Radiology procedure on the UB 04 form.
When completing claims, do not enter the decimal points in ICD-9-CM codes or dollar amounts. If requested information does not fit neatly in the Remarks field (Box 80) of the claim, type it on an 8½ x 11-inch sheet of paper and attach it to the claim.
This is an example only. Please adapt to your billing situation.
In this case a woman who has had the flu goes to a community clinic to have her cough checked. The clinic physician orders an X-ray, which is performed at and billed by the clinic. This claim example illustrates “standard billing” in which the facility bills for both the technical and professional components of the X-ray and reimburses the physician for the professional component according to their mutual agreements.
Enter the two-digit facility type code “73” (clinic – free standing) and one-character claim frequency code “1” as “731” in the Type of Bill field (Box 4).
CPT-4 code 71020 (radiologic examination, chest, two views, frontal and lateral) is billed with modifier ZS (indicating both professional and technical components were provided) in the HCPCS/Rates field
(Box 44). Enter a description of the service (chest X-ray) in the Description field (Box 43). The description is optional but aids in claim adjudication and provider record keeping.
Enter the date of service, June 7, 2007, in six-digit format as 060707
in the Service Date field (Box 45). Enter a “1” in the Service Units field (Box 46) and the usual and customary charges in the Total
Charges field (Box 47). Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23).
Enter “O/P Medi-Cal” to indicate the type of claim and payer in the Payer Name field (Box 50). The community clinic’s provider number is placed in the NPI field (Box 56).
An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this
example, ICD-9-CM code 487.0 represents influenza with pneumonia and is entered on the claim as 4870.
Enter the NPI for the referring or prescribing physician in the Attending field (Box 76). This field is mandatory for radiologists. Enter the NPI for the rendering provider in the Operating field (Box 77).