Wednesday, August 22, 2012

PR B9 Denail code and Action - Enrolled in hospice

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.



Hospice: Non-Attending Physician Denials

Denial Reason, Reason/Remark Code(s)

PR-B9: Patient is enrolled in a Hospice

Procedures: All

Resources/Resolution

Prior to submitting claims to Medicare, determine whether the patient has elected hospice benefits

You may verify eligibility through the Palmetto GBA Interactive Voice Response (IVR) unit or online though an ANSI 270/271 transaction
If the patient has elected hospice benefits, refer to 'Hospice Benefits and Medicare Part B' section below


Hospice Benefits and Medicare Part B

Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition


When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner


Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV if the services are related to the terminal illness. HCPCS modifier GV signifies that:

The service was rendered to a patient enrolled in a hospice

The service was provided by a physician or nurse practitioner identified as the patient’s 'attending physician' at the time of that patient’s enrollment in the hospice program


If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted

If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, HCPCS modifier GV may not be submitted

Any covered Medicare services by the attending or rendering provider that are not related to the treatment of a terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be submitted with HCPCS modifier GW. HCPCS modifier GW signifies that the service was not related to the hospice patient's terminal condition


Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare or the MA plan?

A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.

While a hospice election is in effect, certain types of claims may be submitted to the MAC, by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:

• Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice

• Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition

• MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked

Example:

Beneficiary’s hospice election period ended on 1/10/YY
Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY
Bill the MA plan for claims for dates of service 2/1/YY and beyond

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