UB-92 BILLING INSTRUCTIONS Print

Locator #

Description

Instructions

*1

Provider Name, Address, Telephone #

Enter the name and address of the facility

2 

Unlabeled Field (State)

Leave blank

3 

Patient Control No.

Enter the patient control number. It may consist of letters and/or numbers and may be a maximum of 16 characters.

*4

Type of Bill

Enter the 3-digit code indicating the specific type of facility, bill classification and frequency. This 3-digit code requires one digit each, in the following format:

a. First digit-type facility

1 Hospital
7 Clinic
8 Special Facility

b. Second digit-classification

1 Inpatient Medicaid and/or Medicare Part A or Parts A & B
2 Inpatient Medicaid and Medicare Part B only
3 Outpatient or Ambulatory Surgical Center
4 Other (Non-patient)

c. Third digit-frequency

0 Non-Payment claim
1 Admission through discharge
2 Interim-first claim
3 Interim-continuing
4 Interim-last claim
7 Replacement of prior claim
8 Void of prior claim

5 

Federal Tax No.

*6

Statement Covers Period (From & Through Dates) dates of the period covered by this bill.

Enter the beginning and ending service

*7 

Covered Days

Required for inpatient - Enter the number of days approved by the Utilization Review Committee as medically necessary. The number of covered days plus the number of non-covered days (Form Locator 8) must equal the number of days represented by the billing period in Form Locator 6. If the From and Through dates in Form Locator 6 are equal, enter "1" in "Covered Days."

8

Non-Covered Days

For inpatient, if applicable - Enter the number of days not approved by the Utilization Review Committee as medically necessary or leave days when not in the hospital for part of the stay. The number of non-covered days, plus the number of covered days (Form Locator 7), must equal the number of days represented by the billing period in Form Locator 6.

9

Co-Insurance Days

Required for Medicare Crossover.

10 

Lifetime Reserve Days

Required for Medicare Crossover.

11

Patient's Phone No.

*12 

Patient's Name

Enter the recipient's name exactly as shown on the recipient's Medicaid eligibility card: Last name, first name, middle initial.

13

Patient's Address (City, State, Zip)

Enter patient's permanent address.

14

Patient's Birthdate

Enter the patient's date of birth using 8 digits (MMDDYYYY). If only one digit appears in a field, enter a leading zero.

15

Patient's Sex

Enter sex of the patient as
M = Male
F = Female
U = Unknown

16

Patient's Marital Status

*17

Admission Date

Required for inpatient - Enter 6 digits for the date of admission (MMDDYY). If there is only one digit in a field, enter a leading zero.

*18

Admission Hour

Required for inpatient services - Enter the 2-digit code which corresponds to the hour the patient was admitted for inpatient care as:

Code Time
00 12:00 - 12:59 midnight
01 01:00 - 01:59 A.M.
02 02:00 - 02:59
03 03:00 - 03:59
04 04:00 - 04:59
05 05:00 - 05:59
06 06:00 - 06:59
07 07:00 - 07:59
08 08:00 - 08:59
09 09:00 - 09:59
10 10:00 - 10:59
11 11:00 - 11:59
12 12:00 - 12:59 noon
13 01:00 - 01:59 P.M.
14 02:00 - 02:59
15 03:00 - 03:59
16 04:00 - 04:59
17 05:00 - 05:59
18 06:00 - 06:59
19 07:00 - 07:59
20 08:00 - 08:59
21 09:00 - 09:59
22 10:00 - 10:59
23 11:00 - 11:59

*19

Type Admission

Required for inpatient - Enter one of the appropriate codes indicating the priority of this admission.

1 Emergency
2 Urgent
3 Elective
4 Newborn

20

Source of Admission

Required for inpatient - enter the appropriate code from the list of "Code Structure for Adult and Pediatrics: shown below.
* Newborn coding structure must be used when the type of admission code in Form Locator 19 is "4"

Valid codes if type of admission is 1, 2, or 3
1   Physician Referral
2  Clinic Referral
3  HMO Referral
4  Transfer from a Hospital
5  Transfer from a Skilled Nursing Facility
6  Transfer from Another Health Care Facility
7  Emergency Room
8  Court/Law Enforcement

Valid code if type of admission is "4"
1  Normal Delivery
2  Premature Delivery
3  Sick Baby
4  Extramural Birth

21 

Discharge Hour

Inpatient only - Enter the two-digit code which corresponds to the hour the patient was discharged. (See code structure under Admission Hour, Form Locator 19.)

*22

Patient Status

Required for inpatient - Enter the appropriate code to indicate patient status as of the Statement Covers through date. Valid codes are listed as follows:

01   Discharged (routine)
02   Discharged to another short-term general hospital
03   Discharged to Skilled Nursing Facility
04   Discharged to Intermediate Care Facility
05   Discharged to another type of institution
06   Discharged to home under care of   organized home health services
07   Left against medical advice
08   Discharge/Transfer to home care of Home IV provider

20   Expired
30   Still Patient

* If interim billing, the patient status code must be "30", (frequency code 2 or 3 under type bill).  

23

 Medical Record No.

Enter patient's medical record number (up to 16 characters)

*24-30

Condition Codes

Must be a valid code if entered. Valid codes are listed as follows:
Insurance
01 Military service related
02 Condition is employment related
03 Patient is covered by insurance not reflected here
04 HMO Enrolled
05 Lien has been filed
06 End stage renal disease in first 18 months of entitlement covered by employer group insurance

Accommodations
38 Semi-private room not available
39 Private room medically necessary
40 Same day transfer

Special Program Indicators
A1 EPSDT/CHAP
A2 Physically Handicapped Children's Program
A4 Family Planning

PRO Approval
C1 Approved as billed

31 

Unlabeled Field

(National) Leave blank.

32-35

Occurrence Codes/Dates

a. Enter, if applicable.
b. Each code must be two position numeric and have an associated date.
c. Dates must be valid and in MMDDYY format.
d. Valid codes are listed as follows:

01 Accident/Medical Coverage
02 Auto accident/no fault
03 Accident/tort liability
04 Accident/employment related
05 Accident/No Medical Coverage
06 Crime victim
21 UR/PSRO notice received
22 Date active care ended
24 Date insurance denied
25 Date benefits terminated by primary payer
40 Scheduled date of admission
41 Date of first test for pre-admission testing
42 Date of discharge when "Through" date in Form Locator 6 (Statement Covers Period) is not the actual discharge date and the frequency code in Form Locator 4 is that of final bill.

A3,B3,C3 Benefits exhausted

36

Occurrence Span
(Code and Dates)

 Enter, if applicable - A code and related dates that identity an event that relates to the payment of the claim. Code and date must be valid. Date must be (MMDDYY) format. Valid codes are listed as follows:

72 First/Last visit
74 Non-covered Level of Care

37

A,B,C ICN/DCN #
Original Bill

Not used for an adjustment of a Medicaid paid claim. Continue to use remarks section, Form Locator 84.

38

Responsible Party Name and Address

*39-41

Value Codes and Amounts

Required for benefit determination. The value code structure is intended to provide reporting capability for those data elements that are routinely used but do not warrant dedicated fields. Value codes are listed as follows:

02 Hospital has no semi-private rooms. Entering the code requires $0.00 amount to be shown.
06 Medicare blood deductible
08 Medicare lifetime reserve first CY
09 Medicare coinsurance first CY
10 Medicare lifetime reserve second year
11 Coinsurance amount second year
12 Working Aged Recipient/Spouse with employer group health plan
13 ESRD (End Stage Renal Disease) Recipient in the 12-month coordination period with an employer's group health plan
14 Automobile, no fault or any liability insurance
15 Worker's Compensation including Black Lung
16 VA, PHS, or other Federal Agency
30 Pre-admission testing - this code reflects charges for pre-admission outpatient diagnostic services in preparation for a previously scheduled admission.
37 Pints blood furnished
38 Blood not replaced - deductible is patient's responsibility
39 Blood pints replaced
80 Medicaid eligibility requirement that Medicare recipients utilize lifetime reserve days is not met. Recipient refuses to use available days.
A1,B1,C1 Deductible
A2,B2,C2 Coinsurance

*42 

Revenue Code

Enter the applicable revenue code(s) which identifies a specific accommodation, and ancillary service. Accommodation codes require a rate in Form Locator 44. Revenue Code 490 for Outpatient Surgical procedures requires a CPT/HCPCS procedure code in Form Locator 44.  Other revenue codes such as laboratory services, outpatient therapies, radiology etc. also require a CPT/HCPCS procedure based on current Medicaid policy.

This must be a valid revenue code. Must be in ascending sequence except for final entry for total charges (001). If a revenue code is present, the amount charged must be present in Form Locator 47.

43 

Revenue Description

For inpatient and outpatient claims. Enter the narrative description of the revenue code in the space preceding the dotted line.

*44

HCPCS/Rates

HCPCS/CPT Code
(Outpatient DX Lab) 

Required for inpatient - Enter the accommodation rate for any accommodation revenue codes entered in Form Locator 42. If present, must be numeric.

For revenue code 490, enter the appropriate CPT/HCPCS procedure code for Ambulatory Surgical Services.  Other revenue codes such as laboratory services, outpatient therapies, radiology etc. also require a CPT/HCPCS procedure based on current Medicaid policy.

*45

 Date of Service (Outpatient Only) 

Enter the date of service for outpatient services in the last six digits of the revenue description. The date must be a valid date in (MMDDYY) format.

*46

Units of Service

Enter the quantity of services rendered by Revenue Category for the recipient.

*47

Total Charges 

Enter the total charges pertaining to the related revenue codes. Must be numeric.

Revenue Code "001" represents the total amount charged for this bill, and must be the last entry.

48

Non-Covered Charges

Indicate charges included in column 47 which are not payable under the Medicaid Program.

49

Unlabeled Field (National)

Leave blank.

50-A,B,C

Payer ID 

Enter Medicaid on Line "A" and other payers on Lines "B" and "C". If another insurance company is primary payer, enter name of insurer. If the patient is a Medically Needy Spend-down recipient or has made payment for non-covered services, indicate the patient as payer and the amount paid. The Medically Needy Spend-down form (110-MNP) must be attached if the date of service falls on the first day of the spend-down eligibility period.

Value codes for payer identification are

M = Medicaid
Z = Medicare
4 = All other TPL carriers (specify)

*51-A,B,C

Provider Number

Enter the 7-digit numeric provider identification number which was assigned by the Medicaid Program. If the Medicaid provider number is not on line A, circle or otherwise highlight this number so that it can readily be recognized and keyed.

52-A,B,C

Release of Information 

53-A,B,C

Assignment of Benefits
Cert. Ind.

*54-A,B,C 

Prior Payments

Enter the amount the hospital has received toward payment of this bill from private insurance carrier noted in Form Locator 50 B,C. If the patient has Medicare Part B only, enter the amount billed to Medicare.

55-A,B,C 

Estimated Amt. Due

56 & 57

Unlabeled Fields
(56 State/57 National)

Leave blank.

*58-A,B,C

 Insured's Name

Enter the name of the insured as it appears on the Medicaid identification card. Enter the last name first, first name, middle initial. If there is insurance coverage carried by someone other than the patient, enter the name of that individual to correspond with 50 A,B,C.

 59-A,B,C

Pt's. Relationship
Insured

Enter the patient's relationship to insured from Form Locator 50 A,B, and C that relates to the insured's name in Form Locator 58 A,B, and C.

Acceptable codes are as follows:
01   Patient is insured
02   Spouse
03   Natural child/Insured has financial responsibility
04   Natural child/ Insured does not have financial responsibility
05   Step child
06   Foster child
07   Ward of the court
08   Employee
09   Unknown
10   Handicapped dependent
11   Organ donor
13   Grandchild
14   Niece/Nephew
15   Injured Plaintiff
16   Sponsored dependent
17   Minor dependent of minor dependent
18   Parent
19   Grandparent

*60-A,B,C 

Insured's ID. No.

Enter the recipient/patient's 13-digit Medicaid Identification Number as it appears on the Medicaid ID card in 60-A. If there are other payers, enter the recipient's identification number as assigned by the other payers.

*61-A,B,C

 Insured's Group Name 
(Medicaid not Primary) 

If there is third party insurance, enter carrier code of the insurance company indicated in 50, on the corresponding line.

62-A,B,C

Insured's Group No. 
(Medicaid not Primary)

Enter the number or code assigned by the carrier or administrator to identify the group under which the individual is covered.

*63-A,B,C

Treatment Auth. Code

For services, requiring prior authorization or pre-certification, enter the prior authorization or pre-certification number. Do not bill more than one treatment authorization code per UB-92 and bill only the services covered by that one prior authorization or pre-certification code.

64-A,B,C

Employment Status Code 

To determine primary/secondary responsibility for the bill. 
Valid codes are listed as follows:
1 Employed full time
2 Employed part-time
3 Not employed
4 Self-employed
5 Retired
6 On active military duty
9 Unknown

65-A,B,C 

Employer Name

Enter the name of the employer that may provide health coverage for the patient.

66-A,B,C 

Employer Location 

Not required.

*67

Principal Diagnosis Codes

Enter the ICD-9-CM code for principal diagnosis.

Codes beginning with "E" or "M" are not acceptable for any diagnosis code.

68-75 

Other Diag. Codes 

Codes for diagnoses other than the principal diagnosis are entered in Form Locators 68-75.

76 

Admit Diag. Code

Inpatient only.

77

External Cause Injury 
Code

78

Unlabeled Field (State)

Leave blank.

79 

Procedure Coding 
Method Used

*80

Principal Procedure Code and Date

Required for Inpatient.  Enter a valid ICD-9-CM VOL III code and date for principal procedure. Date must be (MMDD) format. Date must be within date period shown in Form Locator 6.
For Outpatient required on dates of service prior to 03/01/05 for all surgical procedures. 

*81-A-E 

Other Procedure Codes and Dates 

Required for Inpatient. 
Enter codes other than principal procedure performed during billing period. 
For Outpatient must be completed for all surgical procedures for dates of service prior to 03/01/05.

82 

Attending Physician ID

Enter the name and/or number which identifies the physician. This can be the Medicaid ID No., the Louisiana Licensing NO., or the UPIN.

Note: For sterilization procedures, the surgeon's name must appear in item 82.

*83

Other Physician ID

Enter any other physician's licensing number (other than attending physician), i.e., surgeon when surgical procedure(s) are performed.

Note: If the recipient is in the CommunityCARE program, enter the seven-digit referral/ authorization number from the primary care physician. 

84

Remarks

If Admission Source is "4" (transfer from a hospital) enter the name of the hospital the patient was transferred from. If adjustment or void (Form Locator 4, third digit equal "7" or "8") enter the ICN of the paid Medicaid claim and an "A" or "V" to indicate whether adjustment or void.

Also enter a reason code:
Adj.                                                  Void
01 TPL Recovery                            10 Claim paid for wrong recipient
02 Provider correct                         11 Claim paid to wrong provider
03 Fiscal Agency error                   00 Other
99 Other

*85

Provider Rep. Signature

Enter the signature and title of the appropriate person at the facility who is authorized to submit Medicaid billing (Stamped signatures must be initialed).

*86

Date Bill Submitted

Enter the date the bill was signed and submitted for payment. Must be a valid date (MMDDYY) format. Must be greater than the through date in Form Locator 6.