CMS Announcements and Pecos Edits

According to CMS, it may not deny Provider Enrollment, Chain and Ownership System (PECOS) claims starting this month. But then there are two contradictiory statements doing the rounds. Find out which one to believe.

You may or may not meet claim denials this month owing to PECOs edits, depending on which CMS announcement you read.

Background: Presently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you know that the practitioner's information is not there in the system. Earlier, it was believed that CMS would start denying these claims on January 3: however now that's up in the air.

Last November, CMS distributed an email that the agency referred to as an 'Important Update on PECOS and Ordering/Referring', in which CMS noted, "While there are some rumors that the edits will be turned on this month, we want to emphasize that the agency has not announced any date as to when ordering /referring edits will be turned on.

In writing: Even though the agency now clearly denies ever announcing that claim rejections would begin on January 3, MLN Matters article MM6417, which CMS distributed on Feb. 26, 2010, stated "Effective January 3, 2011, if the ordering/ referring provider is not in PECOS, the carrier or Part B MAC will search its claims system for the ordering/referring provider. If the ordering/referring provider is not in PECOS and is not in the claims system, the claim will be rejected."

So which CMS statement to believe? At this juncture, the agency seems to be indicating that you may not face ordering/referring denials this month, despite the earlier MLN Matters article to the contrary. Your best choice is to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality.

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Fracture Care: Take Advantage of 'Manipulation' Opportunity

When your podiatrist carries out fracture care, see to it that you take advantage of manipulation opportunity or you could be missing out on your payments without the proper manipulation knowledge.

Say for instance the podiatrist carries out closed treatment on a fractured fibula: if she uses manipulation, the service will fetch you about $119 more than a non manipulation encounter. But then you should think about several factors before you decide a manipulation warrants the treatment. Equip yourself with these three tips and get started:

Know what you are dealing with

You cannot support your claim if you have no idea about what manipulation is. It involves reduction or attempted reduction of the fracture or dislocation.

Podiatrists would normally carry out a 'closed' manipulation, which occurs when the physician is repositioning or relocating a displaced closed fracture back to the correct anatomical position without surgically opening it. Nonetheless, there is such a thing as "open" manipulation.

Important words give away manipulation procedure

If you depend on physician's notes to give evidence of manipulation, you have a chance of being misled.

Here's why: The word 'manipulation' does not make its way into physician encounter notes regularly.

Typically, what you should look for is the term 'closed reduction', which is used for non-operative treatment of fractures that are treated without surgery. Other terms that might help identify a manipulation procedure include 'reduce', 'align' and 'reset'.

Spot manipulation evidence

Only when you learn to read your physician's notes between the lines will you be able to tell a manipulative treatment from a non-manipulative one.

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