ub-04 review - team tsi university billing series - part 4 ub-04 review for clients of: •...

COMPREHENSIVE BILLING SERIES - PART 4

UB-04 REVIEW

for clients of:

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COMPREHENSIVE BILLING SERIES-PART 4

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POST-TEST

1. What is the Revenue Code that must be included on a Part A claim on the line that includes the RUG?

a) 0022 b) 0057 c) 0011 d) 0000

2. What are the 2 digits following the RUG called? a) RUG digits b) Assessment Indicators c) ARD

3. The Type of Bill code for a Part A claim submitted same month admit and

discharge claim is 211? a) True b) False

4. It is Best Practice to add KX modifiers to all lines of a Part B claim to ensure exception to the therapy cap?

a) True b) False

5. The Type of Bill code for a Part A claim submitted for a first claim in a series is

which of the following?

a) 214b) 213c) 212d) 211



POST TEST ANSWERS

1. What is the Revenue Code that must be included on a Part A claim on the line that includes the RUG?

a) 0022 b) 0057 c) 0011 d) 0000

2. What are the 2 digits following the RUG called? a) RUG digits b) Assessment Indicators c) ARD

3. The Type of Bill code for a Part A claim submitted same month admit and

discharge claim is 211? a) True b) False

4. It is Best Practice to add KX modifiers to all lines of a Part B claim to ensure exception to the therapy cap?

a) True b) False

5. The Type of Bill code for a Part A claim submitted for a first claim in a series is

which of the following?

a) 214b) 213c) 212d) 211


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1

COMPREHENSIVE BILLING SERIES


UB-04 Overview

• Completion of a clean claim

– Field-by-field review of claim form

• Correct use of occurrence, condition, span and status codes that create the UB-04 claim

• Revenue codes

• Assessment Indicators

2



Billing Frequency

• A skilled nursing facility may bill:

– Monthly

– Upon patient discharge

• Inpatient claims within the same admission must be submitted in order of which the service occurred.

• The MAC is required to process or deny a “clean” claim within 30 days from receipt.

3


Billing Frequency - Continued

• “Clean” claim defined:

– Passes all edits

– Processed without need of contacting the provider, beneficiary, or social security administration.

• Payment floor standard (waiting period) for:

– Electronic, HIPAA compliant claims is 13 days

4



Billing Frequency - Continued

• Repetitive services must be billed on a monthly basis and not on visit-by-visit basis on a single claim for:

– Physical Therapy (PT)

– Occupational Therapy (OT)

– Speech-Language Pathology (SLP)

• Internet-Only Manual (IOM), Publication 100-04, Chapter 1, Section 50.2.2

5


Overview of Accurate Part A UB-04 Form

• The UB-04, also known as the Form CMS-1450, is the uniform institutional provider hardcopy claim form.

• Requires specific codes for each form locator (FL) on the UB-04 form.

• Multiple pages of the UB-04 can be utilized for one patient’s monthly bill if necessary.

• The UB-04 is the only hardcopy claim form that the Centers for Medicare & Medicaid Services (CMS) accepts from institutional providers.

• UB-04 can also be used to bill other payers (i.e. Medicaid).6



UB-04 Codes

• We will use the following attachments to review the Form Locators, Codes and elements of the UB-04 form as they pertain to Medicare Part A and Part B claims:

• Blank UB-04 Form

• UB-04 Codes Sheet

• Completed UB-04 (use the 211 bill type as example)

7


UB-04 Form Locators

• The 837 Institutional electronic version of the UB-04 form is used by providers who submit claims electronically.

• Each Form Locator has a specific requirement and code associated with it.

• Medicare Part A and Part B claims are billed on the UB-04 and some of the elements are the same.

8



Form Locator

9


UB-04 Revenue Codes FL 42

10



UB-04

11

Provider and Patient Information

Billing Information


UB-04

12

Payer Information

Diagnosis

Remarks – Additional Information



13

UB-04


SNF TOBs

• First digit

– All claim types start with a leading 0

– The 0 is usually not printed by financial software

– CMS ignores the 0

• Second digit indicates type of facility

• Third digit indicates bill classification

• Fourth digit indicates frequency code

14



Type of Bill

• The second digit identifies the type of facility.– 2 for SNF

• Third digit Bill Classification– 1 Inpatient Part A

– 2 Inpatient Part B (includes Part B plan of treatment)

– 3 Outpatient (includes Part B plan of treatment)

15


Type of Bill

• Fourth Digit - Frequencies– 0 - Non-payment/Zero Claim - use this code when it does

not anticipate payment from the payer for the bill, but is informing the payer about a period of non- payable confinement or termination of care. The “Through” date of this bill (FL 6) is the discharge date for this confinement, or termination of the plan of care.

– 1 - Admit Through Discharge - use this code for a bill encompassing an entire inpatient confinement or course of outpatient treatment for which it expects payment from the payer

16



Type of Bill

• Fourth Digit – Frequencies cont.– 2 - Interim - First Claim - Used for the first of an

expected series of bills.

– 3 - Interim - Continuing Claims - Use this code when a bill for which utilization is chargeable for the same confinement or course of treatment already submitted and further bills are expected to be submitted later.

– 4 - Interim - Last Claim - This code is used for a bill which is the last of a series for this confinement or course of treatment 17


Part A - Frequency

– 210 No Pay

– 211 Admit/Discharge

– 212 First claim in a series of claims

– 213 Continuation of series of claims

– 213 Discharged but resides in facility (use

OC 22, date dropped level of care)

– 214 Discharged final claim

18



Admission Date (FL12)

• Required on inpatient claims

• Date is consistent on series of claims

• MM/DD/YY format

19


Patient Status Codes (FL17)

• 01 Discharged to home

• 02 Discharged/transferred to short term general hospital for inpatient care

• 03 Discharge/transferred to SNF

• 04 Discharged to an intermediate care facility (Assisted Living, NF not Medicare-certified)

• 06 Discharged home with Home Health

• 30 Still a patient

• 20 Expired20



Common Condition Codes (FL18-28)

• 04 Medicare MAO (MAO is responsible for making payment on claim)

• 07 Hospice

• 20 Beneficiary disagrees with SNFs notification of noncoverage (demand bill)

• 21 Denial needed for other insurer

• 39 Private room medically necessary

• 56 Medicare appropriateness SNF (medical predictability)

• 57 SNF readmission

• 58 Termed HMO

21


Common Occurrence Codes(FL31-34)

• OC 22 Date skilled care ended

• OC A3 Date benefits were exhausted (typically used by MAC)

• OC 50 ARD Date (may be multiple)

• OC 55 Date of Death

• OC 11,17,29,30,35,44,45 (all used for Part B therapy)

22



Common Span Codes (FL35-37)

• 70 Qualifying hospital dates

• 74 Noncovered level of care or LOA

• 78 Prior SNF days

• 80 Prior Same-SNF Stay Dates for Payment Ban Purposes (effective 01-01-09)

23


Common Value Codes (FL39-42)

• VC 80 Covered days

• VC 81 Noncovered days

• VC 82 Co-insurance days

• VC 09 $ amount for co-insurance days

24



Revenue Codes

• 0022 revenue code required (FL42)– Billed with HIPPS code

– RUG code (+) two position modifier = HIPPS code, i.e., RUL01

Room & Board revenue code

– Example: 0120 semi-private two beds

• All other ancillaries provided during claim DOS – See attachment for appropriate revenue codes

25


HCPCS/Rates/HIPPS Rate (FL 43-44)

• Room & Board Rate– Per day charge associated with room/board revenue

code billed on UB-04 in FL 42 (i.e., 0120, 110)

• HIPPS code– RUGs code (+) the two position assessment indicator

– Billed in conjunction with revenue 0022 Example -RUX02

• Revenue code 0022 may appear on claim more than once

26



Assessment Indicator

• Sometime referred to as a HIPPS modifier.• For each type of PPS MDS or combination of PPS/OBRA

MDS, an Assessment Indicator is applied as the HIPPS modifier for the claim.

• The HIPPS AI modifier reflects the type of PPS and/or combo MDS performed for the payment period.

• The Assessment Indicator has two digits • For example: RUC10 or RVB21

27


Common Assessment Indicator Combinations

Type of MDS 1st Digit 2nd Digit

5-day PPS MDS 1 0

5-day PPS MDS with Admission OBRA 1 0

14-day PPS MDS 2 0

14-day PPS MDS with Admission OBRA 2 0

30-day PPS MDS 3 0

30-day PPS MDS with Discharge 3 1

5-day PPS MDS/Short Stay 1 7

28



Other Field Locators

• Payer (FL 50)

• Rel of Info (FL 52)

• Assign of Bene (FL 53)

• Insured Name (FL 58)

• Relation (FL 59)

• Insured ID (FL 60)

• Authorization (FL 63)

• Dx Codes (FL 67 A-Q)

• Admit Dx (FL 69)

• Attend Physician (FL 76)

• Remarks (FL 80)

29


30

UB-04



MEDICARE PART B CLAIMS

31


Part B Therapy Services

• SNF is responsible for billing all of the “therapy” that SNF patient receives when they are in a certified bed within the SNF even if patient is in a noncovered stay. SNF providers will bill for “therapy” services for patients in a certified bed in a noncovered stay on 22X TOB.

32



Part B Therapy Services

• Beneficiary in non-certified bed = therapy service is not subject to SNF CB maybe billed for by SNF on 23X TOB.

• Beneficiary in non-certified bed = therapy service may be billed for by an outside entity directly to Medicare.

33


Components of a Part B UB-04

Type of Bill (Field Locator 4) 0221 Part B in certified bed admit through discharge claim

0222 Part B in certified bed first claim in a series

0223 Part B in certified bed interim claim in a series

0224 Part B in certified bed final bill of a series

0231 Part B non-certified bed admit through discharge

0232 Part B non-certified bed first claim in a series

0233 Part B non-certified bed interim claim in a series

0234 Part B non-certified bed final bill of a series 34




The following revenue codes apply Part B UB-04’s:0420 Physical Therapy

0424 Physical Therapy Evaluation

0430 Occupational Therapy

0434 Occupational Therapy Evaluation

0440 Speech Therapy

0444 Speech Therapy Evaluation

Other ancillary revenue codes – see revenue code attachment

35



36

• Occurrence Codes (Field Locator 31-34) – Related to CURRENT POC



Occurrence Codes

37



Codes and Line Item Dates of Service (FL 44-45)– All outpatient therapy bills must include: Healthcare

Common Procedure Coding System (HCPCS) codes Current Procedural Terminology (CPT) codes.

– Line item dates of service must be within from and through date billed.

Claims will be returned if:– HCPCS and no corresponding line item date of service

– Line item date of service and no HCPCS code

– Line item date of service outside the billing period38



Reporting Discipline-Specific Rehab Modifiers

Special circumstances may arise that require explanations about the service or treatment performed. When this occurs, a modifier is utilized to indicate to the payor that special reimbursement should be considered due to this special situation.

A modifier is a two-digit code used as a suffix to the five-digit CPT billing code.

39


Reporting Discipline-Specific Rehab Modifiers

• A modifier must be reported with the CPT code on the UB-04 to designate which discipline (PT, OT, SLP) performed the service. GN-service delivered by a Speech-Language Pathologist

GO-service delivered by an Occupational Therapist

GP-service delivered by a Physical Therapist

59 - Distinct Procedural Service identifies

procedures/services not normally reported together,

but appropriately billable under the circumstances.

40




• Modifiers (Field Locator 44)

41


CPT Codes

• CPT stands for Common Procedural Terminology

• Each code is a five-digit number, with a 2-character modifier.

• Part B therapy services delivered and billed by a skilled nursing facility must be CPT coded.

• CPT codes are not always discipline specific.

42



Two Types of CPT Codes

• Time-based codes (T)

• Service-based codes (S)

43


Time-based Codes (T)

• Billed in 15-minute increments

• Their combined value is included in the overall value assigned to the CPT code.

• Examples of time-based codes:

―Therapeutic exercises (97110)

―Therapeutic activities (97530)

44



Service-based Codes (S)

• Billed in units of “1”

• Examples of Service-Based Codes:

– Swallowing Evaluation (92610)

– Swallowing Treatment (92526)

– Speech Treatment (92507)

– Paraffin Bath (97018)

– Evaluation in PT, OT and SLP (PT-97001, OT-97003, SLP-92506)

45


Combination Codes

• A combination of time and service-based codes can be used.

• Example of combination code

A patient, following hand surgery, receives a paraffin treatment to the hand, followed by therapeutic exercise to the hand for 30 minutes. The clinician would select the following CPT codes:

– 97018 x 1 Paraffin Bath (service-based code)

– 97110 x 2 Therapeutic Exercise (time-based code)46



KX Modifier

47


Exception to the Cap

• When the team determines continued therapy services are medically necessary, and meets criteria for exception rules to the Cap, the following should occur:– Notify resident that the Cap is being met, that services

are medically necessary, and the team believes they qualify for an exception to the Cap.

– Notify resident there is some risk for the resident if claim is denied assuming the SNF would bill resident.

48



Exception to the Cap

• Consider completing the Clinical Justification for the Exception to the Cap for medical record.

• See Therapy Exception Complexity Codes.

• Proceed with care and bill with KX modifier.

• Therapy Cap 2016 - $1,960

49


KX Modifier Usage

• Use of the KX Modifier is an attestation from Provider or Supplier that: – The services are reasonable and necessary above the

Cap

– There is documentation of medical necessity in the patient’s medical record

• Append KX Modifier to applicable therapy services

50



Placement of the KX Modifier

• When the Therapy Cap is met in the middle of the month, how is the KX modifier billed?

– When the Cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same Therapy Cap, regardless of whether the other services exceed the Cap

• Documentation must justify the use of the KX modifier

• Internet-Only Manual (IOM), Publication 100-04, Chapter 5, Section 10.3D

51


Part B Functional Reporting

52



2013 Claims-Based Data Collection Requirement for Outpatient Therapy Services

• Implementation January 1st, 2013– CMS is looking at Medicare beneficiaries’ outpatient

therapy services including PT, OT and SLP to understand patient conditions and outcomes.

– Functional reporting will allow the system to collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes and expenditures. This data will then be used in developing an improved payment system.

– This data collection effort is the first step towards collecting the data needed for this type of payment reform.

53


Claims-Based Data Collection

• 42 non-payable G-codes will be used to identify type of functional limitation reported and status.

• 7 Modifiers will indicate the severity/complexity of the functional limitation being tracked.

54



See G Code Attachment

55



• G-Codes for Claims-Based Functional Reporting – G-Codes will include the current status, the projected

goal status and the status upon discharge for the following categories:

• Mobility: Walking & Moving Around

• Changing & Maintaining Body Position

• Carrying, Moving & Handling Objects

• Self Care

• Other PT/OT Primary Functional Limitation

• Other PT/ OT Subsequent Functional Limitation

• Swallowing 56




• G-Codes for Claims-Based Functional Reporting - Continued

• Motor Speech

• Spoken Language Comprehension

• Spoken Language Expression

• Attention

• Memory

• Voice

• Other SLP Functional Limitation57



• Severity/Complexity Modifiers– For each functional G-code used on a claim a modifier

will be required to report the severity/complexity for the functional limitation.

– A 7-point scale will be used to report the severity or complexity of the functional limitation involved.

– The scale identifies modifiers for zero and 100 percent impairment and separate modifiers for roughly each 20th percentile of impairment/function.

58




• Time Frame for Reporting– The functional status reporting with claims submission

required by the therapists will be at 4 distinct time periods:

• Initial service at the outset of a therapy episode

• At least every ten visits

• Discharge

• The time the beneficiary’s condition changes significantly enough to clinically warrant a re-evaluation such that a HCPCS/CPT code for a re-evaluation or a repeat evaluation is billed. 59


Timing

60




• Documentation-Tracking-Implementation– Documentation of the information used for reporting under

this system must be included in the beneficiary’s medical record.

– Therapist to track G-codes and corresponding severity modifier.

– Required reporting began July 1, 2013

61



• Functional reporting is required on claims throughout entire episode of care.

• Two G-codes are required on a claim for each therapy POC.– Current status and goal status

– Discharge status and goal status

• A claim may contain more than two G-codes if: – Therapy services under multiple POCs for the same

provider

– One-time therapy visit 62



Claim line of service for G-code must contain the following information:

– Functional severity modifier

– Therapy modifier indicating the related discipline/POC (i.e. GP, GO or GN)

– Date of the related therapy service

– Note: Claims with a G-code line of service must also have another billable and separately payable therapy line of service on the claim

• Nominal charge: – $0.01 Institutional claims (UB-04 claim form)

– $0.00 Professional claims (1500 claim form) 63


EXAMPLE UB-04 with G codes

64



Multiple Procedure Payment Reduction (MPPR)

• In January 2011, CMS began applying a MPPR to the practice expense payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures.

• For therapy services, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines; for example, physical therapy, occupational therapy, or speech-language pathology.

6565



• Full payment is made for the unit or procedure with the highest Practice Expense payment.

• For subsequent units and procedures, furnished to the same patient on the same day, payment is a percent of the payment for the PE services furnished in institutional settings.

6666




• On 1/2/13, Congress included a provision in the American Taxpayer Relief Act of 2012 that applies a 50% multiple procedure payment reduction (MPPR) to outpatient therapy services effective April 1, 2013.

• This is an increase from the 20% MPPR reduction that applied for office settings and 25% MPPR reduction that applied for facilities in 2012.

• The reduction applies across disciplines. The work and malpractice components of the therapy service payment would not be reduced.

6767



• Claim Adjustment Reason Code will be on the remittance advice for service lines that have been affected by the Multiple Procedure Payment Reduction:– Code 59: Processed based on multiple or

concurrent procedure rules.

– This new code will make payment adjustments due to the MPPR more easily recognized on your RA.

6868




69


SAMPLE UB-04 REVIEW

70



Sample Part A UB-04’s

• PART A Initial Claim 212

• PART A Admit thru Discharge claim 211

• PART A Sequential (interim) claim 213

• PART A Discharge claim 214

• PART B Therapy Claim

• PART B Therapy Cap

71


QUESTIONS

72


of 2

FL-4 Type of Bill 0 Non-payment/zero claim 07 Left against medical advice or disc. Care 55 SNF bed not available

First Digit – CMS will ignore the leading zero 1 Admit through discharge 09 Admit as inp to this hosp (MCR OPD only) 56 Medical appropriateness SNF Second Digit – Type of Facility (CMS will process the 1st digit) 2 Interim bill – first claim 20 Expired (didn’t recover- RNMHC patient) 57 SNF re-admission

1 Hospital 3 Interim bill – continuing claim 30 Still patient or exp. to return for out serv 58 Terminated Managed Care Org Enrol

2 Skilled Nursing Facility 4 Interim bill – last claim 40 Expired at home – hospice only 59 Non-primary ESRD facility

3 Home Health Agency (includes HH PPS) 5 Late charge only claim 41 Expired at medical facility – hospice only 60 Operating cost day outlier (obsolete)

4 Religious Non-Medical (hosp) 7 Replacement of prior claim 42 Expired place unknown – hospice only 61 Operating cost outlier-DRG (FI use

6 Intermediate Care Facility 8 Void/cancel of prior claim 43 Disc/trans to federal health care facility only)

7 Clinic or Hospital Based Renal Dialysis 9 Final claim HH PPS Episode 50 Disc/trans to Hospice Home 62 PIP bill (FI use only)

Medicare UB-04 Other Codes - Revised October 2010

lee

8 Special Facility or Hospital ASC Surgery FL 11 – Patient Sex 51 Disc/trans to Hospice medical facility 63 Incarcerated Bene (payer only/FI use

Third Digit – Bill Classification (CMS will process as the 2nd digit) (Except Clinic, Special Facilities)

1 Inpatient, Part A

2 Inpatient, Part B (Inc HHA, Part B Plan, RAP)

3 Outpatient (Inc HHA, Part A Plan) 4 Other, Part B ref diag serv; HH no treatment plan

M Male

F Female

FL 12 – Admission Date

MMDDYY Required for Inpatient and Home

Health

61 Disc/trans w/in institution to swing bed 62 Discharged to IRF 63 Discharged to LTC hospital

64 Disc/trans to Medicaid only Nursing home

65 Disc/trans to psych hosp or distinct part unit 66 Disc/trans to CAH (eff 01/01/06)

only) 64 Nonclean claim (FI use only)

65 Non-PPS bill (FI use only)

66 Provider does not wish cost outlier pmt – DRG

67 Bene elects not to use LTR days

6 Intermediate Care – Level II

8 Swing Beds

(Clinics Only) 1 Rural Health Clinic

2 Hosp based or Free-standing Renal Dialysis Center 3 Free-Standing Clinic (FQHC)

1 Emergency

2 Urgent

3 Elective 4 Newborn

5 Trauma Center 9 Information Not Available

FL 18-28 – Condition Codes

02 Condition is employment related

03 Patient covered by ins. not reflected here

04 Information Only Bill (Managed Care Plan) 05 Lien has been filed

69 IMA/DGME/N&A Payment Only

70 Self-administered Anemia Mgmt Drug

(EPO) 71 Full care in unit (dialysis)

72 Self care in unit (dialysis)

73 Self care/training dialysis

4 Outpatient Rehab Facility (ORF)

5 Comp Outpatient Rehab Facility (CORF)

6 Community Mental Health Center (CMHC)

FL 15 – Point of Origin for Adm/Visit

Inpatient

06 ESRD 1st 30 mos entitlement, covered EGHP 74

07 Treat of nonterminal illness for Hospice pt 76

08 Bene would not provide info re: insurance 77

Home dialysis Back up in facility dialysis

Provider accepts as payment in full

9 Other

(Special Facilities Only)

1 Hospice (non-hospital based)

2 Hospice (hospital based)

3 Ambulatory Surgery Center

4 Free-standing Birthing Center

1 Physician referral 2 Clinic transfer

4 Transfer from hospital (dif. facility)

5 Transfer from SNF or intermediate care facility (ICF)

6 Transfer from another health care facility

7 Emergency Room (ER)

09 Neither patient nor spouse is employed

10 Patient and/or spouse employed, no EGHP 11 Patient disabled, no LGHP

15 Clean claims delayed (payer use only)

16 SNF transition exemption (payer use only)

17 Patient is homeless

18 Maiden name retained (dep spouse entitled to

78 New coverage not implements by managed care plan

79 CORF services provided off site, PT/ST/OT

80 Home Dialysis – nursing facility

Special Program Indicator Codes

5 Critical Access Hospital 9 Other

8 Court/law enforcement

9 Information Not Available rd

A3 benefits who does not use her husbands last A5 name) A6

Special federal funding Disability

Vaccines/Medicare 100% Payment

Fourth Digit – Frequency (CMS will process as the 3 digit) Outpatient 19 Child retains Mother’s name A9 Second opinion surgery

1

A Admission/Election Notice 2

B Hospice/Medicare Coordinated Care Demonstration /Religious 4 Non-Medical Health Care Institution 5

C Hospice Change of Provider Notice 6

D Hospice/Medicare Coordinated Care Demonstration/ Religious 7

Non-Medical Health Care Institution Void/Cancel 8 E Hospice Change of Ownership

F Beneficiary Initiated Adjustment Claim (FI use) 9

G CWF Initiated Adjustment (FI use) B

H CMS Initiated Adjustment (FI use) C

I FI Adjustment Other (other than QIO/Provider) (FI use) D

J Initiated Adjustment (FI use)

Physician referral or self referral 20 Clinic referral 21 Referred by another hosp or its physician 26 Referred by physician of a SNF or ICF 27 Referred by other facility or its physician 28 Emergency room (ER) 29 Referred by court/law enforcement agency 30 Not valid for outpatient 31 Transfer from another HH agency 32 Readmission to same HH agency 33 Trans from hosp inpatient in the same 34 facility resulting in sep claim to payer 36

37

Demand – Beneficiary requested billing Billing for denial notice

VA eligible chooses Medicare facility

Pat ref to sole comm. Hosp for diag lab test Pat/spouse EGHP secondary to Medicare

Disabled bene/fam LGHP second to Medicare

Qualifying clinical trials

Patient is student (full time day)

Patient is student (coop/work study)

Patient is student (full time night) Patient is student (part time)

General care patient in special care unit

Ward accommodation at patient request

AA-AH AI

AJ AK

AL AM

AN

B0

B1

Abortion related codes

Sterilization

Payer resp for copayment Air

ambulance required Specialized

treatment/bed unavail Non-ER Med Nec Stretcher Transport

Preadmission screening not required

Medicare Coordinated Care Demo

Program Bene Ineligible for Demonstration

Program K OIG Initiated Adjustment Other (FI use) M MSP Initiated Adjustment (FI use)

FL 17 – Patient Status 38 Semi-private room not available

39 Private room medically necessary B2 Critical Access Hospital

Ambulance Attestation P QIO Adjustment (FI use)

01 Discharged to home/self care

02 Disc/tran to short term gen hosp for inp

care 03 Discharge/transferred to SNF 04 Discharged/transferred to ICF 05 Disc/tran to cancer ctr/children’s hosp

06 Disc/tran to home/under HHA Care

40 Same day transfer B3 41 Partial hospitalization B4 42 Cont care plan not related to Inp Adm 43 CCP related, not w/in post discharge window 44 INP adm changed to outpatient

49 Product replacement w/in product lifecycle 50 Product replacement for known recall

Pregnancy Indicator Admission unrelated to discharge


of 2

QIO Approval Indicator Codes 36 Date inp hosp disch, covered transplant 17 Operating outlier amount (FI use only) A7 Co-payment A

C1 Approved at billed (QIO/UR)

C3 Partial approval (QIO/UR) C4 Admission/services denied (QIO/UR) C5 Postpayment review applicable (QIO/UR)

C6 Preadmission/Pre-procedure (QIO/UR)

C7 Extended authorization (QIO/UR)

H2 Discharge by a Hospice provider for cause

W2 Duplicate of original bill

W3 Level I appeal

W4 Level II appeal W5 Level III appeal

Adjustment Reason/Condition Codes D0 Changes to service dates

D1 Changes to charges D2 Changes to revenue codes/HCPCS/HIPPS Rate

Code

D3 Second or subsequent interim PPS bill

D4 Change to diag/procedure code

D5 Cancel to correct HICN/Provider ID

D6 Cancel only or repay MCR dup or OIG project D7 Change to make Medicare Secondary Payer

D8 Change to make Medicare primary

D9 Any other changes DR Disaster related condition codes continued

E0 Change in patient status

G0 Distinct Medical visit H0 Delayed filing, SOI submitted

M0 All inclusive rate for OPD (CAH)

FL 31 – 34 Occurrence Codes

01 Accident/Medical Coverage

02 No-fault insurance, including auto/other

03 Accident/tort liability

04 Accident/employment related 05 Accident/No Medical or Liability Coverage

06 Crime Victim

09 Start of infertility treatment cycle 10 Last menstrual period

11 Onset of symptoms/illness

12 Date of onset, chronically Dep Ind (HHA only) 16 Date of last therapy

17 Date occ therapy plan established/last reviewed

18 Date of retirement (patient/bene) 19 Date of retirement (spouse)

21 UR notice received

22 Date active care ended

23 Date of Canc of Hospice Elec per (Inter only)

24 Date insurance denied (date denial received)

25 Date benefits terminated by primary payer

26 Date SNF bed available 27 Date hospice cert or recert

37 Date inp hosp disch, noncovered transplant 38 Date Home IV Therapy started (HH)

39 Date disch con course of IV Therapy (HH)

40 Scheduled date of admission (OPD)

41 Date of 1st Test for Pre-Adm Testing

42 Date of discharge/hospice term date (Hospice only)

43 Scheduled date of canceled surgery 44 Date occupational therapy started

45 Date speech therapy started

46 Date cardiac, rehab started 47 Date cost outlier status begins

50 Assessment Reference Date (eff 1/1/2011)

55 Date of Death

A1 Birth date, insured A A2 Effective date, insured A policy

A3 Benefits exhausted

A4 Split Bill Date (Medicaid elig) B1 Birth date, insured B

B2 Effective date insured B policy

B3 Benefits exhausted, payer B C1 Birth date, insured C C2 Effective date, insured C policy

C3 Benefits exhaust, payer C

FL 35 - 36 Occurrence Span Codes

70 Qualifying stay dates for SNF only

70 Non-utilization dates for PPS hospital

71 Hospital prior stay dates

72 First/last

74 Noncovered level of care or LOA, excluding occ/span codes 76, 77, 79

75 SNF level of care 76 Patient liability period

77 Provider liability period – utilization charged

78 SNF prior stay dates 79 Intermediary Use Only

80 Prior same – SNF stay dates for payment ban purposes (eff. 01/01/09)

M0 QIO/UR Approved stay dates M1 Provider Liability-no utilization M2 Dates of Inpatient Respite Care

M3 ICF Level of Care

M4 Residential Level of Care

01 Most common semi-private rate

02 Hospital has no semi-private rooms 04 INP prof comp charges combined bill

05 Prof comp included in charge, billed to carrier 06 Medicare blood deductible

08 Medicare LTR amount, 1st calendar year st

18 Operating disproportionate share (FI use

only) 19 Operating IME amount (FI use only)

32 Multiple Patient Ambulance Transport

37 Pints of blood furnished 38 Blood deductible pints unreplaced

39 Pints of blood replaced

40 New inp coverage not implemented by Managed Care Plan

41 Black Lung

42 VA 43 Disabled bene under 65 with LGHP

44 Amt provr agreed to accept from primary ins

46 Number of grace days 47 Any liability insurance

48 Hemoglobin reading

49 Hematocrit reading

50 Physical therapy visits omit eff 10/1/11

51 Occup therapy visits omit eff 10/1/11

52 Speech therapy visits omit eff 10/1/11 53 Cardiac rehab visits (cumulative)

54 Newborn birth weight in grams

55 Eligibility Threshold for Charity Care 56 Skilled nursing home visits hours (HHA)

57 HH aide, home visit hours (HHA) 58 Arterial blood gas 59 Oxygen saturation

60 HHA Branch MSA 61 Place of residence where service is furnished

(HHA & Hospice)

62 HH Visits – Part A (Intermediary Use Only) 63 HH Visits – Part B (Intermediary Use Only)

64 HH Reimbursement – Part A (Intermediary

Use Only) 65 HH Reimbursement – Part B (Intermediary

Use Only)

66 Medicaid Spend Down Amount 67 Peritoneal dialysis 68 EPO units administered

69 State Charity Care Percent 70 Interest amount (FI use only) 71 Funding of ESRD networks (FI use only)

72 Flat rate surgery charge

77 Medicare new tech add-on payment

80 Covered days

81 Noncovered days

82 Co-insurance days

83 Lifetime reserve day A0 Special Zip Code Reporting

A1 Deductible, payer A

A8 Patient Weight Kilograms A9 Patient Height Centimeters AA Regulatory Surchrgs, Assessmts,

Allowances or Healthcare related Taxes

Payer A

AB Other Assessmts/Allowances (e.g.

Medical Education) Payer A B1 Deductible payer B B2 Co-insurance payer B

B3 Estimated responsibility payer B B7 Co-payment Payer B

BA Regulatory Surchrges, Assessmts, Allowances or Healthcare Related Taxes Payer B

BB Other Assessmts/Allowances (e.g.

Medical Education) Payer B C1 Deductible payer C

C2 Co-insurance payer C

C3 Estimated responsibility payer C C7 Co-payment payer C

CA Regulatory Surchrges, Assessmts, Allowances or Healthcare Related Taxes Payer C

CB Other Assessmts/Allowances (e.g.

Medical Education) Payer C D3 Patient estimated responsibility

D4 Clinical trial # assigned NLM/NIH

G8 Facility where inpatient hospice service

is delivered FC Patient paid amount FD Credit received from the manufacturer

for a replaced medical device

Y1 Part A demonstration payment Y2 Part B demonstration payment

Y3 Part B coinsurance

Y4 Conventional provider payment amount for nondemonstration claims

FL 59 – Patient Relationship to Insured

01 Spouse

18 Self

20 Employee

21 Unknown 39 Organ Donor

40 Cadaver Donor

53 Life Partner G8 Other Relationship

28 Date CORF plan established/last reviewed

29 Date OPD PT plan established/last reviewed

09 Medicare co-ins amount, 1 10 Medicare LTR amount, 2nd

calendar year calendar year

A2 Co-insurance, payer A

A3 Estimated responsibility, payer A

30 Date OPD ST plan established/last reviewed 11 Medicare co-ins amount, 2nd calendar year

A4 Covered Self-administrable drugs/emergency

31 Date bene notified intent to bill (accom)

32 Date bene notified intent to bill (proc/treat) 33 First day of ESRD coordination period

34 Date of election of extended care services

35 Date physical therapy treatment started

12 Working aged bene, spouse with EGHP 13 ESRD bene in coord period with EGHP

14 No-fault, including auto/other insurance

15 Workers’ Compensation 16 PHS Other Federal Agency

situation

A5 Covrd self-admin drugs – not self-admin in

situation

A6 Covrd self-admin drugs – diagnostic study and other

FL 39-41 Value Codes


0001 Total Charge 002X HI Prosp Paymt System – HIPPS 2 SNF PPS (RUG) 3 HH PPS (HRG) 4 IRF PPS (CMG)

0100 All-Inclusive Room & Board/Anc 1 All-Inclusive R&B

0110 Room/Board—PVT 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other

0120 Room/Board—SP 2 bd 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other

0130 Room/Board-SP 3-4 bd 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0140 Room/Board—PVT Deluxe 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other

0150 Room/Board—Ward 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology

8 Rehabilitation 9 Other

0160 Other Room/Board 4 Sterile environment 7 Self Care 9 Other

0180 Leave of Absence 2 Patient Convenience 3 Therapeutic leave 5 Nursing home (for hospitalization) 9 Other

0200 Intensive Care 1 Surgical 2 Medical 3 Pediatric 4 Psychiatric 6 Intermediate—ICU 7 Burn Care 8 Trauma 9 Other Sub-acute Care

0210 Coronary Care 1 Myocardial infarction 2 Pulmonary care 3 Heart Transplant 4 Intermediate—CCU 9 Other

0220 Special Charges 1 Admission 2 Technical support charge 3 U.R. service charge 4 Late discharge—medically necsry 9 Other special charges

0230 Incremental Nursing Care 1 Nursery 2 OB 3 ICU (includes transitional care) 4 CCU (includes transitional care) 9 Other

0240 All Inclusive Ancillary 9 Other All Inclusive Ancillary

0250 Pharmacy 1 Generic drugs 2 Nongeneric drugs 4 Incident to other diagnostic services 5 Incident to radiology 7 Nonprescription 8 IV solutions 9 Other

0260 IV Therapy 1 Infusion pump 2 IV Therapy/ pharmacy services 3 IV Therapy/drug/supply/delivery 4 IV therapy/ supplies

9 Other IV therapy

0270 Medical/Surgical Supplies 1 Nonsterile supplies 2 Sterile supplies 3 Take home supplies 4 Prosthetic/orthotic devices 5 Pacemaker 6 Intraocular lens 7 Oxygen—take home 8 Other implants 9 Other supplies/devices

0280 Oncology 9 Other oncology

0290 Durable Medical Equipment 1 Rental 2 Purchase—new equipment 3 Purchase—used equipment 4 Supplies/drugs for DME (HHA only) 9 Other equipment

0300 Laboratory 1 Chemistry 2 Immunology 3 Renal patient (home) 4 Nonroutine dialysis 5 Hematology 6 Bacteriology/microbiology 7 Urology 9 Other laboratory

0310 Laboratory—Pathology 1 Cytology 2 Histology 4 Biopsy 9 Other

0320 Radiology—Diagnostic 1 Angiocardiography 2 Arthrography 3 Arteriography 4 Chest X-ray 9 Other

0330 Radiology—Therapeutic 1 Chemotherapy—injected 2 Chemotherapy—oral 3 Radiation therapy 5 Chemotherapy—IV 9 Other

0340 Nuclear Medicine 1 Diagnostic procedures 2 Therapeutic procedures 3 Diagnostic radiopharmaceuticals 4 Therapeutic radiopharmaceuticals 9 Other

0350 Computed Tomographic (CT) Scan 1 Head Scan

2 Body Scan 9 Other CT scans

0360 Operating Room Services 1 Minor surgery 2 Organ transplant, other Than kidney 7 Kidney transplant 9 Other Operating Room Services

0370 Anesthesia 1 Incident to radiology 2 Incident to other diagnostic services 9 Other anesthesia

0380 Blood 1 Packed red cells 2 Whole blood 3 Plasma 4 Platelets 5 Leucocytes 6 Other components 7 Other derivatives (cryopricipitates) 9 Other blood

0390 Blood Storage/Processing 1 Blood administration (e.g. transfusion) 2 Processing and storage 9 Other processing & storage

0400 Other Imaging Services 1 Diagnostic mammography 2 Ultrasound 3 Screening mammography 4 PET scan 9 Other imaging services

0410 Respiratory Services 2 Inhalation services 3 Hyperbaric oxygen therapy 9 Other respiratory services

0420 Physical Therapy 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation 9 Other physical therapy

0430 Occupational Therapy 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation 9 Other occupational therapy

0440 Speech-Language Pathology 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation 9 Other speech lang. pathology

0450 Emergency Room

1 ER/EMTALA 2 ER/beyond EMTALA 6 Urgent care 9 Other emergency room

0460 Pulmonary Function 9 Other

0470 Audiology 1 Diagnostic 2 Treatment 9 Other audiology

0480 Cardiology 1 Cardiac catheter lab 2 Stress test 3 Echo cardiology 9 Other cardiology

0490 Ambulatory Surgery 9 Other ambulatory surgical care

0510 Clinic 1 Chronic pain center 2 Dental clinic 3 Psychiatric clinic 4 OB/GYN clinic 5 Pediatric clinic 6 Urgent care clinic 7 Family Clinic 9 Other clinic

0520 Free-Standing Clinic 1 Rural health clinic 2 Rural health home 3 Family practice clinic 4 RHC/FQHC practitioner visit (Part A

covered stay at a SNF) 5 RHC/FQHC practitioner visit

(Noncovered Part A Stay SNF/NF/ ICF MR or other residential facility)

7 RHC/FQHC Visiting Nurse services(s) to a member's home in a HH shortage area

8 RHC/FQHC practitioner to other non RHC/FQHC site

9 Other

0530 Osteopathic Services 1 Osteopathic therapy 9 Other osteopathic services

0550 Skilled Nursing

0540 Ambulance

1 Visit charge 2 Hourly charge 9 Other skilled nursing


0560 Medical Social Services 1 Visit charge 2 Hourly charge 9 Other medical social services

0570 Home Health Aide 1 Visit charge 2 Hourly charge 9 Other home health aide

0580 Other Visits-HHA 1 Visit charge 2 Hourly charge 3 Assessment 9 Other home health visits

0600 Oxygen (Home Health) 1 Stat equip/supply/content 2 Stat equip/supply under 1 LPM 3 Stat equip/supply/ over 4 LPM 4 Portable add-on

0610 Magnetic Resonance Tech. (MRT) 1 Brain (including brainstem) 2 Spinal cord (including spine) 4 MRI—other 5 MRA—head and neck 6 MRA—lower extremities 8 MRA—other 9 MRT - other

062X Med—Surg. Supplies Ext. of 270 1 Incident to radiology 2 Incident to other diagnostic service 3 Surgical dressings 4 Investigational device (IDE)

063X Pharmacy – Extension of 025X 1 Single source drug 2 Multiple source drug 3 Restrictive prescription 4 EPO less than 10,000 units 5 EPO 10,000 or more units 6 Drugs requiring detailed coding

7 Self administrable drugs (insulin admin in emergency-diabetic coma)

065X Hospice 1 Routine Home Care 2 Continuous Home Care 5 Inpatient respite care 6 General inpatient care (non-respite) 7 Physician services 8 Hospice room & board—nursing facility 9 Other hospice

068X Trauma Response 1 Level I 2 Level II 3 Level III 4 Level IV 9 Other trauma response 0700 Cast room________________

0720 Labor Room

0710 Recovery Room____________

1 Labor 2 Delivery 4 Birthing center 9 Other labor room/delivery

0730 EKG/ECG 1 Holter monitor 2 Telemetry 9 Other EKG/ECG 0740 Electroencephalogram EEG

0760 Specialty Services

0750 Gastro-Intestinal Services

1 Treatment room 2 Observation hours 9 Other specialty services

0770 Preventive Care Services 1 Vaccine administration

0780 Telemedicine 0790 Extra-Corporeal Shock Wave

0800 Inpatient Renal Dialysis

Therapy (formerly Lithotripsy)

1 Inpatient hemodialysis 2 Inpatient peritoneal (non-CAPD) 3 Inpatient CAPD 4 Inpatient CCPD 9 Other inpatient dialysis

081X Organ Acquisition 1 Living donor 2 Cadaver donor 3 Unknown donor 4 Unsuccessful organ search donor bank

Charge 9 Other organ donor

082X Hemodialysis – Outpatient/Home 1 Hemodialysis composite or other rate 2 Home supplies 3 Home equipment 4 Maintenance/100% 5 Support services 9 Other hemodialysis outpatient

083X Peritoneal OPD/Home 1 Peritoneal/composite or other rate 2 Home supplies 3 Home equipment 4 Maintenance/100% 5 Support services 9 Other peritoneal dialysis

084X CAPD OPD/Home 1 CAPD/composite or other rate 2 Home supplies 3 Home equipment 4 Maintenance/100% 5 Support services

9 Other CAPD dialysis

0850 CCPD - Outpatient 1 CCPD/composite or other rate 4 Maintenance/100% 5 Support services 9 Other CCPD dialysis

0880 Miscellaneous Dialysis 1 Ultra-filtration 9 Other miscellaneous dialysis

0900 Behavioral Health Treatment/Services 1 Electroshock treatment 2 Milieu therapy 3 Play therapy 4 Activity therapy 5 Intensive outpatient serv—psychiatric 6 Intensive out serv—chem dependency 7 Community behavioral health program

(day treatment)

091X Behavioral Health Treatment/ Services – Ext of 090X 1 Rehabilitation 2 Partial hospitalization—less Intensive 3 Partial hospitalization—Intensive 4 Individual therapy 5 Group therapy 6 Family therapy 7 Bio Feedback 8 Testing 9 Other behavioral treatments/services

0920 Other Diagnostic Services 1 Peripheral vascular lab 2 Electromyelogram 3 Pap smear 4 Allergy test 5 Pregnancy test

9 Other diagnostic services

940 Other Therapeutic Service 1 Recreational therapy 2 Education/training (includes diabetes

related dietary therapy) 3 Cardiac rehabilitation 4 Drug rehabilitation 5 Alcohol rehabilitation 6 Complex medical equipment routine 7 Complex medical equipment ancillary 9 Other therapeutic services

0960 Professional Fees 1 Psychiatric 2 Ophthalmology 3 Anesthesiologist (MD) 4 Anesthetist (CRNA) 9 Other professional fees

097X Professional Fees - Ext of 096X 1 Laboratory 2 Radiology—diagnostic 3 Radiology—therapeutic 4 Radiology—nuclear medicine 5 Operating room 6 Respiratory therapy 7 Physical therapy 8 Occupational therapy 9 Speech pathology

098X Professional Fees - Ext of 096X & 097X 1 Emergency room 2 Outpatient services 3 Clinic 4 Medical social services 5 EKG 6 EEG 7 Hospital visit 8 Consultation 9 Private duty nurse

Published: October 7, 2010


Medicare Part B Therapy Billing Guide

Physical Therapy-GP

Occupational Therapy-GO

Speech/Language Pathology- GN

Occurrence Code: 11 Occurrence Code: 11 Occurrence Code: 11 Date the patient first became aware of the symptoms or illness being treated.

Date the patient first became aware of the symptoms or illness being treated.

Date the patient first became aware of the symptoms or illness being treated.

Occurrence Code: 29 Occurrence Code: 17 Occurrence Code: 30 Date a plan of treatment for outpatient physical therapy was established or last reviewed.

Date a plan of treatment for occupational therapy was established or last reviewed.

Date a plan of treatment for speech therapy was established or last reviewed.

Occurrence Code: 35 Occurrence Code: 44 Occurrence Code: 45

Date physical therapy started.

Date occupational therapy started.

Date speech therapy started.

Part B Billing Guide Polaris Group, 800/275-6252 www.polaris-group.com Revised 02.10


1 2 4

5 FED TAX NO.6 7

8 PATIENT NAME a 9 PATIENT ADDRESS a

b b c d e

ADMISSION CONDITION CODES12 DATE 15 SRC 18

31 OCCURRENCE 32 33 34 35 36 37 CODE DATE

a a

b b39

a

b

c

d

42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGE

0 1

2 2

4 4

5 5

0300 LAB 1

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

1

1

00

00

00

00

00

00

00

00

75

350

60

1000

60

250

7000

750

16

1

12

1

14

14

28250.00

PHYSICAL THERAPY

OCCUPATIONAL THERAPY EVAL

OCCUPATIONAL THERAPY

HIPPS RATE CODE

HIPPS RATE CODE

R &B

PHARMACY

PHYSICAL THERAPY EVAL

xx

00

xxxx

8

80 002809

82

CODE AMOUNT CODE

0628xxxx/xx/xxxx 50 xx/xx/xx 0701xx70

10 02

Sunshine GA 70054 1234

12345 211

11-1111111 0701xx 0729xx

B. MED. REC #

30

Happy Place Nursing Home

2000 Sunshine Place

Sunshine GA 700541234

ADMIT THRU DISCHARGE

12345TYPE

OF BILL

STATEMENT COVERS PERIOD

OCCURRENCECODE DATE CODE

OCCURRENCEDATE

OCCURRENCE SPANCODE

10 BIRTHDATE 11 SEX 17 STAT2813 HR 14 TYP 22 23

29 ACDTSTATE24 25 26 27

50

0022

OCCURRENCE04061907

49

VALUE CODESCODE AMOUNT

0430

0444

RHB10

RVA20

M 0701xx 10 4

DATE

SPEECH THERAPY EVAL

0424

0420

0434

0120

0250

0022

3a PAT

16 DHR19 20 21

CODE

1234 Happy Trails

Doe John

FROM THROUGHOCCURRENCE SPAN

CODE FROM THROUGH

3

41AMOUNT

VALUE CODES VALUE CODES40

3 3

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22

23 001 PAGE OF CREATION DATE TOTALS 23

50 PAYER NAME HEALTH PLAN ID

A 57 A

B B

C C

58 INSURED'S NAME

A A

B B

C C

63 REATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A

B B

C C

66 DX

69 # 72 ECI

73

74 PRINCIPAL PROCEDURE a. b. 75 CODE

C. OTHER PROCEDURE d. e. CODE DATE

84 REMARKS NPI

b

c NPI QUAL

88CC a.

78 OTHER

79 OTHER

J

1223456808

Noname

DATE

77 OPERATINGCODE DATE

XXXXADMIT DX

DATE

xxxxxxxxxxxxxxx

9,545.0056 EST. AMOUNT DUE 56 NPI

62 INSURANCE GROUP NO.61 GROUP NAME

OTHER

PRV ID

Medicare xxxxxx y

08/10/21xx11

Doe John

XXXX

60 INSURED'S UNIQUE ID59 P. REL

51 52 REL

53 ASG

54 PRIOR PAYMENTS

18

Y

123456789A

CODE DATEOTHER PROCEDURE

CODE DATE

LAST

FIRST

FIRST

FIRST

NPI

LAST

LAST

QUAL

QUAL

70 PATIENT REASON DX

68

NPI

XXXX XXXX XXXX XXXXXXXX

OTHER PROCEDURE78 ATTENDING

PPS CODE

OTHER PROCEDURE

OTHER PROCDURECODE

QUAL

d LAST FIRST

UB-04 CMS-1450 APROVED OMB NO 0938-0997 THE CERTIFICATION ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.


1 2 4

5 FED TAX NO.6 7


b b c d e



a a

b b39

a

b

c

d


0 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

AMOUNTVALUE CODES VALUE CODES40

CODE

31

41

1234 Happy Trails

Doe John


CODE FROM THROUGHCODE

0022

0120

0250

0022

3a PAT

16 DHR19 20 21

0424

0420

0434

RHB10

RVA20

M 0701xx 10 4

DATE

0430

3

50

0022

OCCURRENCE04061907

xx/xx/xxxx

49

29 ACDTSTATE24 25 26 27



TYPE OF BILL



OCCURRENCEDATE

OCCURRENCE SPANCODE

30


2000 Sunshine Place


FIRST CLAIM IN SERIES

12345


12345 212

11-1111111 0701xx 0731xx

B. MED. REC #

30

xx/xx/xxxx 50 xx/xx/xx 50 0701xx70 0615xx

09

82

CODE AMOUNT

80 00

00

xxxx

11

xx

HIPPS RATE CODE

HIPPS RATE CODE

HIPPS RATE CODE

R &B

PHARMACY

PHYSICAL THERAPY

OCCUPATIONAL THERAPY EVAL


PHYSICAL THERAPY EVAL

RVA30

250.00

16

1

30

14

16

1

31 7750

750

350

60

1000

60

00

00

00

00

00

00

1

1

3 3

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22



A 57 A

B B

C C

58 INSURED'S NAME

A A

B B

C C


A A

B B

C C

66 DX

69 # 72 ECI

73



84 REMARKS NPI

b

c NPI

OTHER PROCDURECODE

QUAL

QUAL

Noname

78 ATTENDING

PPS CODE

LAST

LAST

OTHER PROCEDURE


XXXX XXXX XXXXXXX

FIRST

FIRST

FIRST

NPI

68

NPI

QUAL

123456789A


CODE DATE

51

Medicare

52 REL

53 ASG

54 PRIOR PAYMENTS

18

Y

59 P. REL

XXXX

60 INSURED'S UNIQUE ID

Doe John

11 08/10/21xx


OTHER

xxxxxx y

PRV ID

xxxxxxxxxxxxxxx


DATE

DATE

XXXXADMIT DX

OTHER PROCEDURE1223456808DATE

77 OPERATINGCODE

79 OTHER

J

QUAL

78 OTHER

LAST

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FIRSTLAST


1 2 4

5 FED TAX NO.6 7


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a

b

c

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0 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

AMOUNTVALUE CODES VALUE CODES40

CODE

31

41

1234 Happy Trails

Doe John



0120

0250

0300

0022

3a PAT

16 DHR19 20 21

0320

0420

0430

RVA30

RMA40

M 0701xx 10 4

DATE

3

50

0022

OCCURRENCE04061907

49

29 ACDTSTATE24 25 26 27



TYPE OF BILL



OCCURRENCEDATE

OCCURRENCE SPANCODE

30


2000 Sunshine Place


CONINUTING CLAIM

12345


12345 213

11-1111111 0801xx 08/31/xx

B. MED. REC #

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xx/xx/xxxx 50 xx/xx/xx 0701xx70 0615xx

09

82

CODE AMOUNT

80 00

00

xxxx

31

xx

HIPPS RATE CODE

HIPPS RATE CODE

R & B

Pharmacy

LAB

PHYSICAL THERAPY


X RAY

250.00

20

25

29

2

31

1

7750

300

50

120

1800

1975

00

00

00

00

00

002

2

3 3

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22



A 57 A

B B

C C

58 INSURED'S NAME

A A

B B

C C


A A

B B

C C

66 DX

69 # 72 ECI

73



84 REMARKS NPI

b

c NPI

OTHER PROCDURECODE

QUAL

QUAL

Noname

78 ATTENDING

PPS CODE

LAST

LAST

OTHER PROCEDURE


XXXX XXXXXXXX

FIRST

FIRST

FIRST

NPI

68

NPI

QUAL

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CODE DATE

51

Medicare

52 REL

53 ASG

54 PRIOR PAYMENTS

18

Y

59 P. REL

XXXX


Doe John

11 10/10/xx


OTHER

xxxxxx y

PRV ID

xxxxxxxxxxxxxxx


DATE

DATE

XXXXADMIT DX

OTHER PROCEDURE1223456808DATE

77 OPERATINGCODE

79 OTHER

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QUAL

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1 2 4

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0 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

7

1

00

00

00

00

00

50

500

500 00

2250

90

110

7

9

9

1

4


HIPPS RATE CODE

R & B

PHARMACY

MEDICAL SUPPLIES

LAB

PHYSICAL THERAPY

xx

00

xxxx

9

80 0009

82

CODE AMOUNT

0615xxxx/xx/xxxx 0701xx70

10 20


12345 214

11-1111111 0901xx 0910xx

B. MED. REC #

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2000 Sunshine Place


DISCHARGE CLAIM

12345TYPE

OF BILL



OCCURRENCEDATE

OCCURRENCE SPANCODE


49

29 ACDTSTATE24 25 26 27


3

50

0022

OCCURRENCE04061907

RMA40

250.00

M 0701xx 10 4

DATE

0420

0430

0250

0270

0300

0120

3a PAT

16 DHR19 20 21

1234 Happy Trails

Doe John



41AMOUNT

VALUE CODES VALUE CODES40CODE

9

3 3

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22



A 57 A

B B

C C

58 INSURED'S NAME

A A

B B

C C


A A

B B

C C

66 DX

69 # 72 ECI

73



84 REMARKS NPI

b

c NPI QUAL

78 OTHER

LAST

88CC a.

J

79 OTHER

1223456808DATE

77 OPERATINGCODE

xxxxADMIT DX

DATE

DATE

xxxxxxxxxxxxxxx


PRV ID

xxxxxx


OTHER

y

10/10/xx11

Doe John

XXXX


52 REL

53 ASG

54 PRIOR PAYMENTS

18

Y

59 P. REL


CODE DATE

51

Medicare

QUAL

123456789A

OTHER PROCEDURE

FIRST

FIRST

FIRST

NPI

68

NPI

XXXX XXXX XXXXXXX

PPS CODE

LAST

LAST

OTHER PROCEDURE


OTHER PROCDURECODE

QUAL

QUAL

Noname

78 ATTENDING

d LAST FIRST



Severity /Complexity Modifiers

Modifier Impairment Limitation Restrictions

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, limited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted

CL At least 60 percent but less than 80 percent impaired, limited or restricted

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted

HCPCS G!Codes

Mobility G!Code Set

Function Short Descriptor

G8978 Mobility: walking and moving around functional limitation, current status, at

therapy episode outset and at reporting intervals.

Mobility current status

G8979 Mobility: walking & moving around functional limitation, projected goal

status, at therapy episode outset, at reporting intervals, and at discharge or

to end reporting.

Mobility goal status

G8980 Mobility: walking & moving around functional limitation, discharge

status, at discharge from therapy or to end reporting.

Mobility D/C status

Changing & Maintaining Body Position G!code Set


G8981 Changing & maintaining body position functional limitation, current

status, at therapy episode outset and at reporting intervals.

Body pos current status

G8982 Changing & maintaining body position functional limitation, projected

goal status, at therapy episode outset, at reporting intervals, and at

discharge or to end reporting

Body pos goal status

G8983 Changing & maintaining body position functional limitation, discharge

status, at discharge from therapy or to end reporting.

Body pos D/C status

Carrying, Moving & Handling Objects G!code Set


G8984 Carrying, moving & handling objects functional limitation, current status,

at therapy episode outset and at reporting intervals

Carry current status

G8985 Carrying, moving & handling objects functional limitation, projected goal

status, at therapy episode outset, at reporting intervals, and at discharge or

to end reporting

Carry goal status

!"!#$%!&' ()'*$#+,-.'/,$0% 1112%$#+,-.34,$0%25$6 *+4!'78'$9':;FH04d - Developed by Polaris Group www.polaris-group.com Page 51 of 58

G8986 Carrying, moving & handling objects functional limitation, discharge

status, at discharge from therapy or to end reporting

Carry D/C status

Self Care G!code Set


G8987 Self care functional limitation, current status, at therapy episode outset and

at reporting intervals

Self care current status

G8988 Self care functional limitation, projected goal status, at therapy episode

outset, at reporting intervals, and at discharge or to end reporting

Self care goal status

G8989 Self care functional limitation, discharge status, at discharge from therapy

or to end reporting

Self care D/C status

Other PT/OT Primary G!code Set


G8990 Other physical or occupational primary functional limitation, current

status, at therapy episode outset and at reporting intervals

Other PT/OT goal status

G8991 Other physical or occupational primary functional limitation, projected



Other PT/OT goal status

G8992 Other physical or occupational primary functional limitation, discharge


Other PT/OT D/C status

Other PT/OT Subsequent G!code Set


G8993

Other physical or occupational subsequent functional limitation, current

status, at therapy episode outset and at reporting intervals

Sub PT/OT goal status

G8994 Other physical or occupational subsequent functional limitation, projected



Sub PT/OT goal status

G8995 Other physical or occupational subsequent functional limitation, discharge


Sub PT/OT D/C status

Swallowing G!code Set


G8996 Swallowing functional limitation, current status at time of initial therapy

treatment/episode outset and reporting intervals

Swallow current status

G8997 Swallowing functional limitation, projected goal status, at initial therapy

treatment/outset and at discharge from therapy

Swallow goal status

!"!#$%!&' ()'*$#+,-.'/,$0% 1112%$#+,-.34,$0%25$6 *+4!'7<'$9':;FH04d - Developed by Polaris Group www.polaris-group.com Page 52 of 58

G8998 Swallowing functional limitation, discharge status, at discharge from

therapy/end of reporting on limitation

Swallow D/C status

Motor Speech G!code Set: (Note: These codes are not sequentially numbered)


G8999 Motor speech functional limitation, current status at time of initial therapy


Motor speech current

status

G9186 Motor speech functional limitation, projected goal status at initial therapy


Motor speech goal status

G9158 Motor speech functional limitation, discharge status at discharge from


Motor speech D/C status

Spoken Language Comprehension G!code Set:


G9159 Spoken language comprehension functional limitation, current status at

time of initial therapy treatment/episode outset and reporting intervals

Language comp current

status

G9160 Spoken language comprehension functional limitation, projected goal

status at initial therapy treatment/outset and at discharge from therapy

Language comp goal

status

G9161 Spoken language comprehension functional limitation, discharge status at

discharge from therapy/end of reporting on limitation

Language comp D/C

status

Spoken Language Expressive G!code Set


G9162 Spoken language expression functional limitation, current status at time of

initial therapy treatment/episode outset and reporting intervals

Language express current

status

G9163 Spoken language expression functional limitation, projected goal status at

initial therapy treatment/outset and at discharge from therapy

Language express goal

status

G9164 Spoken language expression functional limitation, discharge status at


Language express D/C

status

Attention G!code Set


G9165 Attention functional limitation, current status at time of initial therapy


Attention current status

G9166 Attention functional limitation, projected goal status at initial therapy


Attention goal status

G9167 Attention functional limitation, discharge status at discharge from


Attention D/C status

!"!#$%!&' ()'*$#+,-.'/,$0% 1112%$#+,-.34,$0%25$6 *+4!'7='$9':;FH04d - Developed by Polaris Group www.polaris-group.com Page 53 of 58

Memory G!code Set


G9168 Memory functional limitation, current status at time of initial therapy


Memory current status

G9169 Memory functional limitation, projected goal status at initial therapy


Memory goal status

G9170 Memory functional limitation, discharge status at discharge from


Memory D/C status

Voice G!code Set


G9171 Voice functional limitation, current status at time of initial therapy


Voice current status

G9172 Voice functional limitation, projected goal status at initial therapy


Voice goal status

G9173 Voice functional limitation, discharge status at discharge from therapy/end

of reporting on limitation

Voice D/C status

Other Speech Language Pathology G!code Set


G9174 Other speech language pathology functional limitation, current status at

time of initial therapy treatment/episode outset and reporting intervals

Speech Language current

status

G9175 Other speech language pathology functional limitation, projected goal

status at initial therapy treatment/outset and at discharge from therapy

Speech language goal

status

G9176 Other speech language pathology functional limitation, discharge status at


Speech language D/C

status

!"!#$%!&' ()'*$#+,-.'/,$0% 1112%$#+,-.34,$0%25$6 *+4!'7>'$9':;FH04d - Developed by Polaris Group www.polaris-group.com Page 54 of 58

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

A B C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURENPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURENPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROMDATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.

INFO BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 6768

69 ADMIT 70 PATIENT 72 73

74 7576 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STATSTATE

DX REASON DX71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

LIC9213257

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b

12340223

030213 033013

MOUSE, MICKEY1234 DISNEY DRIVE

ANAHEIM CA 911111111

01011910 F 030213 10 2 4 30

11 022513 17 031713 29 031713 35 03171344 031713

MOUSE, MICKEY1234 DISNEY DRIVEANAHEIM, CA 91111-1111

0420 PHYSICAL THERAPY 97110GPKX 031713 1 40.150420 PHYSICAL THERAPY 97116GPKX 031713 1 42.000420 PHYSICAL THERAPY G8978GPCK 031713 1 0.010420 PHYSICAL THERAPY G8979GPCH 031713 1 0.010420 PHYSICAL THERAPY 97116GP59KX 031813 1 42.000420 PHYSICAL THERAPY 97110GPKX 031913 1 40.150420 PHYSICAL THERAPY 97116GP59KX 031913 1 42.000420 PHYSICAL THERAPY 97530GPKX 031913 1 43.000420 PHYSICAL THERAPY 97110GPKX 032013 1 40.150420 PHYSICAL THERAPY 97110GPKX 032213 1 40.150420 PHYSICAL THERAPY 97530GPKX 032313 2 86.000420 PHYSICAL THERAPY 97116GP59KX 032413 1 42.000420 PHYSICAL THERAPY 97110GPKX 032513 1 40.150420 PHYSICAL THERAPY 97110GPKX 032613 2 80.300420 PHYSICAL THERAPY 97116GPKX 032713 1 42.000420 PHYSICAL THERAPY G8980GPCJ 032713 1 0.010420 PHYSICAL THERAPY G8979GPCH 032713 1 0.010424 EVALUATION/RE-EVALUATION 97001GPKX 031713 1 145.000430 OCCUPATIONAL THERAPY G8982GOCH 031713 1 0.010430 OCCUPATIONAL THERAPY 97530GO 031713 3 132.990430 OCCUPATIONAL THERAPY 97110GO 031713 2 80.300430 OCCUPATIONAL THERAPY G8981GOCJ 031713 1 0.01

1 2 013113

J1 MEDICARE 'A' - CA, H01001 Y Y 555513

MOUSE, MICKEY 18 9999991234A

97812 72887 4019 5990

331.0

DUCK DONALD

B2U

!"!#$%!&' ()'*$#+,-.'/,$0% 1112%$#+,-.34,$0%25$6 *+4!':;'$9':;FH04d - Developed by Polaris Group www.polaris-group.com Page 55 of 58

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

xxxx xxxxx C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURENPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURENPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROMDATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.

INFO BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 6768

69 ADMIT 70 PATIENT 72 73

74 7576 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STATSTATE

DX REASON DX71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

LIC9213257

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b

1234022?

030213 033013

MOUSE, MICKEY1234 DISNEY DRIVE

ANAHEIM CA 911111111

01011910 F 030213 10 2 4 30

022513 031713 031713 031713031713

MOUSE, MICKEY1234 DISNEY DRIVEANAHEIM, CA 91111-1111

0420 PHYSICAL THERAPY 97110 031713 1 40.150420 PHYSICAL THERAPY 031713 1 42.000420 PHYSICAL THERAPY 031713 1 0.010420 PHYSICAL THERAPY

97110 G8978G8980 031713 1 0.01

0420 PHYSICAL THERAPY 97116 031813 1 42.000420 PHYSICAL THERAPY 031913 1 40.150420 PHYSICAL THERAPY 031913 1 42.000420 PHYSICAL THERAPY 031913 1 43.000420 PHYSICAL THERAPY 032013 1 40.150420 PHYSICAL THERAPY 032213 1 40.150420 PHYSICAL THERAPY

971109711697530971109711097530 032313 2 86.00

0420 PHYSICAL THERAPY 97116 032413 1 42.000420 PHYSICAL THERAPY 032513 1 40.150420 PHYSICAL THERAPY 032613 2 80.300420 PHYSICAL THERAPY 032713 1 42.000420 PHYSICAL THERAPY 032713 1 0.010420 PHYSICAL THERAPY

971109711097116G8980GPG8979GP 032713 1 0.01

0424 EVALUATION/RE-EVALUATION 97001 031713 1 145.000430 OCCUPATIONAL THERAPY G8982 031713 1 0.010430 OCCUPATIONAL THERAPY 97530 031713 3 132.990430 OCCUPATIONAL THERAPY 97110 031713 2 80.300430 OCCUPATIONAL THERAPY G8981CJ 031713 1 0.01

1 2 013113

J1 MEDICARE 'A' - CA, H01001 Y Y 555513

MOUSE, MICKEY 18 9999991234A

9

xxxx12 xxxxx0

xxxx0

DUCK DONALD

B2U


kbrown

Highlight

CREATION DATE

PAGE OF

POLARIS GROUP HOME

1001 SUNNY LANE

SUNNY HILLS, FLORIDA 32428

(850) 555-0000

PG2114

OP-2114 231

990111099 121810

540 SPRINGER STREET

LOOPER, LOUISE BOUNCER GA 70254

F 09 3 16 30

11 113010 30 120310 45 120310

AETNA HEALTH PLAN

P O BOX 14586

LEXINGTON, KY 40512-4586

0440 SWALLOW DYSFUNCTION TREATMENT 92526GN 120410 1 125.00

825.00

200.00

125.00

125.00

125.00

125.00 0440 SWALLOW DYSFUNCTION TREATMENT 92526GN 120810 1

0440 SWALLOW DYSFUNCTION TREATMENT 92526GN 121110 1



0444 EVALUATE SWALLOWING FUNCTION 92506GN 120310 1

0001 1 1

1100110010

MEDICARE 005555 Y Y

AETNA 990111099 Y Y

LOOPER, LOUISE 18 655443322A

LOOPER, LOUISE 18 W1234 98765

XXXX XXXX XXXX9

XXXX1010101010

MARKHAM JOHN

B3OUTPATIENT PART B ADMIT &

DISCHARGE SAME MONTH FOR

SPEECH THERAPY SERVICES.

314000000X

120310

07201920 091107 4

EXAMPLE 4

MEDICARE PART B SPEECH

OUTPATIENT CLAIM

010411

Developed by Polaris Group www.polaris-group.com Page 39 of 44FH04d - Developed by Polaris Group www.polaris-group.com Page 57 of 58

CREATION DATE

PAGE OF

ConditionComplexity

POLARIS GROUP HOME

1001 SUNNY LANE

SUNNY HILLS, FLORIDA 32428

(850) 555-0000

PG0644

02-0644 223

990111099 043011

265 SPRUCE AVENUE

LAW, LINDA BUCKEYE IA 50006-7773

F 11 3 30

11 111910 17 033111 29 033111 35 112210

44 112210

HARTFORD

P O BOX 2999

HARTFORD, CT 06104-2999

0420 PHYSICAL THERAPY 97110GPKX 040111 2 116.08

1950.32

116.08

187.32

116.08

124.88

62.42

58.04

62.42

116.08

124.88

58.04

102.84

60.24

58.04

60.24

62.42

116.08

51.42

124.84

58.04

51.42

62.42

62.42

0420 PHYSICAL THERAPY 97530GPKX 040111 1

0420 PHYSICAL THERAPY 97116GPKX59 041111 1



0420 PHYSICAL THERAPY 97116GP59 040611 1






0420 PHYSICAL THERAPY 97116GPKX59 041611 2

0430 OCCUPATIONAL THERAPY 97110GOKX 040111 1






0430 OCCUPATIONAL THERAPY 97535GOKX59 041211 2




0001 1 2

1100110010

MEDICARE 005555 Y Y

HARTFORD 990111099 Y Y

LAW, LINDA 18 977887447A

LAW, LINDA 18 256211 2L

XXXX XXXX XXXXX XXXXX XXXX XXXXX9

XXXXX1010101010

MARKHAM JOHN

B3RESIDENT MEETS THE

CRITERIA FOR THERAPY EXCEPTION.

314000000X

040111

11161934 120206 4

EXAMPLE 2

MEDICARE PART B

THERAPY CAP EXCEEDED

050411

Developed by Polaris Group www.polaris-group.com Page 38 of 44FH04d - Developed by Polaris Group www.polaris-group.com Page 58 of 58

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