CMS 1450 (UB-04) - Overview

UB-04 Overview

Medicare Part A Provider Outreach and Education

June 2007

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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

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UB-04

• Uniform bill for institutional providers.

• Replaces the UB-92.

• Mandated May 23, 2007.

Patient Information

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Form Locator 1

Billing Provider Information

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Form Locator 2

Pay-to Name and Address

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Form Locator 3

Patient Control Number/Medical Record Number

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Form Locator 4

Type of Bill (TOB)

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Form Locator 5

Federal Tax Number

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Form Locator 6

Dates of Service

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Form Locator 8

Patient’s Name

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Form Locator 9

Patient’s Address

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Form Locator 10

Patient’s Date of Birth

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Form Locator 11

Patient’s Gender

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Form Locators 12−15

Admission Date, Type and Source

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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.

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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

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Form Locators 16−17

Discharge Hour and Discharge Status

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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

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Form Locators 18−28

Condition Codes

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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

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Form Locator 29

Accident State

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Form Locators 31−34

Occurrence Codes and Dates

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Occurrence CodeExamples

Code Description01 Auto accident04 Accident employment-related11 Onset of illness

18 Date of retirement for patient/beneficiary

24 Date insurance denied

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Form Locators 35−36

Occurrence Span Codes and Dates

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Occurrence SpanCode Examples

Code Description74 Leave of absence76 Patient liability77 Provider liability

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Form Locator 38

Responsible Party’s Name and Address

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Form Locators 39−41

Value Codes and Amounts

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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

Billing Information

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Form Locator 42

Revenue Codes

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Form Locator 43

Revenue Code Description

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Form Locator 44

HCPCS Codes, Rates, HIPPS codes and Modifiers

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Form Locator 45

Service Dates

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Form Locator 46

Service Units

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Form Locator 47

Total Charges

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Form Locator 48

Non-Covered Charges

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Line 23

Payer Information

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Form Locator 50

Payer Name

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Form Locator 51

Health Plan Identification Number

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Form Locators 52−53

Release of Information and Assignment of Benefits

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Form Locator 54

Prior Payments

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Form Locator 55

Estimated Amount Due

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Form Locators 56−57

National Provider Identifier (NPI) and Other Provider Identifier

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Form Locator 58

Insured’s Name

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Form Locator 59

Patient’s Relationship to the Insured

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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

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Form Locator 60

Insured’s Unique Identifier

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Form Locator 61

Insured’s Group Name

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Form Locator 62

Insured’s Group Number

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Form Locator 63

Treatment Authorization Codes

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Form Locator 64

Document Control Number (DCN)

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Form Locator 65

Employer’s Name

Diagnosis Information

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Form Locator 66

Diagnosis and Procedure Code Qualifier

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Form Locator 67

Principal Diagnosis Code and Present on Admission (POA) Indicator

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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

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Form Locator 67A−Q

Other Diagnosis Codes and POA Indicator

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Form Locator 69

Admitting Diagnosis Code

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Form Locator 70

Patient’s Reason for Visit

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Form Locator 71

Prospective Payment System (PPS) Code

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Form Locator 72

External Cause of Injury (ECI) Code

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Form Locator 74

Principal and Other Procedure Codes and Dates

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Form Locator 76

Attending Provider’s Name and Identifiers

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Secondary Identifier Qualifiers

Qualifier Description0B State license number

1G Provider’s UPIN number

G2 Provider’s commercial number

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Form Locator 77

Operating Physician’s Name and Identifiers

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Form Locators 78-79

Other Providers’ Names and Identifiers

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Provider Type Qualifier Codes

Qualifier DescriptionDN Referring provider

ZZ Other operating physician

82 Rendering provider

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Form Locator 80

Remarks

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Form Locator 81

Healthcare Provider Taxonomy Code (HPTC)

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The Healthcare Provider Taxonomy Code (HPTC) list is available at:

www.wpc-edi.com/codes/taxonomy

HPTC

UB-04 Overview

Thank you for attending.parta.educ@trailblazerhealth.com