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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.

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    Laboratory claim submission requirement


    Many UnitedHealthcare benefit plan designs exclude from coverage outpatient diagnostic services that were not ordered by a participating physician. UnitedHealthcare benefit plans may also cover diagnostic services differently when a portion of the service (e.g., the draw) occurs in the physician’s office, but the analysis is performed by a laboratory provider. In addition, many state laws require that most, if not all, laboratory services are ordered by a licensed physician.

    Therefore, all laboratory claims must include the NPI number of the referring physician, in addition to the other
    elements of a Complete Claim described in this Guide. Laboratory claims that do not include the identity of the referring physician will be rejected or denied.

    This requirement applies to claims for laboratory services, both anatomic and clinical.

    This requirement applies to claims received from both participating and non-participating laboratories, unless
    otherwise provided under applicable law. This requirement does not apply to claims for laboratory services provided by physicians in their offices. Please also refer to the Protocol on Use of Non-Participating Laboratory Services.

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    Assistant surgeons or surgical assistants claim submission requirements


    The practice of directing or using non-participating providers significantly increases the costs of services for our members. As such, UnitedHealthcare requires our participating providers to use reasonable commercial efforts to utilize the services of in network providers, including in-network surgical assistants or assistant surgeons to render services to our members. Health care professionals acting as assistant surgeons must report their health care services under the primary surgeon’s TIN. Payment is subject to our payment policies (reimbursement policies).



    Erythropoietin (For Commercial members)
    For Erythropoietin (EPO) claims submitted via paper to UnitedHealthcare on a CMS-1500 Form, enter the Hematocrit  (Hct) level in the shaded area of line 24A in the same row as the J-code. Enter Hct and the lab value (Hctxx). For electronic claims, the Hct level is required in the (837P) Standard Professional Claim Transaction, Loop 2400 – Service Line, segment MEA, Data Element MEA03. The MEA segment should be reported as follows:

    • MEA01 = qualifier “TR”, meaning test results
    • MEA02 = qualifier “R2”, meaning hematocrit
    • MEA03 = hematocrit test result
    Example: MEA*TR*R2*33~
    The following J codes require an Hct level on the claim:
    • J0881 D arbepoetin alfa (non-ESRD use)
    • J0882 D arbepoetin alfa (ESRD on dialysis)
    • J0885 Epoetin alfa (non-ESRD use)
    • J0886 Epoetin alfa, 1,000 units (for ESRD on Dialysis)
    • Q4081 Epoetin alfa (ESRD on dialysis)
    For EPO claims submitted on a UB04 claim form, an Hct level is not required.

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    This is before HIPAA 5010

    Box 1a or11 ––Claimant Case Number Claimant Case Number
    Boxes 12 & 13 Boxes 12 & 13 ––““Signature on File Signature on File””
    Box 21 Box 21 ––ICDICD-9 Diagnosis Codes 9 Diagnosis Codes
    Box 24A Box 24A ––Dates of Service Dates of Service
    Box 24D Box 24D ––CPT/HCPCS Procedure Codes CPT/HCPCS Procedure Codes and modifiers if applicable and modifiers if applicable
    Box 24E ––Diagnosis pointers Diagnosis pointers
    Box 24F ––Line Charges Line Charges
    Box 24G ––Units
    Box 25 ––Provider’’s Federal Tax ID #s Federal Tax ID #
    Box 28 ––Total Charge
    Box 31 ––Signature of physician and bill Signature of physician and bill date



    BOX 31 –Treating Provider
    Appropriate signatureAppropriate signature
    Bill date must be after last date of service Bill date must be after last date of service

    BOX 32 –Service Address
    Address where service was rendered Address where service was rendered
    To include Zip CodeTo include Zip Code


    BOX 33 –Billing Address
    Address where payment is sent Address where payment is sent
    Provider number attained after enrollment Provider number attained after enrollment 
    From a provider perspective this is the most important field on a HCFA. This information is vital to pay the correct provider.

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    The HIPAA 5010 compliance date has arrived! Are you ready?

    Although January 1, 2012 is the official compliance date for submitting claims through the HIPAA 5010 electronic data interchange (EDI) standards, the Centers for Medicare & Medicaid Services' (CMS) Office of E-Health Standards and Services (OESS) will not initiate enforcement action until April 1, 2012.  Nonetheless, it is important to recognize that the 5010 compliance date is upon us and has not changed.

    Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is now accepting transactions using the mandated 5010 standards. We are also accommodating the CMS 5010 enforcement grace period and will not reject 4010/4010A transactions until April 1, 2012.

    If you are not yet HIPAA 5010 compliant, BCBSF urges you to keep moving forward toward achieving compliance.  Reach out to your vendors and payers to confirm compliance. As you probably now know, conformity to 5010 standards is a crucial prerequisite step toward the greater ICD-10 code set mandate which is rapidly approaching.  The ICD-10 compliance date is October 1, 2013.

    Be sure to attend our HIPAA 5010 Open Line Friday teleconferences which will continue to take place weekly until further notice.  For direct access to valuable 5010-related information and resources, visit our website (www.bcbsfl.com) or simply click on the 5010 icon below.

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    Box 1 ––Billing Address Billing Address
    Box 4 ––Type of billT ype of bill
    Box 5 ––Provider tax ID number Provider tax ID number
    Box 6 ––Statement covers period Statement covers period
    Box 17 to 20 ––Admission Admission (date/hour/type/source)(date/hour/type/source)
    Box 21 & 22 Box 21 & 22 ––Discharge hour and Discharge hour and Discharge status Discharge status
    Box 42 to 47 ––Detail line items (Provide Detail line items (Provide HCPCS for required HCPCS for required RCCRCC’’s)
    Box 51 ––Provider number and Medicare Provider number and Medicare
    number number
    Box 60 ––Claimant Claimant’’s case numbers case number
    Box 67 to 75 ––ICD-9 Diagnosis codes 9 Diagnosis codes
    Box 80 to 81 ––Appropriate procedure codes Appropriate procedure codes



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    Claims submitted for payment should be in a HIPAA accepted 837 file format and filed electronically using the CarePlus Payer ID 95092 to Availity at www.availity.com. If all EDI methods have failed and the provider has contacted the CarePlus Claims Status team for assistance, the provider may then submit  their claim on a properly completed CMS 1500 form within the time frame specified in their contract.

    **  Patient name
    **  Patient ID number
    **  Group number
    **  Patient DOB
    **  Patient address and telephone number
    **  Other insurance information
    -  Insured name
    -  Insurance name
    -  Policy/ Group number
    **  Attach other insurance EOBs to show payment or denial
    **  If patient’s condition is related to:
    -  Employment (Worker’s Compensation)
    -  Auto Accident
    -  Other Accident
    **  Referring Physician (when applicable)
    **  Referring Physicians NPI #
    **  Authorization number
    **  ICD-9 Diagnosis Code(s)
    **  Date(s) of Service
    **  Place of Service & Type of Service
    **  CPT-4 HCPC Procedure Codes and (modifiers when applicable)
    **  Charges
    **  Days or Units
    **  CHCU-Family Planning
    **  EMG
    **  COB
    **  Federal TID number
    **  Patients account number
    **  Accept assignment- Y or N
    **  Total charges
    **  Amount paid
    **  Balance due
    **  Name of Physician or supplier of service
    **  NPI # of Physicians or supplier of service
    **  Billing Providers NPI #
    **  Name and address of facility where services were rendered (if other than home or office)
    **  Physician name and address according to the contract
    **  Plan assigned provider number

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    Item 17 - Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician . All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item
    17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

    Additional instructions for form version 02/12: Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician ractitioner) is performing:


    Qualifier Provider Role 

    DN Referring Provider
    DK Ordering Provider
    DQ Supervising Provider

    Enter the qualifier to the left of the dotted vertical line on item 17.


    NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to perform these roles. Refer to Pub 100-02, Medicare Benefit Policy Manual, chapter 15 for non-physician practitioner rules. Enter non-physician practitioner information according to the rules above for physicians.

    The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

    1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

    2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;

    3. A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a), 1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;

    4. A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or

    5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §§1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished.


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    Here is the full list of EDI claim status code. It may be a denial, rejection and Acknowledgement.



    0

    Cannot provide further status electronically.
    Start: 01/01/1995
    1 For more detailed information, see remittance advice.
    Start: 01/01/1995
    2 More detailed information in letter.
    Start: 01/01/1995
    3 Claim has been adjudicated and is awaiting payment cycle.
    Start: 01/01/1995
    6 Balance due from the subscriber.
    Start: 01/01/1995
    12 One or more originally submitted procedure codes have been combined.
    Start: 01/01/1995 | Last Modified: 06/30/2001
    15 One or more originally submitted procedure code have been modified.
    Start: 01/01/1995 | Last Modified: 06/30/2001
    16 Claim/encounter has been forwarded to entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    17 Claim/encounter has been forwarded by third party entity to entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    18 Entity received claim/encounter, but returned invalid status. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    19 Entity acknowledges receipt of claim/encounter. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    20 Accepted for processing.
    Start: 01/01/1995 | Last Modified: 06/30/2001
    21 Missing or invalid information. Note: At least one other status code is required to identify the missing or invalid information.
    Start: 01/01/1995 | Last Modified: 07/09/2007
    23 Returned to Entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    24 Entity not approved as an electronic submitter. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    25 Entity not approved. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    26 Entity not found. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    27 Policy canceled.
    Start: 01/01/1995 | Last Modified: 06/30/2001
    29 Subscriber and policy number/contract number mismatched.
    Start: 01/01/1995
    30 Subscriber and subscriber id mismatched.
    Start: 01/01/1995
    31 Subscriber and policyholder name mismatched.
    Start: 01/01/1995
    32 Subscriber and policy number/contract number not found.
    Start: 01/01/1995
    33 Subscriber and subscriber id not found.
    Start: 01/01/1995
    34 Subscriber and policyholder name not found.
    Start: 01/01/1995
    35 Claim/encounter not found.
    Start: 01/01/1995
    37 Predetermination is on file, awaiting completion of services.
    Start: 01/01/1995
    38 Awaiting next periodic adjudication cycle.
    Start: 01/01/1995
    39 Charges for pregnancy deferred until delivery.
    Start: 01/01/1995
    40 Waiting for final approval.
    Start: 01/01/1995
    41 Special handling required at payer site.
    Start: 01/01/1995
    42 Awaiting related charges.
    Start: 01/01/1995
    44 Charges pending provider audit.
    Start: 01/01/1995
    45 Awaiting benefit determination.
    Start: 01/01/1995
    46 Internal review/audit.
    Start: 01/01/1995
    47 Internal review/audit - partial payment made.
    Start: 01/01/1995
    49 Pending provider accreditation review.
    Start: 01/01/1995
    50 Claim waiting for internal provider verification.
    Start: 01/01/1995
    51 Investigating occupational illness/accident.
    Start: 01/01/1995
    52 Investigating existence of other insurance coverage.
    Start: 01/01/1995
    53 Claim being researched for Insured ID/Group Policy Number error.
    Start: 01/01/1995
    54 Duplicate of a previously processed claim/line.
    Start: 01/01/1995
    55 Claim assigned to an approver/analyst.
    Start: 01/01/1995
    56 Awaiting eligibility determination.
    Start: 01/01/1995
    57 Pending COBRA information requested.
    Start: 01/01/1995
    59 Information was requested by a non-electronic method. Note: At least one other status code is required to identify the requested information.
    Start: 01/01/1995 | Last Modified: 10/17/2010
    60 Information was requested by an electronic method. Note: At least one other status code is required to identify the requested information.
    Start: 01/01/1995 | Last Modified: 10/17/2010
    61 Eligibility for extended benefits.
    Start: 01/01/1995
    64 Re-pricing information.
    Start: 01/01/1995
    65 Claim/line has been paid.
    Start: 01/01/1995
    66 Payment reflects usual and customary charges.
    Start: 01/01/1995
    72 Claim contains split payment.
    Start: 01/01/1995
    73 Payment made to entity, assignment of benefits not on file. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    78 Duplicate of an existing claim/line, awaiting processing.
    Start: 01/01/1995
    81 Contract/plan does not cover pre-existing conditions.
    Start: 01/01/1995
    83 No coverage for newborns.
    Start: 01/01/1995
    84 Service not authorized.
    Start: 01/01/1995
    85 Entity not primary. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    86 Diagnosis and patient gender mismatch.
    Start: 01/01/1995 | Last Modified: 02/28/2000
    88 Entity not eligible for benefits for submitted dates of service. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    89 Entity not eligible for dental benefits for submitted dates of service. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    90 Entity not eligible for medical benefits for submitted dates of service. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    91 Entity not eligible/not approved for dates of service. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    92 Entity does not meet dependent or student qualification. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    93 Entity is not selected primary care provider. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    94 Entity not referred by selected primary care provider. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    95 Requested additional information not received.
    Start: 01/01/1995 | Last Modified: 07/09/2007
    Notes: If known, the payer must report a second claim status code identifying the requested information.
    96 No agreement with entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    97 Patient eligibility not found with entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    98 Charges applied to deductible.
    Start: 01/01/1995
    99 Pre-treatment review.
    Start: 01/01/1995
    100 Pre-certification penalty taken.
    Start: 01/01/1995
    101 Claim was processed as adjustment to previous claim.
    Start: 01/01/1995
    102 Newborn's charges processed on mother's claim.
    Start: 01/01/1995
    103 Claim combined with other claim(s).
    Start: 01/01/1995
    104 Processed according to plan provisions (Plan refers to provisions that exist between the Health Plan and the Consumer or Patient)
    Start: 01/01/1995 | Last Modified: 06/01/2008
    105 Claim/line is capitated.
    Start: 01/01/1995
    106 This amount is not entity's responsibility. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    107 Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)
    Start: 01/01/1995 | Last Modified: 06/01/2008
    109 Entity not eligible. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    110 Claim requires pricing information.
    Start: 01/01/1995
    111 At the policyholder's request these claims cannot be submitted electronically.
    Start: 01/01/1995
    114 Claim/service should be processed by entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    116 Claim submitted to incorrect payer.
    Start: 01/01/1995
    117 Claim requires signature-on-file indicator.
    Start: 01/01/1995
    121 Service line number greater than maximum allowable for payer.
    Start: 01/01/1995
    123 Additional information requested from entity. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    124 Entity's name, address, phone and id number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    125 Entity's name. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    126 Entity's address. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    127 Entity's Communication Number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 06/06/2010
    128 Entity's tax id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    129 Entity's Blue Cross provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    130 Entity's Blue Shield provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    131 Entity's Medicare provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    132 Entity's Medicaid provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    133 Entity's UPIN. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    134 Entity's CHAMPUS provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    135 Entity's commercial provider id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    136 Entity's health industry id number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    137 Entity's plan network id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    138 Entity's site id . Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    139 Entity's health maintenance provider id (HMO). Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    140 Entity's preferred provider organization id (PPO). Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    141 Entity's administrative services organization id (ASO). Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    142 Entity's license/certification number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    143 Entity's state license number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    144 Entity's specialty license number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    145 Entity's specialty/taxonomy code. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    146 Entity's anesthesia license number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    147 Entity's qualification degree/designation (e.g. RN,PhD,MD). Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 02/11/2010
    148 Entity's social security number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    149 Entity's employer id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    150 Entity's drug enforcement agency (DEA) number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    152 Pharmacy processor number.
    Start: 01/01/1995
    153 Entity's id number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    154 Relationship of surgeon & assistant surgeon.
    Start: 01/01/1995
    155 Entity's relationship to patient. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    156 Patient relationship to subscriber
    Start: 01/01/1995
    157 Entity's Gender. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    158 Entity's date of birth. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    159 Entity's date of death. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    160 Entity's marital status. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    161 Entity's employment status. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    162 Entity's health insurance claim number (HICN). Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    163 Entity's policy number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    164 Entity's contract/member number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    165 Entity's employer name, address and phone. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    166 Entity's employer name. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    167 Entity's employer address. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    168 Entity's employer phone number. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    170 Entity's employee id. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    171 Other insurance coverage information (health, liability, auto, etc.).
    Start: 01/01/1995
    172 Other employer name, address and telephone number.
    Start: 01/01/1995
    173 Entity's name, address, phone, gender, DOB, marital status, employment status and relation to subscriber. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    174 Entity's student status. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    175 Entity's school name. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    176 Entity's school address. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    177 Transplant recipient's name, date of birth, gender, relationship to insured.
    Start: 01/01/1995 | Last Modified: 02/28/2000
    178 Submitted charges.
    Start: 01/01/1995
    179 Outside lab charges.
    Start: 01/01/1995
    180 Hospital s semi-private room rate.
    Start: 01/01/1995
    181 Hospital s room rate.
    Start: 01/01/1995
    182 Allowable/paid from other entities coverage NOTE: This code requires the use of an entity code.
    Start: 01/01/1995 | Last Modified: 01/24/2010
    183 Amount entity has paid. Note: This code requires use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 02/11/2010
    184 Purchase price for the rented durable medical equipment.
    Start: 01/01/1995
    185 Rental price for durable medical equipment.
    Start: 01/01/1995
    186 Purchase and rental price of durable medical equipment.
    Start: 01/01/1995
    187 Date(s) of service.
    Start: 01/01/1995
    188 Statement from-through dates.
    Start: 01/01/1995
    189 Facility admission date
    Start: 01/01/1995 | Last Modified: 10/31/2006
    190 Facility discharge date
    Start: 01/01/1995 | Last Modified: 10/31/2006
    191 Date of Last Menstrual Period (LMP)
    Start: 02/28/1997
    192 Date of first service for current series/symptom/illness.
    Start: 01/01/1995
    193 First consultation/evaluation date.
    Start: 02/28/1997
    194 Confinement dates.
    Start: 01/01/1995
    195 Unable to work dates/Disability Dates.
    Start: 01/01/1995 | Last Modified: 09/20/2009
    196 Return to work dates.
    Start: 01/01/1995
    197 Effective coverage date(s).
    Start: 01/01/1995
    198 Medicare effective date.
    Start: 01/01/1995
    199 Date of conception and expected date of delivery.
    Start: 01/01/1995
    200 Date of equipment return.
    Start: 01/01/1995
    201 Date of dental appliance prior placement.
    Start: 01/01/1995
    202 Date of dental prior replacement/reason for replacement.
    Start: 01/01/1995
    203 Date of dental appliance placed.
    Start: 01/01/1995
    204 Date dental canal(s) opened and date service completed.
    Start: 01/01/1995
    205 Date(s) dental root canal therapy previously performed.
    Start: 01/01/1995
    206 Most recent date of curettage, root planing, or periodontal surgery.
    Start: 01/01/1995
    207 Dental impression and seating date.
    Start: 01/01/1995
    208 Most recent date pacemaker was implanted.
    Start: 01/01/1995
    209 Most recent pacemaker battery change date.
    Start: 01/01/1995
    210 Date of the last x-ray.
    Start: 01/01/1995
    211 Date(s) of dialysis training provided to patient.
    Start: 01/01/1995
    212 Date of last routine dialysis.
    Start: 01/01/1995
    213 Date of first routine dialysis.
    Start: 01/01/1995
    214 Original date of prescription/orders/referral.
    Start: 02/28/1997
    215 Date of tooth extraction/evolution.
    Start: 01/01/1995
    216 Drug information.
    Start: 01/01/1995
    217 Drug name, strength and dosage form.
    Start: 01/01/1995
    218 NDC number.
    Start: 01/01/1995
    219 Prescription number.
    Start: 01/01/1995
    222 Drug dispensing units and average wholesale price (AWP).
    Start: 01/01/1995
    223 Route of drug/myelogram administration.
    Start: 01/01/1995
    224 Anatomical location for joint injection.
    Start: 01/01/1995
    225 Anatomical location.
    Start: 01/01/1995
    226 Joint injection site.
    Start: 01/01/1995
    227 Hospital information.
    Start: 01/01/1995
    228 Type of bill for UB claim
    Start: 01/01/1995 | Last Modified: 10/31/2006
    229 Hospital admission source.
    Start: 01/01/1995
    230 Hospital admission hour.
    Start: 01/01/1995
    231 Hospital admission type.
    Start: 01/01/1995
    232 Admitting diagnosis.
    Start: 01/01/1995
    233 Hospital discharge hour.
    Start: 01/01/1995
    234 Patient discharge status.
    Start: 01/01/1995
    235 Units of blood furnished.
    Start: 01/01/1995
    236 Units of blood replaced.
    Start: 01/01/1995
    237 Units of deductible blood.
    Start: 01/01/1995
    238 Separate claim for mother/baby charges.
    Start: 01/01/1995
    239 Dental information.
    Start: 01/01/1995
    240 Tooth surface(s) involved.
    Start: 01/01/1995
    241 List of all missing teeth (upper and lower).
    Start: 01/01/1995
    242 Tooth numbers, surfaces, and/or quadrants involved.
    Start: 01/01/1995
    243 Months of dental treatment remaining.
    Start: 01/01/1995
    244 Tooth number or letter.
    Start: 01/01/1995
    245 Dental quadrant/arch.
    Start: 01/01/1995
    246 Total orthodontic service fee, initial appliance fee, monthly fee, length of service.
    Start: 01/01/1995
    247 Line information.
    Start: 01/01/1995
    249 Place of service.
    Start: 01/01/1995
    250 Type of service.
    Start: 01/01/1995
    251 Total anesthesia minutes.
    Start: 01/01/1995
    252 Entity's authorization/certification number. Note: This code requires the use of an Entity Code.
    Start: 01/01/1995 | Last Modified: 01/30/2011
    254 Principal diagnosis code.
    Start: 01/01/1995 | Last Modified: 01/30/2011
    255 Diagnosis code.
    Start: 01/01/1995
    256 DRG code(s).
    Start: 01/01/1995
    257 ADSM-III-R code for services rendered.
    Start: 01/01/1995
    258 Days/units for procedure/revenue code.
    Start: 01/01/1995
    259 Frequency of service.
    Start: 01/01/1995
    260 Length of medical necessity, including begin date.
    Start: 02/28/1997
    261 Obesity measurements.
    Start: 01/01/1995
    262 Type of surgery/service for which anesthesia was administered.
    Start: 01/01/1995
    263 Length of time for services rendered.
    Start: 01/01/1995
    264 Number of liters/minute & total hours/day for respiratory support.
    Start: 01/01/1995
    265 Number of lesions excised.
    Start: 01/01/1995
    266 Facility point of origin and destination - ambulance.
    Start: 01/01/1995
    267 Number of miles patient was transported.
    Start: 01/01/1995
    268 Location of durable medical equipment use.
    Start: 01/01/1995
    269 Length/size of laceration/tumor.
    Start: 01/01/1995
    270 Subluxation location.
    Start: 01/01/1995
    271 Number of spine segments.
    Start: 01/01/1995
    272 Oxygen contents for oxygen system rental.
    Start: 01/01/1995
    273 Weight.
    Start: 01/01/1995
    274 Height.
    Start: 01/01/1995
    275 Claim.
    Start: 01/01/1995
    276 UB04/HCFA-1450/1500 claim form
    Start: 01/01/1995 | Last Modified: 10/31/2006
    277 Paper claim.
    Start: 01/01/1995
    279 Claim/service must be itemized
    Start: 01/01/1995 | Last Modified: 10/17/2010
    281 Related confinement claim.
    Start: 01/01/1995
    282 Copy of prescription.
    Start: 01/01/1995
    283 Medicare entitlement information is required to determine primary coverage
    Start: 01/01/1995 | Last Modified: 01/27/2008
    284 Copy of Medicare ID card.
    Start: 01/01/1995
    286 Other payer's Explanation of Benefits/payment information.
    Start: 01/01/1995
    287 Medical necessity for service.
    Start: 01/01/1995
    288 Hospital late charges
    Start: 01/01/1995 | Last Modified: 10/17/2010
    290 Pre-existing information.
    Start: 01/01/1995
    291 Reason for termination of pregnancy.
    Start: 01/01/1995
    292 Purpose of family conference/therapy.
    Start: 01/01/1995
    293 Reason for physical therapy.
    Start: 01/01/1995
    294 Supporting documentation. Note: At least one other status code is required to identify the supporting documentation.
    Start: 01/01/1995 | Last Modified: 10/17/2010
    295 Attending physician report.
    Start: 01/01/1995
    296 Nurse's notes.
    Start: 01/01/1995
    297 Medical notes/report.
    Start: 02/28/1997
    298 Operative report.
    Start: 01/01/1995
    299 Emergency room notes/report.
    Start: 01/01/1995
    300 Lab/test report/notes/results.
    Start: 02/28/1997
    301 MRI report.
    Start: 01/01/1995
    305 Radiology/x-ray reports and/or interpretation
    Start: 01/01/1995 | Last Modified: 01/30/2011
    306 Detailed description of service.
    Start: 01/01/1995
    307 Narrative with pocket depth chart.
    Start: 01/01/1995
    308 Discharge summary.
    Start: 01/01/1995
    310 Progress notes for the six months prior to statement date.
    Start: 01/01/1995
    311 Pathology notes/report.
    Start: 01/01/1995
    312 Dental charting.
    Start: 01/01/1995
    313 Bridgework information.
    Start: 01/01/1995
    314 Dental records for this service.
    Start: 01/01/1995
    315 Past perio treatment history.
    Start: 01/01/1995
    316 Complete medical history.
    Start: 01/01/1995
    318 X-rays/radiology films
    Start: 01/01/1995 | Last Modified: 10/17/2010
    319 Pre/post-operative x-rays/photographs.
    Start: 02/28/1997
    320 Study models.
    Start: 01/01/1995
    322 Recent Full Mouth X-rays
    Start: 01/01/1995 | Last Modified: 10/17/2010
    323 Study models, x-rays, and/or narrative.
    Start: 01/01/1995
    324 Recent x-ray of treatment area and/or narrative.
    Start: 01/01/1995
    325 Recent fm x-rays and/or narrative.
    Start: 01/01/1995
    326 Copy of transplant acquisition invoice.
    Start: 01/01/1995
    327 Periodontal case type diagnosis and recent pocket depth chart with narrative.
    Start: 01/01/1995
    329 Exercise notes.
    Start: 01/01/1995
    330 Occupational notes.
    Start: 01/01/1995
    331 History and physical.
    Start: 01/01/1995 | Last Modified: 08/01/2007
    333 Patient release of information authorization.
    Start: 01/01/1995
    334 Oxygen certification.
    Start: 01/01/1995
    335 Durable medical equipment certification.
    Start: 01/01/1995
    336 Chiropractic certification.
    Start: 01/01/1995
    337 Ambulance certification/documentation.
    Start: 01/01/1995
    339 Enteral/parenteral certification.
    Start: 01/01/1995
    340 Pacemaker certification.
    Start: 01/01/1995
    341 Private duty nursing certification.
    Start: 01/01/1995
    342 Podiatric certification.
    Start: 01/01/1995
    343 Documentation that facility is state licensed and Medicare approved as a surgical facility.
    Start: 01/01/1995
    344 Documentation that provider of physical therapy is Medicare Part B approved.
    Start: 01/01/1995
    345 Treatment plan for service/diagnosis
    Start: 01/01/1995
    346 Proposed treatment plan for next 6 months.
    Start: 01/01/1995
    352 Duration of treatment plan.
    Start: 01/01/1995
    353 Orthodontics treatment plan.
    Start: 01/01/1995
    354 Treatment plan for replacement of remaining missing teeth.
    Start: 01/01/1995
    360 Benefits Assignment Certification Indicator
    Start: 01/01/1995 | Last Modified: 10/17/2010
    363 Possible Workers' Compensation
    Start: 01/01/1995 | Last Modified: 10/17/2010
    364 Is accident/illness/condition employment related?
    Start: 01/01/1995
    365 Is service the result of an accident?
    Start: 01/01/1995
    366 Is injury due to auto accident?
    Start: 01/01/1995
    374 Is prescribed lenses a result of cataract surgery?
    Start: 01/01/1995
    375 Was refraction performed?
    Start: 01/01/1995
    380 CRNA supervision/medical direction.
    Start: 01/01/1995 | Last Modified: 10/17/2010
    382 Did provider authorize generic or brand name dispensing?
    Start: 01/01/1995
    383 Nerve block use (surgery vs. pain management)
    Start: 01/01/1995 | Last Modified: 10/17/2010
    384 Is prosthesis/crown/inlay placement an initial placement or a replacement?
    Start: 01/01/1995
    385 Is appliance upper or lower arch & is appliance fixed or removable?
    Start: 01/01/1995
    386 Orthodontic Treatment/Purpose Indicator
    Start: 01/01/1995 | Last Modified: 10/17/2010
    387 Date patient last examined by entity. Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 02/11/2010
    388 Date post-operative care assumed
    Start: 02/28/1997
    389 Date post-operative care relinquished
    Start: 02/28/1997
    390 Date of most recent medical event necessitating service(s)
    Start: 02/28/1997
    391 Date(s) dialysis conducted
    Start: 02/28/1997
    394 Date(s) of most recent hospitalization related to service
    Start: 02/28/1997
    395 Date entity signed certification/recertification Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 02/11/2010
    396 Date home dialysis began
    Start: 02/28/1997
    397 Date of onset/exacerbation of illness/condition
    Start: 02/28/1997
    398 Visual field test results
    Start: 02/28/1997
    400 Claim is out of balance
    Start: 02/28/1997
    401 Source of payment is not valid
    Start: 02/28/1997
    402 Amount must be greater than zero. Note: At least one other status code is required to identify which amount element is in error.
    Start: 02/28/1997 | Last Modified: 09/20/2009
    403 Entity referral notes/orders/prescription
    Start: 02/28/1997
    406 Brief medical history as related to service(s)
    Start: 02/28/1997
    407 Complications/mitigating circumstances
    Start: 02/28/1997
    408 Initial certification
    Start: 02/28/1997
    409 Medication logs/records (including medication therapy)
    Start: 02/28/1997
    414 Necessity for concurrent care (more than one physician treating the patient)
    Start: 02/28/1997 | Last Modified: 10/17/2010
    417 Prior testing, including result(s) and date(s) as related to service(s)
    Start: 02/28/1997
    419 Individual test(s) comprising the panel and the charges for each test
    Start: 02/28/1997
    420 Name, dosage and medical justification of contrast material used for radiology procedure
    Start: 02/28/1997
    428 Reason for transport by ambulance
    Start: 02/28/1997
    430 Nearest appropriate facility
    Start: 02/28/1997
    431 Patient's condition/functional status at time of service.
    Start: 02/28/1997 | Last Modified: 10/17/2010
    432 Date benefits exhausted
    Start: 02/28/1997
    433 Copy of patient revocation of hospice benefits
    Start: 02/28/1997
    434 Reasons for more than one transfer per entitlement period
    Start: 02/28/1997
    435 Notice of Admission
    Start: 02/28/1997
    441 Entity professional qualification for service(s)
    Start: 02/28/1997
    442 Modalities of service
    Start: 02/28/1997
    443 Initial evaluation report
    Start: 02/28/1997
    449 Projected date to discontinue service(s)
    Start: 02/28/1997
    450 Awaiting spend down determination
    Start: 02/28/1997
    451 Preoperative and post-operative diagnosis
    Start: 02/28/1997
    452 Total visits in total number of hours/day and total number of hours/week
    Start: 02/28/1997
    453 Procedure Code Modifier(s) for Service(s) Rendered
    Start: 02/28/1997
    454 Procedure code for services rendered.
    Start: 02/28/1997
    455 Revenue code for services rendered.
    Start: 02/28/1997
    456 Covered Day(s)
    Start: 02/28/1997
    457 Non-Covered Day(s)
    Start: 02/28/1997
    458 Coinsurance Day(s)
    Start: 02/28/1997
    459 Lifetime Reserve Day(s)
    Start: 02/28/1997
    460 NUBC Condition Code(s)
    Start: 02/28/1997
    464 Payer Assigned Claim Control Number
    Start: 02/28/1997 | Last Modified: 10/31/2004
    465 Principal Procedure Code for Service(s) Rendered
    Start: 02/28/1997
    466 Entity's Original Signature. Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 01/30/2011
    467 Entity Signature Date. Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 02/11/2010
    468 Patient Signature Source
    Start: 02/28/1997
    469 Purchase Service Charge
    Start: 02/28/1997
    470 Was service purchased from another entity? Note: This code requires use of an Entity Code.
    Start: 02/28/1997 | Last Modified: 02/11/2010
    471 Were services related to an emergency?
    Start: 02/28/1997
    472 Ambulance Run Sheet
    Start: 02/28/1997
    473 Missing or invalid lab indicator
    Start: 06/30/1998
    474 Procedure code and patient gender mismatch
    Start: 06/30/1998 | Last Modified: 02/29/2000
    475 Procedure code not valid for patient age
    Start: 06/30/1998 | Last Modified: 02/29/2000
    476 Missing or invalid units of service
    Start: 06/30/1998
    477 Diagnosis code pointer is missing or invalid
    Start: 06/30/1998
    478 Claim submitter's identifier
    Start: 06/30/1998 | Last Modified: 01/24/2010
    479 Other Carrier payer ID is missing or invalid
    Start: 06/30/1998
    480 Entity's claim filing indicator. Note: This code requires use of an Entity Code.
    Start: 06/30/1998 | Last Modified: 06/06/2010
    481 Claim/submission format is invalid.
    Start: 10/31/1998
    483 Maximum coverage amount met or exceeded for benefit period.
    Start: 06/30/1999
    484 Business Application Currently Not Available
    Start: 02/29/2000
    485 More information available than can be returned in real time mode. Narrow your current search criteria.
    Start: 02/28/2001
    486 Principal Procedure Date
    Start: 10/31/2001 | Last Modified: 07/01/2009
    487 Claim not found, claim should have been submitted to/through 'entity'. Note: This code requires use of an Entity Code.
    Start: 02/28/2002 | Last Modified: 02/11/2010
    488 Diagnosis code(s) for the services rendered.
    Start: 06/30/2002
    489 Attachment Control Number
    Start: 10/31/2002
    490 Other Procedure Code for Service(s) Rendered
    Start: 02/28/2003
    491 Entity not eligible for encounter submission. Note: This code requires use of an Entity Code.
    Start: 02/28/2003 | Last Modified: 02/11/2010
    492 Other Procedure Date
    Start: 02/28/2003
    493 Version/Release/Industry ID code not currently supported by information holder
    Start: 02/28/2003
    494 Real-Time requests not supported by the information holder, resubmit as batch request
    Start: 02/28/2003
    495 Requests for re-adjudication must reference the newly assigned payer claim control number for this previously adjusted claim. Correct the payer claim control number and re-submit.
    Start: 10/31/2003
    496 Submitter not approved for electronic claim submissions on behalf of this entity. Note: This code requires use of an Entity Code.
    Start: 02/29/2004 | Last Modified: 02/11/2010
    497 Sales tax not paid
    Start: 06/30/2004
    498 Maximum leave days exhausted
    Start: 06/30/2004
    499 No rate on file with the payer for this service for this entity Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    500 Entity's Postal/Zip Code. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    501 Entity's State/Province. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    502 Entity's City. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    503 Entity's Street Address. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    504 Entity's Last Name. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    505 Entity's First Name. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    506 Entity is changing processor/clearinghouse. This claim must be submitted to the new processor/clearinghouse. Note: This code requires use of an Entity Code.
    Start: 06/30/2004 | Last Modified: 02/11/2010
    507 HCPCS
    Start: 10/31/2004
    508 ICD9 NOTE: At least one other status code is required to identify the related procedure code or diagnosis code.
    Start: 10/31/2004 | Last Modified: 07/01/2009
    509 External Cause of Injury Code (E-code).
    Start: 10/31/2004 | Last Modified: 01/30/2011
    510 Future date. Note: At least one other status code is required to identify the data element in error.
    Start: 10/31/2004 | Last Modified: 09/20/2009
    511 Invalid character. Note: At least one other status code is required to identify the data element in error.
    Start: 10/31/2004 | Last Modified: 09/20/2009
    512 Length invalid for receiver's application system. Note: At least one other status code is required to identify the data element in error.
    Start: 10/31/2004 | Last Modified: 09/20/2009
    513 HIPPS Rate Code for services Rendered
    Start: 10/31/2004
    514 Entity's Middle Name Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 01/30/2011
    515 Managed Care review
    Start: 10/31/2004
    516 Other Entity's Adjudication or Payment/Remittance Date. Note: An Entity code is required to identify the Other Payer Entity, i.e. primary, secondary.
    Start: 10/31/2004 | Last Modified: 11/29/2009
    517 Adjusted Repriced Claim Reference Number
    Start: 10/31/2004
    518 Adjusted Repriced Line item Reference Number
    Start: 10/31/2004
    519 Adjustment Amount
    Start: 10/31/2004
    520 Adjustment Quantity
    Start: 10/31/2004
    521 Adjustment Reason Code
    Start: 10/31/2004
    522 Anesthesia Modifying Units
    Start: 10/31/2004
    523 Anesthesia Unit Count
    Start: 10/31/2004
    524 Arterial Blood Gas Quantity
    Start: 10/31/2004
    525 Begin Therapy Date
    Start: 10/31/2004
    526 Bundled or Unbundled Line Number
    Start: 10/31/2004
    527 Certification Condition Indicator
    Start: 10/31/2004
    528 Certification Period Projected Visit Count
    Start: 10/31/2004
    529 Certification Revision Date
    Start: 10/31/2004
    530 Claim Adjustment Indicator
    Start: 10/31/2004
    531 Claim Disproportinate Share Amount
    Start: 10/31/2004
    532 Claim DRG Amount
    Start: 10/31/2004
    533 Claim DRG Outlier Amount
    Start: 10/31/2004
    534 Claim ESRD Payment Amount
    Start: 10/31/2004
    535 Claim Frequency Code
    Start: 10/31/2004
    536 Claim Indirect Teaching Amount
    Start: 10/31/2004
    537 Claim MSP Pass-through Amount
    Start: 10/31/2004
    538 Claim or Encounter Identifier
    Start: 10/31/2004
    539 Claim PPS Capital Amount
    Start: 10/31/2004
    540 Claim PPS Capital Outlier Amount
    Start: 10/31/2004
    541 Claim Submission Reason Code
    Start: 10/31/2004
    542 Claim Total Denied Charge Amount
    Start: 10/31/2004
    543 Clearinghouse or Value Added Network Trace
    Start: 10/31/2004
    544 Clinical Laboratory Improvement Amendment
    Start: 10/31/2004
    545 Contract Amount
    Start: 10/31/2004
    546 Contract Code
    Start: 10/31/2004
    547 Contract Percentage
    Start: 10/31/2004
    548 Contract Type Code
    Start: 10/31/2004
    549 Contract Version Identifier
    Start: 10/31/2004
    550 Coordination of Benefits Code
    Start: 10/31/2004
    551 Coordination of Benefits Total Submitted Charge
    Start: 10/31/2004
    552 Cost Report Day Count
    Start: 10/31/2004
    553 Covered Amount
    Start: 10/31/2004
    554 Date Claim Paid
    Start: 10/31/2004
    555 Delay Reason Code
    Start: 10/31/2004
    556 Demonstration Project Identifier
    Start: 10/31/2004
    557 Diagnosis Date
    Start: 10/31/2004
    558 Discount Amount
    Start: 10/31/2004
    559 Document Control Identifier
    Start: 10/31/2004
    560 Entity's Additional/Secondary Identifier. Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 02/11/2010
    561 Entity's Contact Name. Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 02/11/2010
    562 Entity's National Provider Identifier (NPI). Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 02/11/2010
    563 Entity's Tax Amount. Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 02/11/2010
    564 EPSDT Indicator
    Start: 10/31/2004
    565 Estimated Claim Due Amount
    Start: 10/31/2004
    566 Exception Code
    Start: 10/31/2004
    567 Facility Code Qualifier
    Start: 10/31/2004
    568 Family Planning Indicator
    Start: 10/31/2004
    569 Fixed Format Information
    Start: 10/31/2004
    571 Frequency Count
    Start: 10/31/2004
    572 Frequency Period
    Start: 10/31/2004
    573 Functional Limitation Code
    Start: 10/31/2004
    574 HCPCS Payable Amount Home Health
    Start: 10/31/2004
    575 Homebound Indicator
    Start: 10/31/2004
    576 Immunization Batch Number
    Start: 10/31/2004
    577 Industry Code
    Start: 10/31/2004
    578 Insurance Type Code
    Start: 10/31/2004
    579 Investigational Device Exemption Identifier
    Start: 10/31/2004
    580 Last Certification Date
    Start: 10/31/2004
    581 Last Worked Date
    Start: 10/31/2004
    582 Lifetime Psychiatric Days Count
    Start: 10/31/2004
    583 Line Item Charge Amount
    Start: 10/31/2004
    584 Line Item Control Number
    Start: 10/31/2004
    585 Denied Charge or Non-covered Charge
    Start: 10/31/2004 | Last Modified: 07/09/2007
    586 Line Note Text
    Start: 10/31/2004
    587 Measurement Reference Identification Code
    Start: 10/31/2004
    588 Medical Record Number
    Start: 10/31/2004
    589 Provider Accept Assignment Code
    Start: 10/31/2004 | Last Modified: 10/17/2010
    590 Medicare Coverage Indicator
    Start: 10/31/2004
    591 Medicare Paid at 100% Amount
    Start: 10/31/2004
    592 Medicare Paid at 80% Amount
    Start: 10/31/2004
    593 Medicare Section 4081 Indicator
    Start: 10/31/2004
    594 Mental Status Code
    Start: 10/31/2004
    595 Monthly Treatment Count
    Start: 10/31/2004
    596 Non-covered Charge Amount
    Start: 10/31/2004
    597 Non-payable Professional Component Amount
    Start: 10/31/2004
    598 Non-payable Professional Component Billed Amount
    Start: 10/31/2004
    599 Note Reference Code
    Start: 10/31/2004
    600 Oxygen Saturation Qty
    Start: 10/31/2004
    601 Oxygen Test Condition Code
    Start: 10/31/2004
    602 Oxygen Test Date
    Start: 10/31/2004
    603 Old Capital Amount
    Start: 10/31/2004
    604 Originator Application Transaction Identifier
    Start: 10/31/2004
    605 Orthodontic Treatment Months Count
    Start: 10/31/2004
    606 Paid From Part A Medicare Trust Fund Amount
    Start: 10/31/2004
    607 Paid From Part B Medicare Trust Fund Amount
    Start: 10/31/2004
    608 Paid Service Unit Count
    Start: 10/31/2004
    609 Participation Agreement
    Start: 10/31/2004
    610 Patient Discharge Facility Type Code
    Start: 10/31/2004
    611 Peer Review Authorization Number
    Start: 10/31/2004
    612 Per Day Limit Amount
    Start: 10/31/2004
    613 Physician Contact Date
    Start: 10/31/2004
    614 Physician Order Date
    Start: 10/31/2004
    615 Policy Compliance Code
    Start: 10/31/2004
    616 Policy Name
    Start: 10/31/2004
    617 Postage Claimed Amount
    Start: 10/31/2004
    618 PPS-Capital DSH DRG Amount
    Start: 10/31/2004
    619 PPS-Capital Exception Amount
    Start: 10/31/2004
    620 PPS-Capital FSP DRG Amount
    Start: 10/31/2004
    621 PPS-Capital HSP DRG Amount
    Start: 10/31/2004
    622 PPS-Capital IME Amount
    Start: 10/31/2004
    623 PPS-Operating Federal Specific DRG Amount
    Start: 10/31/2004
    624 PPS-Operating Hospital Specific DRG Amount
    Start: 10/31/2004
    625 Predetermination of Benefits Identifier
    Start: 10/31/2004
    626 Pregnancy Indicator
    Start: 10/31/2004
    627 Pre-Tax Claim Amount
    Start: 10/31/2004
    628 Pricing Methodology
    Start: 10/31/2004
    629 Property Casualty Claim Number
    Start: 10/31/2004
    630 Referring CLIA Number
    Start: 10/31/2004
    631 Reimbursement Rate
    Start: 10/31/2004
    632 Reject Reason Code
    Start: 10/31/2004
    633 Related Causes Code (Accident, auto accident, employment)
    Start: 10/31/2004 | Last Modified: 10/17/2010
    634 Remark Code
    Start: 10/31/2004
    635 Repriced Ambulatory Patient Group Code
    Start: 10/31/2004
    636 Repriced Line Item Reference Number
    Start: 10/31/2004
    637 Repriced Saving Amount
    Start: 10/31/2004
    638 Repricing Per Diem or Flat Rate Amount
    Start: 10/31/2004
    639 Responsibility Amount
    Start: 10/31/2004
    640 Sales Tax Amount
    Start: 10/31/2004
    642 Service Authorization Exception Code
    Start: 10/31/2004
    643 Service Line Paid Amount
    Start: 10/31/2004
    644 Service Line Rate
    Start: 10/31/2004
    645 Service Tax Amount
    Start: 10/31/2004
    646 Ship, Delivery or Calendar Pattern Code
    Start: 10/31/2004
    647 Shipped Date
    Start: 10/31/2004
    648 Similar Illness or Symptom Date
    Start: 10/31/2004
    649 Skilled Nursing Facility Indicator
    Start: 10/31/2004
    650 Special Program Indicator
    Start: 10/31/2004
    651 State Industrial Accident Provider Number
    Start: 10/31/2004
    652 Terms Discount Percentage
    Start: 10/31/2004
    653 Test Performed Date
    Start: 10/31/2004
    654 Total Denied Charge Amount
    Start: 10/31/2004
    655 Total Medicare Paid Amount
    Start: 10/31/2004
    656 Total Visits Projected This Certification Count
    Start: 10/31/2004
    657 Total Visits Rendered Count
    Start: 10/31/2004
    658 Treatment Code
    Start: 10/31/2004
    659 Unit or Basis for Measurement Code
    Start: 10/31/2004
    660 Universal Product Number
    Start: 10/31/2004
    661 Visits Prior to Recertification Date Count CR702
    Start: 10/31/2004
    662 X-ray Availability Indicator
    Start: 10/31/2004
    663 Entity's Group Name. Note: This code requires use of an Entity Code.
    Start: 10/31/2004 | Last Modified: 02/11/2010
    664 Orthodontic Banding Date
    Start: 10/31/2004
    665 Surgery Date
    Start: 10/31/2004
    666 Surgical Procedure Code
    Start: 10/31/2004
    667 Real-Time requests not supported by the information holder, do not resubmit
    Start: 02/28/2005
    668 Missing Endodontics treatment history and prognosis
    Start: 06/30/2005
    669 Dental service narrative needed.
    Start: 10/31/2005
    670 Funds applied from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts
    Start: 06/30/2006 | Last Modified: 02/28/2007
    671 Funds may be available from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts
    Start: 06/30/2006 | Last Modified: 02/28/2007
    672 Other Payer's payment information is out of balance
    Start: 10/31/2006
    673 Patient Reason for Visit
    Start: 10/31/2006
    674 Authorization exceeded
    Start: 10/31/2006
    675 Facility admission through discharge dates
    Start: 10/31/2006
    676 Entity possibly compensated by facility. Note: This code requires use of an Entity Code.
    Start: 10/31/2006 | Last Modified: 02/11/2010
    677 Entity not affiliated. Note: This code requires use of an Entity Code.
    Start: 10/31/2006 | Last Modified: 02/11/2010
    678 Revenue code and patient gender mismatch
    Start: 10/31/2006
    679 Submit newborn services on mother's claim
    Start: 10/31/2006
    680 Entity's Country. Note: This code requires use of an Entity Code.
    Start: 10/31/2006 | Last Modified: 02/11/2010
    681 Claim currency not supported
    Start: 10/31/2006
    682 Cosmetic procedure
    Start: 02/28/2007
    683 Awaiting Associated Hospital Claims
    Start: 02/28/2007
    684 Rejected. Syntax error noted for this claim/service/inquiry. See Functional or Implementation Acknowledgement for details. (Note: Only for use to reject claims or status requests in transactions that were 'accepted with errors' on a 997 or 999 Acknowledgement.)
    Start: 11/05/2007
    685 Claim could not complete adjudication in real time. Claim will continue processing in a batch mode. Do not resubmit.
    Start: 01/27/2008
    686 The claim/ encounter has completed the adjudication cycle and the entire claim has been voided
    Start: 01/27/2008
    687 Claim estimation can not be completed in real time. Do not resubmit.
    Start: 01/27/2008
    688 Present on Admission Indicator for reported diagnosis code(s).
    Start: 01/27/2008
    689 Entity was unable to respond within the expected time frame. Note: This code requires use of an Entity Code.
    Start: 06/01/2008 | Last Modified: 02/11/2010
    690 Multiple claims or estimate requests cannot be processed in real time.
    Start: 06/01/2008
    691 Multiple claim status requests cannot be processed in real time.
    Start: 06/01/2008
    692 Contracted funding agreement-Subscriber is employed by the provider of services
    Start: 09/21/2008
    693 Amount must be greater than or equal to zero. Note: At least one other status code is required to identify which amount element is in error.
    Start: 01/25/2009
    694 Amount must not be equal to zero. Note: At least one other status code is required to identify which amount element is in error.
    Start: 01/25/2009
    695 Entity's Country Subdivision Code. Note: This code requires use of an Entity Code.
    Start: 01/25/2009 | Last Modified: 02/11/2010
    696 Claim Adjustment Group Code.
    Start: 01/25/2009
    697 Invalid Decimal Precision. Note: At least one other status code is required to identify the data element in error.
    Start: 07/01/2009
    698 Form Type Identification
    Start: 07/01/2009
    699 Question/Response from Supporting Documentation Form
    Start: 07/01/2009
    700 ICD10. Note: At least one other status code is required to identify the related procedure code or diagnosis code.
    Start: 07/01/2009
    701 Initial Treatment Date
    Start: 07/01/2009
    702 Repriced Claim Reference Number
    Start: 11/01/2009
    703 Advanced Billing Concepts (ABC) code
    Start: 01/24/2010
    704 Claim Note Text
    Start: 01/24/2010
    705 Repriced Allowed Amount
    Start: 01/24/2010
    706 Repriced Approved Amount
    Start: 01/24/2010
    707 Repriced Approved Ambulatory Patient Group Amount
    Start: 01/24/2010
    708 Repriced Approved Revenue Code
    Start: 01/24/2010
    709 Repriced Approved Service Unit Count
    Start: 01/24/2010
    710 Line Adjudication Information. Note: At least one other status code is required to identify the data element in error.
    Start: 01/24/2010
    711 Stretcher purpose
    Start: 01/24/2010
    712 Obstetric Additional Units
    Start: 01/24/2010
    713 Patient Condition Description
    Start: 01/24/2010
    714 Care Plan Oversight Number
    Start: 01/24/2010
    715 Acute Manifestation Date
    Start: 01/24/2010
    716 Repriced Approved DRG Code
    Start: 01/24/2010
    717 This claim has been split for processing.
    Start: 01/24/2010
    718 Claim/service not submitted within the required timeframe (timely filing).
    Start: 01/24/2010
    719 NUBC Occurrence Code(s)
    Start: 01/24/2010
    720 NUBC Occurrence Code Date(s)
    Start: 01/24/2010
    721 NUBC Occurrence Span Code(s)
    Start: 01/24/2010
    722 NUBC Occurrence Span Code Date(s)
    Start: 01/24/2010
    723 Drug days supply
    Start: 01/24/2010
    724 Drug dosage
    Start: 01/24/2010
    725 NUBC Value Code(s)
    Start: 01/24/2010
    726 NUBC Value Code Amount(s)
    Start: 01/24/2010
    727 Accident date
    Start: 01/24/2010
    728 Accident state
    Start: 01/24/2010
    729 Accident description
    Start: 01/24/2010
    730 Accident cause
    Start: 01/24/2010
    731 Measurement value/test result
    Start: 01/24/2010
    732 Information submitted inconsistent with billing guidelines. Note: At least one other status code is required to identify the inconsistent information.
    Start: 01/24/2010
    733 Prefix for entity's contract/member number.
    Start: 01/24/2010
    734 Verifying premium payment
    Start: 06/06/2010
    735 This service/claim is included in the allowance for another service or claim.
    Start: 06/06/2010
    736 A related or qualifying service/claim has not been received/adjudicated.
    Start: 06/06/2010
    737 Current Dental Terminology (CDT) Code
    Start: 06/06/2010
    738 Home Infusion EDI Coalition (HEIC) Product/Service Code
    Start: 06/06/2010
    739 Jurisdiction Specific Procedure or Supply Code
    Start: 06/06/2010
    740 Drop-Off Location
    Start: 06/06/2010
    741 Entity must be a person. Note: This code requires use of an Entity Code.
    Start: 06/06/2010
    742 Payer Responsibility Sequence Number Code
    Start: 06/06/2010
    743 Entity’s credential/enrollment information. Note: This code requires use of an Entity Code.
    Start: 10/17/2010
    744 Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
    Start: 10/17/2010
    745 Identifier Qualifier Note: At least one other status code is required to identify the specific identifier qualifier in error.
    Start: 10/17/2010
    746 Duplicate Submission Note: use only at the information receiver level in the Health Care Claim Acknowledgement transaction.
    Start: 10/17/2010
    747 Hospice Employee Indicator
    Start: 10/17/2010
    748 Corrected Data Note: Requires a second status code to identify the corrected data.
    Start: 10/17/2010
    749 Date of Injury/Illness
    Start: 10/17/2010
    750 Auto Accident State or Province Code
    Start: 10/17/2010 | Last Modified: 01/30/2011
    751 Ambulance Pick-up State or Province Code
    Start: 10/17/2010 | Last Modified: 01/30/2011
    752 Ambulance Drop-off State or Province Code
    Start: 10/17/2010 | Last Modified: 01/30/2011
    753 Co-pay status code.
    Start: 01/30/2011
    754 Entity Name Suffix. Note: This code requires the use of an Entity Code.
    Start: 01/30/2011
    755 Entity's primary identifier. Note: This code requires the use of an Entity Code.
    Start: 01/30/2011
    756 Entity's Received Date. Note: This code requires the use of an Entity Code.
    Start: 01/30/2011
    757 Last seen date.
    Start: 01/30/2011
    758 Repriced approved HCPCS code.
    Start: 01/30/2011
    759 Round trip purpose description.
    Start: 01/30/2011
    760 Tooth status code.
    Start: 01/30/2011
    761 Entity's referral number. Note: This code requires the use of an Entity Code.
    Start: 01/30/2011
    762 Locum Tenens Provider Identifier. Code must be used with Entity Code 82 - Rendering Provider
    Start: 01/20/2013
    763 Ambulance Pickup ZipCode
    Start: 01/20/2013
    764 Professional charges are non covered.
    Start: 06/02/2013
    765 Institutional charges are non covered.
    Start: 06/02/2013
    766 Services were performed during a Health Insurance Exchange (HIX) premium payment grace period.
    Start: 11/01/2013

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    Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.

    Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to October 1, 2014, on either the old or revised version of the CMS-1500 claim form.

    For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes.

    For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).

    • The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

     Indicator Code Set 
     9 ICD-9-CM diagnosis
    0 ICD-10-CM diagnosis

    Enter the indicator as a single digit between the vertical, dotted lines.

    • Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)

    • If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.

    • Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

    • Do not insert a period in the ICD-9-CM or ICD-10-CM code.

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    Now we can enter 12 DX in single claim.

    See the below changes in the format of 21 BLOCK



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    Required Data Element Requirements

    1 - Paper Claims
    The following instruction describes certain data element formatting requirements to be followed when reporting the calendar year date for the identified items on the F9+o203 rm CMS-1500:
    /
    • If birth dates are furnished in the items stipulated below, then these items must contain 8-digit birth dates (MMDDCCYY). This includes 2-digit months (MM) and days (DD), and 4-digit years (CCYY).
    Form CMS-1500 Items Affected by These Reporting Requirements:

    Item 3 - Patient’s Birth Date
    Item 9b - Other Insured’s Date of Birth
    Item 11a - Insured’s Date of Birth
    Note that 8-digit birth dates, when provided, must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line.

    If a birth date is provided in items 3, 9b, or 11a, and is not in 8-digit format, carriers must return the claim as unprocessable. Use remark code N329 on the remittance advice. For formats other than the remittance, use code(s)/messages that are consistent with the above remark codes.

    If carriers do not currently edit for birth date items because they obtain the information from other sources, they are not required to return these claims if a birth date is reported in items 3, 9b, or 11a. and the birth date is not in 8-digit format. However, if carriers use date of birth information on the incoming claim for processing, they must edit and return claims that contain birth date(s) in any of these items that are not in 8-digit format.

    For certain other Form CMS-1500 conditional or required date items (items 11b, 14, 16, 18, 19, or 24A.), when dates are provided, either a 6-digit date or 8-digit date may be provided.

    If 8-digit dates are furnished for any of items 11a., 14, 16, 18, 19, or 24A. (excluding items 12 and 31), carriers must note the following:
    • All completed date items, except item 24A., must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line;

    • Item 24A. must be reported as one continuous number (i.e., MMDDCCYY), without any spaces between month, day, and year. By entering a continuous number, the date(s) in item 24A. will penetrate the dotted, vertical lines used to separate month, day, and year. Carrier claims processing systems will be able to process the claim if the date penetrates these vertical lines. However, all 8-digit dates reported must stay within the confines of item 24A;

    • Do not compress or change the font of the “year” item in item 24A. to keep the date within the confines of item 24A. If a continuous number is furnished in item 24A. with no spaces between month, day, and year, you will not need to compress the “year” item to remain within the confines of item 24A.;

    • The “from” date in item 24A. must not run into the “to” date item, and the “to” date must not run into item 24B.;

    • Dates reported in item 24A. must not be reported with a slash between month, day, and year; and

    • If the provider of service or supplier decides to enter 8-digit dates for any of items 11b, 14, 16, 18, 19, or 24A. (excluding items 12 and 31), an 8-digit date must be furnished for all completed items. For instance, you cannot enter 8-digit dates for items 11b, 14, 16, 18, 19 (excluding items 12 or 31), and a 6-digit date for item 24A. The same applies to those who wish to submit 6-digit dates for any of these items.

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    This MLN Matters® Article is intended for physicians, non-physician practitioners, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

    CR 8812, from which this article is taken, provides notice that the Centers for Medicare & Medicaid Services (CMS) is establishing a new physician specialty code for Interventional Cardiology. The CR is also changing the description of specialty code 62, and updating the names associated to specialty codes 88 and 95. Make sure your billing staffs are aware of these changes.

    Physicians who enroll in the Medicare program self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855B) or via the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS). Non-physician practitioners who enroll with Medicare are assigned a Medicare specialty code. These Medicare physician/non-physician practitioner specialty codes describe the specific/unique types of medicine that physicians and non-physician practitioners (and certain other suppliers) practice. They become associated with the claims that physician or non-physician practitioners submit; and are used by CMS for programmatic and claims processing purposes.


    CR 8812 establishes a new physician specialty code for Interventional Cardiology (C3). CR8812 is also removing the word “Clinical” from the description of specialty code 62 (Psychologist (Billing Independently)), and is changing the description of specialty code 88 to “Unknown Provider,” and of specialty code 95 to “Unknown Supplier”. The changes to the descriptions for codes 88 and 95 align their names with their intended usages.

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    This article explains the difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN). There are no policy changes in this article.

    All providers and suppliers who provide services and bill Medicare for services provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare Administrative Contractor (MAC), the provider or supplier will also be issued a
    Provider Transaction Access Number (PTAN). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier’s NPI.


    Providers and suppliers receiving requests to revalidate their enrollment information have asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences between the NPI and the PTAN.

    National Provider Identifier (NPI)

    The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions.

    • The NPI is a unique identification number for covered health care providers.
    • The NPI is issued by the National Plan and Provider Enumeration System (NPPES).
    • Covered health care providers and all health plans and health care clearinghouses must use the NPI in the administrative and financial transactions (for example, insurance claims) adopted under HIPAA.

    • The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The NPI does not carry information about healthcare providers, such as the state in which they live or their medical specialty. This reduces the chances of insurance fraud.

    • Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

    Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy provider identifiers, including the Unique Physician Identification Number (UPIN), as the unique identifier for all providers, and suppliers in HIPAA standard transactions.

    You should note that individual health care providers (including physicians who are sole proprietors) may obtain only one NPI for themselves (Entity Type 1 Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1
    Individual) if they are health care providers and an additional NPI(s) for their corporation(s) (Entity Type 2 Organization). Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).

    For more information about the NPI, visit the NPPES website at https://nppes.cms.hhs.gov/NPPES/Welcome.do on the CMS website.

    Provider Transaction Access Number (PTAN)

    A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. When a MAC approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.

    ** The approval letter will note that NPI must be used to bill the Medicare program and that PTAN will be used to autheniticate the provider when using MAC self help tools such as IVR , internet portal , online application etc.

    ** The PTAN's use should generally be limited to the provider's contacts with their MAC


    Where can I find my PTAN?

    You can find your PTAN by doing any one of the following:

    1. View the letter sent by your MAC when your enrollment in Medicare was approved.

    2. Log into Internet-based PECOS. Click on the “My Enrollments” button and then “View Enrollments”. Locate the applicable enrollment and click on the “View Medicare ID Report” link which will list all of the provider or supplier’s active
    PTANs in one report.

    3 The provider (or, in the case of an organizational provider, an authorized or delegated official) shall send a signed written request on company letterhead to your MAC; include your legal name/legal business name, national provider identifier
    (NPI), telephone and fax numbers.


    Relationship of the NPI to the PTAN

    The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system, representing the provider’s enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned.

    Together, the NPI and PTAN identify the provider, or supplier in the Medicare program. CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership System (PECOS), the master provider and supplier enrollment system.



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    Submitting Medical Documentation For Part A/B 5010 Electronic Claims

    Under the Health Insurance Portability and Accountability Act (HIPAA), claims for reimbursement by the Medicare Program must be submitted electronically, except where waived, even for claims with attachments. The process for accepting medical documentation and attaching it to the electronic claim has been improved due to our imaging system. The Claim Supplemental Information segment (PWK) is used whenever paper documentation has been sent for an electronic claim. When sending an electronic claim that contains an attachment, follow these rules to submit the attachment for your electronic claim:

    Maintain the appropriate medical documentation on file for electronic (and paper) claims.
    Complete the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * form. For accurate processing of your claim(s), please complete all requested information in capital letters and avoid contact with the edge of the boxes.

    Important tips to keep in mind when faxing medical records for electronic claims:

    •    Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
    •    The narrative field on the claim is to be utilized in situations where sufficient information for the documentation of a procedure/modifier can be provided without sending the medical records. When additional information cannot be contained in the narrative of the claim, additional documentation (medical records) may be submitted via mail or fax.
    •    Only fax documentation for one patient per cover sheet. The cover sheet is for Part A or B electronic claims.
    •    Clearly write the: Attachment Control Number, Internal Control Number (ICN/DCN), Patient Name, Health Insurance Claim (HIC) Number, Date of Service, Total Claim Billed Amount, National Provider Identification (NPI) Number, Contact Information, and State Where Services Were Provided on the cover sheet.  Failure to submit all items requested will result in documentation being returned and could delay claim processing.
    •    The fax/mail cover sheets are not to be modified.
    •    Only the first iteration of the PWK, at either the claim level and/or line level, will be considered for adjudication.
    •    Submitters must send ALL relevant PWK data at the same time for the same claim.
    •    After submitting the electronic claim, locate the ICN/DCN number on the 277CA claims acknowledgement report.  The ICN/DCN is located in the 2200D REF segment.
    •    Fax the cover sheet and medical documentation to (877) 439-5479. You may fax documentation any time after claim submission, including the same day. Faxing is available 24 hours a day, 7 days a week. Faxes should be sent within seven calendar days of your electronic claim submission.
    Novitas Solutions strongly recommends faxing your medical documentation. If you are not able to fax your documentation, mail the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * and all pertinent medical documentation within ten calendar days of your electronic claim submission.

    In the Claim Supplemental Information Segment (PWK) of the electronic claim:
    •    Select the appropriate Report Type Code for the medical documentation. For information on what codes are needed in the PWK segment.
    •    Use the By Fax or By Mail option for the Attachment Transmission Code
    •    Enter AC for the Identification Code Qualifier
    •    Report the Attachment Control Number - This number may be assigned by your software or can be any number you chose including the patient account number or other identifying number.
    Note: Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
    Technically Speaking, Claim Supplemental Information (PWK) is reported as follows:

    Data Element    Segment
    Attachment Report Type Code    2300 or 2400 - PWK01
    Attachment Transmission Code    2300 or 2400 - PWK02
    Identification Code Qualifier    2300 or 2400 - PWK05
    Attachment Control Number    2300 or 2400 - PWK06

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    This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors
    (DME/MACs)) for services provided to Medicare beneficiaries.

    This change request (CR) 8509 revises the current CMS 1500 claim form instructions to
    reflect the revised CMS 1500 claim form, version 02/12.

    The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

    • DN - Referring Provider
    • DK - Ordering Provider
    DQ - Supervising Provider

    Providers should enter the qualifier to the left of the dotted vertical line on item 17.

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    The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claimis allowed. In addition to billing Medicare, the 837I and Form CMS-1450 may be suitable for billing various
    government and some private insurers.

    Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

    Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).

    ANSI ASC X12N 837I


    The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional) Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.

    ANSI = American National Standards Institute
    ASC = Accredited Standards Committee
    X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
    837 = Standard format for transmitting health care claims electronically
    I = Institutional version of the 837 electronic format
    Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.
    The National Uniform Billing Committee (NUBC) makes their UB-04 manual available through their website. This manual contains the updated specifications for the data elements and codes included on the CMS-1450 and used in the 837I transaction standard. Medicare FFS Contractors may include a crosswalk between the ASC X12N 837I and the CMS-1450 on their websites

    When Does Medicare Accept a Hard Copy Claim Form?

    Initial claims for payment under Medicare must be submitted electronically unless an institutional provider qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

    Before submitting a hard copy claim, providers should self-assess to determine if they meet one
    or more of the ASCA exceptions. For example, institutional providers that have fewer than 25 Full-Time Equivalent (FTE) employees and bill a Medicare FFS Contractor are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If an institutional provider meets an exception, there is no need to submit a waiver request.

    There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of an institutional provider’s staff prevents use of a computer for electronic submission of claims. Institutional providers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their Medicare FFS Contractor.

    Timely Filing


    The timely filing period for both paper and electronic Medicare claims is 12 months, or one calendar year, after the date of service.

    Claims are denied if they arrive after the deadline date. When a claim is denied for having been filed after the timely filing period, such a denial does not constitute an initial determination. As such, the determination that a claim was not filed timely is not subject to appeal.

    In general, the start date for determining the 12-month timely filing period is the date of service or ‘From’ date on the claim. Medicare uses the line item ‘Through’ date to determine the date of service for claims filing timeliness for claims that include span dates of service (i.e., a ‘From’ and ‘Through’ date span on the claim).
    Medicare regulations allow exceptions to the 12-month time limit for filing claims.

    Where to Submit FFS Claims


    Claims for services must be submitted to the appropriate Medicare FFS Contractor. Contact the Medicare FFS Contractor by referencing the
    Provider Compliance Group Interactive Map on the CMS website. Medicare beneficiaries cannot be charged for completing or filing a claim. Providers may be subject to penalty for violations.

    If a beneficiary is enrolled in a Medicare Advantage (MA) Plan, claims should not be submitted to the Medicare FFS Contractor; the beneficiary’s MA Plan is responsible for claims processing. CMS provides a list of MA claims processing contacts on the CMS website.

    Medicare Secondary Payer (MSP)

    MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage and ensure that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying. For more information, reference the “Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff” fact sheet available through the MLN “Catalog of Products” on the CMS website. The Medicare Secondary Payer web page offers information on MSP laws and the various methods employed by CMS to gather data on other insurance that may be primary to Medicare.




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    Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).

    Background: Qualifying Criteria for the Medicare Home Health Benefit
    To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements:
    •    Be confined to the home;
    •    Under the care of a physician;
    •    Receiving services under a plan of care established and periodically reviewed by a physician;
    •    Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
    •    Have a continuing need for occupational therapy.
    The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).

    Major Documentation Errors
    Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF.  The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:
    •    The encounter was related to the primary reason for home care
    •    How the patient’s condition supports the patient’s homebound status; or
    •    How the patient’s condition supports the need for skilled services
    Acceptable FTF documentation does not have to be lengthy or overly detailed.  However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.
    Following are examples of FTF documentation that, used alone, are considered insufficient documentation.

    Homebound Status Need for Skilled Services
    “Functional decline” “Family is asking for help”
    “Dementia” or “confusion” “Continues to have problems”
    “Difficult to travel to doctor’s office” List of tasks for nurse to do
    “Unable to leave home”/ “Unable to drive “Patient unable to do wound care”
    “Weak” “Diabetes”
    “Status post total hip”


    Examples of appropriate documentation include:
    •    “Wound care to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.  Skilled nurse visits to perform wound care and assess wound status.  Patient on bed to chair activities only.”
    •    “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema.  Short of breath with talking and ambulation of 1-2 feet.  Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.”
    •    “CHF, CLL, weakness, 3+ edema in R & L legs; needs cardiac assessment, monitoring of signs & symptoms of disease, and patient education; homebound due to shortness of breath with minimal exertion, e.g., walking 5 feet.”
    •    “Status post right total hip replacement. Needs physical therapy to restore ability to walk without assistance. Homebound temporarily due to requiring a walker, inability to negotiate uneven surfaces and stairs, inability to walk greater than 5 - 10 feet before needing to rest. ”
    In all cases, your documentation must be specific to that patient’s condition at the time of your encounter with him or her.

    Who May Document the FTF Encounter?

    The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or a qualified nonphysician practitioner (NPP) working in conjunction with the certifying physician.  An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility.  That NPP can then report the FTF encounter to the certifying physician.
    Medicare guidelines also contain specific documentation requirements:

    The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.
    If the FTF encounter was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must provide the face-to-face record of the FTF encounter to the certifying physician.  NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF.
    The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP.  He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
    The FTF encounter documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare and must include:
    The date of the FTF encounter, and
    Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services.
    Finally, because the FTF encounter is a requirement for payment, when the FTF encounter requirements as outlined above are not met, the home health agency’s entire claim is denied.  For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF encounter documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

    Home health agencies may ask you to provide supporting documentation from your medical records to ensure that Medicare will cover home health services. You are permitted, and strongly encouraged, to provide this documentation, the disclosure of which is permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). No specific authorization is required from your patients in order to do this. Also, please note that you may not charge the home health agency for providing this information. We ask you to work in partnership with these agencies so they can provide appropriate and medically necessary care for your homebound patients.

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    The following information discusses the conditions and requirements of the item fields within the CMS-1500 (02/12) paper claim form.

    The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here  to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

    Status Key:
    R = Completion of this item is required by Medicare for every claim
    C = Completion of this item is conditionally required based on certain circumstances
    NR = Completion of this item is not required by Medicare Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.

    Note: Providers can utilize the First Coast Service Options Inc. (First Coast) PC-ACE Pro32™ software to submit claims electronically. PC-ACE Pro32™ software has built-in edits to avoid submitting claims without required information being included. Some item numbers contain links to

     Item Number    Item Description and Guidance    Requirement Status
    1    Type of insurance    R
    1a  Patient’s Medicare Health Insurance Claim (HIC) number    R
    2  Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card.    R
    3    Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex.    R
    4    Insured’s name
    (Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.)    C
    5    Patient’s mailing address, city, state, and phone number    R
    6    Check appropriate box for patient’s relationship to insured.
    (Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.)    C
    7    Insured’s address and telephone number.
    Note: When address is the same as patient’s, enter the word SAME.
    (Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.)    C
    8    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    9-9d    Medigap information (Leave Items 9b and 9c blank)    C
    10a-c    Employment/accident indicators    R
    10d    Medicaid ID  C
    11    Primary insurance policy number
    Note: Enter the word NONE if Medicare is primary    R
    11a-c    Insured’s birth date, employer, plan name (Item 11b -- provide this information to the right of the vertical line.)    C
    11d    Another health benefit plan
    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    12    Patient’s signature and date    R
    13    Patient signature -- Medigap authorization
    Note: Must be completed if information contained in 9-9d.    C
    14    Date of current illness, injury, or pregnancy
    Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14.    C
    15    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    16    If patient is employed, enter dates patient will be unable to work in current occupation.    C
    17    Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
    • The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
    • DN -- referring provider
    • DK -- ordering provider
    • DQ -- supervising provider
    • Enter the qualifier to the left of the dotted vertical line on item 17.
    Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
    See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
    See also the Ordering/referring provider FAQs for additional guidance.    C
    Required if services are ordered, referred or supervised
    17a   DO NOT complete    NR
    17b   If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
    (Click here to verify the provider's NPI is eligible to order or refer services.)    C
    Required if services are ordered, referred or supervised
    18    Hospitalization dates    C
    19    Additional claim information
    See CMS IOM Pub 100-04, Chapter 26, Section 10.4  for guidance on completion of Item 19    C
    20    Outside lab
    See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services.    C
    21
    Report up to twelve primary diagnosis codes
    • For dates of service prior to October 1, 2014 -- report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
    • For dates of service on and after October 1, 2014 -- report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
    • If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.    R
    22    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    23    Prior authorization number     C
    24A    Date(s) of service (DOS)    R
    24B
    Place of service (POS)
    See CMS IOM Pub 100-04, Chapter 26, Section 10.5  for codes and definitions.    R
    24C    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    24D    Procedure code/applicable modifiers   R
    24E-Diagnosis pointer
    Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line.     R
    24F    Charge (in dollars) for service    R
    24G    Days/Units    R
    24H    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    24I - Leave blank -- Medicare Part B Providers are not required to complete.    NR
    24J-Enter the NPI of the rendering provider in the lower non-shaded portion.
    Do not report anything in the upper shaded portion of item 24J.    C
    25    Federal tax identification number (TIN)    C
    26    Patient’s account number    C
    27    Assignment
    See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1  for list of provider and claim types for which assignment must always be accepted.    R
    28    Total Charges    R
    29    Enter amount collected from patient, if any.
    Note: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
    C
    30    Leave blank -- Medicare Part B Providers are not required to complete.    NR
    31    Provider signature and date
    Note: "Signature on File" and/or a computer generated signature are acceptable. See section 10.4 Item 32  for details R
    32-For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
    Name, address and ZIP of location where services were rendered for all locations.
    Note: As of January 1, 2011, all locations (including patient's home) must be reported.    R
    32a-If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
    Note: DO NOT report for providers outside of local jurisdiction. Instead, you are required to report the NPI of the provider who purchased the service.    C
    32b-DO NOT complete    NR
    33-Billing provider’s name, address, ZIP and telephone number    R
    33a-Enter the NPI of the billing provider or group.    R
    33b -DO NOT complete    NR


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    Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:

    •    PQRS
    •    Value-Based Payment Modifier (VM)
    •    Medicare Electronic Health Record (EHR) Incentive Program
    •    Medicare Shared Savings Program Accountable Care Organization (ACO)
    •    Pioneer ACO
    •    Comprehensive Primary Care Initiative (CPCI)

    CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
    •    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
    •    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
    •    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
    Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

    How to Report Once
    Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:

    •    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.
    •    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.
    •    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.
    2014 QRDA III SEVT Testing Available
    The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.

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    Generally, Medicare Part B covers one flu vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries.
    Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers, and patients.
    Note: The flu vaccine is not a Part D-covered drug.

    This recurring update notification provides the payment allowances for the following seasonal influenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).
    CPT 90655 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90656 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90657 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90661 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90685 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90686 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90687 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90688 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    HCPCS Q2035 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    HCPCS Q2036 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    HCPCS Q2037 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    HCPCS Q2038 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015

    Payment for the following CPT or HCPCS codes may be made if your MAC determines its
    use is reasonable and necessary for the beneficiary, during the effective dates indicated
    below:
    CPT 90654 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90662 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90672 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    CPT 90673 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
    HCPCS Q2039 Flu Vaccine Adult - Not Otherwise Classified payment allowance is to be
    determined by the local claims processing contractor with effective dates of 8/1/2014 -
    7/31/2015.

    Payment allowances for codes for products that have not yet been approved will be provided
    when the products have been approved and pricing information becomes available to CMS.
    The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP
    and are updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug
    Pricing Files. The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the AWP as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally
    Qualified Health Center (FQHC). Where the vaccine is furnished in the hospital outpatient
    department, RHC, or FQHC, payment for the vaccine is based on reasonable cost.

    Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
    Note: MACs will not search their files either to retract payment for claims already paid or to retroactively pay claims prior to the implementation date of CR8890. However, they will adjust claims that you bring to their attention.

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