CMS-1450 (UB-04) claims — coding for services provided

The CMS-1450 (UB-04) form is the industry standard for submitting institutional claims for inpatient and outpatient services. CMS publishes guidelines for completing the CMS-1450 when billing for services. For more information, refer to the Medicare Claims Processing Manual: Chapter 25 – Completing and Processing the Form CMS-1450 Data Set (PDF).

The National Uniform Billing Committee maintains codes required when using the CMS-1450 form. These include revenue codes, condition codes, occurrence codes, value codes.

Kaiser Permanente also requires that all CMS-1450 claims submitted are reported using the specific code sets as adopted by HIPAA. The code sets for procedures, diagnoses, and drugs are:

• Healthcare Common Procedure Coding System (HCPCS) for ancillary services/procedures
• Current Procedural Terminology (CPT-4) for medical services and procedures performed by physicians and other qualified health professionals
• International Classification of Diseases, version 10 (ICD-10-CM) for diagnosis and hospital inpatient procedures (ICD-10 PCS)
• National Drug Codes (NDCs) are required to be included for all drugs and biologicals that have NDCs. Also required are the NDC quantity and appropriate qualifier (e.g., GR, ML, UN, F2).

Refer to each specific code set for instructions in using these codes appropriately. Some basic coding rules to keep in mind are:
Use only codes that are valid for the date of service.
Link CPT codes to revenue codes when required.
Follow OCE edit guidelines where required.
Follow all guidelines for diagnosis coding. Special attention should be given to the following requirements:

• Diagnosis codes should be coded to the highest specificity required for each code.
• Refer to (ICD-10) for Principal, Admitting, Patient Reason, Other, and External Cause of Injury diagnosis coding.

Some field elements to note include:
Field 56: List the 10-position National Provider Identifier (NPI).
Field 57: Include the appropriate taxonomy code for all lines of business.
Fields 66-67: Present on admission (POA) indicators must be submitted with primary and secondary diagnoses for acute care hospitals or other facilities subject to Center for Medicaid and Medicare Services regulations for reporting POA information. These should be reported for all lines of business. For more information, see POA indicators for inpatient claims: Provider Q&A (PDF).

Units of service

Follow guidelines for billing appropriate units for each service.
Some codes also have guidelines regarding the maximum number of units which can be billed on the code. For more information, refer to the guidelines located in the CMS documents for Medically Unlikely Edits (MUEs).