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CMS offers Medicare guidance for referring/ordering dentists

Washington—After meeting with ADA representatives, Medicare officials identified an abbreviated process for dentists who are not enrolled in Medicare but who order covered items or refer Medicare patients for covered services. The abbreviated process does not apply to dentists already enrolled to provide Medicare services or enrolling for the purpose of submitting claims.

The government insurance program for elderly and disabled beneficiaries requires ordering and referring providers to enroll in Medicare or opt out as reported in the July 12, 2010 ADA News and online at ada.org PECOS enrollment.

The Association has called for a simplified enrollment process and other modifications of the interim final rule published May 5, if not exclusion of dentists from the requirements. ADA representatives met with Centers for Medicare & Medicaid Services officials July 1 and reiterated these recommendations in a July 6 letter to the CMS:

  • Exclude dentists from the requirements of the interim final rule;
  • If exclusion isn't "feasible," adopt a phase-in process for practitioners who rarely refer or order;
  • Develop a simplified enrollment form for submission in electronic or paper format;
  • Delay enforcement until six months after new forms and electronic enrollment processes are in place;
  • Implement procedures to protect practitioners against misuse of their National Provider Identifiers;
  • Apply documentation requirements to only "covered" items/services that are ordered or referred;
  • Exempt certain dentists from document retention requirements;
  • Define "laboratory" to exclude dental laboratories.

CMS in a document posted online Aug. 16 offers new enrollment guidance for dentists including oral surgeons. "In the process of implementing the provisions contained in the Affordable Care Act, we have become aware of several unique enrollment issues for certain types of physicians or practitioners. Specifically, we have modified the process of enrollment to accommodate the special circumstances of the following individual physicians and practitioners," says the document, Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program SpecialEnrollmentFactsheet.

The document is intended as guidance to dentists, including oral surgeons, and physicians in fellowships, federal employment or employed by qualified health centers, rural health clinics or critical access hospitals. More information will be available after the final rule is published.

What is PECOS?

Medicare’s Internet-based Provider, Enrollment, Chain and Ownership System InternetbasedPECOS is managed by the Centers for Medicare & Medicaid Services, a Department of Health and Human Services agency.

Dentists and other practitioners may enroll in Medicare by using the Internet-based PECOS or by filling out the 29-page paper version of the CMS-855I PECOS. The July 12 ADA News offers additional information on PECOS and its relevance to dentists who order or refer Medicare-covered items or services for Medicare beneficiaries.

For example, among situations that may be covered by the PECOS regulation are referral of a Medicare beneficiary to an oral and maxillofacial surgeon for a biopsy, or submission to an oral and maxillofacial pathologist of a biopsy specimen for a patient who is a Medicare beneficiary.

The PECOS regulation is intended to fight Medicare fraud. Congress in the health care reform law, the Patient Protection and Affordable Care Act, told the HHS department to start the system by July 6, 2010 but CMS has not announced an enforcement date.

The following is excerpted from the CMS document Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program:

"I am an Oral Surgeon or Dentist – How do I Enroll in PECOS?

"Dentists, including oral surgeons, must enroll in the Medicare program to receive reimbursement for services furnished to Medicare beneficiaries or to order covered items or services for Medicare beneficiaries. Oral surgeons would complete the same paper forms, or on-line application, as any other practitioner enrolling in PECOS.

"If you elect to enroll as a 'referring and ordering physician-only,' you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC, CAH) who are enrolling to order and refer only. If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries.

"In order to provide covered services to Medicare beneficiaries, a dentist, including oral surgeons, would need to complete the full enrollment application either on-line or in hard copy.

"Note: In completing the enrollment application portion dealing with specialty, oral surgeons would check the 'oral surgery (dentist only)' box found in section 2 of the Medicare enrollment application and any other dentist would check the box titled, 'Undefined Physician Type' and specify that they are a dentist in the space provided. In the near future, we will revise the Medicare enrollment application to add 'Dentist' as a physician specialty."

The above abbreviations:

VA – Department of Veterans Affairs

DoD – Department of Defense

PHS – Public Health Service

FQHC – federally qualified health center

RHC – rural health clinic

CAH – critical access hospital