International Classification of Diseases (ICD) codes that describe diagnoses. These codes are used for diagnostic, billing, and reporting purposes.

The codes are categorized as ICD:9 or ICD:10.

• The ICD:9—code contains three to five characters. The first digit may be alpha or numeric. There is a decimal after the third character with the exception of E codes, which have a decimal after the fourth character.
• The ICD:10—code contains three to seven digits. The first digit is alpha, the second is numeric, and the third through seventh digit are alpha or numeric. A decimal is used after the third character.

Diagnosis codes for the claim. Each diagnosis code has a corresponding diagnosis pointer (with the exception of Institutional)—a single alpha character preceding its corresponding diagnosis code, for example, A: 480.

Note: Diagnosis codes apply to the entire claim line. To associate a Diagnosis code to the Claim Line, enter a value (s) in the Diagnosis Pointer field to point to the Diagnosis code.

• You can enter up to four diagnosis codes for Dental, 12 for Professional, and 26 for Institutional (24 + a principle and admitting diagnosis).

Principal Diagnosis code. The original diagnosis code.

Admission diagnosis code. The diagnosis code when the patient was admitted.

Claim line item identifier.

• Valid claim line numbers are from 1 through the new last claim line number.

• HIPAA HIPAA (Health Insurance Portability and Accountability Act of 1996) is the United States legislation that provides data privacy and security provisions for safeguarding medical information.-compliant, three-digit code consistent with the National Uniform Billing Committee.
• Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.

• The claim schedule determines if revenue accounting is necessary for the claim line.

  Note: 837I claims, may require Revenue codes.

The Healthcare Common Procedure Coding System (HCPCS) is a set of codes that standardize identification of medical services, supplies, and equipment.

• There are two sets of codes. The first, or Level I, code set is a five-digit numeric code that contains the Physicians Current Procedural Terminology (CPT) maintained by the American Medical Association.
• The second code set, or Level II is a code set for medical services not included in Level I, such as durable medical equipment, prosthetics, orthotics and supplies. These codes are alpha-numeric and begin with a single letter followed by four numbers.

Beginning date of service.

End date of service.

Date the procedure was performed—the From date of the service.

Place Of Service. Numeric code describing the location where service was rendered. The codes are defined by the plan administrators but also include basys defaults.

Letter codes that identify tooth surfaces.

• D—Distal
• O—Occlusal
• B—Buccal
• L—Lingual
• LA—Labial
• F—Facial
• I—Incisal
• G—Grooves
• M—Mesial

Procedure Code—A code that identifies a specific service performed by a service provider.

• Comments associated with the procedure code show above the Insert button.

Diagnosis pointers for the claim line. Diagnosis pointers are a single alpha character preceding its corresponding diagnosis code, for example, A: 480. They make it easy to refer to and enter a diagnosis code by just using the alpha character.

Note: When a claim has only one diagnosis code, the Diagnosis Pointer field for all claim lines will default to A. If there is more than one diagnosis code, the Diagnosis Pointer field will default to blank.

Procedure code modifiers—office or medical organization-defined codes that provide additional information concerning a particular service and can be used in the service price calculation.

Quantity. Dollar amount of the service or the number of times the service was provided. The default is 1.

The amount billed for the line item.

The benefit code representing a benefit or service covered in the Summary Plan Description document (e.g. eye exam, emergency outpatient care or an office medical visit).

See also BCode field behavior and messages.

Service Provider. ID and Name of the Service Provider.

• This field updates from the header work space, but you can change it.

Hint: If the full name doesn't display, point your mouse at the field to display the full name.

If there is a prepaid amount at the claim level (on the Detail viewport), it is automatically distributed to each claim line.

• Type—Identifies the source of the prepaid amount, allowed amount, and PPO affiliation: Member, Medicare, Other insurance.
• Prepaid—The claim amount that was paid previously.
• Allowed—Applies to Medicare and other insurance. The amount that is allowed for the claim.
• PPO Flag—Applies to Medicare and other insurance. A Y indicates the plan is affiliated with a PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount..

The allowed amount. The considered amount compared to the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. or fee schedule amount and the lesser of the two is the amount allowed for the line item. Columns display calculated amount for each:

• Member
• Medicare
• Other—another insurance provider

Code that explains why a claim or portion of a claim isn't eligible for payment. Reasons include duplicate charges, services not covered, and coverage not in effect.

Claim or portion of a claim that isn't eligible for payment. The amount that isn't considered for payment.