TABLE OF CONTENTS - HFMA NH VT - HomeOCTOBER 2001 1-4 If an EGHP pays benefits as a primary payer,...

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TABLE OF CONTENTS

SECTION PAGE

Summary of Medicare Secondary Payer Provisions ..........................................................................1.3Inquiries..............................................................................................................................................1.5

Anthem BCBS-NH...................................................................................................................1.5Matthew Thornton Health Plan (MTHP) .................................................................................1.5BCBSVT ..................................................................................................................................1.6TRICARE.................................................................................................................................1.6CHAMPVA ..............................................................................................................................1.6CIGNA NH...............................................................................................................................1.7NH/VT Medicare......................................................................................................................1.7NH Medicaid ............................................................................................................................1.7VT Medicaid ............................................................................................................................1.7

UB92 (HCFA 1450) Billing Forms....................................................................................................1.8Additional Billing Manuals................................................................................................................1.8

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GENERAL INFORMATION

Use of the UB92 Billing Manual

This manual was prepared by the NH/VT HFMA Claims Processing Committee for paper claimssubmissions and is not intended to be all-inclusive. For questions regarding electronic claims submissionor remittance advices, refer to the specific electronic specifications of the payer.

HIPPA Impact

Due to the upcoming HIPPA regulations, it is recognized that much of this manual will change or be outof date at the point that the regulations are implemented. You should receive periodic updates from thepayer, CMS website, Medicare Bulletins, Program Memoranda, or other sources. The content changes asa result of HIPPA will be incorporated in a subsequent manual revision.

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SUMMARY OFMEDICARE SECONDARY PAYER PROVISIONS

Summary of Medicare Secondary Payer Provisions

• Omnibus Reconciliation Act of 1980

Section 953 of the Omnibus Reconciliation Act of 1980 precludes payment under Medicare forotherwise covered items or services to the extent that payment has been made, or can reasonably beexpected to be made, for the items or services under an automobile or liability insurance policy orplan (including a self-insured plan), or under no-fault insurance.

Regulations to implement Section 953 of the Omnibus Reconciliation Act of 1980 were publishedon April 5, 1983. They state that Medicare is secondary even if state law or private contract ofinsurance stipulates that Medicare is primary. Medicare payment will be denied if automobile orno-fault insurance will not pay because of a Medicare primary clause in the automobile insurancepolicy. However, if cases arise in which automobile insurers continue to disallow payments on thisground for services furnished on or after June 6, 1983, the Medicare payments will be conditional,the beneficiary must refund the Medicare payment in the event that payment is later made by theautomobile insurer. Payments made to the beneficiary by the insurer prior to June 6, 1983 are notsubject to collection.

Effective with respect to services related to injuries which occurred on or after December 5, 1980.

• Omnibus Reconciliation Act of 1981

Section 2164 of the Omnibus Reconciliation Act of 1981 makes Medicare benefits secondary tobenefits payable under an employer group health plan (EGHP) in the case of individuals who areentitled to benefits solely on the basis of end stage renal disease (ESRD), during a period of up to 12months.

Policy Implementing 4203(c)(1) of the Omnibus Budget Reconciliation Act of 1990-Amendments tothe ESRD-MSP Provision.

In general, the amendments made by OBRA 90 make Medicare the secondary payer during the first18 months of an individual’s Part A entitlement based solely on ESRD. (Where there is a 3-monthwaiting period before Medicare Part A eligibility or entitlement begins, employer group health plans(EGHPS) will be primary payers for 21 months--the 3-month waiting period plus the first 18 monthsof the individual’s entitlement to or eligibility for Medicare Part A.)

In general, individuals who were in a 12-month period under prior law, and for whom an employerplan was, therefore, the primary payer, on November 5, 1990, are affected by these changes.Individuals whose 12-month periods under prior law ended on October 31, 1990 or earlier are notaffected by these changes.

Section 4631 (b) of the BBA of 1997 permanently extends the coordination period to 30 months forany individual whose coordination period began on or after March 1, 1996. Therefore, individualswho have not completed an 18-month coordination period by July 31, 1997 will have a 30 monthcoordination period under the new law.

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If an EGHP pays benefits as a primary payer, but pays less than the amount which Medicare wouldhave paid in the absence of employer plan coverage, secondary Medicare benefits may be paid. If anemployer plan denies payment for particular services because they are not covered by the plan,primary Medicare benefits may be paid for them. Medicare will continue to evaluate claims underexisting guidelines for covered services.

Effective for items and services furnished on or after October 1, 1981.

• Working Aged Legislation

Section 116(b) of the Tax Equity and Fiscal Responsibility Act of 1982 makes Medicare benefitssecondary to benefits payable under employer group health plans (EGHP) for employees aged 65through 69 and their spouses age 65 through 69. For purposes of this Medicare Secondary provision,employers are required, effective January 1, 1983, to offer coverage to their age 65-69 employees andto the age 65-69 spouses of such employees. Medicare beneficiaries are free to elect Medicare astheir primary coverage instead of primary coverage offered by the employer. However, effectiveJanuary 1, 1983 employers cannot offer such employees or their spouses complementary coverage ona secondary payer basis.

Effective January 1, 1985, Section 2301 of the Deficit Reduction Act (DEFRA) of 1984, madeMedicare secondary for spouses age 65 through 69 of employed individuals of any age under 70covered by an employer group health plan.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) extended the working agedprovision of the Tax Equity and Fiscal Responsibility Act of 1982. Effective for services rendered onand after secondary payer for workers age 65 and older, as well as spouses age 65 or older or workersof any age who elect coverage through an employer group health plan.

Effective for items and services furnished on or after January 1, 1983.

• Omnibus Budget Reconciliation Act of 1986

Section 9319 of the Omnibus Budget Reconciliation Act of 1986 made Medicare benefits secondaryto benefits payable under large group health plans (LGHPs), i.e., plans that have at least oneemployer of 100 or more employees for disabled beneficiaries under age 65, by reasons of theiremployment or the employment of a family member. It also gives the government, the individual andall claimants the right to take legal action against a LGHP which fails to pay primary benefits, whererequired, and to collect double damages.

Effective for items and services furnished on or after January 1, 1987.

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INQUIRIES

Anthem BCBS-NH:

Provider InquiriesBlueChoice® (YGC) .......................................................................................................1 800 332-6558Indemnity (YGA) ...........................................................................................................1 800 332-6558Matthew Thornton BlueSM (YGG) .................................................................................1 800 332-6558Medicomp (YGM)..........................................................................................................1 800 332-6558Preferred Blue® PPO (YGF)...........................................................................................1 800 332-6558BlueCard®.......................................................................................................................1 800 238-2465BlueChoice® New England (NHP, MTP, HPP, MEP, CTP, PVP, SYP).......................1 800 238-2465HMO Blue® New England (NHN, MTN, HPN, MEN, CTN, PVN) .............................1 800 238-2465Federal Employee Program (FEP) (R) ...........................................................................1 800 852-3316

Member InquiriesBlueChoice® (YGC) .......................................................................................................1 800 438-9672Indemnity (YGA) ..........................................................................................................1 800 225-2666Matthew Thornton BlueSM (YGG) ................................................................................1 800 870-3057Medicomp (YGM) .........................................................................................................1 800 225-2666Preferred Blue® PPO (YGF) ..........................................................................................1 800 852-6592BlueChoice® New England (NHP, MTP, HPP, MEP, CTP, PVP, SYP) ......................1 800 870-3122HMO Blue® New England (NHN, MTN, HPN, MEN, CTN, PVN)FEP (R) ..........................................................................................................................1 800 852-3316

Anthem BCBS3000 Goffs Falls Road

Manchester, NH 03111-0001

Matthew Thornton Health Plan (MTHP)Matthew Thornton Benefits Administrator (MTBA) TPA:

Provider InquiriesMTHP.............................................................................................................................1 800 319-5577MTBA TPA....................................................................................................................1 800 319-5577

Member InquiriesMTBA ............................................................................................................................1 800 544-8333MTBA TPA....................................................................................................................1 800 284-2010

MTHP3000 Goffs Falls Road

Manchester, NH 03111-0001

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BCBSVT

Provider InquiriesLocal and Out-of-State ...................................................................................................1 802 229-4777Vermont..........................................................................................................................1 800 924-3494New Hampshire ..............................................................................................................1 800 626-6979

Member InquiriesFee for Service – Local and Out-of-State ......................................................................1 802 223-3494 Vermont......................................................................................................................1 800 247-2583National Accounts ..........................................................................................................1 800 544-5244Federal Employee Program (FEP)..................................................................................1 800 328-0365New England Regional Product .....................................................................................1 800 395-3389State of Vermont ............................................................................................................1 800 757-7161The Vermont Health Plan...............................................................................................1 888 882-3600Vermont Health Partnership...........................................................................................1 800 924-3494

BCBSVTPO Box 186

Montpelier, VT 05601-0186

TRICARE:

Provider InquiriesProvider Customer Service ............................................................................................1 888 999-8422 Claims Inquiries .........................................................................................................1 888 578-1294

Member InquiriesBeneficiary Customer Service........................................................................................1 888 999-5195

General InquiriesNew Hampshire and Southern Vermont ........................................................................1 603 427-0528Central and Northern Vermont.......................................................................................1 315 779-1235

Sierra Military Health Services111 Market Place, Ste 410

Baltimore, MD 21202(Contact you local representative for a local mailing address).

TRICARE Correspondence:PGBA

PO Box 7012Camden, SC 29020-7012

CHAMPVA:

Customer Service ...........................................................................................................1 800 733-8387

CHAMPVA Center4500 Cherry Creek Drive South

Box 300Denver, CO 80222

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CIGNA NH:

Provider InquiriesLocal ...............................................................................................................1 603 228-4584, ext. 2595New Hampshire and Out of State ....................................................................................1 800 531-4010

CIGNA HealthcarePO Box 2041

Concord, NH 03302-2084

NH/VT Medicare:

Provider InquiriesIntermediary Part A .........................................................................................................1 866 539-5593Medicare Secondary Payer (MSP) ..................................................................................1 866 680-0749

Beneficiary InquiresIntermediary Part A .........................................................................................................1 800 522-8323

Anthem Health Plans of NH, Inc.NH/VT Medicare

3000 Goffs Falls RoadManchester, NH 03111-0001

NH Medicaid:

Provider InquiriesLocal and Out-of-State ...................................................................................................1 603 224-1747New Hampshire and Vermont ........................................................................................1 800 423-8303

EDS Federal CorporationPO Box 2040

Concord, NH 03302-2001

VT Medicaid:

Provider InquiriesLocal and Out of State....................................................................................................1 802 878-7871Vermont..........................................................................................................................1 800 925-1706

EDSPO Box 888

Williston, VT 05495-0888

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UB92 (HCFA 1450) BILLING FORMS

The acquisition of the UB92 (HCFA 1450) billing form will be your own responsibility. The UB92billing forms are available by calling the Standard Register at 1 603 432-5151. Information pertaining tothe ordering of these forms may be directed to members of the two-state Claims Processing Committee orthe New Hampshire Hospital Association.

ADDITIONAL BILLING MANUALS

Additional UB92 Billing Manuals are available at a cost of $25.00 each by writing:

Provider Support Services3000 Goffs Falls RoadManchester NH 03111 -0001

Please include your check with the request for additional manuals.

As required, revisions will be provided to you.

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TABLE OF CONTENTS

FORM LOCATORS DATA ELEMENT PAGE

1 Provider Name, Address and Telephone Number 2.3

2 Program Indicator 2.5

3 Patient Control Number 2.6

4 Type of Bill 2.7

5 Federal Tax Number 2.16

6 Statement Covers Period 2.17

7 Covered Days 2.18

8 Noncovered Days 2.19

9 Coinsurance Days 2.21

10 Lifetime Reserve Days 2.22

11 Unlabeled Field 2.24

12 Patient Name 2.25

13 Patient Address 2.26

14 Patient Birthdate 2.27

15 Patient Sex 2.28

16 Patient Marital Status 2.29

17 Admission Date 2.30

18 Admission Hour 2.31

19 Type of Admission 2.32

20 Source of Admission 2.34

21 Discharge Hour 2.40

22 Patient Status 2.41

23 Medical/Health Record Number 2.44

24-30 Condition Codes 2.45


32-35 A,B Occurrence Codes and Dates 2.58

36 A,B Occurrence Span Codes and Dates 2.66

37 A,B,C Internal Control Number (ICN)/Document 2.70

Control Number (DCN)

38 Responsible Party Name and Address 2.71

39-41 A,B,C,D Value Codes and Amounts 2.72

42 Revenue Code 2.83

43 Revenue Description 2.114

44 HCPCS/Rates 2.115

45 Service Date 2.116

46 Units of Service 2.117

47 Total Charges (by Revenue Code Category) 2.119

48 Noncovered Charges 2.121

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FORM LOCATORS DATA ELEMENT PAGE


50 A,B,C Payer Identification 2.123

51 A,B,C Provider Number 2.125

52 A,B,C Release of Information Certification Indicator 2.126

53 A,B,C Assignment of Benefits Certification Indicator 2.127

54 A,B,C,P Prior Payments - Payer and Patients 2.128

55 A,B,C,P Estimated Amount Due 2.129



58 A,B,C Insured’s Name 2.132

59 A,B,C Patient’s Relationship to Insured 2.134

60 A,B,C Certificate/Social Security Number/Health 2.137

Insurance Claim/Identification Number

61 A,B,C Insured Group Name 2.138

62 A,B,C Insured Group Number 2.139

63 A,B,C Treatment Authorization Code 2.140

64 A,B,C Employment Status Code 2.141

65 A,B,C Employer Name 2.142

66 A,B,C Employer Location 2.143

67 Principal Diagnosis Code 2.144

68-75 Other Diagnoses Codes 2.146

76 Admitting Diagnosis 2.147

77 External Cause of Inquiry Code (E-Code) 2.148


79 Procedure Coding Method Used 2.150

80 Principal Procedure Code and Date 2.151

81 A,B,C,D,E Other Procedure Codes and Dates 2.153

82 A,B Attending Physician ID 2.155

83 A,B,C,D Other Physician ID 2.158

84 Remarks 2.160

85 Provider Representative Signature 2.161

86 Date Bill Submitted 2.162

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FORM LOCATOR 1

DATA ELEMENT: Provider Name, Address and Telephone Number

DEFINITION: The name of the provider submitting the bill and the complete mailing address towhich the provider wishes payment sent. Minimum requirement is the provider’sname, city, state and zip code.

FIELD SIZE: 1 field, 4 lines, 25 positions, alphanumeric

NOTE: Line 1 Provider name.Line 2 Street address or post office box.Line 3 City, state, and zip code.

Address may include post office box or street name and number, city, state andzip code.

If a nine digit zip code is used, it should be printed in the form XXXXX-YYYYwhere X’s are five digit zip code and Y’s are the zip code extension.

Providers should abbreviate state in their address according to the Post Officestandard abbreviations that appear on the following page.

DETAILED BILLING INSTRUCTIONS

ANTHEM BCBS-NH: Required. Enter name, address and telephone number.

BCBSVT: Same as Anthem BCBS-NH.

TRICARE: Required. Enter name and address. Provider’s telephone number is helpful.

CIGNA NH: Required. Enter name and address.

MEDICARE: Required. The minimum entry is the provider’s name, city, state and zip code.The post office box number or street name and number may be included. Thestate may be abbreviated using standard post office abbreviations. Five or ninedigit zip codes are acceptable. This information is used in connection with theMedicare provider number (FL 51) to verify provider identity. Phone and/or faxnumbers are desirable.

MTHP: Same as Medicare, but also include the telephone number.

NH MEDICAID: Required. Enter name, address and telephone number as it appears on yourprovider enrollment form.

VT MEDICAID: Required. Enter name and address as it appears on your enrollment form. Do notenter the four character alpha code assigned by Medicare in front of your name.

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STANDARD POST OFFICE STATE ABBREVIATIONS

Alabama AL New Jersey NJAlaska AK New Mexico NMArizona AZ New York NYArkansas AR North Carolina NCCalifornia CA North Dakota NDColorado CO Ohio OHConnecticut CT Oklahoma OKDelaware DE Oregon ORDistrict of Columbia DC Pennsylvania PAFlorida FL Rhode Island RIGeorgia GA South Carolina SCHawaii HI South Dakota SDIdaho ID Tennessee TNIllinois IL Texas TXIndiana IN Utah UTIowa IA Vermont VTKansas KS Virginia VAKentucky KY Washington WALouisiana LA West Virginia WVMaine ME Wisconsin WIMaryland MD Wyoming WYMassachusetts MAMichigan MI American TerritoriesMinnesota MN American Samoa ASMississippi MS Canal Zone CZMissouri MO Guam GUMontana MT Puerto Rico PRNebraska NE Trust Territories TTNevada NV Virgin Islands VINew Hampshire NH

CANADIAN PROVINCES

Alberta AB Nova Scotia NSBritish Columbia BC Ontario ONLabrador LB Pr. Edward Island PEManitoba MB Quebec QCNew Brunswick NB Saskatchewan SKNewfoundland NF Yukon YTNorthwest Territ. NT

IF OTHER THAN THE UNITED STATES OR CANADA, USE CODE – XX

ARMED FORCES

AA Armed Forces (APO/FPO) in AmericaAE Armed Forces (APO/FPO) in EuropeAP Armed Forces (APO/FPO) in the Pacific

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FORM LOCATOR 2

DATA ELEMENT: Program Indicator

DEFINITION: Form Locator 2 has been assigned to assist third-party payers in theidentification of UB92 forms.

FIELD SIZE: 1 field, 30 characters


ANTHEM BCBS-NH: Not required.


TRICARE: Not required.

CIGNA NH: Not Required.

MEDICARE: Required. Example: Medicare Hospital Inpatient orMedicare Hospital OutpatientMedicare Swing Bed

MTHP: Desirable. Example: MTHP Hospital Inpatient orMTHP Hospital Outpatient orMTHP Hospital Surgical OutpatientMTHP Swing Bed

NH MEDICAID: Required. Example: NH Medicaid Hospital Inpatient orNH Medicaid Hospital Outpatient orNH Medicaid Hospital SNF orNH Medicaid Hospital ICF

VT MEDICAID: Required. Example: VT Medicaid Hospital Inpatient orVT Medicaid Hospital Outpatient

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FORM LOCATOR 3

DATA ELEMENT: Patient Control Number

DEFINITION: Patient’s unique alphanumeric identifier assigned by the provider to facilitateretrieval of individual financial records and posting of the payment.

FIELD SIZE: 1 field, 1 line, 20 positions, alphanumeric

NOTE: To enable hospitals to identify payments more easily, it is required that payersinclude the patient control number on the payment check, remittance advice orvoucher. Insurers are required to report back accurate information.


ANTHEM BCBS-NH: Required.

BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required.

MTHP: Required.

NH MEDICAID: Required, if applicable. Accepts up to 12 alphanumeric digits.

VT MEDICAID: Same as NH Medicaid.

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FORM LOCATOR 4

DATA ELEMENT: Type of Bill

DEFINITION: A code indicating the specific type of bill (inpatient, outpatient, adjustments,voids, etc.)


NOTE: This three digit code requires 1 digit each, in the following sequence:

1. Type of Facility2. Bill Classification/Type of Care, and3. Frequency

All positions must be fully coded.

CODE STRUCTURE:

Type of Facility - lst Digit

1 Hospital2 Skilled Nursing3 Home Health4 Religious Non-medical (Hospital)5 Religious Non-medical (Extended Care)6 Intermediate Care7 Clinic* or Hospital Based Renal Dialysis Facility (requires special information in 2nd digit)8 Special Facility or Hospital ASC Surgery (requires special information in 2nd digit)9 Reserved for National Assignment

Bill Classification (Except Clinics and Special Facilities) – 2nd Digit

1 Inpatient (Part A)2 Hospital Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)3 Outpatient (includes HHA visits under a Part A plan of treatment and use of a HHA DME under a

Part A plan of treatment)4 Other (Part B) (includes HHA medical and other health services not under a plan of treatment, SNF

diagnostic clinical laboratory services to “nonpatients”, and referred diagnostic services) and alsoall hospital non-inpatient lab work

5 Intermediate Care – Level I**6 Intermediate Care – Level II**7 Subacute Inpatient (Revenue Code 19X required)8 Swing Bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed

agreement)9 Reserved for National Assignment

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Bill Classification (Clinics Only) - 2nd Digit

1 Rural Health Clinic (RHC)2 Hospital Based or Independent Renal Dialysis Facility3 Free Standing Provider – Based Federally Qualified Health Centers (FQHC)4 Other Rehabilitation Facility (ORF)5 Comprehensive Outpatient Rehabilitation Facility (CORFS)6 Community Mental Health Center (CMHC)7-8 Reserved for National Assignment9 Other

Bill Classification (Special Facilities Only) - 2nd Digit

1 Hospice (Nonhospital Based)2 Hospice (Hospital Based)3 Ambulatory Surgical Center Services to Hospital Outpatients4 Free Standing Birthing Center5 Critical Access Hospital (CAH)6 Residential Facility (not used for Medicare)7-8 Reserved for National Assignment9 Other

* If Type of Facility - code 7 (Clinic) is used, then the Bill Classification (Clinics) - 2nd digits must be used.If Type of Facility - code 8 (Special Facility) is used, then the Bill Classification (Special Facilities) -2nd digit must be used.

** To be defined at the state level.

Frequency - 3rd Digit

0 Nonpayment/Zero Claim1 Admit through Discharge Claim2 Interim – First Claim3 Interim – Continuing Claim (Not valid for PPS bills)4 Interim – Last Claim (Not valid for PPS bills)5 Late Charge Only6 Adjustment of Prior Claim**7 Replacement of Prior Claim8 Void/Cancel of a Prior Claim9 Final Claim for a Home Health PPS Episode

A Admission/Election NoticeB Hospice/Medicare Coordinated Care Demonstration/Religious

Non-Medical Health Care Institution-Termination/Revocation NoticeC Hospice Change of ProviderD Hospice/Medicare Coordinated Care Demonstration/Religious

Non-Medical Health Care Institution-Void/CancelE Hospice Change of OwnershipF Beneficiary Initiated Adjustment ClaimG CWF Initiated Adjustment ClaimH HCFA Initiated Adjustment ClaimI Intermediary Adjustment Claim (other than PRO or Provider)J Initiated Adjustment Claim – Other

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K OIG Initiated Adjustment ClaimM MSP Initiated Adjustment ClaimP PRO Adjustment Claim

* Do not use for Medicare PPS claims (for second and subsequent interim bills use code 7, and seeCondition Code D3 (FLS 24-30)).

** Not an acceptable Medicare Code.

DEFINITIONS FOR FREQUENCY

Nonpayment/Zero Claim (0)

This code is used when the provider does not anticipate payment from the payer for the bill, but isinforming the payer about a period of nonpayable confinement or termination of care. The “Through”date of this bill (FL 6) is the discharge date for this confinement. Medicare requires “nonpayment” billsonly to extend the spell-of-illness in inpatient cases. Other nonpayment bills are not needed and may bereturned to the provider.

Admit Through Discharge Claim (1)

This code is used for a bill encompassing an entire inpatient confinement or course of outpatienttreatment for which the provider expects payment from the payer or which will update deductible forinpatient or Part B claims when Medicare is secondary to an EGHP.

Interim - First Claim (2)

This code is used for the first of an expected series of bills for which utilization is chargeable or whichwill update inpatient deductible for the same confinement or course of treatment.

Interim - Continuing Claim (Not valid for PPS Bills) (3)

This code is used when a bill for which utilization is chargeable for the same confinement or course oftreatment had already been submitted and further bills are expected to be submitted later.

Interim - Last Claim (Not valid for PPS Bills) (4)

This code is used for a bill for which utilization is chargeable and which is the last of a series for thisconfinement or course of treatment. The “Through” date of this bill (FL 6) is the discharge date for thisconfinement or course of treatment.

Late Charge Only (5)

This code is used only for outpatient claims. Late charge bills are not accepted for Medicare inpatient orASC claims.

Adjustment of Prior Claim (6) (Not used for Medicare)

This code is to be used when a specific bill has been issued for a specific Provider, Patient, Payer, Insured and“Statement Covers Period” date and the reimbursement amount is to be recalculated through an increaseor decrease in charges, per them calculations, deductibles, coinsurance, and/or prior third party payments.

To properly adjust a prior bill, the respective plus or minus adjustment must be provided, along with thenet overall charge and the new reimbursement amount.

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Where a revenue code line is to be changed, the provider is to operate on the principle that the change isto be added to information already submitted (new charge line is unsigned) or is to be subtracted frominformation already submitted (new charge line is a credit).

However, this code is not intended to be used in lieu of a Late Charge(s) Only claim.

Replacement of Prior Claim (7)

This code is used by the provider when it wants to correct (other than late charges) a previouslysubmitted bill. This is the code applied to the corrected or new bill.

Void/Cancel of a Prior Claim (8)

This code indicates this bill is an exact duplicate of an incorrect bill previously submitted. A code “7”(Replacement of Prior Claim) is also submitted by the provider showing corrected information.

Final Claim for a Home Health PPS Episode (9)

This code indicates the HH bill should be processed as a debit or credit adjustment to the initial homehealth PPS bill.

Admission/Election Notice (A)

This code is used when the hospice is submitting the HCFA-1450 as an admission notice.

Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Termination/Revocation Notice (B)

Use when the UB-92 is used as a Termination/Revocation of a hospice, Medicare Coordinated CareDemonstration, or Religious Non-medical Health Care Institution election.

Hospice Change of Provider (C)This code is used when the HCFA-1450 is used as a Notice of Change to the hospice provider.

Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Void/Cancel (D)

This code is used when the UB-92 is used as a Notice of a Void/Cancel of a hospice, MedicareCoordinated Care Demonstration Entity, or Religious Non-medical Health Care Institution election.

Hospice Change of Ownership (E)

This code is used when the HCFA-1450 is used as a Notice of Change in Ownership for the hospice.

Beneficiary Initiated Adjustment Claim (F)

This code is used to identify adjustments initiated by the beneficiary. For intermediary use only.

CWF Initiated Adjustment Claim (G)

This code is used to identify adjustments initiated by CWF. For intermediary use only.

HCFA Initiated Adjustment Claim (H)

This code is used to identify adjustments initiated by HCFA. For intermediary use only.

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Intermediary Adjustment Claim (Other than PRO or Provider (I)This code is used to identify adjustments initiated by the fiscal Intermediary. For intermediary use only.

Initiated Adjustment Claim-Other (J)

This code is used to identify adjustments initiated by other entities. For intermediary use only.

OIG Initiated Adjustment Claim (K)

This code is used to identify adjustments initiated be OIG. For intermediary use only.

MSP Initiated Adjustment Claim (M)

This code is used to identify adjustments initiated by MSP. For intermediary use only. Note: MSP takesprecedence over other adjustment sources.

PRO Adjustment Claim (P)

This code is used to identify an adjustment initiated as a result of a PRO review. For intermediary useonly.


ANTHEM BCBS-NH: Required. The three digit numeric code gives three specific pieces ofinformation. The Type of Facility, the type of care or Classification, and thesequence of the bill referred to as the Frequency code. The followinginformation is acceptable:

CODE STRUCTURE:Type of Facility - lst Digit

1 = Hospital, Psychiatric Facility

Classification (Except Clinics and Special Facilities) - 2nd Digit

1 = Inpatient3 = Outpatient8 = Swing Beds

Classification (Special Facilities Only) - 2nd Digit

3 = Ambulatory Surgery Center4 = Free-standing Birthing Center


1 = Admit through Discharge Claim2 = Interim - First Claim3 = Interim - Continuing Claim4 = Interim - Last Claim5 = Late Charge Only

BCBSVT: Same as Anthem BCBS-NH. Note: Interim bills should not be submitted on DRGclaims. 2nd Digit: 4 not valid. 1st Digit: 1,2,8 for Ambulatory Surgery Center.

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TRICARE: Required. The three digit numeric code gives three specific pieces ofinformation. The Type of Facility, the type of care or Classification, and thesequence of the bill referred to as the Frequency code. The followinginformation is acceptable:

CODE STRUCTURE:


1 = Hospital2 = Skilled Nursing3 = Home Health


1 = Inpatient3 = Outpatient


1 = Admit through Discharge Claim2 = Interim - First Claim3 = Interim - Continuing Claim4 = Interim - Last Claim5 = Late Charge(s) Only (Adjustment)6 = Adjustment of Prior Claim7 = Replacement of Prior Claim (Corrected)8 = Void/Cancel (Adjustment)

NOTE: Swing BedTRICARE does not recognize the term “Swing Bed.” If the patient requires onlySNF level of care, payment should be at the SNF rate. Therefore, bill type 211should be used when billing for swing bed.

MEDICARE: Required. This three-digit alpha numeric code gives three specific pieces ofinformation. The first digit identifies the type of facility. The second classifiesthe type of care. The third indicates the sequence of this bill in this particularepisode of care; a frequency code.

CODE STRUCTURE:Type of facility - lst Digit

1 = Hospital2 = Skilled Nursing3 = Home Health4 = Religious Non-medical (Hospital)5 = Religious Non-medical (Extended Care)6 = Intermediate Care7 = Clinic* or Hospital Based Renal Dialysis Facility (requires special information in 2nd digit)8 = Special Facility or Hospital ASC Surgery (requires special information in 2nd digit)9 = Reserved for National Assignment

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Classification – 2nd Digit (Except clinics and special facilities)

1 = Inpatient (Part A)2 = Hospital Based or Inpatient (Part B) (includes HHA visits under a Part B

plan of treatment)3 = Outpatient (includes HHA visits under a Part A plan of treatment and use of

a HHA DME under a Part A plan of treatment)4 = Other (Part B) (includes HHA medical and other health services not under a

plan of treatment, SNF diagnostic clinical laboratory services to “nonpatients”,and referred diagnostic services) and also all hospital non-inpatient lab work

5 = Intermediate Care – Level I**6 = Intermediate Care – Level II**7 = Subacute Inpatient (Revenue Code 19X required)8 = Swing Bed (used to indicate billing for SNF level of care in a hospital with

an approved swing bed agreement)9 = Reserved for National Assignment


0 = Nonpayment/Zero Claims1 = Admit Through Discharge Claim2 = Interim First Claim3 = Interim - Continuing Claim (Not valid for PPS bills)4 = Interim - Last Claim (Not valid for PPS bills)5 = Late Charge Only6 = Adjustment of Prior Claim**7 = Replacement of Prior Claim8 = Void/Cancel of a Prior Claim9 = Final Claim for a Home Health PPS Episode

A = Admission/Election NoticeB = Hospice/Medicare Coordinated Care Demonstration/Religious Non-

Medical Health Care Institution-Termination/Revocation NoticeC = Hospice Change of ProviderD = Hospice/Medicare Coordinated Care Demonstration/Religious Non-

Medical Health Care Institution-Void/CancelE = Hospice Change of OwnershipF = Beneficiary Initiated Adjustment ClaimG = CWF Initiated Adjustment ClaimH = HCFA Initiated Adjustment ClaimI = Intermediary Adjustment Claim (other than PRO or Provider)J = Initiated Adjustment Claim – OtherK = OIG Initiated Adjustment ClaimM = MSP Initiated Adjustment claimP = PRO Adjustment Claim

OCTOBER 2001

2-14

CIGNA NH: Required.

CODE STRUCTURE:Type of Facility - lst Digit

1 = Hospital

Classification - 2nd Digit

1 = Inpatient3 = Outpatient8 = Swing Bed


1 = Admit through Discharge Claim2 = Interim - First Claim3 = Interim - Continuing Claim4 = Interim - Last Claim5 = Late Charge(s) Only Claim6 = Adjustment of Prior Claim7 = Replacement of Prior Claim

MTHP: Required. Note: Interims bills should not be submitted on DRG claims.

CODE STRUCTURE:


1 = Hospital2 = Skilled Nursing7 = Clinic


1 = Inpatient (Part A)2 = Inpatient (Part B)3 = Outpatient

Classification (Clinics Only) - 2nd Digit

1 = Rural Health2 = Hospital Based or Independent Renal Dialysis Center3 = Freestanding9 = Other


0 = Nonpayment/Zero Claim1 = Admit Through Discharge Claim2 = Interim - First Claim3 = Interim - Continuing Claim4 = Interim - Last Claim5 = Late Charge(s) Only Claim6 = Adjustment of Prior Claim7 = Replacement of Prior Claim8 = Void/Cancel of Prior Claim9 = Reserved for National Assignment

OCTOBER 2001

2-15

NH MEDICAID: Required. UB92 is acceptable for inpatient, outpatient and swing bed hospitalpatients. Only the following information is acceptable:

CODE STRUCTURE:

Type of Facility - 1st Digit

1 = Hospital2 = SNF Swing Bed Facility6 = ICF Swing Bed Facility


1 = Inpatient3 = Outpatient8 = Swing Beds


1 = Admit through Discharge Claim (inpatient and outpatient only)*2 = Interim - First Claim*3 = Interim - Continuing Claim*4 = Interim - Last Claim

7 = Replacement Claim per Pro Review

*Accepted for swing bed only

If the patient will have more than one bill for duration of recipient’s stay, makenote of which 3rd digit should be used for the claim.

VT MEDICAID: Required. HCFA-1450 is acceptable for inpatient and outpatient hospital andhome health services. The following information is acceptable:

CODE STRUCTURE:


1 = Hospital


1 = Inpatient3 = Outpatient


1 = Admit through Discharge Claim2 = Interim - First Claim3 = Interim - Continuing Claim4 = Interim - Last Claim5 = Late Charge Only

OCTOBER 2001

2-16

FORM LOCATOR 5

DATA ELEMENT: Federal Tax Number

DEFINITION: The number assigned to the provider by the federal government for tax reportpurposes. Also known as a tax identification number (TIN) or employeridentification number (EIN). To identify affiliated subsidiaries using federal taxsub - ID see NOTE below.

FIELD SIZE: 1 field, upper line - 4 positions (optional), alphanumeric lower line - 10 positions(include hyphen), numeric

NOTE: Upper line - is designated federal tax sub - ID number as assigned by theprovider. To be used by providers which assign a unique identification numberfor their affiliated subsidiaries, e.g. hospital psychiatric pavilion.Lower line - the federal tax number should be entered: NN-NNNNNNN.



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Not required.

MTHP: Required.

NH MEDICAID: Not required.

VT MEDICAID: Not required.

OCTOBER 2001

2-17

FORM LOCATOR 6

DATA ELEMENT: Statement Covers Period

DEFINITION: The beginning and ending service dates of the period included on this bill.

FIELD SIZE: 1 field, 1 line, 12 positions, numeric

NOTE: For all services received on a single day, use both the “From” and “Through”dates, i.e., both will be the same date.

Enter both dates as month, day and year (MMDDCCYY).



BCBSVT: Required.

Outpatient: If the beginning and ending dates are not the same, individual servicedates must be entered in FL 45.

TRICARE: Required.

CIGNA NH: Required. Bills (other than inpatient) may not span two calendar years.

MEDICARE: Required. Enter the beginning and ending dates of the period included on thisbill in numeric fields (MMDDCCYY). Days before the patient’s entitlement arenot shown. Split billing is required for end of fiscal year for DPU (psych, rehab,SNF and Swing).

MTHP: Required.

NH MEDICAID: Required. For Outpatient Claims Only: The beginning and ending dates must bethe same. Only one date of service is allowed per claim.

Required. For Inpatient Claims Only: Enter only Medicaid covered days.

For Swing Bed Claims Only: Enter only Medicaid covered days.

VT MEDICAID: Required. Inpatient: The dates contained in this field must contain onlyconsecutive covered dates of service. Noncovered dates of services must not beincluded. On electronic claims, enter dates in a MMDDCCYY format. Or paperclaims, enter dates in a MMDDCCYY format. Inpatient bills must be split ifdates span state fiscal year end which is June 30.

OCTOBER 2001

2-18

FORM LOCATOR 7

DATA ELEMENT: Covered Days

DEFINITION: The number of days covered by the payer, as qualified by the payer organization



ANTHEM BCBS-NH: Required, inpatient only.

BCBSVT: Required, inpatient only.


CIGNA NH: Required, inpatient only.

MEDICARE: Required. Enter the total number of covered days during the billing periodincluding lifetime reserve days elected for which Medicare payment is requested.This should be the total of accommodation units reported in FL 46. Exclude anydays classified as noncovered as defined in FL 8, leave of absence days, and theday of discharge or death.

Do not deduct any days for payment made under Workers’ Compensation (WC),automobile medical, no-fault, liability insurance, an EGHP for as ESRDbeneficiary, employed beneficiaries and spouses age 65 or over or a LGHP fordisabled beneficiaries. Your intermediary calculates utilization based upon theamount Medicare will pay and makes the necessary utilization adjustment. (See469B and C, and 470B and C, 471B and C, 472B and C, and 475.)

See 411.1C “Utilization Chargeable” for the special situations requiring that noprogram payment bills show an entry of covered days in FL 7.

See 415.1 if you are being paid under PPS.

MTHP: Desirable. Enter the number of covered days.

NH MEDICAID: Inpatient and Swing Bed: Required. Enter the number of covered days. This mustequal the number of days indicated in FL 6 minus the discharge date.

Outpatient: Required. Span dates not allowed.

VT MEDICAID: Inpatient: Required. Enter the number of covered days. This must equal thenumber of days indicated in Form Locator 6. Do not count the day of dischargeor the date of death.

Outpatient: Not required.

OCTOBER 2001

2-19

FORM LOCATOR 8

DATA ELEMENT: Noncovered Days

DEFINITION: Days of care not covered by the primary payer.



ANTHEM BCBS-NH: Required, inpatient only.

BCBSVT: Required, if applicable for inpatient.


CIGNA NH: Not required.

MEDICARE: Required, if applicable. Enter the total number of noncovered days during thebilling period within the “From” and “Through” dates (FL 6) that are notclaimable as Medicare patient days on the cost report and for which thebeneficiary will not be charged utilization for Part A services.

Not covered days include:• Days for which no Part A payment can be made because the services rendered

were furnished without cost or will be paid for by the VA.

• Days for which no Part A payment can be made because payment will be madeunder a National Institutes of Health grant.

• Days after the date covered services ended, such as noncovered level of care,or emergency services after the emergency has ended in nonparticipatinginstitutions.

• Days for which no Part A payment can be made because the patient was on aleave of absence and was not in the hospital.

• Days for which no Part A payment can be made because a hospital provideragreement has terminated, expired, or been cancelled may only be paid forcovered inpatient services during the limited period following suchtermination, expiration, or cancellation. All days after the expiration of theperiod one noncovered.

• Days after the time limit when utilization is not chargeable because the care isno longer acute and patient has been issued a denial letter.

NOTE: Day of discharge or death is not counted as a noncovered day.

NOTE: The reason for noncoverage should be explained by occurrence spancodes, condition codes or remarks. If no occurrence code descriptiondescribes the noncovered days appropriately, fill in reason fornoncovered days in FL 84.

OCTOBER 2001

2-20

MTHP: Not required.



OCTOBER 2001

2-21

FORM LOCATOR 9

DATA ELEMENT: Coinsurance Days

DEFINITION: The inpatient hospital Medicare days occurring after the 60th day and before the91st day in a single spell of illness or the inpatient SNF days occurring after the20th day and before the 101st day of the benefit period as shown for the billingperiod.




BCBSVT: Not required.



MEDICARE: Required, if applicable. Enter the total number of covered inpatient hospital daysoccurring after the 60th day and before the 91st day or the number of coveredinpatient SNF days occurring after the 20th day and before the 101st day of thebenefit period as shown for this billing period.

MTHP: Not required.



OCTOBER 2001

2-22

FORM LOCATOR 10

DATA ELEMENT: Lifetime Reserve Days

DEFINITION: Under Medicare, each beneficiary has a lifetime reserve of 60 additional days ofinpatient hospital services after using 90 days of inpatient hospital servicesduring a spell of illness.







MEDICARE: Required. The number of lifetime reserve days the patient elected during thebilling period must be shown in this form locator. Hospitals are required tonotify the patient of his/her right not to elect the use of lifetime reserve daysbefore billing the program. See the HIMIO Manual for details. Note the specialinstructions below for PPS providers.

PROSPECTIVE PAYMENT PROVIDERS

1 . Beneficiary Has One or More Regular Days Available Upon Admission -If the beneficiary has one or more regular benefit (non-lifetime reserve) daysremaining in the benefit period upon admission, there will be no advantagefor the beneficiary to use his/her lifetime reserve days for nonoutlier days asMedicare will pay the entire prospective payment amount for the nonoutlierdays. Therefore, the beneficiary will be deemed to have elected not to useany lifetime reserve days:

NOTE: The beneficiary may elect not to use lifetime reserve days for theoutlier days, but such an election must apply to all outlier days.

2. Only Lifetime Reserve Days Are Available Upon Admission - If thebeneficiary has completely exhausted the regular benefit days, availablelifetime reserve days will be used automatically for each day of the stayunless the beneficiary elects not to use them.

NOTE: An election not to use lifetime reserve days will apply to the entirehospital stay and Medicare payment will not be made for anyportion of the stay.

OCTOBER 2001

2-23

MTHP: Not required.



OCTOBER 2001

2-24

FORM LOCATOR 11

DATA ELEMENT: Unlabeled Field

MTHP: Required on inpatient claims where applicable. Three-position numeric DRGnumber should be submitted here.

MEDICARE: Not Required.

NH MEDICAID: Not Required.

OCTOBER 2001

2-25

FORM LOCATOR 12

DATA ELEMENT: Patient Name

DEFINITION: Last name, first name and middle initial of the patient.


NOTE: Use a space to separate last and first names.

No space should be left between a prefix and a name as in MacBeth,VonSchmidt, McEnroe.

Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element.

To record suffix of a name, write the last name, leave a space and write thesuffix, then write the first name as in Snyder III, Harold, or Addams Jr., Glen



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required. Enter member’s name exactly as it appears on the CIGNA NH IDCard.

MEDICARE: Required. Enter the patient’s last name, first name, and middle initial exactly asit appears on patient’s Medicare ID Card. Patient’s name must not containhyphens or other characters.

MTHP: Required. Enter the patient’s last name, first name and middle initial exactly as itappears on the patient’s MTHP ID Card.

NH MEDICAID: Required. Enter the patient’s last name, first name, and middle initial exactly asit appears on the Medicaid ID Card. Patient’s name must not contain hyphens orother special characters.

VT MEDICAID: Required. Enter the patient’s last name, first name, and middle initial exactly asit appears on the Medicaid ID Card. Patient’s name must not contain hyphens orother special characters.

OCTOBER 2001

2-26

FORM LOCATOR 13

DATA ELEMENT: Patient Address

DEFINITION: The address of the patient, as defined by the payer organization.


NOTE: Enter the following information: full mailing address including street numberand name or post office box number or RFD; city name; state name; zip code.

Use the Standard Post Office State Abbreviations as listed in Form Locator 1,Provider Name and Address.

If a nine digit zip code is used, it should be printed in the form XXXXX-YYYYwhere X’s are five digit zip code and Y’s are the zip code extension.



BCBSVT: Required.

TRICARE: Required. Use physical address; PO Boxes are not acceptable.

CIGNA NH: Required.

MEDICARE: Required. This form locator requires the patient’s full mailing address includingstreet number and name, post office box number or RFD, city, state and zip code.A valid ZIP code is required for PRO purposes on inpatient bills.

MTHP: Required.



OCTOBER 2001

2-27

FORM LOCATOR 14

DATA ELEMENT: Patient Birthdate

DEFINITION: The date of birth of the patient.


NOTE: Enter the month, date and year of birth (MMDDCCYY).



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. Enter the month, day, and year of birth (MMDDCCYY) of patient. Ifthe full correct date is not known, zero fill the field.

MTHP: Required.

NH MEDICAID Not required.


OCTOBER 2001

2-28

FORM LOCATOR 15

DATA ELEMENT: Patient Sex

DEFINITION: The sex of the patient as recorded at date of admission, outpatient service, orstart of care.

FIELD SIZE: 1 field, 1 line, 1 position, alphanumeric

CODE STRUCTURE:M = MaleF = Female



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. This item is used in conjunction with FL 67-81 (diagnoses andsurgical procedures) to identify inconsistencies.

MTHP: Required.



OCTOBER 2001

2-29

FORM LOCATOR 16

DATA ELEMENT: Patient Marital Status

DEFINITION: The marital status of the patient at date of admission, outpatient service or startof care.


CODE STRUCTURE:

S = SingleM = MarriedX = Legally SeparatedD = DivorcedW = WidowedP = Life PartnerU = Unknown



BCBSVT: Required. Use “P” for same sex partner.

TRICARE: Required. “P” not accepted.



MTHP: Desirable.



OCTOBER 2001

2-30

FORM LOCATOR 17

DATA ELEMENT: Admission Date

DEFINITION: The date the patient was admitted to the provider for inpatient care, outpatientservice or start of care.

NOTE: Enter the admission date as month, day and year (MMDDCCYY)



ANTHEM BCBS-NH: Required. For inpatient, use date of admission. For outpatient, use initial start ofcare date.

BCBSVT: Required. Original admission date must be included on interim bills.

TRICARE: Required. If the patient is admitted to the hospital after having been in anobservation room for more than 24 hours, the admission date should be the datethey were placed in the observation room.

CIGNA NH: Required.

MEDICARE: Required. Enter the date (MMDDYY) the patient was admitted for inpatientcare. When using the HCFA-1450 for as a hospice admission notice, the facilityshows the date the beneficiary elected hospice care.

MTHP: Required for inpatient services.

NH MEDICAID: Required for inpatient and swing bed services. If the patient is admitted as acutecare through the emergency room or for observation, the admit date is the datethe patient was cared for through the Emergency Room or outpatient.

VT MEDICAID: Required for inpatient and outpatient services. When a patient is admitted forobservation and becomes an inpatient, enter the date the patient was admitted toobservation. On electronic claims, enter dates in a MMDDCCYY format. Onpaper claims, enter dates in a MMDDCCYY format.

OCTOBER 2001

2-31

FORM LOCATOR 18

DATA ELEMENT: Admission Hour

DEFINITION: The hour during which the patient was admitted for inpatient or outpatient care.


CODE STRUCTURE:

CODE TIME-AM CODE TIME-PM00 12:00 - 12:59 Midnight 12 12:00 - 12:59 Noon01 01:00 - 01:59 13 01:00 - 01:5902 02:00 - 02:59 14 02:00 - 02:5903 03:00 - 03:59 15 03:00 - 03:5904 04:00 - 04:59 16 04:00 - 04:5905 05:00 - 05:59 17 05:00 - 05:5906 06:00 - 06:59 18 06:00 - 06:5907 07:00 - 07:59 19 07:00 - 07:5908 08:00 - 08:59 20 08:00 - 08:5909 09:00 - 09:59 21 09:00 - 09:5910 10:00 - 10:59 22 10:00 - 10:5911 11:00 - 11:59 23 11:00 - 11:59

99 Unknown


ANTHEM BCBS-NH: Required. 99 is not acceptable.

BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required for Emergency Room services.


MTHP: Required.


VT MEDICAID: Required for outpatient claims.

OCTOBER 2001

2-32

FORM LOCATOR 19

DATA ELEMENT: Type of Admission

DEFINITION: A code indicating the priority of this admission.


CODE STRUCTURE:

1 - Emergency The patient required immediate medical interventionas a result of severe, life threatening or potentiallydisabling conditions. Generally, the patient is admittedthrough the emergency room.

2 - Urgent The patient required immediate attention for the careand treatment of a physical or mental disorder.Generally the patient is admitted to the first availableand suitable accommodation.

3 - Elective The patient’s condition permitted adequate time toschedule the availability of a suitable accommodation.

4 - Newborn Use of this code necessitates the use of special Source ofAdmission codes - see FL 20.

5-8 Reserved for National Assignment

9 - Information not The hospital cannot classify the type of admission. Available This code is not acceptable.



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. Codes 1, 2, 3 and 9

Required on inpatient bills only. This is the code indicating priority of thisadmission.

OCTOBER 2001

2-33

CODE STRUCTURE:

1 - Emergency The patient required immediate medical intervention asa result of severe, life threatening or potentiallydisabling conditions. Generally, the patient is admittedthrough the emergency room.

2 - Urgent The patient required immediate attention for the careand treatment of a physical or mental disorder.Generally the patient is admitted to the first availableand suitable accommodation.

3 - Elective The patient’s condition permitted adequate time toschedule the availability of a suitable accommodation.

9 - Information not The hospital cannot classify the type of admission. Available This code is not acceptable.

MTHP: Required for inpatient and outpatient claims.

NH MEDICAID: Required for inpatient, outpatient and swing bed claims.

VT MEDICAID: Required for inpatient and outpatient claims, codes 1-4 only.

OCTOBER 2001

2-34

FORM LOCATOR 20

DATA ELEMENT: Source of Admission

DEFINITION: A code indicating the source of this admission or outpatient registration

NOTE: Newborn coding structure must be used when the Type of Admission Code in FL19 is code 4.


ANTHEM BCBS-NH, BCBSVT, TRICARE, MEDICARE, CIGNA NH, NH MEDICAIDCODE STRUCTURE: (For Emergency, Elective or Other Type of Admission)

1 Physician Referral Inpatient: The patient was admitted to thisfacility upon recommendation of his or herpersonal physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by his or her personalphysician or the patient independentlyrequested outpatient services (self-referral).

2 Clinic Referral Inpatient: The patient was admitted to thisfacility upon recommendation of thisfacility’s clinic physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenced diagnosticservices by this facility’s clinic or otheroutpatient department physician.

3 HMO Referral Inpatient: The patient was admitted to thisfacility upon the recommendation of ahealth maintenance organization physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by an HMO physician.

4 Transfer from a Hospital Inpatient: The patient was admitted to thisfacility as a transfer from an acute carefacility where he or she was an inpatient.

Outpatient: The patient was referred to thisfacility for outpatient or referenced diagnosticservices by a physician of another acute carefacility.

OCTOBER 2001

2-35

5 Transfer from a SkilledNursing Facility

Inpatient: The patient was admitted to thisfacility as a transfer from a skilled nursingfacility where he or she was an inpatient(including swing-beds and distinct part SNF).

Outpatient: The patient was referred to thisfacility for outpatient or reference diagnosticservices by an physician of the SNF wherehe or she is an inpatient.

6 Transfer from AnotherHealth Care Facility

Inpatient: The patient was admitted to thisfacility as a transfer from a health care otherthan an acute care facility or a skilled nursingfacility. This includes transfers from nursinghomes, long-term care facilities and SNFpatient that are at a nonskilled level of care.

Outpatient: The patient was referred to thisfacility for outpatient or referenced diagnosticservices by a physician of anotherhealthcare facility where he or she is aninpatient.

7 Emergency Room Inpatient: The patient was admitted to thisfacility upon the recommendation of thisfacility’s emergency room physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenced diagnosticservices by this facility’s emergency roomphysician.

8 Court/Law Enforcement Inpatient: The patient was admitted to thisfacility upon the direction of a court of law,or upon the request of a law enforcementagency representative.

Outpatient: The patient was referred to thisfacility upon the direction of a court of law, orupon the request of a law enforcement agencyrepresentative for outpatient or referenceddiagnostic services.

9 Information Not Available Inpatient: The means by which the patientwas admitted to this hospital is not known.

Outpatient: For Medicare outpatient bills,this is not a valid code.

OCTOBER 2001

2-36

A Transfer from a CriticalAccess Hospital (CAH)

Inpatient: The patient was admitted to thisfacility as a transfer from a CAH where heor she was an inpatient.

Outpatient: The patient was referred to thisfacility for outpatient or referenced diagnosticservices by (a physician of) CAH where heor she is an inpatient.

CODE STRUCTURE: (For Newborn) – Applicable to all payers, except Medicare.

1 Normal Delivery A baby delivered without complications.

2 Premature Delivery A baby delivered with time and/or weightfactors qualifying it for premature status.

3 Sick Baby A baby delivered with medical complications,other than those relating to premature status.

4 Extramural Birth A newborn born in a nonsterile environment.

5-8 Reserved for National Assignment.

9 Information Not Available.

MEDICARECODE STRUCTURE: (For Emergency, Elective or Other Type of Admission)

Enter the code indicating the source of this admission or outpatient registration.

1 Physician Referral Inpatient: The patient was admitted to thisfacility upon the recommendation of his orher personal physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by his or her personalphysician or the patient independentlyrequested outpatient services (self-referral).

2 Clinic Referral Inpatient: The patient was admitted to thisfacility upon the recommendation of thisfacility’s clinic physician.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by this facility’s clinicor other outpatient department physician.

OCTOBER 2001

2-37

3 HMO Referral Inpatient: The patient was admitted to thisfacility upon the recommendation of a HMOphysician.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by a HMO physician.

4 Transfer from a Hospital Inpatient: The patient was admitted to thisfacility as a transfer from an acute carefacility where he or she was an inpatient.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by a physician ofanother acute care facility.

5 Transfer from a SNF Inpatient: The patient was admitted to thisfacility as a transfer from a SNF where he orshe was an inpatient (including swing-bedsand distinct part SNF).

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by a physician of theSNF where he or she is an inpatient.

6 Transfer from AnotherHealth Care Facility

Inpatient: The patient was admitted to thisfacility from a health care facility other thanan acute care facility or a SNF. This includestransfers from nursing homes, long-termcare facilities, and SNF patients that are at anonskilled level of care.

Outpatient: This patient was referred tothis facility for outpatient or referenceddiagnostic services by a physician ofanother health care facility where he or sheis an inpatient.

7 Emergency Room Inpatient: The patient was admitted to thisfacility upon the recommendation of thisfacility’s emergency room physician.

Outpatient: The Patient was referred tothis facility for outpatient or referenceddiagnostic services by this facility’semergency room physician.

OCTOBER 2001

2-38

8 Court/Law Enforcement Inpatient: The patient was admitted to thisfacility upon the direction of a court of law,or upon the request of a law enforcementagency representative.

Outpatient: The patient was referred to thisfacility upon the direction of a court of law,or upon the request of a law enforcementagency representative for outpatient orreferenced diagnostic services.

9 Information Not Available Inpatient: The means by which the patientwas admitted to this hospital is not known.

Outpatient: For Medicare outpatient billsthis is not valid code.

A Transfer from a CriticalAccess Hospital

Inpatient: The patient as admitted to thisfacility as a transfer from a Critical AccessHospital where he or she was an inpatient.

Outpatient: The patient was referred to thisfacility for outpatient or referenceddiagnostic services by (a physician of) theCritical Access Hospital were he or she isan inpatient.

B Transfer Form AnotherHome Health Agency

The patient was admitted to this homehealth agency as a transfer from anotherhome health agency.

C Readmission to Same HomeHealth Agency

The patient was readmitted to this homehealth agency within the existing 60 daypayment (For use with bill type 32A)

D-Z Reserved for national assignment.

NH MEDICAIDCODE STRUCTURE: (For Emergency, Elective or Other Type of Admission)

12345679

OCTOBER 2001

2-39

CODE STRUCTURE: (For Newborn)

1234


ANTHEM BCBS-NH: Required. Providers must submit two claims for delivery stays; one for motherand one for baby.

BCBSVT: Required. Providers must submit two claims for delivery stays; one for motherand one for the baby.

TRICARE: Same as BCBSVT.

CIGNA NH: Same as BCBSVT.

MEDICARE: Required. See previous code structure for Medicare.

MTHP: Desirable.

NH MEDICAID: Required.


OCTOBER 2001

2-40

FORM LOCATOR 21

DATA ELEMENT: Discharge Hour

DEFINITION: Hour that the patient was discharged from inpatient care.


NOTE: This data element is not necessary for outpatient bills. Applicable to inpatientbills only.

CODE STRUCTURE:


99 Unknown


ANTHEM BCBS-NH: Required for inpatient and observation only. 99 not acceptable.

BCBSVT: Required for inpatient.

TRICARE: Required.

CIGNA NH: Desirable.


MTHP: Required.



OCTOBER 2001

2-41

FORM LOCATOR 22

DATA ELEMENT: Patient Status

DEFINITION: A code indicating patient’s status as of the “Through” date of the billing period.


ANTHEM BCBS-NH, BCBSVT, TRICARE,CIGNA NH, MTHP AND VT MEDICAIDCODE STRUCTURE:

01 Discharged to home or self-care (routine discharge)02 Discharged/transferred to another short-term general hospital03 Discharged/transferred to skilled nursing facility (SNF)04 Discharged/transferred to an intermediate care facility (ICF)05 Discharged/transferred to another type of institution (e.g., Hospice,

Rehabilitation Facility)06 Discharged/transferred to home under care of organized home health

service organization07 Left against medical advice08-09 Reserved for National Assignment10-19 Discharge to be defined at state level, if necessary20 Expired (or did not recover - Christian Science Patient)21-29 Expired to be defined at state level, if necessary30 Still patient31-39 Still patient to be defined at state level, if necessary43-99 Reserved for National Assignment

MEDICARECODE STRUCTURE:

01 Discharged to home or self care (routine discharge)02 Discharged/transferred to another short-term general hospital for

inpatient care03 Discharged/transferred to (SNF) (For hospitals with an approved swing

bed arrangement, use Code 61-Swing Bed. For reporting discharges/transfers to a non-certified SNF, the hospital must use Code 04-ICF.)

04 Discharged/transferred to an intermediate care facility (ICF)05 Discharged/transferred to another type of institution for inpatient care or

referred for outpatient services to another institution06 Discharged/transferred to home under care of organized home health

service organization07 Left against medical advice or discontinued care08 Discharged/transferred to home under care of a home IV drug therapy

provider*09 Admitted as an inpatient to this hospital20 Expired (or did not recover - Christian Science Patient)30 Still patient or expected to return for outpatient services40 Expired at home (Hospice claims only)41 Expired in a medical facility, such as a hospital ICF or freestanding

hospice (Hospice claims only)

OCTOBER 2001

2-42

42 Expired – place unknown (Hospice claims only)43-49 Reserved for national assignment50 Hospice – home51 Hospice – medical facility52-60 Reserved for national assignment62-70 Reserved for national assignment71 Discharged/transferred/referred to another institution for outpatient

services as specified by the discharge plan of care72 Discharged/transferred/referred to this institution for outpatient services

as specified by the discharge plan of care73-99 Reserved for national assignment

*In situations where a patient is admitted before midnight of the third dayfollowing the day of an outpatient diagnostic service, or service related to thereason for the admission, the outpatient services are considered inpatient.Therefore, code 09 would apply only to services that began longer than 3 daysearlier or were unrelated to the reason for admission, such as observationfollowing outpatient surgery, which results in admission.

NH MEDICAIDCODE STRUCTURE:

01 Discharged to home or self care (routine discharge)02 Discharged/transferred to another short-term general hospital03 Discharged/transferred to skilled nursing facility (SNF)04 Discharged/transferred to an intermediate care facility (ICF)05 Discharged/transferred to another type of institution (e.g., Hospice,

Rehabilitation Facility)06 Discharged/transferred to home under care of organized home health

service organization07 Left against medical advice14 When a recipient is eligible only for a portion of stay, not including day

of discharge15 When a recipient is eligible only for a portion of stay, including day of

discharge20 Expired


ANTHEM BCBS-NH: Required. Enter the appropriate code to indicate the patient’s status as of the“Through” date of the billing period.

CODE CODE CODE CODE01 04 07 4002 05 20 5003 06 30 51

BCBSVT: Same as Anthem BCBS-NH. Status code 30 is not considered valid for type ofbill ending in 1, 4 or 5.

OCTOBER 2001

2-43

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. Enter the appropriate code to indicate the patient’s status as of the“Through” date of the billing period. The following codes are approved forMedicare use.

CODE CODE CODE CODE CODE01 05 09 41 6102 06 20 42 7103 07 30 50 7204 08 40 51

MTHP: Required on inpatient claims.


CODE CODE CODE CODE01 04 07 2002 05 14 3003 06 15

VT MEDICAID: Required on inpatient claims. Enter the appropriate code to indicate the patient’sstatus as of the “through” date of the billing period. The following codes areapproved for VT Medicaid use.

CODE CODE01 0602 0703 2004 3005

OCTOBER 2001

2-44

FORM LOCATOR 23

DATA ELEMENT: Medical/Health Record Number

DEFINITION: The number assigned to the patient’s medical/health record by the provider.


NOTE: The medical/health record number is typically used to do an audit of the historyof treatment. It should not be substituted for the Patient Control Number (FL 3)which is assigned by the provider to facilitate retrieval of the individual financialrecord.



BCBSVT: Required.

TRICARE: Required. This is required to facilitate the retrieval of medical records needed forreview by the PRO.


MEDICARE: Required. This is required on all inpatient and outpatient ambulatory surgicalclaims.

This data element is used by the PRO for retrieval of medical records for casereviews.

MTHP: Not required.



OCTOBER 2001

2-45

FORM LOCATORS 24-30

DATA ELEMENT: Condition Codes

DEFINITION: A code(s) used to identify conditions relating to this bill that may affect payerprocessing.

FIELD SIZE: 7 fields, 1 line, 2 positions, alphanumeric

NOTE: No specific date is associated with this code.

CODE STRUCTURE:

INSURANCE CODES

01 Military Service Related Medical condition incurred during militaryservice

02 Condition Is EmploymentRelated

Patient alleges that medical condition isdue to environment/events resulting fromemployment.

03 Patient Covered ByInsurance Not ReflectedHere

Indicates that patient/patient representativehas stated that coverage may exist beyondthat reflected on this bill.

04 HMO Enrollee Indicates bill is submitted for informationonly and the Medicare beneficiary is enrolledin a risk-based HMO and the hospitalexpects to receive payment from the HMO.

05 Lien Has Been Filed Provider has filed legal claim for recoveryof funds potentially due to a patient as aresult of legal action initiated by or onbehalf of the patient.

06 ERSD Patient In First 18months Of EntitlementCovered By EmployerGroup Health Insurance

Code indicates Medicare may be a secondaryinsurer if the patient is also covered byemployer group health insurance during hisfirst 18 months of end stage renal diseaseentitlement.

07 Treatment Of NonterminalCondition For HospicePatient

Code indicates the patient has electedhospice care but the provider is not treatingthe terminal condition and is, therefore,requesting regular Medicare payment.

08 Beneficiary Would NotProvide InformationConcerning Other InsuranceCoverage

Enter this code if the beneficiary would notprovide information concerning otherinsurance coverage.

OCTOBER 2001

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09 Neither Patient Nor SpouseIs Employed

Code indicates that in response todevelopment questions, the patient and/orspouse have denied any employment.

10 Patient And/Or Spouse IsEmployed But No EGHPCoverage Exists

Indicates that in response to developmentquestions, the patient and/or spouseindicated that one or both are employed buthave no group health insurance coveragefrom an Employer Group Health Plan orother employer sponsored or providedhealth insurance that covers the patient.

11 Disabled Beneficiary, ButNo LGHP Coverage

Indicates that in response to developmentquestions, the disabled beneficiary and/orfamily member indicated that one or moreare employed but no group coverage from aLarge Group Health Plan or provided healthinsurance will not report them.

12-14 Payer Codes These codes are reserved for payer use only.Providers do not report these codes.

15 Clean Claim Delayed inHCFA’s Processing System(Payer Only Code)

Codes indicates that the claim is a cleanclaim in which payment was delayed due toa HCFA processing delay. Interest isapplicable, but the claim is not subject toCPEP/CPT standards. (See §3600.1A.3.)

16 SNF Transition Exemption(Medicare Payer Only Code)

Codes indicates an exemption from the post-hospital requirement applies for this SNFstay or the qualifying stay dates are morethan 30 days prior to the admission date.

SPECIAL CONDITIONS

17 Patient Is Over 100 YearsOld

Indicates that the patient is over 100 years oldat date of admission or outpatient services.

18 Maiden Name Retained A dependent spouse entitled to benefits whodoes not use her husband’s last name.

19 Child Retains Mother’sName

A patient who is a dependent child entitled tobenefits that does not have its father’s last name.

20 Beneficiary RequestedBilling

Indicates that services on this bill are at anoncovered level of care or otherwiseexcluded, but beneficiary requests formaldetermination by payer.

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21 Billing For Denial Notice Indicates that provider realizes services areat a noncovered level of care or excluded,but requests a denial notice from Medicarein order to bill Medicaid or other insurers.

22 Patient On Multiple DrugRegimen

A patient who is receiving multiple intravenousdrugs while on home IV therapy.

23 Home Caregiver Available The patient has a caregiver available toassist him or her during self-administrationof an intravenous drug.

25 Reserved for National Assignment.

26 VA Eligible PatientChooses To ReceiveServices In A MedicareCertified Facility.

Indicates that the patient is a VA eligiblepatient and chooses to receive services in aMedicare certified provider instead of a VAfacility.

27 Patient Referred To A SoleCommunity Hospital For ADiagnostic Laboratory Test

To be reported by Sole Community hospitalsonly. Report this code to indicate the patientwas referred for a diagnostic laboratory test.Payment will be made at 62%. Do not reportthis code when a specimen only is referred.

28 Patient And/Or Spouse’sEGHP Is Secondary ToMedicare

Code indicates that, in response todevelopment questions, the patient and/orspouse indicated that one or both are employedand that there is group health insurancefrom an EGBP or other employer sponsoredor provided health insurance that covers thepatient but that either: (1) the EGHP is a singleemployer health plan and the employer hasfewer than 20 full and part-time employees;or, (2) the EGHP is a multi- or multiple,employer plan that elects to pay secondaryto Medicare for employees and spousesaged 65 and older for those participatingemployers who have fewer than 20 employees.

OCTOBER 2001

2-48

29 Disabled BeneficiaryAnd/Or Family Member’sLGHP Is Secondary ToMedicare

Code indicates that, in response to developmentquestions, the patient and/or family member(s)indicated that one or more are employed andthere is group health insurance coverage froma LGHP or other employer sponsored orprovided health insurance that covers thepatient but that either: (1) the LGHP is asingle employer plan and that the employerhas fewer than 100 full and part-timeemployees; or, (2), the LGHP is a multi- ormultiple employer plan that all employersparticipating in the plan have fewer Um 100full and part-time employees.

30 Qualifying Clinical Trails Non-research services provided to allpatients, including managed care enrollees,enrolled in a Qualified Clinical Trail.

STUDENT STATUS (Required when patient is a dependent child over 18 years old)

NOTE: Use only one of the following codes - lowest code value number takes precedence.

31 Patient Is Student(Full-Time - Day)

Patient declares that he or she is enrolled asa full-time day student.

32 Patient Is Student(Cooperative/Work StudyProgram)

Patient declares that he or she is enrolled ina cooperative/work study program.

33 Patient Is Student(Full-Time - Night)

Patient declares that he or she is enrolled asfull-time night student.

34 Patient Is Student(Part-Time)

Patient declares that he or she is enrolled asa part-time student.

ACCOMMODATIONS

35 Reserved formational Assignment.

36 General Care Patient in aSpecial Unit

(Not used by hospitals under PPS.) Patienttemporarily placed in special care unit bedbecause no general care beds available.Accommodation charges for this period areat the prevalent semi-private rate.

37 Ward Accommodation atPatient Request

Patient assigned to ward accommodations atpatient’s request.

38 Semiprivate Room NotAvailable

Indicates that either private or wardaccommodations were assigned becausesemiprivate accommodations were notavailable.

OCTOBER 2001

2-49

39 Private Room MedicallyNecessary

(Not used by hospitals under PPS.) Patientneeded a private room for medical necessity.

40 Same Day Transfer Patient transferred to another participatingMedicare provider before midnight on theday of admission.

41 Partial Hospitalization Indicates claim is for partial hospitalizationservices. For outpatient Medicare thisincludes a variety of psychiatric programs(such as drug and alcohol). (See MedicareHospital Manual Sections 230.5C and D forcoverage guidelines.)

42 Continuing Care Not Related toInpatient Admission

Continuing care plan is not related to thecondition or diagnosis for which theindividual received inpatient hospitalservices.

43 Continuing Care Not ProvidedWithin Prescribed PostdischargeWindow

Continuing care plan was related to theinpatient admission but the prescribed carewas not provided within the postdischargewindow.


55 SNF Bed Not Available Code indicates the patient’s SNF admissionwas delayed more than 30 days after hospitaldischarge because a SNF bed was notavailable.

56 Medical Appropriateness Code indicates the patient’s SNF admissionwas delayed more than 30 days after hospitaldischarge because the patient’s conditionmade it inappropriate to begin active carewithin that period.

57

58

SNF Readmission

Terminated Medicare+ChoiceOrganization Enrollee

Code indicates the patient previouslyreceived Medicare covered SNF care within30 days of the current SNF admission.

Enter this code to indicate the patientpreviously received Medicare covered SNFcare within 30 days of the current SNFadmission.

OCTOBER 2001

2-50

TRICARE INFORMATION

46 Nonavailability StatementOn File

A nonavailability statement must be onfile with each TRICARE claim fornonemergency inpatient care when theTRICARE beneficiary resides within thecatchment area (usually a 40-mile radius)of a Uniformed Services Hospital.

47 Reserved for TRICARE.

48 Psychiatric ResidentialTreatment Centers ForChildren And Adolescents(RTCs)

Code to identify claims submitted by a“TRICARE - authorized” psychiatricResidential Treatment Center (RTC) forChildren and Adolescents.


PROSPECTIVE PAYMENT

60 Day Outlier A hospital being paid under a prospectivepayment system is reporting this stay as aday outlier. (Not reported by provider)

61 Cost Outlier A hospital being paid under a prospectivepayment system is requesting additionalpayment for this stay as a cost outlier. (Notreported by provided)

62 Payer Code PROVIDERS DO NOT REPORT THIS.FOR PAYER INTERNAL USE ONLY.Indicates the claim was paid under a DRG.

63 Payer Only Code Code reserved for internal use only. HCFAassigns as needed. Providers do not reportthis code.

64 Other Than Clean Claim (Not reported by providers.) Code indicatesthe claim is not “clean”. Record this fromyour system.

65 Non-PPS Bill (Not reported by providers.) Code indicatesbill is not a PPS bill. Record this from yoursystem for non-PPS hospital bills.

66 Provider Does Not WishCost Outlier Payment

Indicates provider is not requesting additionalpayment for this stay as a cost outlier. (Usedonly by hospitals paid under PPS.)

67 Beneficiary Elects Not to UseLife Time Reserve (LTR) Days

Indicates beneficiary elected not to use LTRdays.

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68 Beneficiary Elects to UseLife Time Reserve (LTR)Days

Indicates beneficiary elected to use LTRdays when charges are less than LTRcoinsurance amounts.

69 IME/Payment Only Bill Code indicates a hospital is requesting asupplemental payment consisting only ofapplicable IME for a Medicare managedcare enrollee.

RENAL DIALYSIS SETTING

70 Self-Administered Epoetir(EPO)

Code indicates the billing is for a homeDialysis patient who self-administers EPO.

71 Full Care In Unit Code indicates the billing is for a patientwho received staff-assisted dialysis servicesin a hospital or renal dialysis facility.

72 Self-Care In Unit Code indicates the billing is for a patientwho managed his/her own dialysis serviceswithout staff assistance in a hospital or renaldialysis facility.

73 Self-Care Training Code indicates the billing is for specialdialysis services where a patient and his/herhelper (if necessary) were learning toperform dialysis.

74 Home Code indicates the billing is for a patient whoreceived dialysis services at home, but whereCondition Code 75 below does not apply.

75 Home – 100% (Not to be used for services furnished 4/16/90,or later. Code indicates the billing is for apatient who received dialysis services at homeusing a dialysis machine that was purchasedby Medicare under the 100 percent program.

76 Back-up In Facility Dialysis Code indicates the billing is for a homedialysis patient who received back-updialysis in a facility.

77 Provider Accepts Or IsObligated/Required Due ToA Contractual ArrangementOr Law To Accept PaymentBy A Primary Payer AsPayment In Full

Code indicates provider has accepted or areobligated/required to accept payment aspayment in full due to a contractualarrangement or law. Therefore, no paymentis due.

78 New Coverage NotImplemented By HMO

Code Indicates billing for a newly coveredservice under Medicare for which the HMOdoes not pay. (For outpatient bills, ConditionCode 04 should be omitted).

OCTOBER 2001

2-52

79 CORF Services ProvidedOffsite

Code indicates that physical therapy,occupational therapy or speech pathologyservices were provided offsite

80-99 Reserved for State Assignment.

SPECIAL PROGRAM INDICATOR CODES

A0 Special Zip Code Reporting(Medicare)

Five digit ZIP Code of the location fromwhich the beneficiary is initially placed onboard the ambulance.

A0 TRICARE ExternalPartnership Program

This code identifies TRICARE claimssubmitted under the External PartnershipProgram.

Al EPSDT/CHAP Early and periodic Screening Diagnosis andTreatment.

A2 Physically HandicappedChildren’s Program

Services provided under this programreceive special funding through Title 8 ofthe Social Security Act or the TRICAREprogram for the Handicapped.

A3 Special Federal Funding This code has been designed for uniformuse by state uniform billing committees.

A4 Family Planning This code has been designed for uniformuse by state uniform billing committees.

A5 Disability This code has been designed for uniformuse by state uniform billing committees.

A6 Medicare PneumococcalPneumonia Vaccine (PPV);Influeuza Virus Vaccine

This code identifies the services given thatare to be paid under special Medicareprogram provisions.

A7 Induced Abortion-Dangerto Life

Abortion was performed to avoid danger towoman’s life.

A8 Induced Abortion-VictimRape/Incest

Self-explanatory.

A9 Second Opinion Surgery Services requested to support secondopinion on surgery. Part B deductible andcoinsurance do not apply.

B0 Medicare Coordinated CareDemonstration Program

Patient is participant in a MedicareCoordinated Care Demonstration.

B1-B9 Reserved for National Assignment.

OCTOBER 2001

2-53

NOTE: M0-M9 Payer only codes

M0 All-Inclusive Rate forOutpatient

Used by a Critical Access Hospital electingto be paid an all-inclusive rate for outpatientservices.

M1 Roster Billed InfluenzaVirus Vaccine

Code indicates the influenza virus vaccineor PPV is being billed via the roster billingmethod by providers that mass immunize.

M2 HHA Payment SignificantlyExceeds Total Charges

Used when payment to an HHA issignificantly in excess of covered billedcharges.

PRO APPROVAL INDICATOR SERVICES

C0 Reserved for National Assignment.

C1 Approved As Billed Code indicates claim has been reviewed bythe PRO and is fully approved including anyday or cost outlier.

C2 Automatic Approval AsBilled Based On FocusedReview

This should include only categories of casesthat the PRO/UR has determined it need notreview under a focused review program.(No longer required for Medicare.)

C3 Partial Approval Code indicates the bill has been reviewed bythe PRO and some portion (days or services)has been denied. From/Through dates of theapproved portion of the stay are shown ascode “MO” in FL 36. Exclude grace daysand any period at a noncovered level of care(code “77” in FL 36 or code “46” in FL 39-41.)

C4 Admission/Services Denied Code indicates patient’s need for inpatientservices was reviewed and the PRO foundthat none of the stay was medically necessary.

C5 Postpayment ReviewApplicable

Code indicates that any medical review willbe completed after the claim is paid. Thebill may be a day outlier, cost outlier, partof the sample review, reviewed for otherreasons, or may not be reviewed.

C6 Preadmission/Preprocedure Code indicates that the PRO authorized thisadmission/procedure but has not reviewedthe services provided.

OCTOBER 2001

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C7 Extended Authorization Code indicates the PRO authorized theseservices for an extended length of time, buthas not reviewed the services provided.

CLAIM CHANGE REASONS

D0 Changes To Service Dates Self-explanatory.

Dl Changes To Charges Self-explanatory.

D2 Changes To RevenueCodes/HCPCs/HIPPS RateCode

Self-explanatory.

D3 Second Or SubsequentInterim PPS Bill

Self-explanatory.

D4 Change In GROUPER Input Self-explanatory.

D5 Cancel To Correct HICNOr Provider ID

Cancel only to delete an incorrect HICN orProvider Identification Number.

D6 Cancel Only To Repaya Duplicate or OIGOverpayment

Cancel only to repay a duplicate payment orOIG overpayment. (Includes cancellation ofoutpatient bill containing services requiredto be included on an inpatient bill.)

D7 Change to Make MedicareThe Secondary Payer

Self-explanatory.

D8 Change to Make MedicareThe Primary Payer

Self-explanatory.

D9 Any Other Change Self-explanatory.

E0 Change in Patient Status Self-explanatory.

H0 Delayed Filing, Statementof Intent Submitted

Code indicates that Statement of Intent wassubmitted within the qualifying period tospecifically identify the existence of anotherthird party liability situation.

M0 All-Inclusive Rate forOutpatient Services (PayerOnly Code)

Used by a Critical Access Hospital electingto be paid an all-inclusive rate for outpatientservices.

OCTOBER 2001

2-55


ANTHEM BCBS-NH: Required, if applicable. Identify Insurance Codes 02, 03 and 05.

BCBSVT: Required, if applicable. Accepts all Condition Codes.

TRICARE: Required. All Codes are valid however codes outlined below are TRICARE Specific.

CODE CODE CODE01 19 3802 31 3903 33 4617 34 6018 36 61

CIGNA NH: Required, if applicable. Enter the appropriate code(s) to describe any of theconditions that apply to this billing.

CODE0102033841

MEDICARE: Required, if applicable. Enter the appropriate code(s) to describe the conditionsthat apply to this billing.

NOTE: On outpatient dialysis claims, codes 71-75 and 76 can only be enteredonce per claim. When more than one of these conditions (settings) isinvolved, separate bills are required.

CODE CODE CODE CODE CODE02 26 43 78 D004 27* 55 79 D105 28 56 A0 D206 29 57 A3 D307 30 66 A5 D408 31 67 A6 D509 32 68 A7 D610 33 69 A8 D711 34 70 A9 D812 36 71 B0 D913 37 72 C1 E014 38 73 C3 H015 39 74 C4 M016 40 75 C5 M120 41 76 C6 M221 42 77 C7

*Sole Community Hospital only.

MTHP: Required, if applicable. Identify insurance codes 01, 02, 03, 05, 08, 18, 19, 22,31-34, 38, 39, 41, 60 and 61.

OCTOBER 2001

2-56


State Assigned CodesEnter 01 to indicate yes - EPSDT/CH no - Family PlanningEnter 04 to indicate no - EPSDT/CH yes - Family PlanningEnter 81 to indicate yes to both programsEnter 82 to indicate no to both programs

VT MEDICAID: Required. Outpatient: Vermont Medicaid will only accept 3 values in FLs 24-30.The accepted values are:

02 - Employment RelatedAl - EPSDT RelatedA4 - Family Planning Related

If any of the above condition codes apply to the claim, indicate the conditioncode(s) in FLs 24-30. If none of the above apply to the claim, FLs 24-30 shouldbe left blank.

Inpatient: If any of the following condition codes apply to the claim, indicate thecondition code(s) in FLs 24-30. In addition one of the PRO approval indicatorslisted below must be entered. VT Medicaid will only reimburse claims whichhave a PRO indicator of C1 or C5.

02 - Employment RelatedAl - EPSDT RelatedA4 - Family Planning RelatedC1 - PRO Approval as BilledC5 - PRO Postpayment Review Applicable

OCTOBER 2001

2-57

FORM LOCATOR 31


OCTOBER 2001

2-58

FORM LOCATORS 32-35 A,B

DATA ELEMENT: Occurrence Codes and Dates

DEFINITION: The code and associated date(s) defining specific event(s) relating to this billingperiod that may affect payer processing.

FIELD SIZE: 4 fields (codes), 2 lines, 2 positions, alphanumeric, and4 fields (dates), 2 lines, 6 positions, numeric

CODE STRUCTURE:

ACCIDENT RELATED CODES

01 Auto Accident Code indicating the date of an auto accident.Use this code to report an auto accident thatinvolves liability insurance.

02 No Fault InsuranceInvolved-Including AutoAccident/Other

Code indicating the date of an accidentincluding auto or other where state hasapplicable no-fault liability laws (i.e., legalbasis for settlement without admission ofproof of guilt).

03 Accident/Tort Liability Code indicating the date of an accident(excluding automobile) resulting from athird party’s action. This incident mayinvolve a civil court action in an attempt torequire payment by the third party, otherthan no fault liability.

04 Accident/EmploymentRelated

Code indicating the date of an accidentwhich relates to the patient’s employment.

05 Other Accident Code indicating the date of an accident notdescribed by the preceding occurrencecodes. Use this code to report that providerhas developed for other casualty-relatedpayers and have determined there are none.

06 Crime Victim Code indicating the date on which a medicalcondition resulted from alleged criminalaction committed by one or more parties.


MEDICAL CONDITION CODES

09 Start Of InfertilityTreatment Cycle

Code indicating the date of start ofinfertility treatment cycle.

OCTOBER 2001

2-59

11 Onset of Symptoms/Illness (Outpatient claims only.) Code indicatingthe date the patient first became aware ofsymptoms/illness.

12 Date of Onset for aChronically DependentIndividual (CDI)

(HHA claims only.) Code indicating thedate the patient/beneficiary becomes a CDI.This is the first month of the 3-month periodimmediately prior to eligibility underRespite Care Benefit.

INSURANCE RELATED CODES

17 Date OutpatientOccupational TherapyPlan Established orLast Reviewed

Code indicating the date an occupationaltherapy plan was established or lastreviewed.

18 Date of RetirementPatient/Beneficiary

The date of retirement for the patient/beneficiary.

19 Date of Retirement Spouse The date of retirement for the patient’sspouse.

20 Guarantee of PaymentBegan

Code indicating the date on which theprovider began claiming Medicare paymentunder the guarantee of payment provision.

21 UR Notice Received (Part A SNF claims only.) Code indicatingthe date of receipt by the SNF and hospitalof the UR Committee’s finding that theadmission or future stay was not medically),necessary.

22 Date Active Care Ended Enter code to indicate the date on which acovered/active level of care ended in a SNF,general, psychiatric or tuberculosis hospitalor date on which patient was released on atrial basis from a residential facility. Code isnot required if code A21 is used.

24 Date Insurance Denied Code indicating the date of receipt of adenial of coverage by the a higher prioritypayer.

25 Date Benefits Terminatedby Primary Payer

Code indicating the date on which coverage(including Worker’s Compensation benefitsor no-fault coverage) is no longer availableto the patient.

OCTOBER 2001

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26 Date SNF Bed Available Code indicating the date on which a SNFbed became available to hospital inpatientwho required only SNF level care.

27 Date of HospiceCertification orPrecertification

Code indicating the date of certification orrecertification of the hospice benefit period,beginning with the first two initial benefitperiods of 90 days each and the subsequent60-day benefit periods.

28 Date ComprehensiveOutpatient RehabilitationPlan Established or LastReviewed.

Code indicating the date a comprehensiveoutpatient rehabilitation plan wasestablished or last reviewed.

29 Date OPT Plan Establishedor Last Reviewed

Code indicating the date an OPT plan wasestablished or last reviewed.

30 Date Outpatient SpeechPathology Plan Establishedor Last Reviewed

Code indicating the date a speech pathologyplan was established or last reviewed.

31 Date Beneficiary Notifiedof Intent to Bill(Accommodations)

The date the provider notified the patient/beneficiary that he/she does not (or nolonger) require a covered level of inpatientcare.

32 Date Beneficiary Notifiedof Intent to Bill (Proceduresor Treatment)

The date provider provided notice topatient/beneficiary stating that requestedcare (diagnostic procedures or treatments) isnot considered reasonable or necessary byMedicare.

33 First Day of the MedicareCoordination Period forESRD BeneficiariesCovered by EGHP

Code indicates the first day of the Medicarecoordination period during which Medicareor TRICARE benefits are secondary tobenefits payable under an employer grouphealth plan. Required only for ESRDbeneficiaries.

34 Date of Election ofExtended Care Services

Code indicates the date the guest elected toreceive extended care services (used byChristian Science Sanatoria only).

35 Date Treatment Started forPhysical Therapy

Code indicates the date services wereinitiated for physical therapy.

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2-61

36 Date of Inpatient HospitalDischarge for CoveredTransplant Procedure(s)

Code indicates the date of discharge foran inpatient hospital stay in which thepatient received a covered transplantprocedure when the hospital is billingfor immunosuppressive drugs

NOTE: When the patient received a coveredand a noncovered transplant, this coveredtransplant predominates.

37 Date of Inpatient HospitalDischarge for PatientReceived NoncoveredTransplant Patient

Code indicates the date of discharge foran inpatient hospital stay in which thepatient received a noncovered transplantprocedure when the hospital is billing forimmunosuppressive drugs.

38 Date Treatment Started forHome IV Therapy

Date the patient was first treated at home forIV Therapy (Home IV providers - bill 85X).

39 Date Discharged on aContinuous Course of IVTherapy

Date the patient was discharged from thehospital on a continuous course of IV Therapy.(Home IV providers - bill type 85X)

41 Date of First Test forPre-Admission Testing

The date on which the first outpatientdiagnostic test, was performed as part of aPAT program. This code may only be usedif a date of admission was scheduled prior tothe administration of the test(s).

SERVICE RELATED CODES

42 Date of Discharge (Hospice claims only.) Code indicates thedate on which patient terminated his/herelection to receive hospice benefits from thefacility rendering the bill.

43 Scheduled Date ofCanceled Surgery

The date for which ambulatory surgery wasscheduled.

44 Date Treatment Started forOccupational Therapy

The date services were initiated by thebilling provider for occupational therapy.

45 Date Treatment Started forSpeech Therapy

The date services were initiated by thebilling provider for speech therapy.

46 Date Treatment Started forCardiac Rehabilitation

The date services were initiated by thebilling provider for cardiac rehabilitation.

OCTOBER 2001

2-62

47 Date Cost Outlier StatusBegins

Code indicates that this is the first day thecost outlier threshold is reached. For Medicarepurposes, a beneficiary must have regularcoinsurance and/or lifetime reserve daysavailable beginning on this date to allowcoverage of additional daily charges for thepurpose of making cost outlier payments.

48-49 Payer Codes These codes are reserved for payer use only.Providers do not report these codes.

*50 Medical Emergency Nonaccident medical emergency, enter dateof onset of symptoms.

*51 Outpatient Surgery Surgical procedure shown on this claim wasperformed in outpatient service of provider.Enter date of surgery.

*/**52 Not an Accident Code indicates not accident related.

53-69 Reserved for State assignment.

70-99 See instructions in Occurrence Span Codesand Dates (FL 36).

Al Birthdate - Insured A Code indicates the birthdate of the insuredin whose name the insurance is carried.

A2 Effective Date - Insured APolicy

Code indicates the first date the insurance isin force.

A3 Benefits Exhausted Code indicates the last date for whichbenefits are available and after which nopayment can be made to payer A.

B1 Birthdate - Insured B Code indicates the birthdate of the individualin whose name the insurance is carried.

B2 Effective Date - Insured BPolicy


B3 Benefits Exhausted Code indicates the last date for whichbenefits are available and after which nopayment can be made to payer B.

C1 Birthdate - Insured C Code indicates the birthdate of the individualin whose name the insurance is carried.

C2 Effective Date - Insured CPolicy


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2-63

C3 Benefits Exhausted Code indicates the last date for whichbenefits are available and after which nopayment can be made to payer C.

C4-C9 Reserved for National Assignment.

D0-D9 Reserved for National Assignment

*This is a State assigned code for use by Vermont Medicaid.**This is a State assigned code for use by New Hampshire Medicaid.


ANTHEM BCBS-NH: Required, if applicable for both inpatient and outpatient claims, however onlyone of the following Occurrence Codes may be entered in one of the OccurrenceCode fields when billing an outpatient claim.

CODE CODE01 0602 1103 5004 5105 52

NOTE: Code 52 indicates not accident related and should only be used in conjunctionwith and secondary to code 50 and 51.

BCBSVT: Required for both inpatient and outpatient claims. However, only one of thefollowing occurrence codes must be entered as acceptable in FL 32A whenbilling an outpatient claim.

CODE CODE01 0602 1103 5004 5105

The first occurrence code must be prior to or equal to the admission date (FL 17).Second – fourth occurrence codes may be within date span of services (FL 6).

TRICARE: Required. Enter any of the following codes that apply to this billing.

CODE CODE CODE01 21 2802 22 2903 24 3004 25 3105 26 3206 27 33

OCTOBER 2001

2-64

CIGNA NH: Required. Enter any of the following codes that apply.

CODE01043544454651

MEDICARE: Required, if applicable. Code(s) and date(s) defining a specific event(s) relatingto this billing period must be shown. Occurrence Codes 01-03 and 24 are enteredonly when a provider is claiming conditional payment from Medicare. Theappropriate value code must be entered.

Only the following codes are approved for Medicare use:

CODE CODE CODE CODE01 22 34 4902 23 35 A103 24 36 A204 25 37 A305 26 41 B111 27 42 B212 28 43 B317 29 44 C118 30 45 C219 31 46 C320 32 4721 33 48

MTHP: Required, if applicable. Enter any of the following codes that apply to thisbilling.

CODE CODE01 0602 1103 3604 3805 51

NH MEDICAID: Required. One of the following occurrence codes and associated date must beentered when billing any claim, inpatient or outpatient.

CODE CODE01 0502 0603 5204

OCTOBER 2001

2-65

VT MEDICAID: Required. Enter any of the following occurrence codes applicable when billingany claim, inpatient or outpatient.

CODE CODE01 1102 4203 5004 5105 5206

OCTOBER 2001

2-66

FORM LOCATOR 36 A,B

DATA ELEMENT: Occurrence Span Codes and Dates

DEFINITION: A code and the related dates that identify an event that relates to the payment ofthe claim.

FIELD SIZE: 1 field (codes), 2 lines, 2 positions, alphanumeric, and2 fields (dates), 2 lines, 6 positions, numeric

NOTE: These codes identify occurrences that happened over a span of time.

Enter all dates as month, day, and year (MMDDYY).

Occurrence Span Codes must be entered in numerical sequence starting withcode 70.

CODE STRUCTURE:

70 Qualifying Stay Dates (Part A claims for SNF level of care only.)The From/Through dates for a hospital stayof at least 3 days which qualifies the patientfor payment of the SNF level of careservices billed on this claim.

70 Nonutilization Dates (ForPayer Use or Hospital BillsOnly)

The From/Through dates during a PPS inlierstay for which the patient has exhausted allregular days and/or coinsurance days, butwhich is covered on the cost report.

71 Hospital Prior Stay Dates (Part A claims only.) The From/Throughdates given by the patient of any hospitalstay that ended within 60 days of thishospital or SNF admission

72 First/Last Visit The from/through dates of outpatient services.For use on outpatient bills only where theentire billing record is not represented bythe actual from/through service dates ofStatement Covers Period (FL 6).

73 Benefit Eligibility Period The inclusive dates during which TRICAREmedical benefits are available to a sponsor’sbeneficiary as shown on the beneficiary’sID card.

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74 Noncovered Level of Care The From/Through dates for a period at anoncovered level of care in an otherwisecovered stay, excluding any period reportedwith Occurrence Span Codes 76, 77 or 79.Codes 76 and 77 apply to most noncoveredcare used for leave of absence and also usedfor repetitive Part B services to show a periodof inpatient hospital care or outpatient surgeryduring the billing period. This code is alsoused for HHA or hospice services billedunder Part A.

75 SNF Level of Care Enter the From/Through dates for a periodof SNF level of care during an inpatienthospital stay. Since PROs no longerroutinely review inpatient hospital bills forhospital under PPS the code is needed onlyin length of stay outlier cases (code "60" inFLS 24-30). It is not applicable to swing bedhospitals which transfer the patient from thehospital to a SNF level of care.

76 Patient Liability The From/Through dates for a period ofnoncovered care for which the hospital ispermitted to charge the Medicare beneficiary.Code should be used only where theprovider or the PRO have approved suchcharges in advance and patient has beennotified in writing at least 3 days prior to the“From” date of this period. (See occurrencecodes 31 and/or 32).

77 Provider LiabilityUtilization Charged

Code indicates the From/Through dates fora period of noncovered care for which theprovider is liable (other than for lack ofmedical necessity or custodial care). Thebeneficiary’s record is charged with Part Adays, Part A or Part B deductible, and PartB coinsurance. The provider may collect thePart A or Part B deductible and coinsurancefrom the beneficiary.

78 SNF Prior Stay Dates (Part A claims only.) Code indicates theFrom/Through dates given by the patient fora SNF stay that ended within 60 days of thishospital admission. An inpatient stay in afacility or part of a facility that is certifiedor licensed by the State solely below a SNFlevel of care, does not continue a spell ofillness and, therefore, is not shown in FL 36.

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79 Provider Liability – NoUtilization (Payer Code)

Code indicates From/Through dates of aperiod of noncovered care due to lack ofmedical necessity or custodial care forwhich provider is liable. The beneficiary isnot charged with utilization. Provider maynot collect Part A or Part B deductible orcoinsurance from the beneficiary.


M0 PRO/UR Stay Dates The From/Through dates of the approvedbilling period. (Use when Condition Code C3is used in FL 24-30.)

M1 Provider Liability –No Utilization

Code indicates the From/Through dates of aperiod of noncovered care that is denied dueto lack of medical necessity or as custodialcare for which the provider is liable. Thebeneficiary is not charged with utilization.The provider may not collect Part A or PartB deductible or coinsurance from thebeneficiary.

M2 Dates of InpatientRespite Care

Code indicates From/Through dates of aperiod of inpatient respite care for hospicepatients.

M1-V9 Reserved for National Assignment

X0-Z9 Reserved for State Assignment.




TRICARE: Required. Use only code 73. Use effective dates as indicated on beneficiary'smilitary ID card.


MEDICARE: Required, if applicable. Code and associated beginning and ending date(s)defining a specific event relating to this billing period are shown.

CODE CODE CODE70 76 M171 77 M272 7874 7975 M0

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MTHP: Not required.



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FORM LOCATOR 37 A,B,C

DATA ELEMENT: Internal Control Number (ICN)/Document Control Number (DCN)

DEFINITION: The control number assigned to the original bill by the payer or the payer’sintermediary.

SIZE: 1 field, 3 lines, 23 positions, alphanumeric

NOTE: A = Primary payerB = Secondary payerC = Tertiary payer

as specified in FL 50 A, B, C




TRICARE: Required. When requesting an adjustment to a previously processed claim,indicate the Internal Control Number or Document Control Number from thepreviously processed claim (see EOB) of the claim to be adjusted.


MEDICARE: Required. Enter the ICN/DCN assigned to the original bill. Utilize on adjustmentrequests (Bill Type, FL 4=XX7). When requesting an adjustment to a previouslyprocessed claim, insert the ICN/DCN of the claim to be adjusted. Payer A’sICN/DCN should be shown on line “A” in FL 37. Similarly, the ICN/DCN forPayer B and C should be shown on lines “B” and “C” respectively, in FL 37.

MTHP: Not required.



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FORM LOCATOR 38

DATA ELEMENT: Responsible Party Name and Address

DEFINITION: The name and address of the party responsible for the bill.


NOTE: Address may include post office box or street name and number, city, state andzip code.

Providers should abbreviate state in the address according to the post officestandard abbreviations appearing in the instructions for FL 1.

If a nine digit zip code is used, it should be entered XXXXX-YYYY where thefirst 5 digits are the 5 digit zip code and the last 4 digits are the zip codeextension.

Can also be used by provider as mailing address for bill.

DETAIL BILLING INSTRUCTIONS


BCBSVT: Required, if different from patient information in FL 12 and FL 13.

TRICARE: Required, only when patient is under 18 years.


MEDICARE: (Untitled Except on Patient Copy of the Bill) Responsible Party Name andAddress Not Required). (For Hospice claims only, the name, address, andprovider number of a transferring Hospice is shown by the new Hospice on itsHCFA-1450 admission notice. (See §3648, FL 38.) For claims which involvepayers of higher priority than Medicare as defined in FL 58, the address of theother payer may be shown here or in FL 84 (Remarks).

MTHP: Same as BCBSVT.



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FORM LOCATOR 39-41 A,B,C,D

DATA ELEMENT: Value Codes and Amounts

DEFINITION: A code structure to relate amounts or values to identified data elementsnecessary to process this claim as qualified by the payer organization.

FIELD SIZE: 3 fields (codes), 4 lines, 2 positions, alphanumeric, and3 fields (amounts), 4 lines, 9 positions, numeric

GUIDELINES FOR VALUE CODE UTILIZATION

Whole numbers are right justified to the left of the dollars/cents delimiter. However, some values arereported as cents, thus reference to the instructions for specific codes is necessary. Value codes must beentered in numerical sequence starting with code 01. Fields 39 A through 41 A must be completed beforethe B fields etc. Negative numbers are not allowed except in FL 41.

CODE STRUCTURE:

01 Most Common SemiprivateRate

To provide for the recording of hospital’smost common semiprivate rate.

02 Hospital Has NoSemiprivate Rooms

Entering this code requires $0.00 amount.


04 Inpatient ProfessionalComponent Charges WhichAre Combined Billed

Code indicates the amount shown is the sumof the inpatient professional componentcharges which are combined billed. Medicareuses this information in internal processesand also in the HCFA notice of utilizationsent to the patient to explain that Part Bcoinsurance applies to the professionalcomponent. (Used only by some all-inclusiverate hospitals.)

05 Professional ComponentIncluded in Charges AndAlso Billed Separate toCarrier

(Applies to Part B bills only.) Code indicatesthe charges shown are included in billedcharges FL 47, but a separate billing forthem will also be made to the carrier. Foroutpatient claims, these charges are excludedin determining the deductible and coinsurancedue from the patient to avoid duplicationwhen the bill for physician’s services isprocessed by the carrier. These charges are alsodeducted when computing interim payment.

Code also indicates outpatient treatmentis for mental illness, and professionalcomponent charges are included in FL 47.

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06 Medicare Blood Deductible Code indicates the amount shown is theproduct of the number of unreplaceddeductible pints of blood supplied times thecharge per pint. If the charge per pint varies,the amount shown is the sum of the chargesfor each unreplaced pint furnished. If alldeductible pints have been replaced, thiscode is not used. When you give a discountfor unreplaced deductible blood, showcharges after the discount is applied.


08 Medicare Lifetime ReserveAmount In The FirstCalendar Year in BillingPeriod

Code indicates the amount shown is theproduct of the number of lifetime reservedays used in first calendar year of the billingperiod times the applicable lifetime reservecoinsurance rate. (See 3206 and 3211)These are days used in the year ofadmission.

09 Medicare CoinsuranceAmount In The FirstCalendar Year in BillingPeriod

On Part A Bills, this code indicates theamount shown is the product of the numberof coinsurance days used in the firstcalendar year of the billing period time theapplicable coinsurance rate. These are daysused in the year of admission. (See 3206 and3211).

10 Medicare Lifetime ReserveAmount In The SecondCalendar Year

Medicare lifetime reserve coinsuranceamount charged in the year of dischargewhere the bill spans two calendar years.

11 Medicare CoinsuranceAmount In The SecondCalendar Year

Medicare coinsurance amount charged inthe year of discharge where the inpatient billspans two calendar years.

*12 Working Aged Beneficiary/Spouse With EmployerGroup Health Plan

Amount shown is that portion of a paymentfrom a higher priority employer grouphealth insurance made on behalf of an agedbeneficiary that the provider is applying toMedicare covered services on this bill (HIM 10,Sections 472-473).

*13 ESRD Beneficiary In AMedicare CoordinationPeriod With An EmployerGroup Health Plan

Amount shown is that portion of a paymentfrom a higher priority employer group healthinsurance payment made on behalf of anESRD beneficiary that the provider is applyingto Medicare covered services on this billHIM 10, Sections 471 and 473).

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14 No Fault, IncludingAuto/Other, Or AnyLiability Insurance

Amount shown is that portion from a highpriority, no-fault including auto/other, orliability insurance made on behalf of aMedicare covered services on this bill HIM 10,sections 470 and 473). Where you receiveda reduced no-fault payment because of failureto file a proper claim, enter the amount thatwould have been payable had you filed aproper claim (HIM 10 Section 472).

*15 Workers’ Compensation Amount shown is that portion of a paymentfrom a higher priority workers’ compensationinsurance made on behalf of a Medicarebeneficiary that the provider is applying toMedicare covered services on this bill (HIM,Section 289 ff.).

*Failure to File a Proper ClaimFor situations where the provider received a reduced payment because of failure to file aproper claim, indicate the amount that would have been payable if the provider had filed aproper claim.

*16 PHS or Other FederalAgency

Amount shown is that portion of a paymentfrom a higher priority Public Health Serviceor the Federal Agency made on behalf of aMedicare beneficiary that the provider isapplying to Medicare covered services onthis bill (HIM 10, Sections 260.3Dl).

*A six zero value entry for value codes 12-16 indicates conditional Medicare paymentrequested (000000).

17 Operating Outlier Amount PROVIDERS DO NOT REPORT THIS.FOR PAYER INTERNAL USE ONLY.Indicates the amount of day or cost outlierpayment to be made.

18-20 These codes are set for payer use only.Providers do not report these codes.

25-29 Reserved for National Assignment Medicaid.

30 Preadmission Testing This code reflects charges for preadmissionoutpatient diagnostic services in preparationfor a previously scheduled admission.

31 Patient Liability Amount The amount approved to charge thebeneficiary for noncovered accommodations,diagnostic procedures, or treatments.


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37 Pints of Blood Furnished Code indicates the total number of pints ofwhole blood or units of packed red cellsfurnished, whether or not they werereplaced, is shown. Blood is reported onlyin terms of complete pints rounded upwards,e.g., 1 ¼ pints is shown as 2 pints. Thisentry serves as a basis for counting pintstowards the blood deductible.

38 Blood Deductible Pints Codes indicates the number of unreplaceddeductible pints of blood supplied. If alldeductible pints furnished have beenreplaced, no entry is made.

39 Pints of Blood Replaced Codes indicates the total number of pints ofblood which were donated on the patient’sbehalf. Where one pint is donated, one pintis considered replaced. If arrangements havebeen made for replacement, pints are shown asreplaced. (See §3235.4A.) Where the providercharges only for the blood processing andadministration, (i.e., it does not charge a“replacement deposit fee” for unreplacedpints), the blood is considered replaced forpurposes of this item. In such cases, all bloodcharges are shown under the 39X revenuecode series (blood administration) or underthe 30X revenue code series (laboratory).

40 New Coverage NotImplemented By HMO

(For inpatient service only.) Code indicatesthe amount shown for inpatient chargescovered by the HMO. (Use this code whenthe bill includes inpatient charges of newlycovered services that are not paid by theHMO.) Condition Codes 04 and 78 mustalso be reported.

41 Black Lung Code indicates the amount shown is that portionof a higher priority Black Lung paymentmade on behalf of a Medicare beneficiarythat the provider is applying to Medicarecharges on this bill. If six zeros (0000.00)are entered in the amount field, the provideris claiming a conditional payment becausethere has been a substantial delay in itspayment. (See §§3415ff.) Where the providerreceived no payment or a reduced paymentbecause of failure to file a proper claim, thisis the amount that would have been payablehad it filed a proper claim. (See §3497.6.)

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42 Veterans Affairs Code indicates the amount shown is thatportion of a higher priority LGHP paymentmade on behalf of a disabled beneficiarythat the provider is applying to Medicarecharges on this bill. (See §3153.1A.)

43 Disabled Beneficiary UnderAge 65 With LGHP

Code indicates the amount shown is thatportion of a higher priority LGHP paymentmade on behalf of a disabled beneficiarythat the provider is applying to Medicarecharges on this bill. Where the providerreceived no payment or a reduced paymentbecause of failure to file a proper claim, thisis the amount that would have been payablehad it filed a proper claim. (See §3497.6.)

44 Amount Provider AgreedAccept From Primary PayerWhen this Amount is LessThan Charges But Higherthan Payment Received

Codes indicates the amount shown in theamount the provider was obligated orrequired to accept from a primary payer aspayment in full when the amount is less thanthe charges but higher than amount actuallyreceived. A Medicare secondary payment isdue. (See §3682.1.B.6 for an explanation.)

45 The hour when the accident occurred thatnecessitated medical treatment. Enter theappropriate code indicated below rightjustified to the left of the dollars/cents delimiter.


99 Unknown

46 Number Of Grace Days If a code “C3” or “C4” is in FL 24-30,indicating that the PRO has denied all or aportion of this billing period, the number ofdays determined by the PRO to be coveredwhile arrangements are made for thepatient’s post discharge are shown. Thefield contains one numeric digit.

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47 Any Liability Insurance Code indicates amount shown is that portionfrom a higher priority liability insurancemade on behalf of a Medicare beneficiarythat the provider is applying to Medicarecovered services on this bill. If six zeros(0000.00) are entered in the amount field,the provider is claiming conditional paymentbecause there has been substantial delay inthe other payer’s payment.

48 Hemoglobin Reading The latest hemoglobin reading taken duringthis, billing cycle. Whole numbers, i.e., 2digits and to be reported to the left of thedollar/cents delimiter, decimals, i.e., onedigit is to be reported to the right.

49 Hematocrit Reading Hematocrit reading taken prior to the lastadministration of EPO, during the billingcycle, related to the use of erythropoietin.

50 Physical Therapy Visit Number of physical therapy visits fromonset (at the billing provider) through thisbilling period. Report the number in thedollar portion of the form locator (rightjustified to the left of the dollar/centsdelimiter.)

*Failure to File a Proper ClaimFor situations where the provider received a reduced payment because of failure to file a properclaim, indicate the amount that would have been payable if the provider had filed a proper claim.

51 Occupational TherapyVisits

Number of occupational therapy visits fromonset of symptoms (at the billing provider)through this billing period. Report thenumber in the dollar portion of the formlocator right justified to the left of thedollar/cents delimiter.

52 Speech Therapy Visits Number of speech therapy visits from theonset of symptoms (at the billing provider)through this period. Report the number inthe dollar portion of the form locator rightjustified to the left of the dollar/cents delimiter.

53 Cardiac Rehab. Visits Number of cardiac rehabilitation visits fromthe onset of symptoms (at the billing provider)through this billing period. Report the numberin the dollar portion of the form locator rightjustified to the left of the dollar/cents delimiter.


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56 Skilled Nurse-Home VisitHours (HHA only)

Codes indicates the number of hours ofskilled nursing provider during the billingperiod. Count only hours spent in the home.Exclude travel time. Report in whole hours,right justified to the left of the dollars/centsdelimiter. (Round to the nearest whole hours.)

57 Home Health Aide-HomeVisit Hours (HHA only)

Codes indicates the number of hours ofhome health aide services provided duringthe billing period. Count only the hoursspent in the home. Exclude travel time.Report in whole hours, right justified to theleft of the dollars/cents delimiter. (Round tothe nearest whole hour).

NOTE: Code 50-57 and 60 are not money amounts but represent the number of visits. Entries forthe number of visits are right justified to the left of the dollars/cents delimiter as shown.

1 3

Accept zero or blanks in cents position. Convert blanks to zero for CWF.

58 Arterial Blood Gas(PO2/PA2)

Code indicates arterial blood gas value atthe beginning of each reporting period foroxygen therapy. This value or value 59 willbe required on the initial bill for oxygentherapy and on the fourth month’s bill.Report right justified in the cents area. (SeeNOTE following code 59 for an example.)

59 Oxygen Saturation(02 Sat/Oximetry)

Code indicates oxygen saturation at thebeginning of each reporting period foroxygen therapy. This value or value 58 willbe required on the initial bill for oxygentherapy and on the fourth month’s bill.Report right justified in the cents area. (SeeNOTE following this code for an example.)

NOTE: Code 58 and 59 are not money amounts, but represent arterial blood gas or oxygensaturation levels. Round to two decimals or to the nearest whole percent. For example,a reading of 56.5 is shown as:

5 7

A reading of 100 percent is shown m:

1 0 0

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60 HHA Branch MSA Code indicates MSA in which HHA branchis located (Report MSA when branchlocation is different than the HHA’s –Report the MSA number in dollar portion ofthe form locator right justified to the left ofthe dollar/cents delimiter.)

67 Peritoneal Dialysis The number of hours of peritoneal dialysisprovided during the billing period. Countonly the hours spent in the home. Excludetravel time. Report in whole hours, rightjustify to the left of the dollar/centsdelimiter. (Round to the nearest wholehour.)

68 Number of Units of EPOProvided During the BillingPeriod

Code indicates the number of units of EPOadministered and/or supplied relating to thebilling period and is reported in whole unitsto the left of the dollar/cents delimiter. Forexample, 31,060 units are administered forthe billing period. Thus 31,060 is entered asfollows:

3 1 0 6 0

70-72 Payer Codes THESE CODES ARE SET ASIDE FORPAYER USE ONLY. PROVIDERS DONOT REPORT THESE CODES.

71 Funding of ESRD Networks (For internal use by third party payers only.)Report the amount the Medicare paymentwas reduced to help fund the ESRDnetworks.

72 Flat Rate Surgery Charge Code indicates the amount of the standardcharge for outpatient surgery where thehospital has such a charging structure.

73 Drug Deductible (For internal use by third party payers only).Report the amount of the drug deductible tobe applied to the claim.

74 Drug Coinsurance (For internal use by third parry payers only).Report the amount of drug coinsurance to beapplied to the claim.

75 Gramm/Rudman/Hollings (For internal use by third party payers only.)Report the amount of sequestration.

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76 Provider’s Interim Rate (For internal use by third party payers only.)Report the provider’s percentage of billedcharges interim rate during this billing period.This applied to all outpatient hospital andskilled nursing facility (SNF) claims andhome health agency (HHA) claims to whichan interim rate is applicable. Report to theleft of the dollar/cents delimiter. An interimrate of 50 percent is entered as follows:

5 0 0 0

77-79 Payer Codes THESE CODES ARE SET ASIDE FORPAYER USE ONLY. PROVIDERS DONOT REPORT THESE CODES.


Al Deductible Payer A The amount assumed by the hospital to beapplied to the patients deductible amountinvolving the indicated payer.

B1 Deductible Payer B The amount assumed by the hospital to beapplied to the patient deductible amountinvolving the indicated payer.

C1 Deductible Payer C The amount assumed by the hospital to beapplied to the patient deductible involvingthe indicated payer.

A2 Coinsurance Payer A The amount assumed by the hospital to beapplied toward the patient’s coinsuranceamount involving the indicated payer.

B2 Coinsurance Payer B The amount assumed by the hospital to beapplied toward the patient’s coinsuranceamount involving the indicated payer.

C2 Coinsurance Payer C The amount assumed by the hospital to beapplied toward the patient’s coinsuranceamount involving the indicated payer.

A3 Estimated ResponsibilityPayer A

The amount estimated by the hospital to bepaid by the indicated payer.

B3 Estimated ResponsibilityPayer B


C3 Estimated ResponsibilityPayer C


D3 Estimated ResponsibilityPatient

The amount estimated by the hospital to bepaid by the indicated patient.

A0 Point-of-pickup-Ambulance Reserved for National Assignment.

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A4 Covered Self AdministrableDrugs – Emergency

The amounts included in covered chargesfor self-Administrable drugs administeredto the patient in an emergency situation.(The only covered Medicare Charge for anordinarily non-covered, self-Administereddrug is for insulin administered to a Patientin a diabetic coma.

A5-A9 Reserved for National Assignment.

B0 Reserved for National Assignment.

B4-B9 Reserved for National Assignment.

C0 Reserved for National Assignment.

C4-C9 Reserved for National Assignment.

D0-D2 Reserved for National Assignment.

D4-W9 Reserved for National Assignment.

X0-Z9 Reserved for State Assignment.


ANTHEM BCBS-NH: Required, if applicable. It is imperative that codes 14, 15 and 30 be utilized whenapplicable, to ensure accurate processing.

BCBSVT: Required, if applicable. Accepts all value codes. It is imperative that code 30 beutilized when applicable, to ensure accurate processing.

TRICARE: Required. List the code(s) and related dollar amount(s) that identify data of amonetary nature that is necessary for the processing of the claim. Acceptablecodes are:

CODE01021516

CIGNA NH: Required, if applicable. Enter any of the following codes that apply.

CODE010230

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MEDICARE: Required. Code(s) and related dollar amount(s) identify data of a monetary naturethat are necessary for the processing of this claim. The codes are two alphanumericdigits, and each value allows up to nine numeric digits (0000000.00). Negativeamounts are not allowed except in FL 41. Whole numbers or non-dollar amountsare right justified to the left of the dollars and cents delimiter. Some values arereported as cents, so refer to specific codes for instructions.

NOTE: If six zeros (0000.00) are entered in the amount field for Value Codes(12, 16 and 41), the provider is claiming a conditional payment. Onlythe following codes are approved for Medicare use.

CODE CODE CODE CODE04 15 43 5305 16 44 5606 31 46 5708 37 47 5809 38 48 5910 39 49 6011 40 50 6712 41 51 6813 42 52 A014

MTHP: Same as CIGNA NH.



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FORM LOCATOR 42

DATA ELEMENT: Revenue Code

DEFINITION: A code which identifies a specific accommodation, ancillary service or billingcalculation.

SIZE: 1 field, 23 lines, 4 positions, numeric

NOTE: The “other” codes (NN9) will be assigned at a state level in order to meet localneeds. National payers will read these codes at the zero level (i.e., generalclassification.)

All other not assigned codes (NN1 - NN8) are reserved for National Assignment.

All subcategory codes not used, except the “other” codes (XX9) are reserved forNational Assignment. The NUBC approved the expansion of this field from 3 to4 characters to accommodate possible future needs. The use of 4 digit revenuecodes, however, has not been authorized by the NUBC, and all such codes arereserved for national assignment.


For acceptable codes by payer refer to the Revenue Code matrix section.


Ambulance:

Revenue Code 54X - Units required in FL 46. Units = number of miles traveled.

Treatment/Observation Room:

Revenue Code 76X - Use of this code will be considered when the patient’scondition requires skilled observation, not to exceed 24 hours. The charge for theobservation room should not exceed the most prevalent semiprivate room rate. Ifthe patient is admitted during the 24 hour observation period, the hospital mustbill for the admission and not the observation room.

Professional Fees:

All Professional Fees (PRO FEE) must be billed on the HCFA-1500 claim form.

BCBSVT: Required. A revenue code is required for each charge. Units greater than zero arerequired for each code.

All Professional Fees must be billed on the HCFA-1500 claim form.

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TRICARE: Required.

Ambulatory Surgery:

Ambulatory surgery claims are paid at an Ambulatory Surgery Payment Rate(ASPR). lab and X-Ray not directly related to the surgical procedure; prostheticdevices; ambulance services; leg, arm and back braces; artificial limbs; anddurable medical equipment for use in the patient’s home can be paid in additionto the ASPR; however, they must be submitted on a separate UB92 claim form.

Emergency Room Charges:

If a patient is admitted from the emergency room, the emergency room charges willbe cost shared at the inpatient rate and can be paid in addition to the DRG paymentfor the inpatient charges. However, the emergency room charges for hospitalssubject to the DRG payment method must be submitted separately from the inpatientcharges. Emergency room physician fees can be billed on the same HCFA-1500 asinpatient physician fees, if the hospital chooses. UB92 and HCFA-1500 claimforms should indicate “Patient admitted from ER” to ensure correct payment method.

Observation Room Charges:

If the patient is in an observation room for 24 hours or more, the claim will bepaid at the inpatient rate. If the patient is in the observation room less than 24hours, the claim will be paid at the outpatient rate. If the patient is admitted tothe hospital from the observation room and the patient was in the observationroom less than 24 hours, the observation room charges can be paid in addition tothe inpatient charges; however, the observation room charges must be submittedon a separate UB92 claim form.

Professional Fees:

All professional fees must be billed on the HCFA-1500 claim form

CIGNA NH: Required. Rehabilitation services need to be itemized by Date of Service.

MEDICARE: Required. For each cost center for which a separate charge is billed (type ofaccommodation or ancillary), a revenue code is assigned. The appropriatenumeric revenue code is entered on the adjacent line in FL 42 to explain eachcharge in FL 47.

Additionally, there is no fixed “Total” line in the charge area. Instead, revenuecode “0001” is always entered last in FL 42. Thus, the adjacent charge entry inFL 47 is the sum of charges billed. This is also the same line on whichnoncovered charges, if any, in FL 48 are summed.

For outpatient Part B billing, only charges believed to be covered are submittedin FL 47. Noncovered charges are omitted from the bill.

To assist in bill review, revenue codes are listed in ascending numeric sequenceto the extent possible. To limit the number of line items on each bill, revenuecodes are summed at the “zero” level to the extent possible.

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Providers have been instructed to provide detailed level coding for the followingrevenue code series:

290s – rental/purchase of DME304 – rental and dialysis/laboratory330s – radiology therapeutic367 – kidney transplant420s – therapies520s – type of clinic visit (RHC or other)550s-590s – home health services624 – Investigational Device Exemption (IDE)636 – hemophilia blood clotting factors800850s – ESRD services9000 – 9044 – Medicare SNF demonstration project

Zero level billing is encouraged for all other services. However, based upon youknowledge of a particular provider’s facilities or billing practices, you mayrequire detailed break-outs of other revenue code series. This is acceptable to theextent that it is used for bill review purposes.

See §3626.4 concerning the level of coding for outpatient surgical procedures.

MTHP: Required. Same as Anthem BCBS for Revenue Codes 760 and 762.

NH MEDICAID: Required. Enter appropriate 3 digit Revenue Code in this field, (refer to Matrix).

VT MEDICAID: Required. Enter the appropriate three-digit revenue code in this field. Allprofessional fees must be billed on a HCFA-1500 claim form. The followingguidelines are to be used when billing for observation room and rehabilitativetherapy.

Observation Room:

When the patient remains in an outpatient status in excess of 24 hours, Medicaidwill reimburse for up to 24 hours of medically necessary observation roomservice when the patient has not been admitted as an inpatient.

When the patient has been admitted as an inpatient during the 24 hourobservation period, the hospital must bill for an inpatient day and not foroutpatient observation room services.

Payment will be made for outpatient claims with observation room services atthe lower of the total amount charged or the Medicaid medical/surgical per diemaccommodation rate for the hospital.

Rehabilitative Therapy:

When billing for outpatient rehabilitative therapy, enter the statement “therapystart date,” and indicate the first date the therapy was provided in FL 84 of theUB92 Claim Form. The statement period (FL 6) must contain the dates ofservice of the period for which payment is claimed. If the “from” date of servicein FL 6 is prior to the date indicated in FL 84, then the actual individual therapydates must be listed adjacent to the revenue code descriptions.

Another way to indicate the therapy start date is to list the Procedure Code Y570in the procedure code field and the therapy start date in the date field which

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corresponds with the procedure code. If you already have a principle procedurecode enter the Y570 in the next available procedure code field. Code Y570 mustalways be followed by the therapy start date.

Therapy start dates should only change on subsequent claims when a newtreatment plan has been initiated and authorized.

CODE STRUCTURE:

MAJOR CATEGORY

Payer and Related Information

Rationale: To group items by payer and to assign similar items the same number

001 Total Charge

01X Reserved for Internal Payer Use

02X Health Insurance Prospective Payment System (HIPPS)

Subcategory Standard Abbreviation

0 Reserved1 Reserved2 Skilled Nursing Facility SNF PPS (RUG)

Prospective Payment System3 Home Health Prospective Payment System HH PPS (effective 10/1/00)4 Inpatient Rehabilitation Facility IRF PPS (effective 10/01/01)5 Reserved6 Reserved7 Reserved8 Reserved9 Reserved

03Xto06X Reserved for National Assignment

07Xto09X Reserved for State Use (Assignment of "on revenue" codes only

e.g., deductible, coinsurance, payments,credits, subtotals, DO NOT ASSIGNACCOMMODATION OR ANCILLARYSERVICE REVENUE CODE.)

OCTOBER 2001

2-87

ACCOMODATION REVENUE CODES (10X-21X)

10X All Inclusive Rate

Flat fee charge incurred on either a daily basis or total stay basis for services rendered.Charge may cover room and board plus ancillary services or room and board only.


0 All Inclusive Room and Board Plus ALL INCL R&B/ANCAncillary

1 All Inclusive Room and Board ALL INCL R&B

11X Room and Board - Private Requires # of Days Stay(Medical or General)

Routine service charges for single bed rooms.

Rationale: Most third party payers require that private rooms be separately identified.


0 General Classification ROOM-BOARD/PVT1 Medical/Surgical/GYN MED-SUR-GY/PVT2 OB OB/PVT3 Pediatric PEDS/PVT4 Psychiatric PSYCH/PVT5 Hospice HOSPICE/PVT6 Detoxification DETOX/PVT7 Oncology ONCOLOGY/PVT8 Rehabilitation REHAB/PVT9 Other OTHER/PVT

12X Room and Board - SemiprivateTwo Bed (Medical or General) Requires # of days stay

Routine service charges incurred for accommodations with two beds.

Rationale: Most third party payers require that semi-private rooms be identified.


0 General Classification ROOM-BOARD/SEMI1 Medical/Surgical/GYN MED-SUR-GY/2BED2 OB OB/2BED3 Pediatric PEDS/2BED4 Psychiatric PSYCH/2BED5 Hospice HOSPICE/2BED6 Detoxification DETOX/2BED7 Oncology ONCOLOGY/2BED8 Rehabilitation REHAB/2BED9 Other OTHER/2BED

OCTOBER 2001

2-88

13X Semiprivate-Three and Four Beds Requires # days stayRoutine service charges incurred for accommodations with three and four beds.


0 General Classification ROOM-BOARD/3&4BED1 Medical/Surgical/GYN MM-SUR-GY/3&42 OB OB/3&4BED3 Pediatric PEDS/3&4BED4 Psychiatric PSYCH/3&4BED5 Hospice HOSPICE/3&4BED6 Detoxification DETOX/3&4BED7 Oncology ONCOLOGY/3&4BED8 Rehabilitation REHAB/3&4BED9 Other OTHER/3&4BED

14X Private (Deluxe) Requires # days stay

Deluxe rooms are accommodations with amenities substantially in excess of thoseprovided to other patients.


0 General Classification ROOM-BOARD/PVT/DLX1 Medical/Surgical/GYN MED-SUR-GY/DLX2 OB OB/DLX3 Pediatric PEDS/DLX4 Psychiatric PSYCH/DLX5 Hospice HOSPICE/DLX6 Detoxification DETOX/DLX7 Oncology ONCOLOGY/DLX8 Rehabilitation REHAB/DLX9 Other OTHER/DLX

15X Room and Board Ward(Medical or General) Requires # of days stay

Routine service charge for accommodations with five or more beds.

Rationale: Most third party payers require ward accommodations to be identified.


0 General Classification R&B1 Medical/Surgical/Gyn MED-SUR-GY/WARD2 OB OB/WARD3 Pediatric PEDS/WARD4 Sterile Environment R&B/STERILE5 Hospice HOSPICE/WARD6 Detoxification DETOX/WARD7 Self Care R&B/SELF8 Rehabilitation REHAB/WARD9 Other R&B/OTHER

OCTOBER 2001

2-89

16X Other Room and Board Requires # of days stay

Any routine service charges for accommodations that cannot be included m the morespecific revenue center codes.

Rationale: Provides the ability to identify services as required by payers or individualinstitutions.

Sterile environment is a room and board charge to be used by hospitals thatare currently separating charge for billing.


0 General Classification R&B4 Sterile Environment R&B/STERILE7 Self Care R&B/SELF9 Other R&B/OTHER

17X Nursery Requires # days stay

Charges for nursing care to newborn and premature infants in nurseries.

Subcategories 1-4 are used by facilities with nursery services designed around distinctareas and/or levels of care. Levels of care defined under state regulations or otherstatutes supersede the following guidelines. For example, some states may have fewerthan four levels of care or may have multiple levels within a category such as intensivecare.

Level I – Routines care of apparently normal full-term or per-term neonates (NewbornNursery).

Level II – Low birth-weight neonates who are not sick, but require more hours of nursingthan do normal neonates (Continuing Care).Level III – Sick neonates who do not require intensive care, but require 6-12 hours ofnursing care each day (Intermediate Care).

Level IV – Constant nursing and continuous cardiopulmonary and other support forseverely ill infants (Intensive Care).


0 Classification NURSERY1 Newborn – Level I NURSERY/LEVEL I2 Newborn – Level II NURSERY/LEVEL II3 Newborn – Level III NURSERY/LEVEL III4 Newborn – Level IV NURSERY/LEVEL IV5 NeoNatal ICU NURSERY/ICU9 Other NURSERY/OTHER

OCTOBER 2001

2-90

18X Leave of Absence Requires # of days stay

Charges (including zero charges) for holding a room while the patient is temporarilyaway from the provider.

NOTE: Charges are billable for codes 2-5.


0 General Classification LEAVE OF ABSENCE OR LOA1 RESERVED2 Patient Convenience (charges billable) LOA/PT CONV3 Therapeutic Leave LOAM4 ICF/MR - any reason LOA/ICF/MR5 Nursing Home (for hospitalization) LOA/NURS HOME9 Other Leave of Absence LOA/OTHER

19X Subacute Care

Accommodation charges for subacute care to inpatients in hospitals or skilled nursingfacilities.

Level I – Skilled Care – Minimal nursing intervention. Comorbidities do not complicatetreatment plan. Assessment of vitals and body systems required 1-2 times per day.

Level II – Comprehensive Care – Moderate to extensive nursing intervention. Activetreatment of comorbidities. Assessment of vitals and body systems required 2-3 times perday.

Level III – Complex Care – Moderate to extensive nursing intervention. Active medicalcare and treatment of comorbidities. Potential for comorbidities to affect the treatmentplan. Assessment of vitals and body systems required 3-4 times per day.

Level IV – Intensive Care – Extensive nursing and technical intervention active medicalcare and treatment of comorbidities. Potential for comorbidities to affect the treatmentplan. Assessment of vitals and body systems required 4-6 times per day.


0 General Classification SUBACUTE1 Subacute Care – Level I SUBACUTE/LEVEL I2 Subacute Care – Level II SUBACUTE/LEVEL II3 Subacute Care – Level III SUBACUTE/LEVEL III4 Subacute Care – Level IV SUBACUTE/LEVEL IV9 Other Subacute Care SUBACUTE/OTHER

OCTOBER 2001

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20X Intensive Care Requires # of days stay

Routine service charge for medical or surgical care provided to patients who require amore intensive level of care than is rendered in the general medical or surgical unit.

Rationale: Most third party payers require that charges for this service are to beidentified.


0 General Classification INTENSIVE CARE or (ICU)1 Surgical ICU/SURGICAL2 Medical ICU/MEDICAL3 Pediatric ICU/PEDS4 Psychiatric ICU/PSTAY6 Intermediate ICU POST ICU7 Burn Care ICU/BURN CARE8 Trauma ICU/TRAMA9 Other Intensive Care ICU/OTHER

(Use for Respiratory Care)

21X Coronary Care Requires # days stay

Routine service charge for medical care provided to patients with coronary illness whorequire a more intensive level of care dm is rendered in the general medical care unit.

Rationale: If a discrete unit exists for rendering such services, the hospital or third partymay wish to identify the service.


0 General Classification CORONARY CARE or (CCU)1 Myocardial Infarction CCU/MYO INFARC2 Pulmonary Care CCU/PULMONARY3 Heart Transplant CCU/TRANSPLANT4 Post-CCU POST CCU9 Other Coronary Care CCU/OTHER

ANCILLARY REVENUE CODES (22X – 99X)

22X Special Charges

Charges incurred during an inpatient stay or on a daily basis for certain services.

Rationale: Some hospitals prefer to identify the components of services rendered ingreater detail and thus break out charges for items that normally would beconsidered part of routine services.


0 General Classification SPECIAL CHARGES1 Admission Charge ADMIT CHARGE2 Technical Support Charge TECH SUPPT CHG3 U.R. Service Charge UR CHARGE4 Late Discharge, Medically Necessary LATE DISCH/MED NEC9 Other Special Charges OTHER SPEC CHG

OCTOBER 2001

2-92

23X Incremental Nursing Charge Rate

Charge for nursing service assessed in addition to room and board.


0 General Classification NURSING INCREM1 Nursery NUR INCR/NURSERY2 OB NUR INCR/OB3 ICU NUR INCR/ICU4 CCU NUR INCR/CCU5 Hospice NUR INCR/HOSPICE9 Other NLTR INCR/OTHER

24X All Inclusive Ancillary

A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only.

Rationale: Hospitals that bill in this manner may wish to segregate these charges.


0 General Classification ALL INCL ANCIL1 Basic ALL INCL BASIC2 Comprehensive ALL INCL COMP3 Specialty ALL INCL SPECIAL9 Other All Inclusive Ancillary ALL INCL ANCIL/OTHER

25X Pharmacy

Charges for medication produced, manufactured, packaged, controlled, assayed,dispensed and distributed under the direction of a licensed pharmacist.

Rationale: Additional breakdowns are provided for items that individual hospitals maywish to identify because of internal or third party payer requirements.Subcode 4 is for providers that do not bill drugs used for other diagnosticservices as part of the charge for the diagnostic service. Subcode 5 is forproviders that do not bill drugs used for radiology under radiology.


0 General Classification PHARMACY1 Generic Drugs DRUGS/GENERIC2 Nongeneric Drugs DRUGS/NONGENERIC3 Take Home Drugs DRUGS/TAKEHOME4 Drugs Incident to Other Diagnostic Services DRUGS/INCIDENT OTHER DX5 Drugs Incident to Radiology DRUGS/INCIDENT RAD6 Experimental Drugs DRUGS/EXPERIMT7 Nonprescription DRUGS/NONPSCRPT8 IV Solutions IV SOLUTIONS9 Other Pharmacy DRUGS/OTHER

NOTE: Subcategories for “Blood Plasma” and “Blood other Components” have been established. (See Revenue Code 38X, Blood – effective April 1, 1984.)

OCTOBER 2001

2-93

26X IV Therapy

Equipment charge or administration of intravenous solution by specially trainedpersonnel to individuals requiring such treatment. This code should be used only when adiscrete service unit exists.

Rationale: For outpatient home intravenous drug therapy equipment, which is part ofthe basic per diem fee schedule, providers must identify the actual cost foreach type of pump for updating of the per diem.


0 General Classification IV THERAPY1 Infusion Pump IV THER/INFSN PLW2 IV Therapy/Pharmacy Svcs IV THER/PHARM/SVC3 IV Therapy/Drug/Supply Delivery IV THER/DRUG/SUPPLY DELV4 IV Therapy Supplies IV THER/SUPPLIES9 Other IV Therapy IV THERAPY/OTHER

NOTE: Billing for Home IV providers, requires HCPCS code which describes the pumpto be entered in FL 44.

27X Medical/Surgical Supplies and Devices (also see 62X, an extension of 27X)

Charges for supply items required for patient care.

Rationale: Additional breakdowns are provided for items that hospitals may wish toidentify because of internal or third party payer requirements.


0 General Classification MED-SUR SUPPLIES1 Nonsterile Supply NONSTER SUPPLY2 Sterile Supply STERILE SUPPLY3 Take Home Supplies TAKEHOME SUPPLY4 Prosthetic/Orthotic Devices PROSTH/ORTH DEV5 Pace Maker PACE MAKER6 Intraocular Lens INTR OC LENS7 Oxygen-Take Home 02/TAKEHOME8 Other implants SUPPLY/IMPLANTS9 Other Supplies/Devices SUPPLY/OTHER

28X Oncology

Charges for the treatment of tumors and related diseases.


0 General Classification ONCOLOGY9 Other Oncology ONCOLOGY/OTHER

OCTOBER 2001

2-94

29X Durable Medical Equipment (DME) (Other Than Renal)

Charge for medical equipment that can withstand repeated use (excluding renalequipment).

Rationale: Medicare requires a separate revenue center for billing.


0 General Classification MED EQUIP/DURAB1 Rental MED EQUIP/RENT2 Purchase - New DME MED EQUIP/NEW3 Purchase - Used DME MED EQUIP/USED4 Supplies/Drugs for DME Effectiveness MED EQUIP/SUPPLIES/DRUGS

(HHAS only)9 Other Equipment MED EQUIP/OTHER

30X Laboratory

Charges for the performance of diagnostic and routine clinical laboratory tem.

Rationale: A breakdown of the major areas in the laboratory is provided in order tomeet hospital needs or third party billing requirements.


0 General Classification LABORATORY or (LAB)1 Chemistry LAB/CHEMISTRY2 Immunology LAB/IMMUNOLOGY3 Renal Patient (Home) LAB/RENAL HOMEE4 Nonroutine Dialysis LAB/NR DIALYSIS5 Hematology LAB/HEMATOLOGY6 Bacteriology and Microbiology LAB/BACT-MICRO7 Urology LAB/UROLOGY9 Other Laboratory LAB/OTHER

31X Laboratory Pathological

Charges for diagnostic and routine laboratory tests on tissues and culture.

Rationale: A breakdown of the major areas that hospitals may wish to identify isprovided.


0 General Classification PATHOLOGY LAB or (PATH LAB)1 Cytology PATHOL/CYTOLOGY2 Histology PATHOL/HYSTOL4 Biopsy PATHOL/BIOPSY9 Other PATHOL/OTHER

OCTOBER 2001

2-95

32X Radiology - Diagnostic

Charges for diagnostic radiology services provided for the examination and care ofpatients. Includes: taking, processing, examining and interpreting radiographs andfluorographs.

Rationale: A breakdown is provided of the major areas and procedures that individualhospitals or third party payers may wish to identify.


0 General Classification DX X-RAY1 Angiocardiography DX X-RAY/ANGIO2 Arthrography DX X-RAY/ARTH3 Arteriography DX X-RAY/ARTER4 Chest X-Ray DX X-RAY/CHEST9 Other DX X-RAY/OTHER

33X Radiology

Charges for therapeutic radiology services and chemotherapy are required for careand treatment of patients. Includes therapy by injection or ingestion of radioactivesubstances.

Rationale: A breakdown is provided of the major areas that hospitals or third partiesmay wish to identify. Chemotherapy - IV was added at the request of Ohio.


0 General Classification RX X-RAY1 Chemotherapy - Injected CHEMOTHER/INJ2 Chemotherapy - Oral CHEMOTHER/ORAL3 Radiation Therapy RADIATION RX5 Chemotherapy - IV CHEMOTHERP-IV9 Other RX X-RAY/OTHER

34X Nuclear Medicine

Charges for procedures and test performed by a radioisotope laboratory utilizingradioactive materials as required for diagnosis and treatment of patients.

Rationale: A breakdown is provided in case hospitals desire or are required to identifythe type of service rendered.


0 General Classification NUCLEAR MEDICINE or (NUC MED)1 Diagnostic NUC NM/DX2 Therapeutic NUC MED/RX9 Other NUC MED/OTHER

OCTOBER 2001

2-96

35X Computed Tomographic (CT) Scan # Scans Required

Charges for CT scans of the head and other parts of the body.

Rationale: Due to coverage limitations some third party payers require that the specifictest be identified.


0 General Classification CT SCAN1 Head Scan CT SCAN/HEAD2 Body Scan CT SCAN/BODY9 Other CT Scans CT SCAN/OTHER

36X Operating Room Services

Changes for services provided to patients by specifically trained nursing personnel whoprovide assistance to physicians in the performance of surgical and related proceduresduring and immediately following surgery as well as the operating room (heat, lights)and equipment.

Rationale: Permits identification of particular services.


0 General Classification OR SERVICES1 Minor Surgery OR/MINOR2 Organ Transplant-other than Kidney OR/ORGAN TRANS7 Kidney Transplant OR/KIDNEY TRANS9 Other Operating Room Services OR/OTHER

37X Anesthesia

Charges for anesthesia services in the hospital.

Rationale: Provides additional identification of services. In particular, acupuncture wasidentified because it is not covered by some payers, including Medicare.Subcode 1 is for providers that do not bill anesthesia used for otherdiagnostic services as part of the charge for the diagnostic services. Subcode2 is for providers that do not bill anesthesia used for radiology underradiology revenue codes as part of the radiology procedure charge.


0 General Classification ANESTBESIA1 Anesthesia Incident to Radiology ANESTHE/INCIDENT RAD2 Anesthesia Incident to Other Diagnostic ANESTHE/INCDNT OTHER

Services DX4 Acupuncture ANESTE/ACUPUNC9 Other Anesthesia ANESTHE/OTHER

OCTOBER 2001

2-97

38X Blood

Rationale: Charges for blood must be separately identified for private payer purposes.


0 General Classification BLOOD1 Packed Red Cells BLOOD/PKD RED2 Whole Blood BLOOD/WHOLE3 Plasma BLOOD/PLASMA4 Platelets BLOOD/PLATELETS5 Leucocytes BLOOD/LEUCOCYTES6 Other Components BLOOD/COMPONENTS7 Other Derivatives (Cryopricipitates) BLOOD/DERIVATIVES9 Other Blood BLOOD/OTHER

39X Blood Storage and Processing

Charges for the storage and processing of whole blood.


0 General Classification BLOOD/STOR-PROC1 Blood Administration BLOOD/ADMIN9 Other Blood Storage & Processing BLOOD/OTHER STOR

40X Other Imaging Services


0 General Classification IMAGE SERVICE1 Diagnostic Mammography MAMMOGRAPHY2 Ultrasound ULTRASOUND

*3 Screening Mammography SCR MAMMOGRAPHY4 Positron Emission Tomography (PET) PET SCAN9 Other Imaging Services OTHER IMAG SVS

*NOTE: Medicare will require the hospitals to report the ICD-9-CM diagnosis codes (FL67) to substantiate those beneficiaries considered high risks. These high riskcodes are as follows:

ICD-9Codes Definitions High Risk Indicator

V10.3 Personal History - Malignant A personal history of breast cancerneoplasm breast cancer

V16.3 Family History - Malignant A mother, sister or daughter who has neoplasm breast cancer had breast cancer

V15.89 Other specific personal history, Has not given birth before age 30 or arepresenting hazards to health personal history of biopsy – proven

benign breast disease.

OCTOBER 2001

2-98

41X Respiratory Services # of services required

Charges for administration of oxygen and certain potent drugs through inhalation orpositive pressure and other forms of rehabilitative therapy through measurement ofinhaled and exhaled gases and analysis of blood and evaluation of the patient’s abilityto exchange oxygen and other gases.



0 General Classification RESPIRATORY SVC2 Inhalation Services INHALATION SVC3 Hyperbaric Oxygen Therapy HYPERBARIC 029 Other Respiratory Services OTHER RESPIR SVS

42X Physical Therapy units required

Charges for therapeutic exercises, massage and utilization of effective properties of light,heat, cold, water, electricity, and assistive devices for diagnosis and rehabilitation ofpatients who have neuromuscular, orthopedic and other disabilities.



0 General Classification PHYSICAL THERP1 Visit Charge PHYS THERP/VISIT2 Hourly Charge PHYS THERP/HOUR3 Group Rate PHYS THERP/GROUP4 Evaluation or Re-evaluation PHYS THERP/EVAL9 Other Physical Therapy OTHER PHYS

43X Occupational Therapy # units required

Services provided by a qualified occupational therapy practitioner for therapeuticinterventions to improve, sustain, or restore an individual’s level of function inperformance of activities of daily living and work, including; therapeutic activities,therapeutic exercises; sensorimotor processing; psychosocial skills training; cognitiveretraining; fabrication and application of orthotic devices; and training in the use oforthotic and prosthetic devices; adaptation of environments; and application of physicalagent modalities.


0 General Classification OCCUPATION THER1 Visit Charge OCCUP THERP/VISIT2 Hourly Charge OCCUP THERP/HOUR3 Group Rate OCCUP THERP/GROUP4 Evaluation or Reevaluation OCCUP THERP/EVAL9 Other Occupational Therapy OTHER OCCUP THER

(may include restorative therapy)

OCTOBER 2001

2-99

44X Speech Language Pathology # units required

Charges for services provided to persons with impaired functional communications skills.


0 General Classification SPEECH PATHOL1 Visit Charge SPEECH PATH/VISIT2 Hourly Charge SPEECH PATH/HOUR3 Group Rate SPEECH PATH/GROUP4 Evaluation or Reevaluation SPEECH PATH/EVAL9 Other Speech-Language Pathology OTHER SPEECH PAT

45X Emergency Room of visits required

Charges for emergency treatment to those ill and injured persons who require immediateunscheduled medical or surgical care.

Rationale: Permits identification of particular items for payers. Under the provisions of theEmergency Medical Treatment and Active Labor Act (EMTALA) a hospital withan emergency department must provide, upon request and within thecapabilities of the hospital, an appropriate medical screening examination andstabilizing treatment to any individual with an emergency medical conditionand to any women in active labor, regardless of the individuals’ eligibility forMedicare C Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985).


0 General Classification EMERG ROOM1 EMTALA Emergency Medical ER/EMTALA

Screening Services2 ER Beyond EMTALA Screening ER/BEYOND EMTALA6 Urgent Care URGENT CARE9 Other Emergency Room OTHER EMER ROOM

NOTES: Observation or hold beds are not reported under this code. They are reportedunder revenue code 762.

Usage Notes – An “X” in the matrix below indicates and acceptable coding combination.

450 451 452 456 459a b c

450451 X X X452 X453 X X454 X X

a General Classification code 450 should not be used in conjunction with anysubcategory. The sum of codes 451 and 452 is equivalent to 450. Payers that do notrequire a breakdown should roll up codes 451 and 452 into 450.

b Stand alone wages of code 451 is acceptable when no services beyond an initialscreening/assessment are rendered.

c Stand alone usage of care 452 is not acceptable

OCTOBER 2001

2-100

46X Pulmonary FunctionCharges for tests that measure inhaled and exhaled gases and analysis of blood and fortests that evaluate the patient’s ability to exchange oxygen and other gases.

Rationale: Permits identification of this service if it exists in the hospital.


0 General Classification PULMONARY FUNC9 Other Pulmonary Function OTHER PULMON FUNC

47X Audiology

Charges for the detection and management of communication handicaps centering inwhole or in part on the hearing function.



0 General Classification AUDIOLOGY1 Diagnostic AUDIOLOGY/DX2 Treatment AUDIOLOGY/RX9 Other Audiology OTHER AUDIOL

48X Cardiology

Charges for cardiac procedures rendered in a separate unit within the hospital. Suchprocedures include, but are not limited to: heart catheterization, coronary angiography,Swan-Ganz catheterization, and exercise stress test.

Rationale: This category was established to reflect a growing trend to incorporate thesecharges in a separate unit.


0 General Classification CARDIOLOGY1 Cardiac Cath Lab CARDIAC CATH LAB2 Stress Test STRESS TEST3 Echocardiology ECHOCARDIOLOGY9 Other Cardiology (Use for Cardiac OTHER CARDIOL

Evaluation)

49X Ambulatory Surgical Care

Charges for ambulatory surgery which are not covered by other categories.


0 General Classification AMBUL SURG9 Other Ambulatory Surgical Care OTHER AMBL SURG

NOTE: Observation or hold beds are not reported under this code. They are reportedunder revenue code 762.

OCTOBER 2001

2-101

50X Outpatient Services

Outpatient charges for services rendered to an outpatient who is admitted as an inpatientbefore midnight of the day following the date of service.

NOTE: This revenue code is no longer used for Medicare.


0 General Classification OUTPATIENT SVS9 Other Outpatient Services OUTPATIENT/OTHER

51X Clinic # of visits required

Clinic (nonemergency/scheduled outpatient visit) charges for providing diagnostic,preventive, curative, rehabilitation, and education services on a scheduled basis toambulatory patients.

Rationale: Provides a breakdown of some clinics that hospitals or third party payersmay require.


0 General Classification CLINIC1 Chronic Pain Center CHRONIC PAIN CL2 Dental Clinic DENTAL CLINIC3 Psychiatric Clinic PSYCH CLINIC4 OB-GYN Clinic OB-GYN CLINIC5 Pediatric Clinic PEDS CLINIC\6 Urgent Care Clinic URGENT CLINIC7 Family Practice Clinic FAMILY CLINIC9 Other Clinic OTHER CLINIC

52X Free-Standing Clinic # of visits required

Rationale: Provides a breakdown of some clinics that hospitals or third party payersmay require.


0 General Classification FREESTAND CLINIC1 Rural Health-Clinic RURAL/CLINIC2 Rural Health-Home RURAL/HOME3 Family Practice FAMILY PRACTICE6 Urgent Care Clinic FR/STD URGENT CLINIC9 Other Freestanding Clinic OTHER FR/STD CLINIC

OCTOBER 2001

2-102

53X Osteopathic Services # of visits required

Charges for a structural evaluation of the cranium, -entire cervical, dorsal and lumbarspine by a doctor of osteopathy.

Rationale: There is a service unique to osteopathic hospitals and cannot beaccommodated in any of the existing codes.


0 General Classification OSTEOPATH SVS1 Osteopathic Therapy OSTEOPATH RX9 Other Osteopathic Services OTHER OSTEOPATH

54X Ambulance # of trips required

Charges for ambulance service, usually on an unscheduled basis to the ill and injuredwho require immediate medical attention.

Rationale: Provides subcategories that third party payers or hospitals may wish torecognize. Heart mobile is a specially designed ambulance transport forcardiac patients.


0 General Classification AMBULANCE1 Supplies AMBUL/SUPPLY2 Medical Transport AMBUL/MED TRANS3 Heart Mobile AMBUL/HEARTMOBL4 Oxygen AMBUL/OXY5 Air Ambulance AIR AMBULANCE6 Neonatal Ambulance Service AMBUL/NEONAT7 Pharmacy AMBUL/PHARMACY8 Telephone Transmission EKG AMBUL/TELEPHONIC EKG9 Other Ambulance OTHER AMBULANCE

56X Medical Social Services # visits required

Charges for services such as counseling patients, interviewing patients, and interpretingproblems of social situation rendered to patients on any basis.

Rationale: Necessary for Medicare home health billing requirements. May be used atother times as required by hospital.


0 General Classification MED SOCIAL SVS1 Visit Charge MED SOC SERV/VISIT2 Hourly Charge MED SOC SERV/HOUR9 Other Med Social Services MED SOC SERV/OTHER

OCTOBER 2001

2-103

60X Oxygen (Home Health)Code indicates the charges by an HHA for oxygen equipment supplies or contents,excluding purchased equipment.

In a beneficiary had purchased a stationary oxygen system, an oxygen concentrator orportable equipment, current revenue codes 292 or 293 apply. DME (other than oxygensystems) is billed under current revenue codes 291, 292, or 293.

Rationale: Medicare requires detailed revenue coding. Therefore, codes for this seriesmay not be summed at the zero level.


0 General Classification 02/HOME/HEALTH1 Oxygen – State/Equip/Suppl or Cont 02/EQUIP/SUPPL/CONT2 Oxygen – Stat/Equip/Suppl Under 1 LPM 02/STAT EQUIP/UNDER 1 LPM3 Oxygen – Stat/Equip/Over 4 LPM 02/STAT EQUIP/OVER 4 LPM4 Oxygen – Portable Add-on 02/STAT EQUIP/PORT ADD-ON

61X Magnetic Resonance Technology (MRT)

Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography(MRA) of the brain and the other parts of the body.

Rationale: Due to coverage limitations, some third party payers require that the specifictest be identified.


0 General Classification MRI1 Brain (including Brainstem) MRI-BRAIN2 Spinal Cord (including Spine) MRI-SPINE3 Reserved4 MRI – Other MRI-OTHER5 MRA – Head and Neck MRA-HEAD AND NECK6 MRA – Lower Extremities MRA-LOWER EXT7 Reserved8 MRA Other MRA-OTHER9 Other MRI MRI-OTHER

62X Medical/Surgical Supplies - Extension of 27X

Charges for supply items required for patient care. The category is an extension of 27Xfor reporting additional breakdown where needed. Subcode 1 is for providers that do notbill supplies used for radiology revenue codes as part of the radiology procedure charges.Subcode 2 is for providers that do not bill supplies used for other diagnostic services aspart of the charge for services in the diagnostic service.


1 Supplies Incident to Radiology MED-SUG SUPP/INCDNT RAD2 Supplies incident to Other Diagnostic MED-SUR SUP/INCDNT ODX

Services3 Surgical Dressings SURG DRESSINGS4 Investigational Device IDE

OCTOBER 2001

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63X Drugs Requiring Specific Identification

Charges for drugs and biologicals requiring specific identification as required by thepayer. If HCPCS is used to describe the drug enter the HCPCS code in FL 44.


0 General Classification DRUGS1 Single Source Drug DRUG/SNGLE2 Multiple Source Drug DRUG/MULT3 Restrictive Prescription DRUG/RSTR4 Erythropoietin (EPO) less than 10,000 units DRUG/EPO < 10,000 UNITS5 Erythropoietin (EPO) 10,000 or more units DRUG/EPO> 10,000 UNITS6 Drugs Requiring Detailed Coding* DRUGS/DETAIL CODE7 Self-administrable Drugs DRUGS/SELF ADMIN

*NOTE: Revenue code 636 relates to HCPCS code, so HCPCS is the recommended codeto be used in FL 44. The specified units of service to be reported are to be inhundreds (100s), rounded to the nearest hundred (no decimal).

NOTE: Value Code A4 used in conjunction with revenue code 637 indicates amountincluded for covered charges for the ordinarily non-covered, self-administereddrug insulin administered in an emergency situation to a patient in a diabeticcoma. This is the only ordinarily non-covered, self-administered drug coveredunder Medicare with this value code.

64X Home IV Therapy Services

Charge for intravenous drug therapy services which are performed in the patient’sresidence. For Home IV providers the HCPCS code must be entered for all equipment,and all types of covered therapy.


0 General Classification IV THERAPY SVC1 Nonroutine Nursing, Central Line NON RT NURSING/CENTRAL2 IV Site Care, Central Line (See NOTE) IV SITE CARE/CENTRAL3 IV Start/Change, Peripheral Line IV STRT/CHNG/PERIPHAL4 Nonroutine Nursing, Peripheral Line NONRT NURSING/PERIPHRL5 Training Patient/Caregiver, Central Line TRNG PT/CAREGVR/CENTRL6 Training, Disabled Patient, Central Line TRNG DSBLPT/CENTRAL7 Training, Patient/Caregiver, Peripheral Line TRNG/PT/CARGVR/PERIPHRL8 Training, Disabled Patient, Peripheral Line TRNG/DSBLPAT/PERIPHRL9 Other IV Therapy Services OTHER THERAPY SVC

NOTE: Units need to be reported in one hour increments. Revenue Code 642 relates tothe HCPCS code.

OCTOBER 2001

2-105

65X Hospice ServicesCode indicates the charge for hospital care services for a terminally ill patient if he/sheelects these services in lieu of other services for the terminal condition.

Rationale: The level of hospice care provided for each day during a hospice electionperiod determines the amount of Medicare payment for that day.

Subcategory Standard/Abbreviation

0 General Classification HOSPICE1 Routine Home Care HOSPICE/RTN HOME2 Continuous Home Care – 2 HOSPICE/CTNS HOME3 RESERVED4 RESERVED5 Inpatient Respite Care HOSPICE/IP RESPITE6 General Inpatient Care (nonrespite) HOSPICE/IP NON RESPITE7 Physician Services HOSPICE/PHYSICIAN9 Other Hospice HOSPICE/OTHER

66X Respite Care (HHA only)

Charges for hours of care under the respite care benefit for services of a homemaker orhome health aide, personal care services, and nursing care provided by a licenseprofessional nurse.


0 General Classification RESPITE CARE1 Hourly Charge/Skilled Nursing RESPITE/SKILLED NURSE2 Hourly Charge/Home Health Aide/Homemaker RESPITE/HMEAID/HMEMKE9 Other Respite Care RESPITE/CARE

67X Outpatient Special Residence Charges

Residence arrangements for patients requiring continuous outpatient care.


0 General Classification OP SPEC RES1 Hospital Based OP SPEC RES/HOSP BASED2 Contracted OP SPEC RES/CONTRACTED9 Other Special Residence Charges OP SPEC RES/OTHER

68X Not Assigned

69X Not Assigned

70X Cast Room

Charges for services related to the application, maintenance and removal of casts.

Rationale: Permits identification of this service if necessary.


0 General Classification CAST ROOM9 Other Cast Room OTHER CAST ROOM

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71X Recovery Room

Rationale: Permits identification of particular services if necessary.


0 General Classification RECOVERY ROOM9 Other Recovery Room OTHER RECOV RM

72X Labor Room/Delivery

Charges for labor and delivery room services provided by specially nursing personnel topatients, including prenatal care during labor, assistance during delivery, postnatal carein the recovery room, and minor gynecologic procedures if they are performed in thedelivery suite.

Rationale: Provides a breakdown of items that may require further clarification. Infantcircumcision is included because it is not covered by all third party payers.


0 General Classification DELIVROOM/LABOR1 Labor LABOR2 Delivery DELIVERY ROOM3 Circumcision CIRCUMCISION4 Birthing Center BIRTHING CENTER9 Other Labor Room/Delivery OTHER/DELIV-LABOR

73X Electrocardiogram (EKG/ECG)

Charges for operation of specialized equipment to record electromotive variationsin actions of the heart muscle on an electrocardiograph for diagnosis of heartailments.


0 General Classification EKG/ECG1 Holter Monitor HOLTER MONT2 Telemetry TELEMETRY9 Other EKG/ECG OTHER EKG/ECG

74X Electroencephalogram (EEG)

Charges for operation of specialized equipment to measure impulse frequencies anddifferences in electrical potential in various areas of the brain to obtain data for use indiagnosing brain disorders.


0 General Classification EEG9 Other EEG OTHER EEG

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75X Gastrointestinal Services

Procedures room charges for endoscopic procedures not performed in the operating room.


0 General Classification GASTR-INTS SVS9 Other Gastrointestinal OTHER GASTRO-INTS

76X Treatment or Observation Room

Charges for the use of a treatment room; or for the room charge associated withoutpatient observation services.

Observation services are those services furnished by a hospital on the hospitals premises,including use of a bed and periodic monitoring by a hospital’s nursing or other staff,which are reasonable and necessary to evaluate an outpatient’s condition or determinethe need for a possible admission to the hospital as an inpatient. Such services arecovered only when provided by the order of a physician or another individual authorizedby state licensure law and hospital staff bylaws to admit patients to the hospital or toorder outpatient tests. Must observation services do not exceed one day. Some patients,however, may require a second day of outpatient observation services. The reason forobservation must be stated in the orders for observation. Payer should establish writtenguidelines which identify coverage of observation services.


0 General Classification TREATMENT/OBSERVATION RM1 Treatment Room TREATMENT RM2 Observation Room OBSERVATION RM9 Other Treatment/Observation Room OTHER TREAT/OBSERV RM

77X Preventive Care Services

Charges for the administration of vaccines.


0 General Classification PREVENT CARE SVS1 Vaccine Administration VACCINE ADMIN9 Other OTHER PREVENT

78X Telemedicine

Future use to be announced – Medicare Demonstration Project.


0 General Classification TELEMEDICINE9 Other Telemedicine TELEMEDICINE/OTHER

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79X Lithotripsy

Charges for the use of lithotripsy in the treatment of kidney stones.

Subcategory Abbreviation

0 General Classification LITHOTRIPSY9 Other Lithotripsy LITHOTRIPSY/OTHER

80X Inpatient Renal Dialysis Standard

A waste removal process performed in an inpatient setting, that uses an artificial kidneywhen the body’s own kidney have failed. The waste may be removed directly from theblood (hemodialysis) or indirectly from the blood by flushing a special solution betweenthe abdominal covering and the tissue (peritoneal dialysis).

Rationale: Specific identification required for billing purposes.


0 General Classification RENAL DIALYSIS1 Inpatient Hemodialysis DIALY/INPT2 Inpatient Peritoneal (Non-CAPD) DIALY/INPT/PER3 Inpatient Continuous DIALY /INPT/CAPD

Ambulatory Peritoneal Dialysis (CAPD)4 Inpatient Continuous Cycling DIALY /INPT/CCPD

Peritoneal Dialysis (CCPD)9 Other Inpatient Dialysis DIALY /INPT/OTHER

81X Organ Acquisition

The acquisition and storage costs of various organs used for transplantation.

NOTE: To reference the specific organ(s) used in the transplantation procedure, see thespecific ICD-9-CM codes.

Rationale: Living donor is a living person from whom various organs are obtained fortransplantation. Cadaver is an individual who has been pronounced deadaccording to medical and legal criteria, from whom various organs areobtained for transplantation.

Medicare requires detailed revenue coding; therefore, codes for this seriesmay not be summed at the zero level.


0 General Classification ORGAN ACQUISIT1 Living Donor LIVING/DONOR2 Cadaver Donor CADAVER/DONOR3 Unknown Donor UNKNOWN/DONOR4 Unsuccessful Organ Search - Donor

Bank Charge* UNSUCCESSFUL SEARCH9 Other Organ Acquisition OTHER/DONOR

*NOTE: Revenue Code 814 is used only when costs incurred for an organ search do notresult in an eventual organ acquisition and transplantation.

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82X Hemodialysis - Outpatient or Home

A waste removal process, performed in an outpatient or home setting, necessary whenthe body’s own kidney’s have failed. Waste is removed directly from the blood.

Rationale: Detailed revenue coding is required. Therefore, services may be submitted atthe zero level.


0 General Classification HEMO/OP OR HOME 1 Hemodialysis/Composite or Other Rate HEMO/COMPOSITE

2 Home Supplies HEMO/HOME/SUPPL3 Home Equipment HEMO/HOME/EQUIP4 Maintenance/100% HEMO/HOME/100%5 Support Services HEMO/HOME/SUPSERV9 Other Outpatient Hemodialysis HEMO/HOME/OTHER

83X Peritoneal Dialysis - Outpatient or Home

A waste removal process, performed in an outpatient or home setting, necessary whenthe body’s own kidneys have failed. Waste is removed indirectly by flushing a specialsolution between the abdominal covering and the tissue.


0 General Classification PERITONEAL/OP OR HOME1 Peritoneal/Composite or Other Rate PERTNL/COMPOSITE2 Home Supplies PERTNL/HOME/SUPPL3 Home Equipment PERTNL/HOME/EQUIP4 Maintenance/100% PERTNL/HOME/100%5 Support Services PERTNL/HOME/SUPSERV9 Other Outpatient Peritoneal Dialysis PERTNL/HOME/OTHER

84X Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home

A continuous dialysis process performed in an outpatient or home setting which uses thepatient peritoneal membrane as a dialyzer.


0 General Classification CAPD/OP OR HOME1 CAPD/Composite or Other Rate CAPD/COMPOSITE2 Home Supplies CAPD/HOME/SUPPL3 Home Equipment CAPD/HOME/EQUIP4 Maintenance/100% CAPD/HOME/100%5 Support Services CAPD/HOME/SUPSERV9 Other Outpatient CAPD CAPD/HOME/OTHER

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85X Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home

A continuous dialysis process performed in an outpatient or home setting which uses thepatient’s peritoneal membrane as a dialyzer.


0 General Classification CCPD/OP OR HOME1 CCPD/Composite or Other Rate CCPD/COMPOSITE2 Home Supplies CCPD/HOME/SUPPL3 Home Equipment CCPD/HOME/EQUIP4 Maintenance/100% CCPD/HOME/100%5 Support Services CCPD/HOME/SUPSERV9 Other Outpatient CCPD Dialysis CCPD/HOME/OTHER

86X Reserved for Dialysis (National Assignment

87X Reserved for Dialysis (State Assignment)

88X Miscellaneous Dialysis

Charges for dialysis services not identified elsewhere.

Rationale: Ultrafiltration is the process of removing excess fluid from the blood ofdialysis patients by using a dialysis machine but without the dialysatesolution. The designation is only used when the procedure is not performedas part of a normal dialysis session.


0 General Classification DIALY/MISC1 Ultrafiltration DIALY/ULTRAFILT2 Home Dialysis Aid Visit HOME DIALYSIS AID VISIT9 Other Miscellaneous Dialysis DIALY/MISC/OTHER

89X Reserved for National Assignment

90X Psychiatric/Psychological Treatments # Treatments


0 General Classification PSTAY TREATMENT1 Electroshock Treatment ELECTRO SHOCK2 Milieu Therapy MILIEU THERAPY3 Play Therapy PLAY THERAPY4 Activity Therapy ACTIVITY THERAPY9 Other OTHER PSYCH RX

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91X Psychiatric/Psychological Services

Charges for providing nursing care and professional services for emotionally disturbedpatients. This includes patients admitted for diagnosis and those admitted for treatment.

Rationale: Provides additional identification of services as necessary.

NOTE: Medicare does not recognize codes 912 and 913 services under its partialhospitalization program.


0 General Classification PSYCH SERVICES1 Rehabilitation PSYCH/REHAB2 Partial Hospitalization* - Less Intensive PSYCH/PARTIAL HOSP3 Partial Hospitalization* - Intensive PSYCH/PARTIAL INTENSIVE4 Individual Therapy PSYCH/INDIV RX5 Group Therapy PSYCH/GROUP RX6 Family Therapy PSYCH/FAMILY RX7 Biofeedback PSYCH/BIOFEED8 Testing PSYCH/TESTING9 Other PSYCH/OTHER

92X Other Diagnostic Services


0 General Classification OTHER DX SVS1 Peripheral Vascular Lab PERI VASCUL LAB2 Electromyelgram EMG3 Pap Smear PAP SMEAR4 Allergy Test ALLERGY TEST5 Pregnancy Test PREG TEST9 Other Diagnostic Services ADDITIONAL DX SVS

93X Medical Rehabilitation Day Program

Medical rehabilitation services as contracted with a payer and/or certified by the state.Services may include physical therapy, occupational therapy and speech therapy.

The subcategory of 93X are designed as zero-billed revenue code (i.e., no dollars in theamount field) to be used as a vehicle to supply program information as defined in theprovider/payer contract. Therefore, zero would be reported for in FL 47 and the numberof hours provided would be reported in FL 46. The specific rehabilitation services wouldbe reported under the applicable therapy revenue codes as normal.


1 Half Day HALF DAY2 Full Day FULL DAY

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94X Other Therapeutic Services (Also see 95X and extension of 94X)Code indicates charges for other therapeutic services no otherwise categorized.


0 General Classification OTHER RX SVS1 Recreational Therapy RECREATION RX2 Educational Training (includes diabetes EDUC/TRAINING

related dietary therapy)3 Cardiac Rehabilitation CARDIAC REHAB4 Drug Rehabilitation DRUG REHAB5 Alcohol Rehabilitation ALCOHOL REHAB6 Complex Medical Equipment – Routine RTN COMPLX MED EQUIP7 Complex Medical Equipment - Ancillary COMPLX MED EQUIP9 Other Therapeutic Services ADDITIONAL RX SVS

95X Other Therapeutic Services – Extension 94X

Charges for other therapeutic services not otherwise categorized.

Subcategory Standard Abbreviation0 Reserved1 Athletic Training ATHLETIC TRAINING2 Kinesiotherapy KINESIOTHERAPY

96X Professional Fees

Charges for medical professionals that hospitals or third party payers require to beseparately identified on the billing form. Services that were not identified separatelyprior to uniform billing implementation should not be separately identified on theuniform bill.


0 General Classification PRO FEE1 Psychiatric PRO FEE/PSYCH2 Ophthalmology PRO FEE/EYE3 Anesthesiologist (MD) PRO FEE/ANES MD4 Anesthetist (CRNA) PRO FEE/ANES CRNA9 Other Professional Fees OTHER PRO FEE

97X Professional Fees (Continuation of 96X)


1 Laboratory PRO FEE/LAB2 Radiology – Diagnostic PRO FEE/RAD/DX3 Radiology – Therapeutic PRO FEE/RAD/RX4 Radiology - Nuclear Medicine PRO FEE/NUC MED5 Operating Room PRO FEE/OR6 Respiratory Therapy PRO FEE/RESPIR7 Physical Therapy PRO FEE/PHYSI8 Occupational Therapy PRO FEE/OCCUPA9 Speech Pathology PRO FEE/SPEECH

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98X Professional Fees (Continuation of 96X and 97X)


1 Emergency Room PRO FEE/ER2 Outpatient Services PRO FEE/OUTPT3 Clinic PRO FEE/CLINIC4 Medical Social Services PRO FEE/SOC SVC5 EKG PRO FEE/EKG6 EEG PRO FEE/EEG7 Hospital Visit PRO FEE/HOS VIS8 Consultation PRO FEE/CONSULT9 Private Duty Nurse FEE/PVT NURSE

99X Patient Convenience Items

Charges for items that are generally considered by the third party payers to be strictlyconvenience items and, as such, are not covered.

Rationale: Permits identification of particular services as necessary .


0 General Classification PT CONVENEENCE1 Cafeteria/Guest Tray CAFETERIA2 Private Linen Service LINEN3 Telephone/Telegraph TELEPHONE4 TV/Radio TV/RADIO5 Nonpatient Room Rental NONPT ROOM RENT6 Ute Discharge Charge LATE DISCHARGE7 Admission Kits ADMIT KITS8 Beauty Shop/Barber BARBER/BEAUTY9 Other Patient Convenience Items PT CONVENCE/OTH

1XXXto8999 Reserved for National Assignment

9000to9044 Reserved for Medicare Skilled Nursing Facility Demonstration Project

9045to9099 Reserved for National Assignment

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FORM LOCATOR 43

DATA ELEMENT: Revenue Description

DEFINITION: A narrative description or standard abbreviation for each revenue code shown inFL 42 on the adjacent line in FL 43. The information assists clerical bill review.Descriptions or abbreviations correspond to the revenue codes. “Other”categories are locally defined and individually described on each bill.


NOTE: The description and abbreviations should correspond with the revenue codes asdefined by the National Uniform Billing Committee.



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. A narrative description or standard abbreviation for each revenue codein FL 42 is shown on the adjacent line in FL 43. The information assists clericalbill review. Descriptions or abbreviations correspond to the revenue codes.“Other” code categories descriptions are locally defined and individuallydescribed on each bill.

The Investigational device exemption (IDE) or procedure identifies a specificdevice used only for billing under the specific revenue code 624. The IDE willappear on the paper format of Form HCFA-1450 as follows: FDA IDE #A123456 (17 spaces).

HHAs identify the specific piece of DME or nonroutine supplies for which theyare billing in this area on the line adjacent to the related revenue code. Thisdescription must be shown in HCPCS coding. (Also, see FL 84, Remarks).

MTHP: Required.


VT MEDICAID: Acceptable.

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FORM LOCATOR 44

DATA ELEMENT: HCPCS/Rates

DEFINITION: The accommodation rate for inpatient bills and the HCFA Common ProcedureCoding System (HCPCS) applicable to ancillary services.

FIELD SIZE: 1 field, 23 lines, 9 positions, numeric (for rates) and alphanumeric (for HCPCS).

NOTE: Inpatient Bills

Accommodations must be entered in revenue code sequence. Dollar valuesreported in this field must include whole dollars, the decimal and the cents(NNNNNN.NN).

When multiple rates exist for the same accommodation revenue code (e.g., semi-private room at $300 and $310), a separate revenue line should be used to reporteach rate, and the same revenue code should be reported on each line.


Refer to Matrix for individual payer’s requirements.

ANTHEM BCBS-NH: Required, if applicable. Outpatient: HCPCS codes are required for certainRevenue Codes. Inpatient: Rates are required for inpatient room and boardRevenue Codes.


TRICARE: Required. HCPCS/CPT codes are required on all outpatient claims.

CIGNA NH: Required, if applicable. Enter the accommodation rates for all room charges.CPT codes are required for Revenue Codes specified on the Revenue CodeMatrix.

MEDICARE: Required. When coding HCPCS for outpatient services (i.e. outpatient surgerybills, clinical diagnostic laboratory bills for outpatients or nonpatients, radiology,other diagnostic services, orthotic/prosthetic devices, take home surgicaldressings, therapies (identified in AB 98-63), preventive services, drugsidentified in §3631.C.3, and other services described in §3627.8 and §3627.9),the provider enters the HCPCS code describing the procedure here.

On inpatient hospital or SNF bills, the accommodation rate or HIPPS code isshown here.

MTHP: Same as Anthem BCBS-NH.

NH MEDICAID: Enter the accommodation rate for all inpatient room charges. Enter theapplicable HCPCS code for laboratory outpatient services (see matrix).

VT MEDICAID: Outpatient claims: If the revenue code being billed requires a HCPCS code onemust be entered here. Revenue code 636 requires either the HCPCS or the NDCfor the chemotherapy.

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FORM LOCATOR 45

DATA ELEMENT: Service Date

DEFINITION: The date the indicated service was provided.

FIELD SIZE: 1 field, 23 lines, 6 positions, numeric

NOTE: The date of service should only be reported if it is required and it is a series billwhere the date of service is different than the from and through date on the form.

Enter both dates as month, day and year (MMDDYY).


ANTHEM BCBS-NH: Required, for outpatient only when HCPCS codes are required.

BCBSVT: Required, for outpatient only, The service date is required when HCPCS codesare required (see Matrix). The service date is also required when billingoutpatient physical therapy, occupational therapy, speech therapy and cardiacrehabilitation.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Required. Effective June 5, 2000, CMHCs and hospitals (with the exception ofCAHs, Indian Health Service hospitals and hospitals located in AmericanSamoa, Guam and Saipan) report line item dates of service wherever a HCPCScode is required for services paid under the outpatient prospective paymentsystem (OPPS). This includes claims where the from and through dates areequal.

MTHP: Required. All therapies (e.g., PT, OT, ST, chemotherapy, radiation therapyshould be billed with one date of service per line.


VT MEDICAID: Required for outpatient only.

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FORM LOCATOR 46

DATA ELEMENT: Units of Service

DEFINITION: A quantitative measure of services rendered by revenue category to or for thepatient to include items such as number of accommodation days, miles, pints ofblood or renal dialysis treatments, etc.

SIZE: 1 field, 23 lines, 7 positions, numeric

NOTE: Required as described with revenue code


ANTHEM BCBS-NH: Required. Indicate number of units; number of days stayed; number of visits andnumber of treatments in this field when applicable. For Revenue Code 001 totalonly number of days.

When billing outpatient physical therapy, occupational therapy or speechtherapy, - enter the number of visits in the billing period, not the number ofmodalities performed.


TRICARE: Required. Enter the quantitative measures of services rendered by revenuecategory to or for the patient. Must be entered for all types of roomaccommodations and/or therapies.

CIGNA NH: Same as TRICARE.

MEDICARE: Required. Enter the number of digits or units of service on the line adjacent toRevenue Code and description where appropriate, e.g., number of covered daysin a particular type of accommodation, pints of blood. Provide the number ofcovered days, visits, treatments, tests, etc., as applicable for the following:

Accommodation days: - 100s-150s, 200s, 210s (days)Blood pints – 380s (pints)DME – 290s (rental months)Emergency room visits – 450, 452 and 459 (HCPS code definition for visit orprocedure)Clinic visits – 510s and 520s (HCPS code definition for visit or procedure)Dialysis treatments – 800s (sessions or days)Orthotic/prosthetic devices – 274 (items)Outpatient therapy visits – 410, 420, 430, 440, 480, 910, 943 (Units are equal tothe number of times the procedure/service being reported was performed.)Outpatient clinical diagnostic laboratory tests – 30X – 31X (tests)Radiology – 32x, 34x, 35x, 40x, 61x, 333 (HCPCS code definition of tests orservices)Oxygen – 600s (rental months, feet, or pounds)Hemophilia blood clotting factors – 636

Enter up to seven numeric digits. Show charges for noncovered services asnoncovered.

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NOTE: Hospital outpatient departments report the number of visits/sessionswhen billing under the partial hospitalization program. (See ∋452.)

MTHP: Required. When billing outpatient physical therapy, occupational therapy orspeech therapy, - enter the number of visits in the billing period, not the numberof modalities performed.

NH MEDICAID: Required, if applicable.

Inpatient Indicate number of units, number of days stayed and number oftreatments in this field as applicable. For Revenue Code 001 totalonly number of days for accommodation.

Outpatient Total number of units for all services.

VT MEDICAID: Required. Units of service are required to report the number of services such asaccommodation days, visits, treatments, sessions and all-inclusive ancillaryservices. The number of units must be entered in this column adjacent to therevenue description and associated revenue code. The number of units must bereported for the following types of services but should not be totaled adjacent toRevenue Code “001” (Grand Total).

Inpatient Accommodation Days - Enter the number of daysLeave of Absence Days - Enter the number of leave of absence daysDialysis Treatments/Sessions - Enter the number of dialysistreatments/sessionsEmergency Room - Enter the number of ER visits

Outpatient Diagnostic Clinical Lab - Enter the number of testsEmergency Room - Enter the number of ER visit.Clinic - Enter the number of visitsDialysis - Enter the number of treatments/sessionsAll-inclusive Ancillary - Enter the number of daysRehabilitative Therapies - One unit per date of service billed. Eachdate of service may be billed individually at the detail levelAll-inclusive Ancillary/Other - Enter the number of daysRenal Dialysis Supplies - Enter the number of days the supplies willbe utilizedRadiology - Enter number of x-raysOther Diagnostics - Enter number of tests

NOTE: Dialysis training sessions must be enumerated in FL 84 (Remarks).EXAMPLE: “CAPC” Training Sessions No.’s - 6-10

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FORM LOCATOR 47

DATA ELEMENT: Total Charges (by Revenue Code Category)

DEFINITION: Total charges pertaining to the related revenue code for the current billing periodas entered in the statement covers period.

FIELD SIZE: 1 field, 23 lines, 10 positions (see NOTE), numeric

NOTE: There are 7 positions for dollars, 2 characters for cents, and 1 character tothe right of cents to indicate credit.Enter: NNNNNNN.NNS.

The figures in column 47 add up to a total which is reported in this formlocator using Revenue Code 001.



BCBSVT: Required.

TRICARE: Required.

CIGNA NH: Required.

MEDICARE: Total Charges (by Revenue Code Category)

Required. Sum the total charges for the billing period by Revenue Code or in thecase of diagnostic laboratory tests for outpatient or nonpatients by HCPCSprocedure and enter them on the adjacent line in FL 47. The last Revenue Codeentered in FL 42 “0001” which represents the grand total of all charges billed.FL 47 totals on the adjacent line. Each line allows up to nine numeric digits(0000000.00).

HCFA policy is for providers to bill Medicare on the same basis that they billother payers. This policy provides consistency of bill data with the cost report sothat bill data may be used to substantiate the cost report.

Medicare and non-Medicare charges for the same department must be reportedconsistently on the cost report. This means that the professional component isincluded on, or excluded from, the cost report for Medicare and non-Medicarecharges. Where billing for the professional components is not consistent for allpayers, i.e., where some payers require net billing and others require gross, theprovider must adjust either net charges up to gross or gross charges down to netfor cost report preparation. In such cases, adjust your provider statistical andreimbursement (PS&R) reports that you derive from the bill.

For outpatient Part B billing, only charges believed to be covered are submittedin FL 47. Noncovered charges are omitted from the bill,

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MTHP: Required.


VT MEDICAID: Required.

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FORM LOCATOR 48

DATA ELEMENT: Noncovered Charges

DEFINITION: To reflect noncovered charges for the primary payer pertaining to the relatedRevenue Code.


NOTE: There are 7 positions for dollars, 2 characters for cents, and 1 character to theright of cents to indicate credit. Enter: NNNNNNN.NNS.

The figures in column 48 add up to a total which is reported in this form locatorusing Revenue Code 001.



BCBSVT: Required, if applicable.



MEDICARE: Required. The total noncovered charges pertaining to the related Revenue Codein FL 42 are entered here.

MTHP: Not required.



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FORM LOCATOR 49


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DATA ELEMENT: Payer Identification

DEFINITION: Name and, if required, number identifying each payer organization from whichprovider might expect some payment for the bill.


NOTE: A = Primary payerB = Secondary payerC = Tertiary payer

Example: If Medicare is entered in FL 50 A, this indicates that the provider hasdeveloped for other insurance and has determined that Medicare is the primarypayer.

SUPPLEMENTAL INSURANCE

When billing secondary payer after Medicare, enter the name of the payerfollowed by the appropriate code.

A = VT MedicaidB = VT MedicompC = NH MedicareD = NH MedicaidE = NH Blue CrossF = CommercialG = NH MedicompH = Federal Employee ProgramI = Inter Plan Bank, NH/VT National Accounts, Out of Area


ANTHEM BCBS-NH: Required. Include assigned Blue Cross Plan Number, from the member’sIdentification Card.

a. Federal Employee Program, Enter FEPb. National Accounts, Enter NAT. ACCT.c. Inter-Plan Bank, Enter PAYER AND STATE NAME AND PLAN CODE

(EX: BANK-MASS200), ord. Name of other insurance company


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TRICARE: Required. If TRICARE is the only insurer other than Medicaid and TRICARESupplemental Plans, TRICARE is the primary payer. Enter “TRICARE” in FL50A.

If there are other insurers besides Medicaid, and TRICARE Supplemental Plans,TRICARE is not the primary payer. Enter the name of the group(s) or plan(s) inFL 50A or FL 50A and FL 50B. Enter “TRICARE” in FL 50B orFL 50C.

CIGNA NH: Required. Enter “Healthsource” as the payer.

MEDICARE: Required. If Medicare is the primary payer, enter “Medicare” on line A. Entering“Medicare” indicates that you have developed for other insurance and havedetermined that Medicare is the primary payer. All additional entries across lineA (FLs 51-55) supply information needed by the payer named in FL 50A. IfMedicare is the secondary or tertiary payer, identify the primary payer on line Aand enter Medicare information on line B or C as appropriate. (See ∋∋262, 263,264, and 289 to determine when Medicare is not the primary payer.)

MTHP: Required. Enter “MTHP” as the payer.

NH MEDICAID: Required. Enter the designation provided by the State Medicaid Agency. Enterother insurance carriers on top lines 50A and/or B. Enter NH Medicaidinformation after any other insurance carrier information.

VT MEDICAID: Required. Enter “Vermont Medicaid” in FL 50C.

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DATA ELEMENT: Provider Number

DEFINITION: The number assigned to the provider by the payer indicated in FL 50 A,B,C.


NOTE: A = Primary PayerB = Secondary PayerC = Tertiary Payer


ANTHEM BCBS-NH: Required. Enter the 4 character alpha code and 6 digit number assigned byAnthem BCBS-NH.

BCBSVT: Required. Enter the 6 character provider identification as assigned by Medicare.

TRICARE: Required. Providers should enter their Medicare provider number associatedwith the distinct unit for which they are billing. When billing for a swing bed,the Medicare SNF provider number should be used.

CIGNA NH: Desirable.

MEDICARE: Required. Enter the six position alpha-numeric provider number as assigned byMedicare. It must be entered on the same line as “Medicare” in FL 50.

MTHP: Required. Enter provider number as assigned by MTHP.

NH MEDICAID: Required. Enter the 8 digit NH Medicaid provider number corresponding toNHMA in FL 50.

VT MEDICAID: Required. On line C enter your VT Medicaid provider number. Leave lines Aand B blank.

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DATA ELEMENT: Release of Information Certification Indicator

DEFINITION: A code indicating whether the provider has on file a signed statement permittingthe provider to release data to other organizations in order to adjudicate theclaim.

FIELD) SIZE: 1 field, 3 lines, 1 position, alphanumeric

CODE STRUCTURE:

Y-Yes The provider has signed written authority to releasemedical/billing information for purposes of claimingbenefits.

R-Restricted or The provider has limited or authority to release some Modified Release restricted medical/billing information for purposes of

claiming insurance benefits.

N-No Release The provider does not have permission to release anymedical/billing information.

NOTE: The back of Form HCFA-1450 contains a certification that all necessaryrelease statements are on file.




TRICARE: Required. Indicate that a release has been obtained (code Y- Release).


MEDICARE: Required. A “Y” code indicates you have on file a signed statement permittingyou to release data to other organizations in order to adjudicate the claim. An“R” code indicates the release is limited or restricted. An “N” code indicates norelease is on file.

MTHP: Not required.



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DATA ELEMENT: Assignment of Benefits Certification Indicator

DEFINITION: A code showing whether the provider has a signed form authorizing the thirdparty payer to pay the provider.

FIELD SIZE: 1 field, 3 lines, 1 position, alphanumeric

NOTE: The presence of an assignment does not permit release of medical informationabout a patient.

CODE STRUCTURE:

Y-Yes Benefits AssignedN-No Benefits not Assigned




TRICARE: Required. When participation in TRICARE is mandated by law, required in aprovider agreement, or when the provider accepts the assignment of benefits(indicated by using code Y in this form locator), the provider is agreeing toaccept the charge determination of the TRICARE fiscal intermediary as the fullcharge and the patient is responsible only for the deductible, coinsurance andnoncovered services. Under the Consolidated Omnibus Budget ReconciliationAct of 1985, effective January 1, 1987, Medicare participating hospitals arerequired to also participate in TRICARE and accept patients from thoseprograms.



MTHP: Not required.



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FORM LOCATOR 54 A,B,C,P

DATA ELEMENT: Prior Payments - Payer and Patients

DEFINITION: The amount the provider has received toward payment of this bill prior to thebilling date by the indicated payer.


NOTE: There are 7 positions for dollars, 2 characters for cents, and 1 character to theright of the cents to indicate credit.

Enter: “NNNNNNN.NNS”

A = PrimaryB = SecondaryC = TertiaryP = Due From Patient


ANTHEM BCBS-NH: Required, when payment has been made by other insurer.

BCBSVT: Same as Anthem BCBS-NH. Include copy of other insurance payment notice.

TRICARE: Required.

CIGNA NH: Required, if applicable.

MEDICARE: Required. Enter for all services other than inpatient hospital and SNF services,the sum of any amounts collected from the patient toward deductibles (cash andblood) and/or coinsurance on the patient (fourth/last) line of this column.

In apportioning payments between cash and blood deductibles, the first threepints of blood are treated as noncovered by Medicare. Thus, for example, if totalinpatient hospital charges were $350.00 including $50.00 for a deductible pint ofblood, apportion $300.00 to the Part A deductible and $50.00 to the blooddeductible. Blood is treated the same way in both Part A and Part B.

MTHP: Same as Anthem BCBS-NH.

NH MEDICAID: Required, when payment is made by other payer. Total of all prior paymentsmust be reflected in FL 54A.

VT MEDICAID: Required, if applicable. Enter the spenddown amount from the “Amount PatientResponsible For” column of the “Notice of Decision.” If other insurance hasmade a payment enter amount here. If other insurance has made no payment, theother insurance payment notice must be attached. Total of all prior paymentsmust be reflected in FL 54A.

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FORM LOCATOR 55 A,B,C,P

DATA ELEMENT: Estimated Amount Due

DEFINITION: The amount estimated by the provider to be due from the indicated payer(estimated responsibility less prior payments).


NOTE: There are 7 positions for dollars, 2 character for cents, and 1 character to theright of the cents to indicate credit.

Enter: “NNNNNNN.NNS”

A = PrimaryB = SecondaryC = TertiaryP = Due From Patient







MTHP: Not required.

NH MEDICAID: Required. If other insurance has made a payment, enter the balance being billedto Medicaid. Corresponding to NHMA in FL50.


OCTOBER 2001

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FORM LOCATOR 56


BSBSVT: Requires DRG code when applicable as determined by contract between payerand hospital for inpatient.

OCTOBER 2001

2-131

FORM LOCATOR 57


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DATA ELEMENT: Insured’s Name

DEFINITION: The name of the individual in whose name the insurance is carried, as qualifiedbelow by the payer organization.


NOTE: A = Primary PayerB = Secondary PayerC = Tertiary

Use a space to separate last and first name. Enter last name first.

No space should be left between a prefix and a name as in MacBeth,VonSchmidt, McEnroe.

Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element unlessthey appear on the insured’s health insurance card.

To record suffix of a name, write the last name, leave a space and write thesuffix, then write the first name as in Snyder III, Harold, or Addams Jr., Glen.


ANTHEM BCBS-NH: Required. Enter the name exactly as it appears on the member’s identificationcard.


TRICARE: Required. Enter the sponsor’s name as recorded on the ID card in FL 58 A. (Notrequired if the patient and sponsor are the same.)

CIGNA NH: Required.

MEDICARE: Required. On the same lettered line (A, B or C) that corresponds to the line onwhich Medicare payer information is shown in FLs 50-54, enter the patient’sname as shown on his/her HI card or other Medicare notice. All additionalentries across line A (FLs 59-66) pertain to the person named in FL 58A. Theinstructions that follow explain when to complete these items.

Enter the name of the individual in whose name the insurance is carried if there are payer(s) of higher priority than Medicare and you are requesting paymentbecause:

• Another payer paid some of the charges and Medicare is secondarily liable forthe remainder,

• Another payer denied the claim, or• You are requesting conditional payment as described in ∋∋469G, 470G, 471G,

or 472G.

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If that person is the patient, enter “Patient”. Payers of higher priority thanMedicare include:

• EGHPs for employed beneficiaries and spouses age 65 or over (See ∋263),• EGHPs for beneficiaries entitled to benefits solely on the basis of ESRD

during a period of up to 30 months (See ∋264),• LGHPs for disabled beneficiaries,• An auto-medical, no-fault, or liability insurer (See ∋262), or• WC including BL (See ∋289).

MTHP: Required. Enter patient’s name as it appears on the member’s identification card.

NH MEDICAID: Required. Enter the insured’s last name, first name, and middle initial on line C.Name must correspond with the name on the Medicaid ID Card.


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DATA ELEMENT: Patient’s Relationship to Insured

DEFINITION: A code indicating the relationship of the patient to the identified insured.

FIELD SIZE: 1 field, 3 lines, 2 positions, numeric

NOTE: A = Primary PayerB = Secondary PayerC = Tertiary Payer

CODE STRUCTURE:

PATIENT’S RELATIONSHIP TO INSURED

01 Patient is Insured Self-explanatory

02 Spouse Self-explanatory

03 Natural Child/Insured has Self-explanatoryFinancial Responsibility

04 Natural Child/Insured does Self-explanatorynot have FinancialResponsibility

05 Stepchild Self-explanatory

06 Foster Child Self-explanatory

07 Ward of the Court Patient is ward of the insured as a result of acourt order.

08 Employee Patient is employed by the insured.

09 Unknown Patient’s relationship to the insured is unknown.

10 Handicapped Dependent Dependent child whose coverage extendsbeyond normal termination age limits as a resultof laws or agreements extending coverage.

11 Organ Donor Code is used in cases where bill is submitted forcare given to organ donor where such care is paidby the receiving patient’s insurance coverage.

12 Cadaver Donor Code is used where bill is submitted for procedures performed on cadaver donor where such procedures are paid by the receiving patient’s insurance coverage.

13 Grandchild Self-explanatory

14 Niece/Nephew Self-explanatory

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15 Injured Plaintiff Patient is claiming insurance as a result of injurycovered by insured.

16 Sponsored Dependent Individuals not normally covered by insurancecoverage but coverage has been specially arranged to include relationships such as grandparent or former spouse that would requirefurther investigation by the payer.

17 Minor Dependent of a Minor Code is used where patient is a minor and a

Dependent dependent of another minor who in turn is a dependent (although not a child) of the insured.

18 Parent Self-explanatory

19 Grandparent Self-explanatory

20 Life Partner Patient is covered under insurance policy of his/her life partner (or similar designation eg., domestic partner, significant other)

21-99 Reserved for National Assignment


ANTHEM BCBS-NH: Required. Enter the appropriate code to indicate the patient’s relationship to theinsured.

CODE CODE01 0602 1003 1605 20

BCBSVT: Required.

TRICARE: Required. Enter the patient’s relationship code to the sponsor. Enter theappropriate code to indicate the patient’s relationship to the insured.

CODE010203


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MEDICARE: Required. Enter one of the following codes when claiming a conditional paymentin FL 58 A,B,C. This field may be left blank if a conditional payment is notbeing claimed. Only the following codes are approved for Medicare use.

CODE CODE CODE01 05 1102 06 1203 08 1504 09

MTHP: Required.



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DATA ELEMENT: Certificate/Social Security/Health Insurance Claim/Identification Number

DEFINITION: Insured’s unique identification number assigned by the payer organization.

SIZE: 1 field, 3 lines, 19 positions, alphanumeric



ANTHEM BCBS-NH: Required. Enter member’s identification number exactly as it appears on theidentification card, including the 3-character alpha prefix and 2-digit suffix.


TRICARE: Required. Enter the sponsor’s social security number.

CIGNA NH: Required. Enter member’s ID number as it appears, up to 9 digits. Include thetwo digit suffix with * or - or run it all together.

MEDICARE: Required. Enter the patient’s Medicare HIC number on the same lettered line (A,B or C) that corresponds to the line on which Medicare payer information isshown in FLs 5O-54. If Medicare is the primary payer, enter this information inFL 60A. If any other insurance coverage higher in priority than Medicare isinvolved, employee coverage for the patient or his spouse age 65 to 69 or duringthe first year of ESRD entitlement, the related claim number for that coverageshould be entered on the appropriate line. Show the number as it appears on thepatient’s HI Card, Certificate of Award, Utilization Notice, Explanation ofMedicare Benefits, Temporary Eligibility Notice, or as reported by the SocialSecurity office.

Medicare will accept up to 12 characters in this field.

MTHP: Required. Enter patient’s member ID number exactly as it appears on the IDcard.

NH MEDICAID: Required. Enter Recipient’s Medicaid 11 digit ID number.

VT MEDICAID: Required. Enter Recipient’s Medicaid ID number in FL 60 C.

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DATA ELEMENT: Insured Group Name

DEFINITION: Name of the group or plan through which the insurance is provided to theinsured.



ANTHEM BCBS-NH: Required when billing National Accounts.

BCBSVT: Required.

TRICARE: Required. If primary payer(s) is other than TRICARE, enter the name ofthe group(s) or plan(s) other insurance in FL 61 A or FL 61 A & FL 61 B.


MEDICARE: Required, if applicable. Medicare requires the primary payer information on theprimary payer line when Medicare is secondary and the provider has requestedconditional payment.

MTHP: Desirable.


VT MEDICAID: Required, if applicable. Enter the carrier code(s) on the corresponding line.

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DATA ELEMENT: Insured Group Number

DEFINITION: The identification number, control number, or code assigned by the carrier oradministrator to identify the group under which the individual is covered.




ANTHEM BCBS-NH: Required. Enter information as it appears on the member’s ID card under groupnumber or division number.


TRICARE: Required. If primary payer(s) is other than TRICARE, enter the ID number,control number or carrier code of the groups(s) or plan(s) other insurance inFL 62 A and FL 62 A & FL 62 B.


MEDICARE: Required, if applicable. Medicare requires the primary payer information on thepayer line when Medicare is secondary and the provider has requestedconditional payment.

MTHP: Not required.



OCTOBER 2001

2-140


DATA ELEMENT: Treatment Authorization Code

DEFINITION: A number or other indicator that designates that the treatment covered by thisbill has been authorized by the payer.



ANTHEM BCBS-NH: Acceptable, if applicable. Enter authorized case reference number for inpatientor outpatient services.

BCBSVT: Acceptable, if applicable.

TRICARE: Acceptable.

CIGNA NH: Acceptable.

MEDICARE: Required. Whenever PRO review is performed for outpatient preadmission,preprocedure, or home IV therapy services, the authorization number is requiredfor all approved admissions or services.

MTHP: Acceptable, if applicable.

NH MEDICAID: Required for all out of state “nonborder” providers billing for inpatient servicesunless admitted through the ER. Prior authorization must be obtained from theMedicaid Administration Bureau.

VT MEDICAID: Acceptable.

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DATA ELEMENT: Employment Status Code

DEFINITION: A code used to define the employment status of the individual identified inFL 58.

FIELD SIZE: 1 field, 3 lines, 1 position, numeric


CODE STRUCTURE:

1 Employed full-time Individual states that he or she is employedfull-time.

2 Employed part-time Individual states that he or she is employedpart-time.

3 Not Employed Individual states that he or she is not employedfull-time or part-time.

4 Self-employed Self-explanatory

5 Retired Self-explanatory

6 On Active Military Duty Self-explanatory


9 Unknown Individual’s employment status is unknown.




TRICARE: Required.


MEDICARE: Required, if applicable. Medicare requires the primary payer information on theprimary payer line where Medicare is secondary and the provider has requestedconditional payment.

MTHP: Not required.



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DATA ELEMENT: Employer Name

DEFINITION: The name of the employer that might or does provide health care coverage forthe individual identified in FL 58.






TRICARE: Required.



MTHP: Desirable.



OCTOBER 2001

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DATA ELEMENT: Employer Location

DEFINITION: The specific location of the employer of the individual identified in FL 58.



A specific location is the city, plant, etc. in which the employer is located.




TRICARE: Required.



MTHP: Not required.



OCTOBER 2001

2-144

FORM LOCATOR 67

DATA ELEMENT: Principal Diagnosis Code

DEFINITION: The ICD-9-CM codes describing the principal diagnosis (i.e., the conditionestablished after study to be chiefly responsible for occasioning the admission ofthe patient for care.


NOTE: The reporting of the decimal between third and fourth digit is unnecessarybecause it is implied.

The principal diagnosis code will include the use of “V” codes.



ICD-9-CM “E” codes are not acceptable.

BCBSVT: Required. Use of ICD-9-CM “V” codes for other than routine preventive careservices may create a delay in processing while medical records are obtained todetermine a more specific diagnosis.

ICD-9-CM “E” codes are not acceptable as primary diagnoses and only one perclaim is allowed.

TRICARE: Required. Enter the full ICD-9-CM code for the principal diagnosis. “V” codesare not acceptable for outpatient testing. Submit the referring physician’sdiagnosis if a diagnosis has not been confirmed.

“V” codes are accepted for normal newborn charges.

CIGNA NH: Required. Enter full ICD-9-CM codes. “E” codes and “V” codes are acceptable.Routine “V” codes should be used when applicable.

MEDICARE: Required for Bill types 11x, 12x, and 13x.

Inpatient – Required. Enter the ICD-9-CM code for the principal diagnosis. Thecode must be the full ICD-9-CM diagnosis code, including all five digits whereapplicable. Where the proper code has fewer than 5 digits, do not fill with zeros.The principal diagnosis is the condition established after study to be chieflyresponsible for this admission. Even though another diagnosis may be moresevere than the principal diagnosis, enter the principal diagnosis. Entering anyother diagnosis may result in incorrect assignment of a DRG and cause you to beincorrectly paid under PPS.

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Outpatient – Required. Report the full ICD-9-CM code for the diagnosis shownto be chiefly responsible for the outpatient services in FL 67. Report thediagnosis to your highest degree of certainty. For instance, if the patient is seenon an outpatient basis for an evaluation of a symptom (e.g., cough) for which adefinitive diagnosis is not made, the symptom must be reported (786.2). If duringthe course of the outpatient evaluation and treatment a definitive diagnosis ismade (e.g., acute bronchitis), report the definitive diagnosis (466.0).

When a patient arrives at the hospital for examination or testing without areferring diagnosis and cannot provide a complaint, symptom, or diagnosis,report an ICD-9-CM code for Persons Without Reported Diagnosis EncounteredDuring Examination and Investigation of Individuals and Populations (V70.-V82). Examples include:

• Routine general medical examination (V70.0),• General medical examination without any working diagnosis or complaint,

patient not sure if the examination is a routine checkup (V70.9), and• Examination of ears and hearing (V72.1).

NOTE: Diagnosis codes are not required on nonpatient claims for laboratoryservices where you function as an independent laboratory.

MTHP: Same as Medicare. “E” codes are acceptable as a secondary diagnosis only.

NH MEDICAID: Required. Enter the ICD-9-CM code for the principal diagnosis appearing inFL 67. Enter the codes for diagnosis other than the principal diagnosis inFLs 68-75. ICD-9-CM “E” codes are not acceptable.

ICD-9-CM “V” codes are acceptable.

VT MEDICAID: Required. Enter the primary ICD-9-CM code in FL 67. Enter any additionalcodes for FLs 68-75. ICD-9-CM “E” codes are not acceptable.

ICD-9-CM “V” codes are acceptable, however, medical records may be required.

OCTOBER 2001

2-146

FORM LOCATOR 68-75

DATA ELEMENT: Other Diagnoses Codes

DEFINITION: The ICD-9-CM diagnoses codes corresponding to additional conditions that co-exist at the time of admission, or develop subsequently, and which have an effecton the treatment received or the length of stay.


NOTE: The reporting of the decimal between third and fourth digits is unnecessarybecause it is implied.

Other diagnoses codes will permit the use of ICD-9-CM “V” codes whereappropriate.


ANTHEM BCBS-NH: Required, if applicable. ICD-9-CM “E” codes are not acceptable.


TRICARE: Required.

CIGNA NH: Required, if applicable. Enter full ICD-9-CM codes. “E” and “V” codes areacceptable. Routine “V” codes should be used, if applicable.

MEDICARE: Inpatient – Required. Enter the full ICD-9-CM codes for up to eight additionalconditions if they co-existed at the time of admission or developed subsequently,and which had an effect upon the treatment or the length of stay.

Do not duplicate the principal diagnosis listed in FL 67 as an additional orsecondary diagnosis.

Outpatient – Required. Enter the full ICD-9-CM codes in FLs 68-75 for up toeight other diagnoses that co-existed in addition to the diagnosis reported in FL67.

MTHP: Required, if applicable.

NH MEDICAID: Required, if applicable. ICD-9-CM “E” codes are not acceptable. ICD-9CM “V”codes are acceptable.


OCTOBER 2001

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FORM LOCATOR 76

DATA ELEMENT: Admitting Diagnosis

DEFINITION: The ICD-9-CM diagnoses code provided at the time of admission as stated by thephysician.


NOTE: The ICD-9-CM diagnosis code describing the admitting diagnosis as asignificant finding representing patient distress, an abnormal finding onexamination, a possible diagnosis based on significant findings, a diagnosisestablished from a previous encounter or admission, an injury, a poisoning, or areason or condition (not an illness or injury) such as follow-up or pregnancy inlabor. Report only one admitting diagnosis. This condition shall be determinedbased on the ICD-9-CM coding directives in Volumes I and II of the ICD-9-CMcoding manuals and the official coding guidelines.

The reporting of the decimal between the third and fourth digits is unnecessarybecause it is implied.


ANTHEM BCBS-NH: Required, inpatient only. ICD-9-CM “E” codes are not acceptable.

BCBSVT: Required, inpatient only.

TRICARE: Required for inpatient bills.

CIGNA NH: Required.

MEDICARE: Required. For inpatient hospital claims subject to PRO review, the admittingdiagnosis is required. Admitting diagnosis is the condition identified by thephysician at the time of the patient's admission requiring hospitalization.

Is a dual use field, Patient’s Reason for Visit is not required by Medicare butmay be used by providers for nonscheduled visits for outpatient bills.

MTHP: Required.

NH MEDICAID: Required if applicable. Enter the ICD-9-CM diagnosis code provided at the timeof admission as stated by the physician. ICD-9-CM “E” codes are not acceptable.


OCTOBER 2001

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FORM LOCATOR 77

DATA ELEMENT: External Cause of Injury Code (E-Code)

DEFINITION: The ICD-9-CM Code for the external cause of an injury, poisoning, or adverseeffect.


NOTE: Health care facilities are encouraged to complete FL 77 whenever there is adiagnosis of an injury, poisoning, or adverse effect. The completion of this fieldis voluntary in states where E-coding is not required.

The priorities for recording an E-code in FL 77 are:

1) Principal diagnosis of an injury or poisoning

2) Other diagnosis of an injury, poisoning, or adverse effect directly related tothe principal diagnosis.

3) Other diagnosis with an external cause


ANTHEM BCBS-NH: Required, if applicable.







VT MEDICAID: Required, if applicable.

OCTOBER 2001

2-149

FORM LOCATOR 78


OCTOBER 2001

2-150

FORM LOCATOR 79

DATA ELEMENT: Procedure Coding Method Used

DEFINITION: An indicator that identifies the coding method used for procedure coding on thebill.

FIELD SIZE: I field, 1 line, 1 position, numeric

NOTE: Use only ICD-9-CM (code 9) in New Hampshire and Vermont.

CODE STRUCTURE:

1-3 Reserved for State Assignment4 CPT-45 HCPCS (HCFA Common Procedure Coding System)6-8 Reserved for National Assignment9 ICD-9-CM




TRICARE: Required.



MTHP: Not required.



OCTOBER 2001

2-151

FORM LOCATOR 80

DATA ELEMENT: Principal Procedure Code and Date

DEFINITION: The code that identifies the principal procedure performed during the periodcovered by this bill and the date on which the principal procedure described onthe bill was performed.

FIELD SIZE: 1 field (code), 1 line, 7 positions, alphanumeric1 field (date), 1 line, 8 positions, numeric

Use ICD-9-CM Volume III for all insurers in New Hampshire and Vermont.

NOTE: The reporting of the decimal between the third and fourth digits is unnecessarybecause it is implied.

The code structure must be consistent with the information provided in FL 79.

Enter date as month, day and year (MMDDCCYY).

Use ICD-9-CM Volume III for all insurers in New Hampshire and Vermont.HCPCS codes not acceptable.


ANTHEM BCBS-NH: Required, if applicable. This Form Locator must be completed when services arerendered in the operating room/emergency room. Bill professional fees on theHCFA-1500 claim form.

BCBSVT: Same as Anthem BCBS-NH. Occurrence Code 51 requires completion of FL 80.

TRICARE: Required.

CIGNA NH: Required, if applicable. This form locator is required for outpatient surgeryservices.

MEDICARE: Required for Inpatient only. Enter the full ICD-9-CM, Volume 3, procedurecodes, including all four digits where applicable, for the definitive treatmentrather than for diagnostic or exploratory purposes or which was necessary to takecare of a complication. It is also the procedure most closely related to theprincipal diagnosis (FL 67). See 3626.4 for reporting outpatient procedures.

For this purpose, surgery includes incision, excision, amputation, introduction,repair, destructions, endoscopy, suture, and manipulation.

Show the date of the principal procedure numerically as MM-DD-YY in the“date” portion.

Pacemaker related ICD-9-CM procedure codes (37.70 and 37.73-37.85) requireyou to follow special procedures. (See §3678.)

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MTHP: Required, if applicable. Must be supplied for services rendered in OR.

NH MEDICAID: Required, if applicable. The principal procedure is the procedure performed fordefinitive treatment rather than one performed for diagnostic or exploratorypurposes or to resolve a complication.

VT MEDICAID: Required, if applicable. The principal procedure is the procedure performed fordefinitive treatment rather than one performed for diagnostic or exploratorypurposes. Required if a surgical procedure is performed. Use ICD-9-CM VolumeIII codes. A surgical procedure code must be used when billing revenue codes360 or 490.

OCTOBER 2001

2-153

FORM LOCATOR 81 A,B,C,D,E

DATA ELEMENT: Other Procedure Codes and Dates

DERMTION: The codes identifying all significant procedures other than the principalprocedure and the dates (identified by code) on which the procedures wereperformed. Report those that are most important for the episode of care andspecifically any therapeutic procedures closely related to the principal diagnosis.

FIELD SIZE: 5 fields (codes), 1 line, 7 positions, alphanumeric5 fields (dates), 1 line, 8 positions, numeric

NOTE: The code structure must be consistent with the coding method indicated m FL 79.

Enter codes in descending order of importance.

The reporting of the decimal between the third and fourth digits is unnecessarybecause it is implied.

Enter date as month, day, and year (MMDDCCYY).

Use ICD-9-CM Volume III for all insurers in New Hampshire and Vermont.HCPCS not acceptable.


ANTHEM BCBS-NH: Required, if applicable. ICD-9-CM Volume III coding method must be utilized.Do not use HCPCS.


TRICARE: Required. Enter the full ICD-9-CM codes and dates.


MEDICARE: Require for Inpatient only. Enter the full ICD-9-CM, Volume 3, procedurecodes, including all four digits where applicable, for up to five significantprocedures other than the principal procedure (shown in FL 80). Show the dateof each procedure numerically as MM-DD-YY in the “date” portion of FL 81, asapplicable. Do not repeat procedures unless you do them more than once.The paper Form HCFA-1450 accommodates only two other procedures.An additional three other procedures may be reported in Remarks. Yourintermediary’s data entry screens will be capable of accepting the principalprocedures and five other procedures. EMC formats include principal and fiveother procedures.

Pacemaker related ICD-9-CM procedure codes (37.70 and 37.73-37.85) requireyou to follow special procedures. (See §3678.)


OCTOBER 2001

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NH MEDICAID: Required, if applicable.


OCTOBER 2001

2-155

FORM LOCATOR 82 A,B

DATA ELEMENT: Attending Physician ID

DEFINITION: The name and/or number of the licensed physician who would normally beexpected to certify and recertify the medical necessity of the services renderedand/or who has primary responsibility for the patient’s medical care and treatment.

FIELD SIZE: 1 field, upper line (optional - see NOTE), 23 positions, alphanumeric lower line,32 positions, alphanumeric

NOTE: Recommended format: physician number entered first, then name.

The upper line can be used to capture other state physician ID numbers in casesinvolving Medicare claims crossed over to the Medicaid program since theMedicare program requires UPINs and the Medicaid program may require statelicense numbers.


ANTHEM BCBS-NH: Required. Enter the Anthem BCBS-NH ten character or 7 digit provider ID ofthe inpatient attending physician or the ten character or 7-digit provider ID ofphysician who requested outpatient services. This would be the physician whowould normally be expected to certify the medical necessity of the servicesrendered and/or who has primary responsibility for the patient’s medical careand treatment. Anthem BCBS-NH does not require the name of the Physicianand/or Group Name.

BCBSVT: Required. Enter the four or five character Blue Cross and Blue Shield ofVermont provider number of the individual physician who has primaryresponsibility for the patient’s medical care and treatment. Name is required.The group provider number is not acceptable.

TRICARE: Required. Enter the UPIN, the physician’s last name, first name and middle initial.

CIGNA NH: Required. Enter UPIN number of the attending physician.

MEDICARE: Required. Enter the UPIN and name of the attending physician on inpatient billsor the physician that requested outpatient services. This requirement applies toinpatient bills (hospital and SNF Part A) with a “Through” date of January 1,1992, or later, and to outpatient and other Part B bills with a “From” date ofJanuary 1, 1992, or later.

Inpatient Part A – Enter the UPIN and name of the attending physician. Forhospital services the Uniform Hospital Discharge Data Set definition forattending physician is used. This is the clinician primarily responsible for thecare of the patient from the beginning of the hospital episode. For SNF services,i.e., swing bed, the attending physician is the practitioner who certifies the SNFplan of care. Enter the UPIN in the first six positions, followed by two spaces,the physician’s last name, one space, first name, one space, and middle initial.

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Outpatient and Other Part B – Enter the UPIN and name of the physician whorequested surgery, therapy, diagnostic tests or other services in the first sixpositions followed by two spaces, the physician’s last name, one space, firstname, one space, and middle initial.

Home Health and Hospice – HHAs and hospices must enter the UPIN and nameof the physician that signs the home health or hospice plan of care. Enter theUPIN in the first six positions followed by two spaces, the physician’s last name,one space, first name, one space and middle initial.

If the patient is self-referred (e.g., emergency room or clinic visit), enter SLF000in the first six positions, and do not enter a name.

Claim For Which Physician Not Assigned a UPIN – Not all physicians areassigned UPINs. When the physician is an intern or resident, the numberassignment may not be complete. Also, numbers are not assigned to physicianswho limit their practice to the Public Health Service, Department of VeteransAffairs or Indian Health Services. Use the following UPINs to report thesephysicians:

For interns INT000For residents RES000For Public Health Service physicians, includes Indian Health Services PHS000For Department of Veterans Affairs physicians VAD000For retired physicians RET000For providers to report that the patient is self-referred SLF000For all other unspecified entities not included above OTH000

SLF will be accepted except where the Revenue Code or HCPCS code indicatesthat the service can be provided only as a result of a physician referral. TheSLF000 and OTH000 ID may be audited.

If referrals originate from physician-directed facilities (e.g., rural health clinics),enter the UPIN of the physician responsible for supervising the practitioner whoprovided the medical care to the patient.

If more than one referring physician is indicated, enter the UPIN of the physicianrequesting the service with the highest charge.

MTHP: Required. Enter the UPIN of the physician that requested the surgery, therapy,diagnostic tests or other services in the first six positions followed by two spaces,the physician’s last name, one space, first name, one space and middle initial.

OCTOBER 2001

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NH MEDICAID: Required. Inpatient -- Enter the 8 digit provider number assigned by NHMedicaid for the physician attending an inpatient. This is the physician primarilyresponsible for the care of the patient from the beginning of this hospitalization.If the Medicaid number is not available, enter the physicians name.

Required. Outpatient -- Enter the 8 digit provider number assigned by NHMedicaid for the physician referring the patient to the hospital. If the NHMedicaid number is not available, enter the physician’s name.

VT MEDICAID: Required. Enter the number assigned by VT Medicaid for the physicianrendering services.

OCTOBER 2001

2-158

FORM LOCATOR 83 A,B,C,D

DATA ELEMENT: Other Physician ID

DEFINITION: The name and/or number of the licensed physician other dm the attendingphysician as defined by the payer organization.

FIELD SIZE: 2 fieldsupperline: (optional - see NOTE): 25 positions, alphanumericlowerline: 32 positions, alphanumeric

NOTE: Recommended format: physician number entered first, then name.

The upper line can be used to capture other state physician ID numbers in casesinvolving Medicare claims crossed over to the Medicaid program since Medicarerequires UPINs and the Medicaid program may require state license numbers.


ANTHEM BCBS-NH: Required, if applicable. Enter the Anthem BCBS-NH provider ID of theoperating physician who has the primary responsibility for the principleprocedure. The physician name is not required.

BCBSVT: Required, if applicable. Enter the four or five character Blue Cross and BlueShield of Vermont provider number of operating physician(s) who hasresponsibility for the principle procedure. The group provider number is notacceptable.

TRICARE: Required. Enter the UPIN and the name of the physician who performed theprinciple procedure. The physician’s name should be listed last name, first nameand middle initial.

CIGNA NH: Required, if applicable. Enter UPIN.

MEDICARE: Inpatient Part A Hospital – Required if procedure is performed. Enter the UPINand name of the physician who performed the principal procedure. If noprincipal procedure is performed, enter the UPIN and name of the physician whoperformed the surgical procedure more closely related to the principal diagnosis.If no procedure is performed, leave this FL blank. See FL 82 (Inpatient) forspecifications.

Outpatient Hospital – Required when the HCPCS code reported is subject to theAmbulatory Surgical Center (ASC) payment limitation or when a reportedHCPCS code is on the list of codes the PRO furnished that require approval.Enter the UPIN and name of the operating physician using the format forInpatient reporting.

Other Bills – Not required

OCTOBER 2001

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Line A: Enter the UPIN and last name and first name of the physician primarilyresponsible for the care of the patient, while at the hospital.

Line B: Enter the UPIN and last name and first name of the physician whoperformed the principle procedure (if a surgical procedure is indicated inFL 80).

NH MEDICAID: Required, if applicable, for inpatient and outpatient.

Line A: Enter the NH Medicaid Provider Number and/or the full name of thephysician who performed the principle procedure (if a surgicalprocedure is indicated in FL 80).

Line B: Enter the NH Medicaid Provider Number, last name and first initial ofany other physician rendering care to the beneficiary, other than theprimary care and operating physicians.

VT MEDICAID: Required, if applicable. Enter the VT Medicaid provider number of the physicianwho the patient was referred to for further treatment if applicable.

OCTOBER 2001

2-160

FORM LOCATOR 84

DATA ELEMENT: Remarks

DEFINITION: Notations relating specific state and local needs providing additional informationnecessary to adjudicate the claim or otherwise fulfill state reporting requirements.


RECOMMENDED FORMAT OF STANDARD ENTRIES INTO REMARKS

GENERAL: Print the following fields in each category across the single line with a single spaceseparating each field.

1. To report the address of an insured when it is not the same as that of the patient.

a. Code “ADDR-X” where X is either A, B, or C based upon the insurance reference.b. Street Address (24 characters)c. City and State (18 characters)d. Zip Code (5 characters)

2. To report overflow information (e.g., condition code, value code, occurrence code and occurrencevan code).

a. Code “FL_____” to indicate form locator number.b. Provide appropriate code number.c. Provide appropriate date(s) or value(s).d. Separate multiple entries with a semicolon “;.”e. FORMAT:

- Occurrence Span Code: FL 36: 72, 040295/050395- Value Code: FL 39: 09, 76.00; 11, 89.00


ANTHEM BCBS-NH: Required, if applicable. DRG/Per Diem billing – enter the applicable 3-digit(numeric) DRG or Per Diem code as specified in the contract between AnthemBCBS and the hospital.


TRICARE: Required, if applicable.


MEDICARE: Required, if applicable. Enter any remarks needed to provide information that isnot shown elsewhere on the bill but which is necessary for proper payment.

MTHP: Not required.

NH MEDICAID: Same as Medicare.


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FORM LOCATOR 85

DATA ELEMENT: Provider Representative Signature

DEFINITION: An authorized signature indicating that the information entered on the face ofthis bill is in conformance with the certifications on the back of this bill.

FIELD SIZE: 1 field, 22 positions, alphanumeric

NOTE: Use of a facsimile signature must be approved by the individual payerorganization.


ANTHEM BCBS-NH: Desirable; facsimile signature acceptable.


TRICARE: Required.


MEDICARE: Required. The provider representative signature or facsimile is required forpsychiatric hospitals.

When a certification or recertification is required, the provider representativeshould make sure that the physician’s certification and recertification are in thehospital records. No signature is required for a general hospital stay unless aphysician’s certification or recertification was required during the course of thestay. A stamped signature is acceptable.

MTHP: Required.



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FORM LOCATOR 86

DATA ELEMENT: Date Bill Submitted

DEFINITION: The date on which the bill is submitted to the payer, as defined by the payerorganization procedures given below.


NOTE: Enter month, day and year (MMDDCCYY).



BCBSVT: Required.

TRICARE: Required.


MEDICARE: Required.

MTHP: Required. Enter the date on which the bill was signed, or sent to the payer forpayment.

NH MEDICAID: Same as MTHP


OCTOBER 2001

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TABLE OF CONTENTS

SECTION PAGE

ANTHEM BCBS-NH Claim Samples ...............................................................................................3.2BCBSVT Claim Samples ...................................................................................................................3.4TRICARE Claim Samples..................................................................................................................3.7CHP Claim Samples...........................................................................................................................3.9CIGNA NH Claim Samples .............................................................................................................3.11Medicare Claim Samples .................................................................................................................3.16MTHP Claim Samples .....................................................................................................................3.30NH Medicaid Claim Samples...........................................................................................................3.34VT Medicaid Claim Sample.............................................................................................................3.42

TABLE OF CONTENTS - HFMA NH VT - HomeOCTOBER 2001 1-4 If an EGHP pays benefits as a primary payer,...

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