American College of Physicians: Internal Medicine — Doctors for Adults ®

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Billing changes you need to know for hospice patients

From the May ACP Observer, copyright 2006 by the American College of Physicians.

By Brian Whitman

Just as the transition from curative to palliative care is important for therapeutic options, it also signals an important change in billing practices. While those changes may not be major, it can be easy to make a mistake and, given the nature of patients' illness, hard to recover payments if not properly submitted the first time.

Q: How do patients enroll in the Medicare hospice benefit program?

A: First, physicians need to determine that patients would be best served by enrolling in this program, which is administered through Medicare Part A. Next, two physicians—the patient's primary care physician and the hospice medical director—must verify in writing that the patient is not expected to live more than six months. The patient must also sign a statement agreeing to receive only palliative care in the future and discontinuing all attempts to cure.

Q: How long can the patient receive the hospice benefit?

A: The original certification is good for 90 days and can be recertified for 90 more days.

Q: Does the benefit expire if the patient lives longer than those six months?

A: No, the benefit never expires. It just needs to be recertified every 60 days. Only one physician has to sign this recertification form.

Q: How does the benefit work?

A: Patients select a physician and hospice agency when they enroll for the program. The benefit is based on a capitated system, so the agency is paid for each day the patient lives and thus cannot collect or bill for other services during that time. Usually, these hospice services are provided in the home. Medicare will not pay for room and board for patients treated for hospice in nursing care facilities.

Q: How do physicians get paid?

A: If the physician is not employed by the hospice agency, she can bill for services using the same CPT codes normally used for non-hospice patients. However, if the physician is employed by the hospice, her payment is considered part of the hospice's capitated payment, and she cannot bill separately.

Q: What if I treat a hospice patient for issues not related to the terminal illness?

A: You'll get paid if you use the proper modifier when billing. For services not related to the terminal illness, bill Medicare with the standard CPT codes for that service but include the modifier GW. If a patient with terminal lung cancer breaks an ankle, for instance, treatment for the ankle break would be coded with the modifier GW. Any physician treating the hospice patient for a condition unrelated to the terminal illness may bill with this modifier.

Q: Can I get paid for providing palliative care to the patient?

A: Yes, by using the modifier GV with all codes. Only the provider that the patient selected during enrollment as the hospice physician—and one who is not an employee of the hospice agency—can bill for these services.

Q: Can the patient switch his hospice care to another physician?

A: Yes, but only once per certification period, and the patient must sign a form to do so.

Q: What if the patient improves or chooses curative measures?

A: If the patient decides to pursue anything beyond palliative care, he should be removed from the Medicare hospice benefit program and returned to the standard Medicare program. Once that occurs, physicians should no longer use modifiers when billing for continued care. In such cases, it is important to work with the hospice agency to transition care and ensure that future Medicare bills are paid.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.

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