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• Address where services was rendered
• Physician , health care professional , ancillary provider , or facility “ remit to ” address
• Phone number of Physician , health care professional , ancillary provider , or facility performing the service ( provide this information in a manner consistent with how that information is presented in your agreement with us )
• Physician , health care professional , ancillary provider , or facility NPI and federal TIN
• Referring physician ’ s name and TIN ( if applicable )
• Date of service ( s )
• Place of service ( s )
• Number of services ( days / units ) rendered
• Current CPT-4 and HCPCS procedure codes , with modifiers where appropriate
• Current ICD-10 diagnostic codes by specific service code to the highest level of specificity ( it is essential to communicate the primary diagnosis for the service performed , especially if more than one diagnosis is related to a line item )
• Charges per service and total charges
• Detailed information about other insurance coverage
• Information regarding job-related , auto or accident information , if available
• Retail purchase cost ( or a cumulative retail rental cost ) greater than $ 1000 for DME
• Current National Drug Code ( NDC ) 11-digit number for all claims submitted with drug codes . The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPPA 837 Professional electronic form .
Additional information needed for a complete CMS-1450 ( UB-04 ) form :
• Date and hour of admission
• Discharge date and hour of discharge
• Member status-at-discharge code
• Type of bill code ( 4 digits )
• Type of admission ( e . g ., emergency , urgent , elective , newborn )
• Current 4-digit revenue code ( s )
• Current principal diagnosis code ( highest level of specificity ), with the applicable present on admission ( POA ) indicator on hospital impatient claims per CMS guidelines
• Current other diagnosis codes , if applicable ( highest level of specificity ), with the applicable present on admission ( POA ) indicator on hospital inpatient claims per CMS guidelines
• Current ICD-10 procedure codes for inpatient procedures
• Attending physician ID
• For outpatient procedures , provide the appropriate revenue and CPT or HCPCS codes
• For outpatient services , providers specific CPT or HCPCS codes and appropriate revenue code ( s ) ( e . g ., laboratory , radiology , diagnostic or therapeutic )
• Complete box 45 for physical , occupational or speech therapy services ( revenue codes 0420-0449 )