The UB-04 form locator tool is designed to help facilities understand the definitions of the codes needed for claim submission. Click on the form locator headers for definitions to the codes used when filing the UB-04 claim to Medicare or enter the code in the search box and the definition will be returned.
The use of this tool does not guarantee payment. The information provided is informational only.
| Bill Type Codes |
|---|
| 011X Hospital Inpatient (Part A) |
| 012X Hospital Inpatient Part B |
| 013X Hospital Outpatient |
| 014X Hospital Other Part B |
| 018X Hospital Swing Bed |
| 021X SNF Inpatient |
| 022X SNF Inpatient Part B |
| 023X SNF Outpatient |
| 028X SNF Swing Bed |
| 032X Home Health |
| 034X Home Health (Part B Only) |
| 041X Religious Nonmedical Health Care Institutions |
| 043X Religious Nonmedical Health Care Institutions- Outpatient Services |
| 065X Intermediate Care - Level I |
| 066X Intermediate Care - Level II |
| 071X Clinical Rural Health |
| 072X Clinic ESRD |
| 074X Clinic - Outpatient Rehabilitation Facility (ORF) |
| 075X Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) |
| 076X Community Mental Health Centers |
| 077X Federally Qualified Health Centers |
| 081X Nonhospital based hospice |
| 082X Hospital based hospice |
| 083X Hospital Outpatient (ASC) |
| 085X Critical Access Hospital |
| frequency codes |
|---|
| 0 Non-payment/zero |
| 1 Admit through discharge claim |
| 2 Interim - first claim |
| 3 Interim - continuing claim |
| 4 Interim - last claim |
| 5 Late charge(s) only |
| 7 Replacement of prior claim |
| 8 Void/Cancel of prior claim |
| 9 Final Claim for a home health PPS episode |
| A Admission/election notice |
| B Hospice/CMS Coordinated Care Demonstration/Religious Non-Medical Health Care Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration |
| C Hospice change of provider notice |
| D Hospice/CMS Coordinated Care Institution/Centers of Excellence Demonstration/Provider Partnerships Demonstration Void/Cancel |
| E Hospice change of ownership |
| F Beneficiary initiated adjustment claim |
| G CWF initiated adjustment claim |
| H CMS initiated adjustment |
| I Intermediary adjustment claim |
| J Initiated adjustment claim - other |
| K OIG initiated adjustment claim |
| M MSP initiated adjustment claim |
| O Nonpayment/zero claims |
| P QIO adjustment claim |
| Q Claim submitted for reconsideration/reopening outside of timely limits |
| X Void/Cancel a prior abbrev. Encounter submission |
| Y Replacement a prior abbrev. Encounter submission |
| Z New abbrev. encounter submission |
| Priority (Type) of Admission/Visit |
|---|
| 1 Emergency |
| 2 Urgent |
| 3 Elective |
| 4 Newborn |
| 5 Trauma |
| 6 Information not available |
| Point of Origin for Admission or Visit |
|---|
| 1 Non-health care facility point of origin |
| 2 Clinic or physician's office |
| 4 Transfer from a hospital (different facility) |
| 5 Transfer from a SNF, ICF or ALF |
| 6 Transfer from another health care facility |
| 8 Court/law enforcement |
| 9 Information not available |
| G Transfer from a Designated Disaster Alternative Care Site |
| D Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer |
| E Transfer from ASC |
| F Transfer from hospice facility |
| FL 17 - Patient Status |
|---|
| 01 Discharged to home or self care (Routine discharge) |
| 02 Discharged/transferred to a short-term general hospital for inpatient care |
| 03 Discharged/transferred to SNF with Medicare certification in anticipation of Skilled Care |
| 04 Discharged/transferred to a facility that provides custodial or supportive care |
| 05 Discharged/transferred to a designated cancer center or children's hospital |
| 06 Discharged/transferred to home/under HHA care in anticipation of covered skilled care |
| 07 Left against medical advice or discontinued care |
| 09 Admitted as inpatient to this hospital |
| 21 Discharged/transferred to court/law enforcement |
| 30 Still patient |
| 40 Expired at home |
| 41 Expired in medical facility |
| 42 Expired place unknown |
| 43 Discharged/transferred to federal health care facility |
| 50 Hospice - home |
| 51 Hospice - medical facility providing hospice level of care |
| 61 Discharged/transferred to hospital-based Medicare approved swing bed |
| 62 Discharged/transferred to IRF including rehab distinct part units of a hospital |
| 63 Discharged/transferred to Medicare certified LTCH |
| 64 Discharged/transferred to nursing facility certified under Medicaid but not under Medicare |
| 65 Discharged/transferred to psychiatric hospital or psych dist part unit of a hospital |
| 66 Discharged/transferred to a CAH |
| 69 Discharged/transferred to a designated disaster alternative care site |
| 70 Discharged/transferred to another type of health care institution not defined elsewhere in this code list |
| 81 Discharged to home or self care with a planned acute care hospital inpatient readmission |
| 82 Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission |
| 83 Discharged/transferred to a SNF with Medicare certification with a planned acute care hospital inpatient readmission |
| 84 Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission |
| 85 Discharged/transferred to a designated cancer center or children's hospital with a planned acute care hospital inpatient readmission |
| 86 Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission |
| 87 Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission |
| 88 Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission |
| 89 Discharged/transferred to a hospital-based Medicare approved swing bed with a planned acute care hospital inpatient readmission |
| 90 Discharged/transferred to an IRF including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission |
| 91 Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission |
| 92 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission |
| 93 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission |
| 94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission |
| 95 Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital inpatient readmission.Ocurrence Code 55 also required |
| FL 18-28 - Condition Codes |
|---|
| 01 Military service related |
| 02 Condition is employment related |
| 03 Patient covered by insurance not reflected here |
| 04 Information only bill |
| 05 Lien has been filed |
| 06 ESRD 1st 30 mo. entitlement, covered by EGHP |
| 07 Treatment of non-terminal condition - hospice |
| 08 Would not provide other insurance info |
| 09 Neither patient nor spouse is employed |
| 10 Patient and/or spouse employed, no EGHP |
| 11 Disabled beneficiary but no LGHP |
| 17 Patient is homeless |
| 18 Maiden name retained |
| 19 Child retains mother's name |
| 20 Beneficiary requested billing |
| 21 Billing for denial notice |
| 22 Patient on multiple drug regimen |
| 23 Home care giver available |
| 24 Home IV patient receiving home health services |
| 25 Patient is a non-U.S. resident |
| 26 VA patient chooses Medicare facility |
| 27 Patient referred to sole community hospital for diagnostic lab test |
| 28 Patient/spouse EGHP secondary to Medicare |
| 29 Disabled bene/fam LGHP secondary to Medicare |
| 30 Qualifying clinical trials |
| 31 Patient is a student, full-time |
| 32 Patient is a student, coop/work-study prog |
| 33 Patient is a student, full-time - night |
| 34 Patient is a student, part-time |
| 36 General care patient in special unit |
| 37 Ward accommodation at patient request |
| 38 Semi-private room not available |
| 39 Private room medically necessary |
| 40 Same day transfer |
| 41 Partial hospitalization |
| 42 Continue care plan not related to inpat hospitalization |
| 43 Continue care, not within prescribed post-discharge window |
| 44 Inpatient admission changed to outpatient |
| 45 Ambiguous gender category |
| 46 Non-availability statement on file |
| 47 Transfer from another home health |
| 48 Psychiatric residential treatment centers for children and adolescents |
| 49 Product replacement within product lifecycle |
| 50 Product replacement for known recall of a product |
| 51 Attestation of unrelated outpatient non-diagnostic services |
| 52 Out of hospice service area |
| 53 Initial placement of a medical device provided as part of a clinical trial or a free sample |
| 54 No skilled home health visits in billing period |
| 55 SNF bed not available |
| 56 Medical appropriateness |
| 57 SNF readmission |
| 58 Terminated Medicare Advantage enrollee |
| 59 Non-primary ESRD facility |
| 60 Day outlier |
| 61 Cost outlier |
| 66 Provider does not wish cost outlier payment |
| 67 Beneficiary elects not to use LTR days |
| 68 Beneficiary elects to use LTR days |
| 69 IME/DGME/N&AH payment only |
| 70 Self-administered anemia mgmt. drug |
| 71 Full care in unit (dialysis) |
| 72 Self care in unit (dialysis) |
| 73 Self care training (dialysis) |
| 74 Home dialysis |
| 75 Home dialysis - 100% reimbursement |
| 76 Back-up in facility dialysis |
| 77 Provider accepts as payment in full |
| 78 New coverage not implemented by managed care plan |
| 79 CORF services provided offsite |
| 80 Home Dialysis - nursing facility |
| 81 C-Sections/Inductions < 39 weeks - medical necessity |
| 82 C-Sections/Inductions < 39 weeks - elective |
| 83 C-Sections/Inductions 39 weeks or greater |
| 84 Dialysis for acute kidney injury |
| 85 Delayed recertification of hospice terminal illness |
| 86 Additional hemodialysis treatments with medical justification |
| A0 TRICARE external partnership prog |
| A1 EPSDT/CHAP |
| A2 Physically handicapped children's prog |
| A3 Special federal funding |
| A4 Family planning |
| A5 Disability |
| A6 Vaccines/Medicare 100% payment |
| A9 Second opinion surgery |
| AA Abortion - rape |
| AB Abortion - incest |
| AC Abortion - genetic defect |
| AD Abortion - life endangering condition |
| AE Abortion - not life endangering |
| AF Abortion - emotional health |
| AG Abortion - social/economic Reasons |
| AH Elective abortion |
| AI Sterilization |
| AJ Payer responsible for co-payment |
| AK Air ambulance required |
| AL Specialized treatment/bed unavailable |
| AM Non-emergency medically necessary stretcher transport required |
| AN Pre admission screening not required |
| B0 Medicare coord. care demo claim |
| B1 Beneficiary is ineligible for demo prog |
| B2 CAH ambulance attestation |
| B3 Pregnancy indicator |
| B4 Admission unrelated to discharge on same day |
| BP Gulf oil spill of 2010 |
| C1 Approved as billed (QIO) |
| C2 Automatic approval on focused review (QIO) |
| C3 Partial approval (QIO) |
| C4 Admission/services denied (QIO) |
| C5 Post-payment review applicable (QIO) |
| C6 Admission preauthorization (QIO) |
| C7 Extended authorization (QIO) |
| D0 Changes to service dates |
| D1 Changes to charges |
| D2 Changes to revenue codes/HCPCS/HIPPS rate codes |
| D3 Second or subsequent interim PPS bill |
| D4 Change in ICD procedure codes |
| D5 Cancel to correct insured's/provider ID |
| D6 Cancel only to repay dup or OIG overpayment |
| D7 Medicare as secondary |
| D8 Medicare as primary |
| D9 Other changes |
| DR Disaster related |
| E0 Change in patient status |
| G0 Distinct medical visit |
| H0 Delayed filing: statement of intent submitted |
| H2 Discharge by a hospice provider for cause |
| H3 Reoccurrence of GI bleed comorbid |
| H4 Reoccurrence of Pneumonia comorbid |
| H5 Reoccurrence of Pericarditis comorbid |
| P1 Do not resuscitate order (DNR) |
| P7 Direct inpat admission from ED |
| R1 Request for reopening - math or computational mistakes |
| R2 Request for reopening - inaccurate data entry |
| R3 Request for reopening - misapplication of a fee schedule |
| R4 Request for reopening - computer errors |
| R5 Request for reopening - incorrectly identified dup claim |
| R6 Request for reopening - other clerical and minor errors and omissions |
| R7 Request for reopening - corrections other than clerical errors |
| R8 Request for reopening - new and material evidence |
| R9 Request for reopening - faulty evidence |
| W0 UMWA demonstration indicator |
| W2 Duplicate of original bill |
| W3 Level I appeal |
| W4 Level II appeal |
| W5 Level III appeal |
| FL 31-34 - Occurrence Codes |
|---|
| 01 Accident/medical coverage |
| 02 No-fault insurance, including auto |
| 03 Accident, tort liability |
| 04 Accident, employment-related |
| 05 Accident/no medical or liability cov |
| 06 Crime victim |
| 09 Start of infertility treatment |
| 10 Last menstrual period |
| 11 Onset of symptoms/illness |
| 12 Date of onset, chronically dependent individual |
| 16 Date of last therapy |
| 17 Date outpatient occupational therapy plan established/last reviewed |
| 18 Date of retirement (patient/bene) |
| 19 Date of retirement (spouse) |
| 20 Date guarantee of payment began |
| 21 Date UR notice received |
| 22 Date active care ended |
| 24 Date insurance denied |
| 25 Date benefits terminated by primary payer |
| 26 Date SNF bed available |
| 27 Date hospice cert or recert |
| 28 Date CORF plan estab/last reviewed |
| 29 Date outpatient physical therapy plan estab/last reviewed |
| 30 Date outpatient speech language pathology plan estab/last reviewed |
| 31 Date bene notified intent to bill (accom) |
| 32 Date bene notified intent to bill (proc/treat) |
| 33 First day of ESRD coordination covered by EGHP |
| 34 Date of election of extended care |
| 35 Date physical therapy started |
| 36 Date inp hosp disch, covered transplant |
| 37 Date inp hosp disch, non-covered transplant |
| 38 Date started for home IV therapy |
| 39 Date disch/on a cont/course of IV therapy |
| 40 Scheduled date of admission |
| 41 Date of first test/pre-admission testing |
| 42 Date of discharge |
| 43 Scheduled date of canceled surgery |
| 44 Date occupational therapy started |
| 45 Date speech therapy started |
| 46 Date cardiac rehab started |
| 47 First full day of cost outlier |
| 50 Assessment date |
| 51 Date of last Kt/V reading |
| 52 Medical certification/recert date |
| 54 Physician follow-up date |
| 55 Date of Death |
| A1 Birth date, insured A |
| A2 Effective date, insured A policy |
| A3 Benefits exhausted - Payer A |
| A4 Split bill date |
| FL 35-36 - Occurrence Span Codes |
|---|
| 70 Qualifying stay dates for SNF only |
| 71 Prior stay dates |
| 72 First/last visit dates |
| 73 Benefit eligibility period |
| 74 Noncovered level of care or leave of absence (LOA) |
| 75 SNF level of care dates |
| 76 Patient liability period |
| 77 Provider liability period |
| 78 SNF prior stay dates |
| 80 Prior same-SNF stay dates for payment ban purposes |
| 81 Antepartum Days at Reduced Level of Care |
| M0 QIO/UR approved stay dates |
| M1 Provider liability - no utilization |
| M2 Inpatient respite dates |
| M3 ICF level of care |
| M4 Residential level of care |
| FL 39-41 - Value Codes |
|---|
| 01 Most common semi-private rate |
| 02 Hospital has no semi-private rooms |
| 04 Professional component charges, combined billed |
| 05 Professional component included, billed to carrier |
| 06 Blood deductible |
| 08 LTR amount, 1st calendar year |
| 09 Co-ins amount, 1st calendar year |
| 10 LTR amount, 2nd calendar year |
| 11 Co-ins amount, 2nd calendar year |
| 12 Working aged bene/spouse with EGHP |
| 13 ESRD bene in Medicare coord period with EGHP |
| 14 No-fault, including auto/other ins |
| 15 Worker's compensation |
| 16 PHS or other federal agency |
| 21 Catastrophic |
| 22 Surplus |
| 23 Recurring monthly income |
| 24 Medicaid rate code |
| 25 Offset to pt-pymnt amnt - RX drugs |
| 26 Offset to pt-pymnt amnt - hearing & ear |
| 27 Offset to pt-pymnt amnt - vision & eye |
| 28 Offset to pt-pymnt amnt - dental services |
| 29 Offset to pt-pymnt amnt - chiropractic |
| 30 Pre-admission testing |
| 31 Patient liability amount |
| 32 Multiple patient ambulance transport |
| 33 Offset to pt-pymnt amnt - podiatric |
| 34 Offset to pt-pymnt amnt - other medical |
| 35 Offset to pt-pymnt amnt - health ins. Prem |
| 37 Units of blood furnished |
| 38 Blood deductible units |
| 39 Units of blood replaced |
| 40 New coverage not implemented by HMO |
| 41 Black lung |
| 42 VA |
| 43 Disabled bene under 65 with LGHP |
| 44 Amount provider agreed to accept from primary payer |
| 45 Accident hour |
| 46 Number of grace days |
| 47 Any liability insurance |
| 48 Hemoglobin reading |
| 49 Hematocrit reading |
| 50 Physical therapy visits |
| 51 Occupational therapy visits |
| 52 Speech therapy visits |
| 53 Cardiac rehab visits |
| 54 Newborn birth weight in grams |
| 55 Eligibility threshold for charity care |
| 56 Skilled nursing visits hours (HHA) |
| 57 HH aide, home visit hours (HHA) |
| 58 Arterial blood gas |
| 59 Oxygen saturation |
| 60 HHA branch MSA |
| 61 Arterial blood gas |
| 66 Medicaid spend down amount |
| 67 Peritoneal dialysis (HHA) |
| 68 EPO - drug |
| 69 State charity care percent |
| 80 Covered days |
| 81 Non-covered days |
| 82 Co-insurance days |
| 83 Lifetime reserve days |
| 84 Shorter duration, hemodialysis (Effective 7/1/17) |
| A0 Special ZIP code reporting |
| A1 Deductible, payer A |
| A2 Co-insurance, payer A |
| A3 Estimated responsibility, payer A |
| A4 Cvrd self-administrable drugs/emergency |
| A Cvrd self-administrable drugs - not self administrable form/situation |
| A6 Cvrd self-administrable drugs - study |
| A7 Co-payment payer A |
| A8 Patient weight |
| A9 Patient height |
| AA Regulatory surcharges, assessments, allowances or health care related taxes payer A |
| AB Other assessments or allowances (e.g., medical education) payer A |
| Use B1-GB as A1-A3 and A7-AB for other payers |
| Y1 Part A demonstration payment |
| Y2 Part B demonstration payment |
| Y3 Part B coinsurance |
| Y4 Conventional provider payment |
| Y5 Part B deductible |
| FL 59 - Patient Relationship to Insured |
|---|
| 01 Spouse |
| 18 Self |
| 19 Child |
| 20 Employee |
| 21 Unknown |
| 39 Organ donor |
| 40 Cadaver donor |
| 53 Life partner |
| GS Other relationship |
| Revenue Codes |
|---|
