You might have received a denial with claim adjustment reason code (CARC) CO B9. Possible reasons for this denial message could be:
- The patient is enrolled in Hospice on the date of service
- Medicare Part B only pays for physician services not related to Hospice condition and not paid under arrangement with Hospice entity
- Patient’s Common Working File (CWF) has not been updated to show Hospice election has been revoked
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 their terminal illness during the period the hospice benefit election is in force. Hospice-related services performed by the ‘attending physician’ who is employed/contracted by hospice, should be submitted to the hospice contractor.
However, professional services of an ’attending physician’ who is not an employee of the designated hospice or does not receive compensation from the hospice for those services, are submitted to Medicare Part B. For purposes of administering the hospice benefit provisions, an ‘attending physician’ means an individual who:
- Is a doctor of medicine or osteopathy, or
- A nurse practitioner (for professional services related to the terminal illness and related conditions that are furnished on or after December 8, 2003), or
- A physician assistant (for professional services related to the terminal illness and related conditions that are furnished on or after and January 1, 2019; and
- Is identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.
Avoiding Denial
Before submitting a patient’s claim to Medicare Part B, contact the Part B interactive voice response (IVR) system to determine if the patient is enrolled in a hospice program. The beneficiary information like hospice effective date; hospice termination date (if applicable); and servicing contractor number can be obtained.
The following applicable modifiers should be used when billing for services of a patient enrolled in hospice. The appropriate modifier usage will depend on who is providing the service, what services are being provided, and if the services are for/related to the reason the patient is enrolled in hospice.
- Attending physician not employed by, or paid under an agreement with, the patient’s hospice provider:
- The claim should be submitted with modifier GV.
- If the claim was submitted with the GV modifier, check the patient’s file to verify that the attending physician is not employed by the hospice provider.
- Do not submit the GV modifier in the following conditions:
- The service was provided by a physician employed by the hospice.
- The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his attending physician.
- Services not related to the hospice patient’s terminal condition:
- The claim should be submitted with modifier GW.
- If the claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient’s terminal condition.
If the modifier has been applied appropriately, it may be necessary to appeal the decision. Ensure the correct diagnosis is submitted on the claim. If the patient’s terminal condition is pancreatic cancer and the primary diagnosis on the claim is cancer-related, this can be considered related and would cause the denial.
Example for Modifier GV:
A beneficiary enrolled in Hospice goes to their attending physician’s office for closed treatment of a metatarsal fracture, CPT code 28470. If the service is related to the patient’s terminal condition and the attending physician is not employed or paid under an arrangement by the patient’s hospice provider, the attending physician should bill 28470 with modifier GV (28470GV).
Example for Modifier GW:
A beneficiary enrolled in Hospice goes to a physician’s office for closed treatment of a metatarsal fracture, CPT code 28470. If the procedure is unrelated to the terminal prognosis, the physician should bill it with modifier GW (28470GW).
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