The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 12 Revenue Code, Descriptions,and Charges

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Describe the use of the two types of revenue codes that are reported in FL 42 (Revenue Code) on the UB-04: accommodation revenue codes and ancillary service revenue codes. Become familiar with the narrative description or standard abbreviation that accompanies each revenue code for FL 43 (Revenue Description). Understand the use of FL 44 (HCPCS/Rate/HIPPS Code) for reporting either the required HCPCS codes on outpatient claims or the charge for accommodations on inpatient claims.

3. LEARNING OUTCOMES (cont.) • Understand how to report the date of service in FL 45 (Service Date) and the units of measure in FL 46 (Service Units). • Understand how to report total charges and noncovered charges in FL 47 (Total Charges) and FL 48 (Noncovered Charges).

4. KEY TERMS • accommodation revenue code • all-inclusive rate • ancillary service revenue code • Durable Medical Equipment Regional Carriers (DMERCs) • HIPPS (Health Insurance Prospective Payment System) rate code • observation services • revenue code series • subcategory code • transitional pass-through payment

5. FL 42 REVENUE CODE • A revenue code is a four-digit numeric code used to identify specific items, accommodations, or services billed on the UB-04 claim form. The corresponding charge for each revenue code is reported in FL 47 (Total Charges) on the same line as the revenue code. Revenue codes and their descriptions provide the details needed for payers to determine final reimbursement amounts. • All revenue codes start with a leading zero • Revenue code series are described with an X in the fourth position instead of a number from 0 to 9 (e.g., 011X is the revenue code series “Room and board—Private (One Bed)” • Subcategory codes must be placed in the fourth position for billing purposes • 0 = general code • 1-8 = specific subcategories • 9 = other

6. FL 42 REVENUE CODE (cont.) EXAMPLE: 031X Laboratory Pathology 0310 General classification 0311 Cytology 0312 Histology 0313 Reserved 0314 Biopsy 0315-0318 Reserved 0319 Other laboratory pathology

7. FL 42 REVENUE CODE (cont.) • Accommodation and Ancillary Service Revenue Codes • Two major types of revenue codes: • Accommodation revenue codes • apply only to inpatient claims • identifies type of room accommodation (e.g., private, semiprivate) • identifies board charges (including charges for nursing services) • Ancillary service revenue codes • used on inpatient and outpatient claims • identify services (other than room and board) that are incidental to hospitalization (e.g., radiology, pharmacy, laboratory, operating room, supplies, therapies)

8. Revenue Code and FL 44 (HCPCS/Rate/HIPPS Code) • Inpatient claims require a room rate in FL 44 for all accommodation revenue codes (010X – 021X) • for all other services (ancillary services), FL 44 may be left blank • Outpatient claims require a HCPCS code in FL 44 for almost all ancillary services as this is used as the basis for payment

9. REVENUE CODE (cont.) • Guidelines • Completion of the revenue code field is required for Medicare and all other payers • Depending on non-Medicare payer requirements, the general classification code (usually 0) may be used; using a specific subcategory code when it is applicable and available ensures more accurate and quick processing • For Medicare claims, the general classification code (usually 0) should be used with all revenue code categories except the following which require detailed subcategory codes: • 029X 052X • 0304 055X-059X • 033X 0624 • 0367 0636 • 042X 080X-085X

10. REVENUE CODE (cont.) • Guidelines (cont.) • 22 lines are available for listing revenue codes and charges on a UB-04 claim form • if more lines are needed, additional pages can be attached (up to nine pages) [Note that line 23 contains the text “Page __ of __” and should be filled in on each page] • line 23 is reserved for the claim total on the final page using revenue code 0001 • revenue codes should be listed in ascending numeric order by date of service (except 0001)

11. REVENUE CODE (cont.) • Accommodation Revenue Codes • When an accommodation revenue code is entered in FL 42, a room rate must be entered in FL 44 (HCPCS/Rate/HIPPS Code) and the number of days must be entered in FL 46 (Service Units) • Revenue code 010X indicates an all-inclusive rate, a flat fee charge incurred on either a daily or total stay basis; can include room, board, and ancillary services or room and board only

12. REVENUE CODE (cont.) • Ancillary Service Revenue Codes • On inpatient claims, FL 44 can be blank when ancillary service revenue codes are entered in FL 42; on outpatient claims, almost all ancillary service revenue codes require a HCPCS code in FL 44 and a date of service in FL 45 • Ancillary service revenue codes require the number of service units in FL 46; service units vary depending on the service (e.g., number of tests performed, number of dialysis sessions)

13. REVENUE CODE (cont.) • Ancillary Service Revenue Codes – Misc. • Most medical/surgical devices and supplies are packaged in the ambulatory payment classification (APC) rate; certain medical devices are paid separately under a transitional pass-through payment (these are generally items that are new and not included in the current APC rate) • When revenue code 038X (Blood and Blood Components) is used, the appropriate value code(s) must be used in FLs 39-41 to describe the blood cash deductible paid by the patient, the pints furnished, the pints the patient is responsible for, and/or the pints the patient has replaced • Revenue code 0762 (Observation room) is used to evaluate an outpatient’s condition and to determine the need for possible admission as an inpatient when provided on the order of a physician

14. FL 43 REVENUE DESCRIPTION • FL 43 (Description) is used to report the narrative description or standard abbreviation of each of the revenue codes reported in FL 42 • Guidelines • Completion generally not required for Medicare (with some exceptions) • Description is intended to assist in clerical review and is usually used on paper claims even when not required • If subcategory codes ending in 9 (other) are used, they should be described in FL 43

15. FL 44 HCPCS/RATE/HIPPS CODE • Depending on the type of claim, FL 44 contains one of three types of information: • HCPCS code when required for ancillary services on outpatient claims • Appropriate accommodation rate for inpatient claims • HIPPS rate for SNF, home health, and inpatient rehabilitation facility (IRF) PPS claims • A Health Insurance Prospective Payment System (HIPPS) code is a five-digit alphanumeric code that represents specific sets of patient characteristics or case-mix groups

16. FL 44 HCPCS/RATE/HIPPS CODE (cont.) • Guidelines • Medicare outpatient claims require almost all items and services reported using HCPCS codes in FL 44 (these HCPCS codes and modifiers are the basis of payment) • UB-04 accommodates up to four modifiers of two characters • Generally, the only Medicare outpatient services that do not require HCPCS codes are: supplies, drugs, and ESRD services • Medicare inpatient claims use FL 44 to report the accommodation rate for the revenue code in FL 42 • if there are several codes, they must be listed in revenue code sequence • dollar values entered as whole numbers with a decimal point and cents (e.g., 496.32)

17. FL 45 SERVICE DATE • FL 45 (Service Date) is used to report the date on which the outpatient service reported in FLs 42-44 was provided in MMDDYY format • Each occurrence of an outpatient service requires its own revenue code line and date; claims submitted without the line item date of service will be returned • Guidelines • Required for Medicare outpatient claims; other payers may also require it • Dates must fall within the dates reported in FL 6 (Statement Covers Period) • Last line (23) in FL 45 is “Creation Date” and is used to report date the claim was prepared for submission; creation date should be on every page of multi-page claims

18. FL 46 SERVICE UNITS • FL 46 (Service Units) is used to report the quantitative measure of services provided (e.g., number of visits, drug dosages) • Guidelines • Required for Medicare where appropriate based on the requirements of each revenue code; also required by other payers

19. FL 47 TOTAL CHARGES • FL 47 (Total Charges) is used to report the total charges for the primary payer for the current billing period for each revenue code listed in FL 42, including both covered and noncovered charges • Each line item, whether for a covered or noncovered charge, has a total in FL 47 (noncovered charges are also reported in FL 48 (Noncovered Services) • The last line (23), labeled “TOTALS,” is used to report the total of all line item charges in the Total Charges column – for all payers except Medicare • Medicare: noncovered amounts are subtracted from the total column in FL 47 so the total amount actually represents the total of covered costs • Other payers: the total includes covered and noncovered costs

20. FL 48 NONCOVERED CHARGES • FL 48 is used to report the total noncovered charges for each revenue code line and the total of noncovered charges in FL 48, line 23 • Guidelines • If noncovered days are reported in FLs 39-41 (Value Codes and Amounts) using value code 81 (Noncovered days), noncovered charges must also be reported in FL 48 • Charges for services or items not covered by Medicare are listed in this field (e.g., cost of self-administered drugs such as aspirin, extra cost of a private room) • Medicare requires a claim for every hospital stay, even one for which no payment is expected (FIs and CMS use the information to maintain beneficiary utilization and eligibility records)

21. CHAPTER REVIEW • What is the significance of the X in a revenue series code? • [placeholder to be replaced by a subcategory code] • What is the significance of revenue code 010X? • [indicates an all-inclusive rate, a flat fee charge incurred on either a daily or total stay basis] • To report the grand total of all charges listed, what revenue code is entered in FL 42, line 23? • [0001] • What are the two major types of revenue codes? • [accommodation and ancillary]

22. CHAPTER REVIEW • In what sequence should revenue codes be listed? • [ascending numerical order by date] • Are both covered and noncovered charges included in FL 47 (Total Charges) for Medicare and other payers? • [Medicare does not include noncovered charges, other payers include both]

23. TERMINOLOGY QUIZ • Payments in addition to the APC payment to ensure beneficiary access to new drugs, technologies, etc.: • [transitional pass-through payments] • Code used to identify the type of room and board charges being billed on an inpatient claim: • [accommodation revenue code] • Code used to identify services other than room and board that are incidental to the hospital stay (can also be used for outpatient services): • [ancillary service revenue code] • Codes that replace the X in revenue code series: • [subcategory codes]