UB04 Condition Codes Code 07: Treatment of Non-terminal Condition for Hospice Patient

Overview

Condition Code 07 indicates "Treatment of a non-terminal condition for a hospice patient." This code is used when a hospice patient receives medical treatment for a condition that is not related to their terminal illness or the primary hospice diagnosis. The code signals to payers that the services being billed are for a separate, non-terminal condition, which may have different coverage rules and billing requirements compared to hospice-related care. ^[1]

The code is part of the UB-04 condition code set used in Field 18-28 on the claim form. It is essential for distinguishing between hospice-related services (covered under the hospice benefit) and unrelated medical treatments that may be billed separately. ^[2]

When Condition Code 07 is present, it alerts the payer that the services provided are for a condition that is not part of the patient's terminal illness. This distinction is critical because Medicare and many other payers cover hospice services under a bundled payment, but may allow separate billing for treatments unrelated to the terminal condition. Proper use of this code ensures accurate claim processing and appropriate reimbursement. ^[1]

When to Use

Condition Code 07 should be used when a hospice patient receives medical treatment for a condition that is not related to their terminal illness or the primary hospice diagnosis. For example, if a hospice patient with a terminal cancer diagnosis develops a urinary tract infection or fractures a bone, the treatment for these non-terminal conditions would warrant the use of Code 07. ^[1]

This code is appropriate for both inpatient and outpatient settings where the primary reason for the encounter is a condition unrelated to the hospice diagnosis. It applies to services such as emergency department visits, hospital admissions, surgeries, diagnostic tests, and other medical interventions that address non-terminal issues. The code helps payers identify claims that may be eligible for separate reimbursement outside the hospice bundled payment. ^[1]

Providers should not use Condition Code 07 for services that are part of the hospice plan of care or related to the terminal condition. Those services should be billed under the hospice benefit with appropriate hospice-specific codes. The code is specifically for treatments that are unrelated to the terminal illness and would otherwise be covered under standard Medicare or insurance benefits. ^[1]

Step-by-Step Claim Example

Scenario: A 78-year-old female hospice patient with terminal lung cancer (hospice diagnosis) falls at home and fractures her hip. She is taken to the emergency department and admitted for hip surgery. The fracture is unrelated to her terminal cancer.

Step 1: Patient Information – Enter the patient's name, date of birth, and Medicare/insurance information in Fields 1-13 of the UB-04 form. Ensure the hospice patient's information is accurate, including their hospice election status. ^[2]

Step 2: Condition Code Field – In Field 18-28 (Condition Codes), enter "07" to indicate "Treatment of a non-terminal condition for a hospice patient." This is the critical code that distinguishes this claim from hospice-related services. ^[1]

Step 3: Diagnosis Codes – In Fields 67-75 (Diagnosis Codes), enter the primary diagnosis for the hip fracture (e.g., S72.001A – Fracture of unspecified part of neck of right femur, initial encounter for closed fracture). Do not include the terminal cancer diagnosis as the primary diagnosis for this claim. ^[2]

Step 4: Procedure Codes – In Fields 74-76 (Procedure Codes), enter the appropriate ICD-10-PCS or CPT codes for the hip surgery and any related procedures. For example, 0QS90ZZ (Repair right hip, open approach) or CPT 27236 (Open treatment of femoral fracture). ^[2]

Step 5: Revenue Codes – In Fields 42-49 (Revenue Codes), enter the appropriate revenue codes for the services provided, such as 0450 (Emergency Room), 0110 (Medical/Surgical ICU), or 0360 (Operating Room). ^[2]

Step 6: Submission – Submit the claim to Medicare or the appropriate payer. The Condition Code 07 will alert the payer that this is a non-terminal condition treatment for a hospice patient, allowing for separate reimbursement outside the hospice bundled payment. ^[1]

Common Mistakes & Audit Red Flags

Mistake 1: Using Code 07 for hospice-related services – A common error is using Condition Code 07 for treatments that are actually part of the hospice plan of care. For example, providing pain management for the terminal cancer diagnosis and billing it with Code 07 would be incorrect. This can lead to claim denials and potential audits. ^[1]

Mistake 2: Failing to include Code 07 when appropriate – When a hospice patient receives treatment for a non-terminal condition, failing to include Condition Code 07 may result in the claim being processed as part of the hospice bundled payment, leading to underpayment or denial. Providers must ensure the code is present when the services are unrelated to the terminal diagnosis. ^[1]

Mistake 3: Incorrect diagnosis coding – Using the terminal diagnosis as the primary diagnosis instead of the non-terminal condition can confuse payers and lead to claim rejection. The primary diagnosis should always reflect the reason for the current encounter, not the hospice diagnosis. ^[2]

Audit Red Flag: Frequent use of Code 07 – If a provider frequently bills Condition Code 07 for the same hospice patient, auditors may scrutinize whether the services are truly unrelated to the terminal condition. Documentation should clearly support the medical necessity and non-terminal nature of each treatment. ^[1]

Audit Red Flag: Missing documentation – Claims with Condition Code 07 require thorough documentation showing that the treatment is for a non-terminal condition. Lack of clinical notes, physician orders, or other supporting evidence can trigger audits and recoupment. ^[2]

Related Codes/Fields

Code/Field	Description	Relationship to Code 07
Condition Code 52	Hospice beneficiary moves out of service area	Both relate to hospice patients; Code 52 addresses geographic changes while Code 07 addresses non-terminal treatments
Condition Code 08	Beneficiary would not provide information concerning other insurance coverage	Both are condition codes used in Field 18-28; Code 08 is unrelated to hospice
Revenue Code 0650	Hospice services (general)	Used for hospice-related billing; Code 07 indicates services are NOT hospice-related
Revenue Code 0651	Hospice routine home care	Contrasts with Code 07 which indicates non-hospice treatment
Field 67-75 (Diagnosis Codes)	Primary and secondary diagnoses	Must reflect non-terminal condition when Code 07 is used
Field 42-49 (Revenue Codes)	Service classification codes	Should match the non-terminal treatment being provided
Condition Code 06	ESRD patient in first 30 months of entitlement	Both are condition codes but for different patient populations
Condition Code 09	Neither patient nor spouse is employed	Both are condition codes in Field 18-28; unrelated to hospice

^[1] | ^[2]

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References

[1] Noridian Condition Codes — https://med.noridianmedicare.com/web/jea/topics/claim-submission/condition-codes

[2] MassHealth UB-04 Guide — https://www.mass.gov/doc/ub-04-billing-guide-0/download