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By: Mark Cifarelli, PT
Director of Physical Therapy Clinical Services
Therapy’s role in hospice care can be confusing due to a lack of understanding and misinformation. To provide clarity on how this all works, let’s start by talking about the difference between hospice and palliative care.
Palliative care is for an individual with what is considered a terminal illness. They will receive treatment for the symptoms of the illness, as well as treatment for the illness itself. Hospice is for an individual with a terminal illness when the doctor feels that if left to run its natural course, the person will succumb to their illness in six months or less. They can receive treatment for their symptoms but not a cure for the illness directly. So, with palliative care, an individual with cancer might receive chemotherapy and treatment to control pain; under hospice, they would receive treatment for the pain but not chemotherapy. This is a bit simplified, but it’s the basic concept.
So, where does therapy fit in to this? The individual, whether of hospice or palliative care, is entitled to receive care to maintain and/or improve their quality of life. With palliative care, the patient still receives care for the terminal illness and the related issues from that diagnosis. This means therapy would be a part of their care. The way the Medicare regulations are written for hospice—which most insurers follow—is that hospice must provide all care that is related to the diagnosis that qualifies the patient for hospice. So, if therapy is needed to treat the qualifying diagnosis, then hospice would have to arrange, manage, and pay for the therapy services. The reality though is that there are very, very few terminal illnesses that therapy would treat. In most cases, therapy would be treating conditions that are not terminal illnesses, and so therapy care would not be provided by hospice. Therapy can be provided in the same manner as it would if the patient wasn’t on Hospice.
In the Medicare Claims Processing Manual, in Chapter 11, Section 50 – Billing and Payment for Services Unrelated to Terminal Illness, it states: “Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider using professional or institutional claims for non-hospice Medicare payment.” This is typically most of what therapy would do. To clarify, with Medicare, that the treatment was for a patient under a hospice stay, but the treatment was not for their terminal illness. Therapy simply adds a modifier to the bill, in this case, a -GW or -07 depending on the setting. Medicare has many modifiers for different situations.
As simple as this sounds, there can still be questions or concerns, such as:
- Can I still qualify for hospice if I am receiving therapy services?
Qualifying for hospice is independent of whether someone is receiving therapy services. Receiving services prior to electing hospice or being picked up for therapy after hospice starts will have no effect on the hospice stay.
- Will hospice payment be denied?
As long as you qualify for hospice, hospice will be covered. Therapy services cannot and will not trigger a denial. There is no reason to stop hospice care due to therapy starting.
- Will therapy services payment be denied, and if so, will I have to pay for it?
Therapy will not be denied because someone is under a hospice stay, as the regulation above states. If that were not the case, and therapy was not permitted to bill for services, they it would be a violation, hence illegal, to bill the patient for that care. Luckily, that is not the case, and patients can receive therapy services, paid under Medicare Part B, while they are on hospice.
As with any care during a difficult time, especially when the diagnoses can be so complex, there can be subtleties to how care is provided. Always check with your insurance provider, talk to all the individuals involved in the care, and don’t be afraid to question. As healthcare professionals, we need to be able to answer questions with facts and clarity. We should never resort to fear-mongering and misinformation. We are here to provide the best care possible, to the full extent as someone is entitled, and not to create more anxiety or stress.
References
Medicare Claims Processing Manual, in Chapter 11, Section 50 – Billing and Payment for Services Unrelated to Terminal Illness.
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