La. Admin. Code tit. 48 § V-15127

Current through Register Vol. 50, No. 9, September 20, 2024

Section V-15127 - Guide-Record Formats

A. The accepted data record formats are the UB-92 1450 version 4.1 format and the UB-92 1300 flat file format. 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 the UB-92 Users Manual. See §15125 B.3 to identify possible differences between standard referenced formats and requirements under this rule.

1. UB-92 1450 Version 4.1 Record Specification. The UB-92 1450 claim record is made up of a series of 192-character physical records, as listed in the Louisiana UB-92 Training Manual. Record Types not specified in the required data elements list are requested but are not required for submittal.

2. 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. The 1300 record format is included in §15127. A.2.c below.

a. 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 last entry must be the Total Charge (001) 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 001 entry.

b. Exceptions to 1300 Format. Inclusion of the 1300 format as an accepted data format required the addition of data elements not found in the version currently used in Louisiana. The following fields indicate the locations for the additional data elements.

Number	Field Name	Form Locator
10	Admission Hour	FL18
14	Medical Record Number	FL23
78	Admitting Diagnosis	FL76
93	Operating Physician Number	FL83
153	Infant Birth Weight	(none)
154	Infant APGAR Score	(none)
155	Patient Race	(none)

c. 1300 Discharge Record. The record layouts that follow will provide the following information.

i. Record Number- Sequentially assigned record number (This is not the Form Locator).

ii. Field Name-the name of the data element (field).

iii. Picture-this is the COBOL picture. Pic X is initialized to blanks and Pic 9 is initialized to zeroes. All money and date fields are Pic 9.

iv. Justification-indicates how the data field is justified (left or right).

v. Start Position-leftmost position in the record.

vi. End Position-rightmost position in the record.

vii. Form Locator-this is the number found on the UB-92 paper form associated with the given field.

Record Number	Field Name	Picture	Justif-ication	Start	End	Form Locator
1.	Patient Control Number	X(20)	L	1	20	FL03
2.	Type of Bill	9(3)	R	21	23	FL04
3.	Federal Tax Number (EIN)	X(10)	L	24	33	FL05
4.	Statement Covers Period: FROM MMDDYYYY	9(8)	R	34	41	FL06
5.	Statement Covers Period: TO MMDDYYYY	9(8)	R	42	49	FL06
6.	Patient Address Zip Code	X(9)	L	50	58	FL13
7.	Patient Date of Birth MMDDYYYY	9(8)	R	59	66	FL14
8.	Patient Sex	X(1)	L	67	67	FL15
9.	Admission Date	9(8)	R	68	75	FL17
10.	Admission Hour	9(2)	R	76	77	FL18
11.	Type of Admission	X(1)	L	78	78	FL19
12.	Source of Admission	X(1)	L	79	79	FL20
13.	Patient Status	9(2)	R	80	81	FL22
14.	Medical Record Number	X(17)	L	82	98	FL23
15.	Revenue Code Line 1	9(4)	R	99	102	FL42
16.	Total Charges by Revenue 1	S9(8)V99	R	103	112	FL47
17.	Revenue Code Line 2	9(4)	R	113	116	FL42
18.	Total Charges by Revenue 2	S9(8)V99	R	117	126	FL47
19.	Revenue Code Line 3	9(4)	R	127	130	FL42
20.	Total Charges by Revenue 3	S9(8)V99	R	131	140	FL47
21.	Revenue Code Line 4	9(4)	R	141	144	FL42
22.	Total Charges by Revenue 4	S9(8)V99	R	145	154	FL47
23.	Revenue Code Line 5	9(4)	R	155	158	FL42
24.	Total Charges by Revenue 5	S9(8)V99	R	159	168	FL47
25.	Revenue Code Line 6	9(4)	R	169	172	FL42
26.	Total Charges by Revenue 6	S9(8)V99	R	173	182	FL47
27.	Revenue Code Line 7	9(4)	R	183	186	FL42
28.	Total Charges by Revenue 7	S9(8)V99	R	187	196	FL47
29.	Revenue Code Line 8	9(4)	R	197	200	FL42
30.	Total Charges by Revenue 8	S9(8)V99	R	201	210	FL47
31.	Revenue Code Line 9	9(4)	R	211	214	FL42
32.	Total Charges by Revenue 9	S9(8)V99	R	215	224	FL47
33.	Revenue Code Line 10	9(4)	R	225	228	FL42
34.	Total Charges by Revenue 10	S9(8)V99	R	229	238	FL47
35.	Revenue Code Line 11	9(4)	R	239	242	FL42
36.	Total Charges by Revenue 11	S9(8)V99	R	243	252	FL47
37.	Revenue Code Line 12	9(4)	R	253	256	FL42
38.	Total Charges by Revenue 12	S9(8)V99	R	257	266	FL47
39.	Revenue Code Line 13	9(4)	R	267	270	FL42
40.	Total Charges by Revenue 13	S9(8)V99	R	271	280	FL47
41.	Revenue Code Line 14	9(4)	R	281	284	FL42
42.	Total Charges by Revenue 14	S9(8)V99	R	285	294	FL47
43.	Revenue Code Line 15	9(4)	R	295	298	FL42
44.	Total Charges by Revenue 15	S9(8)V99	R	299	308	FL47
45.	45 Revenue Code Line 16	9(4)	R	309	312	FL42
46.	Total Charges by Revenue 16	S9(8)V99	R	313	322	FL47
47.	Revenue Code Line 17	9(4)	R	323	326	FL42
48.	Total Charges by Revenue 17	S9(8)V99	R	327	336	FL47
49.	Revenue Code Line 18	9(4)	R	337	340	FL42
50.	Total Charges by Revenue 18	S9(8)V99	R	341	350	FL47
51.	Revenue Code Line 19	9(4)	R	351	354	FL42
52.	Total Charges by Revenue 19	S9(8)V99	R	355	364	FL47
53.	Revenue Code Line 20	9(4)	R	365	368	FL42
54.	Total Charges by Revenue 20	S9(8)V99	R	369	378	FL47
55.	Revenue Code Line 21	9(4)	R	379	382	FL42
56.	Total Charges by Revenue 21	S9(8)V99	R	383	392	FL47
57.	Revenue Code Line 22	9(4)	R	393	396	FL42
58.	Total Charges by Revenue 22	S9(8)V99	R	397	406	FL47
59.	Revenue Code Line 23	9(4)	R	407	410	FL42
60.	Total Charges by Revenue 23	S9(8)V99	R	411	420	FL47
61.	Filler	X(25)	421	445
62.	First Provider Number (Payor)	X(13)	L	446	458	FL51A
63.	Patient's Relationship to Insured	X(2)	L	459	460	FL59A
64.	Certificate/SocSecNumber/Health Insurance Claim/ Identification Number	X(19)	L	461	479	FL60A
65.	Insurance Group Number	X(20)	L	480	499	FL62A
66.	Employment Status Code	X(1)	L	500	500	FL64
67.	Employer Name	X(24)	L	501	524	FL65
68.	Employer Zip Code	X(9)	L	525	533	FL66
(For Diagnosis and Procedure Codes (69-90)-omit decimal)
69.	Principal Diagnosis Code	X(6)	L	534	539	FL67
70.	Other Diagnosis Code 1	X(6)	L	540	545	FL68
71.	Other Diagnosis Code 2	X(6)	L	546	551	FL69
72.	Other Diagnosis Code 3	X(6)	L	552	557	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 MMDDYY	9(6)	R	607	612	FL80
82.	Other Procedure 1: Code	X(7)	L	613	619	FL81
83.	Other Procedure 1 : Date MMDDYY	9(6)	R	620	625	FL81
84.	Other Procedure 2 : Code	X(7)	L	626	632	FL81
85.	Other Procedure 2 : Date MMDDYYYY	9(6)	R	633	638	FL81
86.	Other Procedure 3 : Code	X(7)	L	639	645	FL81
87.	Other Procedure 3 : Date MMDDYY	9(6)	R	646	651	FL81
88.	Other Procedure 4 : Code	X(7)	L	652	658	FL81
89.	Other Procedure 4 : DateMMDDYY	9(6)	R	659	664	FL81
90.	Other Procedure 5 : Code	X(7)	L	665	671	FL81
91.	Other Procedure 5 : Date MMDDYY	9(6)	R	672	677	FL81
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.	Filler	X(2)	L	744	745
96.	Century Flag Patient's DOB0=Birth Year 19001=Birth Year<1900	9(1)	R	746	746
(Dates of Service-even numbers from 97-142; MMDDYY)
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.	Units of Service Line 7	9(7)	R	825	831	FL46
110.	Date of Service Line 7	9(6)	R	832	837	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.	Filler	X(25)	L	1046	1070
144.	Second Provider umber (Payor)	X(13)	L	1071	1083	FL51B
145.	Patient's Relationship to Insured	X(2)	L	1084	1085	FL59B
146.	Certificate/SocSecNumber/ Health Insurance Claim/ Identification Number	X(19)	L	1086	1104	FL60B
147.	Insurance Group Number	X(20)	L	1105	1124	FL62B
148.	Filler	X(25)	L	1125	1149
149.	Third Provider Number (Payor)	X(13)	L	1150	1162	FL51C
150.	Patient's Relationship to Insured	X(2)	L	1163	1164	FL59C
151.	Certificate/SocSecNumber/ Health Insurance Claim/ Identification	X(19)	L	1165	1183	FL60C
152.	Insurance Group Number	X(20)	L	1184	1203	FL62C
153.	Infant Birth Weight (in grams)	9(4)	R	1204	1207
154.	Infant APGAR Score	9(4)	R	1208	1211
155.	Patient Race	9(1)	R	1212	1212
156.	Primary Payor Code	X(2)	L	1213	1214	FL50A
157.	Second Payor Code	X(2)	L	1215	1216	FL50B
158.	Third Payor Code	X(2)	L	1217	1218	FL50C
159.	Medicaid Provider Number	X(12)	L	1219	1230	FL51
160.	Medicare Provider Number	X(12)	L	1231	1242	FL51
161.	Patient Social Security Number	X(9)	L	1243	1251	FL60
162.	Primary Payor Carrier ID Code	X(4)	L	1252	1255
163.	Second Payor Carrier ID Code	X(4)	L	1256	1259
164.	Third Payor Carrier ID Code	X(4)	L	1260	1263
165.	Federal Tax Sub ID.	X(4)	L	1264	1267
166.	Filler	X(2)	L	1268	1269
167.	Filler	X(31)	L	1270	1300

La. Admin. Code tit. 48, § V-15127

Promulgated by the Department of Health and Hospitals, Office of Public Health, LR 24:1941 (October 1998).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:1300.112(D).