UB04 Charge Entry

The UB04 Charge Entry

The UB04 Charge Entry screen manages the entry and editing of UB04 charges (institutional charges). Some key points related to UB04 Charge Entry are:

1. UB04 charge entry is used for institutional claims only.

2. There is no mapping between procedure codes and diagnoses.

3. Revenue codes are mandatory, whereas procedure codes are not.

4. A print option is available on the UB04 charge entry screen (see Image 1). This functionality enables users to print the UB04 claim form directly from the interface, much like the print option available on the professional claim charge entry screen.

Sample UB04 Charge Entry Screen

4. All institutional cases and corresponding encounters are displayed on the left. To add a new encounter, click on button in the Encounters pane. To edit an encounter, click on an encounter on the left. Table 1 describes the important fields in the UB04 charge entry screen. Box numbers in the UB04 charge entry form are given in brackets wherever applicable.

Field	Description
Acct. Date	Accounting Date. Defaults to the current date
Rendering Provider	This is a drop-down field listing all the providers.
Type of Bill	A 4-digit alphanumeric code having a leading zero. In order to view the list, double-click in the field. Either select from the list or manually type a 4-digit code.
#	Case number. Only institutional claims are listed in the drop-down. To add a new inst. case, click on button. To edit a case, click on button
Statement Cover Period (6)	Provide the beginning and ending dates of the period included on this bill.
Admission Date (12)	Date of Admission
HR (13)	Admission Hour
TYPE(14)	This is a code indicating the priority of this admission. Double click to view the code list.
SRC(15)	The code indicating the source of the referral for this admission or visit.
DHR(16)	Discharge hours
STAT(17)	This code indicates the patient’s status as of the “Through” date of the billing period.
Condition Codes(18-28)	Describes any of the following conditions or events that apply to this billing period. Double click to view the list.
Occurrence Code and Date(31-34)	Enters code(s) and associated date(s) defining specific event(s) relating to this billing period. Double-click on the drop-down list to view the occurrence code list
Occurrence Span Code and Date(35,36)	The Occurrence Span Code can contain an occurrence code where the “Through” date would not contain an entry. Occurrence and Occurrence Span codes are mutually exclusive.
Treatment Auth.Code (63)	Required when 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.
Document Control #(64 a,b)	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. When an ERA is posted, the ICN# of the claim will automatically save to the Document Control# (Box 64a)
Principal & Other Diagnosis Code (67)	The first box contains the ICD code for the principal diagnosis. Enters the full ICD codes for up to eight additional conditions if they co-existed at the time of admission or developed subsequently,
Value Codes & Amount (39-41)	Code(s) and the related dollar or unit amount(s) identify data of a monetary nature that are necessary for the processing of this claim.
Admit DX (69)	Admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization
Patient Reason DX  (70)	Patient’s Reason for Visit is required for all un-scheduled outpatient visits for outpatient bills.
Principal procedure Code and Date Other Procedure Code and Date(74, 74a, 74b, 74c)	Principal procedure code and date are required on inpatient claims when a procedure was performed. Not used on outpatient claims. Other procedure codes and date required on inpatient claims when additional procedures must be reported. Not used on outpatient claims.
Rev. Code	The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. Double-click to view the revenue code list. Select one as appropriate. Note: New Revenue Codes can be added or modified from the Billing Lookups screen.
HCPCS Code	If the service requires, in addition to the revenue center code, an HCPCS procedure code, provide it here.
DOS (From, To)	From and To Dates of Service (When adding a code, the date of service entered in the ‘From date’ field will auto-populate to the ‘To date’ field.)
M1, M2, M3, M4	Modifiers
Units, UOM, Charges, Total	Units, Unit of Measure, Charge per Unit, and Total Charge
Non-covered Charges	The total non-covered charges pertaining to the related revenue code are entered here.
Paid	Amount paid so far
Adj. Amt.	Adjustment Amount (if any)
Adj. Reason	Reason for Adjustment
Balance	Balance to be paid for the bill
Line Status	Select the appropriate value from the drop-down. BILL-TO_PR, BILL_TO_SE, REBILL_TO_PR, CLAIM_REBILLED_TO PR, CLAIM_REBILLED_TO_SE, HOLD, PAID_CLOSE, VOID, etc., are some of the statuses.
Attending Provider (76)	The name and identification number of the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/encounter.
Operating Provider (77)	The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s).
Serv.Location	Service Location; defaults to the one provided in the Billing Options page
Remarks	Any notes pertaining to the bill can be added here.