HCFA Invoice Header

When you create a CMS-1500 (formerly HCFA) claim form invoice for professional services, complete the relevant fields on the Invoice Header HCFA screen to supply the additional required data.

When you first save the invoice, the Injury and Treatment tables are searched to find data entered previously on those screens. A message displays to inform you of data that has been carried over to the Invoice Header HCFA screen and to alert you to the absence of data that is normally required on a CMS-1500 claim form invoice.



Label Description
Invoice # Carried forward from the previous screen.
Outside Lab Indicate if an outside lab was used (CMS-1500 claim form box 20).
Lab ID The ID of the lab performing work.
ICD (1-12) The code in the ICD-1 field is used as the primary diagnosis (CMS-1500 claim form box 21).
  • If you use the Invoice screen for invoicing, ICD codes populate the header from Injury.
  • If you use the Invoice Find screen (billing jump) for invoicing, ICD codes populate the header from Treatment, when there is a saved treatment with a status of T.

The ICD code set presented in lookup lists is determined by the ICD Code Lookup Selection setting in Utility > Program Preferences. See Program Preferences .

Some states and insurers have published lists of ICD codes that are not allowed for workers' compensation and can cause a claim to be rejected or denied.

If these codes have been added to the ICD Exception table in SYSTOC, selecting one of these codes to include on an invoice produces a message informing you that it is unacceptable. To remove the message and enter a different ICD code, press any key, then select the ICD code you want to use from the lookup list.
Note: You can use an ICD code even though it is in the exception list by pressing any key to remove the message and leaving in the code. The message does not display again if used on an invoice for that injury ID.

See ICD Code Exceptions.ICD Code Exceptions in online Help.

Hospital Admission Date Date of admission to a hospital.
Discharge Date Date of discharge from a hospital.
Outside Lab Charges If an outside lab was used, what is the dollar amount of those charges.
Billing Provider The Staff ID on the Treatment (Inj/Ill Visit) record, or the associated Billing Provider from the medical staff record, if different. However, SYSTOC can be set to always use the Staff ID from the Injury, see field Use Inj Provider for Billing in Program Preferences and Medical Staff field descriptions.
Medicaid Resub. 1500 Claim Form box 22, Medicaid Resubmission code.
Referring/Other Staff Staff ID (medical staff database link).
Accept Assignment 1500 Claim Form, box 27, does the provider accept the assigned benefit for this claim?
Original Ref # If there is a Medicaid Resubmission code, indicate the reference number.
Local Use Comment field.