By Carol Javens and Robin Stawasz

If keeping up with changing medical billing regulations isn’t enough, the United States Office for the Inspector General (OIG) and CMS have added to the challenge by renewing their focus on Medicare coverage for all services provided to hospice patients. Going forward, when providers and pharmacists file claims to Medicare Part A, B, and D after patients begin accessing their CMS Hospice Benefit, they may unintentionally put hospice partners at risk for an audit and financial penalties.

Understanding the proper billing process can minimize the negative affect of this new crackdown on hospice, limit unnecessary Medicare spend, and ensure patients continue to get the care they need and deserve.

Understanding related vs. non-related medical spending

In general, when a person on Medicare elects hospice services, hospice becomes financially responsible for all care related to that patient’s terminal prognosis. The patient waives all rights to traditional Medicare for any service that is related to the treatment and management of their terminal condition. Therefore, most services you provide should be billed directly to the hospice organization. In the rare case that a service is considered non-related, you should bill Medicare as normal.

While billing for a patient on hospice should be straight-forward, determining if a condition is related to the hospice prognosis is circumstantial and variable. The same condition may be related for one hospice patient and non-related for another. 

For example, if a patient who is mobile, not at risk for falls, and is not suffering from any orthopedic involvement from their hospice diagnosis missteps and sprains an ankle, your treatment of the sprained ankle is non-related and should be billed as normal to Medicare Part B. However, if that patient has become weak and unsteady due to their terminal prognosis or is suffering from orthopedic deterioration caused by the condition, then that sprained ankle is related and should be billed to the hospice. 

Fortunately, you don’t have to spend a lot of time worrying about whether a specific service is related. Your hospice partner’s Medical Director determines the relatedness status of the diagnosis or treatment and will provide the correct code to use. It is critical, therefore, that your billing staff develops consistent communication and coordination with your hospice partners to ensure you maintain appropriate billing procedures.

Billing when you are the attending physician

If you are serving as the attending physician for a hospice patient, your billing works a bit differently than as described above. All patients must designate an attending physician at the time of hospice admission. If a patient chooses you as their attending, the hospice organization of choice must gain your consent to serve in that manner and to attest to the patient’s eligibility for hospice care. 

As 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 or not. However, CMS requires you to designate whether the care you provided was related to a hospice condition through the use of a “GV” and “GW” modifier on the claim. 

Services related to the patient’s terminal condition (and not otherwise paid for under an arrangement with the patient’s hospice provider) should be given a “GV” modifier on the claim.  Services not related to the patient’s terminal condition require a “GW” modifier on the claim.  If you are the attending physician for a hospice patient and submit a claim to Part B without a GV or GW modifier, the claim will be denied.

Submitting claims for medications

The related/non-related dynamic also applies to medications. If a medication is related to a patient’s terminal condition, necessary for the patient’s care plan, and within the hospice’s formulary, it is the hospice’s responsibility to cover the cost of that medication. However, if the medication is related to the terminal condition but not necessary for the care plan or outside of the hospice’s formulary, the patient must pay for the medication directly. Medications related to the prognosis should never be billed to any Part D coverage option. 

If the medication is completely unrelated to the terminal condition, that can be billed to Part D coverage providers. 

The following table explains the proper payment source for all medications that a hospice patient receives. 

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

Enhancing connections with hospice

While meeting CMS’ increased scrutiny creates a new level of complexity for your billing department, it may also provide an opportunity to connect more closely with your hospice partners. The hospice organizations you work with are responsible for alerting you to the proper payment source for every aspect of the hospice patient’s care plan, and should minimize any confusion and additional administrative burden on your staff.

Acclivity Health works with hospices to help them monitor all CMS spending and limit unnecessary Medicare spend. It is one more way we help ensure appropriate, compassionate, and responsive care for patients with serious illness.

To learn more, please email or by calling 904 562 1368.