How to Identify Hospice Claims: A Billing Reference for Providers and Payers

Identifying a hospice claim correctly is the starting point for managing billing coordination, Medicare coverage limitations, and compliance obligations correctly in a hospice setting. For hospice providers, understanding the specific coding elements that identify a claim as a hospice claim is essential for correct submission. For non-hospice providers billing for services to patients who are enrolled in the Medicare Hospice Benefit, correctly identifying the patient’s hospice status determines whether and how those services can be billed to Medicare.

This post covers the specific claim elements that identify a hospice claim on the UB-04, the revenue codes associated with each hospice level of care, the condition codes that signal specific hospice billing situations, and the coordination-of-benefits implications for non-hospice providers treating hospice patients.

The Type of Bill Code: The First Identifier

The Type of Bill (TOB) code in field locator 04 of the UB-04 is the most immediate identifier of a hospice claim. All Medicare hospice claims use a TOB beginning with 81 the first two digits that designate the claim as a hospice provider bill. The third digit is 1, indicating the bill type within the hospice setting. The fourth digit is the frequency code that identifies the claim’s position in the billing cycle (1 for admit through discharge, 2 for the first interim claim, 3 for a continuing claim, 4 for the final claim).

A complete Medicare hospice Type of Bill code therefore reads as 8 1 1 X where X is the frequency digit specific to that claim period. Seeing a TOB beginning with 81 on any UB-04 claim immediately identifies it as a hospice provider claim. Non-hospice providers do not use this TOB designation.

Revenue Codes: Identifying the Level of Care

Medicare hospice reimbursement uses four levels of care, each with its own revenue code on the UB-04. The revenue code on a hospice claim identifies which care level was provided on each day of the billing period.

• Revenue Code 0651: Routine Home Care the standard daily hospice care level for patients receiving care at home or in an assisted living setting. This is the most frequently appearing revenue code on hospice claims.
• Revenue Code 0652: Continuous Home Care the highest-reimbursed hospice care level, for patients in crisis requiring continuous nursing or aide attendance of at least eight hours in a 24-hour period.
• Revenue Code 0655: Inpatient Respite Care short-term inpatient care to provide relief for family caregivers, for up to five consecutive days per occurrence.
• Revenue Code 0656: General Inpatient Care inpatient care for acute pain or symptom management that cannot be managed in a home setting.

The presence of any of these revenue codes on a UB-04 claim, combined with the 81X Type of Bill, definitively identifies the claim as a Medicare hospice claim at a specific care level.

Condition Codes That Appear on Hospice Claims

Condition codes communicate specific circumstances about the billing situation to the payer. Several condition codes are specific to or commonly appear on hospice claims.

• Condition Code 07: Treatment of non-terminal condition for hospice patient used when a hospice patient receives treatment for a condition unrelated to their terminal diagnosis. This code signals that the services on the claim are outside the scope of the hospice benefit.
• Condition Code 70: Self-administered EPO used when a patient self-administers erythropoietin, which may be covered outside the hospice consolidated billing in certain circumstances.

The election statement effective date appears as an occurrence code on hospice claims Occurrence Code 27 identifies the date the hospice election took effect. This date is important for billing coordination because it establishes the date on which the beneficiary waived Medicare coverage of curative treatments for the terminal diagnosis and services became the hospice’s billing responsibility under consolidated billing.

Identifying Hospice Patients in a Non-Hospice Billing Environment

For non-hospice providers hospitals, physician practices, home health agencies, or skilled nursing facilities identifying whether a patient is enrolled in the Medicare Hospice Benefit determines how services can be billed to Medicare and whether specific billing modifiers are required.

Medicare does not provide a real-time hospice status indicator in the standard claim’s submission environment. Non-hospice providers can identify a patient’s hospice enrolment through several means. The Medicare Common Working File (CWF) records hospice election dates and can be queried through eligibility verification systems. The patient, their family member, or the hospice organization directly can provide confirmation of enrolment and the effective date. Remittance advice from Medicare on claims submitted for a hospice patient will often include a denial or adjustment indicating that the patient is enrolled in the hospice benefit. When a non-hospice provider identifies that a patient is enrolled in the Medicare Hospice Benefit, the billing implications depend on the nature of the services provided. Services related to the terminal diagnosis are the hospice’s billing responsibility under consolidated billing the non-hospice provider bills the hospice organization, not Medicare directly. Services unrelated to the terminal diagnosis may be billed to Medicare Part B with the GW modifier indicating the service is not related to the hospice patient’s terminal condition.

Billing Conflicts That Arise When Hospice Status Is Not Identified

When a non-hospice provider bill Medicare Part B for services provided to a hospice patient without the required modifiers or when services related to the terminal diagnosis are billed directly to Medicare rather than to the hospice the claim creates a billing conflict with the Medicare hospice election record. Medicare may deny the claim, request refund of payment already made, or flag the billing pattern for audit review.

Common conflict scenarios include hospital emergency department claims for hospice patients where the nature of the ED visit (related versus unrelated to the terminal diagnosis) is not correctly identified before billing; physician claims submitted for services to hospice patients without the appropriate GV or GW modifier; and home health claims for patients in hospice where the services overlap with the hospice’s care obligations.

What this means for your organization: Whether you are a hospice provider, a hospital, a physician practice, or any other provider treating patients who may be enrolled in the Medicare Hospice Benefit, correctly identifying hospice enrolment before billing determines whether your claims are correctly coded, correctly directed to the right payer, and compliant with Medicare’s hospice benefit coordination requirements.

Need Help with Hospice Billing Accuracy?

MCA Medical Billing Solutions, L.L.C. provides specialized hospice billing services including care level billing, election statement management, and Medicare billing compliance for hospice organizations that need accurate, compliant billing management.