April 3, 2024
Hospice Certifying Physician Medicare Enrollment Information
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 May 1, 2024, CMS begins implementing checks to deny hospice claims if the physician in the Attending field is not on the file to enforce this new rule.
There are three enrollment options for certifying physicians. They are:
- CMS-855I for Physicians and Non-Physician Practitioners (NPPs)
- Complete this application if you are an individual practitioner or eligible professional who plans to bill Medicare
- CMS-855O for Ordering and Certifying Physicians and NPPs
- Complete this application if you are an individual 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/NPPs – CGS
Physicians NPs, or PAs must enroll with the Medicare Administrative Contractor (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 MAC for MAC jurisdictions.
The (CMS Order and Referring Dataset
) provides information on all physicians, NPs, or PAs 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 will be added prior to the effective date of this requirement.
Not all opt-out physicians can certify for the Medicare Hospice Benefit. If a physician did not respond with all the information to be an opt-out physician with ordering/certifying/referring rights or had their Medicare enrollment revoked for adverse actions, they cannot certify. Please access the (Provider Opt-Out Affidavits Look-up Tool) and see if the field “Eligible to Order and Refer” has a “Yes” or “No” populated. If “Yes” is populated, they have a PECOS record and can certify. If “No” is populated, they do not have a PECOS record and cannot certify.
If a hospice intends on billing Medicare for medically necessary physician services provided by a hospice employed or compensated physicians, NPs, or PAs on a hospice claim, that physician, NP, or PA is required to have a CMS-855I enrollment with Medicare billing rights. A hospice may not bill services for a physician/practitioner that the Physician/NP/PA 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, NPs, or PAs 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
- CMS Change Request 13342: Implement Edits on Hospice Claims
- CMS: Medicare Enrollment Guide for Providers & Suppliers
- CMS: Medicare Enrollment Application - CMS-855I
- CMS: Medicare Enrollment Application - CMS-855O
- CMS Ordering and Referring Dataset
- CGS: Opting Out of Medicare Webpage
- CGS: Opting Out Affidavit
- CMS: Opt Out Affidavits - List of Practitioners Currently Opted Out of Medicare
- CMS: Medicare Fee-for-Service Provider Enrollment Contact List
- CMS: Medicare Learning Network Educational Tool - 6922507
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