Physician FAQs

How can you tell when a patient has six months or less to live in order to qualify for the Medicare hospice benefit?
The Centers for Medicare and Medicaid Services (CMS) have developed guidelines for establishing a six-month prognosis for several non-cancer terminal illnesses. Those guidelines, as contained under the Hospice Eligibilitysection, are based on normal disease progression. If a patient’s disease process does not run a “normal course,” the benefits can be extended through the first recertification.

What are hospice benefit periods?
In the past, there were four benefit periods, (90, 60, 30 days, then a fourth period that was unlimited). Many patients had entered their 4th benefit period and were in fear of losing their hospice benefits if they were to remain on hospice until they died. Since the end of 1997, the benefit periods have been revised. Now the patient has 90, 90, then continuous 60 day benefit periods for physician recertification of terminality. For example, if a patient improves and is not felt to be terminal at the end of the 2nd benefit period, then the patient can come off of hospice care and be restarted when the patient’s prognosis worsens again. For the initial 90-day benefit period, both the hospice medical director and the patient’s attending physician must certify the patient. For all subsequent benefit periods, recertification is only required from the hospice medical director.

How is the attending physician reimbursed?
Attending physicians who are not employed by the hospice continue to bill Medicare for their services with the same ICD-9 and CPT codes they have previously used. If the physician is employed by the hospice caring for that patient, the hospice is billed for the level of service provided. If the physician is salaried by a different hospice and not by the hospice caring for the patient, Medicare is billed for the level of service provided. If an associate sees the patient, the attending physician of record must bill Medicare Part B for the services using either the Q5 or Q6 modifier, in addition to the GV or GW modifier. HCFA receives a record of the name of each attending physician for each hospice patient.

Can a nurse practitioner serve as an attending physician?
Section 408 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) amended the Social Security Act (Section 1861[dd][3][B]) and Section 1814(a)(7) to include nurse practitioners in the definition of an attending physician for hospice beneficiaries. Beginning December 8, 2003, Medicare pays for services, with the exception of certifying the terminal illness with a prognosis of 6 months or less, provided by nurse practitioners to Medicare beneficiaries who have selected a nurse practitioner as their attending physician. A physician will be required to certify the terminal illness and 6 month prognosis.