UB-04 CMS-1450 Paper Claim Form Revisions - Welcome to TMHP
Changes to the UB-04 CMS-1450 Claim Form
Information posted March 19, 2007
The National Uniform Billing Committee (NUBC) has approved the replacement of the current uniform billing UB-92 CMS-1450 claim form with the new UB-04 CMS-1450 claim form. TMHP will accept the new UB-04 CMS-1450 claim form beginning May 21, 2007. After this effective date, all providers of the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs who currently submit claims on the
UB-92 CMS-1450 claim form will be required to use the new UB-04 CMS-1450 claim form for all claim submissions and appeals, regardless of the version used for prior submissions. All claims submitted on the new UB-04 CMS-1450 claim form that are received by TMHP before May 21, 2007, will be returned to providers.
Information about how to fill in the revised fields of the new paper UB-04 CMS-1450 claim form is on the following pages.
UB-04 CMS-1450 Paper Claim Form Revisions The following table includes the required and optional fields that were revised for the new UB-04 CMS-1450 claim form. All other required fields on the UB-04 CMS-1450 claim form are
unchanged, as outlined in the 2007 Texas Medicaid Provider Procedures Manual (TMPPM), Section 5.6.4, “HCFA-1450 (UB-92) Instruction Table,” on page 5-34, and in the 2007 CSHCN Services Program Provider Manual Part I , Section B.3, “Instructions for Completing the HCFA-1450 (UB-92) Claim Form,“ on page B-7. Field Description Guidelines
2 Unlabeled Optional
No guidelines for this field.
3a Patient control number
Optional
Any alphanumeric character (limit 16) entered in this field will be referenced on the Remittance and Status (R&S) report.
3b Medical record number Enter the client's medical record number (limited to ten digits)
assigned by the hospital.
4 Type of bill
(TOB)
Most
commonly
used:
0111 Inpatient
hospital
0131
Outpatient
hospital
0141
Nonpatient
(laboratory or
radiology
charges)
0331 Home
health agency*
0711 Rural
health clinic
(RHC)
0721 Renal
dialysis center
(RDC)
0731 Federally
qualified health
center (FQHC)
* Use TOB 331
only. All other
TOBs are
invalid and will
deny.
This field has been expanded from 3 to 4 characters with a 0 always as the first digit. Claims will be processed based on the last three digits. Enter the three-digit TOB code. First digit – type of facility 1 Hospital 2 Skilled nursing 3 Home health agency 7 Clinic (RHC, FQHC, RDC) 8 Special facility Second digit – bill classification (except clinics and special facilities) 1 Inpatient (including Medicare Part A) 2 Inpatient (Medicare Part B only) 3 Outpatient 4 Other (for hospital-referenced diagnostic services, for example, laboratories and X-rays) 7 Intermediate care Second digit– bill classification (clinics only) 1 Rural health 2 Hospital-based or independent RDC 3 Free standing 5 Comprehensive outpatient rehabilitation facility (CORF) Third digit – frequency 0 Nonpayment/zero claim 1 Admit through discharge 2 Interim–first claim 3 Interim–continuing claim 4 Interim–last claim
5 Late charges–only claim
6 Adjustment of prior claim
7 Replacement of prior claim
7 Unlabeled Optional
No guidelines for this field.
8a Patient identifier
Optional
Enter the patient identification number if different than the subscriber/insured’s identification number.
8b Patient name Enter the client's last name, first name, and middle initial as printed
on the Medicaid Identification Form.
9a-9b Patient address Starting in 9a, enter the client's complete address as described
(street, city, state, and ZIP code).
10
Birth date Enter the month, day, and year (MM/DD/YYYY) the client was born. 11
Sex Indicate the client's sex by entering an "M" or "F." 12 Admission date Enter the date (MM/DD/YYYY) of admission for inpatient claims;
date of service (DOS) for outpatient claims; start of care (SOC) for
home health claims.
Note: Providers that receive a transfer patient from another
hospital must enter the original admission date to identify the
payer.
13 Admission hour Use military time (00 to 23) for the time of admission for inpatient
claims or time of treatment for outpatient claims. Code 99 is not
acceptable. This field is not required for nonpatients (TOB 141),
home health claims (TOB 331), RHCs (TOB 711), RDCs
(TOB 721), or FQHCs (TOB 731).
14 Type of admission
Enter the appropriate type of admission code for inpatient claims:
1 Emergency
2 Urgent
3 Elective
4 Newborn (This code requires the use of special source of
admission code in Field 15.)
5 Trauma center
15 Source of
admission Enter the appropriate source of admission code for inpatient claims.
For type of admission 1, 2, or 3
1 Physician referral
2 Clinic referral
3 Health maintenance organization (HMO) referral
4 Transfer from a hospital
5 Transfer from skilled nursing facility
6 Transfer from another health care facility
7 Emergency room
8 Court/law enforcement
9 Information not available
For type of admission 4 (newborn)
1 Normal delivery
2 Premature delivery
3 Sick baby
4 Extramural birth
5 Information not available
16 Discharge hour For inpatient claims, enter the hour of discharge or death. Use
military time (00 to 23) to express the hour of discharge. If this is
an interim bill (patient status of "30"), leave the field blank.
Code 99 is not acceptable.
17 Patient status For inpatient claims, enter the appropriate two-digit code to
indicate the client's status as of the statement "through" date.
01 Routine discharge
02 Discharged to another short-term general hospital
03 Discharged to skilled nursing facility (SNF)
04 Discharged to intermediate care facility (ICF)
05 Discharged to another type of institution
06 Discharged to care of home health service organization
07 Left against medical advice
08 Discharged/transferred to home under care of a Home IV
provider
09 Admitted as an inpatient to this hospital (only for use on
Medicare outpatient hospital claims)
20 Expired or did not recover
30 Still patient (To be used only when the client has been in the
facility for 30 consecutive days if payment is based on diagnosis-
related group [DRG])
40 Expired at home (hospice use only)
41 Expired in a medical facility (hospice use only)
42 Expired – place unknown (hospice use only)
43 Federal hospital (such as a Veteran's Administration [VA]
hospital)
50 Hospice – home
51 Hospice – medical facility
61 Medicare – approved swing bed
62 Inpatient rehabilitation facility (IRF), including rehabilitation
distinct part of a hospital
63 Long term care hospital (LTCH)
64 Medicaid-only nursing facility
65 Psychiatric hospital or psychiatric distinct part unit of a hospital
66 Discharged/transferred to a critical access hospital (CAH)
Additional patient status codes for CSHCN Services Program
providers
71 Discharged to another institution of outpatient (OP) services
72 Discharged to another institution
18-28 Condition codes Enter the two-digit condition code "05" and date (MM/DD/YYYY)
the legal claim was filed for recovery of funds potentially due a
client as a result of legal action initiated by or on behalf of the
client if this condition is applicable to the claim.
29 ACDT state Optional
Accident state.
30 Unlabeled Optional
No guidelines for this field.
31-34 Occurrence codes and dates
Enter the appropriate code(s) and date(s). Medicaid-required
codes are found in the 2007 TMPPM, Section 5.6.5, "Occurrence
Codes" on page 5-41, and in the 2007 CSHCN Services Program Provider’s Manual Part I , Section B.3.1 “Occurrence Codes” on
page B-14. Fields 54, 61, 62, and 80 must also be completed as
required.
35-36 Occurrence
span codes
and dates
For inpatient claims, enter code "71" if this hospital admission is a readmission within seven days of a previous stay. Enter the dates of the previous stay. 39-41 Value codes Accident hour – For inpatient claims, if the client was admitted as
the result of an accident, enter value code 45 with the time of the
accident using military time (00 to 23). Use code 99 if the time is
unknown.
For inpatient claims, enter value code 80 with the total days
represented on this claim that are to be covered. Usually, this is
the difference between the admission and discharge dates. In all
circumstances the number in this field will be equal to the number
of covered accommodation days listed in field 46.
For inpatient claims, enter value code 81 with the total days
represented on this claim that are not covered. The sum of fields
39 – 41 must equal the total days billed as reflected in Field 6.
45 (line 23) Creation date
Enter the date the bill was submitted.
57 Other identification (ID) number
Enter the Texas Provider Identifier (TPI) number (nonNational
Provider Identifier (NPI) number) of the billing provider.
67 Principal diagnosis (DX) code and present on admission
(POA) indicator Enter the International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) diagnosis code in the unshaded
area for the principal diagnosis to the highest level of specificity
available.
Optional
POA Indicator – Enter the applicable POA indicator in the shaded
area for inpatient claims.
67A-67Q Other DX
codes and
POA indicator Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Enter one diagnosis per field.
A diagnosis is not required for clinical laboratory services provided
to nonpatients (TOB "141").
Exception: A diagnosis is required when billing for estrogen
receptor assays, plasmapheresis, and cancer antigen CA 125,
immunofluorescent studies, surgical pathology, and alpha-
fetoprotein.
Note: ICD-9-CM diagnosis codes entered in 67I – 67Q are not
required for systematic claims processing.
Optional
POA indicator – Enter the applicable POA indicator in the shaded
area for inpatient claims.
68 Unlabeled Optional
No guidelines for this field
69 Admit DX code Enter the ICD-9-CM diagnosis code indicating the cause of
admission or include narrative.
Note: The admitting diagnosis is only for inpatient claims.
70a – 70c
Patient reason DX
Optional
New field indicating the client’s reason for visit on unscheduled outpatient claims. 71 Prospective Payment
System (PPS) code
Optional
The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary
payer. 72a –
72c External cause of injury (ECI)
and POA
indicator Optional Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis.
POA indicator – Enter the applicable POA indicator in the shaded
area for inpatient claims .
73 Unlabeled Optional
No guidelines for this field.
74 Principal procedure code and date
Enter the ICD-9-CM procedure code for each surgical procedure
and the date (MM/DD/YYYY) each was performed.
74a – 74e Other
procedure
codes and
dates Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.
76 Attending provider Attending provider name and identifiers;
For inpatient claims, enter the physician's license number or
Universal Provider Identification Number (UPIN) of the provider
who performed the service/procedure and/or is responsible for the
treatment and plan of care in the following format: 11233333
1 Two-digit state indicator (for example, TX for Texas)
2 Licensing board indicator examples
B = Doctor of medicine (MD) or doctor of osteopathy (DO)
D = Dentist
P = Podiatrist
C = Chiropractor
3 License number (Example: TXBL1234)
If the provider has a temporary license number, enter "TEMPO."
(Example: TXBTEMPO)
Procedures are defined as those listed in the ICD-9-CM coding
manual volume 3, which includes surgical, diagnostic, or medical
procedures.
For outpatient claims, enter the license number of the physician
referring the patient to the hospital.
TPI must be entered in field to the right of qualifier box, if
applicable
77 Operating
provider Enter operating provider name and identifiers.
This is required when a surgical procedure code is listed on the claim. Include the name and ID number of the individual with the primary responsibility for performing the surgical procedure(s). TPI must be entered in field to the right of qualifier box, if applicable
78-79 Other (a or b)
provider
Other provider name and identifiers:
For outpatient claims, enter the license number for the following:
? The ordering physician for all laboratory and radiology services.
(If a different physician ordered laboratory or radiology services,
enter his/her license number in field 76, and enter the
referring/attending physician's license number or UPIN in this
field.)
? The designated physician for a limited client when the physician
performed or authorized nonemergency care.
? Referring provider – The provider who sent the patient to another
provider for services. Required on an outpatient claim when the
referring provider is different than the attending physician.
Note: If the referring physician is a resident, fields 76 and 78 must
identify the physician who is supervising the resident.
Other operating physician – An individual performing a secondary
surgical procedure or assisting the operating physician. Required
when another operating physician is involved.
Rendering provider – The health care professional who performed,
delivered, or completed a particular medical service or nonsurgical
procedure.
TPI must be entered in field to the right of qualifier box, if
applicable.
FL80 Remarks
This field is used to explain special situations such as the
following:
? The home health agency must document in writing the number of
Medicare visits used in the nursing plan of care and also in this
field.
? If a patient stays beyond dismissal time, indicate the medical
reason if additional charge is made.
? If billing for a private room, the medical necessity must be
indicated and signed by the physician.
? If services are the result of an accident the cause and location of
the accident must be entered in this field. The time must be
entered in Field 39.
? If laboratory work is sent out, the name and address or the
Medicaid provider identifier of the facility where the work was
forwarded must be entered in this field.
? If the patient is deceased, enter the date of death.
? If services were rendered on the date of death, enter the time of
death.
? If the services resulted from a family planning provider's referral,
write "family planning referral."
? If services were provided at another facility, indicate the name
and address of the facility where the services were rendered.
? Enter the date of onset for patients receiving dialysis services.
? Request for 110-day rule for a third-party insurance.
81a – 81d Code code
(CC) Optional
Area to capture additional information necessary to adjudicate the claim. Required when, in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere on the claim data set.
The following table describes fields that have been deleted from the new UB-04 CMS-1450 claim form and are no longer required for claims processing. Field numbers listed on the following table correspond to the fields in the original UB-92 HCFA 1450 claim form:
Field Description
66 Employer location
79 Procedure coding method
85 Provider
signature
86 Date bill submitted
Details about the UB-04 CMS-1450 claim form and instructions for paper billers will also be available in the May/June 2007 Texas Medicaid Bulletin, No. 204, and the May 2007 CSHCN Bulletin No. 62.
Information about electronic billing changes are available in the revised EDI Companion Guides located on the TMHP website. Please refer to the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205, for additional information regarding electronic billing and TDHconnect. For changes relating to National Provider Identifier (NPI) implementation, refer to the National Provider Identifier (NPI) Special Bulletin, No. 202 and the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205.
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Contact Center at 1-800-568-2413.