Pediatric 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?

Answer:  As a pediatric practice, you shouldn’t need to use the UB-04 form. 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 for institutional providers.

Professional providers should generally submit claims using the CMS-1500 forms and institutional providers should submit claims using the UB-04.

Hospital-based ambulatory surgical centers (ASCs) generally use the UB-04 form for facility charges and the CMS-1500 form for the professional charges of the physician, but anyone performing services in an ASC should check payer guidance to determine which code they should report.