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Reason Code Search and Resolution

Disclaimer: This is not a complete listing of reason codes.

This Reason Code Search and Resolution tool has been designed to aid Medicare providers in reviewing reason codes and how to resolve the edit or use them for determining if other action is needed. You may search this database by reason code or keyword. All records matching your search criteria will be returned for your review. Or, if you wish, you may also view the entire listing of reason codes, their descriptions, resolutions, and additional billing information by clicking on the "Show all Reason Codes" option.

If no reason code displays, access the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) and select Option 17 “Reason Codes” from the Inquiry Menu to review the reason code description. For additional information refer to the Chapter 3: Inquiry MenuPDF of the FISS DDE Guide.

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Reason Code U5181

Description:

Hospices use occurrence code (OC) 27 and the date on all notices of election (NOEs) and initial claims following a hospice election. OC 27 and the date are also required on all subsequent claims when the claim's dates of service overlap the first day of the next benefit period. When OC 27 is required, but not reported, or does not include the correct date, the NOE or claim will receive this reason code.

Resolution:

Hospices use occurrence code (OC) 27 and the date on all notices of election (NOEs) and initial claims following a hospice election. OC 27 and the date are also required on all subsequent claims when the claim’s dates of service overlap the first day of the next benefit period. When OC 27 is required, but not reported, or does not include the correct date, the NOE or claim will receive this reason code.

Resolution:

  • Ensure OC 27 is submitted on all NOEs in field locator (FL) 31-34 of the CMS-1450 (UB-04) claim form. The OC 27 date must match the "From" date (FL 6) and "Admit Date" (FL 12) on the NOE.
    • For example: The beneficiary elected the hospice benefit on December 4, 20YY. When submitting the NOE, the "From" date, "Admit date" and OC 27 date must all be 1204YY.

U5181

  • Ensure OC 27 is submitted on an initial claim (the first claim following a beneficiary’s hospice election). The OC 27 date must match the "from" date and the "Admit date" on an initial claim.
    • Example: The beneficiary elected the hospice benefit on December 4, 20YY. The initial claim’s "From" and "To" dates are December 4 to December 31, 20YY. OC 27 and the date, 1204YY, are required on the claim.

U5181

  • Ensure OC 27 is submitted on subsequent claims when the claim’s dates of service overlap the first day of the next benefit period. When the recertification is obtained timely (by the end of the third calendar date after the new benefit period starts), the OC date must be the first day of the new benefit period. (For untimely recertifications, see below.)
    • Example: Using our previous scenario, the 1st day of the next benefit period is March 4, 20YY (90 days from December 4, 20YY). A claim with dates of service March 1 to March 31, 20YY, would require the OC 27 with the 0304YY date.

U5181

  • For transfer situations report OC 27 on our first claim. The date used with OC 27 is based on which benefit period the claim falls within or overlaps.
    • If a patient is in the first certification period when they transfer, the receiving hospice would report OC 27 with the same certification date as the previous hospice.
    • If a patient is in the next certification period when they transfer, the receiving hospice would report OC 27 with the with the next certification period date. For example, the first benefit period was from 5/25 to 8/22. The next benefit period begins on 8/23 and the patient was transferred to your agency on 9/5. Therefore, the receiving hospice would report OC 27 with the date of 8/23.
  • For untimely recertifications, the OC 27 date cannot fall within the occurrence span code (OSC) 77 dates. When a recertification is not obtained timely (by the end of the third calendar day), ensure OSC 77 is submitted on the claim in FL 35. The OC 27 and date must reflect the date the recertification was actually obtained; it cannot occur within the OSC 77 dates.
    • Example: The new benefit period began on March 3, 20YY. However, the recertification was not obtained until March 8. As a result, OSC 77 is used to indicate the noncovered days 0303YY to 0307YY. The OC 27 date indicates the date the recertification was actually obtained: 0308YY.

U5181

  • Verify the correct OC 27 date using ELGH/ELGA. The majority of errors for U5181 occur because the date submitted with OC 27 is incorrect. The eligibility systems, ELGH or ELGA, can be used to determine/verify the first day of the next hospice benefit period, and thus, the correct OC 27 date. The next benefit period begins one day after the "Term Date" of the previous benefit period. This is the correct date to use with OC 27.
    • Example: ELGH Page 19 shows the prior benefit period’s "Term Date" as 03/03/YY. The next benefit period would begin on 03/04/20YY. As a result, the March claim must include OC 27 with the date 0304YY (the first day of the next benefit period.)

U5181

Ensure OC 27 is submitted correctly. If OC 27 is required, but is missing from the NOE/claim, or the date associated with OC 27 is incorrect, the NOE/claim will be sent to your RTP file with reason code U5181.


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