# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | adjustment sequence # | 0;1 | NUMERIC | B | This is a sequence # for the adjustment. It has no value to the COB process. | |
.02 | payer id code | 0;2 | FREE TEXT | |||
.03 | amount paid | 0;3 | NUMERIC | This is the amount that was actually paid on this procedure. | ||
.04 | procedure | 0;4 | FREE TEXT | This is the procedure for which payment was considered. | ||
.09 | description | 0;9 | FREE TEXT | This is the procedure description as reported on the EOB. | ||
.1 | revenue code | 0;10 | POINTER | 399.2 | This is the revenue code that is associated with the procedure being billed. | |
.11 | paid units of service(+) | 0;11 | NUMERIC | This is the number of units of service that were actually reimbursed. | ||
.12 | referenced line # | 0;12 | NUMERIC | AC | This is the line # on the original bill that is referenced by this adjustment. If bundling or unbundling has occurred, this is the line # that has the actual adjustment information attached to it. | |
.13 | allowed amount | 0;13 | NUMERIC | This is the amount MEDICARE will allow for this service line | ||
.14 | per diem amount | 0;14 | NUMERIC | This is the per diem amount reported by MEDICARE for this service line. | ||
.15 | original procedure | 0;15 | FREE TEXT | If this adjustment indicates bundling or unbundling occurred (paid procedure was not the original submitted procedure), this is the procedure that was originally sent for payment on the claim. This field will only have data in it if the procedure was part of a bundling or unbundling process. | ||
.16 | service date from | 0;16 | DATE-TIME | This is the first date of service for the claim. | ||
.17 | service date to | 0;17 | DATE-TIME | This is the last date of service for the claim. | ||
.18 | procedure type | 0;18 | FREE TEXT | This is the code representing the type of procedure as reported in this record. | ||
1 | adjustments | 1;0 | MULTIPLE | 361.1151 | This is the list of line level adjustments, including general category of adjustment, reason code, amount and quantity. | |
2 | paid modifiers | 2;0 | MULTIPLE | 361.1152 | ||
4 | line item remark | 4;0 | MULTIPLE | 361.1154 |
Error: Invalid Global File Type: 361.115