Home Health & Hospice Week

How far have you gotten in checking your physicians?

Hospices have little time left to bulletproof their claims against the new edit requiring that certifying physicians be enrolled in or validly opted out of Medicare.

Follow this expert advice to avoid pitfalls and protect cash flow:

1. Understand the requirement. “As part of [the Centers for Medicare & Medicaid Services’] larger strategy to address hospice program integrity and quality of care … certifying physicians must be enrolled in or opted-out of Medicare for the hospice service to be paid,” CMS laid out in Change Request 13342 issued last October, after CMS issued the 2024 hospice final rule. The Fiscal Intermediary Shared System “shall deny the hospice claim if the physician in the Attending field is not on the file,” meaning the PECOS file “of all enrolled and opted-out physicians,” the transmittal continued.

Then on April 19, CMS issued a new CR 13531 specifying that “the additional edit requirements in this CR will check the REF PHYS NPI field as well as the ATT PHYS NPI field on the hospice claim to ensure the certifying physician as well as the attending physicians are enrolled or validly opted-out in Medicare for payment.” That transmittal listed an effective date of May 1, but an implementation date of Oct. 7.

But the instructions in the CRs raised as many questions as they answered, so on April 26 CMS issued a Question-and-Answer set clarifying details (see related story, p. 114). “In the event of any inconsistency, the policies in this Q & A document supersede those in the March 26, 2024, Medicare Learning Network update regarding the hospice certifying requirement,” CMS says.

Bottom line: “Starting June 3, 2024, CMS is only verifying the enrollment/opt-out status of the physician listed in the claim’s ‘Attending Physician’ field. Accordingly, hospices should enter the certifying physician in the “Attending Physician’ field,” CMS instructs in the Q&As. “So long as the hospice enters a physician in the ‘Attending Physician’ field and that physician is in the PECOS record that is valid for edit dates, the claim will not edit,” the agency says.

Don’t forget that that methodology will revert back to normal on Oct. 7, when CMS will expand the edit to the “Other physician” field as well.

Another clarification: “it is unnecessary for the physician to have designated ‘hospice’ as their specialty on their enrollment application,” CMS details. “If the physician is enrolled or opted-out, they meet the new enrollment/opt-out requirement regardless of the specialty listed on their application,” according to the Q&As at www.cms.gov/files/document/hospice-certifying-enrollment-faqs.pdf.

Hospices should “go through the Q&As published in the MLN Connects article and make sure the hospice has no outstanding questions,” urges consultant Judi Lund Person with Lund Person & Associates.

2. Check every certifying doc — again. “Check and double check,” Lund Person advises. “Look at the list of the hospice’s attending physicians in hospice software to ensure that each of them is enrolled or opted out, using the

Ordering and Referring database” (available at https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/order-and-referring/data), she says.

Providers should “check all their physicians — both hospice and non-hospice — in the PECOS database to make certain they are registered appropriately under the ordering/ referring requirements,” advises reimbursement expert M. Aaron Little with FORVIS in Springfield, Mo.

Clarification: Pay attention to the time. “The hospice physician and attending physician only need to be enrolled or opted-out at the time they make the certification or recertification,” the Q&As reiterate. “The physician does not need to remain enrolled or opted-out during the patient’s entire certification and benefit period. Moreover, if the physician becomes unenrolled and non-opted-out, the hospice does not need to get a new certification to replace the one the previously enrolled or opted-out physician signed,” CMS says.

3. Enroll deficient docs. Get your certifying physicians in compliance as soon as possible “If the physician is enrolling solely to certify hospice services under § 418.22(c) and will not bill Medicare for services furnished, the Form CMS-855O should be submitted,” CMS advises.

4. Check other reasons for reason code 17729. Under the new requirement, “if the physician entered in the Attending Physician field on the claim is not in the Provider Enrollment Chain and Ownership System (PECOS) as an enrolled or opted-out physician, they will not be listed on the CMS Order and Referring Dataset [ORDF] and the claim will be denied with reason code 17729,” explains HHH Medicare Administrative Contractor Palmetto GBA in an article on the topic updated on April 30.

But if the doc is in the ORDF, you may have ordinary reasons that the physician isn’t passing the edit, such as an incorrect NPI or spelling mistake. “Do the first four characters of their last name exactly match the CMS dataset on the claim?” Palmetto asks. And “are any of the [NPI] digits transposed?” HHH MAC National Government Services asks in a similar article.

And make sure the certifying provider isn’t actually a nurse practitioner or physician assistant. “NPs and PAs cannot certify for hospice and should not be entered in the Attending Physician field on a hospice claim,” Palmetto instructs.

5. Be prepared for implementation glitches. Whether the error lies with you or the Medicare claims system, reimbursement delays may be likely. “This new requirement is absolutely an inconvenience, but possibly a cash-flow event,” Little warns.

Wise agencies will be prepared on both cash and operational fronts for extra burden.

Note: The MLN Matters article, which at press time didn’t yet include the updated timeline, is at www.cms.gov/files/document/mm13531-hospice-claims-edits-certifying-physicians.pdf.