Developed by the Centers for Medicare and Medicaid Services (CMS) and implemented in 2007, the UB-04 form—also known as CMS-1450—is the standard claim form providers use to bill CMS. But plenty of other government and commercial insurance carriers use it, too. As CMS explains, UB-04 can be “used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.” So, while most physical therapists operate in an outpatient setting, those who work in inpatient and hospital settings are eligible to bill their claims using UB-04.

Now that we know who can use UB-04, let’s talk about how to use it. According to a report from HCPro, claims submitted using this form “contain several types of codes that help tell the fiscal intermediary (FI) or Medicare administrative contractor (MAC) the story of a [patient’s] treatment.” Some of the key fields you’ll need to complete include:

  • Type of Bill (helps determine requirements for the claim)
  • Statement covers period (includes the start and end dates for the bill period)
  • Patient status
  • Condition codes
  • Occurrence codes
  • Occurrence span code and dates
  • Value codes and amounts
  • Revenue codes
  • HCPCS/Rate
  • Service dates
  • Service units
  • NPI
  • Diagnosis codes

That’s a hefty list, and we haven’t even covered all of the fields. There are a whopping 81 unique fields—known as form locators (FL)—on the UB-04. Thanks to a handy article from About Money, we have a complete list of what goes where:

  • FL 1: Billing provider name, street address, city, state, zip, telephone, fax, and country code
  • FL 2: Billing provider's pay-to name, address, city, state, zip, and ID
  • FL 3: Patient control number and medical record number
  • FL 4: Type of bill
  • FL 5: Federal tax number
  • FL 6: Statement from and through dates
  • FL 7: Not in use
  • FL 8: Patient name
  • FL 9: Patient street address, city, state, zip, and country code
  • FL 10: Patient birthdate
  • FL 11: Patient sex
  • FL 12: Admission date
  • FL 13: Admission hour
  • FL 14: Type of visit
  • FL 15: Point of origin
  • FL 16: Discharge hour
  • FL 17: Discharge status
  • FL 18-28: Condition codes
  • FL 29: Accident state
  • FL 30: Not in use
  • FL 31-34: Occurrence codes and dates
  • FL 35-36: Occurrence span codes and dates
  • FL 37: Not in use
  • FL 38: Responsible party name and address
  • FL 39-41: Value codes and amounts
  • FL 42: Revenue codes
  • FL 43: Revenue code description, investigational device exemption (IDE) number, or medicaid drug rebate NDC (national drug code)
  • FL 44: Healthcare Common Procedure Coding System codes, accommodation rates, Health Insurance Prospective Payment System rate codes
  • FL 45: Service dates
  • FL 46: Service units
  • FL 47: Total charges
  • FL 48: Non-covered charges
  • FL 49: Page_of_ and Creation date
  • FL 50: Payer Identification (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 51: Health plan ID (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 52: Release of information (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 53: Assignment of benefits (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 54: Prior payments (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 55: Estimated amount due (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 56: Billing provider national provider identifier (NPI)
  • FL 57: Other provider ID (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 58: Insured's name (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 59: Patient's relationship (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 60: Insured's unique ID (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 61: Insurance group name (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 62: Insurance group number (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 63: Treatment authorization code (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 64: Document control number (also referred to as Internal control number) (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 65: Insured's employer name (a) Primary, (b) Secondary, and (c) Tertiary
  • FL 66: Diagnosis codes (ICD)
  • FL 67: Principal diagnosis code, other diagnosis and present on admission (POA) indicators
  • FL 68: Not in use
  • FL 69: Admitting diagnosis codes
  • FL 70: Patient reason for visit codes
  • FL 71: Prospective payment system (PPS) code
  • FL 72: External cause of injury code and POA indicator
  • FL 73: Not in use
  • FL 74: Other procedure code and date
  • FL 75: Not in use
  • FL 76: Attending provider NPI, ID, qualifiers, and last and first name
  • FL 77: Operating physician NPI, ID, qualifiers, and last and first name
  • FL 78: Other provider NPI, ID, qualifiers, and last and first name
  • FL 79: Other provider NPI, ID, qualifiers, and last and first name
  • FL 80: Remarks
  • FL 81: Taxonomy code and qualifier

Yes, that’s a lot of information to include, but some insurance carriers may not require you to complete all the data fields. You’ll need to check with all of your payers to establish what information they require to properly process your claims. That way, you’ll have the best possible chances of steering clear of rejections, overpayments, or underpayments. Each payer should be able to provide you with full instructions—like these or these—on how to satisfactorily complete UB-04 claims.

 

This post is a great place to start your UB-04 billing adventure, but it’s just that: a starting point. Have UB-04 filing advice to share with other PTs? If so, share your thoughts in the comments section below.

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