Clinics and Other Outpatient Facility Services Handbook - TMHP

CLINICS AND OTHER OUTPATIENT FACILITY SERVICES HANDBOOK
OP.13
Rural Health Clinic Hospital-Based
1 2 3a PAT.
4 TYPE
CNTL # A12345
OF BILL
b. MED.
REC. #
Community Clinic
8008 Medical Drive
New Cany, Texas 77357
5 FED. TAX NO.
6 STATEMENT COVERS PERIOD
FROM
THROUGH
7
0711
8 PATIENT NAME
a
Doe, John 9 PATIENT ADDRESS a 6789 Courtland Circle New Caney, TX 79065
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
10081964 M 01012012
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
1
2
42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE
45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49
521 Clinic Visit 1-T1015 01012012 1 36 00
1
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
Total Charges 36 00
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
50 PAYER NAME
A
Medicaid
B
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
1342657098
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 123456789
A
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
A
A
B
B
C
66
DX 37200 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
b LAST FIRST
68
C
c
79 OTHER
NPI
QUAL
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-57
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.