MM14219 - Outpatient Services for Hospice Patients: New Edit
We’re enhancing the current systems’ edits to help reduce improper payments for outpatient services provided by acute care hospitals to hospice patients. We created a new edit to automatically compare the outpatient claim’s primary diagnosis codes with the hospice claim’s primary diagnosis codes by doing an exact diagnosis match. This edit will deny hospital inpatient and outpatient claims when there’s a hospice claim for the same Medicare patient within the same covered period with condition code 07 or modifier GW with the same primary diagnosis.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: November 21, 2025
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