Indian Health Services Billing Manual

Indian Health Service (IHS)

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Indian Health Service (IHS)

Providers must be enrolled as a Health First Colorado (Colorado’s Medicaid Program) provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing FQHC and RHC services.

 

NOTE: Health First Colorado should be billed only in the event that an eligible American Indian Alaska Native (AIAN) member is enrolled in Health First Colorado. If the eligible member also possesses a third-party insurance plan, the private plan must be billed first. Any services not covered by the private insurance plan that are covered by Health First Colorado may then be billed. In the event an eligible AIAN member is dually eligible for Medicare and Health First Colorado, Medicare must be billed first. Any services not covered by Medicare that are covered by Health First Colorado may then be billed.

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IHS Provider

In order to bill as an IHS provider with Health First Colorado, the treatment facility must reside on land owned and operated by a federally recognized tribe as defined under Title IV of the Indian Health Care Improvement Act.

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Urban Indian Organization (UIO)

Urban Indian Organizations (UIO) are currently ineligible to receive IHS designation under federal law. However, UIOs may apply to become a federally qualified health center (FQHC) with Health First Colorado, as long as they receive funds under Title V of the Indian Health Care Improvement Act.

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Indian Health Service (IHS) Benefits

Payment for services rendered shall be paid per visit/encounter. Rates are determined by the U.S. Department of Health and Human Services, and are published each year in the Federal Register. Health First Colorado covers the following outpatient services:

  • Physician services
  • Mental health services
  • Hospital outpatient services
  • Podiatry services
  • Optometry services
  • Radiology services
  • Laboratory services

 

Health First Colorado shall accept submission of and make payments for multiple visit/encounter claims for different types of service provided to a member on the same date of service by the same facility only if the services provided are different or are for different diagnosis codes.

Health First Colorado also covers inpatient services at IHS facilities. Payment for services rendered shall be per date of inpatient stay and is set in the Federal Register by the U.S. Department of Health and Human Services. Health First Colorado shall make only one payment per date of service per member.

Professional services rendered by IHS providers at an inpatient hospital or ambulatory surgical center are billed fee for service. Providers should refer to the billing manual for medical and surgical services found on the Billing Manuals web page under the CMSS 1500 drop-down menu. Covered services include anesthesia services, obstetric services, medical services, vaccine/immunization services, psychiatric services, and surgical services as detailed in the medical and surgical services billing manual (see link above).

Behavioral health services are covered by and billed directly to Health First Colorado as a part of the IHS encounter rate. All behavioral health services should be billed with the appropriate revenue and procedure codes (see below).

Pharmacy services rendered by an IHS pharmacy are covered by Health First Colorado, instructions can be found in the pharmacy billing manual.

Dental services are also covered by Health First Colorado, but should be billed to DentaQuest. For more information, see locator 42 on page 11 of this manual.

Urban Indian Organizations (UIO) who are designated as federally qualified health centers (FQHC) with Health First Colorado who use cost reports in lieu of the federal encounter rate should refer to the billing manual for FQHCs found on the Billing Manuals web page under the UB-04 drop-down menu.

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Coding

IHS facilities are required to use revenue codes to bill Health First Colorado. The valid revenue codes for reimbursement are:

Revenue Code Type of Service
529 Physical Health (Outpatient)
900 Behavioral Health (Outpatient)
110 Inpatient Services (Physical & Behavioral Health)

 

IHS services are priced at an encounter rate. All routine services are included in the encounter rate. Encounter rates for Tribal-FQHCs and IHS facilities are determined by the federal Department of Health and Human Services and are published in the Federal Register for each calendar year.

In order to provide the Health First Colorado program with basic clinical information for use in evaluating services requested and received by Health First Colorado members, IHS and Tribal-FQHCs are required to include all procedure codes (CPT  and HCPCS codes) for services provided during a visit on claims. To be reimbursed, a Tribal-FQHC or IHS facility that submits a UB-04 or 837 Institutional (837I) electronic transaction must have at least one (1) claim line that identifies revenue code 0529. All other lines on the claim should have the revenue code most appropriate for the service. The line item with revenue code 0529 or 0521 can appear at any line on the claim and with any procedure code.

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UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for the Health First Colorado as those indicated in the NUBCUB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to the Health First Colorado. The appropriate code values listed in this manual must be used when billing the Health First Colorado.

The UB-04 Certification document (located after the Sterilizations, Hysterectomies, and Abortions instructions and in the Provider Services Forms section) must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to the Health First Colorado for FQHC and RHC services.

Form Locator and Labels Completion Format Instructions
1. Billing Provider Name, Address, Telephone Number Text Abbreviate the state using standard post office abbreviations. Enter the telephone number.
  • Street
  • City
  • State
  • Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
IHS: Use type of Bill 71X or 77X for outpatient, 111 for inpatient.
Digit 1 Frequency
0 Non-Payment/Zero Claim
1 Admit through discharge claim
2 Interim - First claim
3 Interim - Continuous claim
4 Interim - Last claim
7 Replacement of prior claim
8 Void of prior claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system.
6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY
Required
Each date of service must be billed on a separate line. Split an entire month into two claims. This FL must reflect the beginning and ending dates of service listed on the detail dates of service lines.
8a. Patient Identifier   Submitted information is not entered into the claim processing system.
8b. Patient Name Up to 25 characters; letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address – Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address – City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address – State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address – ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address – Country Code Digits Optional
10. Birthdate 8 digits (MMDDYYYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDYYYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Not Required
13. Admission Hour 6 digits Not Required
14. Admission Type 1 digit Conditional
Complete for emergency visits.
1 – Emergency
Member requires immediate intervention as a result of severe, life threatening or potentially disabling conditions.
Exempts outpatient hospital claims from co-payment and PCP referral only if Revenue Code 0450 or 0459 is present. This is the only benefit service for an undocumented alien.
If span billing, emergency services cannot be included in the span bill and must be billed separately from other outpatient services.
15. Source of Admission 1 digit Not Required
16. Discharge Hour 2 digits Not Required
17. Patient Discharge Status 2 digits Not Required
18-28. Conditions Codes 2 digits Conditional Complete with as many codes necessary to identify conditions related to this bill that may affect payer processing.
Condition Codes
01 Military service related
02 Employment related
04 Information only bill
05 Lien has been filed
06 ESRD member - First 30 months entitlement
07 Treatment of non-terminal condition/hospice member
17 Member is homeless
25 Member is a non-US resident
39 Private room medically necessary
60 -DRG (Day outlier)
Renal dialysis settings
71 Full care unit
72 Self care unit
73 Self-care training
74 Home care
75 Home care - 100 percent reimbursement
76 Back-up facility
Special Program Indicator Codes
A1 EPSDT/CHAP
A2 Physically Handicapped Children's Program
A4 Family Planning
A6 PPV/Medicare
A9 Second Opinion Surgery
B3 Pregnancy Indicator
PRO Approval Codes
C1 Approved as billed
C2 Automatic approval as billed - Based on focused review
C3 Partial approval
C4 Admission/Services denied
C5 Post payment review applicable
C6 Admission preauthorization
C7 Extended authorization
29. Accident State 2 digits Not required
31 – 34. Occurrence Code/Date 2 digits & 6 digits Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:
1 Accident/Medical Coverage
2 Auto Accident - No Fault Insurance Involved
3 Accident/Tort Liability
4 Accident/Employment Related
5 Other Accident/No Medical Coverage or Liability Coverage
6 Crime Victim
20 Date Guarantee of Payment Began
24* Date Insurance Denied
25* Date Benefits Terminated by Primary Payer
26 Date Skilled Nursing Facility Bed Available
27 Date of Hospice Certification or Re- certification
40 Scheduled Date of Admission (RTD)
50 Medicare Pay Date
51 Medicare Denial Date
55 Date of Death
A3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line A
B3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line B
C3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line C
*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information
35-36. Occurrence Span Code From/ Through 2 & 6 digits Not required
38. Responsible Party Name/Address None Leave blank
39 – 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
01 Most common semiprivate rate (Accommodation Rate)
06 Medicare blood deductible
14 No fault including auto/other
15 Worker's Compensation
30 Preadmission testing
31 Member Liability Amount
32 Multiple Member Ambulance Transport
37 Pints of Blood Furnished
38 Blood Deductible Pints
40 New Coverage Not Implemented by HMO
45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related
58 Arterial Blood Gas (PO2/PA2)
68 EPO-Drug
80 Covered Days
81 Non-Covered Days
Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
42. Revenue Code 3 digits Required
  • IHS Outpatient Medical Claims
    Use revenue code 0529 on each line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service.
  • IHS Inpatient Medical Claims
    Use any of the following revenue codes: 110, 111, 112, 117, 120-25, 127-31, 140, 145, 150, 159, 160, and 169.
  • IHS Behavioral Health Claims
    Use revenue code 0900 on each line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service.
  • IHS Dental Claims
    For claims with dates of service prior to March 1, 2018, use revenue code 529 on each line of the claim regardless of the type of services identified in locator 44. For claims with dates of service after March 1, 2018, refer to the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest’s website.
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
When reporting an NDC:
  • Enter the NDC qualifier of "N4" in the first two positions on the left side of the field, immediatelyu followed by the 11-digit NDC numeric code
  • Enter one space for separation.
  • Enter the NDC unit of measure qualifier (examples include):
    • F2 – International Unit
    • GR – Gram
    • ML – Milliliter
    • UN – Units
  • Enter the NDC unit of measure quantity
Example:
42 REV.CD. 43 DESCRIPTION
0636 N467066000501 ME.016
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits Required
Medical Claims - There may be multiple lines, each identified by revenue code 529 in locator 42. For each line enter a valid CPT code or HCPCS code that reflects the services rendered during the encounter. This includes any medical, laboratory, radiology, physical therapy, occupational therapy, pharmacy, supply or other service rendered during the encounter.

When a line identifies revenue code in the range of 0631-0636, the HCPCS will be required and an NDC.

CPT and HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

On dental claims the D-code must be put in locator 44 on each line for dates of services prior to July 1, 2014. For dates of services after July 1, 2014, refer to the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest’s website.

Behavioral Health Claims – There may be multiple lines, each identified by revenue code 900 in locator 42. For each line enter a short-term behavioral health service code that reflects the service rendered during the encounter.

HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.
45. Service Date 6 digits Required
Enter the date of service using MMDDYY format for each detail line completed.
Each date of service must fall within the date span entered in the "Statement Covers Period" (FL 6).
Not required for single date of service claims.
46. Service Units Up to 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)
47. Total Charges Up to 9 digits Required
Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total in line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits Required
Enter incurred charges that are not payable by the Health First Colorado.
Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges). Each column requires a grand total.
Non-covered charges cannot be billed for outpatient hospital laboratory or hospital-based transportation services.
50. Payer Name 1 letter and text Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
Source Payment Codes
B Workmen's Compensation
C Medicare
D Health First Colorado
E Other Federal Program
F Insurance Company
G Blue Cross, including Federal Employee Program
H Other - Inpatient (Part B Only)
I Other
Line A Primary Payer
Line B Secondary Payer
Line C Tertiary Payer
51. Health Plan ID 8 digits Required
Enter the provider's Health Plan ID for each payer name. Enter the eight-digit Health First Colorado
Program provider number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information None  
53. Assignment of Benefits None  
54. Prior Payments Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
57. Other Provider ID   Submitted information is not entered into the claim processing system.
58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control Number   Conditional
65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier   Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0   ICD-10-CM (DOS 10/1/15 and after)
9   ICD-10-CM (DOS 9/30/15 and before)
67. Principal Diagnosis Code Up to 6 digits Required
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
Use diagnosis code
Z00.00-10
Z00.110-Z00.111
Z00.121-Z00.129
Z00.6-Z00.8
Z02.0-Z02.6
Z02.81-Z02.89
Z76.2 for EPSDT screenings.
67A. – 67Q. – Other Diagnosis 6 digits Optional
Enter the exact diagnosis code corresponding to additional conditions that co exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
69. Admitting Diagnosis Code 6 digits Not required
70. Patient Reason Diagnosis   Submitted information is not entered into the claim processing system.
71. PPS Code   Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code) 6 digits Required if known
Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Conditional
Enter the procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format.
Apply the following criteria to determine the principle procedure:
  • The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment.
  • The principal procedure is most related to the primary diagnosis.
74A. Other Procedure Code/Date 7 characters and 6 digits Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.
76. Attending NPI – Required





Attending Last/First Name
NPI – 10 digits






Text
Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL – Enter "1D" for Medicaid
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI   Submitted information is not entered into the claim processing system.
78 – 79. Other ID





NPI – Conditional
NPI – 10 digits Conditional
Complete when attending physician is not the PCP or to identify additional physicians.
NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. The Health First Colorado does not require that the PCP number appear more than once on each claim submitted.
The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code – QUAL/CODE/VALUE (a-d) Qualifier: 2 digits
Taxonomy Code: 10 digits
Optional
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier “B3” for the taxonomy code to be captured in the claims processing system. If “B3” is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of “B3” and taxonomy code will be captured in the claims processing system.

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UB-04 Outpatient Claim Example

example of IHS Outpatient claim on UB_04

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UB-04 Inpatient Claim Example

example of IHS outpatient claim on UB-04

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UB-04 Behavioral Health Claim Example

example of UB-04 Behavioral Health Claim

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CMS 1500 Professional Claim Example

Example of CMS 1500 Professional Claim for IHS

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Sterilizations, Hysterectomies, and Abortions

For information on this topic, please see the Sterilization, Hysterectomies, and Abortions section in the Obstetrical and Reproductive Health Billing manual located on the Department’s billing manual web page, under CMS 1500 > Obstetrical Care.

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual located on the Department’s billing manual web page.

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IHS Revisions Log

Revision Date Changes Made by
08/07/2018 Manual created Department
04/22/2019 Updated inpatient revenue code Department
06/19/2019 Updated Appendices links and verbiage DXC
10/02/2019 Updated Procedure Code/HCPCS Department
12/02/2019 Converted to web page Department
8/7/2020 Updated item 81 of the Paper Claim Reference Table for taxonomy code billing DXC
10/7/2020 Changes made to Procedure Code Requirements Department

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