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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.6 UB-04 CMS-1450 Paper Claim Filing Instructions : 6.6.4 Filing Tips for Outpatient Claims

The following are outpatient claim filing tips:
Services and supplies that exceed the 28 items per claim limitation must be submitted on an additional UB-04 CMS-1450 paper claim form and will be assigned a different claim number by TMHP.
Combine central supplies and bill as one item. IV supplies may be combined and billed as one item. Include appropriate quantities and total charges for each combined procedure code used. Using combination procedure codes conserves space on the claim form.
The 28‑item limitation per claim: a UB-04 CMS-1450 paper claim form submitted with 28 or fewer items is given an internal control number (ICN) by TMHP. Multipage claim forms are processed as one claim for that client if all pages contain 28 or fewer items.
Itemized Statements: Itemized statements are not used for assignment of procedure codes. HCPCS codes or narrative descriptions of procedures must be reflected on the face of the UB-04 CMS-1450 paper claim form. Attachments will only be used for clarification purposes.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.