50 - Billing and Payment for Services Unrelated to Terminal Illness (Rev. 4280, Issued: 04-19-2019, Effective: 07-21-19, Implementation: 07-21-19

By a a on Thu, 12/08/2022 - 18:54
Detailed Question

Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider using professional or institutional claims for non-hospice Medicare payment. On professional claims, these services are coded with the GW modifier “service not related to the hospice patient’s terminal condition.” On institutional claims, these services are coded with condition code 07 “Treatment of Non-terminal Condition for Hospice.” A/B MACs (A) and (B) process services coded with the GW modifier or condition code 07 in the normal manner for coverage and payment determinations. See the related chapter of the Medicare Claims Processing Manual chapter for the type of service involved (i.e., Chapter 12 for physician services) for billing instructions. If warranted, A/B MACs (A) and (B) may conduct pre-payment development or post-payment review to validate that services billed with the GW modifier or condition code 07 are not related to the patient’s terminal condition

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Medicare Basics

Medicare Part A is the portion of Medicare that covers hospital insurance. This includes coverage for skilled nursing care provided in a skilled nursing facility (SNF) under certain conditions, for a limited time.

To be eligible for Medicare Part A coverage for skilled nursing care in a SNF, the following conditions must be met:

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