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 Billing Information Payer Information Diagnostic Information Additional Information

Patient/Provider Information

  FL01 FL02  FL03a  FL03b  FL04 Provider Name, Address, Phone and/or Fax number Pay-to Name, Address, Phone and/or Fax number Patient Control Number Medical Record Number Type of Bill  4-digit alphanumeric (example 0111)

Patient/Provider Information

 

FL05 FL06

 FL07  FL08a  FL08b

Federal Tax ID Number Statement Covers Period – From/Through

Unlabeled Patient Name – ID Patient Name

Patient/Provider Information

 FL09a- e 

FL10

 

FL11

FL12 – 16 Patient Address

Patient Birth date Patient Sex

Admission Date/ Hour/Type/Source/ Discharge Hour

Patient/Provider Information



FL17 Patient Status Code

 01 Discharged to home or self care (routine discharge  02 Discharged/transferred  20 Expired

Patient/Provider Information

       

FL18-28 Condition Codes

FL29 FL30 Accident State Unlabeled

FL31-34 Occurrence Code/Date

FL35-36 Occurrence Span Code/From/Through FL37 FL38 Unlabeled Responsible Party Name/Address FL39-41 Value Codes

Billing Information



FL42

 FL43

Revenue 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 Revenue Code Description

Billing Information



FL44



FL45



FL46 Rates/HCPCS/HIPPS Rate Codes

 Rates – cost of the room per day  HCPCS – CPT or HCPCS codes giving details about the service  HIPPS rate codes – alphanumeric code identifying level of care/service

Service Date Unit of Service

Billing Information



FL47

 FL48  FL49

Total Charges

Non-Covered Charges Unlabeled

Payer Information

 FL50 – 65 – Various pieces of information about what insurance may be primary and what they paid   FL56 FL57 NPI (National Provider Identifier) Other Provider ID

Diagnostic Information

 FL66 

FL67

DX (diagnosis) Version Qualifier

Principle Diagnosis Code



FL67A-Q Other Diagnosis

 FL68 Unlabeled  FL69  FL70a-c Admitting Diagnosis Code Patient Reason for Visit Code

Diagnostic Information

  FL71 FL72 a-c PPS Code External Cause of Injury Code (ECI)   FL73

FL74

Unlabeled

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 Discharge status Patient age Patient sex (FL 6 {Through}) (FL 17) (FL 10 {Birth date}) (FL 11)

Items on UB-04 needed for APC

         Bill type Patient age Patient sex Patient status code (FL 17) Revenue/HCPCS code (FL 42 & 44) Date of service Service units (FL 44) (FL 46) Total (billed) charge Diagnosis codes (FL 04) (FL 10 {Birth date}) (FL 11) (FL 47) (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