Tips For Completing The Ub04 (Cms-1450) Claim Form Page 9
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12Source of Admission Codes Except Newborns (Field 15)
Code
Definition
1
Non-Health Care Facility Point of Origin
Clinic or Physician’s Office
2
3
Reserved for assignment by the NUBC
4
Transfer From a Hospital (Different Facility)
5
Transfer from a Skilled Nursing Facility or Intermediate Care Facility or Assisted Living Facility
6
Transfer from Another Health Care Facility
7
Reserved for assignment by the NUBC
8
Court/Law Enforcement
9
Information Not Available
A
Reserved for assignment by the NUBC
B
Reserved for assignment by the NUBC
C
Reserved for assignment by the NUBC
Transfer from One Distinct Unit of the Hospital to Another Distinct Unit of the Same Hospital Resulting in a
D
Separate Claim to the Payer
E
Transfer from Ambulatory Surgery Center
F
Transfer from Hospice Facility
G–Z
Reserved for National Assignment
Additional Source of Admission Codes for Newborns (Field 15)
Code
Definition
1–4
Discontinued
5
Born Inside this Hospital
6
Born Outside this Hospital
7–9
Reserved for National Assignment
9
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Tips for Completing the UB04 (CMS-1450) Claim Form
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