What is Box 14 on UB 04 claim form?
Asked by: Prof. Mitchel D'Amore DDS | Last update: August 31, 2023Score: 4.2/5 (53 votes)
Box 13 – Admission Hour: (Required if applicable) Enter the physical time of admission if applicable – required for Hospital claims. Box 14 – Admission Type (priority) of Visit: (Required) This field requires a one digit code that indicates the priority of the admission.
What are UB-04 codes?
- Accident/medical coverage.
- No-fault insurance, including auto.
- Accident, tort liability.
- Accident, employment-related.
- Accident/no medical or liability cov.
- Crime victim.
What goes in box fl 04 on the ub-04 claim form?
FL4: Type of Bill - The first digit of the three-digit number identifies the type of facility, the second digit classifies the type of care being billed, and the third digit indicates the sequence of the bill for a specific episode of care.
What goes in box 64 on UB04?
64 Document Control Number Control number assigned to the original bill. 65 Employer Name Name of employer providing health coverage.
What goes in box 18 on UB04?
16. Discharge Hour Enter the hour (using a two-digit code below) that the patient entered the facility. 18-28. Condition Codes Enter two digit alpha numeric codes up to eleven occurrences to identify conditions that may affect processing of this claim.
How To Fill A UB-04 Claim Tutorial
What goes in box 19 on a ub04?
Box 19 is used to identify additional information about the patient's condition or the claim.
What is box 17 on UB-04?
17. * Patient Status Enter the 2-digit patient status code that best describes the patient's discharge status. 05-Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution.
What goes in box 80 on UB04?
An Emergency Certification Statement must be attached to the claim or entered in the Remarks field (Box 80).
What is box 53 on UB04?
UB04 Box 53 - Noting an Assignment of Benefits on an institutional claim.
What is value code 61 on UB04?
61 Place of Residence where Service is Furnished (Routine Home Care and Continuous Home Care) MSA or Core Based Statistical Area (CBSA) number (or rural State code) of the place of residence where hospice service is delivered.
What is a UB-04 facility type?
The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).
What is the UB-04 claim form called?
UB-04 (also known as the CMS-1450):
The UB-04 is the claim form for institutional facilities, and includes the following: Hospitals. Rehab facilities, e.g. physical therapy, occupational therapy and speech therapy.
What goes in box 17 on HCFA?
What is it? Box 17 identifies the name of the referring provider on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported.
Is a UB 04 an itemized bill?
The UB-04 is a standardized claim form your hospital uses to bill your insurance provider for the procedures you received. It's generally a single page containing 81 fields, including a line-item breakdown of your procedures, along with CPT, HCPCS, and revenue codes, descriptions, unit quantity and charges.
What does box 15 mean on ub04?
B. Policy: Field Locator 15 of the UB-04 and its electronic equivalence is a required field on all institutional inpatient claims and outpatient registrations for diagnostic testing services. This code indicates the point of patient origin for the admission or visit of the claim being billed. II.
What is ub04 value code 49?
49 - Hematocrit Reading - Code indicates the hematocrit reading taken before the last administration of EPO during this billing cycle. This is usually reported in two positions (a percentage) to the left of the dollar/cents delimiter.
What is value code 54 on UB 04?
54 = Newborn Birth Weight in Grams. The amount must be entered as a positive whole number. Must be a valid number greater than "99" and less than "9001". Birth Weights of "99" grams or less should be reported as "100" grams.
What is code 70 on ub04?
New Patient Status Discharge Code 70 to Define Discharges or Transfers to Other Types of Health Care Institutions not Defined Elsewhere in the UB-04 (CMS-1450) Manual Code List.
What is the value code 12?
1 VALUE CODES FL 39-41 Enter the value codes “12” to indicate Working Aged insurance, or “43” to indicate Disability insurance and the amount you were paid by the primary insurance.
What is ub04 status codes field 17?
17 Patient Status Required. This code indicates the patient's status as of the "Through" date of the billing period (Field 6). 18-28 Condition Codes Leave blank. 29 Accident State Leave blank.
What is occurrence code 11 on UB 04?
Occurrence Code: 11
Date the patient first became aware of the symptoms or illness being treated. Date the patient first became aware of the symptoms or illness being treated.
What is occurrence code 42 on UB 04?
The hospice also reports occurrence code 42 on their claim and the date of their determination. This discharge claim will terminate the beneficiary's current hospice benefit period as of the occurrence code 42 date. This coding may also be used if the beneficiary has chosen to revoke their hospice election.
What is value code 80 on UB 04?
The number of covered days (value code 80) must match the number of units and charges reported for the covered room and board days. Claims to be paid by Per Diem reimbursement should have the appropriate covered days reported to match the authorization. C. Make sure that the value code are in numerical order.
What is box 19 on a claim?
Box 19. Box 19 is commonly used on paper claims for data not otherwise accommodated by the CMS-1500 claim form. Data entered in this field will print but will NOT export electronically. Please contact your payer to determine where the data is expected.
What is box 11 on HCFA?
Box 11 is the insured's policy or group number.