100-04 Medicare Claims Processing Manual: Chapter 25 - Completing and Processing the Form CMS-1450 Data Set

Medicare Claims Processing Manual
Chapter 25 - Completing and Processing the Form
CMS-1450 Data Set
Table of Contents
(Rev. 12423, 12-20-23)
Transmittals for Chapter 25
10 - Reserved
70 - Uniform Bill - Form CMS-1450
70.1 - Uniform Billing with Form CMS-1450
70.2 - Disposition of Copies of Completed Forms
75 - General Instructions for Completion of Form CMS-1450 for Billing
75.1 - Form Locators 1-15
75.2 - Form Locators 16-30
75.3 - Form Locators 31-41
75.4 - Form Locator 42
75.5 - Form Locators43-65
75.6 – Form Locators 66-81
80 - Reserved

10 - Reserved
70 - Uniform Bill - Form CMS-1450
(Rev. 2874, Issued: 02-06-14, Effective: 03-07-14, Implementation: 03-07-14)
70.1 - Uniform Billing with Form CMS-1450
(Rev. 2922, Issued: 04-03-14, Effective: 04-18-14, Implementation: 04-18-14)
This form, also known as the UB-04, is a uniform institutional provider bill suitable for
use in billing multiple third party payers. Because it serves many payers, a particular
payer may not need some data elements. The National Uniform Billing Committee
(NUBC) maintains lists of approved coding for the form. Medicare Administrative
Contractors servicing both Part A and Part B lines of business (A/B MACs (A) and
(HHH)) responsible for receiving institutional claims also maintain lists of codes used by
Medicare. All items on Form CMS-1450 are described. The A/B MAC (A) or (HHH)
must be able to capture all NUBC-approved input data described in section 75 for audit
trail purposes and be able to pass coordination of benefits data to other payers with whom
it has a coordination of benefits agreement.
70.2 - Disposition of Copies of Completed Forms
(Rev. 2922, Issued: 04-03-14, Effective: 04-18-14, Implementation: 04-18-14)
The provider retains the copy designated “Institution Copy” and submits the remaining
copies of the completed Form CMS-1450 to its A/B MAC (A) or (HHH), managed care
plan, or other insurer. Where it knows that a managed care plan will pay the bill, it sends
the bill and any necessary supporting documentation directly to the managed care plan
for coverage determination, payment, and/or denial action. It sends to the A/B MAC (A)
or (HHH) bills that it knows will be paid and processed by the A/B MAC (A) or (HHH).
75 - General Instructions for Completion of Form CMS-1450 for Billing
(Rev. 2922, Issued: 04-03-14, Effective: 04-18-14, Implementation: 04-18-14)
This section contains Medicare requirements for use of codes maintained by the NUBC
that are needed in completion of the Form CMS-1450 and compliant Accredited
Standards Committee (ASC) X12 837 institutional claims. Note that the internal claim
record used for processing is not being expanded. Instructions for completion are the
same for inpatient and outpatient claims unless otherwise noted. The A/B MAC (A) or
(HHH) does not need to search paper files to annotate missing data unless it does not
have an electronic history record. It does not need to obtain data that is not needed to
process the claim.
Effective June 5, 2000, CMS extended the claim size to 450 lines. For the Form CMS-
1450, this simply means that the A/B MAC (A) or (HHH) accepts claims of up to 9
pages. The following layout describes the data specifications Form CMS-1450.

FORM CMS-1450 LAYOUT SUMMARY
FL 	Description 	Line 	Type 	Size Buffer
Space
FL01 	[Billing Provider Name] 	1 	AN 	25
FL01 	[Billing Provider Street Address] 	2 	AN 	25
FL01 	[Billing Provider City, State, Zip] 	3 	AN 	25
FL01 	[Billing Provider Telephone, Fax, Country
Code]
4 	AN 	25
FL02 [Billing Provider’s Designated Pay-to
Name] 1 	AN 	25
FL02 [Billing Provider’s Designated Pay-to
Address] 2 	AN 	25
FL02 [Billing Provider’s Designated Pay-to City,
State] 3 	AN 	25
FL02 	[Billing Provider’s Designated Pay-to ID] 	4 	AN 	25
FL03a 	Patient Control Number 	AN 	24
FL03b 	Medical/Health Record Number 	AN 	24
FL04 	Type of Bill 	1 	AN 	4 	1
FL05 	Federal Tax Number 	1 	AN 	4
FL05 	Federal Tax Number 	2 	AN 	10
FL06 	Statement Covers Period - From/Through 	1 	N/N 	6/6 	1/1
FL07 	Unlabeled 	1 	AN 	7
FL07 	Unlabeled 	2 	AN 	8
FL08 	Patient Name and Identifier (ID) 	1a 	AN 	19
FL08 	Patient Name 	2b 	AN 	29
FL09 	Patient Address - Street 	1a 	AN 	40 	1
FL09 	Patient Address - City 	2b 	AN 	30 	2
FL09 	Patient Address - State 	2c 	AN 	2 	1
FL09 	Patient Address - ZIP 	2d 	AN 	9 	1
FL09 	Patient Address - Country Code 	2e 	AN 	3
FL10 	Patient Birthdate 	1 	N 	8 	1

FL 	Description 	Line 	Type 	Size Buffer
Space
FL11 	Patient Sex 	1 	AN 	1 	2
FL12 	Admission/Start of Care Date 	1 	N 	6
FL13 	Admission Hour 	1 	AN 	2 	1
FL14 	Priority (Type) of Admission or Visit 	1 	AN 	1 	2
FL15 	Point of Origin for Admission or Visit 	1 	AN 	1 	2
FL16 	Discharge Hour 	1 	AN 	2 	1
FL17 	Patient Discharge Status 	1 	AN 	2 	1
FL18 	Condition Code 	AN 	2 	1
FL19 	Condition Code 	AN 	2 	1
FL20 	Condition Code 	AN 	2 	1
FL21 	Condition Code 	AN 	2 	1
FL22 	Condition Code 	AN 	2 	1
FL23 	Condition Code 	AN 	2 	1
FL24 	Condition Code 	AN 	2 	1
FL25 	Condition Code 	AN 	2 	1
FL26 	Condition Code 	AN 	2 	1
FL27 	Condition Code 	AN 	2 	1
FL28 	Condition Code 	AN 	2 	1
FL29 	Accident State 	AN 	2 	1
FL30 	Unlabeled 	1 	AN 	12
FL30 	Unlabeled 	2 	AN 	13
FL31 	Occurrence Code/Date 	a 	AN/N 	2/6 	1/1
FL31 	Occurrence Code/Date 	b 	AN/N 	2/6 	1/1
FL32 	Occurrence Code/Date 	a 	AN/N 	2/6 	1/1
FL32 	Occurrence Code/Date 	b 	AN/N 	2/6 	1/1
FL33 	Occurrence Code/Date 	a 	AN/N 	2/6 	1/1
FL33 	Occurrence Code/Date 	b 	AN/N 	2/6 	1/1

FL 	Description 	Line 	Type 	Size Buffer
Space
FL34 	Occurrence Code/Date 	a 	AN/N 	2/6 	1/1
FL34 	Occurrence Code/Date 	b 	AN/N 	2/6 	1/1
FL35 	Occurrence Span Code/From/Through 	a 	AN/N/N 	2/6/6 	1/1/1
FL35 	Occurrence Span Code/From/Through 	b 	AN/N/N 	2/6/6 	1/1/1
FL36 	Occurrence Span Code/From/Through 	a 	AN/N/N 	2/6/6 	1/1/1
FL36 	Occurrence Span Code/From/Through 	b 	AN/N/N 	2/6/6 	1/1/1
FL37 	Unlabeled 	a 	AN 	8
FL37 	Unlabeled 	b 	AN 	8
FL38 	Responsible Party Name/Address 	1 	AN 	40 	2
FL38 	Responsible Party Name/Address 	2 	AN 	40 	2
FL38 	Responsible Party Name/Address 	3 	AN 	40 	2
FL38 	Responsible Party Name/Address 	4 	AN 	40 	2
FL38 	Responsible Party Name/Address 	5 	AN 	40 	2
FL39 	Value Code 	a 	AN 	2 	1
FL39 	Value Code Amount 	a 	N 	9 	1
FL39 	Value Code 	b 	AN 	2 	1
FL39 	Value Code Amount 	b 	N 	9 	1
FL39 	Value Code 	c 	AN 	2 	1
FL39 	Value Code Amount 	c 	N 	9 	1
FL39 	Value Code 	d 	AN 	2 	1
FL39 	Value Code Amount 	d 	N 	9 	1
FL40 	Value Code 	a 	AN 	2 	1
FL40 	Value Code Amount 	a 	N 	9 	1
FL40 	Value Code 	b 	AN 	2 	1
FL40 	Value Code Amount 	b 	N 	9 	1
FL40 	Value Code 	c 	AN 	2 	1
FL40 	Value Code Amount 	c 	N 	9 	1
FL40 	Value Code 	d 	AN 	2 	1
FL40 	Value Code Amount 	d 	N 	9 	1
FL41 	Value Code 	a 	AN 	2 	1
FL41 	Value Code Amount 	a 	N 	9 	1
FL41 	Value Code 	b 	AN 	2 	1
FL41 	Value Code Amount 	b 	N 	9 	1

FL 	Description 	Line 	Type 	Size Buffer
Space
FL41 	Value Code 	c 	AN 	2 	1
FL41 	Value Code Amount 	c 	N 	9 	1
FL41 	Value Code 	d 	AN 	2 	1
FL41 	Value Code Amount 	d 	N 	9 	1
FL42 	Revenue Codes 1-
23 N 	4
FL43 Revenue Code Description/IDE
Number/Medicaid Drug rebate
1-
23 AN 	24
FL44 HCPCS/Accommodation Rates/HIPPS Rate
Codes
1-
23 N 	14
FL45 	Service Dates 1-
23 N 	6
FL46 	Service Units 1-
23 N 	7
FL47 	Total Charges 1-
23 N 	9
FL48 	Non-Covered Charges 1-
23 N 	9
FL49 	Unlabeled 1-
23 AN 	2
FL50 	Payer Identification - Primary 	A 	AN 	23
FL50 	Payer Identification - Secondary 	B 	AN 	23
FL50 	Payer Identification - Tertiary 	C 	AN 	23
FL51 	Health Plan Identification Number 	A 	AN 	15
FL51 	Health Plan Identification Number 	B 	AN 	15
FL51 	Health Plan Identification Number 	C 	AN 	15
FL52 	Release of Information - Primary 	A 	AN 	1 	1
FL52 	Release of Information - Secondary 	B 	AN 	1 	1
FL52 	Release of Information - Tertiary 	C 	AN 	1 	1
FL53 	Assignment of Benefits - Primary 	A 	AN 	1 	1
FL53 	Assignment of Benefits - Secondary 	B 	AN 	1 	1
FL53 	Assignment of Benefits - Tertiary 	C 	AN 	1 	1
FL54 	Prior Payments - Primary 	A 	N 	10 	1
FL54 	Prior Payments - Secondary 	B 	N 	10 	1

FL 	Description 	Line 	Type 	Size Buffer
Space
FL54 	Prior Payments - Tertiary 	C 	N 	10 	1
FL55 	Estimated Amount Due - Primary 	A 	N 	10 	1
FL55 	Estimated Amount Due - Secondary 	B 	N 	10 	1
FL55 	Estimated Amount Due - Tertiary 	C 	N 	10 	1
FL56 National Provider Identifier (NPI) - Billing
Provider 1 	AN 	15
FL57 	Other Provider ID 	A 	AN 	15
FL57 	Other Provider ID 	B 	AN 	15
FL57 	Other Provider ID 	C 	AN 	15
FL58 	Insured’s Name - Primary 	A 	AN 	25 	1
FL58 	Insured's Name - Secondary 	B 	AN 	25 	1
FL58 	Insured's Name -Tertiary 	C 	AN 	25 	1
FL59 	Patient’s Relationship - Primary 	A 	AN 	2 	1
FL59 	Patient's Relationship - Secondary 	B 	AN 	2 	1
FL59 	Patient's Relationship - Tertiary 	C 	AN 	2 	1
FL60 	Insured's Unique ID - Primary 	A 	AN 	20
FL60 	Insured's Unique ID - Secondary 	B 	AN 	20
FL60 	Insured's Unique ID - Tertiary 	C 	AN 	20
FL61 	Insurance Group Name - Primary 	A 	AN 	14 	1
FL61 	Insurance Group Name - Secondary 	B 	AN 	14 	1
FL61 	Insurance Group Name -Tertiary 	C 	AN 	14 	1
FL62 	Insurance Group Number - Primary 	A 	AN 	17 	1
FL62 	Insurance Group Number - Secondary 	B 	AN 	17 	1
FL62 	Insurance Group Number - Tertiary 	C 	AN 	17 	1
FL63 	Treatment Authorization Code - Primary 	A 	AN 	30 	1
FL63 	Treatment Authorization Code - Secondary 	B 	AN 	30 	1
FL63 	Treatment Authorization Code - Tertiary 	C 	AN 	30 	1
FL64 	Document Control Number (DCN) 	A 	AN 	26
FL64 	DCN 	B 	AN 	26
FL64 	DCN 	C 	AN 	26

FL 	Description 	Line 	Type 	Size Buffer
Space
FL65 	Employer Name (of the insured) - Primary 	A 	AN 	25
FL65 Employer Name (of the insured) -
Secondary B 	AN 	25
FL65 	Employer Name (of the insured) - Tertiary 	C 	AN 	25
FL66 Diagnosis and Procedure Code Qualifier
(ICD Version Indicator) AN 	1
FL67 Principal Diagnosis Code and Present on
Admission (POA) Indicator AN 	8
FL67A 	Other Diagnosis and POA Indicator 	AN 	8
FL67B 	Other Diagnosis and POA Indicator 	AN 	8
FL67C 	Other Diagnosis and POA Indicator 	AN 	8
FL67D 	Other Diagnosis and POA Indicator 	AN 	8
FL67E 	Other Diagnosis and POA Indicator 	AN 	8
FL67F 	Other Diagnosis and POA Indicator 	AN 	8
FL67G 	Other Diagnosis and POA Indicator 	AN 	8
FL67H 	Other Diagnosis and POA Indicator 	AN 	8
FL67I 	Other Diagnosis and POA Indicator 	AN 	8
FL67J 	Other Diagnosis and POA Indicator 	AN 	8
FL67K 	Other Diagnosis and POA Indicator 	AN 	8
FL67L 	Other Diagnosis and POA Indicator 	AN 	8
FL67M 	Other Diagnosis and POA Indicator 	AN 	8
FL67N 	Other Diagnosis and POA Indicator 	AN 	8
FL67O 	Other Diagnosis and POA Indicator 	AN 	8
FL67P 	Other Diagnosis and POA Indicator 	AN 	8
FL67Q 	Other Diagnosis and POA Indicator 	AN 	8
FL68 	Unlabeled 	1 	AN 	8
FL68 	Unlabeled 	2 	AN 	9
L69 	Admitting Diagnosis Code 	AN 	7
FL70a 	Patient Reason for Visit Code 	AN 	7
FL70b 	Patient Reason for Visit Code 	AN 	7
FL70c 	Patient Reason for Visit Code 	AN 	7

FL 	Description 	Line 	Type 	Size Buffer
Space
FL71 	Prospective Payment System (PPS) Code 	AN 	3 	2
FL72a External Cause of Injury (ECI) Code and
POA Indicator AN 	8
FL72b 	ECI Code and POA Indicator 	AN 	8
FL72c 	ECI Code and POA Indicator 	AN 	8
FL73 	Unlabeled 	AN 	9
FL74 	Principal Procedure Code/Date 	N/N 	7/6 	1/1
FL74a 	Other Procedure Code/Date 	N/N 	7/6 	1/1
FL74b 	Other Procedure Code/Date 	N/N 	7/6 	1/1
FL74c 	Other Procedure Code/Date 	N/N 	7/6 	1/1
FL74d 	Other Procedure Code/Date 	N/N 	7/6 	1/1
FL74e 	Other Procedure Code/Date 	N/N 	7/6 	1/1
FL75 	Unlabeled 	1 	AN 	3 	1
FL75 	Unlabeled 	2 	AN 	4 	1
FL75 	Unlabeled 	3 	AN 	4 	1
FL75 	Unlabeled 	4 	AN 	4 	1
FL76 	Attending Provider - IDs 	1 	AN 	11/2/9
FL76 	Attending Provider - Last Name/First Name 	2 	AN 	16/12
FL77 	Operating Physician - IDs 	1 	AN 	11/2/9
FL77 Operating Physician - Last Name/First
Name 2 	AN 	16/12
FL78 	Other Provider - IDs 	1 	AN 	2/11/2/9
FL78 	Other Provider - Last Name/First Name 	2 	AN 	16/12
FL79 	Other Provider - IDs 	1 	AN 	2/11/2/9
FL79 	Other Provider - Last/First 	2 	AN 	16/12
FL80 	Remarks 	1 	AN 	21
FL80 	Remarks 	2 	AN 	26
FL80 	Remarks 	3 	AN 	26
FL80 	Remarks 	4 	AN 	26

FL 	Description 	Line 	Type 	Size Buffer
Space
FL81 	Code-Code - QUALIFIER/CODE/VALUE 	a AN/AN/
AN 2/10/12
FL81 	Code-Code - QUALIFIER/CODE/VALUE 	b AN/AN/
AN 2/10/12
FL81 	Code-Code - QUALIFIER/CODE/VALUE 	c AN/AN/
AN 2/10/12
FL81 	Code-Code - QUALIFIER/CODE/VALUE 	d AN/AN/
AN 2/10/12
75.1 - Form Locators 1-15
(Rev. 3709, Issued: 02-03-17; Effective: 04-04-17; Implementation: 04-04-17)
Form Locator (FL) 1 - Billing Provider Name, Address, and Telephone Number
Required. The minimum entry is the provider name, city, State, and nine-digit ZIP
Code. Phone and/or Fax numbers are desirable.
FL 2 - Billing Provider’s Designated Pay-to Name, address, and Secondary
Identification Fields
Not Required. If submitted, the data will be ignored.
FL 3a - Patient Control Number
Required. The patient’s unique alpha-numeric control number assigned by the provider
to facilitate retrieval of individual financial records and posting payment may be shown if
the provider assigns one and needs it for association and reference purposes.
FL 3b - Medical/Health Record Number
Situational. The number assigned to the patient’s medical/health record by the provider
(not FL3a).
FL 4 - Type of Bill
Required. This four-digit alphanumeric code gives three specific pieces of information
after a leading zero. CMS will ignore the leading zero. CMS will continue to process
three specific pieces of information. The second digit identifies the type of facility. The
third classifies the type of care. The fourth indicates the sequence of this bill in this
particular episode of care. It is referred to as a “frequency” code.
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.

Code Structure
2nd Digit-Type of Facility (CMS will process this as the 1st digit)
3rd Digit-Bill Classification (Except Clinics and Special Facilities) (CMS will process
this as the 2nd digit)
3rd Digit-Classification (Clinics Only) (CMS will process this as the 2nd digit)
3rd Digit-Classification (Special Facilities Only) (CMS will process this as the 2nd digit)
4th Digit-Frequency - Definition (CMS will process this as the 3rd digit)
FL 5 - Federal Tax Number
Required. The format is NN-NNNNNNN.
FL 6 - Statement Covers Period (From-Through)
Required. The provider enters the beginning and ending dates of the period included on
this bill in numeric fields (MMDDYY).
FL 7
Not Used.
FL 8 - Patient’s Name and Identifier
Required. The provider enters the patient’s last name, first name, and, if any, middle
initial, along with patient identifier (if different than the subscriber/insured’s identifier).
FL 9 - Patient’s Address
Required. The provider enters the patient’s full mailing address, including street number
and name, post office box number or RFD, city, State, and ZIP Code.
FL 10 - Patient’s Birth Date
Required. The provider enters the month, day, and year of birth (MMDDCCYY) of
patient. If full birth date is unknown, indicate zeros for all eight digits.
FL 11 - Patient’s Sex
Required. The provider enters an “M” (male) or an “F” (female). The patient’s sex is
recorded at admission, outpatient service, or start of care.

FL 12 - Admission/Start of Care Date
Required For Inpatient and Home Health. The hospital enters the date the patient was
admitted for inpatient care (MMDDYY). The HHA enters the same date of admission
that was submitted on the RAP for the episode.
FL 13 - Admission Hour
Not Required. If submitted, the data will be ignored.
FL 14 - Priority (Type) of Admission or Visit
Required.
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.
FL 15 - Point of Origin for Admission or Visit
Required except for Bill Type 014X. The provider enters the code indicating the source
of the referral for this admission or visit.
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.
75.2 - Form Locators 16-30
(Rev. 1973, Issued: 05-21-10, Effective: 09-01-10, Implementation: 09-01-10)
FL 16 - Discharge Hour
Not Required.
FL 17 - Patient Discharge Status
Required. (For all Part A inpatient, SNF, hospice, home health agency (HHA) and
outpatient hospital services.) This code indicates the patient’s discharge status as of the
“Through” date of the billing period (FL 6).
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 18 - 28 - Condition Codes

Situational. The provider enters the corresponding code (in numerical order) to describe
any of the following conditions or events that apply to this billing period.
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.
FL 29 - Accident State
Not used. Data entered will be ignored.
FL 30 - (Untitled)
Not used. Data entered will be ignored.
75.3 - Form Locators 31-41
(Rev. 2922, Issued: 04-03-14, Effective: 04-18-14, Implementation: 04-18-14)
FLs 31, 32, 33, and 34 - Occurrence Codes and Dates
Situational. Required when there is a condition code that applies to this claim.
GUIDELINES FOR OCCURRENCE AND OCCURRENCE SPAN UTILIZATION
Due to the varied nature of Occurrence and Occurrence Span Codes, provisions have
been made to allow the use of both type codes within each. The Occurrence Span Code
can contain an occurrence code where the “Through” date would not contain an entry.
This allows as many as 10 Occurrence Codes to be utilized. With respect to Occurrence
Codes, complete field 31a - 34a (line level) before the “b” fields. Occurrence and
Occurrence Span codes are mutually exclusive. An example of Occurrence Code use: A
Medicare beneficiary was confined in hospital from January 1, 2005 to January 10, 2005,
however, his Medicare Part A benefits were exhausted as of January 8, 2005, and he was
not entitled to Part B benefits. Therefore, Form Locator 31 should contain code A3 and
the date 010805.
The provider enters code(s) and associated date(s) defining specific event(s) relating to
this billing period. Event codes are two alpha-numeric digits, and dates are six numeric
digits (MMDDYY). When occurrence codes 01-04 and 24 are entered, the provider must
make sure the entry includes the appropriate value code in FLs 39-41, if there is another
payer involved. Occurrence and occurrence span codes are mutually exclusive. When
FLs 36 A and B are fully used with occurrence span codes, FLs 34a and 34b and 35a and
35b may be used to contain the “From” and “Through” dates of other occurrence span
codes. In this case, the code in FL 34 is the occurrence span code and the occurrence
span “From” dates is in the date field. FL 35 contains the same occurrence span code as
the code in FL 34, and the occurrence span “Through” date is in the date field. Other
payers may require other codes, and while Medicare does not use them, they may be
entered on the bill if convenient.

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 35 and 36 - Occurrence Span Code and Dates
Required For Inpatient.
The provider enters codes and associated beginning and ending dates defining a specific
event relating to this billing period. Event codes are two alpha-numeric digits and dates
are shown numerically as MMDDYY.
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.
Special Billing Procedures When more than Ten Occurrence Span Codes (OSCs)
Apply to a Single Stay
The Long Term Care Hospital (LTCH), Inpatient Psychiatric Facility (IPF), and Inpatient
Rehabilitation Facility (IRF) Prospective Payment Systems (PPSs) requires a single claim
to be billed for an entire stay. Interim claims may be submitted to continually adjust all
prior submitted claims for the stay until the beneficiary is discharged. In some instances,
significantly long stays having numerous OSCs may exceed the amount of OSCs allowed
to be billed on a claim.
When a provider paid under the LTCH, IPF or IRF PPSs encounters a situation in which
ten or more OSCs are to be billed on the claim, the provider must bill for the entire stay
up to the Through date of the 10th OSC for the stay (the Through date for the Statement
Covers Period equals the Through date of the tenth OSC). As the stay continues, the
provider must only bill the 11th through the 20th OSC for the stay, if applicable. Once the
twentieth OSC is applied to the claim, the provider must only bill the 21st through the 30th
OSC for the stay, if applicable. The Shared System Maintainers (SSMs) retain the
history of all OSCs billed for the stay to ensure proper processing (i.e., as if no OSC
limitation exists on the claim).
For a detailed billing example that outlines possible billing scenarios, please go to
http://www.cms.hhs.gov/Transmittals/01_Overview.asp and refer to CR 6777 located on
the 2010 Transmittals page.
FL 37 - (Untitled)
Not used. Data entered will be ignored.
FL 38 - Responsible Party Name and Address

Not Required. For claims that involve payers of higher priority than Medicare.
FLs 39, 40, and 41 - Value Codes and Amounts
Required. Code(s) and related dollar or unit amount(s) identify data of a monetary
nature that are necessary for the processing of this claim. The codes are two alpha-
numeric digits, and each value allows up to nine numeric digits (0000000.00). Negative
amounts are not allowed except in FL 41. Whole numbers or non-dollar amounts are
right justified to the left of the dollars and cents delimiter. Some values are reported as
cents, so the provider must refer to specific codes for instructions.
If more than one value code is shown for a billing period, codes are shown in ascending
numeric sequence. There are four lines of data, line “a” through line “d.” The provider
uses FLs 39A through 41A before 39B through 41B (i.e., it uses the first line before the
second).
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.
75.4 - Form Locator 42
(Rev. 1973, Issued: 05-21-10, Effective: 09-01-10, Implementation: 09-01-10)
FL 42 - Revenue Code
Required. The provider enters the appropriate revenue codes from the following list to
identify specific accommodation and/or ancillary charges. It must enter the appropriate
numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47.
Additionally, there is no fixed “Total” line in the charge area. The provider must enter
revenue code 0001 instead in FL 42. Thus, the adjacent charges entry in FL 47 is the sum
of charges billed. This is the same line on which non-covered charges, in FL 48, if any,
are summed. To assist in bill review, the provider must list revenue codes in ascending
numeric sequence and not repeat on the same bill to the extent possible. To limit the
number of line items on each bill, it should sum revenue codes at the “zero” level to the
extent possible.
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.
75.5 - Form Locators 43-65
(Rev. 12423; Issued: 12-20-23; Effective: 01-01-24; Implementation: 01-02-24)
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.
75.6 - Form Locators 66-81
(Rev. 3435, Issued: 12-31-15, Effective: 07-01-15, Implementation: 03-31-16)
FL 66 – Diagnosis and Procedure code Qualifier (ICD Version Indicator)
Required. The qualifier that denotes the version of International Classification of Diseases
(ICD) reported. The following qualifier codes reflect the edition portion of the ICD: 9 -
Ninth Revision, 0 - Tenth Revision.

FL 67 - Principal Diagnosis Code
Required. The hospital enters the ICD code for the principal diagnosis. The code must be
the full ICD diagnosis code, including all five digits where applicable for ICD-9 or all seven
digits for ICD-10. The reporting of the decimal between the third and fourth digit is
unnecessary because it is implied.
The principal diagnosis code will include the use of “V” codes where ICD-9-CM is
applicable. Where the proper code has fewer than five digits (ICD-9-CM) or seven digits
(ICD-10-CM), the hospital may not fill with zeros. The principal diagnosis is the condition
established after study to be chiefly responsible for this admission. Even though another
diagnosis may be more severe than the principal diagnosis, the hospital enters the principal
diagnosis. Entering any other diagnosis may result in incorrect assignment of a Diagnosis
Related Group (DRG) and cause the hospital to be incorrectly paid under PPS. The hospital
reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient
services in FL 67 of the bill. It reports the diagnosis to its highest degree of certainty. For
instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g.,
cough) for which a definitive diagnosis is not made, the symptom must be reported. If during
the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g.,
acute bronchitis), the hospital must report the definitive diagnosis. When a patient arrives at
the hospital for examination or testing without a referring diagnosis and cannot provide a
complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons
Without Reported Diagnosis Encountered During Examination and Investigation of
Individuals and Populations.
FLs 67A-67Q - Other Diagnosis Codes
Situational. Required when other condition(s) coexist or develop(s) subsequently during the
patient’s treatment.
FL 68 – Reserved
Not used. Data entered will be ignored.
FL 69 - Admitting Diagnosis
Required. For inpatient hospital claims subject to QIO review, the admitting diagnosis is
required. Admitting diagnosis is the condition identified by the physician at the time of the
patient’s admission requiring hospitalization.
FL70A – 70C - Patient’s Reason for Visit
Situational. It is required for Medicare institutional claims processing on Type of Bill
013x and 085x when: a) Form Locator 14 (Priority (Type) of Admission or Visit) codes
1, 2, or 5 are reported; and b) Revenue Codes 045x, 0516, or 0762 are reported. The
requirement for reporting Patient’s Reason for Visit is restricted to the outpatient bill
types above.

If the Patient’s Reason for Visit is not required, it may be reported on other 013x and
085x bill types that fail to meet the criteria in a) or b) above at the sender’s discretion
when this information substantiates the medical necessity of services.
FL71 – Prospective Payment System (PPS) Code
Not used. Data entered will be ignored.
FL72 - External Cause of Injury (ECI) Codes
Not used. Data entered will be ignored.
FL 73 – Reserved
Not used. Data entered will be ignored.
FL 74 - Principal Procedure Code and Date
Situational. Required on inpatient claims when a procedure was performed. Not used on
outpatient claims.
FL 74A – 74E - Other Procedure Codes and Dates
Situational. Required on inpatient claims when additional procedures must be reported. Not
used on outpatient claims.
FL 75 – Reserved
Not used. Data entered will be ignored.
FL 76 - Attending Provider Name and Identifiers (including NPI)
Situational. Required when claim/encounter contains any services other than nonscheduled
transportation services. If not required, do not send. The attending provider is the individual
who has overall responsibility for the patient’s medical care and treatment reported in this
claim/ encounter.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 – Provider Commercial Number
FL 77 - Operating Provider Name and Identifiers (including NPI)

Situational. Required when a surgical procedure code is listed on this claim. If not required,
do not send. The name and identification number of the individual with the primary
responsibility for performing the surgical procedure(s).
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 – Provider Commercial Number
FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)
Situational. The name and ID number of the individual corresponding to the qualifier
category indicated in this section of the claim.
Provider Type Qualifier Codes/Definition/Situational Usage Notes:
DN - Referring Provider. The provider who sends the patient to another provider for services.
Required on an outpatient claim when the Referring Provider is different than the Attending
Physician. If not required, do not send.
ZZ - Other Operating Physician. An individual performing a secondary surgical procedure or
assisting the Operating Physician. Required when another Operating Physician is involved.
If not required, do not send.
82 - Rendering Provider. The health care professional who delivers or completes a particular
medical service or non-surgical procedure. Report when state or federal regulatory
requirements call for a combined claim, i.e., a claim that includes both facility and
professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim).
If not required, do not send.
Secondary Identifier Qualifiers:
0B - State License Number
1G - Provider UPIN Number
G2 – Provider Commercial Number
FL 80 – Remarks
Situational. For DME billings the provider shows the rental rate, cost, and anticipated
months of usage so that the provider’s A/B MAC (A or HHH) may determine whether to
approve the rental or purchase of the equipment. Where Medicare is not the primary payer
because WC, automobile medical, no-fault, liability insurer or an EGHP is primary, the
provider enters special annotations. In addition, the provider enters any remarks needed to
provide information that is not shown elsewhere on the bill but which is necessary for proper

payment. For Renal Dialysis Facilities, the provider enters the first month of the 30-month
period during which Medicare benefits are secondary to benefits payable under an EGHP.
(See Occurrence Code 33.)
FL 81 - Code-Code Field
Situational. To report additional codes related to a Form Locator or to report external code
list approved by the NUBC for inclusion to the institutional data set.
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.
80 – Reserved

Transmittals Issued for this Chapter
Rev # 	Issue Date Subject 	Impl Date CR#
R12423CP 12/20/2023 Enforcing Billing Requirements for
Intensive Outpatient Program (IOP)
Services with New Condition Code 92
01/02/2024 13222
R10880CP 08/06/2021 Internet Only Manual Updates to Pub. 100-
01, 100-02, and 100-04 to Implement
Consolidated Appropriations Act Changes
and Correct Errors and Omissions (SNF)
11/08/2021 12009
R4194CP 	01/11/2019 Update to Publication (Pub.) 100-04
Chapter 25 to Provide Language-Only
Changes for the New Medicare Card Project
02/12/2019 11091
R3709CP 	02/03/2017 Internet Only Manual (IOM) Chapter 25
Revision
04/04/2017 9964
R3435CP 	12/31/2015 Clarification on Patient’s Reason for Visit
Necessary to Capture HIPAA Compliant
Fields
03/31/2016 9450
R2922CP 	04/03/2014 Medicare Claims Processing Pub. 100-04
Chapter 25 Update
04/18/2014 8577
R2874CP 	02/06/2014 Medicare Claims Processing Pub. 100-04
Chapter 25 Update – Rescinded and
replaced by Transmittal 2922
03/07/2014 8577
R2683CP 	04/05/2013 Non-systems Internet Only Manual (IOM)
Changes
06/05/2013 8220
R2250CP 	07/01/2011 Non-systems Internet Only Manual (IOM)
Changes
08/01/2011 7437
R1973CP 	05/21/2010 Internet Only Manual (IOM) Chapter 25
Revisions
09/01/2010 6907
R1946CP 	04/15/2010 Billing and Processing Claims with
Unlimited Occurrence Span Codes (OSCs)
07/06/2010 6777

Rev # 	Issue Date Subject 	Impl Date CR#
R1934CP 	03/19/2010 Billing and Processing Claims with
Unlimited Occurrence Span Codes (OSCs)
– Rescinded and replaced by Transmittal
1946
07/06/2010 6777
R1932CP 	03/17/2010 Dialysis Adequacy, Infection and Vascular
Access Reporting
07/06/2010 6782
R1929CP 	03/09/2010 Point of Origin for Admission or Visit
Codes Update to the UB-04 (CMS-1450)
Manual Code List
07/06/2010 6801
1917CP 	02/05/2010 Point of Origin for Admission or Visit
Codes Update to the UB-04 (CMS-1450)
Manual Code List - Rescinded and replaced
by Transmittal 1929
07/06/2010 6801
R1915CP 	02/05/2010 Non-systems Internet Only Manual Chapter
25 Changes
04/14/2010 6788
R1898CP 	01/29/2010 Dialysis Adequacy, Infection and Vascular
Access Reporting - Rescinded and replaced
by Transmittal 1932
07/06/2010 6782
R1877CP 	12/18/2009 Instructions Regarding Processing Claims
Rejecting for Gender/Procedure Conflict
04/05/2010 6638
R1839CP 	10/28/2009 Instructions Regarding Processing Claims
Rejecting for Gender/Procedure Conflict -
Rescinded and replaced by Transmittal
1877
04/05/2010 6638
R1775CP 	07/24/2009 Point of Origin Codes Update to the UB-04
(CMS-1450) Manual Code List
01/04/2010 6478
R1767CP 	07/10/2009 IOM Chapter 25 Revenue Code 076X
Description Change
08/10/2009 6561
R1718CP 	04/24/2009 New Patient Discharge Status Code 21 to
Define Discharges or Transfers to
Court/Law Enforcement
10/05/2009 6385

Rev # 	Issue Date Subject 	Impl Date CR#
R1555CP 	07/18/2008 Revision of the Requirements for Denial of
Payment for New Admissions (DPNA) for
Skilled Nursing Facility (SNF) Billing
01/05/2009 6116
R1496CP 	05/02/2008 Medicare Shared Systems Modifications
Necessary to Capture and Crossover
Medicaid Drug Rebate Data Submitted on
form UB-04 Paper Claims and Direct Data
Entry (DDE) Claims
10/06/2008 5950
R1395CP 	12/14/2007 Updated National Uniform Billing
Committee (NUBC) Codes and Other
Internet Only Manual Chapter 25 Revisions
01/07/2008 5850
R1361CP 	11/02/2007 New Patient Status Discharge Code 70 to
Define Discharges or Transfers to Other
Types of Health Care Institutions not
Defined Elsewhere in the UB-04 (CMS-
1450) Manual Code List
04/07/2008 5764
R1254CP 	05/25/2007 National Uniform Billing Committee
(NUBC) Update to Chapter 25
06/11/2007 5593
R1104CP 	11/03/2006 Uniform Billing (UB-04) Implementation 	03/01/2007 5072
R1078CP 	10/13/2006 Updating the Medicare Secondary Payer
(MSP) Manual for Consistency on
Instructing Part A Contactors on Handling
MSP Claims with Condition Code (cc) 08
04/02/2007 5266
R1018CP 	07/28/2006 Uniform Billing (UB-04) Implementation 	03/01/2007 5072
R980CP 	06/14/2006 Changes Conforming to CR 3648
Instructions for Therapy Services - Replaces
Rev. 941
10/02/2006 4014
R941CP 	05/05/2006 Changes Conforming to CR 3648
Instructions for Therapy Services
10/02/2006 4014

Rev # 	Issue Date Subject 	Impl Date CR#
R901CP 	04/07/2006 New National Uniform Billing Committee
(NUBC) Codes and Other Chapter 25
Revisions
05/08/2006 4384
R529CP 	04/22/2005 Update to Current National Uniform Billing
Committee (NUBC) Codes.
07/05/2005 3794
R493CP 	03/04/2005 Revision to Chapter 1 and Removal of
Section 70 from Chapter 25 of the Medicare
Claims Processing Manual
04/04/2005 3671
R368CP 	11/12/2004 Instructions for Completion of Form CMS-
1450
04/04/2005 3543
R311CP 	10/08/2004 Relocation of Sections 20 and 30 to Chapter
24
Clarification of Noncovered Days, Patient
Status Codes and Revenue Codes
New Condition Codes and Value Codes
1/5/2005 	3417
R303CP 	09/24/2004 Relocation of Sections 20 and 30 to Chapter
24
Clarification of Noncovered Days, Patient
Status Codes and Revenue Codes
New Condition Codes and Value Codes
01/05/2005 3417
R199CP 	06/10/2004 Rejection of Any Outpatient Claim
Containing a Range of Dates in the Line
Item Date of Service (LIDOS) Field
10/04/2004 3337
R167CP 	4/30/2004 Replacement of Revenue Code 0910 by
Revenue Code 0900 to Report Certain
Psychiatric/ Psychological Treatment and
Services.
Addition of Provider Range 4900-4999 to
the Applicable Provider Ranges for
Community Mental Health Centers
10/04/2004 3194

Rev # 	Issue Date Subject 	Impl Date CR#
R149CP 	04/23/2004 Update for New Condition Code, and to
Clarify Patient Status Codes and Revenue
Code 0910
10/04/2004 3183
R107CP 	02/24/2004 Changes in X12N937 Institutional Edits 	07/06/2004 3031
R081CP 	02/06/2004 New Condition and Value Codes Approved
by the National Uniform Billing Committee
(NUBC) and Addition of All NUBC
Approved Codes that Were Not Previously
in Medicare Instructions, to Be Complaint
With the HIPAA Requirements
07/06/2004 3012
R001CP 	10/01/2003 Initial Publication of Manual 	NA 	NA
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