A Medicare beneficiary may choose to receive hospice care after a doctor certifies that they are terminally ill, meaning they have a life expectancy of 6 months or less. Patients who choose hospice care agree to comfort care (palliative care) instead of care to cure their illness. These patients sign a statement indicating that they have selected hospice care, and in doing so, do not receive certain Medicare benefits related to the treatment of their terminal illness and related conditions.
Durable Medical Equipment (DME) and Hospice Guidelines
Hospice is a Medicare Part A benefit. DME provided to Medicare hospice patients is included in the per diem rate paid to hospice providers. Therefore, any billing for DME supplied to a hospice patient will be denied as inclusive to the patient’s hospice care services.
DME, including surgical dressings, may be supplied to a hospice patient and reimbursed by the DMEMAC if the item provided is not related to the hospice patient’s terminal condition. When this occurs, the GW Modifier* should be appended to the applicable HCPCS code.
*GW Modifier – Service not related to the hospice patient’s terminal condition.
GW Modifier for Surgical Dressings
If the GW Modifier is used for surgical dressings, it is important that the documentation reflects that the condition being treated by surgical dressings is unrelated to the hospice patient’s terminal condition. This may not always be appropriate when it comes to surgical dressings. Surgical dressings are intended for chronic wounds and hospice-related conditions such as malnutrition and dehydration are likely to be related to the state of a chronic wound.
Surgical dressings may be a covered service for hospice patients if the condition being treated by the surgical dressings is unrelated to the hospice patient’s terminal condition, represented by the GW modifier. When this occurs, the documentation should support the claim that the condition being treated is unrelated to the terminal condition.
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance with ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.