If the selected clinician agrees to be the hospice patient’s attending clinician, any focused treatment related to the patient’s terminal status that this clinician provides can be billed to Medicare directly. Only an attending clinician who is not employed by the hospice can bill Medicare Part B for hospice care using the CPT E/M code.
How much does Medicare cost for hospice?
Medicare covers hospice care costs once a patient reaches all the criteria. These costs might be up to $10,000 per month, depending on the nature of the disease and the level of care required. However, on average, it is usually around $200 for home care and up to $1000 for general inpatient care per day.
What is the Medicare criteria for hospice?
Medicare eligibility. To elect hospice under Medicare, an individual must be entitled to Medicare Part A and certified as being terminally ill by a physician and have a prognosis of six months or less, if the disease runs its normal course. See the Electronic Code of Federal Regulations, Part 418-22-Hospice care.
How does Medicare pay for hospice?
OIG referred to its prior reports that recommended CMS work with hospices to make sure they're providing drugs covered under the hospice benefit and develop a strategy to make sure Medicare doesn't pay for hospice-covered drugs. OIG said these suggestions ...
Is hospice care covered by Medicare?
Hospice services are provided under Medicare's inpatient benefit, or Part A. When beneficiaries enter hospice care, they waive coverage for services related to their terminal illness but can still get Medicare coverage for unrelated conditions. Hospices ...
What modifier do you use when a patient is in hospice?
GV modifierThe GV modifier is used when a physician is providing a service that is related to the diagnosis for which a patient has been enrolled in hospice.
What is the GV modifier used for?
GV Modifier This modifier should be used by the attending physician when the services are related to the patient's terminal condition or not paid under arrangement by the patient's hospice provider.
What is the procedure code for hospice?
Hospice Care HCPCS Code range T2042-T2046.
What does hospice revocation Code 2 mean?
1 = Revoked by beneficiary. 2 = Revoked (occurrence code 42) 3 = Revoked (occurrence code 23) • NPI. Search the NPI Registry for the hospice provider's contact information.
What is GY modifier for Medicare?
The GY modifier is used to obtain a denial on a Medicare non-covered service. This modifier is used to notify Medicare that you know this service is excluded. The explanation of benefits the patient get will be clear that the service was not covered and that the patient is responsible.
What is hospice modifier GW?
Hospice Modifier GW The GW modifier indicates that the service rendered is unrelated to the patient's terminal condition. All providers must submit this modifier when the service(s) provided are unrelated to the patient's terminal condition.
Is GW modifier only for Medicare?
There are few modifiers which are to be used only when the patient is enrolled in a Medicare certified Hospice. These modifiers play an important role in the payment process or medical billing/claims. Use of modifier GV or GW is only for the hospice patients.
When a patient is enrolled in hospice?
Hospice Coverage They get care from a Medicare-certified hospice. Their attending physician (if they have one) and the hospice physician certifies them as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course.
What is procedure code Q5001?
Q5001. Hospice or home health care provided in patient's home/residence.
How do you discharge a hospice patient?
Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice must obtain a written physician's discharge order from the hospice medical director.
What are the revocation codes for hospice?
Discharge Status Codes Medicare contractors will set the revocation indicator on a beneficiary's hospice benefit period when a hospice claim is received with any discharge status code other than 30, 40, 41, 42, 50 or 51 and when occurrence code 42 is not present.
How can hospice Revocation be prevented?
To prevent hospice revocation, ensure during the admission process that patients who are at high risk for revocation are identified and a proactive plan is in place to provide the additional support that patients and families need, helping them avoid more costly, less beneficial care options.
Primary Attending Physician
The primary (attending) physician is chosen by the patient and listed as the hospice attending physician on the Medicare claim form.
Consulting (or Secondary) Physician
If you are not the physician designated as the hospice primary (attending) physician on the Medicare Election of Benefits, you are considered a consulting (secondary) physician for billing purposes.
What is hospice billing?
To understand physician billing for hospice patients, first understand that hospice, unlike any other Medicare process, is a patient-based benefit. When a patient selects hospice, all the choices are based upon patient-centered care and preferences. Upon referral to hospice, the patient elects to cease curative treatment for the terminal diagnosis.
What is an attending physician in hospice?
The hospice attending physician is an MD, DO, PA or NP who may or may not be an employee of the hospice. An interdisciplinary hospice team includes a physician who oversees elements of the patient’s care.
What is non-attending hospice?
Non-Attending (Consulting) Physician Services. In cases where the patient requires services related to the terminal condition by a physician who is not the attending physician, this specialty physician must have a contractual agreement with the hospice for their services.
What is the life expectancy of a patient in hospice?
The attending physician and the hospice medical director or team physician must certify that the patient has a "medical prognosis that his or her life expectancy is six months or less , if the illness runs its normal course.".
What is administrative care?
Administrative or supervisory activities include establishing, reviewing or updating plans of care, supervising the implementation of care, etc. These services are performed by a medical director or physician employed by the hospice and are included in the hospice payment rate. In other words, they are covered by the Medicare hospice benefit. No additional billing occurs for administrative activities.
Can hospice patients be billed to Medicare?
If the selected clinician agrees to be the hospice patient’s attending clinician, any focused treatment related to the patient’s terminal status that this clinician provides can be billed to Medicare directly. Only an attending clinician who is not employed by the hospice can bill Medicare Part B for hospice care using the CPT E/M code.
Is hospice a Medicare Part B or Part A?
Payments toward any treatment or care services related to the patient’s terminal illness and provided by a specialist contracted with the hospice are the responsibility of the hospice, and not Medicare Part B or Part A.
What is the HCPCS level 2 code for hospice?
Hospices must report a HCPCS Level II code with a level of care revenue code (651, 652, 655, and 6 56) to identify the service location where that level of care was provided. The following HCPCS level II codes report the type of service location for hospice services:#N#Q5001 Hospice or home health care provided in patient’s home/residence#N#Q5002 Hospice or home health care provided in assisted living facility#N#Q5003 Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF)#N#Q5004 Hospice care provided in skilled nursing facility (SNF)#N#Q5005 Hospice care provided in inpatient hospital#N#Q5006 Hospice care provided in inpatient hospice facility#N#Q5007 Hospice care provided in long term care facility#N#Q5008 Hospice care provided in inpatient psychiatric facility#N#Q5009 Hospice or home health care provided in place not otherwise specified (NOS)#N#Q5010 Hospice home care provided in a hospice facility#N#If care is rendered at multiple locations, identify each location on the claim with a corresponding HCPCS Level II code. For example, routine home care may be provided for a portion of the billing period in the patient’s residence, and another portion may be billed for time in an assisted living facility. In this case, report one revenue code 651 with HCPCS Level II code Q5001 and the number of days the routine home care was provided in the residence; and another revenue code 651 with HCPCS Level II code Q5002 and the number of days the routine home care was provided in the assisted living facility.
How long does it take for hospice to accept a NOE?
Providers have a maximum of five days to submit the NOE to (and receive acceptance from) their Medicare Administrative Contractor (MAC). “Provider liable days” apply when the hospice fails to file the NOE within five days. The hospice is responsible for providing all care and services to the patient as detailed in the plan ...
How long does it take to submit NOE to Medicare?
Providers have a maximum of five days to submit the NOE to (and receive acceptance from) ...
How long does it take for hospice to bill?
Time Care Coordination Carefully. Medicare allows hospice providers to bill claims within one year of the start date of service on a claim. Hospices are bound by Medicare’s rule of sequential billing, meaning claims must be filed monthly and must be filed in date order.
What is level of care 656?
Level of care 656: General inpatient care – Payment at the inpatient rate is made when general inpatient care is provided at a Medicare certified hospice facility, hospital, or SNF. When the patient is discharged deceased, the inpatient rate (general or respite) is paid for the discharge date.
What is hospice care?
Hospice care is end-of-life care for more than 1.65 million U.S. citizens every year—and that number is growing. Hospice involves an interdisciplinary team of healthcare professionals and trained volunteers who address symptom control, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. The focus is caring, not curing. It is the model of high-quality, compassionate care that helps patients and families live as fully as possible.#N#I have had three relatives under hospice care. My personal experiences — along with five years’ working in hospice coding and billing — have corrected some misconceptions I used to have about hospice. For example, hospice is not “giving up,” nor is it a form of euthanasia or physician-assisted suicide. A Gallup poll reveals that 88 percent of adults would prefer to die in their homes, free of pain, surrounded by family and loved ones.#N#Hospice works to make this happen. For example, National Hospice and Palliative Care Organization research shows that 94 percent of families who had a loved one cared for by hospice rated the care as very good to excellent. The U.S. Department of Health and Human Services has indicated that expanding the reach of hospice care holds enormous potential benefits for those nearing end of life, whether they are in nursing homes, their own homes, or in hospitals.#N#Another important misconception is that hospice care is limited to six months of service. The Medicare Hospice Benefit does require that a terminally-ill patient have a prognosis of six months or less, but there is not a six-month limit to hospice care services.#N#Hospice eligibility requirements should not be confused with length of service. A patient in the final phase of life may receive hospice care for as long as necessary when a physician certifies that the patient continues to meet eligibility requirements. Under the Medicare Hospice Benefit, two 90-day periods of care (a total of six months) are followed by an unlimited number of 60-day periods.#N#Visit NHPCO’s Caring Connections at www.caringinfo.org for additional information about hospice and palliative care, advance care planning, caregiving, and more. The National Hospice and Palliative Care Organization also has many resources on their website at nhpco.org. Click on the resources tab to find answers to your questions.
How many days does hospice benefit last?
Pay Attention to Hospice Benefit Periods. The Medicare hospice benefit consists of two 90-day benefit periods and an unlimited number of 60-day benefit periods. The benefit periods must be used in that order (90-90-60).
What is hospice billing?
The hospice bills Medicare with revenue codes that describe the type of care that is being provided, such as routine health care, continuous home care, inpatient respite care, or general inpatient care. There are some other services that hospice organization may bill as well.
Can a patient be discharged from hospice?
A patient may be discharged from hospice if they move from one area to another and transfer to a new hospice, the hospice determines that the beneficiary is no longer terminally ill, or the hospice determines the beneficiary meets their policy regarding discharge for cause.
Does Medicare pay for hospice care?
Medicare beneficiaries who have a terminal illness with a life expectancy of six months or less can elect to have their end-of-life care provided by a hospice organization. Medicare then pays hospice to provide all of the care that the patient needs that is related to their terminal illness.
Can hospice patients waive Medicare Part B?
According to Medicare, when the patient chooses to enter hospice they waive their rights to Medicare Part B payments for other services that are related to the treatment or management of their terminal illness , with the exception of care provided by their own attending physician. That is, benefits that would be paid by Part B for physician services ...
How Does Billing Work For Hospice?
Medicare states that hospice patients must file their claims each month and must file them according to the date of their hospitalization. A claim for the January 2018 hospice must initially be processed, for example. In order for a claim to be processed, the NOE must be processed and in payment.
What Modifier Do You Use For Hospice Patients?
In patients referred to as hospice dependents, the attending physician should utilize hospice modifier this year if the services pertain to the patient’s terminal condition; no payments from hospice providers are needed.
What Services Will A Patient Have To Pay For While On Hospice Care?
Medical supplies, drugs, counseling, physical therapy, medicines, and equipment are typically offered to patients with terminal illnesses. Home care is the most common form of care. Providing support to family caregivers is available.
Is Palliative Care A Billable Service?
Part B Professional Services is a very convenient way for palliative care providers to bill for a substantial part of their direct costs (staff time). As a result of quality documentation and billing processes, it is determined whether a fee for service will be covered.
How Do You Bill A Hospice Physician?
On initial hospice claims 81X or 82X, the physician, nurse or physician practice can be billed on these figures along with the required level of treatment and discipline. In the absence of a physician or NP/PA service being included on an initial Hospice claim (717 or 827) adjustment claims are provided to enable the services to be added.
What Is The Bill Type For Hospice?
Bill 81C – Hospice (No Hospital-based) Bill 82C – Hospice (No Hospital-based) Bill 148 Statement covers Period (From-Through) The “From” date would indicate the date change comes into force.
What Are Hospice Modifiers?
GV Modifier is used to refer to care provided by an attending physician who is not employed but provides his patients with hospice services. The “ginger GW” is used instead of GW on referring to the hospice treatment available to them.
When to use GV modifier?
The GV modifier is used when a physician is providing a service that is related to the diagnosis for which a patient has been enrolled in hospice. This physician is not associated with the hospice and is providing services as the attending physician.
Does Medicare reimburse hospice patients?
If the service the physician renders is unrelated to the terminal illnesses that hospice has on record, Medicare will not reimburse for the service unless it is submitted with the modifier GW. The GW modifier cuts through ...
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Hospice - Determining Terminal Status.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What happens when hospice is elected?
When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of their terminal illness during the period the hospice benefit election is in force. Hospice-related services performed by the "attending physician" who is employed/contracted by hospice, should be submitted to the hospice contractor.
Who should submit hospice services?
Hospice-related services performed by the "attending physician" who is employed/contracted by hospice, should be submitted to the hospice contractor. However, professional services of an “attending physician” who is not an employee of the designated hospice or does not receive compensation from the hospice for those services, ...
What is the CPT code for metatarsal fracture?
Example 1: A beneficiary enrolled in Hospice goes to a physician's office for closed treatment of a metatarsal fracture, CPT code 28470. If the procedure is unrelated to the terminal prognosis, the physician should bill it with modifier GW (28470GW). Example 2: A beneficiary enrolled in Hospice goes to hospital for closed treatment ...
What is the modifier for 28470?
If the service is related to the patient's terminal condition and the attending physician is not employed or paid under arrangement by the patient's hospice provider, the attending physician should bill 28470 with modifier GV (28470GV).
What is hospice physician assistant?
A physician assistant (for professional services related to the terminal illness and related conditions that are furnished on or after and January 1, 2019; 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.
When to use the attending physician modifier?
This modifier should be used by the attending physician when the services are related to the patient’s terminal condition or paid under arrangement by the patient’s hospice provider.
Do not submit GV modifier?
Do not submit the GV modifier in the following conditions: The service was provided by a physician employed by the hospice. The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his attending physician.
