# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | procedures | 0;1 | VARIABLE-POINTER | 81, 80.1 | B | These are ICD, CPT, or HCFA procedure codes associated with the episode of care on this bill. |
1 | procedure date | 0;2 | DATE-TIME | This is the date the procedure was performed. | ||
2 | *additional procedure name | 0;3 | FREE TEXT | This is the name of the procedure. This field has been marked for deletion 11/4/91. | ||
3 | print order | 0;4 | NUMERIC | D | This is the relative order that this procedure will appear on the bill. For the UB-04, the procedure with the lowest print order is the principal procedure and the rest print in FL74 in lowest to highest print order. | |
4 | basc billable | 0;5 | BOOLEAN | 1:YES | ASC | This field will be completed by the system if this procedure is an Ambulatory Surgery that can be billed under the HCFA rate system. |
5 | division | 0;6 | POINTER | 40.8 | Enter the Division at which this procedure was performed. This is only required if the bill's charges are based on CPT and region and the division is different than the bill's Default Division. | |
6 | associated clinic | 0;7 | POINTER | 44 | Enter the clinic where this procedure was performed. This field must be completed in order for this procedure to be successfully transferred to the Add/Edit Stop code logic for inclusion in OPC workload. | |
7 | *associated diagnosis | 0;8 | POINTER | 80 | This is the diagnosis most closely related to this procedure. Used on the HFCA 1500, block 24e. | |
8 | place of service | 0;9 | POINTER | 353.1 | This is the Place of Service appropriate for this Procedure. Used only for the CMS-1500 claim form. | |
9 | type of service | 0;10 | POINTER | 353.2 | This is the Type of Service to be associated with this procedure. | |
10 | associated diagnosis (1) | 0;11 | POINTER | 362.3 | The diagnosis most closely related to this procedure. Used only for the CMS-1500, box 24e. | |
11 | associated diagnosis (2) | 0;12 | POINTER | 362.3 | The diagnosis most closely related to this procedure. Used only for the CMS-1500, box 24e. | |
12 | associated diagnosis (3) | 0;13 | POINTER | 362.3 | The diagnosis most closely related to this procedure. Used only for the CMS-1500, box 24e. | |
13 | associated diagnosis (4) | 0;14 | POINTER | 362.3 | The diagnosis most closely related to this procedure. Used only for the CMS-1500, box 24e. | |
14 | *cpt modifier | 0;15 | POINTER | 81.3 | Enter the modifier which should be printed on the claim form with the CPT code. | |
15 | minutes | 0;16 | NUMERIC | Enter the number of minutes of care, usually related to Anesthesia. | ||
16 | cpt modifier sequence | MOD;0 | MULTIPLE | 399.30416 | ||
17 | emergency procedure? | 0;17 | BOOLEAN | 0:NO 1:YES | This field stores whether the procedure performed was emergency or scheduled/routine. | |
18 | provider | 0;18 | POINTER | 200 | This is the provider who performed the procedure. | |
19 | purchased cost | 0;19 | NUMERIC | This is the actual amount the VA paid for a service provided to a VA patient at a NON-VA facility or provider. | ||
20 | outpatient encounter | 0;20 | POINTER | 409.68 | The Outpatient Encounter where this procedure was performed. | |
21 | miles | 0;21 | NUMERIC | Enter the number of miles the patient was transported. | ||
22 | hours | 0;22 | NUMERIC | Enter the number of hours of care, usually related to Observation. | ||
50.01 | *hcfa box 24k (local use only) | AUX;1 | FREE TEXT | This field is obsolete. Field contains the text to print in HCFA box 24K for this line item when the bill is printed locally only. If anything is entered in this field, it will override any system defaults that may apply to this field. However, this data will NEVER be transmitted electronically for the claim. If you need to submit data in this field, set the PRINT LOCAL flag on the claim so you can print and mail it from the site. | ||
50.02 | *last xray date | AUX;2 | DATE-TIME | This field has been deactivated and is not in use anymore. | ||
50.03 | attending not hospice employee | AUX;3 | SET OF CODES | 1: ATTENDING PHYSICIAN IS NOT A HOSPICE EMPLOYEE | This is the flag that indicates that an attending physician for hospice care charges was not employed by the hospice. | |
50.04 | *level of subluxation | AUX;4 | FREE TEXT | This field has been deactivated and is not in use anymore. | ||
50.05 | *chiro treatment series num | AUX;5 | NUMERIC | This field has been deactivated and is not in use anymore. | ||
50.06 | *chiropractic quantity | AUX;6 | NUMERIC | This field has been deactivated and is not in use anymore. | ||
50.07 | epsdt flag | AUX;7 | BOOLEAN | 1:YES | This is the field to indicate a service is EPSDT related (Early and Periodic Screen for Diagnosis and Treatment of children). For printed claims, this data will print in CMS-1500 box 24H. | |
50.08 | service line comment | AUX;8 | FREE TEXT | Enter a free text comment as supplemental information associated with this procedure. This text will print up to 59 characters across the shaded line of Box 24 of the CMS-1500 form. The following qualifiers can be entered after the text when reporting NDC units when the NDC Units are required in addition to the HCPCS units: F2 International Unit GR Gram ML Milliliter UN Unit | ||
50.09 | service line comment qualifier | AUX;9 | FREE TEXT | Enter an optional free text Qualifier. The following qualifiers should be used when reporting the following services. 7 Anesthesia information ZZ Narrative description of unspecified code N4 National Drug Codes (NDC) VP Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ Product Number Health Care Uniform Code Council - Global Trade Item Number (GTIN) CTR Contract rate If required to report other supplemental information not listed above, follow payer instructions for the use of a qualifier for the information being reported. When reporting a service that does not have a qualifier, then leave this field blank. In this case, two blank spaces will be inserted on the printed 1500 form before the service line supplemental information is displayed. | ||
51 | procedure description | 1;4 | FREE TEXT | Enter a 1-80 character NOC - Not Otherwise Classified - procedure description. | ||
53 | ndc | 1;7 | FREE TEXT | Enter a National Drug Code in a 5-4-2 format (nnnnn-nnnn-nn) if required on a non-prescription claim. | ||
54 | units | 1;8 | NUMERIC | Enter the number of units of the non-prescription medication administered. | ||
60 | line provider | LNPRV;0 | MULTIPLE | 399.0404 | These are the providers who performed specific functions for the services on this claim line. | |
70 | attachment control number | 1;1 | FREE TEXT | The Attachment Control Number (alphanumeric) identifies the documentation that will provide additional information for this claim line. | ||
71 | attachment report type | 1;2 | POINTER | 353.3 | The Report Type describes the type of documentation that will provide additional information for this claim line. | |
72 | attachment report trans code | 1;3 | SET OF CODES | AA:Available on Request at Provider Site BM:By Mail EL:Electronically Only EM:E-Mail FT:File Transfer FX:By Fax | This is the method for transmitting the claim line. | |
74 | additional ob minutes | 1;5 | NUMERIC | This is the number of additional minutes needed for anesthesia for obstetric services than those reported in the normal procedure base units. |
Error: Invalid Global File Type: 399.0304