New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Appendices
Appendix C-5 - APPENDIX C-5

APPENDIX C-5.

(cf. section 400.18[h] )

Emergency Service Data elements to be submitted under section 400.18(h) shall include but shall not be limited to the following:

DATA ELEMENT

Submitter Name

Processing Data

SPARCS Identification Number

Patient Control Number

Patient Sex

Patient Birth Date

Admission Date/Start of Care

Admission Hour

Statement Covers Period - From Date

Statement Covers Period - Thru Date

Discharge Hour

Medical Record Number

New York State Patient Status or Disposition

Patient's Race

Patient's Ethnicity

Patient Residence Address - Address Line 1

Patient Residence Address - Address Line 2

Patient's City

Patient's County Code

Patient's State

Patient's Postal Service Zip Code and Extension Code

Unique Personal Identifier

Source of Payment Information

Group Definition

Source of Payment Code

Payor Identification

Provider Identification Number

Type of Bill

Occurrence Information Group Definition

Occurrence Information - Accident Related Codes & Dates

Condition Information Group Definition

Condition Information - Homeless Patients

Value Information Group Definition

Value Information - Accident Hour

Ancillary Services Information Group Def. Ver. 5 & 6

Ancillary Revenue Code

Ancillary Total Charges

Ancillary Total Non-Covered Charges

Procedure Code - CPT-4 and Modifiers

Principal/Primary Diagnosis Code

Other Diagnosis Information Group Definition

Other Diagnosis Code 1-14

Principal Procedure Code

Principal Procedure Date

Other Procedure Information Group Definition

Other Procedure Code 1-14

Other Procedure Date 1-14

Admitting Diagnosis/Patient's Reason for Visit

External Cause-of-Injury Code

Place of Injury Code

Attending/Emergency Department Physician State License Number

Operating/Emergency Department Physician State License Number

Other Physician/Emergency Department State License Number

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