Friday, June 17, 2016

Hospice: Claims Rejected with Reason Code C7010

Palmetto GBA has identified claims that have been submitted for beneficiaries that have elected the hospice benefit and receiving inpatient, home health or other services related to the terminal illness. These claims have been incorrectly billed to Medicare. A provider must respond to an Additional Documentation Request (ADR), if received. However, once reviewed, if the claim does not have a condition code 07; the claim will ultimately be rejected with reason code C7010.

Providers should always verify a recipient’s eligibility before delivering services, both to determine eligibility for the current date and to discover any limitations to the recipient’s coverage.

Top Claim Submission Error – Reason Code C7010 

Reason for error:

Beneficiary has elected the Medicare hospice benefit and services billed as being related to the terminal diagnosis.

How to prevent/resolve:
Verify with the beneficiary or their representative what health care services they are currently receiving at the time you admit him/her.

Review the beneficiary's Medicare eligibility information in the Common Working File (CWF) and/or through the HIPAA Eligibility Transaction System (HETS) at the time of admission and prior to submitting claims, or for home health providers before the Requests for Anticipated Payment (RAPs). It is important to determine whether the beneficiary has elected the hospice benefit and whether this election impacts the dates of service.

Providers should also 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/ses code(s) submitted 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. Enter this in the first available COND CODES field on FISS Page 01. In addition, 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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