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.
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.
The billing gaps most practices don't catch until they show up as denials. Get the checklist — free, no spam.
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