Wednesday, July 13, 2016

UB 04 - Condition code, occurence code and date fields

FLs 18 thru 28. Condition Codes.

a. Each code is two numeric digits.
b. If code 07 is entered, type of bill must not be hospice 81X or 82X.
c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.
d. If code 40 is entered, the “From” and “Through” dates in FL 6 must be equal, and there must be a “0” or “1” in FL 7 (Covered Days).
e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.


FLs 31, 32, 33, and 34. Occurrence Codes and Dates

a. All dates must be valid.
b. Each code must be accompanied by a date.
c. All codes are two alphanumeric positions.
d. If code 20 or 26 is entered, the type of bill must be 11X or 41X. If code 21 or 22 is entered, the type of bill must be 18X or 21X.
e. If code 27 is entered, the type of bill must be 81X or 82X.
f. If code 28 is entered, the first digit in FL 4 must be a “7” and the second digit a “5.”
g. If code 42 is entered, the first digit in FL 4 must be “8” and the second digit “1” or “2” and the third digit “1 or 4.”
h. If 01 - 04 is entered, Medicare cannot be the primary payer, i.e., Medicare-related entries cannot appear on the “A” lines of FLs 58-62.
i. If code 20 is entered:
• Must not be earlier than “Admission” date (FL 17) or later than “Through” date (FL 6).
• Must be less than 13 days after the admission date (FL 17) if “From” date is equal to admission date (less than 14 days if billing dates cover the period December 24 through January 2).
j. If code 21 is entered:
• Cannot be later than “Statement Covers Period” Through date; or
• Cannot be more than 3 days prior to the “Statement Covers Period” From date.
k. If code 22 is entered, the date must be within the billing period shown in FL 6.

Simple rule: include the onset/occurrence date

Blue Cross and Blue Shield of Texas (BCBSTX) asks that you routinely include the Date of Current Illness or Occurrence Code and the associated date in your claim submissions. This will help eliminate the need to contact Customer Service when a claim denies unexpectedly needing this information. When submitting the CMS-1500, enter the Date of Current Illness (also known as the onset date) into Box 14 to indicate the first date of the symptom, illness, accident or injury, or last menstrual period (LMP) for pregnancy. If the patient has had the same or similar illness, enter the first date into Box 15. When submitting the UB-04, enter the Occurrence Code and associated date in fields 31-36; this


defines a significant event related to the claim. The most commonly recognized Occurrence Codes by

BCBSTX are listed below:

Occurrence Code Definition
01 Auto Accident

04 Accident – Employment Related

05 Other Accident

10 Last Menstrual Period (LMP)

11 Onset of Symptom/Illness

33 First Day of Medicare Coordination Period for
End Stage Renal Disease (ESRD)


Remember that the first date of service is not always the onset/occurrence date. Claims may process differently depending on what date is entered. Be sure that you are entering the actual date on all claims.


FL 35 and 36. Occurrence Span Codes and Dates

a. Dates must be valid.
b. Code entry is two alphanumeric positions.
c. Code must be accompanied by dates.
d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.
e. If code 71 is entered, the first digit of FL 4 must be “1,” “2,” or “4” and the second digit must be “1.”
f. If code 72 is entered, the type of bill must be 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, or 85X.
g. If code 74 is entered, the type of bill must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 74X, 75X, 81X, or 82X.
h. If code 75 is entered, the first digit of FL 4 must be “1” or “4” and the second digit must be “1.”
i. If code 76 is entered, occurrence code 31 must be present (inpatient only).
j. If code 76 is entered, occurrence code 32 must be present (outpatient only).
k. If code 76, 77, or M1 is present, the bill type must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 73X, 74X, 75X, 81X, 82X, or 85X.
l. Neither the “From” nor the “Through” portion can exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions of each field.
m. If code M2 is present, the bill type must be 81X or 82X.
n. Code 79 is for payer use only. Providers do not report this code.

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