Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
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CLINICS AND OTHER OUTPATIENT FACILITY SERVICES HANDBOOK<br />
OP.5<br />
Family Planning <strong>Services</strong> for Hospitals, FQHCs<br />
1 2 3a PAT.<br />
4 TYPE<br />
CNTL # 12345678<br />
OF BILL<br />
b. MED.<br />
REC. # 987651234<br />
Federally Qualified Health<br />
1242 Medical Drive<br />
The Colony, Texas 75321<br />
5 FED. TAX NO.<br />
6 STATEMENT COVERS PERIOD<br />
FROM<br />
THROUGH<br />
7<br />
0731<br />
8 PATIENT NAME<br />
a<br />
9 PATIENT ADDRESS a<br />
b<br />
Doe, Jane L. 1234 Bartl<strong>and</strong> Way, Plano, Texas 75011<br />
b c d<br />
10 BIRTHDATE 11 SEX<br />
ADMISSION<br />
CONDITION CODES<br />
12 DATE 13 HR 14 TYPE 15 SRC<br />
16 DHR<br />
29 ACDT 30<br />
17 STAT<br />
18 19 20 21 22 23 24 25 26 27 28 STATE<br />
02141977 F 01012012 11<br />
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN<br />
37<br />
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM<br />
THROUGH CODE FROM<br />
THROUGH<br />
e<br />
a<br />
a<br />
b<br />
b<br />
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES<br />
CODE AMOUNT CODE AMOUNT CODE AMOUNT<br />
a<br />
b<br />
c<br />
d<br />
42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE<br />
45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49<br />
1<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
520 Annual Family Planning Exam 1-99203 FP 01012012 1 47 57<br />
307 Urinalysis 5-81015 FP 01012012 1 4 31<br />
2<br />
3<br />
4<br />
5<br />
6<br />
7<br />
7<br />
8<br />
8<br />
9<br />
9<br />
10<br />
11<br />
12<br />
Total Charges 51 88<br />
10<br />
11<br />
12<br />
13<br />
13<br />
14<br />
14<br />
15<br />
15<br />
16<br />
16<br />
17<br />
17<br />
18<br />
18<br />
19<br />
19<br />
20<br />
20<br />
21<br />
21<br />
22<br />
22<br />
23<br />
50 PAYER NAME<br />
A Medicaid<br />
B<br />
PAGE<br />
OF<br />
51 HEALTH PLAN ID<br />
CREATION DATE<br />
TOTALS<br />
52 REL.<br />
53 ASG.<br />
54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI<br />
INFO BEN.<br />
57<br />
OTHER<br />
1324650879<br />
9876543-21<br />
23<br />
A<br />
B<br />
C<br />
PRV ID<br />
C<br />
A<br />
B<br />
58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.<br />
Doe, Jane L. 123456789<br />
A<br />
B<br />
C<br />
C<br />
A<br />
B<br />
63 TREATMENT AUTHORIZATION CODES<br />
1234567890<br />
64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME<br />
A<br />
B<br />
C<br />
66<br />
DX 67<br />
A B C D E F G H<br />
I J K L M N O P Q<br />
V2509<br />
69 ADMIT 70 PATIENT 71 PPS<br />
72 73<br />
DX<br />
REASON DX a b c CODE<br />
ECI a b c<br />
74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE<br />
75<br />
CODE DATE CODE DATE CODE DATE<br />
76 ATTENDING NPI<br />
QUAL<br />
LAST<br />
FIRST<br />
c. OTHER PROCEDURE<br />
d. OTHER PROCEDURE<br />
e. OTHER PROCEDURE<br />
CODE DATE CODE<br />
DATE<br />
CODE<br />
DATE<br />
77 OPERATING<br />
LAST<br />
NPI<br />
QUAL<br />
FIRST<br />
80 REMARKS<br />
81CC<br />
a<br />
78 OTHER NPI<br />
QUAL<br />
Annual Family Planning Exam<br />
b LAST FIRST<br />
c<br />
79 OTHER NPI<br />
QUAL<br />
68<br />
C<br />
UB-04 CMS-1450<br />
APPROVED OMB NO. 0938-0997<br />
d LAST FIRST<br />
National Uniform<br />
NUBC Billing Committee<br />
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.<br />
OP-49<br />
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
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