Form CMS-1450 (UB-04)
This form, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third party payers. Because it serves many payers, a particular payer may not need some data elements. The National Uniform Billing Committee (NUBC) maintains lists of approved coding for the form. All items on Form CMS-1450 are described. The FI must be able to capture all NUBC-approved input data described in section 75 (of the Medicare Claims Processing Manual Chapter 25) for audit trail purposes and be able to pass all data to other payers with whom it has a coordination of benefits agreement.
CMS1450/UB04 Field: 42 - Revenue Code (Required)
The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. It must enter the appropriate numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47. Additionally, there is no fixed "Total" line in the charge area. The provider must enter revenue code 0001 instead in FL 42. Thus, the adjacent charges entry in FL 47 is the sum of charges billed. This is the same line on which non-covered charges, in FL 48, if any, are summed. To assist in bill review, the provider must list revenue codes in ascending numeric sequence and not repeat on the same bill to the extent possible. To limit the number of line items on each bill, it should sum revenue codes at the "zero" level to the extent possible.
Source: Adapted from the Medicare Claims Processing Manual Chapter 25 - Completing and Processing the Form CMS-1450 Data Set