Hospice Certifying Physician Billing Instructions and Claim Editing

Published 02/25/2025

Hospice certifying physicians, including hospice physicians and hospice independent attending physicians (but not a nurse practitioner (NP) or physician assistant (PA) designated as the attending since they cannot certify or recertify) are required to be enrolled in Medicare or validly opted-out at the time they make the certification or recertification of hospice care for a patient.

For claims with "from" dates on or after June 3, 2024, edits were implemented to deny hospice a claim if the hospice certifying physician(s) entered on the claim are not enrolled in Medicare or have not validly opted-out at the time they make the certification or recertification of hospice care for a patient. 

Table 1: Billing Instructions for all Hospice Claims and Notices Submitted after Nov. 18, 2024

Direct Data Entry (DDE) and electronic physician fields billing instructions for hospice claims and notices.

Field

Enter

DDE: Attending Physician I.D.

Electronic Claims: ATT PHYS
  • The hospice enters the name and National Provider Identifier (NPI) of the attending physician designated by the patient at the time of election as having the most significant role in the determination and delivery of the patient’s medical care
    • The patient’s designated attending physician could be an independent physician, hospice physician, a NP or PA. Although NPs and PAs may be designated as an attending (if state law allows), they still cannot certify for the Hospice Benefit.
  • If there is no attending physician designated by the patient, then the hospice shall report the hospice certifying/recertifying physician

DDE: Other Physician I.D

Electronic Claims: Loop ID 2310F — Referring Provider Name
  • Do not populate this field if there is no attending physician designated by the patient
  • If there is an attending physician designated by the patient, the hospice enters the name and NPI of the hospice physician responsible for certifying/recertifying that the patient is terminally ill, with a life expectancy of six months or less if the disease runs its normal course.
  • When the attending physician is also the hospice physician certifying/recertifying the terminal illness, only the attending physician field is required to be populated. This field would not need to be populated.

How the Edit Applies

The editing for the certifying/recertifying physician edit (reason codes 17729 and 17730) will apply on hospice claims as follows.

  • Hospice admission claims (when occurrence code 27 date is equal to the claim admit date)
    • The edit will be applied to the Other/REF PHYS NPI field (if populated) as well as the ATT PHYS name and NPI fields on the hospice claim to ensure the certifying physician as well as the attending physicians (physicians only) are enrolled or validly opted-out in Medicare for payment. 
    • When an NP or PA is entered on the claim as the attending, the certifying/recertifying physician information submitted in the Other/REF PHYS name and NPI fields will be used to verify the certifying/recertifying physician is on the PECOS Hospice O/R file. The edit will not apply to NPs/PAs serving as an attending.
  • Hospice sequential claims containing occurrence code 27 with a date of recertification that does not match the admission date on the claim and both the attending physician (ATT PHYS name and NPI fields) and the certifying physician (Other/REF PHYS name and NPI fields) are populated, the edit shall only apply to the Other/REF PHYS name and NPI fields for the hospice’s certifying/recertifying physician PECOS enrollment.
  • If Occurrence Code 27 and date are not present on the claim, the certifying/recertifying physician edit will not apply to the claim. CMS will not be conducting certifying/recertifying physician enrollment checks on physicians reported on claims that do not have occurrence code 27 reported.
  • The certifying/recertifying physician edit only applies to type of bill (TOB) 81X/82X and excludes hospice notices (TOB 8XA, 8XB, 8XC, 8XD and 8XE)

Resources


Was this article helpful?