GW Modifier for Care Unrelated to Hospice Terminal Care

Many billers think that if a patient is a Hospice patient that they cannot get reimbursed for services if they are not reimbursed by the Hospice carrier. But actually there is a modifier, GW, that indicates that the care is unrelated to the patient’s terminal condition. In order for a patient to receive Hospice services they must have a life expectancy of six months or less if the terminal illness or disease runs its normal course.

Many people mistakenly think that this means that the patient must be bed ridden or critically ill. However, that is not always the case. In fact, many hospices encourage the patients to continue with social and recreational activities as long as they are able. They try to make the patient’s last few months, or weeks as fulfilling as possible.

This in some cases means that the patient may need to see a medical provider for something that is not related to the terminal condition. For example, maybe the patient has low back pain and seeing a chiropractor gives the patient relief. Their terminal condition is an inoperable brain tumor, or an inoperable aortic aneurysm. The back pain is not related to the terminal condition. The patient receives relief from the chiropractic manipulation.

The chiropractor can still see the patient even though they are receiving hospice and the chiropractor doesn’t have to get hospice to agree to pay for the care. They can bill the patient’s insurance using the GW modifier to indicate “service not related to the hospice patient’s terminal condition”.

There are other examples of care that can be rendered that is not related to the terminal condition. Maybe the patient gets conjunctivitis and needs to see an ophthalmologist to get treatment. Again, the service is unrelated to the terminal condition, but you can’t just ignore the conjunctivitis.

For me the problem is that I use the GW modifier so infrequently that when I need it I can’t remember which modifier it is. So I decided to make it an entry in my rolodex so that when it comes up, I can find it easily! Hey, whatever works.

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Submitting Out of Network Claims

If you are trying to submit claims for a provider who is out of network with the insurance carrier you will most likely run into some problems. For example, if you need to call on the claim you may find that the insurance carrier will not even speak to you since you are out of network. This makes following up on the claim difficult.

Some wonder why you would want to follow up on a claim that is out of network. Sometimes it is not the provider’s choice to be out of network. Or possibly they are trying to help the patient out. In our case, it was an inpatient drug rehab that just opened, still applying to be in network, but accepted the patient as an insurance patient. They had us submit the claim but they are waiting for the payment.

We submitted the claim and then called 2 weeks later to be advised the claim wasn’t on file. We then faxed them the claim and called again 1 week later. Now we were told the claim was received and was in process. Fortunately we didn’t rest on that information. We called again 1 week later to find that the claim was ‘lost’. Now I couldn’t figure out how it could be lost since we were told it was received and in process, but this new person was now telling me that she was sending it back for processing and ‘telling them where to find the claim”.

The funny thing was that we received a letter that day with the claim being returned stating that the type of bill was not a valid type of bill code. Isn’t it amazing that we were told such different information when we called? Well our type of bill certainly was valid, but it turns out that Blue Cross just requires a different type of bill. Now we’ve resubmitted the claim with the new type of bill and you can bet we will keep calling until payment is made.

There are other problems that you can run into when submitting out of network claims. In some cases patients have no out of network benefits which means no payment will be made on the services. Usually out of network claims are paid directly to the patient and this may not be a problem for you if you are just verifying if the claim was paid. If you are waiting for the payment then it can be helpful to know when the patient is receiving the money.

For those of us who are responsible for submitting out of network claims for providers we just have to be diligent in following up on the claims. It is not an easy task but if you just stay on top of it, it can be done.

ICD10 Codes – The Shocking Truth

October 2013 seems a long way away with little need to prepare now for the changes from ICD9 to ICD10 codes but I recently learned the shocking truth. The Healthcare Billing and Management Association held a conference in Boca Raton this month with a session attended by approximately 200 medical billers on the new ICD10 codes. Even though I have looked into the changes and even written on them, I was shocked to hear all that is really involved. We all need to start paying attention now.

My original questions revolved around whether all doctors will be expected to start using ICD10 codes on a specific day and will all the insurance companies be ready to accept them on that same day or will it be more of a transitional thing like the NPI numbers were.

My first surprise was that ICD10 codes are already in effect in all the rest of the world. Other countries have been using them for years. We are way behind the times with regard to the rest of the world.

My second surprise was that ICD9 codes are not just being expanded. ICD10 codes are totally different than ICD9 codes. We won’t just add another number and there aren’t just a few small changes. ICD10 codes will identify much more information about the visit than ICD9s do. ICD10 codes will contain an expansion of disease classification with greater specificity. They will be much more detailed and will help identify fraudulent billing practices. There will be no 1 to 1 crosswalk. This means that a 309.28 will not equal a A40258Z. You won’t take an ICD9 and turn it into an ICD10. They are completely different.

My next thought was how are my doctors going to learn all these codes? We bill many small specialty practices. Many of our chiropractors still do not understand the requirements by Medicare for the ICD9 codes. How are they ever going to get the ICD10 ones right? How are our psychiatrists, psychologists and social workers going to learn ICD10 coding? Most of these are single practitioners who work alone and do not hire a coder.

ICD10 coding will require more clinical information such as “did the patient use tobacco”, “did the patient use alcohol”, “which finger was cut”, “which part of the finger”, “was the nail damaged”. The new codes will contain alpha characters as well as numeric. The number 1 can mean 15 different things. It is estimated that it will require 24 – 40 hours of classroom education to understand the concepts of ICD10 coding.

Another consideration with the codes now using alpha characters as well as numeric is whether your software will allow you to use alpha characters. If you are using a web based software this won’t be a problem, but if you have a server based software, you will want to check with your vendor and make sure you will be able to submit alpha characters in diagnosis codes.

The speaker felt that unspecified codes may be a problem as insurance carriers have yet to tell us if they will pay on unspecified codes with the new changes. Pre-authorization policies will have to be rewritten. Workers comp is not subject to ICD10 changes so some companies say they will not process the ICD10 codes. For a period of time both ICD9 and ICD10 codes will be in effect. Does this sound confusing enough to the average biller yet?

Then came the bombshell. Insurance carriers are not ready for ICD10 codes and most of them won’t be ready. Many have announced that they will try to translate the ICD10 code back into an ICD9 code to pay the claim. This means doctors will be translating the ICD9 codes they are familiar with into a new unfamiliar ICD10 code and the insurance carriers will be translating this ICD10 code back into hopefully the same ICD9 code to pay the claim. I can only imagine the problems this will present.

As one of the speakers said “Hold onto your butts! It’s going to be a rough ride!”