Tips For Completing The Ub04 (Cms-1450) Claim Form (Page 5 of 12) in pdf

Tips For Completing The Ub04 (Cms-1450) Claim Form Page 5

Reserved for

Not

Assignment by the

N/A

Required

NUBC

Enter a valid ICD diagnosis code to its highest level of specificity for

Admitting Diagnosis

Required

services rendered that describes the diagnosis of the patient at the time

of admission.

Patient’s Reason for

The ICD codes that report the reason for the patient’s outpatient visit is

70 a–c

Conditional

Visit

reported here.

This code identifies the DRG based on the grouper software and is

Prospective Payment

Not

required only when the provider is under contract with a health plan using

System (PPS) Code

required

DRG codes.

External Cause of

Not

In the case of external causes of injuries, poisonings, or adverse effects,

Injury (ECI) Code

Required

the appropriate ICD diagnosis code is reported in this field.

Reserved for

Not

Assignment by the

N/A

Required

NUBC

Principal Procedure

N/A exception–if the member resides in the state of Maine, the ICD 10

Conditional

Code and Date

procedure code is required on inpatient claims.

Other Procedure

N/A exception–if the member resides in the state of Maine, the ICD 10

74 a–e

Conditional

Codes and Dates

procedure code is required on inpatient claims.

Reserved for

Not

Assignment by the

N/A

Required

NUBC

Attending Provider

This field is for reporting the name and identifier of the provider with the

Names and

Required

responsibility for the care provided on the claim.

Identifiers

Operating Physician

Report the name and identification number of the physician responsible

Conditional

Name and Identifiers

for performing surgical procedure in this field.

Other Provider

This field is used for reporting the names and identification numbers of

78–79

Names and

Conditional

individuals that correspond to the provider type category.

Identifiers

Not

This field is used to report additional information necessary to process

Remarks

Required

the claim.

This field is used to report codes that overflow other fields and for

externally maintained codes NUBC has approved for the institutional data

81 a–d

Code–Code

Conditional

set. Taxonomy codes should be reported in these fields using a qualifier

of B3.

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

Tips For Completing The Ub04 (Cms-1450) Claim Form Page 5

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