FLs 42-49 on the UB-04 claim are used to record and total the cost of each service received during the billing period reflected on the claim. Two main types of revenue codes are reported in FL 42: accommodation revenue codes (010X-021X) and ancillary service revenue codes (022X-099X). An accommodation revenue code is used to identify the types of routine hospital bed, room accommodation, and board charges that are being billed on an inpatient claim. Ancillary service revenue codes identify services, other than routine room and board charges, that are incidental to the hospital stay. Ancillary service revenue codes are also used on all outpatient claims. Services such as radiology, laboratory, pharmacy, and anesthesia are represented by ancillary service revenue codes. On paper claims, the last line in FL 42, line 23, is used to report revenue code 0001, Total charges.
The revenue description field (FL 43) is used to report the standard abbreviated text for describing each revenue code listed in FL 42. This field is also used to individually describe "other" revenue codes—codes ending in 9 and available with most revenue code categories for describing a code not otherwise listed in that category.
Line 23 of FL 43 includes the text " PAGE OF ". This should be filled in on all pages of the claim.
FL 44 (HCPCS/Rate/HIPPS Code) is used to report one of three types of information, depending on the type of claim. (a) On outpatient claims, FL 44 is used to report the appropriate HCPCS codes for ancillary services. Medicare rules require using HCPCS codes when billing all hospital outpatient medical and clinical services. (b) On inpatient claims, FL 44 is used to report the appropriate accommodation rate, reflecting the type of room and board. Dollar values for accommodation rates must include whole dollars, the decimal, and cents (for example, $425.99). (c) FL 44 is also used to report the HIPPS rate code for claims associated with the SNF, home health, and inpatient rehabilitation facility Prospective Payment Systems.
FL 45 (Service Date) contains the line item date of service—the date on which the corresponding outpatient service listed on the same line in FL 42 was provided. For Medicare outpatient claims, a line item date of service is required for every line where a HCPCS code is required. Line 23 of FL 45 contains a field for reporting the claim's
creation date (MMDDYY).
The unit of service associated with each revenue code line is reported in FL 46 (Service Units); the type of service unit used varies with different revenue code categories. Examples include the number of accommodation days, emergency room visits, renal dialysis sessions, and miles traveled in an ambulance.
The Total Charges field (FL 47) is used to report the total charges for the current billing period pertaining to each revenue code line listed in lines 1-22 of FL 42. Line 23 is used to report the sum total of all line item charges on the claim. For Medicare claims, charges for noncovered services are first subtracted from the total so that the sum total in FL 47 includes covered charges only. For all other claims, the sum total field includes covered and noncovered charges.
FL 48, Noncovered Charges, is used to indicate any noncovered charges on the claim. Lines 1-22 list noncovered charges for individual line items, and line 23 indicates the sum total of all noncovered charges from lines 1-22.
