Code Description Category - Department of Human Services

1 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/2 BED Room & Board - Semi-private Two Bed 0122 OB - OB/2 BED Room & Board - Semi-private Two Bed 0123 Pediatric - PEDS/2 BED Room & Board - Semi-private Two Bed 0124 Psychiatric - PSTAY/2 BED Room & Board - Semi-private Two Bed 0136 Detoxification - DETOX/3&4 BED Room & Board.

2 Semi-Private - Three and Four Beds 0137 Oncology - ONCOLOGY/3&4 BED Room & Board - Semi-Private - Three and Four Beds 0138 Rehabilitation - REHAB/3&4 BED Room & Board - Semi-Private - Three and Four Beds 0139 Other - OTHER/3&4 BED Room & Board - Semi-Private - Three and Four Beds 0150 General Classification - ROOM-BOARD/WARD Room & Board - Ward 0151 Medical/Surgical/GYN - MED-SUR-GY/WARD Room & Board - Ward 0152 OB - OB/WARD Room & Board Ward 0153 Pediatric - PEDS/WARD Room & Board Ward 0154 Psychiatric - PSYCH/WARD Room & Board Ward Provider Handbook UB 92 1 PA PROMISe Provider Handbook 837 Institutional/UB-92 Claim Form Revenue Code Description Category 0156 Detoxification - DETOX/WARD Room & Board Ward 0157 Oncology - ONCOLOGY/WARD Room & Board Ward 0158 Rehabilitation - REHAB/WARD Room & Board Ward 0159 Other - OTHER/WARD Room & Board Ward 0170 General Classification - NURSERY Nursery 0171 Newborn Level I - NURSERY/LEVELI Nursery 0172 Newborn Level II - NURSERY/LEVELII Nursery 0175 Neonatal ICU 0179

3 Other Nursery - NURSERY/OTHER Nursery 0183 Therapeutic Leave - LOA/THERAPEUTIC Leave of Absence 0185 Hospital Bed Days LOA/HOSPITAL BED DAYS Leave of Absence 0200 General Classification - INTENSIVE CARE (or ICU) Intensive Care 0201 Surgical - ICU/SURGICAL Intensive Care 0202 Medical - ICU/MEDICAL Intensive Care 0203 Pediatric - ICU PEDS Intensive Care Psychiatric - ICU/PSTAY Intensive Care 0206 Intermediate ICU - ICU/INTERMEDIATE Intensive Care 0207 Burn Care - ICU/BURN CARE Intensive Care 0208 Trauma - ICU/TRAMA Intensive Care 0209 Other Intensive Care - ICU/OTHER Intensive Care 0210 General Classification - CORONARY CARE (or)

4 CCU) Coronary Care 0211 Myocardial Infarction - CCU/MYO INFARC Coronary Care 0212 Pulmonary Care - CCU/PULMONARY Coronary Care 0213 Heart Transplant - CCU/TRANSPLANT Coronary Care 0214 Intermediate CCU - CCU/INTERMEDIATE Coronary Care 0219 Other Coronary Care - CCU/OTHER Coronary Care 0250 General Classification - PHARMACY Pharmacy (Also see 063X, an extension of 025X) 0251 Generic Drugs -DRUGS/GENERIC Pharmacy (Also see 063X, an extension of 025X) 0252 Non-generic Drugs - DRUGS/NONGENERIC Pharmacy (Also see 063X, an extension of 025X) 0254 Drugs Incident to Other - DRUGS/INCIDENT ODX Pharmacy (Also see 063X, an extension of 025X) 0255 Drugs Incident to Radiology - DRUGS/INCIDENT RAD Pharmacy (Also see 063X, an extension of 025X) 0257 Non-prescription - DRGS/NONPSCRPT Pharmacy (Also see 063X, an extension of 025X) 0258 IV Solutions - IV SOLUTIONS Pharmacy (Also see 063X, an extension of 025X)

5 Provider Handbook UB 92 2 PA PROMISe Provider Handbook 837 Institutional/UB-92 Claim Form Revenue Code Description Category 0259 Other Pharmacy - DRGS/OTHER Pharmacy (Also see 063X, an extension of 025X) 0260 General Classification - IV THERAPY IV Therapy 0261 Infusion Pump - IV THER/INFSN PUMP IV Therapy 0262 IV Therapy/Pharmacy Svcs - IV THER/PHARM/SVC IV Therapy 0263 IV Therapy/Drug/Supply Delivery IV THER/DRUG/SUPPLY DELV IV Therapy 0264 IV Therapy/Supplies - IV THER/SUPPLIES IV Therapy 0269 Other IV Therapy - IV THERAPY/OTHER IV Therapy 0270 General Classification MED-SUR SUPPLIES Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X)

6 0271 Non Sterile Supply NON-STER SUPPLY Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0272 Sterile Supply STERILE SUPPLY Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0274 Prosthetic/Orthotic Devices PROSTH/ORTH DEV Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0275 Pacemaker PACE MAKER Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0276 Intraocular Lens INTRA OC LENS Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0278 Other Implant (a) SUPPLY/IMPLANTS Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0279 Other Supplies/Devices SUPPLY/OTHER Medical/Surgical Supplies and Devices (also see 062X, an extension of 027X) 0280 General Classification ONCOLOGY Oncology 0289 Other Oncology ONCOLOGY/OTHER Oncology 0300 General Classification LABORATORY or (LAB)

7 Laboratory 0301 Chemistry LAB/CHEMISTRY Laboratory 0302 Immunology LAB/IMMUNOLOGY Laboratory 0304 Non-Routine Dialysis LAB/NR DIALYSIS Laboratory 0305 Hematology LAB/HEMATOLOGY Laboratory 0306 Bacteriology & Microbiology LAB/BACT-MICRO Laboratory Provider Handbook UB 92 3 PA PROMISe Provider Handbook 837 Institutional/UB-92 Claim Form Revenue Code Description Category 0307 Urology - LAB/UROLOGY Laboratory 0309 Other Laboratory - LAB/OTHER Laboratory 0310 General Classification - pathology LAB or (PATH LAB)

8 Laboratory Pathological 0311 Cytology - PATHOL/CYTOLOGY Laboratory Pathological 0312 Histology - PATHOL/HYSTOL Laboratory Pathological 0314 Biopsy -PATHOL/BIOPSY Laboratory Pathological 0319 Other Laboratory Pathological PATHOL/OTHER Laboratory Pathological 0320 General Classification DX X-RAY Radiology - Diagnostic 0321 Angiocardiography DX X-RAY/ANGIO Radiology - Diagnostic 0322 Arthrography DX X-RAY/ARTH Radiology - Diagnostic 0323 Arteriography DX X-RAY/ARTER Radiology.

9 Diagnostic 0324 Chest X-Ray DX X-RAY/CHEST Radiology - Diagnostic 0329 Other Radiology - Diagnostic DX X-RAY/OTHER Radiology - Diagnostic 0330 General Classification RX X-RAY Radiology - Therapeutic and/or Chemotherapy Administration 0331 Chemotherapy Administration - CHEMOTHER/INJ Radiology - Therapeutic and/or Chemotherapy Administration 0332 Chemotherapy Administration - CHEMOTHER/ORAL Radiology - Therapeutic and/or Chemotherapy Administration 0333 Radiation Therapy RADIATION RX Radiology - Therapeutic and/or Chemotherapy Administration 0335 Chemotherapy Administration - IV CHEMOTHERP-IV Radiology - Therapeutic and/or Chemotherapy Administration 0339 Other Radiology - Therapeutic RX X-RAY/OTHER Radiology - Therapeut