The UB-04 claim form contains a set of four fields for reporting physician ID information—FLs 76–79. FL 76 identifies the name, the NPI, and the secondary identifier of the licensed physician who normally would be expected to certify the medical necessity of the services rendered and/or who has primary responsibility for the
patient's medical treatment. On inpatient claims this refers to the physician who is responsible for the care of the patient from the beginning of the hospital episode. For outpatient claims it refers to the physician who requested the surgery, therapy, diagnostic tests, or other services.
If there is a surgical procedure on the claim, FL 77 identifies the name, the NPI, and an optional secondary identifier of the licensed physician who performed the surgical procedure. If the physician identified here is the same as the attending physician, the same information is repeated in both form locators. FLs 78 and 79 are used
to report the name, the NPI, and the secondary identifier of other provider types who were involved in the patient's medical care. The format for FLs 78 and 79 is similar to the format for FLs 76 and 77; however, FLs 78 and 79 require a two-digit qualifier code for specifying the type of provider being reported. For example, qualifier code DN indicates that the provider listed in FL 78 or 79 is a referring provider. The provider type qualifier code is reported in the two-digit field that precedes the NPI field in FLs 78 and 79.
The UB-04 also contains a text field for remarks. FL 80 (Remarks) is used to provide information that is necessary to adjudicate the claim and that is not shown elsewhere on the claim. This may be, for example, an explanation of noncovered days and charges, a description of an unlisted procedure code, a note indicating that the claim is a PPS interim bill, the reason for a denial by another insurance carrier, an explanation of why a particular trauma code is not eligible for MSP, the dates to be corrected on a replacement claim, or the rental rate and purchase information for certain equipment on Medicare DME claims.
FL 81, the Code-Code field, is used to report overflow codes from other form locators and/or information represented by externally maintained code sets approved by the NUBC for use with the UB-04. The qualifier code is used in the first column in FL 81 to indicate the type of code and information being reported, such as a value code or
taxonomy code. The actual code itself is listed in the middle column, and the date, numeric value, or amount that may be associated with the code is reported in the right column. Up to four lines, labeled a–d, are available in FL 81 for reporting four different codes.
