When a patient elects the Medicare Hospice Benefit, their healthcare coverage shifts, making medical billing complex. The benefit covers services related to the terminal illness, but not all services a patient might need. This distinction requires specialized alphanumeric codes, known as modifiers, to communicate the exact nature of the service to the payer. Modifiers ensure that claims are processed correctly, differentiating between services covered under the hospice per diem rate and those that must be billed separately.
The Function of Modifiers in Medical Billing
Modifiers are two-character codes appended to the five-character Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes. They serve as flags that provide additional information about a service or procedure without changing the definition of the main code itself. This mechanism is fundamental to the accuracy of the healthcare payment system.
These codes are used to clarify why a service was performed, where it occurred, or if any special circumstances affected the procedure. For example, a modifier might indicate that a service was performed on the left side of the body, was a reduced service, or was provided by a specific type of practitioner. By adding this level of detail, modifiers allow payers to make precise decisions about coverage and payment.
In the context of the Medicare program, modifiers are important for defining the relationship between a service and a patient’s enrollment in a special program, like hospice care. The modifier links the service code with the specific payment rules governing the patient’s benefit election. Correct modifier use is directly tied to the financial integrity of the healthcare claim.
Identifying the Specific Hospice Modifiers
The modifiers used in hospice billing are GW and GV, each addressing a distinct scenario related to the patient’s care. The GW modifier is defined as “Service not related to the patient’s terminal condition.” Its purpose is to signal to the payer that a service provided is for an illness or injury entirely separate from the reason the patient elected hospice care.
The GV modifier is used by the attending physician when they are not employed or paid under arrangement by the patient’s hospice provider. This modifier indicates that the services provided by this independent physician are related to the management of the terminal illness. Using GV ensures the physician can be reimbursed for their professional services outside of the hospice’s fixed payment.
When a provider supplies a service unrelated to the terminal illness, the GW modifier is the correct choice. For services related to the terminal illness provided by an independent attending physician, the GV modifier is required. These codes create a necessary distinction for payment, preventing the service from being automatically bundled into the hospice’s per diem rate.
Practical Application and Billing Scenarios
The practical application of these modifiers determines whether a claim is paid by the hospice provider or by the patient’s standard insurance, such as Medicare Part B. When a patient is under hospice care, they waive their right to Medicare Part B payment for services related to the terminal illness, making the correct use of GW or GV essential for non-hospice claims.
Consider a hospice patient with a terminal cancer diagnosis who breaks a leg in a fall, an injury entirely unrelated to their cancer. When the emergency room physician bills for the fracture treatment, the CPT code for the procedure must be appended with the GW modifier. This flags the claim to the payer, indicating that the service is for a non-terminal condition and should be paid by standard Medicare Part B, not the hospice benefit. Without the GW modifier, the claim would likely be denied.
In a different scenario, the patient’s designated attending physician, who is not employed by the hospice, provides an office visit to manage pain related to the terminal cancer. The claim for this visit must include the GV modifier. This tells Medicare that the service is for the terminal illness but is being billed by the independent attending physician, which is an exception to the rule that all terminal illness-related care is covered by the hospice.
The modifiers GW and GV are primarily used on the CMS-1500 form, which is for professional claims submitted by individual providers like physicians. Institutional claims, which are submitted by facilities like the hospice itself on the UB-04 form, use different mechanisms, such as specific condition codes and revenue codes, to make similar distinctions. Failure to use the correct modifier directly leads to claim rejection.