90-590 - Maine



90-590MAINE HEALTH DATA ORGANIZATIONChapter 241:UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETSSUMMARY: This chapter contains the provisions for filing hospital inpatient data sets and hospital outpatient service data sets. The provisions include:Identification of the organizations required to report;Establishment of requirements for the content, format, method, and time frame for filing hospital inpatient data and hospital outpatient service data;Establishment of standards for the data reported; andCompliance provisions.1.DefinitionsUnless the context indicates otherwise, the following words and phrases shall have the following meanings:A.Attending Provider. Attending Provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim.B.Billing Provider. Provider submitting the bill.C.Designee. "Designee" means an entity with which the MHDO has entered into an arrangement under which the entity performs data collection, validation and management functions for the MHDO and is strictly prohibited from releasing information obtained in such a capacity if the information is not authorized for release by the MHDO.D.Carrier. "Carrier" means an insurance company licensed in accordance with 24A M.R.S.A., including a health maintenance organization, a multiple employer welfare arrangement licensed pursuant to Title 24-A, chapter 81, a preferred provider organization, a fraternal benefit society, or a nonprofit hospital or medical service organization or health plan licensed pursuant to 24?M.R.S.A. An employer exempted from the applicability of 24-A M.R.S.A., chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) is not considered a carrier.E.External Causes Codes. “External causes codes” in ICD-10 are codes designed to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition occurred (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event and the person’s status (e.g. civilian, military).F.Hospital. "Hospital" means any acute care institution required to be licensed pursuant to 22 M.R.S.A., chapter 405. G.Hospital Inpatient Data. "Hospital inpatient data" pertains to the information generated at the time of discharge which is associated with patients who are provided with room, board, and continuous nursing service based on a physician’s written order in an area of the hospital where patients generally stay more than twenty-four hours.H.Hospital Outpatient Data. "Hospital outpatient data" pertains to the data generated for any patient visit that is not considered an inpatient admission, at any department of the hospital, regardless of its physical location. Hospital Outpatient Data also includes services provided by specialty groups or primary care practices when the hospital owns the data.I.MHDO. "MHDO" means the Maine Health Data Organization.J.M.R.S.A. “M.R.S.A.” means Maine Revised Statutes Annotated.K.National Provider Identifier (NPI). The unique identification number assigned to the providerL.Operating Physician. Operating Physician is the individual with the primary responsibility for performing the surgical procedures(s).M.Rendering Provider. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care.N.Third-party Administrator. “Third-party administrator” means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S.A., chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.2.Hospital Inpatient and Outpatient Service Data Sets Filing DescriptionEach hospital shall file with the MHDO or its designee a completed hospital inpatient data set and a completed hospital outpatient data set for every service provided to each patient. A completed hospital data set includes professional and facility services as defined in the appendices.General RequirementsCodes (a)Code Sources. The code sources listed and described in Appendix A are to be utilized with the inpatient and outpatient data file submissions.(b)Specific and Unique Coding. Except for location of service codes and provider number, specific or unique coding systems shall not be permitted as part of the inpatient and outpatient data submissions.(c)External Cause Codes. External Cause Codes shall be assigned for all initial treatments of an injury, poisoning, or adverse effect of drugs. If a patient is transferred to another facility for continued treatment, this facility shall also assign the appropriate External Cause Code.Definitions for Required Data Elements. Unless otherwise specified, the definitions for the required data elements described in Appendix B-1 and Appendix C-1 are the same as those provided in the most current National Uniform Billing Data Element Specifications as developed by the National Uniform Billing Committee and approved by the State of Maine Uniform Billing Committee.(3)Inpatient Data Filing. Data for all inpatient services of the hospital must be submitted based on the discharge date and filed under the MHDO provider code assigned to that hospital.(4)Outpatient Data Filing. Data for all outpatient services of the hospital and all services provided by specialty groups or primary care practices must be filed in one or more outpatient data streams under the MHDO provider code assigned to that hospital. Every encounter that is populated with a designated subset of Place of Service codes must include a Location of Service code, internally created by the Hospital. Also, each hospital shall submit annually an updated Location of Service crosswalk, which includes unique location of service code, full location name, address, city, state, and zip code for those locations only.(5)Adjustment Charges. Adjustment charges and negative values are not to be reported in inpatient and outpatient data sets. The adjustment charges are reconciled to the individual line item for which the adjustment applies.B.Detailed File Specifications(1)Filled Fields. All fields shall be filled where applicable. Non-applicable text fields shall be space filled. Non-applicable numeric fields shall be zero filled and shall not include decimal points.(2)Position. All text fields are to be left justified. All numeric fields are to be right justified.(3)Individual Elements and Mapping. Individual data elements, data types, field lengths, and mapping locators (UB-04, CMS 1500, ANSI X12N 837) for each file type are presented in the following appendices:(a)(i)Inpatient Data Specifications - Appendix B-1(ii)Inpatient Data Mapping to National Standards Formats - Appendix B-2(b)(i)Outpatient Data Specifications - Appendix C-1(ii)Outpatient Data Mapping to National Standards Formats - Appendix C-23.Submission RequirementsA.File Format. The inpatient file and the outpatient file(s) are to be submitted to the MHDO or it designee as separate ASCII files with fixed length records. Each record shall be terminated with a carriage return line feed (ASCII 13, ASCII 10).B.Filing Method. All data files must be encrypted using 256-bit AES (AES-256) encryption, prior to submission/uploading. This can be accomplished using various commercially available software packages. Data files shall be submitted via electronic transmission using the Secure Hypertext Transfer Protocol (HTTPS). E-mail attachments shall not be accepted. C.File Editing. All data files must be processed through the MHDO designee’s system. Corrections must be applied to the data files before the data are transmitted. D.Filing Specifications. Each hospital shall file all applicable data sets to the MHDO in accordance with the electronic specifications for submission of claims to Maine’s designated Medicare intermediary.E.Filing Periods. Each inpatient discharge or outpatient service record must be filed no later than 90 days following the calendar quarter in which the discharge or service occurred. F.Replacement of Data Files. No hospital may amend its data submission more than one year after the end of the quarter in which the discharge or outpatient service occurred unless it can be established by the hospital that exceptional circumstances occurred. Any resubmission of data after the elapse of the one year period must be approved by the MHDO.G.Rejection of Files. Failure to conform to the requirements of subsections A, B, C or D of this section shall result in the rejection of the data file(s). Rejected files must be resubmitted in the appropriate corrected form to the MHDO within 15?days of notification.4.Standards for Data; Notification; ResponseA.Standards. The MHDO shall evaluate each inpatient file and each outpatient file submission in accordance with the following standards:(1)The code for each data element identified in Appendices B-1 and C-1 shall be included within eligible values for the field;(2)Coding values indicating "data not available" "data unknown" or the equivalent shall not be used for individual data elements unless specified as an eligible value for the field;(3)Outpatient data sets shall have Current Procedural Terminology (CPT) Codes and Health Care Common Procedural Coding System (HCPCS) codes reported for specific revenue centers. The list of revenue centers requiring CPT and HCPCS codes shall be provided via the MHDO’s designee; and(4)CPT and HCPCS codes shall be assigned to the correct revenue centers.B.Notification. Upon completion of the evaluation, the MHDO or its designee shall promptly notify each hospital whose data sets do not satisfy the standards for any filing period. This notification shall identify the specific file and the data fields and elements that do not satisfy the standards.C.Response. Each hospital notified under Subsection B shall respond within 32?days of the notification by making the required changes and resubmitting, if necessary, to satisfy the standards.5.Public AccessInformation collected, processed and/or analyzed under this rule shall be subject to release to the public or retained as confidential information in accordance with 22?M.R.S.A. Sec. 8707 and Code of Maine Rules 90-590, Chapter 120: Release of Information to the Public, unless prohibited by state or federal law.6.Extension or Waiver to Data Submission RequirementsIf a hospital, due to circumstances beyond its control, is temporarily unable to meet the terms and conditions of this chapter, a written request must be made to the Compliance Officer of the MHDO as soon as it is practicable after the hospital has determined that an extension or waiver is required. The written request shall include: the specific requirement to be extended or waived; an explanation of the cause; the methodology proposed to eliminate the necessity of the extension or waiver; and the time frame required to come into compliance. If the Compliance Officer does not approve the requested extension or waiver, the hospital making the request may submit a written request appealing the decision to the MHDO Board. The appeal shall be heard by the MHDO Board at the next regularly scheduled meeting following receipt of the request at the MHDO.plianceFailure to file, report, or correct in accordance with the provisions of this chapter may be considered a violation under 22 M.R.S.A. Sec. 8705-A and Code of Maine Rules 90-590, Chapter 100: Enforcement Procedures.STATUTORY AUTHORITY: 22 M.R.S.A. §§ 8704 (4) and 8708EFFECTIVE DATE:May 2, 1990AMENDED:May 14, 1991February 10, 1993July 6, 1994April 19, 1995July 1, 1999February 28, 2006March 18, 2007 – filing 2007-95April 15, 2009 – filing 2009-156February 7, 2010 – filing 2010-23May 21, 2011 – filing 2011-157November 26, 2013 – filing 2013-289November 22, 2015 – filing 2015-226October 31, 2017 – filing 2017-166December 22, 2019 – filing 2019-245November 15, 2021 – filing 2021-229Accredited Standards Committee (ASC)ASC X12N Electronic Data Interchange Transaction Set Implementation GuideHealth Care Claim: Institutional and Professional (837)(Used for all Mapping of HIPAA Reference – Transaction Set/Loop/Segment Qualifier/Data Elements)AVAILABLE FROM: Accredited Standards Committee8300 Greensboro Drive, Suite 800McLean, VA 22102 ABSTRACT: The data implementation guide provides standardized data requirements and content for all users of the ANSI ASC X12N 837 Health Care Claims transaction.American Medical AssociationCurrent Procedural Terminology (CPT) Codes(MHDO Data Elements: OP6105, OP6106, OP6107, OP6112, OP6113, OP6114, OP6119, OP6120, OP6121)SOURCE: Physicians' Current Procedural Terminology (CPT) ManualAVAILABLE FROM: American Medical AssociationAMA Plaza 330 N. Wabash Ave., Suite 39300Chicago, IL 60611ABSTRACT: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians in an outpatient setting.International Country Codes(MHDO Data Elements: IP2021, OP2018)SOURCE: oneworld/country_code_list.htmABSTRACT: The ISO country codes are internationally recognized codes that designate each country and most of the dependent areas with a two- or three-letter combination or a numeric code.?National Uniform Billing Committee (NUBC)National Uniform Billing Data Element Specifications as Developed by?NUBC.(All MHDO Data Elements except for the following: Diagnosis Codes, Procedure Codes, Payer Identification Number, Social Security Number, HCPCS Procedure Codes, HCPCS Procedure Modifiers, Race/Ethnicity, Present on Admission Indicator, Filler)SOURCE: UB-04 Data Specifications Manual.?AVAILABLE FROM: Uniform Billing CommitteeAmerican Hospital Association155 N Wacker DriveChicago, IL 60606ABSTRACT: This serves as the official source of information for institutional health care billing. It contains all billing conventions and codes, including form locators, data element descriptions, definitions, reporting requirements, field attributes, approval and effective dates, and revenue, condition, occurrence, and value codes.U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services Ambulance Modifiers(MHDO Data Element: OP6106, OP6107, OP6113, OP6114, OP6120, OP6121)SOURCE: Medicare Claims Processing ManualAVAILABLE FROM:. Department of Health and Human Services, Centers for Medicare and Medicaid Services7500 Security BoulevardBaltimore, MD 21244-1850ABSTRACT: Ambulance Modifiers are HCPCS modifier codes available for use with Ambulance services.U.S. Department of Health and Human Services, Centers for Medicare and Medicaid ServicesHealth Care Common Procedural Coding System(MHDO Data Elements: OP6105, OP6106, OP6107, OP6112, OP6113, OP6114, OP6119, OP6120, OP6121)SOURCE: Health Care Common Procedural Coding SystemAVAILABLE FROM:HCPCSReleaseCodeSets/ U.S. Department of Health and Human Services, Centers for Medicare and Medicaid ServicesCenter for Health Plans and Providers7500 Security BoulevardBaltimore, MD 212441850ABSTRACT: HCPCS is the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) coding scheme to group procedures performed for payment to providers.U.S. Department of Health and Human Services, Centers for Medicare and Medicaid ServicesNational Provider Identifier (NPI)(MHDO Data Elements: OP6126, OP6128, OP6130, OP8004, OP8005, OP8012, IP8004, IP8005, IP8012)SOURCE: National Plan and Provider Enumeration System (NPPES)AVAILABLE FROM:Centers for Medicare and Medicaid Services7500 Security BoulevardBaltimore, MD 21244-1850ABSTRACT: The Centers for Medicare and Medicaid Services developed the National Provider Identifier (NPI) as the standard, unique identifier for each health care provider under the Health Insurance Portability and Accountability Act of 1996 and the NPI Final Rule was implemented May 23, 2008.United States Postal ServiceStates and Outlying Areas and Zip Codes of the U.S.(MHDO Data Elements: IP0106, IP2009, OP0106, OP2009, IP0107, IP2010, OP0107, OP2010)SOURCE: National Zip Code and Post Office DirectoryThe USPS Domestic Mail ManualAVAILABLE FROM:. Postal ServiceNational Information Data CenterP.O. Box 9408Gaithersburg, MD 20898-9408Or Information Systems ProductsNational Customer Support CenterU.S. Postal Service6060 Primacy Pkwy Ste 231Memphis, TN 38119-5772ABSTRACT: Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S. Microfiche AVAILABLE FROM: NTIS (same as address above). The Canadian Post Office lists the following as "official" codes for Canadian Provinces:AB AlbertaBC British ColumbiaMB ManitobaNB New BrunswickNF NewfoundlandNS Nova ScotiaNT North West TerritoriesON OntarioPE Prince Edward IslandPQ QuebecSK SaskatchewanYT – YukonThe ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two right-most digits identify a local delivery area. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes. The USPS Domestics Mail Manual includes information on the use of the new 11digit zip code.World Health Organization (WHO)International Classification of Diseases Clinical Modification (ICD10CM) (MHDO Data Elements: IP7104, IP7106 IP7110, IP7204, IP7206, IP7208, IP7210, IP7212, IP7214, IP7216, IP7218, IP7304, IP7306, IP7308, IP7310, IP7312, IP7314, IP7316, IP7318, IP7320, IP7322, IP7324, IP7326, IP7404, IP7406, IP7408, IP7410, IP7412, IP7414, IP7416, IP7418, IP7420, IP7422, IP7424, IP7426, OP7104, OP7107, OP7108, OP7109, OP7110, OP7204, OP7206, OP7208, OP7210, OP7212, OP7214, OP7216, OP7218, OP7304, OP7306, OP7308, OP7310, OP7312, OP7314, OP7316, OP7318, OP7320, OP7322, OP7324, OP7326, OP7404, OP7406, OP7408, OP7410, OP7412, OP7414, OP7416, OP7418, OP7420, OP7422, OP7424, OP7426)SOURCE: International Classification of Diseases, 10th Revision, Clinical Modification (ICD10-CM)AVAILABLE FROM: World Health Organization (WHO)Regional Office for the Americas525, 23rd Street, N.W.Washington, DC 20037USAORnchs/icd/icd10cm.htm#9update Centers for Disease Control and Prevention1600 Clifton RoadAtlanta, GA30329-4027ABSTRACT: The International Classification of Diseases, 10th Revision, is used to report medical diagnosis and inpatient procedures. ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.The record types in the file must be in the following order: Record Type 01 - Processor Data Record Type 20 - Sequence 01 - Patient Data Record Type 30 - Sequence 01 - Third Party Payer Data Primary Payer Record Type 30 - Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary. Record Type 40 - Claim Data Record Type 50 - IP Accommodations Data Record Type 60 - IP Ancillary Services Record Type 71 - ICD-10 CM Principal and Admitting Diagnosis Codes, ICD-10 PCS Principal Procedure Code Record Type 72 - ICD-10 PCS Other Procedure Codes Record Type 73 - ICD-10 CM External Cause of Injury Diagnosis Codes Record Type 74 - ICD-10 CM Other Diagnosis Information Record Type 80 - Provider Data Record Type 90 - Claim Control Screen Record Type 99 - File ControlThe individual claim begins with Record Type 20 and ends with Record Type 90.The patient control number must be the same on each record type generated for a single patient record.The medical record number should not be substituted for the patient control number.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP0101Record TypeT201IP0102MHDO-Assigned Hospital ID T6Must be the MHDO-assigned, 6-digit hospital code, left justifiedIP0198FillerT38IP0103Hospital NameT21IP0104AddressT18IP0105CityT15IP0106StateT2IP0107Zip CodeT9IP0199FillerT78IP0108Version T3leave blankData Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP2001Record Type T220IP2002Filler (National Use)T2IP2003Patient Control NumberT20Assigned by the facilityIP2095Filler T30Space filledIP2004Patient Sex T1M = MaleF = FemaleU = UnknownIP2005Patient Birth DateT8CCYYMMDDIP2096FillerT1IP2006Priority (Type) of Admission or VisitT1IP2007Point of Origin for Admission or VisitT1IP2097FillerT30IP2008Patient CityT15IP2009Patient StateT2IP2010Patient Zip CodeT9As defined by US Postal ServiceDo not include dashesIP2011Admission/Start of Care DateT8CCYYMMDDIP2012Admission HourT2Military Time - Range 00-23IP2098FillerT8IP2013Statement Covers Period - ThruT8CCYYMMDDIP2014Patient Discharge StatusT2IP2015Discharge HourT2Military Time - Range 00-23IP2099FillerT20IP2016Medical/Health Record NumberT17Assigned by the facilityIP2017RaceMarch 1, 2007T11 = American Indian or Alaska Native2 = Asian3 = Black or African American4 = Native Hawaiian or Other Pacific Islander5 = White6 = Other Race7 = Patient Elected not to Answer8 = UnknownThe code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.IP2018EthnicityMarch 1, 2007T11 = Hispanic or Latino2 = Non-Hispanic or Non-Latino7 = Patient Elected not to Answer8 = UnknownThe code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.IP2019FillerT1IP2020Statement Covers Period – FromJanuary 1, 2018T8CCYYMMDDIP2021Patient Country CodeJanuary 1, 2018T2Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.IP2022Patient Last NameJanuary 1, 2018T60IP2023Patient First NameJanuary 1, 2018T35IP2024Patient Middle Name or InitialJanuary 1, 2018T25IP2025Patient Name SuffixJanuary 1, 2018T10IP2026Patient Address Line 1January 1, 2018T55IP2027Patient Address Line 2January 1, 2018T55Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP3001Record TypeT230IP3002Sequence NumberT201 Primary Payer02 - 99 Secondary PayerIP3003Patient Control NumberT20Assigned by the facilityIP3095FillerJanuary 1, 2018T10IP3005Social Security NumberApril 1, 2006T19Do not include the dashesFor internal use only – Required if collectedIP3097FillerJanuary 1, 2018T26IP3007Insured’s Group NumberApril 1, 2006T17For internal use only – Required if collectedIP3008Insured’s Unique IdentifierT20Insurance policy or certificate IDIP3099FillerT1IP3009Payer NameJanuary 1, 2018T100Full or unabbreviated payer name, not plan nameData Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP4001Record TypeT240IP4002Sequence NumberT201IP4003Patient Control NumberT20Assigned by the facilityIP4004Type of BillT3Code indicating the specific type of institutional billIP4099FillerT165Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP5001Record TypeT250IP5002Sequence NumberT3001-999IP5003Patient Control NumberT20Assigned by the facilityIP5091FillerT3IP5004Accommodations Revenue Code #1T4Include leading zerosIP5092FillerT9IP5005Accommodations Service Units #1N4Right Justified, leading zerosIP5006Accommodations Total Charges #1T10Two decimal places impliedIP5093FillerT14IP5007Accommodations Revenue Code #2T4Include leading zerosIP5094FillerT9IP5008Accommodations Service Units #2N4Right Justified, leading zerosIP5009Accommodations Total Charges #2N10Two decimal places impliedIP5095FillerT14IP5010Accommodations Revenue Code #3T4Include leading zerosIP5096FillerT9IP5011Accommodations Service Units #3N4Right Justified, leading zerosIP5012Accommodations Total Charges #3N10Two decimal places impliedIP5097FillerT14IP5013Accommodations Revenue Code #4T4Include leading zerosIP5098FillerT9IP5014Accommodations Service Units #4N4Right Justified, leading zerosIP5015Accommodations Total Charges #4N10Two decimal places impliedIP5099FillerT14Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP6001Record Type T260IP6002Sequence NumberT3001 to 999IP6003Patient Control NumberT20Assigned by the facilityIP6093FillerT2IP6004Inpatient Ancillary Revenue Code #1T4Include leading zerosIP6094FillerT16IP6005Inpatient Ancillary Total Charges #1N10Two decimal places impliedIP6095FillerT25IP6006Inpatient Ancillary Revenue Code #2T4Include leading zerosIP6096FillerT16IP6007Inpatient Ancillary Total Charges #2N10Two decimal places impliedIP6097FillerT25IP6008Inpatient Ancillary Revenue Code #3T4Include leading zerosIP6098FillerT16IP6009Inpatient Ancillary Total Charge #3N10Two decimal places impliedIP6099FillerT25Data Element #Data ElementImplementation Date For New Data ElementsTypeLengthDescriptionIP7101Record Type10/1/2014T271IP7102Sequence Number10/1/2014T201IP7103Patient Control Number10/1/2014T20Assigned by facilityIP7104Principal Diagnosis10/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7105Present On Admission Indicator10/1/2014T3Standard POA code set - Left JustifiedIP7106Admitting Diagnosis10/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7107FillerT10IP7108FillerT10IP7109FillerT10IP7110Principal Procedure Code10/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7111Principal Procedure Date10/1/2014T8CCYYMMDDData Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionIP7201Record Type10/1/2014T272IP7202Sequence Number10/1/2014T201 - 03IP7203Patient Control Number10/1/2014T20Assigned by facilityIP7204Other Procedure Code - 110/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7205Other Procedure Date - 110/1/2014T8CCYYMMDDIP7206Other Procedure Code - 210/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7207Other Procedure Date - 210/1/2014T8CCYYMMDDIP7208Other Procedure Code - 310/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7209Other Procedure Date - 310/1/2014T8CCYYMMDDIP7210Other Procedure Code - 410/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7211Other Procedure Date - 410/1/2014T8CCYYMMDDIP7212Other Procedure Code - 510/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7213Other Procedure Date - 510/1/2014T8CCYYMMDDIP7214Other Procedure Code - 610/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7215Other Procedure Date - 610/1/2014T8CCYYMMDDIP7216Other Procedure Code - 710/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7217Other Procedure Date - 710/1/2014T8CCYYMMDDIP7218Other Procedure Code - 810/1/2014T10ICD-10 PCS - do not code decimal point - Left JustifiedIP7219Other Procedure Date - 810/1/2014T8CCYYMMDDData Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionIP7301Record Type10/1/2014T273IP7302Sequence Number10/1/2014T201 - 02IP7303Patient Control Number10/1/2014T20Assigned by facilityIP7304External Cause of Injury Code - 110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7305Present On Admission Indicator - 110/1/2014T3Standard POA code set - Left JustifiedIP7306External Cause of Injury Code - 210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7307Present On Admission Indicator - 210/1/2014T3Standard POA code set - Left JustifiedIP7308External Cause of Injury Code - 310/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7309Present On Admission Indicator - 310/1/2014T3Standard POA code set - Left JustifiedIP7310External Cause of Injury Code - 410/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7311Present On Admission Indicator - 410/1/2014T3Standard POA code set - Left JustifiedIP7312External Cause of Injury Code - 510/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7313Present On Admission Indicator - 510/1/2014T3Standard POA code set - Left JustifiedIP7314External Cause of Injury Code - 610/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7315Present On Admission Indicator - 610/1/2014T3Standard POA code set - Left JustifiedIP7316External Cause of Injury Code - 710/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7317Present On Admission Indicator - 710/1/2014T3Standard POA code set - Left JustifiedIP7318External Cause of Injury Code - 810/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7319Present On Admission Indicator - 810/1/2014T3Standard POA code set - Left JustifiedIP7320External Cause of Injury Code - 910/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7321Present On Admission Indicator - 910/1/2014T3Standard POA code set - Left JustifiedIP7322External Cause of Injury Code - 1010/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7323Present On Admission Indicator - 1010/1/2014T3Standard POA code set - Left JustifiedIP7324External Cause of Injury Code - 1110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7325Present On Admission Indicator - 1110/1/2014T3Standard POA code set - Left JustifiedIP7326External Cause of Injury Code - 1210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7327Present On Admission Indicator - 1210/1/2014T3Standard POA code set - Left JustifiedData Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionIP7401Record Type10/1/2014T274IP7402Sequence Number10/1/2014T201 - 02IP7403Patient Control Number10/1/2014T20Assigned by facilityIP7404Other Diagnosis Code - 110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7405Present On Admission Indicator - 110/1/2014T3Standard POA code set - Left JustifiedIP7406Other Diagnosis Code - 210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7407Present On Admission Indicator - 210/1/2014T3Standard POA code set - Left JustifiedIP7408Other Diagnosis Code - 310/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7409Present On Admission Indicator - 310/1/2014T3Standard POA code set - Left JustifiedIP7410Other Diagnosis Code - 410/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7411Present On Admission Indicator - 410/1/2014T3Standard POA code set - Left JustifiedIP7412Other Diagnosis Code - 510/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7413Present On Admission Indicator – 510/1/2014T3Standard POA code set - Left JustifiedIP7414Other Diagnosis Code - 610/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7415Present On Admission Indicator - 610/1/2014T3Standard POA code set - Left JustifiedIP7416Other Diagnosis Code - 710/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7417Present On Admission Indicator - 710/1/2014T3Standard POA code set - Left JustifiedIP7418Other Diagnosis Code - 810/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7419Present On Admission Indicator - 810/1/2014T3Standard POA code set - Left JustifiedIP7420Other Diagnosis Code - 910/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7421Present On Admission Indicator - 910/1/2014T3Standard POA code set - Left JustifiedIP7422Other Diagnosis Code - 1010/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7423Present On Admission Indicator - 1010/1/2014T3Standard POA code set - Left JustifiedIP7424Other Diagnosis Code - 1110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7425Present On Admission Indicator - 1110/1/2014T3Standard POA code set - Left JustifiedIP7426Other Diagnosis Code - 1210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedIP7427Present On Admission Indicator - 1210/1/2014T3Standard POA code set - Left JustifiedData Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP8001Record Type T280IP8002Sequence T201IP8003Patient Control NumberT20Assigned by the facilityIP8097FillerT2IP8004Attending Provider NPIApril 1, 2009T16NPI of Attending ProviderIP8005Operating Physician NPIApril 1, 2009T16NPI of Operating PhysicianIP8098FillerT32IP8006Attending Provider Last NameT16Cannot be blankIP8007Attending Provider First Name T8Cannot be blankIP8008Attending Provider Middle InitialT1IP8009Operating Physician Last NameT16Must be populated when IP8005 is populated.IP8010Operating Physician First Name T8Cannot be blank if IP8005 is populated.IP8011Operating Physician Middle InitialT1IP8099FillerT52IP8012Billing Provider NPIT16National Provider Identifier assigned to the provider submitting the bill.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP9001Record Type T290IP9002Filler (National Use)T2IP9003Patient Control NumberT20Assigned by the facilityIP9097FillerT20IP9004Total Accommodation Charges – Revenue CentersN10Must equal the sum of record type 50 revenue code dataTwo decimal places impliedIP9098FillerT10 IP9005Total Ancillary Charges – Revenue CentersN10Must equal the sum of record type 60 revenue code dataTwo decimal places impliedIP9099Filler T118Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesIP9901Record TypeT299IP9999FillerT190Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP0101Record TypeNANAIP0102MHDO-Assigned Hospital ID NANAIP0103Hospital Name1837/2010AA/NM1/85/2/03IP0104Address1837/2010AA/N3/01 IP0105City1837/2010AA/N4/01 IP0106State1837/2010AA/N4/02 IP0107Zip Code1837/2010AA/N4/03 IP0108Version NANAData Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP2001Record Type NANAIP2003Patient Control Number3A837/2300/CLM/01IP2004Patient Sex 11837/2010CA/DMG/03837/2010BA/DMG/03IP2005Patient Birth Date10837/2010CA/DMG/D8/02837/2010BA/DMG/D8/02IP2006Priority (Type) of Admission or Visit14837/2300/CL1/01IP2007Point of Origin for Admission or Visit15837/2300/CL1/02IP2008Patient City9B837/2010CA/N4/01837/2010BA/N4/01IP2009Patient State9C837/2010CA/N4/02837/2010BA/N4/02IP2010Patient Zip Code9D837/2010CA/N4/03837/2010BA/N4/03IP2011Admission/Start of Care Date12837/2300/DTP/435/DT/03IP2012Admission Hour13837/2300/DTP/435/DT/03IP2013Statement Covers Period Thru6837/2300/DTP/434/RD8/03 IP2014Patient Discharge Status17837/2300/CL1/03IP2015Discharge Hour16837/2300/DTP/096/TM/03IP2016Medical/Health Record Number3B837/2300/REF/EA/02IP2017RaceNA837/2010CA/DMG/05837/2010BA/DMG/05IP2018EthnicityNA837/2010CA/DMG/05837/2010BA/DMG/05IP2020Statement Covers Period – From6837/2300/DTP/434/RD8/03IP2021Patient Country Code9E837/2010CA/N4/04837/2010BA/N4/04IP2022Patient Last Name8B837/2010CA/NM1/QC/1/03837/2010BA/NM1/IL/1/03IP2023Patient First Name8B837/2010CA/NM1/QC/1/04837/2010BA/NM1/IL/1/04IP2024Patient Middle Name or Initial8B837/2010CA/NM1/QC/1/05837/2010BA/NM1/IL/1/05IP2025Patient Name Suffix8B837/2010CA/NM1/QC/1/07837/2010BA/NM1/IL/1/07IP2026Patient Address Line 19A837/2010CA/N3/01837/2010BA/N3/01IP2027Patient Address Line 29A837/2010CA/N3/02837/2010BA/N3/02Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP3001Record TypeNANAIP3002Sequence NumberNA837/2000B/SBR/01IP3003Patient Control Number3A837/2300/CLM/01IP3005Social Security NumberNANAIP3007Insured’s Group Number (Primary)62A837/2000B/SBR/P/03?Insured’s Group Number (Secondary)62B837/2320A/SBR/S/03IP3008Insured’s Unique Identifier (Primary)60A837/2010BA/NM1/MI/09Insured’s Unique Identifier (Secondary)60B837/2330A/NM1/MI/09IP3009Payer Name (Primary)50A837/2010BB/NM1/PR/2/03Payer Name (Secondary)50B837/2330B/NM1/PR/2/03Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP4001Record TypeNANAIP4002Sequence NumberNANAIP4003Patient Control Number3A837/2300/CLM/01IP4004Type of Bill4837/2300/CLM/05-1837/2300/CLM/05-3Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP5001Record TypeNANAIP5002Sequence NumberNANAIP5003Patient Control Number3A837/2300/CLM/01IP5004Accommodations Revenue Code - 142837/2400/SV2/01IP5005Accommodations Service Units - 146837/2400/SV2/DA/05IP5006Accommodations Total Charges - 147837/2400/SV2/03IP5007Accommodations Revenue Code - 242837/2400/SV2/01IP5008Accommodations Service Units - 246837/2400/SV2/DA/05IP5009Accommodations Total Charges - 247837/2400/SV2/03IP5010Accommodations Revenue Code - 342837/2400/SV2/01IP5011Accommodations Service Units - 346837/2400/SV2/DA/05IP5012Accommodations Total Charges - 347837/2400/SV2/03IP5013Accommodations Revenue Code - 442837/2400/SV2/01IP5014Accommodations Service Units - 446837/2400/SV2/DA/05IP5015Accommodations Total Charges - 447837/2400/SV2/03Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP6001Record Type NANA?IP6002Sequence NumberNANA?IP6003Patient Control Number3A837/2300/CLM/01IP6004Inpatient Ancillary Revenue Code - 142837/2400/SV2/01IP6005Inpatient Ancillary Total Charges - 147837/2400/SV2/03IP6006Inpatient Ancillary Revenue Code - 242837/2400/SV2/01IP6007Inpatient Ancillary Total Charges - 247837/2400/SV2/03IP6008Inpatient Ancillary Revenue Code - 342837/2400/SV2/01IP6009Inpatient Ancillary Total Charges - 347837/2400/SV2/03Data Element #Data Element NameUB-04Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP7101Record TypeNANAIP7102Sequence NumberNANAIP7103Patient Control Number3A837/2300/CLM/01IP7104Principal Diagnosis67837/2300/HI/ABK/01-2IP7105Present On Admission Indicator67 (pos 8)837/2300/HI/01-9IP7106Admitting Diagnosis69837/2300/HI/ABJ/01-2IP7110Principal Procedure Code74837/2300/HI/BBR/01-2IP7111Principal Procedure Date74837/2300/HI/D8/01-4Data Element #Data Element NameUB-04Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP7201Record TypeNANAIP7202Sequence NumberNANAIP7203Patient Control Number3A837/2300/CLM/01IP7204Other Procedure Code - 174A837/2300/HI/BBQ/01-2IP7205Other Procedure Date - 174A837/2300/HI/D8/01-4IP7206Other Procedure Code - 274B837/2300/HI/BBQ/02-2IP7207Other Procedure Date - 274B837/2300/HI/D8/02-4IP7208Other Procedure Code - 374C837/2300/HI/BBQ/03-2IP7209Other Procedure Date - 374C837/2300/HI/D8/03-4IP7210Other Procedure Code - 474D837/2300/HI/BBQ/04-2IP7211Other Procedure Date - 474D837/2300/HI/D8/04-4IP7212Other Procedure Code - 574E837/2300/HI/BBQ/05-2IP7213Other Procedure Date - 574E837/2300/HI/D8/05-4IP7214Other Procedure Code - 6NA837/2300/HI/BBQ/06-2IP7215Other Procedure Date - 6NA837/2300/HI/D8/06-4IP7216Other Procedure Code - 7NA837/2300/HI/BBQ/07-2IP7217Other Procedure Date - 7NA837/2300/HI/D8/07-4IP7218Other Procedure Code - 8NA837/2300/HI/BBQ/08-2IP7219Other Procedure Date - 8NA837/2300/HI/D8/08-4Data Element #Data Element NameUB-04Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP7301Record TypeNANAIP7302Sequence NumberNANAIP7303Patient Control Number3A837/2300/CLM/01IP7304External Cause of Injury Code - 172A837/2300/HI/ABN/01-2IP7305Present On Admission Indicator - 172A (pos 8)837/2300/HI/01-9IP7306External Cause of Injury Code - 272B837/2300/HI/ABN/02-2IP7307Present On Admission Indicator - 272B (pos 8)837/2300/HI/02-9IP7308External Cause of Injury Code - 372C837/2300/HI/ABN/03-2IP7309Present On Admission Indicator - 372C (pos 8)837/2300/HI/03-9IP7310External Cause of Injury Code - 4NA837/2300/HI/ABN/04-2IP7311Present On Admission Indicator - 4NA837/2300/HI/04-9IP7312External Cause of Injury Code - 5NA837/2300/HI/ABN/05-2IP7313Present On Admission Indicator - 5NA837/2300/HI/05-9IP7314External Cause of Injury Code - 6NA837/2300/HI/ABN/06-2IP7315Present On Admission Indicator - 6NA837/2300/HI/06-9IP7316External Cause of Injury Code - 7NA837/2300/HI/ABN/07-2IP7317Present On Admission Indicator - 7NA837/2300/HI/07-9IP7318External Cause of Injury Code - 8NA837/2300/HI/ABN/08-2IP7319Present On Admission Indicator - 8NA837/2300/HI/08-9IP7320External Cause of Injury Code - 9NA837/2300/HI/ABN/09-2IP7321Present On Admission Indicator - 9NA837/2300/HI/09-9IP7322External Cause of Injury Code - 10NA837/2300/HI/ABN/10-2IP7323Present On Admission Indicator - 10NA837/2300/HI/10-9IP7324External Cause of Injury Code - 11NA837/2300/HI/ABN/11-2IP7325Present On Admission Indicator - 11NA837/2300/HI/11-9IP7326External Cause of Injury Code - 12NA837/2300/HI/ABN/12-2IP7327Present On Admission Indicator - 12NA837/2300/HI/12-9Data Element #Data Element NameUB-04Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP7401Record TypeNANAIP7402Sequence NumberNANAIP7403Patient Control Number3A837/2300/CLM/01IP7404Other Diagnosis Code - 167A837/2300/HI/ABF/01-2IP7405Present On Admission Indicator - 167A (pos 8)837/2300/HI/01-9IP7406Other Diagnosis Code - 267B837/2300/HI/ABF/02-2IP7407Present On Admission Indicator - 267B (pos 8)837/2300/HI/02-9IP7408Other Diagnosis Code - 367C837/2300/HI/ABF/03-2IP7409Present On Admission Indicator - 367C (pos 8)837/2300/HI/03-9IP7410Other Diagnosis Code - 467D837/2300/HI/ABF/04-2IP7411Present On Admission Indicator - 467D (pos 8)837/2300/HI/04-9IP7412Other Diagnosis Code - 567E837/2300/HI/ABF/05-2IP7413Present On Admission Indicator - 567E (pos 8)837/2300/HI/05-9IP7414Other Diagnosis Code - 667F837/2300/HI/ABF/06-2IP7415Present On Admission Indicator - 667F (pos 8)837/2300/HI/06-9IP7416Other Diagnosis Code - 767G837/2300/HI/ABF/07-2IP7417Present On Admission Indicator - 767G (pos 8)837/2300/HI/07-9IP7418Other Diagnosis Code - 867H837/2300/HI/ABF/08-2IP7419Present On Admission Indicator - 867H (pos 8)837/2300/HI/08-9IP7420Other Diagnosis Code - 967I837/2300/HI/ABF/09-2IP7421Present On Admission Indicator - 967I (pos 8)837/2300/HI/09-9IP7422Other Diagnosis Code - 1067J837/2300/HI/ABF/10-2IP7423Present On Admission Indicator - 1067J (pos 8)837/2300/HI/10-9IP7424Other Diagnosis Code - 1167K837/2300/HI/ABF/11-2IP7425Present On Admission Indicator - 1167K (pos 8)837/2300/HI/11-9IP7426Other Diagnosis Code - 1267L837/2300/HI/ABF/12-2IP7427Present On Admission Indicator - 1267L (pos 8)837/2300/HI/12-9Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP8001Record Type NANAIP8002Sequence NANAIP8003Patient Control Number3A837/2300/CLM/01IP8004Attending Provider NPI76837/2310A/NM1/71/1/XX/09IP8005Operating Physician NPI77837/2310B/NM1/72/1/XX/09IP8006Attending Provider Last Name76837/2310A/NM1/71/1/03IP8007Attending Provider First Name 76837/2310A/NM1/71/1/04IP8008Attending Provider Middle Initial76837/2310A/NM1/71/1/05IP8009Operating Physician Last Name77837/2310B/NM1/72/1/03IP8010Operating Physician First Name 77837/2310B/NM1/72/1/04IP8011Operating Physician Middle Initial77837/2310B/NM1/72/1/05IP8012Billing Provider NPI56837/2010AA/NM1/XX/09Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP9001Record Type NANAIP9003Patient Control Number3A837/2300/CLM/01IP9004Total Accommodation Charges - Revenue CentersNAThis is the total of the SV2 segments except for Revenue Code 0001IP9005Total Ancillary Charges - Revenue CentersNAThis is the total of the SV2 segments except for Revenue Code 0001Data Element #Data Element NameUB-04 Form LocatorHIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorIP9901Record TypeNANAThe record types in the file must be in the following order:Record Type 01 – Processor Data Record Type 20 Sequence 01 – Patient Data Record Type 30 Sequence 01 – Third Party Payer Data Primary Payer Record Type 30 Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary.Record Type 40 – Claim Data Record Type 61 – Services Record Type 71 – ICD-10 CM Principal and Reason for Visit Diagnosis Codes, ICD-10 PCS Principal Procedure CodeRecord Type 72 – ICD-10 PCS Other Procedure CodesRecord Type 73 – ICD-10 CM External Cause of Injury Diagnosis CodesRecord Type 74 – ICD-10 CM Other Diagnosis InformationRecord Type 80 – Provider Data Record Type 90 – Claim Control Screen Record Type 99 – File Control The individual claim begins with Record Type 20 and ends with Record Type 90.The patient control number must be the same on each record type generated for a single patient record.The medical record number should not be substituted for the patient control number.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP0101Record TypeT201OP0102MHDO-Assigned Hospital ID T6Must be the MHDO-assigned, 6-digit hospital code, left justifiedOP0198FillerT38OP0103Hospital NameT21OP0104AddressT18OP0105CityT15OP0106StateT2OP0107Zip CodeT9OP0199FillerT78OP0108VersionT3Leave blankData Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP2001Record Type T220OP2002Filler (National Use)T2OP2003Patient Control NumberT20Assigned by the facilityOP2094Filler T30OP2004Patient Sex T1M = MaleF = FemaleU = UnknownOP2005Patient Birth DateT8CCYYMMDDOP2095FillerT2OP2007Point of Origin for Admission or VisitT1OP2096FillerT30OP2008Patient CityT15OP2009Patient StateT2OP2010Patient Zip CodeT9As defined by US Postal ServiceDo not include dashesOP2011Admission/Start of Care DateT8CCYYMMDDOP2097FillerT2OP2012Statement Covers Period – FromT8The beginning service date for the period covered on the record CCYYMMDDOP2013Statement Covers Period – ThruT8The ending service date for the period covered on the record CCYYMMDDOP2014Patient Discharge StatusT2OP2098FillerT22OP2015Medical/Health Record NumberT17Assigned by the facilityOP2016RaceMarch 1, 2007T11 = American Indian or Alaska Native2 = Asian3 = Black or African American4 = Native Hawaiian or Other Pacific Islander5 = White6 = Other Race7 = Patient Elected Not to Answer8 = UnknownThe code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.OP2017EthnicityMarch 1, 2007T11 = Hispanic or Latino2 = Non-Hispanic or Non-Latino7 = Patient Elected Not to Answer8 = UnknownThe code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.OP2099FillerT1OP2018Patient Country CodeJanuary 1, 2018T2Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.OP2019Patient Last NameJanuary 1, 2018T60OP2020Patient First NameJanuary 1, 2018T35OP2021Patient Middle Name or InitialJanuary 1, 2018T25OP2022Patient Name SuffixJanuary 1, 2018T10OP2023Patient Address Line 1January 1, 2018T55OP2024Patient Address Line 2January 1, 2018T55Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP3001Record TypeT230OP3002Sequence NumberT201 Primary Payer02 - 99 Secondary PayerOP3003Patient Control NumberT20Assigned by the facilityOP3095FillerJanuary 1, 2018T10OP3005Social Security NumberApril 1, 2006T19Do not include dashesFor internal use only – Required if collectedOP3097FillerJanuary 1, 2018T26OP3007Insured’s Group NumberApril 1, 2006T17For internal use only – Required if collectedOP3008Insured’s Unique IdentifierT20For internal use only – Required if collectedOP3099FillerT1OP3009Payer NameJanuary 1, 2018T100Full or unabbreviated payer name, not plan nameData Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP4001Record TypeT240OP4002Sequence NumberT201OP4003Patient Control NumberT20Assigned by the facilityOP4004Type of BillT3Code indicating the specific type of institutional bill. OP4005Location of ServiceT10When Place of Service field OP4006 contains the values 11, 17, 20, 22, 49, 50, 71, or 72 an encounter shall contain a Location of Service code. The Location of Service code is internally created by the Hospital and primarily for physician practices (primary care, specialty care and clinics). Refer to section 2(A)(3).OP4099FillerT155OP4006Place of ServiceJanuary 1, 2018T2CMS code identifying the entity/location where professional service(s) were rendered.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP6101Record Type T261OP6102Sequence NumberT3001 to 999OP6103Patient Control NumberT20Assigned by the facilityOP6190FillerT2OP6104Revenue Center Code - 1T4Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.OP6105HCPCS Procedure Code - 1T5Health Care Common Procedural Coding System (HCPCS)This includes the CPT code of the American Medical AssociationOP6106Modifier – 1 (HCPCS & CPT-4) - 1T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6107Modifier – 2 (HCPCS & CPT-4) - 1T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6108Service Units - 1N7A quantitative measure of services rendered by the Revenue CenterOP6191FillerT6OP6109Outpatient Total Charges - 1N10Negative charges not acceptedTwo decimal places impliedOP6192FillerT10OP6110Service Date - 1T8The date that the indicated outpatient service, supplies, etc. were provided.Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru”. CCYYMMDDOP6193FillerT1OP6111Revenue Center Code - 2T4Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.OP6112HCPCS Procedure Code - 2T5Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical AssociationOP6113Modifier – 1 (HCPCS & CPT-4) - 2T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6114Modifier – 2 (HCPCS & CPT-4) - 2T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6115Service Units - 2N7A quantitative measure of services rendered by the Revenue CenterOP6194FillerT6OP6116Outpatient Total Charges - 2N10Negative charges not acceptedTwo decimal places impliedOP6195FillerT10OP6117Service Date - 2T8The date that the indicated outpatient service, supplies, etc. were provided.Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru” CCYYMMDDOP6196FillerT1OP6118Revenue Center Code - 3T4Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.OP6119HCPCS Procedure Code - 3T5Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical AssociationOP6120Modifier – 1 (HCPCS & CPT-4) - 3T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6121Modifier – 2 (HCPCS & CPT-4) - 3T2Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure codeOP6122Service Units - 3N7A quantitative measure of services rendered by the Revenue CenterOP6197FillerT6OP6123Outpatient Total Charges - 3N10Negative charges not acceptedTwo decimal places impliedOP6198FillerT10OP6124Service Date - 3T8The date that the indicated outpatient service, supplies, etc. were provided.Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru” CCYYMMDDOP6199FillerT1OP6125Place of Service - 1January 1, 2020T2CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006OP6126Rendering Provider NPI – 1January 1, 2020T16National Provider Identifier for Rendering Provider, the individual providing the service.OP6127Place of Service - 2January 1, 2020T2CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006OP6128Rendering Provider NPI - 2January 1, 2020T16National Provider Identifier for Rendering Provider, the individual providing the service.OP6129Place of Service - 3January 1, 2020T2CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006OP6130Rendering Provider NPI - 3January 1, 2020T16National Provider Identifier for Rendering Provider, the individual providing the service.Sequence numbers go from 001 to 999 with 3 revenue centers on each physical record makes it possible to have 2,997 revenue centers on a single logical record. If revenue center code “0001” is utilized to report the total of all the line item charges, it must be entered on the last revenue center field. The value for revenue code 0001 must equal the total ancillary charges reported on record type 90 and must equal the summation of all line item charges reported on the logical record.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP7101Record Type10/1/2014T271OP7102Sequence Number10/1/2014T201OP7103Patient Control Number10/1/2014T20Assigned by facilityOP7104Principal Diagnosis10/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7105FillerT3OP7106FillerT10OP7107Reason for Visit Diagnosis - 110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7108Reason for Visit Diagnosis - 210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7109Reason for Visit Diagnosis - 310/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7110Principal Procedure Code10/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7111Principal Procedure Date10/1/2014T8CCYYMMDDData Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionOP7201Record Type10/1/2014T272OP7202Sequence Number10/1/2014T201 - 03OP7203Patient Control Number10/1/2014T20Assigned by facilityOP7204Other Procedure Code - 110/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7205Other Procedure Date - 110/1/2014T8CCYYMMDDOP7206Other Procedure Code - 210/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7207Other Procedure Date - 210/1/2014T8CCYYMMDDOP7208Other Procedure Code - 310/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7209Other Procedure Date - 310/1/2014T8CCYYMMDDOP7210Other Procedure Code - 410/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7211Other Procedure Date - 410/1/2014T8CCYYMMDDOP7212Other Procedure Code - 510/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7213Other Procedure Date - 510/1/2014T8CCYYMMDDOP7214Other Procedure Code - 610/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7215Other Procedure Date - 610/1/2014T8CCYYMMDDOP7216Other Procedure Code - 710/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7217Other Procedure Date - 710/1/2014T8CCYYMMDDOP7218Other Procedure Code - 810/1/2014T10If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here.ICD-10 PCS - do not code decimal point - Left JustifiedOP7219Other Procedure Date - 810/1/2014T8CCYYMMDDData Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionOP7301Record Type10/1/2014T273OP7302Sequence Number10/1/2014T201 - 02OP7303Patient Control Number10/1/2014T20Assigned by facilityOP7304External Cause of Injury - 110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7305FillerT3OP7306External Cause of Injury - 210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7307FillerT3OP7308External Cause of Injury - 310/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7309FillerT3OP7310External Cause of Injury - 410/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7311FillerT3OP7312External Cause of Injury - 510/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7313FillerT3OP7314External Cause of Injury - 610/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7315FillerT3OP7316External Cause of Injury - 710/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7317FillerT3OP7318External Cause of Injury - 810/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7319FillerT3OP7320External Cause of Injury - 910/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7321FillerT3OP7322External Cause of Injury - 1010/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7323FillerT3OP7324External Cause of Injury - 1110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7325FillerT3OP7326External Cause of Injury - 1210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7327FillerT3Data Element #Data Element NameImplementation Date For New Data ElementsTypeLengthDescriptionOP7401Record Type10/1/2014T274OP7402Sequence Number10/1/2014T201 - 02OP7403Patient Control Number10/1/2014T20Assigned by facilityOP7404Other Diagnosis Code - 110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7405FillerT3OP7406Other Diagnosis Code - 210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7407FillerT3OP7408Other Diagnosis Code - 310/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7409FillerT3OP7410Other Diagnosis Code - 410/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7411FillerT3OP7412Other Diagnosis Code - 510/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7413FillerT3OP7414Other Diagnosis Code - 610/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7415FillerT3OP7416Other Diagnosis Code - 710/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7417FillerT3OP7418Other Diagnosis Code - 810/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7419FillerT3OP7420Other Diagnosis Code - 910/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7421FillerT3OP7422Other Diagnosis Code - 1010/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7423FillerT3OP7424Other Diagnosis Code - 1110/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7425FillerT3OP7426Other Diagnosis Code - 1210/1/2014T10ICD-10 CM - do not code decimal point - Left JustifiedOP7427FillerT3Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP8001Record Type T280OP8002Sequence T201OP8003Patient Control NumberT20Assigned by the facilityOP8097FillerT2OP8004Attending Provider NPIT16NPI of Attending Provider; Attending provider is located on UB-04OP8005Operating Physician NPIT16NPI of Operating Physician; Operating physician is located on UB-04.OP8098FillerT32OP8006Attending Provider Last NameT16Cannot be blank if OP8004 is present on a facility/institutional claim.OP8007Attending Provider First Name T8Cannot be blank if OP8004 is present on a facility/institutional claim.OP8008Attending Provider Middle InitialT1OP8009Operating Physician Last NameT16Must be populated when OP8005 is populated.OP8010Operating Physician First Name T8Cannot be blank if OP8005 is populated.OP8011Operating Physician Middle InitialT1OP8099FillerT52OP8012Billing Provider NPIT16National Provider Identifier assigned to the provider submitting the bill.Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP9001Record Type T290OP9002Filler (National Use)T2OP9003Patient Control NumberT20Assigned by the facilityOP9098FillerT40OP9004Total Ancillary Charges - Revenue CentersN10Must equal the sum of line item charges excluding revenue center code 0001 if present. Two decimal positions impliedOP9099Filler T118Data Element #Data ElementImplementation Date for New Data ElementsTypeLengthDescription/Codes/SourcesOP9901Record TypeT299OP9998FillerT190Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP0101Record TypeNANANAOP0102MHDO-Assigned Hospital IDNANANAOP0103Hospital Name133837/2010AA/NM1/85/2/03OP0104Address133837/2010AA/N3/01 OP0105City133837/2010AA/N4/01 OP0106State133837/2010AA/N4/02 OP0107Zip Code133837/2010AA/N4/03 OP0108Version NANANAData Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP2001Record Type NANANAOP2003Patient Control Number3A26837/2300/CLM/01OP2004Patient Sex 113837/2010CA/DMG/03 or837/2010BA/DMG/03OP2005Patient Birth Date103837/2010CA/DMG/D8/02 or837/2010BA/DMG/D8/02OP2007Point of Origin for Admission or Visit15NA837/2300/CL1/02OP2008Patient City9B5837/2010CA/N4/01 or837/2010BA/N4/01OP2009Patient State9C5837/2010CA/N4/02837/2010BA/N4/02OP2010Patient Zip Code9D5837/2010CA/N4/03837/2010BA/N4/03OP2011Admission/Start of Care Date12NA837/2300/DTP/435/D8/03OP2012Statement Covers Period - From624A837I/2300/DTP/434/RD8/03837P/2400/DTP/472/RD8/03OP2013Statement Covers Period - Thru624A837I/2300/DTP/434/RD8/03837P/2400/DTP/472/RD8/03OP2014Patient Discharge Status17NA837/2300/CL1/03OP2015Medical/Health Record Number3BNA837/2300/REF/EA/02OP2016RaceNANA837/2010CA/DMG/05OP2017EthnicityNANA837/2010CA/DMG/05OP2018Patient Country Code9ENA837/2010CA/N4/04837/2010BA/N4/04OP2019Patient Last Name8B2837/2010CA/NM1/QC/1/03837/2010BA/NM1/IL/1/03OP2020Patient First Name8B2837/2010CA/NM1/QC/1/04837/2010BA/NM1/IL/1/04OP2021Patient Middle Name or Initial8B2837/2010CA/NM1/QC/1/05837/2010BA/NM1/IL/1/05OP2022Patient Name Suffix8B2837/2010CA/NM1/QC/1/07837/2010BA/NM1/IL/1/07OP2023Patient Address Line 19A5837/2010CA/N3/01837/2010BA/N3/01OP2024Patient Address Line 29A5837/2010CA/N3/02837/2010BA/N3/02Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP3001Record TypeNANANAOP3002Sequence NumberNANA837/2000B/SBR/01OP3003Patient Control Number3A26837/2300/CLM/01OP3005Social Security NumberNANANAOP3007Insured’s Group Number (Primary)62A11837/2000B/SBR/P/03?Insured’s Group Number (Secondary)62B9A837/2320/SBR/S/03OP3008Insured’s Unique Identifier (Primary)60A1A837/2010BA/NM1/MI/09Insured’s Unique Identifier (Secondary)60BNA837/2330A/NM1/MI/09OP3009Payer Name (Primary)50AHeader/Carrier Block837/2010BB/NM1/PR/2/03?Payer Name (Secondary)50BHeader/Carrier Block837/2330B/NM1/PR/2/03Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP4001Record TypeNANANAOP4002Sequence NumberNANANAOP4003Patient Control Number3A26837/2300/CLM/01OP4004Type of Bill4NA837/2300/CLM/A/05-1837/2300/CLM/05-3OP4005Location of ServiceNANAHospital designated code when Place of Service field OP4006 is 11, 17, 20, 22, 49, 50, 71 or 72. Primarily for physician practices (primary care, specialty care and clinics).OP4006Place of ServiceNA24B837/2300/CLM/05-1Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP6101Record Type NANANAOP6102Sequence NumberNANANAOP6103Patient Control Number3A26837/2300/CLM/01OP6104Revenue Center Code - 142NA837/2400/SV2/01OP6105HCPCS Procedure Code - 14424D-1837I/2400/SV2/HC/02-2837P/2400/SV1/HC/01-2OP6106Modifier - 1 (HCPCS & CPT-4) - 14424D-1837I/2400/SV2/HC/02-3837P/2400/SV1/HC/01-3OP6107Modifier - 2 (HCPCS & CPT-4) - 14424D-1837I/2400/SV2/HC/02-4837P/2400/SV1/HC/01-4OP6108Service Units - 14624G-1837I/2400/SV2/DA/05837I/2400/SV2/UN/05837P/2400/SV1/UN/04OP6109Outpatient Total Charges - 14724F-1837I/2400/SV2/03837P/2400/SV1/02OP6110Service Date - 14524A-1837/2400/DTP/472/D8/03OP6111Revenue Center Code - 242NA837/2400/SV2/01OP6112HCPCS Procedure Code - 24424D-2837I/2400/SV2/HC/02-2837P/2400/SV1/HC/01-2OP6113Modifier - 1 (HCPCS & CPT-4) - 24424D-2837I/2400/SV2/HC/02-3837P/2400/SV1/HC/01-3OP6114Modifier - 2 (HCPCS & CPT-4) - 24424D-2837I/2400/SV2/HC/02-4837P/2400/SV1/HC/01-4OP6115Service Units - 24624G-2837I/2400/SV2/DA/05837I/2400/SV2/UN/05837P/2400/SV1/UN/04OP6116Outpatient Total Charges - 24724F-2837I/2400/SV2/03837P/2400/SV1/02OP6117Service Date - 24524A-2837/2400/DTP/472/D8/03OP6118Revenue Center Code - 342NA837/2400/SV2/01OP6119HCPCS Procedure Code - 34424D-3837I/2400/SV2/HC/02-2837P/2400/SV1/HC/01-2OP6120Modifier - 1 (HCPCS & CPT-4) - 34424D-3837I/2400/SV2/HC/02-3837P/2400/SV1/HC/01-3OP6121Modifier - 2 (HCPCS & CPT-4) - 34424D-3837I/2400/SV2/HC/02-4837P/2400/SV1/HC/01-4OP6122Service Units - 34624G-3837I/2400/SV2/DA/05837I/2400/SV2/UN/05837P/2400/SV1/UN/04OP6123Outpatient Total Charges - 34724F-3837I/2400/SV2/03837P/2400/SV1/02OP6124Service Date - 34524A-3837/2400/DTP/472/D8/03OP6125Place of Service - 1NA24B837/2400/SV1/05OP6126Rendering Provider NPI - 1NA24J837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09OP6127Place of Service - 2NA24B837/2400/SV1/05OP6128Rendering Provider NPI - 2NA24J837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09OP6129Place of Service - 3NA24B837/2400/SV1/05OP6130Rendering Provider NPI - 3NA24J837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP7101Record TypeNANANAOP7102Sequence NumberNANANAOP7103Patient Control Number3A26837/2300/CLM/01OP7104Principal Diagnosis6721A837/2300/HI/ABK/01-2OP7107Reason for Visit Diagnosis - 170ANA837/2300/HI/APR/01-2OP7108Reason for Visit Diagnosis - 270BNA837/2300/HI/APR/02-2OP7109Reason for Visit Diagnosis - 370CNA837/2300/HI/APR/03-2OP7110Principal Procedure Code74NA837/2300/HI/BBR/01-2OP7111Principal Procedure Date74NA837/2300/HI/D8/01-4Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP7201Record TypeNANANAOP7202Sequence NumberNANANAOP7203Patient Control Number3A26837/2300/CLM/01OP7204Other Procedure Code - 174ANA837/2300/HI/BBQ/01-2OP7205Other Procedure Date - 174ANA837/2300/HI/D8/01-4OP7206Other Procedure Code - 274BNA837/2300/HI/BBQ/02-2OP7207Other Procedure Date - 274BNA837/2300/HI/D8/02-4OP7208Other Procedure Code - 374CNA837/2300/HI/BBQ/03-2OP7209Other Procedure Date - 374CNA837/2300/HI/D8/03-4OP7210Other Procedure Code - 474DNA837/2300/HI/BBQ/04-2OP7211Other Procedure Date - 474DNA837/2300/HI/D8/04-4OP7212Other Procedure Code - 574ENA837/2300/HI/BBQ/05-2OP7213Other Procedure Date - 574ENA837/2300/HI/D8/05-4OP7214Other Procedure Code - 6NANA837/2300/HI/BBQ/06-2OP7215Other Procedure Date - 6NANA837/2300/HI/D8/06-4OP7216Other Procedure Code - 7NANA837/2300/HI/BBQ/07-2OP7217Other Procedure Date - 7NANA837/2300/HI/D8/07-4OP7218Other Procedure Code - 8NANA837/2300/HI/BBQ/08-2OP7219Other Procedure Date - 8NANA837/2300/HI/D8/08-4Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP7301Record TypeNANANAOP7302Sequence NumberNANANAOP7303Patient Control Number3A26837/2300/CLM/01OP7304External Cause of Injury - 172ANA837/2300/HI/ABN/01-2OP7306External Cause of Injury - 272BNA837/2300/HI/ABN/02-2OP7308External Cause of Injury - 372CNA837/2300/HI/ABN/03-2OP7310External Cause of Injury - 4NANA837/2300/HI/ABN/04-2OP7312External Cause of Injury - 5NANA837/2300/HI/ABN/05-2OP7314External Cause of Injury - 6NANA837/2300/HI/ABN/06-2OP7316External Cause of Injury - 7NANA837/2300/HI/ABN/07-2OP7318External Cause of Injury - 8NANA837/2300/HI/ABN/08-2OP7320External Cause of Injury - 9NANA837/2300/HI/ABN/09-2OP7322External Cause of Injury - 10NANA837/2300/HI/ABN/10-2OP7324External Cause of Injury - 11NANA837/2300/HI/ABN/11-2OP7326External Cause of Injury - 12NANA837/2300/HI/ABN/12-2Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP7401Record TypeNANANAOP7402Sequence NumberNANANAOP7403Patient Control Number3A26837/2300/CLM/01OP7404Other Diagnosis Code - 167A21B837I/2300/HI/ABF/01-2837P/2300/HI/ABF/02-2OP7406Other Diagnosis Code - 267B21C837I/2300/HI/ABF/02-2837P/2300/HI/ABF/03-2OP7408Other Diagnosis Code - 367C21D837I/2300/HI/ABF/03-2837P/2300/HI/ABF/04-2OP7410Other Diagnosis Code - 467D21E837I/2300/HI/ABF/04-2837P/2300/HI/ABF/05-2OP7412Other Diagnosis Code - 567E21F837I/2300/HI/ABF/05-2837P/2300/HI/ABF/06-2OP7414Other Diagnosis Code - 667F21G837I/2300/HI/ABF/06-2837P/2300/HI/ABF/07-2OP7416Other Diagnosis Code - 767G21H837I/2300/HI/ABF/07-2837P/2300/HI/ABF/08-2OP7418Other Diagnosis Code - 867H21I837I/2300/HI/ABF/08-2837P/2300/HI/ABF/09-2OP7420Other Diagnosis Code - 967I21J837I/2300/HI/ABF/09-2837P/2300/HI/ABF/10-2OP7422Other Diagnosis Code - 1067J21K837I/2300/HI/ABF/10-2837P/2300/HI/ABF/11-2OP7424Other Diagnosis Code - 1167K21L837I/2300/HI/ABF/11-2837P/2300/HI/ABF/12-2OP7426Other Diagnosis Code - 1267LNA837I/2300/HI/ABF/12-2Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP8001Record Type NANANAOP8002Sequence NANANAOP8003Patient Control Number3A26837/2300/CLM/01OP8004Attending Provider NPI76NA837/2310A/NM1/71/1/XX/09OP8005Operating Physician NPI77NA837/2310B/NM1/72/1/XX/09OP8006Attending Provider Last Name76NA837/2310A/NM1/71/1/03OP8007Attending Provider First Name 76NA837/2310A/NM1/71/1/04OP8008Attending Provider Middle Initial76NA837/2310A/NM1/71/1/05OP8009Operating Physician Last Name77NA837/2310B/NM1/72/1/03OP8010Operating Physician First Name 77NA837/2310B/NM1/72/1/04OP8011Operating Physician Middle Initial77NA837/2310B/NM1/72/1/05OP8012Billing Provider NPI56NA837/2010AA/NM1/XX/09Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP9001Record Type NANANAOP9003Patient Control Number3A26837/2300/CLM/01OP9004Total Ancillary Charges - Revenue CentersNA28This is the total of the SV2 segments with the exception of Revenue Code 0001Data Element #Data Element NameUB-04 Form LocatorCMS-1500HIPAA Reference ASC X12N/005010A1Transaction Set/Loop/Segment ID/Code Value/Reference DesignatorOP9901Record TypeNANANA ................
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