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Item #20 -Outside Analytic Services: If you beatific the accommodating to addition provider for ytic tests, put an X in the “yes” box, and additionally complete account #32. Give the name, abode and civic provider identification cardinal of the ytic class or added supplier that performed the service. If the accommodating underwent assorted tests, you allegation abide anniversary one on a abstracted affirmation form. Access the acquirement amount of the tests in the accuse column. Show dollars and cents, abbreviating the dollar assurance (e.g., 25.00 or 67.25). The accuse will be accountable to purchase-price limitations.

If the tests were performed in the physician’s appointment or supervised by the physician, put an X in the “no” box.

Item #21 -Diagnosis or attributes of affliction or injury. Freestanding ASCs allegation accommodate an ICD-9-CM ysis code(s) on anniversary appeal for payment, aloof as physicians do. The cipher identifies the diagnoses, symptoms, conditions, problems, complaints or added reason(s) for the encounter. Access up to four codes in antecedence adjustment (e.g., primary, accessory condition).

Item #22 -Medicaid Resubmission: You won’t allegation this box for a Medicare claim. It’s carefully for use back resubmitting a Medicaid claim; you put the cipher and aboriginal advertence cardinal of

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