Delay reason codes (previously billing limit exception codes)

ub comp op UB-92 Completion: Outpatient Services The UB-92 Claim Form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis services and Adult Day Health Care). See UB-92 Completion: Inpatient Services in the Part 2 Inpatient Services Manual for billing instructions for services rendered to a registered hospital inpatient. If the patient is treated as an outpatient in a hospital different from the one in which the patient is registered, the services must be billed by the treating hospital using the UB-92 Claim Form with the appropriate facility type code (which is the first two digits in the Type of Bill field [Box 4]) for the outpatient facility. Most claims for outpatient services can also be submitted through Computer Media Claims (CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1 manual. For additional billing information, refer to the UB-92 Special Billing Instructions for Outpatient Services, UB-92 Submission and Timeliness Instructions and UB-92 Tips for Billing: Outpatient Services sections in this manual. Note: Certain codes that providers enter on the UB-92 Claim Form changed as a result of the federally mandated Health Insurance Portability and Accountability Act (HIPAA). The following codes changed for Outpatient providers: Delay reason codes (previously billing limit exception codes) Condition codes Facility type and frequency codes (for purposes of this manual, the two-digit facility type code replaces the Medi-Cal Place of Service code) Admit type code (used only when designating emergency services) Claims for dates of service prior to September 22, 2003, must include the appropriate Medi-Cal local code. Claims for dates of service on or after September 22, 2003, must bill the appropriate national code. Claims for services rendered to the same recipient for dates of service both prior to and on or after September 22, 2003 must be submitted on separate claims (split billed), except when billing “from-through” services. Refer to the Code Correlation Guide at the end of this section to see the correlation between local and national codes. A handy HIPAA In Review guide also is included at the end of this section that summarizes important HIPAA implementation changes. a b 38 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C A B C a b c d 4 TYPE OF BILL 1 A B C a b c d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C a b a b a b LEAVE BLANK PATIENT ACCOUNT NUMBER 2 3 PATIENT CONTROL NO. PROVIDER NAME/ADDRESS/ZIP CODE TYPE OF BILL CODE NA NA 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD FROM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 11 NA NA NA NA NA NA NA 1 PATIENT’S NAME PATIENT’S ADDRESS 2 PATIENT NAME 13 PATIENT ADDRESS ADMISSION CONDITION CODES 3 DELAY REASON CODE 1 14 BIRTHDATE 15 SEX 16 MS 17 DATE 18 HR 19TYPE 20 SRC 21 DHR 22STAT 23 MEDICAL RECORD NO. 24 25 26 27 28 29 30 DOB SEX NA NA NA NA NA ––– CONDITION CODES ––– TYP NA TYPE NA 32 OCCURRENCE 33 OCCURRENCE 34 OCCURENCE 35 OCCURRENCE 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH A NA –––––––– OCCURRENCE CODES AND DATES –––––––– B C 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT –––––––––– VALUE CODES AND AMOUNTS –––––––––– a b c d 4 2 REV. CD. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 4 SERVICE CHARGE 7 TOTAL CHARGES 48 NON-COVERED CHARGES 4 MODIFIER 3&4 9 REVENUE CODE DESCRIPTION OF SERVICE PROC CD MOD1&2 DATE OF SERVICE UNIT OF SERVICE NA      

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