Claim Page 02 — Entering a Hospice Claim

Change Request 6440 requires hospices to bill additional data on hospice claims. This change is optional for claims with dates of service October 1, 2009. This change is required for claims with dates of service on/after January 1, 2010.

Claim Page 02 (Map 1712) contains revenue code information, charges and service dates.

FISS Claims Page 2

Key:

RED = Required field
BLUE = Optional field
GREEN = Conditional field, depended on the type of claim
PURPLE = System generated field
BLACK = Not required field

Field Descriptions for Claim Page 02 – Maps 1712

The HIC, TOB, S/LOC, and PROVIDER fields are system generated from Claim Page 01.

Field Name / Requirement	Description
REV Required	Enter the appropriate revenue code for the level(s) of care provided (0651, 0652, 0655, 0656) (see descriptions below). Each day of continuous home care (revenue code 0652) must be billed on a separate revenue code line. Note: Effective for claims submitted on/after April 29, 2010, Change Request 6791 requires a separate revenue code line be billed each time the level of care changes. Enter the appropriate revenue code for the discipline(s) provided (055X, 056X, 057X). Enter revenue code 657 for physician services. Effective for dates of service January 1, 2010, hospices are also required to enter the appropriate revenue code for the therapies provided (042X, 043X, 044X) and social worker phone calls (0569). Revenue code 0001 is entered on the last revenue code line of the claim. This page will hold up to 14 revenue code lines. To enter additional revenue code lines, press F6 to scroll down. There are 33 revenue code pages and 450 total revenue code lines available. The REV field is a four-position field. You may enter a zero before the revenue code (e.g., 0651) or enter the three-digit code (e.g., 651) and then use your TAB key to go to the next field.
HCPC Required	Enter the appropriate HCPCS code (Q5001-Q5009) on each level of care revenue code (0651, 0652, 0655 or 0656) line to identify the service location where that level of care was provided. Enter the appropriate HCPCS code that corresponds to the physician service provided (0657). Effective for dates of service January 1, 2010, hospices are required to enter the appropriate HCPC (G0151-G0156) on each discipline revenue code (042X, 043X, 044X, 055X, 056X, 057X) line.
MODIFS Conditionally Required	Modifiers. Use the appropriate modifier on hospice claims (type of bill 81X or 82X). 26 Use modifier 26 to identify a physician’s professional component of a technical service. The modifier may be reported when the patient’s attending physician, or a physician who is contracted or employed by the hospice has provided the professional component of an otherwise technical service. Note: When using the 26 modifier, include a brief remark in the “Remark” field on FISS Claim Page 04 to indicate the service billed is for the professional component of a technical service. GV Report modifier GV with revenue code 0657 when billing services performed by a nurse practitioner acting as the patient’s attending physician.
TOT UNIT Required	Enter the total units for each revenue code line. For revenue codes 0651, 0655, and 0656, units = number of days. NOTE: Effective for claims submitted on/after April 29, 2010, the units reflect the number of consecutive days at that level of care. For revenue code 0652, units = the number of 15-minute increments continuous care was provided. For 0657, units = the number of procedures/services performed. For dates of service prior to January 1, 2010, for discipline revenue codes (055X, 056X, 057X), units = the number of visits provided in the week (Sun-Sat) at that level of care and service location. For dates of service on or after January 1, 2010, for discipline revenue codes (042X, 043X, 044X, 055X, 056X, 057X), units = the duration of the visit in 15-minute increments.
COV UNIT Required	Enter the number of covered units for the services billed .
TOT CHARGE Required	Enter the total charge per revenue code. The decimal point is optional (i.e., $1500.00 can be entered as 1500.00 or 150000). However, you must enter two digits for the cents.
NCOV CHARGE Conditionally Required	Enter any noncovered charges billed per revenue code.
SERV DT Required	For each revenue code line, a service date is required. For revenue codes 0651, 0655, and 0656, service date = the earliest date that each level of care was provided at each service location. NOTE: Effective for claims submitted on/after April 29, 2010, the date reflects the first date that level of care began for that consecutive period. For revenue code 0652, service date = the date continuous home care was provided. Revenue code 0657 (physician services), service date = the date of the physician’s service. For dates of service prior to January 1, 2010, for revenue codes 055X, 056X, 057X, service date = the date of the first visit provided in the week (Sun-Sat). For dates of service on or after January 1, 2010, for revenue codes 042X, 043X, 044X, 055X, 056X, 057X, service date = the date of the visit NOTE: The service date reported must fall within the from/to date reported on the claim.

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Hospice Revenue Codes

Code	Description
0001	Total Units and/or Charges
042X	Physical therapy (Required with dates of service on or after January 1, 2010) 0 – General Classification 1 – Visit Charge
043X	Occupational therapy (Required with dates of service on or after January 1, 2010) 0 – General Classification 1 – Visit Charge
044X	Speech language pathology (Required with dates of service on or after January 1, 2010) 0 – General Classification 1 – Visit Charge
055X	Skilled Nursing 0 – General Classification 1 – Visit Charge
056X	Medical social services 0 – General Classification 1 – Visit Charge 9 – Other (phone calls) (Required with dates of service on or after January 1, 2010)
057X	Home health (hospice) aide 0 – General Classification 1 – Visit Charge
0650	General Classification (Request for denials)
0651	Routine Home Care—(Value code 61 required)
0652	Continuous Home Care—(Value code 61 required) Report in 15-minute increments.
0655	Inpatient Care/Respite—(Value code G8 required)
0656	General Inpatient Care (nonrespite)—(Value code G8 required)
0657	Physician Services—(Modifier GV is required when billing physician services performed by a nurse practitioner.)
0659	Other Hospice (Use this code when billing noncovered room and board)

For definitions of each hospice level of care, refer to the Medicare Claims Processing Manual, (CMS Pub 100-04), Ch. 11, §30.1.

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Hospice HCPCS Codes

The following HCPCS are billed on the level of care revenue code lines to indicate the place where care was provided.

HCPCS	Description
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 (LTC) facility or non-skilled nursing facility (NF). Used for hospice patients in: An unskilled nursing facility; or The NF portion of a dually certification nursing facility who are receiving unskilled care from facility staff
Q5004	Hospice care provided in skilled nursing facility (SNF). Used for hospice patients in: Skilled nursing facility; or SNF portion of a dually certification nursing facility who are receiving skilled care from facility staff.
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 (Eff. 10/1/10)	Hospice care provided in a hospice facility. Used for hospice patients when routine home care or continuous home care is provided in: A hospice residential facility; or A hospice facility which is also certified to provide inpatient care. Note: Q5010 cannot be billed with a respite or general inpatient (GIP) level of care.
For dates of service on or after January 1, 2010, the following HCPCS codes are also required on the discipline revenue code lines (042X, 043X, 044X, 055X, 056X, 057X).
G0151	Physical therapy (042X)
G0152	Occupational therapy (043X)
G0153	Speech language pathology (044X)
G0154	Skilled nursing (055X)
G0155	Medical social services (056X)
G0156	Home health (hospice) aide (057X)