April 18, 2012




All Blue Cross and Blue Shield of Kansas Contracting Providers


Connie Winkley – Education/Communication Coordinator
Institutional Provider Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association


UB-04 Coding Change – Form Locator 70

The purpose of this newsletter is to provide an update to information that was published in a BCBSKS newsletter on December 13, 2010 (BC-10-20).  The update to the information in this 2010 newsletter is in regard to the Patient Reason for Visit (PRV) Code with the implementation of HIPAA 5010, which is Form Locator 70 on the UB-04 Claim Form.

When HIPAA 5010 was released the industry had interpreted that the PRV was required on all outpatient claims.  BCBSKS educated all institutional providers with notification that we would require PRV on all claims involving outpatient visits.  An Electronic Data Interchange (EDI) edit was implemented for HIPAA 5010 837I claims based on the interpretation.

With the testing and implementation of HIPAA 5010, we listened to concerns from our providers requiring the coding of PRV.  The usage note for PRV in the 5010 guide seemed somewhat ambiguous and in turn caused confusion and some misunderstanding.  Accordingly, interpretation from ASCX12 was sought by the National Uniform Billing Committee (NUBC).  Based on the providers concerns and the interpretation from ASCX12, EDI removed the edit that required a Patient Reason for Visit in Form Locator 70 submitted on all outpatient claims.

The requirements for reporting Patient’s Reason for Visit (PRV) are the same for both electronic and paper claims.  PRV is only required on certain outpatient claims. It is required for all unscheduled outpatient visits.  An “unscheduled” outpatient visit is defined as an outpatient Type of Bill  013x, 085x or 078x together with Form Locator 14 (Priority of Visit/Type of Admission) code 1,2 or 5 and Revenue codes 045x, 0516, 0526 or 0762 (Observation Hours).  PRV may be reported at submitter’s discretion for scheduled outpatient visits (such as encounters for ancillary tests) when this information provides additional information to support medical necessity.

If you have any further questions regarding the Patient Reason for Visit, Form Locator 70 on the UB-04 claim form, please contact your BCBSKS Provider Representative.