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PA PROMISe Provider Handbook 837 Institutional/UB-92 Claim Form Inpatient Revenue Codes for Fee-for-Service Providers Revenue Code Description Category 0001 Total Charge 0100 All-Inclusive Room and Board Plus All Inclusive Rate 0110 General Classification ROOM-BOARD/PVT Room & Board - Private 0111 Medical/Surgical/GYN MED-SUR-GY/PVT Room & Board - Private 0112 OB OB/PVT Room & Board - Private 0113 Pediatric PEDS/PVT Room & Board - Private 0114 Psychiatric PSYCH/PVT Room & Board - Private 0116 Detoxification DETOX/PVT Room & Board - Private 0117 Oncology ONCOLOGY/PVT Room & Board - Private 0118 Rehabilitation REHAB/PVT Room & Board - Private 0119 Other OTHER/PVT Room & Board - Private 0120 General Classification ROOM-BOARD/SEMI Room & Board - Semi-private Two Bed 0121 Medical/Surgical/GYNMED-SUR-GY/2BED Room & Board - Semi-private Two Bed 0122 OB - OB/2BED Room & Board - Semi-private Two Bed 0123 Pediatric - PEDS/2BED Room & Board - Semi.

Inpatient Continuous - DIALY/INPT/CAPD Ambulatory Peritoneal Dialysis (CAPD) Inpatient Renal Dialysis Provider Handbook UB –92 7. PA PROMISe™ Provider Handbook 837 Institutional/UB-92 Claim Form Revenue Code Description Category 0804 Inpatient Continuous DIALY/INPT/CCPD Cycling ...

  Dialysis, Continuous, Ambulatory, Peritoneal, Dcap, Capd ambulatory peritoneal dialysis

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