(Medicare Claims Processing Manual)

N 4 74-787 28 17a Legacy  Qualifier/Provider Number of  Referring  Physician  A/N 19 30-48 29 17 Name of  Referring  Physician  or Other Source  A 26 01-26 29 17b NPI Number of Referring Physician  N 17 32-48 29 18 Hospitalization  Related  Current Svcs  (From  Month)  N 2 54-55 29 18 Hospitalization  Related  Current Svcs  (From  Day)  N 2 57-58 29 18 Hospitalization  Related  Current Svcs  (From  Year)  N 4 60-63 29 18 Hospitalization  Related  Current Svcs  (To Month)  N 2 68-69 29 18 Hospitalization  Related  Current Svcs  (To Day)  N 2 71-72 29 18 Hospitalization Related Current Svcs (To Year)  N   30 19 Reserved  for Local  Use A/N 35 14-48 31 19 Reserved  for Local  Use A/N 48 01-48 31 20 Outside Lab (Yes)  M 1 52 * M = mark  (X), A = alpha, N  = numeric  31 20 Outside Lab (No)  M 1 57 31 20 $ Charges  N 8/8 62-78 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  33 21.1 Diagnosis  or Nature of  Illness or  Injury  (Code)  A/N 8 03-10 33 21.3 Diagnosis  or Nature of  Illness or  Injury  (Code)  A/N 8 30-37 33 22 Medicaid  Resubmission  Code  A/N 11 50-60 33 22.2 Original  Reference Number  A/N 18 61-78 35 21.2 Diagnosis  or Nature of  Illness or  Injury  (Code)  A/N 8 03-10 35 21.4 Diagnosis  or Nature of  Illness or  Injury  (Code)  A/N 8 30-37 35 23 Prior Authorization  Number  A/N 29 50-78 38 24 Line  Detail  Narrative  A/N 63 01-63 38 24.1i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 38 24.1j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 39 24.1a Date(s) of  Service -  (From  Month)  N 2 01-02 39 24.1a Date(s) of  Service -  (From  Day)  N 2 04-05 39 24.1a Date(s) of  Service -  (From  Year)  N 2 07-08 39 24.1a Date(s) of  Service -  (To Month)  N 2 10-11 39 24.1a  Date(s) of Service - (To Day)  N 2 13-14 39 24.1a  Date(s) of Service - (To Year)  N 2 16-17 39 24.1b  Place of  Service  A/N 2 19-20 39 24.1c  EMG  A 2 22-23 39 24.1d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 39 24.1d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 39 24.1d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 39 24.1d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 39 24.1d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 * M = mark  (X), A = alpha, N  = numeric  39 24.1e  Diagnosis  Pointer  N 4 45-48 39 24.1f  $ Charges  N 8 50-57 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  39 24.1g Days  or Units  N 3 59-61 39 24.1h  EPSDT  Family  Plan  A 1 63 39 24.li Legacy  Qualifier  Rendering  Provider  (Leave Blank)  A/N 0  39 24.1j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 40 24 Line  Detail  Narrative  A/N 63 01-63 40 24.2i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 40 24.2j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 41 24.2a Date(s) of  Service -  (From  Month)  N 2 01-02 41 24.2a Date(s) of  Service -  (From  Day)  N 2 04-05 41 24.2a Date(s) of  Service -  (From  Year)  N 2 07-08 41 24.2a Date(s) of  Service -  (To Month)  N 2 10-11 41 24.2a Date(s) of  Service -  (To Day)  N 2 13-14 41 24.2a  Date(s) of Service - (To Year)  N 2 16-17 41 24.2b  Place of Service  A/N 2 19-20 41 24.2c  EMG  A 2 22-23 41 24.2d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 41 24.2d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 41 24.2d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 41 24.2d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 41 24.2d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 41 24.2e  Diagnosis  Pointer  N 4 45-48 41 24.2f  $ Charges  N 8 50-57 41 24.2g Days  or Units  N 3 59-61 41 24.2h  EPSDT  Family  Plan  A 1 63 * M = mark  (X), A = alpha, N  = numeric  41 24.2i  Legacy  Qualifier  Rendering  Provider  (Leave Blank)  A/N 0  LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  41 24.2j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 42 24 Line  Detail  Narrative  A/N 63 01-63 42 24.3i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 42 24.3j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 43 24.3a Date(s) of  Service -  (From  Month)  N 2 01-02 43 24.3a Date(s) of  Service -  (From  Day)  N 2 04-05 43 24.3a Date(s) of  Service -  (From  Year)  N 2 07-08 43 24.3a Date(s) of  Service -  (To Month)  N 2 10-11 43 24.3a Date(s) of  Service -  (To Day)  N 2 13-14 43 24.3a Date(s) of  Service -  (To Year)  N 2 16-17 43 24.3b  Place of  Service  A/N 2 19-20 43 24.3c  EMG  A 2 22-23 43 24.3d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 43 24.3d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 43 24.3d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 43 24.3d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 43 24.3d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 43 24.3e  Diagnosis  Pointer  N 4 45-48 43 24.3f  $ Charges  N 8 50-57 43 24.3g Days  or Units  N 3 59-61 43 24.3h  EPSDT  Family  Plan  A 1 63 43 24.3i  Legacy  Qualifier  Rendering  Provider  (Leave Blank)  A/N 0  43 24.3j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 44 24 Line  Detail  Narrative  A/N 63 01-63 * M = mark  (X), A = alpha, N  = numeric  44 24.4i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  44 24.4j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 45 24.4a Date(s) of  Service -  (From  Month)  N 2 01-02 45 24.4a Date(s) of  Service -  (From  Day)  N 2 04-05 45 24.4a  Date(s) of Service - (From  Year)  N 2 07-08 45 24.4a Date(s) of  Service -  (To Month)  N 2 10-11 45 24.4a Date(s) of  Service -  (To Day)  N 2 13-14 45 24.4a Date(s) of  Service -  (To Year)  N 2 16-17 45 24.4b  Place of  Service  A/N 2 19-20 45 24.4c  EMG  A 2 22-23 45 24.4d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 45 24.4d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 45 24.4d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 45 24.4d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 45 24.4d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 45 24.4e  Diagnosis  Pointer  N 4 45-48 45 24.4f  $ Charges  N 8 50-57 45 24.4g Days  or Units  N 3 59-61 45 24.4h  EPSDT  Family  Plan  A 1 63 45 24.4i  Legacy  Qualifier  Rendering  Provider  Blank)  (Leave  A/N 0  45 24.4j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 46 24 Line  Detail  Narrative  A/N 63 01-63 46 24.5i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 46 24.5j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 47 24.5a  Date(s) of Service - (From  Month)  N 2 01-02 * M = mark  (X), A = alpha, N  = numeric  47 24.5a Date(s) of  Service -  (From  Day)  N 2 04-05