Due to the size of
Figure 12.P-1, please go to
the next page.
This is an example of what a RAP might look
like if other line item data had to be added because your software
required a total charge greater than zero on the CMS 1450 UB-04.
The system will look only at the HIPPS code information in order
to generate payment. Remember that you will also need to enter this
line item data on the claim. That is, in this example, your claim
would also contain the charge for the Skilled Nursing visit on October
1, 2000.