What is the difference between a UB-04 and a CMS-1500?
The UB-04 is the institutional claim a hospital or other facility files, and the CMS-1500 is the professional claim a physician files. One visit usually produces both, and the data sits in different fields on each.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: choose the form by who is billing and what the line pays for. The facility files the UB-04 with revenue codes and a bill type, the practitioner files the CMS-1500 with a place of service, and a wrong-form claim has to be rebuilt, not edited.
How do you decide between the UB-04 and the CMS-1500?
Ask who is billing and what the line pays for. The institution that bills for its building, staff and supplies uses the UB-04, and the practitioner who bills for their own work uses the CMS-1500. Our CMS-1500 vs UB-04 rule page covers the definitions, so this post gives you the working steps.
Where does the same data go on each form?
Most of the data on the two claims is the same. It sits in different places and in different shapes, which matters when you map an EHR charge to a claim. The table uses the Chapter 25 and Chapter 26 item numbers.
| Data | CMS-1500 (Chapter 26) | UB-04 (Chapter 25) |
|---|---|---|
| Billing provider NPI | Item 33a | FL 56 |
| Date of service | Item 24A, one per line | FL 6 statement period, plus FL 45 on every outpatient line |
| Setting | Item 24B place of service | FL 4 type of bill |
| Procedure and modifiers | Item 24D, up to four modifiers | FL 44 HCPCS beside a revenue code in FL 42, up to four modifiers |
| Diagnosis | Item 21, pointed to by letters A to L in item 24E | FL 67 principal diagnosis and FL 67A to 67Q others |
| Charge | Item 24F | FL 47, with non-covered charges in FL 48 |
| Units | Item 24G | FL 46 |
| Claim size | Six service lines | Up to 450 lines, which a MAC accepts as up to nine pages |
Notice what has no mate. The CMS-1500 has no revenue code and no bill type, and the UB-04 has no place of service code. The department-level view lives on the facility claim and the setting-level view lives on the professional claim.
Which form does each common scenario use?
The table shows which side bills on which form for scenarios that hospital billing offices see every week. The facility column follows the Medicare type-of-bill designations in Chapter 1.
| Scenario | Facility claim | Professional claim |
|---|---|---|
| Hospital ER visit | UB-04, bill type 13x, revenue code 0450 | CMS-1500, POS 23 for a patient registered in the ER |
| Inpatient admission | UB-04, bill type 11x | CMS-1500, POS 21, one claim per practitioner |
| Procedure in a hospital outpatient department | UB-04, bill type 13x | CMS-1500, POS 22 on campus or POS 19 off campus |
| Ambulatory surgery center case | None. The ASC is not a UB-04 filer | 837 professional or CMS-1500, POS 24 |
| Lab test for a non-patient from a hospital lab | UB-04, bill type 14x | Not applicable |
| Method II critical access hospital physician fees | UB-04, bill type 85x with revenue code 096x, 097x or 098x | Not applicable, billed on the facility claim |
For more on how the ER pair splits, see the emergency medicine billing page, and for the facility payment rule behind it, Medicare's outpatient payment system.
Do the setting codes on the two claims have to agree?
They should tell the same story. The facility claim states the setting through the bill type, and the professional claim states it through the place of service. If a hospital bills an outpatient ER visit on bill type 13x and the physician claim shows POS 21, an inpatient setting, one of the two is wrong, and a payer edit may catch it.
X12 describes CARC 5 as a procedure code or type of bill that is inconsistent with the place of service. Use the checks below before release when the same patient and date appear on both claims.
| Check | Facility claim | Professional claim |
|---|---|---|
| Setting | Bill type 13x for outpatient, 11x for inpatient | POS 23 for an ER patient, 22 or 19 for an outpatient department, 21 for inpatient |
| Date | FL 6 and FL 45 cover the date of service | Item 24A holds the same date |
| Diagnosis | FL 67 principal diagnosis supports the visit | Item 21 diagnoses support the line pointers |
The two claims are paid and denied separately, so fix each one on its own remittance. Correcting one claim does not correct the other.
What do you rebuild when a claim went out on the wrong form?
You cannot convert a claim by changing the form. The line structure is different, so you rebuild it from the charge data. Medicare treats a submission that does not conform to the required format as invalid, so the fix is a new, correct claim inside the filing window.
- Confirm which side was billed in error, the facility or the professional charge, and pull the original charge lines.
- Moving to the UB-04: add the type of bill, the statement period, a revenue code on every line, HCPCS in FL 44 on outpatient lines, a service date on each outpatient line, the patient discharge status and the principal diagnosis.
- Moving to the CMS-1500: drop the revenue codes and type of bill, add the place of service in item 24B, a diagnosis pointer on each line and the service location in item 32.
- Check the filing deadline before you release. Medicare's window is one calendar year after the date of service, and a timely filing denial cannot be appealed.
- Release through your usual clearinghouse path and read the acknowledgment before you assume the claim is on file.
Form and field problems usually come back as CARC 16, claim lacks information or has a submission or billing error, so start there when the remittance reads that way.
What does one ER visit look like on both forms?
The codes are real but the amounts are made up for illustration, and each payer sets its own rates.
If a radiologist reads the film, a third claim follows on a CMS-1500 for the interpretation. Our guide on facility vs professional billing explains how the technical and professional components split.
How do we handle both claims?
Our hospital and facility billing service covers UB-04 inpatient and outpatient claims plus professional claims on the CMS-1500, so one team can check that the pair of claims for a visit agree. If you want us to look at how your facility and professional claims line up, book a call.
- Medicare Claims Processing Manual, Chapter 25: Completing and Processing the Form CMS-1450 Data Set · CMS
- Medicare Claims Processing Manual, Chapter 26: Completing and Processing Form CMS-1500 Data Set · CMS
- Medicare Claims Processing Manual, Chapter 1: General Billing Requirements · CMS
- Medicare Billing: CMS-1450 and 837I (MLN006926) · CMS
- Medicare Claims Processing Manual, Chapter 14: Ambulatory Surgical Centers · CMS
- Medicare Claims Processing Manual, Chapter 4: Part B Hospital (Including Inpatient Hospital Part B and OPPS) · CMS
- Claim Adjustment Reason Codes · X12
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01What is the difference between a UB-04 and a CMS-1500?
The UB-04 is the institutional claim hospitals and other facilities file, and the CMS-1500 is the professional claim physicians and other practitioners file. They feed the 837I and 837P electronic formats. The UB-04 reports revenue codes and a bill type. The CMS-1500 reports a place of service and a diagnosis pointer on each line.
02Does the CMS-1500 use revenue codes?
No. Revenue codes are a UB-04 field, entered in FL 42 beside every charge. The CMS-1500 describes each line with a CPT or HCPCS code in item 24D and the setting with a place of service code in item 24B.
03How many service lines does each form hold?
The CMS-1500 holds six service lines in item 24. For the UB-04, Chapter 25 says CMS extended the claim size to 450 lines, which a Medicare contractor accepts as up to nine pages. Chapter 26 says the six service lines in item 24 have been divided horizontally.
04Can a hospital outpatient claim go on a CMS-1500?
Not as the facility claim. The hospital bills the department charges on the UB-04, bill type 13x. The physician's own work for that visit goes on a CMS-1500 with the right place of service. Confirm any exception in the payer's manual.
Talk to a billing lead.
A 20-minute call about your payers, volume and setup. Monday to Friday, 9am to 5pm Eastern.