Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition

Hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the remainder of the hospice patient’s lifetime. However, a beneficiary may voluntarily terminate his/her election period.

The Notice of Admission (NOA), sometimes referred to as the Notice of Election (NOE), is not required or reviewed for payment, so should not be submitted to Palmetto GBA with Part B claims

To be covered, hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions:

The individual must elect hospice care and a certification that the individual is terminally ill must be completed by the patient’s attending physician (if there is one), and the Medical Director (or the physician member of the Interdisciplinary Group (IDG)

Nurse practitioners serving as the attending physician may not certify or re-certify the terminal illness

A plan of care must be established before services are provided

To be covered, services must be consistent with the plan of care

Certification of terminal illness is based on the physician’s or medical director’s clinical judgment regarding the normal course of an individual’s illness

It should be noted that predicting life expectancy is not always exact

Hospice and Medicare Part B

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner

Attending Physician

Only the direct professional services of an independent attending physician, who may be a nurse practitioner, may be submitted; the costs for services such as lab or x-rays are not to be included on the claim

When the attending physician or nurse practitioner furnishes a terminal illness related service that includes both a professional and technical component (e.g., x-rays), he/she submits the professional component of such services to the carrier and looks to the hospice for payment for the technical component

Likewise, he/she would look to the hospice for payment for terminal illness related services furnished that have no professional component (e.g., clinical lab tests)

Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV. This is true regardless of whether the care is related to the patient’s terminal illness. HCPCS modifier GV signifies that:

The service was rendered to a patient enrolled in a hospice

The service was provided by a physician or nonphysician practitioner identified as the patient’s ‘attending physician’ at the time of that patient’s enrollment in the hospice program

If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted

If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, HCPCS modifier GV may not be submitted

HCPCS Code G0337, ‘Hospice Pre-Election Evaluation and Counseling Services,’ is only payable when submitted by a hospice to its Regional Home Health Intermediary (RHHI)

If a ‘new patient’ physician evaluation and management service (CPT codes 99201-99205) is submitted for the same date of service, same physician, as HCPCS code G0337, it will be denied

Services Unrelated to the Terminal Condition

Any covered Medicare services that are not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be submitted to Palmetto GBA. Submit these services with HCPCS modifier GW: ‘Service not related to the patient’s terminal condition.’

All providers must submit this modifier when this condition applies

Care Plan Oversight

Attending physicians may submit care plan oversight services for a hospice enrollee

Refer to the Medicare Claims Processing Manual (Pub 100-4), Chapter 11, Section 40.1.3.1

  
Managed Care Enrollees who Elect Hospice

Federal regulations require that Medicare fee-for-service contractors (carriers) maintain payment responsibility for managed care enrollees who elect hospice

Refer to the Medicare Claims Processing Manual (Pub 100-04), Chapter 11, Section 40.2.2 for more information regarding claims for Medicare Advantage plan enrolled patients that have elected hospice benefits


Hospice Modifiers Fact Sheet


Definitions:

**  GV – Attending physician not employed or paid under agreement by the patient’s hospice provider.

**  GW – Service not related to the hospice patient’s terminal condition

**  Q5  – Service furnished by a substitute physician under a reciprocal billing arrangement

**  Q6 – Service furnished by a locum tenens physician

Modifier GJ “Opt out” physician or practitioner emergency or urgent services

Facts

** Modifiers are billed when a patient is enrolled in a Hospice.

** Modifier GW is used when a providers of services (physican, ambulance supplier, etc.) is performing services not related to the hospice diagnosis.

** Modifier GV is used when the physician performing services is not employed by the hospice and is designated as the attending physician.

** Certain Medicare beneficiaries can choose hospice benefits instead of Medicare for treatment and management of their terminal condition.

** The beneficiary waives all rights to Medicare Part B payments for services except for professional services of an “attending physician.” (In this case “attending physician” is defined as a doctor of medicine or osteopathy who is identified as having the most significant role in the determination and delivery of their medical care.)

** The professional services of an attending physician are not considered hospice services.

** The services of the attending physician are billed to Medicare Part B with modifier GV modifier Attending physician not employed or paid under agreement by the patient’s hospice provider as long as the provider does not have a payment arrangement with the hospice. In the latter case the services are billed by the hospice to Medicare Part A.

** If a substitute or locum tenens physician provides services, the designated attending physician bills the services using modifier GV and either the Q5 or Q6 modifier.

Q5 – Reciprocal Billing Arrangement Services provided by a substitute physician on an occasional reciprocal basis not over a continuous period of longer than 60 days. Does not apply to substitution within the same group.

The regular physician submits the claim and receives payment for the substitute. The record must identify each service provided by the substitute. 100% of the fee on file

Q6 – LocumTenens Services provided by a substitute physician retained to take over a regular physician’s practice for reasons such as illness, pregnancy, vacation, or continuing education. The substitute is an independent contractor typically paid on a per diem or fee-for-time basis and does not provide services over a period of longer than 60 days.

The regular physician submits claims and receives payment for the substitute. The record must identify each service provided by the substitute. 100% of the fee on file


Here are some examples to give a better understanding of the use of these modifiers:

Example 1: A beneficiary is enrolled in Hospice and goes to a physician’s office for closed treatment of a metatarsal fracture, CPT code 28470.

Resolution: If the procedure is unrelated to the terminal prognosis (Non-Hospice related), the physician’s bill should contain GW modifier (Service not related to the hospice patients terminal condition). If this modifier is not appended, the procedure is related to the terminal prognosis and should not be reimbursed under the part B benefit. Thus, the claim is in error, since the services are considered included with payments under the hospice benefit.

Example 2: The patient is listed as being on hospice starting August 1, 2010 through August 31, 2010. Then a provider billed CPT code 45378, Diagnostic Colonoscopy with no modifiers on August 3, 2010 to Part B.


Resolution: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice and there can be no separate reimbursement unless the service was unrelated to the terminal prognosis or the attending physician was otherwise entitled to separate reimbursement, which would be reflected by GV modifier (Attending physician not employed or paid under arrangement by the patients hospice provider) or GW modifier (Service not related to the hospice patients terminal condition). MACs should also deny services that are submitted with the modifier but for which, during medical review, the service is determined to be related to the terminal prognosis.

Guidelines/Instructions for Modifier GV




The attending physician is not employed or paid under agreement by the patient’s Hospice provider.


Instructions

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

    Service was rendered to a patient enrolled in a Hospice.
    Service was provided by a physician or non-physician practitioner identified as the patient’s ‘attending physician’ at the time of that patient’s enrollment in the Hospice program
    Submit this modifier regardless of whether the services were related to the patient’s terminal condition
    Service was provided by a physician employed by the Hospice, you may not submit this modifier
    Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier

Example:  An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.

Date of Service    Treatment CPT/Modifier

01/14/12 Surgical pathology (professional component) Bill to Part B: 88305 26GV

01/14/12 Surgical pathology (technical component) Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Date of Service  Treatment CPT/Modifier

09/25/12 Chest x-ray (professional component) Bill to Part B: 71010 26GV

09/25/12 Chest x-ray (technical component) Bill to Hospice: 71010 TC

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

…The service was rendered to a patient enrolled in a hospice.
…
The service was provided by a physician or non-physician practitioner  identified as the patient’s “attending physician” at the time of that patient’s enrollment in the hospice program.

…Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

…If the service was provided by a physician employed by the hospice, you may not submit this modifier.

…If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

For beneficiaries enrolled in hospice, MACs should deny any Part B services furnished on or after January 1, 2002, that are submitted without either GV modifier, meaning the attending physician is not employed or paid under arrangement by the beneficiary’s hospice provider and professional services provided are related to the terminal prognosis, or GW modifier, meaning the service is not related to the hospice beneficiary’s terminal prognosis. MACs should deny services that are submitted with the GW modifier when the service is determined to be related to the terminal prognosis. Also, MACs should deny services that are submitted with the GV modifier if it is determined that the Physician services were furnished by Hospice-employed physicians and Nurse Practitioners (NP) or by other  physicians under arrangement with the Hospice.

HCPCS Modifier GV Description:

Attending physician not employed or paid under arrangement by the patient’s hospice provider.

Guidelines/Instructions:

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

** The service was rendered to a patient enrolled in a hospice.

** The service was provided by a physician or non-physician practitioner identified as the patient’s “attending physician” at the time of that patient’s
enrollment in the hospice program.

** Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

** If the service was provided by a physician employed by the hospice, you may not submit this modifier.

** If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

Guidelines/Instruction for Modifier GW

…Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when this condition applies.

For services provided to beneficiaries enrolled in hospice, all providers must submit one of the above applicable modifiers on the detail service line for the service.

Services submitted for a “hospice” beneficiary without one of the hospice modifiers will be denied

FAQs


Q: Who should a provider submit a claim to for payment if the member is enrolled in Hospice?

A: If a member is enrolled in Hospice, Medicare is responsible for claims for the entire month following the member’s election into Hospice. Care Improvement Plus is not responsible for paying any claims while the member is in Hospice. Submitting Hospice claims to Care Improvement Plus is inconsistent with payment guidelines and will require you to resubmit the claim to the correct party. Medicare will also pay physicians, providers and suppliers for non-Hospice related Medicare-covered services furnished to enrollees who have elected hospice.

Q: If a member was discharged from hospice care and was admitted directly to a facility on the same day, who is liable for the payment of the Inpatient facility claim?

A: The inpatient facility claim is NOT the responsibility of Care Improvement Plus. The facility will need to submit to the claim to your designated A/B MAC. All claims from the date of discharge from hospice, to the end of the month, are not paid by Care Improvement Plus.


Q: Will Care Improvement Plus pay a claim if the GW modifier or condition code 07- is billed on a claim while the member was in hospice care?

A: If the claim contains a GW Modifier or a condition code of 07 Care Improvement Plus is not responsible for  payment during the members’ election into Hospice.

** Condition Code 07-The patient has elected hospice care; but the provider is not treating the patient for the terminal condition

** GW modifier-Service not related to the hospice patients terminal condition

** GV modifier-Attending physician not employed or paid under agreement by the patient’s hospice provider.

Modifier Q6 Guidelines


Q6 Modifier

** Services provided by a Locum Tenens physician
** Use this modifier when you have another doctor filling in for you.

** A Locum Tenens doctor can fill in for 60 days.


Definitions


Locum Tenens: Substitute physicians that take over a regular physician’s professional practice when the regular physician is absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them. The substitute physician generally has no practice of their own and moves from area to area as needed. The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee. A regular physician is the physician that is normally scheduled to see a patient.



Modifier Q6: Services furnished by a locum tenens physician



Payment Procedure

A patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) of a  locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not  restricted to the regular physician’s offices, if:

• The regular physician is unavailable to provide the visit services;

• The Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician;

• The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis;

• The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days; and

• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by  entering his/her unique physician identification number (UPIN) or NPI when required to the carrier upon request.

If the only substitution services a physician performs in connection with an operation are postoperative services furnished during the period covered by the global fee, these services need not be identified on the claim as substitution services.

The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims. 


Claims AND Documentation


A record must be kept of each service provided by the locum physician along with the locum’s physician identification number. A seasoned locum tenens provider will be accustomed to the required documentation.

As illustrated below, Medicare requires claims for services provided by a locum tenens physician to include the Q6 modifier, which designates services were performed by a locum tenens physician, in box 24D of the CMS-1500 form. The regular physician’s provider identification number goes in box 24J.


Holding the place of a physician who is returning within 60 days

If you need a locum tenens physician for the traditional “holding one’s place” type of scenario (e.g., coverage for vacations, illness/medical leave, continuing education, etc.), The Medicare Claims Processing Manual allows you to bill for locum tenens professional fees using the absent physician’s billing information as long as the following conditions are met:

• The regular physician is unavailable to provide the visit services.

• The patient has arranged or seeks to receive the visit services from the regular physician.

• The locum tenens provider is paid for his/her services on a per diem or similar fee-for-time basis.

• The substitute physician does not provide services to Medicare patients over a continuous period of  longer than 60 days.

If these conditions are met, you can bill for the locum’s professional services using the absent provider’s national provider number (NPI) in box 24 of the CMS-1500 form. You must also use modifi er –Q6 (Service furnished by a locum tenens physician) in box 24d of the CMS-1500 form for each line item service on the claim to indicate the service was provided by a locum.

Medical Group Claims Under Locum Tenens Arrangements


For a medical group to submit assigned and unassigned claims for the services a locum tenens physician provides for patients of the regular physician who is a member of the group, the requirements of subsection B must be met. For purposes of these requirements, per diem or imilar fee-for-time compensation which the group pays the locum tenens physician is considered paid by the regular physician. Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may bill for the temporary physician for up to 60 days. The group must enter in item 24d of Form CMS-1500 the HCPCS modifier Q6 after the procedure code. Until further notice, the group must keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (PIN) or NPI when required on block 24J of the appropriate line item.

physicians who are members of a group but who bill in their own names are generally treated as independent physicians for purposes of applying the requirements of subsection A for payment for locum tenens physician services. Compensation paid by the group to the locum tenens physician is considered paid by the regular physician for purposes of those requirements. The term “regular physician” includes a physician who has left the group and for whom the group has hired the locum tenens physician as a replacement.

Staffing up to meet demand

In light of the physician shortage, our clients are increasingly using locum tenens physicians as a key component of their long-term staffi ng strategy, to start new service lines, and to augment permanent staff while searching for a permanent doctor, which can be a lengthy process. Under these scenarios, locums are not covering for an absent physician who will be returning and therefore do not meet the requirements for using the –Q6 modifi er. In these cases, Medicare and Medicaid require locum providers to enroll in the programs in order to receive reimbursement.

Many commercial payers require facilities to credential the locum tenens physician through the normal process and allow for retroactive billing. In most case, it is best practice to submit credentialing and enrollment forms in advance of the locum’s fi rst day on assignment.

Billing for locum tenens nurse practitioners

The CMS billing guidelines for locum tenens physicians does not apply to nurse practitioners. The directions for billing locum tenens nurse practitioner services differ from state to state. You should contact your local Medicare administrative contractor to fi nd out if using modifi er –Q6 is appropriate.

Instructions for Modifier GJ

In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the provider may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf.


Correct Use

    Example – Physician was called in to see a patient in the emergency room whom he has not seen before and no contract was signed

Claim Coding Example

CPT Code  Modifier

99282  GJ

Incorrect Use

    Opt out physician to append for non-emergent services that have a private contract with patients.

Providers of hospice-related services

Aetna Medicare members may elect to use the hospice benefit in the Original Medicare program instead of their MA HMO and PPO coverage. Prior to initiating hospice care, the member or his or her representative must sign the “Election of Benefits” waiver. When this election is documented, the case should be referred to the Original Medicare hospice provider. Original Medicare will assume financial responsibility on the date the waiver is signed, and reimbursement will be made by Original Medicare directly to the agency. Durable medical equipment (DME) will be the responsibility of the hospice provider. The MA plan remains responsible for payment of those medical services not related to the terminal illness and additional benefits not covered by Medicare. An example of an additional benefit is the eyeglass reimbursement.

For services not related to the terminal illness, inpatient services should be billed to the Medicare Fiscal Intermediary using the condition code 07. For physician services and ancillary services not related to the terminal illness, the physician or other health care professional should bill the Medicare carrier (as is done for Medicare FFS patients) and use the modifier “GW.”

Attending physician services are billed to the Medicare carrier with the “GV” modifier, provided they were not furnished under a payment arrangement with the hospice. If another physician covers for the designated attending physician, the services of the substituting physician are billed by the designated attending physician under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the “GV” modifier in conjunction with either a “Q5” or “Q6” modifier.

Modifier Q6: Locum Tenens


Applicable Providers

• Physicians, all specialties
• Multi-specialty Clinics
• Optometrists
• Podiatrists
• Chiropractors
• Nurse Practitioners
• Nurse Midwives
• Independent Labs
• Planned Parenthood
• Portable X-ray
• CRNA

General Information

Providers will retain substitute providers to take over their professional practices when the regular provider is absent for reasons such as illness, pregnancy, vacations, etc. These substitute practitioners are called “locum tenens” practitioners and often do not have their  own practice and move to various areas as they are needed. A locum tenens can be any of the above provider types. Services provided by locum tenens are identified with modifier Q6.

Policy Medicaid will allow reimbursement for services rendered by a locum tenens provider. The regular provider submits the claims for services furnished by the substitute provider and receives payment for the services as though he/she performed them. The regular provider generally pays the substitute a fixed amount per diem. The regular provider identifies the services as substitute provider services by appending modifier Q6 to the procedure code on the claim. Modifier Q6 does not affect payment. The regular provider must keep a record on file of each service provided by the substitute, along with the substitute provider’s UPIN. The maximum period of time a substitute practitioner may provide services for the regular provider is 60 consecutive days.


Billing 

• Services rendered by a locum tenens are billed with procedure codes and modifiers as any provider would bill PLUS the modifier Q6 appended to the procedure code.

• The services rendered by a locum tenens must be billed under the provider number of the provider replaced by the locum tenens.

• The patient’s regular practitioner may submit a claim for covered services of a locum tenens practitioner who is not an employee of the regular practitioner when the following guidelines are met:

** The patient has arranged or seeks services from the regular provider,
** The regular provider is unable to provide the services, and
** The regular provider pays for the locum tenens services on a per diem or similar fee for time basis

HOSPICE Overview

Hospice care is an alternative treatment approach that is based on recognition that impending death requires a change from curative treatment to palliative care for the terminally ill patient and support for the family. Palliative care focuses on comfort care and the alleviation of physical, emotional and spiritual suffering. Instead of hospitalization, its focus is on maintaining the terminally ill patient at home with minimal disruptions in normal activities and with as much physical and emotional comfort as possible.

A recipient must be terminally ill in order to receive Medicaid hospice care. An individual is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

Payment of Medical Services Related To The Terminal Illness

Once a recipient elects to receive hospice services, the hospice agency is responsible for either providing or paying for all covered services related to the treatment of the recipient’s terminal illness.

For the duration of hospice care, an individual recipient waives all rights to Medicaid payments for:

• Hospice care provided by a hospice other than the hospice designated by the individual recipient or a person authorized by law to consent to medical treatment for the recipient.

• Any Medicaid services that are related to the treatment of the terminal condition for which hospice care was elected OR a related condition OR that are equivalent to hospice care, except for services provided by: (1) the designated hospice; (2) another hospice under arrangements made by the designated hospice; or (3) the individual’s attending physician if that physician IS NOT an employee of the designated hospice or receiving compensation from the hospice for those services.

Payment For Medical Services Not Related To The Terminal Illness  Any claim for services submitted by a provider other than the elected hospice agency will be denied if the claim does not have attached justification that the service was medically necessary and WAS NOT related to the terminal condition for which hospice care was elected. If documentation is attached to the claim, the claim pends for medical review. Documentation may include:

• A statement/letter from the physician confirming that the service was not related to the recipient’s terminal illness, or

• Documentation of the procedure and diagnosis that illustrates why the service was not related to the recipient’s terminal illness.

If the information does not justify that the service was medically necessary and not related to the terminal condition for which hospice care was elected, the claim will be denied. If review of theclaim and attachments justify that the claim is for a covered service not related to the terminal condition for which hospice care was elected, the claim will be released for payment. Please note, if prior authorization or precertification is required for any covered Medicaid services not related to the treatment of the terminal condition, that prior authorization/precertification is required and must be obtained just as in any other case.

HOSPICE BENEFIT

Hospice services must be prior authorized. Prior authorization requests require medical documentation from the beneficiary’s enrolled CSHCS subspecialist who is authorized (i.e., listed on the beneficiary’s CSHCS authorized provider file) to treat the terminal illness. The medical documentation must include all of the following:

* A statement of the terminal diagnosis.

* A statement that the beneficiary has reached the terminal phase of illness where the CSHCS subspecialist deems end of life care necessary and appropriate.

* Documentation of the need to pursue end of life care.

* A statement of limited life expectancy of six months or less.

* A proposed plan of care to address the service needs of the beneficiary that is:

* less than 30 days old;

* consistent with the philosophy/intent of the CSHCS hospice benefit as described above;

* clinically and developmentally appropriate to the beneficiary’s needs and abilities;

* representative of the pattern of care for a beneficiary who has reached the terminal phase of illness; and

* signed by the CSHCS subspecialist authorized to treat the terminal illness.

The prior authorization time period does not exceed six months. To continue hospice services beyond six months, a new prior authorization request with medical documentation must be submitted as described above.

Hospice may not be authorized and/or continued for a beneficiary when one or more of the following is true:

* The medical documentation no longer supports the above criteria (e.g., change in condition, change in the plan of care, etc.).

* The family chooses to discontinue hospice.

* The medical services being rendered by the hospice provider are available through another benefit.

Requests for hospice must be made in writing to CSHCS. (Refer to the Directory Appendix for contact information.) CSHCS responds to all prior authorization requests for hospice services in writing.