(Medicare Claims Processing Manual)

FL 03b. Medical/Health Record Number   a. If provided by the hospital, must be recorded by the A/B MAC (A) for the QIO.   b. Must be left justified in CWF record for QIO.   FLs 18 thru 28. Condition Codes.  a. Each code is two numeric digits.  b. If code 07 is entered, type of bill must not be hospice 81X or 82X.  c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.  d. If code 40 is entered, the From and Through dates in FL 6 must be equal, and there must be a 0 or 1 in FL 7 (Covered Days).  e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.  FLs 31, 32, 33, and 34. Occurrence Codes and Dates  a. All dates must be valid.   b. Each code must be accompanied by a date.  c. All codes are two alphanumeric positions.  d. If code 20 or 26 is entered, the type of bill must be 11X or 41X.  If code 21 or 22 is entered, the type of bill must be 18X or 21X.  e. If code 27 is entered, the type of bill must be 81X or 82X.  f. If code 28 is entered, the first digit in FL 4 must be a 7 and the second digit a 5.  g. If code 42 is entered, the first digit in FL 4 must be 8 and the second digit 1 or 2 and the third digit 1 or 4.  h. If 01 - 04 is entered, Medicare cannot be the primary payer, i.e., Medicare- related entries cannot appear on the A lines of FLs 58-62.  i. If code 20 is entered:   Must not be earlier than Admission date (FL 17)  or later than Through date (FL 6).   Must be less than 13 days after the admission date (FL 17) if From date is equal to admission date (less than 14 days if billing dates cover the period December 24 through January 2).  j. If code 21 is entered:    Cannot be later than Statement Covers Period Through date; or    Cannot be more than 3 days prior to the Statement Covers Period From date.   k. If code 22 is entered, the date must be within the billing period shown in FL 6.   l. If code 31 is entered, the type of bill must be 11X, 21X, or 41X.   m. If code 32 is entered, the type of bill must be 13X, 14X, 23X, 32X, 33X, 34X, 71X, 72X, 73X, 74X, 75X, 81X, or 82X.   FL 35 and 36. Occurrence Span Codes and Dates   a. Dates must be valid.   b. Code entry is two alphanumeric positions.  c. Code must be accompanied by dates.   d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.   e. If code 71 is entered, the first digit of FL 4 must be 1, 2, or 4 and the second digit must be 1.   f. If code 72 is entered, the type of bill must be 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, or 85X.  g. If code 74 is entered, the type of bill must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 74X, 75X, 81X, or 82X.   h. If code 75 is entered, the first digit of FL 4 must be 1 or 4 and the second digit must be 1.   i. If code 76 is entered, occurrence code 31 must be present (inpatient only).  j. If code 76 is entered, occurrence code 32 must be present (outpatient only).  k. If code 76, 77, or M1 is present, the bill type must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 73X, 74X, 75X, 81X, 82X, or 85X.   l. Neither the From nor the Through portion can exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions of each field.   m. If code M2 is present, the bill type must be 81X or 82X.   n. Code 79 is for payer use only.  Providers do not report this code.   FLs 39, 40, and 41. Value Codes and Amounts.   a. Each code must be accompanied by an amount.   b. All codes are two alphanumeric digits.  c. Amounts may be up to ten numeric positions. (00000000.00)   d. If code 06 is entered, there must be an entry for code 37.   e. If codes 08 and/or 10 are entered, there must be an entry in FL 10.   f. If codes 09 and/or 11 are entered, there must be an entry in FL 9.   g. If codes 12, 13, 14, 15, 41, 43, or 47 are entered as zeros, occurrence codes 01, 02, 03, 04, or 24 must be present.   h. Entries for codes 37, 38, and 39 cannot exceed three numeric positions.  i. If the blood usage data is present, code 37 must be numeric and greater than zero.   FL 42. Revenue Codes.   a. Four numeric positions.  b. Must be listed in ascending numeric sequence except for the final entry, which must be 0001 for hardcopy claims only.  c. There must be a revenue code adjacent to each entry in FL 47.   d. For bill types 32X and 33X the following revenue codes require a 5- position HCPCS code:   0274, 029X, 042X, 043X, 044X, 055X, 056X, 057X, 0601, 0602, 0603, and 0604.  e. For bill type 34X, the following revenue codes require a 5 -position HCPCS   code:   0271- 0274, 42X, 43X, 44X, and 0601- 0604.   f. For bill type 21X, 32X, 33X, or 11X (IRF facilities) the following revenue codes require a 5 -position HIPPS code:   0022 (SNF only), 0023 (HH only), 0024 (IRFs only).  FL 45. Service Date   a. Six numeric positions, MMDDYY.   b. A single line item date of service (LIDOS) is required on every revenue code present on types of bill 12X, 13X, 14X, 22X, 23X, 24X, 32X, 33X, 34X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, and 83X.   Exception:  LIDOS are not required for CAHs, Indian Health Service hospitals, and hospitals located in American Samoa, Guam, and Saipan.   c. When a particular service is rendered more than once during the billing period, the revenue code and HCPCS code must be entered separately for each service date.   FL 46. Units of Service   a. Up to seven numeric positions.   b. Must be present for all services with the exception of the HIPPS line item service.  (Exception:  Units are required on the HIPPS line for SNF claims)   c. Accommodation units must equal covered days with the exception of the R No-Pay.  FL 47. Total Charges   a. Up to 10 numeric positions (00000000.00).  b. There must be an entry adjacent to each entry in FL 42.   c. The 0001 amount must be the sum of all the entries for hardcopy only.  FLs 50A, B, and C. Payer Identification   a. "Medicare must be entered on one of these lines depending upon whether it is the primary, secondary or tertiary payer.   b. If value codes 12, 13, 14, 15, 16, 41, 42, 43, or 47 are present, data pertaining to Medicare cannot be entered in Line A of FLs 50 -62.  FL 56. National Provider Identifier  Billing Provider   a. Effective May 23, 2007, providers are required to submit their NPI.  b. Left justified.   FLs 58A, B, and C. Insureds Name   a. Must be present.  Cannot be all spaces.   FLs 60A, B, and C. Certificate/Social Security Number/HI Claim/Identification Number   a. Must be present.   b. Must contain nine numeric characters and at least one alpha character as a suffix.  The first alpha suffix is entered in position 10, the second in position 11, etc. The first three numbers must fall within the range of 001 through 680 or 700 through 728.  c. The alpha suffix must be A through F, H, J, K, M, T, or W.  Alpha suffixes A and T must not have a numeric subscript.  Alpha suffixes B, C, D, E, F, M, and W may or may not have a numeric subscript.  d. If the alpha suffix is H, it must be followed by A, B or C in position eleven.  The numeric subscript (position twelve) must conform with the above for the A, B, or C suffix to be used.   e. RRB claim numbers must contain either six or nine numeric characters, and must have one, two, or three -character alpha prefix.   f. For prefixes H, MH, WH, WCH, PH and JA only a 6- digit numeric field is permissible.  For all other prefixes, a six or nine numeric field is permissible.   g. Nine numeric character claim numbers must have the same ranges as the SSA 9 -position claim numbers.  FL 67. Principal Diagnosis Code and Present on Admission Indicator.   a. If ICD -9-CM, must be four or five positions left justified, with no decimal points.  If ICD -10-CM, must be three to seven positions, left justified, with no decimal points.  b. Must be valid ICD diagnosis code for date of service.   c. POA is a one position field.  FLs 67 A -  Q.  Other Diagnosis Codes and Present on Admission Indicator.   a. If present, for ICD -9-CM must be four or five positions, left justified, with no decimal points.  For ICD -10-CM must be three to seven positions, left justified, with no decimal points.  b. POA is a one position field.  FL 74. Principal Procedure Code and Date   a. If present, must be valid procedure code for service date.  For ICD -9-CM must be 3 - 5 characters; first character may be numeric or alpha, characters 2 - 5 must be numeric.  For ICD -10-PCS must be 3 -  7 characters; first character must be alpha, second character must be numeric, characters 3  7 may be alpha or numeric.  b. If code is present, date must be present and valid.  c. Date must fall before the Through date in FL 6.  (In some cases it may be before the admission date, i.e., where complications and admission ensue from outpatient surgery.)   FL 74 a -e. Other Procedure Codes and Dates.   a. If present, apply edits for FL 74   FL 76. Attending Provider Name and Identifiers.