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UB-04 claim form and instructions The Office of Management and Budget and the National Uniform Billing Committee have approved the Provider Identifier NPI and has incorporated other important changes. UB-04 CMS-1450 National Uni form 1G 1 2 3 4 5 6 9 8 2 2 D av i d QUAL FI RST NUBC 2222222222 I 65 EMPL OYER CONTR OL NUMBER 491234 69 ADMIT 70 PATIENT REASON DX PRINCI PAL P R OCEDURE a. c. 02468 G R OUP NO. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and 4....
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Hey everyone for this week's activity we're going to be completing the CMS 1500 and the UP for claims forms, so you have the information that you need listed in the activities and there's also a document that I added under the handouts tab that has the patient data table in the provider data table located — handouts'ts portal of unit 10, so I'm not going to completely fill out all the information on the two forms that we're completing, but I do at least want to get you started so if you take a look at the UP for one of our first examples is with Abby Addison so essentially all the different data fields on the before in the CMS 1500 have specific information entered into each of these you can find more information about what is entered into each and every field in these step-by-step directions for completing there are tips for completing the CMS 1500 form and also completing the HBO for claims form found under handouts as well so back to the HBO for I have an area here in section 8 sections 1 in looking at those tips for completing the two claims forms you'll see that the prime provide as information is completed here we have room for the patient's medical record number in field 3b looking at our information we see that Abby's medical record number is listed so in our tips for completing one of the CMS rules for completing both the HBO for in the CMS 1500 form is that you have to use all cap so make sure your all caps button is on your computer, and you can enter Abby's medical record number into field 3b patient name is completed in field eight a patient address you'll find that in the patient data table as well as the birthdate we know that Abby is a female we do have the admission date as March 7th, so that information will be entered into field 12 condition codes you'll find them from more information about the condition codes in the step-by-step directions so take a look at those we don't have all the information available to completely fill out this form to 100% accuracy, so I'm not expecting to have this form and every single field completed with all the information because you just don't have it so do the best that you can our line items start under descriptions in our first line item 4a d a B is room in board, so I'm typing that in we have our service dates which is the date of the encounter our information gives us the total cost for those services so as you can see I'm just abstracting the information from the instructions for completing the exercise, and I'm filling in the appropriate fields for the CMS 1500 form essentially you're doing the same thing you'll have the patient's health insurance information listed under the patient data table, so you can abstract and check off which type of insurance the example that you're using again on the CMS 1500 form the first one is a B Addison, so I'm going to use that as my example as well patients name we're going to list the last name first on this particular form patient's date of birth so...