11 NCAC 12 .1502             REQUIREMENTS FOR USE OF CMS Form 1450 (UB-04)

(a)  The CMS Form 1450 (UB-04) shall be the standard claim form for all manual billing by institutional health care providers, and the CMS Form 1450 shall be accepted by all payors conducting business in this State.

(b)  The cause of injury code shall be located in form locator 72. This code shall be required on all CMS Form 1450 (UB-04) claims generated by institutional health care providers for claims of inpatients and of patients treated in emergency rooms or trauma centers; and where the diagnosis includes an injury diagnosis, which means a diagnostic code in the range or 800-999 as defined in the ICD-10 coding manual.

(c)  Payors may require institutional health care providers to use only the following coding systems for the filing of claims for health care services:

(1)           Codes to report all diagnoses, reasons for encounters, and procedures based upon code level changes made effective October 1 of each year or other effective date designated by the CMS.

(2)           HCPCS Level I and II Codes based upon code level changes made effective October 1 of each year or other effective date designated by the CMS.

(3)           CPT-4 Codes based upon code level changes made effective January 1 of each year or other effective date designated by the CMS.

(d)  When there is no applicable HCPCS Level I or Level II Code or modifier, the payor may establish its own code or modifier. A complete list of all codes and modifiers established by payors shall be published by and available upon request from payors.

History Note:        Authority G.S. 58‑2‑40; 58‑3‑171;

Eff. October 1, 1994;

Amended Eff. March 1, 1995;

Readopted Eff. May 1, 2020.