Fields of the UB-04
UB-04 Billing Claim Form, also known as the
CMS-1450 Form, used for facility and ancillary paper billing. Approved by the Centers for Medicare & Medicaid Services (CMS) and the National Uniform Billing Committee (NUBC).
COMPLETING THE UB-04 CLAIM FORM
There are 81 fields on a Uniform Bill (UB-04) – Form CMS-1450. Each field is referred to as form locators or “FL”. Each form locator is designated for a unique purpose. This form can be used for billing multiple third party payers. Because it serves many payers, a particular payer may not need some data elements. For more information on the UB-04 billing form or to purchase the UB-04 Data Specifications Manual, visit the National Uniform Billing Committee (NUBC) Web site.
FL 10 – Patient Birth Date
Required. Enter the month, day, and year of birth (MMDDCCYY) of the patient without punctuation. If full birth date is unknown, indicate zeros for all eight digits. Used to determine the age of the patient, and to identify readmissions of the same patient.
FL 11 – Patient Sex
Required. The provider enters an “M” (male) or an “F” (female) or “U” for Unknown. The patient’s sex is recorded at admission, outpatient service, or start of care. Used to identify readmissions of the same patient, to match to other patient-level data, and record the sex for population analysis, as well as ensure provided services are appropriate.
FL 12 – Admission/Start of Care Date
Required. Enter the start of care date or date the patient was admitted for inpatient care using a six-digit format (MMDDYY).
FL 13 – Admission Hour
Required on all inpatient claims. Optional for outpatient billing. Enter the appropriate two-digit admission code for the hour during which the patient was admitted. Hours are entered using 24 hour time (military time) from the following table:
- 00 – 12:00-12:59 Midnight
01 – 01:00-01:59
02 – 02:00-02:59
03 – 03:00-03:59
04 – 04:00-04:59
05 – 05:00-05:59
06 – 06:00-06:59
07 – 07:00-07:59
08 – 08:00-08:59
09 – 09:00-09:59
10 – 10:00-10:59
11 – 11:00-11:59 - 12 – 12:00-12:59 Noon
13 – 01:00-01:59
14 – 02:00-02:59
15 – 03:00-03:59
16 – 04:00-04:59
17 – 05:00-05:59
18 – 06:00-06:59
19 – 07:00-07:59
20 – 08:00-08:59
21 – 09:00-09:59
22 – 10:00-10:59
23 – 11:00-11:59
FL 14 – Priority (Type) of Visit
Required. Enter the 1-digit code indicating the priority and type of admission/visit. The coding for this field is defined by the NUBC. The following is a list of valid entries:
1 = Emergency The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions.
Generally, the patient is admitted through the emergency room and documentation must be attached to claim.
2 = Urgent The patient requires immediate attention for the care and treatment of a physical or mental disorder. Claim marked as urgent will not qualify for emergency service consideration.
3 = Elective The patient’s condition permits adequate time to schedule the services.
4 = Newborn: Patient is newborn. Use of this code necessitates the use of a special Source of Admission code – see FL 15.
5 = Trauma 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 American College of Surgeons and involving a trauma activation.
FL 15 – Point of Origin for Admission or Visit
Required for all inpatient admissions. Optional for outpatient claims. The provider enters the single digit code indicating the source of the referral for this admission or visit.
1 – Physician Referral Inpatient – The patient was admitted upon the recommendation of a personal physician. Outpatient – The patient was referred to this facility for outpatient or referenced diagnostic services by his or her personal physician, or the patient independently requested outpatient services (self referral.)
2 – Clinic Referral Inpatient – The patient was admitted upon the recommendation of this facility’s clinic physician. Outpatient – The patient was referred to this facility for outpatient or referenced diagnostic services by this facility’s clinic or other outpatient department physician.
3 – HMO (Health Maintenance Organization) referral Inpatient – The patient was admitted upon the recommendation of an HMO physician. Outpatient – The patient was referred to this facility for outpatient or referenced diagnostic services by HMO physician.
4 – Transfer from a Hospital Inpatient – The patient was admitted as a transfer from an acute care facility where he or she was an inpatient. Outpatient – The patient was referred to this facility for outpatient or reference diagnostic services by a physician of another acute care facility.
5 -Transfer from a SNF (Skilled Nursing Facility) Inpatient – The patient was admitted as a transfer from SNF where he or she was an inpatient. Outpatient – The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where he or she is an inpatient.
6 – Transfer from another health care facility Inpatient – The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility or an SNF. This includes transfers from nursing homes, long-term care facilities, and SNF patients that are at a non-skilled level of care. Outpatient – The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where he or she is an inpatient.
7 – Emergency Room Inpatient – The patient was admitted upon the recommendation of this facility’s emergency room physician. Outpatient: The patient received services in this facility’s emergency department.
8 – Court/Law Enforcement Inpatient – The patient was admitted upon the direction of a court of law, or upon the request of a law enforcement agency’s representative. Outpatient – The patient was referred to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services.
9 – Information not Available Inpatient – The means by which the patient was admitted is not known. Outpatient – For Medicare outpatient bills, this is not a valid code.
A Transfer from a Critical Access Hospital (CAH) Inpatient – The patient was admitted to this facility as a transfer from a Critical Access Hospital where he or she was an inpatient. Outpatient – The patient was referred to this facility for outpatient or reference diagnostic services by (a physician of) the Critical Access Hospital where he or she was an inpatient.
B Transfer from another Home Health Agency The patient was admitted to this Home Health agency as a transfer from another Home Health agency.
C Readmission to the same Home Health Agency The patient was readmitted to this Home Health agency within the same Home Health episode.
D Transfers from hospital inpatient in the same facility. Transfers from hospital inpatient in the same facility resulting in a separate claim to the payer.