The following
are detailed instructions for completing the admission notice (CMS
1450 UB-04):
• Definition: Notify
the contractor responsible for processing your claims of the beneficiary’s
election of hospice benefits by forwarding Form CMS 1450 UB-04.
• Item 5. Federal
Tax Number. Enter Tax Identification Number (TIN) or Employer Identification
Number (EIN) and the sub-identifier assigned by the contractor.
• Item 8. Patient’s
Name Required. Show the patient’s name with the surname first, first
name, and middle initial, if any.
• Item 9. Patient’s
Address Required. Show the patient’s full mailing address including
street name and number or RFD, city, state, and zip code.
• Item 10. Patient’s
Birthdate Required. Show the month, day, and year of birth numerically
as MM-DD-YY. If the date of birth cannot be obtained after a reasonable
effort, leave this field blank.
• Item 11. Patient’s
Sex Required. Show and “M” for male or an “F” for female.
• Item 12. Admission
Date Required. Enter the admission date, which must be the same
date as the effective date of the hospice election or change of
election. The date of admission may not precede the physician’s
certification by more than two calendar days.
• Item 38. Transferring
Hospice ID Required. Only when the admission is for a patient
who has changed an election from one hospice to another.
• Item 58A, B,
C. Insured’s Name Required. If the primary payer(s) is other
than TRICARE, enter the name of person(s) carrying other insurance
in 58A or 58A and 58B as recorded on the ID card. If the TRICARE
Program is primary, enter the sponsor’s name as recorded on the
ID card, in line 58A.
• Item 60A, B,
C. Certificate/Social Security Number (SSN)/Health Insurance Claim/Identification
Number. If primary payer(s) is other than the TRICARE Program,
enter the unique ID number assigned by the primary payer to the person(s)
carrying other insurance in line 60A or 60A and 60B. Enter the sponsor’s SSN
in line 60B or 60C if the patient; or enter the DoD
Benefits Number (DBN) in line 60B or 60C if a North
Atlantic Treaty Organization (NATO)/Partnership
for Peace (PfP) beneficiary.
• Item 67. Principle
Diagnosis Code Required. For services provided before the mandated
date, as directed by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, show the full International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) diagnosis code. For services provided on or after the
mandated date, as directed by HHS, for ICD-10 implementation, show
the full ICD-10-CM diagnosis code. The principal diagnosis is defined
as the condition established after study to be chiefly responsible
for occasioning the patient’s admission.
• Item 76. Attending
Physician ID Required. Enter the name, number and address of
the licensed physician normally expected to certify and recertify
the medical necessity of the services rendered and/or who has primary
responsibility for the patient’s medical care and treatment. Use
Item 94 “Remarks” for additional space for recording this information.
• Item 78. Other
Physician ID Required. Enter the word “employee” or “non-employee”
here to describe the relationship that the patient’s attending physician has
with the hospice program.
• Items 85 and
86. Provider Representative Signature and Date Required. Deleted
from UB-04, see FL 45, line 23. A hospice representative makes sure
that the required physician’s certification and a signed hospice
election statement are in the records.