Medicare Hospice Benefit (MHB)

Brief Overview of Coding and
Billing Hospice Medical Benefits
Hospice Services
 Misconceptions about Medicare Hospice Benefit
 Physician Services
 Patients must have DNR to access hospice.
 Once a patient revokes the HMB (Hospice Medical
Benefits), he cannot receive hospice care again.
 After 6 months on the hospice benefit, the patient is
no longer eligible for hospice care.
 When a patient goes to a hospital, hospice services
 Patients who revoke or are discharged from hospice
are “on their own.”
 Managed care doesn’t pay for hospice.
 Once a patient elects hospice, he may no longer
access other health insurance.
 Self insured companies don’t pay for hospice.
 Can hospice agencies bill for Nurse Practitioners
Here’s the Scoop
 There are a variety of misconceptions and
misinformation about physician services.
Basic Concept
Traditional Medicare is exchanged
for Medicare Hospice Benefit for care
related to the terminal diagnosis.
Medicare Part A continues to provide
coverage for related diagnoses or
conditions treated in the in patient
hospital setting
Who is the Attending Physician?
 Patient’s choice
 MD or DO
 NP
 NOE (Notice of Election)
An Attending Physician Can Be…
 Non-employee
-no relationship with the Hospice
 Employee
Agreements with Consulted Physicians
 Written Agreement
Identify Services
Stipulation of Authorization from the Hospice
Documentation Requirements
Qualifications of Personnel
 Financial Responsibilities
 Professional Management Responsibilities
How are the Services Categorized?
 Professional Services
 Administrative Services
 Technical Services
Professional Services
 Actual procedures performed by the physician as
designated by the appropriate CPT Code
 Only separately billable services
Administrative Services
 Participating in the establishment, review, and
updating of the Plan of Care (POC)
 Care Plan Oversight
 Supervising care and services
 Evaluating therapies
 Assessing need for treatment changes
Technical Services
 X-rays, labs, and any other non-professional services
 Reimbursed through the hospice’s daily rate
 Reimbursement from the hospice is based on an
agreement with the physician
Reimbursement for a Non-employee Attending
 Medicare Part B for professional services
 Medicare Part B for Physician Care Plan Oversight
 Technical services are covered under hospice’s daily
 Subject to deductible, then 80% Medicare payment
and 20% patient co-insurance
Administrative Services Provided by the
Non-employed Physician
 Care plan Oversight is billed by the physician to the
Medicare Part B Carrier
 At least 30 minutes face-to-face services must be
provided in the month.
 Medicare does not pay for oversight services
provided in the nursing home
 Activities and time spent must be documented.
CPT 99377: 15-29 minutes/month
CPT 99378: > 30 minutes/month
Attending Physician Non-Hospice Employee
 Independent attending physician may bill Medicare
Part B for visits.
 GV modifier – used when an independent attending
physician is providing a service that is related to
the terminal diagnosis.
 If another physician covers for a hospice patient’s
designated attending, the services are billed by the
designated attending physician under the reciprocal
or locum tenens billing instructions (using modifier
Q5 or Q6, in addition to the GV)
Non-Attending Non-Hospice Employee
 Hospice
Where the service is related to the hospice patient’s
terminal illness but is furnished by someone other
than the designated “attending physician” (or
physician substituting for the attending) the physician
must look to the hospice for payment.
Reimbursement for an Employed
Attending Physician
 Physician bills Hospice
 Verify service dates, diagnosis being treated, and
service(s) performed
 Medicare Part A will reimburse hospice 100% of the
Medicare allowable amount
 Hospice reimburses the physician based on
agreement between both parties
---Medicare is not involved
Reimbursement for a Consulting Physician
 Same as an employed attending physician
 Contract must be on record prior to rendering the
service, and before filing the professional charges to
Medicare Part A.
NOTE: Medicare Part B will not reimburse any
physician rendering related services to a hospice
patient other than the non-employee attending
Other Situations
Rural Health Clinic Physicians
 Normally billed to Medicare Part A on the clinic bill
 Hospice must contract with the physician and bill as
a consultant physician
Nurse Practitioners
 NPs are only billable if providing services on behalf
of the non-employed attending physician
 Billed to Medicare Part B Carrier
Unrelated Physician Services
HCFA Publication 21, Section 303.2
 All services unrelated to the terminal condition
and related conditions are billable to traditional
Medicare for coverage consideration
 GW Modifier - used when a physician is providing a
service that is not related to the diagnosis for which a
patient has been enrolled into hospice. This
physician is not associated with the hospice and is
providing services as a private physician.
Physician Billing Flowchart

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