Hospice billing

The election, the Notice of Election and the NOTR

Under 42 CFR 418.24, for elections from October 1, 2026, every patient gets an election statement addendum within 5 days, listing what the hospice will not cover as unrelated to the terminal illness. Until then, it was given only on request.

The Notice of Election must be submitted to and accepted by the Medicare contractor within 5 calendar days after admission. Under chapter 11 of the Claims Processing Manual, if it is late, Medicare does not pay the days until acceptance: they are billed as non-covered with occurrence span code 77, and the patient cannot be charged. Exceptions, requested with modifier KX, are narrow.

After a live discharge or revocation, the Notice of Termination/Revocation is due within 5 calendar days, unless the final claim is already in.

Benefit periods, certifications and face-to-face encounters

Hospice runs in two 90-day benefit periods, then unlimited 60-day periods. Under chapter 9 of the Benefit Policy Manual, each period needs an oral or written certification within 2 calendar days of its start, and the signed written certification, with the physician’s own narrative, on file before you bill.

Before the third period and each one after, a hospice physician or nurse practitioner sees the patient face to face within 30 calendar days before recertification, and signs and dates an attestation, which can be a clinical note. Under 42 CFR 418.22, two-way audio and video is allowed through December 31, 2027, except, since January 31, 2026, in moratorium areas, at hospices under enhanced oversight, or by practitioners neither enrolled in nor opted out of Medicare. From January 1, 2027, telehealth encounters are reported on the claim.

Staying inside the hospice cap

Your aggregate cap is the cap amount times your Medicare patients for the year, each counted by their share of hospice days spent with you. A separate inpatient cap holds general inpatient and respite days to 20 percent of your Medicare hospice days. Payment above either cap is an overpayment.

The cap year runs with the federal fiscal year. You file your self-determined cap within 5 months after it ends, by the end of February, and repay any overpayment, or payments are suspended. A new hospice’s first cap period runs at least 12 and under 24 months. Long stays push you toward the cap, so we report your position monthly.

Monthly claims on the 837I and UB-04

Hospices bill the institutional claim, type of bill 081x (not hospital-based) or 082x (hospital-based), once per calendar month. A claim spanning two months is returned. Each level-of-care line carries a site code, such as Q5001 for home, and each visit is its own line in 15-minute units: G0299 for an RN, G0300 for an LPN, G0155 for a social worker, G0156 for an aide.

The claim for a certification month carries occurrence code 27, and Medicare checks the certifying physician’s enrollment on it. An attending physician not employed by the hospice bills Part B with modifier GV, unrelated care takes GW, and Part B claims for hospice patients without either are denied.

Quality data now comes from HOPE, which replaced the Hospice Item Set on October 1, 2025.

Why hospice claims deny

Common hospice denials:

• A late NOE: days before acceptance are the hospice’s loss
• A missing, unsigned or late certification, or a template narrative
• No face-to-face encounter before the third period, or an unsigned or undated attestation
• No addendum for an election from October 1, 2026
• A claim spanning two months, or two claims in one month
• General inpatient days found not necessary, which may be paid at the routine home care rate
• Part B physician claims without GV or GW

Each goes through our denial management process, corrected and resubmitted or appealed with the election, certification and visit notes.

Medicaid hospice and nursing facility room and board

Medicaid pays hospice at rates based on Medicare’s, and states may pay more. Medicaid.gov sets out the room-and-board rule: for a Medicaid resident of a nursing facility, the state pays the hospice 95 percent of the facility rate, less the resident’s own share of cost, and the hospice passes that payment to the facility. Medicare does not pay room and board.

Dual-eligible patients elect hospice under both programs at once. Medicaid also limits inpatient days to 20 percent of hospice days, and states may apply the cap. We bill the pass-through and reconcile it with each facility monthly.

Credentialing and Medicare certification for hospices

Get the state license first where your state requires one. A hospice enrolls in Medicare on the CMS-855A, with the application fee. The Medicare contractor recommends approval, the state or an approved accrediting organization surveys you, and CMS decides. New hospices are screened at Medicare’s high risk level, with fingerprint checks on every owner of 5 percent or more.

Original Medicare pays the hospice for Medicare Advantage members who elect hospice, so next come state Medicaid, any Medicaid plans and your commercial plans. Our provider credentialing service handles them at $189 per payer application, less in bulk.