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Billing Hospice Physician and Nurse Practitioner (NP) Services

Medicare allows for hospices to bill separately for physician's services in the following situations:

  • The services are related to the patient's terminal diagnosis; and
  • The physician is a hospice employee, contracted with the hospice, or a hospice volunteer; and
  • The services are professional, hands-on care.

The information below identifies the type of service provided by the physician, and whether the service is separately billable to Medicare by the hospice agency. The data elements to bill physician and nurse practitioner services are also listed below.

Professional Hands-on Care (Services Related)

  • Professional services provided by a physician who is employed, contracted or a volunteer of the hospice are separately billable by the hospice agency. For billing information, refer to the "Billing Physician and Nurse Practitioner Services – Data Elements Required on Hospice Claim" information below. Reimbursement for these service is the lesser of the actual charge or 100% of the Medicare Physician Fee Schedule (MPFS). Reference: CMS Pub. 100-04, Ch. 11, §40.1.2External PDF
  • Professional services provided by an independent attending physician/nurse practitioner (a physician who is not employed by, or contracted with, your hospice agency) cannot be billed by the hospice. However, these services can be billed by the independent attending physician to the Part B Carrier/MAC. Reference: CMS Pub. 100-04, Ch. 11, §40.1.3External PDF
  • Professional services provided by a Nurse Practitioner who is the patient's attending physician
    When the patient's attending physician, who is a nurse practitioner, provides professional hands-on care related to the patient's terminal diagnosis, the services can be separately billed to and reimbursed by Medicare.
    • NP is employed, contracted or a volunteer of the hospice - these services are billed by the hospice agency. For billing information, refer to the "Billing Physician and Nurse Practitioner Services – Data Elements Required on Hospice Claim" information below. Reimbursement for these service is the lesser of the actual charge or 85% of the MPFS.
    • NP is not employed, contracted or a volunteer of the hospice (independent attending physician) - these services can be billed by the independent NP, who is the patient's attending physician, to the Part B Carrier/MAC.
    Note: Services by an NP who is not the patient's attending physician are included under nursing care, and are not separately billable.

Administrative Activities — these are typically performed by the hospice medical director or physician member of the interdisciplinary group (IDG), and include things such as establishing, review and updating the plan of care, supervising care/services, establishing governing policies, and providing the hospice face-to-face encounter. These services are included in the hospice's daily per diem, and are not separately billable to Medicare. Reference: CMS Pub. 100-04, Ch. 11, §40.1.1External PDF

Care Plan Oversight (CPO) — for patients who require complex care that requires regular physician development and/or revisions to the place of care.

  • CPO provided by a physician who is employed or under arrangement with the hospice is not separately billable. Reference: CMS Pub. 100-04, Ch. 11, §40.1.3.1External PDF
  • Care plan oversight by an independent attending physician can be separately billed by the physician to the Part B Carrier/MAC. Reference: CMS Pub. 100-04, Ch. 12, §180External PDF

Services Unrelated to Terminal Illness
If the services are not related to the patient's terminal illness, the hospice is not responsible for the services. The physician that provided the services can bill their Part B Carrier/MAC, using a "GW" modifier (services not related to the hospice patient's terminal condition). Reference: CMS Pub. 100-04, Ch. 11 §50External PDF

Billing Physician and Nurse Practitioner Services – Data Elements Required on Hospice Claim
When appropriate, physicians and nurse practitioner services can be billed to CGS on the monthly hospice claim that includes the daily levels of care and discipline visits provided. When billing the physician services or nurse practitioner services on a hospice claim, the following information is required, in addition to the usual claim information. If the monthly hospice claim has already been submitted and processed (P B9997), an adjustment claim (type of bill 8X7) can be submitted to add the physician services.

REV
(FISS Page 02)

0657 (Physician services)
HCPC
(FISS Page 02)

Enter the appropriate HCPCS code that correspond with the physician service provided.

MODIFS
(FISS Page 02)

Enter a modifier only if one of the following situations exists.

26 — Use modifier 26 to identify a physician's professional component of a technical service. The modifier may be reported when the patient's attending physician, or a physician who is contracted or employed by the hospice has provided the professional component of an otherwise technical service. NOTE: When using the 26 modifier, include a brief remark in the "Remarks" field on FISS Claim Page 04 to indicate the service billed is for the professional component of a technical service.

GV — Report modifier GV when billing physician services (0657) performed by a nurse practitioner acting as the patient's attending physician.
TOT UNIT

Enter the total units for the physician's service, based on the HCPCS description.

COV UNIT

Enter the number of covered units for the services billed.
TOT CHARGE

Enter the total charge for the physician's service.
SERV
DATE

Enter the date the physician's service was provided.

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Posted: 05.31.13

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