Billing Services During a Hospice Election
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Billing Services During a Hospice Election
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Medicare restricts payment of professional services when a patient elects their hospice benefit. A patient electing Hospice waives their rights to services related to treatment and management of their terminal illness. This waiver is in effect when the hospice election is in force.
Providers must determine correct billing.
Hospice Election
A patient chooses whether to elect their hospice benefit. The patient must have a terminal illness certified by a physician. A physician certifies the patient’s life expectancy is six months or less when the illness runs its normal course.
Upon election, the hospice agency submits a Notice of Election (NOE) to Medicare. The NOE will update Medicare’s processing files. Processing the NOE affects both future claims and services provided after the date of the election.
The patient eligibility files update when Medicare processes the NOE. Determine if the patient elected hospice by:
- Checking the WPS Government Health Administrators portal
- Submitting eligibility requests (electronic transaction 270)
- Asking the patient or caregiver
- Asking the hospice or facility
A patient may revoke their hospice election. The hospice will notify Medicare. Medicare can allow services following the revocation. Verify the hospice submitted the revocation. Use the resources above. Once Medicare removes the election, submit claims. Medicare timely filing guidelines remain in effect.
Contact the patient or hospice when the patient revokes hospice, but the Medicare files do not show the update.
Medicare Payment During Hospice Election
During hospice election, Medicare allows:
- Covered services provided by the Medicare certified hospice agency
- Services related to the terminal condition provided under arrangement/contract with the hospice agency:
- Services are part of the hospice claim to Medicare
- Hospice and provider agree to arrangement/contract
- Provider submits to hospice for payment
- Medicare denies related services submitted directly
- Patient may have liability
- Services provided by non-hospice employed attending professional chosen by the patient
- Physician
- Nurse practitioner
- Physician assistant
- Rural Health Clinics (RHC) under the all-inclusive rate (AIR)
- Federally Qualified Health Centers (FQHC) under the prospective payment system (PPS)
- Services unrelated to the terminal condition
- Diagnosis determines
- Submit the professional services with Modifier GW - Service not related to the hospice patient's terminal condition
- Append condition code 07 to unrelated services sent on a UB-04 (837I)
- Diagnosis determines
- Respite Care
- Short-term facility care to relieve family members or other caregivers when patient receiving care at home
- Occasional allowance
- No more than 5 consecutive days
- Appropriate locations
- Medicare participating inpatient hospital
- Hospice inpatient facility
- Medicare or Medicaid participating nursing facility
- Use place of service (POS) 34 when the patient receives respite care. The claims processing system recognizes POS 34 with two sets of inpatient CPT codes:
- Inpatient (99221-99239) – services in a hospice or facility
- Nursing facility (99304-99318) – freestanding hospice or part of a skilled nursing facility (SNF)
Hospice Claims
For Medicare to consider payment, include a modifier. Medicare requires providers bill with the modifier GV or GW.
Modifier GV
Submit the attending physician’s professional service with modifier GV when not employed by the hospice. The attending physician’s claim is the claim Medicare considers with modifier GV.
Medicare does not allow the modifier GV for physicians:
- Employed by the hospice
- On the hospice board
- Volunteering time as a hospice director
Modifier GW
Any provider may submit the modifier GW when their service does not relate to the hospice condition. The documentation must support the use of modifier GW.
Hospice and Medicare Advantage
When a Medicare Advantage (MA) patient elects hospice coverage, Medicare Fee-For-Service (FFS) (i.e., Original Medicare) becomes the payer. All hospice claim processing instructions apply.
A patient may revoke their hospice benefit in the middle of the month. Submit charges to Medicare FFS (under all hospice instructions) until the first day of the following month. All claims after the first of the month go to the elected MA plan.
Medicare Advantage Value-Based Insurance Design (VBID) Model
The goal of the CMS VBID is to improve health outcomes and lower costs for MA enrollees. One aspect of VBID will keep patients in the MA plan when electing hospice benefits. Nineteen MA Organizations (MAOs) are part of the model. Nine of the 19 are part of the Hospice Benefit Component. CMS has a list of the plans, VBID Model Hospice Benefit Component Participating Plans. For patients enrolled in one of these plans, contact the MA plan to determine the process for submitting claims.
Use POS 21 (inpatient) when:
- The patient remains in the same hospital bed or unit
- The patient elects hospice coverage
- The hospital did not discharge the patient
Use POS 12 (home) when:
- Hospice services are in the home (99341 – 99350)
Contractors may conduct prepayment or post payment reviews to validate the correct use of the modifier.
If you believe Medicare denied a claim in error, you can request a redetermination. Refer to our resource, How to Appeal a Claim Determination for more information.
Hospice Resources
You can find more information in the CMS Internet-Only Manuals (IOMs):
Publication 100-04, Medicare Claims Processing Manual, Chapter 11 – Processing Hospice Claims , sections 30, 40, and 50
Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 – Coverage of Hospice Services Under Hospital Insurance
global-tags: J8A,J5A,Claim Submission,J8B,J5B,Coding Guidelines,Claims,Value-Based Insurance Design (VBID),Hospice
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