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