Billing with the GW Modifier
When a patient elects hospice coverage, he/she waives all right to Medicare Part B payment for professional services related to the treatment and management of he/she terminal illness during the hospice election period. However, the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 11, Section 50 states that Medicare may make payment for services not related to the terminal illness.
Physician offices can determine whether the patient is in a hospice by conversations with the patient, a representative, the hospice, or through the CMS Secure Net Access Portal (C-SNAP). It is the responsibility of the physician office to determine the relationship of the patient encounter to the terminal illness. If the reason for the encounter is related to the terminal illness, then the physician must submit claims for his/her services to the hospice for reimbursement. Medicare does not make separate payment for these claims. (There is an exception for the attending physician - please see our Attending Physician for Patients Who Elect Hospice Coverage article.)
If the reason for the encounter is not related to the terminal illness, then the physician office would append modifier GW - "service not related to the hospice patient's terminal condition" to the service. Contractors may conduct prepayment development or post payment reviews to validate the appropriate use of the modifier.
You can find more information on the Medicare instructions on physician billing for hospice care in the above listed manual on the CMS Manuals(external link) web page.
If you believe Medicare denied a claim in error, you can request an appeal. Please access our Appeals page on the Departments tab on the top navigation.
Page Last Updated: Tuesday, 15-Jul-2014 09:21:18 CDT