19. ADDITIONAL CLAIM Identifies additional information about the INFORMATION beneficiary’s condition or the claim. Enter the appropriate qualifiers describing the identifier. See for qualifiers. 20. OUTSIDE LAB? Not used for DDTCS Transportation Services. $ CHARGES Not required. 21. DIAGNOSIS OR NATURE Enter the applicable ICD indicator to identify which OF ILLNESS OR INJURY version of ICD codes is being reported. Use for ICD-9-CM. “9” Use for ICD-10-CM. “0” Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. 22. RESUBMISSION CODE Reserved for future use. ORIGINAL REF. NO. Any data or information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. 23. PRIOR AUTHORIZATION The prior authorization or benefit extension control NUMBER number if applicable. 24A. DATE(S) OF SERVICE The and dates of service for each billed “from” “to” service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. OF SERVICE Two-digit national standard place of service code. See Section 292.200 for codes. C. EMG Enter for or leave blank if “Y” “Yes” “No.” D. PROCEDURES, SERVICES, OR SUPPLIES One CPT or HCPCS procedure code for each detail. MODIFIER Not applicable to DDTCS Transportation claims.
19. ADDITIONAL CLAIM INFORMATION Identifies additional information about the beneficiary’s condition or the claim. Enter the appropriate qualifiers describing the identifier. See for qualifiers. 20. OUTSIDE LAB? Not used for DDTCS Transportation Services. $ CHARGES Not required. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use “9” for ICD-9-CM. Use “0” for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. 22. RESUBMISSION CODE Reserved for future use. ORIGINAL REF. NO. Any data or information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. 23. PRIOR AUTHORIZATION NUMBER The prior authorization or benefit extension control number if applicable. 24A. DATE(S) OF SERVICE The “from” and “to” dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. OF SERVICE Two-digit national standard place of service code. See Section 292.200 for codes. C. EMG Enter “Y” for “Yes” or leave blank if “No.” D. PROCEDURES, SERVICES, OR SUPPLIES One CPT or HCPCS procedure code for each detail. MODIFIER Not applicable to DDTCS Transportation claims.