Delay reason codes (previously billing limit exception codes)




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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.


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4 TYPE

OF BILL




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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

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14 BIRTHDATE

15 SEX

16 MS

17 DATE

18 HR

19TYPE

20 SRC

21 DHR

22STAT

23 MEDICAL RECORD NO.

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DOB


SEX

NA

NA

NA

NA NA

––– CONDITION CODES –––













TYP







NA TYPE










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OCCURRENCE

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OCCURRENCE

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OCCURENCE

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OCCURRENCE

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OCCURRENCE SPAN

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CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

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THROUGH

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NA

–––––––– OCCURRENCE CODES AND DATES ––––––––

































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VALUE CODES




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VALUE CODES




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VALUE CODES







CODE

AMOUNT




CODE

AMOUNT




CODE

AMOUNT





–––––––––– VALUE CODES AND AMOUNTS ––––––––––



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2 REV. CD.

43 DESCRIPTION

44 HCPCS / RATES

45 SERV. DATE

46 SERV. UNITS

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CHARGE

7 TOTAL CHARGES


48 NON-COVERED CHARGES


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MODIFIER
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REVENUE CODE




DESCRIPTION OF SERVICE




PROC CD MOD1&2




DATE OF SERVICE




UNIT OF

SERVICE











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