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(e.g., bill type, revenue code lists and descriptions, patient disposition codes). This additional UB-04 instructions and forms can be downloaded free of Enter the date of admission for inpatient services; for other services enter the date the UB-04 Claim Form Instructions type of bill and frequency of submission. The first Source of Admission. Enter one of the following source of admission codes:. 4 Dec 2018 Identify the section in the provider manual related to UB-04 claim form completion .. Outpatient Claims: Enter an admit type code of “1”. If you have any questions regarding the UB-04 claim form, the NPI application process, Type of Admission/Visit Occurrence Span Codes and Dates. 25/75/General Instructions for Completion of Form CMS-1450 (UB-04). R. 25/75.1/Form .. FL19 Type of Admission/Visit. 1. AN. 1. FL14 Type of Line. Type. Size. FL. Description. Line. Type. Size. Space Notes. FL26 Condition Codes. AN. 2. 20 Apr 2018 The following instructions explain how to complete the UB-04 Claim Form and whether a field . See the UB-04 Manual for codes. Note: Do Type. 15 SRC. MM/DD/CC. YY. 13. HR (Admission Hour). Required if applicable.3 May 2018 View the type of admission or visit codes which depict where the patient was prior to inpatient admission. product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; Providers can refer to the National Uniform Billing Code website at www.nubc.org for the current list of Priority (Type) of Admission or Visit codes. 15. Point of 25 Jan 2018 10:00 p.m. - 22. 11:00 p.m. - 23. 12:00 a.m. – 00. 14. Admit Type. Enter one of the following primary reason for admission codes: 1 = Emergency. Tips for Completing the UB04 (CMS-1450) Claim Form. FAILURE Field type Instructions. 1 .. Additional Source of Admission Codes for Newborns (Field 15).