UB-04 Field Definitions
The following locators and definitions are available for UB-04 Form:
Form Locator 1
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Prints:
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Agency name and address
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Source:
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Administration > Configuration > BusinessUnits
Agency Name: Basic tab
Agency Address: Address tab
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Other:
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By default, the application prints ZIP codes as 9-digit numbers, unless the Print ZIP Codes in 5-digit format print variation is selected.
If an electronic billing format is enabled for Multiple Billing Address, then for the insurance code, Allscripts Homecare follows the rules established by the agency for Multiple Billing Address.
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Form Locator 2 - Box 2 (Lines 1 through 4)
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Prints:
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This field is blank unless it is completed in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 3a - Patient Control No
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Prints:
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Patient identification number
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Source:
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Patient > General > Basic
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Form Locator 3b - Medical Record No
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Prints:
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This field is blank unless it is completed in Claim Constants.
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Source:
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Patient > General > ClaimConstants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 4 - Type of Bill
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Prints:
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This field contains the appropriate three-letter alphanumeric code based on the bill type rules.
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Source:
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The type of bill is based on settings and information defined in the following locations:
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>
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Administration > Financial > Insurance Codes > Mode setting
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>
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Administration > Configuration > Business Units > Settings > Basic tab > Administration > Hospital-Based setting
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>
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Administration > General > Patient Status Codes
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>
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Patient > General > Admissions & Status > patient status code
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Other:
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If the InsuranceCodes > Mode setting is set to B, the first characters is 8; if Mode is R or P, it is 3. If the Hospital-Based setting is enabled, the second character is 2.
The third character is based on the status of the patient and the type of bill. The system prints 1, 2, 3, 4, 5, 7, 8, 2, or 9 as noted by the following scenarios:
1: Patient is admitted and discharged during this billing period.
2: Patient is admitted during this billing period and remains on service.
3: Patient is admitted during a previous billing period and remains on service.
4: Patient is admitted during a previous billing period and discharged during this billing period.
5: Late claim
7: Replacement claim
8: Voided claim
2: PPS RAP claim
9: PPS Final claim
You can override these values in one of the following locations:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 5 - Federal Tax ID
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Prints:
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By default, line 1 is blank, and line 2 prints the federal tax ID number.
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Source:
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Administration > Configuration > BusinessUnits > Teams and Legal Entities tab.
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Form Locator 6 Statement Covers Period
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Prints:
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The beginning and ending dates of the period
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Source:
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Print variations as defined in Administration > Financial > InsuranceCodes
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Other:
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Print Variations include the following options:
- Use the first and last Dates of Service
- Suppress printing of From/Through date
- Print NOEs with From date and Through date equal date of NOE
- Print NOEs with From but no Through date.
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Form Locator 7 - Box 7 (Lines 1 and 2)
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Prints:
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This box is blank unless it is completed in Claim Constants.
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Source:
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>
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Administration > General > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 8 - Patient Name
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Prints:
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Patient's last, first, and middle names with no punctuation
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Source:
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Patient > General > Basic
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Other:
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The following print variations are available in Administration > Financial > Insurance Codes or Insurance Companies > Plans:
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>
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Print the middle initial only – Prints the middle initial instead of the middle name, for example, "John Smith A."
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>
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Print the first name first (no commas between first, last, and middle names) – For example, "John Smith Adam Jr."
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>
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Include suffix in the name– Prints the patient suffix at the end of the name record, for example, "Smith, John Adam Jr."
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>
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Suppress printing middle name– Prints the first and last name only, for example, "Smith, John."
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Form Locator 9 - Patient Address
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Prints:
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Patient's address
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Source:
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Patient > General > Basic
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Other:
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Line a prints the patient's street/suite information. Line b prints the patient's city. Line c prints the patient's state. Line d prints the patient's ZIP code. By default, line e prints blank.
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Form Locator 10 - Birthdate
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Prints:
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Patient's date of birth in MMDDYYYY format
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Source:
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Patient > General > Basic
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Form Locator 11 - Sex
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Prints:
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Patient's gender
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Source:
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Patient > General > Basic > Sex field
You can select Female, Male, or Unknown.
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Form Locator 12 - Admission Date
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Prints:
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Patient's admission date
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Source:
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Patient > General > Admissions & Status
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Other:
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If the Generate New Orders and SOC Date setting (in Administration > Financial > Insurance Codes) is enabled, the system uses the payer effective date within the SOC date field on the claim.
To print the initial service date instead of the admission date, select the Print first service date instead of Admit Date print variation.
If a patient wants to revoke or terminate hospice care, enter the start date of the hospice period in which the discharge occurs.
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Form Locator 14 - Admission Type
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Prints:
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This field is blank unless it is completed in Claim Constants or print variations.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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>
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Administration > Financial > Insurance Codes
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>
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Administration > Financial > Insurance Companies
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Other:
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The admission type 3 prints based on the Print '3' and '1' Admission Type/Src print variation. You can override the print variation in one of the following locations:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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>
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Claims > Process > Annotate Claims
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 15 - Admission Source
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Prints:
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This field is blank unless it is completed in Claim Constants or print variations.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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>
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Administration > Financial > Insurance Codes
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>
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Administration > Financial > Insurance Companies
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Other:
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The admission source 1 prints based on the Print '3' and '1' Admission Type/Src print variation. You can override the print variation in one of the following locations:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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>
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Claims > Process > Annotate Claims
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 16 - Discharge Time
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Prints:
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This field is blank unless it is completed in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 17 - Patient Status
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Prints:
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This field reflects the patient status as of the THROUGH date on the claim, for example Discharged, deceased or active.
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Source:
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The status code associated with the patient in Patient > General > Admissions & Status.
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Other:
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If the patient status code is type D and the billing mode of the payer (in Administration > Financial > Insurance Codes) is R or P, this field prints with a value of 20. If the billing mode of the payer is B or H and the patient died in a facility, the value is 41.
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If the patient status code is type F and the primary payer source is Medicare Benefit, this field prints with a value of 01.
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If the patient status code is anything other than D or F, this field prints with a value of 30.
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You can define overrides in the Special Bill Type field within Patient Status Codes.
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Form Locators 18 through 28 - Condition Code
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Prints:
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This field is blank unless it is completed in Claim Constants or Annotate Claims.
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Source:
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>
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Patient > General > Claim Constants
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>
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Administration > Financial > Claim Constants
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>
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Claims > Process > Annotate Claims
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Other:
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Claim Constants defined in the Patient component override Claim Constants defined within the Administration component.
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Form Locator 29 - ACDT State
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Prints:
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This field is blank.
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Form Locator 30 - Box 30 (Lines 1 and 2)
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Prints:
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This field is blank.
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Form Locator 31a-b through 34a-b - Occurrence Code/Date
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Prints:
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Occurrence code and date as determined by print variations.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Claims > Process > Annotate Claims
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Other:
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The 27 occurrence code prints for the following print variations:
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Print '27' occurrence code with admit date
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Print '27' occurrence code with most recent recert date
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Print '27' occurrence code + recert date when 'included' in claim/NOE
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The 42 occurrence code prints for the following print variations:
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'42' occurrence date - last billable day
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'42' occurrence code for home health discharges
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Do not print '42' occurrence for transfer-out (hospice patients)
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'42' occurrence only for revocations (hospice patients) – Prints 42 only if the Revocation check box is selected in Administration > General > Patient Status Codes > Discharge Type for the patient status code.
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The 42 occurrence code is not printed when:
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>
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The 52 condition code is present in FL 18–28 and the Do not report occurrence code 42 when condition code 52 is present print variation is selected. The 52 condition code prints in FL 18–28 if it was defined in the Claim Constants window at the appropriate level or in Claims > Process > Annotate Claims.
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>
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A patient is discharged with the status code that has the No Longer Terminally Ill check box selected in Administration > General > Patient Status Codes and the Do not print occurrence code '42' for no longer terminally ill discharges print variation is selected.
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The 51 occurrence code prints if the Print '51' Occurrence Code and Status Date for Discharge and Death print variation is selected.
The 55 occurrence code and the patient's date of death with the D discharge status code (Death) prints if the Print Occurrence Code 55 with date of death print variation is selected.
The 61 occurrence code prints for home health overhead for the Indiana state services.
You can override these print variations in the following locations:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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>
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Claims > Process > Annotate Claims
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
Claim constants defined within the Patient component override claim constants defined within the Administration component.
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Form Locator 35 through 36 - Occurrence Span Code/Date
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Prints:
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Occurrence span code and date as determined by print variations
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Administration > Financial > Insurance Companies > Plans > Print Variations
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Other:
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The X0 occurrence span code prints if the Print 'X0' occurrence span code with most recent cert/recert from/to date print variation is selected.
The M2 occurrence span code prints for the following print variations:
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Print 'M2' occurrence span code with from/through dates of Inpatient Respite Care
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Print 'M2' occurrence span code only when there are multiple occurrences of Respite Care provided in the Benefit Period – The M2 occurrence span code and the periods of inpatient respite care are printed if more than one period was spent in inpatient respite care.
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Form Locator 37a - Box 37a
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Prints:
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This field is blank unless it is completed in Claim Constants.
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Source:
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Patient > General > Claim Constants
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Other:
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Claim Constants defined in the Patient component override Claim Constants defined in the Administration component.
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Form Locator 37b - Box 37b
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Prints:
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This field is blank unless it is completed in Claim Constants.
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Source:
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Patient > General > ClaimConstants
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Other:
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Claim Constants defined in the Patient component override Claim Constants defined within the Administration component.
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Form Locator 38
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Prints:
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If the insurance code associated with the patient is Self-Pay, the Guarantor's name and address prints. If not, this field is blank.
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Source:
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The payer defined in the Insured/Alias field for the Self Pay pay source line (in Patient > General > Payers).
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Form Locator 39a-d through 41a-d - Value Code/Amount
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Prints:
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The locator is blank by default. Various codes and options can be printed depending on the print variations selected.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Administration > Financial > Insurance Companies > Plans > Print Variations
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Other:
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You can select the following print variations:
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Print '12' (age 65+) or '43' (<65) for CSP bills
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>
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Suppress Printing Value Code '44'
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>
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Print CBSA/MSA code in decimal format (XXXX.00 or XXXXX.00)
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Print CBSA/MSA code for non-Medicare claims
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>
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Print Value Code '61' for the Patient's Residence of Service CBSA code on non-Medicare Claims
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>
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Print Value Code 'G8' (Inpatient Acuities(General and Respite)) and/or 61 (Place of Residence (Routine and Continuous)) along with the associated CBSA code. (eff. for DOS of 1/1/2008 or greater)
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Print Value Code 'A2' with net amount for secondary coinsurance claim
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>
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Print Value Code '31' and the spend down amount based on Claim From Date
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Print Value Code '31' and the spend down amount based on Claim Thru Date
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Other (cont.):
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>
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Print Value Code '23' and the spend down amount instead of in revenue section (do not subtract from claim total)
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>
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Print Value Code 'FC' and the spend down amount when the hospice patient resides in a Nursing Home (do not subtract from claim total)
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>
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Print Value Code 'C3' and the Spend Down amount instead of in revenue section (do not subtract from claim total)
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Print Value Code 'X1' for Deductible Payer X, and 'X2' for Coinsurance Payer X, where X=A, B, or C depending on location in FL50
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>
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Print Value Code 'X3' for the estimated payer responsibility as total claim amount - other payer prior payment amount(s) where X=A, B, C depending on location in FL50
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This print variation automatically calculates the A2 or B2 value code amount for the B3 or C3 value code. Both sets of value codes are reported on hardcopy and electronically, if available. For 5010 claims, the A2, B2, and C2 value codes must be reported in the CAS segment.
Note: Incorrect results may occur on the electronic file if Allscripts Homecare was not notified that your payer requires this information.
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Print Value Code '80' with the number of days covered on the claim (Claim Through date - From Date + 1)
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Print Value Code '80' with the number of days covered on each separate claim (last date of service - first date of service + 1)
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Print Value Code '24' and the Total Charge Amount of the Claim
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NY Home Health: Print Value Code '24' and HIPAA: EDI Revenue Code
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Important: We recommend selecting this print variation only for the New York Home Health format.
The print variation prints each service on a separate page with the value code 24 and HIPAA EDI Revenue Code (taken from the HIPAA: EDI Rev Code column in Administration > Financial >Billing Rates > Other). If the HIPAA EDI Revenue Code is not defined, then the other value is taken in the following order:
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•
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CPT Code (defined in Administration > General > CPT Codes)
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•
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HCPCS Code (defined in the HCPCS/HIPPS Code column in Administration > Financial > Billing Rates > Rates)
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•
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Revenue Code (defined in the Revenue Code column in Administration > Financial > Billing Rates > Rates)
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>
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Print Value Codes 'FC' and '23' and the Spend Down amount
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Important: We recommend selecting this print variation only for the New York Home Health specialized format using the UB-04 form.
The print variation prints value codes 23 and FC with the Spend Down amount of the claim. If the Spend Down amount is not specified, nothing is printed.
The information for this locator can also be defined in Patient > General > Claim Constants or Administration > Financial Claim Constants. Claim constants defined within the Patient component override claim constants defined in the Administration component.
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Form Locator 42 - Revenue Code
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Prints:
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Revenue code
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Source:
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Administration > Financial > Billing Rates > Rates
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Other:
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You can select the following print variationse:
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>
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Print the revenue code for Physician Services on every line
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>
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Suppress printing of Revenue Code
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>
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NY Home Health: Print '0240' in the revenue section (if the print variation is not selected, Billing Rate revenue code is printed instead)
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Important: We recommend selecting this print variation only for the New York Home Health specialized formats.
It is selected by default for the New York Home Health specialized formats. If the print variation is selected, then 0240 is printed in FL 42 – Rev. Cd.; otherwise, the service revenue code is printed (taken from the Rev Code column in Administration > Financial > Billing Rates > Rates).
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Form Locator 43 - Description
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Prints:
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Description of the service charge being billed
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Source:
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Administration > Financial > BillingRates
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Other:
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The following print variations are available for this field:
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>
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Print the supply name from the supply code
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>
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Suppress printing a description
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>
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Suppressing printing page numbers on line 23
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Form Locator 44 - HCPCS/Rates
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Prints:
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HCPCS or CPT code defined for the payer
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Source:
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Administration > Financial > Billing Rates > Rates tab for HCPC codes or from the CPT code identified at the service level
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Other:
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CPT codes are associated with services in the Scheduling component, either in Transactions > General > TimeLog > CPT code or Transactions > General > Contract Invoices. For staff resources, associate a CPT code with a service in Administration > General > ResourceTypes > Use CPT Codes setting. For contract resources, associate a CPT code with a service in Administration > General > Service Codes/Contractor.
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Form Locator 45 - Service Date
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Prints:
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Date of service
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Source:
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>
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Transactions > General > TimeLog
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>
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Transactions > General > Contract Invoices
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>
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Transactions > General > Supplies
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If the Medicare Advantage: Print the first service date instead of certification start date for HIPPS details on FFS claims print variation is selected and the FFS - Include PPS HIPPS billing rule is enabled, the date of the first billable service is reported for that month's claim (instead of defaulting to the certification period start date).
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Form Locator 46 - Service Units
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Prints:
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Units as they relate to the service
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Source:
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Calculates the number of service units for the claim according to the value that is specified in the Basis field. Allscripts Homecare uses the values that are specified in Administration > Financial > Billing Rates, unless a value is specified in Patient > General > Negotiated Rates.
The number of units prints as three digits. If the number of units is a one-digit value, for example 4, this field prints with two zeros preceding the value, for example 004. If the number of units is 12, this field prints as 012.
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Other:
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To automatically fill a unit value, select one of the following print variations from the Fee-for-Service Claims section:
15-minute increment reporting
Even when the Basis field is set to V, this option calculates the total number of units, in 15-minute increments, based on the direct time of the visit for Medicare payers.
15-minute increment reporting (non-Medicare)
Even when the Basis field is set to V, this option calculates the total number of units, in 15-minute increments, based on the direct time of the visit for non-Medicare payers.
(Capital) Blue Cross Format for hourly billing
This option calculates the total number of hours, with a minimum of one hour.
Medicare Advantage: Print Unit Value of '1' for HIPPS Service Line
For payers that require a unit value of 1, this option prints 1.
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Form Locator 47 -Total Charges
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Prints:
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Gross amount of a service or supply
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Source:
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Gross Rate column in Administration > Financial > Billing Rates > Rates or Gross Rate or Net Rate column in Patient > General > Negotiated Rates
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Other:
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The Spend Down amount prints as a negative amount after the last revenue line if the Spend Down (From) is greater than $0.
The Spend Down is printed as a positive amount after the last revenue line if the Spend Down (To) is greater than $0.
This field also displays the sum of total charges on the last page of the claim. The decimal point is not printed. If the Max Lines setting is set to 21 or less in Administration > Financial > Insurance Codes > General, the system does not calculate the total for each page of the claim.
You can select the following print variations:
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>
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Print total line on line 22 in revenue section
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This print variation is available for all non-specialized formats and for the New York Home Health specialized format. It prints the total line 001 and amount in line 22 of the revenue section.
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Print net charges on the claim
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>
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Co-insurance only: print the gross charges for the primary payer
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>
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Co-insurance only: print the gross charges for this payer
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Form Locator 48 - Non-Covered Charges
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Prints:
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Non-covered dollar amount or blank
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Source:
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Administration > Financial > BillingRates > Other tab > Non-Covered selection option
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Form Locator 49
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Prints:
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This field is blank by default.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Administration > Financial > Insurance Companies > Plans > Print Variations
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Other:
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To print the Modifier in the positions 6–7 of the HCPCS code or the first two digits of the CPT Modifier in this locator, select the Print modifier in FL 49 print variation.
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Form Locator 50a-c
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Prints:
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Payer name
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Source:
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Administration > Financial > Insurance Companies, but if the payer is not associated with an insurance company, the application uses the description of the insurance code (in Administration > Financial) instead.
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Other:
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Payers are listed in the order in which they are to be paid.
A-First Payer
B-Second Payer
C-Third Payer
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Form Locator 51 - Health Plan ID
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Prints:
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Patient insurance or payer identification number
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Source:
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Administration > Financial > Insurance Companies > Provider ID field, but if the payer is not associated with an insurance company, the application uses the provider number from the insurance code (in Administration > Financial) instead.
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Form Locator 52a-c
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Prints:
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This field is blank if it is not defined by a print variation.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Administration > Financial > Insurance Companies > Plans tab > Print Variations
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You can associate a per-patient release of information on the Patient > General > Payers > HIPAA tab.
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Other:
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>
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The following print variation is available for this field: Print 'Y' in Release and Info.
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Form Locator 53 - Assignment of Benefits
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Prints:
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This field is blank if it is not defined by a print variation.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations
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>
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Administration > Financial > Insurance Companies > Plans tab > Print Variations
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You can assign benefits for each patient on the Patient > General > Payers > HIPAA tab.
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Form Locator 54a-c - Prior Payment
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Prints:
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For CSP claims, the amount paid by prior payers in the CSP chain.
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Source:
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CSP payers are associated with patients in Patient > General > Payers > CSP. Claims are released to CSP payers once the balance of the primary payer source (Patient > General > Payers) is 0 through Collections posted (in Transactions > General > Collections/Patient or Collections/Remittance).
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Other:
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The following print variations are available for this field:
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>
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Coinsurance only: print the net amount from the primary claim
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>
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Only print payments from commercial payer
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Form Locator 55a-c - Estimated Amount
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Prints:
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This field is blank unless it is defined by a print variation.
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Source:
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>
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Administration > Financial > Insurance Codes
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>
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Administration > Financial > Insurance Companies > Plan tab
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Other:
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The following print variations are available for this field:
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Suppress printing estimated amount due
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Always print estimated amount due
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Coinsurance only: print the net due as Total Charges - Prior Payments
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Form Locator 56 - NPI
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Prints:
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Agency National Provider Identifier (NPI)
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Source:
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Administration > Financial > Insurance Company
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Administration > Financial > Insurance Code based on selected configuration of the setting under the NPI tab
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Other:
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Within Administration > Financial > Insurance Code > NPI tab, select the IDs to include in claims.
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Form Locator 57a-c Other Provider ID
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Prints:
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This field is blank by default.
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Form Locator 58 - Insured's Name
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Prints:
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Patient's name
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Source:
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>
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Patient > General > Payers > Pay Source
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Patient > General > Basic
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Form Locator 59 - Patient Relationship
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Prints:
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Patient's relationship to the insured
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Source:
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Patient > General > Payers > PaySource
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Other:
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The following print variations are available:
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Print NUBC Relationship Codes effective 10/16/03
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The following codes are printed on the claims depending on the patient relationship code selected:
01 (The patient is the insured person) – Not applicable to printing.
02 (Spouse) – Prints 01.
03 (Natural Child/Insured has financial responsibility) – Prints 19.
04 (Natural Child/Insured does not have fin. responsibility) – Prints 43.
05 (Step Child) – Prints 17.
06 (Foster Child) – Prints 10.
07 (Ward of the Court) – Prints 15.
08 (Employee) – Prints 20.
09 (Unknown) – Prints 21.
10 (Central Certification) – Prints 22.
11 (Grandchild) – Prints 05.
12 (Niece/Nephew) – Prints 07.
13 (Injured Plaintiff) – Prints 41.
14 (Sponsored Dependent) – Prints 23.
02 (Minor Dependent of a Minor Dependent) – Prints 24.
16 (Mother) – Prints 32.
17 (Grandparent) – Prints 04.
18 (Father) – Prints 33.
29 (Significant Other) – Prints 29.
36 (Organ Donor) – Prints 36.
39 (Organ Donor) – Prints 39.
40 (Cadaver Donor) – Prints 40.
53 (Life Partner) – Prints 53.
G8 (Other Relationship) – Prints G8.
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Print NUBC Relationship Codes effective as of 10/01/11 – Allows printing 5010 codes on hardcopy claims. This print variation does not affect electronic claims where the appropriate code is reported depending on the template version (4010 or 5010). These codes are displayed in the Set Patient Relationship window (in Patient > General > Payers > Pay Source > Rel).
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Suppress printing of Patient Relationship
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Form Locator 60 - Insured's Unique ID
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Prints:
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Patient's unique payer identification number
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Source:
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Patient > General > Payers > PaySource
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Other:
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The following print variation is available for this field: Only print value for current claim payer line.
By default, dashes are suppressed from printing.
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Form Locator 61a-c Group Name
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Prints:
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This field is blank if it is not defined by a print variation.
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Source:
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Administration > Financial > Insurance Codes
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Administration > Financial > Insurance Companies
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Groups are associated with patients in Patient > General > Payers.
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Other:
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If a group is not associated with a patient's payer, this field is blank.
The following print variations are available for this field:
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Print the Insurance Group Name
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Print the payers assigned Carrier Code
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Form Locator 62 - Insurance Group No
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Prints:
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Patient's group number
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Source:
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Patient > General > Payers
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Form Locator 63a-c Treatment Auth Code
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Prints:
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Authorization code associated with services provided
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Source:
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Patient > General > Authorizations
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Form Locator 64a-c Document Control Number
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Prints:
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DCN for the claim
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Source:
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Claims > Process > Annotate Claims
This is completed only for the current pay source.
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Other:
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NY FFS DCN is associated with NY Medicaid claims through EMC/ERA processing.
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Form Locator 65a-c Employer Name
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Prints:
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This field is blank unless it is defined through a Claim Constant.
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Source:
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Administration > Financial > Claim Constants
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 66 - Diagnosis Indicator
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Prints:
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ICD code type that corresponds to the patient's primary diagnosis in FL 67:
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Form Locator 67a - Principal Diagnosis Code
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Prints:
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Patient's primary diagnosis
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Source:
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Patient > General > Diagnoses, which defines the primary diagnosis in Patient > General > Admissions & Status.
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Other:
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The following print variation is available:
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>
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Suppress decimals & dashes in ICD codes
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The UB-04 guidelines recommend that you suppress the printing of decimal points in paper UB-04 claims by selecting the Suppress decimals & dashes in ICD codes print variation, located in the General Rules section of the Print Variations (in Administration > Financial > Insurance Codes). On claims, the decimal point is implied and therefore unnecessary. By suppressing it, you ensure that all all characters (up to 7) of an ICD code prints.
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Report diagnoses as of the claim end date. Applies to NOTR if it's used
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If selected, active diagnoses as of the THROUGH date of the claim are reported. This may be needed if some diagnoses changed during the claim period and you need to report the latest ones. This print variation applies to the notice of termination/revocation and reports active diagnoses as of the patient's discharge. If you use diagnoses groups and the new print variation is selected, the application reports active diagnoses from the latest group as of the claim end date/patient's discharge
Note: This print variation is available for Benefit and Hybrid payers and applies to EMCs.
If a patient's primary diagnosis changes and, later that day, the patient dies, list these events as 2 separate status lines for that day. In the first line, enter the new primary diagnosis. In the second line, enter the discharge status code (F07).
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Form Locator 67b-q Other Diagnosis Codes
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Prints:
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Patient's secondary diagnosis codes. These fields are optional.
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Source:
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Patient > General > Diagnoses
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Other:
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For ICD-10 codes that contain the maximum of 7 characters, the decimal point, is implied between the third and fourth characters. The shaded area is specific to the Present on Admission indicator.
The following print variations are available for this field:
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Suppress printing of secondary ICD codes (N/A)
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>
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Suppress decimals & dashes in ICD codes
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The UB-04 guidelines recommend that you suppress the printing of decimal points in paper UB-04 claims by selecting the Suppress decimals & dashes in ICD codes print variation, located in the General Rules section of the Print Variations (in Administration > Financial > Insurance Codes). On claims, the decimal point is implied and therefore unnecessary. By suppressing it, you ensure that all all characters (up to 7) of an ICD code prints.
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Report all terminal illness diagnoses
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When this print variation is selected, only the patient diagnoses that are indicated as terminal illness diagnoses (as defined in Patient > General > Diagnoses) are reported on the claims.
Per CMS 1629-F, all diagnoses must be reported on claims, not just those related to terminal illnesses. Ensure that this print variation is cleared for Medicare benefit claims.
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Form Locator 68 - Box 68 (Lines 1 and 2)
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Prints:
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This field is blank unless it is defined through Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 69 - Admitting Diagnosis Code
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Prints:
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This field is blank unless it is defined in Claim Constants.
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Source:
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Patient > General > Claim Constants
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Other:
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The following print variation is available for this field: Print the patient's diagnosis code as of the patient's admission date (in Patient > General > Admissions & Status).
If admission diagnosis code is ICD-9, but you need to print the corresponding ICD-10 code on a claim or inversely, then enter this diagnosis code in the Value field.
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Form Locator 70a-c Patient Reason Diag
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Prints:
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This field is blank if it is not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 71 PPS Code
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Prints:
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This field is blank if not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 72a-c External Cause of Injury
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Prints:
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This field is blank if not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 73 - Box 73
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Prints:
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This field is blank if not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 74 - Principal Procedure Code
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Prints:
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This field is blank if not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 74a-e - Other Procedure Code
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Prints:
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This field is blank if it is not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 75 - Box 75 (Lines 1 through 4)
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Prints:
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This field prints blank if it is not defined in Claim Constants.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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Claim constants defined in the Patient component override claim constants defined in the Administration component.
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Form Locator 76 - Attending Physician ID
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Prints:
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The attending physician's NPI number
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Source:
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>
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Patient > General > Admissions & Status
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>
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Resource > General > Roles > Individual NPI or Group NPI number(s)
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Group NPIs are defined in the Group NPI table (in Administration > General).
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Other:
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The following print variations are available for this field:
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Print physician's State License Number and 0B qualifier
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>
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Print physician's Medicaid Provider ID (Other Phys No) and 1D qualifier
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Print physician's Provider ID and 1D qualifier if blank print State License Number and 0B qualifier
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>
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Suppress printing of attending physician
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>
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For NOEs Print physician Part B Provider No and 1C qualifier in locator 76
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Form Locator 77 - Operating Physician ID
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Prints:
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This field prints blank if it is not defined by Claim Constants or print variations.
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Source:
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>
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Patient > General > Claim Constants
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>
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Administration > Financial > Insurance Codes > Print Variations tab
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>
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Administration > Financial > Insurance Companies > Plans tab
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Other:
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The following print variation is available for this field: Print secondary physician information with NPI, Other Phys No and 1D Qualifier (in Patient > General > Admission & Status > MD2)
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Form Locator 78 - Other Physician ID
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Prints:
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This field prints blank if it is not defined by Claim Constants or print variations.
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Source:
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>
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Patient > General > Claim Constants
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>
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Administration > Financial > Insurance Codes > Print Variations tab
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>
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Administration > Financial > Insurance Companies > Plans tab
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Other:
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The following print variations are available for this field:
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>
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Print primary physician's information with NPI
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>
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Print secondary physician's information with NPI
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>
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Print tertiary physician's information with NPI
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>
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Print referring physician's information with NPI
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>
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Print CTI physician's information with NPI
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>
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Print rendering provider's name and split the claim by rendering provider
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>
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Print primary physician's Other Phys No Without Qualifier, if blank print UPIN code without Qualifier
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>
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Print F2F encounter physician's information with NPI effective as of 07/01/14
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Form Locator 79 - Other Physician ID
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Prints:
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This field prints blank if it is not defined by a print variation.
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Source:
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>
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Administration > Financial > Insurance Codes > Print Variations tab
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>
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Administration > Financial > Insurance Companies > Plans tab
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Other:
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The following print variations are available for this field:
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>
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Print primary physician's information with NPI
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>
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Print secondary physician's information with NPI
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>
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Print tertiary physician's information with NPI
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>
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Print referring physician's information with NPI
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>
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Print CTI physician's information with NPI
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>
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Print rendering provider's name and split the claim by rendering provider
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>
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Print F2F encounter physician's information with NPI effective as of 07/01/14
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Form Locator 80a-d Remarks
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Prints:
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This field is blank unless it is completed in Claim Constants or print variations.
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Source:
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>
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Administration > Financial > Claim Constants
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>
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Patient > General > Claim Constants
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Other:
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The following print variations are available for this field:
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>
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Print physician name, address and telephone number
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>
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Print the commercial insurance company address
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>
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Print the Spend Down amount
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>
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Print the Spend Down amount and if an R&B claim, print the Nursing Home Name
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>
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Print the date the Third Party payer paid the claim
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Form Locator 81CCa-d - Code-Qualifier
|
Prints:
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Qualifier ZZ and Provider Taxonomy Code
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Source:
|
Administration > Financial > Insurance Company
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Other:
|
If an insurance company has not defined a provider taxonomy code, the system obtains the number from Administration > Financial > InsuranceCode. The following print variations are available for this field:
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>
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Print agency's taxonomy code and ZZ qualifier in 81CCa
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>
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Print attending provider's taxonomy code and ZZ qualifier in 81CCb.
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>
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For NOEs, print the physician name and address in Remarks.
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