Module 1, Topic 4
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Day 4: UB04 Form Examples

Petria September 3, 2020
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Filling in a UB04 for a RAP

 

Type of Bill (TOB) (FL 4)

Priority (Type) of Admission or Visit Codes (FL 14)

  • 1  Emergency
  • 2  Urgent
  • 3  Elective
  • 4  Newborn
  • 5  Trauma
  • 9  Information Not Available

 

 

Point of Origin (formerly Source of Admission Codes) (FL 15)

  • 1  Non-Health Care Facility Point of Origin
  • 2  Clinic or Physician’s Office
  • 4  Transfer from Hospital (Different Facility)
  • 5  Transfer from Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
  • 6  Transfer from Another Health Care Facility
  • 8  Court/Law enforcement
  • 9  Information not available

 

Patient Status Codes (FL 17)

 

Condition Codes (CC) (FL 18-28)

  • 07 Treatment of nonterminal condition for hospice patient
  • 20  Beneficiary requested billing (demand denial)
  • 21  Billing for denial notice (no-pay bill)
  • 47 Transfer from another HHA
  • 54 No skilled HH visits in billing period.
  • C3  Expedited review – partial approval of Medicare-covered services
  • C4  Expedited review – services denied
  • C7 Expedited review – extended authorization of Medicare-covered services

 

Value Code (FL 39-41)

 

Common Revenue Codes (FL 42) and HCPCS/Rates/HIPPS Rate Codes (FL 44)

Occurrence Codes (OC) (FL 31-34)