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Hospice Care

Medicare beneficiaries entitled to hospital insurance (Part A) who have a terminal illness with a life expectancy of six months or less have the option of electing hospice coverage in lieu of the standard Medicare coverage for treatment and management of their terminal condition. Only care provided by a Medicare certified hospice is covered under the hospice benefits provisions.

Hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the remainder of the hospice patient's lifetime. However, a beneficiary may voluntarily terminate their hospice election period.

If the attending physician, who may be a nurse practitioner, is an employee of the designated hospice, he/she may not receive compensation from the hospice for those services under Part B. These physician professional services are billed to Medicare Part A by the hospice.

To be covered, hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. The individual must elect hospice care and a certification that the individual is terminally ill must be completed by the patient's attending physician (if there is one), and the Medical Director (or the physician member of the Interdisciplinary Group (IDG)). Nurse practitioners serving as the attending physician may not certify or re-certify the terminal illness. A plan of care must be established before services are provided. To be covered, services must be consistent with the plan of care. Certification of terminal illness is based on the physician's or medical director's clinical judgment regarding the normal course of an individual's illness. It should be noted that predicting life expectancy is not always exact.

Where the service is considered a hospice service (i.e., a service related to the hospice patient's terminal illness that was furnished by someone other than the designated "attending physician" [or a physician substituting for the attending physician]) the physician or other provider must look to the hospice for payment.

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Attending Physician Services

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an "attending physician," whom is not an employee of the designated hospice nor receives compensation from the hospice for those services. For purposes of administering the hospice benefit provisions, an "attending physician" means an individual who:

  • Is a doctor of medicine or osteopathy or
  • A nurse practitioner (for professional services related to the terminal illness that are furnished on or after December 8, 2003); and
  • Is identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.

Professional services related to the hospice patient's terminal condition that were furnished by the "attending physician," who may be a nurse practitioner, are billed to the Medicare Part B carrier.

When the attending physician furnishes a terminal illness related service that includes both a professional and technical component (e.g., x-rays), he/she bills the professional component of such services to the Medicare Part B carrier and looks to the hospice for payment for the technical component. Likewise, the attending physician, who may be a nurse practitioner, would look to the hospice for payment for terminal illness related services furnished that have no professional component (e.g., clinical lab tests).

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Coding Guidelines for Attending Physician Services Related to Hospice Condition

The attending physician is the only physician who can be reimbursed by the Medicare Part B Carrier for palliative evaluation and management treatment related to the terminal illness. The attending physician codes services with the "GV" modifier on claims submitted to the Part B carrier for services provided to a hospice patient:

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"Modifier GV: "Attending physician not employed or paid under agreement by the patient's hospice provider"

If another physician covers for a hospice patient's designated attending physician, the designated attending physician bills services of the substituting physician under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the "GV" modifier in conjunction, with either the "Q5" or the "Q6" modifier. For additional information on reciprocal and locum tenens billing, you may refer to the CMS Manual System, Pub-4 Medicare Claims Processing Manual, Chapter 1 – General Billing Requirements Section 30External PDFand Chapter 11 – Processing Hospice Claims Section 40.1.3External PDF.

When the designated attending physician who may be a nurse practitioner furnishes services related to a hospice patient's terminal condition under a payment arrangement with the hospice, the physician must look to the hospice for payment. In this situation, the physicians' services are hospice services and are billed by the hospice to its FI.

Carriers must process and pay for covered, medically necessary Part B services that physicians furnish to patients after their hospice benefits are revoked even if the patient remains under the care of the hospice. Such services are billed without the "GV" or "GW" modifiers. Payment will be based on applicable Medicare payment and deductible rules for each covered service even if the beneficiary continues to be treated by the hospice after hospice benefits are revoked.

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Other Physicians

Medicare Part B coverage is not allowed for services related to the terminal illness when rendered by a physician other than the designated attending physician. If physicians provide services unrelated to the terminal condition, the following modifier should be applied to these claims:

  • Modifier GW: Services unrelated to the hospice condition

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Durable Medical Equipment, Oxygen, Etc.

The hospice pays for all durable medical equipment (DME), prosthetics, orthotics, and supplies while the patient is in the hospice program. Medicare Part B is responsible only if the item was prescribed for a diagnosis completely unrelated to the terminal illness. This is true even when the patient was renting equipment or purchasing supplies prior to the hospice coverage.

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Ambulance

The hospice covers ambulance services if they made the arrangements. Medicare Part B does not cover ambulance services related to the hospice condition.

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Hospice vs. Part B

When treating a patient with a terminal illness, ask if they have elected to receive hospice care. In addition to the regular Medicare card, each hospice patient is issued a card with the hospice name and entitlement period. When undecided about whether to bill the hospice or Medicare Part B, bill the hospice first. If the hospice rejects the claim, file the claim and the hospice denial with the Medicare Part B carrier.

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Additional Resources

For additional information on hospice claims, please access the CMS Manual System, Pub 100-4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 11, Sections 10-120External PDF.

For additional general information about the Hospice benefit, you may access the CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 9External PDF.

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