Transcript Overview of the UB-04
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