Processing Professional Claims for Hospice Beneficiaries

40.2 - Processing Professional Claims for Hospice Beneficiaries (Rev.10485, Issued: 11-19-20, Effective: 09-07-2020, Implementation: 12-01-2020) Professional services of attending physicians, who may be nurse practitioners or physician assistants, furnished to hospice beneficiaries are coded with modifier GV: Attending physician not employed or paid under arrangement by the patient’s hospice provider. This modifier must be retained and reported to CWF. A/B MACs (B) processing professional claims shall presume that hospice benefits are not involved unless the biller codes services on the claim to indicate that the patient is a hospice enrollee (e.g. the GV modifier is billed by the attending physician, or the GW modifier is billed for services unrelated to the patient’s terminal condition) or the trailer information on the CWF reply shows a hospice election. The A/B MAC (B) shall use the hospice enrollment trailer information on the CWF reply to examine and validate the claim information. For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim that are submitted without either the GV or GW modifier. A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the patient’s terminal condition furnished by individuals or entities other than the designated attending physician. Such claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim. DME MACs shall make determinations of relatedness in the same way the A/B MACs Part B do today – based entirely on the presence of the GW modifier and not based on diagnosis coding. In the event that the claim exceeds the number of allowable modifiers, the DME MAC shall instruct the supplier to use modifier 99 on the line to indicate additional modifiers are reported in the remarks field. The supplier must include the GW modifier in the claim remarks. Claims that do not contain the GW modifier shall be denied.