On April 24, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final rule detailing requirements for ordering and referring in Medicare. In 2009, CMS began issuing warnings for Medicare claims that failed to meet CMS’s ordering and referring criteria, including requiring the ordering/referring provider have an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS). An interim final rule released in 2010 further detailed these ordering and referring requirements.
The final rule released yesterday includes changes to some of the previous requirements. CMS changed the regulatory language from requiring an enrollment in PECOS to requiring enrollment in Medicare — including PECOS or other legacy Medicare enrollment systems. Additionally, CMS removed specialist services from those that are required to list the ordering or certifying provider on the claim and meet the other criteria. This change resulted in CMS replacing the term “refer” with “certify” for the applicable items and services. The requirements in this final rule apply to ordered or certified items and services including DMEPOS, clinical laboratory and imaging services, and home health claims billed by Medicare Part B suppliers. For these claims, ordering or certifying providers must be eligible to order or certify in Medicare, their legal name and NPI must be listed on the claim, and they must have an enrollment record in Medicare. The requirements vary slightly for medical interns and residents who order or certify these items and services.
CMS will continue to issue warnings for claims that fail to meet these criteria, but at this point CMS will not deny claims that do not meet the criteria. In the future, CMS will begin to deny claims, but has not indicated when this will occur.