Medical Billing

# Difference Between GV vs GW Modifier & Everything to Know about Hospice Modifier GW

- October 16, 2024
- Posted by Kristen Edwards

25 Aug

Medicare and Medicaid systems regularize a standardized process for allowing medical healthcare providers to facilitate healthcare, provision of medical services, billing and insurance, and almost every aspect included in the haircare industry.

To make the process simple and steady, codes and modifiers are there that help medical providers at every level. Similarly, GV and GW are HCPCS Level II Medicare Hospice Modifiers. What are they and what defines GV vs GW modifiers, here’s everything you need to know.

## What is Hospice and how is it associated with the GV vs GW modifier?

Hospice is a space where supportive and palliative care is delivered for critically ill patients and individuals with the least mobility. In order to have the reimbursements for the service rendered to these terminally ill patients at the Hospice healthcare centers, the providers need to bill the hospice contractor. These healthcare providers are paid/employed/ or are part of the Hospice.

However, if the attending physician is not a part or not an employee under the Hospice tag, but performs the services of healthcare to the patients regardless if the patient was admitted into Hospice, then the reimbursement claims for those services will be submitted to Medicare. These claims will be made along with the GV and GW modifiers, assuring that separate payments would be made.

### But How does Medicare Process GV and GW modifiers?

### Modifier GV

GV modifier is added to the claims when a patient is handled for the diagnosis related to Hospice but the physician who is involved in providing healthcare to that particular patient is not paid by or is not an employer of Hospice.

This means that if a patient is admitted to Hospice and the attending physician is not an employee of Hospice, then they will be paid through Medicare for the service related to Hospice even if they are not employed by Hospice. Also, it is important to add the GV modifier in order to ensure timely and proper reimbursements.

Here are some important things to keep in mind:

- Adding a GV modifier to claims will only be beneficial for non-Hospice physicians. Physicians employed by Hospice should submit their claims to the Hospice contractor.
- Avoid appending GV modifier in claims, when the physician is not recognized as the Hospice employer treating the patient in the Hospice facility.
- Adding a GV modifier from the Hospice contractor will only be possible if the patient is eligible for the Hospice programs and plans even if the attending physician is not an employee of Hospice.

Let’s discuss an example to learn about GV modifier more:

Suppose a patient is enrolled in Hospice for the treatment of pulmonary disease and on his visit, he goes to a doctor who is not associated with the treatment performed for pulmonary disease as a Hospice entity.

In this example, the procedure performed for the said disease by the physician who is not associated with Hospice with that certain disease. Hence, the claim will be submitted to Medicare with GV modifiers reported.

### GW modifier

GW modifiers are used in the claims when the diagnosis of a patient is not associated with the Hospice diagnosis performed through a physician who is not an employee/paid/ or employed by Hospice.

This means that when a patient is admitted to the Hospice and the attending physician is not a part of the Hospice and the patient received services that are not related to the main issue for which he was initially admitted, the provider must use the GW modifier to the CPT-10 code while they submit their claims to Medicare.

Important guidelines to keep in mind;

- GW modifiers will not be added to physicians working for Hospice as healthcare providers for a certain disease. Their claims would be submitted to hospice contractors and GW modifiers to ICD-10 codes can only be read through Medicare standards.
- If a physician is not identified as an attending physician to a patient, GW modifiers would not be used.
- Appending GW modifiers would be beneficial to the physicians when the beneficiary is a Hospice program enrollee and the physician serving them with the healthcare is not employed for the patient’s condition.

### Example to Understand:

A hospice enrolled patient goes to the physician for heart failure congestion when the attending physician is not paid by Hospice as a Hospice entity under debridement of the nail.

Here, the procedure performed by the physician was not associated with the physician’s expertise related to Hospice. Therefore, while providing claims, providers must use GW modifiers with the CPT– 11720 (debridement of the nail) code.

## Common Mistakes and Claim Denials

Utilizing the GV and GW modifiers improperly might result in claim denials, delays, or incorrect compensation. Here are a few common mistakes:

Applying Both Modifiers: Never apply both the GV and GW modifications to the same claim.

Wrong Modifier: Denials may occur from utilizing the GV modifier for terminal condition services or the GW modifier for hospice care.

Lack of Documentation: Failure to present enough paperwork can result in claim denials.

## Special Considerations for GW Modifier in Hospice Care

In some cases, separating between related and unconnected treatments for hospice care might be difficult.

### Complex Medical Conditions:

Patients with various medical issues may need therapy for non-terminal illnesses. Providers should carefully analyze and document whether these treatments are unrelated to the fatal illness in order to apply the GW modifier.

### Overlap of Conditions:

If there is a correlation between terminal and non-terminal disorders, adequate evidence is required to demonstrate why the procedure was for an unconnected condition.

## Reimbursement Implications of GV and GW Modifiers

Impact on Revenue Cycle Management

### GV Modifier:

Whenever the GV modifier is utilized, it shows that the service has connection to the terminal disease but administered by a non-hospice doctor. This may give rise to reimbursement issues if the payer has stringent hospice service requirements.

### GW Modifier:

The GW modifier indicates that the service is unrelated to the terminal condition, which may impact reimbursement rates because some insurers have special regulations for unrelated therapies during hospice care.

### Payer Policies:

Various payers may have different policies for accepting these modifications. Providers should evaluate payer-specific rules to guarantee compliance and prevent claim denials.

## Future Directions for Modifier Implementation

### Evolving Billing Practices

As healthcare grows, how people react to modifiers such as GV and GW may shift. Providers should stay educated about:

- Emerging best practice.
- Innovative billing technologies that improve accuracy and compliance.

### Research and Development

Current studies exploring the influence of modifiers on patient results and healthcare costs may result in novel recommendations or instruments to assist healthcare providers.

## Final Thoughts

GV and GW modifiers are essential for accurate billing in hospice Medicare claims. Non-hospice physicians use the GV modifiers to provide services to patients with terminal illnesses. While GW modifiers are for the services for non-terminal illness. With proper use of these modifiers, billers can reduce the number of claim denials and expect timely reimbursements. With payer-specific rules and claim procedures, billers can avoid common billing errors and navigate the complexities of hospice billing easily by maintaining compliance. It is crucial for both physicians and billers to remain updated with emerging trends and medical best practices for healthcare for effective and continuous revenue management.

## FAQs – GV vs GW Modifier

### 1. When should the GV modifier be used?

The GV modifier is utilized when a physician who does not work for the hospice offers treatment to a hospice patient, irrespective of whether the service has any connection to the terminal disease.

### 2. When should the GW modifier be used?

The GW modifier is utilized when any healthcare professional provides treatments to hospice patients that are not tied to the patient’s terminal diagnosis.

### 3. Are GV and GW modifiers only for Medicare claims?

Yes, GV and GW modifiers are generally utilized for Medicare claims because they allow Medicare to distinguish between hospice-related and non-hospice-related treatments for reimbursement purposes.

### 4. Can GV and GW modifiers be used together?

No, GV and GW modifiers do not work together. The GV modification is for services delivered by non-hospice physicians, whereas the GW modifier is for services irrelevant to terminal illness. The context dictates the use of only one modifier.

### 5. What happens if I incorrectly use the GV or GW modifier?

If the improper modifier is applied, the claim could get refused, delayed, or misprocessed. This can lead to a loss of payment or a requirement for resubmitting the claim using the appropriate modifier.

### 6. How does the hospice program affect billing?

When a patient chooses hospice care, the hospice benefit pays for the majority of terminal-care services. Services irrelevant to the terminal disease or delivered by non-hospice providers can still be invoiced to Medicare with the proper modifier (GV or GW).

### 7. Do I need to use the GW modifier on every claim for a hospice patient?

No, the GW modifier is only necessary when a hospice patient receives a service that is unrelated to their terminal disease. If the treatment is relevant to the severe circumstance, hospice ought to cover it with no modifier required.

### 8. Is prior authorization required for services with the GV or GW modifier?

Medicare does not normally require prior permission for procedures using the GV or GW modifiers. However, local coverage decisions (LCDs) may apply, and clinicians should always consult with Medicare Administrative Contractors (MACs) or similar payer-specific guidelines.

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