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