Medicare – Implement Edits on Hospice Claims

Starting May 1, 2024, CMS is only verifying the enrollment/opt-out status of the physician listed in the claim’s “Attending Physician” field. Accordingly, hospices should enter the certifying physician in the “Attending Physician” field. So long as the hospice enters a physician in the “Attending Physician” field and that physician is in the PECOS record that is valid for edit dates, the claim will not edit.

Beginning October 7, 2024, CMS will begin verifying the enrollment/opt-out status of physicians listed in the “Other Physician” field. Once that occurs:

• CMS will check both the “Attending Physician” field and the “Other Physician” field.
• Both physicians, if different, will be subjected to the ordering and certifying denial edits for the initial certification period.
• For subsequent certifications, CMS will only check the “Other Physician” field for the certifying physician.
• Hospices should enter the attending physician in the “Attending Physician” field and the certifying physician in the “Other Physician” field. If the patient does not have an attending physician, the hospice should report the hospice certifying/recertifying physician in the “Attending Physician” field.

Source: https://www.cms.gov/files/document/r12330otn.pdf