Hospice Billing

Avoiding Reason Code U5181: Appropriate Use of Occurrence Code 27/Occurrence Span Code 77

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Background

Hospice care is available for two periods of 90 days and an unlimited number of subsequent 60-day periods. Certification of the terminal illness is required at the start of each benefit period. The hospice must obtain, no later than two calendar days after the start of each hospice benefit period, oral or written certification of the terminal illness. Initial certifications may be completed up to 15 days before hospice care is elected. For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins. If an oral certification is received, the written certification must be on file in the hospice patient’s record prior to submission of a claim to the Medicare contractor.

When the certification/recertification is done timely, occurrence code (OC) 27 is reported on the claim for the billing period that crosses the new/next election period. The OC 27 date must equal the start date of the next election period. Note that the OC 27 date will create the next election period if one is not currently present. The OC 27 is not required to be reported on claims that do not cross a new election period.

When the recertification is not done timely, an occurrence span code (OSC) 77 must be reported to represent for the days that are provider-liable due to the late recertification. The OC 27 is reported with the date that the actual recertification was obtained.

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Example of the Proper Use of OC 27

When certifications/recertifications are obtained timely, the OC 27 date reported will match the start date of the election period. For example, the patient is admitted to hospice for the first time on 5/8/20XX and revokes the benefit on 9/6/20XX. The initial certification was done on 5/7/20XX and the recertification was done on 8/6/20XX. The election periods are as follows:

Election Period 1 Election Period 2
Start Date: 5/8/20XX Start Date: 8/6/20XX
End Date: 8/5/20XX End Date: 9/6/20XX


The OC 27 will only be reported on the clams with dates of service that cross the new/next election period.

Claim 1 2 3 4 5
Type of Bill 8X2 8X3 8X3 8X3 8X4
Dates of Service 5/8/20XX–5/31/20XX 6/1/20XX–6/30/20XX 7/1/20XX–7/31/20XX 8/1/20XX–8/31/20XX 9/1/20XX–9/6/20XX
OC 27? Yes No* No* Yes No*
OC 27 Date 5/8/20XX N/A N/A 8/6/20XX N/A


*OC 27 is not required to be reported because the claim is not crossing a new hospice election period.

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Examples of the Proper Use of OC 27 with OSC 77

When recertifications are not obtained timely, hospices must report OSC 77 to identify the days of care that are not covered by Medicare due to the untimely physician recertification. The OC 27 date reported will match the actual date that the recertification was obtained. Below are two examples of the appropriate use of OC 27 and OSC77.

Example 1: The patient is admitted to hospice for the first time on 10/15/20XX and revokes the benefit on 1/29/20XX. The initial certification was done on 10/15/20XX, and the recertification was done on 1/19/20XX. The election periods are as follows:

Election Period 1 Election Period 2
Start Date: 10/15/20XX Start Date: 1/13/20XX
End Date: 1/12/20XX End Date: 1/29/20XX


The OC 27 will be reported on the initial claim. Since the recertification was obtained late, the OSC 77 will be reported to reflect the days that are not covered by Medicare. The OSC 77 start date will be the first day of the election period where the recertification was obtained late. The OSC 77 end date will be the day before the actual recertification was obtained. OC 27 will then reflect the date that the actual late recertification was obtained.

Claim 1 2 3 4
Type of Bill 8X2 8X3 8X3 8X4
Dates of Service 10/15/20XX–10/31/20XX 11/1/20XX–11/30/20XX 12/1/20XX–12/31/20XX 1/1/20XX–1/29/20XX
OC 27? Yes No* No* Yes
OC 27 Date 10/15/20XX N/A N/A 10/19/20XX
OSC 77? No No No Yes †
OSC 77 Dates N/A N/A N/A 1/13/20XX–1/18/20XX


*OC 27 is not required to be reported because the claim is not crossing a new hospice election period

†OSC 77 is reported to show the provider-liable days due to the late recertification

Example 2: The patient is admitted to hospice for the first time on 9/28/20XX and revokes the benefit on 1/22/20XX. The initial certification was done on 9/18/20XX, and the recertification was done on 1/2/20XX. The election periods are as follows:

Election Period 1 Election Period 2
Start Date: 9/28/20XX Start Date: 12/27/20XX
End Date: 12/26/20XX End Date: 1/22/20XX


The OC 27 will be reported on the initial claim. Since the recertification was obtained late, the OSC 77 will be reported to reflect the days that are not covered by Medicare. When a provider-liable period crosses a billing cycle, the OSC 77 will be reported on both claims that have provider-liable days. Therefore, the OSC 77 start date on the first claim that has provider-liable days will be the first day of the election period where the recertification was obtained late and the end date will be the last day of the billing period. The OSC 77 start date on the second claim will be the first day of the billing period, and the end date will be the day before the actual recertification was obtained. OC 27 will then reflect the date that the actual late recertification was obtained.

Claim 1 2 3 4 5
Type of Bill 8X2 8X3 8X3 8X3 8X4
Dates of Service 9/28/20XX–9/30/20XX 10/1/20XX–10/31/20XX 11/1/20XX–11/30/20XX 12/1/20XX–12/31/20XX 1/1/20XX–1/22/20XX
OC 27? Yes No* No* No** Yes
OC 27 Date 9/28/20XX N/A N/A N/A 1/2/20XX
OSC 77? No No No Yes † Yes †
OSC 77 Dates N/A N/A N/A 12/27/20XX–12/31/20XX 1/1/20XX–1/1/20XX


*OC 27 is not required to be reported because the claim is not crossing a new hospice election period.

**OC 27 is not reported because the late recertification was not obtained within the billing period.

†OSC 77 is reported to show the provider-liable days due to the late recertification

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