Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION (MHDO)
Chapter 241 - UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETS
Appendix 590-241-B-2 - Maine Health Data Organization
Inpatient Data Record Type 71 Mapping to National Standards
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP7101 |
Record Type |
NA |
NA |
|
IP7102 |
Sequence Number |
NA |
NA |
|
IP7103 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP7104 |
Principal Diagnosis |
67 |
837/2300/HI/ABK/01-2 |
|
IP7105 |
Present On Admission Indicator |
67 (pos 8) |
837/2300/HI/01-9 |
|
IP7106 |
Admitting Diagnosis |
69 |
837/2300/HI/ABJ/01-2 |
|
IP7110 |
Principal Procedure Code |
74 |
837/2300/HI/BBR/01-2 |
|
IP7111 |
Principal Procedure Date |
74 |
837/2300/HI/D8/01-4 |
Inpatient Data Record Type 72 Mapping to National Standards
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP7201 |
Record Type |
NA |
NA |
|
IP7202 |
Sequence Number |
NA |
NA |
|
IP7203 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP7204 |
Other Procedure Code - 1 |
74A |
837/2300/HI/BBQ/01-2 |
|
IP7205 |
Other Procedure Date - 1 |
74A |
837/2300/HI/D8/01-4 |
|
IP7206 |
Other Procedure Code - 2 |
74B |
837/2300/HI/BBQ/02-2 |
|
IP7207 |
Other Procedure Date - 2 |
74B |
837/2300/HI/D8/02-4 |
|
IP7208 |
Other Procedure Code - 3 |
74C |
837/2300/HI/BBQ/03-2 |
|
IP7209 |
Other Procedure Date - 3 |
74C |
837/2300/HI/D8/03-4 |
|
IP7210 |
Other Procedure Code - 4 |
74D |
837/2300/HI/BBQ/04-2 |
|
IP7211 |
Other Procedure Date - 4 |
74D |
837/2300/HI/D8/04-4 |
|
IP7212 |
Other Procedure Code - 5 |
74E |
837/2300/HI/BBQ/05-2 |
|
IP7213 |
Other Procedure Date - 5 |
74E |
837/2300/HI/D8/05-4 |
|
IP7214 |
Other Procedure Code - 6 |
NA |
837/2300/HI/BBQ/06-2 |
|
IP7215 |
Other Procedure Date - 6 |
NA |
837/2300/HI/D8/06-4 |
|
IP7216 |
Other Procedure Code - 7 |
NA |
837/2300/HI/BBQ/07-2 |
|
IP7217 |
Other Procedure Date - 7 |
NA |
837/2300/HI/D8/07-4 |
|
IP7218 |
Other Procedure Code - 8 |
NA |
837/2300/HI/BBQ/08-2 |
|
IP7219 |
Other Procedure Date - 8 |
NA |
837/2300/HI/D8/08-4 |
Inpatient Data Record Type 73 Mapping to National Standards
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP7301 |
Record Type |
NA |
NA |
|
IP7302 |
Sequence Number |
NA |
NA |
|
IP7303 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP7304 |
External Cause of Injury Code - 1 |
72A |
837/2300/HI/ABN/01-2 |
|
IP7305 |
Present On Admission Indicator - 1 |
72A (pos 8) |
837/2300/HI/01-9 |
|
IP7306 |
External Cause of Injury Code - 2 |
72B |
837/2300/HI/ABN/02-2 |
|
IP7307 |
Present On Admission Indicator - 2 |
72B (pos 8) |
837/2300/HI/02-9 |
|
IP7308 |
External Cause of Injury Code - 3 |
72C |
837/2300/HI/ABN/03-2 |
|
IP7309 |
Present On Admission Indicator - 3 |
72C (pos 8) |
837/2300/HI/03-9 |
|
IP7310 |
External Cause of Injury Code - 4 |
NA |
837/2300/HI/ABN/04-2 |
|
IP7311 |
Present On Admission Indicator - 4 |
NA |
837/2300/HI/04-9 |
|
IP7312 |
External Cause of Injury Code - 5 |
NA |
837/2300/HI/ABN/05-2 |
|
IP7313 |
Present On Admission Indicator - 5 |
NA |
837/2300/HI/05-9 |
|
IP7314 |
External Cause of Injury Code - 6 |
NA |
837/2300/HI/ABN/06-2 |
|
IP7315 |
Present On Admission Indicator - 6 |
NA |
837/2300/HI/06-9 |
|
IP7316 |
External Cause of Injury Code - 7 |
NA |
837/2300/HI/ABN/07-2 |
|
IP7317 |
Present On Admission Indicator - 7 |
NA |
837/2300/HI/07-9 |
|
IP7318 |
External Cause of Injury Code - 8 |
NA |
837/2300/HI/ABN/08-2 |
|
IP7319 |
Present On Admission Indicator - 8 |
NA |
837/2300/HI/08-9 |
|
IP7320 |
External Cause of Injury Code - 9 |
NA |
837/2300/HI/ABN/09-2 |
|
IP7321 |
Present On Admission Indicator - 9 |
NA |
837/2300/HI/09-9 |
|
IP7322 |
External Cause of Injury Code - 10 |
NA |
837/2300/HI/ABN/10-2 |
|
IP7323 |
Present On Admission Indicator - 10 |
NA |
837/2300/HI/10-9 |
|
IP7324 |
External Cause of Injury Code - 11 |
NA |
837/2300/HI/ABN/11-2 |
|
IP7325 |
Present On Admission Indicator - 11 |
NA |
837/2300/HI/11-9 |
|
IP7326 |
External Cause of Injury Code - 12 |
NA |
837/2300/HI/ABN/12-2 |
|
IP7327 |
Present On Admission Indicator - 12 |
NA |
837/2300/HI/12-9 |
Inpatient Data Record Type 74 Mapping to National Standards
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP7401 |
Record Type |
NA |
NA |
|
IP7402 |
Sequence Number |
NA |
NA |
|
IP7403 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP7404 |
Other Diagnosis Code - 1 |
67A |
837/2300/HI/ABF/01-2 |
|
IP7405 |
Present On Admission Indicator - 1 |
67A (pos 8) |
837/2300/HI/01-9 |
|
IP7406 |
Other Diagnosis Code - 2 |
67B |
837/2300/HI/ABF/02-2 |
|
IP7407 |
Present On Admission Indicator - 2 |
67B (pos 8) |
837/2300/HI/02-9 |
|
IP7408 |
Other Diagnosis Code - 3 |
67C |
837/2300/HI/ABF/03-2 |
|
IP7409 |
Present On Admission Indicator - 3 |
67C (pos 8) |
837/2300/HI/03-9 |
|
IP7410 |
Other Diagnosis Code - 4 |
67D |
837/2300/HI/ABF/04-2 |
|
IP7411 |
Present On Admission Indicator - 4 |
67D (pos 8) |
837/2300/HI/04-9 |
|
IP7412 |
Other Diagnosis Code - 5 |
67E |
837/2300/HI/ABF/05-2 |
|
IP7413 |
Present On Admission Indicator - 5 |
67E (pos 8) |
837/2300/HI/05-9 |
|
IP7414 |
Other Diagnosis Code - 6 |
67F |
837/2300/HI/ABF/06-2 |
|
IP7415 |
Present On Admission Indicator - 6 |
67F (pos 8) |
837/2300/HI/06-9 |
|
IP7416 |
Other Diagnosis Code - 7 |
67G |
837/2300/HI/ABF/07-2 |
|
IP7417 |
Present On Admission Indicator - 7 |
67G (pos 8) |
837/2300/HI/07-9 |
|
IP7418 |
Other Diagnosis Code - 8 |
67H |
837/2300/HI/ABF/08-2 |
|
IP7419 |
Present On Admission Indicator - 8 |
67H (pos 8) |
837/2300/HI/08-9 |
|
IP7420 |
Other Diagnosis Code - 9 |
67I |
837/2300/HI/ABF/09-2 |
|
IP7421 |
Present On Admission Indicator - 9 |
67I (pos 8) |
837/2300/HI/09-9 |
|
IP7422 |
Other Diagnosis Code - 10 |
67J |
837/2300/HI/ABF/10-2 |
|
IP7423 |
Present On Admission Indicator - 10 |
67J (pos 8) |
837/2300/HI/10-9 |
|
IP7424 |
Other Diagnosis Code - 11 |
67K |
837/2300/HI/ABF/11-2 |
|
IP7425 |
Present On Admission Indicator - 11 |
67K (pos 8) |
837/2300/HI/11-9 |
|
IP7426 |
Other Diagnosis Code - 12 |
67L |
837/2300/HI/ABF/12-2 |
|
IP7427 |
Present On Admission Indicator - 12 |
67L (pos 8) |
837/2300/HI/12-9 |
Inpatient Data Record Type 80 Mapping to National Standards
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
IP8001 |
Record Type |
NA |
NA |
|
IP8002 |
Sequence |
NA |
NA |
|
IP8003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP8004 |
Attending Provider NPI |
76 |
837/2310A/NM1/71/1/XX/09 |
|
IP8005 |
Operating Physician NPI |
77 |
837/2310B/NM1/72/1/XX/09 |
|
IP8006 |
Attending Provider Last Name |
76 |
837/2310A/NM1/71/1/03 |
|
IP8007 |
Attending Provider First Name |
76 |
837/2310A/NM1/71/1/04 |
|
IP8008 |
Attending Provider Middle Initial |
76 |
837/2310A/NM1/71/1/05 |
|
IP8009 |
Operating Physician Last Name |
77 |
837/2310B/NM1/72/1/03 |
|
IP8010 |
Operating Physician First Name |
77 |
837/2310B/NM1/72/1/04 |
|
IP8011 |
Operating Physician Middle Initial |
77 |
837/2310B/NM1/72/1/05 |
|
IP8012 |
Billing Provider NPI |
56 |
837/2010AA/NM1/XX/09 |
|
IP9001 |
Record Type |
NA |
NA |
|
IP9003 |
Patient Control Number |
3A |
837/2300/CLM/01 |
|
IP9004 |
Total Accommodation Charges - Revenue Centers |
NA |
This is the total of the SV2 segments except for Revenue Code 0001 |
|
IP9005 |
Total Ancillary Charges - Revenue Centers |
NA |
This is the total of the SV2 segments except for Revenue Code 0001 |
|
IP9901 |
Record Type |
NA |
NA |
|
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 61 - Services |
|
Record Type 71 - ICD-10 CM Principal and Reason for Visit 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. |
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
OP0101 |
Record Type |
T |
2 |
01 |
|
|
OP0102 |
MHDO-Assigned Hospital ID |
T |
6 |
Must be the MHDO-assigned, 6-digit hospital code, left justified |
|
|
OP0198 |
Filler |
T |
38 |
||
|
OP0103 |
Hospital Name |
T |
21 |
||
|
OP0104 |
Address |
T |
18 |
||
|
OP0105 |
City |
T |
15 |
||
|
OP0106 |
State |
T |
2 |
||
|
OP0107 |
Zip Code |
T |
9 |
||
|
OP0199 |
Filler |
T |
78 |
||
|
OP0108 |
Version |
T |
3 |
Leave blank |
