N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-2

Current through Register Vol. 46, No. 43, October 23, 2024
Appendix C-2

(cf. § 400.18[b])

Uniform Bill Elements

SPARCS Hospital Identification Number

Patient Control Number (Admission Number)

Patient Sex

Patient Birthdate

Source of Admission

Admission Date/Start of Care Date

Admission Hour

Statement Covers From Date

Statement Covers Thru Date

Patient Status/Disposition

Discharge Hour

Medical Record Number

Discharge Date

Type of Alternate Care Required

Patient's Residence Address

Patient's Residence City, County, State, and Zip Code

Source of Payment Code

Policy Number

Insurance Group Number

Payor Covered Days

Payor Non-Covered Days

Provider Number

Payor Alternate Level of Care Days

Payor Leave of Absence Days

Accident Type

Accident Type Date

Blood Furnished

Blood Charge

Special Program--Disability

Special Program--Family Planning

Special Program--Physically Handicapped Children

Special Program--Special Funding Project

Surplus, Catastrophic, or Recurring Monthly Income Code

Surplus, Catastrophic, or Recurring Monthly Income Amount

Workers Compensation/No Fault Indicator

SPARCS Accommodation Code

Accommodation Rate

Accommodation Days

Accommodation Total Non-Covered Charges

Ancillary Revenue Code

Ancillary Total Charges

Ancillary Total Non-Covered Charges

Principal Procedure Code

Other Diagnosis Codes (14 occurrences)

Principal Procedure Code

Principal Procedure Date

Other Procedure Codes (14 occurrences)

Other Procedure Dates (14 occurrences)

Admitting Diagnosis Code

External Cause of Injury Code

Procedure Coding Method Used

State Attending Physician License Number

State Operating Physician License Number

State Other Physician License Number

DRG Billed

Type of Bill

N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-2