5.7.2.8 Instructions for Completing the UB-04 CMS-1450 Paper Claim Form

These instructions describe the information that must be entered in each of the block numbers of the UB-04 CMS-1450 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.

Block No.	Description	Guidelines
1	Unlabeled	Enter the hospital name, street, city, state, ZIP+4 Code, and telephone number.
3a	Patient control number	Optional Any alphanumeric character (limit 16) entered in this block is referenced on the R&S Report.
3b	Medical record number	Enter the client’s medical record number (limited to ten digits) assigned by the hospital.
4	Type of bill (TOB)	Enter a TOB code.   First Digit—Type of Facility: 1 Hospital 3 Home health agency 7 Clinic (rural health clinic [RHC], federally qualified health center [FQHC]) 8 Special facility   Second Digit—Bill Classification (except clinics and special facilities): 1 Inpatient (including Medicare Part A) 2 Inpatient (Medicare Part B only) 3 Outpatient 4 Other (for hospital-referenced diagnostic services, for example, laboratories and X-rays)   Third Digit—Frequency: 0 Nonpayment/zero claim 1 Admit through discharge 2 Interim-first claim 3 Interim-continuing claim 4 Interim-last claim 5 Late charges-only claim 6 Adjustment of prior claim 7 Replacement of prior claim
6	Statement covers period	Enter the beginning and ending dates of service billed.
8a	Patient identifier	Optional Enter the client identification number if it is different than the Subscriber and insured’s identification number.
8b	Patient name	Enter the client’s last name, first name, and middle initial.
9a-9b	Patient address	Starting in 9a, enter the client’s complete address as described (street, city, state, and ZIP+4 Code).
10	Birthdate	Enter the client’s date of birth (MM/DD/YYYY).
11	Sex	Indicate the client’s sex by entering an “M” or “F.”
12	Admission date	Enter the numerical date (MM/DD/YYYY) of admission for inpatient claims; date of service (DOS) for outpatient claims; or start of care (SOC) for home health claims.
13	Admission hour	Use military time (00 to 23) for the time of admission for inpatient claims or time of treatment for outpatient claims.
14	Type of admission	Enter the appropriate type of admission code for inpatient claims: 1 Emergency 2 Urgent 3 Elective 4 Newborn (This code requires the use of special source of admission code in Block 15.) 5 Trauma center
15	Source of admission	Enter the appropriate source of admission code for inpatient claims. For type of admission 1, 2, 3, or 5: 1 Physician referral 2 Clinic referral 3 Health maintenance organization (HMO) referral 4 Transfer from a hospital 5 Transfer from skilled nursing facility (SNF) 6 Transfer from another health-care facility 7 Emergency room 8 Court/law enforcement 9 Information not available   For type of admission 4 (newborn): 1 Normal delivery 2 Premature delivery 3 Sick baby 4 Extramural birth 5 Information not available
16	Discharge hour	For inpatient claims, enter the hour of discharge or death. Use military time (00 to 23) to express the hour of discharge. If this is an interim bill (client status of “30”), leave the block blank.
17	Patient Status	For inpatient claims, enter the appropriate two-digit code to indicate the client’s status as of the statement “through” date. Refer to: Section 5.7.2.9, “Client Status (for block 17),” on page 5‑40.
18-28	Condition codes	Enter the two-digit condition code “05” to indicate that a legal claim was filed for recovery of funds potentially due to a client.
29	ACDT state	Optional Accident state.
31-34	Occurrence codes and dates	Enter the appropriate occurrence code(s) and date(s). Blocks 54, 61, 62, and 80 must also be completed as required. Refer to: Section 5.7.2.10, “Occurrence Codes (for blocks 31 through 34),” on page 5‑41.
35-36	Occurrence span codes and dates	For inpatient claims, enter code “71” if this hospital admission is a readmission within 7 days of a previous stay. Enter the dates of the previous stay.
39-41	Value codes	Accident hour—For inpatient claims, if the client was admitted as the result of an accident, enter value code 45 with the time of the accident using military time (00 to 23). Use code 99 if the time is unknown. For inpatient claims, enter value code 80 and the total days represented on this claim that are to be covered. Usually, this is the difference between the admission and discharge dates. In all circumstances, the number in this block is equal to the number of covered accommodation days listed in Block 46. For inpatient claims, enter value code 81 and the total days represented on this claim that are not covered. The sum of Blocks 39-41 must equal the total days billed as reflected in Block 6.
42-43	Revenue codes and description	For inpatient hospital services, enter the description and revenue code for the total charges and each accommodation and ancillary provided. List accommodations in the order of occurrence. List ancillaries in ascending order. The space to the right of the dotted line is used for the accommodation rate. National Drug Code Enter N4, the 11-digit NDC number (number on package or container from which medication was administered). Optional The unit of measurement code and the unit quantity with a floating decimal for fractional units (limited to 3 digits) can also be submitted, however, are not required. Do not enter hyphens or spaces within this number. Example: N400409231231GR0.025 Refer to: Section 5.6.2.6, “National Drug Codes (NDC),” on page 5‑22.
44	HCPCS/rates	Inpatient Enter the accommodation rate per day. Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis. Each service and supply must be itemized on the claim form. Outpatient Outpatient claims must have the appropriate Healthcare Common Procedure Coding System (HCPCS) code. Each service, except for medical/surgical and intravenous (IV) supplies and medication, must be itemized on the claim form or an attached statement. Note: The UB-04 CMS-1450 claim form is limited to 28 items per outpatient claim. This limitation includes surgical procedures from Blocks 74 and 74a-e. If necessary, combine IV supplies and central supplies on the charge detail and consider them to be single items with the appropriate quantities and total charges by dates of service. Multiple dates of service may not be combined on outpatient claims. Note: HASC providers should enter only one CPT procedure code for the inclusive global fee.
45	Service date	Enter the numerical date of service that corresponds to each procedure for outpatient claims. Multiple dates of service may not be combined on outpatient claims.
45 (line 23)	Creation date	Enter the date the bill was submitted.
46	Serv. units	Provide units of service, if applicable.   For inpatient services, enter the number of days for each accommodation listed. If applicable, enter the number of pints of blood.   When billing for observation room services, the units indicated in this block should always represent hours spent in observation.
47	Total charges	Enter the total charges for each service provided.
47 (line 23)	Totals	Enter the total charges for the entire claim. Note: For multi-page claims enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim. Indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.
48	Noncovered charges	Enter the amount of the total noncovered charges.
50	Payer Name	Enter the health plan name.
51	Health Plan ID	Enter the health plan identification number.
54	Prior payments	Enter amounts paid by any TPR, and complete Blocks 31, 61, 62, and 80 as required.
56	NPI	Enter the NPI of the billing provider. HASC facilities should use the HASC provider identifier for scheduled outpatient day surgeries. Claims for emergency, unscheduled outpatient surgical procedures should be using the hospital’s outpatient provider identifier.
57	Other identification (ID) number	Enter the CSHCN Services Program TPI number (non-NPI number) of the billing provider.
58	Insured’s name	If other health insurance is involved, enter the insured’s name.
60	Insured’s Unique ID	Enter the client’s nine-digit CSHCN Services Program identification number.
61	Insured group name	Enter the name and address of the other health insurance.
62	Insurance group number	Enter the policy number or group number of the other health insurance.
63	Treatment authorization code	Enter the prior authorization number if one was issued.
65	Employer name	Enter the name of the client’s employer if health care might be provided.
67	Principal diagnosis (DX) code and present on admission (POA) indicator	Enter the ICD-9-CM diagnosis code in the unshaded area for the principal diagnosis to the highest level of specificity available. Required POA Indicator—Enter the applicable POA indicator in the shaded area for inpatient claims. HASC providers are not required to enter a diagnosis code. Refer to: Section 5.7.2.11, “POA Indicators (for blocks 67 and 72),” on page 5‑42.
67A-67Q	Other DX codes and POA indicator	Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Enter one diagnosis per block, using Blocks A through J only.   A diagnosis is not required for clinical laboratory services provided for nonpatients (TOB “141”).   Exception: A diagnosis is required when billing for estrogen receptor assays, plasmapheresis, and cancer antigen CA 125, immunofluorescent studies, surgical pathology, and alphafetoprotein. Note: ICD-9-CM diagnosis codes entered in 67K-67Q are not required for systematic claims processing. Required POA indicator-Enter the applicable POA indicator in the shaded area for inpatient claims. Refer to: Section 5.7.2.11, “POA Indicators (for blocks 67 and 72),” on page 5‑42.
69	Admit DX code	Enter the ICD-9-CM diagnosis code indicating the cause of admission or include a narrative. Note: The admitting diagnosis is only for inpatient claims.
70a-70c	Patient’s reason DX	Optional New block indicating the client’s reason for visit on unscheduled outpatient claims.
71	Prospective Payment System (PPS) code	Optional The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer.
72a-72c	External cause of injury (ECI) and POA indicator	Required Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. POA indicator—Enter the applicable POA indicator in the shaded area for inpatient claims. Refer to: Section 5.7.2.11, “POA Indicators (for blocks 67 and 72),” on page 5‑42.
74	Principal procedure code and date	Enter the HCPCS procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed. Note: HASC providers enter only one CPT procedure code for the inclusive global fee.
74a-74e	Other procedure codes and dates	Enter the HCPCS procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.
76	Attending provider	Enter the attending provider name and identifiers. NPI number of the attending provider. For inpatient claims enter the NPI of the provider who perform the service or procedure or is responsible for the treatment and plan of care (POC). For outpatient claims enter the NPI of the physician who referred the client to the hospital.
77	Operating	Enter name (last name and first name) and NPI number of the operating provider (the individual with the primary responsibility for performing the surgical procedures). Required when a surgical procedure codes is listed on the claim.
78-79	Other provider	Other provider’s name (last name and first name) and NPI.   Other operating physician—An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved.   Designated physician—For a limited client when the physician performed or authorized nonemergency care.   Rendering provider—The health-care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure. Note: If the referring physician is a resident, Blocks 76 through 79 must identify the physician who is supervising the resident.
80	Remarks	This block is used to explain special situations such as the following: • The home health agency must document in writing the number of Medicare visits used in the nursing plan of care and also in this block. • If a client stays beyond dismissal time, indicate the medical reason if additional charge is made. • If billing for a private room, the medical necessity must be indicated, signed, and dated by the physician. • If services are the result of an accident, the cause and location of the accident must be entered in this block. The time must be entered in Block 39. • If laboratory work is sent out, the name and address or the provider identifier of the facility where the work was forwarded must be entered in this block. • If the client is deceased, enter the date of death and indicate "DOD." • If services were rendered on the date of death, enter the time of death. • If the services resulted from a family planning provider’s referral, write "family planning referral." • If services were provided at another facility, indicate the name and address of the facility where the services were rendered. • Request for 110-day rule for a third-party insurance.
81A-81D	Code code (CC)	Optional Area to capture additional information necessary to adjudicate the claims. Required when, in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere on the claim data set.