CurrentUnitedHealthcarePolicy N/A

UB-04 (CMS-1450) Patient Discharge Status coding for facility claims

Governance of required Patient Discharge Status coding on UB-04 (CMS-1450) facility claims for UnitedHealthcare Community Plan Medicaid product; applies to inpatient, outpatient, skilled nursing, hospice and home health facility claims submitted on UB-04 or electronic equivalent.

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 (CMS-1450) Patient Discharge Status coding for facility claims

Policy CodePolicy N/A

Change TypeNon-material revisions (coding and state exception updates)

Effective DateN/A

Next Review DateN/A

Key ActionAssign Patient Discharge Status codes that align with the Type of Bill (TOB); incorrect combinations will result in claim denials and follow Florida interim billing rules for stays over 100 days.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Guidelines: Duplicate verbiage removed and Discharge Status table updated.

Reimbursement Guidelines: Codes Section Updated.

State Exceptions: Florida updated.

UB-04billing form governed

Multiple TOBsTypes of bill requiring Patient Discharge Status

Code 30guidance re: 'Still Patient' usage

Florida interim rule

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Coverage Criteria

Reimbursement Guidelines: UnitedHealthcare Community Plan requires Patient Discharge Status codes that align with the type of bill (TOB) submitted. Providers must assign a Patient Discharge Status consistent with national UB-04 guidance and the NUBC definitions of type of bill and frequency.

ALL of the following

Patient Discharge Status codes are required for the following claim types: Hospital Inpatient Claims (TOBs 11X and 12X); Skilled Nursing Claims (TOBs 18X, 21X, 22X and 23X); Outpatient Hospital Services (TOBs 13X, 14X, 71X, 73X, 74X, 76X and 85X); and all Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X and 82X).
The appropriate type of bill is determined per NUBC guidance: first digit = leading zero, second digit = facility type, third digit = type of care being billed, fourth digit = sequence/frequency of the bill for an episode of care (frequency code).
The frequency (fourth) digit should align with the Patient Discharge Status reported. A TOB with a frequency reflective of an ongoing stay should have a discharge status indicating the patient is still receiving care; a final or discharge claim should have a status indicating the patient’s disposition at the conclusion of the encounter or through date of the claim.
If two or more Patient Discharge Status codes could apply, providers must report the highest level of care known.
UnitedHealthcare Community Plan will deny claims when the Patient Discharge Status is inconsistent with the type of bill reported. Example: discharge status 30 (Still Patient) is not appropriate with TOB 211 (Inpatient Nursing Home: Admit through discharge claim).
This policy applies to both inpatient and outpatient claims.
(See Questions and Answers)

Patient Discharge Status Coding

Patient Discharge Status codes (sample entries from table) - alternate formattingmixed

01	Discharged to home or self-care (routine discharge)
02	Discharged/transferred to a short-term general hospital for inpatient care
03	Discharged/transferred to skilled nursing facility (SNF) with Medicare certification
06	Discharged/transferred to home under care of organized home health service
07	Left against medical advice or discontinued care
09	Admitted as an inpatient to this hospital
20	Expired
30	Still patient
50	Hospice - home
51	Hospice - medical facility (certified)

Florida interim inpatient first billing threshold

Florida interim billing sequenceFirst 100 days billed using TOB 112 (first interim claim); thereafter TOB 113 for continuing claims; final claim billed using TOB 114 (discharge TOB).

Discharge status for interim claimsFor TOB 112 and TOB 113, Discharge Status should reflect that the member is still inpatient (use status 30 where applicable).

Admission / through dates for interim claimsInterim TOB 112 and TOB 113 should report admission date to current 'through' date; final TOB 114 should report admission date through discharge date.

Void/replace prior interim claimsPreviously billed interim claims should be voided and replaced with subsequent continuing or final claims that include billed amounts from prior claims through current billing dates.

Provider Actions & Billing Rules

Note

Discharge status must align with TOB; follow Florida interim billing sequence for stays >100 days

Assign Patient Discharge Status codes that align with the Type of Bill (TOB); claims with Patient Discharge Status inconsistent with the TOB will be denied. For Florida inpatient stays exceeding 100 days follow the interim billing sequence: bill the first 100 days as TOB 112 with discharge status indicating the member is still inpatient; bill additional days as TOB 113 (continuing claim) with discharge status indicating still inpatient and include previously billed amounts while voiding/replacing prior interim claims; bill the final claim as TOB 114 with discharge status showing the member has been discharged and admission-to-discharge dates, voiding/replacing prior interim claims as described.

Ensure the fourth digit (frequency) of the TOB aligns with the Patient Discharge Status (ongoing stay → status indicating still receiving care; final claim → discharge status at conclusion of encounter).
If multiple discharge statuses apply, code the highest level of care known.
Example Florida interim sequencing: TOB 112 (first interim, first 100 days) → TOB 113 (continuing, include prior billed amounts; void/replace prior interim claims) → TOB 114 (final discharge claim; include prior billed amounts; void/replace prior interim claims).

Definitions

UB-04 / Patient Discharge Status Code

Form nameUB-04 (CMS-1450) is the uniform bill used to bill facility services.

Purpose of Patient Discharge Status CodeA two-digit code that identifies where the patient is at the conclusion of a facility encounter or at the end of a billing cycle (the 'through' date of a claim).

Authority and maintenanceUB-04 form locators and data elements are determined and revised by the National Uniform Billing Committee (NUBC) and CMS; FL requirements and revenue codes are maintained by the NUBC.

Use across payersThe UB-04/CMS-1450 format is used by Medicare and third-party payers to promote uniform facility claim submission.