TL;DR
Chapter 11 of the Medicare Claims Processing Manual explains how hospices and the physicians who treat hospice patients bill Medicare. It covers the notice of election and the notice of termination or revocation, the four levels of hospice care and their per diem payment, the data required on the institutional claim, billing for attending physician services and for care unrelated to the terminal illness, coinsurance, and the caps on hospice payment.
Chapter 11 at a glance
- Current revision
- Rev. 13190
- Issued April 24, 2025
- Effective
- October 1, 2025
- Implemented October 6, 2025
- Sections
- 44
- 13 top-level sections
- Transmittals in history
- 61
- Listed at the end of the chapter
- Monthly searches
- 40
- Google Ads, US, October 2026
What chapter 11 governs for billing
Section 20 runs the election paperwork. A hospice must file its notice of election so that the MAC receives and accepts it within 5 calendar days after the hospice admission date. When it is late, Medicare does not pay for the days from admission until the notice is accepted; those days are the hospice's liability, cannot be billed to the beneficiary, and are reported as noncovered on the claim with occurrence span code 77. Four exceptional circumstances can waive the consequence. A notice of termination or revocation is due within 5 calendar days of a discharge or revocation as well.
Section 30 covers the institutional claim. Each day of care is billed at one of four levels, routine home care, continuous home care, inpatient respite care and general inpatient care, each paid at its own daily rate (30.1 and 30.2), with a higher routine home care rate in the first 60 days and a service intensity add-on for visits by registered nurses and social workers in the last days of life (30.2.2). Section 30.3 lists the data the claim must carry, including the certifying physician, whose Medicare enrollment is now edited on hospice claims.
Section 40 explains how physician services are billed while a patient is on hospice: services of hospice-employed or contracted physicians are billed by the hospice, while the patient's own attending physician who is not employed by the hospice bills the A/B MAC (B) with modifier GV, and care for conditions unrelated to the terminal illness is billed with modifier GW (40.2 and 50). The chapter closes with coinsurance on drugs and respite care (70), the inpatient and aggregate caps on hospice payments (80), billing for denials (100) and the hospice pricer (130).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 11 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 20.1 | Procedures for Hospice Election and Related Transactions | Procedures for the notice of election, timely filing within 5 calendar days and the exceptions. |
| 30.1 | Levels of Care Data Required on the Intuitional Claim to A/B MAC (HHH) | The four levels of hospice care and the data each requires on the claim. |
| 30.2 | Payment Rates | Hospice payment rates, including the service intensity add-on. |
| 30.3 | Data Required on the Institutional Claim to A/B MAC (HHH) | Data elements required on the hospice institutional claim, including the certifying physician. |
| 40.2 | Processing Professional Claims for Hospice Beneficiaries | Processing professional claims for hospice patients, with the GV and GW modifiers. |
| 80 | Caps and Limitations on Hospice Payments | Caps and limitations on hospice payments. |
How chapter 11 shows up on claims and denials
Two kinds of rejections dominate. Hospice claims fail when the notice of election is missing, late or does not match the claim, or when required data such as the certifying physician is missing; those come back as returned or rejected claims rather than appealable denials. Claims from other providers fail when the patient has an open hospice election: a service related to the terminal illness that is not billed through the hospice is denied with reason code B9, the patient is enrolled in hospice.
When a non-hospice provider treats a condition unrelated to the terminal prognosis, the claim needs modifier GW (or condition code 07 on an institutional claim) to bypass the hospice edit, and the documentation should show why the condition is unrelated. An attending physician not employed by the hospice bills with modifier GV.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| B9 | Claim adjustment reason code | Patient is enrolled in hospice; related care must be billed through the hospice. |
| 50 | Claim adjustment reason code | Hospice level of care or service not reasonable and necessary. |
| 16 | Claim adjustment reason code | Hospice claim missing required data, such as the certifying physician. |
| 27 | Claim adjustment reason code | Expenses incurred after coverage terminated, for example after a revocation. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13190, issued April 24, 2025, effective October 1, 2025, implemented October 6, 2025 (change request 14027). That revision changed section 110 (Payment Procedures for Terminated Hospices). Its subject line reads: “Hospices”.
The newest rows of the transmittal history printed at the end of the chapter (61 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13190CP | April 24, 2025 | Hospices | 14027 |
| R12847CP | September 13, 2024 | Additional Implementation Edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment | 13531 |
| R11286CP | March 3, 2022 | Internet Only Manual Update, Pub. 100-04, Chapter 11, Sections 20.1.4 and 30.3 Regarding the Cancellation of an Election and Billing for Services | 12626 |
| R11280CP | February 25, 2022 | Gap Billing Between Hospice Transfers | 12619 |
| R10173CP | June 12, 2020 | Internet Only Manual Update, Pub. 100-04, Chapter 11 | 11807 |
| R4393CP | September 13, 2019 | Internet Only Manual Update to Add New and Revise Sections of Publication 100-04, Chapter 11 | 11431 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 110 | Payment Procedures for Terminated Hospices | Rev. 13190, April 24, 2025; effective October 1, 2025 |
| 20.1.1 | Notice of Election (NOE) | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 20.1.2 | Notice of Termination/Revocation (NOTR) | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 20.1.3 | Change of Provider/Transfer Notice | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 20.1.4 | Cancellation of an Election | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 20.1.5 | Change of Ownership Notice | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 30.3 | Data Required on the Institutional Claim to A/B MAC (HHH) | Rev. 12847, September 13, 2024; effective June 3, 2024 |
| 40.2 | Processing Professional Claims for Hospice Beneficiaries | Rev. 10485, November 19, 2020; effective September 7, 2020 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 Overview · p. 3 · 1 subsections
- Open section 10 in the PDF
- 10.1 Hospice Pre-Election Evaluation and Counseling Services · p. 3
20 Hospice Notice of Election · p. 4 · 7 subsections
- Open section 20 in the PDF
- 20.1 Procedures for Hospice Election and Related Transactions · p. 4
- 20.1.1 Notice of Election (NOE) · p. 4
- 20.1.2 Notice of Termination/Revocation (NOTR) · p. 11
- 20.1.3 Change of Provider/Transfer Notice · p. 14
- 20.1.4 Cancellation of an Election · p. 18
- 20.1.5 Change of Ownership Notice · p. 21
- 20.1.6 Hospice Election Periods and Benefit Periods in Medicare Systems · p. 24
30 Billing and Payment for General Hospice Services · p. 27 · 7 subsections
- Open section 30 in the PDF
- 30.1 Levels of Care Data Required on the Intuitional Claim to A/B MAC (HHH) · p. 27
- 30.2 Payment Rates · p. 29
- 30.2.1 Payments to Hospice Agencies That Do Not Submit Required Quality Data · p. 30
- 30.2.2 Service Intensity Add-on (SIA) Payments · p. 30
- 30.3 Data Required on the Institutional Claim to A/B MAC (HHH) · p. 31
- 30.4 Claims From Medicare Advantage Organizations · p. 54
- 30.5 Hospice Claims for Vaccine Services · p. 55
40 Billing and Payment for Hospice Services Provided by a Physician · p. 55 · 7 subsections
- Open section 40 in the PDF
- 40.1 Types of Physician Services · p. 55
- 40.1.1 Administrative Activities · p. 55
- 40.1.2 Hospice Attending Physician Services · p. 56
- 40.1.3 Independent Attending Physician Services · p. 57
- 40.1.3.1 Care Plan Oversight · p. 59
- 40.2 Processing Professional Claims for Hospice Beneficiaries · p. 59
- 40.2.1 Claims After the End of Hospice Election Period · p. 60
50 Billing and Payment for Services Unrelated to Terminal Illness · p. 60
60 Billing and Payment for Services Provided by Hospices Under Contractual Arrangements With Other Institutions · p. 60 · 2 subsections
- Open section 60 in the PDF
- 60.1 Instructions for the Contractual Arrangement · p. 62
- 60.2 Clarification of the Payment for Contracted Services · p. 62
70 Deductible and Coinsurance for Hospice Benefit · p. 62 · 3 subsections
- Open section 70 in the PDF
- 70.1 General · p. 62
- 70.2 Coinsurance on Outpatient Drugs and Biologicals · p. 63
- 70.3 Coinsurance on Inpatient Respite Care · p. 63
80 Caps and Limitations on Hospice Payments · p. 64
90 Frequency of Billing and Same Day Billing · p. 64
100 Billing for Hospice Denials · p. 64 · 2 subsections
- Open section 100 in the PDF
- 100.1 Billing for Denial of Room and Board Charges · p. 64
- 100.2 Demand Billing for Hospice General Inpatient Care · p. 65
110 Payment Procedures for Terminated Hospices · p. 65
120 Contractor Responsibilities for Publishing Hospice Information · p. 65
130 HOSPICE Pricer Program · p. 66 · 2 subsections
- Open section 130 in the PDF
- 130.1 Input/Output Record Layout · p. 66
- 130.2 Decision Logic Used by the Pricer on Claims
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Claims Processing Manual chapter 11
QuickRCM covers eligibility, claim readiness, denials, posting and A/R with configurable automation and human review, which is where the billing rules in this chapter are checked before a claim goes out. QuickCode supports qualified coder review of the coding and modifier questions the chapter answers.
Frequently asked questions: chapter 11
How long does a hospice have to file the notice of election?
Chapter 11 section 20 requires the notice of election to be submitted and accepted within 5 calendar days after the hospice admission date. Days before a late notice is accepted are not paid and are the hospice's liability.
What are the four hospice levels of care?
Routine home care, continuous home care, inpatient respite care and general inpatient care. Chapter 11 section 30.1 explains the data each level requires on the claim, and section 30.2 explains the payment rates.
When do physicians use modifiers GV and GW?
An attending physician who is not employed by or paid under arrangement with the hospice bills with modifier GV, and a provider treating a condition unrelated to the terminal illness bills with modifier GW, as described in chapter 11 sections 40 and 50.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Claims Processing Manual, Chapter 11: Processing Hospice ClaimsVersion Rev. 13190, issued 2025-04-24 · effective 2025-10-01 · file clm104c11.pdfSHA-256 74dc3e248b24a797…
- Medicare Claims Processing Manual (Pub. 100-04)Version 39 chapter PDFs; newest revision Rev. 13836 (chapter 14), issued 2026-06-24 · effective 2026-09-27 · file 100-04-claims-processing-manual/*.pdf (39 chapters; SHA-256 of their sha256sum listing)SHA-256 f87bc3bcd9d1570d…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.