(Medicare Claims Processing Manual Crosswalk)

FL 62A, B, and C -  Insurance Group Number     Situational (required if known) . Where the provider is claiming payment under the circumstances described in FLs 58A, B, or C and a WC or an EGHP is involved, it enters the identification number, control number or code assigned by that health insurance carrier to identify the group unde r which the insured individual is covered.    FL 63 -  Treatment Authorization Code     Situational. Required when an authorization or referral number is assigned by the payer and then the services on this claim AND either the services on this claim were preauthorized or a referral is involved.  Whenever Quality Improvement Organization (QIO) review is pe rformed for outpatient preadmission, pre -procedure, or Home IV therapy services, the authorization number is required for all approved admissions or services.     FL 64  Document Control Number (DCN)     Situational. The control number assigned to the original bill by the health plan or the health plans fiscal agent as part of their internal control.    FL 65 -  Employer Name (of the Insured)    Situational. Where the provider is claiming payment under the circumstances described in the second paragraph of FLs 58A, B, or C and there is WC involvement or an EGHP, it enters the name of the employer that provides health care coverage for the individual identified on the same line in FL 58.    75.6 - Form Locators 66 -81 (Rev.  3435, Issued: 12- 31-15, Effective: 07 -01-15, Implementation: 03- 31-16)  FL 66  Diagnosis and Procedure code Qualifier (ICD Version Indicator)  Required.   The qualifier that denotes the version of International Classification of Diseases (ICD) reported.  The following qualifier codes reflect the edition portion of the ICD: 9 - Ninth Revision, 0 - Tenth Revision.   FL 67 - Principal Diagnosis Code   Required .  The hospital enters the ICD code for the principal diagnosis.  The code must be the full ICD diagnosis code, including all five digits where applicable for ICD -9 or all seven digits for ICD -10.  The reporting of the decimal between the third and fourth digit is unnecessary because it is implied.   The principal diagnosis code will include the use of V codes where ICD -9-CM is applicable.  Where the proper code has fewer than five digits (ICD -9-CM) or seven digits (ICD -10-CM), the hospital may not fill with zeros.  The principal diagnosis is the condition established after study to be chiefly responsible for this admission.  Even though another diagnosis may be more severe than the principal diagnosis, the hospital enters the principal diagnosis.  Entering any other diagnosis may result in incorrect assignment of a Diagnosis Related Group (DRG) and cause the hospital to be incorrectly paid under PPS.  The hospital reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient services i n FL 67 of the bill.  It reports the diagnosis to its highest degree of certainty.  For instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom must be reported.  If during the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g., acute bronchitis), the hospital must report the definitive diagnosis.  When a patient arrives at the hospital for examination or testing without  a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations.  FLs 67A -67Q - Other Diagnosis Codes   Situational. Required when other condition(s) coexist or develop(s) subsequently during the patients treatment.   FL 68  Reserved   Not used. Data entered will be ignored.   FL 69 - Admitting Diagnosis   Required . For inpatient hospital claims subject to QIO review, the admitting diagnosis is required.  Admitting diagnosis is the condition identified by the physician at the time of the patients admission requiring hospitalization.   FL70A  70C - Patients Reason for Visit   Situational.  It is required for Medicare institutional claims processing on Type of Bill 013x and 085x when: a) Form Locator 14 (Priority (Type) of Admission or Visit) codes 1, 2, or 5 are reported; and b) Revenue Codes 045x, 0516, or 0762 are reported.  The requirement for reporting Patients Reason for Visit is restricted to the outpatient bill types above.   If the Patients Reason for Visit is not required, it may be reported on other 013x and 085x bill types that fail to meet the criteria in a) or b) above at the senders discretion when this information substantiates the medical necessity of services.   FL71  Prospective Payment System (PPS) Code   Not used. Data entered will be ignored.   FL72 - External Cause of Injury (ECI) Codes   Not used. Data entered will be ignored.   FL 73  Reserved   Not used. Data entered will be ignored.   FL 74 - Principal Procedure Code and Date   Situational. Required on inpatient claims when a procedure was performed. Not used on outpatient claims.   FL 74A  74E - Other Procedure Codes and Dates   Situational. Required on inpatient claims when additional procedures must be reported. Not used on outpatient claims.   FL 75  Reserved   Not used. Data entered will be ignored.   FL 76 - Attending Provider Name and Identifiers (including NPI)   Situational. Required when claim/encounter contains any services other than nonscheduled transportation services. If not required, do not send.  The attending provider is the individual who has overall responsibility for the patients medical care and treatment reported in this claim/ encounter.   Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FL 77 - Operating Provider Name and Identifiers (including NPI)   Situational. Required when a surgical procedure code is listed on this claim. If not required, do not send.  The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s).   Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)   Situational . The name and ID number of the individual corresponding to the qualifier category indicate d in this section of the claim.   Provider Type Qualifier Codes/Definition/Situational Usage Notes:   DN - Referring Provider. The provider who sends the patient to another provider for services. Required on an outpatient claim when the Referring Provider is different than the Attending Physician. If not required, do not send.   ZZ - Other Operating Physician.  An individual performing a secondary surgical procedure or assisting the Operating Physician.  Required when another Operating Physician is involved.  If not required, do not send.  82 - Rendering Provider.  The health care professional who delivers or completes a particular medical service or non-surgical procedure.  Report when state or federal regulatory requirements call for a combined claim, i.e., a claim that includes both facility and professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim).  If not required, do not send.  Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FL 80  Remarks   Situational.  For DME billings the provider shows the rental rate, cost, and anticipated months of usage so that the providers A/B MAC (A or HH H) may determine whether to approve the rental or purchase of the equipment.  Where Medicare is not the primary payer because WC, automobile medical, no-fault, liability insurer or an EGHP is primary, the provider enters special annotations.  In addition, the provider enters any remarks needed to provide information that is not shown elsewhere on the bill but which is necessary for proper payment.  For Renal Dialysis Facilities, the provider enters the first month of the 30-month period during which Medicare benefits are secondary to benefits payable under an EGHP. (See Occurrence Code 33.)   FL 81 - Code -Code Field   Situational.  To report additional codes related to a Form Locator or to report external code list approved by the NUBC for inclusion to the institutional data set.   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.