1. (a) The following elements from the UB-04 reporting standard shall be submitted as follows:

   1. (1) UB-04 Form Locator 01, “billing provider name, address and telephone number”;
   2. (2) UB-04 Form Locator 02, “pay-to name and address”;
   3. (3) UB-04 Form Locator 03a, “patient control number”;
   4. (4) UB-04 Form Locator 03b, “medical/health record number”;
   5. (5) UB-04 Form Locator 04, “type of bill”;
   6. (6) UB-04 Form Locator 05, “federal tax ID number”;
   7. (7) UB-04 Form Locator 06, “statement covers period from/through”;

   8. (8) UB-04 Form Locator 08, “patient name/identifier”, which shall be divided into 4 distinct components containing:

      1. a. Patient last name;
      2. b. Patient first name;
      3. c. Patient middle name, if available; and
      4. d. Patient generational identifier suffix, if available;

   9. (9) UB-04 Form Locator 09, “patient address street, city/town, state, 5-digit zip code, and country code” which shall be:

      1. a. “YYYYY” 5-digit zip code for other country residents; and
      2. b. “XXXXX” 5-digit zip code for unknown or no fixed address;
   10. (10) UB-04 Form Locator 10, “patient birth date”;
   11. (11) UB-04 Form Locator 11, “patient sex”;
   12. (12) UB-04 Form Locator 12, “admission/start of care date”;
   13. (13) UB-04 Form Locator 13, “admission hour”;
   14. (14) UB-04 Form Locator 14, “priority (type) of admission or visit”;
   15. (15) UB-04 Form Locator 15, “point of origin for admission or visit”;
   16. (16) UB-04 Form Locator 16, “discharge hour;
   17. (17) UB-04 Form Locator 17, “patient discharge status”;

   18. (18) UB-04 Form Locator 18 through 28, “condition codes”, which shall:

       1. a. Be submitted as recorded; and
       2. b. Be collected, recorded, and submitted where applicable for “02” = Patient alleges the medical condition or injury causing this episode of care is due to the employment environment or events such as workers' compensation or black lung;

   19. (19) UB-04 Form Locator 31 through 34, “occurrence codes and dates”, which shall:

       1. a. Be submitted as recorded; and
       2. b. Be collected, recorded, and submitted where applicable for 04 = Accident/employment related;
   20. (20) UB-04 Form Locator 35 and 36, “occurrence span codes and dates”;
   21. (21) UB-04 Form Locator 38, “insured date of birth, sex, and address”, if applicable;

   22. (22) UB-04 Form Locator 39 through 41, “value codes and amounts”, which shall:

       1. a. Be submitted as recorded; and

       2. b. Be collected, recorded, and submitted where applicable for:

          1. 1. 54 = Newborn Birth Weight in Grams; and
          2. 2. P0 = For newborns, mother’s medical record number;
   23. (23) UB-04 Form Locator 42, “revenue codes”;
   24. (24) UB-04 Form Locator 44, “HCPCS or CPT/accommodation rates/HIPPS rate codes”, except the length limit shall not apply;
   25. (25) UB-04 Form Locator 45, “service dates”;
   26. (26) UB-04 Form Locator 46, “service units”;
   27. (27) UB-04 Form Locator 47, “total charges”;
   28. (28) UB-04 Form Locator 50, “payer name – primary, secondary, tertiary”, except the length limit shall not apply;
   29. (29) UB-04 Form Locator 51, “health plan identification number – primary, secondary, tertiary”;
   30. (30) UB-04 Form Locator 56, “national provider identifier – billing provider”;
   31. (31) UB-04 Form Locator 57, “other billing provider identifier”;
   32. (32) UB-04 Form Locator 58, “insured name – primary, secondary, tertiary”;
   33. (33) UB-04 Form Locator 59, “patient’s relationship to insured – primary, secondary, tertiary”;
   34. (34) UB-04 Form Locator 64, “document control number”;

   35. (35) UB-04 Form Locator 65, “employer name (of the insured)”, which shall:

       1. a. When the employer is not known, be recorded as “UNKNOWN”; and
       2. b. When not employed, be recorded as “NA.”;
   36. (36) UB-04 Form Locator 66, “diagnosis and procedure code qualifier (ICD version indicator)”;
   37. (37) UB-04 Form Locator 67, “principal diagnosis code and present on admission indicator” which for the present on admission (POA) element shall only be recorded on inpatient discharges;
   38. (38) UB-04 Form Locator 67A-Q, “other diagnosis codes and present on admission indicator” which for the POA element shall only be recorded on inpatient discharges;
   39. (39) UB-04 Form Locator 69, “admitting diagnosis code”;
   40. (40) UB-04 Form Locator 70A-C, “patient’s reason for visit codes”;
   41. (41) UB-04 Form Locator 72A-C, “external cause of injury (ECI) codes and present on admission indicator”, which shall be reported in order for every applicable principal and other diagnoses;
   42. (42) UB-04 Form Locator 74, “principal procedure code and date”;
   43. (43) UB-04 Form Locator 74A-E, “other procedure codes and dates”;
   44. (44) UB-04 Form Locator 76, “attending provider name and identifiers”;
   45. (45) UB-04 Form Locator 77, “operating physician name and identifiers”;
   46. (46) UB-04 Form Locator 78 and 79, “other provider (individual) names and identifiers”;
   47. (47) UB-04 Form Locator 80, “remarks”; and

   48. (48) UB-04 Form Locator 81A-D, “code-code field”, which shall:

       1. a. Be submitted as recorded; and
       2. b. Be collected, recorded, and submitted for 81 which means race and ethnicity.
2. (b) The health care facility shall submit information to the department regarding primary language spoken as the health care facility has coded it in spreadsheet format, mapping internal codes to the language.
3. (c) Whenever health care facility internal mapping changes occur, the health care facility shall submit to the department an updated spreadsheet initially required in (b) above.

4. (d) The following shall not be submitted in the discharge data set:

   1. (1) UB-04 Form Locator 04 “Type of Bill” is equal to 018x (Hospital Swing Beds);
   2. (2) Professional claims, those typically billed on a CMS 1500 billed under the hospital tax ID number or other tax ID numbers except the technical component of professional claims and bundled technical/professional claim lines at critical access hospitals;
   3. (3) Lab specimen only encounters;
   4. (4) Pre-hospital ambulance encounters;
   5. (5) Primary care practices; and
   6. (6) Rural health clinics.

Source. # 9436, eff 3-21-09, EXPIRED: 3-21-17 New. #12139, INTERIM, eff 3-22-17, EXPIRED: 9-18-17 New. #13369, eff 4-20-22 (formerly He-C 1503.04)