UB-04 Highlights: Sample Claim
See Intravenous Therapy - UB-04 Highlights [PDF] to view a sample of the claim explained below.
Note: It may be helpful to print the sample claim, then return to this page.
| Form Identifier | Form Locator | Explanation |
|---|---|---|
| ❶ | 4 | Type of bill 131 indicates the type of facility is a hospital (1), the bill classification is outpatient (3) and the frequency is admission through discharge (1). |
| ❷ | 42 | Revenue code 260 is the correct code for intravenous therapy. Note: Do not use revenue code 280 to bill intravenous therapy. |
| ❸ | 44 | Locally assigned codes and HCPCS codes coincide with the appropriate revenue codes. |
| ❹ | 45 | Each day of treatment is listed on a separate line. Note: The date for the treatment room must be the same as the day the intravenous therapy was administered. |
| ❺ | 46 | Units correspond to the appropriate revenue codes for administration and for intravenous therapy. |
| ❻ | 67 | All drugs and services on the claim must be appropriate for the principal diagnosis code listed in form locator 67. |
Notes:
- Form Locator 46: Refer to Service Units for more information.
- Form Locator 67: For more information on the principal diagnosis code, refer to Diagnosis Coding for Principal Diagnosis.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |