(Medicare Claims Processing Manual Crosswalk)

Required.   The provider enters the month, day, and year of birth (MMDDCCYY) of patient.  If full birth date is unknown, indicate zeros for all eight digits.  FL 11 -  Patients Sex   Required.   The provider enters an M (male) or an F (female).  The patients sex is recorded at admission, outpatient service, or start of care.   FL 12 -  Admission/Start of Care Date   Required For Inpatient and Home Health.   The hospital enters the date the patient was admitted for inpatient care (MMDDYY).  The HHA enters the same date of admission that was submitted on the RAP for the episode.   FL 13 -  Admission Hour   Not Required.   If submitted, the data will be ignored. FL 14 -  Priority (Type) of Admission or Visit   Required.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   FL 15 -  Point of Origin for Admission or Visit   Required except for Bill Type 014X.   The provider enters the code indicating the source of the referral for this admission or visit.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   75.2 - Form Locators 16 -30 (Rev. 1973, Issued: 05- 21-10, Effective: 09 -01-10, Implementation: 09- 01-10)  FL 16 -  Discharge Hour   Not Required .  FL 17  - Patient Discharge Status    Required .  (For all Part A inpatient, SNF, hospice, home health agency (HHA) and outpatient hospital services.)  This code indicates the patients discharge status as of the Through date of the billing period (FL 6).   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   FLs 18 -  28 - Condition Codes   Situational .  The provider enters the corresponding code (in numerical order) to describe any of the following conditions or events that apply to this billing period.  Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   FL 29 -  Accident State  Not used.  Data entered will be ignored. FL 30 -  (Untitled)  Not used.  Data entered will be ignored.  75.3 - Form Locators 31 -41 (Rev. 2922, Issued: 04- 03-14, Effective: 04 -18-14, Implementation: 04- 18-14)  FLs 31, 32, 33, and 34 -  Occurrence Codes and Dates   Situational .  Required when there is a condition code that applies to this claim.   GUIDELINES FOR OCCURRENCE AND OCCURRENCE SPAN UTILIZATION  Due to the varied nature of Occurrence and Occurrence Span Codes, provisions have been made to allow the use of both type codes within each.  The Occurrence Span Code can contain an occurrence code where the Through date would not contain an entry.  This allows as many as 10 Occurrence Codes to be utilized.  With respect to Occurrence Codes, complete field 31a -  34a (line level) before the b fields.  Occurrence and Occurrence Span codes are mutually exclusive.  An example of Occurrence Code use:  A Medi care beneficiary was confined in hospital from January 1, 2005 to January 10, 2005, however, his Medicare Part A benefits were exhausted as of January 8, 2005, and he was not entitled to Part B benefits.  Therefore, Form Locator 31 should contain code A3 a nd the date 010805.   The provider enters code(s) and associated date(s) defining specific event(s) relating to this billing period.  Event codes are two alpha -numeric digits, and dates are six numeric digits (MMDDYY).  When occurrence codes 01 -04 and 24 are entered, the provider must make sure the entry includes the appropriate value code in FLs 39 -41, if there is another payer involved.  Occurrence and occurrence span codes are mutually exclusive.  When FLs 36 A and B are fully used with occurrence span codes, FLs 34a and 34b and 35a and 35b may be used to contain the From and Through dates of other occurrence span codes.  In this case, the code in FL 34 is the occurrence span code and the occurrence span From dates is in the date field.  FL 35 contains the same occurrenc e span code as the code in FL 34, and the occurrence span Through date is in the date field.  Other payers may require other codes, and while Medicare does not use them, they may be entered on the bill if convenient.  Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   FLs 35 and 36 -  Occurrence Span Code and Dates   Required For Inpatient.   The provider enters codes and associated beginning and ending dates defining a specific event relating to this billing period.  Event codes are two alpha -numeric digits and dates are shown numerically as MMDDYY.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   Special Billing Procedures When more than Ten Occurrence Span Codes (OSCs) Apply to a Single Stay   The Long Term Care Hospital (LTCH), Inpatient Psychiatric Facility (IPF), and Inpatient Rehabilitation Facility (IRF) Prospective Payment Systems (PPSs) requires a single claim to be billed for an entire stay.  Interim claims may be submitted to continually adjust all prior submitted claims for the stay until the beneficiary is discharged.  In some instances, significantly long stays having numerous OSCs may exceed the amount of OSCs allowed to be billed on a claim .  When a provider paid under the LTCH, IPF or IRF PPSs encounters a situation in which ten or more OSCs are to be billed on the claim, the provider must bill for the entire stay up to the Through date of the 10th OSC for the stay (the Through date for the Statement Covers Period equals the Through date of the tenth OSC).  As the stay continues, the provider must only bill the 11th through the 20th OSC for the stay, if applicable.  Once the twentieth OSC is applied to the claim, the provider must only bill the 21st through the 30th OSC for the stay, if applicable.  The Shared System Maintainers (SSMs) retain the history of all OSCs billed for the stay to ensure proper processing (i.e., as if no OSC limitation exists  on the claim).   For a detailed billing example that outlines possible billing scenarios, please go to  http://www.cms.hhs.gov/Transmittals/01_Overview.asp and refer to CR 6777 located on the 2010 Transmittals page.  FL 37 -  (Untitled)   Not used.  Data entered will be ignored.  FL 38 -  Responsible Party Name and Address   Not Required .  For claims that involve payers of higher priority than Medicare.   FLs 39, 40, and 41 -  Value Codes and Amounts   Required .  Code(s) and related dollar or unit amount(s) identify data of a monetary nature that are necessary for the processing of this claim.  The codes are two alpha -numeric digits, and each value allows up to nine numeric digits (0000000.00).  Negative amounts  are not allowed except in FL 41.  Whole numbers or non- dollar amounts are right justified to the left of the dollars and cents delimiter.  Some values are reported as cents, so the provider must refer to specific codes for instructions.  If more than one value code is shown for a billing period, codes are shown in ascending numeric sequence.  There are four lines of data, line a through line d.  The provider uses FLs 39A through 41A before 39B through 41B (i.e., it uses the first line before the second).   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   75.4 - Form Locator 42  (Rev. 1973, Issued: 05- 21-10, Effective: 09 -01-10, Implementation: 09- 01-10)  FL 42 -  Revenue Code   Required .  The provider enters the appropriate revenue codes from the following list to identify specific accommodation and/or ancillary charges.  It must enter the appropriate numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47.  Additionally, there is no fixed Total line in the charge area.  The provider must enter revenue code 0001 instead in FL 42.  Thus, the adjacent charges entry in FL 47 is the sum of charges billed.  This is the same line on which non- covered charges, in FL 48, if any, are summed.  To assist in bill review, the provider must list revenue codes in ascending numeric sequence and not repeat on the same bill to the extent possible.  To limit the number of line items on each bill, it should sum revenue codes at the zero level to the extent possible.  Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC ( www.nubc.org ) via the NUBCs Official UB -04 Data Specifications Manual.   75.5 - Form Locators 43 -65 (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.    FL 43 -  Revenue Description/IDE Number/Medicaid Drug Rebate    Not Required .  The provider enters a narrative description or standard abbreviation for each revenue code shown in FL 42 on the adjacent line in FL 43.  The information assists clerical bill review.  Descriptions or abbreviations correspond to the revenue codes. Other code categories are locally defined and individually described on each bill.     The investigational device exemption (IDE) or procedure identifies a specific device used only for billing under the specific revenue code 0624.  The IDE will appear on the paper format of Form CMS -1450 as follows: FDA IDE # A123456 (17 spaces).     HHAs identify the specific piece of durable medical equipment (DME) or non- routine supplies for which they are billing in this area on the line adjacent to the related revenue code.  This description must be shown in Healthcare Common Procedure Coding Syst em (HCPCS) coding.    When required to submit drug rebate data for Medicaid rebates, submit N4 followed by the 11 -digit National Drug Code (NDC) in positions 01- 13 (e.g., N499999999999). Report the NDC quantity qualifier followed by the quantity beginning in position 14.  The D escription Field on Form CMS -1450 is 24 characters in length. An example of the methodology is illustrated below.    N   4   1   2   3   4   5   6   7   8   9   0   1   U   N   1   2   3   4   .   5   6   7       FL 44 -  HCPCS/Rates/HIPPS Rate Codes     Required. When coding HCPCS for outpatient services, the provider enters the HCPCS code describing the procedure here.  On inpatient hospital bills the accommodation rate is shown here.     HCPCS used for Medicare claims are available from Medicare contractors.    Health Insurance Prospective Payment System (HIPPS ) Rate Codes