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Claim Page 02 – Entering a Hospice Claim

Below is an image of the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) claim page 02 (MAP1712) screen.

screenshot

Key:

RED = Required
GREEN = Conditional
PURPLE = Auto-populated
BLACK = Not required

Field Descriptions

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

The tables below describe the required data elements for each DDE field or UB-04 Form Locator.

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 Manual for a complete listing and guidance.

DDE Field	UB-04 Form Locator (FL)	Description
REV	FL 42	Revenue Codes – Report the appropriate code to explain each charge reported on the claim. See the Hospice Revenue Codes table below for details.
HCPC	FL 44	HCPCS Codes – Report the code that describes the item, service, or procedure provided to the patient during the billing period. See the Hospice HCPCS Codes table below for details.
MODIFS	FL 44	Modifiers – When appropriate, add a modifier to a HCPCS code to provide additional information about the item, service, or procedure performed. GV – Used to identify attending physician services performed by a doctor of medicine, doctor of osteopathy, nurse practitioner, or physician assistant acting as the patient's attending physician. PM – Used to identify a post-mortem visit provided on the date of death. KX – Used to request an exception for an untimely notice of election (NOE).
TOT UNIT	FL 46	Total Units – Report the number of times the patient received an item, service, or procedure based on the HCPCS code description. For level of care revenue codes 0651, 0655, or 0656, report the number of consecutive days. For continuous home care (revenue code 0652), report the number of 15-minute increments. For summary drug charges, report 1 or the number of drugs provided during the billing period.
COV UNIT	FL 46	Covered Units – Report the number of total units that are covered.
TOT CHARGE	FL 47	Total Charge – Report the total charge amount for each revenue code line.
NCOV CHARGE	FL 48	Non-covered Charge – Report any non-covered charge amount for each revenue code line.
SERV DATE	FL 45	Service Date – Report the date of service for each revenue code line. For revenue codes 0651, 0655, and 0656, report the earliest date for each level of care at each service location. For revenue code 0652, report each day continuous home care is provided. For service visits that span to the next calendar day, report the date the visit ended.

Hospice Revenue Codes

Revenue Code	Description
0001	Total charges
0250	Pharmacy – Report total charges for all non-injectable prescription drugs.
029X	Durable Medical Equipment – Report total charges for all DME (e.g., infusion pumps and drugs). 0 – General Classification 1 – Med Equip/Rent 2 – Med Equip/New 3 – Med Equip/Used 4 – HHA/Supplies and drugs required for DME effectiveness
Service Visits
Report a separate revenue code line for each visit. GIP or respite care visits provided by non-hospice staff in contracted facilities aren't required.
042X	Physical Therapy 0 – General Classification 1 – Visit Charge
043X	Occupational Therapy 0 – General Classification 1 – Visit Charge
044X	Speech-Language Pathology 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)
057X	Hospice Aide 0 – General Classification 1 – Visit Charge
Level of Care
Report a separate revenue code line for each level of care change or day of continuous care. Only report the same revenue code on a separate line item if the service location (site of service Q code) changes. See CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 11, section 30.1 for definitions.
0651	Routine Home Care
0652	Continuous Home Care
0655	Inpatient Respite Care
0656	General Inpatient Care
0657	Physician Services – See Billing Hospice Physician & Nurse Practitioner Services for more information.
0659	Other Hospice – Report if you wish to receive a line-item denial for non-covered room and board charges.

Hospice HCPCS Codes

Level of Care

Report one of the following HCPCS codes with each level of care revenue code (0651, 0652, 0655, or 0656) to identify the service location.

HCPCS Code	Description
Q5001	Hospice care provided in patient's home/residence Note: Don't report with respite (0655) or GIP (0656).
Q5002	Hospice care provided in assisted living facility Note: Don't report with respite (0655) or GIP (0656).
Q5003	Hospice care provided in nursing long-term care (LTC) facility or non-skilled nursing facility (NF) Note: Don't report with GIP (0656). Report the facility NPI in Loop 2310E.
Q5004	Hospice care provided in skilled nursing facility (SNF) Applies when the beneficiary receives one of the following: Hospice care in a solely-certified SNF General inpatient care in the SNF SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and hospice routine home care (uncommon) Inpatient respite care in a SNF If the beneficiary is in a nursing facility but doesn't meet the criteria above, report HCPCS code Q5003. Note: Don't report with continuous home care (0652). Report the facility NPI in Loop 2310E.
Q5005	Hospice care provided in inpatient hospital Note: Don't report with continuous home care (0652). Report the facility NPI in Loop 2310E.
Q5006	Hospice care provided in inpatient hospice facility Note: Don't report with continuous home care (0652).
Q5007	Hospice care provided in long-term care hospital (LTCH) Note: Don't report with continuous home care (0652). Report the facility NPI in Loop 2310E.
Q5008	Hospice care provided in inpatient psychiatric facility Note: Don't report with continuous home care (0652). Report the facility NPI in Loop 2310E.
Q5009	Hospice care provided in place not otherwise specified (NOS)
Q5010	Hospice home care provided in hospice facility Applies when the beneficiary receives routine or continuous home care in one of the following: Hospice residential facility Hospice facility also certified to provide inpatient care Note: Don't report with respite (0655) or GIP (0656).

Service Visits

Report one of the following HCPCS codes with each service visit revenue code.

Revenue Code	HCPCS Code	Description
042X (Physical Therapy)	G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
042X (Physical Therapy)	G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
043X (Occupational Therapy)	G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
043X (Occupational Therapy)	G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
044X (Speech-Language Pathology)	G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
055X (Skilled Nursing)	G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
055X (Skilled Nursing)	G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes
056X (Medical Social Services)	G0155	Services of a clinical social worker in the home health or hospice setting, each 15 minutes
057X (Hospice Aide)	G0156	Services of a home health or hospice aide in the home health or hospice setting, each 15 minutes

Updated: 08.12.2025