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claim form15000

box 23 quality inprovment number
box 24 a dates of service
box24 b place of service codes
box 24 e procedures services and supplies hcpcs , cpt codes and modifiers
box 24 c Medicare providers dnt have to fill this out
box 24 f providers billed services
box24 g multiple visits number of days units
box 24 i enter id qualifier
24 j rendering providers npi
box 25 provider or suppliers federal id number
box 26 patient account number given by provder or supplier
box 27 check box for rendering provider accepting of Medicare befits
box 28 enter total charges for all services
box 29 enter the total amount of patient paid for (covered services only)
box 31 signature of provider or the signature of authorized representative
box 32 name address and zip of the facility where services where rendered
box 32 a if required my Medicare claims processing enter npi of the facility
box 33 the providers or suppliers billing name ,address ,zip and phone number
box 33 a NPI of billing number or group
evaluation management code 99201-99499
medicine except anesthesiology 990281-99199 995000-99602
circle with small circle in it moderaite conscience sedation
proximal near the point of the trunk
distal far from the point attachment to the trunk
frontal coronal vertical plane dividing the body into anterior and prosterior portions
sagittal vertical plane dividing the pdy into right ond left sides
transverse cross-sectional horizontal plane dividing the body into upper and lower portions
Created by: krialvarez
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