Att L List of UB04 Data Elements

Att L List of UB04 Data Elements.docx

National Hospital Discharge Survey

Att L List of UB04 Data Elements

OMB: 0920-0212

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Attachment L: List of UB-04 Data Elements


FL

Description

FL01

[Billing Provider Name]

FL01

[Billing Provider Street Address]

FL01

[Billing Provider City, State, Zip]

FL01

[Billing Provider Telephone, Fax, Country Code]

FL02

[Billing Provider’s Designated Pay-to Name]

FL02

[Billing Provider’s Designated Pay-to Address]

FL02

[Billing Provider’s Designated Pay-to City, State]

FL02

[Billing Provider’s Designated Pay-to ID]

FL03a

Patient Control Number

FL03b

Medical/Health Record Number

FL04

Type of Bill

FL05

Federal Tax Number

FL05

Federal Tax Number

FL06

Statement Covers Period - From/Through

FL07

Unlabeled

FL07

Unlabeled

FL08

Patient Name/ID

FL08

Patient Name

FL09

Patient Address - Street

FL09

Patient Address - City

FL09

Patient Address - State

FL09

Patient Address - ZIP

FL09

Patient Address - Country Code

FL10

Patient Birthdate

FL11

Patient Sex

FL12

Admission/Start of Care Date

FL13

Admission Hour

FL14

Priority (Type) of Admission or Visit

FL15

Point of Origin for Admission or Visit

FL16

Discharge Hour

FL17

Patient Discharge Status

FL18

Condition Code

FL19

Condition Code

FL20

Condition Code

FL21

Condition Code

FL22

Condition Code

FL23

Condition Code

FL24

Condition Code

FL25

Condition Code

FL26

Condition Code

FL27

Condition Code

FL28

Condition Code

FL29

Accident State

FL30

Unlabeled

FL30

Unlabeled

FL31

Occurrence Code/Date

FL31

Occurrence Code/Date

FL32

Occurrence Code/Date

FL32

Occurrence Code/Date

FL33

Occurrence Code/Date

FL33

Occurrence Code/Date

FL34

Occurrence Code/Date

FL34

Occurrence Code/Date

FL35

Occurrence Span Code/From/Through

FL35

Occurrence Span Code/From/Through

FL36

Occurrence Span Code/From/Through

FL36

Occurrence Span Code/From/Through

FL37

Unlabeled

FL37

Unlabeled

FL38

Responsible Party Name/Address

FL38

Responsible Party Name/Address

FL38

Responsible Party Name/Address

FL38

Responsible Party Name/Address

FL38

Responsible Party Name/Address

FL39

Value Code

FL39

Value Code Amount

FL39

Value Code

FL39

Value Code Amount

FL39

Value Code

FL39

Value Code Amount

FL39

Value Code

FL39

Value Code Amount

FL40

Value Code

FL40

Value Code Amount

FL40

Value Code

FL40

Value Code Amount

FL40

Value Code

FL40

Value Code Amount

FL40

Value Code

FL40

Value Code Amount

FL41

Value Code

FL41

Value Code Amount

FL41

Value Code

FL41

Value Code Amount

FL41

Value Code

FL41

Value Code Amount

FL41

Value Code

FL41

Value Code Amount

FL42

Revenue Codes

FL43

Revenue Code Description/IDE Number/Medicaid Drug rebate

FL44

HCPCS/Accommodation Rates/HIPPS Rate Codes

FL45

Service Dates

FL46

Service Units

FL47

Total Charges

FL48

Non-Covered Charges

FL49

Unlabeled

FL50

Payer Identification - Primary

FL50

Payer Identification - Secondary

FL50

Payer Identification - Tertiary

FL51

Health Plan ID

FL51

Health Plan ID

FL51

Health Plan ID

FL52

Release of Information - Primary

FL52

Release of Information - Secondary

FL52

Release of Information - Tertiary

FL53

Assignment of Benefits - Primary

FL53

Assignment of Benefits - Secondary

FL53

Assignment of Benefits - Tertiary

FL54

Prior Payments - Primary

FL54

Prior Payments - Secondary

FL54

Prior Payments - Tertiary

FL55

Estimated Amount Due - Primary

FL55

Estimated Amount Due - Secondary

FL55

Estimated Amount Due - Tertiary

FL56

NPI – Billing Provider

FL57

Other Provider ID

FL57

Other Provider ID

FL57

Other Provider ID

FL58

Insured’s Name - Primary

FL58

Insured's Name - Secondary

FL58

Insured's Name -Tertiary

FL59

Patient’s Relationship - Primary

FL59

Patient's Relationship - Secondary

FL59

Patient's Relationship - Tertiary

FL60

Insured’s Unique ID-Primary

FL60

Insured's Unique ID - Secondary

FL60

Insured's Unique ID - Tertiary

FL61

Insurance Group Name - Primary

FL61

Insurance Group Name - Secondary

FL61

Insurance Group Name -Tertiary

FL62

Insurance Group No. - Primary

FL62

Insurance Group No. - Secondary

FL62

Insurance Group No. - Tertiary

FL63

Treatment Authorization Codes - Primary

FL63

Treatment Authorization Code - Secondary

FL63

Treatment Authorization Code - Tertiary

FL64

Document Control Number (DCN)

FL64

Document Control Number (DCN)

FL64

Document Control Number (DCN)

FL65

Employer Name (of the insured) - Primary

FL65

Employer Name (of the insured) - Secondary

FL65

Employer Name (of the insured) - Tertiary

FL66

Diagnosis and Procedure Code Qualifier (ICD Version Indicator)

FL67

Principal Diagnosis Code and Present on Admission (POA) Indicator

FL67A

Other Diagnosis and POA Indicator

FL67B

Other Diagnosis and POA Indicator

FL67C

Other Diagnosis and POA Indicator

FL67D

Other Diagnosis and POA Indicator

FL67E

Other Diagnosis and POA Indicator

FL67F

Other Diagnosis and POA Indicator

FL67G

Other Diagnosis and POA Indicator

FL67H

Other Diagnosis and POA Indicator

FL67I

Other Diagnosis and POA Indicator

FL67J

Other Diagnosis and POA Indicator

FL67K

Other Diagnosis and POA Indicator

FL67L

Other Diagnosis and POA Indicator

FL67M

Other Diagnosis and POA Indicator

FL67N

Other Diagnosis and POA Indicator

FL67O

Other Diagnosis and POA Indicator

FL67P

Other Diagnosis and POA Indicator

FL67Q

Other Diagnosis and POA Indicator

FL68

Unlabeled

FL68

Unlabeled

L69

Admitting Diagnosis Code

FL70a

Patient Reason for Visit Code

FL70b

Patient Reason for Visit Code

FL70c

Patient Reason for Visit

FL71

Prospective Payment System (PPS) Code

FL72a

External Cause of Injury Code and POA Indicator

FL72b

External Cause of Injury Code and POA Indicator

FL72c

External Cause of Injury Code and POA

FL73

Unlabeled

FL74

Principal Procedure Code/Date

FL74a

Other Procedure Code/Date

FL74b

Other Procedure Code/Date

FL74c

Other Procedure Code/Date

FL74d

Other Procedure Code/Date

FL74e

Other Procedure Code/Date

FL75

Unlabeled

FL75

Unlabeled

FL75

Unlabeled

FL75

Unlabeled

FL76

Attending Provider - NPI/QUAL/ID

FL76

Attending Provider – Last/First

FL77

Operating Physician - NPI/QUAL/ID

FL77

Operating Physician - Last/First

FL78

Other Provider - QUAL/NPI/QUAL/ID

FL78

Other Provider - Last/First

FL79

Other Provider - QUAL/NPI/QUAL/ID

FL79

Other Provider - Last/First

FL80

Remarks

FL80

Remarks

FL80

Remarks

FL80

Remarks

FL81

Code-Code - QUAL/CODE/VALUE

FL81

Code-Code - QUAL/CODE/VALUE

FL81

Code-Code - QUAL/CODE/VALUE

FL81

Code-Code - QUAL/CODE/VALUE



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorClarice brown
File Modified0000-00-00
File Created2021-02-01

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