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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.6 UB-04 CMS-1450 Paper Claim Filing Instructions : 6.6.4 UB-04 CMS-1450 Instruction Table

The instructions describe what information 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.
Optional: Any alphanumeric character (limit 16) entered in this block is referenced on the R&S Report.
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
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
1 Rural health
2 Hospital-based or independent renal dialysis center
3 Free standing
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
Optional: Enter the patient identification number if it is different than the subscriber/insured’s identification number.
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 patient was admitted into each facility.
Use military time (00 to 23) for the time of admission for inpatient claims or time of treatment for outpatient 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
Source of admission
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
1 Normal delivery
2 Premature delivery
3 Sick baby
4 Extramural birth
5 Information not available
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.
For inpatient claims, enter the appropriate two-digit code to indicate the patient’s status as of the statement “through” date.
Enter the two-digit condition code “05” to indicate that a legal claim was filed for recovery of funds potentially due to a patient.
Optional: Accident state.
Enter the appropriate occurrence code(s) and date(s). Blocks 54, 61, 62, and 80 must also be completed as required.
Refer to:
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.
Accident hour–For inpatient claims, if the patient 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 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.
Enter N4 and the 11-digit NDC number (number on packaged or container from which the 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 but they are not required.
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.
Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding HCPCS code or narrative description.
Each service, except for medical/surgical and intravenous (IV) supplies and medication, must be itemized on the claim form or an attached statement.
The UB-04 CMS-1450 paper 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.
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.
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.
For multi-page claims enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim and the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.
Other identification (ID) number
Medicaid identification number
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.
Refer to:
Secondary 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 required when billing for estrogen receptor assays, plasmapheresis, and cancer antigen CA 125, immunofluorescent studies, surgical pathology, and alphafetoprotein.
ICD-9-CM diagnosis codes entered in 67K–67Q are not required for systematic claims processing.
Refer to:
Optional: New block indicating the patient’s reason for visit on unscheduled outpatient claims.
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.
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.
Refer to:
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.
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.
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.
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
If the referring physician is a resident, Blocks 76 through 79 must identify the physician who is supervising the resident.
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 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.
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.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.