1. Outpatient Case 2: Laboratory Visit - Hospital
(2-3) A Medicare patient presents at the hospital laboratory department with a physician order for hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody studies. Indications for the laboratory procedures are chronic flu-like symptoms and jaundice coloring of the patient. Blood was drawn and studies performed that indicate viral hepatitis A. A laboratory report is sent to the physician.

Indicate what claim form will be used to submit charges for this visit.
CMS â€“ 1450 (UB-04) claim form should be used for this visit. All the outpatient hospital procedure claims are submitted through this form unless otherwise stated.

2. Outpatient Case 2: Laboratory Visit - Hospital
(2-4) A Medicare patient presents at the hospital laboratory department with a physician order for hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody studies. Indications for the laboratory procedures are chronic flu-like symptoms and jaundice coloring of the patient. Blood was drawn and studies performed that indicate viral hepatitis A. A laboratory report is sent to the physician.

State the field(s) on the claim form in which the diagnosis code(s) will be recorded.
Section IV, Field Locator No.67 of UB-04 form records the primary diagnosis code while section IV, field locators 67 (A to Q) records additional diagnosis codes, if any.

3. Outpatient Case 2: Laboratory Visit - Hospital
(2-5) A Medicare patient presents at the hospital laboratory department with a physician order for hepatitis A antibody, hepatitis B core antibody, hepatitis B surface antigen, and hepatitis C antibody studies. Indications for the laboratory procedures are chronic flu-like symptoms and jaundice coloring of the patient. Blood was drawn and studies performed that indicate viral hepatitis A. A laboratory report is sent to the physician.

State the field(s) on the claim form in which the procedure code(s) will be recorded.
Section IV, Field locator 74 records the procedure codes.

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