Supporting Statement and Supporting Regulations Contained in 42 CFR 424

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Supporting Statement and Supporting Regulations Contained in 42 CFR 424.5 for the Uniform Institutional Providers Form -- CMS-1450 (UB-04)

A.	Background

There are new data element changes to the UB-04 CMS-1450 data set.  All hardcopy claims processed by Medicare fiscal intermediaries must be submitted on the UB-04 CMS-1450 after May 23, 2007.  Data fields in the X12N 837 data set are consistent with the UB-04 CMS-1450 data set.

We are requesting approval under a new OMB approval number replacing the UB-92 number 0938-0279.  

CMS is requesting Office of Management and Budget (OMB) approval of the CMS-1450 (UB-04 - attachment 1) Uniform Institutional Provider Claim Form (previously the UB-92 – attachment 2).  The requirements associated with the Medicaid burden are included in the package which was approved under OMB control # 0938-0279 with an expiration date 11/2008 for the UB-92 renewal.

B.	Justification

1. 	Need and Legal Basis

The basic authorities which allow providers of service to bill for services on behalf of the beneficiary are section 1812 (42 USC 1395d - http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+42USC1395d) (a) (1), (2), (3), and (4) and 1833 (2) (B) of the Social Security Act).  Also, section 1835 (42 USC 1395n) requires that payment for services furnished to an individual may be made to providers of services only when a written request for payment is filed in such form as the Secretary may prescribe by regulations.  Section 42 CFR 424.5(a)(5) requires providers of services to submit a claim for payment prior to any Medicare reimbursement.  Charges billed are coded by revenue codes.  The bill specifies diagnoses according to the International Classification of Diseases, Ninth Edition (ICD-9-CM) code.  Inpatient procedures are identified by ICD-9-CM codes, and outpatient procedures are described using the CMS Common Procedure Coding System (HCPCS).  These are standard systems of identification for all major health insurance claims payers.  Submission of information on the CMS-1450 permits Medicare intermediaries to receive consistent data for proper payment.

2.	Information Users

The UB-92 is managed by the NUBC, sponsored by the American Hospital Association.  Most payers are represented on this body, and the UB-92 is widely used in the industry.  The UB-04 is based on of the UB-92 with a similar look.

Medicare receives 98.8 percent of the CMS-1450s submitted by institutional providers electronically.  Because of the number of small and rural providers who do not submit claims electronically, it is not possible to achieve total electronic submission at this time.  Intermediaries use the information on the CMS-1450 to determine whether to make Medicare payment for the services provided, the payment amount, and whether or not to apply deductibles to the claim.  The same method is also used by other payers.

CMS is also a secondary user of data.  CMS uses the information to develop a data base which is used to update and revise established payment schedules and other payment rates for covered services.  CMS also uses the information to conduct studies and reports.

UB-92 to UB-04 mapping









* FL68,75,80 Size Updated 6/21/05 

UB-92 




UB-04 
** FL07, 30 Size Updated 12/15/05 









Buffer 
FL 
Description 
Line 
Type 
Size 
FL 
Description 
Line 
Type 
Size 
Space Notes 
F  FL01 
Provider Name 
1 
AN 
25 
FL01 
Provider Name 
1 
AN 
25 

FL01 
Provider Street Address 
2 
AN 
25 
FL01 
Provider Street Address 
2 
AN 
25 

FL01 
Provider City, State, Zip 
3 
AN 
25 
FL01 
Provider City, State, Zip 
3 
AN 
25 

FL01 
Provider Telephone, Fax, Country Code 
4 
AN 
25 
FL01 
Provider Telephone, Fax, Country Code 
4 
AN 
25 

FL02 
Unlabeled Fields 
1 
AN 
20 
FL02 
Pay-to Name 
1 
AN 
25 
New 
FL02 
Unlabeled Fields 
2 
AN 
30 
FL02 
Pay-to Address 
2 
AN 
25 
New 





FL02 
Pay-to City, State 
3 
AN 
25 
New 





FL02 
Pay-to ID 
4 
AN 
25 
New 
FL03 
Patient Control Number 
1 
AN 
20 
FL03a Patient Control Number 

AN 
24 






FL03b Medical Record Number 

AN 
24 
Moved/New 
FL04 
Type of Bill 
1 
AN 
3 
FL04 
Type of Bill 
1 
AN 
4 
1 Expanded 
FL05 
Federal Tax Number 
1 
AN 
4 
FL05 
Federal Tax Number 
1 
AN 
4 

FL05 
Federal Tax Number 
2 
AN 
10 
FL05 
Federal Tax Number 
2 
AN 
10 

FL06 
Statement Covers Period - From/Through 
1 
N/N 
6/6 
FL06 
Statement Covers Period - From/Through 
1 
N/N 
6/6 
1/1 





FL07 
Unlabeled 
1 
AN 
7** 








2 
AN 
8** 

FL07 
Covered Days 
1 
N 
3

 Eliminated - Substitute new Value Code 




FL08 
Non-covered Days 
1 
N 
4

 Eliminated - Substitute new Value Code 




FL09 
Coinsurance Days 
1 
N 
3

 Eliminated - Substitute new Value Code 




FL10 
Lifetime Reserve Days 
1 
N 
3

 Eliminated - Substitute new Value Code 




FL11 
Unlabeled 
1 

12

 Eliminated 




FL11 
Unlabeled 
2 

13

 Eliminated 




FL12 
Patient Name 
1 
AN 
30 
FL08 
Patient Name - ID 
1a 
AN 
19 
New 





FL08 
Patient Name 
2b 
AN 
29 

FL13 
Patient Address 
1 
AN 
50 
FL09 
Patient Address - Street 
1a 
AN 
40 
1 Discrete 





FL09 
Patient Address - City 
2b 
AN 
30 
2 Discrete 





FL09 
Patient Address - State 
2c 
AN 
2 
1 Discrete 





FL09 
Patient Address - ZIP 
2d 
AN 
9 
1 Discrete 





FL09 
Patient Address - Country Code 
2e 
AN 
3 
Discrete 
FL14 
Patient Birthdate 
1 
N 
8 
FL10 
Patient Birthdate 
1 
N 
8 
1 
FL15 
Patient Sex 
1 
AN 
1 
FL11 
Patient Sex 
1 
AN 
1 
2 
FL16 
Patient Marital Status 
1 
AN 
1

 Eliminated 




FL17 
Admission Date 
1 
N 
6 
FL12 
Admission Date 
1 
N 
6 

FL18 
Admission Hour 
1 
AN 
2 
FL13 
Admission Hour 
1 
AN 
2 
1 
FL19 
Type of Admission/Visit 
1 
AN 
1 
FL14 
Type of Admission/Visit 
1 
AN 
1 
2 
FL20 
Source of Admission 
1 
AN 
1 
FL15 
Source of Admission 
1 
AN 
1 
1 
FL21 
Discharge Hour 
1 
AN 
2 
FL16 
Discharge Hour 
1 
AN 
2 
2 
FL22 
Patient Status/Discharge Code 
1 
AN 
2 
FL17 
Patient Discharge Status 
1 
AN 
2 
2 
FL23 
Medical/Health Record Number 

AN 
17 

Moved to FL3b 




FL24 
Condition Codes 

AN 
2 
FL18 
Condition Codes 

AN 
2 
1 
FL25 
Condition Codes 

AN 
2 
FL19 
Condition Codes 

AN 
2 
1 





FL20 
Condition Codes 

AN 
2 
1 









* FL68,75,80 Size Updated 6/21/05 

UB-92 




UB-04 

** FL07, 30 Size Updated 12/15/05 










Buffer 
FL 
Description 
Line 
Type 
Size 
FL 
Description 
Line 
Type 
Size 
Space Notes 
FL26 
Condition Codes 

AN 
2 
FL21 
Condition Codes 

AN 
2 
1 





FL22 
Condition Codes 

AN 
2 
1 
FL27 
Condition Codes 

AN 
2 
FL23 
Condition Codes 

AN 
2 
1 





FL24 
Condition Codes 

AN 
2 
1 
FL28 
Condition Codes 

AN 
2 
FL25 
Condition Codes 

AN 
2 
1 





FL26 
Condition Codes 

AN 
2 
1 New 
FL29 
Condition Codes 

AN 
2 
FL27 
Condition Codes 

AN 
2 
1 New 





FL28 
Condition Codes 

AN 
2 
1 New 
FL30 
Condition Codes 

AN 
2 











FL29 
Accident State 
1 
AN 
2 
1 New 





FL30 
Unlabeled 
1 
AN 
12 
** No "Xs" on proof 





FL30 
Unlabeled 
2 
AN 
13 

FL31 
Unlabeled 
1 

5 






FL31 
Unlabeled 
2 

6 






FL32 
Occurrence Code/Date 
a 
AN/N 
2/6 
FL31 
Occurrence Code/Date 
a 
AN/N 
2/6 
1/1 
FL32 
Occurrence Code/Date 
b 
AN/N 
2/6 
FL31 
Occurrence Code/Date 
b 
AN/N 
2/6 
1/1 
FL33 
Occurrence Code/Date 
a 
AN 
2/6 
FL32 
Occurrence Code/Date 
a 
AN/N 
2/6 
1/1 
FL33 
Occurrence Code/Date 
b 
AN/N 
2/6 
FL32 
Occurrence Code/Date 
b 
AN/N 
2/6 
1/1 
FL34 
Occurrence Code/Date 
a 
AN 
2/6 
FL33 
Occurrence Code/Date 
a 
AN/N 
2/6 
1/1 
FL34 
Occurrence Code/Date 
b 
AN/N 
2/6 
FL33 
Occurrence Code/Date 
b 
AN/N 
2/6 
1/1 
FL35 
Occurrence Code/Date 
a 
AN 
2/6 
FL34 
Occurrence Code/Date 
a 
AN/N 
2/6 
1/1 
FL35 
Occurrence Code/Date 
b 
AN/N 
2/6 
FL34 
Occurrence Code/Date 
b 
AN/N 
2/6 
1/1 
FL36 
Occurrence Span Code/From/Through 
a 
AN/N/N 
2/6/6 
FL35 
Occurrence Span Code/From/Through 
a 
AN/N/N 
2/6/6 
1/1/1 
FL36 
Occurrence Span Code/From/Through 
b 
AN/N/N 
2/6/6 
FL35 
Occurrence Span Code/From/Through 
b 
AN/N/N 
2/6/6 
1/1/1 





FL36 
Occurrence Span Code/From/Through 
a 
AN/N/N 
2/6/6 
1/1/1 New 





FL36 
Occurrence Span Code/From/Through 
b 
AN/N/N 
2/6/6 
1/1/1 New 





FL37 
Unlabeled 
a 
AN 
8 






FL37 
Unlabeled 
b 
AN 
8 

FL37 
ICN/DCN 
A 
AN 
23 

Moved to FL64 



Relocated 
FL37 
ICN/DCN 
B 
AN 
23 

Moved to FL64 




FL37 
ICN/DCN 
C 
AN 
23 

Moved to FL64 




FL38 
Responsible Party Name/Address 
1 
AN 
40 
FL38 
Responsible Party Name/Address 
1 
AN 
40 
2 
FL38 
Responsible Party Name/Address 
2 
AN 
40 
FL38 
Responsible Party Name/Address 
2 
AN 
40 
2 
FL38 
Responsible Party Name/Address 
3 
AN 
40 
FL38 
Responsible Party Name/Address 
3 
AN 
40 
2 
FL38 
Responsible Party Name/Address 
4 
AN 
40 
FL38 
Responsible Party Name/Address 
4 
AN 
40 
2 
FL38 
Responsible Party Name/Address 
5 
AN 
40 
FL38 
Responsible Party Name/Address 
5 
AN 
40 
2 
FL39 
Value Code - Code 
a 
AN 
2 
FL39 
Value Code - Code 
a 
AN 
2 
1 
FL39 
Value Code - Amount 
a 
N 
9 
FL39 
Value Code - Amount 
a 
N 
9 
1 
FL39 
Value Code - Code 
b 
AN 
2 
FL39 
Value Code - Code 
b 
AN 
2 
1 
FL39 
Value Code - Amount 
b 
N 
9 
FL39 
Value Code - Amount 
b 
N 
9 
1 
FL39 
Value Code - Code 
c 
AN 
2 
FL39 
Value Code - Code 
c 
AN 
2 
1 
FL39 
Value Code - Amount 
c 
N 
9 
FL39 
Value Code - Amount 
c 
N 
9 
1 
FL39 
Value Code - Code 
d 
AN 
2 
FL39 
Value Code - Code 
d 
AN 
2 
1 
FL39 
Value Code - Amount 
d 
N 
9 
FL39 
Value Code - Amount 
d 
N 
9 
1 
FL40 
Value Code - Code 
a 
AN 
2 
FL40 
Value Code - Code 
a 
AN 
2 
1 
FL40 
Value Code - Amount 
a 
N 
9 
FL40 
Value Code - Amount 
a 
N 
9 
1 
FL40 
Value Code - Code 
b 
AN 
2 
FL40 
Value Code - Code 
b 
AN 
2 
1 
FL40 
Value Code - Amount 
b 
N 
9 
FL40 
Value Code - Amount 
b 
N 
9 
1 
FL40 
Value Code - Code 
c 
AN 
2 
FL40 
Value Code - Code 
c 
AN 
2 
1 
FL40 
Value Code - Amount 
c 
N 
9 
FL40 
Value Code - Amount 
c 
N 
9 
1 
FL40 
Value Code - Code 
d 
AN 
2 
FL40 
Value Code - Code 
d 
AN 
2 
1 
FL40 
Value Code - Amount 
d 
N 
9 
FL40 
Value Code - Amount 
d 
N 
9 
1 
FL41 
Value Code - Code 
a 
AN 
2 
FL41 
Value Code - Code 
a 
AN 
2 
1 
FL41 
Value Code - Amount 
a 
N 
9 
FL41 
Value Code - Amount 
a 
N 
9 
1 









* FL68,75,80 Size Updated 6/21/05 

UB-92 




UB-04 

** FL07, 30 Size Updated 12/15/05 










Buffer 
FL 
Description 
Line 
Type 
Size 
FL 
Description 
Line 
Type 
Size 
Space Notes 
FL41 
Value Code - Code 
b 
AN 
2 
FL41 
Value Code - Code 
b 
AN 
2 
1 
FL41 
Value Code - Amount 
b 
N 
9 
FL41 
Value Code - Amount 
b 
N 
9 
1 
FL41 
Value Code - Code 
c 
AN 
2 
FL41 
Value Code - Code 
c 
AN 
2 
1 
FL41 
Value Code - Amount 
c 
N 
9 
FL41 
Value Code - Amount 
c 
N 
9 
1 
FL41 
Value Code - Code 
d 
AN 
2 
FL41 
Value Code - Code 
d 
AN 
2 
1 
FL41 
Value Code - Amount 
d 
N 
9 
FL41 
Value Code - Amount 
d 
N 
9 
1 
FL42 
Revenue Code 
1-23 
N 
4 
FL42 
Revenue Code 
1-23 
N 
4 
0.5 
FL43 
Revenue Code Description 
1-23 
AN 
24 
FL43 
Revenue Code Description 
1-22 
AN 
24 
0.5 





FL43










44 
PAGE ___ OF ___ CREATION DATE 
23 
N/N 
3/3 
0.5 New 
FL44 
HCPCS/Rates/HIPPS Rate Codes 
1-23 AN/N/AN 
9 
FL44 
HCPCS/Rates/HIPPS Rate Codes 
1-22 AN/N/AN 
14 
0.5 Expanded size 
FL45 
Service Date 
1-23 
N 
6 
FL45 
Service Date 
1-22 
N 
6 
0.5 





FL45 
Creation Date 
23 
N 
6 
0.5 New 
FL46 
Units of Service 
1-23 
N 
7 
FL46 
Units of Service 
1-22 
N 
7 
0.5 










Removed 
FL47 
Total Charges 
1-23 
N 
10 
FL47 
Total Charges 
1-23 
N 
9 
0.5 sign field 










Removed 
FL48 
Non-Covered Charges 
1-23 
N 
10 
FL48 
Non-Covered Charges 
1-23 
N 
9 
0.5 sign field 
FL49 
Unlabeled 
1-23 
AN 
4 
FL49 
Unlabeled 
1-23 
AN 
2 
0.5 
FL50 
Payer - Primary 
A 
AN 
25 
FL50 
Payer Name - Primary 
A 
AN 
23 

FL50 
Payer - Secondary 
B 
AN 
25 
FL50 
Payer Name - Secondary 
B 
AN 
23 

FL50 
Payer - Tertiary 
C 
AN 
25 
FL50 
Payer Name - Tertiary 
C 
AN 
23 

FL51 
Provider Number 
A 
AN 
13 
FL51 
Health Plan ID 
A 
AN 
15 

FL51 
Provider Number 
B 
AN 
13 
FL51 
Health Plan ID 
B 
AN 
15 

FL51 
Provider Number 
C 
AN 
13 
FL51 
Health Plan ID 
C 
AN 
15 

FL52 
Release of Information - Primary 
A 
AN 
1 
FL52 
Release of Information - Primary 
A 
AN 
1 
1 
FL52 
Release of Information - Secondary 
B 
AN 
1 
FL52 
Release of Information - Secondary 
B 
AN 
1 
1 
Fl52 
Release of Information - Tertiary 
C 
AN 
1 
FL52 
Release of Information - Tertiary 
C 
AN 
1 
1 
FL53 
Assignment of Benefits - Primary 
A 
AN 
1 
FL53 
Assignment of Benefits - Primary 
A 
AN 
1 
1 
FL53 
Assignment of Benefits - Secondary 
B 
AN 
1 
FL53 
Assignment of Benefits - Secondary 
B 
AN 
1 
1 
FL53 
Assignment of Benefits - Tertiary 
C 
AN 
1 
FL53 
Assignment of Benefits - Tertiary 
C 
AN 
1 
1 
FL54 
Prior Payments - Primary 
A 
N 
10 
FL54 
Prior Payments - Primary 
A 
N 
10 
1 
FL54 
Prior Payments - Secondary 
B 
N 
10 
FL54 
Prior Payments - Secondary 
B 
N 
10 
1 
FL54 
Prior Payments - Tertiary 
C 
N 
10 
FL54 
Prior Payments - Tertiary 
C 
N 
10 
1 
FL54 
Prior Payments - Patient 
4 
N 
10 

Eliminated Patient Prior Payments 




FL55 
Estimated Amount Due - Primary 
A 
N 
10 
FL55 
Estimated Amount Due - Primary 
A 
N 
10 
1 
FL55 
Estimated Amount Due - Secondary 
B 
N 
10 
FL55 
Estimated Amount Due - Secondary 
B 
N 
10 
1 
FL55 
Estimated Amount Due - Tertiary 
C 
N 
10 
FL55 
Estimated Amount Due - Tertiary 
C 
N 
10 
1 
FL55 
Estimated Amount Due - Patient 
4 
N 
10 

Eliminated Due from Patient 




FL56 
Unlabeled 
1 

13 
FL56 
NPI 
1 
AN 
15 

FL56 
Unlabeled 
2 

14 
FL57 
Other Provider ID - Primary 
A 
AN 
15 






FL57 
Other Provider ID - Secondary 
B 
AN 
15 






FL57 
Other Provider ID - Tertiary 
C 
AN 
15 

FL57 
Unlabeled 
1 

27 

Deleted from UB-04 




FL58 
Insured’s Name - Primary 
A 
AN 
25 
FL58 
Insured’s Name - Primary 
A 
AN 
25 
1 
FL58 
Insured's Name - Secondary 
B 
AN 
25 
FL58 
Insured's Name - Secondary 
B 
AN 
25 
1 
FL58 
Insured's Name - Tertiary 
C 
AN 
25 
FL58 
Insured's Name - Tertiary 
C 
AN 
25 
1 
FL59 
Patient’s Relationship - Primary 
A 
AN 
2 
FL59 
Patient’s Relationship - Primary 
A 
AN 
2 
1 
FL59 
Patient's Relationship - Secondary 
B 
AN 
2 
FL59 
Patient's Relationship - Secondary 
B 
AN 
2 
1 

UB-92 
FL Description Line Type Size 
FL59 Patient's Relationship -Tertiary C AN 2 
FL60 CERT./ SSN/ HIC/ ID NO. - Primary A AN 19 FL60 CERT./ SSN/ HIC/ ID NO.- Secondary B AN 19 FL60 CERT./ SSN/ HIC/ ID NO. - Tertiary C AN 19 
FL61 Insurance Group Name - Primary A AN 14 FL61 Insurance Group Name -Secondary B AN 14 FL61 Insurance Group Name - Tertiary C AN 14 
FL62 Insurance Group Number - Primary A AN 17 FL62 Insurance Group Number - Secondary B AN 17 FL62 Insurance Group Number - Tertiary C AN 17 
FL63 Treatment Authorization Code - Primary A AN 18 
Treatment Authorization Code -FL63 Secondary B AN 18 FL63 Treatment Authorization Code - Tertiary C AN 18 
FL64 Employment Status Code - Primary A N 1 FL64 Employment Status Code - Secondary B N 1 FL64 Employment Status Code - Tertiary C N 1 
FL65 Employer Name - Primary A N 24 FL65 Employer Name - Secondary B N 24 FL65 Employer Name - Tertiary C N 24 
FL66 Employer Location - Primary A AN 35 FL66 Employer Location - Secondary B AN 35 FL66 Employer Locations -Tertiary C AN 35 
FL67 Principal Diagnosis Code 1 AN 6 
FL68 Other Diagnoses 1 AN 6 FL69 Other Diagnoses 1 AN 6 FL70 Other Diagnoses 1 AN 6 FL71 Other Diagnoses 1 AN 6 FL72 Other Diagnoses 1 AN 6 FL73 Other Diagnoses 1 AN 6 FL74 Other Diagnoses 1 AN 6 FL75 Other Diagnoses 1 AN 6 
Admitting Diagnosis/Patient’s Reason for FL76 Visit 1 AN 6 
* FL68,75,80 Size Updated 6/21/05UB-04 ** FL07, 30 Size Updated 12/15/05 
Buffer 
FL 
Description 
Line 
Type 
Size 
Space Notes 
FL59 
Patient's Relationship - Tertiary 
C 
AN 
2 
1 

FL60 
Insured's Unique ID - Primary 
A 
AN 
20 


FL60 
Insured's Unique ID - Secondary 
B 
AN 
20 


FL60 
Insured's Unique ID - Tertiary 
C 
AN 
20 


FL61 
Insurance Group Name - Primary 
A 
AN 
14 
1 

FL61 
Insurance Group Name -Secondary 
B 
AN 
14 
1 

FL61 
Insurance Group Name - Tertiary 
C 
AN 
14 
1 

FL62 
Insurance Group Number - Primary 
A 
AN 
17 
1 

FL62 
Insurance Group Number - Secondary 
B 
AN 
17 
1 

FL62 
Insurance Group Number - Tertiary 
C 
AN 
17 
1 

FL63 
Treatment Authorization Code - Primary 
A 
AN 
30 
1 

Treatment Authorization Code -





FL63 
Secondary 
B 
AN 
30 
1 

FL63 
Treatment Authorization Code - Tertiary 
C 
AN 
30 
1 

FL64 
Document Control Number 
A 
AN 
26 


FL64 
Document Control Number 
B 
AN 
26 


FL64 
Document Control Number 
C 
AN 
26 


Deleted from UB-04 





Deleted from UB-04 





Deleted from UB-04 





FL65 
Employer Name - Primary 
A 
AN 
25 


FL65 
Employer Name - Secondary 
B 
AN 
25 


FL65 
Employer Name - Tertiary 
C 
AN 
25 


Deleted from UB-04 





Deleted from UB-04 





Deleted from UB-04 





FL66 
DX Version Qualifier 

AN 
1 

New 





Denotes ICD v. 
FL67 
Principal Diagnosis Code 

AN 
8 

Expanded field 
FL67A Other Diagnosis 

AN 
8 

Expanded field 
FL67B Other Diagnosis 

AN 
8 

Expanded field 
FL67C Other Diagnosis 

AN 
8 

Expanded field 
FL67D Other Diagnosis 

AN 
8 

Expanded field 
FL67E Other Diagnosis 

AN 
8 

Expanded field 
FL67F Other Diagnosis 

AN 
8 

Expanded field 
FL67G Other Diagnosis 

AN 
8 

Expanded field 
FL67H Other Diagnosis 

AN 
8 

Expanded field 
FL67I Other Diagnosis 

AN 
8 

New 
FL67J Other Diagnosis 

AN 
8 

New 
FL67K Other Diagnosis 

AN 
8 

New 
FL67L Other Diagnosis 

AN 
8 

New 
FL67M Other Diagnosis 

AN 
8 

New 
FL67N Other Diagnosis 

AN 
8 

New 
FL67O Other Diagnosis 

AN 
8 

New 
FL67P Other Diagnosis 

AN 
8 

New 
FL67Q Other Diagnosis 

AN 
8 

New 
FL68 
Unlabeled 
1a 
AN 
8* 


FL68 
Unlabeled 
1b 
AN 
9* 


FL69 
Admitting Diagnosis Code 
1 
AN 
7 

Expanded by 1 
FL70 
Patient's Reason for Visit Code 
A 
AN 
7 

Distinct FL 
FL70 
Patient's Reason for Visit Code 
B 
AN 
7 

Distinct FL 
FL70 
Patient's Reason for Visit Code 
C 
AN 
7 

Distinct FL 








* FL68,75,80 Size Updated 6/21/05 

UB-92 



UB-04 

** FL07, 30 Size Updated 12/15/05 








Buffer 
FL 
Description 
Line 
Type 
Size 
FL Description 
Line Type Size 
Space Notes 





FL71 PPS Code 
1 
AN 3 
2 New 
FL77 
External Cause of Injury Code 
1 
AN 
6 
FL72 External Cause of Injury Code 
1a 
AN 8 






FL72 External Cause of Injury Code 
1b 
AN 8 
New 





FL72 External Cause of Injury Code 
1c 
AN 8 
New 
FL78 
Unlabeled 



FL73 Unlabeled 
1 
AN 9 

FL79 
Procedure Coding Method Used 
1 
N 
1 
Deleted from UB-04 


Deleted 
FL80 
Principal Procedure Code/Date 
1 
N/N 
6/6 
FL74 Principal Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 
FL81 
Other Procedure Code/Date 
A 
N/N 
6/6 
FL74a Other Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 
FL81 
Other Procedure Code/Date 
B 
N/N 
6/6 
FL74b Other Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 
FL81 
Other Procedure Code/Date 
C 
N/N 
6/6 
FL74c Other Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 
FL81 
Other Procedure Code/Date 
D 
N/N 
6/6 
FL74d Other Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 
FL81 
Other Procedure Code/Date 
E 
N/N 
6/6 
FL74e Other Procedure Code/Date 

N/N 7/6 
1/1 Expanded by 1 





FL75 Unlabeled 
1 
AN 4* 
0* 





FL75 Unlabeled 
2 
AN 4 
1 





FL75 Unlabeled 
3 
AN 4 
1 





FL75 Unlabeled 
4 
AN 4 
1 
FL82 
Attending Physician ID 
a 
AN 
23 
FL76 Attending - NPI/QUAL/ID 
1 
AN/AN/AN 11/2/9 
New Layout 
FL82 
Attending Physician ID 
b 
AN 
32 
FL76 Attending - Last/First 
2 
AN/AN 16/12 
New Layout 
FL83A 
Other Physician ID 
a 
AN 
25 
FL77 Operating - NPI/QUAL/ID 
1 
AN/AN/AN 11/2/9 
New Layout 
FL83A 
Other Physician ID 
b 
AN 
32 
FL77 Operating - Last/First 
2 
AN/AN 16/12 
New Layout 







AN/AN/ 

FL83B 
Other Physician ID 
a 
AN 
25 
FL78 Other ID - QUAL/NPI/QUAL/ID 
1 
AN/AN 2/11/2/9 
New Layout 
FL83B 
Other Physician ID 
b 
AN 
32 
FL78 Other ID - Last/First 
2 
AN/AN 16/12 
New Layout 







AN/AN/ 






FL79 Other ID - QUAL/NPI/QUAL/ID 
1 
AN/AN 2/11/2/9 
New 





FL79 Other ID - Last/First 
2 
AN/AN 16/12 
New 
FL84 
Remarks 
1 
AN 
43 
FL80 Remarks 
1 
AN 19* 
Reduced Field Size 
FL84 
Remarks 
2 
AN 
48 
FL80 Remarks 
2 
AN 24* 
Reduced Field Size 
FL84 
Remarks 
3 
AN 
48 
FL80 Remarks 
3 
AN 24* 
Reduced Field Size 
FL84 
Remarks 
4 
AN 
48 
FL80 Remarks 
4 
AN 24* 
Reduced Field Size 





FL81 Code-Code - QUAL/CODE/VALUE 
a 
AN/AN/AN 2/10/12 
New 





FL81 Code-Code - QUAL/CODE/VALUE 
b 
AN/AN/AN 2/10/12 
New 





FL81 Code-Code - QUAL/CODE/VALUE 
c 
AN/AN/AN 2/10/12 
New 





FL81 Code-Code - QUAL/CODE/VALUE 
d 
AN/AN/AN 2/10/12 
New 
FL85 
Provider Rep. Signature 
1 
AN 
22 
Deleted from UB-04 



FL86 
Date Bill Submitted 
1 
Date 
6 
Deleted from UB-04; See FL45, line 23 




 

3.	Improved Information Technology

CMS has simplified the claims submission process, effective July 1996, by accepting only national standard electronic claim formats.  This means that CMS only accepts electronic claims in the American National Standards Institute (ANSI) 837 4010A1 format for institutional providers.  

Through the use of the uniform bill, we have been able to achieve a more uniform and a more automated bill processing system for fiscal intermediaries and providers.  This form is consistent with the CMS electronic billing specifications, i.e., all coding data element specifications are identical.  This has promoted and eased the conversion to electronic billing.  Provider billing costs have decreased as a result of standardization of bill preparation, related training and other activities.  The average cost to process a line 1 Part A claim in FY 2004 was $.92 per claim.  

In the electronic media claims process, the Medicare intermediary adjudicates the bill using its computer system after obtaining approval from CMS's Common Working File (CWF) system.

4. 	Duplication of Efforts

Most hospitals participate in both Medicare and many other insurance programs and, without use of the CMS-1450, would have to maintain distinct and duplicate billing systems to handle the billing form, the tape formats, and the diagnostic coding systems for the many programs.  The purpose of the requirements in this package is to eliminate this duplication.  There is no one form that can accommodate as much information as the CMS-1450 does; nor is there another that can handle a variety of services the way the uniform bill does.  

The CMS-1450 is managed by the National Uniform Billing Committee, a standard’s body sponsored by the American Hospital Association.  Most major payers, such as the Blues network, the members of the Health Insurance Association of America, as well as the state hospital associations, are represented on this body.	 

5.	Small Businesses

Burden can be minimized by providing training materials and by obtaining assistance from the uniform bill coordinator designated by each CMS regional office. 

    6. Less Frequent Collection

The use of the UB-04 will not result in less frequent collection than obtained using the UB-92.  

7. 	Special Circumstances

There are no special circumstances.

8.	Federal Register Outside Consultation

We published a notice with a 60-day comment period proposing the information collection on February 24, 2006.

9.	Payments/Gifts To Respondents

There are no payments and gifts to respondents.

10.	Confidentiality	 

Privacy Act requirements have already been addressed under a Notice Systems of Record entitled "Intermediary Medicare Claims Record" system number 09-70-0503, DHHS/CMS/OIS. 

11.	Sensitive Questions

No questions of a sensitive nature are asked.

12.	Burden Estimates (Hours & Wages)

Currently 98.8 percent of all Medicare intermediary bill receipts are EMC.  Application of this percentage to our calendar year 2005 volume of 174,461,278 bills results in the following estimate of burden:

Hardcopy bills at 1.2% = 1.2% x 179,489,721 bills = 2,054,917 bills 
Hardcopy burden = 9 minutes per hardcopy bill x 2,054,917 =  
308,237 hours

EMC bills at 98.8% = 98.8% x 179,489,721  = 177,335,844 bills 

EMC burden = 0.5 minutes per EMC bill x 177,335,844 bills = 1,477,799 hours

Total burden:     308,237    Hardcopy burden
           1,477,799    EMC burden
 --------------------------
           1,786,036    Total burden	        		 

Since the UB-04 will be completed by clerical staff or contractor billing staff, it is unclear of the total wages necessary to complete the form.

13.	Capital Cost

There is no capital or operational costs associated with this collection.

14.	Cost to the Federal Government

The annual costs to the Federal government for the information collection activity include all aspects of the data collection function from the initial data entry to receipt/processing operations.  The costs to the Federal Government for data collection can best be described as the total costs of processing the required billing information.  Calculation of the precise costs for the data collection is not feasible for the purposes of the Paperwork Reduction Act without conducting a costly study.  Therefore, aggregate costs have been developed taking into consideration programming, software, training, tapes, overhead costs, etc.

15.	Changes to Burden

The previous OMB approved burden submission was for the UB-92 renewal.  This is a new burden for the UB-04.  

16.	Publication/Tabulation Dates

The purpose of this data collection is payment to providers for Medicare services rendered.  We do not employ statistical methods to collect this information, but rather all Medicare institutional providers generate this billing information subsequent to the delivery of services.  

17.	Expiration Dates

Previous forms have been cleared without the expiration date present.  Placing the expiration date of the form would require form changes.  Since CMS is not responsible for the design and content of the UB-04 we would have to seek approval from the NUBC, which has responsibility for the UB-04, to make the change. 

18.	Certification Statement

There are no exceptions to the certification statement.

    C. Collection of Information Employing Statistical Methods

This information collection does not employ statistical methods.