Documents marked with XLS (Excel spreadsheet) are readable with Microsoft Excel or any spreadsheet software.Blouin, RN and Shannon Magro, RN, Frederick Surgical Center, Frederick, Maryland.Misajet, RN, BBA, CNOR: Director of Surgical Services, Western States Burn Center.Joy B. Hicks, PhD, MBA, is an expert on the health insurance industry with over 15 years of experience in patient financial services.
The UB-04 uniform billing form is the standard claim form that any institutional provider can use for the billing of medical and mental health claims. Its printed with red ink on white standard paper. Although developed by the Centers for Medicare and Medicaid (CMS), the form has become the standard form used by all insurance carriers. The National Uniform Billing Committee and the American Hospital Association design and modify the specifications for the Official UB-04 Electronic Data Set. To fill out the form accurately and completely, be sure to do the following. ![]() Enter insurance information including the patients name exactly as it appears on the insurance card. Use correct diagnosis codes ( ICD-10 ) and procedure codes (CPTHCPCS) using modifiers when required. Use only the physical address for the service facility location field. Include National Provider Identifier (NPI) information where indicated. ![]() Form locator 5: Federal tax number for your facility Form locator 6: Statement from and through dates for the service covered on the claim, in MMDDYY (month, date, year) format. Form locator 15: Point of origin (source of admission) Form locator 16: Discharge hour in the same format as line 13. Form locator 17: Discharge status using the two-digit codes from the NUBC manual. Form locator 18-28: Condition codes using the two-digit codes from the NUBC manual for up to 11 occurrences.
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