New UB-04 Hospital Claim Validation Edits

  • January 16, 2020

    As of claim process dates February 2, 2020 and after, new facility correct coding claim “validation” edits will be introduced in the Claims Editor. Here are a few things for you to know:

    • These edits are already used by CMS.
    • We already apply these edits for outpatient services; starting in February they will also apply to inpatient services.
    • Edits will confirm we have the information needed to process the claim.
    • The claim will be denied if it’s determined to not meet the requirement. If appropriate, you may correct the claim and resubmit.

    The new edits look at specific data elements that are/are not billed on an inpatient or outpatient hospital claim, depending on whether the data element is required or situational.

    Required data elements are needed on a claim in order to provide specific and key information about the patient or the situation necessitating the services being billed to allow for the claim to be processed. Such required data elements include but are not limited to principle diagnosis, bill type and frequency, or from and to dates.

    Situational data elements are data elements that may be needed depending on the situation or services being submitted for processing. Situational data elements include but are not limited to the patient account code, occurrence codes, or other procedure codes and dates.

    If you bill for either Inpatient or Outpatient hospital services via electronic submission (837i) or via paper (UB-04/CMS-1450), review the data elements/UB-04 FIELDS called out below that will be edited as of process dates February 2, 2020 and after.

    EDIT EDIT DESCRIPTION UB-04 CLAIM FIELD LOCATION AND DESCRIPTION
    Missing Account ID - Inpatient The account ID is missing from the claim. Field 3b - medical/health record number
    Invalid Condition Code The condition code <1> on the claim is invalid. Fields 18-28 - condition codes
    Patient DOB is Missing - Inpatient Patient's date of birth is missing on the claim. Field 10 - birthdate
    Patient DOB is Invalid - Inpatient Patient's date of birth <1>is invalid on the claim. Field 10 - birthdate
    Missing or Invalid Statement Covers Period From/Through Date - Inpatient Missing admission date or invalid statement covers period from or through dates. Field 6 - statement covers period: from-through
    Inpatient Facility Discharge Date Missing The discharge date is missing. Field 6 - statement covers period: from-through
    Inpatient Principal Procedure Required A principal procedure code is required when a procedure code is found in the other procedure code field. Field 74 - principle procedure: code and date
    Facility Medicare ICD-10 Code Rule Per CMS guidelines, ICD-10 codes can’t be billed for dates of service prior to October 1, 2015. Fields 67: principal diagnosis code
    Field 67a through 6yq: other diagnosis codes
    Facility Medicare ICD-9 Code Rule ICD-9 code types can’t be billed for dates of service greater than September 30, 2015. Fields 67: principal diagnosis code
    Field 67a through 6yq: other diagnosis codes
    Invalid Occurrence Code The occurrence code <1> on the claim is invalid. Fields 31-34: code and date
    Invalid Occurrence Span Code The occurrence span code <1> on the claim is invalid. Fields 35-36: occurrence span: code and from/through dates
    Missing Patient ID - Inpatient No patient ID was submitted on the claim. Field 8a: patient Id
    Interim Claims with Frequency Code 2 and 3 Requires Patient Discharge Status Code 30 - Inpatient Per Medicare guidelines, the patient discharge status code must be 30 [still patient] when the frequency digit is the type of bill 2 [Interim- First Claim] or the frequency digit is the type of bill 3 [Interim- Continuing Claim]. Field 4: type of bill
    Field 17: discharge status
    Missing Provider ID - Inpatient The provider ID is missing from the claim. Field 76:attending
    Field 77: operating
    Fields 78-79: other
    Point of Origin for Admission is Required on all Institutional Claims with the Exception of 014X Point of origin for admission is missing or invalid. Field 15: point of origin for admission/visit
    Missing Type of Admission This claim has a missing type of admission code. Field 14: priority/type of admission
    Invalid Type of Admission This claim has an invalid type of admission code <1>. Field 14: priority/type of admission
    Type of Admission Frequency Type of admission code 4 (newborn), can’t be billed more than once in a lifetime. Field 14: priority/type of admission
    Invalid Type of Bill - Inpatient The type of bill code is invalid or missing. Field 4: type of bill
    Missing or Invalid Type of Bill - Inpatient The type of bill code is invalid. Field 4: type of bill
    Invalid Value Code This claim has an invalid value code <1>. Fields 39-41: value codes and amounts

    Here are more resources for completing the UB-04/CMS1450 form or the ASC X12 837i electronic claim form:

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