Medicare Compliance & Reimbursement - 2013 Issue 10
Ordering/Referring: 6 Steps Help You Reduce PECOS Edit Losses
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Article Overview
This article covers Medicare ordering and referring provider enrollment issues related to PECOS edits, with emphasis on why claims may be denied when provider information does not match enrollment records. It is aimed at billing, coding, and practice management staff who handle Medicare claim submission, provider enrollment checks, and denial prevention. The discussion includes CMS guidance, the Medicare Ordering and Referring File, MLN Matters references, and general areas to verify before claims are billed.
Why This Topic Matters
PECOS edit issues can interrupt reimbursement and create avoidable denials if provider enrollment and claim data are not aligned. Understanding the article helps practices identify where enrollment, claim setup, and remittance review workflows may need attention.
Article Sections
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Overview of PECOS edit impact
Introduces the Medicare PECOS edit issue and explains why provider information mismatches can affect claim processing and reimbursement.
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Six steps to reduce denial risk
Summarizes the article’s recommended areas of review, including enrollment status, file matching, claim data consistency, exception handling, and remittance review.
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CMS resources and related guidance
References CMS materials and supporting educational resources used to help providers monitor enrollment and ordering/referring information.
What You Will Learn
- How PECOS-related provider information issues can affect Medicare claims
- What types of provider enrollment and claim-data checks are discussed
- Which CMS resources are referenced for monitoring ordering and referring information
- Why remittance review is part of denial prevention workflows
- Which provider groups and exceptions are discussed in the context of PECOS enrollment
Who Should Read This
- Medical billers
- Certified coders
- Revenue cycle staff
- Practice managers
- Provider enrollment staff
- Medicare-focused compliance staff
Codes Discussed
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