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Claim Type 11 (CHDP) Claim Record Data Specifications1
This section includes two formats for submitting claims: “Claim Record Format Without the Expanded Billed Amount Field”, and “Claim Record Format with Expanded Billed Amount Field”. Providers may use either format to submit electronic claims.
Claim Record Format Without Expanded Billed Amount Field
Record Format: Fixed
Record Length: 683
Field Default Values: Spaces
Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Submitter X(3)A/N13001 – 003MEnter the three-character
Numbersubmitter number assigned by the DHCS Fiscal Intermediary (FI).
Provider IDX(10)A/N110004 – 013MEnter the three- to
Numbernine-character provider
number assigned by DHCS or ten-digit National Provider Identifier (NPI). Left justify
and space fill (do not zero fill).
Claim Type9(2)N12014 – 015MEnter “11”.
Julian Date9(4)N14016 – 019MIn YDDD format, enter the
Julian date of submission from the Submitter Control Record.
Claim9(4)N14020 – 023MEnter the four-digit claim
Sequencesequence number assigned
Numberby the submitter. All claims within a given Provider Control Record must have an individual Claim Sequence Number.
Record TypeX(1)A/N11024 – 024MEnter “0”.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Recipient IDX(15)A/N115025 – 039MLeft justify and enter the
recipient’s nine or
14-character Medi-Cal ID or
Benefits Identification Card
(BIC) number. Do not enter
dashes, hyphens or any special characters. If entering a check digit, please see the Recipient ID Check Digit Algorithms section of this manual. If dataposition 320 has a value of “2”(non-
Medi-Cal), space fill (do not zero fill).
Recipient X(15)A/N115040 – 054MEnter the recipient’s last
Last Namename as it appears on the Medi-Cal ID card.
Recipient X(14)A/N114055 – 068MEnter the recipient’s first
First Namename as it appears on the Medi-Cal ID card.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
CHDP9(1)A/N11069 – 069MEnter the applicable code
Claim Typeas follows:
1 General CHDP
2 Prepaid Health Plan/
Information Only
Recipient Sex9(1)N11070 – 070MEnter a “1” for female or
“2” for male.
Recipient9(6)N16071 – 076MIn six-digit MMDDYY
Date of format, enter the
Birth recipient’s date of
birth (for example,
March 18, 1995 = 031895).
Recipient9(2)N12077 – 078MEnter the recipient’s
County oftwo-digit county code of
Residenceresidence.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Ethnic9(1)N11079 – 079AEnter the ethnic code
Codeas follows:
1 American Indian
2 Asian
3 Black
4 Filipino
5 Hispanic/Mexican American
6 White
7 Other
8 Pacific Islander
Date of9(6)N16080 – 085MIn six-digit MMDDYY format,
Serviceenter the date of service.
History and9(1)N11086 – 086AEnter the assessment
Physical (H&P)code as follows:
Assessment
1 -No problem suspected, or
2 -Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 087 – 094
must be spaces.
Note: If entering a space in position 086, there must be a
value other than a space in at least one of the following four fields. Non-space responses are allowed in all four fields. If this claim is a partial screen,
then positions 086 – 094 can be
blank, and a prior PM 160 date must be present in positions
314 – 319.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
H&P New9(2)N12087 – 088AEnter the follow-up code
Problem 1as follows:
01 No diagnosis (DX)/ prescription (RX) indicated, or now under care
02 Questionable result, recheck scheduled
03 DX made and RX started
04 DX pending/return visit scheduled
05 Referral to another
examiner for DX/RX
06 Referral refused, or
Enter a space if code “01” thru “06” do not apply.
H&P New9(2)N12089 – 090ASee H&P New Problem 1
Problem 2for follow-up code list.
H&P Known9(2)N12091 – 092ASee H&P New Problem 1
Problem 3 for follow-up code list.
H&P Known9(2)N12093 – 094ASee H&P New Problem 1
Problem 3for follow-up code list.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Dental9(1)N11095 – 095AEnter the assessment
Assessmentcode as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 096 – 099
must be spaces.
Note: If entering a space in
position 095, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields. If this claim is a partial screen,
then positions095 – 099 will
be blank, and a prior PM
160 date must be present in
positions 314 – 319.
Dental New9(2)N12096 – 097ASee H&P New Problem 1
Problem for follow-up code list.
Dental Known9(2)N12098 – 099ASee H&P New Problem 1
Problem for follow-up code list.
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Data
AlphaANo. OfPositionAS RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Nutrition9(1)N11100 – 100AEnter the assessment
Assessmentcode as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 101 – 104
must be spaces.
Note: If entering a space in
position 100, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields. If this claim is a partial screen,
then positions 100 – 104
can be blank, and a prior
PM 160 date must be present in positions
314 – 319.
Nutrition New 9(2)N12101 – 102ASee H&P New Problem 1
Problemfor follow-up code list.
Nutrition 9(2)N12103 – 104ASee H&P New Problem 1
Knownfor follow-up code list.
Problem
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Data
AlphaANo. OfPositionAS RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Anticipatory9(1)N11105 – 105AEnter the assessment
Guidancecode as follows:
Assessment
1 No problem suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 106 – 109
must be spaces.
Note: If entering a space in position 104, there must be a value other than a space in at least one of the following two fields.
Non-space responses are
allowed in both fields. If this
claim is a partial screen,
then positions 105 – 109
can be blank and a prior
PM 160 date must be entered in positions
314 – 319.
Anticipatory 9(2)N12106 – 107ASee H&P New Problem 1
Guidancefor follow-up code list.
New Problem
Anticipatory 9(2)N12108 – 109ASee H&P New Problem 1
Guidancefor follow-up code list.
Known
Problem
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Develop9(1)N11110 – 110AEnter the assessment
mentalcode as follows:
Assessment
1 No problem suspected, or
2 Refused, contraindicated,not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 111 – 114
must be spaces.
Note: If entering a space in
position 110, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields. If this claim is a partial screen,
then positions 110 – 114
can be blank, and a prior
PM 160 date must be present in positions
314 – 319.
Develop9(2)N12111 – 112ASee H&P New Problem 1
mentalfor follow-up code list.
New Problem
Develop9(2)N12113 – 114ASee H&P New Problem 1
mentalfor follow-up code list.
Known
Problem
History and99V99N14115 – 118AEnter amount billed for H&P
Physicalservices. At least one Billed
Billed AmountAmount must be entered if
billing CHDP claim type “1”
or “3” only. Do not enter a
dollar sign or decimal point. Right justify and zero fill.
For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Snellen or9(1)N11119 – 119AEnter the assessment
Equivalentcode as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 120 – 123
must be spaces.
Note: If entering a space in
position 119, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields.
Snellen or9(2)N12120 – 121ASee H&P New Problem 1
Equivalentfor follow-up code list.
New Problem
Snellen or9(2)N12122 – 123ASee H&P New Problem 1
Equivalentfor follow-up code list.
Known
Problem
Snellen or99V99N14124 – 127AEnter amount billed for
Equivalentvision services. At least one
Billed AmountBilled Amount must be entered if billing CHDP
claim type “1” or “3” only.
Do not enter a dollar sign or
decimal point. Right justify
and zero fill. For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Audiometric9(1)N11128 – 128AEnter the assessment
Assessmentcode as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 129 – 132
must be spaces.
Note: If entering a space in
position 128, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields.
Audiometric9(2)N12129 – 130ASee H&P New Problem 1
New Problemfor follow-up code list.
Audiometric9(2)N12131 – 132ASee H&P New Problem 1
Knownfor follow-up code list.
Problem
Audiometric99V99N14133 – 136AEnter amount billed for
Billed Amount hearing services. At least one Billed Amount must be entered if billing CHDP
claim type “1” or “3” only.
Do not enter a dollar sign or decimal point. Right justify
and zero fill. For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Hemoglobin 9(1)N11137 – 137AEnter the assessment
or Hematocritcode as follows:
Assessment
1 No problem suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 138 – 141
must be spaces.
Note: If entering a space in
position 137, there must be
a value other than a space in at least one of the following two fields.
Non-space responses are allowed in both fields.
Hemoglobin 9(2)N12138 – 139ASee H&P New Problem 1
or Hematocritfor follow-up code list.
New Problem
Hemoglobin 9(2)N12140 – 141ASee H&P New Problem 1
or Hematocritfor follow-up code list.
Known
Problem
Hemoglobin99V99N14142 – 145AEnter amount billed for
or Hematocritblood services. At least one
Billed AmountBilled Amount must be entered if billing CHDP
claim type “1” or “3” only.
Do not enter a dollar sign or
decimal point. Right justify
and zero fill. For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Urine9(1)N11146 – 146AEnter the assessment
Dipstickcode as follows:
Assessment
1 No problem suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 147 – 150
must be spaces.
Note: If entering a space in
position 146, there must be
a value other than a space in at least one of the following two fields.
Urine Dipstick 9(2)N12147 – 148ASee H&P New Problem – 1
New Problemfor follow-up code list.
Urine Dipstick 9(2)N12149 – 150ASee H&P New Problem – 1
Knownfor follow-up code list.
Problem
Urine Dipstick99V99N14151 – 154AEnter amount billed for urine
Billed Amountdipstick services. At least one Billed Amount must be
entered if billing CHDP
claim type “1” or “3” only.
Do not enter a dollar sign or
decimal point. Right justify
and zero fill. For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Complete9(1)N11155 – 155AEnter the assessment
Urinalysiscode as follows:
Assessment
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 156 – 159
must be spaces.
Complete9(2)N12156 – 157ASee H&P New Problem 1
Urinalysisfor follow-up code list.
New Problem
Complete9(2)N12158 – 159ASee H&P New Problem 1
Urinalysisfor follow-up code list.
Known
Problem
Complete99V99N14160 – 163AEnter amount billed for
Urinalysiscomplete urinalysis
Billed Amountservices. At least one Billed Amount must be entered
if billing CHDP claim type
“1” or “3” only. Do not enter
enter a dollar sign or
decimal point. Right justify
and zero fill. For claim type “2” zero fill.
FillerX(9)A/N19164 – 172AEnter spaces.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
TB Mantoux 9(1)N11173 – 173AEnter the assessment
Assessmentcode as follows:
1 No problem
suspected, or
2 Refused,
contraindicated,
not needed, or
Enter a space if code “1” or “2” do not apply.
If code “1” or “2” is entered,
then positions 174 – 177
must be spaces.
TB Mantoux 9(2)N12174 – 175ASee H&P New Problem 1
New Problemfor follow-up code list.
TB Mantoux9(2)N12176 – 177ASee H&P New Problem 1
Knownfor follow-up code list.
Problem
TB Mantoux99V99N14178 – 181AEnter amount billed for TB
Billed AmountMantoux services. At
least one Billed Amount
must be entered if billing
CHDP claim type “1” or “3”
only. Do not enter a dollar
sign or decimal point. Right
justify and zero fill. For claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Other Tests9(2)N12182 – 183AEnter the other test
Code 1 or pelvic exam code
as follows:
13 Sickle Cell: Electrophoresis
15 Lead: Blood Lead
16 VDRL, RPR, or ART
17 G.C. Culture
18 PAP Smear
20 Chlamydia
21 Pelvic
22 Ova and/or Parasites
23 – Lead test counseling and blood drawing for lead testing
24 – Lead Refer – Counseling and referral for blood drawing for lead testing
25 – Blood Glucose
26 – Total Cholesterol
Enter a space if code does not apply.
Other Tests9(1)N11184 – 184AEnter the assessment
Assessment 1code if billing/reporting
other tests as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” does not apply.
If code “1” or “2” is entered,
then positions 185 – 188
must be spaces.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Other Tests 9(2)N12185 – 186ASee H&P New Problem 1
New Problemfor follow-up code list.
1
Other Tests9(2)N12187 – 188ASee H&P New Problem 1
Knownfor follow-up code list.
Problem 1
Other Tests99V99N14189 – 192AEnter amount billed for
Billed AmountOther Tests – 1 if billing
1CHDP claim type “1” or “3”. Do not enter a dollar sign or decimal point. Right justify
and zero fill. For claim type
“2” zero fill.
Other Tests9(2)N12193 – 194ASee Other Test Code 1 for
Code 2other test code list.
Other Tests9(1)N11195 – 195AEnter the assessment
Assessment 2code if billing/reporting
other test or pelvic exam
as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” does not apply.
If code “1” or “2” is entered,
then positions 196 – 199
must be spaces.
Other Tests 9(2)N12196 – 197ASee H&P New Problem 1
New Problemfor follow-up code list.
2
Other Tests9(2)N12198 – 199ASee H&P New Problem 1
Knownfor follow-up code list.
Problem 2
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Other Tests99V99N14200 – 203AEnter amount billed for
Billed AmountOther Tests 2 if billing
2CHDP claim type “1” or “3”
only. Do not enter a dollar sign or decimal point. Right
justify and zero fill. For claim type “2” zero fill.
Other Tests9(2)N12204 – 205ASee Other Tests Code 1
Code 3for other test code list.
Other Tests9(1)N11206 – 206AEnter the assessment
Assessmentcode if billing/reporting
3other test or pelvic exam as follows:
1 No problem
suspected, or
2 Refused, contraindicated,
not needed, or
Enter a space if code “1” or “2” does not apply.
If code “1” or “2” is entered,
then positions 207 – 210
must be spaces.
Other Tests 9(2)N12207 – 208ASee H&P New Problem 1
New Problemfor follow-up code list.
3
Other Tests9(2)N12209 – 210ASee H&P New Problem 1
Knownfor follow-up code list.
Problem 3
Other Tests99V99N14211 – 214AEnter amount billed for
Billed AmountOther Tests 3 if billing
3CHDP claim type “1” or “3”
only. Do not enter a dollar
sign or decimal point. Right
justify and zero fill. For
claim type “2” zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Passive X(1)A/N11215 – 215AEnter “Y” if the patient is
Tobaccoexposed to passive
Smoke(second-hand) tobacco smoke. Enter “N” if not.
TobaccoX(1)A/N11216 – 216AEnter “Y” if the patient uses
Usedtobacco. Enter “N” if
non-user.
TobaccoX(1)A/N11217 – 217AEnter “Y” if you have
Referralcounseled the patient about tobacco use or if you have referred the patient for counseling. Enter “N” if not.
Weight lbs.9(3)N13218 – 220AEnter weight in pounds.
Right justify and zero fill.
Weight oz.9(2)N12221 – 222AEnter balance of weight
in ounces. Cannot exceed 15 oz. Right justify and zero fill.
Body Mass9(2)N12223 – 224AEnter Body Mass Index
Indexpercentile in whole numbers. Right justify and zero fill.
Blood 9(3)N13225 – 227AMust be greater than
Pressurediastolic. Mandatory for all
Systolic children age three and older. Right justify and zero fill.
Blood 9(3)N13228 – 230AMandatory for all children
Pressureage three and older. Right
Diastolicjustify and zero fill.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Hemoglobin99V9N13231 – 233ARecord to the nearest
0.1 gram. Do not enter decimal point.
Examples:
090FOR9.0
160FOR16.0
095FOR9.5
165FOR16.5
The range is not less than 060 or greater than 240.
Hematocrit9(3)N13234 – 236ARecord to the nearest
1 percent. Left justify and
zero fill. Range is not less
than 18 or more than 72.
Birth Weight9(2)N12237 – 238ARecord birth weight (if
lbs.known) for children 2
years of age or younger. Right justify and zero fill.
Birth Weight9(2)N12239 – 240AEnter balance of weight
oz.in ounces. Cannot exceed 15 oz. Right justify and zero fill.
Immunization9(2)N12241 – 242AEnter the Immunization
Code 1Code.
Immunization9(1)N11243 – 243AEnter the assessment
Assessment code as follows:
- 1
1 Now up-to-date
for age
2 Still not up-to-date
for age
3 Already up-to-date
for age
4 Refused or contraindicated
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Immunization 99V99N14244 – 247AEnter amount billed for
Billed AmountImmunization Code 1. For
- 1CHDP claim types “1” or “3” only.
Do not enter a dollar sign or decimal point. Right justify
and zero fill. For claim type
“2” zero fill.
Immunization9(2)N12248 – 249AEnter the Immunization
Code 2Code.
Immunization9(1)N11250 – 250ASee Immunization
AssessmentAssessment 1 for
- 2assessment code list.
Immunization 99V99N14251 – 254AEnter amount billed for
Billed AmountImmunization Code 2. For
- 2CHDP claim types “1” or “3” only.
Do not enter a dollar sign or
decimal point. Right justify
and zero fill. For claim type “2” zero fill.
Immunization9(2)N12255 – 256AEnter the Immunization
Code 3Code.
Immunization9(1)N11257 – 257ASee Immunization
AssessmentAssessment 1 for
- 3 assessment code list.
Immunization 99V99N14258 – 261AEnter amount billed for
Billed AmountImmunization Code 3. For
- 3 CHDP claim types “1” or “3” only.
Do not enter a dollar sign or decimal point. Right justify
and zero fill. For claim type
“2” zero fill.
Immunization9(2)N12262 – 263AEnter the Immunization
Code 4Code.
Immunization9(1)N11264 – 264ASee Immunization
AssessmentAssessment 1 for
- 4 assessment code list.
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Data
AlphaANo. OfPositionAs RequiredA
Field NamePictureNumericNOccursLengthFromToMandatoryMExplanation Of Items
Immunization 99V99N14265 – 268AEnter amount billed for
Billed AmountImmunization Code 4. For
- 4 CHDP claim types “1” or “3” only.
Do not enter a dollar sign or decimal point. Right justify
and zero fill. For claim type
“2” zero fill.
Immunization9(2)N12269 – 270AEnter the Immunization
Code 5Code.
Immunization9(1)N11271 – 271ASee Immunization
AssessmentAssessment 1 for
- 5 assessment code list.
Immunization 99V99N14272 – 275AEnter amount billed for