Official UB-04 Data Specifications Manual 2022

Official UB-04 Data Specifications Manual 2022

American Hospital Association

Description

The official source of UB-04 billing information adopted by the National Uniform Billing Committee (NUBC). The 2022 edition contains the updated specifications for the data codes included on the Uniform Bill claim form. Available July 1, 2021.

Table of Contents

2022 UB-04 (v. 16.00)
1
Copyright Notice
2
Table of Contents
3
Introduction
5
Form Locators
10
FL 01 - Billing Provider Name, Address and Telephone Number
10
FL 02 - Billing Provider’s Designated Pay-to Address
11
FL 03a - Patient Control Number
12
FL 03b - Medical/Health Record Number
13
FL 04 - Type of Bill
14
FL 04 - Type of Bill p. 1
14
FL 04 - Type of Bill p. 2
15
FL 04 - Type of Bill Codes 000x-041x p. 3
16
FL 04 - Type of Bill Codes 042x-064x p. 4
17
FL 04 - Type of Bill Codes 065x-087x p. 5
18
FL 04 - Type of Bill Codes 088x-999x p. 6
19
FL 04 - Type of Bill p. 7
20
FL 04 - Type of Bill Frequency Codes 0-6 p. 8
21
FL 04 - Type of Bill Frequency Codes 7-C p. 9
22
FL 04 - Type of Bill Frequency Codes D-P p. 10
23
FL 04 - Type of Bill Frequency Codes Q-Z p. 11
24
FL 05 - Federal Tax Number
25
FL 06 - Statement Covers Period (From - Through)
26
FL 06 - Statement Covers Period (From - Through) p. 1
26
FL 06 - Statement Covers Period (From - Through) p. 2
27
FL 07 - Reserved for Assignment by the NUBC
28
FL 08 - Patient Name/Identifier
29
FL 09 - Patient Address
30
FL 10 - Patient Birth Date
31
FL 11 - Patient Sex
32
FL 12 - Admission/Start of Care Date
33
FL 13 - Admission Hour
34
FL 14 - Priority (Type) of Admission or Visit
35
FL 14 - Priority (Type) of Admission or Visit p. 1
35
FL 14 - Priority (Type) of Admission or Visit FAQ p. 2
36
FL 14 - Priority (Type) of Admission or Visit FAQ p. 3
37
FL 14 - Priority (Type) of Admission or Visit FAQ p. 4
38
FL 15 - Point of Origin for Admission or Visit
39
FL 15 - Point of Origin for Admission or Visit p. 1
39
FL 15 - Point of Origin for Admission or Visit 1-5 p. 2
40
FL 15 - Point of Origin for Admission or Visit 6-A p. 3
41
FL 15 - Point of Origin for Admission or Visit B-Z p. 4
42
FL 15 - Point of Origin for Admission or Visit Newborn p. 5
43
FL 15 - Point of Origin for Admission or Visit FAQ p. 6
44
FL 15 - Point of Origin for Admission or Visit FAQ p. 7
45
FL 15 - Point of Origin for Admission or Visit FAQ p. 8
46
FL 15 - Point of Origin for Admission or Visit FAQ p. 9
47
FL 16 - Discharge Hour
48
FL 17 - Patient Discharge Status
49
FL 17 - Patient Discharge Status p. 1
49
FL 17 - Patient Discharge Status p. 2
50
FL 17 - Patient Discharge Status 01-05 p. 3
51
FL 17 - Patient Discharge Status 06-41 p. 4
52
FL 17 - Patient Discharge Status 42-65 p. 5
53
FL 17 - Patient Discharge Status 66-91 p. 6
54
FL 17 - Patient Discharge Status 92-99 p. 7
55
FL 17 - Patient Discharge Status FAQ p. 8
56
FL 17 - Patient Discharge Status FAQ p. 9
57
FL 17 - Patient Discharge Status FAQ p. 10
58
FL 17 - Patient Discharge Status FAQ p. 11
59
FL 17 - Patient Discharge Status FAQ p. 12
60
FL 17 - Patient Discharge Status FAQ p. 13
61
FL 17 - Patient Discharge Status FAQ p. 14
62
FL 17 - Patient Discharge Status FAQ p. 15
63
FL 18-28 - Condition Codes
64
FL 18-28 - Condition Codes 01-05 p. 1
64
FL 18-28 - Condition Codes 06-19 p. 2
65
FL 18-28 - Condition Codes 20-28 p. 3
66
FL 18-28 - Condition Codes 29-42 p. 4
67
FL 18-28 - Condition Codes 43-51 p. 5
68
FL 18-28 - Condition Codes 52-66 p. 6
69
FL 18-28 - Condition Codes 67-76 p. 7
70
FL 18-28 - Condition Codes 77-79 p. 8
71
FL 18-28 - Condition Codes 80-91 p. 9
72
FL 18-28 - Condition Codes 92-A2 p. 10
73
FL 18-28 - Condition Codes A3-AI p. 11
74
FL 18-28 - Condition Codes AJ-C0 p. 12
75
FL 18-28 - Condition Codes C1-D6 p. 13
76
FL 18-28 - Condition Codes D7-H3 p. 14
77
FL 18-28 - Condition Codes H4-H5 p. 15
78
FL 18-28 - Condition Codes H6-R4 p. 16
79
FL 18-28 - Condition Codes R5-VZ p. 17
80
FL 18-28 - Condition Codes W0-ZZ p. 18
81
FL 29 - Accident State
82
FL 30 - Reserved for Assignment by the NUBC
83
FL 31-34/35-36 Guidelines for Occurrence and Occurrence Span Utilization p. 1
84
FL 31-34 - Occurrence Codes and Dates 01-08 p. 2
85
FL 31-34 - Occurrence Codes and Dates 09-22 p. 3
86
FL 31-34 - Occurrence Codes and Dates 23-35 p. 4
87
FL 31-34 - Occurrence Codes and Dates 36-39 p. 5
88
FL 31-34 - Occurrence Codes and Dates 40-50 p. 6
89
FL 31-34 - Occurrence Codes and Dates 51-A0 p. 7
90
FL 31-34 - Occurrence Codes and Dates A1-E3 p. 8
91
FL 31-34 - Occurrence Codes and Dates E4-ZZ p. 9
92
FL 35-36 - Occurrence Span Codes and Dates
93
FL 35-36 - Occurrence Span Codes and Dates p. 1
93
FL 35-36 - Occurrence Span Codes and Dates 70-75 p. 2
94
FL 35-36 - Occurrence Span Codes and Dates 76-99 p. 3
95
FL 35-36 - Occurrence Span Codes and Dates M0-ZZ p. 4
96
FL 37 - Reserved for Assignment by the NUBC
97
FL 38 - Responsible Party Name and Address (Claim Addressee)
98
FL 39-41 - Value Codes and Amounts
99
FL 39-41 - Value Codes and Amounts p. 1
99
FL 39-41 - Value Codes and Amounts p. 2
100
FL 39-41 - Value Codes and Amounts p. 3
101
FL 39-41 - Value Codes and Amounts 01-08 p. 4
102
FL 39-41 - Value Codes and Amounts 09-15 p. 5
103
FL 39-41 - Value Codes and Amounts 16-28 p. 6
104
FL 39-41 - Value Codes and Amounts 29-38 p. 7
105
FL 39-41 - Value Codes and Amounts 39-43 p. 8
106
FL 39-41 - Value Codes and Amounts 44-46 p. 9
107
FL 39-41 - Value Codes and Amounts 47-54 p. 10
108
FL 39-41 - Value Codes and Amounts 55-65 p. 11
109
FL 39-41 - Value Codes and Amounts 66-83 p. 12
110
FL 39-41 - Value Codes and Amounts 84-85 p. 13
111
FL 39-41 - Value Codes and Amounts 86-A1 p. 14
112
FL 39-41 - Value Codes and Amounts A2-A4 p. 15
113
FL 39-41 - Value Codes and Amounts A5-AB p. 16
114
FL 39-41 - Value Codes and Amounts AC-C1 p. 17
115
FL 39-41 - Value Codes and Amounts C2-D2 p. 18
116
FL 39-41 - Value Codes and Amounts D3-E6 p. 19
117
FL 39-41 - Value Codes and Amounts E7-EZ p. 20
118
FL 39-41 - Value Codes and Amounts F0-OZ p. 21
119
FL 39-41 - Value Codes and Amounts P0-Y2 p. 22
120
FL 39-41 - Value Codes and Amounts Y3-ZZ p. 23
121
FL 42 - Revenue Codes
122
FL 42 - Revenue Codes p. 1
122
FL 42 - Revenue Codes p. 2
123
FL 42 - Revenue Codes 0000-010x p. 3
124
FL 42 - Revenue Codes 011x-012x p. 4
125
FL 42 - Revenue Codes 013x-014x p. 5
126
FL 42 - Revenue Codes 015x-016x p. 6
127
FL 42 - Revenue Codes 017x p. 7
128
FL 42 - Revenue Codes 017x p. 8
129
FL 42 - Revenue Codes 018x-019x p. 9
130
FL 42 - Revenue Codes 020x-021x p. 10
131
FL 42 - Revenue Codes 022x-023x p. 11
132
FL 42 - Revenue Codes 024x-025x p. 12
133
FL 42 - Revenue Codes 026x p. 13
134
FL 42 - Revenue Codes 027x p. 14
135
FL 42 - Revenue Codes 028x-030x p. 15
136
FL 42 - Revenue Codes 031x-032x p. 16
137
FL 42 - Revenue Codes 033x-034x p. 17
138
FL 42 - Revenue Codes 035x-037x p. 18
139
FL 42 - Revenue Codes 038x-039x p. 19
140
FL 42 - Revenue Codes 040x-042x p. 20
141
FL 42 - Revenue Codes 043x-044x p. 21
142
FL 42 - Revenue Codes 045x-046x p. 22
143
FL 42 - Revenue Codes 047x-049x p. 23
144
FL 42 - Revenue Codes 050x-051x p. 24
145
FL 42 - Revenue Codes 052x p. 25
146
FL 42 - Revenue Codes 053x-055x p. 26
147
FL 42 - Revenue Codes 056x-059x p. 27
148
FL 42 - Revenue Codes 060x-061x p. 28
149
FL 42 - Revenue Codes 062x p. 29
150
FL 42 - Revenue Codes 063x p. 30
151
FL 42 - Revenue Codes 064x p. 31
152
FL 42 - Revenue Codes 065x-066x p. 32
153
FL 42 - Revenue Codes 067x p. 33
154
FL 42 - Revenue Codes 068x p. 34
155
FL 42 - Revenue Codes 069x-071x p. 35
156
FL 42 - Revenue Codes 072x-075x p. 36
157
FL 42 - Revenue Codes 076x-077x p. 37
158
FL 42 - Revenue Codes 078x-080x p. 38
159
FL 42 - Revenue Codes 081x p. 39
160
FL 42 - Revenue Codes 082x p. 40
161
FL 42 - Revenue Codes 083x p. 41
162
FL 42 - Revenue Codes 084x-085x p. 42
163
FL 42 - Revenue Codes 086x-087x p. 43
164
FL 42 - Revenue Codes 088x-089x p. 44
165
FL 42 - Revenue Codes 090x-091x p. 45
166
FL 42 - Revenue Codes 092x-093x p. 46
167
FL 42 - Revenue Codes 094x-095x p. 47
168
FL 42 - Revenue Codes 096x-097x p. 48
169
FL 42 - Revenue Codes 098x-099x p. 49
170
FL 42 - Revenue Codes 100x-209x p. 50
171
FL 42 - Revenue Codes 210x-309x p. 51
172
FL 42 - Revenue Codes 310x-9999 p. 52
173
FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate/ Line Level Rendering Provider NPI
174
FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate/ Line Level Rendering Provider NPI p. 1
174
FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate/ Line Level Rendering Provider NPI p. 2
175
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes
176
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes p. 1
176
FL 44 - HCPCS/Accommodation Rates/HIPPS Rate Codes p. 2
177
FL 45 - Service/Assessment Date
178
FL 46 - Service Units
179
FL 47 - Total Charges
180
FL 48 - Non-covered Charges
181
FL 49 - Reserved for Assignment by the NUBC
182
FL 50 - Payer Name
183
FL 51 - Payer ID
184
FL 52 - Release of Information Certification Indicator
185
FL 53 - Assignment of Benefits Certification Indicator
186
FL 54 - Prior Payments - Payer
187
FL 55 - Estimated Amount Due - Payer
188
FL 56 - National Provider Identifier - Billing Provider
189
FL 57 - Other (Billing) Provider Identifier
190
FL 58 - Insured’s Name
191
FL 59 - Patient’s Relationship to Insured
192
FL 60 - Insured’s Unique Identifier
193
FL 61 - Insured’s Group Name
194
FL 62 - Insured’s Group Number
195
FL 63 - Authorization Code/Referral Number
196
FL 64 - Document Control Number (DCN)
197
FL 65 - Employer Name (of the Insured)
198
FL 66 - Diagnosis and Procedure Code Qualifier (ICD Revision Indicator)
199
FL 67 - Principal Diagnosis Code and Present on Admission Indicator
200
FL 67 - Principal Diagnosis Code and Present on Admission Indicator p. 1
200
FL 67 - Principal Diagnosis Code and Present on Admission Indicator p. 2
201
FL 67 - Principal Diagnosis Code and Present on Admission Indicator p. 3
202
FL 67a-q - Other Diagnosis Codes and Present on Admission Indicator
203
FL 68 - Reserved for Assignment by the NUBC
204
FL 69 - Admitting Diagnosis Code
205
FL 70a-c - Patient’s Reason for Visit
206
FL 71 - Prospective Payment System (PPS) Code
207
FL 72a-c - External Cause of Injury (ECI) Code and Present on Admission Indicator
208
FL 73 - Reserved for Assignment by the NUBC
209
FL 74 - Principal Procedure Code and Date
210
FL 74a-e - Other Procedure Codes and Dates
211
FL 75 - Reserved for Assignment by the NUBC
212
FL 76 - Attending Provider Name and Identifiers
213
FL 76 - Attending Provider Name and Identifiers p. 1
213
FL 76 - Attending Provider Name and Identifiers p. 2
214
FL 77 - Operating Physician Name and Identifiers
215
FL 77 - Operating Physician Name and Identifiers p. 1
215
FL 77 - Operating Physician Name and Identifiers p. 2
216
FL 78-79 - Other Provider (Individual) Name and Identifiers
217
FL 78-79 - Other Provider (Individual) Name and Identifiers p. 1
217
FL 78-79 - Other Provider (Individual) Name and Identifiers p. 2
218
FL 78-79 - Other Provider (Individual) Name and Identifiers p. 3
219
FL 80 - Remarks Field
220
FL 81 - Code-Code Field
221
FL 81 - Code-Code Field p. 1
221
FL 81 - Code-Code Field p. 2
222
FL 81 - Code-Code Field p. 3
223
FL 81 - Code-Code Field p. 4
224
FL 81 - Code-Code Field p. 5
225
Appendix
226
UB-04 Mapping to 837 Claim Transaction (005010)
227
UB-04/837 Reporting Differences
248
Version 15.00 to 16.00 Change Log
250
UB-04 Form (Front)
251
Back of UB-04 Form (For Informational Purposes Only)
252
UB-04/CMS-1450 Printing Specifications
253