Hospice Billing

17729 and 17730 Hospice Claim Edits for Certifying Physicians

Effective for hospice claims with claim ‘From’ dates on or after 6/3/2024, new claim edits have been implemented per CR 13342 to enforce CMS’ rule to deny hospice claims if the name and NPI of the certifying physician in the ATT PHYS field is not in the PECOS. as an enrolled or opted-out provider. The hospice physician and attending physician need to be enrolled/opted-out at the time they make the certification or recertification of hospice care for a patient.

The following are the reason code descriptions when these guidelines are not met:

Reason Code 17729 – Attending Field Edit

  • If the NPI and first four letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date, the claim will deny with reason code 17729.

Reason Code 17730 – Referring Field Edit

  • If the NPI and first four letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date, the claim will deny with reason code 17730.

You can avoid this reason code by reviewing the CMS Ordering and Referring Data Set for the attending physician (ATT PHYS) entered on the claim to ensure:

  • The physician is listed on the CMS Order and Referring Dataset with a “Y” in the hospice column. If the physician has an “N” in the hospice column, they are not eligible to certify for hospice and the claim cannot be approved for payment.
  • Their NPI is correct
  • The first four characters of their last name exactly matches the dataset. Also verify that the first and last name are not entered in reverse on the claim.
  • The name and NPI is not for a NP or PA. NPs and PAs cannot certify patients for hospice. A physician must be entered.

If the physician entered in the ATT PHYS field on the claim is not in the PECOS as an enrolled or opted-out physician, they will not be listed on the dataset and the claim cannot be approved for payment.

Physicians enroll with the MAC specific to the region where they practice. Physicians can also check with their MAC, which may differ from the hospice’s MAC, regarding their enrollment status. Please see Medicare Fee-for-Service Provider Enrollment Contact List for the MAC jurisdictions.

Claim Adjustments

An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated.

  • Adjustment of non-medical claim denials is allowed; and
  • Providers shall initiate an adjusted claim through their electronic billing software (Direct Data Entry cannot be used)
    • If your electronic billing software does not allow the adjustment to occur, please contact the vendor to have them update their software.

Claim Adjustment Requirements

  • Enter adjustment type of bill 817 or 827 
  • Condition code "D9" 
  • Ensure the claim number of the denied final claim is entered in the cross-reference (X-Ref) Document Control Number field
  • Correct attending physician’s NPI and name, if applicable
  • Enter remarks (FL80) indicating the reason for the adjustment 
    • Correction to attending physician’s NPI and/or name or the physician’s PECOS record has been updated

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Revised 11/26/2024