Effective July 1, 2014, Medicare Home
Health Agency (HHA) Prospective Payment System (PPS) claims must include (a) a
valid individual National Provider Identifier (NPI) and the name of the
physician who certifies/re-certifies the patient's eligibility for home health
services (certifying physician) and (b) the NPI and name of the physician who
signs the patient's plan of care (attending physician).
must be enrolled in the Medicare Provider Enrollment,
Chain, and Ownership System (PECOS) as either a participating or
non-participating provider. Physicians who have opted out of Medicare, but refer
patients for Medicare services, must have completed an updated opt-out affidavit
In most instances, the certifying physician will be the
same physician who signs the plan of care, in which case the HHA only reports
the NPI and the name of the physician as the attending physician. However,
physicians who attend to hospitalized patients, but do not follow them into the
community, are considered certifying physicians and are subject to the ordering
and referral enrollment requirements. On the electronic claim, these physicians
are indicated in the "Other Provider" field.
Protection and Affordable Care Act (ACA) included requirements for referring
physicians (including physician assistants, clinical nurse specialists, and
nurse practitioners) to be enrolled in Medicare. Currently, the enrollment edit
only applies to the attending physician for the home health claim. The edits
instituted on July 1, 2014, will check home health claim submissions to ensure
that attending and certifying physicians have valid National Provider
Identifiers (NPIs) and are of a specialty type eligible to order and refer the
HHA items and services on the claims. Claims will be denied when this
information is missing or invalid.
For more information
regarding the physician referral requirements, refer to the CMS MLN Matters
Physicians and the Phase 2 Ordering and Referring Denial Edits for Home Health
Agencies (HHAs) [PDF].
For questions or additional information, please
e-mail [email protected].