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Claim Page 03 — Entering a Hospice Claim

Claim Page 03 (Map 1713) contains payer information, diagnosis code information, and attending and certifying physician information.

Claim screen shot

Key:

  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, depended on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field

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Field Descriptions for Claim Page 03 – Map 1713

The MID, TOB, S/LOC and PROVIDER fields are system generated from information on Claim Page 01.

Field Name Description

CD
Required

Primary payer code. Valid values are:
Z – Medicare
C – Conditional Payment
In limited situations, Medicare secondary payer (MSP) claims and adjustments can be submitted via direct data entry (DDE) using FISS. Review the 'MSP Billing and AdjustmentsPDF ' quick resource tool for additional information.
The following payer codes are only used on line B (secondary payer) and C (tertiary payer) to identify supplemental insurance payers.
1 – Medicaid
2 – Blue Cross
3 – Other

PAYER
Conditionally Required

Payer name. FISS will automatically insert the payer name "Medicare" in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, you must enter the name of the other insurer on the corresponding A, B or C line.

OSCAR
Conditionally Required

Medicare provider number. FISS will automatically insert your OSCAR number (also known as your PTAN) in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, you must enter the name of the other insurer on the corresponding A, B or C line.

RI
Required

Release of Information.
Valid values are:

I

Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes,

Y

Yes, provider has a signed statement permitting release of information.

SERV FAC NPI Conditionally Required

Per Change Request 8358External PDF(Optional for dates of service beginning Jan. 1, 2014; Required for dates of service on/after April 1, 2014) - Enter the NPI of the nursing facility, hospital or hospice inpatient facility where the patient received services. Only required when reporting HCPCS Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 and Q5008.

MEDICAL RECORD NBR
Optional

Beneficiary's medical record number.

DIAG CODES
Required

For claims with a "From" date prior to October 1, 2015, enter  the ICD-9-CM diagnosis code(s) (25 codes maximum). For claims with a "From" date on or after October 1, 2015, enter the ICD-10-CM diagnosis code(s). (25 codes maximum.)

Note:
V-codes cannot be listed as the primary diagnosis on hospice claims.  In addition, effective with dates of service on or after October 1, 2014, certain diagnosis codes as the principal diagnosis are prohibited, including debility, adult failure to thrive, as well as certain dementia codes. See Attachment A in Change Request 8877 for a list of all codes.

ATT PHYS NPI
Required

Enter the national provider identifier (NPI) of the patient's attending physician. The attending physician is identified by the patient at the time they elect the hospice benefit. If the patient does not have an attending physician, enter the NPI of the certifying physician.

L
Required

Enter the last name of the attending physician. If the patient does not have an attending physician, enter the last name of the certifying physician.

F
Required

Enter the first name of the attending physician. If the patient does not have an attending physician, enter the first name of the certifying physician.

M
Optional

Enter the middle initial of the attending physician.

REF PHYS NPI
Conditionally Required

Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician.

L
Conditionally Required

Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

F
Conditionally Required

Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

M
Optional

Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

 

Additional FISS Claim Pages

 

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Updated: 10.02.18

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