CMS Pub. 100-04, ch. 25, § 75.3

FLs 31, 32, 33, and 34 - Occurrence Codes and Dates

Situational. Required when there is a condition code that applies to this claim.

GUIDELINES FOR OCCURRENCE AND OCCURRENCE SPAN UTILIZATION

Due to the varied nature of Occurrence and Occurrence Span Codes, provisions have

been made to allow the use of both type codes within each. The Occurrence Span Code

can contain an occurrence code where the “Through” date would not contain an entry.

This allows as many as 10 Occurrence Codes to be utilized. With respect to Occurrence

Codes, complete field 31a - 34a (line level) before the “b” fields. Occurrence and

Occurrence Span codes are mutually exclusive. An example of Occurrence Code use: A

Medicare beneficiary was confined in hospital from January 1, 2005 to January 10, 2005,

however, his Medicare Part A benefits were exhausted as of January 8, 2005, and he was

not entitled to Part B benefits. Therefore, Form Locator 31 should contain code A3 and

the date 010805.

The provider enters code(s) and associated date(s) defining specific event(s) relating to

this billing period. Event codes are two alpha-numeric digits, and dates are six numeric

digits (MMDDYY). When occurrence codes 01-04 and 24 are entered, the provider must

make sure the entry includes the appropriate value code in FLs 39-41, if there is another

payer involved. Occurrence and occurrence span codes are mutually exclusive. When

FLs 36 A and B are fully used with occurrence span codes, FLs 34a and 34b and 35a and

35b may be used to contain the “From” and “Through” dates of other occurrence span

codes. In this case, the code in FL 34 is the occurrence span code and the occurrence

span “From” dates is in the date field. FL 35 contains the same occurrence span code as

the code in FL 34, and the occurrence span “Through” date is in the date field. Other

payers may require other codes, and while Medicare does not use them, they may be

entered on the bill if convenient.

Codes used for Medicare claims are available from Medicare contractors. Codes are also

available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data

Specifications Manual.

FLs 35 and 36 - Occurrence Span Code and Dates

Required For Inpatient.

The provider enters codes and associated beginning and ending dates defining a specific

event relating to this billing period. Event codes are two alpha-numeric digits and dates

are shown numerically as MMDDYY.

Codes used for Medicare claims are available from Medicare contractors. Codes are also

available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data

Specifications Manual.

Special Billing Procedures When more than Ten Occurrence Span Codes (OSCs)

Apply to a Single Stay

The Long Term Care Hospital (LTCH), Inpatient Psychiatric Facility (IPF), and Inpatient

Rehabilitation Facility (IRF) Prospective Payment Systems (PPSs) requires a single claim

to be billed for an entire stay. Interim claims may be submitted to continually adjust all

prior submitted claims for the stay until the beneficiary is discharged. In some instances,

significantly long stays having numerous OSCs may exceed the amount of OSCs allowed

to be billed on a claim.

When a provider paid under the LTCH, IPF or IRF PPSs encounters a situation in which

ten or more OSCs are to be billed on the claim, the provider must bill for the entire stay

up to the Through date of the 10th OSC for the stay (the Through date for the Statement

Covers Period equals the Through date of the tenth OSC). As the stay continues, the

provider must only bill the 11th through the 20th OSC for the stay, if applicable. Once the

twentieth OSC is applied to the claim, the provider must only bill the 21st through the 30th

OSC for the stay, if applicable. The Shared System Maintainers (SSMs) retain the

history of all OSCs billed for the stay to ensure proper processing (i.e., as if no OSC

limitation exists on the claim).

For a detailed billing example that outlines possible billing scenarios, please go to

http://www.cms.hhs.gov/Transmittals/01_Overview.asp and refer to CR 6777 located on

the 2010 Transmittals page.

FL 37 - (Untitled)

Not used. Data entered will be ignored.

FL 38 - Responsible Party Name and Address

Not Required. For claims that involve payers of higher priority than Medicare.

FLs 39, 40, and 41 - Value Codes and Amounts

Required. Code(s) and related dollar or unit amount(s) identify data of a monetary

nature that are necessary for the processing of this claim. The codes are two alpha-numeric digits, and each value allows up to nine numeric digits (0000000.00). Negative

amounts are not allowed except in FL 41. Whole numbers or non-dollar amounts are

right justified to the left of the dollars and cents delimiter. Some values are reported as

cents, so the provider must refer to specific codes for instructions.

If more than one value code is shown for a billing period, codes are shown in ascending

numeric sequence. There are four lines of data, line “a” through line “d.” The provider

uses FLs 39A through 41A before 39B through 41B (i.e., it uses the first line before the

second).

Codes used for Medicare claims are available from Medicare contractors. Codes are also

available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data

Specifications Manual.