“Can I still see my doctor while in hospice?” There is a lot of confusion about this question, even among doctors. The answer is “yes, but with limitations.” Only one MD or DO not employed by the hospice can be paid by Medicare for medical care related to the hospice diagnosis. However, all prescribers can be paid for medical care not related to the hospice diagnosis.

Doctors and nurse practitioners can and should get paid for work they do for patients – even when those patients are enrolled in hospice. Denials for these patients are so common that many prescribers give up billing or assume that Medicare does not cover doctor’s care during hospice. In fact, a recent OIG report shows that 44% of hospice patients receive Medicare-reimbursed care or services not related to hospice. Two simple coding tips can get most prescribers paid for the work they do with hospice patients.

Why Does Medicare Limit What Doctors Can Get Paid for During Hospice?

Medicare pays hospice a bundled rate for all covered services, supplies, and meds a patient needs, but only for care that is related to the hospice diagnosis. This is a great advantage for patients, because Medicare also pays 100% for hospice care, saving patients a great deal in deductibles and co-pays. That bundled benefit covers all the medications, nursing, equipment, supplies, aide services, and social services a patient should need, so long as it relates to the hospice diagnosis. This explains why Medicare will not pay providers other than the hospice for services related to the same diagnosis.  Because Medicare is already paying the hospice a bundled fee for all services, the other care would be considered duplicate payment.

What Does Care Related to the Hospice Diagnosis Mean?

A hospice case will have a primary diagnosis submitted to Medicare. It may be something such as kidney failure, pancreatic cancer, heart failure, etc. If a patient needs home nursing for palliative care or a hospital bed at home, that clearly falls into the category of care related to the hospice diagnosis. On the other hand, if a patient receiving hospice care for pancreatic cancer should experience an accidental fall and seek medical attention, care for the fall injury should be considered not related to the pancreatic cancer. Any prescriber should be able to bill Medicare for urgent care in that case.

Extra Coding Requirements for Clinicians During Hospice

It may be the case that if prescribers submit a bill that is not coded exactly right, Medicare’s administrative contractors (MACs) will reject it immediately. First, doctors’ offices need to provide the correct diagnosis on the claim. MACs tend to automatically reject physician claims that list the hospice diagnosis. Second, doctors must put a modifier on their procedure codes. They use modifier GW. The GW modifier signifies that the individual service is not related to the hospice diagnosis. If a claim with the correct diagnosis, the GW modifier, and services not related to the hospice diagnosis is denied for simultaneous hospice enrollment, providers should appeal that denial. 

Can I See My Doctor for Care That Is Related to the Hospice Diagnosis?

Maybe. One MD or DO may bill hospice for services that are indeed related to the hospice diagnosis. This is the doctor listed as the attending physician at the time of hospice enrollment. Some hospice agencies employ their own hospice doctor and will want that doctor to be the attending physician. Other hospice agencies want your trusted family physician or specialist to be the attending physician. In that case, the hospice will follow orders from and report to the doctor you already know.

How Does the Hospice Attending Physician Get Paid?

The hospice attending physician also has some special billing requirements with Medicare. These unusual requirements can be easy to miss or get wrong. One, the hospice attending physician should list the hospice diagnosis on the Medicare claim. Two, procedure codes should have the GV modifier. The GV modifier signifies that hospice-diagnosis-related services are being provided by the hospice-designated attending physician. Without these modifiers, MACs tend to reject claims without further consideration.

Conclusion: Can I Still See My Doctor While in Hospice?

Yes, but with limitations. If the care is not related to what hospice should be doing, absolutely, “yes.” Four out of ten hospice patients get Medicare-reimbursed care outside of what hospice is doing. However, some healthcare providers may say the opposite is true due to past billing difficulties. On the other hand, if the care is related to what hospice is doing, only one MD or DO may bill Medicare directly. This hospice attending physician could be the doctor you already know, or it could be the doctor of the hospice agency. You can discuss this with different hospice agencies ahead of time.