UB-04 Information (5010 Only) Attachment (UB04) 

If the UB Payer check box is selected for the primary carrier in the Ins field at the top of the Procedure Entry screen and/or the UB Billing check box is selected in the Location Code Table for the Location selected, this attachment will be triggered.

 

 

Prompt Response Req Len
Type of Bill Box 4 Enter the type of bill.   50
Admission Date Box 6A and 12 Enter the date you want or click the calendar icon to select a date.   10
Discharge Date Box 6B Enter the date you want or click the calendar icon to select a date.   10
Admission Hour Box 13 Enter the Admission Hour.   50
Admission Type Box 14 Enter the Admission Type.   50
Admission Src Box 15 Enter the Admission Src.   50
Discharge Hour Box 16 Enter the Discharge Hour.   50
Discharge Status Box 17 Enter the Discharge Status.   50
Condition Code Box 18 to Box 28 Enter the Condition Code(s).   50
ACDT State Box 29 Enter the ACDT State.   50
Local Use Box 30     50
Occurrence Code Box 31A to Box 34B Enter the Occurrence Code(s).   50
Occurrence Date Box 31A to Box 34B Enter the date you want or click the calendar icon to select a date.   10
Occurrence Span Code Box 35A to Box 36B Enter the Occurrence Span Code(s).   50
Occurrence Span Start Date Box 35A to Box 36B Enter the Occurrence Span Start Date(s) you want or click the calendar icon to select a date.   10
Occurrence Span End Date Box 35B to Box 36B Enter the Occurrence Span End Date(s) you want or click the calendar icon to select a date.   10
Local Use Box 37A and Box 37B     50
Value Code Box 39A to Box 41D Enter the Value Code(s).   50
Value Amount Box 39A to Box 41D Enter the Value Amounts(s).   50
Authorization Box 63A to Box 63C Enter the Authorization(s).   50
Document Control Box 64A to Box 64C Enter the Document Control(s).   50
Admit Diagnosis Code Box 69 Enter the code(s) you want or click the magnifying glass to search the table.   1
Patient Reason Dx Box 70A to Box 70C Enter the code(s) you want or click the magnifying glass to search the table.   1
PPS Code Box 71 Enter the PPS Code.   1
External Cause of Injury Box 72B to Box 72C Enter the code(s) you want or click the magnifying glass to search the table.   1
Local Use Box 73     50
Principal Procedure Code Box 74 Enter the Principal Procedure Code.   50
Principal Procedure Date Box 74 Enter the date you want or click the calendar icon to select a date.   10
Other Procedure Code Box 74A to Box 74E Enter any Other Procedure Code(s).   50
Other Procedure Date Box 74A to Box 74E Enter any Other Procedure Date(s) you want or click the calendar icon to select a date.   10
Remarks Box 80A to Box 80C Enter any Remark(s).   50
Local Use Box 81 CCA to Box 81 CCD     50