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 patient'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

2 Skilled nursing

3 Home health agency

7 Clinic (rural health clinic [RHC], federally qualified health center

[FQHC], and renal dialysis center [RDC])

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)

7 Intermediate care

Second Digit-Bill Classification (clinics only):

1 Rural health

2 Hospital-based or independent renal dialysis center

3 Free standing

5 CORFs

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 patient identification number if it is different than the subscriber/insured's identification number.

8b

Patient name

Enter the client's last name, first name, and middle initial as printed on the Medicaid identification form.

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.

Providers that receive a transfer patient from another hospital must enter the actual dates the client was admitted into each facility.

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 (patient status of "30"), leave the block blank.

17

Patient Status

For inpatient claims, enter the appropriate two-digit code to indicate the patient's status as of the statement "through" date.

Refer to: "Patient Status Codes" .

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 patient.

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: "Occurrence Codes" .

35-36

Occurrence span codes and dates

For inpatient claims, enter code "71" if this hospital admission is a readmission within seven 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 rejected 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.

Laboratory-If laboratory work is sent out, the name and address or NPI of the laboratory where the work was forwarded must be entered.

National Drug Code

Enter N4, the 11-digit NDC number (number on packaged or container from which the medication was administered), the unit of measurement code, and the unit quantity with a floating decimal for fractional units (limited to 3 digits).

Do not enter hyphens or spaces within this number.

Example: N400409231231GR0.025

Refer to: "National Drug Code (NDC)" .

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.

Home Health Services

Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding HCPCS code or narrative description.

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.

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

If any of the total charges are noncovered, enter this amount.

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 32, 61, 62, and 80 as required.

56

NPI

Enter the NPI of the billing provider.

57

Other identification (ID) number

Enter the 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

Medicaid identification number

Enter the client's nine-digit Medicaid 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.

Optional-POA Indicator-Enter the applicable POA indicator in the shaded area for inpatient claims.

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 to 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.

Optional-POA indicator-Enter the applicable POA indicator in the shaded area for inpatient claims.

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 indication

Optional-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.

74

Principal procedure code and date

Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.

74a-74e

Other procedure codes and dates

Enter the ICD-9-CM 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.

Services that required an attending provider are defined as those listed in the ICD-9-CM coding manual volume 3, which includes surgical, diagnostic, or medical procedures.

77

Operating

Enter operating provider's name (last name and first name) and NPI number of the operating provider.

78-79

Other

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.

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 patient 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 patient 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 support elsewhere on the claim data set.