Claim Page 02 – Entering a Hospice Claim
Claim Page 02 (Map 1712) contains revenue codes, HCPCS codes, units, charges, and service dates. Hospices must report the level(s) of care provided to the beneficiary during the billing period. If the level of care changes, or if the service location changes, a separate revenue code line is required. Separate lines should not be reported for the same level of care unless the site of service Q code changes. Refer to CMS Pub. 100.04, Ch. 11 §30.3 for additional information. In addition, each nursing, aide, social worker, and therapy visit provided must be reported on a separate revenue code line.
Use the key and table below to determine what fields are required, and what information is required in each field.
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 02 – Map 1712
The MID (Medicare ID), TOB, S/LOC and Provider fields are system generated from Claim Page 01.
Field Name/Requirement |
UB-04 Form Locator (FL) |
Description |
---|---|---|
Required |
FL 42 |
FISS Page 02 will hold up to 14 revenue code lines per page. To enter additional revenue code lines, press F6 to scroll down to revenue code page (REV CD PAGE) 02. There are 33 revenue code pages and 450 total revenue code lines available. The REV field is a four-position field. You may enter a zero before the revenue code (e.g. 0651) or enter the three-digit code (e.g. 651) and then use your TAB key to go to the next field. Level of Care
Discipline
Physician Services Room and Board Enter revenue code 0250 when providing non-injectable provided on/after April 1, 2014.
Note: For claims with dates of service before October 1, 2018, in addition to revenue code 0250, hospices must also report the National Drug Code (NDC), quantity and the qualifier for each drug. The NDC is reported in Loop 2410 of the 837 transaction. If you are entering your claim in FISS via DDE, press F11 from Page 02 to access the MAP171E screen to report the NDC. For claims with dates of service on or after October 1, 2018, hospices are no longer required to report a charge total and amount dispensed per drug. Refer to MM10573 for additional information. A list of current NDC codes can be accessed at http://www.fda.gov/drugs/informationondrugs/ucm142438.htm Infusion pump equipment
Enter the revenue code 0294 to report infusion medications.
Enter the revenue code 0636 to report injectable drugs.
For claims with dates of service on or after October 1, 2018, report a monthly charge total for infusion pump equipment with revenue code 029X (X=appropriate 4th digit), and infusion medications with revenue code 0294. Reporting injectable drugs using revenue code 0636 is no longer required. Refer to MM10573 for additional information. |
Required |
FL 44 |
Level of Care Discipline Physician Services The following additional data is to be reported for services on/after April 1, 2014. Enter the appropriate HCPCS code for the injectable drug, infusion pump, or infusion pump medication. A list of HCPCS codes for drugs is available from the CMS website. NOTE: For claims with dates of service on or after October 1, 2018, HCPCS code reporting is not required for infusion pumps, and infusion medications (revenue code 029X and 0294). Refer to Change Request 10573 for additional information. |
MODIFS Conditionally Required |
FL 44 |
Modifiers. Use the appropriate modifier on hospice claims, when appropriate. 26 – Use modifier 26 to identify a physician's professional component of a technical service. The modifier may be reported when the patient's attending physician, or a physician who is contracted or employed by the hospice, has provided the professional component of an otherwise technical service. NOTE: When using the 26 modifier, include a brief remark in the "Remarks" field on FISS Claim Page 04 to indicate the service billed is for the professional component of a technical service. GV – Report modifier GV when billing physician services (0657) performed by a nurse practitioner acting as the patient's attending physician. PM – Report modifier PM when billing post-mortem visits provided on the date of death. Note: reporting of post-mortem is required for services on/after April 1, 2014. KX – Report modifier KX to indicate you are requesting an exceptional circumstance for an untimely filed notice of election (NOE). Note: Per Change Request 8877, the KX modifier may be reported for dates of service on/after October 1, 2014. |
TOT UNIT Required |
FL 46 |
Enter the total units for each revenue code line.
This data is required for services on/after April 1, 2014, and before October 1, 2018. For 0636 (injectable drugs), units = amount filled based on the HCPCS description. For 0250, units = as appropriate. For 029X, units = as appropriate. For 0294, units = amount filled based on the HCPCS description. For services provided on or after October 1, 2018, revenue code 0636 is no longer required. Hospices may choose to report the units as '1' or the number of drugs reported during the billing period. Refer to Change Request 10573 for additional information. |
COV UNIT Required |
FL 46 |
Enter the number of covered units for the services billed. For claims with dates of service on or after October 1, 2018, for revenue codes 0250 and 029X, hospices may choose to report the units as '1' or the number of drugs reported during the billing period. Refer to Change Request 10573 for additional information. |
TOT CHARGE Required |
FL 47 |
Enter the total charge per revenue code. The decimal point is optional (i.e. $1500.00 can be entered as 1500.00 or 150000). However, you must enter the two digits for the cents. For more information about determining charges, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 25, §75.5 and the Provider Reimbursement Manual, Part 1, Ch. 22 §§2202, 2203, and 2204 |
NCOV CHARGE Conditionally Required |
FL 48 |
Enter any noncovered charges billed per revenue code. |
SERV DATE Required |
FL 45 |
For each revenue code line, a service date is required.
For revenue code 0250, 0294, and 0636, service date = date drug filled. Revenue code 0636 is not required on claims with dates of service on or after October 1, 2018. Refer to MM1057 for additional information. For revenue code 029X, service date = date pump ordered. NOTE: The service date reported must fall within the FROM and TO date reported on the claim. |
Additional FISS Claim Pages
- Notice of Elections (NOEs)/Transfer NOE
- Hospice Claims
- Notice of Election Termination/Revocation (NOTR) – 8XB
Hospice Revenue Codes
Code |
Description |
---|---|
0001 |
Total charges |
0250 |
Pharmacy General Classification (required April 1, 2014) |
029X |
Durable Medical Equipment (used to report Infusion Pumps/Medications) (required April 1, 2014) 0 – Durable medical equipment - General Classification |
042X |
Physical Therapy 0 – General Classification |
043X |
Occupational Therapy 0 – General Classification |
044X |
Speech Language Pathology 0 – General Classification |
055X |
Skilled Nursing 0 – General Classification |
056X |
Medical Social Services 0 – General Classification 9 – Other (phone calls) |
057X |
Hospice Aide 0 – General Classification |
0636 |
Drugs Requiring Specific Identification (required April 1, 2014) Revenue code 0636 is not required on claims with dates of service on or after October 1, 2018. Refer to MM10573 for additional information. |
0650 |
General Classification (Request for denials) |
0651 |
|
0652 |
|
0655 |
|
0656 |
|
0657 |
|
0659 |
Other Hospice (use this code when billing noncovered room and board ) |
For definitions of each hospice level of care, refer to the Medicare Claims Processing Manual, (CMS Pub. 100-04), Ch. 11, §30.1 .
Hospice HCPCS Codes
The following HCPCS are billed on the level of care revenue code lines to indicate the place where care was provided.
Hospice HCPCS Codes
Code |
Description |
---|---|
Q5001 |
Hospice care provided in patient's home/residence Note: Q5001 cannot be billed with respite (0655) or GIP (0656). |
Q5002 |
Hospice care provided in assisted living facility Note: Q5002 cannot be billed with respite (0655) or GIP (0656). |
Q5003 |
Hospice care provided in nursing long term care (LTC) facility or non-skilled nursing facility (NF). The MLN article clarifies the use of Q5003. If a beneficiary is in a nursing facility that does not meet the criteria as defined by Q5004 (see below), then Q5003 should be reported. Note: Q5003 cannot be billed with GIP (0656). The facility NPI must also be reported in Loop 2310E. |
Q5004 |
Hospice care provided in skilled nursing facility (SNF). The MLN article clarifies the Q5004 should be reported when the beneficiary is:
Note: Q5004 cannot be billed with continuous home care (0652). The facility NPI must also be reported in Loop 2310E. |
Q5005 |
Hospice care provided in inpatient hospital. Note: Q5005 cannot be billed with continuous home care (0652). The facility NPI must also be reported in Loop 2310E. |
Q5006 |
Hospice care provided in inpatient hospice facility. Note: Q5006 cannot be billed with continuous home care (0652). |
Q5007 |
Hospice care provided in long term care facility (LTCH). Note: Q5007 cannot be billed with continuous home care (0652). The facility NPI must also be reported in Loop 2310E. |
Q5008 |
Hospice care provided in inpatient psychiatric facility. Note: Q5008 cannot be billed with continuous home care (0652). The facility NPI must also be reported in Loop 2310E. |
Q5009 |
Hospice care provided in place not otherwise specified (NOS) |
Q5010 |
Hospice care provided in hospice facility. Used for hospice patients when routine home care or continuous home care is provided in:
Note: Q5010 cannot be billed with respite (0655) or GIP (0656). |
The following HCPCS codes are required on the discipline revenue code lines (042X, 043X, 044X, 055X, 056X, 057X).
Code |
Description |
---|---|
G0151 |
Physical Therapy (042X) |
G0152 |
Occupational Therapy (043X) |
G0153 |
Speech Language Pathology (044X) |
G0154 |
Skilled Nursing (055X) NOTE: Not valid for visits on or after January 1, 2016 |
G0155 |
Medical Social Services (056X) |
G0156 |
Hospice Aide (057X) |
G0299 |
Skilled Nursing (055X) Direct skilled nursing services of a registered nurse (RN) in home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016. |
G0300 |
Skilled Nursing (055X) Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes. Effective for visits on or after January 1, 2016. |
Note: The above codes begin with a G and the number zero (G0); not G and the letter 'O'.
In accordance with Change Request 8358 (required effective April 1, 2014), HCPCS code must be reported on revenue code lines 029X and 0636. A list of HCPCS for drugs is available from the CMS website. HCPCS codes for revenue code 029X is not required on claims with dates of service on or after October 1, 2018. Revenue code 0636 is not required on claims with dates of service on or after October 1, 2018. Refer to MM10573 for additional information.
For additional guidance and resources, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 11, §30.3 .
Updated: 05.03.21