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Physician Billing Guidelines

This table reflects the provision of care and services related to the terminal illness covered by the Hospice Medicare Benefits.

 

 

DESCRIPTION

 

BILL MEDICARE PART B

 

BILL HOSPICE*
Intermediary Pays Hospice
BILL HOSPICE
Covered Under Hospice Benefit
Attending Physician
Professional Fee
X
Use "GV" Modifier

 

 

 

 

Covering Physician
Professional Fee
X
Use "GV" Modifier

 

 

 

 

Consulting Physician
Professional Fee

 

 

X

 

 

 

X-Rays
Technical Component

 

 

X

 

X

 

X-Rays
Physician Component
Attending

 

Consulting

 

Per Agreement

 

Radiation Therapy
Technical Component

 

 

 

 

Per Agreement

 

Radiation Therapy
Physician Component
Attending

 

Consulting

 

Per Agreement

 

Labs
Technical Component

 

 

 

 

Per Agreement

 

Chemotherapy
Technical Component

 

 

 

 

Per Agreement
X
Unrelated Diagnosis
X
Use "GW" Modifier

 

 

 

 

* The Medicare intermediary pays hospice 100% of allowable charges for those physician services furnished under arrangements with the hospice; hospice then provides payment to the physician. Billing through hospice is required for patients covered by the Hospice Medicare Benefit. A written agreement between the hospice and the covering or consulting physician is required.

 

 

 

Attending Physician is the physician designated by the patient to have the most significant role in the determination and delivery of the individual's medical care. As long as a physician is NOT the Hospice Medical Director, nor an employee or volunteer of Hospice Touch, professional services (office, hospital, home, or nursing home visits) continue to be covered under Medicare Part B.


Unrelated Services: Professional services provided for treatment or management of conditions unrelated to the patient's hospice terminal diagnosis should be billed using the "GW" modifier in box 24d of the HCFA 1500 form. The "GW" modifier alerts Medicare that the claim is for "service not related to the hospice patient's terminal condition."
Note: Attending physicians CANNOT bill for outpatient services.


Covering Physician is the physician who sees the patient on behalf of the Attending Physician as part of vacation coverage or on-call status. The services of the substituting physician are to be billed by the Attending Physician under the reciprocal or locum tenens billing instructions. The Attending Physician must use the "GV" (related services) or "GW" (unrelated services) modifier in conjunction with either the "Q5" or "Q6" modifier. The "Q5" modifier indicates "services furnished by a substitute physician under a reciprocal billing arrangement," such as with a partner. Bill Hospice using HCFA 1500.


Consulting Physician is the physician who provides direct patient care to a hospice patient for a condition related to the terminal illness.


Hospice-related Services: A consulting Physician is required to obtain a referral from the Hospice Medical Director and/or the Attending Physician in order to perform services for a Hospice patient.


Any physician (including clinical psychologists and psychiatrists) other than the Attending Physician (or Covering Physician) who provides services related to the hospice terminal diagnosis as part of the Plan of Care, must submit charges to Hospice Touch, which will then submit a claim to Medicare. Hospice Touch will pass on to the Consulting Physician the allowable Medicare rate. The Consulting Physician CANNOT bill for the balance of his/her services to the patient or other insurance provider(s). When billing as a Consulting Physician for approved hospice-related services, only consulting CPT codes may be used. The Consulting Physician is required to provide Hospice Touch with a written evaluation and/or recommended treatment plan.


Unrelated Services: Any physician (including clinical psychologists and psychiatrists) other than the Attending Physician (or Covering Physician) who provides services not related to the terminal diagnosis bills his/her carrier for non-hospice reimbursement using the "GW" modifier in box 24d of the HCFA 1500 form. The "GW" modifier alerts Medicare that the claim is for "services not related to the hospice patient's terminal condition." This bill should also include the name of the hospice. Attending Physician in box 17, their UPIN number in box 17a, treatment diagnosis in box 21 (ICD-9 code - listed as a secondary diagnosis). Consulting physicians must also submit medical documentation, which states that the services were unrelated to the patient's terminal condition. Bill Hospice using HCFA 1500.


NOTE: Revoked or Discharged Patients: Services provided after a patient has revoked or is discharged from the hospice benefit should be billed without the "GV" or "GW" modifiers.