What is Box 72 on a UB04?
72. External Cause of Injury Code Enter the ICD-9-CM diagnosis code pertaining to external cause of injuries. 74. Principal Procedure Code and Date Enter the ICD code that identifies the principal procedure performed.
What is Field 17 on a UB04?
17. * Patient Status Enter the 2-digit patient status code that best describes the patient’s discharge status. 05-Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution.
What is Box 81 on a UB04?
Billing Tip: Enter code “81” when billing for emergency services, or the claim may be reduced or denied. An Emergency Certification Statement must be attached to the claim or entered in the Remarks field (Box 80).
What are the four sections of the UB-04 claim form?
Section 1:
- Credentialing. Section 2:
- Contracting. Section 3:
- Hospital Inpatient Notifications. Section 4:
- Transfer of Patients to/from Facilities. Section 5:
- Hospital Bill Audits. Section 6:
- UB-04 (CMS 1450) Guidelines. Section 7:
- Interim Bills and Late Charges. Section 8:
- Sample UB-04 (CMS 1450) Claim Form. Section 9:
What is Field 11 in CMS 1500 claim form?
Insured person DOB and SEX of destination payer. 11. b. Insured person EMPLOYER name of destination payer.
What is a form locator?
They’re referred to as form locators or “FL.” Each form locator has a unique purpose: Form locator 1: Billing provider name, street address, city, state, zip, telephone, fax, and country code. Form locator 2: Billing provider’s pay-to name, address, city, state, zip, and ID if it’s different from field 1.
What is the field 13 in CMS 1500?
Box 13 is the “authorization of payment of medical benefits to the provider of service.” If this box is completed, the patient is indicating that they want any payments for the services being billed to be sent directly to the provider.
What is the field 12 in CMS 1500 claim form?
Additional Explanation 12 Patient’s or Authorized Person’s Signature Yes Enter the patient’s or authorized person’s signature. Signature on File or “SOF” are acceptable. If the claim is for a Lab or DME provider “No Signature on File” or “Patient Not Present are also acceptable.”
What is the field 11 in CMS 1500?
KEY: R = Required | NR = Not Required | S = Situational, only use if appropriate specific to claim
| Field ID | Field Description | Data Type |
|---|---|---|
| 10c | S | |
| 10d | CLAIM CODES (DESIGNATED BY NUCC) | S |
| 11 | INSURED’S POLICY GROUP OR FECA NUMBER | NR |
| 11a | INSURED’S DATE OF BIRTH, GENDER | NR |
What is Field 12 in CMS claim form?
12 Patient’s or Authorized Person’s Signature Yes Enter the patient’s or authorized person’s signature. Signature on File or “SOF” are acceptable. If the claim is for a Lab or DME provider “No Signature on File” or “Patient Not Present are also acceptable.” Signature on File or “SOF” are acceptable.
