UB04 Billing Instructions Guide - Maine
Oct 28, 2015 · ICD-10-CM diagnosis. other than alcohol or drug disorders, developmental disabilities, dementias, or mental disorders due to general medical conditions, except those with predominantly psychiatric features, or social conditions. Please complete: Primary . ICD-10-CM code: _____ Yes No 2. The applicant is currently enrolled in SSI or SSDI ................
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