enrolled?
CMS has worked with its contractors to create a file listing all of the practitioners eligible to order and/or refer for Medicare services. This file contains all of the NPIs and legal business names of eligible professionals. Practitioners should use this list to determine if they need to revalidate their enrollment information immediately or should wait until prompted by their Medicare contractor to do so. This list can also be used by practices receiving orders and/or referrals to determine if they will be paid for services furnished by their referral sources. The ACC has developed a sample letter to help with notifying referral sources.
Will claims be automatically rejected after July 6?
CMS has said it will not automatically reject claims submitted by providers that have attempted to enroll in PECOS prior to July 6. CMS has also said that "until the autmatice rejections are operational, providers should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid." The ACC continues to request that CMS issue additional guidance and instructions as soon as possible to allow for the education of physician practices and their staffs and any changes in claims submission that must occur. To read the cardiovascular community's formal letter sent June 9 to CMS regarding the interim final rule, click here. For more on Medicare enrollment, click here.
How can you tell if you will be affected by non-enrolled referral sources?
CMS has added a new remark code that practitioners should see on the Explanation of Benefits (EOBs) that they receive. This remark code appears on EOBs that include claims for services where the ordering or referring practitioner is not permitted to order and refer for Medicare services. While those claims are currently still being paid, this will change when CMS implements the new policy. Thus, it is important for physician practices to carefully review the EOBs that they receive from Medicare. Physician practices can use this information to target their enrollment education efforts to referral sources that are not currently enrolled in Medicare.
Are there documentation requirements?
The regulation also requires that practitioners maintain documentation pertaining to covered services for seven years from the date of service and to provide access to that documentation upon request from CMS or a Medicare contractor. This includes documentation pertaining to orders or referrals for imaging and specialist services. Where the document is not maintained, CMS has the ability to revoke a practitioner's enrollment in Medicare for one year.