MC058 ICD-9-CM 1/1/2003 Text 4 Primary procedure code for Procedure Code this line of service Do not code decimal point. Refer to Appendix A Date of Service 1/1/2003 Text 8 First date of service for this – From service line CCYYMMDD MC060 Date of Service 1/1/2003 Text 8 Last date of service for this – Thru service line CCYYMMDD MC061 Quantity 1/1/2003 Number 10 Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. 1/1/2003 Number 10 Do not code decimal point. MC062 Charge Amount MC063 Paid Amount 1/1/2003 Number 10 Includes any withhold amounts Do not code decimal point. MC064 Prepaid Amount 1/1/2003 Number 10 For capitated services, the fee for service equivalent amount Do not code decimal point. 1/1/2003 Number 10 The preset, fixed dollar MC065 Co-pay Amount
MC058 ICD-9-CM Procedure Code 1/1/2003 Text 4 Primary procedure code for this line of service Do not code decimal point. Refer to Appendix A Date of Service – From 1/1/2003 Text 8 First date of service for this service line CCYYMMDD MC060 Date of Service – Thru 1/1/2003 Text 8 Last date of service for this service line CCYYMMDD MC061 Quantity 1/1/2003 Number 10 Count of services performed, which shall be set equal to one on all observation bed service lines and should be set equal to zero on all other room and board service lines, regardless of the length of stay. MC062 Charge Amount 1/1/2003 Number 10 Do not code decimal point. MC063 Paid Amount 1/1/2003 Number 10 Includes any withhold amounts Do not code decimal point. MC064 Prepaid Amount 1/1/2003 Number 10 For capitated services, the fee for service equivalent amount Do not code decimal point. MC065 Co-pay Amount 1/1/2003 Number 10 The preset, fixed dollar
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