3b Medical Record # Optional. Enter patient's medical record number (up to 24 characters) Expanded to 24 characters from 16 characters.4 Type of Bill Required. Enter the appropriate 3-digit code as follows:a. First digit-type facility 8 = Special facility (hospice)b. Second digit-...
FL 13/16 Point of Origin Admission/Visit - FL 15 Patient Discharge Status - FL 17 Condition Codes - FLs 18-28 Occurrence Codes - FLs 31-34 Occurrence Span Codes - FLs 35-36 Value Codes and Amounts - FLs 39-41 Revenue Codes - FL 42 Code Codes - FL 81 Other UB04 Claim Form ...