Charges Data Field Descriptions for Form and Label Templates

Data Repository lists data fields for Charges and data fields for sub category, Diagnosis.

• Chrg 1 Deductible
• Chrg 2 Deductible
• Chrg 3 Deductible
• Chrg 4 Deductible
• Chrg 5 Deductible
• Chrg 6 Deductible
• Chrg1 Additional Provider
• Chrg1 Additional Provider Address 1
• Chrg1 Additional Provider Address 2
• Chrg1 Additional Provider City
• Chrg1 Additional Provider City, State Zip
• Chrg1 Additional Provider State
• Chrg1 Additional Provider Zip
• Chrg1 Adjustments
• Chrg1 Allowed Amounts
• *Chrg1 Amount
• *Chrg1 Amount ($$$$ cc)
• Chrg1 Cpt4 Code
• Chrg1 Cpt4 Description
• *Chrg1 Date of Service
• *Chrg1 Date of Service(mmddyy)
• Chrg1 Diagnosis Code
• Chrg1 Diagnosis Desc
• Chrg1 End Date of Service
• Chrg1 Line Notes
• Chrg1 Location Zip
• Chrg1 Modifier 1
• Chrg1 Modifier 2
• Chrg1 Modifier 3
• Chrg2 Narrative
• Chrg1 Occurrence Code
• Chrg1 Payments
• Chrg1 Place of Service
• Chrg1 Quantity
• Chrg1 Revenue Description
• Chrg1 Service Item
• Chrg1 Service Item Description
• Chrg1 Total Tax Amount
• Chrg1 UD1 Amount
• Chrg1 UD2 Amount
• Chrg1 Value Code
• Chrg2 Additional Provider
• Chrg2 Additional Provider Address1
• Chrg2 Additional Provider Address2
• Chrg2 Additional Provider City
• Chrg2 Additional Provider City, State Zip
• Chrg2 Additional Provider State
• Chrg2 Additional Provider Zip
• Chrg2 Adjustments
• Chrg2 Allowed Amounts
• *Chrg2 Amount
• *Chrg2 Amount ($$$$ cc)
• Chrg2 Cpt4 Code
• Chrg2 Cpt4 Description
• *Chrg2 Date of Service
• *Chrg2 Date of Service(mmddyy)
• Chrg2 Diagnosis Code
• Chrg2 Diagnosis Desc
• Chrg2 End Date of Service
• Chrg2 Line Notes
• Chrg2 Location Zip
• Chrg2 Modifier 1
• Chrg2 Modifier 2
• Chrg2 Modifier 3
• Chrg2 Narrative
• Chrg2 Occurrence Code
• Chrg2 Payments
• Chrg2 Place of Service
• Chrg2 Quantity
• Chrg2 Revenue Description
• Chrg2 Service Item
• Chrg2 Service Item Description
• Chrg2 Total Tax Amount
• Chrg2 UD1 Amount
• Chrg2 UD2 Amount
• Chrg2 Value Code
• Chrg3 Additional Provider
• Chrg3 Additional Provider Address1
• Chrg3 Additional Provider Address2
• Chrg3 Additional Provider City
• Chrg3 Additional Provider City, State Zip
• Chrg3 Additional Provider State
• Chrg3 Additional Provider Zip
• Chrg3 Adjustments
• Chrg3 Allowed Amounts
• *Chrg3 Amount
• *Chrg3 Amount ($$$$ cc)
• Chrg3 Cpt4 Code
• Chrg3 Cpt4 Description
• *Chrg3 Date of Service
• *Chrg3 Date of Service(mmddyy)
• Chrg3 Diagnosis Code
• Chrg3 Diagnosis Desc
• Chrg3 End Date of Service
• Chrg3 Line Notes
• Chrg3 Location Zip
• Chrg3 Modifier 1
• Chrg3 Modifier 2
• Chrg3 Modifier 3
• Chrg3 Narrative
• Chrg3 Occurrence Code
• Chrg3 Payments
• Chrg3 Place of Service
• Chrg3 Quantity
• Chrg3 Revenue Description
• Chrg3 Service Item
• Chrg3 Service Item Description
• Chrg3 Total Tax Amount
• Chrg3 UD1 Amount
• Chrg3 UD2 Amount
• Chrg3 Value Code
• Chrg4 Additional Provider
• Chrg4 Additional Provider Address1
• Chrg4 Additional Provider Address2
• Chrg4 Additional Provider City
• Chrg4 Additional Provider City, State Zip
• Chrg4 Additional Provider State
• Chrg4 Additional Provider Zip
• Chrg4 Adjustments
• Chrg4 Allowed Amounts
• *Chrg4 Amount
• *Chrg4 Amount ($$$$ cc)
• Chrg4 Cpt4 Code
• Chrg4 Cpt4 Description
• *Chrg4 Date of Service
• *Chrg4 Date of Service(mmddyy)
• Chrg4 Diagnosis Code
• Chrg4 Diagnosis Desc
• Chrg4 End Date of Service
• Chrg4 Line Notes
• Chrg4 Location Zip
• Chrg4 Modifier 1
• Chrg4 Modifier 2
• Chrg4 Modifier 3
• Chrg4 Narrative
• Chrg4 Occurrence Code
• Chrg4 Payments
• Chrg4 Place of Service
• Chrg4 Quantity
• Chrg4 Revenue Description
• Chrg4 Service Item
• Chrg4 Service Item Description
• Chrg4 Total Tax Amount
• Chrg4 UD1 Amount
• Chrg4 UD2 Amount
• Chrg4 Value Code
• Chrg5 Additional Provider
• Chrg5 Additional Provider Address1
• Chrg5 Additional Provider Address2
• Chrg5 Additional Provider City
• Chrg5 Additional Provider City, State Zip
• Chrg5 Additional Provider State
• Chrg5 Additional Provider Zip
• Chrg5 Adjustments
• Chrg5 Allowed Amounts
• *Chrg5 Amount
• *Chrg5 Amount ($$$$ cc)
• Chrg5 Cpt4 Code
• Chrg5 Cpt4 Description
• *Chrg5 Date of Service
• *Chrg5 Date of Service(mmddyy)
• Chrg5 Diagnosis Code
• Chrg5 Diagnosis Desc
• Chrg5 End Date of Service
• Chrg5 Line Notes
• Chrg5 Location Zip
• Chrg5 Modifier 1
• Chrg5 Modifier 2
• Chrg5 Modifier 3
• Chrg5 Narrative
• Chrg5 Occurrence Code
• Chrg5 Payments
• Chrg5 Place of Service
• Chrg5 Quantity
• Chrg5 Revenue Description
• Chrg5 Service Item
• Chrg5 Service Item Description
• Chrg5 Total Tax Amount
• Chrg5 UD1 Amount
• Chrg5 UD2 Amount
• Chrg5 Value Code
• Chrg6 Additional Provider
• Chrg6 Additional Provider Address1
• Chrg6 Additional Provider Address2
• Chrg6 Additional Provider City
• Chrg6 Additional Provider City, State Zip
• Chrg6 Additional Provider State
• Chrg6 Additional Provider Zip
• Chrg6 Adjustments
• Chrg6 Allowed Amounts
• *Chrg6 Amount
• *Chrg6 Amount ($$$$ cc)
• Chrg6 Cpt4 Code
• Chrg6 Cpt4 Description
• *Chrg6 Date of Service
• *Chrg6 Date of Service(mmddyy)
• Chrg6 Diagnosis Code
• Chrg6 Diagnosis Desc
• Chrg6 End Date of Service
• Chrg6 Line Notes
• Chrg6 Location Zip
• Chrg6 Modifier 1
• Chrg6 Modifier 2
• Chrg6 Modifier 3
• Chrg6 Narrative
• Chrg6 Occurrence Code
• Chrg6 Payments
• Chrg6 Place of Service
• Chrg6 Quantity
• Chrg6 Revenue Description
• Chrg6 Service Item
• Chrg6 Service Item Description
• Chrg6 Total Tax Amount
• Chrg6 UD1 Amount
• Chrg6 UD2 Amount
• Chrg6 Value Code
• Diag1 Code
• Diag1 Description
• Diag2 Code
• Diag2 Description
• Diag3 Code
• Diag3 Description
• Diag4 Code
• Diag4 Description