Instructions: Complete a UB$-04$ claim for the outpatient hospital case study. Use the UB$-04$ Form provided in this Assignment to enter data from the outpatient hospital case study. ICD$-10-$CM$,$ CPT$,$ and revenue codes required for completion of the UB$-$o$4$ claim are included in the case study. $($Refer to Table $11-1$ in the textbook for instructions on completing the UB$-04$ claim.$)$

Outpatient Hospital Case Study

UB$-04$ Blank Fill$-$in$-$Form

Open the UB$-04$ Form. Save the form to your local computer.

Open and complete the UB$-$o$4$ form in Adobe ${?}^{}$ Acrobat ${?}^{(2)}$ using the typewriter tool,

Save your completed UB$-04$ Form to your local computer. Add your name or other identifying information to the filename before saving.

In this Assignment, click the Browse or Choose File button to search for and select your completed UB$-04$ Form.

Click the Submit Assignment for Grading button. Your completed UB$-04$ Form will be uploaded to the course Dropbox for your instructor to evaluate and assign a grade.

No file chosen

Search