[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much was the total charge, including any amounts that may be paid by health insurance or other sources?
[Do not include any services billed for separately such as physician charges or other services.] [Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the [hospital] bill [or statement].]
IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[SELECT ?INCLUDED WITH OTHER CHARGES? IF THIS IS A FLAT FEE SITUATION.]

AMOUNT ................................. 1 [CP09OV]
INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)................................. 95
[Code One]
HELP AVAILABLE FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY ?Do not include any services billed for billed for separately such as physician charges or other services.? IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ?Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the [hospital] bill [or statement]?. IF CP05 IS CODED ?1? (YES, AND DOCUMENTATION AVAILABLE) AND EVENT TYPE IS NOT PM. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ?hospital? IF EVENT TYPE IS HS, ER, OR OP.OTHERWISE, USE A NULL DISPLAY. DISPLAY ?or statement? IF EVENT TYPE IS MV, DN, OM, HH OR EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY INTERVIEWER INSTRUCTION ?SELECT ?INCLUDED WITH OTHER CHARGES? IF THIS IS A FLAT FEE SITUATION? IF EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY ?GLASSES OR CONTACT LENSES? IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS ?1? (GLASSES OR CONTACT LENSES).
DISPLAY ?AMBULANCE SERVICES? IF THE OM ITEM GROUP IS ?4? (AMBULANCE SERVICES).
DISPLAY ?ORTHOPEDIC ITEMS? IF THE OM ITEM GROUP IS ?5? (ORTHOPEDIC ITEMS).
DISPLAY ?HEARING DEVICES? IF THE OM ITEM GROUP IS ?6? (HEARING DEVICES).
DISPLAY ?PROSTHESES? IF THE OM ITEM GROUP IS ?7? (PROSTHESES).
DISPLAY ?BATHROOM AIDS? IF THE OM ITEM GROUP IS ?8? (BATHROOM AIDS).
DISPLAY ?MEDICAL EQUIPMENT? IF THE OM ITEM GROUP IS ?9? (MEDICAL EQUIPMENT).
DISPLAY ?DISPOSABLE SUPPLIES? IF THE OM ITEM GROUP IS ?10? (DISPOSABLE SUPPLIES).
DISPLAY ?ALTERATIONS OR MODIFICATIONS? IF THE OM ITEM GROUP IS ?11? (ALTERATIONS/MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS ?91? (OTHER).
FOR ?TEXT FROM OTHER SPECIFY?, DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------
----------------------------------------------------
IF ?INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)? DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT.'
----------------------------------------------------
----------------------------------------------------
IF ?INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)? IS SELECTED AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP.'
----------------------------------------------------
----------------------------------------------------
IF ?INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)? IS SELECTED AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEATVISIT GROUP.'
----------------------------------------------------
----------------------------------------------------
IF ?INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)? IS SELECTED AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------