CMS Transmittal R13074CP (CR 13882), § Policy

B. Policy: The principal diagnosis reported on the claim should be the diagnosis most contributory to the

terminal prognosis. When any of the diagnosis codes listed on the MCE unacceptable principal diagnosis list are

reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice

diagnosis. Additionally, when any of the ICD-10-CM diagnosis codes that cannot be used as the principal

diagnosis according to ICD-10-CM Coding Guidelines that require further compliance with various ICD-10-

CM coding conventions (e.g., etiology/manifestation) the claim will be returned to the provider for a more

definitive hospice diagnosis.

The codes in Attachment A would cause the claim to return to provider, as these codes are unacceptable as

principal diagnosis under the Medicare Hospice benefit. Unspecified codes are only to be used when the

medical record, at the time of the encounter, is insufficient to assign a more specific code. However, it is

recognized that the underlying condition causing the disease may be difficult to code because the medical

record may not provide sufficient information. Hospice providers are encouraged to look at the coding

conventions under the disease classification for coding conditions on hospice claims. If any of these diagnoses

are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice

diagnosis.

Liability for Claim Denials during a Hospice Election

It is the responsibility of all Medicare-certified providers to check the Medicare status of each Medicare

beneficiary when rendering and billing for services, a claim missing the GW or GV modifier or condition code

07 would be denied as provider liability. Please see below:

• GV modifier- Indicates that the attending physician is not employed or paid under arrangement by the

patient’s hospice provider. This modifier is used by the attending physician when the services are

related to the patient’s terminal condition and not paid under arrangement by the patient’s hospice

provider

• GW modifier- Indicates the services provided are not related to the hospice patient’s terminal condition

• Condition code 07- Indicates a treatment of a non-terminal condition, not related to the hospice

patient’s terminal condition