Reminders for the New Hospice Certifying Physician Claim Edit Effective 5/1/2024

Effective for hospice claim "From" dates on or after 5/1/2024, CMS implemented edits to enforce a new rule that would deny hospice claims if the certifying physician entered in the Attending field on the claim is not in the PECOS as an enrolled or opted-out physician. The hospice certifying physician needs to be enrolled/opted-out at the time they make the certification or recertification of hospice care for a patient.

Actions to Prevent this Denial

• Is the physician listed on the CMS Order and Referring Dataset on the date of initial certification or recertification and do they have 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.
• For initial benefit periods, complete the Attending Physician and Other Physician fields (with the hospice certifying physician listed in the latter field) unless the patient’s designated attending physician is the same as the hospice physician certifying the terminal illness.
  • When the patient’s designated attending physician is also the hospice certifying physician, only populate the Attending Physician field.
  • When the patient doesn’t designate an attending physician, the hospice certifying physician should be entered in the claim’s Attending Physician field.
• For subsequent benefit periods, the hospice certifying physician should be listed in the claim’s Attending Physician field to avoid this denial.
  • Leave the Other Physician field blank.
• Is the physician’s NPI correct on the claim?
  • Are any of the numbers transposed?
• Do the first four characters of their last name exactly match the CMS dataset on the claim?
• Ensure a NP or PA is not entered in the claim’s Attending Physician field.
  • NPs and PAs cannot certify for hospice and should not be entered in the Attending Physician field on a hospice claim.

If the physician entered in the Attending Physician field on the claim is not in 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.

Related Content

• Change Request 13342
• Hospice Certifying Physician Medicare Enrollment Information
• MLN6922507 - Medicare Payment Systems
  • See “Certification Requirements” under the Hospice Payment System & Coverage topic

Posted 4/19/2024