007-11-09 Ark. Code R. § 1
All facilities operating and licensed as a hospital in the state of Arkansas by ADH, Division of Health Facility Services, will report discharge data to ADH for each patient admitted as an inpatient or with at least one full day of stay (overnight). Discharge data means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a single inpatient hospital stay. The consolidation of discharge data is a discharge data record. The formats are defined later in this Guide.
For a patient with multiple discharges, submit one discharge data record for each discharge. For a patient with multiple billing claims (refer to Section 5.6 Multi - Hospital Submission), consolidate the multiple billings into one discharge data record for submission after the patient's discharge. A discharge data record is submitted for each discharge, not for each bill generated. The discharge data record should be submitted for the reporting period within which the discharge occurs. If a claim will not be submitted to a provider or carrier for collection (e.g., charitable service), a hospital discharge data record should still be submitted to the ADH, with the normal and customary charges, as if the claim was being submitted. All acute and intensive care discharges or deaths, including newborn discharges or deaths, should be reported.
A hospital may submit discharge data directly to ADH, or may designate an intermediary, such as a commercial data clearinghouse. Use of an intermediary does not relieve the hospital from its reporting responsibility.
In order to facilitate communication and problem solving, each hospital should designate a person as contact. Please provide the office name, telephone number, job title and name of the person assigned this responsibility.
Act 670 of 1995, A.C.A. 20-7-301 et seq. (refer to Appendix D5) provides for the strictest confidentiality of data and severe penalties for the violation of the Act. Any information collected from hospitals which identifies a patient, provider, institution, or health plan cannot be released without promulgation of rules and regulations by the Arkansas State Board of Health in accordance with Act 670 Section (2)(g) and (h). ADH will only release data, except as allowed by law that has sufficiently masked these identities.
Since ADH needs patient specific information to complete our analyses, we will take every prudent action to ensure the confidentiality and security of the data submitted to us. Procedures include, but are not limited to, physical security and monitoring, access to the files by authorized personnel only, passwords and encryption. Not all measures taken are documented or mentioned in this Guide to further protect our data.
Discharge data records will be submitted to ADH as specified below. The data to be submitted is based on the discharges occurring in a calendar quarter. If a patient has a bill generated during a quarter but has not yet been discharged by the end of the quarter, data for that stay should not be included in the quarter's data. Deadlines for data submission are 40 days after the end of the quarter for the first through third quarters and 60 days for the fourth quarter.
While most hospitals will be submitting data directly to ADH, some are utilizing third-party intermediaries. When using an intermediary, the reporting deadlines are still to be met. Refer to Section 5.7 Intermediaries for further details.
Patients' date of discharge is: | Discharqe data must be received by: |
January 1 through March 31 | QTR 1 -May 10th |
April 1 through June 30 | QTR 2 -August 10th |
July 1 through September 30 | QTR 3 - November 10th |
October 1 through December 31 | QTR 4-March 1st |
All hospitals will submit discharge data in a form consistent with the requirements unless an extension has been granted. Request for extension should be in writing or E-mail and be directed to:
Arkansas Department of Health
Center for Health Statistics, Slot #H19
Hospital Discharge Data Section
4815 West Markham Street
Little Rock, AR 72205
Phone (501) 661-2231
FAX (501) 661-2544
E-mail: Lynda.Lehing@arkansas.gov
The Center for Health Statistics will review requests submitted to them for extensions to the reporting schedule requirement. A request for an extension should be submitted at least 10 working days prior to the reporting deadline. Extensions may be granted for a maximum of 20 calendar days. Additional 20-day extensions must be requested separately. Extensions may be granted when the hospital documents that unforeseen difficulties, such as technical problems, prevent compliance.
Hospitals will review the discharge data records prior to submission for accuracy and completeness. Correction of invalid records and validation of aggregate tabulation are the responsibility of the hospital. All hospitals will certify the data submitted for each quarter in the manner specified.
Edits that indicate a high probability of error will be highlighted for review, comment, and correction when applicable. The invalid record will be printed in a simplified format providing record identification, an indication or explanation of the error, and space to record corrections. The error report will be sent by fax or E-mail to the attention of the individual designated to receive the correspondence at the hospital. The corrections made by the hospital are to be returned within seven days of receipt to the Center for Health Statistics.
In the event one (1) percent or more of the records for a quarter are indicated as having a high probability of error, the entire submittal may be rejected. A record is in error when one or more required data elements are in error.
Notification of the rejection will accompany the error report and will be sent by fax or e-mail to the attention of the individual designated to receive the correspondence at the hospital. After correction, the submittal is to be returned within seven days of receipt, to the Center for Health Statistics. In some situations, the HDDS staff will make corrections to the hospital's submissions, based on information obtained from hospital staff and/or internal health department databases. When this is done, notice will be given to the hospital.
Currently, data must be submitted via encrypted E-mail, CD's or FTP. Alternate modes of transmission may be established by agreement with the Center for Health Statistics. Data submittals not in compliance with media or format specifications will be rejected unless approval is obtained prior to the scheduled due date from the Center for Health Statistics. Data submittal on physical media should be mailed to:
Arkansas Department of Health
Center for Health Statistics
Hospital Discharge Data System
4815 West Markham Street, Slot H19
Little Rock, AR 72205
If you are submitting data for more than one hospital on one media submission, the additional specifications found in Section 5.6 Multi - Hospital Submission must be followed.
WINZIP is the compression utility of choice by HDDS. If a compression utility other that WINZIP is used, the resulting file must be able to be unzipped by HDDS. Please contact an HDDS colleague prior to sending a file compressed with any compression software other than WINZIP.
Crypt-text is the freeware, encryption software that HDDS recommends. An HDDS colleague can be contacted on how to receive this software. Encryption of data files sent as email attachments is required. Refer to Section 5.4 E-Mail Attachment Submissions - Secondary Submittal Format. All passwords used with encryption software will be supplied by the HDDS. Please contact an HDDS colleague for the correct password for your hospital.
HDDS07Q1V1.dat will tell us Hospital Discharge Data Systems uploaded quarter 1 of 2007 one time. If you do not know the four letter code for the hospital (HHHH), please contact an HDDS colleague for that information.
The following specifications must be met when submitting data by e-mail attachment via the Internet:
The following specifications must be met when submitting data on PC CD'S:
Note: Self-extracting executable file must run on Windows XP or higher operating system. Source and target of WINZIP or executable file must be ASCII. ASCII file must have a carriage-return (CR) and line-feed (LF) at the end of each data record.
HOSPITAL DISCHARGE DATA
Hospital Name:
Date: mm/dd/yy Quarter: mm/dd/yy
Total Record Count: ###### Format: ####
Contact Person___________Phone:________
Extension:_____
ENCRYPTED
Example: 08QTR1 TXT - ASCII data file for the first quarter of 2008
Data from more than one hospital may be submitted on one media submission as one file per hospital. Change the following items on your external label or accompanying information sheet:
In addition to the above changes, a list of hospitals on the medium must be provided, with tax id, number of records, and hospital contact.
Third-party intermediaries may be utilized by hospitals for the delivery of data to ADH. To better manage data collection, intermediaries must be registered with ADH. Additions and deletions to the intermediary's list of hospitals represented must be submitted at least 10 days prior to ADH reporting due date. The intermediary must specify hospitals being represented, media, formats, contacts, and length of contractual obligation.
The following additional requirements and information apply to intermediaries delivering edited data to the ADH:
The following additional requirements and information apply to intermediaries delivering unedited data to ADH:
Data submission methods are always under review. If implemented, all Arkansas hospitals will receive notice of the changes to be implemented.
The accepted data record formats are the UB-04 1450 version 6 formats. This format has altered slightly. The definition specified for each data element is in general agreement with the definition in the UB-04 Users Manual. Hospitals using data sources other than uniform billing should evaluate definitions for agreement with the definitions specified in this Guide and UB-04 Users Manual. Refer to Section 7.0 EXCEPTIONS TO 1450 FORMAT identify possible changes to your current format. Each record must be followed by a carriage return/line feed sequence.
The UB-04 1450 claim 'record' is made up of a series of 192-character physical records and the 1450 Y2K claim "record" is made up of a series of 198-character physical records. Not all of the physical claim records are used in the HDDS, such as the Claim Request Data. Records not specified in the HDDS will be ignored, if included in the submittal. Fields not referenced in the record formats may contain information but will not be processed by computer programs; this also includes fields reserved for national use. The exact record sequence and format of the 1450 is used for the HDDS, when possible. A complete copy of the patient's 1450 records would satisfy the requirements, with exceptions noted in Section 7.0 - EXCEPTIONS TO 1450 FORMAT. The physical records for each claim are divided into logical subsets as follows:
Subset 1 Patient Data - Record Codes 20-29
Subset 2 Third Party Data - Record Codes 30-39
Subset 3 Claim Request Data - Record Codes 40-49
Subset 4Inpatient Accommodations Data - Record Codes 50-59
Subset 5 Ancillary Services Data - Record Codes 60-69
Subset 6 Medical Data - Record Codes 70-79
Subset 7 Physician Data - Record Codes 80-89
The record layouts that follow will provide the following information:
Only one type '10' record is required per hospital per submittal. Only the first type '10' record and each type '10' record following a type '95' record will be processed, all others will be ignored. This record type will be processed as a header record and a record type '95' will be processed as a trailer record. The records encapsulated between the first type '10' and '95' will be processed using the hospital specified on the type '10' record. It is absolutely imperative that each submission includes at least one type '10' record with correct Federal Tax Number. If the Federal Tax Number is not unique to a facility or cost center, the Federal Tax Sub ID must be included.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '10' | XX | L | 1 | 2 | |
* 2 | Federal Tax Number or EIN | 9(10) | R | 8 | 17 | FL05 |
3 | Federal Tax Sub ID | X(4) | L | 18 | 21 | FL05 |
* 4 | National Provider Identifier | X(13) | L | 22 | 34 | FL56 |
* 5 | Medicaid Provider Number | X(13) | L | 35 | 47 | |
* 6 | Provider Telephone Number | 9(10) | R | 87 | 96 | FL01 |
* 7 | Provider Name | X(25) | L | 97 | 121 | FL01 |
* 8 | Provider (Hospital) Data ID | X(4) | L | 122 | 125 | |
PROVIDER ADDRESS (FIELDS 9 - 13) | 126 | 185 | FL01 | |||
9 | Address | X(25) | L | 126 | 150 | |
* 10 | City | X(14) | L | 151 | 164 | |
* 11 | State | XX | L | 165 | 166 | |
* 12 | Zip Code | X(9) | L | 167 | 175 | |
13 | Provider Fax Number | 9(10) | R | 176 | 185 | |
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '20' | XX | L | 1 | 2 | |
* 2 | Patient Control Number | X(20) | L | 5 | 24 | FL3A |
PATIENT NAME (FIELDS 3-5) | FL08 | |||||
3 | Last Name | X(20) | L | 25 | 44 | |
4 | First Name | X(9) | L | 45 | 53 | |
5 | Middle Initial | X | 54 | 54 | ||
6 | Patient Sex | X | 55 | 55 | FL11 | |
7 | Patient Birthdate (mmddccyy) | 9(8) | R | 56 | 63 | FL10 |
8 | Patient Marital Status | X | 64 | 64 | ||
9 | Type Of Admission | X | 65 | 65 | FL14 | |
* 10 | Source Of Admission | X | 66 | 66 | FL15 | |
PATIENT ADDRESS (FIELDS 11-15) | FL09 | |||||
* 11 | Address Line 1 | X(18) | L | 67 | 84 | |
12 | Address Line 2 | X(18) | L | 85 | 102 | |
* 13 | City | X(15) | L | 103 | 117 | |
* 14 | State | XX | L | 118 | 119 | |
* 15 | Zip Code | X(9) | L | 120 | 128 | |
* 16 | Admission Date | 9(6) | R | 129 | 134 | FL12 |
* 17 | Admission Hour | XX | R | 135 | 136 | FL13 |
STATEMENT COVERS PERIOD (FIELDS 18 - 19) | FL06 | |||||
* 18 | From (mmddyy) | 9(6) | R | 137 | 142 | |
* 19 | Thru (mmddyy) | 9(6) | R | 143 | 148 | |
* 20 | Patient Status | 99 | R | 149 | 150 | FL17 |
* 21 | Discharge Hour | XX | R | 151 | 152 | FL16 |
22 | Payments Received (Patient Line) | 9(8)V99S | R | 153 | 162 | FL54 |
23 | Estimated Amt Due (Patient Line) | 9(8)V99S | R | 153 | 167 | FL55 |
* 24 | Medical Record Number | X(17) | L | 173 | 189 | FL3B |
Note: 'Statement Covers Period From' should be the date of the first medical service related to the hospital stay. 'Statement Covers Period Thru' should be the discharge date. 'Payments Received' and 'Estimated Amt Due'
should reflect a single discharge if multiple claims have been submitted.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 Record Type '20' | XX | L | 1 | 2 | ||
* 2 Patient Control Number | X(20) | L | 5 | 24 | FL3A | |
PATIENT NAME (FIELDS 3-5) | FL08 | |||||
* 3 Last Name | X(20) | L | 25 | 44 | ||
* 4 First Name | X(9) | L | 45 | 53 | ||
5 Middle Initial | X | 54 | 54 | |||
6 | Patient Sex | X | 55 | 55 | FL11 | |
7 | Patient Birthdate (mmddccyy) | 9(8) | R | 56 | 63 | FL10 |
8 | Patient Marital Status | X | 64 | 64 | ||
9 | Type Of Admission | X | 65 | 65 | FL14 | |
* 10 | Source Of Admission | X | 66 | 66 | FL15 | |
PATIENT ADDRESS (FIELDS 11-15) | FL09 | |||||
* 11 | Address Line 1 | X(18) | L | 67 | 84 | |
12 | Address Line 2 | X(18) | L | 85 | 102 | |
* 13 | City | X(18) | L | 103 | 120 | |
* 14 | State | XX | L | 121 | 122 | |
* 15 | Zip Code | X(9) | L | 123 | 131 | |
* 16 | Admission Date (mmddccyy) | 9(8) | R | 132 | 139 | FL12 |
* 17 | Admission Hour | XX | R | 140 | 141 | FL13 |
STATEMENT COVERS PERIOD (FIELDS 18 - 19) | FL06 | |||||
* 18 | From (mmddyy) | 9(8) | R | 142 | 149 | |
* 19 | Thru (mmddyy) | 9(8) | R | 150 | 157 | |
* 20 | Patient Status | 99 | R | 158 | 159 | FL17 |
21 | Discharge Hour | XX | R | 160 | 161 | FL16 |
22 | Payments Received (Patient Line) | 9(8)V99S | R | 162 | 171 | FL54 |
23 | Estimated Amt Due (Patient Line) | 9(8)V99S | R | 172 | 181 | FL55 |
* 24 | Medical Record Number | X(17) | L | 182 | 198 | FL3B |
Date changes made by some hospitals for the year 2000 and following require spacing changes in the type 20 and type 70 records for the 1450 record format. For hospitals using the 1450 record format that began using an eight-digit date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2001 is entered 20010207. Where this change is made, all dates (birth date, admission date, statement from data and statement through date) must use this format. The following position changes in the type 20 record are required:
Note: 'Statement Covers Period From' should be the date of the first medical service related to the hospital stay. 'Statement Covers Period Thru' should be the discharge date. 'Payments Received' and 'Estimated Amt Due' should reflect a single discharge if multiple claims have been submitted.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '27' | XX | L | 1 | 2 | |
* 2 | Sequence '01' | 99 | 3 | 4 | ||
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
* 4 | Type of Bill | X(3) | L | 25 | 27 | FL04 |
5 | Patient Social Security Number | 9(10) | R | 28 | 37 | |
* 6 | Patient Race | X | 38 | 38 | ||
* 7 | Patient Ethnicity | X | 39 | 39 | ||
* 8 | Birth Weight | 9999 | R | 40 | 43 | |
* 9 | Total Charges | 9(8)V99S | R | 44 | 53 | |
10 | Estimated Collection rate | 999 | R | 54 | 56 | |
11 | Charitable / Donation rate | 999 | R | 57 | 59 | |
* 12 | APGAR Score | 9999 | R | 60 | 63 | |
13 | Diagnosis-Related Group (DRG) | 9999 | R | 64 | 67 | |
14 | Major Diagnostic Categories (MDC) | 99 | R | 68 | 69 | |
The use of these record types for the HDDS is the same as the UB-04 claim. When reporting for HDDS, records may need to be consolidated and amounts accumulated by payer. Below are specifications and an example as taken from UB-04.
One third party payer record packet (record types 30 3N) must appear in the bill record for each payer involved in the bill. Each third party payer packet must contain a record type 30. However, each record type 30 may or may not have an associated record type 31, depending on the specific third party payer data required by the particular payer.
Example: Medicare is primary, and the secondary payer requires the insured's address.
Record Type Code | Seq.No. | |
Medicare | 30 | 01 |
Secondary Payer | 30 | 02 |
Secondary Payer | 31 | 02 |
Because the sequence number of the type 31 record for the secondary payer matches the sequence number of the secondary payer's type 30 record, it serves as a matching criterion for the specific third party payer record packet.
Sequence 01 represents the primary payer, sequence 02 represents the secondary payer, and sequence 03 represents the tertiary payer.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '30' | XX | L | 1 | 2 | |
* 2 | Sequence Number | 99 | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
* 4 | Source of Payment Code (Payer) | X | 25 | 25 | FL50 | |
5 | Health Plan ID | X(9) | L | 26 | 34 | FL51 |
* 6 | Insured's Unique ID | X(19) | L | 35 | 53 | FL60 |
7 | Insurance Group Number | X(17) | L | 80 | 96 | FL62 |
8 | Insured Group Name | X(14) | L | 97 | 110 | FL61 |
INSURED'S NAME (FIELDS 9-11) | FL58 | |||||
9 | Last Name | X(20) | L | 111 | 130 | |
10 | First Name | X(9) | L | 131 | 139 | |
11 | Middle Initial | X | 140 | 140 | ||
12 | Insured Sex | X | 141 | 141 | ||
13 | Patient Relationship to Insured | 99 | R | 144 | 145 | FL59 |
14 | Employment Status Code | 9 | 146 | 146 | ||
15 | Payments Received | 9(8)V99S | R | 173 | 182 | FL54 |
16 | Estimated Amount Due | 9(8)V99S | R | 183 | 192 | FL55 |
Note: 'Payments Received' and 'Estimated Amt Due' should reflect a single discharge if multiple claims have been submitted.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '31' | XX | L | 1 | 2 | |
* 2 | Sequence Number | 99 | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
INSURED'S ADDRESS (FIELDS 4-8) | ||||||
4 | Address Line 1 | X(18) | L | 25 | 42 | |
5 | Address Line 2 | X(18) | L | 43 | 60 | |
6 | City | X(15) | L | 61 | 75 | |
7 | State | XX | L | 76 | 77 | |
8 | Zip Code | X(9) | L | 78 | 86 | |
9 | Employer Name | X(24) | L | 87 | 110 | FL65 |
EMPLOYER LOCATION (FIELDS 10-13) | ||||||
10 | Employer Address | X(18) | L | 111 | 128 | |
11 | Employer City | X(15) | L | 129 | 143 | |
12 | Employer State | XX | L | 144 | 145 | |
13 | Employer Zip Code | X(9) | R | 146 | 154 | |
The sequence number for record type 50 can go from 01 to 99, each such physical record containing four accommodations, thus making provision for reporting up to 396 accommodations on a single claim. Accommodation revenue codes: 100 through 21X.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '50' | XX | L | 1 | 2 | |
* 2 | Sequence Number | 99 | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
ACCOMMODATIONS (OCCURS 4 TIMES) | ||||||
ACCOMMODATIONS 1 | X(42) | 25 | 66 | |||
* 4 | Revenue Code | 9(4) | R | 25 | 28 | FL42 |
* 5 | Accommodations Rate | 9(7)V99 | R | 29 | 37 | FL44 |
* 6 | Service Units (Accommodations Days) | 9(4) | R | 38 | 41 | FL46 |
* 7 | Total Charges by Revenue Code | 9(8)V99S | R | 42 | 51 | FL47 |
8 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 52 | 61 | FL48 |
ACCOMMODATIONS 2 | X(42) | 67 | 108 | |||
9 | Revenue | 9(4) | R | 67 | 70 | FL42 |
* 10 | Accommodations Rate | 9(7)V99 | R | 71 | 79 | FL44 |
* 11 | Service Units (Accommodations Days) | 9(4) | R | 80 | 83 | FL46 |
* 12 | Total Charges by Revenue Code | 9(8)V99S | R | 84 | 93 | FL47 |
13 | Non-covered Changes by Revenue Code | 9(8)V99S | R | 94 | 103 | FL48 |
ACCOMMODATIONS 3 | X(42) | 109 | 150 | |||
14 | Revenue Code | 9(4) | R | 109 | 112 | FL42 |
* 15 | Accommodations Rate | 9(7)V99 | R | 113 | 121 | FL44 |
* 16 | Service Units (Accommodations Days) | 9(4) | R | 122 | 125 | FL46 |
* 17 | Total Charges by Revenue Code | 9(8)V99S | R | 126 | 135 | FL47 |
18 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 136 | 145 | FL48 |
ACCOMMODATIONS 4 | X(42) | 151 | 192 | |||
19 | Revenue Code | 9(4) | R | 151 | 154 | FL42 |
* 20 | Accommodations Rate | 9(7)V99 | R | 155 | 163 | FL44 |
* 21 | Service Units (Accommodations Days) | 9(4) | R | 164 | 167 | FL46 |
* 22 | Total Charges by Revenue Code | 9(8)V99S | R | 168 | 177 | FL47 |
23 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 178 | 187 | FL48 |
The sequence number for record type 60 can go from 01 to 99, each such physical record contains up to three inpatient ancillary service codes, thus making provision for reporting up to 297 inpatient ancillary services on a single claim. Payer and related information revenue codes: codes 001 - 099. Inpatient ancillary services revenue codes: codes 220 - 99x.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '60' | XX | L | 1 | 2 | |
* 2 | Sequence Number | 99 | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
INPATIENT ANCILLARY SERVICES DA TA (OCCURS 3 TIMES) | ||||||
INPATIENT ANCILLARIES 1 | X(56j | 25 | 80 | |||
* 4 | Revenue Code | 9(4) | R | 25 | 28 | FL42 |
5 | HCPCS / Procedure Code | X(5) | L | 29 | 33 | |
6 | Modifier 1 (HCPCS&CPT4) | X(2) | L | 34 | 35 | |
7 | Modifier 2 (HCPCS & CPT 4) | X(2) | L | 36 | 37 | |
* 8 | Units of Service | 9(7) | R | 38 | 44 | FL46 |
* 9 | Total charges by Revenue Code | 9(8)V99S | R | 45 | 54 | FL47 |
10 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 55 | 64 | FL48 |
INPATIENT ANCILLARIES 2 | X(56j | 81 | 136 | |||
11 | Revenue Code | 9(4) | R | 81 | 84 | FL42 |
12 | HCPCS / Procedure Code | X(5) | L | 85 | 89 | |
13 | Modifier 1 (HCPCS & CPT 4) | X(2) | L | 90 | 91 | |
14 | Modifier 2 (HCPCS & CPT 4) | X(2) | L | 92 | 93 | |
15 | Units of Service | 9(7) | R | 94 | 100 | FL46 |
16 | Total Charges by Revenue Code | 9(8)V99S | R | 101 | 110 | FL47 |
17 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 111 | 120 | FL48 |
INPA TIENT ANCILLARIES 3 | X(56j | 137 | 192 | |||
18 | Revenue Code | 9(4) | R | 137 | 140 | FL42 |
19 | HCPCS / Procedure Code | X(5) | L | 141 | 145 | |
20 | Modifier 1 (HCPCS & CPT 4) | X(2) | L | 146 | 147 | |
21 | Modifier 2 (HCPCS & CPT 4) | X(2) | L | 148 | 149 | |
22 | Units of Service | 9(7) | R | 150 | 156 | FL46 |
23 | Total Charges by Revenue Code | 9(8)V99S | R | 157 | 166 | FL47 |
24 | Non-covered Charges by Revenue Code | 9(8)V99S | R | 136 | 145 | FL48 |
Note: Identical revenue codes should be combined and their charges added together for reporting purposes.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '70' | XX | L | 1 | 2 | |
* 2 | Sequence '01' | XX | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
* 4 | Principle Diagnosis Code | X(7) | L | 25 | 31 | FL67 |
* 5 | Other Diagnosis Code 1 | X(7) | L | 32 | 38 | FL67A |
* 6 | Other Diagnosis Code 2 | X(7) | L | 39 | 45 | FL67B |
* 7 | Other Diagnosis Code 3 | X(7) | L | 46 | 52 | FL67C |
* 8 | Other Diagnosis Code 4 | X(7) | L | 53 | 59 | FL67D |
* 9 | Other Diagnosis Code 5 | X(7) | L | 60 | 66 | FL67E |
* 10 | Other Diagnosis Code 6 | X(7) | L | 67 | 73 | FL67F |
* 11 | Other Diagnosis Code 7 | X(7) | L | 74 | 80 | FL67G |
* 12 | Other Diagnosis Code 8 | X(7) | L | 81 | 87 | FL67H |
* 13 | Other Diagnosis Code 9 | X(7) | L | 88 | 94 | FL67I |
* 14 | Other Diagnosis Code 10 | X(7) | L | 95 | 101 | FL67J |
* 15 | Other Diagnosis Code 11 | X(7) | L | 102 | 108 | FL67K |
* 16 | Other Diagnosis Code 12 | X(7) | L | 109 | 115 | FL67L |
* 17 | Other Diagnosis Code 13 | X(7) | L | 116 | 122 | FL67M |
* 18 | Other Diagnosis Code 14 | X(7) | L | 123 | 129 | FL67N |
* 19 | Other Diagnosis Code 15 | X(7) | L | 130 | 136 | FL670 |
* 20 | Other Diagnosis Code 16 | X(7) | L | 137 | 143 | FL67P |
* 21 | Other Diagnosis Code 17 | X(7) | L | 144 | 150 | FL67Q |
* 22 | POA - Present on Admission | X(1) | 151 | 151 | ||
* 23 | POA 1 - Present on Admission | X(1) | 152 | 152 | ||
* | 24 | POA 2 - Present on Admission | X(1) | 153 | 153 | |
* | 25 | POA 3 - Present on Admission | X(1) | 154 | 154 | |
* | 26 | POA 4 - Present on Admission | X(1) | 155 | 155 | |
* | 27 | POA 5 - Present on Admission | X(1) | 156 | 156 | |
* | 28 | POA 6 - Present on Admission | X(1) | 157 | 157 | |
* | 29 | POA 7 - Present on Admission | X(1) | 158 | 158 | |
* | 30 | POA 8 - Present on Admission | X(1) | 159 | 159 | |
* | 31 | POA 9 - Present on Admission | X(1) | 160 | 160 | |
* | 32 | POA 10 - Present on Admission | X(1) | 161 | 161 | |
* | 33 | POA 11 - Present on Admission | X(1) | 162 | 162 | |
* | 34 | POA 12 - Present on Admission | X(1) | 163 | 163 | |
* | 35 | POA 13 - Present on Admission | X(1) | 164 | 164 | |
* | 36 | POA 14- Present on Admission | X(1) | 165 | 165 | |
* | 37 | POA 15 - Present on Admission | X(1) | 166 | 166 | |
* | 38 | POA 16 - Present on Admission | X(1) | 167 | 167 | |
* | 39 | POA 17 - Present on Admission | X(1) | 168 | 168 | |
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '70' | XX | L | 1 | 2 | |
* 2 | Sequence '02' | XX | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL3A |
* 4 | Principle Procedure Code | X(8) | L | 25 | 32 | FL74 |
* 5 | Principle Procedure Code Data (mmddyy) | X(6) | L | 33 | 38 | |
* 6 | Other Procedure Code 1 | X(8) | L | 39 | 46 | FL74A |
* 7 | OPC 1 - Date (mmddyy) | X(6) | R | 47 | 52 | |
* 8 | Other Procedure Code 2 | X(8) | L | 53 | 60 | FL74B |
* 9 | OPC 2 - Date (mmddyy) | X(6) | R | 61 | 66 | |
* 10 | Other Procedure Code 3 | X(8) | L | 67 | 74 | FL74C |
* 11 | OPC 3 - Date (mmddyy) | X(6) | R | 75 | 80 | |
* 12 | Other Procedure Code 4 | X(8) | L | 81 | 88 | FL74D |
* 13 | OPC 4- Date (mmddyy) | X(6) | R | 89 | 94 | |
* 14 | Other Procedure Code 5 | X(8) | L | 95 | 102 | FL74E |
* 15 | OPC 5 - Date (mmddyy) | X(6) | R | 103 | 108 | |
* 16 | Other Procedure Code 6 | X(8) | L | 109 | 116 | |
* 17 | OPC 6 - Date (mmddyy) | X(6) | R | 117 | 122 | |
* 18 | Other Procedure Code 7 | X(8) | L | 123 | 130 | |
* 19 | OPC 7 - Date (mmddyy) | X(6) | R | 131 | 136 | |
20 | FILLER (empty fields) | 137 | 159 | |||
* 21 | Admitting Diagnosis Code | X(8) | L | 160 | 167 | FL69 |
* 22 | External Cause of Injury Code 1 | X(8) | L | 168 | 175 | FL72 |
* 23 | External Cause of Injury Code 2 | X(8) | L | 176 | 183 | FL72 |
* 24 | External Cause of Injury Code 3 | X(8) | L | 184 | 191 | FL72 |
* 25 | Procedure Coding Method Used | 9(1) | 192 | 192 | ||
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '70' | XX | L | 1 | 2 | |
* 2 | Sequence '02' | XX | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL3A |
* 4 | Principle Procedure Code | X(8) | L | 25 | 32 | FL74 |
* 5 | Principle Procedure Code Date (ccyymmdd) | X(8) | L | 33 | 40 | |
* 6 | Other Procedure Code 1 | X(8) | L | 41 | 48 | FL74A |
* 7 | OPC 1 - Date (ccyymmdd) | X(8) | R | 49 | 56 | |
* 8 | Other Procedure Code 2 | X(8) | L | 57 | 64 | FL74B |
* 9 | OPC 2 - Date (ccyymmdd) | X(8) | R | 65 | 72 | |
* 10 | Other Procedure Code 3 | X(8) | L | 73 | 80 | FL74C |
* 11 | OPC 3 - Date (ccyymmdd) | X(8) | R | 81 | 88 | |
* 12 | Other Procedure Code 4 | X(8) | L | 89 | 96 | FL74D |
* 13 | OPC 4 - Date (ccyymmdd) | X(8) | R | 97 | 104 | |
* 14 | Other Procedure Code 5 | X(8) | L | 105 | 112 | FL74E |
* 15 | OPC 5 - Date (ccyymmdd) | X(8) | R | 113 | 120 | |
* 16 | Other Procedure Code 6 | X(8) | L | 121 | 128 | |
* 17 | OPC 6 - Date (ccyymmdd) | X(8) | R | 129 | 136 | |
* 18 | Other Procedure Code 7 | X(8) | L | 137 | 144 | |
* 19 | OPC 7 - Date (ccyymmdd) | X(8) | R | 145 | 152 | |
20 | FILLER (empty fields) | 153 | 159 | |||
* 21 | Admitting Diagnosis Code | X(8) | L | 160 | 167 | FL69 |
* 21 | External Cause of Injury Code 1 | X(8) | L | 168 | 175 | FL72 |
* 22 | External Cause of Injury Code 2 | X(8) | L | 176 | 183 | FL72 |
* 23 | External Cause of Injury Code 3 | X(8) | L | 184 | 191 | FL72 |
* 24 | Procedure Coding Method Used | 9(1) | 192 | 192 | ||
ICD 9 CM is required for diagnosis coding. Do not report the decimal in the code. The ICD 9 CM diagnosis codes are assigned a COBOL picture of X. Format the actual code in one of four general ways, as follows:
To determine the location of the decimal position and the potential number of decimal positions it is necessary only to examine the high order (left most) position of the field.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '80' | XX | L | 1 | 2 | |
* 2 | Sequence | 99 | R | 3 | 4 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
* 4 | Physician Number Qualifying Code | X(2) | L | 25 | 26 | |
* 5 | Attending Physician Number | X(16) | L | 27 | 42 | FL76 |
* 6 | Operating Physician Number | X(16) | L | 43 | 58 | FL77 |
* 7 | Other Physician Number | X(16) | L | 59 | 74 | FL78 |
* 8 | Other Physician Number | X(16) | L | 75 | 90 | FL79 |
* 9 | Attending Physician Name Last Name First Name Middle Initial | X(25) X(16) X(8) X | L L L | 91 91 107 115 | 115 106 114 115 | |
FIELD NO. | NAME | PICTURE | SPEC | POSITION FROM THRU | FORM LOCATOR | |
10 | Operating Physician Name | X(25) | L | 116 | 140 | |
11 | Other Physician Name | X(25) | L | 141 | 165 | |
12 | Other Physician Name | X(25) | L | 166 | 190 | |
Physician Number Qualifying Codes:
Only one type '95' is allowed per hospital per submittal. The Federal Tax Number must match the type '10' record. This record type will be processed as a trailer record and a record type '10' will be processed as a header record. The records encapsulated between the first type '10' and '95' will be processed using the hospital specified on the type '10' record.
FIELD NO. | NAME | PICTURE | SPEC | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '95' | XX | L | 1 | 2 | |
* 2 | Federal Tax Number (EIN) Federal Tax Sub ID | 9(10) X(4) | R L | 3 13 | 12 16 | FL05 FL05 |
* 3 | Number of Claims | 9(6) | R | 25 | 30 | |
Note: Federal Tax Sub ID must be the same as specified on the type '10' record. 'Number of Claims' should be the number of discharges in the batch (number of type '20' records).
In general, the submittal is identical to the current UB-04 1450 version 6 format used. The differences are minor but nevertheless important. The most notable difference is the requirement for one discharge record for one patient, as opposed to the possibility of multiple claim records for one patient. For discharges with multiple claim records, they should be consolidated into a single discharge, accumulating amounts where necessary (e.g., amounts by Payer).
Only one type '10' is required per hospital per submittal. Only the first type '10' record and each type '10' record following a type '95' record will be processed, all others will be ignored. A record type '10' will be processed as a header record and a record type '95' will be processed as a trailer record. The records encapsulated between the first type '10' and '95' will be processed using the hospital specified on the type '10' record.
In record type '20', 'Statement Covers Period Thru' should be the discharge date.
In record type '95', Federal Tax Sub ID must be the same as specified on the type '10' record.
'Number of Claims'i n record type '95' should be the number of discharges reported in the batch, after the batch equal to the number of type '20' records.
Record type '27' is not a record type used in the UB-04 claim. It contains data that may come from other record types, such as 'Type of Bill' or may be computable, such as 'Total Charges' or should be found in your current databases, 'Patient Social Security Number' for example.
All data except revenue code and charge fields should be duplicated on successive records. All available revenue and charge fields should be completely filled before using additional records. The '0001' revenue code should be the last entry on the last record for a multi-page claim and its charge should be equal to the total charge for all pages.
APPENDICIES
APPENDIX A
DATA DICTIONARY
The definition specified for each data element is in general agreement with the definition in the UB-04 Users Manual. Hospitals using existing UB-04 record formats should reference Section 7.0 - EXCEPTIONS TO 1450 FORMAT, for differences from the established UB-04 record formats. Hospitals using data sources other than uniform billing should evaluate their definitions for agreement with the definitions specified in this Guide and the UB-04 Users Manual.
N = numeric
A = alphanumeric
Required = must be reported
As available = must be present, if captured in your database
Table 1. Definition Breakdown
APPENDIX B
REVENUE CODES AND UNITS OF SERVICE
This section defines acceptable revenue codes representing services provided to a patient, and the unit of measure associated with each revenue service. Any codes not assigned are assumed to be non-applicable unless found in the NUBC's published manual or addenda to this manual.
A three-digit code that identifies a specific accommodation, ancillary service or billing calculation. The first two digits of the three-digit code indicate major category; the third digit, represented by 'x' in the codes, indicates a subcategory.
A quantitative measure of services rendered by revenue category to or for the patient, to include items such as number of accommodation days, miles, pints or treatments.
Table 2. Data Element Description Breakdown
CODE | UNIT | DEFINITION | SUBCATEGORY 'x' |
001 | None | Total Charges | |
01xto 06x | Reserved for National Assignment | ||
07x to 09x | Reserved for State Use | ||
10x | Days | All inclusive rate - a flat fee charge incurred on either a daily basis or total stay basis for services rendered. Charge may cover room and board plus ancillary services or room and board only. | 0 = All inclusive room and board plus ancillary 1 = All inclusive room and board |
11x | Days | Room and board - private medical or general routine services for single bed rooms | 0 = General Classification 1 = Medical/surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other |
12x | Days | Room and board - semi-private (two beds) medical or general - routine service charges incurred for accommodations with two beds | 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other |
13x | Days | Semi-private - three and four beds - routine service charges incurred for accommodations with three and four beds | 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other |
14x | Days | Private deluxe - deluxe rooms are accommodations with amenities substantially in excess of those provided to other patients | 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other |
15x | Days | Room and board - ward medical or general routine service charge for accommodations with five or more beds | 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other |
16x | Days | Other room and board - any routine service charges for accommodations that cannot be included in the more specific revenue center co | 0 = General classification 4 = Sterile environment 7 = Self care 9 = Other |
17x | Days | Nursery - charges for nursing care to newborn and premature infants in nurseries | 0 = General classification 1 = Newborn - Level I 2 = Newborn - Level II 3 = Newborn - Level III 4 = Newborn - Level IV 9 = Other |
18x | Days | Leave of absence - charges for holding a room while the patient is temporarily away from the provider | 0 = General classification 1 = Reserved 2 = Patient convenience 3 = Therapeutic leave 4 = ICF/MR (any reason) 5 = Nursing home (for hospitalization) 9 = Other leave of absence |
19x | Not Assigned | ||
20x | Days | Intensive care - routine service charge for medical or surgical care provided to patients who require a more intensive level of care than is rendered in the general medical or surgical unit | 0 = General classification 1 = Surgical 2 = Medical 3 = Pediatric 4 = Psychiatric 6 = Intermediate ICU 7 = Burn care 8 = Trauma 9 = Other intensive care |
21x | Days | Coronary care - routine service charge for medical care provided to patients with coronary illness who require a more intensive level of care than is rendered in the more general medical care unit | 0 = General classification 1 = Myocardial infarction 2 = Pulmonary care 3 = Heart transplant 4 = Intermediate ICU 9 = Other coronary care |
22x | None | Special charges-charges incurred during an inpatient stay or on a daily basis for certain services | 0 = General classification 1 = Admission charge 2 = Technical support charge 3 = U. R. service charge 4 = Late discharge, medically necessary 9 = Other special charges |
23x | None | Incremental nursing charge rate - charge for nursing service assessed in addition to room and board | 0 = General classification 1 = Nursery 2 = OB 3 = ICU (includes transitional care) 4 = CCU (includes transitional care) 5 = Hospice 9 = Other |
24x | None | All inclusive ancillary - a flat rate charge incurred on either a daily basis or total stay basis for ancillary services only | 0 = General classification 9 = Other inclusive ancillary |
25x | None | Pharmacy - charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist | 0 = General classification 1 = Generic drug 2 = Non-generic drug 3 = Take home drug 4 = Drugs incident to other diagnostic services 5 = Drugs incident to radiology 6 = Experimental drug 7 = Non-prescription 8 = IV solutions 9 = Other pharmacy |
26x | None | IV therapy - equipment charge or administration of intravenous solution by specially trained personnel to individuals requiring such treatment | 0 = General classification 1 = Infusion pump 2 = IV therapy/pharmacy service 3 = IV therapy/drug/supply/delivery 4 = IV therapy/supplies 9 = Other IV therapy |
27x | Item | Medical/surgical supplies and devices -charges for supply items required for patient care | 0 = General classification 1 = Non-sterile supply 2 = Sterile supply 3 = Take home supplies 4 = Prosthetic/orthotic devices 5 = Pace maker 6 = Intraocular lens 7 = Oxygen take home 8 = Other implants 9 = Other supplies/devices |
28x | None | Oncology - charges for the treatment of tumors and related diseases | 0 = General classification 9 = Other oncology |
29x | Item | Durable Medical Equipment (other than rental) charges for medical equipment that can withstand repeated use | 0 = General classification 1 = Rental 2 = Purchase of new DME 3 = Purchase of used DME 4 = Supplies\drugs for DME effectiveness (HHA's only) 9 = Other equipment |
30x | Test | Laboratory - charges for the performance of diagnostic and routine clinical laboratory tests | 0 = General classification 1 = Chemistry 2 = Immunology 3 = Renal patient (home) 4 = Non-routine dialysis 5 = Hematology 6 = Bacteriology and microbiology 7 = Urology 9 = Other laboratory |
31x | Test | Laboratory pathological - charges for diagnostic and routine lab tests on tissue and culture | 0 = General classification 1 = Cytology 2 = Histology 4 = Biopsy 9 = Other |
32x | Test | Radiology diagnostic - charges for diagnostic radiology services provided for the examination and care of patients. Includes: taking, processing, examining and interpreting radiographs and fluorographs | 0 = General classification 1 = Angiocardiography 2 = Arthrography 3 = Arteriography 4 = Chest x-ray 9 = Other |
33x | Test | Radiology therapeutic - charges for therapeutic radiology services and chemotherapy required for care and treatment of patients. Includes therapy by injection or ingestion of radioactive substances | 0 = General classification 1 = Chemotherapy injected 2 = Chemotherapy oral 3 = Radiation therapy 5 = Chemotherapy IV 9 = Other |
34x | Test | Nuclear medicine - charges for procedures and tests performed by a radioisotope laboratory utilizing radioactive materials as required for diagnosis and treatment of patients | 0 = General classification 1 = Diagnostic 2 = Therapeutic 9 = Other |
35x | Scan | CT scan - charges for Computer Tomographic scans of the head and other parts of the body | 0 = General classification 1 = Head scan 2 = Body scan 9 = Other CT scan |
36x | None | Operating room services - charges for services provided by specifically trained nursing personnel who provide assistance to physicians in the performance of surgical and related procedures during and immediately following surgery | 0 = General classification 1 = Minor surgery 2 = Organ transplant other than kidney 7 = Kidney transplant 9 = Other operating room services |
37x | None | Anesthesia - charges for anesthesia services in the hospital | 0 = General classification 1 = Anesthesia incident to RAD 2 = Anesthesia incident to other diagnostic services 4 = Acupuncture 9 = Other anesthesia |
38x | Pint | Blood storage and processing - charges for the storage and processing of whole blood | 0 = General classification 1 = Blood administration 2 = Whole blood 3 = Plasma 4 = Platelets 5 = Leucocytes 6 = Other components 7 = Other derivatives (cryoprecipitates) 9 = Other blood storage and processing |
39x | Blood storage and processing - charges for the storage and processing of whole blood | 0 = General classification 1 = Blood administration 9 = Other blood storage & processing | |
40x | Test | Other imaging services | 0 = General classification 1 = Diagnostic mammography 2 = Ultrasound 3 = Screening mammography 9 = Other imaging services |
41x | Treatment | Respiratory services - charges for administration of oxygen and certain potent drugs through inhalation or positive pressure and other forms of rehabilitative therapy, through measurement of inhaled and exhaled gases and analysis of blood, and evaluation of the patient's ability to exchange oxygen and other gases | 0 = General classification 2 = Inhalation services 3 = Hyper baric oxygen therapy 9 = Other respiratory services |
42x | Treatment | I Physical therapy - charges for therapeutic I exercises, massage, and utilization of effective properties of light, heat, cold, water, electricity and assistive devices for diagnosis I and rehabilitation of patients who have I neuromuscular, orthopedic and other I disabilities | 0 = General classification 1 = Visit charge 2 = Hourly charge 3 = Group rate 4 = Evaluation or re-evaluation 9 = Other physical therapy |
43x | Treatment | I Occupational therapy - charges for teaching I manual skills and independence in personal care to stimulate mental and emotional activity on the part of patients | 0 = General classification 1 = Visit charge 2 = Hourly charge 3 = Group rate 4 = Evaluation or re-evaluation 9 = Other occupational therapy |
44x | Treatment | I Speech language pathology-charges for I services provided to persons with impaired I functional communications skills | 0 = General classification 1 = Visit charge 2 = Hourly charge 3 = Group rate 4 = Evaluation or re-evaluation 9 = Other speech language pathology |
45x | Visit | I Emergency room - charges for emergency I room treatment to those ill and injured persons who require immediate unscheduled I medical or surgical care | 0 = General classification 1 = EMTALA emergency medical screening services 2 = ER beyond EMTALA screening 6 = Urgent care 9 = Other emergency room |
46x | Test | I Pulmonary function - charges for tests that I measure inhaled and exhaled gases and I analysis of blood, and for tests that evaluate I the patient's ability to exchange other gases | 0 = General classification 9 = Other pulmonary function |
47x | Test | Pulmonary function - charges for tests that measure inhaled and exhaled gases and analysis of blood, and for tests that evaluate the patient's ability to exchange other gases | 0 = General classification 1 = Diagnostic 2 = Treatment 9 = Other audiology |
48x | Test | Cardiology - charges for cardiac procedures 1 rendered in a separate unit within the hospital. 1 Such procedures include, but are not limited 1 to: heart catheterization, coronary 1 angiography, Swan-Ganz catheterization and 1 exercise stress test. | 0 = General classification 1 = Cardiac cath lab 2 = Stress test 9 = Other cardiology |
49x | None | 1 Ambulatory surgical care - charges for 1 ambulatory surgery that are not covered by 1 other categories | 0 = General classification 9 = Other ambulatory surgical care |
50x | None | Outpatient service- charges for services rendered to an outpatient who is admitted as 1 an inpatient before midnight of the day 1 following the date of service. These charges 1 are incorporated on the inpatient bill of 1 Medicare patients. | 0 = General classification 9 = Other outpatient services |
51x | Visit | 1 Clinic - charges for providing diagnostic, 1 preventive, curative, rehabilitative and 1 education services on a scheduled basis to an 1 ambulatory patient | 0 = General classification 1 = Chronic pain center 2 = Dental clinic 3 = Psychiatric clinic 4 = OB-GYN clinic 5 = Pediatric clinic 6 = Urgent care clinic 7 = Family practice 9 = Other clinic |
52x | 1 Free 1 Standing | Provides a breakdown of some clinics that hospitals or third party payers may require | 0 = General classification 1 = Rural health -clinic 2 = Rural health - home 3 = Family practice clinic 6 = Urgent care clinic 9 = Other free standing clinic |
53x | 1 Visit | Osteopathic services - charges for a structural evaluation of the cranium, entire cervical, dorsal and lumbar spine by a doctor of osteopathy | 0 = General classification 1 = Osteopathic therapy 9 = Other osteopathic services |
54x | 1 Mile | Ambulance - charges for ambulance service, usually on an unscheduled basis, to the ill and injured who require immediate medical attention | 0 = General classification 1 = Supplies 2 = Medical transport 3 = Heart mobile 4 = Oxygen 5 = Air ambulance 6 = Neonatal ambulance services 7 = Pharmacy 8 = Telephone transmission EKG 9 = Other ambulance |
55x | Skilled 1 Nursing | Charges for nursing services that must be provided under the direct supervision of a licensed nurse to assure the safety of the patient and to achieve the medically desired result. This code may be used for nursing home services or a service charge for home health billing. | 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other skilled nursing |
56x | Visit | Medical social services such as counseling patients, intervening on behalf of patients, and interpreting problems of social situation rendered to patients on any basis. | 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other medical social services |
57x | 1 Home Health Aide | Charges made by an HHA for personnel who are primarily responsible for the personal care of the patient | 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other home health aide |
58x | Other Visits | Code indicates the charge by an HHA for visits other than physical therapy, occupational therapy or speech therapy, which must be specifically identified. | 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other home health visits |
59x | Units of Service | This revenue code is used by an HHA that bills (Home Health) on the basis of units of service. | 0 = General classificatio 9 = Home health other units |
60x | Oxygen | Code indicates the charges by an HHA for (Home Health) oxygen equipment supplies or contents, excluding purchased equipment. If a beneficiary purchased a stationary oxygen system, and oxygen concentrator or portable equipment, current revenue code 292 or 293 applies. DME (other than oxygen systems) is billed under current revenue codes 291, 292 or 293. | 0 = General classification 1 = Oxygen - state/equip/supply/ or content 2 = Oxygen - state/equip/supply under 1 LPM 3 = Oxygen - state/equip/ over 4 LPM 4 = Oxygen - portable add-on |
61x | I Test | MRI - charges for Magnetic Resonance Imaging of the brain and other parts of the body. | 0 = General classification 1 = Brain including brain stem 2 = Spinal cord including spin 9 = Other MRI |
62x | I Days | Medicare/Surgical supplies - charges for supply items required for patient care. The category is an extension of code 27x for reporting additional breakdown where needed. Sub code 1 is for providers that cannot bill supplies used for radiology procedures under radiology. | 1 = Supplies incident to radiology 2 = Supplies incident to other diagnostic services 3 = Surgical dressing 4 = Investigational device |
63x | 1 Drugs Requirin | g Specific Identification | 0 = General classification 1 = Single source drug 2 = Multiple source drug 3 = Restrictive prescription 4 = Erytropepoetin (EPO) - less than 10,000 units 5 = Erytropepoetin (EPO) -10,000 or more units 6 = Drugs requiring detailed coding |
64x | Home 1 Therapy Services | Charge for intravenous drug therapy services performed in the patient's residence. For home IV providers the HCPCS code must be entered for all equipment, and all types of covered therapy. | 0 = General classification 1 = Non-routine nursing 2 = IV site care, central line 3 = IV start/change peripheral line 4 = Non-routine nursing, peripheral line 5 = Training patient/caregiver, central line 6 = Training, disabled patient, central line 7 = Training patient/caregiver, peripheral line 8 = Training, disabled patient, peripheral line 9 = Other IV therapy services |
65x | 1 Day | Hospice service - charges for hospice care services for a terminally ill patient if he/she elects these services in lieu of other services for the terminal condition | 0 = General classification 1 = Routine home care 2 = Continuous home care 3 = Reserved 4 = Reserved 5 = Inpatient respite care 6 = General non-respite inpatient care 7 = Physician services 9 = Other hospice |
70x | 1 None | Cast room - charges for services related to the application, maintenance and removal of casts | 0= General classification 9 = Other cast room |
71x | 1 None | Recovery room | 0 = General classification 9 = Other recovery room |
72x | Labor Room / Delivery Room | Labor room and delivery - charges Delivery Room for labor and delivery room services provided by specially trained nursing personnel to patients, including prenatal care during labor, assistance during delivery, postnatal care in the recovery room, and minor gynecological procedures if they are performed in the delivery suite. | 0 = General classification 1 = Labor 2 = Delivery 3 = Circumcision 4 = Birthing center (unit is days) 9 = Other labor room and delivery |
73x | Test | EKG/ECG (electrocardiogram) - charges for operation of specialized equipment to record electromotive variations in actions of the heart muscle on an electrocardiography for diagnosis of heart ailments | 0 = General classification 1 = Holter monitor 2 = Telemetry 9 = Other EKG/ECG |
74x | Test | EEG (electroencephalogram) - charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders | 0 = General classification 9 = Other EEG |
75x | I Test | Gastrointestinal services - procedure room charges for endoscopic procedures not performed in the operating room. | 0 = General classification 9 = Other gastrointestinal |
76x | None | Treatment or observation room - charges for minor procedures performed outside the operating room | 0 = General classification 1 = Treatment room 2 = Observation room 9 = Other treatment room |
77x | Preventative Care Services | Charges for the administration of vaccines | 0 = General classification 1 = Vaccine administration 9 = Other |
79x | None | Lithotripsy - charges for the use of lithotripsy in the treatment of kidney stones | 0 = General classification 9 = Other lithotripsy |
80x | Session | Inpatient renal dialysis - a waste removal process performed in an inpatient setting that uses an artificial kidney when the body's own kidneys have failed. The waste may be removed directly from the blood (hemodialysis) or indirectly from the abdominal covering and the tissue (peritoneal dialysis). | 0 = General classification 1 = Inpatient hemodialysis 2 = Inpatient peritoneal 3 = Inpatient continuous ambulatory peritoneal dialysis 4 = Inpatient continuous cycling peritoneal dialysis 9 = Other inpatient dialysis |
81x | None | Organ acquisition - the acquisition of a kidney, liver or heart for use in transplantation | 0 = General classification 1 = Living donor- kidney 2 = Cadaver donor - kidney 3 = Unknown donor- kidney 9 = Other organ acquisition |
82x | Hemodialysis I Outpatient or I Home Dialysis | A waste removal performed in an outpatient or home setting necessary when the body's own kidneys have failed. Waste is removed directly from the blood. | 0 = General classification 1 = Hemodialysis/composite or other rate 5 = Support services 9 = Other hemodialysis outpatient |
83x | Peritoneal Dialysis Outpatient or I Home | A waste removal process performed in an outpatient or home setting, necessary when the body's own kidneys have failed. Waste is removed indirectly by flushing a special solution between the abdominal covering and the tissue. | 0 = General classification 1 = Peritoneal/composite or other rate 5 = Support services 9 = Other peritoneal |
84x | Continuous Ambulatory Peritoneal Dialysis (CAPD) Outpatient | A continuous dialysis process performed in an outpatient or home setting, which uses the patient's peritoneal membrane as a dialyzer. | 0 = General classification 1 = CAPD/composite or other rate 5 = Support services 9 = Other CAPD dialysis |
85x | Continuous Cycling Peritoneal Dialysis (CCPD) Outpatient | A continuous dialysis process performed in an outpatient or home setting, which uses the patient's peritoneal membrane as a dialyzer. | 0 = General classification 1 = CCPD/composite or other rate 5 = Support services 9 = Other CCPD dialysis |
86x | Reserved for Dialysis (National Assignment) | ||
87x | Reserved for Dialysis (State Assignment) | ||
88x | Session | Miscellaneous dialysis - charges for dialysis services not identified elsewhere | 0 = General classification 1 = Ultrafiltration 9 = Other miscellaneous dialysis |
89x | None | Other donor bank - charges for the acquisition, storage and preservation of all human organs, excluding kidneys | 0 = General classification 1 = Bone 2 = Organ other than kidney 3 = Skin 4 = Activity therapy 9 = Other donor bank |
90x | Visit | Psychological treatments | 0 = General classification 1 = Electroshock treatment 2 = Milieu therapy 3 = Play therapy 4 = Activity therapy 9 = Other 6 = Family therapy |
91x | Visit | Psychiatric or psychological services -charges for providing nursing care, employee and professional services for emotionally disturbed patients, including patients admitted for diagnosis and those admitted for treatment. | 0 = General classification 1 = Rehabilitation 2 = Partial hospitalization 4 = Individual therapy 5 = Group therapy 7 = Biofeedback 8 = Testing 9 = Other |
92x | Test | Other diagnostic services | 0 = General classification 1 = Peripheral vascular lab. 2 = Electromyelogram 3 = Pap smear 4 = Allergy test 5 = Pregnancy test 9 = Other diagnostic service |
94x | Visit | Other therapeutic services - charges for other therapeutic services not otherwise categorized | 0 = General classification 1 = Recreational therapy 2 = Education or training 3 = Cardiac rehabilitation 4 = Drug rehabilitation 5 = Alcohol rehabilitation 6 = Routine complex medical equipment 7 = Ancillary complex medical equipment 9 = Other therapeutic services |
96x | None | Professional fees - charges for medical professionals that the hospitals or third party payers require to be separately identified on the billing form | 0 = General classification 1 = Psychiatric 2 = Ophthalmology 3 = MD anesthesiologist 4 = CRNA anesthetist 9 = Other professional fees |
97x | None | Professional fees - continued 1 = Laboratory | 2 = Radiology - diagnostic 3 = Radiology - therapeutic 4 = Radiology - nuclear medicine 5 = Operating room 6 = Respiratory therapy 7 = Physical therapy 8 = Occupational therapy 9 = Speech pathology |
98x | None | Professional fees - continued 1 = Emergency room | 2 = Outpatient services 3 = Clinic 4 = Medical; social services 5 = EKG 6 = EEG 7 = Hospital visit 8 = Consultation 9 = Private duty nurse |
99x | None | Patient convenience items - charges for items I | 0 = General classification that are generally considered by the third 1 = Cafeteria/guest tray party payer to be strictly convenience items 2 = Private linen service and as such, are not covered 3 = Telephone/telegraph 4 = TV/radio 5 = Non-patient room rentals 6 = Late discharge charge 7 = Admission kits 8 = Beauty shop/barber 9 = Other convenience items |
APPENDIX C
ACRONYM LISTING
ACRONYM | DESCRIPTION |
ADH | Arkansas Department of Health |
ASCII | PC Text File |
CAH | Critical Access Hospital |
CAPD | Continuous Ambulatory Peritoneal Dialysis |
CCPD | Continuous Cycling Peritoneal Dialysis |
CD | Compact Disk |
COBOL | Common Business Oriented Language |
CPT | Current Procedural Technology |
CR | Carriage-return |
CT | Computer Tomographic |
DAT | PC Text File |
DCN | Document Control Number |
DME | Durable Medical Equipment |
DRG | Diagnosis Related Group |
EEG | Electroencephalogram |
EIN | Employer Identification Number |
EKG/ECG | Electrocardiogram |
EPO | Erythropoetin alpha or Darbepoetin alpha |
FTP | File Transfer Protocol |
HCFA | Health Care Financing Administration |
HCPCS | HCFA Common Procedural Coding System |
HDDS | Hospital Discharge Data System |
HH | Home Health |
HHA | Home Health Agency |
HIPPA | Health Insurance Portability and Accountability Act of 1996 |
ICD | International Classification of Diseases |
ICF | Intermediate Care Facility |
IRF | Inpatient Rehabilitation Facility |
LF | Line-feed |
LTCH | Long Term Care Hospital |
MDC | Major Diagnostic Categories |
MRI | Magnetic Resonance Imaging |
NPI | National Provider Identifier |
NUBC | National Uniform Billing Committee |
PPS | Perspective Payment System |
QTR | Quarter |
RTC | Residential Treatment Center |
SNF | Skilled Nursing Facility |
TIN | Tax Identification Number |
TOB | Type of Bill |
TXT | Text |
UB | Uniform Billing |
UPIN | Universal Physician Identification Number |
ZIP | Compressed file |
APPENDIX D REFERENCES
Current Procedural Terminology
Published by the American Medical Association; ISBN 3-89970-792 -0.
May be purchased from:
Order Department Reference OP054194HA American Medical Association PO Box 10950 Chicago, IL 60610 (800)621-8335
National Uniform Billing Committee (NUBC)
Official UB-04 Data Specifications Manual 2009, Version 3.00, July 2008
Uniform Billing (UB-04)
CMS Manual System, Pub100-04 Medicare Claims Processing, Transmittal 1104, November 3, 2006, Department of Health and Human Services, Centers for Medicare & Medicaid Services or www.cms.hhs.gov/transmittals/downloads/R1104CP.pdf
HCFA Common Procedural Coding System (HCPCS)
Published by the Centers for Medicare and Medicaid Service, (formerly HCFA)
International Classification of Diseases, Ninth Edition (ICD-9)
Published by the Centers for Medicare and Medicaid Service, and the National Center for Health Static.
The materials published by the Centers for Medicare and Medicaid Service may be purchased from:
U.S. Department of Commerce National Technical Information Service Subscription Department 5285 Port Royal Road Springfield, VA 22161 (800) 553-6847
Some materials may also be purchased from large commercial bookstores and from medical office supply firms. These documents are also available for use by the general public at the Arkansas State Library and may be available from your local library by an interlibrary loan.
Arkansas State Library Documents Service One Capitol Mall Little Rock, AR 72201 (501)682-2326
The following Rules and Regulations pertaining to [he Hospital Discharge Data System are duly adopted and promulgated by the Arkansas Board of Health pursuant to the authority expressly conferred by the Slate of Arkansas including, without limitation. Act 670 of 1995 (the Act), as amended, the same being Ark. Code Ann. § 20-7-301 et seq. The Act established the State Health Data Clearing House within the Arkansas Department of Heaith. The Clearing House is mandated by the Act to acquire and disseminate health care information in order to understand patterns and trends in the availability, use and costs of health cure services in the state. Subsection (h) of the Act directs the Arkansas State Board of Health to prescribe and enforce such rules and regulations as may be necessary to carry out the purpose of this Act.
It is the purpose of these regulations to provide direction about the required collection, submission, management and dissemination of health data.
For the purposes of these Regulations, the following words and phrases when used herein shaJl be construed as follows:
"Guide" means the Hospital Discharge Data Submittal Guide published by the Arkansas Department of Health. This Guide contains technical information relating to data format, media and submittal time frames.
All terms used in any one gender or number shall be construed to include any other gender or number.
Each Arkansas hospital which performs activities meeting the definition of inpatient discharges, as set forth in the Guide, shall submit data to the Department in a manner that complies with the provisions of the Guide for all inpatient hospital discharges occurring on or after January 1. 1996,
In addition to data prescribed for Submission in the Guide, the following data must be submitted according to the schedule provided: Each hospital shall provide a complete and accurate copy of the American Hospital Association's Annual Survey to the Arkansas Department of Health or the Arkansas Hospital Association, The required submission date will be published annually with the distribution of the survey.
The Stale Board or the Director shall, upon a showing of good cause and if lime permits, extend the time allowed for the performance of any function or duly required by the provisions of the Actor of these regulations and rules. In making any determination with regard to good cause, the Hoard and the Director shall give due consideration to all relevant facts and circumstances, including such considerations as the complexity of the issues or ihe existence of extraordinary circumstances or unforeseen evenls which have led to the request for an extension of lime. The State Board or the Director shall act upon a request for an extension of time within thirty (30} days of receiving the written request by the hospital, Failure to act within thirty (30) days shall be deemed as a grant of the extension.
Information reported to the Department shall not be disclosed except as authorized by the Arkansas law. See Ark. Code Ann. tj 20-7-305 as amended,
All reports generated by the Department from the aggregate data set for a member of the general public are open for public inspection. Ihe Department shall provide copies of these reports, upon request, at a cost of $.25 per page. The Department shall determine fees to be charged to cover the direct and indirect costs for providing other information requests or special compilations from aggregate data sets. The fee shall include staff lime, computer time, copying costs, postage and supplies,
Ark. Code Ann. § 20-7-301 et seu, sets forth civil and criminal penalties for non-compliance with provisions of the Act and of rules and regulations adopted by the Arkansas State Board of Health to implement the Act, as follows:
Hearings and appeals will be conducted according to the Adjudication and Rule Making Sections of the Department's Administrative Procedures previously promulgated by the Department and any revisions thereto,
All pages of these regulations and rules, and of the Hospital Discharge Data Submittal Guide, issued by the Department are dated at the bottom. As changes occur, replacement pages will lie issued. Al) replacement pages will be dated so that users may be certain they are referring to the most recent
information.
The following documents are hereby incorporated by reference:
If any provision of these Rules and Regulations or [he application thereof to any person or circumstances is held invalid, such invalidity shall not affect other provisions or applications of these Rules and Regulations which can give effect without the invalid provisions or applications, and to
this end the provisions hereto are declared severable.
Al! regulations and parti of regulaiions in confiici herewith are hereby repealed.
Arkansas Code Annotated 20-7-301 et seq.
This subchapter shall be entitled the "State Health Data Clearing House Act."
History. Acts 1995, No. 670, § 1.
The General Assembly finds that as a result of rising health care costs, the shortage of health professionals and health care services in many areas of the state, and the concerns expressed by care providers, consumers, third party payers, and others involved with planning for the provision of health care, there is an urgent need to understand patterns and trends in the availability, use, and costs of these services. Therefore, in order to establish an information base for patients, health professionals, and hospitals, to improve the appropriate and efficient usage of health care services, and to provide for appropriate protection for confidentiality and privacy, the Department of Health shall act as a state health data clearing house for the acquisition and dissemination of data from state agencies and other appropriate sources to carry out the purposes of this subchapter.
History. Acts 1995, No. 670, § 2.
History. Acts 1995, No. 670, § 2.
The Director of the Department of Health shall be empowered to release data collected pursuant to this subchapter, except that data released shall not include any information which identifies or could be used to identify any individual patient, provider, institution, or health plan except as provided in § 20-7-305.
History. Acts 1995, No. 670, § 2.
Cost and Utilization Project. The data shall be treated in a manner consistent with all state and federal privacy requirements, including, without limitation, the federal Health Insurance Portability and Accountability Act of 1996 privacy rule, specifically 45 C.F.R. § 164.512(i). Furthermore, any identifiable data provided, collected, or disseminated under this subsection shall not be subject to discovery pursuant to the Arkansas Rules of Civil Procedure or the Freedom of Information Act of 1967, § 25-19-101 et seq.
History. Acts 1995, No. 670, § 2.
History. Acts 1995, No. 670, § 2; 1997, No. 179, § 22.
History. Acts 1995, No. 670, § 3.
All laws and parts of laws in conflict with this subchapter are hereby repealed, except that nothing herein shall be interpreted to repeal any provision which authorizes the Health Services Agency to gather such data as may be necessary to conduct permit of approval activities.
History. Acts 1995, No. 670, § 6.
007.11.09 Ark. Code R. § 001