What is the difference between the CMS-1500 and UB-04 forms? That is a question that seems to get tossed around a lot, so in this guide, we’ll break down each form to determine how and when each should be used. For more information about billing processes, please read the Billing Guide for Physical therapists.
While the CMS-1500 and UB-04 forms may look similar, they are very different and have distinct purposes. Thus, the two forms cannot be used interchangeably. First, let’s look at the individual forms and see why they are different in their functions.
This is the standard health insurance claim form used for submitting physician and professional claims to bill Medicare providers. In other words, the CMS-1500 is used for individual provider claims and is used to submit charges under Medicare Part-B.
Understanding CMS-1500's definition ensures physicians and healthcare professionals use the CMS-1500 form to file medical claims accurately. Form CMS-1500 is a paper claim form that health care providers use to bill carriers of Medicare.
Most paper claims that are submitted to Medicare are read via Optical Character Recognition (OCR) technology, so you’ll need to fill out the form in red ink. You’ll also need to be sure that you’ve thoroughly completed every necessary section of the form prior to submitting it.
Physicians can submit the CMS-1500 form electronically, although paper claims are still in use. The payment will depend on different factors, including the patient's condition, the network status between the client and the patient and any previous settings.
A CMS-1500 claim form has approximately 33 fields that gather information about the patient, professional, and the treatment process. Every claim form needs to be duly completed for the payer to process the payments. Therefore, healthcare professionals should consult with the payer to understand the billing procedures.
To use electronic claims, both parties must agree on the billing process. Some payers will need a prior third-party agreement before processing the claims. The transactions should meet the EDI requirements. Unique electronic filing codes will minimize mistakes in the claims process.
As of 2007, the UB-04 replaced the UB-92. The AHA (American Hospital Association) and the NUBC (National Uniform Billing Committee) oversee and monitor the use of the UB-04 to ensure it is up-to-date and equally useful for patients, medical providers and insurance companies. The UB-04 is the claim form for institutional facilities, and includes the following:
The form would be used for surgery, radiology, laboratory, or other facility services. This form is used to submit charges under Medicare Part-A.
All institutional providers may use the UB-04 form to bill claims, such as hospitals, specialists, mental health centers, hospices, rehabs, organ procurement organizations and therapy services.
The UB form can be cumbersome. Here are some tips to consider:
There are multiple things to keep in mind when filing a claim form. Notably:
One will quickly notice that the UB-04 form has more than twice the amount of fields than the CMS-1500. This is because hospital billing has many more codes and services in their complex system.
Even though the UB-04 is used to submit charges for Part-A providers, those same providers can still use the UB-04 to bill for Part-B services. This would be most common for institutional facilities such as licensed rehab facilities and SNF’s. The distinction is inpatient (UB-04) and outpatient (CMS 1500 or UB-04 if provided under an institutional license).
Both the CMS-1500 and UB-04 forms contain many of the same boxes that need to be filled out including patient demographics, provider identification information, procedures and charges and insurance plan identification information. The more information you can provide to the patient’s insurance company, the better. It is important to include information like when the first occurrence began, is it recurring or onset, if it was related to an accident, etc. Also, always be sure to recheck all claims for coding accuracy.
Unfortunately, there still may be gray areas as to which form is required. While both the CMS-1500 and UB-04 forms help to process the medical claim of a patient, the insurance company is reimbursing the services and they will reject the claim if it doesn’t meet their criteria. If you still have questions about these forms, the friendly representatives at StrataPT can help. Backed by our 100% US-based customer support, we are the leading business operating system for PT/OT practices in the US and offer exclusive solutions centered around ease of onboarding, revenue cycle management and transparent patient reporting.