UB-04 fields

Field 1: Provider name and address

Field 2: Pay-to location

Field 3A: Patient control number

Field 3B: Medical health record number

Field 4: Type of bill

Field 5: Federal tax identification number

Filed 6: Statement covers period

Field 8: Patient name-ID number

Field 9: Patient address

Field 10: Patient birthdate

Field 11: Patient sex

Field 12: Admission date

Field 13: Admission hour

Field 14: Type of admission

Field 15: Source of admission

Field 17: Patient status

Field 18-28: Condition codes

Field 31-36: Occurrence codes

Field 38: Responsible party name and address

Field 39-41: Value codes (if applicable)

Field 42: Revenue code

Field 43: Description of revenue code

Field 44: HCPCS rates (CPT codes required if billing for lab, diagnostic or therapeutic procedures)

Field 45: Service date

Field 46: Service units (if applicable)

Field 47: Total charges (by revenue code category)

Field 48: Non-covered charges - primary payer (if applicable)

Field 50: Payer name

Field 51: Health plan ID (provider number)

Field 52: Release of information

Field 53: Assignment of benefits

Field 54: Prior payments (if applicable)

Field 55: Estimated amount due

Field 56: National provider identification (NPI)

Field 57: Other/payer identification

Field 58: Insured's name

Field 59: Patient's relationship to insured

Field 60: Policy holder's contract number

Field 61: Group name

Field 62: Group number

Field 66: Internal classification of disease (ICD) version qualifier

Field 67A-Q: Principal diagnosis; also see POA indicators

Field 69: Admitting diagnosis

Field 70: Patient reason for visit (DX)

Field 71: Prospective payment system (PPS) code

Field 72: External cause of injury

Field 73: DRG (inpatient only)

Field 76: NPI for attending physician

Field 77: NPI for operating physician

Field 78: NPI for the other physician