| Procedure Code |
Type the code you want or click the magnifying glass to search the table. |
 |
8 |
| Modifier |
Type the modifier. |
|
6 |
| Amount $ |
This field is informational only and reflects the charge amount. |
|
15 |
| Allowed Amt $ |
Type the allowed amount. |
|
10 |
| Alt. Desc. |
Type an alternate description of the procedure code. |
|
40 |
| Per Dr |
Type the code you want or select from the Doctor list. |
 |
3 |
| Diag 1 |
Type the code you want or click the magnifying glass to search the table. |
 |
10 |
| Diag 2 |
Type the code you want or click the magnifying glass to search the table. |
|
10 |
| Diag 3 |
Type the code you want or click the magnifying glass to search the table. |
|
10 |
| Diag 4 |
Type the code you want or click the magnifying glass to search the table. |
|
10 |
| Service Date |
Type the date you want or click the calendar icon to select a date. |
|
10 |
| Claim Hold |
Type the date you want or click the calendar icon to select a date. |
|
10 |
| Location Code |
Type the code you want or select from the Location list. |
 |
3 |
| Department Code |
Type the code you want or select from the Department list. |
|
3 |
| Multiplier |
Type a multiplier number greater than zero. |
 |
4 |
| Billing Group |
Type the code you want or click the magnifying glass to search the table. |
|
3 |
| Accept Assignment |
If you want to modify the assignment status, select or clear this check box. |
 |
1 |
| Date of Ill/Inj |
Type the date you want or click the calendar icon to select a date. |
|
10 |
| Superbill Number |
Type the superbill number. |
|
10 |
| Service Script |
Select a date from the Service Script list. |
|
10 |
| Referral Source |
Type the code you want or click the magnifying glass to search the table. |
|
6 |
| Case Record |
Type the code you want or select from the Case Record list. |
|
3 |
| Ins Dr |
Type the code you want or select from the Doctor list. |
 |
5 |
| Ins Dr Taxonomy |
Type the batch number you want or click the magnifying glass to search the table. |
|
40 |
| Sup Dr |
|
|
40 |
| Batch Number |
Type the batch number you want or click the magnifying glass to search the table. |
|
20 |
| Coinsurance $ |
If this charge was not paid for because of coinsurance then you must enter the amount that went toward the coinsurance in this field. |
|
10 |
| Other $ |
Type the date you want or click the calendar icon to select a date. |
|
10 |
| Deductible $ |
If a portion or all of this line item went toward the deductible amount, then put the dollar amount that went to deductible. |
|
10 |
| Other Code |
Select a date from the Service Script list. |
|
3 |
| Copay $ |
If this charge was not paid for because of copay then you must enter the amount that went toward the copay in this field. |
|
10 |
| Editing Reason |
Type the date you want or click the calendar icon to select a date. |
 |
40 |
| Edit All Charges for this Accounting Date |
If you want to edit all charges for this accounting date, select this check box. |
|
1 |