Reason Codes 17729 and 17730

Subject

Effective June 3, 2024, for claim "From" dates on or after this date CMS implemented edits to deny hospice claims if the certifying physician(s) entered on the claim are required to be enrolled in Medicare or validly opted-out at the time they make the certification or recertification of hospice care for a patient. 

Reason Code Descriptions

Reason Code 17729 — Attending Field Edit

If the NPI and first four (4) letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first 4 letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date, the claim will deny with reason code 17729.

Reason Code 17730 — Referring Field Edit

If the NPI and first four (4) letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first 4 letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date, the claim will deny with reason code 17730.

Resolution

1. Ensure the claim is billed correctly.
For all claim submissions after November 18, 2024, enter physicians, nurse practitioners (NPs) or physician assistants (PAs) serving as an attending (if applicable) using the direction below.

• Attending Physician Field
  • Enter the name and NPI of the attending physician designated by the patient
    • If there is not an attending physician designated by the patient, enter the hospice certifying/recertifying physician.
    • The patient’s designated attending physician could be an independent physician, hospice physician, an NP, or PA.
      • When a NP or PA is entered as the attending, the processing system shall use the NPI submitted in the Referring Provider Field to verify the physician (medical director or physician member of the interdisciplinary group) has a PECOS enrollment.
• Referring Provider Field
  • Enter the name and NPI of the hospice’s physician responsible for certifying patient’s terminal illness
  • When no attending is designated or the attending physician is also the certifying physician, only populate the Attending physician field and leave this field blank

2. Ensure the physician has a Medicare enrollment or validly opted-out at the time they make the certification or recertification.
The CMS Order and Referring Dataset provides information on all physicians 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 characters of their last name exactly matches the dataset
  • Ensure the first and last name are not entered in reverse 
  • If the provider is going through a name change, the updated name may only be entered on the claim once the dataset shows the update
  • Do not use nicknames 
  • Do not enter a credential (e.g., “Dr.” or “MD”) in a name field
• Ensure that the name and the NPI you enter belongs to a physician and not to an organization

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.

3. Is Occurrence Code 27 and its associated date present on the claim, but not needed?
The OC 27 code/date is only required on claims by CMS where initial certification or recertification occurs. CMS will not be conducting certifying/recertifying physician enrollment checks on physicians reported on claims that do not have occurrence code 27 and date reported.

Claim Adjustments
An adjustment should be submitted when an input error (i.e., 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). If your electronic billing software does not allow the adjustment to occur, please contact the vendor to have them update their software.

Claim Adjustment Requirements

• Enter adjustment type of bill 817 or 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

• Transmittals
  • Change Request 13531, Additional Implementation Edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment (PDF)
  • Change Request 13342, Implement Edits on Hospice Claims  (PDF)
• Medicare Claims Processing Manual (PDF)
• Hospice Certifying Enrollment Questions and Answers (Q & A) Document (PDF)
• Hospice Certifying Physician Medicare Enrollment Information