Hospice Claims Editing for Reason Code U5181

 Current Status

5/3/2019: The U5181 edit issue is for monthly billing in which a hospice’s provider liability (OSC 77) ends for a late Notice of Election (NOE). The hospice is accepting liability for the late NOE and is not requesting an exception. Edit U5181 edit is firing assuming it is for a late recertification, which it is not.

Hospices are continuing reporting claims to the Provider Contact Center that did edit correctly for reason code U5181. Please remember to verify if:

  • There is an open election on file
  • The OC 27 date is the correct date for the next election period start date (first day of the next period)
  • The admission date on the claim matches the hospice election date
  • The OC 27 date is within the DOS on the claim
  • OC 27 is only reported on the claim for the billing period in which the certification or recertification was obtained
  • The patient is in the first certification period when they transfer to another hospice, then the receiving hospice would use the same certification date as the previous hospice until the next certification period
  • The hospice received the recertification of terminal illness later than two days after the first day of a new benefit period, they must report condition code 85 on the claim. This code is reported with OSC 77, which reports the provider liable days associated with the untimely recertification. The OC 27 date should be the first day of covered charges (day after the thru date of OSC 77). You may refer to the Billing Occurrence Code 27, Occurrence Span Code 77 and Late Recertifications Module for billing assistance.

This issue has been escalated. We will provide an update as soon as available. No provider action is required at this time.

Situation:
Some claims are incorrectly returning to provider (RTP) for reason code U5181, stating there are issues with occurrence code OC 27 (missing, incorrect date, outside the dates of service{DOS}, etc.). Most, if not all, of the affected claims have Occurrence Span Code (OSC) 77 (Provider Liability) and dates within the DOS.

Hospices are reporting claims to the Provider Contact Center that did edit correctly for reason code U5181. Please remember to verify if:

  • The OC 27 date is the correct date for the next period start date
  • The OC 27 date is within the DOS on the claim
  • OC 27 is only reported on the claim for the billing period in which the certification or recertification was obtained
  • The patient is in the first certification period when they transfer to another hospice, then the receiving hospice would use the same certification date as the previous hospice until the next certification period
  • The hospice received the recertification of terminal illness later than two days after the first day of a new benefit period, they must report condition code 85 on the claim. This code is reported with OSC 77, which reports the provider liable days associated with the untimely recertification. The OC 27 date should be the first day of covered charges (day after the thru date of OSC 77). You may refer to the Billing Occurrence Code 27, Occurrence Span Code 77 and Late Recertifications Module for billing assistance.

Status:
5/3/2019: The U5181 edit issue is for monthly billing in which a hospice’s provider liability (OSC 77) ends for a late Notice of Election (NOE). The hospice is accepting liability for the late NOE and is not requesting an exception. Edit U5181 edit is firing assuming it is for a late recertification, which it is not.

Hospices are continuing reporting claims to the Provider Contact Center that did edit correctly for reason code U5181. Please remember to verify if:

  • There is an open election on file
  • The OC 27 date is the correct date for the next election period start date (first day of the next period)
  • The admission date on the claim matches the hospice election date
  • The OC 27 date is within the DOS on the claim
  • OC 27 is only reported on the claim for the billing period in which the certification or recertification was obtained
  • The patient is in the first certification period when they transfer to another hospice, then the receiving hospice would use the same certification date as the previous hospice until the next certification period
  • The hospice received the recertification of terminal illness later than two days after the first day of a new benefit period, they must report condition code 85 on the claim. This code is reported with OSC 77, which reports the provider liable days associated with the untimely recertification. The OC 27 date should be the first day of covered charges (day after the thru date of OSC 77). You may refer to the Billing Occurrence Code 27, Occurrence Span Code 77 and Late Recertifications Module for billing assistance.

This issue has been escalated. We will provide an update as soon as available. No provider action is required at this time.

3/21/2019: This issue is ongoing after a recent fix was unsuccessful. We have notified FISS Maintainer of the ongoing issue. We will provide an update as soon as available. No provider action is required at this time.

11/15/2018: This issue is in research. We will provide an update as soon as available. No provider action is required at this time.

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