GW Modifier

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

GW Modifier appends with the service when the physician performs unrelated to the hospice patient’s terminal condition. 

Summary

Modifier GW is used for the services when patients enroll in the hospice and have a life expectancy of 6 months. It is appropriate when the physician performs irrelevant service to the patient’s terminal illness. 

The informational modifier requires when the physician treats the patient and is not paid or employed by the hospice provider for terminal illness. It may need the separate reimbursement of service for unrelated conditions.

The provider should use appropriate E/M codes 99201-25, 99221-99233 in combination with the correct POS or patient’s status at the treatment time.

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 services provided by the hospice team during the terminal illness treatment and can include all the benefits or limited services:

  • Nursing care  
  • Physical therapy services
  • Occupational therapy services  
  • Medical supplies, like bandages or catheters  
  • Doctor services
  • Hospice aide and homemaker services  
  • Medical equipment, like walkers or wheelchairs
  • Short-term inpatient care for pain management and symptoms control
  • Drug prescription for pain management and symptoms control
  • Speech-language pathology services, Dietary counseling, Social work services  
  • Grief and loss therapy for the patient and their family  

Short-term temporary care provided in a hospice inpatient facility, nursing home, or hospital can support patient family members for rest, and some relaxation time

The patient’s usual caregiver can stay for five days in an inpatient respite care in a Medicare-approved facility (hospital, nursing home, or a hospice inpatient facility). It may refer to Short-term respite care

Similarly, the hospice team suggested that any other Medicare-covered service is required to manage pain and other symptoms of terminal illness or related condition.

GW Modifier Description

GW Modifier appends with the service when the physician performs unrelated to the hospice patient’s terminal condition. 

What Is GW Modifier?

GW Modifier signifies that the service performed by the physician is irrelevant to the patient’s terminal condition. The provider submits the claim to the Part A MAC for the cure of a non-terminal disease with condition code 07. 

When To Use GW Modifier

The following are the use of GW Modifier when appending with the service:

Modifier GW appends with the service when the patient’s diagnosis is unrelated to hospice diagnosis and the attending physician who performs the service is not working under the hospice provider.

The physician performs an unrelated service to the patient when the patient admits to the hospice program. They are not part of or employees or not paid by the hospice provider and furnish the service unrelated to the patient’s terminal condition.

Therefore, it is appropriate to report with GW Modifier when bills to Medicare. 

GW Modifier Guidelines

Modifier GW is inappropriate to report to the attending physician working under the hospice provider. Instead, these claims will report to the Hospice contractors for reimbursement.

GW Modifier is inappropriate to report with the physician who performs the service but not his attending physician, as well as not working under the hospice provider. 

Documentation must support the assignment of modifier GW to medically necessary and appropriate services. 

GW Modifier is appropriate to report for the patient enrolled in the hospice program, and the attending physician is not working under the hospice provider. Therefore, they perform the service unrelated to the patient’s terminal condition. 

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. 

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. 

GW Modifier Examples

The following are examples of when GW Modifier is applicable with CPT or HCPCS codes:

Example 1

A 75-year-old male enrols in the hospice for congestive heart failure and is now present to the attending physician with a right shoulder injury. 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 showed swelling in the upper extremities.

The physician orders a CT, MRI, X-ray of the shoulder region, 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 unrelated to congestive heart failure. For instance, a CT scan of the shoulder may report with modifier GW (73200-GW) for reimbursement.

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 73200 with GW Modifier. The claim will submit to the Hospice contractor for payment. 

Example 2

A 66-year-old male enrols in the hospice for end staged renal disease and is now present to the attending physician with headache and ocular pain. The physician reviews all systems and has other problems such as blood pressure, diabetes, etc. 

The patient denies body aches, numbness, shortness of breath, chest pain, and tingling in the body. However, the physical exam reveals swelling in the head and ocular region.

The physician orders a CT, MRI, X-ray scan of the head and orbits, and pathology and labs test. The studies reveal abnormal findings in head and eye regions. The patient needs immediate attention to the organs,

The attending physician who performs CT and MRI of the head and orbit is not an employee of the hospice program. The treating condition was unrelated to end-stage renal disease. For instance, a CT scan of the head and orbit may report with GW Modifier (70450-GW) for reimbursement.

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 70450 with modifier GW. The claim will submit to the Hospice contractor for a 70450 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 lower abdominal pain. The physician reviewed all systems and had other problems such as nausea, vomiting, and diarrhea.  

The patient denies temperature, body aches, headache, numbness, chest pain, and tingling. However, the physical exam reveals gas in the abdominal region and a suspected hiatal hernia.  

The physician orders a CT, MRI, X-ray scan of the Abdomen and pelvis region, and labs test. The studies reveal a small hiatal hernia in the abdomen region. The patient needs treatments.  

The attending physician who performs CT and MRI of the Abdomen and pelvis region is not an employee of the hospice program. In addition, the treating condition was unrelated to Lung cancer.

Therefore, a CT scan of the Abdominal and pelvis region w/wo contrast may report with GW Modifier (74178-GW) for reimbursement. 

If the attending physician performs the service and the employee in the hospice program, it is inappropriate to CPT 74178 with modifier GW. The claim will submit to the Hospice contractor for 74178 payment.  

GV And GW Modifier

GW Modifier and GV 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. However, they do not employ in hospice related to congestive heart failure. Therefore, it is correct 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 GW Modifier. 

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