12 Va. Admin. Code § 5-218-20
Every reporting entity performing outpatient surgical procedures shall submit each patient level data element listed in the table in this section for each patient for which an outpatient surgical procedure is performed and for which the data element is collected on the standard claim form utilized by the reporting entity. Most of these data elements are currently collected from a Uniform Billing Form (UB-04) located in the latest publication of the Uniform Billing Manual prepared by the National Uniform Billing Committee or from the Centers for Medicare and Medicaid (CMS) Health Insurance Claim Form (CMS 1500). The Uniform Billing Form and the Uniform Billing Manual are located on the National Uniform Billing Committee's website at www.nubc.org. The Centers for Medicare and Medicaid Health Insurance Claim Form is available on the CMS website at www.cms.gov. Every reporting entity performing outpatient surgical procedures shall submit in an electronic data format. The nonprofit organization will develop detailed record layouts for use by reporting entities in reporting outpatient surgical data. This detailed record layout will be based upon the type of base electronic or paper-billing form utilized by the reporting entity. Outpatient surgical procedures reported shall be those adopted by the board as referred by the nonprofit organization. The nonprofit organization may recommend changes to the list of procedures to be reported not more than annually.
| Data Element Name | Instructions | ||
| Hospital Identifier | Hospitals and ambulatory care centers enter the six-digit Medicare provider number, or when adopted by the board, the National Provider Identifier or other number assigned by the board. Physicians, leave blank. | ||
| Operating Physician or Oral and Maxillofacial Surgeon Identifier | Enter the nationally assigned physician identification number, either the Uniform Physician Identification Number (UPIN), National Provider Identifier (NPI) or its successor as approved by the board for the physician identified as the operating physician for the principal procedure reported. | ||
| Payor Identifier | Enter the board approved payor designation which will be the nationally assigned PAYERID, its successor, or English description of the payor. | ||
| Employer Identifier | Enter the federally approved EIN, or employer name, whichever is adopted by the board. | ||
| Patient Identifier | Enter the nine-digit social security number of the patient. If a social security number has not been assigned, leave blank. The nine-digit social security number is not required for patients under four years of age. | ||
| Patient Sex | |||
| Date of Birth | Enter the code in MM/DD/YYYY format. | ||
| Street Address | |||
| City or County | |||
| Zip Code | |||
| Employment Status Code | |||
| Status at Discharge | |||
| Admission Date | Admission/start of care date | ||
| Admission Hour | Hour of admission in military time 00-24 | ||
| Admission Diagnosis | Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts. | ||
| Principal Diagnoses | Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts. | ||
| Secondary Diagnoses | Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts. | ||
| External Cause of Injury | (E-code). Record all external cause of injury codes in secondary diagnoses position after recording all treated secondary diagnoses. | ||
| Co-morbid Condition Existing but not Treated | Enter the code for any co-morbid conditions existing but not treated. Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts. | * | * |
| Procedures | Code sets- ICD 9 or CPT 4 or their successors to be specified in detailed record layouts. | ||
| Procedure Dates | |||
| Revenue Center Codes | As specified for UB-04 or its successor completion, not available for CMS 1500 or its successor | ||
| Revenue Center Units | |||
| Revenue Center Charges | |||
| Total Charges |
12 Va. Admin. Code § 5-218-20
Statutory Authority: §§ 32.1-12 and 32.1-276.6 of the Code of Virginia.