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Last Modified: 6/27/2018 Location: FL, PR, USVI Business: Part B

Avoiding denial reason code PR B9 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?
Patient is enrolled in a hospice.
A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.
The following situations require a modifier be applied to the claim prior to submission.
Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
Claim should be submitted with modifier GV.
If claim was submitted with the GV modifier, check patient's file to verify that the attending physician is not employed by the hospice provider.
Services not related to the hospice patient’s terminal condition:
Claim should be submitted with modifier GW.
If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.
If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.
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Source: First Coast Education Action Team
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