Hospice

We learned today that some hospice claims are not processing due to a problem with the attending physician's NPI.   CR 12889 which instructs MACs to have an edit that validates the attending physician's NPI includes hospice claims.   The CR instructs MACs to validate the NPI in the Attending Physician field on a claim against the Provider Enrollment, Chain, and Ownership System (PECOS) file.  If the NPI is not found in the file, the claim will not process.  However, attending physicians for hospice patients are not required to be PECOS enrolled so their NPI will not be in the PECOS file unless they are otherwise enrolled.  The FY 2024 hospice proposed rule includes a proposal that physicians certifying hospice care be PECOS enrolled or have a valid opt-out but that is not finalized. 

Effective April 1, 2023 hospices that submit a claim where the attending physician's NPI is not in the PECOS file, the NPI and last name do not match, or the claim has a date of service equal or greater than the termination date on the PECOS enrolled physician inquiry screen will not have the claim process.  NAHC has reached out to CMS about this issue and will provide additional information as it is available.

We heard from CMS today that this edit was being applied inappropriately and a fix is in the works.  CMS does not have an exact timeframe for the fix being implemented but likely within the next 30 days.  New instructions need to be written for the Medicare Administrative Contractors (MACs) and the MACs will then have 10 business days to implement.  Any hospice claims impacted prior to the fix being implemented will need to resubmit the claim.  The MACs will also likely be putting this information out through their communication channels.