Medicare UB-04 Revenue Codes

1 Medicare UB-04 Revenue Codes Revised August 2010 National Government Services, Inc. For complete information regarding UB-04 coding please refer to the CMS IOM Publication 100-04, Chapter 25 1 294_0810 0001 Total Charge 002X HI Prosp Paymt System HIPPS 2 SNF PPS (RUG) 3 HH PPS (HRG) 4 IRF PPS (CMG) 0100 All-Inclusive Room & Board/Anc 1 All-Inclusive R&B 0110 Room/Board PVT 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0120 Room/Board SP 2 bd 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0130 Room/Board-SP 3-4 bd 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0140 Room/Board

2 PVT Deluxe 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0150 Room/Board Ward 1 Medical/surgical/gyn 2 OB 3 Pediatric 4 Psychiatric 5 Hospice 6 Detoxification 7 Oncology 8 Rehabilitation 9 Other 0160 Other Room/Board 4 Sterile environment 7 Self Care 9 Other 0180 Leave of Absence 2 Patient Convenience 3 Therapeutic leave 5 Nursing home (for hospitalization) 9 Other 0200 Intensive Care 1 Surgical 2 Medical 3 Pediatric 4 Psychiatric 6 Intermediate ICU 7 Burn Care 8 Trauma 9 Other Sub-acute Care 0210 Coronary Care 1 Myocardial infarction 2 Pulmonary care 3 Heart Transplant 4 Intermediate CCU 9 Other 0220 Special Charges 1 Admission 2 Technical support charge 3 service charge 4 Late discharge medically necsry 9 Other special charges 0230 Incremental Nursing Care 1 Nursery 2 OB 3 ICU (includes transitional care) 4 CCU (includes transitional care)

3 9 Other 0240 All Inclusive Ancillary 9 Other All Inclusive Ancillary 0250 Pharmacy 1 Generic drugs 2 Nongeneric drugs 4 Incident to other diagnostic services 5 Incident to radiology 7 Nonprescription 8 IV solutions 9 Other 0260 IV Therapy 1 Infusion pump 2 IV Therapy/ pharmacy services 3 IV Therapy/drug/supply/delivery 4 IV therapy/ supplies 9 Other IV therapy 0270 Medical/Surgical Supplies 1 Nonsterile supplies 2 Sterile supplies 3 Take home supplies 4 Prosthetic/orthotic devices 5 Pacemaker 6 Intraocular lens 7 Oxygen take home 8 Other implants 9 Other supplies/devices 0280 Oncology 9 Other oncology 0290 Durable Medical Equipment 1 Rental 2 Purchase new equipment 3 Purchase used equipment 4 Supplies/drugs for DME (HHA only) 9 Other equipment 0300 Laboratory 1 Chemistry 2 Immunology 3 Renal patient (home)

4 4 Nonroutine dialysis 5 Hematology 6 Bacteriology/microbiology 7 Urology 9 Other laboratory 0310 Laboratory Pathology 1 Cytology 2 Histology 4 Biopsy 9 Other 0320 Radiology Diagnostic 1 Angiocardiography 2 Arthrography 3 Arteriography 4 Chest X-ray 9 Other 0330 Radiology Therapeutic 1 Chemotherapy injected 2 Chemotherapy oral 3 Radiation therapy 5 Chemotherapy IV 9 Other 0340 Nuclear Medicine 1 Diagnostic procedures 2 Therapeutic procedures 3 Diagnostic radiopharmaceuticals 4 Therapeutic radiopharmaceuticals 9 Other 0350 Computed Tomographic (CT) Scan 1 Head Scan 2 Body Scan 9 Other CT scans 0360 Operating Room Services 1 Minor surgery 2 Organ transplant, other Than kidney 7 Kidney transplant 9 Other Operating Room Services 0370 Anesthesia 1 Incident to radiology 2 Incident to other diagnostic services 9 Other anesthesia 0380 Blood 1 Packed red cells 2 Whole blood 3 Plasma 4 Platelets 5 Leucocytes 6 Other components 7 Other derivatives (cryopricipitates)

5 9 Other blood 0390 Blood Storage/Processing 1 Blood administration ( transfusion) 2 Processing and storage 9 Other processing & storage 0400 Other Imaging Services 1 Diagnostic mammography 2 Ultrasound 3 Screening mammography 4 PET scan 9 Other imaging services 0410 Respiratory Services 2 Inhalation services 3 Hyperbaric oxygen therapy 9 Other respiratory services 0420 Physical Therapy 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation 9 Other physical therapy 0430 Occupational Therapy 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation

6 9 Other occupational therapy 0440 Speech-Language Pathology 1 Visit charge 2 Hourly charge 3 Group rate 4 Evaluation/re-evaluation 9 Other speech lang. pathology 0450 Emergency Room 1 ER/EMTALA 2 ER/beyond EMTALA 6 Urgent care 9 Other emergency room 0460 Pulmonary Function 9 Other 0470 Audiology 1 Diagnostic 2 Treatment 9 Other audiology 0480 Cardiology 1 Cardiac catheter lab 2 Stress test 3 Echo cardiology 9 Other cardiology 0490 Ambulatory Surgery 9 Other ambulatory surgical care 0510 Clinic 1 Chronic pain center 2 Dental clinic 3 Psychiatric clinic 4 OB/GYN clinic 5 Pediatric clinic 6 Urgent care clinic 7 Family Clinic 9 Other clinic 0520

7 Free-Standing Clinic 1 Rural health clinic 2 Rural health home 3 Family practice clinic 4 RHC/FQHC practitioner visit (Part A covered stay at a SNF) 5 RHC/FQHC practitioner visit (Noncovered Part A Stay SNF/NF/ ICF MR or other residential facility) 7 RHC/FQHC Visiting Nurse services(s) to a member's home in a HH shortage area 8 RHC/FQHC practitioner to other non RHC/FQHC site 9 Other 0530 Osteopathic Services 1 Osteopathic therapy 9 Other osteopathic services 0550 Skilled Nursing 0540 Ambulance 1 Visit charge 2 Hourly charge 9 Other skilled nursing 0560 Medical Social Services 1 Visit charge 2 Hourly charge 9 Other medical social services 0570 Home Health Aide 1 Visit charge 2 Hourly charge 9 Other home health aide 0580 Other Visits-HHA 1 Visit charge 2 Hourly charge

8 Medicare UB-04 Revenue Codes Revised August 2010 National Government Services, Inc. For complete information regarding UB-04 coding please refer to the CMS IOM Publication 100-04, Chapter 25 2 294_0810 3 Assessment 9 Other home health visits 0600 Oxygen (Home Health) 1 Stat equip/supply/content 2 Stat equip/supply under 1 LPM 3 Stat equip/supply/ over 4 LPM 4 Portable add-on 0610 Magnetic Resonance Tech. (MRT) 1 Brain (including brainstem) 2 Spinal cord (including spine) 4 MRI other 5 MRA head and neck 6 MRA lower extremities 8 MRA other 9 MRT - other 062X Med Surg.

9 Supplies Ext. of 270 1 Incident to radiology 2 Incident to other diagnostic service 3 Surgical dressings 4 Investigational device (IDE) 063X Pharmacy Extension of 025X 1 Single source drug 2 Multiple source drug 3 Restrictive prescription 4 EPO less than 10,000 units 5 EPO 10,000 or more units 6 Drugs requiring detailed coding 7 Self administrable drugs (insulin admin in emergency-diabetic coma) 065X Hospice 1 Routine Home Care 2 Continuous Home Care 5 Inpatient respite care 6 General inpatient care (non-respite)

10 7 Physician services 8 Hospice room & board nursing facility 9 Other hospice 068X Trauma Response 1 Level I 2 Level II 3 Level III 4 Level IV 9 Other trauma response 0700 Cast room_____ 0720 Labor Room 0710 Recovery Room_____ 1 Labor 2 Delivery 4 Birthing center 9 Other labor room/delivery 0730 EKG/ECG 1 Holter monitor 2 Telemetry 9 Other EKG/ECG 0740 Electroencephalogram EEG 0760 Specialty Services 0750 Gastro-Intestinal Services 1 Treatment room 2 Observation hours 9 Other specialty services 0770 Preventive Care Services 1 Vaccine administration 0780 Telemedicine 0790 Extra-Corporeal Shock Wave 0800 Inpatient Renal dialysis Therapy (formerly Lithotripsy) 1 Inpatient hemodialysis 2 Inpatient peritoneal (non-CAPD) 3 Inpatient CAPD 4 Inpatient CCPD 9 Other inpatient dialysi