Medicare Compliance & Reimbursement

Go to the hospice for payment as a last resort.

Billing for hospice patients can seem frustratingly complex. Patients will have an attending physician and a medical director, and the carriers make you jump through hoops to obtain reimbursement. But relax: here are some tips to help you navigate the hospice maze.

According to hospice billing experts, there are four modifiers you need if your physician isn't directly employed by the hospice:

· GV: The physician's services were related to the patient's terminal illness. This modifier on its own also means the physician was the patient's attending physician.

· GW: The physician's services were unrelated to the patient's terminal illness.

· Q5: Another physician in the same practice is covering for the patient's attending physician.

· Q6: Another physician in a different practice is covering for the attending physician.

Pay attention: If you use the GV and Q5 modifiers together, then it means the services were related to the terminal illness, but a colleague was covering for the attending physician.

Under Medicare, the patient has to choose an "attending physician" when he or she enters hospice care.

The hospice medical director provides administrative and general oversight of the program, but the attending physician performs all hands-on care, explains coder Linda Zimmerman with Internal Medicine Associates of Bloomington, IN. If the attending works for the hospice, then the hospice bills Part A, if not the attending can bill Part B directly using the evaluation & management codes and the GV modifier.

Important: You have to use the GV or GW modifiers for the attending physician's services, or you won't get paid.

Place matters: You have to have the correct place of service (POS) on your claims for hospice patients. For a patient admitted to a hospice, you won't get paid unless you use POS code 34. You could also have a hospice patient receiving services in their homes (POS code 12), or in skilled nursing facilities (POS code 31) or in the hospital (POS code 21).

Example: Kansas City Neurosurgery sees a lot of terminal cancer patients for back problems, according to coder Rena Hall. Often, the patients have back pain related to a degenerative disc disease, so they use the GW modifier on the claim to indicate that the diagnosis is unrelated to the hospice diagnosis. If her physicians did see patients for back pain related to vertebral metastases or another related diagnosis, then she would use the GV modifier.

Some Carriers Refuse Q5 Modifier--What You Can Do

Some carriers will refuse to pay for non-attending physician services even if the physician correctly uses the Q5 or Q6 modifiers, complains coder Kristin Jones with Mercy Iowa City. One carrier told Jones that the existence of a modifier doesn't mean the carrier will pay for the claim.

In these cases, Jones will talk to the hospice involved, which will reimburse Mercy directly out of its own payments. But you should only go to the hospice for payment as a last resort, she says.

Also, on some occasions, the non-attending physician will treat a hospice patient for his or her terminal condition by mistake, without being asked to "cover" for the attending physician, notes Zimmerman. In those cases, the hospice will usually reimburse the physician.

Sometimes, the hospice will refer a patient to IMA for testing. In those cases, the hospice will pay directly for the tests, says Zimmerman.

Tip: When using the GV modifier, make sure you use the exact diagnosis that the hospice submitted to Medicare as the covered diagnosis, Jones warns. If the diagnosis is close to the hospice diagnosis, but not exactly the same, the carrier may not cover the claim using the GV modifier. For other diagnoses, try the GW modifier.

Another tip: Use the Q6 modifier when a locum tenens physician is standing in for one of the physicians  in your group, advises Donna Beaulieu with Quality Physician  Services in Stockbridge, GA.