Free UB-04 B Completion Instructions FINAL 12-14-06.xls - Florida

DFS-F5-DWC-90 (UB-04) - B Completion Instructions
Hospitals shall complete the DFS-F5-DWC-90 (UB-04) according to the Field Attributes and Notes, pursuant to the National Uniform Billing Committee Official UB-04 Data Specifications Manual 2007 (UB-04 Manual), September 2006, and the procedure specifications shown below. Form Data Element Locator 1 Provider Name, Address and Telephone Number 2 Pay-to Name and Address 3a Patient Control Number 3b Medical/Health Record Number 4 Type of Bill 5 Federal Tax Number 6 Statement Covers Period 7 Reserved for Assignment by NUBC 8a Patient Name/Identifier 8b 9 10 11 12 13 14 15 16 17 18-28 29 30 31 32-34 35-36 37 38 Patient Name/Identifier Patient Address Patient Birth date Patient Sex Admission/Start of Care Date Admission Hour Priority (Type) of Visit Source of Referral for Admission or Visit Discharge Hour Patient Discharge Status Condition Codes Accident State Reserved for Assignment by NUBC Occurrence Codes and Dates Procedure Specific for Florida Workers' Compensation Required. Enter the provider's Name, Address (including Zip code) and telephone number. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required. Enter patient's social security number or Division assigned number. Required. Enter patient's name: last, first, middle initial, if applicable. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual.

Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required, enter code 18 and all applicable codes. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required. Enter code "04" and enter the date of the accident/injury/illness. Occurrence Codes and Dates Pursuant to the UB-04 Manual. Occurrence Span Codes and Dates Pursuant to the UB-04 Manual. Reserved for Assignment by NUBC Pursuant to the UB-04 Manual. Responsible Party Name and Address Value Codes and Amounts Revenue Code Revenue Description HCPCS/Rates/HIPPS Rate Codes Required. Identify the name of the party responsible for noncompensable charges. Must enter name, address and zip code. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required, as applicable. CPT, HCPCS, or unique workers' compensation code(s) and modifier(s), as required for reimbursement. A surgical CPT code is required for all outpatient surgery bills. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required. Total charges to include both compensable and noncompensable charges.

39-40 42 43 44

45 46 47 48 49

Service Date Service Units Total Charges

Non-covered Charges Pursuant to the UB-04 Manual. Reserved for Assignment by NUBC Pursuant to the UB-04 Manual.

Form DFS-F5-DWC-90 (UB-04) Completion Instructions Rev. 1/1/2007

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DFS-F5-DWC-90 (UB-04) - B Completion Instructions (continued)
50 51 52 53 54 55 56 57 58 59 60 61a 62 63 64 65 Payor Name Health Plan Identification Number Release of Information Certification Indicator Assignment of Benefits Certification Indicator Prior Payments - Payor Estimated Amount Due - Payor National Provider Identifier - Billing Provider Other Provider Identifier Insured's Name Patient's Relationship to the Insured Insured's Unique Identification (Insured) Group Name Insurance Group Number Treatment Authorization Code Document Control Number (DCN) Employer Name (of the Insured) Required. Enter the name, address and zip code for the Workers' Compensation insurer/carrier. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required. Enter the name, address and zip code for the injured workers' employer at the time of onset for the accident/injury/illness (the date entered in FL 31). Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual.

Diagnosis and Procedure Code Qualifier (ICD Version Indicator) 67 Principal Diagnosis Code 67A-Q Other Diagnoses Codes 68 Reserved for Assignment by NUBC 69 Admitting Diagnosis 70a-c Patient's Reason for Visit 71 Prospective Payment System (PPS) Code 72a-c External Cause of Injury (ECI) Code 73 Reserved for Assignment by NUBC 74 Principal Procedure Code and Date 74a-e Other Procedure Codes and Dates 75 Reserved for Assignment by NUBC 76 Attending Provider Name and Identifiers

66

77

78-79 80

81

Required, if applicable. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Pursuant to the UB-04 Manual. Required. Enter the attending provider's name (Last, First) after block labeled 'Attending'; Enter the provider's Florida Department of Health license number after the block labeled 'Qualifier'. Outof-State, enter the provider's license number issued by the licensing entity in that state. Operating Physician Name and Situational. Enter the operating provider's name (Last, First) after Identifiers the block labeled 'Operating'; Enter the provider's Florida Department of Health license number after the block labeled 'Qualifier'. Out-of-State, enter the provider's license number issued by the licensing entity in that state. Other Provider Name and Identifiers Pursuant to the UB-04 Manual. Remarks Field Required Entry - ALL OUTPATIENT SURGICAL BILLS: must enter "scheduled" or "non-scheduled" surgical status. Required Entry - ALL SURGICAL BILLS CHARGING FOR IMPLANTS: must enter the word "Implant(s)" followed by reimbursement calculations made pursuant to rule 69L-7.501, F.A.C. Code - Code Field Pursuant to the UB-04 Manual.

Form DFS-F5-DWC-90 (UB-04) Completion Instructions Rev. 1/1/2007

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