Denial Reason Code PR B9: Patient is enrolled in a Hospice.
Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.
The following situations require a modifier be applied to the claim prior to submission.
• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
• Claim should be submitted with modifier GV.
• If claim was submitted with the GV modifier, check patient’s file to verify that the attending physician is not employed by the hospice provider.
• Services not related to the hospice patient’s terminal condition:
• Claim should be submitted with modifier GW.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient’s terminal condition.
• If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.
Common Reasons for Message
- Patient is enrolled in Hospice on date of service
- Medicare Part B only pays for physician services not related to Hospice condition and not paid under arrangement with Hospice entity
- Patient’s Common Working File (CWF) has not been updated to show Hospice election has been revoked
Next Step
- Append Hospice modifier if appropriate
- Modifier GV– Attending physician is not employed or paid under agreement by patient’s Hospice provider
- Modifier GW– Condition not related to patient’s terminal condition
- Submit Appeal request – Items or services with this message have appeal rights
Items & Services Included in the Hospice Benefit
The Medicare hospice benefit includes these items and services to reduce pain or disease severity and manage the terminal illness and related conditions:
- Services from a hospice-employed physician, nurse practitioner (NP), or other physicians chosen by the patient
- Nursing care
- Medical equipment
- Medical supplies
- Drugs to manage pain and symptoms
- Hospice aide and homemaker services
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Dietary counseling
- Spiritual counseling
- Individual and family or just family grief and loss counseling before and after the patient’s death
- Short-term inpatient pain control and symptom management and respite care
Medicare may pay for other reasonable and necessary hospice services in the patient’s POC. The hospice program must offer and arrange these services
Learn More…
Denial Reason CO-50: Non-Covered Services
Decoding Common Denials: Denial Code CO-97
