The document provides an overview of the UB-04 form which replaced the UB-92 form and was mandated for use in May 2007, it describes the various form locators that make up the UB-04 including those for patient information, billing information, diagnosis codes, and provider information. The presentation aims to educate Medicare Part A providers on properly completing the UB-04 form.

1. UB-04 Overview
Medicare Part A Provider Outreach and Education
June 2007

2. IMPORTANT
The information contained in this
presentation was current as of June 2007
and can be found in Change Request
(CR) 5593, Pub. 100-04, Transmittal
1254, dated May 25, 2007, which can be
downloaded from:
www.cms.hhs.gov/Transmittals/Downloads/R1254CP.pdf
Slide 2

3. UB-04
• Uniform bill for
institutional
providers.
• Replaces the UB-
92.
• Mandated May 23,
2007.
Slide 3

4. Patient Information

5. Form Locator 1
Billing Provider Information
Slide 5

6. Form Locator 2
Pay-to Name and Address
Slide 6

7. Form Locator 3
Patient Control Number/Medical Record
Number
Slide 7

8. Form Locator 4
Type of Bill (TOB)
Slide 8

9. Form Locator 5
Federal Tax Number
Slide 9

10. Form Locator 6
Dates of Service
Slide 10

11. Form Locator 8
Patient’s Name
Slide 11

12. Form Locator 9
Patient’s Address
Slide 12

13. Form Locator 10
Patient’s Date of Birth
Slide 13

14. Form Locator 11
Patient’s Gender
Slide 14

15. Form Locators 12−15
Admission Date, Type and Source
Slide 15

16. Admission Type
Examples
Code Description Definition
The patient requires immediate medical intervention as a result of
1 Emergency
severe, life-threatening or potentially disabling conditions.
The patient requires immediate attention for the care and treatment of a
2 Urgent
physical or mental disorder.
3 Elective The patient’s condition permits adequate time to schedule the services.
Use of this code necessitates the use of special source of admission
4 Newborn
codes (Form Locator 15).
Visit to a trauma center/hospital as licensed or designated by the state
or local government authority authorized to do so, or as verified by the
5 Trauma
American College of Surgeons and involving a trauma activation. (Use
revenue code 068X to capture trauma activation charges.)
Information Information not available.
9
not available
Slide 16

17. Admission Source
Examples
Code Description
1 Physician referral
2 Clinic referral
3 HMO referral
4 Transfer from a hospital
5 Transfer from a Skilled Nursing Facility (SNF)
6 Transfer from another health care facility
7 Emergency room
8 Court/law enforcement
9 Information not available
A Transfer from a Critical Access Hospital (CAH)
B Transfer from another home health agency
C Readmission to same home health agency
Transfer from hospital inpatient in the same facility resulting in a separate claim
D
to the payer
Slide 17

18. Form Locators 16−17
Discharge Hour and Discharge Status
Slide 18

19. Discharge Status Code
Examples
Code Description
01 Discharged to home or self-care (routine discharge)
Discharged/transferred to a short-term general hospital for inpatient
02
care
Discharged/transferred to an SNF with Medicare certification in
03
anticipation of covered skilled care
Discharged/transferred to another type of health care institution not
05
defined elsewhere in this code list
Discharged/transferred to home under care of an organized home
06
health service organization in anticipation of covered skilled care
07 Left against medical advice or discontinued care
20 Expired
Slide 19

20. Form Locators 18−28
Condition Codes
Slide 20

21. Condition Code
Examples
Code Description
02 Condition is employment-related
Treatment of non-terminal condition for
07
hospice
Beneficiary would not provide
08
information concerning other coverage
20 Beneficiary requested billing
21 Billing for denial notice
Slide 21

22. Form Locator 29
Accident State
Slide 22

23. Form Locators 31−34
Occurrence Codes and Dates
Slide 23

24. Occurrence Code
Examples
Code Description
01 Auto accident
04 Accident employment-related
11 Onset of illness
Date of retirement for
18
patient/beneficiary
24 Date insurance denied
Slide 24

25. Form Locators 35−36
Occurrence Span Codes and Dates
Slide 25

26. Occurrence Span
Code Examples
Code Description
74 Leave of absence
76 Patient liability
77 Provider liability
Slide 26

27. Form Locator 38
Responsible Party’s Name and Address
Slide 27

28. Form Locators 39−41
Value Codes and Amounts
Slide 28

29. Value Code
Examples
Code Description
12 Working aged
37 Pints of blood furnished
50 Physical therapy visits
53 Cardiac rehabilitation visits
80 Covered days
81 Non-covered days
82 Coinsurance days
83 Lifetime reserve days
Slide 29

30. Billing Information

31. Form Locator 42
Revenue Codes
Slide 31

32. Form Locator 43
Revenue Code Description
Slide 32

33. Form Locator 44
HCPCS Codes, Rates, HIPPS codes and
Modifiers
Slide 33

34. Form Locator 45
Service Dates
Slide 34

35. Form Locator 46
Service Units
Slide 35

36. Form Locator 47
Total Charges
Slide 36

37. Form Locator 48
Non-Covered Charges
Slide 37

38. Line 23
Slide 38

39. Payer Information

40. Form Locator 50
Payer Name
Slide 40

41. Form Locator 51
Health Plan Identification Number
Slide 41

42. Form Locators 52−53
Release of Information and Assignment of
Benefits
Slide 42

43. Form Locator 54
Prior Payments
Slide 43

44. Form Locator 55
Estimated Amount Due
Slide 44

45. Form Locators 56−57
National Provider Identifier (NPI) and Other
Provider Identifier
Slide 45

46. Form Locator 58
Insured’s Name
Slide 46

47. Form Locator 59
Patient’s Relationship to the Insured
Slide 47

48. Patient’s Relationship
Code Examples
Code Description
01 Spouse
18 Patient is insured
19 Natural child/insured financial responsibility
43 Natural child/insured does not have financial
responsibility
22 Handicapped dependent
29/53 Life partner
32 Mother
33 Father
Slide 48

49. Form Locator 60
Insured’s Unique Identifier
Slide 49

50. Form Locator 61
Insured’s Group Name
Slide 50

51. Form Locator 62
Insured’s Group Number
Slide 51

52. Form Locator 63
Treatment Authorization Codes
Slide 52

53. Form Locator 64
Document Control Number (DCN)
Slide 53

54. Form Locator 65
Employer’s Name
Slide 54

55. Diagnosis Information

56. Form Locator 66
Diagnosis and Procedure Code Qualifier
Slide 56

57. Form Locator 67
Principal Diagnosis Code and Present on
Admission (POA) Indicator
Slide 57

58. POA Indicator
Indicator Description
Y Yes
N No
W Clinically undetermined
U No information in the record
Unreported or not used Exempt from POA reporting
Slide 58

59. Form Locator
67A−Q
Other Diagnosis Codes and POA Indicator
Slide 59

60. Form Locator 69
Admitting Diagnosis Code
Slide 60

61. Form Locator 70
Patient’s Reason for Visit
Slide 61

62. Form Locator 71
Prospective Payment System (PPS) Code
Slide 62

63. Form Locator 72
External Cause of Injury (ECI) Code
Slide 63

64. Form Locator 74
Principal and Other Procedure Codes and
Dates
Slide 64

65. Form Locator 76
Attending Provider’s Name and Identifiers
Slide 65

66. Secondary Identifier
Qualifiers
Qualifier Description
0B State license number
1G Provider’s UPIN number
G2 Provider’s commercial number
Slide 66

67. Form Locator 77
Operating Physician’s Name and Identifiers
Slide 67

68. Form Locators 78-79
Other Providers’ Names and Identifiers
Slide 68

69. Provider Type Qualifier
Codes
Qualifier Description
DN Referring provider
ZZ Other operating physician
82 Rendering provider
Slide 69

70. Form Locator 80
Remarks
Slide 70

71. Form Locator 81
Healthcare Provider Taxonomy Code
(HPTC)
Slide 71

72. HPTC
The Healthcare Provider Taxonomy Code
(HPTC) list is available at:
www.wpc-edi.com/codes/taxonomy
Slide 72

73. UB-04 Overview
Thank you for attending.
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