Skip to Main Content

Print | Bookmark | Font Size: + | –

Hospice Medicare Billing Codes Sheet – FISS Fields and UB-04 Field Locators (FL) for Hospice Billing

R = required
C = conditional
N = not required
O = optional

FISS Fields and UB-04 Field Locators (FL) for Hospice Billing
FISS Pg FISS Field Name UB FL Data Entered NOE Claim
1 HIC 60 Medicare (HIC) number R R
1 TOB 4 Type of Bill R R
1 NPI 56 NPI number R R
1 Pat.Cntl#: 3a Patient Control Number O O
1 Stmt Date From 6 From date of service R R
1 To 6 To date of service N R
1 Last 8 Patient's last name R R
1 First 8 Patient's first name R R
1 DOB 10 Patient's date of birth R R
1 Addr 1 9 Patient's address R R
1 Addr 2 9 City State R R
1 Zip 9 Zip R R
1 Sex 11 Sex code (M or F) R R
1 Admit Date 12 Date of admission R R
1 Hr 13 Admission hour R 1 R 1
1 Type 14 Type of Admission N R
1 Stat 17 Patient status N R
1 Cond Codes 18-28 Condition codes N C
1 Occ Cds/Date 31-34 Occurrence code(s)/date(s) R C 2
1 Span Codes/Dates 35-36 Occurrence span code(s)/date(s) N C 3
1 DCN 64 Document control number N C 4
1 Value Codes 39-41 Value codes N R 5
2 Rev 42 Revenue codes N R
2 HCPC 44 HCPCS N R
2 Modifs 44 Modifier N C
2 Tot Unit 46 Total units N R
2 Cov Unit 46 Covered units N R
2 Tot Charges 47 Total charges N R
2 Ncov Charge 48 Noncovered charges N C
2 Serv Dt 45 Service date N R
3 CD 50 Payer code R R
3 Payer 50 Payer name R R
3 RI 52 Release of information R R
3 Medical Record Nbr 3b Medical Record Number O O
3 Diagnosis codes 67 Diagnosis codes R R
3 Att Phys NPI 76 Attending physician's NPI R R
3 LN 76 Attending physician's last name R R
3 FN 76 Attending physician's first name R R
3 MI 76 Attending physician's middle initial O O
3 Opr Phys NPI 77 Operating physician's NPI N N
3 LN 77 Operating physician's last name N N
3 FN 77 Operating physician's first name N N
3 MI 77 Operating physician's middle initial N N
3 Oth Phys NPI 78 Certifying physician's NPI R R
3 LN 78 Certifying physician's last name R R
3 FN 78 Certifying physician's first name R R
3 MI 78 Certifying physician's middle initial O O
4 Remarks 80 Remarks C C
5 Insured name 58 Insured's last name, first name N C 6
5 Sex N/A Insured's sex code N C 6
5 DOB N/A Insured's date of birth N C 6
5 Rel 59 Patient's relationship N C 6
5 Cert-SSN-HIC 60 Insured's ID/HIC# N C 6
5 Group name 61 Insurance group name N C 6
5 Ins Group Number 62 Insurance group number N C 6
6 1st Insurer Address 80 Insurer's address N C 6
6 City 80 Insurer's city N C 6
6 St 80 Insurer's state N C 6
6 Zip 80 Insurer's zip N C 6

1 Required for DDE
2 OC 27 is required when certification/recertification overlaps the claim's date of service.

OC 42 is required when the patient has been discharged/revoked hospice.

3 OSC 77 is required when the recertification was not obtained timely.
4 Adjustments and cancels only
5 Value code 61 and CBSA code required for rev. code 0651 or 0652. Value code G8 and CBSA code required for rev. code 0655 or 0656.
6 Required when Medicare is secondary.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved