Home Health & Hospice Week

Keep in mind that requirements will change in the fall.

While the new hospice certifying physician edit was delayed once before, hospices hoping for a repeat performance from Medicare are disappointed. At press time, the Centers for Medicare & Medicaid Services and its HHH Medicare Administrative Contractors appear to be all systems go for the new — and potentially troublesome — claims system edit.

Background: In last year’s hospice final rule issued in July, CMS adopted a requirement that two categories of physicians must be enrolled in or validly opted out of Medicare for hospice services to be paid: the hospice medical director or the physician member of the hospice interdisciplinary group; and the attending physician that certifies the patient for hospice. CMS did at least grant hospices’ requests for an implementation delay at that time, moving the deadline from the proposed Oct. 1, 2023 to May 1, 2024. Then on the eve of that start date, CMS bumped the edit for one more month (see HHHW by AAPC, Vol. XXXIII, No. 15).

At least one HHH MAC, Palmetto GBA, has been regularly issuing reminders that the edit is coming. “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 and the claim will be denied with reason code 17729,” Palmetto warned in a May 20 update on its website.

CMS also adds some detail to its transmittal containing the directive. “For electronic claims, [the certifying physician’s name and NPI are] reported in Loop ID 2310F — Referring Provider Name,” specifies updated Medlearn Matters article MM13531, based on revised Change Request R12365CP.

But watch out: These instructions won’t hold forever — or even for very long. “For claims you submit on or after October 7, 2024, with dates of service as of June 3, 2024, or later, we’ll check the REF PHYS NPI field and the ATT PHYS NPI field on hospice claims to make sure the certifying physicians, including hospice physicians and hospice attending physicians, are enrolled in or opted-out of Medicare,” CMS says in the transmittal. “We’ll subject both physicians, if different, to the ordering and referring denial edits for the initial certification period,” the agency adds.

Note: The article, which includes a link to the transmittal, is at www.cms.gov/files/document/mm13531-hospice-claims-edits-certifying-physicians.pdf.