UB-92 Form

Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied. Below is the downloadable UB-92 forms designed to facilitate successful claim submissions. Examples of claim forms and potential codes that may be appropriate when billing for Cathflo and related services are included as well.

Note: Select the appropriate billing code when filing all claims. Billing codes should be based on diagnosis and the services provided.

UB-92 Form (interactive PDF)
Example of UB-92 (PDF)

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How to complete the UB-92

The UB-92 is the form accepted by CMS for hospitals and free-standing clinics to use when billing Medicare Fiscal Intermediaries (FI). UB-92 forms can be submitted either electronically or on paper ("hard copy"). The UB-92 was adopted in 1992 to replace the UB-82.

Providers billing with the UB-92 must supply specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPC. The number of services rendered and the charge for these services depends on the facility's charge master.

The following table lists instructions for completing a UB-92 form. Bill fields are also known as locator or location codes.

Locator or Location Code	Instruction
1	Enter the provider's name, address, and telephone number.
2	Leave blank.
3	Enter the Patient Control Number, which is not required by Medicare but can be used by providers for internal patient identification.
4	Enter the appropriate three-digit code. First digit—describes your facility type Second digit—describes your facility sub-type Third digit—"1" (admit through discharge claim, encompassing entire services provided for that service period) or "5" (late charge only for stand-alone late charges omitted from initial bill) or "7" (to designate that this claim replaces a previously submitted claim) or "8" (cancel the entire prior claim). Centers submitting a claim with an "8" as the final digit should indicate why this form is being submitted (ie, duplicate claim) in the Remarks section (location 84).
5	Enter the Federal Tax ID Number for the service provider.
6	Enter the beginning and ending dates of service. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd. Most statements span a 30- or 31-day period. If there is a break in service days, such as for an inpatient hospitalization, then contact your FI to determine how to designate this on the UB-92 form.
7-11	Leave blank.
12	Enter the patient's name as it appears on his or her Medicare card (last name, first name, middle initial).
13	Enter the patient's full mailing address (including street name, city, state, and ZIP code).
14	Enter the patient's date of birth. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd.
15	Enter the patient's sex ("M" for male or "F" for female).
16	Leave blank.
17	Enter the patient's admission date.
1822	Leave blank.
23	Enter the medical record number.
24-30	Enter the condition codes if applicable.
31	Leave blank.
32-36	Check with your intermediary to verify the format for admissions or other breaks in service. If the patient is within his or her 30-month coordination period, enter "33" in one of these fields. If there is a break in service, such as an admission, enter a date in locator 36 and enter code "74" in the code section.
37	Leave blank.
38	Leave blank.
39-41	Enter the appropriate code and amount for certain services such as blood and blood products.
42	Enter the appropriate Revenue Code. Revenue Codes are based on type of service provided and billed for. Insert appropriate Revenue Code.
43	Enter the Revenue Code narrative description to match the code in locator 42. Insert appropriate description.
44	Enter Healthcare Common Procedural Coding System (HCPCS). The Healthcare Common Procedural Codes (HCPC) for certain services are set locally by the Fiscal Intermediary; check with your intermediary for specific information. Insert appropriate HCPC code.
45	Leave blank.
46	Enter the units of service. Furthermore, most FIs may reimburse an additional $0.50 for the supplies.
47	Enter total charges. For hard copy claims enter "Revenue Code 001" to designate the total charges for that claim.
48	Leave blank.
49	Leave blank.
50	Enter up to three payers: "A" "B" and "C."
51	Enter the provider number.
52-57	Leave blank.
58	Enter up to three individuals who are responsible for insurance coverage: "A" "B" and "C."
59	Enter the patient's relationship to the insured: "A" "B" and "C."
60	Enter the Certificate/Social Security Number/HI Claim/Identification number for "A" "B" and "C."
61	Enter the group name.
62	Enter the group identification number.
63	Leave blank.
64	Leave blank.
65	Leave blank.
66	Leave blank.
67	Enter the Primary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart.
68-75	Enter the Secondary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart.
7681	Leave blank.
82	Enter the attending physician's UPIN.
83	Leave blank.
84	Enter remarks required by your FI.
85	Have the provider representative sign and date this locator.

The submission criteria for completing the UB-92 form may vary. To ensure all local submission criteria are met, providers should contact their representative before submitting claims.