Important Update: PECOS Ordering/Referring for Provider Claims
Submission for Lab, Imaging, DMEPOS, and Part A Home Health Services
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) instructed Medicare plan
contractors to implement denial edits, which were effective Jan. 6, 2014. These edits check the following
categories of claims for a valid individual National Provider Identifier (NPI) and deny the claim when the
NPI is invalid:
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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
(DME-POS)
Claims from Part A Home Health Agencies (HHAs)
For more information, go to MLN Matters® Article #SE1305, “Full Implementation of Edits on the
Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency Claims
(Change Requests 6417, 6421, 6696, and 6856)” under the Educational Materials section of
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html
Effective April 7, 2014, CMS instructed Medicare plan contractors to deny certain Power Mobility Devise
(PMD) DME-POS claims identifying an ordering/referring physician or non-physician practitioner who is
not of an authorized specialty. For more information, please refer to MLN Matters article #MM8239
under the Educational Materials section of cms.gov.
About the Ordering and Referring Files
Downloads of the files contain the National Provider Identifier (NPI) and legal name (last name, first
name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible
to order and refer Part B (clinical laboratory and imaging), DME and HHA claims in the Medicare
program and who have current enrollment records in Medicare (i.e., they have enrollment records in the
CMS’ Provider Enrollment, Chain and Ownership System known as PECOS). A separate file is also
available identifying physicians and non-physician practitioners who are eligible to order and refer PMD
and have a current Medicare provider enrollment record.
The list of specified covered, PMD items: HCPCS Code and Description includes the following:
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K0800-K0808 and K0812: all power operated vehicles
K0813-K0891, K0898: power wheelchairs
K0013: custom motorized/ power wheelchair base
To keep the available information up to date, CMS will replace the information twice a week. At any
given time, the most current information will be available for downloading. The file can be downloaded
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by users with technical expertise and further sorted or manipulated. It can also be used to search for a
particular physician or non-physician practitioner by NPI or name.
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Records are in alphabetical order based on the surname of the physician or non-physician
practitioner.
Name suffixes (e.g., Jr.) are not displayed.
There are no duplicates in the file as NPIs are associated with each name.
The Medicare Ordering and Referring files are ZIP files available for download in a CSV format. The
CSV file allows users to open the Ordering and Referring data in Excel, Notepad and other software
formats that could be easier for users to search and sort.
References
• MLN Matters® article #SE1305 Full Implementation of Edits on the Ordering/Referring
Providers in Medicare Part B, DME and Part A Home Health Agency Claims
• MLN Matters® article #MM8239 Denial for Power Mobility Device Claim from a Supplier of
Durable Medical, Orthotics, Prosthetics, and Supplies When Ordered By a Non-Authorized
Provider
• Medicare Enrollment Guidelines for Ordering/Referring Providers
• The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare
Reimbursement
• More information is available at http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html
For more information, please contact Provider Services at 877-842-3210. Thank you.
Doc#: PCA14398_20141015