(Medicare Claims Processing Manual)

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 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  47 24.5a Date(s) of  Service -  (From  Year)  N 2 07-08 47 24.5a  Date(s) of Service - (To Month)  N 2 10-11 47 24.5a  Date(s) of Service - (To Day)  N 2 13-14 47 24.5a Date(s) of  Service -  (To Year)  N 2 16-17 47 24.5b  Place of  Service  A/N 2 19-20 47 24.5c  EMG  A 2 22-23 47 24.5d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 47 24.5d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 47 24.5d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 47 24.5d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 47 24.5d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 47 24.5e  Diagnosis  Pointer  N 4 45-48 47 24.5f  $ Charges  N 8 50-57 47 24.5g Days  or Units  N 3 59-61 47 24.5h  EPSDT  Family  Plan  A 1 63 47 24.5i  Legacy  Qualifier  Rendering  Provider  (Leave Blank)  A/N 0  47 24.5j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 48 24 Line  Detail  Narrative  A/N 63 01-63 48 24.6i  Legacy  Qualifier  Rendering  Provider A/N 2 65-66 48 24.6j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 49 24.6a Date(s) of  Service -  (From  Month)  N 2 01-02 49 24.6a Date(s) of  Service -  (From  Day)  N 2 04-05 49 24.6a Date(s) of  Service -  (From  Year)  N 2 07-08 49 24.6a  Date(s) of Service - (To Month)  N 2 10-11 49 24.6a Date(s) of  Service -  (To Day)  N 2 13-14 * M = mark  (X), A = alpha, N  = numeric  49 24.6a Date(s) of  Service -  (To Year)  N 2 16-17 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  49 24.6b  Place of  Service  A/N 2 19-20 49 24.6c  EMG  A 2 22-23 49 24.6d  Procedures,  Svcs  or Supplies  (CPT/HCPCS)  A/N 6 25-30 49 24.6d  Procedures,  Svcs  or Supplies  (Modifier 1) A/N 2 33-34 49 24.6d  Procedures,  Svcs  or Supplies  (Modifier 2) A/N 2 36-37 49 24.6d  Procedures,  Svcs  or Supplies  (Modifier 3) A/N 2 39-40 49 24.6d  Procedures,  Svcs  or Supplies  (Modifier 4) A/N 2 42-43 49 24.6e  Diagnosis  Pointer  N 4 45-48 49 24.6f  $ Charges  N 8 50-57 49 24.6g Days  or Units  N 3 59-61 49 24.6h  EPSDT  Family  Plan  A 1 63 49 24.6i  Legacy  Qualifier  Rendering  Provider  (Leave Blank)  A/N 0  49 24.6j  Legacy  Provider Number  Rendering  Provider  A/N 11 68-78 51 25 Federal  Tax ID  Number  N 15 1-15 51 25 Federal  Tax ID  Number (SSN)  M 1 17 51 25 Federal  Tax ID  Number (EIN)  M 1 19 51 26 Patient's  Account Number  A/N 14 23-36 51 27 Accept  Assignment  (Yes)  M 1 38 51 27 Accept  Assignment  (No) M 1 43 51 28 Total  Charge  N 9 51-59 51 29 Amount Paid  N 8 62-69 51 30 Balance Due  N 8 71-78 52 33 Billing  Provider Phone  Number Area  Code  N 3 66-68 52 33 Billing  Provider  Phone  Number  N 9 70-78 * M = mark  (X), A = alpha, N  = numeric  53 32 Name of  Facility  Where  Svcs  Rendered  A/N 26 23-48 LINE  FIELD  LITERAL  FIELD  TYPE*  BYTES  COL -UMNS  53 33 Physician/Supplier Billing  Name  A/N 29 50-78 54 32 Address  of Facility  Where Svcs  Rd d  A/N 26 23-48 54 33 Physician/Supplier Address  A/N 29 50-78 55 31 Left Blank  for Signature Physician/Supplier     55 32 City,  State and ZIP  Code  of Facility  A/N 26 23-48 55 33 City,  State and ZIP  Code  of Billing  P id  A/N 29 50-78 56 32a Facility  NPI  Number  N 10 24-33 56 32b Facility  Qualifier  and Legacy  Number  A/N 14 35-48 56 33a Billing  Provider NPI  Number  N 10 51-60 56 33b Billing  Provider Qualifier and Legacy  Nb  A/N 17 62-78 * M = mark  (X), A = alpha, N  = numeric