GBSS: Accounts Receivable, Follow-up Quick Reference Guide

Applies to: All Stakeholder(s): New Onboards

Level 2: Revenue Cycle Management

Chapter 1: UNDERSTANDING CLAIMS

1.1 UNDERSTANDING CLAIMS

All the services provided are billed on a claim form with the help of medical codes.

There are two types of claim forms – UB 04 and CMS 1500

UB 04 CMS 1500

UB 04 is also called uniform billing form.
UB 04 form is used to bill medical claims by Hospitals,
Home Health agencies, and Hospice Provider.
CMS 1500 form also known as Healthcare Financing
Administration form (or HCFA form) is used by
Physician offices.
CMS stands for Centers for Medicare and Medicaid
Services.

1.2 UB 04: UNIFORM BILLING FORM

Each field in the UB 04 claim form is referred as field locators and each field locator has a unique purpose. There are
total 81 field locators in UB 04 form.

Form
Description
Fields
Fields 1 -7 contain General Claim Information
General Billing Related Information:
Fields • Billing Provider Name
1 -7 • Provider’s Address
• Type of Bill, etc.
Field 4 - Type of Bill:

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GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

Type of Bill (TOB) is a four-digit code used to identify the Bill being submitted to a payer. Let me explain
you with an example:

Type of Facility: Beginning with zero, the second digit identifies the type of facility.
Example: Hospital or Skilled Nursing Facility, etc.
Type of care: The third classifies the type of care being billed.
Example: Impatient and Outpatient care
Sequence of the bill: The fourth digit specifies the sequence of the bill for a specific episode of care.
Referred to as a "frequency" code.
Example: corrected claim or fresh claim
Type of Bill 0111 is used for Fresh Claim, where the fourth digit “1” is the frequency" code.
Likewise, 0117 is used for Corrected Claim, where the fourth digit “7” is the frequency" code.

Field 5 - Federal Tax ID:

• It is used to submit the Federal Tax ID number for the facility. Tax ID is a 9-digit number used for
taxation purposes by providers.
• Along with Tax ID number, we have a broad range of Identifiers.

Field 6 - Date of Service (DOS):

• Field locator 6 is Date of service for the claim.
• Services rendered to a patient ‘From’ and ‘Through’ dates are specified here.

Field 8-41 is for patient data and billing codes

• Patient’s Name
• Date of Birth
Field • Date of Service, etc.
8-41 Field 18 - 28 Condition Codes
• Field locator 18 to 28 are for Condition Codes
• These are two-digit numeric codes which describes the condition or circumstances of the
patient getting treated in a facility.
For example, condition code number 44 is used for all Outpatient claims.
Field 42 & 43 - Revenue Codes & description
• Field 42 contains Revenue codes, and field 43 contains the description of Revenue Codes.
• Revenue code identifies the department in which the service was rendered, the types of
Field
services provided, and the supplies used.
42 & 43
• These codes determine the dollar amounts charged for hospital services provided to a patient.
• Revenue Codes are for hospital services only and not for Physician services
Example: Revenue Code 0233 is used to bill ICU claims
Revenue Code 0235 is used to bill Hospice claims

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GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

Field 44 Field 44 -HCPCS Codes

• HCPCS codes are updated in Field locator 44
Field 66, Field 66, 67, 69, 70, 72, 74- ICD Codes
67, 69, • ICD codes are updated in Field locator 66, 67, 69, 70, 72, and 74
70, 72,
74

Field 76 Field 76 – 79 - NPI IDs

– 79 • Providers NPI IDs are entered in Field locator 76 to 79

1.2.1 IDENTIFIERS: PROVIDER AND PATIENT

PROVIDER IDENTIFIERS
S.No Provider Identifiers Definition
A unique 10-digit identification number issued to health care
providers in the United States by the Centers for Medicare and
1 National Provider Identifier (NPI)
Medicaid Services (CMS)

A six-character alpha-numeric identifier used by Medicare to identify

Unique Physician Identification doctors. They were discontinued in June 2007 and replaced by
2
number (UPIN) National Provider Identifier, or NPI numbers

A Medicare-only number issued to providers by Medicare

Provider Transaction Access Number
3 Administrative Contractors (MACs) upon enrollment to Medicare
(PTAN)

4 Tax ID 9-digit number used by providers for taxation purposes

PATIENT IDENTIFIERS
There are 18 Patient identifiers in total. All these are considered as Protected Health Information also known as PHI and
is governed by Health Insurance Portability and Accountability Act of 1996 also known as HIPAA

1 Patient’s Name 10 Account Number

2 Date of Birth (DOB) 11 Certificate or license number
3 Social Security number (SSN) 12 Vehicle Identifiers, like number plate
4 Address 13 Device identifiers and serial numbers
5 Telephone number 14 Web URL
6 Fax number 15 Internet Portal Address
7 Email address 16 Finger or voice print
8 Medical Record Number 17 Photographic image
Any other characteristic that could uniquely identify
9 Health plan Benefit number 18
the patient
1.2.2 CODES
You will encounter a vast category of Codes in Healthcare, like

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GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

CPT codes HCPCS codes ICD 10 CM codes Modifiers

Current Procedural Healthcare Common International Classification Modifiers are 2-digit

Terminology (CPT) are Procedure Coding System of Diseases, Tenth Revision, numerical, alpha, and
numerical codes used (HCPCS) are 5-digit Clinical Modification (ICD alphanumerical codes.
primarily to identify alphanumeric codes used to 10 CM) are 3 to 7-digit alpha Modifiers are added to a
medical services and identify non-physician numerical codes used by all procedure codes to notify
procedures furnished services such as ambulance providers to classify the insurance for services altered
by qualified healthcare services, durable medical diseases and conditions of a or changed without changing
professionals equipment, and pharmacy patient the definition of procedure
code.

EXAMPLE OF ICD 10 CM CODES

Each code begins with a letter, that letter is followed by two numbers.

The first 3 letters are referred as the Category, the

Category category describes the General type of injury or
disease.

Subcategory The Category is followed by the decimal point and

the Subcategory

Subcategory is followed by up to two

Subclassifications which further explains the cause,
Subclassifications
symptoms, location, severity, and type of injury or
disease

The last character is the Extension. The Extension

describes the type of encounter, i.e., if the provider
Initial Encounter
has treated the patient for the first time, it is listed
as the Initial Encounter

Every encounter after the first encounter is listed as

Subsequent Encounter the Subsequent Encounter

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GBSS: Accounts Receivable, Follow-up Quick Reference Guide
Applies to: All Stakeholder(s): New Onboards

Patients visits related to the effects of a previous

Sequela
disease or injury is listed with the term Sequela

Codes depict the specifics of services rendered and

hence justifies the associated charges billed.

1.3 CMS 1500: HEALTHCARE FINANCING ADMINISTRATION

CMS 1500 claim form has 33 fields

Form Fields Description

Field 1, 1A, 4, 7 & 11- Insurance details
Field 1, 1A, 4, 7 & 11
• Insurance details are found in Field 1, 1A, 4, 7 & 11
Field 2, 3, 5 & 6 - Client/Patient information
Field 2, 3, 5 & 6
• You will find Client/Patient information in Field 2, 3, 5 & 6
Field 21 – ICD 10CM Codes
Field 21
• Diagnosis Codes are found in Field 21
Field 23 – Prior authorization
Field 23
• Prior authorization number is updated in Field 23
Field 24A - Date of Service (DOS)
Field 24A
• Date of Service (DOS) is found in Field 24A
Field 24B & 32- Service Location
Field 24B & 32 • These Field indicates where health care services where rendered to the
patient, i.e., Service location
Field 24D & 24G- Procedure Codes
Field 24D & 24G • Procedure Codes are found in Field 24D & 24G
• CPT and HCPCS codes are found in these Field
Field 24F- Charges
Field 24F
• Charges are found in Field 24F
Field 24J- Rendering Provider
Field 24J
• Rendering Provider details are found in Field 24J
Field 33 - Billing Provider
Field 33
• Billing Provider details are found in Field number 33

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