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The UB-04 Claim Form

PART TWO. The UB-04 Claim Form. Chapter 10. Occurrence Codes and Dates. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and:

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The UB-04 Claim Form

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  1. PART TWO The UB-04 Claim Form Chapter 10 Occurrence Codes and Dates

  2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Discuss the codes that are used in FLs 31-34 of the UB-04 to report significant events, or occurrences, connected with claims that affect how they are processed and paid. Understand the four categories of occurrence codes. Discuss the types of codes that are used in FLs 35-36 of the UB-04 to report occurrence spans and dates. Explain various billing situations that arise when particular occurrence codes and occurrence span codes are used.

  3. LEARNING OUTCOMES (cont.) Recognize which occurrence codes and occurrence span codes contain data that must be coordinated with other fields on the UB-04. Explain what information belongs in FL 38, Responsible Party Name and Address, of the UB-04 form.

  4. KEY TERMS • conditional payment • guarantee of payment provision • leave of absence (LOA) days • Medicare Conditional Payment request • occurrence code • occurrence span code • spell of illness

  5. FLs 31-34 OCCURRENCE CODES AND DATES An occurrence code is a two-digit numeric or alphanumeric code that defines a significant event that happened in connection with a claim and affects payer processing of the claim. Occurrence codes and dates factor into payer liability decisions, patient coverage, appropriateness of the services rendered, and Medicare Secondary Payer development. They cover a wide range of circumstances and range from 01 to 69 and A0 to LZ.

  6. FLs 31-34 OCCURRENCE CODES AND DATES (cont.) • Guidelines • If applicable, completion of these fields is required for Medicare and all other payers • Codes usually grouped into four categories: • accident-related codes • medical condition codes • insurance-related codes • service-related codes • If more than one occurrence code is listed, enter the codes in alphanumeric sequence (numeric codes first, followed by alphanumeric codes) in the following order: • Line 1 (FLs 31a-34a) should be filled in first • Line 2 (FLs 31b-34b) should follow

  7. FLs 31-34 OCCURRENCE CODES AND DATES (cont.) • The same occurrence code can be listed only once on a claim, although as many as eight different codes (and dates) may be used on a single claim. If more than eight codes are necessary, the next two fields (FLs 35-36, Occurrence Span Code and Date) can be modified to report the overflow by using the from date and leaving the through date blank. If these fields are not available, FL 81 (Code-Code) may be used with the appropriate qualifier.

  8. OCCURRENCE CODE CATEGORIES • Accident-Related Codes 01 – 08 • Medical Condition Codes 09 – 15 • Insurance-Related Codes 16 – 39 • Service-Related Codes 40 – 69, A0 – LZ

  9. FLs 35-36 OCCURRENCE SPAN CODES AND DATES Occurrence span codes are two-digit numeric or alphanumeric codes that identify significant events that happened over a span of time and affect claim processing and payment. Every occurrence span code must have a beginning (from) date and an ending (through) date in MMDDYY format. Occurrence span codes cover a wide range of circumstances and have two ranges: 70 to 99 and M0 to ZZ.

  10. FLs 35-36 OCCURRENCE SPAN CODES AND DATES (cont.) • Guidelines • If applicable, completion of these fields is required for Medicare, Tricare, and commercial claims; they may be required by Medicaid; Blue Cross only requires this information when specified under a particular plan or contract • If more than one occurrence code is listed, enter the codes in alphanumeric sequence (numeric codes first, followed by alphanumeric codes) in the following order: • Line 1 (FLs 35a-36a) should be filled in first • Line 2 (FLs 35b-36b) should follow • If more than four codes are necessary, FL 81 (Code-Code) may be used with the appropriate qualifier (A3).

  11. FL 37 UNLABELED FIELD • FL 38 RESPONSIBLE PARTY NAME AND ADDRESS • FL 38 is used to report the name and address of the party responsible for the bill (the beneficiary or someone handling the beneficiary’s affairs). • Guidelines • Not required for Medicare, Medicaid, Blue Cross, or TRICARE; desirable for commercial claims. • For Medicare claims, this field can be used to report the name and address of a payer that is primary to Medicare.

  12. CHAPTER REVIEW • Codes in the accident-related category require review for compliance with what program? • [Medicare Secondary Payer] • How many times can a particular occurrence code be used on a claim form? • [one] • What date format is used on the UB-04 form? for electronic transactions? • [MMDDYY, CCYYMMDD]

  13. TERMINOLOGY QUIZ • A two-digit numeric or alphanumeric code that identifies a significant event that happened in connection with a claim: • [occurrence code] • A two-digit numeric or alphanumeric code that identifies an event that occurred over a period of time that relates to a claim: • [occurrence span code] • Provision that ensures that Medicare will pay for hospital inpatient services even if the beneficiary’s benefits were exhausted prior to admission: • [guarantee of payment provision]

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