CMS has issued a special edition Medicare Learning Network® article which confirms that both the certifying physician and the attending physician will be subject to the Provider Enrollment, Chain and Ownership System (PECOS) edit when listed on the claim.
Effective July 1, 2014, HHAs are required to report the NPI of the physician who certifies/re-certifies the patient’s eligibility (Certifying Physician). This is in addition to reporting the NPI and name of the physician who signs the patient’s plan of care (Attending Physicians) when the attending physician is not the same physician who certified/recertified the patient’s eligibility to receive services under the Medicare home health benefit. This will occur when the acute or post acute care physician is the physician who documents the face to face encounter, certifies the patient for home health services, and hands off the patient to the community physician who will sign the plan of care.
Therefore, for episodes that begin on or after July 1, 2014, the certifying physician and the attending physician must be enrolled in PECOS or have validly opted out.
If the Certifying and Attending physicians are different, both physicians are subject to the ordering and referring denial edits.
If the Certifying and Attending physicians are the same, the edits will only be applied to the “Attending” field.
The denial edits will serve as validation and verification that the attending and/or certifying physician that is ordering/referring services listed on the billing provider claims is eligible and enrolled in Medicare in an approved or opt out status.
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