Cms 1450 (ub-04) - Overview
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Overview
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UB-04 Overview
Medicare Part A Provider Outreach and Education
June 2007
IMPORTANT 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
Slide 2
UB-04 • Uniform bill for institutional providers. • Replaces the UB92. • Mandated May 23, 2007.
Slide 3
Patient Information
Form Locator 1 Billing Provider Information
Slide 5
Form Locator 2 Pay-to Name and Address
Slide 6
Form Locator 3 Patient Control Number/Medical Record Number
Slide 7
Form Locator 4 Type of Bill (TOB)
Slide 8
Form Locator 5 Federal Tax Number
Slide 9
Form Locator 6 Dates of Service
Slide 10
Form Locator 8 Patient’s Name
Slide 11
Form Locator 9 Patient’s Address
Slide 12
Form Locator 10 Patient’s Date of Birth
Slide 13
Form Locator 11 Patient’s Gender
Slide 14
Form Locators 12−15 Admission Date, Type and Source
Slide 15
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.
Slide 16
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
Slide 17
Form Locators 16−17 Discharge Hour and Discharge Status
Slide 18
Discharge Status Code Examples Code
Description
01
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 care
20
Expired
Slide 19
Form Locators 18−28 Condition Codes
Slide 20
Condition Code Examples Code 02 07 08 20 21
Description Condition is employment-related Treatment of non-terminal condition for hospice Beneficiary would not provide information concerning other coverage Beneficiary requested billing Billing for denial notice
Slide 21
Form Locator 29 Accident State
Slide 22
Form Locators 31−34 Occurrence Codes and Dates
Slide 23
Occurrence Code Examples Code 01 04 11 18 24
Description Auto accident Accident employment-related Onset of illness Date of retirement for patient/beneficiary Date insurance denied
Slide 24
Form Locators 35−36 Occurrence Span Codes and Dates
Slide 25
Occurrence Span Code Examples Code 74 76 77
Description Leave of absence Patient liability Provider liability
Slide 26
Form Locator 38 Responsible Party’s Name and Address
Slide 27
Form Locators 39−41 Value Codes and Amounts
Slide 28
Value Code Examples Code 12 37 50 53 80 81 82 83
Description Working aged Pints of blood furnished Physical therapy visits Cardiac rehabilitation visits Covered days Non-covered days Coinsurance days Lifetime reserve days Slide 29
Billing Information
Form Locator 42 Revenue Codes
Slide 31
Form Locator 43 Revenue Code Description
Slide 32
Form Locator 44 HCPCS Codes, Rates, HIPPS codes and Modifiers
Slide 33
Form Locator 45 Service Dates
Slide 34
Form Locator 46 Service Units
Slide 35
Form Locator 47 Total Charges
Slide 36
Form Locator 48 Non-Covered Charges
Slide 37
Line 23
Slide 38
Payer Information
Form Locator 50 Payer Name
Slide 40
Form Locator 51 Health Plan Identification Number
Slide 41
Form Locators 52−53 Release of Information and Assignment of Benefits
Slide 42
Form Locator 54 Prior Payments
Slide 43
Form Locator 55 Estimated Amount Due
Slide 44
Form Locators 56−57 National Provider Identifier (NPI) and Other Provider Identifier
Slide 45
Form Locator 58 Insured’s Name
Slide 46
Form Locator 59 Patient’s Relationship to the Insured
Slide 47
Patient’s Relationship Code Examples Code Description 01 Spouse 18 Patient is insured 19 43
Natural child/insured financial responsibility Natural child/insured does not have financial responsibility 22 Handicapped dependent 29/53 Life partner 32 Mother 33 Father Slide 48
Form Locator 60 Insured’s Unique Identifier
Slide 49
Form Locator 61 Insured’s Group Name
Slide 50
Form Locator 62 Insured’s Group Number
Slide 51
Form Locator 63 Treatment Authorization Codes
Slide 52
Form Locator 64 Document Control Number (DCN)
Slide 53
Form Locator 65 Employer’s Name
Slide 54
Diagnosis Information
Form Locator 66 Diagnosis and Procedure Code Qualifier
Slide 56
Form Locator 67 Principal Diagnosis Code and Present on Admission (POA) Indicator
Slide 57
POA Indicator Indicator
Description
Y
Yes
N
No
W
Clinically undetermined
U
No information in the record
Unreported or not used Exempt from POA reporting
Slide 58
Form Locator 67A−Q Other Diagnosis Codes and POA Indicator
Slide 59
Form Locator 69 Admitting Diagnosis Code
Slide 60
Form Locator 70 Patient’s Reason for Visit
Slide 61
Form Locator 71 Prospective Payment System (PPS) Code
Slide 62
Form Locator 72 External Cause of Injury (ECI) Code
Slide 63
Form Locator 74 Principal and Other Procedure Codes and Dates
Slide 64
Form Locator 76 Attending Provider’s Name and Identifiers
Slide 65
Secondary Identifier Qualifiers Qualifier 0B
Description State license number
1G
Provider’s UPIN number
G2
Provider’s commercial number
Slide 66
Form Locator 77 Operating Physician’s Name and Identifiers
Slide 67
Form Locators 78-79 Other Providers’ Names and Identifiers
Slide 68
Provider Type Qualifier Codes Qualifier DN
Description Referring provider
ZZ
Other operating physician
82
Rendering provider
Slide 69
Form Locator 80 Remarks
Slide 70
Form Locator 81 Healthcare Provider Taxonomy Code (HPTC)
Slide 71
HPTC The Healthcare Provider Taxonomy Code (HPTC) list is available at: www.wpc-edi.com/codes/taxonomy
Slide 72
UB-04 Overview Thank you for attending. [email protected]
Medicare Part A Provider Outreach and Education
June 2007
IMPORTANT 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
Slide 2
UB-04 • Uniform bill for institutional providers. • Replaces the UB92. • Mandated May 23, 2007.
Slide 3
Patient Information
Form Locator 1 Billing Provider Information
Slide 5
Form Locator 2 Pay-to Name and Address
Slide 6
Form Locator 3 Patient Control Number/Medical Record Number
Slide 7
Form Locator 4 Type of Bill (TOB)
Slide 8
Form Locator 5 Federal Tax Number
Slide 9
Form Locator 6 Dates of Service
Slide 10
Form Locator 8 Patient’s Name
Slide 11
Form Locator 9 Patient’s Address
Slide 12
Form Locator 10 Patient’s Date of Birth
Slide 13
Form Locator 11 Patient’s Gender
Slide 14
Form Locators 12−15 Admission Date, Type and Source
Slide 15
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.
Slide 16
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
Slide 17
Form Locators 16−17 Discharge Hour and Discharge Status
Slide 18
Discharge Status Code Examples Code
Description
01
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 care
20
Expired
Slide 19
Form Locators 18−28 Condition Codes
Slide 20
Condition Code Examples Code 02 07 08 20 21
Description Condition is employment-related Treatment of non-terminal condition for hospice Beneficiary would not provide information concerning other coverage Beneficiary requested billing Billing for denial notice
Slide 21
Form Locator 29 Accident State
Slide 22
Form Locators 31−34 Occurrence Codes and Dates
Slide 23
Occurrence Code Examples Code 01 04 11 18 24
Description Auto accident Accident employment-related Onset of illness Date of retirement for patient/beneficiary Date insurance denied
Slide 24
Form Locators 35−36 Occurrence Span Codes and Dates
Slide 25
Occurrence Span Code Examples Code 74 76 77
Description Leave of absence Patient liability Provider liability
Slide 26
Form Locator 38 Responsible Party’s Name and Address
Slide 27
Form Locators 39−41 Value Codes and Amounts
Slide 28
Value Code Examples Code 12 37 50 53 80 81 82 83
Description Working aged Pints of blood furnished Physical therapy visits Cardiac rehabilitation visits Covered days Non-covered days Coinsurance days Lifetime reserve days Slide 29
Billing Information
Form Locator 42 Revenue Codes
Slide 31
Form Locator 43 Revenue Code Description
Slide 32
Form Locator 44 HCPCS Codes, Rates, HIPPS codes and Modifiers
Slide 33
Form Locator 45 Service Dates
Slide 34
Form Locator 46 Service Units
Slide 35
Form Locator 47 Total Charges
Slide 36
Form Locator 48 Non-Covered Charges
Slide 37
Line 23
Slide 38
Payer Information
Form Locator 50 Payer Name
Slide 40
Form Locator 51 Health Plan Identification Number
Slide 41
Form Locators 52−53 Release of Information and Assignment of Benefits
Slide 42
Form Locator 54 Prior Payments
Slide 43
Form Locator 55 Estimated Amount Due
Slide 44
Form Locators 56−57 National Provider Identifier (NPI) and Other Provider Identifier
Slide 45
Form Locator 58 Insured’s Name
Slide 46
Form Locator 59 Patient’s Relationship to the Insured
Slide 47
Patient’s Relationship Code Examples Code Description 01 Spouse 18 Patient is insured 19 43
Natural child/insured financial responsibility Natural child/insured does not have financial responsibility 22 Handicapped dependent 29/53 Life partner 32 Mother 33 Father Slide 48
Form Locator 60 Insured’s Unique Identifier
Slide 49
Form Locator 61 Insured’s Group Name
Slide 50
Form Locator 62 Insured’s Group Number
Slide 51
Form Locator 63 Treatment Authorization Codes
Slide 52
Form Locator 64 Document Control Number (DCN)
Slide 53
Form Locator 65 Employer’s Name
Slide 54
Diagnosis Information
Form Locator 66 Diagnosis and Procedure Code Qualifier
Slide 56
Form Locator 67 Principal Diagnosis Code and Present on Admission (POA) Indicator
Slide 57
POA Indicator Indicator
Description
Y
Yes
N
No
W
Clinically undetermined
U
No information in the record
Unreported or not used Exempt from POA reporting
Slide 58
Form Locator 67A−Q Other Diagnosis Codes and POA Indicator
Slide 59
Form Locator 69 Admitting Diagnosis Code
Slide 60
Form Locator 70 Patient’s Reason for Visit
Slide 61
Form Locator 71 Prospective Payment System (PPS) Code
Slide 62
Form Locator 72 External Cause of Injury (ECI) Code
Slide 63
Form Locator 74 Principal and Other Procedure Codes and Dates
Slide 64
Form Locator 76 Attending Provider’s Name and Identifiers
Slide 65
Secondary Identifier Qualifiers Qualifier 0B
Description State license number
1G
Provider’s UPIN number
G2
Provider’s commercial number
Slide 66
Form Locator 77 Operating Physician’s Name and Identifiers
Slide 67
Form Locators 78-79 Other Providers’ Names and Identifiers
Slide 68
Provider Type Qualifier Codes Qualifier DN
Description Referring provider
ZZ
Other operating physician
82
Rendering provider
Slide 69
Form Locator 80 Remarks
Slide 70
Form Locator 81 Healthcare Provider Taxonomy Code (HPTC)
Slide 71
HPTC The Healthcare Provider Taxonomy Code (HPTC) list is available at: www.wpc-edi.com/codes/taxonomy
Slide 72
UB-04 Overview Thank you for attending. [email protected]
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