GV Modifier

GV Modifier (2022) Description, Uses, Guidelines & Examples

GV Modifier appends with service when the attending physician may not employ or pay under the arrangement by the patient’s hospice provider. 

Summary

GV Modifier is used for the service when the patient enrolls in the hospice, and the attending provider(not employed or paid under hospice arrangement) performs the procedure related to the hospice condition. 

Hospice care deals with the comfort, maintenance, and quality of life of a person suffering from illness or close to the End of life. Sometimes, the patient’s condition is impossible to treat, or they refuse a specific treatment. Hospice accommodates this kind of patient with no cure treatments or slows the disease progress.

The patient with medicare insurance is entitled to hospital insurance (Part A) and has a life expectancy of 6 months or less to treat the terminal illness. In addition, they can choose hospice benefits for Medicare coverage.

Hospice care may have two pay periods of 90 days and an unlimited number of 60-day periods during the residual of the hospice patient’s lifetime. The patients have the choices to terminate their services voluntarily. 

The Medicare beneficiary who opts for hospice coverage waives all rights to Medicare Part B payments. The services associated with treating and managing their terminal illness during any period of their hospice benefit unless the attending physician performs the professional services, including a nurse practitioner. 

The Notice of Admission (NOA), also called the Notice of Election (NOE), may not review for the payment and should not submit to Palmetto GBA with Part B claims

The following are the reasonable and necessary hospice services for the management of terminal illness and related conditions:

A plan of care (POC) must establish before the start of care.

As service must be consistent with the POC for the reimbursement.

Attending physicians such as Nurse practitioners may not certify or re-certify the terminal illness.

The predicted life expectancy may not always be exact. 

The patient must elect for hospice care, and a certificate requires by the attending physician of the patient (If only one physician sees the patient) and the medical director MD (member of the Interdisciplinary Group [IDG]). 

The physician or medical directors certify the patient’s terminal illness regarding the treatment of the patient disease or condition. 

GV Modifier Description

GV Modifier appends with service when the attending physician may not employ or pay under the arrangement by the patient’s hospice provider. 

What Is GV Modifier?

GV Modifier indicates the service rendered to a patient enrolled in a hospice. It appends with the service when the attending physician provides assistance related to the hospice diagnosis or at the time of that patient’s enrolment in the hospice program.

When To Use GV Modifier

The following are the uses of GV Modifier when applicable with the service:

Modifier GV use for the service when the physician performs the procedure associated with a hospice diagnosis.

The attending physician performs the service related to the patient’s condition admitted to the hospice. The attending physician who renders the services is not employed, part of the hospice provider, or paid under hospice. It means that when a patient admits to hospice. 

GV Modifier must require when the claimant submits to the Medicare insurance for reimbursement. 

GV Modifier Guidelines

Documentation must support the assignment of GV Modifier to medically necessary and appropriate services. The patient’s condition should reflect in the medical record. 

Modifier GV is inappropriate to bills with service when the attending physician is an employee of the hospice provider. Therefore, it is appropriate to bill these claims to the hospice contractor for reimbursement. 

GV Modifier is inappropriate to bills with service when the physician is not attending provider of the patient, employed by the hospice provider. 

Modifier GV applies to the service when the patient enrolls in the hospice program, and an attending physician is the employee of the hospice provider who renders the procedure related to the patient’s terminal condition. 

Modifier GV is inappropriate to report with medicare services unrelated to the treatment of the terminal condition, and it is appropriate to bill with modifier GW during a hospice election period. All providers must require to submit the modifier when applicable. 

The attending physician, nurse practitioner, or other skilled professional will bill only direct professional services. The cost of service the physician provides, such as Lab and X-ray, may not include in the claim.

Suppose the attending physician performs services related to the terminal illness, including the technical and professional components (X-ray). In that case, they submit professional services to the insurance and technical component to the hospice contractor for reimbursement. 

Suppose an attending physician, nurse practitioner, or other skilled professional performs Professional services only. In that case, it may bill with modifier 26 and technical procedure with TC modifier along with GW or GV Modifier on the same claim line.  

The hospice contractor will pay for the services with no professional component, such as clinical lab tests for terminal illness-related services.

GV Modifier Examples

The following are the examples when GV Modifier bills:

Example 1

A 75-year-old male enrolls in the hospice for congestive heart failure and is now present to the attending physician with an irregular heartbeat. The physician reviewed all systems and had other problems such as diabetes. 

The patient refuses shortness of breath, chest pain, body aches, headache, numbness, and tingling in the body. The physical exam reveals irregular heartbeat and edema in both upper and lower extremities.

The physician orders a CT, MRI, X-ray of the chest region, EKG and pathology, and labs test. The studies reveal that abnormal findings of the heart and the patient need immediate procedures.

The attending physician who performs all these services is not an employee of the hospice program. In addition, the treating condition was related to congestive heart failure. For instance, a chest CT scan may report with modifier GV (71250-GV) for reimbursement.

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 71250 with GV Modifier. The claim will submit to the Hospice contractor for payment. 

Example 2

A 66-year-old male enrolls in the hospice for End staged renal disease and is now present to the attending physician with renal insufficiency. The physician reviewed all systems and had other problems such as nausea, vomiting, and genitourinary function. 

The patient denies body aches, headache, numbness, shortness of breath, chest pain, and tingling in the body. However, the physical exam reveals irregular heartbeat and edema in both upper and lower extremities.

The physician orders a CT, MRI, X-ray scan of the abdominal and pelvis region, and pathology and labs test. The studies reveal abnormal findings in both kidneys. Therefore, the patient needs immediate dialysis. Otherwise, It may lead to the death of the patient.

The attending physician who performs CT and MRI of the abdomen and pelvis region is not an employee of the hospice program. The treating condition was related to end-stage renal disease. Therefore, a CT scan of the pelvis and abdomen may report with GV Modifier (74176-GV) for reimbursement.

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 74176 with GV Modifier. Therefore, the claim will submit to the Hospice contractor for 74176 payment. 

Example 3

A 78-year-old male enrolls in the hospice for stage IV lung cancer and is now present to the attending physician for chemotherapy and pain management. The physician reviewed all systems and had other lung problems such as bloody cough, SOB, and opacities.  

The patient denies temperature, body aches, headache, numbness, chest pain, and tingling. However, the physical exam reveals opacities in the lungs and the possibility of severe infection.  

The physician orders a CT, MRI, X-ray of the chest region, and pathology and labs test. The studies reveal lung tumors metastasized to the other kidney and organs. 

The patient needs immediate need chemotherapy and infusion treatments. The attending physician who performs CT and MRI of the chest is not an employee of the hospice program. The treating condition was related to Lung cancer.

For instance, a chest CT scan with and without contrast may report with GV Modifier (717270-GV) for reimbursement. 

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 71270 with modifier GV. Therefore, the claim will submit to the Hospice contractor for a 71270 payment.  

GV And GW Modifier

Modifier GW and GV Modifier append for service when the physician provides the service to the hospice patient. Therefore, it may be slightly different between GW and GV modifiers

Modifier GV is applicable when the physician or other qualified health professional provides services unrelated to the hospice diagnosis.

For instance, the patient admits to hospice for congestive heart failure and receives service from an attending physician. They do not employ in hospice related to congestive heart failure. Therefore, it is suitable to report this procedure with a GW modifier. 

In Contrast, Modifier GW indicates the service rendered for the diagnosis related to the hospice condition. 

The patient was admitted to hospice for congestive heart failure and had service from the attending physician for debridement of the nail. Therefore, it is appropriate to report this procedure 11720 with modifier GW. 

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