Overview of the UB-04. Sources National Uniform Billing Committee – Centers for Medicare and...
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Transcript of Overview of the UB-04. Sources National Uniform Billing Committee – Centers for Medicare and...
Sources
National Uniform Billing Committee– www.nubc.org
Centers for Medicare and Medicaid Services (CMS)– www.cms.gov/manuals
Chapter 25 – Completing and Processing the form CMS 1450 data sets
– www.cms.gov/MLNProducts Web based training courses – Uniform Billing (UB) -04
(July 2007)
Patient/Provider Information
Diagnostic Information
Payer Information
Additional Information
Billing Information
Patient/Provider Information
FL01Provider Name, Address, Phone and/or Fax number
FL02Pay-to Name, Address, Phone and/or Fax number
FL03a Patient Control Number FL03b Medical Record Number FL04Type of Bill
4-digit alphanumeric (example 0111)
Patient/Provider Information
FL05Federal Tax ID Number FL06Statement Covers Period –
From/Through FL07Unlabeled FL08a Patient Name – ID FL08b Patient Name
Patient/Provider Information
FL09a- e Patient Address FL10 Patient Birth date FL11 Patient Sex FL12 – 16 Admission Date/
Hour/Type/Source/
Discharge Hour
Patient/Provider Information
FL17 Patient Status Code01 Discharged to home or self care
(routine discharge02 Discharged/transferred20 Expired
Patient/Provider Information
FL18-28 Condition Codes FL29 Accident State FL30 Unlabeled FL31-34 Occurrence Code/Date FL35-36 Occurrence Span
Code/From/Through FL37 Unlabeled FL38 Responsible Party Name/Address FL39-41 Value Codes
Billing Information
FL42Revenue Code– 4-position code that identifies a specific
accommodation, ancillary service or billing calculation.
0022 – Skilled nursing facility 0024 – Inpatient rehab facility 0124 – Psychiatric room charge
FL43 Revenue Code Description
Billing Information
FL44 Rates/HCPCS/HIPPS Rate CodesRates – cost of the room per dayHCPCS – CPT or HCPCS codes giving
details about the serviceHIPPS rate codes – alphanumeric code
identifying level of care/service
FL45 Service Date FL46 Unit of Service
Payer Information
FL50 – 65 – Various pieces of information about what
insurance may be primary and what they paid
FL56 NPI (National Provider Identifier) FL57 Other Provider ID
Diagnostic Information
FL66 DX (diagnosis) Version Qualifier
FL67 Principle Diagnosis Code FL67A-Q Other Diagnosis FL68 Unlabeled FL69 Admitting Diagnosis Code FL70a-c Patient Reason for Visit Code
Diagnostic Information
FL71 PPS Code FL72a-c External Cause of Injury Code
(ECI) FL73 Unlabeled FL74 Principle Procedure
Code/Date FL74a-e Other Procedure Code/Date
Additional Information
FL75 – 81a-d– Includes the name and ID of the attending and
operating physicians, a place for remarks, as well as the code list qualifiers.
Items on UB-04 needed for the DRG Grouper
Diagnoses codes (FL 67 A-Q) Procedure codes (FL 74 Principle
procedure and fields a-e) Discharge date (FL 6 {Through}) Discharge status (FL 17) Patient age (FL 10 {Birth date}) Patient sex (FL 11)
Items on UB-04 needed for APC
Bill type (FL 04) Patient age (FL 10 {Birth date}) Patient sex (FL 11) Patient status code (FL 17) Revenue/HCPCS code (FL 42 & 44) Date of service (FL 44) Service units (FL 46) Total (billed) charge (FL 47) Diagnosis codes (FL 67 & 67A-Q)
Information for Pricers
Provider’s 6-digit Medicare facility ID number,* or
Select by provider name, and/or Location
* List of providers and Medicare numbers is on the IHS web site