If billing for more than one month of activities, use one detail line for each month s activities with the date of service determined as described below. Refer to Appendix 2 of this handbook for a completed sample claim form that shows more than one month s activities billed on the same claim form. Refer to Appendix 5 of this handbook for Medicaid-allowable POS codes. Claims received without an appropriate procedure code are denied by Wisconsin Medicaid. Refer to Appendix 4 of this handbook for definitions of modifiers.
Charges Enter the total charge for each line item.
Element 24G Days or Units Enter the appropriate number of hours billed on each line. Round to the nearest 0.1 hour. Appendix 6 of this handbook lists the rules for rounding. Optional - provider may enter up to 12 characters of the patient s internal office account number. Element 28 Total Charge Enter the total charges for this claim.