UB04 — Institutional Claim
CMS-1450Universal Billing form for hospitals, SNFs, and other institutional providers
1
Provider Information — Boxes 1–7
FL 1–7
FL 1 Provider Name
FL 2 Pay-to Provider Name
FL 5 Federal Tax Number
FL 3a Patient Control Number
FL 3b Medical Record Number
FL 4 Type of Bill
2
Patient Information — Boxes 8–17
FL 8–17
FL 8a Patient ID
FL 8b Patient Name
FL 10 Patient DOB
FL 11 Patient Sex
FL 12 Admission Date
FL 13 Admission Hour
FL 14 Priority (Type of Admission)
FL 15 Source of Admission
FL 16 Discharge Hour
FL 17 Patient Discharge Status
FL 6 Statement Covers Period
FL 9 Patient Address
3
Condition & Occurrence Codes — Boxes 18–31
FL 18–31
FL 18–28 Condition Codes
FL 31–34 Occurrence Codes
FL 35–36 Occurrence Span Codes
FL 38 Responsible Party
FL 39–41 Value Codes
FL 42 Revenue Code
4
Revenue Code Lines — Service Details
FL 42–49
| # | Rev Code | Description | HCPCS Code | Service Date | Units | Total Charges | Non-Covered |
|---|---|---|---|---|---|---|---|
| 1 | |||||||
| 2 | |||||||
| 3 | |||||||
| 4 | |||||||
| 5 | |||||||
| TOTAL CHARGES: | $39,150.00 | $0.00 | |||||
5
Payer Information — Boxes 50–65
FL 50–65
A — Primary Payer
FL 50A Payer Name
FL 51A Provider Number
FL 60A Insured's ID #
B — Secondary Payer
FL 50B Payer Name
FL 51B Provider Number
FL 60B Insured's ID #
C — Tertiary Payer
FL 50C Payer Name
FL 51C Provider Number
FL 60C Insured's ID #
6
Diagnosis Codes — ICD-10 (Boxes 67–81)
FL 67–81
FL 67 Principal Diagnosis (ICD-10)
FL 67A Secondary Diagnosis A
FL 67B Secondary Diagnosis B
FL 67C Secondary Diagnosis C
FL 67D Secondary Diagnosis D
FL 67E Secondary Diagnosis E
FL 69 Admitting Diagnosis
FL 74 Principal Procedure Code
FL 76 Attending Provider NPI
FL 76 Attending Provider Name
FL 80 Remarks
Total Charges
$39,150.00
Non-Covered
$0.00
LOS
7 days