Beginning October 7, 2024, the Centers for Medicare & Medicaid Services (CMS) will implement significant changes to hospice claims processing, as detailed in Change Request (CR) 13531 and the FY2024 Hospice Wage Index and Payment Rate Update final rule. These changes are designed to enhance hospice program integrity and ensure that claims are compliant with…
Beginning October 7, 2024, the Centers for Medicare & Medicaid Services (CMS) will implement significant changes to hospice claims processing, as detailed in Change Request (CR) 13531 and the FY2024 Hospice Wage Index and Payment Rate Update final rule. These changes are designed to enhance hospice program integrity and ensure that claims are compliant with Section 6405 of the Affordable Care Act, which addresses the enrollment status of certifying physicians. For claims submitted on or after October 7, 2024, with dates of service on or after June 3, 2024, CMS will begin applying edits to verify the Medicare enrollment or opt-out status of both the certifying and attending physicians listed on hospice claims.
Key Changes to Claims Processing
The revised edits will check the REF PHYS NPI field, which contains the National Provider Identifier (NPI) of the certifying physician, and the ATT PHYS NPI field, which identifies the attending physician. For hospice claims to be processed, both physicians, if different, must be enrolled in or opted-out of Medicare. These checks apply to claims during the initial certification period and subsequent recertifications. If the patient designates a nurse practitioner (NP) or physician assistant (PA) as their attending physician, CMS will only check the certifying physician’s enrollment status in the REF PHYS NPI field, bypassing the ATT PHYS NPI field. However, if the attending physician and certifying physician are the same individual, edits will be applied only to the Attending field.
Compliance with Physician Enrollment Requirements
This policy is an extension of CMS’s efforts to ensure that hospice claims are compliant with physician ordering and referring guidelines. If the physicians listed in either the attending or certifying fields are not enrolled in or opted out of Medicare, the claim will be denied. This measure directly ties into improving program integrity and the quality of care provided to hospice patients. Under the new rules, claims with dates of service on or after June 3, 2024, that are submitted on or after October 7, 2024, must reflect accurate physician enrollment status to avoid denials.
Change Request (CR) 13531 Clarifications
CR 13531 also provides critical guidance on how to correctly populate the attending and certifying physician fields on hospice claims:
- Attending Physician I.D.: This field should include the name and NPI of the attending physician designated by the patient at the time of election. This physician is expected to play a significant role in the patient’s care, and they could be a hospice physician, an independent physician, NP, or PA. If the patient does not have an attending physician, the hospice must report the hospice certifying or recertifying physician in this field.
- Other Physician I.D.: The hospice enters the name and NPI of the physician responsible for certifying or recertifying the patient’s terminal illness in this field. This physician certifies that the patient has a life expectancy of six months or less if the disease runs its normal course. For electronic claims, this information should be entered in Loop ID 2310F – Referring Provider Name.
Both the attending and certifying physician fields should be completed, unless the attending physician is also the certifying or recertifying physician. If the attending physician is the same as the certifying physician, the Attending Physician field must be populated, and the Other Physician field can be left blank.
Implementation Timeframes and Key Dates
Hospices must take note of the specific implementation timeframes:
- October 7, 2024: CMS will begin checking both the REF PHYS NPI and ATT PHYS NPI fields for compliance with the enrollment or opt-out requirement. Claims submitted on or after this date will be subject to edits if the attending and certifying physicians are not properly enrolled. If an NP or PA is listed as the attending physician, the edit will bypass the ATT PHYS NPI field and focus only on the REF PHYS NPI field.
- November 18, 2024: Another phase of the edits will be applied. If the ATT PHYS NPI field contains an NP or PA, CMS will only verify the certifying physician listed in the REF PHYS NPI field. If both physicians are listed, CMS will verify both fields unless the attending physician is an NP or PA.
Conclusion
As CMS continues to roll out these updates, hospices must ensure that their claims accurately reflect the enrollment status of both certifying and attending physicians. This means verifying the enrollment or opt-out status of the physicians before submitting claims to avoid potential denials. Hospices should also closely follow the guidelines in CR 13531 to ensure compliance with the new physician reporting requirements on hospice claims. Failure to adhere to these updates may result in denied claims, making it critical for hospice providers to stay updated on these changes and adjust their claim submission practices accordingly.
