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UB04 BILLING INSTRUCTIONS Nursing Facility & ICF/IID
a long term care hospital 18-28 Condition Codes Leave blank. 29 Accident State Leave blank. 30 Unlabeled Field Leave blank. 31-34 Occurrence Codes/Dates Leave blank. 35-36 Occurrence Spans (Code and Dates) Leave blank. 37 Unlabeled Leave Blank. 38 Responsible Party Name and Address Optional. 39-41 Value Codes and Amounts Required. Enter the ...
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