UB04 Condition Codes Code H0: Delayed Recertification of Hospice Terminal Illness

Overview

Code H0, "Delayed Recertification of Hospice Terminal Illness," is a condition code used on the UB-04 claim form (Form Locators 18-28) to indicate that a hospice patient's recertification of terminal illness was completed after the required timeframe. This code is part of the standard condition code set maintained by Medicare contractors like Noridian, which lists H0 specifically for this purpose ^[1]. The code signals to payers that the hospice provider is billing for services despite a delay in obtaining the physician's recertification that the patient continues to meet hospice eligibility criteria, typically required at 60-day intervals after the initial 90-day benefit period. MassHealth's UB-04 billing guide confirms that condition codes are entered in Form Locators 18-28, though it does not specifically list H0 ^[2]. Providers use this code to explain why the recertification was not submitted on time, often due to administrative delays, patient transitions between care settings, or physician availability issues. The code helps avoid automatic claim denials by providing a documented reason for the late recertification, allowing payers to process the claim with appropriate medical review.

When to Use

Use code H0 when a hospice patient's recertification of terminal illness was completed after the regulatory deadline but the services provided during the gap period are still considered medically necessary and covered. This situation typically arises when the hospice provider has a legitimate reason for the delay, such as the attending physician being unavailable, the patient being hospitalized or transferred between facilities, or administrative processing errors. The code should be applied to claims for hospice services rendered during the period between the recertification due date and the actual date the recertification was signed. It is critical to note that H0 does not automatically guarantee payment; payers will review the claim to determine if the delay was reasonable and if the patient continued to meet hospice eligibility criteria during the gap period. Providers should also ensure that the recertification itself is properly documented in the patient's medical record, including the physician's statement confirming the terminal prognosis. Code H0 is distinct from code 07 (Treatment of a non-terminal condition for a hospice patient) and should not be used interchangeably ^[1]. Always verify payer-specific requirements, as some payers may have additional documentation or prior authorization requirements for delayed recertifications.

Step-by-Step Claim Example

Scenario: A hospice patient, John Doe, was admitted on January 15, 2025, with a terminal diagnosis of lung cancer. His initial 90-day benefit period ended on April 14, 2025. The first recertification was due by April 14, 2025, but due to the attending physician being out of the country, the recertification was not signed until April 28, 2025. The hospice provided continuous care from April 15 through April 28. The provider must bill for these 14 days of service.

Step 1: Complete patient demographic information in Form Locators 1-13, including patient name, address, and Medicare HIC number.

Step 2: Enter the statement covers period in Form Locators 6 and 8. For this example, enter "04152025" in FL6 (From) and "04282025" in FL8 (Through).

Step 3: In Form Locators 18-28 (Condition Codes), enter "H0" in the first available field (FL18). This tells the payer that the recertification was delayed. If other condition codes apply (e.g., code 07 for non-terminal treatment), list them in subsequent fields.

Step 4: Complete revenue codes and charges in Form Locators 42-47. For hospice services, use revenue code 0651 (Hospice - Routine Home Care) for each day of service. Enter the appropriate charges for each day.

Step 5: In Form Locator 50 (Payer Identification), enter the primary payer (e.g., Medicare Part A).

Step 6: Attach a cover letter or electronic attachment explaining the reason for the delay (e.g., "Physician was out of country; recertification obtained on 04/28/2025"). Include the actual recertification date and a copy of the signed recertification if required by the payer.

Step 7: Submit the claim to the appropriate Medicare Administrative Contractor (MAC) or other payer. The claim will be processed with condition code H0, triggering a medical review of the delayed recertification.

Common Mistakes & Audit Red Flags

Mistake 1: Using H0 without supporting documentation. Payers will deny claims if the medical record does not contain the actual recertification or a clear explanation for the delay. Always attach a cover letter or include a remark in the electronic claim explaining the reason.

Mistake 2: Confusing H0 with other condition codes. Code 07 (Treatment of a non-terminal condition for a hospice patient) is for services unrelated to the terminal diagnosis, not for recertification delays. Using the wrong code can lead to improper payment or audit flags ^[1].

Mistake 3: Failing to update the recertification date in the patient's record. The recertification must be signed and dated, and the date must match the documentation submitted with the claim. Discrepancies between the claim and medical record are a major audit red flag.

Mistake 4: Billing for services beyond the delayed recertification period without a new recertification. If the delay extends beyond a few days, the provider must obtain a new recertification before continuing to bill. H0 only covers the gap period, not ongoing services without a valid recertification.

Audit Red Flags: Frequent use of H0 for the same patient or provider may trigger a focused medical review. Payers will look for patterns of late recertifications, which may indicate poor care coordination or inadequate documentation. Additionally, if the recertification delay exceeds 30 days, payers may question whether the patient still met hospice eligibility criteria during the gap period.

Related Codes/Fields

Code/Field	Description	Relationship to H0
Code 07	Treatment of a non-terminal condition for a hospice patient	Distinct; used for services unrelated to terminal diagnosis, not for recertification delays [1]
Code 52	Hospice beneficiary moves out of service area	Related; may co-occur if patient moves during a recertification gap
Revenue Code 0651	Hospice - Routine Home Care	Commonly billed with H0 for home hospice services
Revenue Code 0652	Hospice - Continuous Home Care	May be billed with H0 if patient required continuous care during the gap
Form Locator 50	Payer Identification	Must be completed to identify the payer processing the claim
Form Locator 6/8	Statement Covers Period	Defines the date range for which H0 applies
Form Locator 80	Remarks	Use to explain the reason for the delayed recertification (e.g., "Physician unavailable")
Code 01	Military service related	Unrelated; used for VA coordination, not hospice recertification [1]

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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