The original X12 standards document indicates that the REASON FOR VISIT is "Required when claim involves outpatient visits. If not required by this implementation guide, do not send."
Then, in RFI #1256, you clarified that the field is only required on "certain outpatient claims as directed by the NUBC billing manual."
The description is:
"Required only on 013x, 078x and 085x claims when:
a) Priority (Type) of Admission or Visit codes 1, 2 or 5 are reported (FL 14).
AND
b) Revenue Codes 045x, 0516, 0526, or 0762 are reported (FL 42).
Reporting Patient’s Reason for Visit is *restricted* to the three bill types above. If not required, it may be reported on other 013x, 078x, and 085x claims that fail to meet the criteria in a) or b) above at the sender’s discretion when this information substantiates the medical necessity, but cannot be required by the receiver."
The text is unclear.
- Is it "RESTRICTED" to the "three bill types above"?
- May it be sent at "sender’s discretion when this information substantiates the medical necessity"?
What if the bill is not of any of the three bill types but the sender wishes to send the code?
The sender’s discretion is still limited to the 3 bill types (013x, 078x, and 085x) per the 2026 UB-04 manual and cannot be sent on all claims. Implementers need to ensure they are always using the most current version of the UB-04 manual.
RFI Recommendation:
Further clarification of the UB Manual can be requested via NUBC.
Related RFIs: 1256