Reporting revenue code on UB 04

Revenue Codes for Billing


An ASC shall report Revenue Codes in Form Locator 42 in addition to HCPCS® codes or Workers Compensation unique codes in Form Locator 44, where indicated.

When reporting multiple procedures performed during a single operative session, an ASC shall report the appropriate Revenue Code in Form Locator 42 on each line with the corresponding HCPCS® Level I or Level II code in Form Locator 44. Modifiers shall be used, when appropriate.

Note: HCPCS® codes or Workers’ Compensation unique codes are required in Form Locator 44 unless the Revenue Code billed is listed on the Division’s list of Revenue Codes that do not require a HCPCS® code.


Official Guidelines for Billing

All ASC providers shall complete the Form DFS-F5-DWC-90 (UB-04) according to the Form Locator attributes and Notes, pursuant to the National Uniform Billing Committee Official UB-04 Data Specifications Manual 2010, July 2009.

Billing for a Compensable Injury

All medical claim form(s) for medical bill(s) related to services rendered for a compensable injury shall be submitted by an ASC to the insurer, service company/TPA or any entity acting on behalf of the insurer, as a requirement for billing.
Methods for Billing

Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by an ASC to the insurer, service company/TPA or any entity acting on behalf of the insurer, provided the insurer agrees.