Home Health & Hospice Week

But SIA-related snafu is not yet resolved, MAC reveals.

Medicare would like to require all physicians ordering hospice services be enrolled in PECOS — but it can’t do it quite yet, and that’s why it’s rolling back a new requirement causing a system glitch.

The problem: “Change Request 12889, which purpose was to validate the attending physician’s NPI submitted on institutional claims was not being fictitiously substituted with an organization NPI, was implemented in the April Systems Release and activated reason code 34963,” HHH Medicare Administrative Contractor Palmetto GBA explains on its Claims Payment Issues Log. “It has been determined that edit was being applied to hospice claims inappropriately and would be bypassed on hospice claims,” the MAC says.

In other words, “the CR instructs MACs to validate the NPI in the Attending Physician field on a claim against the Provider Enrollment, Chain, and Ownership System (PECOS) file,” the National Association for Home Care & Hospice explains in its member listserv. “If the NPI is not found in the file, the claim will not process. However, attending physicians for hospice patients are not required to be PECOS enrolled so their NPI will not be in the PECOS file unless they are otherwise enrolled.”

The Centers for Medicare & Medicaid Services has proposed that requirement in the hospice 2024 proposed rule (see story, p. 99), “but that is not finalized,” NAHC points out.

The solution: “Within ten business days of this notifi­cation, reason code 34963 will be bypassed for hospice claims and the A/B Medicare Administrative Contractors (MACs) will return all hospice claims to processing that were returned for reason code 34963,” Palmetto says. The notice was posted on April 7.

Another hospice billing glitch doesn’t yet have a solution however.

“When a patient is discharged deceased on a claim within the first six days of a month, CMS’ system is to perform a look back on the prior month’s claim to identify if there were [Service Intensity Add-on] eligible services provided within the last seven days of life and if there are, a system-initiated adjustment would occur,” Palmetto explains in a separate CPIL entry. “The look back is currently not occurring.”

For now, “until the issue is fixed, providers may adjust the previous monthly claim to receive applicable SIA payment,” Palmetto instructs. “Using Condition Code D9 on the adjustment, please add the remarks ‘SIA PRIOR MONTH ADJUSTMENT.’”

Palmetto’s CPIL is at www.palmettogba.com/palmetto/ jmhhh.nsf/T/Claims~Claims Payment Issues Log.