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Occurrence Codes and Dates

FLs 31-34 of the UB-04 are used to record significant occurrences connected with claims that affect how payers evaluate them. For example, the fact of an automobile accident or the dates on which speech therapy was provided affect payments for claims. The payer needs to know the details of the occurrence—in particular, the date it happened—to decide what benefits are due. The events may be related to such factors as liability decisions, patient coverage, the appropriateness of the services rendered, and Medicare Secondary Payer (MSP) development during the admissions process.

Two other fields of the UB-04, FLs 35 and 36, Occurrence Span Codes and Dates, are used to report similar information. In these two form locators, however, the significant event being reported is defined by a span of time rather than by a single date. For example, occurrence span code 76 (Patient liability) is used to report a period of noncovered care for which the patient is responsible. Another code, occurrence span code 70, is used to report a period of skilled nursing-level care that occurs during an inpatient acute care hospital stay. The period must be at least a three-day stay.

Chapter 10 also covers FLs 37 and 38. FL 37 is an unlabeled field reserved for national assignment. FL 38 (Responsible Party Name and Address) is not required for Medicare billing but is used on commercial claims to report the name and mailing address of the beneficiary or other person responsible for the bill. FL 38 is positioned on the UB-04 so that the address will show through the window of the envelope if the claim is mailed in an envelope with a window.

As is the case with the condition codes described in Chapter 9, many members of the hospital staff—not only the patient account specialist—must coordinate their work to identify and assign correct occurrence codes and occurrence span codes for timely filing. Chapter 10 describes each occurrence code and occurrence span code briefly and provides billing tips when appropriate. Appendix A also contains a list of occurrence codes for easy reference.

Discuss the codes that are used in FLs 31–34 of the UB-04 to report significant events, or occurrences, connected with claims that affect how they are processed and paid.

Understand the four categories of occurrence codes.

Discuss the types of codes that are used in FLs 35–36 of the UB-04 to report occurrence spans and dates.

Explain various billing situations that arise when particular occurrence codes and occurrence span codes are used.

Recognize which occurrence codes and occurrence span codes contain data that must be coordinated with other fields on the UB-04.

Explain what information belongs in FL 38, Responsible Party Name and Address, of the UB-04 form.

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