Updates to Hospice Related Services – Part B

CMS published an article to alert providers that they should identify if a beneficiary is enrolled in hospice. Providers can ask the beneficiary or his/her legal representative if he or she is enrolled in Hospice. This information should be documented in the beneficiaries medical record. Providers should educate beneficiaries and their families that once the beneficiary is enrolled in Hospice, they should contact the Hospice provider to arrange for any care they need. If the Hospice provider does not arrange the services the beneficiary needs, the beneficiary may be financially responsible for the services. The beneficiary and their family should also be aware that the beneficiary or his/her legal representative may revoke the election of hospice care at any time in writing. To revoke the election of hospice care, the beneficiary must file a document with the hospice that includes a signed statement that the beneficiary revokes the election for Medicare coverage of hospice care for the remainder of that election period and the effective date of that revocation. Note that a verbal revocation of benefits is NOT acceptable.. CMS emphasizes that the revocation of the hospice election must be done in writing.

Upon revoking the election of Medicare coverage of hospice care for a particular election period, a beneficiary resumes Medicare coverage of the benefits waived when hospice care was elected. A beneficiary may at any time elect to receive hospice coverage as long as he or she continues to meet the eligibility criteria, meaning the beneficiary is entitled to Medicare Part A and has been certified as terminally ill. with a medical prognosis of six months or less. For more information regarding Hospice services, please see the references listed in the Additional Information section of this article.A beneficiary may not designate an effective date of the revocation, that is earlier than the date that the revocation is made. 

Services related to a Hospice terminal prognosis provided during a Hospice period are included in the Hospice payment and are not paid separately.

For beneficiaries enrolled in hospice, MACs should deny any Part B services furnished on or after January 1, 2002, that are submitted without either GV modifier, meaning the attending physician is not employed or paid under arrangement by the beneficiary’s hospice provider and professional services provided are related to the terminal prognosis, or GW modifier, meaning the service is not related to the hospice beneficiary’s terminal prognosis. MACs should deny services that are submitted with the GW modifier when the service is determined to be related to the terminal prognosis. Also, MACs should deny services that are submitted with the GV modifier if it is determined that the Physician services were furnished by Hospice-employed physicians and Nurse Practitioners (NP) or by other physicians under arrangement with the Hospice.

Here are some examples to give a better understanding of the use of these modifiers:

Example 1: A beneficiary is enrolled in Hospice and goes to a physician’s office for closed treatment of a metatarsal fracture, CPT code 28470.

Resolution: If the procedure is unrelated to the terminal prognosis (Non-Hospice related), the physician’s bill should contain GW modifier (Service not related to the hospice patients terminal condition). If this modifier is not appended, the procedure is related to the terminal prognosis and should not be reimbursed under the part B benefit. Thus, the claim is in error, since the services are considered included with payments under the hospice benefit.

Example 2: The patient is listed as being on hospice starting August 1, 2010 through August 31, 2010. Then a provider billed CPT code 45378, Diagnostic Colonoscopy with no modifiers on August 3, 2010 to Part B. 

Resolution: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice and there can be no separate reimbursement unless the service was unrelated to the terminal prognosis or the attending physician was otherwise entitled to separate reimbursement, which would be reflected by GV modifier (Attending physician not employed or paid under arrangement by the patients hospice provider) or GW modifier (Service not related to the hospice patients terminal condition). MACs should also deny services that are submitted with the modifier but for which, during medical review, the service is determined to be related to the terminal prognosis.