Question: CMS-1500 And UB-O4 Claims 179 ASSIGNMENT 11.4 – COMPLETING THE UB-04 CLAIM OBJECTIVES At The Conclusion Of This Assignment, The Student Should Be Able To: 1. Explain The Purpose Of The UB-01 Dalm. 2. Complete The UB-04 Dalm, Following Daims Completion Instruction OVERVIEW The UB Of Daim Contains Data Entry Blocks Called Form Locator (PLA) That Are Similar …

CMS-1500 and UB-O4 Claims 179 ASSIGNMENT 11.4 – COMPLETING THE UB-04 CLAIM OBJECTIVES At the conclusion of this assignment, the student should be able to: 1. Explain the purpose of the UB-01 dalm. 2. Complete the UB-04 dalm, following daims completion instruction OVERVIEW The UB of daim contains data entry blocks called form locator (PLA) that are similar to the CMS-1500 claim blocks used to input information about procedures or services provided to a patient. Although some institutions marmally complete the UB-04 dalm and submit it to third-party payers for reimbursement, others perform data entry of UB-04 Information using commercial software However, most institutions do not complete the UB-O because it is automatically generated from chargemaster data entered by providers leg. more, therapists, laboratory, and so on). Data are transmitted to the facility Milling department by providers who dircle procedure/service CPT/HCPCS codes on a paper based chargemaster (after which keyboarding specialists enter the code into the facility’s computer) or select codes using a hand-held computer, such as a personal digital distant (PDA) (and click to transmit the codes). INSTRUCTIONS Complete a separate UB-01 dalm for each case study Blank UB-01 dalms can be copied from Appendix Tof the textbook or calms can be printed from the Student Companion Website at www.cengagebrain.com. Eater 9876543211 as the NPT for Alfred State Medical Center in F156. For the purpose of this assignment, enter data in the following UB-04 ferm locators . ..13 – FLI • Pla – FL – FLO • PLA F15 • PLC – FUL • FLS • FL FEA FLAT • P.IO 2 (DATE) .PL • FL43 • FLA . FLAS • FL46 CREATION DATE • TOTALS . 1.50 • LSI F1.52 FL53 F156 • PL.SE . 159 • 41.60 PL16 ( for ICD-10-CM) • FL67 • H.21 1176 • HL80 • PLC Note: Enter letter for You In Form Locator 53 ASG. BEN. (assignment of benefits on each completed UB-04 claim. The patient in each outpatient case has agreed to the sigment of benefits so that the provider is reimbursed directly by the payer 180 Chapter 11 CUADO-040 OUTPATIENT CASE #1 MOD-SUSHTONES 1903 Alfred Medical Center. 548 N Main St. Alfred NY 14802 Outpatient Case #1 BE (607) 555-1234 EIN: 871349061 TOB 131 PET BLE GEOFA BADEOF OUTRA Mary Sue Patient 859451563867 0605YYYY 1300 Physician referral MATALIN TELEONE ME GER 10 Main St, Alfred NY 14802 (607) 555-2345 10-15-1980 Pemale (P) -டாயா CALCIO LANCHE NOTES Single (5) 123456 BCHS 1350 Discharged Home MERCERIT PARTY AND ALTUNGEOME Mary Sue Patient 10 Main St, Alfred NY 14802 63596365 LOOP LOINT ESAU OP EMPLOYER Selt (18) Employed Pull Time (1) city College, Alfred NY SHOP ALE HEALM RAD Comercial 506G BCRS, P.O. Box 761, Buffalo NY 14201 123456789 TYPE OF ADEON Blective (3) 100 DOG Hypothyroidism B03.9 Terry Smith, M.D. 2376902906 MER Patient was registered in the outpatient clinic and underwent venipuncture for repeat T3 and T4 update laboratory test for hypothyroidism. Patient discharged home, to be followed by primary physician. CHARGE DESCRIPTION MASTER Printed on 08/05/TTY ALL CAI, CA 548 KN SY ALTRED HT 14001 DEPOT CORE 01.955 DEPARTE Laboratory RVICE CODE BGSDO02 565002 ERVICE BRRIPTIGH and Toptake, TIR Vesipuincture REVIGE DOOR 0901 0009 CIT COOR 14479 36415 GORGE 74.50 24.95 EV 0.90 0.50 181 CMS-1500 and UB-04 Claims OUTPATIENT CASE #2 San TTSTUO Alized Medical Center. 548 X Main St. Mfred NY 14802 Outpatient Case #2 (607) 555-1234 EIN: 871349061 TOB: 131 TE NORGE OF NEWTON James World 645791254301 0401YYYY 0400 Physician referral WEN NEWTORE 7416 Light Street, Anywhere NY 12345 (101) 111-7700 03-08-1992 Male (N) TOU NON BEARS KAMAL SALUD MARTO MALERMER Single (8) 746381 Aetna 0600 Discharged Home ENRY LE RIVAROSS ELUNNEER James World 7416 Light Street, Anywhere NY 12345 32569841 PENT HELD ENTRS MO Self (18) Koployed Pull Time (1) Security R Us MYWALNE HAUR PARD Comercial 2114 Aetna, PO Box 45, Stillwater PA 12345 7485713659 INMON PORER TYPE ONE Sejal Raja, M.D. 5548732106 Elective (3) GAMES BOSE COLE Patient was registered in the outpatient clinta Cardiac Arrhythmia and underwent Rod with Interpretation. Patient 149.9 (Unspecified) discharged home, to be followed by primary physician. CHARGE DESCRIPTION MASTER Printed on 04/01/TITY ALIKE MEDICAL CENTE 540 IND IT ALFRED HT 14001 DETARTGRT CODE 01.953 DEPARTMENT Radiolony SERVICE COON B650400 SERVICE DESCRIPTION Be with interpretation KEVERK CODE 0730 GPT CODE 93000 EVO CELOR 75.00 182 Chapter 11 na to OUTPATIENT CASE W3 Altred Medical Center. 548 N Main St. Alfred NY 14802 (607) 555-1234 KINI 149061 TOB: 131 Outpatient Case #3 NINT CONTROL MATEROWENT GERAL Audry Waddoups 846279461307 0809YYYY 0900 Physician referral URTAR TELE UNIH MRE 8990 Date St, Anywhere NY 12345 (101) 124-5789 10-19-1972 Female (F) WELL GAL WER Married (N) 976431 Health Net 1200 Discharged Home OPERTY LETY MED John Waddoupa 8990 Date St, Anywhere NY 12345 316497 NINCS PLOT PLOVER Spouse (01) Pamployed Pull Time (1) Ldfetime Books ALTRAD Comercial 348 Health Net, PO Box 9900, New York NY 12300 1024867932 TYPEOF AN Tina Betker, M.D. 4567890123 Klective (3) CD ON Patient was registered in the outpatient clinie and undervent evaluation. Patient discharged Aathan (Acute) J45.901 with exacerbation home, to be followed by primary physician. CHARGE DESCRIPTION MASTERS ALTINDOTCL GOTTES HUBY FREM 14101 Printed on 08/09/ DOPLNIT CES: 01.900 DEPARTMENTS Outpatient Service ERVICE CON SOLG SERVICE CENTER Outpatient evaluatie, Level TI, paket VULCE esco CTT COS 102 GAR 65.00 VO 0.65 CMS-1500 and U3-04 Claims 183 OUTPATIENT CASE #4 Alfred Medical Center. 548 N Main St Alfred NY 14802 (607) 555-1234 EIN: 871349061 TOB: 131 Outpatient Case #4 IM OF OWENT MORGEON Todd Terry 546987254361 02-07-YYYY 1400 Physician referral WARNIR TILENCE 115 Glenn Street, Anywhere NY 12345 (101) 555-8457 12-30-1985 Male () ANUL MOCHAINE Married ( 648570 Trioare 2000 Discharged Home LE Todd Terry 115 Glenn Street, Anywhere NY 12345 342870 MIS MU Bolt 18) Reployed Pull Time (1) US Navy GER PER LA ERLER Tricare, PO Box 2107. Tricity sc 76654 1144886250 w TROFA Arnold Young. M.D. 0123458760 Klective (3) w Patient was registered in the outpatient clinic Pont-traumatic 943.12 and underwent 45-minute paychotherapy evaluation. stress disorder, Patient discharged home, to be followed by chronic primary physician. CHARGE DESCRIPTION MASTER Pettel 2/7/TTTT ALPED METAL DE 545 MINST LED 1412 DATE O 01.950 BETARET Peytaty BOX ELVIO BRITION Pythony. mim within ETVER CODE 0910 DT DOOR GULAGE 350.00 VU 0.70 184 Chapter 11 OUTPATIENT CASE #5 Alfred Medical Center. 548 N Main St Alfred NY 14802 (607) 555-1234 RIN: 871349061 TOB: 131 Outpatient Case #5 Na MINECROL DATUTE OF TENTA SOURCE OF ADUN Candy Santos 215478965230 05-01-YYYY 0230 Physician referral MEN MED TELEPHONE BOTH DE 3902 Hatzel St, Anywhere NY 12345 (101) 111-5128 06-16-1999 Female (1) MARITAL SUUS CAL RECORDER WWE OWNERO MENTS Single (8) 356478 Medicaia 0500 Discharged Home NURRY RESPONENTY ADDRESS HAIWANEIDER Candy Santos 3902 Hatzel Street, Anywhere NY 12345 241793 MINTOLAN EMPLOITATUS ME OF EMPLORER Self (18) Keployed Part Time (1) Fashion Joy PAR YER ALMADORES WEALTH PLANE Medicaid, PO Box 9800, New York NY 12300 1997458701 LERAS MER TYPE OF AMG Bill Maters, M.D. 1149678520 Klective (3) BART KOLE Patient was registered in the outpatient clinic Benign neoplasm of D24.1 and underwent excision of mass of right breast. right breast Patient discharged home, to be followed by primary physician. CHARGE DESCRIPTION MASTER ALFRED MICAL GOTT ALTID S 14802 Printed on 05/01/TITY DERARNET GEDE 01.957 DEPARTE Surgery SERVICE CODE B650101 BRVICE DRCRIPTION EVOU CODE os of . right breast 0314 CYT CODE 19120-T CHARGE 950.00 vo 1.05