UB04 Admission Source Code 4: Transfer from a Hospital (Different Facility)

Overview

Admission Source Code 4 on the UB‑04 form indicates Transfer from a Hospital (Different Facility). According to Noridian, for inpatient stays this code is used when a patient is “admitted as hospital transfer from acute care facility,” and for outpatient services it applies when the patient is “referred for outpatient services by physician of different facility.” ^[1] The code is distinct from transfers originating from a distinct unit of the same hospital (code D) or from non‑hospital facilities such as skilled nursing facilities (code 5). ^[1] The UB‑04 form itself is used by acute inpatient hospitals and acute outpatient hospitals when submitting paper claims to payers like MassHealth. ^[2] Proper assignment of code 4 ensures that the receiving facility’s claim reflects the patient’s origin from a separate acute care hospital, which can affect payment methodologies, billing edits, and quality‑measure calculations.

When to Use

Code 4 should be used only when the patient is transferred directly from another acute care hospital (a different facility). For inpatients, this means the patient was admitted to the reporting facility after being admitted as an inpatient at another acute care hospital and then transferred. ^[1] For outpatients, code 4 applies when the patient presents for outpatient services and was referred by a physician from a different hospital; the patient may have been seen in that other hospital’s outpatient department or emergency department. ^[1] It is important to exclude transfers that occur between distinct units within the same hospital (e.g., from the inpatient psychiatric unit to a general medical unit), which require code D. ^[1] Also, do not use code 4 for patients admitted from a skilled nursing facility, intermediate care facility, assisted living facility, or nursing facility (use code 5), or from an ambulatory surgery center (code E) or hospice facility (code F). ^[1] The receiving facility’s medical records must document the transfer order and the name of the transferring hospital to support the code choice.

Step-by-Step Claim Example

Scenario: A 65‑year‑old patient is admitted to “General Hospital B” as an inpatient after being transferred from “City Hospital A” (a different acute care hospital). The patient had been an inpatient at City Hospital A for three days with pneumonia and is now being transferred for a higher level of respiratory support.

Step 1 – Admission: The admitting physician at General Hospital B writes a transfer‑admission order stating, “Transfer from City Hospital A.” A transportation record and copies of the transferring facility’s records are placed in the patient’s chart.

Step 2 – Complete UB‑04 Form Field 15 (Admission Source): Enter 4 in the Admission Source field. This is the correct code per Noridian because the patient is “admitted as hospital transfer from acute care facility” — a different facility. ^[1]

Step 3 – Complete Related Fields: Enter the patient’s name in Field 12, the dates of service in Fields 6–8, and the transferring facility’s name and location in the “Transfer From” information (Fields 39–41, if required by payer). For the Type of Admission (Field 14), enter “1” for Emergency or “2” for Urgent, depending on the clinical circumstances. ^[2] Ensure the Patient Discharge Status (Field 17) is coded appropriately after the stay.

Step 4 – Biller Review: The biller verifies that the transferring facility is not the same organization as General Hospital B. If the two hospitals share a parent organization but are separate Medicare providers, code 4 remains correct. The biller also checks that no Condition Code (e.g., code 40–42) is needed; some payers may require Condition Code 42 for a hospital transfer. ^[1]

Step 5 – Submission: The UB‑04 claim is submitted (electronically or on paper if a waiver is obtained). The payer’s claims processing system will see code 4 and may treat the claim as a transfer, often paying a per‑diem or different DRG rate.

Common Mistakes & Audit Red Flags

1. Using code 4 for same‑hospital unit transfers. This is a frequent error. If a patient moves from a hospital’s inpatient psychiatric unit to its general medical floor, the correct admission source is code D (Transfer from One Distinct Unit of Hospital to Another Distinct Unit of Same Hospital). ^[1] Auditors look for a mismatch between the admission source and the “transfer from” facility name.

2. Confusing acute‑hospital transfers with skilled‑nursing‑facility transfers. Code 4 is only for acute care hospitals. Transfers from a SNF, ICF, ALF, or NF must use code 5. ^[1] Red flag: a claim lists a SNF as the transferring facility but uses code 4.

3. Missing documentation of the transfer order. Payers require evidence that a physician ordered the transfer. If the medical record lacks a transfer‑admission order or a referral note from the other hospital, the claim may be denied. ^[1] Auditors will review physician orders, transport records, and inter‑facility communication logs.

4. Outpatient claims using code 4 when the patient was not referred by a physician from a different facility. For outpatient services, code 4 requires that a physician at the transferring hospital ordered the outpatient tests or treatment. If the patient self‑referred or came from home, code 1 (Non‑Health Care Facility Point of Origin) would be correct. ^[1]

5. Using code 4 for transfers from an Ambulatory Surgery Center (ASC). ASC transfers require code E. ^[1] Similarly, hospice‑facility transfers require code F. Using the wrong code may cause the claim to be rejected or paid incorrectly.

Related Codes/Fields

The table below lists common UB‑04 Admission Source codes that are closely related to code 4, as well as related fields on the form. All definitions are from Noridian’s point‑of‑origin guidelines. ^[1]

Code	Meaning (Short)	Related Fields
1	Non‑Health Care Facility Point of Origin (physician referral, home, workplace)	Field 14 Type of Admission; Field 12 Patient Name
2	Clinic or Physician’s Office	Field 14 Type of Admission; Field 39–41 Transfer From
4	Transfer from a Hospital (Different Facility)	Field 14 Type of Admission; Field 39–41 Transfer From
5	Transfer from SNF, ICF, ALF, or Nursing Facility	Field 14; Field 39–41; Condition Code (if ICF/ALF)
6	Transfer from Another Health Care Facility (not defined elsewhere)	Field 14; Field 39–41
8	Court/Law Enforcement	Field 14; Field 39–41 (if incarceration facility)
9	Information Not Available	Field 14; used only when source truly unknown
D	Transfer from One Distinct Unit to Another in Same Hospital	Field 14; no separate Transfer From field needed
E	Transfer from Ambulatory Surgery Center	Field 14; Field 39–41 (ASC name)
F	Transfer from Hospice Facility	Field 14; Field 39–41 (hospice facility)

Related fields on UB‑04:

• Field 12 – Patient Name
• Field 14 – Type of Admission (e.g., 1=Emergency, 2=Urgent, 3=Elective)
• Field 15 – Admission Source (this field)
• Field 17 – Patient Discharge Status
• Field 23 – Condition Codes (e.g., code 42 for “Hospital Transfer from Inpatient”)
• Fields 39–41 – Transfer From Facility Name, Address, and ID

When documenting a transfer from a different facility, always cross‑check code 4 against the transferring facility’s identity to avoid audit exposure. ^[1]

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References

[1] Noridian Point of Origin — https://med.noridianmedicare.com/web/jea/topics/claim-submission/point-of-origin-codes

[2] MassHealth UB-04 Guide — https://www.mass.gov/doc/ub-04-billing-guide-0/download