Mastering the UB-04 Medical Billing Form

FL 6. Statement Covers Period (From – Through)
a. Cannot exceed eight positions in either “From” or “Through” portion allowing for separations (nonnumeric characters) in the third and sixth positions.
b. The “From” date must be a valid date that is not later than the “Through” date.
c. The “Through” date must be a valid date that is not later than the current date.
d. With the exception of Home Health PPS claims, the statement covers period may not span 2 accounting years.

FL 09. Patient’s Address
a. The address of the patient must include:
City
State (P.O. Code)
ZIP
b. Valid ZIP Code must be present if the type of bill is 11X, 13X, 18X, or 83X or 85X.
c. Cannot exceed 62 positions.

FL 10. Birthdate
a. Must be valid if present.
b. Cannot exceed 10 positions allowing for separations (nonnumeric characters) in the third and sixth positions.

FL 11. Sex
a. One alpha position.
b. Valid characters are “M” or “F.”
c. Must be present.

FL 12. Admission Date
a. Must be valid if present.
b. Cannot exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions.
c. Present only if the type of bill is 11X, 12X, 18X, 21X, 22X, 32X, 33X, 41X, 81X or 82X.

FL 14. Priority (Type) of Admission or Visit
a. One numeric position.
b. Required only if the type of bill is 11X, 12X, 18X, 21X, 22X, or 41X.

FL 15. Point of Origin for Admission or Visit.
a. One numeric position
b. Must be present

FL 17. Patient Discharge Status.
a. Two numeric positions
b. Present on all Part A inpatient, SNF, hospice, home health agency, and outpatient hospital services. Types of bill: 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, or 85X.