Enrollment submission of PECOS

who is new patient - Medicare rule of group practice

The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7) now defines “new patient” for the E/M visit code and reads as follows.

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Enrollment submission of PECOS

I am a physician who needs to have an enrollment record in PECOS. What do I do?

You can submit your enrollment application in one of two ways:

(1) Use Internet-based PECOS

· Step 1. Before you begin, be sure you have a National Provider Identifier (NPI) and have created a User ID and password in the National Plan and Provider Enumeration System (NPPES). You will need the NPPES User ID and password in order to access Internet-based PECOS. If you need help creating an NPPES User ID and password, or if you are not sure you ever created them or cannot remember what they are, you may contact the NPI Enumerator for assistance at 1-800-465-3203.

· Step 2. Read the documents that are available about Internet-based PECOS on the CMS Provider/Supplier Enrollment web page (www.cms.hhs.gov/MedicareProviderSupEnroll)

· Step 3. Once you have completed and submitted your enrollment application using Internet-based PECOS, be sure to print the Certification Statement, sign and date it, and mail it, along with any required supporting documentation, to the carrier or A/B MAC whose name and mailing address will be displayed to you by the system.

Note: If you reassign some or all of your Medicare benefits to a group practice, there will be two Certification Statements to print, sign and date, and one of them will also need to be signed and dated by an Authorized Official of the group practice.

The carrier or A/B MAC cannot begin to process your web-submitted enrollment application without having the signed and dated Certification Statement(s) in hand.

(2) Complete the paper Medicare enrollment application (CMS-855I) as an initial application.

· Step 1. Complete the CMS-855I (if you reassign benefits to a clinic or group practice other than your own, complete a CMS-855R as well), sign and date (blue ink recommended) and mail the application(s), along with any required additional supporting documentation, to the Medicare carrier or A/B MAC.These forms are downloadable from the CMS Provider/Supplier Enrollment web page (shown above) or the CMS forms page www.cms.hhs.gov/cmsforms, or you may request the necessary forms from the carrier or A/B MAC.

· Step 2. Once the paper application has been received by the carrier or A/B MAC, the carrier or A/B MAC will begin to process your enrollment application. If additional information is needed by the carrier or A/B MAC to complete the processing of your enrollment application, they will contact you.

If you need more information about Medicare enrollment or how to use Internet-based PECOS, visit the CMS Provider/Supplier Enrollment web page at: www.cms.hhs.gov/MedicareProviderSupEnroll.