Home Health & Hospice

Ordering and Referring Physicians and PECOS

Homecare Insider, June 27, 2011

In order for a homecare agency to bill Medicare for services, they must be enrolled in Medicare with ordering or referring information. The Centers for Medicare and Medicaid Services (CMS) recently issued a reminder, and it’s important that agencies understand the three basic requirements for ordering and referring to homecare. These include:

  1. The physician must be enrolled in Medicare or in an opt-out status. The ordering/referring provider must have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS).
  2. The National Provider Identifier (NPI) used for ordering/referring must be for an individual physician – it cannot be an organizational NPI.
  3. The physician must be of a specialist type that is eligible to order and refer; for home health those eligible specialists are a Doctor of Medicine or Osteopathy or a Doctor of Podiatric Medicine.

If a physician does not meet these three basic requirements, they must enroll in Medicare and obtain an NPI to be able to order/refer. The quickest and most efficient way to enroll is through internet-based PECOS. After initially enrolling, they should verify their enrollment or pending application. Agencies can also access a list of pending applications and read a Medicare Learning Network fact sheet entitled “Medicare’s Enrollment Guidelines for Ordering/Referring Providers”.

What may be confusing to homecare providers is that CMS has delayed the Phase II PECOS implementation-indefinitely. Phase II is the nonpayment of home health claims if the ordering physician is not listed in PECOS. So, even though ordering and referring physicians must be enrolled in Medicare, and have an enrollment record in PECOS, home health claims will not be edited, at this point, for compliance and denied based on PECOS enrollment.