RAC Alert: How to Bill Medicare for Hospice Patients When You Are Not the Hospice Provider

Hospice Care

What is Hospice?

Hospice care focuses on improving the quality of life for persons and their families faced with a life-limiting illness. The primary goals of hospice care are to provide comfort, relieve physical, emotional, and spiritual suffering, and promote the dignity of terminally ill persons. Hospice care neither prolongs nor hastens the dying process. As such, it is palliative not curative. Hospice care is a philosophy or approach to care rather than a place. Care may be provided in a person’s home, nursing home, hospital, or independent facility devoted to end-of-life care.

How is Medicare Hospice Care Paid?

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner. If the attending physician, who may be a nurse practitioner, is an employee of the designated hospice, he or she may not receive compensation from the hospice for those services under Part B. These physician professional services are billed to Medicare Part A by the hospice.

What is the RAC Issue?

Recovery Auditors recently reported a billing issue for physicians providing services unrelated to a Hospice terminal diagnosis provided during a Hospice period. Hospice claims are filed under Part A, while services not related to a Hospice diagnosis are filed under Part B. In these cases, unrelated care was billed without the accompanying GW modifier. All services related to a Hospice terminal diagnosis are included in the Hospice payment and are not paid separately.

For beneficiaries enrolled in Hospice, Medicare Administrative Contractors (MACs) and/or Medicare Carriers must deny any service furnished on or after January 1, 2002, that are submitted without either GV or GW modifier.

GV Modifier = Attending physician treating a patient with a Hospice related terminal diagnosis, but not employed or paid under arrangement by the patient’s hospice provider

GW Modifier = Service not related to the Hospice patient’s terminal condition

Recovery Auditor Finding

In this audit, the recovery auditors conducted an automated review of claims for physician services. A significant number were deemed to contain improper billing resulting in overpayment.

Claim Example 1: A patient is enrolled in Hospice and goes to a physician’s office for open treatment of a femoral fracture, with internal fixation or prosthetic replacement, CPT code 27236.

Finding: If the procedure is unrelated to the terminal diagnosis (Non-Hospice related), the physician’s bill should contain modifier GW. If this modifier is not appended, the procedure is related to the terminal diagnosis and should not be reimbursed under the part B benefit, instead paid under the hospice benefit.

Claim Example 2: The patient is shown as being on hospice starting August 1, 2010, through August 31, 2010. A provider billed CPT code 45378, Colonoscopy, with no modifiers to Part B on August 3, 2010.

Finding: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice. There can be no separate reimbursement unless the service was unrelated to the terminal diagnosis, which has to be reflected by the proper modifier.

How to Capture Medicare Hospice Information

  • Identify patients enrolled in Hospice, and document in your system the Hospice in which they are enrolled.
  • If you have referred a patient to Hospice, flag their account in the computer so anyone performing coding or billing can investigate the of use appropriate modifiers.
  • If you have received correspondence notifying you of a patient’s enrollment in Hospice, notify staff and make sure the billing record is flagged for appropriate coding.
  • If you become aware during the patient’s care that the patient you are treating is in Hospice, document the name of the Hospice and notify staff, making sure the billing record is flagged.
  • Patients sometimes dis-enroll or are discharged from Hospice, so do not assume a patient is continuing care under Hospice. When in doubt, contact the patient’s Hospice to clarify if the patient is or is not enrolled.
  • A little extra leg work will not only cause your claim to be paid on time and properly, it will also keep you from having to pay back any money if improperly paid to you.


Faced a RAC Recovery Audit? Take Frank Cohen’s Survey!

If you have, please consider taking a few minutes to fill out the post-Audit survey being compiled and made available free by the Frank Cohen Group. This is the last week the survey is being offered, so hurry!

Centers for Medicare and Medicaid Services Logo

“Just a reminder that the RAC audits and appeals survey will close on Monday the 17th – so if you haven’t responded, please do so as soon as possible. The results of this survey will be passed along to congressional representatives to aid in their case for creating an accountability provision for the RAC auditors. It has become quite obvious that RACs have become far too aggressive and zealous with regard to their audit tactics and findings, invalidating their original purpose. The concern is that, by acting in an abusive manner, RACs are actually adding to the cost of healthcare, not reducing it.

The survey is only six questions and takes less than three minutes to complete; so I urge anyone who has been subject to a RAC audit in the past year to please respond. You can access the survey at www.FrankCohenGroup.com by clicking on the Surveys tab.

Thanks again for your help. I will be publishing the results shortly after the survey has closed.”

Taking the survey is a great, quick way to have your voice as a medical practice manager heard by policymakers and the voting public at large. Take advantage of it!

RAC Prepayment Reviews – the Game is Changing: CMS Provider Call on August 9th

Medicare Fee-For-Service Recovery Auditor Prepayment Review Demonstration

Thursday, August 9, 2012

2:00PM – 4:00PM ET

Conference Call Only

The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss the recently approved Recovery Auditor Prepayment Review Demonstration that will begin August 27, 2012.

This Special ODF is designed specifically for Medicare Fee-For-Service providers who may be subject to Recovery Auditor review in the 11 approved demonstration states: FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO. Recovery Auditors will review claims before they are paid to ensure that the provider complied with all Medicare payment rules. These reviews will focus on certain types of claims that historically result in high rates of improper payments. Initially, Recovery Auditors will review short stay inpatient hospital claims. This demonstration will also help lower the error rate by preventing improper payments, rather than the traditional “pay and chase” methods of looking for improper payments after they have been made.

During this ODF, CMS will provide an overview of the Recovery Auditor Prepayment Review Demonstration, including:

• Why the Demonstration is being implemented;

• How it will impact providers in the affected states;

• Specific operational details regarding the reviews; and

• Where to find additional information.


After the CMS presentation, participants will have an opportunity to ask questions.

Discussion materials for this Special ODF will be available to download at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html. Discussion materials will be available on August 8, 2012.

Special Open Door Forum Participation Instructions:

Dial: 1-866-501-5502

Reference Conference ID#:16834984

Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

An audio recording and transcript of this Special Open Door Forum will be posted to the Special Open Door Forum website: http://www.cms.gov/OpenDoorForums/05_ODF_SpecialODF.asp

and will be accessible for downloading beginning on or around August 16, 2012 and will be available for 30 days.

The Cohen Report: Analysis and “Quickinar” of the NCCI 17.1 Changes Effective April 1, 2011

There are 11,831 new edit pairs, which pushes the total for effective edits to 709,527.  There were 346 terminations for a net gain of 11,485.  In this release, we find that there are around 350 edit pairs that have termination and/or effective dates retroactive to an earlier period with some going as far back as October, 2001.  In fact, all but 10 of the terminated edit pairs are retroactive, adding to the complexity of billing and possible targets for RAC auditors.

If you would like to get a copy of his summary report along with a couple of worksheets that detail these changes, go to www.frankcohengroup.com and click on the Download tab.  There is no charge for the analysis or the worksheets.

Free Quikinar on NCCI

Frank will also be conducting a brief (free) Quickinar„¢ to go over the NCCI policies and changes for this release on March 24, 2011 from 11:00 to 11:30.  To register, go to his website at www.frankcohengroup.com and click on the Quickinar tab.

If you have any questions, please feel free to contact Frank Cohen.

The Frank Cohen Group, LLC



855.THE.GROUP (855.843.4768)

Direct:  727.322.4232