Hospice Pre-Election Counseling: When Every Referral Becomes Another Medicare Bill

Hospice pre-election counseling billing covers Medicare’s separate, one-time payment for a physician consultation before a patient elects hospice. The patient or the patient’s physician must initiate it, and the Centers for Medicare & Medicaid Services expressly rejects using it as a preliminary evaluation for every referral. If you work in admissions, clinical care or billing, you may know whether the consultation began with a request for help or an instruction to charge for everyone who came through intake.

This is a hospice fraud question about hospice billing before enrollment. Ordinary hospice payment follows the enrolled day. This payment comes before election, when the patient seeks expertise about care options and symptom management. An intake policy that automatically adds the charge turns that opportunity for advice into another Medicare bill for taxpayers.

What Is Hospice Pre-Election Counseling For?

The service evaluates a person’s need for pain and symptom management and provides counseling about hospice and other care options. It may also include advance-care planning. Under Medicare’s hospice coverage manual, the patient must have a terminal illness, meaning a prognosis of six months or less if the illness follows its normal course. The patient must have no previous hospice election and must not have received this pre-election service before.

The coverage manual describes a patient with end-stage COPD, distressing symptoms and unresolved advance-directive decisions. The patient’s physician seeks the hospice medical director’s expertise. After the consultation, the patient can express care wishes and the physician has recommendations for managing symptoms.

Previous counseling matters, too. In another example, a hospital’s palliative care team has already discussed options, evaluated pain and symptoms, and recommended hospice for a patient with end-stage lung cancer. The manual calls another evaluation under this benefit duplicative. The actual work already done matters more than the fact that someone has mentioned hospice.

Who May Request and Provide the Consultation?

The request must originate with the patient or the patient’s physician. Medicare bars the hospice receiving the payment from initiating the service. That makes the source of the request a payment question, something an admissions employee may understand better than anyone reading the final claim.

The coverage manual specifies the hospice medical director or a physician employed by the hospice as the person who furnishes the consultation. It expressly bars delegating it to a nurse practitioner, registered nurse, social worker or other hospice personnel, and bars furnishing it through a physician under contract with the hospice. The appointment record, physician agreement and clinical note therefore answer different parts of the question: who was there, what relationship that person had with the hospice, and what work occurred.

The manual also addresses the patient’s own physician who is already a hospice medical director, a hospice employee or experienced in palliative care. The manual explains that this physician already has the expertise and will have received payment through evaluation and management services. That overlap makes prior physician billing relevant to whether another consultation duplicates work already paid for.

The Request, the Clinical Note and the Medicare Claim

G0337 identifies hospice pre-election evaluation and counseling services, and Medicare pays it only on a hospice claim. The claims-processing manual directs contractors to deny that code on a professional claim. A physician provides the service, but the hospice receives this payment.

The useful evidence connects the request to the encounter and the bill:

• The request. For a physician-initiated consultation, the coverage manual says the request or referral should be written and the documentation should include the terminal-illness determination. A referral for admission and a request for this consultation serve different purposes.
• The clinical note. Medicare expects the hospice medical director or employee physician to write a note in the patient’s medical chart and maintain a written service record. The note connects the billed consultation to the pain, symptoms and care decisions addressed.
• The patient’s own request. When the patient initiates the service, the hospice should keep a written service record. With the patient’s permission, communication with the patient’s physician should occur as needed for continuity of care.
• The claim and prior services. The hospice claim uses revenue code 0657 with no other revenue codes. The patient’s election history and previous receipt of the pre-election service matter because this is a one-time benefit available before any hospice election.

The claims manual also describes duplicate-billing safeguards for a new-patient physician service and this consultation when the beneficiary, date of service and physician are the same. For a biller, that makes the other claim part of the same story. The broader physician double-billing question includes care-plan oversight by a hospice employee physician that the daily hospice payment already covers.

When Every Referral Generates a Charge

The coverage manual describes a hypothetical hospice receiving referrals for terminally ill patients who want to elect hospice:

We see the absurdity in that example: a benefit for requested advice becomes an automatic intake charge. The patient’s request for specialist advice has disappeared from the decision. An insider who knows how that charge became automatic can explain something the billing code alone never will.

The manual’s nursing-home example makes the same problem concrete. A facility sends a hospice a list of patients who can be certified as terminally ill. The hospice medical director makes rounds on them, although many cannot communicate and their symptoms are already well managed. The manual calls this use inappropriate. The facility list and rounds supplied an encounter, but the example does not describe a patient-driven need for the consultation.

In the same guidance, the Centers for Medicare & Medicaid Services says hospice payments to physicians or others able to refer patients for this service may implicate the federal Anti-Kickback Statute. That puts payments to referral sources beside the request-origin question. We examine who initiated the encounter, who received money and what the hospice billed.

What Admissions and Billing Staff Can Show

The hospice fraud inquiry connects the service billed with what the patient received and what management knew. Here, an instruction to charge every referral can be read beside the original request, the physician’s note and the resulting claim. Your knowledge of who set that practice can connect the individual bills to the business decision behind them.

The election statement records the signed choice of hospice, while the election addendum explains care the hospice considers unrelated and will not cover. Neither record tells us who requested the separately billed consultation or what counseling the physician provided. Those questions lead back to the request and clinical note, which an insider can connect to the intake instructions.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Our whistleblower experts help healthcare insiders build the case around who ordered the charges, what patients received and what Medicare paid.

When Intake Became a Billing Instruction

If your hospice billed pre-election counseling whenever a referral arrived, tell our whistleblower experts how the charge became routine. We build the case with you around the admissions practice and Medicare claims, and bring in hospice fraud whistleblower lawyers who understand physician billing. You bring the inside view of that health care business, and we stay beside you as the case develops.