PECOS Edit Denials Could Affect 3 Out of 4 Home Health Agencies
Monday, April 8, 2013
by: VNAA Policy Team

Section: Public Policy and Advocacy




A report released March 22 by Medicare administrative contractor (MAC) CGS finds that three in four home health agencies would receive denials under the pending provider enrollment, chain and ownership system (PECOS) edit. The report also found that approximately four percent of home health claims received remark code N272 during the period covered by the analysis (September 2012 and February 2013). This code has been used by CMS since 2009 to flag claims that would fail the PECOS edit based on invalid or incomplete physician’s information on the ordering/referring file.
 
Additionally, the analysis shows that several common errors that lead to the remark code were made by the submitting agency: 1) the national provider identifier (NPI) on the claim did not match the physician’s name in PECOS, or 2) the name was correct but contained spacing that was not present in the PECOS record. CGS is advising agencies to check the ordering/referring file for the physician’s listed name and omit physician credentials and nicknames from claims.
 
A CMS analysis concluded only one percent of claims would be denied under the edit. The agency does note that the one percent figure applies across all affected claims, including durable medical equipment, lab and imaging services. This analysis was based on the number of claims generating informational messages which include the home health-specific remark code. 

To read and review the CGS report, click here.
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