Ophthalmology and Optometry Coding Alert

Question: I used to bill for a facility and am new to the role of practice manager on the physician side. Can you explain to me when a practice would use the CMS-1500 form instead of the UB-04?

South Dakota Subscriber

Answer: As a physician practice, you shouldn’t need to use the UB-04 form and you would only use the CMS 1500 form for professional fee services.

Here’s why: Professional providers should generally submit claims using the CMS-1500 forms and institutional providers should submit claims using the UB-04.

If you are managing a freestanding ambulatory surgical center, things are a bit different. ASCs typically report services globally on the CMS-1500. However, you may need to use both forms, depending upon payer requirements. Hospital-based ASCs generally use the UB-04 form for facility charges and the CMS-1500 form for the professional charges of the physician, but again check payer guidance.

The definitions of the UB-04 and CMS-1500 are as follows:

• CMS-1500: The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim.

• UB-04 Form: An electronic format of the CMS-1450 paper claim form that has been in general use since 1993.