Starting May 1, CMS will deny home health claims where the physician on the claim didn’t have an enrollment record in the provider enrollment, chain and ownership system (PECOS).
 
The claims will be denied with one of two reason codes, according to a March 1 MLN Matters article:
  • 37236: The statement “From” date is on or after May 1, the type of bill is “32” or “33” and the attending physician’s national provider identifier (NPI) is not present in PECOS. The claim could also be denied if the NPI is present in PECOS, but the name given on the claim doesn’t match the one on the physician’s enrollment record.
  • 37237: Same as above, but this denial reason code will be assigned only when the type of bill frequency code is “7,” which indicates an adjustment, or “F-P.”
 
In addition to denials, many agencies could see payment delays starting May 1 if they’re forced to hold claims which list physicians without an enrollment record, says Joan Usher, president of JLU Health Record Systems in Pembroke, Mass.
 
For in-depth coverage of what the PECOS denials mean for home health, turn to the next issue of Home Health Line.