Is My Patient Eligible?

In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and certified as being terminally ill by a physician and having a prognosis of 6 months or less if the disease runs its normal course. 42 CFR 418.20 § 418.20 Eligibility requirements.

Hospice Pre-Election Evaluation and Counseling Services (CR 3585) - Medicare allows for a one-time visit by a physician who is either the medical director of or employee of a hospice agency to: evaluate the individual’s need for pain and symptom management counsel the individual regarding hospice and other care options advise the individual regarding advanced care planning In order to be eligible to receive this service, a beneficiary must:

  • be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course)
  • not have made a hospice election
  • not previously received the pre-election hospice services Eligibility and the Local Coverage Determinations (LCDs)

The LCDs for the hospice’s geographic area are used as guidelines to help a physician determine hospice eligibility. The LCDs are not regulations and should not be used exclusively to determine or provide evidence of hospice eligibility. Certification or recertification is based upon a physician’s clinical judgment and is not an exact science.

Congress made this clear in Section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), which says that the hospice certification of terminal illness “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”

How To Bill It?

If your Medicare patient is enrolled in hospice, ask yourself before billing Medicare:

  • Are the services you provided related to the patient’s terminal illness?
  • Are you the patient’s designated “attending physician”?

The answers to these questions will determine whether you can bill Medicare for your service and if so, which modifier to use on your claim.

Medicare patients who elect hospice coverage waive all rights to Medicare Part B payments for services related to the treatment and management of their terminal illness while the hospice benefit election is in force, except for professional services of an attending physician who is not an employee of or paid by the designated hospice.

If you answer “No” to question No. 1 above, you can bill Medicare using the GW modifier (service not related to the hospice patient’s terminal condition). All physicians, including the attending physician, may bill with the GW modifier.

If you answer “Yes” to question No. 1, and “Yes” to question No. 2, you may bill Medicare with the GV modifier (attending physician not employed or paid under arrangement by the patient’s hospice provider) — see below for details.

If you answer “Yes” to question No. 1 and “No” to question No. 2 — and you are not the attending physician — then you cannot bill Medicare for your service.

Novitas Solutions’ decision can help you determine whether to bill Medicare and which modifier to use.

GV modifier: In this context, an “attending physician” is an MD, DO, or nurse practitioner whom the hospice patient identifies as having the most significant role in determining and delivering the patient’s medical care at the time he or she elected hospice coverage, and is neither an employee of nor receives compensation from the hospice.

As an attending physician, you should use modifier GV when your services are related to the patient’s terminal condition and are not paid under arrangement by the patient’s hospice provider. If you are employed by the hospice, or if you are not the patient’s attending physician and your services are related to the patient’s terminal illness, do not bill Medicare.

GW modifier: all physicians, attending or not, must use this modifier to bill Medicare for a service to hospice patient that is unrelated to the patient’s terminal condition.

Remember also that the hospice patient, or his or her legal representative, may revoke the election of hospice care at any time by filing a signed document with the hospice; thus your patient’s hospice enrollment status could change from one visit to the next. Be sure to explain to Medicare patients and their families that once the patient is enrolled in hospice, they should contact the hospice provider to arrange for any care they need. Otherwise, the patient may be financially responsible for the services.