UB04 Documentation Requirements
Expedite payment with the right paperwork
There seems to be some confusion about what documentation needs to be sent when billing for hospital services. Submission of the following items will help expedite payment.
- Therapy service documentation (i.e. PT/OT/RT)
- Radiology reports*
- Laboratory reports
- Physician orders
- Medication administration records, including IV
- Anesthesia record including flow sheet
- Pre and Post operative records
- Implant listing
*Providers may only bill for radiology services that are provided directly. Global services cannot be billed when a provider completes the technical component and contracts for external radiological services to read the radiographs. The provider listed in Box 31 of the CMS 1500 form must be the provider performing the service.