Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix G

A. Completion of the National Uniform Billing Claim Form (UB-04)

NOTE: Form Locators (FL) not required by Georgia DMA are not included in these

Instructions.

FL 1 Provider Name, Mailing Address, and Telephone Number

Enter the name of the provider submitting the bill, the complete mailing address, and telephone number.

FL 2 Pay-to Name, Pay-to Address, Pay-to city, State

Enter the name of the provider, the complete mailing address and telephone number for Pay-to information.

FL 3A Patient Control Number

Enter the patient’s unique alpha-numeric number assigned by the provider to

facilitate retrieval of individual case records and posting of payment.

FL 3B Medical Record Number

Enter the number assigned to the patient’s medical/health record by the provider.

NOTE:

The medical/health record number is typically used in auditing the history of Treatment and can expedite the

processing of claims when medical records are required. It should not be submitted for the Patient Control

Number (FL3A) which is assigned by the provider to facilitate retrieval of the individual financial record.

FL 4 Type of Bill

Enter 813 or 823 as the type of bill (e.g. interim, final)

FL5 Federal Tax Number

Enter the provider’s federal identification number.

FL 6 Statement Covers Period

Enter the beginning and ending service date (s) of the period included on this bill.

FL 8 Patient Name

Enter last name, first name, and middle initial of the patient. If the name on the Medicaid card is

incorrect, the member or the member’s representative should contact the local DFCS to have it corrected

immediately.

FL 9 Patient Address

Enter the full mailing address including street number and name of post office box number or RFD, city

name: state name; zip code.

FL 10 Patient Birth date

Record date of birth exactly as it appears on the Medicaid card. An unknown birth date is not acceptable.

If the date on the Medicaid card is incorrect, the member or the member’s representative should contact

the DFCS to have it corrected immediately.

FL 11 Patient Sex

Enter the sex of the patient as “M” for male or “F” for female. If the sex on the Medicaid card is

incorrect, the member or the member’s representative should contact DFCS to have it corrected

immediately.

FL 12 Admission Date

The admission date or hour is no longer permitted on Hospice outpatient claims when submitted

electronically via Web Portal, EDI 837 I (institutional claims) 5010 version, and Provider Electronic

Solution (Gainwell Technologies’s electronic claim submission software) 5010 version.

FL 14 Type of Admission

Enter the appropriate code to indicate the priority of this admission.

(3) Elective-the patient’s condition permits adequate time to schedule the availability a stable

accommodation.

FL 15 Source of Admission

Enter the appropriate code to indicate the source of this admission. Enter code structure (for Emergency,

Elective, or Other Type of Admission).

1 - Physician Referral

2 - Clinic Referral

3 - HMO Referral

4 - Transfer from a Hospital

5 - Transfer from a Skilled Nursing Home

6 - Transfer from Another Health Facility

7 - Emergency Room

8 - Court/Law Enforcement

9 - Information Not Available

FL 17 Patient Discharge Status

Enter a code indicating patient status as of the “Statement covers thru date”.

Effective for claims with a Date of Service (DOS) on or after 9/1/2016, Patient Discharge Status 20

(expired) is no longer accepted for Hospice SIA claims with DOS on or after 9/1/2016.

Only PDS 40, 41, or 42, may be used for SIA claims.

Use the applicable code from the list below:

01 - Discharged to home or self-care (routine discharge)

02 - Discharged/transferred to another short-term general hospital

03 - Discharged/transferred to skilled nursing facility (SNF)

04 - Discharged/transferred to an intermediate care facility (ICF) 05 Discharged/transferred to another

type of institution

06 - Discharged/transferred to home under care of organized home health service organization

07 - Left against medical advice

30 - Still patient

40 - Expired at home

41 - Expired in a medical facility (e.g., hospital, SNF, ICF, or freestanding hospice)

42 - Expired- place unknown

FL 39-41 Value Code

It is necessary to fill in the Value Code Section on all hospice claims except for

claims for Revenue Code 659-- hospice nursing facility room and board, On the paper UB04 Form this

is field #s 39-41.

Regional Codes:

In the Value Code field enter 61 as the Value code. In the Amount field next to the value code enter the

Regional Code followed by a decimal and two zeros (i.e., 3.00). The following is a list of Regional

Codes that are associated with your Region.

Rural GA counties not listed in the regions shown below will be covered under GA Rural Region 8. (See

Appendix A, pgs. A-1 and A-2)

Rural AL counties not listed in the regions shown below will be covered under AL Rural Region 12.

(See Appendix A)

Regional Codes

Effective Dates 10/01/2025

Regions

Albany, GA 1

Athens – Clark County, GA 2

Atlanta – Sandy Springs – Roswell, GA 3

Augusta – Richmond County, GA - SC 4

Macon – Bibb County, GA 5

Savannah, GA 6

Columbus, GA - AL 7

GA Rural Area 8

Chattanooga, TN - GA 9

Dothan, AL 10

Greenville – Anderson – Greer, SC 11

AL Rural Area 12

Gainesville, GA 20

Valdosta, GA 21

Brunswick – St. Simons, GA 25

Dalton, GA 26

South Carolina Rural Area 28

Hinesville, GA 31

Warner Robins, GA 32

Rome, GA 34

Marietta, GA 35

Georgia 36

Covered Days:

In the Value Code field enter 80. In the Amount field next to the value code enter the number of days in

whole numbers to the left of the dotted line.

Non-Covered Days:

In the Value Code field enter 81. In the Amount field next to the value code enter the number of days in

whole numbers to the left of the dotted line.

FL 42 Revenue Code

Enter the appropriate Revenue Code from the list below. When billing the following Hospice Revenue

Codes, providers must select the most appropriate CPT code, and a valid CPT code, as indicated below,

must be present for the claim to adjudicate successfully.

651 Routine Home Care (RTN Home)

When billing for revenue code 651, procedure codes (Q5001-Q5010) must be present.

652 Continuous Home Care (CTNS Home)

A minimum of 8 hours not necessarily consecutive, in a 24-hour period is required. Less than 8 hours is

routine home care for reimbursement purposes. A portion of an hour is 1 hour. 1 unit is billed for each

hour. When billing for revenue code 652, procedure codes (Q5001-Q5003, Q5009Q5010) must be

present.

655 Inpatient Respite Care (IP Respite)

When billing for revenue code 655, procedure codes (Q5003-Q5009) must be present.

656 General Inpatient Care (GNL IP)

When billing for revenue code 656, procedure codes (Q5004-Q5009) must be present.

657 Physician Services (PHY SVCS) (CPT Code required)

Note: If Revenue Code 657 is billed, attending Physician ID in Field 76 must be completed on the

UB04.

659 Nursing Home

*Other /NH RB (use of this revenue code requires Room & Board that field 83 includes Medicaid

Provider number of the nursing facility). Additionally, field 84 should have the Nursing Facility’s name

and address listed.

NOTE:

Month-to-month span billing is not allowed. Claims that cross span months or years will deny and will

not adjudicate successfully due to the span billing.

Effective January 1, 2008, all payment rates (routine home care, continuous home care, inpatient respite

and general inpatient care) will be adjusted by the geographic wage index value of the area where

hospice services are provided. In other words, the wage component of each payment rate is multiplied

by the wage index value applicable to the location in which the hospice services are provided. Hospice

providers will be required to indicate on hospice claims, the Core Based Statistical Area (CBSA) for the

location where hospice care is provided.

001 Total Charge TTL CHG

FL 43 Revenue Description

Enter a narrative description or standard abbreviation for each Revenue code shown in column 51 on the

adjacent line in column 42. The information assists clerical bill review. The description and

abbreviations should correspond with the revenue codes as defined in the l992 Georgia Uniform Billing

Manual.

FL 44 CPT/HCPCS/Rates

When billing for revenue code 657 a valid CPT-4 code must be entered.

FL 45 Service Date

Enter the line-item service date.

FL 45 Creation Date (Line 23)

FL 46 Units of Service

Enter the units of service or number of days associated with Revenue Codes in FL 42.

FL 47 Total Charges (by Revenue Category)

Enter the total charges pertaining to the related revenue code for the current billing period as entered in

the statement covers period. Only charges relating to the covered eligibility dates should be included in

total charges. The figures in this field add up to a total which is reported in this FL using revenue code

001.

FL 50 A, B, C Payer

Hospice providers must enter the letter ‘D’ in this field.

A reasonable effort must be made to collect all benefits from other third-party coverage. Federal

regulations require that Medicaid be the payer of last resort. (See Chapter 300 of the Policies and

Procedures Manual applicable to all Medicaid providers.) When a liable third-party carrier is identified

on the card, the provider must bill the third party.

NOTE: Lines A, B, and C are used for FL 50 through 65 to indicate primary (A), secondary

(B) and tertiary (C) payers. For examples: If Medicaid is the primary payer listed on line (A) of FL 50,

Medicaid information must be listed on line (A) through FL 65.

FL 51 Health Plan ID

A, B, C Enter provider number for each payer listed in 50.

FL 54 A, B, C Prior Payments

Enter the amount that the hospital has received toward payment of this bill from the carrier.

FL 55 A, B, C Estimate Amount Due

Enter the estimated amount due from Medicaid, generally equals the patient liability.

FL 56 National Provider ID

Enter the National Provider ID of the Provider.

FL 57 A, B, C Other Provider ID

Enter other provider identifiers as assigned by the health plan as indicated in FL 50 A, B, C

FL 58 A, B, C Insured’s Name

Enter the insured’s last name, first name, and middle initial. Name must correspond with the name on

the Medicaid card. If the name on the Medicaid care is incorrect, the member or the member’s

representative should contact the local DFCS to have it corrected immediately.

A number or other indicator which designates that the treatment covered by this bill has been authorized

by the DMA. Enter the 6-digit authorization number as required for inpatient hospital admissions and

selected outpatient procedures, if applicable.

FL 59 A, B, C Patient’s Relationship to Insured

Enter relationship of the patient to the identified insurer, if applicable, for each payer listed in Field

Locator 50.

FL 60 A, B, C Insured’s Unique ID

Enter Medicaid member’s identification number on the Medicaid card or the approval letter (for the

member being treated) to the line associated with Medicaid in field locator box 50. Enter appropriate ID

numbers for any other payers identified in field locator box 50.

FL 61 A, B, C Insurance Group Name

Enter other payer’s group/employer name.

FL 62 A, B, C Insurance Group Number

Enter group number, if applicable, for each coverage listed in Field

Locator 50

FL 65 Employer Name

Enter name, if applicable, for each payer listed in Field Locator 50.

FL 66 Diagnosis and Procedure Code Qualifier (ICD Version Indicator)

Enter the version of International Classification of Diseases (ICD)

reported.

Effective 10/1/2015, GA Medicaid will only accept ICD-10 codes.

FL 67 Principal Diagnosis Code

Enter the ICD-10 CM code for the principal diagnosis appearing in FL76. Effective 10/1/2015, enter the

ICD-10 CM code. Codes prefixed in ‘E’ or ‘M’ are not accepted by the Division. A limited number of

‘V’ Codes are accepted.

FL 69 Admitting Diagnosis

Enter the ICD-10 CM diagnosis code provided at the time of admission as stated by the physician.

Effective 10/1/2015, enter the ICD-10 CM code.

FL 76 Attending Physician ID

Enter the name or number assigned by Medicaid (or the state license number) to the physician attending

the patient. This is the physician primarily responsible for the care of the patient. Note: If Revenue Code

657 is billed, this field must be completed on the UB04.

FL 78 Other Provider Identifiers NPI)

Enter the name and ID number of the individual corresponding to the provider type qualifiers: DN:

Referring Provider; ZZ: Other Operating MD; and 82: Rendering Provider. Secondary ID

qualifiers: OB: State License number; 1G: Provider UPIN; and G2: Provider Commercial

number, if applicable. Hospice must use field 78. (Do not enter any information in field 79).

NOTE:

Revenue Code 657 is used on FL 42 to indicate the physician’s or nurse practitioner’s hands-on visit to

the Medicaid member. The hospice provider submits the UB-04 claim using Revenue Code 657 on the

line item for the professional service of the hospice physician/nurse practitioner, the appropriate HCPCS

code for the applicable time spent (one [1] unit allowed) and the date of the service. Non-hospice

physicians, e.g. consultants, should bill on the CMS-1500 for the member’s professional services that

are not related to the terminal illness.

B. The allowed procedure codes for use with Hospice Revenue Code 657:

i. 99212

Office or other outpatient visit for the evaluation and management of an established patient,

which requires at least 2 of these 3 key components:

1. A problem focused history

2. A problem focused examination

3. Straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are

self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family

ii. 99213

Office or other outpatient visit for the evaluation and management of an established patient, which

requires at least 2 of these 3 key components:

4. An expanded problem focused history

5. An expanded problem focused examination

6. Medical decision making of low complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15

minutes face-to-face with the patient and/or family.

iii. 99214

Office or other outpatient visit for the evaluation and management of an established patient, which

requires at least 2 of these 3 key components:

7. A detailed history

8. A detailed examination

9. Medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25

minutes face-to-face with the patient and/or family.

iv. 99215

Office or other outpatient visit for the evaluation and management of an established patient, which

requires at least 2 of these 3 key components:

10. A comprehensive history

11. A comprehensive examination

12. Medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40

minutes face-to-face with the patient and/or family.

Hospice providers (Provider Contract, COS 690) who have experienced these claims denials will be able

to submit new claims to replace those that denied using the correct procedure code(s).

Hospice Providers will have thirty (30) days from the posting date of this notice to do so. Following the

thirty (30) day period of resubmission, Georgia Medicaid will perform a Mass Adjustment to reprocess

the new claims to override timely filing only. Only those claims submitted cleanly, and which only deny

for timely filing only will successfully adjudicate in this one-time mass adjustment to allow hospice

claims for physician services.

NOTE:

For electronic claim submission, the nursing facility provider number should be entered in Field 78.

Placement of the nursing facility provider number in any other field will result in claim denial for

exception 4106 – Rate Record Not Found