(Medicare Claims Processing Manual)

B. Billing of Covered Services   Medicare hospices bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage.  Billing begins with a notice of election for an initial hospi ce benefit period, and followed by claims with types of bill 81X or 82X.  If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so t hat the beneficiarys medical care and payment is not disrupted.  Medicare physicians may also bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met.  These claims should be submitted  with a GV or GW modifier as applicable.  A/B MACs (HHH) process these claims in accordance with regular claims processing rules.  When these modifiers are used, A/B MAC (HHH) are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.   As specified above, by regulation, the duration of payment responsibility by fee -for-service A/B MACs (HHH) extends through the remainder of the month in which hospice is revoked by hospice beneficiaries.  MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee -for-service A/B MACs (HHH) as if the beneficiary were a fee -for-service beneficiary until the first day of the month following the month in which hospice was revoked.   30.5  Hospice Claims for Vaccine Services (Rev. 3621, Issued: 10- 07-16, Effective: 10- 01-16, Implementation:  10-03-16)  For dates of service on or after October 1, 2016, services for the vaccines provided by a hospice may be billed on an institutional claim to the hospices Medicare contractor.  Since these services are not part of the Medicare hospice benefit, they must be billed on a separate claim that includes only the vaccines and their administration.  For information on coding and payment of vaccine services, see chapter 18, section 10 of this manual.  40 - Billing and Payment for Hospice Services Provided by a Physician  (Rev. 1, 10- 01-03) HSP-406, B3 -4175, B3- 2020, B3- 15513  40.1 - Types of Physician Services  (Rev. 1, 10- 01-03) HSP-406  Payment for physician services provided in conjunction with the hospice benefit is made based on the type of service performed.   40.1.1 - Administrative Activities  (Rev.4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Payment  for physicians  administrative  and general  supervisory activities  is included in  the hospice  payment  rates.   These activities  include  participating  in the establishment,  review  and updating of  plans  of care,  supervising care and services  and establishing  governing policies.   These activities  are generally  performed  by the  physician  serving as  the medical  director  and the physician member  of the interdisciplinary  group (IDG).  Nurse practitioners or physician assistants may not serve as or replace the medical director or physician member of the IDG.   40.1.2 - Hospice Attending Physician Services  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Under the Medicare hospice benefit, an attending physician is defined as a doctor of medicine or osteopathy or a nurse practitioner or physician assistant (for professional services related to the terminal illness that are furnished on or after December 8,  2003 and January 1, 2019, respectively) who is identified by the  patient,  at the time  he/she  elects  hospice  coverage,  as having the  most  significant  role in the determination  and delivery  of his or her medical  care.  Payment  for physicians, nurse practiti oners, or physician assistants serving as the attending physician, who provide direct  patient  care services  and who are hospice  employees  or working under  arrangement  with  the hospice , is made in  the following manner:    Hospices  establish  a charge and  bill the  A/B MAC (HHH)  for these services under Medicare Part A.    The A/B MAC (HHH)  pays the hospice at the lesser of the actual charge or 100 percent of the Medicare physician fee schedule for physician services or 85 percent of the fee schedule amount for nurse practitioner or physician assistant services.  This payment is in addition to the daily hospice rates.    Payment for  attending physician services  is counted with  the payments  made at  the daily  payment  rates  to determine  whether  the overall  hospice  cap amount  has been  exceeded.    No payment  is made for attending physician services  furnished voluntarily.  However,  some  attending physicians may seek payment for certain services while furnishing other services on a volunteer basis.  Payment may be made for services not furnished voluntarily if the hospice is obligated to pay the attending physician for the services.  An attending physician must treat Medicare patients on the same basis as other patients in the hospice and may  not designate  all services  rendered  to non- Medicare patients  as volunteer  and at the same time  bill the  hospice  for services  rendered  to Medicare patients.    EXAMPLE: Dr. Jones has an agreement with a hospice to serve as its medical director on a volunteer basis.  Dr. Jones does not furnish any direct patient care services on a volunteer basis.  A Medicare beneficiary enters the hospice and designates Dr. Jones  as her attending physician.  When he furnishes a direct service to the beneficiary, he bills the hospice for this service and the hospice in turn bills the A/B MAC (HHH) and is paid for the service.  Dr. Jones may not bill Medicare Part B as an independen t attending physician because as a volunteer he is deemed to be a hospice employee.    No payment is made for nurse practitioner services that can be performed by a registered nurse, nor is payment made for nurse practitioner services that are performed outside of the attending physician role.   40.1.3 - Independent Attending Physician Services  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  When  hospice  coverage is  elected,  the beneficiary  waives  all rights  to Medicare Part  B payments  for professional 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 independent  attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services.  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.   Hospices should reiterate with patients that they must not see independent physicians for care related to their terminal illness other than their independent attending physician unless the hospice arranges it.   Even  though a  beneficiary  elects  hospice  coverage,  he/she  may  designate  and use  an independent attending physician, who  is not employed by nor receives compensation from the  hospice  for professional  services  furnished, in  addition to  the services  of hospice-employed physicians.  The  professional  services  of an independent attending physician that  are reasonable and  necessary  for the  treatment  and management  of a hospice  patients  terminal illness  are not  considered Medicare Part A  hospice  services.  Where the  service is  related to the hospice patients terminal illness, but was furnished by someone other than the designated attending physician [or a physician substituting for the attending physician] the physician or other provider must look to the hospice for payment.  Professional services related to the hospice patients terminal condition that were furnished by an independent attending physician are billed to the A/B MAC (B) through Medicare Part B.  When the independent attending physician furnishes a service related to the patients terminal illness and related conditions that includes both a professional and technical component (e.g., x-rays), he/she bills the professional component of such services to the A/B MAC (B) on a professional claim and looks to the hospice for payment for the technical component.  Likewise, the independent attending physician would look to the hospice for payment for services furnished that have no professional component (e.g., clinical lab tests). The remainder of this section explains thi s in greater detail.   When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, not employed by the hospice, in addition to receiving care from hospice-employed physicians.  The professional services of a non-hospice affiliated attending physic ian for the treatment and management of a hospice patients terminal illness and related conditions are not considered Medicare Part A hospice services.  These independent attending physician services are billed through Medicare Part B to the A/B MAC (B), provided they were not furnished under a payment arrangement with the hospice.  The independent attending physician codes services with the GV modifier Attending physician not employed or paid under agreement by the patients hospice provider when billing his/her professional services furnished for the treatment and management of a hospice patients terminal condition. The A/B MAC (B) makes payment to the independent attending physician based on the payment and deductible rules applicable to each covered service.   Payments for the services of an independent a ttending physician are not  counted  in determining  whether  the hospice  cap amount  has been  exceeded  because Part B  services  provided by an  independent  attending physician are  not part of the hospices  care.   Services  provided by an independent  attending physician must  be coordinated with  any direct  care services  provided by hospice  physicians.  Only  the direct professional  services of an  independent  attending physician, to a  patient  may be billed; the  costs  for services  such  as lab or x-rays are not to be included  in the bill.  If another physician covers for a hospice patients designated attending physician, the services of the substitute physician are billed by the designated attending physician under either the reciprocal billing or fee -for-time compensation arrangement (formerly referred to as Locum Tenens Arrangements) instructions.  In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.   When services related to a hospice patients terminal condition are furnished under a payment arrangement with the hospice by the designated attending physician, the attending physician must look to the hospice for payment.  In this situation the physicians services are Part A hospice services and are billed by the hospice to its A/B MAC (HHH).   The CWF response contains the periods of hospice entitlement. This information is a permanent part of the notice and is furnished on all CWF replies and automatic notices. A/B MACs (B) use the CWF reply for validating dates of hospice coverage and to resea rch, examine and adjudicate services coded with the GV or GW modifiers.   40.1.3.1 - Care Plan Oversight  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Care plan oversight (CPO) exists where there is physician supervision of patients under care of hospices that require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. Implicit in the conce pt of CPO is the expectation that the physician has coordinated an aspect of the patients care with the hospice during the month for which CPO services were billed.