<div class="form-area">
  <div class="action"><a href="javascript:;"><span class="glyphicon glyphicon-trash delete_form-area" aria-hidden="true"></span></a></div>
  <div class="row">
    <div class="col-xs-4">
      <div class="form-group m_b20">
        <label>Code Type</label>
        <div class="val">
          <select name="primary[]" class="form-control code_type">
            <option value="dCodesPrimary">Dx-Primary</option>
            <option value="dCodesSecondary">Dx-Secondary</option>
            <option value="pCodesPrimary">PCS-Primary</option>
            <option value="pCodesSecondary">PCS-Secondary</option>
            <option value="cpt">CPT</option>

          </select>
        </div>
      </div>
    </div>
    <div class="col-xs-4">
      <div class="form-group m_b20">
        <label>Code</label>
        <div class="val"><input required type="text" class="form-control code" placeholder="Code" autocomplete="off" name="code[]"></div>
      <div id="suggesstion-box" class="suggesstion"></div>

      </div>
    </div>
    <div class="col-xs-4">
      <div class="form-group m_b20">
        <label>Tag</label>
        <div class="val"><input type="text" class="form-control tag" placeholder="Tag" autocomplete="off" name="tag[]"></div>
        <div id="suggesstion-tag" class="suggesstion"></div>

    </div>
  </div>
    <div class="col-sm-12">
      <div class="form-group m_b20">
        <label>Code Description</label>
        <div class="val"><textarea class="form-control description"  name="description[]"></textarea></div>
    </div>
  </div>
    <div class="col-sm-12">
      <div class="form-group m_b20">
        <label>Rationale</label>
        <div class="val"><input type="text" class="form-control rationale" placeholder="Rationale" name="relation[]"></div>
    </div>
  </div>
  </div>
</div>