Denial Reason, Reason/Remark Code(s)
- PR-B9: Services not covered because the patient is enrolled in a hospice
- Procedures: all, especially CPT code 36415 (venipuncture) and ambulance HCPCS codes A0425, A0427 and A0428
Resources/Resolution
- Determine whether the patient has elected hospice benefits prior to submitting claims to Medicare
- You may verify eligibility through the Palmetto GBA Interactive Voice Response unit (IVR) or online through an ANSI 270/271 transaction
- If the patient has elected hospice benefits, refer to 'Hospice Benefits and Medicare Part B,' below
Hospice Benefits and Medicare Part B
Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition.
- When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner
- Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be submitted by the rendering provider for non-hospice payment
- These services are coded with HCPCS modifier GW: 'Service not related to the patient’s terminal condition'
- Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when this condition applies.
Online Eligibility Verification
CMS offers real-time Internet-based eligibility transactions as an alternative to the IVR. These ANSI 270/271 transactions are processed through the CMS data center. Providers and clearinghouses must be authenticated by CMS before conducting these transactions. Telecommunications software is also required in order to access the CMS network.
Steps to obtain access for Internet eligibility (270/271) transactions:
- Access the CMS HIPAA Eligibility Transaction System (HETS)
- From the left navigation menu, select Sign Up Now
- In order to obtain access to the CMS 270/271 Medicare Eligibility transaction from the Medicare Data Communication Network (MDCN), you must access and complete the Trading Partner Agreement and Access Form
- This agreement outlines security and privacy procedures for the Medicare beneficiary database. Complete all the information on the form electronically and click on the appropriate assurances. If you do not consent to the terms of the agreement, the access process will be terminated.
- If you check the appropriate boxes of the agreement and supply the information requested, a copy of the completed form will be electronically submitted to the CMS 270/271 MEIC for security authentication
- The access process will then continue, and you will be directed to complete the Medicare Data Communication Network (MDCN) Connectivity Form. This form must be submitted electronically in order for you to be connected to the 270/271 eligibility database.
- CMS will ensure that all necessary information is provided on the forms, and ensure the complete connectivity to the 270/271 application. The Medicare Eligibility Integration Contractor (MEIC) will be responsible for contacting the clearinghouses, providers and trading partners to authenticate the accessing entity's identity. Once authentication has been completed, the MEIC will provide you with a submitter ID that must be used on all 270/271 transactions. Testing will be coordinated by the MEIC. After successful testing, 270 production inquiries may be sent in real-time.
Reference
- For more information about hospice coverage and claim submission, refer to the Palmetto GBA Physician/Supplier Guide:
- Access CMS guidelines related to hospice through the following links: