CMS published a final rule on April 27, 2012 that updates regulations regarding Medicare and Medicaid provider and supplier enrollment, ordering and referring, documentation requirements, and provider agreements, effective June 26, 2012. The rule modifies and finalizes several ACA provisions implemented in the May 5, 2010 interim final rule with comment period. Among other things, the rule:

  • Requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all Medicare and Medicaid enrollment applications and claims.
  • Requires physicians and other professionals who are permitted to order and certify Medicare covered items and services to be enrolled in Medicare. The final rule modifies a requirement that had been in the interim final rule that the ordering provider be registered in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). While the rule still requires ordering physicians and other eligible professionals to be enrolled in the Medicare program (or to maintain a valid opt-out record), enrollment in PECOS is no longer required.
  • Mandates document retention and provision requirements for certain providers and suppliers that order and certify items and services for Medicare beneficiaries. The provision specifically applies to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), laboratory, imaging, and home health services – importantly, CMS has dropped an earlier reference to “specialist services” being subject to these requirements. The final rule also clarifies that the documentation requirement is not the responsibility of the physicians interpreting imaging studies -- only the technical component entity has to meet these requirements. Under the final rule, necessary documentation must be retained for 7 years from the date of service (rather than the date of the order or certification as provided under the interim final rule). A provider or supplier that does not meet the documentation retention requirements is subject to revocation for not more than 1 year for each act of noncompliance.