|BlockNo.||Block Name||Block Code||Notes|
|24a||Dates of Service||M/M||Enter the applicable date(s) of service. |
If billing for a service that was provided on one day only, complete either the From or the To column (but not both.).
If the same service was provided on consecutive days, enter the first day of the service in the From column and the last day of service in the To column. Use an eight-digit (MMDDCCYY) format to record the From and To dates, (e.g. 03012004).
If the dates are not consecutive, separate claim lines must be used.
|24b||Place of Service||M||Enter the 2-digit place of service code that indicates where the recipient was transported (i.e., destination). |
12 – Patient’s Home
21 – Inpatient Hospital
22 – Outpatient Hospital
23 – Emergency Room
24 – Ambulatory Surgical Center (ASC)/ Hospital
Short Procedure Unit (SPU)
32 – Nursing Facility
49 – Independent Clinic
50 – Federally Qualified Health Center
54 – Intermediate Care Facility/Mentally Retarded
55 – Residential Substance Abuse Treatment
65 – End Stage Renal Disease Treatment Facility
72 – Rural Health Clinic
99 – Other Unlisted Facility