Hospice billing operates under a distinct Medicare Part A benefit structure that's unlike any other service line. Four levels of care, a daily rate model, election and revocation rules, and strict certification requirements; all of it has to be right before you submit. The financial stakes here are real: a recurring gap in this area adds up to lost or delayed revenue every month.
If you're working through these issues, our specialty billing services can help you address them systematically.
Medicare reimburses hospice at four levels, each with its own revenue code and daily rate:
General Inpatient Care is the most audited hospice level. CMS requires that GIP be provided for pain control or acute or chronic symptom management that can't be managed in the home setting. "Couldn't be managed at home" needs to be explicit in the nursing notes, not implied.
Common GIP denial reasons: the documentation shows the patient was in GIP for caregiver exhaustion (that's IRC, not GIP), or notes don't show ongoing pain or symptom management requiring that level of intensity.
To bill hospice, the patient must have elected the benefit by signing an election statement. That statement must include the specific hospice chosen, the starting date, and acknowledgment that the patient understands the hospice benefit waives their right to other Medicare-covered services for the terminal diagnosis.
Certification of terminal illness must come from the attending physician and hospice medical director, stating the patient has a life expectancy of six months or less if the illness runs its normal course. This has to be documented before you bill.
The first two benefit periods are 90 days each. After that, the hospice can certify for unlimited 60-day periods. At each recertification, a face-to-face encounter with the patient is required, a hospice physician or nurse practitioner must personally assess the patient before the third and subsequent benefit periods.
Missing the face-to-face requirement means you can't certify the patient for the next period. And a gap in certification means a gap in your billing. Track these dates rigorously.
Palliative care provided outside the hospice benefit uses standard E&M codes. The key difference: the patient hasn't elected hospice, so they retain all their Medicare benefits. Palliative care visits bill as regular outpatient or inpatient E&M depending on the setting.
There's a growing push to establish separate palliative care codes, but for now, most palliative care visits are billed under time-based E&M (99202–99215 for outpatient, 99221–99223 for inpatient). Concurrent care (billing palliative care alongside the primary treating physician) is allowed when the palliative care service is distinct and not duplicative.
Medicare requires hospices to provide at least 5% of total care hours through volunteers. This isn't a billing issue directly, but hospices that fall below the threshold face reimbursement reductions. Track volunteer hours as carefully as clinical hours.
See how Rcmaxis handles the full scope of Hospice & Palliative Care billing on our Hospice & Palliative Care billing services page.
Hospice reviews concentrate on three questions. Did the patient meet the terminal prognosis requirement and was the certification signed on time? Was the level of care billed the level actually provided? And is the election statement complete? General inpatient care draws the most scrutiny because the record has to show symptoms that couldn't be managed at home, in specific clinical terms, not a general statement of need. A 3-year lookback with even a modest error rate can turn a small per-claim gap into a sizable repayment demand, which is why a quarterly self-check is worth the time.
Each recertification adds another test, including the face-to-face encounter after the first two benefit periods. A late or missing certification can void payment for the days it covers. Contractors can look back three years, and the daily-rate model means a level-of-care error is repeated for every day of the stay, so the dollars add up quickly.
Hospice payment depends on dates. The initial certification, each recertification, and each face-to-face encounter have due dates, and a late one can cost the days it covers. Build a calendar in your system that shows, for every patient, the next certification date, the next face-to-face date, and the person responsible. Review it weekly.
Include the narrative that supports the terminal prognosis. A recertification with a thin narrative, or one copied from the last period, is a common finding. Ask physicians to write a few sentences about the patient's decline, including function, weight, symptoms, and recent events, in their own words.
Every level of care has to be supported by what the patient needed on that day. For general inpatient care, write the specific symptom, what was tried at home, and why it couldn't be managed there. For continuous home care, document the crisis and the hours of nursing care. For respite, note the caregiver's need and the dates.
Review level-of-care changes weekly. When a patient moves from one level to another, confirm the orders and the notes match the dates on the claim. A mismatch between the notes and the billed days is the sort of error that repeats across an entire stay.
The volunteer hours requirement doesn't show up on a claim, but it affects payment. Track volunteer time each month against the total care hours, and act early if the ratio is drifting. The same goes for any other program-level requirement. A small monthly report keeps those items visible before they turn into a payment reduction.
Pull a handful of new admissions each month and check the election statement and certification against the requirements: signatures, dates, and required content. Fix any gaps right away, since missing pieces are easy to correct early and hard to fix after the claim has been billed.
Routine home care, continuous home care, inpatient respite care, and general inpatient care, each with its own revenue code and daily rate according to the article. Routine home care is the most common level.
The first two benefit periods are 90 days each, and after that the hospice can certify unlimited 60-day periods. A face-to-face encounter is required at each recertification once the patient reaches the later periods.
No. The article explains that palliative care outside the hospice benefit uses standard E/M codes, and the patient hasn't elected hospice, so they keep all their regular Medicare benefits.
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