Headshot of Carol Javens

According to the Office of the Inspector General (OIG), over a 10-year period, Medicare paid $6.6 billion to nonhospice providers that should have been covered by hospice. Consequently, both the OIG and the Centers for Medicare & Medicaid Services are now focused on the issue of duplicate payments and are working to minimize fraud and the financial burden on Medicare.  

If you are filing any Medicare claim for a patient accessing the CMS hospice benefit, you may unintentionally be putting your hospice partners at risk for an audit as well as financial and even criminal penalties. Understanding the proper billing process and the rare services that can be billed directly to Medicare is key to reducing that risk and ensuring proper reimbursement.

Once a patient begins accessing the CMS hospice benefit, the hospice designated by the individual is responsible for providing almost all care for that patient. According to CMS, “Services unrelated to the terminal illness and related conditions should be exceptional, unusual and rare.”

It may be difficult to determine if a condition is related to the hospice prognosis because it depends on the circumstance. The exact same diagnosis may be related for one hospice patient and non-related for another.

Consider, for example, a patient whose terminal illness makes them so weak they fall out of bed, break a wrist and require orthopedic care. Since the injury is related to the terminal prognosis, hospice should be billed for that care.

But if a hospice patient is still mobile and able to enjoy a morning walk, but inadvertently runs into a curb, falls and breaks a wrist, the accident may be considered nonrelated to their terminal illness. In this case, you’d bill Medicare directly.

Hospice medical directors are always responsible for determining the relatedness designation. When you’re uncertain if a condition is related, assume it is unless told otherwise by the designated hospice organization. Encourage your billing staff to develop consistent communication and coordination with your hospice partners to ensure appropriate billing procedures.

Billing procedures for attending physicians

If your patient designates you as their attending physician, their hospice organization of choice gets your consent to serve in that manner and attest to the patient’s eligibility for hospice care. Because you are the attending physician, you will continue to bill Medicare Part B as you had prior to the hospice admission, regardless of whether your service is related to the terminal condition. However, when you submit a claim, you will need to designate a “GV” or “GW” modifier to confirm whether the care you provided was related to a hospice condition or not. Without that modifier, claims submitted to Part B for hospice patients will be denied.

You will use the GV modifier when your service is related to the patient’s terminal condition but not paid for under an arrangement with the patient’s hospice provider. When the service is not related to the patient’s terminal condition, you use the “GW” modifier on the claim.

Billing for hospice medications

When a medication is related to a patient’s terminal condition, necessary for the patient’s care plan, and within the hospice’s formulary, the hospice is responsible forthe cost of that medication. If there is no formulary alternative that is effective for the patient’s related symptoms, the hospice also pays for the non-formulary medication. However, if a patient declines the formulary option or the medication is not necessary for the care plan, the patient must pay for that medication directly. If the medication is completely unrelated to the terminal condition, it can be billed to Part D coverage providers. 

While the Medicare hospice benefit is designed to pay for medications related to the terminal prognosis, communications between Medicare Part A, B, and D programs are so challenging that when Part D receives the claims, they pay them. Consequently, in the most recent report by the OIG, OIG identified 198,543 hospice beneficiaries who received 677,022 prescription drugs through Medicare Part D that potentially should have been covered under the per diem payments made to hospice organizations.

The following table explains how medications for hospice patients should be billed. 

Meds for pain, nausea, constipation or anxietyMeds related to the terminal prognosis and considered NECESSARYMeds related to the terminal prognosis and considered UNNECESSARYMeds completely unrelated to the terminal prognosis
FormularyHospiceHospicePatientPart D
Non-FormularyPatientPatientPatientPart D
Guide for billing hospice medications

An opportunity for more connected care

With CMS’ increased scrutiny, your practice is challenged to keep up with yet another billing regulation. But this scrutiny also provides an opportunity to work more closely with your hospice partners in ensuring the most appropriate and high-quality end-of-life care for seriously ill patients. The more your practice can work together to manage serious illness as a team, the more you improve the end-of-life experience for the patient and family and ensure every member of the care team is reimbursed for the time they spend providing care.

Carol Javens, RN, BSN, is an account manager for Acclivity Health Solutions with extensive experience in hospice nursing and EHR development. She currently helps clients understand and implement the full functionality of the company’s data analytics platform for serious illness management.

Robin Stawasz is a program development executive for Acclivity Health Solutions, focuses on creating a partnership between hospices, the families who would benefit from palliative care, the providers that serve those families, and the payers who make care possible.