1

Provider name, address, and telephone number

Enter the hospital name, street, city, state, ZIP Code, and telephone number.

2

Unlabeled

Optional
No guidelines for this block.

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)

Most commonly used:

111 Inpatient hospital

131 Outpatient hospital

141 Nonpatient (laboratory or radiology charges)

331 Home health agency*

711 RHCs

721 RDCs

731 FQHCs

* Use TOB 331 only. All other TOBs are invalid and will deny.

This block has been expanded from 3 to 4 characters with a 0 always as the first digit. Claims will be processed based on the last three digits.

Enter the three-digit 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

For inpatient and home health claims, enter the beginning and ending dates of service billed. For inpatient claims, this is usually the date of admission and discharge.

7

Unlabeled

Optional
No guidelines for this block.

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 Code).

10

Birth date

Enter the month, day, and year (MM/DD/YYYY) the client was born.

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.

Note: Providers that receive a transfer patient from another hospital must enter the original admission date to identify the payor.

13

Admission hour

Use military time (00 to 23) for the time of admission for inpatient claims or time of treatment for outpatient claims. Code 99 is not acceptable. This block is not required for nonpatients (TOB 141), home health claims (TOB 331), RHCs (TOB 711), or FQHCs (TOB 731).

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, or 3:

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. Code 99 is not acceptable.

17

Patient status

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

01 Routine Discharge

02 Discharged to another short-term general hospital

03 Discharged to SNF

04 Discharged to ICF

05 Discharged to another type of institution

06 Discharged to care of home health service organization

07 Left against medical advice

08 Discharged/transferred to home under care of a Home IV provider

09 Admitted as an inpatient to this hospital (only for use on Medicare outpatient hospital claims)

20 Expired or did not recover

30 Still patient (To be used only when the client has been in the facility for 30 consecutive days if payment is based on DRG)

40 Expired at home (hospice use only)

41 Expired in a medical facility (hospice use only)

42 Expired-place unknown (hospice use only)

43 Discharged/Transferred to a federal hospital (such as a Veteran's Administration [VA] hospital)

50 Hospice-Home

51 Hospice-Medical Facility

61 Discharged/ Transferred within this institution to a hospital-based Medicare-approved swing bed

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)

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)

18-28

Condition codes

Enter the two-digit condition code "05" and date (MM/DD/YYYY) on which the legal claim was filed for recovery of funds potentially due to a client as a result of legal action that was initiated by or on behalf for the client if this condition is applicable to the claim.

29

ACDT state

Optional
Accident state.

30

Unlabeled

Optional
No guidelines for this block.

31-34

Occurrence codes and dates

Enter the appropriate code(s) and date(s). Blocks 54, 61, 62, and 84 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.

Note: All claims for services submitted on a UB-04 CMS-1450 form based on procedure codes rather than revenue codes will be denied. Claims for services based on procedure codes, including drugs and other injections, must be billed using a CMS-1500 claim form.

Exception: Electronic billers must not use revenue code 001. Use of this code causes the claim billed amount to be doubled. Electronic billers should not put a code in this block.

44

HCPCS/rates

Inpatient:

Enter the accommodation rate per day.

Enter the numerical date of service (MM/DD/YY) for each service rendered and the block number of the 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 or narrative description. Do not use revenue codes for billing these services.

Enter the date of service numerically, and the block number of the diagnosis 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, except for medical/surgical and intravenous (IV) supplies and medication, must be itemized on the claim form or an attached statement.

Example:

•Take-home drugs must be billed with revenue code B-253.

•Take-home supplies must be billed with revenue code B-273.

•Self-administered drugs must be billed with revenue code B-637.

The drug description must include the name, strength, and quantity.

44 cont.

File claims for unscheduled emergency outpatient surgical procedures with separate charges (e.g., lab, radiology, anesthesia, and emergency room) for all services using TOB 131 and the hospital's provider identifier.

Note: The UB-04 CMS-1450 claim form is limited to 28 items per outpatient claim. 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 Block 46 should always represent hours spent in observation.

47

Total charges

Enter the total charges for each service provided.

48

Noncovered charges

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

51

Provider identifier

Enter the nine-digit provider identifier.

54

Prior payments

Enter amounts paid by any third-party resource (TPR), and complete Blocks 32, 61, 62, and 84 as required.

56

NPI

Optional
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 patient'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 for home health services, freestanding psychiatric facilities, freestanding rehabilitation facilities, and for surgery 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 H 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 alpha-fetoprotein.

Note: Note: ICD-9-CM diagnosis codes entered in 67I-67Q are not required for systematic claims processing.

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

68

Unlabeled

Optional
No guidelines for this block.

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.

73

Unlabeled

Optional
No guidelines for this block.

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.

Optional
NPI number of the attending provider.

Required
TPI must be entered in block to the right of qualifier box, if applicable.

For inpatient claims, enter the physician's license number or UPIN of the provider who performed the service/procedure and/or is responsible for the treatment and plan of care in the following format: 11233333

1 Two-digit state indicator (e.g., TX for Texas).

2 Licensing board indicator examples

B = Doctor of Medicine (MD) or Doctor of Osteopathy (DO)
D = Dentist
P = Podiatrist
C = Chiropractor

3 License number. Example: TXBL1234.

If the provider has a temporary license number, enter "TEMPO." Example: TXBTEMPO

Procedures are defined as those listed in the ICD-9-CM coding manual volume 3, which includes surgical, diagnostic, or medical procedures.

For outpatient claims, enter the license number of the physician referring the patient to the hospital.

77

Operating provider

Enter operating provider's name (last name and first name) and identifiers.

Optional
NPI number of the operating provider.

Required
TPI in the block to the right of qualifier box, if applicable.

This is required when a surgical procedure code is listed on the claim. Include the name and ID number of the individual with the primary responsibility for performing the surgical procedure(s).

78-79

Other (A or B) provider

Other provider's name (last name and first name) and identifiers:

Optional
NPI number of the other provider. See below for additional information.

Required
TPI in the block to the right of qualifier box, if applicable.

For outpatient claims, enter the license number for the following:

•The ordering physician for all laboratory and radiology services. (If a different physician ordered laboratory or radiology services, enter his or her license number in Block 76, and enter the referring/attending physician's license number or UPIN in this block.)

•The designated physician for a limited client when the physician performed or authorized nonemergency care.

•Referring provider-The provider who sent the patient to another provider for services. Required on an outpatient claim when the referring provider is different than the attending physician.

Note: If the referring physician is a resident, Blocks 76 and 78 must identify the physician who is supervising the resident.

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.

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.

•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.

•Enter the date of onset for patients receiving dialysis services.

•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.