CMS Pub. 100-04, ch. 25, § 75.5

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary's Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period

and after for certain business areas that will continue to use the HICN as part of their

processes.

FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate

Not Required. The provider enters a narrative description or standard abbreviation for

each revenue code shown in FL 42 on the adjacent line in FL 43. The information assists

clerical bill review. Descriptions or abbreviations correspond to the revenue codes.

“Other” code categories are locally defined and individually described on each bill.

The investigational device exemption (IDE) or procedure identifies a specific device used

only for billing under the specific revenue code 0624. The IDE will appear on the paper

format of Form CMS-1450 as follows: FDA IDE # A123456 (17 spaces).

HHAs identify the specific piece of durable medical equipment (DME) or non-routine

supplies for which they are billing in this area on the line adjacent to the related revenue

code. This description must be shown in Healthcare Common Procedure Coding System

(HCPCS) coding.

When required to submit drug rebate data for Medicaid rebates, submit N4 followed by

the 11-digit National Drug Code (NDC) in positions 01-13 (e.g., N499999999999).

Report the NDC quantity qualifier followed by the quantity beginning in position 14.

The Description Field on Form CMS-1450 is 24 characters in length. An example of the

methodology is illustrated below.

N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 3 4 . 5 6 7

FL 44 - HCPCS/Rates/HIPPS Rate Codes

Required. When coding HCPCS for outpatient services, the provider enters the HCPCS

code describing the procedure here. On inpatient hospital bills the accommodation rate is

shown here.

HCPCS used for Medicare claims are available from Medicare contractors.

Health Insurance Prospective Payment System (HIPPS) Rate Codes

The HIPPS rate code consists of the three-character resource utilization group (RUG)

code that is obtained from the “Grouper” software program followed by a 2-digit

assessment indicator (AI) that specifies the type of assessment associated with the RUG

code obtained from the Grouper. SNFs must use the version of the Grouper software

program identified by CMS for national PPS as described in the Federal Register for that

year. The Grouper translates the data in the Long Term Care Resident Instrument into a

case mix group and assigns the correct RUG code. The AIs were developed by CMS.

The Grouper will not automatically assign the 2-digit AI, except in the case of a swing

bed MDS that is will result in a special payment situation AI (see below). The HIPPS

rate codes that appear on the claim must match the assessment that has been transmitted

and accepted by the State in which the facility operates. The SNF cannot put a HIPPS

rate code on the claim that does not match the assessment.

HIPPS Rate Codes used for Medicare claims are available from Medicare contractors. As

of October 1, 2019, SNF PDPM changes are effective (see §§120ff. in Chapter 6 of this

manual).

HIPPS Modifiers/Assessment Type Indicators

The assessment indicators (AI) were developed by CMS to identify on the claim, which

of the scheduled Medicare assessments or off-cycle assessments is associated with the

assessment reference date and the RUG that is included on the claim for payment of

Medicare SNF services. In addition, the AIs identify the Effective Date for the beginning

of the covered period and aid in ensuring that the number of days billed for each

scheduled Medicare assessment or off cycle assessment accurately reflect the changes in

the beneficiary's status over time. The indicators were developed by utilizing codes for

the reason for assessment contained in section AA8 of the current version of the Resident

Assessment Instrument, Minimum Data Set in order to ease the reporting of such

information. Follow the CMS manual instructions for appropriate assignment of the

assessment codes.

HIPPS Modifiers/Assessment Type Indicators used for Medicare claims are available

from Medicare contractors. As of October 1, 2019, SNF PDPM changes are effective

(see §§120ff. in Chapter 6 of this manual).

HCPCS Modifiers (Level I and Level II)

Form CMS-1450 accommodates up to four modifiers, two characters each. See AMA

publication CPT 20xx (xx= to current year) Current Procedural Terminology Appendix A

- HCPCS Modifiers Section: “Modifiers Approved for Ambulatory Surgery Center (ASC)

Hospital Outpatient Use”. Various CPT (Level I HCPCS) and Level II HCPCS codes

may require the use of modifiers to improve the accuracy of coding. Consequently,

reimbursement, coding consistency, editing and proper payment will benefit from the

reporting of modifiers. Hospitals should not report a separate HCPCS (five-digit code)

instead of the modifier. When appropriate, report a modifier based on the list indicated in

the above section of the AMA publication.

HCPCS modifiers used for Medicare claims are available from Medicare contractors.

FL 45 - Service Date

Required Outpatient. CMHCs and hospitals (with the exception of CAHs, Indian Health

Service hospitals and hospitals located in American Samoa, Guam and Saipan) report line

item dates of service on all bills containing revenue codes, procedure codes or drug codes.

This includes claims where the “from” and “through” dates are equal. This change is due

to a HIPAA requirement.

There must be a single line item date of service (LIDOS) for every iteration of every

revenue code on all outpatient bills (TOBs 013X, 014X, 023X, 024X, 032X, 033X,

034X, 071X, 072X, 073X, 074X, 075X, 076X, 077X (effective April 1, 2010), 081X,

082X, 083X, and 085X and on inpatient Part B bills (TOBs 012x and 022x). If a

particular service is rendered 5 times during the billing period, the revenue code and

HCPCS code must be entered 5 times, once for each service date.

FL 46 - Units of Service

Required. Generally, the entries in this column quantify services by revenue code

category, e.g., number of days in a particular type of accommodation, pints of blood.

However, when HCPCS codes are required for services, the units are equal to the number

of times the procedure/service being reported was performed.

The provider enters up to seven numeric digits. It shows charges for noncovered services

as noncovered, or omits them. NOTE: Hospital outpatient departments report the

number of visits/sessions when billing under the partial hospitalization program or the

intensive outpatient program.

FL 47 - Total Charges - Not Applicable for Electronic Billers

Required. This is the FL in which the provider sums the total charges for the billing

period for each revenue code (FL 42); or, if the services require, in addition to the

revenue center code, a HCPCS procedure code, where the provider sums the total charges

for the billing period for each HCPCS code. The last revenue code entered in FL 42 is

“0001” which represents the grand total of all charges billed. The amount for this code,

as for all others is entered in FL 47. Each line for FL 47 allows up to nine numeric digits

(0000000.00). The CMS policy is for providers to bill Medicare on the same basis that

they bill other payers. This policy provides consistency of bill data with the cost report

so that bill data may be used to substantiate the cost report. Medicare and non-Medicare

charges for the same department must be reported consistently on the cost report. This

means that the professional component is included on, or excluded from, the cost report

for Medicare and non-Medicare charges. Where billing for the professional components

is not consistent for all payers, i.e., where some payers require net billing and others

require gross, the provider must adjust either net charges up to gross or gross charges

down to net for cost report preparation. In such cases, it must adjust its provider

statistical and reimbursement (PS&R) reports that it derives from the bill. Laboratory

tests (revenue codes 0300-0319) are billed as net for outpatient or nonpatient bills

because payment is based on the lower of charges for the hospital component or the fee

schedule. The A/B MAC (A or HHH) determines, in consultation with the provider,

whether the provider must bill net or gross for each revenue center other than laboratory.

Where “gross” billing is used, the A/B MAC (A or HHH) adjusts interim payment rates to

exclude payment for hospital-based physician services. The physician component

must be billed to the Part B MAC to obtain payment. All revenue codes requiring

HCPCS codes and paid under a fee schedule are billed as net.

FL 48 - Noncovered Charges

Required. The total non-covered charges pertaining to the related revenue code in FL 42

are entered here.

FL 49 - (Untitled)

Not used. Data entered will be ignored.

Note: the “PAGE ____ OF ____” and CREATION DATE on line 23 should be reported

on all pages of the UB-04.

FL 50A (Required), B (Situational), and C (Situational) - Payer Identification

If Medicare is the primary payer, the provider must enter “Medicare” on line A. Entering

Medicare indicates that the provider has developed for other insurance and determined

that Medicare is the primary payer. All additional entries across line A (FLs 51-55)

supply information needed by the payer named in FL 50A. If Medicare is the secondary

or tertiary payer, the provider identifies the primary payer on line A and enters Medicare

information on line B or C as appropriate.

FL 51A (Required), B (Situational), and C (Situational) – Health Plan ID

Report the national health plan identifier when one is established; otherwise report the

“number” Medicare has assigned.

FLs 52A, B, and C - Release of Information Certification Indicator

Required. A “Y” code indicates that the provider has on file a signed statement

permitting it to release data to other organizations in order to adjudicate the claim.

Required when state or federal laws do not supersede the HIPAA Privacy Rule by

requiring that a signature be collected. An “I” code indicates Informed Consent to

Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes.

Required when the provider has not collected a signature and state or federal laws do not

supersede the HIPAA Privacy Rule by requiring a signature be collected.

NOTE: The back of Form CMS-1450 contains a certification that all necessary release

statements are on file.

FL 53A, B, and C - Assignment of Benefits Certification Indicator

Not used. Data entered will be ignored.

FLs 54A, B, and C - Prior Payments

Situational. Required when the indicated payer has paid an amount to the provider

towards this bill.

FL 55A, B, and C - Estimated Amount Due From Patient

Not required.

FL 56 – Billing Provider National Provider ID (NPI)

Required on or after May 23, 2008.

FL 57 – Other Provider ID (primary, secondary, and/or tertiary)

Not used. Data entered will be ignored.

FLs 58A, B, and C - Insured’s Name

Required. The name of the individual under whose name the insurance benefit is carried.

FL 59A, B, and C - Patient’s Relationship to Insured

Required. If the provider is claiming payment under any of the circumstances described

under FLs 58 A, B, or C, it must enter the code indicating the relationship of the patient

to the identified insured, if this information is readily available.

Codes used for Medicare claims are available from Medicare contractors. Codes are also

available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data

Specifications Manual.

FLs 60A (Required), B (Situational), and C (Situational) – Insured’s Unique ID

(Certificate/Social Security Number/Medicare beneficiary identifier)

The unique number assigned by the health plan to the insured.

FL 61A, B, and C - Insurance Group Name

Situational (required if known). Where the provider is claiming payment under the

circumstances described in FLs 58A, B, or C and a Worker’s Compensation (WC) or an

Employer Group Health Plan (EGHP) is involved, it enters the name of the group or plan

through which that insurance is provided.

FL 62A, B, and C - Insurance Group Number

Situational (required if known). Where the provider is claiming payment under the

circumstances described in FLs 58A, B, or C and a WC or an EGHP is involved, it enters

the identification number, control number or code assigned by that health insurance

carrier to identify the group under which the insured individual is covered.

FL 63 - Treatment Authorization Code

Situational. Required when an authorization or referral number is assigned by the payer

and then the services on this claim AND either the services on this claim were

preauthorized or a referral is involved. Whenever Quality Improvement Organization

(QIO) review is performed for outpatient preadmission, pre-procedure, or Home IV

therapy services, the authorization number is required for all approved admissions or

services.

FL 64 – Document Control Number (DCN)

Situational. The control number assigned to the original bill by the health plan or the

health plan’s fiscal agent as part of their internal control.

FL 65 - Employer Name (of the Insured)

Situational. Where the provider is claiming payment under the circumstances

described in the second paragraph of FLs 58A, B, or C and there is WC involvement

or an EGHP, it enters the name of the employer that provides health care coverage

for the individual identified on the same line in FL 58.