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Required Information<br />
FIELD NUMBER NAME AND DESCRIPTION<br />
24C<br />
24D<br />
24D<br />
24E<br />
24E<br />
EMG (Shaded Area) School Based Providers only<br />
Enter number of students in the group on the shaded area above EMG. Valid entry is 1-6<br />
Procedures, services or Modifiers<br />
(Shaded Area)<br />
Enter EI for employee ID followed by the three digit employee ID # (School Based Providers)<br />
(Shaded Area)<br />
Enter EI for employee ID followed by the four digit employee ID # (Community Mental Health)<br />
(Shaded Area above modifier)<br />
Enter the appropriate EPSDT Referral code if applicable<br />
(Non-Shaded Area)<br />
Enter appropriate procedure code (non-shaded area)<br />
Modifier (Non-Shaded Area)<br />
Enter appropriate Modifier to identify the procedure.<br />
Diagnosis Pointer (Shaded Area)<br />
Enter Military Time of Pickup (Transportation only)<br />
Diagnosis Pointer (Non-Shaded Area)<br />
Diagnosis Code Indicator Enter 1, 2, 3, or 4<br />
Cabinet for Health and Family Services<br />
11
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