UB04 Charge Entry screen manages the entry and edit of UB04 charges. Some key points related to UB04 Charge Entry are:

1. UB04 charge entry is used for institutional claims only.

2. There is no mapping between CPT codes and diagnosis.

3. Revenue codes are mandatory, whereas CPT codes are not.

Shown in Image 1 is a sample UB04 charge entry screen.

Image 1

4. All institutional cases and corresponding encounters are displayed on the left. To add a new encounter, click on button in the Encounters pane. To edit an encounter, click on encounter on the left. Table 1 describes the important fields in the UB04 charge entry screen. Box numbers in the UB04 charge entry form are given in brackets wherever applicable.

Field Description
Acct. Date Accounting Date. Defaults to the current date
Rendering Provider This is a drop-down field listing all the providers.
Type of Bill A 4-digit alphanumeric code having a leading zero. In order to view the list, double click in the field. Either select from the list or manually type a 4-digit code.

# Case number. Only institutional claims are listed in the drop-down. To add a new inst. case, click on button. To edit a case, click on button
Statement Cover Period(6) Provide the beginning and ending dates of the period included on this bill
Admission Date(12)  Date of Admission
HR(13) Admission Hour
TYPE(14) This is a code indicating the priority of this admission. Double click to view the code list.

SRC(15) The code indicating the source of the referral for this admission or visit.
DHR(16) Discharge hours
STAT(17) This code indicates the patient’s status as of the “Through” date of the billing period
Condition Codes(18-28) Describes any of the following conditions or events that apply to this billing period. Double click to view the list.

Occurrence Code and Date(31-34) Enters code(s) and associated date(s) defining specific event(s) relating to this billing period. Double click on the drop-down list to view the occurrence code list
Occurrence Span Code and Date(35,36) The Occurrence Span Code can contain an occurrence code where the “Through” date would not contain an entry. Occurrence and Occurrence Span codes are mutually exclusive.
Treatment Auth.Code (63) Required when authorization or referral number is assigned by the payer and then the services on this claim AND either the services on this claim were preauthorized or a referral is involved.
Document Control #(64 a,b) The control number assigned to the original bill by the health plan or the health plan’s fiscal agent as part of their internal control.
Principal & Other Diagnosis Code (67) The first box contains the ICD code for the principal diagnosis. Enters the full ICD codes for up to eight additional conditions if they co-existed at the time of admission or developed subsequently,
Value Codes & Amount (39-41)  Code(s) and the related dollar or unit amount(s) identify data of a monetary nature that are necessary for the processing of this claim.
Admit DX (69) Admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization
Patient Reason DX  (70)  Patient’s Reason for Visit is required for all un-scheduled outpatient visits for outpatient bills.
Principal procedure Code and Date

Other Procedure Code and Date(74, 74a, 74b, 74c)

 Principal Procedure code and Date are required on inpatient claims when a procedure was performed. Not used on outpatient claims.

Other Procedure codes and Date required on inpatient claims when additional procedures must be reported. Not used on outpatient claims.

Rev. Code The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. Double click to view the revenue code list. Select one as appropriate.

HCPCS Code  If the service requires, in addition to the revenue center code, an HCPCS procedure code, provide it here.
DOS (From, To) From and Two Dates of Service
M1, M2, M3, M4 Modifiers
Units, UOM, Charges, Total Units, Unit of Measure, Charge per unit and Total charge
Non-covered Charges The total non-covered charges pertaining to the related revenue code are entered here.
Paid Amount paid so far
Adj. Amt. Adjustment Amount (if any)
Adj. Reason Reason for Adjustment
Balance Balance to be paid for the bill
Line Status Select the appropriate value from the drop-down. BILL-TO_PR, BILL_TO_SE, REBILL_TO_PR, CLAIM_REBILLED_TO PR, CLAIM_REBILLED_TO_SE, HOLD, PAID_CLOSE, VOID, etc., are some of the statuses.
Attending Provider (76) The name and identification number of the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/ encounter.
Operating Provider (77) The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s).
Serv.Location Service Location
Remarks Any notes pertaining to the bill can be added here