Suppose a family doctor has been treating a patient for the past fifteen years. The patient is now diagnosed with advanced heart disease and decides to enter hospice care. However, both the patient and the doctor want to continue their long-standing care relationship. The doctor provides the necessary care, documents the visit properly, and submits the claim to Medicare as usual. Despite everything being done correctly during the visit, Medicare denies the claim.
The missing piece is the GV modifier. It is one of the smallest items on a claim, yet it decides whether Medicare pays an attending physician for caring for a patient who is on hospice. Many private practices do not learn about it until the first denial.
This guide explains the GV modifier in full. You will learn what it means, who can use it, when it applies, how to put it on a claim, what to keep in your records, and what causes denials. If you want the big picture first, read our guide to Hospice Modifiers. This page stays on GV and does not repeat the basics of the hospice benefit.
| The short answer Use the GV modifier on a Medicare Part B claim line when three things are true. You are the attending physician of the patient named for hospice. You are not employed by the hospice and the hospice does not pay you under an arrangement for those services. And the service treats the terminal illness or a condition related to it. |
What the GV Modifier Means
The official descriptor for GV is “attending physician not employed or paid under arrangement by the patient’s hospice provider.” It is a HCPCS Level II modifier. You add it to a Part B claim line for a service you give to a Medicare patient who has elected hospice.
That short descriptor hides three tests, and all three must be true.
The first test is about your role. You must be the attending physician the patient named when choosing hospice, or the replacement the patient named later in writing. The second test is about your relationship with the hospice. You cannot be employed by the hospice, and the hospice cannot be paying you under a contract or other arrangement for the services you bill. The third test is about the service. It must treat the terminal illness or a related condition, as the hospice has determined.
If one test fails, GV is the wrong choice. A doctor who is not attending should not use it. A hospice employee should not use it. And if the attending sees the patient for something unrelated, the correct choice is GW modifier, not GV.
What GV Does and Does Not Do
GV is an information modifier. It does not raise or lower your payment. It does not replace good documentation, and it does not prove you are the attending, because Medicare and the hospice already hold that record. What it does is tell the claims system that your claim is a permitted exception. When a patient elects hospice, Medicare stops paying for care related to the terminal illness outside the hospice, with two exceptions: the hospice itself and the patient’s attending physician. GV marks your claim as the second exception.
Hospice agencies do not use GV on their own claims. It belongs to the attending’s practice.
Who Counts as the Attending Physician
Medicare’s hospice rules define the attending physician as a doctor of medicine or osteopathy, a nurse practitioner, or, since January 1, 2019, a physician assistant. The person must be the one the patient identified at the time of election as having the most significant role in determining and delivering the patient’s medical care.
Three points follow from that definition. First, the patient chooses. The hospice does not assign an attending. Second, there is only one attending at a time. Third, a patient can choose to have no attending at all. In that case the hospice’s own physician provides the physician care, and nobody bills GV.
Patients can change their attending. They do this by giving the hospice a signed statement with the effective date of the change. From that date the new attending bills GV, and the former attending’s related services will be denied. Billing teams are often surprised by this, so ask the hospice for the effective date whenever you learn that a patient has switched doctors.
Nurse practitioners and physician assistants who serve as attending follow the same GV rule. They bill under their own NPI, and Medicare pays them 85 percent of the physician fee schedule amount. As CMS rules stand today, the certification of terminal illness comes from a physician, so an NP or PA attending works with the hospice physician on that part. Check current CMS language, since this area has seen proposals for change.
Who Bills and Who Does Not
| Your role | Who bills | GV used? |
| Attending physician in private practice, not tied to the hospice | Your practice, on a Part B claim | Yes, for related services |
| Attending NP or PA in private practice | Your practice, on a Part B claim, paid at 85 percent | Yes, for related services |
| Attending physician employed by the hospice | The hospice | No |
| Physician paid by the hospice under a contract or arrangement | The hospice, under the agreement | No |
| Hospice medical director | The hospice | No |
| Consulting specialist, not the attending, treating a related condition | The hospice pays under an agreement | No |
| Attending seeing the patient for an unrelated condition | Your practice, on a Part B claim | No, use GW |
When to Use GV: Services Related to the Terminal Illness
The hospice sets which conditions are related, and CMS expects most of a patient’s care to fall on the related side. For an attending, that means most visits carry GV. Typical examples are office visits, home visits, assisted living and nursing facility visits, and visits at a hospice inpatient unit. The reason for the visit is usually pain, breathing trouble, nausea, poor appetite, confusion, medication changes, or a change in the patient’s condition tied to the illness.
Care plan oversight for hospice patients has its own HCPCS code, G0182. It has separate time and documentation rules, so ask your MAC how it expects GV to be used there before you bill it.
What Stays With the Hospice
The attending bills for the attending’s own professional services. Nursing visits by hospice staff, hospice aide care, and drugs, supplies, and equipment for the terminal illness belong to the hospice. If your office orders a related drug or a piece of equipment, the hospice pays for it, not Medicare Part B. Medicare also does not generally pay a separate fee for signing a certification. It is treated as part of your work.
Visits That Cover Both Related and Unrelated Problems
Sometimes one visit touches the terminal illness and an unrelated problem. This is a gray area. You generally cannot bill two evaluation and management services for one visit, so you cannot split the visit into one GV line and one GW line. Document which problems you addressed and ask your MAC how it wants these visits handled. Do not guess, and save the answer you get.
Telehealth Visits
Attending visits by telehealth are Part B services. Medicare’s telehealth rules have changed several times in recent years, so confirm the current rules and the right telehealth modifier (95 or GT) with your MAC. When a hospice modifier applies, it still goes on the line.
How to Bill GV on the Claim
The rendering provider NPI must be the NPI of the attending named on the hospice record. If you bill under a group NPI, the rendering field still needs the attending’s individual NPI. A mismatch is a common reason for a denial that looks like a modifier problem.
Use the place of service where the patient was seen: 11 for office, 12 for home, 13 for assisted living, 31 for a skilled nursing facility, 32 for a nursing facility, and 34 for a hospice facility. If a payment affecting modifier such as 25 is on the same line, list it first and place GV after it. Add GV to every line that needs it, not only the first.
Your diagnosis codes should show why you saw the patient. List the terminal illness or the related condition first. Some practices add Z51.5, encounter for palliative care, as a secondary code, which can help tell the story, but it should not replace the main diagnosis.
A Sample Claim to Understand GV Modifier
Dr. Patel is a family physician. His patient has Alzheimer’s disease and is on hospice. Dr. Patel is the named attending and has no contract with the hospice. He makes two home visits in the same month. The claim looks like this.
| Line | Date of service | POS | CPT | Modifier | Diagnosis codes |
| 1 | 10/06/2026 | 12 | 99349 | GV | G30.9, F02.80 |
| 2 | 10/20/2026 | 12 | 99350 | GV | G30.9, F02.80 |
How Payment Works
GV claims are paid under the Medicare Physician Fee Schedule. The Part B deductible and the 20 percent coinsurance still apply to the patient. Hospice does not remove those costs. If the patient has a Medigap plan, it usually pays the coinsurance. Medicare pays NPs and PAs at 85 percent of the fee schedule, as noted above. Part B claims must be filed within 12 months of the date of service.
Before You Bill: A GV Check in Six Parts
The best GV claims are decided before billing. Here is the check we recommend, in the order that saves the most rework.
Start with hospice status for the date of service. Your MAC portal or eligibility tool shows the hospice, the election date, and the benefit period. Check again before you bill, because patients can enter or leave hospice between the visit and the claim.
Next, confirm that you are the attending of record. Eligibility data tells you about the hospice, but it does not always tell you who the attending is. Call the hospice, ask for the attending’s name, and write down who you spoke with and when.
Then confirm that you have no employment, contract, or other arrangement with the hospice for the services you are billing. If you do, GV is not the right path.
Fourth, confirm that the condition you treated is related to the terminal illness. If you are not sure, ask the hospice.
Fifth, check the dates. GV applies only to dates inside the election period. A patient can revoke hospice at any time, and a hospice can discharge a patient who no longer meets the criteria. After a revocation or discharge, your claims go back to normal billing with no GV. A visit before the election date is also a normal claim.
Last, build the check into your system. Set a claim scrubber rule that flags any patient with a hospice flag, and add a second rule that checks for the right modifier before the claim leaves your office.
Documentation That Supports a GV Claim
A reviewer reading your note should be able to see three things without effort: that you were the attending, that the visit treated the terminal illness or a related condition, and that you worked with the hospice team. A good GV note usually has the following.
- Reason for the Visit: Document the reason for the visit, the condition being treated, and its relationship to the patient’s terminal illness or related conditions.
- Symptoms and Treatment: Record the symptoms assessed, changes in the patient’s condition, and any medication or treatment adjustments.
- Attending Physician Status: Clearly document your role as the patient’s designated hospice attending physician.
- Hospice Team Communication: Include any communication with the hospice care team, along with the date and name of the person contacted.
- Time or Medical Decision Making: Document the total time spent or the medical decision-making elements used to determine the appropriate E/M visit level.
Attending physicians are also part of the care team. Hospice nurses will call you for orders, to report changes in the patient’s condition, and to coordinate the plan of care. Record those calls in the chart. Medicare does not generally pay separately for phone calls like these, but the records show that you were actively attending, and they help in a review.
Keep a copy of your eligibility check, the hospice call log, and any election statement information you receive. If your claim is ever questioned, these records answer the question quickly.
Few Examples to Understand How GV Modifier Works
These examples are made up, but they reflect situations billing teams see often.
The Nurse Practitioner in the Nursing Facility
Nurse practitioner Rivera is the named attending for a patient on hospice for end stage COPD. The patient lives in a nursing facility. She visits to adjust the patient’s breathing treatments and review comfort. She bills 99308 with GV, place of service 32, and J44.9 as the main diagnosis. Medicare pays at 85 percent of the fee schedule. The hospice physician handles the certification.
The Attending Who Changed
A patient’s daughter signs a statement on October 8 naming Dr. Chen as the new attending in place of Dr. Lopez. Dr. Lopez’s office does not know. On October 14 the office sees the patient and bills the visit with GV. It is denied. The office calls the hospice, learns of the change, and stops billing GV for dates after October 7. Visits on or before October 7 are still billable with GV. If the hospice asked Dr. Lopez to see the patient on October 14, the correct path is to bill the hospice under their agreement.
The Medical Director Who Is Also the Family Doctor
Dr. Okafor is a hospice medical director. He is also the longtime doctor of a patient at that hospice. Because he works for the hospice, services he gives in that role are not billed to Medicare Part B with GV. He should ask the hospice how his services are paid. This is the case where the physician and the hospice relationship is closer than the billing office assumes.
One Patient, Two Modifiers
A patient receiving hospice care for advanced heart failure needs medical attention twice.
First Visit (GV Modifier): The patient experiences breathing difficulties and visits their chosen attending physician, who is independent of the hospice. The doctor treats the heart-related symptoms and uses the GV modifier when billing Medicare.
Second Visit (GW Modifier): A few days later, the patient falls and injures their ankle. They visit an orthopedic doctor who confirms that the injury is unrelated to the patient’s terminal illness and related conditions. The orthopedic doctor uses the GW modifier when billing Medicare.
The difference: GV applies to qualifying services from the patient’s designated attending physician, while GW identifies treatment unrelated to the patient’s terminal illness and related conditions.
Common GV Modifier Denials and How to Fix Them
| Cause | What you see | How to fix it |
| Practice is not the attending of record | Denial that points to hospice | Confirm the attending with the hospice. If you are not attending, stop using GV. |
| Attending changed on a date | Denial for dates after the change | Get the effective date in writing. Bill GV only for dates before it. |
| GV missing on a related service | Denial as hospice related | Add GV and resubmit, or ask for a reopening, depending on your MAC. |
| GV used on an unrelated service | Paid first, then recouped in review | Use GW and confirm relatedness with the hospice. |
| Rendering NPI does not match the attending | Denial for provider mismatch | Correct the rendering NPI and check group billing setup. |
| Date of service outside the election period | Denial, or GV used when it should not be | Check election and revocation dates. Remove GV if the patient was not in hospice. |
| Provider is a hospice employee or contractor | Denial or later recoupment | Bill the hospice under the arrangement. |
| Consultant used GV | Denial | The hospice pays consultants. Bill the hospice. |
Check the group code on your remittance advice. Denials caused by a missing or wrong modifier usually come back with a CO group code, which means the provider carries the liability. You cannot bill the patient for a denial that your own billing error caused.
For a simple clerical fix, many MACs accept a reopening. For a disagreement about the decision, you can file a redetermination within 120 days of the initial determination. Either way, watch the 12 month filing limit.
Hospice denials rarely look large on their own, but they pile up. A few unpaid claims each month stretch your days in A/R and pull your staff off other work. Strong revenue cycle management services put the hospice check at scheduling and registration, so the problem is caught before the claim exists.
GV With Medicare Advantage, Medicaid, and Commercial Plans
For Medicare Advantage members who elect hospice, Original Medicare generally pays for the hospice and for the attending physician’s services related to the terminal illness. That usually means your related claim goes to your MAC with GV, not to the plan. Care unrelated to the terminal illness follows the plan’s own rules. Because plans differ, confirm the routing with the plan before you bill.
For patients with both Medicare and Medicaid, Medicare is billed first and Medicaid may pick up the coinsurance, but each state has its own rules and data requirements. Commercial plans do not all use GV the same way, and some do not use it at all. Read the payer’s provider manual or ask your representative, and save the answer in your payer rules file.
How GV Claims Are Reviewed and How to Protect Your Practice
Hospice claims draw attention from MACs and other review contractors. A reviewer will usually compare your claim against the hospice record. They look at whether you were the attending, whether you were tied to the hospice by employment or contract, whether the service was related, and whether your notes support the visit.
The best protection is a regular internal review. Regular medical billing audits let you find problems while they are still small. For GV, pull every GV claim for the quarter, or a sample if your volume is high. For each claim, check that you verified hospice status for that date, that you were the attending, that the rendering NPI is correct, that the note ties to the terminal illness, and that payment and patient responsibility posted correctly.
Also look the other way. Pull claims for patients you know were in hospice and check for any that have no GV or GW. Those claims point to missing modifiers, lost payments, or claims sent to the wrong payer. If you find an overpayment, return it within the period Medicare requires.
GV and GW in One Paragraph
GV is about who you are and what you treat: the independent attending, treating the terminal illness. GW is about what the service is: care that has nothing to do with the terminal illness, from any provider. The same doctor can use both for the same patient on different dates, as the example above shows.
Who Can Help You Bill GV Claims Correctly?
At Proactive Healthcare Services (PHCS), our experienced team can help you bill GV claims and reduce denials. Our hospice medical billing support covers hospice status checks before each claim, confirmation of the attending of record, the right choice between GV and GW, and denial follow up until payment. We also run medical billing audits to find missing or wrong modifiers before a contractor does, and our revenue cycle management services keep your hospice claims moving from scheduling to payment.
Frequently Asked Questions
Can a nurse practitioner or physician assistant use the GV modifier?
Yes, if the patient named the NP or PA as the attending and the NP or PA is not employed by or paid under arrangement by the hospice. Payment is 85 percent of the physician fee schedule.
Can I use GV if I am the hospice medical director?
No. GV is for attending physicians who are not employed by or paid under arrangement by the hospice. Ask the hospice how your services are paid.
Do I need GV after the patient revokes hospice?
No. After a revocation or discharge, the patient returns to regular Medicare coverage, and you bill the usual way for those dates. Confirm the exact date with the hospice.
Can I bill the patient if my claim is denied for a missing GV?
Generally no. A denial caused by your own modifier error usually carries a CO group code, which puts the liability on the provider. Fix the claim instead.
What if my patient sees more than one doctor?
Only one doctor is the attending. A specialist treating a related condition is paid by the hospice, and any doctor treating an unrelated condition bills with GW.
Does GV apply to telehealth visits?
It can, when the visit meets Medicare’s telehealth rules. Telehealth rules change often, so check the current rules and modifier order with your MAC.
How do I find out if I am attending a record?
Ask the hospice. The patient named the attending at election, and the hospice can confirm your name and the effective date. Keep a record of the call.
Final Thoughts
The GV modifier looks simple, but it carries a lot of meaning. It says you are attending, you are independent of the hospice, and your service treats the terminal illness. When all three are true and documented, the claim is straightforward. When one is missing, the claim is at risk.
Check hospice status, confirm the attending, ask the hospice when you are unsure, and keep your notes.
