2013 ub 04 manual for valid values

New ub04 claim form completion instructions providers should use the instructions in attachment 1. Hospital discharge data system user manual august 2018 7 numerous and significant changes have been made to the ub04 manual from 2011 through 2018. Blue cross and blue shield of oklahoma offers this guide to help you complete the ub04 form for your patients with blue cross facility coverage. Tips for completing the ub04 cms 1450 claim form page 2 of 17. Sep 17, 20 ub04 claim form instructions may 14, 20 nevada medicaid may 14, 20 updated. These values are valid for paper claim subm ssion on the ub04 claim form only. Immune globulins hcpcs j1559, j1561, j1562, j1569 and associated infusion pump hcpcs e0779 where route of administration is subcutaneous. Dataelem0075 manual performance measurement network. The ub 92 claim form will no longer be accepted after may 22, 2007. Ub04 claim form instructions may 14, 20 nevada medicaid may 14, 20 updated.

National uniform billing committee nubc ub04 reference manual. Aug 19, 20 the ub04 is the basic hardcopy form and is also known as the form cms1450 like its predecessor, the ub92. Page kn range iii additional hilti technical data not part of eta040027, issue 20626. The ub04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims.

You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. Astcodc data system user manual january 2020 7 changes in the manual from 20 through 2018 continued. The data for this analysis, obtained from the ub04 uniform billing form, was submitted electronically to phc4 by pennsylvania general and specialty acute care hospitals. The national uniform billing committee nubc makes their ub 04 manual available through their website. Wisconsin medicaid will continue to accept the ub92. Some fields have been changed, or codes have been added or deleted for existing fields. This manual, ed by the american hospital association, is the only. Blue cross and blue shield of new mexico offers this guide for completion of the ub 04 form for your patients with blue cross facility coverage. Condition, occurrence, value, and patient relationship, and remarks field codes. Jan 07, 2016 the ub 04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims. The provider uses this code only on bills spanning 2.

In the amount fields, after the appropriate code, enter the amount. To view a sample cmcm ub04 claim form, see appendix a. Unless otherwise noted, all data form locators on the ub04 have the same attributes specifications for the colorado medical assistance program as those indicated in the. The revision date and transmittal number apply only to red italicized material. Ub04 discharge status codes a patient discharge status code is a twodigit code entered into form locator fl 17 on the ub04 claim form that identifies the patients status at the conclusion of a health care facility encounter this could be a visit or an actual inpatient stay or at the time end of a billing cycle the through date of a. Enter the name and address of the facility 2 pay to nameaddressid situational.

For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual, visit the national uniform billing committee nubc web site at. Ub04 form the uniform bill ub04 is the standardized billing form for institutional services. Please see the national ub04 manual for complete instructions and specific codes. This chapter supplements information contained within previous chapters of this manual. Fl 10 lifetime reserve days converted to value code codes that do not fit into other fields. Review the resolution instructions below for the edit codes that apply to your claim. For information on the ub04 billing form, or to obtain an official ub04 data specifications manual, visit the national uniform billing committee nubc web site.

This form, also known as the ub04, is a uniform institutional provider bill. Ub04 billing instructions guide health pasonline maine. We are recommending using the references distributed by the national uniform billing committee nubc official ub 04 data specifications manual. Guide to the ub04 manual this ub04 manual is the official source for ub04 information adopted by the. Cms will not pay the ccmcc drg for those selected hacs that are coded as 1 for the poa indicator. Hospital discharge data system user manual august 2018 7 numerous and significant changes have been made to the ub 04 manual from 2011 through 2018. The ub04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives. The displayed claim form is a sample and is for illustration purposes only. For part b coinsurance use value codes a2, b2 and c2. These fields must be completed or the claim is denied. Chapter 25 completing and processing the form cms1450 data set. Ub04 claim form instructions geisinger health plan.

Home health 2digit patient status code, as follows. The ub04 claim form may be used to bill for inpatient hospital care or to replace a claim for inpatient hospital care that was paid ub04 desk reference for long term care facilities. The data included demographic information, hospital charges, and diagnosis and procedure codes icd9cm. Ry2019 eohhs technical specifications manual for masshealth acute 6 table 6.

These values are valid for paper claim submission on the ub04 claim form only. B3 benefits ub04 claim form and instructions independence blue cross the ub04 claim form includes several fields that accommodate the use of your npi. The data for the hpr, obtained from the ub04 uniform billing form, was submitted electronically to the pennsylvania health care cost containment council by pennsylvania phc4 hospital performance report cy 20 data technical notes. Form locators 1828 ai sterilization patient consent form ma 31.

It is to be used as a companion to, and not a replacement. Hospital ub04 claim filing instructions, section 2 billing book. Inpatient services billing example inpatient services 492. Although the form is similar in appearance to the older version of the facility claim form, ub 92, a number of fields have been moved or expanded and. Ub92 desk reference these values are valid for paper claim subm ssion on the ub04 claim form only. The ub92 claim form will no longer be accepted after may 22, 2007. This value or value 58 is required on the initial bill for oxygen therapy and on the fourth months bill. Macs may include a crosswalk between the asc x12n 837i and the cms1450 on their websites. Access to information on this site is only allowed for necessary.

R2683cp 040520 nonsystems internet only manual iom. You can access the ub04 billing information adopted by the nubc by subscribing. Inpatient services in the part 2 inpatient services manual for billing instructions for services rendered to a registered hospital inpatient. The hospital reports right justified in the cents area. January 2020 integrated outpatient code editor ioce. Face sheet discharge summary ub04, field locations. This code is equivalent to a blank on the ub04, however. Starting may 23, 2007 all institutional paper claims must use the ub04. We are recommending using the references distributed by the national uniform billing committee nubc official ub04 data specifications manual. The product of the number of lifetime reserve days used in the second calendar year of the billing period multiplied by the applicable lifetime reserve rate.

Blue cross and blue shield of oklahoma offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. Dataelem0072 manual performance measurement network. Submit a the claim was submitted with an idrd waiverspecific. This manual contains the updated specifications for the data elements and codes included on the cms1450 and used in the 837i transaction standard. The national uniform billing committee nubc makes their ub04 manual available through their website. Effective for services provided onafter january 1, 2016, computed tomography ct imaging furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association nema xr29 20 standard. Ub04 claim form, also known as the cms1450 form, for facility and sample ub04 forms for. To license the electronic data file of ub 04 data specifications, contact tim carlson at 312 8936816. Reference the official ub04 data specifications manual for valid values. Medicare lifetime reserve amount in the second calendar year in billing period. A guide for completing the ub04 form blue cross blue.

Valid codes now include all codes listed in the most current nubc official ub04 specifications manual. The 202016 nhcs data available in the rdc are based on a sample of 581 hospitals drawn from the universe of eligible hospitals. You can access the ub 04 billing information adopted by the nubc by subscribing to the official ub 04 data specifications manual. Dec 4, 2018 identify the section in the provider manual related to ub04 claim form completion icd10cm diagnosis codes and icd10 pcs codes on a claim to ensure payment at the nubc ub04 data specifications manual. This chapter contains participation, claims and billing information for providers who bill on a ub04 cms 1450 claim form. Enter integer values to the left of the dashed line so that no decimal point will be added. Patient status code 08 dischargetransfer to home care of home iv provider is no longer valid. Ub 04 form the uniform bill ub 04 is the standardized billing form for institutional services.

The uniform bill ub04 is the standardized billing form for institutional services. While vizient data collect similar information as ub 04, patient identifiers are not included, and the dates of the encounter are masked. Ub04 instructions for hospitals louisiana medicaid. Tob values must be submitted on the ub04 cms1450 claim form or electronic equivalent in accordance. Ub 04 medicare discharge status code cms 1500 claim form.

Loop 2300 dtp03 when dtp01 434 enter the dates of service claimed in accordance with the instructions provided below. Enter the name, address, and louisiana medicaid id of the provider if different from the provider. New patient discharge status codes on ub04 claim form. Influence of concrete strength influence of edge distance influence of spacing valid for a group of two anchors. Ub04 instructions ub04 instructions page 5 of 11 revised 11. No other publication governmental or privatecommercial can be considered authoritative. Use the ub 04 data specifications manual and the icd10cm official guidelines for coding and reporting to facilitate the assignment of the poa indicator for each principal diagnosis and other diagnoses codes reported on claim forms ub 04 and 837 institutional. To obtain a copy of the nubc ub04 manual, please visit. The principal diagnosis is defined in the uniform hospital discharge data set uhdds as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. A guide for completing the ub04 form blue cross and. Indiana health coverage programs updated ub04 paper claim form requirements provider bulletin bt200702 january 30, 2007 ub 04 claim form requirements this section provides a brief overview of the changes required for completion of the ub 04 claim form. Number assigned to patients medical record by provider. Immune globulin hcpcs j1575 and associated infusion pump hcpcs e0781 where route of administration is subcutaneous.

The patient status code form locator 17 on the ub04 claim form identifies patient status as of statement covers through date and is required on all institutional inpatient. To license the electronic data file of ub04 data specifications, contact tim carlson at 312 8936816. Indiana health coverage programs updated ub04 paper claim form requirements provider bulletin bt200702 january 30, 2007 ub04 claim form requirements this section provides a brief overview of the changes required for completion of the ub04 claim form. Shield of texas offers this guide to help you complete the ub 04 form for your patients with blue cross facility coverage. Any other material was previously published and remains unchanged. Kansas workers compensation kansas department of labor. Jan 05, 2014 ub92 desk reference these values are valid for paper claim subm ssion on the ub04 claim form only. This manual, ed by the american hospital association, is the only official source of ub data.

Medicare will only accept codes listed in fields ah. In addition, please refer to appendix c for the codes and values associated with this data element. Inpatient services billing example inpatient services 522. Blue cross and blue shield of new mexico offers this guide for completion of the ub04 form for your patients with blue cross facility coverage. Bt200702 tr654 updated ub04 paper claim form requirements. The ub 04 data specifications manual is the official source of data specifications adopted by the nubc and contains codes used in the 837 institutional electronic claims. This article includes tables of some of the most common condition, occurrence, value, patient relationship, and remarks field codes associated with msp claims. Premera reference manual premera blue cross 023695 022012 ub04 billing chapter 12 page 1 12 ub04 billing.

Although the form is similar in appearance to the older version of the facility claim form, ub92, a number of fields have been moved or expanded and. Effective for services provided onafter january 1, 2016, computed tomography ct imaging furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association nema xr2920 standard. Since the characters q and z are not available on all touchtone phones, enter the digit 7 for the letter q and. For a detailed billing example that outlines possible billing scenarios, please go. Standard text characters with ascii values between 32 and 127 are accepted.

The ub 04 claim form is a hardcopy facility claim form recently redesigned to accommodate various changes to facility claims filing necessitated by current and upcoming governmental initiatives. For information on the ub04 billing form, or to obtain an official ub04 data specifications manual. Please use the following link to read the complete patient discharge status faqs from nubc. Chars procedure manual washington state department of. All code values listed in the nubc ub04 reference manual for each form locator ub04 claim form medical. For information on the ub 04 billing form, or to obtain an official ub 04 data specifications manual.