Reason Code C7010

Reason Code Description
An inpatient, outpatient or SNF claim has service dates equal to or overlapping a hospice election period. Therefore, no Medicare payment can be made. If billing is for the treatment of a non-terminal condition for the hospice patient, please resubmit claim with the appropriate condition code. 

Why the Reason Code Was Assigned
For the dates of services billed, the beneficiary has an open Medicare Hospice Benefit Election.

Resolution
Prior to rendering services or admission:

• Verify with the beneficiary or their representative if the beneficiary is currently receiving hospice services prior to rendering services or admission; and
• Access the beneficiary’s eligibility record in eServices or other Medicare eligibility system to verify if there is a current hospice election

If there is a current hospice election, contact the hospice to verify if the beneficiary is still active in the hospice election.

• If no, request the hospice submit a discharge claim or Notice of Termination/Revocation (NOTR). An NOTR is used when the hospice beneficiary is discharged alive from the hospice or revokes the election of hospice services and a final claim is not ready to be submitted.
• If yes, you may ask the hospice if your services are unrelated to the terminal prognosis of the individual (not just the primary diagnosis, but all related conditions to the terminal illness) and/or request a Hospice Election Statement Addendum for the beneficiary
  • If the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement

• If services are unrelated to the terminal prognosis of the individual (not just the primary diagnosis, but all related conditions to the terminal illness), ensure condition code "07" is entered on the claim
  • Condition code "07" can only be used when the services are unrelated to the terminal prognosis; any other use of condition code "07" may be considered abusive
  • If warranted, A/B MACs may conduct pre-payment development or post-payment review to validate that services billed with condition code 07 are not related to the patient’s terminal condition
• If the services are related, but not coordinated with the hospice prior to delivery, no payment can be made by Medicare or the hospice

 Resources

• Section 20.2.1.2 — Hospice Election Statement Addendum, of the Medicare Benefit Policy Manual, Chapter 9 — Coverage of Hospice Services Under Hospital Insurance (PDF)
• 50 — Billing and Payment for Services Unrelated to Terminal Illness, Medicare Claims Processing Manual, Chapter 11 — Processing Hospice Claims (PDF)