CMS Pub. 100-04, ch. 6, § 40.6

ASC X12 837 Institutional Claim See the related implementation guide on the official

Washington Publishing Company website. Form CMS -1450 For each cost center for

which a separate charge is billed (type of accommodation or ancillary), a revenue code is

assigned and is entered on the claim with the related charges. On Form CMS-1450 the

appropriate numeric revenue code is entered in FL 42 to explain each charge in FL 47.

Additionally, there is no fixed “Total” line in the charge area. Instead, revenue code

“0001” is always entered last in FL 42. Thus, the adjacent charge entry, in FL 47, is the

sum of charges billed. This is also the same line on which noncovered charges, if any, in

FL 48, are summed. The total charge for all services, covered and noncovered, will

generally be shown. See §40.6.1 below, for certain exceptions. In the “noncovered

charges” column (FL48) enter the amount of any noncovered charge except where: • The

A/B MAC (A) has notified the SNF that payment can be made under the limitation of

liability provisions; and • A payer primary to Medicare is involved. (See the Medicare

Secondary Payer [MSP] Manual, Chapter 3, “MSP Provider Billing Requirements,” and

Chapter 4, “Contractor Prepayment Processing Requirements.”) Where a bill is submitted

for a period including both covered and noncovered days (e.g., days submitted for

noncovered level of care), the SNF must list the charges for noncovered days under

noncovered charges. Refer to the Medicare Claims Processing Manual, Chapter 25 for

further information about completing the claim. For claims that contain both covered

days and noncovered days, and those noncovered days are the responsibility of the

beneficiary (e.g., days submitted for noncovered level of care), the provider should

append span code 76 to indicate the days the beneficiary is liable.