Additional Charge Entry Information

The Additional Charge Entry Information dialog is typically used while posting a charge to a patient's account to enter details related to workers' compensation cases. It is also used to edit these details after charges have been posted. The dialog has two tabs: HCFA and UB. The tabs correspond to industry standard claim forms used for both paper and electronic billing.

Versions of this dialog are available in the Demographics, CDM  and Financial Management modules. This topic refers to the Additional Charge Entry Information dialogAdditional Charge Entry Information dialog, launched from the Charge Entry screen in Financial Management by clicking the Additional Information button. Entries you make on this dialog are specific to the Charge, while entries you make in the Demographics or CDM modules apply to all charges in the case.

Information entered in the following fields prior to posting charges, regardless of which module you enter them from, will be associated to all of the charges posted for the case:

• Accident Date
• Accident State
• PI, SI and TI Document Control # fields
• Value Code and Amount Information

Once charges have been posted, you can add or edit information in these fields on the Additional Charge Entry Information dialog.

HCFA and UB Tabs

The tabs on the Additional Charge Entry Information dialog contain some common fields. Where there are fields in common, the information users enter in one tab is automatically transferred to the other tab. For example, if you enter an Accident Date on the UB tab, that information automatically populates in the Accident Date field on the HCFA tab. Complete/edit the fields that are appropriate to the specific case.

To learn more about the fields on each tab, click the following links:

UB Tab

• Exclude from EMCExclude from EMC

  Check this box to prevent the claim from being sent to the payor electronically.

• Document NeededDocument Needed

  Select if payor requires any documents be submitted with the claim.

• Auto AccidentAuto Accident

  Select this check box to indicate the claim involves an auto accident.

• Other AccidentOther Accident

  Select this check box to indicate the claim involves an  accident other than an auto accident.

• Work RelatedWork Related

  Select this check box to indicate the claim involves an accident related to employment.

• EmergencyEmergency

  Select this check box to indicate the patient was seen in the Emergency Department.

• PregnantPregnant

  Select this check box to indicate the patient is pregnant.

• Allowed AmountAllowed Amount

  Enter the payor’s amount allowed for this service

• Deductible AmountDeductible Amount

  Enter the amount of the patient’s deductible.

• Accident DateAccident Date

  • If you selected either Auto Accident or Other Accident, use this field to record the date the accident took place.

  • Accident Date is report on the UB-04 with the applicable Occurrence Code and Date FL 31 – 34.

• Accident StateAccident State

  • If you selected either Auto Accident or Other Accident, use this field to record the state in which the accident took place.

  • This field is referenced on UB-04 paper claims as FL 29.

• PI Document Control #PI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Primary payor.
     • This field is referenced on UB-04 paper claims as FL 64 a.
• SI Document Control #SI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Secondary payor.
     • This field is referenced on UB-04 paper claims as FL 64 b.

   

• TI Document Control #TI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Tertiary payor.
     • This field is referenced on UB-04 paper claims as FL 64 c.
• 81 CC81 CC

  This field corresponds to the 81 CC field on the UB-04 form, and is generally used if additional information is requested by the payor. Use this field to enter any overflow or additional codes related to field locators or to report externally maintained codes approved by the NUBC (National Uniform Billing Committee) for inclusion into the institutional data set.

• Charge Narrative DataCharge Narrative Data

  Free text field with limited character capacity.

• Value Code & Amount InformationValue Code & Amount Information
  1. • Used to record codes and the related dollar amounts or values that are necessary to process the claim by the payor.

     • This field is referenced on UB-04 paper claims as FL 39 a-d – 41a-d.

   

• Line Supplemental InformationLine Supplemental Information

  • Used to identify supplemental reports such as a plan of treatment or certified test report.

  • Click the plus sign icon to add a line to the table.

  • Select a Report Type Code from the drop down list or click Alt + D in the field to access the dictionary to add a new Report Type Code.

  • Select the Transmission Code in the same manner. CMS generates a Control Number that you can enter here to ensure all reports are matched to the correct claim.

  • This information is specific to HCFA-1500 and EMC (electronic medical claims) only and does not print on a paper UB-04 form.

• Charge Note InformationCharge Note Information
  1. • Similar to the Line Supplemental information field, this field is used to include additional information related to the charge.  Select the Note Reference Code from the drop down menu and enter text in the Description field.
     • This information is specific to HCFA-1500 and EMC (electronic medical claims) only and does not print on a paper UB-04 form.

HCFA tab

• Auto AccidentAuto Accident

  • Select this check box to indicate the claim involves an auto accident.

  • This field is referenced on HCFA-1500 paper claims as FL 10b.

• Other AccidentOther Accident

  • Select this check box to indicate the claim involves an  accident other than an auto accident.

  • This field is referenced on HCFA-1500 paper claims as FL 10c.

• Work RelatedWork Related

  • Select this check box to indicate the claim involves an accident related to employment.

  • This field is referenced on HCFA-1500 paper claims as FL 10a.

• EmergencyEmergency

  • Select this check box to indicate the claim is related to an emergency.

  • This field is referenced on HCFA-1500 paper claims as FL 24c.

   

• Accident DateAccident Date

  • If you selected either Auto Accident or Other Accident, use this field to record the date the accident took place.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with appropriate qualifier)

• Disability StatusDisability Status

  Select the appropriate radio button to indicate whether the disability is None (default), Partial, or Full.

• Exclude from EMCExclude from EMC   

  Check this box to prevent the claim from being sent to the payor electronically.

• Outside LabOutside Lab

  Check Yes when billing for purchased services.  A Yes mark indicates the reported service was provided by an entity other than the billing provider.

• Outside Lab ChargeOutside Lab Charge

  Enter any charge amount from an outside lab in this free text field.

• Accident StateAccident State

  • If you selected either Auto Accident or Other Accident, use this field to record the state in which the accident took place.

  • This field is referenced on HCFA-1500 paper claims as HCFA-1500 FL 10b.

  • When processing claims, the system will display an error if an Auto Accident Date is entered without an Accident State being referenced.

• Document NeededDocument Needed

  Select if payor requires any documents be submitted with the claim.

• PregnantPregnant

  • Select this check box to indicate the patient is pregnant.

  • This field will also update the Pregnant field located on the Case Details dialog.

• First OccurrenceFirst Occurrence

  • Use this field to record the date of illness, injury or pregnancy (LMP, or Last Missed Period).

  • This field is referenced on HCFA-1500 paper claims as FL 14 (with appropriate qualifier).

• Similar SymptomsSimilar Symptoms

  • Use this field to record the date the patient had the same or similar symptoms.

  • This field is referenced on HCFA-1500 paper claims as HCFA-1500 FL 15 (with appropriate qualifier).

• Date Last SeenDate Last Seen

  • Use this field to record the date the patient had last been seen in the facility.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Last Menstrual PeriodLast Menstrual Period

  • Used to record the date of the first day of a female patient's last menstrual period.

  • This field is referenced on HCFA-1500 paper claims as FL 14(with applicable qualifier).

   

• Auth Return to WorkAuth Return to Work

  Used to record the date the patient is authorized to return to work.

• Disability From and ThruDisability From and Thru

  • Use these fields to record the beginning date the patient was unable to work and the ending date of that period of inability to work.

  • This field is referenced on HCFA-1500 paper claims as FL 16.

• Hospitalization From and ThruHospitalization From and Thru

  • Use these fields to record the admission and discharge dates of an inpatient stay associated to services on the claim.

  • This field is referenced on HCFA-1500 paper claims as FL 18.

• Assumed CareAssumed Care

  • Required on Medicare claims for situations where providers share post-operative care (global surgery claims). Assumed Care Date is the date care was assumed by another provider during post-operative care. See Medicare guidelines for further explanation of this date.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Relinquished CareRelinquished Care  

  • Required on Medicare claims for situations where providers share post-operative care (global surgery claims). Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of this date.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Initial TreatmentInitial Treatment

  • Used to record the date the patient first received treatment related to this claim.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• First ContactFirst Contact

  • Used to record the date the patient first made contact with your facility regarding this date of service.

  • This field is referenced on HCFA-1500 paper claims as FL15 (with applicable qualifier).

• Last WorkedLast Worked  

  Used to record the last day the patient worked.

• Original Ref #Original Ref #

  • Used in the case of a resubmitted claim to denote the original claim number.

  • This field is referenced on HCFA-1500 paper claims as FL 22.

• Resubmission CodeResubmission Code

  • Used in the case of a resubmitted claim.

  • This field is referenced on HCFA-1500 paper claims as FL 22.

• Allowed AmountAllowed Amount

  Enter the payor’s amount allowed for this service.

• Deductible AmountDeductible Amount

  Enter the amount of the patient’s deductible.

• EPSDT Indicator and Reason CodeEPSDT Indicator and Reason Code

  • If the claim is related to Early & Periodic Screening, Diagnosis, and Treatment, select the Yes radio button and enter the appropriate code in the Reason Code field.

  • This field is referenced on HCFA-1500 paper claims as FL 24h.

• Family Planning Indicator and Reason CodeFamily Planning Indicator and Reason Code
  • If the claim is related to Family Planning, select the Yes radio button and enter the appropriate code in the Reason Code field.
  • This field is referenced on HCFA-1500 paper claims as FL 24h.
• Last X-Ray DateLast X-Ray Date

  • Used to record the date of last x-ray when the claim involves spinal manipulation.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Acute Manifestation DateAcute Manifestation Date

  • Used to record the date on which an acute condition manifested for a claim involving spinal manipulation where the payer is Medicare.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Spinal Manipulation CodeSpinal Manipulation Code

  Used to record patient condition code when spinal manipulation is involved.

• Spinal Condition CodeSpinal Condition Code

  Used to record patient condition code when the claim is related to the spine.

• Charge Narrative DataCharge Narrative Data

  Free text field with limited character capacity.

• Line Supplemental InformationLine Supplemental Information

  • Used to identify supplemental reports such as a plan of treatment or certified test report. Select a Report Type Code from the drop down list or click Alt + D in the field to access the dictionary to add a new Report Type Code. Select the Transmission Code in the same manner. CMS (Centers for Medicare & Medicaid Services) generates a Control Number that you can enter here to ensure all reports are matched to the correct claim.

  • This field is referenced on HCFA-1500 paper claims as FL 19.

• Charge Note InformationCharge Note Information
  1. • Similar to the Line Supplemental information field, this field is used to include additional information related to the charge.  Select the Note Reference Code from the drop down menu and enter text in the Description field.
     • This information is specific to HCFA-1500 and EMC (electronic medical claims) only and does not print on a paper UB-04 form.

Related topics:

charge

additional case detail (demographics folder)

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