Hospice

• 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
• Hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the remainder of the hospice patient’s lifetime. However, a beneficiary may voluntarily terminate his/her election period.
• The Notice of Admission (NOA), sometimes referred to as the Notice of Election (NOE), is not required or reviewed for payment, so should not be submitted to Palmetto GBA with Part B claims
• To be covered, hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions:
  • The individual must elect hospice care and a certification that the individual is terminally ill must be completed by the patient’s attending physician (if there is one), and the Medical Director (or the physician member of the Interdisciplinary Group (IDG)
  • Nurse practitioners serving as the attending physician may not certify or re-certify the terminal illness
  • A plan of care must be established before services are provided
  • To be covered, services must be consistent with the plan of care
  • Certification of terminal illness is based on the physician’s or medical director’s clinical judgment regarding the normal course of an individual’s illness
  • It should be noted that predicting life expectancy is not always exact

• 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 or 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

• Only the direct professional services of an independent attending physician, who may be a nurse practitioner, may be submitted; the costs for services such as lab or X-rays are not to be included on the claim
  • When the attending physician or nurse practitioner furnishes a terminal illness related service that includes both a professional and technical component (e.g., X-rays), he/she submits the professional component of such services to the carrier and looks to the hospice for payment for the technical component
  • Likewise, he or she would look to the hospice for payment for terminal illness related services furnished that have no professional component (e.g., clinical lab tests)
• Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV. This is true regardless of whether the care is related to the patient’s terminal illness. HCPCS modifier GV signifies that:
  • The service was rendered to a patient enrolled in a hospice
  • The service was provided by a physician or nonphysician practitioner identified as the patient’s attending physician at the time of that patient’s enrollment in the hospice program
• If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted
• If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his or her attending physician, HCPCS modifier GV may not be submitted
• HCPCS Code G0337, "Hospice Pre-Election Evaluation and Counseling Services," is only payable when submitted by a hospice to its Regional Home Health Intermediary (RHHI)
• If a new patient physician evaluation and management service (CPT codes 99201–99205) is submitted for the same date of service, same physician, as HCPCS code G0337, it will be denied
• Refer to the CMS Medicare Claims Processing Manual (Pub 100-04), Chapter 11, Section 10.1 (PDF, 397 KB) for more information    

• Any covered Medicare services that are 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 to Palmetto GBA. Submit these services with HCPCS modifier GW: "Service not related to the patient’s terminal condition."
• All providers must submit this modifier when this condition applies

• Attending physicians may submit care plan oversight services for a hospice enrollee
• Refer to the Medicare Claims Processing Manual (Pub 100-4), Chapter 11, Section 40.1.3.1   

Managed Care Enrollees who Elect Hospice

• Federal regulations require that Medicare fee-for-service contractors (carriers) maintain payment responsibility for managed care enrollees who elect hospice
• Refer to the Medicare Claims Processing Manual (Pub 100-04), Chapter 11, Section 40.2.2 for more information regarding claims for Medicare Advantage plan enrolled patients that have elected hospice benefits

References

• Access CMS guidelines related to hospice through the following links:
  • CMS Pub. 100-02, chapter 9 (PDF, 264 KB) 
  • CMS hospice web page