Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 241 - UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETS
Appendix 590-241-B-1 - Maine Health Data Organization Inpatients Data Submission Specifications General
|
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 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. |
Record Type 01 - Processor Data
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
IP0101 |
Record Type |
T |
2 |
01 |
|
|
IP0102 |
MHDO-Assigned Hospital ID |
T |
6 |
Must be the MHDO-assigned, 6-digit hospital code, left justified |
|
|
IP0198 |
Filler |
T |
38 |
||
|
IP0103 |
Hospital Name |
T |
21 |
||
|
IP0104 |
Address |
T |
18 |
||
|
IP0105 |
City |
T |
15 |
||
|
IP0106 |
State |
T |
2 |
||
|
IP0107 |
Zip Code |
T |
9 |
||
|
IP0199 |
Filler |
T |
78 |
||
|
IP0108 |
Version |
T |
3 |
leave blank |
|
|
IP2001 |
Record Type |
T |
2 |
20 |
|
|
IP2002 |
Filler (National Use) |
T |
2 |
||
|
IP2003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP2095 |
Filler |
T |
30 |
Space filled |
|
|
IP2004 |
Patient Sex |
T |
1 |
M = Male F = Female U = Unknown |
|
|
IP2005 |
Patient Birth Date |
T |
8 |
CCYYMMDD |
|
|
IP2096 |
Filler |
T |
1 |
||
|
IP2006 |
Priority (Type) of Admission or Visit |
T |
1 |
||
|
IP2007 |
Point of Origin for Admission or Visit |
T |
1 |
||
|
IP2097 |
Filler |
T |
30 |
||
|
IP2008 |
Patient City |
T |
15 |
||
|
IP2009 |
Patient State |
T |
2 |
||
|
IP2010 |
Patient Zip Code |
T |
9 |
As defined by US Postal Service Do not include dashes |
|
|
IP2011 |
Admission/Start of Care Date |
T |
8 |
CCYYMMDD |
|
|
IP2012 |
Admission Hour |
T |
2 |
Military Time - Range 00-23 |
|
|
IP2098 |
Filler |
T |
8 |
||
|
IP2013 |
Statement Covers Period - Thru |
T |
8 |
CCYYMMDD |
|
|
IP2014 |
Patient Discharge Status |
T |
2 |
||
|
IP2015 |
Discharge Hour |
T |
2 |
Military Time - Range 00-23 |
|
|
IP2099 |
Filler |
T |
20 |
||
|
IP2016 |
Medical/Health Record Number |
T |
17 |
Assigned by the facility |
|
|
IP2017 |
Race |
March 1, 2007 |
T |
1 |
1 = American Indian or Alaska Native 2 = Asian 3 = Black or African American 4 = Native Hawaiian or Other Pacific Islander 5 = White 6 = Other Race 7 = Patient Elected not to Answer 8 = Unknown The code value "8" (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank. |
|
IP2018 |
Ethnicity |
March 1, 2007 |
T |
1 |
1 = Hispanic or Latino 2 = Non-Hispanic or Non-Latino 7 = Patient Elected not to Answer 8 = Unknown The code value "8" (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank. |
|
IP2019 |
Filler |
T |
1 |
||
|
IP2020 |
Statement Covers Period - From |
January 1, 2018 |
T |
8 |
CCYYMMDD |
|
IP2021 |
Patient Country Code |
January 1, 2018 |
T |
2 |
Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. |
|
IP2022 |
Patient Last Name |
January 1, 2018 |
T |
60 |
|
|
IP2023 |
Patient First Name |
January 1, 2018 |
T |
35 |
|
|
IP2024 |
Patient Middle Name or Initial |
January 1, 2018 |
T |
25 |
|
|
IP2025 |
Patient Name Suffix |
January 1, 2018 |
T |
10 |
|
|
IP2026 |
Patient Address Line 1 |
January 1, 2018 |
T |
55 |
|
|
IP2027 |
Patient Address Line 2 |
January 1, 2018 |
T |
55 |
|
|
IP3001 |
Record Type |
T |
2 |
30 |
|
|
IP3002 |
Sequence Number |
T |
2 |
01 Primary Payer 02 - 99 Secondary Payer |
|
|
IP3003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP3095 |
Filler |
January 1, 2018 |
T |
10 |
|
|
IP3005 |
Social Security Number |
April 1, 2006 |
T |
19 |
Do not include the dashes For internal use only - Required if collected |
|
IP3097 |
Filler |
January 1, 2018 |
T |
26 |
|
|
IP3007 |
Insured's Group Number |
April 1, 2006 |
T |
17 |
For internal use only - Required if collected |
|
IP3008 |
Insured's Unique Identifier |
T |
20 |
Insurance policy or certificate ID |
|
|
IP3099 |
Filler |
T |
1 |
||
|
IP3009 |
Payer Name |
January 1, 2018 |
T |
100 |
Full or unabbreviated payer name, not plan name |
|
IP4001 |
Record Type |
T |
2 |
40 |
|
|
IP4002 |
Sequence Number |
T |
2 |
01 |
|
|
IP4003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP4004 |
Type of Bill |
T |
3 |
Code indicating the specific type of institutional bill |
|
|
IP4099 |
Filler |
T |
165 |
||
|
IP5001 |
Record Type |
T |
2 |
50 |
|
|
IP5002 |
Sequence Number |
T |
3 |
001-999 |
|
|
IP5003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP5091 |
Filler |
T |
3 |
||
|
IP5004 |
Accommodations Revenue Code #1 |
T |
4 |
Include leading zeros |
|
|
IP5092 |
Filler |
T |
9 |
||
|
IP5005 |
Accommodations Service Units #1 |
N |
4 |
Right Justified, leading zeros |
|
|
IP5006 |
Accommodations Total Charges #1 |
T |
10 |
Two decimal places implied |
|
|
IP5093 |
Filler |
T |
14 |
||
|
IP5007 |
Accommodations Revenue Code #2 |
T |
4 |
Include leading zeros |
|
|
IP5094 |
Filler |
T |
9 |
||
|
IP5008 |
Accommodations Service Units #2 |
N |
4 |
Right Justified, leading zeros |
|
|
IP5009 |
Accommodations Total Charges #2 |
N |
10 |
Two decimal places implied |
|
|
IP5095 |
Filler |
T |
14 |
||
|
IP5010 |
Accommodations Revenue Code #3 |
T |
4 |
Include leading zeros |
|
|
IP5096 |
Filler |
T |
9 |
||
|
IP5011 |
Accommodations Service Units #3 |
N |
4 |
Right Justified, leading zeros |
|
|
IP5012 |
Accommodations Total Charges #3 |
N |
10 |
Two decimal places implied |
|
|
IP5097 |
Filler |
T |
14 |
||
|
IP5013 |
Accommodations Revenue Code #4 |
T |
4 |
Include leading zeros |
|
|
IP5098 |
Filler |
T |
9 |
||
|
IP5014 |
Accommodations Service Units #4 |
N |
4 |
Right Justified, leading zeros |
|
|
IP5015 |
Accommodations Total Charges #4 |
N |
10 |
Two decimal places implied |
|
|
IP5099 |
Filler |
T |
14 |
Record Type 60 - IP Ancillary Services Data
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
IP6001 |
Record Type |
T |
2 |
60 |
|
|
IP6002 |
Sequence Number |
T |
3 |
001 to 999 |
|
|
IP6003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP6093 |
Filler |
T |
2 |
||
|
IP6004 |
Inpatient Ancillary Revenue Code #1 |
T |
4 |
Include leading zeros |
|
|
IP6094 |
Filler |
T |
16 |
||
|
IP6005 |
Inpatient Ancillary Total Charges #1 |
N |
10 |
Two decimal places implied |
|
|
IP6095 |
Filler |
T |
25 |
||
|
IP6006 |
Inpatient Ancillary Revenue Code #2 |
T |
4 |
Include leading zeros |
|
|
IP6096 |
Filler |
T |
16 |
||
|
IP6007 |
Inpatient Ancillary Total Charges #2 |
N |
10 |
Two decimal places implied |
|
|
IP6097 |
Filler |
T |
25 |
||
|
IP6008 |
Inpatient Ancillary Revenue Code #3 |
T |
4 |
Include leading zeros |
|
|
IP6098 |
Filler |
T |
16 |
||
|
IP6009 |
Inpatient Ancillary Total Charge #3 |
N |
10 |
Two decimal places implied |
|
|
IP6099 |
Filler |
T |
25 |
Record Type 71 - ICD-10 CM Principal and Admitting Diagnosis Codes, ICD-10 PCS Principal Procedure Code
|
Data Element # |
Data Element |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
IP7101 |
Record Type |
10/1/2014 |
T |
2 |
71 |
|
IP7102 |
Sequence Number |
10/1/2014 |
T |
2 |
01 |
|
IP7103 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
IP7104 |
Principal Diagnosis |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7105 |
Present On Admission Indicator |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7106 |
Admitting Diagnosis |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7107 |
Filler |
T |
10 |
||
|
IP7108 |
Filler |
T |
10 |
||
|
IP7109 |
Filler |
T |
10 |
||
|
IP7110 |
Principal Procedure Code |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7111 |
Principal Procedure Date |
10/1/2014 |
T |
8 |
CCYYMMDD |
Record Type 72 - ICD-10 PCS Other Procedure Codes
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
IP7201 |
Record Type |
10/1/2014 |
T |
2 |
72 |
|
IP7202 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 03 |
|
IP7203 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
IP7204 |
Other Procedure Code - 1 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7205 |
Other Procedure Date - 1 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7206 |
Other Procedure Code - 2 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7207 |
Other Procedure Date - 2 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7208 |
Other Procedure Code - 3 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7209 |
Other Procedure Date - 3 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7210 |
Other Procedure Code - 4 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7211 |
Other Procedure Date - 4 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7212 |
Other Procedure Code - 5 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7213 |
Other Procedure Date - 5 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7214 |
Other Procedure Code - 6 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7215 |
Other Procedure Date - 6 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7216 |
Other Procedure Code - 7 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7217 |
Other Procedure Date - 7 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
IP7218 |
Other Procedure Code - 8 |
10/1/2014 |
T |
10 |
ICD-10 PCS - do not code decimal point - Left Justified |
|
IP7219 |
Other Procedure Date - 8 |
10/1/2014 |
T |
8 |
CCYYMMDD |
Record Type 73 - ICD-10 CM Other Diagnosis Information
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
IP7301 |
Record Type |
10/1/2014 |
T |
2 |
73 |
|
IP7302 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 02 |
|
IP7303 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
IP7304 |
External Cause of Injury Code - 1 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7305 |
Present On Admission Indicator - 1 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7306 |
External Cause of Injury Code - 2 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7307 |
Present On Admission Indicator - 2 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7308 |
External Cause of Injury Code - 3 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7309 |
Present On Admission Indicator - 3 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7310 |
External Cause of Injury Code - 4 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7311 |
Present On Admission Indicator - 4 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7312 |
External Cause of Injury Code - 5 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7313 |
Present On Admission Indicator - 5 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7314 |
External Cause of Injury Code - 6 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7315 |
Present On Admission Indicator - 6 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7316 |
External Cause of Injury Code - 7 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7317 |
Present On Admission Indicator - 7 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7318 |
External Cause of Injury Code - 8 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7319 |
Present On Admission Indicator - 8 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7320 |
External Cause of Injury Code - 9 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7321 |
Present On Admission Indicator - 9 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7322 |
External Cause of Injury Code - 10 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7323 |
Present On Admission Indicator - 10 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7324 |
External Cause of Injury Code - 11 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7325 |
Present On Admission Indicator - 11 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7326 |
External Cause of Injury Code - 12 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7327 |
Present On Admission Indicator - 12 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
Record Type 74 - ICD-10 CM Other Diagnosis Information
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
IP7401 |
Record Type |
10/1/2014 |
T |
2 |
74 |
|
IP7402 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 02 |
|
IP7403 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
IP7404 |
Other Diagnosis Code - 1 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7405 |
Present On Admission Indicator - 1 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7406 |
Other Diagnosis Code - 2 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7407 |
Present On Admission Indicator - 2 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7408 |
Other Diagnosis Code - 3 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7409 |
Present On Admission Indicator - 3 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7410 |
Other Diagnosis Code - 4 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7411 |
Present On Admission Indicator - 4 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7412 |
Other Diagnosis Code - 5 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7413 |
Present On Admission Indicator - 5 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7414 |
Other Diagnosis Code - 6 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7415 |
Present On Admission Indicator - 6 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7416 |
Other Diagnosis Code - 7 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7417 |
Present On Admission Indicator - 7 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7418 |
Other Diagnosis Code - 8 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7419 |
Present On Admission Indicator - 8 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7420 |
Other Diagnosis Code - 9 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7421 |
Present On Admission Indicator - 9 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7422 |
Other Diagnosis Code - 10 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7423 |
Present On Admission Indicator - 10 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7424 |
Other Diagnosis Code - 11 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7425 |
Present On Admission Indicator - 11 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
|
IP7426 |
Other Diagnosis Code - 12 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
IP7427 |
Present On Admission Indicator - 12 |
10/1/2014 |
T |
3 |
Standard POA code set - Left Justified |
Record Type 80 - Provider Data
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
IP8001 |
Record Type |
T |
2 |
80 |
|
|
IP8002 |
Sequence |
T |
2 |
01 |
|
|
IP8003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP8097 |
Filler |
T |
2 |
||
|
IP8004 |
Attending Provider NPI |
April 1, 2009 |
T |
16 |
NPI of Attending Provider |
|
IP8005 |
Operating Physician NPI |
April 1, 2009 |
T |
16 |
NPI of Operating Physician |
|
IP8098 |
Filler |
T |
32 |
||
|
IP8006 |
Attending Provider Last Name |
T |
16 |
Cannot be blank |
|
|
IP8007 |
Attending Provider First Name |
T |
8 |
Cannot be blank |
|
|
IP8008 |
Attending Provider Middle Initial |
T |
1 |
||
|
IP8009 |
Operating Physician Last Name |
T |
16 |
Must be populated when IP8005 is populated. |
|
|
IP8010 |
Operating Physician First Name |
T |
8 |
Cannot be blank if IP8005 is populated. |
|
|
IP8011 |
Operating Physician Middle Initial |
T |
1 |
||
|
IP8099 |
Filler |
T |
52 |
||
|
IP8012 |
Billing Provider NPI |
T |
16 |
National Provider Identifier assigned to the provider submitting the bill. |
Record Type 99 - File Control
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
IP9001 |
Record Type |
T |
2 |
90 |
|
|
IP9002 |
Filler (National Use) |
T |
2 |
||
|
IP9003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
IP9097 |
Filler |
T |
20 |
||
|
IP9004 |
Total Accommodation Charges - Revenue Centers |
N |
10 |
Must equal the sum of record type 50 revenue code data Two decimal places implied |
|
|
IP9098 |
Filler |
T |
10 |
||
|
IP9005 |
Total Ancillary Charges - Revenue Centers |
N |
10 |
Must equal the sum of record type 60 revenue code data Two decimal places implied |
|
|
IP9099 |
Filler |
T |
118 |
Inpatient Data Submission Specifications Record Type 99 - File Control
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
IP9901 |
Record Type |
T |
2 |
99 |
|
|
IP9999 |
Filler |
T |
190 |
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP0101 |
Record Type |
NA |
NA |
|
IP0102 |
MHDO-Assigned Hospital ID |
NA |
NA |
|
IP0103 |
Hospital Name |
1 |
837/2010AA/NM1/85/2/03 |
|
IP0104 |
Address |
1 |
837/2010AA/N3/01 |
|
IP0105 |
City |
1 |
837/2010AA/N4/01 |
|
IP0106 |
State |
1 |
837/2010AA/N4/02 |
|
IP0107 |
Zip Code |
1 |
837/2010AA/N4/03 |
|
IP0108 |
Version |
NA |
NA |
|
IP2001 |
Record Type |
NA |
NA |
|
IP2003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP2004 |
Patient Sex |
11 |
837/2010CA/DMG/03 837/2010BA/DMG/03 |
|
IP2005 |
Patient Birth Date |
10 |
837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02 |
|
IP2006 |
Priority (Type) of Admission or Visit |
14 |
837/2300/CL1/01 |
|
IP2007 |
Point of Origin for Admission or Visit |
15 |
837/2300/CL1/02 |
|
IP2008 |
Patient City |
9B |
837/2010CA/N4/01 837/2010BA/N4/01 |
|
IP2009 |
Patient State |
9C |
837/2010CA/N4/02 837/2010BA/N4/02 |
|
IP2010 |
Patient Zip Code |
9D |
837/2010CA/N4/03 837/2010BA/N4/03 |
|
IP2011 |
Admission/Start of Care Date |
12 |
837/2300/DTP/435/DT/03 |
|
IP2012 |
Admission Hour |
13 |
837/2300/DTP/435/DT/03 |
|
IP2013 |
Statement Covers Period Thru |
6 |
837/2300/DTP/434/RD8/03 |
|
IP2014 |
Patient Discharge Status |
17 |
837/2300/CL1/03 |
|
IP2015 |
Discharge Hour |
16 |
837/2300/DTP/096/TM/03 |
|
IP2016 |
Medical/Health Record Number |
3B |
837/2300/REF/EA/02 |
|
IP2017 |
Race |
NA |
837/2010CA/DMG/05 837/2010BA/DMG/05 |
|
IP2018 |
Ethnicity |
NA |
837/2010CA/DMG/05 837/2010BA/DMG/05 |
|
IP2020 |
Statement Covers Period - From |
6 |
837/2300/DTP/434/RD8/03 |
|
IP2021 |
Patient Country Code |
9E |
837/2010CA/N4/04 837/2010BA/N4/04 |
|
IP2022 |
Patient Last Name |
8B |
837/2010CA/NM1/QC/1/03 837/2010BA/NM1/IL/1/03 |
|
IP2023 |
Patient First Name |
8B |
837/2010CA/NM1/QC/1/04 837/2010BA/NM1/IL/1/04 |
|
IP2024 |
Patient Middle Name or Initial |
8B |
837/2010CA/NM1/QC/1/05 837/2010BA/NM1/IL/1/05 |
|
IP2025 |
Patient Name Suffix |
8B |
837/2010CA/NM1/QC/1/07 837/2010BA/NM1/IL/1/07 |
|
IP2026 |
Patient Address Line 1 |
9A |
837/2010CA/N3/01 837/2010BA/N3/01 |
|
IP2027 |
Patient Address Line 2 |
9A |
837/2010CA/N3/02 837/2010BA/N3/02 |
|
IP3001 |
Record Type |
NA |
NA |
|
IP3002 |
Sequence Number |
NA |
837/2000B/SBR/01 |
|
IP3003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP3005 |
Social Security Number |
NA |
NA |
|
IP3007 |
Insured's Group Number (Primary) |
62A |
837/2000B/SBR/P/03 |
|
Insured's Group Number (Secondary) |
62B |
837/2320A/SBR/S/03 |
|
|
IP3008 |
Insured's Unique Identifier (Primary) |
60A |
837/2010BA/NM1/MI/09 |
|
Insured's Unique Identifier (Secondary) |
60B |
837/2330A/NM1/MI/09 |
|
|
IP3009 |
Payer Name (Primary) |
50A |
837/2010BB/NM1/PR/2/03 |
|
Payer Name (Secondary) |
50B |
837/2330B/NM1/PR/2/03 |
|
|
IP4001 |
Record Type |
NA |
NA |
|
IP4002 |
Sequence Number |
NA |
NA |
|
IP4003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP4004 |
Type of Bill |
4 |
837/2300/CLM/05-1 837/2300/CLM/05-3 |
|
IP5001 |
Record Type |
NA |
NA |
|
IP5002 |
Sequence Number |
NA |
NA |
|
IP5003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP5004 |
Accommodations Revenue Code - 1 |
42 |
837/2400/SV2/01 |
|
IP5005 |
Accommodations Service Units - 1 |
46 |
837/2400/SV2/DA/05 |
|
IP5006 |
Accommodations Total Charges - 1 |
47 |
837/2400/SV2/03 |
|
IP5007 |
Accommodations Revenue Code - 2 |
42 |
837/2400/SV2/01 |
|
IP5008 |
Accommodations Service Units - 2 |
46 |
837/2400/SV2/DA/05 |
|
IP5009 |
Accommodations Total Charges - 2 |
47 |
837/2400/SV2/03 |
|
IP5010 |
Accommodations Revenue Code - 3 |
42 |
837/2400/SV2/01 |
|
IP5011 |
Accommodations Service Units - 3 |
46 |
837/2400/SV2/DA/05 |
|
IP5012 |
Accommodations Total Charges - 3 |
47 |
837/2400/SV2/03 |
|
IP5013 |
Accommodations Revenue Code - 4 |
42 |
837/2400/SV2/01 |
|
IP5014 |
Accommodations Service Units - 4 |
46 |
837/2400/SV2/DA/05 |
|
IP5015 |
Accommodations Total Charges - 4 |
47 |
837/2400/SV2/03 |
|
IP6001 |
Record Type |
NA |
NA |
|
IP6002 |
Sequence Number |
NA |
NA |
|
IP6003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP6004 |
Inpatient Ancillary Revenue Code - 1 |
42 |
837/2400/SV2/01 |
|
IP6005 |
Inpatient Ancillary Total Charges - 1 |
47 |
837/2400/SV2/03 |
|
IP6006 |
Inpatient Ancillary Revenue Code - 2 |
42 |
837/2400/SV2/01 |
|
IP6007 |
Inpatient Ancillary Total Charges - 2 |
47 |
837/2400/SV2/03 |
|
IP6008 |
Inpatient Ancillary Revenue Code - 3 |
42 |
837/2400/SV2/01 |
|
IP6009 |
Inpatient Ancillary Total Charges - 3 |
47 |
837/2400/SV2/03 |
