cms 1450 (ub-04) - overview
TRANSCRIPT
UB-04 Overview
Medicare Part A Provider Outreach and Education
June 2007
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The information contained in this presentation was current as of June 2007 and can be found in Change Request (CR) 5593, Pub. 100-04, Transmittal 1254, dated May 25, 2007, which can be downloaded from:
www.cms.hhs.gov/Transmittals/Downloads/R1254CP.pdf
IMPORTANT
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UB-04
• Uniform bill for institutional providers.
• Replaces the UB-92.
• Mandated May 23, 2007.
Patient Information
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Form Locator 1
Billing Provider Information
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Form Locator 2
Pay-to Name and Address
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Form Locator 3
Patient Control Number/Medical Record Number
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Form Locator 4
Type of Bill (TOB)
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Form Locator 5
Federal Tax Number
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Form Locator 6
Dates of Service
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Form Locator 8
Patient’s Name
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Form Locator 9
Patient’s Address
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Form Locator 10
Patient’s Date of Birth
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Form Locator 11
Patient’s Gender
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Form Locators 12−15
Admission Date, Type and Source
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Admission Type Examples
Code Description Definition
1 Emergency The patient requires immediate medical intervention as a result of severe, life-threatening or potentially disabling conditions.
2 Urgent The patient requires immediate attention for the care and treatment of a physical or mental disorder.
3 Elective The patient’s condition permits adequate time to schedule the services.
4 Newborn Use of this code necessitates the use of special source of admission codes (Form Locator 15).
5 Trauma
Visit to a trauma center/hospital as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. (Use revenue code 068X to capture trauma activation charges.)
9 Information not available
Information not available.
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Admission Source Examples
Code Description
1 Physician referral
2 Clinic referral
3 HMO referral
4 Transfer from a hospital
5 Transfer from a Skilled Nursing Facility (SNF)
6 Transfer from another health care facility
7 Emergency room
8 Court/law enforcement
9 Information not available
A Transfer from a Critical Access Hospital (CAH)
B Transfer from another home health agency
C Readmission to same home health agency
D Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer
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Form Locators 16−17
Discharge Hour and Discharge Status
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Discharge Status Code Examples
Code Description01 Discharged to home or self-care (routine discharge)
02 Discharged/transferred to a short-term general hospital for inpatient care
03 Discharged/transferred to an SNF with Medicare certification in anticipation of covered skilled care
05 Discharged/transferred to another type of health care institution not defined elsewhere in this code list
06 Discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care
07 Left against medical advice or discontinued care20 Expired
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Form Locators 18−28
Condition Codes
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Condition CodeExamples
Code Description02 Condition is employment-related
07 Treatment of non-terminal condition for hospice
08 Beneficiary would not provide information concerning other coverage
20 Beneficiary requested billing21 Billing for denial notice
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Form Locator 29
Accident State
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Form Locators 31−34
Occurrence Codes and Dates
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Occurrence CodeExamples
Code Description01 Auto accident04 Accident employment-related11 Onset of illness
18 Date of retirement for patient/beneficiary
24 Date insurance denied
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Form Locators 35−36
Occurrence Span Codes and Dates
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Occurrence SpanCode Examples
Code Description74 Leave of absence76 Patient liability77 Provider liability
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Form Locator 38
Responsible Party’s Name and Address
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Form Locators 39−41
Value Codes and Amounts
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Value CodeExamples
Code Description12 Working aged37 Pints of blood furnished50 Physical therapy visits
80 Covered days81 Non-covered days82 Coinsurance days83 Lifetime reserve days
53 Cardiac rehabilitation visits
Billing Information
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Form Locator 42
Revenue Codes
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Form Locator 43
Revenue Code Description
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Form Locator 44
HCPCS Codes, Rates, HIPPS codes and Modifiers
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Form Locator 45
Service Dates
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Form Locator 46
Service Units
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Form Locator 47
Total Charges
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Form Locator 48
Non-Covered Charges
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Line 23
Payer Information
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Form Locator 50
Payer Name
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Form Locator 51
Health Plan Identification Number
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Form Locators 52−53
Release of Information and Assignment of Benefits
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Form Locator 54
Prior Payments
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Form Locator 55
Estimated Amount Due
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Form Locators 56−57
National Provider Identifier (NPI) and Other Provider Identifier
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Form Locator 58
Insured’s Name
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Form Locator 59
Patient’s Relationship to the Insured
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Patient’s RelationshipCode Examples
Code Description01 Spouse18 Patient is insured19 Natural child/insured financial responsibility43 Natural child/insured does not have financial
responsibility22 Handicapped dependent
29/53 Life partner32 Mother33 Father
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Form Locator 60
Insured’s Unique Identifier
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Form Locator 61
Insured’s Group Name
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Form Locator 62
Insured’s Group Number
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Form Locator 63
Treatment Authorization Codes
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Form Locator 64
Document Control Number (DCN)
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Form Locator 65
Employer’s Name
Diagnosis Information
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Form Locator 66
Diagnosis and Procedure Code Qualifier
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Form Locator 67
Principal Diagnosis Code and Present on Admission (POA) Indicator
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POA Indicator
Indicator Description
U No information in the record
Unreported or not used Exempt from POA reporting
Y Yes
N No
W Clinically undetermined
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Form Locator 67A−Q
Other Diagnosis Codes and POA Indicator
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Form Locator 69
Admitting Diagnosis Code
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Form Locator 70
Patient’s Reason for Visit
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Form Locator 71
Prospective Payment System (PPS) Code
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Form Locator 72
External Cause of Injury (ECI) Code
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Form Locator 74
Principal and Other Procedure Codes and Dates
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Form Locator 76
Attending Provider’s Name and Identifiers
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Secondary Identifier Qualifiers
Qualifier Description0B State license number
1G Provider’s UPIN number
G2 Provider’s commercial number
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Form Locator 77
Operating Physician’s Name and Identifiers
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Form Locators 78-79
Other Providers’ Names and Identifiers
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Provider Type Qualifier Codes
Qualifier DescriptionDN Referring provider
ZZ Other operating physician
82 Rendering provider
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Form Locator 80
Remarks
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Form Locator 81
Healthcare Provider Taxonomy Code (HPTC)
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The Healthcare Provider Taxonomy Code (HPTC) list is available at:
www.wpc-edi.com/codes/taxonomy
HPTC
