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ICD-9 Code Research Paper

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21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY - Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field.

9 ICD-9-CM
0 ICD-10-CM

Enter the 3-5 alpha/numeric character code from the ICD-9 related to the procedures, services, or supplies listed in Block #24e. List the primary diagnosis on Line A, with any subsequent codes to be entered on Lines B thru H (the highest level of specificity in priority order). Additional diagnoses are optional and may be listed on Lines I thru L. – Required

NOTE: Effective April 1, 2014 Medical Assistance (MA) will only accept the revised CMS-1500 form (02-12) version
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– Required

Block 24A DATE(S) OF SERVICE – Enter each separate date of service as a 6-digit numeric date (e.g. June 1, 2005 would be 06/01/05) under the FROM heading. Leave the space under the TO heading blank. Each date of service on which a service was rendered must be listed on a separate line. Ranges of dates are not accepted on this form. – Required

Block 24B PLACE OF SERVICE – For each date of service, enter the appropriate 2-digit place of service code listed below to describe the site. – Required

Code Location
03 School 42 Ambulance – Air or Water
11 Office 50 Federally Qualified Health Ctr.
12 Patient’s Residence 51 Inpatient Psychiatric Facility
20 Urgent Care 52 Psychiatric Facility Partial Hospitalization
21 Inpatient Hospital 53 Community Mental Health Ctr.
22 Outpatient Hospital 56 Psychiatric Residential Treatment Ctr.
23 Emergency Room – Hospital 57 Non-Residential Substance Abuse Facility
24 Ambulatory Surgical Ctr. 61 Comprehensive Inpatient Rehabilitation Ctr.
25 Birthing Ctr 62 Comprehensive Outpatient Rehab. Ctr
26 Military Treatment Ctr 65 End-Stage Renal Disease Treatment Facility
31 Skilled Nursing Facility 71 State or Local Public Health Clinic
32 Nursing Home 72 Rural Health Clinic
33 Custodial Care 81 Independent Laboratory
34 Hospice 99 Other Unlisted Facility
41 Ambulance – Land

Block 24C EMG – Leave Blank.

Block 24D PROCEDURES, SERVICES OR SUPPLIES – Enter the five-character procedure code that describes the service provided and
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