Modifiers GV and GW: Hospice Care Services

Modifiers GV and GW: Hospice Care Services Under Medicare Part B

Medicare beneficiaries with terminal illnesses and a prognosis of six months or less can choose hospice benefits instead of regular Medicare coverage for the treatment and management of their terminal condition. Hospice care is structured into two 90-day periods followed by an unlimited number of 60-day periods for the remainder of the patient's life. However, beneficiaries retain the right to voluntarily discontinue their hospice election period at any time.

When a beneficiary chooses hospice coverage, they forfeit their rights to Medicare Part B payments for services related to the treatment and management of their terminal illness while their hospice election is active. However, this does not apply to professional services provided by an attending physician or nurse practitioner. 

For hospice services to be covered, they must be deemed reasonable and necessary for the alleviation or management of the terminal illness and related conditions:

• The patient must opt for hospice care, and their terminal illness must be certified by their attending physician (if applicable) and the medical director (or physician member of the Interdisciplinary Group [IDG]).
• Nurse practitioners acting as the attending physician cannot certify or recertify the terminal illness.
• A care plan must be developed before any services are provided.
• Services must align with the established care plan to be covered.
• Certification of the terminal illness relies on the clinical judgment of the physician or medical director regarding the typical progression of the illness.
• It is important to acknowledge that estimating life expectancy is not always precise.

Attending Physician

Only the direct professional services of an independent attending physician, which may include a nurse practitioner, can be billed. Costs for additional services such as lab tests or X-rays should be excluded from the claim.

• When the attending physician or nurse practitioner provides a service related to the terminal illness that includes both professional and technical components (e.g., X-rays), the professional component should be billed to the carrier, and payment for the technical component should be sought from the hospice.

• Similarly, for terminal illness-related services that do not have a professional component (e.g., clinical lab tests), payment should be requested from the hospice.

Modifier GV 

The GV modifier signifies that the attending physician is not employed or compensated under arrangement by the patient's hospice provider. This modifier should be applied when the services are associated with the patient's terminal condition and not reimbursed under arrangements by the hospice provider. Attending physicians should use HCPCS modifier GV when submitting claims for services provided to hospice-enrolled patients. This applies regardless of whether the care is related to the patient's terminal illness. HCPCS modifier GV indicates:

• The service was administered to a patient enrolled in hospice care.
• The service was delivered by a physician or nonphysician practitioner designated as the patient's attending physician at the time of hospice enrollment.
• HCPCS modifier GV should not be used if the service was provided by a physician employed by the hospice.
• HCPCS modifier GV should not be used if the service was provided by a physician who was not identified by the patient as their attending physician.

Modifier GW

Hospice Modifier GW The GW modifier signifies that the service rendered is unrelated to the patient’s terminal condition. Providers must apply this modifier when submitting claims for services that do not pertain to the patient’s terminal illness. Claims for treatment of non-terminal conditions under Medicare Part B must include the GW modifier. Effective January 5, 2019, services submitted without the GW modifier for non-terminal conditions will be denied.

HCPCS Code G0337

HCPCS Code G0337 Hospice Pre-Election Evaluation and Counseling Services (HCPCS code G0337) are eligible for reimbursement when submitted by the hospice to its Medicare Administrative Contractor (MAC). If a new patient evaluation and management service (CPT® codes 99202–99205) is billed for the same date and by the same physician as HCPCS code G0337, it will be rejected.

Services Unrelated to the Terminal Condition

• Medicare-covered services unrelated to the treatment of the patient's terminal condition during a hospice election period can be submitted. These services require HCPCS modifier GW: "Service not related to the patient’s terminal condition".
• Providers are required to apply this modifier whenever such services are claimed.

Conclusion

Understanding the nuances of modifiers GW and GV in hospice billing is crucial for ensuring accurate reimbursement and compliance with Medicare guidelines. At Stat Medical Consulting, Inc., we bring over 30 years of experience in medical billing services, specializing in navigating complex coding scenarios with efficiency and precision. Medical claim processing demands meticulous attention to detail, and our expertise has consistently helped healthcare providers optimize revenue and reduce costs through streamlined billing processes.

Our tailored services cater to the unique needs of each practice, ensuring that every claim is handled expertly to maximize reimbursement. Whether you're facing claim denials or uncertainty about reimbursement amounts, our dedicated team of billing experts is willing to provide a thorough medical billing analysis at no cost to you, to identify any areas in your existing billing that could be improved. 

Trust Stat Medical Consulting, Inc. to be your partner in achieving financial success and operational excellence in healthcare billing.