016.24.06 Ark. Code R. 008
ARKANSAS CODE - "STATE HEALTH DATA CLEARING HOUSE ACT"
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.
History. Acts 1995, No. 670, § 2.
History. Acts 1995, No. 670, § 2 ; 1997, No. 179, § 22.
History. Acts 1995, No. 670, § 3.
20-7-308. Repealer.
All laws and parts of laws in conflict with this subchapter are hereby repealed, except that nothing herein shall be interpreted to repeal any provision which authorizes the Health Services Agency to gather such data as may be necessary to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.
RULES AND REGULATIONS PERTAINING TO HOSPITAL DISCHARGE DATA SYSTEM
INTRODUCTION
A statewide Hospital Discharge Data System is one of the most important tools for addressing a broad range of health policy issues. Act 670 of 1995, A.C.A. 20-7-301 et seq. requires all hospitals licensed by the state of Arkansas to report information on inpatient discharges.
In order to simplify the reporting process, the Arkansas Hospital Discharge Data System is based on the HCFA UB-92. Two-thirds of the states in the nation already have hospital discharge data systems; at least two-thirds of those are based on the HCFA UB-92 claim.
In accordance, the Arkansas Department of Health and Human Services is required to collect, analyze and disseminate selected health care data. This guide defines the data that hospitals will submit for the specific purpose of constructing the Hospital Discharge Data System.
The Center for Health Statistics can provide technical consultation and assistance. Initially, such consultation or assistance must necessarily be limited to activities that specifically enable the hospital to submit data that will meet the requirements. For further information, contact Ed Carson, Manager of Hospital Discharge Data System.
Arkansas Department of Health
Center for Health Statistics, Slot H19
P O Box 1437
Little Rock, AR 72203-1437
Ph: (800) 482- 5400 ext. 2368
FAX 661-2544
Ed Carson
john.carson@arkansas.gov
(501) 661-2046
Sue Ellen Peglow
sue.peglow@arkansas.gov
(501) 280-4063
thomas rainer
thomas.rainer@arkansas.gov
(501) 280-4066
Yanzhe Zhao
yanzhe.zhao@arkansas.gov
(501) 661-2853
Katrina Hritz
katrina.hritz@arkansas.gov
501-280-4046
DATA REPORTING SOURCE
All facilities operating and licensed as a hospital in the state of Arkansas by the Arkansas Department of Health, Division of Health Facility Services, will report discharge data to the Arkansas Department of Health 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, 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 Department of Health and Human Services, 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 the Arkansas Department of Health and Human Services, 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.
CONFIDENTIALITY OF DATA
Act 670 of 1995, A.C.A. 20-7-301 et seq. 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). The Arkansas Department of Health and Human Services will only release data, except as allowed by law that has sufficiently masked these identities.
Since the Department of Health and Human Services 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.
SUBMITTAL SCHEDULE
Discharge data records will be submitted to the Department of Health and Human Services 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 the Department of Health, some are utilizing third-party intermediaries. When using an intermediary, the reporting deadlines are still to be met. All hospitals will submit data within 30 days to the Department of Health or to the intermediary. See the section on use of INTERMEDIARIES for further details.
SCHEDULE
PERSON'S DATE OF DISCHARGE IS | DISCHARGE DATA MUST BE RECEIVED BY |
January 1 through March 31 | May 10 |
April 1 through June 30 | August 10 |
July 1 through September 30 | November 10 |
October 1 through December 31 | March 1 |
REQUEST FOR EXTENSION
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
P O Box 1437
Little Rock, AR 72203-1437
Phone (501) 661-2046
FAX (501) 661-2544
E-mail: john.carson@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.
DATA ERRORS AND CERTIFICATION
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.
ERROR CORRECTION
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 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, Hospital Discharge Data System 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.
DATA SUBMITTAL SPECIFICATIONS
Currently, data must be submitted via encrypted E-mail, diskette or magnetic tape (reel). 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 and Human Services
Center for Health Statistics, Slot H19
Hospital Discharge Data System
P O Box 1437
Little Rock, AR 72203-1437
If you are submitting data for more than one hospital on one media submission, the additional specifications found in the section named MULTI-HOSPITAL SUBMISSION must be followed.
E-MAIL ATTACHMENT SUBMISSIONS
The following specifications must be met when submitting data by e-mail attachment via the Internet:
DISKETTE AND CD ROM SPECIFICATIONS
The following specifications must be met when submitting data on PC diskettes:
Notes: 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.
An example of the diskette label
'ZIP' for a file compressed with PKZIP or 'EXE' for a self-extracting file
Example: 06QTR1.TXT - ASCII data file for the first quarter of 2006
FILE COMPRESSION
WINZIP is the compression utility of choice by the Hospital Discharge Data Section. If a compression utility other that WINZIP is used, the resulting file must be able to be unzipped by the Hospital Discharge Data Section. Please contact an HDDS colleague prior to sending a file compressed with any compression software other than WINZIP.
FILE ENCRYPTION
Cryptext is the freeware, encryption software that the HDDS recommends. An HDDS colleague can be contacted on how to receive this software. Encryption of data files sent as email attachments is required. See item a. under E-Mail attachment submissions. All passwords used with encryption software will be supplied by the HDDS. Please contact an HDDS colleague for the correct password for your hospital.
REEL TAPE SPECIFICATIONS
The following specifications must be met when submitting data on magnetic tape:
An example of the tape label
FILE TRANSFER PROTOCOL
No FTP discharge data submissions are permitted at the present time. FTP and other data submission methods are always under review. If implemented, all Arkansas hospitals will receive notice of the ability to submit discharge data using the new method.
MULTI - HOSPITAL SUBMISSION
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:
X. If you are not a hospital, replace 'Hospital:' with your company name.
X. If you are a hospital or subsidiar2006DHHSDATAGUIDE.docy of a hospital, replace 'Hospital:' with 'Agent:' and your hospital name.
X. If multiple files are on the submission, replace 'Total Record Count:' with 'Number of Files:'
X. The contact person and phone number should be that of the agent or company, not the hospital.
X. If multiple files are placed on diskette, the 'filename.extension' file-naming standard must change. The last two positions of the filename (follows 'QTR' and quarter number) must be the file number provided.
In addition to the above changes, a list of hospitals on the tape must be provided with tax id, number of records, and hospital contact.
INTERMEDIARIES
Third-party intermediaries may be utilized by hospitals for the delivery of data to the Department of Health and Human Services. To better manage data collection, intermediaries must be registered with the Department of Health and Human Services. Additions and deletions to the intermediary's list of hospitals represented must be submitted at least 10 days prior to the Department of Health and Human Services reporting due date. The intermediary must specify hospitals being represented, media, formats, contacts, length of contractual obligation, etc.
EDITING INTERMEDIARIES
The following additional requirements and information apply to intermediaries delivering edited data to the Department of Health and Human Services:
PASS - THRU INTERMEDIARIES
The following additional requirements and information apply to intermediaries delivering unedited data to the Department of Health:
DATA RECORD FORMATS
The accepted data record formats are the UB-92 1450 version 6 format and UB-92 1300 flat file format. Both of these formats have been altered slightly. These alterations are the result of standardizing similar data elements of the two formats. The definition specified for each data element is in general agreement with the definition in the UB-92 Users Manual. Hospitals using data sources other than uniform billing should evaluate definitions for agreement with the definitions specified in this Guide and UB-92 Users Manual. See the EXCEPTIONS section for each format to identify possible changes to your current formats. Each record must be followed by a carriage return/line feed sequence.
'UB-92-1450' RECORD SPECIFICATION
The UB-92 1450 claim 'record' is made up of a series of 192-character physical records. Not all of the physical claim records are used in the Hospital Discharge Data System, such as the Claim Request Data. Records not specified in the Hospital Discharge Data System 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 Hospital Discharge Data System, when possible. A complete copy of the patient's 1450 records would satisfy the requirements, with exceptions noted in 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 4 - Inpatient 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:
Thru = Rightmost position in the record (low order). 10. Form Locator: Number found on the UB-92 Form and associated with the field in that location.
1450 -RECORD TYPE 10 - PROVIDER DATA
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 | SPECIFI- CATION | POSIT ION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '10' | XX | L | 1 | 2 | |
* 4 | Federal Tax Number or EIN | 9(10) | R | 8 | 17 | FL05 |
5 | Federal Tax Sub ID | X() | L | 18 | 21 | FL05 |
* 6 | National Provider Identifier | X(13) | L | 22 | 34 | |
* 7 | Medicaid Provider Number | X(13) | L | 35 | 47 | |
11 | Provider Telephone Number | 9(10) | R | 87 | 96 | FL01 |
12 | Provider Name | X(5) | L | 97 | 121 | FL01 |
Provider Address (Fields 13-16) | FL01 | |||||
13 | Address | X(5) | L | 122 | 146 | |
14 | City | X(4) | L | 147 | 160 | |
15 | State | XX | L | 161 | 162 | |
16 | ZIP Code | X() | L | 163 | 171 | |
17 | Provider FAX Number | 9(10) | R | 172 | 181 | |
*An asterisk denotes the field is required and must contain data if applicable.
1450 -RECORD TYPE 20 - PATIENT DATA
FIELD NO. | NAME | SPECI PICTURE | FI- PO CATION | SITION FORM | LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '20' | XX | L | 1 | 2 | |
* 3 | Patient Control Number | X(20) | L | 5 | 24 | FL03 |
Patient Name (Fields 4-6) | FL12 | |||||
* 4 | Last Name | X(20) | L | 25 | 44 | |
* 5 | First Name | X(9) | L | 45 | 53 | |
* 6 | Middle Initial | X | 54 | 54 | ||
* 7 | Patient Sex | X | 55 | 55 | FL15 | |
* 8 | Patient Birthdate (mmddccyy) | 9(8) | R | 56 | 63 | FL14 |
9 | Patient Marital Status | X | 64 | 64 | FL16 | |
* 10 | Type of Admission | X | 65 | 65 | FL19 | |
* 11 | Source of Admission | X | 66 | 66 | FL20 | |
Patient Address (Fields 12-16) | FL13 | |||||
* 12 | Address - Line 1 | X(18) | L | 67 | 84 | |
13 | Address - Line 2 | X(8) | L | 85 | 102 | |
* 14 | City | X(5) | L | 103 | 117 | |
* 15 | State | XX | L | 118 | 119 | |
* 16 | ZIP Code | X() | L | 120 | 128 | |
* 17 | Admission Date | 9(6) | R | 129 | 134 | FL17 |
* 18 | Admission Hour | XX | R | 135 | 136 | FL18 |
Statement Covers Period | FL06 | |||||
* 19 | From (mmddyy) | 9(6) | R | 137 | 142 | |
* 20 | Thru (mmddyy) | 9(6) | R | 143 | 148 | |
* 21 | Patient Status | 99 | R | 149 | 150 | FL22 |
22 | Discharge Hour | XX | R | 151 | 152 | FL21 |
23 | Payments Received (Patient line) | 9(8V99S | R | 153 | 162 | FL54 |
24 | Estimated Amt Due(atient line) | 9(8)V99S | R | 163 | 172 | FL55 |
* 25 | Medical Record Number | X(7) | L | 173 | 189 | FL23 |
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.
1450 Y2K-RECORD TYPE 20 - PATIENT DATA
FIELD NO. | NAME | PICTURE | SPECIFICATION | POSITION | FORM LOCATOR | |
FROM THRU | ||||||
* 1 | Record Type '20' | XX | L | 1 | 2 | |
* 3 | Patient Control Number Patient Name (Fields 4-6) | X(20) | L | 5 | 24 | FL03 FL12 |
* 4 | Last Name | X(20) | L | 25 | 44 | |
* 5 | First Name | X(9) | L | 45 | 53 | |
* 6 | Middle Initial | X | 54 | 54 | ||
* 7 | Patient Sex | X | 55 | 55 | FL15 | |
* 8 | Patient Birthdate(ccyymmdd) | 9(8) | R | 56 | 63 | FL14 |
9 | Patient Marital Status | X | 64 | 64 | FL16 | |
* 10 | Type of Admission | X | 65 | 65 | FL19 | |
* 11 | Source of Admission Patient Address (Fields 12-16) | X | 66 | 66 | FL20 FL13 | |
* 12 | Address - Line 1 | X(8) | L | 67 | 84 | |
13 | Address - Line 2 | X(8) | L | 85 | 102 | |
* 14 | City | X(5) | L | 97 | 111 | |
* 15 | State | XX | L | 112 | 113 | |
* 16 | ZIP Code | X() | L | 114 | 122 | |
* 17 | Admission Date (ccyymmdd) | 9(8) | R | 123 | 130 | FL17 |
* 18 | Admission Hour Statement Covers Period | XX | R | 131 | 132 | FL18 FL06 |
* 19 | From (ccyymmdd) | 9(8) | R | 133 | 140 | |
* 20 | Thru (ccyymmdd) | 9(8) | R | 141 | 148 | |
* 21 | Patient Status | 99 | R | 149 | 150 | FL22 |
22 | Discharge Hour | XX | R | 151 | 152 | FL21 |
23 | Payments Received (Patient line) 9(8)V99S | R | 153 | 162 | FL54 | |
24 | Estimated Amt Due(atient line) | 9(8)V99S | R | 163 | 172 | FL55 |
* 25 | Medical Record Number | X(7) | L | 173 | 189 | FL23 |
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.
1450 -RECORD TYPE 27 - HEALTH DEPT. SPECIFIC DATA
FIELD NO. | NAME | PICTURE | SPECIFICATION | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '27' | XX | L | 1 | ||
* 2 | Sequence '01' | 99 | R | 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 | FL60 |
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 |
DEFINITION OF ELEMENTS (RECORD TYPE 27)
Type of Bill
A code indicating the specific type of bill (inpatient, outpatient, etc.). This three-digit code requires one digit each, in the following sequence:
All positions must be fully coded. See UB-92 guidelines for codes and definitions. In most situations, the discharge should be coded as '111'.
Patient Social Security Number The Social Security Number of the patient receiving inpatient care.
If the patient is a newborn, use the mother's SSN.
If a patient does not have a social security number, fill with zeroes.
Patient Race
This item gives the race of the patient. Use the following codes:
1 = American Indian or Alaskan Native
2 = Asian or Pacific Islander
3 = Black
4 = White
5 = Other Any possible options not covered in the above categories
6 = Unknown A person who chooses not to answer the question Blank Space The hospital made no effort to obtain the information
***************************************************************************** Patients may self identify themselves as Hispanic or the admissions registration person may identify the patient as Hispanic. However, Hispanic is not a correct race classification for our data gathering purposes. Hispanic is considered to be an ethnicity group. Hispanic patients should be registered as Hispanic for the ethnicity field and white for the race field unless the patient self identifies as being of a race other than white. Other should not be used for the race field for Hispanic patients. *****************************************************************************
Patient Ethnicity
This item gives the ethnicity of the patient. Use the following codes:
1 = Hispanic origin
2 = Not of Hispanic origin
6 = Unknown A person who chooses not to respond to the inquiry Blank Space = The hospital made no effort to obtain the information
Birth Weight
Birth weight in grams for a newborn. Zero fillif unknown.
Total Charges
Total of charges for this inpatient occurrence.
Estimated Collection Rate
Collection rate (percentage) expected from all sources for this inpatient occurrence.
This percentage could be the result of bad debt, contracted amounts or rates with insurance carriers, etc.
Charitable / Donation Rate
This item identifies the inpatient discharge fully or partially as charitable or a donation of services. (This should not be confused with a bad debt.)
Use the following rates:
100 | fully charitable / donation |
1 - 99 | partially charitable, expecting some reimbursement of expenses, estimate the percentage of total charges that will be charitable |
0 | not charitable, expect collection of all or some of the charges, or does not apply |
APGAR Score
APGAR score for a newborn. Zero fillif unknown or does not apply.
1450 -RECORD TYPES 30-31 - THIRD PARTY PAYER
The use of these record types for the Hospital Discharge Data System (HDDS) is the same as the UB-92 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-92.
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 3l, 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 | Sequence Number | |
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.
1450 -RECORD TYPE 30 - THIRD PARTY PAYER DATA
FIELD NO. | NAME | PICTURE | SPECIFICATION | 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 | X | 25 | 25 | FL50 | |
5-6 | PayerIdentification | X(9) | L | 26 | 34 | FL51 |
7 | Certificate/SocSecNumber/ Health Insurance Claim/ Identification Number | X(9) | L | 35 54 | 53 79 | FL60 |
10 | Insurance Group Number | X(7) | L | 80 | 96 | FL62 |
11 | Insured Group Name | X(4) | L | 97 | 110 | FL61 |
Insured's Name (Fields 12-14) | FL58 | |||||
12 | Last Name | X(0) | L | 111 | 130 | |
13 | First Name | X() | L | 131 | 139 | |
14 | Middle Initial | X | 140 | 140 | ||
15 | Insured Sex | X | 141 | 141 | ||
18 | Patient Relationship to Insured | 99 | R | 144 | 145 | FL59 |
19 | Employment Status Code | 9 | 146 | 146 | FL64 | |
25 | Payments Received | 9(8)V99S | R | 173 | 182 | FL54 |
26 | Estimated Amount Due | 9(8)V99SR | 183 | 192 | FL55 | |
NOTE: 'Payments Received' and 'Estimated Amount Due' should reflect a single discharge per payer if multiple claims have been submitted.
1450 -RECORD TYPE 31 - THIRD PARTY PAYER DATA
FIELD NO. | NAME | PICTURE | SPECIFICATION | POSITION | FROM 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(8) | L | 25 | 42 | |
5 | Address - Line 2 | X(8) | L | 43 | 60 | |
6 | City | X(5) | L | 61 | 75 | |
7 | State | XX | L | 76 | 77 | |
8 | ZIP Code | X() | L | 78 | 86 | |
9 | Employer Name | X(4) | L | 87 | 110 | FL65 |
Employer Location (Fields 10 - | 13) | FL66 | ||||
10 | Employer Address | X(8) | L | 111 | 128 | |
11 | Employer City | X(5) | L | 129 | 143 | |
12 | Employer State | XX | L | 144 | 145 | |
13 | Employer ZIP Code | X() | R | 146 | 154 | |
1450 -RECORD TYPE 50 -INPATIENT ACCOMMODATIONS DATA
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: 100through21X.
FIELD NO. | NAME | PICTURE | SPECIFICATION | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '50' | XX | L | 1 | 2 | |
* 2 | Sequence Number | 99 | R | 3 | 4 | |
* 3 | Patient Control Number Accommodations (occurs 4 times) | X(20) | L | 5 | 24 | FL03 |
Accommodations - 1 | X(2) | 25 | 66 | |||
* 4 | Revenue Code | 9(4) | R | 25 | 28 | FL42 |
5 | Accommodations Rate | 9(7)V99 | R | 29 | 37 | FL44 |
* 6 | Accommodations Days | 9(4) | R | 38 | 41 | FL46 |
* 7 | Total Charges by Revenue Code | 9(8)V99S | R | 42 | 51 | FL47 |
8 | Noncovered Charges by Revenue | |||||
Code | 9(8)99S | R | 52 | 61 | FL48 | |
Accommodations - 2 | X(2) | 67 | 108 | |||
* 9 | Revenue Code | 9(4) | R | 67 | 70 | FL42 |
10 | Accommodations Rate | 9(7)V99 | R | 71 | 79 | FL44 |
* 11 | Accommodations Days | 9(4) | R | 80 | 83 | FL46 |
* 12 | Total Charges by Revenue Code | 9(8)V99S | R | 84 | 93 | FL47 |
13 | Noncovered Charges by Revenue Code | 9(8V99S | 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 | Accommodations Days | 9(4) | R | 122 | 125 | FL46 |
* 17 | Total Charges by Revenue Code | 9(8)V99S | R | 126 | 135 | FL47 |
18 | Noncovered 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 | Accommodations Days | 9(4) | R | 164 | 167 | FL46 |
* 22 | Total Charges by Revenue Code | 9(8)V99S | R | 168 | 177 | FL47 |
23 | Noncovered Charges by Revenue Code | 9(8)V99S | R | 178 | 187 | FL48 |
1450 -RECORD TYPE 60 - INPATIENT ANCILLARY SERVICES DATA
The sequence number for record type 60 can go from 0l to 99, each such physical record containing 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 | SP PICTURE | ECIFI-CATION | POSITION | FORM LOCATOR | |
FROM T | HRU | |||||
* 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 Ancillaries (occurs 3 | times) | |||||
Inpatient Ancillaries - 1 | X(56) | 25 | 80 | |||
* 4 | Revenue Code | 9(4) | R | 25 | 28 | FL42 |
5 | HCPCS / Procedure Code | X(5) | L | 29 | 34 | |
6 | Modifier 1 (HCPCS & CPT-4) | 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 | Noncovered Charges by Revenue Code | 9(8)V99S | R | 55 | 64 | FL48 |
Inpatient Ancillaries - 2 | X(56) | 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 | Noncovered Charges by Revenue Code | 9(8)V99S | R | 111 | 120 | FL48 |
Inpatient Ancillaries - 3 | X(56) | 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 | Noncovered Charges by Revenue Code | 9(8)V99S | R | 167 | 176 | FL48 |
Note: Identical revenue codes should be combined and their charges added together for reporting purposes.
1450 -RECORD TYPE 70 - MEDICAL DATA (SEQUENCE 1)
FIELD NO. | NAME | PICTURE | SPECIFICATION | 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 | Principal Diagnosis Code | X(6) | L | 25 | 30 | FL67 |
* 5 | Other Diagnosis Code - 1 | X(6) | L | 31 | 36 | FL68 |
* 6 | Other Diagnosis Code - 2 | X(6) | L | 37 | 42 | FL68 |
* 7 | Other Diagnosis Code - 3 | X(6) | L | 43 | 48 | FL68 |
* 8 | Other Diagnosis Code - 4 | X(6) | L | 49 | 54 | FL68 |
* 9 | Other Diagnosis Code - 5 | X(6) | L | 55 | 60 | FL68 |
* 10 | Other Diagnosis Code - 6 | X(6) | L | 61 | 66 | FL68 |
* 11 | Other Diagnosis Code - 7 | X(6) | L | 67 | 72 | FL68 |
* 12 | Other Diagnosis Code - 8 | X(6) | L | 73 | 78 | FL68 |
* 13 | Principal Procedure Code | X(7) | L | 79 | 85 | FL80 |
* 14 | Principal Procedure Date(mmddyy) | 9(6) | R | 86 | 91 | FL80 |
* 15 | Other Procedure Code - 1 | X(7) | L | 92 | 98 | FL81 |
* 16 | Other Procedure Date - 1 (mmddyy) | 9(6) | R | 99 | 104 | FL81 |
* 17 | Other Procedure Code - 2 | X(7) | L | 105 | 111 | FL81 |
* 18 | Other Procedure Date - 2 (mmddyy) | 9(6) | R | 112 | 117 | FL81 |
* 19 | Other Procedure Code - 3 | X(7) | L | 118 | 124 | FL81 |
* 20 | Other Procedure Date - 3 (mmddyy) | 9(6) | R | 125 | 130 | FL81 |
* 21 | Other Procedure Code - 4 | X(7) | L | 131 | 137 | FL81 |
* 22 | Other Procedure Date - 4 (mmddyy) | 9(6) | R | 138 | 143 | FL81 |
* 23 | Other Procedure Code - 5 | X(7) | L | 144 | 150 | FL81 |
* 24 | Other Procedure Date - 5 (mmddyy) | 9(6) | R | 151 | 156 | FL81 |
* 25 | Admitting Diagnosis Code | X(6) | L | 157 | 162 | FL76 |
* 26 | External Cause of Injury(E-Code) | X(6) | L | 163 | 168 | FL77 |
* 27 | Procedure Coding Method Used | 9 | R | 169 | 169 | FL79 |
1450 Y2K-RECORD TYPE 70 - MEDICAL DATA (SEQUENCE 1)
Date changes made by some hospitals for the year 2000 and following require spacing changes in the type 20 and the 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, statement through date and procedure dates) must use this format. The following position changes in the type 70 record are required:
FIELD NO. | NAME P | SPECI ICTURE | FI- POSI CATION | TION 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 | Principal Diagnosis Code | X(6) | L | 25 | 30 | FL67 |
* 5 | Other Diagnosis Code - 1 | X(6) | L | 31 | 36 | FL68 |
* 6 | Other Diagnosis Code - 2 | X(6) | L | 37 | 42 | FL68 |
* 7 | Other Diagnosis Code - 3 | X(6) | L | 43 | 48 | FL68 |
* 8 | Other Diagnosis Code - 4 | X(6) | L | 49 | 54 | FL68 |
* 9 | Other Diagnosis Code - 5 | X(6) | L | 55 | 60 | FL68 |
* 10 | Other Diagnosis Code - 6 | X(6) | L | 61 | 66 | FL68 |
* 11 | Other Diagnosis Code - 7 | X(6) | L | 67 | 72 | FL68 |
* 12 | Other Diagnosis Code - 8 | X(6) | L | 73 | 78 | FL68 |
* 13 | Principal Procedure Code | X(7) | L | 79 | 85 | FL80 |
* 14 | Principal Procedure Date (ccyymmdd) | 9(8) | R | 86 | 93 | FL80 |
* 15 | Other Procedure Code - 1 | X(7) | L | 94 | 100 | FL81 |
* 16 | Other Procedure Date - 1 (ccyymmdd) | 9(8) | R | 101 | 108 | FL81 |
* 17 | Other Procedure Code - 2 | X(7) | L | 109 | 115 | FL81 |
* 18 | Other Procedure Date - 2 (ccyymmdd) | 9(8) | R | 116 | 123 | FL81 |
* 19 | Other Procedure Code - 3 | X(7) | L | 124 | 130 | FL81 |
* 20 | Other Procedure Date - 3 (ccyymmdd) | 9(8) | R | 131 | 138 | FL81 |
* 21 | Other Procedure Code - 4 | X(7) | L | 139 | 145 | FL81 |
* 22 | Other Procedure Date - 4 (ccyymmdd) | 9(8) | R | 146 | 153 | FL81 |
* 23 | Other Procedure Code - 5 | X(7) | L | 154 | 160 | FL81 |
* 24 | Other Procedure Date - 5 (ccyymmdd) | 9(8) | R | 161 | 168 | FL81 |
* 25 | Admitting Diagnosis Code | X(6) | L | 169 | 174 | FL76 |
* 26 | External Cause of Injury(E-Code) | X(6) | L | 175 | 180 | FL77 |
* 27 | Procedure Coding Method Used | 9 | R | 181 | 181 | FL79 |
FOR BOTH 1450 AND 1450 Y2K
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:
If you report 99999, it translates to 999.99. If you report V9999, it translates to V99.99. If you report E9999, it translates to E999.9. If you report M99999, it translates to M9999/9.
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.
-RECORD TYPE 80 - 8N - PHYSICIAN DATA 1450
FIELD NO. | NAME | PICTURE | SPECIFICATION | 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 | FL82 |
* 6 | Operating Physician Number | X(16) | L | 43 | 58 | |
* 7 | Other Physician Number | X(16) | L | 59 | 74 | FL83 |
* 8 | Other Physician Number | X(16) | L | 75 | 90 | FL83 |
9 | Attending Physician Name | X(25) | L | 91 | 115 | |
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 Name is to be broken down as follows:
Last Name | Positions | 1-16 |
First Name | Positions | 17-24 |
Middle Initial | Position | 25 |
Physician Number Qualifying Codes:
UP = Universal Physician Identification Number (UPIN)- Alpha and 5 digits
FI = Federal Taxpayer's Identification Number
SL = State License Number - Alpha and 4 digits
SP = Specialty License Number
NI = National Provider Identifier (NPI) - 10 digit number
1450 -RECORD TYPE 95 - PROVIDER BATCH CONTROL
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 | SPECIFICATION | POSITION | FORM LOCATOR | |
FROM | THRU | |||||
* 1 | Record Type '95' | XX | L | 1 | 2 | |
* 2 | Federal Tax Number (EIN) | 9(10) | R | 3 | 12 | FL05 |
Federal Tax Sub ID | X(4) | L | 13 | 16 | FL05 | |
* 6 | 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).
EXCEPTIONS TO 1450 FORMAT
In general, the submittal is identical to the current UB-92 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 is a new field and must be the same as specified on the type '10' record.
'Number of Claims' in record type '95' should be the number of discharges in the batch, the number of type '20' records.
Record type '27' is not a record type used in the UB-92 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.
UB-92 1300 RECORD SPECIFICATION
The UB-92 1300 flat file contains one record per discharge, except in the case of multi-page claims. However, the standard 1300 format does not contain some fields that are found on the 1450 format. To make the 1450 and 1300 compatible, only those elements we deemed necessary for effective analysis have been included in an enhanced version of the 1300; these exceptions are documented in EXCEPTIONS TO 1300 FORMAT. Variations of the 1300 from other states have been examined and their usage of free space incorporated, standardizing whenever possible.
The record layouts that follow will provide the following information:
An asterisk '*' denotes the field is a required field and must contain data if applicable.
L = Left justification, and R = Right justification.
Thru = Rightmost position in the record (low order).
1300 DISCHARGE RECORD
Only one record per patient discharge is allowed except for multi-page claims. The last entry in the series of Revenue Code/Total Charges fields must be the Total Charge (0001) Revenue Code and the Charge Amount must be the total of all previous entries. Any remaining revenue and charge fields must be blank or zero filled. No zero or space filled fields should precede the 0001 entry.
FIE NO. | LD NAME | SPECIFI-PICTURE | POSITION CATION | FORM | LOCATOR | |
FROM | THRU | |||||
* 1 | Patient Control Number | X(20) | L | 1 | 20 | FL03 |
* 2 | Type of Bill | X(3) | L | 21 | 23 | FL04 |
* 3 | Federal Tax Number (EIN) | 9(10) | R | 24 | 33 | FL05 |
* 4 | Statement Covers Period: FROM | 9(8) | R | 34 | 41 | FL06 |
* 5 | Statement Covers Period: TO | 9(8) | R | 42 | 49 | FL06 |
* 6 | Patient Address Zip Code | X(9) | L | 50 | 58 | FL13 |
* 7 | Patient Date of Birth | 9(8) | R | 59 | 66 | FL14 |
* 8 | Patient Sex | X | 67 | 67 | FL15 | |
* 9 | Admission Date | 9(8) | R | 68 | 75 | FL17 |
* 10 | Admission Hour | X(2) | L | 76 | 77 | FL18 |
* 11 | Type of Admission | X | 78 | 78 | FL19 | |
* 12 | Source of Admission | X | 79 | 79 | FL20 | |
* 13 | Patient Status | 9(2) | L | 80 | 81 | FL22 |
* 14 | Medical Record Number | X(17) | L | 82 | 98 | FL23 |
* 15 | Revenue Code Line 1 | 9999 | R | 99 | 102 | FL42 |
* 16 | Total Charges by Revenue 1 | S9(8)V99 | R | 103 | 112 | FL47 |
* 17 | Revenue Code Line 2 | 9999 | R | 113 | 116 | FL42 |
* 18 | Total Charges by Revenue 2 | S9(8)V99 | R | 117 | 126 | FL47 |
* 19 | Revenue Code Line 3 | 9999 | R | 127 | 130 | FL42 |
* 20 | Total Charges by Revenue 3 | S9(8)V99 | R | 131 | 140 | FL47 |
* 21 | Revenue Code Line 4 | 9999 | R | 141 | 144 | FL42 |
* 22 | Total Charges by Revenue 4 | S9(8)V99 | R | 145 | 154 | FL47 |
* 23 | Revenue Code Line 5 | 9999 | R | 155 | 158 | FL42 |
* 24 | Total Charges by Revenue 5 | S9(8)V99 | R | 159 | 168 | FL47 |
* 25 | Revenue Code Line 6 | 9999 | R | 169 | 172 | FL42 |
* 26 | Total Charges by Revenue 6 | S9(8)V99 | R | 173 | 182 | FL47 |
* 27 | Revenue Code Line 7 | 9999 | R | 183 | 186 | FL42 |
* 28 | Total Charges by Revenue 7 | S9(8)V99 | R | 187 | 196 | FL47 |
* 29 | Revenue Code Line 8 | 9999 | R | 197 | 200 | FL42 |
* 30 | Total Charges by Revenue 8 | S9(8)V99 | R | 201 | 210 | FL47 |
* 31 | Revenue Code Line 9 | 9999 | R | 211 | 214 | FL42 |
* 32 | Total Charges by Revenue 9 | S9(8)V99 | R | 215 | 224 | FL47 |
* 33 * 34 | Revenue Code Line 10 Total Charges by Revenue 10 | 9999 S9(8)V99 | R R | 225 229 | 228 238 | FL4 FL47 |
* 35 | Revenue Code Line 11 | 9999 | R | 239 | 242 | FL42 |
* 36 | Total Charges by Revenue 11 | S9(8)V99 | R | 243 | 252 | FL47 |
* 37 | Revenue Code Line 12 | 9999 | R | 253 | 256 | FL42 |
* 38 | Total Charges by Revenue 12 | S9(8)V99 | R | 257 | 266 | FL47 |
* 39 | Revenue Code Line 13 | 9999 | R | 267 | 270 | FL42 |
* 40 | Total Charges by Revenue 13 | S9(8)V99 | R | 271 | 280 | FL47 |
* 41 | Revenue Code Line 14 | 9999 | R | 281 | 284 | FL42 |
* 42 | Total Charges by Revenue 14 | S9(8)V99 | R | 285 | 294 | FL47 |
* 43 | Revenue Code Line 15 | 9999 | R | 295 | 298 | FL42 |
* 44 | Total Charges by Revenue 15 | S9(8)V99 | R | 299 | 308 | FL47 |
* 45 | Revenue Code Line 16 | 9999 | R | 309 | 312 | FL42 |
* 46 | Total Charges by Revenue 16 | S9(8)V99 | R | 313 | 322 | FL47 |
* 47 | Revenue Code Line 17 | 9999 | R | 323 | 326 | FL42 |
* 48 | Total Charges by Revenue 17 | S9(8)V99 | R | 327 | 336 | FL47 |
* 49 | Revenue Code Line 18 | 9999 | R | 337 | 340 | FL42 |
* 50 | Total Charges by Revenue 18 | S9(8)V99 | R | 341 | 350 | FL47 |
* 51 | Revenue Code Line 19 | 9999 | R | 351 | 354 | FL42 |
* 52 | Total Charges by Revenue 19 | S9(8)V99 | R | 355 | 364 | FL47 |
* 53 | Revenue Code Line 20 | 9999 | R | 365 | 368 | FL42 |
* 54 | Total Charges by Revenue 20 | S9(8)V99 | R | 369 | 378 | FL47 |
* 55 | Revenue Code Line 21 | 9999 | R | 379 | 382 | FL42 |
* 56 | Total Charges by Revenue 21 | S9(8)V99 | R | 383 | 392 | FL47 |
* 57 | Revenue Code Line 22 | 9999 | R | 393 | 396 | FL42 |
* 58 | Total Charges by Revenue 22 | S9(8)V99 | R | 397 | 406 | FL47 |
* 59 | Revenue Code Line 23 | 9999 | R | 407 | 410 | FL42 |
* 60 | Total Charges by Revenue 23 | S9(8)V99 | R | 411 | 420 | FL47 |
61 | Filler | X(25) | 421 | 445 | ||
62 | Payer Identification (1st Payer) | X(13) | L | 446 | 458 | FL51 |
63 | Patient's Relationship | |||||
to Insured | 9(2) | R | 459 | 460 | FL59 | |
64 | Certificate/SocSecNumber/ | |||||
Health Insurance Claim/ | ||||||
Identification Number | X(19) | L | 461 | 479 | FL60 | |
65 | Insurance Group Number | X(20) | L | 480 | 499 | FL62 |
66 | Employment Status Code | X | 500 | 500 | FL64 | |
67 | Employer Name | X(24) | L | 501 | 524 | FL65 |
68 | Employer Zip Code | X(9) | L | 525 | 533 | FL66 |
* 69 | Principal Diagnosis Code | X(6) | L | 534 | 539 | FL67 |
* 70 | Other Diagnosis Code 1 | X(6) | L | 540 | 545 | FL68 |
* 71 * 72 | Other Diagnosis Code 2 Other Diagnosis Code 3 | X(6) X(6) | L L | 546 552 | 551 557 | FL69 FL70 |
* 73 | Other Diagnosis Code 4 | X(6) | L | 558 | 563 | FL71 |
* 74 | Other Diagnosis Code 5 | X(6) | L | 564 | 569 | FL72 |
* 75 | Other Diagnosis Code 6 | X(6) | L | 570 | 575 | FL73 |
* 76 | Other Diagnosis Code 7 | X(6) | L | 576 | 581 | FL74 |
* 77 | Other Diagnosis Code 8 | X(6) | L | 582 | 587 | FL75 |
* 78 | Admitting Diagnosis | X(6) | L | 588 | 593 | FL76 |
* 79 | External Cause of Injury (E-Code) | X(6) | L | 594 | 599 | FL77 |
* 80 | Principal Procedure Code | X(7) | L | 600 | 606 | FL80 |
* 81 | Principal Procedure Date | 9(6) | R | 607 | 612 | FL80 |
* 82 | Other Procedure 1: Code | X(7) | L | 613 | 619 | FL81 |
* 83 | Other Procedure 1: Date | 9(6) | R | 620 | 625 | FL81 |
* 84 | Other Procedure 2: Code | X(7) | L | 626 | 632 | |
* 85 | Other Procedure 2: Date | 9(6) | R | 633 | 638 | |
* 86 | Other Procedure 3: Code | X(7) | L | 639 | 645 | |
* 87 | Other Procedure 3: Date | 9(6) | R | 646 | 651 | |
* 88 | Other Procedure 4: Code | X(7) | L | 652 | 658 | |
* 89 | Other Procedure 4: Date | 9(6) | R | 659 | 664 | |
* 90 | Other Procedure 5: Code | X(7) | L | 665 | 671 | |
* 91 | Other Procedure 5: Date | 9(6) | R | 672 | 677 | |
* 92 | Attending Physician Number | X(22) | L | 678 | 699 | FL82 |
* 93 | Other Physician Number | X(22) | L | 700 | 721 | FL83 |
* 94 | Other Physician Number | X(22) | L | 722 | 743 | FL84 |
* 95 | Physician Number | |||||
Qualifying Code | X(2) | L | 744 | 745 | ||
96 | Century Flag Patient's DOB | 9 | 746 | 746 | ||
0 = Birth Year [GREATER THAN] 1900 | ||||||
1 = Birth Year [LESS THAN] 1900 | ||||||
* 97 | Units of Service Line 1 | 9(7) | R | 747 | 753 | FL46 |
98 | Date of Service Line 1 | 9(6) | R | 754 | 759 | FL45 |
* 99 | Units of Service Line 2 | 9(7) | R | 760 | 766 | FL46 |
100 | Date of Service Line 2 | 9(6) | R | 767 | 772 | FL45 |
* 101 | Units of Service Line 3 | 9(7) | R | 773 | 779 | FL46 |
102 | Date of Service Line 3 | 9(6) | R | 780 | 785 | FL45 |
* 103 | Units of Service Line 4 | 9(7) | R | 786 | 792 | FL46 |
104 | Date of Service Line 4 | 9(6) | R | 793 | 798 | FL45 |
* 105 | Units of Service Line 5 | 9(7) | R | 799 | 805 | FL46 |
106 | Date of Service Line 5 | 9(6) | R | 806 | 811 | FL45 |
* 107 | Units of Service Line 6 | 9(7) | R | 812 | 818 | FL46 |
108 | Date of Service Line 6 | 9(6) | R | 819 | 824 | FL45 |
* 109 110 | Units of Service Line 7 Date of Service Line 7 | 9(7) 9(6) | R R | 825 832 | 831 837 | FL46 FL45 |
* 111 | Units of Service Line 8 | 9(7) | R | 838 | 844 | FL46 |
112 | Date of Service Line 8 | 9(6) | R | 845 | 850 | FL45 |
* 113 | Units of Service Line 9 | 9(7) | R | 851 | 857 | FL46 |
114 | Date of Service Line 9 | 9(6) | R | 858 | 863 | FL45 |
* 115 | Units of Service Line 10 | 9(7) | R | 864 | 870 | FL46 |
116 | Date of Service Line 10 | 9(6) | R | 871 | 876 | FL45 |
* 117 | Units of Service Line 11 | 9(7) | R | 877 | 883 | FL46 |
118 | Date of Service Line 11 | 9(6) | R | 884 | 889 | FL45 |
* 119 | Units of Service Line 12 | 9(7) | R | 890 | 896 | FL46 |
120 | Date of Service Line 12 | 9(6) | R | 897 | 902 | FL45 |
* 121 | Units of Service Line 13 | 9(7) | R | 903 | 909 | FL46 |
122 | Date of Service Line 13 | 9(6) | R | 910 | 915 | FL45 |
* 123 | Units of Service Line 14 | 9(7) | R | 916 | 922 | FL46 |
124 | Date of Service Line 14 | 9(6) | R | 923 | 928 | FL45 |
* 125 | Units of Service Line 15 | 9(7) | R | 929 | 935 | FL46 |
126 | Date of Service Line 15 | 9(6) | R | 936 | 941 | FL45 |
* 127 | Units of Service Line 16 | 9(7) | R | 942 | 948 | FL46 |
128 | Date of Service Line 16 | 9(6) | R | 949 | 954 | FL45 |
* 129 | Units of Service Line 17 | 9(7) | R | 955 | 961 | FL46 |
130 | Date of Service Line 17 | 9(6) | R | 962 | 967 | FL45 |
* 131 | Units of Service Line 18 | 9(7) | R | 968 | 974 | FL46 |
132 | Date of Service Line 18 | 9(6) | R | 975 | 980 | FL45 |
* 133 | Units of Service Line 19 | 9(7) | R | 981 | 987 | FL46 |
134 | Date of Service Line 19 | 9(6) | R | 988 | 993 | FL45 |
* 135 | Units of Service Line 20 | 9(7) | R | 994 | 1000 | FL46 |
136 | Date of Service Line 20 | 9(6) | R | 1001 | 1006 | FL45 |
* 137 | Units of Service Line 21 | 9(7) | R | 1007 | 1013 | FL46 |
138 | Date of Service Line 21 | 9(6) | R | 1014 | 1019 | FL45 |
* 139 | Units of Service Line 22 | 9(7) | R | 1020 | 1026 | FL46 |
140 | Date of Service Line 22 | 9(6) | R | 1027 | 1032 | FL45 |
* 141 | Units of Service Line 23 | 9(7) | R | 1033 | 1039 | FL46 |
142 | Date of Service Line 23 | 9(6) | R | 1040 | 1045 | FL45 |
* 143 | Operating Physician Number | X(22) | L | 1046 | 1067 | |
Filler | X(3) | 1068 | 1070 | |||
144 | Payer Identification (2nd Payer) | X(13) | L | 1071 | 1083 | FL51 |
145 | Patient's Relationship | |||||
to Insured | 9(2) | L | 1084 | 1085 | FL59 | |
146 | Certificate/SocSecNumber/ | |||||
Health Insurance Claim/ | ||||||
147 | Identification Number Insurance Group Number | X(19) X(20) | L L | 1086 1105 | 1104 1124 | FL60 FL62 |
* 148 | Patient's Name | X(25) | L | 1125 | 1149 | FL12 |
149 | Payer Identification (3rd Payer) | X(13) | L | 1150 | 1162 | FL51 |
150 | Patient's Relationship | |||||
to Insured | 9(2) | L | 1163 | 1164 | FL59 | |
151 | Certificate/SocSecNumber/ | |||||
Health Insurance Claim/ | ||||||
Identification Number | X(19) | L | 1165 | 1183 | FL60 | |
152 | Insurance Group Number | X(20) | L | 1184 | 1203 | FL62 |
* 153 | Birth Weight (In Grams) | 9(4) | R | 1204 | 1207 | |
* 154 | APGAR Score | 9(4) | R | 1208 | 1211 | |
* 155 | Patient Race | X | 1212 | 1212 | ||
* 156 | Source of Payment Code (1st) | X(2) | L | 1213 | 1214 | FL50 |
* 157 | Source of Payment Code (2nd) | X(2) | L | 1215 | 1216 | FL50 |
* 158 | Source of Payment Code (3rd) | X(2) | L | 1217 | 1218 | FL50 |
* 159 | Medicaid Provider Number | X(12) | L | 1219 | 1230 | FL51 |
* 160 | National Provider Identifier | X(12) | L | 1231 | 1242 | FL51 |
* 161 | Patient's Social Security Number | 9(9) | R | 1243 | 1251 | FL60 |
162 | Filler | X(12) | 1252 | 1263 | ||
163 | Federal Tax Sub Id | X(4) | L | 1264 | 1267 | FL05 |
* 164 | Patient Address - City | X(15) | L | 1268 | 1282 | FL13 |
* 165 | Patient Address - State | X(2) | L | 1283 | 1284 | FL13 |
* 166 | Patient Address - Street | X(16) | L | 1285 1300 | FL13 | |
USE OF MULTI-PAGE CLAIMS
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.
EXCEPTIONS TO 1300 FORMAT
With the inclusion of the 1300 format as an accepted data format, the standard 1300 required the addition of data elements not found on the 1300 format but found on the 1450 format. Formats used by other states have been reviewed in an attempt to use standard data layouts. Their usage of free space has been incorporated whenever possible.
The following fields are the additional data elements:
Field Number | Field Name | Form Locator |
10 | Admission Hour | FL18 |
14 | Medical Record Number | FL23 |
78 | Admitting Diagnosis | FL76 |
95 | Physician Number Qualifying Code | |
143 | Operating Physician Number | |
148 | Patient's Name | FL12 |
164 | Patient Address - City | FL13 |
165 | Patient Address - State | FL13 |
166 | Patient Address - Street | FL13 |
DATA DICTIONARY
The definition specified for each data element is in general agreement with the definition in the UB-92 Users Manual. Hospitals using existing UB-92 record formats should reference the sections, EXCEPTIONS TO 1450 FORMAT and EXCEPTIONS TO 1300 FORMAT, for differences from the established UB-92 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-92 Users Manual.
The dictionary format that follows will provide the following information:
N = numeric
A = alphanumeric
Level: Required = must be reported
As available = must be present, if captured in your database
Accommodations Days | N | 4 |
Data Reporting Level: Required (1450 only)
Definition: A numeric count of accommodations days in accordance with payer instructions. Includes UB-92 revenue codes 10X through 21X. General Comments: This field should be a numeric value greater than zero. Edit: The total number of days between admission date and discharge date must be within +/- 2 days of Accommodations Days.
Accommodations Rate | N | 9,2 |
Data Reporting Level: Required
Definition: Per-diem rate for related UB-92 accommodations revenue codes. General Comments: The rate should be right justified with leading zeroes.
There is an implied decimal place 2 positions from the right. Edit: If present, rate must be greater than zero.
Admission Date | N | 6 or 8 | 1450 |
N | 8 | 1300 |
Data Reporting Level: Required
Definition: The date the patient was admitted to the hospital.
General Comments: The admission date is to be entered as month, day, and year. The format is MMDDYY for 1450 record and MMDDCCYY for 1300 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. The 1300 record also contains a two digit century. Any unused space to the left must be zero filled. For example February 7, 1992 is entered as 020792 (1450) or 02071992 (1300).
For hospitals using the 1450 record format that began using a different 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 must use this format. Edit: Admission date must be present and a valid date. The date cannot be before date of birth or be after ending date in Statement Covers Period.
Admission Hour | A | 2 |
Data Reporting Level: Required
Definition: The hour during which the patient was admitted for inpatient care.
General Comments: Military time should be used to represent the hour of admission. If admitted between midnight and noon, use the values from 00 to 11; if admitted between noon and 11:59 pm, use the values from 12 to 23.
Edit: Valid numeric value for the hour of admission or blank.
Admitting Diagnosis Code | A | 6 |
Data Reporting Level: Required
Definition: The ICD-9-CM diagnosis code provided at the time of admission as stated by the physician.
General Comments: This field is to contain the appropriate ICD-9-CM code without a decimal. In the ICD-9-CM codebook there are three, four and five digit codes plus 'V' and 'E' codes. Use of the fourth, fifth, 'V' and 'E' is not optional, but must be entered when present in the code.
For example, a five-digit code is entered as '12345"; a 'V' code is entered as 'V270.' All entries are to be left justified with spaces to the right to complete the field length. An 'E' code should not be recorded as the principal diagnosis. Edit: A principal diagnosis must be present and valid. When the principal diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
APGAR Score | N | 4 |
Data Reporting Level: Required
Definition: APGAR Score for a newborn. Zero fill if not a newborn.
General Comments: Right justify the field with zeroes to the left to complete the field. Edit: If present, must be numeric.
Attending Physician Name | A | 25 |
Data Reporting Level: As available
Definition: Name of the licensed physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient's medical care and treatment. General Comments: Entered in the order of last name, first name and middle initial. Last name in positions 1-16, first name in positions 17-24 and initial in position 25. Edit: None
Attending Physician Number | A | 16 | 1450 |
A | 22 | 1300 |
Data Reporting Level: Required
Definition: License number of the physician who is expected to certify and recertify the medical necessity of the services rendered or who has primary responsibility for the patient's medical care and treatment. General Comments: This field is to be left justified with spaces to the right to complete the field. Edit: This field must contain a valid license or assigned number according to 'Physician Number Qualifying Code.'
Birth Weight | N | 4 |
Data Reporting Level: Required
Definition: Birth weight in grams for a newborn. Zero fill if not a newborn.
General Comments: Right justify the field with zeroes to the left to complete the field. Edit: Must be numeric.
Certificate/Social Security Number/ Health Insurance Claim/ Identification Number | A | 19 |
Data Reporting Level: Required
Definition: Insured's unique identification number assigned by the payer organization. Medicare purposes, enter the patient's Medicare HIC number as on the Health Insurance Card, Certificate of Award, Utilization Notice, Temporary Eligibility Notice, Hospital Transfer Form, or as reported by the Social Security Office.
General Comments: The payer organization's assigned identification number is to be entered in this field. It should be entered exactly as printed on the Insured's proof of coverage.
Edit: None
Charitable / Donation Rate | N | 3 |
Data Reporting Level: As available
Definition: This item identifies the 'claim' fully or partially as charitable or a donation of services. (This should not be confused with a bad debt.) General Comments: Use the following percentage rates:
100 | Fully charitable / donation |
1 - 99 | Partially charitable, expecting some reimbursement of expenses, estimate the percentage of total charges that will be charitable |
0 | Not charitable, expect collection of all or some of the charges |
Edit: If present, must be a valid numeric value.
Date of Service | N | 6 |
Data Reporting Level: As available
Definition: Date the service indicated by the related revenue code was performed or provided. General Comments: None Edit: If present, must be a valid date.
Discharge Hour | A | 2 |
Data Reporting Level: As available
Definition: Hour that the patient was discharged from inpatient care.
General Comments: Military time should be used to represent the hour of discharge. If discharged between midnight and noon, use the values from 00 to 11; if discharged between noon and 11:59 pm, use the values from 12 to 23.
Edit: Valid numeric value for the hour of discharge or blank.
Employer Location | A | 44 |
Data Reporting Level: As available
Definition: The specific location represented by the address of the employer of the individual identified by the second of two entries in employment information data field General Comments: This is to be the full and complete address of the employer of the individual. Edit: None
Employer Name | A | 24 |
Data Reporting Level: As available
Definition: The name of the employer that might or does provide health care coverage for the individual identified by the first of two entries in the employment information data fields. General Comments: Enter the full and complete name of the employer providing health care coverage. Edit: None
Employer ZIP Code | A | 9 |
Data Reporting Level: As available
Definition: The ZIP Code of the employer of the individual identified by the first of two entries in the employment information data fields. General Comments: None
Edit: None
Employment Status Code | A | 1 |
Data Reporting Level: As available Definition: A code used to define the employment status of the individual identified in the first of two employment information data fields General Comments: This field contains the employment status of the person described in the first of two employment information data fields. The codes to be used are as follows:
1 = Employed full time - individual states that he/she is employed full time
2 = Employed part time - individual states that he/she is employed part time.
3 = Not employed - individual states that he/she is not employed part time or full time.
4 = Self employed
5 = Retired
6 = On active military duty
9 = Unknown - individual's employment status is unknown. Edit: If an entry is present, it must be a valid code.
Estimated Amount Due | N | 8, 2 |
Data Reporting Level: As available
Definition: The amount estimated by the hospital to be due from the indicated payer (estimated responsibility less prior payments).
General Comments: The format of this estimate is dollars and cents. The dollar amount can be a maximum of 6 digits with 2 additional digits for cents (no decimal is entered). If the amount has no cents then the last 2 digits must be zeros. For example, an estimate of $500 is entered as 50000; an estimate of $50.55 is entered as 5055. The entry is right justified within the field.
Edit: None
Estimated Amount Due (Patient) | A | 8, 2 |
Data Reporting Level: As available
Definition: The amount estimated by the hospital to be due from the patient (estimated responsibility less prior payments).
General Comments: The format of this estimate is dollars and cents. The dollar amount can be a maximum of 6 digits with 2 additional digits for cents (no decimal is entered). If the amount has no cents then the last 2 digits must be zero. For example, an estimate of $500 is entered as 50000 and an estimate of $50.55 is entered as 5055. The entry is right justified within the field.
Edit: None
Estimated Collection Rate | N | 3 |
Data Reporting Level: As available
Definition: Collection rate (percentage) expected from all sources for this inpatient occurrence. This percentage could be the result of bad debt, contracted amounts or rates with insurance carriers, etc.
General Comments: The value could be for the specific patient or could be the hospital's percentage of collections against charges. The hospital collection rate should also include capitated rates against normal charges.
Edit: Numeric value; range 0 to 100
External Cause of Injury Code (E-code) | A | 6 |
Data Reporting Level: Required
Definition: The ICD-9-CM code for the external cause of injury, poisoning or adverse effect. General Comments: Hospitals are to complete this field whenever there is a diagnosis of an injury, poisoning or adverse effect. The priorities for recording an E-code are:
All entries are to be left justified without a decimal. Edit: Must be valid. When the diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Federal Tax Number (EIN) | N | 10 |
Data Reporting Level: Required
Definition: The number assigned to the provider by the Federal government for tax report purposes, also known as a tax identification number (TIN) or employer identification number (EIN). General Comments: None
Edit: None
Federal Tax Sub ID | A | 4 |
Data Reporting Level: Required when Federal Tax Number is not unique. Definition: Four-position modifier to Federal Tax ID. General Comments: Used by providers to identify their affiliated subsidiaries when the Federal Tax Number does not distinguish between separate facilities or cost centers. Edit: None
HCPCS / Procedure Code | A | 5 |
Data Reporting Level: As available
Definition: Procedure codes reported in record types identify services so that appropriate payment can be made. HCFA Common Procedural Coding System (HCPCS) code is required for many specific types of outpatient services and a few inpatient services. May include up to two modifiers.
General Comments: None
Edit: None
Insured Address | A | 62 |
Data Reporting Level: As available
Definition: Insured's current mailing address. Address Line 1. Address Line 2.
City. State. Zip. General Comments: None Edit: None
Insured Group Name | A | 14 |
Data Reporting Level: As available
Definition: Name of the group or plan through which the insurance is provided to the Insured's Name listed in the first Insured's Name field. General Comments: Enter the complete name of the group or plan name. If the name exceeds 16 characters, truncate the excess. Edit: None
Insurance Group Number | A | 17 | 1450 |
A | 20 | 1300 |
Data Reporting Level: As available
Definition: The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered General Comments: None Edit: None
Insured's Name | A | 30 |
Data Reporting Field: As available
Definition: The name of the individual in whose name the insurance is carried.
General Comments: Enter the name of the insured individual in last name, first name, middle initial order. Titles such as Sir, Mr. or Dr. should not be recorded in this data field. Record hyphenated names with the hyphen as in Smith-Jones. To record suffix of a name, write the last name, leave a space then write the suffix, for example, Snyder III or Addams Jr.
Edit: None
Insured's Sex | A | 1 |
Data Reporting Level: As available.
Definition: A code indicating the sex of the insured.
General Comments: This is a one-character code. The sex is to be reported as male, female or unknown using the following coding:
M = Male
F = Female
U = Unknown Edit: If present, the code must be valid.
Medicaid Provider Number | A | 13 | 1450 |
A | 12 | 1300 |
Data Reporting Level: Required.
Definition: The number assigned to the provider by Medicaid.
General Comments: None
Edit: Will be verified against Department of Health databases.
Medical Record Number | A | 17 |
Data Reporting Level: Required
Definition: Number assigned to patient by hospital or other provider to assist in retrieval of medical records General Comments: This number is assigned by the hospital for each patient. Edit: None
Medicare Provider Number (See National Provider Identifier)
Modifier | A | 2 |
Data Reporting Level: As available.
Definition: Two-position codes serving as modifier to HCPCS
procedure. General Comments: None Edit: None
National Provider Identifier | A | 13 | 1450 |
A | 12 | 1300 |
Data Reporting Level: Required
Definition: The National Provider Identifier (NPI) is a ten-position identifier issued by Medicare. General Comments: Beginning January 1, 1997, the Medicare Provider Number is the NPI. On April 1, 1997, only the NPI will be accepted by
Medicare. Edit: Will be verified against Department of Health databases obtained from Medicare.
Non-Covered Charges by Revenue Code | N | 10, 2 |
Data Reporting Level: As available.
Definition: Charges pertaining to the related UB-92 revenue code that are not covered by the primary payer as determined by the provider. General Comments: The total allows for an 8-digit dollar amount followed by 2
digits for cents (no decimal point). All entries are right justified.
If the charge has no cents, then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000; a charge of $37.50 is entered as 3750. Edit: This field must be present and contain a value greater than 0 when revenue code field is greater than 0.
Number of Claims | N | 6 |
Data Reporting Level: Required (1450 only)
Definition: The number of discharge submitted by a hospital for this submitted. Used to verify a complete submittal, no losses of data. General Comments: None.
Edit: Must be the total number of discharges for the hospital in the batch (type '20'records).
Operating Physician Name | A | 25 |
Data Reporting Level: As available.
Definition: Name used by the provider to identify the operating physician in the provider records. General Comments: Entered in the order of last name, first name and middle initial. Last name in positions 1-16, first name in positions 17-24 and initial in position 25. Edit: None
Operating Physician Number | A | 16 | 1450 |
A | 22 | 1300 |
Data Reporting Level: Required.
Definition: Number used by the provider to identify the operating physician in the provider records. General Comments: Must be left justified in the field. Edit: This field must contain a valid license or assigned number according to 'Physician Number Qualifying Code.'
Other Diagnosis Code | A | 6 |
Data Reporting Level: Required
Definition: ICD-9-CM codes describing other diagnoses corresponding to additional conditions that co-exist at the time of admission or develop subsequently, and which have an effect on the treatment received or the length of stay.
General Comments: The first of eight additional diagnoses. This field must contain the appropriate ICD-9-CM code without a decimal. In the ICD-9-CM codebook there are three, four, and five digit codes, plus 'V' and
'E' codes. Use of the fourth, fifth, 'V,' and 'E' is not optional, but must be entered when present in the code. For example, a five-digit code is entered as '12345', a 'V' code is entered as 'V270.' All entries are to be left justified with spaces to the right to complete the field length. An 'E' code should not be recorded as the principal diagnosis. Edit: If other diagnoses are present, they must be valid. When diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Other Physician Name | A | 25 |
Data Reporting Field: As available
Definition: This is the name of a physician other than the attending physician as defined by the payer organization. General Comments: Entered in the order of last name, first name and middle initial. Last name in positions 1-16, first name in positions 17-24 and initial in position 25. Edit: None
Other Physician Number | A | 16 | 1450 |
A | 22 | 1300 |
Data Reporting Field: Required
Definition: This is the license number of a physician other than the attending physician as defined by the payer organization. General Comments: Must be left justified in the field. Edit: This field must contain a valid license or assigned number according to 'Physician Number Qualifying Code.
Other Procedure Code | A | 7 |
Data Reporting Level: Required
Definition: The code that identifies the other procedures performed during the patient's hospital stay covered by this discharge record. This may include diagnostic or exploratory procedures.
General Comments: Procedures that make for accurate DRG Categorization must be included. The coding method used must agree with the coding method used for the principal procedure. Entries must include all digits. In the ICD-9-CM there are three-digit procedure codes and four-digit codes, use of the fourth digit is NOT optional. It must be present. Enter the code left justified, without a decimal.
Edit: If this field is present, there must be a principal procedure entered. Codes entered must be valid. When a procedure is gender-specific, the gender code entered in the record must be consistent.
Other Procedure Date | N | 6 |
Data Reporting Level: Required
Definition: Date that the procedure indicated by the related procedure code was performed General Comments: None Edit: Must be a valid date.
Patient Address | A | 62 | 1450 |
- Street | A | 16 | 1300 |
- City | A | 15 | 1300 |
- State | A | 2 | 1300 |
- ZIP Code | A | 9 | 1300 |
Data Reporting Level: Required
Definition: The address including postal zip code of the patient, as defined by the payer organization. (Address line 1 & 2, City, State, & ZIP
Code).
General Comments: The order of the complete address if provided should be street number, apartment number, city, state and zip code, left justified with spaces to the right to complete the field. The state must be the standard post office abbreviations (AR for Arkansas). If the nine digit zip code is used, it must be entered in the form XXXXXYYYY where X's are the five digit zip code and the Y's are the zip code extension. If Street Address is not provided, the nine digit postal ZIP code is required for a valid address.
Edit: This field is edited for the presence of an address with a valid and complete postal ZIP code.
Patient Control Number | A | 20 |
Data Reporting Level; Required
Definition: A patient's unique alpha-numeric number assigned by the hospital to facilitate retrieval of individual discharge records, if editing or correction is required. General Comments: This number should not be the same as the Medical Record
Number. This number will be used for reference in correspondence,
problem solving or edit corrections. Edit: The number must be present and should be unique within a hospital.
Patient's Date of Birth | N | 8 |
Data Reporting Level: Required
Definition: The date of birth of the patient in month day year order; year is 4 digits.
General Comments: The date of birth must be present and recorded in an eight-digit format of month day year (MMDDYYYY). The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging form 01-31. The year is recorded as four digits ranging from 1800-2100. Each of the first two components (month, day) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 1982 is entered as 02071982. If the birth date is unknown, then the field must contain '00000000.'
For hospitals using the 1450 record format that began using a different date in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2001 format is entered 20010207. Where this change is made, all dates must use this format. Edit: This field is edited for the presence of a valid date and of a date that it is not equal to the current date. Age is calculated and used in the clinic code edit to identify age/diagnosis conflicts and invalid or unknown age.
Patient's Ethnicity (1450 only) | A | 1 |
Data Reporting Level: Required
Definition: This item gives the ethnicity of the patient. The information is based on self-identification, and is to be obtained from the patient, a relative, or a friend. The hospital is not to categorize the patient based on observation or personnel judgment.
General Comments: The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled.
1 = Hispanic origin
Definition: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
2 = Not of Hispanic Origin
Definition: A person who is not classified in 1. 6 = Unknown
Definition: A person who chooses not to respond to the inquiry Blank Space
Definition: The hospital made no effort to obtain the information. Edit: If the data field contains an entry, it must be a valid code combination.
Patient's Marital Status | A | 1 |
Data Reporting Level: As available
Definition: The marital status of the patient at date of admission, or start of care. General Comments: The marital status of the patient is to be reported as a one character code whenever the information is recorded in the patient's hospital record. The following codes apply:
S = Single M = Married X = Legally Separated D = Divorced W = Widowed U = Unknown
Space = Not present in patient's record Edit: This field is edited for a valid entry.
Patient Name | A | 31 | 1450 |
A | 25 | 1300 |
Data Reporting Level: Required
Definition: The name of the patient in last, first and middle initial order. General Comments: Titles such as Sir, Msgr., Dr. should not be recorded.
Record hyphenated names with the hyphen, as in Smith-Jones. To record a suffix of a name, write the last name, leave a space, then write the suffix,
for example: Snyder III or Addams Jr. Edit: The name will be edited for the presence of the last name and the first name.
Patient's Race | (1450 only) | A | 1 | 1450 |
Data Reporting Level: Required
Definition: This item gives the race of the patient.
General Comments: The patient may choose not to provide the information.
If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled.
1 = American Indian or Alaskan Native
Definition: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.
2 = Asian or Pacific Islander
Definition: A person having origins in any of the original oriental peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa.
3 = Black
Definition: A person having origins in any of the black racial groups of Africa
4 = White
Definition: A person having origins in any of the original Caucasian peoples of Europe, North Africa or the Middle East.
5 = Other
Definition: Any possible options not covered in the above categories.
6 = Unknown
Definition: A person who chooses not to answer the question. Blank Space
Definition: The hospital made no effort to obtain the information.
Patient's Race/Ethnicity(1300 only) | A | 1 | 1300 |
Data Reporting Level: Required
Definition: This item gives the race of the patient.
General Comments: The patient may choose not to provide the information.
If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled.
0 = White
Definition: A person having origins in any of the original
Caucasian peoples of Europe, North Africa or the Middle East.
1 = Black
Definition: A person having origins in any of the black racial groups of Africa.
2 = Other
Definition: Any possible options not covered in the other categories.
3 = Asian or Pacific Islander
Definition: A person having origins in any of the original oriental peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa.
4 = American Indian or Alaskan Native
Definition: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.
5 = Hispanic origin - White
Definition: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and whose race is white.
6 = Hispanic origin - Black
Definition: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and whose race is black. 9 = Unknown
Definition: A person who chooses not to answer the question. Blank Space
Definition: The hospital made no effort to obtain the information.
Patient's Relationship to Insured | N | 2 |
Data Reporting Level: As available
Definition: A code indicating the relationship, such as patient, spouse, child, etc., of the patient to the identified insured person listed in the first of three Insured's Name fields.
General Comments: Enter the 2 digit code representing the patient's relationship to the individual named. All codes are to be right justified with a leading 0, if needed. The following codes apply:
01 = Spouse
Definition: Self-explanatory
04 = Grandparent
Definition: Self-explanatory
05 = Grandchild
Definition: Self-explanatory 07 = Niece or Nephew
Definition: Self-explanatory 10 = Foster Child
Definition: Self-explanatory 15 = Ward of the Court
Definition: Patient is ward of the insured as a result of a court order
17 = Step Child
Definition: Self-explanatory
18 = Patient is named insured
Definition: Self-explanatory
19 = Natural child/insured financially responsible
Definition: Self-explanatory
20 = Employee
Definition: The patient is employed by the named insured.
21 = Unknown
Definition: The patient's relationship to the named insured is unknown
22 = Handicapped Dependent
Definition: Dependent child whose coverage extends beyond normal termination age limits as a result of laws or agreements extending coverage
23 = Sponsored Dependent
Definition: Individual not normally covered by insurance coverage but coverage has been specially arranged to include relationships such as grandparent or former spouse that would require further investigation by the payer.
24 = Minor Dependent of a Minor Dependent
Definition: Code is used where patient is a minor and a dependent of another minor who in turn is a dependent, although not a child of the insured. 29 = Significant Other
32 = Mother
33 = Father
Definition: Self-explanatory 36 = Emancipated Minor
39 = Organ Donor
Definition: Code is used in cases where bill is submitted for care given to organ donor where such care is paid by the receiving patient's insurance coverage.
40 = Cadaver Donor
Definition: Code is used where bill is submitted for procedures performed on cadaver donor where such procedures are paid by the receiving patient's insurance coverage.
41 = Injured Plaintiff
Definition: Patient is claiming insurance as a result of injury covered by insured.
43 = Natural child/insured does not have financial responsibility
Definition: Self-explanatory 53 = Life Partner G8 = Other Relationship Edit: A code must be present and valid if Insured's Name is entered.
Patient's Sex | A | 1 |
Data Reporting Level: Required
Definition: The gender of the patient as recorded at date of admission. General Comments: This is a one-character code. The sex is to be reported as male, female or unknown using the following coding: M = Male F = Female U = Unknown Edit: A valid code must be present. The gender of the patient is checked for consistency with diagnosis and procedure codes. The edit is to identify gender diagnosis conflicts and invalid or unknown gender.
Patient Social Security Number | N | 10 | 1450 |
N | 9 | 1300 |
Data Reporting Level: As Available
Definition: The social security number of the patient receiving inpatient care.
General Comments: For 1450 submissions, this field is to be right justified, with zeroes to the left to complete the field. The format of SSN is 0123456789 without hyphens. For 1300 submissions, the SSN should fill the field. If the patient is a newborn, use the mother's SSN. If a patient does not have a social security number, fill with zeroes.
Edit: The field is edited for a valid entry.
Patient's Status | N | 2 |
Data Reporting Level: Required
Definition: A code indicating patient status at the time of the discharge. It is the arrangement or event ending a patient's stay in the hospital. General Comments: This is a two-character code. This should be the status at the time of discharge, the last 'Patient Status'; this would invalidate any patient's stay codes of 30-39. The patient's status is coded as follows:
01 = Discharged to Home or Self Care (Routine Discharge)-
Includes discharges to home; jail or law enforcement; home on oxygen if DME only; any other DME only; home IV care; group home, foster care, and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs; assisted living facilities that are not state-designated
02 = Discharged/transferred to a Short-Term General Hospital for Inpatient Care
03 = Discharge/transferred to Skilled Nursing Facility (SNF)
with Medicare Certification in Anticipation of Covered Skilled Care-Indicates that the patient is discharged/transferred to a Medicare certified nursing facility. For hospitals with an approved swing bed arrangement, use Code 61-Swing Bed. For reporting other discharges/transfers to nursing facilities see 04 and 64.
04 = Discharge/transferred to an Intermediate Care Facility
(ICF) - Typically defined at the state lever for specifically designated intermediate care facilities. Used to designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to state designated Assisted Living Facilities.
05 = Discharge/transferred to another Type of Health Care
Institution not Defined Elsewhere in this Code List if a patient is discharged from an inpatient program to a residential program, code it as '05'.
06 = Discharge/transferred to Home Under Care of Organized
Home Health Service Organization in Anticipation of Covered Skilled Care
07 = Left Against Medical Advice or Discontinued Care
09 = Admitted as an Inpatient to this Hospital-Use only with Medicare outpatient claims. Applies only to those Medicare outpatient services that begin greater than three days prior to an admission.
20 = Expired
30= Still a Patient in the Hospital- ***not a valid code
40= Expired at home- hospice claims only
41= Expired in a Medical Facility-hospital, skilled nursing facility, intermediate care facility, or freestanding hospice (hospice claims only)
42= Expired - Place Unknown (hospice claims only)
43= Discharge/transferred to a Federal Health Care Facility e.g. Department of Defense hospital, a VA hospital, or a VA nursing facility
50= Hospice - Home
51= Hospice - Medical Facility
61= Discharged/transferred to a hospital based (Medicare approved) swing bed- For Medicare discharges, use for reporting patients discharged/transferred to a SNF level of care within the hospital's approved swing bed arrangement.
62= Discharged/transferred to an Inpatient Rehabilitation Facility (IRF)
including Rehabilitation Distinct Part Units of a Hospital 63= Discharged/transferred to a Long Term Care Hospital (LTCH)
64= Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare
65= Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a hospital
66= Discharged/transferred to a critical Access Hospital (CAH)
Edit: The patient status code must be present and a valid code as defined. A patient status code of 30 is not a valid code.
*In situations where a patient is admitted before midnight of the third day following the day of an outpatient service, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier, such as observation following outpatient surgery, which results in admission.
Payer Identification | A | 9 | 1450 |
A | 13 | 1300 |
Data Reporting Level: As available
Definition: An identifier of the primary payer organization from which the hospital might expect some payment for the bill. The sub-identification is of the specific office within the insurance carrier designated as responsible for this claim.
General Comments: This can be a unique identifier used solely by the hospital. Edit: None
Payments
8, 2
Received N
Data Level: As
Reporting available Definition: The amount the hospital has received toward payment of a bill prior to the billing date from an indicated payer.
General Comments: The format of this payment is dollar and cents. The dollar amount can be a maximum of 6 digits with 2 additional digits for cents (no decimal is entered). If the amount has no cents, then the last 2 digits must be zeros. For example, an estimate of $500 is entered as 50000 and a payment of $50.00 is entered as 5000. The entry is right justified within the field.
Edit: None
Payments Received (Patient) | N | 8, 2 |
Data Reporting Level: As available
Definition: The amount the hospital has received from the patient toward payment of a bill prior to the billing date.
General Comments: The format of this payment is dollar and cents. The dollar amount can be a maximum of 6 digits with 2 additional digits for cents (no decimal is entered). If the amount has no cents, then the last 2 digits must be zeros. For example, an estimate of $500 is entered as 50000 and a payment of $50.00 is entered as 5000. The entry is right justified within the field.
Edit: None
Physician Number Qualifying Code | A | 2 |
Data Reporting Level: Required
Definition: The type of Physician Number being submitted. Applies to all
Physician Numbers for a single hospital discharge. General Comments: Use one of the following codes:
UP = UPIN
FI = Federal Taxpayer ID Number
SL = State License ID Number
SP = Specialty License Number
XX = National Provider Identifier
If the UPIN coding is used, the following may be used for physicians without assigned UPINs:
INT000 | for each intern |
RES000 | for each resident |
PHS000 | for Public Health Service physicians |
VAD000 | for Department of Veterans Affairs physicians |
RET000 | for retired physicians |
SLF000 | for providers to report that the patient is self-referred |
OTH000 | for all other unspecified entities without UPINs |
Edit: Must be a valid code or spaces. Spaces will be assumed to be UPIN.
Principal Diagnosis Code | A | 6 |
Data Reporting Level: Required
Definition: The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient for care. An ICD-9-CM code describes the principal disease.
General Comments: This field is to contain the appropriate ICD-9-CM code without a decimal. In the ICD-9-CM codebook there are three, four, and five digit codes plus 'V' and 'E' codes. Use of the fourth, fifth, 'V' and 'E' is not optional, but must be entered when present in the code. For example, a five-digit code is entered as '12345'; a 'V' code is entered as 'V270'. All entries are to be left justified with spaces to the right to complete the field length. An 'E' code should not be recorded as the principal diagnosis.
Edit: A principal diagnosis must be present and valid. When the principal diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Principal Procedure Code | A | 7 |
Data Reporting Level: Required
Definition: The code that identifies the principal procedure performed during the hospital stay covered by this discharge data record. The principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or is necessary as a result of complications. The principal procedure is that procedure most related to the principal diagnosis.
General Comments: The coding method used should be ICD-9. If some other coding method is used, Procedure Coding Method Used field must NOT be 9, but must indicate the code for all digits and decimal. In the ICD-9-CM, there are three-digit procedure codes and four-digit procedure codes; use of the fourth-digit is NOT optional. It must be present. Enter the code left justified without a decimal Edit: This field must be present if other procedures are reported and be a valid code. When a procedure is sex-specific, the sex code entered in the record must be consistent.
Principal Procedure Date | N | 6 |
Data Reporting Level: Required
Definition: The date on which the principal procedure described on the bill was performed. General Comments: None Edit: Must be a valid date falling between admission and discharge dates.
Procedure Coding Method Used | N | 1 |
Data Report Level: Required (1450 only) if procedure coding is
NOT ICD-9-CM Definition: An indicator that identifies the coding method used for procedure coding. General Comments: The default value is 9 for ICD-9. If coding method is NOT ICD-9,enter appropriate code from the list:
4 = CPT - 4
5 = HCPCS (HCFA Common Procedure Coding System) 9 = ICD - 9 - CM
Edit: This field must agree with the coding method used to code procedures.
Provider Address | A | 50 |
Data Reporting Level: Required
Definition: Complete mailing address to which the provider correspondence is to be sent for the correction and acknowledgment of discharge data.
Street address or box number, city, state and ZIP code are required. General Comments: None Edit: All address fields must be present.
Provider FAX Number | N | 10 |
Data Reporting Level: As available
Definition: FAX number for provider.
General Comments: Fax number to be used for transmission of correction documents and acknowledgment of discharge data. If a FAX number does not exist, fill with zeroes. Edit: Must be numeric data.
Provider Name | A | 25 |
Data Reporting Level: Required
Definition: The name of the hospital submitting the record.
General Comments: The hospital's name is entered in the first 25 character positions and must be the name as it is licensed by the Department of
Health. Edit: The name must be present and match a name in a coding table.
Provider Telephone Number | N | 10 |
Data Reporting Level: Required
Definition: Telephone number, including area code, at which the provider wishes to be contacted for correction and acknowledgment of discharge data. General Comments: None Edit: Must be present and numeric, cannot be all zeroes.
Record Type | N | 2 |
Data Reporting Level: Required (1450 only) Definition: The record format type indicator.
General Comments: This field is used to specify each type of record. Use the following numbers:
Record Name | Record Type Code |
Processor Data | 01 |
Reserved for National Assignment | 02-04 |
Local Use | 05-09 |
Provider Data | 10 |
Reserved for National Assignment | 11-14 |
Local Use | 15-19 |
Patient Data | 20 |
Noninsured Employment Information | 21 |
Unassigned State Form Locators | 22 |
Reserved for National Assignment | 23-24 |
Local Use | 25-29 |
Third Party Payer Data | 30-31 |
Reserved for National Assignment | 32-33 |
Authorization | 34 |
Local Use | 35-39 |
Claim Data TAN-Occurrence | 40 |
Claim Data Condition-Value | 41 |
Reserved for National Assignment | 42-44 |
Local Use | 45-49 |
IP Accommodations Data | 50 |
Reserved for National Assignment | 51-54 |
Local Use | 55-59 |
IP Ancillary Services Data | 60 |
Outpatient Procedures | 61 |
Reserved for National Assignment | 62-64 |
Local Use | 65-69 |
Medical Data | 70 |
Plan of Treatment and Patient Information | 71 |
Specific Services and Treatments | 72 |
Plan of Treatment/Medical Update Narrative | 73 |
Patient Information | 74 |
Reserved for National Assignment | 75-78 |
Local Use | 79 |
Physician Data | 80 |
Pacemaker Registry Record | 81 |
Reserved for National Assignment | 82-84 |
Local Use | 85-89 |
Claim Control Screen | 90 |
Remarks (Overflow from RT 90) | 91 |
Reserved for National Assignment | 92-94 |
Provider Batch Control | 95 |
Local Use | 96-98 |
File Control | 99 |
Edit: The number must be present and valid.
Revenue Code | N | 4 |
Data Reporting Level: Required
Definition: A four-digit code that identifies a specific accommodation, ancillary service or billing calculation.
General Comments: For every patient there must be at least one revenue service entered. There may be an entry representing the sum of all revenue services; this entry would have a revenue code of '0001.' If the summed entry ('0001') is one of the entries, the revenue amount associated must equal 'TOTAL CHARGE' found on record type 27.
Edit: This field must be present and contain a valid revenue code as defined in Revenue Codes and Units of Service section.
Sequence Number | N | 2 |
Data Reporting Level: Required (1450 only)
Definition: Sequential number from 01 to nn assigned to individual records within the same specific record type code to indicate the sequence of the physical record within the record type. Records 21-2n do not have a sequence number greater than 01. Records 01, 10, 90, 91, 95 and 99 do not have sequence numbers. The sequence numbers for record types 30, 31, 34, 80 and 81 are used as matching criteria to determine which type 30, type 31, type 34, type 80 and/or type 81 records are associated, like sequence numbers indicating the records are associated.
General Comments: None
Edit: Must be valid sequence number for record type.
Source of Admission | A | 1 |
Data Reporting Level: Required
Definition: A code indicating the source of the admission.
General Comments: This is a single-digit code whose meaning depends on the code entered for Type of Admission. For Type of Admission codes 1, 2 or 3, Source of Admission codes 1 - 9 are valid. For Type of Admission code 4 (newborn), Source of Admission codes 1 - 4 are valid, and have different meanings than when Type of Admission is a 1, 2 or 3. The code structure is as follows:
CODE STRUCTURE FOR EMERGENCY (1), URGENT (2), AND ELECTIVE (3)
1 = Physician Referral
Definition: The patient was admitted to this facility upon the recommendation of his or her personal physician. (See code 3 if the physician has an HMO affiliation.)
2 = Clinical Referral
Definition: The patient was admitted to this facility upon recommendation of this facility's clinic physician.
3 = HMO Referral
Definition: The patient was admitted to this facility upon the recommendation of a health maintenance organization (HMO) physician.
4 = Transfer from a Hospital
Definition: The patient was admitted to this facility as a transfer from an acute care facility where he/she was an inpatient
5 = Transfer from a Skilled Nursing Facility
Definition: The patient was admitted to this facility as a transfer from a skilled nursing facility where he/she was an inpatient.
6 = Transfer from another Health Care Facility
Definition: The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility or skilled nursing facility. This includes transfers from nursing homes, and long term care facilities, and skilled nursing facility patients who are at a non-skilled level of care.
7 = Emergency Room
Definition: The patient was admitted to this facility upon the recommendation of this facility's emergency room physician.
8 = Court/Law Enforcement
Definition: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative.
9 - Information not available
Definition: The means by which the patient was admitted to this hospital is not known. D - Inpatient transfers within the same facility
Definition: The patient was transferred from a separate unit of a hospital to another unit of the same hospital which results in separate claim to the payers
CODE STRUCTURE FOR NEWBORN (4)
If Type of Admission is a 4, the following codes apply:
1 = Normal delivery
Definition: A baby delivered without complications.
2 = Premature delivery
Definition: A baby delivered with time or weight factors qualifying it for premature status.
3 = Sick baby
Definition: A baby delivered with medical complications, other than those relating to premature status.
4 = Extramural birth
Definition: A baby born in a non-sterile environment. 9 = Information not available.
Edit: The code must be present and valid and agree with the Type of Admission code entered.
Source of Payment Code (1450 only) | A | 1 | 1450 |
Data Reporting Level: Required
Definition: A code indicating source of payment associated with this payer record. General Comments: Valid codes are:
A = Self Pay
B = Worker's Compensation C = Medicare D = Medicaid
E = Other Federal Programs F = Commercial Insurance
G = Blue Cross/Blue Shield, Medi-Pak, Medi-Pak Plus H = CHAMPUS I = Other
J = County or State (ex:state or county employees) L = Managed Assistance N = Division of Health Services Q = HMO/Managed Care S = Self Insured Z = Medically Indigent/Free Edit: Code must be present and valid
Source of Payment Code (1300 only) | A | 1 | 1300 |
Data Reporting Level: Required
Definition: A code indicating source of payment associated with this payer record. General Comments: Valid codes are:
P = Self Pay
W = Worker's Compensation M = Medicare D = Medicaid
V = Other Federal Programs I = Commercial Insurance
B = Blue Cross/Blue Shield, Medi-Pak, Medi-Pak Plus C = CHAMPUS O = Other
E = County or State (ex: state or county employees) L = Managed Assistance N = Division of Health Services H = HMO/Managed Care S = Self Insured Z = Medically Indigent/Free Edit: Code must be present and valid.
Statement Covers Period From | N | 6 | 1450 |
N | 8 | 1300 |
Data Reporting Level: Required
Definition: The date of the first medical service relating to this patient=s stay in the hospital.
General Comments: The format is MMDDYY for 1450 record and MMDDCCYY for 1300 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. The 1300 record also contains a two-digit century. Any unused space to the left must be zero filled. For example February 7, 1992 is entered as 020792 (1450) or 02071992 (1300).
For hospitals using the 1450 record format that began using a different 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 must use this format. Edit: This date must be present and be valid.
Statement Covers Period To | N | 6 | 1450 |
(Discharge Date) | N | 8 | 1300 |
Data Reporting Level: Required
Definition: The discharge date of the patient in the hospital or the ending date of a hospital stay longer than 24 hours.
General Comments: The format is MMDDYY for 1450 record and MMDDCCYY for 1300 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. The 1300 record also contains a two-digit century. Any unused space to the left must be zero filled. For example February 7, 1992 is entered as 020792 (1450) or 02071992 (1300).
For hospitals using the 1450 record format that began using a different 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 must use this format.
Edit: This date must be present and be valid.
Total Charges | N | 10, 2 |
Data Reporting Level: Required
Definition: Total of charges for this inpatient hospital stay.
General Comments: The total allows for an 8-digit dollar amount followed by 2 digits for cents (no decimal point). All entries are right justified. If the charge has no cent then the last two digits must be zero. For example, a charge of
$500.00 is entered as 50000 and a charge of $37.50 is entered as 3750.
Edit: This field must be present and contain a value greater than 0 when any revenue code field is greater than 0.
Total Charges by Revenue Code | N | 10, 2 |
Data Reporting Level: Required
Definition: Total dollars and cents amount charged for the related revenue service entered. General Comments: The total allows for an 8-digit dollar amount followed by 2
digits for cents (no decimal point). All entries are right justified.
If the charge has no cents, then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000 and a charge of $37.50
is entered as 3750. Edit: This field must be present and contain a value greater than 0 when the associated revenue code field is greater than 0.
Type of Admission | A | 1 |
Data Reporting Level: Required
Definition: A code indicating priority of the admission.
General Comments: This is a one-digit code ranging from 1 - 4, or may be 9. The code structure is as follows.
1 = Emergency
Definition: The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient is admitted through the emergency room.
2 = Urgent
Definition: The patient requires immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient is admitted to the first available and suitable accommodation.
3 = Elective
Definition: The patient's condition permits adequate time to schedule the availability of a suitable accommodation. An elective admission can be delayed without substantial risk to the health of the individual.
4 = Newborn
Definition: Use of this code necessitates the use of special Source of Admission codes; see Source of Admission. Generally, the child is born within the facility. 9 = Information not available
Definition: Information was not collected or was not available. Edit: The field must be present and be a valid code 1 - 4 or 9. If the code is entered 4 (newborn), the Source of Admission codes will be checked for consistency as well as the date of birth and diagnosis.
Type of Bill | A | 3 |
Data Reporting Level: Required
Definition: A code indicating the specific type of bill (inpatient,
outpatient, etc.). This three digit code requires 1 digit each, in the following sequence:
General Comments: All positions must be fully coded. See UB-92 guidelines for codes and definitions. This code indicates the specific type of inpatient billing.
Edit: None
Units Of Service | N | 7 |
Data Reporting Level: Required if the revenue code needs units; see Revenue Codes and Units of Service section.
Definition: A quantitative measure of services rendered, by revenue category to the patient. It includes such items as the number of scans, number of pints, number of treatments, number of visits, number of miles or number of sessions.
General Comments: This number qualifies the revenue service. The presence of this code ensures that charges per revenue service are adjusted to a common base for comparison. Revenue Codes and Units of Service section (Appendix B) defines the appropriate units for each revenue code.
Edit: The units of service must be present for those revenue services that require a unit; see Revenue Codes and Units of Service section.
REVENUE CODES AND UNITS OF SERVICE
RESOURCE LIST
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
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
RULES AND REGULATIONS PERTAINING TO HOSPITAL DISCHARGE DATA SYSTEM
(Typed Version of scanned pages 6-8 of this document are supplied to insure legibility of these 1997 Rules and Regulations.)
The Act established the State Health Data Clearing House within the Arkansas Department of Health. 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 care 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.
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 data will be published annually with the distribution of the survey.
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.
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 time, computer time, copying cost, postage and supplies.
All incorporated material is available for public review at the central administrative office of the Department.
016.24.06 Ark. Code R. 008