Do you know that a missing two-letter modifier can cause Medicare to deny a claim for a patient receiving hospice care, even when the service was provided, the documentation was complete, and the procedure code was correct?
Hospice care changes how Medicare covers and pays for certain services, and modifiers help identify whether a service is related to the patient’s terminal illness. Using the wrong modifier, or leaving it off entirely, can lead to claim denials and payment delays. That’s why understanding hospice modifiers is essential for accurate Medicare billing.
This guide explains hospice modifiers from the billing side. You will learn what they are, why Medicare requires them, how to decide which one fits, where they go on the claim, and how to build a process that keeps denials low. It is written for billers, coders, practice managers, and providers who treat patients that have chosen hospice.
| Key takeaways • Hospice modifiers tell Medicare whether a service is tied to the patient’s terminal illness and who is billing for it. • The two modifiers most billers use are GV and GW. They go on Part B claims, not on the hospice agency’s own claim. • The hospice decides what is related to the terminal illness. Your job is to confirm it, not guess it. • Most hospice denials start with a missed eligibility check, not a coding error. • Hospice rules change. Check CMS manuals and your MAC every year. |
What Are Hospice Modifiers?
Hospice modifiers are two-character codes from the HCPCS Level II code set. You add them to a claim line next to the CPT or HCPCS procedure code. They tell Medicare how a service relates to a patient’s hospice election.
A procedure code says what you did. A hospice modifier says how that service fits into the patient’s hospice care. Without that second piece, Medicare cannot tell if it should pay the claim or if the hospice has already been paid for that care.
In daily billing, the term hospice modifiers mostly points to two modifiers: the GV modifier and the GW modifier. Both are used on Part B claims. The hospice agency does not add them to its own claim.
Why Medicare Uses Them
Hospice follows a different payment model than most types of care. Medicare pays hospice providers a fixed daily rate, known as a per diem, for each day a patient enrolls in hospice care. This rate covers care for the patient’s terminal illness and related conditions. If another provider also bills Medicare for that same care, Medicare would pay twice.
To stop this, Medicare checks every Part B claim against hospice election data. If the patient is in hospice, the claim is held up unless it carries the right modifier. The modifier is your signal that the claim belongs in the normal payment path, and why.
A hospice modifier does not change how much you are paid for the service. It only lets Medicare process the claim the right way.
Hospice Basics Every Biller Should Know
You do not have to be a hospice biller to bill for a hospice patient. But the modifier rules sit on top of a few basic hospice rules, so it helps to know them.
The Medicare hospice benefit is part of Medicare Part A. A patient qualifies when a physician certifies a life expectancy of six months or less if the illness runs its normal course.
The patient chooses hospice by signing an election statement. By signing, the patient gives up Medicare payment for care related to the terminal illness, with two exceptions: the hospice itself and the patient’s chosen attending physician.
The hospice sends a Notice of Election (NOE) to the Medicare Administrative Contractor (MAC), generally within five calendar days. This record is what triggers the edits on your Part B claims.
Hospice is billed in benefit periods: two 90 day periods, then an unlimited number of 60 day periods. The patient must be recertified for each one.
- Medicare pays hospice providers a daily rate according to four levels of care: routine home care, continuous home care, inpatient respite care, and general inpatient care.
- The hospice’s interdisciplinary group (IDG) writes the plan of care. It decides which conditions, services, drugs, and equipment are related to the terminal illness.
- Patients receiving hospice care can still receive Medicare-covered treatment for conditions unrelated to their terminal illness.
The hospice itself covers nursing, physician services, medical social work, counseling, home health aide care, therapy, drugs for pain and symptom control, supplies, equipment, short term inpatient care, volunteer support, and bereavement support for the family.
Who Bills What for a Hospice Patient
| Situation | Who bills | How it is billed |
| Hospice care for the terminal illness and related conditions | The hospice agency | Institutional claim (UB-04 or 837I) with revenue codes and level of care |
| Attending physician, NP, or PA who is not employed by the hospice, treating the terminal illness or related conditions | The attending’s practice | Part B claim with the GV modifier |
| Attending physician who is employed by the hospice | The hospice | Hospice claim, physician service line |
| Any Medicare provider treating a condition not related to the terminal illness | That provider | Regular claim with the GW modifier |
| Specialist or consultant who is not the attending, treating a related condition | The hospice pays under an agreement | Bill the hospice, not Medicare Part B |
The Main Hospice Modifiers at a Glance
| Modifier | What it means in plain words | Who usually uses it | Quick example |
| GV | Attending physician is not employed by or paid under arrangement by the patient’s hospice. The service is related to the terminal illness. | Designated attending physician, NP, or PA in private practice | Primary care visit to manage heart failure symptoms for a patient on hospice for heart failure |
| GW | The service is not related to the patient’s terminal condition. | Any provider or supplier treating an unrelated problem | Orthopedic care for a broken wrist in a patient on hospice for lung cancer |
The short version: GV is about attending physician services for the terminal illness. GW is about care that has nothing to do with it. Each one has rules, claim examples, and common errors of its own, so we cover them on separate pages.
How to Tell if a Service Is Related to the Terminal Illness
This is the question behind every hospice modifier. It is also where most billing mistakes begin, because billers often guess.
The hospice makes the call, not the billing office and not the outside provider. The hospice’s IDG reviews the patient’s conditions and writes the plan of care. CMS expects hospices to cover care for the terminal illness and related conditions broadly, so unrelated care is the exception, not the rule.
Here is a simple way to think about it:
- A patient on hospice for pancreatic cancer falls and breaks a wrist. The fracture is usually not tied to the cancer, so the hospice may call it unrelated.
- A patient on hospice for end stage COPD gets a chest infection. That is closely tied to the lung disease, so the hospice will likely treat it as related.
- A patient on hospice for heart failure develops a skin rash from a new soap. The hospice will decide, and the answer depends on the patient’s overall condition.
Notice that the third case has no clean answer. That is why you ask.
Steps to Confirm Relatedness
1.Call the hospice and ask for its determination on the condition you are treating. Ask for the name of the person you spoke with and the date.
2.Ask whether the hospice has a written list of unrelated conditions. Patients or their representatives can request a written addendum to the election statement that lists the conditions, items, services, and drugs the hospice considers unrelated.
3.Write the result in your visit note or billing note.
4.Pick the modifier only after you have the answer.
Your documentation should show the reason for the visit, the condition treated, and a short line that the hospice confirmed whether it is related. If an auditor reviews the claim later, that line protects you.
Where Hospice Modifiers Go on the Claim
- On a paper CMS-1500 claim, the modifier goes in Item 24D beside the procedure code.
- On an electronic 837P claim, it goes in the service line (Loop 2400), in the procedure code field, as the first modifier or in the position your payer requires.
- You can list up to four modifiers on one line. Put modifiers that affect payment first, then informational ones such as GV or GW.
- Add the modifier to every line that needs it, not only the first line of the claim.
Facility claims can work differently. Some Part A institutional claims use condition code 07, which marks treatment of a non-terminal condition for a hospice patient. Check your MAC’s instructions for the claim type you submit.
What the Hospice Reports on Its Own Claim
The hospice agency does not use GV or GW. It bills with revenue codes that show the level of care, plus HCPCS codes that show where the care was given. Knowing these helps you read a patient’s claim history.
| Revenue code | What it reports |
| 0651 | Routine home care |
| 0652 | Continuous home care |
| 0655 | Inpatient respite care |
| 0656 | General inpatient care |
| 0657 | Physician services billed by the hospice |
The hospice also reports the site of service with HCPCS codes in the Q5001 to Q5010 range, such as the patient’s home, an assisted living facility, a nursing facility, a skilled nursing facility, or a hospice inpatient facility.
Other Modifiers You May See Near Hospice Claims
These are not hospice modifiers. They can sit on the same claim line, though, and billers often mix them up.
| Modifier | What it is | How it connects |
| Q5 | Substitute physician, reciprocal billing arrangement | May appear when a covering doctor sees a hospice patient. Confirm with your MAC how to combine it with GV or GW. |
| Q6 | Substitute physician, locum tenens arrangement | Same as above. |
| GT or 95 | Telehealth service | A telehealth visit for a hospice patient still needs the right hospice relationship modifier when one applies. |
| GY | Item or service is not a Medicare benefit | Do not use GY when GW is the correct choice. They answer different questions. |
Who Needs to Understand Hospice Modifiers
- Primary care practices, because many patients keep their long time doctor as the attending when they enter hospice.
- Specialty practices such as orthopedics, cardiology, oncology, and dermatology, which may treat unrelated conditions.
- Emergency departments, urgent care centers, and hospital outpatient departments.
- Laboratories, imaging centers, and ambulance companies that receive orders for a hospice patient.
- Durable medical equipment suppliers, since related equipment is paid by the hospice and unrelated equipment is not.
- Billing companies that handle claims for many practices and need a repeatable check for hospice status.
A Step by Step Workflow for Billing Hospice Patients
Strong teams do not rely on memory. They build the check into the process. Here is a workflow that works in most practices.
1.Ask at registration. Add a plain question to your intake form: “Is the patient currently receiving hospice care?” Ask again at each visit, because patients can enter hospice between visits.
2.Verify eligibility. Look up the patient in your MAC portal or your eligibility tool. Note the hospice name, election date, and current benefit period.
3.Find the attending. Ask who the patient named as the attending physician. This tells you if GV could apply to your provider.
4.Confirm relatedness. If the condition is not clearly the terminal illness, call the hospice and record the answer.
5.Choose the modifier. Use GV for attending services tied to the terminal illness. Use GW for care that is not related. If a hospice consultant saw the patient, bill the hospice.
6.Match the diagnosis codes. The ICD-10-CM codes should support the modifier you picked and the reason for the visit.
7.Scrub the claim. Set a rule in your claim scrubber that flags any claim for a patient with a hospice flag and no modifier.
8.Track the result. Watch remittance advice for hospice related denials and send them to a named person for follow up.
Learn Basic Hospice Rules From Examples
These examples are made up, but the situations are common.
Example 1: An unrelated injury
Mr. Hale, age 78, is in hospice for advanced lung cancer. He falls at home and fractures his wrist. An orthopedic practice sees him. The biller checks eligibility, sees the hospice election, and calls the hospice. The hospice says the fracture is not part of the cancer plan of care. The practice bills the fracture care with the GW modifier on each line and notes the call in the chart. Without the modifier, Medicare would deny the claim because the patient is in hospice.
Example 2: The long time family doctor
Mrs. Reyes, age 84, is on hospice for end stage heart failure. She kept her family doctor as her attending physician, and he is not employed by the hospice. When he visits to manage her heart failure symptoms, his practice bills Part B with the GV modifier. The practice confirmed with the hospice that he is the named attending before billing.
Example 3: The consultant who bills the wrong party
A hospice patient with advanced cancer has severe pain. The hospice asks a pain specialist to consult. The specialist is not attending, and the service is related to cancer. The specialist’s office sends the claim to Medicare Part B and it is denied. The correct path was to bill the hospice under the agreement between the two. No GV or GW modifier would have fixed this claim, because the problem was the payer.
Common Hospice Modifier Mistakes and How to Prevent Them
| Mistake | What happens | How to prevent it |
| No modifier on a hospice patient’s claim | The claim denies because the patient is in hospice | Check eligibility before billing and add a scrubber edit |
| Modifier added to only the first claim line | The remaining lines deny | Add the modifier to every line that needs it |
| GW used for a related service | The claim may pay at first, then be recouped in a review | Confirm relatedness with the hospice and keep notes |
| Billing Medicare for a hospice consultant | Denial, because the hospice owes that payment | Bill the hospice under the agreement |
| Assuming your provider is the attending | GV claim denies | Confirm the attending of record with the hospice |
| Using GY instead of GW | Wrong denial reason and extra work on appeal | Use GW for unrelated care, GY only for non-covered items |
| Not rechecking hospice dates | A claim paid last month is adjusted after hospice data changes | Recheck eligibility before final billing and when working old accounts |
| Letting denials sit | Timely filing passes | Work hospice denials within days, since Part B claims must be filed within 12 months of the date of service |
If you do get a denial that should have been paid, you can ask for a reopening to fix a clerical error, or file an appeal. The first level of appeal for Medicare, called a redetermination, must be requested within 120 days of the initial determination.
How Hospice Modifiers Affect Your Revenue Cycle
One missed modifier looks small. Across a year, it adds up. Each denial costs staff time to rework, delays cash, and adds days to your accounts receivable. In a strong revenue cycle management program, hospice status is checked early, at scheduling and registration, instead of being found after the denial.
If your practice sees more than a few hospice patients, track these numbers each month:
- Number of denials tied to hospice, and their dollar value.
- First pass acceptance rate for claims with a hospice flag.
- Days in A/R for hospice related accounts.
- Appeal success rate and average time to resolve.
- Top denial reasons, grouped by cause: eligibility, modifier, wrong payer, or documentation.
These numbers show you where to fix the process. A rising denial count with a flat patient count usually means the front end check is slipping. A good RCM process treats this as a standing item in the monthly review, and the practice’s denial management plan should name who owns hospice denials.
Auditing Hospice Modifier Use
Hospice claims draw attention. Medicare contractors can review claims before or after payment, and overpayments can be recouped. The best protection is your own review. A regular medical billing audit finds problems while they are still small.
What to Check in an Internal Review
- Is there proof of the hospice status check on file, with the date?
- Does the modifier match what the documentation shows?
- For GW claims, is there a note that the hospice confirmed the service is unrelated?
- For GV claims, is it clear that the provider is the attending of record and is not employed by the hospice?
- Do the diagnosis codes support the modifier and the service?
- Is the modifier on every line that needs it?
- Did the payment and any adjustments post correctly?
A common starting point is 20 to 30 claims per quarter, or every hospice related claim if your volume is low. Sort the results by provider, by biller, and by error type. Patterns point to training needs.
What to Do With Findings
If you find an overpayment, act quickly. Medicare requires you to report and return identified overpayments within 60 days, with limited time allowed for a good faith review of what happened. Fix the cause too. That may mean a new scrubber rule, a revised intake form, or a short training session. A written internal billing audit policy, with dates and results saved, shows regulators that your practice takes compliance seriously.
Outside reviewers include MACs, Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), and the CERT program. They ask for records, so keep your eligibility checks, hospice calls, and visit notes easy to find.
Hospice Modifiers Beyond Original Medicare
Medicare Advantage
When a Medicare Advantage member elects hospice, Original Medicare generally pays for the hospice care and related services. The Medicare Advantage plan may still cover other benefits and care unrelated to the terminal illness. Where your claim goes depends on the service, so confirm with the plan before you bill.
Medicaid
State Medicaid programs have their own hospice benefit and billing rules. For patients who have both Medicare and Medicaid, the Medicare rules usually come first, but the state may need extra data. Read your state manual.
Commercial Payers
Many commercial plans have a hospice benefit, but they do not all use GV and GW the same way. Some use other codes or none. Check the payer’s provider manual or ask your provider representative, and save the answer in your payer rules file.
Documentation and Compliance Tips
- Save a screenshot or printout of the eligibility check that shows the hospice name and election date.
- Record who you spoke with at the hospice, when, and what they said.
- Make sure the visit note states the reason for the visit and the condition treated.
- Keep a copy of the election statement addendum when the patient or family provides one.
- Keep a list of local hospices and their billing contacts.
- Train front desk staff to spot the words hospice, comfort care, and end of life care in patient conversations, and to pass them to billing.
Billing a service that Medicare already paid for through the hospice can lead to recoupment. Repeated or knowing errors can raise False Claims Act concerns. Good records and a consistent process are your best defense.
How to Keep Up With Hospice Billing Rules
Rules change. Use primary sources, not blog posts, including this one, for the final word.
- Medicare Benefit Policy Manual, Chapter 9, which covers hospice coverage rules.
- Medicare Claims Processing Manual, Chapter 11, which covers hospice claims.
- Your MAC’s website, news items, and local billing guides.
- The annual CMS hospice payment rule, usually released in summer and effective October 1.
- Quarterly HCPCS updates, which can add or change modifiers.
- CMS Medicare Learning Network (MLN) hospice materials.
Review this list at least twice a year, and share changes with your billing team in writing.
Frequently Asked Questions
Q1- What are hospice modifiers in medical billing?
They are HCPCS Level II modifiers that tell Medicare how a service relates to a patient’s hospice election. The two most used are GV and GW.
Q2- Does the hospice agency use GV and GW?
No. Hospice agencies bill on an institutional claim with revenue codes and level of care. GV and GW are used by other providers on Part B claims.
Q3- Do hospice modifiers change payment?
No. They do not raise or lower the amount paid. They let the claim be processed correctly.
Q4- What happens if I forget the modifier?
Medicare will usually deny the claim as related to hospice. You can correct it and ask for reprocessing or file an appeal, as long as you are inside the time limits.
Q5- Who decides if a service is related to the terminal illness?
The hospice does, through its interdisciplinary group and plan of care. Always confirm with the hospice before you choose a modifier.
Q6- Do Medicare Advantage plans use the same rules?
Not always. Original Medicare pays for hospice and related care, while the plan may handle other care. Check with the plan before billing.
Q7- How long do I have to file a Part B claim?
Medicare Part B claims must be filed within 12 months of the date of service.
Final Thoughts
Hospice modifiers are small, but they sit at a point where billing, compliance, and patient care meet. The rules are not hard once you see the logic: the hospice is paid to cover care for the terminal illness, and the modifier shows Medicare how your service fits around that.
Build the habit of checking hospice status early, asking the hospice when you are unsure, and writing down the answer. Pair that with a clean medical billing process, regular audits, and denial tracking, and hospice claims become routine instead of a source of rework.
How PHCS Can Help With Hospice Billing and Modifier Denials?
At Proactive Healthcare Services, we check hospice status before each claim goes out, confirms with the hospice whether a service is related to the terminal illness, applies the correct modifier, and follows up on every denial until it is resolved. This keeps your claims clean and your payments on time.
