# CMS 1450/UB-92 Form

Contents

[About the CMS-1450 / UB-92 Form B-3](#__RefHeading___Toc143579337)

[Form Locator (FL) Fields B-3](#__RefHeading___Toc143579338)

[FL1 -- (Untitled) B-3](#__RefHeading___Toc143579339)

[FL2 -- (Untitled) B-3](#__RefHeading___Toc143579340)

[FL3 -- Patient Control Number B-4](#__RefHeading___Toc143579341)

[FL4 -- Type of Bill B-4](#__RefHeading___Toc143579342)

[FL5 -- Federal Tax Number B-7](#__RefHeading___Toc143579343)

[FL6 -- Statement Covers Period (From-Through)
B-7](#__RefHeading___Toc143579344)

[FL7 -- Covered Days B-7](#__RefHeading___Toc143579345)

[FL8 -- Noncovered Days B-8](#__RefHeading___Toc143579346)

[FL9 -- Coinsurance Days B-8](#__RefHeading___Toc143579347)

[FL10 -- Lifetime Reserve Days B-8](#__RefHeading___Toc143579348)

[FL11 -- (Untitled) B-8](#__RefHeading___Toc143579349)

[FL12 -- Patient's Name B-8](#__RefHeading___Toc143579350)

[FL13 -- Patient's Address B-8](#__RefHeading___Toc143579351)

[FL14 -- Patient's Birthdate B-9](#__RefHeading___Toc143579352)

[FL15 -- Patient Sex B-9](#__RefHeading___Toc143579353)

[FL16 -- Patient's Marital Status B-9](#__RefHeading___Toc143579354)

[FL17 -- Admission Date B-9](#__RefHeading___Toc143579355)

[FL18 -- Admission Hour B-9](#__RefHeading___Toc143579356)

[FL19 -- Type of Admission/Visit B-9](#__RefHeading___Toc143579357)

[FL20 -- Source of Admission B-10](#__RefHeading___Toc143579358)

[FL21 -- Discharge Hour B-10](#__RefHeading___Toc143579359)

[FL22 -- Patient Status B-10](#__RefHeading___Toc143579360)

[FL23 -- Medical Record Number B-11](#__RefHeading___Toc143579361)

[FL24 - FL30 -- Condition Codes B-11](#__RefHeading___Toc143579362)

[FL31 -- (Untitled) B-16](#__RefHeading___Toc143579363)

[FL32 - FL35 -- Occurrence Codes and Dates
B-16](#__RefHeading___Toc143579364)

[FL36 -- Occurrence Span Code and Dates
B-19](#__RefHeading___Toc143579365)

[FL37 -- Internal Control Number (ICN)/Document Control Number (DCN)
B-20](#__RefHeading___Toc143579366)

[FL38 -- (Untitled Except on Patient Copy of the Bill)\
Responsible Party Name and Address B-20](#__RefHeading___Toc143579367)

[FL39 - FL41 -- Value Codes and Amounts
B-20](#__RefHeading___Toc143579368)

[FL42 -- Revenue Code B-25](#__RefHeading___Toc143579369)

[FL43 -- Revenue Description B-45](#__RefHeading___Toc143579370)

[FL44 -- HCPCS/Rates B-45](#__RefHeading___Toc143579371)

[FL45 -- Service Date B-45](#__RefHeading___Toc143579372)

[FL46 -- Service Units B-46](#__RefHeading___Toc143579373)

[FL47 -- Total Charges B-46](#__RefHeading___Toc143579374)

[FL48 -- Non-Covered Charges B-47](#__RefHeading___Toc143579375)

[FL49 -- Untitled B-47](#__RefHeading___Toc143579376)

[FL50A, B, C -- Payer identification B-47](#__RefHeading___Toc143579377)

[FL51A, B, C -- Provider Number B-47](#__RefHeading___Toc143579378)

[FL52A, B, C -- Release of Information
B-48](#__RefHeading___Toc143579379)

[FL53A, B, C -- Assignment of Benefits Certification Indicator
B-48](#__RefHeading___Toc143579380)

[FL54A, B, C -- Prior Payments B-48](#__RefHeading___Toc143579381)

[FL55A, B, C -- Estimated Amount Due B-48](#__RefHeading___Toc143579382)

[FL56 -- (Untitled) B-48](#__RefHeading___Toc143579383)

[FL57 -- (Untitled) B-48](#__RefHeading___Toc143579384)

[FL58A, B, C -- Insured's Name B-49](#__RefHeading___Toc143579385)

[FL59A, B, C -- Patient's Relationship to Insured
B-49](#__RefHeading___Toc143579386)

[FL60A, B, C -- Certificate/Social Security Number/HI Claim\
/Identification Number B-50](#__RefHeading___Toc143579387)

[FL61A, B, C -- Group Name B-50](#__RefHeading___Toc143579388)

[FL62A, B, C -- Insurance Group Number
B-50](#__RefHeading___Toc143579389)

[FL63 -- Treatment Authorization Code
B-50](#__RefHeading___Toc143579390)

[FL64 -- Employment Status Code B-50](#__RefHeading___Toc143579391)

[FL65 -- Employer Name B-51](#__RefHeading___Toc143579392)

[FL66 -- Employer Location B-51](#__RefHeading___Toc143579393)

[FL67 -- Principal Diagnosis Code B-51](#__RefHeading___Toc143579394)

[FL68 - FL75 -- Other Diagnoses Codes
B-52](#__RefHeading___Toc143579395)

[FL76 -- Admitting Diagnosis/Patient's Reason for Visit
B-53](#__RefHeading___Toc143579396)

[FL77 -- E-Code B-53](#__RefHeading___Toc143579397)

[FL78 -- (Untitled) B-53](#__RefHeading___Toc143579398)

[FL79 -- Procedure Coding Method B-53](#__RefHeading___Toc143579399)

[FL80 -- Principal Procedure Code and Date
B-53](#__RefHeading___Toc143579400)

[FL81 -- Other Procedure Codes and Dates
B-54](#__RefHeading___Toc143579401)

[FL82 -- Attending/Referring Physician ID
B-54](#__RefHeading___Toc143579402)

[FL83 -- Other Physician ID B-55](#__RefHeading___Toc143579403)

[FL84 -- Remarks B-55](#__RefHeading___Toc143579404)

[FL85 -- Provider Representative Signature
B-56](#__RefHeading___Toc143579405)

[FL86 -- Date B-56](#__RefHeading___Toc143579406)

[]{#__RefHeading___Toc143579337 .anchor}About the CMS-1450 / UB-92 Form

The CMS-1450 form, more commonly known as UB-92, serves the needs of
many payers. Not all of the data elements need to be completed for every
payer.

Data elements in the CMS uniform electronic billing specifications are
consistent with the CMS-1450 form data set to the extent that one
processing system can handle both. Definitions are also identical.
However, due to the space constraints on the form, the electronic record
contains more characters for some items than the corresponding items on
the form

The revenue coding system for both Form CMS-1450 and the electronic
specifications are identical.

Effective June 5, 2000, CMS extended the claim size to 450 lines. For
the hard copy UB-92 or Form CMS-1450, CMS will accept claims of up to 9
pages. In addition, effective October 16, 2003, all state fields will be
discontinued and reclassified as reserved for national assignment.

[]{#__RefHeading___Toc143579338 .anchor}Form Locator (FL) Fields

The following sections provide descriptions of the form locator (FL)
fields and whether the information is required.

[]{#__RefHeading___Toc143579339 .anchor}FL1 -- (Untitled)

Provider Name, Address, and Telephone Number

*Required*. The minimum entry is the provider's name, city, State, and
zip code. The post office box number or street name and number may be
included. The State may be abbreviated using standard post office
abbreviations. Five or nine digit zip codes are acceptable. Telephone
and fax numbers are desirable.

[]{#__RefHeading___Toc143579340 .anchor}FL2 -- (Untitled)

Not Required. This is one of the four fields which have not been
assigned for national use.

[]{#__RefHeading___Toc143579341 .anchor}FL3 -- Patient Control Number

*Required*. The patient's unique alphanumeric number assigned by the
provider to facilitate retrieval of individual financial records and
posting of payments

[]{#__RefHeading___Toc143579342 .anchor}FL4 -- Type of Bill

*Required*. This three-digit alphanumeric code gives three specific
pieces of information:

-   The first digit identifies the type of facility.

-   The second digit classifies the type of care.

-   The third digit indicates the sequence of this bill in this
    particular episode of care; also referred to as "Frequency" code.

First Digit -- Type of Facility

  -----------------------------------------------------------------------
  1st Digit Type of Facility
  --------- -------------------------------------------------------------
  1         Hospital

  2         Skilled Nursing

  3         Home Health

  4         Religious Non-Medical (Hospital)

  5         Religious Non-Medical (Extended Card)

  6         Intermediate Care

  7         Clinic or Hospital Based Renal Dialysis Facility

  8         Special Facility of Hospital ASC Surgery

  9         Reserved for National Assignment
  -----------------------------------------------------------------------

Second Digit -- Classification (Except Clinics and Special Facilities)

  -----------------------------------------------------------------------
  2nd Digit Classification             Definition
  --------- -------------------------- ----------------------------------
  1         Inpatient (Part A)         

  2         Hospital Based or          Includes Home Health Agency (HHA)
            Inpatient (Part B)         visits under a Part B plan of
                                       treatment

  3         Outpatient                 Includes HHA visits under a Part A
                                       plan of treatment and use of HHA
                                       Durable Medical Equipment (DME)
                                       under Part A plan of treatment

  4         Other (Part B)             Includes HHA medical and other
                                       health services not under a plan
                                       of treatment, Skilled Nursing
                                       Facility (SNF) diagnostic clinical
                                       laboratory services to
                                       "nonpatients" and referred
                                       diagnostic services

  5         Intermediate Care -- Level 
            I                          

  6         Intermediate Care -- Level 
            II                         

  7         Subacute Inpatient         Revenue code 19X required

  8         Swing bed                  Used to indicate billing for SNF
                                       level of care in a hospital with
                                       an approved swing bed agreement

  9         Reserved for National      
            Assignment                 
  -----------------------------------------------------------------------

Second Digit -- Classification (Clinics Only)

  -----------------------------------------------------------------------
  2nd Digit Classification (Clinics Only)
  --------- -------------------------------------------------------------
  1         Rural Health Clinic (RHC)

  2         Hospital Based or Independent Renal Dialysis Facility

  3         Free-Standing provider-Based Federally Qualified Health
            Center (FQHC)

  4         Other (Part B)

  5         Comprehensive outpatient Rehabilitation Facility (CORF)

  6         Community Mental Health Center (CMHC)

  7         Reserved for National Assignment

  8         Reserved for National Assignment

  9         Other
  -----------------------------------------------------------------------

Second Digit -- Classification (Special Facilities Only)

  -----------------------------------------------------------------------
  2nd Digit Classification (Special Facilities Only)
  --------- -------------------------------------------------------------
  1         Hospice (Nonhospital based)

  2         Hospice (Hospital based)

  3         Ambulatory Surgical Center Services to Hospital Outpatients

  4         Free Standing Birthing Centers

  5         Critical Access Hospital

  6         Residential Facility

  7         Reserved for National Assignment

  8         Reserved for National Assignment

  9         Other
  -----------------------------------------------------------------------

Third Digit -- Frequency

The third digit, referred to as the Frequency code, indicates the
sequence of this bill in this particular episode of care.

+-------+----------------------+--------------------------------------+
| 3rd   | Frequency            | Definition                           |
| Digit |                      |                                      |
+=======+======================+======================================+
| A     | Admission/Election   | Use when a hospice or religious      |
|       | Notice               | non-medical health care institution  |
|       |                      | is submitting the Form CMS-1450 as   |
|       |                      | an admission notice                  |
+-------+----------------------+--------------------------------------+
| B     | Hospice/Medicare     | Use when the UB-92 is used as a      |
|       | Coordinated Care     | Termination/Revocation of a hospice, |
|       | Demon                | Medicare coordinated care            |
|       | strations/Revocation | demonstration or religious           |
|       | Notice               | non-medical health care institution  |
|       |                      | election.                            |
+-------+----------------------+--------------------------------------+
| C     | Hospice Change of    | Use when the Form CMS-1450 is used   |
|       | Provider             | as a Notice of Change to the hospice |
|       |                      | provider.                            |
+-------+----------------------+--------------------------------------+
| D     | Hospice/Medicare     | Use when the UB-92 is used as a      |
|       | Coordinated Care     | Notice of a Void/Cancel of a         |
|       | Demonstration/Ins    | hospice, Medicare Coordinated Care   |
|       | titution-Void/Cancel | Demonstration Entity, or Religious   |
|       |                      | Non-medical Health Care Institution  |
|       |                      | election                             |
+-------+----------------------+--------------------------------------+
| E     | Hospice Change of    | Use when the Form CMS-1450 is used   |
|       | Ownership            | for a Notice of Change in Ownership  |
|       |                      | for the hospice.                     |
+-------+----------------------+--------------------------------------+
| F     | Beneficiary          | Use to identify adjustments          |
|       | Initiated Adjustment | initiated by the beneficiary. For    |
|       | Claim                | intermediary use only.               |
+-------+----------------------+--------------------------------------+
| G     | Common Working File  | Use to identify adjustments          |
|       | (CWF) Initiated      | initiated by CWF. For intermediary   |
|       | Adjustment Claim     | use only.                            |
+-------+----------------------+--------------------------------------+
| H     | CMS Initiated        | Use to identify adjustments          |
|       | Adjustment Claim     | initiated by CMS. For intermediary   |
|       |                      | use only.                            |
+-------+----------------------+--------------------------------------+
| I     | Internal Adjustment  | This code is used to identify        |
|       | Claim (Other than    | adjustments initiated by you. For    |
|       | provider or PRO)     | intermediary use only.               |
+-------+----------------------+--------------------------------------+
| J     | Initiated Adjustment | Use to identify adjustments          |
|       | Claim -- Other       | initiated by other entities. For     |
|       |                      | intermediary use only.               |
+-------+----------------------+--------------------------------------+
| K     | Office of Inspector  | Use to identify adjustments          |
|       | General (OIG)        | initiated by OIG. For intermediary   |
|       | Initiated Adjustment | use only.                            |
|       | Claim                |                                      |
+-------+----------------------+--------------------------------------+
| M     | Medicare Secondary   | Use to identify adjustments          |
|       | Payer (MSP)          | initiated by MSP. For intermediary   |
|       | Initiated Adjustment | use only.                            |
|       | Claim                |                                      |
|       |                      | **Note:** MSP takes precedence over  |
|       |                      | other adjustment sources.            |
+-------+----------------------+--------------------------------------+
| P     | PRO Adjustment Claim | Use to identify an adjustment        |
|       |                      | initiated as a result of a PRO       |
|       |                      | review. For intermediary use only.   |
+-------+----------------------+--------------------------------------+
| 0     | Nonpayment/zero      | Use when the provider does not       |
|       | claims               | anticipate payment from the payer    |
|       |                      | for the bill, but is informing the   |
|       |                      | payer about a period of nonpayable   |
|       |                      | confinement or termination of care.  |
|       |                      | The "through" date is the date of    |
|       |                      | discharge.                           |
+-------+----------------------+--------------------------------------+
| 1     | Admit Through        | Use for a bill encompassing an       |
|       | Discharge Claim      | entire inpatient confinement or      |
|       |                      | course of outpatient treatment for   |
|       |                      | which the provider expects payments  |
|       |                      | from the payer or which will update  |
|       |                      | deductible for inpatient or Part B   |
|       |                      | claims when Medicare is secondary to |
|       |                      | an EGHP.                             |
+-------+----------------------+--------------------------------------+
| 2     | Interim -- First     | Use for the first of an expected     |
|       | claim                | series of bills for which            |
|       |                      | utilization is chargeable or which   |
|       |                      | will update inpatient deductible for |
|       |                      | the same confinement or course of    |
|       |                      | treatment.                           |
+-------+----------------------+--------------------------------------+
| 3     | Interim --           | Use when a bill for which            |
|       | Continuing Claims    | utilization is chargeable for the    |
|       | (Not valid for PPS   | same confinement or course of        |
|       | bills)               | treatment had already been submitted |
|       |                      | and further bills are expected to be |
|       |                      | submitted later.                     |
+-------+----------------------+--------------------------------------+
| 4     | Interim -- Last      | Use for a bill for which utilization |
|       | Claim (Not valid for | is chargeable and which is the last  |
|       | PPS bills)           | of a series for this confinement or  |
|       |                      | course of treatment. The "through"   |
|       |                      | date is the date of discharge.       |
+-------+----------------------+--------------------------------------+
| 5     | Late Charge Only     | Use only for outpatient claims. Late |
|       |                      | charge bills are not accepted for    |
|       |                      | Medicare inpatient or ASC claims.    |
+-------+----------------------+--------------------------------------+
| 7     | Replacement of Prior | Used by the provider when provider   |
|       | Claim                | wants to correct (other than late    |
|       |                      | charges) a previously submitted      |
|       |                      | bill.                                |
+-------+----------------------+--------------------------------------+
| 8     | Void/Cancel of a     | Use to indicate that this bill is an |
|       | Prior Claim          | exact duplicate of an incorrect bill |
|       |                      | previously submitted.                |
+-------+----------------------+--------------------------------------+
| 9     | Final Claim for Home | Use to indicate that the HH bill     |
|       | Health PPS Episode   | should be processed as a debit or    |
|       |                      | credit adjustment to the request for |
|       |                      | anticipated payment.                 |
+-------+----------------------+--------------------------------------+

[]{#__RefHeading___Toc143579343 .anchor}FL5 -- Federal Tax Number

Not Required

[]{#__RefHeading___Toc143579344 .anchor}FL6 -- Statement Covers Period
(From-Through)

*Required*. The beginning and ending dates of the period include on this
bill are shown in numeric fields (MMDDYY). Days before the entitlement
are not shown. Use the "From" date to determine timely filing.

[]{#__RefHeading___Toc143579345 .anchor}FL7 -- Covered Days

*Required*. The total number of covered days during the billing period
applicable to the cost report including lifetime reserve days elected
for which Medicare payment is requested, is entered. This should be the
total of accommodation units reported in FL 46.

Covered days exclude any days classified as noncovered, as defined in FL
8, leave of absence days, and the day of discharge or death.

The provider does not deduct any days for payment made in the following
instances:

-   Workers' Compensation

-   Automobile medical, no-fault, liability insurance

-   An EGHP for an ESRD beneficiary

-   Employed beneficiaries and spouses age 65 or over

-   An LGHP for disabled beneficiaries

[]{#__RefHeading___Toc143579346 .anchor}FL8 -- Noncovered Days

Required. The total number of noncovered days during the billing period
within the "From" and "Through" date that are no claimable as Medicare
patient days on the cost report.

[]{#__RefHeading___Toc143579347 .anchor}FL9 -- Coinsurance Days

*Required*. The number of covered inpatient hospitals days occurring
after the 60^th^ day and before the 91^st^ day or the number of covered
inpatient SNF days occurring after the 20^th^ day and before the 101^st^
day of the benefit period are shown for this billing period.

[]{#__RefHeading___Toc143579348 .anchor}FL10 -- Lifetime Reserve Days

*Required*. The provider enters the number of lifetime reserve days
applicable.

[]{#__RefHeading___Toc143579349 .anchor}FL11 -- (Untitled)

Not Required. This is one of the seven fields which have not been
assigned for national use.

[]{#__RefHeading___Toc143579350 .anchor}FL12 -- Patient's Name

*Required*. The patient's name is shown with the surname first, first
name, and middle initial, if any.

[]{#__RefHeading___Toc143579351 .anchor}FL13 -- Patient's Address

*Required*. This item shows the patients' full mailing address including
street number and name, post office box number or RFD, City, State, and
Zip code.

[]{#__RefHeading___Toc143579352 .anchor}FL14 -- Patient's Birthdate

*Required*. The month, day, and year of birth is shown numerically as
MMDDYYYY. If the date of birth was not obtained, the field will be zero
filled.

[]{#__RefHeading___Toc143579353 .anchor}FL15 -- Patient Sex

*Required*. An "M" for male and an "F" for female. This item is used in
conjunction with FLs 67-81 to identify inconsistencies.

[]{#__RefHeading___Toc143579354 .anchor}FL16 -- Patient's Marital Status

Not Required.

[]{#__RefHeading___Toc143579355 .anchor}FL17 -- Admission Date

*Required*. The month, day, and year of admission for inpatient care are
shown numerically as MMDDYY.

[]{#__RefHeading___Toc143579356 .anchor}FL18 -- Admission Hour

Not Required.

[]{#__RefHeading___Toc143579357 .anchor}FL19 -- Type of Admission/Visit

*Required* on inpatient bills only. This code indicates the admission's
priority.

Code Structure

  ------------------------------------------------------------------------
  Code     Admission/Visit    Definition
           Type               
  -------- ------------------ --------------------------------------------
  1        Emergency          The patient required immediate medical
                              intervention as a result of severe, life
                              threatening or potentially disabling
                              conditions. Generally, the patient was
                              admitted through the emergency room.

  2        Urgent             The patient required immediate attention for
                              the care and treatment of a physical or
                              mental disorder. Patient admitted to first
                              available accommodation.

  3        Elective           The patient's condition permitted adequate
                              time to schedule the availability of a
                              suitable accommodation.

  4        Newborn            Need to use a special source of admission
                              codes.

  5        Trauma Center      Centers licensed by the state

  9        Information not    The hospital cannot classify the type of
           available          admission. (Rarely used)
  ------------------------------------------------------------------------

[]{#__RefHeading___Toc143579358 .anchor}FL20 -- Source of Admission

*Required* -- Source of admission or outpatient registration

  -----------------------------------------------------------------------
  Code     Source of Admission
  -------- --------------------------------------------------------------
  1        Physician Referral

  2        Clinic Referral

  3        HMO referral

  4        Transfer from a Hospital

  5        Transfer from a SNF

  6        Transfer from another Health Care Facility

  7        Emergency Room

  8        Court/Law Enforcement

  9        Information Not Available

  A        Transfer from a Critical Access Hospital

  B        Transfer from another Home Health Agency

  C        Readmission to Same Home Health Agency period

  D-Z      Reserved for national assignment
  -----------------------------------------------------------------------

[]{#__RefHeading___Toc143579359 .anchor}FL21 -- Discharge Hour

Not Required

[]{#__RefHeading___Toc143579360 .anchor}FL22 -- Patient Status

*Required* -- for inpatient, outpatient, HHA, and SNF.

+-------+--------------------------------------------------------------+
| Code  | Patient Status                                               |
+=======+==============================================================+
| 01    | Discharged to home or self care (routine discharge)          |
+-------+--------------------------------------------------------------+
| 02    | Discharged/transferred to another short-term general         |
|       | hospital for inpatient care                                  |
+-------+--------------------------------------------------------------+
| 03    | Discharged/transferred to SNF. (for swing bed, use code 61)  |
+-------+--------------------------------------------------------------+
| 04    | Discharged/transferred to an Intermediate Care Facility      |
+-------+--------------------------------------------------------------+
| 05    | Discharged/transferred to another type of institution        |
+-------+--------------------------------------------------------------+
| 06    | Discharged/transferred to home under care of HH              |
+-------+--------------------------------------------------------------+
| 07    | Left against medical advice or discontinued care             |
+-------+--------------------------------------------------------------+
| 08    | Discharged/transferred to home under care of a home IV drug  |
|       | therapy provider                                             |
+-------+--------------------------------------------------------------+
| 09    | Admitted as an inpatient to this hospital                    |
|       |                                                              |
|       | **Note:** When a patient is admitted before midnight of the  |
|       | third day following the day of an outpatient service, the    |
|       | outpatient services are considered inpatient. Therefore,     |
|       | code 09 would apply only to services that began longer than  |
|       | 3 days earlier, such as observation following outpatient     |
|       | surgery, which results in admission.                         |
+-------+--------------------------------------------------------------+
| 20    | Expired or did not recover                                   |
+-------+--------------------------------------------------------------+
| 30    | Still patient                                                |
+-------+--------------------------------------------------------------+
| 40    | Expired at home (hospice only)                               |
+-------+--------------------------------------------------------------+
| 41    | Expired in medical facility                                  |
+-------+--------------------------------------------------------------+
| 42    | Expired, place unknown (hospice only)                        |
+-------+--------------------------------------------------------------+
| 43    | Discharge/transferred to a federal facility                  |
+-------+--------------------------------------------------------------+
| 44-49 | Reserved for national assignment                             |
+-------+--------------------------------------------------------------+
| 50    | Hospice -- home                                              |
+-------+--------------------------------------------------------------+
| 52-60 | Reserved for national assignment                             |
+-------+--------------------------------------------------------------+
| 61    | Discharged/transferred within this institution to a          |
|       | hospital-based Medicare approved swing bed                   |
+-------+--------------------------------------------------------------+
| 62-70 | Reserved for National Assignment                             |
+-------+--------------------------------------------------------------+
| 73-99 | Reserved for National Assignment                             |
+-------+--------------------------------------------------------------+

[]{#__RefHeading___Toc143579361 .anchor}FL23 -- Medical Record Number

*Required*. This is the number assigned to the patient's medical/health
record by the provider. If the provider enters a number, you must carry
the number through your system and return it to the provider.

[]{#__RefHeading___Toc143579362 .anchor}FL24 - FL30 -- Condition Codes

*Required*.

+------+----------------------+---------------------------------------+
| Code | Condition            | Definition                            |
+======+======================+=======================================+
| 02   | Condition is         | Code indicates patient alleges that   |
|      | employment related   | the medical condition in this episode |
|      |                      | of care is due to environments/events |
|      |                      | resulting from employment             |
+------+----------------------+---------------------------------------+
| 04   | Patient is HMO       | Bill submitted for information only   |
|      | Enrollee             |                                       |
+------+----------------------+---------------------------------------+
| 05   | Lien has been filed  | Provider has filed legal claim for    |
|      |                      | recovery of funds potentially due to  |
|      |                      | a patient as a result of legal action |
|      |                      | initiated by or on behalf of a        |
|      |                      | patient.                              |
+------+----------------------+---------------------------------------+
| 06   | ESRD patient in      | Code indicates that Medicare may be a |
|      | first 30 months;     | secondary insurer.                    |
|      | covered by employer  |                                       |
|      | group health         |                                       |
|      | insurance            |                                       |
+------+----------------------+---------------------------------------+
| 07   | Treatment of         | Code indicates patient has elected    |
|      | nonterminal          | hospice but the provider is not       |
|      | condition for        | treating the terminal condition.      |
|      | hospice              |                                       |
+------+----------------------+---------------------------------------+
| 08   | Beneficiary would    | Same                                  |
|      | not provide          |                                       |
|      | information          |                                       |
|      | concerning other     |                                       |
|      | insurance coverage   |                                       |
+------+----------------------+---------------------------------------+
| 09   | Neither patient nor  | Patient and spouse have denied        |
|      | spouse employed      | employment.                           |
+------+----------------------+---------------------------------------+
| 10   | Patient and/or       | There is no group health insurance    |
|      | spouse is employed   | from an EGHP or other health          |
|      | but no EGHP coverage | insurance that covers the patient,    |
|      | exists               |                                       |
+------+----------------------+---------------------------------------+
| 11   | Disabled beneficiary | There is no group health insurance    |
|      | but no LGHP          | from an LGHP or other health          |
|      |                      | insurance that covers the patient.    |
+------+----------------------+---------------------------------------+
| 1    | Payer codes          | Reserved for internal use only by     |
| 2-14 |                      | third party payer.                    |
+------+----------------------+---------------------------------------+
| 15   | Clean claim delayed  | CMS delayed claim processing.         |
|      | in HCFA's (CMS's)    | Interest is applicable.               |
|      | processing system    |                                       |
|      | (payer code only)    |                                       |
+------+----------------------+---------------------------------------+
| 16   | SNF Transition       | Code indicates an exemption from the  |
|      | Exemption (Medicare  | post-hospital requirements applies    |
|      | payer only code)     | for this SNF stay or the qualifying   |
|      |                      | stay dates are more than 30 days      |
|      |                      | prior to admission.                   |
+------+----------------------+---------------------------------------+
| 20   | Beneficiary          | Provider realizes the services on     |
|      | requested billing    | this bill are not covered but the     |
|      |                      | beneficiary has requested a formal    |
|      |                      | determination.                        |
+------+----------------------+---------------------------------------+
| 21   | Billing for denial   | Provider realizes the services on     |
|      | notice               | this bill are not covered, but        |
|      |                      | requests a denial notice from         |
|      |                      | Medicare in order to bill Medicaid or |
|      |                      | other insurer.                        |
+------+----------------------+---------------------------------------+
| 26   | VA eligible patient  | Same                                  |
|      | chooses to receive   |                                       |
|      | services in a        |                                       |
|      | Medicare certified   |                                       |
|      | facility             |                                       |
+------+----------------------+---------------------------------------+
| 27   | Patient referred to  | Sole community hospital only.         |
|      | a sole community     |                                       |
|      | hospital for a       |                                       |
|      | diagnostic lab test  |                                       |
+------+----------------------+---------------------------------------+
| 28   | Patient and/or       | Code indicates that either the EGHP   |
|      | spouse's EGHP is     | is a single employer plan and the     |
|      | secondary to         | employer has fewer than 20 full and   |
|      | Medicare             | part-time employees or the EGHP is    |
|      |                      | multi-or multiple employers' plan     |
|      |                      | that elects to pay secondary to       |
|      |                      | Medicare for employees and spouses    |
|      |                      | aged 65 and older for those           |
|      |                      | participating employers who have      |
|      |                      | fewer than 20 employees.              |
+------+----------------------+---------------------------------------+
| 29   | Disabled beneficiary | Code indicates that either the EGHP   |
|      | and/or family        | is a single employer plan and the     |
|      | member's LGHP is     | employer has few than 100 full and    |
|      | secondary to         | part-time employees or the LGHP is a  |
|      | Medicare             | multi- or multiple employer plans and |
|      |                      | that all employers participating in   |
|      |                      | the plan have fewer than 100 full and |
|      |                      | part-time employees.                  |
+------+----------------------+---------------------------------------+
| 30   | Qualifying clinical  | Non-research services provided to all |
|      | trials               | patients enrolled in qualified        |
|      |                      | clinical trials.                      |
+------+----------------------+---------------------------------------+
| 31   | Patient is a         | Same                                  |
|      | full-time day        |                                       |
|      | student              |                                       |
+------+----------------------+---------------------------------------+
| 32   | Patient is a         | Same                                  |
|      | cooperative work     |                                       |
|      | study student        |                                       |
+------+----------------------+---------------------------------------+
| 33   | Patient is a         | Same                                  |
|      | full-time night      |                                       |
|      | student              |                                       |
+------+----------------------+---------------------------------------+
| 34   | Patient is a         | Same                                  |
|      | part-time student    |                                       |
+------+----------------------+---------------------------------------+
| 35   |                      | Reserved for national assignment      |
+------+----------------------+---------------------------------------+
| 36   | General Care Patient | (Not used by hospitals under PPS)     |
|      | in a special unit    |                                       |
|      |                      | Patient placed in special unit in     |
|      |                      | that no general beds were available.  |
+------+----------------------+---------------------------------------+
| 37   | Ward accommodation   | (Not used by hospitals under PPS)     |
|      | at patient's request |                                       |
|      |                      | Patient assigned to ward.             |
+------+----------------------+---------------------------------------+
| 38   | Semi-private room    | (Not used by hospitals under PPS)     |
|      | not available        |                                       |
|      |                      | Patient assigned to ward; no          |
|      |                      | semi-private room available.          |
+------+----------------------+---------------------------------------+
| 39   | Private room medical | (Not used by hospitals under PPS)     |
|      | necessary            |                                       |
|      |                      | Assignment to private room was        |
|      |                      | medically necessary.                  |
+------+----------------------+---------------------------------------+
| 40   | Same day transfer    | Patient transferred from one provider |
|      |                      | to another before midnight on the day |
|      |                      | of admission                          |
+------+----------------------+---------------------------------------+
| 41   | Partial              | For partial hospitalization. For      |
|      | Hospitalization      | outpatient this includes a variety of |
|      |                      | psychiatric programs                  |
+------+----------------------+---------------------------------------+
| 42   | Continuing care not  | Continuing care plan is not related   |
|      | related to inpatient | to condition or diagnosis             |
|      | admission            |                                       |
+------+----------------------+---------------------------------------+
| 43   | Continuing care not  | Continuing care plan was related to   |
|      | provided within      | the inpatient admission but the       |
|      | prescribed           | prescribed care was not provided      |
|      | post-discharge       | within the post-discharge window.     |
|      | window               |                                       |
+------+----------------------+---------------------------------------+
| 55   | SNF bed not          | SNF admission was delayed more than   |
|      | available            | 30 days after hospital discharge      |
|      |                      | because a SNF bed was not available.  |
+------+----------------------+---------------------------------------+
| 56   | Medical              | SNF admission was delayed more than   |
|      | appropriateness      | 30 days after hospital discharge      |
|      |                      | because the patient's condition made  |
|      |                      | it inappropriate to begin active care |
|      |                      | within that period.                   |
+------+----------------------+---------------------------------------+
| 57   | SNF readmissions     | Patient previously received Medicare  |
|      |                      | covered SNF care within 30 days of    |
|      |                      | the current SNF admission.            |
+------+----------------------+---------------------------------------+
| 58   | Terminated           | Code indicates that the patient is a  |
|      | Medicare+Choice      | terminated enrollee in a              |
|      | Organization         | Medicare+Choice Organization plan     |
|      | enrollee             | whose three-day inpatient hospital    |
|      |                      | stay was waived.                      |
+------+----------------------+---------------------------------------+
| 59   |                      | Reserved for national assignment      |
+------+----------------------+---------------------------------------+
| 60   | Operating cost day   | Pricer indicates this bill is a       |
|      | outlier              | length-of-stay outlier                |
+------+----------------------+---------------------------------------+
| 61   | Operating cost       | Pricer indicates this bill is a cost  |
|      | outlier              |                                       |
+------+----------------------+---------------------------------------+
| 62   | PIP bill             | Bill was paid under PIP               |
+------+----------------------+---------------------------------------+
| 63   | Payer only code      | Code reserved for internal use only.  |
+------+----------------------+---------------------------------------+
| 64   | Other than clean     | Claim is not "clean".                 |
|      | claim                |                                       |
+------+----------------------+---------------------------------------+
| 65   | Non-PPS bill         | Bill is not a PPS bill.               |
+------+----------------------+---------------------------------------+
| 66   | Provider does not    | Hospital paid under PPS and is not    |
|      | wish cost outlier    | requesting additional payment as a    |
|      | payment              | cost outlier for this stay.           |
+------+----------------------+---------------------------------------+
| 67   | Beneficiary elects   | Same                                  |
|      | not to use Lifetime  |                                       |
|      | Reserve Days         |                                       |
+------+----------------------+---------------------------------------+
| 68   | Beneficiary elects   | Same                                  |
|      | to use Lifetime      |                                       |
|      | Reserve Days         |                                       |
+------+----------------------+---------------------------------------+
| 69   | IME/DGME/N&A payment | A request for supplemental payment    |
|      | only                 | from Indirect Medical                 |
|      |                      | Education/Graduate Medical            |
|      |                      | Education/Nursing and Allied Health   |
+------+----------------------+---------------------------------------+
| 70   | Self-administered    | Code indicates the billing is for a   |
|      | EPO                  | dialysis patient who self-administers |
|      |                      | EPO.                                  |
+------+----------------------+---------------------------------------+
| 71   | Full Care in unit    | Patient who receives staff-assisted   |
|      |                      | dialysis services                     |
+------+----------------------+---------------------------------------+
| 72   | Self-Care in unit    | Patient who manages his/her own       |
|      |                      | dialysis services without staff       |
|      |                      | assistance.                           |
+------+----------------------+---------------------------------------+
| 73   | Self-Care training   | Billing is for special dialysis       |
|      |                      | services where the patient and        |
|      |                      | his/her helper were learning to       |
|      |                      | perform dialysis.                     |
+------+----------------------+---------------------------------------+
| 74   | Home                 | Billing for a patient who received    |
|      |                      | dialysis services at home.            |
+------+----------------------+---------------------------------------+
| 75   | Home 100 percent     | Not to be used for services after     |
|      | payment              | April 16, 1990                        |
+------+----------------------+---------------------------------------+
| 76   | Back-up facility     | Billing is for a home dialysis        |
|      | dialysis             | patient who received back-up dialysis |
|      |                      | in a facility                         |
+------+----------------------+---------------------------------------+
| 77   | Provider accepts or  | No Medicare payment is due.           |
|      | is                   |                                       |
|      | obligated/required   |                                       |
|      | due to a contractual |                                       |
|      | arrangement by law   |                                       |
|      | to accept payment by |                                       |
|      | a primary payer as   |                                       |
|      | payment in full.     |                                       |
+------+----------------------+---------------------------------------+
| 78   | New coverage not     | Medicare newly covered service for    |
|      | implemented by HMO   | which an HMO does not pay             |
+------+----------------------+---------------------------------------+
| 79   | CORF services        | Occupational, physical, and speech    |
|      | provided off site    | therapy were provided off site.       |
+------+----------------------+---------------------------------------+
| A0   | Special zip code     | Five digit zip code of the location   |
|      | reporting            | from which the beneficiary is         |
|      |                      | initially placed on board the         |
|      |                      | ambulance.                            |
+------+----------------------+---------------------------------------+
| A3   | Special Federal      | Code is designed for uniform use by   |
|      | funding              | State uniform billing committee.      |
+------+----------------------+---------------------------------------+
| A5   | Disability           | Same as above                         |
+------+----------------------+---------------------------------------+
| A6   | PPV/Medicare         | Paid under a special Medicare program |
|      | Pneumonia/Influenza  | provision.                            |
|      | 100%                 |                                       |
+------+----------------------+---------------------------------------+
| A7   | Induced              | An abortion was performed to avoid    |
|      | abortion-danger to   | danger to a women's life.             |
|      | life                 |                                       |
+------+----------------------+---------------------------------------+
| A8   | Induced abortion --  | Discontinued October 1, 2002.         |
|      | victim of            |                                       |
|      | rape/incest          |                                       |
+------+----------------------+---------------------------------------+
| A9   | Second opinion       | Services requested to support second  |
|      | surgery              | opinion in surgery. Part B deductible |
|      |                      | and coinsurance do not apply.         |
+------+----------------------+---------------------------------------+
| AA   | Abortion performed   | Self-explanatory                      |
|      | due to rape          |                                       |
+------+----------------------+---------------------------------------+
| AB   | Abortion performed   | Self-explanatory                      |
|      | due to incest        |                                       |
+------+----------------------+---------------------------------------+
| AC   | Abortion performed   | Self-explanatory                      |
|      | due to serious fetal |                                       |
|      | genetic defect,      |                                       |
|      | deformity, or        |                                       |
|      | abnormality          |                                       |
+------+----------------------+---------------------------------------+
| AD   | Abortion performed   | Self-explanatory                      |
|      | due to a life        |                                       |
|      | endangering physical |                                       |
|      | condition caused by, |                                       |
|      | arising from or      |                                       |
|      | exacerbated by the   |                                       |
|      | pregnancy itself     |                                       |
+------+----------------------+---------------------------------------+
| AE   | Abortion performed   | Self-explanatory                      |
|      | due to physical      |                                       |
|      | health of mother     |                                       |
|      | that is not life     |                                       |
|      | endangering          |                                       |
+------+----------------------+---------------------------------------+
| AF   | Abortion performed   | Self-explanatory                      |
|      | due to               |                                       |
|      | emo                  |                                       |
|      | tional/psychological |                                       |
|      | health of the mother |                                       |
+------+----------------------+---------------------------------------+
| AG   | Abortion performed   | Self-explanatory                      |
|      | due to social        |                                       |
|      | economic reasons     |                                       |
+------+----------------------+---------------------------------------+
| AH   | Elective abortion    | Self-explanatory                      |
+------+----------------------+---------------------------------------+
| AI   | Sterilization        | Self-explanatory                      |
+------+----------------------+---------------------------------------+
| AJ   | Payer responsible    | Self-explanatory                      |
|      | for co-payment       |                                       |
+------+----------------------+---------------------------------------+
| AK   | Air ambulance        | For ambulance claims                  |
|      | required             |                                       |
+------+----------------------+---------------------------------------+
| AL   | Specialized          | For ambulance claims                  |
|      | treatment bed        |                                       |
|      | unavailable          |                                       |
+------+----------------------+---------------------------------------+
| AM   | Non-emergency        | For ambulance claims                  |
|      | medically necessary  |                                       |
|      | stretcher transport  |                                       |
|      | required             |                                       |
+------+----------------------+---------------------------------------+
| A    |                      | Reserved for national assignment      |
| N-AZ |                      |                                       |
+------+----------------------+---------------------------------------+
| B0   | Medicare Coordinate  | Self-explanatory                      |
|      | Care Demonstration   |                                       |
|      | Program              |                                       |
+------+----------------------+---------------------------------------+
| B1   | Beneficiary is       | Full definition pending               |
|      | ineligible for       |                                       |
|      | Demonstration        |                                       |
|      | Program              |                                       |
+------+----------------------+---------------------------------------+
| B2   | Critical Access      | Attestation that CAH meets the        |
|      | Hospital Ambulance   | criteria for exemption from the       |
|      | Attestation          | ambulance fee schedule.               |
+------+----------------------+---------------------------------------+
| B3   | Pregnancy indicator  | Indicates patient is pregnant.        |
+------+----------------------+---------------------------------------+
| B    | Reserved for         |                                       |
| 4-BZ | National Assignment  |                                       |
+------+----------------------+---------------------------------------+
| M0   | All-inclusive rate   | Payer only code. Used by a CAH        |
|      | for outpatient       | electing to be paid an all-inclusive  |
|      |                      | rate for outpatient services          |
+------+----------------------+---------------------------------------+
| M1   | Roster billed        | Payer only code. For providers that   |
|      | influenza virus      | mass immunize.                        |
|      | vaccine or pneumonia |                                       |
|      | vaccine              |                                       |
+------+----------------------+---------------------------------------+
| M2   | HHA payment          | Payer only code. Charges in excess of |
|      | significantly        | covered billed charges.               |
|      | exceeds total charge |                                       |
+------+----------------------+---------------------------------------+
| C1   | Approved as billed   | PRO review and fully approved all     |
|      |                      | days and any outliers.                |
+------+----------------------+---------------------------------------+
| C3   | Partial approval     | PRO review and some portion of stay   |
|      |                      | denied                                |
+------+----------------------+---------------------------------------+
| C4   | Admission denied     | PRO review and none of stay was       |
|      |                      | medically necessary.                  |
+------+----------------------+---------------------------------------+
| C5   | Postpayment review   | PRO review after admission stay       |
+------+----------------------+---------------------------------------+
| C6   | Preadmission or      | PRO authorized admission but has not  |
|      | preprocedure         | reviewed the services provided.       |
+------+----------------------+---------------------------------------+
| C7   | Extended             | PRO authorized admission for an       |
|      | authorization        | extended length of time but has not   |
|      |                      | reviewed the services provided.       |
+------+----------------------+---------------------------------------+
| D0   | Changes to service   | Self-explanatory                      |
|      | date                 |                                       |
+------+----------------------+---------------------------------------+
| D1   | Changes to charges   | Self-explanatory                      |
+------+----------------------+---------------------------------------+
| D2   | Changes to revenue   | Changes in codes                      |
|      | codes/HCPCs/rate     |                                       |
|      | codes                |                                       |
+------+----------------------+---------------------------------------+
| D3   | Second or subsequent | Self-explanatory                      |
|      | interim PPS bill     |                                       |
+------+----------------------+---------------------------------------+
| D4   | Change in ICD-9-CM   | Change in codes                       |
|      | diagnosis and/or     |                                       |
|      | procedure code       |                                       |
+------+----------------------+---------------------------------------+
| D5   | Cancel to correct    | Cancel only to correct an HICN or     |
|      | HICN or provider ID  | provider ID number                    |
+------+----------------------+---------------------------------------+
| D6   | Cancel only to repay | Self-explanatory                      |
|      | a duplicate or OIG   |                                       |
|      | overpayment          |                                       |
+------+----------------------+---------------------------------------+
| D7   | Change to make       | Self-explanatory                      |
|      | Medicare the         |                                       |
|      | secondary payer      |                                       |
+------+----------------------+---------------------------------------+
| D8   | Change to make       | Self-explanatory                      |
|      | Medicare the primary |                                       |
|      | payer                |                                       |
+------+----------------------+---------------------------------------+
| D9   | Any other change     | Self-explanatory                      |
+------+----------------------+---------------------------------------+
| E0   | Change in patient    | Self-explanatory                      |
|      | status               |                                       |
+------+----------------------+---------------------------------------+
| E    |                      | Reserved for national assignment      |
| 1-E9 |                      |                                       |
+------+----------------------+---------------------------------------+
| G0   | Distinct medical     | Report this code when multiple        |
|      | visit                | medical visits occurred on the same   |
|      |                      | day in the same revenue. Each visit   |
|      |                      | was distinct.                         |
+------+----------------------+---------------------------------------+
| G    |                      | Reserved for national assignment      |
| 1-G9 |                      |                                       |
+------+----------------------+---------------------------------------+
| H0   | Delayed filing,      | Code indicates that Statement of      |
|      | statement of intent  | Intent was submitted within the       |
|      | submitted specially  | qualifying period to identify the     |
|      |                      | existence of another third party      |
|      |                      | liability situation.                  |
+------+----------------------+---------------------------------------+

[]{#__RefHeading___Toc143579363 .anchor}FL31 -- (Untitled)

Not required.

[]{#__RefHeading___Toc143579364 .anchor}FL32 - FL35 -- Occurrence Codes
and Dates

*Required*. Event codes are two alphanumeric characters, and dates are
shown as six numeric digits (MMDDYY).

1.  Occurrence and occurrence span codes are mutually exclusive.
    Occurrence codes values are 01 through 69 and A0 through L9.

+------+----------------------+----------------------------------------+
| Code | Occurrence           | Definition                             |
+------+----------------------+----------------------------------------+
| 01   | Accident/Medical     | Available medical payment coverage.    |
|      | coverage             | Include date of accident/injury        |
+------+----------------------+----------------------------------------+
| 02   | No-fault insurance   | State has applicable no-fault or       |
|      | involved, including  | liability laws (legal basis for        |
|      | auto accident/other  | settlement without admission or proof  |
|      |                      | of guilt)                              |
+------+----------------------+----------------------------------------+
| 03   | Accident/Tort        | Third party's action may involve a     |
|      | Liability            | civil court process in an attempt to   |
|      |                      | require payment by third party.        |
+------+----------------------+----------------------------------------+
| 04   | Accident/employment  | Date of accident related to patient's  |
|      | related              | employment                             |
+------+----------------------+----------------------------------------+
| 05   | Accident/No medical  | There is no medical payment or         |
|      | or liability         | third-party liability coverage.        |
|      | coverage             | Include date of accident/injury        |
+------+----------------------+----------------------------------------+
| 11   | Onset of             | When the patient first became aware of |
|      | symptoms/illness     | symptoms/illness                       |
+------+----------------------+----------------------------------------+
| 12   | Date of onset for a  | HHA claim only.                        |
|      | chronically          |                                        |
|      | dependent individual | This is the first month of the 3 month |
|      |                      | period immediately prior to            |
|      |                      | eligibility under respite care benefit |
+------+----------------------+----------------------------------------+
| 16   | Date of last therapy | Last day of physical, occupational or  |
|      |                      | speech therapy.                        |
+------+----------------------+----------------------------------------+
| 18   | Date of retirement,  | Self-explanatory                       |
|      | patient beneficiary  |                                        |
+------+----------------------+----------------------------------------+
| 19   | Date of retirement   | Self-explanatory                       |
|      | ,spouse              |                                        |
+------+----------------------+----------------------------------------+
| 20   | Guarantee of payment | Part A claim only. Date provider began |
|      | began                | claiming payment under the guarantee   |
|      |                      | of payment provision.                  |
+------+----------------------+----------------------------------------+
| 21   | UR notice received   | Part A SNF claims only. Admission or   |
|      |                      | further stay was not medically         |
|      |                      | necessary.                             |
+------+----------------------+----------------------------------------+
| 22   | Date active care     | Date covered level of care ended. Code |
|      | ended                | is not required if code "21" is used.  |
+------+----------------------+----------------------------------------+
| 23   | Date of cancellation | For intermediary use only              |
|      | of hospice election  |                                        |
|      | period               |                                        |
+------+----------------------+----------------------------------------+
| 24   | Date insurance       | Receipt date of denial of coverage by  |
|      | denied               | a higher priority payer                |
+------+----------------------+----------------------------------------+
| 25   | Date benefits        | Date on which coverage no longer       |
|      | terminated by        | available to patient.                  |
|      | primary payer        |                                        |
+------+----------------------+----------------------------------------+
| 26   | Date SNF bed         | Date SNF bed available to hospital     |
|      | available            | inpatient.                             |
+------+----------------------+----------------------------------------+
| 27   | Date of hospice      | Date of certification for hospice      |
|      | certification or     | benefit period.                        |
|      | re-certification     |                                        |
+------+----------------------+----------------------------------------+
| 28   | Date CORF plan       | Date the plan of treatment was         |
|      | established or last  | established or reviewed for CORF care. |
|      | reviewed             |                                        |
+------+----------------------+----------------------------------------+
| 29   | Date OPT plan        | Date a plan was established or last    |
|      | established or last  | reviewed for OPT.                      |
|      | reviewed             |                                        |
+------+----------------------+----------------------------------------+
| 30   | Date outpatient      | Data a plan was established or last    |
|      | speech pathology     | reviewed for outpatient speech         |
|      | plan established or  | therapy.                               |
|      | last reviewed        |                                        |
+------+----------------------+----------------------------------------+
| 31   | Date beneficiary     | Date of notice provided by the         |
|      | notified of intent   | hospital to the patient that inpatient |
|      | to bill              | care is not longer required.           |
|      | (accommodations)     |                                        |
+------+----------------------+----------------------------------------+
| 32   | Date beneficiary     | Date of notice provided to the         |
|      | notified of intent   | beneficiary that requested care may    |
|      | to bill (procedures  | not be reasonable or necessary under   |
|      | or treatments)       | Medicare.                              |
+------+----------------------+----------------------------------------+
| 33   | First day of the     | Required only for ESRD beneficiaries.  |
|      | Medicare             |                                        |
|      | coordination period  |                                        |
|      | for ESRD,            |                                        |
|      | beneficiaries        |                                        |
|      | covered by an EGHP   |                                        |
+------+----------------------+----------------------------------------+
| 34   | Date of election of  | Date the guest elected to receive      |
|      | extended care        | extended care services                 |
|      | services             |                                        |
+------+----------------------+----------------------------------------+
| 35   | Date treatment       | Self-explanatory                       |
|      | started for physical |                                        |
|      | therapy              |                                        |
+------+----------------------+----------------------------------------+
| 36   | Date of inpatient    | Date of discharge for inpatient in     |
|      | hospital discharge   | which patient received a transplant    |
|      | for transplant       | procedure when the hospital is billing |
|      | procedure            | for immunosuppressive drugs.           |
+------+----------------------+----------------------------------------+
| 37   | Date of inpatient    | Date of discharge for inpatient which  |
|      | hospital discharge,  | the patient received a non-covered     |
|      | non-covered          | transplant procedure when the hospital |
|      | transplant patient   | is billing for immunosuppressive       |
|      |                      | drugs.                                 |
+------+----------------------+----------------------------------------+
| 41   | Date of first test   | Date on which the first outpatient     |
|      | for pre-admission    | diagnostic test was performed as part  |
|      | testing              | of a PAT program.                      |
+------+----------------------+----------------------------------------+
| 42   | Date of discharge    | (hospice claims only) Date beneficiary |
|      |                      | terminated his/her election to receive |
|      |                      | benefits.                              |
+------+----------------------+----------------------------------------+
| 43   | Schedule date of     | Date for which ambulatory surgery was  |
|      | canceled surgery     | scheduled.                             |
+------+----------------------+----------------------------------------+
| 44   | Date treatment       | Self-explanatory                       |
|      | started for          |                                        |
|      | occupational therapy |                                        |
+------+----------------------+----------------------------------------+
| 45   | Date treatment       | Self-explanatory                       |
|      | started for speech   |                                        |
|      | therapy              |                                        |
+------+----------------------+----------------------------------------+
| 46   | Date treatment       | Self-explanatory                       |
|      | started for cardiac  |                                        |
|      | rehabilitation       |                                        |
+------+----------------------+----------------------------------------+
| 47   | Date cost outlier    | First day the inpatient cost outlier   |
|      | status begins        | threshold is reached.                  |
+------+----------------------+----------------------------------------+
| 4    |                      | Payer codes                            |
| 8-49 |                      |                                        |
+------+----------------------+----------------------------------------+
| A1   | Birthdate -- Insured | Birth date of insured in whose name    |
|      | A                    | the insurance is carried.              |
+------+----------------------+----------------------------------------+
| A2   | Effective date --    | First date the insurance is in force.  |
|      | insured A policy     |                                        |
+------+----------------------+----------------------------------------+
| A3   | Benefits exhausted   | Last date for which benefits are       |
|      |                      | available and after which no payment   |
|      |                      | can be made.                           |
+------+----------------------+----------------------------------------+
| A4   | Split bill date      | Date patient became Medicaid eligible  |
|      |                      | due to medically needy spend down.     |
|      |                      | Also called "split bill date".         |
+------+----------------------+----------------------------------------+
| B1   | Birthdate -- Insured | Birth date of individual in whose name |
|      | B                    | the insurance is carried.              |
+------+----------------------+----------------------------------------+
| B2   | Effective date --    | First date the insurance is in force.  |
|      | insured B policy     |                                        |
+------+----------------------+----------------------------------------+
| B3   | Benefits exhausted   | Last date for which benefits are       |
|      |                      | available and after which no payment   |
|      |                      | can be made.                           |
+------+----------------------+----------------------------------------+
| C1   | Birthdate -- Insured | Birth date of insured in whose name    |
|      | C                    | the insurance is carried.              |
+------+----------------------+----------------------------------------+
| C2   | Effective date --    | First date the insurance is in force.  |
|      | insured C policy     |                                        |
+------+----------------------+----------------------------------------+
| C3   | Benefits exhausted   | Last date for which benefits are       |
|      |                      | available and after which no payment   |
|      |                      | can be made.                           |
+------+----------------------+----------------------------------------+
| C    | Reserved for         |                                        |
| 4-C9 | National Assignment  |                                        |
+------+----------------------+----------------------------------------+
| D    | Reserved for         |                                        |
| 0-D9 | National Assignment  |                                        |
+------+----------------------+----------------------------------------+

[]{#__RefHeading___Toc143579365 .anchor}FL36 -- Occurrence Span Code and
Dates

*Required*. Event codes are two alphanumeric characters, and dates are
shown numerically as MMDDYY.

2.  Occurrence and occurrence span codes are mutually exclusive.
    Occurrence span codes values are 70 through 99 and M0 through Z9.

+-------+----------------------+---------------------------------------+
| Code  | Occurrence Span      | Definition                            |
+-------+----------------------+---------------------------------------+
| 70    | Qualifying stay      | Part A claims for SNF level care only |
|       | dates                |                                       |
|       |                      | Hospital stay of at least 3 days      |
|       |                      | which qualifies the patient for       |
|       |                      | payment of SNF level of care          |
+-------+----------------------+---------------------------------------+
| 71    | Nonutilization dates | PPS inlier stays for which            |
|       | (for payer use on    | beneficiary had exhausted all regular |
|       | hospital bills only) | days and/or coinsurance days.         |
+-------+----------------------+---------------------------------------+
| 72    | Prior stay dates     | Part A claims only. Code indicates    |
|       |                      | from/through dates given by the       |
|       |                      | patient for any hospital stay that    |
|       |                      | ended within 60 days of this hospital |
|       |                      | or SNF admission.                     |
+-------+----------------------+---------------------------------------+
| 73    | First/last visit     | Actual dates of the first and last    |
|       |                      | visit occurring in this billing       |
|       |                      | period where thee dates are different |
|       |                      | from those in FL6.                    |
+-------+----------------------+---------------------------------------+
| 74    | Noncovered level of  | From/through dates for a period of at |
|       | care                 | a noncovered level of care in an      |
|       |                      | otherwise covered stay.               |
+-------+----------------------+---------------------------------------+
| 75    | SNF level of care    | From/through dates for a period of    |
|       |                      | SNF level of care during an inpatient |
|       |                      | hospital stay.                        |
+-------+----------------------+---------------------------------------+
| 76    | Patient liability    | From/through dates for a period of    |
|       |                      | noncovered care for which the         |
|       |                      | hospital is permitted to charge the   |
|       |                      | beneficiary.                          |
+-------+----------------------+---------------------------------------+
| 77    | Provider liability   | From/through dates for a period of    |
|       | -- utilization       | noncovered care for which the         |
|       | charged              | provider is liable.                   |
+-------+----------------------+---------------------------------------+
| 78    | SNF prior stay dates | Part A claims only. From/through      |
|       |                      | dates given by the patient for a SNF  |
|       |                      | stay that ended within 60 days of     |
|       |                      | this hospital or SNF admission.       |
+-------+----------------------+---------------------------------------+
| 79    | Payer code           | For payer use only.                   |
+-------+----------------------+---------------------------------------+
| M0    | PRO/UR stay dates    | If a code "C3" is in FLs 24-30, the   |
|       |                      | from and through dates of the         |
|       |                      | approved billing period are here.     |
+-------+----------------------+---------------------------------------+
| M1    | Provider liability   | From/through dates of a period of     |
|       | -- no utilization    | noncovered care that is denied due to |
|       |                      | lack of medical necessity or as       |
|       |                      | custodial care for which the provider |
|       |                      | is liable.                            |
+-------+----------------------+---------------------------------------+
| M2    | Dates of inpatient   | From/through dates of a period of     |
|       | respite care         | intermediate level of care            |
+-------+----------------------+---------------------------------------+
| M4    | Residential level of | From and through dates of a period of |
|       | care                 | residential care                      |
+-------+----------------------+---------------------------------------+
| M5-WZ | Reserved for         |                                       |
|       | National Assignment  |                                       |
+-------+----------------------+---------------------------------------+

[]{#__RefHeading___Toc143579366 .anchor}FL37 -- Internal Control Number
(ICN)/Document Control Number (DCN)

*Required*. The control number assigned to the original bill needs to be
documented in this field. All providers requesting an adjustment to a
previously processed claim insert the ICN/DCN of the claim to be
adjusted.

[]{#__RefHeading___Toc143579367 .anchor}FL38 -- (Untitled Except on
Patient Copy of the Bill) Responsible Party Name and Address

Not Required.

[]{#__RefHeading___Toc143579368 .anchor}FL39 - FL41 -- Value Codes and
Amounts

*Required*. Code(s) and related dollar amount(s) identify data of a
monetary nature that are necessary for the processing of this claim. The
codes are two alphanumeric characters, and each value allows up to nine
numeric digits.

Negative amounts are not allowed except in FL 41. Whole numbers or
non-dollar amounts are right justified to the left of the dollars and
cents delimiter. Some values are reported as cents.

If more than one value code is shown for a billing period, codes are
shown in ascending alphanumeric sequence. There are four lines of data,
line "A" through line "D".

+------+------------------------+--------------------------------------+
| Code | Title                  | Definition                           |
+======+========================+======================================+
| 04   | Inpatient professional | Code indicates the amount shown is   |
|      | component charges      | the sum of the inpatient             |
|      | which are combined     | professional component charges which |
|      | billed                 | are combined billed. (Used only by   |
|      |                        | some all-inclusive rate hospitals)   |
+------+------------------------+--------------------------------------+
| 05   | Professional component | Code indicates the charges shown are |
|      | included in charges    | included in billing charges (column  |
|      | and also billed        | 53) but a separate billing for them  |
|      | separately to Carrier  | will also be made to the Carrier.    |
|      |                        | For outpatient claims, these charges |
|      |                        | are excluded in determining the      |
|      |                        | deductible and coinsurance due from  |
|      |                        | the patient to avoid duplication     |
|      |                        | when the bill for physician's        |
|      |                        | services is processed by the         |
|      |                        | Carrier. These charges are also      |
|      |                        | deducted when computing interim      |
|      |                        | payment.                             |
+------+------------------------+--------------------------------------+
| 06   | Medicare Part A and    | Code indicates the amount shown is   |
|      | Part B blood           | the product of the number of         |
|      | deductible             | unreplaced deductible pints of blood |
|      |                        | supplied times the charge per pint.  |
+------+------------------------+--------------------------------------+
| 08   | Medicare lifetime      | Code indicates the amount shown is   |
|      | reserve amount for     | the product of the number of         |
|      | first calendar year in | lifetime reserve days used in the    |
|      | billing period         | first calendar year of the billing   |
|      |                        | period times the applicable lifetime |
|      |                        | reserve coinsurance rate. These are  |
|      |                        | days used in the year of admission.  |
+------+------------------------+--------------------------------------+
| 09   | Medicare coinsurance   | On Part A bills, this code indicates |
|      | amount for first       | the amount shown is the product of   |
|      | calendar year in       | the number of coinsurance days used  |
|      | billing period         | in the first calendar year of the    |
|      |                        | billing period times the applicable  |
|      |                        | coinsurance rate. This code is not   |
|      |                        | used on Part B bills.                |
+------+------------------------+--------------------------------------+
| 10   | Medicare lifetime      | Code indicates the amount shown is   |
|      | reserve amount for     | the product of the number of         |
|      | second calendar year   | lifetime reserve days used in the    |
|      | in the billing period. | 2^nd^ calendar year of the billing   |
|      |                        | period times the applicable lifetime |
|      |                        | reserve rate. The code is used only  |
|      |                        | for stays spanning two calendar      |
|      |                        | years when lifetime reserve days     |
|      |                        | were used in the year of discharge.  |
+------+------------------------+--------------------------------------+
| 11   | Medicare Coinsurance   | On Part A bills, this code indicates |
|      | Amount for second      | the amount shown is the product of   |
|      | calendar year in       | the number of coinsurance days used  |
|      | billing period         | in the second calendar year of the   |
|      |                        | billing period the applicable        |
|      |                        | coinsurance rate. This code is used  |
|      |                        | only for stays spanning two calendar |
|      |                        | years when coinsurance days were     |
|      |                        | used in the year of discharge. This  |
|      |                        | code is not used on Part B bills.    |
+------+------------------------+--------------------------------------+
| 12   | Working aged           | Code indicates the amount shown is   |
|      | beneficiary/spouse     | that portion of a higher priority    |
|      | with an EGHP           | EGHP payment made on behalf of an    |
|      |                        | aged beneficiary that the provider   |
|      |                        | is applying to cover. If six zeros   |
|      |                        | are entered in the amount field, the |
|      |                        | provider is claiming a conditional   |
|      |                        | payment because the EGHP has denied  |
|      |                        | coverage.                            |
+------+------------------------+--------------------------------------+
| 13   | ESRD beneficiary in a  | Code indicates the amount shown is   |
|      | Medicare coordination  | that portion of a higher priority    |
|      | period with an EGHP    | EGHP payment made on behalf of an    |
|      |                        | ESRD beneficiary that the provider   |
|      |                        | is applying to covered Medicare      |
|      |                        | charges on the bill.                 |
+------+------------------------+--------------------------------------+
| 14   | No-Fault, including    | Code indicates the amount shown is   |
|      | auto/other insurance   | that portion of a higher priority    |
|      |                        | no-fault including auto/other        |
|      |                        | insurance payment made on behalf of  |
|      |                        | a Medicare beneficiary that the      |
|      |                        | provider is applying to covered      |
|      |                        | Medicare charges on this bill. If    |
|      |                        | six zeros are entered in the amount  |
|      |                        | field, the provider is claiming a    |
|      |                        | conditional payment because the      |
|      |                        | other insurance has denied coverage  |
|      |                        | or there has been a substantial      |
|      |                        | delay in its payment.                |
+------+------------------------+--------------------------------------+
| 15   | Worker's Compensation  | Codes indicates the amount shown is  |
|      |                        | that portion of a higher priority WC |
|      |                        | payment made on behalf of a Medicare |
|      |                        | beneficiary that the provider is     |
|      |                        | applying to covered Medicare         |
|      |                        | charges. If six zeros are entered in |
|      |                        | the amount field, the provider is    |
|      |                        | claiming a conditional payment       |
|      |                        | because there has been a substantial |
|      |                        | delay in the other payer's payment.  |
+------+------------------------+--------------------------------------+
| 16   | PHS, other Federal     | Code indicates the amount shown is   |
|      | agency                 | that portion of a higher priority    |
|      |                        | PHS or other Federal agency's        |
|      |                        | payment made on behalf of a Medicare |
|      |                        | beneficiary that the provider is     |
|      |                        | applying to covered Medicare         |
|      |                        | charges.                             |
+------+------------------------+--------------------------------------+
| 17   | Operating Outlier      | Codes indicates the amount shown is  |
|      | amount                 | that portion of a higher priority    |
|      |                        | PHS or other Federal agency's        |
|      |                        | payment made on behalf of a Medicare |
|      |                        | beneficiary that the provider is     |
|      |                        | applying to covered Medicare         |
|      |                        | charges.                             |
+------+------------------------+--------------------------------------+
| 18   | Operating              | (Not reported by providers). Report  |
|      | disproportionate share | operating indirect medical education |
|      | amount                 | amount applicable with this code.    |
|      |                        | Use the amount indicated in the      |
|      |                        | pricer.                              |
+------+------------------------+--------------------------------------+
| 19   | Operating indirect     | (Not reported by providers). Report  |
|      | medical education      | operating indirect medical education |
|      | amount                 | amount applicable with this code.    |
|      |                        | Use the amount indicated in the      |
|      |                        | pricer.                              |
+------+------------------------+--------------------------------------+
| 31   | Patient liability      | Code indicates the amount show is    |
|      | amount                 | that which was approved by you or    |
|      |                        | the PRO to charge the beneficiary    |
|      |                        | for noncovered accommodations,       |
|      |                        | diagnostic procedures or treatments. |
+------+------------------------+--------------------------------------+
| 32   | Multiple patient       | If more than one patient is          |
|      | ambulance transport    | transported in a single ambulance    |
|      |                        | trip, report the total number of     |
|      |                        | patients transported.                |
+------+------------------------+--------------------------------------+
| 37   | Pints of blood         | Code indicates the total number of   |
|      | furnished              | pints of whole blood or units of     |
|      |                        | packed red cells furnished, whether  |
|      |                        | or not they were replaced.           |
+------+------------------------+--------------------------------------+
| 38   | Blood deductible pints | Code indicates the number of         |
|      |                        | unreplaced deductible pints of blood |
|      |                        | supplied. If all deductible pints    |
|      |                        | furnished have been replaced, no     |
|      |                        | entry is made.                       |
+------+------------------------+--------------------------------------+
| 39   | Pints of blood         | Code indicates the total number of   |
|      | replaced               | pints of blood which were donated on |
|      |                        | the patient's behalf.                |
+------+------------------------+--------------------------------------+
| 40   | New coverage not       | (For inpatient services only). Code  |
|      | implemented by HMO     | indicates the amount shown for       |
|      |                        | inpatient charges covered by HMO.    |
+------+------------------------+--------------------------------------+
| 41   | Black lung             | Code indicates the amount shown is   |
|      |                        | that portion of a higher priority BL |
|      |                        | payment made on behalf of a Medicare |
|      |                        | beneficiary that the provider is     |
|      |                        | applying to Medicare charges on this |
|      |                        | bill. If six zeros are entered in    |
|      |                        | the amount field, the provider is    |
|      |                        | claiming a conditional payment       |
|      |                        | because there has been a substantial |
|      |                        | delay in its payment.                |
+------+------------------------+--------------------------------------+
| 42   | Veterans Affairs       | Code indicates the amount shown is   |
|      |                        | that portion of a higher priority VA |
|      |                        | payment made on behalf of a disabled |
|      |                        | beneficiary that the provider is     |
|      |                        | applying to Medicare charges on this |
|      |                        | bill.                                |
+------+------------------------+--------------------------------------+
| 43   | Disable beneficiary    | Code indicates the amount shown is   |
|      | under age 65 with LGHP | that portion of a higher priority    |
|      |                        | LGHP payment made on behalf of a     |
|      |                        | disabled beneficiary that the        |
|      |                        | provider is applying to Medicare     |
|      |                        | charges on this bill.                |
+------+------------------------+--------------------------------------+
| 44   | Amount provider agreed | Code indicates the amount shown is   |
|      | to accept from primary | the amount the provider was          |
|      | payer when this amount | obligated or required to accept from |
|      | is less than charges   | a primary payer as payment in full   |
|      | but higher than        | when that that amount is less than   |
|      | payment received       | the charges but higher than amount   |
|      |                        | actually received. A Medicare        |
|      |                        | secondary payment is due.            |
+------+------------------------+--------------------------------------+
| 46   | Number of grace days   | A code "C3" or "C4" is in FL 24-30   |
|      |                        | (condition code) indicating that the |
|      |                        | PRO has denied all or a portion of   |
|      |                        | the billing period.                  |
+------+------------------------+--------------------------------------+
| 47   | Any liability          | Code indicates amount shown is that  |
|      | insurance              | portion from a higher priority       |
|      |                        | liability insurance made on behalf   |
|      |                        | of a Medicare beneficiary that the   |
|      |                        | provider is applying to Medicare     |
|      |                        | covered services on this bill. If    |
|      |                        | six zeros are entered in the amount  |
|      |                        | field, the provider is claiming      |
|      |                        | conditional payment because there    |
|      |                        | has been substantial delay in the    |
|      |                        | other payer's payment.               |
+------+------------------------+--------------------------------------+
| 48   | Hemoglobin reading     | Code indicates the latest hemoglobin |
|      |                        | reading taken during this billing    |
|      |                        | cycle. This is usually reported in   |
|      |                        | three positions (a percentage) to    |
|      |                        | the left of the dollar/cent          |
|      |                        | delimiter. If the reading is         |
|      |                        | provided with a decimal, use the     |
|      |                        | position to the right of the         |
|      |                        | delimiter for the third digit.       |
+------+------------------------+--------------------------------------+
| 49   | Hematocrit reading     | Code indicates the latest hematocrit |
|      |                        | reading taken during this billing    |
|      |                        | cycle. This is usually reported in   |
|      |                        | two positions (a percentage) to the  |
|      |                        | left of the dollar/cent delimiter.   |
|      |                        | If the reading is provided with a    |
|      |                        | decimal, use the position to the     |
|      |                        | right of the delimiter for the third |
|      |                        | digit.                               |
+------+------------------------+--------------------------------------+
| 50   | Physical therapy       | Code indicates the number of         |
|      | visits                 | physical therapy visits from onset   |
|      |                        | through this billing period.         |
+------+------------------------+--------------------------------------+
| 51   | Occupational therapy   | Code indicates the number of         |
|      | visits                 | occupational therapy visits from     |
|      |                        | onset through this billing period.   |
+------+------------------------+--------------------------------------+
| 52   | Speech therapy visits  | Code indicates the number of speech  |
|      |                        | therapy visits from onset through    |
|      |                        | this billing period.                 |
+------+------------------------+--------------------------------------+
| 53   | Cardiac rehabilitation | Code indicates the number of cardiac |
|      | visits                 | rehabilitation visits from onset     |
|      |                        | through this billing period.         |
+------+------------------------+--------------------------------------+
| 54   | Newborn birth weight   | Actual birth weight or weight at     |
|      | in grams               | time of admission for an extramural  |
|      |                        | birth. Required on all claims with   |
|      |                        | type of admission of 4 and on other  |
|      |                        | claims as required by state law.     |
+------+------------------------+--------------------------------------+
| 55   | Eligibility threshold  | Code identifies the corresponding    |
|      | for charity care       | value amount at which a health care  |
|      |                        | facility determines the eligibility  |
|      |                        | threshold for charity care.          |
+------+------------------------+--------------------------------------+
| 56   | Skilled nurse-home     | Number of skilled hours during the   |
|      | visit hours (HHA only) | billing period. Count only hours     |
|      |                        | spent in the home. Exclude travel    |
|      |                        | time. Report in hours.               |
+------+------------------------+--------------------------------------+
| 57   | Home health aide-home  | Number of hours of home health aide  |
|      | visit hours (HHA only) | services provided during the billing |
|      |                        | period. Count only hours spent in    |
|      |                        | the home. Exclude travel time.       |
|      |                        | Report in hours.                     |
+------+------------------------+--------------------------------------+
| 58   | Arterial blood gas     | Code indicates arterial blood gas    |
|      | (PO2/PA2)              | value at the beginning of each       |
|      |                        | reporting period for oxygen therapy. |
+------+------------------------+--------------------------------------+
| 59   | Oxygen saturation (02  | Code indicates oxygen saturation at  |
|      | Sat/oximetry)          | the beginning of each reporting      |
|      |                        | period for oxygen therapy.           |
+------+------------------------+--------------------------------------+
| 60   | HHA branch MSA         | Code indicates MSA in which HHS      |
|      |                        | branch is located.                   |
+------+------------------------+--------------------------------------+
| 61   | Location where service | MSA number (or rural state code) of  |
|      | is furnished (HHA and  | the location where the home health   |
|      | hospice)               | or hospice service is delivered.     |
+------+------------------------+--------------------------------------+
| 6    | Payer codes only       |                                      |
| 2-65 |                        |                                      |
+------+------------------------+--------------------------------------+
| 66   | Medicaid spend down    | The dollar amount that was used to   |
|      | amount                 | meet the recipient's spend down      |
|      |                        | liability for this claim             |
+------+------------------------+--------------------------------------+
| 67   | Peritoneal dialysis    | The number of hours of peritoneal    |
|      |                        | dialysis provided during the billing |
|      |                        | period.                              |
+------+------------------------+--------------------------------------+
| 68   | Number of units of EPO | Self-explanatory. Reported in whole  |
|      | provided during the    | units.                               |
|      | billing period         |                                      |
+------+------------------------+--------------------------------------+
| 69   | State charity care     | Code indicates the percentage of     |
|      | percent                | charity care eligibility for the     |
|      |                        | patient. Report the whole number.    |
+------+------------------------+--------------------------------------+
| 70   | Interest amount        | (For internal use by third party     |
|      |                        | payers only)                         |
+------+------------------------+--------------------------------------+
| 71   | Funding of ESRD        | (For internal use by third party     |
|      | networks               | payers only)                         |
+------+------------------------+--------------------------------------+
| 72   | Flat rate surgery      | Code indicates the amount of the     |
|      | charge                 | standard charge for outpatient       |
|      |                        | surgery where the hospital has such  |
|      |                        | a charging structure.                |
+------+------------------------+--------------------------------------+
| 75   | Gramm/Rudman/Hollings  | (For internal use by third party     |
|      |                        | payers only)                         |
+------+------------------------+--------------------------------------+
| 76   | Provider's interim     | (For internal use by third party     |
|      | rate                   | payers only) Report the provider's   |
|      |                        | percentage of billed charges interim |
|      |                        | rate during this period.             |
+------+------------------------+--------------------------------------+
| 7    | Payer codes            |                                      |
| 7-79 |                        |                                      |
+------+------------------------+--------------------------------------+
| A0   | Special zip code       | Five digit zip code of the location  |
|      | reporting              | from which the beneficiary is        |
|      |                        | initially placed on board the        |
|      |                        | ambulance.                           |
+------+------------------------+--------------------------------------+
| A1   | Deductible Payer A     | The amount assumed by the provider   |
|      |                        | to be applied to the patient's       |
|      |                        | deductible amount involving the      |
|      |                        | indicated payer.                     |
+------+------------------------+--------------------------------------+
| A2   | Coinsurance Payer A    | The amount assumed by the provider   |
|      |                        | to be applied to the patient's       |
|      |                        | coinsurance amount involving the     |
|      |                        | indicated payer.                     |
+------+------------------------+--------------------------------------+
| A3   | Estimated              | The amount estimated by the provider |
|      | responsibility Payer A | to be paid by the indicated payer.   |
+------+------------------------+--------------------------------------+
| A4   | Covered                | The amount included in covered       |
|      | self-administrable     | charges for self-administrable drugs |
|      | drugs-emergency        | administered to the patient in an    |
|      |                        | emergency situation.                 |
+------+------------------------+--------------------------------------+
| A5   | Covered                | The amount included in covered       |
|      | self-administrable     | charges for self-administrable drugs |
|      | drugs -- not           | administered to the patient because  |
|      | self-administrable in  | the drug was not self-administrable  |
|      | form and situation     | in the form and situation in which   |
|      | furnished to patient   | it was furnished to the patient.     |
+------+------------------------+--------------------------------------+
| A6   | Covered                | The amount included in covered       |
|      | self-administrable     | charges for self-administrable drugs |
|      | drugs -- diagnostic    | administered to the patient because  |
|      | study and other        | the drug was necessary for           |
|      |                        | diagnostic study or other reason.    |
+------+------------------------+--------------------------------------+
| A7   | Co-payment A           | The amount assumed by the provider   |
|      |                        | to be applied toward the patient's   |
|      |                        | coinsurance amount involving the     |
|      |                        | indicated payer.                     |
+------+------------------------+--------------------------------------+
| A    |                        | Reserved for National Assignment     |
| 8-A9 |                        |                                      |
+------+------------------------+--------------------------------------+
| AA   | Regulatory surcharges, | Self-explanatory                     |
|      | assessments,           |                                      |
|      | allowances or health   |                                      |
|      | care related taxes     |                                      |
|      | Payer A                |                                      |
+------+------------------------+--------------------------------------+
| AB   | Other assessments or   | Self-explanatory                     |
|      | allowances (e.g.,      |                                      |
|      | Medical Education),    |                                      |
|      | Payer A                |                                      |
+------+------------------------+--------------------------------------+
| A    |                        | Reserved for National Assignment     |
| C-AZ |                        |                                      |
+------+------------------------+--------------------------------------+
|      |                        | NOTE: B1-C0 is the same as Payer A   |
|      |                        | except for Payer B.                  |
|      |                        |                                      |
|      |                        | C1-DZ is the same as Payer A except  |
|      |                        | for Payer C                          |
|      |                        |                                      |
|      |                        | E0-F0 is the same as Payer A except  |
|      |                        | for Payer D                          |
|      |                        |                                      |
|      |                        | F1-GB is the same as Payer A except  |
|      |                        | for Payer E                          |
+------+------------------------+--------------------------------------+
| G    |                        | Reserved for National Assignment     |
| C-GZ |                        |                                      |
+------+------------------------+--------------------------------------+
| H    |                        | Reserved for National Assignment     |
| 0-WZ |                        |                                      |
+------+------------------------+--------------------------------------+
| X    |                        | Reserved for National Assignment     |
| 0-ZZ |                        |                                      |
+------+------------------------+--------------------------------------+

[]{#__RefHeading___Toc143579369 .anchor}FL42 -- Revenue Code

*Required*. For each cost center for which a separate charge is billed
(type of accommodation or ancillary), a revenue code is assigned.

Additionally, there is no fixed "Total" line in the charge area.
Instead, revenue code "0001" is always entered last in FL 42. Zero level
billing is encouraged for all services which do not require HCPC codes.

+------------+---------------------------------------------------------+
| Code       | Title/Definition                                        |
+------------+---------------------------------------------------------+
| 0001       | **Total Charge**                                        |
|            |                                                         |
|            | For use on paper claims only. For electronic            |
|            | transactions, report the total charge in the            |
|            | appropriate data segment/field.                         |
+------------+---------------------------------------------------------+
| 001X       | Reserved for internal payer use                         |
+------------+---------------------------------------------------------+
| 002X       | **Health Insurance Prospective Payment System**         |
|            |                                                         |
|            | Subcatetory                                             |
|            |                                                         |
|            | 0 -- Reserved                                           |
|            |                                                         |
|            | 1 -- Reserved                                           |
|            |                                                         |
|            | 2 -- Skilled Nursing Facility PPS                       |
|            |                                                         |
|            | 3 -- Home Health PPS                                    |
|            |                                                         |
|            | 4 -- Inpatient Rehabilitation Facility PPS              |
|            |                                                         |
|            | 5-9 -- Reserved                                         |
+------------+---------------------------------------------------------+
| 003X to    | Reserved for national assignment                        |
| 006X       |                                                         |
+------------+---------------------------------------------------------+
| 007X to    | Reserved for state use.                                 |
| 009X       |                                                         |
+------------+---------------------------------------------------------+
| 010X       | **All Inclusive Rate**                                  |
|            |                                                         |
|            | Flat fee charge incurred on either a daily basis or     |
|            | total stay basis for services rendered. Charge may      |
|            | cover room and board plus ancillary services or room    |
|            | and board only.                                         |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- All-inclusive room and board plus ancillary        |
|            |                                                         |
|            | 1 -- All-inclusive room and board                       |
+------------+---------------------------------------------------------+
| 011X       | **Room & Board -- Private** (Medical or General)        |
|            |                                                         |
|            | Routine service charges for single bed rooms. Most      |
|            | payers require private rooms to be separately           |
|            | identified.                                             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Medical/Surgical/Gyn                               |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 6 0 Detoxification                                      |
|            |                                                         |
|            | 7 -- Oncology                                           |
|            |                                                         |
|            | 8 -- Rehabilitation                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 012X       | **Room & Board -- Semi-private two bed** (Medical or    |
|            | General)                                                |
|            |                                                         |
|            | Routine service chares incurred for accommodations with |
|            | two beds. Most payers require that semi-private rooms   |
|            | be identified.                                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Medical/Surgical/Gyn                               |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 6 -- Detoxification                                     |
|            |                                                         |
|            | 7 -- Oncology                                           |
|            |                                                         |
|            | 8 -- Rehabilitation                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 013X       | **Semi-Private -- Three and Four Beds**                 |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Medical/Surgical/Gyn                               |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 6 -- Detoxification                                     |
|            |                                                         |
|            | 7 -- Oncology                                           |
|            |                                                         |
|            | 8 -- Rehabilitation                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 014X       | **Private (Deluxe)**                                    |
|            |                                                         |
|            | Deluxe rooms are accommodations with amenities          |
|            | substantially in excess of that provider to other       |
|            | patients\...                                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Medical/Surgical/Gyn                               |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 6 -- Detoxification                                     |
|            |                                                         |
|            | 7 -- Oncology                                           |
|            |                                                         |
|            | 8 -- Rehabilitation                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 015X       | **Room & Board Ward (Medical or General)**              |
|            |                                                         |
|            | Routine service charge for accommodations with five or  |
|            | more beds.                                              |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Medical/Surgical/Gyn                               |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 6 -- Detoxification                                     |
|            |                                                         |
|            | 7 -- Oncology                                           |
|            |                                                         |
|            | 8 -- Rehabilitation                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 016X       | **Other Room & Board**                                  |
|            |                                                         |
|            | Any routine service charges for accommodations that     |
|            | cannot be included in the more specific revenue codes.  |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 4 -- Sterile Environment                                |
|            |                                                         |
|            | 7 -- Self Care                                          |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 017X       | **Nursery**                                             |
|            |                                                         |
|            | Charges for nursing care to newborn and premature       |
|            | infants in nurseries.                                   |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Newborn, Level I -- Routine care                   |
|            |                                                         |
|            | 2 -- Newborn, Level II -- Low-birth-weight neonates who |
|            | are not sick but require frequent feeding and care      |
|            |                                                         |
|            | 3 -- Newborn , Level III -- Sick neonates who do not    |
|            | require intensive care, but require 6-12 hours of       |
|            | nursing care                                            |
|            |                                                         |
|            | 4 -- Newborn, Level IV -- Constant nursing and          |
|            | continuous cardiopulmonary and other support for        |
|            | severely ill infants                                    |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 018X       | **Leave of Absence**                                    |
|            |                                                         |
|            | Charges (including zero charges) for holding a room     |
|            | while the patient is temporarily away from the          |
|            | provider. Charges are billable for codes 2-5.           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Reserved                                           |
|            |                                                         |
|            | 2 -- Patient Convenience                                |
|            |                                                         |
|            | 3 -- Therapeutic Leave                                  |
|            |                                                         |
|            | 4 -- ICF Mentally Retarded -- any reason                |
|            |                                                         |
|            | 5 -- Nursing Home (hospitalization)                     |
|            |                                                         |
|            | 9 -- Other leave of absence                             |
+------------+---------------------------------------------------------+
| 019X       | **Subacute Care**                                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Subacute Care, Level I -- Skilled Care (minimal    |
|            | nursing intervention)                                   |
|            |                                                         |
|            | 2 -- Subacute Care, Level II -- Comprehensive Care      |
|            | (Moderate to extensive nursing intervention)            |
|            |                                                         |
|            | 3 -- Subacute Care, Level III -- Complex Care (Moderate |
|            | to extensive nursing intervention)                      |
|            |                                                         |
|            | 4 -- Subacute Care, Level IV -- Intensive Care          |
|            | (Extensive nursing and technical intervention)          |
|            |                                                         |
|            | 9 -- Other Subacute Care                                |
+------------+---------------------------------------------------------+
| 020X       | **Intensive Care**                                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Surgical                                           |
|            |                                                         |
|            | 2 -- Medical                                            |
|            |                                                         |
|            | 3 -- Pediatric                                          |
|            |                                                         |
|            | 4 -- Psychiatric                                        |
|            |                                                         |
|            | 6 -- Intermediate ICU                                   |
|            |                                                         |
|            | 7- Burn Care                                            |
|            |                                                         |
|            | 8 -- Trauma                                             |
|            |                                                         |
|            | 9 -- Other Intensive Care                               |
+------------+---------------------------------------------------------+
| 021X       | **Coronary Care**                                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Myocardial infarction                              |
|            |                                                         |
|            | 2 -- Pulmonary Care                                     |
|            |                                                         |
|            | 3 -- Heart Transplant                                   |
|            |                                                         |
|            | 4 -- Intermediate CCU                                   |
|            |                                                         |
|            | 9 -- Other Coronary Care                                |
+------------+---------------------------------------------------------+
| 022X       | **Special Charges**                                     |
|            |                                                         |
|            | Some hospitals prefer to break out charges that are     |
|            | normally considered part of routine services.           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Admission Charge                                   |
|            |                                                         |
|            | 2 -- Technical Support Charge                           |
|            |                                                         |
|            | 3 -- U.R. Service Charge                                |
|            |                                                         |
|            | 4 -- Late Discharge, medically necessary                |
|            |                                                         |
|            | 9 -- Other Special Charge                               |
+------------+---------------------------------------------------------+
| 023X       | **Incremental Nursing Charge Rate**                     |
|            |                                                         |
|            | Charge for nursing service assessed in addition to room |
|            | and board                                               |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Nursery                                            |
|            |                                                         |
|            | 2 -- OB                                                 |
|            |                                                         |
|            | 3 -- ICU (includes transitional care)                   |
|            |                                                         |
|            | 4 -- CCU (includes transitional care)                   |
|            |                                                         |
|            | 5 -- Hospice                                            |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 024X       | **All Inclusive Ancillary**                             |
|            |                                                         |
|            | A flat rate charge incurred on either a daily basis or  |
|            | total stay basis for ancillary services only.           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Basic                                              |
|            |                                                         |
|            | 2 -- Comprehensive                                      |
|            |                                                         |
|            | 3 -- Specialty                                          |
|            |                                                         |
|            | 9 -- Other All Inclusive Ancillary                      |
+------------+---------------------------------------------------------+
| 025X       | **Pharmacy**                                            |
|            |                                                         |
|            | Code indicates the charges for medication produced,     |
|            | manufactured, packaged, controlled, assayed, dispensed, |
|            | and distributed under the direction of a licensed       |
|            | pharmacist.                                             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Generic Drugs                                      |
|            |                                                         |
|            | 2 -- Nongeneric Drugs                                   |
|            |                                                         |
|            | 3 -- Take Home Drugs                                    |
|            |                                                         |
|            | 4 -- Drugs Incident to Other Diagnostic Services        |
|            |                                                         |
|            | 5 -- Drugs Incident to Radiology                        |
|            |                                                         |
|            | 6 -- Experimental Drugs                                 |
|            |                                                         |
|            | 7 -- Nonprescription                                    |
|            |                                                         |
|            | 8 -- IV Solutions                                       |
|            |                                                         |
|            | 9 -- Other Pharmacy                                     |
+------------+---------------------------------------------------------+
| 026X       | **IV Therapy**                                          |
|            |                                                         |
|            | Code indicates the administration of intravenous        |
|            | solution by specialty trained personnel to individuals  |
|            | requiring such treatment.                               |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Infusion Pump                                      |
|            |                                                         |
|            | 2 -- IV Therapy/Pharmacy Services                       |
|            |                                                         |
|            | 3 -- IV Therapy/Drug/Supply/Delivery                    |
|            |                                                         |
|            | 4 -- IV Therapy/Supplies                                |
|            |                                                         |
|            | 9 -- Other IV Therapy                                   |
+------------+---------------------------------------------------------+
| 027X       | **Medical/Surgical Supplies**                           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Nonsterile Supply                                  |
|            |                                                         |
|            | 2 -- Sterile Supple                                     |
|            |                                                         |
|            | 3 -- Take Home Supplies                                 |
|            |                                                         |
|            | 4 -- Prosthetic/Orthotic Devices                        |
|            |                                                         |
|            | 5 -- Pacemaker                                          |
|            |                                                         |
|            | 6 -- Intraocular Lens                                   |
|            |                                                         |
|            | 7 -- Oxygen-Take Home                                   |
|            |                                                         |
|            | 8 -- Other Implants                                     |
+------------+---------------------------------------------------------+
| 028X       | **Oncology**                                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | O -- General Classification                             |
|            |                                                         |
|            | 9 -- Other Oncology                                     |
+------------+---------------------------------------------------------+
| 029X       | **Durable medical Equipment (DME**) (Other than Rental) |
|            |                                                         |
|            | Equipment that can stand repeated use.                  |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Rental                                             |
|            |                                                         |
|            | 2 -- Purchase of new DME                                |
|            |                                                         |
|            | 3 -- Purchase of used DME                               |
|            |                                                         |
|            | 4 -- Supplies/Drugs for DME Effectiveness (HHAs only)   |
|            |                                                         |
|            | 9 -- Other Equipment                                    |
+------------+---------------------------------------------------------+
| 030X       | **Laboratory**                                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Chemistry                                          |
|            |                                                         |
|            | 2 -- Immunology lab                                     |
|            |                                                         |
|            | 3 -- Renal patient (Home)                               |
|            |                                                         |
|            | 4 -- Nonroutine Dialysis                                |
|            |                                                         |
|            | 5 -- Hematology                                         |
|            |                                                         |
|            | 6 -- Bacteriology & Microbiology                        |
|            |                                                         |
|            | 7 -- Urology                                            |
|            |                                                         |
|            | 9 -- Other Laboratory                                   |
+------------+---------------------------------------------------------+
| 031X       | **Laboratory Pathological**                             |
|            |                                                         |
|            | Tests on tissues and cultures.                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- cytology                                           |
|            |                                                         |
|            | 2 -- Histology                                          |
|            |                                                         |
|            | 4 -- Biopsy                                             |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 032X       | **Radiology -- Diagnostic**                             |
|            |                                                         |
|            | Includes taking, processing, examining, and             |
|            | interpreting radiographs and fluorographs.              |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Angiocardiography                                  |
|            |                                                         |
|            | 2 -- Arthrography                                       |
|            |                                                         |
|            | 3 -- Arteriography                                      |
|            |                                                         |
|            | 4 -- Chest X-ray                                        |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 033X       | **Radiology -- Therapeutic**                            |
|            |                                                         |
|            | Includes injection or ingestion of radioactive          |
|            | substances.                                             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Chemotherapy -- Injected                           |
|            |                                                         |
|            | 2 -- Chemotherapy -- oral                               |
|            |                                                         |
|            | 3 -- Radiation Therapy                                  |
|            |                                                         |
|            | 4 -- Chemotherapy -- IV                                 |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 034X       | **Nuclear Medicine**                                    |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Diagnostic                                         |
|            |                                                         |
|            | 2 -- Therapeutic                                        |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 035X       | **CT Scan**                                             |
|            |                                                         |
|            | Due to coverage limitations, some insurers require that |
|            | the specific test be identified.                        |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Head Scan                                          |
|            |                                                         |
|            | 2 -- Body Scan                                          |
|            |                                                         |
|            | 0 -- Other CT Scan                                      |
+------------+---------------------------------------------------------+
| 036X       | **Operating Room**                                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Minor Surgery                                      |
|            |                                                         |
|            | 2 -- Organ Transplant -- other than kidney              |
|            |                                                         |
|            | 7 -- Kidney Transplant                                  |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 037X       | **Anesthesia**                                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Anesthesia Incident to Radiology                   |
|            |                                                         |
|            | 2 -- Anesthesia Incident to other Diagnostic Services   |
|            |                                                         |
|            | 4 -- Acupuncture                                        |
|            |                                                         |
|            | 9 -- Other Anesthesia                                   |
+------------+---------------------------------------------------------+
| 038X       | **Blood**                                               |
|            |                                                         |
|            | Charges for blood must be separately identified.        |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Packed Red Cells                                   |
|            |                                                         |
|            | 2 -- Whole Blood                                        |
|            |                                                         |
|            | 3 -- Plasma                                             |
|            |                                                         |
|            | 4 -- Platelets                                          |
|            |                                                         |
|            | 5 -- leucocytes                                         |
|            |                                                         |
|            | 6 -- Other Components                                   |
|            |                                                         |
|            | 7 -- Other Derivatives (Cryopricipitates)               |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 039X       | **Blood Storage and processing**                        |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Blood Administration (transfusion)                 |
|            |                                                         |
|            | 9 -- Other Processing & Storage                         |
+------------+---------------------------------------------------------+
| 040X       | **Other Imaging Services**                              |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Diagnostic mammography                             |
|            |                                                         |
|            | 2 -- Ultrasound                                         |
|            |                                                         |
|            | 3 -- Screening Mammography                              |
|            |                                                         |
|            | 4 -- Positron Emission Tomography                       |
|            |                                                         |
|            | 9 -- Other Imaging Services                             |
+------------+---------------------------------------------------------+
| 041X       | **Respiratory Services**                                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Inhalation Services                                |
|            |                                                         |
|            | 2 -- Hyperbaric Oxygen Therapy                          |
|            |                                                         |
|            | 9 -- Other Respiratory Services                         |
+------------+---------------------------------------------------------+
| 042X       | **Physical Therapy**                                    |
|            |                                                         |
|            | Charges for therapeutic exercises, massage, and         |
|            | utilization of effective properties of light, heat,     |
|            | cold, water, electricity, and assistive devices for     |
|            | diagnosis and rehabilitation of patients who have       |
|            | neuromuscular, orthopedic, and other disabilities.      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General classification                             |
|            |                                                         |
|            | 1 -- Visit Charge                                       |
|            |                                                         |
|            | 2 -- Hourly charge                                      |
|            |                                                         |
|            | 3 -- Group Rate                                         |
|            |                                                         |
|            | 4 -- Evaluation or Re-evaluation                        |
|            |                                                         |
|            | 9 -- Other Physical Therapy                             |
+------------+---------------------------------------------------------+
| 043X       | **Occupational Therapy**                                |
|            |                                                         |
|            | Services provided by a qualified occupational therapy   |
|            | practitioner for therapeutic interventions to improve,  |
|            | sustain, or restore an individual's level of function   |
|            | in performance of activities of daily living and work,  |
|            | including, therapeutic activities, therapeutic          |
|            | exercises, sensorimotor processing, psychosocial skills |
|            | training, cognitive retraining, fabrication and         |
|            | application of orthotic devices, and training in the    |
|            | use of orthotic and prosthetic devices, adaptation of   |
|            | environments, and application of physical agent         |
|            | modalities.                                             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Visit Charge                                       |
|            |                                                         |
|            | 2 -- Hourly Charge                                      |
|            |                                                         |
|            | 3 -- Group Rate                                         |
|            |                                                         |
|            | 4 -- Evaluation or Re-evaluation                        |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 044X       | **Speech-Language Pathology**                           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Visit Charge                                       |
|            |                                                         |
|            | 2 -- Hourly Charge                                      |
|            |                                                         |
|            | 3 -- Group Rate                                         |
|            |                                                         |
|            | 4 -- Evaluation or Re-evaluation                        |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 045X       | **Emergency Room**                                      |
|            |                                                         |
|            | Under the provisions of EMTALA (Emergency Medical       |
|            | Treatment and Active Labor Act), a hospital with an     |
|            | emergency department must provide upon request and      |
|            | within the capabilities of the hospital an appropriate  |
|            | medical screening examination and stabilizing treatment |
|            | to any individual with an emergency medical condition   |
|            | and to any woman in active labor, regardless of the     |
|            | individual's eligibility for Medicare.                  |
|            |                                                         |
|            | Observation or "hold beds" are not reported under this  |
|            | code. They are reported under revenue code 762.         |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- EMTALA Emergency Medical screening services        |
|            |                                                         |
|            | 2 -- ER beyond EMTALA Screening                         |
|            |                                                         |
|            | 6 -- Urgent Care                                        |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 046X       | **Pulmonary Function**                                  |
|            |                                                         |
|            | Charges for tests that measure inhaled and exhaled      |
|            | gases and analysis of blood and for tests that evaluate |
|            | the patient's ability to exchange oxygen and other      |
|            | gases.                                                  |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 047X       | **Audiology**                                           |
|            |                                                         |
|            | Charges for the detection and management of             |
|            | communication handicaps centering in whole or in part   |
|            | on the hearing function.                                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Diagnostic                                         |
|            |                                                         |
|            | 2 -- Treatment                                          |
|            |                                                         |
|            | 9 -- Other Audiology                                    |
+------------+---------------------------------------------------------+
| 048X       | **Cardiology**                                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Cardiac Cath Lab                                   |
|            |                                                         |
|            | 2 -- Stress Test                                        |
|            |                                                         |
|            | 3 -- Echocardiology                                     |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 049X       | **Ambulatory Surgical Care**                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 050X       | **Outpatient Services**                                 |
|            |                                                         |
|            | Outpatient charges for services rendered to an          |
|            | outpatient who is admitted as an inpatient before       |
|            | midnight of the day following the date of service. This |
|            | revenue code is no longer used for Medicare.            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General                                            |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 051X       | **Clinic**                                              |
|            |                                                         |
|            | Clinic (non-emergency/scheduled outpatient visit)       |
|            | charges for providing diagnostic, preventive, curative, |
|            | rehabilitative, and education services to ambulatory    |
|            | patients.                                               |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Chronic Pain Center                                |
+------------+---------------------------------------------------------+
| 052X       | **Free-Standing Clinic**                                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Rural Health -- Clinic                             |
|            |                                                         |
|            | 2 -- Rural Health -- Home                               |
|            |                                                         |
|            | 3 -- Family Practice Clinic                             |
|            |                                                         |
|            | 6 -- Urgent Care Clinic                                 |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 053X       | **Osteopathic Services**                                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Osteopathic Therapy                                |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 054X       | **Ambulance**                                           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Supplies                                           |
|            |                                                         |
|            | 2 -- Medical Transport                                  |
|            |                                                         |
|            | 3 -- Heart Mobile                                       |
|            |                                                         |
|            | 4 -- Oxygen                                             |
|            |                                                         |
|            | 5 -- Air Ambulance                                      |
|            |                                                         |
|            | 6 -- Neo-natal Ambulance                                |
|            |                                                         |
|            | 7 -- Pharmacy                                           |
|            |                                                         |
|            | 8 -- Telephone Transmission EKG                         |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 056X       | **Medical Social Services**                             |
|            |                                                         |
|            | Charges for services such as counseling patients,       |
|            | interviewing patients, and interpreting problems of a   |
|            | social situation to patients on any basis.              |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Visit Charge                                       |
|            |                                                         |
|            | 2 -- Hourly Charge                                      |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 057X       | **Home Health Aide (Home Health)**                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Visit charge                                       |
|            |                                                         |
|            | 2 -- Hourly charge                                      |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 058X       | **Other Visits (Home Health)**                          |
|            |                                                         |
|            | Code indicates the charges by an HHA for visits other   |
|            | than physical therapy, occupational therapy, or speech  |
|            | therapy, which must be specifically identified.         |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Visit Charge                                       |
|            |                                                         |
|            | 2 -- Hourly Charge                                      |
|            |                                                         |
|            | 3 -- Assessment                                         |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 059X       | **Units of Service (Home Health)**                      |
|            |                                                         |
|            | This revenue code is used by an HHA that bills on the   |
|            | basis of units of service.                              |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Home Health other                                  |
+------------+---------------------------------------------------------+
| 060X       | **Oxygen (Home Health)**                                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Oxygen -- Stat/Equip/Suppl or Cont.                |
|            |                                                         |
|            | 2 -- Oxygen -- Stat/Equip/Suppl under 1 LPM             |
|            |                                                         |
|            | 3 -- Oxygen -- Stat/Equip/Over 4 LPM                    |
|            |                                                         |
|            | 4 -- Oxygen -- Portable Add-on                          |
+------------+---------------------------------------------------------+
| 061X       | **Magnetic Resonance Technology (MRT)**                 |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Brain                                              |
|            |                                                         |
|            | 2 -- Spinal Cord                                        |
|            |                                                         |
|            | 3 -- Reserved                                           |
|            |                                                         |
|            | 4 -- MRI -- Other                                       |
|            |                                                         |
|            | 5 -- MRA Head and Neck                                  |
|            |                                                         |
|            | 6 -- MRA -- Lower Extremities                           |
|            |                                                         |
|            | 7 -- Reserved                                           |
|            |                                                         |
|            | 8 -- MRA -- Other                                       |
|            |                                                         |
|            | 9 -- Other MRI                                          |
+------------+---------------------------------------------------------+
| 062X       | **Medical/Surgical Supplies** -- Extension of 027X      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 1 -- Supplies Incident to Radiology                     |
|            |                                                         |
|            | 2 -- Supplies Incident to Other Diagnostic Services     |
|            |                                                         |
|            | 3 -- Surgical Dressings                                 |
|            |                                                         |
|            | 4 -- Investigational Device                             |
+------------+---------------------------------------------------------+
| 063X       | **Pharmacy -- Extension of 025X**                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- Reserved                                           |
|            |                                                         |
|            | 1 -- Single Source Drug                                 |
|            |                                                         |
|            | 2 -- Multiple Source Drug                               |
|            |                                                         |
|            | 3 -- Restrictive Prescription                           |
|            |                                                         |
|            | 4 -- Erythroepoetin (EPO) less than 10,000 units        |
|            |                                                         |
|            | 5 -- Erythroepoetin (EPO) 10,000 or more units          |
|            |                                                         |
|            | 6 -- Drugs requiring detailed coding\*                  |
|            |                                                         |
|            | 7 -- Self-administrable Drugs                           |
|            |                                                         |
|            | \*Revenue code 636 relates to HCPCS code, so HCPCS is   |
|            | the recommended code to be used in FL 44. The specified |
|            | units of service to be reported are to be in hundreds   |
|            | rounded to the nearest hundred.                         |
+------------+---------------------------------------------------------+
| 064X       | **Home IV Therapy Services**                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 - Nonroutine Nursing Central Line                     |
|            |                                                         |
|            | 2 -- IV Site Care, Central Line                         |
|            |                                                         |
|            | 3 -- IV Start/Change Peripheral Line                    |
|            |                                                         |
|            | 4 -- Nonroutine Nursing, Peripheral Line                |
|            |                                                         |
|            | 5 -- Training patient/Caregiver Central line            |
|            |                                                         |
|            | 6 -- Training Disabled Patient, Central line            |
|            |                                                         |
|            | 7 -- Training Patient/Caregiver, Peripheral Line        |
|            |                                                         |
|            | 8 -- Training, Disabled Patient, Peripheral Line        |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 065X       | **Hospice Services**                                    |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Routine Home Care                                  |
|            |                                                         |
|            | 2 -- Continuous Home Care                               |
|            |                                                         |
|            | 3 -- Reserved                                           |
|            |                                                         |
|            | 4 -- Reserved                                           |
|            |                                                         |
|            | 5 -- Inpatient Respite Care                             |
|            |                                                         |
|            | 6 -- General Inpatient Care (non respite)               |
|            |                                                         |
|            | 7 -- Physician Services                                 |
|            |                                                         |
|            | 8 -- Hospice Room and Board                             |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 066X       | **Respite Care** (HHA only)                             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Hourly Charge/Nursing                              |
|            |                                                         |
|            | 2 - Hourly Charge/Aide/Homemaker/Companion              |
|            |                                                         |
|            | 3 -- Daily Respite Charge                               |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 067X       | **Outpatient Special Residence Charges**                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Hospital Based                                     |
|            |                                                         |
|            | 2 -- Contracted                                         |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 068X       | **Trauma Response**                                     |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- Not used                                           |
|            |                                                         |
|            | 1 -- Level I                                            |
|            |                                                         |
|            | 2 -- Level II                                           |
|            |                                                         |
|            | 3 -- Level III                                          |
|            |                                                         |
|            | 4 -- Level IV                                           |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 069X       | Not Assigned                                            |
+------------+---------------------------------------------------------+
| 070X       | **Cast Room**                                           |
|            |                                                         |
|            | Charges for services related to the application,        |
|            | maintenance, and removal of casts.                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 071X       | **Recovery Room**                                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 072X       | **Labor Room/Delivery**                                 |
|            |                                                         |
|            | Charges for labor and delivery room services are        |
|            | provided by specially trained nursing personnel to      |
|            | include prenatal, assistance during delivery and        |
|            | postnatal care.                                         |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Labor                                              |
|            |                                                         |
|            | 2 -- Delivery                                           |
|            |                                                         |
|            | 3 -- Circumcision                                       |
|            |                                                         |
|            | 4 -- Birthing Center                                    |
|            |                                                         |
|            | 9 -- Other                                              |
+------------+---------------------------------------------------------+
| 073X       | **EKG/ECG (Electrocardiogram)**                         |
|            |                                                         |
|            | Charges for operation of specialized equipment to       |
|            | record electromotive variations in actions of the heart |
|            | muscle on an electrocardiograph for diagnosis of heart  |
|            | ailments.                                               |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Holter Monitor                                     |
|            |                                                         |
|            | 2 -- Telemetry                                          |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 074X       | **EEG Electroencephalogram**                            |
|            |                                                         |
|            | Charges for operation of specialized equipment to       |
|            | measure impulse frequencies and differences in          |
|            | electrical potential in various areas of the brain to   |
|            | obtain data for use in diagnosing brain disorders.      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 075X       | **Gastro-Intestinal Services**                          |
|            |                                                         |
|            | Procedure room charges for endoscopic procedures not    |
|            | performed in an operating room.                         |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 9 -- Other Gastro-Intestinal                            |
+------------+---------------------------------------------------------+
| 076X       | **Treatment or Observation Room**                       |
|            |                                                         |
|            | Observation services are those services furnished by a  |
|            | hospital on the hospital's premises, including use of a |
|            | bed and periodic monitoring by a hospital's nursing or  |
|            | other staff, which are reasonable and necessary to      |
|            | evaluate an outpatient's condition or determine the     |
|            | need for a possible admission to the hospital as an     |
|            | inpatient.                                              |
|            |                                                         |
|            | Such services are covered only when provided by the     |
|            | order of a physician or another individual authorized   |
|            | by State licensure law and hospital staff bylaws to     |
|            | admit patients to the hospital or to order outpatient   |
|            | tests. Most observation services do not exceed one day. |
|            |                                                         |
|            | Some patients, however, may require a second day of     |
|            | outpatient observation services. The reasons for        |
|            | observation must be stated in the orders for            |
|            | observation.                                            |
|            |                                                         |
|            | Payers should establish written guidelines which        |
|            | identify coverage of observation services. Only 762     |
|            | should be used for observation services.                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Treatment Room                                     |
|            |                                                         |
|            | 2 -- Observation Room                                   |
|            |                                                         |
|            | 9 -- Other Treatment Room                               |
+------------+---------------------------------------------------------+
| 077X       | **Preventative Care Services**                          |
|            |                                                         |
|            | Charges for the administration of vaccines.             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Vaccine Administration                             |
|            |                                                         |
|            | 9 - Other                                               |
+------------+---------------------------------------------------------+
| 078X       | Telemedicine                                            |
|            |                                                         |
|            | Future Medicare Demonstration project                   |
+------------+---------------------------------------------------------+
| 079X       | **Extra-Corporeal Shock Wave Therapy** (formerly        |
|            | Lithotripsy)                                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 0 - Other                                               |
+------------+---------------------------------------------------------+
| 080X       | **Inpatient Renal Dialysis**                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Inpatient Hemodialysis                             |
|            |                                                         |
|            | 2 -- Inpatient Peritoneal (Non-CAPD)                    |
|            |                                                         |
|            | 3 -- Inpatient Continuous Ambulatory Peritoneal         |
|            | Dialysis (CAPD)                                         |
|            |                                                         |
|            | 4 -- Inpatient Continuous Cycling Peritoneal Dialysis   |
|            | (CCPD)                                                  |
|            |                                                         |
|            | 9 -- Other Inpatient Dialysis                           |
+------------+---------------------------------------------------------+
| 081X       | **Organ Acquisition**                                   |
|            |                                                         |
|            | The acquisition and storage costs of body tissue, bone  |
|            | marrow, organs and other body components not otherwise  |
|            | identified used for transplantation. Medicare requires  |
|            | detailed revenue coding. Therefore, codes for this      |
|            | series may not be summed at the zero level. Note:       |
|            | Revenue code 814 is used only when costs incurred for   |
|            | an organ search does not result in an eventual organ    |
|            | acquisition and transplantation.                        |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Living Donor                                       |
|            |                                                         |
|            | 2 -- Cadaver Donor                                      |
|            |                                                         |
|            | 3 -- Unknown Donor                                      |
|            |                                                         |
|            | 4 -- Unsuccessful Organ Search Donor Bank Charge        |
|            |                                                         |
|            | 9 -- Other Organ Donor                                  |
+------------+---------------------------------------------------------+
| 082X       | **Hemodialysis -- Outpatient or Home Dialysis**         |
|            |                                                         |
|            | A waste removal process performed in an outpatient or   |
|            | home setting, necessary when the body's own kidneys     |
|            | have failed.                                            |
|            |                                                         |
|            | Waste is removed directly from the blood. Detailed      |
|            | revenue coding is required. Therefore, services may not |
|            | be summed at the zero level.                            |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Hemodialysis/Composite or other rate               |
|            |                                                         |
|            | 2 -- Home Supplies                                      |
|            |                                                         |
|            | 3 -- Home Equipment                                     |
|            |                                                         |
|            | 4 -- Maintenance 100%                                   |
|            |                                                         |
|            | 5 -- Support Services                                   |
|            |                                                         |
|            | 9 -- Other Hemodialysis Outpatient                      |
+------------+---------------------------------------------------------+
| 083X       | **Peritoneal Dialysis -- Outpatient or Home**           |
|            |                                                         |
|            | A waste removal process performed in an outpatient or   |
|            | home setting, necessary when the body's own kidneys     |
|            | have failed.                                            |
|            |                                                         |
|            | Waste is removed indirectly by flushing a special       |
|            | solution between the abdominal covering and the tissue. |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Peritoneal/Composite or other rate                 |
|            |                                                         |
|            | 2 -- Home supplies                                      |
|            |                                                         |
|            | 3 -- Home Equipment                                     |
|            |                                                         |
|            | 4 -- Maintenance 100%                                   |
|            |                                                         |
|            | 5 -- Support Services                                   |
|            |                                                         |
|            | 9 -- Other Peritoneal Dialysis                          |
+------------+---------------------------------------------------------+
| 084X       | **Continuous Ambulatory Peritoneal Dialysis (CAPD) --   |
|            | Outpatient**                                            |
|            |                                                         |
|            | A continuous dialysis process performed in an           |
|            | outpatient or home setting, which uses the patient's    |
|            | peritoneal membrane as a dialyzer.                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- CAPD/Composite or other rate                       |
|            |                                                         |
|            | 2 -- Home Supplies                                      |
|            |                                                         |
|            | 3 -- Home Equipment                                     |
|            |                                                         |
|            | 4 -- Maintenance 100%                                   |
|            |                                                         |
|            | 5 -- Support Services                                   |
|            |                                                         |
|            | 9 -- Other CAPD Dialysis                                |
+------------+---------------------------------------------------------+
| 085X       | **Continuous Cycling Peritoneal Dialysis** (CCPD) --    |
|            | Outpatient                                              |
|            |                                                         |
|            | A continuous dialysis process performed in an           |
|            | outpatient or home setting, which uses the patient's    |
|            | peritoneal membrane as a dialyzer.                      |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- CCPD/Composite or other rate                       |
|            |                                                         |
|            | 2 -- Home Supplies                                      |
|            |                                                         |
|            | 3 -- Home Equipment                                     |
|            |                                                         |
|            | 4 -- Maintenance 100%                                   |
|            |                                                         |
|            | 5 -- Support Services                                   |
|            |                                                         |
|            | 9 -- Other CCPD Dialysis                                |
+------------+---------------------------------------------------------+
| 086X       | Reserved for Dialysis (National Assignment)             |
+------------+---------------------------------------------------------+
| 087X       | Reserved for Dialysis (State Assignment)                |
+------------+---------------------------------------------------------+
| 088X       | **Miscellaneous Dialysis**                              |
|            |                                                         |
|            | Charges for dialysis services not identified elsewhere. |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Ultra Filtration                                   |
|            |                                                         |
|            | 2 -- Home Dialysis Aid Visit                            |
|            |                                                         |
|            | 9 -- Miscellaneous Dialysis Other                       |
+------------+---------------------------------------------------------+
| 089X       | Reserved for National Assignment                        |
+------------+---------------------------------------------------------+
| 090X       | **Behavior Health Treatments/Services**                 |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Electroshock Treatment                             |
|            |                                                         |
|            | 2 -- Milieu Therapy                                     |
|            |                                                         |
|            | 3 -- Play Therapy                                       |
|            |                                                         |
|            | 4 -- Activity Therapy                                   |
|            |                                                         |
|            | 5 -- Intensive Outpatient Services -- Psychiatric       |
|            |                                                         |
|            | 6 -- Intensive Outpatient Services -- Chemical          |
|            | Dependency                                              |
|            |                                                         |
|            | 7 -- Community Behavioral Health Program (Day           |
|            | Treatment)                                              |
|            |                                                         |
|            | 8 -- Reserved for National Use                          |
|            |                                                         |
|            | 9 -- Reserved for National Use                          |
+------------+---------------------------------------------------------+
| 091X       | **Behavioral Health Treatment/Services -- Extension of  |
|            | 090X**                                                  |
|            |                                                         |
|            | Code indicates charges for providing nursing care and   |
|            | professional services for emotionally disturbed         |
|            | patient. This includes patients admitted for diagnosis  |
|            | and those admitted for treatment.                       |
|            |                                                         |
|            | Subcategories 0912 and 0913 are designed as zero-billed |
|            | revenue codes (no dollars in the amount field) to be    |
|            | used as a vehicle to supply program information as      |
|            | defined in the provider/payer contract. Note: Medicare  |
|            | does not recognize codes 912 and 913 services under its |
|            | partial hospitalization program.                        |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- Reserved for National Use                          |
|            |                                                         |
|            | 1 -- Rehabilitation                                     |
|            |                                                         |
|            | 2 -- partial Hospitalization -- Less Intensive          |
|            |                                                         |
|            | 3 -- Partial Hospitalization -- Intensive               |
|            |                                                         |
|            | 4 -- Individual Therapy                                 |
|            |                                                         |
|            | 5 -- Group Therapy                                      |
|            |                                                         |
|            | 6 -- Family Therapy                                     |
|            |                                                         |
|            | 7 -- Bio Feedback                                       |
|            |                                                         |
|            | 8 -- Testing                                            |
|            |                                                         |
|            | 9 -- Other Behavior Health Treatments/Services          |
+------------+---------------------------------------------------------+
| 092X       | **Other Diagnostic Services**                           |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Peripheral Vascular Lab                            |
|            |                                                         |
|            | 2 -- Electromyelogram                                   |
|            |                                                         |
|            | 3 -- Pap Smear                                          |
|            |                                                         |
|            | 4 -- Allergy Test                                       |
|            |                                                         |
|            | 5 -- Pregnancy Test                                     |
|            |                                                         |
|            | 9 -- Other Diagnostic Service                           |
+------------+---------------------------------------------------------+
| 093X       | **Medical Rehabilitation Day Program**                  |
|            |                                                         |
|            | Medical rehabilitation services as contracted with a    |
|            | payer and/or certified by the State. Services may       |
|            | include physical therapy, occupational therapy, and     |
|            | speech therapy.                                         |
|            |                                                         |
|            | The subcategories of 93X are designed as zero-billed    |
|            | revenue codes (no dollars in the amount field) to be    |
|            | used as a vehicle to supply program information as      |
|            | defined in the provider/payer contract. Therefore, zero |
|            | would be reported in FL 47 and the number of hours      |
|            | provided would be reported in FL 46. The specific       |
|            | rehabilitation services would be reported under the     |
|            | applicable therapy revenue codes as normal.             |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 1 -- Half Day                                           |
|            |                                                         |
|            | 2 -- Full Day                                           |
+------------+---------------------------------------------------------+
| 094X       | **Other Therapeutic Services**                          |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Recreational Therapy                               |
|            |                                                         |
|            | 2 -- Education/Training (includes diabetes related      |
|            | dietary therapy)                                        |
|            |                                                         |
|            | 3 -- Cardiac Rehabilitation                             |
|            |                                                         |
|            | 4 -- Drug Rehabilitation                                |
|            |                                                         |
|            | 5 -- Alcohol Rehabilitation                             |
|            |                                                         |
|            | 6 -- Complex Medical Equipment Routine                  |
|            |                                                         |
|            | 7 -- Complex Medical Equipment Ancillary                |
|            |                                                         |
|            | 9 -- Other Therapeutic Services                         |
+------------+---------------------------------------------------------+
| 095X       | **Other Therapeutic Services** (An extension of 94X)    |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- Reserved                                           |
|            |                                                         |
|            | 1 -- Athletic Training                                  |
|            |                                                         |
|            | 2 - Kinesiotherapy                                      |
+------------+---------------------------------------------------------+
| 096X       | **Professional Fees**                                   |
|            |                                                         |
|            | Charges for medical professional that hospitals or      |
|            | third party payers require to be separately identified  |
|            | on the billing form. Services that were not identified  |
|            | separately prior to uniform billing implementation      |
|            | should not be separately identified on the uniform      |
|            | bill.                                                   |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Psychiatric                                        |
|            |                                                         |
|            | 2 -- Ophthalmology                                      |
|            |                                                         |
|            | 3 -- Anesthesiologist (MD)                              |
|            |                                                         |
|            | 4 -- Anesthetist (CRNA)                                 |
|            |                                                         |
|            | 9 -- Other Professional Fees                            |
+------------+---------------------------------------------------------+
| 097X       | **Professional Fees (Extension of 96X)**                |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 1 -- Laboratory                                         |
|            |                                                         |
|            | 2 -- Radiology -- Diagnostic                            |
|            |                                                         |
|            | 3 -- Radiology -- Therapeutic                           |
|            |                                                         |
|            | 4 -- Radiology -- Nuclear Medicine                      |
|            |                                                         |
|            | 5 -- Operating Room                                     |
|            |                                                         |
|            | 6 -- Respiratory Therapy                                |
|            |                                                         |
|            | 7 -- Physical Therapy                                   |
|            |                                                         |
|            | 8 -- Occupational Therapy                               |
|            |                                                         |
|            | 9 -- Speech Pathology                                   |
+------------+---------------------------------------------------------+
| 099X       | **Patient Convenience Items**                           |
|            |                                                         |
|            | Charges for items that are generally considered by the  |
|            | third party payers as strictly convenience items and    |
|            | are not covered. This code permits identification of    |
|            | particular services as necessary.                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Cafeteria/Guest Tray                               |
|            |                                                         |
|            | 2 -- Private Linen Service                              |
|            |                                                         |
|            | 3 -- Telephone/Telegraph                                |
|            |                                                         |
|            | 4 -- TV/Radio                                           |
|            |                                                         |
|            | 5 -- Nonpatient Room Rentals                            |
|            |                                                         |
|            | 6 -- Late discharge Charge                              |
|            |                                                         |
|            | 7 -- Admission Kits                                     |
|            |                                                         |
|            | 8 -- Beauty Shop/Barber                                 |
|            |                                                         |
|            | 9 -- Other Patient Convenience Items                    |
+------------+---------------------------------------------------------+
| 100X       | **Behavioral Health Accommodations**                    |
|            |                                                         |
|            | Routine service charges incurred for accommodations at  |
|            | specified behavior health facilities                    |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Residential Treatment -- Psychiatric               |
|            |                                                         |
|            | 2 -- Residential Treatment -- Chemical Dependency       |
|            |                                                         |
|            | 3 -- Supervised Living                                  |
|            |                                                         |
|            | 4 -- Halfway House                                      |
|            |                                                         |
|            | 5 -- Group Home                                         |
+------------+---------------------------------------------------------+
| 101X to    | Reserved for National Assignment                        |
| 209X       |                                                         |
+------------+---------------------------------------------------------+
| 210X       | **Alternative Therapy Services**                        |
|            |                                                         |
|            | Alternative therapy is intended to enhance and improve  |
|            | standard medical treatment. The following revenue codes |
|            | would be used to report services in a separately        |
|            | designated alternative inpatient/outpatient unit.       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- General Classification                             |
|            |                                                         |
|            | 1 -- Acupuncture                                        |
|            |                                                         |
|            | 2 -- Accupressure                                       |
|            |                                                         |
|            | 3 -- Massage                                            |
|            |                                                         |
|            | 4 -- Reflexology                                        |
|            |                                                         |
|            | 5 -- Biofeedback                                        |
|            |                                                         |
|            | 6 -- Hypnosis                                           |
|            |                                                         |
|            | 9 -- Other Alternative Therapy Services                 |
+------------+---------------------------------------------------------+
| 211X to    | Reserved for National Assignment                        |
| 300X       |                                                         |
+------------+---------------------------------------------------------+
| 310X       | Adult Care                                              |
|            |                                                         |
|            | Charges for personal, medical, psycho-social, and/or    |
|            | therapeutic services in a special community setting for |
|            | adults needing supervision and/or assistance with       |
|            | Activities of Daily Living (ADLs)                       |
|            |                                                         |
|            | Subcategory                                             |
|            |                                                         |
|            | 0 -- Not used                                           |
|            |                                                         |
|            | 1 -- Adult Day Care, Medical and Social -- Hourly       |
|            |                                                         |
|            | 2 -- Adult Day Care, Social -- Hourly                   |
|            |                                                         |
|            | 3 -- Adult Day Care, Medical and Social -- Day          |
|            |                                                         |
|            | 4 -- Adult Day Care, Social -- Daily                    |
|            |                                                         |
|            | 5 -- Adult Foster Care -- Daily                         |
|            |                                                         |
|            | 9 -- Other Adjult Care                                  |
+------------+---------------------------------------------------------+
| 311X to    | Reserved for National Assignment                        |
| 899X       |                                                         |
+------------+---------------------------------------------------------+
| 9000 to    | Reserved for Medicare Skill Nursing Facility            |
| 9044       | Demonstration project                                   |
+------------+---------------------------------------------------------+
| 9045 to    | Reserved for National Assignment                        |
| 9099       |                                                         |
+------------+---------------------------------------------------------+

[]{#__RefHeading___Toc143579370 .anchor}FL43 -- Revenue Description

Not required. A narrative description or standard abbreviation for each
revenue code in FL 42 is shown on the adjacent line in FL 43. The
information assists clerical bill review. Descriptions or abbreviations
correspond to the revenue codes. "Other" code categories descriptions
are locally defined and individual described on each bill.

Home Health Agencies identify the specific piece of DME or nonroutine
supplies for which they are billing in this area on the line adjacent to
the related revenue code. This description must be shown in HCPCS
coding.

[]{#__RefHeading___Toc143579371 .anchor}FL44 -- HCPCS/Rates

*Required*. When coding HCPCS for outpatient services, the provider
enters the HCPCS code describing the procedure here. On inpatient or SNF
bills, the accommodation rate is shown here.

[]{#__RefHeading___Toc143579372 .anchor}FL45 -- Service Date

*Required*. *Except* Indian Health Service hospitals and other hospitals
located in American Samoa, Guam and Saipan, the line item dates of
service is required with every HCPCS code.

[]{#__RefHeading___Toc143579373 .anchor}FL46 -- Service Units

*Required*. Generally, the entries in this column quantify services by
revenue category, for example, number of days in a particular type of
accommodation, pints of blood. However, when HCPCS codes are required
for services, the units are equal to the number of times the
procedure/service being reported was performed.

Providers have been instructed to provide the number of covered days,
visits, treatments, procedures, tests, etc., as applicable for the
following:

  --------------------------- -------------------------------------------
  Service Type                Units/Quantity

  Accommodations              100s -- 150s, 200s, 210s (days)

  Blood                       380s (pints)

  DME                         290s (rental months)

  Emergency Room              450, 452, and 459 (HCPCS code definition
                              for visit or procedure)

  Clinic                      510s and 520s (HCPCS code definition for
                              visit or procedure)

  Dialysis Treatments         800s (sessions or days)

  Orthotic/prosthetic         264 (items
  devices)                    

  Outpatient therapy visits   410, 420, 430, 440, 480, 910, and 943.
                              Units are equal to the number of times the
                              procedure/service being reported was
                              performed)

  Outpatient clinical         -- 30X-31X (tests)
  diagnostic laboratory tests 

  Radiology                   32X, 34X, 35X, 40X, 61X, and 333 (HCPCS
                              code definition of tests or services)

  Oxygen                      600s (rental months, feet or pounds)

  Hemophilia blood clotting   636
  factors                     
  --------------------------- -------------------------------------------

Up to seven (7) numeric digits may be entered. Charges for non-covered
services are shown as noncovered or are omitted.

[]{#__RefHeading___Toc143579374 .anchor}FL47 -- Total Charges

*Required*. The total charges for the billing period are summed by
revenue code (FL 42) or in the case of revenue codes requiring HCPCS by
procedure code entered on the adjacent line n FL 47. The last revenue
code entered in FL 42 is "0001" which represents the grand total of all
covered and non-covered charges billed. FL 47 totals on the adjacent
line. Each line allows up to nine numeric digits.

CMS policy is for providers to bill Medicare on the same basis that they
bill other payers. This policy provides consistency of bill data with
the cost report so that bill data may be used to substantiate the cost
report.

Medicare and non-Medicare charges for the same department must be
reported consistently on the cost report. This means that the
professional component is included on, or excluded from, the cost report
for Medicare and non-Medicare charges. Where billing for the
professional component is not consistent for all payers, i.e., where
some payers require net billing and others require gross, the provider
must adjust either net charges up to gross or gross charges down to net
for cost report preparation. In such cases, adjust your provider
statistical and reimbursement reports (PS&R) that you derive from the
bill.

All revenue codes requiring HCPCS codes and paid under a fee schedule
are billed as net.

[]{#__RefHeading___Toc143579375 .anchor}FL48 -- Non-Covered Charges

*Required*. The total non-covered charges pertaining to the related
revenue code in FL 42 are entered here.

[]{#__RefHeading___Toc143579376 .anchor}FL49 -- Untitled

Not Required. This is one of the four fields which have not been
assigned.

[]{#__RefHeading___Toc143579377 .anchor}FL50A, B, C -- Payer
identification

*Required*. If Medicare is the primary payer, "Medicare" is entered on
line A. If Medicare is entered, the provider has developed for other
insurance and has determined has determined that Medicare is the
primary. All additional entries across line A (FLs 51-55) supply
information needed by the payer named in FL 50A. If Medicare is the
secondary or tertiary payer, the provider identifies the primary payer
on Line A and enters Medicare information on lines B or C, as
appropriate.

[]{#__RefHeading___Toc143579378 .anchor}FL51A, B, C -- Provider Number

*Required*. This is the six-digit number assigned by Medicare. It must
be entered on the same line as "Medicare" in FL 50.

[]{#__RefHeading___Toc143579379 .anchor}FL52A, B, C -- Release of
Information

*Required*. A "Y" code indicates the provider has on file a signed
statement permitting the provider to release data to other organizations
in order to adjudicate the claim. An "R" code indicates the release is
limited or restricted. An "N" code indicates no release on file. Note:
The back of Form HCFA-1450 contains a certification that all necessary
release statements are on file.

[]{#__RefHeading___Toc143579380 .anchor}FL53A, B, C -- Assignment of
Benefits Certification Indicator

Not Required.

[]{#__RefHeading___Toc143579381 .anchor}FL54A, B, C -- Prior Payments

*Required*. For all services other than inpatient hospital and SNF
services, the sum of any amount(s) collected by the provider from the
patient toward deductibles (cash and blood) and/or coinsurance are
entered on the patient (fourth/last) line of this column. Part A home
health DME cost sharing amounts collected from the patient are also
reported in this item.

[]{#__RefHeading___Toc143579382 .anchor}FL55A, B, C -- Estimated Amount
Due

Not Required.

[]{#__RefHeading___Toc143579383 .anchor}FL56 -- (Untitled)

Not Required. This is one of the seven fields which have not been
assigned for national use.

[]{#__RefHeading___Toc143579384 .anchor}FL57 -- (Untitled)

Not Required. This is one of the seven fields which have not been
assigned for national use.

[]{#__RefHeading___Toc143579385 .anchor}FL58A, B, C -- Insured's Name

*Required*. On the same lettered line (A, B, or C) that corresponds to
the line on which Medicare payer information is shown in FLs 50-54, the
provider enters the patient's Name as shown on his Health Insurance card
or other Medicare notice. All additional entries across that line (FLs
59-66) pertain to the person named in FL 58.

[]{#__RefHeading___Toc143579386 .anchor}FL59A, B, C -- Patient's
Relationship to Insured

*Required*. If the provider is claiming a payment under any of the
circumstances described in the second paragraph of FL 58 A, B or C, it
may enter the code indicating the relationship of the patient to the
identified insured, if this information is available.

  ------------------------------------------------------------------------
  Code    Relationship            Definition
  ------- ----------------------- ----------------------------------------
  01      Spouse                  

  04      Grandfather or          
          Grandmother             

  05      Grandson or             
          Granddaughter           

  07      Nephew or Niece         

  10      Foster child            

  15      Ward                    Ward of the Court. This code indicates
                                  that the patient is a ward of the
                                  insured as a result of a court order

  17      Stepson or Stepdaughter 

  18      Self                    

  19      Child                   

  20      Employee                

  21      Unknown                 

  22      Handicapped Dependent   

  23      Sponsored Dependent     

  24      Dependent of Minor      
          Dependent               

  29      Significant Other       

  32      Mother                  

  33      Father                  

  36      Emancipated Minor       

  39      Organ Donor             

  40      Cadaver Donor           

  41      Injured Plaintiff       

  43      Child Where Insured Has 
          No Financial            
          Responsibility          

  53      Life Partner            

  G8      Other Relationship      
  ------------------------------------------------------------------------

[]{#__RefHeading___Toc143579387 .anchor}FL60A, B, C --
Certificate/Social Security Number/HI Claim/Identification Number

*Required*. The provider enters the patients' Medicare Health Insurance
Claim Number as shown on the Health Insurance Card, Certificate of
Award, Utilization Notice, EOMB, Temporary Eligibility Notice, Hospital
Transfer Form, or as reported by the SSO. On the same lettered line (A,
B, or C) that corresponds to the line on which Medicare payer
information is shown in FLs 50-54, the provider enters the patient's
HICN, i.e., if Medicare is primary payer, in FL 60A.

[]{#__RefHeading___Toc143579388 .anchor}FL61A, B, C -- Group Name

Required. Where the provider is claiming a payment under the
circumstances described in the second paragraph of FLs 58 A, B or C, it
enters the name of the insurance group or plan.

[]{#__RefHeading___Toc143579389 .anchor}FL62A, B, C -- Insurance Group
Number

*Required*. Where the provider is claiming a payment under the
circumstances described in the second paragraph of FLs 58A, B, or C, it
enters the identification number, control number, or code assigned by
such health insurance carrier.

[]{#__RefHeading___Toc143579390 .anchor}FL63 -- Treatment Authorization
Code

*Required*. Whenever PRO review is performed for outpatient
preadmission, pre-procedure, or inpatient preadmission, the
authorization number is required for all approved admissions or
services.

[]{#__RefHeading___Toc143579391 .anchor}FL64 -- Employment Status Code

*Required*. Where the provider is claiming a payment under the
circumstances described in the second paragraph of FL 58 A, B, or C, it
enters the code which defines the employment status of the individual
identified on the same line in FL 58, if the information is readily
available.

  -----------------------------------------------------------------------
  Code     Employment Status
  -------- --------------------------------------------------------------
  1        Employed Full-Time

  2        Employed Part Time

  3        Not Employed, full or part time

  4        Self-employed

  5        Retired

  6        On Active Military Duty

  7-8      Reserved for National Assignment

  9        Unknown
  -----------------------------------------------------------------------

[]{#__RefHeading___Toc143579392 .anchor}FL65 -- Employer Name

*Required*. Where the provider is claiming a payment under the
circumstances described in the second paragraph of FL 58 A, B, or C and
there is Workers' Compensation, it enters the name of the employer that
provides health care coverage for the individual identified on the same
line in FL 58.

[]{#__RefHeading___Toc143579393 .anchor}FL66 -- Employer Location

*Required*. Where the provider is claiming a payment under the
circumstances described in the second paragraph of FL 58 A, B, or C, and
there is Workers' Compensation, it enters the specific location of the
employer of the individual identified on the same line FL 58. A specific
location is the city, plant, etc. in which the employer is located.

[]{#__RefHeading___Toc143579394 .anchor}FL67 -- Principal Diagnosis Code

CMS only accepts ICD-9-CM diagnostic and procedural codes which use
definitions contained in the Department of Health and Human Services
Publication No. (PHS) 89-1260. CMS approves only changes issued by the
Federal ICD-9-CM Coordination and Maintenance Committee. Diagnosis codes
must be full ICD-9-CM diagnoses codes, including all five digits where
applicable.

Inpatient

*Required*. The provider reports the principal diagnosis in this field.
The principal diagnosis is the condition established after study to be
chiefly responsible for this admission. Even though another diagnosis
may be more severe than the principal diagnosis, the principal
diagnosis, as defined above, is entered. Entering any other diagnosis
may result in incorrect assignment of a DRG and an overpayment to a
hospital.

Outpatient

*Required*. Hospitals report the full ICD-9-CM code for the diagnosis
shown to be chiefly responsible for the outpatient services in FL 67.
Hospitals report the diagnosis to their highest degree of certainty. For
instance, if the patient is seen on an outpatient basis for an
evaluation of a symptom (such as cough), for which a definitive
diagnosis is not made, the symptom is reported (786.2). If during, the
course of the outpatient evaluation and treatment, a definitive
diagnosis is made (such as acute bronchitis); the definitive diagnosis
is reported (466.0).

If a patient arrives at the hospital for examination or testing without
a referring diagnosis and cannot provide a complaint, symptom, or
diagnosis, the hospital reports an ICD-9-CM code for "Persons without
reported diagnosis encountered during examination and investigation of
individuals and populations" (V70-V82). Examples include:

-   Routine general medical examination (V70.0)

-   General medical examination without any working diagnosis or
    complaint; patient unsure if the examination is a routine checkup
    (V79.9)

-   Examination of ears and hearing (V72.1)

[]{#__RefHeading___Toc143579395 .anchor}FL68 - FL75 -- Other Diagnoses
Codes

Inpatient

*Required*. The provider reports the full ICD-9-CM codes for up to eight
additional conditions if they co-existed at the time of admission or
developed subsequently, and which had an effect upon the treatment or
length of stay. The principal diagnosis entered in FL 67 should not
under any circumstances be duplicated as an additional or secondary
diagnosis. If it is duplicated, it should be eliminated by the GROUPER.

Outpatient

*Required*. Hospitals report the full ICD-9-CM codes in FLs 68-75 for up
to eight other diagnoses that coexisted in addition to the diagnosis
reported n FL 67. For instance, if the patient is referred to the
hospital for evaluation of hypertension and the medical record also
documents diabetes, diabetes is reported here.

[]{#__RefHeading___Toc143579396 .anchor}FL76 -- Admitting
Diagnosis/Patient's Reason for Visit

*Required*. For inpatient hospital claims subject to PRO review, the
admitting diagnosis is required. Admitting diagnosis is the condition
identified by the physician at the time of the patient's admission
requiring hospitalization. FL 76 is a dual use field. Patient's reason
for visit is not required by Medicare but may be used by providers for
non scheduled visits for outpatient bills.

[]{#__RefHeading___Toc143579397 .anchor}FL77 -- E-Code

Not Required.

[]{#__RefHeading___Toc143579398 .anchor}FL78 -- (Untitled)

Not Required. This is one of the four fields which have not been
assigned for national use.

[]{#__RefHeading___Toc143579399 .anchor}FL79 -- Procedure Coding Method

Not Required

[]{#__RefHeading___Toc143579400 .anchor}FL80 -- Principal Procedure Code
and Date

*Required -- Inpatient Only*. The provider enters the ICD-9-CM code for
the inpatient principal procedure. The principal procedure is the
procedure performed for definitive treatment rather than for diagnostic
or exploratory purposes or which was necessary to take care of a
complication. It is also the procedure most closely related to the
principal diagnosis (FL 67). For this item, surgery includes incision,
excision, amputation, introduction, repair, destructions, endoscopy,
suture, and manipulation.

The procedure code shown must be the full ICD-9-CM, Volume 3, procedure
code, including all four digit codes where applicable. The date
applicable to the principal procedure is shown numerically as MMDDYY in
the "date" portion.

[]{#__RefHeading___Toc143579401 .anchor}FL81 -- Other Procedure Codes
and Dates

*Required -- Inpatient Only*. The full ICD-9-CM, Volume 3, procedure
codes, including all four digits where applicable, must be shown for up
to five significant procedures other than the principal procedure (which
is shown in FL80). The date of each procedure is shown in the date
portion of Item 81, as applicable, numerically as MMDDYY.

[]{#__RefHeading___Toc143579402 .anchor}FL82 -- Attending/Referring
Physician ID

*Required*. Providers must enter the unique physician identification
number (UPIN) and name of the attending/referring physician on inpatient
bills or the physician that requested outpatient services. Paper bill
specifications are listed below.

Inpatient Part A

*Required*. Hospitals and SNFs must enter the UPIN and name of the
attending/referring physician. For hospital services, the Uniform
Hospital Discharge Data Set definition for attending physicians is used.
This is the clinician primarily responsible for the care of the patient
from the beginning of the hospital episode. For SNF services, the
attending physician is the practitioner who certifies the SNF plan of
care. Enter the UPIN in the first six positions, followed by two spaces,
the physician's last name, one space, first name, one space, and middle
initial.

Home Health and Hospice

*Required*. HHAs and hospices must enter the UPIN of the physician that
signs the home health or hospice plan of care. Enter the UPIN in the
first six positions followed by two spaces, the physician's last name,
one space, first name, one space, and middle initial.

Outpatient and Other Part B

*Required*. All providers must enter the UPIN of the physician that
requested the surgery, therapy, diagnostic tests or other services in
the first six positions followed by two spaces, the physician's last
name, one space, first name, one space, and middle initial. If the
patient is self-referred (e.g., emergency room or clinic visit), SLF000
is entered in the first six positions and no name is shown.

Claims Where Physician Not Assigned a UPIN -- Not all physicians are
assigned UPINs. Where the physician is an intern or resident, the number
assignment may not be complete.

Accept the SLF entry unless the revenue code or HCPCS code indicates the
service can be provided only as a result of physician referral. If more
than one referring physician is involved, the provider enters the UPIN
of the physician requesting the service with the highest charge. If
referrals originate from physician-directed facilities (e.g., rural
health clinics) enter the UPIN of the physician responsible for
supervising the practitioner that provided the medical care to the
patient.

[]{#__RefHeading___Toc143579403 .anchor}FL83 -- Other Physician ID

Inpatient Part A Hospital

*Required if procedure is performed*. Hospitals must enter the UPIN and
name of the physician who performed the principal procedure. If there is
no principal procedure, the hospital enters the UPIN and name of the
physician who performed the surgical procedure most closely related to
the principal diagnosis. If no procedure is performed, the hospital
leaves this item blank.

Outpatient Hospital

*Required* where the HCPCS code reported is subject to the Ambulatory
Surgical Center payment limitation or a reported HCPCS code is on the
list of codes the PRO furnishes that require approval.

Other Bills

Not Required.

[]{#__RefHeading___Toc143579404 .anchor}FL84 -- Remarks

*Required*. For DME billings by HHAs, the renal rate, cost and
anticipated months of usage are shown so that you may determine whether
to approve the rental or purchase of equipment. In addition, special
annotations may be entered where Medicare is not the primary payer
because Workers' Compensation, an automobile medical or no-fault
insurer, any liability insurer or an EGHP/LGHP is primary to Medicare.

This space is also available to report overflow from other items.

[]{#__RefHeading___Toc143579405 .anchor}FL85 -- Provider Representative
Signature

Not Required. No signature is required for a general care hospital
unless a certification is required. A provider representative's
signature or facsimile is required on the bill of a psychiatric or
tuberculosis hospital.

[]{#__RefHeading___Toc143579406 .anchor}FL86 -- Date

Not Required. This is the date of the provider representative's
signature.