Hospice care is a specialized benefit focused on providing comfort and support for individuals with a terminal illness, typically with a prognosis of six months or less. This care emphasizes palliative treatment, which means relieving symptoms and improving quality of life, rather than pursuing curative measures. Because this care is distinct from standard medical treatment, billing procedures must be altered. Specific codes, known as modifiers, are used in medical claims to communicate the patient’s enrollment status to the payer and ensure services are accurately classified under the hospice benefit.
The Necessity of Special Billing Modifiers
The need for special billing modifiers arises from a patient’s formal decision to elect the hospice benefit. When a patient chooses to enroll, they waive their rights to standard Medicare Part B payments for services related to the treatment and management of their terminal illness. This fundamentally changes the payment liability for related medical services, shifting financial responsibility to the hospice agency itself.
This election triggers “Consolidated Billing,” a rule that requires the hospice agency to assume responsibility for and manage the billing of most services related to the terminal illness. The hospice receives a daily payment rate, called a per diem, which is intended to cover the costs of these services. Modifiers act as a notification mechanism, alerting the payer that the patient is under this specific election status.
When a non-hospice provider submits a claim for a service given to a patient enrolled in hospice, the modifier communicates whether that service should be part of the hospice’s consolidated payment or billed separately. Without the correct modifier, a claim from an outside provider will likely be denied because the payer assumes the service should have been covered by the hospice’s per diem. The modifier is the mechanism that allows providers outside the hospice agency to seek separate payment for non-related services.
Defining the Primary Hospice Billing Modifiers
Healthcare Common Procedure Coding System (HCPCS) modifiers are two-character codes that provide additional detail about a billed service without changing the main procedure code. Non-hospice providers use two modifiers to clarify the context of the service provided to a hospice patient. These modifiers are necessary for ensuring compliance and accurate reimbursement from the payer.
Modifier GV is used by the patient’s designated attending physician or non-physician practitioner. This code signifies that the attending physician is not employed by or paid under an arrangement with the patient’s hospice provider. The GV modifier is applied when the attending physician provides professional services related to the patient’s terminal condition. It allows the attending physician to bill Medicare Part B directly for their professional services, which is an exception to the rule that all terminal-illness related care is covered by the hospice.
Modifier GW indicates that the service rendered is not related to the patient’s terminal condition. This modifier is used by any provider when treating an illness or injury separate from the terminal diagnosis. For example, a provider would apply the GW modifier when treating a hospice patient for a condition like a broken ankle or an unrelated infection. Using this modifier confirms that the claim should be processed and paid separately by the payer, as the hospice is not financially responsible for unrelated conditions.
Distinguishing Between Related and Unrelated Services
Determining the correct application of Modifier GW requires a careful assessment of whether a service is related to the patient’s terminal condition. A service is considered “related” if it addresses the terminal illness itself or any condition that is a direct consequence or complication of that illness. For instance, chemotherapy or radiation therapy administered to control symptoms of a terminal cancer diagnosis would be considered related, even though they are palliative.
Conversely, an “unrelated” service is one that treats a medical issue entirely separate from the terminal diagnosis. If a patient is receiving hospice care for end-stage heart failure but visits an emergency department for a sudden injury like a wrist fracture, the treatment for the fracture would be unrelated. The provider treating the wrist fracture would append the GW modifier to their claim to indicate that the service should be billed to Medicare Part B rather than the hospice agency.
The decision regarding whether a service is related or unrelated is generally made by the treating provider in consultation with the hospice agency. Documentation must clearly support the use of the GW modifier, as incorrect application can lead to claim denials or audits. If a provider fails to use the GW modifier for an unrelated service, the payer assumes the service is related to the terminal illness and denies the claim, shifting the financial liability to the patient.