Hospice billing services for Medicare hospices and the providers who treat their patients

The hospice codes we bill most

Modifiers that matter

Payer rules to know

Top denials in hospice billing services for medicare hospices and the providers who treat their patients

What does hospice billing cover?

Medicare hospice billing covers the monthly institutional claim a hospice sends for each patient, plus the professional claims of attending physicians and the unrelated-care claims of every other provider. The hospice bills on the UB-04 or its electronic form, the 837I, with bill type 81x for a non-hospital-based hospice and 82x for a hospital-based one. Medicare pays one of four daily rates, not a fee per service.

Chapter 11, section 90 of the Claims Processing Manual returns any hospice claim that spans two calendar months, and hospices have 12 months from the date of service to file. Medicare Advantage does not change the payer: under section 30.4 the fee-for-service MAC still pays hospice claims for managed care members. Home-based skilled care outside the benefit is on our home health billing page.

What is the notice of election and when is it due?

The notice of election opens the hospice election in Medicare's system, and it is due within 5 calendar days after the admission date. 42 CFR 418.24(e) sets the 5 days, and chapter 11, section 20.1.1 defines timely as submitted and accepted by the contractor in that window. Weekends count: the manual's example admits on a Friday and makes Wednesday day 5.

A late NOE costs days. Medicare does not cover the days from admission up to the date the NOE is accepted, they are provider liability, and the patient cannot be billed. The acceptance date itself is payable. The hospice reports the uncovered days with occurrence span code 77 and reports their charges as non-covered, or the claim is returned.

An exception is possible. The hospice files the claim with span code 77 and adds modifier KX to the Q code on the earliest level-of-care line, and the MAC asks for proof. Qualifying causes in section 20.1.1 are a disaster, a CMS or MAC systems problem, a newly certified hospice still waiting for its user ID, or another event outside its control. A refusal comes back as CARC 96 with RARC MA54. No exception applies when the hospice could have corrected the NOE without waiting for Medicare systems or filed a partial NOE.

What is the election statement addendum for elections starting October 1, 2026?

For elections beginning on or after October 1, 2026, every patient gets a written addendum titled "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." 42 CFR 418.24(c) and (d) set it, and the FY 2027 hospice final rule (91 FR 49118, August 3, 2026) finalized it for all beneficiaries.

It lists the conditions, items, services and drugs the hospice considers unrelated, with a clinical explanation. The hospice provides it within the first 5 days, files it with the election statement, and updates it within 3 days of a plan of care change that affects it. Non-hospice providers and contractors can see it, so it is the first document to check when unrelated care is questioned.

How do hospice levels of care affect billing?

Each hospice day is billed at one of four levels, and each level line also needs a Q5001 to Q5010 code for where the care happened. Chapter 11, section 30.1 gives the revenue codes; 42 CFR 418.302 defines the days.

A new line starts whenever the level or location changes. Home, then general inpatient, then home again is three lines, each dated on its first day, with units in days. The day of discharge from an inpatient level is paid at the home rate unless the patient dies. Q5003, Q5004, Q5005, Q5007 and Q5008 require the facility's NPI in loop 2310E, or the claim is returned. Our Q5001 page covers the home code.

Visit lines carry no extra payment. Nursing goes on 055x with G0299 or G0300, social work on 056x with G0155, aides on 057x with G0156, and therapy on 042x to 044x, in 15-minute units. Medicare bundles them into the daily rate and the remit shows CO-97. Combined inpatient and respite days are also limited to 20% of a hospice's Medicare days (Benefit Policy Manual chapter 9, section 90.1).

How do the two routine home care rates and the service intensity add-on work?

Routine home care pays a higher rate for days 1 to 60 of the election and a lower rate from day 61. Section 30.2 counts the 60 days from admission, covered or not, and a new election within 60 days of a discharge continues the count; a gap of more than 60 days resets it. One 0651 line can span both rates. In our made-up election starting 2026-11-04, day 61 is 2027-01-03.

The service intensity add-on is paid on routine home care days in the last 7 days of life when the discharge is due to death. Under 42 CFR 418.302(b)(1) it equals the continuous home care hourly rate times direct RN or social worker time, up to 4 hours a day, or 16 units. Social worker phone calls do not count.

For FY 2027 CMS finalized a 2.3 percent payment update, a 3.2 percent market basket less a 0.9 point productivity adjustment. A hospice that misses quality data reporting loses 4 percentage points of the update under 42 CFR 418.306(b), as it has since FY 2024.

How do benefit periods, recertification and the face-to-face encounter work?

A patient gets two 90-day periods and then unlimited 60-day periods, in that order, and each period needs its own certification (42 CFR 418.21 and 418.22). With a made-up election on 2026-11-04, period 1 runs to 2027-02-01, period 2 to 2027-05-02, and period 3 starts 2027-05-03.

The written certification must be on file before the claim goes out; if it is not ready within 2 calendar days after the period starts, an oral one is needed in that window. It may be signed up to 15 days early, only by an MD or DO, with a patient-specific narrative and no checkboxes.

From the third period on, a hospice physician or hospice nurse practitioner must see the patient no more than 30 calendar days before the recertification, which here means on or after 2027-04-03, and attest in writing. Physician assistants cannot perform it. Telehealth is allowed for the encounter only through December 31, 2027 (or the end of a public health emergency if later), and such encounters must be reported on the claim from January 1, 2027.

Gaps become provider liability. For a late recertification the hospice uses span code 77, enters the real certification date in occurrence code 27 and adds condition code 85. If the face-to-face is late, the patient must be discharged and can be readmitted after the encounter. When a patient is discharged alive or revokes, the NOTR is due within 5 calendar days (42 CFR 418.28(d)), and the final claim carries occurrence code 42, condition code 52 or H2, never discharge status 20.

How do we bill physician services for hospice patients?

An independent attending physician bills Part B with modifier GV, and every other provider bills only unrelated care with GW. Chapter 11, sections 40.1.3 and 40.2 define GV as an attending physician not employed or paid under arrangement by the hospice; the attending can be a physician, an NP or, since 2019, a PA.

Medical director and IDG physician duties are in the daily rate and cannot be billed. For unrelated visits such as 99214, GW invites review, and 42 CFR 418.24(b)(3) tells patients unrelated care is exceptional and unusual. See internal medicine billing, hospitalist billing and oncology billing for visit and chemotherapy rules.

Why do other providers get CO-B9 denials for hospice patients?

CO-B9 means the patient is enrolled in hospice, and it appears when a claim for a patient with an active election has no GV or GW. X12 defines B9 as "Patient is enrolled in a Hospice." Chapter 11, section 40.2 has MACs deny professional lines without GV or GW when the Common Working File shows a hospice election, and deny related DME, supplies and therapy.

The fix depends on the cause. If the care was unrelated, add GW (or condition code 07) and resubmit. If it was related, bill the hospice. If the patient revoked, the NOTR date decides, so check dates first. Eligibility checks at scheduling and again at claim time catch most of these; the remit steps are on our CO-B9 page.

How does the hospice cap work?

The aggregate cap multiplies a per-patient amount by the number of patients a hospice served in the cap year, and the hospice repays payments above it (Benefit Policy Manual chapter 9, section 90.2). The cap year is the 12 months ending September 30. The FY 2027 final rule sets the amount at $36,174.75, the FY 2026 amount of $35,361.44 raised 2.3 percent.

Patients are counted by days: a patient with 119 days, 76 at one hospice and 43 at another, counts 0.64 and 0.36. The hospice must file its own cap notice within 5 months after the cap year ends and repay the excess, or payments are suspended. Determinations can be reopened for 3 years, and an appeal is due in writing within 180 days.

What are the most common hospice denials and how are they worked?

The common ones are CO-B9, claims returned before processing, CO-96 after a refused NOE exception and CO-97 on bundled visits, all in the table above. We check NOE and period dates, then level of care and Q codes, then diagnoses: the principal diagnosis must be the one most contributory to the terminal prognosis, not a Z-code or an unspecified debility, failure to thrive or dementia code. Redeterminations are due within 120 calendar days (42 CFR 405.942).

How we handle hospice billing

Our AAPC and AHIMA certified coders prepare the UB-04 and 837I for hospices and the professional claims for the physicians and hospitals treating their patients, with automated eligibility checks and multiple claim scrubbing rules. Our denial management team works the 835 remit.

Our numbers are a 95% clean claim rate, 97% client retention and 15 to 20% revenue recovered from denials and old A/R. Book a call and we will go through your last remittances with you, or see revenue cycle management.