Hospice
Both Medicare and Medicaid have a designated Hospice Benefit. The Hospice Medicare and Medicaid Benefits covers team services at 100 percent and also pays for such items as medications, medical supplies and durable medical equipment related to the hospice diagnosis with little or no out of pocket expense to the patient. Many commercial insurance plans also have hospice benefits.
Services are equally available to eligible patients/families regardless of payer source.
Physician Billing Guidelines for Hospice Medicare Benefit
The information presented below is intended as a guide only. Please refer to the CMS Medicare Claims Processing Manual (Publication 100-4, Medicare Claims Processing, Chapter 11) for specific Medicare guidelines and instructions related to billing.
| Physician Type7 | Service | Source | Who Bills | Modifier Code |
| Attending | Professional | Medicare Part B | Physician bills Medicare B carrier | Use “GV” for services related to terminal illness |
| Attending | Technical | Hospice daily rate | Physician bills Hospice of Spokane | N/A |
| Attending | Administrative | Medicare Part B1,2,3,4 | Physician bills Medicare B carrier | G01825 |
| Consulting | Professional | Medicare Part A | Physician bills Hospice of Spokane6 | N/A |
| Consulting | Technical | Hospice daily rate | Physician bills Hospice of Spokane6 | N/A |
1 Payment is available for one physician per month involving 30 minutes of the physician’s time per month.
2 Must not submit the claim until after the end of the month in which the service is performed.
3 Must report care planning only once per calendar month.
4 Use CPT code 99377 for 15-29 minutes per month; use code 99387 for 30 minutes or more (reimbursement not increased for documenting more than 30 minutes).
5 HCPCS code G0182 must be the first and last date during which documented care planning services were actually provided during the calendar month (not the first and last calendar date of the month in which the claim in submitted).
6The physician bills Hospice of Spokane who then bills Medicare Part A for both professional and technical services.
7Effective January 1, 2019, physician assistants (PA’s) will be recognized as designated hospice attending physicians, in addition to physicians and nurse practitioners.
Billing Definitions
The attending physician is the physician designated by the patient to have the most significant role in the determinations and delivery of the patient’s medical care while under the Hospice Medicare Benefit during the election process. The primary physician, as indicated on the Notice of Election (NOE), is the attending physician.
The consulting physician is the physician, other than the attending, who provides direct patient care at the request of the hospice interdisciplinary team, for a condition related to the terminal illness.
The covering physician is the physician who has reciprocal billing arrangements with another physician or another member of the physician’s group under the following guidelines:
- The attending physician is unavailable to provide the services.
- The patient sought the visit with the attending physician.
- The covering physician does not provide services to the patient for a continuous period of longer than 60 days.
*Bill according to Attending Physician guidelines, but use Q5 in item 24D of the HCFA 1500.
Professional services are the actual procedures performed by the physician as designated by the appropriate CPT-4 code. Examples include patient visits, procedures, physician interpretation of x-rays, CT scan, MRI or physician interpretation of a laboratory test.
*Look up the code in the CPT-4 Code book to ensure that the service was a professional service and not technical or administrative.
Technical services include labs, x-rays and any other non-professional services performed by the physician or other health care professional required for the management of the terminal illness.
Administrative services include participating in the establishment, review and updating of the plan of care, supervising care and services and establishing governing policies.
- Bill Medicare Part B, Code G0182.
Other General Information
- Any physician, attending or consultant, who provides services to hospice patients not related to the terminal illness should bill as though the patient were not on hospice utilizing modifier code GW for services not related to the terminal illness.
- Complexity based E and M coding may be used for any of your patient visits using the standard E and M guidelines which are based on the complexity of the history, exam and problem solving.
- Time based coding: if more than half of your time was spent in counseling and/or coordination of care, you may bill based on the time guidelines, regardless of the complexity. Please refer to CPT code book for specific coding guidelines.
Favorite Links
The Hospice Payment System Fact Sheet, which offers providers information about the Medicare hospice benefit, is now available from the Centers for Medicare & Medicaid Services Medicare Learning Network in downloadable format here.
The Medicare Claims Processing Manual, CMS Pub 100-4, Ch. 11, Sections 40.1.3 and 40.2 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf
The Washington Health Benefit Exchange offering current information on the Washington Healthplanfinder – an easily accessible, online tool for individuals and small groups to compare, purchase and enroll in plans . http://www.wahbexchange.org/