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CMS 1450 (UB-04) - Overview

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									UB-04 Overview

Medicare Part A Provider Outreach and Education

June 2007

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:

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• Uniform bill for institutional providers. • Replaces the UB92. • Mandated May 23, 2007.

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Patient Information

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 1 2 3 4 Description Emergency Urgent Elective Newborn Definition The patient requires immediate medical intervention as a result of severe, life-threatening or potentially disabling conditions. The patient requires immediate attention for the care and treatment of a physical or mental disorder. The patient’s condition permits adequate time to schedule the services. Use of this code necessitates the use of special source of admission codes (Form Locator 15). 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.) Information not available.




Information not available

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Admission Source Examples
Code 1 2 3 4 5 6 7 8 9 A B C D Physician referral Clinic referral HMO referral Transfer from a hospital Transfer from a Skilled Nursing Facility (SNF) Transfer from another health care facility Emergency room Court/law enforcement Information not available Transfer from a Critical Access Hospital (CAH) Transfer from another home health agency Readmission to same home health agency Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer Description

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Form Locators 16−17
Discharge Hour and Discharge Status

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Discharge Status Code Examples
Code 01 02 03 05 06 07 20 Description Discharged to home or self-care (routine discharge) Discharged/transferred to a short-term general hospital for inpatient care Discharged/transferred to an SNF with Medicare certification in anticipation of covered skilled care Discharged/transferred to another type of health care institution not defined elsewhere in this code list Discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care Left against medical advice or discontinued care Expired

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Form Locators 18−28
Condition Codes

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Condition Code Examples
Code 02 07 08 20 21 Description Condition is employment-related Treatment of non-terminal condition for hospice Beneficiary would not provide information concerning other coverage Beneficiary requested billing 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 Code Examples
Code 01 04 11 18 24 Description Auto accident Accident employment-related Onset of illness Date of retirement for patient/beneficiary Date insurance denied

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Form Locators 35−36
Occurrence Span Codes and Dates

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Occurrence Span Code Examples
Code 74 76 77 Description Leave of absence Patient liability 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 Code Examples
Code 12 37 50 53 80 81 82 83 Description Working aged Pints of blood furnished Physical therapy visits Cardiac rehabilitation visits Covered days Non-covered days Coinsurance days Lifetime reserve days
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Billing Information

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

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Payer Information

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 Relationship Code Examples
Code Description 01 Spouse 18 Patient is insured Natural child/insured financial responsibility Natural child/insured does not have financial responsibility 22 Handicapped dependent 29/53 Life partner 32 Mother 33 Father
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19 43

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

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Diagnosis Information

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 Y N W U Yes No Clinically undetermined No information in the record Description

Unreported or not used Exempt from POA reporting

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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 0B 1G G2 Description State license number Provider’s UPIN number 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 DN ZZ 82 Description Referring provider Other operating physician Rendering provider

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Form Locator 80

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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:

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UB-04 Overview
Thank you for attending.

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