Claims for hospital services, often called institutional claims, require a specific, standardized document for accurate processing by insurance payers. This standardized form is formally known as the UB-04. The UB-04 serves as the primary communication tool for hospitals, skilled nursing facilities, and other institutions to request payment from Medicare, Medicaid, and private insurance companies. Its structure captures the complex charges associated with a facility stay, from room and board to surgical supplies.
Identifying the Institutional Billing Form
The form used for billing hospital and other institutional services is the UB-04 (Uniform Billing Form), officially designated as the CMS-1450 by the Centers for Medicare and Medicaid Services. It is the mandatory method for facilities to submit charges for services like inpatient stays, outpatient procedures, and emergency room visits. The UB-04 is a highly structured document designed to standardize data elements across the industry.
The UB-04 is utilized by a wide range of institutional providers, including acute care hospitals, rehabilitation centers, skilled nursing facilities, and hospice agencies. Its purpose is to detail the charges incurred by the facility itself, covering the cost of the physical location, equipment, nursing care, and supplies. The form captures facility-related costs, which are distinct from the charges for professional services rendered by individual doctors.
The UB-04 contains 81 fields, or “form locators,” used to capture the necessary information for a payer to process the institutional claim. This standardized format simplifies the billing process for the millions of claims hospitals submit annually. By focusing on facility charges, the UB-04 ensures that operational healthcare costs are clearly and uniformly documented for reimbursement.
Key Data Elements and Reporting
The UB-04 utilizes unique data elements tailored to institutional billing, most notably Revenue Codes. These four-digit codes specify the department, type of service, or item being charged, translating patient care into billable data. For instance, a hospital room and board charge might use a code in the 011X series, while pharmacy charges would fall under the 025X series.
Every line item on the UB-04 must have a revenue code attached to identify the source of the service. These codes allow payers to understand precisely where the hospital’s costs originated, such as the operating room, laboratory, or radiology department. This system differs from the procedure codes used in non-institutional billing, as it focuses on the category of service provided within the facility.
The UB-04 also requires a “Type of Bill” (T.O.B.) code, a four-digit field specifying the type of facility, the type of care, and the sequence of the bill within a patient’s episode of care. The T.O.B. code helps payers correctly categorize and process the claim, indicating if it is an inpatient, outpatient, or skilled nursing claim, and whether it is the first, last, or an interim bill.
Patient Status Code
The form also includes the “Patient Status Code,” a two-digit code that identifies where the patient was discharged to, such as home, a skilled nursing facility, or another acute care hospital. This information helps insurance companies track the patient’s movement through the healthcare system and ensures appropriate payment.
Distinguishing Institutional vs. Professional Claims
A common source of confusion is receiving multiple bills for a single hospital stay, stemming from the distinction between institutional and professional claims. The UB-04 is solely for institutional billing, covering the facility’s charges for resources like the physical building, equipment, drugs, and nursing staff. The other standardized form, the CMS-1500, is used for professional claims, covering services rendered by individual, non-institutional providers.
The CMS-1500 is used by physicians, surgeons, anesthesiologists, and independent laboratories to bill for their specific time and expertise. For example, during surgery, the hospital uses the UB-04 to bill for the operating room and supplies, while the surgeon uses the CMS-1500 to bill for their professional fee.
This separation of billing authority ensures that facility costs and provider fees are accounted for distinctly. Institutional claims are submitted by the hospital or facility, while professional claims are submitted by the individual provider’s practice or billing service. The CMS-1500 is used primarily by non-institutional providers and is not designed to capture the complex revenue stream of a large facility.