1. Section Modifications

Transcription

1 Table of Contents 1. Section Modifications UB04 Claim Form Completing the UB Helpful Tips for Filling out a Paper Claim Claim Form Field s Billing Information Appendix A. Home Health Policy - Institutional Appendix B. Hospice Institutional Appendix C. Hospital C.1 Accommodation/Room Revenue C.2 Ancillary Revenue C.3 Free Standing Dialysis Appendix D. Long Term Care Facility Appendix E. Idaho Medicaid Approved Bill Types for Specific Provider Types and Specialties 36 E.1 Home Health E.2 Hospice E.3 Hospital E.4 Skilled Nursing Facility/Long Term Care Bill Types E.5 Renal Dialysis Bill Types October 20, 2017 Page i

2 1. Section Modifications Versio n Section/Column Modification Publish Date 41.0 All Published version 10/20/17 TQD 40.2 Appendix C. Hospital Removed all revenue codes listed as Not Covered 10/20/17 D Baker E Garibovic 40.1 Appendix B. Hospice Institutional Added reference to Appendix E.2 for /20/17 D Baker E Garibovic 40.0 All Published version 9/21/17 TQD 39.5 C.4 Free Standing Revised CPT verbiage/references 9/21/17 D Baker Dialysis 39.4 C.3 Ancillary Revenue Added verbiage for ambulance 9/21/17 D Baker codes 39.3 Appendix A. Home Added CPT/HCPCS footnote for /21/17 D Baker Health Policy Institutional Billing Information New section for reference 9/21/17 D Baker Claim Form Updated CPT and HCPCS language 9/21/17 D Baker s 39.0 All Published version 6/27/17 TQD 38.1 C.3 Ancillary Revenue Changed Claim Type to Out for /27/17 D Baker E Garibovic 38.0 All Published version 5/9/17 TQD 37.2 C.3 Ancillary Revenue Changed Claim Type to for /9/17 E Garibovic Claim Form Field s Removed Medicaid ID from field 76; added fields to reflect current ORP requirements 5/8/17 J Kennedy- King D Baker 37.0 All Published version 4/20/17 TQD 36.1 C.3 Ancillary Revenue Added rev code 0527 as not covered for this claim type 4/20/17 D Baker E Garibovic 36.0 All Published version 2/27/17 TQD 35.1 C.3 Ancillary Revenue Updated rev code 0343 to reflect now covered for IP claims 2/27/17 D Baker E Garibovic 35.0 All Published version 2/1/17 TQD Helpful Tips for Filling Out a Paper Claim Added statement regarding cost centers 2/1/17 T Lombard D Baker E Garibovic 34.0 All Published version 12/15/16 TQD 33.1 C.3 Ancillary Revenue Updated yearly capitation amounts for 0420, 0430, and 0440 effective 1/1/17 12/15/16 D Baker E Garibovic 33.0 All Published version 9/12/16 TQD 32.1 C.3 Ancillary Revenue Specified prior to January 1, 2012 for 9/12/16 D Baker 0420, 0430, and All Published version 7/28/16 TQD 31.1 C.3 Ancillary Revenue Updated description for rev code /28/16 D Baker 31.0 All Published version 4/14/16 TQD 30.1 C.3 Ancillary Revenue Rev. 0684, updated to read: Level IV Trauma Center Rev 0413: number of units allowed updated to match the MUE of 5 SME 4/14/16 D Baker 30.0 All Published version 3/1/16 TQD 29.1 Appendix E. Re-inserted appendix, and changed title to 3/1/16 D Baker Idaho Medicaid Approved Bill Types for Specific Provider Types and Specialties 29.0 All Published version 2/12/16 TQD 28.2 Appendix E. Deletion of Appendix E. (Bill type) 2/12/16 D Baker October 20, 2017 Page 1 of 37

3 Versio n Section/Column Claim Form Field s Modification Publish Date SME Field No. 4, changes to language 2/11/16 D Baker J Kennedy 28.0 All Published version 1/4/16 TQD 27.1 C.3 Ancillary Revenue Edited code descriptions (0254, 0343, 0344) change/delete rev. code (0681, 0682, 0883, 1/4/16 D Baker J Siroky 0684) 27.0 All Published version 11/5/15 TQD 26.1 C.3 Ancillary Revenue Added level I, II, and III trauma 11/5/15 J Siroky D Baker 26.0 All Published version 8/28/15 TQD Claim Form Field s Updated for ICD-10 8/28/15 A Coppinger C Taylor D Baker 25.0 All Published version 7/2/15 TQD 24.1 C.3 Ancillary Revenue Updated description for 0413 Hyperbaric oxygen therapy 7/2/15 C Van Zile D Baker C Taylor 24.0 All Published version 6/26/15 TQD 23.2 Appendix E.1 Home Updated bill types per RQ 40911; removed 6/26/15 D Baker Health Outpatient outpatient designation 23.1 Appendix A Home Health Updated bill types per RQ /26/15 D Baker Policy Institutional 23.0 All Published version 3/30/15 TQD 22.1 C.3 Ancillary Revenue Updated description for rev code /30/15 A Coppinger C Taylor 22.0 All Published version 2/26/15 TQD 21.1 C.3 Ancillary Revenue Corrected service name for 0404 and 2/26/15 C Taylor removed reference to outdated IR All Published version 12/18/14 TQD 20.1 C.1 Accommodation/Room Removed codes from C.1 and inserted into new C.2 Special Charges table 12/18/14 C Taylor D Baker Revenue C.2 Special Charges 20.0 All Published version 12/4/14 TQD 19.1 C.2 Ancillary Revenue Added note that CPT codes marked with an asterisk (*) must be used for outpatient billing only. 12/4/14 C Coyle C Taylor 19.0 All Published version 10/9/14 TQD 18.1 C.2 Ancillary Revenue Added rev code 0637 for self-administrable drugs 10/9/14 A Coppinger C Taylor 18.0 All Published version 08/08/14 TQD 17.1 C.2 Ancillary Revenue Added Rev code 0780 for Telemedicine 08/08/14 C Taylor 17.0 All Published version 07/01/14 TQD 16.1 C.2 Ancillary Revenue Added Rev 0948 to show not covered 07/01/14 C Taylor D Baker 16.0 All Published version 05/23/14 TQD 15.2 C.2 Ancillary Revenue Updated description for Rev 0230, 05/23/14 C Taylor 0231, 0232, 0233, Claim Form Field Updated dates for ICD-10 to /23/14 C Taylor s 15.0 All Published version 04/11/14 TQD Claim Form Field s Clarified information for entering PA number in field /11/14 D Decrevel D Baker 14.0 All Published version 03/28/14 TQD Claim Form Field Reworded fields 76 (NPI) and 76 (QUAL and 03/28/14 C Taylor s ID) for clarity Claim Form Field s Field 67 A-Q, changed to required 03/28/14 C Taylor October 20, 2017 Page 2 of 37

4 Versio Section/Column n Claim Form Field s Claim Form Field s Modification Publish Date SME Updated field 66, 67, 67 A-Q, 72, 74, and 03/28/14 C Taylor 74a-e for ICD-10 Added field 63 and requirements 03/28/14 C Taylor 13.0 All Published version 01/10/14 TQD 12.1 Appendix C.2 Ancillary Removed references for PW; added 01/10/14 C Taylor Revenue statement that pregnancy related diabetic diagnosis is required in Education/Training table 12.0 All Published version 10/25/13 TQD 11.1 Appendix E Added missing 0s to bill type codes and 10/25/13 C Taylor clarified descriptions relating to Medicare Part A and B. Changed ICF/MR to ICF/ID All Published version 10/04/13 TQD 10.3 Added Appendix E. Bill Types Added bill types for Home Health, Hospice, SNF/LTC, Renal Dialysis 10/04/13 K McNeal C Taylor 10.2 C.2 Ancillary Revenue Updated 0274, 0510, 0541, 0544, 5048, and /04/13 K McNeal W Walther C Taylor Claim Form Field s Updated fields 66, 67, 67 A-Q 10/04/13 D Decrevel C Taylor 10.0 All Published version 7/25/13 D Baker Claim Form Field Inserted field 70 a,b,c 7/25/13 D Baker s Claim Form Field s 9.0 All Published version 6/24/13 D Baker 8.1 C.1 Accommodation Split section C.1 into two tables, C.1 6/24/13 D Baker Revenue Accommodation/Room Revenue and C.2 Ancillary 8.0 All Published version 2/21/13 TQD 7.3 C.1 Accommodation Updated information for /21/13 C Taylor Revenue 7.2 C.1 Accommodation Updated information for /21/13 C Taylor Revenue 7.1 C.1 Accommodation Updated information for /21/13 C Taylor Revenue 7.0 All Published version 10/02/12 TQD 6.3 C.1 Accommodation Updated description for rev codes 0420, 10/02/12 C Taylor Revenue 0430, and C.1 Accommodation Updated description for rev code /02/12 A Farmer Revenue 6.1 C.1 Accommodation Added rev code /02/12 S Pugatch Revenue 6.0 All Published version 02/28/12 TQD Claim Form Field Added ME to NDC unit of measure 02/28/12 J Decrevel s 5.0 All Published version 11/23/11 TQD 4.1 Appendix C Hospital Corrected Rev 0307 and /23/11 D Decrevel 4.0 All Published version 10/20/11 TQD 3.5 C.2 Free Standing Updated Revenue code information for /20/11 K Mcneal Dialysis 3.4 C.1 Accommodation Revenue Updated Revenue code 0183, 0189, 0420, 0430, 0440 information 10/20/11 B Rassmussen 3.3 Appendix A Home Health Policy - Institutional Claim Form Field s Field 80 Updated description for Revenue code 0658 Room and Board Care 10/20/11 Added 10/20/11 K Mcneal October 20, 2017 Page 3 of 37

5 Versio Section/Column n Claim Form Field s Fields 18, 35-a-b, and 36 a-b Modification Publish Date SME Added note 10/20/11 K Mcneal 3.0 All Published version 8/27/10 TQD 2.6 C.1 Combined tables for ease of use 8/27/10 TQD 2.5 C.2 Added /27/10 M Meints 2.4 C.1 Removed NDC number is required when 8/27/10 M Meints available for outpatient services for C.1 Removed not covered from 0183 and /27/10 M Meints Rev 2.2 C.1 Corrected Rev from 1081 to /27/10 M Meints 2.1 Field 4 Updated for clarity 8/27/10 M Wood 2.0 All Published Version 06/14/10 TQD Updated for clarity 06/14/10 E Charles Changed field name from Required to Use, 06/14/10 E Charles and updated the column entries to Required, etc. 1.5 Field 2 Changed 11 to 14-digit to 12 to 14-digit 06/14/10 E Charles 1.4 Field 64 Added this sentence: 06/14/10 E Charles Only enter if submitting a replacement or void to a previously submitted claim, otherwise leave blank. 1.3 Field 79 (NPI) Updated Notes: 06/14/10 E Charles Enter Referring Physician s NPI 1.2 Field 79 (QUAL and ID) Updated Notes: 06/14/10 E Charles Enter 1D followed by Referring Physician Medicaid Provider ID only If Referring Physician has not registered their NPI with Idaho Medicaid 1.1 All Sections were renumbered to accommodate 06/14/10 C Stickney additional information 1.0 All Initial document 5/7/2010 TQD October 20, 2017 Page 4 of 37

6 2. UB04 Claim Form October 20, 2017 Page 5 of 37

7 3. Completing the UB Helpful Tips for Filling out a Paper Claim Do not enter any data or documentation on the claim form that is not listed as required below. A maximum of twenty-two (22) line items per claim can be accepted; if the number of services performed exceeds twenty-two (22) lines, prepare a new claim form and complete the required data elements; total each claim separately. You can bill with a date span (From and To Dates of ) only if the service was provided every consecutive day within the span. Idaho Medicaid does not support billing and payment by cost centers, hospitals should bill all associated revenue codes as identified in the Ancillary Revenue section Claim Form Field s Field No. Field Name Use Notes 1 PROVIDER NAME AND ADDRESS 2 SERVICE FACILITY NAME AND ADDRESS Required Required if Applicable Billing Provider s Name, Address, City, State, and Zip. Enter name and address of service facility only if service location is different than billing provider name and address in box 1, otherwise leave box 2 blank. Enter 12 or 14-digit Facility Identifier following Facility name and address in box 2 only if service location identifier is different than billing provider box 1, otherwise leave box 2 completely blank. SERVICE FACILITY ID 3a PAT. CNTL # Required Patient CNTL Number - The patient s unique alpha-numeric control number assigned by the provider. 3b MED REC # Required Medical Record Number Medical/Health Record Number: The number assigned to the participant s medical/health record. 4 Type of Bill Required October 20, 2017 Page 6 of 37

8 Field No. Field Name Use Notes The first digit of the four-digit number is always 0, the second digit identifies the type of facility, the third digit classifies the type of care being billed and the fourth digit indicates the sequence of the bill for a specific episode of care. Please refer to national uniform billing information to ensure you are using the correct Type of Bill. If using bill sequence 7 or 8, please be sure to include the original claim number in box Fed. Tax No. Required Enter numeric 9 digit Federal Tax ID. 6 Statement Covers Period Required Statement Covers Period From/Through: The beginning and ending service dates of the period included on the bill. Enter each date as MMDDYY or MMDDCCYY. 8a Patient s Medicaid Member ID Required Enter the Participant s Idaho Medicaid ID number exactly as it appears on their Medicaid ID card. 8b PATIENT NAME Required Patient s name and address is required. 9a Patient s Required Enter participant s street address. Address 9b Patient s City Required Enter participant s city. 9c Patient s State Required Enter participant s state. 9d Patient s Zip Required Enter participant s zip code. 10 Date of Birth Required Enter participant s date of birth. Formatted: MMDDCCYY 11 Sex Required Enter participant s one digit gender code F Female M Male U Unknown 12 Admission Date Required if Inpatient, Hospice, Nursing Home Enter the month, day, and year the participant entered the facility. Enter as MMDDYY. October 20, 2017 Page 7 of 37

9 Field No. Field Name Use Notes 13 Admission Hour Required if Inpatient, Enter the 2-digit hour the participant was admitted for inpatient or outpatient care in military time. Outpatient, Examples: Enter 01 for 1:00 a.m. Enter 10 for 10:00 a.m. Enter 22 for Hospice, Nursing Home 10:00 p.m. 14 Admission Type Required if Enter one (1) digit Admission Type code. Inpatient 15 Admission Required if Enter one (1) digit Admission Source. Source Inpatient 16 Discharge Hour (DHR) 17 Patient Status (STAT) Required, on all final Inpatient Required if Inpatient Discharge Hour: Enter the 2-digit hour the participant was discharged in military time. Examples: Enter 01 for 1:00 a.m. Enter 10 for 10:00 a.m. Enter 22 for 10:00 p.m. Required for inpatient claims. If applicable Condition Desired Use the codes listed in the NUBC billing manual. Enter up to 11 codes. NOTE: For Home Health: If the participant has Medicare and Home Health services are not homebound, use Condition a thru 34a 31b thru 34b 35a-b and 36a-b Occurrence and Occurrence Date Occurrence and Occurrence Date Occurrence Span and Occurrence Span From and Through Date Desired Desired Desired Use the codes listed in the NUBC billing manual and enter the date of the occurrence. Up to eight occurrences. Use the codes listed in the NUBC billing manual and enter the date of the occurrence. Up to eight occurrences. Enter Occurrence (s) and their related date spans. Dates formatted as MMDDYY. Note: For Home Health: Occurrence Span dates indicate the dates of the physician signed plan of care. The Statement Covers Period must be the same as or within the occurrence span dates. October 20, 2017 Page 8 of 37

10 Field No. Field Name Use Notes 39 a-d, 40 a-d, and 41 a-d Value and Amounts Required Value and corresponding amounts/days. Up to twelve. For Days fields use: Value code 80 = Covered Days Value code 81 = Non-Covered Days Value code 82 = Coinsurance Days Value code 83 = Lifetime Reserved Days 42 Revenue Required, Inpatient Enter the 4-digit Revenue. Revenue code 0001 is no longer to be used for the total charges; the total charges are to be entered in the designated box on line 23. Any provider billing on a UB04 form, must bill a 4-digit revenue code in order for claim to be considered for payment. 43 Situational When billing for a drug, you must enter the NDC qualifier of N4, followed by the 11-digit NDC number, (space), and the unit of measurement followed by the metric decimal quantity or unit, followed by the unit price. Do not enter a space between the qualifier and NDC. Do not enter hyphens or spaces within the NDC number. The NDC number being submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered. Enter the NDC unit of measurement code, numeric quantity administered to the patient, and the unit price. Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. The unit of measurement codes are as follows: F2 -International Unit GR-Gram ML-Milliliter ME Milligram UN- Unit Example: N ML HCPCS /RATE/ HIPPS CODE Required with some Revenue 45 Date Required Outpatient For Outpatient claims only; enter the appropriate CPT or HCPCS procedure code, followed by up to four, 2-digit modifiers. If a CPT or HCPCS code is required it will be denoted by CPT or HCPCS in the appendix tables for that particular revenue code. Enter the line item service date. Required for all outpatient services. October 20, 2017 Page 9 of 37

11 Field No. Field Name Use Notes 46 Units Required Units of : Enter the total number of covered days Units of service for covered days and/or LOA days must correlate accurately to the service rendered. Example: Covered Days 31 Detail From DOS 01/01/2008: Revenue code 100: Units 10 Detail From DOS 01/11/2008: Revenue code 183: Units 3 Detail From DOS 01/14/2008: Revenue code 100 Units Total Charges Required Enter service line total charge. 48 Non Covered Required if Enter service line non-covered charges. Charges applicable Line 23 Column 47 TOTAL CHARGES All LINES Required Enter service line total charge. Line 23 Column 48 TOTAL NON- COVERED CHARGES ALL LINES Required if applicable Enter service line non-covered charges. In Fields 50 and 51, each field has three (3) lines: A, B, and C. If Medicaid is the only payer, enter all Medicaid data on line A. If there is one (1) other payer in addition to Medicaid, enter all primary payer data on line A and all Medicaid data on line B. If there are two (2) other payers in addition to Medicaid, enter all primary payer data on line A, all secondary payer data on line B, and all Medicaid data on line C. 50 A,B,C Payer Name A, Required B, Situational C, Situational 51 A, B,C Health Plan ID A, Required B, Situational C, Situational 56 NPI Required Enter billing provider s NPI. Enter the name identifying each payer organization from which the provider received some payment for the bill. Enter Medicaid for the State Medicaid payer identification. Enter the name of the third party payer if applicable using the following instructions: 50A for the primary payer, 50 B for the secondary payer, and 50C for the tertiary payer. If Field 56 is blank: Provider number must be 10 digits. October 20, 2017 Page 10 of 37

12 Field No. Field Name Use Notes 58 Insured s Name Desired Insured s Name: If the participant s name is entered, be sure it is exactly as each payer uses it. For Medicaid, enter the name as it appears on the participant s Medicaid ID card. Be sure to enter the last name first, followed by the first name, and middle initial. Enter the participant Medicaid data in the same line used to enter the Medicaid provider data. Example: Medicaid provider information is entered in 50A, and then the Medicaid participant data must be entered in 58A. 59 P. REL Desired Patient s relationship to insured See the UB-04 Manual for the 2-digit relationship codes. 60 Insured s Unique ID Required Enter all of the insured s unique ID numbers assigned by each payer organization. The participant s Medicaid ID number must be entered and correspond with the Medicaid entry in field 50 A, B, or C. If Medicaid is primary, enter the participant s Medicaid ID in Field 60A. If Medicaid is secondary, enter the participant s Medicaid ID in Field 60B. If Medicaid is tertiary, enter the participant s Medicaid ID in Field 60C. 63 Treatment Authorization 64 Document Control Number 66 Diagnosis and Procedure Qualifier (ICD Version Indicator) 67 DX: principal diagnosis code Required if services need a PA Required if replacement or void Required Required Enter the PA number exactly as appears on the Notice of Decision. Enter the Claim ID Number of the claim to be adjusted or voided. Only enter if submitting a replacement or void to a previously submitted claim, otherwise leave blank. This qualifier is used to indicate the version of ICD being used. For ICD-9, a nine (9) is required in this field. For ICD-10, a zero (0) should be used. Enter the valid ICD-9-CM diagnosis code (including fourth and fifth digits if applicable) or ICD-10-CM diagnosis code that describes the principal diagnosis for services rendered. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. October 20, 2017 Page 11 of 37

13 Field No. Field Name Use Notes 67 A-Q Other diagnosis codes and Present On Admission (POA) indicator Required 69 ADMIT DX Required if inpatient 70 a, b, c Patient Reason Required if DX outpatient 72 External Cause Not Required - ECI 74 Principal Procedure and Date 74a-e Other Procedure and Date Required Desired This field is for reporting all diagnosis codes in addition to the principal diagnosis that coexist, develop after admission, or impact the treatment of the patient or the length of stay. The ICD-9 or ICD-10 code completed to its fullest character must be used. The present on admission (POA) indicator applies to diagnosis codes (i.e., principal, secondary, ICD-9 E codes, ICD-10 W codes) for general acute-care hospitals or other facilities, as required by law or regulation for public health reporting. The indicator should be added in the shaded box next to the corresponding diagnosis code. Use the following values for POA. Definition Y Present at the time of inpatient admission N Not present at the time of inpatient admission U Documentation is insufficient to determine if condition is present on admission W Provider is unable to clinically determine whether condition was present on admission or not Admitting Diagnosis : Required for inpatient. Additional patient reason diagnosis required for outpatient. External Cause of Injury : Based on dates of service, enter the ICD-9-CM or ICD-10-CM code for the external cause of an injury, poisoning or adverse effect. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. Principal Procedure and Date: Based on dates of service, enter the ICD- 9-PCS or ICD-10-PCS code identifying the principal surgical, diagnostic or obstetrical procedure. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. Procedure date is required if procedure code is used, formatted as MMDDYY. Other Procedure and Dates: Enter all secondary surgical, diagnostic or obstetrical procedures. Use the appropriate ICD-9-PCS or ICD-10-PCS coding based on dates of service. For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements. Procedure date is required if procedure code is used, formatted MMDDYY. October 20, 2017 Page 12 of 37

14 Field No. Field Name Use Notes 76 (Name and NPI) Attending Physician NPI Required Enter the Attending Physician s NPI. 76 (QUAL and ID) 77 (Name and NPI) 78 (Name and NPI) 79 (Name and NPI) Attending Physician Last and First Name Operating Physician Other Physician Other Physician Required if applicable Required if applicable Required if applicable Required if applicable Required if Attending Physician NPI is Present. Required if billing surgical services. Required if billing for items or services ordered, referred, or prescribed by another physician. Required if other rendering, operating, or referring provider exists. 80 Remarks Situational Use remarks field to indicate any additional information helpful for claims processing, e.g. injury/accident how, where, and when injury/accident happened. October 20, 2017 Page 13 of 37

15 4. Billing Information For Appendix A, B, C and D - The following key applies: PO These revenue codes must have a signed physician s order attached to the claim form. CPT These revenue codes must be billed with a valid CPT code on all outpatient bill types. HCPCS These revenue codes must be billed with a valid HCPCS code on all outpatient bill types. Appendix A. Home Health Policy - Institutional Revenue Occurrence (Fields 31-34) Patient Status (Field 17) Type of Bill Home Health 0270 Home Health Supplies 0291 Rental Durable Medical Equipment 0421 Home Health Physical Therapy Visit Includes dietary products. All items must be included in the written plan of care. All items must be included in the written plan of care. Must be included in the written plan of care. 01 Auto Accident Auto Accident 02 Auto Accident/No Fault Auto Accident/No Fault 03 Accident/Tort Accident/To rt 04 Accident/Employment Related Accident/Employ ment Related 05 Other Accident Other Accident 06 Crime Victim Crime Victim 01 Discharge to Home or self care 02 Transfer to Hospital 03 Transfer to Nursing Home 04 Transfer to Intermediate Care Facility 05 Discharged to Another Type of health care institution not defined elsewhere in this list 06 Discharge/Transfer to Home Under Care of Organized Home Health Organization in Anticipation of Covered Skilled Care (Indicate in 0321 Admit through Discharge Admit through Discharge 0322 Interim-First Claim Interim- First Claim 0323 Interim- Continuing Claim Interim- Continuing Claim October 20, 2017 Page 14 of 37

16 Revenue Occurrence (Fields 31-34) Patient Status (Field 17) Type of Bill 0431 Home Health Occupatio nal Therapy Visit 0441 Home Health Speech- Language Pathology Visit 0551 Skilled Nurse Visit Must be included in the written plan of care. Must be included in the written plan of care. Requires the skills of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Must be included in the written plan of care. 24 Date Insurance Denied Date Insurance Denied 25 Date Benefits Terminated by Primary Carrier Date Benefits Terminated by Primary Carrier 42 Date of Discharge Date of Discharge X0 Plan of Care on file Plan of Care on file appropriate field the status or location of patient and time they left the facility) 07 Left Against Medical Advice 08 Discharged/Transferred to Home Under Care of a Home IV Provider 20 Death 30 Not Discharged, Still A Patient 40 Expired at Home 41 Expired in an Institution 42 Expired, Place Unknown 43 Discharged/transferred to a Federal Health Care Facility 0324 Interim-Last Claim Interim- Last Claim 0571 Aide Visit s that can be adequately performed by trained nurse aides. However, they may be performed by either licensed personnel or the home health aide. Must be included in the written plan of care. October 20, 2017 Page 15 of 37

17 Revenue Occurrence (Fields 31-34) Patient Status (Field 17) Type of Bill 0771 Drugs Requiring Special Coding CPT/HCPCS Use revenue code 771 and CPT/HCPCS code for the administration. Refer to the Allopathic and Osteopathic Physicians guidelines. Appendix B. Hospice Institutional Revenue Occurrence (Fields 31- Patient Status (Field 17) Type of Bill (Field 4) Hospice 0651 Routine Care 0652 Continuous Care Daily care provided for general hospice care. Care rendered during crisis conditions. Requires a minimum of eight hours. Hours are counted from midnight to midnight. This procedure must be billed using units of time in 15 minute increments. Partial blocks may be billed in 15 minute increments. s must be provided by a registered or licensed practical nurse. 24 Date Insurance Denied 25 Date Benefits Terminated by Primary Carrier 42 Date of Discharge 01 Discharged to Home 20 Expired 30 Still a Patient, Not Discharged 0138 Outpatient: Void/cancel of prior claim 0811 Admit through Discharge 0812 Interim, First Claim 0817 Outpatient: Replacement of prior claim For Medicare Part A crossover claims only, use the following codes: October 20, 2017 Page 16 of 37

18 Revenue 0655 Inpatient Respite Care Respite care is limited to five days per election period (calendar month) for each participant in an approved inpatient facility. Occurrence (Fields 31- Patient Status (Field 17) Type of Bill (Field 4) 0813 Continuing Claim 0814 Last Claim Respite care may only be rendered in a licensed freestanding hospice or a qualified nursing facility General Inpatient Care (Non- Respite) Participant care must be rendered in an approved inpatient hospital or freestanding hospice bed Physician Care - Hospice-employed physician services must be billed with the appropriate CPT procedure codes on each line for each service. When the physician billing for services is an employee of the hospice, the UB-04 claim form must be used with Revenue October 20, 2017 Page 17 of 37

19 Revenue 0658 Room and Board Care Room and Board reimbursement for a hospice participant only occurs when the participant has been approved for a level of care in a long-term care facility. Medicaid is always the primary payer of the hospice room and board charge. Per diems are paid for Medicaid or dually eligible hospice participants residing in a Medicare certified nursing facility. The reimbursement rate will be 95 percent of the nursing facility rate on file in which the hospice participant is a resident. The 9-digit Medicaid Nursing Home provider number must be submitted on the claim in field 80 of the UB-04 claim form or in the appropriate field of the electronic claim form. Any participant liability will be withheld from the total hospice payments. Prior Authorization is required. Occurrence (Fields 31- Patient Status (Field 17) Type of Bill (Field 4) See E.2 Hospice for allowed Hospice bill types October 20, 2017 Page 18 of 37

20 Appendix C. Hospital Idaho Medicaid does not support billing and payment by cost centers, hospitals should bill all associated revenue codes as identified in this Appendix. Note: Revenue codes not listed in the tables below are not covered by Idaho Medicaid. C.1 Accommodation/Room Revenue Rev Patient Status 0100 All inclusive room-board plus ancillary and swing bed Not covered. Except in hospitals approved for swing bed status All inclusive room-board In 0110 Private PO Covered with medically necessary documentation. In 0111 Medical/Surgical/Gyn PO In 0112 Obstetric (OB) PO When using this revenue code for birthing room accommodation, make sure the facility has an accommodation rate on file and specify Birthing In Room in the Remarks field (field 80) of the UB-04 claim form Pediatric PO In 0114 Psychiatric PO In 0115 Hospice Must be billed using hospice provider number Detoxification Medicaid will reimburse for acute level of care medical conditions only. The physician s order In must be attached Oncology PO In 0118 Rehabilitation PO In 0120 Room and board, semiprivate In Can Also Be Billed With Administratively Necessary Days (AND) Revenue Medical/Surgical/Gyn In 0122 OB In 0123 Pediatric In 0124 Psychiatric In 0126 Detoxification Medicaid will reimburse for acute level of care medical conditions only. Prior Authorization for In detoxification procedures is required October 20, 2017 Page 19 of 37

21 Rev Patient Status 0127 Oncology In 0128 Rehabilitation In 0130 Semiprivate, 3 and 4 beds In 0131 Medical/Surgical/Gyn In 0132 OB In 0133 Pediatric In 0134 Psychiatric In 0136 Detoxification Medicaid will reimburse for acute level of care medical conditions only. The physician s order In must be attached Oncology In 0138 Rehabilitation In 0140 Private (luxury) PO In 0141 Medical/Surgical/Gyn PO (luxury) In Can Also Be Billed With Administratively Necessary Days (AND) Revenue OB (luxury) PO In 0143 Pediatric (luxury) PO In 0144 Psychiatric (luxury) PO In 0146 Detoxification (luxury) PO Medicaid will reimburse for acute level of care medical conditions only. The physician s order In must be attached Oncology (luxury) PO In 0148 Rehabilitation (luxury) PO In 0150 Room and board, ward In 0151 Medical/Surgical/Gyn In 0152 OB In 0153 Pediatric In 0154 Psychiatric In 0156 Detoxification PO Medicaid will reimburse for acute level of care medical conditions only. The physician s order In must be attached Oncology In 0158 Rehabilitation In October 20, 2017 Page 20 of 37

22 Rev Patient Status 0164 Room and board, sterile environment PO In 0170 Nursery In 0171 Newborn - level 1 In 0172 Premature - level II In 0173 Newborn - level III In 0174 Newborn - level IV, Neonatal Intensive Care Unit (NICU) In 0183 Leave of absence/therapeutic Must be billed using LTC provider number Can Also Be Billed With Administratively Necessary Days (AND) Revenue Other leave of absence Must be billed using LTC provider number 0200 Intensive Care Unit (ICU) In 0201 Surgical In 0202 Medical In 0203 Pediatrics In 0204 Psychiatric In 0207 Burn care In 0208 Trauma In 0210 Coronary Care Unit (CCU) In 0211 Myocardial infarction In 0212 Pulmonary care In 0213 Heart transplant In October 20, 2017 Page 21 of 37

23 C.2 Ancillary Revenue Rev Claim Type 0230 Incremental nursing charge Justification for extraordinary nursing services must be noted in the medical record. In 0231 Nursery Justification for extraordinary nursing services must be noted in the medical record. In 0232 OB Justification for extraordinary nursing services must be noted in the medical record. In 0233 ICU Justification for extraordinary nursing services must be noted in the medical record. In 0234 CCU Justification for extraordinary nursing services must be noted in the medical record. In 0235 Hospice Must bill using hospice provider number 0250 Pharmacy 0251 Generic drugs 0252 Nongeneric drugs 0253 Take home drugs Must be under $4. Do not reduce charge to $4 and bill as an outpatient service. Bill correct amount on Out the Pharmacy claim form if amount exceeds $ Drugs incident to other diagnostic services 0255 Drugs incident to radiology 0257 Non-prescription 0258 IV solutions 0260 IV therapy 0261 Infusion pump 0262 IV therapy pharmacy services 0263 IV Therapy/Drug/ Supply delivery 0264 IV Therapy/Supplies 0270 Medical/Surgical supplies and devices Extraordinary volume on TPN with prior approval only 0271 Non-sterile supply Can Also Be Billed With Administratively Necessary Days (AND) Revenue 671 October 20, 2017 Page 22 of 37

24 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Sterile supply 0274 CPT/HCP CS Prosthetic/Orthotic devices Medicaid pays for permanent or temporary medical prosthetics to reinforce or replace a biological part implanted through surgery. Devices must be prescribed by the physician. Devices without Federal Drug Administration (FDA) approval are Out not covered. Providers must submit documentation for specific device information. Out patient claims require corresponding CPT/HCPCS codes. Inpatient claims do not Pacemaker 0276 Intraocular lens 0278 Other implant Document in the remarks field (field 80) of the UB-04 claim form the specific device or implant used. See the Ambulatory Healthcare Facility guidelines section on Payment under Ambulatory Surgical Center for more specific information Oncology general Yes 0289 Oncology other Yes 0291 Rental Out 0300 Laboratory CPT Yes 0301 Chemistry CPT Yes 0302 Immunology CPT Yes 0303 Renal patient (home) CPT Yes 0304 Non-routine dialysis CPT Yes 0305 Hematology CPT Yes 0306 Bacteriology and microbiology CPT Yes 0307 Urology CPT Yes 0310 Laboratory pathological Yes 0311 Cytology Yes 0312 Histology Yes 0314 Biopsy Yes 0320 Radiology diagnostic CPT Yes 0321 Angiocardiography CPT Yes 0322 Arthrography CPT Yes October 20, 2017 Page 23 of 37

25 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Arteriography CPT Yes 0324 Chest x-ray CPT Yes 0330 Radiology therapeutic Yes 0331 Chemotherapy, injected Yes 0332 Chemotherapy, oral Yes 0333 Radiation therapy Yes 0335 Chemotherapy - IV Yes 0340 Nuclear medicine CPT Yes 0341 Diagnostic CPT Yes 0342 Therapeutic Yes 0343 Diagnostic radiopharmaceuticals CPTCPT Outpatient must report appropriate CPT or HCPCS or HCPCS when applicable Therapeutic CPTCPT or HCPCS Must report appropriate CPT or HCPCS when applicable 0350 CT scan CPT Yes 0351 Head scan CPT Yes 0352 Body scan CPT Yes 0360 Operating room services CPT 0361 Minor surgery CPT 0362 Organ transplant, other than kidney 0367 Kidney transplant 0370 Anesthesia 0371 Anesthesia incident to radiology 0372 Anesthesia incident to other diagnostic services 0380 Blood Yes 0381 Packed red cells Yes 0382 Whole blood Yes 0383 Plasma Yes 0384 Platelets Yes 0385 Leukocytes Yes 0386 Other components Yes 0387 Other derivatives (cryopricipitates) Yes 0390 Blood storage and processing Yes October 20, 2017 Page 24 of 37

26 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Blood administration (E.g. transfusions) Yes 0400 Other imaging service CPT Yes 0401 Diagnostic mammography CPT Must be physician ordered Yes 0402 Ultrasound CPT Yes 0403 Screening mammography CPT Physician s order is not required. Participant must be age 40 or older. Yes 0404 Positron emission tomography (PET) Must report appropriate HCPCS code. HCPCS Yes 0410 Respiratory services Yes 0412 Inhalation services 0413 Hyperbaric oxygen therapy CPT/HCPCS HCPCS G0277 is required for outpatient. No HCPCS required for inpatient. Limit of 5 units per day Physical therapy (PT) CPT/HCPCS* Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations. Outpatient limitation: Prior to January 1, 2012, only 25 visits per calendar year were allowed, regardless of provider. Effective January 1, 2012 both Physical Therapy and Speech Therapy visits combined are subject to a yearly capitation rate of $ Effective January 1, 2017, the yearly capitation rate for Physical Therapy and Speech Therapy visits combined will be increased to $ Evaluation or re-evaluation CPT Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT/HCPCS procedure code rather than the outpatient rate for the revenue code billed. October 20, 2017 Page 25 of 37

27 Rev 0430 Occupational therapy (OT) CPT/HCPCS Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations. Outpatient limitation: Prior to January 1, 2012, only 25 visits per calendar year were allowed, regardless of provider. Effective January 1, 2012 Occupational Therapy visits are subject to a yearly capitation rate of $ Claim Type Effective January 1, 2017, the yearly capitation rate for Occupational Therapy visits will be increased to $ Evaluation or re-evaluation OT CPT 0440 Speech/ Language Pathology CPT/HCPCS Multiple services will be considered for payment when the corresponding CPT /HCPCS codes and appropriate modifier (if applicable) are included for each line item. These services are subject to standard limitations Evaluation or re-evaluation Speech/Language CPT Outpatient limitation: Prior to January 1, 2012, only 40 visits per calendar year were allowed, regardless of provider. Effective January 1, 2012 both Physical Therapy and Speech Therapy visits combined are subject to a yearly capitation rate of $ Effective January 1, 2017, the yearly capitation rate for Physical Therapy and Speech Therapy visits combined will be increased to $ Can Also Be Billed With Administratively Necessary Days (AND) Revenue 671 Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT/HCPCS procedure code rather than the outpatient rate for the revenue code billed. Effective for dates of service on or after July 1, 2011, payments to hospitals for outpatient occupational therapy, physical therapy, and speech therapy will be paid according to the fee for service for the corresponding CPT/HCPCS procedure code rather than the outpatient rate for the revenue code billed. October 20, 2017 Page 26 of 37

28 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Emergency room 0456 Urgent Care 0460 Pulmonary function Yes 0470 Audiology Yes 0471 Diagnostic Yes 0472 Treatment Yes 0480 Cardiology Yes 0481 Cardiac catheter lab Yes 0482 Stress test Yes 0483 Echocardiology 0489 Other cardiology Yes 0490 Ambulatory surgical care CPT/HCPCS Must report appropriate CPT or HCPCS when applicable Out 0500 Outpatient services Out 0510 Clinic CPT Covered Out 0520 Free standing clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0521 Rural health, clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0522 Rural health, home not covered on this claim type. Must bill on a CMS-1500 claim form 0523 Family practice clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0527 Free-standing clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0529 Other free standing clinic not covered on this claim type. Must bill on a CMS-1500 claim form 0540 Ambulance: Ground ambulance, nonemergency Hospital owned and operated ambulance services should be billed using the hospital s Medicaid provider number. Requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes Ambulance supplies Includes oxygen related supplies. Requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes. Out Out Yes Yes October 20, 2017 Page 27 of 37

29 Rev 0542 Medical transport: Ground ambulance emergency Hospital owned and operated ambulance services should be billed using the hospital s Medicaid provider number. Requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes. Claim Type 0544 Ambulance oxygen Oxygen only, requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes. Out 0545 Air ambulance: All levels of life Requires Medicaid Ambulance Review support Authorization. Do not bill with CPT/HCPCS codes. Out 0546 Neonatal ambulance services: Requires Medicaid Ambulance Review Ground or air ambulance Authorization. Do not bill with CPT/HCPCS codes. Out 0547 Ambulance pharmacy Requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes. Out 0548 Ambulance EKG services Electrocardiogram (EKG), requires Medicaid Ambulance Review Authorization. Do not bill with Out CPT/HCPCS codes Other ambulance s downgraded: Respond and Evaluate or Treat and Release Out Requires Medicaid Ambulance Review Authorization. Do not bill with CPT/HCPCS codes Skilled nursing HCPCS HCPCS code must be indicated in field 44 on the (S9123) UB-04 claim form. Restricted to pregnant women only. Not to exceed 2 visits per pregnancy. Also used to bill home health services. Must bill using home health provider number Skilled nursing visit Must bill using home health provider number Medical social services In 0561 Individual and family social services (S9127) HCPCS HCPCS code must be indicated in field 44 on the UB-04 claim form. Restricted to pregnant women only. Not to exceed 2 visits Risk reduction follow-up (G9005) HCPCS HCPCS code must be indicated in field 44 on the UB-04 claim form. Restricted to pregnant women only. Out Out Out Can Also Be Billed With Administratively Necessary Days (AND) Revenue 671 Yes Yes Yes Yes Yes Yes October 20, 2017 Page 28 of 37

30 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Home health visit charge Home health claims are billed on a UB-04 claim form. Out 0610 Magnetic resonance tomography (MRT) CPT Yes 0611 Magnetic resonance imaging (MRI), brain and brainstem CPT Yes 0612 MRI, spine and spinal cord CPT Yes 0614 MRI, other 0615 Magnetic resonance angiogram (MRA), head and neck CPT 0616 MRA, lower extremities CPT 0618 MRA, other CPT 0621 Supplies incident to radiology 0622 Supplies incident to other diagnostic services 0623 Surgical dressings 0634 EPO < units CPT Less than 10,000 units Out 0635 EPO > units CPT More than 10,000 units NDC information required Out 0636 Drugs requiring detailed coding CPT/HCPCS NDC information required Out 0671 Outpatient special residence charges, hospital based administratively necessary day (AND) Out Yes 0681 Level I Trauma Covered if certified as a Level I Trauma Center 0682 Level II Trauma Covered if certified as a Level II Trauma Center 0683 Level III Trauma Covered if certified as a Level III Trauma Center 0684 Level IV Trauma Covered if certified as a Level IV Trauma Center 0700 Cast room 0710 Recovery room 0720 Labor room/delivery 0721 Labor 0722 Delivery 0723 Circumcision October 20, 2017 Page 29 of 37

31 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Birthing center Charge must reflect a service area not an accommodation (inpatient bed, etc.) EKG/ECG Yes 0731 Holter monitor Yes 0732 Telemetry (including fetal monitor) Yes 0740 Electroencephalogram (EEG) Yes 0750 Gastro-intestinal services Yes 0760 Treatment/Observation room 0761 Treatment room 0762 Observation room 0771 Vaccine administration CPT Out 0780 Telemedicine HCPCS Out 0790 Lithotripsy Yes 0800 Inpatient renal dialysis In 0801 Inpatient hemodialysis In 0802 Inpatient peritoneal (non-capd) In 0803 Inpatient CAPD In 0804 Inpatient CCPD In 0810 Organ acquisition 0811 Living donor A liver transplant from a live donor is not covered by Medicaid. Yes 0812 Cadaver donor Yes 0813 Unknown donor Yes 0814 Unsuccessful organ search, donor bank Used only when costs incurred for an organ search charges does not result in an eventual organ acquisition and transplantation Cadaver donor 0816 Other heart acquisition 0817 Donor, liver A liver transplant from a live donor is not covered by Medicaid Other organ acquisition Yes 0820 Hemodialysis outpatient or home Out Yes 0821 Hemodialysis/Composite or other rate CPT Out Yes October 20, 2017 Page 30 of 37

32 Rev October 20, 2017 Page 31 of 37 Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Peritoneal dialysis, outpatient or home Out Yes 0831 Peritoneal/Composite or other rate CPT Out Yes 0840 CAPD outpatient or home Out Yes 0841 CAPD composite or other rate CPT Out Yes 0850 CCPD outpatient or home Out Yes 0851 CCPD/Composite or other rate CPT Out Yes 0880 Miscellaneous dialysis Yes 0881 Ultrafiltration Yes 0889 Other miscellaneous dialysis Yes 0890 Other donor bank 0891 Bone 0892 Organ other than kidney, liver, and heart 0893 Skin Not payable if for cosmetic surgery 0901 Electroshock treatment 0914 Individual psychiatric therapy 0915 Group psychiatric therapy 0916 Family psychiatric therapy 0918 Testing psychiatric services Out 0920 Other diagnostic services Document specific diagnostic services rendered Peripheral vascular lab Yes 0922 Electromyogram (EMG) Yes 0923 Pap smear Yes 0924 Allergy test CPT/HCPCS Yes 0925 Pregnancy test Yes 0940 Other therapeutic services Document specific therapeutic services rendered Recreational therapy In 0942 Education/Training HCPCS For diabetes education and training, use HCPCS G0108 (Individual Counseling) and G0109 (Group Counseling). Out When billing for PW members a pregnancy related diabetic diagnosis is required Cardiac rehabilitation Indicate the date of the cardiac surgery and document specific cardiac rehabilitation services rendered.

33 Rev Claim Type Can Also Be Billed With Administratively Necessary Days (AND) Revenue Drug rehabilitation 0945 Alcohol rehabilitation 0946 Complex medical equipment, routine e.g., Air fluidized support bed. Yes 0947 Complex medical equipment, ancillary Yes 0964 Anesthetist (Certified Registered Nurse Anesthetist - CRNA) Must bill on a CMS-1500 claim form using the CRNA s provider number, unless there is a Medicare exception to bill using the UB-04 claim form Admission kit In October 20, 2017 Page 32 of 37

34 C.3 Free Standing Dialysis Revenue Type of Bill Freestanding Dialysis Units 0821 Outpatient dialysis, CPT code (hemodialysis composite or other rate). Requires documentation Dialysis supplies (medical surgical supplies) Special supplies (sterile supplies) CPT Epoetin up to 10,000 units. (One billing unit = 1000 Units.) 0635 CPT Epoetin over 10,000 units. (One billing unit = 1000 Units.) Dialysis drugs (drugs requiring detailed coding), use the appropriate 0636 CPT corresponding J-code from the most current HCPCS Level II Manual and attach the NDC detail attachment with the claim form (see Medicaid Information Release MA03-69) Peritoneal composite rate, CPT code or CAPD composite or other rate, CPT code 90945/90947 or CCPD composite or other rate; CPT code 90945/90947 or through 0724 Swing Bed October 20, 2017 Page 33 of 37

35 Appendix D. Long Term Care Facility Revenu e (Field 42) Admission Source of Admission Patient Status (Field 17) Type of Bill 0100 Inpatient days (NF, ICF/ID, or swing bed) 0101 All Inclusive R&B LTC (For Special Rate or participant Specific Pricing) 0183 LO A (NF therapeu tic leave to home) 0189 LO A (ICF/MR therapeu tic leave to home) LOA (NF therapeutic leave to home) ICF/ID LOA (Other Leave of Absence) -3 -Elective -The participant s condition permits adequate time to schedule the availability of a suitable accommodation. 1 Physician Referral 2 Clinic Referral 3 HMO Referral Transfer from a Hospital Transfer from a Nursing Facility or Skilled Nursing Facility Transfer from Another Health Care Facility 7 Emergency Department 8 Court/Law Enforcement The participant was admitted to this facility upon recommendation of his/her personal physician. The participant was admitted to this facility upon recommendation of this facility s clinic physician. The participant was admitted to this facility upon the recommendation of a health maintenance organization physician. The participant was admitted to this facility as a transfer from an acute care facility where he/she was an inpatient. The participant was admitted to this facility as a transfer from a nursing facility or skilled nursing facility where he/she was an inpatient. The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility, a nursing facility, or skilled nursing facility. This includes transfers from ICF/ID Long Term Care facilities. Not applicable to Long Term Care facilities. The participant was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. 01 Discharge to home 0211 Admit through discharge 02 Transfer to hospital 0212 Interim, first claim 03 Transfer to Long Term Care facility 0213 Interim, continuing claim 04 Transfer to state hospital 0214 Last claim 05 Discharged to another type of institution for inpatient care or referred for outpatient services 06 Discharge/transfer to other (Indicate in field 80 of the UB-04 claim form or in the appropriate field of the electronic claim form, the status or location of the participant and the time they left the Long Term Care facility) 07 Left against medical advice 08 Discharged/transferred to home under care of a home IV provider 20 Death 30 Not discharged, still a patient 40 Expired at home 0215 Late charges only October 20, 2017 Page 34 of 37