Billing instruction for Ambulance Billing – Box 20 to 23
| BlockNo. | Block Name | Block Code | Notes |
| 20 | Outside Lab? | LB | Do not complete this block. |
| 21 | Diagnosis or Nature of Illness or Injury | M/A | Enter the most specific three-, four-, or five-digit ICD-9-CM code that describes the diagnosis. The primary ICD-9-CM code block (21.1) must be completed. The second, third, and fourth diagnosis codes must be completed if applicable. |
| 22 | Medicaid Resubmission | A/A | This block has two uses: 1) When resubmitting a rejected claim. If resubmitting a rejected claim, enter the 13- digit internal control number (ICN) of the ORIGINAL rejected claim in the right portion of this block (e.g., | 1103123523123). 2) When submitting a claim adjustment for a previously approved claim. If submitting a claim adjustment, enter ADJ in the left portion of the block and the LAST APPROVED 13-digit ICN, a space and the two-digit line number from the RA Statement in the right portion of the block (e.g., ADJ | 1103123523123 01). Note: If your claim was submitted prior to the implementation of PROMISe™, enter the 10-digit claim reference number (CRN) in place of the ICN. |
| 23 | Prior Authorization Number | LB | Do not complete this block. |
Medicaid Resubmission Code and Original Reference Number: Complete only if replacing or voiding/canceling a previously paid claim. If submitting a replacement claim, enter resubmission code 7 in the left side of item 22 and enter the 10- digit CRN of the paid claim you are replacing in the right side of item 22. If submitting a void/cancel claim, enter resubmission code 8 in the left side of item 22 and enter the 10- digit CRN of the paid claim you are voiding/canceling in the right side of item 22.
Instructions: When resubmitting a claim, enter the appropriate claim frequency code left justified in the left-hand side of the field.
7 – Replacement of prior claim
8 – Void/cancel of prior claim
References:
[1] Understanding Box 22 Resubmission Codes on CMS 1500 Claims-CMS 1500 (cms1500claimbilling.com)
[2] Box 22 Resubmission Code/Original Ref. No. – Therabill
[3] CCR_CorrectedVoidedClaimsResubmissionGuide_English_110218.pdf (countycare.com)
http://www.cms1500claimbilling.com/2010/12/box-22-medicaid-resubmission-status-how.html