Home Health & Hospice Week

Q&As clear up some confusion.

Despite what you might have read from Medicare or your MAC as recently as this week, hospices have another month to prepare for the potentially burdensome edit requiring hospice certifying physicians to be enrolled or validly opted out of the program.

Background: In last year’s hospice final rule issued in July, the Centers for Medicare & Medicaid Services 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 (see HHHW by AAPC, Vol. XXXII, No. 28). 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.

The problem: Hospices have been telling CMS for months that its guidance on the certifying physician requirement was too unclear for implementation on May 1, including in the agency’s April 5 Open Door Forum (see HHHW by AAPC, Vol. XXXIII, No. 12).

The solution — sort of: On April 26, CMS issued an MLN Connects article and a four-page Question-and-Answer set announcing a one-month delay to the requirement, to June 3, and clarifying some outstanding issues.

CMS doesn’t give a reason for the delay, but the National Association for Home Care & Hospice and the National Hospice and Palliative Care Organization have put it down to their lobbying efforts. “Earlier this week, NAHC and NHPCO met with CMS to relay the concerns of the provider community and request expedient and clear guidance, flexibility in claim processing, and Part B Medicare Administrative Contractor (MAC) physician enrollment processing guidance,” the trade groups say in a joint statement.

NAHC and NHPCO “welcome CMS’ announcement to delay the implementation” and “thank CMS,” they add. The trade groups, which are pursuing a merger, “look forward to continued engagement on these issues to ensure seamless and appropriate implementation of the requirement,” they say.

The news is very welcome to hospices. “Hospice providers were relieved, particularly because there were discrepancies in the guidance from CMS, which was also confusing to hospice software vendors,” notes Judi Lund Person with Lund Person & Associates.

This mandate is perplexing hospices, even though “home health has already been subject to this requirement,” observes M. Aaron Little with FORVIS in Springfield, Mo. “The requirement is a different animal for hospices because of the way physicians are reported on the hospice claim,” Little tells AAPC.

Beware October Switcheroo

The Q&As are helpful, but the road to implementation in a few short weeks is far from clear, experts fear.

One problem: “In cases when the hospice patient chooses a non-hospice attending physician, then both the non-hospice attending physician (reported in the ‘attending physician’ claim form locator) and the certifying hospice physician (reported in the ‘other provider’ claim form locator) are reported on the claim,” Little explains. “The instructions issued by CMS in the Q&As — not the Claims Processing Manual, just the Q&As — instruct hospices to report the certifying physician in the ‘attending physician’ field until the physician edit is expanded to the ‘other provider’ claim form locator in October,” he summarizes.

“This presents a real challenge for EMRs and opens up numerous potential claims processing problems,” Little warns.

Another problem: Thanks to the very brief delay, hospices confused about which certifying physicians can pass this edit have little time to figure it out and get providers in their correct status.

“Hospices can verify a physician’s enrollment or opt-out status using the CMS ordering and referring data file (ORDF), which lists all Medicare-enrolled and opted-out physicians,” CMS says in the Q&As.

But that isn’t the end of the story. Physicians also need to have a “Y” in the “Hospice” column in the ORDF to order hospice services, CMS stresses.

So for example: “Simply because a non-physician practi­tioner type is enrolled or opted-out does not in and of itself mean that said type can order/certify a service/item under Medicare regulations,” CMS says in the Q&As. “It is critical to distinguish the enrollment/opt-out requirement under §424.507 from the ability of a certain provider type to order or certify a particular service or item,” the agency emphasizes.

Once hospices figure out who is qualified to order and re-check their roster to find docs who need to either enroll or opt out, it may be too late to meet the June 3 deadline.

And “if a hospice has waited until now to get their hospice and attending physicians enrolled, there could be a delay, depending on the processing on the PECOS website,” points out Lund Person, who was formerly with NHPCO.

Watch out: And of course, any time Medicare claims system changes are scheduled, operational glitches are possible — and perhaps likely. “All of us hope for the best with the CMS systems and MAC instruction,” Lund Person tells AAPC.

Watch for: While the instructions are out in the Q&As, expect official revised directions to MACs in a transmittal soon.

Note: The four-page Q&As are at >www.cms.gov/files/document/hospice-certifying-enrollment-Q&As.pdf.