[Solved]: Assignment 19.5 Completing the UB-04 Using workbook Fig

Assignment 19.5 Completing the UB-04 Using workbook Fig 19.1 and information in the textbook, answer the following questions regarding the UB-04. 1. Match the following fields on the UB-04 to the description of the data they should contain. Be careful as some of the answers indicate more than one FL 1. FL 50 -51(A-C) 2. FL 10 3. FL 74 4. FL 17 5. FL 3 (a-b) 6. FL12 7. FL42 8. FL44 9. FL46 10. FL 53 11. FL63 (A-C) 12. FL 77 13. FL 1 14. FL 18-28 15. FL 4 16. FL 61-62 17. FL 72 18. FL 69 19. FL 43 20. FL 8-9 a. FL description of services that link to the revenue code b. FL revenue codes based on type of service or item c. FL number of days, quarterly of items or dose of medications for each revenue code d. FL patient’s name and address e. FL type of bill code f. FL insured’s group name and number g. FL discharge status such as home, SNF, or expired h. FL admitting diagnosis code i. FL patient identifiers such as account number and medical record number j. FL operating physician name and identifier k. FL payer names and identification numbers l. FL treatment authorization code m. FL condition codes that may affect processing of the claim n. FL principal procedure code and date o. FL external cause of injury code and the present on admission indicator p. FL admission date q. FL patient date of birth r. FL HCPCS codes or accommodation rates s. FL assignment of benefits authorization indicator t. FL billing provider name, address and telephone number 2. Based on information in workbook Fig 19.1, workbook Fig 19.2 and the textbook, answer the following questions. a. What is the Type of Bill code that would be entered in FL 4 if the UB-04 encompassed the patient’s entire inpatient admission? 111 b. Did the patient complete paperwork allowing the insurance companies to pay the hospital directly? ____________________ Where would this be indicated on the UB-04? ______________________ c. On the final page of the UB-04, what line would list the total charges and what revenue code would be listed? _____________, _________________ What is the amount that would appear on Ms. Smith’s claim form? ___________________ d. Based on the patient’s summary sheet, what are some value codes that may be listed in box 39 to assist the processing of the claim? _____________ and ______________ e. How many nights was Ms. Smith in the hospital? Where is this information reflected on the UB-04? f. Where was Ms. Smith admitted from? ____________ Where is this information reflected on the UB-04? _____________ What code would be used? _____________ g. Where was Ms. Smith discharged to? ____________ Where is this information reflected on the UB-04? ______ What code would be used? __________________ h. What would be entered in FLL74? ____________________ i. What information would be entered in FL76? _______________________ j. What information would be entered in FL 69? __________________