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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 ManualExternal Website.

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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
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
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, §90External PDF). 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.
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
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.
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.
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 7792External PDF).
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:
  • The recertification was not obtained timely. The dates indicate the period of noncovered hospice care. In this case, condition code 85 (Delayed recertification of hospice terminal illness) must be reported for claims received on or after January 1, 2017. Refer to MM9590External PDF for additional information.
  • The notice of election (NOE) was not submitted timely. The dates indicate the period of noncoverage hospice care (admit date to one day prior to date NOE submitted/accepted). See CR 8877 Web page for more information.
NOTE: Occurrence span code 77 should not be used in situations where the hospice face-to-face encounter was not done timely. (See the Untimely Face-to-Face Encounter webpage.)
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.

Value code 61 and the core based statistical area (CBSA) code are required when billing routine (revenue code 0651) and/or continuous home care (revenue code 0652).

Value code G8 and the CBSA code are required when billing respite (revenue code 0655) and/or general inpatient care (revenue code 0656).

To determine the correct CBSA code, access the CMS Hospice Provider CenterExternal Website Web page. Under the "Wage Index Files" header, select the appropriate Fiscal Year (FY) Wage Index, and search for the geographic area where the beneficiary is receiving the hospice care. If the area (CBSA code) changes during a billing period, use the CBSA code that reflects the area as of the "TO" date on the claim.

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.

Code

Title

Definition

62

Number of High Routine Home Care Days

Days that fall within the first 60 days of a routine home care hospice claim. 

63

Number of Low Routine Home Care Days

Days that come after the first 60 days of a routine home care hospice claim.

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Additional FISS Claim Pages

Priority (Type) Admission or Visit Codes

Priority (Type) Admission or Visit Codes
Code Description
1 Emergency
2 Urgent
3 Elective
4 Newborn
5 Trauma
9 Information not available

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Point of Origin (Source of Admission) Codes

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

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Discharge Status Codes

A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website. 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.

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Hospice Condition Codes

A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website.

Hospice Condition Codes
Code Description
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.

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Expedited Review Condition Codes

Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1External PDF

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.

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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

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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 ManualExternal Website.

When appropriate, enter one of the following hospice related occurrence codes and corresponding date:

Hospice Occurrence Codes and Dates
Code Description
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.

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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
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:

  • The recertification was not obtained timely (by the end of the 3rd calendar day after the start of each benefit period). Enter the FROM and TO dates of the period of care for which the provider is liable. Note that condition code 85 (Delayed recertification of hospice terminal illness) must be reported for claims received on or after January 1, 2017. Refer to MM9590External PDF for additional information.
  • The NOE was not submitted timely (within 5 calendar days after the hospice admission date). Enter the FROM and TO dates of the period of care for which the provider is liable.

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.

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Value Codes and Amounts

The following codes are the most commonly used on a hospice claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website.

Value Codes and Amounts
Code Description
61 Location Where Service is Furnished (Core Based Statistical Area) (CBSA)

Value code '61' should be used when billing revenue codes 0651 (routine home care) and 0652 (continuous home care). Following the '61', enter the CBSA code that corresponds with the location where the routine or continuous home care service was provided.

If hospice services are provided to the beneficiary in more than one CBSA area during the billing period, the hospice reports the CBSA that applies at the end of the billing period.

CBSA codes are available in the Wage Index Files found on the Hospice Provider Center Web pageExternal Website

G8 Facility Where Inpatient Hospice Service is Delivered (General Inpatient and Inpatient Respite Care).

Value code 'G8' should be used when billing revenue code 655 (respite) or 656 (general inpatient care). Following the 'G8', enter the CBSA code of the facility where the inpatient care (respite of general inpatient) was delivered.

If hospice services are provided to the beneficiary in more than one CBSA area during the billing period, the hospice reports the CBSA that applies at the end of the billing period.

CBSA codes are available in the Wage Index Files found on the Hospice Provider Center Web pageExternal Website.

Claim Page 01 displays space for 9 value codes/amounts. However, FISS allows you to enter up to 36 value codes/amounts by pressing F6 to scroll forward.

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Updated: 04.30.21

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