HCR 203 Week 2 UB-04 Form Worksheet

Complete the University of Phoenix Material: UB-04 Form Worksheet.

Click the Assignment Files tab to submit your assignment.

UB-04 Form Worksheet

Resources: Section 17.6 in Ch.17 of Medical Insurance, Table 17.1 “UB-04 Form Completion” and Figure 17.4 “UB-04 Form”

Review the resources listed above.

Complete the tables below.

Determine the data field number the data given should be placed on the UB-04 form. An example has been provided.

Data Field Number	Data
3a	The patient control number
	The patient name
	The patient’s date of birth
	Admission Date
	Source of admission-Point of origin of admission
	Admission Hour
	Occurrence codes
	Revenue codes
	Revenue code description
	Total charges
	Estimated amount due
	Insured’s Name
	Insured’s Group number
	Diagnosis codes
	Procedure codes
	Principal diagnosis
	Admitting diagnosis
	External cause of injury
	Attending provider’s name
	Operating physician’s name

Determine the data that needs to be listed under the data field number given of the UB-04 form. An example has been provided.