An 81-year-old patient with end-stage heart failure elects the Medicare hospice benefit on a Tuesday. On Thursday she sees her internist of fifteen years, who adjusts her diuretic and talks with her daughter about what to expect. The following Monday she sees a dermatologist about a bleeding lesion on her forearm. Both offices bill Medicare as usual. Both claims deny with CO-B9, patient is enrolled in a hospice. Both billers assume the visits are unpayable and write them off.
Both visits were payable. The internist was the patient's designated attending physician and should have billed with modifier GV. The dermatologist was treating something unrelated to the heart failure and should have billed with modifier GW. Hospice billing for physicians comes down to those two questions, asked for every visit: is this clinician the attending the patient named when she elected hospice, and is this service related to the terminal illness? Get the two answers right and the claim pays; guess, and it either denies or, worse, pays when it should not have.
This piece explains what the hospice election does to Part B coverage, who the attending physician is and how that changed in 2019, when GV and GW apply, how the hospice itself pays for the rest, and how to know a patient is on hospice before the claim goes out.
Key takeaways
- When a patient elects hospice, Medicare Part B stops paying physicians for care related to the terminal illness, with one exception: the attending physician the patient designated, who is not employed by the hospice.
- Modifier GV means "I am the designated attending and this service is related to the terminal illness"; modifier GW means "this service is unrelated to the terminal illness," and any physician can use it.
- A physician who is neither the attending nor treating an unrelated condition is paid by the hospice under an arrangement, not by Medicare, and should not bill Part B at all.
- CO-B9 is not a final answer; it is a prompt to determine which modifier, if any, applies and to resubmit.
What the hospice election changes
The Medicare hospice benefit is a Part A benefit. When a beneficiary with a prognosis of six months or less elects it, the hospice receives a per-diem payment and takes responsibility for all care related to the terminal illness and related conditions: nursing, medications, equipment, aides, social work and physician services. In exchange, the beneficiary waives Medicare payment to anyone else for treatment of the terminal illness and related conditions. Care for conditions unrelated to the terminal illness is still covered by Medicare in the ordinary way.
The one carve-out on the physician side is the attending physician. At election the patient may name a physician, nurse practitioner or, since January 1, 2019, a physician assistant as the attending: the clinician the patient identifies as having the most significant role in determining and delivering medical care. The attending can keep seeing the patient for the terminal illness and bill Medicare Part B directly, provided the attending is not employed by the hospice or paid by the hospice for those services. The election form has a space for the attending's name, and the hospice records it.
Two boundaries on the attending role matter for billing. An NP or PA attending can manage the patient and bill with GV (paid at the usual 85 percent of the fee schedule), but cannot certify or recertify the terminal illness; only a physician can. And the attending is one person, not a practice. If the patient named Dr. A and Dr. A's partner Dr. B sees the patient for the terminal illness, Dr. B is not the attending and cannot use GV. The patient can change the attending by signing a new designation with the hospice.
GV, GW and the third case
Every Part B professional claim for a hospice patient falls into one of three situations, and the modifier tells the MAC which one.
| Situation | Who is billing | Modifier | Who pays |
|---|---|---|---|
| Care related to the terminal illness by the designated attending, not hospice-employed | Attending physician, NP or PA | GV on each line | Medicare Part B, through the MAC |
| Care unrelated to the terminal illness, by anyone | Any physician or practitioner | GW on each line | Medicare Part B, through the MAC |
| Care related to the terminal illness by a physician who is not the attending (a consultant, a covering partner) | The hospice, on its claim, or the physician bills the hospice under a contract | None; do not bill Part B | The hospice, from its per diem |
| Care by a hospice-employed physician, including the hospice medical director | The hospice | None on a Part B claim | The hospice |
Return to our two patients. The internist is the named attending, and diuretic management for end-stage heart failure is plainly related, so the office visit is 99214-GV. The dermatologist is not the attending and the forearm lesion has nothing to do with heart failure, so the biopsy is 11102-GW and the visit, if separately billable, is 99213-25-GW. Had the patient instead been sent by her attending to a cardiologist to adjust the same heart failure regimen, the cardiologist's visit would be related care by a non-attending, and the cardiologist would need an arrangement with the hospice to be paid.
The modifiers go on every line of the claim, including procedures, injections and any E/M. A claim with GV on the visit and nothing on the injection will pay the visit and deny the injection.
Related or unrelated: who decides and how to document it
The hospice decides what is related, and it decides broadly. Medicare's long-standing position, restated in the hospice payment rules, is that the hospice is responsible for virtually all care a terminally ill patient needs, and that unrelated conditions should be exceptional. Diabetes in a patient dying of pancreatic cancer is related. Hypertension in a patient dying of heart failure is related. A fractured wrist from a fall in a patient with dementia is often judged related, because falls are part of the trajectory. A new melanoma in a patient with end-stage COPD is unrelated.
When you bill GW, your note should say why. One sentence does it: "This condition is unrelated to the patient's hospice terminal diagnosis of end-stage COPD." If there is any doubt, call the hospice before the visit and ask; the hospice case manager can tell you in a minute, and the answer determines whether you bill Medicare, bill the hospice or do not get paid. We have seen offices bill GW on chemotherapy-related visits for a patient whose hospice diagnosis was the same cancer. Those claims paid, and they became an overpayment when the MAC reviewed them.
The attending's claims need less justification, because relatedness is expected, but the note should reflect the attending role: managing symptoms, coordinating with the hospice team, discussing goals. Care plan oversight for a hospice patient is separately billable by the attending with HCPCS G0182 when the physician spends 30 minutes or more in a calendar month on plan review and communication with the hospice team, and the time must be documented by date.
Medicare Advantage patients on hospice
When a Medicare Advantage enrollee elects hospice, Original Medicare pays for the hospice care, and the enrollee's other Medicare-covered services are also paid by Original Medicare rather than the plan, with the plan continuing to cover only supplemental benefits. For the physician office that means the GV and GW claims go to the MAC, not to the MA plan, for the duration of the election. A claim sent to the plan out of habit will be denied or, occasionally, paid and later recouped.
The exception was the hospice component of the Value-Based Insurance Design model, under which participating MA plans covered hospice themselves from 2021 through 2024. CMS ended that component on December 31, 2024, so in 2026 the rule is uniform: hospice enrollees' Medicare claims go to fee-for-service Medicare.
Knowing before the claim goes out
The CO-B9 denial exists because offices find out about the election from the remittance. There is a better place: the eligibility response. Medicare's eligibility system returns hospice election periods, including the start date and the hospice provider, and most clearinghouse 270/271 eligibility checks display them. A front desk that runs eligibility two days before the visit will see the election and can flag the encounter for the coder. For Medicare Advantage patients the MA plan's eligibility response may not show it, so check Medicare directly when the patient is frail or the chart mentions hospice.
A worked recovery. A five-physician internal medicine group asked us to look at 63 CO-B9 denials from one quarter, about $9,400 in allowed charges. Thirty-one were visits by the named attending for related conditions: resubmitted with GV, paid. Nineteen were visits for clearly unrelated problems by various physicians: resubmitted with GW and a note statement, paid. Nine were related care by partners covering for the attending: not payable by Medicare, and the group now routes those patients back to the attending or arranges coverage with the hospice. Four were dates of service after the patient had revoked hospice, where the denial itself was wrong; those were appealed with the revocation date. The write-offs the group had planned were about four times what it actually lost.
Questions we hear
The hospice says our physician is not listed as attending, but the patient says she is. Who is right?
The hospice record controls the claim. Ask the hospice to have the patient sign an updated attending designation; the change is effective from the date signed, not retroactively. Until then, GV claims from your physician will deny, and the visits are only payable if unrelated (GW) or covered by an arrangement with the hospice.
Can we bill the patient when Medicare denies with CO-B9?
Not for related care that the hospice is responsible for; the patient has waived Medicare coverage but has not agreed to pay you privately, and the hospice benefit is meant to be complete. The right path is to bill the hospice under an arrangement, or accept that the service belongs to the hospice team. An Advance Beneficiary Notice does not fit this situation, because the service is not a Medicare non-covered service; it is covered, by the hospice.
Our NP is the designated attending. Can she sign the recertification?
No. An NP or PA attending can manage care and bill with GV, but certification and recertification of terminal illness require a physician: the hospice medical director or physician member of the hospice team, plus the attending physician for the initial certification if the attending is a physician. When the attending is an NP, the hospice physician certifies alone.
What to do this week
- Pull every CO-B9 denial from the last 12 months and sort it into the three situations in the table: attending and related, unrelated, or non-attending and related.
- Resubmit the first two groups with GV or GW and a one-line relatedness statement in the note; Medicare's timely filing limit is 12 months from the date of service, so the oldest ones need to go first.
- Add "hospice election on file" to the eligibility check script so the front desk flags the encounter before the visit, and add a hospice status field to the chart banner if your system allows it.
- Write down which of your physicians is the named attending for each hospice patient, and route related visits to that person.
- If your physicians regularly consult on hospice patients for related conditions, ask the local hospices for a written arrangement so that work is paid rather than written off; our medical billing team can help set up the invoicing.
