Adding elements on the UB04 form

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UB04 / HCFA 1450 Boxes and Where Information is Pulled
DrChrono will pull data from a patient’s chart to populate the UB04/HCFA 1450 form. The following is a guide identifying which fields the data will be pulled from. Box 1 - Billing Provider Name, Street Address, City, State, Zip, Tel...
UB04 Box 2 - How Do I Use an Alternative Pay to Address on an institutional claim?
If you want to add an alternative pay-to-address or lockbox (P.O. Box) address in box 2 on the UB04 Form, follow the steps outlined below: 1. Hover your cursor on the Account tab and select Offices . 2. Click on the E...
UB04 Box 3A - Patient Control Number on an institutional claim
Within box 3A of the UB04 form, DrChrono will print a patient control number that will follow the patient throughout their history with your practice. It is similar to the chart ID number (example: AABB000001) in that once assigned to a patient, it...
UB04 Box 4 - Type of Bill on an institutional claim
On an institutional claim, a 4-digit code in box 4 identifies the type of facility and type of care, and the frequency code is generated based on parameters set under the office settings and attached to a patient's claim. Facility Level ...
UB04 Box 6 - Start/End Care Dates on an institutional claim
When billing institutional care, the start/end dates of care included on that billing statement must appear in box 6 of the UB04 claim form. In DrChrono, it is easy to enter/update this information from within the patient claim in the Live Claim...
UB04 Boxes 12-13 - Adding an admission date and hour to an institutional claim form
DrChrono makes it easy to add an admission date and hour to your patient's claim. It can be done right within the patient's encounter. Navigate to Billing > Live Claims Feed > Inside the patient's appointment > Right column > Info tab ...
UB04 Box 14 - How to add type of admission to an institutional claim
Box 14 of the UB04 institutional claim form requires a description of the patient's type of admission. You can quickly add this information via the patient's encounter under your Live Claims Feed. Navigate to Billing > Live Claims Feed ...
UB04 Box 15 - What is a Point of Origin Code and how do I include it on an institutional claim?
A point of origin code discloses to the payer the source or method of the patient's referral for admission. The point of origin code is similar to a "place of service" code on a professional claim/HCFA-1500 form. To add it to an institutiona...
UB04 Box 16 - How to add a discharge hour to an institutional claim
DrChrono makes it easy to add the discharge hour to your patient's claim. It can be done right within the patient's encounter. Navigate to Billing > Live Claims Feed > Inside the patient's appointment > Right column > Info tab ...
UB04 Box 17 - How to add a patient's discharge status to an institutional claim
DrChrono makes it simple to add the patient's discharge status to their institutional claim which will be printed in box 17 on the UB04 institutional claim form and transmitted on the EDI file. Navigate to Billing > Live Claims Feed > Insid...
UB04 Boxes 18-28 - What is a condition code and how do I enter them on an institutional claim?
Condition codes are a 2-digit numerical or alphanumeric representation of aspects of a patient, services provided, the type of service venue, and/or billing situations that can impact the processing of an institutional claim by a payer. These co...
UB04 Box 26 - Utilizing a claim ID from a claim form
Each patient appointment within DrChrono will be assigned a unique claim ID number automatically. This number will be transmitted to the payer with each submitted claim. On the HCFA-1500 form , it will print in box 26 under the label "Pati...
UB04 Boxes 31-34 - What are occurrence codes and how do I add them to an institutional claim?
Occurrence codes and their respective dates disclose the payer-specific event(s) related to the billing period on the UB04. They are located in boxes 31-36 on the UB04. To view and enter them into your patient's...
UB04 Boxes 39 - 41 - What is a value code and why is it needed on my institutional claim?
Value codes are required on an institutional claim to identify data elements such as: Medicare lifetime reserve days, no-fault payments, and the number of days not covered by the primary payer. They can be easily added to the U...
UB04 Box 42 - Adding revenue codes to an institutional claim
As you build your institutional claim for services rendered, you will need to add revenue codes to each charge line. This will combine charges by category. Revenue codes can be added first to your fee schedule, and then to each patient enc...
UB04 Box 52 - Notating a signed release or informed consent on an institutional claim
On your institutional claim, you will need to note that you either have (Y) a signed statement on file from the patient permitting a data release or (I) have informed consent to release medical information. DrChrono makes it easy to note both ...
UB04 Box 53 - Noting an Assignment of Benefits on an institutional claim
On your institutional claim, you will need to notate that you either have (Y) a signed assignment of benefits from the patient permitting direct payment from the payer to the provider, (N) if there is no signed assignment of benefits on file whi...
UB04 Box 66 - Procedure Code Qualifier
On both professional and institutional claims, the billing provider must disclose whether ICD-9 or ICD-10 codes are being utilized. Since October 1, 2015 claims have been required to use ICD-10 coding. DrChrono will automatically print procedu...
UB04 Box 67 - How to add diagnosis codes to a patient's institutional claim
There are a few ways in DrChrono to add diagnosis codes to a patient's claim. Which one is best depends on where you are in the system and what fits better in your workflow. Adding directly to the appointment Navigate to Billing > Live ...
UB04 Box 69 - Where do I add the admitting diagnosis on an institutional claim?
The patient's admitting diagnosis must be printed in box 69 on the UB04 institutional claim form. DrChrono makes it easy to add to your patient's claim. Navigate to Billing > Live Claims Feed > inside patient's appointment > Line items transa...
UB04 Box 70 - When do I need to use a Patient Reason for Visit Code?
Patient reason for visit codes is required on institutional claims when the Type of Bill is 013X (hospital outpatient) and 085X (Critical Access Hospital) when the type of visit codes are 1, 2, or 5 and revenue codes 045X, 0516, or 0762 are billed. ...
UB04 Box 74 - Where do I add the Principal Procedure Code for an institutional claim?
For inpatient claims where a procedure was performed, the claim must include the procedure code(s) and dates on which they were performed. This field is not currently required on outpatient claims. Be sure to check t he Medicare Claims Processing ...
UB04 Boxes 76 - 79 - Where do I add attending, operating, and consulting provider information on an institutional claim?
Providers involved in a patient's institutional care can quickly, and easily be added to the claim. Adding these providers to your contacts will make the process of adding them to any claim that much faster. Navigate to Billing > Live Claim...
UB04 Box 80 - Can I add free-text remarks on an institutional claim?
Yes! You can add any information that the payer may need when adjudicating the claim can be added to appear in box 80 on the UB04 form. Navigate to Billing > Live Claims Feed > Inside patient's appointment > Info tab If you need additio...