Oncology & Hematology Coding Alert

Choose between GV and GW to end your reimbursement woes

Carriers may make you jump through hoops for hospice-related reimbursement, but properly applying certain modifiers will help springboard you to success.
 
According to hospice coding experts, you must master the following modifiers when the physician you code for isn't directly employed by the hospice:

 - GV -- Attending physician not employed or paid under arrangement 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.

Important: You have to use modifier GV or GW  for the attending physician's services, or you won't get paid.
 
Explanation: Under Medicare, the patient has to choose an -attending physician- when he enters hospice care.
 
The hospice medical director provides administrative and general oversight of the program, but the attending physician performs all hands-on care, says Indiana coder Linda Zimmerman. If the attending works for the hospice, the hospice bills Part A. If not, the attending can bill Part B directly using evaluation and management codes and modifier GV.
 
Example: Your oncologist is the designated attending physician and sees a patient in hospice for vertebral metastases, which is the reason the patient is in the hospice. You append modifier GV, not GW, to your claim to reflect that the oncologist is not employed by the hospice and the service is related to the patient's terminal condition.
 
Tip: When using modifier GV, your best bet is to use the exact diagnosis that the hospice submitted to Medicare as the covered, or admitting, diagnosis, says coder Kristin Jones with Mercy Iowa City.
 
But only report this diagnosis if your physician documents it as the reason for the visit. If the diagnosis is close to the hospice diagnosis but not exactly the same, the carrier may not cover the claim using modifier GV. For other diagnoses, consider modifier GW.

Plan Ahead to Overcome Q5, Q6 Denials

You should use Q6 when a locum tenens physician is standing in for one of the physicians in your group, says Donna Beaulieu with Quality Physician Services in Stockbridge, Ga.
 
But when a hospice patient receives terminal-quot;illness- related services from a group member covering for the designated attending physician, the designated attending physician should report Q5 in item 24 of Form CMS-1500, according to CMS. Check out the CMS rules on the Web at www.cms.hhs.gov/manuals/downloads/clm104c01.pdf, page 55).
 
Note: If you use GV and Q5 together, you-re saying the services were related to the terminal illness but that a physician was covering for the attending physician under a reciprocal arrangement.
 
Problem: Some carriers will refuse to pay for non-attending physician services even if the physician correctly uses modifiers Q5 or Q6, Jones says. One carrier told Jones that the existence of a modifier doesn't necessarily 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.
 
Sometimes, the hospice will refer a patient to your physician for testing. In those cases, the hospice will pay directly for the tests, Zimmerman says.
 
Remember, place matters: You have to have the correct place of service on your claims for hospice patients. For a patient admitted to a hospice, you won't get paid unless you use POS code 34 (hospice).
 
You could also have a hospice patient receiving services in his home (POS code 12), or in skilled nursing facilities (POS code 31), or as in inpatient in the hospital (POS code 21).