CMS 1450 (UB-04) - Overview
Transcript of CMS 1450 (UB-04) - Overview
![Page 1: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/1.jpg)
UB-04 Overview
Medicare Part A Provider Outreach and Education
June 2007
![Page 2: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/2.jpg)
Slide 2
The information contained in this presentation was current as of June 2007 and can be found in Change Request (CR) 5593, Pub. 100-04, Transmittal 1254, dated May 25, 2007, which can be downloaded from:
www.cms.hhs.gov/Transmittals/Downloads/R1254CP.pdf
IMPORTANT
![Page 3: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/3.jpg)
Slide 3
UB-04
• Uniform bill for institutional providers.
• Replaces the UB-92.
• Mandated May 23, 2007.
![Page 4: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/4.jpg)
Patient Information
![Page 5: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/5.jpg)
Slide 5
Form Locator 1
Billing Provider Information
![Page 6: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/6.jpg)
Slide 6
Form Locator 2
Pay-to Name and Address
![Page 7: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/7.jpg)
Slide 7
Form Locator 3
Patient Control Number/Medical Record Number
![Page 8: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/8.jpg)
Slide 8
Form Locator 4
Type of Bill (TOB)
![Page 9: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/9.jpg)
Slide 9
Form Locator 5
Federal Tax Number
![Page 10: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/10.jpg)
Slide 10
Form Locator 6
Dates of Service
![Page 11: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/11.jpg)
Slide 11
Form Locator 8
Patient’s Name
![Page 12: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/12.jpg)
Slide 12
Form Locator 9
Patient’s Address
![Page 13: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/13.jpg)
Slide 13
Form Locator 10
Patient’s Date of Birth
![Page 14: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/14.jpg)
Slide 14
Form Locator 11
Patient’s Gender
![Page 15: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/15.jpg)
Slide 15
Form Locators 12−15
Admission Date, Type and Source
![Page 16: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/16.jpg)
Slide 16
Admission Type Examples
Code Description Definition
1 Emergency The patient requires immediate medical intervention as a result of severe, life-threatening or potentially disabling conditions.
2 Urgent The patient requires immediate attention for the care and treatment of a physical or mental disorder.
3 Elective The patient’s condition permits adequate time to schedule the services.
4 Newborn Use of this code necessitates the use of special source of admission codes (Form Locator 15).
5 Trauma
Visit to a trauma center/hospital as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. (Use revenue code 068X to capture trauma activation charges.)
9 Information not available
Information not available.
![Page 17: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/17.jpg)
Slide 17
Admission Source Examples
Code Description
1 Physician referral
2 Clinic referral
3 HMO referral
4 Transfer from a hospital
5 Transfer from a Skilled Nursing Facility (SNF)
6 Transfer from another health care facility
7 Emergency room
8 Court/law enforcement
9 Information not available
A Transfer from a Critical Access Hospital (CAH)
B Transfer from another home health agency
C Readmission to same home health agency
D Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer
![Page 18: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/18.jpg)
Slide 18
Form Locators 16−17
Discharge Hour and Discharge Status
![Page 19: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/19.jpg)
Slide 19
Discharge Status Code Examples
Code Description01 Discharged to home or self-care (routine discharge)
02 Discharged/transferred to a short-term general hospital for inpatient care
03 Discharged/transferred to an SNF with Medicare certification in anticipation of covered skilled care
05 Discharged/transferred to another type of health care institution not defined elsewhere in this code list
06 Discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care
07 Left against medical advice or discontinued care20 Expired
![Page 20: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/20.jpg)
Slide 20
Form Locators 18−28
Condition Codes
![Page 21: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/21.jpg)
Slide 21
Condition CodeExamples
Code Description02 Condition is employment-related
07 Treatment of non-terminal condition for hospice
08 Beneficiary would not provide information concerning other coverage
20 Beneficiary requested billing21 Billing for denial notice
![Page 22: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/22.jpg)
Slide 22
Form Locator 29
Accident State
![Page 23: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/23.jpg)
Slide 23
Form Locators 31−34
Occurrence Codes and Dates
![Page 24: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/24.jpg)
Slide 24
Occurrence CodeExamples
Code Description01 Auto accident04 Accident employment-related11 Onset of illness
18 Date of retirement for patient/beneficiary
24 Date insurance denied
![Page 25: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/25.jpg)
Slide 25
Form Locators 35−36
Occurrence Span Codes and Dates
![Page 26: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/26.jpg)
Slide 26
Occurrence SpanCode Examples
Code Description74 Leave of absence76 Patient liability77 Provider liability
![Page 27: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/27.jpg)
Slide 27
Form Locator 38
Responsible Party’s Name and Address
![Page 28: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/28.jpg)
Slide 28
Form Locators 39−41
Value Codes and Amounts
![Page 29: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/29.jpg)
Slide 29
Value CodeExamples
Code Description12 Working aged37 Pints of blood furnished50 Physical therapy visits
80 Covered days81 Non-covered days82 Coinsurance days83 Lifetime reserve days
53 Cardiac rehabilitation visits
![Page 30: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/30.jpg)
Billing Information
![Page 31: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/31.jpg)
Slide 31
Form Locator 42
Revenue Codes
![Page 32: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/32.jpg)
Slide 32
Form Locator 43
Revenue Code Description
![Page 33: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/33.jpg)
Slide 33
Form Locator 44
HCPCS Codes, Rates, HIPPS codes and Modifiers
![Page 34: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/34.jpg)
Slide 34
Form Locator 45
Service Dates
![Page 35: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/35.jpg)
Slide 35
Form Locator 46
Service Units
![Page 36: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/36.jpg)
Slide 36
Form Locator 47
Total Charges
![Page 37: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/37.jpg)
Slide 37
Form Locator 48
Non-Covered Charges
![Page 38: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/38.jpg)
Slide 38
Line 23
![Page 39: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/39.jpg)
Payer Information
![Page 40: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/40.jpg)
Slide 40
Form Locator 50
Payer Name
![Page 41: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/41.jpg)
Slide 41
Form Locator 51
Health Plan Identification Number
![Page 42: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/42.jpg)
Slide 42
Form Locators 52−53
Release of Information and Assignment of Benefits
![Page 43: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/43.jpg)
Slide 43
Form Locator 54
Prior Payments
![Page 44: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/44.jpg)
Slide 44
Form Locator 55
Estimated Amount Due
![Page 45: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/45.jpg)
Slide 45
Form Locators 56−57
National Provider Identifier (NPI) and Other Provider Identifier
![Page 46: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/46.jpg)
Slide 46
Form Locator 58
Insured’s Name
![Page 47: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/47.jpg)
Slide 47
Form Locator 59
Patient’s Relationship to the Insured
![Page 48: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/48.jpg)
Slide 48
Patient’s RelationshipCode Examples
Code Description01 Spouse18 Patient is insured19 Natural child/insured financial responsibility43 Natural child/insured does not have financial
responsibility22 Handicapped dependent
29/53 Life partner32 Mother33 Father
![Page 49: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/49.jpg)
Slide 49
Form Locator 60
Insured’s Unique Identifier
![Page 50: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/50.jpg)
Slide 50
Form Locator 61
Insured’s Group Name
![Page 51: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/51.jpg)
Slide 51
Form Locator 62
Insured’s Group Number
![Page 52: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/52.jpg)
Slide 52
Form Locator 63
Treatment Authorization Codes
![Page 53: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/53.jpg)
Slide 53
Form Locator 64
Document Control Number (DCN)
![Page 54: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/54.jpg)
Slide 54
Form Locator 65
Employer’s Name
![Page 55: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/55.jpg)
Diagnosis Information
![Page 56: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/56.jpg)
Slide 56
Form Locator 66
Diagnosis and Procedure Code Qualifier
![Page 57: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/57.jpg)
Slide 57
Form Locator 67
Principal Diagnosis Code and Present on Admission (POA) Indicator
![Page 58: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/58.jpg)
Slide 58
POA Indicator
Indicator Description
U No information in the record
Unreported or not used Exempt from POA reporting
Y Yes
N No
W Clinically undetermined
![Page 59: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/59.jpg)
Slide 59
Form Locator 67A−Q
Other Diagnosis Codes and POA Indicator
![Page 60: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/60.jpg)
Slide 60
Form Locator 69
Admitting Diagnosis Code
![Page 61: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/61.jpg)
Slide 61
Form Locator 70
Patient’s Reason for Visit
![Page 62: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/62.jpg)
Slide 62
Form Locator 71
Prospective Payment System (PPS) Code
![Page 63: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/63.jpg)
Slide 63
Form Locator 72
External Cause of Injury (ECI) Code
![Page 64: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/64.jpg)
Slide 64
Form Locator 74
Principal and Other Procedure Codes and Dates
![Page 65: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/65.jpg)
Slide 65
Form Locator 76
Attending Provider’s Name and Identifiers
![Page 66: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/66.jpg)
Slide 66
Secondary Identifier Qualifiers
Qualifier Description0B State license number
1G Provider’s UPIN number
G2 Provider’s commercial number
![Page 67: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/67.jpg)
Slide 67
Form Locator 77
Operating Physician’s Name and Identifiers
![Page 68: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/68.jpg)
Slide 68
Form Locators 78-79
Other Providers’ Names and Identifiers
![Page 69: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/69.jpg)
Slide 69
Provider Type Qualifier Codes
Qualifier DescriptionDN Referring provider
ZZ Other operating physician
82 Rendering provider
![Page 70: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/70.jpg)
Slide 70
Form Locator 80
Remarks
![Page 71: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/71.jpg)
Slide 71
Form Locator 81
Healthcare Provider Taxonomy Code (HPTC)
![Page 72: CMS 1450 (UB-04) - Overview](https://reader034.fdocuments.net/reader034/viewer/2022051609/5464b527b4af9f2e588b470d/html5/thumbnails/72.jpg)
Slide 72
The Healthcare Provider Taxonomy Code (HPTC) list is available at:
www.wpc-edi.com/codes/taxonomy
HPTC