What would you do when a hospice patient needs a treatment that has nothing to do with the terminal disease? You can’t bill the service normally; it will trigger a denial. This is a problem that many billers struggle with.
Luckily, the solution is simple: using the GW modifier. Now, the question is when you should use this modifier, how to use it, and when to avoid it. We have created this guide to answer all these queries. So, let’s start.
GW Modifier – Description
GW modifier is defined as:
“Service not related to the hospice patient’s terminal condition.”
Let’s break this down in more detail. To some, the term “hospice” might be new. It simply means a specialized model of healthcare for people with terminal illnesses. In hospice care, healthcare providers focus more on pain management and the comfort of the patient, rather than curative treatment.
Now connect this to the definition. Modifier GW is used when a beneficiary has elected hospice, but the item or service being billed is for a condition that is outside the terminal illness. The distinction between hospice care and other services is very important to understand.
According to the Centers for Medicare and Medicaid Services (CMS) guidelines, you should bill services unrelated to the terminal illness using GW on professional claims. Whereas institutional claims should use condition code 07. If you don’t use this modifier or use it incorrectly, Medicare will not reimburse your claims.
Another important thing to note is that using GW does not create a separate fee amount of its own. CMS says claims billed with GW are processed in the normal manner. This means that even with GW, the actual CPT or HCPCS codes decide the reimbursement amount.
Appropriate Use Cases for GW Modifier
A common misconception is that every service delivered while a patient is in hospice must be paid by the hospice. So, to help you understand how to use the modifier GW properly, let’s discuss a couple of real-world scenarios in which it can be used.
Scenario 1
Suppose a patient has stage 4 lung cancer. The physicians tried their best to remove the tumor. However, despite all efforts, the cancer metastasized and could no longer be treated. The physician decides the patient should now receive hospice care. So, all care services are now billed under hospice.
However, after a few days, the patient fell, and his wrist was fractured. Now, since the fracture is completely unrelated to the cancer, its treatment will be billed with the GW modifier appended to the appropriate CPT code.
Scenario 2
Now imagine a patient has end-stage Congestive Heart Failure (CHF). Despite aggressive medical management, the disease progressed, and further curative treatment was determined to be ineffective. The physician decides the patient should now be treated under hospice care. Therefore, all services related to the CHF are billed under hospice.
A few weeks later, the patient develops a severe urinary tract infection (UTI). Since the UTI is completely unrelated to the patient’s CHF, its treatment, including prescription antibiotics and related lab work, will be billed with the GW modifier appended to the appropriate CPT code.
Accurate Usage Guidelines for GW Modifier
Here are some additional guidelines that you should follow to reduce your chances of denials:
- First, verify that the patient was in an active hospice election period on the date of service. CMS and Medicare Administrative Contractor (MAC) guidelines consistently stress checking hospice status before billing.
- Second, document why the condition is unrelated to the terminal illness and related conditions. Your documentation should clearly show and justify that the service for which you used the GW modifier is separate from terminal illness. That usually means the assessment, diagnosis, clinical reasoning, and treatment plan.
- Third, match the billing indicator to the claim type. Use GW on professional claims for unrelated services. Use condition code 07 on institutional claims for treatment of a non-terminal condition.
- Fourth, append the modifier GW to the CPT or HCPCS code of the unrelated service, not the codes used for hospice care.
Final Thoughts on GW Modifier
Let’s wrap up this guide. GW modifier is an important tool that billers can use to differentiate between hospice care and other unrelated services. However, you must use this modifier responsibly. If the service is related to the terminal illness, the modifier will not protect the claim from denial, audit scrutiny, or repayment demands.
To prevent such things from happening, it is better to get professional medical billing and coding services from specialized companies like NeuraBill.
