UB-04 SNF Billing Examples

TrailBlazer Health Enterprises UB-04 Skilled Nursing Facility

Billing Examples

Published March 2012

? 2012 TrailBlazer Health Enterprises ? /TrailBlazer ? . All rights reserved.

Skilled Services ? Admit to Discharge

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

040110

041710

4 TYPE OF BILL

0211

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

040110

32 OCCURRENCE

XX

33 OCCURRENCE

XX

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a 50

XXXXXX 50

XXXXXX

70

031510

032510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

16 00

CODE

AMOUNT

CODE

AMOUNT

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430

RHB01 RVA07

14

1

2

2

16

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? First Interim Claim

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

060110

063010

4 TYPE OF BILL

0212

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

30

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a 50

XXXXXX 50

XXXXXX

70

061510

062510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

30 00

CODE

82

AMOUNT

10 00

CODE

09

AMOUNT

1375 00

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430

RHB01 RVA07

14

1

16

2

30

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? Second Interim Claim

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

070110

073110

4 TYPE OF BILL

0213

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

30

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a 50

XXXXXX 50

XXXXXX

70

051510

052510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

31 00

CODE

82

AMOUNT

31 00

CODE

09

AMOUNT

4262 50

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430

RVA02 RVA03

30

1

1

2

31

$$$ $$

3

6

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? Third Interim Claim

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

080110

083110

4 TYPE OF BILL

0213

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

30

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a 50

XXXXXX 50

XXXXXX

70

051510

052510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

31 00

CODE

82

AMOUNT

31 00

CODE

09

AMOUNT

4262 50

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430

RVA03 RVA04

30

1

1

2

31

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? Fourth Interim Claim - Benefits Exhaust During the Month

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

090110

093010

4 TYPE OF BILL

0213

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

30

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a A3

090810 50

XXXXXX

70

051510

052510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b 81 c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

CODE

8 00

82

22 00

AMOUNT

8 00

CODE

09

AMOUNT

1100 00

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430

RVA04

30

1

30

$$$ $$

2

X

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

1

20

2

21

3

22

4 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

All charges for services rendered after the A3 date

b

LAST

FIRST

should be billed as non-covered.

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? Discharge Claim

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

100110

100510

4 TYPE OF BILL

0214

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

XX

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a 50

XXXXXX

70

051510

052510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

4 00

CODE

AMOUNT

CODE

AMOUNT

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430

RVA04

4

1

4

$$$ $$

2

X

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

Skilled Services ? Benefits Fully Exhausted

1

Provider Name

Street Address City, State, ZIP Code Telephone; Fax; Country Code

2

Pay-to Name

Street Address or Post Office Box City, State, ZIP Code

3a PAT.

CNTL # Required

b. MED.

REC. # Recommended

5 FED. TAX NO. SubID

6 STATEMENT COVERS PERIOD

7

FROM

THROUGH

XX-XXXXXXXX

100110

103110

4 TYPE OF BILL

0213

8 PATIENT NAME

a

9 PATIENT ADDRESS

a Street Address or Post Office Box

b Patient Last, First, Middle Initial

b City

10 BIRTHDATE

ADMISSION

11 SEX

16 DHR 17 STAT

12 DATE

13 HR

14 TYPE 15 SRC

18

CONDITION CODES

c State d ZIP Code

29 ACDT 30

19

20

21

22

23

24

25

26

27

28

STATE

e Country Code

MMDDCCYY X

31 OCCURRENCE

060110

32 OCCURRENCE

XX

33 OCCURRENCE

30

34 OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

37

CODE

DATE

CODE DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE FROM

THROUGH

a

70

051510

052510

a

b

b

38

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

42 REV. CD.

43 DESCRIPTION

CODE

a 80 b c d

44 HCPCS / RATE / HIPPS CODE

AMOUNT

31 00

CODE

82

AMOUNT

11 00

CODE

09

AMOUNT

1512 50

45 SERV. DATE

46 SERV. UNITS 47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430

AAA00

31

1

31

$$$ $$

2

X

$$$ $$

3

X

$$$ $$

4

X

$$$ $$

5

X

$$$ $$

6

X

$$$ $$

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21

22

22

23 0001

PAGE X OF X

CREATION DATE

MMDDYY TOTALS

$$$ $$

23

50 PAYER NAME

51 HEALTH PLAN ID

52 REL INFO

53 ASG BEN

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56 NPI

XXXXXXXXXX

A Medicare

X

57

A

B

OTHER

B

C

PRV ID

C

58 INSURED'S NAME

59 P.REL 60 INSURED'S UNIQUE ID

61 GROUP NAME

62 INSURANCE GROUP NO.

A Beneficiary Last, First Name

XX

XXX-XX-XXXXX

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

A

B

C

66 DX

XXXXX

X

A

9

I

J

A

B

C

B

C

D

E

F

G

H

68

K

L

M

N

O

P

Q

69 ADMIT

XXXXX

70 PATIENT

a

b

DX

REASON DX

c

71 PPS

CODE

72

a

ECI

73

b

c

74

PRINCIPAL PROCEDURE

a.

CODE

DATE

c.

OTHER PROCEDURE

d.

CODE

DATE

80 REMARKS

OTHER PROCEDURE

b.

CODE

DATE

OTHER PROCEDURE

e.

CODE

DATE

81 CC a

OTHER PROCEDURE

75

CODE

DATE

OTHER PROCEDURE

CODE

DATE

76 ATTENDING

NPI XXXXXXXXXX

LAST Last Name

77 OPERATING

NPI

FIRST

LAST

FIRST

78 OTHER

NPI

QUAL

First Name

QUAL

QUAL

Add any additional information here.

b

LAST

FIRST

c

79 OTHER

NPI

QUAL

d

LAST

FIRST

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