N.H. Medicaid Hospice Provider Manual, Vol. II, § 11, UB04 Claim Completion Instructions

Box 1

Enter the name of the hospice provider, address, city/town, zip and phone number.

Box 2

Not applicable

Box 3a

Patient Control Number – optional

Box 3b

Medical Record Number – optional

Box 4

Type of Bill - required

1st Digit:

Type of Facility

Choose “8” to designate Special (Hospice)

2nd Digit:

Classification (Special Facility)

Choose “1” to designate Hospice (Non-hospital based); or

Choose “2” to designate Hospice (Hospital based)

3rd Digit

Frequency

Choose 3rd digit based on Table 1, below

TABLE 1 - “FREQUENCY”

Frequency

(3rd Digit)

Description

0

Nonpayment/Zero Claims - Use when no payment from Medicare is anticipated.

1

Admit thru Discharge Claim - Use for a bill encompassing an entire course of

hospice treatment for which the provider expects payment from the payer, i.e. no

further bills will be submitted for this patient.

2

Interim - First Claim - Use for the first of an expected series of payment bills for a

hospice course of treatment.

3

Interim – Continuing Claim - Use when a payment bill for a hospice course of

treatment has already been submitted, and further bills are expected to be

submitted.

4

Interim – Last Claim - Use for a payment bill that is the last of a series for a

hospice course of treatment. The “through” date of the bill is the discharge date,

transfer date, or date of death.

5

Late Charges - Use this code for late charges that need to be billed. Late charges

can be submitted only for revenue codes not on the original bill.

7

Replacement of Prior Claim - Use when the provider wants to correct a previously

submitted bill. Use this code on the “new” bill.

8

Void/Cancel of a Prior Claim-Use to cancel a previously processed claim.

Box 5

Federal Tax Number

Box 6

Statement of Covered

Period - enter the beginning and ending service dates included on

this bill. For all services rendered on a single day, use both the from and through dates.

Indicate dates in MMDDYY format.

Box 7

Not applicable

Box 8a

Patient Identifier – Not applicable

Box 8b

Patient Name – Last name, first name, and middle initial of the member.

Box 9a

Patient Address – street

Box 9b

Patient Address – city

Box 9c

Patient Address – state

Box 9d

Patient Address – zip code

Box 9e

Patient Address – country code (optional)

Box 10

Birthdate – entered in the MMDDYY format

Box 11

Sex – enter M for male and F for female

Box 12

Admission Date – enter the date that the member entered hospice care.

Box 13

Admission Hour – optional

Box 14

Admission Type – Not applicable

Box 15

Admission SRC – Not applicable

Box 16

Discharge Hour – Not applicable

Box 17

Member Status Codes – Refer to Table 2 below to enter the status code indicating the

members discharge status as of the ending of the service date period covered on this bill

TABLE 2 – “MEMBER STATUS CODE”

Member

Status Codes

Description

01

Discharged to home or self-care, routine discharge

02

Discharged or transferred to another short term general hospital for inpatient

care

03

Discharged or transferred to skilled nursing facility (SNF)

04

Discharged or transferred to an intermediate care facility (ICF)

05

Discharges or transferred to a designated cancer center or children’s hospital

06

Discharged or transferred to home under the care of a home health agency

07

Left against medical advice or discontinued care

08

Discharged or transferred to home under the care of a home infusion provider

20

Expired

30

Still a hospice member

40

Expired at home

41

Expired in a medical facility, such as a hospital, SNF, ICF or free standing

hospice house

50

Discharged to hospice - home

51

Discharged to hospice – medical facility

62

Discharged or transferred to another rehabilitation facility

63

Discharged or transferred to a long-term care hospital

64

Discharged or transferred to a Medicaid certified nursing facility but not

Medicare certified

65

Discharged or transferred to a psychiatric hospital or psychiatric distinct part

unit of a hospital

70

Discharged or transferred to another type of healthcare institution not defined

elsewhere in the code list

Boxes 18 – 37

Not applicable

Box 38

Unlabeled

Boxes 39- 41

Medicare value codes – Not applicable

Box 42

Revenue Codes –Refer to Table 3 below. Use the specific revenue code that

identifies the level of care and the detail of the visits type. The appropriate three-

digit numerical revenue code must be entered to explain each charge entered.

Refer to the section of the manual that outlines covered services, description of

the level of care, limitations and Medicaid rules

TABLE 3 – “REVENUE CODES”

Revenue

Code

Description of Care

Units Reported In

421

Physical Therapy

Number of visits

431

Occupational Therapy

Number of visits

441

Speech Therapy

Number of visits

551

Skilled Nursing Visit

Number of visits

561

Medical Social Worker Visit

Number of visits

569

Other Medical Social Worker Service

Per time of the phone call

571

Home Health Aide

Number of visits

651

Routine Home Care

Per day

652

Continuous Home Care

Per hour

655

Inpatient Respite Care

Per day

656

General Inpatient Care

Per day

657

Hospice Physician

Number of Procedure Codes performed by

the physician

Box 43

Description – enter a narrative description of the related revenue code or procedure code.

Box 44

HCPCS – Use the Healthcare Common Procedure Coding System (HCPCS) code

applicable to the service provided. See Table 4 for commonly used HCPCS codes.

TABLE 4 – COMMON HCPCS CODES

Box 44

Location - This field is also used to indicate where the hospice services were provided.

All hospice levels of care must be reported with a HCPCS code that identifies the

location where that level of care was provided. If there are different, or multiple locations

where the care was provided, each location is to be identified with the corresponding

HCPC code as a separate and distinct line item.

Code

Short Description

Q5001

Hospice care provided in a member’s home

Q5002

Hospice care provided in assisted living facility

Q5003

Hospice care provided in long term care nursing facility (LTC) or non-skilled nursing

facility

Q5004

Hospice care provided in skilled nursing facility (SNF)

Q5005

Hospice care provided in inpatient hospital

Q5007

Hospice care provided in long term care facility (LTCH)

Q5008

Hospice care provided in inpatient psych

Service

HCPCS

Required Detail

Physical Therapy

G0151

Each visit is identified on a separate line with the appropriate

line item, date of service and the charged amount. The units are

reported on the claim are the multiplier for the total time of the

visit defined in the HCPCS description.

Occupational

Therapy

G0152

Each visit is identified on a separate line with the appropriate

line item, date of services and the charged amount. The units are

reported on the claim are the multiplier for the total time of the

visit defined in the HCPCS description.

Speech Therapy

–

Language Pathology

G0153

Each visit is identified on a separate line item with the

appropriate line item, date of service, and a charge amount. The

units reported on the claim are the multiplier for the total time of

the visit defined in the HCPCS description.

Skilled Nursing

G0154

Each visit is identified on a separate line item with the

appropriate line item, date of service, and a charge amount. The

units reported on the claim are the multiplier for the total time of

the visit defined in the HCPCS description.

Medical

Social

Worker

G0155

Each visit is identified on a separate line item with the

appropriate line item, date of service, and a charge amount. The

units reported on the claim are the multiplier for the total time of

the visit defined in the HCPCS description

Other Medical Social

Worker Services

G0155

Each visit is identified on a separate line item with the

appropriate line item, date of service, and a charge amount. The

units reported on the claim are the multiplier for the total time of

the visit defined in the HCPCS description

Home Health Aide

G0156

Each visit is identified on a separate line item with the

appropriate line item, date of service, and a charge amount. The

units reported on the claim are the multiplier for the total time of

the visit defined in the HCPCS description

Q5009

Hospice care provided in a place not otherwise specified

Box 45

Service Date – provide the date that the service was rendered.

Box 46

Service Units – provide the number of units corresponding to the revenue code or

procedure code. Units must be billed using whole numbers.

Box 47

Total Charges – enter the total charges pertaining to the related revenue code for the

statement coverage period.

Box 48

Non-Covered Charges – Not applicable

Box 49

Unlabeled Field – Not applicable

Box 50

Payer Name – enter the applicable payor name

Box 51

Health Plan ID- enter the provider ID number

Box 52

Rel Info – Not applicable

Box 53

Assignment of Benefits – Not applicable

Box 54

Prior Payments – Not applicable

Box 55

Estimated Amount Due – Not applicable

Box 56

NPI – enter the 10-digit NPI for the billing provider

Box 57

Other Provider ID – Not applicable

Box 58

Insured Name – enter the member’s last name, first name and middle initial

Box 59

P. Rel – Not applicable

Box 60

Insured’s Unique ID – enter the member’s 11-digit identification number

Box 61

Group Name – Not applicable

Box 62

Insurance Group Number – Not applicable

Box 63

Treatment Authorization Codes – Not applicable

Box 64

Document Control Number – Not applicable

Box 65

Employer Name – Not applicable

Box 66 - 67

Diagnosis Codes – provided the ICD-9 CM code corresponding to the condition

Boxes 68-75

Admit Diagnosis, Patient Reason Diagnosis, PPS Code, Principal Procedure Code,

and Other Procedure - Not applicable

Box 76

Attending Physician ID – enter the attending physicians 10-digit numeric NPI

number, physicians last name and first name

Box 77

Operating Physician ID - enter the operating physicians 10-digit numeric NPI

number, physicians last name and first name

Box 78

Other – enter other physician’s (referring/ PCP physician) 10-digit numeric NPI

number, physicians last name and first name

Box 80

Remarks – use this field for claim note text

Box 81CC

Additional Codes – Not applicable