UB-04 FL Fields 10 – 15

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

FL 15 – Point of Origin for Admission or Visit