Skip to Main Content

Print | Bookmark | Email | Font Size: + | –

June 24, 2024

Hospice Certifying Physician Medicare Enrollment Information – Revised

Pursuant to our authority under section 6405 of the Affordable Care Act, and as part of CMS’ larger strategy to address hospice program integrity and quality of care, certifying physicians, including hospice physicians and hospice attending physicians must be enrolled in or opted-out of Medicare for the hospice service to be paid.

Effective June 3, 2024, (delayed from May 1, 2024) CMS will begin implementing edits to enforce this new rule and will deny hospice claims if the physician entered in the Attending field on the claim is not in the Provider Enrollment Chain and Ownership System (PECOS) as an enrolled or opted-out physician.

There are three Medicare enrollment options for physicians who want to certify for the Medicare Hospice Benefit (these enrollment options also include enrollments for non-physician practitioners, but they cannot certify for the benefit). They are:

  • CMS-855IExternal PDF Medicare Enrollment Application for Physicians and Non-Physician Practitioners
    • Complete this application if you are an individual physician, practitioner or eligible professional who plans to bill Medicare and/or certify, refer or order Medicare services.
    • It is not required that the primary specialty of “Hospice/Palliative Care” is selected in Section 2G of the CMS-855I application, as a medical doctor or doctor of osteopathy of any specialty may certify or re-certify an individual for the Medicare Hospice Benefit.
  • CMS-855OExternal PDF Medicare Enrollment Application for Eligible Ordering/Certifying Physicians and Other Eligible Professionals
    • Complete this application if you are an individual physician, practitioner or eligible professional and enrolling sole purpose of ordering or certifying items and/or services to beneficiaries in the Medicare program.
  • Opt-Out Affidavit for Eligible Physicians/Non-Physician Practitioners with certifying rights

Physicians and non-physician practitioners must enroll with the MAC specific to the region where they practice. They can also check in with their MAC, which may differ from the hospice’s MAC, regarding their enrollment status. Please see Contact Your MACExternal PDF for MAC jurisdictions.

The CMS Order and Referring DatasetExternal Website provides information on all physicians and non-physician practitioners by their National Provider Identifier (NPI), who are of a type/specialty that is legally eligible to order, certify and refer in the Medicare program and who have current enrollment records in Medicare. A hospice column was added prior to the effective date of this requirement. A professional listed with an “N” in the hospice column of the CMS Order and Referring Dataset cannot certify for hospice. Non-physician practitioners cannot certify for hospice and therefore will have a “N” in the hospice column of the CMS Order and Referring Dataset.

If an opt-out physician does not appear on the CMS Order and Referring Dataset, they may not be eligible to order, certify and refer in the Medicare Program, including for hospice. You may access the Provider Opt-Out Affidavits Look-up ToolExternal Website and see if the field “Eligible to Order and Refer” has a “Yes” or “No” populated. If “No” is populated, they do not have a PECOS record and cannot certify. They physician may contact their MAC for the reason they are not eligible to order, refer, or certify.

If a hospice intends on billing Medicare for medically necessary physician services on a hospice claim, provided by a physician or allowed non-physician practitioners serving as the attending physician who are hospice employees or working under arrangement with the hospice, they are required to have a CMS-855I enrollment with Medicare billing rights. A hospice may not bill services for a physician/practitioner that the physician or allowed non-physician practitioners does not have the right to bill Medicare for physician services in a non-hospice setting.

  • Physician services billing, when applicable, is separate from other hospice billing, such as the level of care, skilled nursing, medical social services, drugs, etc.
  • Hospices’ use revenue code 0657 to identify physician services furnished to patients by physicians or allowed non-physician practitioners employed by or receiving compensation from the hospice.
  • Payment for physicians’ administrative and general supervisory activities are included in the hospice payment rates and are not separately billable.

Resources:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved