General Surgery Coding Alert

Question: I recently switched from billing for hospital outpatient surgeries to coding for a general surgery practice. Can you explain to me when a practice would use the CMS-1500 form instead of the UB-04?

Maine Subscriber

Answer: You shouldn’t need to use the UB-04 form in a private surgery practice. The definitions of the UB-04 and CMS-1500 are as follows:

• CMS -1500: The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim.
• UB-04 Form: An electronic format of the CMS-1450 paper claim form that has been in general use since 1993 for institutional providers.

Professional providers such as general surgeons in your practice should generally submit claims using the CMS-1500 forms, while institutional providers such as a hospital should submit claims using the UB-04.

Hospital-based ambulatory surgical centers (ASCs) generally use the UB-04 form for facility charges and the CMS-1500 form for the professional charges of the physician, but anyone performing services in an ASC should check payer guidance to determine which code they should report.