Form Locators 66-81

75.6 - Form Locators 66-81 (Rev. 3435, Issued: 12-31-15, Effective: 07-01-15, Implementation: 03-31-16) 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.