CARC B9 Active

PR-B9: Patient Enrolled in Hospice

TL;DR

The patient is enrolled in hospice, so this service should be billed through the hospice provider. If the service is unrelated to the terminal illness, rebill with the GW modifier and a non-terminal diagnosis code.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-B9 Mean?

CARC B9 indicates the claim was denied because the patient is actively enrolled in a hospice program. When a patient elects hospice, most services related to the terminal illness become the hospice provider's responsibility. Other providers cannot separately bill Medicare or the payer for services that fall within the hospice benefit.

However, services unrelated to the terminal illness can still be billed separately — but they must be billed with the appropriate GW modifier (indicating the service is unrelated to the hospice diagnosis) and a diagnosis code that is not related to the terminal condition. Without this modifier, the payer's system automatically denies claims for patients with an active hospice election.

The most common cause of this denial is that the rendering provider was unaware the patient had enrolled in hospice and billed without the GW modifier. In other cases, the service may genuinely be related to the terminal diagnosis, in which case it should be billed through the hospice provider.

How to Resolve

Determine if the service is related or unrelated to the hospice diagnosis, then rebill with GW modifier or coordinate billing through the hospice.

  1. Verify hospice enrollment status Confirm the patient's hospice enrollment status and the specific terminal diagnosis covered under the hospice benefit.
  2. Determine service relationship to terminal diagnosis Evaluate whether the billed service is related to the patient's terminal illness or a completely separate medical condition.
  3. Rebill with GW modifier if unrelated If the service is unrelated to the terminal illness, resubmit the claim with modifier GW and an appropriate non-terminal diagnosis code.
  4. Coordinate with hospice if related If the service is related to the terminal diagnosis, the charges should be billed through the hospice provider, not separately.
  5. Appeal if improperly denied If the claim was denied despite proper GW modifier usage, appeal with clinical documentation demonstrating the service is unrelated to the hospice diagnosis.
Do Not Appeal This Code

Patient Enrolled in Hospice grouped under PR places the financial responsibility on the patient. The specific reason depends on the context of this adjustment — review any accompanying RARC codes for detail. Because this represents a placement of responsibility rather than a coverage denial, an appeal isn't the right action; verify the placement is correct before billing the patient.

Also Filed As

The same CARC B9 may appear with different Group Codes:

CO-B9 OA-B9

Related Denial Codes

PR-13 — Date of Death Precedes Date of Service PR-14 — Date of Birth Follows Date of Service PR-19 — Workers' Compensation Claim PR-20 — Liability Carrier Responsible PR-21 — No-Fault Carrier Responsible

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://www.mdclarity.com/denial-code/b9
  3. https://www.cms.gov/medicare/payment/hospice
  4. Codes maintained by X12. Visit x12.org for official definitions.