The above professional services must be billed on the hcfa 1500 claim form. Instructions for completing the ub 92 claim form if one of the codes below is used, a status code from the table above must still be entered in fl22. Hospital services billing manual f245425000 washington state. Revenue code description effective from effective through inpatien t outpatient fqhcrhc dialysis hhpdn rtc hospice nf comments 0010.
No other publication governmental or privatecommercial can be considered authoritative. Understanding hospital revenue codes value healthcare. Because it serves many payers, a particular payer may not need some data elements. Oct 1, 2015 note all requirements will be enforced on january 1, 2015. Revenue code 636 relates to hcpcs code, so hcpcs is the recommended code to be used in form locator 44. Purpose of the following provider types in successfully completing the ub04 claim form.
Failure to comply enter 0 then the appropriate 3 digit code for type of bill. Enter additional surgical procedure codes and dates. Desk reference for inpatient revenue codes for feeforservice 837 institutionalub92 claim form. Hospitals should use the ub92 claim form to bill for hospital services provided to medicaid recipients. Room and board private one bed 0111 medicalsurgicalgyn.
Revenue code enter the applicable revenue code for the services rendered. Type of service revenue codes dme rental 0290 0299. You can access the ub04 billing information adopted by the nubc by subscribing to the official ub04 data specifications manual. The uniform bill for institutional providers is the ub04. Chapter 25 completing and processing the form cms1450 data set. Annual clotting factor furnishing fee update 2019 cms. Part b services with applicable revenue codes include. Both state and nonstate long term care facilities will use leave of absence codes 0183, 0185, and 0189. Inpatient services billing example inpatient services. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download free ub92 revenue codes. Revenue codes are not to be indicated for outpatient services.
R 25100 form cms1450, ub92, ansi x12n 837a 4010 and 3051 3a. Enter the website for a list of drugs that require ndc codes. This includes items such as cpt codes, cdt codes, icd10 and other ub04 codes. The ub92 will not be furnished by the state or csc. This manual, ed by the american hospital association, is the only official source of ub data. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download ub 92 type of bill codes. This form will be used by various hospitals, health care centers, and nursing facilities to submit a claim to medicare or another third party health insurance company. The date must be within the fromthrough dates on the claim. An asterisk next to a field indicates that further information is necessary to complete the field e. For nursing facilities, use only the following revenue codes. Revenue code listing below revenue codes must be filed with appropriate cpt and hcpcs codes for outpatient and ambulatory surgery ub04 or 837institutional healthcare claims.
Oct 5, 2018 2019 annual update of healthcare common procedure ed materials including the ub04 codes and descriptions may not be. See ub04 manual for revenue codes and abbreviations. In addition, a list of revenue codes hospitals need to complete the. Inpatient claims have a minimum of nine records per claim. Hcpcs codes for outpatient and ambulatory surgery ub04 or. Below revenue codes must be filed with appropriate cpt and. The revenue codes were developed for the medicare system but. Revenue code description comments pharmacy b250 general classification. In some instances, a hcpcs procedure code is required in addition to the revenue code for accurate claims processing.
Removed the revenue code 5 psychiatric clinic section updated the list of codes in the revenue code linkages for managed care billing only section updated information in fields 1, 15, and 77 in table 4 ub04 claim form fields updated figure 9 ub04 claim form added the portal institutional claim submission process section. Required for inpatient claims billing revenue codes 03600379, 04900499, or 07100719. R 25100 form cms1450, ub 92, ansi x12n 837a 4010 and 3051 3a. Ub92 completion aid for inpatient hospital pennsylvania ub04 billing guide for promise inpatient hospitals. Mvp health care has developed this guide to help orient you to the key data fields that are changing on the new ub04 paper claim form that will be required by mvp health care beginning 52307. The ub92 claim form is used to submit claims for outpatient services by institutional facilities for example, outpatient departments, rural health clinics, chronic dialysis services and. The billing process begins with a download of data from the providers information system, usually in the form of a print spool file containing the ub92 or hcfa 1500 claims, and then the billing application analyzes each claim for completeness and accuracy of data. For the ub92 flat file as well as the hipaa 837, fis report as follows.
A valid procedure code must be accompanied by a revenue code for it to be accepted by the insurance provider. Revenue code 0900 remains a valid code under the general classification. Language is being added to clarify ub92 billing instructions for form locator 42 to reflect appropriate leave of absence revenue codes for nursing homes and assisted living facilities. For complete information regarding ub04 coding please refer to the cms iom publication 4, chapter 25 2. Enter one of the appropriate codes indicating the priority of this admission.
Inpatient services billing example inpatient services 492. Enter the appropriate revenue codes and descriptors in the revenue. Revenue codes requiring cpthcpcs codes on outpatient bills. Form cms1450, ub92, ansi x12n 837a 4010 and 3051 3a. Instructions for completing the ub92 claim form all entries on a ub92 are made in a field called the form locator fl. Medicare ub92 summary revised 112103fl 42 revenue code. The specified units of service to be reported should be in hundreds 100s, rounded to the nearest hundred no decimal.
Inpatient emergency renal dialysis must be billed using revenue code 809. Inpatient revenue codes for feeforservice providers. Completing the ub04 claim form guidelines for facility. All cigna products and services are provided exclusively by or through operating subsidiaries of cigna corporation, including cigna. Ub04 revenue codes icd 10 codes, cpt codes, hcpcs codes. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download revenue code for ub92. Up to 22 revenue codes and associated charges may be entered on each ub04 the type of bill codes and ub04 claim frequency type code values for refer to the service code descriptions in subchapter 6 of the home. Value codes and amount enter the appropriate twodigit value code and value if there is a value code and value appropriate for this claim.
Skilled nursing facility quick reference billing manual community. The example in this section is to assist providers in. December 2019 page 5 of 187 inpatient ub04 data reporting data element description field number ub04 form locator page number noncovered charges by revenue code 48a48v 100 noncovered charges total 48w 101 occurrence codes 31a4b1 80 occurrence dates 31a234b2 81 occurrence span codes 35a6b1 82. The instructions used to complete the claim form follow the sample. There are 81 fields on the ub04 and the revenue codes are located by field 4249 fl4249.
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