UB-04 LOCATORS
NUMERICAL ORDER
Page
Form Locators
FL 01 - Billing Provider Name, Address and Telephone Number
FL 02 - Billing Provider’s Designated Pay-to Address
FL 03a - Patient Control Number
FL 03b - Medical/Health Record Number
FL 04 - Type of Bill
FL 05 - Federal Tax Number
FL 06 - Statement Covers Period (From - Through)
FL 07 - Reserved for Assignment by the NUBC
FL 08 - Patient Name/Identifier
FL 09 - Patient Address
FL 10 - Patient Birth Date
FL 11 - Patient Sex
FL 12 - Admission/Start of Care Date
FL 13 - Admission Hour
FL 14 - Priority (Type) of Admission or Visit
FL 15 - Point of Origin for Admission or Visit
FL 16 - Discharge Hour
FL 17 - Patient Discharge Status
FL 18-28 - Condition Codes
FL 29 - Accident State
FL 30 - Reserved for Assignment by the NUBC
FL 31-34 - Occurrence Codes and Dates
FL 35-36 - Occurrence Span Codes and Dates
FL 37 - Reserved for Assignment by the NUBC
FL 38 - Responsible Party Name and Address (Claim Addressee)
FL 39-41 - Value Codes and Amounts
FL 42 - Revenue Codes
FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes
FL 45 - Service Date
FL 46 - Service Units
FL 47 - Total Charges
FL 48 - Non-covered Charges
FL 49 - Reserved for Assignment by the NUBC
FL 50 - Payer Name
FL 51 - Health Plan Identification Number
FL 52 - Release of Information Certification Indicator
FL 53 - Assignment of Benefits Certification Indicator
FL 54 - Prior Payments - Payer
FL 55 - Estimated Amount Due - Payer
FL 56 - National Provider Identifier - Billing Provider
FL 57 - Other (Billing) Provider Identifier
FL 58 - Insured’s Name
FL 59 - Patient’s Relationship to Insured
FL 60 - Insured’s Unique Identifier
FL 61 - Insured’s Group Name
FL 62 - Insured’s Group Number
FL 63 - Treatment Authorization Code
FL 64 - Document Control Number (DCN)
FL 65 - Employer Name (of the Insured)
FL 66 - Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
FL 67 - Principal Diagnosis Code and Present on Admission Indicator
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November 2012
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Form Locators
Page
FL 67A-Q - Other Diagnosis Code and Present on Admission Indicator
FL 68 - Reserved for Assignment by the NUBC
FL 69 - Admitting Diagnosis Code
FL 70a-c - Patient’s Reason for Visit
FL 71 - Prospective Payment System (PPS/DRG) Code
FL 72a-c - External Cause of Injury (ECI) Code and POA Indicator
FL 73 - Reserved for Assignment by the NUBC
FL 74 - Principal Procedure Code and Date
FL 74a-e - Other Procedure Codes and Dates
FL 75 - Reserved for Assignment by the NUBC
FL 76 - Attending Provider Name and Identifiers
FL 77 - Operating Physician Name and Identifiers
FL 78-79 - Other Provider name and Identifiers
FL 80 - Remarks Field
FL 81 - Code-Code Field
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Form Locator 01
Data Element
Billing Provider Name, Address and Telephone Number
Definition:
The name and service location of the provider submitting the bill.
Required
Yes
Reporting
Name and Address, Telephone, Country Code Required
Telephone
UB-04: Required
004010/004010A1: Situational. Required when this information is different than that
contained in the Submitter PER segment (Loop ID-1000A).
005010: Situational. Required when this information is different than that contained in
the Submitter PER segment (Loop ID-1000A).
County Code
UB-04: Situational. Required when the address is outside the United States of
America.
004010/004010A1: Situational. Required when the address is outside of the U.S.
005010: Situational. Required when the address is outside of the U.S.
Field
Attributes
1 Field
4 Lines
Notes
The Billing Address must be a street address. Post Office Box or Lock Box
addresses are to be sent in the Pay-To-Address field of Form locator 02, if necessary.
Form Locator 01 uses the full nine-digit ZIP.
25 Positions
Alphanumeric
Left-justified
Enter the information provided on the appropriate line:
Line 1 Provider Name
Line 2 Street Address
Line 3 City (Positions 1-12 Left-justified), State (Positions 14-15), and
Zip Code (Positions 17-25)
Line 4 Telephone (Positions 1-10); Fax (Positions 13-22); Country Code
(Positions 24-25); Use the alpha-2 country codes from Part 1 of ISO 3166)
Form Locator 02
Data Element
Billing Provider’s Designated Pay-to Address
Definition:
The address that the provider submitting the bill intends payment to be sent if different
than FL 01.
Required
If Applicable
Reporting
UB-04: Situational. Required when the address for payment is different than that of
the Billing Provider in Form Locator 01.
00410/004010A1: Situational. Required if the Pay-to Provider is a different entity than
the Billing Provider.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
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Form Locator 02
005010: Situational. Required when the address for payment is different than that of
the Billing Provider. (Note: The purpose of Loop ID-2010AB has changed from
previous versions. Loop ID-2010AB only contains address information when different
from the Billing Provider Address. There are no applicable identifiers for Pay-To
Address information.)
Field
Attributes
1 Field
4 Lines
Notes
Enter the information provided on the appropriate line:
25 Positions
Alphanumeric
Left-justified
Line 1 Pay-to Name
Line 2 Street Address or Post Office Box
Line 3 City (Positions 1-16, Left-justified), State (Positions 18-19), and
Zip Code (Positions 21-25)
Line 4 NOT USED. Reserved for Assignment by the NUBC.
Address may include post office box or street name and number, city, state and ZIP
Code. Form Locator 02 uses a 5-digit ZIP Code.
Form Locator 03a
Data Element
Patient Control Number
Definition:
Patient’s unique (alphanumeric) number assigned by the provider to facilitate retrieval
of the individual’s account of services (accounts receivable) containing the financial
billing records and any postings of payment.
Required
Yes
Reporting
UB-04; 004010/004010A1; 00510 Required
Field
Attributes
1 Field
1 Line
Notes
To enable providers to reconcile payments against the account receivable for the
patient, it is a requirement that payers include the patient control number on the
payment check, remittance advice or voucher.
24 Positions
Alphanumeric
Left-justified
Form Locator 03b
Data Element
Medical/Health Record Number
Definition:
The number assigned to the patient’s medical/health record by the provider.
Required
No
BCNEPA/FPH/FPLIC Billing Manual
November 2012
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Form Locator 03b
Reporting
UB-04: Situational. Required when the provider needs to identify for future inquiries,
the actual medical record of the patient.
004010/004010A1, 005010: Situational. Required when the provider needs to identify
for future inquiries, the actual medical record of the patient identified in either Loop ID2010BA or Loop ID-2010CA for this episode of care.
Field
Attributes
1 Field
1 Line 24 Positions
Notes
The medical/health record number references a file that contains the history of
treatment. It should not be substituted for the Patient Control Number (FL 03a), which
is assigned by the provider to facilitate retrieval of the individual financial record, which
is typically associated with an episode of care.
Alphanumeric Left-justified
Form Locator 04
Data Element
Type of Bill
Definition:
A code indicating the specific type of bill (e.g., hospital inpatient, outpatient,
replacements, voids, etc.). The first digit is a leading zero (Do not include the leading
zero on electronic claims). The fourth digit defines the frequency of the bill for the
institutional and electronic professional claim.
Required
Yes
Reporting
Required
Field
Attributes
1 Field (2 Components) 1 Line
4 Positions
Alphanumeric Left-justified (all positions fully coded)
Notes
The “x” in the following tables (first component) represents a placeholder for the
frequency code (second component).
Inpatient and Outpatient Designation
The matrix which follows contains general guidelines on what constitutes an “inpatient” or “outpatient” claim
according to the first three digits of Type of Bill (TOB).
Inpatient Part B Only – Type of Bill 012x and 022x
The general designations for TOBs 012x and 022x are “OP”. Medicare will pay, under Part B for physician
services and for non-physician medical and other health services when furnished by a participating hospital or
SNF to an inpatient of the facility when patients are not eligible or entitled to Part A benefits or the patient has
exhausted their Part A benefits.
This is done when the patients are not eligible or entitles to, or have exhausted, their Part A benefits. Such
services are billed on these two bill types.
Inpatient/Outpatient
General Designation/
Exception # on FL04
Type of Bill
000x-010x
011x
012x
013x
014x
015x-017x
018x
Reserved for Assignment by NUBC
Hospital Inpatient (Including Medicare Part A)
Hospital Inpatient (Medicare Part B only)
Hospital Outpatient
Hospital - Laboratory Services Provided to Non-patients
Reserved for Assignment by NUBC
Hospital - Swing Beds
BCNEPA/FPH/FPLIC Billing Manual
November 2012
IP
OP/1, 3
OP
OP/6
IP
Page 5
Form Locator 04
Inpatient/Outpatient
General Designation/
Exception # on FL04
Type of Bill
019x-020x
021x
022x
023x
024x-027x
028x
029x-031x
032x
033x
034x
035x-040x
041x
042x
043x
044x-064x
065x
066x
067x-070x
071x
072x
073x
074x
075x
076x
077x
078x
079x
080x
081x
082x
083x
084x
085x
086x
087x-088x
089x
090x-999x
Reserved for Assignment by NUBC
Skilled Nursing - Inpatient (Including Medicare Part A)
Skilled Nursing - Inpatient (Medicare Part B)
Skilled Nursing - Outpatient
Reserved for Assignment by NUBC
Skilled Nursing - Swing Beds
Reserved for Assignment by NUBC
Home Health - Inpatient (plan of treatment under Part B only)
Home Health - Outpatient (plan of treatment under Part A,
Including DME under Part A
Home Health - Other (for medical and surgical services not
Under a plan of treatment)
Reserved for Assignment by NUBC
Religious Non-Medical Health Care Institutions - Hospital
Inpatient
Reserved for Assignment by NUBC
Religious Non-Medical Health Care Institutions - Outpatient
Services
Reserved for Assignment by NUBC
Intermediate Care - Level I
Intermediate Care - Level II
Reserved for Assignment by NUBC
Clinic - Rural Health
Clinic - Hospital Based or Independent Renal Dialysis Center
Clinic - Freestanding
Clinic - Outpatient Rehabilitation Facility (ORF)
Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
Clinic - Community Mental Health Center
Clinic - Federally Qualified Health Center (FQHC) (Effective 4/1/10)
Licensed Freestanding Emergency Medical Facility (Effective 7/1/12)
Clinic - Other
Reserved for Assignment by NUBC
Hospice (non-hospital based)
Hospice (hospital based)
Ambulatory Surgery Center
Free Standing Birthing Center
Critical Access Hospital
Residential Facility
Reserved for Assignment by NUBC
Special Facility - Other
Reserved for Assignment by NUBC
IP/2, 4
OP/1, 3
OP
IP/3
OP/1
OP/1
OP/1
IP
OP
IP/3
IP/3
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP/1
OP/1
OP
OP
OP
IP/3
IP or OP*
-
*Effective 7/1/13, the general designation is OP only.
Exceptions to Inpatient/Outpatient general Designation by Data Element/Form Locator:
Exc. #
1
Data Element
FL12 - Admission/Start of Care Date
Usage Note in 005010 837:
Required on inpatient claims.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Usage Requirement by Type of Bill
Required on all inpatient claims (IP) and
012x, 022x, 032x, 033x, 034x, 081x and
082x.
Page 6
Form Locator 04
Exceptions to Inpatient/Outpatient general Designation by Data Element/Form Locator:
Data Element
FL13 - Admission Hour
Usage Note in 00510 837:
Selection of the appropriate qualifier
Is designated by the NUBC Billing Manual.
Usage Requirement by Type of Bill
Required on all inpatient claims (IP) except
for 021x.
3
FL69 - Admitting Diagnosis:
Usage Note in 00510 837: Required
when claim involves an inpatient admission.
Required on 012x, 022x and inpatient claims
(IP) except 028x, 065x, 066x, 086x.
4
FL16 - Discharge Hour:
Usage Note in 00510 837: Required
on all final inpatient claims.
Required on inpatient claims (IP) with a
Frequency Code of 1, 4 or 7, except for 021x.
5
FL70a-c - Patient’s Reason for Visit:
Usage Note in 00510 837: Required
when claim involves outpatient visits.
Not required on any claim except for 013x,
085x and 078x when:
Exc. #
2
a) Priority (Type) of Admission/Visit Codes
1,2, or 5 are reported
AND
b) Revenue Codes 045x, 0516, 0526, or 0762
are reported.
May be reported on all other 013x, 078x and
085x types of bills at submitter’s discretion
when this information provides additional
information to support medical necessity.
See FL70 a-c for more information.
6
FL15 – Point of Origin for Admission or Visit
Required on all claims except 014x.
Usage Note in 00510 837:
Required for all inpatient and outpatient services.
Type of Bill Frequency Codes:
0
1
2
3
4
5
6
7
8
9
A
B
C
Non-Payment/Zero
Admit Through Discharge Claim (a)
Interim - First Claim
Interim - Continuing Claim (b)
Interim - Last Claim (b)
Late Charge(s) Only
Reserved for assignment by the NUBC
Replacement of Prior Claim (a)
Void/Cancel of Prior Claim (a)
Final Claim for a Home Health PPS Episode
Admission/Election Notice
Hospice/CMS Coordinated Care Demonstration/Religious Non-Medical Health Care
Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration
Hospice Change of Provider Notice
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November 2012
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Form Locator 04
Type of Bill Frequency Codes:
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R-W
X
Y
Z
Hospice/CMS Coordinated Care Demonstration/Religious Non-Medical Health Care
Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration
Void/Cancel
Hospice Change of Ownership
Beneficiary Initiated Adjustment Claim
CWF Initiated Adjustment Claim
CMS Initiated Adjustment
Intermediary Adjustment Claim (Other than QIO or Provider)
Initiated Adjustment Claim - Other
OIG Initiated Adjustment Claim
Reserved for assignment by the NUBC
MSP Initiated Adjustment Claim
Reserved for assignment by the NUBC
Nonpayment/Zero Claims
QIO Adjustment Claim
Claim Submitted for Reconsideration Outside of Timely Limits
Reserved for assignment by the NUBC
Void/Cancel a Prior Abbreviated Encounter Submission
Replacement of Prior Abbreviated Encounter Submission
New Abbreviated Encounter Submission
Footnotes for Frequency Codes
(a) The developers of the Professional and Dental Health Care Claim Implementation Guides have
indicated that this code is acceptable for use in those transactions.
(b) Do not use for Medicare inpatient hospital PPS claims. (For second and subsequent interim bills use
code 7, and see Condition Code D3 (FL18-FL28).
Form Locator 05
Data Element
Federal Tax Number
Definition:
The number assigned to the provider by the federal government for tax reporting
purposes. Also known as a tax identification number (TIN) or employer identification
number (EIN). To identify affiliated subsidiaries using federal tax “sub-ID” (see note
below).
Required
Yes
Reporting
Required
Field Attributes
1 Field Upper Line, 4 positions (sub-ID - optional) Alphanumeric Left-justified
Lower Line, 10 positions (include hyphen) Alphanumeric Left-justified
Notes
Upper line is the federal tax sub-ID number as assigned by the provider. To be used
by providers that assign a unique identifying number for their affiliated subsidiaries,
e.g., hospital psychiatric pavilion.
Lower line is the federal tax number entered as: NN-NNNNNNN.
For electronic claims, do not use the hyphen when reporting federal tax ID.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 8
Form Locator 06
Data Element
Statement Covers Period (From-Through)
Definition:
The beginning and ending service dates of the period included on this bill.
Required
Yes
Reporting
Required: UB-04, 004010/004010A1, 005010
Field
Attributes
2 Field 1 Line 6 Positions (two six-digit dates)
Numeric Right-justified (all positions fully coded)
Notes
1. For all services received on a single day, use the same date for “From” and
“Through”.
2. Enter both dates as month, day, and year (MMDDYY). Example: 010112
3. The “From” date should not be confused with the Admission Date (FL12).
The Statement Covers Period From date in Form Locator 6 (“From” Date) is distinctly
different than the Admission Date in Form Locator 12. The dates may coincide in
some circumstances, but should not be confused. It is also not a requirement that the
Admission Date Fall in between the “From” Date and the Statement Covers Period
“Through” date.
Any edit that requires that the two dates match is invalid. In addition, an edit that
compares the number of days in the Statement Covers Period to any other data
element (e.g., total accommodation days reported in the revenue code section) is
inherently flawed.

The Admission Date is purely the date the patient was admitted as an
inpatient to the facility (or indicates the start of care date for home health and
hospice). It is reported on all inpatient claims regardless of whether it is an
initial, interim, or final bill.

The Statement Covers Period indentifies the span of service dates included in
a particular bill. The “From” Date is the earliest date of service on the bill.
Summary
The billing process for providers is easier if the correct distinctions and validation edits
are properly applied. Some edits are forcing the Admission Date, Procedure Date and
“From” date to be identical. Maintaining the distinction alleviates any special routines
that providers must now undertake in order to circumvent a flawed edit.
The same issues and methodology apply to the 837 institutional claim, which has
distinct data segments and qualifiers to properly distinguish Admission Date and
Statement Covers Period dates.
2012 Update
The Admission Date and Statement Covers Period on claims are two distinctly
different data elements:
 The Admission Date (Form Locator 12) is purely the date the patient was
admitted as an inpatient to the facility ( or indicates the start of care date for
home health and hospice). It is reported on all inpatient claims regardless of
whether it is an initial, interim, or final bill.
 The Statement Covers period (“From” and “Through” dates in FL 6) identifies
the span of service dates included in a particular bill. The From Date is the
earliest date of service on the bill.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 9
Form Locator 07
Data Element
Reserved for Assignment by the NUBC.
Definition:
Required
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
7 Positions (upper line)
8 Positions (lower line)
Form Locator 08
Data Element
Patient Name/Identifier
Definition:
Last name, first name and middle initial of the patient and the patient identifier as
assigned by the payer.
Required
Yes
Reporting
Patient Name
UB-04: Required
004010/004010A1: Required
 If the patient is the subscriber, the name is reported in Loop ID 2010BA.
 If the patient is not the subscriber, the name is reported in Loop ID 2010CA.
005010: Required
 If the patient is the subscriber, the name is reported in Loop ID 2010BA.
 If the patient is not the subscriber but has a unique identifier assigned by the
destination payer, the name is reported in Loop ID 2010BA.
 If the patient is not the subscriber and cannot be identified by a unique
identifier assigned by the destination payer, the name is reported in Loop ID
2010CA.
Reporting
Patient ID
UB-04: Report if number is different from the subscriber/insured’s ID (FL 60).
004010/004010A1: Required
 If the patient is the subscriber, the identifier is reported in Loop ID 2010BA.
 If the patient is not the subscriber, the identifier is reported in Loop ID 2010CA.
005010: Required when the patient name has been mapped to Loop ID 2010BA. Not
Used when the patient name has been mapped to Loop ID 2010CA.
Field
Attributes
1 Field
2 Lines
2 Subfields Alphanumeric
Left-justified
Subfield a: Patient Identifier (19positions) Subfield b: Patient Name (29 positions)
Notes
On the paper UB-04 form, use a comma or space to separate last and first names.
No space should be left between a prefix and a name as in MacBeth and McEnroe.
Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element.
Record hyphenated names with the hyphen as in Smith-Jones, Rebecca.
To record suffix of a name, write the last name, leave a space and write the suffix,
then write the first name as in Snyder Iii, Harold, or Addams Jr., Glen.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 10
Form Locator 09
Data Element
Patient Address
Definition:
The mailing address of the patient. Enter the complete mailing address including
street number and name or post office box number or RFD; city name; state name; ZIP
code.
Required
Yes
Reporting
UB-04 Required
004010/004010A1, 005010: Required. Reported in the same Loop ID (2010BA or
2010CA) that the Patient Name has been mapped to.
Field
Attributes
1 Field
2 Lines
5 Subfields
Subfield a: Street Address (40 Positions)
Subfield b: City (30 Positions)
Subfield c: State (2 Positions)
Subfield d: ZIP Code (9 Positions)
Subfield e: Country Code (2 Positions) Alphanumeric
Left-justified
Notes
Form Locator 10
Data Element
Patient Birth Date
Definition:
The date of birth of the patient.
Required
Yes
Reporting
UB-04 Required
004010/004010A1, 005010: Required. Reported in the same Loop ID (2010BA or
2010CA) that the Patient Name has been mapped to.
Field
Attributes
1 Field
1 Line 8 Positions
Notes
For paper claims only, if full birth date is unknown, indicate zeros for all eight digits.
Enter: “MMDDYYY”
Numeric
Right-justified (all positions fully coded)
Form Locator 11
Data Element
Patient Sex
Definition:
The sex of the patient as recorded at admission, outpatient service, or start of care.
Required
Yes
Reporting
UB-04 Required
004010/004010A1, 005010: Required. Reported in the same Loop ID (2010BA or
2010CA) that the Patient Name has been mapped to.
Field
Attributes
1 Field
Left-justified
1 Line
1 Position
Alphanumeric
Form Locator 11
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 11
Notes
M = Male
F = Female
U = Unkown
Form Locator 12
Data Element
Admission/Start of Care Date
Definition:
The start date for this episode of care. For inpatient services, this is the date of
admission. For other (home health) services, it is the date the episode of care began.
Required
Yes
Reporting
UB-04: Required on all inpatient claims (“IP”), 012x, 022x, 032x, 033x, 034x, 081x,and
082x.
004010/004010A1: Required
00510: Required on inpatient claims, home health claims and hospice claims.
Field
Attributes
1 Field
1 Line
6 Positions
Right-justified (all positions fully coded)
Notes
Enter the admission date as month, day and year (MMDDYY).
The Admission/Start of Care Date is a discrete data element and should not be
confused with the Statement Covers Period “From” date on Form Locator 06.
Numeric
Form Locator 13
Data Element
Admission Hour
Definition:
The code referring to the hour during which the patient was admitted for inpatient care.
Required
Yes (Inpatient only)
Reporting
UB-04: Required on all inpatient claims except for Type of Bill 021x.
004010/004010A1: This segment is required on all inpatient claims.
005010: Selection of the appropriate qualifier is designated by the NUBC Billing
Manual. (Therefore, required on inpatient claims except for Type of Bill 021x as noted
above.)
Field
Attributes
1 Field
Alphanumeric
Notes
Code Structure
Code Time - A.M.
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 - 05:49
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
1 Line
2 Positions
Left-justified (all positions fully coded, unless blank)
Code
12
13
14
15
16
17
18
19
20
21
22
23
Time - P.M.
12:00 - 12:59 Noon
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
Form Locator 14
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 12
Data Element
Priority (Type) of Admission or Visit
Definition:
A code indicating the priority of this admission/visit.
Required
Yes
Reporting
UB-04: Required on inpatient and outpatient services.
004010/004010A1: Required when patient is being admitted to the hospital for
inpatient services.
005010: Required on inpatient and outpatient services.
Field
Attributes
1 Field
Alphanumeric
Notes
See codes below
Code
Definition
1 Line
Left-justified
1 Position
1
Emergency
The patient requires immediate medical intervention as a result of severe, life
threatening or potentially disabling conditions.
2
Urgent
The patient requires immediate attention for the care and treatment of a physical or
mental disorder.
3
Elective
The patient’s condition permits adequate time to schedule the services.
4
Newborn
Use of this code necessitates the use of special Source of Admission Codes (Form
Locator 15).
5
Trauma
Visit to 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. (Use Revenue Code 068x to capture
trauma activation charges.)
6-8
9
Reserved for assignment by NUBC
Information
not Available
Information not available.
Form Locator 15
Data Element
Point of Origin for Admission or Visit
Definition:
A code indicating the point of patient origin for this admission or visit.
Required
Yes (Inpatient, SNF, Home Health and Hospice)
If Applicable (Outpatient)
Reporting
UB04: Required on all bill types except 014x.
004010/004010A1: Required for all inpatient admissions. Required on Medicare
outpatient registrations for diagnostic testing services.
005010: Required for all inpatient and outpatient services. (Therefore required on all
bill types marked “IP” and “OP” per FL 04 except for bill type 014x, which is equivalent
to the UB-or requirement.)
Form Locator 15
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 13
Field
Attributes
1 Field
Alphanumeric
1 Line
Left-justified
1 Position
Notes
The updated and revised code list has been designed to focus on patients’ place or
point of origin rather than the source of a physician order or referral. A physician order
or referral is implicit in any admission or visit. By modifying the definitions of the codes
in this manner, the ambiguity in the code structure has been eliminated; all of the
codes become mutually exclusive. The point of origin is the direct source for the
particular facility.
I. Transfers - From an Another Facility
While at another acute care hospital/facility, the patient is seen by the emergency
room physicians. The patient is then transferred to our facility. The patient arrives at
our facility through the emergency room. Point of Origin Code 4 - Transfer from a
Hospital (Different Facility)
II. Transfers - Skilled Nursing Facility
A resident from a skilled nursing facility is taken to an acute care hospital for medical
care. Point of Origin Code 5 - Transfer from a Skilled Nursing Facility
III. Transfer by Law Enforcement or Court
A patient arrives at the health care facility accompanied by policy. Point of Origin
Code 8 - Court/Law Enforcement
Description
Code
1
2
3
4
5
6
7
Inpatient: The patient was admitted to this facility.
Outpatient: The patient presented to this facility for outpatient services.
Examples: Includes patients coming from home, or workplace and
patients receiving care at home (such as home health services).
Clinic or Physician’s
Inpatient: The patient was admitted to this facility.
Office
Outpatient: The patient presented to this facility for outpatient services.
Reserved for assignment by the NUBC
(Discontinued effective 10/1/07)
Transfer from a Hospital Inpatient: The patient was admitted to this facility as a hospital transfer
(Different Facility)
from an acute care facility where he or she was an inpatient or
outpatient.
Outpatient: The patient was transferred to this facility as an outpatient from
an acute care facility.
Usage Note: Excludes Transfers from Hospital Inpatient in the
Same Facility (See Code D).
Transfer from a Skilled
Inpatient: The patient was admitted to this facility as a transfer from a
Nursing Facility (SNF)
SNF, ICF or ALF where he or she was a resident.
Intermediate Care
Outpatient: The patient was referred to this facility for outpatient or referenced
Facility (ICF) or Assisted
diagnostic services from a SNF, ICF or ALF where he or she was
Living Facility (ALF)
a resident.
Transfer from Another
Inpatient: The patient was admitted to this facility as a transfer from
Health Care Facility
another type of health care facility not defined elsewhere in this
code list.
Outpatient: The patient presented to this facility for services from another
health care facility not defined elsewhere in this code list.
Reserved for assignment by the NUBC.
(Discontinued effective 7/1/10)
Non-Health Care
Facility Point of Origin
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 14
Form Locator 15
Code
8
Description
Court/Law Enforcement
Inpatient:
Outpatient:
9
Information Not
Available
Inpatient:
Outpatient:
A
B
C
D
Transfer From Another Home
Health Agency
Transfer from One Distinct Inpatient:
Unit of the Hospital to another
Distinct Unit of the Same
Hospital Resulting in a
Outpatient:
Separate Claim to the Payer
E
Transfer from Ambulatory Inpatient:
Surgery Center
Outpatient:
F
Transfer from a Hospice
Facility
Inpatient:
Outpatient:
G-Z
The patient was admitted to this facility upon the direction of
a court of law, or upon the request of a law enforcement
agency representative.
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.
The patient’s Point of Origin is not know.
The patient’s Point of Origin is not know.
Reserved for assignment by the NUBC
(Discontinued effective 10/1/07)
Discontinued Effective 7/1/10.
(Replaced with Condition Code 47 FL 18-28)
Discontinued Effective 7/1/10
The patient was admitted to this facility as a transfer from
hospital inpatient within this hospital resulting in a separate
claim to the payer.
The patient received outpatient services in this facility as a
transfer from within this hospital resulting in a separate claim to
the payer.
Usage Note: For purposes of this code, “Distinct Unit” is defined
as a unique unit or level of care at the hospital requiring the
issuance of a separate claim to the payer. Examples could include
observation services, psychiatric units, rehabilitation units, a unit
in a critical access hospital, or a swing bed located in an acute
hospital.
The patient was admitted to this facility as a transfer from an
ambulatory surgery center.
The patient presented to this facility for outpatient or referenced
diagnostic services from an ambulatory surgery center.
The patient was admitted to this facility as a transfer from a
hospice facility.
The patient presented to this facility for outpatient or referenced
diagnostic services from a hospice facility.
Reserved for assignment by the NUBC
Code Structure for Newborn
1-4
5
6
7-9
Born Inside this Hospital
Born Outside of this Hospital
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Reserved for assignment by the NUBC.
(Discontinued Effective 10/1/07)
A baby born inside this Hospital.
A baby born outside of this Hospital.
Reserved for assignment by the NUBC.
Page 15
Form Locator 16
Data Element
Discharge Hour
Definition:
Code indicating the discharge hour of the patient from inpatient care.
Required
Yes (Inpatient, SNF, Home Health and Hospice)
If Applicable (Outpatient)
Reporting
UB-04: Required on inpatient claims (“IP”) with a Frequency Code of 1 or 4, except for
Type of Bill 021x.
004010/004010A1, 005010: Required on all final inpatient claims.
Field
Attributes
1 Field
Alphanumeric
Notes
Code Structure
Code
00
01
02
03
04
05
06
07
08
09
10
11
1 Line
2 Positions
Left-justified (all positions fully coded, unless blank)
Time - A.M.
12:00 - 12:59 Midnight
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:49
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
Code
12
13
14
15
16
17
18
19
20
21
22
23
Time - P.M.
12:00 - 12:59 Noon
01:00 - 01:59
02:00 - 02:59
03:00 - 03:59
04:00 - 04:59
05:00 - 05:59
06:00 - 06:59
07:00 - 07:59
08:00 - 08:59
09:00 - 09:59
10:00 - 10:59
11:00 - 11:59
Form Locator 17
Data Element
Patient Discharge Status
Definition:
A code indicating the disposition or discharge status of the patient at the end service
for the period covered on this bill, as reported in FL6, Statement Covers Period.
Required
Yes (Inpatient, SNF, Home Health and Hospice)
Not Required (Outpatient)
Reporting
Required for inpatient claims/encounters.
Field
Attributes
1 Field
Numeric
Notes
The patient’s discharge status is required on all institutional claims. Identifying the
appropriate code may often be confusing; judgment must be used in all cases. A
basic rule of thumb is to code to the highest level of care that is known - -for example,
an individual discharged to home with a home health plan of care is coded as 06,
rather than 01.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
1 Line
Right-justified
2 Positions
Page 16
Form Locator 17
Code Structure
01
02
03
04
05
06
07
08
09
10-19
20
21
22-29
30
31-39
40
41
42
43
44-49
50
51
52-60
Discharged to Home or Self Care (Routine Discharge)
Usage Note: Includes discharge to home; home on oxygen if DME only; any other DME only;
group home, foster care, independent living and other residential care arrangements;
outpatient programs; such as partial hospitalization or outpatient chemical dependency
programs.
Discharged/transferred to a Short-Term General Hospital for Inpatient Care
Discharged/transferred to Skilled Nursing Facility (SNF) with Medicare Certification in
Anticipation of Skilled Care
Usage Note: Medicare - Indicates that the patient is discharged/transferred to a Medicare
certified nursing facility. For hospitals with an approved swing bed arrangement, use Code
61 - Swing Bed. For reporting other discharges/transfers to nursing facilities, see codes 04
and 64.
Discharged/transferred to a Facility that Provides Custodial or Supportive Care
Usage Note: Includes intermediate care facilities (ICFs) if specifically designated at the state
level. Also used to designate patients that are discharged/transferred to a nursing facility with
neither Medicare or Medicaid certification and for discharges/transfers to Assisted Living
Facilities.
Discharged/transferred to a Designated Cancer Center or Children’s Hospital
Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list of
(National Cancer Institute) Designated Cancer Centers can be found at
http://www3.cancer.gov/cancercenters/centerslist.html.
Discharged/transferred to Home Under Care of an Organized Home Health Service
Organization in Anticipation of Covered Skilled Care
Usage Note: Report this code when the patient is discharged/transferred to home with a
written plan of care (tailored to the patient’s medical needs) for home care services. Not used
for home health services provided by a DME supplier or from a Home IV provider for home IV
services.
Left Against Medical Advice or Discontinued Care
Reserved for Assignment by the NUBC
Admitted as an Inpatient to this Hospital
Usage Note: For use only on Medicare outpatient claims. Applies only to those Medicare
outpatient services that begin greater than three days prior to an admission.
Reserved for Assignment by the NUBC
Expired
Discharged/transferred to Court/Law Enforcement
Reserved for Assignment by the NUBC
Still patient
Usage Note: Used when patient is still within the same facility; typically used when billing for
leave of absence days or interim bills.
Reserved for Assignment by the NUBC
Expired at Home
Expired in a Medical Facility (e.g. hospital, SNF, ICF, or free standing hospice)
Expired - Place Unknown
Usage Note: For use only on Medicare and TRICARE claims for hospice care.
Discharged/transferred to a Federal Health Care Facility
Usage Note: Discharges and transfers to a government operated health facility such as a
Department of Defense hospital, a Veteran’s Administration hospital or a Veteran’s
Administration nursing facility. To be used whenever the destination at discharge is a federal
health care facility, whether the patient lives there or not.
Reserved for Assignment by the NUBC
Hospice - Home
Hospice - Medical Facility (Certified) Providing Hospice Level of Care
Reserved for Assignment by the NUBC
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 17
Form Locator 17
Code Structure
61
62
63
64
65
66
67-69
70
71-99
Discharged/transferred to Hospital-Based Medicare Approved Swing Bed
Usage Note: Medicare - Used for reporting patients discharged/transferred to a SNF level of care
within the hospital’s approved swing bed arrangement.
Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation
Distinct Part Units of a Hospital
Discharged/transferred to a Medicare Certified Long Term Care Hospital (LTCH)
Usage Note: For hospitals that meet the Medicare criteria for LTCH certification.
Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under
Medicare
Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital
Discharged/transferred to a Critical Access Hospital (CAH)
Reserved for Assignment by the NUBC
Discharged/transferred to another Type of Health Care Institution not Defined
Elsewhere in this Code List (See Code 05)
Reserved for Assignment by the NUBC
Form Locator 18-28
Data Element
Condition Codes
Definition:
A code(s) used to identify conditions or events relating to this bill that may affect
processing.
Required
If Applicable
Reporting
UB-04, 004010/004010A1, 005010: Required when there is a Condition Code that
applies to this claim.
Field
Attributes
11 Fields
Alphanumeric
Notes
No specific date is associated with this code.
Condition Codes should be entered in alphanumeric sequence.
Codes assigned as Payer Codes are for internal use only by the payer: they are
assigned by the payer and are not required to be communicated to another payer for
COB, unless these Payer Codes are communicated to the other payers as part of their
contracted working relationship.
If all of the Condition Code fields are filled, use FL 81 Code-Code field with the
appropriate qualifier code (A1) to indicate that a Condition Code is being reported.
1 Line
2 Positions
All positions fully coded
Code Structure
01
02
03
04
05
06
07
08
Military Service Related
Condition is Employment Related
Patient Covered by Insurance Not Reflected Here
Information Only Bill
Lien Has Been Filed
ESRD Patient in First 30 Months of Entitlement Covered by Employer Group Health
Insurance
Treatment of Non-terminal Condition for Hospice Patient
Beneficiary Would Not Provide Information Concerning Other Insurance Coverage
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 18
Form Locator 18-28
Code Structure
09
10
11
12-16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53-55
56
57
58
59
60
61
62-65
66
67
68
69
70
Neither Patient nor Spouse is Employed
Patient and/or Spouse is Employed but no EGHP Exists
Disabled Beneficiary but No LGHP
Payer Codes
Patient is Homeless
Maiden Name Retained
Child Retains Mother’s Name
Beneficiary Requested Billing
Billing for Denial Notice
Patient on Multiple Drug Regimen
Home Care Giver Available
Home IV Patient Also Receiving-HHA Services
Patient is Non-U.S. Resident
VA Eligible Patient Chooses to Receive Services in a Medicare Certified Facility
Patient Referred to a Sole Community Hospital for a Diagnostic Laboratory Test
Patient and/or Spouse’s EGHP is Secondary to Medicare
Disabled Beneficiary and/or Family Member’s LGHP is Secondary to Medicare
Qualifying Clinical Trials
Patient is Student (Full Time - Day)
Patient is Student (Cooperative/Work Study Program)
Patient is Student (Full Time - Night)
Patient is Student (Part Time)
Reserved for assignment by the NUBC
General Care Patient in a Special Unit
Ward Accommodation at Patient Request
Semi-Private Room Not Available. Note: Required when billing to indicate
member not liable for private room difference.
Private Room Medically Necessary. Note: Required when billing to indicate
member not liable for private room difference.
Same Day Transfer
Partial Hospitalization
Continuing Care not Related to Inpatient Hospitalization
Continuing Care not Provided Within Prescribed Post-discharge Window
Inpatient Admission Changed to Outpatient
Ambiguous Gender Category
Non-availability Statement on File
Transfer from Another Home Health Agency (Effective 7/1/10)
Psychiatric Residential Treatment Centers for Children and Adolescents (RTCs)
Product Replacement within Product Lifecycle
Product Replacement for Known Recall of a Product
Attestation of Unrelated Outpatient Nondiagnostic Services (Effective 4/1/11)
Out of Hospice Service Area (Effective 7/1/12)
Reserved for assignment by the NUBC
Medical Appropriateness
SNF Readmission
Terminated Medicare Advantage Enrollee
Non-primary ESRD Facility
Day Outlier
Cost Outlier
Payer Code
Provider does not Wish Cost Outlier Payment
Beneficiary Elects not to use Life Time Reserve (LTR) Days
Beneficiary Elects to use Life Time Reserve (LTR) Days
IME/DGME/N&AH Payment Only
Self Administered Anemia Management Drug
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 19
Form Locator 18-28
Code Structure
71
72
73
74
75
76
77
78
79
80
81-99
A0
A1
A2
A3
A4
A5
A6
A7-A8
A9
AA(a)
AB(a)
AC(a)
AD(a)
AE(a)
AF(a)
AG(a)
AH(a)
AI
AJ
AK
AL
AM
AN
AO-AZ
B0
B1
B2
B3
B4
B5-B0
BP
BQ-C0
C1
C2
C3
C4
C5
C6
C7
C8-CZ
Full Care in Unit
Self Care in Unit
Self Care Training
Home
Home - 100 Percent Reimbursement
Back-up in Facility Dialysis
Provider Accepts or is Obligated/Required due to a Contractual Arrangement or
Law to Accept Payment by a Primary Payer as Payment in Full
New Coverage not Implemented by Managed Care Plan
CORF Services Provided Offsite
Home Dialysis - Nursing Facility
Reserved for assignment by the NUBC
TRICARE External Partnership Program
EPSDT/CHAP (Early and Periodic Screening Diagnosis and Treatment)
Physically Handicapped Children’s Program
Special Federal Funding
Family Planning
Disability
Vaccines/Medicare 100% Payment
Reserved for assignment by the NUBC
Second Opinion Surgery
Abortion Performed due to Rape
Abortion Performed due to Incest
Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality
Abortion Performed due to a Life Endangering Physical Condition
Abortion Performed due to Physical Health of Mother that is not Life Endangering
Abortion Performed due to Emotional/psychological Health of the Mother
Abortion Performed due to Social or Economic Reasons
Elective Abortion
Sterilization
Payer Responsible for Co-payment
Air Ambulance Required
Specialized Treatment/bed Unavailable - Alternate Facility Transport
Non-emergency Medically Necessary Stretcher Transport Required
Preadmission Screening Not Required
Reserved for assignment by the NUBC
Medicare Coordinated Care Demonstration Claim
Beneficiary is Ineligible for Demonstration Program
Critical Access Hospital Ambulance Attestation
Pregnancy Indicator
Admission Unrelated to Discharge on Same Day
Reserved for assignment by the NUBC
Gulf Oil Spill of 2010 (Effective 4/20/10)
Reserved for assignment by the NUBC
Approved as Billed
Automatic Approval as Billed Based on Focused Review
Partial Approval
Admission/Services Denied
Post Payment Review Applicable
Admission Pre-authorization
Extended Authorization
Reserved for assignment by the NUBC
(a) Code is acceptable for use in Professional Health Care Claim Implementation Guide (ASC X12N/005010X222)
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 20
Form Locator 18-28
Code Structure
D0
D1
D2
D3
D4
D5
D6
D7
D8
D9
DA-DQ
DR
DS-DZ
E0
E1-FZ
G0
G1-GZ
H0
H1
H2
H3
H4
H5
H6-LZ
M0-MZ
N0-OZ
P0
P1
P2-P6
P7
P8-PZ
Q0-UT
UU
UV-VZ
W0
W1
W2(a)
W3(a)
W4(a)
W5(a)
W6-ZZ
Changes to Service Dates
Changes to Charges
Changes in Revenue Codes/HCPCS/HIPPS Rate Codes
Second or Subsequent Interim PPS Bill
Change in clinical codes (ICD) for Diagnosis and/or Procedure Codes
Cancel to Correct Insured’s ID or Provider ID
Cancel Only to Repay a Duplicate or OIG Overpayment
Change to Make Medicare the Secondary Payer
Change to Make Medicare the Primary Payer
Any Other Change
Reserved for assignment by the NUBC
Disaster Related
Reserved for assignment by the NUBC
Change in Patient Status
Reserved for assignment by the NUBC
Distinct Medical Visit
Reserved for assignment by the NUBC
Delayed Filing; Statement of Intent Submitted
Reserved for assignment by the NUBC
Discharge by a Hospice Provider for Cause (Effective 1/1/09)
Reoccurrence of GI Bleed Comorbid Category (Effective 1/1/11)
Reoccurrence of Pneumonia Comorbid Category (Effective 1/1/11)
Reoccurrence of Pericarditis Comorbid Category (Effective 1/1/11)
Reserved for assignment by the NUBC
Reserved for payer assignment
Reserved for assignment by the NUBC
Reserved for Public Health Data Reporting
Do Not Resuscitate Order (DNR)
Reserved Public Health Data Reporting
Direct Inpatient Admission from Emergency Room (Effective 7/1/10)
Reserved Public Health Data Reporting
Reserved for assignment by the NUBC
Payer Code
Reserved for assignment by the NUBC
United Mine Workers of America (UMWA) Demonstration Indicator
Reserved for assignment by the NUBC
Duplicate of Original Bill
Level I Appeal
Level II Appeal
Level III Appeal
Reserved for assignment by the NUBC
(a) Code is acceptable for use in Professional Health Care Claim Implementation Guide (ASC X12N/005010X222)
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 21
Form Locator 29
Data Element
Accident State
Definition:
The accident state filed contains the two-digit state abbreviation where the accident
occurred.
Required
If Applicable
Reporting
UB-04, 005010: Required when the services reported on this claim are related to an
auto accident and the accident occurred in a country or location that has a state,
province, or sub-country code named in X12 code source 22 (ISO 3166-2 Codes for
the representation of names of countries and their subdivisions).
004010/004010A1: Not Used
Field
Attributes
1 Field
2 Positions
1 Line
Alphanumeric
Left-justified
Notes
Form Locator 30
Data Element
Reserved for Assignment by the NUBC.
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
13 Positions (lower line)
11 Positions (upper line)
Alphanumeric
Left-justified
Form Locator 31-34
Data Element
Occurrence Codes and Dates
Definition:
The code and associated date defining a significant event relating to this bill that may
affect payer processing.
Required
If Applicable
Reporting
UB-04, 004010/004010A1, 005010: Situational. Required when there is an Occurrence
Code that applies to this claim.
Field
Attributes
4 Fields
2 Lines
2 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
Enter all dates as month, day, and year (MMDDYY)
4 Fields
2 Lines
6 Positions
Numeric
Right-justified
Occurrence Codes should be entered in alphanumeric sequence (numbered codes
precede alpha codes).
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 22
Form Locator 31-34
Code Structure
01
02
03
04
05
06
07-08
09
10
11
12
13-15
16
17
18
19
20
21
22
23
24
25
26
27
Accident/Medical
Coverage
No Fault Insurance
Involved -Including
Auto Accident/Other
Accident/Tort Liability
Accident/Employment
Related
Accident/No Medical
or Liability Coverage
Crime Victim
Start of Infertility
Treatment Cycle
Last Menstrual Period
Code indicating accident-related injury for which there is medical
payment coverage. Provide the date of accident/injury.
Code indicating the date of an accident including auto or other
where state has applicable no fault liability laws (i.e., legal basis
for settlement without admission of proof of guilt).
Code indicating the date of an accident resulting from a third party’s action
that may involve a civil court process in an attempt to require payment by the
third party, other than no fault liability.
Code indicating the date of an accident allegedly relating to the
an accident allegedly relating to the patient’s employment.
Code indicating accident related injury for which there is no medical
payment or third-party liability coverage. Provide the date of accident/injury.
Code indicating the date on which the medical condition resulted from alleged
criminal action committed by one or more parties.
Reserved for assignment by the NUBC.
Code indicating the start date of infertility treatment cycle.
Code indicating the date of the last menstrual period; ONLY applies
when patient is being treated for maternity-related condition.
Onset of Symptoms/
Code indicating the date the patient first became aware of the
Illness
symptoms/illness.
Date of Onset for a
(HHA Claims Only) Code denotes date the patient/beneficiary becomes a
Chronically Dependent Chronically Dependent Individual (CDI). This is the first month of the 3
Individual
month period immediately before eligibility under respite care benefit.
Reserved for assignment by the NUBC
Date of Last Therapy
Code denotes last day of therapy services (e.g. physical therapy,
occupational therapy, speech therapy).
Date Outpatient
Code denotes date an occupational therapy plan was established
Occupational Therapy or last reviewed.
Plan Established or
Last Reviewed
Date of Retirement The date of retirement for the patient/beneficiary.
Patient/Beneficiary
Date of Retirement The date of retirement for the patient’s spouse.
Spouse
Date Guarantee of
Code indicates date on which the provider began claiming Medicare
Payment Began
payment under the guarantee of payment provision.
Date UR Notice
Code indicating the date of receipt by the provider of the UR Committee’s
Received
finding that the admission or future stay was not medically necessary.
Date Active Care
Code indicates the date covered level of care ended in a SNF or
Ended
general hospital, or date on which active care ended in a psychiatric or
tuberculosis hospital, or date on which patient was released on a trial basis
from a residential facility. Code not required when Condition Code 21 is used.
Payer Code
Date Insurance Denied Code indicating the date the denial of coverage was received by the health
care facility from any insurer.
Date Benefits
Code indicating the date on which coverage (including Worker’s
Terminated by Primary Compensation benefits of no-fault coverage) is no longer available to the
Payer
patient.
Date SNF Bed Became Code indicating the date on which a SNF bed became available to
Available(Inpatient)
hospital inpatient who requires only SNF level of care.
Date of Hospice
Code indicating the date of certification or re-certification of the
Certification or
hospice benefit periods.
Re-Certification
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 23
Form Locator 31-34
Code Structure
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Date Comprehensive Code indicating the date a comprehensive outpatient rehabilitation
Outpatient
plan was established or last reviewed.
Rehabilitation Plan
Established or Last
Reviewed
Date Outpatient
Code indicating the date a physical therapy plan was established
Physical Therapy Plan or last reviewed.
Established or Last
Reviewed
Date Outpatient Speech Code indicating the date a speech pathology plan was established
Pathology Plan
or last reviewed.
Established or Last
Reviewed
Date Beneficiary
The date of notice provided by the hospital to the patient that inpatient
Notified of Intent to
care is not longer required.
Bill (Accommodations)
Date Beneficiary
The date of notice provided to the beneficiary that requested care
Notified of Intent to
(diagnostic procedures or treatments) may not be reasonable or
Bill (Procedures or
necessary.
Treatments)
First Day of the
Code indicates the first day of coordination for benefits that are
Coordination Period
are secondary to benefits payable under an employer’s group health
for ESRD Beneficiaries plan. Required only for ESRD beneficiaries.
Covered by EGHP
Date of Election of
Code indicates the date the guest elected to receive extended
Extended Care
care services (used by Religious Non-Medical only).
Facilities
Date Treatment Started Code indicates the initial date services by the billing provider for
for Physical Therapy
physical therapy.
Date of Inpatient
Code indicates the date of discharge for inpatient hospital stay in which
Hospital Discharge for the patient received a covered transplant procedure when the hospital
Covered Transplant
is billing for immunosuppressive drugs.
Patients
Note: When the patient received both a covered and a non-covered
transplant, the covered transplant predominates.
Date of Inpatient
Code indicates the date of discharge for the inpatient hospital stay
Hospital Discharge for in which the patient received a non-covered transplant procedure
Non-Covered
when the hospital is billing for immunosuppressive drugs.
Transplant Patient
Date Treatment Started Date the patient was first treated at home for IV therapy (Home IV
for Home IV Therapy
providers - Bill Type 085x).
Date Discharged on a Date the patient was discharged from the hospital on a continuous
Continuous Course of course of IV therapy. (Home IV providers - Bill Type 085x).
IV Therapy
Schedule Date of
The scheduled date the patient will be admitted as an inpatient to the
Admission
hospital. (This code may only be used on an outpatient claim).
Date of First Test for
The date on which the first outpatient diagnostic test was performed as
Pre-Admission Testing part of a PAT program. This code may only be used if a date of
admission was scheduled before the administration of the test(s).
Date of Discharge
Use only when the “Through” date in Locator 06 (Statement Covers
Period) is not the actual discharge date and the frequency code
in Locator 04 is that of a final bill. For final bill for hospice care,
enter the date the Medicare beneficiary terminated his election of
hospice care.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 24
Form Locator 31-34
Code Structure
43
44
45
46
47
48-49
50
Scheduled Date of
Canceled Surgery
Date Treatment Started
Occupational Therapy
Date Treatment Started
for Speech Therapy
Date Treatment Started
for Cardiac
Rehabilitation
Date Cost Outlier
Status Begins
Assessment Date
51
Date of Last Kt/V
Reading
52
Medical Certification/
Recertification Date
(Effective 1/1/11)
53
54
55
56-69
70-99
A0
A1
A2
A3
A4
A5-AZ
B0
B1
B2
B3
B4-BZ
C0
C1
C2
C3
C4-DQ
DR
DS-DZ
E0
E1-E3
E4-EZ
F0
The date for which outpatient surgery was scheduled.
The date services were initiated by the billing provider for occupational
therapy.
The date services were initiated by the billing provider for speech therapy.
The date services were initiated by the billing provider for cardiac
rehabilitation.
Code indicates that this is the first day after the day the Cost Outlier
threshold is reached.
Payer Codes
Code indicating an assessment date as defined by the assessment
instrument applicable tot this provider type (e.g., Minimum Data Sets (MDS)
for skilled nursing). (Effective 1/1/11)
For in-center hemodialysis patients, this is the date of the last reading taken
during the billing period. For peritoneal dialysis patients (and home
hemodiaysis patients, this date may be before the current billing period but
should be within 4 months of the date of service. (Effective 07/01/10)
The date of the most recent non-hospice medical certification or
recertification of the patient. Use Occurrence Code 27 for Date of Hospice
Certification of Recertification.
Reserved for assignment by the NUBC
Last date of a physician follow-up with the patient.
Physician Follow-up
Date (Effective 1/1/11)
Date of Death
Report his code when patient discharge status codes 20 (expired), 40
(Effective 10/1/12)
(expired at home), 41 (expired in a medical facility, or 42 (expired – place
unknown) are used.
Reserved for assignment by the NUBC
See instructions in Form Locators 35-36 Occurrence Span Codes and Dates
Reserved for assignment by the NUBC
Birth Date - Insured A The birth date of the individual in whose name the insurance is carried.
Effective Date - Insured A code indicating the first date insurance is in force.
A Policy
Benefits Exhausted Code indicating the last date for which benefits are available and
Payer A
after which no payment can be made to Payer A.
Split Bill Date
Date patient became eligible due to medically needy spend down
(sometimes referred as “Split Bill Date”).
Reserved for assignment by the NUBC
Reserved for assignment by the NUBC
Birth Date - Insured B The birth date of the individual in whose name the insurance is carried.
Effective Date - Insured A code indicating the first date insurance is in force.
B Policy
Benefits Exhausted Code indicating the last date for which benefits are available and after
Payer B
which no payment can be made by Payer B.
Reserved for assignment by the NUBC
Reserved for assignment by the NUBC
Birth Date - Insured C The birth date of the individual in whose name the insurance is carried.
Effective Date - Insured A code indicating the first date insurance is in force.
C Policy
Benefit Exhausted Code indicating the last date for which benefits are available and after
Payer C
which no payment can be made by Payer C.
Reserved for assignment by the NUBC
Reserved for Disaster Related Occurrence Code
Reserved for assignment by the NUBC
Reserved for assignment by the NUBC
Discontinued 3/1/07
Reserved for assignment by the NUBC
Reserved for assignment by the NUBC
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 25
F1
Discontinued 3/1/07
Form Locator 31-34
Code Structure
F2
F3
F4-FZ
Discontinued 3/1/07
Discontinued 3/1/07
Reserved for assignment by the NUBC
G0
G1-G3
G4-LZ
M0-ZZ
Reserved for assignment by the NUBC
Discontinued 3/1/07
Reserved for assignment by the NUBC
See instructions in Form Locators 35-36 Occurrence Span Codes and Dates
Form Locator 35-36
Data Element
Occurrence Span Codes and Dates
Definition:
A code and the related dates that identify an event that relates to the payment of the
claim.
Required
Reporting
UB-04, 004010/004010A1, 005010: Situational. Required when there is an
Occurrence Span Code that applies to this claim.
Field
Attributes
2 Fields (codes)
2 Lines
2 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
These codes identify occurrences that happened over a span of time.
Enter all dates as month, day, and year (MMDDYY).
4 Fields (dates)
2 Lines
6 Positions
Numeric
Right-justified
Enter Occurrence Span Codes in alphanumeric sequence starting with code 70 and
ending with ZZ (numbered codes precede alpha codes). If FL 35a&b and FL 36a&b
have been filled and additional occurrence span codes are required, use FL 81 with
the appropriate qualifier code (A3) to indicate that an Occurrence Span Code is being
reported.
Code Structure
70
71
72
73
74
75
Qualifying Stay Dates
For SNF Use Only
The from/through date of at least a 3 day inpatient hospital stay that
qualifies the resident for Medicare payment of SNF services billed.
Code can be used only by SNF for billing.
Prior Stay Dates
The from/through dates given by the patient of any hospital stay that ended
within 60 days of this hospital or SNF admission.
First/Last Visit Dates
The from/through dates of outpatient services. For use on outpatient bills
(Outpatient only)
only where the entire billing record is not represented by the actual
from/through service dates of Locator 06 (Statement Covers Period).
Benefit Eligibility
The inclusive dates during which TRICARE medical benefits are
available
Period
to a sponsor’s beneficiary as shown on the beneficiary’s identification card.
Non-Covered Level of The from/through dates of a period at a non-covered level of care
Care/Leave of Absence or leave of absence in an otherwise covered stay, excluding any
Dates
period reported by Occurrence Span Code 76, 77, or 79 below.
SNF Level of Care
The from/through dates of a period of SNF level of care during
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 26
Dates
an inpatient hospital stay. (Inpatient only)
Form Locator 35-36
Code Structure
76
Patient Liability
77
Provider Liability
Period
SNF Prior Stay Dates
78
79
80
81
82-99
M0
Payer Code
Prior Same-SNF
Stay Dates for
Payment Ban
Purposes
Antepartum Days at
Reduced Level of Care
(Effective 7/1/12)
The from/through dates of a period of non-covered care for which
the hospital is permitted to charge the Medicare beneficiary. Code
should be used only where the QIO or intermediary has approved
such charges in advance and patient has been notified in writing
at least three days prior to the “from” date of this period.
The from/through dates of a period of non-covered care for which
the provider is liable; utilization is charged.
The from/through dates given by the patient of any SNF or nursing home
stay that ended within 60 days of this hospital or SNF admission.
The from/through dates of a prior same-SNF stay indicating a patient
resided in the SNF prior to, and if applicable, during a payment ban period
up until their discharge to a hospital. (Effective 1/1/09)
This code and corresponding dates indicate the from and through dates of
an antepartum hospital stay where the level of care is non-acute.
Reserve for assignment by the NUBC
The first and last days that were approved where not all of the stay
was approved. (Use when Condition Code C3 is used in Locators 18-28).
M1
Code indicates the from/through dates of a period of non-covered care
that is denied due to lack of medical necessity or as custodial care for which
the provider is liable. The beneficiary is not charged with utilization. The
provider may not collect Part A or Part B deductible or coinsurance from the
beneficiary.
M2
Inpatient Respite Dates The from/through dates of a period of inpatient respite care.
M3
ICF Level of Care
The from/through dates of a period of intermediate level of care during an
inpatient hospital stay.
M4
Residential Level of
The from/through dates of a period of residential level of care during an
Care
inpatient hospital stay.
M5-MQ
Reserved for assignment by the NUBC
MR
Reserved for Disaster Related Occurrence Span Code
MS-ZZ
Reserved for assignment by the NUBC
QIO/UR Approved
Stay Dates
Provider Liability - No
Utilization
Form Locator 37
Data Element
Reserved for Assignment by the NUBC
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
8 Positions
Alphanumeric
Left-justified
Form Locator 38
Data Element
Responsible Party Name and Address (Claim Addressee)
Definition:
The name and address of the party to whom the bill is being submitted.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 27
Required
Required
Form Locator 38
Reporting
UB-04: Use to print the name and mailing address of the party deemed responsible for
the bill (health plan, patient, etc.) if a window envelope is utilized.
004010/004010A1: Situational 005010: Not Used
Field
Attributes
1 Field
Alphanumeric
Notes
Address may include post office box or street name and number, city, state and ZIP
code. Hospitals should abbreviate state in the address according to the post office
stand abbreviations appearing in the instructions for Locator 01.
If a nine-digit ZIP code is used, it should be entered XXXXX-XXXX.
5 Lines
Left-justified
40 Positions
Form Locator 39-41
Data Element
Value Codes and Amounts
Definition:
A code structure to relate amounts or values to identify data elements necessary to
process this claim as qualified by the payer organization.
Required
If Applicable
Reporting
UB-04, 004010/004010A1, 005010: Situational. Required when there is a Value Code
that applies to this claim.
Field
Attributes
3 Fields (codes)
4 Lines
2 Positions
Alphanumeric
Left-justified (all positions fully coded)
Notes
Whole numbers or non-dollar amounts are right-justified to the left of the dollars/cents
delimiter.
Enter value codes in alphanumeric sequence.
Fields 39a through 41a must be completed before the b fields, etc.
If all of the Value Code fields are filled, use FL 81 Code-Code field with the appropriate
qualifier code (A4) to indicate that a Value Code is being reported.
3 Fields (amounts)
4 Lines
9 Positions
Numeric
Right-justified (see Notes)
Code Structure
01
02
03
04
05
Most Common
To provide for the recording of hospital’s most common semi-private
Semi-Private Rate
rate. Note: Required when billing private room revenue codes.
Hospital has No Semi- Entering this code requires $0.00 amount.
Private Rooms
Reserved for assignment by the NUBC
Professional
Code indicates the amount shown is the sum of technical and professional
Component Charges
charges, which are combined, billed. Medicare uses this information in
which are Combined
internal processes and also in the CMS notice of utilization sent to the
Billed
patient to explain that Part B co-insurance applies to the professional
component. (Used only by some all inclusive rate hospitals.)
Professional
Amount shown is the combined billed charges (technical and professional);
Component Included in however the provider is submitting a separate professional bill to the health
Charges and also Billed plan. For use on Medicare or TRICARE bills and all Medicaid bills if state
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 28
Separate to Carrier
specifies need for this information.
Form Locator 39-41
Code Structure
06
07
08
09
10
11
12
13
14
15
16
17-20
21
22
23
24
25
26
27
28
Blood Deductible
Total cash blood deductible.
If appropriate, enter Medicare Part A or Part B blood deductible amount.
(To report other than the blood deductible, that is to report the program
deductible, see Value Codes (FL 39-41) A1, B1 and C1.
Reserved for assignment by the NUBC
Life Time Reserve
Lifetime reserve amount charged in the year of admission.
Amount in the First
Note: For Medicare, use this code only for Part A bills. For Part B
Calendar Year
Coinsurance use Value Codes (FL 39-41) A2, B2 and C2.
Coinsurance Amount
Coinsurance amounts charged in the year of admission.
in the First Calendar Year
Lifetime Reserve
Lifetime reserve amount charged in the year of discharge where the bill
Amount in the Second spans two calendar years.
Calendar Year
Coinsurance Amount
Coinsurance amount charged in the year of discharge where the inpatient
in the Second Calendar bill spans two calendar years.
Year
Working Aged
Amount shown reflects that portion of a payment from a higher priority
Beneficiary/Spouse
employer group health insurance made on behalf of an aged beneficiary.
With Employer Group For Medicare purposes the provider is billing Medicare as the secondary
Health Plan
payer (based on MSP development) for covered services on this bill.
ESRD Beneficiary in a Amount shown is that portion of a payment from a higher priority employer
Medicare Coordination group health insurance payment made on behalf of an ESRD beneficiary
Period with an
that the provider is applying to Medicare covered services on this bill.
Employer Group Health Plan
No-Fault, Including
Amount shown is that portion from a higher priority no-fault insurance,
Auto/Other
including auto/other made on behalf of the patient or insured.
Worker’s
Amount shown is that portion of payment from a higher priority worker’s
Compensation
compensation insurance made on behalf of the patient or insured.
For Medicare beneficiaries the provider should apply this amount to Medicare
covered services on this bill.
PHS, or Other FederalAmount shown is that portion of a payment from a higher priority Public
Agency
Health Service or the Federal Agency made on behalf of a Medicare
beneficiary that the provider is applying to Medicare covered services on this
bill.
Payer Code
Catastrophic
Medicaid-eligibility requirements to be determined at state level.
Surplus
Medicaid-eligibility requirements to be determined at state level.
Recurring Monthly
Medicaid-eligibility requirements to be determined at state level.
Income
Medicaid Rate Code
Medicaid-eligibility requirements to be determined at state level.
Offset to the PatientPrescription drugs paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Prescription Drugs
Covers Period).
Offset to the PatientHearing and ear services paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Hearing and Ear
Covers Period).
Services
Offset to the PatientVision and eye services paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Vision and Eye
Covers Period).
Services
Offset to the PatientDental services paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Dental Services
Covers Period).
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 29
Form Locator 39-41
Code Structure
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
Offset to the PatientPayment Amount Chiropractic Services
Preadmission Testing
Chiropractic services paid for out of a long-term care facility
resident/patient’s funds in the billing period submitted (Statement
Covers Period).
This code reflects charges for preadmission outpatient diagnostic
services in preparation for a previously scheduled admission.
Patient Liability
Approved amount to charge the beneficiary for non-covered
Amount
accommodations, diagnostic procedures or treatments.
Multiple Patient
When more than one patient is transported in a single ambulance
Ambulance Transport trip, report the total number of patients transported.
Offset to the PatientPodiatric services paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Podiatric Services
Covers Period).
Offset to the PatientOther medical services paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Other Medical Services Covers Period).
Offset to the PatientHealth insurance premiums paid for out of a long-term care facility
Payment Amount resident/patient’s funds in the billing period submitted (Statement
Health Insurance
Covers Period).
Premiums
Reserved for assignment by the NUBC
Units of Blood
The total number of units of whole blood or packed red cells
Furnished
furnished to the patient, regardless of whether the hospital charges for
blood or not.
Blood Deductible Units The number of unreplaced deductible units of packed red cells
furnished for which the patient is responsible. If all deductible units furnished
have been replaced, no entry is made.
Units of Blood
The total number of units of whole blood or packed red cells
Replaced
furnished to the patient that have been replaced by or on behalf of the patient.
New Coverage not
Amount shown is for inpatient charges covered by the HMO. (Use this code
Implemented by HMO when the bill includes inpatient charges for newly covered services that are
(for inpatient service)
not paid by the HMO.) Note: Condition Codes 04 and 78 should also be
reported.
Black Lung
Code indicates the amount shown is that portion of a higher priority Black
Lung (federal program) payment made on behalf of a Medicare beneficiary.
VA (Veteran’s
Code indicates the amount shown is that portion of a higher priority
Administration)
VA payment made on behalf of a Medicare beneficiary and that you are
applying to Medicare as secondary payer for covered Medicare services on
this claim.
Disabled Beneficiary
Code indicates the amount shown is that portion of a higher priority
Under Age 65 with
LGHP payment made on behalf of a disabled beneficiary that you are
LGHP
applying to covered Medicare charges on this bill.
Amount Provider
Report the amount the provider was obligated to accept from a primary
Agreed to Accept frompayer when the amount is less than charges but higher than or equal to the
Primary Payer when
payment received. Secondary payment may be due.
this Amount is less than Note: The following value codes report the actual amounts paid: 12-16,
Charges but Higher
41-43, and 47. Value Code 44 should always be equal to, or, greater than
than Payment
the amounts indicated in the value codes indicated immediately above.
Received
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 30
Form Locator 39-41
Code Structure
45
46
47
made
48
49
50
51
52
53
54
55
Accident Hour
The hour when the accident occurred that necessitated medical treatment.
Enter the appropriate code indicated below right justified to the left of the
dollar/cents delimiter.
00
12:00 - 12:59 (midnight) 13
01:00 - 01:59
01
01:00 - 01:59
14
02:00 - 02:59
02
02:00 - 02:59
15
03:00 - 03:59
03
03:00 - 03:59
16
04:00 - 04:59
04
04:00 - 04:59
17
05:00 - 05:59
05
05:00 - 05:59
18
06:00 - 06:59
06
06:00 - 06:59
19
07:00 - 07:59
07
07:00 - 07:59
20
08:00 - 08:59
08
08:00 - 08:59
21
09:00 - 09:59
09
09:00 - 09:59
22
10:00 - 10:59
10
10:00 - 10:59
23
11:00 - 11:59
11
11:00 - 11:59
12
12:00 - 12:59 (Noon)
Number of Grace Days Following the QIO determination. This is the number of days determined
by the QIO (medical necessity reviewer) as necessary to arrange for the
patient’s post-discharge care.
Any Liability Insurance
Amount shown is that portion from a higher priority liability insurance
on behalf of a Medicare beneficiary that the provider is applying to Medicare
or Blue Cross covered services on this bill.
Note: The decimal is implied and refers to the dollar and cents delimiter.
Hemoglobin Reading
The most recent hemoglobin reading taken before the start of this billing
period. For patients just starting, use the most recent value prior to the onset
if treatment. Whole numbers, i.e., two digits are to be right justified to the left
of the dollar/cents delimiter; decimals, i.e., one digit, is to be reported to the
right.
Hematocrit Reading
The most recent hematocrit reading taken before the start of this billing
period. For patients just starting, use the most recent value prior to the onset
if treatment. Whole numbers, i.e., two digits are to be right justified to the left
of the dollar/cents delimiter; decimals, i.e., one digit, is to be reported to the
right.
Physical Therapy Visit Report the number of physical therapy visits provided from the onset of
treatment from this billing provider through this billing period. Report the
number in the dollar portion of the form locator right justified to the left of the
dollar/cents delimiter.
Occupational Therapy Report the number of occupational therapy visits provided from the onset of
Visits
treatment from this billing period. Report the number in the dollar portion of
the locator right justified to the left of the dollar/cents delimiter.
Speech Therapy Visits Report the number of speech therapy visits provided from the onset of
treatment by this billing provider through this period. Report the number in
the dollar portion of the locator right justified to the left of the dollar/cents
delimiter.
Cardiac Rehabilitation The number of cardiac rehabilitation visits from the onset of treatment
Visits
from the billing provider through this billing period. Report the number in
the dollar portion of the locator right justified to the left of the dollar/cents
delimiter.
Newborn Birth Weight Actual birth weight or weight at time of admission for an extramural birth.
in Grams
Required on all claims with Type of Admission of 4 and on other claims as
required by state law.
Eligibility Threshold
The amount at which a health care facility determines the eligibility
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 31
for Charity Care
threshold for charity care.
Form Locator 39-41
Code Structure
56
Skilled Nurse-Home
Visit Hours
(HHA only)
57
Home Health AideHome Visit Hours
(HHA only)
58
Arterial Blood Gas
(PO2/PA2)
59
Oxygen Saturation
(O2 SAT/Oximetry)
60
HHA Branch MSA
61
Place of Residence
Where Service is
Furnished
(HHA and Hospice)
Payer Codes
Medicaid Spend Down The dollar amount that was used to meet the recipient’s spend down
Amount
liability for this claim.
Peritoneal Dialysis
The number of hours of peritoneal dialysis provided during the billing
period. Count only the hours spent in the home. Exclude travel time.
Report in whole hours, right justify to the left of the dollar/cent delimiter.
(Round to the nearest whole hour.)
EPO-Drug
Number of units of EPO administered and/or supplied relating to the billing
period. Report amount in whole units right justified to the left of the
dollar/cents delimiter.
State Charity Care
Code indicates the percentage of charity care eligibility for the patient.
Percent
Report the whole number right justified to the left of the dollar/cents
delimiter and fractional amounts to the right. For example, a rate of 10.5%
is shown as: 1050
Payer Codes
Covered Days
The number of days covered by the primary payer as qualified by the
62-65
66
67
68
69
The number of home visit hours of skilled nursing provided during the billing
period. Count only hours spent in the home. Exclude travel time.
Report in whole hours, right justified to the left of the dollar/cents
delimiter. (Round to the nearest whole hour).
The number of hours of home health aide services provided during the billing
period. Count only the hours spent in the home. Exclude travel time.
Report in whole hours, right justified to the left of the dollar/cents delimiter.
(Round to the nearest whole hour).
Arterial blood gas value at beginning of each reporting period for oxygen
therapy. This value or the value in Value Code 59 will be required on the
initial bill for oxygen therapy and on the fourth month’s bill.
Report right justified in the cents area rounded to the nearest whole number
(report 2 digits). Example: A value of 56.5 should be reported as 000000 57,
i.e., with the 57 reported in the cents area.
Oxygen saturation at the beginning of each reporting period for oxygen
therapy. This value or the value in Value Code 58 will be required on the
initial bill for oxygen therapy and on the fourth month’s bills. Report right
justified in the cent area. Round to the nearest whole percent (report 2 digits).
Example: 93.5 percent should be reported as 000000 94, i.e., with 94 being
reported in the cents area. A value of 100 percent would be reported as
000001 00.
MSA in which HHA branch is located. Report MSA when branch location
is different than the HHA’s. Report the MSA number in dollar portion of the
form locator right justified to the left of the dollar/cents delimiter.
MSA or Core Based Statistical Area (CBSA) number (or rural state code)
of the place of residence where the home health or hospice service is
delivered. Report the number in dollar portion of the form locator right justified
to the left of the dollar/cents delimiter.
70-79
80(a)
payer.
81(a) Non-Covered Days
82(a) Co-insurance Days
83(a)
Days of care not covered by the primary payer.
The inpatient Medicare days occurring after the 60th day and before the 91st
day or inpatient SNF/Swing Bed days occurring after the 20th and before the
101st day in a single spell of illness.
Lifetime Reserve Days Under Medicare, each beneficiary has a lifetime reserve of 60 additional days
of inpatient hospital services after using 90 days of inpatient hospital services
during a spell of illness.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 32
84-99
Reserved for assignment by the NUBC.
(a) Do not use on v. 004010/004010A1 837 electronic claims (use Claim Quantity in Loop ID 2300 /
QTY01 instead).
Form Locator 39-41
Code Structure
A0
Special ZIP Code
Reporting
Deductible Payer A
Five digit ZIP Code of the location from which the beneficiary is initially
placed on board the ambulance.
A1(b)
The amount assumed by the provider to be applied to the patient’s
policy/program deductible amount involving the indicated payer.
Note: Report Medicare blood deductibles under Value Code 06.
Required for Blue Cross claims when billing for balance after Medicare.
A2(b) Coinsurance Payer A The amount assumed by the provider to be applied toward the patient’s
coinsurance amount involving the indicated payer. Note: For Medicare, use
this code only for reporting Part B coinsurance amounts. For Part A
coinsurance amounts use Value Codes 8-11. Required for Blue Cross
claims when billing for balance after Medicare.
A3
Estimated
The amount estimated by the provider to be paid by the indicated payer;
Responsibility Payer A
it is not the actual payment.
A4
Covered SelfThe covered charge amount for self-administrable drugs administered to the
Administrable Drugs - patient in an emergency situation (e.g., diabetic coma). For use with
Emergency
Revenue Code 0637.
A5
Covered SelfThe amount included in covered charges for self-administrable drugs
administrable Drugs - administered to the patient because the drug was not self-administrable in the
not Self-administrable form and situation in which it was furnished to the patient.
in the form and
For use with Revenue Code 0637.
Situation Furnished to Patient
A6
Covered SelfThe amount assumed by the provider to be applied toward the patient’s
Administrable Drugs - co-payment amount involving the indicated payer.
Diagnostic Study and Other
A7(b) Co-payment Payer A
The amount assumed by the provider to be applied toward the patient’s
co-payment amount involving the indicated payer.
A8
Patient Weight
Weight of patient in kilograms. Report this data only when the health plan
has a predefined change in reimbursement that is affected by weight.
For newborns, use Value Code 54.
A9
Patient Height
Height of patient in centimeters. Report this data only when the health
plan has a predefined change in reimbursement that is affected by height.
AA
Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances or
Assessments,
health care related taxes pertaining to the indicated payer.
Allowances or Health
Care Related Taxes
Payer A
AB
Other Assessments or The amount of other assessments or allowances (e.g., medical
Allowances (e.g.,
education) pertaining to the indicated payer.
Medical Education)
Payer A
AC-AZ
Reserved for assignment by the NUBC
B0
Reserved for assignment by the NUBC
B1(b) Deductible Payer B
The amount assumed by the provider to be applied to the patient’s
policy/program deductible amount involving the indicated payer.
Note: Medicare blood deductibles should be reported under Value Code 06.
B2(b) Coinsurance Payer B The amount assumed by the provider to be applied toward the patient’s
coinsurance amount involving the indicated payer. For Part A coinsurance
amounts use Value Codes 08-11.
B3
Estimated
The amount estimated by the provider to be paid by the indicated payer;
Responsibility Payer B it is not the actual payment.
B4-B6
Reserved for assignment by the NUBC
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 33
(b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320 CAS segment
(Claim Adjustment Group Code “PR”).
Form Locator 39-41
Code Structure
B7(b)
B8-B9
BA
BB
BC-C0
C1(b)
C2(b)
C3
C4-C6
C7(b)
C8-C9
CA
CB
CC-D2
D3
D4
D5
D6-DQ
DR
DS-DZ
E0
E1
E2
E3
E4-E6
E7
E8-E9
Co-payment Payer B
The amount assumed by the provider to be applied toward the patient’s
co-payment amount involving the indicated payer.
Reserved for assignment by the NUBC
Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances or health
Assessments,
care related taxes pertaining to the indicated payer.
Allowances or Health
Care Related Taxes
Payer B
Other Assessments or The amount of other assessments or allowances (e.g., medical
Allowances (e.g.,
education) pertaining to the indicated payer.
Medical Education)
Payer B
Reserved for assignment by the NUBC
Deductible Payer C
The amount assumed by the provider to be applied to the patient’s
policy/program deductible amount involving the indicated payer.
Note: Medicare Blood deductibles should be reported under Value Code 06.
Coinsurance Payer C The amount assumed by the provider to be applied toward the patient’s
coinsurance amount involving the indicated payer. For Part A coinsurance
amounts use Value Codes 08-11.
Estimated
The amount estimated by the provider to be paid by the indicated payer;
Responsibility Payer C it is not the actual payment.
Reserved for assignment by the NUBC
Co-payment Payer C
The amount assumed by the provider to be applied toward the patient’s
co-payment amount involving the indicated payer.
Reserved for assignment by the NUBC
Regulatory Surcharges, The amount of regulatory surcharges, assessments, allowances
Assessments,
or health care related taxes pertaining to the indicated payer.
Allowances or Health
Care Related Taxes Payer C
Other Assessments or The amount of other assessments or allowances (e.g., medical
Allowances (e.g.,
education) pertaining to the indicated payer.
Medical Education)
Payer C
Reserved for assignment by the NUBC.
Patient Estimated
The amount estimated by the provider to be paid by the
Responsibility
indicated patient.
Clinical Trial Number
8-digit, numeric National Library of Medicine/National Institutes of Health
Assigned by NLM/NIH assigned clinical trail number.
Last Kt/V Reading
Result of the last Kt/V reading. For in-center hemodialysis patients, this is the
last reading taken during the billing period. For peritoneal dialysis patients
(and home hemodialysis patients), this may be before the current billing period
but should be within 4 months of the date of service. Note: Only report on
FL 04 Type of Bill 072x. (Effective 07/01/10)
Reserved for assignment by the NUBC
Reserved for Disaster Related Value Code
Reserved for assignment by the NUBC
Reserved for assignment by the NUBC
Discontinued 3/1/07
Discontinued 3/1/07
Discontinued 3/1/07
Reserved for assignment by the NUBC
Discontinued 3/1/07
Reserved for assignment by the NUBC
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 34
EA
Discontinued 3/1/07
EB
Discontinued 3/1/07
EC-EZ
Reserved for assignment by the NUBC
(b) This code is to be used only on paper claims. For electronic 837 claims, use Loop ID 2320 CAS segment
(Claim Adjustment Group Code “PR”).
Form Locator 39-41
Code Structure
F0-F3
F4-F6
F7
F8-F9
FA-FB
FC
Patient Paid Amount
FD
FE-G0
G1-G3
G4-G6
G7
G8
G9
GA
GB
GC-OZ
P0-PZ
Q0-Y0
Y1
Y2
Y3
Y4
Y5-ZZ
Discontinued 3/1/07
Reserved for assignment by the NUBC
Discontinued 3/1/07
Reserved for assignment by the NUBC
Discontinued 3/1/07
The amount the provider has received from the patient toward payment of this
bill. (Effective 7/1/08)
Credit Received from The amount the provider has received from a medical device manufacturer
the Manufacturer for a as credit fro a replaced device. (Effective 7/1/08)
Replaced Medical Device
Reserved for assignment by the NUBC
Discontinued 3/1/07
Reserved for assignment by the NUBC
Discontinued 3/1/07
Facility where Inpatient MSA or Core Based Statistical Area (CBSA) number (or rural state code) of
Hospice Service is
the facility where inpatient hospice service is delivered. Report the number in
Delivered
dollar portion of the form locator right justified to the left of the dollar/cents
delimiter.
Reserved for assignment by the NUBC
Discontinued 3/1/07
Discontinued 3/1/07
Reserved for assignment by the NUBC
Reserved for PUBLIC HEALTH DATA REPORTING
Reserved for assignment by the NUBC
Part A Demonstration This is the portion of the payment designated as reimbursement for
Payment
Part A services under the demonstration. This amount is instead of the
traditional prospective DRG payment (operating and capital) as well as any
outlier payments that might have been applicable in the absence of the
demonstration. No deductible or coinsurance has been applied. Payments
for operating IME and DSH which are processed in the traditional manner
are also not included in this amount.
Part B Demonstration This is the portion of payment designed as reimbursement for Part B
Payment
services under the demonstration. No deductible or coinsurance has been
applied.
Part B Coinsurance
This is the amount of Part B coinsurance applied by the intermediary to this
claim. For demonstration claims this will be a fixed copayment unique to each
hospital and DRG (or DRG/procedure group).
Conventional Provider This is the amount Medicare would have reimbursed the provider for
Payment Amount for
Part A services if there had been no demonstration. This should include
Non-Demonstration
the prospective DRG payment (both capital as well as operational) as well
Claims
as any outlier payment, which would be applicable. It does not include any
pass through amounts such as that for direct medical education nor interim
payments for operating IME and DSH.
Reserved for assignment by the NUBC
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 35
Form Locator 42
Data Element
Revenue Code
Definition:
Codes that identify specific accommodation, ancillary service or unique billing
calculations or arrangements.
Required
Yes
Reporting
UB-04, 004010/004010A1, 005010: Required
Field
Attributes
1 Field
Alphanumeric
23 Lines (a)
4 Positions
Left-justified (all positions filled)
(a) The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total
for covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
(b) On a multiple page UB-04, all of the (claim level) information is repeated on each
page: only the line items in the revenue code section will vary.
Notes
Revenue Code categories are four digits with an “x” in the fourth position to denote the
subcategory number. The subcategory number provides a more detailed list
generally ranging from “0” through “9”. When reporting the revenue code on the claim,
the fourth position must include one of the numeric choices available in that category.
The reporting of an “x” is not appropriate.
The “0” in many cases denotes the “General” category and can be used in lieu of other
more specific subcategories (“1” through “9”) if the health plan has no need for a more
specific revenue code subcategory. Health plans receiving such detail, without a need
for that detail, should accept the subcategory and treat it as though it was reported at
the “General” level. Nonetheless, it is recommended that providers use the more
detailed subcategory when applicable/available rather than revenue codes that end in
“0” (General) or “9” (Other); to do otherwise may cause processing delays for the
claim.
Each service should be assigned a revenue code.
 For inpatient services involving multiple services for the same item providers
should aggregate the services under the assigned revenue code and then
report the total number of units that represent those services.
 For outpatient services providers should report the corresponding HCPCS
code for the service along with the date of service as well as the revenue
code.
 If multiple services are provided on the same day for like services, that is,
those with the same HCPCS, the provider should aggregate the like services
for each day and report the date along with a number of units provided, as well
as the revenue code. The exception is for Evaluation and management (E/M)
HCPCS. For E/M HCPCS, report each of these separately but also use
Condition Code “G0” to indicate a Distinct Medical Visit.
 Services provided on different days should be listed separately along with the
date of service, units and revenue code.
Revenue codes should be listed in ascending numeric order, by date of service
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 36
(outpatient). The exception is Revenue Code 0001 - Total Charge, which is used on
paper claims only and is reported on Line 23 of the last page of the claim.
Form Locator 42
Notes
The Standard Abbreviation is intended for use in the provider’s Charge Description
Master and is not reported on electronic claims.
The HCPCS usage notations in the revenue code section (FL42) are provided for
general guidance only; they do not represent hard and fast rules. Actual application
may vary depending on certain circumstances.
Revenue Code Changes from UB-92
In the process of developing the UB-04, the “9 - Other” revenue subcategory codes
were reviewed for necessity, clarity and redundancy. As a result several “9” codes
were re-designated as reserved for assignment by the NUBC because the “0 - General
Classification” codes are sufficient.
Specific revenue codes removed from UB-92 include 0599, 0709, 0719, 0749, 0759,
0779, 0789 and 0799. For clarity, RC 0392 was added to UB-04 to distinguish
“Processing and Storage” from “Other” (RC 0399). In addition, any unused code in
UB-92 has been specifically designated as “RESERVED” in UB-04.
These changes are not reflected in any UB-92 update. As noted on FL42, the
changes are effective 3/1/07 (for UB-04 claims).
0001
TOTAL CHARGE
Report Revenue Code 0001 on paper claims only. No allowed on electronically submitted claims.
0002 to 0009
RESERVED
001x
RESERVED FOR INTERNAL PAYER USE
002x
HEALTH INSURANCE - PROSPECTIVE PAYMENT SYSTEM (HIPPS)
This revenue code is used to denote that a HIPPS rate code is being reported in FL44.
Sub-Category
0 RESERVED
1 RESERVED
2 Skilled Nursing Facility - PPS
3 Home Health - PPS
4 Inpatient Rehab Facility - PPS
5-9 RESERVED
003x to 009x
010x
Standard Abbreviation
SNF PPS (RUG)
HH PPS (HRG)
REHAB PPS (CMG)
RESERVED
ALL INCLUSIVE RATE
Flat fee charge incurred on either a daily basis or total stay basis for service rendered. Charge may
cover room and board plus ancillary services and board only.
Sub-Category
0 All Inclusive Room and
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
All INCL R & B/ANC
Unit
Days
HCPCS
N
Page 37
Board plus Ancillary.
1 All Inclusive Room and Board.
2-9 RESERVED
All INCL R & B
Days
N
Form Locator 42
011x
ROOM & BOARD - PRIVATE (ONE BED)
Routine service charges for accommodations in a private room (1 bed).
Sub-Category
0 General Classification
1 Medical/Surgical/GYN
2 Obstetrics (OB)
3 Pediatric
4 Psychiatric
5 Hospice
6 Detoxification
7 Oncology
8 Rehabilitation
9 Other
Standard Abbreviation
ROOM-BOARD/PVT
MED-SURG-GY/PVT
OB/PVT
PEDS/PVT
PSYCH/PVT
HOSPICE/PVT
DETOX/PVT
ONCOLOGY/PVT
REHAB/PVT
OTHER/PVT
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Note: Most health plans require private rooms be separately identified.
012x
ROOM & BOARD - SEMI-PRIVATE (Two Beds)
Routine service charges for accommodations in a semi-private room (2 beds).
Sub-Category
0 General Classification
1 Medical/Surgical/GYN
2 Obstetrics (OB)
3 Pediatric
4 Psychiatric
5 Hospice
6 Detoxification
7 Oncology
8 Rehabilitation
9 Other
013x
Standard Abbreviation
ROOM-BOARD/SEMI
MED-SURG-GY/SEMI
OB/SEMI-PVT
PEDS/SEMI-PVT
PSYCH/SEMI-PVT
HOSPICE/SEMI-PVT
DETOX/SEMI-PVT
ONCOLOGY/SEMI
REHAB/SEMI-PVT
OTHER/SEMI-PVT
ROOM & BOARD - THREE and FOUR BEDS
Routine service charges incurred for rooms containing three or four beds.
Sub-Category
0 General Classification
1 Medical/Surgical/GYN
2 Obstetrics (OB)
3 Pediatric
4 Psychiatric
5 Hospice
6 Detoxification
7 Oncology
8 Rehabilitation
9 Other
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
ROOM-BOARD/3 & 4 BED
MED-SURG-GY/3 & 4 BED
OB/3 & 4 BED
PEDS/3 & 4 BED
PSYCH/3 & 4 BED
HOSPICE/3 & 4 BED
DETOX/3 & 4 BED
ONCOLOGY/3 & 4 BED
REHAB/3 & 4 BED
OTHER/3 & 4 BED
Page 38
Form Locator 42
014x
ROOM & BOARD - DELUXE PRIVATE
Deluxe accommodations substantially in excess of private room services.
Sub-Category
0 General Classification
1 Medical/Surgical/GYN
2 Obstetrics (OB)
3 Pediatric
4 Psychiatric
5 Hospice
6 Detoxification
7 Oncology
8 Rehabilitation
9 Other
015x
Standard Abbreviation
ROOM-BOARD/DLX PVT
MED-SURG-GY/DLX PVT
OB/DLX PVT
PEDS/DLX PVT
PSYCH/DLX PVT
HOSPICE/DLX PVT
DETOX/DLX PVT
ONCOLOGY/DLX PVT
REHAB/DLX PVT
OTHER/DLX PVT
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
Unit
Days
Days
Days
Days
Days
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
N
N
N
N
N
ROOM AND BOARD - WARD
Routine service charges for accommodations with five or more beds.
Sub-Category
0 General Classification
1 Medical/Surgical/GYN
2 Obstetrics (OB)
3 Pediatric
4 Psychiatric
5 Hospice
6 Detoxification
7 Oncology
8 Rehabilitation
9 Other
016x
Standard Abbreviation
ROOM-BOARD/WARD
MED-SURG-GY/WARD
OB/WARD
PEDS/WARD
PSYCH/WARD
HOSPICE/WARD
DETOX/WARD
ONCOLOGY/WARD
REHAB/WARD
OTHER/WARD
ROOM AND BOARD - OTHER
Any routine service charges for accommodations that cannot be included in the more specific revenue
center codes. Sterile environment is a room and board charge to be used by hospitals that are
currently separating this charge for billing.
Sub-Category
0 General Classification
1-3 RESERVED
4 Sterile Environment
5-6 RESERVED
7 Self-Care
8 RESERVED
9 Other
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
R&B
Unit
Days
HCPCS
N
R&B/STERILE
Days
N
R&B/SELF
Days
N
R&B/OTHER
Days
N
Page 39
Form Locator 42
017x
NURSERY
Accommodation charges for nursing care to newborns and premature infants in nurseries.
Sub-Category
0 General Classification
1 Newborn – Level I
2 Newborn – Level II
3 Newborn – Level III
4 Newborn – Level IV
5-8 RESERVED
9 Other Nursery
Standard Abbreviation
NURSERY
NURSERY/LEVEL I
NURSERY/LEVEL II
NURSERY/LEVEL III
NURSERY/LEVEL IV
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
NURSERY/OTHER
Notes: If used in conjunction with other room charges (i.e., the mother’s room charges), the units for
this revenue code is not included into the grand total, (i.e., revenue code 001 units).
The levels of care correlate to the intensity of medical care provided to an infant and not the NICU
facility certification level assigned by the state.
Level I: Routine care of apparently normal full-term or pre-term neonates. (Newborn Nursery)
Level II: Low birth-weight neonates who are not sick, but require frequent feeding, and neonates who
require more hours of nursing than do normal neonates. (Continuing Care/Premature)
Level III: Sick neonates, who do not require intensive care, but require 6-12 hours of nursing each day.
(Intermediate Care)
Level IV: Constant nursing and continuous cardiopulmonary and other support for severely ill infants.
(Intensive Care)
018x
LEAVE OF ABSENCE
Charges for holding a room while the patient is temporarily away from the provider
Sub-Category
0 General Classification
1 RESERVED
2 Patient Convenience
3 Therapeutic Leave
4 RESERVED
5 Nursing Home (for Hospitalization)
6-8 RESERVED
9 Other Leave of Absence
Note:
Standard Abbreviation
Leave of Absence or LOA
Unit
Days
HCPCS
N
LOA/PT CONV
LOA/THERAPEUTIC
Days
Days
N
N
LOA/NURS HOME
Days
N
LOA/OTHER
Days
N
This field requires the units field to be entered; however, the units must not be added to the
grand total (i.e., revenue code 001).
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 40
Form Locator 42
019x
SUBACUTE CARE
Accommodations charges for subacute care to inpatients or skilled nursing facilities
Sub-Category
0 General Classification
1 Subacute Care – Level I
2 Subacute Care – Level II
3 Subacute Care – Level III
4 Subacute Care – Level IV
5-8 RESERVED
9 Other Subacute Care
Standard Abbreviation
SUBACUTE
SUBACUTE/LEVEL I
SUBACUTE/LEVEL II
SUBACUTE/LEVEL III
SUBACUTE/LEVEL IV
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
SUBACUTE/OTHER
Days
N
Usage Note: Revenue code 19X may be used in multiple types of bills. However, if Bill Type X7X is
used in Form Locator 4, Revenue code 019X must be used
Level I - Skilled Care: Minimal nursing intervention. Comorbidities do not complicate treatment
plan. Assessment of vitals and body systems required 1-2 times per day.
Level II - Comprehensive Care: Moderate nursing intervention. Active treatment of comorbidities.
Assessment of vitals and body systems required 2-3 times per day.
Level III - Complex Care: Moderate to extensive nursing intervention. Active medical care and
treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of
vitals and body systems required 3-4 times per day.
Level IV - Intensive Care: Extensive nursing and technical intervention. Active medical care and
treatment of comorbidities. Potential for comorbidities to affect the treatment plan. Assessment of
vitals and body systems required 4-6 times per day.
020x
INTENSIVE CARE UNIT
Routine service charges for medical or surgical care provided to patients who require a more intensive
level of care that is rendered in the general medical or surgical unit.
Sub-Category
0 General Classification
1 Surgical
2 Medical
3 Pediatric
4 Psychiatric
5 RESERVED
6 Intermediate ICU
7 Burn Care
8 Trauma
9 Other Intensive Care
021x
Standard Abbreviation
INTENSIVE CARE (ICU)
ICU/SURGICAL
ICU/MEDICAL
ICU/PEDS
ICU/PSYCH
Unit
Days
Days
Days
Days
Days
HCPCS
N
N
N
N
N
ICU/INTERMEDIATE
ICU/BURN CARE
ICU/TRAUMA
ICU/OTHER
Days
Days
Days
Days
N
N
N
N
CORONARY CARE UNIT
Routine service charges for medical care provided to patients with coronary illness who require a more
intensive level of care than is rendered in the general medical or surgical unit.
Sub-Category
0 General Classification
1 Myocardial Infarction
2 Pulmonary Care
3 Heart Transplant
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
CORONARY CARE (CCU)
CCU/MYO INFARC
CCU/PULMONARY
CCU/TRANSPLANT
Unit
Days
Days
Days
Days
HCPCS
N
N
N
N
Page 41
4 Intermediate CCU
5-8 RESERVED
9 Other Coronary Care
CCU/INTERMEDIATE
Days
N
CCU/OTHER
Days
N
Report when a discrete coronary care unit exists for rendering such services.
Form Locator 42
022x
SPECIAL CHARGES
Charges incurred during an inpatient stay or on a daily basis for certain services.
Sub-Category
0 General Classification
1 Admission Charges
2 Technical Support Charge
3 U.R. Service Charge
4 Late Discharge, Medically Necessary
5-8 RESERVED
9 Other Special Charges
Standard Abbreviation
SPECIAL CHARGES
ADMIT CHARGE
TECH SUPPORT CHG
UR CHARGE
LATE DISCH/MED NEC
Unit
OTHER SPEC CHG
HCPCS
N
N
N
N
N
N
Some hospitals may prefer to identify the components of services rendered in greater detail and thus
break out charges that normally would be considered part of routine services.
023x
INCREMENTAL NURSING CHARGE
Extraordinary charges for nursing services assessed in addition to the normal nursing charge
associated with the typical room and board unit.
Sub-Category
0 General Classification
1 Nursery
2 OB
3 ICU
4 CCU
5 Hospice
6-8 RESERVED
9 Other
024x
Standard Abbreviation
NURSING INCREM
NUR INCR/NURSERY
NUR INCR/OB
NUR INCR/ICU
NUR INCR/CCU
NUR INCR/HOSPICE
Unit
Hours
Hours
Hours
Hours
Hours
Hours
HCPCS
N
N
N
N
N
N
NUR INCR/OTHER
Hours N
ALL INCLUSIVE ANCILLARY
A flat rate charge that is applied on a daily basis or on a total stay basis for ancillary services only.
Sub-Category
0 General Classification
1 Basic
2 Comprehensive
3 Specialty
4-8 RESERVED
9 Other All Inclusive Ancillary
Standard Abbreviation
All INCL ANCIL
All INCL BASIC
All INCL COMP
All INCL SPECIAL
All INCL ANCIL/OTHER
Unit
HCPCS
N
N
N
N
N
Note: Revenue codes 0241, 0242 and 0243 are designed for use by Special Residential Facilities
only.
See Form Locator 4, Type of Bill 086x.
Hospitals billing in this manner may wish to segregate these charges.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 42
Form Locator 42
025x
PHARMACY (also see 063x, an extension of 025x)
Charges for medication produced, manufactured, packed, controlled, assayed, dispensed and
distributed under the direction of a licensed pharmacist.
Sub-Category
0 General Classification
1 General Drugs
2 Non-Generic Drugs
3 Take Home Drugs
4 Drugs Incident to Other
Diagnostic Services
5 Drugs Incident to Radiology
6 Experimental Drugs
7 Non-Prescription
8 IV Solutions
9 Other Pharmacy
026x
Standard Abbreviation
PHARMACY
DRUGS/GENERIC
DRUGS/NON-GENERIC
DRUGS/TAKE HOME
DRUGS/INCIDENT/DX
Unit
DRUGS/INCIDENT RAD
DRUGS/EXPERIMT
DRUGS/NONPSCRIPT
IV SOLUTIONS
DRUGS/OTHER
HCPCS
N
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
IV THERAPY
Equipment charge or administration of intravenous solution by specially trained personnel to
individuals requiring such treatment.
Sub-Category
0 General Classification
1 Infusion Pump
2 IV Therapy/Pharmacy Services
3 IV Therapy/Drug/Supply Delivery
4 IV Therapy/Supplies
5-8 RESERVED
9 Other IV Therapy
Standard Abbreviation
Unit
IV THERAPY
IV THER/INFSN PUMP
IV THER/PHARM/SVC
IV THER/DRUG/SUPPLY/ DEL
IV THER/SUPPLIES
HCPCS
Y-OP
Y-OP
Y-OP
Y-OP
Y-OP
IV THERAPY/OTHER
Y-OP
Billing for Home IV providers, require the HCPCS code which describes the pump to be entered in
FL 44.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 43
Form Locator 42
027x
MEDICAL/SURGICAL SUPPLIES AND DEVICES (also see 062x, an extension of 027x)
Charges for supply items required for patient care
Sub-Category
0 General Classification
1 Non-Sterile Supply
2 Sterile Supply
3 Take Home Supplies
4 Prosthetic/Orthotic Devices
5 Pace Maker
6 Intraocular Lens
7 Oxygen - Take Home
8 Other Implants (a)
9 Other Supplies/Devices
Standard Abbreviation
MED-SUR SUPPLIES
NON-STER SUPPLY
STERILE SUPPLY
TAKE HOME SUPPLY
PROSTH/ORTH DEV
PACE MAKER
INTRA OC LENS
02/TAKE HOME
SUPPLY/IMPLANTS
SUPPLY/OTHER
Unit
HCPCS
Devices
Y
(a) Implantables: That which is implanted, such as a piece of tissue, a tooth, a pellet of medicine, or a
tube or needle containing a radioactive substance, a graft, or an insert. Also included are liquid and
solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed.
An object or material partially or totally inserted or grafted into the body for prosthetic, therapeutic,
diagnostic purposes.
Examples of Other Implants (not all9inclusive): Stents, artificial joints, shunts, grafts, pins, plates,
screws, anchors, radioactive seeds.
Experimental devices that are implantable and have been granted an FDA Investigational Device
Exemption (IDE) number should be billed with revenue code 0624.
028x
ONCOLOGY
Charges for the treatment of tumors and related diseases
Sub-Category
0 General Classification
1-8 RESERVED
9 Other Oncology
029x
Standard Abbreviation
ONCOLOGY
Unit
HCPCS
ONCOLOGY/OTHER
DURABLE MEDICAL EQUIPMENT (OTHER THAN RENAL)
Charge for medical equipment that can withstand repeated use (excluding rental equipment)
Sub-Category
0 General Classification
1 Rental
2 Purchase of New DME
3 Purchase of Used DME
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
DME
DME-RENTAL
DME-NEW
DME-USED
Unit
HCPCS
Y
Y
Y
Page 44
4 Supplies/Drugs for DME
5-8 RESERVED
9 Other Equipment
DME-SUPPLIES/DRUGS
Y
DME-OTHER
Y
Form Locator 42
030x
LABORATORY
Charges for the performance of diagnostic and routine clinical laboratory tests
Sub-Category
0 General classification
1 Chemistry
2 Immunology
3 Renal Patient (Home)
4 Non-Routine Dialysis
5 Hematology
6 Bacteriology & Microbiology
7 Urology
8 RESERVED
9 Other Laboratory
031x
Standard Abbreviation
LAB
CHEMISTRY TESTS
IMMUNOLOGY TESTS
RENAL HOME
NON-RTNE DIALYSIS
HEMATOLOGY TESTS
BACT & MICRO TESTS
UROLOGY TESTS
Unit
HCPCS
Tests
Tests
Tests
Tests
Tests
Tests
Tests
Y
Y
Y
Y
Y
Y
Y
OTHER LAB TESTS
Tests
Y
Standard Abbreviation
PATHOLOGY LAB
CYTOLOGY TESTS
HISTOLOGY TESTS
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
BIOPSY TESTS
Tests
Y
PATH LAB OTHER
Tests
Y
LABORATORY PATHOLOGY
Charges for diagnostic and routine laboratory tests on tissues and culture
Sub-Category
0 General Classification
1 Cytology
2 Histology
3 RESERVED
4 Biopsy
5-8 RESERVED
9 Other Laboratory Pathology
032x
RADIOLOGY - DIAGNOSTIC
Charges for diagnostic radiology services including interpretation of radiographs and fluorographs
Sub-Category
0 General Classification
1 Angiocardiology
2 Arthrography
3 Arteriography
4 Chest X-Ray
5-8 RESERVED
9 Other Radiology - Diagnostic
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
DX X-RAY
DX X-RAY/ANGIO
DX X-RAY/ARTHO
DX X-RAY/ARTER
DX X-RAY/CHEST
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
DX X-RAY/OTHER
Tests
Y
Page 45
Form Locator 42
033x
RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION
Charges for therapeutic radiology services and chemotherapy administration to care and treat
patients. Therapies also include injection and/or ingestion of radioactive substances.
Excludes charges for chemotherapy drugs; report these under the appropriate revenue code
(025x or 063x).
Sub-Category
0 General Classification
1 Chemotherapy Administration - Injected
2 Chemotherapy Administration - Oral
3 Radiation Therapy
4 RESERVED
5 Chemotherapy Administration - IV
6-8 RESERVED
9 Other Radiology - Therapeutic
Standard Abbreviation
RADIOLOGY THERAPY
RAD-CHEMO-INJECT
RAD-CHEMOTHER-ORAL
RAD-RADIATION
Unit
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
RAD-CHEMOTHER-IV
Tests
Y
RADIOLOGY OTHER
Tests
Y
Usage note: When using 0331, 0332, or 0335 there must be use of Revenue Code 0636.
034x NUCLEAR MEDICINE
Charges for procedures, tests, and radiopharmaceuticals performed by a department handling
radioactive materials as required for diagnosis and treatment of patients.
Sub-Category
0 General Classification
1 Diagnostic
2 Therapeutic
3 Diagnostic Radiopharmaceuticals
4 Therapeutic Radiopharmaceuticals
5-8 RESERVED
9 Other Nuclear Medicine
Standard Abbreviation
NUCLEAR MEDICINE
NUC MED/DX
NUC MED/RX
NUC MED/DX RADIOPHARM
NUC MED/RX RADIOPHARM
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
NUC MED/OTHER
Tests
Y
Standard Abbreviation
CT SCAN
CT SCAN/HEAD
CT SCAN/BODY
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
CT SCAN/OTHER
Tests
Y
035x CT SCAN
Charges for computed tomographic scans of the head and other parts of the body
Sub-Category
0 General Classification
1 CT - Head Scan
2 CT - Body Scan
3-8 RESERVED
9 CT- OTHER
036x OPERATING ROOM SERVICES
Charges for services provided to patients by specifically trained nursing personnel who assist physicians
in the performance of surgical and related procedures during and immediately following surgery.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 46
Sub-Category
0 General Classification
1 Minor Surgery
2 Organ Transplant Other than Kidney
3-6 RESERVED
7 Kidney Transplant
8 RESERVED
9 Other Operating Room Service
Standard Abbreviation
OR SERVICES
OR/MINOR
OR/ORGAN TRANS
Unit
HCPCS
Y
Y
Y
OR/KIDNEY TRANS
Y
OR/OTHER
Y
Form Locator 42
037x ANESTHESIA
Charges for anesthesia services
Sub-Category
0 General Classification
1 Anesthesia Incident to Radiology
2 Anesthesia Incident to Other
Diagnostic Services
3 RESERVED
4 Acupuncture
5-8 RESERVED
9 Other Anesthesia
Standard Abbreviation
ANESTHESIA
ANESTHE/INCIDENT RAD
ANES/INCDNT OTHER DX
Unit
HCPCS
Unit
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
ANESTHE/ACUPUNC
ANESTHE/OTHER
038x BLOOD and BLOOD COMPONENTS
Charges for blood and blood components
Sub-Category
0 General Classification
1 Packed Red Cells
2 Whole Blood
3 Plasma
4 Platelets
5 Leukocytes
6 Other Components
7 Other Derivatives (Cryoprecipitate)
8 RESERVED
9 Other Blood
Standard Abbreviation
BLOOD & BLOOD COMP
BLOOD/PKD RED
BLOOD/WHOLE
BLOOD/PLASMA
BLOOD/PLATELETS
BLOOD/LEUKOCYTES
BLOOD/COMPONENTS
BLOOD/DERIVATIVES
Pints
Pints
Pints
BLOOD/OTHER
Y
039x ADMINISTRATION, PROCESSING, AND STORAGE FOR BLOOD AND BLOOD COMPONENTS
Charges for administration, processing and storage of whole blood, red blood cells, platelets, and other
blood components
Sub-Category
0 General Classification
1 Administration (e.g., Transfusion)
2 Processing and Storage
3-8 RESERVED
9 Other Blood Handling
Standard Abbreviation
BLOOD/ADMIN/STOR
BLOOD/ADMIN
BLOOD/STORAGE
BLOOD/ADMIN/STOR/OTHER
Unit
Pints
Pints
HCPCS
Y
Y
Y
Y
040x OTHER IMAGING SERVICES
Charges for specialty imaging services for body structures
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 47
Sub-Category
0 General Classification
1 Diagnostic Mammography
2 Ultrasound
3 Screening Mammography
4 Position Emission Tomography
5-8 RESERVED
9 Other Imaging Services
Standard Abbreviation
IMAGE SERVICE
DIAG MAMMOGRAPHY
ULTRASOUND
SCRN MAMMOGRAPHY
PET SCAN
OTHER IMAG SVS
Unit
Tests
Tests
Tests
Tests
Tests
HCPCS
Y
Y
Y
Y
Y
Tests
Y
Form Locator 42
041x RESPIRATORY SERVICES
Charges for respiratory services including administration of oxygen and certain potent drugs through
inhalation or positive pressure and other forms of rehabilitative therapy.
Sub-Category
0 General Classification
1 RESERVED
2 Inhalation Services
3 Hyperbaric Oxygen Therapy
4-8 RESERVED
9 Other Respiratory Services
Standard Abbreviation
RESPIRATORY SVC
Unit
HCPCS
Treatment Y
INHALATION SVC
HYPERBARIC 02
Treatment
Treatment
Y
Y
OTHER RESPIR SVS
Treatment
Y
042x PHYSICAL THERAPY
Charges for therapeutic exercises, massage and utilization of Effective Date properties of light, heat,
cold, water, electricity and assist devices for diagnosis and rehabilitation of patients who have
neuromuscular, orthopedic and other disabilities.
Sub-Category
0 General Classification
1 Visit
2 Hourly
3 Group
4 Evaluation or Re-Evaluation
5-8 RESERVED
9 Other Physical Therapy
Standard Abbreviation
PHYSICAL THERP
PHYS THERP/VISIT
PHYS THERP/HOUR
PHYS THERP/GROUP
PHYS THERP/EVAL
Unit
HCPCS
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
OTHER PHYS THERP
HCPCS
Y
043x OCCUPATIONAL THERAPY
Charges for therapeutic interventions to improve, sustain or restore an individual’s level of function in
performance, of activities of daily living and work, including: therapeutic activities; therapeutic exercise;
sensorimotor processing; psychosocial skills training; cognitive retraining; fabrication and application of
orthotic devices; and training in the use of orthotic and prosthetic devices; adaptation of environments;
and application of physical agent modalities.
Sub-Category
0 General Classification
1 Visit
2 Hourly
3 Group
4 Evaluation or Re-Evaluation
5-8 RESERVED
9 Other Occupational Therapy
Standard Abbreviation
OCCUPATIONAL THER
OCCUP THERP/VISIT
OCCUP THERP/HOUR
OCCUP THERP/GROUP
OCCUP THERP/EVAL
Unit
HCPCS
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
OTHER OCCUP THER
HCPCS
Y
Services are provided by a qualified occupational therapist.
044x SPEECH therapy - LANGUAGE PATHOLOGY
Charges for services related to impaired functional communications skills.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 48
Standard Abbreviation
Sub-Category
0 General Classification
SPEECH THERAPY
1 Visit
SPEECH THERP/VISIT
2 Hourly
SPEECH THERP/HOUR
3 Group
SPEECH THERP/GROUP
4 Evaluation or Re-Evaluation
SPEECH THERP/EVAL
5-8 RESERVED
9 Other Speech Therapy
OTHER SPEECH THERP
Services are provided by a qualified speech therapist.
Unit
HCPCS
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
HCPCS
Y
Form Locator 42
045x EMERGENCY ROOM
Charges for emergency treatment to those ill and injured persons who require immediate unscheduled
medical or surgical care.
Sub-Category
0 General Classification
1 EMTALA Emergency Medical Screening
2 ER Beyond EMTALA
3-5 RESERVED
6 Urgent Care
7-8 RESERVED
9 Other Emergency Room
Standard Abbreviation
EMERG ROOM
ER/EMTALA
ER/BEYOND EMTALA
Unit
Visit
Visit
Visit
HCPCS
Y
Y
Y
URGENT CARE
Visit
Y
OTHER EMER ROOM
Visit
Y
Usage Notes: Report Patient’s Reason for Visit code in FL 70 in conjunction with this revenue code.
(a) General classification code 0450 should not be used in conjunction with any subcategory. The sum
of 0451 and 0452 is equivalent to 0450.
(b) Stand-alone usage of 0451 is acceptable when no services beyond an initial screening/assessment
are rendered.
(c) Stand-alone usage of 0452 is not acceptable.
046x PULMONARY FUNCTION
Charges for tests that measure inhaled and exhaled gases and analysis of blood for tests that evaluate
the patient’s ability to exchange oxygen and other gases.
Sub-Category
0 General Classification
1-8 RESERVED
9 Other Pulmonary Function
Standard Abbreviation
PULMONARY FUNC
Unit
Test
HCPCS
Y
OTHER PULMON FUNC
Test
Y
047x AUDIOLOGY
Charges for the detection and management of communication handicaps centering in whole or in part
on the hearing function
Sub-Category
0 General Classification
1 Diagnostic
2 Treatment
3-8 RESERVED
9 Other Audiology
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
AUDIOLOGY
AUDIOLOGY/DX
AUDIOLOGY/RX
Unit
Test
Test
Test
HCPCS
Y
Y
Y
OTHER AUDIOL
Test
Y
Page 49
Services are provided by or through the supervision of a qualified audiologist.
Form Locator 42
048x CARDIOLOGY
Charges for cardiac procedures.
Sub-Category
0 General Classification
1 Cardiac CATH LAB
2 Stress Test
3 Echocardiology
4-8 RESERVED
9 Other Cardiology
Standard Abbreviation
CARDIOLOGY
CARDIAC CATH LAB
STRESS TEST
ECHOCARDIOLOGY
Unit
Test
Test
Test
Test
HCPCS
Y
Y
Y
Y
OTHER CARDIOL
Test
Y
Services provided are by staff from the cardiology department of the hospital or under arrangement.
Services include such procedures such as: heart catheterization, coronary angiography, Swan-Ganz
catheterization, and exercise stress test.
049x AMBULATORY SURGICAL CARE
Charges for ambulatory surgery not covered by other categories.
Sub-Category
0 General Classification
1-8 RESERVED
9 Other Ambulatory Surgical Care
Standard Abbreviation
AMBULTRY SURG
Unit
HCPCS
HCPCS
Y
OTHER AMBL SURG
HCPCS
Y
050x OUTPATIENT SERVICES
Charges for services rendered to an outpatient who is then admitted as an inpatient before midnight of
the day following the date of service.
Sub-Category
0 General Classification
1-8 RESERVED
9 Other Outpatient
051x
Standard Abbreviation
OUTPATIENT SVCS
Unit
Test
HCPCS
Y
OTHER – O/P SERVICES
Test
Y
CLINIC
Clinic visit charges for providing diagnostic, preventative, curative, rehabilitative and education services
to ambulatory patients.
Sub-Category
0 General Classification
1 Chronic Pain Center
2 Dental Clinic
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
CLINIC
CHRONIC PAIN CLINIC
DENTAL CLINIC
Unit
Visit
Visit
Visit
HCPCS
Y
Y
Y
Page 50
3
4
5
6
7
8
9
Psychiatric Clinic
OB-GYN Clinic
Pediatric Clinic
Urgent Care Clinic*
Family Practice Clinic
RESERVED
Other Clinic
PSYCHIATRIC CLINIC
OB-GYN CLINIC
PEDIATRIC CLINIC
URGENT CARE CLINIC
FAMILY CLINIC
Visit
Visit
Visit
Visit
Visit
Y
Y
Y
Y
Y
OTHER CLINIC
Visit
Y
* Report the Patient’s Reason for Visit diagnosis codes for all Urgent Care Clinic visits.
Form Locator 42
052x FREE-STANDING CLINIC
Charges for the outpatient visit at a freestanding clinic.
Sub-Category
0 General Classification
1 Clinic Visit by Member to RHC/FQHC
2 Home Visit by RHC/FQHC Practitioner
3 Family Practice Clinic
4 Visit by RHC/FQHC Practitioner to a
Member in a Covered Part A Stay at SNF
5 Visit by RHC/FQHC Practitioner to a Member
In a SNF (not in a Covered Part A Stay) or
NF or ICF MR or Other Residential Facility
6 Urgent Care Clinic*
7 Visiting Nurse Service(s) to a Member’s
Home when in a Home Health Shortage Area
8 Visit by RHC/FQHC Practitioner to Other
Non-RHC/FQHC Site (e.g. Scene of Accident)
9 Other Free-Standing Clinic
Standard Abbreviation
FREESTAND CLINIC
FS-RURAL/CLINIC
FS-RURAL/HOME
FS-FAMILY PRACT
FR/STD FAMILY CLINIC
Unit
Visit
Visit
Visit
Visit
HCPCS
Y
Y
Y
Y
FR/STD URGENT CLINIC
RHC/FQHC/HOME/VIS
NURSE
RHC/FQHC/OTHER SITE
Visit
Y
OTHER FS-CLINIC
Visit
Y
RHC/FWHC/SNF/
NONCOVERED
* Report the Patient’s Reason for Visit diagnosis codes for all Urgent Care Clinic visits.
053x OSTEOPATHIC SERVICES
Charges for a structural evaluation of the cranium, entire cervical, dorsal and lumbar spine by a doctor
of osteopathy.
Sub-Category
0 General Classification
1 Osteopathic Therapy
2-8 RESERVED
9 Other Osteopathic Services
Standard Abbreviation
OSTEOPATH SVS
OSTEOPATH RX
Unit
Visit
Visit
HCPCS
Y
Y
OTHER OSTEOPATH
Visit
Y
Generally, these services are unique to osteopathic hospitals and cannot be accommodated in any of
the existing revenue codes.
054x
AMBULANCE
Charges for ambulance services necessary for the transport of the ill or injured who require medical
attention at a health care facility
Sub-Category
0 General Classification
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
AMBULANCE
Unit
Mile
HCPCS
Y
Page 51
1
2
3
4
5
6
7
8
9
Supplies
Medical Transport
Heart Mobile
Oxygen
Air Ambulance
Neonatal Ambulance Services
Pharmacy
EKG Transmission
Other Ambulance
BCNEPA/FPH/FPLIC Billing Manual
November 2012
AMBUL/SUPPLY
AMBUL/MED TRANS
AMBUL/HEARTMOB
AMBUL/OXYGEN
AIR AMBULANCE
AMBUL/NEONAT
AMBUL/PHARMACY
AMBUL/EKG TRANS
OTHER AMBULANCE
Item
Mile
Mile
Unit
Mile
Mile
Unit
Unit
Mile
N
Y
Y
Y
Y
Y
Y
Y
Y
Page 52
Form Locator 42
055x SKILLED NURSING
Charges for nursing services that must be provided under the direct supervision of a licensed nurse to
assure the safety of the patient and to achieve the medically desired result. This code may be used for
nursing home services, CORFS, or a service charge for home health billing.
Sub-Category
0 General Classification
1 Visit Charge
2 Hourly Charge
3-8 RESERVED
9 Other Skilled Nursing
Standard Abbreviation
SKILLED NURSING-HH
SKILLED NURS-VISIT
SKILLED NURS-HOUR
Unit
Visit
Hour
SKILLED NURS/OTHER
HCPCS
Y
Y
Y
Y
056x HOME HEALTH (HH) - MEDICAL SOCIAL SERVICES
Home Health (HH) charges for services such as counseling patients, interviewing patients and
interpreting problems of social situation rendered to patients on any basis.
Sub-Category
0 General Classification
1 Visit Charge
2 Hourly Charge
3-8 RESERVED
9 Other Medical Social Services
Standard Abbreviation
MED SOCIAL-HH
MED SOC SERV-VISIT
MED SOC SERV-HOUR
Unit
Visit
Hour
MED SOC SERV-OTHER
HCPCS
Y
Y
Y
Y
057x HOME HEALTH (HH) AIDE
Home Health (HH) charges for personnel (aides) that are primarily responsible for the personal care of
the patient.
Sub-Category
0 General Classification
1 Visit Charge
2 Hourly Charge
9 Other Home Health Aide
Standard Abbreviation
HH AIDE
HH AIDE-VISIT
HH AIDE-HOUR
HH AIDE-OTHER
Unit
Visit
Hour
HCPCS
Y
Y
Y
Y
058x HOME HEALTH (HH) - OTHER VISITS
Home Health agency charges for visits other than physical therapy, occupational therapy or speech
therapy, requiring specific identification.
Sub-Category
0 General Classification
1 Visit Charge
2 Hourly Charge
3 Assessment
4-8 RESERVED
9 Other Home Health Visit
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
HH-OTH VIS
HH-OTH VIS/VISIT
HH-OTH VIS/HOUR
HH-OTH VIS/ASSESS
Unit
Visit
Hour
Visit
HCPCS
Y
Y
Y
Y
HH-OTH VIS/OTHER
Visit
Y
Page 53
Form Locator 42
059x HOME HEALTH (HH) UNITS OF SERVICE
Home Health (HH) charges for services billed according to the units of service provided.
Sub-Category
0 General Classification
1-9 RESERVED
Standard Abbreviation
HH-SVCS/UNIT
Unit
Unit
HCPCS
Y
060x HOME HEALTH (HH) - OXYGEN
Home Health agency charges for oxygen equipment, supplies or contents, excluding purchased
equipment.
If patient purchases a stationary oxygen system, an oxygen concentrator or portable equipment, current
revenue codes 0292 or 0293 apply. DME (other than oxygen systems) is billed under revenue codes
0291, 0292, or 0293.
Sub-Category
0 General Classification
1 Oxygen - Stat Equip/Supply/Content
2 Oxygen - Stat Equip/Supply<1 LPM
3 Oxygen - Stat Equip/Supply>4 LPM
4 Oxygen - Portable Add-on
5-8 RESERVED
9 Oxygen - Other
Standard Abbreviation
02/HOME HEALTH
02/STAT/EQP/SUP/CONT
02/STAT/EQP/SUP< 1 LPM
02/STAT/EQP/SUP> 4 LPM
02/PORTABLE ADD-ON
Unit
HCPCS
Y
Ft/Lbs Y
Mos
Y
Mos
Y
Mos
Y
02/OTHER
Y
061x MAGNETIC RESONANCE TECHNOLOGY (MRT)
Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography.
Sub-Category
Standard Abbreviation
0 General Classification
MRT
1 MRI - Brain/Brainstem
MRI/BRAIN
2 MRI - Spinal Cord/Spine
MRI/SPINE
3 RESERVED
4 MRI - Other
MRI/OTHER
5 MRA - Head and Neck
MRA/HEAD AND NECK
6 MRA - Lower Extremities
MRA/LOWER EXTRM
7 RESERVED
8 MRA - Other
MRA/OTHER
9 Other MRT
MRT/OTHER
Note:
If revenue code 619 is used, enter the type of MRI into the remarks field.
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
Tests
Tests
Tests
Y
Y
Y
Tests
Tests
Y
Y
062x MEDICAL SURGICAL SUPPLIES - Extension of 027x
Charges for supply items required for patient care. The category is an extension of 027x for reporting
additional breakdown where needed. Subcategory code 1 is for providers that cannot bill supplies used
for radiology procedures under radiology. Subcategory code 2 is for providers that cannot bill supplies
used for other diagnostic procedures.
Sub-Category
0 RESERVED (Use 0270 for
General Classification)
1 Supplies Incident to Radiology
2 Supplies Incident to Other DX Services
3 Surgical Dressings
4 FDA Investigational Devices
5-9 RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
Unit
HCPCS
MED SUR SUPL-INCDT RAD
MED SUR SUPL-INCDT ODX
SURG DRESSING
FDA INVEST DEVICE
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
Page 54
Form Locator 42
063x PHARMACY - Extension of 025x
Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and
distributed under the direction of a licensed pharmacist. The category is an extension of 025X for
reporting additional breakdown where needed.
Sub-Category
0 RESERVED (Use 0250 for
General Classification)
1 Single Source Drug
2 Multiple Source Drug
3 Restrictive Prescription
4 Erythropoietin (EPO) <10,000 Units
5 Erythropoietin (EPO)>=10,000 Units
6 Drugs Requiring Detail Coding (a)
7 Self-Administrable Drugs (b)
Standard Abbreviation
Unit
HCPCS
DRUG/SINGLE
DRUG/MULTIPLE
DRUG/RESTRICT
DRUG/EPO<10,000 Units
DRUG/EPO>=10,000 Units
DRUG/DETAIL CODE
DRUG/SELF ADMIN
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
HCPCS
Y
Y
Y
Y
Y
Y
Y
(a) Charges for drugs and biologicals (with the exception of radiopharmaceuticals, which are
reported under Revenue Codes 0343 and 0344) requiring specific identification as required by the
payer. If using a HCPCS to describe the drug, enter the HCPCS code in the appropriate HCPCS
column. The specific service units reported should be in hundreds (100s), rounded to the nearest
hundred; do not use a decimal.
(b) Charges for self-administrable drugs not requiring detailed coding. Use Value Codes A4, A5, and
A6 to indicate the dollar amount included in covered charges for self-administrable drugs. Amounts
for non-covered self-administrable drugs should be charged using Revenue Code 0637 in the noncovered column.
064x HOME IV THERAPY SERVICES
Charge for intravenous therapy services performed in the patient’s residence. For Home IV providers
enter the HCPCS code for all equipment, and all types of covered therapy.
Sub-Category
0 General Classification
1 Non-routine Nursing, Central Line
2 IV Site Care, Central Line (see note)
3 IV Start/Change, Peripheral Line
4 Non-routine Nursing, Peripheral Line
5 Training Patient/Care Giver, Central Line
6 Training, Disabled Patient, Central Line
7 Training, Patient/Care Giver, Peripheral Line
8 Training, Disabled Patient, Peripheral Line
9 Other IV Therapy Services
Standard Abbreviation
Unit
IV THERAPY SVC
NON RT NURSING/CENTRAL
IV SITE CARE/CENTRAL
IV STRT CARE/PERIPHRL
NONRT NURSING/PERIPHRL
TRNG PT/CAREGVR/CNTRL Hour
TRNG DSBLPT/CENTRAL
Hour
TRNG/PT/CARGVR/PERIPHRL Hour
TRNG/DSBLPT/PERIPHRL
Hour
OTHER IV THERAPY SVC
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Note: Report units in one hour increments; Revenue code 0642 relates to the HCPCS code.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 55
Form Locator 42
065x HOSPICE SERVICES
Charge for hospice care services for a terminally ill patient electing hospice services in lieu of other
medical services for the terminal condition.
Sub-Category
Standard Abbreviation
0 General Classification
HOSPICE
1 Routine Home Care
HOSPICE/RTN HOME
2 Continuous Home Care
HOSPICE/CTNS HOME
3-4 RESERVED
5 Inpatient Respite Care
HOSPICE/IP RESPITE
Days
6 General Inpatient Care Non-Respite
HOSPICE/IP NON-RESPITE
7 Physician Services
HOSPICE/PHYSICIAN
8 Hospice Room & Board - Nursing Facility
HOSPICE/R&B NURS FAC
9 Other Hospice Service
HOSPICE/OTHER
Unit
HCPCS
Y
Hours Y
Hours Y
Y
Days Y
HCPCS Y
Days Y
Y
Note: To receive the continuous home car rate from Medicare use code 0652, a minimum of 8 hours of
care, not necessarily consecutive, must be accompanied by a physician procedure code. Enter this
information in the HCPCS column (Form Locator 44). This code is used by the hospice to bill for
charges for physicians employed by the hospice or receiving compensation from the hospice for
services rendered. The unit will be either days or hours depending on subcategory and billing contracts.
066x RESPITE CARE
Charges for non-hospice respite care.
Sub-Category
0 General Classification
1 Hourly Charge - Nursing
2 Hourly Charge/Aide/Homemaker/
Companion
3 Daily Respite Charge
4-8 RESERVED
9 Other Respite Care
Standard Abbreviation
RESPITE CARE
RESPITE/NURSING
RESPITE/AIDE/HMEMKR/
COMP
RESPITE/DAILY
Unit
Hours
Hours
RESPITE/OTHER
Hours
HCPCS
Day
067x OUTPATIENT SPECIAL RESIDENCE CHARGES
Residence arrangements for patients requiring continuous outpatient care.
Sub-Category
0 General Classification
1 Hospital Owned
2 Contracted
3-8 RESERVED
9 Other Special Residence Charge
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
OP SPEC RES
OP SPEC RES/HOSP
OWNED
OP SPEC
Unit
Day
OP SPEC RES/OTHER
Day
HCPCS
Day
Page 56
Form Locator 42
068x TRAUMA RESPONSE
Charges representing the activation of the trauma team
Sub-Category
0 Not Used
1 Level I Trauma
2 Level II Trauma
3 Level III Trauma
4 Level IV Trauma
5-8 RESERVED
9 Other Trauma Response
Standard Abbreviation
Unit
HCPBS
TRAUMA LEVEL I
TRAUMA LEVEL II
TRAUMA LEVEL III
TRAUMA LEVEL IV
Activation
Activation
Activation
Activation
TRAUMA OTHER
Activation
Usage Notes:
1. For use by trauma center/hospitals, licensed or designated by the state or local government authority
authorized as a trauma center, or verified by the American College of Surgeons and as a facility with a
trauma activation team.
2. Revenue Category 068x is used for patients for whom a trauma activation occurred. A trauma team
activation/response is a “Notification of key hospital personnel in response to triage information from
pre-hospital caregivers in advance of the patient’s arrival.”
3. Revenue Category 068x is for reporting trauma activation costs only. It is an activation fee and not a
replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will
normally be both a 045x and 068x revenue code reported.
4. Revenue Category 068x is not limited to admitted patients.
5. Revenue Category 068x must be used in conjunction with FL14 Priority (Type) of Admission/Visit
Code 5 (“Trauma Center”), however FL 14 Code 5 can be used alone for trauma activations that lack
pre-hospital notification.
Only patients for whom there has been pre-hospital notification, who meet either local, state or
American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are
given the appropriate team response, can be billed the trauma activation fee charge. Patients who are
“drive-by” or arrive without notification cannot be charged for activations, but can be classified as trauma
under Type of Admission Code 5 for statistical and follow-up purposes.
6. Levels I, II, III, or IV refer to designations given to the trauma facility by the state or local government
authority or as verified by the American College of Surgeons.
7. Subcategory 9 is for states or local authorities with levels beyond IV.
069x RESERVED
070x CAST ROOM
Charge for services related to the application, maintenance and removal of casts.
Sub-Category
0 General Classification
1-9 RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
CAST ROOM
Unit
HCPCS
Page 57
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 58
Form Locator 42
071x RECOVERY ROOM
Room charge for patient recovery after surgery.
Sub-Category
0 General Classification
1-9 RESERVED
Standard Abbreviation
RECOVERY ROOM
Unit
HCPCS
N
072x LABOR ROOM/DELIVERY
Charges for labor and delivery room services provided by specifically trained nursing personnel to
patients, including prenatal care during labor, assistance during delivery, postnatal care in the recovery
room and minor gynecologic procedures if they are performed in the delivery suite.
Sub-Category
0 General Classification
1 Labor
2 Delivery Room
3 Circumcision
4 Birthing Center
4-8 RESERVED
9 Other Labor Room/Delivery
Standard Abbreviation
DELIVERY ROOM/LABOR
LABOR
DELIVERY ROOM
CIRCUMCISION
BIRTHING CENTER
Unit
HCPCS
Days
Days
Each
Days
OTHER/DELIV/LABOR
073x EKG/ECG (ELECTROCARDIOGRAM)
Charges for operation of specialized equipment to record variations in actions of the heart muscle for
diagnosis of heart ailments.
Sub-Category
0 General Classification
1 Holter Monitor
2 Telemetry
3-8 RESERVED
9 Other EKG/ECG
Standard Abbreviation
EKG/ECG
HOLTER MONT
TELEMETRY
Unit
Tests
Tests
Tests
HCPCS
Y
Y
Y
OTHER EKG/ECG
Tests
Y
074x EEG (ELECTROENCEPHALOGRAM)
Charges for operation of specialized equipment to measure impulse frequencies and differences in
electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders.
Sub-Category
0 General Classification
1-9 RESERVED
Standard Abbreviation
EEG
Unit
Tests
HCPCS
Y
Unit
Tests
HCPCS
Y
075x GASTRO - INTESTINAL (GI) SERVICES
Charges for GI procedures not performed in the operating room.
Sub-Category
0 General Classification
1-9 RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
GASTRO-INTSTL SVS
Page 59
Form Locator 42
076x SPECIALTY SERVICES
Charges for patients requiring treatment room services or patients placed under observation.
Sub-Category
0 General Classification
1 Treatment Room
2 Observation Hours (a)
3-8 RESERVED
9 Other Specialty Services
Standard Abbreviation
SPECIALTY SVC
TREATMENT ROOM
OBSERVATION
Unit
HCPCS
Y
OTHER SPECIALTY SVC
Note:
Observation services are those services furnished by a hospital on the hospital’s premises, including
use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and
necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the
hospital or as an inpatient. Such services are covered only when provided by the order of a physician or
another individual authorized by State licensure law and hospital staff bylaws to admit patients to the
hospital or to order outpatient tests. The reason for observation must be stated in the orders for
observation. Payers should establish written guidelines, which identify coverage of observation
services.
(a) FL 70a-c – Patient’s Reason for Visit should be reported in conjunction with 0762.
077x PREVENTIVE CARE SERVICES
Revenue Code used to capture preventive care services established by payers (e.g., vaccination).
Sub-Category
0 General Classification
1 Vaccine Administration
2-9 RESERVED
Standard Abbreviation
PREVENT CARE SVCS
VACCINE ADMIN
Unit
HCPCS
Y
Y
Unit
HCPCS
Unit
HCPCS
Y
078x TELEMEDICINE
Facility charges related to the use of telemedicine services
Sub-Category
0 General Classification
1-9 RESERVED
Standard Abbreviation
TELEMEDICINE
079x EXTRA-CORPOREAL SHOCK WAVE THERAPY (Formerly Lithotripsy)
Charges related to Extra-Corporeal Shock Wave Therapy (ESWT).
Sub-Category
0 General Classification
1-9 RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
ESWT
Page 60
Form Locator 42
080x INPATIENT RENAL DIALYSIS
Charges for the use of equipment designed to remove waste when the body’s own kidneys have failed.
The waste may be removed directly from the blood (hemodialysis) or indirectly from the blood by
flushing a special solution between the abdominal covering and the tissue (peritoneal dialysis).
Sub-Category
0 General Classification
1 Inpatient Hemodialysis
2 Inpatient Peritoneal (Non-CAPD)
3 Inpatient Continuous Ambulatory
Peritoneal Dialysis (CAPD)
4 Inpatient Continuous Cycling
Peritoneal Dialysis (CCPD)
5-8 RESERVED
9 Other Inpatient Dialysis
Standard Abbreviation
RENAL DIALYSIS
DIALY/INPATIENT
DIALY/INPT/PER
DIALY/IP/CAPD
Unit
HCPCS
Sessions
Sessions
Sessions
Sessions
DIALY/INPT/CCPD
Sessions
DIALY/INPT/OTHER
Sessions
081x ACQUISITION OF BODY COMPONENTS
The acquisition and storage costs of body tissue, bone marrow, organs and other body components not
otherwise identified used for transplantation.
Sub-Category
0 General Classification
1 Living Donor
2 Cadaver Donor
3 Unknown Donor
4 Unsuccessful Organ Search - Donor
Bank Charges
5-8 RESERVED
9 Other Donor
Standard Abbreviation
ORGAN ACQUISIT
LIVING DONOR
CADAVER DONOR
UNKNOWN DONOR
UNSUCCESSFUL SEARCH
Unit
OTHER DONOR
HCPCS
Y
Y
Y
Y
Y
Y
Notes:
Living donor is a living person from whom an organ is collected and used for transplantation purposes.
Cadaver is an individual pronounce dead according to medical and legal criteria, and whose organs may
be harvested for transplantation.
Unknown is used whenever the status of the individual source cannot be determined. Use the other
category whenever the organ is non-human.
Revenue Code 0814 is used only when costs incurred for an organ search do not result in an eventual
organ acquisition and transplantation.
082x HEMODIALYSIS - OUTPATIENT OR HOME
A waste removal process, performed in an outpatient or home setting, necessary when the body’s own
kidneys have failed. Waste is removed directly from the blood.
Sub-Category
0 General Classification
1 Hemodialysis/Composite or Other Rate
2 Home Supplies
3 Home Equipment
4 Maintenance - 100%
5 Support Services
6-8 RESERVED
9 Other Outpatient Hemodialysis
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
HEMO/OP or HOME
HEMO/COMPOSITE
HEMO/HOME/SUPPL
HEMO/HOME/EQUIP
HEMO/HOME/100%
HEMO/HOME/SUPSERV
Unit
HCPCS
Y
Sessions Y
Sessions Y
Sessions Y
Sessions Y
Sessions Y
HEMO/OTHER/OP
Sessions Y
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Form Locator 42
083x PERITONEAL DIALYSIS - OUTPATIENT OR HOME
Charges for a waste removal process performed in an outpatient or home setting, necessary when the
body’s own kidneys have failed. Waste is removed indirectly by flushing a special solution between the
abdominal covering and the tissue.
Sub-Category
0 General Classification
1 Peritoneal/Composite or Other Rate
2 Home Supplies
3 Home Equipment
4 Maintenance - 100%
5 Support Services
6-8 RESERVED
9 Other Outpatient Peritoneal Dialysis
Standard Abbreviation
PERITONEAL/OP or HOME
PERTNL/COMPOSITE
PERTNL/HOME/SUPPL
PERTNL/HOME/EQUIP
PERTNL/HOME/100%
PERTNL/HOME/SUPSERV
Unit
HCPCS
Sessions Y
Sessions Y
Sessions Y
Sessions Y
Sessions Y
Sessions Y
PERTNL/HOME/OTHER
Sessions Y
084x CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) - OUTPATIENT OR HOME
Charges for continuous dialysis process performed in an outpatient or home setting which uses the
patient’s peritoneal membrane as a dialyzer.
Sub-Category
0 General Classification
1 CAPD/Composite or Other Rate
2 Home Supplies
3 Home Equipment
4 Maintenance - 100%
5 Support Services
6-8 RESERVED
9 Other Outpatient CAPD
Standard Abbreviation
CAPD/OP or HOME
CAPD/COMPOSITE
CAPD/HOME/SUPPL
CAPD/HOME/EQUIP
CAPD/HOME/100%
CAPD/HOME/SUPSERV
Unit
Days
Days
Days
Days
Days
Days
HCPCS
Y
Y
Y
Y
Y
Y
CAPD/HOME/OTHER
Days
Y
085x CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) - OUTPATIENT OR HOME
Charges for continuous dialysis process performed in an outpatient or home setting which uses a
machine to make automatic exchanges at night.
Sub-Category
0 General Classification
1 CCPD/Composite or Other Rate
2 Home Supplies
3 Home Equipment
4 Maintenance - 100%
5 Support Services
6-8 RESERVED
9 Other Outpatient CCPD
Standard Abbreviation
CCPD/OP or HOME
CCPD/COMPOSITE
CCPD/HOME/SUPPL
CCPD/HOME/EQUIP
CCPD/HOME/100%
CCPD/HOME/SUPSERV
Unit
Days
Days
Days
Days
Days
Days
HCPCS
Y
Y
Y
Y
Y
Y
CCPD/HOME/OTHER
Days
Y
Unit
Test
Test
HCPCS
Y
Y
086x Magnetoencephalography (MEG) Effective 04/01/10
Sub-Category
0 General Classification
1 MEG
2-9 RESERVED
Standard Abbreviation
087x RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 62
Form Locator 42
088x MISCELLANEOUS DIALYSIS
Charges for dialysis services not identified elsewhere.
Sub-Category
0 General Classification
1 Ultrafiltration
2 Home Dialysis Aid Visit
3-8 RESERVED
9 Other Miscellaneous Dialysis
Standard Abbreviation
DIALY/MISC
DIALY/ULTRAFILT
HOME DIALYSIS AID VISIT
Unit
HCPCS
Sessions Y
Sessions Y
Sessions Y
DIALY/MISC/OTHER
Sessions Y
Note:
Ultrafiltration is the process of removing excess fluid from the blood of dialysis patients by using a
dialysis machine but without the dialysate solution. The designation is only used when the procedure is
not performed as part of a normal dialysis session.
089x RESERVED
090x BEHAVORIAL HEALTH TREATMENT/SERVICES (also see 091x, an extension of 090x)
Charges for prevention, intervention, and treatment services in the areas of mental health, substance
abuse, developmental disabilities, and sexuality. Behavioral Health Care services are individualized,
holistic, and culturally competent and may include on-going care and support and non-traditional
services.
Sub-Category
0 General Classification
1 Electroshock Treatment
2 Milieu Therapy
3 Play Therapy
4 Activity Therapy
5 Intensive Outpatient Services - Psychiatric
6 Intensive Outpatient Services - Chemical
Dependency
7 Community Behavioral Health Program
(Day Treatment)
8-9 RESERVED
Standard Abbreviation
BH/TREATMENTS
BH/ELECTRO SHOCK
BH/MILIEU THERAPY
BH/PLAY THERAPY
BH/ACTIVITY THERAPY
BH/INTENS OP/PSYCH
BH/INTENS OP/CHEM DEP
Unit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
HCPCS
Y
Y
Y
Y
Y
Y
Y
BH/COMMUNITY
Visit
Y
Unit
HCPCS
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Y
Y
Y
Y
Y
Y
Y
Y
Y
091x BEHAVIORAL HEALTH TREATMENTS/SERVICES - Extension of 090x
See Revenue Code 090x
Standard Abbreviation
Sub-Category
0 RESERVED (use 090 for General Classification)
1 Rehabilitation
BH//REHAB
2 Partial Hospitalization - Less Intensive
BH/PARTIAL HOSP
3 Partial Hospitalization - Intensive
BH/PARTIAL INTENSV
4 Individual Therapy
BH/INDIV RX
5 Group Therapy
BH/GROUP RX
6 Family therapy
BH/FAMILY RX
7 Bio Feedback
BH/BIOFEED
8 Testing
BH/TESTING
9 Other Behavioral Health Treatments
BH/OTHER
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November 2012
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Form Locator 42
092x OTHER DIAGNOSTIC SERVICES
Charges for various diagnostic services specific to common screenings for disease, illness or medical
condition.
Sub-Category
0 General Classification
1 Peripheral Vascular Lab
2 Electomyelgram
3 Pap Smear
4 Allergy Test
5 Pregnancy Test
6-8 RESERVED
9 Other Diagnostic Service
Standard Abbreviation
OTHER DX SVCS
PERI VASCUL LAB
EMG
PAP SMEAR
ALLERGY TEST
PREG TEST
Unit
HCPCS
Tests
Tests
Tests
Tests
Tests
Y
Y
Y
Y
Y
OTHER DX SVCS
Tests
Y
093x MEDICAL REHABILITATION DAY PROGRAM
Medical rehabilitation services as contracted with a payer and/or certified by the state.
Services may include physical therapy, occupational therapy and speech therapy.
Sub-Category
0 RESERVED
1 Half Day
2 Full Day
3-9 RESERVED
Standard Abbreviation
Unit
HALF DAY
FULL DAY
Hours
Hours
HCPCS
Note:
The subcategories of 093x are designed as zero-bill revenue code (i.e., no dollars are reported in the
Total Charge column (FL 47) for this revenue code) it should be used as a vehicle to supply program
information as defined in the provider/payer contract. Therefore, zero would be reported in the Total
Charge column and the number of hours provided would be reported in the Units field. The specific
rehabilitation services would be reported under the applicable therapy revenue codes as normal.
094x OTHER THERAPEUTIC SERVICES (also see 095x, and extension of 094x)
Charges for other therapeutic services not otherwise categorized.
Sub-Category
0 General Classification
1 Recreational Therapy
2 Education/Training
3 Cardiac Rehabilitation
4 Drug Rehabilitation
5 Alcohol Rehabilitation
6 Complex Medical Equipment Routine
7 Complex Medical Equipment Ancillary
8 Pulmonary Rehabilitation
9 Other Therapeutic Service
Standard Abbreviation
OTHER RX SVCS
RECREATION RX
EDUC/TRAINING
CARDIAC REHAB
DRUG REHAB
ALCOHOL REHAB
CMPLX MED EQUIP/ROUT
CMPLX MED EQUIP/ANC
PULMONARY REHAB
ADDITIONAL RX SVCS
095x OTHER THERAPEUTIC SERVICES (Extension of 094x)
See Revenue Code 094x
Standard Abbreviation
Sub-Category
0 RESERVED (use 0940 for General Classification)
1 Athletic Training
ATHLETIC TRAINING
2 Kinesiotherapy
KINESIOTHERAPY
3-9 RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Unit
HCPCS
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Visit
Y
Y
Y
Y
Y
Y
Y
Y
Y
Unit
HCPCS
Visit
Visit
Y
Y
Page 64
Form Locator 42
096x PROFESSIONAL FEES (also see 097x and 098x)
Charges for medical professionals that the institutional health care provider along with the third party
payer require the professional fee component to be billed on the UB. The professional fee component is
separately identified by this revenue code. Generally used by Critical Access Hospitals (CAH) that bill
both the technical and professional service components on the UB.
Sub-Category
0 General Classification
1 Psychiatric
2 Ophthalmology
3 Anesthesiologist (MD)
4 Anesthetist (CRNA)
5-8 RESERVED
9 Other Professional Fee
Standard Abbreviation
PRO FEE
PRO FEE/PSYCH
PRO FEE/EYE
PRO FEE/ANES MD
PRO FEE/ANES CRNA
Unit
HCPCS
Y
Y
Y
Y
PRO FEE/OTHER
Y
097x PROFESSIONAL FEES (Extension of 096x)
See Revenue Code 096x.
Standard Abbreviation
Sub-Category
0 RESERVED (use 0960 for General Classification)
1 Laboratory
PRO FEE/LAB
2 Radiology - Diagnostic
PRO FEE/RAD/DX
3 Radiology - Therapeutic
PRO FEE/RAD/RX
4 Radiology - Nuclear Medicine
PRO FEE/NUC MED
5 Operating Room
PRO FEE/OR
6 Respiratory Therapy
PRO FEE/RESPIR
7 Physical Therapy
PRO FEE/PHYSI
8 Occupational Therapy
PRO FEE/OCCUPA
9 Speech Pathology
PRO FEE/SPEECH
Unit
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
098x PROFESSIONAL FEES (Extension of 096x and 097x)
Charges for medical professionals that the institutional health care provider along with the third-party
payer require the professional fee component to be billed on the UB. The professional fee component
is separately identified by this revenue code. Generally used by Critical Access Hospitals (CAH).
Sub-Category
0 RESERVED (use 0960 for General Category)
1 Emergency Room
2 Outpatient Services
3 Clinic
4 Medical Social Services
5 EKG
6 EEG
7 Hospital Visit
8 Consultation
9 Private Duty Nurse
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Standard Abbreviation
PRO FEE/ER
PRO FEE/OUTPT
PRO FEE/CLINIC
PRO FEE/SOC SVC
PRO FEE/EKG
PRO FEE/EEG
PRO FEE/HOS VIS
PRO FEE/CONSULT
FEE/PVT NURSE
Unit
HCPCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
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Form Locator 42
099x PATIENT CONVENIENCE ITEMS
Charges for items that are generally considered by the third-party payers to be strictly convenience
items and therefore are not covered by many health plans.
Sub-Category
0 General Classification
1 Cafeteria/Guest Tray
2 Private Linen Service
3 Telephone/Telecom
4 TV/Radio
5 Non-Patient Room Rentals
6 Late Discharge
7 Admission Kits
8 Beauty Shop/Barber
9 Other Convenience Items
Standard Abbreviation
PT CONVENIENCE
CAFETERIA
LINEN
TELEPHONE
TV/RADIO
NONPT ROOM RENT
LATE DISCHARGE
ADMIT KITS
BARBER/BEAUTY
PT CONV/OTH
Unit
HCPCS
Unit
HCPCS
100x BEHAVIORAL HEALTH ACCOMMODATIONS
Charges for routine accommodations at specified behavior health facilities.
Sub-Category
0 General Classification
1 Residential Treatment - Psychiatric
2 Residential Treatment - Chemical
Dependency
3 Supervised Living
4 Halfway House
5 Group Home
6-9 RESERVED
Standard Abbreviation
BH R&B
BH R&B RES/PSYCH
BH R&B RES/CHEM DEP
Day
Day
BH R&B SUP LIVING
BH R&B HALFWAY HOUSE
BH R&B GROUP HOME
Day
Day
Day
101x to 209x RESERVED
210x ALTERNATIVE THERAPY SERVICES
Charges for therapies not elsewhere categorized under other therapeutic service revenue codes
(042x, 043x, 044x, 091x, 094x, 095x) or services such as anesthesia or clinic (0374, 0511).
Sub-Category
0 General Classification
1 Acupuncture
2 Acupressure
3 Massage
4 Reflexology
5 Biofeedback
6 Hypnosis
7-8 RESERVED
9 Other Alternative Therapy Service
Standard Abbreviation
ALTTHERAPY
ACUPUNCTURE
ACUPRESSURE
MASSAGE
REFLEXOLOGY
BIOFEEDBACK
HYPNOSIS
Unit
Session
Session
Session
Session
Session
Session
OTHER ALTTHERAPY
Session
HCPCS
Notes:
Alternative therapy is intended to enhance and improve standard medical treatment. These revenue
code(s) would be used to report services in a separately designated alternative inpatient/outpatient unit.
211x to 309x RESERVED
BCNEPA/FPH/FPLIC Billing Manual
November 2012
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Form Locator 42
310x ADULT CARE
Charges for personal, medical, psycho-social, and/or therapeutic services in a special community
setting for adults needing supervision and/or assistance with Activities of Daily Living (ADL).
Sub-Category
0 RESERVED
1 Adult Day Care, Medical and SocialHourly
2 Adult Day Care, Social-Hourly
3 Adult Day Care, Medical and Social- Daily
4 Adult Day Care, Social-Daily
5 Adult Foster Care Daily
6-8 RESERVED
9 Other Adult Care
Standard Abbreviation
Unit
ADULT MED/SOC HR
Hour
ADULT SOC HR
ADULT MED/SOC DAY
ADULT SOC DAY
ADULT FOSTER DAY
Hour
Day
Day
Day
HCPCS
OTHER ADULT
311x to 999x RESERVED
Form Locator 43
Data Element
Revenue Description/IDE Number/Medicaid Drug Rebate
Definition:
The standard abbreviated description of the related revenue code categories included
on this bill. (See FL 42 for description of each revenue code category.)
FL 43 is also used to report Investigational Device Exemption (IDE) Numbers and
information on Medicaid drug rebates.
Required
Yes - for paper bills only
Reporting
UB-04: Required (for paper bills only)
004010/004010A1, 005010: Not Used
Field
Attributes
1 Field
22 Lines*
24 Positions
Alphanumeric
Left-justified
Notes
The standard abbreviated description should correspond with the Revenue Codes as
defined by the NUBC.
* The 23rd line contains an incrementing page count and total number of pages for the
claim on each page, creation date of the claim on each page, and a claim total for
covered and non-covered charges on the final claim page only indicated with a
Revenue Code of “0001”.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 67
Form Locator 44
Data Element
HCPCS/Accommodation Rates/HIPPS Rate Codes
Definition:
1. The Healthcare Common Procedure Coding System (HCPCS) applicable to
ancillary service and outpatient bills.
2. The accommodation rate for inpatient bills.
3. Health Insurance Prospective Payment System (HIPPS) rate codes represent
specific sets of patient characteristics (or case-mix groups) on which payment
determinations are made under several prospective payment systems.
Required
See reporting
Reporting
HCPCS and HIPPS Rate Codes
UB-04: Situational. Required for outpatient claims when an appropriate procedure or
HIPPS code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics
only) or HIPPS code exists for this service line item.
004010/004010A1: Situational
005010X223A2: Situational. Required for outpatient claims when an appropriate
procedure code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or Biologics
only) or HIPPS code exists for this service line item.
Accommodation Rates
UB-04: Required when a room & board revenue code is reported.
004010/004010A1: Required when the associated revenue code is 100-219.
005010: Not Used. (Rationale: The rate can be computed by dividing the total charge
by the number of units.)
HCPCS Modifiers
UB-04: Required when a modifier clarifies or improves the reporting accuracy of the
associated procedure code.
004010/004010A1: Required when the Provider needs to convey additional
clarification for the associated procedure code.
005010: Required when a (first, second, third or fourth) modifier clarifies or improves
the reporting accuracy of the associated procedure code.
Field
Attributes
1 Field
22 Lines (a)
14 Positions (b)
Numeric for Accommodation Rate; alphanumeric for HCPCS and HIPPS Rate Codes.
Right-justified for Accommodation Rates; left-justified for HCPCS and HIPPS Rate
Codes.
Dollar values reported for Accommodation Rates must include whole dollars, the
decimal, and the cents.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
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Form Locator 44
Notes
Field Attributes
(a) The 23rd line contains an incrementing page count and total number of pages for
the claim on each page, creation date of the claim on each page, and a claim total
for covered and non-covered charges on the final claim page only indicated using
Revenue Code 0001.
(b) For HCPCS, the filed consists of 5 positions for the base code plus 8 positions for
up to four HCPCS modifiers; thus, the field contains one extra/unused position.
(c) HIPPS rate code are alphanumeric codes of 5 positions. Each code contains
intelligence, with certain positions of the code indicating the case mix group itself,
and other positions providing additional informational; the additional information
varies amount HIPPS codes.
HIPPS Rate Codes
The Centers for Medicare and Medicaid services develops and publishes the HIPPS
codes to establish a coding system for claims submission and claims payment under
prospective payment systems. These codes represent the case mix classification
groups that are used to determine payment rates under prospective payment systems.
Case mix classification groups include, but may not be limited to, resource utilization
groups (RUGs) for skilled nursing facilities, home health resource groups (HHRGs) for
home health agencies, and case mix groups (CMGs) for inpatient rehabilitation
facilities.
HCPCS Modifiers (Level I and Level II)
The UB-04 accommodates up to four modifiers, two characters each.
Various CPT (Level I HCPCS) and Level II HCPCS codes may require the use of
modifiers to improve the accuracy of coding. Consequently, reimbursement, coding
consistency, editing and proper payment will benefit from the reporting of modifiers.
Hospital should not report a separate HCPCS (five-digit code) instead of the modifier.
When appropriate, report a modifier bas on the list indicated in the above section of
the AMA publication.
Form Locator 45
Data Element
Service Date
Definition:
The date (MMDDYY) the outpatient service was provided. (Applies to Lines 1-22; Line 23
refers to the Creation Date (MMDDYY) of the bill (the date bill was created/printed)).
This field is also used to report the assessment reference date when billing SNF PPS
services (Type of Bill 021x).
Required
Required on outpatient claims
Reporting
Service Date
UB-04: Required on outpatient claims.
004010/004010A1: Required on outpatient claims when revenue, procedure, HIEC or drug
codes are reported in the SV2 segment.
005010: Required on outpatient service line where a drug is not being billed and the
Statement Covers Period is greater than one day.
OR
Required on service lines where a drug is being billed and the payer’s adjudication is
known to be impacted y the drug duration or the date the prescription was written.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 69
Form Locator 45
Reporting
Assessment Date
Require when this field is used to report the assessment reference date when billing SNF
PPS services (Type of Bill 021x). 005010: Not Used
Creation Date
Required for Line 23 (Creation Date). Enter the date the bill was created or prepared for
submission. Creation Date on Line 23 should be reported on all pages of the UB-04.
Field
Attributes
Service Date:
1 Field
22 Lines
Numeric
Right-justified
Data Element
Service Units
Definition:
A quantitative measure of services rendered by revenue category to or for the patient to
include items such as number of accommodation days, miles, pints f blood, renal dialysis
treatments, etc.
Required
Yes
Reporting
UB-04, 004010/004010A1, 005010: Required
Field
Attributes
1 Field
Numeric
Notes
Enter the total number of covered accommodation days, ancillary units of service, or visits,
where appropriate.
 Leading zeros should not be reported.
 If the amount is an integer, no decimal point is reported.
 The maximum length for this field is 7 digits excluding the decimal.
 When a decimal is used, the maximum number of digits allowed to the right of the
decimal is three.
6 Positions
Creation Date:
1 Field 1 Line (23)
6 Positions
Numeric
Right-justified
Form Locator 46
22 Lines
Right-justified
7 Positions
Decimal
The following notes are intended as general guidance.
Inpatient
Room & board accommodations: Units reflect the total number of days of care provided to
the patient.
Other revenue codes: Although the inpatient UB-04 is a summary level claim, units can be
reported as “1” or more based on the provider’s practice, health plan requirements or
regulation. A zero or negative value is not allowed.
Outpatient
When HPCPS codes are reported, the unit is defined by the HCPCS definition. Where the
unit is not defined by the HCPCS code, units can be reported as “1” or more based on the
provider’s practice, health plan requirements or regulation. A zero or negative value is not
allowed.
Form Locator 47
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November 2012
Page 70
Data
Element
Total Charges
Definition:
Total Charges for the primary payer pertaining to the related revenue code for the current
billing period as entered in the statement covers period. Total Charges includes both
covered and non-covered charges.
Required
Yes
Reporting
Line Item Charges Required: UB-04 (Lines 1-22). 004010/004010A1, 005010 Loop ID
2400 | SV203
Total (Summary) Charges Required: UB-04 Line 23 of the final claim page using Revenue
Code 0001. (Revenue 0001 is not used on electronic transactions; report the total claim
charge in the appropriate data segment/field as indicated below.)
004010/004010A1, 005010 Loop ID 2300 | CLM02
Field
Attributes
1 Field
Numeric
Notes
There are 7 positions for dollars, 2 positions for cents.
Amounts greater than or equal to zero are acceptable values for this element.
The 23rd line contains an incrementing page count and total number of pages for the
claim on each page, creation date of the claim on each page, and a claim total for covered
and non-covered charges on the final claim page only indicated using Revenue Code
0001.
23 Lines *
Right-justified
9 Positions (see notes)
Form Locator 48
Data
Element
Non-covered Charges
Definition:
To reflect non-covered charges for the destination payer as it pertains to the related
revenue code.
Required
Not required
Reporting
Line Item Non-Covered Charges Required:
UB-04: Lines 1-22. Required if needed to report line specific non-covered charge amount.
004010/004010A1: Situational
005010: Required if needed to report line specific non-covered charge amount.
Total (Summary) Non-Covered Charges Required:
UB-04: Required on Line 23 of the final claim page using Revenue code 00001 when there
are non-covered charges on the claim.
004010/004010A1, 005010: Not Used
Field
Attributes
1 Field
Right-justified
23 Lines *
9 Positions (see Notes)
Numeric
Notes
There are 7 positions for dollars, 2 positions for cents.
* The 23rd line contains an incrementing page count and total number of pages for the
claim on each page, creation date of the claim on each page, and a claim total for covered
and non-covered charges on the final claim page only indicated using Revenue Code
0001.
Form Locator 49
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 71
Data
Element
Reserved for Assignment by the NUBC
Reporting
Not used
Field
Attributes
1 Field
23 Lines
2 Positions
Alphanumeric
Left-justified
Form Locator 50
Data
Element
Payer Name
Definition:
Name of health plan that the provider might expect some payment for the bill.
Required
Yes
Reporting
UB-04: Line A Required. Lines B and C Situational. Required when other payers are
known to potentially be involved in paying this claim.
004010/004010A1, 005010: Required
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines
23 Positions
Alphanumeric
Left-justified
Example: If “Medicare” is entered in Form Locator 50A, this indicates that the provider has
determined based on the responses form the patient or the patient’s representative or from
the insurance enrollment card information that Medicare is the primary payer.
Form Locator 51
Data
Element
Health Plan Identification Number
Definition:
The number used by the health plan to identify itself.
Required
No
Reporting
Report the HIPAA National Plan Identifier when it become mandated; otherwise report the
(legacy/proprietary) number (i.e., whatever number used has been defined between
trading partners).
UB-04: Line A Required. Lines B and C Situational. Required when other health plans are
known to potentially be involved in paying this claim.
004010/004010A1, 005010: Required
Field
Attributes
1 Field
3 Lines
15 Positions
Alphanumeric
Left-justified
Form Locator 52
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November 2012
Page 72
Data
Element
Release of Information Certification Indicator
Definition:
Code indicating whether the provider has on file a signed statement (from the patient or
the patient’s legal representative) permitting the provider to release data to another
organization.
Required
Yes
Reporting
UB-04 and 005010: Required. See “code structure” noted below.
004010/004010A1: Required. Note: The 004010/004010A1 includes additional codes that
are no longer applicable due to the HIPAA medical privacy rule.
Field
Attributes
1 Field
Notes
The Release of Information response is limited to the information carried in this claim.
3 Lines
1 Position
Alphanumeric
Left-justified
A = Primary
B = Secondary
C = Tertiary
Code Structure
I Informed Consent to Release Medical Information for Conditions or Diagnoses
Regulated by Federal Statutes
Usage Note:
Required when the provider has not collected a signature and state or federal laws do
not supersede the HIPAA Privacy Rule by requiring a signature be collected.
Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data
Related to a Claim
Usage Note:
Required when state or federal laws do not supersede the HIPAA Privacy Rule by
requiring a signature be collected.
Form Locator 53
Data
Element
Assignment of Benefits Certification Indicator
Definition:
Code indicates provider has a signed form authorizing the third party payer to remit
payment directly to the provider.
Required
Yes
Reporting
UB-04, 004010/004010A1, 005010: Required
Field
Attributes
1 Field
3 Lines
1 Position
Alphanumeric
Left-justified
Form Locator 53
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 73
Notes
Health plans that have arrangements with affiliate health plans in different states may
utilize this code to make payments to the provider rather than the insured individual. This
element answers the question whether or not the insured has authorized the plan to remit
payment directly to the provider.
The presence of an assignment does not permit release of medical information about a
patient.
Code
Structure
N No
W Not Applicable (Use code ‘W’ when the patient refuses to assign benefits.)
Y Yes
Form Locator 54
Data
Element
Prior Payments - Payer
Definition:
The amount the provider has received (to date) by the health plan toward payment of this
bill.
Required
If applicable
Reporting
UB-04: Required when the indicated payer has paid an amount to the provider towards this
bill. Report “0.00” if there is no payment made by the health plan or payment was applied
to coinsurance or deductible.
004010/004010A1: Required when the present payer ha paid an amount to the provider
towards this bill.
005010: Required when the claim has been adjudicated by the payer identified in Loop ID2330B of this loop. OR Required when Loop ID-2919AC is present. In this case, the
claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
Field
Attributes
1 Field
Notes
There are 8 positions for dollars, 2 positions for cents.
3 Lines
10 Positions
Numeric
Right-justified
A = Primary
B = Secondary
C = Tertiary
Form Locator 55
Data
Element
Estimated Amount Due - Payer
Definition:
The amount estimated by the provider to be due from the indicated payer (estimated
responsibility less prior payments).
Required
If applicable
Reporting
UB-04: Required when the provider estimates an amount due from the indicated payer.
004010/004010A1: Required when the Payer Estimated Amount Due is applicable to this
claim.
005010: Not Used
Form Locator 55
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 74
Field
Attributes
1 Field
3 Lines 10 Positions
Alphanumeric
Notes
There are 8 positions for dollars, 2 positions for cents.
Left-justified
A = Primary
B = Secondary
C = Tertiary
Form Locator 56
Data
Element
National Provider Identifier - Billing Provider
Definition:
The unique identification number assigned to the provider submitting the bill: NPI is the
national provider identifier.
Required
Yes
Reporting
The NPI Final Rule was implemented May 23, 2008.
UB-04: Required for providers in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the provider
is eligible to receive an NPI.
OR
005010: Required for providers not in the United States or its territories when the provider
has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider
has received an NPI and the submitter has the capability to send it.
Field
Attributes
1 Field
3 Lines 15 Positions*
Alphanumeric
*Note: The NPI is ten characters in length.
Left-justified*
Notes
Proprietary identifiers necessary for the receiver to identify Billing Providers that area not
covered entities are to be reported in FL 57 Lines A-C.
Form Locator 57
Data
Element
Other (Billing) Provider Identifier
Definition:
A unique identification number assigned to the provider submitting the bill by the health
plan.
Required
Yes
Form Locator 57
Reporting
The NPI Final Rule was implemented May 23, 2008.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 75
004010/004010A1: NPI usage is not applicable due to the implementation of the NPI Final
Rule.
UB-04: Required when NPI is not used in FL 56 and an identification number other than
the NPI is necessary for the receiver to identify the provider.
005010: Required when NM109 in Loop 2010AA is not used and an identification number
other than the NPI is necessary for the receiver to identify the provider.
Field
Attributes
1 Field
3 Lines 15 Positions
Alphanumeric
Left-justified
Notes
The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider Identifier.
Use this field to report other provider identifiers as assigned by the health plan (as
indicated in FL 50 Lines A-C).
Form Locator 58
Data
Element
Insured’s Name
Definition:
The name of the individual under whose name the insurance benefit is carried.
Required
Yes
Reporting
UB-04, 004010/004010A1, 005010: Required
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines 25 Positions
Alphanumeric
Left-justified
Use a comma or space to separate land and first names. Enter last name first.
No space should be left between a prefix and a name as in MacBeth, and McEnroe.
Titles (such as Sir, Msgr, Dr.) should not be recorded in this data element.
Record hyphenated names with the hyphen as in Smith-Jones, Rebecca.
To record suffix of a name, write the last name, leave a space and write the suffix, then
write the first name as in Snyder III, Harold, or Addams JR., Glen
Form Locator 59
Data
Patient’s Relationship to Insured
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 76
Element
Definition:
Code indicating the relationship of the patient to the indentified insured.
Required
Yes
Reporting
UB-04: Line A required. Lines B and C Situational. Required when other payers are
known to potentially be involved in paying on this claim.
004010/004010A1: Required. If the patient is the subscriber, report in Loop ID 2000B.
Required if the patient is not the subscriber but has a unique identifier assigned by the
destination payer, report in Loop ID 2000C.
005010: Required. If the patient is the subscriber, the name is reported in Loop ID 2000B.
If the patient is not the subscriber but has a unique identifier assigned by the destination
payer, the name is reported in Loop ID 2000B.
If the patient is not the subscriber and cannot be identified by a unique identifier assigned
by the destination payer, report in Loop ID 2000C.
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
Code
01
18
19
20
21
39
40
53
G8
3 Lines 2 Positions
Alphanumeric
Left-justified
Title
Spouse
Self
Child
Employee
Unknown
Organ Donor
Cadaver Donor
Life Partner
Other Relationship
Form Locator 60
Data
Element
Insured’s Unique Identifier
Definition:
The unique number assigned by the health plan to the insured.
Required
Yes
Reporting
UB-04: Line A Required. Lines B and C Situational. Required when other health plans are
known to potentially be involved in paying this claim.
004010/004010A1, 005010: Required
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines
20 Positions
Alphanumeric
Left-justified
Form Locator 61
Data
Insured’s Group Name
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 77
Element
Definition:
The group or plan name through which the insurance is provided to the insured.
Required
Reporting
UB-04: Line A Situational. Required if the Group Name is available and FL 62 (Insurance
Group Number) is not used.
Lines B and C Situational. Required when other insurance/payers/health plans are known
to potentially be involved in paying this claim and when FL62 B and C are not used.
004010/004010A1: Situational. Used only when no group number is reported.
005010: Required when Group Number (Loop ID 2000B) is not used and the group name
is available.
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines
14 Positions
Alphanumeric
Left-justified
Form Locator 62
Data
Element
Insured’s Group Number
Definition:
The identification number, control number, or code assigned by the carrier or administrator
to identify the group under which the individual is covered.
Required
Yes
Reporting
UB-04: Line A Situational. Required when the insured’s identification card shows a group
number. Lines B and C Situational. Required when other insurance/payers/health plans
are known to potentially be involved in paying this claim and when the other insurance’s
identification card shows a group number.
004010/004010A1: Situational
005010: Required when the subscriber’s identification card for the destination payer (Loop
ID 2010BB) shows a group number.
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines
17 Positions
Alphanumeric
Left-justified
Form Locator 63
Data
Authorization Code/Referral Number
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 78
Element
Definition:
An identifier that designates that services on this bill have been authorized by the payer or
indicates that a referral is involved.
Required
No
Reporting
Authorization
UB-04: Situational. Required when an authorization code is assigned by the payer or UMO
(Utilization Management Organization) is required to be reported on the claim.
004010/004010A1: Situational. Required where services on this claim were preauthorized
or where a referral is involved.
005010: Situational. Required when an authorization code is assigned by the payer or
UMO (Utilization Management Organization) AND the services on this claim were
preauthorized.
Referral Number
UB-04: Situational. Required when a referral number is code assigned by the payer or
UMO (Utilization Management Organization) AND a referral is involved.
004010/004010A1: Situational. Required where services on this claim were preauthorized
or where a referral is involved.
005010: Situational. Required when a referral number is assigned by the payer or UMO
(Utilization Management Organization) AND a referral is involved.
Field
Attributes
1 Field
3 Lines
30 Positions
Notes
A = Authorization Code
B = Referral Number
C = Secondary Payer Authorization Code
Alphanumeric
Left-justified
Form Locator 64
Data
Element
Document Control Number (DCN)
Definition:
The control number assigned to the original bill by the health plan or the health plan’s fiscal
agent as part of their internal control.
Required
No
Reporting
UB-04: Situational. Required when Type of Bill Frequency Code (FL 04) indicates this
claim is a replacement or void to a previously adjudicated claim.
004010/004010A1: Situational
005010: Situational. (Payer Claim Control Number) required when CLM05-3 (Claim
Frequency Code) indicates this claim is a replacement or void to a previously adjudicated
claim.
Form Locator 64
Field
1 Field
BCNEPA/FPH/FPLIC Billing Manual
November 2012
3 Lines
26 Positions
Alphanumeric
Left-justified
Page 79
Attributes
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
Payer A’s ICN/DCN should be shown on Line “A” of FL 64. Similarly, the ICN/DCN for
Payers B and C should be shown on lines B and C respectively, of FL 64.
Form Locator 65
Data
Element
Employer Name (of the Insured)
Definition:
The name of the employer that provides health care coverage for the insured individual
identifier in FL 58.
Required
No
Reporting
UB-04: Situational. Lines A, B, C required when the employer of the insured is known to
potentially be involved in paying on this claim.
004010/004010A1 and 005010: Not Used
Field
Attributes
1 Field
Notes
A = Primary Payer
B = Secondary Payer
C = Tertiary Payer
3 Lines
25 Positions
Alphanumeric
Left-justified
Form Locator 66
Data
Element
Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
Definition:
The qualifier that denotes the version of International Classification of Diseases (ICD)
reported.
Required
No
Reporting
UB-04: Qualifier Code “9” Required on claims through September 30, 2014. ICD-9-CM
cannot be reported on HIPAA covered entity claims on or after October 1, 2014 (a).
The NUBC strongly encourages all entities – covered and non-covered alike – to
follow the diagnosis and procedure code rules in effect pre and post October 1,
2014(a).
Qualifier Code “0” designating ICD-10-CM and ICD-10-PCS can only be used on or after
October 1, 2014(a) based on a final rule naming ICD-10-CM and ICD-10-PCS as allowable
code sets under HIPAA, and a proposed rule dated 4/17/12 changing the compliance date
from October 1, 2013 to October 1, 2014.
OR
For claims which are not covered under HIPAA (before October 1, 2014(a)).
Form Locator 66
Reporting
004010/004010A1: Not Applicable. Only ICD-9-CM qualifier codes are available in version
4010/4010A1.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 80
005010: Data Element not Applicable. Version 5010 contains distinct qualifier codes for
ICD-9-CM (“BF”), ICD-10-CM (“ABF”) and ICD-10-PCS (“BBR”). “ABF” and “BBR” that
can only be used on or after October 1, 2014(a) based on a final rule naming the ICD-10CM and ICD-10-PCS as allowable code sets under HIPAA, and a proposed rule dated
4/17/12 changing the compliance date from October 1, 2013 to October 1, 2014.
OR
For claims which are not covered under HIPAA (before October 1, 2014(a ).
Field
Attributes
1 Field
1 Lines
1 Positions
Alphanumeric
Notes
Qualifier codes reflects the edition portion of the ICD:
9 - Ninth Revision
0 - Tenth Revision
Left-justified
(a)
In a proposed rule dated 4/17/12, DHHS proposed to change the compliance date for the
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
for diagnosis coding, including the Official ICD-10-CM Guidelines for Coding and
Reporting, and the International Classification of Diseases, 10th Revision, Procedure
Coding System (ICD-10-PCS) for inpatient hospital procedure coding, including the Official
ICD-10-PCS Guidelines for Coding and Reporting, from October 1, 2013 and October 1,
2014.
Form Locator 67
Data
Element
Principal Diagnosis Code and Present on Admission Indicator
Definition:
The ICD-9-CM codes describing the principal diagnosis (i.e., the condition established
after study to be chiefly responsible for occasioning the admission of the patient for care.)
See FL 67 for information on the Present on Admission Indicator noted below.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Required
Yes
Reporting
UB-04, 004010/004010A1, 005010: Principal Diagnosis Code – Required
Present on Admission Indicator - See FL 67 for further information on usage.
Field
Attributes
1 Field
1 Line
Alphanumeric
Left-justified
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Notes
Follow the official coding guidelines for ICD reporting.
The reporting of the decimal between the third and fourth digit is unnecessary because it is
implied.
The principal diagnosis code will include the use of “V” codes.
Present on Admission (POA) Indicator
 The eighth digit of FL 67 - Principal Diagnosis and each of the secondary diagnosis
fields FL A-Q.
 The eighth digit of FL 72 – External Cause of Injury (ECI) (3 fields on the form).
Form Locator 67
Notes
Present on Admission (POA) Indicator
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 81
General Reporting Requirements
 All claims involving inpatient admissions to general acute care hospitals or other
facilities that are subject to a law or regulation (e.g., Deficit Reduction Act of 2005)
mandating collection of present on admission information.
Effective 1/1/2011:
All claims involving inpatient admissions to general acute care hospitals
or other facilities that are subject to a law or regulation (e.g. Deficit
Reduction Act of 2005) mandating collection of present on admission
information, or as mutually agreed to under contract with an insurance
program.
 Present on admission is defined as present at the time the order for inpat4ient
admission occurs – conditions that develop during an outpatient encounter,
including emergency department, observation, or outpatient surgery, are
considered as present on admission.
 POA indicator is assigned to principal and secondary diagnoses ( as defined in
Section II of the Official Guidelines for Coding and Reporting) and the external
cause of injury codes.
 Issues related to inconsistent, missing, conflicting or unclear documentation must
still be resolved by the provider.
 If a condition would not be coded and reported based on UHDDS definitions and
current official coding guidelines, then the POA indicator would not be reported.
Reporting Options
The five reporting options for all diagnosis reporting are as follows:
Code
Y
Yes
N
No
U
No Information in the Record
W
Clinically Undetermined
Blank Field on UB-04/ Exempt from POA Reporting
Not Populated in 005010 837
Effective July 1, 2011
1 on UB-04 Only/Not
Exempt from POA Reporting
Populated in 005010 837
Reporting Definitions:
Code
Y
N
U
Definition
Present at the time of inpatient admission
Not present at the time of inpatient admission
Documentation is insufficient to determine if condition is present on
admission
W
=
Provider is unable to clinically determine whether condition was
present on admission or not
Effective July 1, 2011
1*
=
Exempt from POA Reporting
=
=
=
* UB-04 only; not for use on 837
Form Locator 67
Notes
Present on Admission (POA) Indicator (continued)
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 82
Health plans that receive POA information on the claim should not reject the claim if their
claims processing systems have no use for any of the POA information.
The American Health Information Management Association, American hospital
Association, CMS and the National Center for Health Statistics (known as the “Cooperating
Parties”) has published a list of ICD-9-CM codes that are exempt from POA reporting.
The indicator can be left unreported only for the codes on this list, that is, the filed is left
blank on the paper form and “Not Used” on the 00510 837 electronic claim. The list of
exempt diagnosis codes will be included in the POA guideline published in the ICD-9-CM
Official Guidelines for Coding and Reporting (Appendix I - Present on Admission Reporting
Guidelines). These guidelines will be updated as needed to address identified coding
errors or areas of confusion.
POA for 00410/00410A1 837 Medicare Claims
Section 5001© of the Deficit Reduction Act of 2005 requires hospitals to begin reporting
the secondary diagnoses that are present on the admission (POA) of patients effective for
discharges on or after October 1, 2007.
Effective October 1, 2007, Medicare will begin to accept a POA indicator for every
diagnosis on your inpatient acute care hospital claims. However, providers must submit
the POA on hospital claims beginning with discharges on or after January 1, 2008. Critical
access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals,
and children’s inpatient facilities are exempt from this requirement.
CMS does not require a POA indicator for the external cause of injury code unless it is
being reported as an “other diagnosis.”
CMS Reporting Options and Definitions
 Y = Yes = present at the time of inpatient admission
 N = No = not present at the time of inpatient admission
 U = Unknown = the documentation is insufficient to determine if the condition was
present at the time of inpatient admission.
 W = Clinically Undetermined = the provider is unable to clinically determine whether
the condition was present at the time of inpatient admission or not
 1 = Unreported/Not used - Exempt from POA reporting. This code is the equivalent
code of a blank on the UB-04, however, it was determined that blanks were
undesirable when submitting this data via the 0410/00410A1
The POA element on your electronic claims must contain the letters “POA” followed by a
single POA indicator for every diagnosis that your report. The POA indicator for the
principal diagnosis should be the first indicator after “POA,” and (when applicable) the POA
indicators for secondary diagnoses would follow. The last POA indicator must be followed
by the letter “Z” to indicate the end of the data element (or FIs and A/B MACs will allow the
letter “X” which CMS may use to identify special data processing situations in the future).
Form Locator 67
Notes
Present on Admission (POA) Indicator (continued)
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 83
POA for 00410/00410A1 837 Medicare Claims
Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL
67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on
claims submitted electronically via 00410/00410A1 837 format, you must use segment K3
in the 2300 loop, data element K301.
Below is an example of what this coding should look like on an electronic claim: If
segment K3 read as follows: “POAYNUWIYZ,” it would represent the POA indictors for a
claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y),
the first secondary diagnosis was not POA (N), it was unknown if the second secondary
diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was
POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the
fifth secondary diagnosis was POA (Y).
As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA
data and POA data will also be included with any secondary claims sent by Medicare for
coordination of benefits purposes.
The official instruction, CR5679, issued to FIs or A/B MACs can be found at
http://www.cms.hhs.gov/Transmittals/downloads/R289OTN.pdf.
Hospitals Exempt from Present on Admission (POA) Reporting (i.e. non-Inpatient
Prospective Payment System (IPPS) Hospitals) and the Grouper
Although POA reporting is not required for IPPS exempt hospitals, their claims still process
through Grouper. Some exempt hospitals report the POA, however, due to other payer
requirements or business needs. When exempt hospitals report the POA, they must
include an “X” to indicate the end of POA reporting in the K3 segment of the claim. The
“X” indicator will prevent Grouper from Applying Hospital-Acquired Condition (HAC)
Diagnosis Related Group (DRG) logic to the claim.
Effective October 1, 2008, FISS will automatically replace any reported ‘Z’ indicator with an
‘X’ for providers exempt from reporting POA. However, exempt providers should begin to
report an ‘X’ to indicate the end of POA reporting as soon as possible.
The official instruction, CR6086, can be found at
http://www.cms.hhs.gov/Transmittals/downloads/R354OTN.pdf.
Form Locator 67A-Q
Data
Other Diagnosis Code and Present on Admission Indicator
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 84
Element
Definition:
The ICD-9-CM codes corresponding to all conditions that coexist at the time of admission,
that develop subsequently, or that affect the treatment received and/or length of stay.
Exclude diagnoses that relate to an earlier episode which have no bearing on the current
hospital stay.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Required
Reporting
Other Diagnosis Codes
UB-04: Situational. Required when other condition(s) coexist or develop(s) subsequently
during the patient’s treatment.
004010/004010A1: Situational. Required when other condition(s) coexists with the
Principal Diagnosis, coexists at the time of admission or develops subsequently during the
patient’s treatment.
005010: Situational. Required when other condition(s) coexist or develop(s) subsequently
during the patient’s treatment.
Present on Admission Indicator
For use on the UB-04 and 00510 only; not for use in any manner on 004010/004010A1
Field
Attributes
17 Fields
2 Lines
Alphanumeric
Left-justified
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Notes
The reporting of the decimal between the third and fourth digits is unnecessary because it
is implied.
Other diagnoses codes will permit the use of ICD-9-CM “V” and “E” codes where
appropriate.
Other diagnosis is interpreted as additional conditions that affect patient care in terms of
requiring: Clinical Evaluation, or Therapeutic Treatment, or Diagnostic Procedures, or
Extended Length of Hospital Stay, or Increased Nursing Care and/or Monitoring.
Form Locator 68
Data
Element
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
2 Lines
8 Positions (Line 1)
Alphanumeric
9 Positions (Line 2)
Left-justified
Form Locator 69
Data
Admitting Diagnosis Code
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 85
Element
Definition:
The ICD diagnosis code describing the patient’s diagnosis at the time of admission.
Required
Yes - Inpatient only
Reporting
UB-04: Situational. Required when claim involves an inpatient admission.
Required on 012x, 022x and inpatient claims (“IP”) except 028x, 065x, 066x, 084x, 086x.
004010/004010A1: Situational. The Admitting Diagnosis is required on all inpatient
admission claims and encounters.
005010: Situational. Required when claim involves an inpatient admission.
Field
Attributes
1 Field
Notes
The ICD-9-CM diagnosis code describing the admitting diagnosis as a significant finding
representing patient distress, an abnormal finding on examination, a possible diagnosis
based on significant findings, a diagnosis established from a previous encounter or
admission, an inquiry, a poisoning, or a reason or condition (not an illness or injury) such
as follow-up or pregnancy in labor. Report only one admitting diagnosis. This condition
shall be determined based on the ICD-9-CM coding directives in Volumes I and II of the
ICD-9-CM coding manuals (ICD-9-CM codes 001 – V82.9). The reporting of the decimal
between the third and fourth digits is unnecessary because it is implied.
1 Line
7 Positions
Alphanumeric
Left-justified
Form Locator 70a-c
Data
Element
Patient’s Reason for Visit
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 86
Definition:
The ICD-CM diagnosis codes describing the patient’s reason for visit at the time of
outpatient registration.
Required
Reporting
UB-04: Situational.
1. Required for all unscheduled outpatient visits. An “unscheduled” outpatient visit is
defined as an outpatient Type of Bill 013x, 085x, or 078x together with FL 14 (Priority
of Visit/Type of Admission) codes 1,2 or 5 and Revenue Codes 045x, 0516, 0526, or
0762 (Observation Hours).
2. May be reported at submitter’s discretion for scheduled outpatient visits (such as
encounters for ancillary tests) when this information provides additional information to
support medical necessity. This information may be any documented reason for the
service provided, including patient’s stated reason for seeking care or the reason
provided by the physician as part of the order for the service. This information is not
required for all scheduled outpatient encounters.
3. Payers should not reject outpatient claims that contain patient’s reason for visit
information in FL 70 if this information is not needed for their adjudication of the claim.
004010/004010A1: Situational. Required for all unscheduled outpatient visits or upon the
patient’s admission to the hospital.
005010: Situational. Required when claim involves outpatient visits.
See ASC X12N/TG2 interpretation (RFI #1256) on Reporting Patient’s Reason for Visit
(005010X223A2) http://www.x12.org/x12org/subcommittees/x12rfi.cfm
(See specific UB-04 requirements above and FL 04.)
Field
Attributes
1 Field, 3 Subfields (a,b,c)
7 Positions
1 Line
Alphanumeric
Left-justified
Notes
The ICD-9-CM diagnosis code describing the patient’s stated reason for seeking care (or
as stated by the patient’s representative). This may be a condition representing patient
distress, an injury, a poisoning, or a reason or condition (not an illness or injury) such as
follow-up or pregnancy in labor. Report the first diagnosis code describing the patient’s
primary reason for seeking care in subfield a. This condition shall be determined based on
the ICD-9-CM coding directives in Volumes I and II of the ICD-9-CM coding manuals (ICD9-CM codes 001 - V82.9). There are two other diagnosis code subfields to report
additional reasons for the patient’s visit for care. Reporting the decimal between the third
and fourth digits is unnecessary because it is implied.
Form Locator 71
Data
Element
Prospective Payment System (PPS) Code
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November 2012
Page 87
Definition:
The PPS code assigned to the claim to identify the DRG based on the grouper software
called for under contract with the primary payer.
Required
Reporting
UB-04: Situational. Required for inpatient claims when the hospital is under contract with
the health plan to provide this information.
004010/004010A1: Situational. Required when an inpatient hospital is under DRG
contract with a payer and the contract requires the provider to identify the DRG to the
payer.
005010: Situational. Required when an inpatient hospital is under DRG contract with a
payer and the contract requires the provider to identify the DRG to the payer.
Field
Attributes
1 Field
1 Line
4 Positions
Right-justified (all positions fully coded)
Note
Many workers’ compensation programs require this information.
Numeric
Form Locator 72a-c
Data
External Cause of Injury (ECI) Code and Present on Admission Indicator
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 88
Element
Definition:
The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or adverse
effect.
For additional information, refer to the Official ICD-9-CM Guidelines for Coding and
Reporting.
Required
Reporting
External Cause of Injury (ECI) Code
UB-04: Situational. Required when an injury, poisoning, or adverse effect is the cause for
seeking medical treatment or occurs during the medical treatment.
004010/004010A1: Situational. Required whenever a diagnosis is needed to describe an
injury, poisoning or adverse effect.
005010: Situational. Required when an external Cause of Injury is needed to describe an
injury, poisoning, or adverse effect.
Present on Admission Indicator:
For use on the UB-04 and 005010 only; not for use in any manner on 004010/004010A1.
See FL 67 for further information on usage.
Field
Attributes
3 Fields
1 Line
Left-justified
8 Positions (1-7: Principal Diagnosis Code; position 8 (shaded area): Present on
Admission Indicator)
Note
The priorities for recording an ECI code in Form Locator 72a-c are:
1. Principal diagnosis of an injury or poisoning.
2. Other diagnosis of an injury, poisoning, or adverse effect directly related to the
principal diagnosis.
3. Other diagnosis with an external cause.
Form Locator 73
Data
Element
Reserved for Assignment by the NUBC
Definition:
Reporting
Not Used
Field
Attributes
1 Field
1 Line
Alphanumeric
BCNEPA/FPH/FPLIC Billing Manual
November 2012
9 Positions
Left-justified
Page 89
Form Locator 74
Data
Element
Principal Procedure Code and Date
Definition:
The ICD code that identifies the inpatient principal procedure performed at the claim level
during the period covered by this bill and the corresponding date.
Required
Reporting
UB-04: Situational. Required on inpatient claims when a procedure was performed. If not
required (i.e., on outpatient claims) do not send.
004010/004010A1: Situational. Required on Home IV therapy claims or encounters when
surgery was performed during the inpatient stay from which the course of therapy was
initiated. Required on inpatient claims or encounters when a procedure was performed.
005010: Situational. Required on inpatient claims when a procedure was performed. If
not required by the 005010 implementation guide, do not send.
Field
Attributes
1 Field (code)
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
Reporting the decimal between the second and third digits of the ICD is unnecessary
because it is implied.
Enter date as MMDDYY
1 Field (date)
1 Line
6 Positions
Numeric
Right-justified
Form Locator 74a-c
Data
Element
Other Procedure Codes and Dates
Definition:
The ICD codes identifying all significant procedures other than the principal procedure and
the dates (identified by code) on which the procedures were performed. Report those that
are most important for the episode of care and specifically any therapeutic procedures
closely related to the principal diagnosis.
Required
Reporting
UB-04: Situational. Required on inpatient claims when additional procedures must be
reported. If not required (i.e., on outpatient claims) do not send.
004010/004010A1: Situational. Required on Home IV therapy claims or encounters when
surgery was performed during the inpatient stay from which the course of therapy was
initiated. Required on inpatient claims or encounters when additional procedures must be
reported.
005010: Situational. Required on inpatient claims when additional procedures must be
reported. If not required by the 005010 implementation guide (TR3), do no send.
Field
Attributes
5 Fields (code)
1 Line
7 Positions
Alphanumeric
Left-justified
Notes
Reporting the decimal between the second and third digits of the ICD is unnecessary
because it is implied. Enter date as MMDDYY
BCNEPA/FPH/FPLIC Billing Manual
November 2012
5 Fields (date)
1 Line
6 Positions
Numeric
Right-justified
Page 90
Form Locator 75
Data
Element
Reserved for Assignment by the NUBC
Definition:
Required
Reporting
Not Used
Field
Attributes
1 Field
Alphanumeric
4 Lines
Left-justified
4 Positions
Form Locator 76
Data
Element
Attending Provider Name and Identifiers
Definition:
The Attending Provider is the individual who has overall responsibility for the patient’s
medical care and treatment reported in this claim.
Required
Yes
Reporting
Name
UB-04 and 005010: Situational. Required when the claim contains any services other than
non-scheduled transportation claims.
004010/004010A1: Situational. Required on all inpatient claims or encounters. Required
to indicate the Primary Physician responsible on a Home Health Agency Plan of
Treatment.
Identifiers - National Provider Identifier
The NPI Final Rule was implemented on May 23, 2008.
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of the
NPI Final Rule.
UB-04: Situational. Required for providers in the United States or its territories when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories when the provider has
received an NPI.
005010: Situational. Required for providers in the United States or its territories on or
after the mandated HIPAA NPI implementation date when the provider is eligible to receive
an NPI.
OR
Required for providers not in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider has
received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider
has received an NPI and the submitter has the capability to send it.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 91
Form Locator 76
Reporting
Identifiers - Secondary
UB-04: Situational. Required when the NPI in this field is not used and an identification
number other than the NPI is necessary for the receiver to identify the provider.
005010: Situational. Required prior to the mandated HIPAA National Provider Identifier
(NPI) implementation date when an identification number other than the NPI is necessary
for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this field is
not used and an identification number other than the NPI is necessary for the receiver to
identify the provider.
Field
Attributes
5 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
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November 2012
Page 92
Form Locator 77
Data
Element
Operating Physician Name and Identifiers
Definition:
The name and identification number of the individual with the primary responsibility for
performing the surgical procedure(s).
Required
Reporting
Name
UB-04 and 005010: Situational. Required when a surgical procedure code is listed on this
claim.
004010/004010A1: Situational. Required when any surgical procedure code is listed on
this claim.
Identifiers - National Provider Identifier
The NPI Final Rule was implemented on May 23, 2008.
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of the
NPI Final Rule.
UB-04: Situational. Required for providers in the United States or its territories when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories when the provider has
received an NPI.
005010: Situational. Required for providers in the United States or its territories on or
after the mandated HIPAA NPI implementation date when the provider is eligible to receive
an NPI.
OR
Required for providers not in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider has
received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider
has received an NPI and the submitter has the capability to send it.
Identifiers - Secondary
UB-04: Situational. Required when the NPI in this field is not used and an identification
number other than the NPI is necessary for the receiver to identify the provider.
005010: Situational. Required prior to the mandated HIPAA National Provider Identifier
(NPI) implementation date when an identification number other than the NPI is necessary
for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this field is
not used and an identification number other than the NPI is necessary for the receiver to
identify the provider.
BCNEPA/FPH/FPLIC Billing Manual
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Page 93
Form Locator 77
Field
Attributes
5 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
Form Locator 78-79
Data
Element
Other Provider (Individual) Names and Identifiers
Definition:
The name and ID number of the individual corresponding to the Provider Type category
indicated in this section of the claim. See notes below.
Required
Reporting
Name
UB-04 and 005010: Situational. See allowable provider type qualifier codes and usage
notes.
004010/004010A1: Situational. Required when the claim/encounter involves another
provider such as, but not limited to: Referring Provider, Ordering Provider, Assisting
Provider, etc.
Identifiers - National Provider Identifier
The NPI Final Rule was implemented May 23, 2008.
For purposes of this manual, the 004010/004010A1 National Provider Identifier and
Secondary Identifier situational usage is not applicable due to the implementation of the
NPI Final Rule.
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 94
Form Locator 78-79
Reporting
Other Operating Physician and Rendering Provider:
UB-04: Situational. Required for providers in the United States or its territories when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories when the provider has
received an NPI.
005010: Situational. Required for providers in the United States or its territories on or
after the mandated HIPAA NPI implementation date when the provider is eligible to receive
an NPI.
OR
Required for providers not in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider has
received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider
has received an NPI and the submitter has the capability to send it.
Referring Provider:
UB-04: Required for providers when the provider has received an NPI and the NPI is
available to the submitter.
005010: Required for providers on or after the mandated HIPAA National Provider
Identifier (NPI) implementation date when the provider has received an NPI and the NPI is
available to the submitter.
OR
Required for providers prior to the mandated NPI Implementation date when the provider
has received an NPI and the submitter has the capability to send it.
Identifiers - Secondary
UB-04: Situational. Required when the NPI in this field is not used and an identification
number other than the NPI is necessary for the receiver to identify the provider.
005010: Situational. Required prior to the mandated HIPAA National Provider Identifier
(NPI) implementation date when an identification number other than the NPI is necessary
for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when the NPI in this field is
not used and an identification number other than the NPI is necessary for the receiver to
identify the provider.
Field
Attributes
6 Fields
2 Lines
Alphanumeric
Left-justified
Line 1:
2 Positions - Provider Type Qualifier (see below)
11 Positions* - National Provider Identifier
2 Positions - Secondary Identifier Qualifier (see below)
9 Positions - Secondary Identifier
Line 2:
16 Positions - Last Name
12 Positions - First Name
*Note: The NPI is ten characters in length.
BCNEPA/FPH/FPLIC Billing Manual
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Page 95
Form Locator 78-79
Notes
Provider Type Qualifier Codes/Definition/Situational Usage Notes for UB-04 and 005010:
DN - Referring Provider. The provider who sends the patient to another provider for
services. Required on an outpatient claim when the Referring Provider is different than the
Attending Physician. If not required, do not send.
ZZ - Other Operating Physician. An individual performing a secondary surgical procedure
or assisting the Operating Physician. Required when another Operating Physician is
involved. If not required, do not send.
82 - Rendering Provider. The health care professional who delivers or completes a
particular medical service or non-surgical procedure. Report when state or federal
regulatory requirements call for a combined claim, i.e., a claim that includes both facility
and professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital
claim). If not required, do not send.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
Form Locator 80
Data
Element
Remarks Field
Definition:
Area to capture additional information necessary to adjudicate the claim.
Required
Reporting
UB-04: Situational. Required when in the judgment of the provider, the information is
needed to substantiate the medical treatment and is not supported elsewhere within the
claim data set.
004010/004010A1: Situational. The Billing Note segment (Loop ID 2300 | NTE) is used to
convey additional information necessary to adjudicate the claim. Required when: (1) State
regulations mandate information not identified elsewhere within the claim set; or (2) in the
opinion of the provider, the information is needed to substantiate the medical treatment
and is not supported elsewhere within the claim data set.
005010: Situational (Loop ID 2300 | NTE). Required when in the judgment of the provider,
the information is needed to substantiate the medical treatment and is not supported
elsewhere within the claim data set.
OR
Required when in the judgment of the provider, narrative information from the forms “Home
Health Certification and Plan of Treatment” or “Medical Update and Patient Information” is
needed to substantiate home health services.
Field
Attributes
1 Field
4 Lines
Line 1: 19 Positions
Notes
The UB-04 Remarks Field is too small to accommodate addresses. Therefore, do not use
this field for the patient or health plan address; FL 38 is designed for window envelopes
and should be used for this purpose.
BCNEPA/FPH/FPLIC Billing Manual
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Alphanumeric
Line 2-4: 24 Positions
Left-justified
Page 96
Form Locator 81
Data
Element
Code-Code Field
Definition:
To report additional codes related to a Form Locator (overflow) or to report externally
maintained codes approved by the NUBC for inclusion in the institutional data set.
Required
Reporting
Situational. See specifics below. For overflow NUBC codes (A1-A4), see applicable Form
Locator.
Field
Attributes
Middle Column
Right Column
Left Column
1 Field (Code Qualifier)
1 Field (Code)
1 Field (Number or Value)
4 Lines
4 Lines
4 Lines
2 Positions
10 Positions
12 Positions
Alphanumeric
Alphanumeric
Alphanumeric
Left-justified
Left-justified
Right-justified
(fully coded)
Notes
Code List Qualifiers:
01-A0
Reserved for National Assignment
A1
National Uniform Billing Committee Condition Codes (FL 18-28)
Right
Example:
A 1 4
A2
National Uniform Billing Committee Occurrence Codes (FL 31-34)
Example:
A 2 0
A3
4
1
0
2
2
8
0
6
National Uniform Billing Committee Occurrence Span Codes (FL 35-36)
All positions fully coded in the right column.
Example:
A
A4
3
M
4
0
3
0
1
0
6
0
3
0
9
0
6
National Uniform Billing Committee Value Codes (FL 39-41)
For Value Codes, there is an implied dollar/cents delimiter in the right column of
FL 81 separating the last two positions as illustrated below.
$
$
$
$
$
$
$
$
$
$
c
c
See FL 39-41 for special rules for reporting values. Whole numbers or nondollar amounts are right justified to the left of the implied dollars/cents delimiter.
Do not zero fill the positions to the left of the implied delimiter. However, values
are reported as cents, thus reference to the instructions for specific does is
necessary.
A
BCNEPA/FPH/FPLIC Billing Manual
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4
5
4
3
3
3
3
Page 97
Form Locator 81
Notes
A5-AB
Reserved for Assignment by the NUBC.
AC
Attachment Control Number (Effective 1/1/09)
Code Source: ASC X12 Data Element 755 - Report Type Code
Codes valid for use on UB-04:
04
Drugs Administered (medications)
AM
Ambulance Certification
DS
Discharge Summary
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
OB
Operative Notes
OZ
Support Data for Claim (e.g., itemized bill)
PN
Physical Therapy Notes
RR
Radiology Reports
UL
Other Type of Report
Example:
A
C
R
R
E
L
A
C
1
2
3
4
5
6
AD-B0
Reserved for Assignment by the NUBC.
B1
Standards for the Classification of Federal Data on Race and Ethnicity Code
Source: ASC X12 External Code Source 859 (Centers for Disease Control and
Prevention (CDC))
Reporting*
FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or
federal law or regulations.
Example:
B 1 R
B2
5
E
2
Reserved for Martial Status
Code Source: ASC X12 Data Element 1067
Reporting* (Effective Date to be Determined)
FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or
federal law or regulations.
Example:
B 2 M
* Use of Code List Qualifiers B1 and B2 is intended to promote standardized
public health reporting of these data elements.
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November 2012
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Form Locator 81
Notes
B3
Health Care Provider Taxonomy Code
Code Source: ASC X12 External Code Source 682 (National Uniform Claim
Committee)
Reporting
UB-04: Situational. Used for Billing Provider Only (FL01). Required when the
payer’s adjudication is known to be impacted by the provider taxonomy code.
004010/004010A1 (Loop ID 2000A | PRV03): Situational. Required when
adjudication is known to be impacted by the provider taxonomy code, and the
Service Facility Provider is the same entity as the Billing and/or Pay-to Provider.
005010 (Loop ID 2000A | PRV03): Situational. Required when the payer’s
adjudication is known to be impacted by the provider taxonomy code.
All positions fully coded in the middle column; the right-hand column is left blank.
Example:
B 3 2 8 2 N 0 0 0 0 0 X
B4-B6
Source of Payment Typology
Code Source: Public Health Data Standards Consortium
(http://www.phdsc.org/)
(ASC X12 External Code Source 944)
B4 = Payer A (Primary)
B5 = Payer B (Secondary)
B6 = Payer C (Tertiary)
Reporting* (Effective Date July 1, 2009)
FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or
federal law or regulations.
Example:
B 4 1
2
1
B 5 2
*Use of Code List Qualifiers B4-B6 is intended to promote standardized Public
Health Reporting of these data elements.
B7
Preferred Language Spoken
Code Source: ISO 639-2 Language Codes
Definition: The language the patient prefers for discussing health care
information with those in the health care community.
Reporting (Effective Date January 1, 2011)
FOR PUBLIC HEALTH DATA REPORTING ONLY when required by state or
federal law or regulations.
Example*:
B 7 SPA
*ISO 639-2 recommends use of the language codes in lower case, but they
should be considered case-insensitive and are unique codes regardless of case.
This examples uses upper case letters which coincides with the basic character
set used in the X12 standard (Appendix B.1.1.2.2 of the implementation guides).
B8-ZZ
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Reserved for Assignment by the NUBC.
Page 99
BCNEPA/FPH/FPLIC Billing Manual
November 2012
Page 100