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Sub-Field: 361.115

Package: Integrated Billing

EXPLANATION OF BENEFITS(#361.1)-->361.115

Sub-Field: 361.115


Information

Parent File Name Number Package
EXPLANATION OF BENEFITS(#361.1) 835 LINE LEVEL ADJUSTMENTS 361.115 Integrated Billing

Details

Field # Name Loc Type Details
.01 ADJUSTMENT SEQUENCE # 0;1 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  OCT 21, 2019
  • HELP-PROMPT:  Type a Number between 1 and 9999, 0 Decimal Digits
  • DESCRIPTION:  
    This is a sequence # for the adjustment. It has no value to the COB process.
  • CROSS-REFERENCE:  361.115^B
    1)= S ^IBM(361.1,DA(1),15,"B",$E(X,1,30),DA)=""
    2)= K ^IBM(361.1,DA(1),15,"B",$E(X,1,30),DA)
.02 PAYER ID CODE 0;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<1) X
  • LAST EDITED:  OCT 06, 1998
  • HELP-PROMPT:  Answer must be 1-20 characters in length.
.03 AMOUNT PAID 0;3 NUMBER

  • INPUT TRANSFORM:  S:X["$" X=$P(X,"$",2) K:X'?."-".N.1".".2N!(X>9999999999)!(X<-9999999999)!(X?.E1"."3.N) X
  • LAST EDITED:  SEP 12, 2003
  • HELP-PROMPT:  Type a Dollar amount between -9999999999 and 9999999999, 2 Decimal Digits
  • DESCRIPTION:  
    This is the amount that was actually paid on this procedure.
  • TECHNICAL DESCR:  
    This data is found in the electronic 835 at the SVC03 data element.
.04 PROCEDURE 0;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<3) X
  • LAST EDITED:  OCT 06, 2003
  • HELP-PROMPT:  Answer must be 3-15 characters in length.
  • DESCRIPTION:  
    This is the procedure for which payment was considered.
  • TECHNICAL DESCR:  
    This data is found in the electronic 835 at the SVC01-02 data element.
.09 DESCRIPTION 0;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>80!($L(X)<1) X
  • LAST EDITED:  OCT 06, 1998
  • HELP-PROMPT:  Answer must be 1-80 characters in length.
  • DESCRIPTION:  
    This is the procedure description as reported on the EOB.
  • TECHNICAL DESCR:  
    This data is found in the electronic 835 at the SVC01-07 data element.
.1 REVENUE CODE 0;10 POINTER TO REVENUE CODE FILE (#399.2) REVENUE CODE(#399.2)

  • LAST EDITED:  OCT 06, 1998
  • DESCRIPTION:  
    This is the revenue code that is associated with the procedure being billed.
  • TECHNICAL DESCR:  
    This data element is used only for Institutional claims and can be found in the electronic EOB (835) in the SVC-04 data element.
.11 PAID UNITS OF SERVICE 0;11 NUMBER
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:+X'=X!(X>99999999)!(X<0)!(X?.E1"."2.N) X
  • LAST EDITED:  AUG 23, 2004
  • HELP-PROMPT:  Type a number between 0 and 99999999, 1 Decimal Digit
  • DESCRIPTION:  
    This is the number of units of service that were actually reimbursed.
  • TECHNICAL DESCR:  
    This data is found in the electronic 835 at the SVC05 data element.
.12 REFERENCED LINE # 0;12 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  FEB 02, 1999
  • HELP-PROMPT:  Type a Number between 1 and 999, 0 Decimal Digits
  • DESCRIPTION:  
    This is the line # on the original bill that is referenced by this adjustment. If bundling or unbundling has occurred, this is the line # that has the actual adjustment information attached to it.
  • TECHNICAL DESCR:  
    This data is calculated from the results of the 835 or EOB.
  • CROSS-REFERENCE:  361.115^AC
    1)= S ^IBM(361.1,DA(1),15,"AC",$E(X,1,30),DA)=""
    2)= K ^IBM(361.1,DA(1),15,"AC",$E(X,1,30),DA)
    3)= Please do not delete
    This xref is the 'key' field for sorting the lines level adjustments by VISTA line number so the adjustments can be placed in the proper sequence when the 837 COB data is assembled.
.13 ALLOWED AMOUNT 0;13 NUMBER

  • INPUT TRANSFORM:  S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
  • LAST EDITED:  FEB 02, 1999
  • HELP-PROMPT:  Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
  • DESCRIPTION:  
    This is the amount MEDICARE will allow for this service line
  • TECHNICAL DESCR:  
    This data can be found in the electronic EOB (835) at the AMT-02 (qualifier 'B6') data element at the line item level.
.14 PER DIEM AMOUNT 0;14 NUMBER

  • INPUT TRANSFORM:  S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
  • LAST EDITED:  FEB 02, 1999
  • HELP-PROMPT:  Type a Dollar Amount between 0 and 9999999999, 2 Decimal Digits
  • DESCRIPTION:  
    This is the per diem amount reported by MEDICARE for this service line.
  • TECHNICAL DESCR:  
    This data can be found in the electronic EOB (835) at the AMT-02 (qualifier 'DY') data element at the line item level.
.15 ORIGINAL PROCEDURE 0;15 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
  • LAST EDITED:  OCT 28, 1999
  • HELP-PROMPT:  Answer must be 1-15 characters in length.
  • DESCRIPTION:  If this adjustment indicates bundling or unbundling occurred (paid procedure was not the original submitted procedure), this is the procedure that was originally sent for payment on the claim. This field will only have
    data in it if the procedure was part of a bundling or unbundling process.
  • TECHNICAL DESCR:  
    If there is data in this field, there will be one or more procedures that will need additional line items output for 837 COB due to bundling/unbundling of procedures by the payer.
.16 SERVICE DATE FROM 0;16 DATE

  • INPUT TRANSFORM:  S %DT="EX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  MAR 24, 2003
  • HELP-PROMPT:  Enter the date the service was performed
  • DESCRIPTION:  
    This is the first date of service for the claim.
.17 SERVICE DATE TO 0;17 DATE

  • INPUT TRANSFORM:  S %DT="EX" D ^%DT S X=Y K:Y<1 X
  • LAST EDITED:  MAR 24, 2003
  • HELP-PROMPT:  Enter the date the service was performed
  • DESCRIPTION:  
    This is the last date of service for the claim.
.18 PROCEDURE TYPE 0;18 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>2!($L(X)<1) X
  • LAST EDITED:  MAR 25, 2003
  • HELP-PROMPT:  Answer must be 1-2 characters in length.
  • DESCRIPTION:  
    This is the code representing the type of procedure as reported in this record.
1 ADJUSTMENTS 1;0 SET Multiple #361.1151 361.1151

  • DESCRIPTION:  
    This is the list of line level adjustments, including general category of adjustment, reason code, amount and quantity.
2 PAID MODIFIERS 2;0 Multiple #361.1152 361.1152
4 LINE ITEM REMARK 4;0 Multiple #361.1154 361.1154
6 SERVICE SUPPLEMENTAL QUANTITY 6;0 Multiple #361.1156 361.1156

  • DESCRIPTION:  
    This multiple stores up to 5 Service Supplemental Quantity entries as received on the 41 record of the 835 ERA, pieces 5 through 9.
7 SERVICE PAYMENT QUALIFIER 7;0 Multiple #361.1157 361.1157

  • DESCRIPTION:  
    This stores the Service Payment Qualifier and Reference Identification entries as received on the 43 record of the 835 ERA.
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