PR B9 Patient is enrolled in a hospice
(THESE SERVICES ARE DENIED BECAUSE THE PATIENT IS IN A HOSPICE)
Resources/tips for avoiding this denial
Specific guidelines exist pertaining to Medicare hospice benefits. Certain Medicare coverage does not apply to a beneficiary enrolled in a hospice program.
• View the document titled Medicare Hospice Benefits , detailing guidelines applying to hospice cases
Before submitting a patient's claim to Medicare Part B, contact the Part B interactive voice response (IVR) system to determine if the patient is enrolled in a hospice program. The following beneficiary information can be obtained:
• Hospice effective date
• Hospice termination date (if applicable)
• Servicing contractor number
Certain modifiers apply when services or providers are not related to hospice:
• Modifier GV: Attending physician not employed or paid under agreement by the patient’s hospice provider
• Modifier GW: Services not related to the hospice patient’s terminal condition
• If a modifier is applicable to the claim, apply the appropriate modifier prior to submitting the claim.
Tips to correct the denied claim
If you have submitted the claim without an appropriate modifier, refer to the modifier guidelines above.
• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim.
If you have submitted the claim with a GV modifier, double-check the patient's file to ensure the attending physician is in fact not employed by the hospice provider.
• If the system suspected a match when cross-referencing the performing provider with the list of hospice providers, this denial may have been assessed.
If you have submitted the claim with a GW modifier, double-check the primary diagnosis on the claim to ensure the services are not related to the hospice patient's terminal condition.
• Ensure the correct diagnosis is submitted on the claim.
• For example, if the patient's terminal condition is pancreatic cancer and the primary diagnosis on the claim is cancer-related, this can be considered related and would cause the denial.
If the modifier has been applied appropriately, it may be necessary to appeal the decision.
