Codes for procedures should not be reported on the IRF-PAI. Billing FTIN Federal tax identification number of the organization … UB-04 Claim Entry – Page 6 ... DCN Document Control Number DDE Direct Data Entry DME Durable Medical Equipment ... validity of diagnosis codes, revenue codes, and HCPCS codes, checking beneficiary/patient eligibility, check the status of claims, view Additional The patient's principal diagnosis should be recorded in form locator 67 of the UB-04 form. Other or secondary diagnoses, complications and comorbidities should be listed in form locators 67 A-Q. The admitting diagnosis (if different from the principal diagnosis) should be listed in form locator 69. Example of Selecting a Diagnosis Code Policy: With the implementation of the 5010 837I, providers can now report up to 25 ICD-9-CM Diagnosis and Procedure Codes. This includes: 1. www.cms.gov. PRINCIPAL DIAGNOSIS CODE AND PRESENT ON ADMISSION INDICATOR Enter the principal diagnosis code torthe patient's condition. Note: The ICD-9-CM "E" and "M" series diagnosis codes are not part of the current diagnosis file and should not be used when completing claims to be submitted to Medicaid. ... AS OF APRIL 1, 2014 WHAT IS THE MAXIMUM NUMBER OF DIAGNOSIS CODES CAM BE ON THE CMS-1500 CLAIM FORM BEFROE A FURTHER CLAIM IS REQUIRED? Certain obstetrical diagnostic services may have assigned maximum units per day limits based upon presence or absence of diagnosis codes indicative of multiple gestation. 67. ICD-10-CM codes have a maximum of five characters. 29. For more information on POAs, refer to the National Uniform Billing Committee's Official UB-04 Data Specifications Manual. Able to code and bill for dietetic/ nutrition services to obtain reimbursement from public or private insurers: 1. 5. We only accept those codes published in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 codes). OTHER DIAGNOSIS CODES Enter additional diagnosis codes if more than one diagnosis code applies to claim. 3. The antigen codes (95144-95170) are considered single dose codes. 5. Accident State Leave blank. Change “diagnosis” to “diagnostic” in reference to EPSDT: 6.0: Change “diagnosis” to “diagnostic” in reference to EPSDT: 6.11: ... W & I Code, Division 5, Part 2, Chapter 1, § 5600.3 . Enter the address, without a comma between the city and state, and a nine‐digit ZIP code, without a hyphen. Describe the differences between medical billing and medical coding 5. Consequently, what is the maximum number of characters in an ICD 10 CM code? For CMC ordering and enrollment information, refer to the . City, State, Zip Code (Area Code) Telephone Number 2 (Required when the address for payment is different than that of the Billing Provider information located in Form Locator 1) ... 42 Revenue Code (Refer to UB04 Manual) 43 Revenue Description (Refer to UB04 Manual) 44 HCPCS/Rates. 67 a - q Other Diagnosis Codes / Present on Admission Indicator (POA) Conditional This field is for reporting all diagnosis codes in … • Enter all required data. 21 Required Diagnosis or Nature of Illness or Injury: Enter up to 12 diagnosis codes in fields A - L. Codes may not be required for HCBS waiver or non-emergency transportation claims. The UB-04 is used by Rehab Centers. The UB-04, also known as the Form CMS-1450, is the uniform institutional provider hardcopy claim form suitable for use in billing multiple third party payers. The ICD-9-CM Official Guidelines for Coding and Reporting are used to assign codes reported on the UB-04. www.cms.gov. Diagnosis Code-3 . Part 2 – UB-04 Special Billing Instructions for Inpatient Services UB-04 Special Billing Instructions for Inpatient Services Page updated: August 2020 This section contains information about billing for day of discharge, private accommodations, emergency room charges and other special billing situations. Type of Bill. Another example appears at the end of this presentation. 30. ICD 10 codes are required for services starting 10/01/2015. ICD10 codes are required for all dates of service 10/01/2015 or later. Submitting the claim form with all required fields will assist us in paying your claim in a timely manner. TCNs from other TAR forms (18-1 or 20-1) are used only by hospitals 1500 Item Number ; Correlates to the field numbers on the CMS-1500 paper claim form. In a variety of settings ‐physician’s office, private practice, a consultant to long‐term care and/ or ... o Is there a maximum number of visits allowed? It may be duplicated if the copy is legible. The UB-04 is used by Physicians offices. Providers must use a standard CMS 1500 claim form or UB-04 claim form for submission of claims to Meridian Providers must use industry standard procedure and diagnosis codes such as CPT, Revenue, HCPCS, and ICD-10 when billing Meridian Claims billed using ICD-9 codes will not be accepted for services delivered on or after 10/1/2015, and Which is the maximum number of digits in a valid ICD 10 CM code? UB-04 Billing Instructions for Hemodialysis Claims 9 Locator # Description Instructions Alerts 67 67 A-Q Principal Diagnosis Codes Other Diagnosis code Required. Electronic UB- 04 claims must be submitted in a format that is HIPAA compliant with the ANSI X 12 UB-04 claim standards. Control Number (ICN). The UB-04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. The scanned documents are then identified and sorted by form type and indexed by identifiers such as client name, prime identification number, the date of service, and provider number. The Provider must enter ICD-10 codes clearly on the claim form and include all digits and characters. A copy of a UB-04 form follows. Required Information Description. maximum number of the UB-04 codes (value codes, condition codes, occurrence ... January 2016 … diagnosis codes and ICD-10 PCS codes on a claim to ensure payment at the appropriate level. Figure 17-5 (p. 605). Diagnosis Coding Most claims for outpatient services can also be submitted through Computer Media Claims (CMC). In these fields, use HIPAA-compliant codes that are current for the date(s) of service on the claim. In order for a code to be valid, it must reflect the highest level of specificity (i.e., contain the highest number of characters) required by the code set. Non-DRG Hospitals Non-DRG reimbursed hospitals are hospitals that are not paid according to the DRG reimbursement methodology. • CPT code 99211 when billed with modifier 25 on a CMS 1500 claim form. All Diagnosis Codes are to their highest number of digits available Principle Diagnosis billed reflects an allowed Principle Diagnosis as defined in the current volume of ICD-9 CM, or ICD-10 CM for the date of service billed. There are 81 fields or lines on a UB-04. They're referred to as form locators or "FL." Each form locator has a unique purpose: Form locator 1: Billing provider name, street address, city, state, zip, telephone, fax, and country code Form locator 2: Billing provider's pay-to name, address, city, state, zip, and ID if it's different from field 1 Provider Handbook UB-04 July 12, 2018 . Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. claim form with the appropriate facility type code (which is the first two digits in the . Required for all unscheduled outpatient visits with a type of bill 013X or 085X with a type of admission 1, 2, or 5 and revenue codes of DATE(S) OF SERVICE* Field 57: Include the appropriate taxonomy code for all lines of business. Enter all letters and/or numbers of the ICD-9 CM code for the primary diagnosis including the fourth and fifth digit if … This . The provider will use an occurrence span code 74 (Leave of Absence) on the …. maximum number of the UB-04 codes (value codes, condition codes, occurrence. Situational. UB-04 HEALTH INSURANCE CLAIM FORM ... Name and/or number of licensed attending physician who carries primary responsibility for this patient. When billing multiple diagnosis codes, the recoding is based on the highest level of service associated to one or more of the diagnosis codes billed. Inaccurate coding may cause inappropriate reimbursement, erroneous reductions in … NR 511 Final Exam Study Guide (Question and Answers) NR 511 WEEK 1 1. O Imp Guide: Required if Diagnosis Code Qualifier (492-WE) and Diagnosis Code ... 5Ø3-F3 AUTHORIZATION NUMBER R 547-5F APPROVED MESSAGE CODE COUNT Maximum count of 5. 42 Revenue Code Maximum allowed lines per claim is 92. 4. . please enter the prior TRICARE claim number. Type of Bill Code. If you have any questions regarding this release, you can contact our Careficient support team at 772-212-2776, send us an email at Support@Careficient.com or you can send us a support request through the Careficient AMS system Help link. Enter codes used to identify conditions relating to the bill that may affect payer processing. Define diagnostic reasoning 2. • HCFA 1500claims, the health partner must include the original CareSource claim number and a frequency code of “7” per industry standards. Situational. Fields 67: principal diagnosis code Field 67a through 6yq: other diagnosis codes: Facility Medicare ICD-9 Code Rule: ICD-9 code types can’t be billed for dates of service greater than September 30, 2015. This is a single digit field used to “point” to the most appropriate ICD -9 codes by linking the correspond ing diagnosis reference number (1, 2, 3, and/or 4) from the diagnosis indicated in item number 21. 68 If Applicable If Applicable Other Diagnosis Codes - Enter all letters and/or numbers of the secondary ICD-9 CM code including fourth and fifth digits if present. WHAT IS A UB-04 FORM? You may also report your current provider identification numbers in addition to your NPI(s). Units billed in excess of the maximum per day limits will be denied. National Provider Identifiers (NPIs) are required on all claims (Blue Cross-assigned provider numbers are no longer used). Conditionally Required 72A-C. Which is the maximum number of digits in a valid ICD 10 CM code? Kaiser Permanente also requires that all CMS-1450 claims submitted are reported using the specific code sets as adopted by HIPAA. column 47. 530.81 is gastroesophageal reflux disease (GERD). UB-04 claim form for certain allied providers) including appropriate Physicians’ Current Procedural Terminology (CPT®) codes and ICD-10-CM diagnosis codes. Click to see full answer. diagnosis codes and ICD-10 PCS codes on a claim to ensure payment at the appropriate level. Team surgery and co-surgery maximums are handled separately and are edited based on the same provider, Discuss and identify subjective & objective data 3. Diag A1. If ICD10 Diagnosis Codes are submitted, any procedure codes submitted must be ICD10 Procedure Codes X: 2 H25652: If ICD9 Diagnosis Codes are submitted, any procedure codes submitted must be ICD9 Procedure Codes X: 2 H25653: If ICD10 and ICD9 Diagnosis Codes cannot be sent on the same claim please split the claim before resubmitting X: 2 H25655 External Cause of Injury (ECI) Code – The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or Other diagnosis codes and Present On Admission (POA) indicator. This indicator affects DRG reimbursement and is … All codes allow a high level of detail for a condition. The diagnosis pointers are located in box 24E on the paper claim form for each CPT code … Enter the ICD-10 codes and CPT codes on the appointment. The limits for an 837 transaction are set by the Accredited Standards Committee (ASC) of the American National Standards Institute (ANSI), and are specific to claim type. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available. Fields 67: principal diagnosis code Field 67a through 6yq: other diagnosis codes: Facility Medicare ICD-9 Code Rule: ICD-9 code types can’t be billed for dates of service greater than September 30, 2015. Patient Information, Billing Information, Physician Information, Diagnosis Information. • Professional evaluation and management (E/M) codes when billed by a facility on a UB04 claim form except for professional services provided in the emergency room. 67A–Q Other Dx Codes Enter the complete ICD-9-CM diagnosis codes for up to 17 additional conditions. Authority. Use the most specific diagnosis code from the ICD-9-CM Code Book. Required Block. Most ICD-9 codes are three digits to the left of a decimal point and one or two digits to the right of one. The most specific diagnosis codes must be used. ... (frequency code) UB-04 box 4 . That means all claims with dates of service on or before September 30 must contain only ICD-9 codes, whereas all claims with dates of service on or after October 1 must contain only ICD-10. State Exceptions California California Medicaid allows the following ICD-10 diagnosis code Z64.0 to be billed in the primary position Kansas Kansas Medicaid uses a customized, state identified Inappropriate Primary ICD-10 Diagnosis Codes list. Type of bill code (UB-04, field 4) is required and shall include a “7” in the third position if the claim is a corrected claim. We believe that the number of fields for procedure codes should be increased as well. Specifically, diagnosis codes are found in box 21 A-L on the claim form and should be entered using ICD-10-CM codes. the claim: DIAGNOSIS CODING We require Providers to enter the appropriate diagnosis code on each claim submitted. Per CMS guidelines, ICD-10 codes can’t be billed for dates of service prior to October 1, 2015. The transition to ICD-10 will go by date of service. First Digit—Type of Facility: • 1 Hospital • •2 Skilled nursing • 3 Home health agency Field 4 – Enter the Type of Bill Code. Enter the ICD-10 codes and CPT codes on the appointment. The Diagnosis Codes entered in Box 21 are now referenced as by alpha (A – L) pointers rather ... • UB04 – Form Locator 03a Patient Control Number ... • For claims filed in an 837 ASC X12 format the MAXIMUM NUMBER OF CHARACTERS to be UB-04 Form. This is the primary condition you are testing. FIELD NUMBER AND NAME INSTRUCTIONS FOR COMPLETION. Diagnosis indicator is missing POA indicator is not valid ... 22 on the CMS-1500 and field 4 on the UB-04), the original claim number is required (field 22 on CMS-1500 and field 64 on UB-04) CMS-1500 box 22 UB-04 box 4 and 64 . Primary diagnosis code and all additional diagnosis codes (up to 24 for institutional) with the proper ICD indicator (only ICD 10 codes are applicable for claims with dates of service on and after October 1, 2015). o For a CMS 1500 Claim Form, this criteria looks at all procedure codes billed and the diagnosis they are pointing to. A telephone number is optional in this field. The principal diagnosis code will include the use of “V” codes where ICD-9-CM is applicable. Enter the NPI number of the referring physician or provider. Tips for Completing the UB04 (CMS-1450) Claim Form FAILURE TO PROVIDE VALID INFORMATION MATCHING THE INSURED’S ID CARD COULD RESULT IN A REJECTION OF YOUR CLAIM. Tips for Completing the UB04 (CMS-1450) Claim Form Page 1 of 17 Field Field description Field type Instructions (note that before this change, the 4010 supported up to eight (8) unique diagnosis codes per claim, and the older CMS-1500 supported four (4). With the 10/1/2015 implementation of ICD-10, it may be appropriate to report either ICD-9 or ICD-10 codes depending upon the dates of service. This change was never intended to increase the number of diagnosis codes per line item. ... been added to the UB04 such as NPI, additional diagnosis code fields, and a specified DRG field. CMS 1500 Block 1a. Instructions for Completing the UB-04 Claim Form ... address and zip code and telephone number this section. Enter the ICD-9-CM code for the principal diagnosis. 023697 (02-2012) UB-04 Billing Chapter 12 Page 1 12 UB-04 Billing . CMS 1500 Block 2. 2. 02/01/2008 2.5 1500 Item Number ANSI 837 Loop and Segment Paper Claim Field Name Electronic Claim Field / Element Name 2300 HI04 . Question 1 1 out of 1 points The UB 04 contains which four information sections? Updated:12/24/2018 UB-04 Claim Form Instructions pv05/30/2017 7 Instructions for completing the UB-04 form Fields Marked With an Asterisk: In the Field column of the table below, some field numbers are preceded with an asterisk (*). If the . Enter the ICD-9-CM code describing the principal (primary) diagnosis. Any codes exceeding those limits would split the 837 into two (2) claims and paper claims into three (3). Claims with an ICD-9 diagnosis code will be denied. Consequently, what is the maximum number of characters in an ICD 10 CM code? Hover your cursor on Billing > Live claims Feed. Claim Diagnosis B2-L12. Hover your cursor on Billing > Live claims Feed. codes occurrence span codes, etc) that may be reported for the UB-92 and not …. Diagnosis Code X Enter the ICD-9-CM code that corresponds to the primary diagnosis or the item number (1-4) from field 21. Expansion of Size of Diagnosis and Procedure Code Fields (FL#66, 66A-Q, 68-69, 73, 73a-e) We fully support the expansion of the size of the diagnosis and procedure code fields in … > Step 1: To link a Diagnosis code to a CPT on the Billing detail screen: 1. 19. Form Locator Number Form Locator Name Form Locator Code Notes 8 (a, b) Patient Name a) Patient ID b) Patient Name LB M Do not complete this portion of the Form Locator. ICD-9 codes and ICD-10 codes can never appear together on the same claim. 67 a–q Other Diagnosis Codes/Present on Situational This field is for reporting all diagnosis codes in addition to the principal diagnosis that coexist, develop after admission, or impact the treatment Discuss and identify the components of the HPI 4. Refer to the Inappropriate Primary Diagnosis Code List for all codes applicable to this policy. ICD-10-CM codes have a maximum of five characters. 6. Because these claims are submitted with a diagnosis code, an ICD indicator is required in the white space below the DX field (Box 66). For help understanding the DRG model, refer to the Diagnosis-Related Groups (DRG): Inpatient Services section (diagnosis ip) of the Part 2 Inpatient Services manual. 4. Section 2 UB-04 Claim Filing Instructions November 2012 2.5 . UB04 Type of Bill Codes List- TOB Codes (2021) TOB or Type of Bill Codes is 4 digit alphanumeric code that identifies the kind of bill submitted to a payer from the billing company. Enter the diagnosis/condition of the patient indicated by the ICD-9 code. 9= ICD 9 0= ICD 10: Missing Diagnosis orProcedure Code Qualifier: 2300: HI01=ICD qualifier: Principal Diagnosis Codes 67: Required: Required: Pass/Reject: Required forTypesofBill: 11X, 12X, 13X, 14X, 21X where X is any number, reject if invalid Missing Diagnosis Codes Invalid Diagnosis Codes: 2300: HI01-1= ABK or BK HI01-2= Principal Diagnosis Code Designation: NM (Non-Monetary). Selected Answer: A. When filing claims using the UB-04, please remember to populate the diagnosis code in the correct field. The total number of diagnoses that can be listed on a single claim are twelve (12). This change was never intended to increase the number of diagnosis codes per line item. National Uniform Billing Committee's UB-04 Data Specifications Manual is available here. Notes. 70A-C C Patient Reason Code for Visit Enter the appropriate ICD-9 or ICD-10 reason code, if applicable. The Medicare system does not process decimal points in diagnosis codes or International Classification of Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers. • Number of diagnosis codes on a claim: For electronic submissions, it is a requirement that diagnoses are reported with a maximum of 12 diagnosis codes per claim under the 5010 format and paper CMS 1500 submissions contain a maximum of 12 diagnosis codes per claim. materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any ... 1.The table below provides a reasonable maximum number of studies per diagnostic category necessary for a physician to arrive at a diagnosis in 90% of patients with that final diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. In this instance, the claim should contain condition code 41. CMC. The UB-04 paper claim form should be legibly printed by hand or electronically. UB-04. If a procedure points to the diagnosis as primary, and that 21. Enter the TCN only from a 50-1 TAR form. Click to see full answer It's printed with red ink on white standard paper. BMC HealthNet Plan can accept 25 total diagnosis codes for 837I (UB-04) claims and 12 total diagnosis codes for 837P (CMS-1500) claims. Added patient class 56 to the Patient Class Code table and ….. Where on the UB-. If services are provided in the hospital, give hospitalization dates related to the current services. When submitting the UB-04, use Field 74A-E (Principal Procedure Code and Date). Effective October 1, 2015 State of California Medi-Cal will require an ICD-10 Indicator in the Diagnosis Code field (box 66) on claims submitted with Dates of Service on or after 10/01/15. Figure 3 14: FL18-28 Condition Codes. The level of detail for ICD diagnosis codes is expressed as the level of specificity. Enter all letters and/or numbers of the ICD-9 CM code for the primary diagnosis including the fourth and fifth digit if present. 67. Code Specificity for Diagnosis. 69 RI Admitting Diagnosis Code Enter the appropriate ICD-10 admitting diagnosis code, if applicable. AHCCCS does not accept DSM-4 diagnosis codes, and behavioral health services billed with DSM-4 diagnosis codes will be denied. Some ICD-9 codes have "V" or "E" in front of them. 42 Revenue Code Enter a four digit Revenue Code beside each service described in column 43. enter 0 for iCd-10 or 9 for iCd-9 based on date of service/discharge date. Injection, Epoetin alfa, 100 units (for ESRD on Dialysis) The maximum number of administrations of EPO for a billing cycle is 13 times in 30 days and 14 times in 31 days. CODING Correct coding is key to submitting valid claims. A claim was submitted with either no code or an invalid code as the Primary/Principal Diagnosis Code or with an invalid code as one of the Other Diagnosis Codes. Please use the National UB-04 manual for specific codes. Select the Save/Close button to save the authorization. 71 Benefit maximum for time period/occurrence reached ... 87 Diagnosis code not effective on date of service ... (UB-04 claims) 154 The patient status code is missing The patient status code submitted on the claim is missing (UB-04 claims) 16 The service performed is not a covered benefit. Diagnosis and Procedure Code (ICD-9 Procedure) and date of principal procedure for inpatient services, if applicable Note: Do not report ICD-10-CM and ICD-PCS codes for claims with dates of service prior to implementation of ICD-10-CM/ICD-10-PCS, on either the old or revised version of the UB-04… Enter the ICD-9-CM code or codes for all other applicable diagnoses for this claim. The initial claim submitted should be billed with a Type of Bill Frequency Code of 1 or 2 and any UB-04 Claim Form Instructions Page 2 of 17 • UB 04 claims, the health partner must include the original CareSource claim number in Box 64 and a valid type of bill frequency code in Box 4 per industry standards. what is the maximum number of procedure codes that can appear on a ub-04 paper claim form for a hospital inpatient: six: which answer below is not correct for assignment of the ms-drg : attending and consulting physicians: what is the maximum number of diagnosis codes that can appear on the ub-04 paper form locator 67 for a hospital inpatient principle and secondary diagnoses? UB-04 (CMS 1450) billing guidelines. UB-04 Type of Bill Codes List reported in field locator 4 on line 1. FL51 Health Plan ID FL51 Health Plan ID FL51 Health … R. 25/75.1 /Form …. Diagnosis codes, revenue codes, CPT, HCPCS, modifiers, or HIPPS codes that are current and active for the date of service. Part 2 – UB-04 Special Billing Instructions for Outpatient Services Page updated: August 2020 • Enter the 11-digit TAR Control Number (TCN) from the approved TAR in the Treatment Authorization Codes field (Box 63) on the UB-04 claim. manual contains the updated specifications for the data elements and codes included on the CMS-1450 and used in the 837I transaction standard. S 548-6F APPROVED MESSAGE CODE S 13Ø-UF ADDITIONAL MESSAGE INFORMATION COUNT Maximum count of 25. ! ICD-10 codes are required. ICD codes is being reported. Facility phone number Member name and/or identification number ... (English or ICD-9 code) If available, admitting procedure code (English or ICD-9/CPT code) Premera Reference Manual . ICD-10-CM diagnosis codes are required for treatment services provided in a single visit. 24a. The maximum number of administrations of Aranesp for a billing cycle is 5 times in 30/ 31days. General codes are not acceptable. 3. Provider’s federal tax ID number (UB-04, field 5) 6. 3. Diagnosis Code-1 . Hospital-based inpatient services should be billed on the UB-04 showing revenue center charges, ICD diagnostic and procedure codes and the hospital's Medicare number. 87 . This is the example of the UB-04 form discussed here. Codes are not assigned for conditions that develop or are first identified the day prior to or the day of discharge. Present on Admission (POA) codes POA codes are associated with diagnosis codes and indicate whether the diagnosis was observed when the patient entered the hospital, or if it developed at a later time. 81. Enter the name of the hospital. 77 . 491-VE DIAGNOSIS CODE COUNT Maximum count of 5. For paper claims, use Field 80 (Principal Procedure Code and Date) and enter any additional ICD-10-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). Institutional inpatient claims (UB-04 claim form or electronic equivalent) must include an admission type code of 1, … About this billing Manual. UB-04. This may be a condition representing patient distress, an injury, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor. See NUBC manual for specific codes. 67 Principal Diagnosis Code Required Enter the valid ICD-10 diagnosis to the highest level of specificity for services rendered. modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. field [Box 4]) for the outpatient facility. FL43 Revenue Code Description/IDE Number/Medicaid Drug rebate FL44 HCPCS/Accommodation Rates/HIPPS Rate Codes FL45 Service Dates FL46 Service Units FL47 Total Charges FL48 Non-Covered Charges FL49 Unlabeled FL50 Payer Identification - Primary FL50 Payer Identification - Secondary FL50 Payer Identification - Tertiary . 3. o For a CMS 1500 claim form, this criteria looks at all procedure codes billed and the diagnosis they are pointing to. ADMIT DX Any codes exceeding those limits would split the 837 into two (2) claims and paper claims into three (3). 67 & 67a–q Prin diag cd (principle diagnosis code) m enter the primary diagnosis code. Claims with information in the 2320 (Other Subscriber Information) and 2330A Fields 67: principal diagnosis code Patient control number (UB-04, field 3) 4. The 5010 and CMS-1500 forms were modified to support up to 12 diagnosis codes per claim (while maintaining the limit to four diagnosis code pointers) in an effort to reduce paper and electronic claims from splitting. (note that before this change, the 4010 supported up to eight (8) unique diagnosis codes per claim, and the older CMS-1500 supported four (4). Admit Code Admittance Diagnosis Code indicating patient’s diagnosis at time of admittance, as stated by physician. Paper claim forms have an ICD Indicator that identifies the ICD code set being reported on the claim. Section 5 UB-04 Claim Filing Instructions - Outpatient November 2012 5.1 SECTION 5 UB-04 CLAIM FILING INSTRUCTIONS OUTPATIENT HOSPITAL . For claims with Type of Bill 011x, 018x, 021x, or 032x, the last date of service is used for th e ICD 9/10 Any institutional provider can use the UB-04 for billing medical claims.