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Printed Date: 9/22/2015
Beneficiary has elected the Medicare hospice benefit and services billed as being related to the terminal diagnosis.
Explanation and Suggestion:
Verify what health care services the beneficiary is receiving at the time of admission. Review the beneficiary's Medicare eligibility information in the Common Working File (CWF), the HIPAA Eligibility Transaction System (HETS) or the eServices portal Inpatient tab at the time of admission and prior to submitting a claim, or Requests for Anticipated Payment (RAP).
Consult with the hospice to ensure that the services being provided are not related to the hospice terminal diagnosis. When submitting a claim to Medicare for services that are determined as unrelated to the terminal illness, verify that the diagnosis on the claim are not an exact match or related to the terminal diagnosis and ensure condition code 07 is entered in FL 18-28 of the CMS-1450 claim form. Condition code 07 can only be used when the services are unrelated to the terminal diagnosis; any other use of condition code 07 may be considered abusive.
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Last Updated: 02/05/2018