Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 04, 2007 PDF

Close relationship with hospice billers helps avoid denials

Question: We keep receiving denials from Medicare because our patients have elected hospice services. We don't find out the patients have hospice care until we receive the denials. Is there any way to recoup those charges?

Answer: When a patient elects hospice, he or she must choose one -attending- physician who provides all relevant medical services. You must use two modifiers (GV and GW) to specify whether your physician was treating the patient's terminal illness.

If the physician's services were related to the hospice patient's terminal illness then you should use GV, says coder Rena Hall with Kansas City Neurosurgery. If the services weren't related to the terminal diagnosis, then you should use modifier GW.

Tip: You should work very closely with the hospices in your area to avoid these denials, says Kristin Jones, office manager with Mercy Services Kalona in Kalona, IA. -Hospice is very difficult to bill,- says Jones--and close coordination with the hospice's billing person can make all the difference.

For example: The diagnoses the hospice submits for its patients affect how you bill and what reimbursement (if any) you receive, says Jones. If you know which diagnosis the hospice uses, you-ll know whether to append the GV or GW modifier.

Make sure the hospice lists your doctor as the patient's attending physician, Jones urges.

If your doctor isn't the attending physician, you-ll have to append modifier Q5 or Q6, and getting paid may be harder. Modifier Q5 means your doctor worked in the same practice as the attending physician, and modifier Q6 means your doctor was in another practice but covering for the attending physician. (See The Insider, Vol. 7, No. 23.)

If you-re using the correct modifiers and still not getting paid, you should look at the place of service (POS) and type of service (TOS), says Sarah James-Bentz with Palmetto Primary Care in Summerville, SC. Medicare won't pay for hospice services unless you list POS 34 (hospice), 12 (home), skilled nursing facility (31) or hospital (21).

Note: Medicare used to require you to list the provider number of the patient's hospice (and home health agency) on the claim. Now, Medicare no longer requires this, says Jones. In fact, if you include the hospice's provider number, Medicare will automatically deny the claim.

As a last resort: You can always bill the hospice directly for your physician's services, and the hospice can bill Medicare on your behalf, says Jones.