Department of Health &

CMS Manual System Human Services (DHHS)

Pub 100-04 Medicare Claims Centers for Medicare &

Medicaid Services (CMS)
Processing
Transmittal 1104 Date: NOVEMBER 3, 2006
Change Request 5072

NOTE: Transmittal 1018, dated July 28 2006, is rescinded and replaced with Transmittal 1104, dated
November 3, 2006. (In BR 5072.2(3rd line) it reads FL3a, when it should correctly read: FL3b. In
BR5072.2.1(2nd line) it also reads FL3a, when it should correctly read: FL3b. All other information
remains the same.

SUBJECT: Uniform Billing (UB-04) Implementation

I. SUMMARY OF CHANGES: The CMS needs to be ready to receive the new UB-04 by March 1, 2007.
Institutional providers can use the UB-04 beginning March 1, 2007, however, they will have a transitional
period between March 1, 2007 and May 22, 2007 where they can use the UB-04 or the UB-92. Starting May
23, 2007 all institutional paper claims must use the UB-04. The UB-92 will no longer be accepted after this
date. The UB-04 incorporates the National Provider Identifier (NPI), taxonomy, and additional codes (note
the attached crosswalk file). Many UB-92 data locations have changed on the UB-04 although most of the
data usage descriptions and allowable data values have not changed. Bill type processing will change. Note
that this CR does not expand the claim record used for processing. Starting May 23, 2007, all UB-04s must
include a valid NPI.

New / Revised Material

Effective Date: March 1, 2007
Implementation Date: March 1, 2007

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)

R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D Chapter / Section / Subsection / Title

R 25/TOC/Completing and Processing the CMS 1450 Data Set
R 25/50/Uniform Bill (UB) - Form CMS-1450 for Billing (UB-92)
R 25/60/General Instructions for Completion of Form CMS-1450 for Billing (UB-92)
R 25/70.1/Uniform Billing with form CMS-1450
R 25/70.2/Disposition of Copies of Completed Forms
R 25/75/General Instructions for Completion of Form CMS-1450 (UB-04)
R 25/75.1/Form Locators 1-15
 R 25/75.2/Form Locators 16-30
R 25/75.3/Form Locators 31-41
R 25/75.4/Form Locator 42
R 25/75.5/Form Locators 43-81

III. FUNDING:
No additional funding will be provided by CMS; contractor activities are to be carried out within their FY
2007 operating Budgets.

IV. ATTACHMENTS:

Business Requirements
Manual Instruction

*Unless otherwise specified, the effective date is the date of service.

 Attachment - Business Requirements
Pub. 100-04 Transmittal: 1104 Date: November 3, 2006 Change Request 5072

NOTE: Transmittal 1018, dated July 28 2006, is rescinded and replaced with Transmittal 1104, dated
November 3, 2006. (In BR 5072.2(3rd line) it reads FL3a, when it should correctly read: FL3b. In
BR5072.2.1(2nd line) it also reads FL3a, when it should correctly read: FL3b. All other information
remains the same.

SUBJECT: Uniform Billing (UB-04) Implementation

I. GENERAL INFORMATION

A. Background: Following the close of a public comment period and careful review of comments received,
the National Uniform Billing Committee (NUBC) approved the UB-04 as the replacement for the UB-92 at its
February 2005 meeting. The CMS needs to be ready to receive the new UB-04 by March 1, 2007. Institutional
providers can use the UB-04 beginning March 1, 2007; however, they will have a transitional period between
March 1, 2007 and May 22, 2007 where they can use the UB-04 or the UB-92. This coincides with the NUBC’s
planned UB-04 implementation. Starting May 23, 2007 all institutional paper claims must be received on the
UB-04. The UB-92 will no longer be accepted after this date. The UB-04 incorporates the National Provider
Identifier (NPI), taxonomy, and additional codes.

Included in this change request are the UB-04 (front and back), the UB-92 to UB-04 crosswalk, and UB-
04 mapping to the HIPAA institutional 837. To receive copies of the revised form with the specifications
needed for testing purposes, contact TFP Data Systems at [email protected].

B. Policy: The Form UB-04 (CMS-1450) answers the needs of many health insurers. It is the basic
form prescribed by CMS for the Medicare program and is only accepted from institutional providers that
are excluded from the mandatory electronic claims submission requirements set forth in the
Administrative Simplification Compliance Act, Pub.L. 107-105 (ASCA) and the implementing regulation
at 42 CFR 424.32. Just as CMS is applying the NPI requirement to both paper and electronic claims, we
are also applying the same NPI editing requirements to NPIs submitted on either type of claim. The
internal claim record used for processing is not being expanded.

II. BUSINESS REQUIREMENTS

“Shall" denotes a mandatory requirement

"Should" denotes an optional requirement

Requirement Requirements Responsibility (“X” indicates the

Number columns that apply)
F R C D Shared System Other
I H a M Maintainers
H r E
 F M V C
I C M W
S S S F
S
5072.1 Contractor and/or FISS shall modify front end X X X
systems (including on-line screens) to receive
UB-04 data, except as limited by the following
business requirements.
5072.1.1 FISS shall modify on-line screens to permit X
only the 2nd through 4th positions of the bill
type, treating the 2nd through 4th positions as the
1st through 3rd positions for processing (internal
processing will not change), ignoring the
leading zero (1st position) from the UB-04. For
example Type of Bill 0111 shall be processed as
Type of Bill 111.
5072.1.1.1 After May 22, 2007, contractor shall not allow a X X
UB-92 to be accepted as an adjustment claim.
5072.1.2 For the UB-04 on-line screens, FISS shall retain X
the UB-92 limits as to permitting only up to the
maximum number of the UB-04 codes (value
codes, condition codes, occurrence codes
occurrence span codes, etc) that may be
reported for the UB-92 and not expand the size
of these fields.
5072.1.3 FISS shall modify edits to process the following X
UB-04 only value codes:
80 - Covered days (the number of days covered
by the primary payer as qualified by the payer)
81 - Non-Covered Days (days of care not
covered by the primary payer)
82 - Co-insurance Days (the inpatient Medicare
days occurring after the 60th day and before the
91st day or inpatient SNF/Swing Bed days
occurring after the 20th and before the 101st day
in a single spell of illness)
83 - Lifetime Reserve Days (under Medicare,
each beneficiary has a lifetime reserve of 60
additional days of inpatient hospital services
after using 90 days of inpatient hospital services
during a spell of illness

5072.1.4 FISS shall include value code 80, 81, 82, or 83 X

data to on the internal claim file used to
generate coordination of benefit claims.
Requirement Requirements Responsibility (“X” indicates the
Number columns that apply)
F R C D Shared System Other
I H a M Maintainers
H r E
F M V C
I r R
I C M W
i C
S S S F
e
S
r
5072.2 FISS shall ignore data from hardcopy UB-04 X
Form Locators (FL) FL02 (Pay-to Information),
FL3b (Medical/Health Record Number), FL08a
(Patient Name-ID), FL25 (Condition Code),
FL26 (Condition Code), FL27 (Condition
Code), FL28 (Condition Code), FL29 (Accident
State), FL66 (DX Version Qualifier), FL71
(PPS Code), FL72b (External Cause of Injury
Code), and FL72c (External Cause of Injury
Code) FL67I (Other Diagnosis), FL67J (Other
Diagnosis), FL67K (Other Diagnosis), FL67L
(Other Diagnosis), FL67M (Other Diagnosis),
FL67N (Other Diagnosis), FL67O (Other
Diagnosis), FL67P (Other Diagnosis), FL67Q
(Other Diagnosis), FL79 (Other-ID), and FL81
(Code-code) except for code B3 (taxonomy).
5072.2.1 FISS shall not expand on-line screens to support X
UB-04 FL02 (Pay-to Information), FL3b
(Medical/Health Record Number), FL08a
(Patient Name-ID), FL25 (Condition Code),
FL26 (Condition Code), FL27 (Condition
Code), FL28 (Condition Code), FL29 (Accident
State), FL66 (DX Version Qualifier), FL71
(PPS Code), FL72b (External Cause of Injury
Code), and FL72c (External Cause of Injury
Code) FL67I (Other Diagnosis), FL67J (Other
Diagnosis), FL67K (Other Diagnosis), FL67L
(Other Diagnosis), FL67M (Other Diagnosis),
FL67N (Other Diagnosis), FL67O (Other
Diagnosis), FL67P (Other Diagnosis), FL67Q
(Other Diagnosis), FL79 (Other-ID), and FL81
(Code-code) except for code B3 (taxonomy).
5072.3 FISS shall use Uniform Bill Code “A” X
internally to represent the UB-04.
5072.3.1 Contractors that use Optical Character X X
Recognition (OCR) equipment/software for
institutional claims entry shall modify the
equipment/software as needed for UB-04 entry.
Requirement Requirements Responsibility (“X” indicates the
Number columns that apply)
F R C D Shared System Other
I H a M Maintainers
H r E
F M V C
I r R
I C M W
i C
S S S F
e
S
r
5072.3.2 Contractors that use OCR equipment/software X X
shall modify the equipment/software to map
only the 2nd through 4th positions of the bill
type, treating the 2nd through 4th positions as the
1st through 3rd positions for processing (internal
processing will not change), ignoring the
leading zero (1st position) from the UB-04. For
example Type of Bill 0111 shall be processed as
Type of Bill 111.
5072.4 Between March 1, 2007 and May 22, 2007, X X
contactors shall accept either the UB-92 or the
UB-04.
5072.5 Contactors shall reject UB-92s received after X X
May 22, 2007.
5072.5.1 After May 22, 2007, contractors shall have the X X
option to return a UB-92 to the submitter prior
to data entry with a cover letter explaining why
the UB-92 is being returned.
5072.6 Contractors shall make all necessary changes to X X
your internal business processes to receive, sort,
process, and store the UB-04.
5072.7 FISS shall make all the necessary shared system X
changes to accept only valid NPIs received on
the UB-04 after May 22, 2007.
5072.7.1 FISS shall make all the necessary shared system X
changes to accept valid NPIs received on the
UB-04 between March 1, 2007 and May 22,
2007.
5072.7.2 Prior to March 1, 2007, contractors shall have X X
the option to return a UB-04 to the submitter
with a cover letter explaining why the UB-04 is
being returned.
5072.7.3 Contractor and/or FISS shall not implement X X X
additional NPI edits over and above those
covered in Change Request 4023.
III. PROVIDER EDUCATION

Requirement Requirements Responsibility (“X” indicates the

Number columns that apply)
F R C D Shared System Other
I H a M Maintainers
H r E
F M V C
I r R
I C M W
i C
S S S F
e
S
r
5072.9 A provider education article related to this X X
instruction will be available at
www.cms.hhs.gov/medlearn/matters shortly
after the CR is released. You will receive
notification of the article release via the
established "medlearn matters" listserv.
Contractors shall post this article, or a direct
link to this article, on their Web site and include
information about it in a listserv message within
1 week of the availability of the provider
education article. In addition, the provider
education article shall be included in your next
regularly scheduled bulletin and incorporated
into any educational events on this topic.
Contractors are free to supplement Medlearn
Matters articles with localized information that
would benefit their provider community in
billing and administering the Medicare program
correctly.

IV. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS

A. Other Instructions: N/A

X-Ref Requirement # Instructions

B. Design Considerations: N/A

X-Ref Requirement # Recommendation for Medicare System Requirements

C. Interfaces: N/A
D. Contractor Financial Reporting /Workload Impact: N/A

E. Dependencies: N/A

F. Testing Considerations: N/A

V. SCHEDULE, CONTACTS, AND FUNDING

Effective Date*: March 1, 2007 for UB-92s and Medicare contractors shall
UB-04s accepted. implement these instructions
within their current FY 2007
Implementation Date: March 1, 2007 operating budget.

Pre-Implementation Contact(s): Matt Klischer

([email protected])

Post-Implementation Contact(s): Matt Klischer

([email protected])

*Unless otherwise specified, the effective date is the date of service.

 * FL68,75,80 Size Updated 6/21/05
UB-92 UB-04 ** FL07, 30 Size Updated 12/15/05
Buffer
FL Description Line Type Size FL Description Line Type Size Space Notes

FL01 Provider Name 1 AN 25 FL01 Provider Name 1 AN 25

FL01 Provider Street Address 2 AN 25 FL01 Provider Street Address 2 AN 25
FL01 Provider City, State, Zip 3 AN 25 FL01 Provider City, State, Zip 3 AN 25
FL01 Provider Telephone, Fax, Country 4 AN 25 FL01 Provider Telephone, Fax, Country 4 AN 25
Code Code
FL02 Unlabeled Fields 1 AN 20 FL02 Pay-to Name 1 AN 25 New
FL02 Unlabeled Fields 2 AN 30 FL02 Pay-to Address 2 AN 25 New
FL02 Pay-to City, State 3 AN 25 New
FL02 Not Used 4 AN 25

FL03 Patient Control Number 1 AN 20 FL03a Patient Control Number AN 20

FL03b Medical Record Number AN 24 Moved/New

FL04 Type of Bill 1 AN 3 FL04 Type of Bill 1 AN 4 1 Expanded

FL05 Federal Tax Number 1 AN 4 FL05 Federal Tax Number 1 AN 4

FL05 Federal Tax Number 2 AN 10 FL05 Federal Tax Number 2 AN 10

Statement Covers Period - Statement Covers Period -

FL06 1 N/N 6/6 FL06 1 N/N 6/6 1/1
From/Through From/Through

FL07 Unlabeled 1 AN 7**

2 AN 8**
FL07 Covered Days 1 N 3 Eliminated - Substitute new Value
Code 80
Eliminated - Substitute new Value
FL08 Non-covered Days 1 N 4
Code 81
Eliminated - Substitute new Value
FL09 Coinsurance Days 1 N 3
Code 82
Eliminated - Substitute new Value
FL10 Lifetime Reserve Days 1 N 3
Code 83

FL11 Unlabeled 1 12 Eliminated

FL11 Unlabeled 2 13 Eliminated

FL12 Patient Name 1 AN 30 FL08 Patient Name - ID 1a AN 19 New

FL08 Patient Name 2b AN 29

FL13 Patient Address 1 AN 50 FL09 Patient Address - Street 1a AN 40 1 Discrete

FL09 Patient Address - City 2b AN 30 2 Discrete
FL09 Patient Address - State 2c AN 2 1 Discrete

FL09 Patient Address - ZIP 2d AN 9 1 Discrete

FL09 Patient Address - Country Code 2e AN 3 Discrete

FL14 Patient Birthdate 1 N 8 FL10 Patient Birthdate 1 N 8 1

FL15 Patient Sex 1 AN 1 FL11 Patient Sex 1 AN 1 2

FL16 Patient Marital Status 1 AN 1 Eliminated

FL17 Admission Date 1 N 6 FL12 Admission Date 1 N 6

FL18 Admission Hour 1 AN 2 FL13 Admission Hour 1 AN 2 1

FL19 Type of Admission/Visit 1 AN 1 FL14 Type of Admission/Visit 1 AN 1 2

FL20 Source of Admission 1 AN 1 FL15 Source of Admission 1 AN 1 1

FL21 Discharge Hour 1 AN 2 FL16 Discharge Hour 1 AN 2 2

FL22 Patient Status/Discharge Code 1 AN 2 FL17 Patient Discharge Status 1 AN 2 2

FL23 Medical/Health Record Number AN 17 Moved to FL3b

FL24 Condition Codes AN 2 FL18 Condition Codes AN 2 1

FL25 Condition Codes AN 2 FL19 Condition Codes AN 2 1

FL20 Condition Codes AN 2 1

* FL68,75,80 Size Updated 6/21/05

UB-92 UB-04 ** FL07, 30 Size Updated 12/15/05
Buffer

FL Description Line Type Size FL Description Line Type Size Space Notes
FL26 Condition Codes AN 2 FL21 Condition Codes AN 2 1

FL22 Condition Codes AN 2 1

FL27 Condition Codes AN 2 FL23 Condition Codes AN 2 1
FL24 Condition Codes AN 2 1
FL28 Condition Codes AN 2 FL25 Condition Codes AN 2 1
FL26 Condition Codes AN 2 1 New
FL29 Condition Codes AN 2 FL27 Condition Codes AN 2 1 New
FL28 Condition Codes AN 2 1 New
FL30 Condition Codes AN 2

FL29 Accident State 1 AN 2 1 New

** No "Xs" on
FL30 Unlabeled 1 AN 12 proof
FL30 Unlabeled 2 AN 13

FL31 Unlabeled 1 5
FL31 Unlabeled 2 6

FL32 Occurrence Code/Date a AN/N 2/6 FL31 Occurrence Code/Date a AN/N 2/6 1/1
FL32 Occurrence Code/Date b AN/N 2/6 FL31 Occurrence Code/Date b AN/N 2/6 1/1

FL33 Occurrence Code/Date a AN 2/6 FL32 Occurrence Code/Date a AN/N 2/6 1/1
FL33 Occurrence Code/Date b AN/N 2/6 FL32 Occurrence Code/Date b AN/N 2/6 1/1

FL34 Occurrence Code/Date a AN 2/6 FL33 Occurrence Code/Date a AN/N 2/6 1/1
FL34 Occurrence Code/Date b AN/N 2/6 FL33 Occurrence Code/Date b AN/N 2/6 1/1

FL35 Occurrence Code/Date a AN 2/6 FL34 Occurrence Code/Date a AN/N 2/6 1/1
FL35 Occurrence Code/Date b AN/N 2/6 FL34 Occurrence Code/Date b AN/N 2/6 1/1
Occurrence Span Occurrence Span
FL36 AN/N/N 2/6/6 FL35 AN/N/N 2/6/6 1/1/1
Code/From/Through a Code/From/Through a
FL36 Occurrence Span b AN/N/N 2/6/6 FL35 Occurrence Span b AN/N/N 2/6/6 1/1/1
Code/From/Through Code/From/Through
Occurrence Span
FL36 AN/N/N 2/6/6 1/1/1 New
Code/From/Through a
FL36 Occurrence Span b AN/N/N 2/6/6 1/1/1 New
Code/From/Through
FL37 Unlabeled a AN 8
FL37 Unlabeled b AN 8

FL37 ICN/DCN A AN 23 Moved to FL64 Relocated

FL37 ICN/DCN B AN 23 Moved to FL64
FL37 ICN/DCN C AN 23 Moved to FL64

FL38 Responsible Party Name/Address 1 AN 40 FL38 Responsible Party Name/Address 1 AN 40 2

FL38 Responsible Party Name/Address 2 AN 40 FL38 Responsible Party Name/Address 2 AN 40 2
FL38 Responsible Party Name/Address 3 AN 40 FL38 Responsible Party Name/Address 3 AN 40 2
FL38 Responsible Party Name/Address 4 AN 40 FL38 Responsible Party Name/Address 4 AN 40 2
FL38 Responsible Party Name/Address 5 AN 40 FL38 Responsible Party Name/Address 5 AN 40 2
 FL39 Value Code - Code a AN 2 FL39 Value Code - Code a AN 2 1
FL39 Value Code - Amount a N 9 FL39 Value Code - Amount a N 9 1
FL39 Value Code - Code b AN 2 FL39 Value Code - Code b AN 2 1
FL39 Value Code - Amount b N 9 FL39 Value Code - Amount b N 9 1
FL39 Value Code - Code c AN 2 FL39 Value Code - Code c AN 2 1
FL39 Value Code - Amount c N 9 FL39 Value Code - Amount c N 9 1
FL39 Value Code - Code d AN 2 FL39 Value Code - Code d AN 2 1
FL39 Value Code - Amount d N 9 FL39 Value Code - Amount d N 9 1

FL40 Value Code - Code a AN 2 FL40 Value Code - Code a AN 2 1

FL40 Value Code - Amount a N 9 FL40 Value Code - Amount a N 9 1
FL40 Value Code - Code b AN 2 FL40 Value Code - Code b AN 2 1
FL40 Value Code - Amount b N 9 FL40 Value Code - Amount b N 9 1
FL40 Value Code - Code c AN 2 FL40 Value Code - Code c AN 2 1
FL40 Value Code - Amount c N 9 FL40 Value Code - Amount c N 9 1
FL40 Value Code - Code d AN 2 FL40 Value Code - Code d AN 2 1
FL40 Value Code - Amount d N 9 FL40 Value Code - Amount d N 9 1

FL41 Value Code - Code a AN 2 FL41 Value Code - Code a AN 2 1

FL41 Value Code - Amount a N 9 FL41 Value Code - Amount a N 9 1

* FL68,75,80 Size Updated 6/21/05

UB-92 UB-04 ** FL07, 30 Size Updated 12/15/05
Buffer

FL Description Line Type Size FL Description Line Type Size Space Notes
FL41 Value Code - Code b AN 2 FL41 Value Code - Code b AN 2 1
FL41 Value Code - Amount b N 9 FL41 Value Code - Amount b N 9 1
FL41 Value Code - Code c AN 2 FL41 Value Code - Code c AN 2 1
FL41 Value Code - Amount c N 9 FL41 Value Code - Amount c N 9 1
FL41 Value Code - Code d AN 2 FL41 Value Code - Code d AN 2 1
FL41 Value Code - Amount d N 9 FL41 Value Code - Amount d N 9 1

FL42 Revenue Code 1-23 N 4 FL42 Revenue Code 1-23 N 4 0.5

FL43 Revenue Code Description 1-23 AN 24 FL43 Revenue Code Description 1-22 AN 24 0.5

FL43
44 PAGE ___ OF ___ CREATION DATE 23 N/N 3/3 0.5 New

FL44 HCPCS/Rates/HIPPS Rate Codes 1-23 AN/N/AN 9 FL44 HCPCS/Rates/HIPPS Rate Codes 1-22 AN/N/AN 14 0.5 Expanded size

FL45 Service Date 1-23 N 6 FL45 Service Date 1-22 N 6 0.5

FL45 Creation Date 23 N 6 0.5 New

FL46 Units of Service 1-23 N 7 FL46 Units of Service 1-22 N 7 0.5

Removed
FL47 Total Charges 1-23 N 10 FL47 Total Charges 1-23 N 9 0.5 sign field

Removed
FL48 Non-Covered Charges 1-23 N 10 FL48 Non-Covered Charges 1-23 N 9 0.5 sign field

FL49 Unlabeled 1-23 AN 4 FL49 Unlabeled 1-23 AN 2 0.5

FL50 Payer - Primary A AN 25 FL50 Payer Name - Primary A AN 23

FL50 Payer - Secondary B AN 25 FL50 Payer Name - Secondary B AN 23
FL50 Payer - Tertiary C AN 25 FL50 Payer Name - Tertiary C AN 23

FL51 Provider Number A AN 13 FL51 Health Plan ID A AN 15

FL51 Provider Number B AN 13 FL51 Health Plan ID B AN 15
FL51 Provider Number C AN 13 FL51 Health Plan ID C AN 15

FL52 Release of Information - Primary A AN 1 FL52 Release of Information - Primary A AN 1 1

FL52 Release of Information - Secondary B AN 1 FL52 Release of Information - Secondary B AN 1 1
Fl52 Release of Information - Tertiary C AN 1 FL52 Release of Information - Tertiary C AN 1 1

FL53 Assignment of Benefits - Primary A AN 1 FL53 Assignment of Benefits - Primary A AN 1 1

FL53 Assignment of Benefits - Secondary B AN 1 FL53 Assignment of Benefits - Secondary B AN 1 1
FL53 Assignment of Benefits - Tertiary C AN 1 FL53 Assignment of Benefits - Tertiary C AN 1 1

FL54 Prior Payments - Primary A N 10 FL54 Prior Payments - Primary A N 10 1

FL54 Prior Payments - Secondary B N 10 FL54 Prior Payments - Secondary B N 10 1
FL54 Prior Payments - Tertiary C N 10 FL54 Prior Payments - Tertiary C N 10 1
FL54 Prior Payments - Patient 4 N 10 Eliminated Patient Prior Payments

FL55 Estimated Amount Due - Primary A N 10 FL55 Estimated Amount Due - Primary A N 10 1
FL55 Estimated Amount Due - Secondary B N 10 FL55 Estimated Amount Due - Secondary B N 10 1
FL55 Estimated Amount Due - Tertiary C N 10 FL55 Estimated Amount Due - Tertiary C N 10 1
FL55 Estimated Amount Due - Patient 4 N 10 Eliminated Due from Patient

FL56 Unlabeled 1 13 FL56 NPI 1 AN 15

FL56 Unlabeled 2 14 FL57 Other Provider ID - Primary A AN 15
FL57 Other Provider ID - Secondary B AN 15
FL57 Other Provider ID - Tertiary C AN 15
FL57 Unlabeled 1 27 Deleted from UB-04

FL58 Insured’s Name - Primary A AN 25 FL58 Insured’s Name - Primary A AN 25 1

FL58 Insured's Name - Secondary B AN 25 FL58 Insured's Name - Secondary B AN 25 1
FL58 Insured's Name - Tertiary C AN 25 FL58 Insured's Name - Tertiary C AN 25 1

FL59 Patient’s Relationship - Primary A AN 2 FL59 Patient’s Relationship - Primary A AN 2 1

FL59 Patient's Relationship - Secondary B AN 2 FL59 Patient's Relationship - Secondary B AN 2 1

Buffer
FL Description Line Type Size Space Notes
FL59 Patient's Relationship - Tertiary C AN 2 1

FL60 Insured's Unique ID - Primary A AN 20

FL60 Insured's Unique ID - Secondary B AN 20
FL60 Insured's Unique ID - Tertiary C AN 20

FL61 Insurance Group Name - Primary A AN 14 1

FL61 Insurance Group Name -Secondary B AN 14 1
FL61 Insurance Group Name - Tertiary C AN 14 1

FL62 Insurance Group Number - Primary A AN 17 1

FL62 Insurance Group Number - Secondary B AN 17 1
FL62 Insurance Group Number - Tertiary C AN 17 1

Treatment Authorization Code -

FL63 A AN 30 1
Primary
Treatment Authorization Code -
FL63 Secondary B AN 30 1
FL63 Treatment Authorization Code - C AN 30 1
Tertiary
FL64 Document Control Number A AN 26
FL64 Document Control Number B AN 26
FL64 Document Control Number C AN 26

Deleted from UB-04

Deleted from UB-04
Deleted from UB-04

FL65 Employer Name - Primary A AN 25

FL65 Employer Name - Secondary B AN 25
FL65 Employer Name - Tertiary C AN 25

Deleted from UB-04

Deleted from UB-04
Deleted from UB-04
 FL66 DX Version Qualifier AN 1 New
Denotes
ICD v.
Expanded
FL67 Principal Diagnosis Code AN 8
field
Expanded
FL67A Other Diagnosis AN 8
field
FL67B Other Diagnosis AN 8 Expanded
field
FL67C Other Diagnosis AN 8 Expanded
field
FL67D Other Diagnosis AN 8 Expanded
field
FL67E Other Diagnosis AN 8 Expanded
field
FL67F Other Diagnosis AN 8 Expanded
field
FL67G Other Diagnosis AN 8 Expanded
field
FL67H Other Diagnosis AN 8 Expanded
field
FL67I Other Diagnosis AN 8 New
FL67J Other Diagnosis AN 8 New
FL67K Other Diagnosis AN 8 New
FL67L Other Diagnosis AN 8 New
FL67M Other Diagnosis AN 8 New
FL67N Other Diagnosis AN 8 New
FL67O Other Diagnosis AN 8 New
FL67P Other Diagnosis AN 8 New
FL67Q Other Diagnosis AN 8 New

FL68 Unlabeled 1a AN 8*
FL68 Unlabeled 1b AN 9*

Expanded
FL69 Admitting Diagnosis Code 1 AN 7
by 1

FL70 Patient's Reason for Visit Code A AN 7 Distinct FL

FL70 Patient's Reason for Visit Code B AN 7 Distinct FL

FL70 Patient's Reason for Visit Code C AN 7 Distinct FL

* FL68,75,80 Size Updated 6/21/05

UB-92 UB-04 ** FL07, 30 Size Updated 12/15/05
Buffer
FL Description Line Type Size FL Description Line Type Size Space Notes

FL71 PPS Code 1 AN 3 2 New

FL77 External Cause of Injury Code 1 AN 6 FL72 External Cause of Injury Code 1a AN 8
FL72 External Cause of Injury Code 1b AN 8 New
FL72 External Cause of Injury Code 1c AN 8 New

FL78 Unlabeled FL73 Unlabeled 1 AN 9

FL79 Procedure Coding Method Used 1 N 1 Deleted from UB-04 Deleted

FL80 Principal Procedure Code/Date 1 N/N 6/6 FL74 Principal Procedure Code/Date N/N 7/6 1/1 Expanded by 1

FL81 Other Procedure Code/Date A N/N 6/6 FL74a Other Procedure Code/Date N/N 7/6 1/1 Expanded by 1
FL81 Other Procedure Code/Date B N/N 6/6 FL74b Other Procedure Code/Date N/N 7/6 1/1 Expanded by 1
FL81 Other Procedure Code/Date C N/N 6/6 FL74c Other Procedure Code/Date N/N 7/6 1/1 Expanded by 1
FL81 Other Procedure Code/Date D N/N 6/6 FL74d Other Procedure Code/Date N/N 7/6 1/1 Expanded by 1
FL81 Other Procedure Code/Date E N/N 6/6 FL74e Other Procedure Code/Date N/N 7/6 1/1 Expanded by 1

FL75 Unlabeled 1 AN 4* 0*
FL75 Unlabeled 2 AN 4 1
FL75 Unlabeled 3 AN 4 1
FL75 Unlabeled 4 AN 4 1
AN/AN/AN
FL82 Attending Physician ID a AN 23 FL76 Attending - NPI/QUAL/ID 1 11/2/9 New Layout
FL82 Attending Physician ID b AN 32 FL76 Attending - Last/First 2 AN/AN 16/12 New Layout
AN/AN/AN
FL83A Other Physician ID AN 25 FL77 Operating - NPI/QUAL/ID 1 New Layout
a 11/2/9
FL83A Other Physician ID b AN 32 FL77 Operating - Last/First 2 AN/AN 16/12 New Layout

AN/AN/
FL83B Other Physician ID a AN 25 FL78 Other ID - QUAL/NPI/QUAL/ID 1 AN/AN 2/11/2/9 New Layout
FL83B Other Physician ID b AN 32 FL78 Other ID - Last/First 2 AN/AN 16/12 New Layout

AN/AN/
FL79 Other ID - QUAL/NPI/QUAL/ID 1 AN/AN 2/11/2/9 New
FL79 Other ID - Last/First 2 AN/AN 16/12 New

FL84 Remarks 1 AN 43 FL80 Remarks 1 AN 19* Reduced Field Size

FL84 Remarks 2 AN 48 FL80 Remarks 2 AN 24* Reduced Field Size
FL84 Remarks 3 AN 48 FL80 Remarks 3 AN 24* Reduced Field Size
FL84 Remarks 4 AN 48 FL80 Remarks 4 AN 24* Reduced Field Size
AN/AN/AN
FL81 Code-Code - QUAL/CODE/VALUE a 2/10/12 New
FL81 Code-Code - QUAL/CODE/VALUE b AN/AN/AN New
2/10/12
FL81 Code-Code - QUAL/CODE/VALUE AN/AN/AN New
c
2/10/12
FL81 Code-Code - QUAL/CODE/VALUE d AN/AN/AN New
2/10/12
FL85 Provider Rep. Signature 1 AN 22 Deleted from UB-04

FL86 Date Bill Submitted 1 Date 6 Deleted from UB-04; See FL45, line 23
 UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR
FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS
THE BASIS FOR CIVIL MONETARY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION
INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

Submission of this claim constitutes certification that the billing 9. For TRICARE Purposes:
information as shown on the face hereof is true, accurate and
complete. That the submitter did not knowingly or recklessly (a) The information on the face of this claim is true, accurate and
disregard or misrepresent or conceal material facts. The following complete to the best of the submitter’s knowledge and belief,
certifications or verifications apply where pertinent to this Bill: and services were medically and appropriate for the health of
the patient;
1. If third party benefits are indicated, the appropriate (b) The patient has represented that by a reported residential
assignments by the insured /beneficiary and signature of address outside a military medical treatment facility
the patient or parent or a legal guardian covering catchment area he or she does not live within the catchment
authorization to release information are on file. area of a U.S. Public Health Service medical facility, or if the
Determinations as to the release of medical and financial patient resides within a catchment area of such a facility, a
information should be guided by the patient or the copy of Non-Availability Statement (DD Form 1251) is on file,
patient’s legal representative. or the physician has certified to a medical emergency in any
2. If patient occupied a private room or required private instance where a copy of a Non-Availability Statement is not
nursing for medical necessity, any required certifications on file;
are on file. (c) The patient or the patient’s parent or guardian has responded
directly to the provider’s request to identify all health
3. Physician’s certifications and re-certifications, if required insurance coverage, and that all such coverage is identified
by contract or Federal regulations, are on file. on the face of the claim except that coverage which is
exclusively supplemental payments to TRICARE-determined
4. For Religious Non-Medical facilities, verifications and if benefits;
necessary re-certifications of the patient’s need for (d) The amount billed to TRICARE has been billed after all such
services are on file. coverage have been billed and paid excluding Medicaid, and
the amount billed to TRICARE is that remaining claimed
5. Signature of patient or his representative on certifications, against TRICARE benefits;
authorization to release information, and payment (e) The beneficiary’s cost share has not been waived by consent
request, as required by Federal Law and Regulations (42 or failure to exercise generally accepted billing and collection
USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 efforts; and,
CFR 199) and any other applicable contract regulations, is (f) Any hospital-based physician under contract, the cost of
on file. whose services are allocated in the charges included in this
bill, is not an employee or member of the Uniformed Services.
6. The provider of care submitter acknowledges that the bill For purposes of this certification, an employee of the
is in conformance with the Civil Rights Act of 1964 as Uniformed Services is an employee, appointed in civil service
amended. Records adequately describing services will be (refer to 5 USC 2105), including part-time or intermittent
maintained and necessary information will be furnished to employees, but excluding contract surgeons or other
such governmental agencies as required by applicable personal service contracts. Similarly, member of the
law. Uniformed Services does not apply to reserve members of
the Uniformed Services not on active duty.
7. For Medicare Purposes: If the patient has indicated that (g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
other health insurance or a state medical assistance participating in Medicare must also participate in TRICARE
agency will pay part of his/her medical expenses and for inpatient hospital services provided pursuant to
he/she wants information about his/her claim released to admissions to hospitals occurring on or after January 1,
them upon request, necessary authorization is on file. 1987; and
The patient’s signature on the provider’s request to bill (h) If TRICARE benefits are to be paid in a participating status,
Medicare medical and non-medical information, including the submitter of this claim agrees to submit this claim to the
employment status, and whether the person has employer appropriate TRICARE claims processor. The provider of care
group health insurance which is responsible to pay for the submitter also agrees to accept the TRICARE determined
services for which this Medicare claim is made. reasonable charge as the total charge for the medical
services or supplies listed on the claim form. The provider of
8. For Medicaid purposes: The submitter understands that care will accept the TRICARE-determined reasonable charge
because payment and satisfaction of this claim will be even if it is less than the billed amount, and also agrees to
from Federal and State funds, any false statements, accept the amount paid by TRICARE combined with the cost-
documents, or concealment of a material fact are subject share amount and deductible amount, if any, paid by or on
to prosecution under applicable Federal or State Laws. behalf of the patient as full payment for the listed medical
services or supplies. The provider of care submitter will not
attempt to collect from the patient (or his or her parent or
guardian) amounts over the TRICARE determined reasonable
charge. TRICARE will make any benefits payable directly to
the provider of care, if the provider of care a participating
provider.
UB-04 Printing Standards
The UB-04 is designed to accommodate 10-pitch Pica type, 6 lines per inch. Once
adjusted to the left and right, alignment points in the first print line and characters appear
within form lines as shown in the print file matrix in Exhibit __.
The Printing Standards are used in conjunction with the negative layout that was
approved by the National Uniform Billing Committee (NUBC) and distributed by TFP
Data Systems. Compliance with these standards is required to facilitate the use of image
processing technology such as Optical Character Recognition, facsimile transmissions,
and image storage.
Contact Information for purchase of License agreement and negatives should be made
with TFP Data Systems Compliance Department: 800-482-9367 ext. 1770.
The National Uniform Billing Committee has responsibility for the printing specifications
for Form CMS-1450 (paper UB-04). These specifications are as follows:
Cut Sheet:
Size - 8 ½ inches (plus or minus 0.1 inch) by 11 inches (plus or minus 1/6 inch).
217mm by 281mm plus or minus 2mm.
Print - Face and back, head to head.
Margins:
Face-The top margin from the top edge of the form to the first print position is 1/6 inches
or .4 mm. The left margin is 0.15 inches to the left end of the first print position.
Back - x.xx inch head and foot, x.xx inch left and right. (TBD)
Offset -The X and Y offset for margins must not vary by more than +/-0.1 inch from
sheet to sheet.
The X offset refers to the horizontal distance from the left edge of the paper to the
beginning of the printing. The Y offset refers to the vertical distance between the top of
the paper and the beginning of the printing.
Askewity - The askewity of the printed image must be no greater than 0.15mm in
100mm.
Paper Stock - White, OCR Bond, 20 lbs., equal to JCP-O-25. Cut square with each corner
90 degrees, plus or minus 0.025 degrees.
Ink color:
Front - Ink is to be PMS no. 192 (OCR-Red) (For Example, Flint J6983, formerly known
as Sinclair Valentine). There is to be no contamination with “Black” ink or pigment.
Printed product must meet specifications established as ANSI Standard X-3.86. Printer
must maintain proper ink reflectance limits of the OCR reader specified by the purchaser.
Back - Ink is to be PMS no. 421 (Grey)
Titles - Placement will be indicated on negative;
One Part Marginally Punched Continuous Form:
Size - Same dimensions as for Cut Sheet, plus 0.5” left and right, (overall: 9.5” by 11”;
detached: 8.5” by 11”).
Print - Face and back, head to head.
Margins - On detached sheet, same as for Cut Sheet.
Askewity - On detached sheet, same as for Cut Sheet.
Paper Stock - Same as for Cut Sheet
Ink Color - Same as for Cut Sheet.
Perforations- Marginally ½” left and right, tear line horizontally every 11”
Titles - Placement will be indicated on negative.
Two Part Marginally Punched Continuous Forms:
Size - Same dimensions as for Cut Sheet, plus ½” left and right, (overall: 9.5” x 11”;
detached: 8.5” x 11”).
Print:
Part 1 - Face and back, head to head.
Part 2 - Face and back, head to head.
Margins - On detached sheet, same as for Cut Sheet.
Askewity - On detached sheet, same as for Cut Sheet.
Paper Stock:
Part 1 - Same as for Cut Sheet.
Part 2 - Any color or weight that does not interfere with scanning of part 1
sheet. Suggest the following sequence:
1st part is 20 CB - OCR
• 2nd part is 14 CFB (if not last part)
• Last part is 15 CF
CB = Coated Back (Carbonless black print)
CFB = Coated Front and Back (Carbonless black print)
CF = Coated Front (Carbonless black print)
Ink Color:
Part 1 - Same as for cut sheet.
Part 2 - Any color that will not interfere with scanning of the part 1 sheet.
Perforations - Marginally ½” left and right, tear line horizontally every 11”.
Titles - Placement will be indicated on negative.
The top copy is to be labeled “OCR/Original”.
The remaining copies are to be labeled copy 1, copy 2, copy 3, etc.
Color of the above titles is to be in the same ink as the form (see above).
Note: Users may determine the number of parts that are applicable to their needs.
Up to four total parts are feasible on some printers; some other printers may limit the
readability of multiple plies.
 __ __ __

1 2 3a PAT. 4 TYPE
CNTL # OF BILL
b. MED.
REC. #
__

6 STATEMENT COVERS PERIOD 7

5 FED. TAX NO.
FROM THROUGH

8 PATIENT NAME a 9 PATIENT ADDRESS a

b b c d e

10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 29 ACDT 30

12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE

31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37

CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES

CODE AMOUNT CODE AMOUNT CODE AMOUNT
a
b
c
d
42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

1
1

2
2

3
3

4
4

5
5

6
6

7
7

8
8

9
9

10
10

11
11

12
12

13
13

14
14

15
15

16
16

17
17

18
18

19
19

20
20

21
21

22
22

23

PAGE OF CREATION DATE TOTALS 23

52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
INFO BEN.

A 57 A

B OTHER B

C PRV ID C

58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A A

B B

C C

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A

B B

C C

66
DX 67 A B C D E F G H 68

I J K L M N O P Q
69 ADMIT

74
DX
70 PATIENT
REASON DX
PRINCIPAL PROCEDURE a.
aOTHER PROCEDURE
b b.
c 71 PPS
CODE
OTHER PROCEDURE 75
72
ECI
73

76 ATTENDING NPI QUAL

CODE DATE CODE DATE CODE DATE
LAST FIRST
c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE QUAL
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI

LAST FIRST
81CC
80 REMARKS 78 OTHER NPI QUAL
a
b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST
UB-04 CMS-1450 APPROVED OMB NO. THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

NUBC
™
National Uniform
Billing Committee
LIC9213257
 Medicare Claims Processing Manual
Chapter 25 - Completing and Processing the CMS 1450
Data Set

Table of Contents
(Rev.1104, 11-03-06)
Crosswalk to Old Manuals

50 - Uniform Bill (UB) - Form CMS-1450 (UB-92)

60 - General Instructions for Completion of Form CMS-1450 for Billing (UB-92)
50 - Uniform Bill (UB) - Form CMS-1450 (UB-92)
(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

60 - General Instructions for Completion of Form CMS-1450 for Billing

(UB-92)
(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

This section contains Medicare requirements for use of codes maintained by the National
Uniform Billing Committee that are needed in completion of the Form CMS-1450 and
compliant X12N 837 version 4010A1 institutional claims.
Instructions for completion are the same for inpatient and outpatient claims unless
otherwise noted. If required data is omitted, the FI obtains it from the provider or other
sources and maintains it on its history record. The FI need not search paper files to
annotate missing data unless it does not have an electronic history record. It need not
obtain data that is not needed to process the claim.
Data elements in the CMS uniform electronic billing specifications are consistent with
the Form CMS-1450 data set to the extent that one processing system can handle both.
Definitions are identical. In some situations, the electronic record contains more
characters than the corresponding item on the form because of constraints on the form
size not applicable to the electronic record. Also, for a few data elements not used by
Medicare, conversion may be needed from an alpha code to a numeric, but these do not
affect Medicare processing. The revenue coding system is the same for both the Form
CMS-1450 and the electronic specifications.
Effective June 5, 2000, CMS extended the claim size to 450 lines. For the Form CMS-
1450, this simply means that the FI accepts claims of up to 9 pages. Effective October
16, 2003, all state fields are discontinued and reclassified as reserved for national
assignment.

70 - Uniform Bill - Form CMS-1450 (UB-04)

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

70.1 - Uniform Billing with Form CMS-1450

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

This form, also known as the UB-04, is a uniform institutional provider bill suitable for
use in billing multiple third party payers. Because it serves many payers, a particular
payer may not need some data elements. The National Uniform Billing Committee
(NUBC) maintains lists of approved coding for the form. All items on Form CMS-1450
are described. The FI must be able to capture all NUBC-approved input data described
in section 75 for audit trail purposes and be able to pass all data to other payers with
whom it has a coordination of benefits agreement.
70.2 - Disposition of Copies of Completed Forms
(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

The provider retains the copy designated “Institution Copy” and submits the remaining
copies of the completed Form CMS-1450 to its FI, managed care plan, or other insurer.
Where it knows that a managed care plan will pay the bill, it sends the bill and any
necessary supporting documentation directly to the managed care plan for coverage
determination, payment, and/or denial action. It sends to the FI bills that it knows will be
paid and processed by the FI.

75 - General Instructions for Completion of Form CMS-1450 for Billing

(UB-04)

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

This section contains Medicare requirements for use of codes maintained by the National
Uniform Billing Committee that are needed in completion of the Form CMS-1450 and
compliant X12N 837 version 4010A1 institutional claims. Note that the internal claim
record used for processing is not being expanded. Instructions for completion are the
same for inpatient and outpatient claims unless otherwise noted. The FI need not search
paper files to annotate missing data unless it does not have an electronic history record.
It need not obtain data that is not needed to process the claim.

Effective June 5, 2000, CMS extended the claim size to 450 lines. For the Form CMS-
1450, this simply means that the FI accepts claims of up to 9 pages. Effective October
16, 2003, all state fields are discontinued and reclassified as reserved for national
assignment. The following layout describes the data specifications for the UB-04.

UB-04 LAYOUT SUMMARY

Buffer
FL Description Line Type Size Space

FL01 [Provider Name] 1 AN 25

FL01 [Provider Street Address] 2 AN 25
FL01 [Provider City, State, Zip] 3 AN 25
FL01 [Provider Telephone, Fax, Country Code] 4 AN 25

FL02 [Pay-to Name] 1 AN 25

FL02 [Pay-to Address] 2 AN 25
FL02 [Pay-to City, State] 3 AN 25
FL02 [Pay-to ID] 4 AN 25

FL03a Patient Control Number AN 24

FL03b Medical Record Number AN 24

FL04 Type of Bill 1 AN 4 1

FL05 Federal Tax Number 1 AN 4

FL05 Federal Tax Number 2 AN 10

FL06 Statement Covers Period - From/Through 1 N/N 6/6 1/1

FL07 Unlabeled 1 AN 7
FL07 Unlabeled 2 AN 8

FL08 Patient Name - ID 1a AN 19

FL08 Patient Name 2b AN 29

FL09 Patient Address - Street 1a AN 40 1

FL09 Patient Address - City 2b AN 30 2
FL09 Patient Address - State 2c AN 2 1
FL09 Patient Address - ZIP 2d AN 9 1
FL09 Patient Address - Country Code 2e AN 3

FL10 Patient Birthdate 1 N 8 1

FL11 Patient Sex 1 AN 1 2

FL12 Admission Date 1 N 6

FL13 Admission Hour 1 AN 2 1

FL14 Type of Admission/Visit 1 AN 1 2

FL15 Source of Admission 1 AN 1 2

FL16 Discharge Hour 1 AN 2 1

FL17 Patient Status Code 1 AN 2 1

FL18 Condition Codes AN 2 1

FL19 Condition Codes AN 2 1
FL20 Condition Codes AN 2 1
FL21 Condition Codes AN 2 1
FL22 Condition Codes AN 2 1
FL23 Condition Codes AN 2 1
FL24 Condition Codes AN 2 1
FL25 Condition Codes AN 2 1
FL26 Condition Codes AN 2 1
FL27 Condition Codes AN 2 1
FL28 Condition Codes AN 2 1

FL29 Accident State AN 2 1

FL30 Unlabeled 1 AN 12
FL30 Unlabeled 2 AN 13

FL31 Occurrence Code/Date a AN/N 2/6 1/1

FL31 Occurrence Code/Date b AN/N 2/6 1/1

FL32 Occurrence Code/Date a AN/N 2/6 1/1

FL32 Occurrence Code/Date b AN/N 2/6 1/1

FL33 Occurrence Code/Date a AN/N 2/6 1/1

FL33 Occurrence Code/Date b AN/N 2/6 1/1

FL34 Occurrence Code/Date a AN/N 2/6 1/1

FL34 Occurrence Code/Date b AN/N 2/6 1/1

FL35 Occurrence Span Code/From/Through a AN/N/N 2/6/6 1/1/1

FL35 Occurrence Span Code/From/Through b AN/N/N 2/6/6 1/1/1

FL36 Occurrence Span Code/From/Through a AN/N/N 2/6/6 1/1/1

FL36 Occurrence Span Code/From/Through b AN/N/N 2/6/6 1/1/1

FL37 Unlabeled a AN 8
FL37 Unlabeled b AN 8

FL38 Responsible Party Name/Address 1 AN 40 2

FL38 Responsible Party Name/Address 2 AN 40 2
FL38 Responsible Party Name/Address 3 AN 40 2
FL38 Responsible Party Name/Address 4 AN 40 2
FL38 Responsible Party Name/Address 5 AN 40 2
FL39 Value Codes a AN 2 1
FL39 Value Codes a N 9 1
FL39 Value Codes b AN 2 1
FL39 Value Codes b N 9 1
FL39 Value Codes c AN 2 1
FL39 Value Codes c N 9 1
FL39 Value Codes d AN 2 1
FL39 Value Codes d N 9 1

FL40 Value Codes a AN 2 1

FL40 Value Codes a N 9 1
FL40 Value Codes b AN 2 1
FL40 Value Codes b N 9 1
FL40 Value Codes c AN 2 1
FL40 Value Codes c N 9 1
FL40 Value Codes d AN 2 1
FL40 Value Codes d N 9 1

FL41 Value Codes a AN 2 1

FL41 Value Codes a N 9 1
FL41 Value Codes b AN 2 1
FL41 Value Codes b N 9 1
FL41 Value Codes c AN 2 1
FL41 Value Codes c N 9 1
FL41 Value Codes d AN 2 1
FL41 Value Codes d N 9 1
1-
FL42 Revenue Code N 4
23
1-
FL43 Revenue Code Description AN 24
23
1-
FL44 HCPCS/Rates/HIPPS Rate Codes N 14
23
1-
FL45 Service Date N 6
23
1-
FL46 Units of Service N 7
23
1-
FL47 Total Charges N 9
23
1-
FL48 Non-Covered Charges N 9
23
 1-
FL49 Unlabeled AN 2
23

FL50 Payer Identification - Primary A AN 23

FL50 Payer Identification - Secondary B AN 23
FL50 Payer Identification - Tertiary C AN 23

FL51 Health Plan ID A AN 15

FL51 Health Plan ID B AN 15
FL51 Health Plan ID C AN 15

FL52 Release of Information - Primary A AN 1 1

FL52 Release of Information - Secondary B AN 1 1
FL52 Release of Information - Tertiary C AN 1 1

FL53 Assignment of Benefits - Primary A AN 1 1

FL53 Assignment of Benefits - Secondary B AN 1 1
FL53 Assignment of Benefits - Tertiary C AN 1 1

FL54 Prior Payments - Primary A N 10 1

FL54 Prior Payments - Secondary B N 10 1
FL54 Prior Payments - Tertiary C N 10 1

FL55 Estimated Amount Due - Primary A N 10 1

FL55 Estimated Amount Due - Secondary B N 10 1
FL55 Estimated Amount Due - Tertiary C N 10 1

FL56 NPI 1 AN 15

FL57 Other Provider ID A AN 15

FL57 Other Provider ID B AN 15
FL57 Other Provider ID C AN 15

FL58 Insured’s Name - Primary A AN 25 1

FL58 Insured's Name - Secondary B AN 25 1
FL58 Insured's Name -Tertiary C AN 25 1

FL59 Patient’s Relationship - Primary A AN 2 1

FL59 Patient's Relationship - Secondary B AN 2 1
FL59 Patient's Relationship - Tertiary C AN 2 1
FL60 Insured's Unique ID - Primary A AN 20
FL60 Insured's Unique ID - Secondary B AN 20
FL60 Insured's Unique ID - Tertiary C AN 20

FL61 Insurance Group Name - Primary A AN 14 1

FL61 Insurance Group Name - Secondary B AN 14 1
FL61 Insurance Group Name -Tertiary C AN 14 1

FL62 Insurance Group No. - Primary A AN 17 1

FL62 Insurance Group No. - Secondary B AN 17 1
FL62 Insurance Group No. - Tertiary C AN 17 1

FL63 Treatment Authorization Codes - Primary A AN 30 1

FL63 Treatment Authorization Code - Secondary B AN 30 1
FL63 Treatment Authorization Code - Tertiary C AN 30 1

FL64 Document Control Number A AN 26

FL64 Document Control Number B AN 26
FL64 Document Control Number C AN 26

FL65 Employer Name - Primary A AN 25

FL65 Employer Name - Secondary B AN 25
FL65 Employer Name - Tertiary C AN 25

FL66 DX Version Qualifier AN 1

FL67 Principal Diagnosis Code AN 8

FL67A Other Diagnosis AN 8

FL67B Other Diagnosis AN 8
FL67C Other Diagnosis AN 8
FL67D Other Diagnosis AN 8
FL67E Other Diagnosis AN 8
FL67F Other Diagnosis AN 8
FL67G Other Diagnosis AN 8
FL67H Other Diagnosis AN 8
FL67I Other Diagnosis AN 8
FL67J Other Diagnosis AN 8
FL67K Other Diagnosis AN 8
FL67L Other Diagnosis AN 8
FL67M Other Diagnosis AN 8
FL67N Other Diagnosis AN 8
FL67O Other Diagnosis AN 8
FL67P Other Diagnosis AN 8
FL67Q Other Diagnosis AN 8

FL68 Unlabeled 1 AN 8
FL68 Unlabeled 2 AN 9

FL69 Admitting Diagnosis Code AN 7

FL70a Patient Reason for Visit Code AN 7

FL70b Patient Reason for Visit Code AN 7
FL70c Patient Reason for Visit Code AN 7

FL71 PPS Code AN 3 2

FL72a External Cause of Injury Code AN 8

FL72b External Cause of Injury Code AN 8
FL72c External Cause of Injury Code AN 8

FL73 Unlabeled AN 9

FL74 Principal Procedure Code/Date N/N 7/6 1/1

FL74a Other Procedure Code/Date N/N 7/6 1/1

FL74b Other Procedure Code/Date N/N 7/6 1/1
FL74c Other Procedure Code/Date N/N 7/6 1/1
FL74d Other Procedure Code/Date N/N 7/6 1/1
FL74e Other Procedure Code/Date N/N 7/6 1/1

FL75 Unlabeled 1 AN 3 1
FL75 Unlabeled 2 AN 4 1
FL75 Unlabeled 3 AN 4 1
FL75 Unlabeled 4 AN 4 1

FL76 Attending - NPI/QUAL/ID 1 AN 11/2/9

FL76 Attending – Last/First 2 AN 16/12

FL77 Operating - NPI/QUAL/ID 1 AN 11/2/9

FL77 Operating - Last/First 2 AN 16/12

FL78 Other - QUAL/NPI/QUAL/ID 1 AN 2/11/2/9

FL78 Other - Last/First 2 AN 16/12

FL79 Other - QUAL/NPI/QUAL/ID 1 AN 2/11/2/9

FL79 Other - Last/First 2 AN 16/12

FL80 Remarks 1 AN 21
FL80 Remarks 2 AN 26
FL80 Remarks 3 AN 26
FL80 Remarks 4 AN 26

FL81 Code-Code - QUAL/CODE/VALUE a AN/AN/AN 2/10/12

FL81 Code-Code - QUAL/CODE/VALUE b AN/AN/AN 2/10/12
FL81 Code-Code - QUAL/CODE/VALUE c AN/AN/AN 2/10/12
FL81 Code-Code - QUAL/CODE/VALUE d AN/AN/AN 2/10/12

75.1 - Form Locators 1-15

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

Form Locator (FL) 1 - (Untitled) Provider Name, Address, and Telephone Number
Required. The minimum entry is the provider name, city, State, and ZIP code. The post
office box number or street name and number may be included. The State may be
abbreviated using standard post office abbreviations. Five or nine-digit ZIP codes are
acceptable. This information is used in connection with the Medicare provider number
(FL 51) to verify provider identity. Phone and/or Fax numbers are desirable.

FL 2 – Pay-to Name, address, and Secondary Identification Fields

Situational. Required when the pay-to name and address information is different than
the Billing Provider information in FL1. If used, the minimum entry is the provider
name, address, city, State, and ZIP code.

FL 3a - Patient Control Number

Required. The patient’s unique alpha-numeric control number assigned by the provider
to facilitate retrieval of individual financial records and posting payment may be shown
if the provider assigns one and needs it for association and reference purposes.

FL 3b – Medical/Health Record Number

Situational. The number assigned to the patient’s medical/health record by the provider
(not FL3a).

FL 4 - Type of Bill
Required. This four-digit alphanumeric code gives three specific pieces of information
after a leading zero. CMS will ignore the leading zero. CMS will continue to process
three specific pieces of information. The second digit identifies the type of facility. The
third classifies the type of care. The fourth indicates the sequence of this bill in this
particular episode of care. It is referred to as a “frequency” code.
Code Structure
2nd Digit-Type of Facility (CMS will process this as the 1st digit)
1. Hospital
2. Skilled Nursing
3. Home Health (Includes Home Health PPS claims, for which CMS determines
whether the services are paid from the Part A Trust Fund or the Part B Trust
Fund.)
4. Religious Nonmedical (Hospital)
5. Reserved for national assignment (discontinued effective 10/1/05).
6. Intermediate Care
7. Clinic or Hospital Based Renal Dialysis Facility (requires special information
in second digit below).
8. Special facility or hospital ASC surgery (requires special information in second
digit below).
9. Reserved for National Assignment
3rd Digit-Bill Classification (Except Clinics and Special Facilities) (CMS will process
this as the 2nd digit)
1. Inpatient (Part A)
2. Inpatient (Part B) - (For HHA non PPS claims, Includes HHA visits under a Part
B plan of treatment, for HHA PPS claims, indicates a Request for Anticipated
Payment - RAP.) Note: For HHA PPS claims, CMS determines from which Trust
Fund payment is made. Therefore, there is no need to indicate Part A or Part B
on the bill.
3. Outpatient (For non-PPS HHAs, includes HHA visits under a Part A plan of
treatment and use of HHA DME under a Part A plan of treatment). For home
health agencies paid under PPS, CMS determines from which Trust Fund, Part A
or Part B. Therefore, there is no need to indicate Part A or Part B on the bill.
4. Other (Part B) - Includes HHA medical and other health services not under a
plan of treatment, hospital and SNF for diagnostic clinical laboratory services for
“nonpatients,” and referenced diagnostic services. For HHAs under PPS,
indicates an osteoporosis claim. NOTE: 24X is discontinued effective 10/1/05.
5. Intermediate Care - Level I
6. Intermediate Care - Level II
7. Reserved for national assignment (discontinued effective 10/1/05).
8. Swing Bed (may be used to indicate billing for SNF level of care in a hospital with
an approved swing bed agreement).
9. Reserved for National Assignment
3rd Digit-Classification (Clinics Only) (CMS will process this as the 2nd digit)
1. Rural Health Clinic (RHC)
2. Hospital Based or Independent Renal Dialysis Facility
3. Free Standing Provider-Based Federally Qualified Health Center (FQHC)
4. Other Rehabilitation Facility (ORF)
5. Comprehensive Outpatient Rehabilitation Facility (CORF)
6. Community Mental Health Center (CMHC)
 7-8. Reserved for National Assignment
9. OTHER
3rd Digit-Classification (Special Facilities Only) (CMS will process this as the 2nd
digit)
1. Hospice (Nonhospital Based)
2. Hospice (Hospital Based)
3. Ambulatory Surgical Center Services to Hospital Outpatients
4. Free Standing Birthing Center
5. Critical Access Hospital
6-8. Reserved for National Assignment
9. OTHER
4th Digit-Frequency – Definition (CMS will process this as the 3rd digit)
A Admission/Election Notice Used when the hospice or Religious Non-medical
Health Care Institution is submitting Form CMS-
1450 as an Admission Notice.
B Hospice/Medicare Used when the Form CMS-1450 is used as a notice
Coordinated Care of termination/revocation for a previously posted
Demonstration/Religious Hospice/Medicare Coordinated Care
Nonmedical Health Care Demonstration/Religious Non-medical Health Care
Institution Institution election.
Termination/Revocation
Notice
C Hospice Change of Used when Form CMS-1450 is used as a Notice of
Provider Notice Change to the hospice provider.
D Hospice/Medicare Used when Form CMS-1450 is used as a Notice of
Coordinated Care a Void/Cancel of Hospice/Medicare Coordinated
Demonstration/Religious Care Demonstration/Religious Non-medical Health
Nonmedical Health Care Care Institution election.
Institution Void/Cancel
E Hospice Change of Used when Form CMS-1450 is used as a Notice of
Ownership Change in Ownership for the hospice.
F Beneficiary Initiated Used to identify adjustments initiated by the
Adjustment Claim beneficiary. For FI use only.
G CWF Initiated Adjustment Used to identify adjustments initiated by CWF.
Claim For FI use only.
H CMS Initiated Adjustment Used to identify adjustments initiated by CMS. For
Claim FI use only.
I FI Adjustment Claim (Other Used to identify adjustments initiated by the FI.
than QIO or Provider For FI use only
J Initiated Adjustment Claim- Used to identify adjustments initiated by other
Other entities. For FI use only.
K OIG Initiated Adjustment Used to identify adjustments initiated by OIG. For
Claim FI use only.
M MSP Initiated Adjustment Used to identify adjustments initiated by MSP. For
Claim FI use only. Note: MSP takes precedence over
other adjustment sources.
 P QIO Adjustment Claim Used to identify an adjustment initiated as a result
of a QIO review. For FI use only.
0 Nonpayment/Zero Claims Provider uses this code when it does not anticipate
payment from the payer for the bill, but is
informing the payer about a period of non-payable
confinement or termination of care. The
“Through” date of this bill (FL 6) is the discharge
date for this confinement, or termination of the
plan of care.
1 Admit Through Discharge The provider uses this code for a bill encompassing
Claim an entire inpatient confinement or course of
outpatient treatment for which it expects payment
from the payer or which will update deductible for
inpatient or Part B claims when Medicare is
secondary to an EGHP.
2 Interim-First Claim Used for the first of an expected series of bills for
which utilization is chargeable or which will
update inpatient deductible for the same
confinement of course of treatment. For HHAs,
used for the submission of original or replacement
RAPs.
3 Interim-Continuing Claims Use this code when a bill for which utilization is
(Not valid for PPS Bills) chargeable for the same confinement or course of
treatment had already been submitted and further
bills are expected to be submitted later.
4 Interim-Last Claim (Not This code is used for a bill for which utilization is
valid for PPS Bills) chargeable, and which is the last of a series for this
confinement or course of treatment. The
“Through” date of this bill (FL 6) is the discharge
for this treatment.
5 Late Charge Only Used for outpatient claims only. Late charges are
not accepted for Medicare inpatient, home health,
or Ambulatory Surgical Center (ASC) claims.
7 Replacement of Prior Claim This is used to correct a previously submitted bill.
The provider applies this code to the corrected or
“new” bill.
8 Void/Cancel of a Prior The provider uses this code to indicate this bill is
Claim an exact duplicate of an incorrect bill previously
submitted. A code “7” (Replacement of Prior
Claim) is being submitted showing corrected
information.
9 Final Claim for a Home This code indicates the HH bill should be
Health PPS Episode processed as a debit or credit adjustment to the
request for anticipated payment.

Bill Type Codes

The following table lists “Type of Bill,” FL4, codes by Provider Number Range(s). For a
definition of each facility type, see the Medicare State Operations Manual.

Bill Type Code

011X Hospital Inpatient (Part A)

012X Hospital Inpatient Part B
013X Hospital Outpatient
014X Hospital Other Part B
018X Hospital Swing Bed
021X SNF Inpatient
022X SNF Inpatient Part B
023X SNF Outpatient
028X SNF Swing Bed
032X Home Health
033X Home Health
034X Home Health (Part B Only)
041X Religious Nonmedical Health Care
Institutions
071X Clinical Rural Health
072X Clinic ESRD
073X Federally Qualified Health Centers
074X Clinic OPT
075X Clinic CORF
076X Community Mental Health Centers
081X Nonhospital based hospice
082X Hospital based hospice
083X Hospital Outpatient (ASC)
085X Critical Access Hospital

FL 5 - Federal Tax Number

Required. The format is NN-NNNNNNN.

FL 6 - Statement Covers Period (From-Through)

Required. The provider enters the beginning and ending dates of the period included on
this bill in numeric fields (MMDDYY). Days before the patient’s entitlement are not
shown. With the exception of home health PPS claims, the period may not span two
accounting years. The FI uses the “From” date to determine timely filing.

FL 7
Not Used.

FL 8 - Patient’s Name
Required. The provider enters the patient’s last name, first name, and, if any, middle
initial, along with patient ID (if different than the subscriber/insured’s ID).
FL 9 - Patient’s Address
Required. The provider enters the patient’s full mailing address, including street number
and name, post office box number or RFD, city, State, and Zip code.

FL 10 - Patient’s Birth Date

Required. The provider enters the month, day, and year of birth (MMDDCCYY) of
patient. If full birth date is unknown, indicate zeros for all eight digits.

FL 11 - Patient’s Sex
Required. The provider enters an “M” (male) or an “F” (female). The patient’s sex is
recorded at admission, outpatient service, or start of care.

FL 12 - Admission Date
Required For Inpatient and Home Health. The hospital enters the date the patient was
admitted for inpatient care (MMDDYY). The HHA enters the same date of admission
that was submitted on the RAP for the episode.

FL 13 - Admission Hour
Not Required. If submitted, the data will be ignored.

FL 14 - Type of Admission/Visit
Required on inpatient bills only. This is the code indicating priority of this admission.
Code Structure:
1 Emergency - The patient required immediate medical intervention as a result of
severe, life threatening or potentially disabling conditions. Generally, the patient
was admitted through the emergency room.
2 Urgent- The patient required immediate attention for the care and treatment of a
physical or mental disorder. Generally, the patient was admitted to the first
available, suitable accommodation.
3 Elective - The patient’s condition permitted adequate time to schedule the
availability of a suitable accommodation.
4 Newborn - Use of this code necessitates the use of a Special Source of Admission
codes.
5 Trauma Center - Visits to a trauma center/hospital as licensed or designated by
the State or local government authority authorized to do so, or as verified by the
American College of surgeons and involving a trauma activation.
6-8 Reserved for National Assignment
9 Information Not Available – Visits to a trauma center/hospital as licensed or
designated by the State or local government authority authorized to do so, or
verified by the American College of Surgeons and involving a trauma activation.

FL 15 – Source of Admission
Required. The provider enters the code indicating the source of the referral for this
admission or visit.
Code Structure:
1 Physician Referral Inpatient: The patient was admitted to this facility upon
 the recommendation of their personal physician.
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by their
personal physician or the patient independently
requested outpatient services (self-referral).
2 Clinic Referral Inpatient: The patient was admitted to this facility upon
the recommendation of this facility’s clinic physician.
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by this
facility’s clinic or other outpatient department
physician.
3 Managed Care Plan Inpatient: The patient was admitted to this facility upon
Referral the recommendation of a Managed Care Plan physician.
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by a
Managed Care Plan physician.
4 Transfer from a Inpatient: The patient was admitted to this facility as a
Hospital transfer from a different acute care facility where they
(different facility *) were an inpatient
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by a
physician of a different acute care facility.
* For transfers from hospital inpatient in the same
facility, see code D.
5 Transfer from a SNF Inpatient: The patient was admitted to this facility as a
transfer from a SNF where he or she was an inpatient.
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by a
physician of the SNF where he or she was an inpatient.
6 Transfer from Another Inpatient: The patient was admitted to this facility from
Health Care Facility a health care facility other than an acute care facility or
SNF. This includes transfers from nursing homes, long
term care facilities and SNF patients that are at a non-
skilled level of care.
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by a
physician of another health care facility where they are
an inpatient.
7 Emergency Room Inpatient: The patient was admitted to this facility upon
the recommendation of this facility’s emergency room
physician.
Outpatient: The patient received services in this
facility’s emergency department.
8 Court/Law Inpatient: The patient was admitted to this facility upon
Enforcement the direction of a court of law, or upon the request of a
law enforcement agency representative.
 Outpatient: The patient was referred to this facility
upon the direction of a court of law, or upon the request
of a law enforcement agency representative for
outpatient or referenced diagnostic services.
9 Information Not Inpatient: The means by which the patient was
Available admitted to this facility is not known.
Outpatient: For Medicare outpatient bills, this is not a
valid code.
A Transfer from a Inpatient: The patient was admitted to this facility as a
Critical Access transfer from a CAH where he or she was an inpatient.
Hospital (CAH)
Outpatient: The patient was referred to this facility for
outpatient or referenced diagnostic services by (a
physician of) the CAH were the patient was an inpatient.
B Transfer From Another The patient was admitted to this home health agency as
Home Health Agency a transfer from another home health agency
C Readmission to Same The patient was readmitted to this home health agency
Home Health Agency within the same home health episode period.

D Transfer from hospital The patient was admitted to this facility as a transfer
inpatient in the same from hospital inpatient within this facility resulting in a
facility resulting in a separate claim to the payer.
separate claim to the
payer
E-Z Reserved for national assignment.

75.2 - Form Locators 16-30

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

FL 16 – Discharge Hour
Not Required.

FL 17 – Patient Status
Required. (For all Part A inpatient, SNF, hospice, home health agency (HHA) and
outpatient hospital services.) This code indicates the patient’s status as of the
“Through” date of the billing period (FL 6).
Code Structure
01 Discharged to home or self care (routine discharge)
02 Discharged/transferred to a short-term general hospital for inpatient
care.
03 Discharged/transferred to SNF with Medicare certification in
anticipation of covered skilled care (effective 2/23/05). See Code 61
below.
04 Discharged/transferred to an Intermediate Care Facility (ICF)
05 Discharged/transferred to another type of institution not defined
elsewhere in this code list (effective 2/23/05).
Code Structure
Usage Note: Cancer hospitals excluded from Medicare PPS and
children’s hospitals are examples of such other types of institutions.
06 Discharged/transferred to home under care of organized home health
service organization in anticipation of covered skills care (effective
2/23/05).
07 Left against medical advice or discontinued care
08 Reserved for National Assignment
*09 Admitted as an inpatient to this hospital
10-19 Reserved for National Assignment
20 Expired (or did not recover - Religious Non Medical Health Care Patient)
21-29 Reserved for National Assignment
30 Still patient or expected to return for outpatient services
31-39 Reserved for National Assignment
40 Expired at home (Hospice claims only)
41 Expired in a medical facility, such as a hospital, SNF, ICF or
freestanding hospice (Hospice claims only)
42 Expired - place unknown (Hospice claims only)
43 Discharged/transferred to a federal health care facility. (effective
10/1/03)
Usage note: Discharges and transfers to a government operated health
care facility such as a Department of Defense hospital, a Veteran’s
Administration (VA) hospital or VA hospital or a VA nursing facility. To
be used whenever the destination at discharge is a federal health care
facility, whether the patient lives there or not.
44-49 Reserved for national assignment
50 Discharged/transferred to Hospice - home
51 Discharged/transferred to Hospice - medical facility
52-60 Reserved for national assignment
61 Discharged/transferred within this institution to a hospital based
Medicare approved swing bed.
62 Discharged/transferred to an inpatient rehabilitation facility including
distinct part units of a hospital
63 Discharged/transferred to long term care hospitals
64 Discharged/transferred to a nursing facility certified under Medicaid but
not certified under Medicare
65 Discharged/transferred to a psychiatric hospital or psychiatric distinct
part unit of a hospital.
66 Discharged/transferred to a Critical Access Hospital (CAH). (effective
1/1/06)
67-99 Reserved for national assignment
*In situations where a patient is admitted before midnight of the third day following the
day of an outpatient diagnostic service or service related to the reason for the admission,
the outpatient services are considered inpatient. Therefore, code 09 would apply only to
services that began longer than 3 days earlier or were unrelated to the reason for
admission, such as observation following outpatient surgery, which results in admission.
FLs 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28 - Condition Codes
Situational. The provider enters the corresponding code (in numerical order) to
describe any of the following conditions or events that apply to this billing period.
Code Title Definition
02 Condition is Employment Patient alleges that the medical condition
Related causing this episode of care is due to
environment/events resulting from the
patient’s employment.
03 Patient Covered by Insurance Indicates that patient/patient representative
Not Reflected Here has stated that coverage may exist beyond
that reflected on this bill.
04 Information Only Bill Indicates bill is submitted for informational
purposes only. Examples would include a
bill submitted as a utilization report, or a bill
for a beneficiary who is enrolled in a risk-
based managed care plan and the hospital
expects to receive payment from the plan.
05 Lien Has Been Filed The provider has filed legal claim for
recovery of funds potentially due to a patient
as a result of legal action initiated by or on
behalf of a patient.
06 ESRD Patient in the First 18 Medicare may be a secondary insurer if the
Months of Entitlement Covered patient is also covered by employer group
By Employer Group Health health insurance during the patient’s first 18
Insurance months of end stage renal disease
entitlement.
07 Treatment of Non-terminal The patient has elected hospice care, but the
Condition for Hospice Patient provider is not treating the patient for the
terminal condition and is, therefore,
requesting regular Medicare payment.
08 Beneficiary Would Not Provide The beneficiary would not provide
Information Concerning Other information concerning other insurance
Insurance Coverage coverage. The FI develops to determine
proper payment.
09 Neither Patient Nor Spouse is In response to development questions, the
Employed patient and spouse have denied employment.
10 Patient and/or Spouse is In response to development questions, the
Employed but no EGHP patient and/or spouse indicated that one or
Coverage Exists both are employed but have no group health
insurance under an EGHP or other employer
sponsored or provided health insurance that
covers the patient.
11 Disabled Beneficiary But no In response to development questions, the
Large Group Health Plan disabled beneficiary and/or family member
(LGHP) indicated that one or more are employed, but
Code Title Definition
have no group coverage from an LGHP.
12-14 Payer Codes Codes reserved for internal use only by third
party payers. The CMS will assign as
needed for FI use. Providers will not report.
15 Clean Claim Delayed in The claim is a clean claim in which payment
CMS’s Processing System was delayed due to a CMS processing delay.
(Medicare Payer Only Code) Interest is applicable, but the claim is not
subject to CPE/CPT standards.
16 SNF Transition Exemption An exemption from the post-hospital
(Medicare Payer Only Code) requirement applies for this SNF stay or the
qualifying stay dates are more than 30 days
prior to the admission date.
17 Patient is Homeless The patient is homeless.
18 Maiden Name Retained A dependent spouse entitled to benefits who
does not use her husband’s last name.
19 Child Retains Mother’s Name A patient who is a dependent child entitled to
benefits that does not have his/her father’s
last name.
20 Beneficiary Requested Billing Provider realizes services are non-covered
level of care or excluded, but beneficiary
requests determination by payer. (Currently
limited to home health and inpatient SNF
claims.)
21 Billing for Denial Notice The provider realizes services are at a
noncovered level or excluded, but it is
requesting a denial notice from Medicare in
order to bill Medicaid or other insurers.
26 VA Eligible Patient Chooses to Patient is VA eligible and chooses to receive
Receive Services In a Medicare services in a Medicare certified facility
Certified Facility instead of a VA facility.
27 Patient Referred to a Sole (Sole Community Hospitals only). The
Community Hospital for a patient was referred for a diagnostic
Diagnostic Laboratory Test laboratory test. The provider uses this code
to indicate laboratory service is paid at 62
percent fee schedule rather than 60 percent
fee schedule.
28 Patient and/or Spouse’s EGHP In response to development questions, the
is Secondary to Medicare patient and/or spouse indicated that one or
both are employed and that there is group
health insurance from an EGHP or other
employer-sponsored or provided health
insurance that covers the patient but that
either: (1) the EGHP is a single employer
plan and the employer has fewer than 20 full
and part time employees; or (2) the EGHP is
Code Title Definition
a multi or multiple employer plan that elects
to pay secondary to Medicare for employees
and spouses aged 65 and older for those
participating employers who have fewer than
20 employees.
29 Disabled Beneficiary and/or In response to development questions, the
Family Member’s LGHP is patient and/or family member(s) indicated
Secondary to Medicare that one or more are employed and there is
group health insurance from an LGHP or
other employer-sponsored or provided
health insurance that covers the patient but
that either: (1) the LGHP is a single
employer plan and the employer has fewer
than 100 full and part time employees; or (2)
the LGHP is a multi or multiple employer
plan and that all employers participating in
the plan have fewer than 100 full and part-
time employees.
30 Qualifying Clinical Trials Non-research services provided to all
patients, including managed care enrollees,
enrolled in a Qualified Clinical Trial.
31 Patient is a Student (Full-Time Patient declares that they are enrolled as a
- Day) full-time day student.
32 Patient is a Student Patient declares that they are enrolled in a
(Cooperative/Work Study cooperative/work study program.
Program)
33 Patient is a Student (Full-Time Patient declares that they are enrolled as a
- Night) full-time night student.
34 Patient is a Student (Part- Patient declares that they are enrolled as a
Time) part-time student.
Accommodations
35 Reserved for National Reserved for National Assignment.
Assignment
36 General Care Patient in a (Not used by hospitals under PPS.) The
Special Unit hospital temporarily placed the patient in a
special care unit because no general care
beds were available.
Accommodation charges for this period are
at the prevalent semi-private rate.
37 Ward Accommodation at (Not used by hospitals under PPS.) The
Patient’s Request patient was assigned to ward
accommodations at their own request.
38 Semi-private Room Not (Not used by hospitals under PPS.) Either
Available private or ward accommodations were
assigned because semi-private
Code Title Definition
accommodations were not available.
NOTE: If revenue charge codes indicate a ward accommodation was assigned and
neither code 37 nor code 38 applies, and the provider is not paid under PPS, the
provider’s payment is at the ward rate. Otherwise, Medicare pays semi-private costs.
39 Private Room Medically (Not used by hospitals under PPS.) The
Necessary patient needed a private room for medical
reasons.
40 Same Day Transfer The patient was transferred to another
participating Medicare provider before
midnight on the day of admission.
41 Partial Hospitalization The claim is for partial hospitalization
services. For outpatient services, this
includes a variety of psychiatric programs
(such as drug and alcohol).
42 Continuing Care Not Related Continuing care plan is not related to the
to Inpatient Admission condition or diagnosis for which the
individual received inpatient hospital
services.
43 Continuing Care Not Provided Continuing care plan was related to the
Within Prescribed Post inpatient admission but the prescribed care
Discharge Window was not provided within the post discharge
window.
44 Inpatient Admission Changed For use on outpatient claims only, when the
to Outpatient physician ordered inpatient services, but
upon internal utilization review performed
before the claim was originally submitted,
the hospital determined that the services did
not meet its inpatient criteria. (Note: For
Medicare, the change in patient status from
inpatient to outpatient is made prior to
discharge or release while the patient is still
a patient of the hospital).
45 Reserved for national assignment
46 Non-Availability Statement on A nonavailability statement must be issued
File for each TRICARE claim for nonemergency
inpatient care when the TRICARE
beneficiary resides within the catchment
area (usually a 40-mile radius) of a
Uniformed Services Hospital.
47 Reserved for TRICARE
48 Psychiatric Residential Code to identify claims submitted by a
Treatment Centers for “TRICARE – authorized” psychiatric
Children and Adolescents Residential Treatment Center (RTC) for
(RTCs) Children and Adolescents.
49 Product replacement within Replacement of a product earlier than the
Code Title Definition
product lifecycle anticipated lifecycle due to an indication that
the product is not functioning properly.
50 Product replacement for Manufacturer or FDA has identified the
known recall of a product product for recall and therefore
replacement.
51-54 Reserved for national assignment
55 SNF Bed Not Available The patient’s SNF admission was delayed
more than 30 days after hospital discharge
because a SNF bed was not available.
56 Medical Appropriateness The patient’s SNF admission was delayed
more than 30 days after hospital discharge
because the patient’s condition made it
inappropriate to begin active care within
that period.
57 SNF Readmission The patient previously received Medicare
covered SNF care within 30 days of the
current SNF admission.
58 Terminated Managed Care Code indicates that patient is a terminated
Organization Enrollee enrollee in a Managed Care Plan whose
three-day inpatient hospital stay was waived.
59 Non-primary ESRD Facility Code indicates that ESRD beneficiary
received non-scheduled or emergency
dialysis services at a facility other than
his/her primary ESRD dialysis facility.
Effective 10/01/04
60 Operating Cost Day Outlier Day Outlier obsolete after FY 1997. (Not
reported by providers, not used for a capital
day outlier.) PRICER indicates this bill is a
length-of-stay outlier. The FI indicates the
cost outlier portion paid value code 17.
61 Operating Cost Outlier (Not reported by providers, not used for
capital cost outlier.) PRICER indicates this
bill is a cost outlier. The FI indicates the
operating cost outlier portion paid in value
code 17.
62 PIP Bill (Not reported by providers.) Bill was paid
under PIP. The FI records this from its
system.
63 Payer Only Code Reserved for internal payer use only. CMS
assigns as needed. Providers do not report
this code. Indicates services rendered to a
prisoner or a patient in State or local
custody meets the requirements of 42 CFR
411.4(b) for payment
64 Other Than Clean Claim (Not reported by providers.) The claim is
Code Title Definition
not “clean.” The FI records this from its
system.
65 Non-PPS Bill (Not reported by providers.) Bill is not a
PPS bill. The FI records this from its system
for non-PPS hospital bills.
66 Hospital Does Not Wish Cost The hospital is not requesting additional
Outlier Payment payment for this stay as a cost outlier. (Only
hospitals paid under PPS use this code.)
67 Beneficiary Elects Not to Use The beneficiary elects not to use LTR days.
Lifetime Reserve (LTR) Days
68 Beneficiary Elects to Use The beneficiary elects to use LTR days when
Lifetime Reserve (LTR) Days charges are less than LTR coinsurance
amounts.
69 IME/DGME/N&A Payment Code indicates a request for a supplemental
Only payment for IME/DGME/N&AH (Indirect
Medical Education/Graduate Medical
Education/Nursing and Allied Health.
70 Self-Administered Anemia Code indicates the billing is for a home
Management Drug dialysis patient who self administers an
anemia management drug such as
erythropoetin alpha (EPO) or darbepoetin
alpha.
71 Full Care in Unit The billing is for a patient who received
staff-assisted dialysis services in a hospital
or renal dialysis facility.
72 Self-Care in Unit The billing is for a patient who managed
their own dialysis services without staff
assistance in a hospital or renal dialysis
facility.
73 Self-Care Training The bill is for special dialysis services where
a patient and their helper (if necessary) were
learning to perform dialysis.
74 Home The bill is for a patient who received dialysis
services at home.
75 Home 100-percent Not used for Medicare.
76 Back-up In-Facility Dialysis The bill is for a home dialysis patient who
received back-up dialysis in a facility.
77 Provider Accepts or is The provider has accepted or is
Obligated/Required Due to a obligated/required to accept payment as
Contractual Arrangement or payment in full due to a contractual
Law to Accept Payment by the arrangement or law. Therefore, no
Primary Payer as Payment in Medicare payment is due.
Full
78 New Coverage Not The bill is for a newly covered service under
Implemented by Managed Medicare for which a managed care plan
Code Title Definition
Care Plan does not pay. (For outpatient bills, condition
code 04 should be omitted.)
79 CORF Services Provided Off- Physical therapy, occupational therapy, or
Site speech pathology services were provided off-
site.
80 Home Dialysis-Nursing Home dialysis furnished in a SNF or
Facility Nursing Facility.
81-99 Reserved for National assignment.
Special Program Indicator Codes Required
The only special program indicators that apply to Medicare are:

A0 TRICARE External Not used for Medicare.

Partnership Program

A3 Special Federal Funding This code is for uniform use by State uniform
billing committees.
A5 Disability This code is for uniform use by State uniform
billing committees.
A6 PPV/Medicare Pneumococcal Medicare pays under a special Medicare
Pneumonia/Influenza 100% program provision for pneumococcal
Payment pneumonia/influenza vaccine (PPV) services.
A7-A8 Reserved for national assignment
A9 Second Opinion Surgery Services requested to support second opinion
on surgery. Part B deductible and
coinsurance do not apply.
AA Abortion Performed due to Self-explanatory – Effective 10/1/02
Rape
AB Abortion Performed due to Self-explanatory – Effective 10/1/02
Incest
AC Abortion Performed due to Self-explanatory – Effective 10/1/02
Serious Fetal Genetic Defect,
Deformity, or Abnormality
AD Abortion Performed due to a Self-explanatory – Effective 10/1/02
Life Endangering Physical
Condition Caused by, Arising
From or Exacerbated by the
Pregnancy Itself
AE Abortion Performed due to Self-explanatory – Effective 10/1/02
Physical Health of Mother
that is not Life Endangering
AF Abortion Performed due to Self-explanatory – Effective 10/1/02
Emotional/psychological
Health of the Mother
AG Abortion Performed due to Self-explanatory – Effective 10/1/02
Social Economic Reasons
Code Title Definition
AH Elective Abortion Self-explanatory – Effective 10/1/02
AI Sterilization Self-explanatory – Effective 10/1/02
AJ Payer Responsible for Self-explanatory – Effective 4/1/03
Copayment
AK Air Ambulance Required For ambulance claims. Air ambulance
required – time needed to transport poses a
threat – Effective 10/16/03
AL Specialized Treatment/bed For ambulance claims. Specialized
Unavailable treatment/bed unavailable. Transported to
alternate facility. – Effective 10/16/03
AM Non-emergency Medically For ambulance claims. Non-emergency
Necessary Stretcher medically necessary stretcher transport
Transport Required required. Effective 10/16/03
AN Preadmission Screening Not Person meets the criteria for an exemption
Required from preadmission screening. Effective
1/1/04
AO-AZ Reserved for national assignment
B0 Medicare Coordinated Care Patient is participant in a Medicare
Demonstration Program Coordinated Care Demonstration.
B1 Beneficiary is Ineligible for Full definition pending
Demonstration Program
B2 Critical Access Hospital Attestation by Critical Access Hospital that it
Ambulance Attestation meets the criteria for exemption from the
Ambulance Fee Schedule
B3 Pregnancy Indicator Indicates patient is pregnant. Required when
mandated by law. The determination of
pregnancy should be completed in
compliance with applicable Law. – Effective
10/16/03
B4 Admission Unrelated to Admission unrelated to discharge on same
Discharge day. This code is for discharges starting on
January 1, 2004. Effective January 1, 2005
B5-BZ Reserved for national assignment
QIO Approval Indicator Codes
C1 Approved as Billed Claim has been reviewed by the QIO and has
been fully approved including any outlier.
C3 Partial Approval The QIO has reviewed the bill and denied
some portion (days or services).
From/Through dates of the approved portion
of the stay are shown as code “M0” in FL
36. The hospital excludes grace days and
any period at a non-covered level of care
(code “77” in FL 36 or code “46” in FL 39-
41).
C4 Admission Denied The patient’s need for inpatient services was
Code Title Definition
reviewed and the QIO found that none of the
stay was medically necessary.
C5 Post-payment Review Any medical review will be completed after
Applicable the claim is paid.
C6 Preadmission/Pre-procedure The QIO authorized this
admission/procedure but has not reviewed
the services provided.
C7 Extended Authorization The QIO has authorized these services for an
extended length of time but has not reviewed
the services provided.
C8-CZ Reserved for national assignment
Claim Change Reasons
D0 Changes to Service Dates Self-explanatory
D1 Changes to Charges Self-explanatory
D2 Changes to Revenue Report this claim change reason code on a
Codes/HCPCS/HIPPS Rate replacement claim (Bill Type Frequency Code
Code 7) to reflect a change in Revenue Codes
(FL42)/HCPCS/HIPPS Rate Codes (FL44)
D3 Second or Subsequent Interim Self-explanatory
PPS Bill
D4 Changes In ICD-9-CM Use for inpatient acute care hospital, long-
Diagnosis and/or Procedure term care hospital, inpatient rehabilitation
Code facility and inpatient Skilled Nursing Facility
(SNF).
D5 Cancel to Correct HICN or Cancel only to delete an incorrect HICN or
Provider ID Provider Identification Number.
D6 Cancel Only to Repay a Cancel only to repay a duplicate payment or
Duplicate or OIG OIG overpayment (Includes cancellation of an
Overpayment outpatient bill containing services required to
be included on an inpatient bill.)
D7 Change to Make Medicare the Self-explanatory
Secondary Payer
D8 Change to Make Medicare the Self-explanatory
Primary Payer
D9 Any Other Change Self-explanatory
DA – Reserved for national assignment
DQ
DR Disaster related Used to identify claims that are or may be
impacted by specific payer/health plan
policies related to a national or regional
disaster.
DS – Reserved for national assignment
DZ
E0 Change in Patient Status Self-explanatory
E1 – Reserved for national assignment
Code Title Definition
FZ
G0 Distinct Medical Visit Report this code when multiple medical visits
occurred on the same day in the same revenue
center. The visits were distinct and
constituted independent visits. An example of
such a situation would be a beneficiary going
to the emergency room twice on the same day,
in the morning for a broken arm and later for
chest pain. Proper reporting of Condition
Code G0 allows for payment under OPPS in
this situation. The OCE contains an edit that
will reject multiple medical visits on the same
day with the same revenue code without the
presence of Condition Code G0.
G1 – Reserved for national assignment
GZ
H0 Delayed Filing, Statement Of Code indicates that Statement of Intent was
Intent Submitted submitted within the qualifying period to
specifically identify the existence of another
third party liability situation.
H1-LZ Reserved for national assignment
M0 All Inclusive Rate for Used by a Critical Access Hospital electing to
Outpatient Services (Payer be paid an all-inclusive rate for outpatient.
Only Code)
M1- Reserved for national assignment
MZ
N0-OZ Reserved for national assignment
P0-PZ Reserved for national assignment. FOR
PUBLIC HEALTH DATA REPORTING
ONLY
Q0-VZ Reserved for national assignment.
W0 United Mine Workers of United Mine Workers of America (UMWA)
America (UMWA) Demonstration Indicator ONLY
Demonstration Indicator
W1-ZZ Reserved for national assignment.

FL 29 – Accident State
Not used. Data entered will be ignored.

FL 30 - (Untitled)
Not used. Data entered will be ignored.
75.3 - Form Locators 31-41
(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

FLs 31, 32, 33, and 34 - Occurrence Codes and Dates

Situational. Required when there is a condition code that applies to this claim.

GUIDELINES FOR OCCURRENCE AND OCCURRENCE SPAN UTILIZATION

Due to the varied nature of Occurrence and Occurrence Span Codes, provisions have
been made to allow the use of both type codes within each. The Occurrence Span Code
can contain an occurrence code where the “Through” date would not contain an entry.
This allows as many as 10 Occurrence Codes to be utilized. With respect to Occurrence
Codes, complete field 31a - 34a (line level) before the “b” fields. Occurrence and
Occurrence Span codes are mutually exclusive. An example of Occurrence Code use: A
Medicare beneficiary was confined in hospital from January 1, 2005 to January 10,
2005, however, his Medicare Part A benefits were exhausted as of January 8, 2005, and
he was not entitled to Part B benefits. Therefore, Form Locator 31 should contain code
A3 and the date 010805.

The provider enters code(s) and associated date(s) defining specific event(s) relating to
this billing period. Event codes are two alpha-numeric digits, and dates are six numeric
digits (MMDDYY). When occurrence codes 01-04 and 24 are entered, the provider must
make sure the entry includes the appropriate value code in FLs 39-41, if there is another
payer involved. Occurrence and occurrence span codes are mutually exclusive. When
FLs 36 A and B are fully used with occurrence span codes, FLs 34a and 34b and 35a and
35b may be used to contain the “From” and “Through” dates of other occurrence span
codes. In this case, the code in FL 34 is the occurrence span code and the occurrence
span “From” dates is in the date field. FL 35 contains the same occurrence span code as
the code in FL 34, and the occurrence span “Through” date is in the date field. Other
payers may require other codes, and while Medicare does not use them, they may be
entered on the bill if convenient.
Code Structure (Only codes affecting Medicare payment/processing are shown.)
Code Title Definition
01 Accident/Medical Coverage Code indicating accident-related injury for
which there is medical payment coverage.
Provide the date of accident/injury
02 No-Fault Insurance Involved - Date of an accident, including auto or other,
Including Auto Accident/Other where the State has applicable no-fault or
liability laws (i.e., legal basis for settlement
without admission or proof of guilt).
03 Accident/Tort Liability Date of an accident resulting from a third
party’s action that may involve a civil court
action in an attempt to require payment by
the third party, other than no-fault liability.
04 Accident/Employment Related Date of an accident that relates to the
patient’s employment.
Code Title Definition
05 Accident/No Medical or Code indicating accident related injury for
Liability Coverage which there is no medical payment or third-
party liability coverage. Provide date of
accident or injury.
06 Crime Victim Code indicating the date on which a medical
condition resulted from alleged criminal
action committed by one or more parties.
07-08 Reserved for national assignment.

09 Start of Infertility Treatment Code indicating the date of start of infertility

Cycle treatment cycle.

10 Last Menstrual Period Code indicating the date of the last menstrual
period. ONLY applies when patient is being
treated for maternity related condition.

11 Onset of Symptoms/Illness (Outpatient claims only.) Date that the

patient first became aware of
symptoms/illness.
12 Date of Onset for a (HHA Claims Only.) The provider enters the
Chronically Dependent date that the patient/beneficiary becomes a
Individual (CDI) chronically dependent individual (CDI). This
is the first month of the 3-month period
immediately prior to eligibility under Respite
Care Benefit.
13-15 Reserved for national assignment
16 Date of Last Therapy Code indicates the last day of therapy
services (e.g., physical, occupational or
speech therapy).
17 Date Outpatient Occupational The date the occupational therapy plan was
Therapy Plan Established or established or last reviewed.
Reviewed
18 Date of Retirement Date of retirement for the patient/beneficiary.
Patient/Beneficiary
19 Date of Retirement Spouse Date of retirement for the patient’s spouse.
20 Guarantee of Payment Began (Part A hospital claims only.) Date on which
the hospital begins claiming payment under
the guarantee of payment provision.
21 UR Notice Received (Part A SNF claims only.) Date of receipt by
the SNF and hospital of the URC finding that
an admission or further stay was not
medically necessary.
22 Date Active Care Ended Date on which a covered level of care ended
in a SNF or general hospital, or date on
Code Title Definition
which active care ended in a psychiatric or
tuberculosis hospital or date on which patient
was released on a trial basis from a
residential facility. Code is not required if
code “21” is used.
23 Date of Cancellation of Code is not required if code “21” is used.
Hospice Election Period. For
FI Use Only. Providers Do
Not Report.
24 Date Insurance Denied Date of receipt of a denial of coverage by a
higher priority payer.
25 Date Benefits Terminated by The date on which coverage (including
Primary Payer Worker’s Compensation benefits or no-fault
coverage) is no longer available to the
patient.
26 Date SNF Bed Available The date on which a SNF bed became
available to a hospital inpatient who required
only SNF level of care.
27 Date of Hospice Certification The date of certification or re-certification of
or Re-Certification the hospice benefit period, beginning with the
first two initial benefit periods of 90 days
each and the subsequent 60-day benefit
periods.
28 Date CORF Plan Established The date a plan of treatment was established
or Last Reviewed or last reviewed for CORF care.
29 Date OPT Plan Established or The date a plan was established or last
Last Reviewed reviewed for OPT.
30 Date Outpatient Speech The date a plan was established or last
Pathology Plan Established or reviewed for outpatient speech pathology.
Last Reviewed
31 Date Beneficiary Notified of The date the hospital notified the beneficiary
Intent to Bill that the beneficiary does not (or no longer)
(Accommodations) requires inpatient care and that coverage has
ended.
32 Date Beneficiary Notified of The date of the notice provided to the
Intent to Bill (Procedures or beneficiary that requested care (diagnostic
Treatments) procedures or treatments) that may not be
reasonable or necessary under Medicare.
33 First Day of the Medicare The first day of the Medicare coordination
Coordination Period for ESRD period during which Medicare benefits are
Beneficiaries Covered by an secondary to benefits payable under an
EGHP EGHP. This is required only for ESRD
beneficiaries.
34 Date of Election of Extended The date the guest elected to receive extended
Care Services care services (used by Religious Nonmedical
Code Title Definition
Health Care Institutions only).
35 Date Treatment Started for The date the provider initiated services for
Physical Therapy physical therapy.
36 Date of Inpatient Hospital The date of discharge for a hospital stay in
Discharge for a Covered which the patient received a covered
Transplant Procedure(s) transplant procedure. Entered on bills for
which the hospital is billing for
immunosuppressive drugs.
NOTE: When the patient received a covered
and a non-covered transplant, the covered
transplant predominates.
37 Date of Inpatient Hospital The date of discharge for an inpatient
Discharge - Patient Received hospital stay during which the patient
Non-covered Transplant received a non-covered transplant procedure.
Entered on bills for which the hospital is
billing for immunosuppressive drugs.
38 Date treatment started for Date the patient was first treated at home for
Home IV Therapy IV therapy (Home IV providers - bill type
85X).
39 Date discharged on a Date the patient was discharged from the
continuous course of IV hospital on a continuous course of IV
therapy therapy. (Home IV providers- bill type 85X).
40 Scheduled Date of Admission The date on which a patient will be admitted
as an inpatient to the hospital. (This code
may only be used on an outpatient claim.)
41 Date of First Test for Pre- The date on which the first outpatient
admission Testing diagnostic test was performed as a part of a
PAT program. This code may be used only if
a date of admission was scheduled prior to
the administration of the test(s).
42 Date of Discharge (Hospice claims only.) The date on which a
beneficiary terminated their election to
receive hospice benefits from the facility
rendering the bill. The frequency digit
should be 1 or 4.

43 Scheduled Date of Cancelled The date for which outpatient surgery was
Surgery scheduled.
44 Date Treatment Started for The date the provider initiated services for
Occupational Therapy occupational therapy.
45 Date Treatment Started for The date the provider initiated services for
Speech Therapy speech therapy.
46 Date Treatment Started for The date the provider initiated services for
Cardiac Rehabilitation cardiac rehabilitation.
Code Title Definition
47 Date Cost Outlier Status Code indicates that this is the first day the
Begins inpatient cost outlier threshold is reached.
For Medicare purposes, a beneficiary must
have regular coinsurance and/or lifetime
reserve days available beginning on this date
to allow coverage of additional daily charges
for the purpose of making cost outlier
payments.
48-49 Payer Codes For use by third party payers only. The CMS
assigns for FI use. Providers do not report
these codes.
50-69 Reserved for State Assignment. Discontinued
Effective October 16, 2003.
A1 Birth Date-Insured A The birth-date of the insured in whose name
the insurance is carried.
A2 Effective Date-Insured A The first date the insurance is in force.
Policy
A3 Benefits Exhausted The last date for which benefits are available
and after which no payment can be made by
payer A.
A4 Split Bill Date Date patient became Medicaid eligible due to
medically needy spend down (sometimes
referred to as “Split Bill Date”). Effective
10/1/03.
A5-AZ Reserved for national assignment
B1 Birth Date-Insured B The birth-date of the individual in whose
name the insurance is carried.
B2 Effective Date-Insured B The first date the insurance is in force.
Policy
B3 Benefits Exhausted The last date for which benefits are available
and after which no payment can be made by
payer B.
B4-BZ Reserved for national assignment
C1 Birth Date-Insured C The birth-date of the individual in whose
name the insurance is carried.
C2 Effective Date-Insured C The first date the insurance is in force.
Policy
C3 Benefits Exhausted The last date for which benefits are available
and after which no payment can be made by
payer C.
C4-CZ Reserved for National Assignment.
D0-DQ Reserved for National Assignment.
DR Reserved for Disaster Related Code
DS-DZ Reserved for National Assignment
E0 Reserved for National Assignment
Code Title Definition
E1 Birth Date-Insured D Discontinued 3/1/07.
E2 Effective Date-Insured D Discontinued 3/1/07.
Policy
E3 Benefits Exhausted Discontinued 3/1/07.
E4-EZ Reserved for national assignment
F0 Reserved for national assignment
F1 Birth Date-Insured E Discontinued 3/1/07.
F2 Effective Date-Insured E Discontinued 3/1/07.
Policy
F3 Benefits Exhausted Discontinued 3/1/07.
F4-FZ Reserved for national assignment
G0 Reserved for national assignment
G1 Birth Date-Insured F Discontinued 3/1/07.
G2 Effective Date-Insured F Discontinued 3/1/07.
Policy
G3 Benefits Exhausted Discontinued 3/1/07.
G4-LZ Reserved for national assignment
M0- See instructions in FLs 35 and 36 –
MQ Occurrence Span Codes and Dates
MR Reserved for Disaster Related Code
MS-ZZ Reserved for national assignment
FLs 35 and 36 - Occurrence Span Code and Dates
Required For Inpatient.
The provider enters codes and associated beginning and ending dates defining a specific
event relating to this billing period. Event codes are two alpha-numeric digits and dates
are shown numerically as MMDDYY.

Code Structure
Code Title Definition
70 Qualifying Stay Dates (Part A claims for SNF level of care only.)
The From/Through dates for a hospital stay of
at least 3 days that qualifies the patient for
payment of the SNF level of care services
billed on this claim.
70 Non-utilization Dates (For The From/Through dates during a PPS inlier
Payer Use on Hospital Bills stay for which the beneficiary has exhausted
Only) all regular days and/or coinsurance days, but
which is covered on the cost report.
71 Hospital Prior Stay Dates (Part A claims only.) The From/Through
dates given by the patient of any hospital stay
that ended within 60 days of this hospital or
SNF admission.
72 First/Last Visit The actual dates of the first and last visits
occurring in this billing period where these
dates are different from those in FL 6,
Code Title Definition
Statement Covers Period.
74 Non-covered Level of Care The From/Through dates for a period at a
non-covered level of care in an otherwise
covered stay, excluding any period reported
with occurrence span codes 76, 77, or 79.
Codes 76 and 77 apply to most non-covered
care. Used for leave of absence, or for
repetitive Part B services to show a period of
inpatient hospital care or outpatient surgery
during the billing period. Also used for HHA
or hospice services billed under Part A, but
not valid for HHA under PPS.
75 SNF Level of Care The From/Through dates for a period of SNF
level of care during an inpatient hospital stay.
Since QIOs no longer routinely review
inpatient hospital bills for hospitals under
PPS, this code is needed only in length of stay
outlier cases (code “60” in FLs 24-30). It is
not applicable to swing-bed hospitals that
transfer patients from the hospital to a SNF
level of care.
76 Patient Liability The From/Through dates for a period of non-
covered care for which the provider is
permitted to charge the beneficiary. Codes
should be used only where the FI or the QIO
has approved such charges in advance and
the patient has been notified in writing 3 days
prior to the “From” date of this period. (See
occurrence codes 31 and/or 32.)
77 Provider Liability- Utilization The From/Through dates of a period of care
Charged for which the provider is liable (other than for
lack of medical necessity or custodial care).
The beneficiary’s record is charged with Part
A days, Part A or Part B deductible and Part
B coinsurance. The provider may collect the
Part A or Part B deductible and coinsurance
from the beneficiary.
78 SNF Prior Stay Dates (Part A claims only.) The From/Through
dates given to the hospital by the patient of
any SNF stay that ended within 60 days of this
hospital or SNF admission. An inpatient stay
in a facility or part of a facility that is
certified or licensed by the State solely below
a SNF level of care does not continue a spell
of illness and, therefore, is not shown in FL
Code Title Definition
36.
79 Payer Code THIS CODE IS SET ASIDE FOR PAYER USE
ONLY. PROVIDERS DO NOT REPORT
THIS CODE.
M0 QIO/UR Stay Dates If a code “C3” is in FL 24-30, the provider
enters the From and Through dates of the
approved billing period.
M1 Provider Liability-No Code indicates the From/Through dates of a
Utilization period of non-covered care that is denied due
to lack of medical necessity or as custodial
care for which the provider is liable. The
beneficiary is not charged with utilization.
The provider may not collect Part A or Part B
deductible or coinsurance from the
beneficiary.
M2 Dates of Inpatient Respite From/Through dates of a period of inpatient
Care respite care for hospice patients.
M3 ICF Level of Care The From/Through dates of a period of
intermediate level of care during an inpatient
hospital stay
M4 Residential Level of Care The From/Through dates of a period of
residential level of care during an inpatient
stay
M5-ZZ Reserved for National Assignment

FL 37 - (Untitled)
Not used. Data entered will be ignored.

FL 38 - Responsible Party Name and Address

Not Required. For claims that involve payers of higher priority than Medicare.

FLs 39, 40, and 41 - Value Codes and Amounts

Required. Code(s) and related dollar or unit amount(s) identify data of a monetary
nature that are necessary for the processing of this claim. The codes are two alpha-
numeric digits, and each value allows up to nine numeric digits (0000000.00). Negative
amounts are not allowed except in FL 41. Whole numbers or non-dollar amounts are
right justified to the left of the dollars and cents delimiter. Some values are reported as
cents, so the provider must refer to specific codes for instructions.

If more than one value code is shown for a billing period, codes are shown in ascending
numeric sequence. There are four lines of data, line “a” through line “d.” The provider
uses FLs 39A through 41A before 39B through 41B (i.e., it uses the first line before the
second). Note that codes 80-83 are only available for use on the UB-04.

Code Title Definition

Code Title Definition
01 Most Common Semi-Private To provide for the recording of hospital’s most
Rate common semi-private rate.
02 Hospital Has No Semi- Entering this code requires $0.00 amount.
Private Rooms
03 Reserved for national assignment
04 Inpatient Professional The sum of the inpatient professional component
Component Charges Which charges that are combined billed. Medicare uses
Are Combined Billed this information in internal processes and also in
the CMS notice of utilization sent to the patient to
explain that Part B coinsurance applies to the
professional component. (Used only by some all-
inclusive rate hospitals.)
05 Professional Component (Applies to Part B bills only.) Indicates that the
Included in Charges and charges shown are included in billed charges FL
Also Billed Separately to 47, but a separate billing for them will also be
Carrier made to the carrier. For outpatient claims, these
charges are excluded in determining the
deductible and coinsurance due from the patient
to avoid duplication when the carrier processes
the bill for physician’s services. These charges
are also deducted when computing interim
payment.
The hospital uses this code also when outpatient
treatment is for mental illness, and professional
component charges are included in FL 47.

06 Medicare Part A and Part B The product of the number of un-replaced

Blood Deductible deductible pints of blood supplied times the
charge per pint. If the charge per pint varies, the
amount shown is the sum of the charges for each
un-replaced pint furnished.
If all deductible pints have been replaced, this
code is not to be used.
When the hospital gives a discount for un-
replaced deductible blood, it shows charges after
the discount is applied.

07 Reserved for National Assignment

08 Medicare Lifetime Reserve The product of the number of lifetime reserve

Amount in the First Calendar days used in the first calendar year of the billing
Year in Billing Period period times the applicable lifetime reserve
coinsurance rate. These are days used in the year
Code Title Definition
of admission.
09 Medicare Coinsurance The product of the number of coinsurance days
Amount in the First Calendar used in the first calendar year of the billing
Year in Billing Period period multiplied by the applicable coinsurance
rate. These are days used in the year of
admission. The provider may not use this code
on Part B bills.
For Part B coinsurance use value codes A2, B2
and C2.
10 Medicare Lifetime Reserve The product of the number of lifetime reserve
Amount in the Second days used in the second calendar year of the
Calendar Year in Billing billing period multiplied by the applicable
Period lifetime reserve rate. The provider uses this code
only on bills spanning 2 calendar years when
lifetime reserve days were used in the year of
discharge.
11 Medicare Coinsurance The product of the number of coinsurance days
Amount in the Second used in the second calendar year of the billing
Calendar Year in Billing period times the applicable coinsurance rate.
Period The provider uses this code only on bills spanning
2 calendar years when coinsurance days were
used in the year of discharge. It may not use this
code on Part B bills.
12 Working Aged Beneficiary That portion of a higher priority EGHP payment
Spouse With an EGHP made on behalf of an aged beneficiary that the
provider is applying to covered Medicare charges
on this bill. It enters six zeros (0000.00) in the
amount field to claim a conditional payment
because the EGHP has denied coverage. Where
it received no payment or a reduced payment
because of failure to file a proper claim, it enters
the amount that would have been payable had it
filed a proper claim.
13 ESRD Beneficiary in a That portion of a higher priority EGHP payment
Medicare Coordination made on behalf of an ESRD priority beneficiary
Period With an EGHP that the provider is applying to covered Medicare
charges on the bill. It enters six zeros (0000.00)
in the amount field if it is claiming a conditional
payment because the EGHP has denied coverage.
Where it received no payment or a reduced
payment because of failure to file a proper claim,
it enters the amount that would have been
payable had it filed a proper claim.
14 No-Fault, Including That portion of a higher priority no-fault
Auto/Other Insurance insurance payment, including auto/other
Code Title Definition
insurance, made on behalf of a Medicare
beneficiary, that the provider is applying to
covered Medicare charges on this bill. It enters
six zeros (0000.00) in the amount field if it is
claiming a conditional payment because the other
insurer has denied coverage or there has been a
substantial delay in its payment. If it received no
payment or a reduced no-fault payment because
of failure to file a proper claim, it enters the
amount that would have been payable had it filed
a proper claim
15 Worker’s Compensation That portion of a higher priority WC insurance
(WC) payment made on behalf of a Medicare
beneficiary that the provider is applying to
covered Medicare charges on this bill. It enters
six zeros (0000.00) in the amount field if it is
claiming a conditional payment because there has
been a substantial delay in its payment. Where
the provider received no payment or a reduced
payment because of failure to file a proper claim,
it enters the amount that would have been
payable had it filed a proper claim.
16 PHS, Other Federal Agency That portion of a higher priority PHS or other
Federal agency’s payment, made on behalf of a
Medicare beneficiary that the provider is
applying to covered Medicare charges.
NOTE: A six zero value entry for Value Codes
12-16 indicates conditional Medicare payment
requested (000000).
17 Operating Outlier Amount (Not reported by providers.) The FI reports the
amount of operating outlier payment made (either
cost or day (day outliers have been obsolete since
1997)) in CWF with this code. It does not include
any capital outlier payment in this entry.
18 Operating Disproportionate (Not reported by providers.) The FI reports the
Share Amount operating disproportionate share amount
applicable. It uses the amount provided by the
disproportionate share field in PRICER. It does
not include any PPS capital DSH adjustment in
this entry.
19 Operating Indirect Medical (Not reported by providers.) The FI reports
Education Amount operating indirect medical education amount
applicable. It uses the amount provided by the
indirect medical education field in PRICER. It
does not include any PPS capital IME adjustment
Code Title Definition
in this entry.
20 Payer Code (For internal use by third party payers only.)
21 Catastrophic Medicaid-eligibility requirements to be
determined at State level.
22 Surplus Medicaid-eligibility requirements to be
determined at State level.
23 Recurring Monthly Income Medicaid-eligibility requirements to be
determined at State level.
24 Medicaid Rate Code Medicaid-eligibility requirements to be
determined at State level.
25 Offset to the Patient- Prescription drugs paid for out of a long-term
Payment Amount – care facility resident/patient’s funds in the billing
Prescription Drugs period submitted (Statement Covers Period).
26 Offset to the Patient- Hearing and ear services paid for out of a long-
Payment Amount – Hearing term care facility resident/patient’s funds in the
and Ear Services billing period submitted (Statement Covers
Period).
27 Offset to the Patient- Vision and eye services paid for out of a long-
Payment Amount – Vision term care facility resident/patient’s funds in the
and Eye Services billing period submitted (Statement Covers
Period).
28 Offset to the Patient- Dental services paid for out of a long-term care
Payment Amount – Dental facility resident/patient’s funds in the billing
Services period submitted (Statement Covers Period).
29 Offset to the Patient- Chiropractic Services paid for out of a long term
Payment Amount – care facility resident/patient’s funds in the billing
Chiropractic Services period submitted (Statement Covers Period).
31 Patient Liability Amount The FI approved the provider charging the
beneficiary the amount shown for non-covered
accommodations, diagnostic procedures, or
treatments.
32 Multiple Patient Ambulance If more than one patient is transported in a single
Transport ambulance trip, report the total number of
patients transported.
33 Offset to the Patient- Podiatric services paid for out of a long-term
Payment Amount – Podiatric care facility resident/patient’s funds in the billing
Services period submitted (Statement Covers Period).
34 Offset to the Patient- Other medical services paid for out of a long-
Payment Amount – Other term care facility resident/patient’s funds in the
Medical Services billing period submitted (Statement Covers
Period).
35 Offset to the Patient- Health insurance premiums paid for out of long-
Payment Amount – Health term care facility resident/patient’s funds in the
Insurance Premiums billing period submitted (Statement Covers
Period).
Code Title Definition
36 Reserved for national assignment.
37 Pints of Blood Furnished The total number of pints of whole blood or units
of packed red cells furnished, whether or not they
were replaced. Blood is reported only in terms of
complete pints rounded upwards, e.g., 1 1/4 pints
is shown as 2 pints. This entry serves as a basis
for counting pints towards the blood deductible.
38 Blood Deductible Pints The number of un-replaced deductible pints of
blood supplied. If all deductible pints furnished
have been replaced, no entry is made.
39 Pints of Blood Replaced The total number of pints of blood that were
donated on the patient’s behalf. Where one pint
is donated, one pint is considered replaced. If
arrangements have been made for replacement,
pints are shown as replaced. Where the hospital
charges only for the blood processing and
administration, (i.e., it does not charge a
“replacement deposit fee” for un-replaced pints),
the blood is considered replaced for purposes of
this item. In such cases, all blood charges are
shown under the 039X revenue code series (blood
administration) or under the 030X revenue code
series (laboratory).

40 New Coverage Not (For inpatient service only.) Inpatient charges

Implemented by Managed covered by the Managed Care Plan. (The
Care Plan hospital uses this code when the bill includes
inpatient charges for newly covered services that
are not paid by the Managed Care Plan. It must
also report condition codes 04 and 78.)
41 Black Lung (BL) That portion of a higher priority BL payment
made on behalf of a Medicare beneficiary that the
provider is applying to covered Medicare charges
on this bill. It enters six zeros (0000.00) in the
amount field if it is claiming a conditional
payment because there has been a substantial
delay in its payment. Where it received no
payment or a reduced payment because of failure
to file a proper claim, it enters the amount that
would have been payable had it filed a proper
claim.
42 Veterans Affairs (VA) That portion of a higher priority VA payment
made on behalf of a Medicare beneficiary that the
provider is applying to Medicare charges on this
Code Title Definition
bill.
43 Disabled Beneficiary Under That portion of a higher priority LGHP payment
Age 65 With LGHP made on behalf of a disabled beneficiary that it is
applying to covered Medicare charges on this
bill. The provider enters six zeros (0000.00) in
the amount field, if it is claiming a conditional
payment because the LGHP has denied coverage.
Where it received no payment or a reduced
payment because of failure to file a proper claim,
it enters the amount that would have been
payable had it filed a proper claim.
44 Amount Provider Agreed to That portion that the provider was obligated or
Accept From Primary Payer required to accept from a primary payer as
When this Amount is Less payment in full when that amount is less than
than Charges but Higher charges but higher than the amount actually
than Payment Received received. A Medicare secondary payment is due.
45 Accident Hour The hour when the accident occurred that
necessitated medical treatment. Enter the
appropriate code indicated below, right justified
to the left of the dollar/cents delimiter.
46 Number of Grace Days If a code “C3” or “C4” is in FL 24-30,
indicating that the QIO has denied all or a
portion of this billing period, the provider shows
the number of days determined by the QIO to be
covered while arrangements are made for the
patient’s post discharge. The field contains one
numeric digit.
47 Any Liability Insurance That portion from a higher priority liability
insurance paid on behalf of a Medicare
beneficiary that the provider is applying to
Medicare covered charges on this bill. It enters
six zeros (0000.00) in the amount field if it is
claiming a conditional payment because there has
been a substantial delay in the other payer’s
payment.
48 Hemoglobin Reading The latest hemoglobin reading taken during this
billing cycle. The provider reports in three
positions (a percentage) to the left of the
dollar/cent delimiter. If the reading is provided
with a decimal, it uses the position to the right of
the delimiter for the third digit. Effective January
1, 2006 the definition of value code 48 is changed
to indicate the patient’s most recent hemoglobin
reading taken before the start of the billing
period.
Code Title Definition
49 Hematocrit Reading Hematocrit Reading - Code indicates the
hematocrit reading taken before the last
administration of EPO during this billing cycle.
This is usually reported in two positions (a
percentage) to the left of the dollar/cents
delimiter. If the reading is provided with a
decimal, use the position to the right of the
delimiter for the third digit. Effective January 1,
2006 the definition of value code 49 is changed to
indicate the patient’s most recent hematocrit
reading taken before the start of the billing
period.
50 Physical Therapy Visits The number of physical therapy visits from onset
(at the billing provider) through this billing
period.
51 Occupational Therapy Visits The number of occupational therapy visits from
onset (at the billing provider) through this billing
period.
52 Speech Therapy Visits The number of speech therapy visits from onset
(at the billing provider) through this billing
period.
53 Cardiac Rehabilitation Visits The number of cardiac rehabilitation visits from
onset (at the billing provider) through this billing
period.
54 Newborn birth weight in Actual birth weight or weight at time of admission
grams for an extramural birth. Required on all claims
with type f admission of 4 and on other claims as
required by State law.
55 Eligibility Threshold for Code identifies the corresponding value amount
Charity Care at which a health care facility determines the
eligibility threshold for charity care.
56 Skilled Nurse – Home Visit The number of hours of skilled nursing provided
Hours (HHA only) during the billing period. The provider counts
only hours spent in the home. It excludes travel
time. It reports in whole hours, right justified to
the left of the dollars/cents delimiter. (Rounded
to the nearest whole hour.)
57 Home Health Aide – Home The number of hours of home health aide services
Visit Hours (HHA only) provided during the billing period. The provider
counts only hours spent in the home. It excludes
travel time. It reports in whole hours, right
justified to the left of the dollars/cents delimiter.
(The number is rounded to the nearest whole
hour.)
NOTE: Codes 50-57 represent the number of visits or hours of service provided. Entries
Code Title Definition
for the number of visits are right justified from the dollars/cents delimiter as follows:

1 3
The FI accepts zero or blanks in the cents position, converting blanks to zero for CWF.
58 Arterial Blood Gas (PO2/PA2) Indicates arterial blood gas value at the
beginning of each reporting period for oxygen
therapy. This value or value 59 is required on
the initial bill for oxygen therapy and on the
fourth month’s bill. The provider reports
right justified in the cents area. (See note
following code 59 for an example.)
59 Oxygen Saturation (02 Indicates oxygen saturation at the beginning
Sat/Oximetry) of each reporting period for oxygen therapy.
This value or value 58 is required on the
initial bill for oxygen therapy and on the
fourth month’s bill. The hospital reports right
justified in the cents area. (See note following
this code for an example.)
NOTE: Codes 58 and 59 are not money amounts. They represent arterial blood gas or
oxygen saturation levels. Round to two decimals or to the nearest whole percent. For
example, a reading of 56.5 is shown as:
5 7
A reading of 100 percent is shown as:
1 0 0

Code Title Definition

60 HHA Branch MSA The MSA in which HHA branch is located.
(The HHA reports the MSA when its branch
location is different than the HHA’s main
location – It reports the MSA number in dollar
portion of the form locator, right justified to
the left of the dollar/cents delimiter.)
Code Title Definition
61 Location Where Service is MSA number or Core Based Statistical Area
Furnished (HHA and Hospice) (CBSA) number (or rural State code) of the
location where the home health or hospice
service is delivered. The HHA reports the
number in dollar portion of the form locator
right justified to the left of the dollar/cents
delimiter.
For episodes in which the beneficiary’s site of
service changes from one MSA to another
within the episode period, HHAs should
submit the MSA code corresponding to the site
of service at the end of the episode on the
claim.

62 HH Visits – Part A The number of visits determined by Medicare

(Internal Payer Use Only) to be payable from the Part A trust fund to
reflect the shift of payments from the Part A to
the Part B Trust Fund as mandated by
§1812(a)(3) of the Social Security Act.
63 HH Visits – Part B The number of visits determined by Medicare
(Internal Payer Use Only) to be payable from the Part B trust fund to
reflect the shift of payments from the Part A to
the Part B Trust Fund as mandated by
§1812(a)(3) of the Social Security Act.
64 HH Reimbursement – Part A The dollar amounts determined to be
(Internal Payer Use Only) associated with the HH visits identified in a
value code 62 amount. This Part A payment
reflects the shift of payments from the Part A
to the Part B Trust Fund as mandated by
§1812(a)(3) of the Social Security Act.
65 HH Reimbursement – Part B The dollar amounts determined to be
(Internal Payer Use Only) associated with the HH visits identified in a
value code 63 amount. This Part B payment
reflects the shift of payments from the Part A
to the Part B Trust Fund as mandated by
§1812(a)(3) of the Social Security Act.
66 Medicare Spend-down Amount The dollar amount that was used to meet the
recipient’s spend-down liability for this claim.
67 Peritoneal Dialysis The number of hours of peritoneal dialysis
provided during the billing period. The
provider counts only the hours spent in the
home, excluding travel time. It reports in
whole hours, right justifying to the left of the
dollar/cent delimiter. (Rounded to the nearest
whole hour.)
68 Number of Units of EPO Indicates the number of units of EPO
Code Title Definition
Provided During the Billing administered and/or supplied relating to the
Period billing period. The provider reports in whole
units to the left of the dollar/cent delimiter.
For example, 31,060 units are administered
for the billing period. Thus, 31,060 is entered
as follows:

3 1 0 6 0

Code Title Definition

69 State Charity Care Percent Code indicates the percentage of charity
care eligibility for the patient. Report the
whole number right justified to the left of the
dollar/cents delimiter and fractional amounts
to the right.
70 Interest Amount (For use by third party payers only.) The
contractor reports the amount of interest
applied to this Medicare claim.
71 Funding of ESRD Networks (For third party payer use only.) The FI
reports the amount the Medicare payment
was reduced to help fund ESRD networks.
72 Flat Rate Surgery Charge (For third party payer use only.) The
standard charge for outpatient surgery
where the provider has such a charging
structure.
73-74 Payer Codes (For use by third party payers only.)
75 Gramm/Rudman/Hollings (For third party payer internal use only.)
The contractor reports the amount of
sequestration.
76 Provider’s Interim Rate (For third party payer internal use only.)
Provider’s percentage of billed charges
interim rate during this billing period. This
applies to all outpatient hospital and skilled
nursing facility (SNF) claims and home
health agency (HHA) claims to which an
interim rate is applicable. The contractor
reports to the left of the dollar/cents
delimiter. An interim rate of 50 percent is
entered as follows:

5 0 0 0
Code Title Definition
77 Medicare New Technology Add- Code indicates the amount of Medicare
On Payment additional payment for new technology.
78-79 Payer Codes Codes reserved for internal use only by
third party payers. The CMS assigns as
needed. Providers do not report payer
codes.
80 Covered days The number of days covered by the
primary payer as qualified by the payer.
81 Non-Covered Days Days of care not covered by the primary
payer.
82 Co-insurance Days The inpatient Medicare days occurring
after the 60th day and before the 91st day
or inpatient SNF/Swing Bed days
occurring after the 20th and before the
101st day in a single spell of illness.
83 Lifetime Reserve Days Under Medicare, each beneficiary has a
lifetime reserve of 60 additional days of
inpatient hospital services after using 90
days of inpatient hospital services during
a spell of illness.
84-99 Reserved for national assignment.
A0 Special Zip Code Reporting Five digit ZIP Code of the location from
which the beneficiary is initially placed
on board the ambulance.
A1 Deductible Payer A The amount the provider assumes will be
applied to the patient’s deductible
amount involving the indicated payer.
A2 Coinsurance Payer A The amount the provider assumes will be
applied toward the patient’s coinsurance
amount involving the indicated payer.
For Medicare, use this code only for
reporting Part B coinsurance amounts.
For Part A coinsurance amounts use
Value Codes 8-11.
A3 Estimated Responsibility Payer A Amount the provider estimates will be
paid by the indicated payer.
A4 Covered Self-Administrable Drugs The amount included in covered charges
- Emergency for self-administrable drugs administered
to the patient in an emergency situation.
(The only covered Medicare charges for
an ordinarily non-covered, self-
administered drug are for insulin
administered to a patient in a diabetic
coma. For use with Revenue Code 0637.
See The Medicare Benefit Policy
Code Title Definition
Manual).
A5 Covered Self-Administrable Drugs The amount included in covered charges
– Not Self-Administrable in Form for self-administrable drugs administered
and Situation Furnished to Patient to the patient because the drug was not
self-administrable in the form and
situation in which it was furnished to the
patient. For use with Revenue Code
0637.
A6 Covered Self-Administrable Drugs The amount included in covered charges
– Diagnostic Study and Other for self-administrable drugs administered
to the patient because the drug was
necessary for diagnostic study or other
reasons (e.g., the drug is specifically
covered by the payer). For use with
Revenue Code 0637.
A7 Co-payment A The amount assumed by the provider to
be applied toward the patient’s co-
payment amount involving the indicated
payer.
A8 Patient Weight Weight of patient in kilograms. Report
this data only when the health plan has a
predefined change in reimbursement that
is affected by weight. For newborns, use
Value Code 54. (Effective 1/01/05)
A9 Patient Height Height of patient in centimeters. Report
this data only when the health plan has a
predefined change in reimbursement that
is affected by height. (Effective 1/01/05)
AA Regulatory Surcharges, The amount of regulatory surcharges,
Assessments, Allowances or assessments, allowances or health care
Health Care Related Taxes Payer related taxes pertaining to the indicated
A payer. Effective 10/16/2003
AB Other Assessments or Allowances The amount of other assessments or
(e.g., Medical Education) Payer A allowances (e.g., medical education)
pertaining to the indicated payer.
Effective 10/16/2003
AC-B0 Reserved for national assignment.
B1 Deductible Payer B The amount the provider assumes will be
applied to the patient’s deductible
amount involving the indicated payer.
B2 Coinsurance Payer B The amount the provider assumes will be
applied toward the patient’s coinsurance
amount involving the indicated payer.
For Part A coinsurance amounts use
Value Codes 8-11.
Code Title Definition
B3 Estimated Responsibility Payer B Amount the provider estimates will be
paid by the indicated payer.
B4-B6 Reserved for national assignment
B7 Co-payment Payer B The amount the provider assumes will be
applied toward the patient’s co-payment
amount involving the indicated payer.
B8-B9 Reserved for national assignment
BA Regulatory Surcharges, The amount of regulatory surcharges,
Assessments, Allowances or assessments, allowances or health care
HealthCare Related Taxes Payer related taxes pertaining to the indicated
B payer. Effective 10/16/03
BB Other Assessments or Allowances The amount of other assessments or
(e.g., Medical Education) Payer B allowances (e.g., medical education)
pertaining to the indicated
BC-C0 Reserved for national assignment
C1 Deductible Payer C The amount the provider assumes will be
applied to the patient’s deductible
amount involving the indicated payer.
(Note: Medicare blood deductibles
should be reported under Value Code 6.)
C2 Coinsurance Payer C The amount the provider assumes will be
applied toward the patient’s coinsurance
amount involving the indicated payer.
For Part A coinsurance amounts use
Value Codes 8-11.
C3 Estimated Responsibility Payer C Amount the provider estimates will be
paid by the indicated payer.
C4-C6 Reserved for national assignment
C7 Co-payment Payer C The amount the provider assumes is
applied to the patient’s co-payment
amount involving the indicated payer.
C8-C9 Reserved for national assignment
CA Regulatory Surcharges, The amount of regulatory surcharges,
Assessments, Allowances or assessments, allowances or health care
HealthCare Related Taxes Payer related taxes pertaining to the indicated
C payer. Effective 10/16/03
CB Other Assessments or Allowances The amount of other assessments or
(e.g., Medical Education) Payer C allowances (e.g., medical education)
pertaining to the indicated payer.
Effective 10/16/2003
CC-CZ Reserved for national assignment
D0-D2 Reserved for national assignment
D3 Reserved for national assignment
(effective 3/1/07)
D4-DQ Reserved for national assignment
Code Title Definition
DR Reserved for disaster related code
DS-DZ Reserved for national assignment
E0 Reserved for national assignment
E1 Deductible Payer D Reserved for national assignment
(effective 3/1/07)
E2 Coinsurance Payer D Reserved for national assignment
(effective 3/1/07)
E3 Estimated Responsibility Payer D Reserved for national assignment
(effective 3/1/07)
E4-E6 Reserved for national assignment
E7 Co-payment Payer D Reserved for national assignment
(effective 3/1/07)
E8-E9 Reserved for national assignment
EA Regulatory Surcharges, Reserved for national assignment
Assessments, Allowances or (effective 3/1/07)
HealthCare Related Taxes Payer
D
EB Other Assessments or Allowances Reserved for national assignment
(e.g., Medical Education) Payer D (effective 3/1/07)
EC-EZ Reserved for national assignment
F0 Reserved for national assignment
F1 Deductible Payer E Reserved for national assignment
(effective 3/1/07)
F2 Coinsurance Payer E Reserved for national assignment
(effective 3/1/07)
F3 Estimated Responsibility Payer E Reserved for national assignment
(effective 3/1/07)
F4-F6 Reserved for national assignment
F7 Co-payment Payer E Reserved for national assignment
(effective 3/1/07)
F8-F9 Reserved for national assignment
FA Regulatory Surcharges, Reserved for national assignment
Assessments, Allowances or (effective 3/1/07)
HealthCare Related Taxes Payer
E
FB Other Assessments or Allowances Reserved for national assignment
(e.g., Medical Education) Payer E (effective 3/1/07)
FC-FZ Reserved for national assignment
G0 Reserved for national assignment
G1 Deductible Payer F Reserved for national assignment
(effective 3/1/07)
G2 Coinsurance Payer F Reserved for national assignment
(effective 3/1/07)
G3 Estimated Responsibility Payer F Reserved for national assignment
(effective 3/1/07)
Code Title Definition
G4-G6 Reserved for national assignment
G7 Co-payment Payer F Reserved for national assignment
(effective 3/1/07)
G8-G9 Reserved for national assignment
GA Regulatory Surcharges, Reserved for national assignment
Assessments, Allowances or (effective 3/1/07)
HealthCare Related Taxes Payer
F
GB Other Assessments or Allowances Reserved for national assignment
(e.g., Medical Education) Payer F (effective 3/1/07)
GC-GZ Reserved for national assignment
H0-WZ Reserved for national assignment
X0-Y0 Reserved for national assignment
Y1 Part A Demonstration This is the portion of the payment
Payment designated as reimbursement for Part A
services under the demonstration. This
amount is instead of the traditional
prospective DRG payment (operating
and capital) as well as any outlier
payments that might have been
applicable in the absence of the
demonstration. No deductible or
coinsurance has been applied. Payments
for operating IME and DSH which are
processed in the traditional manner are
also not included in this amount.

Y2 Part B Demonstration This is the portion of the payment

Payment designated as reimbursement for Part B
services under the demonstration. No
deductible or coinsurance has been
applied.

Y3 Part B Coinsurance This is the amount of Part B coinsurance

applied by the intermediary to this claim.
For demonstration claims this will be a
fixed copayment unique to each hospital
and DRG (or DRG/procedure group).

Y4 Conventional Provider This is the amount Medicare would have

Payment Amount for Non- reimbursed the provider for Part A
Demonstration Claims services if there had been no
demonstration. This should include the
prospective DRG payment (both
capital as well as operational) as well as
Code Title Definition
any outlier payment, which would be
applicable. It does not include any pass
through amounts such as that for direct
medical education nor interim payments
for operating IME and DSH.

Y5-ZZ Reserved for national assignment

75.4 - Form Locator 42

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

FL 42 - Revenue Code
Required. The provider enters the appropriate revenue codes from the following list to
identify specific accommodation and/or ancillary charges. It must enter the appropriate
numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47.
Additionally, there is no fixed “Total” line in the charge area. The provider must enter
revenue code 0001 instead in FL 42. Thus, the adjacent charges entry in FL 47 is the
sum of charges billed. This is the same line on which non-covered charges, in FL 48, if
any, are summed. To assist in bill review, the provider must list revenue codes in
ascending numeric sequence and not repeat on the same bill to the extent possible. To
limit the number of line items on each bill, it should sum revenue codes at the “zero”
level to the extent possible.
The biller must provide detail level coding for the following revenue code series:
0290s - Rental/purchase of DME
0304 - Renal dialysis/laboratory
0330s - Radiology therapeutic
0367 - Kidney transplant
0420s - Therapies
0520s - Type or clinic visit (RHC or other)
0550s - 590s - home health services
0624 - Investigational Device Exemption (IDE)
0636 - Hemophilia blood clotting factors
0800s - 0850s - ESRD services
9000 - 9044 - Medicare SNF demonstration project
Zero level billing is encouraged for all other services; however, an FI may require
detailed breakouts of other revenue code series from its providers.
NOTE: RHCs and FQHCs, in general, use revenue codes 052X and 091X with
appropriate subcategories to complete the Form CMS-1450. The other codes provided
are not generally used by RHCs and FQHCs and are provided for informational
purposes. Those applicable are: 0025-0033, 0038-0044, 0047, 0055-0059, 0061, 0062,
0064-0069, 0073-0075, 0077, 0078, and 0092-0095.
NOTE: Renal Dialysis Centers bill the following revenue center codes at the detailed
level:
0304 - rental and dialysis/laboratory,
 0636 - hemophilia blood clotting factors,
0800s thru 0850s - ESRD services.
The remaining applicable codes are 0025, 0027, 0031-0032, 0038-0039, 0075,
and 0082-0088.
NOTE: The Hospice uses revenue code 0657 to identify its charges for services furnished
to patients by physicians employed by it, or receiving compensation from it. In
conjunction with revenue code 0657, the hospice enters a physician procedure code in
the right hand margin of FL 43 (to the right of the dotted line adjacent to the revenue
code in FL 42). Appropriate procedure codes are available to it from its FI. Procedure
codes are required in order for the FI to make reasonable charge determinations when
paying the hospice for physician services.
The Hospice uses the following revenue codes to bill Medicare:
Code Description Standard Abbreviation
0651* Routine Home Care RTN Home
0652* Continuous Home Care CTNS Home (A minimum of 8 hours, not
necessarily consecutive, in a 24-hour
period is required. Less than 8 hours is
routine home care for payment purposes.
A portion of an hour is 1 hour.
0655 Inpatient Respite Care IP Respite
0656 General Inpatient Care GNL IP
0657 Physician Services PHY Ser (must be accompanied by a
physician procedure code.)
*The hospice must report value code 61 with these revenue codes.
Below is a complete description of the revenue center codes for all provider types:
Revenue Description
Code
0001 Total Charge
For use on paper or paper facsimile (e.g., “print images”) claims only.
For electronic transactions, FIs report the total charge in the appropriate
data segment/field
001X Reserved for Internal Payer Use
002X Health Insurance Prospective Payment System (HIPPS)
Subcategory Standard Abbreviations
0 - Reserved
1 - Reserved
2 - Skilled Nursing Facility SNF PPS (RUG)
Prospective Payment System
3 - Home Health Prospective HHS PPS (Health Resource Groups
Payment System (HRG))
4 - Inpatient Rehabilitation IRF PPS (Case-Mix Groups (CMG))
Facility Prospective Payment
System
5 - Reserved
6 - Reserved
7 - Reserved
Revenue Description
Code
8 - Reserved
9 - Reserved
003X to Reserved for National Assignment
006X
007X to Reserved for State Use until October 16, 2003. Thereafter, Reserved for
009X National Assignment
ACCOMMODATION REVENUE CODES (010X - 021X)
010X All Inclusive Rate

Flat fee charge incurred on either a daily basis or total stay basis for services
rendered. Charge may cover room and board plus ancillary services or room
and board only.
Subcategory Standard Abbreviations
0 All-Inclusive Room and Board ALL INCL R&B/ANC
Plus Ancillary
1 All-Inclusive Room and Board ALL INCL R&B
011X Room & Board - Private (Medical or General)
Routine service charges for single bedrooms.
Rationale: Most third party payers require that private rooms be separately
identified.
Subcategory Standard Abbreviations
0 - General Classification ROOM-BOARD/PVT
1 - Medical/Surgical/Gyn MED-SUR-GY/PVT
2 - OB OB/PVT
3 - Pediatric PEDS/PVT
4 - Psychiatric PSYCH/PVT
5 - Hospice HOSPICE/PVT
6 - Detoxification DETOX/PVT
7 - Oncology ONCOLOGY/PVT
8 - Rehabilitation REHAB/PVT
9 - Other OTHER/PVT
012X Room & Board - Semi-private Two Beds (Medical or General)
Routine service charges incurred for accommodations with two beds.
Rationale: Most third party payers require that semi-private rooms be
identified.
Subcategory Standard Abbreviations
0 - General Classification ROOM-BOARD/SEMI
1 - Medical/Surgical/Gyn MED-SUR-GY/2BED
2 - OB OB/2BED
3 - Pediatric PEDS/2BED
4 - Psychiatric PSYCH/2BED
5 - Hospice HOSPICE/2BED
6 - Detoxification DETOX/2BED
7 - Oncology ONCOLOGY/2BED
Revenue Description
Code
8 - Rehabilitation REHAB/2BED
9 - Other OTHER/2BED
013X Semi-private - three and Four Beds (Medical or General)
Routine service charges incurred for accommodations with three and four
beds.
Subcategory Standard Abbreviations
0 - General Classification ROOM-BOARD/3&4 BED
1 - Medical/Surgical/Gyn MED-SUR-GY/3&4 BED
2 - OB OB/3&4 BED
3 - Pediatric PEDS/3&4 BED
4 - Psychiatric PSYCH/3&4 BED
5 - Hospice HOSPICE/3&4 BED
6 - Detoxification DETOX/3&4 BED
7 - Oncology ONCOLOGY/3&4 BED
8 - Rehabilitation REHAB/3&4 BED
9 - Other OTHER/3&4 BED
014X Private - (Deluxe) (Medical or General)
Deluxe rooms are accommodations with amenities substantially in excess of
those provided to other patients.
Subcategory Standard Abbreviations
0 - General Classification ROOM-BOARD/ PVT/DLX
1 - Medical/Surgical/Gyn MED-SUR-GY/ PVT/DLX
2 - OB OB/ PVT/DLX
3 - Pediatric PEDS/ PVT/DLX
4 - Psychiatric PSYCH/ PVT/DLX
5 - Hospice HOSPICE/ PVT/DLX
6 - Detoxification DETOX/ PVT/DLX
7 - Oncology ONCOLOGY/ PVT/DLX
8 - Rehabilitation REHAB/ PVT/DLX
9 - Other OTHER/ PVT/DLX
015X Room & Board - Ward (Medical or General)
Routine service charges incurred for accommodations with five or more beds.
Rationale: Most third party payers require ward accommodations to be
identified.
Subcategory Standard Abbreviations
0 - General Classification ROOM-BOARD/WARD
1 - Medical/Surgical/Gyn MED-SUR-GY/ WARD
2 - OB OB/ WARD
3 - Pediatric PEDS/ WARD
4 - Psychiatric PSYCH/ WARD
5 - Hospice HOSPICE/ WARD
6 - Detoxification DETOX/ WARD
7 - Oncology ONCOLOGY/ WARD
8 - Rehabilitation REHAB/ WARD
Revenue Description
Code
9 - Other OTHER/ WARD
016X Other Room & Board (Medical or General)
Any routine service charges incurred for accommodations that cannot be
included in the more specific revenue center codes
Rationale: Provides the ability to identify services as required by payers or
individual institutions.
Sterile environment is a room and board charge to be used by hospitals that are
currently separating this charge for billing.

Subcategory Standard Abbreviations

0 - General Classification R&B
4 - Sterile Environment R&B/STERILE
7 - Self Care R&B/SELF
9 - Other R&B/OTHER
017X Nursery Charges for nursing care to newborn and premature infants in
nurseries Subcategories 1-4 are used by facilities with nursery services designed
around distinct areas and/or levels of care. Levels of care defined under State
regulations or other statutes supersede the following guidelines. For example,
some States may have fewer than four levels of care or may have multiple levels
within a category such as intensive care.

Level I Routine care of apparently normal full-term or pre-term neonates

(Newborn Nursery).
Level II Low birth-weight neonates who are not sick, but require frequent
feeding and neonates who require more hours of nursing than do
normal neonates (Continuing Care).
Level III Sick neonates who do not require intensive care, but require 6-12
hours of nursing care each day (Intermediate Care).
Level IV Constant nursing and continuous cardiopulmonary and other
support for severely ill infants (Intensive Care).
Subcategory Standard Abbreviations
0 - Classification NURSERY
1 - Newborn - Level I NURSERY/LEVEL I
2 - Newborn - Level II NURSERY/LEVEL II
3 - Newborn - Level III NURSERY/LEVEL III
4 - Newborn - Level IV NURSERY/LEVEL IV
9 - Other NURSERY/OTHER
018X Leave of Absence
Charges (including zero charges) for holding a room while the patient is
temporarily away from the provider.
NOTE: Charges are billable for codes 2 - 5.
Subcategory Standard Abbreviations
0 - General Classification LEAVE OF ABSENCE OR LOA
1 - Reserved
 2 - Patient Convenience -Charges LOA/PT CONV CHGS BILLABLE
billable
3 - Therapeutic Leave LOA/THERAP
4 – RESERVED Effective 4/1/04
5 - Hospitalization LOA/HOSPITALIZATION
Effective 4/1/04
9 - Other Leave of Absence LOA/OTHER
019X Sub-acute Care
Accommodation charges for sub acute care to inpatients in hospitals or
skilled nursing facilities.
Level I Skilled Care: Minimal nursing intervention. Co-morbidities
do not complicate treatment plan. Assessment of vitals and
body systems required 1-2 times per day.
Level II Comprehensive Care: Moderate to extensive nursing
intervention. Active treatment of co morbidities. Assessment
of vitals and body systems required 2-3 times per day.
Level III Complex Care: Moderate to extensive nursing intervention.
Active medical care and treatment of co morbidities.
Potential for co morbidities to affect the treatment plan.
Assessment of vitals and body systems required 3-4 times per
day.
Level IV Intensive Care: Extensive nursing and technical
intervention. Active medical care and treatment of co
morbidities. Potential for co morbidities to affect the
treatment plan. Assessment of vitals and body systems
required 4-6 times per day.
Subcategory Standard Abbreviations
0 - Classification SUBACUTE
1 – Sub-acute Care - Level I SUBACUTE /LEVEL I
2 – Sub-acute Care - Level II SUBACUTE /LEVEL II
3 – Sub-acute Care - Level III SUBACUTE /LEVEL III
4 – Sub-acute Care - Level IV SUBACUTE /LEVEL IV
9 - Other Sub-acute Care SUBACUTE /OTHER
Usage Note: Revenue code 019X may be used in multiple types of bills.
However, if bill type X7X is used in Form Locator 4, Revenue Code 019X
must be used. (Note: Bill Type X7X to be DISCONTINUED as of 10/1/05.)
020X Intensive Care
Routine service charge for medical or surgical care provided to patients who
require a more intensive level of care than is rendered in the general medical
or surgical unit.
Rationale: Most third party payers require that charges for this service be
identified.
Subcategory Standard Abbreviations
0 - General Classification INTENSIVE CARE or (ICU)
1 - Surgical ICU/SURGICAL
2 - Medical ICU/MEDICAL
 3 - Pediatric ICU/PEDS
4 - Psychiatric ICU/PSTAY
6 - Intermediate ICU ICU/INTERMEDIATE
7 - Burn Care ICU/BURN CARE
8 - Trauma ICU/TRAMA
9 - Other Sub-acute Care ICU/OTHER
021X Coronary Care
Routine service charge for medical care provided to patients with coronary
illness who require a more intensive level of care than is rendered in the
general medical care unit.
Rationale: If a discrete unit exists for rendering such services, the hospital or
third party may wish to identify the service.
Subcategory Standard Abbreviations
0 - General Classification CORONARY CARE or (CCU)
1 - Myocardial Infarction CCU/MYO INFARC
2 - Pulmonary Care CCU/PULMONARY
3 - Heart Transplant CCU/TRANSPLANT
4 - Intermediate CCU CCU/INTERMEDIATE
9 - Other Coronary Care CCU/OTHER

Code Description
ANCILLARY REVENUE CODES (022X - 099X)
022X Special Charges
Charges incurred during an inpatient stay or on a daily basis for certain
services.
Rationale: Some hospitals prefer to identify the components of services
furnished in greater detail and thus break out charges for items that normally
would be considered part of routine services.
Subcategory Standard Abbreviations
0 - General Classification SPECIAL CHARGES
1 - Admission Charge ADMIT CHARGE
2 - Technical Support Charge TECH SUPPT CHG
3 - U.R. Service Charge UR CHARGE
4 - Late Discharge, medically LATE DISCH/MED NEC
necessary
9 - Other Special Charges OTHER SPEC CHG
023X Incremental Nursing Care Charges
Charges for nursing services assessed in addition to room and board.
Subcategory Standard Abbreviations
0 - General Classification NURSING INCREM
1 - Nursery NUR INCR/NURSERY
2 - OB NUR INCR/OB
3 - ICU (includes transitional care) NUR INCR/ICU
4 - CCU (includes transitional NUR INCR/CCU
care)
5 - Hospice NUR INCR/HOSPICE
 9 - Other NUR INCR/OTHER
024X All Inclusive Ancillary
A flat rate charge incurred on either a daily basis or total stay basis for
ancillary services only.
Rationale: Hospitals that bill in this manner may wish to segregate these
charges.
Subcategory Standard Abbreviations
0 - General Classification ALL INCL ANCIL
1 - Basic ALL INCL BASIC
2 - Comprehensive ALL INCL COMP
3 - Specialty ALL INCL SPECIAL
9 - Other All Inclusive ALL INCL ANCIL/OTHER
Ancillary
025X Pharmacy
Code indicates charges for medication produced, manufactured, packaged,
controlled, assayed, dispensed, and distributed under the direction of a licensed
pharmacist.
Rationale: Additional breakdowns are provided for items that individual
hospitals may wish to identify because of internal or third party payer
requirements. Sub code 4 is for hospitals that do not bill drugs used for other
diagnostic services as part of the charge for the diagnostic service. Sub code 5
is for hospitals that do not bill drugs used for radiology under radiology
revenue codes as part of the radiology procedure charge.
Subcategory Standard Abbreviations
0 – General Classification PHARMACY
1 – Generic Drugs DRUGS/GENERIC
2 - Non-generic Drugs DRUGS/NONGENERIC
3 - Take Home Drugs DRUGS/TAKEHOME
4 - Drugs Incident to Other DRUGS/INCIDENT ODX
Diagnostic Services
5 - Drugs Incident to DRUGS/INCIDENT RAD
Radiology
6 - Experimental Drugs DRUGS/EXPERIMT
7 - Nonprescription DRUGS/NONPSCRPT
8 - IV Solutions IV SOLUTIONS
9 - Other DRUGS/OTHER DRUGS/OTHER
026X IV Therapy
Code indicates the administration of intravenous solution by specially trained
personnel to individuals requiring such treatment.
Rationale: For outpatient home intravenous drug therapy equipment, which is
part of the basic per diem fee schedule, providers must identify the actual cost
for each type of pump for updating of the per diem rate.
Subcategory Standard Abbreviations
0 – General Classification IV THERAPY
1 – Infusion Pump IV THER/INFSN PUMP
2 - IV Therapy/Pharmacy IV THER/PHARM/SVC
 Services
3 - IV IV THER/DRUG/SUPPLY DELV
Therapy/Drug/Supply/Delivery
4 - IV Therapy/Supplies IV THER/SUPPLIES
9 - Other IV Therapy IV THERAPY/OTHER
027X Medical/Surgical Supplies (Also see 062X, an extension of 027X)
Code indicates charges for supply items required for patient care.
Rationale: Additional breakdowns are provided for items that hospitals may
wish to identify because of internal or third party payer requirements.
Subcategory Standard Abbreviations
0 – General Classification MED-SUR SUPPLIES
1 – Non--sterile Supply NONSTER SUPPLY
2 - Sterile Supply STERILE SUPPLY
3 - Take Home Supplies TAKEHOME SUPPLY
4 - Prosthetic/Orthotic Devices PROSTH/ORTH DEV
5 - Pace maker PACE MAKER
6 - Intraocular Lens INTR OC LENS
7 – Oxygen - Take Home 02/TAKEHOME
8 - Other Implants SUPPLY/IMPLANTS
9 - Other Supplies/Devices SUPPLY/OTHER
028X Oncology
Code indicates charges for the treatment of tumors and related diseases.
Subcategory Standard Abbreviations
0 – General Classification ONCOLOGY
9 - Other Oncology ONCOLOGY/OTHER
029X Durable Medical Equipment (DME) (Other Than Rental)
Code indicates the charges for medical equipment that can withstand repeated
use (excluding renal equipment).
Rationale: Medicare requires a separate revenue center for billing.
Subcategory Standard Abbreviations
0 – General Classification MED EQUIP/DURAB
1 – Rental MED EQUIP/RENT
2 - Purchase of new DME MED EQUIP/NEW
3 - Purchase of used DME MED EQUIP/USED
4 - Supplies/Drugs for DME MED EQUIP/SUPPLIES/DRUGS
Effectiveness (HHA’s Only)
9 - Other Equipment MED EQUIP/OTHER
030X Laboratory
Charges for the performance of diagnostic and routine clinical laboratory tests.
Rationale: A breakdown of the major areas in the laboratory is provided in
order to meet hospital needs or third party billing requirements.
Subcategory Standard Abbreviations
0 – General Classification LABORATORY or (LAB)
1 - Chemistry LAB/CHEMISTRY
2 - Immunology LAB/IMMUNOLOGY
3 - Renal Patient (Home) LAB/RENAL HOME
 4 – Non-routine Dialysis LAB/NR DIALYSIS
5 - Hematology LAB/HEMATOLOGY
6 - Bacteriology & LAB/BACT-MICRO
Microbiology
7 – Urology LAB/UROLOGY
9 - Other Laboratory LAB/OTHER
031X Laboratory Pathological
Charges for diagnostic and routine laboratory tests on tissues and culture.
Rationale: A breakdown of the major areas that hospitals may wish to identify
is provided.
Subcategory Standard Abbreviations
0 - General Classification PATHOLOGY LAB or (PATH LAB)
1 - Cytology PATHOL/CYTOLOGY
2 - Histology PATHOL/HYSTOL
4 – Biopsy PATHOL/BIOPSY
9 – Other PATHOL/OTHER
032X Radiology - Diagnostic
Charges for diagnostic radiology services provided for the examination and
care of patients. Includes taking, processing, examining and interpreting
radiographs and fluorographs.
Rationale: A breakdown is provided for the major areas and procedures that
individual hospitals or third party payers may wish to identify.
Subcategory Standard Abbreviations
0 - General Classification DX X-RAY
1 - Angiocardiography DX X-RAY/ANGIO
2 - Arthrography DX X-RAY/ARTH
3 - Arteriography DX X-RAY/ARTER
4 - Chest X-Ray DX X-RAY/CHEST
9 – Other DX X-RAY/OTHER
033X Radiology - Therapeutic
Charges for therapeutic radiology services and chemotherapy are required for
care and treatment of patients. Includes therapy by injection or ingestion of
radioactive substances.
Rationale: A breakdown is provided for the major areas that hospitals or third
parties may wish to identify. Chemotherapy - IV was added at the request of
Ohio.
Subcategory Standard Abbreviations
0 - General Classification RX X-RAY
1 - Chemotherapy - Injected CHEMOTHER/INJ
2 - Chemotherapy - Oral CHEMOTHER/ORAL
3 - Radiation Therapy RADIATION RX
5 - Chemotherapy - IV CHEMOTHERP-IV
9 – Other RX X-RAY/OTHER
034X Nuclear Medicine
 Charges for procedures and tests performed by a radioisotope laboratory
utilizing radioactive materials as required for diagnosis and treatment of
patients.
Rationale: A breakdown is provided for the major areas that hospitals or third
parties may wish to identify.
Subcategory Standard Abbreviations
0 - General Classification NUCLEAR MEDICINE or (NUC MED)
1 – Diagnostic Procedures NUC MED/DX
2 – Therapeutic Procedures NUC MED/RX
3 – Diagnostic NUC MED/DX RADIOPHARM
Radiopharmaceuticals Effective 10/1/04
4 – Therapeutic NUC MED/RX RADIOPHARM
Radiopharmaceuticals Effective 10/1/04
9 – Other NUC MED/OTHER
035X Computed Tomographic (CT) Scan
Charges for CT scans of the head and other parts of the body.
Rationale: Due to coverage limitations, some third party payers require that
the specific test be identified.
Subcategory Standard Abbreviations
0 - General Classification CT SCAN
1 - Head Scan CT SCAN/HEAD
2 - Body Scan CT SCAN/BODY
9 - Other CT Scans CT SCAN/OTHER
036X Operating Room Services
Charges for services provided to patients by specially trained nursing
personnel who provide assistance to physicians in the performance of surgical
and related procedures during and immediately following surgery as well the
operating room (heat, lights) and equipment.
Rationale: Permits identification of particular services.
Subcategory Standard Abbreviations
0 - General Classification OR SERVICES
1 - Minor Surgery OR/MINOR
2 - Organ Transplant - Other OR/ORGAN TRANS
than Kidney
7 - Kidney Transplant OR/KIDNEY TRANS
9 - Other Operating Room OR/OTHER
Services
037X Anesthesia
Charges for anesthesia services in the hospital.
Rationale: Provides additional identification of services. In particular,
acupuncture was identified because some payers, including Medicare, do not
cover it. Subcode 1 is for providers that do not bill anesthesia used for
radiology under radiology revenue codes as part of the radiology procedure
charge. Subcode 2 is for providers that do not bill anesthesia used for another
diagnostic service as part of the charge for the diagnostic service.
Subcategory Standard Abbreviations
 0 - General Classification ANESTHESIA
1 - Anesthesia Incident to RAD ANESTHE/INCIDENT RAD
2 - Anesthesia Incident to Other ANESTHE/INCIDENT ODX
Diagnostic Services
4 - Acupuncture ANESTHE/ACUPUNC
9 - Other Anesthesia ANESTHE/OTHER
038X Blood
Rationale: Charges for blood must be separately identified for private payer
purposes.
Subcategory Standard Abbreviations
0 - General Classification BLOOD
1 - Packed Red Cells BLOOD/PKD RED
2 - Whole Blood BLOOD/WHOLE
3 – Plasma BLOOD/PLASMA
4 – Platelets BLOOD/PLATELETS
5 - Leucocytes BLOOD/LEUCOCYTES
6 - Other Components BLOOD/COMPONENTS
7 - Other Derivatives BLOOD/DERIVATIVES
Cryopricipitates)
9 - Other Blood BLOOD/OTHER
039X Blood Storage and Processing
Charges for the storage and processing of whole blood
Subcategory Standard Abbreviations
0 - General Classification BLOOD/STOR-PROC
1 - Blood Administration (e.g., BLOOD/ADMIN
Transfusions
9 - Other Processing and BLOOD/OTHER STOR
Storage
040X Other Imaging Services
Subcategory Standard Abbreviations
0 - General Classification IMAGE SERVICE
1 - Diagnostic Mammography MAMMOGRAPHY
2 - Ultrasound ULTRASOUND
3 - Screening Mammography SCR MAMMOGRAPHY/GEN MAMMO
4 - Positron Emission PET SCAN
Tomography
9 - Other Imaging Services OTHER IMAG SVS
NOTE: Medicare will require the hospitals to report the ICD-9 diagnosis codes (FL 67)
to substantiate those beneficiaries considered high risks. These high-risk codes are as
follows:
ICD-9
Codes Definitions High Risk Indicator
V10.3 Personal History - Malignant A personal history of breast cancer
neoplasm breast cancer
V16.3 Family History - Malignant A mother, sister, or daughter who has had
neoplasm breast cancer breast cancer
V15.89 Other specified personal history Has not given birth before age 30 or a
representing hazards to health personal history of biopsy-proven benign
breast disease
041X Respiratory Services
Charges for administration of oxygen and certain potent drugs through
inhalation or positive pressure and other forms of rehabilitative therapy
through measurement of inhaled and exhaled gases and analysis of blood and
evaluation of the patient’s ability to exchange oxygen and other gases.
Rationale: Permits identification of particular services.
Subcategory Standard Abbreviations
0 - General Classification RESPIRATORY SVC
2 - Inhalation Services INHALATION SVC
3 - Hyperbaric Oxygen HYPERBARIC 02
Therapy
9 - Other Respiratory OTHER RESPIR SVS
Services
042X Physical Therapy
Charges for therapeutic exercises, massage and utilization of effective
properties of light, heat, cold, water, electricity, and assistive devices for
diagnosis and rehabilitation of patients who have neuromuscular, orthopedic
and other disabilities.
Rationale: Permits identification of particular services.
Subcategory Standard Abbreviations
0 – General Classification PHYSICAL THERP
1 - Visit Charge PHYS THERP/VISIT
2 - Hourly Charge PHYS THERP/HOUR
3 - Group Rate PHYS THERP/GROUP
4 - Evaluation or Re- PHYS THERP/EVAL
evaluation
9 - Other Physical Therapy OTHER PHYS THERP
043X Occupational Therapy
Services provided by a qualified occupational therapy practitioner for
therapeutic interventions to improve, sustain, or restore an individual’s level of
function in performance of activities of daily living and work, including:
therapeutic activities, therapeutic exercises; sensorimotor processing;
psychosocial skills training; cognitive retraining; fabrication and application
of orthotic devices; and training in the use of orthotic and prosthetic devices;
adaptation of environments; and application of physical agent modalities.
Subcategory Standard Abbreviations
0 – General Classification OCCUPATION THER
1 - Visit Charge OCCUP THERP/VISIT
2 - Hourly Charge OCCUP THERP/HOUR
3 - Group Rate OCCUP THERP/GROUP
4 - Evaluation or Re-evaluation OCCUP THERP/EVAL
9 - Other Occupational OTHER OCCUP THER
Therapy (may include
 restorative therapy)
044X Speech-Language Pathology
Charges for services provided to persons with impaired functional
communications skills.
Subcategory Standard Abbreviations
0 - General Classification SPEECH PATHOL
1 - Visit Charge SPEECH PATH/VISIT
2 - Hourly Charge SPEECH PATH/HOUR
3 - Group Rate SPEECH PATH/GROUP
4 - Evaluation or Re-evaluation SPEECH PATH/EVAL
9 - Other Speech-Language OTHER SPEECH PAT
Pathology
045X Emergency Room
Charges for emergency treatment to those ill and injured persons who require
immediate unscheduled medical or surgical care.
Rationale: Permits identification of particular items for payers. Under the
provisions of the Emergency Medical Treatment and Active Labor Act
(EMTALA), a hospital with an emergency department must provide, upon
request and within the capabilities of the hospital, an appropriate medical
screening examination and stabilizing treatment to any individual with an
emergency medical condition and to any woman in active labor, regardless of
the individual’s eligibility for Medicare (Consolidated Omnibus Budget
Reconciliation Act (COBRA) of 1985).
Subcategory Standard Abbreviations
0 - General Classification EMERG ROOM
1 - EMTALA Emergency Medical ER/EMTALA
screening services
2 - ER Beyond EMTALA ER/BEYOND EMTALA
Screening
6 - Urgent Care URGENT CARE
9 - Other Emergency Room OTHER EMER ROOM
NOTE: Observation or hold beds are not reported under this code. They are reported
under revenue code 0762, “Observation Room.”
Usage Notes
An “X” in the matrix below indicates an acceptable coding combination.

a b c
0450 0451 0452 0456 0459
0450
0451 X X X
0452 X
0456 X X
0459 X X
a. General Classification code 0450 should not be used in conjunction with any
subcategory. The sum of codes 0451 and 0452 is equivalent to code 0450. Payers that do
not require a breakdown should roll up codes 0451 and 0452 into code 0450.
b. Stand alone usage of code 0451 is acceptable when no services beyond an initial
screening/assessment are rendered.
c. Stand alone usage of code 0452 is not acceptable.

046X Pulmonary Function

Charges for tests that measure inhaled and exhaled gases and analysis of blood
and for tests that evaluate the patient’s ability to exchange oxygen and other
gases.
Rationale: Permits identification of this service if it exists in the hospital.
Subcategory Standard Abbreviations
0 – General Classification PULMONARY FUNC
9 - Other Pulmonary Function OTHER PULMON FUNC
047X Audiology
Charges for the detection and management of communication handicaps
centering in whole or in part on the hearing function.
Rationale: Permits identification of particular services.
Subcategory Standard Abbreviations
0 – General Classification AUDIOLOGY
1 - Diagnostic AUDIOLOGY/DX
2 - Treatment AUDIOLOGY/RX
9 - Other Audiology OTHER AUDIOL
048X Cardiology
Charges for cardiac procedures furnished in a separate unit within the
hospital. Such procedures include, but are not limited to, heart catheterization,
coronary angiography, Swan-Ganz catheterization, and exercise stress test.
Rationale: This category was established to reflect a growing trend to
incorporate these charges in a separate unit.
Subcategory Standard Abbreviations
0 – General Classification CARDIOLOGY
1 – Cardiac Cath Lab CARDIAC CATH LAB
2 - Stress Test STRESS TEST
3 - Echo cardiology ECHOCARDIOLOGY
9 - Other Cardiology OTHER CARDIOL
049X Ambulatory Surgical Care
Charges for ambulatory surgery not covered by any other category.
Subcategory Standard Abbreviations
0 – General Classification AMBUL SURG
9 - Other Ambulatory Surgical OTHER AMBL SURG
Care
NOTE: Observation or hold beds are not reported under this code. They are reported
under revenue code 0762, “Observation Room.”
050X Outpatient Services
Outpatient charges for services rendered to an outpatient who is admitted as an
inpatient before midnight of the day following the date of service. This revenue
code is no longer used for Medicare.
Subcategory Standard Abbreviations
0 – General Classification OUTPATIENT SVS
 9 - Other Outpatient Services OUTPATIENT/OTHER
051X Clinic
Clinic (non-emergency/scheduled outpatient visit) charges for providing
diagnostic, preventive, curative, rehabilitative, and education services to
ambulatory patients.
Rationale: Provides a breakdown of some clinics that hospitals or third party
payers may require.
Subcategory Standard Abbreviations
0 – General Classification CLINIC
1 – Chronic Pain Center CHRONIC PAIN CL
2 - Dental Clinic DENTAL CLINIC
3 - Psychiatric Clinic PSYCH CLINIC
4 - OB-GYN Clinic OB-GYN CLINIC
5 - Pediatric Clinic PEDS CLINIC
6 - Urgent Care Clinic URGENT CLINIC
7 - Family Practice Clinic FAMILY CLINIC
9 - Other Clinic OTHER CLINIC
052X Free-Standing Clinic
Rationale: Provides a breakdown of some clinics that hospitals or third party
payers may require.
Subcategory Standard Abbreviations
0 - General Classification FREESTAND CLINIC
1 - Rural Health-Clinic (Effective RURAL/CLINIC
7/1/06 will be changed to: Clinic
visit by member to RHC/FQHC)
2 - Rural Health-Home (Effective RURAL/HOME
7/1/06 will be changed to: Home
visit by RHC/FQHC practitioner)
3 - Family Practice FR/STD FAMILY CLINIC
4 - Effective 7/1/06 - Visit by
RHC/FQHC practitioner to a
member in a covered Part A stay
at the SNF
5 - Effective 7/1/06 - Visit by
RHC/FQHC practitioner to a
member in a SNF (not in a
covered Part A stay) or NF or
ICF MR or other residential
facility
6 - Urgent Care Clinic FR/STD URGENT CLINIC
7 - Effective 7/1/06 - RHC/FQHC
Visiting Nurse Service(s) to a
member’s home when in a home
health shortage area
8 - Effective 7/1/06 - Visit by
RHC/FQHC practitioner to other
 non RHC/FQHC site (e.g. scene
of accident)
9 - Other Freestanding Clinic OTHER FR/STD CLINIC
053X Osteopathic Services
Charges for a structural evaluation of the cranium, entire cervical, dorsal and
lumbar spine by a doctor of osteopathy.
Rationale: This is a service unique to osteopathic hospitals and cannot be
accommodated in any of the existing codes.

Subcategory Standard Abbreviations

0 - General Classification OSTEOPATH SVS
1 - Osteopathic Therapy OSTEOPATH RX
9 - Other Osteopathic Services OTHER OSTEOPATH
054X Ambulance
Charges for ambulance service usually on an unscheduled basis to the ill and
injured who require immediate medical attention.
Rationale: Provides subcategories that third party payers or hospitals may
wish to recognize. Heart mobile is a specially designed ambulance transport
for cardiac patients.
Subcategory Standard Abbreviations
0 - General Classification AMBULANCE
1 - Supplies AMBUL/SUPPLY
2 - Medical Transport AMBUL/MED TRANS
3 - Heart Mobile AMBUL/HEARTMOBL
4 – Oxygen AMBUL/0XY
5 - Air Ambulance AIR AMBULANCE
6 - Neo-natal Ambulance AMBUL/NEO-NATAL
7 - Pharmacy AMBUL/PHARMACY
8 - Telephone Transmission AMBUL/TELEPHONIC EKG
EKG
9 - Other Ambulance OTHER AMBULANCE
055X Skilled Nursing
Charges for nursing services that must be provided under the direct supervision
of a licensed nurse to assure the safety of the patient and to achieve the
medically desired result. This code may be used for nursing home services or a
service charge for home health billing.
Subcategory Standard Abbreviations
0 - General Classification SKILLED NURSING
1 - Visit Charge SKILLED NURS/VISIT
2 - Hourly Charge SKILLED NURS/HOUR
9 - Other Skilled Nursing SKILLED NURS/OTHER
056X Medical Social Services
Charges for services such as counseling patients, interviewing patients, and
interpreting problems of social situation rendered to patients on any basis.

Rationale: Necessary for Medicare home health billing requirements. May be

 used at other times as required by hospital.
Subcategory Standard Abbreviations
0 - General Classification MED SOCIAL SVS
1 - Visit Charge MED SOC SERV/VISIT
2 - Hourly Charge MED SOC SERV/HOUR
9 - Other Med. Soc. Services MED SOC SERV/OTHER
057X Home Health Aide (Home Health)
Charges made by an HHA for personnel that are primarily responsible for the
personal care of the patient.
Rationale: Necessary for Medicare home health billing requirements.
Subcategory Standard Abbreviations
0 - General Classification AIDE/HOME HEALTH
1 - Visit Charge AIDE/HOME HLTH/VISIT
2 - Hourly Charge AIDE/HOME HLTH/HOUR
9 - Other Home Health Aide AIDE/HOME HLTH/OTHER
058X Other Visits (Home Health)
Code indicates charges by an HHA for visits other than physical therapy,
occupational therapy or speech therapy, which must be specifically identified.
Rationale: This breakdown is necessary for Medicare home health billing
requirements.
Subcategory Standard Abbreviations
0 - General Classification VISIT/HOME HEALTH
1 - Visit Charge VISIT/HOME HLTH/VISIT
2 - Hourly Charge VISIT/HOME HLTH/HOUR
3 - Assessment VISIT/HOME HLTH/ASSES
9 - Other Home Health Visits VISIT/HOME HLTH/OTHER
059X Units of Service (Home Health)
This revenue code is used by an HHA that bills on the basis of units of service.
Rationale: This breakdown is necessary for Medicare home health billing
requirements.
Subcategory Standard Abbreviations
0 - General Classification UNIT/HOME HEALTH
9 - Home Health Other Units UNIT/HOME HLTH/OTHER
060X Oxygen (Home Health)
Code indicates charges by a home health agency for oxygen equipment supplies
or contents, excluding purchased equipment.
If a beneficiary had purchased a stationary oxygen system, oxygen
concentrator or portable equipment, current revenue codes 0292 or 0293
apply. DME (other than oxygen systems) is billed under current revenue codes
0291, 0292, or 0293.
Rationale: Medicare requires detailed revenue coding. Therefore, codes for
this series may not be summed at the zero level.
Subcategory Standard Abbreviations
0 - General Classification 02/HOME HEALTH
1 - Oxygen - State/Equip/Suppl or 02/EQUIP/SUPPL/CONT
Cont
 2 - Oxygen - Stat/Equip/Suppl Under 02/STAT EQUIP/UNDER 1 LPM
1 LPM
3 – Oxygen - Stat/Equip/Over 4 LPM 02/STAT EQUIP/OVER 4 LPM
4 – Oxygen - Portable Add-on 02/STAT EQUIP/PORT ADD-ON
061X Magnetic Resonance Technology (MRT)
Code indicates charges for Magnetic Resonance Imaging (MRI) and Magnetic
Resonance Angiography (MRA) of the brain and other parts of the body.
Rationale: Due to coverage limitations, some third party payers require that
the specific test be identified.
Subcategory Standard Abbreviations
0 - General Classification MRT
1 - Brain (including Brainstem) MRI - BRAIN
2 - Spinal Cord (including spine) MRI - SPINE
3 - Reserved
4 - MRI - Other MRI - OTHER
5 - MRA - Head and Neck MRA - HEAD AND NECK
6 - MRA - Lower Extremities MRA - LOWER EXT
7 - Reserved
8 - MRA - Other MRA - OTHER
9 - MRT- Other MRT - OTHER
062X Medical/Surgical Supplies - Extension of 027X
Code indicates charges for supply items required for patient care. The
category is an extension of 027X for reporting additional breakdown where
needed. Subcode 1 is for hospitals that do not bill supplies used for radiology
revenue codes as part of the radiology procedure charges. Subcode 2 is for
providers that cannot bill supplies used for other diagnostic procedures.
Subcategory Standard Abbreviations
1 - Supplies Incident to Radiology MED-SUR SUPP/INCIDNT RAD
2 - Supplies Incident to Other MED-SUR SUPP/INCIDNT ODX
Diagnostic Services
3 - Surgical Dressings SURG DRESSING
4 - Investigational Device IDE
063X Pharmacy - Extension of 025X
Code indicates charges for drugs and biologicals requiring specific
identification as required by the payer. If HCPCS is used to describe the drug,
enter the HCPCS code in FL 44.
Subcategory Standard Abbreviations
0 - RESERVED (Effective 1/1/98
1 - Single Source Drug DRUG/SNGLE
2 - Multiple Source Drug DRUG/MULT
3 - Restrictive Prescription DRUG/RSTR
4 - Erythropoietin (EPO) less than DRUG/EPO <10,000 units
10,000 units
5 - Erythropoietin (EPO) 10,000 or DRUG/EPO >10,000 units
more units
6 - Drugs Requiring Detailed DRUGS/DETAIL CODE
 Coding (a)
7 - Self-administrable Drugs (b) DRUGS/SELFADMIN
NOTE: (a) Charges for drugs and biologicals (with the exception of
radiopharmaceuticals, which are reported under Revenue Codes 0343 and 0344)
requiring specific identifications as required by the payer (effective 10/1/04). If HCPCs
are used to describe the drug, enter the HCPCS code in Form Locator 44. The specified
units of service to be reported are to be in hundreds (100s) rounded to the nearest
hundred (no decimal).

064X Home IV Therapy Services

Charge for intravenous drug therapy services that are performed in the
patient’s residence. For Home IV providers, the HCPCS code must be entered
for all equipment and all types of covered therapy.
Subcategory Standard Abbreviations
0 - General Classification IV THERAPY SVC
1 – Non-routine Nursing, Central NON RT NURSING/CENTRAL
Line
2 - IV Site Care, Central Line IV SITE CARE/CENTRAL
3 - IV Start/Change Peripheral Line IV STRT/CHNG/PERIPHRL
4 – Non-routine Nursing, NONRT NURSING/PERIPHRL
Peripheral Line
5 - Training Patient/Caregiver, TRNG/PT/CARGVR/CENTRAL
Central Line
6 - Training, Disabled Patient, TRNG DSBLPT/CENTRAL
Central Line
7 - Training Patient/Caregiver, TRNG/PT/CARGVR/PERIPHRL
Peripheral Line
8 - Training, Disabled Patient, TRNG/DSBLPAT/PERIPHRL
Peripheral Line
9 - Other IV Therapy Services OTHER IV THERAPY SVC
NOTE: Units need to be reported in 1-hour increments. Revenue code 0642 relates to the
HCPCS code.
065X Hospice Services
Code indicates charges for hospice care services for a terminally ill patient if
the patient elects these services in lieu of other services for the terminal
condition.
Rationale: The level of hospice care that is provided each day during a hospice
election period determines the amount of Medicare payment for that day.
Subcategory Standard Abbreviations
0 - General Classification HOSPICE
1 - Routine Home Care HOSPICE/RTN HOME
2 - Continuous Home Care HOSPICE/CTNS HOME
3 - RESERVED
4 - RESERVED
5 - Inpatient Respite Care HOSPICE/IP RESPITE
6 - General Inpatient Care (non- HOSPICE/IP NON RESPITE
 respite)
7 - Physician Services HOSPICE/PHYSICIAN
8 –Hospice Room & Board – HOSPICE/R&B/NURS FAC
Nursing Facility
9 - Other Hospice HOSPICE/OTHER
066X Respite Care (HHA Only)
Charge for hours of care under the respite care benefit for services of a
homemaker or home health aide, personal care services, and nursing care
provided by a licensed professional nurse.
Subcategory Standard Abbreviations
0 - General Classification RESPITE CARE
1 – Hourly Charge/ Nursing RESPITE/ NURSE
2 - Hourly Charge/ RESPITE/AID/HMEMKE/COMP
Aide/Homemaker/Companion
3 – Daily Respite Charge RESPITE DAILY
9 - Other Respite Care RESPITE/CARE
067X Outpatient Special Residence Charges
Residence arrangements for patients requiring continuous outpatient care.
Subcategory Standard Abbreviations
0 - General Classification OP SPEC RES
1 - Hospital Based OP SPEC RES/HOSP BASED
2 - Contracted OP SPEC RES/CONTRACTED
9 - Other Special Residence OP SPEC RES/OTHER
Charges
068X Trauma Response
Charges for a trauma team activation.
Subcategory Standard Abbreviations
0 - Not Used
1 - Level I TRAUMA LEVEL I
2 - Level II TRAUMA LEVEL II
3 - Level III TRAUMA LEVEL III
4 - Level IV TRAUMA LEVEL IV
9 - Other Trauma Response TRAUMA OTHER
Usage Notes:
1. To be used by trauma center/hospitals as licensed or designated by the State
or local government authority authorized to do so, or as verified by the
American College of Surgeons and involving a trauma activation.
2. Revenue Category 068X is used for patients for whom a trauma activation
occurred. A trauma team activation/response is a “Notification of key hospital
personnel in response to triage information from pre-hospital caregivers in
advance of the patient’s arrival.”
3. Revenue Category 068X is for reporting trauma activation costs only. It is
an activation fee and not a replacement or a substitute for the emergency room
visit fee; if trauma activation occurs, there will normally be both a 045X and
068X revenue code reported.
4. Revenue Category 068X is not limited to admitted patients.
 5. Revenue Category 068X must be used in conjunction with FL 19 Type of
Admission/Visit code 05 (“Trauma Center”), however FL 19 Code 05 can be
used alone.
Only patients for who there has been pre-hospital notification, who meet either
local, State or American College of Surgeons field triage criteria, or are
delivered by inter-hospital transfers, and are given the appropriate team
response, can be billed the trauma activation fee charge. Patients who are
“drive-by” or arrive without notification cannot be charged for activations, but
can be classified as trauma under Type of Admission Code 5 for statistical and
follow-up purposes.
6. Levels I, II, III or IV refer to designations by the State or local government
authority or as verified by the American College of Surgeons.
7. Subcategory 9 is for sate or local authorities with levels beyond IV.
069X Not Assigned
070X Cast Room
Charges for services related to the application, maintenance and removal of
casts.
Rationale: Permits identification of this service, if necessary.
Subcategory Standard Abbreviations
0 - General Classification CAST ROOM
9 - Other Cast Room OTHER CAST ROOM
071X Recovery Room
Rationale: Permits identification of particular services, if necessary.
Subcategory Standard Abbreviations
0 - General Classification RECOVERY ROOM
9 - Other Recovery Room OTHER RECOV RM
072X Labor Room/Delivery
Charges for labor and delivery room services provided by specially trained
nursing personnel to patients, including prenatal care during labor, assistance
during delivery, postnatal care in the recovery room, and minor gynecologic
procedures if they are performed in the delivery suite.
Rationale: Provides a breakdown of items that may require further
clarification. Infant circumcision is included because not all third party payers
cover it.
Subcategory Standard Abbreviations
0 - General Classification DELIVROOM/LABOR
1 – Labor LABOR
2 - Delivery DELIVERY ROOM
3 - Circumcision CIRCUMCISION
4 - Birthing Center BIRTHING CENTER
9 - Other Labor Room/Delivery OTHER/DELIV-LABOR
073X Electrocardiogram (EKG/ECG)
Charges for operation of specialized equipment to record electromotive
variations in actions of the heart muscle on an electrocardiograph for
diagnosis of heart ailments.
Subcategory Standard Abbreviations
 0 - General Classification EKG/ECG
1 – Holter Monitor HOLTER MONT
2 - Telemetry TELEMETRY
9 - Other EKG/ECG OTHER EKG-ECG
074X Electroencephalogram (EEG)
Charges for operation of specialized equipment to measure impulse frequencies
and differences in electrical potential in various areas of the brain to obtain
data for use in diagnosing brain disorders.
Subcategory Standard Abbreviations
0 - General Classification EEG
9 - Other EEG OTHER EEG
075X Gastro-Intestinal Services
Procedure room charges for endoscopic procedures not performed in an
operating room.
Subcategory Standard Abbreviations
0 - General Classification GASTR-INTS SVS
9 - Other Gastro-Intestinal OTHER GASTRO-INTS
076X Treatment or Observation Room
Charges for the use of a treatment room or for the room charge associated with
outpatient observation services. Only 0762 should be used for observation
services.
Observation services are those services furnished by a hospital on the
hospital’s premises, including use of a bed and periodic monitoring by a
hospital’s nursing or other staff, which are reasonable and necessary to
evaluate an outpatient’s condition or determine the need for a possible
admission to the hospital as an inpatient. Such services are covered only when
provided by the order of a physician or another individual authorized by State
licensure law and hospital staff bylaws to admit patients to the hospital or to
order outpatient tests. Most observation services do not exceed one day. Some
patients, however, may require a second day of outpatient observation services.
The reason for observation must be stated in the orders for observation. Payer
should establish written guidelines that identify coverage of observation
services.
Subcategory Standard Abbreviations
0 - General Classification TREATMENT/OBSERVATION RM
1 - Treatment Room TREATMENT RM
2 - Observation Room OBSERVATION RM
9 – Other Treatment Room OTHER TREATMENT RM
077X Preventative Care Services
Charges for the administration of vaccines.
Subcategory Standard Abbreviations
0 - General Classification PREVENT CARE SVS
1 - Vaccine Administration VACCINE ADMIN
9 – Other OTHER PREVENT
078X Telemedicine - Future use to be announced - Medicare Demonstration Project
 Subcategory Standard Abbreviations
0 - General Classification TELEMEDICINE
9 – Other Telemedicine TELEMEDICINE/OTHER
079X Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy)
Charges related to Extra-Corporeal Shock Wave Therapy (ESWT)..
Subcategory Standard Abbreviations
0 - General Classification ESWT
9 – Other ESWT ESWT/OTHER
080X Inpatient Renal Dialysis
A waste removal process performed in an inpatient setting, that uses an
artificial kidney when the body’s own kidneys have failed. The waste may be
removed directly from the blood (hemodialysis) or indirectly from the blood by
flushing a special solution between the abdominal covering and the tissue
(peritoneal dialysis).
Rationale: Specific identification required for billing purposes.
Subcategory Standard Abbreviations
0 - General Classification RENAL DIALYSIS
1 - Inpatient Hemodialysis DIALY/INPT
2 - Inpatient Peritoneal (Non- DIALY/INPT/PER
CAPD)
3 - Inpatient Continuous DIALY/INPT/CAPD
Ambulatory Peritoneal Dialysis
(CAPD)
4 - Inpatient Continuous Cycling DIALY/INPT/CCPD
Peritoneal Dialysis (CCPD)
9 – Other Inpatient Dialysis DIALY/INPT/OTHER
081X Organ Acquisition
The acquisition and storage costs of body tissue, bone marrow, organs and
other body components not otherwise identified used for transplantation.
Rationale: Living donor is a living person from whom various organs are
obtained for transplantation. Cadaver is an individual who has been
pronounced dead according to medical and legal criteria, from whom various
organs are obtained for transplantation.
Medicare requires detailed revenue coding. Therefore, codes for this series
may not be summed at the zero level.

Subcategory Standard Abbreviations

0 - General Classification ORGAN ACQUISIT
1 - Living Donor LIVING/DONOR
2 - Cadaver Donor CADAVER/DONOR
3 - Unknown Donor UNKNOWN/DONOR
4 - Unsuccessful Organ Search UNSUCCESSFUL SEARCH
Donor Bank Charge*
9 – Other Organ Donor OTHER/DONOR
NOTE: *Revenue code 0814 is used only when costs incurred for an organ search do not
result in an eventual organ acquisition and transplantation.
082X Hemodialysis - Outpatient or Home Dialysis
A waste removal process performed in an outpatient or home setting, necessary
when the body’s own kidneys have failed. Waste is removed directly from the
blood.
Rationale: Detailed revenue coding is required. Therefore, services may not be
summed at the zero level.
Subcategory Standard Abbreviations
0 - General Classification HEMO/OP OR HOME
1 - Hemodialysis/Composite or HEMO/COMPOSITE
Other Rate
2 – Home Supplies HEMO/HOME/SUPPL
3 – Home Equipment HEMO/HOME/EQUIP
4 - Maintenance/100% HEMO/HOME/100%
5 - Support Services HEMO/HOME/SUPSERV
9 – Other Hemodialysis Outpatient HEMO/HOME/OTHER
083X Peritoneal Dialysis - Outpatient or Home
A waste removal process performed in an outpatient or home setting, necessary
when the body’s own kidneys have failed. Waste is removed indirectly by
flushing a special solution between the abdominal covering and the tissue.
Subcategory Standard Abbreviations
0 - General Classification PERITONEAL/OP OR HOME
1 - Peritoneal/Composite or Other PERTNL/COMPOSITE
Rate
2 – Home Supplies PERTNL/HOME/SUPPL
3 – Home Equipment PERTNL/HOME/EQUIP
4 - Maintenance/100% PERTNL/HOME/100%
5 - Support Services PERTNL/HOME/SUPSERV
9 – Other Peritoneal Dialysis PERTNL/HOME/OTHER
084X Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home
A continuous dialysis process performed in an outpatient or home setting,
which uses the patient’s peritoneal membrane as a dialyzer.
Subcategory Standard Abbreviations
0 - General Classification CAPD/OP OR HOME
1 - CAPD/Composite or Other Rate CAPD/COMPOSITE
2 – Home Supplies CAPD/HOME/SUPPL
3 – Home Equipment CAPD/HOME/EQUIP
4 - Maintenance/100% CAPD/HOME/100%
5 - Support Services CAPD/HOME/SUPSERV
9 – Other CAPD Dialysis CAPD/HOME/OTHER
085X Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient
A continuous dialysis process performed in an outpatient or home setting,
which uses the patient’s peritoneal membrane as a dialyzer.
Subcategory Standard Abbreviations
0 - General Classification CCPD/OP OR HOME
1 - CCPD/Composite or Other Rate CCPD/COMPOSITE
2 – Home Supplies CCPD/HOME/SUPPL
 3 – Home Equipment CCPD/HOME/EQUIP
4 - Maintenance/100% CCPD/HOME/100%
5 - Support Services CCPD/HOME/SUPSERV
9 – Other CCPD Dialysis CCPD/HOME/OTHER
086X Reserved for Dialysis (National Assignment)
087X Reserved for Dialysis (National Assignment)
088X Miscellaneous Dialysis
Charges for dialysis services not identified elsewhere.
Rationale: Ultra-filtration is the process of removing excess fluid from the
blood of dialysis patients by using a dialysis machine but without the dialysate
solution. The designation is used only when the procedure is not performed as
part of a normal dialysis session.
Subcategory Standard Abbreviations
0 - General Classification DIALY/MISC
1 – Ultra-filtration DIALY/ULTRAFILT
2 - Home Dialysis Aid Visit HOME DIALYSIS AID VISIT
9 - Other Miscellaneous Dialysis DIALY/MISC/OTHER
089X Reserved for National Assignment
090X Behavior Health Treatments/Services (Also see 091X, an extension of 090X)
Subcategory Standard Abbreviations
0 - General Classification BH
1 - Electroshock Treatment BH/ELECTRO SHOCK
2 - Milieu Therapy BH/MILIEU THERAPY
3 - Play Therapy BH/PLAY THERAPY
4 - Activity Therapy BH/ACTIVITY THERAPY
5 – Intensive Outpatient Services- BH/INTENS OP/PSYCH
Psychiatric
6 – Intensive Outpatient Services- BH/INTENS OP/CHEM DEP
Chemical Dependency
7 – Community Behavioral Health BH/COMMUNITY
Program (Day Treatment)
8 – Reserved for National Use
9 – Reserved for National Use
091X Behavioral Health Treatment/Services-Extension of 090X
Code indicates charges for providing nursing care and professional services
for emotionally disturbed patients. This includes patients admitted for
diagnosis and those admitted for treatment.
Subcategories 0912 and 0913 are designed as zero-billed revenue codes (no
dollars in the amount field) to be used as a vehicle to supply program
information as defined in the provider/payer contract.
Subcategory Standard Abbreviations
0 – Reserved for National Assignment
1 - Rehabilitation BH/REHAB
2 - Partial Hospitalization* - Less BH/PARTIAL HOSP
Intensive
3 - Partial Hospitalization* - Intensive BH/PARTIAL INTENSIVE
 4 - Individual Therapy BH/INDIV RX
5 - Group Therapy BH/GROUP RX
6 - Family Therapy BH/FAMILY RX
7 - Bio Feedback BH/BIOFEED
8 - Testing BH/TESTING
9 – Other Behavior Health BH/OTHER
Treatments/Services
NOTE: *Medicare does not recognize codes 0912 and 0913 services under its partial
hospitalization program.
092X Other Diagnostic Services
Code indicates charges for other diagnostic services not otherwise categorized.
Subcategory Standard Abbreviations
0 - General Classification OTHER DX SVS
1 - Peripheral Vascular Lab PERI VASCUL LAB
2 - Electromyelogram EMG
3 - Pap Smear PAP SMEAR
4 - Allergy test ALLERGY TEST
5 - Pregnancy test PREG TEST
9 - Other Diagnostic Service ADDITIONAL DX SVS
093X Medical Rehabilitation Day Program
Medical rehabilitation services as contracted with a payer and/or certified by
the State. Services may include physical therapy, occupational therapy, and
speech therapy. The subcategories of 093X are designed as zero-billed revenue
codes (i.e., no dollars in the amount field) to be used as a vehicle to supply
program information as defined in the provider/payer contract. Therefore, zero
would be reported in FL47 and the number of hours provided would be
reported in FL46. The specific rehabilitation services would be reported under
the applicable revenue codes as normal.
Subcategory Standard Abbreviations
1 – Half Day HALF DAY
2 – Full Day FULL DAY
094X Other Therapeutic Services (also See 095X, an extension of 094X)
Code indicates charges for other therapeutic services not otherwise
categorized.
Subcategory Standard Abbreviations
0 - General Classification OTHER RX SVS
1 - Recreational Therapy RECREATION RX
2 - Education/Training (includes EDUC/TRAINING
diabetes related dietary therapy)
3 - Cardiac Rehabilitation CARDIAC REHAB
4 - Drug Rehabilitation DRUG REHAB
5 - Alcohol Rehabilitation ALCOHOL REHAB
6 - Complex Medical Equipment COMPLX MED EQUIP-ROUT
Routine
7 - Complex Medical Equipment COMPLX MED EQUIP-ANC
Ancillary
 9 - Other Therapeutic Services ADDITIONAL RX SVS
095X Other Therapeutic Services-Extension of 094X
Charges for other therapeutic services not otherwise categorized
Subcategory Standard Abbreviations
0 - Reserved
1 - Athletic Training ATHLETIC TRAINING
2 - Kinesiotherapy KINESIOTHERAPY
096X Professional Fees
Charges for medical professionals that hospitals or third party payers require
to be separately identified on the billing form. Services that were not identified
separately prior to uniform billing implementation should not be separately
identified on the uniform bill.
Subcategory Standard Abbreviations
0 - General Classification PRO FEE
1 - Psychiatric PRO FEE/PSYCH
2 - Ophthalmology PRO FEE/EYE
3 - Anesthesiologist (MD) PRO FEE/ANES MD
4 - Anesthetist (CRNA) PRO FEE/ANES CRNA
9 - Other Professional Fees OTHER PRO FEE
097X Professional Fees - Extension of 096X
Subcategory Standard Abbreviations
1 - Laboratory PRO FEE/LAB
2 - Radiology - Diagnostic PRO FEE/RAD/DX
3 - Radiology - Therapeutic PRO FEE/RAD/RX
4 - Radiology - Nuclear Medicine PRO FEE/NUC MED
5 - Operating Room PRO FEE/OR
6 - Respiratory Therapy PRO FEE/RESPIR
7 - Physical Therapy PRO FEE/PHYSI
8 - Occupational Therapy PRO FEE/OCUPA
9 - Speech Pathology PRO FEE/SPEECH
098X Professional Fees - Extension of 096X & 097X
Subcategory Standard Abbreviations
1 - Emergency Room PRO FEE/ER
2 - Outpatient Services PRO FEE/OUTPT
3 - Clinic PRO FEE/CLINIC
4 - Medical Social Services PRO FEE/SOC SVC
5 – EKG PRO FEE/EKG
6 – EEG PRO FEE/EEG
7 - Hospital Visit PRO FEE/HOS VIS
8 - Consultation PRO FEE/CONSULT
9 - Private Duty Nurse FEE/PVT NURSE
099X Patient Convenience Items
Charges for items that are generally considered by the third party payers to be
strictly convenience items and, as such, are not covered.
Rationale: Permits identification of particular services as necessary.
Subcategory Standard Abbreviations
 0 - General Classification PT CONVENIENCE
1 - Cafeteria/Guest Tray CAFETERIA
2 - Private Linen Service LINEN
3 - Telephone/Telegraph TELEPHONE
4 - TV/Radio TV/RADIO
5 – Non-patient Room Rentals NONPT ROOM RENT
6 - Late Discharge Charge LATE DISCHARGE
7 - Admission Kits ADMIT KITS
8 - Beauty Shop/Barber BARBER/BEAUTY
9 - Other Patient Convenience Items PT CONVENCE/OTH
100X Behavioral Health Accommodations
Routine service charges incurred for accommodations at specified behavior
health facilities.
Subcategory Standard Abbreviations
0 - General Classification BH R&B
1 – Residential Treatment - BH – R&B RES/PSYCH
Psychiatric
2 – Residential Treatment – BH R&B RES/CHEM DEP
Chemical Dependency
3 – Supervised Living BH R&B SUP LIVING
4 – Halfway House BH R&B HALFWAY HOUSE
5 – Group Home BH R&B GROUP HOME
101X TO 209X Reserved for National Assignment
210X Alternative Therapy Services
Charges for therapies not elsewhere categorized under other therapeutic
service revenue codes (042X, 043X, 044X, 091X, 094X, 095X) or services such
as anesthesia or clinic (0374, 0511).
Alternative therapy is intended to enhance and improve standard medical
treatment. The following revenue codes(s) would be used to report services in
a separately designated alternative inpatient/outpatient unit.
Subcategory Standard Abbreviations
0 - General Classification ALTTHERAPY
1 - Acupuncture ACUPUNCTURE
2 - Accupressure ACCUPRESSURE
3 - Massage MASSAGE
4 - Reflexology REFLEXOLOGY
5 - Biofeedback BIOFEEDBACK
6 - Hypnosis HYPNOSIS
9 - Other Alternative Therapy Service OTHER THERAPY
211X to 300X Reserved for National Assignment
310X Adult Care - Effective April 1, 2003
Charges for personal, medical, psycho-social, and/or therapeutic services in a
special community setting for adults needing supervision and/or assistance with
Activities of Daily Living (ADLs)

Subcategory Standard Abbreviations

 0 - Note Used
1 - Adult Day Care, Medical and ADULT MED/SOC HR
Social - Hourly
2 - Adult Day Care, Social - Hourly ADULT SOC HR
3 - Adult Day Care, Medical and ADULT MED/SOC DAY
Social - Day
4 - Adult Day Care, Social - Daily ADULT SOC DAY
5 - Adult Foster Care - Daily ADULT FOSTER CARE
9 – Other Adult Care Other Adult
311X to 899X Reserved for National Assignment
9000 to 9044 Reserved for Medicare Skilled Nursing Facility Demonstration Project
9045 - 9099 Reserved for National Assignment

75.5 - Form Locators 43-81

(Rev.1104, Issued: 11-03-06, Effective: 03-01-07, Implementation: 03-01-07)

FL 43 - Revenue Description
Not Required. The provider enters a narrative description or standard abbreviation for
each revenue code shown in FL 42 on the adjacent line in FL 43. The information assists
clerical bill review. Descriptions or abbreviations correspond to the revenue codes.
“Other” code categories are locally defined and individually described on each bill.
The investigational device exemption (IDE) or procedure identifies a specific device used
only for billing under the specific revenue code 0624. The IDE will appear on the paper
format of Form CMS-1450 as follows: FDA IDE # A123456 (17 spaces).
HHAs identify the specific piece of DME or non-routine supplies for which they are
billing in this area on the line adjacent to the related revenue code. This description
must be shown in HCPCS coding. (Also see FL 80, Remarks.)

FL 44 - HCPCS/Rates/HIPPS Rate Codes

Required. When coding HCPCS for outpatient services, the provider enters the HCPCS
code describing the procedure here. On inpatient hospital bills the accommodation rate
is shown here.

Health Insurance Prospective Payment System (HIPPS) Rate Codes

The HIPPS rate code consists of the three-character resource utilization group (RUG)
code that is obtained from the “Grouper” software program followed by a 2-digit
assessment indicator (AI) that specifies the type of assessment associated with the RUG
code obtained from the Grouper. SNFs must use the version of the Grouper software
program identified by CMS for national PPS as described in the Federal Register for that
year. The Grouper translates the data in the Long Term Care Resident Instrument into a
casemix group and assigns the correct RUG code. The AIs were developed by CMS.
The Grouper will not automatically assign the 2-digit AI, except in the case of a
swing bed MDS that is will result in a special payment situation AI (see below). The
HIPPS rate codes that appear on the claim must match the assessment that has been
transmitted and accepted by the State in which the facility operates. The SNF cannot
put a HIPPS rate code on the claim that does not match the assessment.

HIPPS Modifiers/Assessment Type Indicators

The assessment indicators (AI) were developed by CMS to identify on the claim,
which of the scheduled Medicare assessments or off-cycle assessments is associated
with the assessment reference date and the RUG that is included on the claim for
payment of Medicare SNF services. In addition, the AIs identify the Effective Date
for the beginning of the covered period and aid in ensuring that the number of days
billed for each scheduled Medicare assessment or off cycle assessment accurately
reflect the changes in the beneficiary's status over time. The indicators were developed
by utilizing codes for the reason for assessment contained in section AA8 of the current
version of the Resident Assessment Instrument, Minimum Data Set in order to ease the
reporting of such information. Follow the CMS manual instructions for appropriate
assignment of the assessment codes.

HCPCS Modifiers (Level I and Level II)

The UB-04 accommodates up to four modifiers, two characters each. See AMA
publication CPT 200x (x= to current year) Current Procedural Terminology
Appendix A - HCPCS Modifiers Section: “Modifiers Approved for Ambulatory Surgery
Center (ASC) Hospital Outpatient Use”. 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. Hospitals should not report a separate HCPCS
(five-digit code) instead of the modifier. When appropriate, report a modifier based on
the list indicated in the above section of the AMA publication.

Claims for home health (HH), inpatient skilled nursing facility (SNF), swing bed
providers and inpatient rehabilitation facilities (IRF) enter the HIPPS code here where
applicable. RHC/FQHC encounters billed on TOBs 071x or 073x do not require HCPCS
coding. The complete list of HIPPS codes for use on SNF, swing bed, IRF and HH
claims can be accessed at the following Web site:
http://new.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp.

FL 45 - Service Date
Required Outpatient. Effective June 5, 2000, CMHCs and hospitals (with the exception
of CAHs, Indian Health Service hospitals and hospitals located in American Samoa,
Guam and Saipan) report line item dates of service on all bills containing revenue codes,
procedure codes or drug codes. This includes claims where the “from” and “through”
dates are equal. This change is due to a HIPAA requirement.
Inpatient claims for skilled nursing facilities and swing bed providers enter the
assessment reference date (ARD) here where applicable.
There must be a single line item date of service (LIDOS) for every iteration of every
revenue code on all outpatient bills (TOBs 013X, 014X, 023X, 024X, 032X, 033X, 034X,
071X, 072X, 073X, 074X, 075X, 076X, 081X, 082X, 083X, and 085X and on inpatient
Part B bills (TOBs 012x and 022x). If a particular service is rendered 5 times during the
billing period, the revenue code and HCPCS code must be entered 5 times, once for each
service date. Assessment Date – used for billing SNF PPS (Bill Type 021X).

FL 46 - Units of Service
Required. Generally, the entries in this column quantify services by revenue code
category, e.g., number of days in a particular type of accommodation, pints of blood.
However, when HCPCS codes are required for services, the units are equal to the
number of times the procedure/service being reported was performed. Providers have
been instructed to provide the number of covered days, visits, treatments, procedures,
tests, etc., as applicable for the following:
• Accommodations - 0100s - 0150s, 0200s, 0210s (days)

• Blood pints - 0380s (pints)

• DME - 0290s (rental months)

• Emergency room - 0450, 0452, and 0459 (HCPCS code definition for visit or
procedure)

• Clinic - 0510s and 0520s (HCPCS code definition for visit or procedure)

• Dialysis treatments - 0800s (sessions or days)

• Orthotic/prosthetic devices - 0274 (items)

• Outpatient therapy visits - 0410, 0420, 0430, 0440, 0480, 0910, and 0943 (Units
are equal to the number of times the procedure/service being reported was
performed.)

• Outpatient clinical diagnostic laboratory tests - 030X-031X (tests)

• Radiology - 032x, 034x, 035x, 040x, 061x, and 0333 (HCPCS code definition of
tests or services)

• Oxygen - 0600s (rental months, feet, or pounds)

• Drugs and Biologicals- 0636 (including hemophilia clotting factors)

The provider enters up to seven numeric digits. It shows charges for noncovered services
as noncovered, or omits them. NOTE: Hospital outpatient departments report the
number of visits/sessions when billing under the partial hospitalization program.
For RHCs or FQHCs, a “visit” is defined as a face-to-face encounter between a
clinic/center patient, and one of the certified RHC or FQHC health professionals.
Encounters with more than one health professional, and encounters with the same health
professional which take place on the same day and at a single location constitute a single
“visit,” except for cases in which the patient, subsequent to the first encounter, suffers
illness or injury requiring additional diagnosis or treatment.
EXAMPLE 1
A known diabetic visits the provider on the morning on May l and sees the physician
assistant. The physician assistant believes an adjustment in current medication is
required, but wishes to have the clinic’s physician, who will be present in the afternoon,
check the determination. The patient returns in the afternoon and sees the physician,
who revises the prescribed medication. The physician recommends that the patient
return the following week, on May 8, for a fasting blood sugar analysis to check the
response to the change in medication. In this situation, the provider bills the Medicare
program for one visit. Also, it includes a line item charge for laboratory services for
May 1.
EXAMPLE 2
A patient visits the provider on July l complaining of a sore throat, and sees the physician
assistant. The physician assistant examines the patient, takes a throat culture and
requests that the patient return on July 8 for a follow-up visit to the physician assistant.
In this situation, the provider bills the Medicare program for two visits. Also, it includes
an entry for laboratory.

FL 47 - Total Charges - Not Applicable for Electronic Billers

Required. This is the FL in which the provider sums the total charges for the billing
period for each revenue code (FL 42); or, if the services require, in addition to the
revenue center code, a HCPCS procedure code, where the provider sums the total
charges for the billing period for each HCPCS code. The last revenue code entered in
FL 42 is “0001” which represents the grand total of all charges billed. The amount for
this code, as for all others is entered in FL 47. Each line for FL 47 allows up to nine
numeric digits (0000000.00). The CMS policy is for providers to bill Medicare on the
same basis that they bill other payers. This policy provides consistency of bill data with
the cost report so that bill data may be used to substantiate the cost report. Medicare
and non-Medicare charges for the same department must be reported consistently on the
cost report. This means that the professional component is included on, or excluded
from, the cost report for Medicare and non-Medicare charges. Where billing for the
professional components is not consistent for all payers, i.e., where some payers require
net billing and others require gross, the provider must adjust either net charges up to
gross or gross charges down to net for cost report preparation. In such cases, it must
adjust its provider statistical and reimbursement (PS&R) reports that it derives from the
bill. Laboratory tests (revenue codes 0300-0319) are billed as net for outpatient or
nonpatient bills because payment is based on the lower of charges for the hospital
component or the fee schedule. The FI determines, in consultation with the provider,
whether the provider must bill net or gross for each revenue center other than
laboratory. Where “gross” billing is used, the FI adjusts interim payment rates to
exclude payment for hospital-based physician services. The physician component must
be billed to the carrier to obtain payment. All revenue codes requiring HCPCS codes
and paid under a fee schedule are billed as net.

FL 48 - Noncovered Charges
Required. The total non-covered charges pertaining to the related revenue code in FL
42 are entered here.
FL 49 - (Untitled)
Not used. Data entered will be ignored.

Note: the “PAGE ____ OF ____” and CREATION DATE on line 23 should be reported
on all pages of the UB-04.

FL 50A, B, and C - Payer Identification

Required. If Medicare is the primary payer, the provider must enter “Medicare” on line
A. Entering Medicare indicates that the provider has developed for other insurance and
determined that Medicare is the primary payer. All additional entries across line A (FLs
51-55) supply information needed by the payer named in FL 50A. If Medicare is the
secondary or tertiary payer, the provider identifies the primary payer on line A and
enters Medicare information on line B or C as appropriate. Conditional payments for
Medicare Secondary Payer (MSP) situations will not be made based on a Home Health
Agency Request for Anticipated Payment (RAP). A = Primary Payer, B = Secondary
Payer, and
C = Tertiary Payer. For example: If “Medicare” is entered in Form Locator 50A, this
indicates that the provider has determined based on the responses from the patient or the
patient’s representative or from the insurance enrollment card information that Medicare
is the primary payer. In the UB-04, there are a number of value codes to indicate
various reasons and amounts associated with insurance or other payers that are primary
to Medicare (e.g., Form Locators 39-41, Codes 12, 13, 14, 15, 16, 41, 42, and 43). These
value codes are analogous to “Payer Codes” (A, B, D, E, F, H, I, and G respectively).
When applicable, use these value codes so they are consistent with the associated payer
codes (both are required).

FL 51A (Required), B (Situational), and C (Situational) – Health Plan ID

Report the national health plan identifier when one is established;
otherwise report the “number” Medicare has assigned.

FLs 52A, B, and C - Release of Information Certification Indicator

Required. A “Y” code indicates that the provider has on file a signed statement
permitting it to release data to other organizations in order to adjudicate the claim.
Required when state or federal laws do not supersede the HIPAA Privacy Rule by
requiring that a signature be collected. An “I” code indicates Informed Consent to
Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes.
Required when the provider has not collected a signature and state or federal laws do not
supersede the HIPAA Privacy Rule by requiring a signature be collected.
NOTE: The back of Form CMS-1450 contains a certification that all necessary release
statements are on file.

FL 53A, B, and C - Assignment of Benefits Certification Indicator

Not used. Data entered will be ignored.

FLs 54A, B, and C - Prior Payments

Situational. For all services other than inpatient hospital or SNF the provider must
enter the sum of any amounts collected from the patient toward deductibles (cash and
blood) and/or coinsurance on the patient (fourth/last line) of this column. In
apportioning payments between cash and blood deductibles, the first 3 pints of blood are
treated as non-covered by Medicare. Thus, for example, if total inpatient hospital
charges were $350.00 including $50.00 for a deductible pint of blood, the hospital would
apportion $300.00 to the Part A deductible and $50.00 to the blood deductible. Blood is
treated the same way in both Part A and Part B. Part A home health DME cost sharing
amounts collected from the patient are reported in this item.

FL 55A, B, and C - Estimated Amount Due From Patient

Not required.

FL 56 – National Provider ID (NPI)

Required, effective May 23, 2007.

FL 57 – Other Provider ID (primary, secondary, and/or tertiary)

Situational. Use this field to report other provider identifiers as assigned by a health
plan (as indicated in FL50 lines 1-3) prior to May 23, 2007.

FLs 58A, B, and C - Insured’s Name

Required. On the same lettered line (A, B or C) that corresponds to the line on which
Medicare payer information is shown in FLs 50-54, the provider must enter the patient’s
name as shown on the HI card or other Medicare notice. All additional entries across
line A (FLs 59-66) pertain to the person named in Item 58A. The instructions that follow
explain when to complete these items.
The provider must enter the name of the individual in whose name the insurance is
carried if there are payer(s) of higher priority than Medicare and it is requesting
payment because:
• Another payer paid some of the charges and Medicare is secondarily liable for
the remainder;

• Another payer denied the claim; or

• The provider is requesting conditional payment. If that person is the patient, the
provider enters “Patient.” Payers of higher priority than Medicare include:

• EGHPs for employed beneficiaries and spouses age 65 or over;

• EGHPs for beneficiaries entitled to benefits solely on the basis of ESRD during
a period of up to l2 months;

• LGHPs for disabled beneficiaries;

• An auto-medical, no-fault, or liability insurer; or

 • WC including BL.
FL 59A, B, and C - Patient’s Relationship to Insured
Required. If the provider is claiming payment under any of the circumstances described
under FLs 58 A, B, or C, it must enter the code indicating the relationship of the patient
to the identified insured, if this information is readily available.
Effective October 16, 2003
Code Title
01 Spouse
18 Self
19 Child
20 Employee
21 Unknown
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship

FLs 60A, B, and C – Insured’s Unique ID (Certificate/Social Security Number/HI

Claim/Identification Number (HICN))
Required. On the same lettered line (A, B, or C) that corresponds to the line on which
Medicare payer information is shown in FLs 50-54, the provider enters the patient’s
HICN, i.e., if Medicare is the primary payer, it enters this information in FL 60A. It
shows the number as it appears on the patient’s HI Card, Certificate of Award, Medicare
Summary Notice, or as reported by the Social Security Office.
If the provider is reporting any other insurance coverage higher in priority than
Medicare (e.g., EGHP for the patient or the patient’s spouse or during the first year of
ESRD entitlement), it shows the involved claim number for that coverage on the
appropriate line.

FL 61A, B, and C - Insurance Group Name

Situational (required if known). Where the provider is claiming payment under the
circumstances described in FLs 58A, B, or C and a WC or an EGHP is involved, it enters
the name of the group or plan through which that insurance is provided.

FL 62A, B, and C - Insurance Group Number

Situational (required if known). Where the provider is claiming payment under the
circumstances described in FLs 58A, B, or C and a WC or an EGHP is involved, it enters
the identification number, control number or code assigned by that health insurance
carrier to identify the group under which the insured individual is covered.

FL 63 - Treatment Authorization Code

Situational. Required when an authorization or referral number is assigned by the
payer and then the services on this claim AND either the services on this claim were
preauthorized or a referral is involved. Whenever QIO review is performed for
outpatient preadmission, pre-procedure, or Home IV therapy services, the authorization
number is required for all approved admissions or services.
FL 64 – Document Control Number (DCN)
Situational. The control number assigned to the original bill by the health plan or the
health plan’s fiscal agent as part of their internal control.

FL 65 - Employer Name
Situational. Where the provider is claiming payment under the circumstances described
in the second paragraph of FLs 58A, B, or C and there is WC involvement or an EGHP,
it enters the name of the employer that provides health care coverage for the individual
identified on the same line in FL 58.

FL 66 – Diagnosis and Procedure code Qualifier (ICD Version Indicator)

Required. The qualifier that denotes the version of International Classification of
Diseases (ICD) reported. The following qualifier codes reflect the edition portion of
the ICD: 9 - Ninth Revision, 0 - Tenth Revision. Medicare does not accept ICD-10
codes. Medicare only processes ICD-9 codes.

FL 67 - Principal Diagnosis Code

Required. The hospital enters the ICD code for the principal diagnosis. The code must
be the full ICD diagnosis code, including all five digits where applicable. The reporting
of the decimal between the third and fourth digit is unnecessary because it is implied.
The principal diagnosis code will include the use of “V” codes. Where the proper code
has fewer than five digits, the hospital may not fill with zeros. The principal diagnosis is
the condition established after study to be chiefly responsible for this admission. Even
though another diagnosis may be more severe than the principal diagnosis, the hospital
enters the principal diagnosis. Entering any other diagnosis may result in incorrect
assignment of a DRG and cause the hospital to be incorrectly paid under PPS. The
hospital reports the full ICD code for the diagnosis shown to be chiefly responsible for
the outpatient services in FL 67 of the bill. It reports the diagnosis to its highest degree
of certainty. For instance, if the patient is seen on an outpatient basis for an evaluation
of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom
must be reported (7862). If during the course of the outpatient evaluation and treatment
a definitive diagnosis is made (e.g., acute bronchitis), the hospital must report the
definitive diagnosis (4660). When a patient arrives at the hospital for examination or
testing without a referring diagnosis and cannot provide a complaint, symptom, or
diagnosis, the hospital should report an ICD code for Persons Without Reported
Diagnosis Encountered During Examination and Investigation of Individuals and
Populations (V70-V82). Examples include:
• Routine general medical examination (V700);

• General medical examination without any working diagnosis or complaint,

patient not sure if the examination is a routine checkup (V709); and

• Examination of ears and hearing (V721).

NOTE: Diagnosis codes are not required on nonpatient claims for laboratory services
where the hospital functions as an independent laboratory.
FLs 67A-67Q - Other Diagnosis Codes
Inpatient Required. The hospital enters the full ICD codes for up to eight additional
conditions if they co-existed at the time of admission or developed subsequently, and
which had an effect upon the treatment or the length of stay. It may not duplicate the
principal diagnosis listed in FL 67 as an additional or secondary diagnosis. If the
principal diagnosis is duplicated, the FI will remove the duplicate diagnosis before the
record is processed by GROUPER for IPPS claims. The MCE identifies situations where
the principal diagnosis is duplicated for IPPS claims.
Outpatient - Required. The hospital enters the full ICD codes in FLs 67A-67Q for up to
eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
NOTE: Medicare will ignore data submitted in 67I – 67Q.

FL 68
Not used. Data entered will be ignored.

FL 69 - Admitting Diagnosis
Required. For inpatient hospital claims subject to QIO review, the admitting diagnosis
is required. Admitting diagnosis is the condition identified by the physician at the time of
the patient’s admission requiring hospitalization. This definition is not the same as that
for SNF admissions.

FL70A – 70C - Patient’s Reason for Visit

Situational. Patient’s Reason for Visit is required for all un-scheduled outpatient visits
for outpatient bills.

FL71 – Prospective Payment System (PPS) Code

Not used. Data entered will be ignored.

FL72 - External Cause of Injury (ECI) Codes

Not used. Data entered will be ignored.

FL 73
Not used. Data entered will be ignored.

FL 74 - Principal Procedure Code and Date

Situational. Required on inpatient claims when a procedure was performed. Not used
on outpatient claims.

FL 74A – 74E - Other Procedure Codes and Dates

Situational. Required on inpatient claims when additional procedures must be reported.
Not used on outpatient claims.

FL 75
Not used. Data entered will be ignored.
FL 76 - Attending Provider Name and Identifiers (including NPI)
Situational. Required when claim/encounter contains any services other than
nonscheduled transportation services. If not required, do not send. The attending
provider is the individual who has overall responsibility for the patient’s medical care
and treatment reported in this claim/ encounter.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 – Provider Commercial Number

FL 77 - Operating Provider Name and Identifiers (including NPI)

Situational. Required when a surgical procedure code is listed on this claim. If not
required, do not send. The name and identification number of the individual with the
primary responsibility for performing the surgical procedure(s).
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
EI - Employer’s Identification Number
SY - Social Security Number

FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)

The name and ID number of the individual corresponding to the qualifier category
indicated in this section of the claim.
Provider Type Qualifier Codes/Definition/Situational Usage Notes:
DN - Referring Provider. The provider who sends the patient to another provider for
services. Required on an outpatient claim when the Referring Provider is different
than the Attending Physician. If not required, do not send.
ZZ - Other Operating Physician. An individual performing a secondary surgical
procedure or assisting the Operating Physician. Required when another Operating
Physician is involved. If not required, do not send.
82 - Rendering Provider. The health care professional who delivers or completes a
particular medical service or non-surgical procedure. Report when state or federal
regulatory requirements call for a combined claim, i.e., a claim that includes both
facility and professional fee components (e.g., a Medicaid clinic bill or Critical
Access Hospital claim). If not required, do not send.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
EI - Employer’s Identification Number
SY - Social Security Number

FL 80 - Remarks
Situational. For DME billings the provider shows the rental rate, cost, and anticipated
months of usage so that the provider’s FI may determine whether to approve the rental or
purchase of the equipment. Where Medicare is not the primary payer because WC,
automobile medical, no-fault, liability insurer or an EGHP is primary, the provider
enters special annotations. In addition, the provider enters any remarks needed to
provide information that is not shown elsewhere on the bill but which is necessary for
proper payment. For Renal Dialysis Facilities, the provider enters the first month of the
30-month period during which Medicare benefits are secondary to benefits payable
under an EGHP. (See Occurrence Code 33.)

FL 81 - Code-Code Field
Situational. To report additional codes related to a Form Locator or to report external
code list approved by the NUBC for inclusion to the institutional data set.
Code List Qualifiers:
01-A0 Reserved for National Assignment
A1 National Uniform Billing Committee Condition Codes – not used for Medicare
A2 National Uniform Billing Committee Occurrence Codes – not used for Medicare
A3 National Uniform Billing Committee Occurrence Span Codes – not used for Medicare
A4 National Uniform Billing Committee Value Codes – not used for Medicare
A5 - B0 Reserved for National Assignment
B3 Health Care Provider Taxonomy Code
Code Source: ASC X12 External Code Source 682 (National Uniform
Claim Committee)
B4-ZZ Reserved for National Assignment