UB 04 insurance forms

In This Month’s Issue:

1 May – On March 1, 2007, facility providers will be using the UB-04 form, replacing the UB-92.

Almost concurrent with the update on the CMS-1500 claim forms (for medical providers), facility providers are upgrading to a new paper form too. On March 1, 2007, facility providers will be using the UB-04 form, replacing the UB-92. By May 23, 2007, it will replace officially the old form.

The new form retains the designation CMS-1450 used by the Centers for Medicare and Medicaid Services. The electronic format accommodates more characters though.

The UB-04 incorporates the National Provider Identifier (NPI), taxonomy changes and allows additional procedure and diagnosis codes. The diagnostic code field size has been expanded to accommodate the ICD-10 codes. It has a box providers use to designate whether they are using ICD-9 or 10. The total number of diagnoses has been increased from nine to sixteen. For outpatient claims that report individual services, the procedure code field length has increased to 14 characters, allowing a procedure to use up to four modifiers.

Instructions for completing the forms remain the same unless noted differently on the form instructions.

The biggest difference is the presence of the “Present on Admission” (POA), an indicator utilized with the primary and secondary diagnoses and external causes of injury codes (E-codes). The indicator can have four values:

Y=Yes
N=No
U=No information in the record
W=clinically undetermined
Unreported/not used – exempt from reporting

The reason presumably for the addition of the indicator is due to the fact that nosocomial infections (acquired while staying in the hospital) can increase the DRG rate (and incorrect calculation). This is because the infection appears as a comorbid condition that complicated treating the underlying disease. However, the reality is that the infection occurred during the hospitalization and is therefore independent of the initial diagnosis and would not increase the payment rate (even though a longer hospitalization might be required).

The ICD-10-CM coding guidelines have been revised to include the new POA indicator and the list of codes that are exempted from the POA reporting requirements. To aid coders in determining whether a condition was nosocomial or a likely comorbidity, the Centers for Disease Control have published diagnostic criteria.

To view the new UB-04 and read the Medicare instructions for completing it, observing the crosswalk between the -04 and -92 forms, correlating the mapping of the HIPAA institutional 837, visit:

www.cms.hhs.gov/transmittals/downloads/R1104CP.pdf

POA indicator descriptions are available at:
www.nubc.org/public/whatsnew/POA.pdf

The ICD-9-CM coding guidelines went into effect on November 15th and can be downloaded at:
www.cdc.gov/hchs/datawh/ftpserv/ft-picd9/icdeguide06.pdf

Center for Disease Control diagnostic criteria at:
www.cdc.gov/ncidod/dhqp/pdf/nnis/nosinfdefinitions.pdf