Home Health & Hospice Week

Teaching referral sources how to use modifiers can help them gain their rightful Medicare reimbursement.

You can encourage hospice referrals by letting referral sources know they can still get paid for rendering certain services to hospice patients.

Many physicians think attending physicians for the hospice patient should append modifiers GV and GW, and that the non-attending physician should use modifiers Q5 and Q6, but this is incorrect, notes Jean Acevedo of Acevedo Consulting in Delray Beach, FL. (Modifier Q5 means the doctor worked in the same practice as the attending physician, and modifier Q6 means the doctor was in another practice but covering for the attending physician.)

"The GV and GW modifiers are a common source of confusion," Acevedo says. The definitions of the modifiers are:

• GV--Attending physician not employed or paid under arrangement by the patient's hospice provider (this has nothing to do with whether the patient is being seen for her terminal illness).

• GW--Service not related to the hospice patient's terminal illness.

"One of the most common hospice misconceptions is that once a patient is in hospice, a physician cannot bill for any services," Acevedo says. "This is a widespread problem."

Reality: When a patient goes into hospice, he elects an attending physician for hospice purposes. "If that physician is a community-based doctor and not a hospice employee, that physician bills Part B for his or her care of the patient related to the hospice diagnosis," Acevedo explains. "That physician must, however, add modifier GV to the claim to show he isn't paid by the hospice."

When GW applies: Suppose the patient has an attending physician for his hospice care, but requires a different physician to address a problem not related to the hospice diagnosis. For instance, the patient is under hospice care due to cancer, so the attending physician is an oncologist. But the patient experiences diabetes-related complications and requires an endocrinologist. "In that case, the endocrinologist will bill Medicare for his or her services with modifier GW appended," Ace-vedo says.

Alternate scenario: Suppose a doctor is not the hospice patient's attending physician, but sees the patient regarding the terminal illness anyway. In this case, the hospice would pay the physician directly, and the physician would not bill the insurer.

Example: A patient has terminal cancer and a primary care physician is her attending doctor at the hospice. The patient's cancer progresses to the point that palliative chemotherapy would help ease symptoms, so an oncologist sees the patient to address the chemotherapy. In this case, the hospice will pay the oncologist directly, Acevedo advises. "The hospice should be consulted in advance, and if it's really something that will ease the patient's pain, they'll pay for it," she says.

Modifiers Q5 and Q6: "These modifiers would never be used for a physician in the same practice," Acevedo says. "If the attending physician is out of town and a covering doctor is filling in, they would bill locum tenens and append modifiers GV and Q5 to tell the insurer, 'I'm not contracted with the hospice, and by the way, if you ask for my records for this encounter, you'll find proof that the doctor covering for me was seeing the patient.'"

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