Hospice Claim Edit

Beginning on May 1, 2024 a new claim edit will be implemented for hospice. 

This edit is associated with the condition of payment that was finalized in the FY 2024 Hospice Wage Index final rule that requires hospice certifying physician(s) to be enrolled in Medicare or have a valid opt-out on file. 

There are still some details and concerns to be clarified and addressed regarding this change due to confusion on data entry for the Attending Physician field as instructions indicate it should be completed differently for the initial and subsequent benefit period claims.

At this point, hospices should focus on these two points:

Provided that the Attending Physician field on the claim contains the NPI of a physician that is enrolled or validly opted-out, the May 1 edit that goes into effect will allow the claim to process and be paid.

The May 1 edit will only authenticate the physician listed in the Attending Physician field on the claim.

However, beginning on October 7, 2024, a new edit will be put into action that will verify the physician listed in the Attending Physician field on the claim AND the physician listed in the Referring Physician (Other Physician) field on the claim.

The Medicare Claims Processing Manual has been updated effective 04/18/2024 with the Attending Physician field instructions as noted below:

The hospice enters the name and provider identifier 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 nurse practitioner, or physician assistant. If there is no attending physician listed, then the hospice shall report the hospice certifying/recertifying physician.

For further information, for NAHC members please reference this article:

https://nahc.org/hospice-certifying-physician-condition-of-payment/