1. UB-04 Overview
Medicare Part A Provider Outreach and Education
June 2007

2. IMPORTANT
The information contained in this
presentation was current as of June 2007
and can be found in Change Request
(CR) 5593, Pub. 100-04, Transmittal
1254, dated May 25, 2007, which can be
downloaded from:
www.cms.hhs.gov/Transmittals/Downloads/R1254CP.pdf
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3. UB-04
• Uniform bill for
institutional
providers.
• Replaces the UB-
92.
• Mandated May 23,
2007.
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4. Patient Information

5. Form Locator 1
Billing Provider Information
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6. Form Locator 2
Pay-to Name and Address
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7. Form Locator 3
Patient Control Number/Medical Record
Number
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8. Form Locator 4
Type of Bill (TOB)
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9. Form Locator 5
Federal Tax Number
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10. Form Locator 6
Dates of Service
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11. Form Locator 8
Patient’s Name
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12. Form Locator 9
Patient’s Address
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13. Form Locator 10
Patient’s Date of Birth
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14. Form Locator 11
Patient’s Gender
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15. Form Locators 12−15
Admission Date, Type and Source
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16. Admission Type
Examples
Code Description Definition
The patient requires immediate medical intervention as a result of
1 Emergency
severe, life-threatening or potentially disabling conditions.
The patient requires immediate attention for the care and treatment of a
2 Urgent
physical or mental disorder.
3 Elective The patient’s condition permits adequate time to schedule the services.
Use of this code necessitates the use of special source of admission
4 Newborn
codes (Form Locator 15).
Visit to a trauma center/hospital as licensed or designated by the state
or local government authority authorized to do so, or as verified by the
5 Trauma
American College of Surgeons and involving a trauma activation. (Use
revenue code 068X to capture trauma activation charges.)
Information Information not available.
9
not available
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17. Admission Source
Examples
Code Description
1 Physician referral
2 Clinic referral
3 HMO referral
4 Transfer from a hospital
5 Transfer from a Skilled Nursing Facility (SNF)
6 Transfer from another health care facility
7 Emergency room
8 Court/law enforcement
9 Information not available
A Transfer from a Critical Access Hospital (CAH)
B Transfer from another home health agency
C Readmission to same home health agency
Transfer from hospital inpatient in the same facility resulting in a separate claim
D
to the payer
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18. Form Locators 16−17
Discharge Hour and Discharge Status
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19. Discharge Status Code
Examples
Code Description
01 Discharged to home or self-care (routine discharge)
Discharged/transferred to a short-term general hospital for inpatient
02
care
Discharged/transferred to an SNF with Medicare certification in
03
anticipation of covered skilled care
Discharged/transferred to another type of health care institution not
05
defined elsewhere in this code list
Discharged/transferred to home under care of an organized home
06
health service organization in anticipation of covered skilled care
07 Left against medical advice or discontinued care
20 Expired
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20. Form Locators 18−28
Condition Codes
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21. Condition Code
Examples
Code Description
02 Condition is employment-related
Treatment of non-terminal condition for
07
hospice
Beneficiary would not provide
08
information concerning other coverage
20 Beneficiary requested billing
21 Billing for denial notice
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22. Form Locator 29
Accident State
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23. Form Locators 31−34
Occurrence Codes and Dates
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24. Occurrence Code
Examples
Code Description
01 Auto accident
04 Accident employment-related
11 Onset of illness
Date of retirement for
18
patient/beneficiary
24 Date insurance denied
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25. Form Locators 35−36
Occurrence Span Codes and Dates
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26. Occurrence Span
Code Examples
Code Description
74 Leave of absence
76 Patient liability
77 Provider liability
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27. Form Locator 38
Responsible Party’s Name and Address
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28. Form Locators 39−41
Value Codes and Amounts
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29. Value Code
Examples
Code Description
12 Working aged
37 Pints of blood furnished
50 Physical therapy visits
53 Cardiac rehabilitation visits
80 Covered days
81 Non-covered days
82 Coinsurance days
83 Lifetime reserve days
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30. Billing Information

31. Form Locator 42
Revenue Codes
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32. Form Locator 43
Revenue Code Description
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33. Form Locator 44
HCPCS Codes, Rates, HIPPS codes and
Modifiers
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34. Form Locator 45
Service Dates
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35. Form Locator 46
Service Units
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36. Form Locator 47
Total Charges
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37. Form Locator 48
Non-Covered Charges
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38. Line 23
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39. Payer Information

40. Form Locator 50
Payer Name
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41. Form Locator 51
Health Plan Identification Number
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42. Form Locators 52−53
Release of Information and Assignment of
Benefits
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43. Form Locator 54
Prior Payments
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44. Form Locator 55
Estimated Amount Due
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45. Form Locators 56−57
National Provider Identifier (NPI) and Other
Provider Identifier
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46. Form Locator 58
Insured’s Name
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47. Form Locator 59
Patient’s Relationship to the Insured
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48. Patient’s Relationship
Code Examples
Code Description
01 Spouse
18 Patient is insured
19 Natural child/insured financial responsibility
43 Natural child/insured does not have financial
responsibility
22 Handicapped dependent
29/53 Life partner
32 Mother
33 Father
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49. Form Locator 60
Insured’s Unique Identifier
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50. Form Locator 61
Insured’s Group Name
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51. Form Locator 62
Insured’s Group Number
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52. Form Locator 63
Treatment Authorization Codes
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53. Form Locator 64
Document Control Number (DCN)
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54. Form Locator 65
Employer’s Name
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55. Diagnosis Information

56. Form Locator 66
Diagnosis and Procedure Code Qualifier
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57. Form Locator 67
Principal Diagnosis Code and Present on
Admission (POA) Indicator
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58. POA Indicator
Indicator Description
Y Yes
N No
W Clinically undetermined
U No information in the record
Unreported or not used Exempt from POA reporting
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59. Form Locator
67A−Q
Other Diagnosis Codes and POA Indicator
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60. Form Locator 69
Admitting Diagnosis Code
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61. Form Locator 70
Patient’s Reason for Visit
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62. Form Locator 71
Prospective Payment System (PPS) Code
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63. Form Locator 72
External Cause of Injury (ECI) Code
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64. Form Locator 74
Principal and Other Procedure Codes and
Dates
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65. Form Locator 76
Attending Provider’s Name and Identifiers
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66. Secondary Identifier
Qualifiers
Qualifier Description
0B State license number
1G Provider’s UPIN number
G2 Provider’s commercial number
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67. Form Locator 77
Operating Physician’s Name and Identifiers
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68. Form Locators 78-79
Other Providers’ Names and Identifiers
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69. Provider Type Qualifier
Codes
Qualifier Description
DN Referring provider
ZZ Other operating physician
82 Rendering provider
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70. Form Locator 80
Remarks
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71. Form Locator 81
Healthcare Provider Taxonomy Code
(HPTC)
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72. HPTC
The Healthcare Provider Taxonomy Code
(HPTC) list is available at:
www.wpc-edi.com/codes/taxonomy
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73. UB-04 Overview
Thank you for attending.
parta.educ@trailblazerhealth.com