US · guidance

CMS Pub. 100-04, ch. 11, § 120

A/B MACs (B) Responsibilities for Publishing Hospice

activein force · 2026-08-25 – presentas-observed

Information

(Rev. 2258, Issued: 07- 29-11, Effective: 01-01-12, Implementation: 01-03-12)

A/B MACs (B) processing professional claims shall, at least annually, include in

newsletters and bulletins to physicians and suppliers an explanation of the hospice

program and the requirements for billing for physicians who serve as the attending

physician to a hospice patient. A/B MACs (B) shall include information on the use of

special modifiers that are in effect at that time. A/B MACs (B) may also publish related

material on Web pages.

130 HOSPICE Pricer Program

(Rev. 3930; Issued: 12-01-17, Effective: 03-01-18, Implementation: 03-01-18)

Hospice services billed on TOB 081x and 082x are reimbursed based on calculations

made by the Hospice Pricer. The Hospice Pricer is a module within Medicare claims

processing systems. The Hospice Pricer makes all payment calculations applicable under

Hospice claims, including all levels of care (Routine Home Care, Continuous Home

Care, Inpatient Respite Care, and General Inpatient Care).

Medicare claims processing systems must send an input record to Pricer for all claims

with covered visits, and Pricer will return an output record to the shared systems. The

following section describes the elements of Hospice claims that are used in the Hospice

Pricer and the logic that is used to make payment determinations. The following is

presented for A/B MACs (HHH) in order to help understand their Hospice payments and

how they are determined.

130.1 Input/Output Record Layout

(Rev. 4393, Issued: 09- 13-19: Effective: 11-25-19, Implementation: 11-25-19)

The required data and format for the Hospice Pricer input/output record are shown below:

FIELD

NAME

FIELD

LAYOUT

POSITION DESCRIPTION

NPI X(10) 1-10 Input item: The billing provider's National Provider

Identifier, copied from the claim.

PROV-NO X(6) 11-16 Input item: The billing provider's CMS Certification

Number (CCN), copied from the claim. (FISS

crosswalks the CCN based on the NPI submitted by the

provider.)

FROM-DATE

9(8) 17-24 Input item: The statement covers period “From” date,

copied from the claim. Date format must be

CCYYMMDD.

ADMISSI

ON- DATE

9(8) 25-32 Input item: The admission date, copied from the

claim. Date format must be CCYYMMDD.

Filler x(10) 33-42

PROV-CBSA

X(5) 43-47 Input item: The CBSA code used to wage -adjust

inpatient levels of care. Copied from the value code G8

amount on the claim

BENE-CBSA

X(5) 48-52 Input item: The CBSA code used to wage-adjust home

levels of care. Copied from the value code 61 amount on

the claim

PROV-

WAGE-

IND

99V9(4) 53-58 Output item: The wage index value that corresponds to

the PROV-CBSA

BENE-

WAGE-

IND

99V9(4) 59-64 Output item: The wage index value that corresponds to

the BENE-CBSA

Day 1

Add-on

Units

x(2) 65-66 Input item: The number of days from a prior hospice

benefit period if identified by CWF as part of the first

60 days of RHC.

Day 2

Add-on

Units

x(2) 67-68 Input item: Not used

EOL Day 1

Add-on

Units

x(2) 69-70 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death. No units input if the lines are

not associated with routine home care (revenue code

0651)

EOL Day 2

Add-on

Units

x(2) 71-72 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 1 day. No units input if

the lines are not associated with routine home care

(revenue code 0651)

EOL Day 3

Add-on

Units

x(2) 73-74 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 2 days. No units input

if the lines are not associated with routine home care

(revenue code 0651)

EOL Day 4

Add-on

Units

x(2) 75-76 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 3 days. No units input

if the lines are not associated with routine home care

(revenue code 0651)

EOL Day 5

Add-on

Units

x(2) 77-78 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 4 days. No units input

if the lines are not associated with routine home care

(revenue code 0651)

EOL Day 6

Add-on

Units

x(2) 79-80 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 5 days. No units input

if the lines are not associated with routine home care

(revenue code 0651)

EOL Day 7

Add-on

Units

x(2) 81-82 Input item: The sum of the units associated with revenue

codes 055x (if G0299 present) and 056x (other than

0569) on the date of death minus 6 days. No units input

if the lines are not associated with routine home care

(revenue code 0651)

Filler x(10) 83-92

QIP-

REDUCTI

ON- IND

x 93 Input item: An indicator of whether the hospice's

payments are subject to the 2% reduction for not

reporting quality data. Copied from field 74 on the

Outpatient Provider Specific File. Valid values: blank =

no reduction, 1 = 2% reduction applies. See CR 8241

for details.

REV1 X(4) 94-97 Input item: Revenue code 0651 (if present) copied from

the claim.

HCPC1 X(5) 98-102 Input item: HCPCS G code associated with revenue code

0651, copied from the claim.

Line

Item

DOS1

9(8) 103-110 Input item: The line item date of service associated with

revenue code 651, copied from the claim.

UNITS1 9(7) 111-117 Input item: The number of units associated with revenue

code 0651, copied from the claim. This represents the

number of days of routine home care to be paid.

THEIR-PAY-

CHG1

9(6)V99 118-125 Output item: The total payment to be made on the

revenue code 0651 line.

REV2 X(4) 126-129 Input item: Revenue code 0652 (if present) copied from

the claim.

HCPC2 x(5) 130-134 Input item: HCPCS G code associated with revenue code

0652, copied from the claim.

Line

Item

DOS2

9(8) 135-142 Input item: The line item date of service associated with

revenue code 652, copied from the claim.

UNITS2 9(7) 143-149 Input item: The number of units associated with

revenue code 0652, copied from the claim. This

represents the number of 15 minute increments of

continuous home care to be paid.

THEIR-PAY-

CHG2

9(6)V99 150-157 Output item: The total payment to be made on the

revenue code 0652 line.

REV3 X(4) 158-161 Input item: Revenue code 0655 (if present) copied from

the claim.

HCPC3 x(5) 162-166 Input item: HCPCS G code associated with revenue code

0655, copied from the claim.

Line

Item

DOS3

9(8) 167-174 Input item: The line item date of service associated with

revenue code 655, copied from the claim.

UNITS3 9(7) 175-181 Input item: The number of units associated with revenue

code 0655, copied from the claim. This represents the

number of days of inpatient respite care to be paid.

THEIR-PAY-

CHG3

9(6)V99 182-189 Output item: The total payment to be made on the

revenue code 0655 line.

REV4 X(4) 190-193 Input item: Revenue code 0656 (if present) copied from

the claim.

HCPC4 x(5) 194-198 Input item: HCPCS G code associated with revenue code

0656, copied from the claim.

Line

Item

DOS4

9(8) 199-206 Input item: The line item date of service associated with

revenue code 656, copied from the claim.

UNITS4 9(7) 207-213 Input item: The number of units associated with revenue

code 0656, copied from the claim. This represents the

number of days of general inpatient care to be paid.

THEIR-PAY-

CHG4

9(6)V99 214-221 Output item: The total payment to be made on the

revenue code 0656 line.

NA Day 1

Add-on

Pay

9(6)V99 222-229 Output item: Not used

NA Day 2

Add-on

Pay

9(6)V99 230-237 Output item: Not used

EOL Day 1

Add-on Pay

9(6)V99 238-245 Output item: Payment associated with the corresponding