Professional Services During a Hospice Election

When a patient chooses to elect Medicare hospice coverage, they waive all rights to Medicare Part B payments for services related to the treatment and management of the terminal illness during any period in which the hospice election is in force.

This resource provides an overview of Medicare payment when a patient elects the hospice benefit and instructs physician and nonphysician practitioners (NPPs) on providing services under arrangement with the hospice agency.

Hospice Election
The patient can elect to use the hospice benefit when a physician certifies they have a terminal illness. The patient would have a life expectancy of six months or less if the illness runs its normal course. The hospice agency must submit a Notice of Election (NOE) to Medicare. The NOE updates the Medicare processing files.

Medicare Payment During Hospice Election
Once the patient elects the hospice benefit, Medicare can allow:

• Services provided by a Medicare certified hospice agency
• Services related to the terminal condition made under contract with the hospice:
  • Related services are part of the hospice claim to Medicare
  • Medical professional would make arrangements with the hospice
• Medicare will deny related services submitted by the medical professional
• The denied services could be patient liability
• Services provided by the patient-designated attending physician, nurse practitioner, or physician assistant, (if one has been designated)
• Services unrelated to the terminal condition
  • Professionals can submit unrelated services to Medicare separately

Determining the Correct Entity to Bill
Providers must verify the correct entity to bill for their services. Billing Medicare without determining the correct billing method is inappropriate.

You can find more information in the CMS Internet-Only Manuals (IOMs)

• Publication 100-04, Medicare Claims Processing Manual, Chapter 11 (PDF, 521 KB), Section 40.1.3
• Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 (PDF, 452 KB)

Separately Payable Part B Services
Use the following tips to help determine if submission to Part B is correct:

• Is the patient in a Medicare-certified hospice coverage period? Verify this by using the following:
  • eServices
  • Contact the patient or representative
  • Contact the hospice 
• Is the patient reporting they are no longer in hospice? 
  • The hospice notifies the Home Health and Hospice MAC of the disenrollment
  • Verify the hospice end date is in the eServices
    • If the record does not contain the exit date:
      • Contact the hospice; or
      • Contact the patient to request the hospice update the file
  • Once the eServices shows the exit date, bill the claim. Providers must file the claim timely. 
• Is the service related to the hospice condition? Determine if Medicare pays for the services separately:
  • Bill services related to the terminal illness to the hospice for reimbursement
    • When the hospice arranges for the services
      • The entity will look to the hospice for payment
      • Services not-covered and patient liable if related services not under arrangement with the hospice
    • When not employed by the hospice, submit to Medicare services provided by the patient-designated attending physician/nurse practitioner/physician assistant
      • Submit using Modifier GV
  • Bill services unrelated to the terminal illness to Medicare for reimbursement
  • Submit using Modifier GW

Hospice and Medicare Advantage
Once a Medicare Advantage patient elects hospice coverage, Medicare Fee-For-Service (FFS) (i.e., Original Medicare) becomes the payer. This applies to all services provided to the patient under the normal hospice processing instructions.

A patient may revoke their hospice benefit in the middle of the month. Submit charges to Medicare FFS (under all hospice instructions) until the first day of the following month. All claims after the first of the month go to the elected Medicare Advantage plan. 

For more information, visit the CMS IOM Publication 100-04, Chapter 11, (PDF, 521 KB) Section 30.4.

Medicare Advantage Value-Based Insurance Design (VBID) Model 

The CMS VBID goal is to improve health outcomes and lower costs for MA enrollees. One aspect of VBID will keep patients in the MA when electing hospice benefits. Nineteen MA Organizations (MAOs) are part of the model. Nine of the 19 are part of the Hospice Benefit Component. CMS has a list of the plans. For patient enrolled in one of these plans, contact the MA to determine claims submission.    

Attending Physician
Upon hospice election, the patient waives their right to payment for professional services for management of the terminal illness. The exception is for the professional services of an attending physician chosen by the patient who is not an employee of the hospice. Medicare considers physicians volunteering as Medicare hospice as hospice employees.

The attending physician, chosen by the patient and not a hospice agency employee is the medical professional with the most significant role in the patient’s care. Submit services related to the terminal illness with the GV Modifier. Professionals recognized as attending physicians include:

• Doctor of medicine or osteopathy
• Nurse practitioner
• Physician assistant

To locate instructions on physician billing for hospice care, use the CMS IOM Publication 100-04, Chapter 11, Section 40 (PDF, 521 KB).

Services Unrelated to Hospice
Medicare considers separate payment for services not related to the terminal illness. Before billing Medicare, it is the provider’s responsibility to determine the relationship of the service to the terminal illness.

Use the following to determine whether the claim’s diagnosis relates to the hospice diagnosis:

• Determine if the patient has elected hospice
• Determine if the hospice notified Medicare of the hospice election by checking with:
  • The patient
  • A patient’s representative
  • The hospice
  • eServices
• On the claim, append modifier GW indicating the service’s diagnosis does not relate to the hospice diagnosis
• If submitting charges not related to hospice on a UB-04 (or 837I electronic), append condition code 07

Contractors may conduct prepayment development or post payment reviews to validate the appropriate use of the modifier.

If you believe Medicare denied a claim in error, you can request a redetermination.

For more information on unrelated hospice services, see the CMS IOM Publication 100-04, Chapter 11, (PDF, 521 KB) Section 50.

Evaluation and Management Codes for Hospice
Providers not employed by a hospice agency may bill for evaluation and management services during respite care in a facility. The physician determines the type of facility in order to submit the correct procedure code. Providers use place of service (POS) 34 to represent a patient in hospice. The claims processing system recognizes POS 34 with two sets of inpatient CPT codes:

• Inpatient (99221-99239) – services in a hospice or facility
• Nursing facility (99304-99318) – freestanding hospice or part of a skilled nursing facility (SNF)

We do not recognize POS 34 with the following:

• Office or other outpatient (99202–99215)
• Observation (99217–99226)
• Domiciliary care CPT codes (99324–99340)

Use POS 21 (inpatient) when:

• The patient remains in the same hospital bed or unit
• The patient elects hospice coverage
• The hospital did not discharge the patient

Use POS 12 (home) when hospice services are in the home (99341–99350).

Hospice Modifiers
Consider using the following modifiers when billing Medicare.  

• GV — Attending physician not employed or paid under agreement by the patient's hospice provider
• GW — Service not related to the hospice patient's terminal condition 
• Q5 — Service furnished by a substitute physician under a reciprocal billing arrangement 
• Q6 — Service furnished by a Fee-For-Time Compensation Arrangements physician 

The following tips may help you avoid denials:

• Append either modifier GV or GW only when a patient enrolls in a Medicare-certified hospice
• Use modifier GV to bill attending physician services to Medicare Part B when:
  • The attending physician is not a hospice employee
  • Payment to the attending physician is not under agreement by the patient's hospice 
    • If payment is under arrangement, then the hospice includes the attending physician’s services in its Medicare Part A bill
    • Medicare considers a physician volunteer with the hospice to be an employee
• If a substitute or Fee-For-Time Compensation Arrangements physician provides services:
  • The designated attending physician bills the services
  • The designated attending physician appends the modifier GV
  • The designated attending physician appends either the Q5 or the Q6 modifier

For more information on hospice services, please see the CMS IOM Publication 100-02, Chapter 9 (PDF, 452 KB) and Publication 100-04, Chapter 11 (PDF, 521 KB).