Hospice Claims Edits for Certifying Physicians

Hospice Claims Edits for Certifying Physicians
Centers for Medicare & Medicaid Services (CMS); Related CR Release Date 4/18/24; Effective Date: 5/1/24; Implementation Date: 10/7/24
Related CR Title: Additional Implementation Edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment
Starting May 1, 2024, we’ll deny hospice claims if the certifying physician, including hospice physician and hospice attending physician, isn’t on our PECOS hospice ordering and referring files. This addresses hospice program integrity and quality of care per Section 6405 of the Affordable Care Act.

Affected Providers

• Hospices
• Physicians and other providers billing Medicare Administrative Contractors (MACs) for hospice services they provide to Medicare patients

Action Needed

• CMS will pay for hospice services if certifying physicians, including hospice physicians and hospice attending physicians, are enrolled in or opted-out of Medicare
• The hospice attending and certifying physicians will be subjected to ordering and referring denial edits