evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual Crosswalk)
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.
(Medicare Claims Processing Manual Crosswalk)
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
(Medicare Claims Processing Manual Crosswalk)
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
(Medicare Claims Processing Manual Crosswalk)
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.
(Medicare Claims Processing Manual Crosswalk)
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     The HIPPS rate code consists of the three- character resource utilization group (RUG) code that is obtained from the Grouper software program followed by a 2- digit assessment indicator (AI) that specifies the type of assessment associated with the RUG code obtained from the Grouper.  SNFs must use the version of the Grouper software program identified by CMS for national PPS as described in the Federal Register for that year.  The Grouper translates the data in the Long Term Care Resident Instrument into a case mix group and assigns the correct RUG code.  The AIs were developed by CMS.
(Medicare Claims Processing Manual Crosswalk)
The Grouper will not automatically assign the 2- digit AI, except in the case of a swing bed MDS that is will result in a special payment situation AI (see below).  The HIPPS rate codes that appear on the claim must match the assessment that has been transm itted and accepted by the State in which the facility operates.  The SNF cannot put a HIPPS rate code on the claim that does not match the assessment.    HIPPS Rate Codes used for Medicare claims are available from Medicare contractors.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff. in Chapter 6 of this manual).    HIPPS Modifiers/Assessment Type Indicators     The assessment indicators (AI) were developed by CMS to identify on the claim, which of the scheduled Medicare assessments or off -cycle assessments is associated with the assessment reference date and the RUG that is included on the claim for payment of Medicare SNF services.  In addition, the AIs identify the Effective Date for the beginning of the covered period and aid in ensuring that the number of days billed for each scheduled Medicare assessment or off cycle assessment accurately reflect the changes in the beneficiary's status over time.  The indicators were developed by utilizing codes for the reason for assessment contained in section AA8 of the current version of the Resident Assessment Instrument, Minimum Data Set in order to ease the reporting of  such information.  Follow the CMS manual instructions for appropriate assignment of the assessment codes.    HIPPS Modifiers/Assessment Type Indicators used for Medicare claims are available from Medicare contractors.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff. in Chapter 6 of this manual).    HCPCS Modifiers (Level I and Level II)
(Medicare Claims Processing Manual Crosswalk)
HCPCS Modifiers (Level I and Level II)     Form CMS -1450 accommodates up to four modifiers, two characters each.  See AMA publication CPT 20xx (xx= to current year) Current Procedural Terminology Appendix A - HCPCS Modifiers Section: Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use.  Various CPT (Level I HCPCS) and Level II HCPCS codes may require the use of modifiers to improve the accuracy of coding.  Consequently, reimbursement, coding consistency, editing and proper payment will benefit from the reporting of modif iers.  Hospitals should not report a separate HCPCS (five -digit code) instead of the modifier.  When appropriate, report a modifier based on the list indicated in the above section of the AMA publication.    HCPCS modifiers used for Medicare claims are available from Medicare contractors.    FL 45 -  Service Date     Required Outpatient. CMHCs and hospitals (with the exception of CAHs, Indian Health  Service hospitals and hospitals located in American Samoa, Guam and Saipan) report line item dates of service on all bills containing revenue codes, procedure codes or drug codes.  This includes claims where the from and through dates are equal.  This change is due to a HIPAA requirement.     There must be a single line item date of service (LIDOS) for every iteration of every revenue code on all outpatient bills (TOBs 013X, 014X, 023X, 024X, 032X, 033X, 034X, 071X, 072X, 073X, 074X, 075X, 076X, 077X (effective April 1, 2010), 081X, 082X, 083X, and 085X and on inpatient Part B bills (TOBs 012x and 022x).  If a particular service is rendered 5 times during the billing period, the revenue code and HCPCS code must be entered 5 times, once for each service date.    FL 46 -  Units of Service
(Medicare Claims Processing Manual Crosswalk)
FL 46 -  Units of Service     Required . Generally, the entries in this column quantify services by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood.  However, when HCPCS codes are required for services, the units are equal to the number of times  the procedure/service being reported was performed.    The provider enters up to seven numeric digits. It shows charges for noncovered services as noncovered, or omits them.  NOTE: Hospital outpatient departments report the number of visits/sessions when billing under the partial hospitalization program or the intensive outpatient program .    FL 47 -  Total Charges -  Not Applicable for Electronic Billers
(Medicare Claims Processing Manual Crosswalk)
FL 47 -  Total Charges -  Not Applicable for Electronic Billers    Required .  This is the FL in which the provider sums the total charges for the billing period for each revenue code (FL 42); or, if the services require, in addition to the revenue center code, a HCPCS procedure code, where the provider sums the total charges for the billing period for each HCPCS code.  The last revenue code entered in FL 42 is 0001 which represents the grand total of all charges billed.  The amount for this code, as for all others is entered in FL 47.  Each line for FL 47 allows up to nine numer ic digits (0000000.00).  The CMS policy is for providers to bill Medicare on the same basis that they bill other payers.  This policy provides consistency of bill data with the cost report so that bill data may be used to substantiate the cost report.  Medicare and non- Medicare charges for the same department must be reported consistently on the cost report.  This means that the professional component is included on, or excluded from, the cost report for Medicare and non- Medicare charges.  Where billing for  the professional components is not consistent for all payers, i.e., where some payers require net billing and others require gross, the provider must adjust either net charges up to gross or gross charges down to net for cost report preparation.  In such cases, it must adjust its provider statistical and reimbursement (PS&R) reports that it derives from the bill.  Laboratory tests (revenue codes 0300 -0319) are billed as net for outpatient or nonpatient bill s because payment is based on the lower of charges for the hospital component or the fee schedule.  The A/B MAC (A or HHH) determines, in consultation with the provider, whether the provider must bill net or gross for each revenue center other than laborat ory.  Where gross billing is used, the A/B MAC (A or HHH) adjusts interim payment rates to exclude payment for hospital -based physician services.  The physician component  must be billed to the Part B MAC  to obtain payment.  All revenue codes requiring HCPCS codes and paid under a fee schedule are billed as net.    FL 48 -  Noncovered Charges     Required . The total non- covered charges pertaining to the related revenue code in FL 42 are entered here.     FL 49 -  (Untitled)
(Medicare Claims Processing Manual Crosswalk)
FL 48 -  Noncovered Charges     Required . The total non- covered charges pertaining to the related revenue code in FL 42 are entered here.     FL 49 -  (Untitled)     Not used. Data entered will be ignored.     Note: the PAGE ____ OF ____ and CREATION DATE on line 23 should be reported on all pages of the UB -04.    FL 50A (Required), B (Situational), and C (Situational) -  Payer Identification     If Medicare is the primary payer, the provider must enter Medicare on line A.  Entering Medicare indicates that the provider has developed for other insurance and determined that Medicare is the primary payer.  All additional entries across line A (FLs 5 1-55) supply information needed by the payer named in FL 50A.  If Medicare is the secondary or tertiary payer, the provider identifies the primary payer on line A and enters Medicare information on line B or C as appropriate.    FL 51A (Required), B (Situational), and C (Situational)  Health Plan ID     Report the national health plan identifier when one is established; otherwise report the number Medicare has assigned.     FLs 52A, B, and C -  Release of Information Certification Indicator     Required . A Y code indicates that the provider has on file a signed statement permitting it to release data to other organizations in order to adjudicate the claim.  Required when state or federal laws do not supersede the HIPAA Privacy Rule by requiring that a signature be collected. An I code indicates Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes.  Required when the provider has not collected a signature and state or federal laws do not supersede the HIPAA Privacy Rule by requiring a signature be collected.    NOTE: The back of Form CMS -1450 contains a certification that all necessary release statements are on file.    FL 53A, B, and C -  Assignment of Benefits Certification Indicator     Not used. Data entered will be ignored.     FLs 54A, B, and C -  Prior Payments     Situational . Required when the indicated payer has paid an amount to the provider towards this bill.     FL 55A, B, and C -  Estimated Amount Due From Patient     Not required.     FL 56  Billing Provider National Provider ID (NPI)     Required on or after May 23, 2008.
(Medicare Claims Processing Manual Crosswalk)
FL 55A, B, and C -  Estimated Amount Due From Patient     Not required.     FL 56  Billing Provider National Provider ID (NPI)     Required on or after May 23, 2008.    FL 57  Other Provider ID (primary, secondary, and/or tertiary)     Not used. Data entered will be ignored.     FLs 58A, B, and C -  Insureds Name     Required . The name of the individual under whose name the insurance benefit is carried.    FL 59A, B, and C -  Patients Relationship to Insured     Required .  If the provider is claiming payment under any of the circumstances described under FLs 58 A, B, or C, it must enter the code indicating the relationship of the patient to the identified insured, if this information is readily available.    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 60A (Required), B (Situational), and C (Situational)  Insureds Unique ID (Certificate/Social Security Number/ Medicare beneficiary identifier)     The unique number assigned by the health plan to the insured.    FL 61A, B, and C -  Insurance Group Name     Situational (required if known) .  Where the provider is claiming payment under the circumstances described in FLs 58A, B, or C and a Workers Compensation (WC) or an Employer Group Health Plan (EGHP) is involved, it enters the name of the group or plan through which that insurance is pr ovided.    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
(Medicare Claims Processing Manual Crosswalk)
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.