CMS Pub. 100-04, ch. 4, § 260.5

Hospitals other than CAHs are required to report line item dates of service per revenue

code line for partial hospitalization claims. Where services are provided on more than

one day included in the billing period, the date of service must be identified. Each

service (revenue code) provided must be repeated on a separate line item along with

the specific date the service was provided for every occurrence. See examples below

of reporting line item dates of service. These examples are for group therapy services

provided twice during a billing period.

For the claims, report as follows:

Revenue

Code HCPCS

Dates of

Service Units

Total

Charges

0915 G0410 20240505 1 $80.00

0915 G0410 20240529 2 $160.00

NOTE: Information regarding the Form CMS-1450 form locators that correspond

with these fields is found in Chapter 25 of this manual. See the ASC X12 837

Institutional Claim Implementation Guide for related guidelines for the electronic

claim.

The A/B MAC (A) must return to the hospital (RTP) claims where a line item date of

service is not entered for each HCPCS code reported, or if the line item dates of

service reported are outside of the statement covers period. Line item date of service

reporting is effective for claims with dates of service on or after June 5, 2000.