Physician Billing for Medicare Hospice Patients
To understand physician billing for hospice patients, first understand that hospice, unlike any other Medicare process, is a patient-based benefit. When a patient selects hospice, all the choices are based upon patient-centered care and preferences.
Upon referral to hospice, the patient elects to cease curative treatment for the terminal diagnosis. The attending physician and the hospice medical director or team physician must certify that the patient has a "medical prognosis that his or her life expectancy is six months or less, if the illness runs its normal course."
All patient care not related to the terminal diagnosis continues to be billed directly to Medicare using the appropriate billing codes.
Physician Service Categories
Once a Medicare patient elects hospice, care related to the terminal diagnosis is paid directly by the Centers for Medicare and Medicaid Services (CMS) to the hospice provider. Physician services are billed by the hospice according to the nature of the service performed.
Attending Physician Services
The hospice attending physician is an MD, DO, PA or NP who may or may not be an employee of the hospice.
An interdisciplinary hospice team includes a physician who oversees elements of the patient’s care. In addition, a hospice patient may elect to have their primary care physician (PCP), another doctor or a physician assistant/nurse practitioner be their attending physician.
If the selected clinician agrees to be the hospice patient’s attending clinician, any focused treatment related to the patient’s terminal status that this clinician provides can be billed to Medicare directly. Only an attending clinician who is not employed by the hospice can bill Medicare Part B for hospice care using the CPT E/M code.
If the hospice physician serves as the attending physician, all services related to the terminal condition are billed to Medicare by the hospice, not directly by the physician. The patient’s PCP/other clinician is kept informed of the patient's status by the hospice team and contributes to the dialogue but does not assume any direct care related to the terminal diagnosis.
Following Physician Services
The attending MD or DO (although not a PA or NP) may opt to be the patient’s following physician, responsible for providing actual hospice care, i.e. writing orders, conferring with the hospice team nurse and giving direction.
Non-Attending (Consulting) Physician Services
In cases where the patient requires services related to the terminal condition by a physician who is not the attending physician, this specialty physician must have a contractual agreement with the hospice for their services. Payments toward any treatment or care services related to the patient’s terminal illness and provided by a specialist contracted with the hospice are the responsibility of the hospice, and not Medicare Part B or Part A.
Administrative Activities
Administrative or supervisory activities include establishing, reviewing or updating plans of care, supervising the implementation of care, etc. These services are performed by a medical director or physician employed by the hospice and are included in the hospice payment rate. In other words, they are covered by the Medicare hospice benefit. No additional billing occurs for administrative activities.