In a November 20 Change Request (CR 14219), the Centers for Medicare and Medicaid Services instructed Part A/B Medicare Administrative Contractors (MACs) to implement new system edits which will automatically compare the primary diagnosis codes on hospital inpatient and outpatient claims with the hospice claim’s primary diagnosis codes. The edit will deny hospital inpatient and outpatient claims when there is a hospice claim for the same Medicare beneficiary within the same covered period with condition code 07 with same primary diagnosis. This edit is in response to concerns first raised in a 2024 Office of Inspector General (OIG) report on outpatient services provided to hospice enrollees. The report identified improper payments for services provided to hospice enrollees related to their terminal illness which were already covered under the hospice benefit. In these instances, the services should have been provided directly by the hospices or under arrangement with the hospice and the hospital.

The edit will be effective April 1, 2026, and CMS issued additional education for providers to comply with billing expectations.