Tips For Completing The Ub04 (Cms-1450) Claim Form (Page 11 of 12) in pdf

Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH)

Discharged/Transferred to a Nursing Facility Certified Under Medicaid but Not Certified Under Medicare

Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital

Discharged/Transferred to a Critical Access Hospital

67–68

Reserved for Assignment by the NUBC

Discharged/transferred to a Designated Disaster Alternative Care Site (effective October 1, 2013)

Discharged/Transferred to Another Type of Healthcare Institution Not Defined Elsewhere in this Code List

71–80

Reserved for Assignment by the NUBC

Discharged to Home or Self-Care with a Planned Acute Care Hospital Inpatient Readmission

Discharged/Transferred to a Short-Term General Hospital for Inpatient Care with a Planned Acute Care Hospital

Inpatient Readmission

Discharged/Transferred to a Skilled Nursing Facility with Medicare Certificat ion with a Planned Acute Care

Hospital Inpatient Readmission

Discharged/Transferred to a Facility that Provides Custodial of Supportive Care with a Planned Acute Care

Hospital Inpatient Readmission

Discharged/Transferred to a Designated Cancer Center or Children’s Hospital with a Planned Acute Care

Hospital Inpatient Readmission

Discharged/Transferred to Home Under Care of Organized Home Health Service Organization with a Planned

Acute Care Hospital Inpatient Readmission

Discharged/Transferred to Court/Law Enforcement with a Planned Acute Care Hospital Inpatient Readmission

Discharged/Transferred to a Federal Health Care Facility with a Planned Acute Care Hospital Inpatient

Readmission

Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed with a Planned Acute Care Hospital

Inpatient Readmission

Discharged/Transferred to an Inpatient Rehabilitation Facility Including Rehabilitation Distinct Part Units of a

Hospital with a Planned Acute Care Hospital Inpatient Readmission

Discharged/Transferred to a Medicare Certified Long-term Care Hospital with a Planned Acute Care Hospital

Inpatient Readmission

Discharged/Transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare with a

Planned Acute Care Hospital Inpatient Readmission

Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part unit of a Hospital with a Planned

Acute Care Hospital Inpatient Readmission

Discharged/Transferred to a Critical Access Hospital with a Planned Acute Care Hospital Inpatient Readmission

Discharged/Transferred to Another Type of Healthcare Institution Not Defined Elsewhere in this Code List with a

Planned Acute Care Hospital Inpatient Readmission

Tips for Completing the UB04 (CMS-1450) Claim Form

Tips For Completing The Ub04 (Cms-1450) Claim Form Page 11