Billing Medicare for Hospice Patients: When and How

Billing Medicare for hospice care is tripping up physicians, the Centers for Medicare & Medicaid Services (CMS) reports following automated review of hospice claims by recovery audit contractors.

If your Medicare patient is enrolled in hospice, ask yourself before billing Medicare:

  1. Are the services you provided related to the patient’s terminal illness?
  2. Are you the patient’s designated “attending physician”?

The answers to these questions will determine whether you can bill Medicare for your service and if so, which modifier to use on your claim.

Medicare patients who elect hospice coverage waive all rights to Medicare Part B payments for services related to the treatment and management of their terminal illness while the hospice benefit election is in force, except for professional services of an attending physician who is not an employee of or paid by the designated hospice.

  • If you answer “No” to question No. 1 above, you can bill Medicare using the GW modifier (Service not related to the hospice patient’s terminal condition). All physicians, including the attending physician, may bill with the GW modifier.
  • If you answer “Yes” to question No. 1, and “Yes” to question No. 2, you may bill Medicare with the GV modifier (Attending physician not employed or paid under arrangement by the patient’s hospice provider) — see below for details.
  • If you answer “Yes” to question No. 1 and “No” to question No. 2 — you are not the attending physician — then you cannot bill Medicare for your service.

Novitas Solutions’ decision trees can help you determine whether to bill Medicare and which modifier to use.

  •  GV modifier: In this context, an “attending physician” is an MD, DO, or nurse practitioner whom the hospice patient identifies as having the most significant role in determining and delivering the patient’s medical care at the time he or she elected hospice coverage, and is neither an employee of nor receives compensation from the hospice.

As an attending physician, you should use modifier GV when your services are related to the patient’s terminal condition and are not paid under arrangement by the patient’s hospice provider.

If you are employed by the hospice, or if you are not the patient’s attending physician and your services are related to the patient’s terminal illness, do not bill Medicare.

  •  GW modifier: All physicians, attending or not, must use this modifier to bill Medicare for a service to hospice patient that is unrelated to the patient’s terminal condition.

Remember also:

  • The hospice patient or his or her legal representative may revoke the election of hospice care at any time by filing a signed document with the hospice; thus your patient’s hospice enrollment status could change from one visit to the next.
  • Be sure to explain to Medicare patients and their families that once the patient is enrolled in hospice, they should contact the hospice provider to arrange for any care they need. Otherwise, the patient may be financially responsible for the services. 

For more information, see CMS’ MLN Matters No. SE1321(PDF) and the Medicare Claims Processing Manual, Chapter 11 — Processing Hospice Claims (PDF) for the full rules.

Published Aug. 13, 2013

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