The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 15 Physician Information, Remarks, and Code-Code Field

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Explain the use of FL 76 (Attending Provider Name and Identifiers) when reporting the name, the NPI, and the other identifier number of the physician who has primary responsibility for the patient’s medical care and treatment. Explain the use of FLs 77-79 when reporting the name, the NPI, and the other identifier numbers of the operating physician on a claim that contains a surgical procedure and/or the name, the NPI, and the other identifier numbers of other providers, such as a referring provider, if other providers were involved in the patient’s care.

3. LEARNING OUTCOMES (cont.) List the various types of notes that can be reported in the Remarks field (FL 80) to help payers process claims more accurately and efficiently. Describe the function of the Code-Code field in reporting overflow codes from other form locators in addition to listing information represented by externally maintained code sets, such as taxonomy codes, that have been approved by the NUBC for use with the UB-04 form.

4. KEY TERMS • qualifier codes • secondary identifiers • taxonomy code • UPIN (unique physician identification number)

5. FL 76 ATTENDING PROVIDER NAME AND IDENTIFIERS FL 76 is used to report the name, the National Provider Identifier (NPI), and the secondary identifier (when required) of the attending provider. The attending provider is the licensed physician who normally certifies the medical necessity of the services rendered and/or who has primary responsibility for the medical care and treatment reported in the claim.

6. FL 76 ATTENDING PROVIDER NAME AND IDENTIFIERS (cont.) • Guidelines • Completion required by Medicare and other payers • The attending provider’s 10-digit NPI is reported on line 1; next to the NPI is a two-character field for reporting the type of secondary identifier and a nine-character field for the secondary identifier itself • Line 2 allows up to 16 positions for the provider’s last name and 12 positions for the first name

7. Secondary Identifiers In each of the provider information form locators (FLs 76-79), there is a field for reporting a secondary provider identifier. These are old identifier numbers such as physician UPINs or state license numbers that were considered primary identifiers prior to the implementation of NPI.

8. Secondary Identifiers (cont.) • When secondary identifiers are required, a qualifier code is reported to indicate the type of identifier. These qualifier codes are: • 0B: State license number • 1G: Provider UPIN • G2: Provider commercial number • While the NPI system is still being tested, CMS and NUBC recommend reporting both NPI and secondary identifiers on claims.

9. FL 77 OPERATING PHYSICIAN NAME AND IDENTIFIERS • FL 77 contains the name, NPI, and secondary identifier (when required) of the individual primarily responsible for performing the surgical procedure on the claim. If no surgical procedure was performed, the field should be left blank. • Guidelines • Completion required by Medicare and all other payers for claims containing a surgical procedure code • The format for FL 77 is the same as for FL 76 • When the operating physician is the same as the attending physician identified in FL 76, the same information should be repeated in FL 77

10. FLs 78-79 OTHER PROVIDER NAMES AND IDENTIFIERS • FLs 78-79 are used to report the name, NPI, and secondary identifiers of up to two other provider types. When using FLs 78-79, the other type of provider, such as a referring physician, must be indicated using the appropriate provider type qualifier code. • If no other provider type is involved in the patient’s care, this field is left blank. • Guidelines • Completion required by Medicare and other payers when another provider type is involved in the patient’s care • A two-digit field to the left of the NPI field is used to report the provider type; the remaining fields are reported the same as FLs 76 and 77

11. Provider Type Qualifier Codes • FLs 78-79 require a provider type qualifier code as follows: • CodeProvider Type • DN Referring provider: required on outpatient claims only when the referring provider is different than the attending provider • ZZ Other operating physician: required when a physician performs a secondary surgical procedure or assists the operating physician • 82 Rendering provider: required when state or federal regulations call for both facility and professional fees to be reported on same claim (combined bill)

12. FL 80 REMARKS • FL 80 is used to make notes about any outstanding details on the claim. Information that has not been reported elsewhere and that, in the judgment of the provider, is needed to substantiate the medical treatment may be entered as a remark. • Guidelines • Completion required by Medicare and all other payers when applicable • FL 80 contains four lines: the first allows 19 alphanumeric characters; the other three allow 24 alphanumeric characters each • This field can be used to report an address (for example, when the address of the insured if not the same as the patient)

13. FL 80 REMARKS (cont.) • Guidelines • On Medicare claims, notations should be entered in this field for a number of situations, including: • Explaining the reason for reporting noncovered days if none of the reasons represented by occurrence codes 20, 21, or 22 applies • Providing a narrative description of an unlisted procedure, test, drug, or service on an outpatient claim • Explaining why another carrier denied a claim

14. FL 81 CODE-CODE FIELD • FL 81 is used to report overflow codes from other form locators. It is also used to report data represented by externally maintained code sets, such as taxonomy codes. • Guidelines • Completion required by Medicare and all other payers when applicable • FL 81 contains four lines (a-d) for reporting up to four codes • Each line contains three columns that report: the qualifier code indicating the type of information (e.g., code A2 indicates an overflow occurrence code); the actual code being reported; and a date, numeric value, or amount associated with the code

15. Taxonomy Codes Qualifier code B3 is used in FL 81 to report the billing provider’s taxonomy code, which describes the type of hospital submitting the claim. Taxonomy codes are required on Medicare claims for hospitals containing distinct subparts (e.g., rehabilitation units) for which individual NPIs have not been requested. The taxonomy code assists Medicare in determining which part of the hospital is submitting the claim. To avoid confusion during the transition to the NPI system, it is recommended that all hospitals report taxonomy codes.

16. CHAPTER REVIEW • Which provider has primary responsibility for the medical care and treatment of a patient? • [attending physician] • What does provider type qualifier code ZZ represent? • [other operating physician] • Why is FL 81 called the Code-Code field? • [it contains a qualifier code followed by another code]

17. TERMINOLOGY QUIZ • Ten-digit physician identifier implemented by CMS in response to HIPAA requirements: • [National Provider Identifier (NPI)] • Identifiers that were considered primary prior to the implementation of NPI: • [secondary identifiers] • Code that indicates the type of secondary identifier: • [qualifier code] • Administrative code set used to report the billing provider’s type of facility: • [taxonomy codes]