CMS Pub. 100-04, ch. 11, § 30.3

See Pub. 100-02, Medicare Benefit Policy Manual, chapter 9, for coverage requirements for Hospice

benefits. This section addresses only claims submission. Before submitting claims, the hospice must

submit a Notice of Election (NOE) to the A/B MAC (HHH).

See section 20, of this chapter for information on NOE transaction types.

The Social Security Act at §1862 (a)(22) requires that all claims for Medicare payment must be

submitted in an electronic form specified by the Secretary of Health and Human Services, unless an

exception described at §1862 (h) applies. The electronic format required for billing hospice services

is the ASC X12 837 institutional claim transaction.

Since the data structure of this transaction is difficult to express in narrative form and to provide

assistance to small providers excepted from the electronic claim requirement, the instructions below

are given relative to the data element names on the Form CMS-1450 hardcopy form. Each data

element name is shown in bold type. Information regarding the form locator numbers that

correspond to these data element names is found in Chapter 25.

Because claim formats serve the needs of many payers, some data elements may not be needed by a

particular payer. Detailed information is given only for items required for

Medicare hospice claims. Items not listed need not be completed although hospices may complete

them when billing multiple payers.

Provider Name, Address, and Telephone Number The hospice

enters this information for their agency. Type of Bill

The hospice enters on of the following Type of Bill codes: 081x – Hospice

(non-hospital based)

082x – Hospice (hospital based)

4th Digit – Frequency Definition

0 - Nonpayment/Zero Claims Used when no payment from Medicare is

anticipated.

l - Admit Through Discharge Claim This code is used 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 This code is used for the first of an expected

series of payment bills for a hospice course

of treatment.

3 - Interim - Continuing Claim This code is used when a payment bill for a

hospice course of treatment has already been

submitted and further bills are expected to

be submitted.

4th Digit – Frequency Definition

4 - Interim - Last Claim This code is used for a payment bill that is

the last of a series for a hospice course of

treatment. The “Through” date of this bill is

the discharge date, transfer date, or date of

death.

7 - Replacement of Prior Claim This code is used by the provider when it

wants to correct a previously submitted bill.

This is the code used on the corrected or

“new” bill.

8 - Void/Cancel of a Prior Claim This code is used to cancel a previously

processed claim.

Statement Covers Period (From-Through)

The hospice shows the beginning and ending dates of the period covered by this bill in numeric fields

(MM-DD-YY). The hospice does not show days before the patient’s entitlement began.

Statement periods should follow the frequency of billing instructions in section 90.

Patient Name/Identifier

The hospice enters the beneficiary’s name exactly as it appears on the Medicare card.

Patient Address Patient Birth date Patient Sex

The hospice enters the appropriate address, date of birth and gender information describing the

beneficiary.

Admission/Start of Care Date

The hospice enters the admission date, which must be the same date as the effective date of the hospice

election or change of election. The date of admission may not precede the physician’s certification by

more than 2 calendar days.

The admission date stays the same on all continuing claims for the same hospice election.

Patient Discharge Status

This code indicates the patient’s status as of the “Through” date of the billing period. The hospice

enters the most appropriate National Uniform Billing Committee (NUBC) approved code.

NOTE: that patient discharge status code 20 is not used on hospice claims. If the patient has died

during the billing period, use codes 40, 41 or 42 as appropriate.

Medicare regulations at 42 CFR 418.26 define three reasons for discharge from hospice care:

1) The beneficiary moves out of the hospice’s service area or transfers to another

hospice,

2) The hospice determines that the beneficiary is no longer terminally ill or

3) The hospice determines the beneficiary meets their internal policy regarding

discharge for cause.

Each of these discharge situations requires different coding on Medicare claims. Reason 1: A

beneficiary may move out of the hospice’s service area either with, or without, a transfer to another

hospice. In the case of a discharge when the beneficiary moves out of the hospice’s service area

without a transfer, the hospice uses the NUBC approved discharge status code that best describes the

beneficiary’s situation and appends condition code 52. The hospice does not report occurrence code

42 on their claim. This discharge claim will terminate the beneficiary’s current hospice benefit period

as of the “Through”

date on the claim. The beneficiary may re-elect the hospice benefit at any time as long they remain

eligible for the benefit.

In the case of a discharge when the beneficiary moves out of the hospice’s service area and transfers

to another hospice, the hospice uses discharge status code 50 or 51, depending on whether the

beneficiary is transferring to home hospice or hospice in a medical facility. The hospice does not

report occurrence code 42 on their claim. This discharge claim does not terminate the beneficiary’s

current hospice benefit period. The admitting hospice submits a transfer Notice of Election (type of

bill 8xC) after the transfer has occurred and the beneficiary’s hospice benefit is not affected.

Reason 2: In the case of a discharge when the hospice determines the beneficiary is no longer

terminally ill, the hospice uses the NUBC approved discharge status code that best describes the

beneficiary’s situation. The hospice does not report occurrence code 42 on their claim. This

discharge claim will terminate the beneficiary’s current hospice benefit period as of the "Through”

date on the claim.

Reason 3: In the case of a discharge for cause, the hospice uses the NUBC approved discharge status

code that best describes the beneficiary’s situation. The hospice does not report occurrence code 42

on their claim. Instead, the hospice reports condition code H2 to indicate a discharge for cause. The

effect of this discharge claim on the beneficiary’s current hospice benefit period depends on the

discharge status.

If the beneficiary is transferred to another hospice (discharge status codes 50 or 51) the claim does

not terminate the beneficiary’s current hospice benefit period. The admitting hospice submits a

transfer Notice of Election (type of bill 8xC) after the transfer has occurred and the beneficiary’s

hospice benefit is not affected. If any other appropriate discharge status code is used, this discharge

claim will terminate the beneficiary’s current hospice benefit period as of the “Through” date on the

claim. The beneficiary may reelect the hospice benefit if they are certified as terminally ill and

eligible for the benefit again in the future and are willing to be compliant with care.

If the beneficiary has chosen to revoke their hospice election, the provider uses the NUBC approved

discharge patient status code and the occurrence code 42 indicating the date the beneficiary revoked

the benefit. The beneficiary may re-elect the hospice benefit if they are certified as terminally ill and

eligible for the benefit again in the future.

Discharge Reason Coding Required in Addition to

Patient Status Code

Beneficiary Moves Out of

Service Area

Condition Code 52

Beneficiary Transfers Hospices Patient Status Code 50 or 51; no other

indicator

Beneficiary No Longer

Terminally Ill

No other indicator

Beneficiary Discharged for

Cause

Condition code H2

Beneficiary Revokes Occurrence code 42

If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice

care, the hospice shall file a timely-filed Notice of Election Termination / Revocation (NOTR) using

type of bill 8xB, unless it has already filed a final claim. A timely-filed NOTR is a NOTR that is

submitted to the A/B MAC (HHH) and accepted by the A/B MAC (HHH) within 5 calendar days

after the effective date of discharge or revocation. While a timely-filed NOTR is one that is

submitted to and accepted by the A/B MAC (HHH) within 5 calendar days after the hospice election,

posting to the CWF may not occur within that same timeframe. The date of posting to the CWF is

not a reflection of whether the NOTR is considered timely filed. A NOTR (type of bill 8xB) is

entered via Direct Data Entry in the same way as an NOE (type of bill 8xA). Hospices continue to

have 12 months from the date of service in which to file their claims timely.

A patient can also be admitted and discharged on the same day. They would submit an 8x1 Type of

Bill (“Admission through Discharge Claim”), matching “From” and “Through” dates, and whatever

the appropriate level of care the revenue code was, with 1 unit. A patient cannot be discharged and re-admitted to the same hospice on the same day.

Untimely Face-to-Face Encounters and Discharge

When a required face-to-face encounter occurs prior to, but no more than 30 calendar days prior to,

the third benefit period recertification and every benefit period recertification thereafter, it is

considered timely. A timely face-to-face encounter would be evident when examining the face-to-face attestation, which is part of the recertification, as that attestation includes the date of the

encounter. While the face-to- face encounter itself must occur no more than 30 calendar days prior to

the start of the third benefit period recertification and each subsequent recertification, its

accompanying attestation must be completed before the claim is submitted.

If the required face-to-face encounter is not timely, the hospice would be unable to recertify the

patient as being terminally ill, and the patient would cease to be eligible for the Medicare hospice

benefit. In such instances, the hospice must discharge the patient from the Medicare hospice benefit

because he or she is not considered terminally ill for Medicare purposes.

When a discharge from the Medicare hospice benefit occurs due to failure to perform a required face-to-face encounter timely, the claim should include the most appropriate

patient discharge status code. Occurrence span code 77 does not apply when the face-to- face

encounter has not occurred timely.

The hospice can re-admit the patient to the Medicare hospice benefit once the required encounter

occurs, provided the patient continues to meet all of the eligibility requirements and the patient (or

representative) files an election statement in accordance with CMS regulations. Where the only

reason the patient ceases to be eligible for the Medicare hospice benefit is the hospice’s failure to

meet the face-to-face requirement, CMS would expect the hospice to continue to care for the patient

at its own expense until the required encounter occurs, enabling the hospice to re-establish Medicare

eligibility.

Condition Codes

The hospice enters any appropriate NUBC approved code(s) identifying conditions related to this bill

that may affect processing.

Codes listed below are only those most frequently applicable to hospice claims. For a complete list of

codes, see the NUBC manual.

07 Treatment of Nonterminal

Condition for Hospice

Code indicates the patient has elected hospice care,

but the provider is not treating the terminal

condition, and is, therefore, requesting regular

Medicare payment.

20 Beneficiary Requested

Billing

Code indicates the provider realizes the services on

this bill are at a noncovered level of care or

otherwise excluded from coverage, but the

beneficiary has requested a formal determination.

21 Billing for Denial Notice Code indicates the provider realizes services are at

a noncovered level of care or excluded, but

requests a denial notice from Medicare in order to

bill Medicaid or other insurers.

H2 Discharge by a Hospice

Provider for Cause

Discharge by a Hospice Provider for Cause.

NOTE: Used by the provider to indicate the

patient meets the hospice’s documented policy

addressing discharges for cause.

52 Out of Hospice Service Area Code indicates the patient is discharged for moving

out of the hospice service area. This can include

patients who relocate or who go on vacation

outside of the hospice’s service area, or

patients who are admitted to a hospital or SNF

that does not have contractual arrangements with

the hospice.

85 Delayed recertification of

hospice terminal illness

Code indicates the hospice received the

recertification of terminal illness later than 2 days

after the first day of a new benefit period. This

code is reported with occurrence span code 77,

which reports the provider liable days associated

with the untimely recertification.

Occurrence Codes and Dates

The hospice enters any appropriate NUBC approved code(s) and associated date(s) defining specific

event(s) relating to this billing period. Event codes are two numeric digits, and dates are six numeric

digits (MM-DD-YY). If there are more occurrences than there are spaces on the form, use the

occurrence span code fields to record additional occurrences and dates.

Codes listed below are only those most frequently applicable to hospice claims. For a complete list of

codes, see the NUBC manual.

Code Title Definition

23 Cancellation of Hospice

Election Period (A/B

MAC (HHH) USE ONLY)

Code indicates date on which a hospice period of

election is cancelled by an A/B MAC (HHH) as

opposed to revocation by the beneficiary.

24 Date Insurance Denied Code indicates the date of receipt of a denial of

coverage by a higher priority payer.

27 Date of Hospice

Certification or

Recertification

Code indicates the date of certification or

recertification of the hospice benefit period,

beginning with the first 2 initial benefit periods of 90

days each and the subsequent 60-day benefit periods.

The OC 27 code/date is only required on claims

where initial certification or recertification occurs.

CMS will not be conducting certifying/recertifying

physician enrollment checks on physicians reported on

claims that do not have occurrence code 27 and date

reported.

NOTE: regarding transfers from one hospice to

another hospice: If a patient is in the first certification

period when they transfer to another hospice, the

receiving hospice would use the same certification

date as the previous hospice until the

next certification period. However, if they were in

the next certification at the time of transfer, then

they would enter that date in the Occurrence Code

27 and date.

42 Date of Termination of

Hospice Benefit

Enter code to indicate the date on which beneficiary

terminated his/her election to receive hospice

benefits. This code can be used only when the

Code Title Definition

beneficiary has revoked the benefit. It is not used in

transfer situations.

55 Beneficiary is Deceased Report the appropriate NUBC discharge status code

that best describes the place in which the beneficiary

died (40, 41, or 42). Discharge status code 20 is not

used on hospice claims.

Occurrence code 27 is required on the claim for the billing period in which the certification or recertification was obtained. It may be optionally reported on other claims.

When the re-certification is late and not obtained during the month it was due, the occurrence span

code 77 should be reported with the through date of the span code equal to the through date of the

claim.

Occurrence Span Code and Dates

The hospice enters any appropriate NUBC approved code(s) and associated beginning and ending

date(s) defining a specific event relating to this billing period are shown. Event codes are two

alphanumeric digits and dates are shown numerically as MM- DDYY.

Codes listed below are only those most frequently applicable to hospice claims. For a complete list of

codes, see the NUBC manual.

Code Title Definition

M2 Dates of Inpatient Respite

Care

Code indicates From/Through dates of a period of

inpatient respite care for hospice patients to

differentiate separate respite periods of less than 5

days each. M2 is used when respite care is

provided more than once during a billing period.

77 Provider Liability –

Utilization Charged

Code indicates From/Through dates for a period of

non-covered hospice care for which the provider

accepts payment liability (other than for medical

necessity or custodial care).

Respite care is payable only for periods of respite up to 5 consecutive days. Claims reporting respite

periods greater than 5 consecutive days will be returned to the provider. Days of respite care beyond 5

days must be billed at the appropriate home care rate for payment consideration.

For example: If the patient enters a respite period on July 1 and is returned to routine home care on

July 6, the units of respite reported on the line item would be 5 representing July 1 through July 5,

July 6 is reported as a day of routine home care regardless of the time of day entering respite or

returning to routine home care.

When there is more than one respite period in the billing period, the provider must include the M2

occurrence span code for all periods of respite. The individual respite periods reported shall not

exceed 5 days, including consecutive respite periods.

For example: If the patient enters a respite period on July 1 and is returned to routine home care on

July 6 and later returns to respite care from July 15 to July 18, and completes the month on routine

home care, the provider must report two separate line items for the respite periods and two occurrence

span code M2, as follows:

Revenue Line items:

• Revenue code 0655 with line item date of service 07/01/XX (for respite period

July 1 through July 5) and line item units reported as 5

• Revenue code 0651 with line item date of service 07/06/XX (for routine home

care July 6 through July 14) and line item units reported as 9

• Revenue code 0655 with line item date of service 07/15/XX (for respite period

July 15 through 17th) and line item units reported as 3

• Revenue code 0651 with line item date of service 07/18/XX (for routine home

care on date of discharge from respite through July 31 and line item units reported

as 14.

Occurrence Span Codes:

• M2 0701XX – 07/05/XX

• M2 0715XX – 07/17/XX

Provider Liability Periods Using Occurrence Span Code 77: Hospices must use occurrence span code

77 to identify days of care that are not covered by Medicare due to:

• Untimely physician recertification. This is particularly important when the

noncovered days fall at the beginning of a billing period other than the initial

certification period.

Example:

A new benefit period begins on 6/14/20XX

The hospice is required to obtain the recertification (verbal or written) by 6/16/20XX.

The hospice obtains the recertification 6/19/20XX.

The hospice reports 6/14 – 6/18 as non-covered days using occurrence span code 77.

The hospice reports the date the certification was actually obtained, 6/19/20XX, in occurrence code

27.

Condition code 85 is only reported in this case because the certification was untimely.

• Late-filing of a Notice of Election (NOE). A timely-filed NOE is a NOE that is

submitted to the A/B MAC (HHH) and accepted by the A/B MAC (HHH) within

5 calendar days after the hospice admission date. When the hospice files a NOE

late, Medicare shall not cover and pay for the days of hospice care from the

hospice admission date to the date the NOE is submitted to and accepted by the

A/B MAC (HHH). The date the NOE is submitted to and accepted by the A/B

MAC (HHH) is an allowable day for payment.

Example:

Admission date is 10/10/20XX (Fri). Day 1 = Sat.

10/11/20XX

Day 2 = Sun. 10/12/20XX Day 3 = Mon.

10/13/20XX Day 4 = Tues. 10/14/20XX

Day 5 = Weds. 10/15/20XX 10/15/20XX is the NOE Due Date.

IF NOE Receipt date is 10/16/20XX, the hospice reports 10/10- 10/15 as noncovered days using

occurrence span code 77 or Medicare systems return the claim to the provider for correction.

Value Codes and Amounts

The hospice enters any appropriate NUBC approved code(s) and the associated value amounts

identifying numeric information related to this bill that may affect processing. Provider-submitted

codes:

The most commonly used value codes on hospice claims are value codes 61 and G8, which are used

to report the location of the site of hospice services. Otherwise, value codes are commonly used only

to indicate Medicare is secondary to another payer. For

detailed information on reporting Medicare secondary payer information, see the Medicare

Secondary Payer Manual.

Code Title Definition

61 Place of Residence where Service is

Furnished (Routine Home Care and

Continuous Home Care)

MSA or Core-Based Statistical Area (CBSA)

number (or rural State code) of the location where

the hospice service is delivered.

A residence can be an inpatient facility if an

individual uses that facility as a place of residence.

It is the level of care that is required and not the

location where hospice services are provided that

determines payment. In other words, if an individual

resides in a freestanding hospice facility and requires

routine home care, then claims are submitted for

routine home care.

Hospices must report value code 61 when billing

revenue codes 0651 and 0652.

G8 Facility where Inpatient Hospice

Service is Delivered (General

Inpatient and Inpatient Respite Care).

MSA or Core Based Statistical Area (CBSA) number

(or rural State code) of the facility where inpatient

hospice services are delivered.

Hospices must report value code G8 when billing

revenue codes 0655 and 0656.

Medicare-applied codes: The following codes are added during processing and may be visible in the

A/B MAC (HHH)’s online claim history. They are never submitted by the hospice.

Code Title Definition

62 Number of High Routine Home

Care Days

Days that fall within the first 60 days of a

routine home care hospice claim. The

Medicare system puts the high days returned

by Pricer on the claim as a value code 62

amount.

63 Number of Low Routine Home

Care Days

Days that come after the first 60 days of a

routine home care hospice claim. The

Medicare system puts the low days returned by

Pricer on the claim as a value code 63 amount.

If hospice services are provided to the beneficiary in more than one CBSA area during the billing

period, the hospice reports the CBSA that applies at the end of the billing period. For routine home

care and continuous home care (e.g., the beneficiary’s residence changes between locations in

different CBSAs), report the CBSA of the beneficiary’s residence at the end of the billing period.

For general inpatient and inpatient respite care (e.g., the beneficiary is served in inpatient facilities in

different CBSAs), report the CBSA of the latest facility that served the beneficiary. If the

beneficiary receives both home and inpatient care during the billing period, the latest home CBSA is

reported with value code 61 and the latest facility CBSA is reported with value code G8.

Revenue Codes

The hospice assigns a revenue code for each type of service provided and enters the appropriate four-digit numeric revenue code to explain each charge.

Hospice claims are required to report separate line items for the level of care each time the level of

care changes. This includes revenue codes 0651, 0655 and 0656. For example, if a patient begins the

month receiving routine home care followed by a period of general inpatient care and then later

returns to routine home care all in the same month, in addition to the one line reporting the general

inpatient care days, there should be two separate line items for routine home care. Each routine

home care line reports a line item date of service to indicate the first date that level of care began for

that consecutive period.

Code Description Standard Abbreviation

0651 Routine Home Care RTN Home

0652 Continuous Home Care CTNS Home

A minimum of 8 hours of primarily nursing care

within a 24-hour period. The 8-hours of care do not

need to be continuous within the 24-hour period,

but a need for an aggregate of 8 hours of primarily

nursing care is required. Nursing care must be

provided by a registered nurse or a licensed

practical nurse. If skilled intervention is required

for less than 8 aggregate hours (or less than 32

units) within a 24 hour period, then the care

rendered would be covered as a routine home care

day. Services provided by a nurse practitioner as

the attending physician are not included in the CHC

computation nor is care that is not directly related to

the crisis included in the computation.

CHC billing should reflect direct patient care

during a period of crisis and should not reflect time

related to staff working hours, time taken for meal

breaks, time used for educating staff, time

used to report etc.

0655** Inpatient Respite Care IP Respite

0656** General Inpatient Care GNL IP

0657 Physician Services PHY SER (must be accompanied by a physician

procedure code)

• ** The date of discharge from general inpatient or inpatient respite care is paid at

the appropriate home care rate and must be billed with the appropriate home care

revenue code unless the patient is deceased at time of discharge in which case, the

appropriate inpatient respite or general inpatient care revenue code should be used.

NOTE: Hospices use revenue code 0657 to identify hospice charges for services furnished to patients

by physicians, nurse practitioners, or physician assistants employed by the hospice; or physicians,

nurse practitioners or physician assistants receiving compensation from the hospice. Procedure codes

are required in order for the A/B MAC (HHH) to determine the reimbursement rate for the physician

services. Appropriate procedure codes are available from the A/B MAC (HHH).

Additional revenue codes are reported describing the visits provided under each level of care.

To constitute a visit, the discipline, (as defined above) must have provided care to the beneficiary.

Services provided by a social worker to the beneficiary’s family also constitute a visit. For example,

documentation in the medical/clinical record,

interdisciplinary group meetings, obtaining physician orders, rounds in a facility or any other activity

that is not related to the provision of items or services to a beneficiary, do not count towards a visit to

be placed on the claim. During an initial or comprehensive assessment, it would not be best practice

to wait until later (after the clinician has left the home) to document the findings of an assessment or

the interventions provided during a patient visit. It is recommended that this information be

documented as close to the time of the assessment or intervention as possible. In addition, the visit

must be reasonable and necessary for the palliation and management of the terminal illness and related

conditions as described in the patient’s plan of care.

If a hospice patient is receiving routine home care while residing in a nursing home, the hospice

would record visits for all of its physicians, nurses, social workers, and home health aides who visit

the patient to provide care for the palliation and management of the terminal illness and related

conditions, as described in the patient’s plan of care. In this example the nursing home is acting as the

patient’s home. Only the patient care provided by the hospice staff constitutes a visit.

When making the determination as to whether or not a particular visit should be reported, a hospice

should consider whether the visit would have been reported, and how it would have been reported, if

the patient were receiving RHC in his or her private home. If a group of tasks would normally be

performed in a single visit to a patient living in his or her private home, then the hospice should count

the tasks as a single visit for the patient residing in a facility. Hospices should not record a visit every

time a staff member enters the patient’s room. Hospices should use clinical judgment in counting

visits and summing time.

Hospices report social worker phone calls and all visits performed by hospice staff in 15- minute

increments using the following revenue codes and associated HCPCS. This includes visits by hospice

nurses, aides, social workers, physical therapists, occupational therapists, and speech-language

pathologists.

All visits to provide care related to the palliation and management of the terminal illness or related

conditions, whether provided by hospice employees or provided under arrangement, must be reported.

The two exceptions are related to General Inpatient Care and Respite care. CMS is not requiring

hospices to report visit data at this time for visits made by non-hospice staff providing General

Inpatient Care or respite care in contract facilities. However, General Inpatient Care or respite care

visits related to the palliation and management of the terminal illness or related conditions provided

by hospice staff in contract facilities must be reported, and all General Inpatient Care and respite care

visits related to the palliation and management of the terminal illness or related conditions provided in

hospice-owned facilities must be reported.

Social worker phone calls made to the patient or the patient’s family should be reported using revenue

code 0569, and HCPCS G-code G0155 for the length of the call, with each call being a separate line

item. Only phone calls that are necessary for the palliation and

management of the terminal illness and related conditions as described in the patient’s plan of care

(such as counseling or speaking with a patient’s family or arranging for a placement) should be

reported. Report only social worker phone calls related to providing and or coordinating care to the

patient and family and documented as such in the clinical records.

When recording any visit or social worker phone call time, providers should sum the time for each

visit or call, rounding to the nearest 15-minute increment. Providers should not include travel time or

documentation time in the time recorded for any visit or call.

Additionally, hospices may not include interdisciplinary group time in time and visit reporting.

For dates of service before October 1, 2018, Hospice agencies shall report injectable and non-injectable prescription drugs for the palliation and management of the terminal illness and related

conditions on their claims. Both injectable and non-injectable prescription drugs shall be reported on

claims on a line-item basis per fill, based on the amount dispensed by the pharmacy.

When a facility (hospital, SNF, NF, or hospice inpatient facility) uses a medication management

system where each administration of a hospice medication is considered a fill for hospice patients

receiving care, the hospice shall report a monthly total for each drug (i.e., report a total for the period

covered by the claim), along with the total dispensed.

Hospices shall report multi-ingredient compound prescription drugs (non-injectable) using revenue

code 0250. The hospice shall specify the same prescription number for each ingredient of a

compound drug according to the 837i guidelines in loop 2410. In addition, the hospice shall provide

the NDC for each ingredient in the compound; the NDC qualifier represents the quantity of the drug

filled (meaning the amount dispensed) and shall be reported as the unit measure.

When reporting prescription drugs in a comfort kit/pack, the hospice shall report the NDC of each

prescription drug within the package, in accordance with the procedures for non-injectable

prescriptions.

Hospice agencies shall report infusion pumps (a type of DME) on a line-item basis for each pump

and for each medication fill and refill. The hospice claim shall reflect the total charge for the

infusion pump for the period covered by the claim, whether the hospice is billed for it daily, weekly,

biweekly, with each medication refill, or in some other fashion. The hospice shall include on the

claim the infusion pump charges on whatever basis is easiest for its billing systems, so long as in

total, the claim reflects the charges for the pump for the time period of that claim.

Effective for dates of service on and after 10/1/2018, hospices are no longer required to report drugs

using line item detail. Hospices may report summary charges for drugs as shown in the table below.

Hospices must enter the following visit revenue codes, when applicable:

Revenue

Code

Required HCPCS Required Detail

0250 Non-injectable

Prescription

Drugs

N/A Required detail: Report on a line-item basis per

fill, using revenue code 0250 and the National

Drug Code (NDC). The NDC qualifier represents

the quantity of the drug filled and should be

reported as the unit measure.

For dates of service on and after 10/1/2018:

Report a monthly charge total for all drugs (i.e.,

report a total charge amount for the period

covered by the claim) using revenue code 0250.

029X

Infusion

pumps

Applicable HCPCS

N/A

Required detail: Report on the claim on a line

item basis per pump order and per medication

refill, using revenue code 029X for the equipment

and 0294 for the drugs along with the appropriate

HCPCS.

For dates of service on and after 10/1/18: Report a

monthly charge total for infusion DME (i.e.,

report a total charge amount for the period

covered by the claim), including DME infusion

drugs, using revenue center 029X for the infusion

pumps and 0294 for DME infusion

drugs.

042x

Physical

Therapy

G0151 or G0157 Required detail: 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.

043x

Occupational

Therapy

G0152 or G0158 Required detail: 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.

044x Speech

Therapy –

Language

Pathology

G0153 Required detail: 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.

055x Skilled

Nursing

G0299 or G0300 Required detail: 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.

056x

Medical

Social

Services

G0155 Required detail: 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.

0569 Other

Medical

Social

Services

G0155 Required detail: Each social service phone call 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 call defined in

the HCPCS description.

057x Aide G0156 Required detail: 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 the total

time of the visit defined in the HCPCS

description.

0636

Injectable

Drugs

Applicable HCPCS Required detail: Report on a line item basis per

fill with units representing the amount filled. (i.e.,

Q1234 Drug 100mg and the fill was for 200 mg,

units reported = 2).

For dates of service on and after 10/1/2018:

Revenue code 0636 is not required.

* If revenue code 656 with HCPCS Q5006 is reported on a claim, then claim lines with a visit revenue

code 055x, 056x, or 057x do not need a corresponding visit HCPCS codes if those lines fall under the

general inpatient revenue code line (656/Q5006) dates.

Visits by registered nurses, licensed vocational nurses and nurse practitioners (unless the nurse

practitioner is acting as the beneficiary’s attending physician) are reported under revenue code 055x.

Hospices shall use G0299 for “direct skilled nursing services of a

registered nurse (RN) in the home health or hospice setting” and G0300 “direct skilled nursing of a

licensed practical nurse (LPN) in the home health or hospice setting.”

Charges associated with the reported visits are covered under the hospice bundled payment and

reflected in the payment for the level of care billed on the claim. No additional payment is made

on the visit revenue lines.

The contractor shall use the following remittance advice messages and associated codes when

bundling line items under this policy. This CARC/RARC combination is compliant with CAQH

CORE Business Scenario Four. Group Code: CO

CARC: 97 RARC: N/A

MSN: N/A

Hospices should report in the unit field on the line level the units as a multiplier of the visit time

defined in the HCPCS description.

For information regarding the billing requirements for Coverage of Kidney Disease Patient

Education Services under hospice see Chapter 32, §20.1).

HCPCS/Accommodation Rates/HIPPS Rate Codes

Hospices must report a HCPCS code along with each level of care revenue code (651, 652, 655 and

656) to identify the type of service location where that level of care was provided.

The following HCPCS codes will be used to report the type of service location for hospice

services:

HCPCS Code Definition

Q5001 HOSPICE CARE PROVIDED IN PATIENT'S HOME/RESIDENCE

Q5002 HOSPICE CARE PROVIDED IN ASSISTED LIVING FACILITY

Q5003 HOSPICE CARE PROVIDED IN NURSING LONG TERM CARE FACILITY

(LTC) OR NON-SKILLED NURSING FACILITY (NF)

Q5004 HOSPICE CARE PROVIDED IN SKILLED NURSING FACILITY (SNF)

Q5005 HOSPICE CARE PROVIDED IN INPATIENT HOSPITAL

Q5006 HOSPICE CARE PROVIDED IN INPATIENT HOSPICE FACILITY

Q5007 HOSPICE CARE PROVIDED IN LONG TERM CARE HOSPITAL (LTCH)

Q5008 HOSPICE CARE PROVIDED IN INPATIENT PSYCHIATRIC FACILITY

Q5009 HOSPICE CARE PROVIDED IN PLACE NOT OTHERWISE SPECIFIED (NOS)

Q5010 Hospice home care provided in a hospice facility

If care is rendered at multiple locations, each location is to be identified on the claim with a

corresponding HCPCS code. For example, routine home care may be provided for a portion of the

billing period in the patient’s residence and another portion in an assisted living facility. In this case,

report one revenue code 651 line with HCPCS code Q5001 and the number of days of routine home

care provided in the residence and another revenue code 651 line with HCPCS code Q5002 and the

number of days of routine home care provided in the assisted living facility.

Q5004 shall be used for hospice patients in a skilled nursing facility (SNF), or hospice patients in

the SNF portion of a dually-certified nursing facility. There are 4 situations where this would occur:

1) If the beneficiary is receiving hospice care in a solely-certified SNF.

2) If the beneficiary is receiving general inpatient care in the SNF.

3) If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit

for a condition unrelated to the terminal illness and related conditions, and is

receiving hospice routine home care; this is uncommon.

4) If the beneficiary is receiving inpatient respite care in a SNF.

If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site shall be

coded as Q5003, for a long term care nursing facility.

General inpatient care provided by hospice staff requires line item visit reporting in units of 15

minute increments when provided in the following sites of service: Skilled Nursing Facility (Q5004),

Inpatient Hospital (Q5005), Long Term Care Hospital (Q5007), Inpatient Psychiatric Facility

(Q5008).

These service location HCPCS codes are not required on revenue code lines describing the visits

provided under each level of care. These lines report the HCPCS codes shown in the table under

Revenue Codes.

Modifiers

The following modifier is required reporting for claims:

PM – Post-mortem visits. Hospices shall report visits and length of visits (rounded to the nearest 15-minute increment), for nurses, aides, social workers, and therapists who are employed by the hospice,

that occur on the date of death, after the patient has passed away. Post mortem visits occurring on a

date subsequent to the date of death are not to be reported. The reporting of post-mortem visits, on

the date of death, should occur regardless of the patient’s level of care or site of service. Date of

death is defined as the date of death reported on the death certificate. Hospices shall report hospice

visits that occur before death on a separate line from those which occur after death.

For example, assume that a nurse arrives at the home at 9 pm to provide routine home care (RHC) to

a dying patient, and that the patient passes away at 11 pm. The nurse stays with the family until 1:30

am. The hospice should report a nursing visit with eight 15minute time units for the visit from 9 pm

to 11 pm. On a separate line, the hospice should report a nursing visit with a PM modifier with four

15-minute time units for the portion of the visit from 11 pm to midnight to account for the 1 hour post

mortem visit.

If the patient passes away suddenly, and the hospice nurse does not arrive until after his death at

11:00 pm, and remains with the family until 1:30 am, then the hospice should report a line item

nursing visit with a PM modifier and four 15-minute increments of time as the units to account for the

1 hour post mortem visit from 11:00 pm to midnight.

The following modifier may be used to identify requests for an exception to the consequences of not

filing the NOE timely:

KX - Even if a hospice believes that exceptional circumstances beyond its control are the cause of its

late-filed NOE, the hospice shall file the associated claim with occurrence span code 77 used to

identify the non-covered, provider liable days. The hospice shall also report a KX modifier with the

Q HCPCS code reported on the earliest dated level of care line on the claim. The KX modifier shall

prompt the A/B MAC (HHH) to request the documentation supporting the request for an exception.

Based on that documentation, the A/B MAC (HHH) shall determine if a circumstance encountered by

a hospice qualifies for an exception.

If the request for an exception is approved by the A/B MAC (HHH), the A/B MAC (HHH) shall

process the claim with the CWF override code and remove the submitted provider liable days, which

will allow payment for the days associated with the late-filed NOE. If the A/B MAC (HHH) finds

that the documentation does not support allowing an exceptional circumstance, the A/B MAC (HHH)

shall process the claim as submitted.

The contractor shall use the following remittance advice messages and associated codes under this

policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three

Group

Code: CO CARC: 96

RARC: MA54 MSN: N/A

Hospices may appeal the contractor’s determination that an exceptional circumstance did not apply.

Modifier GV may be used to identify attending physician services performed by a doctor of medicine,

doctor of osteopathy, nurse practitioner or physician assistant.

Service Date

The HIPAA standard 837 Institutional claim format requires line item dates of service for all

outpatient claims. Medicare classifies hospice claims as outpatient claims (see Chapter 1, §60.4).

Service date reporting requirements will vary between continuous home care lines (revenue code 652)

and other revenue code lines.

Revenue code 652 – report a separately dated line item for each day that continuous home care is

provided, reporting the number of hours, or parts of hours rounded to 15minute increments, of

continuous home care that was provided on that date.

Other level of care revenue codes – report a separate line for each level of care provided at each

service location type, as described in the instructions for HCPCS coding reported above. Hospices

report the earliest date that each level of care was provided at each service location. Attending

physician services should be individually dated, reporting the date that each HCPCS code billed was

delivered.

Service reporting revenue codes – report dates as described in the table above under Revenue Codes.

For service visits that begin in one calendar day and span into the next calendar day, report one visit

using the date the visit ended as the service date.

Service Units

The hospice enters the number of units for each type of service. Units are measured in days for

revenue codes 651, 655, and 656. , Units for revenue code 652 are reported in 15-minute increments.

When days are non-covered due to not filing a timely NOE, the hospice reports two lines for the

affected level of care. For example, if a billing period contains 31 days of routine home care and the

first 5 days are non-covered due to not filing a timely NOE:

• The hospice reports one revenue code 0651 line containing the earliest

noncovered date of service, 5 units and all non-covered charges.

• The hospice reports a second revenue code 0651 line containing the first covered

date of service, 26 units and all covered charges.

•

Report units for service reporting lines as a multiplier of the visit time defined in the HCPCS

description.

When the revenue code or HCPCS code requires 15-minute increment reporting, visits of any length

are to be reported, rounding the time to the nearest 15-minute increment.

Units for summary drug charges lines may be reported using ‘1’ to satisfy the required field or

using a number of drugs provided during the billing period, at the

option of the hospice. Service unit data will not be used by Medicare for payment or data analysis.

Total Charges

The hospice enters the total charge for the service described on each revenue code line. This

information is being collected for purposes of research and will not affect the amount of

reimbursement.

Non-Covered Charges

The hospice enters a charge amount equal to the Total Charges for any revenue code line with a

Service Date within a non-covered period (e.g., an occurrence span code 77 period).

Payer Name

The hospice identifies the appropriate payer(s) for the claim.

National Provider Identifier – Billing Provider

The hospice enters its own National Provider Identifier (NPI).

Principal Diagnosis Code

The hospice enters diagnosis coding as required by ICD-9-CM / ICD-10-CM Coding Guidelines.

CMS accepts only HIPAA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes, depending on the

date of service. The official ICD-9-CM codes, which were updated annually through October 1, 2013,

are posted at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

The official annual updates to ICD-10-CM and ICD-10-PCS codes are posted at

http://www.cms.gov/Medicare/Coding/ICD10/index.html.

Use full diagnosis codes including all applicable digits, up to five digits for ICD-9-CM and up to

seven digits for ICD-10-CM.

The principal diagnosis listed is the diagnosis most contributory to the terminal prognosis.

Non-reportable Principal Diagnosis Codes to be returned to the provider for correction:

• Hospices may not report ICD-9CM v-codes and ICD-10-CM z-codes as the

principal diagnosis on hospice claims.

• Hospices may not report debility, failure to thrive, or dementia codes classified as

unspecified as principal hospice diagnoses on the hospice claim.

• Hospices may not report diagnosis codes that cannot be used as the principal

diagnosis according to ICD-9-CM or ICD-10-CM Coding Guidelines or require

further compliance with various ICD-9-CM or ICD-10-CM coding conventions,

such as those that have principal diagnosis code sequencing guidelines.

Other Diagnosis Codes

The hospice enters diagnosis coding as required by ICD-9-CM and ICD-10-CM Coding Guidelines.

Hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice

claims, whether related or unrelated to the terminal prognosis of the individual. This will also include

the reporting of any mental health disorders and conditions that would affect the plan of care.

Attending Provider Name and Identifiers

The hospice enters the name and provider identifier of the attending physician designated by the

patient at the time of election as having the most significant role in the determination and delivery of

the patient’s medical care. The patient’s designated attending physician could be an independent

physician, hospice physician, a nurse practitioner, or physician assistant. If there is no attending

physician listed, then the hospice shall report the hospice certifying/recertifying physician.

Other Provider Name and Identifiers

The hospice enters the name and provider identifier of the hospice physician responsible for

certifying/recertifying that the patient is terminally ill, with a life expectancy of 6 months or less if the

disease runs its normal course. For electronic claims, this information is reported in Loop ID 2310F –

Referring Provider Name.

NOTE: Both the attending physician and other physician fields should be completed unless the

patient’s designated attending physician is the same as the physician certifying/recertifying the

terminal illness. When the attending physician is also the physician certifying/recertifying the

terminal illness, only the attending physician field is required to be populated, the other physician

field would not need to be populated.

Hospices shall report the NPI of any nursing facility, hospital, or hospice inpatient facility where the

patient is receiving hospice services, regardless of the level of care provided when the site of service

is not the billing hospice. The billing hospice shall obtain the NPI for the facility where the patient is

receiving care and report the facility’s name, address and NPI on the 837 Institutional claim format in

Loop 2310E- Service Facility Location. When the patient has received care in more than one facility

during the billing

month, the hospice shall report the NPI of the facility where the patient

was last treated. Failure to report this information for claims reporting

place of service HCPCS Q5003 (long term care nursing facility),

Q5004 (skilled nursing facility), Q5005 (inpatient hospital), Q5007

(long term care hospital) and Q5008 (inpatient psychiatric facility) will

result in the claim being returned to the provider.