Updating Institutional UB-04 Claim Forms (Box 1-81)

Box 1 - Billing Provider, Address, Phone Number

Box 2 - Pay-To Name and Address

Box 3a - Patient Control Number

Box 3b - Medical Record Number

Box 4 - Type of Bill

Box 5 - Federal Tax ID

Box 6 - Statement Covers Period

Box 7 - Reserved for Assignment by the NUBC

Box 8a, 8b - Patient Identifier and Patient Name

Boxes 9a, 9b, 9c, 9d, 9e - Patient Address

Box 10 - Patient Birth Date

Box 11 - Patient Sex

Box 12 - Admission/Start of Care Date

Box 13 - Admission Hour

Box 14 - Admission Type

Box 15 - Admission Source

Box 16 - Discharge Hour (DHR)

Box 17 - Patient Discharge Status

Box 18-28 - Condition Codes

Box 29 - Accident State

Box 30 - Reserved for Assignment by the NUBC

Box 31-34 Occurrence Code/Date

Box 35 and 36 - Occurrence Span Code/Date

Box 37 - Reserved for Assignment by the NUBC

Box 38 - Responsible Party Name and Address

Box 39-41 - Value Code/Amount

Box 42 - Revenue Code

Box 43 - Revenue Code Description

Box 44 - HCPCS/Rate/HIPPS Code

Box 45 - Service Date

Box 46 - Service Units

Box 47 - Total Charges

Box 48 - Non-Covered Charges

Box 49 - Reserved for Assignment by the NUBC

Box 50a, 50b, 50c - Payer Name

Box 51a, 51b, 51c - Health Plan ID

Box 52a, 52b, 52c - Release of Information

Box 53a, 53b, 53c - Assignment of Benefits Certification indicator

Box 54a, 54b, 54c - Prior Payments

Box 55a, 55b, 55c - Estimated Amount Due

Box 56 - Billing Provider NPI

Box 57 - Other Provider ID

Box 58a, 58b, 58c - Insured's Name

Box 59a, 59b, 59c - Patient Relationship to Insured

Box 60a, 60b, 60c - Insured's Unique ID

Box 61a, 61b, 61c - Group Name

Box 62a, 62b, 62c - Insurance Group Number

Box 63a, 63b, 63c - Treatment Authorization Codes

Box 64a, 64b, 64c - Document Control Number

Box 65a, 65b, 65c - Employer Name

Box 66 - Diagnosis and Procedure Code Qualifier

Box 67a-q - ICD-10 Diagnosis Codes

Box 68 - Reserved for Assignment by the NUBC

Box 69 - Admitting Diagnosis Code

Box 70a-c - Patient Reason DX

Box 71 - PPS Code

Box 72 - External Cause of Injury (ECI) Code

Box 73 - Reserved for Assignment by the NUBC

Box 74 - Principal Procedure Code and Date

Box 74a-e - Other Procedure Information

Box 75 - Reserved for Assignment by the NUBC

Box 76 - Attending Provider Name and Identifiers

Box 77 - Operating Physician Name, Secondary ID, Last Name, First Name

Box 78 - Other Provider Names and Identifiers

Box 79 - Other provider NPI, ID, qualifiers, and last and first name

Box 80 - Remarks

Box 81CCa-d, Taxonomy Code and Qualifier