Completion of UB 04 claim – Additional information

Additional information needed for a complete UB-04 form


• Date and hour of admission
• Discharge date and hour of discharge
• Member status-at-discharge code
• Type of bill code (three digits)
• Type of admission (e.g. emergency, urgent, elective, newborn)
• Current four-digit revenue code(s)
• Current principal diagnosis code (highest level of specificity) with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines
• Current other diagnosis codes, if applicable (highest level of specificity), with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines
• Current ICD -9-CM (or its successor) procedure codes for inpatient procedures
• Attending physician ID
• Bill all outpatient procedures with the appropriate revenue and CPT or HCPCS codes• Provide specific CPT or HCPCS codes and appropriate revenue code(s) (e.g., laboratory, radiology, diagnostic or therapeutic) for outpatient services
• Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449) submitted on a UB-04
• Submit claims according to any special billing instructions that may be indicated in your agreement with us
• On an inpatient hospital bill type of 11x, the admission date and time should always reflect the actual time the
member was admitted to inpatient status
• If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, a nominal monetary amount ($.01 or $1.00) must be reported on all other surgical revenue code lines to assure appropriate adjudication