PHYSICIAN REIMBURSEMENT FOR NON-HOSPICE EMPLOYED PHYSICIANS

PHYSICIAN REIMBURSEMENT FOR PATIENTS ON THE HOSPICE MEDICARE BENEFIT

Ask yourself the following questions (A, B, C) and then proceed with 1,2 and 3.

A) Are you the attending or primary physician providing professional service to this Medicare patient?

B) Are the services that you provide related to the hospice diagnosis?

C) Are you providing consulting services related to the hospice diagnosis?

The following will pertain only to those patients who have elected the Hospice Medicare Benefit, not those who are on Palliative Home Care.

*** NOTE: When a patient has United Health or Blue Chip Senior Plans, you need to bill Medicare not the HMO.

1) If you answered Yes to questions A and B, follow these instructions:

The physician bills Medicare using HCFA form 1500.
Use modifier “GV” in Box 24 D. (This modifier indicates that the billing MD has been designated as the attending physician for this hospice patient, and is not employed, nor paid by the hospice for these services.

2) If you answered Yes to question A, but No to question B, follow these instructions:

Process the claim to the intermediary as you would ordinarily.
Use modifier “GW” in Box 24 D. (This modifier indicates services are not related to the patient’s terminal condition.

3) If you answered No to question A, but Yes to question C, follow these instructions:

Process billing and documentation of services for hospice patient to Home & Hospice Care of Rhode Island at the contracted amount. Fulfills Hospice Medicare regulation (42 CFR 418.56)

4) If you answered NO to questions A and C, follow these instructions:

Process the claim to the intermediary, as you would ordinarily.

Definitions:

Attending/Primary Physician: The physician designated by the patient to have the most significant role in his/her care.
Consulting Physician: This physician provides patient services documented as needed for the palliation (pain/symptom management ) of a terminal diagnosis in the patient’s Plan of Care.
Covering (Stand-In) Physician: This physician is designated by the attending physician to care the patient on (his/her behalf as part of vacation or on-call coverage.
Contracted amount: The amount agreed upon between the physician and Home & Hospice Care of Rhode Island.

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