FLs 39, 40, and 41. Value Codes and Amounts.a. Each code must be accompanied by an amount.
b. All codes are two alphanumeric digits.
c. Amounts may be up to ten numeric positions. (00000000.00)
d. If code 06 is entered, there must be an entry for code 37.
e. If codes 08 and/or 10 are entered, there must be an entry in FL 10.
f. If codes 09 and/or 11 are entered, there must be an entry in FL 9.
g. If codes 12, 13, 14, 15, 41, 43, or 47 are entered as zeros, occurrence codes 01, 02, 03, 04, or 24 must be present.
h. Entries for codes 37, 38, and 39 cannot exceed three numeric positions.
i. If the blood usage data is present, code 37 must be numeric and greater than zero.
FL 42. Revenue Codes.
a. Four numeric positions.
b. Must be listed in ascending numeric sequence except for the final entry, which must be “0001” for hardcopy claims only.
c. There must be a revenue code adjacent to each entry in FL 47.
d. For bill types 32X and 33X the following revenue codes require a 5-position HCPCS code:
0274, 029X, 042X, 043X, 044X, 055X, 056X, 057X, 0601, 0602, 0603, and 0604.
e. For bill type 34X, the following revenue codes require a 5-position HCPCS code:
0271-0274, 42X, 43X, 44X, and 0601-0604.
f. For bill type 21X, 32X, 33X, or 11X (IRF facilities) the following revenue codes require a 5-position HIPPS code:
0022 (SNF only), 0023 (HH only), 0024 (IRFs only).