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Claim Page 01 – Entering a Hospice Claim

This page describes the information required for Medicare hospice claims using the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) format.

Image of the FISS DDE claim page 01 (MAP1711) screen:

screen shot

Legend:
RED = Required
BLUE = Optional
GREEN = Conditional
PURPLE = Auto-polulated
BLACK = Not required

Field Descriptions

The table below explains each DDE field or UB-04 Form Locator and its required data elements.

Note: The National Uniform Billing Committee (NUBC) maintains certain UB-04 billing codes that are copyrighted by the American Hospital Association. The code lists below only provide the most common used for hospice claims. Reference the Official UB-04 Data Specifications ManualExternal PDF for a complete listing and guidance.

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 11, section 30.3External PDF

DDE Field UB-04 Form Locator (FL) Description
MID FL 60

Medicare ID

Enter the beneficiary's Medicare ID number.
TOB FL 4

Type of Bill

Enter the appropriate code that identifies the type of facility, type of care, and frequency for the services reported on the claim.

Digit 1 Digit 2 Digit 3

8 – Hospice

1 – Non-hospital based

2 – Hospital based

0 – No payment

1 – Admit through discharge

2 – Interim (first claim)

3 – Interim (continuing claim)

4 – Interim (last claim)

7 – Adjustment

8 – Void/cancel
NPI FL 56

National Provider Identifier

Enter the hospice agency's NPI number.
STMT DATES FROM/TO FL 6

Statement Covers Period

Enter the beginning and ending dates for this billing period (must conform to a calendar month).

See CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 11, section 90External PDF.
LAST FL 8

Last Name

Enter the beneficiary's last name exactly as it appears on the Medicare card or eligibility file.
FIRST FL 8

First Name

Enter the beneficiary's first name exactly as it appears on the Medicare card or eligibility file.
DOB FL 10

Date of Birth

Enter the beneficiary's date of birth.
ADDR 1-6 FL 9

Address

Enter the beneficiary's full mailing address, including street name and number, post office box number or RFD, city and state.
ZIP FL 9

ZIP Code

Enter the beneficiary's ZIP code.
SEX FL 11

Sex

Enter the beneficiary's sex (M = Male or F= Female).
ADMIT DATE FL 12

Admission Date

Enter the hospice election or hospice transfer effective date.

The admission date:

  • Must match the Admit Date on the Notice of Election or Notice of Change (Transfer).
  • May not precede the physician's certification by more than 2 calendar days.
  • Stays the same on all continuing claims for the same hospice election.
TYPE FL 14

Priority (Type) of Admission or Visit

Enter the applicable code:

  • 1 – Emergency
  • 2 – Urgent
  • 3 – Elective
  • 4 – Newborn
  • 5 – Trauma
  • 9 – Information not available
SRC FL 15

Point of Origin for Admission or Visit

Enter the applicable code:

  • 1 – Non-health care facility
  • 2 – Clinic or physician's office
  • 4 – Transfer from hospital
  • 5 – Transfer from skilled nursing facility (SNF) or intermediate care facility (ICF)
  • 6 – Transfer from another health care facility
  • 8 – Court/law enforcement
  • 9 – Information not available
STAT FL 17

Patient Discharge Status

Enter the code that represents the beneficiary's status on this claim's "TO" date of service.

Code Description
01

Discharged to home or self-care

(not for patients who expire under hospice care)
30

Still a patient

(receiving hospice care)
40*

Expired at home
41*

Expired in a medical facility (e.g., hospital, SNF, ICF, or freestanding hospice)
42*

Expired – place unknown
50

Discharged/transferred to hospice – home

(for patients who transfer to another hospice under routine or continuous care)
51

Discharged/transferred to hospice – medical facility

(for patients who transfer to another hospice under respite or general inpatient care)

*Report the date of death as the "TO" date of service and with occurrence code 55.
COND CODES FL 18-28

Condition Codes

Enter code(s) that describe specific conditions or events applicable to this billing period.

Hospice

Code Description
07

Treatment of non-terminal condition for hospice

The patient elected hospice care, but the provider isn't treating the terminal condition and is requesting regular Medicare payment.
20

Beneficiary requested billing

The provider is aware that the services on the claim are at a non-covered level of care or otherwise excluded from coverage, but the beneficiary requested a formal determination.
21

Billing for denial notice

The provider is aware that the services on the claim are at a non-covered level of care or otherwise excluded from coverage but is requesting a denial notice from Medicare to bill other insurers.

Don't use this code when an Advance Beneficiary Notice of Noncoverage (ABN) is required or non-covered room and board charges are reported (see Hospice Room and Board).
52

Out of hospice service area

The patient is discharged for moving out of the hospice service area (e.g., relocate, go on vacation, admitted to a hospital or SNF that doesn't have contractual arrangements with the hospice).
85

Delayed recertification of hospice terminal illness

The hospice received the recertification of terminal illness later than 2 days after the first day of a new benefit period; report occurrence code 77 and the provider liable days associated with the untimely recertification.
H2

Discharge for cause

The patient meets the hospice's documented policy addressing discharges for cause (e.g., patient or hospice staff safety); discharges the patient from the provider's care, not necessarily the hospice benefit.

Expedited Review

Code Description
C3

Partial approval

Based on a Quality Improvement Organization (QIO) review, some days or services are denied; report occurrence span code M0 and approved dates of service.
C4

Services denied

Based on a QIO review, all services beyond the discharge date are denied; report occurrence span code 76 (patient liability), if applicable.

Don't report patient discharge status code 30 (unless condition code 20 or occurrence code 32 also apply).
C7

Extended authorization

The QIO authorizes extended services without a review.

Claim Adjustment

Code Description TOB
D0

Change to service dates

*Use D9 to change line-item dates of service.

XX7
D1

Change in charges (add or remove)

*Use D9 to change units.

XX7
D2

Change in revenue/HCPCS/HIPPS codes

*Use D9 to add revenue/HCPCS/HIPPS codes.

XX7
D5

Cancel to correct a Medicare beneficiary or provider identification number

XX8
D6

Cancel to repay a duplicate payment or OIG overpayment

XX8
D9

Any other change (not described above or multiple changes)

XX7
OCC CDS/DATE FL 31-34

Occurrence Codes & Dates

Enter code(s) and associated date(s) that define specific event(s) related to this billing period, when applicable.

Code Description
24

Date insurance denied

Report the date you received a higher priority payer's denial of coverage.
27

Date of hospice certification or recertification

When the claim From and To dates overlap a certification period, report the first day of the new hospice benefit period.

Example 1: The claim dates of service (0101YY – 0131YY) overlap the start of a new hospice benefit period (0115YY) and the physician's certification is obtained timely. Report occurrence code 27 and 0115YY.

Example 2: The claim date of service don't overlap the start of a new hospice benefit period and a physician's recertification isn't required. Don't report occurrence code 27.
32

Date beneficiary notified of intent to bill

Report the date you issued an Advance Beneficiary Notice of Noncoverage (ABN) to the patient.
42

Date of hospice benefit termination

Report the date the patient revoked his/her election to receive hospice benefits.
55

Date of death

Report the date of death and the most appropriate patient discharge status code (40, 41, or 42).
SPAN CODES/DATES FL 35-36

Occurrence Span Codes & Dates

Enter code(s) and associated beginning and ending date(s) that define specific event(s) related to this billing period, when applicable.

Code Description
77

Provider liability (utilization charged)

Report the period of non-covered hospice care (other than for medical necessity or custodial care) for which the provider accepts payment liability (e.g., recertification or Notice of Election isn't timely).

Don't use this code to indicate that the face-to-face encounter isn't timely.
M2

Dates of inpatient respite care

When respite care is provided more than once during a benefit period, report the dates for each respite period (5 days or less).
FAC.ZIP FL 1

Facility ZIP Code

Enter the hospice agency's 9-digit ZIP code.
VALUE CODES – AMOUNTS FL 39-41

Value Codes & Amounts

Enter code(s) and associated value amount(s) that are necessary for processing the claim.

Code Description
61

Place of residence where service is furnished

When billing routine home care (revenue code 0651) and continuous home care (revenue code 0652):

  • Report the Core-Based Statistical Area (CBSA) or special 50xxx code that corresponds to the state and county where hospice services were provided.
  • For beneficiaries in areas with more than one unique CBSA due to the wage index cap policy, use the special 50xxx codes to determine the appropriate code to report in place of the CBSA code.
  • If the beneficiary receives hospice services in more than one CBSA area during the billing period, report the CBSA that applies at the end of the billing period.

See Hospice Wage IndexExternal Website for CBSA codes.
G8

Facility where inpatient hospice service is delivered

When billing inpatient respite care (revenue code 0655) and general inpatient care (revenue code 0656):

  • Report the Core-Based Statistical Area (CBSA) or special 50xxx code that corresponds to the state and county where hospice services were provided.
  • For beneficiaries in areas with more than one unique CBSA due to the wage index cap policy, use the special 50xxx codes to determine the appropriate code to report in place of the CBSA code.
  • If the beneficiary receives hospice services in more than one CBSA area during the billing period, report the CBSA that applies at the end of the billing period.

See Hospice Wage IndexExternal Website for CBSA codes.

Payer Only Codes

Providers don't submit these codes; FISS applies them during processing, when applicable.

Code Description
62

Number of high routine home care days

(days within the first 60 days)
63

Number of low routine home care days

(days after the first 60 days)

Updated: 10.01.2026

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