CMS Pub. 100-04, ch. 25, § 75.6

FL 66 – Diagnosis and Procedure code Qualifier (ICD Version Indicator)

Required. The qualifier that denotes the version of International Classification of Diseases

(ICD) reported. The following qualifier codes reflect the edition portion of the ICD: 9 -

Ninth Revision, 0 - Tenth Revision.

FL 67 - Principal Diagnosis Code

Required. The hospital enters the ICD code for the principal diagnosis. The code must be

the full ICD diagnosis code, including all five digits where applicable for ICD-9 or all seven

digits for ICD-10. The reporting of the decimal between the third and fourth digit is

unnecessary because it is implied.

The principal diagnosis code will include the use of “V” codes where ICD-9-CM is

applicable. Where the proper code has fewer than five digits (ICD-9-CM) or seven digits

(ICD-10-CM), the hospital may not fill with zeros. The principal diagnosis is the condition

established after study to be chiefly responsible for this admission. Even though another

diagnosis may be more severe than the principal diagnosis, the hospital enters the principal

diagnosis. Entering any other diagnosis may result in incorrect assignment of a Diagnosis

Related Group (DRG) and cause the hospital to be incorrectly paid under PPS. The hospital

reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient

services in FL 67 of the bill. It reports the diagnosis to its highest degree of certainty. For

instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g.,

cough) for which a definitive diagnosis is not made, the symptom must be reported. If during

the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g.,

acute bronchitis), the hospital must report the definitive diagnosis. When a patient arrives at

the hospital for examination or testing without a referring diagnosis and cannot provide a

complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons

Without Reported Diagnosis Encountered During Examination and Investigation of

Individuals and Populations.

FLs 67A-67Q - Other Diagnosis Codes

Situational. Required when other condition(s) coexist or develop(s) subsequently during the

patient’s treatment.

FL 68 – Reserved

Not used. Data entered will be ignored.

FL 69 - Admitting Diagnosis

Required. For inpatient hospital claims subject to QIO review, the admitting diagnosis is

required. Admitting diagnosis is the condition identified by the physician at the time of the

patient’s admission requiring hospitalization.

FL70A – 70C - Patient’s Reason for Visit

Situational. It is required for Medicare institutional claims processing on Type of Bill

013x and 085x when: a) Form Locator 14 (Priority (Type) of Admission or Visit) codes

1, 2, or 5 are reported; and b) Revenue Codes 045x, 0516, or 0762 are reported. The

requirement for reporting Patient’s Reason for Visit is restricted to the outpatient bill

types above.

If the Patient’s Reason for Visit is not required, it may be reported on other 013x and

085x bill types that fail to meet the criteria in a) or b) above at the sender’s discretion

when this information substantiates the medical necessity of services.

FL71 – Prospective Payment System (PPS) Code

Not used. Data entered will be ignored.

FL72 - External Cause of Injury (ECI) Codes

Not used. Data entered will be ignored.

FL 73 – Reserved

Not used. Data entered will be ignored.

FL 74 - Principal Procedure Code and Date

Situational. Required on inpatient claims when a procedure was performed. Not used on

outpatient claims.

FL 74A – 74E - Other Procedure Codes and Dates

Situational. Required on inpatient claims when additional procedures must be reported. Not

used on outpatient claims.

FL 75 – Reserved

Not used. Data entered will be ignored.

FL 76 - Attending Provider Name and Identifiers (including NPI)

Situational. Required when claim/encounter contains any services other than nonscheduled

transportation services. If not required, do not send. The attending provider is the individual

who has overall responsibility for the patient’s medical care and treatment reported in this

claim/ encounter.

Secondary Identifier Qualifiers:

0B - State License Number

1G - Provider UPIN Number

G2 – Provider Commercial Number

FL 77 - Operating Provider Name and Identifiers (including NPI)

Situational. Required when a surgical procedure code is listed on this claim. If not required,

do not send. The name and identification number of the individual with the primary

responsibility for performing the surgical procedure(s).

Secondary Identifier Qualifiers:

0B - State License Number

1G - Provider UPIN Number

G2 – Provider Commercial Number

FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)

Situational. The name and ID number of the individual corresponding to the qualifier

category indicated in this section of the claim.

Provider Type Qualifier Codes/Definition/Situational Usage Notes:

DN - Referring Provider. The provider who sends the patient to another provider for services.

Required on an outpatient claim when the Referring Provider is different than the Attending

Physician. If not required, do not send.

ZZ - Other Operating Physician. An individual performing a secondary surgical procedure or

assisting the Operating Physician. Required when another Operating Physician is involved.

If not required, do not send.

82 - Rendering Provider. The health care professional who delivers or completes a particular

medical service or non-surgical procedure. Report when state or federal regulatory

requirements call for a combined claim, i.e., a claim that includes both facility and

professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim).

If not required, do not send.

Secondary Identifier Qualifiers:

0B - State License Number

1G - Provider UPIN Number

G2 – Provider Commercial Number

FL 80 – Remarks

Situational. For DME billings the provider shows the rental rate, cost, and anticipated

months of usage so that the provider’s A/B MAC (A or HHH) may determine whether to

approve the rental or purchase of the equipment. Where Medicare is not the primary payer

because WC, automobile medical, no-fault, liability insurer or an EGHP is primary, the

provider enters special annotations. In addition, the provider enters any remarks needed to

provide information that is not shown elsewhere on the bill but which is necessary for proper

payment. For Renal Dialysis Facilities, the provider enters the first month of the 30-month

period during which Medicare benefits are secondary to benefits payable under an EGHP.

(See Occurrence Code 33.)

FL 81 - Code-Code Field

Situational. To report additional codes related to a Form Locator or to report external code

list approved by the NUBC for inclusion to the institutional data set.

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.

80 – Reserved