Condition - Professional

The Condition section displays information about the condition relating to the claim.

The Condition fields are defined below:

Was an EPSDT referral given? Was an EPSDT referral given?

Indicates whether an EPSDT referral was given to the patient. Options are Yes or No.

Referral for Early & Periodic Screening, Diagnosis, and Treatment (EPSDT). Up to three (3) referrals can be added. Options are:

AV	Available - Not used (Patient refused referral)
NU	Not used (required value if indicator = No)
S2	Under Treatment
ST	New Service Requested

Homebound Indicator Homebound Indicator

A code indicating whether a patient is homebound. Required for Medicare claims/encounters when an independent laboratory renders an EKG tracing or obtains a speciment from a homebound or institutionalized patient.

Care Plan Oversight NumberCare Plan Oversight Number

Medicare provider number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished, and for which the physician signed the plan of care.

Service Authorization Exception CodeService Authorization Exception Code

Required when providers are required by state law (e.g., NY State Medicaid) to obtain authorization for specific services, but for the reasons listed below, performed the service without obtaining the service authorization. Check with your state Medicaid to see if this applies in your state. Options are:

1	Immediate/Urgent Care
2	Services Rendered in a Retroactive Period
3	Emergency Care
4	Client as Temporary Medicaid
5	Request from County for Second Opinion so Recipient Can Work
6	Request for Override Pending
7	Special Handling

Mammography Certification NumberMammography Certification Number

A certification authorizing the patient gets a mammography. Required on Medicare claims for all mammography services.

CLIA NumberCLIA Number

Clinical Laboratory Improvement Amendment (CLIA) Number. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act.

Investigation Exempt NumberInvestigation Exempt Number

Number or reference identifying the exemption assigned to an investigational device referenced in the claim.

Demonstration Project IDDemonstration Project ID

Identification number for a Medicare demonstration project.

Special Program CodeSpecial Program Code

Code indicating the Special Program under which the services rendered to the patient were performed. Options are:

02	Physically Handicapped Children's Program
03	Special Federal Funding
05	Disability
09	Second Opinion or Surgery

Delay Reason CodeDelay Reason Code

Code indicating the reason why a request was delayed. Options are:

1	Proof of Eligibility Unknown or Unavailable
2	Litigation
3	Authorization Delays
4	Delay in Certifying Provider
5	Delay in Supplying Billing Forms
6	Delay in Delivery of Custom-Made Appliances
7	Third Party Processing Delay
8	Delay in Eligibility Determination
9	Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10	Administration Delay in the Prior Approval Process
11	Other
15	Natural Disaster

Condition CodesCondition Codes

Code(s) used to identify condition(s) relating to this bill or relating to this patient. Click (+) to add more fields to the screen. Up to 24 codes may be entered.