CMS Pub. 100-04, ch. 11, § 40.1.3

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B

payments for professional 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 independent attending physician, who is not an

employee of the designated hospice nor receives compensation from the hospice for those

services. For purposes of administering the hospice benefit provisions, an “attending

physician” means an individual who:

• Is a doctor of medicine or osteopathy, or

• A nurse practitioner (for professional services related to the terminal illness and

related conditions that are furnished on or after December 8, 2003), or

• A physician assistant (for professional services related to the terminal illness and

related conditions that are furnished on or after and January 1, 2019; and

• Is identified by the individual, at the time he/she elects hospice coverage, as

having the most significant role in the determination and delivery of their medical

care.

Hospices should reiterate with patients that they must not see independent physicians for

care related to their terminal illness other than their independent attending physician

unless the hospice arranges it.

Even though a beneficiary elects hospice coverage, he/she may designate and use an

independent attending physician, who is not employed by nor receives compensation

from the hospice for professional services furnished, in addition to the services of

hospice-employed physicians. The professional services of an independent attending

physician that are reasonable and necessary for the treatment and management of a

hospice patient’s terminal illness are not considered Medicare Part A hospice services.

Where the service is related to the hospice patient’s terminal illness, but was furnished by

someone other than the designated “attending physician” [or a physician substituting for

the attending physician] the physician or other provider must look to the hospice for

payment.

Professional services related to the hospice patient’s terminal condition that were

furnished by an independent attending physician are billed to the A/B MAC (B) through

Medicare Part B. When the independent attending physician furnishes a service related

to the patient’s terminal illness and related conditions that includes both a professional

and technical component (e.g., x-rays), he/she bills the professional component of such

services to the A/B MAC (B) on a professional claim and looks to the hospice for

payment for the technical component. Likewise, the independent attending physician

would look to the hospice for payment for services furnished that have no professional

component (e.g., clinical lab tests). The remainder of this section explains this in greater

detail.

When a Medicare beneficiary elects hospice coverage he/she may designate an attending

physician, not employed by the hospice, in addition to receiving care from hospice-employed physicians. The professional services of a non-hospice affiliated attending

physician for the treatment and management of a hospice patient’s terminal illness and

related conditions are not considered Medicare Part A “hospice services.” These

independent attending physician services are billed through Medicare Part B to the A/B

MAC (B), provided they were not furnished under a payment arrangement with the

hospice. The independent attending physician codes services with the GV modifier

“Attending physician not employed or paid under agreement by the patient’s hospice

provider” when billing his/her professional services furnished for the treatment and

management of a hospice patient’s terminal condition. The A/B MAC (B) makes

payment to the independent attending physician based on the payment and deductible

rules applicable to each covered service.

Payments for the services of an independent attending physician are not counted in

determining whether the hospice cap amount has been exceeded because Part B services

provided by an independent attending physician are not part of the hospice’s care.

Services provided by an independent attending physician must be coordinated with any

direct care services provided by hospice physicians.

Only the direct professional services of an independent attending physician, to a patient

may be billed; the costs for services such as lab or x-rays are not to be included in the

bill.

If another physician covers for a hospice patient’s designated attending physician, the

services of the substitute physician are billed by the designated attending physician under

either the reciprocal billing or fee-for-time compensation arrangement (formerly referred

to as Locum Tenens Arrangements) instructions. In such instances, the attending

physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.

When services related to a hospice patient’s terminal condition are furnished under a

payment arrangement with the hospice by the designated attending physician, the

attending physician must look to the hospice for payment. In this situation the

physicians’ services are Part A hospice services and are billed by the hospice to its A/B

MAC (HHH).

The CWF response contains the periods of hospice entitlement. This information is a

permanent part of the notice and is furnished on all CWF replies and automatic notices.

A/B MACs (B) use the CWF reply for validating dates of hospice coverage and to

research, examine and adjudicate services coded with the GV or GW modifiers.