ID

25573

Description

Muster 5 - Abrechnungsschein ambulante Behandlung, belegärztliche Behandlung, Abklärung somatischer Ursachen vor Aufnahme einer Psychotherapie, anerkannte Psychotherapie (Freigabe: 01.09.2014) - 10.2014, Formulare für die vertragsärztliche Versorgung Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php Forms for contract medical care Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

Link

www.kbv.de

Keywords

Versions (2)
  1. 9/7/16 9/7/16 -
  2. 9/6/17 9/6/17 -
Copyright Holder

KBV

Uploaded on

September 6, 2017

DOI

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License

Creative Commons BY-NC 3.0
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KBV Billing documentation Template 5

German

KBV Billing documentation Template 5

1 forms  
Briefkopf
Description

Briefkopf

Krankenkasse bzw. Kostenträger
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1]
C0021682
Name, Vorname des Versicherten
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Adresse des Versicherten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
geb. am
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451
Kostenträgerkennung
Description

Insurance Company ID

Data type

integer

Alias
UMLS CUI [1]
C1547687
Versicherten-Nr.
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1]
C1549712
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1]
C0449438
Betriebsstätten-Nr.
Description

Facility ID

Data type

integer

Alias
UMLS CUI [1]
C1549700
Arzt-Nr.
Description

Physician ID

Data type

integer

Alias
UMLS CUI [1]
C1548646
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Abrechnungsschein
Description

Abrechnungsschein

Abrechnungsgrund
Description

Reason for billing

Data type

integer

Alias
UMLS CUI [1,1]
C1611700
UMLS CUI [1,2]
C0566251
Quartal
Description

1-4/JJ

Data type

text

Alias
UMLS CUI [1]
C2825406
Geschlecht
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
Diagnosen / ggf. Abrechnungsbegründungen
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Bei Psychotherapie: Datum des Anerkennungsbescheides
Description

Date of approval for psychotherapy

Data type

date

Alias
UMLS CUI [1,1]
C2346844
UMLS CUI [1,2]
C0033968
Leistungsziffern nach Datum
Description

Leistungsziffern nach Datum

Tag Monat
Description

Day and month of patient visit

Data type

partialDate

Alias
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0011008
Leistungsziffer nach EBM
Description

Service type code

Data type

integer

Alias
UMLS CUI [1]
C2986279
Mutmaßlicher Tag der Entbindung
Description

Estimated date of delivery

Data type

date

Alias
UMLS CUI [1]
C1287845
Stationäre belegärztliche Behandlung
Description

Inpatient treatment by affiliated doctor

Data type

boolean

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C1510825
Stationäre belegärztliche Behandlung von (tt:mm)
Description

Inpatient treatment by affiliated doctor start date

Data type

partialDate

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C1510825
UMLS CUI [1,3]
C0808070
Stationäre belegärztliche Behandlung bis (tt:mm)
Description

Inpatient treatment by affiliated doctor end date

Data type

partialDate

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C1510825
UMLS CUI [1,3]
C0806020
Ich bin bei der oben genannten Krankenkasse versichert
Description

Patient confirmation of insurance

Data type

boolean

Alias
UMLS CUI [1,1]
C0521091
UMLS CUI [1,2]
C0021682
Datum der Versicherungsbestätigung
Description

Date of confirmation

Data type

date

Alias
UMLS CUI [1]
C0011008
Unterschrift des Versicherten
Description

Patient signature

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C0030705
Brieffuß
Description

Brieffuß

Stempel des Vertragsarztes/Therapeuten
Description

Physician Stamp and signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

KBV Billing documentation Template 5

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Briefkopf
Health Insurance name
Item
Krankenkasse bzw. Kostenträger
text
C0021682 (UMLS CUI [1])
Patient Name
Item
Name, Vorname des Versicherten
text
C1299487 (UMLS CUI [1])
Patient address
Item
Adresse des Versicherten
text
C0421449 (UMLS CUI [1])
Patient Birth Date
Item
geb. am
date
C0421451 (UMLS CUI [1])
Insurance Company ID
Item
Kostenträgerkennung
integer
C1547687 (UMLS CUI [1])
Insurance number
Item
Versicherten-Nr.
integer
C1549712 (UMLS CUI [1])
Status
Item
Status
integer
C0449438 (UMLS CUI [1])
Facility ID
Item
Betriebsstätten-Nr.
integer
C1549700 (UMLS CUI [1])
Physician ID
Item
Arzt-Nr.
integer
C1548646 (UMLS CUI [1])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Item Group
Abrechnungsschein
Item
Abrechnungsgrund
integer
C1611700 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Reason for billing
Code List
Abrechnungsgrund
CL Item
Ambulante Behandlung (1)
CL Item
Bei belegärztlicher Behandlung (2)
CL Item
Unfall/Unfallfolgen (3)
CL Item
Abklärung somatischer Ursachen vor Aufnahme einer Psychotherapie (4)
CL Item
Anerkannte Psychotherapie (5)
Quarter
Item
Quartal
text
C2825406 (UMLS CUI [1])
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
Gender
Code List
Geschlecht
CL Item
W (W)
CL Item
M (M)
Diagnosis
Item
Diagnosen / ggf. Abrechnungsbegründungen
text
C0011900 (UMLS CUI [1])
Date of approval for psychotherapy
Item
Bei Psychotherapie: Datum des Anerkennungsbescheides
date
C2346844 (UMLS CUI [1,1])
C0033968 (UMLS CUI [1,2])
Item Group
Leistungsziffern nach Datum
Day and month of patient visit
Item
Tag Monat
partialDate
C1512346 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Service type code
Item
Leistungsziffer nach EBM
integer
C2986279 (UMLS CUI [1])
Estimated date of delivery
Item
Mutmaßlicher Tag der Entbindung
date
C1287845 (UMLS CUI [1])
Inpatient treatment by affiliated doctor
Item
Stationäre belegärztliche Behandlung
boolean
C0019993 (UMLS CUI [1,1])
C1510825 (UMLS CUI [1,2])
Inpatient treatment by affiliated doctor start date
Item
Stationäre belegärztliche Behandlung von (tt:mm)
partialDate
C0019993 (UMLS CUI [1,1])
C1510825 (UMLS CUI [1,2])
C0808070 (UMLS CUI [1,3])
Inpatient treatment by affiliated doctor end date
Item
Stationäre belegärztliche Behandlung bis (tt:mm)
partialDate
C0019993 (UMLS CUI [1,1])
C1510825 (UMLS CUI [1,2])
C0806020 (UMLS CUI [1,3])
Patient confirmation of insurance
Item
Ich bin bei der oben genannten Krankenkasse versichert
boolean
C0521091 (UMLS CUI [1,1])
C0021682 (UMLS CUI [1,2])
Date of confirmation
Item
Datum der Versicherungsbestätigung
date
C0011008 (UMLS CUI [1])
Patient signature
Item
Unterschrift des Versicherten
text
C1519316 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
Item Group
Brieffuß
Physician Stamp and signature
Item
Stempel des Vertragsarztes/Therapeuten
text
C1519316 (UMLS CUI [1])
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