UB-04 Overview Medicare Part A Provider Outreach and Education June 2007 IMPORTANT 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 Slide 2 UB-04 • Uniform bill for institutional providers. • Replaces the UB92. • Mandated May 23, 2007. Slide 3 Patient Information Form Locator 1 Billing Provider Information Slide 5 Form Locator 2 Pay-to Name and Address Slide 6 Form Locator 3 Patient Control Number/Medical Record Number Slide 7 Form Locator 4 Type of Bill (TOB) Slide 8 Form Locator 5 Federal Tax Number Slide 9 Form Locator 6 Dates of Service Slide 10 Form Locator 8 Patient’s Name Slide 11 Form Locator 9 Patient’s Address Slide 12 Form Locator 10 Patient’s Date of Birth Slide 13 Form Locator 11 Patient’s Gender Slide 14 Form Locators 12−15 Admission Date, Type and Source Slide 15 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. 5 Trauma 9 Information not available Slide 16 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 Slide 17 Form Locators 16−17 Discharge Hour and Discharge Status Slide 18 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 Slide 19 Form Locators 18−28 Condition Codes Slide 20 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 Slide 21 Form Locator 29 Accident State Slide 22 Form Locators 31−34 Occurrence Codes and Dates Slide 23 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 Slide 24 Form Locators 35−36 Occurrence Span Codes and Dates Slide 25 Occurrence Span Code Examples Code 74 76 77 Description Leave of absence Patient liability Provider liability Slide 26 Form Locator 38 Responsible Party’s Name and Address Slide 27 Form Locators 39−41 Value Codes and Amounts Slide 28 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 Slide 29 Billing Information Form Locator 42 Revenue Codes Slide 31 Form Locator 43 Revenue Code Description Slide 32 Form Locator 44 HCPCS Codes, Rates, HIPPS codes and Modifiers Slide 33 Form Locator 45 Service Dates Slide 34 Form Locator 46 Service Units Slide 35 Form Locator 47 Total Charges Slide 36 Form Locator 48 Non-Covered Charges Slide 37 Line 23 Slide 38 Payer Information Form Locator 50 Payer Name Slide 40 Form Locator 51 Health Plan Identification Number Slide 41 Form Locators 52−53 Release of Information and Assignment of Benefits Slide 42 Form Locator 54 Prior Payments Slide 43 Form Locator 55 Estimated Amount Due Slide 44 Form Locators 56−57 National Provider Identifier (NPI) and Other Provider Identifier Slide 45 Form Locator 58 Insured’s Name Slide 46 Form Locator 59 Patient’s Relationship to the Insured Slide 47 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 Slide 48 19 43 Form Locator 60 Insured’s Unique Identifier Slide 49 Form Locator 61 Insured’s Group Name Slide 50 Form Locator 62 Insured’s Group Number Slide 51 Form Locator 63 Treatment Authorization Codes Slide 52 Form Locator 64 Document Control Number (DCN) Slide 53 Form Locator 65 Employer’s Name Slide 54 Diagnosis Information Form Locator 66 Diagnosis and Procedure Code Qualifier Slide 56 Form Locator 67 Principal Diagnosis Code and Present on Admission (POA) Indicator Slide 57 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 Slide 58 Form Locator 67A−Q Other Diagnosis Codes and POA Indicator Slide 59 Form Locator 69 Admitting Diagnosis Code Slide 60 Form Locator 70 Patient’s Reason for Visit Slide 61 Form Locator 71 Prospective Payment System (PPS) Code Slide 62 Form Locator 72 External Cause of Injury (ECI) Code Slide 63 Form Locator 74 Principal and Other Procedure Codes and Dates Slide 64 Form Locator 76 Attending Provider’s Name and Identifiers Slide 65 Secondary Identifier Qualifiers Qualifier 0B 1G G2 Description State license number Provider’s UPIN number Provider’s commercial number Slide 66 Form Locator 77 Operating Physician’s Name and Identifiers Slide 67 Form Locators 78-79 Other Providers’ Names and Identifiers Slide 68 Provider Type Qualifier Codes Qualifier DN ZZ 82 Description Referring provider Other operating physician Rendering provider Slide 69 Form Locator 80 Remarks Slide 70 Form Locator 81 Healthcare Provider Taxonomy Code (HPTC) Slide 71 HPTC The Healthcare Provider Taxonomy Code (HPTC) list is available at: www.wpc-edi.com/codes/taxonomy Slide 72 UB-04 Overview Thank you for attending. email@example.com
"CMS 1450 (UB-04) - Overview"