UB-04 Claim Form — Click any field
FL 1 Billing Provider Name & Address
FL 2 Pay-To Name & Address
FL 3a Patient Control No.
FL 3b Medical Record No.
FL 4 Type of Bill
FL 5 Federal Tax No.
FL 6 Statement Covers Period From/Through
FL 7 Reserved
FL 8 Patient Name
FL 9 Patient Address
FL 10 Birthdate
FL 11 Sex
FL 12 Admission Date
FL 13 Adm. Hr
FL 14 Priority of Admission
FL 15 Point of Origin
FL 16 Dis. Hr
FL 17 Patient Discharge Status
Condition Codes
FL 18
FL 19
FL 20
FL 21
FL 22
FL 23
FL 24
FL 25
FL 26
FL 27
FL 28
Occurrence Codes & Dates
FL 29 Accident State
FL 30 Reserved
FL 31-34 Occurrence Codes & Dates
FL 35-36 Occurrence Span Codes & Dates
FL 38 Responsible Party Name & Address
FL 39-41 Value Codes & Amounts
Service Lines (Revenue Codes)
FL 42
Rev Code FL 43
Description FL 44
HCPCS/Rate FL 45
Svc Date FL 46
Units FL 47
Total Chg FL 48
Non-Cov FL 49
FL 42
FL 43
FL 44
FL 45
FL 46
FL 47
FL 48
FL 49
FL 42
FL 43
FL 44
FL 45
FL 46
FL 47
FL 48
FL 49
0001
Total
Payer Information
FL 50 — Payer Name FL 51
Health Plan ID FL 52
Release Info FL 53
Assignment FL 54
Prior Auth
Primary
FL 51
FL 52
FL 53
FL 54
Secondary
FL 51
FL 52
FL 53
FL 54
FL 55 Estimated Amount Due
FL 56 NPI
FL 57 Other Provider ID
FL 58 Insured's Name
FL 59 Patient Relationship
FL 60 Insured's Unique ID
FL 61 Insured Group Name
FL 62 Insured Group No.
FL 63 Treatment Auth. Code
FL 64 Document Control No.
FL 65 Employer Name
Diagnosis Codes
FL 66 Dx Code Qualifier
FL 67 Principal Diagnosis
FL 67A-Q Additional Diagnoses
FL 68 Reserved
FL 69 Admitting Diagnosis
FL 70 Patient Reason for Visit
FL 71 PPS Code
FL 72 External Cause of Injury
Procedure Codes
FL 74 Principal Procedure Code & Date
FL 74A-E Other Procedure Codes & Dates
Provider Information
FL 76 Attending Provider NPI & Name
FL 77 Operating Provider NPI & Name
FL 78-79 Other Provider NPI
FL 80 Remarks
FL 81CC Code-Code (Taxonomy)
Critical field
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Revenue Code Quick Reference

Key UB-04 revenue codes for behavioral health facility billing — with typical HCPCS pairings and notes.

Revenue Code Service Description Level of Care Typical HCPCS Notes
0001 Total Charges (summary line) All — Required last line on every UB-04. Sum of all charges.
0100 Room and Board, General Residential — Per diem accommodation; typically no HCPCS required.
0101 Room and Board, Private Residential — Single-occupancy room charge.
0110 Room and Board, Semiprivate Residential — Shared room accommodation charge.
0124 Room and Board, Mental Health Center Residential — Used for CMHC or psychiatric residential facilities.
0900 Behavioral Health Treatments (General) All Varies Broad category; use more specific 090x subcategory when possible.
0902 Milieu Therapy Inpatient/Residential H0018 Therapeutic community programming within the facility.
0903 Occupational Therapy (Psychiatric) All 97530, 97535 OT delivered in psychiatric context.
0904 Physical Therapy (Psychiatric) All 97110, 97530 PT delivered in psychiatric context.
0905 Recreational Therapy All — Therapeutic recreation, fitness, and leisure activities.
0906 Education (Psychiatric) All — Psychoeducation, health literacy programming.
0907 Training (Psychiatric) All — Skills training, ADL training in behavioral health setting.
0911 Community Transition Services Residential — Discharge planning, community re-integration services.
0912 Partial Hospitalization (Less Intensive) PHP S0201 Lower-acuity PHP programming.
0913 Partial Hospitalization (Intensive) PHP H0035, S0201 Standard PHP per diem billing code.
0914 Intensive Outpatient — Substance Use IOP H0015 SUD-focused IOP. Confirm payer prefers H0015 vs S0201.
0915 Intensive Outpatient — Mental Health IOP H0015, S0201 MH-focused IOP. Some payers use same code as SUD IOP.
0916 PHP — Adult Psychiatric PHP H0035 Most common revenue code for adult PHP claims.
0917 PHP — Child/Adolescent Psychiatric PHP H0035 Used when program is specifically designed for minors.
0944 Other Therapeutic Services All H0004, H0005 Individual or group therapy not captured by specific codes.
0960 Professional/Physician Fees All 90837, 90847 Psychiatrist or licensed clinician professional fees, if billing facility and professional on same claim.
1000 Behavioral Health — General All Varies Catchall BH code; prefer more specific 09xx codes.
1001 Psychiatric Residential Treatment (Under 21) PRTF H0019 Psychiatric Residential Treatment Facility for minors. Medicaid-specific program in many states.
0272 Medical/Surgical Supplies — IV Solutions Detox — Used for medical detox when IV fluids/medications are administered.

Top 8 UB-04 Mistakes in BH Facility Billing

These errors cause the most claim denials and payment delays in behavioral health facility billing.

1
Wrong Type of Bill for level of care Using inpatient TOB (011x) for PHP or IOP — which are outpatient services — causes payer rejection and incorrect benefit application.
2
Interim claims showing discharge status instead of "30" FL 17 must show "30 — Still Patient" on every interim claim. Using a discharge code signals the episode ended and cuts off further reimbursement.
3
Missing or incorrect authorization number FL 54 must contain the exact prior auth number, matching the level of care and authorized date range. Typos and wrong auth numbers both cause denials.
4
Revenue code doesn't match level of care Billing 0916 (PHP adult) for an IOP patient, or 0100 (room and board) when the service is an outpatient program, results in medical necessity mismatches.
5
Wrong ICD-10 qualifier in FL 66 FL 66 must be "0" for ICD-10-CM. A blank field or incorrect qualifier causes immediate claim rejection. ICD-9 ("9") has not been valid since October 2015.
6
Facility NPI used in FL 76 instead of individual provider NPI FL 76 requires the Type 1 NPI of the attending physician or licensed independent practitioner — not the facility's Type 2 NPI.
7
Dates of service outside the auth period Billing for dates before the authorization starts or after it expires creates denials that are difficult to overturn. Track auth dates in your EHR.
8
HCPCS code not matching revenue code Each revenue code has expected HCPCS pairings. Mismatches (e.g., H0004 on revenue 0916) flag claims for audit and trigger payer edits.