Washington University School of Medicine

Washington University School of Medicine

PBS Information Systems

GE Dictionary Form

Form Name: BAR 100 Locations Dictionary Form

Revision Date:

Requested By: / Departmental Support Review:
Requestor Phone #:
Today's Date: / Date Reviewed:
Date Needed:
ADD _____ / EDIT _____ / DEACTIVATE _____

* is a required field

1 *NAME:
1A BUILDING NAME:
1B FLOOR, SUITE OR ROOM NUMBER:
1C BUILDING ADDRESS:
1D IS THIS LOCATION SHARED WITH ANOTHER DEPARTMENT?:
IF YES, WHAT DEPARTMENT(S)?:
IE OTHER INFORMATION ABOUT THIS LOCATION:
1F IF ILLNOIS LOCATION – ADD LOCATION TO FSC DEFAULT TABLE FOR IL MEDICARE:
2 MMNEMONIC:
3 NUMBER:
4 CORR LOCATION ON BS:
5 CORR LOCATION ON MCR FORM:
6 CORR LOCATION ON WELFARE FORM:
7 CORR LOCATION FOR HIC:
8 TYPE OF LOCATION:
11 WELFARE BILLING #:
13 MEDICARE BILLING 3:
18 IS THIS LOCATION INPT?:
23 REPORTING CATEGORY #1:
24 REPORTING CATEGORY #2:
25 REPORTING CATEGORY #3:
49 CORR LOCATION ON IDPA FORM:
50 CORR HOSPITAL:
51 CLIA #:
If CLIA number required for billing, enter a “Y” in field 76, CLIA Number Required
54 MCRE CPIN #:
55 MCRE 2ND LOCATION:
56 CORR COMM LAB:
57 DME MEDICARE POS:
58 HMO REFERRAL NOT NEEDED:
59 IDPA OUTPT EM POS:
60 PARTNERS LAB CAP LOC:
61 OB ULTRASOUND LOC:
62 OB ULTRASOUND LOC ADDR1:
63 OB ULTRASOUND LOC ADDR2:
64 OB ULTRASOUND LOC CITY, ST:
65 OB ULTRASOUND LOC ZIP:
66 OB ULTRASOUND LOCATION NAME:
67 TES PRUDENTIAL MC+ REF NOT NEEDED:
68 TES HMO RAD ONC REF NEEDED:
69 CHAMPUS POS:
70 IL OFFICE NAME:
71 IL OFFICE ADDRESS LINE 1:
72 IL OFFICE ADDRESS LINE 2:
73 IL OFFICE CITY, STATE:
74 IL OFFICE ADDRESS ZIPCODE:
75 RR MEDICARE NUMBER:
76 CLIA NUMBER REQUIRED?:
77 ILLINOIS LOCATION:
78 OB CLIA #:
79 CARE PARTNERS CAP LOCATION:
80 MEDICARE SUBMITTER ID:
81 DESCRIPTION FOR STATEMENT:
86 BOX 32 ADDR 1:
87 BOX 32 CITY, ST:
88 BOX 32 ZIP CODE+4:
89 TRICARE SUFFIX:
100 HIPAA PLACE OF SERVICE CODE:
135 NPI NUMBER (DME ONLY):
144 SCHED LOC RPT CAT#1:
145 SCHED LOC RPT CAT#2:
146 SCHED LOC RPT CAT#3:
ETM FIELDS
125 ETM ROLE:
(LOC:OFFICE OR LOC:HOSP)
126 ETM IM OFFICE REGISTRATION ROUTE TO CENT:
127 ETM IM OFFICE AUTHORIZATION ROUTE TO HUB:
130 ETM IM FUP GROUPING:
131 ETM (IM) PBS IM FUP GRP BY:
140 ETM SU/OB MTC CATEGORY FOR GROUP BY:

Does the FSC default table need to be updated? Yes____ No____

Both Groups? 3______4______

What is the FSC default based on and what should the default FSC be?

FOR INFORMATION SYSTEMS USE ONLY:
Entered by: / Notification Sent:
Date entered:

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