Reason Code 17729

Subject
Effective June 3, 2024, (delayed from May 1, 2024), for claim "from" dates on or after this date, CMS implemented edits to enforce a new rule that would deny hospice claims if the certifying 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.

Reason Code Description
The attending physician’s National Provider Identifier (NPI) data on the claim does not match the PECOS Enrolled Physicians File, or the dates do not fall within the physicians effective/termination dates.

This reason code will edit the claim’s attending physician’s NPI data against the PECOS Enrolled Physicians File for hospice claims, type of bill 81X and 82X (excluding 8XA, 8XB, 8XC, 8XD and 8XE) with a statement "from" date on or after May 1, 2024, and will assign when:

• Occurrence Code 27 and associated date (hospice certification or recertification date) are present, and the Occurrence Code 27 date does not fall on or after the physician's effective date but before the termination date on the PECOS Enrolled Physicians File
   
• Occurrence Code 27 and associated date are not present and the claim statement “from" date is not on or after the physician's effective date but before the termination date 
   
• The attending physician’s NPI and/or the first four characters of the physician's last name does not match the NPI and/or the first four characters of the physician's last name                                  

Resolution
The CMS Order and Referring Dataset provides information on all physicians, as well as nurse practitioners (NPs) or physician assistants (PAs) by their 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. Check the dataset to ensure the attending physician entered on the claim is:

• Listed on the CMS Order and Referring Dataset with a “Y” in the hospice column. If the physician has an “N” in the hospice column, they are not eligible to certify for hospice and the claim cannot be approved for payment.
   
• Their NPI is correct
   
• Their first four (4) characters of their last name exactly matches the dataset. Ensure the first and last name are not entered in reverse on the claim.
   
• For initial benefit periods, complete the Attending Physician and Other fields (with the hospice certifying physician listed in the latter field) unless the patient’s designated attending physician is the same as the hospice physician certifying the terminal illness. When the attending physician is also the hospice certifying physician, only populate the Attending Physician field.
   
• For subsequent benefit periods, the hospice certifying physician may be listed in the claim’s Attending Physician field to avoid this denial; leave the Other field blank
   
• NP or PA — NPs and PAs cannot certify patients for hospice. A physician must be entered.

If the physician entered in the Attending field on the claim is not in the PECOS as an enrolled or opted-out physician, they will not be listed on the dataset and the claim cannot be approved for payment."

Starting May 1, 2024, CMS will only verify the enrollment or opt-out status of the physician listed in the claim’s Attending Physician field. We’ll begin verifying the enrollment or opt-out status of physicians listed in the Other Physician field later in 2024.

Physicians 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 (PDF) for MAC jurisdictions.

Claim Adjustments
An adjustment should be submitted when an input error (e.g., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated.

• Adjustment of non-medical claim denials is allowed; and
• Providers shall initiate an adjusted claim through their electronic billing software (Direct Data Entry cannot be used)

Claim Adjustment Requirements

• Enter type of bill 817 and 827
• Condition code "D9"
• Ensure the claim number of the denied final claim is entered in the cross-reference (X-Ref) Document Control Number field
• Correct attending physician’s NPI and name, if applicable
• Enter remarks (FL80) indicating the reason for the adjustment; correction to attending physician’s NPI and/or name or the physician’s PECOS record has been updated

References

• Change Request 13342 (PDF) 
• MLN Matters Number: MM13531
• Hospice Certifying Physician Medicare Enrollment Information 
• MLN6922507 — Medicare Payment Systems (see “Certification Requirements” in under the "Hospice Payment System and Coverage" topic)