Supplemental information
Shaded line
�� In the shaded area across Fields 24A through 24H, enter supplemental information about the service rendered.
�� If entering more than one item of information on a line, make sure each item begins with a qualifier and is separated by at least 1 blank space.
Box 24A – Required
Date of Service
�� This box must list numeric dates of service.
�� If billing for one day, complete only the “from” column.
�� If the “from and to” dates are used, a service must be on consecutive days and provided no more than once per day.
Box 24B – Required
Place of Service
�� Enter the two-digit place of service code of where the service was provided.
�� Place of service codes can be found in CPT/HCPCS codebooks or on the Web site at:
http://www.medicarepaymentandreimbursement.com/2010/05/full-place-of-service-codes.html
Box 24C – Optional
Emergency Indicator
�� If the service you provided was a result of an emergency, enter a “Y” for “yes” in this box for each line item.
�� If this was not an emergent service, leave blank or enter a “N” for “nonemergent”.
Box 24D – Required
Procedure Code
�� Enter the five-digit/character CPT or HCPCS code(s) for the specific service provided.
�� Optional – Enter up to four two-digit national modifiers that relate to this service.
�� For procedure codes that indicate “unlisted,” you must attach an operative/medical report.
Box 24E – Required
Diagnosis Pointer
�� Enter the one-digit diagnosis code reference number (pointer) as shown in box 21 to relate
the date of service and the procedure performed to the primary diagnosis.
�� Do not enter the actual ICD-9-CM code here.
Box 24F – Required
Total Charges
�� Enter the total usual and customary charge for each line.
�� Do not list credits.
�� Do not use dashes.
Box 24G – Required
Service Days or Units
�� Enter the number of days or units for each number of consecutive days or services as
indicated in box 24A.
�� Some services are billed by units depending on the service provided.
Box 24J – Optional
Rendering Provider ID
�� This box is only required when clinics or group practices use a specific billing provider number in box 33. This identifies who rendered the service.
�� Shaded – Enter the six (6)-or nine (9)- digit DHS provider number of the individual rendering the service.
�� Non-shaded – Enter the ten-digit NPI of the rendering provider that was identified in the shaded area.
Box 26 – Optional
Patient Account Number
�� Enter your patient account number here.
�� This box allows up to twelve characters.
�� This number will appear on your Remittance Advice (RA).
Box 28 – Required
Total Charge
�� Enter the total charge amount for all services listed in column 24F.
�� Each claim form is a separate document, and is to be totaled as such.
Box 29 – Optional
Amount Paid
�� Enter the total amount paid by any prior resource(s).
�� Do not include write-offs.
�� Do not include copayments.
Box 30 – Required
Balance Due
�� Enter the balance due.
�� Box 28 minus box 29 must equal box 30.
Box 33 – Required
Billing Provider Information
�� Box 33 – (Billing provider info & phone number) Enter the name and address of the provider that is requesting to be paid for the services rendered.
�� 33a – (NPI) Enter the ten-digit NPI of the billing provider.
�� 33b – (Other ID) Enter the six (6)-or nine (9)-digit provider number of the billing provider.
Note: Non-medical services do not require NPI (e.g., taxis).
