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-C-1 - Maine Health Data Organization
Outpatient Data Submission Specifications Record Type 30 - Payer
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
OP2001 |
Record Type |
T |
2 |
20 |
|
|
OP2002 |
Filler (National Use) |
T |
2 |
||
|
OP2003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP2094 |
Filler |
T |
30 |
||
|
OP2004 |
Patient Sex |
T |
1 |
M = Male F = Female U = Unknown |
|
|
OP2005 |
Patient Birth Date |
T |
8 |
CCYYMMDD |
|
|
OP2095 |
Filler |
T |
2 |
||
|
OP2007 |
Point of Origin for Admission or Visit |
T |
1 |
||
|
OP2096 |
Filler |
T |
30 |
||
|
OP2008 |
Patient City |
T |
15 |
||
|
OP2009 |
Patient State |
T |
2 |
||
|
OP2010 |
Patient Zip Code |
T |
9 |
As defined by US Postal Service Do not include dashes |
|
|
OP2011 |
Admission/Start of Care Date |
T |
8 |
CCYYMMDD |
|
|
OP2097 |
Filler |
T |
2 |
||
|
OP2012 |
Statement Covers Period - From |
T |
8 |
The beginning service date for the period covered on the record CCYYMMDD |
|
|
OP2013 |
Statement Covers Period - Thru |
T |
8 |
The ending service date for the period covered on the record CCYYMMDD |
|
|
OP2014 |
Patient Discharge Status |
T |
2 |
||
|
OP2098 |
Filler |
T |
22 |
||
|
OP2015 |
Medical/Health Record Number |
T |
17 |
Assigned by the facility |
|
|
OP2016 |
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. |
|
OP2017 |
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. |
|
OP2099 |
Filler |
T |
1 |
||
|
OP2018 |
Patient Country Code |
January 1, 2018 |
T |
2 |
Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A. |
|
OP2019 |
Patient Last Name |
January 1, 2018 |
T |
60 |
|
|
OP2020 |
Patient First Name |
January 1, 2018 |
T |
35 |
|
|
OP2021 |
Patient Middle Name or Initial |
January 1, 2018 |
T |
25 |
|
|
OP2022 |
Patient Name Suffix |
January 1, 2018 |
T |
10 |
|
|
OP2023 |
Patient Address Line 1 |
January 1, 2018 |
T |
55 |
|
|
OP2024 |
Patient Address Line 2 |
January 1, 2018 |
T |
55 |
|
|
OP3001 |
Record Type |
T |
2 |
30 |
|
|
OP3002 |
Sequence Number |
T |
2 |
01 Primary Payer 02 - 99 Secondary Payer |
|
|
OP3003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP3095 |
Filler |
January 1, 2018 |
T |
10 |
|
|
OP3005 |
Social Security Number |
April 1, 2006 |
T |
19 |
Do not include dashes For internal use only - Required if collected |
|
OP3097 |
Filler |
January 1, 2018 |
T |
26 |
|
|
OP3007 |
Insured's Group Number |
April 1, 2006 |
T |
17 |
For internal use only - Required if collected |
|
OP3008 |
Insured's Unique Identifier |
T |
20 |
For internal use only - Required if collected |
|
|
OP3099 |
Filler |
T |
1 |
||
|
OP3009 |
Payer Name |
January 1, 2018 |
T |
100 |
Full or unabbreviated payer name, not plan name |
|
OP4001 |
Record Type |
T |
2 |
40 |
|
|
OP4002 |
Sequence Number |
T |
2 |
01 |
|
|
OP4003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP4004 |
Type of Bill |
T |
3 |
Code indicating the specific type of institutional bill. |
|
|
OP4005 |
Location of Service |
T |
10 |
When 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). |
|
|
OP4099 |
Filler |
T |
155 |
||
|
OP4006 |
Place of Service |
January 1, 2018 |
T |
2 |
CMS code identifying the entity/location where professional service(s) were rendered. |
Outpatient Data Submission Specifications Record Type 61 - Services
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
OP6101 |
Record Type |
T |
2 |
61 |
|
|
OP6102 |
Sequence Number |
T |
3 |
001 to 999 |
|
|
OP6103 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP6190 |
Filler |
T |
2 |
||
|
OP6104 |
Revenue Center Code - 1 |
T |
4 |
Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros. |
|
|
OP6105 |
HCPCS Procedure Code - 1 |
T |
5 |
Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association |
|
|
OP6106 |
Modifier - 1 (HCPCS & CPT-4) - 1 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6107 |
Modifier - 2 (HCPCS & CPT-4) - 1 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6108 |
Service Units - 1 |
N |
7 |
A quantitative measure of services rendered by the Revenue Center |
|
|
OP6191 |
Filler |
T |
6 |
||
|
OP6109 |
Outpatient Total Charges - 1 |
N |
10 |
Negative charges not accepted Two decimal places implied |
|
|
OP6192 |
Filler |
T |
10 |
||
|
OP6110 |
Service Date - 1 |
T |
8 |
The 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". CCYYMMDD |
|
|
OP6193 |
Filler |
T |
1 |
||
|
OP6111 |
Revenue Center Code - 2 |
T |
4 |
Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros. |
|
|
OP6112 |
HCPCS Procedure Code - 2 |
T |
5 |
Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association |
|
|
OP6113 |
Modifier - 1 (HCPCS & CPT-4) - 2 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6114 |
Modifier - 2 (HCPCS & CPT-4) - 2 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6115 |
Service Units - 2 |
N |
7 |
A quantitative measure of services rendered by the Revenue Center |
|
|
OP6194 |
Filler |
T |
6 |
||
|
OP6116 |
Outpatient Total Charges - 2 |
N |
10 |
Negative charges not accepted Two decimal places implied |
|
|
OP6195 |
Filler |
T |
10 |
||
|
OP6117 |
Service Date - 2 |
T |
8 |
The 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" CCYYMMDD |
|
|
OP6196 |
Filler |
T |
1 |
||
|
OP6118 |
Revenue Center Code - 3 |
T |
4 |
Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros. |
|
|
OP6119 |
HCPCS Procedure Code - 3 |
T |
5 |
Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association |
|
|
OP6120 |
Modifier - 1 (HCPCS & CPT-4) - 3 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6121 |
Modifier - 2 (HCPCS & CPT-4) - 3 |
T |
2 |
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code |
|
|
OP6122 |
Service Units - 3 |
N |
7 |
A quantitative measure of services rendered by the Revenue Center |
|
|
OP6197 |
Filler |
T |
6 |
||
|
OP6123 |
Outpatient Total Charges - 3 |
N |
10 |
Negative charges not accepted Two decimal places implied |
|
|
OP6198 |
Filler |
T |
10 |
||
|
OP6124 |
Service Date - 3 |
T |
8 |
The 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" CCYYMMDD |
|
|
OP6199 |
Filler |
T |
1 |
||
|
OP6125 |
Place of Service - 1 |
January 1, 2020 |
T |
2 |
CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006 |
|
OP6126 |
Rendering Provider NPI - 1 |
January 1, 2020 |
T |
16 |
National Provider Identifier for Rendering Provider, the individual providing the service. |
|
OP6127 |
Place of Service - 2 |
January 1, 2020 |
T |
2 |
CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006 |
|
OP6128 |
Rendering Provider NPI - 2 |
January 1, 2020 |
T |
16 |
National Provider Identifier for Rendering Provider, the individual providing the service. |
|
OP6129 |
Place of Service - 3 |
January 1, 2020 |
T |
2 |
CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006 |
|
OP6130 |
Rendering Provider NPI - 3 |
January 1, 2020 |
T |
16 |
National 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.
Outpatient Data Submission Specifications Record Type 71 - ICD-10 CM Principal and Reason for Visit Diagnosis Codes, ICD-10 PCS Principal Procedure Code
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
OP7101 |
Record Type |
10/1/2014 |
T |
2 |
71 |
|
OP7102 |
Sequence Number |
10/1/2014 |
T |
2 |
01 |
|
OP7103 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
OP7104 |
Principal Diagnosis |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7105 |
Filler |
T |
3 |
||
|
OP7106 |
Filler |
T |
10 |
||
|
OP7107 |
Reason for Visit Diagnosis - 1 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7108 |
Reason for Visit Diagnosis - 2 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7109 |
Reason for Visit Diagnosis - 3 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7110 |
Principal Procedure Code |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7111 |
Principal Procedure Date |
10/1/2014 |
T |
8 |
CCYYMMDD |
Outpatient Data Submission Specifications Record Type 72 - ICD-10 PCS Other Procedure Codes
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
OP7201 |
Record Type |
10/1/2014 |
T |
2 |
72 |
|
OP7202 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 03 |
|
OP7203 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
OP7204 |
Other Procedure Code - 1 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7205 |
Other Procedure Date - 1 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7206 |
Other Procedure Code - 2 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7207 |
Other Procedure Date - 2 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7208 |
Other Procedure Code - 3 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7209 |
Other Procedure Date - 3 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7210 |
Other Procedure Code - 4 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7211 |
Other Procedure Date - 4 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7212 |
Other Procedure Code - 5 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7213 |
Other Procedure Date - 5 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7214 |
Other Procedure Code - 6 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7215 |
Other Procedure Date - 6 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7216 |
Other Procedure Code - 7 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7217 |
Other Procedure Date - 7 |
10/1/2014 |
T |
8 |
CCYYMMDD |
|
OP7218 |
Other Procedure Code - 8 |
10/1/2014 |
T |
10 |
If 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 Justified |
|
OP7219 |
Other Procedure Date - 8 |
10/1/2014 |
T |
8 |
CCYYMMDD |
Record Type 73 - ICD-10 CM External Cause of Injury Diagnosis Codes
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
OP7301 |
Record Type |
10/1/2014 |
T |
2 |
73 |
|
OP7302 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 02 |
|
OP7303 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
OP7304 |
External Cause of Injury - 1 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7305 |
Filler |
T |
3 |
||
|
OP7306 |
External Cause of Injury - 2 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7307 |
Filler |
T |
3 |
||
|
OP7308 |
External Cause of Injury - 3 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7309 |
Filler |
T |
3 |
||
|
OP7310 |
External Cause of Injury - 4 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7311 |
Filler |
T |
3 |
||
|
OP7312 |
External Cause of Injury - 5 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7313 |
Filler |
T |
3 |
||
|
OP7314 |
External Cause of Injury - 6 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7315 |
Filler |
T |
3 |
||
|
OP7316 |
External Cause of Injury - 7 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7317 |
Filler |
T |
3 |
||
|
OP7318 |
External Cause of Injury - 8 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7319 |
Filler |
T |
3 |
||
|
OP7320 |
External Cause of Injury - 9 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7321 |
Filler |
T |
3 |
||
|
OP7322 |
External Cause of Injury - 10 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7323 |
Filler |
T |
3 |
||
|
OP7324 |
External Cause of Injury - 11 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7325 |
Filler |
T |
3 |
||
|
OP7326 |
External Cause of Injury - 12 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7327 |
Filler |
T |
3 |
Outpatient Data Submission Specifications Record Type 74 - ICD-10 CM Other Diagnosis Information
|
Data Element # |
Data Element Name |
Implementation Date For New Data Elements |
Type |
Length |
Description |
|
OP7401 |
Record Type |
10/1/2014 |
T |
2 |
74 |
|
OP7402 |
Sequence Number |
10/1/2014 |
T |
2 |
01 - 02 |
|
OP7403 |
Patient Control Number |
10/1/2014 |
T |
20 |
Assigned by facility |
|
OP7404 |
Other Diagnosis Code - 1 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7405 |
Filler |
T |
3 |
||
|
OP7406 |
Other Diagnosis Code - 2 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7407 |
Filler |
T |
3 |
||
|
OP7408 |
Other Diagnosis Code - 3 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7409 |
Filler |
T |
3 |
||
|
OP7410 |
Other Diagnosis Code - 4 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7411 |
Filler |
T |
3 |
||
|
OP7412 |
Other Diagnosis Code - 5 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7413 |
Filler |
T |
3 |
||
|
OP7414 |
Other Diagnosis Code - 6 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7415 |
Filler |
T |
3 |
||
|
OP7416 |
Other Diagnosis Code - 7 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7417 |
Filler |
T |
3 |
||
|
OP7418 |
Other Diagnosis Code - 8 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7419 |
Filler |
T |
3 |
||
|
OP7420 |
Other Diagnosis Code - 9 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7421 |
Filler |
T |
3 |
||
|
OP7422 |
Other Diagnosis Code - 10 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7423 |
Filler |
T |
3 |
||
|
OP7424 |
Other Diagnosis Code - 11 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7425 |
Filler |
T |
3 |
||
|
OP7426 |
Other Diagnosis Code - 12 |
10/1/2014 |
T |
10 |
ICD-10 CM - do not code decimal point - Left Justified |
|
OP7427 |
Filler |
T |
3 |
Outpatient Data Submission Specifications Record Type 80 - Provider Data
|
Data Element # |
Data Element |
Implementation Date for New Data Elements |
Type |
Length |
Description/Codes/Sources |
|
OP8001 |
Record Type |
T |
2 |
80 |
|
|
OP8002 |
Sequence |
T |
2 |
01 |
|
|
OP8003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP8097 |
Filler |
T |
2 |
||
|
OP8004 |
Attending Provider NPI |
T |
16 |
NPI of Attending Provider; Attending provider is located on UB-04 |
|
|
OP8005 |
Operating Physician NPI |
T |
16 |
NPI of Operating Physician; Operating physician is located on UB-04. |
|
|
OP8098 |
Filler |
T |
32 |
||
|
OP8006 |
Attending Provider Last Name |
T |
16 |
Cannot be blank if OP8004 is present on a facility/institutional claim. |
|
|
OP8007 |
Attending Provider First Name |
T |
8 |
Cannot be blank if OP8004 is present on a facility/institutional claim. |
|
|
OP8008 |
Attending Provider Middle Initial |
T |
1 |
||
|
OP8009 |
Operating Physician Last Name |
T |
16 |
Must be populated when OP8005 is populated. |
|
|
OP8010 |
Operating Physician First Name |
T |
8 |
Cannot be blank if OP8005 is populated. |
|
|
OP8011 |
Operating Physician Middle Initial |
T |
1 |
||
|
OP8099 |
Filler |
T |
52 |
||
|
OP8012 |
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 |
|
OP9001 |
Record Type |
T |
2 |
90 |
|
|
OP9002 |
Filler (National Use) |
T |
2 |
||
|
OP9003 |
Patient Control Number |
T |
20 |
Assigned by the facility |
|
|
OP9098 |
Filler |
T |
40 |
||
|
OP9004 |
Total Ancillary Charges - Revenue Centers |
N |
10 |
Must equal the sum of line item charges excluding revenue center code 0001 if present. Two decimal positions implied |
|
|
OP9099 |
Filler |
T |
118 |
||
|
OP9901 |
Record Type |
T |
2 |
99 |
|
|
OP9998 |
Filler |
T |
190 |
|
Data Element # |
Data Element Name |
UB-04 Form Locator |
CMS-1500 |
HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
|
OP0101 |
Record Type |
NA |
NA |
NA |
|
OP0102 |
MHDO-Assigned Hospital ID |
NA |
NA |
NA |
|
OP0103 |
Hospital Name |
1 |
33 |
837/2010AA/NM1/85/2/03 |
|
OP0104 |
Address |
1 |
33 |
837/2010AA/N3/01 |
|
OP0105 |
City |
1 |
33 |
837/2010AA/N4/01 |
|
OP0106 |
State |
1 |
33 |
837/2010AA/N4/02 |
|
OP0107 |
Zip Code |
1 |
33 |
837/2010AA/N4/03 |
|
OP0108 |
Version |
NA |
NA |
NA |
|
OP2001 |
Record Type |
NA |
NA |
NA |
|
OP2003 |
Patient Control Number |
3A |
26 |
837/2300/CLM/01 |
|
OP2004 |
Patient Sex |
11 |
3 |
837/2010CA/DMG/03 or 837/2010BA/DMG/03 |
|
OP2005 |
Patient Birth Date |
10 |
3 |
837/2010CA/DMG/D8/02 or 837/2010BA/DMG/D8/02 |
|
OP2007 |
Point of Origin for Admission or Visit |
15 |
NA |
837/2300/CL1/02 |
|
OP2008 |
Patient City |
9B |
5 |
837/2010CA/N4/01 or 837/2010BA/N4/01 |
|
OP2009 |
Patient State |
9C |
5 |
837/2010CA/N4/02 837/2010BA/N4/02 |
|
OP2010 |
Patient Zip Code |
9D |
5 |
837/2010CA/N4/03 837/2010BA/N4/03 |
|
OP2011 |
Admission/Start of Care Date |
12 |
NA |
837/2300/DTP/435/D8/03 |
|
OP2012 |
Statement Covers Period - From |
6 |
24A |
837I/2300/DTP/434/RD8/03 837P/2400/DTP/472/RD8/03 |
|
OP2013 |
Statement Covers Period - Thru |
6 |
24A |
837I/2300/DTP/434/RD8/03 837P/2400/DTP/472/RD8/03 |
|
OP2014 |
Patient Discharge Status |
17 |
NA |
837/2300/CL1/03 |
|
OP2015 |
Medical/Health Record Number |
3B |
NA |
837/2300/REF/EA/02 |
|
OP2016 |
Race |
NA |
NA |
837/2010CA/DMG/05 |
|
OP2017 |
Ethnicity |
NA |
NA |
837/2010CA/DMG/05 |
|
OP2018 |
Patient Country Code |
9E |
NA |
837/2010CA/N4/04 837/2010BA/N4/04 |
|
OP2019 |
Patient Last Name |
8B |
2 |
837/2010CA/NM1/QC/1/03 837/2010BA/NM1/IL/1/03 |
|
OP2020 |
Patient First Name |
8B |
2 |
837/2010CA/NM1/QC/1/04 837/2010BA/NM1/IL/1/04 |
|
OP2021 |
Patient Middle Name or Initial |
8B |
2 |
837/2010CA/NM1/QC/1/05 837/2010BA/NM1/IL/1/05 |
|
OP2022 |
Patient Name Suffix |
8B |
2 |
837/2010CA/NM1/QC/1/07 837/2010BA/NM1/IL/1/07 |
|
OP2023 |
Patient Address Line 1 |
9A |
5 |
837/2010CA/N3/01 837/2010BA/N3/01 |
|
OP2024 |
Patient Address Line 2 |
9A |
5 |
837/2010CA/N3/02 837/2010BA/N3/02 |
|
OP3001 |
Record Type |
NA |
NA |
NA |
|
OP3002 |
Sequence Number |
NA |
NA |
837/2000B/SBR/01 |
|
OP3003 |
Patient Control Number |
3A |
26 |
837/2300/CLM/01 |
|
OP3005 |
Social Security Number |
NA |
NA |
NA |
|
OP3007 |
Insured's Group Number (Primary) |
62A |
11 |
837/2000B/SBR/P/03 |
|
Insured's Group Number (Secondary) |
62B |
9A |
837/2320/SBR/S/03 |
|
|
OP3008 |
Insured's Unique Identifier (Primary) |
60A |
1A |
837/2010BA/NM1/MI/09 |
|
Insured's Unique Identifier (Secondary) |
60B |
NA |
837/2330A/NM1/MI/09 |
|
|
OP3009 |
Payer Name (Primary) |
50A |
Header/ Carrier Block |
837/2010BB/NM1/PR/2/03 |
|
Payer Name (Secondary) |
50B |
Header/ Carrier Block |
837/2330B/NM1/PR/2/03 |
|
|
OP4001 |
Record Type |
NA |
NA |
NA |
|
OP4002 |
Sequence Number |
NA |
NA |
NA |
|
OP4003 |
Patient Control Number |
3A |
26 |
837/2300/CLM/01 |
|
OP4004 |
Type of Bill |
4 |
NA |
837/2300/CLM/A/05-1 837/2300/CLM/05-3 |
|
OP4005 |
Location of Service |
NA |
NA |
Hospital 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). |
|
OP4006 |
Place of Service |
NA |
24B |
837/2300/CLM/05-1 |
|
OP6101 |
Record Type |
NA |
NA |
NA |
|
OP6102 |
Sequence Number |
NA |
NA |
NA |
|
OP6103 |
Patient Control Number |
3A |
26 |
837/2300/CLM/01 |
|
OP6104 |
Revenue Center Code - 1 |
42 |
NA |
837/2400/SV2/01 |
|
OP6105 |
HCPCS Procedure Code - 1 |
44 |
24D-1 |
837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2 |
|
OP6106 |
Modifier - 1 (HCPCS & CPT-4) - 1 |
44 |
24D-1 |
837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3 |
|
OP6107 |
Modifier - 2 (HCPCS & CPT-4) - 1 |
44 |
24D-1 |
837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4 |
|
OP6108 |
Service Units - 1 |
46 |
24G-1 |
837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 |
|
OP6109 |
Outpatient Total Charges - 1 |
47 |
24F-1 |
837I/2400/SV2/03 837P/2400/SV1/02 |
|
OP6110 |
Service Date - 1 |
45 |
24A-1 |
837/2400/DTP/472/D8/03 |
|
OP6111 |
Revenue Center Code - 2 |
42 |
NA |
837/2400/SV2/01 |
|
OP6112 |
HCPCS Procedure Code - 2 |
44 |
24D-2 |
837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2 |
|
OP6113 |
Modifier - 1 (HCPCS & CPT-4) - 2 |
44 |
24D-2 |
837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3 |
|
OP6114 |
Modifier - 2 (HCPCS & CPT-4) - 2 |
44 |
24D-2 |
837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4 |
|
OP6115 |
Service Units - 2 |
46 |
24G-2 |
837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 |
|
OP6116 |
Outpatient Total Charges - 2 |
47 |
24F-2 |
837I/2400/SV2/03 837P/2400/SV1/02 |
|
OP6117 |
Service Date - 2 |
45 |
24A-2 |
837/2400/DTP/472/D8/03 |
|
OP6118 |
Revenue Center Code - 3 |
42 |
NA |
837/2400/SV2/01 |
|
OP6119 |
HCPCS Procedure Code - 3 |
44 |
24D-3 |
837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2 |
|
OP6120 |
Modifier - 1 (HCPCS & CPT-4) - 3 |
44 |
24D-3 |
837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3 |
|
OP6121 |
Modifier - 2 (HCPCS & CPT-4) - 3 |
44 |
24D-3 |
837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4 |
|
OP6122 |
Service Units - 3 |
46 |
24G-3 |
837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04 |
|
OP6123 |
Outpatient Total Charges - 3 |
47 |
24F-3 |
837I/2400/SV2/03 837P/2400/SV1/02 |
|
OP6124 |
Service Date - 3 |
45 |
24A-3 |
837/2400/DTP/472/D8/03 |
|
OP6125 |
Place of Service - 1 |
NA |
24B |
837/2400/SV1/05 |
|
OP6126 |
Rendering Provider NPI - 1 |
NA |
24J |
837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09 |
|
OP6127 |
Place of Service - 2 |
NA |
24B |
837/2400/SV1/05 |
|
OP6128 |
Rendering Provider NPI - 2 |
NA |
24J |
837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09 |
|
OP6129 |
Place of Service - 3 |
NA |
24B |
837/2400/SV1/05 |
|
OP6130 |
Rendering Provider NPI - 3 |
NA |
24J |
837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09 |
