(Medicare Claims Processing Manual Crosswalk)

Medicare Claims Processing Manual  Chapter 25 - Completing and Processing the Form CMS -1450 Data Set   Table of Contents  (Rev. 12423, 12- 20-23)  Transmittals for Chapter 25  10 - Reserved  70 - Uniform Bill -  Form CMS -1450 70.1 -  Uniform Billing with Form CMS -1450 70.2 -  Disposition of Copies of Completed Forms  75 - General Instructions for Completion of Form CMS -1450 for Billing  75.1 -  Form Locators 1 -15 75.2 -  Form Locators 16- 30  75.3 -  Form Locators 31- 41 75.4 -  Form Locator 42  75.5 -  Form Locators43- 65 75.6  Form Locators 66 -81 80 - Reserved  10 - Reserved   70 - Uniform Bill - Form CMS -1450 (Rev. 2874, Issued: 02- 06-14, Effective: 03 -07-14, Implementation: 03- 07-14)  70.1 - Uniform Billing with Form CMS -1450 (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  This form, also known as the UB -04, is a uniform institutional provider bill suitable for use in billing multiple third party payers.  Because it serves many payers, a particular payer may not need some data elements.  The National Uniform Billing Committe e (NUBC) maintains lists of approved coding for the form.  Medicare Administrative Contractors servicing both Part A and Part B lines of business (A/B MACs (A) and (HHH)) responsible for receiving institutional claims also maintain lists of codes used by Medicare.  All items on Form CMS -1450 are described.  The A/B MAC (A) or (HHH) must be able to capture all NUBC -approved input data described in section 75 for audit trail purposes and be able to pass coordination of benefits data to other payers with whom it has a coordination of benefits agreement.   70.2 - Disposition of Copies of Completed Forms (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  The provider retains the copy designated Institution Copy and submits the remaining copies of the completed Form CMS -1450 to its A/B MAC (A) or (HHH), managed care plan, or other insurer.  Where it knows that a managed care plan will pay the bill, it sends the bill and any necessary supporting documentation directly to the managed care plan for coverage determination, payment, and/or denial action.  It sends to the A/B MAC (A) or (HHH) bills that it knows will be paid and processed by the A/B MAC (A) or ( HHH).   75 - General Instructions for Completion of Form CMS -1450 for Billing (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  This section contains Medicare requirements for use of codes maintained by the NUBC that are needed in completion of the Form CMS -1450 and compliant Accredited Standards Committee (ASC) X12 837 institutional claims.  Note that the internal claim record used for processing is not being expanded.  Instructions for completion are the same for inpatient and outpatient claims unless otherwise noted.  The A/B MAC (A) or (HHH) does not need to search paper files to annotate missing data unless it does not have an electronic history record.  It does not need to obtain data that is not needed to process the claim.   Effective June 5, 2000, CMS extended the claim size to 450 lines.  For the Form CMS -1450, this simply means that the A/B MAC (A) or (HHH) accepts claims of up to 9 pages.  The following layout describes the data specifications Form CMS -1450.    FORM CMS -1450 LAYOUT SUMMARY   FL Description  Line  Type  Size Buffer  Space  FL01  [Billing Provider Name]  1  AN  25   FL01  [Billing Provider Street Address]  2  AN  25   FL01  [Billing Provider City, State, Zip]  3  AN  25   FL01  [Billing Provider Telephone, Fax, Country Code]  4  AN  25         FL02  [Billing Providers Designated Pay -to Name]  1  AN  25   FL02  [Billing Providers Designated Pay -to Address]  2  AN  25   FL02  [Billing Providers Designated Pay -to City, State]  3  AN  25   FL02  [Billing Providers Designated Pay -to ID]  4  AN  25         FL03a  Patient Control Number   AN  24   FL03b  Medical/Health Record Number   AN  24         FL04  Type of Bill  1  AN  4  1        FL05  Federal Tax Number  1  AN  4   FL05  Federal Tax Number  2  AN  10         FL06  Statement Covers Period - From/Through  1  N/N  6/6  1/1        FL07  Unlabeled  1  AN  7   FL07  Unlabeled  2  AN  8         FL08  Patient Name and Identifier (ID)  1a  AN  19   FL08  Patient Name  2b  AN  29         FL09  Patient Address - Street  1a  AN  40  1  FL09  Patient Address - City  2b  AN  30  2  FL09  Patient Address - State  2c  AN  2  1  FL09  Patient Address - ZIP  2d  AN  9  1  FL09  Patient Address - Country Code  2e  AN  3         FL10  Patient Birthdate  1  N  8  1        FL Description  Line  Type  Size Buffer  Space  FL11  Patient Sex  1  AN  1  2        FL12  Admission/Start of Care Date  1  N  6         FL13  Admission Hour  1  AN  2  1        FL14  Priority (Type) of Admission or Visit  1  AN  1  2        FL15  Point of Origin for Admission or Visit  1  AN  1  2        FL16  Discharge Hour  1  AN  2  1        FL17  Patient Discharge Status   1  AN  2  1        FL18  Condition Code   AN  2  1  FL19  Condition Code   AN  2  1  FL20  Condition Code   AN  2  1  FL21  Condition Code   AN  2  1  FL22  Condition Code   AN  2  1  FL23  Condition Code   AN  2  1  FL24  Condition Code   AN  2  1  FL25  Condition Code   AN  2  1  FL26  Condition Code   AN  2  1  FL27  Condition Code   AN  2  1  FL28  Condition Code   AN  2  1        FL29  Accident State   AN  2  1        FL30  Unlabeled  1  AN  12   FL30  Unlabeled  2  AN  13         FL31  Occurrence Code/Date  a  AN/N  2/6  1/1  FL31  Occurrence Code/Date  b  AN/N  2/6  1/1        FL32  Occurrence Code/Date  a  AN/N  2/6  1/1  FL32  Occurrence Code/Date  b  AN/N  2/6  1/1        FL33  Occurrence Code/Date  a  AN/N  2/6  1/1  FL33  Occurrence Code/Date  b  AN/N  2/6  1/1        FL Description  Line  Type  Size Buffer  Space  FL34  Occurrence Code/Date  a  AN/N  2/6  1/1  FL34  Occurrence Code/Date  b  AN/N  2/6  1/1        FL35  Occurrence Span Code/From/Through  a  AN/N/N  2/6/6  1/1/1  FL35  Occurrence Span Code/From/Through  b  AN/N/N  2/6/6  1/1/1        FL36  Occurrence Span Code/From/Through  a  AN/N/N  2/6/6  1/1/1  FL36  Occurrence Span Code/From/Through  b  AN/N/N  2/6/6  1/1/1        FL37  Unlabeled  a  AN  8   FL37  Unlabeled  b  AN  8         FL38  Responsible Party Name/Address  1  AN  40  2  FL38  Responsible Party Name/Address  2  AN  40  2  FL38  Responsible Party Name/Address  3  AN  40  2  FL38  Responsible Party Name/Address  4  AN  40  2  FL38  Responsible Party Name/Address  5  AN  40  2        FL39  Value Code  a  AN  2  1  FL39  Value Code Amount  a  N  9  1  FL39  Value Code  b  AN  2  1  FL39  Value Code Amount  b  N  9  1  FL39  Value Code  c  AN  2  1  FL39  Value Code Amount  c  N  9  1  FL39  Value Code  d  AN  2  1  FL39  Value Code Amount  d  N  9  1        FL40  Value Code  a  AN  2  1  FL40  Value Code Amount  a  N  9  1  FL40  Value Code  b  AN  2  1  FL40  Value Code Amount  b  N  9  1  FL40  Value Code  c  AN  2  1  FL40  Value Code Amount  c  N  9  1  FL40  Value Code  d  AN  2  1  FL40  Value Code Amount  d  N  9  1        FL41  Value Code  a  AN  2  1  FL41  Value Code Amount  a  N  9  1  FL41  Value Code  b  AN  2  1  FL41  Value Code Amount  b  N  9  1  FL Description  Line  Type  Size Buffer  Space  FL41  Value Code  c  AN  2  1  FL41  Value Code Amount  c  N  9  1  FL41  Value Code  d  AN  2  1  FL41  Value Code Amount  d  N  9  1        FL42  Revenue Codes  1-23  N  4   FL43  Revenue Code Description/IDE Number/Medicaid Drug rebate  1-23  AN  24   FL44  HCPCS/Accommodation Rates/HIPPS Rate Codes  1-23  N  14   FL45  Service Dates  1-23  N  6   FL46  Service Units  1-23  N  7   FL47  Total Charges  1-23  N  9   FL48  Non-Covered Charges  1-23  N  9         FL49  Unlabeled  1-23  AN  2         FL50  Payer Identification - Primary  A  AN  23   FL50  Payer Identification - Secondary  B  AN  23   FL50  Payer Identification - Tertiary  C  AN  23         FL51  Health Plan Identification Number  A  AN  15   FL51  Health Plan Identification Number  B  AN  15   FL51  Health Plan Identification Number  C  AN  15         FL52  Release of Information - Primary  A  AN  1  1  FL52  Release of Information - Secondary  B  AN  1  1  FL52  Release of Information - Tertiary  C  AN  1  1