UB04 Type of Bill Code 0117: Hospital Inpatient (Including Medicare Part A) - Replacement of Prior Claim

Overview

Code 0117 is a UB-04 Type of Bill (TOB) code used for Hospital Inpatient (Including Medicare Part A) - Replacement of Prior Claim. The code is structured as a four-digit alphanumeric sequence where the first digit (0) is a leading zero ignored by CMS, the second digit (1) indicates a hospital facility, the third digit (1) denotes inpatient Part A care, and the fourth digit (7) signifies a replacement of a prior claim. ^[1]

The frequency digit "7" indicates this is not a new claim or an interim claim, but rather a complete replacement of a prior submission. ^[1]

When to Use

Common scenarios include:

• Incorrect patient information: Wrong name, date of birth, or Medicare beneficiary identifier on the original claim. ^[1]
• Coding errors: Incorrect diagnosis codes (ICD-10-CM), procedure codes (ICD-10-PCS), or revenue codes that affect payment. ^[1]
• Date of service errors: Wrong admission date, discharge date, or statement covers period. ^[1]
• Charge corrections: Incorrect charges for services rendered, including room and board, pharmacy, or ancillary services. ^[1]
• Third-party liability updates: When other insurance information was incorrect or missing on the original claim. ^[2]

Do not use 0117 for:

• New claims (use 0111 for admit through discharge)
• Interim claims (use 0112, 0113, or 0114)
• Late charges only (use 0115)
• Voiding a claim (use 0118)

Step-by-Step Claim Example

Scenario: A hospital submitted a Medicare Part A inpatient claim for a 5-day stay (admit 01/10/2025, discharge 01/15/2025) with TOB 0111. After processing, the hospital discovered the principal diagnosis code was incorrect (I10 instead of I11.9). The hospital must submit a replacement claim.

Step 1: Complete the UB-04 Header

• Field 1: Provider name, address, and NPI
• Field 2: Pay-to name and address
• Field 3: Patient control number (same as original)
• Field 4: Type of Bill = 0117 (Hospital Inpatient - Replacement of Prior Claim) ^[1]

Step 2: Complete Patient Information

• Field 8a: Patient name (verify correct spelling)
• Field 8b: Patient ID number (same as original)
• Field 10: Patient date of birth
• Field 11: Patient sex
• Field 12: Admission date = 01/10/2025
• Field 13: Admission hour
• Field 14: Admission type
• Field 15: Admission source
• Field 16: Discharge hour
• Field 17: Discharge status code

Step 3: Complete Financial Information

• Field 42: Revenue codes for all services (e.g., 0100 for room and board, 0250 for pharmacy, 0300 for lab)
• Field 43: Description of each revenue code
• Field 44: HCPCS/Rates for each revenue code
• Field 45: Service date for each revenue code
• Field 46: Service units for each revenue code
• Field 47: Total charges for each revenue code
• Field 48: Non-covered charges for each revenue code

Step 4: Complete Diagnosis and Procedure Codes

• Field 67: Principal diagnosis code = I11.9 (corrected from I10)
• Field 67a-q: Other diagnosis codes (same as original)
• Field 74: Principal procedure code and date (if applicable)

Step 5: Complete Other Required Fields

• Field 50: Payer identification (Medicare Part A)
• Field 51: Provider ID (Medicare number)
• Field 52: Release of information
• Field 53: Assignment of benefits
• Field 54: Prior payments
• Field 55: Estimated amount due
• Field 56: NPI of provider
• Field 57: Other provider ID
• Field 58: Insured's name
• Field 59: Patient's relationship to insured
• Field 60: Insured's unique ID
• Field 61: Group name
• Field 62: Insurance group number
• Field 63: Treatment authorization codes
• Field 64: Document control number (original claim ICN)
• Field 65: Employer name
• Field 66: Diagnosis version indicator
• Field 67: Principal diagnosis code
• Field 68: Admitting diagnosis
• Field 69: Patient reason for visit
• Field 70: Patient reason for visit
• Field 71: PPS code
• Field 72: External cause of injury
• Field 73: External cause of injury
• Field 74: Procedure codes and dates
• Field 75: Procedure codes and dates
• Field 76: Attending provider
• Field 77: Operating provider

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References

[1] Noridian Bill Types — https://med.noridianmedicare.com/web/jea/topics/claim-submission/bill-types

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