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July 13, 2022, 02:14 EDT

Chapter : Billing Instructions (PP)

Updated: 7/13/2022

INTRODUCTION

The purpose of this chapter is to explain the procedures for billing the Virginia Medicaid Program (Medicaid) for covered services provided to Medicaid-eligible individuals on a fee-for-service basis. The Department of Medical Assistance Services (DMAS) is the agency that oversees Medicaid in the Commonwealth of Virginia.

This chapter will address:

  • General Information - This section contains information about DMAS’ claims systems and requirements, including timely filing and the use of appropriate claims forms.
  • Billing Procedures – This section provides instructions on completing claim forms, submitting adjustment requests, and additional payment services.

Electronic Submission of Claims

Electronic billing using Electronic Data Interchange (EDI) is an efficient way to submit Medicaid claims. Providers use EDI software that enables the automated transfer of data in a specific format following specific data content rules directly to DMAS. For more information, go to https://vamedicaid.dmas.virginia.gov/edi.

The mailing address, phone number and fax number for the EDI program are:

EDI Coordinator

Virginia Medicaid Fiscal Agent

P.O. Box 26228

Richmond, Virginia 23260-6228

Phone: (866) 352-0766

Fax number: (888) 335-8460

The email to use for technical/web support for EDI is MESEDISupport@dmas.virginia.gov.

DIRECT DATA ENTRY (DDE)

Providers may submit Professional (CMS-1500), Institutional (UB-04) and Medicare Crossover claims using Direct Data Entry (DDE).  Providers also may make adjustments or void previously submitted claims through DDE. DDE is provided at no cost to providers. Paper claims submissions are not allowed except when requested by DMAS.

Providers must use the Medicaid Enterprise System (MES) Provider Portal to complete DDE. The MES Provider Portal can be accessed at https://vamedicaid.dmas.virginia.gov/provider.

MEDICAID PROVIDER TAXONOMY

Beginning March 25, 2022, providers must include a valid provider taxonomy code as part of the claims submission process for all Medicaid-covered services.  Providers must select at least one taxonomy code based on the service or services rendered. Providers may validate the taxonomy that is associated with their National Provider Identifier (NPI) and practice location through the MES Provider Portal.

Timely Filing

Federal regulations [42 CFR § 447.45(d)] require the initial submission of all Medicaid claims (including accident cases) within 12 months from the date of service. Only claims that are submitted within 12 months from the date of service are eligible for Federal financial participation. To request a waiver of timely filing requirements, providers billing electronically must submit a Claim Attachment Form (DMAS-3) with the appropriate attachments.

DMAS is not authorized to make payment on claims that are submitted late, except under the following conditions:

Retroactive Eligibility - Medicaid eligibility can begin as early as the first day of the third month prior to the month in which the individual makes application for benefits. All eligibility requirements must be met within that period for retroactive eligibility to be granted. In these instances, unpaid bills for that period may be submitted to DMAS as Medicaid claims.

Delayed Eligibility - Initial denials of an individual’s Medicaid eligibility application may be overturned or other actions may cause an eligibility determination to be delayed. DMAS may make payments for dates of service more than 12 months in the past when the claims are for an individual whose determination of eligibility was delayed.

It is the provider’s obligation to verify the individual’s Medicaid eligibility. The individual’s local department of social services will notify providers who have rendered care during a period of delayed eligibility. The notification will indicate notification of the delayed eligibility and include the Medicaid ID number, and the time span for which eligibility has been granted. The provider must submit a claim within 12 months from the date of the notification of the delayed eligibility. A copy of the “signed and dated” letter from the local department of social services indicating the delayed claim information must be attached to the claim.

Denied claims - Denied claims must be submitted and processed on or before 13 months from the date of the initial claim denial where the initial claim was filed according to the timely filing requirements. The procedures for resubmission are:

  • Complete invoice as explained in this billing chapter.
  • Attach written documentation to justify/verify the explanation. If billing electronically and waiver of timely filing is being requested, submit the claim with the appropriate attachments. (The DMAS-3 form is to be used by electronic billers for attachments. See exhibits).

Accident Cases - The provider may either bill DMAS or wait for a settlement from the responsible liable third party in accident cases. However, all claims for services in accident cases must be billed to DMAS within 12 months from the date of the service. If the provider waits for the settlement before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS shall make no reimbursement.

Other Primary Insurance - The provider must bill other insurance as primary.  However, all claims for services must be billed to DMAS within 12 months from the date of the service. If the provider waits for payment before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS will make no reimbursements. If payment is made from the primary insurance carrier after a payment from DMAS has been made, an adjustment or void should be filed at that time.

Other Insurance - The member can keep private health insurance and still be covered by Medicaid. The other insurance plan pays first. Having other health insurance does not change the co-payment amount that providers may collect from a Medicaid member. For members with a Medicare supplemental policy, the policy can be suspended with Medicaid coverage for up to 24 months while the member has Medicaid without penalty from their insurance company. The member must notify the insurance company within 90 days of the end of Medicaid coverage to reinstate the supplemental insurance.

Billing Invoices (PP)

The requirements for submission of physician billing information and the use of the appropriate claim form or billing invoice are dependent upon the type of service being rendered by the provider and/or the billing transaction being completed. The billing invoice to be used for physician services is:

    • Health Insurance Claim Form, CMS-1500 (02-12)

Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid members who are dually eligible for Medicare and Medicaid. However, the amount paid under the Medicaid program in combination with the Medicare payment will not exceed the amount DMAS would pay for the service if it were billed solely under the Medicaid program.

Automated Crossover Claims Processing (PP)

Most claims for dually eligible members are automatically submitted to DMAS for processing. The Medicare claims processor will submit claims based on electronic information exchanges between these entities and DMAS. As a result of this automatic process, the claims are often referred to as “crossovers” since the claims are automatically crossed over from Medicare to the DMAS Medicaid system for processing.

Requests for Billing Materials (PP)

Paper versions of the Health Insurance Claim Form CMS-1500 (02-12) and CMS-1450 (UB-04) are available from the U.S. Government Bookstore at https://bookstore.gpo.gov/.

Providers may use the paper forms only if specifically requested to do so by DMAS. DMAS does not provide CMS-1500 and CMS-1450 (UB-04) forms.

Although not mandated by HIPAA, DMAS has opted to produce an Unsolicited 277 transaction to report information on pended claims.

Preventable Emergency Room Payment Reductions (PP)

Chapter 1289 [2020] Virginia Acts of Assembly mandated that DMAS make the following reimbursement changes effective July 1, 2020.

  • Reduce payment for emergency room claims for codes 99282, 99283 and 99284 to the rate for code 99281 if the emergency room claim is identified as a preventable emergency room event.

Outpatient Hospital Preventable Emergency Room Claim Changes – The principal diagnosis code (locator 21A on the CMS-1500 for the diagnosis & locator 24E set with “A” for primary) will be reviewed when CPT codes 99282, 99283, and 99284 are used for billing. If the principal diagnosis code on the claim is contained in the Preventable Emergency Room Listing (the avoidable emergency room diagnosis code list currently used for Managed Care Organization clinical efficiency rate adjustments), the claim will be reduced to pay the Medicaid allowable for CPT code 99281.

Refer to exhibits for the LANE Preventable Diagnosis Code listing.

Claimcheck/Correct Coding Initiative (CCI) (PP)

DMAS utilizes the Medicaid-specific National Correct Coding Initiative (NCCI) edits through ClaimCheck/CCI.  NCCI is part of the daily claims adjudication cycle on concurrent basis. The current claim will be processed to edit current and historic claims. Any adjustments or denial of payments from the current or historic claim(s) will be done during the daily adjudication cycle and reported on the providers weekly remittance cycle. All ClaimCheck/CCI edits are based on the following global claim factors: same member, same provider, and same date of service or date of service is within established pre- or post-operative period.

  • PTP Edits:

CMS has combined the Medicare Incidental and Mutually Exclusive edits into a new PTP category. The PTP edits define pairs of CPT/HCPCS codes that should not be reported together. The PTP codes utilize a column one listing of codes to a column two listing of codes. In the event a column one code is billed with a column two code, the column one code will pay, the column two code will deny. The only exception to the PTP is the application of an accepted Medicaid NCCI modifier. Note: Prior to this implementation, DMAS modified the CCI Mutually Exclusive edit to pay the procedure with the higher billed charge. This is no longer occurring, since CMS has indicated that the code in column one is to be paid regardless of charge.

  • MUE Edits:

DMAS implemented the Medicaid NCCI MUE edits. These edits define for each CPT/HCPCS code the maximum units of service that a provider would report under most circumstances for a single member on a single date of service and by same servicing provider. The MUEs apply to the number of units allowed for a specific procedure code, per day. If the claim units billed exceed the per day allowed, the claim will deny. With the implementation of the MUE edits, providers must bill any bilateral procedure correctly. The claim should be billed with one unit and the 50 modifier. The use of two units will subject the claim to the MUE, resulting in a denial of the claim.

  • Modifiers:

DMAS only allows the Medicaid NCCI associated modifiers as identified by CMS for the Medicaid NCCI. The modifier indicator currently applies to the PTP edits. The application of this modifier is determined by the modifier indicator of “1”or “0” in the listing of the NCCI PTP column code. The MUE edits do not contain a modifier indicator table on the edit table. Per CMS, modifiers may only be applied if the clinical circumstances justify the use of the modifier. A provider cannot use the modifier just to bypass the edit. The recipient’s medical record must contain documentation to support the use of the modifier by clearly identifying the significant, identifiable service that allowed the use of the modifier. DMAS or its agent will monitor and audit the use of these modifiers to assure compliance. These audits may result in recovery of overpayment(s) if the medical record does not appropriately demonstrate the use of the modifiers.

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include: E1 –E4, FA, F1 – F9, TA T1 – T9, LT, RT, LC, LD, RC, LM, RI, 24, 25, 57, 58, 78, 79, 27, 59, 91. Modifiers 22, 76 and 77 are not

Medicaid PTP NCCI approved modifiers. If these modifiers are used, they will not bypass the Medicaid PTP NCCI edits.

Reconsideration

Providers that disagree with the action taken by a ClaimCheck edit may request a reconsideration of the process via email (claimcheck@dmas.virginia.gov) or by submitting a request to the following mailing address:

Payment Processing Unit, ClaimCheck Division of Program Operations Department of Medical Assistance Services 600 East Broad Street, Suite 1300

Richmond, Virginia 23219

There is a 30-day time limit form the date of the denial letter or the date of the remittance advice containing the denial for requesting reconsideration. A review of additional documentation may sustain the original determination or result in an approval or denial of additional day(s). Requests received without additional documentation or after the 30-day limit will not be considered.

Billing Instructions: Vaccine Billing Information (PP)

Billing Codes for the Administration Fee

Providers must use the specific CPT/HCPCS billing codes when billing Medicaid for the administration fee for free vaccines under the Vaccines for Children (VFC)  program. These codes identify the VFC vaccine provided and will assist VDH with its accountability plan which the Centers for Medicare and Medicaid Services (CMS) require. The billing codes are provided in the Current Procedural Terminology (CPT-4) books.

Billing Medicaid as Primary Insurance

For immunizations, DMAS should be billed first for the vaccine administration under the Medicaid benefit. This is regardless of any other coverage that the child may have, even if the other coverage would reimburse the vaccine administration costs. DMAS will then seek reimbursement from other appropriate payers. When a child has other insurance, check “YES” in Block 11-D (Is there another health benefit plan?) on the CMS-1500 claim form.

Reimbursement for Children Ages 19 and 20

Since Medicaid provides coverage for vaccines for children up to the age of 21, and VFC provides coverage only up to the age of 19, there may be instances where the provider will provide immunizations to children who are ages 19 and 20. Bill DMAS with the appropriate CPT/HCPCS code and DMAS will reimburse the acquisition cost for these vaccines. DMAS will not reimburse an administration fee since these vaccines were not provided under the VFC Program to this age group.

LONG ACTING REVERSIBLE CONTRACEPTIVE (LARC) BILLING INFORMATION (PP)

Medicaid and FAMIS Fee For Service LARC Billing Processes

Hospital Billing (two claims)

  • Delivery: Bill the inpatient UB claim for the hospital stay on the UB form (bill type 011x) Do not include the LARC device on the inpatient bill.
    • LARC Device: The LARC device inserted during a delivery hospitalization is to be billed on a separate UB claim (bill type 013X). The facility will bill using the applicable pharmaceutical revenue code 0250 and/or 063x, with the appropriate “J” code and NDC (see below).

Reimbursement is based on the Fee for Service methodology and excluded from DRG/EAPG methodology if billed correctly on the outpatient claim.  

    • Covered J codes for LARCS are:
    • J7297 – Liletta
    • J7298 – Mirena
    • J7301 – Skyla
    • J7300 – Paragard
    • J7296 - Kyleena
  • J7307-Implanon/Nexplanon

PHYSICIAN BILLING PROCESS MEDICAID AND FAMIS FEE FOR SERVICES (PP)

Providers billing for the insertion of the device must using the CMS 1500 using either 11981 (implant insertion) or 58300 (IUD insertion) depending on the device used and must use place of service Inpatient Hospital (21). Providers will also be allowed to bill for and receive separate reimbursement for the applicable CPT code for the delivery. Prior authorization is not required for these codes.

Billing Instructions: Billing Instructions Reference for Services Requiring Service Authorization (PP)

Please refer to the “Service Authorization” Appendix D in the physician manual.

INSTRUCTIONS FOR USE OF THE CMS-1500 (02-12), BILLING FORM STARTING 04/01/2014 AND AFTER (PP)

Providers typically use Direct Data Entry (DDE), however, the CMS-1500 (02-12) form must be used in those instances where DMAS has requested the use of the paper form. The following instructions have numbered items corresponding to fields on the CMS-1500 (02-12).

SPECIAL NOTE: The provider number in locator 24J must be the same in locator 33 unless the Group/Billing Provider relationship has been established and approved by DMAS for use.

Locator                                  Instructions                                                                     

1

REQUIRED

Enter an "X" in the MEDICAID box for the Medicaid Program.  Enter an “X” in the OTHER box for Temporary Detention Order (TDO) or Emergency Detention Order (EDO).

 

1a

REQUIRED

Insured's I.D. Number - Enter the 12-digit Virginia Medicaid Identification number for the member receiving the service.

 

2

REQUIRED

Patient's Name - Enter the name of the member receiving the service.

 

3

NOT REQUIRED

Patient's Birth Date

4

NOT REQUIRED

Insured's Name

5

NOT REQUIRED

Patient's Address

6

NOT REQUIRED

Patient Relationship to Insured

7

NOT REQUIRED

Insured's Address

8

NOT REQUIRED

Reserved for NUCC Use

9

NOT REQUIRED

Other Insured's Name

9a

NOT REQUIRED

Other Insured's Policy or Group Number

9b

NOT REQUIRED

Reserved for NUCC Use

9c

NOT REQUIRED

Reserved for NUCC Use

9d

NOT REQUIRED

Insurance Plan Name or Program Name

 

10

REQUIRED

Is Patient's Condition Related To: - Enter an "X" in the appropriate box. 

a. Employment?

b. Auto accident

c. Other Accident? (This includes schools, stores, assaults, etc.)  NOTE: The state postal code should be entered if known.

 

10d

Conditional

Claim Codes (Designated by NUCC)

Enter “ATTACHMENT” if documents are attached to the claim form.

11

NOT REQUIRED

Insured's Policy Number or FECA Number

11a

NOT REQUIRED

Insured's Date of Birth

11b

NOT REQUIRED

Other Claim ID

 

11c

REQUIRED

If applicable

 

Insurance Plan or Program Name

Providers that are billing for non-Medicaid MCO copays only- please insert “HMO Copay”.

 

 

11d

REQUIRED

If applicable

Is There Another Health Benefit Plan?

Providers should only check Yes, if there is other third party coverage.

 

12

NOT REQUIRED

Patient's or Authorized Person's Signature

13

NOT REQUIRED

Insured's or Authorized Person's Signature

14

REQUIRED

If Applicable

 

Date of Current Illness, Injury, or Pregnancy

Enter date MM DD YY format

Enter Qualifier 431 – Onset of Current Symptoms or Illness

15

NOT REQUIRED

Other Date

16

NOT REQUIRED

Dates Patient Unable to Work in Current Occupation

 

17

REQUIRED

If applicable

 

Name of Referring Physician or Other Source – Enter the name of the referring physician.

17a shaded red

REQUIRED

If applicable

 

I.D. Number of Referring Physician - The qualifier ‘ZZ’ may be entered if the provider taxonomy code is needed to adjudicate the claim.

Refer to the specific Medicaid Provider manual for special Billing Instructions for specific services.

 

17b

REQUIRED

If applicable

 

I.D. Number of Referring Physician - Enter the National Provider Identifier of the referring physician. 

 

18

NOT REQUIRED

Hospitalization Dates Related to Current Services

 

19

REQUIRED

If applicable

 

Additional Claim Information

Enter the CLIA #.

20

NOT REQUIRED

Outside Lab

 

21

A-L

REQUIRED

Diagnosis or Nature of Illness or Injury - Enter the appropriate ICD diagnosis code, which describes the nature of the illness or injury for which the service was rendered in locator 24E.  Note: Line ‘A’ field should be the Primary/Admitting diagnosis followed by the next highest level of specificity in lines B-L.

 

 

 

 

22

REQUIRED

If applicable

 

Resubmission Code – Original Reference Number.  Required for adjustment and void.  See the instructions for Adjustment and Void Invoices.

 

23

REQUIRED

If applicable

 

Service Authorization (SA) Number – Enter the PA number for approved services that require a service authorization.

 

 

NOTE: The locators 24A thru 24J have been divided into open areas and a shaded line area.  The shaded area is ONLY for supplemental information.  DMAS has given instructions for the supplemental information that is required when needed for DMAS claims processing. ENTER REQUIRED INFORMATION ONLY.

 

24A

lines

1-6

open area

 

 

 

 

 

 

 

 

 

REQUIRED

Dates of Service - Enter the from and thru dates in a 2-digit format for the month, day and year (e.g., 01/01/14).  DATES MUST BE WITHIN THE SAME MONTH

 

 

 

24A

lines 1-6

red shaded

REQUIRED

If applicable

 

DMAS requires the use of qualifier ‘TPL’.  This qualifier is to be used whenever an actual payment is made by a third party payer.  The ‘TPL’ qualifier is to be followed by the dollar/cents amount of the payment by the third party carriers. Example: Payment by other carrier is $27.08; red shaded area would be filled as TPL27.08.  No spaces between qualifier and dollars.  No $ symbol but the decimal between dollars and cents is required.

 

 

DMAS requires the use of the qualifier ‘N4’.  This qualifier is to be used for the National Drug Code (NDC) whenever a HCPCS drug related code is submitted in 24D to DMAS.  No spaces between the qualifier and the NDC number. 

NOTE: The unit of measurement qualifier code is followed by the metric decimal quantity

Unit of Measurement Qualifier Codes:

F2 – International Units

GR – Gram

ML – Milliliter

UN – Unit

Examples of NDC quantities for various dosage forms as follows:

a. Tablets/Capsules – bill per UN

b. Oral Liquids – bill per ML

c. Reconstituted (or liquids) injections – bill per ML

d. Non-reconstituted injections (I.E. vial of Rocephin

powder) – bill as UN (1 vial = 1 unit)

e. Creams, ointments, topical powders – bill per GR

f. Inhalers – bill per GR

 

BILLING EXAMPLES:

 

TPL, NDC and UOM submitted:

 

TPL3.50N412345678901ML1.0

 

NDC, UOM and TPL submitted:

 

N412345678901ML1.0TPL3.50

 

 

 

NDC and UOM submitted only:

 

N412345678901ML1.0

 

 

TPL submitted  only:

 

TPL3.50

 

Note: Enter only TPL, NDC and UOM information in the supplemental shaded area. (see billing examples)

All supplemental information is to be left justified.

 

 

 

SPECIAL NOTE: DMAS will set the coordination of benefit code based on information supplied as followed: 

  • If there is nothing indicated or ‘NO’ is checked in locator 11d, DMAS will set that the patient had no other third party carrier.   This relates to the old coordination of benefit code 2.
  • If locator 11d is checked ‘YES’ and there is nothing in the locator 24a red shaded line; DMAS will set that the third party carrier was billed and made no payment.  This relates to the old coordination of benefit code 5. An EOB/documentation must be attached to the claim to verify nonpayment.
  • If locator 11d is checked ‘YES’ and there is the qualifier ‘TPL’ with payment amount (TPL15.50), DMAS will set that the third party carrier was billed and payment made of $15.50.  This relates to the old coordination of benefit code 3.

 

24B

open area

REQUIRED

Place of Service - Enter the 2-digit CMS code, which describes where the services were rendered. 

 

 

24C

open area

REQUIRED

If applicable

Emergency Indicator - Enter either ‘Y’ for YES or leave blank.  DMAS will not accept any other indicators for this locator.

 

24D

open  area

REQUIRED

Procedures, Services or Supplies – CPT/HCPCS –

ter HCPCS Code, which des  Enter the CPT/HCPCS code that describes the procedure rendered or the service provided.

                                                  Modifier - Enter the appropriate CPT/HCPCS modifiers if applicable. 

 

 

24E

open area

REQUIRED

Diagnosis Code - Enter the diagnosis code reference letter A-L (pointer) as shown in Locator 21 to relate the date of service and the procedure performed to the primary diagnosis.  The primary diagnosis code reference letter for each service should be listed first.  NOTE:  A maximum of 4 diagnosis code reference letter pointers should be entered.  Claims with values other than A-L in Locator 24-E or blank may be denied. 

 

24F

open area

REQUIRED

Charges - Enter your total usual and customary charges for the procedure/services.

 

 

24G

open area

REQUIRED

Days or Unit - Enter the number of times the procedure, service, or item was provided during the service period.

 

24H

open area

REQUIRED

If applicable

EPSDT or Family Planning - Enter the appropriate indicator.  Required only for EPSDT or family planning services.

1 - Early and Periodic, Screening, Diagnosis and Treatment Program Services

2 - Family Planning Service

 

 

 

 

24I

open

REQUIRED

 

NPI – This is to identify that it is a NPI that is in locator 24J

 

 

24 I

red-shaded

REQUIRED

If applicable

ID QUALIFIER –The qualifier ‘ZZ’ is entered to identify the rendering provider taxonomy code.

 

24J

open

REQUIRED

If applicable

Rendering provider ID# - Enter the 10 digit NPI number for the provider that performed/rendered the care.

 

24J

red-shaded

REQUIRED

If applicable

Rendering provider ID# - The qualifier ‘ZZ’ is entered to identify the provider taxonomy code.

 

25

NOT REQUIRED

Federal Tax I.D. Number

 

26

REQUIRED

Patient's Account Number – Up to FOURTEEN alpha-numeric characters are acceptable.

 

27

NOT REQUIRED

Accept Assignment

 

28

REQUIRED

Total Charge - Enter the total charges for the services in 24F lines 1-6

 

29

REQUIRED

If applicable

Amount Paid – For personal care and waiver services only – enter the patient pay amount that is due from the patient.  NOTE: The patient pay amount is taken from services billed on 24A - line 1.  If multiple services are provided on same date of service, then another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service.

 

30

NOT REQUIRED

Rsvd for NUCC Use

 

31

REQUIRED

Signature of Physician or Supplier Including Degrees or Credentials - The provider or agent must sign and date the invoice in this block.

 

32

REQUIRED

If applicable

Service Facility Location Information – Enter the name as first line, address as second line, city, state and 9 digit zip code as third line for the location where the services were rendered.  NOTE: For physician with multiple office locations, the specific Zip code must reflect the office location where services given.  Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.

 

32a open

REQUIRED

If applicable

 

NPI # - Enter the 10 digit NPI number of the service location.

 

32b

red shaded

REQUIRED

If applicable

Other ID#: - The qualifier of ‘ZZ’ is entered to identify the provider taxonomy code.

 

33

REQUIRED

Billing Provider Info and PH # - Enter the billing name as first line, address as second line, city, state, and 9-digit zip code as third line.  This locator is to identify the provider that is requesting to be paid.

NOTE: Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.  The phone number is to be entered in the area to the right of the field title. Do not use hyphen or space as separator within the telephone number.

 

33a open

REQUIRED

NPI – Enter the 10 digit NPI number of the billing provider.

 

 

33b

red shaded

REQUIRED

If applicable

Other Billing ID - The qualifier ‘ZZ’ is entered to identify the provider taxonomy code.

NOTE: DO NOT use commas, periods, space, hyphens or other punctuations between the qualifier and the number.

 


Instructions for the Completion of the Health Insurance Claim Form, CMS‑1500 (02-12), as an Adjustment Invoice

The Adjustment Invoice is used to change information on an approved claim.  Follow the instructions for the completion of the Health Insurance Claim Form, CMS-1500 (02-12), except for the locator indicated below.

 

Locator 22

Medicaid Resubmission

Code - Enter the 4-digit code identifying the reason for the submission of the adjustment invoice.

 

1023

Primary Carrier has made additional payment

 

1024

Primary Carrier has denied payment

 

1025

Accommodation charge correction

 

1026

Patient payment amount changed

 

1027

Correcting service periods

 

1028

Correcting procedure/service code

 

1029

Correcting diagnosis code

 

1030

Correcting charges

 

1031

Correcting units/visits/studies/procedures

 

1032

IC reconsideration of allowance, documented

 

1033

Correcting admitting, referring, prescribing, provider identification number

 

1053

Adjustment reason is in the Misc. Category

 

 

 

 

Original Reference Number/ICN - Enter the claim reference number/ICN of the paid claim.  This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted.  Only one claim can be adjusted on each CMS-1500 (02-12) submitted as an Adjustment Invoice.  (Each line under Locator 24 is one claim)

 

 

NOTE: ICNs can only be adjusted through the MES Provider Portal up to three years from the date the claim was paid. After three years, ICNs are purged from the MES and can no longer be adjusted through the system. If an ICN is purged from the system, the provider must send a refund check made payable to DMAS and include the following information:

    • A cover letter on the provider’s letterhead which includes the current address, contact name and phone number.
    • An explanation about the refund.
    • A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to:

       Department of Medical Assistance Services

      Attn:  Fiscal & Procurement Division, Cashier

                                          600 East Broad St. Suite 1300

                                          Richmond, VA 23219

 



 

Instructions for the Completion of the Health Insurance Claim Form CMS‑1500 (02-12), as a Void Invoice

The Void Invoice is used to void a paid claim.  Follow the instructions for the completion of the Health Insurance Claim Form, CMS-1500 (02-12), except for the locator indicated below.

 

Locator 22

Medicaid Resubmission

Code - Enter the 4-digit code identifying the reason for the submission of the void invoice.

 

1042

Original claim has multiple incorrect items

 

1044

Wrong provider identification number

 

1045

Wrong enrollee eligibility number

 

1046

Primary carrier has paid DMAS maximum allowance

 

1047

Duplicate payment was made

 

1048

Primary carrier has paid full charge

 

1051

Enrollee not my patient

 

1052

Miscellaneous

 

1060

Other insurance is available

 

 

Original Reference Number/ICN - Enter the claim reference number/ICN of the paid claim.  This number may be obtained from the remittance voucher and is required to identify the claim to be voided.  Only one claim can be voided on each CMS-1500 (02-12) submitted as a Void Invoice.  (Each line under Locator 24 is one claim).

       

 

NOTE: ICNs can only be voided through the MES Provider Portal up to three years from the date the claim was paid. After three years, ICNs are purged from the MES and can no longer be voided through the system. If an ICN is purged from the system, the provider must send a refund check made payable to DMAS and include the following information:

    • A cover letter on the provider’s letterhead which includes the current address, contact name and phone number.
    • An explanation about the refund.
    • A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to:

      Department of Medical Assistance Services

      Attn:  Fiscal & Procurement Division, Cashier

                                          600 East Broad St. Suite 1300

                                          Richmond, VA 23219

Billing Instructions: Negative Balance Information

Negative balances occur when one or more of the following situations have occurred:

 

        Provider submitted adjustment/void request

        DMAS completed adjustment/void

        Audits

        Cost settlements

        Repayment of advance payments made to the provider by DMAS

 

In the remittance process the amount of the negative balance may be either off set by the total of the approved claims for payment leaving a reduced payment amount or may result in a negative balance to be carried forward. The remittance will show the amount as, “less the negative balance” and it may also show “the negative balance to be carried forward”. 

The negative balance will appear on subsequent remittances until it is satisfied. An example is if the claims processed during the week resulted in approved allowances of $1000.00 and the provider has a negative balance of $2000.00 a check will not be issued, and the remaining $1000.00 outstanding to DMAS will carry forward to the next remittance.

Billing Instructions: Telemedicine Billing Information (PP)

Telemedicine billing information is described in the manual supplement “Telehealth Services.” MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth.

SPECIAL BILLING INSTRUCTIONS CLIENT MEDICAL MANAGEMENT PROGRAM (PP)

The primary care provider (PCP) and any other provider who is part of the PCP’S CMM Affiliation Group bills for services in the usual manner, but other physicians must follow special billing instructions to receive payment. (Affiliation Groups are explained in Chapter 1 under CMM.) Other physicians must indicate a PCP referral or an emergency unless the service is excluded from the requirement for a referral. Excluded services are listed in Chapter I.

 

All services should be coordinated with the primary health care provider whose name is provided at the time of verification of eligibility. The CMM PCP referral does not override Medicaid service limitations. All DMAS requirements for reimbursement, such as pre- authorization, still apply as indicated in each provider manual.

 

When treating a restricted member, a physician covering for the primary care provider or on referral from the primary care provider must place the primary care provider’s NPI in locator 17b or the API in Locator 17a with the qualifier ‘1D’and attach a copy of the Practitioner Referral Form (DMAS-70) to the invoice. The name of the referring PCP must be entered in locator 17.

 

In a medical emergency situation, if the practitioner rendering treatment is not the primary care physician, he or she must certify that a medical emergency exists for payment to be made. The provider must enter a “Y” in Locator 24C and attach an explanation of the nature of the emergency.

LOCATOR SPECIAL INSTRUCTIONS

When a restricted member is treated on referral from the primary physician, enter the qualifier ‘1D’ and the appropriate provider number (current Medicaid or an API) (as indicated on the DMAS-70 referral form) and attach a copy of the Practitioner Referral Form to the invoice. Write “ATTACHMENT” in Locator 10d.

 

Note: Please refer to the time line for the appropriate provider number as indicated in main instruction above.

 

17b open

 

When a restricted member is treated on referral from the primary physician, enter the NPI number (as indicated on the DMAS-70 referral form) and attach a copy of the Practitioner Referral Form to the invoice. Write “ATTACHMENT” in Locator 10d.

Note: This locator can only be used for claims received on or after Late February 2007.

 

 

24C                 When a restricted member is treated in an emergency situation by a provider other than the primary physician, the non-designated physician enters a “Y” in this Locator and explains the nature of the emergency in an attachment. Write “ATTACHMENT” in Locator 10d.

Billing Instructions: EDI Billing (Electronic Claims)

Please refer to X-12 Standard Transactions & our Companion Guides that are listed in the chapter.

 

SPECIAL BILLING INSTRUCTIONS – HEALTH DEPARTMENTS (DRUGS, FAMILY PLANNING AND NUTRITIONAL SUPPLEMENTS) (PP)

Tuberculosis Oral Drugs

Health Department clinics should bill for all drugs using the unlisted HCPCS code J8499. Modifier U2 must be used in Block 24-D of the CMS-1500 (02-12) claim form. Clinics bill Medicaid with their actual cost for the drugs. If no modifier is billed, the claim may be denied. The qualifier ‘N4’ should be in locator 24 red shaded line followed by the NDC of the J code listed in 24D.

Family Planning Drugs and Devices

Birth control pills must be billed using code J8499 along with modifiers FP and U2 in Block 24-D of the CMS-1500 (02-12) claim form. The qualifier ‘N4’ should be in locator 24 red shaded line followed by the NDC of the J code listed in 24D.

 

Family planning supplies (such as condoms, Intrauterine Devices, etc.) should be billed using unlisted supply code 99070 with the FP and U2 modifiers. Actual costs for the drugs and supplies should be reflected in the charges. Claims submitted without the modifiers may be denied.

Nutritional Supplements

Nutritional Supplements should be billed using the national HCPCS codes for Enteral and Parenteral Therapy (B4000-B9999) with the U2 modifier in Block 24-D of the CMS-1500 (02-12) claim form. Actual cost for the supplements should be billed.

If no modifier is billed, the claim may be denied.

SPECIAL BILLING INSTRUCTIONS – TEMPORARY DETENTION ORDERS (TDO) AND EMERGENCY CUSTODY ORDERS (ECO) (PP)

Services can only be billed for services related to the specific time frame of the TDO or for an Emergency Custody Order (ECO). Refer to the TDO Supplement for details and carve out rules. The below listed locators are instructions related specifically for TDO/ECO services. All other billing information remains the same as  those in main CMS-1500 (02-12) instructions.

 

1

LOCATOR REQUIRED

SPECIAL INSTRUCTIONS

Enter an "X" in the OTHER box.

1a

REQUIRED

Insured's I.D. Number – This locator to be left blank.

3

REQUIRED

Patient's Birth Date – Enter the 8 digit birth date (MM DD CCYY) and enter an ‘X’ in the correct box for the sex of the patient.

9

REQUIRED

Other Insured’s Name: Write the appropriate name for the detention order, either TDO or EDO. This will allow DMAS to identify that the claim is for this program.

10d

CONDITIONAL

 

23

REQUIRED

Service Authorization (SA) Number – Enter the TDO number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO.

24C

REQUIRED

Emergency Indicator - Enter ‘Y’ for YES

Special Note: All TDO and ECO claims are submitted to the following address: Department of Medical Assistance Service

Attention: TDO Program

600 E. Broad Street Suite 1300

Richmond, Virginia 23219

Also refer to the TDO Supplement for carve out instructions.

Instructions for Billing Medicare Crossover Part B Services (Hospital)

The Virginia Medical Assistance Program implemented the consolidation process for Virginia Medicare crossover process, referred to as the Coordination of Benefits Agreement (COBA) in January 23, 2006. This process resulted in the transferring the claims crossover functions from individual Medicare contractors to one national claims crossover contractor.

The COBA process is only using the 837 electronic claims format. Refer to the applicable 837 Implementation Guide and the Virginia Medicaid 837 Companion Guide at https://vamedicaid.dmas.virginia.gov/edi  for more information.

Beginning March 1, 2006, Virginia Medicaid began accepting secondary claims to Medicaid when Medicare is primary from providers and not just thru the COBA process. If you receive notification that your Medicare claims did not cross to Virginia Medicaid or the crossover claim has not shown on your Medicaid remittance advice after 30 days, you should submit your claim directly to Medicaid. These claims can be resubmitted directly to DMAS either electronically, via Direct Data Entry or by using the CMS 1500 (02-12) paper claim form. Refer to the applicable 837 Implementation Guide and the Virginia Medicaid 837 Companion Guide at https://vamedicaid.dmas.virginia.gov/edi for more information.

An electronic claim can be sent to Virginia Medicaid if you need to resubmit a crossover claim that originally denied, such as for other coverage, or if you need to adjust or void a paid crossover claim, such as to include patient liability.

NOTE: Medicaid eligibility is reaffirmed each month for most members. Therefore, bills must be for services provided during each calendar month, e.g., 01/01/06 – 01/31/06.

Billing Instructions: Instructions for Completing the Paper CMS-1500 (02-12) Form for Medicare and Medicare Advantage Plan Deductible, Coinsurance and Copay Payments for Professional Services (Effective 11/02/2014) (Hospital)

The Direct Data Entry (DDE) Crossover Part B claim form can be located through the MES Provider Portal. Please note that providers are encouraged to use DDE for submission of claims that cannot be submitted electronically to DMAS. Registration with MES is required to access and use DDE within the MES Provider Portal.

Once logged on to MES, choose Provider Resources and then select Claims. Providers have the ability to create a new initial claim, as well as a claim adjustment or a void through the DDE process. The status of the claim(s) submitted can be checked the next business day if claims were submitted by 5pm. DDE is provided at no cost to providers. Paper claim submissions should only be submitted when requested specifically by DMAS.

Purpose: A method of billing Medicare’s deductible, coinsurance and copay for professional Providers typically use Direct Data Entry (DDE), however, the CMS-1500 (02-12) form must be used in those instances where DMAS has requested the use of the paper form. The following instructions have numbered items corresponding to fields on the CMS-1500 (02-12).

NOTE:             Note changes in locator 11c and 24A lines 1-6 red shaded area. These changes are specific to Medicare Part B billing only.

Locator                                  Instructions                                                                    

1

REQUIRED

Enter an "X" in the MEDICAID box for the Medicaid Program.  Enter an “X” in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO).

 

1a

REQUIRED

Insured's I.D. Number - Enter the 12-digit Virginia Medicaid Identification number for the member receiving the service.

 

2

REQUIRED

Patient's Name - Enter the name of the member receiving the service.

 

3

NOT REQUIRED

Patient's Birth Date

4

NOT REQUIRED

Insured's Name

5

NOT REQUIRED

Patient's Address

6

NOT REQUIRED

Patient Relationship to Insured

7

NOT REQUIRED

Insured's Address

8

NOT REQUIRED

Reserved for NUCC Use

9

NOT REQUIRED

Other Insured's Name

9a

NOT REQUIRED

Other Insured's Policy or Group Number

9b

NOT REQUIRED

Reserved for NUCC Use

9c

NOT REQUIRED

Reserved for NUCC Use

9d

NOT REQUIRED

Insurance Plan Name or Program Name

 

10

REQUIRED

Is Patient's Condition Related To: - Enter an "X" in the appropriate box. 

a. Employment?

b. Auto accident

c. Other Accident? (This includes schools, stores, assaults, etc.)  NOTE: The state should be entered if known.

 

10d

Conditional

Claim Codes (Designated by NUCC)

Medicare/Medicare Advantage Plan EOB should be attached.

11

NOT REQUIRED

Insured's Policy Number or FECA Number

11a

NOT REQUIRED

Insured's Date of Birth

11b

NOT REQUIRED

Other Claim ID

 

11c

REQUIRED

 

Insurance Plan or Program Name

Enter the word ‘CROSSOVER

IMPORTANT:  DO NOT enter ‘HMO COPAY’ when billing for Medicare/Medicare Advantage Plan copays! Only enter the word ‘CROSSOVER

 

11d

REQUIRED

If applicable

Is There Another Health Benefit Plan?

If Medicare/Medicare Advantage Plan and Medicaid only, check “NO”. Only check “Yes”, if there is additional insurance coverage other than Medicare/Medicare Advantage Plan and Medicaid.

12

NOT REQUIRED

Patient's or Authorized Person's Signature

13

NOT REQUIRED

Insured's or Authorized Person's Signature

14

NOT REQUIRED

 

Date of Current Illness, Injury, or Pregnancy

Enter date MM DD YY format

Enter Qualifier 431 – Onset of Current Symptoms or Illness

15

NOT REQUIRED

Other Date

16

NOT REQUIRED

Dates Patient Unable to Work in Current Occupation

17

NOT REQUIRED

 

Name of Referring Physician or Other Source – Enter the name of the referring physician.

17a shaded red

NOT REQUIRED

 

I.D. Number of Referring Physician - The qualifier ‘ZZ’ is be entered if the provider taxonomy code is needed to adjudicate the claim.

Refer to the specific Medicaid Provider manual for special Billing Instructions for specific services.

17b

NOT REQUIRED

 

I.D. Number of Referring Physician - Enter the National Provider Identifier of the referring physician. 

18

NOT REQUIRED

Hospitalization Dates Related to Current Services

19

NOT REQUIRED

 

Additional Claim Information

Enter the CLIA #.

20

NOT REQUIRED

Outside Lab?

 

21

A-L

REQUIRED

Diagnosis or Nature of Illness or Injury - Enter the appropriate ICD diagnosis code, which describes the nature of the illness or injury for which the service was rendered in locator 24E.  Note: Line ‘A’ field should be the Primary/Admitting diagnosis followed by the next highest level of specificity in lines B-L.

Note:  ICD Ind. Not required at this time. 

 

22

REQUIRED

If applicable

 

Resubmission Code – Original Reference Number.  Required for adjustment or void. 

Enter one of the following resubmission codes for an adjustment:

 

1023     Primary Carrier has made additional payment

1024     Primary Carrier has denied payment

1026     Patient payment amount changed

1027     Correcting service periods

1028     Correcting procedure/service code

1029     Correcting diagnosis code

1030     Correcting charges

1031     Correcting units/visits/studies/procedures

1032     IC reconsideration of allowance, documented

1033  Correcting admitting, referring, prescribing provider identification number

1053     Adjustment reason is in the miscellaneous category

 

Enter one of the following resubmission codes for a void:

 

1042     Original claim has multiple incorrect items

1044     Wrong provider identification number

1045     Wrong member eligibility number

1046   Primary carrier has paid DMAS’ maximum allowance

1047     Duplicate payment was made

1048     Primary carrier has paid full charge

1051     Member is not my patient

1052     Void reason is in the miscellaneous category

1060     Other insurance is available

 

Original Reference Number - Enter the claim reference number/ICN of the Virginia Medicaid paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted or voided. Only one paid claim can be adjusted or voided on each CMS-1500 (02-12) claim form. (Each line under Locator 24 is one claim).

 

 

NOTE: ICNs can only be adjusted or voided through the MES up to three years from the date the claim was paid. After three years, ICNs are purged from the MES and can no longer be adjusted or voided through the system. If an ICN is purged from the system, the provider must send a refund check made payable to DMAS and include the following information:

            A cover letter on the provider’s letterhead which includes the current address, contact name and phone number.

            An explanation about the refund.

            A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to:

Department of Medical Assistance Services

              Attn:  Fiscal & Procurement

              Division, Cashier

               600 East Broad St. Suite 1300

               Richmond, VA 23219

 

23

REQUIRED

If applicable

 

 

Service Authorization (SA) Number – Enter the PA number for approved services that require a service authorization.

 

NOTE: The locators 24A through 24J have been divided into open and shaded line areas.  The shaded area is ONLY for supplemental information.  DMAS has given instructions for the supplemental information that is required when needed for DMAS claims processing. ENTER REQUIRED INFORMATION ONLY.

 

24A

lines

1-6

open area

 

REQUIRED

Dates of Service - Enter the from and through dates in a 2-digit format for the month, day and year (e.g., 01 01 14). 

 

 

24A-H

lines 1-6

red shaded

REQUIRED

 

 

DMAS is requiring the use of the following qualifiers in the red shaded for Part B billing:

A1 =    Deductible  (Example: A120.00) = $20.00 ded 

A2 =   Coinsurance (Example: A240.00) = $40.00 coins

A7=    Copay (Example: A735.00) = $35.00 copay

AB=   Allowed by Medicare/Medicare Advantage Plan (Example AB145.10) = $145.10 Allowed Amount  

MA= Amount Paid by Medicare/Medicare Advantage   Plan  (Example MA27.08) see details below

CM= Other insurance payment (not Medicare/Medicare Advantage Plan) if applicable (Example CM27.08) see details below

N4 =   National Drug Code (NDC)+Unit of Measurement

 

‘MA’:  This qualifier is to be used to show Medicare/Medicare Advantage Plan’s payment.  The ‘MA’ qualifier is to be followed by the dollar/cents amount of the payment by Medicare/Medicare Advantage Plan

Example:

 Payment by Medicare/Medicare Advantage Plan is $27.08; enter MA27.08 in the red shaded area

 

‘CM’:  This qualifier is to be used to show the amount paid by the insurance carrier other than Medicare/Medicare Advantage plan.  The ‘CM’ qualifier is to be followed by the dollar/cents amount of the payment by the other insurance.

Example:

 Payment by the other insurance plan is $27.08; enter CM27.08 in the red shaded area

 

NOTE: No spaces are allowed between the qualifier and dollars.  No $ symbol is allowed. The decimal between dollars and cents is required.

 

DMAS is requiring the use of the qualifier ‘N4’.  This qualifier is to be used for the National Drug Code (NDC) whenever a drug related HCPCS code is submitted in 24D to DMAS.  The Unit of Measurement Qualifiers must follow the NDC number.  The unit of measurement qualifier code is followed by the metric decimal quantity or unit. Do not enter a space between the unit of measurement qualifier and NDC.

Example: N400026064871UN1.0 

Any spaces unused for the quantity should be left blank.

Unit of Measurement Qualifier Codes:

F2 – International Units

GR – Gram

ML – Milliliter

UN – Unit

 

 

Examples of NDC quantities for various dosage forms as follows:

a. Tablets/Capsules – bill per UN

b. Oral Liquids – bill per ML

c. Reconstituted (or liquids) injections – bill per ML

d. Non-reconstituted injections (I.E. vial of Rocephin

powder) – bill as UN (1 vial = 1 unit)

e. Creams, ointments, topical powders – bill per GR

f. Inhalers – bill per GR

 

Note: All supplemental information entered in locator 24A through 24H is to be left justified.

 

 

Examples:

  1. Deductible is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $20.00, Medicare/Medicare Advantage Plan Paid Amt is $16.00, Coinsurance is $4.00.
  • Enter:A110.00 AB20.00 MA16.00 A24.00

 

  1. Copay is $35.00, Medicare/Medicare Advantage Plan Paid Amt is $0.00

Medicare/Medicare Advantage Plan Allowed Amt is $100.00

  • Enter: A735.00 MA0.00 AB100.00

 

  1. Medicare/Medicare Advantage Plan Paid Amt is $10.00, Other Insurance payment is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $10.00, Coinsurance is $5.00, NDC is 12345678911, Unit of measure is 2 grams
  • Enter:

MA10.00 CM10.00 AB10.00 A25.00 N412345678911GR2

 

**Allow a space in between each qualifier set**

 

 

 

24B

open area

REQUIRED

Place of Service - Enter the 2-digit CMS code, which describes where the services were rendered. 

 

 

24C

open area

REQUIRED

If applicable

Emergency Indicator - Enter either ‘Y’ for YES or leave blank.  DMAS will not accept any other indicators for this locator.

 

24D

open  area

 

 

REQUIRED

Procedures, Services or Supplies – CPT/HCPCS –

ter HCPCS Code, which des Enter the CPT/HCPCS code that describes the procedure rendered or the service provided.

                                                  Modifier - Enter the appropriate CPT/HCPCS modifiers if applicable. 

 

 

 

24E

open area

REQUIRED

Diagnosis Code - Enter the diagnosis code reference letter A-L (pointer) as shown in Locator 21 to relate the date of service and the procedure performed to the primary diagnosis.  The primary diagnosis code reference letter for each service should be listed first.  NOTE:  A maximum of 4 diagnosis code reference letter pointers should be entered.  Claims with values other than A-L in Locator 24-E or blank will be denied. 

 

24F

open area

REQUIRED

Charges - Enter the Medicare/Medicare Advantage Plan billed amount for the procedure/services. NOTE: Enter the Medicare/Medicare Advantage Plan Copay amount as the charged amount when billing for the Medicare/Medicare Advantage Plan Copay ONLY.

.

 

 

24G

open area

REQUIRED

Days or Unit - Enter the number of times the procedure, service, or item was provided during the service period.

 

24H

open area

REQUIRED

If applicable

EPSDT or Family Planning - Enter the appropriate indicator.  Required only for EPSDT or family planning services.

1 - Early and Periodic, Screening, Diagnosis and Treatment Program Services

2 - Family Planning Service

 

 

 

 

24I

open

REQUIRED

If applicable

NPI – This is to identify that it is a NPI that is in locator 24J

 

 

24 I

red-shaded

REQUIRED

If applicable

 

 

24J

open

REQUIRED

If applicable

Rendering provider ID# - Enter the 10 digit NPI number for the provider that performed/rendered the care.

 

24J

red-shaded

REQUIRED

If applicable

Rendering provider ID# - If the qualifier ‘ZZ’ was entered in 24I shaded area enter the provider taxonomy code if the NPI is entered in locator 24J open line.

 

25

NOT REQUIRED

Federal Tax I.D. Number

 

26

REQUIRED

Patient's Account Number – Up to FOURTEEN alpha-numeric characters are acceptable.

 

27

NOT REQUIRED

Accept Assignment

 

28

REQUIRED

Total Charge - Enter the total charges for the services in 24F lines 1-6 

 

 

29

REQUIRED

If applicable

Amount Paid – For personal care and waiver services only – enter the patient pay amount that is due from the patient.  NOTE: The patient pay amount is taken from services billed on 24A - line 1.  If multiple services are provided on same date of service, then another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service.

 

30

NOT REQUIRED

Rsvd for NUCC Use

 

31

REQUIRED

Signature of Physician or Supplier Including Degrees or Credentials - The provider or agent must sign and date the invoice in this block.

 

32

REQUIRED

If applicable

Service Facility Location Information – Enter the name as first line, address as second line, city, state and 9 digit zip code as third line for the location where the services were rendered.  NOTE: For physician with multiple office locations, the specific Zip code must reflect the office location where services given.  Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.

 

32a open

REQUIRED

If applicable

 

NPI # - Enter the 10 digit NPI number of the service location.

 

32b

red shaded

REQUIRED

If applicable

Other ID#: - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier of ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 32a open line.

 

33

REQUIRED

Billing Provider Info and PH # - Enter the billing name as first line, address as second line, city, state and 9-digit zip code as third line.  This locator is to identify the provider that is requesting to be paid.

NOTE: Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.  The phone number is to be entered in the area to the right of the field title. Do not use hyphen or space as separator within the telephone number.

 

33a open

REQUIRED

NPI – Enter the 10 digit NPI number of the billing provider.

 

 

33b

red shaded

REQUIRED

If applicable

Other Billing ID - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 33a open line.

NOTE: DO NOT use commas, periods, space, hyphens or other punctuations between the qualifier and the number.

The information may be typed (recommend font Sans Serif 12) or legibly handwritten.  Retain a copy for the office files.

Mail the completed claims to:

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Invoice Processing (PP)

The Medicaid invoice processing system utilizes a sophisticated electronic system to process Medicaid claims. Once a claim has been received, imaged, assigned a crossreference number, and entered into the system, it is placed in one of the following categories:

 

           Remittance Voucher

 

           Approved - Payment is approved or Pended. Pended claims are placed in a pended status for manual adjudication (the provider must not resubmit).

 

           Denied - Payment cannot be approved because of the reason stated on the remittance voucher.

 

           Pend – Payment is pended for claim to be manually reviewed by DMAS staff or waiting on further information from provider.

 

           NO RESPONSE - if one of the above responses has not been received within 30 days, the provider should assume non-delivery and rebill using a new invoice form.  

The provider's failure to follow up on these situations does not warrant individual or additional consideration for late billing.

 

Please use this link to search for DMAS Forms: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch

 

 

Billing Instructions: Lane Reduction ER Code List (Hospital)

ICD-10 Codes

ICD-10 Description

A09.

Infectious gastroenteritis and colitis, unspecified

J02.0

Streptococcal pharyngitis

J03.00

Acute streptococcal tonsillitis, unspecified

J03.01

Acute recurrent streptococcal tonsillitis

B01.9

Varicella without complication

B02.9

Zoster without complications

B00.2

Herpesviral gingivostomatitis and pharyngotonsillitis

B00.9

Herpesviral infection, unspecified

B09.

Unspecified viral infection characterized by skin and mucous membrane lesions

B08.5

Enteroviral vesicular pharyngitis

B08.4

Enteroviral vesicular stomatitis with exanthem

B27.80

Other infectious mononucleosis without complication

B27.81

Other infectious mononucleosis with polyneuropathy

B27.89

Other infectious mononucleosis with other complication

B27.90

Infectious mononucleosis, unspecified without complication

B27.91

Infectious mononucleosis, unspecified with polyneuropathy

B27.99

Infectious mononucleosis, unspecified with other complication

B07.9

Viral wart, unspecified

B07.0

Plantar wart

B97.11

Coxsackievirus as the cause of diseases classified elsewhere

B97.10

Unspecified enterovirus as the cause of diseases classified elsewhere

B97.89

Other viral agents as the cause of diseases classified elsewhere

A54.00

Gonococcal infection of lower genitourinary tract, unspecified

A54.02

Gonococcal vulvovaginitis, unspecified

A54.09

Other gonococcal infection of lower genitourinary tract

A54.1

Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess

A64.

Unspecified sexually transmitted disease

B35.0

Tinea barbae and tinea capitis

B35.4

Tinea corporis

B35.5

Tinea imbricata

B37.0

Candidal stomatitis

B37.83

Candidal cheilitis

B37.3

Candidiasis of vulva and vagina

B37.9

Candidiasis, unspecified

A59.01

Trichomonal vulvovaginitis

B86.

Scabies

E11.9

Type 2 diabetes mellitus without complications

E13.9

Other specified diabetes mellitus without complications

E10.9

Type 1 diabetes mellitus without complications

E11.65

Type 2 diabetes mellitus with hyperglycemia

E10.65

Type 1 diabetes mellitus with hyperglycemia

E11.69

Type 2 diabetes mellitus with other specified complication

E13.10

Other specified diabetes mellitus with ketoacidosis without coma

E10.10

Type 1 diabetes mellitus with ketoacidosis without coma

E10.69

Type 1 diabetes mellitus with other specified complication

E11.620

Type 2 diabetes mellitus with diabetic dermatitis

E11.621

Type 2 diabetes mellitus with foot ulcer

E11.622

Type 2 diabetes mellitus with other skin ulcer

E11.628

Type 2 diabetes mellitus with other skin complications

E11.638

Type 2 diabetes mellitus with other oral complications

E11.649

Type 2 diabetes mellitus with hypoglycemia without coma

E13.620

Other specified diabetes mellitus with diabetic dermatitis

E13.621

Other specified diabetes mellitus with foot ulcer

E13.622

Other specified diabetes mellitus with other skin ulcer

E13.628

Other specified diabetes mellitus with other skin complications

E13.638

Other specified diabetes mellitus with other oral complications

E13.649

Other specified diabetes mellitus with hypoglycemia without coma

E13.65

Other specified diabetes mellitus with hyperglycemia

E13.69

Other specified diabetes mellitus with other specified complication

E10.620

Type 1 diabetes mellitus with diabetic dermatitis

E10.621

Type 1 diabetes mellitus with foot ulcer

E10.622

Type 1 diabetes mellitus with other skin ulcer

E10.628

Type 1 diabetes mellitus with other skin complications

E10.638

Type 1 diabetes mellitus with other oral complications

E10.649

Type 1 diabetes mellitus with hypoglycemia without coma

E11.8

Type 2 diabetes mellitus with unspecified complications

E13.8

Other specified diabetes mellitus with unspecified complications

E16.2

Hypoglycemia, unspecified

M10.9

Gout, unspecified

G44.209

Tension-type headache, unspecified, not intractable

G43.909

Migraine, unspecified, not intractable, without status migrainosus

G51.0

Bell's palsy

G56.00

Carpal tunnel syndrome, unspecified upper limb

G56.01

Carpal tunnel syndrome, right upper limb

G56.02

Carpal tunnel syndrome, left upper limb

G56.90

Unspecified mononeuropathy of unspecified upper limb

G56.91

Unspecified mononeuropathy of right upper limb

G56.92

Unspecified mononeuropathy of left upper limb

H10.30

Unspecified acute conjunctivitis, unspecified eye

H10.31

Unspecified acute conjunctivitis, right eye

H10.32

Unspecified acute conjunctivitis, left eye

H10.33

Unspecified acute conjunctivitis, bilateral

H10.021

Other mucopurulent conjunctivitis, right eye

H10.022

Other mucopurulent conjunctivitis, left eye

H10.023

Other mucopurulent conjunctivitis, bilateral

H10.029

Other mucopurulent conjunctivitis, unspecified eye

H10.411

Chronic giant papillary conjunctivitis, right eye

H10.412

Chronic giant papillary conjunctivitis, left eye

H10.413

Chronic giant papillary conjunctivitis, bilateral

H10.419

Chronic giant papillary conjunctivitis, unspecified eye

H10.45

Other chronic allergic conjunctivitis

H10.9

Unspecified conjunctivitis

H11.001

Unspecified pterygium of right eye

H11.002

Unspecified pterygium of left eye

H11.003

Unspecified pterygium of eye, bilateral

H11.009

Unspecified pterygium of unspecified eye

H11.011

Amyloid pterygium of right eye

H11.012

Amyloid pterygium of left eye

H11.013

Amyloid pterygium of eye, bilateral

H11.019

Amyloid pterygium of unspecified eye

H00.011

Hordeolum externum right upper eyelid

H00.012

Hordeolum externum right lower eyelid

H00.013

Hordeolum externum right eye, unspecified eyelid

H00.014

Hordeolum externum left upper eyelid

H00.015

Hordeolum externum left lower eyelid

H00.016

Hordeolum externum left eye, unspecified eyelid

H00.019

Hordeolum externum unspecified eye, unspecified eyelid

H00.031

Abscess of right upper eyelid

H00.032

Abscess of right lower eyelid

H00.033

Abscess of eyelid right eye, unspecified eyelid

H00.034

Abscess of left upper eyelid

H00.035

Abscess of left lower eyelid

H00.036

Abscess of eyelid left eye, unspecified eyelid

H00.039

Abscess of eyelid unspecified eye, unspecified eyelid

H00.11

Chalazion right upper eyelid

H00.12

Chalazion right lower eyelid

H00.13

Chalazion right eye, unspecified eyelid

H00.14

Chalazion left upper eyelid

H00.15

Chalazion left lower eyelid

H00.16

Chalazion left eye, unspecified eyelid

H00.19

Chalazion unspecified eye, unspecified eyelid

H57.10

Ocular pain, unspecified eye

H57.11

Ocular pain, right eye

H57.12

Ocular pain, left eye

H57.13

Ocular pain, bilateral

H60.00

Abscess of external ear, unspecified ear

H60.01

Abscess of right external ear

H60.02

Abscess of left external ear

H60.03

Abscess of external ear, bilateral

H60.10

Cellulitis of external ear, unspecified ear

H60.11

Cellulitis of right external ear

H60.12

Cellulitis of left external ear

H60.13

Cellulitis of external ear, bilateral

H60.311

Diffuse otitis externa, right ear

H60.312

Diffuse otitis externa, left ear

H60.313

Diffuse otitis externa, bilateral

H60.319

Diffuse otitis externa, unspecified ear

H60.321

Hemorrhagic otitis externa, right ear

H60.322

Hemorrhagic otitis externa, left ear

H60.323

Hemorrhagic otitis externa, bilateral

H60.329

Hemorrhagic otitis externa, unspecified ear

H60.391

Other infective otitis externa, right ear

H60.392

Other infective otitis externa, left ear

H60.393

Other infective otitis externa, bilateral

H60.399

Other infective otitis externa, unspecified ear

H61.20

Impacted cerumen, unspecified ear

H61.21

Impacted cerumen, right ear

H61.22

Impacted cerumen, left ear

H61.23

Impacted cerumen, bilateral

H65.191

Other acute nonsuppurative otitis media, right ear

H65.192

Other acute nonsuppurative otitis media, left ear

H65.193

Other acute nonsuppurative otitis media, bilateral

H65.194

Other acute nonsuppurative otitis media, recurrent, right ear

H65.195

Other acute nonsuppurative otitis media, recurrent, left ear

H65.196

Other acute nonsuppurative otitis media, recurrent, bilateral

H65.197

Other acute nonsuppurative otitis media recurrent, unspecified ear

H65.199

Other acute nonsuppurative otitis media, unspecified ear

H65.00

Acute serous otitis media, unspecified ear

H65.01

Acute serous otitis media, right ear

H65.02

Acute serous otitis media, left ear

H65.03

Acute serous otitis media, bilateral

H65.04

Acute serous otitis media, recurrent, right ear

H65.05

Acute serous otitis media, recurrent, left ear

H65.06

Acute serous otitis media, recurrent, bilateral

H65.07

Acute serous otitis media, recurrent, unspecified ear

H65.20

Chronic serous otitis media, unspecified ear

H65.21

Chronic serous otitis media, right ear

H65.22

Chronic serous otitis media, left ear

H65.23

Chronic serous otitis media, bilateral

H65.90

Unspecified nonsuppurative otitis media, unspecified ear

H65.91

Unspecified nonsuppurative otitis media, right ear

H65.92

Unspecified nonsuppurative otitis media, left ear

H65.93

Unspecified nonsuppurative otitis media, bilateral

H66.001

Acute suppurative otitis media without spontaneous rupture of ear drum, right ear

H66.002

Acute suppurative otitis media without spontaneous rupture of ear drum, left ear

H66.003

Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral

H66.004

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear

H66.005

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear

H66.006

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral

H66.007

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear

H66.009

Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear

H66.90

Otitis media, unspecified, unspecified ear

H66.91

Otitis media, unspecified, right ear

H66.92

Otitis media, unspecified, left ear

H66.93

Otitis media, unspecified, bilateral

H72.90

Unspecified perforation of tympanic membrane, unspecified ear

H72.91

Unspecified perforation of tympanic membrane, right ear

H72.92

Unspecified perforation of tympanic membrane, left ear

H72.93

Unspecified perforation of tympanic membrane, bilateral

H83.3X1

Noise effects on right inner ear

H83.3X2

Noise effects on left inner ear

H83.3X3

Noise effects on inner ear, bilateral

H83.3X9

Noise effects on inner ear, unspecified ear

H93.11

Tinnitus, right ear

H93.12

Tinnitus, left ear

H93.13

Tinnitus, bilateral

H93.19

Tinnitus, unspecified ear

H92.10

Otorrhea, unspecified ear

H92.11

Otorrhea, right ear

H92.12

Otorrhea, left ear

H92.13

Otorrhea, bilateral

H92.20

Otorrhagia, unspecified ear

H92.21

Otorrhagia, right ear

H92.22

Otorrhagia, left ear

H92.23

Otorrhagia, bilateral

H92.01

Otalgia, right ear

H92.02

Otalgia, left ear

H92.03

Otalgia, bilateral

H92.09

Otalgia, unspecified ear

H93.8X1

Other specified disorders of right ear

H93.8X2

Other specified disorders of left ear

H93.8X3

Other specified disorders of ear, bilateral

H93.8X9

Other specified disorders of ear, unspecified ear

H94.80

Other specified disorders of ear in diseases classified elsewhere, unspecified ear

H94.81

Other specified disorders of right ear in diseases classified elsewhere

H94.82

Other specified disorders of left ear in diseases classified elsewhere

H94.83

Other specified disorders of ear in diseases classified elsewhere, bilateral

I10.

Essential (primary) hypertension

I50.9

Heart failure, unspecified

K64.9

Unspecified hemorrhoids

J00.

Acute nasopharyngitis [common cold]

J01.00

Acute maxillary sinusitis, unspecified

J01.01

Acute recurrent maxillary sinusitis

J01.90

Acute sinusitis, unspecified

J01.91

Acute recurrent sinusitis, unspecified

J02.8

Acute pharyngitis due to other specified organisms

J02.9

Acute pharyngitis, unspecified

J03.80

Acute tonsillitis due to other specified organisms

J03.81

Acute recurrent tonsillitis due to other specified organisms

J03.90

Acute tonsillitis, unspecified

J03.91

Acute recurrent tonsillitis, unspecified

J04.10

Acute tracheitis without obstruction

J06.9

Acute upper respiratory infection, unspecified

J20.8

Acute bronchitis due to other specified organisms

J20.9

Acute bronchitis, unspecified

J31.0

Chronic rhinitis

J32.0

Chronic maxillary sinusitis

J32.9

Chronic sinusitis, unspecified

J30.1

Allergic rhinitis due to pollen

J30.0

Vasomotor rhinitis

J30.9

Allergic rhinitis, unspecified

J18.1

Lobar pneumonia, unspecified organism

J18.0

Bronchopneumonia, unspecified organism

J18.8

Other pneumonia, unspecified organism

J18.9

Pneumonia, unspecified organism

J10.1

Influenza due to other identified influenza virus with other respiratory manifestations

J11.1

Influenza due to unidentified influenza virus with other respiratory manifestations

J40.

Bronchitis, not specified as acute or chronic

J44.9

Chronic obstructive pulmonary disease, unspecified

J44.1

Chronic obstructive pulmonary disease with (acute) exacerbation

J42.

Unspecified chronic bronchitis

J43.9

Emphysema, unspecified

J43.0

Unilateral pulmonary emphysema [MacLeod's syndrome]

J43.1

Panlobular emphysema

J43.2

Centrilobular emphysema

J43.8

Other emphysema

J45.20

Mild intermittent asthma, uncomplicated

J45.30

Mild persistent asthma, uncomplicated

J45.40

Moderate persistent asthma, uncomplicated

J45.50

Severe persistent asthma, uncomplicated

J45.22

Mild intermittent asthma with status asthmaticus

J45.32

Mild persistent asthma with status asthmaticus

J45.42

Moderate persistent asthma with status asthmaticus

J45.52

Severe persistent asthma with status asthmaticus

J45.21

Mild intermittent asthma with (acute) exacerbation

J45.31

Mild persistent asthma with (acute) exacerbation

J45.41

Moderate persistent asthma with (acute) exacerbation

J45.51

Severe persistent asthma with (acute) exacerbation

J45.990

Exercise induced bronchospasm

J45.991

Cough variant asthma

J45.909

Unspecified asthma, uncomplicated

J45.998

Other asthma

J45.902

Unspecified asthma with status asthmaticus

J45.901

Unspecified asthma with (acute) exacerbation

K04.4

Acute apical periodontitis of pulpal origin

K04.7

Periapical abscess without sinus

K08.8

Other specified disorders of teeth and supporting structures

M26.79

Other specified alveolar anomalies

K08.9

Disorder of teeth and supporting structures, unspecified

K12.2

Cellulitis and abscess of mouth

K12.0

Recurrent oral aphthae

K13.1

Cheek and lip biting

K13.4

Granuloma and granuloma-like lesions of oral mucosa

K13.6

Irritative hyperplasia of oral mucosa

K13.70

Unspecified lesions of oral mucosa

K13.79

Other lesions of oral mucosa

K21.9

Gastro-esophageal reflux disease without esophagitis

K40.90

Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent

K52.89

Other specified noninfective gastroenteritis and colitis

K52.9

Noninfective gastroenteritis and colitis, unspecified

K58.0

Irritable bowel syndrome with diarrhea

K58.9

Irritable bowel syndrome without diarrhea

K60.0

Acute anal fissure

K60.1

Chronic anal fissure

K60.2

Anal fissure, unspecified

N10.

Acute tubulo-interstitial nephritis

N11.9

Chronic tubulo-interstitial nephritis, unspecified

N12.

Tubulo-interstitial nephritis, not specified as acute or chronic

N13.6

Pyonephrosis

N30.00

Acute cystitis without hematuria

N30.01

Acute cystitis with hematuria

N30.90

Cystitis, unspecified without hematuria

N30.91

Cystitis, unspecified with hematuria

N34.1

Nonspecific urethritis

N34.2

Other urethritis

N39.0

Urinary tract infection, site not specified

N45.1

Epididymitis

N45.2

Orchitis

N45.3

Epididymo-orchitis

N47.6

Balanoposthitis

N48.1

Balanitis

N50.9

Disorder of male genital organs, unspecified

R10.2

Pelvic and perineal pain

N64.4

Mastodynia

N63.

Unspecified lump in breast

N73.5

Female pelvic peritonitis, unspecified

N73.9

Female pelvic inflammatory disease, unspecified

N72.

Inflammatory disease of cervix uteri

N76.0

Acute vaginitis

N76.1

Subacute and chronic vaginitis

N76.2

Acute vulvitis

N76.3

Subacute and chronic vulvitis

N83.20

Unspecified ovarian cysts

N83.29

Other ovarian cysts

N89.8

Other specified noninflammatory disorders of vagina

N94.4

Primary dysmenorrhea

N94.5

Secondary dysmenorrhea

N94.6

Dysmenorrhea, unspecified

N94.89

Other specified conditions associated with female genital organs and menstrual cycle

N92.0

Excessive and frequent menstruation with regular cycle

N92.5

Other specified irregular menstruation

N92.6

Irregular menstruation, unspecified

N89.7

Hematocolpos

N93.8

Other specified abnormal uterine and vaginal bleeding

N93.9

Abnormal uterine and vaginal bleeding, unspecified

O21.0

Mild hyperemesis gravidarum

O25.11

Malnutrition in pregnancy, first trimester

O25.12

Malnutrition in pregnancy, second trimester

O25.13

Malnutrition in pregnancy, third trimester

O99.281

Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester

O99.282

Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester

O99.283

Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester

O99.511

Diseases of the respiratory system complicating pregnancy, first trimester

O99.512

Diseases of the respiratory system complicating pregnancy, second trimester

O99.513

Diseases of the respiratory system complicating pregnancy, third trimester

O99.611

Diseases of the digestive system complicating pregnancy, first trimester

O99.612

Diseases of the digestive system complicating pregnancy, second trimester

O99.613

Diseases of the digestive system complicating pregnancy, third trimester

O99.711

Diseases of the skin and subcutaneous tissue complicating pregnancy, first trimester

O99.712

Diseases of the skin and subcutaneous tissue complicating pregnancy, second trimester

O99.713

Diseases of the skin and subcutaneous tissue complicating pregnancy, third trimester

O9A.111

Malignant neoplasm complicating pregnancy, first trimester

O9A.112

Malignant neoplasm complicating pregnancy, second trimester

O9A.113

Malignant neoplasm complicating pregnancy, third trimester

O9A.211

Injury, poisoning and certain other consequences of external causes complicating pregnancy, first trimester

O9A.212

Injury, poisoning and certain other consequences of external causes complicating pregnancy, second trimester

O9A.213

Injury, poisoning and certain other consequences of external causes complicating pregnancy, third trimester

L02.92

Furuncle, unspecified

L02.93

Carbuncle, unspecified

L02.511

Cutaneous abscess of right hand

L02.512

Cutaneous abscess of left hand

L02.519

Cutaneous abscess of unspecified hand

L03.011

Cellulitis of right finger

L03.012

Cellulitis of left finger

L03.019

Cellulitis of unspecified finger

L03.021

Acute lymphangitis of right finger

L03.022

Acute lymphangitis of left finger

L03.029

Acute lymphangitis of unspecified finger

L02.611

Cutaneous abscess of right foot

L02.612

Cutaneous abscess of left foot

L02.619

Cutaneous abscess of unspecified foot

L03.031

Cellulitis of right toe

L03.032

Cellulitis of left toe

L03.039

Cellulitis of unspecified toe

L03.041

Acute lymphangitis of right toe

L03.042

Acute lymphangitis of left toe

L03.049

Acute lymphangitis of unspecified toe

L02.01

Cutaneous abscess of face

L03.211

Cellulitis of face

L03.212

Acute lymphangitis of face

L02.211

Cutaneous abscess of abdominal wall

L02.212

Cutaneous abscess of back [any part, except buttock]

L02.213

Cutaneous abscess of chest wall

L02.214

Cutaneous abscess of groin

L02.215

Cutaneous abscess of perineum

L02.216

Cutaneous abscess of umbilicus

L02.219

Cutaneous abscess of trunk, unspecified

L03.311

Cellulitis of abdominal wall

L03.312

Cellulitis of back [any part except buttock]

L03.313

Cellulitis of chest wall

L03.314

Cellulitis of groin

L03.315

Cellulitis of perineum

L03.316

Cellulitis of umbilicus

L03.319

Cellulitis of trunk, unspecified

L03.321

Acute lymphangitis of abdominal wall

L03.322

Acute lymphangitis of back [any part except buttock]

L03.323

Acute lymphangitis of chest wall

L03.324

Acute lymphangitis of groin

L03.325

Acute lymphangitis of perineum

L03.326

Acute lymphangitis of umbilicus

L03.329

Acute lymphangitis of trunk, unspecified

L02.411

Cutaneous abscess of right axilla

L02.412

Cutaneous abscess of left axilla

L02.413

Cutaneous abscess of right upper limb

L02.414

Cutaneous abscess of left upper limb

L02.419

Cutaneous abscess of limb, unspecified

L03.111

Cellulitis of right axilla

L03.112

Cellulitis of left axilla

L03.113

Cellulitis of right upper limb

L03.114

Cellulitis of left upper limb

L03.119

Cellulitis of unspecified part of limb

L03.121

Acute lymphangitis of right axilla

L03.122

Acute lymphangitis of left axilla

L03.123

Acute lymphangitis of right upper limb

L03.124

Acute lymphangitis of left upper limb

L03.129

Acute lymphangitis of unspecified part of limb

L02.31

Cutaneous abscess of buttock

L03.317

Cellulitis of buttock

L03.327

Acute lymphangitis of buttock

L02.415

Cutaneous abscess of right lower limb

L02.416

Cutaneous abscess of left lower limb

L03.115

Cellulitis of right lower limb

L03.116

Cellulitis of left lower limb

L03.125

Acute lymphangitis of right lower limb

L03.126

Acute lymphangitis of left lower limb

L02.811

Cutaneous abscess of head [any part, except face]

L02.818

Cutaneous abscess of other sites

L03.811

Cellulitis of head [any part, except face]

L03.818

Cellulitis of other sites

L03.891

Acute lymphangitis of head [any part, except face]

L03.898

Acute lymphangitis of other sites

L02.91

Cutaneous abscess, unspecified

L03.90

Cellulitis, unspecified

L03.91

Acute lymphangitis, unspecified

L98.3

Eosinophilic cellulitis [Wells]

L01.00

Impetigo, unspecified

L01.01

Non-bullous impetigo

L01.02

Bockhart's impetigo

L01.03

Bullous impetigo

L01.09

Other impetigo

L01.1

Impetiginization of other dermatoses

L05.01

Pilonidal cyst with abscess

L05.02

Pilonidal sinus with abscess

L05.91

Pilonidal cyst without abscess

L05.92

Pilonidal sinus without abscess

L08.9

Local infection of the skin and subcutaneous tissue, unspecified

L21.9

Seborrheic dermatitis, unspecified

L22.

Diaper dermatitis

L20.0

Besnier's prurigo

L20.81

Atopic neurodermatitis

L20.82

Flexural eczema

L20.84

Intrinsic (allergic) eczema

L20.89

Other atopic dermatitis

L20.9

Atopic dermatitis, unspecified

L23.7

Allergic contact dermatitis due to plants, except food

L24.7

Irritant contact dermatitis due to plants, except food

L25.5

Unspecified contact dermatitis due to plants, except food

L55.0

Sunburn of first degree

L55.9

Sunburn, unspecified

L23.9

Allergic contact dermatitis, unspecified cause

L24.9

Irritant contact dermatitis, unspecified cause

L25.9

Unspecified contact dermatitis, unspecified cause

L30.0

Nummular dermatitis

L30.2

Cutaneous autosensitization

L30.8

Other specified dermatitis

L30.9

Dermatitis, unspecified

L27.0

Generalized skin eruption due to drugs and medicaments taken internally

L27.1

Localized skin eruption due to drugs and medicaments taken internally

L27.2

Dermatitis due to ingested food

L42.

Pityriasis rosea

L29.9

Pruritus, unspecified

L60.0

Ingrowing nail

L63.2

Ophiasis

L63.8

Other alopecia areata

L63.9

Alopecia areata, unspecified

L66.3

Perifolliculitis capitis abscedens

L73.1

Pseudofolliculitis barbae

L73.8

Other specified follicular disorders

L74.0

Miliaria rubra

L74.1

Miliaria crystallina

L74.2

Miliaria profunda

L74.3

Miliaria, unspecified

L74.8

Other eccrine sweat disorders

L75.0

Bromhidrosis

L75.1

Chromhidrosis

L75.8

Other apocrine sweat disorders

L70.0

Acne vulgaris

L70.1

Acne conglobata

L70.3

Acne tropica

L70.4

Infantile acne

L70.5

Acne excoriee des jeunes filles

L70.8

Other acne

L70.9

Acne, unspecified

L73.0

Acne keloid

L72.0

Epidermal cyst

L72.2

Steatocystoma multiplex

L72.3

Sebaceous cyst

L72.8

Other follicular cysts of the skin and subcutaneous tissue

L72.9

Follicular cyst of the skin and subcutaneous tissue, unspecified

L50.9

Urticaria, unspecified

M12.9

Arthropathy, unspecified

M22.90

Unspecified disorder of patella, unspecified knee

M22.91

Unspecified disorder of patella, right knee

M22.92

Unspecified disorder of patella, left knee

M23.90

Unspecified internal derangement of unspecified knee

M23.91

Unspecified internal derangement of right knee

M23.92

Unspecified internal derangement of left knee

M25.461

Effusion, right knee

M25.462

Effusion, left knee

M25.469

Effusion, unspecified knee

M25.511

Pain in right shoulder

M25.512

Pain in left shoulder

M25.519

Pain in unspecified shoulder

M25.521

Pain in right elbow

M25.522

Pain in left elbow

M25.529

Pain in unspecified elbow

M25.531

Pain in right wrist

M25.532

Pain in left wrist

M25.539

Pain in unspecified wrist

M25.561

Pain in right knee

M25.562

Pain in left knee

M25.569

Pain in unspecified knee

M25.571

Pain in right ankle and joints of right foot

M25.572

Pain in left ankle and joints of left foot

M25.579

Pain in unspecified ankle and joints of unspecified foot

M25.50

Pain in unspecified joint

M54.2

Cervicalgia

M54.5

Low back pain

M54.14

Radiculopathy, thoracic region

M54.15

Radiculopathy, thoracolumbar region

M54.16

Radiculopathy, lumbar region

M54.17

Radiculopathy, lumbosacral region

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M54.03

Panniculitis affecting regions of neck and back, cervicothoracic region

M54.04

Panniculitis affecting regions of neck and back, thoracic region

M54.05

Panniculitis affecting regions of neck and back, thoracolumbar region

M54.06

Panniculitis affecting regions of neck and back, lumbar region

M54.07

Panniculitis affecting regions of neck and back, lumbosacral region

M54.08

Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region

M54.09

Panniculitis affecting regions, neck and back, multiple sites in spine

M62.830

Muscle spasm of back

M25.751

Osteophyte, right hip

M25.752

Osteophyte, left hip

M25.759

Osteophyte, unspecified hip

M70.60

Trochanteric bursitis, unspecified hip

M70.61

Trochanteric bursitis, right hip

M70.62

Trochanteric bursitis, left hip

M70.70

Other bursitis of hip, unspecified hip

M70.71

Other bursitis of hip, right hip

M70.72

Other bursitis of hip, left hip

M76.00

Gluteal tendinitis, unspecified hip

M76.01

Gluteal tendinitis, right hip

M76.02

Gluteal tendinitis, left hip

M76.10

Psoas tendinitis, unspecified hip

M76.11

Psoas tendinitis, right hip

M76.12

Psoas tendinitis, left hip

M76.20

Iliac crest spur, unspecified hip

M76.21

Iliac crest spur, right hip

M76.22

Iliac crest spur, left hip

M76.30

Iliotibial band syndrome, unspecified leg

M76.31

Iliotibial band syndrome, right leg

M76.32

Iliotibial band syndrome, left leg

M76.50

Patellar tendinitis, unspecified knee

M76.51

Patellar tendinitis, right knee

M76.52

Patellar tendinitis, left knee

M76.70

Peroneal tendinitis, unspecified leg

M76.71

Peroneal tendinitis, right leg

M76.72

Peroneal tendinitis, left leg

M77.50

Other enthesopathy of unspecified foot

M77.51

Other enthesopathy of right foot

M77.52

Other enthesopathy of left foot

M77.9

Enthesopathy, unspecified

M25.70

Osteophyte, unspecified joint

M65.831

Other synovitis and tenosynovitis, right forearm

M65.832

Other synovitis and tenosynovitis, left forearm

M65.839

Other synovitis and tenosynovitis, unspecified forearm

M65.841

Other synovitis and tenosynovitis, right hand

M65.842

Other synovitis and tenosynovitis, left hand

M65.849

Other synovitis and tenosynovitis, unspecified hand

M65.10

Other infective (teno)synovitis, unspecified site

M65.111

Other infective (teno)synovitis, right shoulder

M65.112

Other infective (teno)synovitis, left shoulder

M65.119

Other infective (teno)synovitis, unspecified shoulder

M65.121

Other infective (teno)synovitis, right elbow

M65.122

Other infective (teno)synovitis, left elbow

M65.129

Other infective (teno)synovitis, unspecified elbow

M65.131

Other infective (teno)synovitis, right wrist

M65.132

Other infective (teno)synovitis, left wrist

M65.139

Other infective (teno)synovitis, unspecified wrist

M65.141

Other infective (teno)synovitis, right hand

M65.142

Other infective (teno)synovitis, left hand

M65.149

Other infective (teno)synovitis, unspecified hand

M65.151

Other infective (teno)synovitis, right hip

M65.152

Other infective (teno)synovitis, left hip

M65.159

Other infective (teno)synovitis, unspecified hip

M65.161

Other infective (teno)synovitis, right knee

M65.162

Other infective (teno)synovitis, left knee

M65.169

Other infective (teno)synovitis, unspecified knee

M65.171

Other infective (teno)synovitis, right ankle and foot

M65.172

Other infective (teno)synovitis, left ankle and foot

M65.179

Other infective (teno)synovitis, unspecified ankle and foot

M65.18

Other infective (teno)synovitis, other site

M65.19

Other infective (teno)synovitis, multiple sites

M65.80

Other synovitis and tenosynovitis, unspecified site

M65.811

Other synovitis and tenosynovitis, right shoulder

M65.812

Other synovitis and tenosynovitis, left shoulder

M65.819

Other synovitis and tenosynovitis, unspecified shoulder

M65.821

Other synovitis and tenosynovitis, right upper arm

M65.822

Other synovitis and tenosynovitis, left upper arm

M65.829

Other synovitis and tenosynovitis, unspecified upper arm

M65.851

Other synovitis and tenosynovitis, right thigh

M65.852

Other synovitis and tenosynovitis, left thigh

M65.859

Other synovitis and tenosynovitis, unspecified thigh

M65.861

Other synovitis and tenosynovitis, right lower leg

M65.862

Other synovitis and tenosynovitis, left lower leg

M65.869

Other synovitis and tenosynovitis, unspecified lower leg

M65.88

Other synovitis and tenosynovitis, other site

M65.89

Other synovitis and tenosynovitis, multiple sites

M67.30

Transient synovitis, unspecified site

M67.311

Transient synovitis, right shoulder

M67.312

Transient synovitis, left shoulder

M67.319

Transient synovitis, unspecified shoulder

M67.321

Transient synovitis, right elbow

M67.322

Transient synovitis, left elbow

M67.329

Transient synovitis, unspecified elbow

M67.331

Transient synovitis, right wrist

M67.332

Transient synovitis, left wrist

M67.339

Transient synovitis, unspecified wrist

M67.341

Transient synovitis, right hand

M67.342

Transient synovitis, left hand

M67.349

Transient synovitis, unspecified hand

M67.351

Transient synovitis, right hip

M67.352

Transient synovitis, left hip

M67.359

Transient synovitis, unspecified hip

M67.361

Transient synovitis, right knee

M67.362

Transient synovitis, left knee

M67.369

Transient synovitis, unspecified knee

M67.371

Transient synovitis, right ankle and foot

M67.372

Transient synovitis, left ankle and foot

M67.379

Transient synovitis, unspecified ankle and foot

M67.38

Transient synovitis, other site

M67.39

Transient synovitis, multiple sites

M62.40

Contracture of muscle, unspecified site

M62.411

Contracture of muscle, right shoulder

M62.412

Contracture of muscle, left shoulder

M62.419

Contracture of muscle, unspecified shoulder

M62.421

Contracture of muscle, right upper arm

M62.422

Contracture of muscle, left upper arm

M62.429

Contracture of muscle, unspecified upper arm

M62.431

Contracture of muscle, right forearm

M62.432

Contracture of muscle, left forearm

M62.439

Contracture of muscle, unspecified forearm

M62.441

Contracture of muscle, right hand

M62.442

Contracture of muscle, left hand

M62.449

Contracture of muscle, unspecified hand

M62.451

Contracture of muscle, right thigh

M62.452

Contracture of muscle, left thigh

M62.459

Contracture of muscle, unspecified thigh

M62.461

Contracture of muscle, right lower leg

M62.462

Contracture of muscle, left lower leg

M62.469

Contracture of muscle, unspecified lower leg

M62.471

Contracture of muscle, right ankle and foot

M62.472

Contracture of muscle, left ankle and foot

M62.479

Contracture of muscle, unspecified ankle and foot

M62.48

Contracture of muscle, other site

M62.49

Contracture of muscle, multiple sites

M62.831

Muscle spasm of calf

M62.838

Other muscle spasm

M60.80

Other myositis, unspecified site

M60.811

Other myositis, right shoulder

M60.812

Other myositis, left shoulder

M60.819

Other myositis, unspecified shoulder

M60.821

Other myositis, right upper arm

M60.822

Other myositis, left upper arm

M60.829

Other myositis, unspecified upper arm

M60.831

Other myositis, right forearm

M60.832

Other myositis, left forearm

M60.839

Other myositis, unspecified forearm

M60.841

Other myositis, right hand

M60.842

Other myositis, left hand

M60.849

Other myositis, unspecified hand

M60.851

Other myositis, right thigh

M60.852

Other myositis, left thigh

M60.859

Other myositis, unspecified thigh

M60.861

Other myositis, right lower leg

M60.862

Other myositis, left lower leg

M60.869

Other myositis, unspecified lower leg

M60.871

Other myositis, right ankle and foot

M60.872

Other myositis, left ankle and foot

M60.879

Other myositis, unspecified ankle and foot

M60.88

Other myositis, other site

M60.89

Other myositis, multiple sites

M60.9

Myositis, unspecified

M79.1

Myalgia

M79.7

Fibromyalgia

M79.601

Pain in right arm

M79.602

Pain in left arm

M79.603

Pain in arm, unspecified

M79.604

Pain in right leg

M79.605

Pain in left leg

M79.606

Pain in leg, unspecified

M79.609

Pain in unspecified limb

M79.621

Pain in right upper arm

M79.622

Pain in left upper arm

M79.629

Pain in unspecified upper arm

M79.631

Pain in right forearm

M79.632

Pain in left forearm

M79.639

Pain in unspecified forearm

M79.641

Pain in right hand

M79.642

Pain in left hand

M79.643

Pain in unspecified hand

M79.644

Pain in right finger(s)

M79.645

Pain in left finger(s)

M79.646

Pain in unspecified finger(s)

M79.651

Pain in right thigh

M79.652

Pain in left thigh

M79.659

Pain in unspecified thigh

M79.661

Pain in right lower leg

M79.662

Pain in left lower leg

M79.669

Pain in unspecified lower leg

M79.671

Pain in right foot

M79.672

Pain in left foot

M79.673

Pain in unspecified foot

M79.674

Pain in right toe(s)

M79.675

Pain in left toe(s)

M79.676

Pain in unspecified toe(s)

M79.89

Other specified soft tissue disorders

M94.0

Chondrocostal junction syndrome [Tietze]

R42.

Dizziness and giddiness

G93.3

Postviral fatigue syndrome

R53.0

Neoplastic (malignant) related fatigue

R53.1

Weakness

R53.81

Other malaise

R53.83

Other fatigue

R21.

Rash and other nonspecific skin eruption

R22.0

Localized swelling, mass and lump, head

R22.1

Localized swelling, mass and lump, neck

R22.30

Localized swelling, mass and lump, unspecified upper limb

R22.31

Localized swelling, mass and lump, right upper limb

R22.32

Localized swelling, mass and lump, left upper limb

R22.33

Localized swelling, mass and lump, upper limb, bilateral

R22.40

Localized swelling, mass and lump, unspecified lower limb

R22.41

Localized swelling, mass and lump, right lower limb

R22.42

Localized swelling, mass and lump, left lower limb

R22.43

Localized swelling, mass and lump, lower limb, bilateral

R22.9

Localized swelling, mass and lump, unspecified

R23.3

Spontaneous ecchymoses

R23.4

Changes in skin texture

G44.1

Vascular headache, not elsewhere classified

R51.

Headache

R90.0

Intracranial space-occupying lesion found on diagnostic imaging of central nervous system

R04.0

Epistaxis

R59.0

Localized enlarged lymph nodes

R59.1

Generalized enlarged lymph nodes

R59.9

Enlarged lymph nodes, unspecified

R05.

Cough

R11.2

Nausea with vomiting, unspecified

R11.0

Nausea

R11.10

Vomiting, unspecified

R11.11

Vomiting without nausea

R11.12

Projectile vomiting

R14.0

Abdominal distension (gaseous)

R14.1

Gas pain

R14.2

Eructation

R14.3

Flatulence

R19.7

Diarrhea, unspecified

R19.4

Change in bowel habit

R30.0

Dysuria

R30.9

Painful micturition, unspecified

R35.0

Frequency of micturition

R35.8

Other polyuria

R35.1

Nocturia

R36.0

Urethral discharge without blood

R36.9

Urethral discharge, unspecified

R10.0

Acute abdomen

R10.9

Unspecified abdominal pain

R10.11

Right upper quadrant pain

R10.12

Left upper quadrant pain

R10.31

Right lower quadrant pain

R10.32

Left lower quadrant pain

R10.13

Epigastric pain

R10.84

Generalized abdominal pain

R10.10

Upper abdominal pain, unspecified

R10.30

Lower abdominal pain, unspecified

R16.0

Hepatomegaly, not elsewhere classified

R19.00

Intra-abdominal and pelvic swelling, mass and lump, unspecified site

Z33.1

Pregnant state, incidental

Z76.0

Encounter for issue of repeat prescription