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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.
Data Field Number | Data |
1 | Provider’s name and address |
3b | |
5 | |
9 | |
13 | |
14 | |
17 | |
18-28 | |
29 | |
39-41 |