License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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April 13, 2023

Hospice and GW Modifier Prepayment Reviews

CGS Medical Review has initiated prepayment review of claims for which the GW modifier is appended to claim line(s). The GW modifier is used to indicate items or services that are not related to the hospice beneficiary's terminal illness or a related condition. The Medicare hospice benefit is administered under Medicare Part A and includes items and services provided to palliate or manage a beneficiary's terminal illnesses and related conditions. Medicare pays the hospice for the DMEPOS items provided to the beneficiaries if the items are necessary part of treatment of their terminal illness or related condition. If it meets this condition, payment is bundled into the hospice's per diem payment.

Suppliers may bill DME MACs separately for an item or service that is not related to the hospice patient's terminal condition. These items or services are indicated on the claim by appending the GW modifier to the claim line. Use of the GW modifier means that the item or service is not related to the hospice patient's terminal condition.

As noted by the Centers for Medicare and Medicaid Services (CMS) and repeated in numerous CMS publications and regulations related to the hospice benefit, payment for items and services separate from the hospice per diem should be "exceptional and unusual" and that hospices are required to "provide virtually all the care that is needed by terminally ill patients."

What are some tips for suppliers who may have claims selected for GW modifier review?

First, you need to maintain close communication with the hospice provider to ensure that the use of the GW is appropriate.

Second, before using the GW modifier, ask the hospice provider to send you their Hospice Election Statement Addendum. You should have this in your files before billing any items with the GW modifier.

The Hospice Election Statement Addendum document, created by CMS in 2020, is designed to provide essential information for patients, their families and caregivers to make informed care decisions and to anticipate any financial liability associated with needed items, services, and drugs not provided under the Medicare hospice benefit.

A complete list of the requirements for this document may be found in the CMS Benefit Policy Manual, Ch. 9, Section 20.2.1.2. Highlighted below are three of the important points that the hospice is required to list in the Hospice Election Statement Addendum:

The individual's conditions present on hospice admission (or upon plan of care update) and the associated items, services, and drugs not covered by the hospice because they have been determined by the hospice to be unrelated to the terminal illness and related conditions.
A written clinical explanation, in language the individual (or representative) can understand, as to why the identified conditions, items, services, and drugs are considered unrelated to the individual's terminal illness and related conditions and not needed for pain or symptom management.
References to any relevant clinical practice, policy, or coverage guidelines.

The Hospice Election Statement Addendum is an educational document and promotes transparency for the hospice beneficiary, their families or caregivers and any other stakeholders, such as DME suppliers and Medicare Administrative Contractors.

If you use the GW modifier, you should request the Hospice Election Statement Addendum from the hospice provider and have it in your files before using the GW modifier on a claim. CGS will be requesting the Hospice Election Statement Addendum from DME suppliers that use the GW modifier and have claims selected for prepayment review, in addition to medical records to support that the item provided was reasonable and necessary.

How to determine if the beneficiary is in a hospice covered stay? Suppliers can use the myCGS secure web portal to access eligibility information or by using the Interactive Voice Response Unit or IVR. These tools are available 24-hours a day/7-days a week.

Below are helpful resources related to the hospice benefit and the Hospice Election Statement Addendum:

CMS Hospice Pages: https://www.cms.gov/medicare/hospice/hospice-educational-resources; https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice

Federal Register / Vol. 84, No. 151 / Tuesday, August 6, 2019 / Rules and Regulations – Hospice Election Statement Addendum: https://www.federalregister.gov/documents/2019/08/06/2019-16583/medicare-program-fy-2020-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

Office of Inspector General Report (A-09-20-03026) – Medicare Improperly Paid Suppliers An Estimated $117 Million Over 4 Years For Durable Medical Equipment, Prosthetics, Orthotics, And Supplies Provided To Hospice Beneficiaries – November 2021: https://oig.hhs.gov/oas/reports/region9/92003026.pdf

CGS' video series To The Point: Consolidated Billing and Hospice: https://cgsmedicare.com/jc/education/point/hospice.html

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Hospice and GW Modifier Prepayment Reviews

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