Clinics and Other Outpatient Facility Services Handbook - TMHP

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013
OP.6
FQHC Encounter (T1015)
1 2 3a PAT.
4 TYPE
CNTL # 12345678
OF BILL
b. MED.
REC. # A12345
0731
Rio Grande Community
1200 Medical Circle
Rio Grande, Texas 78582
5 FED. TAX NO.
6 STATEMENT COVERS PERIOD
FROM
THROUGH
7
8 PATIENT NAME
a Doe, John M. 9 PATIENT ADDRESS a 1403 Ross Lane, Rio Grande, Texas 78582
b
b c d
10 BIRTHDATE 11 SEX
ADMISSION
CONDITION CODES
12 DATE 13 HR 14 TYPE 15 SRC
16 DHR
29 ACDT 30
17 STAT
18 19 20 21 22 23 24 25 26 27 28 STATE
11031990 M 01012012 10
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN
37
CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM
THROUGH CODE FROM
THROUGH
e
a
a
b
b
38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES
CODE AMOUNT CODE AMOUNT CODE AMOUNT
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 CHARGES 49
1
1
2
3
4
520 Encounter 1-T1015 01012012 1 35 00
2
3
4
5
5
6
6
7
7
8
8
9
9
10
11
12
Total Charges 35 00
10
11
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
50 PAYER NAME
A
B
Medicaid
PAGE
OF
51 HEALTH PLAN ID
CREATION DATE
TOTALS
52 REL.
53 ASG.
54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
INFO BEN.
57
OTHER
1324570986
9876543-21
23
A
B
C
PRV ID
C
A
B
58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.
Doe, John M. 123456789
A
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
A
A
B
C
1234567890
66
DX 07799 67
A B C D E F G H
I J K L M N O P Q
69 ADMIT 70 PATIENT 71 PPS
72 73
DX
REASON DX a b c CODE
ECI a b c
74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE
75
CODE DATE CODE DATE CODE DATE
76 ATTENDING NPI
QUAL
LAST
FIRST
c. OTHER PROCEDURE
d. OTHER PROCEDURE
e. OTHER PROCEDURE
CODE DATE CODE
DATE
CODE
DATE
77 OPERATING
LAST
NPI
QUAL
FIRST
80 REMARKS
81CC
a
78 OTHER NPI
QUAL
Conjunctivitis
b LAST FIRST
c
79 OTHER NPI
QUAL
68
B
C
UB-04 CMS-1450
APPROVED OMB NO. 0938-0997
d LAST FIRST
National Uniform
NUBC Billing Committee
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
OP-50
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.