Medicare Hospice Modifier GV and GW

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Medicare:
How to use Modifier GV and Modifier GW

Medicare modifier GV and modifier GWWe do medical billing for physician offices that do Care Plan Oversight (CPO) for Hospice Patients.  When billing for those services, G0182, we use the following Medicare modifiers:

GV Modifier

The GV modifier is used when a physician is providing a service that is 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 the attending physician.

GW Modifier

The GW modifier is 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 the attending physician.

When a patient is under hospice, there is a certain diagnosis that was indicated at the beginning of care. If the service the physician renders is unrelated to the terminal illnesses that hospice has on record, Medicare will not reimburse for the service unless it is submitted with the modifier GW.  The GW modifier cuts through the Medicare edits and will pay.

For more information on properly billing GV and GW modifiers, see CMS Pub 100-4, Chap 11 Section 40.2

 

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13 Responses to “Medicare Hospice Modifier GV and GW”

  1. I am an LCSW who provides mental health services to clients in assisted living facilities and skilled nursing facilities. Some of my clients are enrolled in Hospice. Can I bill for services, adding the GW modifier or will claims deny?

    Reply
  2. Great article and very well explained. I believe in professionals so this is a very useful article for everyone. Many thanks for your share.

    Reply
  3. If Medicare has paid a claim billed with GW modifier and kept patient responsibility. Will secondary insurance cover the service.

    Reply
  4. I have a patient who was in hospice at the time of service here in our office for something not related,but she had avmed medicare hmo.. Who do I bill? medicare directly or avmed? Can you please help. Thank you!

    Reply
    • Leidy, typically once a patient is hospice we know to bill Medicare directly. We have had one or two Medicare Advantage plans pay but usually, once the patient is on hospice they deny the claim and refer you to bill Medicare instead. Just to be safe bill the patient’s Medicare Advantage plan first and if it is denied then you can bill Medicare directly. The insurance carrier will let you know once the claim is received and processed. Hope this helps! –Manny

      Reply
  5. The GV modifier is only to be used by an ATTENDING physician who is not employed or under contract by the Hospice Agency when the diagnosis is related to the hospice care. Every Medicare website I review says that any physician who is not the ATTENDING, and provides care to a patient that is related to the patient’s hospice diagnosis cannot bill their services to Part B Medicare.

    Your statement above regarding the GV modifier where you state “private physician” should read “attending physician.” The attending physician is the physician the patient designates on the hospice election form as the physician who is identified as having the most significant role in the determination and delivery of their medical care.

    Your definition of when to use the GV modifier may lead people to think that if the diagnosis is related to hospice care any physician can bill with the GV modifier and that is not the case. Only the ATTENDING physician can bill with the GV modifier when they are not employed by or under contract with the hospice agency and the diagnosis is related to the patient’s hospice care.

    For example,Medicare’s claims processing manual CLM104c11 Processing Hospice claims says the following:

    “A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the terminal illness furnished by individuals or entities other than the designated ATTENDING physician, who may be a nurse practitioner. Such claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.”

    The problem we are having is that all the websites leave it hanging like that…….if you aren’t the attending and the diagnosis is related to the patient’s hospice care you can’t bill Medicare Part B. So who do you bill? Or do we have to write the charges off?

    I did find in one Medicare publication regarding hospice where it says the following(Medicare publication R1885CP-page 40): “where the service is related to the hospice patient’s terminal illness but was furnished by someone other than the designated “attending physician” [or physician substituting for the attending physician] the physician or other provider must look to the hospice for payment.” We tried that and the Hospice agency returned all of the claims and said they were not responsible.

    Other websites that state only the attending physician can bill the GV modifier when the diagnosis is related to the hospice diagnosis-both of these are medicare intermediaries:

    http://www.novitas-solutions.com/webcenter/portal/MedicareJH/page/pagebyid?contentId=00097911&_adf.ctrl-state=6bb8nappb_179&_afrLoop=1084291949401622#!

    http://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Part%20B~Browse%20by%20Topic~Denial%20Resolution~Hospice%20Non-Attending%20Physician%20Denials

    Reply
    • Hi Beth I just found your comment in a pending folder.

      Yes, Attending physician is clearer. Thanks for pointing that out.

      The few time this has happened to our practices we have had to write off the visit.

      Reply
  6. We did bill out to Medicare with GW modifier but Medicare has rejected it twice. The reason of the rejection is B15 : This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Any thought about this case Mr. Oliverez ?

    Thanks.

    Reply
    • The denial could be diagnosis driven as the GW modifier indicates that the “service is not related to the hospice patient’s terminal condition” http://www.wpsmedicare.com/j8macpartb/resources/modifiers/hospicemodifier.shtml – the very first thing I would look at would be the diagnoses. That could easily explain the denial. Another area to look at would be the CPT code being billed out and place of service location code.

      We did bill the GW modifier for some of our clients but also had some denials and we reverted to the GV modifier since that is the most applicable in our situation and the claims were paid.

      GV – Attending physician not employed or paid under agreement by the patient’s hospice provider.

      Another issue may be frequency – was the patient seen by another provider on the same date of service?

      Looking at the denial again I am leaning towards Medicare has either not qualified the patient as hospice or it is a CPT error.

      Just some thoughts.

      Reply
  7. I have a doctor in the office that has a medicare provider number and is active, the other doctor is not – can that patient see the patient because the primary doctor is not available ?
    I did think so with a proper modifier

    Reply
    • Well Yes and No.

      Yes the other doctor can see the patient but will have to bill under their own name. Make sure you use the limited charge. You can give the paperwork to the patient to submit a claim to Medicare for reimbursement.

      No there is no modifier. You may be thinking Incident-to but it does not apply in this case.

      For more info on how to bill for a non-participating provider check with your local Medicare carrier. There you will find specific instructions you must follow to remain in compliance.

      Reply

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