BLOCK 14 DATE OF CURRENT ILLNESS
.Note: Effective for dates of service January 1, 2000 and after, the x-ray date is no longer required for chiropractic services.Completion of this field is required for all chiropractic services; conditional for other services.
BLOCK 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS
blank. Not required by Medicare.BLOCK 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
the six - digit dates (MMDDYY) patient is employed and unable to work in current occupation. An entry in this block may indicate employment related insurance coverage.Completion of this field is conditional for disability information.BLOCK 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.Referring Physician - A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician - A physician who orders nonphysician services for the patient, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.All claims for Medicare covered services and items that are the result of a physician's order or referral must include the ordering/referring physician's name and Unique Physician Identification Number (UPIN) and National provider number (NPI)
BLOCK 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
Enter the six - digit date (MMDDYY) when a medical service is furnished as a result of, or subsequent to, a related hospitalization.Completion of this field is conditional for medical services related to hospitalization.
BLOCK 19 RESERVED FOR LOCAL USE
BLOCK 20 OUTSIDE LAB
Complete this block when billing for purchased diagnostic tests. Enter the purchase price under charges if the "YES" block is checked. A "YES" check indicates that an entity other than the entity billing for the service performed the diagnostic test. A "NO" check indicates that "no purchased tests are included on the claim". When "YES" is annotated, block 32 must be completed.BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Enter the patient's diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.All narrative diagnosis codes must be submitted on an attachment.
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