Overview of the UB-04

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

Billing Information

FL47Total Charges FL48Non-Covered Charges FL49Unlabeled

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

QUESTIONS