Attributes Numeric for Accommodation Rate; alphanumeric for HCPCS and HIPPS Rate Codes. Right-justified for Accommodation Rates; left-justified for HCPCS and HIPPS Rate Codes.
Dollar values reported for Accommodation Rates must include whole dollars, the decimal, and the cents.
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Notes Field Attributes
(a) The 23rd line contains an incrementing page count and total number of pages for the claim on each page, creation date of the claim on each page, and a claim total for covered and non-covered charges on the final claim page only indicated using Revenue Code 0001.
(b) For HCPCS, the filed consists of 5 positions for the base code plus 8 positions for up to four HCPCS modifiers; thus, the field contains one extra/unused position. (c) HIPPS rate code are alphanumeric codes of 5 positions. Each code contains
intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional informational; the additional information varies amount HIPPS codes.
HIPPS Rate Codes
The Centers for Medicare and Medicaid services develops and publishes the HIPPS codes to establish a coding system for claims submission and claims payment under prospective payment systems. These codes represent the case mix classification groups that are used to determine payment rates under prospective payment systems. Case mix classification groups include, but may not be limited to, resource utilization groups (RUGs) for skilled nursing facilities, home health resource groups (HHRGs) for home health agencies, and case mix groups (CMGs) for inpatient rehabilitation facilities.
HCPCS Modifiers (Level I and Level II)
The UB-04 accommodates up to four modifiers, two characters each.
Various CPT (Level I HCPCS) and Level II HCPCS codes may require the use of modifiers to improve the accuracy of coding. Consequently, reimbursement, coding consistency, editing and proper payment will benefit from the reporting of modifiers. Hospital should not report a separate HCPCS (five-digit code) instead of the modifier. When appropriate, report a modifier bas on the list indicated in the above section of the AMA publication.
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Data Element Service Date
Definition: The date (MMDDYY) the outpatient service was provided. (Applies to Lines 1-22; Line 23 refers to the Creation Date (MMDDYY) of the bill (the date bill was created/printed)).
This field is also used to report the assessment reference date when billing SNF PPS services (Type of Bill 021x).
Required Required on outpatient claims
Reporting Service Date
UB-04: Required on outpatient claims.
004010/004010A1: Required on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment.
005010: Required on outpatient service line where a drug is not being billed and the Statement Covers Period is greater than one day.
OR
Required on service lines where a drug is being billed and the payer’s adjudication is known to be impacted y the drug duration or the date the prescription was written.
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Reporting Assessment Date
Require when this field is used to report the assessment reference date when billing SNF PPS services (Type of Bill 021x). 005010: Not Used
Creation Date
Required for Line 23 (Creation Date). Enter the date the bill was created or prepared for submission. Creation Date on Line 23 should be reported on all pages of the UB-04.
Field Service Date: Creation Date:
Attributes 1 Field 22 Lines 6 Positions 1 Field 1 Line (23) 6 Positions
Numeric Right-justified Numeric Right-justified
Form Locator 46
Data Element Service Units
Definition: A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints f blood, renal dialysis
treatments, etc.
Required Yes
Reporting UB-04, 004010/004010A1, 005010: Required
Field 1 Field 22 Lines 7 Positions Decimal
Attributes Numeric Right-justified
Notes Enter the total number of covered accommodation days, ancillary units of service, or visits, where appropriate.
Leading zeros should not be reported.
If the amount is an integer, no decimal point is reported.
The maximum length for this field is 7 digits excluding the decimal.
When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The following notes are intended as general guidance.
Inpatient
Room & board accommodations: Units reflect the total number of days of care provided to
the patient.
Other revenue codes: Although the inpatient UB-04 is a summary level claim, units can be reported as “1” or more based on the provider’s practice, health plan requirements or regulation. A zero or negative value is not allowed.
Outpatient
When HPCPS codes are reported, the unit is defined by the HCPCS definition. Where the unit is not defined by the HCPCS code, units can be reported as “1” or more based on the provider’s practice, health plan requirements or regulation. A zero or negative value is not allowed.
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Data Total Charges
Element
Definition: Total Charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total Charges includes both covered and non-covered charges.
Required Yes
Reporting Line Item Charges Required: UB-04 (Lines 1-22). 004010/004010A1, 005010 Loop ID 2400 | SV203
Total (Summary) Charges Required: UB-04 Line 23 of the final claim page using Revenue Code 0001. (Revenue 0001 is not used on electronic transactions; report the total claim charge in the appropriate data segment/field as indicated below.)
004010/004010A1, 005010 Loop ID 2300 | CLM02