Claim Page 01 – Entering a Hospice Claim
Claim Page 01 (Map 1711) contains general patient information, condition codes, occurrence codes, occurrence span codes, and value codes.
Begin entering data on Claim Page 01 and continue until the necessary fields are completed. Use the key and table below to determine what fields are required and what information to enter.
Note: The codes listed on this page represent those most frequently submitted on hospice claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.
Key:
- RED = Required field
- BLUE = Optional field
- GREEN = Conditional field, dependent on the type of claim
- PURPLE = System generated field
- BLACK = Not required field
Field Descriptions for Claim Page 01 – Map 1711
Field Name/Requirement | UB-04 Form Locator (FL) | Description | |||||||||
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MID Required |
FL 60 |
Enter the beneficiary's Medicare ID number | |||||||||
TOB Required |
FL 4 |
Type of bill (system generated). FISS Page 01 defaults the type of bill (TOB) to 811. You may need to change this depending on the TOB you are entering. 1st Digit 8 – Hospice 2nd Digit 1 – Hospice (nonhospital based) 2 – Hospice (hospital based) 3rd Digit 0 – Nonpayment/zero claims 1 – Admit through discharge 2 – Interim – First claim 3 – Interim – Continuing claim 4 – Interim – Last claim 7 – Replacement of prior claim (adjustment claim) 8 – Void/cancel of prior claim |
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NPI Required |
FL 56 |
Enter your National Provider Identifier. | |||||||||
PAT.CNTL# Optional |
FL 3a |
Up to 20 digits are available for you to enter your internal account number for tracking purposes. This number will display on your Remittance Advice or your Electronic Remittance Advice. | |||||||||
STMT DATES FROM/TO Required |
FL 6 |
Enter the beginning and ending dates for this billing period. Hospice claims are required to be billed monthly, and must conform to a calendar month (Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 11, §90). The FROM date should reflect the first day in the month you are billing. The TO date should reflect the last day of the month, or the day of discharge, transfer, or death. |
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LAST Required |
FL 8 |
Enter the beneficiary's last name exactly as it appears on the Medicare card or the beneficiary's eligibility file. | |||||||||
FIRST Required |
FL 8 |
Enter the beneficiary's first name exactly as it appears on the Medicare card or the beneficiary's eligibility file. | |||||||||
MI Optional |
FL 8 |
Enter the beneficiary's middle initial. | |||||||||
DOB Required |
FL 10 |
Enter the beneficiary's date of birth. | |||||||||
ADDR 1-6 Required |
FL 9 |
Enter the beneficiary's full mailing address, including street name and number, post office box number or RFD, city and state. | |||||||||
ZIP Required |
FL 9 |
Enter the beneficiary's zip code. | |||||||||
SEX Required |
FL 11 |
Enter the beneficiary's gender using the appropriate alpha character. M = Male F= Female |
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MS Optional |
N/A |
Beneficiary's marital status | |||||||||
ADMIT DATE Required |
FL 12 |
Enter the effective date of the hospice election or hospice transfer. This date must be the same as the Admit Date on the Notice of Election or Notice of Change (Transfer). | |||||||||
HR Required |
FL 13 |
Hour of Admission – Enter the hour of admission (based on a 24-hour clock). If the hour of admission is unknown, enter '01'. This information is required when entering your claim via direct data entry (DDE) only. It is not required on claims submitted on paper or via batch-file-transfer. |
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TYPE Required |
FL 14 |
Enter the Priority (Type) of Admission code. | |||||||||
SRC Required |
FL 15 |
Enter a Point of Origin (Source of Admission) code. | |||||||||
STAT Required |
FL 17 |
Enter the beneficiary's Discharge Status Code as of the "TO" date on this claim. | |||||||||
COND CODES Conditionally Required |
FL 18-28 |
Condition codes. Condition code 52 Condition code 52 is required to report a discharge due to the patient's unavailability/inability to receive hospice services from the hospice which has been responsible for the patient. Condition code 85 Condition code 85 is required when the hospice recertification is not received within the required time. Effective for claims received on or after January 1, 2017. Condition code H2 is required when a patient is discharged by the hospice for cause. Note: Claim Page 01 displays space for 10 condition codes. However, FISS allows you to enter up to 30 condition codes by pressing F6 to scroll forward. |
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OCC CDS/DATE Conditionally Required |
FL 31-34 |
Occurrence codes (OC) and dates. Occurrence code 27 is required if the "FROM" and "TO" dates on the claim overlap the start of a new hospice benefit period. The date used with OC 27 is the first day of the new benefit period. Use ELGH Page 19 to determine the first day of the new benefit period. Occurrence code 32 and date are required when the Advance Beneficiary Notice (ABN) was provided to the beneficiary, and the beneficiary requested the services provided be billed to Medicare. The date reflects the date the ABN was provided to the beneficiary. (See the Advance Beneficiary Notice Web page for more information.) Occurrence code 42 Is only required when the patient revokes their hospice election. Occurrence code 55 For claims submitted on/after October 1, 2012 – Occurrence code 55 and date of death (MMDDYY) is required when a patient discharge status code of 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown) is reported on a claim. (See Change Request 7792). |
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SPAN CODES/DATES Conditionally Required |
FL 35-36 |
Occurrence span codes. Occurrence span code M2 and dates are required when more than one respite period is provided within the "FROM" and "TO" dates on the claim. The dates identify the beginning and end of each respite stay. Occurrence span code 77 and dates are required when:
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FAC.ZIP Required |
FL 1 |
Facility ZIP code of the provider or the subpart (9-digit). The ZIP code entered must match the ZIP code in the Master Address field of the provider's address file at CGS. | |||||||||
VALUE CODES – AMOUNTS Required |
FL 39-41 |
Value codes and amounts. NOTE: Value codes 62 and 63 will be applied by the Fiscal Intermediary Standard System during processing to identify which RHC days are paid at the high or low rate. These codes are not submitted by the provider.
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Additional FISS Claim Pages
- Notice of Elections (NOEs)/Transfer NOE
- Hospice Claims
- Notice of Election Termination/Revocation (NOTR) – 8XB
Priority (Type) Admission or Visit Codes
Code | Description |
---|---|
1 | Emergency |
2 | Urgent |
3 | Elective |
4 | Newborn |
5 | Trauma |
9 | Information not available |
Point of Origin (Source of Admission) Codes
Code | Description |
---|---|
1 | Non-health care facility |
2 | Clinic or physician's office |
4 | Transfer from hospital |
5 | Transfer from SNF or ICF |
6 | Transfer from Another Health Care Facility |
8 | Court/Law Enforcement |
9 | Information not available |
Discharge Status Codes
A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual. Use the code that reflects the patient's status as of the "TO" date on your claim.
Patient Discharge Codes and Descriptions
Code | Description |
---|---|
01 | Discharged to home or self-care. This code should not be used for patients who die while under hospice care. |
30 | Still a hospice patient - hospice services continue to be provided. |
40 | Expired at home.* Note: When patient status code '40' is reported, an occurrence code 55 and the date of death must also be reported. |
41 | Expired in a medical facility, such as a hospital, skilled nursing facility (SNF), intermediate care facility (ICF) or freestanding hospice.* Note: When patient status code '41' is reported, an occurrence code 55 and the date of death must also be reported. |
42 | Expired – place unknown.* Note: When patient status code '42' is reported, an occurrence code 55 and the date of death must also be reported. |
50 | Discharged/transferred to hospice – home. Use this code when a patient transfers to another hospice under routine or continuous care. |
51 | Discharged/transferred to hospice – medical facility. Use this code when a patient transfers to another hospice under respite or general inpatient care. |
*Ensure the "TO" date on the claim is the date of death.
Hospice Condition Codes
A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.
Hospice Condition Codes
Code | Description |
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21 | Billing for Denial Notice
Enter this code to indicate those services you believe are at a noncovered level of care or excluded, but you wish to request a denial notice from Medicare in order to bill Medicaid or other insurers. Use this code only when an Advance Beneficiary Notice (ABN) was not required to be given to the beneficiary. NOTE: This condition code should not be used when reporting noncovered room and board charges. For detailed instructions on billing noncovered room and board, refer to the Hospice Room and Board Web page. |
H2 | Discharge for Cause
Used to indicate the patient meets the hospice's documented policy addressing discharges for cause. Examples of discharge for cause could include issues where patient safety or hospice staff safety is compromised. This results only in a discharge from the provider's care; not necessarily a discharge from the hospice benefit. |
52 | Discharge due to patient's unavailability or inability to receive hospice services Used to indicate the patient's unavailability or inability to receive hospice services from the hospice that has been responsible for the patient. Examples of when this code should be used include, but are not limited to, when hospice patient moves to another part of the country or when a hospice patient leaves the area for vacation. |
85 | Delayed recertification of hospice terminal illness Used when the recertification was not obtained timely (by the end of the 3rd calendar day after the start of each benefit period). Condition code 85 is effective for claims received on or after January 1, 2017. Refer to MM9590 for additional information. |
Expedited Review Condition Codes
Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1
The following condition codes are used in accordance with the Expedited Review process. For additional information, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1, §150.3.3, Billing and Claims Processing Requirements related to Expedited Determinations.
Additional information is also available on the CGS "Hospice Expedited Determination Process" Web page.
Expedited Review Condition Codes
C3 | Partial Approved
The claim was reviewed by the Quality Improvement Organization (QIO), and some days of the stay or services were denied; occurrence span code M0 indicates the dates of service for the stay that were approved. Your claims or adjustment will be returned if occurrence span code M0 is not also present. |
C4 | Services Denied
The claim was reviewed by the QIO, and all services beyond the discharge date were denied. Reflect QIO/Qualified Independent Contractor (QIC) determinations upholding discharge by reporting C4 on original claims and provider-submitted adjustments. In cases where the beneficiary may be liable for payment, and where C4 applies, also report occurrence span code 76, denoting "patient liability period". Your claim or adjustment containing C4 will be returned if the patient status code is 30, unless condition code 20 or occurrence code 32 is also present on the claim. |
C7 | Extended Authorization
QIO authorization for services extended. Report C7 on original claims and provider submitted adjustments. |
Claim Change Reason Condition Codes and Corresponding Bill Type
When submitted adjustments/cancellation bill types (8X7 or 8X8), enter one of the following required reason codes in the first available condition code field. Use a code that represents why the adjustment/cancel is being submitted.
NOTE: Use one claim change reason code per claim. If more than one code is necessary to reflect the reason for the change or if the following codes do not apply, use reason code 'D9'. When reason code D9 is used, an explanation of the adjustments/cancellation must be recorded in the Remarks field (FISS Claim Page 04).
Claim Change Reason Condition Codes and Corresponding Bill Type
Code | Description | TOB |
---|---|---|
D0 | Changes to service dates (FL6)
*do not use for adjusting line item DOS; use D9 instead |
XX7 |
D1 | Changes to charges
*adding or removing charges (do not use for adjusting units; use D9 for units) |
XX7 |
D2 | Change in revenue codes/HCPCS
*to change revenue or HCPCS codes. (Use D9 to add a revenue or HCPCS.) |
XX7 |
D5 | Cancel to correct HICN or provider number | XX8 |
D6 | Cancel duplicate or OIG overpayment | XX8 |
D9 | Any other change or multiple changes | XX7 |
Hospice Occurrence Codes and Dates
The following codes are the most commonly used on hospice claims. A complete listing of all occurrence codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.
When appropriate, enter one of the following hospice related occurrence codes and corresponding date:
Hospice Occurrence Codes and Dates
Code | Description |
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24 | Date Insurance Denied
Enter the date of receipt of a denial of coverage by a higher priority payer. |
27 | Date of Certification/Recertification
Enter the date of certification/recertification (i.e. the start of a new hospice benefit period). This code is required on all claims in which a certification period falls within the claim's FROM and TO date. The date entered with OC 27 should reflect the first day (MMDDYY) of the new hospice benefit period. Hospice benefit periods can be determined by using ELGH Page 19. Example 1: The dates of service on your claim are 0101YY-0131YY. The claim overlaps the start of a new hospice benefit period on 0115YY, and the physician certification was obtained timely. An occurrence code 27 and a date of 0115YY would be required on this claim. Example 2: The dates of service on your claim are 0101YY-0131YY. The claim does not overlap the start of a new hospice benefit period, and no physician recertification was required during these dates. Therefore, do not include occurrence code 27 or date on this claim. |
32 | Date Beneficiary Notified of Intent to Bill (Procedures or Treatments)
Enter this code to indicate that an Advance Beneficiary Notice (ABN) was required AND the beneficiary demanded you submit the claim to Medicare for review. Include the date the ABN was signed by the beneficiary. |
42 | Date of Termination of Hospice Benefit
Occurrence code 42 is only required when the patient revokes their hospice election. |
55 | Date of Death For dates of service on/after October 1, 2012 – Occurrence code 55 and date of death is required when the Patient Discharge Status Code indicates death (40-expired at home, 41-expired at medical facility, or 42-expired place unknown). |
Note: Claim Page 01 displays space for 10 occurrence span codes/dates. However, FISS allows you to enter up to 30 occurrence codes/dates by pressing F6 to scroll forward.
Occurrence Span Codes and Dates
When appropriate, enter the associated beginning and ending dates defining a specific event related to this billing period.
Occurrence Span Codes and Dates
Code | Description |
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77 | Provider Liability – Utilization Charge
Use this code to indicate the span of days that were not covered on claims when one of the following situations occurred:
NOTE: This code should not be used to indicate and untimely Face-To-Face encounter. |
M2 | Dates of Inpatient Respite Care
M2 is used when respite care is provided more than once during a benefit period. Enter M2 along with the From and To date for each respite period, to differentiate each respite period of 5 days or less. |
Value Codes and Amounts
The list below only includes codes used for hospice claims. Refer to the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manualfor a complete list of codes and billing guidance.
Value Codes and Amounts
Code | Description |
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61 |
Place of Residence Where Service is Furnished Applies when billing revenue codes 0651 (routine home care) and 0652 (continuous home care). Report the Core-Based Statistical Area (CBSA) or special 50xxx code that corresponds to the state and county where hospice services were provided. For beneficiaries in areas with more than one unique CBSA due to the wage index cap policy, use the special 50xxx codes to determine the appropriate code to report in place of the CBSA code. If the beneficiary receives hospice services in more than one CBSA area during the billing period, report the CBSA that applies at the end of the billing period. Refer to the Hospice Wage Index file for a list of CBSA codes. |
G8 |
Facility Where Inpatient Hospice Service is Delivered Applies when billing revenue code 0655 (respite) or 0656 (general inpatient care). Report the Core-Based Statistical Area (CBSA) or special 50xxx code that corresponds to the state and county where hospice services were provided. For beneficiaries in areas with more than one unique CBSA due to the wage index cap policy, use the special 50xxx codes to determine the appropriate code to report in place of the CBSA code. If the beneficiary receives hospice services in more than one CBSA area during the billing period, report the CBSA that applies at the end of the billing period. Refer to the Hospice Wage Index file for a list of CBSA codes. |
Updated: 10.04.24