CMS 1450 – Field 4 – 3 digit number how to form ?
UB 04 FL 4. Type of Bill
a. Must not be spaces.
b. Must be a valid code for billing. Valid codes are:
First Digit – Type of Facility:
1 – Hospital
NOTE: Hospital-based multi-unit complexes may also have use for the following first digits when billing non-hospital services:
2 – Skilled Nursing
3 – Home Health
4 – Religious Non-Medical (Hospital)
7 – Clinic or Renal Dialysis Facility (requires special information in second digit below)
8 – Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)
Second Digit – Classification (if first digit is 1-5):
1 – Inpatient (Part A)
2 – Hospital-Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)
3 – Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)
4 – Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “nonpatients”)
8 – Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)
Second Digit – Classification (first digit is 7):
1 – Rural Health Clinic (RHC)
2 – Hospital-Based or Independent Renal Dialysis Facility
4 – Other Rehabilitation Facility (ORF)
5 – Comprehensive Outpatient Rehabilitation Facility (CORF)
6 – Community Mental Health Center (CMHC)
7 – Free-Standing Provider-Based Federally Qualified Health Center (FQHC)
Second Digit – Classification (first digit is 8):
1 – Hospice (Nonhospital-based)
2 – Hospice (Hospital-based)
5 – Critical Access Hospital (CAH)
Third Digit – Frequency:
A – Admission/Election Notice
B – Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Termination/Revocation Notice
C – Hospice Change of Provider
D – Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Void/Cancel
E – Hospice Change of Ownership
F – Beneficiary Initiated Adjustment Claim (For A/B MAC (A) use only)
G – CWF Initiated Adjustment Claim (For A/B MAC (A) use only)
H – CMS initiated Adjustment Claim (For A/B MAC (A) use only)
I – A/B MAC (A) Adjustment Claim (Other than QIO or Provider) (For A/B MAC (A) use only)
J – Initiated Adjustment Claim-Other (For A/B MAC (A) use only)
K – OIG Initiated Adjustment Claim (For A/B MAC (A) use only)
M – MSP Initiated Adjustment Claim (For A/B MAC (A) use only)
P – QIO Adjustment Claim (For A/B MAC (A) use only)
Q – Claim Submitted for Reconsideration Outside of Timely Limits (For A/B MAC (A) use only)
0 – Nonpayment/zero claims
1 – Admit Through Discharge Claim
2 – Interim – First Claim
3 – Interim – Continuing Claims (Not valid for PPS bills. Exception: SNF PPS bills)
4 – Interim – Last Claim (Not valid for PPS bills. Exception: SNF PPS bills)
5 – Late charge
7 – Correction
8 – Void/Cancel
9 – Final Claim for a Home Health PPS Episode
UB 04 FL 4. Type of Bill
a. Must not be spaces.
b. Must be a valid code for billing. Valid codes are:
First Digit – Type of Facility:
1 – Hospital
NOTE: Hospital-based multi-unit complexes may also have use for the following first digits when billing non-hospital services:
2 – Skilled Nursing
3 – Home Health
4 – Religious Non-Medical (Hospital)
7 – Clinic or Renal Dialysis Facility (requires special information in second digit below)
8 – Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)
Second Digit – Classification (if first digit is 1-5):
1 – Inpatient (Part A)
2 – Hospital-Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)
3 – Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)
4 – Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “nonpatients”)
8 – Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)
Second Digit – Classification (first digit is 7):
1 – Rural Health Clinic (RHC)
2 – Hospital-Based or Independent Renal Dialysis Facility
4 – Other Rehabilitation Facility (ORF)
5 – Comprehensive Outpatient Rehabilitation Facility (CORF)
6 – Community Mental Health Center (CMHC)
7 – Free-Standing Provider-Based Federally Qualified Health Center (FQHC)
Second Digit – Classification (first digit is 8):
1 – Hospice (Nonhospital-based)
2 – Hospice (Hospital-based)
5 – Critical Access Hospital (CAH)
Third Digit – Frequency:
A – Admission/Election Notice
B – Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Termination/Revocation Notice
C – Hospice Change of Provider
D – Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution-Void/Cancel
E – Hospice Change of Ownership
F – Beneficiary Initiated Adjustment Claim (For A/B MAC (A) use only)
G – CWF Initiated Adjustment Claim (For A/B MAC (A) use only)
H – CMS initiated Adjustment Claim (For A/B MAC (A) use only)
I – A/B MAC (A) Adjustment Claim (Other than QIO or Provider) (For A/B MAC (A) use only)
J – Initiated Adjustment Claim-Other (For A/B MAC (A) use only)
K – OIG Initiated Adjustment Claim (For A/B MAC (A) use only)
M – MSP Initiated Adjustment Claim (For A/B MAC (A) use only)
P – QIO Adjustment Claim (For A/B MAC (A) use only)
Q – Claim Submitted for Reconsideration Outside of Timely Limits (For A/B MAC (A) use only)
0 – Nonpayment/zero claims
1 – Admit Through Discharge Claim
2 – Interim – First Claim
3 – Interim – Continuing Claims (Not valid for PPS bills. Exception: SNF PPS bills)
4 – Interim – Last Claim (Not valid for PPS bills. Exception: SNF PPS bills)
5 – Late charge
7 – Correction
8 – Void/Cancel
9 – Final Claim for a Home Health PPS Episode