Doctors, nurse practitioners, and physician assistants can and should be paid for covered work they perform for patients enrolled in hospice. Yet hospice enrollment continues to create confusion for medical practices. A claim is denied because the patient is receiving hospice, the billing staff assumes Medicare will not pay for outside medical care, and sometimes the practice simply stops billing for that care.
That is a mistake.
Hospice enrollment does change how Medicare pays for some services, but it does not mean that a patient loses access to physicians or other practitioners outside the hospice. In many cases, the difference between a denied claim and a properly paid claim comes down to understanding whether the service is related to the patient’s terminal illness and using the correct Medicare modifier.
This issue is receiving renewed attention. Beginning October 1, 2026, Medicare requires hospices to routinely provide every newly enrolling Medicare patient with a Hospice Election Statement Addendum. The addendum identifies conditions, services, items, and medications the hospice considers unrelated to the patient’s terminal illness and related conditions. The information is also maintained so it can be made available to non-hospice providers and Medicare contractors.
For community physicians, this should make it easier to understand where hospice coverage ends and ordinary Medicare coverage may continue.
First Determine Whether the Care Is Related to Hospice
The key question is not simply whether the patient is enrolled in hospice. It is whether the service being provided is related to the patient’s terminal illness and related conditions. Consider a patient receiving hospice care for pancreatic cancer who is injured in a motor vehicle accident. Treatment of an accident-related fracture may have nothing to do with the terminal illness. Medicare can continue to pay for medically necessary covered services unrelated to the terminal illness through the patient’s regular Medicare benefits. The distinction is broader than simply comparing diagnosis codes. Medicare expects hospice to provide or arrange virtually all care related to the terminal illness and related conditions. Providers should therefore coordinate with the hospice when there is uncertainty about whether a condition or service is considered related.
Once that determination has been made, the coding solution is relatively straightforward.
Unrelated Care: Think GW
When a physician or other eligible practitioner provides a service that is not related to the patient’s terminal illness and related conditions, the Medicare claim should generally include the GW modifier.
GW tells Medicare:
This service is not related to the hospice patient’s terminal condition.
The claim should also contain the diagnosis that accurately supports the service being provided. For example, an orthopedic physician treating an unrelated fracture, an ophthalmologist treating an unrelated eye condition, or another clinician treating a clearly unrelated medical problem may be able to bill Medicare normally with the GW modifier. Without the appropriate hospice modifier, Medicare may deny an otherwise payable professional claim simply because its records show that the beneficiary is enrolled in hospice. If a medically necessary, genuinely unrelated service is submitted with the appropriate diagnosis and GW modifier but is still denied because of hospice enrollment, the provider should investigate the denial and, when appropriate, appeal it rather than assuming that hospice enrollment automatically prevents payment.
Hospice-Related Care by the Patient’s Attending Practitioner: Think GV
A hospice patient may also designate an attending physician, nurse practitioner, or physician assistant who is not employed by or paid under an arrangement with the hospice. That practitioner may continue to provide professional services for the treatment and management of the patient’s terminal condition. For eligible professional services related to the terminal illness, the independent designated attending practitioner generally bills Medicare using the GV modifier.
GV tells Medicare:
This service is being provided by the patient’s designated attending practitioner, who is not employed by or paid under arrangement with the hospice.
This distinction is important. Other clinicians generally cannot independently bill Medicare Part B for services related to the terminal illness simply by adding GV. Hospice-related services outside the designated independent attending practitioner’s professional services are ordinarily the responsibility of the hospice and must be provided directly or under an arrangement with the hospice.
An Easier Conversation Beginning October 1
The new Hospice Election Statement Addendum should help physicians and hospices coordinate this care more effectively. Rather than discovering hospice enrollment only after a claim is denied, an outside practice caring for a hospice patient can contact the hospice when the relationship of a service is unclear. The addendum provides additional documentation of the hospice’s determination regarding conditions, services, items, and drugs it considers unrelated to the terminal illness. That does not eliminate every judgment call, but it gives physicians, patients, hospices, and Medicare contractors a clearer starting point.
Medicare also recognizes other physician services that may be important in advanced illness, including advance care planning under CPT 99497 and 99498 and hospice care plan oversight under HCPCS G0182, when the individual requirements for those services are met.
The larger message is simple: hospice enrollment does not mean physicians stop getting paid.
For many professional claims, understanding the patient’s hospice status, coordinating with the hospice, determining whether the service is related or unrelated, and using GV or GW appropriately can prevent avoidable denials. For questions about coordinating care for hospice patients in the Houston area, or for more information about working with Avatar Hospice, please feel free to contact our team.
Working With Avatar Hospice
Good hospice care depends on good communication between the hospice team and the physicians and practitioners who continue to care for the patient.
Avatar Hospice serves patients throughout Greater Houston and The Woodlands with a team available to support patients, families, and referring providers throughout the course of care. If you are caring for a patient who may benefit from hospice, or if you have questions about coordinating care for a patient already enrolled with Avatar Hospice, our team is available to help.
We welcome the opportunity to work alongside you, support your patients, and make hospice coordination as straightforward as possible.
