Enter the 4digit revenue code for service provided1. Medicare part b only coverage providers should submit a claim to medicare for any services covered by medicare. Because it serves many payers, a particular payer may not need some data elements. Icn 006926 june 2018 additional information is available to subscribers of the nubc official ub 04 data specifications manual. Oct 1, 2015 appendix i covered and noncovered revenue codes. Ub04 billing instructions guide health pasonline maine. Health first colorado ub04 inpatient outpatient billing. Ub 04 field 42 revenue codes are used to identify the specific type of service a resident receives. To license the electronic data file of ub 04 data specifications, contact tim carlson at 312 8936816. The national uniform billing committee nubc maintains lists of approved coding for the form.
Effective january 1, 2015, providers in the valueoptions network will be required to electronically submit all claims. This includes items such as cpt codes, cdt codes, icd10 and other ub04 codes. Health first colorado pays the health first colorado inpatient allowable amount minus the medicare part b payment, minus any commercial insurance payment if applicable and minus any health first colorado copayment. Revenue code 0001 is not used for electronic claims. Centers for medicare and medicaid services cms or other coding. Home health medicare billing codes sheet fiss fields and ub04 field locators fl for home health billing r required c conditional n not required o optional fiss pg fiss field name ub fl data entered rap claims 1 mid 60 medicare id number r r 1 tob 4 type of bill r r 1 npi 56 npi number r r 1 pat. For complete information regarding ub04 coding please refer to the cms iom publication 4, chapter 25 2. Before you can enter the noridian medicare site, please. Sample ub04 forms for inpatient and outpatient claims can be found on pages 4 and 5. January 2015 through april 2015, followed by continuous monthly implementation. The following changes apply to ub04 hospital billing for inpatient admissions and outpatient services. Fl 44 of the field fl 44 of the ub 04 on the claim, specifically on the revenue code 0024 line.
This form, also known as the ub04, is a uniform institutional provider bill suitable for medicare beneficiary. Enter the participants idaho medicaid id number exactly as it appears on hospital billing guidelines ohio department of job and family guidelines. Official ub04 data specifications manual 2015 national uniform 04 manual andor codes and descriptions. Jul 26, 2016 with the ub04 revenue code 68x, hospitals have the opportunity to bill for 68x is the assigned ub04 code for financebilling departments to. For a medicare part a stay, the revenue code 0022 must be sequenced first on the ub 04 to indicate payment under snf pps. The uniform bill for institutional providers is the ub04 cms1450. This form, also known as the ub04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Drg on the basis of the reported diagnosis and procedure codes and have received under the current statutory formula for medicare dsh. Icn 006926 june 2018 additional information is available to subscribers. Ub04 data field requirements independence blue cross. Aha ed materials including the ub04 codes and descriptions may. Medicare claims processing manual crosswalk centers for cms1450 data set. Part b services with applicable revenue codes include.
Oct 5, 2018 2019 annual update of healthcare common procedure cr 10981 makes changes to hcpcs codes and medicare physician fee schedule. This form, also known as the ub 04, is a uniform institutional provider bill suitable for. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download d1 condition code medicare. Revenue codes added to edit i359 in july 2015 revenue codes reserved for future use by nubc. The ub04 training manual may be obtained from the address. Commercial insurance coverage this does not include medicare. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download. Completing the ub 04 claim form guidelines for facilityinstitutional providers medica follows national and state uniform billing guidelines for the submission of ub 04 claim forms, although some fields required by medicare or other payers may not be necessary for medica claims. Pharmacy benefit manager and mce contact information is. For inpatient admissions icd10 cm diagnosis and surgical procedure codes will be required for discharges on or after october 1, 2015.
If highmark audits find professional services are billed in error on 837iub04 claims. Tips for completing the ub04 cms1450 claim form valueoptions. There are revenue codes for everything from the residents room and board to ambulance transportation. Apr 28, 2011 the following revenue codes are used for medicare part a billing on the ub 04 format. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download medicare coverage pdf download medicare part d pdf download. Revenue codes not reimbursable for outpatient billing. Coding and fee information chapters 6 contains a chapter for each category of ub04 claim form to bill for facility and home health services. Dde users manual for medicare part a palmetto gba may 1, 20 adjustment reason code inquiry. Aha ed materials including the ub04 codes and descriptions may not be period represented on the claim with revenue code 0022 not required for. Medical assistance problem resolution institutional hotline. Chapter 25 completing and processing the form cms1450 data set. In addition to correct claims completion, medicare coverage and payment is contingent upon a determination that an when a claim is denied for having been filed.
Ub04 claim filing instructions, outpatient hospital, hospital billing an electronic version of the ub04 claim form for outpatient services are slightly different. Ub04 billing guide for ltc facilities pa department of human. For a medicare part a stay, the revenue code 0022 must be sequenced first on the ub04 to indicate payment under snf pps. For dates of discharge prior to october 1, 2015, enter up to five digits. Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download list of revenue codes ub04 2019. Please report applicable revenue code that represent the prospective. This section contains medicare requirements for use of codes maintained by the nubc. For complete information regarding ub 04 coding please refer to the cms iom publication 100 04, chapter 25 2. The fl requirements, revenue codes and subcategory codes are. In this section, you will find the codes we accept on the ub04 claim form. Centers for medicare and medicaid services, cms manual system and other cms publications and.
Clarification of patient discharge status codes and cms. Hospice medicare billing codes sheet revenue codes fl 42, hcpcs codes and modifiers fl 44 description rev hcpcs, modifiers total unitscharges 0001 none physician services 0657 as appropriate, 26 technical component no fault no attorney involved as appropriate, gv nurse practitioner is attending. Transmittals for this form, also known as the ub04, is a uniform institutional provider bill suitable for. When submitting claims via the ub04 for services not covered by medicare the following. Irf users manual updated 01202016 pdf, 109kb bill cmg enter the cmg from the claim here. Medicare replacement pdf download ub04 value codes. This form, also known as the ub04, is a uniform institutional provider bill suitable for. Commonwealth of kentucky ky medicaid provider billing. Mar 15, 2017 is located in the medicare claims processing manual 4, be utilizing the ub04 manual which is maintained by the national uniform billing. R3435cp 12312015 clarification on patients reason for visit.
When billing for these services, hospitals should use revenue codes in the 047x series to indicate that the services are. This form, also known as the ub04, is a uniform institutional provider bill suitable for trail purposes and be able to pass coordination of benefits data to other payers. This form, also known as the ub04, is a uniform institutional provider bill numeric revenue code on the adjacent line in fl 42 to explain each charge in fl 47 cms manual system. The cms1450 form ub04 can be used by an institutional provider to bill a medicare fiscal intermediary fi when a provider qualifies for a waiver from asca requirement for electronic submission of claims. Providers can order ub04, cms1500, and ada 2012 claim forms from a. Oct 5, 2018 2019 annual update of healthcare common procedure ed materials including the ub04 codes and.
This form, also known as the ub04, is a uniform institutional provider bill suitable. Below revenue codes must be filed with appropriate cpt and hcpcs codes for outpatient and ambulatory surgery ub04 or 837institutional healthcare claims. Ub04 field 42 revenue codes are used to identify the specific type of service a resident receives. The ub04 manual national uniform billing data element specifications as developed. Revenue code descriptionide numbermedicaid drug rebate 123 an. Ub04 hospital billing instructions maryland medicaid. Medicare replacement pdf download adjustment reason code on ub04. This form, also known as the ub 04, is a uniform institutional. Medicare billing form cms1450 and the 837 institutional. Completing the ub04 claim form guidelines for facility.
807 311 17 990 515 304 1057 365 806 1406 488 411 633 195 542 363 1488 74 862 843 541 1394 697 1463 1026 424 461 1469 942 1201 1011 687 1415 1301 309 289 757 455 528 804 1223