Place of Service Codes
Place of service codes do not apply when filing the UB-04 claim form. Only type of Bill has been used in UB 04 FORM.
Type of Bill
Enter the four digit code that identifies the specific type of bill and frequency of submission. The first digit is a leading zero.
Enter the 4-digit code to indicate the specific type of bill (e.g., hospital inpatient, outpatient, replacements, voids, etc.).The first digit is a leading zero,The next 2 digits indicate the type of bill, The fourth digit indicates the frequency of the bill. Type of bill must be consistent with services rendered
2nd Digit – Submitting Facility
1 = Hospital
2 = Skilled Nursing
3 = Home Health
4 = Christian Science (Hospital)
5 = Christian Science (Extended Care)
6 = Intermediate Care
7 = Clinic (Use “2nd Digit – Clinics Only” below)
8 = Special Facility (Use “2nd Digit – Special Facilities Only” below)
2nd Digit – Bill Classification (Except Clinics and Special Facilities)
1 = Inpatient (Including Medicare Part A)
2 = Inpatient (Medicare Part B Only)
3 = Outpatient
4 = Other
5 = Intermediate Care – Level I
6 = Intermediate Care – Level II
7 = Intermediate Care – Level III
8 = Swing Beds
2nd Digit – Clinics Only
1 = Rural Health
2 = Hospital Based or Independent Renal Dialysis Center
3 = Free Standing
4 = Outpatient Rehabilitation Facility (ORF)
5 = Comprehensive Outpatient Rehabilitation
Facility (CORF)
9 = Other
2nd Digit – Special Facilities Only
1 = Hospice (Non-Hospital Based)
2 = Hospice (Hospital Based)
3 = Ambulatory Surgery Center
4 = Free Standing Birthing Center
9 = Other
3rd Digit – Frequency
0 = Non-Payment/Zero Claim
1 = Admit Through Discharge Date (one claim covers entire stay)
2 = First Interim Claim
3 = Continuing Interim Claim
4 = Last Interim Claim
5 = Late Charge(s) Only Claim
6 =
7 = Replacement of Prior Claim
8 = Void/Cancel of Prior Claim
Procedure Codes and Modifiers
ASC providers use the Current Procedural Terminology (CPT) coding system. The CPT manual lists most required procedure codes. This manual may be obtained by contacting the Order Department, American Medical Association, 515 North State Street, Chicago, IL 60610-9986. The (837) Institutional electronic claim and the paper claim have been modified to accept up to four procedure code modifiers.
Only procedures listed in the ASC Procedures List are reimbursable in the ambulatory surgical setting. The list of covered outpatient procedures is located in Appendix I.
Where to Report Modifiers on the Hospital Part B Claim
Modifiers are reported on the hardcopy Form CMS-1450 with the HCPCS code. See Chapter 25 of this manual for related instructions. There is space for four modifiers on the hardcopy.
See the ASC X12 837 Institutional Claim implementation guide for instructions for reporting HCPCS modifiers when using the ASC X12 837 institutional claim format.
The dash that is often seen preceding a modifier should never be reported.
When it is appropriate to use a modifier, the most specific modifier should be used first. That is, when modifiers E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or -59.
NOTE:
Procedures not listed on the ASC Procedures List may be covered under special circumstances. Approval must be obtained prior to the surgery. Refer to Section 9.3, Prior Authorization and Referral Requirements, for more information. Prior to providing services, providers should inform recipients of their responsibilities for payment of services not covered by Medicaid.
Q: My UB-04 claims are being returned for “Service Date (FL45) Must Be Within Statement Covers Period Dates (FL06)”. Why?
A: All dates listed on the UB-04 (with the exception of the Date of Birth, Admission Date, Third Party Liability Pay/Deny Date (if applicable), and the Medicare Paid Date) MUST fall within the Statement Covers Period dates billed in Form Locator (FL) 06. Since the Service Date (FL45) is not a required field, but situational, claims billed with Revenue Code 0022 should leave the date blank on the claim if it does not fall within the date range
