Hospice Billing

Hospice Certifying Physician Medicare Enrollment Information

Under CMS' current regulations, the hospice medical director or the physician member of the hospice interdisciplinary group (the “hospice physician”) and the attending physician (if the beneficiary has one) must initially certify the patient’s terminal condition. Per 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 5/1/2024, 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 PECOS as an enrolled or opted-out physician.

There are three enrollment options for certifying physicians. They are:

  • CMS-855I for Physicians, NPs, or PAs
    • Complete this application if you are an individual practitioner or eligible professional who plans to bill Medicare, certify, refer or order services
  • CMS-855O for Ordering and Certifying Physicians/NPs/PAs
    • 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/NPs/PAs

Physicians, NPs, or PAs must enroll with the MAC specific to the region where they practice and may have additional requests for information while they process their application. They can also check in with their MAC, which may differ from the hospice’s MAC, regarding your enrollment status (contact Your MAC).

The CMS Order and Referring Dataset provides information on all physicians, NPs, or PAs by their NPI who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare.

Not all opt-out physicians can certify for the 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 physician, NP or PA 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 nonhospice 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.

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Revised 3/27/2024