Reason Code C7010

Description
The edited inpatient or outpatient claim has "from"/"through" dates that overlap a hospice election period and is not indicated as treatment of a non-terminal condition (condition code 07). Or, a MCCD/DMD notice of election (89a) from date overlaps a hospice election period.

Resolution
Common Working File (CWF) shows a hospice election period open during claim dates of services (DOS). A non-hospice related claim has been billed without (zero) 07 condition code. Condition code 07 indicates that, although beneficiary elected Medicare hospice benefit, services he/she received were for treatment or management of conditions not related to his/her hospice terminal illness.

If services being provided are related to the open CWF hospice election period, claim must be billed to hospice, not Medicare. If services are not related to hospice election period append 07 condition code to claim.

Verify if beneficiary is enrolled in (elected) Medicare hospice benefit and/or determine if the services are related to the terminal illness or not.

If the services are related to the terminal illness, bill the hospice agency. Bill Medicare for non-terminal illness related services:

  • Must meet Medicare billing/coverage requirements
  • Include condition code 07 (zero 7) in Form Locator 18-28 of UB-04 claim or electronic equivalent field of 837I

Resources

  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, chapter 9 (PDF, 639 KB)
  • CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, chapter 11 (PDF, 483 KB), section 30.3 

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