MC058 ICD-9-CM Procedure Code 1/1/2003 Text 4 Primary procedure code for this line of service Do not code decimal point. Refer to Appendix A Date of Service – From 1/1/2003 Text 8 First date of service for this service line CCYYMMDD MC060 Date of Service – Thru 1/1/2003 Text 8 Last date of service for this service line CCYYMMDD MC061 Quantity 1/1/2003 Number 10 Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. MC062 Charge Amount 1/1/2003 Number 10 Do not code decimal point. MC063 Paid Amount 1/1/2003 Number 10 Includes any withhold amounts Do not code decimal point. MC064 Prepaid Amount 1/1/2003 Number 10 For capitated services, the fee for service equivalent amount Do not code decimal point. MC065 Co-pay Amount 1/1/2003 Number 10 The preset, fixed dollar
Provider Last Name or Organization Name. Service Facility National Provider IDdentifier – Service Facility 10/1/2014 Text 20 National Provider ID for laboratory or service facility If blank or not specified, populate with MC077 -- National Provider ID – Billing Provider. Refer to Appendix A MC087 Service Facility Location Address Line 1 10/1/2014 Text 55 Address information for laboratory or service facility If blank or not specified, populate with MC080 -- Billing Provider Address Line 1. MC088 Service Facility Location Address Line 2 10/1/2014 Text 55 Address information for laboratory or service facility If blank or not specified, populate with MC081 -- Billing Provider Address Line 2. MC089 Service Facility Location City Name 10/1/2014 Text 30 City name of laboratory or service facility If blank or not specified, populate with MC082 -- Billing Provider City Name. Refer to Appendix A MC090 Service Facility Location Address 10/1/2014 Text 2 As defined by the US Postal Service and Canada Post
MC104 Member Last Name 1/1/2010 Text 60 The member last name Member Name 1/1/2010 Text 35 The member name Member Middle Name 1/1/2010 Text 25 The member middle name or initial MC107 Attending Provider Number 1/1/2016 Text 30 Payer assigned attending provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. National Provider ID – Attending Provider 1/1/2016 Text 20 National Provider ID for attending provider Refer to Appendix A MC109 Attending Provider First Name 1/1/2016 Text 40 Individual first name MC110 Attending Provider Middle Name 1/1/2016 Text 25 Individual middle name or initial MC111 Attending Provider Last Name 1/1/2016 Text 60 Individual last name Attending Provider Suffix 1/1/2016 Text 10 Individual name suffix The attending provider suffix
MC206 External Cause of Injury - 1 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator - 1 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External of Injury - 2 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A MC209 Present On Admission Indicator - 2 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC210 External Cause of Injury - 3 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC211 Present On Admission Indicator - 3 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC212 External of Injury - 4 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A Present On Admission Indicator - 4 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC214 External of 10/1/2014 Text 7 ICD-10-CM Do not code
Injury - 5 decimal Refer to Appendix A Present On Admission Indicator - 5 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC216 External Cause of Injury - 6 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC217 Present On Admission Indicator - 6 10/1/2014 Text 1 Standard POA code set to Appendix A External Cause of Injury - 7 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC219 Present On Admission Indicator - 7 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External Cause of Injury - 8 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC221 Present On Admission Indicator - 8 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External of Injury - 9 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A
MC223 Present On Admission Indicator - 9 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC224 External of Injury - 10 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC225 Present On Admission Indicator - 10 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC226 External Cause of Injury - 11 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC227 Present On Admission Indicator - 11 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC228 External Cause of Injury - 12 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC229 Present On Admission Indicator - 12 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC230 External Cause of Injury - 13 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator - 13 10/1/2014 Text 1 Standard POA code set Refer to Appendix A
External Cause of Injury - 14 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A MC233 Present On Admission Indicator - 14 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC234 External Cause of Injury - 15 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A MC235 Present On Admission Indicator - 15 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC236 External Cause of Injury - 16 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A MC237 Present On Admission Indicator - 16 10/1/2014 Text 1 Standard POA code set to Appendix A MC238 External Cause of Injury - 17 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC239 Present On Admission Indicator - 17 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC240 External of Injury - 18 10/1/2014 Text 7 ICD-10-CM Do not code decimal point.
Refer to Appendix A MC241 Present On Admission Indicator - 18 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External Cause of Injury - 19 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC243 Present On Admission Indicator - 19 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC244 External Cause of Injury - 20 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A MC245 Present On Admission Indicator - 20 10/1/2014 Text 1 Standard POA code set to Appendix A MC246 External Cause of Injury - 21 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A MC247 Present On Admission Indicator - 21 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External of Injury - 22 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A Present On 10/1/2014 Text 1 Standard POA code set
MC293 Present On Admission Indicator – 20 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC294 Other Diagnosis – 21 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC295 Present On Admission Indicator – 21 10/1/2014 Text 1 Standard POA code set to Appendix A MC296 Diagnosis – 22 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC297 Present On Admission Indicator – 22 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC298 Other Diagnosis – 23 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC299 Present On Admission Indicator – 23 10/1/2014 Text 1 Standard POA code set to Appendix A MC300 Other Diagnosis – 24 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC301 Present On Admission Indicator – 24 10/1/2014 Text 1 Standard POA code set Refer to Appendix A
MC302 Principal Procedure Code 10/1/2014 Text 7 IDC-10-CM Primary procedure code for this line of service Do not code decimal point. Refer to Appendix A Other Procedure Code - 1 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A Procedure Code - 2 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A Other Procedure Code - 3 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A Other Procedure Code - 4 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC307 Other Procedure Code - 5 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC308 Other Procedure Code - 6 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC309 Other Procedure Code - 7 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC310 Other Procedure 10/1/2014 Text 7 ICD-10 PCS Do not code
MC319 Other Procedure Code - 17 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC320 Other Procedure Code - 18 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC321 Procedure Code - 19 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC322 Other Procedure Code - 20 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. to Appendix A MC323 Other Procedure Code - 21 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. to Appendix A MC324 Other Procedure Code - 22 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC325 Other Procedure Code - 23 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC326 Other Procedure Code - 24 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. to Appendix A Record Type 1/1/2003 Text 2 Value = MC