UB-04 LOCATORS NUMERICAL ORDER. Form Locators

Transcription

1 UB-04 LOCATORS NUMERICAL ORDER Form Locators Page FL 01 - Billing Provider Name, Address and Telephone Number 3 FL 02 - Billing Provider s Designated Pay-to Address 3 FL 03a - Patient Control Number 4 FL 03b - Medical/Health Record Number 4 FL 04 - Type of Bill 5 FL 05 - Federal Tax Number 8 FL 06 - Statement Covers Period (From - Through) 9 FL 07 - Reserved for Assignment by the NUBC 10 FL 08 - Patient Name/Identifier 10 FL 09 - Patient Address 11 FL 10 - Patient Birth Date 11 FL 11 - Patient Sex 11 FL 12 - Admission/Start of Care Date 12 FL 13 - Admission Hour 12 FL 14 - Priority (Type) of Admission or Visit 13 FL 15 - Point of Origin for Admission or Visit 13 FL 16 - Discharge Hour 16 FL 17 - Patient Discharge Status 16 FL Condition Codes 18 FL 29 - Accident State 22 FL 30 - Reserved for Assignment by the NUBC 22 FL Occurrence Codes and Dates 22 FL Occurrence Span Codes and Dates 26 FL 37 - Reserved for Assignment by the NUBC 27 FL 38 - Responsible Party Name and Address (Claim Addressee) 27 FL Value Codes and Amounts 28 FL 42 - Revenue Codes 36 FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate 65 FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes 66 FL 45 - Service Date 67 FL 46 - Service Units 68 FL 47 - Total Charges 69 FL 48 - Non-covered Charges 69 FL 49 - Reserved for Assignment by the NUBC 70 FL 50 - Payer Name 70 FL 51 - Health Plan Identification Number 70 FL 52 - Release of Information Certification Indicator 71 FL 53 - Assignment of Benefits Certification Indicator 71 FL 54 - Prior Payments - Payer 72 FL 55 - Estimated Amount Due - Payer 72 FL 56 - National Provider Identifier - Billing Provider 73 FL 57 - Other (Billing) Provider Identifier 73 FL 58 - Insured s Name 74 FL 59 - Patient s Relationship to Insured 75 FL 60 - Insured s Unique Identifier 75 FL 61 - Insured s Group Name 76 FL 62 - Insured s Group Number 76 FL 63 - Treatment Authorization Code 77 FL 64 - Document Control Number (DCN) 77 FL 65 - Employer Name (of the Insured) 78 FL 66 - Diagnosis and Procedure Code Qualifier (ICD Version Indicator) 78 FL 67 - Principal Diagnosis Code and Present on Admission Indicator 79 BCNEPA/FPH/FPLIC Billing Manual Page 1

2 Form Locators Page FL 67A-Q - Other Diagnosis Code and Present on Admission Indicator 83 FL 68 - Reserved for Assignment by the NUBC 83 FL 69 - Admitting Diagnosis Code 84 FL 70a-c - Patient s Reason for Visit 85 FL 71 - Prospective Payment System (PPS/DRG) Code 86 FL 72a-c - External Cause of Injury (ECI) Code and POA Indicator 87 FL 73 - Reserved for Assignment by the NUBC 87 FL 74 - Principal Procedure Code and Date 88 FL 74a-e - Other Procedure Codes and Dates 88 FL 75 - Reserved for Assignment by the NUBC 89 FL 76 - Attending Provider Name and Identifiers 89 FL 77 - Operating Physician Name and Identifiers 91 FL Other Provider name and Identifiers 92 FL 80 - Remarks Field 94 FL 81 - Code-Code Field 95 BCNEPA/FPH/FPLIC Billing Manual Page 2

3 Form Locator 01 Data Element Billing Provider Name, Address and Telephone Number The name and service location of the provider submitting the bill. Yes Name and Address, Telephone, Country Code Telephone UB-04: /004010A1: Situational. when this information is different than that contained in the Submitter PER segment (Loop ID-1000A) : Situational. when this information is different than that contained in the Submitter PER segment (Loop ID-1000A). County Code UB-04: Situational. when the address is outside the United States of America /004010A1: Situational. when the address is outside of the U.S : Situational. when the address is outside of the U.S. Field 1 Field Attributes 4 Lines 25 Positions Alphanumeric Left-justified The Billing Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To-Address field of Form locator 02, if necessary. Form Locator 01 uses the full nine-digit ZIP. Enter the information provided on the appropriate line: Line 1 Provider Name Line 2 Street Address Line 3 City (Positions 1-12 Left-justified), State (Positions 14-15), and Zip Code (Positions 17-25) Line 4 Telephone (Positions 1-10); Fax (Positions 13-22); Country Code (Positions 24-25); Use the alpha-2 country codes from Part 1 of ISO 3166) Form Locator 02 Data Element Billing Provider s Designated Pay-to Address The address that the provider submitting the bill intends payment to be sent if different than FL 01. If Applicable UB-04: Situational. when the address for payment is different than that of the Billing Provider in Form Locator /004010A1: Situational. if the Pay-to Provider is a different entity than the Billing Provider. BCNEPA/FPH/FPLIC Billing Manual Page 3

4 Form Locator : Situational. when the address for payment is different than that of the Billing Provider. (Note: The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.) Field 1 Field Attributes 4 Lines 25 Positions Alphanumeric Left-justified Enter the information provided on the appropriate line: Line 1 Pay-to Name Line 2 Street Address or Post Office Box Line 3 City (Positions 1-16, Left-justified), State (Positions 18-19), and Zip Code (Positions 21-25) Line 4 NOT USED. Reserved for Assignment by the NUBC. Address may include post office box or street name and number, city, state and ZIP Code. Form Locator 02 uses a 5-digit ZIP Code. Form Locator 03a Data Element Patient Control Number Patient s unique (alphanumeric) number assigned by the provider to facilitate retrieval of the individual s account of services (accounts receivable) containing the financial billing records and any postings of payment. Yes UB-04; /004010A1; Field 1 Field Attributes 1 Line 24 Positions Alphanumeric Left-justified To enable providers to reconcile payments against the account receivable for the patient, it is a requirement that payers include the patient control number on the payment check, remittance advice or voucher. Data Element Medical/Health Record Number Form Locator 03b The number assigned to the patient s medical/health record by the provider. No BCNEPA/FPH/FPLIC Billing Manual Page 4

5 Form Locator 03b UB-04: Situational. when the provider needs to identify for future inquiries, the actual medical record of the patient /004010A1, : Situational. when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID- 2010BA or Loop ID-2010CA for this episode of care. Field 1 Field Attributes 1 Line 24 Positions Alphanumeric Left-justified The medical/health record number references a file that contains the history of treatment. It should not be substituted for the Patient Control Number (FL 03a), which is assigned by the provider to facilitate retrieval of the individual financial record, which is typically associated with an episode of care. Data Element Type of Bill Form Locator 04 A code indicating the specific type of bill (e.g., hospital inpatient, outpatient, replacements, voids, etc.). The first digit is a leading zero (Do not include the leading zero on electronic claims). The fourth digit defines the frequency of the bill for the institutional and electronic professional claim. Yes Field 1 Field (2 Components) 1 Line Attributes 4 Positions Alphanumeric Left-justified (all positions fully coded) The x in the following tables (first component) represents a placeholder for the frequency code (second component). Inpatient and Outpatient Designation The matrix which follows contains general guidelines on what constitutes an inpatient or outpatient claim according to the first three digits of Type of Bill (TOB). Inpatient Part B Only Type of Bill 012x and 022x The general designations for TOBs 012x and 022x are OP. Medicare will pay, under Part B for physician services and for non-physician medical and other health services when furnished by a participating hospital or SNF to an inpatient of the facility when patients are not eligible or entitled to Part A benefits or the patient has exhausted their Part A benefits. This is done when the patients are not eligible or entitles to, or have exhausted, their Part A benefits. Such services are billed on these two bill types. Type of Bill Inpatient/Outpatient General Designation/ Exception # on FL04 000x-010x Reserved for Assignment by NUBC - 011x Hospital Inpatient (Including Medicare Part A) IP 012x Hospital Inpatient (Medicare Part B only) OP/1, 3 013x Hospital Outpatient OP 014x Hospital - Laboratory Services Provided to Non-patients OP/6 015x-017x Reserved for Assignment by NUBC - 018x Hospital - Swing Beds IP BCNEPA/FPH/FPLIC Billing Manual Page 5

6 Form Locator 04 Type of Bill Inpatient/Outpatient General Designation/ Exception # on FL04 019x-020x Reserved for Assignment by NUBC - 021x Skilled Nursing - Inpatient (Including Medicare Part A) IP/2, 4 022x Skilled Nursing - Inpatient (Medicare Part B) OP/1, 3 023x Skilled Nursing - Outpatient OP 024x-027x Reserved for Assignment by NUBC - 028x Skilled Nursing - Swing Beds IP/3 029x-031x Reserved for Assignment by NUBC - 032x Home Health - Inpatient (plan of treatment under Part B only) OP/1 033x Home Health - Outpatient (plan of treatment under Part A, OP/1 Including DME under Part A 034x Home Health - Other (for medical and surgical services not OP/1 Under a plan of treatment) 035x-040x Reserved for Assignment by NUBC - 041x Religious Non-Medical Health Care Institutions - Hospital IP Inpatient 042x Reserved for Assignment by NUBC - 043x Religious Non-Medical Health Care Institutions - Outpatient OP Services 044x-064x Reserved for Assignment by NUBC - 065x Intermediate Care - Level I IP/3 066x Intermediate Care - Level II IP/3 067x-070x Reserved for Assignment by NUBC - 071x Clinic - Rural Health OP 072x Clinic - Hospital Based or Independent Renal Dialysis Center OP 073x Clinic - Freestanding OP 074x Clinic - Outpatient Rehabilitation Facility (ORF) OP 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) OP 076x Clinic - Community Mental Health Center OP 077x Clinic - Federally Qualified Health Center (FQHC) (Effective 4/1/10) OP 078x Licensed Freestanding Emergency Medical Facility (Effective 7/1/12) OP 079x Clinic - Other OP 080x Reserved for Assignment by NUBC - 081x Hospice (non-hospital based) OP/1 082x Hospice (hospital based) OP/1 083x Ambulatory Surgery Center OP 084x Free Standing Birthing Center OP 085x Critical Access Hospital OP 086x Residential Facility IP/3 087x-088x Reserved for Assignment by NUBC - 089x Special Facility - Other IP or OP* 090x-999x Reserved for Assignment by NUBC - *Effective 7/1/13, the general designation is OP only. Exceptions to Inpatient/Outpatient general Designation by Data Element/Form Locator: Exc. # Data Element Usage Requirement by Type of Bill 1 FL12 - Admission/Start of Care Date on all inpatient claims (IP) and Usage Note in : 012x, 022x, 032x, 033x, 034x, 081x and on inpatient claims. 082x. BCNEPA/FPH/FPLIC Billing Manual Page 6

7 Form Locator 04 Exceptions to Inpatient/Outpatient general Designation by Data Element/Form Locator: Exc. # Data Element Usage Requirement by Type of Bill 2 FL13 - Admission Hour on all inpatient claims (IP) except Usage Note in : for 021x. Selection of the appropriate qualifier Is designated by the NUBC Billing Manual. 3 FL69 - Admitting Diagnosis: on 012x, 022x and inpatient claims Usage Note in : (IP) except 028x, 065x, 066x, 086x. when claim involves an inpatient admission. 4 FL16 - Discharge Hour: on inpatient claims (IP) with a Usage Note in : Frequency Code of 1, 4 or 7, except for 021x. on all final inpatient claims. 5 FL70a-c - Patient s Reason for Visit: Not required on any claim except for 013x, Usage Note in : 085x and 078x when: when claim involves outpatient visits. a) Priority (Type) of Admission/Visit Codes 1,2, or 5 are reported AND b) Revenue Codes 045x, 0516, 0526, or 0762 are reported. May be reported on all other 013x, 078x and 085x types of bills at submitter s discretion when this information provides additional information to support medical necessity. See FL70 a-c for more information. 6 FL15 Point of Origin for Admission or Visit on all claims except 014x. Usage Note in : for all inpatient and outpatient services. Type of Bill Frequency Codes: 0 Non-Payment/Zero 1 Admit Through Discharge Claim (a) 2 Interim - First Claim 3 Interim - Continuing Claim (b) 4 Interim - Last Claim (b) 5 Late Charge(s) Only 6 Reserved for assignment by the NUBC 7 Replacement of Prior Claim (a) 8 Void/Cancel of Prior Claim (a) 9 Final Claim for a Home Health PPS Episode A Admission/Election Notice B Hospice/CMS Coordinated Care Demonstration/Religious Non-Medical Health Care Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration C Hospice Change of Provider Notice BCNEPA/FPH/FPLIC Billing Manual Page 7

8 Type of Bill Frequency Codes: Form Locator 04 D E F G H I J K L M N O P Q R-W X Y Z Hospice/CMS Coordinated Care Demonstration/Religious Non-Medical Health Care Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration Void/Cancel Hospice Change of Ownership Beneficiary Initiated Adjustment Claim CWF Initiated Adjustment Claim CMS Initiated Adjustment Intermediary Adjustment Claim (Other than QIO or Provider) Initiated Adjustment Claim - Other OIG Initiated Adjustment Claim Reserved for assignment by the NUBC MSP Initiated Adjustment Claim Reserved for assignment by the NUBC Nonpayment/Zero Claims QIO Adjustment Claim Claim Submitted for Reconsideration Outside of Timely Limits Reserved for assignment by the NUBC Void/Cancel a Prior Abbreviated Encounter Submission Replacement of Prior Abbreviated Encounter Submission New Abbreviated Encounter Submission Footnotes for Frequency Codes (a) The developers of the Professional and Dental Health Care Claim Implementation Guides have indicated that this code is acceptable for use in those transactions. (b) Do not use for Medicare inpatient hospital PPS claims. (For second and subsequent interim bills use code 7, and see Condition Code D3 (FL18-FL28). Form Locator 05 Data Element Federal Tax Number The number assigned to the provider by the federal government for tax reporting purposes. Also known as a tax identification number (TIN) or employer identification number (EIN). To identify affiliated subsidiaries using federal tax sub-id (see note below). Yes Field Attributes 1 Field Upper Line, 4 positions (sub-id - optional) Alphanumeric Left-justified Lower Line, 10 positions (include hyphen) Alphanumeric Left-justified Upper line is the federal tax sub-id number as assigned by the provider. To be used by providers that assign a unique identifying number for their affiliated subsidiaries, e.g., hospital psychiatric pavilion. Lower line is the federal tax number entered as: NN-NNNNNNN. For electronic claims, do not use the hyphen when reporting federal tax ID. BCNEPA/FPH/FPLIC Billing Manual Page 8

9 Form Locator 06 Data Element Statement Covers Period (From-Through) The beginning and ending service dates of the period included on this bill. Yes : UB-04, /004010A1, Field Attributes 2 Field 1 Line 6 Positions (two six-digit dates) Numeric Right-justified (all positions fully coded) 1. For all services received on a single day, use the same date for From and Through. 2. Enter both dates as month, day, and year (MMDDYY). Example: The From date should not be confused with the Admission Date (FL12). The Statement Covers Period From date in Form Locator 6 ( From Date) is distinctly different than the Admission Date in Form Locator 12. The dates may coincide in some circumstances, but should not be confused. It is also not a requirement that the Admission Date Fall in between the From Date and the Statement Covers Period Through date. Any edit that requires that the two dates match is invalid. In addition, an edit that compares the number of days in the Statement Covers Period to any other data element (e.g., total accommodation days reported in the revenue code section) is inherently flawed. The Admission Date is purely the date the patient was admitted as an inpatient to the facility (or indicates the start of care date for home health and hospice). It is reported on all inpatient claims regardless of whether it is an initial, interim, or final bill. The Statement Covers Period indentifies the span of service dates included in a particular bill. The From Date is the earliest date of service on the bill. Summary The billing process for providers is easier if the correct distinctions and validation edits are properly applied. Some edits are forcing the Admission Date, Procedure Date and From date to be identical. Maintaining the distinction alleviates any special routines that providers must now undertake in order to circumvent a flawed edit. The same issues and methodology apply to the 837 institutional claim, which has distinct data segments and qualifiers to properly distinguish Admission Date and Statement Covers Period dates Update The Admission Date and Statement Covers Period on claims are two distinctly different data elements: The Admission Date (Form Locator 12) is purely the date the patient was admitted as an inpatient to the facility ( or indicates the start of care date for home health and hospice). It is reported on all inpatient claims regardless of whether it is an initial, interim, or final bill. The Statement Covers period ( From and Through dates in FL 6) identifies the span of service dates included in a particular bill. The From Date is the earliest date of service on the bill. BCNEPA/FPH/FPLIC Billing Manual Page 9

10 Form Locator 07 Data Element Reserved for Assignment by the NUBC. Not Used Field 1 Field Attributes 2 Lines 7 Positions (upper line) 8 Positions (lower line) Form Locator 08 Data Element Patient Name/Identifier Last name, first name and middle initial of the patient and the patient identifier as assigned by the payer. Yes Patient Name UB-04: /004010A1: If the patient is the subscriber, the name is reported in Loop ID 2010BA. If the patient is not the subscriber, the name is reported in Loop ID 2010CA : If the patient is the subscriber, the name is reported in Loop ID 2010BA. If the patient is not the subscriber but has a unique identifier assigned by the destination payer, the name is reported in Loop ID 2010BA. If the patient is not the subscriber and cannot be identified by a unique identifier assigned by the destination payer, the name is reported in Loop ID 2010CA. Patient ID UB-04: Report if number is different from the subscriber/insured s ID (FL 60) /004010A1: If the patient is the subscriber, the identifier is reported in Loop ID 2010BA. If the patient is not the subscriber, the identifier is reported in Loop ID 2010CA : when the patient name has been mapped to Loop ID 2010BA. Not Used when the patient name has been mapped to Loop ID 2010CA. Field 1 Field 2 Lines 2 Subfields Alphanumeric Left-justified Attributes Subfield a: Patient Identifier (19positions) Subfield b: Patient Name (29 positions) On the paper UB-04 form, use a comma or space to separate last and first names. No space should be left between a prefix and a name as in MacBeth and McEnroe. Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element. Record hyphenated names with the hyphen as in Smith-Jones, Rebecca. To record suffix of a name, write the last name, leave a space and write the suffix, then write the first name as in Snyder Iii, Harold, or Addams Jr., Glen. BCNEPA/FPH/FPLIC Billing Manual Page 10

11 Form Locator 09 Data Element Patient Address The mailing address of the patient. Enter the complete mailing address including street number and name or post office box number or RFD; city name; state name; ZIP code. Yes UB /004010A1, :. Reported in the same Loop ID (2010BA or 2010CA) that the Patient Name has been mapped to. Field 1 Field 2 Lines 5 Subfields Attributes Subfield a: Street Address (40 Positions) Subfield b: City (30 Positions) Subfield c: State (2 Positions) Subfield d: ZIP Code (9 Positions) Subfield e: Country Code (2 Positions) Alphanumeric Left-justified Form Locator 10 Data Element Patient Birth Date The date of birth of the patient. Yes UB /004010A1, :. Reported in the same Loop ID (2010BA or 2010CA) that the Patient Name has been mapped to. Field 1 Field Attributes 1 Line 8 Positions Numeric Right-justified (all positions fully coded) For paper claims only, if full birth date is unknown, indicate zeros for all eight digits. Enter: MMDDYYY Form Locator 11 Data Element Patient Sex The sex of the patient as recorded at admission, outpatient service, or start of care. Yes UB /004010A1, :. Reported in the same Loop ID (2010BA or 2010CA) that the Patient Name has been mapped to. Field 1 Field 1 Line 1 Position Alphanumeric Attributes Left-justified Form Locator 11 BCNEPA/FPH/FPLIC Billing Manual Page 11

12 M = Male F = Female U = Unkown Form Locator 12 Data Element Admission/Start of Care Date The start date for this episode of care. For inpatient services, this is the date of admission. For other (home health) services, it is the date the episode of care began. Yes UB-04: on all inpatient claims ( IP ), 012x, 022x, 032x, 033x, 034x, 081x,and 082x /004010A1: 00510: on inpatient claims, home health claims and hospice claims. Field 1 Field 1 Line 6 Positions Numeric Attributes Right-justified (all positions fully coded) Enter the admission date as month, day and year (MMDDYY). The Admission/Start of Care Date is a discrete data element and should not be confused with the Statement Covers Period From date on Form Locator 06. Form Locator 13 Data Element Admission Hour The code referring to the hour during which the patient was admitted for inpatient care. Yes (Inpatient only) UB-04: on all inpatient claims except for Type of Bill 021x /004010A1: This segment is required on all inpatient claims : Selection of the appropriate qualifier is designated by the NUBC Billing Manual. (Therefore, required on inpatient claims except for Type of Bill 021x as noted above.) Field 1 Field 1 Line 2 Positions Attributes Alphanumeric Left-justified (all positions fully coded, unless blank) Code Structure Code Time - A.M. Code Time - P.M :00-12:59 Midnight 12 12:00-12:59 Noon 01 01:00-01: :00-01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11:59 Form Locator 14 BCNEPA/FPH/FPLIC Billing Manual Page 12

13 Data Element Priority (Type) of Admission or Visit A code indicating the priority of this admission/visit. Yes UB-04: on inpatient and outpatient services /004010A1: when patient is being admitted to the hospital for inpatient services : on inpatient and outpatient services. Field 1 Field 1 Line 1 Position Attributes Alphanumeric Left-justified Code See codes below 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 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.) 6-8 Reserved for assignment by NUBC 9 Information Information not available. not Available Form Locator 15 Data Element Point of Origin for Admission or Visit A code indicating the point of patient origin for this admission or visit. Yes (Inpatient, SNF, Home Health and Hospice) If Applicable (Outpatient) UB04: on all bill types except 014x /004010A1: for all inpatient admissions. on Medicare outpatient registrations for diagnostic testing services : for all inpatient and outpatient services. (Therefore required on all bill types marked IP and OP per FL 04 except for bill type 014x, which is equivalent to the UB-or requirement.) Form Locator 15 BCNEPA/FPH/FPLIC Billing Manual Page 13

14 Field 1 Field 1 Line 1 Position Attributes Alphanumeric Left-justified The updated and revised code list has been designed to focus on patients place or point of origin rather than the source of a physician order or referral. A physician order or referral is implicit in any admission or visit. By modifying the definitions of the codes in this manner, the ambiguity in the code structure has been eliminated; all of the codes become mutually exclusive. The point of origin is the direct source for the particular facility. I. Transfers - From an Another Facility While at another acute care hospital/facility, the patient is seen by the emergency room physicians. The patient is then transferred to our facility. The patient arrives at our facility through the emergency room. Point of Origin Code 4 - Transfer from a Hospital (Different Facility) II. Transfers - Skilled Nursing Facility A resident from a skilled nursing facility is taken to an acute care hospital for medical care. Point of Origin Code 5 - Transfer from a Skilled Nursing Facility III. Transfer by Law Enforcement or Court A patient arrives at the health care facility accompanied by policy. Point of Origin Code 8 - Court/Law Enforcement Code Description 1 Non-Health Care Inpatient: The patient was admitted to this facility. Facility Point of Origin Outpatient: The patient presented to this facility for outpatient services. Examples: Includes patients coming from home, or workplace and patients receiving care at home (such as home health services). 2 Clinic or Physician s Inpatient: The patient was admitted to this facility. Office Outpatient: The patient presented to this facility for outpatient services. 3 Reserved for assignment by the NUBC (Discontinued effective 10/1/07) 4 Transfer from a Hospital Inpatient: The patient was admitted to this facility as a hospital transfer (Different Facility) from an acute care facility where he or she was an inpatient or outpatient. Outpatient: The patient was transferred to this facility as an outpatient from an acute care facility. Usage Note: Excludes Transfers from Hospital Inpatient in the Same Facility (See Code D). 5 Transfer from a Skilled Inpatient: The patient was admitted to this facility as a transfer from a Nursing Facility (SNF) SNF, ICF or ALF where he or she was a resident. Intermediate Care Outpatient: The patient was referred to this facility for outpatient or referenced Facility (ICF) or Assisted diagnostic services from a SNF, ICF or ALF where he or she was Living Facility (ALF) a resident. 6 Transfer from Another Inpatient: The patient was admitted to this facility as a transfer from Health Care Facility another type of health care facility not defined elsewhere in this code list. Outpatient: The patient presented to this facility for services from another health care facility not defined elsewhere in this code list. 7 Reserved for assignment by the NUBC. (Discontinued effective 7/1/10) BCNEPA/FPH/FPLIC Billing Manual Page 14

15 Form Locator 15 Code Description 8 Court/Law Enforcement Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. Outpatient: The patient was referred to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services. 9 Information Not Inpatient: The patient s Point of Origin is not know. A Available Outpatient: The patient s Point of Origin is not know. Reserved for assignment by the NUBC (Discontinued effective 10/1/07) B Transfer From Another Home Discontinued Effective 7/1/10. Health Agency (Replaced with Condition Code 47 FL 18-28) C Discontinued Effective 7/1/10 D Transfer from One Distinct Inpatient: The patient was admitted to this facility as a transfer from Unit of the Hospital to another hospital inpatient within this hospital resulting in a separate Distinct Unit of the Same claim to the payer. Hospital Resulting in a Outpatient: The patient received outpatient services in this facility as a Separate Claim to the Payer transfer from within this hospital resulting in a separate claim to the payer. Usage Note: For purposes of this code, Distinct Unit is defined as a unique unit or level of care at the hospital requiring the issuance of a separate claim to the payer. Examples could include observation services, psychiatric units, rehabilitation units, a unit in a critical access hospital, or a swing bed located in an acute hospital. E Transfer from Ambulatory Inpatient: The patient was admitted to this facility as a transfer from an Surgery Center ambulatory surgery center. Outpatient: The patient presented to this facility for outpatient or referenced diagnostic services from an ambulatory surgery center. F Transfer from a Hospice Inpatient: The patient was admitted to this facility as a transfer from a G-Z Facility hospice facility. Outpatient: The patient presented to this facility for outpatient or referenced diagnostic services from a hospice facility. Reserved for assignment by the NUBC Code Structure for Newborn 1-4 Reserved for assignment by the NUBC. (Discontinued Effective 10/1/07) 5 Born Inside this Hospital A baby born inside this Hospital. 6 Born Outside of this Hospital A baby born outside of this Hospital. 7-9 Reserved for assignment by the NUBC. BCNEPA/FPH/FPLIC Billing Manual Page 15

16 Form Locator 16 Data Element Discharge Hour Code indicating the discharge hour of the patient from inpatient care. Yes (Inpatient, SNF, Home Health and Hospice) If Applicable (Outpatient) UB-04: on inpatient claims ( IP ) with a Frequency Code of 1 or 4, except for Type of Bill 021x /004010A1, : on all final inpatient claims. Field 1 Field 1 Line 2 Positions Attributes Alphanumeric Left-justified (all positions fully coded, unless blank) Code Structure Code Time - A.M. Code Time - P.M :00-12:59 Midnight 12 12:00-12:59 Noon 01 01:00-01: :00-01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11:59 Form Locator 17 Data Element Patient Discharge Status A code indicating the disposition or discharge status of the patient at the end service for the period covered on this bill, as reported in FL6, Statement Covers Period. Yes (Inpatient, SNF, Home Health and Hospice) Not (Outpatient) for inpatient claims/encounters. Field 1 Field 1 Line 2 Positions Attributes Numeric Right-justified The patient s discharge status is required on all institutional claims. Identifying the appropriate code may often be confusing; judgment must be used in all cases. A basic rule of thumb is to code to the highest level of care that is known - -for example, an individual discharged to home with a home health plan of care is coded as 06, rather than 01. BCNEPA/FPH/FPLIC Billing Manual Page 16

17 Form Locator 17 Code Structure 01 Discharged to Home or Self Care (Routine Discharge) Usage Note: Includes discharge to home; home on oxygen if DME only; any other DME only; group home, foster care, independent living and other residential care arrangements; outpatient programs; such as partial hospitalization or outpatient chemical dependency programs. 02 Discharged/transferred to a Short-Term General Hospital for Inpatient Care 03 Discharged/transferred to Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care Usage Note: Medicare - Indicates that the patient is discharged/transferred to a Medicare certified nursing facility. For hospitals with an approved swing bed arrangement, use Code 61 - Swing Bed. For reporting other discharges/transfers to nursing facilities, see codes 04 and Discharged/transferred to a Facility that Provides Custodial or Supportive Care Usage Note: Includes intermediate care facilities (ICFs) if specifically designated at the state level. Also used to designate patients that are discharged/transferred to a nursing facility with neither Medicare or Medicaid certification and for discharges/transfers to Assisted Living Facilities. 05 Discharged/transferred to a Designated Cancer Center or Children s Hospital Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list of (National Cancer Institute) Designated Cancer Centers can be found at 06 Discharged/transferred to Home Under Care of an Organized Home Health Service Organization in Anticipation of Covered Skilled Care Usage Note: Report this code when the patient is discharged/transferred to home with a written plan of care (tailored to the patient s medical needs) for home care services. Not used for home health services provided by a DME supplier or from a Home IV provider for home IV services. 07 Left Against Medical Advice or Discontinued Care 08 Reserved for Assignment by the NUBC 09 Admitted as an Inpatient to this Hospital Usage Note: For use only on Medicare outpatient claims. Applies only to those Medicare outpatient services that begin greater than three days prior to an admission Reserved for Assignment by the NUBC 20 Expired 21 Discharged/transferred to Court/Law Enforcement Reserved for Assignment by the NUBC 30 Still patient Usage Note: Used when patient is still within the same facility; typically used when billing for leave of absence days or interim bills Reserved for Assignment by the NUBC 40 Expired at Home 41 Expired in a Medical Facility (e.g. hospital, SNF, ICF, or free standing hospice) 42 Expired - Place Unknown Usage Note: For use only on Medicare and TRICARE claims for hospice care. 43 Discharged/transferred to a Federal Health Care Facility Usage Note: Discharges and transfers to a government operated health facility such as a Department of Defense hospital, a Veteran s Administration hospital or a Veteran s Administration nursing facility. To be used whenever the destination at discharge is a federal health care facility, whether the patient lives there or not Reserved for Assignment by the NUBC 50 Hospice - Home 51 Hospice - Medical Facility (Certified) Providing Hospice Level of Care Reserved for Assignment by the NUBC BCNEPA/FPH/FPLIC Billing Manual Page 17

18 Form Locator 17 Code Structure 61 Discharged/transferred to Hospital-Based Medicare Approved Swing Bed Usage Note: Medicare - Used for reporting patients discharged/transferred to a SNF level of care within the hospital s approved swing bed arrangement. 62 Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital 63 Discharged/transferred to a Medicare Certified Long Term Care Hospital (LTCH) Usage Note: For hospitals that meet the Medicare criteria for LTCH certification. 64 Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare 65 Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital 66 Discharged/transferred to a Critical Access Hospital (CAH) Reserved for Assignment by the NUBC 70 Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List (See Code 05) Reserved for Assignment by the NUBC Form Locator Data Element Condition Codes A code(s) used to identify conditions or events relating to this bill that may affect processing. If Applicable UB-04, /004010A1, : when there is a Condition Code that applies to this claim. Field 11 Fields 1 Line 2 Positions Attributes Alphanumeric All positions fully coded No specific date is associated with this code. Condition Codes should be entered in alphanumeric sequence. Codes assigned as Payer Codes are for internal use only by the payer: they are assigned by the payer and are not required to be communicated to another payer for COB, unless these Payer Codes are communicated to the other payers as part of their contracted working relationship. If all of the Condition Code fields are filled, use FL 81 Code-Code field with the appropriate qualifier code (A1) to indicate that a Condition Code is being reported. Code Structure 01 Military Service Related 02 Condition is Employment Related 03 Patient Covered by Insurance Not Reflected Here 04 Information Only Bill 05 Lien Has Been Filed 06 ESRD Patient in First 30 Months of Entitlement Covered by Employer Group Health Insurance 07 Treatment of Non-terminal Condition for Hospice Patient 08 Beneficiary Would Not Provide Information Concerning Other Insurance Coverage BCNEPA/FPH/FPLIC Billing Manual Page 18

19 Form Locator Code Structure 09 Neither Patient nor Spouse is Employed 10 Patient and/or Spouse is Employed but no EGHP Exists 11 Disabled Beneficiary but No LGHP Payer Codes 17 Patient is Homeless 18 Maiden Name Retained 19 Child Retains Mother s Name 20 Beneficiary Requested Billing 21 Billing for Denial Notice 22 Patient on Multiple Drug Regimen 23 Home Care Giver Available 24 Home IV Patient Also Receiving-HHA Services 25 Patient is Non-U.S. Resident 26 VA Eligible Patient Chooses to Receive Services in a Medicare Certified Facility 27 Patient Referred to a Sole Community Hospital for a Diagnostic Laboratory Test 28 Patient and/or Spouse s EGHP is Secondary to Medicare 29 Disabled Beneficiary and/or Family Member s LGHP is Secondary to Medicare 30 Qualifying Clinical Trials 31 Patient is Student (Full Time - Day) 32 Patient is Student (Cooperative/Work Study Program) 33 Patient is Student (Full Time - Night) 34 Patient is Student (Part Time) 35 Reserved for assignment by the NUBC 36 General Care Patient in a Special Unit 37 Ward Accommodation at Patient Request 38 Semi-Private Room Not Available. Note: when billing to indicate member not liable for private room difference. 39 Private Room Medically Necessary. Note: when billing to indicate member not liable for private room difference. 40 Same Day Transfer 41 Partial Hospitalization 42 Continuing Care not Related to Inpatient Hospitalization 43 Continuing Care not Provided Within Prescribed Post-discharge Window 44 Inpatient Admission Changed to Outpatient 45 Ambiguous Gender Category 46 Non-availability Statement on File 47 Transfer from Another Home Health Agency (Effective 7/1/10) 48 Psychiatric Residential Treatment Centers for Children and Adolescents (RTCs) 49 Product Replacement within Product Lifecycle 50 Product Replacement for Known Recall of a Product 51 Attestation of Unrelated Outpatient Nondiagnostic Services (Effective 4/1/11) 52 Out of Hospice Service Area (Effective 7/1/12) Reserved for assignment by the NUBC 56 Medical Appropriateness 57 SNF Readmission 58 Terminated Medicare Advantage Enrollee 59 Non-primary ESRD Facility 60 Day Outlier 61 Cost Outlier Payer Code 66 Provider does not Wish Cost Outlier Payment 67 Beneficiary Elects not to use Life Time Reserve (LTR) Days 68 Beneficiary Elects to use Life Time Reserve (LTR) Days 69 IME/DGME/N&AH Payment Only 70 Self Administered Anemia Management Drug BCNEPA/FPH/FPLIC Billing Manual Page 19

20 Form Locator Code Structure 71 Full Care in Unit 72 Self Care in Unit 73 Self Care Training 74 Home 75 Home Percent Reimbursement 76 Back-up in Facility Dialysis 77 Provider Accepts or is Obligated/ due to a Contractual Arrangement or Law to Accept Payment by a Primary Payer as Payment in Full 78 New Coverage not Implemented by Managed Care Plan 79 CORF Services Provided Offsite 80 Home Dialysis - Nursing Facility Reserved for assignment by the NUBC A0 TRICARE External Partnership Program A1 EPSDT/CHAP (Early and Periodic Screening Diagnosis and Treatment) A2 Physically Handicapped Children s Program A3 Special Federal Funding A4 Family Planning A5 Disability A6 Vaccines/Medicare 100% Payment A7-A8 Reserved for assignment by the NUBC A9 Second Opinion Surgery AA(a) Abortion Performed due to Rape AB(a) Abortion Performed due to Incest AC(a) Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality AD(a) Abortion Performed due to a Life Endangering Physical Condition AE(a) Abortion Performed due to Physical Health of Mother that is not Life Endangering AF(a) Abortion Performed due to Emotional/psychological Health of the Mother AG(a) Abortion Performed due to Social or Economic Reasons AH(a) Elective Abortion AI Sterilization AJ Payer Responsible for Co-payment AK Air Ambulance AL Specialized Treatment/bed Unavailable - Alternate Facility Transport AM Non-emergency Medically Necessary Stretcher Transport AN Preadmission Screening Not AO-AZ Reserved for assignment by the NUBC B0 Medicare Coordinated Care Demonstration Claim B1 Beneficiary is Ineligible for Demonstration Program B2 Critical Access Hospital Ambulance Attestation B3 Pregnancy Indicator B4 Admission Unrelated to Discharge on Same Day B5-B0 Reserved for assignment by the NUBC BP Gulf Oil Spill of 2010 (Effective 4/20/10) BQ-C0 Reserved for assignment by the NUBC C1 Approved as Billed C2 Automatic Approval as Billed Based on Focused Review C3 Partial Approval C4 Admission/Services Denied C5 Post Payment Review Applicable C6 Admission Pre-authorization C7 Extended Authorization C8-CZ Reserved for assignment by the NUBC (a) Code is acceptable for use in Professional Health Care Claim Implementation Guide (ASC X12N/005010X222) BCNEPA/FPH/FPLIC Billing Manual Page 20

21 Code Structure Form Locator D0 Changes to Service Dates D1 Changes to Charges D2 Changes in Revenue Codes/HCPCS/HIPPS Rate Codes D3 Second or Subsequent Interim PPS Bill D4 Change in clinical codes (ICD) for Diagnosis and/or Procedure Codes D5 Cancel to Correct Insured s ID or Provider ID D6 Cancel Only to Repay a Duplicate or OIG Overpayment D7 Change to Make Medicare the Secondary Payer D8 Change to Make Medicare the Primary Payer D9 Any Other Change DA-DQ Reserved for assignment by the NUBC DR Disaster Related DS-DZ Reserved for assignment by the NUBC E0 Change in Patient Status E1-FZ Reserved for assignment by the NUBC G0 Distinct Medical Visit G1-GZ Reserved for assignment by the NUBC H0 Delayed Filing; Statement of Intent Submitted H1 Reserved for assignment by the NUBC H2 Discharge by a Hospice Provider for Cause (Effective 1/1/09) H3 Reoccurrence of GI Bleed Comorbid Category (Effective 1/1/11) H4 Reoccurrence of Pneumonia Comorbid Category (Effective 1/1/11) H5 Reoccurrence of Pericarditis Comorbid Category (Effective 1/1/11) H6-LZ Reserved for assignment by the NUBC M0-MZ Reserved for payer assignment N0-OZ Reserved for assignment by the NUBC P0 Reserved for Public Health Data P1 Do Not Resuscitate Order (DNR) P2-P6 Reserved Public Health Data P7 Direct Inpatient Admission from Emergency Room (Effective 7/1/10) P8-PZ Reserved Public Health Data Q0-UT Reserved for assignment by the NUBC UU Payer Code UV-VZ Reserved for assignment by the NUBC W0 United Mine Workers of America (UMWA) Demonstration Indicator W1 Reserved for assignment by the NUBC W2(a) Duplicate of Original Bill W3(a) Level I Appeal W4(a) Level II Appeal W5(a) Level III Appeal W6-ZZ Reserved for assignment by the NUBC (a) Code is acceptable for use in Professional Health Care Claim Implementation Guide (ASC X12N/005010X222) BCNEPA/FPH/FPLIC Billing Manual Page 21

22 Form Locator 29 Data Element Accident State The accident state filed contains the two-digit state abbreviation where the accident occurred. If Applicable UB-04, : when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in X12 code source 22 (ISO Codes for the representation of names of countries and their subdivisions) /004010A1: Not Used Field 1 Field 1 Line Attributes 2 Positions Alphanumeric Left-justified Form Locator 30 Data Element Reserved for Assignment by the NUBC. Not Used Field 1 Field 2 Lines 11 Positions (upper line) Attributes 13 Positions (lower line) Alphanumeric Left-justified Form Locator Data Element Occurrence Codes and Dates The code and associated date defining a significant event relating to this bill that may affect payer processing. If Applicable UB-04, /004010A1, : Situational. when there is an Occurrence Code that applies to this claim. Field 4 Fields 4 Fields Attributes 2 Lines 2 Lines 2 Positions 6 Positions Alphanumeric Numeric Left-justified (all positions fully coded) Right-justified Enter all dates as month, day, and year (MMDDYY) Occurrence Codes should be entered in alphanumeric sequence (numbered codes precede alpha codes). BCNEPA/FPH/FPLIC Billing Manual Page 22

23 Form Locator Code Structure 01 Accident/Medical Code indicating accident-related injury for which there is medical Coverage payment coverage. Provide the date of accident/injury. 02 No Fault Insurance Code indicating the date of an accident including auto or other Involved -Including where state has applicable no fault liability laws (i.e., legal basis Auto Accident/Other for settlement without admission of proof of guilt). 03 Accident/Tort Liability Code indicating the date of an accident resulting from a third party s action that may involve a civil court process in an attempt to require payment by the third party, other than no fault liability. 04 Accident/Employment Code indicating the date of an accident allegedly relating to the Related an accident allegedly relating to the patient s employment. 05 Accident/No Medical Code indicating accident related injury for which there is no medical or Liability Coverage payment or third-party liability coverage. Provide the date of accident/injury. 06 Crime Victim Code indicating the date on which the medical condition resulted from alleged criminal action committed by one or more parties Reserved for assignment by the NUBC. 09 Start of Infertility Code indicating the start date of infertility treatment cycle. Treatment Cycle 10 Last Menstrual Period Code indicating the date of the last menstrual period; ONLY applies when patient is being treated for maternity-related condition. 11 Onset of Symptoms/ Code indicating the date the patient first became aware of the Illness symptoms/illness. 12 Date of Onset for a (HHA Claims Only) Code denotes date the patient/beneficiary becomes a Chronically Dependent Chronically Dependent Individual (CDI). This is the first month of the 3 Individual month period immediately before eligibility under respite care benefit Reserved for assignment by the NUBC 16 Date of Last Therapy Code denotes last day of therapy services (e.g. physical therapy, occupational therapy, speech therapy). 17 Date Outpatient Code denotes date an occupational therapy plan was established Occupational Therapy or last reviewed. Plan Established or Last Reviewed 18 Date of Retirement - The date of retirement for the patient/beneficiary. Patient/Beneficiary 19 Date of Retirement - The date of retirement for the patient s spouse. Spouse 20 Date Guarantee of Code indicates date on which the provider began claiming Medicare Payment Began payment under the guarantee of payment provision. 21 Date UR Notice Code indicating the date of receipt by the provider of the UR Committee s Received finding that the admission or future stay was not medically necessary. 22 Date Active Care Code indicates the date covered level of care ended in a SNF or Ended general hospital, or date on which active care ended in a psychiatric or tuberculosis hospital, or date on which patient was released on a trial basis from a residential facility. Code not required when Condition Code 21 is used. 23 Payer Code 24 Date Insurance Denied Code indicating the date the denial of coverage was received by the health care facility from any insurer. 25 Date Benefits Code indicating the date on which coverage (including Worker s Terminated by Primary Compensation benefits of no-fault coverage) is no longer available to the Payer patient. 26 Date SNF Bed Became Code indicating the date on which a SNF bed became available to Available(Inpatient) hospital inpatient who requires only SNF level of care. 27 Date of Hospice Code indicating the date of certification or re-certification of the Certification or hospice benefit periods. Re-Certification BCNEPA/FPH/FPLIC Billing Manual Page 23

24 Form Locator Code Structure 28 Date Comprehensive Code indicating the date a comprehensive outpatient rehabilitation Outpatient plan was established or last reviewed. Rehabilitation Plan Established or Last Reviewed 29 Date Outpatient Code indicating the date a physical therapy plan was established Physical Therapy Plan or last reviewed. Established or Last Reviewed 30 Date Outpatient Speech Code indicating the date a speech pathology plan was established Pathology Plan or last reviewed. Established or Last Reviewed 31 Date Beneficiary The date of notice provided by the hospital to the patient that inpatient Notified of Intent to care is not longer required. Bill (Accommodations) 32 Date Beneficiary The date of notice provided to the beneficiary that requested care Notified of Intent to (diagnostic procedures or treatments) may not be reasonable or Bill (Procedures or necessary. Treatments) 33 First Day of the Code indicates the first day of coordination for benefits that are Coordination Period are secondary to benefits payable under an employer s group health for ESRD Beneficiaries plan. only for ESRD beneficiaries. Covered by EGHP 34 Date of Election of Code indicates the date the guest elected to receive extended Extended Care care services (used by Religious Non-Medical only). Facilities 35 Date Treatment Started Code indicates the initial date services by the billing provider for for Physical Therapy physical therapy. 36 Date of Inpatient Code indicates the date of discharge for inpatient hospital stay in which Hospital Discharge for the patient received a covered transplant procedure when the hospital Covered Transplant is billing for immunosuppressive drugs. Patients Note: When the patient received both a covered and a non-covered transplant, the covered transplant predominates. 37 Date of Inpatient Code indicates the date of discharge for the inpatient hospital stay Hospital Discharge for in which the patient received a non-covered transplant procedure Non-Covered when the hospital is billing for immunosuppressive drugs. Transplant Patient 38 Date Treatment Started Date the patient was first treated at home for IV therapy (Home IV for Home IV Therapy providers - Bill Type 085x). 39 Date Discharged on a Date the patient was discharged from the hospital on a continuous Continuous Course of course of IV therapy. (Home IV providers - Bill Type 085x). IV Therapy 40 Schedule Date of The scheduled date the patient will be admitted as an inpatient to the Admission hospital. (This code may only be used on an outpatient claim). 41 Date of First Test for The date on which the first outpatient diagnostic test was performed as Pre-Admission Testing part of a PAT program. This code may only be used if a date of admission was scheduled before the administration of the test(s). 42 Date of Discharge Use only when the Through date in Locator 06 (Statement Covers Period) is not the actual discharge date and the frequency code in Locator 04 is that of a final bill. For final bill for hospice care, enter the date the Medicare beneficiary terminated his election of hospice care. BCNEPA/FPH/FPLIC Billing Manual Page 24

25 Code Structure Form Locator Scheduled Date of The date for which outpatient surgery was scheduled. Canceled Surgery 44 Date Treatment Started The date services were initiated by the billing provider for occupational Occupational Therapy therapy. 45 Date Treatment Started The date services were initiated by the billing provider for speech therapy. for Speech Therapy 46 Date Treatment Started The date services were initiated by the billing provider for cardiac for Cardiac rehabilitation. Rehabilitation 47 Date Cost Outlier Code indicates that this is the first day after the day the Cost Outlier Status Begins threshold is reached Payer Codes 50 Assessment Date Code indicating an assessment date as defined by the assessment instrument applicable tot this provider type (e.g., Minimum Data Sets (MDS) for skilled nursing). (Effective 1/1/11) 51 Date of Last Kt/V For in-center hemodialysis patients, this is the date of the last reading taken Reading during the billing period. For peritoneal dialysis patients (and home hemodiaysis patients, this date may be before the current billing period but should be within 4 months of the date of service. (Effective 07/01/10) 52 Medical Certification/ The date of the most recent non-hospice medical certification or Recertification Date recertification of the patient. Use Occurrence Code 27 for Date of Hospice (Effective 1/1/11) Certification of Recertification. 53 Reserved for assignment by the NUBC 54 Physician Follow-up Last date of a physician follow-up with the patient. Date (Effective 1/1/11) 55 Date of Death Report his code when patient discharge status codes 20 (expired), 40 (Effective 10/1/12) (expired at home), 41 (expired in a medical facility, or 42 (expired place unknown) are used Reserved for assignment by the NUBC See instructions in Form Locators Occurrence Span Codes and Dates A0 Reserved for assignment by the NUBC A1 Birth Date - Insured A The birth date of the individual in whose name the insurance is carried. A2 Effective Date - Insured A code indicating the first date insurance is in force. A Policy A3 Benefits Exhausted - Code indicating the last date for which benefits are available and Payer A after which no payment can be made to Payer A. A4 Split Bill Date Date patient became eligible due to medically needy spend down (sometimes referred as Split Bill Date ). A5-AZ Reserved for assignment by the NUBC B0 Reserved for assignment by the NUBC B1 Birth Date - Insured B The birth date of the individual in whose name the insurance is carried. B2 Effective Date - Insured A code indicating the first date insurance is in force. B Policy B3 Benefits Exhausted - Code indicating the last date for which benefits are available and after Payer B which no payment can be made by Payer B. B4-BZ Reserved for assignment by the NUBC C0 Reserved for assignment by the NUBC C1 Birth Date - Insured C The birth date of the individual in whose name the insurance is carried. C2 Effective Date - Insured A code indicating the first date insurance is in force. C Policy C3 Benefit Exhausted - Code indicating the last date for which benefits are available and after Payer C which no payment can be made by Payer C. C4-DQ Reserved for assignment by the NUBC DR Reserved for Disaster Related Occurrence Code DS-DZ Reserved for assignment by the NUBC E0 Reserved for assignment by the NUBC E1-E3 Discontinued 3/1/07 E4-EZ Reserved for assignment by the NUBC F0 Reserved for assignment by the NUBC BCNEPA/FPH/FPLIC Billing Manual Page 25

26 F1 Discontinued 3/1/07 Code Structure Form Locator F2 Discontinued 3/1/07 F3 Discontinued 3/1/07 F4-FZ Reserved for assignment by the NUBC G0 Reserved for assignment by the NUBC G1-G3 Discontinued 3/1/07 G4-LZ Reserved for assignment by the NUBC M0-ZZ See instructions in Form Locators Occurrence Span Codes and Dates Form Locator Data Element Occurrence Span Codes and Dates A code and the related dates that identify an event that relates to the payment of the claim. UB-04, /004010A1, : Situational. when there is an Occurrence Span Code that applies to this claim. Field 2 Fields (codes) 4 Fields (dates) Attributes 2 Lines 2 Lines 2 Positions 6 Positions Alphanumeric Numeric Left-justified (all positions fully coded) Right-justified These codes identify occurrences that happened over a span of time. Enter all dates as month, day, and year (MMDDYY). Enter Occurrence Span Codes in alphanumeric sequence starting with code 70 and ending with ZZ (numbered codes precede alpha codes). If FL 35a&b and FL 36a&b have been filled and additional occurrence span codes are required, use FL 81 with the appropriate qualifier code (A3) to indicate that an Occurrence Span Code is being reported. Code Structure 70 Qualifying Stay Dates The from/through date of at least a 3 day inpatient hospital stay that For SNF Use Only qualifies the resident for Medicare payment of SNF services billed. Code can be used only by SNF for billing. 71 Prior Stay Dates The from/through dates given by the patient of any hospital stay that ended within 60 days of this hospital or SNF admission. 72 First/Last Visit Dates The from/through dates of outpatient services. For use on outpatient bills (Outpatient only) only where the entire billing record is not represented by the actual from/through service dates of Locator 06 (Statement Covers Period). 73 Benefit Eligibility The inclusive dates during which TRICARE medical benefits are available Period to a sponsor s beneficiary as shown on the beneficiary s identification card. 74 Non-Covered Level of The from/through dates of a period at a non-covered level of care Care/Leave of Absence or leave of absence in an otherwise covered stay, excluding any Dates period reported by Occurrence Span Code 76, 77, or 79 below. 75 SNF Level of Care The from/through dates of a period of SNF level of care during BCNEPA/FPH/FPLIC Billing Manual Page 26

27 Dates an inpatient hospital stay. (Inpatient only) Form Locator Code Structure 76 Patient Liability The from/through dates of a period of non-covered care for which the hospital is permitted to charge the Medicare beneficiary. Code should be used only where the QIO or intermediary has approved such charges in advance and patient has been notified in writing at least three days prior to the from date of this period. 77 Provider Liability The from/through dates of a period of non-covered care for which Period the provider is liable; utilization is charged. 78 SNF Prior Stay Dates The from/through dates given by the patient of any SNF or nursing home stay that ended within 60 days of this hospital or SNF admission. 79 Payer Code 80 Prior Same-SNF The from/through dates of a prior same-snf stay indicating a patient Stay Dates for resided in the SNF prior to, and if applicable, during a payment ban period Payment Ban up until their discharge to a hospital. (Effective 1/1/09) Purposes 81 Antepartum Days at This code and corresponding dates indicate the from and through dates of Reduced Level of Care an antepartum hospital stay where the level of care is non-acute. (Effective 7/1/12) Reserve for assignment by the NUBC M0 QIO/UR Approved The first and last days that were approved where not all of the stay Stay Dates was approved. (Use when Condition Code C3 is used in Locators 18-28). M1 Provider Liability - No Code indicates the from/through dates of a period of non-covered care Utilization that is denied due to lack of medical necessity or as custodial care for which the provider is liable. The beneficiary is not charged with utilization. The provider may not collect Part A or Part B deductible or coinsurance from the beneficiary. M2 Inpatient Respite Dates The from/through dates of a period of inpatient respite care. M3 ICF Level of Care The from/through dates of a period of intermediate level of care during an inpatient hospital stay. M4 Residential Level of The from/through dates of a period of residential level of care during an Care inpatient hospital stay. M5-MQ Reserved for assignment by the NUBC MR Reserved for Disaster Related Occurrence Span Code MS-ZZ Reserved for assignment by the NUBC Form Locator 37 Data Element Reserved for Assignment by the NUBC Not Used Field 1 Field Attributes 2 Lines 8 Positions Alphanumeric Left-justified Form Locator 38 Data Element Responsible Party Name and Address (Claim Addressee) The name and address of the party to whom the bill is being submitted. BCNEPA/FPH/FPLIC Billing Manual Page 27

28 Form Locator 38 UB-04: Use to print the name and mailing address of the party deemed responsible for the bill (health plan, patient, etc.) if a window envelope is utilized /004010A1: Situational : Not Used Field 1 Field 5 Lines 40 Positions Attributes Alphanumeric Left-justified Address may include post office box or street name and number, city, state and ZIP code. Hospitals should abbreviate state in the address according to the post office stand abbreviations appearing in the instructions for Locator 01. If a nine-digit ZIP code is used, it should be entered XXXXX-XXXX. Form Locator Data Element Value Codes and Amounts A code structure to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization. If Applicable UB-04, /004010A1, : Situational. when there is a Value Code that applies to this claim. Field 3 Fields (codes) 3 Fields (amounts) Attributes 4 Lines 4 Lines 2 Positions 9 Positions Alphanumeric Numeric Left-justified (all positions fully coded) Right-justified (see ) Whole numbers or non-dollar amounts are right-justified to the left of the dollars/cents delimiter. Enter value codes in alphanumeric sequence. Fields 39a through 41a must be completed before the b fields, etc. If all of the Value Code fields are filled, use FL 81 Code-Code field with the appropriate qualifier code (A4) to indicate that a Value Code is being reported. Code Structure 01 Most Common To provide for the recording of hospital s most common semi-private Semi-Private Rate rate. Note: when billing private room revenue codes. 02 Hospital has No Semi- Entering this code requires $0.00 amount. Private Rooms 03 Reserved for assignment by the NUBC 04 Professional Code indicates the amount shown is the sum of technical and professional Component Charges charges, which are combined, billed. Medicare uses this information in which are Combined internal processes and also in the CMS notice of utilization sent to the Billed patient to explain that Part B co-insurance applies to the professional component. (Used only by some all inclusive rate hospitals.) 05 Professional Amount shown is the combined billed charges (technical and professional); Component Included in however the provider is submitting a separate professional bill to the health Charges and also Billed plan. For use on Medicare or TRICARE bills and all Medicaid bills if state BCNEPA/FPH/FPLIC Billing Manual Page 28

29 Separate to Carrier specifies need for this information. Code Structure Form Locator Blood Deductible Total cash blood deductible. If appropriate, enter Medicare Part A or Part B blood deductible amount. (To report other than the blood deductible, that is to report the program deductible, see Value Codes (FL 39-41) A1, B1 and C1. 07 Reserved for assignment by the NUBC 08 Life Time Reserve Lifetime reserve amount charged in the year of admission. Amount in the First Note: For Medicare, use this code only for Part A bills. For Part B Calendar Year Coinsurance use Value Codes (FL 39-41) A2, B2 and C2. 09 Coinsurance Amount Coinsurance amounts charged in the year of admission. in the First Calendar Year 10 Lifetime Reserve Lifetime reserve amount charged in the year of discharge where the bill Amount in the Second spans two calendar years. Calendar Year 11 Coinsurance Amount Coinsurance amount charged in the year of discharge where the inpatient in the Second Calendar bill spans two calendar years. Year 12 Working Aged Amount shown reflects that portion of a payment from a higher priority Beneficiary/Spouse employer group health insurance made on behalf of an aged beneficiary. With Employer Group For Medicare purposes the provider is billing Medicare as the secondary Health Plan payer (based on MSP development) for covered services on this bill. 13 ESRD Beneficiary in a Amount shown is that portion of a payment from a higher priority employer Medicare Coordination group health insurance payment made on behalf of an ESRD beneficiary Period with an that the provider is applying to Medicare covered services on this bill. Employer Group Health Plan 14 No-Fault, Including Amount shown is that portion from a higher priority no-fault insurance, Auto/Other including auto/other made on behalf of the patient or insured. 15 Worker s Amount shown is that portion of payment from a higher priority worker s Compensation compensation insurance made on behalf of the patient or insured. For Medicare beneficiaries the provider should apply this amount to Medicare covered services on this bill. 16 PHS, or Other Federal Amount shown is that portion of a payment from a higher priority Public Agency Health Service or the Federal Agency made on behalf of a Medicare beneficiary that the provider is applying to Medicare covered services on this bill Payer Code 21 Catastrophic Medicaid-eligibility requirements to be determined at state level. 22 Surplus Medicaid-eligibility requirements to be determined at state level. 23 Recurring Monthly Medicaid-eligibility requirements to be determined at state level. Income 24 Medicaid Rate Code Medicaid-eligibility requirements to be determined at state level. 25 Offset to the Patient- Prescription drugs paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Prescription Drugs Covers Period). 26 Offset to the Patient- Hearing and ear services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Hearing and Ear Covers Period). Services 27 Offset to the Patient- Vision and eye services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Vision and Eye Covers Period). Services 28 Offset to the Patient- Dental services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Dental Services Covers Period). BCNEPA/FPH/FPLIC Billing Manual Page 29

30 Form Locator Code Structure 29 Offset to the Patient- Chiropractic services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Chiropractic Services Covers Period). 30 Preadmission Testing This code reflects charges for preadmission outpatient diagnostic services in preparation for a previously scheduled admission. 31 Patient Liability Approved amount to charge the beneficiary for non-covered Amount accommodations, diagnostic procedures or treatments. 32 Multiple Patient When more than one patient is transported in a single ambulance Ambulance Transport trip, report the total number of patients transported. 33 Offset to the Patient- Podiatric services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Podiatric Services Covers Period). 34 Offset to the Patient- Other medical services paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Other Medical Services Covers Period). 35 Offset to the Patient- Health insurance premiums paid for out of a long-term care facility Payment Amount - resident/patient s funds in the billing period submitted (Statement Health Insurance Covers Period). Premiums 36 Reserved for assignment by the NUBC 37 Units of Blood The total number of units of whole blood or packed red cells Furnished furnished to the patient, regardless of whether the hospital charges for blood or not. 38 Blood Deductible Units The number of unreplaced deductible units of packed red cells furnished for which the patient is responsible. If all deductible units furnished have been replaced, no entry is made. 39 Units of Blood The total number of units of whole blood or packed red cells Replaced furnished to the patient that have been replaced by or on behalf of the patient. 40 New Coverage not Amount shown is for inpatient charges covered by the HMO. (Use this code Implemented by HMO (for inpatient service) when the bill includes inpatient charges for newly covered services that are not paid by the HMO.) Note: Condition Codes 04 and 78 should also be reported. 41 Black Lung Code indicates the amount shown is that portion of a higher priority Black Lung (federal program) payment made on behalf of a Medicare beneficiary. 42 VA (Veteran s Code indicates the amount shown is that portion of a higher priority Administration) VA payment made on behalf of a Medicare beneficiary and that you are applying to Medicare as secondary payer for covered Medicare services on this claim. 43 Disabled Beneficiary Code indicates the amount shown is that portion of a higher priority Under Age 65 with LGHP payment made on behalf of a disabled beneficiary that you are LGHP applying to covered Medicare charges on this bill. 44 Amount Provider Report the amount the provider was obligated to accept from a primary Agreed to Accept from payer when the amount is less than charges but higher than or equal to the Primary Payer when payment received. Secondary payment may be due. this Amount is less than Note: The following value codes report the actual amounts paid: 12-16, Charges but Higher 41-43, and 47. Value Code 44 should always be equal to, or, greater than than Payment the amounts indicated in the value codes indicated immediately above. Received BCNEPA/FPH/FPLIC Billing Manual Page 30

31 Form Locator Code Structure 45 Accident Hour The hour when the accident occurred that necessitated medical treatment. Enter the appropriate code indicated below right justified to the left of the dollar/cents delimiter :00-12:59 (midnight) 13 01:00-01: :00-01: :00-02: :00-02: :00-03: :00-03: :00-04: :00-04: :00-05: :00-05: :00-06: :00-06: :00-07: :00-07: :00-08: :00-08: :00-09: :00-09: :00-10: :00-10: :00-11: :00-11: :00-12:59 (Noon) 46 Number of Grace Days Following the QIO determination. This is the number of days determined by the QIO (medical necessity reviewer) as necessary to arrange for the patient s post-discharge care. 47 Any Liability Insurance Amount shown is that portion from a higher priority liability insurance made on behalf of a Medicare beneficiary that the provider is applying to Medicare or Blue Cross covered services on this bill. Note: The decimal is implied and refers to the dollar and cents delimiter. 48 Hemoglobin Reading The most recent hemoglobin reading taken before the start of this billing period. For patients just starting, use the most recent value prior to the onset if treatment. Whole numbers, i.e., two digits are to be right justified to the left of the dollar/cents delimiter; decimals, i.e., one digit, is to be reported to the right. 49 Hematocrit Reading The most recent hematocrit reading taken before the start of this billing period. For patients just starting, use the most recent value prior to the onset if treatment. Whole numbers, i.e., two digits are to be right justified to the left of the dollar/cents delimiter; decimals, i.e., one digit, is to be reported to the right. 50 Physical Therapy Visit Report the number of physical therapy visits provided from the onset of treatment from this billing provider through this billing period. Report the number in the dollar portion of the form locator right justified to the left of the dollar/cents delimiter. 51 Occupational Therapy Report the number of occupational therapy visits provided from the onset of Visits treatment from this billing period. Report the number in the dollar portion of the locator right justified to the left of the dollar/cents delimiter. 52 Speech Therapy Visits Report the number of speech therapy visits provided from the onset of treatment by this billing provider through this period. Report the number in the dollar portion of the locator right justified to the left of the dollar/cents delimiter. 53 Cardiac Rehabilitation The number of cardiac rehabilitation visits from the onset of treatment Visits from the billing provider through this billing period. Report the number in the dollar portion of the locator right justified to the left of the dollar/cents delimiter. 54 Newborn Birth Weight Actual birth weight or weight at time of admission for an extramural birth. in Grams on all claims with Type of Admission of 4 and on other claims as required by state law. 55 Eligibility Threshold The amount at which a health care facility determines the eligibility BCNEPA/FPH/FPLIC Billing Manual Page 31

32 for Charity Care threshold for charity care. Form Locator Code Structure 56 Skilled Nurse-Home The number of home visit hours of skilled nursing provided during the billing Visit Hours period. Count only hours spent in the home. Exclude travel time. (HHA only) Report in whole hours, right justified to the left of the dollar/cents delimiter. (Round to the nearest whole hour). 57 Home Health Aide- The number of hours of home health aide services provided during the billing Home Visit Hours period. Count only the hours spent in the home. Exclude travel time. (HHA only) Report in whole hours, right justified to the left of the dollar/cents delimiter. (Round to the nearest whole hour). 58 Arterial Blood Gas Arterial blood gas value at beginning of each reporting period for oxygen (PO2/PA2) therapy. This value or the value in Value Code 59 will be required on the initial bill for oxygen therapy and on the fourth month s bill. Report right justified in the cents area rounded to the nearest whole number (report 2 digits). Example: A value of 56.5 should be reported as , i.e., with the 57 reported in the cents area. 59 Oxygen Saturation Oxygen saturation at the beginning of each reporting period for oxygen (O2 SAT/Oximetry) therapy. This value or the value in Value Code 58 will be required on the initial bill for oxygen therapy and on the fourth month s bills. Report right justified in the cent area. Round to the nearest whole percent (report 2 digits). Example: 93.5 percent should be reported as , i.e., with 94 being reported in the cents area. A value of 100 percent would be reported as HHA Branch MSA MSA in which HHA branch is located. Report MSA when branch location is different than the HHA s. Report the MSA number in dollar portion of the form locator right justified to the left of the dollar/cents delimiter. 61 Place of Residence MSA or Core Based Statistical Area (CBSA) number (or rural state code) Where Service is of the place of residence where the home health or hospice service is Furnished delivered. Report the number in dollar portion of the form locator right justified (HHA and Hospice) to the left of the dollar/cents delimiter Payer Codes 66 Medicaid Spend Down The dollar amount that was used to meet the recipient s spend down Amount liability for this claim. 67 Peritoneal Dialysis The number of hours of peritoneal dialysis provided during the billing period. Count only the hours spent in the home. Exclude travel time. Report in whole hours, right justify to the left of the dollar/cent delimiter. (Round to the nearest whole hour.) 68 EPO-Drug Number of units of EPO administered and/or supplied relating to the billing period. Report amount in whole units right justified to the left of the dollar/cents delimiter. 69 State Charity Care Code indicates the percentage of charity care eligibility for the patient. Percent Report the whole number right justified to the left of the dollar/cents delimiter and fractional amounts to the right. For example, a rate of 10.5% is shown as: Payer Codes 80(a) Covered Days The number of days covered by the primary payer as qualified by the payer. 81(a) Non-Covered Days Days of care not covered by the primary payer. 82(a) Co-insurance Days The inpatient Medicare days occurring after the 60 th day and before the 91 st day or inpatient SNF/Swing Bed days occurring after the 20 th and before the 101 st day in a single spell of illness. 83(a) Lifetime Reserve Days Under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services after using 90 days of inpatient hospital services during a spell of illness. BCNEPA/FPH/FPLIC Billing Manual Page 32

33 84-99 Reserved for assignment by the NUBC. (a) Do not use on v /004010A1 837 electronic claims (use Claim Quantity in Loop ID 2300 / QTY01 instead). Form Locator Code Structure A0 Special ZIP Code Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulance. A1(b) Deductible Payer A The amount assumed by the provider to be applied to the patient s policy/program deductible amount involving the indicated payer. Note: Report Medicare blood deductibles under Value Code 06. for Blue Cross claims when billing for balance after Medicare. A2(b) Coinsurance Payer A The amount assumed by the provider to be applied toward the patient s coinsurance amount involving the indicated payer. Note: For Medicare, use this code only for reporting Part B coinsurance amounts. For Part A coinsurance amounts use Value Codes for Blue Cross claims when billing for balance after Medicare. A3 Estimated The amount estimated by the provider to be paid by the indicated payer; Responsibility Payer A it is not the actual payment. A4 Covered Self- The covered charge amount for self-administrable drugs administered to the Administrable Drugs - patient in an emergency situation (e.g., diabetic coma). For use with Emergency Revenue Code A5 Covered Self- The amount included in covered charges for self-administrable drugs administrable Drugs - administered to the patient because the drug was not self-administrable in the not Self-administrable form and situation in which it was furnished to the patient. in the form and For use with Revenue Code Situation Furnished to Patient A6 Covered Self- The amount assumed by the provider to be applied toward the patient s Administrable Drugs - co-payment amount involving the indicated payer. Diagnostic Study and Other A7(b) Co-payment Payer A The amount assumed by the provider to be applied toward the patient s co-payment amount involving the indicated payer. A8 Patient Weight Weight of patient in kilograms. Report this data only when the health plan has a predefined change in reimbursement that is affected by weight. For newborns, use Value Code 54. A9 Patient Height Height of patient in centimeters. Report this data only when the health plan has a predefined change in reimbursement that is affected by height. AA Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances or Assessments, health care related taxes pertaining to the indicated payer. Allowances or Health Care Related Taxes Payer A AB Other Assessments or The amount of other assessments or allowances (e.g., medical Allowances (e.g., education) pertaining to the indicated payer. Medical Education) Payer A AC-AZ Reserved for assignment by the NUBC B0 Reserved for assignment by the NUBC B1(b) Deductible Payer B The amount assumed by the provider to be applied to the patient s policy/program deductible amount involving the indicated payer. Note: Medicare blood deductibles should be reported under Value Code 06. B2(b) Coinsurance Payer B The amount assumed by the provider to be applied toward the patient s coinsurance amount involving the indicated payer. For Part A coinsurance amounts use Value Codes B3 Estimated The amount estimated by the provider to be paid by the indicated payer; Responsibility Payer B it is not the actual payment. B4-B6 Reserved for assignment by the NUBC BCNEPA/FPH/FPLIC Billing Manual Page 33

34 (b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320 CAS segment (Claim Adjustment Group Code PR ). Code Structure Form Locator B7(b) Co-payment Payer B The amount assumed by the provider to be applied toward the patient s co-payment amount involving the indicated payer. B8-B9 Reserved for assignment by the NUBC BA Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances or health Assessments, care related taxes pertaining to the indicated payer. Allowances or Health Care Related Taxes Payer B BB Other Assessments or The amount of other assessments or allowances (e.g., medical Allowances (e.g., education) pertaining to the indicated payer. Medical Education) Payer B BC-C0 Reserved for assignment by the NUBC C1(b) Deductible Payer C The amount assumed by the provider to be applied to the patient s policy/program deductible amount involving the indicated payer. Note: Medicare Blood deductibles should be reported under Value Code 06. C2(b) Coinsurance Payer C The amount assumed by the provider to be applied toward the patient s coinsurance amount involving the indicated payer. For Part A coinsurance amounts use Value Codes C3 Estimated The amount estimated by the provider to be paid by the indicated payer; Responsibility Payer C it is not the actual payment. C4-C6 Reserved for assignment by the NUBC C7(b) Co-payment Payer C The amount assumed by the provider to be applied toward the patient s co-payment amount involving the indicated payer. C8-C9 Reserved for assignment by the NUBC CA Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances Assessments, or health care related taxes pertaining to the indicated payer. Allowances or Health Care Related Taxes Payer C CB Other Assessments or The amount of other assessments or allowances (e.g., medical Allowances (e.g., education) pertaining to the indicated payer. Medical Education) Payer C CC-D2 Reserved for assignment by the NUBC. D3 Patient Estimated The amount estimated by the provider to be paid by the Responsibility indicated patient. D4 Clinical Trial Number 8-digit, numeric National Library of Medicine/National Institutes of Health Assigned by NLM/NIH assigned clinical trail number. D5 Last Kt/V Reading Result of the last Kt/V reading. For in-center hemodialysis patients, this is the last reading taken during the billing period. For peritoneal dialysis patients (and home hemodialysis patients), this may be before the current billing period but should be within 4 months of the date of service. Note: Only report on FL 04 Type of Bill 072x. (Effective 07/01/10) D6-DQ Reserved for assignment by the NUBC DR Reserved for Disaster Related Value Code DS-DZ Reserved for assignment by the NUBC E0 Reserved for assignment by the NUBC E1 Discontinued 3/1/07 E2 Discontinued 3/1/07 E3 Discontinued 3/1/07 E4-E6 Reserved for assignment by the NUBC E7 Discontinued 3/1/07 E8-E9 Reserved for assignment by the NUBC BCNEPA/FPH/FPLIC Billing Manual Page 34

35 EA Discontinued 3/1/07 EB Discontinued 3/1/07 EC-EZ Reserved for assignment by the NUBC (b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320 CAS segment (Claim Adjustment Group Code PR ). Form Locator Code Structure F0-F3 Discontinued 3/1/07 F4-F6 Reserved for assignment by the NUBC F7 Discontinued 3/1/07 F8-F9 Reserved for assignment by the NUBC FA-FB Discontinued 3/1/07 FC Patient Paid Amount The amount the provider has received from the patient toward payment of this bill. (Effective 7/1/08) FD Credit Received from The amount the provider has received from a medical device manufacturer the Manufacturer for a as credit fro a replaced device. (Effective 7/1/08) Replaced Medical Device FE-G0 Reserved for assignment by the NUBC G1-G3 Discontinued 3/1/07 G4-G6 Reserved for assignment by the NUBC G7 Discontinued 3/1/07 G8 Facility where Inpatient MSA or Core Based Statistical Area (CBSA) number (or rural state code) of Hospice Service is the facility where inpatient hospice service is delivered. Report the number in Delivered dollar portion of the form locator right justified to the left of the dollar/cents delimiter. G9 Reserved for assignment by the NUBC GA Discontinued 3/1/07 GB Discontinued 3/1/07 GC-OZ Reserved for assignment by the NUBC P0-PZ Reserved for PUBLIC HEALTH DATA REPORTING Q0-Y0 Reserved for assignment by the NUBC Y1 Part A Demonstration This is the portion of the payment designated as reimbursement for Payment Part A services under the demonstration. This amount is instead of the traditional prospective DRG payment (operating and capital) as well as any outlier payments that might have been applicable in the absence of the demonstration. No deductible or coinsurance has been applied. Payments for operating IME and DSH which are processed in the traditional manner are also not included in this amount. Y2 Part B Demonstration This is the portion of payment designed as reimbursement for Part B Payment services under the demonstration. No deductible or coinsurance has been applied. Y3 Part B Coinsurance This is the amount of Part B coinsurance applied by the intermediary to this claim. For demonstration claims this will be a fixed copayment unique to each hospital and DRG (or DRG/procedure group). Y4 Conventional Provider This is the amount Medicare would have reimbursed the provider for Payment Amount for Part A services if there had been no demonstration. This should include Y5-ZZ Non-Demonstration Claims the prospective DRG payment (both capital as well as operational) as well as any outlier payment, which would be applicable. It does not include any pass through amounts such as that for direct medical education nor interim payments for operating IME and DSH. Reserved for assignment by the NUBC BCNEPA/FPH/FPLIC Billing Manual Page 35

36 Form Locator 42 Data Element Revenue Code Codes that identify specific accommodation, ancillary service or unique billing calculations or arrangements. Yes UB-04, /004010A1, : Field 1 Field 23 Lines (a) 4 Positions Attributes Alphanumeric Left-justified (all positions filled) (a) The 23 rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code (b) On a multiple page UB-04, all of the (claim level) information is repeated on each page: only the line items in the revenue code section will vary. Revenue Code categories are four digits with an x in the fourth position to denote the subcategory number. The subcategory number provides a more detailed list generally ranging from 0 through 9. When reporting the revenue code on the claim, the fourth position must include one of the numeric choices available in that category. The reporting of an x is not appropriate. The 0 in many cases denotes the General category and can be used in lieu of other more specific subcategories ( 1 through 9 ) if the health plan has no need for a more specific revenue code subcategory. Health plans receiving such detail, without a need for that detail, should accept the subcategory and treat it as though it was reported at the General level. Nonetheless, it is recommended that providers use the more detailed subcategory when applicable/available rather than revenue codes that end in 0 (General) or 9 (Other); to do otherwise may cause processing delays for the claim. Each service should be assigned a revenue code. For inpatient services involving multiple services for the same item providers should aggregate the services under the assigned revenue code and then report the total number of units that represent those services. For outpatient services providers should report the corresponding HCPCS code for the service along with the date of service as well as the revenue code. If multiple services are provided on the same day for like services, that is, those with the same HCPCS, the provider should aggregate the like services for each day and report the date along with a number of units provided, as well as the revenue code. The exception is for Evaluation and management (E/M) HCPCS. For E/M HCPCS, report each of these separately but also use Condition Code G0 to indicate a Distinct Medical Visit. Services provided on different days should be listed separately along with the date of service, units and revenue code. Revenue codes should be listed in ascending numeric order, by date of service BCNEPA/FPH/FPLIC Billing Manual Page 36

37 (outpatient). The exception is Revenue Code Total Charge, which is used on paper claims only and is reported on Line 23 of the last page of the claim. Form Locator 42 The Standard Abbreviation is intended for use in the provider s Charge Description Master and is not reported on electronic claims TOTAL CHARGE The HCPCS usage notations in the revenue code section (FL42) are provided for general guidance only; they do not represent hard and fast rules. Actual application may vary depending on certain circumstances. Revenue Code Changes from UB-92 In the process of developing the UB-04, the 9 - Other revenue subcategory codes were reviewed for necessity, clarity and redundancy. As a result several 9 codes were re-designated as reserved for assignment by the NUBC because the 0 - General Classification codes are sufficient. Specific revenue codes removed from UB-92 include 0599, 0709, 0719, 0749, 0759, 0779, 0789 and For clarity, RC 0392 was added to UB-04 to distinguish Processing and Storage from Other (RC 0399). In addition, any unused code in UB-92 has been specifically designated as RESERVED in UB-04. These changes are not reflected in any UB-92 update. As noted on FL42, the changes are effective 3/1/07 (for UB-04 claims). Report Revenue Code 0001 on paper claims only. No allowed on electronically submitted claims to 0009 RESERVED 001x 002x RESERVED FOR INTERNAL PAYER USE HEALTH INSURANCE - PROSPECTIVE PAYMENT SYSTEM (HIPPS) This revenue code is used to denote that a HIPPS rate code is being reported in FL44. Sub-Category Standard Abbreviation 0 RESERVED 1 RESERVED 2 Skilled Nursing Facility - PPS SNF PPS (RUG) 3 Home Health - PPS HH PPS (HRG) 4 Inpatient Rehab Facility - PPS REHAB PPS (CMG) 5-9 RESERVED 003x to 009x RESERVED 010x ALL INCLUSIVE RATE Flat fee charge incurred on either a daily basis or total stay basis for service rendered. Charge may cover room and board plus ancillary services and board only. 0 All Inclusive Room and All INCL R & B/ANC Days N BCNEPA/FPH/FPLIC Billing Manual Page 37

38 Board plus Ancillary. 1 All Inclusive Room and Board. All INCL R & B Days N 2-9 RESERVED Form Locator x ROOM & BOARD - PRIVATE (ONE BED) Routine service charges for accommodations in a private room (1 bed). 0 General Classification ROOM-BOARD/PVT Days N 1 Medical/Surgical/GYN MED-SURG-GY/PVT Days N 2 Obstetrics (OB) OB/PVT Days N 3 Pediatric PEDS/PVT Days N 4 Psychiatric PSYCH/PVT Days N 5 Hospice HOSPICE/PVT Days N 6 Detoxification DETOX/PVT Days N 7 Oncology ONCOLOGY/PVT Days N 8 Rehabilitation REHAB/PVT Days N 9 Other OTHER/PVT Days N Note: Most health plans require private rooms be separately identified. 012x ROOM & BOARD - SEMI-PRIVATE (Two Beds) Routine service charges for accommodations in a semi-private room (2 beds). 0 General Classification ROOM-BOARD/SEMI Days N 1 Medical/Surgical/GYN MED-SURG-GY/SEMI Days N 2 Obstetrics (OB) OB/SEMI-PVT Days N 3 Pediatric PEDS/SEMI-PVT Days N 4 Psychiatric PSYCH/SEMI-PVT Days N 5 Hospice HOSPICE/SEMI-PVT Days N 6 Detoxification DETOX/SEMI-PVT Days N 7 Oncology ONCOLOGY/SEMI Days N 8 Rehabilitation REHAB/SEMI-PVT Days N 9 Other OTHER/SEMI-PVT Days N 013x ROOM & BOARD - THREE and FOUR BEDS Routine service charges incurred for rooms containing three or four beds. 0 General Classification ROOM-BOARD/3 & 4 BED Days N 1 Medical/Surgical/GYN MED-SURG-GY/3 & 4 BED Days N 2 Obstetrics (OB) OB/3 & 4 BED Days N 3 Pediatric PEDS/3 & 4 BED Days N 4 Psychiatric PSYCH/3 & 4 BED Days N 5 Hospice HOSPICE/3 & 4 BED Days N 6 Detoxification DETOX/3 & 4 BED Days N 7 Oncology ONCOLOGY/3 & 4 BED Days N 8 Rehabilitation REHAB/3 & 4 BED Days N 9 Other OTHER/3 & 4 BED Days N BCNEPA/FPH/FPLIC Billing Manual Page 38

39 Form Locator x ROOM & BOARD - DELUXE PRIVATE Deluxe accommodations substantially in excess of private room services. 0 General Classification ROOM-BOARD/DLX PVT Days N 1 Medical/Surgical/GYN MED-SURG-GY/DLX PVT Days N 2 Obstetrics (OB) OB/DLX PVT Days N 3 Pediatric PEDS/DLX PVT Days N 4 Psychiatric PSYCH/DLX PVT Days N 5 Hospice HOSPICE/DLX PVT Days N 6 Detoxification DETOX/DLX PVT Days N 7 Oncology ONCOLOGY/DLX PVT Days N 8 Rehabilitation REHAB/DLX PVT Days N 9 Other OTHER/DLX PVT Days N 015x ROOM AND BOARD - WARD Routine service charges for accommodations with five or more beds. 0 General Classification ROOM-BOARD/WARD Days N 1 Medical/Surgical/GYN MED-SURG-GY/WARD Days N 2 Obstetrics (OB) OB/WARD Days N 3 Pediatric PEDS/WARD Days N 4 Psychiatric PSYCH/WARD Days N 5 Hospice HOSPICE/WARD Days N 6 Detoxification DETOX/WARD Days N 7 Oncology ONCOLOGY/WARD Days N 8 Rehabilitation REHAB/WARD Days N 9 Other OTHER/WARD Days N 016x ROOM AND BOARD - OTHER Any routine service charges for accommodations that cannot be included in the more specific revenue center codes. Sterile environment is a room and board charge to be used by hospitals that are currently separating this charge for billing. 0 General Classification R&B Days N 1-3 RESERVED 4 Sterile Environment R&B/STERILE Days N 5-6 RESERVED 7 Self-Care R&B/SELF Days N 8 RESERVED 9 Other R&B/OTHER Days N BCNEPA/FPH/FPLIC Billing Manual Page 39

40 Form Locator x NURSERY Accommodation charges for nursing care to newborns and premature infants in nurseries. 0 General Classification NURSERY Days N 1 Newborn Level I NURSERY/LEVEL I Days N 2 Newborn Level II NURSERY/LEVEL II Days N 3 Newborn Level III NURSERY/LEVEL III Days N 4 Newborn Level IV NURSERY/LEVEL IV Days N 5-8 RESERVED 9 Other Nursery NURSERY/OTHER : If used in conjunction with other room charges (i.e., the mother s room charges), the units for this revenue code is not included into the grand total, (i.e., revenue code 001 units). The levels of care correlate to the intensity of medical care provided to an infant and not the NICU facility certification level assigned by the state. Level I: Routine care of apparently normal full-term or pre-term neonates. (Newborn Nursery) Level II: Low birth-weight neonates who are not sick, but require frequent feeding, and neonates who require more hours of nursing than do normal neonates. (Continuing Care/Premature) Level III: Sick neonates, who do not require intensive care, but require 6-12 hours of nursing each day. (Intermediate Care) Level IV: Constant nursing and continuous cardiopulmonary and other support for severely ill infants. (Intensive Care) 018x LEAVE OF ABSENCE Charges for holding a room while the patient is temporarily away from the provider 0 General Classification Leave of Absence or LOA Days N 1 RESERVED 2 Patient Convenience LOA/PT CONV Days N 3 Therapeutic Leave LOA/THERAPEUTIC Days N 4 RESERVED 5 Nursing Home (for Hospitalization) LOA/NURS HOME Days N 6-8 RESERVED 9 Other Leave of Absence LOA/OTHER Days N Note: This field requires the units field to be entered; however, the units must not be added to the grand total (i.e., revenue code 001). BCNEPA/FPH/FPLIC Billing Manual Page 40

41 019x SUBACUTE CARE Form Locator 42 Accommodations charges for subacute care to inpatients or skilled nursing facilities 0 General Classification SUBACUTE Days N 1 Subacute Care Level I SUBACUTE/LEVEL I Days N 2 Subacute Care Level II SUBACUTE/LEVEL II Days N 3 Subacute Care Level III SUBACUTE/LEVEL III Days N 4 Subacute Care Level IV SUBACUTE/LEVEL IV Days N 5-8 RESERVED 9 Other Subacute Care SUBACUTE/OTHER Days N Usage Note: Revenue code 19X may be used in multiple types of bills. However, if Bill Type X7X is used in Form Locator 4, Revenue code 019X must be used Level I - Skilled Care: Minimal nursing intervention. Comorbidities do not complicate treatment plan. Assessment of vitals and body systems required 1-2 times per day. Level II - Comprehensive Care: Moderate nursing intervention. Active treatment of comorbidities. Assessment of vitals and body systems required 2-3 times per day. Level III - Complex Care: Moderate to extensive nursing intervention. Active medical care and treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of vitals and body systems required 3-4 times per day. Level IV - Intensive Care: Extensive nursing and technical intervention. Active medical care and treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of vitals and body systems required 4-6 times per day. 020x INTENSIVE CARE UNIT Routine service charges for medical or surgical care provided to patients who require a more intensive level of care that is rendered in the general medical or surgical unit. 0 General Classification INTENSIVE CARE (ICU) Days N 1 Surgical ICU/SURGICAL Days N 2 Medical ICU/MEDICAL Days N 3 Pediatric ICU/PEDS Days N 4 Psychiatric ICU/PSYCH Days N 5 RESERVED 6 Intermediate ICU ICU/INTERMEDIATE Days N 7 Burn Care ICU/BURN CARE Days N 8 Trauma ICU/TRAUMA Days N 9 Other Intensive Care ICU/OTHER Days N 021x CORONARY CARE UNIT Routine service charges for medical care provided to patients with coronary illness who require a more intensive level of care than is rendered in the general medical or surgical unit. 0 General Classification CORONARY CARE (CCU) Days N 1 Myocardial Infarction CCU/MYO INFARC Days N 2 Pulmonary Care CCU/PULMONARY Days N 3 Heart Transplant CCU/TRANSPLANT Days N BCNEPA/FPH/FPLIC Billing Manual Page 41

42 4 Intermediate CCU CCU/INTERMEDIATE Days N 5-8 RESERVED 9 Other Coronary Care CCU/OTHER Days N Report when a discrete coronary care unit exists for rendering such services. Form Locator x SPECIAL CHARGES Charges incurred during an inpatient stay or on a daily basis for certain services. 0 General Classification SPECIAL CHARGES N 1 Admission Charges ADMIT CHARGE N 2 Technical Support Charge TECH SUPPORT CHG N 3 U.R. Service Charge UR CHARGE N 4 Late Discharge, Medically Necessary LATE DISCH/MED NEC N 5-8 RESERVED 9 Other Special Charges OTHER SPEC CHG N Some hospitals may prefer to identify the components of services rendered in greater detail and thus break out charges that normally would be considered part of routine services. 023x INCREMENTAL NURSING CHARGE Extraordinary charges for nursing services assessed in addition to the normal nursing charge associated with the typical room and board unit. 0 General Classification NURSING INCREM Hours N 1 Nursery NUR INCR/NURSERY Hours N 2 OB NUR INCR/OB Hours N 3 ICU NUR INCR/ICU Hours N 4 CCU NUR INCR/CCU Hours N 5 Hospice NUR INCR/HOSPICE Hours N 6-8 RESERVED 9 Other NUR INCR/OTHER Hours N 024x ALL INCLUSIVE ANCILLARY A flat rate charge that is applied on a daily basis or on a total stay basis for ancillary services only. 0 General Classification All INCL ANCIL N 1 Basic All INCL BASIC N 2 Comprehensive All INCL COMP N 3 Specialty All INCL SPECIAL N 4-8 RESERVED 9 Other All Inclusive Ancillary All INCL ANCIL/OTHER N Note: Revenue codes 0241, 0242 and 0243 are designed for use by Special Residential Facilities only. See Form Locator 4, Type of Bill 086x. Hospitals billing in this manner may wish to segregate these charges. BCNEPA/FPH/FPLIC Billing Manual Page 42

43 Form Locator x PHARMACY (also see 063x, an extension of 025x) Charges for medication produced, manufactured, packed, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist. 0 General Classification PHARMACY N 1 General Drugs DRUGS/GENERIC Y-OP 2 Non-Generic Drugs DRUGS/NON-GENERIC Y-OP 3 Take Home Drugs DRUGS/TAKE HOME Y-OP 4 Drugs Incident to Other DRUGS/INCIDENT/DX Y-OP Diagnostic Services 5 Drugs Incident to Radiology DRUGS/INCIDENT RAD Y-OP 6 Experimental Drugs DRUGS/EXPERIMT Y-OP 7 Non-Prescription DRUGS/NONPSCRIPT Y-OP 8 IV Solutions IV SOLUTIONS Y-OP 9 Other Pharmacy DRUGS/OTHER Y-OP 026x IV THERAPY Equipment charge or administration of intravenous solution by specially trained personnel to individuals requiring such treatment. 0 General Classification IV THERAPY Y-OP 1 Infusion Pump IV THER/INFSN PUMP Y-OP 2 IV Therapy/Pharmacy Services IV THER/PHARM/SVC Y-OP 3 IV Therapy/Drug/Supply Delivery IV THER/DRUG/SUPPLY/ DEL Y-OP 4 IV Therapy/Supplies IV THER/SUPPLIES Y-OP 5-8 RESERVED 9 Other IV Therapy IV THERAPY/OTHER Y-OP Billing for Home IV providers, require the HCPCS code which describes the pump to be entered in FL 44. BCNEPA/FPH/FPLIC Billing Manual Page 43

44 Form Locator x MEDICAL/SURGICAL SUPPLIES AND DEVICES (also see 062x, an extension of 027x) Charges for supply items required for patient care 0 General Classification MED-SUR SUPPLIES 1 Non-Sterile Supply NON-STER SUPPLY 2 Sterile Supply STERILE SUPPLY 3 Take Home Supplies TAKE HOME SUPPLY 4 Prosthetic/Orthotic Devices PROSTH/ORTH DEV Devices 5 Pace Maker PACE MAKER 6 Intraocular Lens INTRA OC LENS 7 Oxygen - Take Home 02/TAKE HOME 8 Other Implants (a) SUPPLY/IMPLANTS 9 Other Supplies/Devices SUPPLY/OTHER Y (a) Implantables: That which is implanted, such as a piece of tissue, a tooth, a pellet of medicine, or a tube or needle containing a radioactive substance, a graft, or an insert. Also included are liquid and solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. An object or material partially or totally inserted or grafted into the body for prosthetic, therapeutic, diagnostic purposes. Examples of Other Implants (not all9inclusive): Stents, artificial joints, shunts, grafts, pins, plates, screws, anchors, radioactive seeds. Experimental devices that are implantable and have been granted an FDA Investigational Device Exemption (IDE) number should be billed with revenue code x ONCOLOGY Charges for the treatment of tumors and related diseases 0 General Classification ONCOLOGY 1-8 RESERVED 9 Other Oncology ONCOLOGY/OTHER 029x DURABLE MEDICAL EQUIPMENT (OTHER THAN RENAL) Charge for medical equipment that can withstand repeated use (excluding rental equipment) 0 General Classification DME 1 Rental DME-RENTAL Y 2 Purchase of New DME DME-NEW Y 3 Purchase of Used DME DME-USED Y BCNEPA/FPH/FPLIC Billing Manual Page 44

45 4 Supplies/Drugs for DME DME-SUPPLIES/DRUGS Y 5-8 RESERVED 9 Other Equipment DME-OTHER Y Form Locator x LABORATORY Charges for the performance of diagnostic and routine clinical laboratory tests 0 General classification LAB 1 Chemistry CHEMISTRY TESTS Tests Y 2 Immunology IMMUNOLOGY TESTS Tests Y 3 Renal Patient (Home) RENAL HOME Tests Y 4 Non-Routine Dialysis NON-RTNE DIALYSIS Tests Y 5 Hematology HEMATOLOGY TESTS Tests Y 6 Bacteriology & Microbiology BACT & MICRO TESTS Tests Y 7 Urology UROLOGY TESTS Tests Y 8 RESERVED 9 Other Laboratory OTHER LAB TESTS Tests Y 031x LABORATORY PATHOLOGY Charges for diagnostic and routine laboratory tests on tissues and culture 0 General Classification PATHOLOGY LAB Tests Y 1 Cytology CYTOLOGY TESTS Tests Y 2 Histology HISTOLOGY TESTS Tests Y 3 RESERVED 4 Biopsy BIOPSY TESTS Tests Y 5-8 RESERVED 9 Other Laboratory Pathology PATH LAB OTHER Tests Y 032x RADIOLOGY - DIAGNOSTIC Charges for diagnostic radiology services including interpretation of radiographs and fluorographs 0 General Classification DX X-RAY Tests Y 1 Angiocardiology DX X-RAY/ANGIO Tests Y 2 Arthrography DX X-RAY/ARTHO Tests Y 3 Arteriography DX X-RAY/ARTER Tests Y 4 Chest X-Ray DX X-RAY/CHEST Tests Y 5-8 RESERVED 9 Other Radiology - Diagnostic DX X-RAY/OTHER Tests Y BCNEPA/FPH/FPLIC Billing Manual Page 45

46 Form Locator x RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION Charges for therapeutic radiology services and chemotherapy administration to care and treat patients. Therapies also include injection and/or ingestion of radioactive substances. Excludes charges for chemotherapy drugs; report these under the appropriate revenue code (025x or 063x). 0 General Classification RADIOLOGY THERAPY Tests Y 1 Chemotherapy Administration - Injected RAD-CHEMO-INJECT Tests Y 2 Chemotherapy Administration - Oral RAD-CHEMOTHER-ORAL Tests Y 3 Radiation Therapy RAD-RADIATION Tests Y 4 RESERVED 5 Chemotherapy Administration - IV RAD-CHEMOTHER-IV Tests Y 6-8 RESERVED 9 Other Radiology - Therapeutic RADIOLOGY OTHER Tests Y Usage note: When using 0331, 0332, or 0335 there must be use of Revenue Code x NUCLEAR MEDICINE Charges for procedures, tests, and radiopharmaceuticals performed by a department handling radioactive materials as required for diagnosis and treatment of patients. 0 General Classification NUCLEAR MEDICINE Tests Y 1 Diagnostic NUC MED/DX Tests Y 2 Therapeutic NUC MED/RX Tests Y 3 Diagnostic Radiopharmaceuticals NUC MED/DX RADIOPHARM Tests Y 4 Therapeutic Radiopharmaceuticals NUC MED/RX RADIOPHARM Tests Y 5-8 RESERVED 9 Other Nuclear Medicine NUC MED/OTHER Tests Y 035x CT SCAN Charges for computed tomographic scans of the head and other parts of the body 0 General Classification CT SCAN Tests Y 1 CT - Head Scan CT SCAN/HEAD Tests Y 2 CT - Body Scan CT SCAN/BODY Tests Y 3-8 RESERVED 9 CT- OTHER CT SCAN/OTHER Tests Y 036x OPERATING ROOM SERVICES Charges for services provided to patients by specifically trained nursing personnel who assist physicians in the performance of surgical and related procedures during and immediately following surgery. BCNEPA/FPH/FPLIC Billing Manual Page 46

47 0 General Classification OR SERVICES Y 1 Minor Surgery OR/MINOR Y 2 Organ Transplant Other than Kidney OR/ORGAN TRANS Y 3-6 RESERVED 7 Kidney Transplant OR/KIDNEY TRANS Y 8 RESERVED 9 Other Operating Room Service OR/OTHER Y 037x ANESTHESIA Charges for anesthesia services Form Locator 42 0 General Classification ANESTHESIA 1 Anesthesia Incident to Radiology ANESTHE/INCIDENT RAD 2 Anesthesia Incident to Other ANES/INCDNT OTHER DX Diagnostic Services 3 RESERVED 4 Acupuncture ANESTHE/ACUPUNC 5-8 RESERVED 9 Other Anesthesia ANESTHE/OTHER 038x BLOOD and BLOOD COMPONENTS Charges for blood and blood components 0 General Classification BLOOD & BLOOD COMP Y 1 Packed Red Cells BLOOD/PKD RED Pints Y 2 Whole Blood BLOOD/WHOLE Pints Y 3 Plasma BLOOD/PLASMA Pints Y 4 Platelets BLOOD/PLATELETS Y 5 Leukocytes BLOOD/LEUKOCYTES Y 6 Other Components BLOOD/COMPONENTS Y 7 Other Derivatives (Cryoprecipitate) BLOOD/DERIVATIVES Y 8 RESERVED 9 Other Blood BLOOD/OTHER Y 039x ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS Charges for administration, processing and storage of whole blood, red blood cells, platelets, and other blood components 0 General Classification BLOOD/ADMIN/STOR Y 1 Administration (e.g., Transfusion) BLOOD/ADMIN Pints Y 2 Processing and Storage BLOOD/STORAGE Pints Y 3-8 RESERVED 9 Other Blood Handling BLOOD/ADMIN/STOR/OTHER Y 040x OTHER IMAGING SERVICES Charges for specialty imaging services for body structures BCNEPA/FPH/FPLIC Billing Manual Page 47

48 0 General Classification IMAGE SERVICE Tests Y 1 Diagnostic Mammography DIAG MAMMOGRAPHY Tests Y 2 Ultrasound ULTRASOUND Tests Y 3 Screening Mammography SCRN MAMMOGRAPHY Tests Y 4 Position Emission Tomography PET SCAN Tests Y 5-8 RESERVED 9 Other Imaging Services OTHER IMAG SVS Tests Y Form Locator x RESPIRATORY SERVICES Charges for respiratory services including administration of oxygen and certain potent drugs through inhalation or positive pressure and other forms of rehabilitative therapy. 0 General Classification RESPIRATORY SVC Treatment Y 1 RESERVED 2 Inhalation Services INHALATION SVC Treatment Y 3 Hyperbaric Oxygen Therapy HYPERBARIC 02 Treatment Y 4-8 RESERVED 9 Other Respiratory Services OTHER RESPIR SVS Treatment Y 042x PHYSICAL THERAPY Charges for therapeutic exercises, massage and utilization of Effective Date properties of light, heat, cold, water, electricity and assist devices for diagnosis and rehabilitation of patients who have neuromuscular, orthopedic and other disabilities. 0 General Classification PHYSICAL THERP HCPCS Y 1 Visit PHYS THERP/VISIT HCPCS Y 2 Hourly PHYS THERP/HOUR HCPCS Y 3 Group PHYS THERP/GROUP HCPCS Y 4 Evaluation or Re-Evaluation PHYS THERP/EVAL HCPCS Y 5-8 RESERVED 9 Other Physical Therapy OTHER PHYS THERP HCPCS Y 043x OCCUPATIONAL THERAPY Charges for therapeutic interventions to improve, sustain or restore an individual s level of function in performance, of activities of daily living and work, including: therapeutic activities; therapeutic exercise; sensorimotor processing; psychosocial skills training; cognitive retraining; fabrication and application of orthotic devices; and training in the use of orthotic and prosthetic devices; adaptation of environments; and application of physical agent modalities. 0 General Classification OCCUPATIONAL THER HCPCS Y 1 Visit OCCUP THERP/VISIT HCPCS Y 2 Hourly OCCUP THERP/HOUR HCPCS Y 3 Group OCCUP THERP/GROUP HCPCS Y 4 Evaluation or Re-Evaluation OCCUP THERP/EVAL HCPCS Y 5-8 RESERVED 9 Other Occupational Therapy OTHER OCCUP THER HCPCS Y Services are provided by a qualified occupational therapist. 044x SPEECH therapy - LANGUAGE PATHOLOGY Charges for services related to impaired functional communications skills. BCNEPA/FPH/FPLIC Billing Manual Page 48

49 0 General Classification SPEECH THERAPY HCPCS Y 1 Visit SPEECH THERP/VISIT HCPCS Y 2 Hourly SPEECH THERP/HOUR HCPCS Y 3 Group SPEECH THERP/GROUP HCPCS Y 4 Evaluation or Re-Evaluation SPEECH THERP/EVAL HCPCS Y 5-8 RESERVED 9 Other Speech Therapy OTHER SPEECH THERP HCPCS Y Services are provided by a qualified speech therapist. Form Locator x EMERGENCY ROOM Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care. 0 General Classification EMERG ROOM Visit Y 1 EMTALA Emergency Medical Screening ER/EMTALA Visit Y 2 ER Beyond EMTALA ER/BEYOND EMTALA Visit Y 3-5 RESERVED 6 Urgent Care URGENT CARE Visit Y 7-8 RESERVED 9 Other Emergency Room OTHER EMER ROOM Visit Y Usage : Report Patient s Reason for Visit code in FL 70 in conjunction with this revenue code. (a) General classification code 0450 should not be used in conjunction with any subcategory. The sum of 0451 and 0452 is equivalent to (b) Stand-alone usage of 0451 is acceptable when no services beyond an initial screening/assessment are rendered. (c) Stand-alone usage of 0452 is not acceptable. 046x PULMONARY FUNCTION Charges for tests that measure inhaled and exhaled gases and analysis of blood for tests that evaluate the patient s ability to exchange oxygen and other gases. 0 General Classification PULMONARY FUNC Test Y 1-8 RESERVED 9 Other Pulmonary Function OTHER PULMON FUNC Test Y 047x AUDIOLOGY Charges for the detection and management of communication handicaps centering in whole or in part on the hearing function 0 General Classification AUDIOLOGY Test Y 1 Diagnostic AUDIOLOGY/DX Test Y 2 Treatment AUDIOLOGY/RX Test Y 3-8 RESERVED 9 Other Audiology OTHER AUDIOL Test Y BCNEPA/FPH/FPLIC Billing Manual Page 49

50 Services are provided by or through the supervision of a qualified audiologist. Form Locator x CARDIOLOGY Charges for cardiac procedures. 0 General Classification CARDIOLOGY Test Y 1 Cardiac CATH LAB CARDIAC CATH LAB Test Y 2 Stress Test STRESS TEST Test Y 3 Echocardiology ECHOCARDIOLOGY Test Y 4-8 RESERVED 9 Other Cardiology OTHER CARDIOL Test Y Services provided are by staff from the cardiology department of the hospital or under arrangement. Services include such procedures such as: heart catheterization, coronary angiography, Swan-Ganz catheterization, and exercise stress test. 049x AMBULATORY SURGICAL CARE Charges for ambulatory surgery not covered by other categories. 0 General Classification AMBULTRY SURG HCPCS Y 1-8 RESERVED 9 Other Ambulatory Surgical Care OTHER AMBL SURG HCPCS Y 050x OUTPATIENT SERVICES Charges for services rendered to an outpatient who is then admitted as an inpatient before midnight of the day following the date of service. 0 General Classification OUTPATIENT SVCS Test Y 1-8 RESERVED 9 Other Outpatient OTHER O/P SERVICES Test Y 051x CLINIC Clinic visit charges for providing diagnostic, preventative, curative, rehabilitative and education services to ambulatory patients. 0 General Classification CLINIC Visit Y 1 Chronic Pain Center CHRONIC PAIN CLINIC Visit Y 2 Dental Clinic DENTAL CLINIC Visit Y BCNEPA/FPH/FPLIC Billing Manual Page 50

51 3 Psychiatric Clinic PSYCHIATRIC CLINIC Visit Y 4 OB-GYN Clinic OB-GYN CLINIC Visit Y 5 Pediatric Clinic PEDIATRIC CLINIC Visit Y 6 Urgent Care Clinic* URGENT CARE CLINIC Visit Y 7 Family Practice Clinic FAMILY CLINIC Visit Y 8 RESERVED 9 Other Clinic OTHER CLINIC Visit Y * Report the Patient s Reason for Visit diagnosis codes for all Urgent Care Clinic visits. Form Locator x FREE-STANDING CLINIC Charges for the outpatient visit at a freestanding clinic. 0 General Classification FREESTAND CLINIC Visit Y 1 Clinic Visit by Member to RHC/FQHC FS-RURAL/CLINIC Visit Y 2 Home Visit by RHC/FQHC Practitioner FS-RURAL/HOME Visit Y 3 Family Practice Clinic FS-FAMILY PRACT Visit Y 4 Visit by RHC/FQHC Practitioner to a FR/STD FAMILY CLINIC Member in a Covered Part A Stay at SNF 5 Visit by RHC/FQHC Practitioner to a Member RHC/FWHC/SNF/ In a SNF (not in a Covered Part A Stay) or NONCOVERED NF or ICF MR or Other Residential Facility 6 Urgent Care Clinic* FR/STD URGENT CLINIC Visit Y 7 Visiting Nurse Service(s) to a Member s RHC/FQHC/HOME/VIS Home when in a Home Health Shortage Area NURSE 8 Visit by RHC/FQHC Practitioner to Other RHC/FQHC/OTHER SITE Non-RHC/FQHC Site (e.g. Scene of Accident) 9 Other Free-Standing Clinic OTHER FS-CLINIC Visit Y * Report the Patient s Reason for Visit diagnosis codes for all Urgent Care Clinic visits. 053x OSTEOPATHIC SERVICES Charges for a structural evaluation of the cranium, entire cervical, dorsal and lumbar spine by a doctor of osteopathy. 0 General Classification OSTEOPATH SVS Visit Y 1 Osteopathic Therapy OSTEOPATH RX Visit Y 2-8 RESERVED 9 Other Osteopathic Services OTHER OSTEOPATH Visit Y Generally, these services are unique to osteopathic hospitals and cannot be accommodated in any of the existing revenue codes. 054x AMBULANCE Charges for ambulance services necessary for the transport of the ill or injured who require medical attention at a health care facility 0 General Classification AMBULANCE Mile Y BCNEPA/FPH/FPLIC Billing Manual Page 51

52 1 Supplies AMBUL/SUPPLY Item N 2 Medical Transport AMBUL/MED TRANS Mile Y 3 Heart Mobile AMBUL/HEARTMOB Mile Y 4 Oxygen AMBUL/OXYGEN Unit Y 5 Air Ambulance AIR AMBULANCE Mile Y 6 Neonatal Ambulance Services AMBUL/NEONAT Mile Y 7 Pharmacy AMBUL/PHARMACY Unit Y 8 EKG Transmission AMBUL/EKG TRANS Unit Y 9 Other Ambulance OTHER AMBULANCE Mile Y BCNEPA/FPH/FPLIC Billing Manual Page 52

53 Form Locator x SKILLED NURSING Charges for nursing services that must be provided under the direct supervision of a licensed nurse to assure the safety of the patient and to achieve the medically desired result. This code may be used for nursing home services, CORFS, or a service charge for home health billing. 0 General Classification SKILLED NURSING-HH Y 1 Visit Charge SKILLED NURS-VISIT Visit Y 2 Hourly Charge SKILLED NURS-HOUR Hour Y 3-8 RESERVED 9 Other Skilled Nursing SKILLED NURS/OTHER Y 056x HOME HEALTH (HH) - MEDICAL SOCIAL SERVICES Home Health (HH) charges for services such as counseling patients, interviewing patients and interpreting problems of social situation rendered to patients on any basis. 0 General Classification MED SOCIAL-HH Y 1 Visit Charge MED SOC SERV-VISIT Visit Y 2 Hourly Charge MED SOC SERV-HOUR Hour Y 3-8 RESERVED 9 Other Medical Social Services MED SOC SERV-OTHER Y 057x HOME HEALTH (HH) AIDE Home Health (HH) charges for personnel (aides) that are primarily responsible for the personal care of the patient. 0 General Classification HH AIDE Y 1 Visit Charge HH AIDE-VISIT Visit Y 2 Hourly Charge HH AIDE-HOUR Hour Y 9 Other Home Health Aide HH AIDE-OTHER Y 058x HOME HEALTH (HH) - OTHER VISITS Home Health agency charges for visits other than physical therapy, occupational therapy or speech therapy, requiring specific identification. 0 General Classification HH-OTH VIS Y 1 Visit Charge HH-OTH VIS/VISIT Visit Y 2 Hourly Charge HH-OTH VIS/HOUR Hour Y 3 Assessment HH-OTH VIS/ASSESS Visit Y 4-8 RESERVED 9 Other Home Health Visit HH-OTH VIS/OTHER Visit Y BCNEPA/FPH/FPLIC Billing Manual Page 53

54 Form Locator x HOME HEALTH (HH) UNITS OF SERVICE Home Health (HH) charges for services billed according to the units of service provided. 0 General Classification HH-SVCS/UNIT Unit Y 1-9 RESERVED 060x HOME HEALTH (HH) - OXYGEN Home Health agency charges for oxygen equipment, supplies or contents, excluding purchased equipment. If patient purchases a stationary oxygen system, an oxygen concentrator or portable equipment, current revenue codes 0292 or 0293 apply. DME (other than oxygen systems) is billed under revenue codes 0291, 0292, or General Classification 02/HOME HEALTH Y 1 Oxygen - Stat Equip/Supply/Content 02/STAT/EQP/SUP/CONT Ft/Lbs Y 2 Oxygen - Stat Equip/Supply<1 LPM 02/STAT/EQP/SUP< 1 LPM Mos Y 3 Oxygen - Stat Equip/Supply>4 LPM 02/STAT/EQP/SUP> 4 LPM Mos Y 4 Oxygen - Portable Add-on 02/PORTABLE ADD-ON Mos Y 5-8 RESERVED 9 Oxygen - Other 02/OTHER Y 061x MAGNETIC RESONANCE TECHNOLOGY (MRT) Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography. 0 General Classification MRT Tests Y 1 MRI - Brain/Brainstem MRI/BRAIN Tests Y 2 MRI - Spinal Cord/Spine MRI/SPINE Tests Y 3 RESERVED 4 MRI - Other MRI/OTHER Tests Y 5 MRA - Head and Neck MRA/HEAD AND NECK Tests Y 6 MRA - Lower Extremities MRA/LOWER EXTRM Tests Y 7 RESERVED 8 MRA - Other MRA/OTHER Tests Y 9 Other MRT MRT/OTHER Tests Y Note: If revenue code 619 is used, enter the type of MRI into the remarks field. 062x MEDICAL SURGICAL SUPPLIES - Extension of 027x Charges for supply items required for patient care. The category is an extension of 027x for reporting additional breakdown where needed. Subcategory code 1 is for providers that cannot bill supplies used for radiology procedures under radiology. Subcategory code 2 is for providers that cannot bill supplies used for other diagnostic procedures. 0 RESERVED (Use 0270 for General Classification) 1 Supplies Incident to Radiology MED SUR SUPL-INCDT RAD HCPCS Y 2 Supplies Incident to Other DX Services MED SUR SUPL-INCDT ODX HCPCS Y 3 Surgical Dressings SURG DRESSING HCPCS Y 4 FDA Investigational Devices FDA INVEST DEVICE HCPCS Y 5-9 RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 54

55 Form Locator x PHARMACY - Extension of 025x Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist. The category is an extension of 025X for reporting additional breakdown where needed. 0 RESERVED (Use 0250 for General Classification) 1 Single Source Drug DRUG/SINGLE HCPCS Y 2 Multiple Source Drug DRUG/MULTIPLE HCPCS Y 3 Restrictive Prescription DRUG/RESTRICT HCPCS Y 4 Erythropoietin (EPO) <10,000 Units DRUG/EPO<10,000 Units HCPCS Y 5 Erythropoietin (EPO)>=10,000 Units DRUG/EPO>=10,000 Units HCPCS Y 6 Drugs Requiring Detail Coding (a) DRUG/DETAIL CODE HCPCS Y 7 Self-Administrable Drugs (b) DRUG/SELF ADMIN HCPCS Y (a) Charges for drugs and biologicals (with the exception of radiopharmaceuticals, which are reported under Revenue Codes 0343 and 0344) requiring specific identification as required by the payer. If using a HCPCS to describe the drug, enter the HCPCS code in the appropriate HCPCS column. The specific service units reported should be in hundreds (100s), rounded to the nearest hundred; do not use a decimal. (b) Charges for self-administrable drugs not requiring detailed coding. Use Value Codes A4, A5, and A6 to indicate the dollar amount included in covered charges for self-administrable drugs. Amounts for non-covered self-administrable drugs should be charged using Revenue Code 0637 in the noncovered column. 064x HOME IV THERAPY SERVICES Charge for intravenous therapy services performed in the patient s residence. For Home IV providers enter the HCPCS code for all equipment, and all types of covered therapy. 0 General Classification IV THERAPY SVC Y 1 Non-routine Nursing, Central Line NON RT NURSING/CENTRAL Y 2 IV Site Care, Central Line (see note) IV SITE CARE/CENTRAL Y 3 IV Start/Change, Peripheral Line IV STRT CARE/PERIPHRL Y 4 Non-routine Nursing, Peripheral Line NONRT NURSING/PERIPHRL Y 5 Training Patient/Care Giver, Central Line TRNG PT/CAREGVR/CNTRL Hour Y 6 Training, Disabled Patient, Central Line TRNG DSBLPT/CENTRAL Hour Y 7 Training, Patient/Care Giver, Peripheral Line TRNG/PT/CARGVR/PERIPHRL Hour Y 8 Training, Disabled Patient, Peripheral Line TRNG/DSBLPT/PERIPHRL Hour Y 9 Other IV Therapy Services OTHER IV THERAPY SVC Y Note: Report units in one hour increments; Revenue code 0642 relates to the HCPCS code. BCNEPA/FPH/FPLIC Billing Manual Page 55

56 Form Locator x HOSPICE SERVICES Charge for hospice care services for a terminally ill patient electing hospice services in lieu of other medical services for the terminal condition. 0 General Classification HOSPICE Y 1 Routine Home Care HOSPICE/RTN HOME Hours Y 2 Continuous Home Care HOSPICE/CTNS HOME Hours Y 3-4 RESERVED 5 Inpatient Respite Care HOSPICE/IP RESPITE Days Y 6 General Inpatient Care Non-Respite HOSPICE/IP NON-RESPITE Days Y 7 Physician Services HOSPICE/PHYSICIAN HCPCS Y 8 Hospice Room & Board - Nursing Facility HOSPICE/R&B NURS FAC Days Y 9 Other Hospice Service HOSPICE/OTHER Y Note: To receive the continuous home car rate from Medicare use code 0652, a minimum of 8 hours of care, not necessarily consecutive, must be accompanied by a physician procedure code. Enter this information in the HCPCS column (Form Locator 44). This code is used by the hospice to bill for charges for physicians employed by the hospice or receiving compensation from the hospice for services rendered. The unit will be either days or hours depending on subcategory and billing contracts. 066x RESPITE CARE Charges for non-hospice respite care. 0 General Classification RESPITE CARE 1 Hourly Charge - Nursing RESPITE/NURSING Hours 2 Hourly Charge/Aide/Homemaker/ RESPITE/AIDE/HMEMKR/ Hours Companion COMP 3 Daily Respite Charge RESPITE/DAILY Day 4-8 RESERVED 9 Other Respite Care RESPITE/OTHER Hours 067x OUTPATIENT SPECIAL RESIDENCE CHARGES Residence arrangements for patients requiring continuous outpatient care. 0 General Classification OP SPEC RES 1 Hospital Owned OP SPEC RES/HOSP Day OWNED 2 Contracted OP SPEC Day 3-8 RESERVED 9 Other Special Residence Charge OP SPEC RES/OTHER Day BCNEPA/FPH/FPLIC Billing Manual Page 56

57 Form Locator x TRAUMA RESPONSE Charges representing the activation of the trauma team Sub-Category Standard Abbreviation Unit HCPBS 0 Not Used 1 Level I Trauma TRAUMA LEVEL I Activation 2 Level II Trauma TRAUMA LEVEL II Activation 3 Level III Trauma TRAUMA LEVEL III Activation 4 Level IV Trauma TRAUMA LEVEL IV Activation 5-8 RESERVED 9 Other Trauma Response TRAUMA OTHER Activation Usage : 1. For use by trauma center/hospitals, licensed or designated by the state or local government authority authorized as a trauma center, or verified by the American College of Surgeons and as a facility with a trauma activation team. 2. Revenue Category 068x is used for patients for whom a trauma activation occurred. A trauma team activation/response is a Notification of key hospital personnel in response to triage information from pre-hospital caregivers in advance of the patient s arrival. 3. Revenue Category 068x is for reporting trauma activation costs only. It is an activation fee and not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will normally be both a 045x and 068x revenue code reported. 4. Revenue Category 068x is not limited to admitted patients. 5. Revenue Category 068x must be used in conjunction with FL14 Priority (Type) of Admission/Visit Code 5 ( Trauma Center ), however FL 14 Code 5 can be used alone for trauma activations that lack pre-hospital notification. Only patients for whom there has been pre-hospital notification, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response, can be billed the trauma activation fee charge. Patients who are drive-by or arrive without notification cannot be charged for activations, but can be classified as trauma under Type of Admission Code 5 for statistical and follow-up purposes. 6. Levels I, II, III, or IV refer to designations given to the trauma facility by the state or local government authority or as verified by the American College of Surgeons. 7. Subcategory 9 is for states or local authorities with levels beyond IV. 069x RESERVED 070x CAST ROOM Charge for services related to the application, maintenance and removal of casts. 0 General Classification CAST ROOM 1-9 RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 57

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59 Form Locator x RECOVERY ROOM Room charge for patient recovery after surgery. 0 General Classification RECOVERY ROOM N 1-9 RESERVED 072x LABOR ROOM/DELIVERY Charges for labor and delivery room services provided by specifically trained nursing personnel to patients, including prenatal care during labor, assistance during delivery, postnatal care in the recovery room and minor gynecologic procedures if they are performed in the delivery suite. 0 General Classification DELIVERY ROOM/LABOR 1 Labor LABOR Days 2 Delivery Room DELIVERY ROOM Days 3 Circumcision CIRCUMCISION Each 4 Birthing Center BIRTHING CENTER Days 4-8 RESERVED 9 Other Labor Room/Delivery OTHER/DELIV/LABOR 073x EKG/ECG (ELECTROCARDIOGRAM) Charges for operation of specialized equipment to record variations in actions of the heart muscle for diagnosis of heart ailments. 0 General Classification EKG/ECG Tests Y 1 Holter Monitor HOLTER MONT Tests Y 2 Telemetry TELEMETRY Tests Y 3-8 RESERVED 9 Other EKG/ECG OTHER EKG/ECG Tests Y 074x EEG (ELECTROENCEPHALOGRAM) Charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders. 0 General Classification EEG Tests Y 1-9 RESERVED 075x GASTRO - INTESTINAL (GI) SERVICES Charges for GI procedures not performed in the operating room. 0 General Classification GASTRO-INTSTL SVS Tests Y 1-9 RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 59

60 Form Locator x SPECIALTY SERVICES Charges for patients requiring treatment room services or patients placed under observation. 0 General Classification SPECIALTY SVC 1 Treatment Room TREATMENT ROOM Y 2 Observation Hours (a) OBSERVATION 3-8 RESERVED 9 Other Specialty Services OTHER SPECIALTY SVC Note: Observation services are those services furnished by a hospital on the hospital s premises, including use of a bed and periodic monitoring by a hospital s nursing or other staff, which are reasonable and necessary to evaluate an outpatient s condition or determine the need for a possible admission to the hospital or as an inpatient. Such services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. The reason for observation must be stated in the orders for observation. Payers should establish written guidelines, which identify coverage of observation services. (a) FL 70a-c Patient s Reason for Visit should be reported in conjunction with x PREVENTIVE CARE SERVICES Revenue Code used to capture preventive care services established by payers (e.g., vaccination). 0 General Classification PREVENT CARE SVCS Y 1 Vaccine Administration VACCINE ADMIN Y 2-9 RESERVED 078x TELEMEDICINE Facility charges related to the use of telemedicine services 0 General Classification TELEMEDICINE 1-9 RESERVED 079x EXTRA-CORPOREAL SHOCK WAVE THERAPY (Formerly Lithotripsy) Charges related to Extra-Corporeal Shock Wave Therapy (ESWT). 0 General Classification ESWT Y 1-9 RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 60

61 Form Locator x INPATIENT RENAL DIALYSIS Charges for the use of equipment designed to remove waste when the body s own kidneys have failed. The waste may be removed directly from the blood (hemodialysis) or indirectly from the blood by flushing a special solution between the abdominal covering and the tissue (peritoneal dialysis). 0 General Classification RENAL DIALYSIS Sessions 1 Inpatient Hemodialysis DIALY/INPATIENT Sessions 2 Inpatient Peritoneal (Non-CAPD) DIALY/INPT/PER Sessions 3 Inpatient Continuous Ambulatory DIALY/IP/CAPD Sessions Peritoneal Dialysis (CAPD) 4 Inpatient Continuous Cycling DIALY/INPT/CCPD Sessions Peritoneal Dialysis (CCPD) 5-8 RESERVED 9 Other Inpatient Dialysis DIALY/INPT/OTHER Sessions 081x ACQUISITION OF BODY COMPONENTS The acquisition and storage costs of body tissue, bone marrow, organs and other body components not otherwise identified used for transplantation. 0 General Classification ORGAN ACQUISIT Y 1 Living Donor LIVING DONOR Y 2 Cadaver Donor CADAVER DONOR Y 3 Unknown Donor UNKNOWN DONOR Y 4 Unsuccessful Organ Search - Donor UNSUCCESSFUL SEARCH Y Bank Charges 5-8 RESERVED 9 Other Donor OTHER DONOR Y : Living donor is a living person from whom an organ is collected and used for transplantation purposes. Cadaver is an individual pronounce dead according to medical and legal criteria, and whose organs may be harvested for transplantation. Unknown is used whenever the status of the individual source cannot be determined. Use the other category whenever the organ is non-human. Revenue Code 0814 is used only when costs incurred for an organ search do not result in an eventual organ acquisition and transplantation. 082x HEMODIALYSIS - OUTPATIENT OR HOME A waste removal process, performed in an outpatient or home setting, necessary when the body s own kidneys have failed. Waste is removed directly from the blood. 0 General Classification HEMO/OP or HOME Y 1 Hemodialysis/Composite or Other Rate HEMO/COMPOSITE Sessions Y 2 Home Supplies HEMO/HOME/SUPPL Sessions Y 3 Home Equipment HEMO/HOME/EQUIP Sessions Y 4 Maintenance - 100% HEMO/HOME/100% Sessions Y 5 Support Services HEMO/HOME/SUPSERV Sessions Y 6-8 RESERVED 9 Other Outpatient Hemodialysis HEMO/OTHER/OP Sessions Y BCNEPA/FPH/FPLIC Billing Manual Page 61

62 Form Locator x PERITONEAL DIALYSIS - OUTPATIENT OR HOME Charges for a waste removal process performed in an outpatient or home setting, necessary when the body s own kidneys have failed. Waste is removed indirectly by flushing a special solution between the abdominal covering and the tissue. 0 General Classification PERITONEAL/OP or HOME Sessions Y 1 Peritoneal/Composite or Other Rate PERTNL/COMPOSITE Sessions Y 2 Home Supplies PERTNL/HOME/SUPPL Sessions Y 3 Home Equipment PERTNL/HOME/EQUIP Sessions Y 4 Maintenance - 100% PERTNL/HOME/100% Sessions Y 5 Support Services PERTNL/HOME/SUPSERV Sessions Y 6-8 RESERVED 9 Other Outpatient Peritoneal Dialysis PERTNL/HOME/OTHER Sessions Y 084x CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) - OUTPATIENT OR HOME Charges for continuous dialysis process performed in an outpatient or home setting which uses the patient s peritoneal membrane as a dialyzer. 0 General Classification CAPD/OP or HOME Days Y 1 CAPD/Composite or Other Rate CAPD/COMPOSITE Days Y 2 Home Supplies CAPD/HOME/SUPPL Days Y 3 Home Equipment CAPD/HOME/EQUIP Days Y 4 Maintenance - 100% CAPD/HOME/100% Days Y 5 Support Services CAPD/HOME/SUPSERV Days Y 6-8 RESERVED 9 Other Outpatient CAPD CAPD/HOME/OTHER Days Y 085x CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) - OUTPATIENT OR HOME Charges for continuous dialysis process performed in an outpatient or home setting which uses a machine to make automatic exchanges at night. 0 General Classification CCPD/OP or HOME Days Y 1 CCPD/Composite or Other Rate CCPD/COMPOSITE Days Y 2 Home Supplies CCPD/HOME/SUPPL Days Y 3 Home Equipment CCPD/HOME/EQUIP Days Y 4 Maintenance - 100% CCPD/HOME/100% Days Y 5 Support Services CCPD/HOME/SUPSERV Days Y 6-8 RESERVED 9 Other Outpatient CCPD CCPD/HOME/OTHER Days Y 086x Magnetoencephalography (MEG) Effective 04/01/10 0 General Classification Test Y 1 MEG Test Y 2-9 RESERVED 087x RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 62

63 Form Locator x MISCELLANEOUS DIALYSIS Charges for dialysis services not identified elsewhere. 0 General Classification DIALY/MISC Sessions Y 1 Ultrafiltration DIALY/ULTRAFILT Sessions Y 2 Home Dialysis Aid Visit HOME DIALYSIS AID VISIT Sessions Y 3-8 RESERVED 9 Other Miscellaneous Dialysis DIALY/MISC/OTHER Sessions Y Note: Ultrafiltration is the process of removing excess fluid from the blood of dialysis patients by using a dialysis machine but without the dialysate solution. The designation is only used when the procedure is not performed as part of a normal dialysis session. 089x RESERVED 090x BEHAVORIAL HEALTH TREATMENT/SERVICES (also see 091x, an extension of 090x) Charges for prevention, intervention, and treatment services in the areas of mental health, substance abuse, developmental disabilities, and sexuality. Behavioral Health Care services are individualized, holistic, and culturally competent and may include on-going care and support and non-traditional services. 0 General Classification BH/TREATMENTS Visit Y 1 Electroshock Treatment BH/ELECTRO SHOCK Visit Y 2 Milieu Therapy BH/MILIEU THERAPY Visit Y 3 Play Therapy BH/PLAY THERAPY Visit Y 4 Activity Therapy BH/ACTIVITY THERAPY Visit Y 5 Intensive Outpatient Services - Psychiatric BH/INTENS OP/PSYCH Visit Y 6 Intensive Outpatient Services - Chemical BH/INTENS OP/CHEM DEP Visit Y Dependency 7 Community Behavioral Health Program BH/COMMUNITY Visit Y (Day Treatment) 8-9 RESERVED 091x BEHAVIORAL HEALTH TREATMENTS/SERVICES - Extension of 090x See Revenue Code 090x 0 RESERVED (use 090 for General Classification) 1 Rehabilitation BH//REHAB Visit Y 2 Partial Hospitalization - Less Intensive BH/PARTIAL HOSP Visit Y 3 Partial Hospitalization - Intensive BH/PARTIAL INTENSV Visit Y 4 Individual Therapy BH/INDIV RX Visit Y 5 Group Therapy BH/GROUP RX Visit Y 6 Family therapy BH/FAMILY RX Visit Y 7 Bio Feedback BH/BIOFEED Visit Y 8 Testing BH/TESTING Visit Y 9 Other Behavioral Health Treatments BH/OTHER Visit Y BCNEPA/FPH/FPLIC Billing Manual Page 63

64 Form Locator x OTHER DIAGNOSTIC SERVICES Charges for various diagnostic services specific to common screenings for disease, illness or medical condition. 0 General Classification OTHER DX SVCS 1 Peripheral Vascular Lab PERI VASCUL LAB Tests Y 2 Electomyelgram EMG Tests Y 3 Pap Smear PAP SMEAR Tests Y 4 Allergy Test ALLERGY TEST Tests Y 5 Pregnancy Test PREG TEST Tests Y 6-8 RESERVED 9 Other Diagnostic Service OTHER DX SVCS Tests Y 093x MEDICAL REHABILITATION DAY PROGRAM Medical rehabilitation services as contracted with a payer and/or certified by the state. Services may include physical therapy, occupational therapy and speech therapy. 0 RESERVED 1 Half Day HALF DAY Hours 2 Full Day FULL DAY Hours 3-9 RESERVED Note: The subcategories of 093x are designed as zero-bill revenue code (i.e., no dollars are reported in the Total Charge column (FL 47) for this revenue code) it should be used as a vehicle to supply program information as defined in the provider/payer contract. Therefore, zero would be reported in the Total Charge column and the number of hours provided would be reported in the Units field. The specific rehabilitation services would be reported under the applicable therapy revenue codes as normal. 094x OTHER THERAPEUTIC SERVICES (also see 095x, and extension of 094x) Charges for other therapeutic services not otherwise categorized. 0 General Classification OTHER RX SVCS 1 Recreational Therapy RECREATION RX Visit Y 2 Education/Training EDUC/TRAINING Visit Y 3 Cardiac Rehabilitation CARDIAC REHAB Visit Y 4 Drug Rehabilitation DRUG REHAB Visit Y 5 Alcohol Rehabilitation ALCOHOL REHAB Visit Y 6 Complex Medical Equipment Routine CMPLX MED EQUIP/ROUT Visit Y 7 Complex Medical Equipment Ancillary CMPLX MED EQUIP/ANC Visit Y 8 Pulmonary Rehabilitation PULMONARY REHAB Visit Y 9 Other Therapeutic Service ADDITIONAL RX SVCS Visit Y 095x OTHER THERAPEUTIC SERVICES (Extension of 094x) See Revenue Code 094x 0 RESERVED (use 0940 for General Classification) 1 Athletic Training ATHLETIC TRAINING Visit Y 2 Kinesiotherapy KINESIOTHERAPY Visit Y 3-9 RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 64

65 Form Locator x PROFESSIONAL FEES (also see 097x and 098x) Charges for medical professionals that the institutional health care provider along with the third party payer require the professional fee component to be billed on the UB. The professional fee component is separately identified by this revenue code. Generally used by Critical Access Hospitals (CAH) that bill both the technical and professional service components on the UB. 0 General Classification PRO FEE 1 Psychiatric PRO FEE/PSYCH Y 2 Ophthalmology PRO FEE/EYE Y 3 Anesthesiologist (MD) PRO FEE/ANES MD Y 4 Anesthetist (CRNA) PRO FEE/ANES CRNA Y 5-8 RESERVED 9 Other Professional Fee PRO FEE/OTHER Y 097x PROFESSIONAL FEES (Extension of 096x) See Revenue Code 096x. 0 RESERVED (use 0960 for General Classification) 1 Laboratory PRO FEE/LAB Y 2 Radiology - Diagnostic PRO FEE/RAD/DX Y 3 Radiology - Therapeutic PRO FEE/RAD/RX Y 4 Radiology - Nuclear Medicine PRO FEE/NUC MED Y 5 Operating Room PRO FEE/OR Y 6 Respiratory Therapy PRO FEE/RESPIR Y 7 Physical Therapy PRO FEE/PHYSI Y 8 Occupational Therapy PRO FEE/OCCUPA Y 9 Speech Pathology PRO FEE/SPEECH Y 098x PROFESSIONAL FEES (Extension of 096x and 097x) Charges for medical professionals that the institutional health care provider along with the third-party payer require the professional fee component to be billed on the UB. The professional fee component is separately identified by this revenue code. Generally used by Critical Access Hospitals (CAH). 0 RESERVED (use 0960 for General Category) 1 Emergency Room PRO FEE/ER Y 2 Outpatient Services PRO FEE/OUTPT Y 3 Clinic PRO FEE/CLINIC Y 4 Medical Social Services PRO FEE/SOC SVC Y 5 EKG PRO FEE/EKG Y 6 EEG PRO FEE/EEG Y 7 Hospital Visit PRO FEE/HOS VIS Y 8 Consultation PRO FEE/CONSULT Y 9 Private Duty Nurse FEE/PVT NURSE Y BCNEPA/FPH/FPLIC Billing Manual Page 65

66 Form Locator x PATIENT CONVENIENCE ITEMS Charges for items that are generally considered by the third-party payers to be strictly convenience items and therefore are not covered by many health plans. 0 General Classification PT CONVENIENCE 1 Cafeteria/Guest Tray CAFETERIA 2 Private Linen Service LINEN 3 Telephone/Telecom TELEPHONE 4 TV/Radio TV/RADIO 5 Non-Patient Room Rentals NONPT ROOM RENT 6 Late Discharge LATE DISCHARGE 7 Admission Kits ADMIT KITS 8 Beauty Shop/Barber BARBER/BEAUTY 9 Other Convenience Items PT CONV/OTH 100x BEHAVIORAL HEALTH ACCOMMODATIONS Charges for routine accommodations at specified behavior health facilities. 0 General Classification BH R&B 1 Residential Treatment - Psychiatric BH R&B RES/PSYCH Day 2 Residential Treatment - Chemical BH R&B RES/CHEM DEP Day Dependency 3 Supervised Living BH R&B SUP LIVING Day 4 Halfway House BH R&B HALFWAY HOUSE Day 5 Group Home BH R&B GROUP HOME Day 6-9 RESERVED 101x to 209x RESERVED 210x ALTERNATIVE THERAPY SERVICES Charges for therapies not elsewhere categorized under other therapeutic service revenue codes (042x, 043x, 044x, 091x, 094x, 095x) or services such as anesthesia or clinic (0374, 0511). 0 General Classification ALTTHERAPY 1 Acupuncture ACUPUNCTURE Session 2 Acupressure ACUPRESSURE Session 3 Massage MASSAGE Session 4 Reflexology REFLEXOLOGY Session 5 Biofeedback BIOFEEDBACK Session 6 Hypnosis HYPNOSIS Session 7-8 RESERVED 9 Other Alternative Therapy Service OTHER ALTTHERAPY Session : Alternative therapy is intended to enhance and improve standard medical treatment. These revenue code(s) would be used to report services in a separately designated alternative inpatient/outpatient unit. 211x to 309x RESERVED BCNEPA/FPH/FPLIC Billing Manual Page 66

67 Form Locator x ADULT CARE Charges for personal, medical, psycho-social, and/or therapeutic services in a special community setting for adults needing supervision and/or assistance with Activities of Daily Living (ADL). 0 RESERVED 1 Adult Day Care, Medical and Social- ADULT MED/SOC HR Hour Hourly 2 Adult Day Care, Social-Hourly ADULT SOC HR Hour 3 Adult Day Care, Medical and Social- Daily ADULT MED/SOC DAY Day 4 Adult Day Care, Social-Daily ADULT SOC DAY Day 5 Adult Foster Care Daily ADULT FOSTER DAY Day 6-8 RESERVED 9 Other Adult Care OTHER ADULT 311x to 999x RESERVED Form Locator 43 Data Element Revenue Description/IDE Number/Medicaid Drug Rebate The standard abbreviated description of the related revenue code categories included on this bill. (See FL 42 for description of each revenue code category.) FL 43 is also used to report Investigational Device Exemption (IDE) Numbers and information on Medicaid drug rebates. Field Attributes Yes - for paper bills only UB-04: (for paper bills only) /004010A1, : Not Used 1 Field 22 Lines* 24 Positions Alphanumeric Left-justified The standard abbreviated description should correspond with the Revenue Codes as defined by the NUBC. * The 23 rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated with a Revenue Code of BCNEPA/FPH/FPLIC Billing Manual Page 67

68 Form Locator 44 Data Element HCPCS/Accommodation Rates/HIPPS Rate Codes 1. The Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary service and outpatient bills. 2. The accommodation rate for inpatient bills. 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems. See reporting HCPCS and HIPPS Rate Codes UB-04: Situational. for outpatient claims when an appropriate procedure or HIPPS code exists for this service line item. OR for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item /004010A1: Situational X223A2: Situational. for outpatient claims when an appropriate procedure code exists for this service line item. OR for inpatient claims when an appropriate HCPCS (drugs and/or Biologics only) or HIPPS code exists for this service line item. Accommodation Rates UB-04: when a room & board revenue code is reported /004010A1: when the associated revenue code is : Not Used. (Rationale: The rate can be computed by dividing the total charge by the number of units.) HCPCS Modifiers UB-04: when a modifier clarifies or improves the reporting accuracy of the associated procedure code /004010A1: when the Provider needs to convey additional clarification for the associated procedure code : when a (first, second, third or fourth) modifier clarifies or improves the reporting accuracy of the associated procedure code. Field 1 Field 22 Lines (a) 14 Positions (b) Attributes Numeric for Accommodation Rate; alphanumeric for HCPCS and HIPPS Rate Codes. Right-justified for Accommodation Rates; left-justified for HCPCS and HIPPS Rate Codes. Dollar values reported for Accommodation Rates must include whole dollars, the decimal, and the cents. BCNEPA/FPH/FPLIC Billing Manual Page 68

69 Form Locator 44 Field Attributes (a) The 23 rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code (b) For HCPCS, the filed consists of 5 positions for the base code plus 8 positions for up to four HCPCS modifiers; thus, the field contains one extra/unused position. (c) HIPPS rate code are alphanumeric codes of 5 positions. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional informational; the additional information varies amount HIPPS codes. HIPPS Rate Codes The Centers for Medicare and Medicaid services develops and publishes the HIPPS codes to establish a coding system for claims submission and claims payment under prospective payment systems. These codes represent the case mix classification groups that are used to determine payment rates under prospective payment systems. Case mix classification groups include, but may not be limited to, resource utilization groups (RUGs) for skilled nursing facilities, home health resource groups (HHRGs) for home health agencies, and case mix groups (CMGs) for inpatient rehabilitation facilities. HCPCS Modifiers (Level I and Level II) The UB-04 accommodates up to four modifiers, two characters each. Various CPT (Level I HCPCS) and Level II HCPCS codes may require the use of modifiers to improve the accuracy of coding. Consequently, reimbursement, coding consistency, editing and proper payment will benefit from the reporting of modifiers. Hospital should not report a separate HCPCS (five-digit code) instead of the modifier. When appropriate, report a modifier bas on the list indicated in the above section of the AMA publication. Form Locator 45 Data Element Service Date The date (MMDDYY) the outpatient service was provided. (Applies to Lines 1-22; Line 23 refers to the Creation Date (MMDDYY) of the bill (the date bill was created/printed)). This field is also used to report the assessment reference date when billing SNF PPS services (Type of Bill 021x). on outpatient claims Service Date UB-04: on outpatient claims /004010A1: on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment : on outpatient service line where a drug is not being billed and the Statement Covers Period is greater than one day. OR on service lines where a drug is being billed and the payer s adjudication is known to be impacted y the drug duration or the date the prescription was written. BCNEPA/FPH/FPLIC Billing Manual Page 69

70 Form Locator 45 Assessment Date Require when this field is used to report the assessment reference date when billing SNF PPS services (Type of Bill 021x) : Not Used Creation Date for Line 23 (Creation Date). Enter the date the bill was created or prepared for submission. Creation Date on Line 23 should be reported on all pages of the UB-04. Field Service Date: Creation Date: Attributes 1 Field 22 Lines 6 Positions 1 Field 1 Line (23) 6 Positions Numeric Right-justified Numeric Right-justified Data Element Service Units Form Locator 46 A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints f blood, renal dialysis treatments, etc. Yes UB-04, /004010A1, : Field 1 Field 22 Lines 7 Positions Decimal Attributes Numeric Right-justified Enter the total number of covered accommodation days, ancillary units of service, or visits, where appropriate. Leading zeros should not be reported. If the amount is an integer, no decimal point is reported. The maximum length for this field is 7 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. The following notes are intended as general guidance. Inpatient Room & board accommodations: Units reflect the total number of days of care provided to the patient. Other revenue codes: Although the inpatient UB-04 is a summary level claim, units can be reported as 1 or more based on the provider s practice, health plan requirements or regulation. A zero or negative value is not allowed. Outpatient When HPCPS codes are reported, the unit is defined by the HCPCS definition. Where the unit is not defined by the HCPCS code, units can be reported as 1 or more based on the provider s practice, health plan requirements or regulation. A zero or negative value is not allowed. Form Locator 47 BCNEPA/FPH/FPLIC Billing Manual Page 70

71 Data Element Total Charges Total Charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total Charges includes both covered and non-covered charges. Yes Line Item Charges : UB-04 (Lines 1-22) /004010A1, Loop ID 2400 SV203 Total (Summary) Charges : UB-04 Line 23 of the final claim page using Revenue Code (Revenue 0001 is not used on electronic transactions; report the total claim charge in the appropriate data segment/field as indicated below.) /004010A1, Loop ID 2300 CLM02 Field 1 Field 23 Lines * 9 Positions (see notes) Attributes Numeric Right-justified There are 7 positions for dollars, 2 positions for cents. Amounts greater than or equal to zero are acceptable values for this element. The 23 rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code Form Locator 48 Data Element Non-covered Charges To reflect non-covered charges for the destination payer as it pertains to the related revenue code. Not required Line Item Non-Covered Charges : UB-04: Lines if needed to report line specific non-covered charge amount /004010A1: Situational : if needed to report line specific non-covered charge amount. Total (Summary) Non-Covered Charges : UB-04: on Line 23 of the final claim page using Revenue code when there are non-covered charges on the claim /004010A1, : Not Used Field 1 Field 23 Lines * 9 Positions (see ) Numeric Attributes Right-justified There are 7 positions for dollars, 2 positions for cents. * The 23 rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code Form Locator 49 BCNEPA/FPH/FPLIC Billing Manual Page 71

72 Data Element Reserved for Assignment by the NUBC Not used Field 1 Field 23 Lines 2 Positions Alphanumeric Left-justified Attributes Form Locator 50 Data Element Payer Name Name of health plan that the provider might expect some payment for the bill. Yes UB-04: Line A. Lines B and C Situational. when other payers are known to potentially be involved in paying this claim /004010A1, : Field 1 Field 3 Lines 23 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Example: If Medicare is entered in Form Locator 50A, this indicates that the provider has determined based on the responses form the patient or the patient s representative or from the insurance enrollment card information that Medicare is the primary payer. Form Locator 51 Data Element Health Plan Identification Number The number used by the health plan to identify itself. No Report the HIPAA National Plan Identifier when it become mandated; otherwise report the (legacy/proprietary) number (i.e., whatever number used has been defined between trading partners). UB-04: Line A. Lines B and C Situational. when other health plans are known to potentially be involved in paying this claim /004010A1, : Field 1 Field 3 Lines 15 Positions Alphanumeric Left-justified Attributes Form Locator 52 BCNEPA/FPH/FPLIC Billing Manual Page 72

73 Data Element Release of Information Certification Indicator Code indicating whether the provider has on file a signed statement (from the patient or the patient s legal representative) permitting the provider to release data to another organization. Yes UB-04 and :. See code structure noted below /004010A1:. Note: The /004010A1 includes additional codes that are no longer applicable due to the HIPAA medical privacy rule. Field 1 Field 3 Lines 1 Position Alphanumeric Left-justified Attributes The Release of Information response is limited to the information carried in this claim. A = Primary B = Secondary C = Tertiary Code Structure I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Usage Note: when the provider has not collected a signature and state or federal laws do not supersede the HIPAA Privacy Rule by requiring a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Usage Note: when state or federal laws do not supersede the HIPAA Privacy Rule by requiring a signature be collected. Form Locator 53 Data Element Assignment of Benefits Certification Indicator Code indicates provider has a signed form authorizing the third party payer to remit payment directly to the provider. Yes UB-04, /004010A1, : Field 1 Field 3 Lines 1 Position Alphanumeric Left-justified Attributes Form Locator 53 BCNEPA/FPH/FPLIC Billing Manual Page 73

74 Health plans that have arrangements with affiliate health plans in different states may utilize this code to make payments to the provider rather than the insured individual. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. The presence of an assignment does not permit release of medical information about a patient. Code N No Structure W Not Applicable (Use code W when the patient refuses to assign benefits.) Y Yes Data Element Prior Payments - Payer Form Locator 54 The amount the provider has received (to date) by the health plan toward payment of this bill. If applicable UB-04: when the indicated payer has paid an amount to the provider towards this bill. Report 0.00 if there is no payment made by the health plan or payment was applied to coinsurance or deductible /004010A1: when the present payer ha paid an amount to the provider towards this bill : when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR when Loop ID-2919AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. Field 1 Field 3 Lines 10 Positions Numeric Right-justified Attributes There are 8 positions for dollars, 2 positions for cents. A = Primary B = Secondary C = Tertiary Form Locator 55 Data Element Estimated Amount Due - Payer The amount estimated by the provider to be due from the indicated payer (estimated responsibility less prior payments). If applicable UB-04: when the provider estimates an amount due from the indicated payer /004010A1: when the Payer Estimated Amount Due is applicable to this claim : Not Used Form Locator 55 BCNEPA/FPH/FPLIC Billing Manual Page 74

75 Field 1 Field 3 Lines 10 Positions Alphanumeric Left-justified Attributes There are 8 positions for dollars, 2 positions for cents. A = Primary B = Secondary C = Tertiary Form Locator 56 Data Element National Provider Identifier - Billing Provider The unique identification number assigned to the provider submitting the bill: NPI is the national provider identifier. Yes The NPI Final Rule was implemented May 23, UB-04: for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI. OR : for providers not in the United States or its territories when the provider has received an NPI. OR for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. Field 1 Field 3 Lines 15 Positions* Alphanumeric Left-justified* Attributes *Note: The NPI is ten characters in length. Proprietary identifiers necessary for the receiver to identify Billing Providers that area not covered entities are to be reported in FL 57 Lines A-C. Form Locator 57 Data Element Other (Billing) Provider Identifier A unique identification number assigned to the provider submitting the bill by the health plan. Yes Form Locator 57 The NPI Final Rule was implemented May 23, BCNEPA/FPH/FPLIC Billing Manual Page 75

76 004010/004010A1: NPI usage is not applicable due to the implementation of the NPI Final Rule. UB-04: when NPI is not used in FL 56 and an identification number other than the NPI is necessary for the receiver to identify the provider : when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. Field 1 Field 3 Lines 15 Positions Alphanumeric Left-justified Attributes The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider Identifier. Use this field to report other provider identifiers as assigned by the health plan (as indicated in FL 50 Lines A-C). Form Locator 58 Data Element Insured s Name The name of the individual under whose name the insurance benefit is carried. Yes UB-04, /004010A1, : Field 1 Field 3 Lines 25 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Use a comma or space to separate land and first names. Enter last name first. No space should be left between a prefix and a name as in MacBeth, and McEnroe. Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element. Record hyphenated names with the hyphen as in Smith-Jones, Rebecca. To record suffix of a name, write the last name, leave a space and write the suffix, then write the first name as in Snyder III, Harold, or Addams JR., Glen Form Locator 59 Data Patient s Relationship to Insured BCNEPA/FPH/FPLIC Billing Manual Page 76

77 Element Code indicating the relationship of the patient to the indentified insured. Yes UB-04: Line A required. Lines B and C Situational. when other payers are known to potentially be involved in paying on this claim /004010A1:. If the patient is the subscriber, report in Loop ID 2000B. if the patient is not the subscriber but has a unique identifier assigned by the destination payer, report in Loop ID 2000C :. If the patient is the subscriber, the name is reported in Loop ID 2000B. If the patient is not the subscriber but has a unique identifier assigned by the destination payer, the name is reported in Loop ID 2000B. If the patient is not the subscriber and cannot be identified by a unique identifier assigned by the destination payer, report in Loop ID 2000C. Field 1 Field 3 Lines 2 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Code Title 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship Form Locator 60 Data Element Insured s Unique Identifier The unique number assigned by the health plan to the insured. Yes UB-04: Line A. Lines B and C Situational. when other health plans are known to potentially be involved in paying this claim /004010A1, : Field 1 Field 3 Lines 20 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Form Locator 61 Data Insured s Group Name BCNEPA/FPH/FPLIC Billing Manual Page 77

78 Element The group or plan name through which the insurance is provided to the insured. UB-04: Line A Situational. if the Group Name is available and FL 62 (Insurance Group Number) is not used. Lines B and C Situational. when other insurance/payers/health plans are known to potentially be involved in paying this claim and when FL62 B and C are not used /004010A1: Situational. Used only when no group number is reported : when Group Number (Loop ID 2000B) is not used and the group name is available. Field 1 Field 3 Lines 14 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Form Locator 62 Data Element Insured s Group Number The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered. Yes UB-04: Line A Situational. when the insured s identification card shows a group number. Lines B and C Situational. when other insurance/payers/health plans are known to potentially be involved in paying this claim and when the other insurance s identification card shows a group number /004010A1: Situational : when the subscriber s identification card for the destination payer (Loop ID 2010BB) shows a group number. Field 1 Field 3 Lines 17 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Data Authorization Code/Referral Number Form Locator 63 BCNEPA/FPH/FPLIC Billing Manual Page 78

79 Element An identifier that designates that services on this bill have been authorized by the payer or indicates that a referral is involved. No Authorization UB-04: Situational. when an authorization code is assigned by the payer or UMO (Utilization Management Organization) is required to be reported on the claim /004010A1: Situational. where services on this claim were preauthorized or where a referral is involved : Situational. when an authorization code is assigned by the payer or UMO (Utilization Management Organization) AND the services on this claim were preauthorized. Referral Number UB-04: Situational. when a referral number is code assigned by the payer or UMO (Utilization Management Organization) AND a referral is involved /004010A1: Situational. where services on this claim were preauthorized or where a referral is involved : Situational. when a referral number is assigned by the payer or UMO (Utilization Management Organization) AND a referral is involved. Field 1 Field 3 Lines 30 Positions Alphanumeric Left-justified Attributes A = Authorization Code B = Referral Number C = Secondary Payer Authorization Code Form Locator 64 Data Element Document Control Number (DCN) The control number assigned to the original bill by the health plan or the health plan s fiscal agent as part of their internal control. No UB-04: Situational. when Type of Bill Frequency Code (FL 04) indicates this claim is a replacement or void to a previously adjudicated claim /004010A1: Situational : Situational. (Payer Claim Control Number) required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. Form Locator 64 Field 1 Field 3 Lines 26 Positions Alphanumeric Left-justified BCNEPA/FPH/FPLIC Billing Manual Page 79

80 Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Payer A s ICN/DCN should be shown on Line A of FL 64. Similarly, the ICN/DCN for Payers B and C should be shown on lines B and C respectively, of FL 64. Form Locator 65 Data Element Employer Name (of the Insured) The name of the employer that provides health care coverage for the insured individual identifier in FL 58. No UB-04: Situational. Lines A, B, C required when the employer of the insured is known to potentially be involved in paying on this claim /004010A1 and : Not Used Field 1 Field 3 Lines 25 Positions Alphanumeric Left-justified Attributes A = Primary Payer B = Secondary Payer C = Tertiary Payer Form Locator 66 Data Element Diagnosis and Procedure Code Qualifier (ICD Version Indicator) The qualifier that denotes the version of International Classification of Diseases (ICD) reported. No UB-04: Qualifier Code 9 on claims through September 30, ICD-9-CM cannot be reported on HIPAA covered entity claims on or after October 1, 2014 (a). The NUBC strongly encourages all entities covered and non-covered alike to follow the diagnosis and procedure code rules in effect pre and post October 1, 2014 (a). Qualifier Code 0 designating ICD-10-CM and ICD-10-PCS can only be used on or after October 1, 2014 (a) based on a final rule naming ICD-10-CM and ICD-10-PCS as allowable code sets under HIPAA, and a proposed rule dated 4/17/12 changing the compliance date from October 1, 2013 to October 1, OR For claims which are not covered under HIPAA (before October 1, 2014 (a) ). Form Locator /004010A1: Not Applicable. Only ICD-9-CM qualifier codes are available in version 4010/4010A1. BCNEPA/FPH/FPLIC Billing Manual Page 80

81 005010: Data Element not Applicable. Version 5010 contains distinct qualifier codes for ICD-9-CM ( BF ), ICD-10-CM ( ABF ) and ICD-10-PCS ( BBR ). ABF and BBR that can only be used on or after October 1, 2014 (a) based on a final rule naming the ICD-10- CM and ICD-10-PCS as allowable code sets under HIPAA, and a proposed rule dated 4/17/12 changing the compliance date from October 1, 2013 to October 1, OR For claims which are not covered under HIPAA (before October 1, 2014 (a ). Field 1 Field 1 Lines 1 Positions Alphanumeric Left-justified Attributes Qualifier codes reflects the edition portion of the ICD: 9 - Ninth Revision 0 - Tenth Revision (a) In a proposed rule dated 4/17/12, DHHS proposed to change the compliance date for the International Classification of Diseases, 10 th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, including the Official ICD-10-CM Guidelines for Coding and, and the International Classification of Diseases, 10 th Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding, including the Official ICD-10-PCS Guidelines for Coding and, from October 1, 2013 and October 1, Form Locator 67 Data Element Principal Diagnosis Code and Present on Admission Indicator The ICD-9-CM codes describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for occasioning the admission of the patient for care.) See FL 67 for information on the Present on Admission Indicator noted below. For additional information, refer to the Official ICD-9-CM Guidelines for Coding and. Yes UB-04, /004010A1, : Principal Diagnosis Code Present on Admission Indicator - See FL 67 for further information on usage. Field 1 Field 1 Line Alphanumeric Left-justified Attributes 8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on Admission Indicator) Follow the official coding guidelines for ICD reporting. The reporting of the decimal between the third and fourth digit is unnecessary because it is implied. The principal diagnosis code will include the use of V codes. Present on Admission (POA) Indicator The eighth digit of FL 67 - Principal Diagnosis and each of the secondary diagnosis fields FL A-Q. The eighth digit of FL 72 External Cause of Injury (ECI) (3 fields on the form). Form Locator 67 Present on Admission (POA) Indicator BCNEPA/FPH/FPLIC Billing Manual Page 81

82 General Requirements All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation (e.g., Deficit Reduction Act of 2005) mandating collection of present on admission information. Effective 1/1/2011: All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation (e.g. Deficit Reduction Act of 2005) mandating collection of present on admission information, or as mutually agreed to under contract with an insurance program. Present on admission is defined as present at the time the order for inpat4ient admission occurs conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. POA indicator is assigned to principal and secondary diagnoses ( as defined in Section II of the Official Guidelines for Coding and ) and the external cause of injury codes. Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider. If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported. Options The five reporting options for all diagnosis reporting are as follows: Code Y Yes N No U No Information in the Record W Clinically Undetermined Blank Field on UB-04/ Exempt from POA Not Populated in Effective July 1, on UB-04 Only/Not Exempt from POA Populated in Definitions: Code Definition Y = Present at the time of inpatient admission N = Not present at the time of inpatient admission U = Documentation is insufficient to determine if condition is present on admission W = Provider is unable to clinically determine whether condition was present on admission or not Effective July 1, * = Exempt from POA * UB-04 only; not for use on 837 Form Locator 67 Present on Admission (POA) Indicator (continued) BCNEPA/FPH/FPLIC Billing Manual Page 82

83 Health plans that receive POA information on the claim should not reject the claim if their claims processing systems have no use for any of the POA information. The American Health Information Management Association, American hospital Association, CMS and the National Center for Health Statistics (known as the Cooperating Parties ) has published a list of ICD-9-CM codes that are exempt from POA reporting. The indicator can be left unreported only for the codes on this list, that is, the filed is left blank on the paper form and Not Used on the electronic claim. The list of exempt diagnosis codes will be included in the POA guideline published in the ICD-9-CM Official Guidelines for Coding and (Appendix I - Present on Admission Guidelines). These guidelines will be updated as needed to address identified coding errors or areas of confusion. POA for 00410/00410A1 837 Medicare Claims Section 5001 of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on the admission (POA) of patients effective for discharges on or after October 1, Effective October 1, 2007, Medicare will begin to accept a POA indicator for every diagnosis on your inpatient acute care hospital claims. However, providers must submit the POA on hospital claims beginning with discharges on or after January 1, Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, and children s inpatient facilities are exempt from this requirement. CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an other diagnosis. CMS Options and Definitions Y = Yes = present at the time of inpatient admission N = No = not present at the time of inpatient admission U = Unknown = the documentation is insufficient to determine if the condition was present at the time of inpatient admission. W = Clinically Undetermined = the provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not 1 = Unreported/Not used - Exempt from POA reporting. This code is the equivalent code of a blank on the UB-04, however, it was determined that blanks were undesirable when submitting this data via the 0410/00410A1 The POA element on your electronic claims must contain the letters POA followed by a single POA indicator for every diagnosis that your report. The POA indicator for the principal diagnosis should be the first indicator after POA, and (when applicable) the POA indicators for secondary diagnoses would follow. The last POA indicator must be followed by the letter Z to indicate the end of the data element (or FIs and A/B MACs will allow the letter X which CMS may use to identify special data processing situations in the future). Form Locator 67 Present on Admission (POA) Indicator (continued) BCNEPA/FPH/FPLIC Billing Manual Page 83

84 POA for 00410/00410A1 837 Medicare Claims Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL 67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on claims submitted electronically via 00410/00410A1 837 format, you must use segment K3 in the 2300 loop, data element K301. Below is an example of what this coding should look like on an electronic claim: If segment K3 read as follows: POAYNUWIYZ, it would represent the POA indictors for a claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y), the first secondary diagnosis was not POA (N), it was unknown if the second secondary diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the fifth secondary diagnosis was POA (Y). As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA data and POA data will also be included with any secondary claims sent by Medicare for coordination of benefits purposes. The official instruction, CR5679, issued to FIs or A/B MACs can be found at Hospitals Exempt from Present on Admission (POA) (i.e. non-inpatient Prospective Payment System (IPPS) Hospitals) and the Grouper Although POA reporting is not required for IPPS exempt hospitals, their claims still process through Grouper. Some exempt hospitals report the POA, however, due to other payer requirements or business needs. When exempt hospitals report the POA, they must include an X to indicate the end of POA reporting in the K3 segment of the claim. The X indicator will prevent Grouper from Applying Hospital-Acquired Condition (HAC) Diagnosis Related Group (DRG) logic to the claim. Effective October 1, 2008, FISS will automatically replace any reported Z indicator with an X for providers exempt from reporting POA. However, exempt providers should begin to report an X to indicate the end of POA reporting as soon as possible. The official instruction, CR6086, can be found at Form Locator 67A-Q Data Other Diagnosis Code and Present on Admission Indicator BCNEPA/FPH/FPLIC Billing Manual Page 84

85 Element The ICD-9-CM codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital stay. For additional information, refer to the Official ICD-9-CM Guidelines for Coding and. Other Diagnosis Codes UB-04: Situational. when other condition(s) coexist or develop(s) subsequently during the patient s treatment /004010A1: Situational. when other condition(s) coexists with the Principal Diagnosis, coexists at the time of admission or develops subsequently during the patient s treatment : Situational. when other condition(s) coexist or develop(s) subsequently during the patient s treatment. Present on Admission Indicator For use on the UB-04 and only; not for use in any manner on /004010A1 Field 17 Fields 2 Lines Alphanumeric Left-justified Attributes 8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on Admission Indicator) The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. Other diagnoses codes will permit the use of ICD-9-CM V and E codes where appropriate. Other diagnosis is interpreted as additional conditions that affect patient care in terms of requiring: Clinical Evaluation, or Therapeutic Treatment, or Diagnostic Procedures, or Extended Length of Hospital Stay, or Increased Nursing Care and/or Monitoring. Form Locator 68 Data Element Reserved for Assignment by the NUBC Not Used Field 1 Field 2 Lines Alphanumeric Left-justified Attributes 8 Positions (Line 1) 9 Positions (Line 2) Data Admitting Diagnosis Code Form Locator 69 BCNEPA/FPH/FPLIC Billing Manual Page 85

86 Element The ICD diagnosis code describing the patient s diagnosis at the time of admission. Yes - Inpatient only UB-04: Situational. when claim involves an inpatient admission. on 012x, 022x and inpatient claims ( IP ) except 028x, 065x, 066x, 084x, 086x /004010A1: Situational. The Admitting Diagnosis is required on all inpatient admission claims and encounters : Situational. when claim involves an inpatient admission. Field 1 Field 1 Line 7 Positions Alphanumeric Left-justified Attributes The ICD-9-CM diagnosis code describing the admitting diagnosis as a significant finding representing patient distress, an abnormal finding on examination, a possible diagnosis based on significant findings, a diagnosis established from a previous encounter or admission, an inquiry, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor. Report only one admitting diagnosis. This condition shall be determined based on the ICD-9-CM coding directives in Volumes I and II of the ICD-9-CM coding manuals (ICD-9-CM codes 001 V82.9). The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. Form Locator 70a-c Data Element Patient s Reason for Visit BCNEPA/FPH/FPLIC Billing Manual Page 86

87 The ICD-CM diagnosis codes describing the patient s reason for visit at the time of outpatient registration. UB-04: Situational. 1. for all unscheduled outpatient visits. An unscheduled outpatient visit is defined as an outpatient Type of Bill 013x, 085x, or 078x together with FL 14 (Priority of Visit/Type of Admission) codes 1,2 or 5 and Revenue Codes 045x, 0516, 0526, or 0762 (Observation Hours). 2. May be reported at submitter s discretion for scheduled outpatient visits (such as encounters for ancillary tests) when this information provides additional information to support medical necessity. This information may be any documented reason for the service provided, including patient s stated reason for seeking care or the reason provided by the physician as part of the order for the service. This information is not required for all scheduled outpatient encounters. 3. Payers should not reject outpatient claims that contain patient s reason for visit information in FL 70 if this information is not needed for their adjudication of the claim /004010A1: Situational. for all unscheduled outpatient visits or upon the patient s admission to the hospital : Situational. when claim involves outpatient visits. See ASC X12N/TG2 interpretation (RFI #1256) on Patient s Reason for Visit (005010X223A2) (See specific UB-04 requirements above and FL 04.) Field 1 Field, 3 Subfields (a,b,c) 1 Line Alphanumeric Left-justified Attributes 7 Positions The ICD-9-CM diagnosis code describing the patient s stated reason for seeking care (or as stated by the patient s representative). This may be a condition representing patient distress, an injury, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor. Report the first diagnosis code describing the patient s primary reason for seeking care in subfield a. This condition shall be determined based on the ICD-9-CM coding directives in Volumes I and II of the ICD-9-CM coding manuals (ICD- 9-CM codes V82.9). There are two other diagnosis code subfields to report additional reasons for the patient s visit for care. the decimal between the third and fourth digits is unnecessary because it is implied. Form Locator 71 Data Element Prospective Payment System (PPS) Code BCNEPA/FPH/FPLIC Billing Manual Page 87

88 The PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. UB-04: Situational. for inpatient claims when the hospital is under contract with the health plan to provide this information /004010A1: Situational. when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer : Situational. when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. Field 1 Field 1 Line 4 Positions Numeric Attributes Right-justified (all positions fully coded) Note Many workers compensation programs require this information. Form Locator 72a-c Data External Cause of Injury (ECI) Code and Present on Admission Indicator BCNEPA/FPH/FPLIC Billing Manual Page 88

89 Element The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or adverse effect. For additional information, refer to the Official ICD-9-CM Guidelines for Coding and. External Cause of Injury (ECI) Code UB-04: Situational. when an injury, poisoning, or adverse effect is the cause for seeking medical treatment or occurs during the medical treatment /004010A1: Situational. whenever a diagnosis is needed to describe an injury, poisoning or adverse effect : Situational. when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. Present on Admission Indicator: For use on the UB-04 and only; not for use in any manner on /004010A1. See FL 67 for further information on usage. Field 3 Fields 1 Line Left-justified Attributes 8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on Admission Indicator) Note The priorities for recording an ECI code in Form Locator 72a-c are: 1. Principal diagnosis of an injury or poisoning. 2. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. 3. Other diagnosis with an external cause. Form Locator 73 Data Element Reserved for Assignment by the NUBC Not Used Field 1 Field 1 Line 9 Positions Attributes Alphanumeric Left-justified BCNEPA/FPH/FPLIC Billing Manual Page 89

90 Form Locator 74 Data Element Principal Procedure Code and Date The ICD code that identifies the inpatient principal procedure performed at the claim level during the period covered by this bill and the corresponding date. UB-04: Situational. on inpatient claims when a procedure was performed. If not required (i.e., on outpatient claims) do not send /004010A1: Situational. on Home IV therapy claims or encounters when surgery was performed during the inpatient stay from which the course of therapy was initiated. on inpatient claims or encounters when a procedure was performed : Situational. on inpatient claims when a procedure was performed. If not required by the implementation guide, do not send. Field 1 Field (code) 1 Field (date) Attributes 1 Line 1 Line 7 Positions 6 Positions Alphanumeric Numeric Left-justified Right-justified the decimal between the second and third digits of the ICD is unnecessary because it is implied. Enter date as MMDDYY Form Locator 74a-c Data Element Other Procedure Codes and Dates The ICD codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. UB-04: Situational. on inpatient claims when additional procedures must be reported. If not required (i.e., on outpatient claims) do not send /004010A1: Situational. on Home IV therapy claims or encounters when surgery was performed during the inpatient stay from which the course of therapy was initiated. on inpatient claims or encounters when additional procedures must be reported : Situational. on inpatient claims when additional procedures must be reported. If not required by the implementation guide (TR3), do no send. Field 5 Fields (code) 5 Fields (date) Attributes 1 Line 1 Line 7 Positions 6 Positions Alphanumeric Numeric Left-justified Right-justified the decimal between the second and third digits of the ICD is unnecessary because it is implied. Enter date as MMDDYY BCNEPA/FPH/FPLIC Billing Manual Page 90

91 Form Locator 75 Data Element Reserved for Assignment by the NUBC Not Used Field 1 Field 4 Lines 4 Positions Attributes Alphanumeric Left-justified Form Locator 76 Data Element Attending Provider Name and Identifiers The Attending Provider is the individual who has overall responsibility for the patient s medical care and treatment reported in this claim. Yes Name UB-04 and : Situational. when the claim contains any services other than non-scheduled transportation claims /004010A1: Situational. on all inpatient claims or encounters. to indicate the Primary Physician responsible on a Home Health Agency Plan of Treatment. Identifiers - National Provider Identifier The NPI Final Rule was implemented on May 23, For purposes of this manual, the /004010A1 National Provider Identifier and Secondary Identifier situational usage is not applicable due to the implementation of the NPI Final Rule. UB-04: Situational. for providers in the United States or its territories when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories when the provider has received an NPI : Situational. for providers in the United States or its territories on or after the mandated HIPAA NPI implementation date when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI. OR for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. BCNEPA/FPH/FPLIC Billing Manual Page 91

92 Form Locator 76 Identifiers - Secondary UB-04: Situational. when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider : Situational. prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR on or after the mandated NPI Implementation Date when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. Field 5 Fields 2 Lines Alphanumeric Left-justified Attributes Line 1: 11 Positions* - National Provider Identifier 2 Positions - Secondary Identifier Qualifier (see below) 9 Positions - Secondary Identifier Line 2: 16 Positions - Last Name 12 Positions - First Name *Note: The NPI is ten characters in length. Secondary Identifier Qualifiers: 0B - State License Number 1G - Provider UPIN Number G2 - Provider Commercial Number BCNEPA/FPH/FPLIC Billing Manual Page 92

93 Form Locator 77 Data Element Operating Physician Name and Identifiers The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s). Name UB-04 and : Situational. when a surgical procedure code is listed on this claim /004010A1: Situational. when any surgical procedure code is listed on this claim. Identifiers - National Provider Identifier The NPI Final Rule was implemented on May 23, For purposes of this manual, the /004010A1 National Provider Identifier and Secondary Identifier situational usage is not applicable due to the implementation of the NPI Final Rule. UB-04: Situational. for providers in the United States or its territories when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories when the provider has received an NPI : Situational. for providers in the United States or its territories on or after the mandated HIPAA NPI implementation date when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI. OR for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. Identifiers - Secondary UB-04: Situational. when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider : Situational. prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR on or after the mandated NPI Implementation Date when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. BCNEPA/FPH/FPLIC Billing Manual Page 93

94 Form Locator 77 Field 5 Fields 2 Lines Alphanumeric Left-justified Attributes Line 1: 11 Positions* - National Provider Identifier 2 Positions - Secondary Identifier Qualifier (see below) 9 Positions - Secondary Identifier Line 2: 16 Positions - Last Name 12 Positions - First Name *Note: The NPI is ten characters in length. Secondary Identifier Qualifiers: 0B - State License Number 1G - Provider UPIN Number G2 - Provider Commercial Number Form Locator Data Element Other Provider (Individual) Names and Identifiers The name and ID number of the individual corresponding to the Provider Type category indicated in this section of the claim. See notes below. Name UB-04 and : Situational. See allowable provider type qualifier codes and usage notes /004010A1: Situational. when the claim/encounter involves another provider such as, but not limited to: Referring Provider, Ordering Provider, Assisting Provider, etc. Identifiers - National Provider Identifier The NPI Final Rule was implemented May 23, For purposes of this manual, the /004010A1 National Provider Identifier and Secondary Identifier situational usage is not applicable due to the implementation of the NPI Final Rule. BCNEPA/FPH/FPLIC Billing Manual Page 94

95 Form Locator Other Operating Physician and Rendering Provider: UB-04: Situational. for providers in the United States or its territories when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories when the provider has received an NPI : Situational. for providers in the United States or its territories on or after the mandated HIPAA NPI implementation date when the provider is eligible to receive an NPI. OR for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI. OR for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. Referring Provider: UB-04: for providers when the provider has received an NPI and the NPI is available to the submitter : for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter. OR for providers prior to the mandated NPI Implementation date when the provider has received an NPI and the submitter has the capability to send it. Identifiers - Secondary UB-04: Situational. when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider : Situational. prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR on or after the mandated NPI Implementation Date when the NPI in this field is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. Field 6 Fields 2 Lines Alphanumeric Left-justified Attributes Line 1: 2 Positions - Provider Type Qualifier (see below) 11 Positions* - National Provider Identifier 2 Positions - Secondary Identifier Qualifier (see below) 9 Positions - Secondary Identifier Line 2: 16 Positions - Last Name 12 Positions - First Name *Note: The NPI is ten characters in length. BCNEPA/FPH/FPLIC Billing Manual Page 95

96 Form Locator Provider Type Qualifier Codes/Definition/Situational Usage for UB-04 and : DN - Referring Provider. The provider who sends the patient to another provider for services. on an outpatient claim when the Referring Provider is different than the Attending Physician. If not required, do not send. ZZ - Other Operating Physician. An individual performing a secondary surgical procedure or assisting the Operating Physician. when another Operating Physician is involved. If not required, do not send Rendering Provider. The health care professional who delivers or completes a particular medical service or non-surgical procedure. Report when state or federal regulatory requirements call for a combined claim, i.e., a claim that includes both facility and professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim). If not required, do not send. Secondary Identifier Qualifiers: 0B - State License Number 1G - Provider UPIN Number G2 - Provider Commercial Number Form Locator 80 Data Element Remarks Field Area to capture additional information necessary to adjudicate the claim. UB-04: Situational. when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set /004010A1: Situational. The Billing Note segment (Loop ID 2300 NTE) is used to convey additional information necessary to adjudicate the claim. when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) in the opinion of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set : Situational (Loop ID 2300 NTE). when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR when in the judgment of the provider, narrative information from the forms Home Health Certification and Plan of Treatment or Medical Update and Patient Information is needed to substantiate home health services. Field 1 Field 4 Lines Alphanumeric Left-justified Attributes Line 1: 19 Positions Line 2-4: 24 Positions The UB-04 Remarks Field is too small to accommodate addresses. Therefore, do not use this field for the patient or health plan address; FL 38 is designed for window envelopes and should be used for this purpose. BCNEPA/FPH/FPLIC Billing Manual Page 96

97 Form Locator 81 Data Element Code-Code Field To report additional codes related to a Form Locator (overflow) or to report externally maintained codes approved by the NUBC for inclusion in the institutional data set. Situational. See specifics below. For overflow NUBC codes (A1-A4), see applicable Form Locator. Field Left Column Middle Column Right Column Attributes 1 Field (Code Qualifier) 1 Field (Code) 1 Field (Number or Value) 4 Lines 4 Lines 4 Lines 2 Positions 10 Positions 12 Positions Alphanumeric Alphanumeric Alphanumeric Left-justified Left-justified Right-justified (fully coded) Code List Qualifiers: 01-A0 Reserved for National Assignment A1 National Uniform Billing Committee Condition Codes (FL 18-28) Right Example: A A2 National Uniform Billing Committee Occurrence Codes (FL 31-34) Example: A A3 National Uniform Billing Committee Occurrence Span Codes (FL 35-36) All positions fully coded in the right column. Example: A 3 M A4 National Uniform Billing Committee Value Codes (FL 39-41) For Value Codes, there is an implied dollar/cents delimiter in the right column of FL 81 separating the last two positions as illustrated below. $ $ $ $ $ $ $ $ $ $ c c See FL for special rules for reporting values. Whole numbers or nondollar amounts are right justified to the left of the implied dollars/cents delimiter. Do not zero fill the positions to the left of the implied delimiter. However, values are reported as cents, thus reference to the instructions for specific does is necessary. A BCNEPA/FPH/FPLIC Billing Manual Page 97

98 Form Locator 81 A5-AB Reserved for Assignment by the NUBC. AC Attachment Control Number (Effective 1/1/09) Code Source: ASC X12 Data Element Report Type Code Codes valid for use on UB-04: 04 Drugs Administered (medications) AM Ambulance Certification DS Discharge Summary LA Laboratory Results M1 Medical Record Attachment NN Nursing OB Operative OZ Support Data for Claim (e.g., itemized bill) PN Physical Therapy RR Radiology Reports UL Other Type of Report Example: A C R R E L A C AD-B0 B1 Reserved for Assignment by the NUBC. Standards for the Classification of Federal Data on Race and Ethnicity Code Source: ASC X12 External Code Source 859 (Centers for Disease Control and Prevention (CDC)) * FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or federal law or regulations. Example: B 1 R 5 E 2 B2 Reserved for Martial Status Code Source: ASC X12 Data Element 1067 * (Effective Date to be Determined) FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or federal law or regulations. Example: B 2 M * Use of Code List Qualifiers B1 and B2 is intended to promote standardized public health reporting of these data elements. BCNEPA/FPH/FPLIC Billing Manual Page 98

99 Form Locator 81 B3 Health Care Provider Taxonomy Code Code Source: ASC X12 External Code Source 682 (National Uniform Claim Committee) UB-04: Situational. Used for Billing Provider Only (FL01). when the payer s adjudication is known to be impacted by the provider taxonomy code /004010A1 (Loop ID 2000A PRV03): Situational. when adjudication is known to be impacted by the provider taxonomy code, and the Service Facility Provider is the same entity as the Billing and/or Pay-to Provider (Loop ID 2000A PRV03): Situational. when the payer s adjudication is known to be impacted by the provider taxonomy code. All positions fully coded in the middle column; the right-hand column is left blank. Example: B N X B4-B6 Source of Payment Typology Code Source: Public Health Data Standards Consortium ( (ASC X12 External Code Source 944) B4 = Payer A (Primary) B5 = Payer B (Secondary) B6 = Payer C (Tertiary) * (Effective Date July 1, 2009) FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or federal law or regulations. Example: B B 5 2 *Use of Code List Qualifiers B4-B6 is intended to promote standardized Public Health of these data elements. B7 Preferred Language Spoken Code Source: ISO Language Codes The language the patient prefers for discussing health care information with those in the health care community. (Effective Date January 1, 2011) FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or federal law or regulations. Example*: B 7 SPA *ISO recommends use of the language codes in lower case, but they should be considered case-insensitive and are unique codes regardless of case. This examples uses upper case letters which coincides with the basic character set used in the X12 standard (Appendix B of the implementation guides). B8-ZZ Reserved for Assignment by the NUBC. BCNEPA/FPH/FPLIC Billing Manual Page 99

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