Download Official UB-04 Data Specifications Manual Official UB-04

National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
Official UB-04
Data Specifications Manual
2007
Version 1.00
September 2006
© Copyright 2006 AHA. All rights reserved.
Copyright for the members of the National Uniform Billing Committee (NUBC)
by the American Hospital Association (AHA).
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
Table of Contents
Introduction
Form Locators
FL 01 - Billing Provider Name, Address and Telephone Number
FL 02 - Pay-to Name and Address
FL 03a - Patient Control Number
FL 03b - Medical/Health Record Number
FL 04 - Type of Bill
FL 05 - Federal Tax Number
FL 06 - Statement Covers Period
FL 07 - Reserved for Assignment by the NUBC
FL 08 - Patient Name/Identifier
FL 09 - Patient Address
FL 10 - Patient Birth Date
FL 11 - Patient Sex
FL 12 - Admission/Start of Care Date
FL 13 - Admission Hour
FL 14 - Priority (Type) of Visit
FL 15 - Source of Referral for Admission or Visit
FL 16 - Discharge Hour
FL 17 - Patient Discharge Status
FL 18-28 - Condition Codes
FL 29 - Accident State
FL 30 - Reserved for Assignment by the NUBC
FL 31-34 - Occurrence Codes and Dates
FL 35-36 - Occurrence Span Codes and Dates
FL 37 - Reserved for Assignment by the NUBC
FL 38 - Responsible Party Name and Address
FL 39-41 - Value Codes and Amounts
FL 42 - Revenue Codes
FL 43 - Revenue Description
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes
FL 45 - Service Date
FL 46 - Service Units
FL 47 - Total Charges
FL 48 - Non-covered Charges
FL 49 - Reserved for Assignment by the NUBC
FL 50 - Payer Name
FL 51 - Health Plan Identification Number
FL 52 - Release of Information Certification Indicator
FL 53 - Assignment of Benefits Certification Indicator
FL 54 - Prior Payments - Payer
FL 55 - Estimated Amount Due - Payer
FL 56 - National Provider Identifier - Billing Provider
FL 57- Other (Billing) Provider Identifier
FL 58 - Insured’s Name
FL 59 - Patient’s Relationship to Insured
FL 60 - Insured’s Unique Identifier
FL 61 - Insured’s Group Name
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4
6
8
9
10
11
20
21
22
23
25
26
27
28
29
30
31
35
36
48
61
62
63
71
74
75
76
93
152
153
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
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National Uniform Billing Committee
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Table of Contents
Page 2 of 2
Form Locators
FL 62 - Insured’s Group Number
FL 63 - Treatment Authorization Code
FL 64 - Document Control Number (DCN)
FL 65 - Employer Name (of the Insured)
FL 66 - Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
FL 67 - Principal Diagnosis Code and Present on Admission Indicator
FL 67A-Q - Other Diagnosis Codes
FL 68 - Reserved for Assignment by the NUBC
FL 69 - Admitting Diagnosis Code
FL 70a-c - Patient’s Reason for Visit
FL 71 - Prospective Payment System (PPS) Code
FL 72a-c - External Cause of Injury (ECI) Code
FL 73 - Reserved for Assignment by the NUBC
FL 74 - Principal Procedure Code and Date
FL 74a-e - Other Procedure Codes and Dates
FL 75 - Reserved for Assignment by the NUBC
FL 76 - Attending Provider Name and Identifiers
FL 77 - Operating Physician Name and Identifiers
FL 78-79 - Other Provider Name and Identifiers
FL 80 - Remarks Field
FL 81 - Code-Code Field
172
173
174
175
176
177
180
181
182
183
184
185
186
187
188
189
190
192
194
196
197
State Guidelines
Florida
South Carolina
203
209
Appendix
UB-92 to UB-04 Crosswalk
UB-04 Mapping to 837 Claim Transaction
Change Log
UB-04 Form (front)
Back of UB-04 Form (For Informational Purposes Only -- No Fonts Imbedded)
UB-04/CMS-1450 Printing Specifications
216
224
240
242
243
244
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National Uniform Billing Committee
The UB-04 Manual
Official UB-04 Data Specifications Manual 2007
Page 1 of 2
Introduction
The uniform bill for institutional providers is known as the UB-04 and was approved by the National
Uniform Billing Committee (NUBC) at its February 2005 meeting. The UB-04 is the replacement for
the UB-92 form and represents the culmination of a four-year study that involved numerous public
surveys and discussions at various NUBC meetings. The members of the NUBC mutually agreed to the
data elements for inclusion to the UB-04 Manual and the layout of the UB-04 form. Many of the data
elements referenced in the UB-04 Manual are also used in the electronic claim standard as called upon
by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Consequently, there was
additional emphasis placed on aligning the reporting instructions to closely mirror the HIPAA claim
standard for institutional providers. Other HIPAA changes included adding forthcoming national
identifiers for providers and health plans.
In addition to aligning the UB-04 to the electronic standard, the NUBC recognized the changing need
for information and its importance with respect to health services research and health policy
development. As a result, the NUBC introduced several new data elements to the UB-04 to further
improve the understanding of health care services. Most of the UB-04, however, is conceptually similar
to earlier versions -- the UB-92 and UB-82. (The numeric suffix (i.e., 82, 92, and 04) references the
year in which the NUBC approved the adoption of the data set.)
Transitioning to the UB-04
Receivers (health plans and clearinghouses) need to be ready to receive the new UB-04 by March 1,
2007. Submitters (health care providers such as hospitals, skilled nursing facilities, hospice, and other
institutional claim filers) may use the UB-04 beginning March 1, 2007; however, there is a transitional
period between March 1, 2007 and May 22, 2007 where either the UB-04 or the UB-92 may be used.
Starting May 23, 2007 all institutional paper claims must use the UB-04; the UB-92 will no longer be
acceptable after this date.
Guide to the UB-04 Manual
This UB-04 Manual is the Official source for UB-04 information adopted by the NUBC. It has been
created as an Adobe Portable Document File (PDF) that allows users to print or view the file from their
computer. It is organized by the corresponding boxes or “Form Locators” on the paper UB-04. The
PDF includes bookmarks that allow the user to quickly find various sections indexed either by form
locator number or by data element description. The manual also includes a crosswalk to help users
understand the changes from the UB-92 to the UB-04 and the print specifications of the paper form.
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Page 2 of 2
The first page of each Form Locator contains the data element name, a brief definition, and the
reporting requirements for the data element for submission in either paper or electronic format. Also
included are the field attributes for each data element, i.e., alphanumeric/numeric characteristics,
left/right justification and the number of lines, subfields and positions available on the paper form.
Finally, on some pages you will find usage notes that further explain or elaborate on the reporting of
information. There are some form locators that have specific codes along with a narrative description
of the code. Codes are listed in numeric order followed by alpha order. “Reserved” (unassigned)
codes are not to be used; only the NUBC members will determine when they should be approved for a
particular purpose.
The UB-04 Manual also contains a section established for State Guidelines. This section is intended to
elaborate on the special reporting requirements established by the state billing committee for the
purpose of reporting to state data gathering agencies or for reporting to worker’s compensation
programs. This section should not be used for establishing different or unique billing requirements at
the state level; it is intended solely for reporting not covered under the HIPAA legislative provisions.
Updates
The first (2007) edition of the UB-04 Manual is v. 1.00. Errata, information on new codes,
clarifications, and other guidance will be posted periodically to the subscribers section of the NUBC
website (http://www.nubc.org/). New State Guidelines will also be posted to the website as they
become available.
A new release of the UB-04 manual will occur each year along with a change log indicating the changes
made during the course of the year. New UB-04 codes will be implemented according to an annual
update cycle each July 1. All newly approved codes, including emergency (off-cycle) changes, together
with their respective effective dates, will be available to UB-04 subscribers. Version 2.00 (2008) is
scheduled for release July 1, 2007.
UB-04 Mapping to the 837 Claim Transaction
The UB-04 to 837 (004010X096/004010X096A1) map has been significantly enhanced for v. 1.00; all
fields, subfields and lines have been detail mapped to the 837 with more specific X12 qualifier
references. Although every effort has been made to properly identify the corresponding 837 data
segment and element, the user should verify the corresponding reference.
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Official UB-04 Data Specifications Manual 2007
Effective Date: March 1, 2007
Meeting Date:
Data
Element
Billing Provider Name, Address and Telephone Number
Definition:
The name and service location of the provider submitting the bill.
Reporting
Name and Address
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Form Locator 01
Page 1 of 2
Telephone
• UB-04: Required.
• 004010/004010A1: Situational. Required when this information is different than
that contained in the Submitter PER segment (Loop ID-1000A).
• 005010: Situational. Required when this information is different than that
contained in the Submitter PER segment (Loop ID-1000A).
Country Code
• UB-04: Situational. Required when the address is outside the United States of
America.
• 004010/004010A1: Situational. Required when the address is outside of the U.S.
• 005010: Situational. Required when the address is outside the United States of
America.
Field
Attributes
1 Field
4 lines
25 Positions
Alphanumeric
Left-justified
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Effective Date: March 1, 2007
Meeting Date:
Notes
Form Locator 01
Page 2 of 2
The Billing Provider Address must be a street address. Post Office Box or Lock Box
addresses are to be sent in the Pay-To Address field of Form Locator 02, if necessary.
Form Locator 01 uses the full nine-digit ZIP.
Enter the information provided in Form Locator 1 on the appropriate line:
Line 1 - Provider Name
Line 2 - Street Address
Line 3 - City (Positions 1-12, Left-justified), State (Positions 14-15), and ZIP Code
(Positions 17-25)
Line 4 - Telephone (Positions 1-10); Fax (Positions 13-22); Country Code (Positions
24-25; Use the alpha-2 country codes from Part 1 of ISO 3166)
External Code Sources
State abbreviations and ZIP Codes:
National ZIP Code and Post Office Directory, Publication 65
The USPS Domestic Mail Manual
Available from:
U.S Postal Service
Washington, DC 20260
Country Codes:
Codes for Representation of Names of Countries, ISO 3166-(Latest Release)
Available from:
American National Standards Institute
11 West 42nd Street, 13th Floor
New York, NY 10036
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Form Locator 02
Data
Element
Pay-to Name and Address
Definition:
The address that the provider submitting the bill intends payment to be sent if
different than FL 01.
Reporting
• UB-04: Situational. Required when the address for payment is different than that of
the Billing Provider in Form Locator 01.
• 004010/004010A1: Situational. Required if the Pay-to Provider is a different entity
than the Billing Provider.
• 005010: Situational. Required when the address for payment is different than that
of the Billing Provider. (Note: The purpose of Loop ID-2010AB has changed from
previous versions. Loop ID-2010AB only contains address information when
different from the Billing Provider Address. There are no applicable identifiers for
Pay-To Address information.)
Field
Attributes
1 Field
4 Lines
25 Positions
Alphanumeric
Left-justified
Notes
Enter the information provided in Form Locator 02 on the appropriate line:
Line 1 - Pay-to Name
Line 2 - Street Address or Post Office Box
Line 3 - City (Positions 1-16, Left-justified), State (Positions 18-19), and ZIP Code
(Positions 21-25)
Line 4 - NOT USED. Reserved for Assignment by the NUBC
Address may include post office box or street name and number, city, state and ZIP
Code. Form Locator 02 uses a 5-digit ZIP Code.
External code source for state abbreviations and ZIP Codes:
National ZIP Code and Post Office Directory, Publication 65
The USPS Domestic Mail Manual
Available from:
U.S Postal Service
Washington, DC 20260
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Official UB-04 Data Specifications Manual 2007
Form Locator 03a
Data
Element
Patient Control Number
Definition:
Patient’s unique (alphanumeric) number assigned by the provider to facilitate retrieval
of the individual’s account of services (accounts receivable) containing the financial
billing records and any postings of payment.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
1 Line
24 Positions*
Alphanumeric
Left-justified
Notes
To enable providers to reconcile payments against the account receivable for the
patient, it is a requirement that payers include the patient control number on the
payment check, remittance advice or voucher.
* The MAXIMUM NUMBER OF CHARACTERS to be supported for this field is
’20’. Providers may submit fewer characters depending upon their needs. However,
the HIPAA maximum requirement to be supported by any responding system is ’20’.
Characters beyond 20 are not required to be stored nor returned by any receiving
system or returned by any 837-receiving system.
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Meeting Date:
Official UB-04 Data Specifications Manual 2007
Form Locator 03b
Data
Element
Medical/Health Record Number
Definition:
The number assigned to the patient’s medical/health record by the provider.
Reporting
• UB-04: Situational. Required when the provider needs to identify for future
inquiries, the actual medical record of the patient.
• 004010/004010A1: Situational. Required when the provider needs to identify for
future inquiries, the actual medical record of the patient identified in either Loop ID2010BA or Loop ID-2010CA for this episode of care.
• 005010: Situational. Required when the provider needs to identify for future
inquiries, the actual medical record of the patient identified in either Loop ID2010BA or Loop ID-2010CA for this episode of care.
Field
Attributes
1 Field
1 Line
24 Positions
Alphanumeric
Left-justified
Notes
The medical/health record number references a file that contains the history of
treatment. It should not be substituted for the Patient Control Number (FL 03a),
which is assigned by the provider to facilitate retrieval of the individual financial
record, which is typically associated with an episode of care.
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Form Locator 04
Page 1 of 9
Data
Element
Type of Bill
Definition:
A code indicating the specific type of bill (e.g., hospital inpatient, outpatient,
replacements, voids, etc.). The first digit is a leading zero*. The fourth digit defines
the frequency of the bill for the institutional and electronic professional claim.
Reporting
• UB-04: Required.
• 004010/004010A: Required.
• 005010: Required.
Field
Attributes
1 Field (2 Components)
1 Line
4 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
*Do not include the leading zero on electronic claims.
The “x” in the following tables (first component) represents a placeholder for the
frequency code (second component).
Inpatient and Outpatient Designation
The matrix which follows contains general guidelines on what constitutes an
“inpatient” or “outpatient” claim according to the first three digits of Type of Bill
(TOB).
The usage requirements of many data elements are based on this designation. For
example, HCPCS are reported on outpatient bills while ICD-9-CM procedure codes
are reported on inpatient bills. A key factor in determining inpatient/outpatient is the
concept of summary level vs. detail level bills. Traditionally, inpatient hospital bills
are summary level bills wherein all the charges are summarized (“rolled-up”) by
revenue code. For example, on an inpatient admission, the room rate, number of days
and the resultant total charge are reported on one line. On a detail bill, all services are
itemized at the line level (lines 1 to 22 on the UB-04) by Revenue Code, Date of
Service, Unit of Service and HCPCS code. With the advent of Outpatient PPS, all
Medicare hospital outpatient bills list every service by HCPCS code.
Exceptions and augmentations to the general guidelines that result from specific data
element requirements are documented at the end of the matrix.
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Form Locator 04
Page 2 of 9
Inpatient Part B Only -- Type of Bill 012x and 022x
The general designations for TOBs 012x and 022x are “OP”. Medicare will pay,
under Part B for physician services and for non-physician medical and other health
services when furnished by a participating hospital or SNF to an inpatient of the
facility when patients are not eligible or entitled to Part A benefits or the patient has
exhausted their Part A benefits.
This is done when these patients are not eligible or entitled to, or have exhausted,
their Part A benefits. Such services are billed on these two bill types. Medicare
directs that revenue codes covered by Part B should be listed with their HCPCS,
Units, and Service Date, just like an outpatient claim.
The standard Medicare systems perform edits to prevent payment on Inpatient Part B
Only claims containing the revenue codes listed in the table below.
010x 011x 012x 013x 014x 015x 016x 017x
018x 019x 020x 021x 022x 023x 0250 0251
0252 0253 0256 0257 0258 0259 0261 0269
0270 0273 0277 0279 029x 0339 036x 0370
0374 041x 045x 0472 0479 049x 050x 051x
052x 053x 0541 0542 0543 0544 0546 0547
0548 0549 055x 057x 058x 059x 060x 0630
0631 0632 0633 0637 064x 065x 066x 067x
068x 072x 0762 078x 079x 093x 0940 0941
0943 0944 0945 0946 0947 0949 095x 0960
0961 0962 0969 097x 098x 099x 100x 210x
310x
After Medicare Part B pays, and if the patient has a secondary insurance, CMS
instructs the provider to bill the entire claim to the second payer, with all the charges
(including the inpatient room rate, etc.) and indicating the amount paid by Medicare
for Part B services.
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Inpatient/Outpatient
General Designation*
Type of Bill
0000-010x
Form Locator 04
Page 3 of 9
Reserved for Assignment by NUBC
-
011x
Hospital Inpatient (Including Medicare Part A)
IP
012x
Hospital Inpatient (Medicare Part B only)
OP
013x
Hospital Outpatient
OP
014x
Hospital - Laboratory Services Provided to Non-patients
OP
015x-017x
018x
019x-020x
Reserved for Assignment by NUBC
Hospital - Swing Beds
Reserved for Assignment by NUBC
IP
-
021x
Skilled Nursing - Inpatient (Including Medicare Part A)
IP
022x
Skilled Nursing - Inpatient (Medicare Part B
OP
023x
Skilled Nursing - Outpatient
OP
024x-027x
028x
029x-031x
Reserved for Assignment by NUBC
Skilled Nursing - Swing Beds
Reserved for Assignment by NUBC
IP
-
032x
Home Health - Inpatient (plan of treatment under Part B
only)
OP
033x
Home Health - Outpatient (plan of treatment under Part A,
including DME under Part A)
OP
034x
Home Health - Other (for medical and surgical services not
under a plan of treatment)
OP
035x-040x
Reserved for Assignment by NUBC
041x
Religious Non-Medical Health Care Institutions - Hospital
Inpatient
042x
Reserved for Assignment by NUBC
043x
Religious Non-Medical Health Care Institutions Outpatient Services
044x-064x
Reserved for Assignment by NUBC
IP
OP
-
*See exceptions and notes on FL 04 Page 5.
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Form Locator 04
Page 4 of 9
Inpatient/Outpatient
General Designation*
Type of Bill
065x
Intermediate Care - Level I
IP
066x
Intermediate Care - Level II
IP
067x-070x
Reserved for Assignment by NUBC
-
071x
Clinic - Rural Health
OP
072x
Clinic - Hospital Based or Independent Renal Dialysis
Center
OP
073x
Clinic - Freestanding
OP
074x
Clinic - Outpatient Rehabilitation Facility (ORF)
OP
075x
Clinic - Comprehensive Outpatient Rehabilitation Facility
(CORF)
OP
076x
Clinic - Community Mental Health Center
OP
077x-078x
Reserved for Assignment by NUBC
-
079x
Clinic - Other
080x
Reserved for Assignment by NUBC
081x
Special Facility - Hospice (non-hospital based)
OP
082x
Special Facility - Hospice (hospital based)
OP
083x
Special Facility - Ambulatory Surgery Center
OP
084x
Special Facility - Free Standing Birthing Center
IP
085x
Special Facility - Critical Access Hospital
OP
086x
Special Facility - Residential Facility
IP
087x-088x
Reserved for Assignment by NUBC
-
089x
090x-9999
Special Facility - Other
Reserved for Assignment by NUBC
OP
-
IP
-
*See exceptions and notes on FL 04 Page 5.
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Meeting Date:
Form Locator 04
Page 5 of 9
Exceptions to Inpatient/Outpatient General Designation by Data Element/Form Locator:
Data Element
Usage Requirement by Type of Bill
FL12
Admission/Start of Care Date
Usage Note in 005010 837:
Required on inpatient claims.
Required on all inpatient claims (“IP”), 032x,
033x, and 034x.
FL13
Admission Hour
Usage Note in 005010 837:
Selection of the appropriate
qualifier is designated by the
NUBC Billing Manual.
Required on all inpatient claims (”IP”) except for
021x.
FL69
Admitting Diagnosis
Usage Note in 005010 837:
Required when claim involves an
inpatient admission.
Required ONLY on 011x, 012x, 018x, and 021x.
FL16
Discharge Hour
Usage Note in 005010 837:
Required on all final inpatient
claims.
Required on inpatient claims (“IP”) with a
Frequency Code of 1 or 4, except for 021x.
FL70a-c
Patient’s Reason for Visit
Usage Note in 005010 837:
Required when claim involves
outpatient visits.
Required on 013x and 085x when:
a) Type of Admission Codes 1,2, or 5 are
reported
AND
b) Revenue Codes 045x, 0516, 0526, or 0762 are
reported.
May be reported on all other 013x and 085x
types of bills at submitter’s discretion when this
information provides additional information to
support medical necessity.
See FL70a-c for more information.
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Form Locator 04
Page 6 of 9
Type of Bill Frequency Codes:
0
Non-Payment/Zero
Use this code when the bill is submitted to a
payer for informational purposes, the provider
does not anticipate payment to result from
submitting the bill; but needs to inform the payer
of the non-reimbursable periods of confinement
or termination of care.
1
Admit Through Discharge Claim
(a)
Use this code when billing for a confined
treatment or inpatient period. This will include
bills representing a total confinement or course
of treatment, and bills that represent an entire
benefit period of the primary third party payer.
2
Interim - First Claim
This code is to be used for the first of a series of
bills to the same third party payer for the same
confinement or course of treatment.
3
Interim - Continuing Claim (b)
This code is to be used when a bill for the same
confinement or course of treatment has
previously been submitted and it is expected that
further bills for the same confinement or course
of treatment will be submitted.
4
Interim - Last Claim (b)
Use this code for the last of a series of bills, for
which payment is expected, to the same third
party payer for the same confinement or course
of treatment.
Note: Do not use this code in lieu of a code for
Late Charges or Non-Payment/Zero Claims.
5
Late Charge(s) Only
Use this code for submitting charges to the payer,
which were received by the provider after the
Admit Through Discharge, or the Last Interim
Claim has been submitted.
Note: This code is not intended to be used in
lieu of a Replacement Claim
6
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Official UB-04 Data Specifications Manual 2007
Form Locator 04
Page 7 of 9
Type of Bill Frequency Codes:
7
Replacement of Prior Claim (a)
This code is used when a specific bill has been
issued for a specific Provider, Patient, Payer,
Insured and “Statement Covers Period” and it
needs to be restated in its entirety, except for the
same identity information. In using this code, the
payer is to operate on the principle to void the
original bill, and that the information present on
this bill represents a complete replacement of the
previously issued bill. However, this code is not
intended to be used in lieu of a Late Charge(s)
Only claim.
8
Void/Cancel of Prior Claim (a)
This code reflects the elimination in its entirety
of a previously submitted bill for a specific
Provider, Patient, Payer, Insured and “Statement
Covers Period.” The provider may wish to
follow a Void Bill with a bill containing the
correct information when a Payer is unable to
process a Replacement to a Prior Claim. The
appropriate Frequency Code must be used when
submitting the new bill.
9
Final Claim for a Home Health
PPS Episode
This code indicates the HH bill should be
processed as a debit or credit adjustment to the
initial home health PPS bill. This code is
specific to home health and does not replace
Frequency Codes 7 or 8.
A
Admission/Election Notice
This code is used when a hospice, home health
agency, CMS Coordinated Care Demonstration
entity, Centers of Excellence Demonstration
entity, Provider Partnerships Demonstration
entity or Religious Non-medical Health Care
Institution is submitting the UB-04 as an
admission or election notice.
B
Hospice/CMS Coordinated Care
Demonstration/Religious NonMedical Health Care
Institution/Centers of Excellence
Demonstration/ Provider
Partnerships Demonstration
This code is used when the UB-04 is used as a
Termination/Revocation of a hospice, Medicare
Coordinated Care Demonstration, Centers of
Excellence Demonstration, Provider Partnerships
Demonstration or Religious Non-Medical Care
Institution election.
C
Hospice Change of Provider
Notice
Use when the UB-04 is used as a Notice of
Change to the hospice provider.
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Official UB-04 Data Specifications Manual 2007
Form Locator 04
Page 8 of 9
Type of Bill Frequency Codes:
D
Hospice/CMS Coordinated Care
Demonstration/Religious NonMedical Health Care
Institution/Centers of Excellence
Demonstration/ Provider
Partnerships Demonstration
Void/Cancel
This code is used when the UB-04 is used as a
Notice of a Void/Cancel of a hospice, CMS
Coordinated Care Demonstration entity, Centers
of Excellence Demonstration entity, Provider
Partnerships Demonstration entity or Religious
Non-medical Health Care Institution election.
E
Hospice Change of Ownership
This code is used to indicate a Notice of Change
in Ownership for the hospice.
F
Beneficiary Initiated Adjustment
Claim
For intermediary use only, use to identify
adjustments initiated by the beneficiary.
G
CWF Initiated Adjustment Claim
For intermediary use only, to identify
adjustments initiated by CWF.
H
CMS Initiated Adjustment
For intermediary use only, to identify
adjustments initiated by CMS.
I
Intermediary Adjustment Claim
(Other than QIO or Provider)
For intermediary use only, to identify
adjustments initiated by the intermediary.
J
Initiated Adjustment Claim Other
For intermediary use only, to identify
adjustments initiated by other entities.
K
OIG Initiated Adjustment Claim
For intermediary use only, to identify
adjustments initiated by OIG.
L
Reserved for assignment by the NUBC.
M
MSP Initiated Adjustment Claim
For intermediary use only, to identify
adjustments initiated by MSP. Note: MSP takes
precedence over other adjustment sources.
N
QIO Adjustment Claim
For intermediary use only, to identify an
adjustment initiated because of a QIO review.
O
Nonpayment/Zero Claims
This code is used when you do not anticipate
payment from the payer for the bill, but you are
informing the payer about a period of nonpayable confinement or termination of care. The
“Through” date of this bill (FL 06) is the
discharge date for this confinement. Medicare
requires “nonpayment” bills only to extend the
spell-of-illness in inpatient cases. Other
nonpayment bills are not needed and may be
returned.
P
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Official UB-04 Data Specifications Manual 2007
Form Locator 04
Page 9 of 9
Type of Bill Frequency Codes:
Q
Claim Submitted for
Reconsideration Outside of
Timely Limits
R-W
This code is used to identify claims submitted for
reconsideration that fall outside of the payer’s
timely filing limits. THIS CODE IS SET ASIDE
FOR INTERNAL PAYER USE ONLY.
PROVIDERS DO NOT REPORT THIS CODE.
Reserved for assignment by the NUBC.
X
Void/Cancel a Prior Abbreviated
Encounter Submission
This code is used by a Medicare Advantage
contractor or other plan required to submit
encounter data that indicates that this encounter
data submission is an exact duplicate of an
incorrect previous encounter data submission
using the abbreviated UB-04 format. A code “Y”
(Replacement of Prior Abbreviated Encounter
Submission) is also submitted by the plan
showing corrected information.
Y
Replacement of Prior
Abbreviated Encounter
Submission
This code is used by a Medicare Advantage
contractor or other plan required to submit
encounter data when it wants to correct a
previous encounter submission using the
abbreviated UB-04 format. This is the code
applied to the corrected or new encounter.
Z
New Abbreviated Encounter
Submission
This code is used by a Medicare Advantage
contractor or other plan required to submit
encounter data to indicate it is submitting new
encounter data using the abbreviated UB-04
format. It is applicable for both inpatient and
outpatient services.
Footnotes for Frequency Codes
(a)
The developers of the Professional and Dental Health Care Claim Implementation
Guides (ASC X12N 837 (004010X098, 004010X097, 005010X222 and
005010X224)) have indicated that this code is acceptable for use in those
transactions.
(b)
Do not use for Medicare PPS claims. (For second and subsequent interim bills use
code 7, and see Condition Code D3 (FL18-FL28).
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Meeting Date:
Official UB-04 Data Specifications Manual 2007
Form Locator 05
Data
Element
Federal Tax Number
Definition:
The number assigned to the provider by the federal government for tax reporting
purposes. Also known as a tax identification number (TIN) or employer identification
number (EIN). To identify affiliated subsidiaries using federal tax “sub-ID” (see note
below).
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
Upper Line, 4 positions (sub-ID - optional)
Alphanumeric
Left-justified
Lower Line, 10 positions (include hyphen)
Alphanumeric
Left-justified
Notes
Upper line is the federal tax sub-ID number as assigned by the provider. To be used
by providers that assign a unique identifying number for their affiliated subsidiaries,
e.g., hospital psychiatric pavilion.
Lower line is the federal tax number entered as: NN-NNNNNNN.
For electronic claims, do not use the hyphen when reporting federal tax ID.
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Official UB-04 Data Specifications Manual 2007
Form Locator 06
Data
Element
Statement Covers Period
Definition:
The beginning and ending service dates of the period included on this bill.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
1 Line
12 Positions
Numeric
Right-justified (all positions fully coded)
Notes
The “From” date should not be confused with the Admission Date (FL 12).
For all services received on a single day, use the same date for “From” and
“Through”.
Enter both dates as month, day, and year (MMDDYY). Example: 010104
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 07
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
7 Positions (upper line)
8 Positions (lower line)
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Form Locator 08
Page 1 of 2
Data
Element
Patient Name/Identifier
Definition:
Last name, first name and middle initial of the patient and the patient identifier as
assigned by the payer.
Reporting
Patient Name
• UB-04: Required.
• 004010/004010A1: Required.
- If the patient is the subscriber, the name is reported in Loop ID 2010BA.
- If the patient is not the subscriber, the name is reported in Loop ID 2010CA.
• 005010: Required.
- If the patient is the subscriber, the name is reported in Loop ID 2010BA.
- If the patient is not the subscriber but has a unique identifier assigned by the
destination payer, the name is reported in Loop ID 2010BA.
- If the patient is not the subscriber and cannot be identified by a unique
identifier assigned by the destination payer, the name is reported in Loop ID
2010CA.
Patient ID
• UB-04: Situational. Report if number is different from the subscriber/insured’s ID
(FL 60).
• 004010/004010A1: Required.
- If the patient is the subscriber, the identifier is reported in Loop ID 2010BA.
- If the patient is not the subscriber, the idnetifier is reported in Loop ID
2010CA.
• 005010: Situational. Required when the patient name has been mapped to Loop ID
2010BA. Not Used when the patient name has been mapped to Loop ID 2010CA.
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Field
Attributes
1 Field
2 Lines
2 Subfields
Subfield a: Patient Identifier (19 Positions)
Subfield b: Patient Name (29 Positions)
Alphanumeric
Left-justified
Notes
-
Official UB-04 Data Specifications Manual 2007
Form Locator 08
Page 2 of 2
On the paper UB-04 form, use a comma or space to separate last and first names.
No space should be left between a prefix and a name as in MacBeth,
VonSchmidt, and McEnroe.
Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element.
Record hyphenated names with the hyphen as in Smith-Jones, Rebecca.
To record suffix of a name, write the last name, leave a space and write the
suffix, then write the first name as in Snyder III, Harold, or Addams Jr., Glen.
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Meeting Date:
Form Locator 09
Data
Element
Patient Address
Definition:
The mailing address of the patient. Enter the complete mailing address including
street number and name or post office box number or RFD; city name; state name;
ZIP code.
Reporting
• UB-04: Required.
• 004010/004010A1: Required. Reported in the same Loop ID (2010BA or 2010CA)
that the Patient Name has been mapped to.
• 005010: Required. Reported in the same Loop ID (2010BA or 2010CA) that the
Patient Name has been mapped to.
Field
Attributes
I Field
2 Lines
5 Subfields
Subfield a: Street Address (40 Positions)
Subfield b: City (30 Positions)
Subfield c: State (2 Positions)
Subfield d: ZIP Code (9 Positions)
Subfield e: Country Code (2 Positions; use the alpha-2 country codes from Part I of
ISO 3166) (report if other than USA)
Alphanumeric
Left-justified
Notes
External Code Sources
State abbreviations and ZIP Codes:
National ZIP Code and Post Office Directory, Publication 65
The USPS Domestic Mail Manual
Available from:
U.S Postal Service
Washington, DC 20260
Country Codes:
Codes for Representation of Names of Countries, ISO 3166 (Latest Release)
Available from:
American National Standards Institute
11 West 42nd Street, 13th Floor
New York, NY 10036
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Meeting Date:
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Form Locator 10
Data
Element
Patient Birth Date
Definition:
The date of birth of the patient.
Reporting
• UB-04: Required.
• 004010/004010A1: Required. Reported in the same Loop ID (2010BA or 2010CA)
that the Patient Name has been mapped to.
• 005010: Required. Reported in the same Loop ID (2010BA or 2010CA) that the
Patient Name has been mapped to.
Field
Attributes
1 Field
1 Line
8 Positions
Numeric
Right-justified (all positions fully coded)
Notes
For paper claims only, if full birth date is unknown, indicate zeros for all eight digits.
Enter: “MMDDYYYY” Example: 01012004
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Meeting Date:
Official UB-04 Data Specifications Manual 2007
Form Locator 11
Data
Element
Patient Sex
Definition:
The sex of the patient as recorded at admission, outpatient service, or start of care.
Reporting
• UB-04: Required.
• 004010/004010A1: Required. Reported in the same Loop ID (2010BA or 2010CA)
that the Patient Name has been mapped to.
• 005010: Required. Reported in the same Loop ID (2010BA or 2010CA) that the
Patient Name has been mapped to.
Field
Attributes
1 Field
1 Line
1 Position
Alphanumeric
Left-justified
Notes
M = Male
F = Female
U = Unknown
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Form Locator 12
Data
Element
Admission/Start of Care Date
Definition:
The start date for this episode of care. For inpatient services, this is the date of
admission. For other (home health) services, it is the date the episode of care began.
Reporting
• UB-04: Required on all inpatient claims (“IP”), 032x, 033x, and 034x.
• 004010/004010A1: Required
• 005010: Required on inpatient claims.
Field
Attributes
1 Field
1 Line
6 Positions
Numeric
Right-justified (all positions fully coded)
Notes
Enter the admission date as month, day and year (MMDDYY). Example: “010104”
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Form Locator 13
Data
Element
Admission Hour
Definition:
The code referring to the hour during which the patient was admitted for inpatient or
outpatient care.
Reporting
• UB-04: Situational. Required on inpatient claims except for 021x.
• 004010/004010A1: Situational. This segment is required on all inpatient claims.
• 005010: Situational. Selection of the appropriate qualifier is designated by the
NUBC Billing Manual. (Therefore, required on inpatient claims except for 021x as
noted above.)
Field
Attributes
1 Field
1 Line
2 Positions
Alphanumeric
Left-justified (all positions fully coded, unless blank)
Code Structure
Code
00
01
02
03
04
05
06
07
08
09
10
11
Time - AM
12:00 - 12:59 Midnight
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
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Code
12
13
14
15
16
17
18
19
20
21
22
23
Time - PM
12:00 - 12:59 Noon
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
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Meeting Date:
Form Locator 14
Data
Element
Priority (Type) of Visit
Definition:
A code indicating the priority of this admission/visit.
Reporting
• UB-04: Required.
• 004010/004010A1: Situational. Required when patient is being admitted to the
hospital for inpatient services.
• 005010: Situational. Required when patient is being admitted for inpatient
services. (Therefore required on all bill types marked “IP” per FL 04 Pages 3-4.)
Field
Attributes
1 Field
1 Line
1 Position
Alphanumeric
Left-justified
Notes
See codes below
Code
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.)
6-8
9
Reserved for assignment by NUBC.
Information
not Available
Information not available.
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Form Locator 15
Page 1 of 4
Data
Element
Source of Referral for Admission or Visit
Definition:
A code indicating the source of the referral for this admission or visit.
Reporting
• UB-04: Required
• 004010/004010A1: Situational. Required for all inpatient admissions. Required on
Medicare outpatient registrations for diagnostic testing services.
• 005010: Situational. Required for all inpatient and outpatient services. (Note:
Therefore required on all bill types marked “IP” and “OP” per FL 04 Pages 3-4,
which is equivalent to the UB-04 requirement.)
Field
Attributes
1 Field
1 Line
1 Position
Alphanumeric
Left-justified
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1
Physician Referral
Official UB-04 Data Specifications Manual 2007
Form Locator 15
Page 2 of 4
Inpatient: The patient was admitted to this
facility upon the recommendation of his or her
personal physician.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by his or her personal physician or the
patient independently requested outpatient
services (self-referral).
2
Clinic Referral
Inpatient: The patient was admitted to this
facility upon recommendation of this facility’s
clinic physician.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by this facility’s clinic or other
outpatient department physician.
3
HMO Referral
Inpatient: The patient was admitted to this
facility upon the recommendation of a health
maintenance organization physician.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by a health maintenance organization’s
physician.
4
Transfer from a Hospital
(Different Facility*)
Inpatient: The patient was admitted to this
facility as a hospital transfer from a different
acute care facility where he or she was an
inpatient.
*For Transfers from Hospital
Inpatient in the Same Facility, see Outpatient: The patient was referred to this
Code D.
facility for outpatient or referenced diagnostic
services by (a physician of) a different acute care
facility.
5
Transfer from a Skilled Nursing
Facility
Inpatient: The patient was admitted to this
facility as a transfer from a skilled nursing
facility where he or she was a resident.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by (a physician of) the skilled nursing
facility where he or she is a resident.
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6
Transfer from Another Health
Care Facility
Official UB-04 Data Specifications Manual 2007
Form Locator 15
Page 3 of 4
Inpatient: The patient was admitted to this
facility as a transfer from a health care facility
other than an acute care facility or a skilled
nursing facility. This includes transfers from
nursing homes, long term care facilities and
skilled nursing facility patients that are at a
non-skilled level of care.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by (a physician of) another health care
facility where he or she is an inpatient.
7
Emergency Room
Inpatient: The patient was admitted to this
facility upon the recommendation of this
facility’s emergency room physician.
Outpatient: The patient received services in this
facility’s emergency department.
8
Court/Law Enforcement
Inpatient: The patient was admitted to this
facility upon the direction of a court of law, or
upon the request of a law enforcement agency
representative.
Outpatient: The patient was referred to this
facility upon the direction of a court of law, or
upon the request of a law enforcement agency
representative for outpatient or referenced
diagnostic services.
9
Information Not Available
Inpatient: The means by which the patient was
admitted to this hospital is not known.
Outpatient: For Medicare outpatient bills this is
not a valid code.
A
Transfer From a Critical Access
Hospital
Inpatient: The patient was admitted to this
facility as a transfer from a Critical Access
Hospital where he or she was an inpatient.
Outpatient: The patient was referred to this
facility for outpatient or referenced diagnostic
services by (a physician of) the Critical Access
Hospital where he or she was an inpatient.
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Form Locator 15
Page 4 of 4
B
Transfer From Another Home
Health Agency
The patient was admitted to this home health
agency as a transfer from another home health
agency.
C
Readmission to Same Home
Health Agency
The patient was readmitted to this home health
agency within the existing 60-day payment. (For
use with Medicare bill type 032A.)
D
Transfer from Hospital Inpatient
in the Same Facility Resulting in
a Separate Claim to the Payer
The patient was admitted to this facility as a
transfer from hospital inpatient within this
facility resulting in a separate claim to the payer.
E-Z
Reserved for assignment by the NUBC.
Code Structure for Newborn
1
Normal Delivery
A baby delivered without complications.
2
Premature Delivery
A baby delivered with time and/or weight factors
qualifying it for premature status.
3
Sick Baby
A baby delivered with medical complications,
other than those relating to premature status.
4
Extramural Birth
A newborn born in a non-sterile environment.
5-9
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Form Locator 16
Data
Element
Discharge Hour
Definition:
Code indicating the discharge hour of the patient from inpatient care.
Reporting
• UB-04: Situational. Required on inpatient claims with a Frequency Code of 1 or 4,
except for Type of Bill 021x.
• 004010/004010A1: Situational. This segment is required on all final inpatient
claims/encounters.
• 005010: Situational. Required on all final inpatient claims.
Field
Attributes
1 Field
1 Line
2 Positions
Alphanumeric
Left-justified (all positions fully coded, unless blank)
Code Structure
Code
00
01
02
03
04
05
06
07
08
09
10
11
Time - AM
12:00 - 12:59 Midnight
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
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Code
12
13
14
15
16
17
18
19
20
21
22
23
Time - PM
12:00 - 12:59 Noon
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
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Form Locator 17
Page 1 of 12
Data
Element
Patient Discharge Status
Definition:
A code indicating the disposition or discharge status of the patient at the end service
for the period covered on this bill, as reported in FL6, Statement Covers Period.
Reporting
• UB-04: Required
• 004010/004010A1: Situational. Required for inpatient claims/encounters.
• 005010: Required
Field
Attributes
1 Field
1 Line
2 Positions
Numeric
Right-justified (all positions fully coded)
Notes
The patient’s discharge status is required on all institutional claims. Identifying the
appropriate code may often be confusing; judgment must be used in all cases. A basic
rule of thumb is to code to the highest level of care that is known -- for example, an
individual discharged to home with a home health plan of care is coded as 06, rather
than 01. See the FAQ section on pages 5-12 of this Form Locator for further
guidance.
Many health plans utilize discharge status codes in their reimbursement policies.
Some commercial payers use the Medicare model outlined below.
Under Medicare’s post acute care transfer policy (from 42 CFR 412.4), a discharge of
a hospital inpatient is considered to be a transfer when the patient’s discharge is
assigned to one of the qualifying diagnosis-related groups (DRGs) and the discharge
is made under any of the following circumstances:
To a hospital or distinct part hospital unit excluded from the inpatient
prospective payment system (Inpatient Rehabilitation Facilities, Long Term
Care Hospitals, psychiatric hospitals, cancer hospitals and children’s hospitals).
To a skilled nursing facility (not swing beds).
To home under a written plan of care for the provision of home health services
from a home health agency and those services begin within 3 days after the date
of discharge.
Based on the regulation, providers code these transfers with 62, 63, 65, 05, 03 and 06.
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01
Form Locator 17
Page 2 of 12
Discharged to Home or Self Care (Routine Discharge)
Usage Note:
Includes discharge to home; jail or law enforcement; home on oxygen if DME only;
any other DME only; group home, foster care, and other residential care
arrangements; outpatient programs, such as partial hospitalization or outpatient
chemical dependency programs; assisted living facilities that are not state-designated.
02
Discharged/transferred to a Short-Term General Hospital for Inpatient Care
03
Discharged/transferred to Skilled Nursing Facility (SNF) with Medicare Certification
in Anticipation of Covered Skilled Care
Usage Note:
Medicare - Indicates that the patient is discharged/transferred to a Medicare certified
nursing facility. For hospitals with an approved swing bed arrangement, use Code 61
- Swing Bed. For reporting other discharges/transfers to nursing facilities see 04 and
64.
04
Discharged/transferred to an Intermediate Care Facility (ICF)
Usage Note:
Typically defined at the state level for specifically designated intermediate care
facilities. Also used to designate patients that are discharged/transferred to a nursing
facility with neither Medicare nor Medicaid certification and for discharges/transfers
to state designated Assisted Living Facilities.
05
Discharged/transferred to another Type of Health Care Institution not Defined
Elsewhere in this Code List
Usage Note:
Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples
of such other types of health care institutions.
Definition Effective 10/1/07:
Discharged/transferred to a Designated Cancer Center or Children’s Hospital
Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list
of (National Cancer Institute) Designated Cancer Centers can be found at
http://www3.cancer.gov/cancercenters/centerslist.html .
06
Discharged/transferred to Home Under Care of Organized Home Health Service
Organization in Anticipation of Covered Skilled Care
Usage Note:
Report this code when the patient is discharged/transferred to home with a written
plan of care (tailored to the patient’s medical needs) for home care services. Not used
for home health services provided by a DME supplier or from a Home IV provider for
home IV services.
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07
Left Against Medical Advice or Discontinued Care
08
Reserved for Assignment by the NUBC
09
Admitted as an Inpatient to this Hospital
Form Locator 17
Page 3 of 12
Usage Note:
For use only on Medicare outpatient claims. Applies only to those Medicare
outpatient services that begin greater than three days prior to an admission.
10-19
20
21-29
30
Reserved for Assignment by the NUBC
Expired
Reserved for Assignment by the NUBC
Still Patient
Usage Note:
Used when patient is still within the same facility; typically used when billing for
leave of absence days or interim bills.
31-39
40
Reserved for Assignment by the NUBC
Expired at Home
Usage Note:
For use only on Medicare and TRICARE claims for hospice care.
41
Expired in a Medical Facility (e.g. hospital, SNF, ICF, or free standing hospice)
Usage Note:
For use only on Medicare and TRICARE claims for hospice care.
42
Expired - Place Unknown
Usage Note:
For use only on Medicare and TRICARE claims for hospice care.
43
Discharged/transferred to a Federal Health Care Facility
Usage Note:
Discharges and transfers to a government operated health facility such as a
Department of Defense hospital, a Veteran’s Administration hospital or a Veteran’s
Administration nursing facility. To be used whenever the destination at discharge is a
federal health care facility, whether the patient lives there or not.
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44-49
Form Locator 17
Page 4 of 12
Reserved for Assignment by the NUBC
50
Hospice - Home
51
Hospice - Medical Facility (Certified) Providing Hospice Level of Care
52-60
61
Reserved for Assignment by the NUBC
Discharged/transferred to a Hospital-Based Medicare Approved Swing Bed
Usage Note:
Medicare - Used for reporting patients discharged/transferred to a SNF level of care
within the hospital’s approved swing bed arrangement.
62
Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including
Rehabilitation Distinct Part Units of a Hospital
63
Discharged/transferred to a Medicare Certified Long Term Care Hospital (LTCH)
Usage Note:
For hospitals that meet the Medicare criteria for LTCH certification.
64
Discharged/transferred to a Nursing Facility Certified under Medicaid but not
Certified under Medicare
65
Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a
Hospital
66
Discharged/transferred to a Critical Access Hospital (CAH)
67-69
70
71-99
Reserved for Assignment by the NUBC
Effective 10/1/07:
Discharged/transferred to another Type of Health Care Institution not Defined
Elsewhere in this Code List
(See Code 05)
Reserved for Assignment by the NUBC
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FAQ #
1
Form Locator 17
Page 5 of 12
Question/Answer
Q: A patient is discharged from our facility (disposition code 01) and is to go to a
doctor’s appointment the same day. The patient is then admitted to another hospital
after seeing the doctor. What disposition code is appropriate, 01 or 02?
A: Based on the information the hospital had at discharge, the patient was
discharged to home (01). If your facility was unaware of the planned admission at
the second facility, it is likely that you will have to provide support for your coding
decision when the fiscal intermediary receives the claim for admission to another
hospital on the same day you discharged the patient.
2
Q: If a patient leaves before triage, or is triaged and leaves without being seen by the
physician, what is the appropriate discharge status? It does not seem right to use 07,
left against medical advice, because no “medical advice” was provided.
A: The full definition of 07 is “Left against medical advice or discontinued care;”
therefore, that is the appropriate code to use when the patient discontinues care.
3
Q: What status code should be used for a patient transferred to a SNF rehabilitation
unit? This unit is within the SNF. Is this considered a transfer to a SNF or to a
rehabilitation facility?
A: A rehabilitation unit that is part of a skilled nursing facility is paid under the SNF
prospective payment system. Moving a patient from one unit to another does not
constitute a transfer for billing purposes and should not result in separate claims.
If a patient is discharged from an acute inpatient hospital to a SNF, use 03. Status
code 03 is also used if the patient moves from an acute inpatient hospital to a rehab
unit in a SNF.
4
Q: What code is used for patients discharged on home oxygen?
A: Use discharge status 01, discharged to home or self care.
5
Q: What code is used for patients discharged to partial hospitalization?
A: Use discharge status 01, discharged to home or self care.
6
Q: What code is used for patients discharged to home with follow-up visiting nurses?
A: If the patient is discharged to home with a written plan of care for home care
services -- whether home attendant, nursing aides, certified attendants, etc. -- use
status code 06.
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FAQ #
7
Form Locator 17
Page 6 of 12
Question/Answer
Q: What code is used for patients discharged to home with services by a DME
supplier?
A: Use discharge status 01, discharged to home or self care.
8
Q: What code is used for patients discharged to court/law enforcement?
A: Use discharge status 01, discharged to home or self care.
9
Q: What code is used for patients discharged/transferred to residential care?
A: Use discharge status 01, discharged to home or self care.
10
Q: What code is used for patients discharged/transferred to a foster care facility?
A: Use discharge status 01, discharged to home or self care.
11
Q: What code is used for patients discharged/transferred to a foster care facility with
home care?
A: Use discharge status 06, discharged/transferred to home under care of organized
home health services in anticipation of covered skilled care.
12
Q: What code is used for patients discharged to home under a home health agency
with oxygen?
A: Use discharge status 06, discharged/transferred to home under care of organized
home health services in anticipation of covered skilled care. If the patient is
discharged home with oxygen that is not provided through a home health plan of
care, use status code 01, discharged to home or self care.
13
Q: What code is used for patients discharged to home under a home health agency
with DME?
A: Use status code 06, discharged/transferred to under care of organized home
health service organization in anticipation of covered skilled care.
14
Q: How is a “long-term care hospital” (which the UB manual indicates should be
coded to 63) different from a SNF (often called a long-term care facility)? Should it
be coded 03 or 04?
A: A long-term care facility (63) provides acute inpatient care with an average
length of stay greater than 25 days. A skilled nursing facility certified by Medicare is
coded with 03 and an intermediate care facility with 04. A nursing facility that is not
Medicare-certified is coded with 64.
15
Q: A facility may be licensed for multiple types of care. For example, a facility may
hold licenses for both skilled nursing and hospice. If it is not documented in the
medical record as to which type of care a patient is being discharged to, what code
should be used?
A: Just like Medical Records follows up if there is no diagnosis, they should follow
up on this, confirm where the patient is being placed and code accordingly.
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FAQ #
16
Official UB-04 Data Specifications Manual 2007
Form Locator 17
Page 7 of 12
Question/Answer
Q: Code 04 is to be used for transfer to “state-designated assisted living facilities.”
What is the appropriate code if a patient is discharged/transferred to a skilled nursing
component within an assisted living facility?
A: If the discharge plan suggests an assisted living facility code with 04. Use 03 if
the plan identifies a skilled level of care in a Medicare-certified SNF.
17
Q: What discharge status code should be used in Form Locator 22 if the patient is
going from an inpatient hospital to an inpatient VA?
A: Use status code 43, discharged/transferred to a federal health care facility.
18
Q: Are the codes 50 (hospice/home) and 51 (hospice/facility) used by the hospital
when the patient is discharged from an inpatient bed or are they only to be used on
hospice or home health type of bills?
A: Use 50 or 51 if the patient is discharged from an inpatient hospital to a hospice.
19
Q: What if a doctor indicated one thing but the discharge planner indicates another?
What should be coded?
A: Use common sense and use the best source to code. In this instance, probably the
discharge planner will have the most accurate and most current patient status.
20
Q: What code should be used by a home health agency when a patient has moved
without notice and the agency is unable to complete the plan of care?
A: Use status code 07, left against medical advice or discontinued care.
21
Q: We were of the understanding that Patient Code 65 would become effective with
the admissions of April 1, 2004. Now our coding and abstracting vendor is telling us
that they have been notified by CMS that this implementation will not be effective
until October 2004 or January 2005 with the implementation of the Medicare
Psychiatric Prospective Payment System. Can this code be used for payers other than
Medicare? Our Medicaid agency is asking us to use it.
A: Code 65 is appropriate for all payers.
22
Q: Can discharge status 30, Still Patient, be used on both inpatient and outpatient
claims?
A: Yes, it can be used on both types of claims. Note, however, that Code 30 is
primarily designed to be used on inpatient claims when billing for leave of absence
days or interim bills; on outpatient claims, the primary method to identify that the
patient is still receiving care is the bill type frequency code (e.g., Frequency Code 3:
Interim - Continuing Claim).
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FAQ #
23
Form Locator 17
Page 8 of 12
Question/Answer
Q: What discharge status code should be used when a patient is
discharged/transferred to a SNF that is both Medicare and Medicaid certified?
A: Use 03, discharged/transferred to skilled nursing facility (SNF) with Medicare
certification in anticipation of covered skilled care.
24
Q: What discharge status code should be used when a patient is discharged to a
chemical dependency treatment facility that is not part of a hospital?
A; If the chemical dependency treatment facility is not a psychiatric hospital or
psychiatric distinct part unit of a hospital, and the patient is undergoing
inpatient/residential treatment, use Code 05, discharged/transferred to another type
of health care institution not defined elsewhere in this code list.
(Note: The NUBC has approved the establishment of a new code (70) to take effect
10/1/07 for other types of health care facilities not defined elsewhere in the code
list.)
25
Q: What is the appropriate patient discharge status code for a patient transferred to a
nursing facility for a non-skilled/custodial/residential level of care? For example:
The patient is discharged to a facility that is only certified with skilled beds but
the patient does not qualify for a skilled level of care.
The Medicare certified nursing facility is licensed for both skilled and
intermediate care beds, and the patient is transferred to intermediate care.
The patient resides at a Medicare certified SNF but only receives non-skilled
services.
The patient’s Medicare coverage for skilled nursing days has been exhausted for
the year and patient will only be receiving non-skilled care.
A: Use Code 04, discharged/transferred to an intermediate care facility (ICF).
26
Q: If a patient is discharged from acute hospital care but remains at the same hospital
under hospice care, what status code should be used for the acute stay discharge?
A: Use Code 51 Hospice - medical facility
27
Q: What patient status code should be used for a patient transferred from an inpatient
acute care hospital to a Medicare-certified SNF under the following conditions?
a. Patient has elected the hospice benefit and will be receiving hospice care
under arrangement with a hospice organization; the patient is receiving
residential care only.
b. Patient does not qualify for skilled level of care outside the hospice benefit
for conditions unrelated to the terminal illness.
A: For both conditions, use Code 51 Hospice - medical facility
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Official UB-04 Data Specifications Manual 2007
Form Locator 17
Page 9 of 12
Question/Answer
Q: If a facility discharges a patient to a personal care home, which is similar to
assisted living facilities, are they most appropriately coded as 01 or 04?
A: If the personal care home is the person’s place of residence, even temporarily,
use Code 01, discharged to home or self care.
29
Q: If a patient is discharged from a hospital based Transitional Care Unit (i.e., skilled
nursing unit) to the acute hospital under Observation Status, what is the Discharge
Status for the TCU claim?
A: Use Code 05, discharged/transferred to another type of health care institution not
defined elsewhere in this code list.
30
Q: What discharge status code should be used when a patient is sent to another acute
care facility for an outpatient procedure later in the day? This occurs when we do not
have the equipment to perform the procedure and the intention is that the patient will
not be returning to our facility after the procedure.
A: Since this is a discharge to outpatient treatment, and it is expected that the patient
will go home afterward, use discharge status 01, discharged to home or self care.
31
Q: If a patient is discharged from an acute care hospital to a Medicare-certified swing
bed in a SNF, is the discharge status of 03 correct, or should it be 61?
A: SNFs do not have Medicare-certified swing beds. Use 03 if the patient is
discharged/transferred to skilled nursing facility (SNF) with Medicare certification in
anticipation of covered skilled care. Use Code 61 for reporting patients
discharged/transferred to a SNF level of care within the hospital’s approved swing
bed arrangement.
32
Q: Per FAQ #17 on the NUBC website, “When discharge status code should be used
in Form Locator 17 if the patient is going from an inpatient hospital to an inpatient
VA.... Use status code 43”. If the VA has a psych unit, would it still be 43 and not
65?
A: If the patient is transferred to a VA hospital or to a psych unit within a VA
hospital, Code 43, discharged/transferred to a federal health care facility, should be
used.
33
Q: We have a Home Health Agency with DME. Often we find the orders reads
“Home with Walker”. We do not see a physician order for home health care nor has
there been an assessment documented by the receiving home health nurse. The
nursing discharges instructions check “home”. Is the Patient Status Code still 06?
A: No. “Home with Walker” does not imply a discharge to home under care of
organized home health service organization in anticipation of covered skilled care.
Accordingly, Code 01, discharged to home or self care (routine discharge) would be
appropriate.
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34
Official UB-04 Data Specifications Manual 2007
Form Locator 17
Page 10 of 12
Question/Answer
Q: Various issues/questions regarding the use of Code 08, discharged/transferred to
home under care of a Home IV provider:
We are having a problem coding patients who go home with IVs. If we code
home with IV, Medicare states it should be home healthcare only. We need
something we can identify to know when to use home with IV.
If IV services are provided under a home health agency which patient status
code is assigned? The status code of 08 is confusing when they refer to a
“Home IV provider.”
A point of confusion at our facilities. A Patient is discharged from the hospital
with a PICC line for Home IV therapy. Is this Home Health 06 or IV Infusion
08?
How would you abstract disposition for patients who go home with a PICC line
and an Infusion company is coming in for PICC line care only? No drugs are
administered to the patient. Would the disposition be 01 - Home, 06 - Home
Health, or 08 - Home on IV drug therapy?
A: Code 06 is to be used only when a patient is discharged/transferred to home
under care of organized home health service organization in anticipation of covered
skilled care. Although Code 08 might be appropriate for the situations described
above, it is used infrequently, redundant to Code 01 and causes confusion.
Accordingly, Code 08 was DISCONTINUED effective October 1, 2005 at which time
the appropriate patient status code for these types of situations is simply Code 01,
discharged to home.
35
Q: If a patient is discharged from an acute care hospital and PT/OT is arranged to be
done in the home by a rehabilitation agency that is not affiliated with the home health
care agency that made the arrangements, what is the appropriate code to use -- 01 or
06?
A: If the therapy services are being provided under the home health benefit (e.g.,
Medicare Part A), use Code 06; if the therapy is provided under the outpatient
therapy benefit (e.g., Medicare Part B), use Code 01.
36
Q: What is the difference between residential care and assisted living care?
A: In terms of patient status codes, there is no difference. Discharges to residential
care and private (non-state designated/supported) assisted living facilities are coded
alike (01).
37
Q: A patient in a swing bed at a Critical Access Hospital is discharged back to the
acute care part of the CAH. What patient status code do we use?
A: Use Code 66, Discharged/transferred to a Critical Access Hospital (CAH).
38
Q: A patient is discharged from an acute hospital to a CAH swing bed. What patient
status code do we use?
A: Use Code 61, Discharged/transferred to hospital-based Medicare approved swing
bed. Swing beds are not part of the post acute care transfer policy.
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38
Official UB-04 Data Specifications Manual 2007
Form Locator 17
Page 11 of 12
Question/Answer
Q: A patient is discharged from an acute hospital to a CAH swing bed. What patient
status code do we use?
A: Use Code 61, Discharged/transferred to hospital-based Medicare approved swing
bed. Swing beds are not part of the post acute care transfer policy.
39
Q: What are the general guidelines that hospitals should used to determine the proper
patient status code to use when discharging someone to hospice?
A: The level of care that will be provided by the hospice upon discharge is essential
to determining the proper code to use.
Hospice Levels of Care
1. Routine or Continuous Home Care. Patient status code “50: Hospice home”
should be used if the patient went to his/her own home or an alternative setting that is
the patient’s “home,” such as a nursing facility, and will receive in-home hospice
services.
2. General Inpatient Care. Patient status code “51 Hospice medical facility” should
be used if the patient went to an inpatient facility that is qualified and the patient is to
receive the general inpatient hospice level of care.
3. Inpatient Respite. Patient status code “51 Hospice medical facility” should be
used if the patient went to a facility that is qualified and the patient is receiving
hospice inpatient respite level of care.
Unless a patient has already been admitted to/accepted by a hospice, level of care
can not be determined. Therefore, it is recommended that, if a patient is going home
or to an institutional setting with a hospice “referral only,” (without having already
been accepted for hospice care by a hospice organization) the patient status code
should simply reflect the site to which the patient was discharged, not hospice (i.e.
01: home or self care, or 04: an intermediate care nursing facility, assuming it is not
a Medicare SNF admission).
40
Q: An established non-skilled nursing home patient (i.e. the nursing home is their
permanent residence) is transferred to an acute setting. Upon discharge, they are sent
back to the same nursing home from which they came to a designated hospice
unit/bed. What patient status code would be appropriate?
A: Use Code 50, Hospice - Home if the person is going back to that bed as a routine
or continuous home care hospice patient. If the patient is going back to a skilled
level of care (even though it is the same bed/facility) use Code 03.
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FAQ #
41
Official UB-04 Data Specifications Manual 2007
Form Locator 17
Page 12 of 12
Question/Answer
Q: An established nursing home patient (i.e. the nursing home is their permanent
residence) is transferred to an acute setting. Upon discharge, they are sent back to the
same nursing home with a hospice referral only. What patient status code would be
appropriate?
A: If the patient has not made a hospice election, and has a referral only, use Code
01, Discharged to Home.
42
Q: A patient is admitted from home (a private residence) to an acute setting. Upon
discharge, the patient is transferred as a new nursing home placement to a designated
hospice unit/bed. What patient status code would be appropriate?
A: Use Code51, Hospice - Medical Facility.
43
Q: A patient is admitted from home (a private residence) to an acute setting. Upon
discharge, the patient is transferred as a new nursing home placement with a hospice
referral only. What patient status code would be appropriate?
A: If the patient has made a hospice election, the appropriate code would be 50 or 51
depending on the level of care (See FAQ #39).
If no hospice election has been made, and the nursing facility is non-skilled, the
appropriate code would be 04; if the transfer is to a Medicare certified SNF in
anticipation of covered skilled care, the appropriate code would be 03.
44
Q: A patient was discharged to home with home health services. Two days later the
patient was readmitted to our hospital. We were notified by the discharge planner of
the patient’s readmission and the fact that home health services were not started for
the patient and the discharge status code needed to be changed to 01. By the time of
the discharge planner’s notification, we had already submitted the patient’s bill with
the discharge status code of 06. In this instance what should the correct discharge
status code be on this patient?
A: To ensure accurate reimbursement and reporting, send a replacement claim with
the correct discharge status code (01).
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Form Locator: 18-28
Page 1 of 13
Data
Element
Condition Codes
Definition:
A code(s) used to identify conditions or events relating to this bill that may affect
processing.
Reporting
• UB-04: Situational. Required when there is a Condition Code that applies to this
claim.
• 004010/004010A1: Situational. Required when condition information applies to
the claim or encounter.
• 005010: Situational. Required when there is a Condition Code that applies to this
claim.
Field
Attributes
11 Fields
1 Line
2 Positions
Alphanumeric
All positions fully coded
Notes
No specific date is associated with this code.
Condition Codes should be entered in alphanumeric sequence.
Codes assigned as Payer Codes are for internal use only by the payer; they are
assigned by the payer and are not required to be communicated to another payer for
COB, unless these Payer Codes are communicated to the other payers as part of their
contracted working relationship.
If all of the Condition Code fields are filled, use FL 81 Code-Code field with the
appropriate qualifier code (A1) to indicate that a Condition Code is being reported.
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Form Locators 18-28
Page 2 of 13
01
Military Service Related
Medical condition incurred during military
service.
02
Condition is Employment
Related
Patient alleges that medical condition is due to
environment/events resulting from employment.
03
Patient Covered by Insurance Not
Reflected Here
Indicates that patient/patient representative has
stated that coverage may exist beyond that
reflected on this bill.
04
Information Only Bill
Indicates submission of bill is for informational
purposes only. Examples would include a bill
submitted as a utilization report, or a bill for a
beneficiary who enrolled in a risk-based
managed care plan and the hospital expects to
receive payment from the plan.
05
Lien Has Been Filed
Provider has filed legal claim for recovery of
funds potentially due a patient resulting from
legal action initiated by or on behalf of the
patient.
06
ESRD Patient in First 18 Months
of Entitlement Covered by
Employer Group Health
Insurance
Code indicates Medicare as the secondary insurer
because the patient also is covered through an
employer group health insurance during his first
18 months of End Stage Renal Disease (ESRD)
entitlement.
07
Treatment of Non-Terminal
Condition for Hospice Patient
Code indicates the patient is a hospice enrollee,
but the provider is not treating his terminal
condition and is therefore, requesting regular
Medicare reimbursement.
08
Beneficiary Would Not Provide
Information Concerning Other
Insurance Coverage
Enter this code if the beneficiary would not
provide information concerning other insurance
coverage.
09
Neither Patient Nor Spouse is
Employed
Indicates that in response to development
questions, the patient and spouse have denied any
employment.
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10
Patient and/or Spouse is
Employed but No EGHP Exists
Code indicates that in response to development
questions, the patient and/or spouse have
indicated that one is or both are employed but
have no group health insurance from an EGHP or
other employer sponsored or provided health
insurance that covers the patient.
11
Disabled Beneficiary but No
LGHP
Code indicates that in response to development
questions, the disabled beneficiary and/or family
members have indicated that one is or more are
employed but have no group health insurance
from an LGHP or other employer sponsored or
provided health insurance that covers the patient.
Payer Codes
CODES ARE FOR PAYER USE ONLY.
PROVIDERS DO NOT REPORT THESE
CODES.
17
Patient is Homeless
The patient is homeless.
18
Maiden Name Retained
A dependent spouse entitled to benefits who does
not use her husband’s last name.
19
Child Retains Mother’s Name
A patient who is a dependent child entitled to
benefits and does not have its father’s last name.
20
Beneficiary Requested Billing
Provider realizes services are non-covered level
of care or excluded, but beneficiary requests
determination by payer. (Currently limited to
home health and inpatient SNF claims.)
21
Billing for Denial Notice
Provider realizes services are non-covered level
of care or excluded, but requests notice from
Medicare or other payer.
22
Patient on Multiple Drug
Regimen
A patient who is receiving multiple intravenous
drugs while on home IV therapy.
23
Home Care Giver Available
The patient has a caregiver available to assist him
or her during self-administration of an
intravenous drug.
24
Home IV Patient Also
Receiving-HHA Services
The patient is under the care of Home Health
Agency while receiving home IV drug therapy
services.
25
Patient is Non-U.S. Resident
The patient is not a resident of the United States.
12-16
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26
VA Eligible Patient Chooses to
Receive Services in a Medicare
Certified Facility
Indicates that the patient is a VA eligible patient
and chooses to receive services in a Medicare
certified provider instead of a VA facility.
27
Patient Referred to a Sole
Community Hospital for a
Diagnostic Laboratory Test
To be reported by Sole Community hospitals
only. Report this code to indicate the patient was
referred for a diagnostic laboratory test. Do not
report this code when a specimen only is
referred.
28
Patient and/or Spouse’s EGHP is
Secondary to Medicare
Code indicates that in response to development
questions, the patient and/or spouse have
indicated that one is or both are employed and
that there is group health insurance from an
EGHP or other employer sponsored or provided
health insurance that covers the patient but that
either: (1) the EGHP is a single employer plan
and the employer has fewer than 20 full and parttime employees; or, (2) the EGHP is a multi or
multiple employer plan that elects to pay
secondary to Medicare for employees and
spouses aged 65 and older for those participating
employers who have fewer than 20 employees.
29
Disabled Beneficiary and/or
Family Member’s LGHP is
Secondary to Medicare
Code indicates that in response to development
questions, the patient and/or family member(s)
have indicated that one is or more are employed.
There also is group health insurance coverage
from a LGHP or other employer sponsored or
provided health insurance that covers the
patient. Generally, (1) the LGHP is a single
employer plan and that the employer has fewer
than 100 full and part-time employees; or, (2),
the LGHP is a multiple employer plan and that
all employers participating in the plan have fewer
than 100 full and part-time employees.
30
Qualifying Clinical Trials
Non-research services provided to patients
enrolled in a Qualified Clinical Trial.
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31
Patient is Student (Full Time Day)
Patient declares that he or she is enrolled as a full
time day student.
32
Patient is Student
(Cooperative/Work Study
Program)
Self-explanatory.
33
Patient is Student (Full Time Night)
Patient declares that he or she is enrolled as a full
time night student.
34
Patient is Student (Part Time)
Patient declares that he or she is enrolled as a
part time student.
35
Reserved for assignment by the NUBC.
36
General Care Patient in a Special
Unit
Patient temporarily placed in special care unit
bed because no general care beds available.
37
Ward Accommodation at Patient
Request
Patient assigned to ward accommodations at
patient’s request.
38
Semi-Private Room Not
Available
Indicates that either private or ward
accommodations were assigned because semiprivate accommodations were not available.
39
Private Room Medically
Necessary
Patient needs a private room for medical
requirements.
40
Same Day Transfer
Patient transferred to another facility before
midnight on the day of admission.
41
Partial Hospitalization
Indicates claim is for partial hospitalization
services.
42
Continuing Care Not Related to
Inpatient Admission
Continuing care not related to the condition or
diagnosis for which the individual received
inpatient hospital services.
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43
Continuing Care Not Provided
Within Prescribed Post-discharge
window
Continuing care related to the inpatient
admission but the prescribed care was not
provided within the post-discharge window.
44
Inpatient Admission Changed to
Outpatient
For use on outpatient claims only, when the
physician ordered inpatient services, but upon
internal utilization review performed before the
claim was originally submitted, the hospital
determined that the services did not meet its
inpatient criteria. (Note: For Medicare, the
change in patient status from inpatient to
outpatient is made prior to discharge or release,
while the beneficiary is still a patient of the
hospital.)
45
Ambiguous Gender Category
Claim indicates patient has ambiguous gender
characteristics (e.g. transgendered or
hermaphrodite).
46
Non-Availability Statement on
File
A non-availability statement must be issued for
each TRICARE claim for non-emergency
inpatient care when the TRICARE beneficiary
resides within the catchment’s area (usually a
40-mile radius) of a Uniformed Services
Hospital.
47
Reserved for assignment by the NUBC.
48
Psychiatric Residential Treatment
Centers for Children and
Adolescents (RTCs)
Code to identify claims submitted by a
“TRICARE - authorized” psychiatric Residential
Treatment Center (RTC) for Children and
Adolescents.
49
Product Replacement within
Product Lifecycle
Replacement of a product earlier than the
anticipated lifecycle due to an indication that
the product is not functioning properly.
50
Product Replacement for Known
Recall of a Product
Manufacturer or FDA has identified the product
for recall and therefore replacement.
51-54
55
Reserved for assignment by the NUBC.
SNF Bed Not Available
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Code indicates the patient’s SNF admission was
delayed more than 30 days after hospital
discharge because a SNF bed was not available.
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56
Medical Appropriateness
Code indicates the patient’s SNF admission was
delayed more than 30 days after hospital
discharge because his condition made it
inappropriate to begin active care within that
period.
57
SNF Readmission
Code indicates the patient was previously
receiving Medicare covered SNF care within 30
days of this readmission.
58
Terminated Medicare Advantage
Enrollee
Code indicates that patient is a terminated
enrollee in a Medicare Advantage plan whose
three-day inpatient hospital stay was waived.
59
Non-primary ESRD Facility
Code indicates that ESRD beneficiary received
non-scheduled or emergency dialysis services at
a facility other than his/her primary ESRD
dialysis facility.
60
Day Outlier
A hospital being paid under a prospective
payment system is reporting this stay as a day
outlier.
61
Cost Outlier
A hospital being paid under a prospective
payment system is requesting additional payment
for this stay as a cost outlier.
62
Payer Code
FOR PAYER INTERNAL USE ONLY.
(Providers do not report this code.)
63
Payer Code
FOR PAYER INTERNAL USE ONLY.
(Providers do not report this code.)
64-65
Payer Code
FOR PAYER INTERNAL USE ONLY.
(Providers do not report this code.)
66
Provider Does Not Wish Cost
Outlier Payment
A hospital paid under a prospective payment
system is NOT requesting additional payment for
this stay as a cost outlier.
67
Beneficiary Elects Not to Use
Life Time Reserve (LTR) Days
Indicates beneficiary elects not to use LTR days.
68
Beneficiary Elects to use Life
Time Reserve (LTR) Days
Indicates beneficiary has elected to use LTR days
when charges are less than LTR co-insurance
amounts.
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69
IME/DGME/N&AH
Payment Only
Code indicates a request for a supplemental
payment for IME/DGME/N&AH (Indirect
Medical Education/Graduate Medical
Education/Nursing and Allied Health).
70
Self Administered Anemia
Management Drug
Code indicates the billing is for a home dialysis
patient who self administers an anemia
management drug, such as erythropoetin alpha
(EPO) or darbepoetin alpha.
71
Full Care in Unit
Code indicates the billing is for a patient who
received staff-assisted dialysis services in a
hospital or renal dialysis facility.
72
Self Care in Unit
Code indicates the billing is for a patient who
managed his own dialysis services without staff
assistance in a hospital or renal dialysis facility.
73
Self Care Training
Code indicates the billing is for special dialysis
services where a patient and his helper (if
necessary) were learning to perform dialysis.
74
Home
Code indicates the billing is for a patient who
received dialysis services at home, but where
code 75 below does not apply.
75
Home - 100 Percent
Reimbursement
Code indicates the billing is for a patient who
received dialysis services at home, using a
dialysis machine that was purchased by Medicare
under the 100 percent program.
(Code is no longer used for Medicare.)
76
Back-up in Facility Dialysis
Code indicates the billing is for a home dialysis
patient who received back-up dialysis in a
facility.
77
Provider Accepts or is
Obligated/Required due to a
Contractual Arrangement or Law
to Accept Payment by a Primary
Payer as Payment in Full.
Code indicates you have accepted or are
obligated/required due to a contractual
arrangement or law to accept payment as
payment in full. Therefore, no payment is due.
(If Medicare, prepare the bill as a no payment
bill See Medicare Manual instructions)
78
New Coverage Not Implemented
by Managed Care Plan
Billing is for a newly covered service for which
the managed care plan/HMO does not pay.
(Note: For outpatient bills Condition Code 04
should be omitted).
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79
CORF Services Provided Offsite
Enter this code to indicate that physical therapy,
occupational therapy, or speech pathology
services were provided offsite.
80
Home Dialysis - Nursing Facility
Home dialysis furnished in a SNF or nursing
facility.
81-99
Reserved for assignment by the NUBC.
A0
TRICARE External Partnership
Program
This code identifies TRICARE claims submitted
under the External Partnership Program.
A1
EPSDT/CHAP
Early and Periodic Screening Diagnosis and
Treatment.
A2
Physically Handicapped
Children’s Program
Services provided under this program receive
special funding through Title VII of the Social
Security Act or the TRICARE program for the
Handicapped.
A3
Special Federal Funding
This code has been designed for uniform use as
defined by state law.
A4
Family Planning
This code has been designed for uniform use as
defined by state law.
A5
Disability
This code has been designed for uniform use as
defined by state law.
A6
Vaccines/Medicare 100%
Payment
This code identifies that pneumococcal
pneumonia and influenza vaccine services are
reimbursed under special Medicare program
provisions and Medicare deductible and
coinsurance requirements do not apply.
A7-A8
Reserved for assignment by the NUBC.
A9
Second Opinion Surgery
Services requested to support second opinion on
surgery. Part B deductible and coinsurance do
not apply.
AA
Abortion Performed due to Rape
Code indicates abortion performed due to a rape.
AB
Abortion Performed due to Incest
Code indicates abortion performed due to an
incident of incest.
AC
Abortion Performed due to
Serious Fetal Genetic Defect,
Deformity, or Abnormality
Code indicates abortion performed due to a
genetic defect, a deformity, or abnormality to the
fetus.
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AD
Abortion Performed due to a Life
Endangering Physical Condition
Abortion performed due to a life endangering
physical condition caused by, or, arising from or
exacerbated by the pregnancy itself.
AE
Abortion Performed due to
Physical Health of Mother that is
not Life Endangering
Abortion performed due to physical health of
mother that is not life endangering.
AF
Abortion Performed due to
Emotional/psychological Health
of the Mother
Abortion performed due to
emotional/psychological health of the mother.
AG
Abortion Performed due to Social Abortion performed due to social or economic
or Economic Reasons
reasons.
AH
Elective Abortion
Elective abortion.
AI
Sterilization
Sterilization.
AJ
Payer Responsible for Copayment
Payer responsible for co-payment.
AK
Air Ambulance Required
For ambulance claims. Air ambulance required;
time needed to transport poses a threat.
AL
Specialized Treatment/bed
Unavailable - Alternate Facility
transport
For ambulance claims. Specialized
treatment/bed unavailable. Transport to alternate
facility.
AM
Non-emergency Medically
Necessary Stretcher Transport
Required
For ambulance claims. Non-emergency
medically necessary stretcher transport required.
AN
Preadmission Screening Not
Required
Person meets the criteria for an exemption from
preadmission screening.
AO-AZ
Reserved for assignment by the NUBC.
B0
Medicare Coordinated Care
Demonstration Claim
Patient is participant in the Medicare
Coordinated Care Demonstration.
B1
Beneficiary is Ineligible for
Demonstration Program
Beneficiary is ineligible for demonstration
program.
B2
Critical Access Hospital
Ambulance Attestation
Attestation by Critical Access Hospital that it
meets the criteria for exemption from the
ambulance fee schedule.
B3
Pregnancy Indicator
Indicates patient is pregnant. Required when
mandated by law; determination of pregnancy
completed in compliance with applicable law.
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B4
Admission Unrelated to
Discharge on Same Day
B5-C0
Form Locators 18-28
Page 11 of 13
Report code when a patient is
discharged/transferred from an acute care PPS
hospital on the same day for symptoms unrelated
to and/or not for evaluation and management of,
the prior stay’s medical condition.
Reserved for assignment by the NUBC.
C1
Approved as Billed
The services provided for this billing period have
been reviewed by the QIO or intermediary, as
appropriate, and are fully approved including any
day or cost outlier.
C2
Automatic Approval as Billed
Based on Focused Review
This should include only categories of cases that
the QIO has determined it need not review under
a focused review program. (No longer used for
Medicare.)
C3
Partial Approval
The services provided for this billing period have
been reviewed by the QIO or intermediary, as
appropriate, and some portion has been denied
(days, or services).
C4
Admission/Services Denied
This should only be used to indicate that all of
the services were denied by the QIO.
C5
Post Payment Review Applicable
This should be used indicated that the QIO
review will take place after payment.
C6
Admission Preauthorization
The QIO authorized this admission/service but
has not reviewed the services provided.
C7
Extended Authorization
The QIO has authorized these services for an
extended length of time but has not reviewed the
services provided.
C8-CZ
Reserved for assignment by the NUBC.
D0
Changes to Service Dates
Changes to service dates.
D1
Changes to Charges
Changes to charges.
D2
Changes in Revenue Codes/
HCPCS/HIPPS Rate Codes
Report this claim change reason code on a
replacement claim (Bill Type Frequency Code 7)
to reflect a change in Revenue Codes (FL42)/
HCPCS/HIPPS Rate Codes (FL44).
D3
Second or Subsequent Interim
PPS Bill
Second or subsequent Interim PPS bill.
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D4
Change in clinical codes (ICD)
for Diagnosis and/or Procedure
Codes
Report this claim change reason code on a
replacement claim (Bill Type Frequency Code 7)
to reflect a change in diagnosis (FL67) and
procedure codes (FL74).
D5
Cancel to Correct Insured’s ID or
Provider ID
Cancel only to correct insured’s ID or provider
identification number.
D6
Cancel Only to Repay a
Duplicate or OIG Overpayment
Cancel only to repay a duplicate payment or OIG
overpayment. (Includes cancellation of an
outpatient bill containing services required to be
included on the inpatient bill.)
D7
Change to Make Medicare the
Secondary Payer
Change to make Medicare the secondary payer.
D8
Change to Make Medicare the
Primary Payer
Change to make Medicare the primary payer.
D9
Any Other Change
Any other change.
DA-DQ
DR
Reserved for assignment by the NUBC.
Disaster Related
Used to identify claims that are or may be
impacted by specific payer/health plan policies
related to a national or regional disaster.
Change in Patient Status
Change in patient status.
DS-DZ
E0
E1-E9
G0
Reserved for assignment by the NUBC.
Distinct Medical Visit
G1-GZ
H0
Report this code when multiple medical visits
occurred on the same day in the same revenue
center but the visits were distinct and constituted
independent visits. An example of such a
situation would be a beneficiary going to the
emergency room twice on the same day, in the
morning for a broken arm and later for chest
pain.
Reserved for assignment by the NUBC.
Delayed Filing; Statement of
Intent Submitted
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Code indicates submission of “Statement of
Intent” within the qualifying period to
specifically identify the existence of another third
party liability situation.
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H1-LZ
Reserved for assignment by the NUBC.
M0-MZ
Reserved for payer assignment.
N0-OZ
Reserved for assignment by the NUBC.
P0
Reserved for PUBLIC HEALTH DATA
REPORTING.
P1
Do Not Resuscitate Order (DNR)
FOR PUBLIC HEALTH REPORTING ONLY.
Code indicates that a DNR order was written at
the time of or within the first 24 hours of the
patient’s admission to the hospital and is clearly
documented in the patient’s medical record.
P2-PZ
Reserved for PUBLIC HEALTH DATA
REPORTING.
Q0-VZ
Reserved for assignment by the NUBC.
W0
United Mine Workers of America
(UMWA) Demonstration
Indicator
W1-ZZ
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Reserved for assignment by the NUBC.
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Form Locator 29
Data
Element
Accident State
Definition:
The accident state field contains the two-digit state abbreviation where the accident
occurred.
Reporting
• UB-04: Situational. Required when the services reported on this claim are related
to an auto accident and the accident occurred in a country or location that has a state,
province, or sub-country code named in X12 code source 22 (ISO 3166-2 Codes for
the representation of names of countries and their subdivisions).
• 004010/004010A1: Not Used
• 005010: Situational. Required when the services reported on this claim are related
to an auto accident and the accident occurred in a country or location that has a state,
province, or sub-country code named in X12 code source 22 (ISO 3166-2 Codes for
the representation of names of countries and their subdivisions).
Field
Attributes
1 Field
1 Line
2 Positions
Alphanumeric
Left-justified
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 30
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
11 Positions (upper line)
13 Positions (lower line)
Alphanumeric
Left-justified
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Form Locators 31-34, 35-36
Page 1 of 8
GUIDELINES FOR OCCURRENCE AND
OCCURRENCE SPAN UTILIZATION
Occurrence and Occurrence Span codes are mutually exclusive. Occurrence Codes have values from
01-69 and A0-LZ; Occurrence Span Codes have values from 70-99 and M0-ZZ.
Example of Occurrence Code use: A Medicare beneficiary was confined in the hospital from
January 1, 2005 to January 10, 2005, however his Medicare Part A benefits were exhausted as of
January 8, 2005, and he was not entitled to Part B benefits. Therefore, Form Locator 31 should
contain code A3 and the date 010805.
The Occurrence Span Code fields can be utilized to submit additional Occurrence Codes when
necessary. This is accomplished by leaving the THROUGH date blank in FL 35-36. As a result, as
many as 12 Occurrence Codes may be reported.
Report Occurrence Codes in the following order: FL 31a, 32a, 33a, 34a, 31b, 32b, 33b, 34b. If there
are Occurrence Span Code fields available, fields 35a FROM, 36a FROM, 35b FROM and 36b
FROM may then be used as an overflow. After all of these fields are exhausted, FL 81 (Code-Code
field) can be used with the appropriate qualifier (A2) to report additional codes and dates.
Report Occurrence Span Codes in the following order: FL 35a, 36a, 35b, 36b. Use qualifier A3 on
FL 81 as an overflow for Occurrence Span Codes. The third column in FL 81 is 12 positions, which
accommodates both the FROM and THOUGH date in a single field.
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Form Locator: 31-34
Page 2 of 8
Data
Element
Occurrence Codes and Dates
Definition:
The code and associated date defining a significant event relating to this bill that may
affect payer processing.
Reporting
• UB-04: Situational. Required when there is an Occurrence Code that applies to this
claim.
• 004010/004010A1: Situational. Required when occurrence information applies to
the claim or encounter.
• 005010: Situational. Required when there is an Occurrence Code that applies to
this claim.
Field
Attributes
4 Fields (codes)
2 Lines
2 Positions
Alphanumeric
Left-Justified (all positions fully coded)
Notes
Enter all dates as month, day, and year (MMDDYY). Example: “010105”
4 Fields (dates)
2 Lines
6 Positions
Numeric
Right-justified
Occurrence Codes should be entered in alphanumeric sequence (numbered codes
precede alpha codes). See “GUIDELINES FOR OCCURRENCE AND
OCCURRENCE SPAN UTILIZATION” on the preceding page.
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Official UB-04 Data Specifications Manual 2007
Form Locators 31-34
Page 3 of 8
01
Accident/Medical Coverage
Code indicating accident-related injury for which
there is medical payment coverage. Provide the
date of accident/injury.
02
No Fault Insurance Involved Including Auto Accident/Other
Code indicating the date of an accident including
auto or other where state has applicable no fault
liability laws (i.e., legal basis for settlement
without admission of proof of guilt).
03
Accident/Tort Liability
Code indicating the date of an accident resulting
from a third party’s action that may involve a
civil court process in an attempt to require
payment by the third party, other than no fault
liability.
04
Accident/Employment Related
Code indicating the date of an accident allegedly
relating to the patient’s employment.
05
Accident/No Medical or Liability
Coverage
Code indicating accident related injury for which
there is no medical payment or third-party
liability coverage. Provide the date of
accident/injury.
06
Crime Victim
Code indicating the date on which a medical
condition resulted from alleged criminal action
comitted by one or more parties.
07-08
Reserved for assignment by the NUBC.
09
Start of Infertility Treatment
Cycle
Code indicating the date of start of infertility
treatment cycle.
10
Last Menstrual Period
Code indicating the date of the last menstrual
period; ONLY applies when patient is being
treated for maternity related condition.
11
Onset of Symptoms/Illness
Code indicating the date the patient first became
aware of symptoms/illness.
12
Date of Onset for a Chronically
Dependent Individual
(HHA Claims Only.) Code denotes date the
patient/beneficiary becomes a Chronically
Dependent Individual (CDI). This is the first
month of the 3-month period immediately before
eligibility under respite care benefit.
13-15
16
Reserved for assignment by the NUBC.
Date of Last Therapy
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Code denotes last day of therapy services (e.g.,
physical therapy, occupational therapy, speech
therapy).
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Official UB-04 Data Specifications Manual 2007
Form Locators 31-34
Page 4 of 8
17
Date Outpatient Occupational
Therapy Plan Established or Last
Reviewed
Code denotes date an occupational therapy plan
was established or last reviewed.
18
Date of Retirement
Patient/Beneficiary
The date of retirement for the patient/beneficiary.
19
Date of Retirement Spouse
Code denotes the retirement date for the patient’s
spouse.
20
Date Guarantee of Payment
Began
Code indicates date on which the provider began
claiming Medicare payment under the guarantee
of payment provision (see Medicare manual for
special Medicare instructions).
21
Date UR Notice Received
Code indicating the date of receipt by the
provider of the UR Committee’s finding that the
admission or future stay was not medically
necessary.
22
Date Active Care Ended
Code indicates the date covered level of care
ended in a SNF or general hospital, or date on
which active care ended in a psychiatric or
tuberculosis hospital, or date on which patient
was released on a trial basis from a residential
facility. Code not required when Condition Code
21 is used.
23
Payer Code
THESE CODES ARE SET ASIDE FOR PAYER
USE ONLY. PROVIDERS DO NOT REPORT
THESE CODES.
24
Date Insurance Denied
Code indicating the date the denial of coverage
was received by the health care facility from any
insurer.
25
Date Benefits Terminated by
Primary Payer
Code indicating the date on which coverage
(including Worker’s Compensation benefits or
no-fault coverage) is no longer available to the
patient.
26
Date SNF Bed Became Available
Code indicating the date on which a SNF bed
became available to hospital inpatient who
requires only SNF level care.
27
Date of Hospice Certification or
Re-Certification
Code indicating the date of certification or recertification of the hospice benefit period.
28
Date Comprehensive Outpatient
Rehabilitation Plan Established
or Last Reviewed
Code indicating the date a comprehensive
outpatient rehabilitation plan was established or
last reviewed.
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Official UB-04 Data Specifications Manual 2007
Form Locators 31-34
Page 5 of 8
29
Date Outpatient Physical Therapy Code indicating the date a physical therapy plan
Plan Established or Last
established or last reviewed.
Reviewed
30
Date Outpatient Speech
Pathology Plan Established or
Last Reviewed
Code indicating the date a speech pathology plan
was established or last reviewed.
31
Date Beneficiary Notified of
Intent to Bill (Accommodations)
The date of notice provided by the hospital to the
patient that inpatient care is no longer required.
32
Date Beneficiary Notified of
Intent to Bill (Procedures or
Treatments)
The date of notice provided to the beneficiary
that requested care (diagnostic procedures or
treatments) may not be reasonable or necessary.
33
First Day of the Coordination
Period for ESRD Beneficiaries
Covered by EGHP
Code indicates the first day of coordination for
benefits that are secondary to benefits payable
under an employer’s group health plan. Required
only for ESRD beneficiaries.
34
Date of Election of Extended
Care Facilities
Code indicates the date the guest elected to
receive extended care services (used by Religious
Non-Medical only).
35
Date Treatment Started for
Physical Therapy
Code indicates the initial date services by the
billing provider for physical therapy began.
36
Date of Inpatient Hospital
Code indicates the date of discharge for inpatient
Discharge for Covered Transplant hospital stay in which the patient received a
Patients
covered transplant procedure when the hospital is
billing for immunosuppressive drugs. Note:
When the patient received both a covered and a
non-covered transplant, the covered transplant
predominates.
37
Date of Inpatient Hospital
Discharge for Non-covered
Transplant Patient
Code indicates the date of discharge for the
inpatient hospital stay in which the patient
received a non-covered transplant procedure
when the hospital is billing for
immunosuppressive drugs.
38
Date Treatment Started for Home
IV Therapy
Date the patient was first treated at home for IV
therapy. (Home IV providers - Bill Type 085x.)
39
Date Discharged on a Continuous
Course of IV Therapy
Date the patient was discharged from the hospital
on continuous course of IV therapy. (Home IV
providers - Bill Type 085x.)
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Official UB-04 Data Specifications Manual 2007
Form Locators 31-34
Page 6 of 8
40
Scheduled Date of Admission
The scheduled date the patient will be admitted
as an inpatient to the hospital. (This code may
only be used on an outpatient claim.)
41
Date of First Test Pre-admission
Testing
The date on which the first outpatient diagnostic
test was performed as part of a PAT program.
This code may only be used if a date of
admission was scheduled before the
administration of the test(s).
42
Date of Discharge
Use only when “Through” date in Form Locator
06 (Statement Covers Period) is not the actual
discharge date and the frequency code in Form
Locator 04 is that of a final bill.
For final bill for hospice care, enter the date the
Medicare beneficiary terminated his election of
hospice care.
43
Scheduled Date of Canceled
Surgery
The date for which outpatient surgery was
scheduled.
44
Date Treatment Started
Occupational Therapy
The date services were initiated by the billing
provider for occupational therapy.
45
Date Treatment Started for
Speech Therapy
The date services were initiated by the billing
provider for speech therapy.
46
Date Treatment Started for
Cardiac Rehabilitation
The date services were initiated by the billing
provider for cardiac rehabilitation.
47
Date Cost Outlier Status Begins
Code indicates that this is the first day after the
day the Cost Outlier threshold is reached.
For Medicare purposes, a beneficiary must have
regular, coinsurance and/or lifetime reserve days
available beginning on this date to allow
coverage of additional daily charges for the
purpose of making a cost outlier payment.
48-49
Payer Codes
50-69
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THESE CODES ARE SET ASIDE FOR PAYER
USE ONLY. PROVIDERS DO NOT REPORT
THESE CODES.
Reserved for assignment by the NUBC.
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Meeting Date:
A0
Official UB-04 Data Specifications Manual 2007
Form Locators 31-34
Page 7 of 8
Reserved for assignment by the NUBC.
A1
Birth Date - Insured A
The birth date of the individual in whose name
the insurance is carried.
A2
Effective Date - Insured A Policy
A code indicating the first date insurance is in
force.
A3
Benefits Exhausted - Payer A
Code indicating the last date for which benefits
are available and after which no payment can be
made to Payer A
A4
Split Bill Date
Date patient became eligible due to medically
needy spend down (sometimes referred to as
“Split Bill Date”).
A5-AZ
Reserved for assignment by the NUBC.
B0
Reserved for assignment by the NUBC.
B1
Birth Date - Insured B
The birth date of the individual in whose name
the insurance is carried.
B2
Effective Date - Insured B Policy
A code indicating the first date insurance is in
force.
B3
Benefits Exhausted - Payer B
Code indicating the last date for which benefits
are available and after which no payment can be
made by Payer B.
B4-BZ
Reserved for assignment by the NUBC.
C0
Reserved for assignment by the NUBC.
C1
Birth Date - Insured C
The birth date of the individual in whose name
the insurance is carried.
C2
Effective Date - Insured C Policy
A code indicating the first date insurance is in
force.
C3
Benefits Exhausted - Payer C
Code indicating the last date for which benefits
are available and after which no payment can be
made by Payer C.
C4-DQ
DR
DS-DZ
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Reserved for assignment by the NUBC.
Reserved for Disaster Related Occurrence Code.
Reserved for assignment by the NUBC.
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Official UB-04 Data Specifications Manual 2007
Effective Date: March 1, 2007
Meeting Date:
Form Locators 31-34
Page 8 of 8
E0
Reserved for assignment by the NUBC.
E1
Discontinued 3/1/07.
E2
Discontinued 3/1/07.
E3
Discontinued 3/1/07.
E4-EZ
Reserved for assignment by the NUBC.
F0
Reserved for assignment by the NUBC.
F1
Discontinued 3/1/07.
F2
Discontinued 3/1/07.
F3
Discontinued 3/1/07.
F4-FZ
Reserved for assignment by the NUBC.
G0
Reserved for assignment by the NUBC.
G1
Discontinued 3/1/07.
G2
Discontinued 3/1/07.
G3
Discontinued 3/1/07.
G4-LZ
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Official UB-04 Data Specifications Manual 2007
Form Locators 35-36
Page 1 of 3
Data
Element
Occurrence Span Codes and Dates
Definition:
A code and the related dates that identify an event that relates to the payment of the
claim.
Reporting
• UB-04: Situational. Required when there is an Occurrence Span Code that applies
to this claim.
• 004010/004010A1: Situational. Required when occurrence span information
applies to the claim or encounter.
• 005010: Situational. Required when there is an Occurrence Span Code that applies
to this claim.
Field
Attributes
2 Fields (codes)
2 Lines
2 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
These codes identify occurrences that happened over a span of time.
Enter all dates as month, day, and year (MMDDYY). Example: “FROM” 010105;
“THROUGH” 010705
4 Fields (dates)
2 Lines
6 Positions
Numeric
Right-justified (all positions fully
coded)
Enter Occurrence Span Codes in alphanumeric sequence starting with code 70 and
ending with ZZ (numbered codes precede alpha codes). If FL 35a & b and FL 36a &
b have been filled and additional occurrence span codes are required, use FL 81 with
the appropriate qualifier code (A3) to indicate that an Occurrence Span Code is being
reported.
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Official UB-04 Data Specifications Manual 2007
Form Locators 35-36
Page 2 of 3
70
Qualifying Stay Dates For SNF
Use Only
The from/through date of at least a 3-day
inpatient hospital stay that qualifies the resident
for Medicare payment of SNF services billed.
Code can be used only by SNF for billing.
71
Prior Stay Dates
The from/through dates given by the patient of
any hospital stay that ended within 60 days of
this hospital or SNF admission.
72
First/Last Visit Dates
The from/through dates of outpatient services.
For use on outpatient bills only where the entire
billing record is not represented by the actual
From/Through service dates of Form Locator 06
(Statement Covers Period).
73
Benefit Eligibility Period
The inclusive dates during which TRICARE
medical benefits are available to a sponsor’s
beneficiary as shown on the beneficiary’s ID
card.
74
Non-covered Level of
Care/Leave of Absence Dates
The from/through dates of a period at a noncovered level of care or leave of absence in an
otherwise covered stay, excluding any period
reported by Occurrence Span Code 76, 77, or 79
below.
75
SNF Level of Care Dates
The from/through dates of a period of SNF level
of care during an inpatient hospital stay.
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Official UB-04 Data Specifications Manual 2007
Form Locators 35-36
Page 3 of 3
76
Patient Liability
The from/through dates of a period of
non-covered care for which the hospital is
permitted to charge the Medicare beneficiary.
Code should be used only where the QIO or
intermediary has approved such charges in
advance and patient has been notified in writing
at least three days prior to the from date of this
period.
77
Provider Liability Period
The from/through dates of a period of
non-covered care for which the provider is
liable; utilization is charged.
78
SNF Prior Stay Dates
The from/through dates given by the patient of
any SNF or nursing home stay that ended within
60 days of this hospital or SNF admission.
79
Payer Code
THIS CODE IS SET ASIDE FOR PAYER USE
ONLY. PROVIDERS DO NOT REPORT THIS
CODE.
80-99
Reserved for assignment by the NUBC.
M0
QIO/UR Approved Stay Dates
The first and last days that were approved where
not all of the stay was approved. (Use when
Condition Code C3 is used in Form Locators 1828.)
M1
Provider Liability - No
Utilization
Code indicates the from/through dates of a period
of noncovered care that is denied due to lack of
medical necessity or as custodial care for which
the provider is liable. The beneficiary is not
charged with utilization. The provider may not
collect Part A or Part B deductible or coinsurance
from the beneficiary.
M2
Inpatient Respite Dates
The from/through dates of a period of inpatient
respite care.
M3
ICF Level of Care
The from/through dates of a period of
intermediate level of care during an inpatient
hospital stay.
M4
Residential Level of Care
The from/through dates of a period of residential
level of care during an inpatient hospital stay.
M5-MQ
MR
MS-ZZ
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Reserved for assignment by the NUBC.
Reserved for Disaster Related Occurrence
Span Code.
Reserved for assignment by the NUBC.
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 37
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
8 Positions
Alphanumeric
Left-justified
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Meeting Date:
Form Locator 38
Data
Element
Responsible Party Name and Address
Definition:
The name and address of the party responsible for the bill.
Reporting
• UB-04: Situational. Use to print the name and mailing address of the party
responsible for the bill if a window envelope is utilized.
• 004010/004010A1: Situational.
• 005010: Not Used.
Field
Attributes
1 Field
5 Lines
40 Positions
Alphanumeric
Left-justified
Notes
Address may include post office box or street name and number, city, state and ZIP
code. Hospitals should abbreviate state in the address according to the post office
standard abbreviations appearing in the instructions for Form Locator 01.
If a nine-digit ZIP code is used, it should be entered XXXXX-XXXX.
Example: “12345-6789”
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Effective Date: March 1, 2007
Meeting Date:
Form Locators 39-41
Page 1 of 17
Data
Element
Value Codes and Amounts
Definition:
A code structure to relate amounts or values to identify data elements necessary to
process this claim as qualified by the payer organization.
Reporting
• UB-04: Situational. Required when there is a Value Code that applies to this claim.
• 004010/004010A1: Situational. Required when value information applies to the
claim or encounter.
• 005010: Situational. Required when there is a Value Code that applies to this
claim.
Field
Attributes
3 Fields (codes)
4 Lines
2 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
Whole numbers or non-dollar amounts are right-justified to the left of the
dollars/cents delimiter.
3 Fields (amounts)
4 Lines
9 Positions
Numeric
Right-justified (see Notes)
Do not zero fill the positions to the left of the delimiter. However, some values are
reported as cents, thus reference to the instructions for specific codes are necessary.
Enter value codes in alphanumeric sequence.
Fields 39a through 41a must be completed before the b fields, etc.
Negative numbers are not allowed except in Form Locator 41.
When reporting six zeros (000000), do not report the decimal; it is implied and
denotes the delimited field between whole dollars and cents.)
If all of the Value Code fields are filled, use FL 81 Code-Code field with the
appropriate qualifier code (A4) to indicate that a Value Code is being reported.
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Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 2 of 17
01
Most Common Semi-private Rate To provide for the recording of hospital’s most
common semi-private rate.
02
Hospital has no Semi-private
rooms
03
04
Entering this code requires $0.00 amount.
Reserved for assignment by the NUBC.
Professional Component Charges
Which are Combined Billed
Code indicates the amount shown is the sum of
technical and professional charges, which are
combined, billed.
Medicare uses this information in internal
processes and in the CMS notice of utilization
sent to the patient to explain that Part B
coinsurance applies to the professional
component. (Used only by some all inclusive rate
hospitals.)
05
Professional Component included Amount shown is the combined billed charges
in Charges and also Billed
(technical and professional); however the
Separate to Carrier
provider is submitting a separate professional bill
to the health plan.
For use on Medicare or TRICARE bills and all
Medicaid bills if state specifies need for this
information.
06
Blood Deductible
Total cash blood deductible.
If appropriate, enter Medicare Part A or Part B
blood deductible amount. (To report other than
the blood deductible, that is to report the
program deductible, see Value Codes (FL39FL41) A1, B1, and C1.)
07
08
Reserved for assignment by the NUBC.
Life Time Reserve Amount in the Lifetime reserve amount charged in the year of
First Calendar Year
admission.
Note: For Medicare, use this code only for Part
A bills. For Part B Coinsurance use Value
Codes (FL39-41) A2, B2, and C2).
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Form Locators 39-41
Page 3 of 17
09
Coinsurance Amount in the First
Calendar Year
Coinsurance amounts, charged in the year of
admission.
10
Lifetime Reserve Amount in the
Second Calendar Year
Lifetime reserve amount charged in the year of
discharge where the bill spans two calendar
years.
11
Coinsurance Amount in the
Second Calendar Year
Coinsurance amount charged in the year of
discharge where the inpatient bill spans two
calendar years.
12
Working Aged
Beneficiary/Spouse with
Employer Group Health Plan
Amount shown reflects that portion of a payment
from a higher priority employer group health
insurance made on behalf of an aged beneficiary.
For Medicare purposes the provider is billing
Medicare as the secondary payer (based on MSP
development) for covered services on this bill.
13
ESRD Beneficiary in a Medicare
Coordination Period with an
Employer Group Health Plan
Amount shown is that portion of a payment from
a higher priority employer group health insurance
payment made on behalf of an ESRD beneficiary
that the provider is applying to Medicare covered
services on this bill.
14
No-Fault, Including Auto/Other
Amount shown is that portion from a higher
priority no-fault insurance, including auto/other
made on behalf of the patient or insured.
For Medicare beneficiaries the provider should
apply this amount to the Medicare covered
services on this bill Enter six zeros (0000.00) in
the amount field if you are claiming conditional
payment. Note: The decimal is implied and not
reported; it refers to the dollar and cents
delimiter.
15
Worker’s Compensation
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Amount shown is that portion of a payment from
a higher priority worker’s compensation
insurance made on behalf of the patient or
insured. For Medicare beneficiaries the provider
should apply this amount to Medicare covered
services on this bill.
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16
PHS, or Other Federal Agency
Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 4 of 17
Amount shown is that portion of a payment from
a higher priority Public Health Service or the
Federal Agency made on behalf of a Medicare
beneficiary that the provider is applying to
Medicare covered services on this bill.
Note: A six zero value entry for Value Codes 12-16 indicates conditional Medicare payment
requested (0000.00). The decimal is implied and not reported; it refers to the dollar and cents
delimiter.
17-20
Payer Code
THESE CODES ARE SET ASIDE FOR PAYER
USE ONLY. PROVIDERS DO NOT REPORT
THESE CODES.
21
Catastrophic
Medicaid-eligibility requirements to be
determined at state level.
22
Surplus
Medicaid-eligibility requirements to be
determined at state level.
23
Recurring Monthly Income
Medicaid-eligibility requirements to be
determined at state level.
24
Medicaid Rate Code
Medicaid-eligibility requirements to be
determined at state level.
25
Offset to the Patient-Payment
Amount - Prescription Drugs
Prescription drugs paid for out of a long-term
care facility resident/patient’s funds in the billing
period submitted (Statement Covers Period).
26
Offset to the Patient-Payment
Amount - Hearing and Ear
Services
Hearing and ear services paid for out of a longterm care facility resident/patient’s funds in the
billing period submitted (Statement Covers
Period).
27
Offset to the Patient-Payment
Amount - Vision and Eye
Services
Vision and eye services paid for out of a longterm care facility resident/patient’s funds in the
billing period submitted (Statement Covers
Period).
28
Offset to the Patient-Payment
Amount - Dental Services
Dental services paid for out of a long-term care
facility resident/patient’s funds in the billing
period submitted (Statement Covers Period).
29
Offset to the Patient-Payment
Amount - Chiropractic Services
Chiropractic services paid for out of a long-term
care facility resident/patient’s funds in the billing
period submitted (Statement Covers Period).
30
Preadmission Testing
This code reflects charges for preadmission
outpatient diagnostic services in preparation for a
previously scheduled admission.
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Form Locators 39-41
Page 5 of 17
31
Patient Liability Amount
Approved amount to charge the beneficiary for
non-covered accommodations, diagnostic
procedures or treatments.
32
Multiple Patient Ambulance
Transport
When more than one patient is transported in a
single ambulance trip, report the total number of
patients transported.
33
Offset to the Patient-Payment
Amount - Podiatric Services
Podiatric services paid for out of a long-term care
facility resident/patient’s funds in the billing
period submitted (Statement Covers Period).
34
Offset to the Patient-Payment
Other medical services paid for out of a longAmount - Other Medical Services term care facility resident/patient’s funds in the
billing period submitted (Statement Covers
Period).
35
Offset to the Patient-Payment
Amount - Health Insurance
Premiums
Health insurance premiums paid for out of longterm care facility resident/patient’s funds in the
billing period submitted (Statement Covers
Period).
Reserved for assignment by the NUBC.
36
37
Pints of Blood Furnished
The total number of pints of whole blood or units
of packed red cells furnished to the patient,
regardless of whether the hospital charges for
blood or not.
38
Blood Deductible Pints
The total number of pints of whole blood or units
of packed red cells furnished to the patient,
regardless of whether the hospital charges for
blood or not.
39
Pints of Blood Replaced
The total number of pints of whole blood or units
of packed red cells furnished to the patient,
regardless of whether the hospital charges for
blood or not.
40
New Coverage Not Implemented
by HMO (for inpatient service
only)
Amount shown is for inpatient charges covered
by the HMO. (Use this code when the bill
includes inpatient charges for newly covered
services that are not paid by the HMO.)
Note: Condition Codes 04 and 78 should also be
reported.
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41
Black Lung
Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 6 of 16
Code indicates the amount shown is that portion
of a higher priority Black Lung (federal program)
payment made on behalf of a Medicare
beneficiary.
Note: The reporting of zeros indicates the
provider is claiming a conditional payment
because there has been a substantial delay in
payment from the Black Lung Program. (See
Medicare manual for further instructions on the
use of this code along with other related UB
code.)
42
VA
Code indicates the amount shown is that portion
of a higher priority VA payment made on behalf
of a Medicare beneficiary and that you are
applying to Medicare as secondary payer for
covered Medicare services on this claim. (See
Medicare manual for further instructions on the
use of this code along with other related UB
codes.)
43
Disabled Beneficiary Under Age
65 with LGHP
Code indicates the amount shown is that portion
of a higher priority LGHP payment made on
behalf of a disabled beneficiary that you are
applying to covered Medicare charges on this
bill. (See Medicare manual for further
instructions on the use of this code along with
other related UB codes.)
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44
Amount provider agreed to
accept from primary payer when
this amount is less than charges
but higher than payment received.
Form Locators 39-41
Page 7 of 17
Report the amount the provider was obligated to
accept from a primary payer when the amount is
less than charges but higher than or equal to the
payment received. Secondary payment may be
due.
Note: The following value codes report the
actual amounts paid: 12- 16, 41-43, and 47.
Value Code 44 should always be equal to, or,
greater than the amounts indicated in the value
codes indicated immediately above.
45
Accident Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
99
The hour when the accident occurred that
necessitated medical treatment. Enter the
appropriate code indicated below right justified
to the left of the dollars/cents delimiter.
12:00 - 12:59 (Midnight)
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
12:00 - 12:59 (Noon)
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
Unknown
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Form Locators 39-41
Page 8 of 17
46
Number of Grace Days
Follows the QIO determination. This is the
number of days determined by the QIO (medical
necessity reviewer) as necessary to arrange for
the patient’s post-discharge care.
47
Any Liability Insurance
Amount shown is that portion from a higher
priority liability insurance made on behalf of a
Medicare beneficiary that the provider is
applying to Medicare covered services on this
bill. Enter six zeros (000000) in the amount field
if you are claiming a conditional payment.
(Note: The decimal is implied and refers to the
dollar and cents delimiter.)
48
Hemoglobin Reading
The most recent hemoglobin reading taken
before the start of this billing period. For
patients just starting, use the most recent value
prior to the onset if treatment. Whole numbers,
i.e., two digits are to be right-justified to the left
of the dollar/cents delimiter; decimals, i.e., one
digit, is to be reported to the right.
49
Hematocrit Reading
The most recent hematocrit reading taken before
the start of this billing period. For patients just
starting, use the most recent value prior to the
onset if treatment. Whole numbers, i.e., two
digits are to be right-justified to the left of the
dollar/cents delimiter; decimals, i.e., one digit, is
to be reported to the right.
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Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 9 of 17
50
Physical Therapy Visit
Report the number of physical therapy visits
provided from the onset of treatment from this
billing provider through this billing period.
Report the number in the dollar portion of the
form locator (right justified to the left of the
dollar/cents delimiter.)
51
Occupational Therapy Visits
Report the number of occupational therapy visits
provided from the onset of treatment t from this
billing provider) through this billing period.
Report the number in the dollar portion of the
form locator right justified to the left of the
dollar/cents delimiter.
52
Speech Therapy Visits
Report the number of speech therapy visits
provided from the onset of treatment by this
billing provider through this period. Report the
number in the dollar portion of the form locator
right justified to the left of the dollar/cents
delimiter.
53
Cardiac Rehab Visits
The number of cardiac rehabilitation visits from
the onset of treatment from the billing provider
through this billing period. Report the number in
the dollar portion of the form locator right
justified to the left of the dollar/cents delimiter.
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Form Locators 39-41
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54
Newborn Birth Weight in Grams
Actual birth weight or weight at time of
admission for an extramural birth. Required on
all claims with Type of Admission of 4 and on
other claims as required by state law.
55
Eligibility Threshold for Charity
Care
The amount at which a health care facility
determines the eligibility threshold for charity
care.
56
Skilled Nurse - Home Visit
Hours (HHA only)
The number of home visit hours of skilled
nursing provided during the billing period.
Count only hours spent in the home. Exclude
travel time. Report in whole hours, right
justified to the left of the dollar/cents delimiter.
(Round to the nearest whole hour.)
57
Home Health Aide - Home Visit
Hours (HHA only)
The number of hours of home health aide
services provided during the billing period.
Count only hours spent in the home. Exclude
travel time. Report in whole hours, right
justified to the left of the dollar/cents delimiter.
(Round to the nearest whole hour.)
58
Arterial Blood Gas (PO2/PA2)
Arterial blood gas value at beginning of each
reporting period for oxygen therapy. This value
or the value in Value Code 59 will be required on
the initial bill for oxygen therapy and on the
fourth month’s bill. Report right justified in the
cent area rounded to the nearest whole number
(report two digits). Example: A value of 56.5
should be reported as 000000 57, i.e., with the 57
reported in the cents area.
59
Oxygen Saturation (O2
Sat/Oximetry)
Oxygen saturation at the beginning of each
reporting period for oxygen therapy. This value
or the value in Value Code 58 will be required on
the initial bill for oxygen therapy and on the
fourth month’s bill. Report right justified in the
cent area. Round to the nearest whole percent
(report two digits). Example: 93.5 percent
should be reported as 000000 94, i.e., with 94
being reported in the cents area. A value of 100
percent would be reported as 000001 00.
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Form Locators 39-41
Page 11 of 17
60
HHA Branch MSA
MSA in which HHA branch is located (Report
MSA when branch location is different than the
HHA’s. Report the MSA number in dollar
portion of the form locator right justified to the
left of the dollar/cents delimiter.
61
Location Where Service is
Furnished (HHA and Hospice)
MSA or Core Based Statistical Area (CBSA)
number (or rural state code) of the location where
the home health or hospice service is delivered.
Report the number in dollar portion of the form
locator right justified to the left of the
dollar/cents delimiter.
Payer Codes
THESE CODES ARE SET ASIDE FOR PAYER
USE ONLY. PROVIDERS DO NOT REPORT
THESE CODES.
66
Medicaid Spend Down Amount
The dollar amount that was used to meet the
recipient’s spend down liability for this claim.
67
Peritoneal Dialysis
The number of hours of peritoneal dialysis
provided during the billing period. Count only
the hours spent in the home. Exclude travel
time. Report in whole hours, right justify to the
left of the dollar/cent delimiter. (Round to the
nearest whole hour.)
68
EPO-Drug
Number of units of EPO administered and/or
supplied relating to the billing period. Report
amount in whole units right justified to the left of
the dollar/cents delimiter.
69
State Charity Care Percent
Code indicates the percentage of charity care
eligibility for the patient. Report the whole
number right justified to the left of the
dollars/cents delimiter and fractional amounts to
the right. For example, a rate of 10.5% is shown
as:
62-65
1
0
5
0
70-79
Payer Codes
THESE CODES ARE SET ASIDE FOR PAYER
USE ONLY. PROVIDERS DO NOT REPORT
THESE CODES.
80(a)
Covered Days
The number of days covered by the primary
payer as qualified by the payer.
(a) Do not use on v. 004010/004010A1 837 electronic claims (use Claim Quantity in Loop ID 2300 |
QTY01 instead).
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Form Locators 39-41
Page 12 of 17
81(a)
Non-Covered Days
Days of care not covered by the primary payer.
82(a)
Co-insurance Days
The inpatient Medicare days occurring after the
60th day and before the 91st day or inpatient
SNF/Swing Bed days occurring after the 20th and
before the 101st day in a single spell of illness.
83(a)
Lifetime Reserve Days
Under Medicare, each beneficiary has a lifetime
reserve of 60 additional days of inpatient hospital
services after using 90 days of inpatient hospital
services during a spell of illness.
84-99
A0
Reserved for assignment by the NUBC.
Special ZIP Code Reporting
Five digit ZIP Code of the location from which
the beneficiary is initially placed on board the
ambulance.
A1(b)
Deductible Payer A
The amount assumed by the provider to be
applied to the patient’s policy/program
deductible amount involving the indicated payer.
(Note: Report Medicare blood deductibles under
Value Code 6.)
A2(b)
Coinsurance Payer A
The amount assumed by the provider to be
applied toward the patient’s coinsurance amount
involving the indicated payer. (Note: For
Medicare, use this code only for reporting Part B
coinsurance amounts. For Part A coinsurance
amounts use Value Codes 8-11.)
A3
Estimated Responsibility Payer A The amount estimated by the provider to be paid
by the indicated payer; it is not the actual
payment.
A4
Covered Self-Administrable
Drugs - Emergency
The covered charge amount for selfadministrable drugs administered to the patient in
an emergency situation (e.g., diabetic coma). For
use with Revenue Code 0637.
A5
Covered Self-Administrable
Drugs - Not Self-Administrable
in Form and Situation Furnished
to Patient
The covered charge amount for selfadministrable drugs administered to the patient
because the drug was necessary for diagnostic
study or other reason (e.g., the drug is
specifically covered by the payer). For use with
Revenue Code 0637.
(a) Do not use on v. 004010/004010A1 837 electronic claims (use Claim Quantity in Loop ID 2300 |
QTY01 instead).
(b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320
| CAS segment (Claim Adjustment Group Code “PR”).
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A6
Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 13 of 17
Covered Self-Administrable
Drugs - Diagnostic Study and
Other
The amount assumed by the provider to be
applied toward the patient’s co-payment amount
involving the indicated payer.
Co-payment Payer A
The amount assumed by the provider to be
applied toward the patient’s co-payment amount
involving the indicated payer.
A8
Patient Weight
Weight of patient in kilograms. Report this data
only when the health plan has a predefined
change in reimbursement that is affected by
weight. For newborns, use Value Code 54
A9
Patient Height
Height of patient in centimeters. Report this data
only when the health plan has a predefined
change in reimbursement that is affected by
height.
AA
Regulatory Surcharges,
Assessments, Allowances or
Health Care Related Taxes Payer
A
The amount of regulatory surcharges,
assessments, allowances or health care related
taxes pertaining to the indicated payer.
AB
Other Assessments or
Allowances (e.g., Medical
Education) Payer A
The amount of other assessments or allowances
(e.g., medical education) pertaining to the
indicated payer.
A7(b)
AC-AZ
Reserved for assignment by the NUBC.
B0
Reserved for assignment by the NUBC.
B1(b)
Deductible Payer B
The amount assumed by the provider to be
applied to the patient’s policy/program
deductible amount involving the indicated payer.
(Note: Medicare blood deductibles should be
reported under Value Code 6.)
B2(b)
Coinsurance Payer B
The amount assumed by the provider to be
applied toward the patient’s coinsurance amount
involving the indicated payer. For Part A
coinsurance amounts use Value Codes 8-11.)
Estimated Responsibility Payer B
The amount estimated by the provider to be paid
by the indicated payer; it is not the actual
payment.
B3
B4-B6
Reserved for assignment by the NUBC.
(b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320
| CAS segment (Claim Adjustment Group Code “PR”).
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B7(b)
Co-payment Payer B
B8-B9
Official UB-04 Data Specifications Manual 2007
Form Locators 39-41
Page 14 of 17
The amount assumed by the provider to be
applied toward the patient’s co-payment amount
involving the indicated payer.
Reserved for assignment by the NUBC.
BA
Regulatory Surcharges,
Assessments, Allowances or
Health Care Related Taxes Payer
B
The amount of regulatory surcharges,
assessments, allowances or health care related
taxes pertaining to the indicated payer.
BB
Other Assessments or
Allowances (e.g., Medical
Education) Payer B
The amount of other assessments or allowances
(e.g., medical education) pertaining to the
indicated payer.
BC-C0
Reserved for assignment by the NUBC.
C1(b)
Deductible Payer C
The amount assumed by the provider to be
applied to the patient’s policy/program
deductible amount involving the indicated payer.
(Note: Medicare blood deductibles should be
reported under Value Code 6.)
C2(b)
Coinsurance Payer C
The amount assumed by the provider to be
applied toward the patient’s coinsurance amount
involving the indicated payer. For Part A
coinsurance amounts use Value Codes 8-11.)
Estimated Responsibility Payer C
The amount estimated by the provider to be paid
by the indicated payer; it is not the actual
payment.
C3
C4-C6
C7(b)
Reserved for assignment by the NUBC.
Co-payment Payer C
The amount assumed by the provider to be
applied toward the patient’s co-payment amount
involving the indicated payer.
CA
Regulatory Surcharges,
Assessments, Allowances or
Health Care Related Taxes Payer
C
The amount of regulatory surcharges,
assessments, allowances or health care related
taxes pertaining to the indicated payer.
CB
Other Assessments or
Allowances (e.g., Medical
Education) Payer C
The amount of other assessments or allowances
(e.g., medical education) pertaining to the
indicated payer.
CC-D2
Reserved for assignment by the NUBC.
(b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320
| CAS segment (Claim Adjustment Group Code “PR”).
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D3
Patient Estimated Responsibility
D4-DQ
DR
Form Locators 39-41
Page 15 of 17
The amount estimated by the provider to be paid
by the indicated patient.
Reserved for assignment by the NUBC.
Reserved for Disaster Related Value Code.
DS-DZ
Reserved for assignment by the NUBC.
E0
Reserved for assignment by the NUBC.
E1
Discontinued 3/1/07.
E2
Discontinued 3/1/07.
E3
Discontinued 3/1/07.
E4-E6
E7
E8-E9
Reserved for assignment by the NUBC.
Discontinued 3/1/07.
Reserved for assignment by the NUBC.
EA
Discontinued 3/1/07.
EB
Discontinued 3/1/07.
EC-EZ
Reserved for assignment by the NUBC.
F0
Discontinued 3/1/07.
F1
Discontinued 3/1/07.
F2
Discontinued 3/1/07.
F3
Discontinued 3/1/07.
F4-F6
F7
F8-F9
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Form Locators 39-41
Page 16 of 17
FA
Discontinued 3/1/07.
FB
Discontinued 3/1/07.
FC-G0
Reserved for assignment by the NUBC.
G1
Discontinued 3/1/07.
G2
Discontinued 3/1/07.
G3
Discontinued 3/1/07.
G4-G6
G7
G8-G9
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Form Locators 39-41
Page 17 of 17
GA
Discontinued 3/1/07.
GB
Discontinued 3/1/07.
GC-OZ
Reserved for assignment by the NUBC.
P0
Reserved for PUBLIC HEALTH DATA
REPORTING.
P1
Reserved for PUBLIC HEALTH DATA
REPORTING.
P2 - PZ
Reserved for PUBLIC HEALTH DATA
REPORTING.
Q0-Y0
Reserved for assignment by the NUBC.
Y1
Part A Demonstration Payment
This is the portion of the payment designated as
reimbursement for Part A services under the
demonstration. This amount is instead of the
traditional prospective DRG payment (operating
and capital) as well as any outlier payments that
might have been applicable in the absence of the
demonstration. No deductible or coinsurance has
been applied. Payments for operating IME and
DSH which are processed in the traditional
manner are also not included in this amount.
Y2
Part B Demonstration Payment
This is the portion of the payment designated as
reimbursement for Part B services under the
demonstration. No deductible or coinsurance has
been applied.
Y3
Part B Coinsurance
This is the amount of Part B coinsurance applied
by the intermediary to this claim. For
demonstration claims this will be a fixed
copayment unique to each hospital and DRG (or
DRG/procedure group).
Y4
Conventional Provider Payment
Amount for Non-Demonstration
Claims
This is the amount Medicare would have
reimbursed the provider for Part A services if
there had been no demonstration. This should
include the prospective DRG payment (both
capital as well as operational) as well as any
outlier payment, which would be applicable. It
does not include any pass through amounts such
as that for direct medical education nor interim
payments for operating IME and DSH.
Y5-ZZ
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Official UB-04 Data Specifications Manual 2007
Form Locator 42
Page 1 of 59
Data
Element
Revenue Code
Definition:
Codes that identify specific accommodation, ancillary service or unique billing
calculations or arrangements.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
23 Lines (a)
4 Positions
Alphanumeric
Left-justified (all positions filled)
(a) The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
Notes
Revenue Code categories are four digits with an “x” in the fourth position to denote
the subcategory number. The subcategory number provides a more detailed list
generally ranging from “0” through “9”. When reporting the revenue code on the
claim, the fourth position must include one of the numeric choices available in that
category. The reporting of an “x” is not appropriate.
The “0” in many cases denotes the “General” category and can be used in lieu of other
more specific subcategories (“1” through “9”) if the health plan has no need for a
more specific revenue code subcategory. Health plans receiving such detail, without a
need for that detail, should accept the subcategory and treat it as though it was
reported at the “General” level. Nonetheless, it is recommended that providers use
the more detailed subcategory when applicable/available rather than revenue codes
that end in “0” (General) or “9” (Other); to do otherwise may cause processing delays
for the claim.
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Form Locator 42
Page 2 of 59
Each service should be assigned a revenue code.
For inpatient services involving multiple services for the same item providers
should aggregate the services under the assigned revenue code and then report
the total number of units that represent those services.
For outpatient services providers should report the corresponding HCPCS code
for the service along with the date of service as well as the revenue code.
If multiple services are provided on the same day for like services, that is, those
with the same HCPCS, the provider should aggregate the like services for each
day and report the date along with the number of units provided, as well as the
revenue code. The exception is for Evaluation and Management (E/M)
HCPCS. For E/M HCPCS, report each of these separately but also use
Condition Code “G0” to indicate a Distinct Medical Visit.
Services provided on different days should be listed separately along with the
date of service, units and revenue code.
Revenue codes should be listed in ascending numeric order, by date of service
(outpatient). The exception is Revenue Code 0001 - Total Charge, which is used on
paper claims only and is reported on Line 23 of the last page of the claim.
The Standard Abbreviation is intended for use in the provider’s Charge Description
Master and is not reported on electronic claims.
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0001
Form Locator 42
Page 3 of 59
Total Charge
On the paper UB-04 report the total for all revenue codes as indicated in FL47 Total Charges
and FL48 Non-covered Charges on Line 23 of the last page of the UB-04.
For electronic transactions, report the total charge in the appropriate data segment/field –
Loop 2300 CLM02.
001x
Reserved for Internal Payer Use
002x
Health Insurance - Prospective Payment System (HIPPS)
This revenue code is used to denote that a HIPPS rate code is being reported in FL44.
SubC
0
1
2
3
4
5-9
Subcategory
RESERVED
RESERVED
Skilled Nursing Facility - PPS
Home Health - PPS
Inpatient Rehab Facility –PPS
RESERVED
003x
to
009x
RESERVED
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Standard Abbreviation
SNF PPS (RUG)
HH PPS (HRG)
REHAB PPS (CMG)
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010x
Form Locator 42
Page 4 of 59
All-inclusive Rate
Flat fee charge incurred on either a daily basis or total stay basis for service rendered.
Charge may cover room and board plus ancillary services and board only
SubC
0
1
2-9
Subcategory Definition
All-inclusive room and board
plus ancillary
All-inclusive room and board
RESERVED
Standard Abbreviation
ALL INCL R&B/ANC
Unit
Days
HCPCS
N
ALL INCL R&B
Days
N
011x
Room & Board - Private (One Bed)
Routine service charges for accommodations in a private room (1 bed)
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Medical/Surgical/GYN
Obstetrics (OB)
Pediatric
Psychiatric
Hospice
Detoxification
Oncology
Rehabilitation
Other
Standard Abbreviation
ROOM-BOARD/PVT
MED-SURG-GY/PVT
OB/PVT
PEDS/PVT
PSYCH/PVT
HOSPICE/PVT
DETOX/PVT
ONCOLOGY/PVT
REHAB/PVT
OTHER/PVT
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Note: Most health plans require private rooms be separately identified.
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Room & Board - Semi-private (Two Beds)
Routine service charges for accommodations in a semi-private room (2 beds)
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Medical/Surgical/GYN
Obstetrics (OB)
Pediatric
Psychiatric
Hospice
Detoxification
Oncology
Rehabilitation
Other
Standard Abbreviation
ROOM-BOARD/SEMI
MED-SURG-GY/SEMI
OB/SEMI-PVT
PEDS/SEMI-PVT
PSYCH/SEMI-PVT
HOSPICE/SEMI-PVT
DETOX/SEMI-PVT
ONCOLOGY/SEMI
REHAB/SEMI-PVT
OTHER/SEMI-PVT
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
NOTES: Most health plans cover semi-private rooms
013x
Room & Board - Three and Four Beds
Routine service charges for rooms containing three or four beds
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Medical/Surgical/GYN
Obstetrics (OB)
Pediatric
Psychiatric
Hospice
Detoxification
Oncology
Rehabilitation
Other
Standard Abbreviation
ROOM-BOARD/3&4BED
MED-SURG-GY/3&4BED
OB/3&4BED
PEDS/3&4BED
PSYCH/3&4BED
HOSPICE/3&4BED
DETOX/3&4BED
ONCOLOGY/3&4BED
REHAB/3&4BED
OTHER/3&4BED
NOTES: Most health plans require private rooms be separately identified
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Room & Board – Deluxe Private
Deluxe accommodations substantially in excess of private room services.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Medical/Surgical/GYN
Obstetrics (OB)
Pediatric
Psychiatric
Hospice
Detoxification
Oncology
Rehabilitation
Other
Standard Abbreviation
ROOM-BOARD/DLX PVT
MED-SURG-GY/DLX PVT
OB/DLXPVT
PEDS/DLX PVT
PSYCH/DLXPVT
HOSPICE/DLXPVT
DETOX/DLXPVT
ONCOLOGY/DLXPVT
REHAB/DLXPVT
OTHER/DLXPVT
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
NOTES: Most health plans require deluxe private rooms to be separately identified; these are
generally not covered.
015x
Room & Board - Ward
Routine service charges for accommodations with five or more beds.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Medical/Surgical/GYN
Obstetrics (OB)
Pediatric
Psychiatric
Hospice
Detoxification
Oncology
Rehabilitation
Other
Standard Abbreviation
ROOM-BOARD/WARD
MED-SURG-GY/WARD
OB/WARD
PEDS/WARD
PSYCH/WARD
HOSPICE/WARD
DETOX/WARD
ONCOLOGY/WARD
REHAB/WARD
OTHER/WARD
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
NOTES: Most health plans require ward rooms be separately identified
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Room & Board - Other
Any routine service charges for accommodations that cannot be included in the more specific
revenue center codes. Sterile environment is a room and board charge to be used by
hospitals that are currently separating this charge for billing.
SubC
0
1-3
4
5-6
7
8
9
Subcategory Definition
General Classification
RESERVED
Sterile Environment
RESERVED
Self Care
RESERVED
Other
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Standard Abbreviation
R&B
Unit
Days
HCPCS
N
R&B/STERILE
Days
N
R&B/SELF
Days
N
R&B/OTHER
Days
N
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Nursery
Accommodation charges for nursing care to newborns and premature infants in nurseries.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Newborn - Level I
Newborn - Level II
Newborn - Level III
Newborn - Level IV
RESERVED
Other Nursery
Standard Abbreviation
NURSERY
NURSERY/LEVEL I
NURSERY/LEVEL II
NURSERY/LEVEL III
NURSERY/LEVEL IV
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
NURSERY-OTHER
Days
N
Notes: The levels of care correlate to the intensity of medical care provided to an infant and not the
NICU facility certification level assigned by the state.
The level of care should be clinically evaluated on a daily basis, typically based on the resources
provided to the infant. The assigned revenue code corresponds to the level of care determined during
the daily evaluation. The levels of care and resulting revenue codes may, and likely will, fluctuate
during the infant’s stay in the facility.
Subcategories 1 - 4 for use by facilities with nursery services designed around distinct areas and/or
levels of care. Levels of care defined under state regulations or other statutes that supersede the
guidelines below. For example, some states may have fewer than four levels of care or may have
multiple levels within a category such as intensive care.
Level I: Routine care of apparently normal full-term or pre-term neonates. (Newborn Nursery*)
Level II: Low birth-weight neonates who are not sick, but require frequent feeding, and neonates
who require more hours of nursing than do normal neonates. (Continuing Care*)
Level III: Sick neonates, who do not require intensive care, but require 6-12 hours of nursing each
day. (“Intermediate Care”*)
Level IV: Constant nursing and continuous cardiopulmonary and other support for severely ill
infants. (Intensive Care*)
*As defined in the guidelines adapted from Chapter 2 (Physical Facilities) of Guidelines for Perinatal
Care, Second Edition and published by the American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (1988).
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Leave of Absence
Charges for holding a room while the patient is temporarily away from the provider
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
Reserved
Patient Convenience
Therapeutic Leave
Reserved
Nursing Home (for
Hospitalization)
RESERVED
Other LOA
019x
Subacute Care
Standard Abbreviation
Leave of Absence or LOA
Unit
Days
HCPCS
N
LOA/ PT CONV
LOA/THERAPEUTIC
Days
Days
N
N
LOA/NURS HOME
Days
N
LOA/OTHER
Days
N
Accommodations charges for subacute care to inpatients or skilled nursing facilities
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Subacute Care – Level I
Subacute Care – Level II
Subacute Care – Level III
Subacute Care – Level IV
RESERVED
Other Subacute Care
Standard Abbreviation
SUBACUTE
SUBACUTE/LEVEL I
SUBACUTE/LEVEL II
SUBACUTE/LEVEL III
SUBACUTE/LEVEL IV
SUBACUTE/OTHER
Unit
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
Level I - Skilled Care: Minimal nursing intervention. Comorbidities do not complicate treatment
plan. Assessment of vitals and body systems required 1-2 times per day.
Level II - Comprehensive Care: Moderate nursing intervention. Active treatment of comorbidities.
Assessment of vitals and body systems required 2-3 times per day.
Level III - Complex Care: Moderate to extensive nursing intervention. Active medical care and
treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of
vitals and body systems required 3-4 times per day.
Level IV - Intensive Care: Extensive nursing and technical intervention. Active medical care and
treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of
vitals and body systems required 4-6 times per day.
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Intensive Care Unit
Routine service charges for medical or surgical care provided to patients who require a more
intensive level of care than is rendered in the general medical or surgical unit.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Surgical
Medical
Pediatric
Psychiatric
RESERVED
Intermediate ICU
Burn Care
Trauma
Other Intensive Care
Standard Abbreviation
INTENSIVE CARE (ICU)
ICU/SURGICAL
ICU/MEDICAL
ICU/PEDS
ICU/PSYCH
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
ICU/INTERMEDIATE
ICU/BURN CARE
ICU/TRAUMA
ICU/OTHER
Days
Days
Days
Days
N
N
N
N
Most third-party payers require that charges for this service are to be identified
021x
Coronary Care Unit
Routine service charges for medical care provided to patients with coronary illness who
require a more intensive level of care than is rendered in the general medical or surgical unit.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Myocardial Infarction
Pulmonary Care
Heart Transplant
Intermediate CCU
RESERVED
Other Coronary CCU
Standard Abbreviation
CORONARY CARE (CCU)
CCU/MYO INFARC
CCU/PULMONARY
CCU/TRANSPLANT
CCU/INTERMEDIATE
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
CCU/OTHER
Days
N
Report when a discrete coronary care unit exists for rendering such services.
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Special Charges
Charges incurred during an inpatient stay or on a daily basis for certain services .
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Admission Charges
Technical Support Charge
U.R. Service Charge
Late Discharge, Medically
Necessary
RESERVED
Other Special Charges
Standard Abbreviation
SPECIAL CHARGE
ADMIT CHARGE
TECH SUPPORT CHG
UR CHARGE
LATE DISCH/MED NEC
Unit
OTHER SPEC CHG
HCPCS
N
N
N
N
N
N
Some hospitals may prefer to identify the components of services rendered in greater detail and thus
break out charges that normally would be considered part of routine services.
023x
Incremental Nursing Charge
Extraordinary charges for nursing services assessed in addition to the normal nursing charge
associated with the typical room and board unit.
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
Nursery
OB
ICU
CCU
Hospice
RESERVED
Other
Standard Abbreviation
NURSING INCREM
NUR INCR/NURSERY
NUR INCR/OB
NUR INCR/ICU
NUR INCR/ CCU
NUR INCR/HOSPICE
Unit
Hours
Hours
Hours
Hours
Hours
Hours
HCPCS
N
N
N
N
N
N
NUR INCR/OTHER
Hours
N
Most third-party payers require that charges for this service are to be identified
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All Inclusive Ancillary
A flat-rate charge that is applied on a daily basis or on a total stay basis for ancillary services
only.
SubC
0
1
2
3
4-8
9
Subcategory Definition
General Classification
Basic
Comprehensive
Specialty
RESERVED
Other All Inclusive Ancillary
Standard Abbreviation
ALL INCL ANCIL
ALL INCL BASIC
ALL INCL COMP
ALL INCL SPECIAL
Unit
ALL INCL ANCIL/OTHER
HCPCS
N
N
N
N
N
Hospitals billing in this manner may wish to segregate these charges.
Notes: Revenue codes 0241, 0242, and 0243 are designed for use by Special Residential Facilities
only. See FL 4 Type of Bill 086x.
025x
Pharmacy (also see 063x, an extension of 025x)
Charges for medication produced, manufactured, packed, controlled, assayed, dispensed and
distributed under the direction of a licensed pharmacist.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Generic Drugs
Non-Generic Drugs
Take Home Drugs
Drugs Incident to Other
Diagnostic Services
Drugs Incident to Radiology
Experimental Drugs
Non-Prescription
IV Solutions
Other Pharmacy
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Standard Abbreviation
PHARMACY
DRUGS/GENERIC
DRUGS/NONGENERIC
DRUGS/TAKEHOME
DRUGS/ICIDENT ODX
DRUGS/INCIDENT RAD
DRUGS/EXPERIMT
DRUGS/NONPSCRPT
IV SOLUTIONS
DRUGS/OTHER
Unit
HCPCS
N
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
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IV Therapy
Equipment charge or administration of intravenous solution by specially trained personnel to
individuals requiring such treatment.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Infusion Pump
IV Therapy/Pharmacy Svcs
IV Therapy/Drug/Supply
Delivery
IV Therapy/Supplies
RESERVED
Other IV Therapy
Standard Abbreviation
IV THERAPY
IV THER/INFSN PUMP
IV THER/PHARM SVC
IV
THER/DRUG/SUPPPLY/DEL
IV THER/SUPPLIES
IV THERAPY/OTHER
Unit
HCPCS
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Billing for Home IV providers, require the HCPCS code which describes the pump to be entered in
FL 44.
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027x
Form Locator 42
Page 14 of 59
Medical/Surgical Supplies and Devices (also see 062x, an extension of 027x)
Charges for supply items required for patient care
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Non-sterile Supply
Sterile Supply
Take Home Supplies
Prosthetic/Orthotic Devices
Pacemaker
Intraocular Lens
Oxygen - Take Home
Other Implant (a)
Other Supplies/Devices
Standard Abbreviation
MED-SUR SUPPLIES
NON-STER SUPPLY
STERILE SUPPLY
TAKEHOME SUPPLY
PROSTH/ORTH DEV
PACEMAKER
INTRA OC LENS
O2/TAKEHOME
SUPPLY/IMPLANTS
SUPPLY/OTHER
Unit
HCPCS
Devices
Y
(a) Implantables: That which is implanted, such as a piece of tissue, a tooth, a pellet of medicine, or a
tube or needle containing a radioactive substance, a graft, or an insert. Also included are liquid and
solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed.
An object or material partially or totally inserted or grafted into the body for prosthetic, therapeutic,
diagnostic purposes.
Examples of Other Implants (not all-inclusive): Stents, artificial joints, shunts, grafts, pins, plates,
screws, anchors, radioactive seeds.
Experimental devices that are implantable and have been granted an FDA Investigational Device
Exemption (IDE) number should be billed with revenue code 0624.
028x
Oncology
Charges for the treatment of tumors and related diseases.
SubC
0
1-8
9
Subcategory Definition
General Classification
RESERVED
Other Oncology
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Standard Abbreviation
ONCOLOGY
Unit
HCPCS
ONCOLOGY OTHER
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Durable Medical Equipment (other than renal)
Charges for medical equipment that can withstand repeated use (excludes renal equipment)
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Rental
Purchase of New DME
Purchase of Used DME
Supplies/Drugs for DME
RESERVED
Other Equipment
030x
Laboratory
Standard Abbreviation
DME
DME-RENTAL
DME-NEW
DME-USED
DME-SUPPLIES/DRUGS
Unit
HCPCS
Y
Y
Y
Y
DME-OTHER
Y
Charges for the performance of diagnostic and routine clinical laboratory tests.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Chemistry
Immunology
Renal Patient (Home)
Non-Routine Dialysis
Hematology
Bacteriology & Microbiology
Urology
RESERVED
Other Laboratory
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Standard Abbreviation
MED-SUR SUPPLIES
CHEMISTRY TESTS
IMMUNOLOGY TESTS
RENAL - HOME
NON-RTNE DIALYSIS
HEMATOLOGY TESTS
BACT & MICRO TESTS
UROLOGY TESTS
Unit
HCPCS
Tests
Tests
Tests
Tests
Tests
Tests
Tests
Y
Y
Y
Y
Y
Y
Y
OTHER LAB TESTS
Tests
Y
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Laboratory Pathology
Charges for diagnostic and routine laboratory tests on tissues and culture.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Cytology
Histology
Reserved
Biopsy
RESERVED
Other Laboratory Pathology
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Standard Abbreviation
PATHOLOGY LAB
CYTOLOGY TESTS
HISTOLOGY TESTS
BIOPSY TESTS
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
PATH LAB OTHER
Tests
Y
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Radiology - Diagnostic
Charges for diagnostic radiology services including interpretation of radiographs and
fluorographs.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Angiocardiology
Arthrography
Arteriography
Chest X-Ray
RESERVED
Other Radiology – Diagnostic
Standard Abbreviation
DX X-RAY
DX X-RAY/ANGIO
DX X-RAY/ARTHO
DX X-RAY/ARTER
DX X-RAY/CHEST
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
DX X-RAY/OTHER
Tests
Y
033x
Radiology - Therapeutic and/or Chemotherapy Administration
Charges for therapeutic radiology services and chemotherapy administration to care and treat
patients. Therapies also include injection and/or ingestion of radioactive substances.
Excludes charges for chemotherapy drugs; report these under the appropriate revenue code
(025x or 063x).
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
Chemotherapy Admin Injected
Chemotherapy Admin –Oral
Radiation Therapy
Reserved
Chemotherapy Admin - IV
RESERVED
Other Radiology –
Therapeutic
Standard Abbreviation
RADIOLOGY THERAPY
RAD-CHEMO-INJECT
Unit
Tests
Tests
HCPCS
Y
Y
RAD-CHEMO-ORAL
RAD-RADIATION
Tests
Tests
Y
Y
RAD-CHEMO-IV
Tests
Y
RADIOLOGY OTHER
Tests
Y
Usage note: When using 0331, 0332, or 0335 there must be use of RC 0636.
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034x
Form Locator 42
Page 18 of 59
Nuclear Medicine
Charges for procedures, tests, and radiopharmaceuticals performed by a department handling
radioactive materials as required for diagnosis and treatment of patients.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Diagnostic
Therapeutic
Diagnostic
Radiopharmaceuticals
Therapeutic
Radiopharmaceuticals
RESERVED
Other Nuclear Medicine
Standard Abbreviation
NUCLEAR MEDICINE
NUC MED/DX
NUC MED/RX
NUC MED/DX
RADIOPHARM
NUC MED/RX
RADIOPHARM
Unit
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Tests
Y
NUC MED/OTHER
Tests
Y
Subcategories provide a breakdown to identify specific types of services billed under Nuclear
Medicine
035x
CT Scan
Charges for computed tomographic scans of the head and other parts of the body.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
CT - Head Scan
CT - Body Scan
RESERVED
CT – Other
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Standard Abbreviation
CT SCAN
CT SCAN/HEAD
CT SCAN/BODY
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
CT SCAN/OTHER
Tests
Y
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Operating Room Services
Charges for services provided to patients by specifically trained nursing personnel who assist
physicians in the performance of surgical and related procedures during and immediately
following surgery.
SubC
0
1
2
3-6
7
8
9
Subcategory Definition
General Classification
Minor Surgery
Organ Transplant–Other than
Kidney
RESERVED
Kidney Transplant
RESERVED
Other OR Services
037x
Anesthesia
Standard Abbreviation
OR SERVICES
OR/MINOR
OR/ORGAN TRANS
Unit
HCPCS
Unit
HCPCS
Y
Y
OR/KIDNEY TRANS
OR/OTHER
Charges for anesthesia services.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Anesthesia Incident to
Radiology
Anesthesia Incident to Other
DX Services
RESERVED
Acupuncture
RESERVED
Other Anesthesia
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Standard Abbreviation
ANESTHESIA
ANESTH/INCIDENT RAD
ANESTH/INCIDNT OTHR
DX
Y
ANESTH/ACUPUNC
Y
ANESTH/OTHER
Y
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Blood and Blood Components
Charges for blood and blood components.
SubC
0
1
2
3
4
5
6
7
8
9
039x
Subcategory Definition
General Classification
Packed Red Cells
Whole Blood
Plasma
Platelets
Leukocytes
Other Blood Components
Other Derivatives
(Cryoprecipitate)
RESERVED
Other Blood and Blood
Components
Standard Abbreviation
BLOOD & BLOOD COMP
BLOOD/PKD RED
BLOOD/WHOLE
BLOOD/PLASMA
BLOOD/PLATELETS
BLOOD/LEUKOCYTES
BLOOD/COMPONENTS
BLOOD/DERIVATIVES
Unit
Pints
Pints
Pints
BLOOD/OTHER
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Administration, Processing, and Storage for Blood and Blood Components
Charges for administration, processing and storage of whole blood, red blood cells, platelets,
and other blood components.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Administration (e.g.,
Transfusion)
Processing and Storage
RESERVED
Other Blood Handling
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Standard Abbreviation
BLOOD/ADMIN/STOR
BLOOD/ADMIN
Unit
Pints
HCPCS
Y
Y
BLOOD/STORAGE
Pints
Y
BLOOD/ADMIN/STOR
/OTHER
Y
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Form Locator 42
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Other Imaging Services
Charges for specialty imaging services for body structures.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Diagnostic Mammography
Ultrasound
Screening Mammography
Positron Emission
Tomography
RESERVED
Other Imaging Services
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Standard Abbreviation
IMAGING SERVICE
DIAG MAMMOGRAPHY
ULTRASOUND
SCRN MAMMOGRAPHY
PET SCAN
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
OTHER IMAGE SVCS
Tests
Y
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Respiratory Services
Charges for respiratory services including administration of oxygen and certain potent drugs
through inhalation or positive pressure and other forms of rehabilitative therapy.
SubC
0
1
2
3
4-8
9
Subcategory Definition
General Classification
Reserved
Inhalation Services
Hyperbaric Oxygen Therapy
RESERVED
Other Respiratory Services
042x
Physical Therapy
Standard Abbreviation
RESPIRATORY SVC
Unit
HCPCS
Treatment Y
INHALATION SVC
HYPERBARIC O2
Treatment Y
Treatment Y
OTHER RESPIR SVCS
Treatment Y
Charges for therapeutic exercises, massage and utilization of Effective Date properties of
light, heat, cold, water, electricity, and assist devices for diagnosis and rehabilitation of
patients who have neuromuscular, orthopedic and other disabilities.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Visit
Hourly
Group
Evaluation or Re-evaluation
RESERVED
Other Physical Therapy
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Standard Abbreviation
PHYSICAL THERP
PHYS THERP/VISIT
PHYS THERP/HOUR
PHYS THERP/GROUP
PHYS THERP/EVAL
Unit
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
Y
OTHER PHYS THERP
HCPCS
Y
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Occupational Therapy
Charges for therapeutic interventions to improve, sustain, or restore an individual’s level of
function in performance, of activities of daily living and work, including, therapeutic
activities, therapeutic exercises; sensorimotor processing; psychosocial skills training;
cognitive retraining, fabrication and application of orthotic devices; and training in the use of
orthotic and prosthetic devices; adaptation of environments; and application of physical
agent modalities.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Visit
Hourly
Group
Evaluation or Reevaluation
RESERVED
Other Occupational Therapy
Standard Abbreviation
OCCUPATIONAL THER
OCCUP THERP/VISIT
OCCUP THERP/HOUR
OCCUP THERP/GROUP
OCCUP THERP/EVAL
Unit
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
Y
OCCUP THER/OTHER
HCPCS Y
Services are provided by a qualified occupational therapist.
044x
Speech Therapy - Language Pathology
Charges for services related to impaired functional communications skills.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Visit
Hourly
Group
Evaluation or Reevaluation
RESERVED
Other Speech Therapy
Standard Abbreviation
SPEECH THERAPY
SPEECH THERP/VISIT
SPEECH THERP/HOUR
SPEECH THERP/GROUP
SPEECH THERP/EVAL
Unit
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
Y
OTHER SPEECH THERP
HCPCS Y
Services are provided by a qualified speech therapist.
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045x
Form Locator 42
Page 24 of 59
Emergency Room
Charges for emergency treatment to those ill and injured persons who require immediate
unscheduled medical or surgical care.
SubC
0
1
2
3-5
6
7-8
9
Subcategory Definition
General Classification
EMTALA Emergency
Medical Screening
ER Beyond EMATAL
RESERVED
Urgent Care
RESERVED
Other Emergency Room
Standard Abbreviation
EMERG ROOM
ER/EMATALA
Unit
Visit
HCPCS
Y
Y
ER/BEYOND EMTALA
Visit
Visit
ER/URGENT
Visit
Y
OTHER EMERG ROOM
Visit
Y
Y
Usage Notes:
Report Patient’s Reason for Visit code in FL 70 in conjunction with this revenue code.
An “X” in the matrix below indicates acceptable coding.
0450
0451
0452
0456
0459
0450 0451 0452 0456 0459
(a)
(b)
(c)
X
X
X
X
X
X
X
X
(a) General classification code 0450 should not be used in conjunction with any subcategory. The
sum of 0451 and 0452 is the equivalent to 0450.
(b) Stand-alone usage of 0451 is acceptable when no services beyond an initial screening/assessment
are rendered.
(c) Stand-alone usage of 0452 is not acceptable.
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Form Locator 42
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Pulmonary Function
Charges for tests that measure inhaled and exhaled gases and analysis of blood and for tests
that evaluate the patient’s ability to exchange oxygen and other exhaled gases.
SubC
0
1-8
9
Subcategory Definition
General Classification
RESERVED
Other Pulmonary
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Standard Abbreviation
PULMONARY FUNC
Unit
Test
HCPCS
Y
OTHER PULMONARY
FUNC
Test
Y
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Audiology
Charges for the detection and management of communication handicaps centering in whole
or in part on the hearing function
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Diagnostic
Treatment
RESERVED
Other Audiology
Standard Abbreviation
AUDIOLOGY
AUDIOLOGY/DX
AUDIOLOGY/RX
Unit
Test
Test
Test
HCPCS
Y
Y
Y
OTHER AUDIOL
Test
Y
Standard Abbreviation
CARDIOLOGY
CARDIAC CATH LAB
STRESS TEST
ECHOCARDIOLOGY
Unit
Test
Test
Test
Test
HCPCS
Y
Y
Y
Y
OTHER CARDIOL
Test
Y
Services are provided by or through the supervision of a qualified audiologist
048x
Cardiology
Charges for cardiac procedures.
SubC
0
1
2
3
4-8
9
Subcategory Definition
General Classification
Cardiac Cath Lab
Stress Test
Echocardiology
RESERVED
Other Cardiology
Services provided are by staff from the cardiology department of the hospital or under arrangement.
Services include such procedures such as: heart catherization, coronary angiography, Swan-Ganz
catherization, and exercise stress test.
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049x
Form Locator 42
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Ambulatory Surgical Care
Charges for ambulatory surgery not covered by other categories.
SubC
0
1-8
9
Subcategory Definition
General Classification
RESERVED
Other Ambulatory Surgical
050x
Outpatient Services
Standard Abbreviation
AMBULTRY SURG
Unit
HCPCS
HCPCS Y
OTHER AMBL SURG
HCPCS Y
Charges for services rendered to an outpatient who is then admitted as an inpatient before
midnight of the day following the date of services. (Note: Medicare no longer requires this
revenue code.)
SubC
0
1-8
9
Subcategory Definition
General Classification
RESERVED
Other Outpatient
051x
Clinic
Standard Abbreviation
OUTPATIENT SVCS
Unit
Test
HCPCS
Y
OTHER - O/P SERVICES
Test
Y
Clinic visit charges for providing diagnostic, preventative, curative, rehabilitative, and
education services to ambulatory patients.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Chronic Pain Center
Dental Clinic
Psychiatric Clinic
OB-GYN Clinic
Pediatric Clinic
Urgent Care Clinic*
Family Practice Clinic
RESERVED
Other Clinic
Standard Abbreviation
CLINIC
CHRONIC PAIN CLINIC
DENTAL CLINIC
PSYCHIATRIC CLINIC
OB-GYN CLINIC
PEDIATRIC CLINIC
URGENT CARE CLINIC
FAMILY CLINIC
Unit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
OTHER CLINIC
Visit
Y
* Report the Patient’s Reason for Visit diagnosis codes for all Urgent Care Clinic visits.
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052x
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Page 28 of 59
Free-Standing Clinic
Charges for the outpatient visit at a freestanding clinic.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Clinic Visit by Member to
RHC/FQHC
Home Visit by RHC/FQHC
Practitioner
Family Practice Clinic
Visit by RHC/FQHC
Practitioner to a Member in a
Covered Part A Stay at SNF
Visit by RHC/FQHC
Practitioner to a Member in a
SNF (not in a Covered Part
A Stay) or NF or ICF MR or
Other Residential Facility
Urgent Care Clinic*
Visiting Nurse Service(s) to
a Member’s Home when in a
Home Health Shortage
Area
Visit by RHC/FQHC
Practitioner to Other nonRHC/FQHC Site (e.g. Scene
of Accident)
Other Freestanding Clinic
Standard Abbreviation
FREESTAND CLINIC
FS-RURAL/CLINIC
Unit
Visit
Visit
HCPCS
Y
Y
FS-RURAL/HOME
Visit
Y
FS-FAMILY PRACT
FR/STD FAMILY CLINIC
Visit
Y
Visit
Y
Visit
Y
RHC/FQHC/SNF/
NONCOVERED
FR/STD URGENT CLINIC
RHC/FQHC/HOME/VIS
NURSE
RHC/FQHC/OTHER SITE
OTHER FS – CLINIC
* Report the Patient’s Reason for Visit diagnosis codes for all Urgent Care Clinic visits.
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Form Locator 42
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Osteopathic Services
Charges for a structural evaluation of the cranium, entire cervical, dorsal and lumber spine by
a doctor of osteopathy.
SubC
0
1
2-8
9
Subcategory Definition
General Classification
Osteopathic Therapy
RESERVED
Other Osteopathic Services
Standard Abbreviation
OSTEOPATH SVCS
OSTEOPATH RX
Unit
Visit
Visit
HCPCS
Y
Y
OTHER OSTEOPATH
Visit
Y
Generally, these services are unique to osteopathic hospitals and cannot be accommodated in any of
the existing revenue codes.
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Ambulance
Charges for ambulance services necessary for the transport of the ill or injured who require
medical attention at a health care facility.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Supplies
Medical Transport
Heart Mobile
Oxygen
Air Ambulance
Neonatal Ambulance Services
Pharmacy
EKG Transmission
Other Ambulance
Standard Abbreviation
AMBULANCE
AMBUL/SUPPLY
AMBUL/MED TRANS
AMBUL/HEART MOB
AMBUL/OXYGEN
AIR AMULANCE
AMBUL/NEONAT
AMBUL/PHARMAS
AMBUL/EKG TRANS
AMBUL/OTHER
055x
Home Health (HH) - Skilled Nursing
Unit
Mile
Item
Mile
Mile
Unit
Mile
Mile
Unit
Unit
Mile
HCPCS
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Charges for nursing services provided under the direct supervision of a home health (HH)
licensed nurse.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Visit Charge
Hourly Charge
RESERVED
Other Skilled Nursing
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Standard Abbreviation
SKILLED NURSING-HH
SKILLED NURS-VISIT
SKILLED NURS-HOUR
SKILLED NURS/OTHER
Unit
Visit
Hour
HCPCS
Y
Y
Y
Y
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Home Health (HH) -Medical Social Services
Home Health (HH) charges for services such as counseling patients, interviewing patients,
and interpreting problems of social situation rendered to patients on any basis.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Visit Charge
Hourly Charge
RESERVED
Other Med. Social Service
057x
Home Health (HH) Aide
Standard Abbreviation
MED SOCIAL-HH
MED SOC SVCS-VISIT
MED SOC SVCS-HOUR
Unit
Visit
Hour
MED SOC SVCS-OTHER
HCPCS
Y
Y
Y
Y
Home Health (HH) charges for personnel (aides) that are primarily responsible for the
personal care of the patient.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Visit Charge
Hourly Charge
RESERVED
Other HH - Aide
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Standard Abbreviation
HH AIDE
HH AIDE-VISIT
HH AIDE-HOUR
HH AIDE- OTHER
Unit
Visit
Hour
HCPCS
Y
Y
Y
Y
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Home Health (HH) - Other Visits
Home Health (HH) agency charges for visits other than physical therapy, occupational
therapy or speech therapy, requiring specific identification.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Visit Charge
Hourly Charge
RESERVED
Other Med. Social Service
Standard Abbreviation
MED SOCIAL-HH
MED SOC SVCS-VISIT
MED SOC SVCS-HOUR
059x
Home Health (HH) Units of Service
Unit
Visit
Hour
MED SOC SVCS-OTHER
HCPCS
Y
Y
Y
Y
Home Health (HH) charges for services billed according to the units of service provided.
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
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Standard Abbreviation
HH – SVCS/UNIT
Unit
Unit
HCPCS
Y
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Home Health (HH) - Oxygen
Home Health (HH) agency charges for oxygen equipment, supplies or contents, excluding
purchased equipment.
If patient purchases a stationary oxygen system, an oxygen concentrator or portable
equipment, current revenue codes 0292 or 0293 apply. DME (other than oxygen systems) is
billed under revenue codes 0291, 0292, or 0293.
SubC
0
1
4
5-8
9
Subcategory Definition
General Classification
Oxygen - Stat
Equip/Supply/Content
Oxygen - Stat
Equip/Supply<1 LPM
Oxygen - Stat
Equip/Supply>4 LPM
Oxygen - Port Add-on
RESERVED
Oxygen - Other
061x
Magnetic Resonance Technology (MRT)
2
3
Standard Abbreviation
O2/HOME HEALTH
O2/STAT
EQUIP/SUPLY/CONT
O2/STAT EQP/SUPPL<1
LPM
O2/STAT EQP/SUPPL>4
LPM
O2/PORTBLE ADD-ON
Unit
Ft/Lbs
HCPCS
Y
Y
Mos
Y
Mos
Y
Mos
Y
O2/OTHER
Y
Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
MRI - Brain/Brainstem
MRI - Spinal Cord/Spine
RESERVED
MRI - Other
MRA - Head and Neck
MRA - Lower Extremities
RESERVED
MRA - Other
Other MRT
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Standard Abbreviation
MRT
MRI/BRAIN
MRI/SPINE
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
MRI/OTHER
MRA/HEAD & NECK
MRA/LOWER EXTRM
Tests
Tests
Tests
Y
Y
Y
MRA/OTHER
MRT/OTHER
Tests
Tests
Y
Y
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Form Locator 42
Page 34 of 59
Medical Surgical Supplies - Extension of 027x
Charges for supply items required for patient care. The category is an extension of 027x for
reporting additional breakdown where needed. Subcategory code 1 is for providers that
cannot bill supplies used for radiology procedures under radiology. Subcategory code 2 is
for providers that cannot bill supplies used for other diagnostic procedures.
SubC
0
1
2
3
4
5-9
Subcategory Definition
RESERVED (Use 0270 for
General Classification)
Supplies Incident to
Radiology
Supplies Incident to Other
DX Services
Surgical Dressings
FDA Investigational Devices
RESERVED
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Standard Abbreviation
Unit
HCPCS
MED SURG SUPL-INCDT
RAD
MED SURG SUPL-INCDT
ODX
SURG DRESSINGS
FDA INVEST DEVICE
HCPCS Y
HCPCS Y
HCPCS Y
HCPCS Y
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Form Locator 42
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Pharmacy - Extension of 025x
Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed
and distributed under the direction of a licensed pharmacist. The category is an extension of
025x for reporting additional breakdown where needed.
SubC
0
1
2
3
4
5
6
7
8-9
Subcategory Definition
RESERVED (Use 0250 for
General Classification)
Single Source Drug
Multiple Source Drug
Restrictive Prescription
Erythropoietin (EPO)
<10,000 Units
Erythropoietin
(EPO)>=10,000 Units
Drugs Requiring Detailed
Coding (a)
Self-administrable Drugs (b)
RESERVED
Standard Abbreviation
Unit
HCPCS
DRUG/SINGLE
DRUG/MULTIPLE
DRUG/RESTRICT
DRUG/EPO <10,000 UNITS
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
DRUG/EPO>=10,000 UNITS
HCPCS Y
DRUG/DETAIL CODE
HCPCS Y
DRUG/SELF ADMIN
HCPCS Y
(a) Charges for drugs and biologics (with the exception of radiopharmaceuticals, which are reported
under Revenue Codes 0343 and 0344) requiring specific identification as required by the payer. If
using a HCPCS to describe the drug, enter the HCPCS code in the appropriate HCPCS column. The
specific service units reported should be in hundreds (100s); rounded to the nearest hundred; do not
use a decimal.
(b) Charges for self-administrable drugs not requiring detailed coding. Use Value Codes A4, A5,
and A6 to indicate the dollar amount included in covered charges for self-administrable drugs.
Amounts for non-covered self-administrable drugs should be charged using Revenue Code 0637 in
the non-covered column.
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064x
Form Locator 42
Page 36 of 59
Home IV Therapy Services
Charge for intravenous therapy services performed in the patient’s residence. For Home IV
providers enter the HCPCS code for all equipment, and all types of covered therapy.
SubC Subcategory Definition
0
General Classification
1
Non-routine Nursing, Central
Line
2
IV Site Care, Central Line
(see Note)
3
IV Start /Care, Peripheral
Line
4
Non-routine Nursing,
Peripheral Line
5
Training Patient/Caregiver,
Central Line
6
Training Disabled Patient,
Central Line
7
Training Patient/Caregiver,
Peripheral Line
8
Training Disabled Patient,
Peripheral Line
9
Other IV Therapy Services
Standard Abbreviation
IV THERAPY SVC
NON RT NURSING/CENTRL
Unit
HCPCS
Y
IV SITE CARE/CENTRAL
Y
IV STRT CARE/PERIPHRL
Y
NONRT NURSING/PERIPHRL
Y
TRNG PT/CAREGVR/
CENTRAL
TRNG DSBLPT/CENTRL
Hour
Y
Hour
Y
TRNG/PT/CARGVR/PERIPHRL
Hour
Y
TRNG/DSBLPT/PERIPHRL
Hour
Y
OTHER IV THERAPY SVC
Y
Note: Report units in one hour increments; Revenue Code 0642 relates to the HCPCS code.
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Official UB-04 Data Specifications Manual 2007
Effective Date: March 1, 2007
Meeting Date:
065x
Form Locator 42
Page 37 of 59
Hospice Service
Charge for hospice care services for a terminally ill patient electing hospice services in lieu
of other medical services for their terminal condition.
SubC
0
1
2
3-4
5
6
7
8
9
Subcategory Definition
General Classification
Routine Home Care
Continuous Home Care
RESERVED
Inpatient Respite Care
General Inpatient Care NonRespite
Physician Services
Hospice Room & Board Nursing Facility
Other Hospice Service
Standard Abbreviation
HOSPICE
HOSPICE/RTN HOME
HOSPICE/CTNS HOME
Unit
HOSPICE/IP RESPITE
HOSPICE/IP NON-RESPITE
Days
Days
HOSPICE/PHYSICIAN
HOSPICE/R&B NURSE
FAC
HOSPICE/OTHER
HCPCS Y
Days
Y
Hours
Hours
HCPCS
Y
Y
Y
Y
Y
Y
Y
Note: To receive the continuous home care rate from Medicare use code 0652, a minimum of 8
hours of care, not necessarily consecutive, must be accompanied by a physician procedure code.
Enter this information in the HCPCS column (Form Locator 44). This code is used by the hospice to
bill for charges for physicians employed by the hospice or receiving compensation from the hospice
for services rendered. The unit will be either days or hours depending on subcategory and billing
contracts.
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066x
Form Locator 42
Page 38 of 59
Respite Care
Charge for non-hospice respite care.
SubC
0
1
2
3
4-8
9
Subcategory Definition
General Classification
Hourly Charge - Nursing
Hourly Charge
/Aide/Homemaker/
Companion
Daily Respite Charge
RESERVED
Other Respite Care
Standard Abbreviation
RESPITE CARE
RESPITE/NURSING
RESPITE/AIDE/HMEMKR
/COMP
Unit
RESPITE/DAILY
Day
RESPITE/OTHER
Hours
067x
Outpatient Special Residence Charges
HCPCS
Hours
Hours
Residence arrangements for patients requiring continuous outpatient care.
SubC
0
1
Subcategory Definition
General Classification
Hospital Owned
2
Contracted
3-8
9
RESERVED
Other Special Residence
Charge
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Standard Abbreviation
OP SPEC RES
OP SPEC RES/HOSP
OWNED
OP SPEC
RES/CONTRACTED
Unit
OP SPEC RES/OTHER
Day
HCPCS
Day
Day
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068x
Form Locator 42
Page 39 of 59
Trauma Response
Charges representing the activation of the trauma team
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
Not Used
Level I Trauma
Level II Trauma
Level III Trauma
Level IV Trauma
RESERVED
Other Trauma Response
Standard Abbreviation
Unit
TRAUMA LEVEL I
TRAUMA LEVEL II
TRAUMA LEVEL III
TRAUMA LEVEL IV
Activation
Activation
Activation
Activation
TRAUMA OTHER
Activation
HCPCS
Usage Notes:
1. For use by trauma center/hospitals, licensed or designated by the state or local government
authority, authorized as a trauma center, or verified by the American College of Surgeons and as a
facility with a trauma activation team.
2. Revenue Category 068x is used for patients for whom a trauma activation occurred. A trauma
team activation/response is a “Notification of key hospital personnel in response to triage information
from pre-hospital caregivers in advance of the patient’s arrival.”
3. Revenue Category 068x is for reporting trauma activation costs only. It is an activation fee and
not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there
will normally be both a 045x and 068x revenue code reported.
4. Revenue Category 068x is not limited to admitted patients.
5. Revenue Category 068x must be used in conjunction with FL14 Type of Admission/Visit Code 5
(“Trauma Center”); however FL 14 Code 5 can be used alone.
Only patients for whom there has been pre-hospital notification, who meet either local, state or
American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are
given the appropriate team response, can be billed the trauma activation fee charge. Patients who are
“drive-by” or arrive without notification cannot be charged for activations, but can be classified as
trauma under Type of Admission Code 5 for statistical and follow-up purposes.
6. Levels I, II, III, or IV refer to designations given to the trauma facility by the state or local
government authority or as verified by the American College of Surgeons.
7. Subcategory 9 is for states or local authorities with levels beyond IV.
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Meeting Date:
069x
RESERVED
070x
Cast Room
Form Locator 42
Page 40 of 59
Charge for services related to the application, maintenance and removal of casts
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
071x
Recovery Room
Standard Abbreviation
CAST ROOM
Unit
HCPCS
Unit
HCPCS
N
Room charge for patient recovery after surgery.
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
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Standard Abbreviation
RECOVERY ROOM
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Meeting Date:
072x
Form Locator 42
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Labor Room/Delivery
Charges for labor and delivery room services provided by specifically trained nursing
personnel to patients including prenatal care during labor, assistance during delivery,
postnatal care in the recovery room, and minor gynecologic procedures if they are performed
in the delivery suite.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Labor
Delivery Room
Circumcision
Birthing Center
RESERVED
Other Labor Room/Delivery
073x
EKG/ECG (Electrocardiogram)
Standard Abbreviation
DELIVERY ROOM/LABOR
LABOR
DELIVERY ROOM
CIRCUMCISION
BIRTHING CNTR
Unit
HCPCS
Days
Days
Each
Days
OTHER/DELIV-LABOR
Charges for operation of specialized equipment to record variations in actions of the heart
muscle for diagnosis of heart aliments.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Holter Monitor
Telemetry
RESERVED
Other EKG/ECG
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Standard Abbreviation
EKG/ECG
HOLTER MONT
TELEMETRY
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
OTHER EKG/ECG
Tests
Y
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074x
Form Locator 42
Page 42 of 59
EEG (Electroencephalogram)
Charges for operation of specialized equipment to measure impulse frequencies and
differences in electrical potential in various areas of the brain to obtain data for use in
diagnosing brain disorders.
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
075x
Gastro-Intestinal (GI) Services
Standard Abbreviation
EEG
Unit
Tests
HCPCS
Y
Unit
Tests
HCPCS
Y
Charges for GI procedures not performed in the operating room.
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
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Standard Abbreviation
GASTRO-INTSTL SVCS
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Effective Date: March 1, 2007
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076x
Form Locator 42
Page 43 of 59
Specialty Room - Treatment/Observation Room
Charges for the use of a specialty rooms such as treatment or observation rooms.
SubC
0
1
2
3-8
9
Subcategory Definition
General Classification
Treatment Room
Observation Room (a)
RESERVED
Other Specialty Rooms
Standard Abbreviation
SPECIALTY ROOM
TREATMENT RM
OBSERVATION RM
Unit
HCPCS
Y
OTHER SPECIALTY RMS
Note:
Observation services are those services furnished by a hospital on the hospital’s premises, including
use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and
necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the
hospital or as an inpatient. Such services are covered only when provided by the order of a physician
or another individual authorized by State licensure law and hospital staff bylaws to admit patients to
the hospital or to order outpatient tests. The reason for observation must be stated in the orders for
observation. Payers should establish written guidelines, which identify coverage of observation
services.
(a) FL 76 - Patient’s Reason for Visit should be reported in conjunction with 0762.
077x
Preventive Care Services
Revenue Code used to capture preventive care services established by payers (e.g.,
vaccination).
SubC
0
1
2-9
Subcategory Definition
General Classification
Vaccine Administration
RESERVED
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Standard Abbreviation
PREVENT CARE SVCS
VACCINE ADMIN
Unit
HCPCS
Y
Y
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Meeting Date:
078x
Form Locator 42
Page 44 of 59
Telemedicine
Facility charges related to the use of telemedicine services
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
Standard Abbreviation
TELEMEDICINE
079x
Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy)
Unit
HCPCS
Unit
HCPCS
Y
Charges related to Extra-Corporeal Shock Wave Therapy (ESWT).
SubC
0
1-9
Subcategory Definition
General Classification
RESERVED
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Standard Abbreviation
ESWT
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Effective Date: March 1, 2007
Meeting Date:
080x
Form Locator 42
Page 45 of 59
Inpatient Renal Dialysis
Charges for the use of equipment designed to remove waste when the body’s own kidneys
have failed. The waste may be removed from the blood (hemodialysis) or indirectly from the
blood by flushing a special solution between the abdominal covering and the tissue
(peritoneal dialysis).
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Inpatient Hemodialysis
Inpatient Peritoneal (NonCAPD)
Inpatient Continuous
Ambulatory Peritoneal
Dialysis (CAPD)
Inpatient Continuous Cycling
Peritoneal Dialysis (CCPD)
RESERVED
Other Inpatient Dialysis
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Standard Abbreviation
RENAL DIALYSIS
DIALY/INPATIENT
DIALY/IP/PER
Unit
HCPCS
Sessions
Sessions
Sessions
DIALY/IP/CAPD
Sessions
DIALY/IP/CCPD
Sessions
DIALY/IP/OTHER
Sessions
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Effective Date: March 1, 2007
Meeting Date:
081x
Form Locator 42
Page 46 of 59
Acquisition of Body Components
The acquisition and storage costs of body tissue, bone marrow, organs and other body
components not otherwise identified used for transplantation.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Living Donor
Cadaver Donor
Unknown Donor
Unsuccessful Organ Search Donor Bank Charges
RESERVED
Other Donor
Standard Abbreviation
ORGAN ACQUISIT
LIVING DONOR
CADAVER DONOR
UNKNOWN DONOR
UNSUCCESSFUL SEARCH
Unit
OTHER DONOR
HCPCS
Y
Y
Y
Y
Y
Y
Notes:
Living donor is a living person from whom an organ is collected and used for transplantation
purposes.
Cadaver is an individual pronounced dead according to medical and legal criteria, and whose organs
may be harvested for transplantation.
Unknown is used whenever the status of the individual source cannot be determined. Use the other
category whenever the organ is non-human.
Revenue Code 0814 is used only when costs incurred for an organ search do not result in an eventual
organ acquisition and transplantation.
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Effective Date: March 1, 2007
Meeting Date:
082x
Form Locator 42
Page 47 of 59
Hemodialysis - Outpatient or Home
A waste removal process, performed in an outpatient or home setting, necessary when the
body’s own kidneys have failed. Waste is removed directly from the blood.
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
Hemodialysis Composite or
Other Rate
Home Supplies
Home Equipment
Maintenance – 100%
Support Services
RESERVED
Other OP Hemodialysis
Standard Abbreviation
HEMO/OP OR HOME
HEMO/COMPOSITE
Unit
083x
Peritoneal Dialysis - Outpatient or Home
HCPCS
Y
Sessions Y
HEMO/HOME/SUPPL
HEMO/HOME/EQUIP
HEMO/HOME/100%
HEMO/HOME/SUPSERV
Sessions
Sessions
Sessions
Sessions
HEMO – OTHER OP
Sessions Y
Y
Y
Y
Y
Charges for a waste removal process performed in an outpatient or home setting, necessary
when the body’s own kidneys have failed. Waste is removed indirectly by flushing a special
solution between the abdominal covering and the tissue.
SubC
0
Subcategory Definition
General Classification
1
Peritoneal/Composite or
Other Rate
Home Supplies
Home Equipment
Maintenance - 100%
Support Services
RESERVED
Other Outpatient
Peritoneal Dialysis
2
3
4
5
6-8
9
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Standard Abbreviation
PERITONEAL/OP OR
HOME
PERTNL/COMPOSITE
Unit
Sessions
HCPCS
Y
Sessions
Y
PERTNL/HOME/SUPPL
PERTNL/HOME/EQUIP
PERTNL/HOME/100%
PERTNL/HOME/SUPSERV
Sessions
Sessions
Sessions
Sessions
Y
Y
Y
Y
PERTNL/HOME/OTHER
Sessions
Y
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Effective Date: March 1, 2007
Meeting Date:
084x
Form Locator 42
Page 48 of 59
Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home
Charges for continuous dialysis process performed in an outpatient or home setting which
uses the patient peritoneal membrane as a dialyzer.
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
CAPD/Composite or Other
Rate
Home Supplies
Home Equipment
Maintenance - 100%
Support Services
RESERVED
Other Outpatient CAPD
Standard Abbreviation
CAPD/OP OR HOME
CAPD/COMPOSITE
Unit
Days
Days
HCPCS
Y
Y
CAPD/HOME/SUPPL
CAPD/HOME/EQUIP
CAPD/HOME/100%
CAPD/HOME/SUPSERV
Days
Days
Days
Days
Y
Y
Y
Y
CAPD/HOME/OTHER
Days
Y
085x
Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home
Charges for continuous dialysis process performed in an outpatient or home setting which
uses a machine to make automatic exchanges at night. .
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
CCPD/Composite or Other
Rate
Home Supplies
Home Equipment
Maintenance - 100%
Support Services
RESERVED
Other Outpatient CCPD
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Standard Abbreviation
CCPD/OP OR HOME
CCPD/COMPOSITE
Unit
Days
Days
HCPCS
Y
Y
CCPD/HOME/SUPPL
CCPD/HOME/EQUIP
CCPD/HOME/100%
CCPD/HOME/SUPSERV
Days
Days
Days
Days
Y
Y
Y
Y
CCPD/HOME/OTHER
Days
Y
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National Uniform Billing Committee
Effective Date: March 1, 2007
Meeting Date:
086x
RESERVED
087x
RESERVED
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Page 49 of 59
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Effective Date: March 1, 2007
Meeting Date:
088x
Form Locator 42
Page 50 of 59
Miscellaneous Dialysis
Charges for dialysis services not identified elsewhere.
SubC
0
1
2
Subcategory Definition
General Classification
Ultrafiltration
Home Dialysis Aid Visit
3-8
9
RESERVED
Other Miscellaneous Dialysis
Standard Abbreviation
DIALY/MISC
DIALY/ULTRAFILT
HOME DIALYSIS AID
VISIT
Unit
Sessions
Sessions
Sessions
HCPCS
Y
Y
Y
DIALY/MISC/OTHER
Sessions Y
Note:
Ultrafiltration is the process of removing excess fluid from the blood of dialysis patients by using a
dialysis machine but without the dialysate solution. The designation is only used when the procedure
is not performed as part of a normal dialysis session.
089x
RESERVED
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Effective Date: March 1, 2007
Meeting Date:
090x
Form Locator 42
Page 51 of 59
Behavioral Health Treatment/Services (also see 091x, an extension of 090x)
Charges for prevention, intervention, and treatment services in the areas of mental health,
substance abuse, developmental disabilities, and sexuality. Behavioral Health Care services
are individualized, holistic, and culturally competent and may include on-going care and
support and non-traditional services.
SubC
0
1
2
3
4
5
8-9
Subcategory Definition
General Classification
Electroshock Treatment
Milieu Therapy
Play Therapy
Activity Therapy
Intensive Outpatient ServicesPsychiatric
Intensive Outpatient ServicesChemical Dependency
Community Behavioral
Health Program (Day
Treatment)
RESERVED
091x
Behavioral Health Treatments/Services - Extension of 090x
6
7
Standard Abbreviation
BH/TREATMENTS
BH/ELECTRO SHOCK
BH/MILIEU THERAPY
BH/PLAY THERAPY
BH/ACTIVITY THERAPY
BH/INTENS OP/PSYCH
Unit
Visit
Visit
Visit
Visit
Visit
Visit
HCPCS
Y
Y
Y
Y
Y
Y
BH/INTENS OP/CHEM DEP
Visit
Y
BH/COMMUNITY
Visit
Y
Standard Abbreviation
Unit
HCPCS
BH/REHAB
BH/PARTIAL HOSP
Visit
Visit
Y
Y
BH/PARTIAL INTENSV
Visit
Y
BH/INDIV RX
BH/GROUP RX
BH/FAMILY RX
BH/BIOFEED
BH/TESTING
BH/OTHER
Visit
Visit
Visit
Visit
Visit
Visit
Y
Y
Y
Y
Y
Y
See Revenue Code 090x
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
RESERVED (use 090 for
General Classification)
Rehabilitation
Partial Hospitalization - Less
Intensive
Partial Hospitalization Intensive
Individual Therapy
Group Therapy
Family Therapy
Bio Feedback
Testing
Other Behavioral Health
Treatments
Note:
Subcategories 0912 and 0913 are designed as zero-billed revenue codes (i.e., no dollars in the amount
field) to be used as a vehicle to supply program information as defined in the provider/payer contract.
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Meeting Date:
092x
Form Locator 42
Page 52 of 59
Other Diagnostic Services
Charges for various diagnostic services specific to common screenings for disease, illness or
medical condition.
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
General Classification
Peripheral Vascular Lab
Electromyelgram
Pap Smear
Allergy Test
Pregnancy Test
RESERVED
Other Diagnostic Service
Standard Abbreviation
OTHER DX SVCS
PERI VASCUL LAB
EMG
PAP SMEAR
ALLERGY TEST
PREG TEST
Unit
HCPCS
Tests
Tests
Tests
Tests
Tests
Y
Y
Y
Y
Y
OTHER DX SVCS
Tests
Y
093x
Medical Rehabilitation Day Program
Medical rehabilitation services as contracted with a payer and/or certified by the state.
Services may include physical therapy, occupational therapy, and speech therapy.
SubC
0
1
2
3-9
Subcategory Definition
RESERVED
Half Day
Full Day
RESERVED
Standard Abbreviation
Unit
HALF DAY
FULL DAY
Hours
Hours
HCPCS
Note:
The subcategories of 093x are designed as zero-bill revenue code (i.e., no dollars are reported in the
Total Charge column (FL 47) for this revenue code) it should be used as a vehicle to supply program
information as defined in the provider/payer contract. Therefore, zero would be reported in the Total
Charge column and the number of hours provided would be reported in the Units field. The specific
rehabilitation services would be reported under the applicable therapy revenue codes as normal.
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Meeting Date:
094x
Form Locator 42
Page 53 of 59
Other Therapeutic Services (also see 095x, an extension of 094x)
Charges for other therapeutic services not otherwise categorized.
SubC
0
1
2
3
4
5
6
8
9
Subcategory Definition
General Classification
Recreational Therapy
Education/Training
Cardiac Rehabilitation
Drug Rehabilitation
Alcohol Rehabilitation
Complex Medical
Equipment-Routine
Complex Medical
Equipment-Ancillary
RESERVED
Other Therapeutic Service
095x
Other Therapeutic Services (Extension of 094x)
7
Standard Abbreviation
OTHER RX SVCS
RECREATION RX
EDUC/TRAINING
CARDIAC REHAB
DRUG REHAB
ALCOHOL REHAB
CMPLX MED EQUIPROUT
CMPLX MED EQUIP-ANC
Unit
HCPCS
Visit
Visit
Visit
Visit
Visit
Visit
Y
Y
Y
Y
Y
Y
Visit
Y
ADDITIONAL RX SVCS
Visit
Y
See Revenue Code 094x
SubC
0
1
2
3-9
Subcategory Definition
RESERVED (use 0940 for
General Classification)
Athletic Training
Kinesiotherapy
RESERVED
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Standard Abbreviation
Unit
ATHLETIC TRAINING
KINESIOTHERAPY
Visit
Visit
HCPCS
Y
Y
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Meeting Date:
096x
Form Locator 42
Page 54 of 59
Professional Fees (also see 097x and 098x)
Charges for medical professionals that the institutional health care provider along with the
third-party payer require the professional fee component to be billed on the UB. The
professional fee component is separately identified by this revenue code. Generally used by
Critical Access Hospitals (CAH) that bill both the technical and professional service
components on the UB.
SubC
0
1
2
3
4
5-8
9
Subcategory Definition
General Classification
Psychiatric
Ophthalmology
Anesthesiologist (MD)
Anesthesiologist (CRNA)
RESERVED
Other Professional Fee
Standard Abbreviation
PRO FEE
PRO FEE/PSYCH
PRO FEE/EYE
PRO FEE/ANEST MD
PRO FEE/ANEST CRNA
097x
Professional Fees (Extension of 096x)
Unit
HCPCS
Y
Y
Y
Y
PRO FEE/OTHER
Y
See Revenue Code 096x.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
RESERVED (use 0960 for
General Classification)
Laboratory
Radiology - Diagnostic
Radiology - Therapeutic
Radiology - Nuclear
Operating Room
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
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Standard Abbreviation
PRO FEE/LAB
PRO FEE/RAD/DX
PRO FEE/RAD/RX
PRO FEE/NUC MED
PRO FEE/OR
PRO FEE/RESPIR
PRO FEE/PHYSI
PRO FEE/OCCUPA
PRO FEE/SPEECH
Unit
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
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Professional Fees (Extension of 096x and 097x)
Charges for medical professionals that the institutional health care provider along with the
third-party payer require the professional fee component to be billed on the UB. The
professional fee component is separately identified by this revenue code. Generally used by
Critical Access Hospitals (CAH)
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
RESERVED (use 0960 for
General Category)
Emergency Room Services
Outpatient Services
Clinic
Medical Social Services
EKG
EEG
Hospital Visit
Consultation
Private Duty Nurse
099x
Patient Convenience Items
Standard Abbreviation
Unit
PRO FEE/ER
PRO FEE/OUTPT
PRO FEE/CLINIC
PRO FEE/SOC SVC
PRO FEE/EKG
PRO FEE/EEG
PRO FEE/HOS VIS
PRO FEE/CONSULT
PRO FEE/PVT NURSE
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Charges for items that generally considered by the third-party payers to be strictly
convenience items and therefore are not covered by many health plans.
SubC
0
1
2
3
4
5
6
7
8
9
Subcategory Definition
General Classification
Cafeteria/Guest Tray
Private Linen Service
Telephone/Telecom
TV/Radio
Non-patient Room Rentals
Late Discharge
Admissions Kits
Beauty Shop/Barber
Other Convenience Items
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Standard Abbreviation
PT CONVENIENCE
CAFETERIA
LINEN
TELEPHONE
TV/RADIO
NONPT ROOM RENT
LATE DISCHARGE
ADM KITS
BARBER/BEAUTY
PT CONV/OTHER
Unit
HCPCS
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100x
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Behavioral Health Accommodations
Charges for routine accommodations at specified behavioral health facilities.
SubC
0
1
3
4
Subcategory Definition
General Classification
Residential Treatment Psychiatric
Residential Treatment Chemical Dependency
Supervised Living
Halfway House
5
6-9
Group Home
RESERVED
2
Standard Abbreviation
BH R&B
BH R&B RES/PSYCH
Unit
BH R&B RES/CHEM
Day
BH R&B SUP LIVING
BH R&B HALFWAY
HOUSE
BH R&B GROUP HOME
Day
Day
HCPCS
Day
Day
101x RESERVED
to
209x
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Form Locator 42
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Alternative Therapy Services
Charges for therapies not elsewhere categorized under other therapeutic service revenue
codes (042x, 043x, 044x, 091x, 094, 095x) or services such as anesthesia or clinic (0374,
0511).
SubC
0
1
2
3
4
5
6
7-8
9
Subcategory Definition
General Classification
Acupuncture
Acupressure
Massage
Reflexology
Biofeedback
Hypnosis
RESERVED
Other Alternative Therapy
Service
Standard Abbreviation
ALTTHERAPY
ACUPUNCTURE
ACUPRESSURE
MASSAGE
REFLEXOLOGY
BIOFEEDBACK
HYPNOSIS
Unit
OTHER ALTTHERAPY
Session
HCPCS
Session
Session
Session
Session
Session
Session
Notes:
Alternative therapy is intended to enhance and improve standard medical treatment. These revenue
code(s) would be used to report services in a separately designated alternative inpatient/outpatient
unit.
211x
to
309x
RESERVED
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Adult Care
Charges for personal, medical, psycho-social, and/or therapeutic services in a special
community setting for adults needing supervision and/or assistance with Activities of Daily
Living (ADL).
SubC
0
1
2
3
4
5
6-8
9
Subcategory Definition
RESERVED
Adult Day Care, Medical and
Social Hourly
Adult Day Care, SocialHourly
Adult Day Care, Medical and
Social - Daily
Adult Day Care, Social -Daily
Adult Foster Care Daily
RESERVED
Other Adult Care
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Standard Abbreviation
Unit
ADULT MED/SOC HR
Hour
ADULT SOC HR
Hour
ADULT MED/SOC DAY
Day
ADULT SOC DAY
ADULT FOSTER DAY
Day
Day
HCPCS
OTHER ADULT
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999x
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RESERVED
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Form Locator 43
Data
Element
Revenue Description
Definition:
The standard abbreviated description of the related revenue code categories included
on this bill. (See FL 42 for description of each revenue code category.)
Reporting
• UB-04: Required (for paper bills only).
• 004010/004010A1: Not Used.
• 005010: Not Used.
Field
Attributes
1 Field
22 Lines*
24 Positions
Alphanumeric
Left-justified
Notes
The standard abbreviated description should correspond with the Revenue Codes as
defined by the NUBC.
* The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated with a
Revenue Code of “0001”.
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Form Locator 44
Page 1 of 2
Data
Element
HCPCS/Accommodation Rates/HIPPS Rate Codes
Definition:
1. The Healthcare Common Procedure Coding System (HCPCS) applicable to
ancillary service and outpatient bills.
2. The accommodation rate for inpatient bills.
3. Health Insurance Prospective Payment System (HIPPS) rate codes represent
specific sets of patient characteristics (or case-mix groups) on which payment
determinations are made under several prospective payment systems.
Reporting
HCPCS and HIPPS Rate Codes
• UB-04 and 005010: Situational. Required for outpatient claims when an
appropriate HCPCS or HIPPS code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics
only) or HIPPS code exists for this service line item.
• 004010/004010A1: Situational
Accommodation Rates
• UB-04: Situational. Required when a room & board revenue code is reported.
• 004010/004010A1: Situational. Required when the associated revenue code is 100219.
• 005010: Not Used. (Rationale: The rate can be computed by dividing the total
charge by the number of units.)
HCPCS Modifiers
• UB-04: Situational. Required when a modifier clarifies or improves the reporting
accuracy of the associated procedure code.
• 004010/004010A1: Situational. Required when the Provider needs to convey
additional clarification for the associated procedure code.
• 005010: Situational. Required when a (first, second, third or fourth) modifier
clarifies or improves the reporting accuracy of the associated procedure code.
Field
Attributes
1 Field
22 Lines (a)
14 Positions (b)
Numeric for Accommodation Rates; alphanumeric for HCPCS and HIPPS Rate
Codes
Right-justified for Accommodation Rates; left-justified for HCPCS and HIPPS Rate
Codes
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Notes
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Form Locator 44
Page 2 of 2
Field Attributes
(a) The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
(b) For HCPCS, the field consists of 5 positions for the base code plus 8 positions for
up to four HCPCS modifiers; thus, the field contains one extra/unused position.
(c) HIPPS rate codes are alphanumeric codes of 5 positions. Each code contains
intelligence, with certain positions of the code indicating the case mix group itself,
and other positions providing additional information; the additional information
varies among HIPPS codes.
HIPPS Rate Codes
The Centers for Medicare and Medicaid services develops and publishes the
HIPPS codes to establish a coding system for claims submission and claims payment
under prospective payment systems. These codes represent the case mix classification
groups that are used to determine payment rates under prospective payment systems.
Case mix classification groups include, but may not be limited to, resource utilization
groups (RUGs) for skilled nursing facilities, home health resource groups (HHRGs)
for home health agencies, and case mix groups (CMGs) for inpatient rehabilitation
facilities.
HCPCS Modifiers (Level I and Level II)
The UB-04 accommodates up to four modifiers, two characters each.
See AMA publication CPT 200x (x= to current year) Current Procedural
Terminology, Appendix A - HCPCS Modifiers Section: “Modifiers Approved for
Ambulatory Surgery Center (ASC) Hospital Outpatient Use”.
Various CPT (Level I HCPCS) and Level II HCPCS codes may require the use of
modifiers to improve the accuracy of coding. Consequently, reimbursement, coding
consistency, editing and proper payment will benefit from the reporting of modifiers.
Hospitals should not report a separate HCPCS (five-digit code) instead of the
modifier. When appropriate, report a modifier based on the list indicated in the above
section of the AMA publication.
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Form Locator 45
Data
Element
Service Date
Definition:
The date (MMDDYY) the outpatient service was provided. (Applies to Lines 1 - 22;
Line 23 refers to the Creation Date (MMDDYY) of the bill (the date bill was
created/printed)).
This field is also used to report the assessment reference date when billing SNF PPS
services (Type of Bill 021x).
Reporting
Service Date
• UB-04 Lines 1-22: Situational. Required on outpatient claims.
• 004010/004010A1: Situational. Required on outpatient claims when revenue,
procedure, HIEC or drug codes are reported in the SV2 segment.
• 005010: Situational. Required on outpatient service lines where a drug is not being
billed and the Statement Covers Period is greater than one day.
OR
Required on service lines where a drug is being billed and the payer’s adjudication is
known to be impacted by the drug duration or the date the prescription was written.
Assessment Date
• UB-04: Situational. Required when this field is used to report the assessment
reference date when billing SNF PPS services (Type of Bill 021x).
• 004010/004010A1: Situational. Required when an assessment date is necessary
(i.e., Medicare PPS processing).
• 005010: Not Used. (Assessment Date and Service Date are combined in 005010,
whereas they were separate segments in version 004010/004010A1.)
Creation Date
• UB-04: Required for Line 23 (Creation Date). Enter the date the bill was created or
prepared for submission. Creation Date on Line 23 should be reported on all pages of
the UB-04.
• 004010/004010A1: Required. (The BHT04 segment (Transaction Set Creation
Date) is used as the date that the original submitter created the claim file from their
business application system.)
• 005010: Required. (The BHT04 segment (Transaction Set Creation Date) is used
as the date that the original submitter created the claim file from their business
application system.)
Field
Attributes
Service Date:
1 Field
22 Lines
6 Positions
Numeric
Right-justified
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Creation Date:
1 Field
1 Line (23)
6 Positions
Numeric
Right-justified
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Form Locator 46
Data
Element
Service Units
Definition:
A quantitative measure of services rendered by revenue category to or for the patient
to include items such as number of accommodation days, miles, pints of blood, renal
dialysis treatments, etc.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
22 Lines
7 Positions
Numeric
Right-justified
Notes
Enter the total number of covered accommodation days, ancillary units of service, or
visits, where appropriate and defined by revenue code requirements.
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Form Locator 47
Data
Element
Total Charges
Definition:
Total charges for the primary payer pertaining to the related revenue code for the
current billing period as entered in the statement covers period. Total Charges
includes both covered and non-covered charges.
Reporting
Line Item Charges
• UB-04: Required (Lines 1-22).
• 004010/004010A1: Required (Loop ID 2400 | SV203).
• 005010: Required (Loop ID 2400 | SV203).
Total (Summary) Charges
• UB-04: Situational. Required on Line 23 of the final claim page using Revenue
Code 0001. (Revenue Code 0001 is not used on electronic transactions; report the
total claim charge in the appropriate data segment/field as indicated below.)
• 004010/004010A1: Required (Loop ID 2300 | CLM02).
• 005010: Required (Loop ID 2300 | CLM02).
Field
Attributes
1 Field
23 Lines*
9 Positions (see notes)
Numeric
Right-justified
Notes
There are 7 positions for dollars, 2 positions for cents.
Amounts greater than or equal to zero are acceptable values for this element.
* The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
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Form Locator 48
Data
Element
Non-covered Charges
Definition:
To reflect the non-covered charges for the destination payer as it pertains to the
related revenue code.
Reporting
Line Item Non-Covered Charges
• UB-04: Situational (Lines 1-22). Required if needed to report line specific noncovered charge amount.
• 004010/004010A1: Situational.
• 005010: Situational. Required if needed to report line specific non-covered charge
amount.
Total (Summary) Non-Covered Charges
• UB-04: Situational. Required on Line 23 of the final claim page using Revenue
Code 0001 when there are non-covered charges on the claim.
• 004010/004010A1: Not Used.
• 005010: Not Used.
Field
Attributes
1 Field
23 Lines*
9 Positions (see Notes)
Numeric
Right-justified
Notes
There are 7 positions for dollars, 2 positions for cents.
* The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 49
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
23 Lines
2 Positions
Alphanumeric
Left-justified
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Form Locator 50
Data
Element
Payer Name
Definition:
Name of health plan that the provider might expect some payment for the bill.
Reporting
• UB-04: Line A Required.
Lines B and C Situational. Required when other payers are known to potentially be
involved in paying this claim.
• 004010/00410A1: Required.
• 005010: Required.
Field
Attributes
1 Field
3 Lines
23 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
Example: If “Medicare” is entered in Form Locator 50A, this indicates that the
provider has determined based on the responses from the patient or the patient’s
representative or from the insurance enrollment card information that Medicare is the
primary payer.
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Form Locator 51
Data
Element
Health Plan Identification Number
Definition:
The number used by the health plan to identify itself.
Reporting
Report the HIPAA National Plan Identifier when it becomes mandated; otherwise
report the (legacy/proprietary) number (i.e., whatever number used has been defined
between trading partners).
• UB-04: Line A Required.
Lines B and C Situational. Required when other health plans are known to potentially
be involved in paying this claim.
• 004010/00410A1: Required.
• 005010: Required.
Field
Attributes
1 Field
3 Lines
15 Positions
Alphanumeric
Left-justified
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Form Locator 52
Data
Element
Release of Information Certification Indicator
Definition:
Code indicates whether the provider has on file a signed statement (from the patient
or the patient’s legal representative) permitting the provider to release data to another
organization.
Reporting
• UB-04 and 005010: Required. See codes usage notes below.
• 004010/004010A1: Required. Note, however, that the 004010/004010A1 includes
additional codes that are no longer applicable due to the HIPAA medical privacy rule.
Field
Attributes
1 Field
3 Lines
1 Position
Alphanumeric
Left-justified
Notes
The Release of Information response is limited to the information carried in this
claim.
A = Primary
B = Secondary
C = Tertiary
Code
Structure
I
Informed Consent to Release Medical Information for Conditions or Diagnoses
Regulated by Federal Statutes
Usage Note:
Required when the provider has not collected a signature and state or federal
laws do not supersede the HIPAA Privacy Rule by requiring a signature be
collected.
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing
Data Related to a Claim
Usage Note:
Required when state or federal laws do not supersede the HIPAA Privacy Rule
by requiring a signature be collected.
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Form Locator 53
Data
Element
Assignment of Benefits Certification Indicator
Definition:
Code indicates provider has a signed form authorizing the third party payer to remit
payment directly to the provider.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
3 Lines
1 Position
Alphanumeric
Left-justified
Notes
Health plans that have arrangements with affiliate health plans in different states may
utilize this code to make payments to the provider rather than the insured individual.
This element answers the question whether or not the insured has authorized the plan
to remit payment directly to the provider.
The presence of an assignment does not permit release of medical information about a
patient.
Code
Structure
N
W
Y
No
Not Applicable (Use code ‘W’ when the patient refuses to assign benefits.)
Yes
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Form Locator 54
Data
Element
Prior Payments - Payer
Definition:
The amount the provider has received (to date) by the health plan toward payment of
this bill.
Reporting
• UB-04: Situational. Required when the indicated payer has paid an amount to the
provider towards this bill. It is acceptable to show “0” as the amount paid.
• 004010/004010A1: Situational. Required when the present payer has paid an
amount to the provider towards this bill.
• 005010: Situational. Required when the claim has been adjudicated by the payer
identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment
recovery claim submitted by a subrogated Medicaid agency.
Field
Attributes
1 Field
3 Lines
10 Positions
Numeric
Right-justified
Notes
There are 7 positions for dollars, 2 positions for cents.
A = Primary
B = Secondary
C = Tertiary
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Form Locator 55
Data
Element
Estimated Amount Due - Payer
Definition:
The amount estimated by the provider to be due from the indicated payer (estimated
responsibility less prior payments).
Reporting
• UB-04: Situational. Required when the provider estimates an amount due from the
indicated payer.
• 004010/004010A1: Situational. Required when the Payer Estimated Amount Due
is applicable to this claim.
• 005010: Not Used.
Field
Attributes
1 Field
3 Lines
10 Positions
Alphanumeric
Left-justified
Notes
There are 7 positions for dollars, 2 positions for cents.
A = Primary
B = Secondary
C = Tertiary
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Form Locator 56
Data
Element
National Provider Identifier - Billing Provider
Definition:
The unique identification number assigned to the provider submitting the bill; NPI is
the national provider identifier.
Reporting
• UB-04 and 005010: Situational. Required for providers in the United States or its
territories on or after the mandated HIPAA National Provider Identifier (NPI)
implementation date when the provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it.
• 004010/004010A1: For purposes of this manual, the 004010/004010A1 National
Provider Identifier (NPI) situational usage is not applicable due to the implementation
of the NPI Final Rule.
Field
Attributes
1 Field
1 Line
15 Positions*
Alphanumeric
Left-justified*
*Note: The NPI is ten characters in length.
Notes
1. Beginning on the NPI compliance date, when the Billing Provider is an
organization health care provider, the organization health care provider’s NPI or its
subpart’s NPI is reported in FL 56. When a health care provider organization has
determined that it needs to enumerate its subparts, it will report the NPI of a subpart
as the Billing Provider. The subpart reported as the Billing Provider must always
represent the most detailed level of enumeration as determined by the organization
health care provider and must be the same identifier sent to any trading partner
2. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver
to identify the Billing Provider entity are to be reported in FL 57 Lines A-C.
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Form Locator 57
Data
Element
Other (Billing) Provider Identifier
Definition:
A unique identification number assigned to the provider submitting the bill by the
health plan.
Reporting
• UB-04: Situational. Required prior to the mandated NPI Implementation Date
when an additional identification number is necessary for the receiver to identify the
provider.
OR
Required on or after the mandated NPI Implementation Date NPI is not used FL 56
and an identification number other than the NPI is necessary for the receiver to
identify the provider.
• 004010/004010A1: Required when a secondary identification number is necessary
to identify the entity.
• 005010: Situational. Required prior to the mandated NPI Implementation Date
when an additional identification number is necessary for the receiver to identify the
provider.
OR
Required on or after the mandated NPI Implementation Date when NM109
in Loop 2010AA is not used and an identification number other than the
NPI is necessary for the receiver to identify the provider.
Field
Attributes
1 Field
3 Lines
15 Position
Alphanumeric
Left-justified
Notes
The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider
Identifier.
Use this field to report other provider identifiers as assigned by the health plan (as
indicated in FL50 Lines A-C).
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Form Locator 58
Data
Element
Insured’s Name
Definition:
The name of the individual under whose name the insurance benefit is carried.
Reporting
• UB-04: Required.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
3 Lines
25 Positions
Alphanumeric
Left-justified
Notes
A = Primary payer
B = Secondary payer
C = Tertiary payer
Use a comma or space to separate last and first names. Enter last name first.
No space should be left between a prefix and a name as in MacBeth, VonSchmidt,
and McEnroe.
Titles (such as Sir, Msgr, Dr.) should not be recorded in this date element.
Record hyphenated names with the hyphen as in Smith-Jones, Rebecca.
To record suffix of a name, write the last name, leave a space and write the suffix,
then write the first name as in Snyder III, Harold, or Addams Jr., Glen
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Form Locator 59
Data
Element
Patient’s Relationship to Insured
Definition:
Code indicating the relationship of the patient to the identified insured.
Reporting
• UB-04: Line A Required.
Lines B and C Situational. Required when other payers are known to potentially be
involved in paying on this claim.
• 004010/004010A1: Required. (Note: The 004010/004010A1 version has 16 more
(specific) coding possibilities than the UB-04 and 005010.)
- If the patient is the subscriber, report in Loop ID 2000B.
- If the patient is not the subscriber but has a unique identifier assigned by the
destination payer, report in Loop ID 2000B.
• 005010: Required.
- If the patient is the subscriber, the name is reported in Loop ID 2000B.
- If the patient is not the subscriber but has a unique identifier assigned by the
destination payer, the name is reported in Loop ID 2000B.
- If the patient is not the subscriber and cannot be identified by a unique
identifier assigned by the destination payer, report in Loop ID 2000C.
Field
Attributes
1 Field
3 Lines
2 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
Code
01
18
19
20
21
39
40
53
G8
Title
Spouse
Self
Child
Employee
Unknown
Organ Donor
Cadaver Donor
Life Partner
Other Relationship
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Form Locator 60
Data
Element
Insured’s Unique Identifier
Definition:
The unique number assigned by the health plan to the insured.
Reporting
• UB-04: Line A Required.
Lines B and C Situational. Required when other health plans are known to potentially
be involved in paying this claim.
• 004010/004010A1: Required.
• 005010: Required.
Field
Attributes
1 Field
3 Lines
20 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
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Form Locator 61
Data
Element
Insured’s Group Name
Definition:
The group or plan name through which the insurance is provided to the insured.
Reporting
• UB-04: Line A Situational. Required if the Group Name is available and FL62
(Insurance Group Number) is not used.
Lines B and C Situational. Required when other insurance/payers/health plans are
known to potentially be involved in paying this claim and when FL62 B and C are not
used.
• 004010/004010A1: Situational. Used only when no group number is reported.
• 005010: Situational. Required when Group Number (Loop ID 2000B | SBR03) is
not used and the group name is available.
Field
Attributes
1 Field
3 Lines
14 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
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Form Locator 62
Data
Element
Insured’s Group Number
Definition:
The identification number, control number, or code assigned by the carrier or
administrator to identify the group under which the individual is covered.
Reporting
• UB-04: Line A Situational. Required when the insured’s identification card shows
a group number.
Lines B and C Situational. Required when other insurance/payers/health plans are
known to potentially be involved in paying this claim and when the other insurance’s
identification card shows a group number.
• 004010/004010A1: Situational.
• 005010: Situational. Required when the subscriber’s identification card for the
destination payer (Loop ID 2010BB) shows a group number.
Field
Attributes
1 Field
3 Lines
17 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
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Form Locator 63
Data
Element
Treatment Authorization Code
Definition:
A number or other indicator that designates that the treatment indicated on this bill
has been authorized by the payer.
Reporting
• UB-04: Situational. Required when an authorization number is assigned by the
payer or UMO (Utilization Management Organization)
AND
the services on this claim were preauthorized.
• 004010/004010A1: Situational. Required where services on this claim were
preauthorized or where a referral is involved.
• 005010: Situational. Required when an authorization number is assigned by the
payer or UMO (Utilization Management Organization)
AND
the services on this claim were preauthorized.
Field
Attributes
1 Field
3 Lines
30 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
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Form Locator 64
Data
Element
Document Control Number (DCN)
Definition:
The control number assigned to the original bill by the health plan or the health plan’s
fiscal agent as part of their internal control.
Reporting
• UB-04: Situational. Required when Type of Bill Frequency Code (FL 04) indicates
this claim is a replacement or void to a previously adjudicated claim.
• 004010/004010a1: Situational.
• 005010: Situational. (Payer Claim Control Number) required when CLM05-3
(Claim Frequency Code) indicates this claim is a replacement or void to a previously
adjudicated claim.
Field
Attributes
1 Field
3 Lines
26 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
Payer A’s ICN/DCN should be shown on Line “A” of FL 64. Similarly, the
ICN/DCN for Payers B and C should be shown on lines B and C respectively, of FL
64.
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Form Locator 65
Data
Element
Employer Name (of the Insured)
Definition:
The name of the employer that provides health care coverage for the insured
individual identified in FL 58.
Reporting
• UB-04: Situational. Lines A, B, C required when the employer of the insured is
known to potentially be involved in paying on this claim.
• 004010/004010A1: Not Used.
• 005010: Not Used.
Field
Attributes
1 Field
3 Lines
25 Positions
Alphanumeric
Left-justified
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
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Form Locator 66
Data
Element
Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
Definition:
The qualifier that denotes the version of International Classification of Diseases
(ICD) reported.
Reporting
• UB-04: Qualifier Code “9” Required.
Qualifier Code “0” designating ICD-10-CM and ICD-10-PCS is not allowed for use
under HIPAA as of March 1, 2007. The qualifier can only be used:
If a new rule names ICD-10-CM and/or ICD-10-PCS as an allowable code set under
HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed
under the law,
OR
For claims which are not covered under HIPAA.
• 004010/004010A1: Not Applicable. Only ICD-9-CM qualifier codes are available
in version 4010/4010A1.
• 005010: Not Applicable. Version 5010 contains distinct qualifier codes for ICD-9CM (“BF”), ICD-10-CM (“ABF”) and ICD-10-PCS (“BBR”). “ABF” and “BBR” are
not allowed for use under HIPAA as of March 1, 2007. These qualifiers can only be
used:
If a new rule names the ICD-10-CM and/or ICD-10-PCS as an allowable code set
under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed
under the law,
OR
For claims which are not covered under HIPAA.
Field
Attributes
1 Field
1 Line
1 Position
Alphanumeric
Left-justified
Notes
Qualifier codes reflects the edition portion of the ICD:
9 - Ninth Revision
0 - Tenth Revision
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Form Locator 67
Page 1 of 3
Data
Element
Principal Diagnosis Code and Present on Admission Indicator
Definition:
The ICD-9-CM codes describing the principal diagnosis (i.e., the condition
established after study to be chiefly responsible for occasioning the admission of the
patient for care.)
See FL 67 Pages 2-3 for information on the Present on Admission Indicator.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Reporting
Principal Diagnosis Code
• UB-04: Required.
• 004010/004010A: Required.
• 005010: Required.
Present on Admission Indicator
For use on the UB-04 and 005010 only; not for use in any manner on
004010/004010A.
See FL 67 Pages 2-3 for further information on usage.
Field
Attributes
1 Field
1 Line
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Alphanumeric
Left-justified
Notes
Follow the official coding guidelines for ICD reporting.
The reporting of the decimal between the third and fourth digit is unnecessary because
it is implied.
The principal diagnosis code will include the use of “V” codes.
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Form Locator 67
Page 2 of 3
Present on Admission (POA) Indicator
·
The eighth digit of FL 67 - Principal Diagnosis and each of the secondary
diagnosis fields FL 67A-Q.
·
The eighth digit of FL 72 - External Cause of Injury (ECI) (3 fields on the
form).
Usage
1. The POA Indicator applies to the diagnosis codes for claims involving inpatient
admissions to general acute-care hospitals or other facilities, as required by law or
regulation for public health reporting.
2. The POA Indicator is based not only on the conditions known at the time of
admission, but also include those conditions that were clearly present, but not
diagnosed, until after the admission took place.
3. Present on admission is defined as present at the time the order for inpatient
admission occurs -- conditions that develop during an outpatient encounter, including
emergency department, are considered as present on admission.
4. The POA Indicator is applied to the principal diagnosis as well as all secondary
diagnoses that are reported.
5. The five reporting options for all diagnosis reporting are as follows:
Code
Y
N
U
W
(Unreported/Not Used)
Definition
Yes
No
No Information in the Record
Clinically Undetermined
Exempt from POA Reporting
The American Health Information Management Association, American Hospital
Association, CMS and the National Center for Health Statistics (known as the
“Cooperating Parties”) will publish a list of ICD-9-CM codes that are exempt from
POA reporting. The indicator can be left unreported only for the codes on this list,
that is, the field is left blank on the paper form and “Not Used” on the electronic
claim. The list of exempt diagnosis codes will be included in the POA guidelines
published in the ICD-9-CM Official Guidelines for Coding and Reporting and
updated as needed.
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Form Locator 67
Page 3 of 3
Present on Admission (POA) Indicator (continued)
6. The POA Indicator should also be reported for all E (External Cause) codes. “Ecode” categories for which the POA Indicator is not applicable would not be reported.
7. Health plans that receive POA information on the claim should not reject the claim
if their claims processing systems have no use for any of the POA information.
8. Coding professionals should follow the comprehensive guidelines on POA as
published in the ICD-9-CM Official Guidelines for Coding and Reporting to further
assist coding professionals in accurate and consistent reporting of all POA data. These
guidelines will be updated as needed to address identified coding errors or areas of
confusion.
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Form Locators 67A-Q
Data
Element
Other Diagnosis Codes
Definition:
The ICD-9-CM diagnoses codes corresponding to all conditions that coexist at the
time of admission, that develop subsequently, or that affect the treatment received
and/or the length of stay. Exclude diagnoses that relate to an earlier episode which
have no bearing on the current hospital stay.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Reporting
Other Diagnosis Codes
• UB-04: Situational. Required when other condition(s) coexist or develop(s)
subsequently during the patient’s treatment.
• 004010/004010A: Situational. Required when other condition(s) co-exists with the
Principal Diagnosis, co-exists at the time of admission or develops subsequently
during the patient’s treatment.
• 005010: Situational. Required when other condition(s) coexist or develop(s)
subsequently during the patient’s treatment.
Present on Admission Indicator
For use on the UB-04 and 005010 only; not for use in any manner on
004010/004010A.
See FL 67 Pages 2-3 for further information on usage.
Field
Attributes
17 Fields
2 Lines
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Alphanumeric
Left-justified
Notes
The reporting of the decimal between the third and fourth digits is unnecessary
because it is implied.
Other diagnoses codes will permit the use of ICD-9-CM “V” and “E” codes where
appropriate.
Other diagnosis is interpreted as additional conditions that affect patient care in terms
of requiring: Clinical Evaluation, or Therapeutic Treatment, or Diagnostic
Procedures, or Extended Length of Hospital Stay, or Increased Nursing Care and/or
Monitoring.
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 68
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
8 Positions (Line 1)
9 Positions (Line 2)
Alphanumeric
Left-justified
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Form Locator 69
Data
Element
Admitting Diagnosis Code
Definition:
The ICD diagnosis code describing the patient’s diagnosis at the time of admission.
Reporting
• UB-04: Situational. Required when claim involves an inpatient admission.
Required ONLY on 011x, 012x, 018x, and 021x types of bills.
• 004010/004010A1: Situational. The Admitting Diagnosis is required on all
inpatient admission claims and encounters.
• 005010: Situational. Required when claim involves an inpatient admission.
Field
Attributes
1 Field
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
The ICD-9-CM diagnosis code describing the admitting diagnosis as a significant
finding representing patient distress, an abnormal finding on examination, a possible
diagnosis based on significant findings, a diagnosis established from a previous
encounter or admission, an injury, a poisoning, or a reason or condition (not an illness
or injury) such as follow-up or pregnancy in labor. Report only one admitting
diagnosis. This condition shall be determined based on the ICD-9-CM coding
directives in Volumes I and II of the ICD-9-CM coding manuals (ICD-9-CM codes
001 - V82.9). The reporting of the decimal between the third and fourth digits is
unnecessary because it is implied.
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Form Locator 70a-c
Data
Element
Patient’s Reason for Visit
Definition:
The ICD-CM diagnosis codes describing the patient’s reason for visit at the time of
outpatient registration.
Reporting
• UB-04: Situational.
1. Required for all unscheduled outpatient visits. An “unscheduled” outpatient visit
is defined as an outpatient Type of Bill 013X or 085X, together with Form Locator 14
(Priority of Visit/Type of Admission) codes 1, 2 or 5 and Revenue Codes 045X, 0516,
0526, or 0762 (Observation Room).
2. May be reported at submitter’s discretion for scheduled outpatient visits (such as
encounters for ancillary tests) when this information provides additional information
to support medical necessity. This information may be any documented reason for the
service provided, including patient’s stated reason for seeking care or the reason
provided by the physician as part of the order for the service. This information is not
required for all scheduled outpatient encounters.
3. Payers should not reject outpatient claims that contain patient’s reason for visit
information in FL 70 if this information is not needed for their adjudication of the
claim.
• 004010/004010A1: Situational. Required for all unscheduled outpatient visits or
upon the patient’s admission to the hospital.
• 005010: Situational. Required when claim involves outpatient visits. (See specific
UB-04 requirements above and FL 04.)
Field
Attributes
1 Field, 3 Subfields (a, b, c)
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
The ICD-9-CM diagnosis code describing the patient’s stated reason for seeking care
(or as stated by the patient’s representative). This may be a condition representing
patient distress, an injury, a poisoning, or a reason or condition (not an illness or
injury) such as follow-up or pregnancy in labor. Report the first diagnosis code
describing the patient’s primary reason for seeking care in subfield a. This condition
shall be determined based on the ICD-9-CM directives in Volumes I and II of the
ICD-9-CM coding manuals (ICD-9-CM codes 001 - V82.9). There are two other
diagnosis code subfields to report additional reasons for the patient’s visit for care.
Reporting the decimal between the third and fourth digits is unnecessary because it is
implied.
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Form Locator 71
Data
Element
Prospective Payment System (PPS) Code
Definition:
The PPS code assigned to the claim to identify the DRG based on the grouper
software called for under contract with the primary payer.
Reporting
• UB-04: Situational. Required for inpatient claims when the hospital is under
contract with the health plan to provide this information.
• 004010/004010A1: Situational. Required when an inpatient hospital is under DRG
contract with a payer and the contract requires the provider to identify the DRG to the
payer.
• 005010: Situational. Required when an inpatient hospital is under DRG contract
with a payer and the contract requires the provider to identify the DRG to the payer.
Field
Attributes
1 Field
1 Line
4 Positions
Numeric
Right-justified (all positions fully coded)
Note
Many workers’ compensation programs require this information.
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Form Locator 72a-c
Data
Element
External Cause of Injury (ECI) Code
Definition:
The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or
adverse effect.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Reporting
External Cause of Injury (ECI) Code
• UB-04: Situational. Required when an injury, poisoning, or adverse effect is the
cause for seeking medical treatment or occurs during the medical treatment.
• 004010/004010A1: Situational. Required whenever a diagnosis is needed to
describe an injury, poisoning or adverse effect.
• 005010: Situational. Required when an external Cause of Injury is needed to
describe an injury, poisoning, or adverse effect.
Present on Admission Indicator
For use on the UB-04 and 005010 only; not for use in any manner on
004010/004010A.
See FL 67 Pages 2-3 for further information on usage.
Field
Attributes
3 Fields
1 Line
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Left-justified
Notes
The priorities for recording an ECI code in Form Locator 72a-c are:
1. Principal diagnosis of an injury or poisoning.
2. Other diagnosis of an injury, poisoning, or adverse effect directly related to the
principal diagnosis.
3. Other diagnosis with an external cause.
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Element
Official UB-04 Data Specifications Manual 2007
Form Locator 73
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
1 Line
9 Positions
Alphanumeric
Left-Justified
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Form Locator 74
Data
Element
Principal Procedure Code and Date
Definition:
The ICD code that identifies the inpatient principal procedure performed at the claim
level during the period covered by this bill and the corresponding date.
Reporting
• UB-04: Situational. Required on inpatient claims when a procedure was
performed. If not required (i.e., on outpatient claims) do not send.
• 004010/004010A1: Situational. Required on Home IV therapy claims or
encounters when surgery was performed during the inpatient stay from which the
course of therapy was initiated. Required on inpatient claims or encounters when a
procedure was performed.
• 005010: Situational. Required on inpatient claims when a procedure was
performed. If not required by the 005010 implementation guide, do not send.
Field
Attributes
1 Field (code)
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
Reporting the decimal between the second and third digits of the ICD is unnecessary
because it is implied.
1 Field (date)
1 Line
6 Positions
Numeric
Right-justified
Enter date as MMDDYY.
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Form Locator 74a-e
Data
Element
Other Procedure Codes and Dates
Definition:
The ICD codes identifying all significant procedures other than the principal
procedure and the dates (identified by code) on which the procedures were performed.
Report those that are most important for the episode of care and specifically any
therapeutic procedures closely related to the principal diagnosis.
Reporting
• UB-04: Situational. Required on inpatient claims when additional procedures must
be reported. If not required (i.e., on outpatient claims) do not send.
• 004010/004010A1: Situational. Required on Home IV therapy claims or
encounters when surgery was performed during the inpatient stay from which the
course of therapy was initiated. Required on inpatient claims or encounters when
additional procedures must be reported.
• 005010: Situational. Required on inpatient claims when additional procedures must
be reported. If not required by the 005010 implementation guide (TR3), do not send.
Field
Attributes
5 Fields (code)
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
Reporting the decimal between the second and third digits of the ICD is unnecessary
because it is implied.
5 Fields (date)
1 Line
6 Positions
Numeric
Right-justified
Enter date as MMDDYY.
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Data
Element
Official UB-04 Data Specifications Manual 2007
Form Locator 75
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
4 Lines
4 Positions
Alphanumeric
Left-justified
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Form Locator 76
Page 1 of 2
Data
Element
Attending Provider Name and Identifiers
Definition:
The Attending Provider is the individual who has overall responsibility for the
patient’s medical care and treatment reported in this claim.
Reporting
Name
• UB-04 and 005010: Situational. Required when the claim contains any services
other than non-scheduled transportation claims.
• 004010/004010A1: Situational. Required on all inpatient claims or encounters.
Required to indicate the Primary Physician responsible on a Home Health Agency
Plan of Treatment.
Identifiers - National Provider Identifier
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of
the NPI Final Rule.
• UB-04 and 005010: Situational. Required for providers in the United States or its
territories on or after the mandated HIPAA NPI implementation date when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it.
Identifiers - Secondary
• UB-04 and 005010: Situational. Required prior to the mandated HIPAA National
Provider Identifier (NPI) implementation date when an identification number other
than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this
field is not used and an identification number other than the NPI is necessary for the
receiver to identify the provider.
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Field
Attributes
Official UB-04 Data Specifications Manual 2007
Form Locator 76
Page 2 of 2
5 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
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Form Locator 77
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Data
Element
Operating Physician Name and Identifiers
Definition:
The name and identification number of the individual with the primary responsibility
for performing the surgical procedure(s).
Reporting
Name
• UB-04 and 005010: Situational. Required when a surgical procedure code is listed
on this claim.
• 004010/004010A1: Situational. Required when any surgical procedure code is
listed on this claim.
Identifiers - National Provider Identifier
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of
the NPI Final Rule.
• UB-04 and 005010: Situational. Required for providers in the United States or its
territories on or after the mandated HIPAA NPI implementation date when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it.
Identifiers - Secondary
• UB-04 and 005010: Situational. Required prior to the mandated HIPAA National
Provider Identifier (NPI) implementation date when an identification number other
than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this
field is not used and an identification number other than the NPI is necessary for the
receiver to identify the provider.
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Field
Attributes
Official UB-04 Data Specifications Manual 2007
Form Locator 77
Page 2 of 2
5 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
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Form Locators 78-79
Page 1 of 2
Data
Element
Other Provider (Individual) Names and Identifiers
Definition:
The name and ID number of the individual corresponding to the Provider Type
category indicated in this section of the claim. See notes below.
Reporting
Name
• UB-04: Situational. See allowable provider type qualifier codes and usage notes on
next page.
• 004010/004010A1: Situational. Required when the claim/encounter involves
another provider such as, but not limited to: Referring Provider, Ordering Provider,
Assisting Provider, etc.
• 5010: Situational. See allowable qualifiers and usage notes on next page.
Identifiers - National Provider Identifier
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of
the NPI Final Rule.
• UB-04 and 005010: Situational. Required for providers in the United States or its
territories on or after the mandated HIPAA NPI implementation date when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it.
Identifiers - Secondary
• UB-04 and 005010: Situational. Required prior to the mandated HIPAA National
Provider Identifier (NPI) implementation date when an identification number other
than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this
field is not used and an identification number other than the NPI is necessary for the
receiver to identify the provider.
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Field
Attributes
Official UB-04 Data Specifications Manual 2007
Form Locators 78-79
Page 2 of 2
6 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
2 Positions - Provider Type Qualifier (see below)
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
Notes
Provider Type Qualifier Codes/Definition/Situational Usage Notes for UB-04 and
005010:
DN - Referring Provider. The provider who sends the patient to another provider for
services. Required on an outpatient claim when the Referring Provider is different
than the Attending Physician. If not required, do not send.
ZZ - Other Operating Physician. An individual performing a secondary surgical
procedure or assisting the Operating Physician. Required when another Operating
Physician is involved. If not required, do not send.
82 - Rendering Provider. The health care professional who delivers or completes a
particular medical service or non-surgical procedure. Report when state or federal
regulatory requirements call for a combined claim, i.e., a claim that includes both
facility and professional fee components (e.g., a Medicaid clinic bill or Critical
Access Hospital claim). If not required, do not send.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
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Form Locator 80
Data
Element
Remarks Field
Definition:
Area to capture additional information necessary to adjudicate the claim.
Reporting
• UB-04: Situational. Required when in the judgment of the provider, the
information is needed to substantiate the medical treatment and is not supported
elsewhere within the claim data set.
• 004010/004010A1: Situational. The Billing Note segment (Loop ID 2300 | NTE) is
used to convey additional information necessary to adjudicate the claim. Required
when: (1) State regulations mandate information not identified elsewhere within the
claim set; or (2) in the opinion of the provider, the information is needed to
substantiate the medical treatment and is not supported elsewhere within the claim
data set.
• 005010: Situational (Loop ID 2300 | NTE). Required when in the judgment of the
provider, the information is needed to substantiate the medical treatment and is not
supported elsewhere within the claim data set.
OR
Required when in the judgment of the provider, narrative information from the forms
“Home Health Certification and Plan of Treatment” or “Medical Update and Patient
Information” is needed to substantiate home health services.
Field
Attributes
1 Field
4 Lines
Line 1: 19 Positions
Lines 2-4: 24 Positions
Alphanumeric
Left-justified
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Form Locator 81
Page 1 of 5
Data
Element
Code-Code Field
Definition:
To report additional codes related to a Form Locator (overflow) or to report externally
maintained codes approved by the NUBC for inclusion in the institutional data set.
Reporting
Situational. See specifics below. For overflow NUBC codes (A1-A4), see applicable
Form Locator.
Field
Attributes
Left Column
1 Field (Code Qualifier)
4 Lines
2 Positions
Alphanumeric
Left-justified
(fully coded)
Notes
Code List Qualifiers:
01-A0
A1
Middle Column
1 Field (Code)
4 Lines
10 Positions
Alphanumeric
Left-justified
Right Column
1 Field (Number or Value)
4 Lines
12 Positions
Numeric
Right-justified
Reserved for National Assignment
National Uniform Billing Committee Condition Codes (FL 18-28)
Right column is blank.
Example:
A 1 4 4
A2
National Uniform Billing Committee Occurrence Codes (FL 31-34)
Example:
A 2 0 1
A3
0 2 2 8 0 6
National Uniform Billing Committee Occurrence Span Codes (FL 35-36)
All positions fully coded in the right column.
Example:
A 3 M 4
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A4
Form Locator 81
Page 2 of 5
National Uniform Billing Committee Value Codes (FL 39-41)
For Value Codes, there is an implied dollar/cents delimiter in the right
column of FL 81 separating the last two positions as illustrated below.
$ $ $ $ $ $ $ $ $ $ c c
See FL 39-41 for special rules for reporting values. Whole numbers or
non-dollar amounts are right justified to the left of the implied dollars/cents
delimiter. Do not zero fill the positions to the left of the implied delimiter.
However, values are reported as cents, thus reference to the instructions for
specific codes is necessary.
Example:
A 4 5 4
A5-B0
B1
3 3 3 3
Reserved for Assignment by the NUBC.
Standards for the Classification of Federal Data on Race and Ethnicity
Code Source: ASC X12 External Code Source 859 (Health Information
and Surveillance Systems Board)
Reporting*
FOR PUBLIC HEALTH DATA REPORTING ONLY when required
by state or federal law or regulations.
Example:
B 1 R 5 E 5
B2
Reserved for Marital Status
Code Source: ASC X12 Data Element 1067
Reporting* (Effective Date to be Determined)
FOR PUBLIC HEALTH DATA REPORTING ONLY when required
by state or federal law or regulations.
Example:
B 2 M
* Use of Code List Qualifiers B1 and B2 is intended to promote standardized public
health reporting of these data elements.
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Meeting Date:
B3
Form Locator 81
Page 3 of 5
Health Care Provider Taxonomy Code
Code Source: ASC X12 External Code Source 682 (National Uniform
Claim Committee)
Reporting
• UB-04: Situational. Used for Billing Provider Only (FL01). Required
when the payer’s adjudication is known to be impacted by the provider
taxonomy code. (See Medicare requirements below.)
• 004010/004010A1 (Loop ID 2000A | PRV03): Situational. Required
when adjudication is known to be impacted by the provider taxonomy code,
and the Service Facility Provider is the same entity as the Billing and/or
Pay-to Provider.
• 005010 (Loop ID 2000A | PRV03): Situational. Required when the
payer’s adjudication is known to be impacted by the provider taxonomy
code.
All positions fully coded in the middle column; the right-hand column is
left blank.
Example:
B 3 2 8 2 N 0 0 0 0 0 X
Medicare Taxonomy Reporting Requirements
CMS has determined that it is necessary to require institutional providers to
submit a taxonomy code for proper Medicare claim adjudication.
Institutional providers submitting claims for their primary facility and its
subparts (i.e.; psychiatric unit, rehabilitation unit, etc.) will report a
taxonomy code on all of their claims submitted to the fiscal intermediary.
The taxonomy code will assist in crosswalking from the NPI of the
provider to each of its subparts when a provider has chosen not to apply for
a unique national provider number for those subparts individually. The
following chart supplies the crosswalk from the OSCAR number to the
appropriate taxonomy code based on the provider’s facility type:
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OSCAR Provider Type
OSCAR
Coding
Short-term (General and
Specialty) Hospitals
0001-0879
282N00000X
*Positions 3-6
Critical Access Hospitals
1300-1399*
282NC0060X
Long-Term Care
Hospitals (LTCH Swing
Beds submitting with
type of bill 018x must use
the LTCH taxonomy
code)
2000-2299*
282E00000X
Hospital Based Renal
Dialysis Facilities
2300-2499*
261QE0700X
Independent Renal
Dialysis Facilities
2500-2899*
261QE0700X
Rehabilitation Hospitals
3025-3099*
283X00000X
Children’s Hospitals
3300-3399*
282NC2000X
Hospital Based Satellite
Renal Dialysis Facilities
3500-3699
Type of bill code 072x +
261QE0700X + different
zip code than any renal
dialysis facility issued an
OSCAR that is located on
that hospital’s campus.
Psychiatric Hospitals
4000-4499*
283Q00000X
Organ Procurement
Organization (OPO)
P in third
Position
335U00000X
Psychiatric Unit
M or S in
third Position
273R00000X
Rehabilitation Unit
R or T in third 273Y00000X
Position
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OSCAR Provider Type
Swing-Bed
B4-ZZ
Form Locator 81
Page 5 of 5
OSCAR
Coding
U, W, Y, or Z
in third
Position
Taxonomy Code
Type of bill code 018x and
028x (swing bed) with one
of the following taxonomy
codes to define the type of
facility in which the swing
bed is located:
275N00000X if unit in a
short-term hospital (U);
282E00000X if unit in a
long-term care hospital
(W); 283X00000X if unit in
a rehab facility (Y); or
282NC0060X if unit in a
critical access hospital (Z).
Reserved for Assignment by the NUBC.
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Official UB-04
Data Specifications Manual
State Guidelines
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State Guidelines - Florida
Subcategory
Official UB-04 Data Specifications Manual 2007
Page 1 of 6
Florida Nursery Level Designations: Revenue Code 017X
Standard Abbrev
Definition
Accommodation charges for nursing care to newborn and
premature infants in nurseries.
0 - General
NURSERY
Classification
1 - Newborn – NURSERY/LEVELI
Level I
2 – Newborn – NURSERY/LEVELII
Level II
Subcategories 1 - 4 to be used by facilities with nursery
services designed around distinct areas and/or levels of
care. Levels of care defined under Florida regulations
supersede national guidelines.
Well-baby care services which include sub-ventilation
care, intravenous feedings, and gavage to neonates.
Services which include the provision of ventilator services,
and at least 6 hours of nursing care per day. Restricted to
neonates of 1000 grams birth weight and over with the
exception of those neonates awaiting transfer to Level III.
3 – Newborn – NURSERY/LEVELIII Services which include the provision of continuous
Level III
cardiopulmonary support services, 12 or more hours of
nursing care per day, complex pediatric surgery, neonatal
cardiovascular surgery, pediatric neurology and
neurosurgery, and pediatric cardiac catheterization.
4 – Newborn – NURSERY/LEVELIV Not applicable under Florida licensure.
Level IV
9 – Other
NURSERY/OTHER
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Page 2 of 6
Florida Medicaid: Revenue Code 0510 - Clinic
Subcategory
Definition
Charges for scheduled non-emergency outpatient clinic visits for the purpose of providing diagnostic,
preventive, curative, rehabilitative services.
0510 - General Classification
Medicaid policy regarding limited usage of code 0510.
Code 0510 (Clinic Visit) can be reported on a hospital claim only when it
accompanies any of the revenue center codes identifying therapy and other medical
services listed below in this section. Code 0510 cannot be billed to Medicaid as a
stand-alone code.
Code 0510 is limited to the billing of charges associated with the use of the
hospital’s clinic setting, whether the location of the clinic is contiguous with the
main hospital or off-site, when any therapy or medical service listed below is
rendered on such premise. If the site or location is not referred to or known as a
“clinic” setting, then code 0510 should not be reported on the claim when reporting
therapy or other medical services noted below.
General classification code 0510 can be billed with any one or more of the services identified by the
following revenue center codes:
0258 Pharmacy/IV Solutions
0261 Infusion Pump
0262 IV Therapy/Pharmacy Services
0264 IV Therapy/Supplies
0269 Other IV Therapy
0330 Therapeutic Radiology/General
0331 Therapeutic Radiology/Injected Chemotherapy
0332 Therapeutic Radiology/Oral Chemotherapy
0333 Therapeutic Radiology/Radiation Therapy
0335 Therapeutic Radiology/Chemotherapy-IV
0339 Other Therapeutic Radiology
0410 Respiratory Services/General (All Ages)
0412 Respiratory Services/Inhalation (All Ages)
0413 Respiratory Services/Hyperbaric Oxygen Therapy (All Ages)
0419 Other Respiratory Services
0421 Physical Therapy/Visit Charges (All Ages)
0424 Physical Therapy/Evaluation and Re-evaluation (All Ages)
0431 Occupational Therapy/Visit Charges (Under 21 Only)
0434 Occupational Therapy/Evaluation and Re-evaluation (Under 21 Only)
0441 Speech-Language Pathology/Visit Charges (Under 21 Only)
0444 Speech-Language Pathology/Evaluation and Re-evaluation (Under 21 Only)
0480 Cardiology (General)
0481 Cardiology/Cardiac Cath Lab
0482 Cardiology Stress Test
0483 Cardiology/Echocardiology Cath
0489 Other Cardiology
0821 Hemodialysis OP
0831 Peritoneal Dialysis OP
0880 Miscellaneous Dialysis/General
0881 Ultrafiltration
0943 Other Therapeutic Services/Cardiac Rehab
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Florida Medicaid: Revenue Code 0510 – Clinic (cont.)
Subcategory
Definition
Clinic revenue code 0510 is not covered and not billable to Medicaid when the services identified
below are rendered in hospital-owned clinics. Instead, the hospital should bill these services to
Medicaid on the CMS-1500 claim form exclusively, using the appropriate 5-digit CPT or HCPCS
procedure codes covered under the Medicaid Physician Services program.
Primary care services
Routine prenatal and postnatal care
Well-checkups and screenings for children and adults
Dental services rendered in hospital-owned dental clinics
Services rendered in psychiatric clinics (See revenue code 0513 covered for that
purpose).
All services rendered in walk-in clinics, wound care centers, urgent care centers
Services rendered in family practice clinics
Any type of service rendered in a hospital-owned clinic that could also be accessed
and furnished in a physician’s office
Effective November 1, 2004 revenue code 0510, Clinic/General, is reimbursable by Medicaid for
health care services (except dental) in outpatient clinic facilities where a public hospital assumed the
fiscal and operating responsibilities of one or more primary care centers previously operated by the
Florida Department of Health or the local county government.
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State Guidelines - Florida
Page 4 of 6
Coordination of Benefits
Florida Statutes 627.4235
(1) A group hospital, medical, or surgical expense policy, group health care services plan, or group-type
self-insurance plan that provides protection or insurance against hospital, medical or surgical expense
delivered or issued for delivery in this state must contain a provision for coordinating its benefits with
any similar benefits provided by any other group hospital, medical, or surgical expense policy, any
group health care services plan, or any group-type self-insurance plan that provides protection or
insurance against hospital, medical or surgical expenses for the same loss.
(2) A hospital, medical or surgical expense policy, health care services plan, or self-insurance plan that
provides protection or insurance against hospital, medical, or surgical expenses issued in this state or
issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay
benefits otherwise payable there under solely on account of the existence of similar benefits provided
under insurance policies issued by the same or another insurer, health care services plan, or selfinsurance plan which provides protection or insurance against hospital, medical, or surgical expenses
only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100
percent of the total reasonable expenses actually incurred of the type of expense within the benefits
described in the policies and presented to the insurer for payment.
(3) The standards provided in subsection (2) apply to coordination of benefits payable under Medicare,
Title XVIII of the Social Security Act.
(4) If a claim is submitted in accordance with any group hospital, medical, or surgical expense policy,
or in accordance with any group health care service plan or group-type self-insurance plan, that
provides protection, insurance, or indemnity against hospital, medical or surgical expenses, and the
policy or any other document that provides coverage includes a coordination-of-benefits provision and
the claim involves another policy or plan which has a coordination-of-benefits provision, the following
rules determine the order in which benefits under the respective health policies or plans will be
determined:
(a) 1. The benefits of a policy or plan which covers the person as an employee, member, or
subscriber, other than as a dependent, are determined before those of the policy or plan
which covers the person as a dependent.
2. However, if the person is also a Medicare beneficiary, and if the rule established under the
Social Security Act of 1965, as amended, makes Medicare secondary to the plan covering
the person as a dependent of an active employee, the order of benefit determination is:
a. First, benefits of a plan covering a person as an employee, member, or subscriber.
b. Second, benefits of a plan of an active worker covering a person as a dependent.
c. Third, Medicare benefits.
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Coordination of Benefits
Florida Statutes 627.4235 (cont.)
(b) Except as stated in paragraph (c), if two or more policies or plans cover the same child as a
dependent of different parents:
1. The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls
earlier in a year are determined before the benefits of the policy or plan of the parent whose
birthday, excluding year of birth, falls later in that year; but;
2. If both parents have the same birthday, the benefits of the policy or plan which covered the
parent for a longer period of time are determined before those of the policy or plan which
covered the parent for a shorter period of time.
However, if a policy or plan subject to the rule based on the birthdays of the parents
coordinates with an out-of-state policy or plan which contains provisions under which the
benefits of a policy or plan which covers a person as a dependent of a male are determined
before those of a policy or plan which covers the person as a dependent of a female and if, as
a result, the policies or plans do not agree on the order of benefits, the provisions of the
other policy or plan determine the order of benefits.
(c) If two or more policies or plans cover a dependent child of divorced or separated parents,
benefits for the child are determined in this order:
1.
First, the policy or plan of the parent with custody of the child.
2.
Second, the policy or plan of the spouse of the parent with custody of the child.
3.
Third, the policy or plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents is responsible
for the health care expenses of the child and if the entity obliged to pay or provide the
benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits
of that policy or plan are determined first, except with respect to any claim determination
period or plan or policy year during which any benefits are actually paid or provided before
the entity has the actual knowledge.
(d) The benefits of a policy or plan which covers a person as an employee who is neither laid off
nor retired, or as that employee’s dependent, are determined before those of a policy or plan
which covers the person as a laid-off or retired employee or as the employee’s dependent. If the
other policy or plan is not subject this rule, and if, as a result, the policies or plans do not agree
on the order of benefits, this paragraph does not apply.
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - Florida
Page 6 of 6
Coordination of Benefits
Florida Statutes 627.4235 (cont.)
(e) If none of the rules in paragraph (a) paragraph, (b) paragraph, (c) paragraph (d) determine the
order of benefits, the benefits of the policy or plan which covered an employee, member or
subscriber for a longer period of time are determined before those of the policy or plan which
covered the person for the shorter period of time.
(5) Coordination of benefits is not permitted against an indemnity-type policy, an excess insurance
policy as defined in s. 627.635, a policy with coverage limited to specified illnesses or accidents, or a
Medicare supplement policy.
(6) If an individual is covered under a COBRA continuation plan as a result of the purchase of coverage
as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987 (Pub. L. No. 99-272),
and also under another group plan, the following order of benefits applies:
(a) First, the plan covering the person as an employee, or as the employee’s dependent. Second,
the coverage purchased under the plan covering the person as a former employee, or as the
former employee’s dependent provided according to the provisions of COBRA.
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Page 208 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - South Carolina
Page 1 of 6
The Medically Indigent Assistance Act (MIAA)
The Medically Indigent Assistance Act was passed by the South Carolina legislature in July, 1985, and
later amended in 1989 and 1993. Part of the Act directed the Office of Research and Statistics (ORS)
of the State Budget and Control Board to collect and analyze certain provider-specific information
found on the patient medical record. As a result, extracts of the following medical record information
are required to be submitted to ORS. Data may be submitted to ORS on a monthly or quarterly basis,
or via your clearinghouse/vendor. The format for reporting is the same for inpatient and outpatient data
and may be included on the same tape submission. See next page for type of outpatient claims required
to be submitted (without regard to payer). All inpatient records must be submitted (without regard to
payer).
MIAA Required Data Reporting Codes
Data Element
UB-92
FL
17
82
24-30
78
68-75
6
77
05
23
83
I/P
Admission Date
R
Attending Physician ID
R
Patient Race - Condition Codes 80-85 or Value Code 23
R
Patient County of Residence (or Value Code 21)
R
Diagnoses Codes, Other - Up to 8 Other Diagnoses Codes Required
R
Discharge Date
R
External Cause of Injury Code (E-code)
R
Provider I.D. # (Federal Tax Number)
R
Medical/Health Record Number
R
Other Physician ID - Primary Surgeon Required for State Data
R
Reporting
Other Procedure Codes and Dates - Up to 5 Other Procedure Codes
81
R
Required
Patient Address
13
R
Patient Birthdate
14
R
Patient Control Number
03
R
Patient Name
12
R
Patient Sex
15
R
Patient Social Security Number (or Value Code 22)
02
R
Patient Status at Discharge
22
R
Patient Zip Code
13
R
Payer Identification - Principal Source of Payment Required
50
R
Principal Diagnosis Code
67
R
Principal Procedure Code and Date
80
R
Revenue Codes
42
R
Source of Admission
20
R
Total Charges (by Revenue Code Category)
47
R
Type of Admission
19
R
Units of Service
46
R
* Required only for observation and E.R. records.
Note: ORS would like to have the Admission/Discharge times reported for E.D. visits.
AHA © 2006
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O/P
837I
R
R
R
R
R
R*
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R*
R
R
R
R
R
R*
R
R*
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
Version 1.00 September 2006
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - South Carolina
Page 2 of 6
The Medically Indigent Assistance Act (cont.)
Outpatient Data Reporting
In accordance with the recommendations of the Data Oversight Council and State law ORS began
outpatient data collection effective July 1, 1995.
ORS points of contact for outpatient data are Sandra Kelly (803/898-9958) and Isaac McCullum
(803/898-9968). Please do not hesitate to call them with substantive or technical questions.
Records to be reported must have bill types of 13X, 14X, 83X or 84X, and meet the following criteria:
*Outpatient Surgery
Emergency Room
Service
Labor and Delivery
*Radiation Therapy
*Chemotherapy
*Imaging
*Lithotripsy/ExtraCorporeal Shock Wave
Therapy
Observation
All records with either a principal procedure in the range of ICD-9CM Codes 01.XX-86.XX, or a nonzero charge in Revenue Codes 360,
481 or 490
Nonzero charge in Revenue Code 450
Nonzero charge in Revenue Codes 720, 722 or 724
All records with either a principal procedure of ICD-9-CM 92.XX; or
a nonzero charge in Revenue Codes 330 or 333
All records with either a principal procedure of 99.25; or a nonzero
charge in Revenue Codes 331, 332 or 335
All records with either a principal procedure in the range of ICD-9CM codes 88.91 through 88.97, or in the range of 92.0X through
92.1X; or a nonzero charge in Revenue Codes 404, 610, 611 or 612
All records with either a principal procedure of 98.5X; or a nonzero
charge in Revenue Codes 790 or 799
Non-zero charge in Revenue Code 762
* Where both Procedure Codes and Revenue Codes are listed, both types of records need to be
extracted to account for variations in billing practices.
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Version 1.00 September 2006
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National Uniform Billing Committee
State Guidelines - South Carolina
EFFECTIVE: 10/16/03
APPROVED: 09/25/0
Official UB-04 Data Specifications Manual 2007
Page 3 of 6
(UB-92) FORM LOCATOR 77
E-Code Reporting to Statewide Data Base
Requirements: Required when the primary diagnosis falls in the following ranges of ICD-9-CM
codes:
800.00 - 904.9 910.0 - 995.89
Specifically excluded are requirements for E-Codes when “late effects” (905-909) or “complications of
surgical and medical care" (996-999) are reported as the primary diagnosis.
For purposes of these requirements, the Primary E-Code will be defined as the direct cause of the injury
regardless of the number of injuries and must fall in the following ranges:
E800-E848
E850-E869
E880-3998
When the Primary E Code falls in the ranges E850-869, E880-E928, a Place of Occurrence E-Code will
also be required (E849.0-E849.9).
Format for Reporting:
The Primary E-Code should be reported in FL77; the Place of Occurrence E-Code should be reported in
the secondary diagnoses as the last non-missing secondary diagnosis. The Primary E-Code must be
reported in FL77. ORS recognizes that there may be cases in which all 9 secondary diagnoses will be
necessary for medical diagnoses. In this case, the Place of Occurrence E-Code will not be required.
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - South Carolina
Page 4 of 6
EFFECTIVE: 10/16/03
APPROVED: 09/25/0
(UB-92) FORM LOCATOR 77
E-Code Reporting to Statewide Data Base (cont.)
Editing Procedures:
ORS will search all diagnosis fields for both Primary and Place of Occurrence E-Codes and will create
new statistical fields on the statewide data base for Primary E-Code and Place of Occurrence. ORS will
edit for valid E-Codes as defined above for “Primary" and "Place.”
If the hospital reports E-Codes in regular secondary diagnosis fields, ORS will assume the first E-Code
found which falls in the valid ranges for primary E-Code is the Primary E-Code and similarly for Place
of Occurrence.
The following additional age-specific edits will be performed:
E-Code
E800-807
E810-819
4th Digit
0
0, 2
Valid Age
14 & Older
2 & Older
E820-825
E826-828
0, 2
2
2 & Older
2 & Older
E830-838
4, 6
2 & Older
E840-845
E840-845
E902
E910
2, 8
7
2
0
14 & Older
2 & Older
2 & Older
2 & Older
E910
E950-959
1
all
2 & Older
2 & Older
AHA © 2006
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Description
Railway, railway employee
Motor vehicle traffic, driver or motorcyclist
Motor vehicle non-traffic, driver or
motorcyclist
Other road vehicle, rider of animal
Water transport, water skier, dockers,
stevedores
Air/space transport, crew, ground crew,
airlines employee
Air/space transport, parachutist
Air pressure, diving
Drowning while water skiing
Drowning while engaged with diving
equipment
Suicide and self-inflicted injury
Version 1.00 September 2006
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - South Carolina
Page 5 of 6
REVENUE CODES NOT REQUIRING HCPCS CODES
ON OUTPATIENT CLAIMS FOR BLUE CROSS AND MEDICARE
The applicable revenue codes are:
250
251
252
254
255
257
258
259
260
262
263
264
269
270
271
272
274
275
276
278
279
280
289
290
370
371
372
379
390
399
560
569
621
622
624
630
631
632
633
637
700
709
710
719
720
721
762
810
819
942
66X
67X
68X
70X
71X
74X
75X
76X
80X
81X
94X
99X
ON OUTPATIENT CLAIMS FOR TRICARE
The applicable revenue codes are:
24X
250
270
39X
56X
57X
58X
59X
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
State Guidelines - South Carolina
Page 6 of 6
Revenue Code 0459 needs to be included because of definition.
045X Emergency Room
Subcategory
9
Other Emergency
Room
Standard
Abbreviation
OTHER EMER
ROOM
Definition
For Medicaid use when an emergency room screening has
been denied or determined inappropriate by the PEP
recipient’s primary care physician.
This series needs to be included because of the definitions.
017X Nursery
Subcategory
0
Standard
Abbreviation
NUR
Definition
NURSERY/LEVEL
I
Accommodation charges for uncomplicated deliveries and
normal neonates who are at least 36 weeks of gestation
with an anticipated birth weight of greater than 2000
grams.
Accommodation charges for both normal and selected
high-risk obstetrical and neonatal patients. Neonates are at
least 32 weeks of gestation with an anticipated birth
weight of at least 1500 grams. Neonates shall be without
acute distress or complex management requirements and
shall not be in need of ventilatory support for distress or
complex management requirements and shall not be in
need of ventilatory support for more than six cumulative
hours. Neonates shall not require high-frequency
ventilation support.
In addition to Level II requirements, provides services for
both normal and selected high-risk obstetrical and neonatal
patients. Includes the management of neonates who are at
least 30 weeks of gestation with an anticipated birth
weight of at least 1240 grams. Neonates shall not be in
need of ventilatory support for more than 24 cumulative
hours. Neonates shall not require high-frequency
ventilation support.
Provide all aspects of perinatal care, including intensive
care and a range of continuously available, subspecialty
consultation, staffing & technical capability to manage
high risk obstetric & complex neonatal patients- including
sepsis, meningitis, respiratory problems requiring assisted
ventilation, congenital problems requiring surgery.
1
General
Classification
Newborn - Level I
2
Newborn - Level II
NURSERY/LEVEL
II
3
Newborn - Level
IIE
NURSERY/LEVEL
IIE
4
Newborn - Level III NURSERY/LEVEL
III
9
Other
NURSERY/OTHER
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
Official UB-04
Data Specifications Manual
Appendix
AHA © 2006
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eresion
Version
1.00
1.00
September
September
2006
2006
Page 215 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 1 of 8
UB-92
FL
FL01
Description
FL01
Provider Name
Provider Street
Address
Provider City, State,
Zip
Provider Telephone,
Fax, Country Code
FL02
FL02
Unlabeled Fields
Unlabeled Fields
FL03
Patient Control
Number
FL01
FL01
UB-04
Line Type Size
FL
Description
Line
Type
Buffer
Size Space
Notes
1
AN
25
FL01
Provider Name
1
AN
25
2
AN
25
FL01
2
AN
25
3
AN
25
FL01
3
AN
4
AN
25
FL01
Provider Street Address
Provider City, State,
Zip
Provider Telephone,
Fax, Country Code
4
AN
See UB-04
25 Manual
See UB-04
25 Manual
1
2
AN
AN
20
30
FL02
FL02
FL02
FL02
Pay-to Name
Pay-to Address
Pay-to City, State
NOT USED
1
2
3
4
AN
AN
AN
AN
25
25
25
25
AN
20
FL03
a
FL03
b
Patient Control Number
Medical Record
Number
AN
24
AN
24
1
New
New
New
FL04
Type of Bill
1
AN
3
FL04
Type of Bill
1
AN
4
FL05
FL05
Federal Tax Number
Federal Tax Number
1
2
AN
AN
4
10
FL05
FL05
Federal Tax Number
Federal Tax Number
1
2
AN
AN
4
10
FL06
Statement Covers
Period - From/Through
1
N/
N
6/6
FL06
Statement Covers
Period - From/Through
1
N/N
6/6
FL07
Unlabeled
1
2
AN
AN
7
8
1a
2b
1a
2b
2c
2d
AN
AN
AN
AN
AN
AN
19
29
40
30
2
9
1
2
1
1
Discrete
Discrete
Discrete
Discrete
FL09
Patient Name - ID
Patient Name
Patient Address - Street
Patient Address - City
Patient Address - State
Patient Address - ZIP
Patient Address Country Code
2e
AN
2
1
Discrete
FL07
Covered Days
1
N
3
Eliminated - Substitute
new Value Code
FL08
Non-covered Days
1
N
4
Eliminated - Substitute
new Value Code
FL09
Coinsurance Days
1
N
3
Eliminated - Substitute
new Value Code
FL10
Lifetime Reserve Days
1
N
3
Eliminated - Substitute
new Value Code
FL11
FL11
Unlabeled
Unlabeled
1
2
12
13
Eliminated
Eliminated
FL12
Patient Name
1
AN
30
FL13
Patient Address
1
AN
50
FL08
FL08
FL09
FL09
FL09
FL09
1
1/1
New
FL14
Patient Birth Date
1
N
8
FL10
Patient Birth Date
1
N
8
1
FL15
Patient Sex
1
AN
1
FL11
Patient Sex
1
AN
1
2
FL16
Patient Marital Status
1
AN
1
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Expanded
Eliminated
Version 1.00 September 2006
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 2 of 8
UB-92
FL19
Description
Admission Date
Type of
Admission/Visit
FL20
UB-04
1
AN
1
FL14
Description
Admission Date
Type of
Admission/Visit
Source of Admission
1
AN
1
FL15
Source of Admission
1
AN
1
1
FL21
Discharge Hour
1
AN
2
FL16
Discharge Hour
1
AN
2
2
FL22
Patient
Status/Discharge Code
1
AN
2
FL17
Patient Discharge
Status
1
AN
2
2
FL23
FL24
Medical/Health Record
Number
Condition Codes
AN
AN
17
2
FL18
Moved to FL3b
Condition Codes
AN
2
1
FL25
Condition Codes
AN
2
FL26
Condition Codes
AN
2
FL27
Condition Codes
AN
2
FL28
Condition Codes
AN
2
FL29
Condition Codes
AN
2
FL19
FL20
FL21
FL22
FL23
FL24
FL25
FL26
FL27
FL28
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
Condition Codes
AN
AN
AN
AN
AN
AN
AN
AN
AN
AN
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
New
New
New
FL30
Condition Codes
AN
2
FL29
Accident State
1
AN
2
1
New
FL30
FL30
Unlabeled
Unlabeled
1
2
AN
AN
11
13
2/6
FL31
Occurrence Code/Date
a
AN/N
2/6
1/1
2/6
FL31
Occurrence Code/Date
b
AN/N
2/6
1/1
2/6
FL32
Occurrence Code/Date
a
AN/N
2/6
1/1
2/6
FL32
Occurrence Code/Date
b
AN/N
2/6
1/1
2/6
FL33
Occurrence Code/Date
a
AN/N
2/6
1/1
2/6
FL33
Occurrence Code/Date
b
AN/N
2/6
1/1
FL
FL17
Line Type Size
1
N
6
FL31
FL31
Unlabeled
Unlabeled
1
2
FL32
Occurrence Code/Date
a
FL32
Occurrence Code/Date
b
FL33
Occurrence Code/Date
a
FL33
Occurrence Code/Date
b
FL34
Occurrence Code/Date
a
FL34
Occurrence Code/Date
b
FL35
Occurrence Code/Date
a
FL35
Occurrence Code/Date
b
FL36
Occurrence Span
Code/From/Through
Occurrence Span
Code/From/Through
a
FL36
AHA © 2006
b
FL
FL12
Buffer
Size Space
6
Line
1
Type
N
1
AN
1
2
Notes
(No "Xs" on
proof)
5
6
AN/
N
AN/
N
AN
AN/
N
AN
AN/
N
AN
AN/
N
2/6
FL34
Occurrence Code/Date
a
AN/N
2/6
1/1
2/6
FL34
Occurrence Code/Date
b
AN/N
2/6
1/1
AN/
N/N
AN/
N/N
2/6
/6
2/6
/6
FL35
Occurrence Span
Code/From/Through
Occurrence Span
Code/From/Through
a
AN/N
/N
AN/N
/N
2/6/
6
2/6/
6
1/1/
1
1/1/
1
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FL35
b
Version 1.00 September 2006
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National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 3 of 8
UB-92
FL
Description
UB-04
Line Type Size
FL
FL36
Description
Occurrence Span
Code/From/Through
Occurrence Span
Code/From/Through
FL37
FL37
Unlabeled
Unlabeled
FL36
FL37
FL37
FL37
ICN/DCN
ICN/DCN
ICN/DCN
A
B
C
AN
AN
AN
23
23
23
1
AN
40
FL38
2
AN
40
FL38
3
AN
40
FL38
4
AN
40
FL38
5
AN
40
FL38
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
a
a
b
b
c
c
d
d
a
a
b
b
c
c
d
d
a
a
b
b
c
c
d
d
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
FL39
FL39
FL39
FL39
FL39
FL39
FL39
FL39
FL40
FL40
FL40
FL40
FL40
FL40
FL40
FL40
FL41
FL41
FL41
FL41
FL41
FL41
FL41
FL41
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
N
4
FL42
24
FL38
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
Responsible Party
Name/Address
FL39
FL39
FL39
FL39
FL39
FL39
FL39
FL39
FL40
FL40
FL40
FL40
FL40
FL40
FL40
FL40
FL41
FL41
FL41
FL41
FL41
FL41
FL41
FL41
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
Value Code - Code
Value Code - Amount
FL42
Revenue Code
1-23
FL43
Revenue Code
Description
1-23 AN
FL38
FL38
FL38
FL38
AHA © 2006
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Please do not copy or distribute.
Line
b
Type
AN/N
/N
AN/N
/N
a
b
AN
AN
a
Buffer
Size Space Notes
2/6/ 1/1/
6
1
2/6/ 1/1/
6
1 New
8
8
Moved to FL64
Moved to FL64
Moved to FL64
Relocated
1
AN
40
2
2
AN
40
2
3
AN
40
2
4
AN
40
2
5
AN
40
2
a
a
b
b
c
c
d
d
a
a
b
b
c
c
d
d
a
a
b
b
c
c
d
d
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
AN
N
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
2
9
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Revenue Code
1-23
N
4
0.5
FL43
Revenue Code
Description
1-22
AN
24
0.5
FL43
-44
PAGE ___ OF ___
CREATION DATE
23
N/N
3/3
0.5 New
Version 1.00 September 2006
Page 218 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 4 of 8
UB-92
FL
Description
UB-04
Line Type Size
AN
/N/
1-23 AN 9
1-23 N
6
7
Expanded
0.5 size
0.5
0.5 New
0.5
N
10
FL47
Total Charges
1-23
N
9
0.5
N
10
FL48
Non-Covered Charges
1-23
N
9
0.5
4
FL49
Unlabeled
1-23
AN
2
AN
25
FL50
A
AN
23
B
C
AN
AN
25
25
FL50
FL50
Payer Name - Primary
Payer Name Secondary
Payer Name - Tertiary
B
C
AN
AN
23
23
A
B
C
AN
AN
AN
13
13
13
FL51
FL51
FL51
Health Plan ID
Health Plan ID
Health Plan ID
A
B
C
AN
AN
AN
15
15
15
A
AN
1
FL52
A
AN
1
1
B
AN
1
FL52
B
AN
1
1
C
AN
1
FL52
C
AN
1
1
A
AN
1
FL53
A
AN
1
1
B
AN
1
FL53
B
AN
1
1
C
AN
1
FL53
C
AN
1
1
A
N
10
FL54
A
N
10
1
B
N
10
FL54
B
N
10
1
C
N
10
FL54
C
N
10
1
4
N
10
A
N
10
FL55
A
N
10
1
B
N
10
FL55
B
N
10
1
C
N
10
FL55
C
N
10
1
4
N
10
1
AN
15
A
AN
15
FL47
Total Charges
1-23
FL48
Non-Covered Charges
1-23
FL49
Unlabeled
FL50
Payer - Primary
A
FL50
FL50
Payer - Secondary
Payer - Tertiary
FL51
FL51
FL51
Provider Number
Provider Number
Provider Number
FL53
FL53
FL53
FL54
FL54
FL54
FL54
Assignment of Benefits
- Primary
Assignment of Benefits
- Secondary
Assignment of Benefits
- Tertiary
Prior Payments Primary
Prior Payments Secondary
Prior Payments Tertiary
Prior Payments Patient
1-23
N
1-23 AN
FL55
Estimated Amount Due
- Primary
Estimated Amount Due
- Secondary
Estimated Amount Due
- Tertiary
Estimated Amount Due
- Patient
FL56
Unlabeled
1
13
FL56
FL56
Unlabeled
2
14
FL57
FL55
FL55
FL55
AHA © 2006
Notes
14
6
6
7
Units of Service
Fl52
Type
AN/N
1-22 /AN
1-22
N
23
N
1-22
N
FL46
FL52
Line
HCPCS/Rates/HIPPS
Rate Codes
Service Date
Creation Date
Units of Service
HCPCS/Rates/HIPPS
Rate Codes
Service Date
Release of Information
- Primary
Release of Information
- Secondary
Release of Information
- Tertiary
Description
FL44
FL45
FL45
FL46
FL44
FL45
FL52
FL
Buffer
Size Space
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Release of Information
- Primary
Release of Information
- Secondary
Release of Information
- Tertiary
Assignment of Benefits
- Primary
Assignment of Benefits
- Secondary
Assignment of Benefits
- Tertiary
Prior Payments Primary
Prior Payments Secondary
Prior Payments Tertiary
Eliminated Patient
Prior Payments
Estimated Amount Due
- Primary
Estimated Amount Due
- Secondary
Estimated Amount Due
- Tertiary
Eliminated Due from
Patient
NPI
Other Provider ID –
Primary
Removed
sign field
Removed
sign field
0.5
Changed
to Health
Plan ID
Version 1.00 September 2006
Page 219 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 5 of 8
UB-92
FL
Description
UB-04
Line Type Size
FL
FL57
FL57
FL57
FL58
FL58
FL58
FL59
FL59
FL59
FL60
FL60
FL60
FL61
FL61
FL61
FL62
FL62
FL62
FL63
FL63
FL63
Unlabeled
Insured’s Name Primary
Insured's Name Secondary
Insured's Name Tertiary
Patient’s Relationship Primary
Patient's Relationship Secondary
Patient's Relationship Tertiary
CERT./ SSN/ HIC/ ID
NO. - Primary
CERT./ SSN/ HIC/ ID
NO.- Secondary
CERT./ SSN/ HIC/ ID
NO. - Tertiary
Insurance Group Name
- Primary
Insurance Group Name
-Secondary
Insurance Group Name
- Tertiary
Insurance Group
Number - Primary
Insurance Group
Number - Secondary
Insurance Group
Number - Tertiary
Treatment
Authorization Code Primary
Treatment
Authorization Code Secondary
Treatment
Authorization Code Tertiary
Line
Type
B
AN
15
C
AN
15
A
AN
25
1
B
AN
25
1
C
AN
25
1
A
AN
2
1
B
AN
2
1
C
AN
2
1
A
AN
20
B
AN
20
C
AN
20
A
AN
14
1
B
AN
14
1
C
AN
14
1
A
AN
17
1
B
AN
17
1
C
AN
17
1
A
AN
30
1
B
AN
30
1
C
AN
30
1
A
AN
26
B
AN
26
C
AN
26
Notes
Deleted from UB-04
A
AN
25
FL58
B
AN
25
FL58
C
AN
25
FL58
A
AN
2
FL59
B
AN
2
FL59
C
AN
2
FL59
A
AN
19
FL60
B
AN
19
FL60
C
AN
19
FL60
A
AN
14
FL61
B
AN
14
FL61
C
AN
14
FL61
A
AN
17
FL62
B
AN
17
FL62
C
AN
17
FL62
A
AN
18
FL63
B
AN
18
FL63
C
AN
18
FL63
FL64
FL64
FL64
AHA © 2006
Description
Other (Bill) Provider
ID - Secondary
Other (Bill) Provider
ID – Tertiary
Buffer
Size Space
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Insured’s Name –
Primary
Insured's Name –
Secondary
Insured's Name –
Tertiary
Patient’s Relationship
to Insured - Primary
Patient's Relationship
to Insured - Secondary
Patient's Relationship
to Insured - Tertiary
Insured's Unique ID –
Primary
Insured's Unique ID –
Secondary
Insured's Unique ID Tertiary
Insured’s Group Name
– Primary
Insured’s Group Name
-Secondary
Insured’s Group Name
– Tertiary
Insured’s Group
Number - Primary
Insured’s Group
Number - Secondary
Insured’s Group
Number - Tertiary
Treatment
Authorization Code Primary
Treatment
Authorization Code Secondary
Treatment
Authorization Code Tertiary
Document Control
Number (DCN)
Document Control
Number (DCN)
Document Control
Number (DCN)
Version 1.00 September 2006
Page 220 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 6 of 8
UB-92
FL
FL64
FL64
FL64
FL65
FL65
FL65
FL66
FL66
FL66
Description
Employment Status
Code - Primary
Employment Status
Code - Secondary
Employment Status
Code - Tertiary
Employer Name Primary
Employer Name Secondary
Employer Name Tertiary
Employer Location Primary
Employer Location Secondary
Employer Locations Tertiary
UB-04
Line Type Size
Description
A
N
1
Deleted from UB-04
B
N
1
Deleted from UB-04
C
N
1
Deleted from UB-04
A
N
24
FL65
B
N
24
FL65
C
N
24
FL65
A
AN
35
Deleted from UB-04
B
AN
35
Deleted from UB-04
C
AN
35
Deleted from UB-04
FL67
Principal Diagnosis
Code
1
AN
6
FL68
Other Diagnoses
1
AN
6
FL69
Other Diagnoses
1
AN
6
FL70
Other Diagnoses
1
AN
6
FL71
Other Diagnoses
1
AN
6
FL72
Other Diagnoses
1
AN
6
FL73
Other Diagnoses
1
AN
6
FL74
Other Diagnoses
1
AN
6
FL75
Other Diagnoses
1
AN
6
AHA © 2006
FL
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Employer Name Primary
Employer Name Secondary
Employer Name Tertiary
Buffer
Size Space
Line
Type
A
AN
25
B
AN
25
C
AN
25
Notes
FL66
ICD Version Indicator
AN
1
New
(Denotes
ICD v.)
FL67
Principal Diagnosis
Code
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
Expanded
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
FL67
A
FL67
B
FL67
C
FL67
D
FL67
E
FL67
F
FL67
G
FL67
H
FL67
I
FL67
J
FL67
K
FL67
L
FL67
M
FL67
N
FL67
O
Version 1.00 September 2006
Page 221 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 7 of 8
UB-92
FL
Description
UB-04
Line Type Size
FL
FL67
P
FL67
O
FL67
P
FL67
Q
FL76
Admitting
Diagnosis/Patient’s
Reason for Visit
1
AN
6
1
AN
6
Unlabeled
FL79
Procedure Coding
Method Used
1
N
1
FL80
Principal Procedure
Code/Date
1
N/
N
6/6
FL81
FL81
FL81
FL81
FL81
AHA © 2006
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
A
B
C
D
E
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
N/
N
N/
N
N/
N
N/
N
N/
N
6/6
6/6
6/6
6/6
6/6
Notes
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
Other Diagnosis
AN
8
New
1a
1b
AN
AN
8
9
FL68
FL68
FL69
Admitting Diagnosis
Code
1
AN
7
Expanded
A
AN
7
B
AN
7
C
AN
7
1
N
4
FL70
Patient's Reason for
Visit
Patient's Reason for
Visit
Patient's Reason for
Visit
FL71
PPS Code
Distinct
FL
Distinct
FL
Distinct
FL
1
New
1a
AN
8
1b
AN
8
New
FL72
External Cause of
Injury (ECI) Code
External Cause of
Injury (ECI) Code
External Cause of
Injury (ECI) Code
1c
AN
8
New
FL73
Unlabeled
1
AN
9
FL72
FL72
FL78
Type
Unlabeled
Unlabeled
FL70
External Cause of
Injury Code
Line
FL68
FL68
FL70
FL77
Description
Buffer
Size Space
Deleted from UB-04
FL74
Principal Procedure
Code/Date
FL74
a
FL74
b
FL74
c
FL74
d
FL74
e
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
Other Procedure
Code/Date
FL75
FL75
FL75
FL75
Unlabeled
Unlabeled
Unlabeled
Unlabeled
Deleted
1
2
3
4
N/N
7/6
1/1 Expanded
N/N
7/6
1/1 Expanded
N/N
7/6
1/1 Expanded
N/N
7/6
1/1 Expanded
N/N
7/6
1/1 Expanded
N/N
7/6
1/1 Expanded
AN
AN
AN
AN
4
4
4
4
0
1
1
1
Version 1.00 September 2006
Page 222 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-92 to UB-04 Crosswalk
Page 8 of 8
UB-92
Line Type Size
FL
Buffer
Line Type Size Space
AN/AN 11/
1
/AN
2/9
16/
2 AN/AN 12
FL82
Attending Physician ID
a
AN
23
FL76
Description
Attending NPI/QUAL/ID
FL82
Attending Physician ID
b
AN
32
FL76
Attending - Last/First
FL83A
Other Physician ID
a
AN
25
FL77
Operating NPI/QUAL/ID
1
FL83A
Other Physician ID
b
AN
32
FL77
Operating - Last/First
2
1
2
FL
Description
UB-04
FL83B
Other Physician ID
a
AN
25
FL78
Other ID QUAL/NPI/QUAL/ID
FL83B
Other Physician ID
b
AN
32
FL78
Other ID - Last/First
FL79
Other ID QUAL/NPI/QUAL/ID
1
FL79
Other ID - Last/First
2
AN/AN 11/
/AN
2/9
16/
AN/AN 12
AN/AN 2/1
/
1/2/
AN/AN 9
16/
AN/AN 12
AN/AN 2/1
/
1/2/
AN/AN 9
16/
AN/AN 12
FL84
Remarks
1
AN
43
FL80
Remarks
1
FL84
Remarks
2
AN
48
FL80
Remarks
2
FL84
Remarks
3
AN
48
FL80
Remarks
3
AN
24
FL84
Remarks
4
AN
48
FL80
Remarks
4
AN
FL81
Code-Code Field
QUAL/CODE/VALUE
a
AN/AN
/AN
FL81
Code-Code Field
QUAL/CODE/VALUE
b
AN/AN
/AN
FL81
Code-Code Field
QUAL/CODE/VALUE
c
AN/AN
/AN
FL81
Code-Code Field
QUAL/CODE/VALUE
d
AN/AN
/AN
24
2/1
0/1
2
2/1
0/1
2
2/1
0/1
2
2/1
0/1
2
FL85
Provider Rep.
Signature
1
AN
22
Deleted from UB-04
FL86
Date Bill Submitted
1
Date
6
Deleted from UB-04;
See FL45, line 23
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Notes
AN
AN
19
24
New
New
Reduced
Field Size
Reduced
Field Size
Reduced
Field Size
Reduced
Field Size
New
New
New
New
Version 1.00 September 2006
Page 223 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 1 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 01
FL 02
FL
03a
FL
03b
FL 04
FL 05
Reference
Designator
Composite
X12 Data
Element #
Billing Provider Name, Address
and Telephone Number
Line 1 – Name
2010AA
NM103
1035
Line 2 - Street Address
Line 3 – City (positions 1-12)
Line 3 – State (positions 14-15
Line 3 - ZIP Code (positions 17-25)
Line 4 – Telephone
2010AA
2010AA
2010AA
2010AA
2010AA
N301, N302
N401
N402
N403
PER04
166
19
156
116
364
Line 4 – Fax
2010AA
PER06
364
Line 4 – Country Code
Pay-to Name and Address
Line 1 – Pay-to Name
2010AA
N404
26
2010AB
NM103
1035
Line 2 – Street Address or Post
Office Box
Line 3 – City (positions 1-16)
Line 3 – State (positions 18-19)
Line 3 – ZIP Code (positions 2125)
Line 4 – NOT USED
Patient Control Number
2010AB
N301
166
2010AB
2010AB
2010AB
N401
N402
N403
19
156
156
2300
CLM01
1028
Medical Record Number
2300
REF02
128
Type of Bill
Facility Code (positions 2-3 of 4 in
FL 04))
2300
CLM05-1
C023-1
1331
2300
CLM05-3
C023-3
1325
2010AA
NM109
Frequency Code (position 4 of 4 in
FL 04)
Federal Tax Number
Upper Line/Lower Line (when no
NPI is reported)
Qualifier/
Ref. Des./
Data
Element
Notes
85 in
NM101
DE 98; 2
in
NM102
DE 1065
TE in
PER03
DE 365
FX in
PER05
DE 365
87 in
NM101
DE 98; 2
in
NM102
DE 1065
EA in
REF01
DE 127
Leading
zero in FL
04 is not
reported on
837
24 in
NM108
2010AA
DE 66
Upper Line/Lower Line (when
REF02
127
EI in
2010AA NM108 = XX)
REF01
DE 128
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
67
Version 1.00 September 2006
Page 224 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 2 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Reference
Designator
DTP03
Composite
X12 Data
Element #
1251
FL 06
Statement Covers Period
Loop ID
2300
FL 07
Reserved for Assignment by the
NUBC
Patient Name/Identifier
a - Patient ID
2010BA
NM109
67
2010CA
NM109
67
2010BA
NM103-105
1035-1037
2010CA
NM103-105
2010BA
N301
166
2010CA
N301
166
2010BA
N401
19
2010CA
N401
19
2010BA
N402
156
2010CA
N402
156
FL 08
b - Patient Name
FL 09
Patient Address
a - Street Address
b - City
c - State
Qualifier/
Ref. Des./
Data
Element
434 in
DTP01
DE 374;
RD8 in
DTP02
DE 1250
MI in
NM108
DE 66
MI in
NM108
DE 66
IL in
NM101
DE 98; 1
in
NM102
DE
1065; MI
in
NM108
DE 66
QC in
NM101
DE 98; 1
in
NM102
DE
1065; MI
in
NM108
DE 66
Notes
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 225 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 3 of 16
UB-04 Form Locator
d - ZIP Code
e - Country Code
FL 10
FL 11
Patient Birth Date
Patient Sex
837 (00410X096/004010X096A1)
Loop ID
2010BA
Reference
Designator
N403
2010CA
N403
116
2010BA
N404
26
2010CA
N404
26
2010BA
DMG02
1251
2010CA
DMG02
1251
2010BA
DMG03
1068
2010CA
DMG03
1068
Composite
X12 Data
Element #
116
FL 12
Admission/Start of Care Date
2300
DTP03
1251
FL 13
Admission Hour
2300
DTP03
1251
FL 14
FL 15
FL 16
Priority (Type) of Visit
Source of Admission
Discharge Hour
2300
2300
2300
CL101
CL102
DTP03
1315
1314
1251
FL 17
FL
18-28
Patient Discharge Status
Condition Codes
2300
CL103
1352
18
2300
HI01x-2
C022
1271
19
2300
HI01x-2
C022
1271
Qualifier/
Ref. Des./
Data
Element
D8 in
DMG08
DE 1250
D8 in
DMG08
DE 1250
F,M,U in
DMG03
DE 1068
F,M,U in
DMG03
DE 1068
435 in
DTP01
DE 374;
DT in
DTP02
DE 1250
435 in
DTP01
DE 374;
DT in
DTP02
DE 1250
Notes
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
When
FL59=18
When
FL59 is not
18
096 in
DTP01
DE 374;
TM in
DTP02
DE 1250
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 226 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 4 of 16
UB-04 Form Locator
FL 29
FL 30
FL
31-34
837 (00410X096/004010X096A1)
20
Loop ID
2300
Reference
Designator
HI01x-2
Composite
C022
X12 Data
Element #
1271
21
2300
HI01x-2
C022
1271
22
2300
HI01x-2
C022
1271
23
2300
HI01x-2
C022
1271
24
2300
HI01x-2
C022
1271
25
2300
HI01x-2
C022
1271
26
2300
HI01x-2
C022
1271
27
2300
HI01x-2
C022
1271
28
2300
HI01x-2
C022
1271
Qualifier/
Ref. Des./
Data
Element
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
BG in
HI0x-1
DE 1270
Accident State
Reserved for Assignment by the
NUBC
Occurrence Codes and Dates
Notes
No map
31a – Code
2300
HI0x-2
C022
1271
31a – Date
2300
HI0x-4
C022
1251
32a – Code
2300
HI0x-2
C022
1271
32a – Date
2300
HI0x-4
C022
1251
33a – Code
2300
HI0x-2
C022
1271
33a – Date
2300
HI0x-4
C022
1251
34a – Code
2300
HI0x-2
C022
1271
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 227 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 5 of 16
UB-04 Form Locator
FL
35-36
837 (00410X096/004010X096A1)
34a – Date
Loop ID
2300
Reference
Designator
HI0x-4
Composite
C022
X12 Data
Element #
1251
31b – Code
2300
HI0x-2
C022
1271
31b – Date
2300
HI0x-4
C022
1251
32b – Code
2300
HI0x-2
C022
1271
32b – Date
2300
HI0x-4
C022
1251
33b – Code
2300
HI0x-2
C022
1271
33b – Date
2300
HI0x-4
C022
1251
34b – Code
2300
HI0x-2
C022
1271
34b – Date
2300
HI0x-4
C022
1251
35a – Code
2300
HI0x-2
C022
1271
35a – From/Though
2300
HI0x-4
C022
1251
36a – Code
2300
HI0x-2
C022
1271
36a – From/Through
2300
HI0x-4
C022
1251
35b – Code
2300
HI0x-2
C022
1271
35b – From/Though
2300
HI0x-4
C022
1251
36b – Code
2300
HI0x-2
C022
1271
36b – From/Though
2300
HI0x-4
C022
1251
Qualifier/
Ref. Des./
Data
Element
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
Notes
Occurrence Span Codes and Dates
BI in
HI0x-1
DE 1270
RD8 in
HI0x-3
DE 1250
BI in
HI0x-1
DE 1270
RD8 in
HI0x-3
DE 1250
BI in
HI0x-1
DE 1270
RD8 in
HI0x-3
DE 1250
BI in
HI0x-1
DE 1270
RD8 in
HI0x-3
DE 1250
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 228 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 6 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 37
FL 38
FL
39-41
Reserved for Assignment by the
NUBC
Responsible Party Name
Reference
Designator
2010BD
NM103,
NM104
39a – Code
2300
HI0x-2
39a – Amount
39b – Code
2300
2300
39b – Amount
39c – Code
Composite
X12 Data
Element #
Qualifier/
Ref. Des./
Data
Element
1035, 1036
QD in
NM101
DE 98
C022
1271
BE in
HI0x-1
DE 1270
HI0x-5
HI0x-2
C022
C022
782
1271
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
39c – Amount
39d – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
39d – Amount
40a – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
40a – Amount
40b – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
40b – Amount
40c – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
40c – Amount
40d – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
40d – Amount
41a – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
41a – Amount
41b – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
41b – Amount
41c – Code
2300
2300
HI0x-5
HI0x-2
C022
C022
782
1271
41c – Amount
2300
HI0x-5
C022
782
Notes
Last Name,
First Name
Value Codes and Amounts
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
BE in
HI0x-1
DE 1270
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 229 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 7 of 16
UB-04 Form Locator
Loop ID
2300
Reference
Designator
HI0x-2
41d – Amount
Revenue Code
Revenue Description
HCPCS/Accommodation
Rates/HIPPS Rate Codes
HCPCS
2300
2400
HI0x-5
SV201
2400
SV202-2
C003
234
HIPPS Rate Code
2400
SV202-2
C003
234
Accommodation Rates
HCPCS Modifiers
2400
2400
SV206
SV202-3, 4, 5,
6
C003
1371
1339
Service Date
Service Date
2400
DTP03
1251
Assessment Date
2400
DTP03
1251
Creation Date
Service Units
Header
2400
BHT04
SV205
373
380
2400
2300
SV203
CLM02
782
782
2400
SV207
782
41d – Code
FL 42
FL 43
FL 44
FL 45
FL 46
FL 47
FL 48
FL 49
FL 50
837 (00410X096/004010X096A1)
Total Charges
Line Item
Total (Summary)
Non-covered Charges
Line Item
Total (Summary)
Reserved for Assignment by the
NUBC
Payer Name
A/B/C
Composite
C022
C022
X12 Data
Element #
1271
Qualifier/
Ref. Des./
Data
Element
BE in
HI0x-1
DE 1270
Notes
782
234
No map
HC in
SV202-1
DE 235
ZZ in
SV202-1
DE 235
HC in
SV202-1
DE 235
472 in
DTP01
DE 374;
D8 in
DTP02
DE 1250
866 in
DTP01
DE 374;
D8 in
DTP02
DE 1250
DA, UN
in SV204
DE 355
No map
2010BC for
the
Destination
Payer of the
Claim
NM103
1035
2 in
NM102
DE 1065
2330B for
NonDestination
Payers
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 230 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 8 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 51
Health Plan Identifier
A/B/C
2010BC for
the
Destination
Payer of the
Claim
Reference
Designator
Composite
X12 Data
Element #
Qualifier/
Ref. Des./
Data
Element
NM109
67
PI, XV
in
NM108
DE 66
2300 for
Destination
Payer
2320 for
NonDestination
Payer
CLM09
1363
OI06
1363
I, Y in
CLM09
DE 1363
I, Y in
CLM09
DE 1363
2300 for
Destination
Payer
2320 for
NonDestination
Payer
CLM08
1073
OI03
1073
2320
AMT02
782
C4 in
AMT01
DE 522
2300 for
Destination
Payer
AMT02
782
C5 in
AMT01
DE 522
B
2300 for
Destination
Payer
AMT02
782
C5 in
AMT01
DE 522
C
2300 for
Destination
Payer
AMT02
782
C5 in
AMT01
DE 522
National Provider Identifier Billing Provider
2010AA
NM109
67
XX in
NM108
DE 66
Notes
2330B for
NonDestination
Payers
FL 52
FL 53
FL 54
FL 55
FL 56
Release of Information
Certification Indicator
A/B/C
Assignment of Benefits
Certification Indicator
A/B/C
Prior Payments - Payer
A/B/C
Estimated Amount Due - Payer
A
N, Y in
CLM08
DE 1073
N, Y in
CLM08
DE 1073
No map for
W
No map for
W
Value code
A3 when
NonDestination
Payer
Value code
B3 when
NonDestination
Payer
Value code
C3 when
NonDestination
Payer
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 231 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 9 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 57
FL 58
Reference
Designator
Composite
X12 Data
Element #
Qualifier/
Ref. Des./
Data
Element
Notes
Other (Billing) Provider Identifier
A
2010AA
REF02
127
B
2010AA
REF02
127
C
2010AA
REF02
127
2010BA for
Destination
Payer
NM103,
NM104
1035,1036
2000B for
Destination
Payer
2000C for
Destination
Payer
2320 for
NonDestination
Payer
SBR02
1069
When
FL59 = 18
PAT01
1069
SBR02
1069
When
FL59 not
= 18
When
FL59 = 18
and not =
18
2010BA for
Destination
Payer
NM109
67
SBR04
93
Insured’s Name
A/B/C
G2 in
REF01
DE 128
G2 in
REF01
DE 128
G2 in
REF01
DE 128
2330A for
NonDestination
Payer
FL 59
FL 60
Patient’s Relationship to Insured
A/B/C
Insured’s Unique Identifier
AB/C
MI in
NM108
DE 66
2330A for
NonDestination
Payer
FL 61
Insured’s Group Name
A/B/C
2000B for
Destination
Payer
2320A for
NonDestination
Payer
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 232 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 10 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 62
Insured’s Group Number
A/B/C
2000B for
Destination
Payer
Reference
Designator
Composite
X12 Data
Element #
Qualifier/
Ref. Des./
Data
Element
SBR03
127
REF02
127
G1 in
REF01
DE 128
REF02
127
F8 in
REF01
DE 128
Notes
2320A for
NonDestination
Payer
FL 63
Treatment Authorization Code
AB/C
2300 for
Destination
Payer
2330B for
NonDestination
Payer
FL 64
Document Control Number
A/B/C
2000B for
Destination
Payer
2330B for
NonDestination
Payer
FL 65
FL 66
FL 67
FL
67AQ
Employer Name (of the Insured)
A/B/C
Diagnosis and Procedure Code
Qualifier (ICD Version Indicator)
Principle Diagnosis Code
Code (positions 1-7)
No map
No map
2300
HI01-2
CO22
1271
BK in
HI0x-1
DE 1270
POA Indicator (position 8)
Other Diagnosis Codes
No map
A – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
A – POA Indicator (position 8)
B – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
B – POA Indicator (position 8)
C – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
C – POA Indicator (position 8)
D – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
No map
No map
No map
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 233 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 11 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
Reference
Designator
Composite
X12 Data
Element #
Qualifier/
Ref. Des./
Data
Element
D – POA Indicator (position 8)
E – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
E – POA Indicator (position 8)
F – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
F – POA Indicator (position 8)
G – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
G – POA Indicator (position 8)
H – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
H – POA Indicator (position 8)
I – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
I – POA Indicator (position 8)
J – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
J – POA Indicator (position 8)
K – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
K – POA Indicator (position 8)
L – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
L – POA Indicator (position 8)
M – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
M – POA Indicator (position 8)
N – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
N – POA Indicator (position 8)
O– Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
O – POA Indicator (position 8)
P – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
P – POA Indicator (position 8)
Q – Code (positions 1-7)
2300
HI0x-2
CO22
1271
BF in
HI0x-1
DE 1270
Q – POA Indicator (position 8)
Notes
No map
No map
No map
No map
No map
No map
No map
No map
No map
No map
No map
No map
No map
No map
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 234 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 12 of 16
UB-04 Form Locator
837 (00410X096/004010X096A1)
Loop ID
FL 68
FL 69
FL
70a-c
Reserved for Assignment by the
NUBC
Admitting Diagnosis Code
FL
72a-c
b
c
Prospective Payment System (PPS)
Code
FL 74
74a-e
X12 Data
Element #
2300
HI0x-2
C022
1271
BJ in
HI0x-1
DE 1270
2300
HI0x-2
C022
1271
ZZ in
HI0x-1
DE 1270
Notes
No map
No map
2300
HI01-2
C022
1271
DR in
HI01-1
DE 1270
2300
H103-2
C022
1271
BN in
HI03-1
DE 1270
External Cause of Injury Code
a - Code (positions 1-7)
FL 73
Composite
Patient’s Reason for Visit
a
FL 71
Reference
Designator
Qualifier/
Ref. Des./
Data
Element
a - POA Indicator (position 8)
b - Code (positions 1-7)
b - POA Indicator (position 8)
c - Code (positions 1-7)
c - POA Indicator (position 8)
Reserved for Assignment by the
NUBC
Principal Procedure Code and Date
Code
No map
No map
No map
No map
No map
2300
HI01-2
C022
1271
Date
2300
HI01-4
C022
1251
Other Procedure Codes and Dates
a – Code
2300
HI0x-2
C022
1271
a – Date
2300
HI0x-4
C022
1251
b – Code
2300
HI0x-2
C022
1271
b – Date
2300
HI0x-4
C022
1251
c – Code
2300
HI0x-2
C022
1271
c – Date
2300
HI0x-4
C022
1251
BR in
HI01-1
DE 1270
D8 in
HI01-3
DE1250
BQ in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BQ in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BQ in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 235 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 13 of 16
UB-04 Form Locator
FL 75
FL 76
FL 77
837 (00410X096/004010X096A1)
d – Code
Loop ID
2300
Reference
Designator
HI0x-2
Composite
C022
X12 Data
Element #
1271
d – Date
2300
HI0x-4
C022
1251
e – Code
2300
HI0x-2
C022
1271
e – Date
2300
HI0x-4
C022
1251
Reserved for Assignment by the
NUBC
Attending Provider Name and
Identifiers
NPI
2310A
NM109
67
Secondary Identifier Qualifier
2310A
REF01
128
Secondary Identifier
2310A
REF02
127
Last Name
2310A
NM103
1035
First Name
2310A
NM104
1036
Operating Physician Name and
Identifiers
NPI
2310B
NM109
67
Qualifier/
Ref. Des./
Data
Element
BQ in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
BQ in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
Notes
71 in
NM101
DE 98;
XX in
NM108
DE 66
71 in
NM101
DE 98;
0B, 1G,
G2 in
REF01
DE 128
71 in
NM101
DE 98
71 in
NM101
DE 98; 1
in
NM102
DE 1065
71 in
NM101
DE 98; 1
in
NM102
DE 1065
72 in
NM101
DE 98;
XX in
NM108
DE 66
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 236 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 14 of 16
UB-04 Form Locator
FL
78-79
837 (00410X096/004010X096A1)
Secondary Identifier Qualifier
Loop ID
2310B
Reference
Designator
REF01
Secondary Identifier
2310B
REF02
127
Last Name
2310B
NM103
1035
First Name
2310B
NM104
1036
Other Provider (Individual) Names
and Identifiers
78 - Provider Type Qualifier
2310C
NM101
98
78 - NPI
2310C
NM109
67
78 - Secondary Identifier Qualifier
2310C
REF01
128
Composite
X12 Data
Element #
128
Qualifier/
Ref. Des./
Data
Element
72 in
NM101
DE 98;
0B, 1G,
G2 in
REF01
DE 128
72 in
NM101
DE 98;
0B, 1G,
G2 in
REF01
DE 128
72 in
NM101
DE 98; 1
in
NM102
DE 1065
72 in
NM101
DE 98; 1
in
NM102
DE 1065
Notes
73 in
NM101
DE 98; 1
in
NM102
DE 1065
73 in
NM101
DE 98;
XX in
NM108
DE 66
73 in
NM101
DE 98;
0B, 1G,
G2 in
REF01
DE 128
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 237 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
Page 15 of 16
UB-04 Form Locator
FL 80
FL 81
837 (00410X096/004010X096A1)
78 - Secondary Identifier
Loop ID
2310C
Reference
Designator
REF02
78 - Last Name
2310C
NM103
1035
78 - First Name
2310C
NM104
1036
79 - Provider Type Qualifier
79 - NPI
79 - Secondary Identifier Qualifier
79 - Secondary Identifier
79 - Last Name
79 - First Name
Remarks
2300
NTE02
Code-Code Field
A1 – NUBC Condition Codes
2300
HI01x-2
A2 – NUBC Occurrence Codes and
Dates
Code
2300
Date
A3 – NUBC Occurrence Span
Codes and Dates
Code
From/Though
A4 – NUBC Value Codes and
Amounts
Code
Amount
Composite
X12 Data
Element #
127
Qualifier/
Ref. Des./
Data
Element
73 in
NM101
DE 98;
0B, 1G,
G2 in
REF01
DE 128
73 in
NM101
DE 98; 1
in
NM102
DE 1065
73 in
NM101
DE 98; 1
in
NM102
DE 1065
Notes
No map
No map
No map
No map
No map
No map
352
ADD in
NTE01
DE 363
C022
1271
BG in
HI0x-1
DE 1270
HI0x-2
C022
1271
2300
HI0x-4
C022
1251
BH in
HI0x-1
DE 1270
D8 in
HI0x-3
DE 1250
2300
HI0x-2
C022
1271
2300
HI0x-4
C022
1251
2300
HI0x-2
C022
1271
2300
HI0x-5
C022
782
BI in
HI0x-1
DE 1270
RD8 in
HI0x-3
DE 1250
BE in
HI0x-1
DE 1270
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 238 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04 Mapping to 837 Claim Transaction
UB-04 Form Locator
B3 – Health Care Taxonomy Code
(Billing Provider)
Page 16 of 16
837 (00410X096/004010X096A1)
Loop ID
2000A
Reference
Designator
PRV03
Composite
X12 Data
Element #
127
Qualifier/
Ref. Des./
Data
Element
BI in
PRV01
DE
1221; ZZ
in
PRV02
DE 128
Notes
Disclaimer: Although every effort has been made to properly identify the corresponding 837 data segment and element, the user
should verify the corresponding reference.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 239 of 246
National Uniform Billing Committee
UB-04: Beta 3 to Version 1.00 Change Log
Official UB-04 Data Specifications Manual 2007
Page 1 of 2
Table of Contents added.
Introduction added; includes link for v. 1.00 errata.
FL 01
FL 04
FL 08
FL 09
FL 10
FL 11
FL 12
FL 13
FL 17
FL 18-28
FL 30
FL 39-41
FL 42
FL 42
FL 44
FL 45
FL 47
FL 48
FL 50
p. 1 - Changed name: Billing Provider Name, Address and Telephone Number
Changed definition: “The name and service location of the provider submitting the
bill.”
p. 2 - Changed Line positions (to accommodate 9-digit ZIP).
p. 2 - ZIP changed to 9 digits.
p. 2 - Changed Country Code note and positions.
p. 2 - CMS has changed Medicare’s instructions. Hospitals are no longer required to
omit specific revenue codes from the Inpatient Part B only claim. Included CMS
editing instructions from their Claims Processing Manual section.
p. 3 - TOB 064x now Reserved for Assignment by NUBC
p. 5 - Changed usage requirement by TOB for FL12, FL13, FL16, FL70a-c
p. 7 - Added footnote (a) to Codes 7 and 8.
p. 9 - Fixed footnote references.
Changed Reporting requirements for 004010/004010A1 and 005010 for both data
elements.
Changed Reporting requirements for 004010/004010A1 and 005010.
Changed Country Code note.
Changed Reporting requirements for 004010/004010A1 and 005010.
Changed Reporting requirements for 004010/004010A1 and 005010.
Changed Definition and Reporting requirements.
Changed Reporting requirements.
p. 1 - Added language to Notes.
p. 2 - Added future definitional change to Code 05.
p. 4 - Added new future effective Code (70).
p. 8 - Added note to FAQ re future Code (70)
p. 10-12 - Added new FAQs.
Added Condition Code 45 approved 6/21/06 effective 1/1/07
Changed attributes to 11 positions upper and 13 positions lower.
p. 2 - Removed from 06 references to E1, F1, G1
p. 12-14 - Added footnotes to A1, A2, A7, B1, B2, C1, C2, C7
p. 14 - Added C1, C2, C3 value codes omitted in error
For Revenue Code 0449 - currently the definition is Other Physical Therapy, but the
Revenue Code 044x is defined as Speech Therapy - Language Pathology and the
standard abbreviation is OTHER SPEECH THERP
p. 23 - RC 043- Changed the standard abbreviation changed to OCCUP
THERP/HOUR
p. 23 - Changed RC 0449 to “Other Speech Therapy”.
p. 28 - Added Standard Abbreviation RHC/FQHC/SNF/COVERED to RC 0524.
Added “Accommodation” to title.
Added 837 requirements to Creation Date.
Added Note that amounts greater than or equal to zero are acceptable.
Changed Definition and Reporting requirements.
Changed 837 Reporting requirements.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 240 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04: Beta 3 to Version 1.00 Change Log
FL 51
FL 54
FL 55
FL 57
FL 59
FL 60
FL 61
FL 63
FL 67
FL 67A-Q
FL 69
FL 72a-e
FL 74a-e
FL 76
FL 77
FL 78
FL 80
FL 81
Page 2 of 2
Changed Definition and Reporting requirements.
Added that it is acceptable to show “0” as the amount paid.
Changed Notes.
“Billing Provider” added to FL 57 description.
Changed Reporting requirements for UB-04 to cover “atypical” providers who do not
have NPIs.
Changed Reporting requirements.
Code 20 (Employee) added.
Changed Reporting requirements.
Changed title.
Code applies to prior authorization only, not referrals. Changed Reporting
requirements.
p. 1 - Changed title to include Present on Admission Indicator
p. 1 - For POA added “For use on the UB-04 and 005010 only; do not use in any
manner on 004010/004010A.” to Reporting requirements.
p. 1 - Added “For use on the UB-04 and 005010 only; do not use in any manner on
004010/004010A.” to Reporting requirements.
Added exception note to Reporting requirements.
Changed FL to include a-e.
For POA, added “For use on the UB-04 and 005010 only; do not use in any manner
on 004010/004010A.” to Reporting requirements.
Added “ICD” to Definition.
p.2 - Added note that NPI is 10 characters.
p.2 - Added note that NPI is 10 characters.
p.2 - Added note that NPI is 10 characters.
Added “OR” to 005010 Reporting requirement.
p. 3-5 - Added CMS guidance on taxonomy to B3.
State Guidelines
Added Florida.
Appendix
UB-92 to
UB-04
Crosswalk
UB-04
Mapping to
837 Claim
Transaction
Minor updates/corrections.
Corrected and enhanced.
Added (OMB approved) UB-04 Form (front)
Added Back of UB-04 Form (for informational purposes only)
Updated UB-04/CMS-1450 Printing Specifications (final)
Added (OMB approved) UB-04 Form (front)
Added Back of UB-04 Form (via link to NUBC website)
Updated UB-04/CMS-1450 Printing Specifications (final)
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version
Version1.00
1.00September
September2006
2006
Page 241 of 246
__
__
4
3a PAT.
CNTL #
b. MED.
REC. #
2
__
1
__
6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
10 BIRTHDATE
11 SEX
31
OCCURRENCE
CODE
DATE
12
DATE
a
c
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
32
OCCURRENCE
CODE
DATE
33
OCCURRENCE
DATE
CODE
18
7
STATEMENT COVERS PERIOD
FROM
THROUGH
b
b
TYPE
OF BILL
19
20
34
OCCURRENCE
CODE
DATE
CONDITION CODES
24
22
23
21
35
CODE
25
26
27
36
CODE
OCCURRENCE SPAN
FROM
THROUGH
d
28
e
29 ACDT 30
STATE
37
OCCURRENCE SPAN
FROM
THROUGH
a
a
b
b
38
39
CODE
40
CODE
VALUE CODES
AMOUNT
41
CODE
VALUE CODES
AMOUNT
VALUE CODES
AMOUNT
a
b
c
d
42 REV. CD.
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE
23
OF
TOTALS
CREATION DATE
50 PAYER NAME
52 REL.
INFO
51 HEALTH PLAN ID
53 ASG.
BEN.
23
55 EST. AMOUNT DUE
54 PRIOR PAYMENTS
A
56 NPI
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED’S NAME
59 P. REL 60 INSURED’S UNIQUE ID
62 INSURANCE GROUP NO.
61 GROUP NAME
A
A
B
B
C
C
65 EMPLOYER NAME
64 DOCUMENT CONTROL NUMBER
63 TREATMENT AUTHORIZATION CODES
A
A
B
B
C
C
66
DX
67
I
A
J
69 ADMIT
70 PATIENT
DX
REASON DX
PRINCIPAL PROCEDURE
a.
74
CODE
DATE
B
K
a
b
OTHER PROCEDURE
CODE
DATE
C
L
b.
c
D
M
71 PPS
CODE
OTHER PROCEDURE
CODE
DATE
E
N
75
72
ECI
F
O
a
76 ATTENDING
G
P
b
NPI
LAST
c.
OTHER PROCEDURE
CODE
DATE
d.
OTHER PROCEDURE
DATE
CODE
e.
OTHER PROCEDURE
CODE
DATE
77 OPERATING
SingleUB-04
UserCMS-1450
License
APPROVED OMB NO. 0938-0997
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
81CC
a
78 OTHER
b
LAST
c
79 OTHER
d
LAST
NUBC
™
National Uniform
Billing Committee
73
QUAL
FIRST
NPI
LAST
80 REMARKS
H
Q
c
68
QUAL
FIRST
NPI
QUAL
FIRST
NPI
QUAL
FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
LIC9213257
Page 242 of 246
UB-04 NOTICE:
THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).
Submission of this claim constitutes certification that the billing
information as shown on the face hereof is true, accurate and complete.
That the submitter did not knowingly or recklessly disregard or
misrepresent or conceal material facts. The following certifications or
verifications apply where pertinent to this Bill:
1. If third party benefits are indicated, the appropriate assignments by
the insured /beneficiary and signature of the patient or parent or a
legal guardian covering authorization to release information are on file.
Determinations as to the release of medical and financial information
should be guided by the patient or the patient’s legal representative.
2. If patient occupied a private room or required private nursing for
medical necessity, any required certifications are on file.
3. Physician’s certifications and re-certifications, if required by contract
or Federal regulations, are on file.
4. For Religious Non-Medical facilities, verifications and if necessary recertifications of the patient’s need for services are on file.
5. Signature of patient or his representative on certifications,
authorization to release information, and payment request, as
required by Federal Law and Regulations (42 USC 1935f, 42 CFR
424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other
applicable contract regulations, is on file.
6. The provider of care submitter acknowledges that the bill is in
conformance with the Civil Rights Act of 1964 as amended. Records
adequately describing services will be maintained and necessary
information will be furnished to such governmental agencies as
required by applicable law.
7. For Medicare Purposes: If the patient has indicated that other health
insurance or a state medical assistance agency will pay part of
his/her medical expenses and he/she wants information about
his/her claim released to them upon request, necessary authorization
is on file. The patient’s signature on the provider’s request to bill
Medicare medical and non-medical information, including
employment status, and whether the person has employer group
health insurance which is responsible to pay for the services for
which this Medicare claim is made.
8. For Medicaid purposes: The submitter understands that because
payment and satisfaction of this claim will be from Federal and State
funds, any false statements, documents, or concealment of a
material fact are subject to prosecution under applicable Federal or
State Laws.
9. For TRICARE Purposes:
(a) The information on the face of this claim is true, accurate and
complete to the best of the submitter’s knowledge and belief, and
services were medically necessary and appropriate for the health
of the patient;
(b) The patient has represented that by a reported residential address
outside a military medical treatment facility catchment area he or
she does not live within the catchment area of a U.S. military
medical treatment facility, or if the patient resides within a
catchment area of such a facility, a copy of Non-Availability
Statement (DD Form 1251) is on file, or the physician has certified
to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file;
(c) The patient or the patient’s parent or guardian has responded
directly to the provider’s request to identify all health insurance
coverage, and that all such coverage is identified on the face of
the claim except that coverage which is exclusively supplemental
payments to TRICARE-determined benefits;
(d) The amount billed to TRICARE has been billed after all such
coverage have been billed and paid excluding Medicaid, and the
amount billed to TRICARE is that remaining claimed against
TRICARE benefits;
(e) The beneficiary’s cost share has not been waived by consent or
failure to exercise generally accepted billing and collection efforts;
and,
(f) Any hospital-based physician under contract, the cost of whose
services are allocated in the charges included in this bill, is not an
employee or member of the Uniformed Services. For purposes of
this certification, an employee of the Uniformed Services is an
employee, appointed in civil service (refer to 5 USC 2105),
including part-time or intermittent employees, but excluding
contract surgeons or other personal service contracts. Similarly,
member of the Uniformed Services does not apply to reserve
members of the Uniformed Services not on active duty.
(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
participating in Medicare must also participate in TRICARE for
inpatient hospital services provided pursuant to admissions to
hospitals occurring on or after January 1, 1987; and
(h) If TRICARE benefits are to be paid in a participating status, the
submitter of this claim agrees to submit this claim to the
appropriate TRICARE claims processor. The provider of care
submitter also agrees to accept the TRICARE determined
reasonable charge as the total charge for the medical services or
supplies listed on the claim form. The provider of care will accept
the TRICARE-determined reasonable charge even if it is less
than the billed amount, and also agrees to accept the amount
paid by TRICARE combined with the cost-share amount and
deductible amount, if any, paid by or on behalf of the patient as
full payment for the listed medical services or supplies. The
provider of care submitter will not attempt to collect from the
patient (or his or her parent or guardian) amounts over the
TRICARE determined reasonable charge. TRICARE will make
any benefits payable directly to the provider of care, if the
provider of care is a participating provider.
SEE http://www.nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Page 243 of 246
National Uniform Billing Committee
UB-04/CMS-1450 Printing Specifications
Official UB-04 Data Specifications Manual 2007
Page 1 of 3
The UB-04 is designed to accommodate 10-pitch Pica type, 6 lines per inch. Once adjusted to the left
and right, alignment points in the first print line and characters appear within form lines as shown in the
print file matrix.
The Printing Specifications are used in conjunction with the negative layout that was approved by the
National Uniform Billing Committee (NUBC) and licensed through TFP Data Systems. Compliance
with these standards is required to facilitate the use of image processing technology such as Optical
Character Recognition (OCR), facsimile transmissions, and image storage.
Contact information for purchase of license agreement and negatives should be made with TFP Data
Systems Compliance Department: (800) 482-9367 ext. 1770.
The National Uniform Billing Committee has responsibility for the printing standards for paper form
UB-04 CMS-1450. These specifications are as follows:
Form Name: UB-04 CMS-1450 Paper Billing Form, Approved by the National Uniform Billing
Committee (NUBC).
Form Identification: The lower left-hand margin contains the approval OMB number and should be
consistent throughout (“APPROVED OMB NO. 0938-0997”). No modification is to be made to the
UB-04.
Cut Sheet:
Size -
8 ½ inches (plus or minus 0.1 inch) by 11 inches (plus or minus 1/16 inch).
217 mm by 281mm plus or minus 2mm.
Print -
Face and back, head to head.
Margins -
Face - The top margin from the top edge of the form to the first print position is 1/16
inches or .4 mm. The left margin is 0.15 inches to the left end of the first print position.
Back-Centered head and foot, 0.25 inch left and right.
Offset - The X and Y offset for margins must not vary by more than +/-0.1 inch from
sheet to sheet.
The X offset refers to the horizontal distance from the left edge of the paper to the
beginning of the printing. The Y offset refers to the vertical distance between the top of
the paper and the beginning of the printing.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 244 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04/CMS-1450 Printing Specifications
Askewity -
Page 2 of 3
The askewity of the printed image must be no greater than 0.15mm in 100mm.
Paper Stock - Basis weight 20# recycled 30% postconsumer waste, White Environmental Paper
Alliance (EPA) or approved paper stock. Smoothness: FS to be (140-160), or
equivalent stock.
Ink color Front - Ink is to be (OCR-Red) or equivalent (For Example, Flint J6983, formerly
known as Sinclair Valentine). There is to be no contamination with “Black” ink or
pigment. Printer must maintain proper ink reflectance limits of the OCR reader
specified by the purchaser.
Back - Ink is to be PMS No. 421 (Grey) or equivalent.
Titles -
Placement will be indicated on negative. Color of any titles if applicable: Are to be in
the same ink as the form, OCR Red “dropout” ink.
Logo -
The identifiable NUBC logo located at the bottom center margin must be included to
assure compliance.
One Part Marginally Punched Continuous Form:
Size Same dimensions as for Cut Sheet, plus 0.5” left and right, (overall: 9.5” by 11”,
Detached: 8.5” by 11”).
Print -
Face and back, head to head.
Margins -
On detached sheet, same as for Cut Sheet.
Askewity -
On detached sheet, same as for Cut Sheet.
Paper Stock - Same as for Cut Sheet.
Ink Color -
Same as for Cut Sheet.
Perforations - Marginally ½” left and right, tear line horizontally every 11”.
Titles -
Placement will be indicated on negative. Color of any titles if applicable: Are to be in
the same ink as the form, OCR Red “dropout” ink.
Logo -
The identifiable NUBC logo located at the bottom center margin must be included to
assure compliance.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 245 of 246
National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2007
UB-04/CMS-1450 Printing Specifications
Page 3 of 3
Two Part Marginally Punched Continuous Forms:
Size Same dimensions as for Cut Sheet, plus ½” left and right, (overall: 9.5” x 11”, detached:
8.5” x 11”).
Print -
Part 1 - Face and back, head to head.
Part 2 - Face and back, head to head.
Margins -
On detached sheet, same as for Cut Sheet.
Askewity -
On detached sheet, same as for Cut Sheet.
Paper Stock - Part 1 - White Carbonless Recycled Paper (EPA) or approved paper stock.
Part 2 - Any color or weight that does not interfere with scanning of part 1 sheet.
Suggest the following sequence:
Paper Weight:
·
·
·
1st part is 20 CB - Recycled White (EPA) or equivalent
2nd part is 14 CFB (if not last part) Recycled White (EPA) or equivalent
Last part is 15CF Recycled White (EPA) or equivalent
CB = Coated Back (Carbonless black print)
CFB = Coated Front and Back (Carbonless black print)
CF = Coated Front (Carbonless black print)
Ink color -
Part 1 - Same as for cut sheet.
Part 2 - Any color that will not interfere with scanning of the Part 1 sheet, same as Part
1.
Perforations - Marginally ½” left and right, tear line horizontally every 11”.
Titles -
Placement will be indicated on negative. Color of any titles if applicable: Are to be in
the same ink as the form, OCR Red “dropout” ink.
Logo -
The identifiable NUBC logo located at the bottom center margin must be included to
assure compliance.
Note:
Users may determine the number of parts that are applicable to their needs. Up to four
total parts are feasible on some printers; some other printers may limit the readability of
multiple plies.
AHA © 2006
Single User License
Registered to: EZ Bala | Piedmont Behavioral Healthcare
Please do not copy or distribute.
Version 1.00 September 2006
Page 246 of 246