"CPT Copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.""

Featured Post

2018 New CPT codes

00731  Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified ...

Denial reason B9 Patient is enrolled in a Hospice - Tips to correct this denial


Claim Adjustment Reason Codes B9 Patient is enrolled in a Hospice.

Reason for this denial:

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. Only care provided by a Medicare-certified hospice is covered under the hospice benefit provisions. Certain Medicare coverage does not apply to a beneficiary enrolled in a hospice program.

Tips to avoid this denial:

Before submitting a patient's claim to Medicare Part B, contact the Part B interactive voice response (IVR) system to determine if the patient is enrolled in a hospice program. The following beneficiary information can be obtained:

• Hospice effective date

• Hospice termination date (if applicable)

• Servicing contractor number

The following applicable modifiers should be used when billing for services of a patient enrolled in hospice. The appropriate modifier usage will depend on who is providing the service, what services are being provided and if the services are for/related to the reason the patient is enrolled in hospice.

GV Modifier - Attending physician not employed or paid under arrangement by the patient’s hospice provider

This modifier should be used by the attending physician when the services are related to the patient’s terminal condition and are not paid under arrangement by the patient’s hospice provider. Also, this modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

The service was rendered to a patient enrolled in a hospice.

The service was provided by a physician or non-physician practitioner identified as the patient’s attending physician at the time of that patient’s enrollment in the hospice program.

Do not submit the GV modifier in the following conditions:

The service was provided by a physician employed by the hospice.

The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his attending physician.

GW Modifier - Service not related to the hospice terminal condition

This modifier should be used 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 or when claims are submitted for treatment for a non-terminal condition to the Part A contractor with condition code 07.

Ensure the correct diagnosis is submitted on the claim. For example, if the patient's terminal condition is pancreatic cancer and the primary diagnosis on the claim is cancer-related, this can be considered related and would cause the denial.

If the modifier has been applied appropriately, it may be necessary to appeal the decision.

See also Medicare coverage for Hospice care

Popular Posts