Compilation of edits for priority fields by state

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Compilation of edits for priority fields by state Powered By Docstoc
					DATA ELEMENTS                                         Edit                                   UB Form Locator   X12 Reference

Provider Information

Service Provider Name                                 UB Defined                             FL 1
Service Provider Identification Number                HIPAA NPI                              FL 1




Patient Information

Patient's Last Name                                   X12 Defined
Patient's First Name                                  X12 Defined
Patient's Middle Name                                 X12 Defined
Patient Control Number                                UB Defined                             FL 03
Medical Record Number                                 UB Defined                             FL 23
Unique Personal Identifier / Social Security Number   State Specific Edit




Patient's Race                                        Validated from Master List or
                                                      refomating of that list to fit state
                                                      needs




                                                      Page 1 of 24
Patient's Ethnicity                                    Validated from Master List or
                                                       refomating of that list to fit state
                                                       needs
Patient Address Line 1                                 X12 Defined
Patient Address Line 2                                 X12 Defined
Patient's City                                         X12 Defined
Patient's County Code                                  Validated from local county list or national
                                                       FIPS file
Patient's State                                        Standard US Postal Codes                       FL 13      X12 Code Source 22
Patient's Postal Service Zip Code and Extension Code   Validtation with US Postal or                             X12 Code Source 51
                                                       Universal Postal Code lists                               & Code Source 932




Patient Sex                                            X12 & UB Defined                               FL 15      X12 DE 1068
Patient Birthdate                                      Date Edit
Newborn Birth Weight                                   UB Value Code value                            FL 39-41
Mother's Medical Record Number for Newborn Child       State Specific Edit




Expected Patient Responsibility                        UB Defined                                     FL 55

Claim Information

Type of Admission                                      Validated from UB Type of                      FL 19
                                                       Admission code list
Source of Admission                                    Validated from UB Source of                    FL 20
                                                       Admission code list
Admission Date/Start of Care                           Date Edit

Admission Hour                                         Hour Edit                                      FL 18
Statement Covers Period - From Date                    Date Edit                                      FL 6
Statement Covers Period - Thru Date                    Date Edit                                      FL 6
Service Date                                           Date Edit                                      FL 45


                                                       Page 2 of 24
Discharge Date - Derived from Statement From Date & Type of Bill   Date Edit                    FL 21

Discharge Hour                                                     Hour Edit
Patient Status or Disposition                                      Validated from UB Patient    FL 22
                                                                   Status Code list
Facility Type Code                                                 UB Code Value                FL 4 - Positions 1-2




Claim Frequency Code                                               UB Code Value                FL 4 - Position 3

Accident Related Codes & Dates                                     UB Occurrence SpanCode       FL 32-35
                                                                   Value & Date Edit

ALC Span Dates                                                     UB Occurrence Code value &   FL 36
                                                                   Date Edit




LOA Span Dates                                                     UB Occurrence Code value &   FL 36
                                                                   Date Edit
Homeless Patient Indicator                                         UB Condition Code value      FL 24-30

Non-US Resident Patient Indicator                                  UB Condition Code value      FL 24-30




                                                                   Page 3 of 24
Readmission Code                                                       UB Condition Code value   FL 24-30




Medicaid Special Program (PHC) Indicator                               UB Condition Code value   FL 24-30

Medicaid Special Program (SFP) Indicator                               UB Condition Code value   FL 24-30

Medicaid Special Program (FP) Indicator                                UB Condition Code value   FL 24-30

Medicaid Special Program (DIS) Indicator                               UB Condition Code value   FL 24-30

Workers' Compensation Indicator and Amount                             UB Value Code value       FL 39-41

No Fault Indicator and Amount                                          UB Value Code value       FL 39-41

Mcaid Surplus, Catastrophic, Recurring Monthly Amount                  UB Value Code value       FL 39-41

Blood Furnished Indicator and Amount                                   UB Value Code value       FL 39-41


Note: The above data elements using UB Occurrence Codes,
Occurrence Span Code, Condition Codes, and Value Codes are
examples of how public health would use the UB code lists, they are
not meant to be all inclusive. The Readmission Code is left to
describe how maintenance to a UB code list could satisfy a potential
public health data need.




                                                                       Page 4 of 24
Insurance Information

Source of Payment Code                     X12 Defined              DE 1032




Payer Identification                       UB Defined       FL 50




Policy Number                              X12 Defined



Covered Days                               X12 Defined      FL 7
Non-Covered Days                           X12 Defined      FL 8
Payer Estimated Amount Due                 X12 Defined
Payer Prior Payment                        X12 Defined

Service Line Information

UB-92 Accommodation Code                   UB Code Source   FL 42

Accommodations Rate                        UB Defined       FL 44
Accommodations Days                        UB Defined       FL 46
Accommodations Total Charges               UB Defined       FL 47
Accommodations Total Non-Covered Charges   UB Defined       FL 48
Ancillary Revenue Code                     UB Code Source   FL 42




                                           Page 5 of 24
Ancillary Units of Service            UB Defined                     FL 46
Ancillary Total Charges               UB Defined                     FL 47
Ancillary Total Non-Covered Charges   UB Defined                     FL 48
Total Charges
Procedure Code - HCPCS or CPT4        HCPC or CPT4 Validation File   FL 44



Modifier 1 (HCPC & CPT4)              HCPC or CPT4 Validation File   FL 44



Modifier 2 (HCPC & CPT4)              HCPC or CPT4 Validation File   FL 44




Medical Information

Principal Diagnosis Code              ICD-9 Validation File




Other Diagnosis Code                  ICD-9 Validation File




Other Diagnosis Emergent Indicator    X12 Defned                             DE 1073




                                      Page 6 of 24
Principal Procedure Code        ICD-9 Validation File




Principal Procedure Date        Date Edit

Other Procedure Code            ICD-9 Validation File




Other Procedure Date            Date Edit

Admitting Diagnosis Code        ICD-9 Validation File


Patient's Reason for Visit      ICD-9 Validation File


External Cause-of-Injury Code   ICD-9 Validation File




Place-of-Injury Code            ICD-9 Validation File




                                Page 7 of 24
Other E-Codes                                               ICD-9 Validation File


Diagnosis Related Groups

Physician Information

Attending Physician License Number                          UB Defined              FL 82




Operating Physician License Number                          UB Defined              FL 83




Other Physician License Number                              UB Defined              FL 83




Referring Physician License Number                          UB Defined              FL 83




Additional Information

State Mandated Information Not Supported by Standard

Below are the data elements identified in the development



                                                            Page 8 of 24
of the Health Care Service Data Reporting Guide
NOT mapped in the 837 Standard. These data
elements will need busines cases and justifications to be
developed for inclusion in future national standards

Adjusted Total Charges
Attending Physician Location Code
Attending Physician Service Code
Baby's 5 Minute APGAR Score
Category of Service
Date Prescribed/Ordered
Do Not Resuscitate (DNR) Code
Encounter Control Number
Encounter Type Indicator
EPSDT Indicator
Facility Data Processing Number
Facility Site Number
Injury Code
Method of Anesthesia Minutes
Number of Administratively Necessary Days
Operating Physician Location Code
Operating Room Time
Other Physician Locaiton Code
Patient Residence Code
Prescriber License Number
Previous Encounter Reference Number
Product Code
Provider Specialty Code
Referral Source Code
Residential Days
Service Type Code
Transfer Out (Destination) Code
Units or Anesthesia Minutes
Vendor Software Version
Vendor Software Version Update Level
Veteran's Status




                                                            Page 9 of 24
Notes                   Code List URL                                    Accesss File Key




Alpha numeric entry                                                      TS837A1_2010AA_NM103__ServiceProviderLastOrOrganizationName
Will be subject to     URL with NPI information
implementation of      http://www.cms.hhs.gov/hipaa/hipaa2/default.asp
HIPAA NPI with
check digit logic for
10th digit, until that
implementation local
ID's in effect with
local editing rules
                                                                         TS837A1_2010AA_NM109__ServiceProviderIdentifier



Alpha numeric entry                                                      TS837A1_2010CA_NM103__PatientLastName
Alpha numeric entry                                                      TS837A1_2010CA_NM104__PatientFirstName
Alpha numeric entry                                                      TS837A1_2010CA_NM105__PatientMiddleName
Alpha numeric entry                                                      TS837A1_2300_CLM01__PatientAccountNumber
Alpha numeric entry                                                      TS837A1_2300_REF02__MedicalRecordNumber
NYS ID, first 6
characters must be
alpha and last 4 must
be numeric - first 2
and last 2 characters
of last name, first 2
characters of first
name, last 4
characters of SSN
                                                                         TS837A1_2010CA_NM109__PatientPrimaryIdentifier
CDC Hierarchical List http://www.cdc.gov/od/hissb/docs.htm

                                                                         TS837A1_2010BA_DMG05_C05603U6_RaceOrEthnicityCode




                                                                    Page 10 of 24
CDC Hierarchical List http://www.cdc.gov/od/hissb/docs.htm

                                                                           TS837A1_2010BA_DMG05_C05603U6_RaceOrEthnicityCode
Alpha numeric entry                                                        TS837A1_2010CA_N301__PatientAddressLine
Alpha numeric entry                                                        TS837A1_2010CA_N302__PatientAddressLine
Alpha numeric entry                                                        TS837A1_2010CA_N401__PatientCityName
                         http://www.itl.nist.gov/fipspubs/fip6-4.htm       TS837A1_2010CA_N406__LocationIdentifier
See State Edit                                                             TS837A1_2010CA_N402__PatientStateCode
In NYS, cross
validation is done
between the first 3
characters of US Zip
codes and valid NYS
counties                  http://www.upu.int/post_code/en/postcodes.html   TS837A1_2010CA_N403__PatientPostalZoneOrZIPCode
M, F, U code values                                                        TS837A1_2010CA_DMG03__PatientGenderCode
                                                                           TS837A1_2010CA_DMG02__PatientBirthDate
UB Value Code 54                                                           TS837A1_2300_HI01_C02202U667_ValueCode
In NYS, this element
is required when valid
newborn diagnosis
code reported (V300
ICD-9-CM Dx codes)
                                                                           TS837A1_2300_REF02__MothersMedicalRecordNumber
Numeric                                                                    TS837A1_2300_AMT02__PatientResponsibilityAmount



                         http://www.nubc.org (contained in UB
                         specifications that can be purchased from AHA)    TS837A1_2300_CL101__AdmissionTypeCode
                         http://www.nubc.org (contained in UB
                         specifications that can be purchased from AHA)    TS837A1_2300_CL102__AdmissionSourceCode
Must be valid date
within span of stay                                                        TS837A1_2300_DTP03__AdmissionDateAndHour
See houredit file                                                          TS837A1_2300_DTP03__AdmissionDateAndHour
see dateedit file                                                          TS837A1_2300_DTP03__StatementFromOrToDate
see dateedit file                                                          TS837A1_2300_DTP03__StatementFromOrToDate
see dateedit file                                                          TS837A1_2400_DTP03__ServiceDate



                                                                       Page 11 of 24
see dateedit file
                                                                           TS837A1_2300_DTP03__StatementFromOrToDate
See houredit file                                                          TS837A1_2300_DTP03__DischargeHour
                          http://www.nubc.org (contained in UB
                          specifications that can be purchased from AHA)   TS837A1_2300_CL103__PatientStatusCode
Validiity edits for UB
type of bill depend on
type of service
provided (ie inpatient,
ambulatory surgery,
or outpatient)
                                                                           TS837A1_2300_CLM05_C02301U15_FacilityTypeCode
                      http://www.nubc.org (contained in UB
                      specifications that can be purchased from AHA)       TS837A1_2300_CLM05_C02303U17_ClaimFrequencyCode
Valid Codes are       http://www.nubc.org (contained in UB
01,02,03,04,05, or 06 specifications that can be purchased from AHA)
                                                                           TS837A1_2300_HI01_C02204U429_OccurrenceOrOccurrenceSpanCodeAssociatedDate
Valid code for SNF        http://www.nubc.org (contained in UB
ALC is 75 (note if        specifications that can be purchased from AHA)
other types of ALC
need to be defined,
then maintenance
request must be
made to the NUBC)                                                          TS837A1_2300_HI01_C02204U429_OccurrenceOrOccurrenceSpanCodeAssociatedDate
Valid Code is 74          http://www.nubc.org (contained in UB
                          specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02204U429_OccurrenceOrOccurrenceSpanCodeAssociatedDate
Valid Code is 17          http://www.nubc.org (contained in UB
                          specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is 25          http://www.nubc.org (contained in UB
                          specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode




                                                                       Page 12 of 24
A valid code is 57, for
Medicare SNF
readmission. If other
types of readmission
are needed then
maintenance request
must be made to
NUBC . In NYS the
presence of a patient
identifier allows for an
alogrithmic solution.

                                                                            TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is A2           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is A3           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is A4           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is A5           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI01_C02202U787_ConditionCode
Valid Code is 15           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI02_C02205U680_ValueCodeAssociatedAmount
Valid Code is 14           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI02_C02205U680_ValueCodeAssociatedAmount
Valid Codes are            http://www.nubc.org (contained in UB
21,22, or 23               specifications that can be purchased from AHA)   TS837A1_2300_HI02_C02205U680_ValueCodeAssociatedAmount
Valid Code is 37           http://www.nubc.org (contained in UB
                           specifications that can be purchased from AHA)   TS837A1_2300_HI02_C02205U680_ValueCodeAssociatedAmount




                                                                        Page 13 of 24
There is an internal
code list which is
restricted in the
institutional claim
implementation
guide.                                                                    TS837A1_2000B_SBR09__ClaimFilingIndicatorCode
The National Plan Id
will eventually be
used to validate this
field. Until then NAIC
typically would be
used for commercial
payers. Blue
Cross/Blue Shield
plan numbers also
used.                                                                     TS837A1_2010BC_NM109__PayerIdentifier
Alpha Numeric
number assigned by
payer to covered
patient                                                                   TS837A1_2010BA_NM109__SubscriberPrimaryIdentifier
Numeric                                                                   TS837A1_2300_QTY02__ClaimDaysCount
Numeric                                                                   TS837A1_2300_QTY02__ClaimDaysCount
Numeric                                                                   TS837A1_2300_AMT02__EstimatedClaimDueAmount
Numeric                                                                   TS837A1_2320_AMT02__OtherPayerPatientPaidAmount



                         http://www.nubc.org (contained in UB
                         specifications that can be purchased from AHA)   TS837A1_2400_SV201__ServiceLineRevenueCode
Numeric Entry                                                             TS837A1_2400_SV206__ServiceLineRate
Numeric Entry                                                             TS837A1_2400_SV205__ServiceUnitCount
Numeric Entry                                                             TS837A1_2400_SV203__LineItemChargeAmount
Numeric Entry                                                             TS837A1_2400_SV207__LineItemDeniedChargeOrNonCoveredChargeAmount
                         http://www.nubc.org (contained in UB
                         specifications that can be purchased from AHA)   TS837A1_2400_SV201__ServiceLineRevenueCode



                                                                      Page 14 of 24
Numeric Entry                                                            TS837A1_2400_SV205__ServiceUnitCount
Numeric Entry                                                            TS837A1_2400_SV203__LineItemChargeAmount
Numeric Entry                                                            TS837A1_2400_SV207__LineItemDeniedChargeOrNonCoveredChargeAmount
                                                                         TS837A1_2300_CLM02__TotalClaimChargeAmount
                      CPT4 URLhttp://www.ama-
                      assn.org/ama/pub/category/3113.html HCPC URL
                      http://www.hcfa.gov/medicare/hcpcs.htm
                                                                         TS837A1_2400_SV202_C00302U930_ProcedureCode
                      CPT4 URLhttp://www.ama-
                      assn.org/ama/pub/category/3113.html HCPC URL
                      http://www.hcfa.gov/medicare/hcpcs.htm
                                                                         TS837A1_2400_SV202_C00303U931_ProcedureModifier
                      CPT4 URLhttp://www.ama-
                      assn.org/ama/pub/category/3113.html HCPC URL
                      http://www.hcfa.gov/medicare/hcpcs.htm
                                                                         TS837A1_2400_SV202_C00304U932_ProcedureModifier



In NYS, age and sex   ICD-9-CM URL
specifc diagnosis     www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
conditions cross
edited with gender
field. Only certain
diagnoses
permissable to be
reported as a
principal diagnosis                                                      TS837A1_2300_HI01_C02202U25_IndustryCode
In NYS, age and sex   ICD-9-CM URL
specifc diagnosis     www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
conditions cross
edited with gender
field.                                                                   TS837A1_2300_HI01_C02202U166_IndustryCode
Valid Values are Y,
N, or U                                                                  TS837A1_2300_HI01_C02209U173_OnsetOfDiagnosisIndicator




                                                                  Page 15 of 24
In NYS, for              ICD-9-CM URL
Ambulatory Surgery       www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
and Inpatient
services this field
must be reported if
an operating
physician is reported.
Must be within span
of stay.                                                                    TS837A1_2300_HI01_C02202U286_IndustryCode
Must be valid date
within span of stay                                                         TS837A1_2300_HI01_C02204U288_DateTimePeriod
In NYS, procedure        ICD-9-CM URL
must be reported         www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
within span of stay.
For outpatient stays
range of stay
extended to
accommodate
observation days.                                                           TS837A1_2300_HI01_C02202U307_ProcedureCode
Must be valid date
within span of stay                                                         TS837A1_2300_HI01_C02204U309_ProcedureDate
Reported for Inpatient   ICD-9-CM URL
discharges               www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
                                                                            TS837A1_2300_HI02_C02202U35_IndustryCode
Reported for             ICD-9-CM URL
Outpatient               www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
discharges                                                                  TS837A1_2300_HI02_C02202U35_IndustryCode
In NYS, if diagnosis     ICD-9-CM URL
codes between 800        www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
and 999 are reported,
then External Cause
of Injury codes must
be reported
                                                                            TS837A1_2300_HI03_C02202U45_IndustryCode
                         ICD-9-CM URL
                         www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
                                                                            TS837A1_2300_HI03_C02202U45_IndustryCode



                                                                     Page 16 of 24
                     ICD-9-CM URL
                     www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm
                                                                        TS837A1_2300_HI03_C02202U45_IndustryCode
                                                                        TS837A1_2300_HI02_C02209U183_OnsetOfDiagnosisIndicator



Currently validated  URL with NPI information
with State or UPIN   http://www.cms.hhs.gov/hipaa/hipaa2/default.asp
license Numbers, but
will migrate to NPI
when implemented
                                                                        TS837A1_2310A_NM109__AttendingPhysicianPrimaryIdentifier
Currently validated  URL with NPI information
with State or UPIN   http://www.cms.hhs.gov/hipaa/hipaa2/default.asp
license Numbers, but
will migrate to NPI
when implemented
                                                                        TS837A1_2310B_NM109__OperatingPhysicianPrimaryIdentifier
Currently validated  URL with NPI information
with State or UPIN   http://www.cms.hhs.gov/hipaa/hipaa2/default.asp
license Numbers, but
will migrate to NPI
when implemented
                                                                        TS837A1_2310C_NM109__OtherPhysicianIdentifier
Currently validated  URL with NPI information
with State or UPIN   http://www.cms.hhs.gov/hipaa/hipaa2/default.asp
license Numbers, but
will migrate to NPI
when implemented
                                                                        TS837A1_2310C_NM109__OtherPhysicianIdentifier




                                                                  Page 17 of 24
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SpanCodeAssociatedDate




SpanCodeAssociatedDate

SpanCodeAssociatedDate




                         Page 21 of 24
Page 22 of 24
ChargeAmount




               Page 23 of 24
ChargeAmount




               Page 24 of 24

				
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