UB-04 Data Set and Claim Form

January 29, 2005

To: National Uniform Billing Committee c/o George Argus, Chairman

RE: UB-04 Data Set and Claim Form

Dear Chairman Argus:

This letter is sent to provide comment from the American Health Information Management Association (AHIMA) on the new UB-04 data set and form to replace the UB-92.

The American Health Information Management Association is the premier association of health information management (HIM) professionals. AHIMA's 50,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning.

As part of AHIMA's effort to ensure consistency in coding, we serve as a member of the Cooperating Parties, along with CMS, the Department of Health and Human Services' (HHS) National Center for Health Statistics (NCHS), and the American Hospital Association (AHA). The Cooperating Parties oversee correct coding rules associated with the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM).

Our comments focus on those areas that are of particular interest to our members. We chose to submit a letter instead of the survey form because of the nature and limited scope of our comments.

Diagnosis Present on Admission Indicator Code (FL#66A-Q - far right field)

While AHIMA recognizes the value of capturing information regarding whether or not a diagnosis was present on admission, we are concerned about balancing this value against the administrative burden of collecting this information.

Capturing this information will most likely be the responsibility of HIM coding professionals, and the U.S. is already faced with a serious coder shortage. This data collection task will be labor-intensive, resulting in decreased coder productivity. There may be situations when it is difficult to determine from the medical record documentation whether a condition was present on admission or not, requiring the coding professional to query the physician, resulting in further loss of productivity. Many hospitalizations are extremely complex clinically and there are not always easy distinctions between conditions that were present on admission and those that developed subsequently. If the reported information is not actively being used for risk adjustment, "pay-for-performance" initiatives, outcomes analyses, or other purposes, the administrative burden of collecting and reporting this information may be considered unreasonable.

AHIMA believes that the value of a flag indicating if a diagnosis was present on admission will only be realized if the information is consistently reported across all hospitals and for all payer types. Without an economic incentive or federal regulatory requirement, reporting practices are likely to be inconsistent. Currently, only a few states require this information to be reported. Thus, hospitals in other states may choose to use this indicator flag only if the payer to whom the claim is being submitted requires this information. If hospital reporting of this information is driven by individual payer requirements rather than a national standard, the data will be incomplete and of questionable quality.

If an indicator flag for "diagnosis present on admission" is implemented as part of the UB-04, a standard, uniform definition of this indicator will be necessary in order to ensure consistent, comparable data. It will be necessary to provide very clear instructions for reporting this information in order to ensure consistent interpretation as to the correct use of this indicator code. These instructions will need to clarify whether reporting this information is optional (i.e., to be reported only if desired or required by payer or state data agency) or required; and for which types of healthcare encounter it is applicable (i.e., acute-care inpatient hospital admissions only or all users of this claim form). AHIMA recommends that the Cooperating Parties (AHA, AHIMA, CMS, NCHS) assist with the development of a standardized definition and guidelines for use of the indicator flag for diagnoses present on admission. The Cooperating Parties have extensive expertise and experience with the development of national, standardized ICD-9-CM coding and reporting guidelines.

Increase in Number of Fields for Other Diagnoses (FL#66A-Q)

AHIMA fully supports adding nine new fields for Other Diagnoses. This will allow more accurate and complete reporting a patient's diagnoses. We believe that the number of fields for procedure codes should be increased as well.

Expansion of Size of Diagnosis and Procedure Code Fields (FL#66, 66A-Q, 68-69, 73, 73a-e)

We fully support the expansion of the size of the diagnosis and procedure code fields in order to accommodate ICD-10-CM and ICD-10-PCS. AHIMA has been a strong advocate for immediate adoption of ICD-10-CM and ICD-10-PCS as replacements for ICD-9-CM in order to ensure the collection of accurate and complete healthcare data.

Distinct Fields for Admitting Diagnosis and Patient's Reason for Visit (FL#68-69)

AHIMA supports creating separate fields for Admitting Diagnosis and Patient's Reason for Visit.


We appreciate the opportunity to comment on the UB-04 data set and claim form. If AHIMA can provide any further information, or if there are any questions or concerns with regard to this letter and its recommendations, please contact either Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115 or sue.bowman@ahima.org, or myself at the numbers above or dan.rode@ahima.org.


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc: Sue Bowman, RHIA, CCS