Type of Bill (form locater 4): 0NNN
The Type of Bill (TOB)
provides specific information about the bill.
The TOB is made up of four digits, the first digit is always a
zero. The second digit indicates the
type of facility (hospital, SNF, Home Health, Clinic, etc.). The third digit classifies the type of care
being billed (Inpatient, Outpatient, Lab service, Swing bed, etc.). The fourth digit identifies the sequence of
the bill for a specific episode of care ((Admit through discharge, first and
continuing interim claim, last interim claim, etc.).
Patient Discharge Status (form locater 17): The patient discharge status code is a required item and must be available to identify transfer situations. This code represents the patient’s disposition or discharge status at the ending date of service for the period of care.
Condition Codes (form locators 18-26): these codes provide additional information on the condition of the patient that may affect processing of the claim.
Occurrence Codes (form locaters 31 - 36): Occurrence codes and dates should be completed for all accident, maternity, and illness claims. These codes may relate to payment of the claim and identify occurrences that happened over a span of time noted in this section. Report the specific Condition code, the beginning/from date and the ending/through date associated with the specific reported occurrence span code.
Value Codes and Amounts (form locater 39, 40, 41): These fields contain codes and related dollar amounts that are necessary to process and reimburse the claim correctly. Entries in these fields can represent semi-private room rates, blood deductibles, coinsurance amounts, dialysis charges to name a few.
Revenue Codes (form locator 42): Revenue codes represent a specific accommodation and/or ancillary service. The revenue code must be four digits. Revenue
codes may affect reimbursement, particularly for outpatient claims based on
contract reimbursement terms.
HCPCS/Rate/HIPPS Codes (form locator 44): Enter a HCPCS code applicable for the ancillary service for outpatient claims, a HIPPS rate code, or the inpatient accommodation rate. A HCPCS code is required when a drug or biological is reported. An accommodation rate is required when a room and board revenue code is billed (revenue codes 0100s through 0219)
Service Date (form locator 45): The dates for when the service indicated was provided.
- Outpatient Claims: This is a mandatory field and must be populated.
- Inpatient Claims: Room and board lines must be itemized-one line for each date of service.
Diagnosis Codes (form locators 67, 67a – 67q, 69): Enter ICD-10 CM diagnosis codes.
- Field 67 – Principal
Diagnosis Code: The patient condition established after inpatient discharge or outpatient procedure. The
ICD-10 CM code can be up to seven digits without a decimal, nclude an appropriate present on admission
(POA) indicator for each diagnosis code listed for inpatient claims.
- Fields 67a-67q – Other Diagnosis Codes: Corresponding conditions existing at the time of the inpatient admission or outpatient procedure, include
an appropriate present on admission (POA) indicator for each diagnosis code
listed for inpatient claims.
- Field 69 – Admitting
Diagnosis Code: The patient’s diagnosis at the time of admission
Procedure Codes (form locator 74, 74a – 74e):
- Field 74 – Principal
Procedure Code and Date: the principal procedure(s) performed for the period represented on the claim (from – through dates); ICD-10 PCS procedure codes are required for inpatient claims and CPT procedure codes (seven
digits in length) are required for outpatient claims
- Fields 74a-74e – Other
Procedure Codes and Dates: up to five additional PCS procedure codes (Inpatient) and CPT procedure codes (Outpatient) along with date of service when the procedure was rendered
Remarks (form locater 80): Additional information needed to help in the processing of the claim.
- When billing for secondary coverage, document the level of care in the Remarks field.
- When billing for non-covered days, enter a description of the non-covered days
Special facility billing scenarios
- All mother/baby bills should be submitted as two separate claims, batched together for either paper or electronic submission.
ICD-10 CM Official Coding Guidelines, when claims are submitted for deliveries a diagnosis that identifies the outcome of the delivery using an ICD-10 CM diagnosis code is required.
Age of Patient and Age Bands of Diagnosis codes or Procedure Codes: The age of a patient should match the same age band of a diagnosis code or procedure code:
- ICD-10-CM diagnosis code Z00.111 – Health examination for newborn 8 to 28 days old and the patient age is 5 years old.
- CPT procedure code 99385 – Preventive medicine examination, 18-39 years and the patient age is 47 years old.