Independent Attending Physician Services

40.1.3 - Independent Attending Physician Services (Rev. 4280, Issued: 04-19-2019, Effective: 07-21-19, Implementation: 07-21-19) 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 independent attending physician, who 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 and related conditions that are furnished on or after December 8, 2003), or • 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. Hospices should reiterate with patients that they must not see independent physicians for care related to their terminal illness other than their independent attending physician unless the hospice arranges it. Even though a beneficiary elects hospice coverage, he/she may designate and use an independent attending physician, who is not employed by nor receives compensation from the hospice for professional services furnished, in addition to the services of hospice-employed physicians. The professional services of an independent attending physician that are reasonable and necessary for the treatment and management of a hospice patient’s terminal illness are not considered Medicare Part A hospice services. Where the service is related to the hospice patient’s terminal illness, but 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. Professional services related to the hospice patient’s terminal condition that were furnished by an independent attending physician are billed to the A/B MAC (B) through Medicare Part B. When the independent attending physician furnishes a service related to the patient’s terminal illness and related conditions that includes both a professional and technical component (e.g., x-rays), he/she bills the professional component of such services to the A/B MAC (B) on a professional claim and looks to the hospice for payment for the technical component. Likewise, the independent attending physician would look to the hospice for payment for services furnished that have no professional component (e.g., clinical lab tests). The remainder of this section explains this in greater detail. When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, not employed by the hospice, in addition to receiving care from hospice- employed physicians. The professional services of a non-hospice affiliated attending physician for the treatment and management of a hospice patient’s terminal illness and related conditions are not considered Medicare Part A “hospice services.” These independent attending physician services are billed through Medicare Part B to the A/B MAC (B), provided they were not furnished under a payment arrangement with the hospice. The independent attending physician codes services with the GV modifier “Attending physician not employed or paid under agreement by the patient’s hospice provider” when billing his/her professional services furnished for the treatment and management of a hospice patient’s terminal condition. The A/B MAC (B) makes payment to the independent attending physician based on the payment and deductible rules applicable to each covered service. Payments for the services of an independent attending physician are not counted in determining whether the hospice cap amount has been exceeded because Part B services provided by an independent attending physician are not part of the hospice’s care. Services provided by an independent attending physician must be coordinated with any direct care services provided by hospice physicians. Only the direct professional services of an independent attending physician, to a patient may be billed; the costs for services such as lab or x-rays are not to be included in the bill. If another physician covers for a hospice patient’s designated attending physician, the services of the substitute physician are billed by the designated attending physician under either the reciprocal billing or fee-for-time compensation arrangement (formerly referred to as Locum Tenens Arrangements) instructions. In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier. When services related to a hospice patient’s terminal condition are furnished under a payment arrangement with the hospice by the designated attending physician, the attending physician must look to the hospice for payment. In this situation the physicians’ services are Part A hospice services and are billed by the hospice to its A/B MAC (HHH). The CWF response contains the periods of hospice entitlement. This information is a permanent part of the notice and is furnished on all CWF replies and automatic notices. A/B MACs (B) use the CWF reply for validating dates of hospice coverage and to research, examine and adjudicate services coded with the GV or GW modifiers.