HCR 203 Week 2 UB-04 Form Worksheet

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HCR 203 Week 2 UB-04 Form Worksheet
HCR 203 Week 2 UB-04 Form Worksheet
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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 NumberData
3aThe 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 NumberData
1Provider’s name and address
3b
5
9
13
14
17
18-28
29
39-41