HCR 203 Week 2 UB-04 Form Worksheet

Entire Course Download Link

https://uopcourses.com/category/hcr-203/

 
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
 
 

 
 
Powered by