Overview of the UB04 Sources l National Uniform

Overview of the UB-04

Sources l National Uniform Billing Committee – l www. nubc. org Centers for Medicare and Medicaid Services (CMS) – www. cms. gov/manuals l – Chapter 25 – Completing and Processing the form CMS 1450 data sets www. cms. gov/MLNProducts l Web based training courses – Uniform Billing (UB) -04 (July 2007)

Patient/Provider Information Billing Information Payer Information Diagnostic Information Additional Information

Patient/Provider Information l FL 01 l FL 02 l FL 03 a FL 03 b FL 04 l l Provider Name, Address, Phone and/or Fax number Pay-to Name, Address, Phone and/or Fax number Patient Control Number Medical Record Number Type of Bill l 4 -digit alphanumeric (example 0111)

Patient/Provider Information l l l FL 05 FL 06 FL 07 FL 08 a FL 08 b Federal Tax ID Number Statement Covers Period – From/Through Unlabeled Patient Name – ID Patient Name

Patient/Provider Information l l FL 09 a- e FL 10 FL 11 FL 12 – 16 Patient Address Patient Birth date Patient Sex Admission Date/ Hour/Type/Source/ Discharge Hour

Patient/Provider Information l FL 17 Patient Status Code 01 Discharged to home or self care (routine discharge l 02 Discharged/transferred l 20 Expired l

Patient/Provider Information l l l l FL 18 -28 FL 29 FL 30 FL 31 -34 FL 35 -36 FL 37 FL 38 FL 39 -41 Condition Codes Accident State Unlabeled Occurrence Code/Date Occurrence Span Code/From/Through Unlabeled Responsible Party Name/Address Value Codes

Billing Information l FL 42 Revenue Code – 4 -position code that identifies a specific accommodation, ancillary service or billing calculation. l l FL 43 0022 – Skilled nursing facility 0024 – Inpatient rehab facility 0124 – Psychiatric room charge Revenue Code Description

Billing Information l FL 44 Rates/HCPCS/HIPPS Rate Codes Rates – cost of the room per day l HCPCS – CPT or HCPCS codes giving details about the service l HIPPS rate codes – alphanumeric code identifying level of care/service l l l FL 45 FL 46 Service Date Unit of Service

Billing Information l l l FL 47 FL 48 FL 49 Total Charges Non-Covered Charges Unlabeled

Payer Information l FL 50 – 65 – l l Various pieces of information about what insurance may be primary and what they paid FL 56 FL 57 NPI (National Provider Identifier) Other Provider ID

Diagnostic Information l FL 66 l FL 67 Principle Diagnosis Code FL 67 A-Q Other Diagnosis l l DX (diagnosis) Version Qualifier FL 68 Unlabeled FL 69 Admitting Diagnosis Code FL 70 a-c Patient Reason for Visit Code

Diagnostic Information l l l FL 71 PPS Code FL 72 a-c External Cause of Injury Code (ECI) FL 73 Unlabeled FL 74 Principle Procedure Code/Date FL 74 a-e Other Procedure Code/Date

Additional Information l FL 75 – 81 a-d – Includes the name and ID of the attending and operating physicians, a place for remarks, as well as the code list qualifiers.

Items on UB-04 needed for the DRG Grouper l l l Diagnoses codes (FL 67 A-Q) Procedure codes (FL 74 Principle procedure and fields a-e) Discharge date(FL 6 {Through}) Discharge status (FL 17) Patient age (FL 10 {Birth date}) Patient sex (FL 11)

Items on UB-04 needed for APC l l l l l Bill type Patient age Patient sex Patient status code Revenue/HCPCS code Date of service Service units Total (billed) charge Diagnosis codes (FL 04) (FL 10 {Birth date}) (FL 11) (FL 17) (FL 42 & 44) (FL 46) (FL 47) (FL 67 & 67 A-Q)

Information for Pricers l l l Provider’s 6 -digit Medicare facility ID number, * or Select by provider name, and/or Location * List of providers and Medicare numbers is on the IHS web site

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