The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 11 Value Codesand Amounts

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Describe the types of value codes that are used in FLs 39-41 on the UB-04 to report monetary data that affect the way the claim is processed and paid. Explain the relationship between value codes and the dollar amounts, units, or number of visits that are reported with them. Recognize various billing patterns that arise in connection with value codes. Understand which value codes contain data that must be coordinated with data supplied in other fields on the UB-04.

3. KEY TERMS • Medicare blood deductible • MSP value code • noncovered days • value code

4. FLs 39-41 VALUE CODES AND AMOUNTS • A value code is a two-digit numeric or alphanumeric code used to identify a dollar amount, unit amount, or number of visits associated with a claim. Payers need value codes to determine the patient’s benefits and process claims accurately. • Guidelines • If applicable, completion of this field is required for Medicare and most other payers • Codes range from 01 to 99 and A0 to ZZ • The UB-04 contains four lines for value codes; if more than one value code is used, enter the codes in alphanumeric sequence in the following order: • fill in the top line fully before beginning the next line (i.e., FLs 39a-41a should be used first, followed by FLs 39b-41b, etc.) • if all value code fields are filled, FL 81 (Code-Code) can be used with the appropriate value code qualifier (A4)

5. FLs 39-41 VALUE CODES AND AMOUNTS (cont.) • Every value code must also have an amount (dollar amount, number of visits or units, weight of a newborn in grams, etc.) • Medicare Part A claims are processed through Fiscal Intermediary Shared System (FISS), which requires nondollar amounts to end in two zeros (e.g., thirteen visits = 13.00) • FLs 39-41 have delimiters, a character that separates one item from another, so decimal points do not have to be entered

6. VALUE CODE CATEGORIES • General Codes 01 – 55 • Home Health-Specific Codes 56 - 69 • Payer-Specific Codes 70 – 79 • Codes for Covered and Noncovered Days 80 – 83(for use on paper claims only) • Reserved or National Assignment 84 - 99 • Alphanumeric and Alphabetic Value Codes A0 – ZZ

7. Example • No-Fault, Including Auto/Other [14] • Amount $3,900.50 [3900 50] • Accident Hour [45] • Time 4:12 a.m. [04 00] • Covered Days [80] • Three days [3 00]

8. CHAPTER REVIEW • All value codes must end with what two characters? • [zeros] • What is the term for the character that eliminates the need for using decimal points? • [delimiter] • How many pints of blood must a Medicare beneficiary either pay for or replace in order to meet the blood deductible? • [three]

9. TERMINOLOGY QUIZ • A two-digit numeric or alphanumeric code that identifies a dollar amount, unit amount, or number of visits associated with a claim: • [value code] • First three pints of blood each year that a Medicare beneficiary must either pay for or replace: • [Medicare blood deductible] • MSP stand for: • [Medicare Secondary Payer]