UB-04 SNF Billing Examples
TrailBlazer Health Enterprises UB-04 Skilled Nursing Facility
Billing Examples
Published March 2012
? 2012 TrailBlazer Health Enterprises ? /TrailBlazer ? . All rights reserved.
Skilled Services ? Admit to Discharge
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
040110
041710
4 TYPE OF BILL
0211
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
040110
32 OCCURRENCE
XX
33 OCCURRENCE
XX
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a 50
XXXXXX 50
XXXXXX
70
031510
032510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
16 00
CODE
AMOUNT
CODE
AMOUNT
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430
RHB01 RVA07
14
1
2
2
16
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? First Interim Claim
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
060110
063010
4 TYPE OF BILL
0212
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
30
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a 50
XXXXXX 50
XXXXXX
70
061510
062510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
30 00
CODE
82
AMOUNT
10 00
CODE
09
AMOUNT
1375 00
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430
RHB01 RVA07
14
1
16
2
30
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? Second Interim Claim
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
070110
073110
4 TYPE OF BILL
0213
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
30
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a 50
XXXXXX 50
XXXXXX
70
051510
052510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
31 00
CODE
82
AMOUNT
31 00
CODE
09
AMOUNT
4262 50
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430
RVA02 RVA03
30
1
1
2
31
$$$ $$
3
6
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? Third Interim Claim
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
080110
083110
4 TYPE OF BILL
0213
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
30
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a 50
XXXXXX 50
XXXXXX
70
051510
052510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
31 00
CODE
82
AMOUNT
31 00
CODE
09
AMOUNT
4262 50
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0022 3 0120 4 0250 5 0300 6 0420 7 0430
RVA03 RVA04
30
1
1
2
31
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? Fourth Interim Claim - Benefits Exhaust During the Month
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
090110
093010
4 TYPE OF BILL
0213
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
30
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a A3
090810 50
XXXXXX
70
051510
052510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b 81 c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
CODE
8 00
82
22 00
AMOUNT
8 00
CODE
09
AMOUNT
1100 00
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430
RVA04
30
1
30
$$$ $$
2
X
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
1
20
2
21
3
22
4 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
All charges for services rendered after the A3 date
b
LAST
FIRST
should be billed as non-covered.
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? Discharge Claim
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
100110
100510
4 TYPE OF BILL
0214
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
XX
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a 50
XXXXXX
70
051510
052510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
4 00
CODE
AMOUNT
CODE
AMOUNT
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430
RVA04
4
1
4
$$$ $$
2
X
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
Skilled Services ? Benefits Fully Exhausted
1
Provider Name
Street Address City, State, ZIP Code Telephone; Fax; Country Code
2
Pay-to Name
Street Address or Post Office Box City, State, ZIP Code
3a PAT.
CNTL # Required
b. MED.
REC. # Recommended
5 FED. TAX NO. SubID
6 STATEMENT COVERS PERIOD
7
FROM
THROUGH
XX-XXXXXXXX
100110
103110
4 TYPE OF BILL
0213
8 PATIENT NAME
a
9 PATIENT ADDRESS
a Street Address or Post Office Box
b Patient Last, First, Middle Initial
b City
10 BIRTHDATE
ADMISSION
11 SEX
16 DHR 17 STAT
12 DATE
13 HR
14 TYPE 15 SRC
18
CONDITION CODES
c State d ZIP Code
29 ACDT 30
19
20
21
22
23
24
25
26
27
28
STATE
e Country Code
MMDDCCYY X
31 OCCURRENCE
060110
32 OCCURRENCE
XX
33 OCCURRENCE
30
34 OCCURRENCE
35
OCCURRENCE SPAN
36
OCCURRENCE SPAN
37
CODE
DATE
CODE DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
CODE FROM
THROUGH
a
70
051510
052510
a
b
b
38
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
42 REV. CD.
43 DESCRIPTION
CODE
a 80 b c d
44 HCPCS / RATE / HIPPS CODE
AMOUNT
31 00
CODE
82
AMOUNT
11 00
CODE
09
AMOUNT
1512 50
45 SERV. DATE
46 SERV. UNITS 47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1 0022 2 0120 3 0250 4 0270 5 0300 6 0420 7 0430
AAA00
31
1
31
$$$ $$
2
X
$$$ $$
3
X
$$$ $$
4
X
$$$ $$
5
X
$$$ $$
6
X
$$$ $$
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23 0001
PAGE X OF X
CREATION DATE
MMDDYY TOTALS
$$$ $$
23
50 PAYER NAME
51 HEALTH PLAN ID
52 REL INFO
53 ASG BEN
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56 NPI
XXXXXXXXXX
A Medicare
X
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED'S NAME
59 P.REL 60 INSURED'S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A Beneficiary Last, First Name
XX
XXX-XX-XXXXX
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
B
C
66 DX
XXXXX
X
A
9
I
J
A
B
C
B
C
D
E
F
G
H
68
K
L
M
N
O
P
Q
69 ADMIT
XXXXX
70 PATIENT
a
b
DX
REASON DX
c
71 PPS
CODE
72
a
ECI
73
b
c
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
c.
OTHER PROCEDURE
d.
CODE
DATE
80 REMARKS
OTHER PROCEDURE
b.
CODE
DATE
OTHER PROCEDURE
e.
CODE
DATE
81 CC a
OTHER PROCEDURE
75
CODE
DATE
OTHER PROCEDURE
CODE
DATE
76 ATTENDING
NPI XXXXXXXXXX
LAST Last Name
77 OPERATING
NPI
FIRST
LAST
FIRST
78 OTHER
NPI
QUAL
First Name
QUAL
QUAL
Add any additional information here.
b
LAST
FIRST
c
79 OTHER
NPI
QUAL
d
LAST
FIRST
................
................
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