National Hospital Care Survey (NHCS) Data Elements and Definitions
UB 04: Form
Locator Name (if
different from
DHCS variable
name)
DHCS Variable
Definition (UB04)
Billing Provider Name
The name and service location of the provider
submitting the bill
The service location of the provider submitting
the bill. The Billing Provider Address must be a
street address
The service location of the provider submitting
the bill: city , state and ZIP (full nine-digit)
The service location of the provider submitting
the bill: For country codes, use the alpha-2
country codes from part 1 of ISO 3166
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
The number assigned to the patient’s
medical/health record by the provider
A code indicating the specific type of bill (e.g.,
hospital, inpatient, outpatient, replacements,
voids, etc.). The first digit is a leading zero*. The
fourth digit defines the frequency of the bill for
the institutional and electronic professional
claim. (*Do not include leading zero on
electronic claims)
011X- Hospital Inpatient (including Medicare
Part A), 012x Hospital Inpatient (Medicare Part B
only); 013x – Hospital Outpatient
1-Admit to discharge
Billing Provider Street
Address
Billing Provider City,
State, Zip
Billing Provider Phone,
Fax & Country
Patient control number
(NV)
Medical record number
(NV)
Type of bill (NV)
TOB Frequency
Statement covers
period (FromThrough)
Patient Address
Date of Discharge
The beginning and ending service dates on the
period included on this bill.
Patient Name
Last name, First name and middle of the patient
and the patient identifier as assigned by the
payer
The mailing address of the patient. Enter the
complete mailing address including street
number and name of post office box number or
RFD; city name. state name; ZIP code
Patient Street Address
Patient City
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Patient State
Patient ZIP
Patient Country
Patient Birth Date
The date of birth of the patient
Patient sex
The sex of the patient as recorded at admission,
outpatient service, or start of care.
The start date for this episode of care. For
inpatient services, this is the date of admission.
For other 9home health0 services, it is the date
the episode of care began.
A code indicating the priority of this
admission/visit
Admission/ Start of
Care Date
Priority (Type) of
Admission or
Visit
Type of Admission
1= Emergency
2= Urgent
3= Elective
4= Newborn
5= Trauma
6-8 Reserved
9= information not
available
Point of Origin
for Admission /
Admission
Source Code
1= Non-health
care facility point
of origin
2= Clinic
3= Reserved for
assignment
4= Transfer from
12/12/2011
Point of Origin
The patient requires immediate medical
intervention as a result of severe, life
threatening or potentially disabling conditions.
The patient requires immediate attention for the
care and treatment of a physical or mental
disorder
The patient’s condition permits adequate time
to schedule the services.
Use of this code necessitates the use of special
point of Origin Codes
Visit to a trauma center/hospital licensed as
designated by the state or local government
authority to do so, or as verified by the
American College of Surgeons and involving a
trauma activation.
Reserved for assignment by NUBC
Information not available
A code indicating the point of patient origin for
this admission or visit.
The patient was admitted to this facility
1 = Physician referral
2 = Clinical referral
The patient was admitted to this facility
3 = HMO referral
4 = Transfer from a
The patient was admitted to this facility as a
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hospital
5= Transfer from
SNF
6= Transfer from
another Health
Care facility
7= Reserved for
assignment by
NUBC
8= Court/law
enforcement
9= Info not
available
A= Reserved
hospital
5 = Transfer from SNF
6 = Transfer from other
health facility
7 = Emergency room
8 = Court/Law
enforcement
9 = Other
0 = Not available
Patient Discharge
Status
1 = Routine to Home
2 = Left Against
Medical Advice
3 = Transf. to ShortTerm Facility
4 = Transf. to LongTerm Facility
5 = Alive, Not Stated
6 = Dead
7 = Status Not Stated
Revenue codes (NV)
Service units (NV)
Total charges
Noncoverd charges
(NV)
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hospital transfer from an acute care facility
where he or she was an inpatient or outpatient.
The patient was admitted to this facility as a
transfer from a SNF, ICF, or ALF where he or she
was a resident.
The patient was admitted to this facility as a
transfer from another type of healthcare facility
not defined elsewhere in this code list
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’s Point of origin is not known
A code indicating the disposition or discharge
status of the patient at the end service for the
period covered on this bill, as reported n FL6,
Statement Covers Period
Discharged to Home or Self Care
Left Against Medical Advice or Discontinued
Care
Codes that identify specific accommodation,
ancillary service or unique billing calculations or
arrangements.
A quantitative measure of service rendered by
revenue category to or for the patient to include
items such as number of accommodations days,
miles, pints of blood, renal dialysis treatments
etc.
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 include both covered and
non-covered charges.
To reflect the non-covered charges for the
destination payer as it pertains to the related
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Payer Name
Primary
Payer Name
Secondary
Payer Name
Tertiary
Diagnosis and
procedure Code
Qualifier (ICD
Version
Indicator)
Expected Payer #1
Expected Payer #2
Expected Payer #3
PT Relationship 1
Insured, primary payer
PT Relationship 2
Insured, secondary
payer
Code indicating the relationship of the patient to
the identified insured
PT Relationship 3
Insured, tertiary payer
Code indicating the relationship of the patient to
the identified insured
Flag for version of ICD
The qualifier that denotes the version of
International Classification of Diseases (ICD):
9-Ninth Revision
0-Tenth Revision
Principal Diagnosis
Code and Present on
Admission Indicator
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.
POA indicator is assigned to principal and
secondary diagnoses.
Present on Admission
indicator
Other Diagnosis Codes
and Present on
Admission Indicator
Admitting Diagnosis
Code
Prospective Payment
System (PPS) Code
External cause of injury
(ECI) code and present
on Admission indicator
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revenue code.
Name of health plan that the provider might
expect some payment for the bill
Name of health plan that the provider might
expect some payment for the bill
Name of health plan that the provider might
expect some payment for the bill
Code indicating the relationship of the patient to
the identified insured
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 the length of stay.
Exclude diagnoses that relate to an earlier
episode which have no bearing on the current
hospital stay.
The ICD diagnosis code describing the patient’s
diagnosis at the time of admission
The PPS code assigned to the claim to identify
the DRG based on the grouper software called
for under contract with the primary payer
The ICD diagnosis codes pertaining to external
cause of injuries, poisoning, or adverse effect.
POA indicator is assigned to the external cause
of injury codes.
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ECI POA flag for ECI #1
ECI POA flag for ECI #2
ECI POA flag for ECI #3
Principal
procedure and
date
(PROCEDURE)
Procedure #1
Principal
procedure and
date (DATE)
Date of Procedure #01
Other
procedures and
dates
(PROCEDURE)
Procedure #02
Other
procedures and
dates (DATE)
Date of Procedure #02
Attending
Provider name
and
Operating
Physician Name
and Identifiers
NPI for Attending
Physician
NPI for Operating
Physician
Priorities for recording an ECI code: Principal
diagnosis of an injury or poisoning
Priorities for recording an ECI code: Other
diagnosis of an injury, poisoning, or adverse
effect directly related to the principal diagnosis
Priorities for recording an ECI code: Other
diagnosis with an external cause
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.
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 procedure closely
related to the principal diagnosis
The Attending provide is the individual who has
overall responsibility for the patient’s medical
care and treatment reported in this claim
The name and identification number of the
individual with the primary responsibility for
performing the surgical procedure(s)
Patient Ethnicity
1= Hispanic Origin
2= Not Hispanic
3= Not Stated
Patient Race
1 = White
2 = Black or African
American
3 = American
Indian/Alaskan Native
4 = Asian
5 = Native
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Hawaiian/Oth Pacific
Islder
6 = Other race
7 = Race not stated
8 = Multiple race
indicated
Patient Marital Status
Health Care
Provider
Taxonomy Code
(Claim Filing
Code)
12/12/2011
1 = Married
2 = Single
3 = Widowed
4 = Divorced
5 = Separated
6 = Not Stated
7 = Unknown
Expected Source of
Payment
Source of Payment
Typology (PHDSC)Payer A
A code identifying payer types In the most
granular way
Source of Payment
Typology (PHDSC)Payer B
A code identifying payer types In the most
granular way
Source of Payment
Typology (PHDSC)Payer C
A code identifying payer types In the most
granular way
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