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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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(Last Updated - 05/29/2013) Tj
ET
BT
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ET
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EMC
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[(15.10 ) -70 (THIRD PARTY LI) -6 (ABI) -6 (L) 2 (ITY \(TPL\)) -6 ( ) ] TJ
EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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(ven to Xerox Care and Quality ) Tj
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EMC
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EMC
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EMC
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ET
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ET
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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(e diagnosis that, ) Tj
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EMC
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<646961676E6F736973206669656C642C2074686520636F6465206973206368616E67656420746F20937A65726F739420696E20> Tj
0.0002 Tc
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[(processing the claim) 8 (. Th) ] TJ
0.0004 Tc
0.0820999965 Tw
10.0799999237 0 Td
(is can result in reducing ) Tj
0.244599998 Tw
-30.6100006104 -1.3350000381 Td
[(the num) 8 (ber) -7 ( of PAS da) -6 (ys a secondary diagnosis a) ] TJ
0.0006 Tc
0.2434999943 Tw
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[(llows for inpatient days exem) 8 (pt from) 8 ( Xer) -6 (o) 1 (x ) ] TJ
0.0003 Tc
0 Tw
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EMC
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-0.0001 Tc
-0.0007 Tw
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[(15.14.A PRESENT ON ADMISSI) -6 (ON \(POA\) ) ] TJ
EMC
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0.0004 Tc
0.0137999998 Tw
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[(In accordan) 5 (ce with Section 5001\(c\) of the Defi) ] TJ
0.0007 Tc
0.0142999999 Tw
18.9099998474 0 Td
[(cit Reduction Act of 2005 and state reg) 6 (u) 1 (lation ) ] TJ
-0.0001 Tc
0.0535999984 Tw
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(13 CSR 70-3.230, MO HealthNet requires the Pres) Tj
0.0003 Tc
0.0538000017 Tw
20.7350006104 0 Td
[(ent on Adm) 8 (i) -2 (ssion \(POA\) indicator for all ) ] TJ
0.0006 Tc
0.1544000059 Tw
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[(diagnosis codes subm) 8 (it) -7 (ted on inpatient hospita) 7 (l claim) 8 (s. Som) 8 (e) -6 ( diagnosis codes are exem) 8 (pt ) ] TJ
0.0593999997 Tw
0 -1.3300000429 TD
[(from) 8 ( the POA requirem) 8 (e) -1 (nt and can be found in t) -7 (h) 1 (e ICD Official Guidelines for Coding and ) ] TJ
0.0008 Tc
0.0392000005 Tw
0 -1.3350000381 TD
[(Reporting. Claim) 9 (s containing an in) 6 (valid or m) 9 (i) ] TJ
0.0006 Tc
0.0386000015 Tw
[(ssing POA indicato) 6 (r) -1 ( will be denied unless the ) ] TJ
0.0533999987 Tw
T*
[(diagnosis is exem) 9 (pt from) 9 ( the POA requirem) 9 (ent) ] TJ
0.0002 Tc
0.0540000014 Tw
19.2099990845 0 Td
[(. W) 9 (hen appropriate, the POA indicator m) 8 (ust) -7 ( ) ] TJ
0.0008 Tc
0.1488000005 Tw
-19.2099990845 -1.3300000429 Td
[(be pres) 5 (ent f) 9 (o) 1 (r all d) 6 (i) -1 (agn) 6 (o) 1 (sis cod) 6 (es reflected) 6 <20696E2074686520935072696E> 6 (cip) 6 <616C9420616E64> 6 <20934F74686572942064> 6 (i) -1 (agno) 6 (sis cod) 6 (e ) ] TJ
0 Tc
0 Tw
T*
<6669656C64732C20696E636C7564696E67209345787465726E616C204361> Tj
0.0004 Tc
-0.0029 Tw
11.9399995804 0 Td
[<7573657394207265706F72746564206F6E20636C61696D> 8 ( for) -7 (m) 8 (s ) -7 (UB) ] TJ
0 Tc
-0.001 Tw
13.6850004196 0 Td
(-04 and 837 Institutional. ) Tj
EMC
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0.0011 Tc
0.1581999958 Tw
-25.625 -2.0050001144 Td
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0.0003 Tc
0.2788000107 Tw
0 -1.3300000429 TD
[(adm) 8 (i) -2 (ssion occurs. Conditions that develop du) ] TJ
0 Tc
0.2800000012 Tw
20.1550006866 0 Td
(ring an outpatient encounter prior to an ) Tj
0.0008 Tc
0.1092000008 Tw
-20.1550006866 -1.3300000429 Td
[(adm) 9 (i) -1 (ssion to inpatient, including em) 9 (ergency de) ] TJ
0.0005 Tc
0.1081999987 Tw
19.5049991608 0 Td
[(partm) 8 (e) -1 (nt, observation or outpatient surgery, ) ] TJ
0.0004 Tc
0.0445999987 Tw
-19.5049991608 -1.3350000381 Td
[(are considered as present on adm) 8 (i) -2 (ssion. Use ) ] TJ
0.0436999984 Tw
18.5 0 Td
[(the UB-04 Dat) -7 (a) -1 ( Specifications Manual and the ) ] TJ
-0.0003 Tc
0.2903000116 Tw
-18.5 -1.3350000381 Td
(ICD Official Guidelines for Coding and Re) Tj
-0.0007 Tc
0.2890000045 Tw
(porting for proper assi) Tj
0.0001 Tc
0.2899000049 Tw
28.8299999237 0 Td
[(gnm) 8 (e) -1 (nt of the POA ) ] TJ
0.0002 Tc
0.123999998 Tw
-28.8299999237 -1.3300000429 Td
[(indicator. The POA guidelines are not inte) -3 (nded to provide guidance on when a condition ) ] TJ
0.1448000073 Tw
0 -1.3350000381 TD
(should be coded, but rather, how to apply the ) Tj
0.0005 Tc
0.1445000023 Tw
19.6100006104 0 Td
(POA indicator to the final set of diagnosis ) Tj
-0.0001 Tc
0.0001 Tw
-19.6100006104 -1.3350000381 Td
(codes that have been assigned. ) Tj
EMC
/P <> BDC
2.75 Tc
0 Tw
-3 -2.3399999142 Td
( ) Tj
/TT1 1 Tf
0.0001 Tc
-0.0001 Tw
(15.14.A\(1\) POA VALUES ) Tj
EMC
/P <> BDC
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0.0002 Tc
-0.0002 Tw
6 -1.9950000048 Td
(As taken from the General Reporting Require) Tj
0.0006 Tc
-0.0006 Tw
18.2749996185 0 Td
[(m) 8 (e) -1 (nts in th) 6 (e IC) 8 (D Off) 4 (i) -2 (cial Guidelines f) 4 (o) 1 (r) 4 ( ) ] TJ
0 Tc
-0.0008 Tw
-18.2749996185 -1.3300000429 Td
(Coding and Reporting, the following values ar) Tj
-0.0001 Tc
0.0001 Tw
18.5799999237 0 Td
(e to be used when assigning the POA ) Tj
-0.0002 Tc
0 Tw
-18.5799999237 -1.3350000381 Td
(indicator: ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0020000001 Tw
-6 -2 Td
[( ) -2751 ( ) -2751 ( ) -2751 <59203D2059657320962070726573656E74206174207468652074696D> 8 (e of inpatient adm) 8 (i) -2 (ssion. ) ] TJ
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -2 TD
[( ) -2750 ( ) -2750 ( ) -2750 <4E203D204E6F2096206E6F742070726573656E74206174207468652074696D> 8 (e of inpatient adm) 8 (i) -2 (ssion. ) ] TJ
EMC
ET
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0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
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0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
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2.75 Tc
0 Tw
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[( ) 1000 ( ) ] TJ
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( ) Tj
ET
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( ) Tj
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( ) Tj
0.003 Tc
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[(12) 6 ( ) ] TJ
EMC
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0.0002 Tc
-0.001 Tw
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[( ) -2751 ( ) -2751 ( ) -2751 <55203D20556E6B6E6F776E209620646F63756D656E746174696F6E20697320696E7375> ] TJ
0.0007 Tc
-0.0023000001 Tw
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[(fficient to determ) 9 (ine if condition is ) ] TJ
0.0005 Tc
2.7495000362 Tw
-24.5100002289 -1.3300000429 Td
[( present ) 2750 (on ) 2755 (adm) 8 (i) -2 (ssion. ) ] TJ
EMC
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[( ) -2750 ( ) -2750 ( ) -2750 (W = Clinically undeterm) 8 <696E656420962070726F766964> ] TJ
0.0003 Tc
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[(er is unable to clinically determ) 8 (ine ) ] TJ
-0.001 Tw
0 -1.3300000429 TD
[( ) -2751 ( ) -2751 ( ) -2751 ( ) -2751 (whether condition was present on adm) 8 (i) -2 (ssion or not. ) ] TJ
EMC
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-0.0014 Tw
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[( ) -2751 ( ) -2751 ( ) -2751 <426C616E6B203D20556E7265706F727465642F4E6F7420557365642096206578> ] TJ
-0.0011 Tw
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[(empt from) 8 ( POA reporting. \(See the ICD ) ] TJ
0.0001 Tc
2.7499001026 Tw
-23.0349998474 -1.3300000429 Td
[( Official ) 2750 (Guidelines ) 2750 (for ) 2750 (Codi) ] TJ
0 Tc
0 Tw
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(ng and Reporting for list of exempt ) Tj
-0.0002 Tc
2.7502000332 Tw
-23.3050003052 -1.3350000381 Td
[( diagnosis ) 2755 (codes\) ) ] TJ
EMC
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0 Tw
0 -2.3450000286 TD
( ) Tj
/TT1 1 Tf
-0.0001 Tc
0.0017 Tw
(15.14.A\(2\) MEDICAL DOCUMENTATION ) Tj
EMC
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0.0007 Tc
0.3637999892 Tw
6 -1.9900000095 Td
[(As stated in the Intro) 6 (duction to the ICD Of) 4 (f) 4 (i) -1 (cial Guideline) 5 (s f) 4 (o) 1 (r Coding and) 6 ( ) ] TJ
0.0003 Tc
0.0496999994 Tw
0 -1.3300000429 TD
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0.0007 Tc
0.0485000014 Tw
18.4449996948 0 Td
(re provider and the coder is essential to ) Tj
0.0004 Tc
0.2182999998 Tw
-18.4449996948 -1.3350000381 Td
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0.0006 Tc
0.2194000036 Tw
17.7549991608 0 Td
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0.1884000003 Tw
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0.0001 Tc
0.1898999959 Tw
17.9750003815 0 Td
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0.0004 Tc
0.0526000001 Tw
-17.9750003815 -1.3300000429 Td
(record cannot be overemphasized. Medica) Tj
0 Tc
0.0549999997 Tw
17.4300003052 0 Td
[(l record docum) 8 (entation from any provider) -7 ( ) ] TJ
0.0004 Tc
0.3086000085 Tw
-17.4300003052 -1.3350000381 Td
(involved in the care and tr) Tj
0.0006 Tc
0.3093999922 Tw
12.0200004578 0 Td
[(eatm) 8 (ent of the patient m) 8 (a) ] TJ
0.0003 Tc
0.3106999993 Tw
11.3950004578 0 Td
(y be used to support the ) Tj
0.0008 Tc
0.0794999972 Tw
-23.4150009155 -1.3350000381 Td
[(determ) 9 (inatio) 6 (n of) 4 ( whether a conditio) 6 (n was present on adm) 9 (i) -1 (ssion or not. The contex) 6 (t ) ] TJ
0.0002 Tc
0.2522999942 Tw
T*
(of the official coding guide) Tj
0.0006 Tc
0.2536999881 Tw
11.8999996185 0 Td
[(lines, the term) 8 <209370726F766964657294206D> 8 (eans a phy) 6 (sician o) 6 (r) -1 ( any) 6 ( ) ] TJ
0.0002 Tc
0.3248000145 Tw
-11.8999996185 -1.3350000381 Td
(qualified healthcare practitioner who is ) Tj
0.0001 Tc
0.3235999942 Tw
17.5400009155 0 Td
(legally accountable for establishing the ) Tj
0.0002 Tc
-0.0002 Tw
-17.5400009155 -1.3350000381 Td
<70617469656E74927320646961676E6F7369732E20> Tj
0 Tc
0 Tw
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( ) Tj
EMC
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0.0012000001 Tc
0.0706999972 Tw
13.9799995422 0 0 13.9799995422 72 340.4400024414 Tm
[(15.15) 3 ( ACCOMMODATION ) 69 (REVENUE ) 73 (CODE ) ] TJ
EMC
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0.0003 Tc
0.0971999988 Tw
12 0 0 12 72 316.0799865723 Tm
(An accommodation revenue code is ) Tj
0.0005 Tc
0.0982000008 Tw
15.0699996948 0 Td
[(required on an inpatien) 6 (t) 3 ( cla) 4 (i) -2 (m) 8 (.) 1 ( ) ] TJ
0.0003 Tc
0.0996999964 Tw
[(Refer to) 5 ( Section) 5 ( 19 Procedu) 5 (r) -2 (e ) ] TJ
0.0008 Tc
0.1433999985 Tw
-15.0699996948 -1.3300000429 Td
(Codes of the Hospital Manual for the Inpatien) Tj
0.0003 Tc
0.1427000016 Tw
19.4400005341 0 Td
[(t Hospital Revenue Codes listing. Accomm) 8 (oda) -6 (tion ) ] TJ
0.0006 Tc
-0.0006 Tw
-19.4400005341 -1.3300000429 Td
[(codes are those num) 8 (bered from) 8 ( 0110 to 0219. ) ] TJ
0 Tc
0 Tw
18.5799999237 0 Td
[(Ancillary codes are those from) 8 ( 0250 to 0949. ) ] TJ
EMC
/P <> BDC
0.0003 Tc
0.4296999872 Tw
-18.5799999237 -2.0050001144 Td
[(An ancillary code, for exam) 8 (ple 0720, Delivery/Labor Room) 8 (, can ) ] TJ
/TT2 1 Tf
0.0009 Tc
0 Tw
30.0200004578 0 Td
(never) Tj
/TT0 1 Tf
-0.0003 Tc
0.4302999973 Tw
2.2249999046 0 Td
( be considered an ) Tj
0.0005 Tc
0.0144999996 Tw
-32.2449989319 -1.3300000429 Td
[(accomm) 8 (odat) -7 (i) -2 (on code even if the provider shows a rate and number of units \(days\). A claim) 8 ( denies if ) ] TJ
0 Tc
0 Tw
0 -1.3350000381 TD
(no valid, covered accommoda) Tj
-0.0001 Tc
0.0001 Tw
11.9949998856 0 Td
(tion code is shown. ) Tj
EMC
/P <> BDC
0.0004 Tc
0.0096000005 Tw
-11.9949998856 -2 Td
[(The num) 8 (ber of covered and non-covered days is s) ] TJ
0.0005 Tc
0.0088 Tw
20.0249996185 0 Td
[(hown in Field # 39-41, Value Codes and Am) 8 (ounts. ) 9 ( ) ] TJ
0.0003 Tc
0.172999993 Tw
-20.0249996185 -1.3300000429 Td
(Code 80 is entered to reflect the ) Tj
0 Tc
0.174999997 Tw
14.2449998856 0 Td
[(num) 8 (ber of covered days and code) ] TJ
0.0016 Tc
0.1733999997 Tw
14.3299999237 0 Td
[( 8) 7 (1) 2 ( is en) 7 (ter) 5 (e) 1 (d) 7 ( to r) 5 (ef) 5 (l) -1 (ect a) 5 (n) 2 (y ) ] TJ
0 Tc
0.1083000004 Tw
-28.5750007629 -1.3350000381 Td
(applicable non-covered days. The tota) Tj
-0.0002 Tc
0.1102000028 Tw
16.3899993896 0 Td
[(l num) 8 (ber of covered and non-covered days ) ] TJ
/TT2 1 Tf
0 Tw
18.1049995422 0 Td
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0.0022 Tw
9.4460000992 0 Td
<4F434544555245974649454C442023373420> Tj
EMC
/P <> BDC
/TT0 1 Tf
0.0007 Tc
0.0729999989 Tw
12 0 0 12 72 368.1000061035 Tm
[(This is to clarif) 4 (y situa) ] TJ
-0.0003 Tc
0.0753000006 Tw
9.0249996185 0 Td
(tions in which Fields #74,) Tj
/TT2 1 Tf
0 Tc
0 Tw
( ) Tj
/TT0 1 Tf
0.0003 Tc
0.0746999979 Tw
10.9799995422 0 Td
[(Principal P) 7 (r) -2 (ocedure Code and Date, and #74 A-E, ) ] TJ
-0.0011 Tw
-20.0049991608 -1.3300000429 Td
(Other Procedure Codes and Dates, are to be) Tj
0.0002 Tc
-0.0027000001 Tw
[( completed on the inpatient claim) 8 ( for) -7 (m) 8 (. ) -7 ( ) ] TJ
EMC
/P <> BDC
0.0003 Tc
-0.0008 Tw
0 -2.0050001144 TD
[(If it is necessary to use the operating room) 8 ( to per) -7 (f) ] TJ
-0.0004 Tw
19.8850002289 0 Td
[(or) -7 (m) 8 ( a procedure, then the principal procedure Field ) ] TJ
0 Tc
0.2199999988 Tw
-19.8850002289 -1.3300000429 Td
(#74, Principal Procedure Code and Date, on the cl) Tj
0.0002 Tc
0.2182999998 Tw
21.8099994659 0 Td
[(aim) 8 ( should be completed. If more than one ) ] TJ
0.0003 Tc
0.0088999998 Tw
-21.8099994659 -1.3300000429 Td
[(procedure was perform) 8 (e) -1 (d, identify and date any ot) ] TJ
0.0002 Tc
20.2299995422 0 Td
(hers in Field #74 A-E, Ot) Tj
0.0004 Tc
0.0078999996 Tw
(her Procedure Codes and ) Tj
-0.0002 Tc
0.0002 Tw
-20.2299995422 -1.3350000381 Td
(Dates, using ICD Procedure Codes. ) Tj
EMC
/P <> BDC
0.0002 Tc
0.1435000002 Tw
T*
[(If a pro) 5 (cedu) 5 (r) -2 (e is perform) 8 (e) ] TJ
0.0016 Tc
0.1425999999 Tw
11 0 Td
[(d in the patien) 7 (t) -1 <9273> 6 ( ro) 7 (om) 9 (, in a tr) 5 (e) 5 (atm) 9 (ent roo) 7 (m) 4 (, or in) 7 ( an) 7 (other) 5 ( are) 5 (a) 1 ( o) 7 (f) 5 ( the ) ] TJ
0.0013 Tc
0.1437000036 Tw
-11 -1.3300000429 Td
[(hospita) 5 (l tha) 5 (t) 4 ( is ) ] TJ
/TT2 1 Tf
0 Tc
0 Tw
6.5199999809 0 Td
(not) Tj
/TT0 1 Tf
-0.0003 Tc
0.1453000009 Tw
1.2799999714 0 Td
( an operating room, do ) Tj
/TT2 1 Tf
0 Tc
0 Tw
10.0500001907 0 Td
(not) Tj
/TT0 1 Tf
0.0002 Tc
0.1448000073 Tw
1.2799999714 0 Td
[( com) 8 (plete th) 5 (e surgical procedure cod) 5 (e) -1 ( fields of the ) ] TJ
0.0017 Tc
-0.0017 Tw
-19.1299991608 -1.3300000429 Td
[(claim) 10 ( for) -5 (m) 10 (. ) ] TJ
EMC
/P <> BDC
0.0008 Tc
0.264200002 Tw
T*
[(If a proced) 6 (ure is en) 6 (tered in this field, th) 6 (ere ) ] TJ
/TT2 1 Tf
-0.0002 Tc
0 Tw
19.6599998474 0 Td
(must) Tj
/TT0 1 Tf
0.0004 Tc
0.2646000087 Tw
1.8899999857 0 Td
( be a revenue code ) Tj
0 Tc
0.2649999857 Tw
9.0200004578 0 Td
(shown for operating or ) Tj
0.0003 Tc
0.0009 Tw
-30.5699996948 -1.3300000429 Td
[(labor/delivery room) 8 (. A claim) 8 (s proce) ] TJ
-0.0003 Tw
14.5249996185 0 Td
[(ssing edit m) 8 (o) -5 (nitors for compliance. ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.0188999996 Tw
-14.5249996185 -2.0050001144 Td
(ICD procedure code for other genitourinary instilla) Tj
0.0001 Tc
0.0192000009 Tw
20.5599994659 0 Td
[(tion is restricted by MO HealthNet and requires a) -6 ( ) ] TJ
0.0002 Tc
0.1298000067 Tw
-20.5599994659 -1.3300000429 Td
(Certificate of Medical Necessity ) Tj
0.1284999996 Tw
13.7399997711 0 Td
[(for Abortion. T) 6 (he Procedural Cros) ] TJ
-0.0007 Tc
0.1307000071 Tw
14.3149995804 0 Td
(s Coder: Essential Links from ) Tj
0.0002 Tc
0.1298000067 Tw
-28.0550003052 -1.3300000429 Td
(ICD Volume 3 Procedural Code) Tj
-0.0001 Tc
0.1308999956 Tw
13.4149999619 0 Td
(s to CPT Codes and HCPCS Leve) Tj
0.0008 Tc
0.1291999966 Tw
14.3950004578 0 Td
(l II Codes crosswalks the ICD ) Tj
0.0002 Tc
0.1048000008 Tw
-27.8099994659 -1.3350000381 Td
(procedure code for other genitour) Tj
0.0005 Tc
0.1045000032 Tw
13.8549995422 0 Td
[(in) 6 (ary ins) 5 (t) -2 (illa) 4 (tion to CPT procedur) ] TJ
-0.0001 Tc
0.1050999984 Tw
13.9149999619 0 Td
(e codes for abor) Tj
0.0008 Tc
0.1024999991 Tw
6.7249999046 0 Td
[(tion as we) 5 (ll as) 5 ( ) ] TJ
0.0007 Tc
0.0643000007 Tw
-34.4949989319 -1.3350000381 Td
[(som) 9 (e that are ) ] TJ
/TT2 1 Tf
0 Tc
0 Tw
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(not) Tj
/TT0 1 Tf
0.0004 Tc
0.063699998 Tw
1.2799999714 0 Td
( abortion related. If the IC) Tj
0.0002 Tc
0.0637999997 Tw
11.0799999237 0 Td
(D procedure code for other ge) Tj
0.0008 Tc
0.064199999 Tw
12.345000267 0 Td
[(nitou) 6 (r) -1 (ina) 5 (r) 4 (y instillation) 6 ( is ) ] TJ
0.0001 Tc
0.2498999983 Tw
-30.4799995422 -1.3300000429 Td
[(most appropriate for the procedure perform) 8 (e) -1 (d a) ] TJ
0.0005 Tc
0.2481999993 Tw
20.4850006104 0 Td
[(nd is) 5 ( unrelated to an) 6 ( ) ] TJ
0.0020000001 Tc
0.2479999959 Tw
9.6000003815 0 Td
[(elec) 6 (tive) 6 ( ab) 7 (ortion,) 7 ( sub) 7 (m) 10 (it ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
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( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(15) 6 ( ) ] TJ
EMC
/P <> BDC
0.001 Tc
0.0022 Tw
12 0 0 12 72 688.2600097656 Tm
[(m) 9 (edical docum) 9 (entation which reflects) ] TJ
0.0003 Tc
0.0046999999 Tw
15.2650003433 0 Td
( the non-abortion related procedur) Tj
0.0007 Tc
0.0052999998 Tw
13.6800003052 0 Td
[(e that was perform) 9 (ed or fetal ) ] TJ
0.0002 Tc
-0.0002 Tw
-28.9449996948 -1.3350000381 Td
[(dem) 8 (i) -2 (se prior to the procedure being perform) 8 (e) -1 (d. ) ] TJ
/TT1 1 Tf
0 Tc
0 Tw
19.1599998474 0 Td
( ) Tj
EMC
/P <> BDC
/TT2 1 Tf
0.0007 Tc
0.0711999983 Tw
13.9799995422 0 0 13.9799995422 72 632.4000244141 Tm
[(15.19 MO ) 69 (HEALTHNET ) 73 (UB) ] TJ
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-0.0019 Tw
12.5279998779 0 Td
(-04 \(CMS-1450\) INPATI) Tj
0.0002 Tc
0.003 Tw
10.5749998093 0 Td
[(ENT HO) -3 (SPITAL CLAIM ) ] TJ
0.0007 Tc
-0.0018 Tw
-20.5279998779 -1.1499999762 Td
(FILING INSTRUCTIONS ) Tj
EMC
/P <> BDC
/TT0 1 Tf
0.0004 Tc
0.3246000111 Tw
12 0 0 12 72 592.0200195312 Tm
[(NOTE: An asterisk \(*\) beside field num) 8 (bers) 5 ( indicates required fields. These fields ) ] TJ
/TT1 1 Tf
-0.0002 Tc
0 Tw
37.0950012207 0 Td
(must) Tj
/TT0 1 Tf
0.0006 Tc
0.3194000125 Tw
1.8899999857 0 Td
( be ) Tj
0.0593999997 Tw
-38.9850006104 -1.3300000429 Td
[(com) 8 (p) 1 (leted or the claim) 8 ( i) -7 (s denied. All other fields) ] TJ
0.0003 Tc
0.059700001 Tw
[( should be com) 8 (pleted as applicable. Two asterisks ) ] TJ
-0.001 Tw
0 -1.3350000381 TD
(\(**\) beside the field number indicate a fiel) Tj
0.0008 Tc
-0.0027999999 Tw
17.0249996185 0 Td
[(d is req) 6 (u) 1 (ired in spec) 5 (if) 4 (ic situation) 6 (s. ) ] TJ
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
-17.0249996185 -2.0050001144 Td
(FIELD NUMBER & NAME ) Tj
EMC
/P <> BDC
18.3500003815 0 Td
(INST) Tj
-0.0004 Tc
0.0029 Tw
2.2200000286 0 Td
[(RUCTIONS FOR COMPLETI) -7 (ON ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.0014 Tw
-17.4200000763 -1.75 Td
(*1. ) Tj
EMC
/P <> BDC
2.1510000229 0 Td
[(Provider Nam) 8 (e) -1 (, Address, ) ] TJ
0.0004 Tc
-0.0054000001 Tw
-0.001 -1.3300000429 Td
[(Telephone Num) 8 (ber ) ] TJ
EMC
/P <> BDC
-0.0004 Tw
13.0500001907 1.3300000429 Td
[(Enter the provider nam) 8 (e) -1 ( and address. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
0 -1.75 TD
( ) Tj
EMC
/P <> BDC
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-0.75 -1.75 Td
(2. ) Tj
EMC
/P <> BDC
1.6499999762 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-1.1950000525 -1.75 Td
(3a. ) Tj
EMC
/P <> BDC
0 Tc
2.0950000286 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Patien) 6 (t) -1 ( Control Num) 9 (b) 1 (er ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
0.7178000212 Tw
T*
<466F72207468652070726F76696465729273206F776E20696E666F726D6174696F6E2C206120> Tj
-0.0060999999 Tc
0.0210999995 Tw
0 -1.3300000429 TD
[(ma) -7 (x) -6 (i) -13 (mu) -11 (m o) -11 (f) ] TJ
/TT2 1 Tf
0 Tc
0 Tw
5.1500000954 0 Td
( ) Tj
/TT0 1 Tf
0.0006 Tc
0.0143999998 Tw
0.2649999857 0 Td
[(20 alpha/num) 8 (eric characters m) 8 (a) -1 (y ) ] TJ
0.0002 Tc
-0.0018 Tw
-5.4149999619 -1.3300000429 Td
(be entered here. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(3b. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
(Med Rec # ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(*4. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[(Type of) 4 ( Bill ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0009 Tc
0.0876000002 Tw
T*
[(The require) 5 (d thre) 5 (e dig) 6 (i) -1 (ts in this cod) 6 (e iden) 6 (tif) 4 (y ) ] TJ
0.0012000001 Tc
-0.0012000001 Tw
0 -1.3300000429 TD
[(the f) 4 (o) 1 (llowin) 6 (g) 1 (: ) ] TJ
EMC
/P <> BDC
0.001 Tc
-0.003 Tw
0 -1.7549999952 TD
[( ) -1132 (1st digit: typ) 6 (e of) 4 ( f) 4 (acility ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
[( ) -1130 (2nd digit: bill classification ) ] TJ
0.0003 Tc
-0.0003 Tw
T*
[( ) -1130 (3rd digit: frequency ) ] TJ
EMC
/P <> BDC
-0.0002 Tc
0.3452000022 Tw
0 -1.7549999952 TD
[(The allowed values for each of the dig) 5 (i) -2 (ts) 4 ( ) ] TJ
0.0003 Tc
-0.0014 Tw
0 -1.3300000429 TD
[(found in the type of bill are listed b) 5 (e) -1 (low: ) ] TJ
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
0 -1.7549999952 TD
[(Type of) 4 ( Facility) 6 (: 1st d) 6 (i) -1 (git: ) ] TJ
EMC
/P <> BDC
0.0002 Tc
1.129799962 Tw
0 -1.75 TD
[( \(1\) ) 1130 (Hospital ) ] TJ
EMC
/P <> BDC
0.0003 Tc
-0.0019 Tw
T*
[(Bill Clas) 5 (sification) 5 (:) -2 ( 2nd digit: ) ] TJ
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[( ) -1130 (\(1\) Inpa) 4 (tient \(Includ) 6 (i) ] TJ
-0.0001 Tc
-0.0015 Tw
9.7700004578 0 Td
(ng Medicare Part A\) ) Tj
0.0002 Tc
-0.0012000001 Tw
-9.7700004578 -1.3300000429 Td
[( ) -1131 (\(2\) Inpatient \(Medicare Part B only\) ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
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BT
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2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
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74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(16) 6 ( ) ] TJ
EMC
/P <> BDC
-0.0001 Tc
-0.0024000001 Tw
12 0 0 12 292.200012207 683.2199707031 Tm
(Frequency: 3rd digit ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
0 -1.75 TD
[( ) -1130 (\(1\) Adm) 9 (it thru Discharg) 6 (e Claim ) ] TJ
0.0008 Tc
1.1291999817 Tw
0 -1.3300000429 TD
[( \(2\) ) 1130 (In) 6 (ter) 4 (i) -1 (m) 9 ( ) 1125 <42696C6C97466972737420> 1135 (Claim ) ] TJ
0.0008 Tw
0 -1.3350000381 TD
[( ) -1128 (\(3\) In) 6 (ter) 4 (i) -1 (m) 9 <2042696C6C97436F6E74696E75696E6720436C61696D> 9 ( ) ] TJ
1.1291999817 Tw
T*
[( \(4\) ) 1130 (In) 6 (ter) 4 (i) -1 (m) 9 ( ) 1125 <42696C6C974C6173> 5 (t) -1 ( ) 1135 (Claim ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-0.75 -1.75 Td
(5. ) Tj
EMC
/P <> BDC
1.6499999762 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.0035000001 Tw
0 -1.75 TD
[(Federal Tax Num) 9 (b) 1 (er ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0016 Tw
T*
[(Enter the provider') 6 (s federal tax num) 8 (ber. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(*6. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
T*
[(Statem) 8 (ent Covers Period ) ] TJ
0 -1.3300000429 TD
[(\(from) 8 ( and through dates\) ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0500000007 Tw
0 -1.75 TD
(Indicate the beginning ) Tj
-0.0005 Tc
0.0555000007 Tw
9.3500003815 0 Td
(and ending dates being ) Tj
0.0001 Tc
0.0009 Tw
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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<20696E204669656C64202336302C20496E7375726564927320> Tj
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EMC
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EMC
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EMC
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T*
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EMC
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EMC
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EMC
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ET
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
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( ) Tj
EMC
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( of birth in MMDDYY ) Tj
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EMC
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( ) Tj
EMC
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(11. ) Tj
EMC
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( ) Tj
EMC
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T*
(Patient Sex ) Tj
EMC
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( ) Tj
EMC
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[(Enter th) 6 (e p) 6 (atien) 6 (t) -1 (') 6 (s sex, "M" \(m) 9 (ale) 5 (\)) -1 ( or "F") 4 ( ) ] TJ
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EMC
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(*12. ) Tj
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( ) Tj
EMC
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EMC
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EMC
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T*
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T*
( ) Tj
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(*14. ) Tj
EMC
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EMC
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(ype of admission; the ) Tj
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EMC
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<3297557267656E7420> Tj
EMC
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EMC
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EMC
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[(5---Traum) 9 (a ) ] TJ
EMC
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EMC
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( ) Tj
EMC
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(**15. ) Tj
EMC
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( ) Tj
EMC
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(or Visit ) Tj
EMC
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( ) Tj
EMC
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EMC
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EMC
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EMC
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EMC
ET
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12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
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0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
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ET
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[(18) 6 ( ) ] TJ
EMC
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EMC
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( ) Tj
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EMC
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EMC
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EMC
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EMC
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0.0008 Tc
-0.0008 Tw
0 -1.3300000429 TD
[(F---Tran) 6 (sfer from) 9 ( a Hospice Fac) 5 (ility) 6 ( ) ] TJ
EMC
/P <> BDC
-0.001 Tc
0.001 Tw
0 -1.3350000381 TD
[(NE) -5 (WBORN CODE) -5 (S) -5 ( ) ] TJ
EMC
/P <> BDC
0.0004 Tc
-0.0020000001 Tw
T*
[(5---Born Ins) 5 (i) -2 (de This Hos) 5 (pita) 4 (l ) ] TJ
EMC
/P <> BDC
-0.0003 Tw
0 -1.3300000429 TD
[(6---Born Ou) 5 (tside Th) 5 (is Hospita) 4 (l ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(16. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
0 -1.75 TD
[(Discharge H) 8 (our ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*17. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
T*
(Patient Discharge Status ) Tj
EMC
/P <> BDC
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.1283999979 Tw
T*
(Enter the 2-digit patient ) Tj
-0.0003 Tc
0.1303000003 Tw
10.2899999619 0 Td
(status code that best ) Tj
0.0002 Tc
-0.0002 Tw
-10.2899999619 -1.3300000429 Td
[(describes the patient') 5 (s discharge status ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
0 -1.7549999952 TD
(Common values are: ) Tj
EMC
/P <> BDC
0.0003 Tc
0.0896999985 Tw
0 -1.3300000429 TD
<3031974469736368617267656420746F20686F6D65206F722073656C662D636172652028726F7574696E6520> Tj
0.0001 Tc
0 Tw
2 -1.3300000429 Td
(discharge\) ) Tj
EMC
/P <> BDC
0.0004 Tc
0.4645999968 Tw
-2 -1.3350000381 Td
[<303297446973636861726765642F7472616E7366657272656420746F20612073686F72742D7465726D> 8 ( ) ] TJ
-0.0003 Tw
2 -1.3350000381 Td
(general hospital for inpatient care ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.1150999963 Tw
-2 -1.3300000429 Td
<303397446973636861726765642F7472616E7366657272656420746F20736B696C6C6564206E757273696E6720> Tj
0.0009 Tc
0.4241000116 Tw
2 -1.3350000381 Td
[(f) 4 (acility with Medicar) 4 (e) 5 ( certif) 4 (icatio) 6 (n in ) ] TJ
0.0008 Tc
-0.0024000001 Tw
0 -1.3350000381 TD
[(antic) 5 (ipation of) 4 ( skilled c) 5 (a) 5 (r) -1 (e) 5 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.2448000014 Tw
-2 -1.3300000429 Td
<303497446973636861726765642F7472616E7366657272656420746F206120666163696C697479207468617420> Tj
0.0001 Tc
-0.0001 Tw
2 -1.3350000381 Td
(provides custodial or) Tj
0.0009 Tc
-0.0024999999 Tw
[( sup) 6 (portiv) 6 (e care ) ] TJ
EMC
/P <> BDC
-0.0001 Tc
0.4300999939 Tw
-2 -1.3350000381 Td
<303597446973636861726765642F7472616E7366657272656420746F20612064657369676E6174656420> Tj
0.0003 Tc
-0.0015 Tw
2 -1.3300000429 Td
[(cancer center or children) 5 <927320686F73706974616C20> ] TJ
EMC
/P <> BDC
0.0001 Tc
0.5048999786 Tw
-2 -1.3350000381 Td
[<303697446973636861726765642F7472616E7366657272656420746F20686F6D> 8 (e under ) ] TJ
-0.0004 Tc
0.3054000139 Tw
2 -1.3350000381 Td
(care of organized hom) Tj
0.0013 Tc
0.3037 Tw
9.875 0 Td
[(e hea) 5 (lth) 6 ( se) 5 (rvice) 5 ( ) ] TJ
-0.0001 Tc
0.3000999987 Tw
-9.875 -1.3300000429 Td
(organization in anticipation of covered ) Tj
0.0001 Tw
T*
(skilled care ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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2111 0 obj
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2114 0 obj
<<
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<<
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2118 0 obj
<<
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/OC /MC0 BDC
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/GS0 gs
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0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(19) 6 ( ) ] TJ
EMC
/P <> BDC
0.0004 Tc
1.0845999718 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
<3037974C65667420616761696E7374206D65646963616C206164766963652C206F7220> Tj
-0.0005 Tc
0.0005 Tw
2 -1.3350000381 Td
(discontinued care ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-2 -1.3350000381 Td
<3230974578706972656420> Tj
EMC
/P <> BDC
0.0005 Tc
1.2144999504 Tw
0 -1.3300000429 TD
[(21---Dis) 5 (charge/transferre) 4 (d) 1 ( to Court/Law) 8 ( ) ] TJ
0.001 Tc
0 Tw
2 -1.3350000381 Td
[(Enforcem) 9 (ent ) ] TJ
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
-2 -1.3350000381 Td
<3330975374696C6C20612070617469656E7420> Tj
EMC
/P <> BDC
0.0003 Tc
0.0247000009 Tw
T*
[(43---Dis) 5 (charged/transferred to a federal hea) 4 (l) -2 (th) 5 ( ) ] TJ
0.0006 Tc
-0.0006 Tw
2 -1.3350000381 Td
[(care facility) 6 ( ) ] TJ
EMC
/P <> BDC
0.6876000166 Tw
-2 -1.3350000381 Td
[(61---Dis) 5 (charged/transferred to a hospita) 5 (l-) ] TJ
0 Tc
0 Tw
2 -1.3300000429 Td
(based Medicare approved swing bed ) Tj
EMC
/P <> BDC
0.0004 Tc
0.5228999853 Tw
-2 -1.3350000381 Td
[(62---Dis) 5 (charged/transferred to) 5 ( an inpatien) 5 (t ) ] TJ
0.0007 Tc
0.592599988 Tw
2 -1.3350000381 Td
[(rehabilitatio) 6 (n) 1 ( f) 4 (acility \(IRF\) inc) 5 (l) -1 (u) 6 (d) 1 (ing ) ] TJ
0.0002 Tc
0.4797999859 Tw
T*
(rehabilitation distin) Tj
0.0006 Tc
0.4769000113 Tw
8.2849998474 0 Td
(ct part units of a ) Tj
-0.0005 Tc
0 Tw
-8.2849998474 -1.3350000381 Td
(hospital ) Tj
EMC
/P <> BDC
0.0002 Tc
0.5947999954 Tw
-2 -1.3350000381 Td
<363397446973636861726765642F7472616E7366657272656420746F2061204D6564696361726520> Tj
0.0008 Tc
-0.0020000001 Tw
2 -1.3300000429 Td
[(certified lon) 6 (g) 1 (-term) 9 ( care hospital \(LT) 7 (C) 3 (H\) ) ] TJ
EMC
/P <> BDC
-0.0001 Tc
0.8550999761 Tw
-2 -1.3350000381 Td
<363497446973636861726765642F7472616E7366657272656420746F2061206E757273696E6720> Tj
0.0001 Tc
0.1349000037 Tw
2 -1.3350000381 Td
(facility certified unde) Tj
0.0003 Tc
0.1347000003 Tw
8.8800001144 0 Td
(r Medicaid but not ) Tj
-0.0003 Tw
-8.8800001144 -1.3300000429 Td
[(certified und) 5 (er Medicare.) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-2 -1.3350000381 Td
<363597446973636861726765642F7472616E736665727265> Tj
-0.0003 Tc
0.393599987 Tw
10.6649999619 0 Td
(d to a psychiatric ) Tj
0.0002 Tc
0.1997999996 Tw
-8.6649999619 -1.3350000381 Td
(hospital or psychiatric distinct part unit ) Tj
-0.0002 Tw
T*
(of a hospital. ) Tj
EMC
/P <> BDC
0.0005 Tc
0.9294999838 Tw
-2 -1.3350000381 Td
[(66---Dis) 5 (charged/transferred to a) 4 ( critica) 4 (l) 3 ( ) ] TJ
0.0004 Tc
-0.0004 Tw
2 -1.3350000381 Td
[(access hosp) 5 (i) 3 (tal ) ] TJ
EMC
/P <> BDC
0.0005 Tc
0.2594999969 Tw
-2 -1.3300000429 Td
[(70---Dis) 5 (charged/transferred to another typ) 6 (e) 4 ( ) ] TJ
0.0001 Tc
0.4348999858 Tw
2 -1.3350000381 Td
(of health care institution not defined ) Tj
0.0006 Tc
-0.0006 Tw
0 -1.3350000381 TD
[(elsewhere in) 6 ( this cod) 6 (e) -1 ( lis) 5 (t) -2 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-15.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-3.0850000381 -1.75 Td
(*18-24. ) Tj
EMC
/P <> BDC
0 Tc
3.9849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
0 -1.75 TD
[(Condition C) 8 (odes ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
0.1181000024 Tw
T*
[(Enter the appropriate tw) 8 (o-character condition ) ] TJ
0.3443999887 Tw
0 -1.3300000429 TD
[(code\(s\). A com) 8 (p) 1 (lete list of values can be ) ] TJ
0 Tc
1.0800000429 Tw
0 -1.3350000381 TD
(found in the Official UB-04 Data ) Tj
0.0005 Tc
0.0494999997 Tw
T*
[(Specificatio) 6 (ns Manual. The values applicable ) ] TJ
0 Tc
0 Tw
0 -1.3300000429 TD
(to MO HealthNet are: ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.3350000381 TD
<433197417070726F7665642061732062696C6C656420> Tj
EMC
/P <> BDC
0.0001 Tc
1.043200016 Tw
T*
[( ) -867 (Indicates) 4 <2074686520666163696C6974799273205574696C697A6174696F6E20> ] TJ
0.0005 Tc
0.2224999964 Tw
2.1600000858 -1.3300000429 Td
(Review authority has certified all days ) Tj
0.0004 Tc
-0.0054000001 Tw
T*
(billed. ) Tj
EMC
/P <> BDC
0 Tc
-0.0049999999 Tw
-2.1600000858 -1.3350000381 Td
<4333975061727469616C20417070726F76616C20> Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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<<
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2124 0 obj
<<
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2125 0 obj
<<
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2126 0 obj
<<
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stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(20) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.159799993 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[( ) -1750 (The stay being billed on this claim has ) ] TJ
0.0248000007 Tw
2.1600000858 -1.3350000381 Td
(been approved by the UR as appropriate; ) Tj
0.0003 Tc
0.0296999998 Tw
0 -1.3350000381 TD
[(however, som) 8 (e) -1 ( portion of the days billed ) ] TJ
0.0006 Tc
0.0394000001 Tw
0 -1.3300000429 TD
(have been denied. ) Tj
/TT1 1 Tf
0.0009 Tc
0.0390999988 Tw
7.5700001717 0 Td
[(If C3 is entered, F) 7 (i) -1 (eld) 6 ( ) ] TJ
0.0003 Tc
-0.0015 Tw
-7.5700001717 -1.3400000334 Td
(#35 must be completed. ) Tj
EMC
/P <> BDC
/TT2 1 Tf
-0.0012000001 Tc
0 Tw
-2.1600000858 -1.75 Td
(NOTE:) Tj
/TT0 1 Tf
-0.0004 Tc
0.0012000001 Tw
3.1649999619 0 Td
[( CODE C1 OR C3 IS REQUIRED.) -5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-3.1649999619 -1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0008 Tc
T*
[<41319745505344542F43484150> -5 ( ) ] TJ
EMC
/P <> BDC
0.0009 Tc
0.3172000051 Tw
T*
[( ) -1592 (If) 4 ( this) 5 ( hos) 5 (pita) 5 (l s) 5 (t) -1 (ay is a result of) 4 ( an ) ] TJ
0.0007 Tc
0.1342999935 Tw
2.1600000858 -1.3350000381 Td
[(EPSDT referral or is an EPSDT related) 6 ( ) ] TJ
0.0002 Tc
0.0480999984 Tw
0 -1.3350000381 TD
(stay, this condition code ) Tj
/TT1 1 Tf
-0.0002 Tc
0 Tw
(must) Tj
/TT0 1 Tf
-0.0011 Tc
0.0511000007 Tw
12.0600004196 0 Td
( be entered ) Tj
0.0003 Tc
-0.0003 Tw
-12.0600004196 -1.3300000429 Td
(on the claim. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-2.1600000858 -1.3350000381 Td
[<4134974661> -6 (m) 8 (ily Planning ) ] TJ
EMC
/P <> BDC
-0.0002 Tc
0.5113999844 Tw
T*
[( ) -1399 (If fa) -6 (m) 8 (ily planning services occurred ) ] TJ
0.0002 Tc
0.1298000067 Tw
2.375 -1.3300000429 Td
(during the inpatient stay, this condition ) Tj
0.0006 Tc
0 Tw
T*
(code ) Tj
/TT1 1 Tf
-0.0002 Tc
2.1400001049 0 Td
(must) Tj
/TT0 1 Tf
-0.0001 Tc
-0.0015 Tw
1.8899999857 0 Td
( be entered. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-20.3549995422 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-2.5850000381 -1.75 Td
(25-28. ) Tj
EMC
/P <> BDC
0 Tc
3.4849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
0 -1.75 TD
[(Condition C) 8 (odes ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(29. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
T*
(Accident State ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(30. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-3.5850000381 -1.75 Td
(**31-34. ) Tj
EMC
/P <> BDC
0 Tc
4.4850001335 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0017 Tw
T*
(Occurrence Code and Date ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
0.2305999994 Tw
T*
[(If one or more of the) -6 ( following occurrence ) ] TJ
0.0007 Tc
0.1225999966 Tw
0 -1.3300000429 TD
[(codes app) 6 (l) -1 (y) 6 (,) 1 ( enter the ) ] TJ
-0.0004 Tc
0.1254000068 Tw
9.4600000381 0 Td
(appropriate code\(s\) on ) Tj
0.001 Tc
0.1589999944 Tw
-9.4600000381 -1.3300000429 Td
[(the c) 5 (l) -1 (aim) 9 (.) 1 ( A com) 9 (p) 1 (lete lis) 5 (t of) 4 ( valu) 6 (es can b) 6 (e) 5 ( ) ] TJ
0 Tc
1.0800000429 Tw
0 -1.3350000381 TD
(found in the Official UB-04 Data ) Tj
0.0005 Tc
0.0494999997 Tw
T*
[(Specificatio) 6 (ns Manual. The values applicable ) ] TJ
0 Tc
0 Tw
0 -1.3300000429 TD
(to MO HealthNet are: ) Tj
EMC
/P <> BDC
-0.0002 Tc
-0.0048000002 Tw
0 -1.7549999952 TD
<3031974163636964656E742F4D65646963616C20436F76657261676520> Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
0 -1.3300000429 TD
[<3032974E6F204661756C7420496E737572616E636520> 9 <496E766F6C766564209620496E636C7564696E6720> ] TJ
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
0 -1.3350000381 TD
( Auto Accident/other ) Tj
EMC
/P <> BDC
0.0001 Tc
0 Tw
0 -1.3300000429 TD
<3033974163636964656E742F546F72> Tj
-0.0001 Tw
7.3299999237 0 Td
(t Liability ) Tj
EMC
/P <> BDC
-7.3299999237 -1.3350000381 Td
[<3034974163636964656E742F456D> 8 (ployment Related ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
0 -1.3350000381 TD
<3035974163636964656E742F4E6F204D65646963616C206F72204C696162696C69747920> Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
endobj
2127 0 obj
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<<
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>>
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2130 0 obj
<<
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>>
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2131 0 obj
<<
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/TT1 3174 0 R
/TT2 3153 0 R
/F0 3156 0 R
/F1 3157 0 R
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>>
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2132 0 obj
<<
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endobj
2133 0 obj
<<
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>>
endobj
2134 0 obj
<<
/Length 3221 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(21) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
( Coverage ) Tj
EMC
/P <> BDC
0.0012000001 Tc
0.0038000001 Tw
0 -1.3350000381 TD
[<3036974372696D> 9 (e Victim) 9 ( ) ] TJ
EMC
/P <> BDC
0.0001 Tc
0.0491000004 Tw
T*
<34329744617465206F6620446973636861726765202D2D20546F20626520656E7465726564207768656E20> Tj
0.0003 Tc
0.3786999881 Tw
1.7999999523 -1.3300000429 Td
[<937468726F75676894206461746520696E204669656C642023362C2053746174656D> 8 (ent) -7 ( ) ] TJ
0.6396999955 Tw
T*
(Covers Period is ) Tj
/TT1 1 Tf
0 Tc
0 Tw
(not) Tj
/TT0 1 Tf
0.0013 Tc
0.6387000084 Tw
10.0600004196 0 Td
[( equal to) 6 ( the ) ] TJ
0.0002 Tc
0.0948000029 Tw
-10.0600004196 -1.3350000381 Td
(discharge date and the frequency code in ) Tj
0.0004 Tc
0.0996000022 Tw
0 -1.3300000429 TD
[(Field #4, Type of Bill, indicates th) 5 (at this) 5 ( ) ] TJ
0.0012000001 Tc
-0.0024000001 Tw
0 -1.3350000381 TD
[(is the f) 4 (i) -1 (na) 5 (l b) 6 (ill. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-15.75 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**35. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Occurrence Span Codes and ) Tj
0.0004 Tc
0.0012000001 Tw
0 -1.3300000429 TD
[(Dates \(from) 8 ( and through\) ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.2246000022 Tw
0 -1.75 TD
(Required if C3 is entered in Fields #18-24, ) Tj
0.2397000045 Tw
0 -1.3300000429 TD
<436F6E646974696F6E20436F6465732E20456E74657220636F646520934D309420616E642074686520> Tj
0.0013 Tc
0.3587000072 Tw
T*
[(f) 4 (i) -1 (rst and) 6 ( la) 5 (st days) 6 ( th) ] TJ
-0.0003 Tc
0.3585999906 Tw
9.4949998856 0 Td
(at were approved by ) Tj
0.0002 Tc
-0.0052 Tw
-9.4949998856 -1.3350000381 Td
(Utilization Review. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(36. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Occurrence Span Codes and ) Tj
-0.001 Tc
0 Tw
0 -1.3300000429 TD
(Dates ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(37. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(38. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
[(Responsible Party Nam) 8 (e) -6 ( and ) ] TJ
-0.0008 Tc
0 Tw
0 -1.3300000429 TD
(Address ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
T*
( ) Tj
EMC
/P <> BDC
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-3.0850000381 -1.75 Td
(*39-41. ) Tj
EMC
/P <> BDC
0 Tc
3.9849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
T*
[(Value Codes and Am) 8 (ounts ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.7142999768 Tw
T*
(Enter the appropriate code\(s\) and unit ) Tj
0.0007 Tc
0.9542999864 Tw
0 -1.3300000429 TD
[(am) 9 (ount\(s\) to identif) ] TJ
0.9517999887 Tw
9.8500003815 0 Td
[(y the inform) 9 (ation ) ] TJ
0.0005 Tc
-0.0005 Tw
-9.8500003815 -1.3350000381 Td
[(necessary for the pro) 6 (cess) 5 (i) -2 (ng of the claim) 8 (.) -4 ( ) ] TJ
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.7549999952 TD
<383097436F7665726564204461797320> Tj
EMC
/P <> BDC
0.0004 Tc
0.1102000028 Tw
0 -1.75 TD
(Enter the number of days shown in Field #6, ) Tj
0.2247000039 Tw
0 -1.3300000429 TD
[(Statem) 8 (ent Covers Period, m) 8 (i) -2 (nus the date of ) ] TJ
-0.0001 Tc
0.0401000008 Tw
T*
[(discharge. T) 6 (he discharge date is ) ] TJ
/TT1 1 Tf
0 Tc
0 Tw
13.2449998856 0 Td
(not) Tj
/TT0 1 Tf
0.0004 Tc
0.0370999984 Tw
1.2749999762 0 Td
[( a covered) 5 ( ) ] TJ
0 Tc
0.5350000262 Tw
-14.5200004578 -1.3350000381 Td
(day and should ) Tj
/TT1 1 Tf
0 Tw
(not) Tj
/TT0 1 Tf
0.0012000001 Tc
0.5325000286 Tw
9.1850004196 0 Td
[( be includ) 6 (ed in) 6 ( th) 6 (e) 5 ( ) ] TJ
0.0001 Tc
-0.0017 Tw
-9.1850004196 -1.3350000381 Td
(calculation of this field. ) Tj
EMC
/P <> BDC
0.4099000096 Tw
0 -1.75 TD
(The through date of ) Tj
0.0003 Tc
0.4079999924 Tw
9.8050003052 0 Td
(service in Field #6, ) Tj
0.0006 Tc
0.2743999958 Tw
-9.8050003052 -1.3300000429 Td
[(Statem) 8 (ent Covers Period ) ] TJ
/TT2 1 Tf
0.0022 Tc
0 Tw
11.0200004578 0 Td
(is) Tj
/TT0 1 Tf
0.0013 Tc
0.2736999989 Tw
0.6700000167 0 Td
[( inc) 5 (l) -1 (u) 6 (d) 1 (ed in th) 6 (e) 5 ( ) ] TJ
0.0003 Tc
0.3134000003 Tw
-11.6899995804 -1.3350000381 Td
(covered days, if the pa) Tj
0 Tc
0.3149999976 Tw
10.2849998474 0 Td
(tient status code in ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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2135 0 obj
<<
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2136 0 obj
<<
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<<
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>>
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<<
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2139 0 obj
<<
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/TT2 3153 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
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>>
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2140 0 obj
<<
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2141 0 obj
<<
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>>
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2142 0 obj
<<
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/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(22) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
(Field #17, Patient Discharge Status, is equal to ) Tj
0.0006 Tc
-0.0055999998 Tw
0 -1.3350000381 TD
<223330977374696C6C20612070617469656E742E2220> Tj
EMC
/P <> BDC
/TT1 1 Tf
-0.0012000001 Tc
0 Tw
0 -1.7549999952 TD
(NOTE:) Tj
/TT0 1 Tf
0.001 Tc
0.0240000002 Tw
3.1649999619 0 Td
[( The units en) 6 (tere) 5 (d in this f) 4 (i) -1 (e) 5 (l) 4 (d ) ] TJ
/TT2 1 Tf
-0.0002 Tc
0 Tw
12.4250001907 0 Td
(must) Tj
/TT0 1 Tf
0.0006 Tc
0.0243999995 Tw
1.8899999857 0 Td
( be ) Tj
0.2678999901 Tw
-17.4799995422 -1.3300000429 Td
[(equal to the num) 8 (ber of days in "Statem) 8 (e) -1 (nt ) ] TJ
0.0001 Tc
0.4282000065 Tw
0 -1.3300000429 TD
(Covers Period", less day of discharge. If ) Tj
0.0009 Tc
0.0932999998 Tw
0 -1.3350000381 TD
[(patien) 6 (t) -1 ( statu) 6 (s is "s) 5 (till a patien) 6 (t) -1 (," un) 6 (its entered) 6 ( ) ] TJ
0.0001 Tc
-0.0026 Tw
T*
(include through day. ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
0 -1.75 TD
<3831974E6F6E636F7665726564204461797320> Tj
EMC
/P <> BDC
0.0005 Tc
0.0094999997 Tw
T*
[(If applicable, enter the num) 8 (b) 1 (er of non-covered ) ] TJ
0 Tc
0.0299999993 Tw
0 -1.3300000429 TD
(days. Examples of non-c) Tj
0.0001 Tc
0.0282000005 Tw
9.9750003815 0 Td
(overed days are those ) Tj
0.0007 Tc
-0.0007 Tw
-9.9750003815 -1.3350000381 Td
[(days f) 4 (o) 1 (r which the pa) 5 (tien) 6 (t) -1 ( is in) 6 (eligible. ) ] TJ
EMC
/P <> BDC
/TT1 1 Tf
-0.0012000001 Tc
0 Tw
0 -1.7549999952 TD
(NOTE:) Tj
/TT0 1 Tf
0.0011 Tc
0.2124000043 Tw
3.1649999619 0 Td
[( The tota) 5 (l units) 5 ( entered in this f) 4 (i) -1 (eld) 6 ( ) ] TJ
/TT2 1 Tf
-0.0002 Tc
0 Tw
-3.1649999619 -1.3300000429 Td
(must) Tj
/TT0 1 Tf
0.0009 Tc
0.3373999894 Tw
1.8899999857 0 Td
[( be eq) 6 (ual to the total accom) 9 (m) 4 (odation ) ] TJ
0.0001 Tc
-0.0009 Tw
-1.8899999857 -1.3300000429 Td
(units listed in Field #46, Service Units. ) Tj
EMC
/P <> BDC
0.0005 Tc
0.0882999972 Tw
T*
[(A com) 8 (p) 1 (lete list of) 4 ( va) 4 (lue) 4 (s can) 6 ( be f) 4 (o) 1 (u) 6 (nd in the ) ] TJ
-0.0001 Tc
0.0001 Tw
0 -1.3300000429 TD
(Official UB-04 Data Sp) Tj
0.0001 Tc
-0.0034 Tw
9.5249996185 0 Td
(ecifications Manual. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-23.4750003815 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*42. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Revenue Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
0.0571999997 Tw
T*
[(List appropriate accom) 9 (m) 4 (odation co) 6 (des firs) 5 (t in) 6 ( ) ] TJ
-0.0001 Tc
0.0001 Tw
0 -1.3300000429 TD
(chronological order. ) Tj
EMC
/P <> BDC
0.0005 Tc
0.0236000009 Tw
0 -1.75 TD
[(Ancillary co) 6 (des should b) 6 (e) -1 ( shown in num) 8 (e) -1 (rical ) ] TJ
0 Tc
0 Tw
0 -1.3300000429 TD
(order. ) Tj
EMC
/P <> BDC
0.0004 Tc
1.2846000195 Tw
0 -1.7549999952 TD
(Show duplicate revenue codes for ) Tj
0.0001 Tc
0.4688999951 Tw
0 -1.3300000429 TD
[(accomm) 8 (odat) -7 (i) -2 (ons when) 5 ( the rate differs or ) ] TJ
0.0004 Tc
0.1037999988 Tw
0 -1.3350000381 TD
[(when transfers are m) 8 (a) -1 (de back and forth, e.g., ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
(general to ICU to general. ) Tj
EMC
/P <> BDC
0.0009 Tc
0.1516000032 Tw
0 -1.7549999952 TD
[(A private room) 9 ( ) ] TJ
/TT2 1 Tf
-0.0002 Tc
0 Tw
(must) Tj
/TT0 1 Tf
0.0005 Tc
0.1544999927 Tw
8.7100000381 0 Td
[( be m) 8 (e) -1 (dically necessary ) ] TJ
0.0009 Tc
0.1040999964 Tw
-8.7100000381 -1.3300000429 Td
[(and the m) 9 (edical n) 6 (eed ) ] TJ
/TT2 1 Tf
-0.0002 Tc
0 Tw
9.1400003433 0 Td
(must) Tj
/TT0 1 Tf
-0.0001 Tc
0.1050999984 Tw
1.8899999857 0 Td
[( be docum) 8 (ented in ) ] TJ
0.0006 Tc
0.6194000244 Tw
-11.029999733 -1.3350000381 Td
[(the patient') 6 (s m) 8 (e) -1 (dical records unless the ) ] TJ
-0.0002 Tc
0.1801999956 Tw
0 -1.3300000429 TD
[(hospital has only private room) 8 (s. The private ) ] TJ
0.0012000001 Tc
0.0438000001 Tw
0 -1.3350000381 TD
[(room) 9 ( rate tim) 9 (es the number of) 4 ( days is enter) 4 (ed) 6 ( ) ] TJ
0.0009 Tc
-0.0009 Tw
T*
[(as the ch) 6 (arg) 6 (e. ) ] TJ
EMC
/P <> BDC
0.0007 Tc
0.0693000033 Tw
0 -1.75 TD
[(If the patien) 6 (t requested) ] TJ
0.0667999983 Tw
9.404999733 0 Td
[( a private room) 9 (, which ) ] TJ
0.0485000014 Tw
-9.404999733 -1.3300000429 Td
[(is non-covered, m) 8 (u) 1 (ltiply) 6 ( the p) 6 (r) -1 (iv) 6 (ate room) 8 ( rate ) ] TJ
0.0002 Tc
0.0992000028 Tw
0 -1.3350000381 TD
(by the number of days for the total charge in ) Tj
-0.0003 Tc
0.0553000011 Tw
T*
[(Field #47, T) 6 (otal Charges. Enter the difference ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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2143 0 obj
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2145 0 obj
<<
/Im0 3150 0 R
>>
endobj
2146 0 obj
<<
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>>
endobj
2147 0 obj
<<
/TT0 3152 0 R
/TT1 3153 0 R
/TT2 3174 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
endobj
2148 0 obj
<<
/MC0 3160 0 R
>>
endobj
2149 0 obj
<<
/GS0 3161 0 R
>>
endobj
2150 0 obj
<<
/Length 3227 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(23) 6 ( ) ] TJ
EMC
/P <> BDC
0.001 Tc
0.0540000014 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[(between the) 5 ( private roo) 6 (m) 4 ( total char) 4 (ge and the ) ] TJ
0 Tc
0.2340999991 Tw
0 -1.3350000381 TD
[(sem) 8 (i) -2 (private room) 8 ( total charge in Field #48, ) ] TJ
0.0002 Tc
-0.0002 Tw
T*
(Non-covered Charges, ) Tj
-0.0001 Tc
-0.0049000001 Tw
9.25 0 Td
(non-covered charges. ) Tj
EMC
/P <> BDC
0.0005 Tc
0.0544999987 Tw
-9.25 -1.75 Td
(After all revenue codes are shown, skip a line ) Tj
0.0003 Tc
0.1204999983 Tw
0 -1.3300000429 TD
(and list revenue code 0001, which represents ) Tj
0.0015 Tc
-0.0015 Tw
0 -1.3350000381 TD
[(tota) 5 (l charg) 7 (es) 6 (.) 2 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(43. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
0 -1.75 TD
(Revenue Description ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*44. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
T*
(HCPCS/Rates/HIPPS Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.4925000072 Tw
T*
(Enter the daily room and board rate to ) Tj
0.0006 Tc
0.2093999982 Tw
0 -1.3300000429 TD
[(coincid) 6 (e) -1 ( with accommodation rev) 6 (e) -1 (nue code.) 6 ( ) ] TJ
0.5433999896 Tw
T*
[(W) 5 (h) 1 (en m) 9 (u) 1 (ltiple rates exist f) 4 (o) 1 (r the sam) 9 (e ) ] TJ
0.0002 Tc
0.1397999972 Tw
0 -1.3350000381 TD
[(accomm) 8 (odat) -7 (i) -2 (on revenue code, use a separate ) ] TJ
0.0009 Tc
-0.0034 Tw
T*
[(line to repo) 6 (rt each rate.) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(45. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0 -1.75 TD
(Service Date ) Tj
EMC
/P <> BDC
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*46. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Service Units ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
T*
( ) Tj
EMC
/P <> BDC
13.0500001907 3.5 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
0.9294999838 Tw
T*
[(Enter the num) 8 (b) 1 (er of unit) -7 (s for the ) ] TJ
0.0003 Tc
0.0397000015 Tw
0 -1.3300000429 TD
[(accomm) 8 (odat) -7 (i) -2 (on line\(s\) o) 5 (nly. This field should) 5 ( ) ] TJ
0.0001 Tc
0.2149000019 Tw
0 -1.3350000381 TD
[(show the total num) 8 (ber of days hospitalized, ) ] TJ
-0.0013 Tw
T*
(including covered and non-covered days. ) Tj
EMC
/P <> BDC
/TT1 1 Tf
-0.0012000001 Tc
0 Tw
0 -1.75 TD
(NOTE:) Tj
/TT0 1 Tf
0.0009 Tc
0.1890999973 Tw
3.1649999619 0 Td
[( The num) 9 (b) 1 (er of units in Fields #39-) ] TJ
0.0005 Tc
0.1895000041 Tw
-3.1649999619 -1.3300000429 Td
[(#41, Value Codes and Am) 8 (ounts, ) ] TJ
/TT2 1 Tf
0.0011 Tc
0 Tw
14.1999998093 0 Td
(must) Tj
/TT0 1 Tf
-0.0006 Tc
0.1905999929 Tw
1.8949999809 0 Td
( equal ) Tj
0.0004 Tc
-0.0004 Tw
-16.0949993134 -1.3350000381 Td
[(the num) 8 (ber of units in this field. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*47. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Total Charg) 6 (es ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.1530999988 Tw
T*
[(Enter the to) 5 (tal charg) 5 (e) -1 ( for each rev) 5 (e) -1 (nue code ) ] TJ
0.0012000001 Tc
0.0930000022 Tw
0 -1.3300000429 TD
[(listed. W) 10 (h) 1 (en all charge) 5 (\(s\) are lis) 5 (te) 5 (d, skip one ) ] TJ
0.0009 Tc
0.2741000056 Tw
T*
[(line and s) 5 (t) -1 (a) 5 (t) -1 (e the to) 6 (ta) 5 (l of) 4 ( these charges to) 6 ( ) ] TJ
0.0003 Tc
-0.0015 Tw
0 -1.3350000381 TD
(correspond with revenue code 0001. ) Tj
EMC
/P <> BDC
/TT1 1 Tf
-0.0012000001 Tc
0 Tw
0 -1.7549999952 TD
(NOTE:) Tj
/TT0 1 Tf
0.0007 Tc
0.4242999852 Tw
3.1649999619 0 Td
[( The room) 9 ( rate m) 9 (u) 1 (ltiplie) 5 (d) 1 ( by th) 6 (e ) ] TJ
0.0009 Tc
0.0340999998 Tw
-3.1649999619 -1.3300000429 Td
[(num) 9 (b) 1 (er of units ) ] TJ
/TT2 1 Tf
-0.0027000001 Tc
0 Tw
(must) Tj
/TT0 1 Tf
0.0006 Tc
0.0344000012 Tw
8.5749998093 0 Td
[( eq) 6 (ual th) 6 (e charge entered) 6 ( ) ] TJ
0.0004 Tc
-0.0004 Tw
-8.5749998093 -1.3300000429 Td
[(for room) 8 ( acc) -6 (omm) 8 (odation\(s\). ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**48. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Non-covered Charges ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
0.0848999992 Tw
T*
(Enter any non-covered charges. This includes ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
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<<
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2154 0 obj
<<
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>>
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<<
/TT0 3152 0 R
/TT1 3153 0 R
/TT2 3174 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
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2156 0 obj
<<
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>>
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2157 0 obj
<<
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>>
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2158 0 obj
<<
/Length 3230 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(24) 6 ( ) ] TJ
EMC
/P <> BDC
-0.0001 Tc
0.070100002 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
(all charges incurred during those non-covered ) Tj
0.0003 Tc
0.1196999997 Tw
0 -1.3350000381 TD
(days entered in Fields #39-#41, Value Codes ) Tj
0.0008 Tc
0.1092000008 Tw
T*
[(and Am) 9 (ount) -6 (s. If Medicare Part B was billed) 6 (,) 6 ( ) ] TJ
0.0004 Tc
0.0445999987 Tw
0 -1.3300000429 TD
[(those Part B) 7 ( charges should be shown as non-) ] TJ
0.0001 Tc
0 Tw
0 -1.3350000381 TD
(covered. ) Tj
EMC
/P <> BDC
0.0003 Tc
0.2097000033 Tw
0 -1.7549999952 TD
(The difference in charges for private versus ) Tj
0.0002 Tc
0.2035000026 Tw
0 -1.3300000429 TD
[(non-private room) 8 ( accommodations when the ) ] TJ
0 Tc
0.3799999952 Tw
T*
(private room was ) Tj
/TT1 1 Tf
0 Tw
8.3299999237 0 Td
(not) Tj
/TT0 1 Tf
0.001 Tc
0.3815000057 Tw
1.2799999714 0 Td
[( m) 9 (edically) 6 ( necessary) 6 ( ) ] TJ
0.0002 Tc
-0.0009 Tw
-9.6099996567 -1.3350000381 Td
(should be shown as non-covered in this field. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(49. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
0 -1.75 TD
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*50. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
T*
[(Payer Nam) 8 (e) -6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.0483000018 Tw
T*
[(The prim) 8 (ary payer is always listed first. If the ) ] TJ
0.001 Tc
0.0189999994 Tw
0 -1.3300000429 TD
[(patien) 6 (t) -1 ( has insurance, th) 6 (e insuranc) 5 (e plan is th) 6 (e) 5 ( ) ] TJ
0.0005 Tc
0.1544999927 Tw
T*
[(prim) 8 <61727920706179657220616E6420934D4F> 8 <204865616C74684E657494206973206C697374656420> ] TJ
0.0016 Tc
0 Tw
0 -1.3350000381 TD
[(last.) 7 ( ) ] TJ
EMC
/P <> BDC
0 Tc
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(51. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.003 Tw
0 -1.75 TD
(Health Plan ID ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(52. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
[(Release of Infor) -7 (m) 8 (ation ) ] TJ
0.0013 Tc
-0.0013 Tw
0 -1.3300000429 TD
[(Certif) 4 (ica) 5 (tion) 6 ( Indica) 5 (tor) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(53. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.0022 Tw
T*
[(Assignm) 8 (ent of Benefits ) ] TJ
0.0012000001 Tc
-0.0012000001 Tw
0 -1.3300000429 TD
[(Certif) 4 (ica) 5 (tion) 6 ( of) 4 ( Indicato) 6 (r) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**54. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
T*
[(Prior Paym) 8 (ents ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.0434000008 Tw
T*
(Enter the amount the hosp) Tj
-0.0001 Tc
0.0450999998 Tw
10.6750001907 0 Td
(ital received toward ) Tj
0.0007 Tc
0.3492999971 Tw
-10.6750001907 -1.3300000429 Td
[(paym) 9 (ent of this bill from) 9 ( all other health ) ] TJ
0.0003 Tc
1.2697000504 Tw
0 -1.3350000381 TD
[(insurance com) 8 (panies. Payments ) ] TJ
/TT1 1 Tf
-0.0002 Tc
0 Tw
16.8099994659 0 Td
(must) Tj
/TT0 1 Tf
0 Tc
1.8899999857 0 Td
( ) Tj
-0.0004 Tc
0.058699999 Tw
-18.7000007629 -1.3300000429 Td
(correspond with the appr) Tj
-0.0001 Tc
0.0601000004 Tw
10.1450004578 0 Td
(opriate payer entered ) Tj
0.0001 Tc
-0.0001 Tw
-10.1450004578 -1.3350000381 Td
(in Field #50, Payer Name. \(See Note\)) Tj
-0.0022 Tc
0 Tw
7.9800000191 0 0 7.9800000191 472.8599853516 164.7601013184 Tm
[(\(1) -6 (\)) ] TJ
0 Tc
12 0 0 12 482.1600036621 159.2400970459 Tm
( ) Tj
EMC
/P <> BDC
-0.0011 Tc
-15.8299999237 -1.7549999952 Td
(Do ) Tj
/TT1 1 Tf
0 Tc
1.9850000143 0 Td
(not) Tj
/TT0 1 Tf
0.0003 Tc
0.5146999955 Tw
1.2799999714 0 Td
[( enter a p) 5 (r) -2 (evious MO HealthNet ) ] TJ
0.0005 Tc
0.3919999897 Tw
-3.2650001049 -1.3300000429 Td
[(paym) 8 (ent, Medicare paym) 8 (ent or copaym) 8 (ent) -7 ( ) ] TJ
0.0008 Tc
-0.0015 Tw
0 -1.3300000429 TD
[(am) 9 (ount received from) 9 ( the patient in this field) 6 ( ) ] TJ
EMC
/P <> BDC
0.6499999762 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
( ) Tj
EMC
/P <> BDC
13.9499998093 0 Td
( ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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2159 0 obj
<<
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/Length 3231 0 R
>>
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<<
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<<
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>>
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<<
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<<
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/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
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2164 0 obj
<<
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>>
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2165 0 obj
<<
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>>
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2166 0 obj
<<
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>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(25) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
12 0 0 12 109.8000030518 683.2199707031 Tm
(55. ) Tj
EMC
/P <> BDC
2.1510000229 0 Td
[(Estim) 8 (ated Amount Due ) ] TJ
EMC
/P <> BDC
13.0500001907 0 Td
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*56. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.001 Tw
0 -1.75 TD
[(National P) 7 (r) -1 (o) 6 (v) 1 (ider Id) 6 (entif) 4 (i) -1 (er ) ] TJ
-0.0009 Tc
0 Tw
0 -1.3300000429 TD
(\(NPI\) ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
-0.0013 Tw
0 -1.75 TD
[(Enter th) 6 (e ho) 6 (spita) 5 (l') 7 (s ) ] TJ
0.0001 Tc
-0.0001 Tw
7.8699998856 0 Td
(10-digit NPI number. ) Tj
EMC
/P <> BDC
0.2849000096 Tw
-7.8699998856 -1.75 Td
(If applicable: Enter the corresponding 10-) Tj
0 Tc
0.625 Tw
0 -1.3300000429 TD
[(digit Provider Taxonom) 8 (y code in Field ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3350000381 TD
(81CCa, Code-Code Field. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(57. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Other Provider ID ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**58. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[(Insured') 6 (s Nam) 8 (e) -6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
0.2536999881 Tw
T*
[(Com) 9 (p) 1 (lete if) 4 ( the insure) 5 <649273206E616D> 9 (e is dif) 4 (f) 4 (erent ) ] TJ
0.0009 Tc
0.0001 Tw
0 -1.3300000429 TD
[(from) 9 ( the patient') 6 (s nam) 9 (e. \(See Note\)) ] TJ
-0.0026 Tc
0.0007 Tw
7.9800000191 0 0 7.9800000191 462.3599853516 493.7401123047 Tm
( \(1\)) Tj
0 Tc
0 Tw
12 0 0 12 473.5799865723 488.2200012207 Tm
( ) Tj
EMC
/P <> BDC
-29.0650005341 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(59. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0026 Tw
0 -1.75 TD
<50617469656E7492732052656C6174696F6E7368697020746F20> Tj
0.001 Tc
0 Tw
0 -1.3300000429 TD
[(Insured) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*60. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
T*
[(Insured') 5 (s Unique ID ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
0.2140000015 Tw
T*
[(Enter the p) 6 (atien) 6 (t) -1 (') 6 (s 8-digit MO HealthNet or) 4 ( ) 215 ( ) ] TJ
-0.0002 Tc
1.1502000093 Tw
0 -1.3300000429 TD
(MO HealthNet Managed Care Plan ) Tj
0 Tc
0.7549999952 Tw
0 -1.3350000381 TD
[(identification num) 8 (ber. If insurance was ) ] TJ
0.0005 Tc
0.0777999982 Tw
0 -1.3300000429 TD
(indicated in Field #50, ) Tj
0.0004 Tc
0.0795999989 Tw
9.5749998093 0 Td
[(Payer Nam) 8 (e) -1 (, enter the ) ] TJ
0.1630000025 Tw
-9.5749998093 -1.3350000381 Td
[(insurance num) 8 (ber to correspond to the order ) ] TJ
0.0001 Tc
0.0007 Tw
0 -1.3350000381 TD
[(shown in Field #50, Payer Nam) 8 (e) -1 (. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**61. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
0 -1.75 TD
[(Insurance Group Nam) 8 (e) -6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.3300999999 Tw
T*
(If insurance is shown in Field #50, Payer ) Tj
-0.0005 Tc
0.2405000031 Tw
0 -1.3300000429 TD
[(Na) -7 (m) 7 (e) -2 (, state the nam) 7 (e) -2 ( of) ] TJ
0.0001 Tc
0.2373999953 Tw
10.6400003433 0 Td
( the group or plan ) Tj
0.0003 Tc
0.0147000002 Tw
-10.6400003433 -1.3350000381 Td
(through which the insurance is provided to the ) Tj
-0.0027999999 Tw
0 -1.3350000381 TD
(insured. \(See Note\)) Tj
-0.0020999999 Tc
0.0002 Tw
7.9800000191 0 0 7.9800000191 385.200012207 223.7400970459 Tm
[( \(1) -6 (\)) ] TJ
0 Tc
0 Tw
12 0 0 12 396.4800109863 218.2200012207 Tm
( ) Tj
EMC
/P <> BDC
-22.6399993896 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**62. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
0 -1.75 TD
[(Insurance Group Num) 8 (b) 1 (er ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.3300999999 Tw
T*
(If insurance is shown in Field #50, Payer ) Tj
0.0003 Tc
0.4647000134 Tw
0 -1.3300000429 TD
[(Na) -6 (m) 8 (e) -1 (, state the num) 8 (ber assigned by the ) ] TJ
0.0006 Tc
0.4993999898 Tw
0 -1.3350000381 TD
[(insurance com) 8 (p) 1 (any to identify the group ) ] TJ
0 Tc
0.2240999937 Tw
T*
(under which the individual is covered. \(See ) Tj
0.0003 Tc
0 Tw
0 -1.3300000429 TD
(Note\)) Tj
-0.0020999999 Tc
0.0002 Tw
7.9800000191 0 0 7.9800000191 319.5599975586 117.7800979614 Tm
[( \(1) -6 (\)) ] TJ
0 Tc
0 Tw
12 0 0 12 330.8399963379 112.2600021362 Tm
( ) Tj
EMC
/P <> BDC
0.6499999762 Tc
-17.1700000763 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
( ) Tj
EMC
/P <> BDC
13.9499998093 0 Td
( ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
endobj
2167 0 obj
<<
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2168 0 obj
<<
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>>
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2169 0 obj
<<
/Im0 3150 0 R
>>
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2170 0 obj
<<
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>>
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2171 0 obj
<<
/TT0 3152 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
endobj
2172 0 obj
<<
/MC0 3160 0 R
>>
endobj
2173 0 obj
<<
/GS0 3161 0 R
>>
endobj
2174 0 obj
<<
/Length 3236 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(26) 6 ( ) ] TJ
EMC
/P <> BDC
0.0003 Tc
0.649699986 Tw
12 0 0 12 97.8000030518 683.2199707031 Tm
(**63. ) Tj
EMC
/P <> BDC
[(Treatm) 8 (e) -1 (nt ) 650 (Authorization ) ] TJ
0.0001 Tc
0 Tw
3.1500000954 -1.3300000429 Td
(Codes ) Tj
EMC
/P <> BDC
0.0008 Tc
0.2958000004 Tw
13.0500001907 1.3300000429 Td
[(For claim) 9 (s requiring ce) ] TJ
0.0002 Tc
0.2922999859 Tw
10.1949996948 0 Td
(rtification, enter the ) Tj
0.2597999871 Tw
-10.1949996948 -1.3300000429 Td
(unique 7-digit certific) Tj
0.0003 Tc
9.2399997711 0 Td
[(ation num) 8 (ber supplied ) ] TJ
0.0001 Tc
-0.0001 Tw
-9.2399997711 -1.3350000381 Td
(by Xerox. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**64. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-0.0003 Tw
0 -1.75 TD
[(Docum) 8 (e) -1 (nt Control Number ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
0.1286000013 Tw
T*
[(If the cu) 6 (rre) 4 (nt claim) 8 ( exceeds the tim) 8 (ely filing ) ] TJ
0.0005 Tc
0.0650999993 Tw
0 -1.3300000429 TD
[(lim) 8 (it of one year from) 8 ( the "through" date, but ) ] TJ
0.001 Tc
0.2290000021 Tw
T*
[(was origin) 6 (a) 5 (lly subm) 9 (itte) 5 (d tim) 9 (ely and denied,) 6 ( ) ] TJ
0 -1.3350000381 TD
[(the prov) 6 (ider) 4 ( m) 9 (ay enter the 13) 6 (-digit In) 6 (tern) 6 (a) 5 (l) 4 ( ) ] TJ
0.0008 Tc
0.2691999972 Tw
T*
[(Control Nu) 6 (mber \(ICN\)) 4 ( f) 4 (r) -1 (om) 9 ( the r) 4 (em) 9 (ittance ) ] TJ
0.0012000001 Tc
0.3738000095 Tw
0 -1.3300000429 TD
[(advice that docum) 9 (ents that the c) 5 (l) -1 (aim) 9 ( was ) ] TJ
0.0003 Tc
0.2446999997 Tw
0 -1.3350000381 TD
(previously filed and de) Tj
0.0009 Tc
0.2441000044 Tw
9.9300003052 0 Td
[(nied within) 6 ( the one-) ] TJ
0.0008 Tc
-0.0008 Tw
-9.9300003052 -1.3350000381 Td
[(year lim) 9 (it. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(65. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
-0.0013 Tw
0 -1.75 TD
[(Em) 9 (ployer Nam) 9 (e) -5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
0.3594999909 Tw
T*
[(If the patient is em) 8 (ployed, the employer') 6 (s) -5 ( ) ] TJ
0.0002 Tc
0.001 Tw
0 -1.3300000429 TD
[(nam) 8 (e) -1 ( m) 8 (a) -1 (y be entered here. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(66. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Diagnosis & Procedure Code ) Tj
0.0011 Tc
0 Tw
0 -1.3300000429 TD
[(Qualif) 4 (ier) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*67. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Principal Diagnosis Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.0153000001 Tw
T*
(Enter the complete ICD diagnosis code for the ) Tj
-0.0001 Tc
0.0800999999 Tw
0 -1.3300000429 TD
(condition established afte) Tj
0.0002 Tc
0.0785000026 Tw
10.3800001144 0 Td
(r study to be chiefly ) Tj
-0.0018 Tw
-10.3800001144 -1.3300000429 Td
[(responsible for the adm) 8 (i) -2 (ssion. ) ] TJ
EMC
/P <> BDC
0.0012000001 Tc
0.3179999888 Tw
0 -1.7549999952 TD
[(Rem) 9 (e) -5 (m) 9 (b) 1 (er to code to) 6 ( the h) 6 (i) -1 (ghes) 5 (t) -1 ( lev) 6 (el of) 4 ( ) ] TJ
-0.0003 Tc
0.0502999984 Tw
0 -1.3300000429 TD
(specificity shown in the current version of the ) Tj
0 Tc
0 Tw
0 -1.3350000381 TD
(ICD diagnosis code book. ) Tj
EMC
/P <> BDC
0.0002 Tc
0.3998000026 Tw
0 -1.75 TD
[(Present On Ad) -5 (m) 8 (i) -2 (ssion \(POA\) Indicator is ) ] TJ
0.1580999941 Tw
0 -1.3300000429 TD
(reported in eighth digit ) Tj
0 Tc
0.1599999964 Tw
10.0850000381 0 Td
(\(shaded area\) of this ) Tj
0.0001 Tc
-0.0001 Tw
-10.0850000381 -1.3350000381 Td
(field. Values are: ) Tj
EMC
/P <> BDC
0.0003 Tc
-0.0003 Tw
0 -1.1499999762 TD
<2020202020202059203D2059657320962070726573656E7420> Tj
-0.0001 Tc
-0.0019 Tw
9.2299995422 0 Td
[(at the tim) 8 (e) -1 ( of i) -7 (npatient ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
-9.2299995422 -1.1499999762 Td
[( adm) 8 (i) -2 (ssion. ) ] TJ
EMC
/P <> BDC
0.0004 Tc
-0.0001 Tw
T*
[<202020202020204E203D204E6F2096206E6F742070726573656E74206174207468652074696D> 8 (e) -1 ( of ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
0 -1.1449999809 TD
[( inpatient adm) 8 (i) -2 (ssion. ) ] TJ
EMC
/P <> BDC
0 -1.1499999762 TD
[<2020202020202055203D20556E6B6E6F776E209620646F63756D> 8 (entation is ) ] TJ
EMC
/P <> BDC
-0.0004 Tw
T*
[( insufficient to determ) 8 (ine if condition ) ] TJ
EMC
/P <> BDC
-0.0007 Tw
T*
[( is present on adm) 8 (i) -2 (ssion. ) ] TJ
EMC
/P <> BDC
0.0005 Tc
-0.0001 Tw
T*
[( W) 9 ( = Clinically undeterm) 8 <696E656420962070726F766964657220> ] TJ
EMC
/P <> BDC
0 Tc
-0.0005 Tw
T*
[( is unable to clinically determ) 8 (ine) -6 ( ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
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2175 0 obj
<<
/Filter [/FlateDecode]
/Length 3237 0 R
>>
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2176 0 obj
<<
/Filter [/FlateDecode]
/Length 3238 0 R
>>
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2177 0 obj
<<
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>>
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2178 0 obj
<<
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>>
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2179 0 obj
<<
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/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
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2180 0 obj
<<
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>>
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2181 0 obj
<<
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>>
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2182 0 obj
<<
/Length 3239 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(27) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0007 Tw
12 0 0 12 292.200012207 690.4799804688 Tm
( whether condition was present on ) Tj
EMC
/P <> BDC
0.0003 Tc
-0.0003 Tw
T*
[( adm) 8 (i) -2 (ssion or not. ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
[<2020202020202020426C616E6B203D20556E7265706F727465642F4E6F7420557365642096206578656D> 8 (pt) -7 ( ) ] TJ
EMC
/P <> BDC
0.0001 Tc
-0.0003 Tw
T*
( from POA reporting. \(See the ICD ) Tj
EMC
/P <> BDC
-0.0001 Tw
T*
( Official Guidelines for Coding and ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
3.4000000954 -1.3350000381 Td
[(Reporting for list of exempt ) -190 ( ) -2750 ( ) ] TJ
-0.0002 Tc
-0.0048000002 Tw
0 -1.3350000381 TD
(diagnosis codes\) ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-17.3500003815 -1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0005 Tc
0.0005 Tw
-4.2750000954 -1.75 Td
(**67. A-D ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
5.1750001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
0 -1.75 TD
(Other Diagnosis Codes ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0009 Tc
0.0231999997 Tw
T*
[(Enter any ad) 6 (dition) 6 (al diag) 6 (nosis codes that hav) 6 (e) 5 ( ) ] TJ
0.0006 Tc
0.3244000077 Tw
0 -1.3300000429 TD
[(an effect on the treatm) 8 (e) -1 (nt received or the ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3350000381 TD
(length of stay. ) Tj
EMC
/P <> BDC
0.0002 Tc
0.3998000026 Tw
0 -1.7549999952 TD
[(Present On Ad) -5 (m) 8 (i) -2 (ssion \(POA\) Indicator is ) ] TJ
0.1580999941 Tw
0 -1.3300000429 TD
(reported in eighth digit ) Tj
0 Tc
0.1599999964 Tw
10.0850000381 0 Td
(\(shaded area\) of this ) Tj
0.0001 Tc
-0.0001 Tw
-10.0850000381 -1.3300000429 Td
(field. Values are listed above. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-0.0004 Tc
0.0004 Tw
-3.1649999619 -1.75 Td
(67. E-Q ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
4.0650000572 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
0 -1.75 TD
(Other Diagnosis Codes ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(68. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(69. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.001 Tw
T*
[(Adm) 9 (itting Diagnosis) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(70. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
[(Patient') 5 (s) -1 ( Reason for Visit ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(71. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0011 Tc
-0.0035999999 Tw
T*
[(Prospective Paym) 9 (ent system) 9 ( ) ] TJ
0 Tc
0 Tw
0 -1.3300000429 TD
(\(PPS\) Code ) Tj
EMC
/P <> BDC
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(72. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
(External Cause of Injury ) Tj
-0.0005 Tc
0.0005 Tw
0 -1.3300000429 TD
(Code \(E Code\) ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(73. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**74. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
(Principal Procedure Code and ) Tj
0.0006 Tc
0 Tw
0 -1.3300000429 TD
(Date ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
0.3576000035 Tw
0 -1.75 TD
(Enter the full ICD procedure code of the ) Tj
0.0004 Tc
0.4496000111 Tw
0 -1.3300000429 TD
(principal surgical procedure. The date on ) Tj
0.1645999998 Tw
0 -1.3350000381 TD
[(which the procedure was perform) 8 (e) -1 (d ) ] TJ
/TT1 1 Tf
-0.0002 Tc
0 Tw
15.4549999237 0 Td
(must) Tj
/TT0 1 Tf
-0.0019 Tc
0.166899994 Tw
1.8899999857 0 Td
( be ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
endobj
2183 0 obj
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2184 0 obj
<<
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/Length 3241 0 R
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<<
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>>
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2186 0 obj
<<
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2187 0 obj
<<
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/TT1 3174 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
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2188 0 obj
<<
/MC0 3160 0 R
>>
endobj
2189 0 obj
<<
/GS0 3161 0 R
>>
endobj
2190 0 obj
<<
/Length 3242 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(28) 6 ( ) ] TJ
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[(shown. Only m) 8 (onth and day are required. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
-4.1649999619 -1.75 Td
(**74. A-E ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
5.0650000572 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0016 Tw
0 -1.75 TD
(Other Procedure Codes and ) Tj
-0.001 Tc
0 Tw
0 -1.3300000429 TD
(Dates ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.2547000051 Tw
0 -1.75 TD
(Identify and date any other procedures that ) Tj
-0.0003 Tw
0 -1.3300000429 TD
[(m) 8 (a) -1 (y have be) -6 (en perform) 8 (e) -6 (d. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(75. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
0 -1.75 TD
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*76. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[(Attending P) 7 (r) -1 (ovider Nam) 8 (e) -1 ( and ) ] TJ
0.0005 Tc
0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.3195999861 Tw
0 -1.75 TD
[(Enter the attending provider') 6 (s 10-digit NPI ) ] TJ
0.0006 Tc
0.0684999973 Tw
0 -1.3300000429 TD
[(num) 8 (b) 1 (er. Enter the attending provider') 6 (s nam) 8 (e) -1 (, ) ] TJ
0.0016 Tc
-0.0031999999 Tw
T*
[(last n) 7 (am) 9 (e f) 5 (i) -1 (rst. ) ] TJ
EMC
/P <> BDC
0.0001 Tc
0.2849000096 Tw
0 -1.3350000381 TD
(If applicable: Enter the corresponding 10-) Tj
0 Tc
0.625 Tw
T*
[(digit Provider Taxonom) 8 (y code in Field ) ] TJ
0 Tw
0 -1.3300000429 TD
(81CCb, Code-Code Field. ) Tj
EMC
/P <> BDC
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**77. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
0 -1.75 TD
[(Operating P) 7 (r) -1 (ovider Nam) 8 (e) -1 ( and ) ] TJ
0.0005 Tc
0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.3097000122 Tw
0 -1.75 TD
[(Enter the operating provider') 6 (s 10-digit NPI ) ] TJ
0.0007 Tc
0.0584000014 Tw
0 -1.3300000429 TD
[(num) 9 (b) 1 (er. Enter the operating provider') 6 (s na) -5 (m) 9 (e, ) ] TJ
0.0016 Tc
-0.0031999999 Tw
0 -1.3350000381 TD
[(last n) 7 (am) 9 (e f) 5 (i) -1 (rst. ) ] TJ
EMC
/P <> BDC
0.0001 Tc
0.2849000096 Tw
0 -1.3300000429 TD
(If applicable: Enter the corresponding 10-) Tj
0 Tc
0.625 Tw
0 -1.3350000381 TD
[(digit Provider Taxonom) 8 (y code in Field ) ] TJ
0.0001 Tc
-0.0001 Tw
T*
(81CCc, Code-Code Field. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-3.5850000381 -1.75 Td
(**78-79. ) Tj
EMC
/P <> BDC
0 Tc
4.4850001335 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
0 -1.75 TD
[(Other Provider Nam) 8 (e) -1 ( and ) ] TJ
0.0005 Tc
0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 -1.7549999952 TD
( ) Tj
EMC
/P <> BDC
13.0500001907 4.8350000381 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.6546999812 Tw
0 -1.75 TD
[(Enter the other provider') 6 (s 10-digit NPI ) ] TJ
0.0006 Tc
0.0631000027 Tw
0 -1.3300000429 TD
[(num) 8 (b) 1 (er. Enter the othe) ] TJ
0.0004 Tc
0.0645999983 Tw
9.6649999619 0 Td
[(r provider') 6 (s nam) 8 (e) -1 (, last ) ] TJ
0.0005 Tc
0.0044999998 Tw
-9.6649999619 -1.3350000381 Td
[(nam) 8 (e) -1 ( first. ) 10 ( ) ] TJ
EMC
/P <> BDC
0.0001 Tc
0.2849000096 Tw
0 -1.3350000381 TD
(If applicable: Enter the corresponding 10-) Tj
0 Tc
0.625 Tw
0 -1.3300000429 TD
[(digit Provider Taxonom) 8 (y code in Field ) ] TJ
0 Tw
0 -1.3350000381 TD
(81CCd, Code-Code Field. ) Tj
EMC
/P <> BDC
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**80. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0 -1.75 TD
[(Re) -6 (m) 8 (a) -1 (rks ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.0395999998 Tw
T*
[(Use this field to draw attention to attachm) 8 (e) -1 (nts ) ] TJ
0.0005 Tc
0.0344999991 Tw
0 -1.3300000429 TD
[(such as operative no) 6 (tes,) ] TJ
0.0001 Tc
0.0315000005 Tw
9.6049995422 0 Td
( TPL denial, Medicare ) Tj
-0.0017 Tw
-9.6049995422 -1.3300000429 Td
(Part B only, etc. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-4.0300002098 -1.75 Td
(**81CCa. ) Tj
EMC
/P <> BDC
0 Tc
4.9299998283 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Code-Code Field ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.3436000049 Tw
T*
(Enter the B3 Provider Taxonomy qualifier ) Tj
0 Tc
1.3899999857 Tw
0 -1.3300000429 TD
(and corresponding 10-digit Provider ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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/Length 3243 0 R
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<<
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<<
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>>
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2194 0 obj
<<
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>>
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<<
/TT0 3152 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
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<<
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<<
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<<
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/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(29) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0.1008000001 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[(Taxonom) 8 (y code for the NPI num) 8 (be) -6 (r reported ) ] TJ
0.0001 Tc
0.1791000068 Tw
0 -1.3350000381 TD
<696E204669656C6420232035362C204E6174696F6E616C2050726F7669646572204964656E746966696572209620> Tj
0.0004 Tc
-0.0004 Tw
T*
[(Billing P) 7 (r) -2 (ov) 5 (ider) 3 (: ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
0 -1.3300000429 TD
(1) Tj
0.0018 Tc
7.9800000191 0 0 7.9800000191 298.200012207 645.7800292969 Tm
(st) Tj
0.0003 Tc
-0.0013 Tw
12 0 0 12 303.5400085449 640.2600097656 Tm
( Box: B3 Qualifier ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-0.9449999928 -1.3350000381 Td
(2) Tj
0.0038000001 Tc
7.9800000191 0 0 7.9800000191 298.200012207 629.7600097656 Tm
(nd) Tj
0.0002 Tc
-0.0002 Tw
12 0 0 12 306.2399902344 624.2399902344 Tm
[( Box: Provider Taxonom) 8 (y code ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-15.1199998856 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-4.0850000381 -1.75 Td
(**81CCb. ) Tj
EMC
/P <> BDC
0 Tc
4.9850001335 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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[(\(1) -6 (\)) ] TJ
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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ET
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EMC
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EMC
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EMC
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EMC
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EMC
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0.0001 Tc
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EMC
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EMC
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[( Listed below is) 5 ( the) 5 ( ) ] TJ
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(revenue code that represents th) Tj
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EMC
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( ) Tj
EMC
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EMC
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(icipant was in observation as units billed. ) Tj
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EMC
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EMC
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EMC
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(Revenue ) Tj
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EMC
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EMC
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( ) Tj
EMC
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EMC
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( ) Tj
EMC
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T*
( ) Tj
EMC
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T*
(Description) Tj
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( ) Tj
EMC
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(0762.......... ) Tj
EMC
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EMC
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EMC
ET
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EMC
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EMC
BT
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ET
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1.2749999762 0 Td
( cover other fields. ) Tj
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0.0353000015 Tw
-10.125 -1.3350000381 Td
[(Claim) 8 ( for) -7 (m) 8 (s) -5 ( m) 8 (a) -1 (y be ordered from) 8 ( the fiscal ) ] TJ
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0.8424999714 Tw
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[(agent with) 6 ( this r) 4 (eq) 6 (u) 1 (ired inf) 4 (o) 1 (rm) 9 (ation ) ] TJ
0.0003 Tc
0.0009 Tw
0 -1.3300000429 TD
[(preprinted on the form) 8 (. ) ] TJ
EMC
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0 Tw
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( ) Tj
EMC
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(2. ) Tj
EMC
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( ) Tj
EMC
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EMC
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0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0007 Tc
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T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
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0 Tw
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( ) Tj
EMC
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EMC
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0 Tc
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( ) Tj
EMC
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EMC
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0 Tw
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( ) Tj
EMC
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0 -1.3300000429 TD
[(m) 9 (axi) -6 (m) 9 (u) -4 (m of 20 alpha/num) 9 (eric ch) 6 (aracters) 5 ( ) ] TJ
EMC
ET
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BT
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0.001 Tc
-0.0035000001 Tw
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[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
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EMC
BT
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0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
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BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
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EMC
EMC
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( ) Tj
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( ) Tj
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[(35) 6 ( ) ] TJ
EMC
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0.0004 Tc
-0.0016 Tw
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[(m) 8 (a) -1 (y be entered here. ) ] TJ
EMC
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0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
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(3b. ) Tj
EMC
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( ) Tj
EMC
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0.0004 Tc
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(Med Rec # ) Tj
EMC
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( ) Tj
EMC
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T*
(Not required. ) Tj
EMC
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0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
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(*4. ) Tj
EMC
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( ) Tj
EMC
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0.0006 Tc
-0.0006 Tw
T*
[(Type of) 4 ( Bill ) ] TJ
EMC
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0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0006 Tc
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T*
(The required three digits in this code ) Tj
-0.0040000002 Tw
0 -1.3300000429 TD
[(identif) 4 (y) 1 ( the f) 4 (o) 1 (llowing: ) ] TJ
EMC
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0.001 Tc
-0.003 Tw
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[( ) -1132 (1st digit: typ) 6 (e of) 4 ( f) 4 (acility ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
[( ) -1130 (2nd digit: bill classification ) ] TJ
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T*
[( ) -1130 (3rd digit: frequency ) ] TJ
EMC
/P <> BDC
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-0.0020999999 Tw
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[(The valid ty) 6 (pe of bill is "131." ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
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(5. ) Tj
EMC
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1.6499999762 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.0035000001 Tw
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[(Federal Tax Num) 9 (b) 1 (er ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
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T*
[(Enter the provider') 6 (s federal tax number or ) ] TJ
0.0008 Tc
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0 -1.3300000429 TD
[(leave b) 6 (l) -1 (ank.) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(**6. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
[(Statem) 8 (ent Covers Period ) ] TJ
0 -1.3300000429 TD
[(\(from) 8 ( and through dates\) ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.3799999952 Tw
0 -1.75 TD
(Indicate the beginning and ending dates ) Tj
0.0012000001 Tc
0.2529999912 Tw
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[(being b) 6 (illed) 6 ( on th) 6 (is claim) 9 ( f) 4 (o) 1 (rm) 9 (. Enter in) 6 ( ) ] TJ
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T*
[(MMDDYY or MMDDYYYY num) 8 (eric ) ] TJ
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-0.0001 Tw
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[(for) -7 (m) 8 (at or leave blank. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
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-0.75 -1.75 Td
(7. ) Tj
EMC
/P <> BDC
1.6499999762 1.75 Td
( ) Tj
EMC
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0.0008 Tc
-0.0008 Tw
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[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
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0.0003 Tc
-1.1950000525 -1.75 Td
(8a. ) Tj
EMC
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0 Tc
2.0950000286 1.75 Td
( ) Tj
EMC
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[(Patien) 6 (t) -1 (') 7 (s) 1 ( Nam) 9 (e - ID ) ] TJ
EMC
/P <> BDC
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13.0500001907 1.75 Td
( ) Tj
EMC
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[(Enter the p) 6 (a) -1 (tien) 6 (t) -2 (') 6 (s 8-digit MO HealthNet ) ] TJ
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0.0441000015 Tw
0 -1.3300000429 TD
[(DCN or M) -6 (O) 2 ( HealthNet Managed Care Plan ) ] TJ
0.0007 Tc
-0.0007 Tw
T*
[(identificatio) 6 (n num) 9 (b) 1 (er. ) ] TJ
EMC
/P <> BDC
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-0.0012000001 Tc
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(NOTE:) Tj
/TT0 1 Tf
0.0008 Tc
0.2192000002 Tw
3.1649999619 0 Td
[( The MO HealthNet DCN or MO) 8 ( ) ] TJ
-0.0003 Tc
1.8602999449 Tw
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(HealthNet Managed Care Plan ) Tj
0.0008 Tc
0.8841999769 Tw
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[(identificatio) 6 (n num) 9 (b) 1 (er is ) ] TJ
/TT2 1 Tf
0.0002 Tc
0 Tw
12.4600000381 0 Td
(required) Tj
/TT0 1 Tf
0.0011 Tc
0.8838999867 Tw
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( in ) Tj
0 Tc
0 Tw
-15.904999733 -1.3300000429 Td
<4669656C64202336302C20496E7375726564927320556E69717565204964656E7469666965722E20> Tj
EMC
/P <> BDC
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*8b. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-0.0003 Tw
0 -1.75 TD
[(Patien) 5 (t) -2 ( Name ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0008 Tc
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T*
[(Enter th) 6 (e p) 6 (atien) 6 (t) -1 (') 6 (s name in the f) 4 (o) 1 (llowing ) ] TJ
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[(f) 5 (o) 2 (rm) 10 (at: las) 6 (t nam) 10 (e) 1 (, f) 5 (irst n) 7 (a) 1 (m) 10 (e) 1 (, m) 10 (iddle initial.) 7 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-0.75 -1.75 Td
(9. ) Tj
EMC
/P <> BDC
1.6499999762 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0006 Tc
0.0006 Tw
0 -1.75 TD
(Patient Address ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
0.4377000034 Tw
T*
[(Enter th) 6 (e patien) 6 (t) -1 (') 7 (s) 1 ( f) 4 (u) 1 (ll m) 9 (ailing address,) 6 ( ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
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2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
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12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(36) 6 ( ) ] TJ
EMC
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0.4097000062 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[(including street num) 8 (ber and nam) 8 (e) -1 (, post ) ] TJ
0.1608999968 Tw
0 -1.3350000381 TD
[(office box num) 8 (ber or RF) ] TJ
-0.0001 Tc
0.1616999954 Tw
(D, city, state and ) Tj
-0.0004 Tc
0.0004 Tw
T*
(zip code. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(10. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
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0.0009 Tc
-0.0009 Tw
0 -1.75 TD
[(Patien) 6 (t) -1 ( Birth) 6 ( Date ) ] TJ
EMC
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0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0011 Tc
0.743900001 Tw
T*
[(Enter the) 5 ( patien) 6 (t) -1 (') 6 (s date of) 4 ( birth in) 6 ( ) ] TJ
-0.0007 Tc
0.0057000001 Tw
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[(MMDDYY for) -8 (m) 7 (at. ) ] TJ
EMC
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0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(11. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0006 Tc
0.0006 Tw
0 -1.75 TD
(Patient Sex ) Tj
EMC
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0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
0.1821999997 Tw
T*
[(Enter the p) 6 (atien) 6 (t) -1 (') 7 (s) 1 ( sex, "M" \(m) 9 (ale\) or "F) 7 (") 5 ( ) ] TJ
0.0023000001 Tc
0 Tw
0 -1.3300000429 TD
[(\(fem) 10 (ale\).) 7 ( ) ] TJ
EMC
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0 Tc
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(12. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
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[(Ad) -5 (m) 8 (i) -2 (ssion Date ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(13. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
T*
[(Adm) 8 (i) -2 (ssion Hour ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0001 Tc
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T*
(Not required. ) Tj
EMC
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0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
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-2.25 -1.75 Td
(**14. ) Tj
EMC
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3.1500000954 1.75 Td
( ) Tj
EMC
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0.0006 Tc
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T*
[(Adm) 8 (i) -2 (ssion Type ) ] TJ
EMC
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0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
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0.0011 Tc
0.3488999903 Tw
T*
[(Leave blan) 6 (k unless th) 6 (is claim) 9 ( is for an ) ] TJ
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0.0008 Tc
0.0333000012 Tw
T*
[(Adm) 9 (i) -1 (ssion Type ') 6 (1) 1 (.') 6 ( Condition code AJ also ) ] TJ
/TT1 1 Tf
-0.0002 Tc
0 Tw
0 -1.3350000381 TD
(must) Tj
/TT0 1 Tf
0.0004 Tc
0.4546000063 Tw
1.8899999857 0 Td
[( be listed in Field #18, Condition) 5 ( ) ] TJ
0.0346000008 Tw
-1.8899999857 -1.3350000381 Td
[(Codes, to exem) 8 (pt the patient from) 8 ( the $3.00 ) ] TJ
-0.0004 Tw
0 -1.3300000429 TD
[(copaym) 8 (ent amount for the service. ) ] TJ
EMC
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0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
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-1.25 -1.75 Td
(15. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
[(Source of Adm) 8 (i) -2 (ssion \(S) 7 (RC\) ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(16. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
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0.0007 Tc
-0.0007 Tw
T*
[(Discharge H) 8 (our ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(17. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
T*
(Patient Discharge Status ) Tj
EMC
/P <> BDC
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-3.5850000381 -1.75 Td
(**18-24. ) Tj
EMC
/P <> BDC
0 Tc
4.4850001335 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
T*
[(Condition C) 8 (odes ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0012000001 Tc
0.0099999998 Tw
T*
[(Enter the ap) 6 (plicab) 6 (le two-char) 4 (acte) 5 (r c) 5 (onditio) 6 (n) 6 ( ) ] TJ
0.0004 Tc
0.0046000001 Tw
0 -1.3300000429 TD
[(code. A com) 8 (plete list of) ] TJ
0.0005 Tc
0.0031999999 Tw
9.5900001526 0 Td
( values can be found ) Tj
0.0007 Tc
0.2343000025 Tw
-9.5900001526 -1.3350000381 Td
[(in the Of) 4 (f) 4 (i) -1 (cial UB-04 Data Specif) 4 (ications) 5 ( ) ] TJ
0 Tc
-0.0012000001 Tw
T*
(Manual. The values are: ) Tj
EMC
/P <> BDC
0.0001 Tc
0 Tw
0 -1.7549999952 TD
<4131974843592F455053445420> Tj
EMC
/P <> BDC
0.0009 Tc
0.3583999872 Tw
0 -1.75 TD
[(If) 4 ( this se) 5 (rv) 6 (ice is the result of) 4 ( an HCY ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
endstream
endobj
2255 0 obj
<<
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2256 0 obj
<<
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>>
stream
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2257 0 obj
<<
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>>
endobj
2258 0 obj
<<
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>>
endobj
2259 0 obj
<<
/TT0 3152 0 R
/TT1 3174 0 R
/F0 3156 0 R
/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
>>
endobj
2260 0 obj
<<
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>>
endobj
2261 0 obj
<<
/GS0 3161 0 R
>>
endobj
2262 0 obj
<<
/Length 3269 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(37) 6 ( ) ] TJ
EMC
/P <> BDC
0.0005 Tc
0.0238000005 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[(ref) 4 (e) -1 (rra) 4 (l or) 4 ( is) 5 ( an HCY related v) 6 (i) -2 (sit, e) 4 (n) 1 (ter this) 5 ( ) ] TJ
0 Tc
0 Tw
0 -1.3350000381 TD
(condition code. ) Tj
EMC
/P <> BDC
0 -1.7549999952 TD
[<4134974661> -6 (m) 8 (ily Planning. ) ] TJ
EMC
/P <> BDC
0.0008 Tc
0.4492000043 Tw
0 -1.75 TD
[(If) 4 ( the f) 4 (amily p) 6 (l) -1 (anni) ] TJ
0.0005 Tc
0.4469999969 Tw
9.1000003815 0 Td
[(n) 6 (g) 1 ( service occurred) 6 ( ) ] TJ
0.0006 Tc
0.1909999996 Tw
-9.1000003815 -1.3300000429 Td
(during the visit, ente) Tj
-0.0005 Tc
0.1921000034 Tw
8.8050003052 0 Td
(r this condition code. ) Tj
-0.0011 Tc
0 Tw
-8.8050003052 -1.3300000429 Td
(Do ) Tj
/TT1 1 Tf
0 Tc
1.5700000525 0 Td
(not) Tj
/TT0 1 Tf
0.0005 Tc
0.0978000015 Tw
1.2799999714 0 Td
[( bill f) 4 (a) -6 (m) 8 (ily plan) ] TJ
-0.0002 Tc
0.1001999974 Tw
6.7049999237 0 Td
(ning services on the ) Tj
0.0003 Tc
0.0007 Tw
-9.5550003052 -1.3350000381 Td
[(sam) 8 (e) -1 ( claim) 8 ( as non-fam) 8 (ily planning services. ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.8435000181 Tw
0 -1.7549999952 TD
<414A975061796572204E6F7420526573706F6E7369626C6520666F7220436F2D> Tj
0.0009 Tc
0 Tw
0 -1.3300000429 TD
[(Pay) -4 (m) 9 (ent ) ] TJ
EMC
/P <> BDC
0.0005 Tc
0.2894999981 Tw
0 -1.75 TD
[(If visit is the result of an em) 8 (ergency or ) ] TJ
0.0007 Tc
0.9642999768 Tw
0 -1.3300000429 TD
[(therapy) 6 ( services) 5 ( are) 5 ( provided,) 6 ( then) 6 ( ) ] TJ
0 Tc
0.1949999928 Tw
0 -1.3350000381 TD
(condition code ) Tj
/TT1 1 Tf
-0.0002 Tc
0 Tw
6.5549998283 0 Td
(must) Tj
/TT0 1 Tf
0.0009 Tc
0.1941000074 Tw
1.8899999857 0 Td
[( b) 6 (e entered) 6 ( to) 6 ( exem) 9 (pt ) ] TJ
0.0006 Tc
0.5644000173 Tw
-8.4449996948 -1.3350000381 Td
[(the patient from) 8 ( the $3.00 copaym) 8 (ent ) ] TJ
0.0018 Tc
0 Tw
0 -1.3300000429 TD
[(am) 10 (ount. ) ] TJ
EMC
/P <> BDC
0 Tc
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-2.5850000381 -1.75 Td
(25-28. ) Tj
EMC
/P <> BDC
0 Tc
3.4849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
0 -1.75 TD
[(Condition C) 8 (odes ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(29. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
T*
(Accident State ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(30. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-3.5850000381 -1.75 Td
(**31-34. ) Tj
EMC
/P <> BDC
0 Tc
4.4850001335 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
-0.0015 Tw
T*
(Occurrence Code and Dates ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.1057000011 Tw
T*
(If one or more of the following occurrence ) Tj
0.0003 Tc
0.2187000066 Tw
0 -1.3300000429 TD
(codes apply, enter the appropriate code\(s\) ) Tj
0.0006 Tc
0.0544000007 Tw
0 -1.3350000381 TD
[(on the claim) 8 (.) 1 ( A com) 8 (p) 1 (lete lis) 5 (t of values can ) ] TJ
-0.0001 Tc
0.5551000237 Tw
0 -1.3300000429 TD
(be found in the Official UB-04 Data ) Tj
0.0005 Tc
0.934499979 Tw
0 -1.3350000381 TD
[(Specificatio) 6 (ns Manual. The values) 5 ( ) ] TJ
0.0001 Tc
-0.0013 Tw
T*
(applicable to MO HealthNet are: ) Tj
EMC
/P <> BDC
-0.0002 Tc
-0.0048000002 Tw
0 -1.75 TD
<3031974163636964656E742F4D65646963616C20436F76657261676520> Tj
0 Tc
-0.0012000001 Tw
0 -1.3300000429 TD
<3032974E6F204661756C7420496E737572616E636520496E766F6C766564209620> Tj
EMC
/P <> BDC
0 Tw
0 -1.7549999952 TD
( Including Auto Accident/Other ) Tj
0.0001 Tc
0 -1.3300000429 TD
<3033974163636964656E742F546F72> Tj
-0.0001 Tw
7.3299999237 0 Td
(t Liability ) Tj
-7.3299999237 -1.3350000381 Td
[<3034974163636964656E742F456D> 8 (ployment Related ) ] TJ
0 Tc
0 Tw
T*
<3035974163636964656E742F4E6F204D65646963616C206F72204C696162696C69747920> Tj
-0.0002 Tc
0 -1.3350000381 TD
(Coverage ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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2263 0 obj
<<
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2264 0 obj
<<
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>>
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<<
/Im0 3150 0 R
>>
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2266 0 obj
<<
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>>
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2267 0 obj
<<
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/TT1 3174 0 R
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/F1 3157 0 R
/F2 3158 0 R
/F3 3159 0 R
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2268 0 obj
<<
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>>
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2269 0 obj
<<
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>>
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2270 0 obj
<<
/Length 3272 0 R
>>
stream
/Artifact <> BDC
/OC /MC0 BDC
BT
/GS0 gs
/TT0 1 Tf
0.0006 Tc
-0.0018 Tw
12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
f
BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
Q
EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(38) 6 ( ) ] TJ
EMC
/P <> BDC
0.0012000001 Tc
0.0038000001 Tw
12 0 0 12 292.200012207 688.2600097656 Tm
[<3036974372696D> 9 (e Victim) 9 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-2.5850000381 -1.75 Td
(35-36. ) Tj
EMC
/P <> BDC
0 Tc
3.4849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Occurrence Span Codes and ) Tj
-0.001 Tc
0 Tw
0 -1.3300000429 TD
(Dates ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(37. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(38. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
[(Responsible Party Nam) 8 (e) -6 ( ) ] TJ
-0.0005 Tc
0.0005 Tw
0 -1.3300000429 TD
(and Address ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-2.5850000381 -1.75 Td
(39-41. ) Tj
EMC
/P <> BDC
0 Tc
3.4849998951 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[(Value Code and Am) 8 (ounts ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*42. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Revenue Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0012000001 Tc
0.7888000011 Tw
T*
[(If) 4 ( billing) 6 ( f) 4 (o) 1 (r a facility ch) 6 (a) 5 (r) -1 (ge, an) 6 ( ) ] TJ
0.0004 Tc
1.4996000528 Tw
0 -1.3300000429 TD
[(observation) 5 ( room charg) 5 (e) -1 (,) 5 ( card) 5 (i) -2 (ac ) ] TJ
-0.0001 Tc
0.9800999761 Tw
0 -1.3350000381 TD
(rehabilitation, supplies and/or on-site ) Tj
0.0002 Tc
0.2197999954 Tw
T*
[(m) 8 (e) -1 (dications, enter only the appropriate 4-) ] TJ
0.0004 Tc
0.4995999932 Tw
0 -1.3300000429 TD
[(digit revenue code\(s\) for the hospital') 6 (s ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3350000381 TD
(outpatient facility charge\(s\). ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(43. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
0 -1.75 TD
(Revenue Description ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*44. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0001 Tc
0.0001 Tw
T*
(HCPCS/Rates/HIPPS Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.0245999992 Tw
T*
[(Enter the C) 7 (P) 2 (T or HCPCS procedure code\(s\) ) ] TJ
0.0005 Tc
-0.0017 Tw
0 -1.3300000429 TD
[(and any applicable m) 8 (odifier. ) ] TJ
EMC
/P <> BDC
0.0002 Tc
0.5748000145 Tw
0 -1.75 TD
[(Only ente) 4 (r the p) 5 (r) -2 (ocedure cod) 5 (e) 4 ( if for ) ] TJ
0.0006 Tc
0 Tw
0 -1.3300000429 TD
(services ) Tj
/TT1 1 Tf
-0.0017 Tc
4.2100000381 0 Td
(other) Tj
/TT0 1 Tf
0.0009 Tc
0.730700016 Tw
2.1050000191 0 Td
[( than outpatient f) 4 (acility) 6 ( ) ] TJ
0.0011 Tc
-0.0027000001 Tw
-6.3150000572 -1.3350000381 Td
[(charges lis) 5 (te) 5 (d in Fiel) ] TJ
-0.0002 Tc
0.0002 Tw
8.3100004196 0 Td
(d #42, Revenue Code. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-22.2600002289 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*45. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0 -1.75 TD
(Service Date ) Tj
EMC
/P <> BDC
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0011 Tc
0.0588999987 Tw
T*
[(Enter the da) 5 (te of) 4 ( service) 5 ( on each line bille) 5 (d) 6 ( ) ] TJ
-0.0004 Tc
0.0020000001 Tw
0 -1.3300000429 TD
[(in MMDDYY for) -7 (m) 7 (at. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*46. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Service Units ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
0.6836000085 Tw
T*
[(Enter the num) 8 (ber of units for each) 6 ( ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
(procedure or revenue code. ) Tj
EMC
/P <> BDC
/TT2 1 Tf
-0.001 Tc
0 Tw
0 -1.7549999952 TD
(NOTE) Tj
/TT0 1 Tf
0.001 Tc
0.0240000002 Tw
[(: If) 4 ( no entry) 6 ( is) 5 ( made, th) 6 (e sys) 5 (t) 4 (em) 9 ( auto ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
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ET
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
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0 Tw
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[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
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/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
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( ) Tj
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( ) Tj
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[(39) 6 ( ) ] TJ
EMC
/P <> BDC
0.0004 Tc
-0.0014 Tw
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(plugs a unit of "1". ) Tj
EMC
/P <> BDC
0.1296000034 Tw
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(Facility codes 0450, 0459, 0490, 0510 and ) Tj
-0.0001 Tc
0.2351000011 Tw
0 -1.3300000429 TD
(0943; supply codes 0260, 0270 and 0274 ) Tj
0.0007 Tc
0.1193000004 Tw
0 -1.3350000381 TD
[(should always be billed) 6 ( with a unit of "1." ) ] TJ
0.0001 Tc
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0 -1.3300000429 TD
(The outpatient obse) Tj
0 Tc
0.6775000095 Tw
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(rvation code 0762 ) Tj
0.0003 Tc
0.6247000098 Tw
-9.2449998856 -1.3350000381 Td
[(should be billed with the ap) 5 (propriate ) ] TJ
0.394600004 Tw
0 -1.3350000381 TD
[(num) 8 (ber of hours the participant was in ) ] TJ
0.0001 Tc
-0.0051000002 Tw
0 -1.3300000429 TD
(observation status. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*47. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
0 -1.75 TD
[(Total Charg) 6 (es ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
0.2442000061 Tw
T*
[(Enter th) 6 (e total ch) 6 (arge for each line item) 9 (.) 1 ( ) ] TJ
0.0007 Tc
0.1193000004 Tw
0 -1.3300000429 TD
[(After all ch) 6 (arges are lis) 5 (t) -1 (ed, skip a line and) 6 ( ) ] TJ
0.0013 Tc
0.0081000002 Tw
0 -1.3350000381 TD
[(enter) 4 ( the) 5 ( total of) 4 ( all ch) 6 (ar) 4 (ges f) 4 (o) 1 (r th) 6 (is claim) 9 ( to) 6 ( ) ] TJ
0.0002 Tc
-0.0012000001 Tw
0 -1.3300000429 TD
(correspond to revenue code 0001. ) Tj
EMC
/P <> BDC
/TT1 1 Tf
-0.0004 Tc
0.0353999995 Tw
0 -1.7549999952 TD
(NOTE: ) Tj
/TT0 1 Tf
-0.0002 Tc
0.0351999998 Tw
3.7400000095 0 Td
(When two encounters occur on the ) Tj
0.001 Tc
0.3740000129 Tw
-3.7400000095 -1.3300000429 Td
[(sam) 9 (e patient, a com) 9 (p) -4 (leted Cer) 4 (tif) 9 (icate of ) ] TJ
0.324000001 Tw
0 -1.3350000381 TD
[(Medica) 5 (l Necessity deta) 5 (iling th) 6 (e need f) 4 (o) 1 (r) 4 ( ) ] TJ
0.0008 Tc
-0.0008 Tw
0 -1.3300000429 TD
[(each vis) 5 (it m) 9 (u) 1 (st be subm) 9 (itted with the) 5 ( claim) 9 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(48. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Non-covered Charges ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(49. ) Tj
EMC
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2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*50. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
T*
[(Payer Nam) 8 (e) -6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
0.138500005 Tw
T*
[(The prim) 9 (ary payer is always listed first. If ) ] TJ
0.001 Tc
0.0289999992 Tw
0 -1.3300000429 TD
[(the patient h) 6 (as insuran) 6 (ce) 5 (,) 1 ( the insuran) 6 (ce plan) 6 ( ) ] TJ
0.0008 Tc
0.0083999997 Tw
0 -1.3350000381 TD
[(is the pr) 4 (im) 9 <61727920706179657220616E6420934D4F204865616C7468> 6 <4E65749420697320> ] TJ
-0.0033 Tw
0 -1.3300000429 TD
[(listed la) 5 (st. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(51. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.003 Tw
0 -1.75 TD
(Health Plan ID ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(52. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
[(Release of Infor) -7 (m) 8 (ation ) ] TJ
0.0013 Tc
-0.0013 Tw
0 -1.3300000429 TD
[(Certif) 4 (ica) 5 (tion) 6 ( Indica) 5 (tor) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(53. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.0022 Tw
T*
[(Assignm) 8 (ent of Benefits ) ] TJ
0.0012000001 Tc
-0.0012000001 Tw
0 -1.3300000429 TD
[(Certif) 4 (ica) 5 (tion) 6 ( of) 4 ( Indicato) 6 (r) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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0.0006 Tc
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12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
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BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
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/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(40) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
12 0 0 12 124.8000030518 683.2199707031 Tm
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**54. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
[(Prior Paym) 8 (ents ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
0.2236000001 Tw
T*
[(Indicate the a) -6 (m) 8 (ount the provider received ) ] TJ
0.0014 Tc
0.1743000001 Tw
0 -1.3300000429 TD
[(toward paym) 9 (ent of) 4 ( this bill f) 4 (r) -1 (om all oth) 6 (e) 5 (r) 4 ( ) ] TJ
0.0009 Tc
0.0573999994 Tw
0 -1.3350000381 TD
[(health insurance com) 9 (p) 1 (anies. Paym) 9 (ents ) ] TJ
/TT1 1 Tf
-0.0002 Tc
0 Tw
15.9350004196 0 Td
(must) Tj
/TT0 1 Tf
0 Tc
1.8849999905 0 Td
( ) Tj
-0.0001 Tc
0.6500999928 Tw
-17.8199996948 -1.3350000381 Td
(correspond with the appropriate payer ) Tj
0.0004 Tc
0.3479000032 Tw
0 -1.3300000429 TD
(entered in Field #50, Payer Name. \(See ) Tj
-0.0001 Tc
0 Tw
0 -1.3350000381 TD
(Note\)\(1\) ) Tj
EMC
/P <> BDC
-0.0011 Tc
0 -1.7549999952 TD
(Do ) Tj
/TT1 1 Tf
0 Tc
1.8400000334 0 Td
(not) Tj
/TT0 1 Tf
0.0002 Tc
0.3698000014 Tw
1.2799999714 0 Td
[( enter a p) 5 (r) -2 (evio) 5 (us MO HealthNet ) ] TJ
0.0005 Tc
0.1694999933 Tw
-3.1199998856 -1.3300000429 Td
[(paym) 8 (ent, M) -5 (e) -1 (dicare paym) 8 (ent or copaym) 8 (ent) -7 ( ) ] TJ
0.0006 Tc
0.304399997 Tw
0 -1.3300000429 TD
[(am) 8 (ount received from the patien) 6 (t) 3 ( in th) 6 (is ) ] TJ
-0.0004 Tc
0 Tw
0 -1.3350000381 TD
(field. ) Tj
EMC
/P <> BDC
0 Tc
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(55. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
[(Estim) 8 (ated Amount Due ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*56. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.001 Tw
T*
[(National P) 7 (r) -1 (o) 6 (v) 1 (ider Id) 6 (entif) 4 (i) -1 (er ) ] TJ
-0.0009 Tc
0 Tw
0 -1.3300000429 TD
(\(NPI\) ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
-0.0013 Tw
0 -1.75 TD
[(Enter th) 6 (e ho) 6 (spita) 5 (l') 7 (s ) ] TJ
0.0001 Tc
-0.0001 Tw
7.8699998856 0 Td
(10-digit NPI number. ) Tj
EMC
/P <> BDC
0 Tc
0.1391000003 Tw
-7.8699998856 -1.75 Td
(If applicable: Enter the corresponding 10-) Tj
-0.0005 Tc
0.4505000114 Tw
0 -1.3300000429 TD
(digit Provider Taxonomy code in Field ) Tj
0.0001 Tc
-0.0001 Tw
T*
(81CCa, Code-Code Field. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(57. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
0 -1.75 TD
(Other Provider ID ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**58. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Insured) 6 <92> -1 (s Nam) 9 (e) -5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0011 Tc
0.1089000031 Tw
T*
[(Com) 9 (p) 1 (lete if) 4 ( the insu) 6 (red) 6 <92> -1 (s nam) 9 (e is dif) 4 (f) 4 (erent ) ] TJ
0.0009 Tc
0.0001 Tw
0 -1.3300000429 TD
[(from) 9 ( the patient') 6 (s nam) 9 (e. \(See Note\)) ] TJ
-0.0022 Tc
0 Tw
7.9800000191 0 0 7.9800000191 462.3599853516 281.7601013184 Tm
[(\(1) -6 (\)) ] TJ
0 Tc
12 0 0 12 471.6000061035 276.2401123047 Tm
( ) Tj
EMC
/P <> BDC
-28.8999996185 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(59. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0026 Tw
0 -1.75 TD
<50617469656E7492732052656C6174696F6E7368697020746F20> Tj
0.001 Tc
0 Tw
0 -1.3300000429 TD
[(Insured) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*60. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
T*
[(Insured') 5 (s Unique ID ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
0.0693000033 Tw
T*
[(Enter the p) 6 (a) 5 (tien) 6 (t) -1 (') 6 (s 8-digit MO HealthNet or ) ] TJ
0.0004 Tc
0.9296000004 Tw
0 -1.3300000429 TD
[(MO HealthNet Man) 5 (a) -1 (ged Care) 4 ( Plan) 5 ( ) ] TJ
0 Tc
0.5350000262 Tw
0 -1.3350000381 TD
[(identification num) 8 (ber. If insurance was ) ] TJ
0.1941000074 Tw
T*
[(indicated in Field #50, Payer Nam) 8 (e) -1 (, enter ) ] TJ
0.0003 Tc
0.1647000015 Tw
0 -1.3300000429 TD
[(the insurance num) 8 (ber to correspond to the ) ] TJ
0 Tc
0 Tw
0 -1.3350000381 TD
(order shown in Field #50, Payer Name. ) Tj
EMC
/P <> BDC
0.6499999762 Tc
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
( ) Tj
EMC
/P <> BDC
13.9499998093 0 Td
( ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
() Tj
ET
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
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0 Tw
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[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
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/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
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( ) Tj
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( ) Tj
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[(41) 6 ( ) ] TJ
EMC
/P <> BDC
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0.2049999982 Tw
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(**61. ) Tj
EMC
/P <> BDC
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[(Insurance ) 205 (Group ) 205 (Nam) 8 (e) -6 ( ) ] TJ
EMC
/P <> BDC
13.0480003357 0 Td
(If insurance is shown in Field #50, Payer ) Tj
-0.0005 Tc
0.1298000067 Tw
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[(Na) -7 (m) 7 (e) -2 (, state the nam) 7 (e) -2 ( of the group or plan ) ] TJ
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0.0009 Tc
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T*
[(the insu) 6 (red. \(See Note\)) 4 (\() 4 (1) 1 (\) ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**62. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0005 Tc
-0.0005 Tw
0 -1.75 TD
[(Insurance Group Num) 8 (b) 1 (er ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
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T*
(If insurance is shown in Field #50, state the ) Tj
0.0006 Tc
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[(num) 8 (b) 1 (er assigned by the insurance com) 8 (p) 1 (any ) ] TJ
-0.0002 Tc
0.4902000129 Tw
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[(to identify the gr) -4 (oup under which the ) ] TJ
0.0001 Tc
-0.0013 Tw
T*
(individual is covered. \(See Note\)\(1\) ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(63. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
0 -1.75 TD
[(Treatm) 8 (e) -1 (nt Authorization ) ] TJ
0.0001 Tc
0 Tw
0 -1.3300000429 TD
(Codes ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**64. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
-0.0003 Tw
T*
[(Docum) 8 (e) -1 (nt Control Number ) ] TJ
EMC
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0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0014 Tc
0.0035999999 Tw
T*
[(If) 4 ( the cu) 6 (rren) 6 (t) -1 ( claim) 9 ( exce) 5 (eds the) 5 ( tim) 9 (ely f) 4 (iling) 6 ( ) ] TJ
-0.0001 Tc
0.1708000004 Tw
0 -1.3300000429 TD
[(lim) 8 (it of one year from) 8 ( the "through" date, ) ] TJ
0.0012000001 Tc
0.3788000047 Tw
0 -1.3350000381 TD
[(but was origina) 5 (lly sub) 6 (m) 9 (itted tim) 9 (ely and) 6 ( ) ] TJ
0.0002 Tc
0.1130999997 Tw
0 -1.3300000429 TD
[(denied, the provider m) 8 (a) ] TJ
0.0004 Tc
0.1111999974 Tw
9.8400001526 0 Td
(y enter the 13-digit ) Tj
0.0007 Tc
0.3143000007 Tw
-9.8400001526 -1.3350000381 Td
[(Intern) 6 (al Co) 6 (ntrol Num) 9 (b) -4 (er \(ICN\) from) 9 ( the ) ] TJ
0.0011 Tc
0.2358999997 Tw
0 -1.3350000381 TD
[(rem) 9 (ittance) 5 ( advice) 5 ( tha) 5 (t) -1 ( docum) 9 (ents that the) 5 ( ) ] TJ
0.0004 Tc
0.524600029 Tw
0 -1.3300000429 TD
[(claim) 8 ( was previously filed and denied ) ] TJ
0.0012000001 Tc
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0 -1.3350000381 TD
[(within th) 6 (e o) 6 (n) 1 (e-yea) 5 (r) -1 ( lim) 9 (it. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(65. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
-0.0013 Tw
0 -1.75 TD
[(Em) 9 (ployer Nam) 9 (e) -5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0013 Tc
0.2124000043 Tw
T*
[(If) 4 ( the pa) 5 (tie) 5 (nt is em) ] TJ
0.0007 Tc
0.2117999941 Tw
8.3500003815 0 Td
[(ployed, the employer') 6 (s ) ] TJ
0.0002 Tc
0.001 Tw
-8.3500003815 -1.3300000429 Td
[(nam) 8 (e) -1 ( m) 8 (a) -1 (y be entered here. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(66. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0018 Tw
T*
(Diagnosis & Procedure Code ) Tj
0.0011 Tc
0 Tw
0 -1.3300000429 TD
[(Qualif) 4 (ier) 4 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
0 -1.75 TD
(Not required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.75 -1.75 Td
(*67. ) Tj
EMC
/P <> BDC
2.6500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
(Principal Diagnosis Code ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.1187999994 Tw
T*
[(Enter the complete ICD) 8 ( diagnosis code for ) ] TJ
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
(the condition the service was provided. ) Tj
EMC
/P <> BDC
0.0004 Tc
0.1931000054 Tw
0 -1.7549999952 TD
[(Re) -6 (m) 8 (e) -6 (m) 8 (ber to code to the highest level of) 8 ( ) ] TJ
0.0002 Tc
0.1547999978 Tw
0 -1.3300000429 TD
(specificity shown in the current version of ) Tj
0 Tc
-0.0012000001 Tw
T*
(the ICD diagnosis code book. ) Tj
EMC
/P <> BDC
0.6499999762 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
( ) Tj
EMC
/P <> BDC
13.9499998093 0 Td
( ) Tj
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
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() Tj
ET
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
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0 Tw
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[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
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/Im0 Do
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EMC
EMC
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/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(42) 6 ( ) ] TJ
EMC
/P <> BDC
0.0004 Tc
-0.0004 Tw
12 0 0 12 73.5 683.2199707031 Tm
(**67. A-D ) Tj
EMC
/P <> BDC
5.1799998283 0 Td
[(Other Diagn) 5 (osis Codes) 5 ( ) ] TJ
EMC
/P <> BDC
13.0489997864 0 Td
[(Enter ) -70 (any ) ] TJ
0.0005 Tc
0.0732000023 Tw
4.256000042 0 Td
[(addition) 6 (a) -1 (l d) 6 (i) -2 (agnoses th) 6 (at have an) 6 ( ) ] TJ
-0.0005 Tw
-4.2600002289 -1.3300000429 Td
[(effect on the treatm) 8 (ent received.) 6 ( ) ] TJ
EMC
/P <> BDC
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0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-0.0004 Tc
0.0004 Tw
-3.1649999619 -1.75 Td
(67. E-Q ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
4.0650000572 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
0 -1.75 TD
(Other Diagnoses Codes ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(68. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(69. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.001 Tc
-0.001 Tw
T*
[(Adm) 9 (itting Diagnosis) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(70. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
-0.0001 Tw
T*
[(Patient') 5 (s) -1 ( Reason for Visit ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
T*
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(71. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0011 Tc
-0.0035999999 Tw
T*
[(Prospective Paym) 9 (ent system) 9 ( ) ] TJ
0 Tc
0 Tw
0 -1.3300000429 TD
(\(PPS\) Code ) Tj
EMC
/P <> BDC
13.0500001907 3.0799999237 Td
( ) Tj
EMC
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-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0850000381 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(72. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
(External Cause of Injury ) Tj
-0.0003 Tc
0.0003 Tw
0 -1.3300000429 TD
(Code \(E-Code\) ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Not required ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -3.0799999237 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(73. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
T*
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**74. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0002 Tc
-0.0002 Tw
T*
(Principal Procedure Code and ) Tj
0.0006 Tc
0 Tw
0 -1.3300000429 TD
(Date ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
0.0843999982 Tw
0 -1.75 TD
[(Enter the full ICD surgical procedu) 6 (r) 4 (e code. ) ] TJ
0.0002 Tc
0.4788999856 Tw
0 -1.3300000429 TD
(The date on which the procedure was ) Tj
0.0003 Tc
0 Tw
0 -1.3350000381 TD
[(perform) 8 (e) -1 (d ) ] TJ
/TT1 1 Tf
-0.0002 Tc
4.5399999619 0 Td
(must) Tj
/TT0 1 Tf
-0.0007 Tc
0.1256999969 Tw
1.8899999857 0 Td
( be stated. Only month and ) Tj
0.0006 Tc
-0.0038999999 Tw
-6.4299998283 -1.3350000381 Td
(day are required. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0002 Tc
0.0002 Tw
-4.1649999619 -1.75 Td
(**74. A-E ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
5.0650000572 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0004 Tc
-0.0016 Tw
0 -1.75 TD
(Other Procedure Codes and ) Tj
-0.001 Tc
0 Tw
0 -1.3300000429 TD
(Dates ) Tj
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0001 Tc
0.1098999977 Tw
0 -1.75 TD
(Identify and date any other procedures that ) Tj
0.0003 Tc
-0.0003 Tw
0 -1.3300000429 TD
[(m) 8 (a) -1 (y have be) -6 (en perform) 8 (e) -6 (d. ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(75. ) Tj
EMC
/P <> BDC
2.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0008 Tc
-0.0008 Tw
0 -1.75 TD
[(Unlabeled F) 7 (i) -1 (eld) 6 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
-0.0007 Tw
T*
[(Leave blank) 6 (.) 1 ( ) ] TJ
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.75 Td
( ) Tj
EMC
/P <> BDC
-2.25 -1.75 Td
(**76. ) Tj
EMC
/P <> BDC
3.1500000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
T*
[(Attending P) 7 (r) -1 (ovider Nam) 8 (e) -1 ( and ) ] TJ
0.0005 Tc
0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
/P <> BDC
0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
/P <> BDC
0.0003 Tc
0.1437000036 Tw
0 -1.75 TD
[(Enter the attending provider') 6 (s 10-digit NPI ) ] TJ
0.0014 Tc
0 Tw
0 -1.3300000429 TD
[(num) 9 (b) 1 (er. ) ] TJ
EMC
/P <> BDC
0.0005 Tc
0.33950001 Tw
0 -1.3350000381 TD
[(Enter the attending provider') 6 (s nam) 8 (e) -1 (, last ) ] TJ
EMC
ET
/Artifact <> BDC
BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
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[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
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BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
ET
q
74.8200073242 0 0 24.3000030518 433.5 731.700012207 cm
/Im0 Do
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EMC
EMC
BT
/Artifact <<>> BDC
/TT0 1 Tf
0 Tc
12 0 0 12 72 718.0800170898 Tm
( ) Tj
0 -1.1499999762 TD
( ) Tj
0.003 Tc
10.0200004578 0 0 10.0200004578 547.9799804688 62.3400993347 Tm
[(43) 6 ( ) ] TJ
EMC
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0.0005 Tc
0.0044999998 Tw
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[(nam) 8 (e) -1 ( first. ) 10 ( ) ] TJ
EMC
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0 Tc
0.1391000003 Tw
0 -1.3350000381 TD
(If applicable: Enter the corresponding 10-) Tj
-0.0005 Tc
0.4505000114 Tw
T*
(digit Provider Taxonomy code in Field ) Tj
0 Tc
0 Tw
0 -1.3300000429 TD
(81CCb, Code-Code Field. ) Tj
EMC
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-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-1.25 -1.75 Td
(77. ) Tj
EMC
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( ) Tj
EMC
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0.0006 Tc
-0.0006 Tw
0 -1.75 TD
[(Operating P) 7 (r) -1 (ovider Nam) 8 (e) -1 ( and ) ] TJ
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0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
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13.0500001907 3.0799999237 Td
( ) Tj
EMC
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0.134100005 Tw
0 -1.75 TD
[(Enter th) 6 (e o) 6 (p) 1 (erating pro) 6 (v) 1 (ider') 6 (s 10-d) 6 (i) -1 (git NPI) 4 ( ) ] TJ
0.0014 Tc
0 Tw
0 -1.3300000429 TD
[(num) 9 (b) 1 (er. ) ] TJ
EMC
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0.0005 Tc
0.3285000026 Tw
0 -1.3350000381 TD
[(Enter the operating provider') 6 (s nam) 8 (e) -1 (, last ) ] TJ
0.0044999998 Tw
0 -1.3300000429 TD
[(nam) 8 (e) -1 ( first. ) 10 ( ) ] TJ
EMC
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0 Tc
0.1391000003 Tw
0 -1.3350000381 TD
(If applicable: Enter the corresponding 10-) Tj
-0.0005 Tc
0.4505000114 Tw
T*
(digit Provider Taxonomy code in Field ) Tj
0.0001 Tc
-0.0001 Tw
0 -1.3300000429 TD
(81CCc, Code-Code Field. ) Tj
EMC
/P <> BDC
0 Tc
0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
/P <> BDC
-3.5 -1.75 Td
(**78.79. ) Tj
EMC
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4.4000000954 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0006 Tc
-0.0006 Tw
0 -1.75 TD
[(Other Provider Nam) 8 (e) -1 ( and ) ] TJ
0.0005 Tc
0 Tw
0 -1.3300000429 TD
[(Identifiers) 5 ( ) ] TJ
EMC
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0 Tc
13.0500001907 3.0799999237 Td
( ) Tj
EMC
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0.0004 Tc
0.4776000082 Tw
0 -1.75 TD
[(Enter the other provider') 6 (s 10-digit NPI ) ] TJ
0.0014 Tc
0 Tw
0 -1.3300000429 TD
[(num) 9 (b) 1 (er. ) ] TJ
EMC
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0.0004 Tc
0.1587000042 Tw
0 -1.3350000381 TD
[(Enter the other provider') 6 (s na) -6 (m) 8 (e) -1 (, last nam) 8 (e) -1 ( ) ] TJ
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-0.0034 Tw
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EMC
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0.0009 Tc
0.0781000033 Tw
0 -1.3350000381 TD
[(Adm) 9 (i) -1 (nistra) 5 (tive Lock-in) 6 (:) -1 ( If) 4 ( the pa) 5 (rticipant') 6 (s ) ] TJ
0.0004 Tc
0.0935999975 Tw
T*
[(services are res) 5 (t) -2 (ricted) 5 ( d) 5 (ue to adm) 8 (i) -2 (nistrative ) ] TJ
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0 -1.3300000429 TD
[(lock-in, enter the lock-in provider') 6 (s num) 8 (ber ) ] TJ
0.0006 Tc
0.0581 Tw
0 -1.3350000381 TD
[(in th) 6 (is f) 4 (i) -2 (eld and att) ] TJ
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0.0562999994 Tw
7.7350001335 0 Td
(ach the Medical Referral ) Tj
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-0.0020000001 Tw
-7.7350001335 -1.3350000381 Td
[(Form) 9 ( of Restricted Pa) 5 (rticipant \(PI-1) 6 (18\). ) ] TJ
EMC
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0.2142000049 Tw
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[(Em) 6 (ergency) -6 ( services are) 6 ( only) -6 ( considered for ) ] TJ
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[(attached Cer) -6 (tificate) -5 ( of Medical Necessity) -6 ( and ) ] TJ
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0.1615000069 Tw
T*
[(m) 7 (e) 1 (dical reco) -5 (rds docum) 7 (enting the em) 7 (ergenc) 6 (y) -5 ( ) ] TJ
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[(circum) 7 (stance) -4 (s.) ] TJ
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( ) Tj
EMC
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(If applicable: Enter the corresponding 10-) Tj
-0.0005 Tc
0.4505000114 Tw
0 -1.3300000429 TD
(digit Provider Taxonomy code in Field ) Tj
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0 Tw
0 -1.3350000381 TD
(81CCd, Code-Code Field. ) Tj
EMC
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( ) Tj
EMC
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-1.25 -1.75 Td
(80. ) Tj
EMC
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( ) Tj
EMC
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-0.0001 Tc
0 -1.75 TD
[(Re) -6 (m) 8 (a) -1 (rks ) ] TJ
EMC
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13.0500001907 1.75 Td
( ) Tj
EMC
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T*
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(denial, Medicare Part B only, etc. ) Tj
EMC
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0 Tw
-13.9499998093 -1.7549999952 Td
( ) Tj
EMC
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0.0008 Tc
-4.0300002098 -1.75 Td
(**81CCa. ) Tj
EMC
/P <> BDC
0 Tc
4.9299998283 1.75 Td
( ) Tj
EMC
/P <> BDC
-0.0003 Tc
0.0003 Tw
0 -1.75 TD
(Code-Code Field ) Tj
EMC
/P <> BDC
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0 Tw
13.0500001907 1.75 Td
( ) Tj
EMC
/P <> BDC
0.0007 Tc
0.1693000048 Tw
T*
[(Enter the B) 8 (3) 1 ( Provider Taxonom) 9 (y qualifier ) ] TJ
EMC
ET
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BT
/OC /MC0 BDC
/TT0 1 Tf
0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
ET
EMC
BT
/F0 12 Tf
0 0 0 rg
305.8619995117 23 Td
(Last Updated - 05/29/2013) Tj
ET
BT
0 0 1 rg
/F1 12 Tf
55.9939880371 764 Td
() Tj
ET
BT
0 0 1 rg
/F1 12 Tf
493.666015625 764 Td
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ET
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12 0 0 12 72 731.8200073242 Tm
[<53656374696F6E2031352096> 6 ( Billing Instr) 4 (u) 1 (ctions) ] TJ
ET
72 729.9000244141 156 0.6000000238 re
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BT
/TT0 1 Tf
2.75 Tc
0 Tw
12 0 0 12 228 731.8200073242 Tm
[( ) 1000 ( ) ] TJ
23.375 0 Td
( ) Tj
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/Im0 Do
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( ) Tj
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( ) Tj
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T*
(reported in Field # ) Tj
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EMC
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( ) Tj
EMC
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(**81CCb. ) Tj
EMC
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( ) Tj
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(Code-Code Field ) Tj
EMC
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( ) Tj
EMC
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0.0007 Tc
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T*
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1.0981999636 Tw
0 -1.3300000429 TD
[(and corresponding 10-digit P) 6 (r) -2 (ovider ) ] TJ
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0.6600000262 Tw
0 -1.3350000381 TD
[(Taxonom) 8 (y code for the NPI num) 8 (be) -6 (r) -7 ( ) ] TJ
0.0003 Tc
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0 -1.3300000429 TD
[(reported in Field # 76, Attending P) 7 (r) -2 (ovider ) ] TJ
0.0012000001 Tc
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[(Nam) 9 (e and Identif) 4 (ie) 5 (rs.) 6 ( ) ] TJ
EMC
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( Box: B3 qualifier ) Tj
EMC
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(2) Tj
0.0038000001 Tc
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(nd) Tj
0.0002 Tc
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12 0 0 12 306.2399902344 450.1799926758 Tm
[( Box: Provider Taxonom) 8 (y code. ) ] TJ
EMC
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0 Tc
0 Tw
-15.1199998856 -1.75 Td
( ) Tj
EMC
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0.0008 Tc
-4.0300002098 -1.75 Td
(**81CCc. ) Tj
EMC
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0 Tc
4.9299998283 1.75 Td
( ) Tj
EMC
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-0.0003 Tc
0.0003 Tw
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(Code-Code Field ) Tj
EMC
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0 Tw
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( ) Tj
EMC
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0.0007 Tc
0.1693000048 Tw
T*
[(Enter the B) 8 (3) 1 ( Provider Taxonom) 9 (y qualifier ) ] TJ
0.0001 Tc
1.0981999636 Tw
0 -1.3300000429 TD
[(and corresponding 10-digit P) 6 (r) -2 (ovider ) ] TJ
0 Tc
0.6600000262 Tw
T*
[(Taxonom) 8 (y code for the NPI num) 8 (be) -6 (r) -7 ( ) ] TJ
0.0005 Tc
0.1578000039 Tw
0 -1.3350000381 TD
(reported in Field # ) Tj
0.0002 Tc
0.1572999954 Tw
8.3100004196 0 Td
[(77, Operating P) 6 (r) -2 (ovider ) ] TJ
0.0012000001 Tc
-0.0012000001 Tw
-8.3100004196 -1.3350000381 Td
[(Nam) 9 (e and Identif) 4 (ie) 5 (rs.) 6 ( ) ] TJ
EMC
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( Box: B3 qualifier ) Tj
EMC
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(2) Tj
0.0038000001 Tc
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(nd) Tj
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[( Box: Provider Taxonom) 8 (y code. ) ] TJ
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-15.1199998856 -1.75 Td
( ) Tj
EMC
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0.0007 Tc
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(**81CCd. ) Tj
EMC
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( ) Tj
EMC
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EMC
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( ) Tj
EMC
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0.1693000048 Tw
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[(Enter the B) 8 (3) 1 ( Provider Taxonom) 9 (y qualifier ) ] TJ
0.0001 Tc
1.0981999636 Tw
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[(and corresponding 10-digit P) 6 (r) -2 (ovider ) ] TJ
0 Tc
0.6600000262 Tw
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[(Taxonom) 8 (y code for the NPI num) 8 (be) -6 (r) -7 ( ) ] TJ
0.0001 Tc
0.3424000144 Tw
T*
(reported in Fields ) Tj
-0.0004 Tc
0.342900008 Tw
8.3350000381 0 Td
(78-79, Other Provider ) Tj
0.0012000001 Tc
-0.0012000001 Tw
-8.3350000381 -1.3300000429 Td
[(Nam) 9 (e and Identif) 4 (ie) 5 (rs.) 6 ( ) ] TJ
EMC
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(1) Tj
0.0018 Tc
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(st) Tj
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0.0003 Tw
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( Box: B3 qualifier ) Tj
EMC
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(2) Tj
0.0038000001 Tc
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(nd) Tj
0.0002 Tc
-0.0002 Tw
12 0 0 12 306.2399902344 154.1999969482 Tm
[( Box: Provider Taxonom) 8 (y code. ) ] TJ
EMC
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0 Tw
-19.5200004578 -1.8150000572 Td
( ) Tj
EMC
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/TT1 1 Tf
0.6650000215 -1.2400000095 Td
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EMC
ET
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BT
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( ) Tj
EMC
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[(These ) 6 (fields a) 7 (r) 4 (e m) 12 (a) 1 (ndatory ) 6 (on ) ] TJ
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[( Ou) -4 (tp) -4 (atient UB-0) -4 (4 claim) 10 ( ) -6 (form) 10 (s. ) ] TJ
EMC
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0 Tw
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(**) Tj
EMC
ET
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( ) Tj
EMC
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[(These ) 6 (fields a) 7 (r) 4 (e m) 11 (a) 1 (ndatory ) 6 (only in ) ] TJ
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EMC
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( ) Tj
EMC
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[(NOTE: Th) -4 (is fi) 7 (eld) -4 ( is for priv) -4 (ate in) -4 (suran) -4 (c) -1 (e inform) 10 (at) -5 (io) -4 (n) -4 ( ) ] TJ
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EMC
ET
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0.001 Tc
-0.0035000001 Tw
12 0 0 12 72 38.7000007629 Tm
[(Hospital M) 5 (a) 5 (nual ) ] TJ
EMC
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0 0 0 rg
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(Last Updated - 05/29/2013) Tj
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