Professional Claim Entry
Facility Claim Entry
Type
Inpatient
Outpatient
Type of Bill
Claim Type
InpatientMedicare Advantage
InpatientMedicare Supplemental
Commercial
OutpatientMedicare Advantage
OutpatientMedicare Supplemental
Statement From
Through
Admit Date
Admit Type
1
2
3
Patient Information
Gender
Undefined
Male
Female
Date of Birth
Patient Status
Line
Rev Code
HCPCS/HIPPS
Modifier
Date
Units
Total Charges
1
2
3
Code Type
ICD-10
ICD-9
Diagnoses
Diagnosis
Code
POA
Principal
Y
N
U
W
1
Admitting
Y
N
U
W
1
Other Codes
Diagnosis
Code
POA
Other
Y
N
U
W
1
Procedures
Procedure
Code
Date
Principal
Other Codes
Procedure
Code
Date
Other
Additional fields
Point of Origin:
Facility ID:
Condition Codes
Occurrence/Span Codes
Code
Date From
Date To
Value Codes
Code
Amount