Claim field list
Form field (vermilion border = CMS red dropout ink)
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Variant: Inpatient · Heart failure admission · DRG 292 · 4-day stay
1–5
Provider name / address / phone
STONEBRIDGE GENERAL HOSPITAL
475 MILLBROOK PKWY
STONEBRIDGE, MA 01452
TEL: 508-555-0100
3a
Patient control no
PT-2024-088431
3b
Medical record no
MRN-441892
4
Type of bill
0111
5
Fed tax no
04-3891220
6
Statement covers period FROM
2024-03-10
6
THROUGH
2024-03-14
7
(Reserved)
8a
Patient ID
HIC-881234567A
8b
Patient name (Last, First MI)
DOE, JANE Q
9a
Patient address
22 OAK RIDGE RD
9b
City
STONEBRIDGE
9c
State
MA
9d
ZIP
01452
10
DOB
1952-08-17
11
Sex
F
12
Admission date
2024-03-10
13
Admit hr
14
14
Type of admit
2
15
Pt source
7
16
Disch hr
11
17
Pat status
01
18–28
Condition codes
31
Occur code/date
11 2024-03-10
32
Occur code/date
33
Occur code/date
34
Occur code/date
35
Occur span code/dates
36
Occur span code/dates
37
Internal control no
ICN-2024-88431
39
Value code / amount
A1 / $4.00
40
Value code / amount
41
Value code / amount
38
Responsible party name / address
DOE, JANE Q 22 OAK RIDGE RD STONEBRIDGE MA 01452
| FL42 Rev Cd | FL43 Description | FL44 HCPCS/Rate | FL45 Serv Date | FL46 Units | FL47 Total Charges | FL48 Non-Cvrd Chgs |
|---|---|---|---|---|---|---|
| 0120 | MED/SURG ROOM&BOARD | (no HCPCS) | 2024-03-10 | 4 | $6,100.00 | |
| 0250 | PHARMACY | 2024-03-10 | 1 | $892.50 | ||
| 0260 | IV THERAPY | 2024-03-10 | 2 | $630.00 | ||
| 0301 | LAB/HEMATOLOGY | 2024-03-10 | 1 | $284.00 | ||
| 0730 | EKG/ECG | 2024-03-10 | 1 | $210.00 | ||
| 0001 | TOTALS | $8,116.50 | $0.00 |
50
Payer name (A=primary)
A: MEDICARE TRADITIONAL
51
Health plan ID
A: 00112
52
Rel info
Y
53
Asgn ben
Y
54
Prior payments
$0.00
55
Est amount due
$8,116.50
56
NPI (billing provider)
1004567818
57
Other provider ID
58
Insured's name
DOE, JANE Q
59
P rel
18
60
Cert/SSN/HI#/ID
1HH4-A72-9981
61
Group name
MEDICARE PART A
62
Group no
PARTA
63
Treatment auth codes
64
Doc ctrl no
DCN-8843100
65
Employer name
RETIRED
FL66–FL67 Principal/Secondary Diagnoses (ICD-10-CM) & POA Indicators
FL66 DX Version Qual
0 (ICD-10)
FL67 Principal Dx
I50.23
POA: Y
A Other Dx
I10
POA: Y
B Other Dx
E11.9
POA: Y
C Other Dx
N17.9
POA: N
D Other Dx
E Other Dx
69
Admitting diagnosis
R06.02
70
Patient's reason for visit
(inpatient: not required)
71
PPS code/DRG
292
72
External cause of injury
FL74 Principal procedure
(blank)
74a Other procedure
74b Other procedure
74c Other procedure
74d Other procedure
76
Attending NPI / Name
5009876454
CHEN, MICHAEL R MD
77
Operating NPI / Name
78
Other provider NPI / Name
79
Other provider NPI / Name
80
Remarks
81a
CC qualifier
B3
81b
Code
02
81cc
Value
MEDICARE REMIT CODE