N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-5
(cf. section 400.18[h])
Emergency Service Data elements to be submitted under section 400.18(h) shall include but shall not be limited to the following:
DATA ELEMENT
Submitter Name
Processing Data
SPARCS Identification Number
Patient Control Number
Patient Sex
Patient Birth Date
Admission Date/Start of Care
Admission Hour
Statement Covers Period - From Date
Statement Covers Period - Thru Date
Discharge Hour
Medical Record Number
New York State Patient Status or Disposition
Patient's Race
Patient's Ethnicity
Patient Residence Address - Address Line 1
Patient Residence Address - Address Line 2
Patient's City
Patient's County Code
Patient's State
Patient's Postal Service Zip Code and Extension Code
Unique Personal Identifier
Source of Payment Information
Group Definition
Source of Payment Code
Payor Identification
Provider Identification Number
Type of Bill
Occurrence Information Group Definition
Occurrence Information - Accident Related Codes & Dates
Condition Information Group Definition
Condition Information - Homeless Patients
Value Information Group Definition
Value Information - Accident Hour
Ancillary Services Information Group Def. Ver. 5 & 6
Ancillary Revenue Code
Ancillary Total Charges
Ancillary Total Non-Covered Charges
Procedure Code - CPT-4 and Modifiers
Principal/Primary Diagnosis Code
Other Diagnosis Information Group Definition
Other Diagnosis Code 1-14
Principal Procedure Code
Principal Procedure Date
Other Procedure Information Group Definition
Other Procedure Code 1-14
Other Procedure Date 1-14
Admitting Diagnosis/Patient's Reason for Visit
External Cause-of-Injury Code
Place of Injury Code
Attending/Emergency Department Physician State License Number
Operating/Emergency Department Physician State License Number
Other Physician/Emergency Department State License Number
N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-5