1. Overview of the UB-04

2. Sources National Uniform Billing Committee
Centers for Medicare and Medicaid Services (CMS)
Chapter 25 – Completing and Processing the form CMS 1450 data sets
Web based training courses – Uniform Billing (UB) -04 (July 2007)

3. Patient/Provider Information
Billing Information
Payer Information
Diagnostic Information
Additional Information

4. Patient/Provider Information
FL01 Provider Name, Address, Phone and/or Fax number
FL02 Pay-to Name, Address, Phone and/or Fax number
FL03a Patient Control Number
FL03b Medical Record Number
FL04 Type of Bill
4-digit alphanumeric (example 0111)

5. Patient/Provider Information
FL05 Federal Tax ID Number
FL06 Statement Covers Period – From/Through
FL07 Unlabeled
FL08a Patient Name – ID
FL08b Patient Name

6. Patient/Provider Information
FL09a- e Patient Address
FL10 Patient Birth date
FL11 Patient Sex
FL12 – 16 Admission Date/ Hour/Type/Source/
Discharge Hour

7. Patient/Provider Information
FL17 Patient Status Code
01 Discharged to home or self care (routine discharge
02 Discharged/transferred
20 Expired

8. Patient/Provider Information
FL Condition Codes
FL29 Accident State
FL30 Unlabeled
FL Occurrence Code/Date
FL Occurrence Span Code/From/Through
FL37 Unlabeled
FL38 Responsible Party Name/Address
FL Value Codes

9. Billing Information FL42 Revenue Code FL43 Revenue Code Description
4-position code that identifies a specific accommodation, ancillary service or billing calculation.
0022 – Skilled nursing facility
0024 – Inpatient rehab facility
0124 – Psychiatric room charge
FL43 Revenue Code Description

10. Billing Information FL44 Rates/HCPCS/HIPPS Rate Codes
Rates – cost of the room per day
HCPCS – CPT or HCPCS codes giving details about the service
HIPPS rate codes – alphanumeric code identifying level of care/service
FL45 Service Date
FL46 Unit of Service

11. Billing Information FL47 Total Charges FL48 Non-Covered Charges
FL49 Unlabeled

12. Payer Information FL50 – 65 FL56 NPI (National Provider Identifier)
Various pieces of information about what insurance may be primary and what they paid
FL56 NPI (National Provider Identifier)
FL57 Other Provider ID

13. Diagnostic Information
FL66 DX (diagnosis) Version Qualifier
FL67 Principle Diagnosis Code
FL67A-Q Other Diagnosis
FL68 Unlabeled
FL69 Admitting Diagnosis Code
FL70a-c Patient Reason for Visit Code

14. Diagnostic Information
FL71 PPS Code
FL72a-c External Cause of Injury Code (ECI)
FL73 Unlabeled
FL74 Principle Procedure Code/Date
FL74a-e Other Procedure Code/Date

15. Additional Information
FL75 – 81a-d
Includes the name and ID of the attending and operating physicians, a place for remarks, as well as the code list qualifiers.

16. Items on UB-04 needed for the DRG Grouper
Diagnoses codes (FL 67 A-Q)
Procedure codes (FL 74 Principle procedure and fields a-e)
Discharge date (FL 6 {Through})
Discharge status (FL 17)
Patient age (FL 10 {Birth date})
Patient sex (FL 11)

17. Items on UB-04 needed for APC
Bill type (FL 04)
Patient age (FL 10 {Birth date})
Patient sex (FL 11)
Patient status code (FL 17)
Revenue/HCPCS code (FL 42 & 44)
Date of service (FL 44)
Service units (FL 46)
Total (billed) charge (FL 47)
Diagnosis codes (FL 67 & 67A-Q)

18. Information for Pricers
Provider’s 6-digit Medicare facility ID number,* or
Select by provider name, and/or
Location
* List of providers and Medicare numbers is on the IHS web site

20. QUESTIONS