Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part VI - Health Care Cost Containment Council
Chapter 913 - PAYOR DATA REPORTING REQUIREMENTS
Subchapter D - INTERPRETATIONS
Appendix A - PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM
Universal Citation: 28 PA Code ยง A
Current through Register Vol. 54, No. 12, March 23, 2024
HOSPITAL/AMBULATORY SERVICE FACILITY PAYMENTS AND PHYSICIAN PAYMENTS REPORTING MANUAL
HC-87-101
VOLUME B
TABLE OF CONTENTS
| I. | Facility and Physician Payments Reporting Manual. |
| II. | Header Record Manual. |
| III. | Trailer Record Manual. |
| IV. | Tape Format for Facility and Physician Payments Reporting. |
INDEX
| DATA ELEMENT NAME | FIELD # |
| Certification/SSN/Health Insurance Claim Number | 20 |
| Date of Admission/Start of Care/Date of Service | 6 |
| Date of Discharge/End of Care/Last Date of Service | 7 |
| Identifier of Physician | 10 |
| Other Payments | 15 |
| Patient Control Number | 17 |
| Patient's Birthdate | 4 |
| Patient - Uniform Identification | 3 |
| Patient Relationship to Insured | 19 |
| Patient's Sex | 5 |
| Payor Group Number | 16 |
| Place of Service | 2 |
| Primary Payor Payments | 14 |
| Procedure Code | 8 |
| Procedure Coding Method Used | 18 |
| Record Type | 1 |
| Reserve Field | 21 |
| Total Charges | 13 |
| Type of Professional Service | 11 |
| Uniform Identifier of Health Care Facility | 9 |
| Units of Service | 12 |
I. REPORTING MANUAL
| FIELD: 1 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Record Type |
| DEFINITION: | Indicator distinguishing between the different types of records. |
| PROCEDURE: | 1 = Facility payment record. |
| 2 = Physician payment record. | |
| 3 = Continuing physician payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.) | |
| 4 = Continuing facility payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.) | |
| 5 = This record is a delivery which includes newborn payments. | |
| FIELD SIZE: | 1 field, 1 character |
| RECORD POSITION: | 1 |
| FORMAT: | Numeric |
| FIELD: 2 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Place of Service |
| DEFINITION: | Type of setting. |
| PROCEDURE: | 1 = Hospital Inpatient |
| 2 = Hospital Outpatient | |
| 3 = Other Ambulatory Service Facility | |
| 4 = Unknown | |
| FIELD SIZE: | 1 field, 1 character |
| RECORD POSITION: | 2 |
| FORMAT: | Numeric |
| FIELD: 3 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Uniform Patient I.D. |
| DEFINITION: | Patient's Social Security Number. |
| PROCEDURES: | Left justify. No dashes. If the patient's Social Security Number is unknown, fill this field with zeroes. |
| FIELD SIZE: | 1 field, 9 characters. |
| RECORD POSITION: | 3-11 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, Item 2a. |
| FIELD: 4 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Patient's Birthdate. |
| DEFINITION: | The date of birth of the patient. |
| PROCEDURE: | MMDDYYYY. If full birthdate is unknown, place the patient's year of birth in this field. Right justify. No dashes. |
| FIELD SIZE: | 1 field, 8 characters. |
| RECORD POSITION: | 12-19 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, Item 12 or HCFA 1500, Item 2 |
| FIELD: 5 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Patient's Sex. |
| DEFINITION: | The sex of the patient as recorded at the date of admission, outpatient service, or start of care. |
| PROCEDURE: | M = Male or 1 = Male |
| F = Female 2 = Female | |
| U = Unknown 3 = Unknown | |
| M, F, U is the preferred method. Data submitted in the format of a 1, 2, or 3 will be converted to M, F, or U by the Council. Edit reports to data sources will contain M, F, U. | |
| FIELD SIZE: | 1 field, 1 character. |
| RECORD POSITION: | 20 |
| FORMAT: | Alphanumeric |
| REFERENCE: | UB-82, item 13 or HCFA 1500, item 5 |
| FIELD: 6 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Date of Admission/Start of Care/First Date of Service |
| DEFINITION: | The date that the patient was admitted to the provider for inpatient care, outpatient services, start of care or the beginning date of the period covered by this bill. |
| PROCEDURE: | MMDDYY. |
| FIELD SIZE: | 1 field, 6 characters. |
| RECORD POSITION: | 21-26 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 15 or HCFA 1500, item 20 (the first 6 characters of this field.) |
| FIELD: 7 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Date of Discharge/End of Care/Last Date of Service |
| DEFINITION: | The ending service date of the period covered by this bill or the date that the patient was discharged from the provider's care. |
| PROCEDURE: | MMDDYY. |
| FIELD SIZE: | 1 field, 6 characters. |
| RECORD POSITION: | 27-32 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 22 (the last 6 characters in this field.) or HCFA 1500, item 20 (the last 6 characters of this field.) |
| FIELD: 8 | |
| REQUIRED: | Physician Payments Reporting Only (Blank fill for Facility Payments Records.) |
| DATA ELEMENT: | Procedure Code |
| DEFINITION: | Surgical Procedure Code, if any. Other procedure codes when available. |
| PROCEDURE: | The code structure must be consistent with the information provided in field 18. This field is required if field 11 is equal to an 02 or 05. This field is optional if field 11 is equal to an 01, 03, or 04. Use ICD-9-CM, HCPCS or CPT-4 codes. Left justify. Use decimal. Blank fill right. If unknown, blank fill. |
| FIELD SIZE: | 1 field, 9 characters |
| RECORD POSITION: | 33-41 |
| FORMAT: | Alphanumeric |
| REFERENCE: | UB-82, item 84 or HCFA 1500, item 24d |
| FIELD: 9 | |
| REQUIRED: | Facility Payments Reporting Only (Blank fill for Physician Payments Records.) |
| DATA ELEMENT: | Uniform Identifier for Health Care Facility |
| DEFINITION: | Medicaid Number, Federal Tax I.D. Number, or Medicare Number. |
| PROCEDURE: | Character 1: 1 or A = Medicaid Number 2 or B = Tax I.D. Number 3 or C = Medicare Number |
| Characters 2-11: Medicaid Number, Tax I.D. Number, or Medicare Number. Left justify. | |
| The Medicaid Number is the preferred number. Data Sources using other numbering systems must provide the Council with a Facility I.D. Dictionary on tape according to a format approved by the Council. The facility I.D. dictionary must have one number for each separately licensed facility. | |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 42-52 |
| FORMAT: | Alphanumeric |
| REFERENCE: | UB-82, item 6 |
| FIELD: 10 | |
| REQUIRED: | Physician Payments Reporting Only (Blank fill for Facility Payments Records.) |
| DATA ELEMENT: | Identifier of Physician |
| DEFINITION: | PA State License Number, Social Security Number, or Tax I.D. of the Physician. Other Unique Provider Numbers may be acceptable, however, prior approval must be obtained from the Council. |
| PROCEDURE: | Character 1: 1 or A = PA State License 2 or B = S.S. Number 3 or C = Tax I.D. Number 4 or D = Unique Provider Number |
| Characters 2-10 = PA State License, S.S. Number, Tax I.D., Unique Provider Number | |
| Characters 11-20 = Physician Last Name | |
| Characters 21-22 = Physician First and Middle Initial | |
| Left Justify, Blank fill. The Pa. State license number is the preferred number. Data sources using other numbering systems must provide the Council with a dictionary of physician I.D. numbers on tape according to a format approved by the Council. (The approved format is described in Appendix B.) The Physician I.D. dictionary must have one number for each separately licensed physician. | |
| FIELD SIZE: | 1 field, 22 characters |
| RECORD POSITION: | 53-74 |
| FORMAT: | Alphanumeric |
| REFERENCE: | HCFA 1500, item 33. |
| FIELD: 11 | |
| REQUIRED: | Physician Payments Reporting Only (Zero fill for Facility Payments Records.) |
| DATA ELEMENT: | Type of Professional Service |
| DEFINITION: | The type of service that the physician performed for which payment is expected. |
| PROCEDURE: | 01 = Medical, Consulting, Psychiatric (Includes drug abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in Surgery |
| FIELD SIZE: | 1 field, 2 characters |
| RECORD POSITION: | 75-76 |
| FORMAT: | Numeric |
| REFERENCE: | HCFA 1500, item 24c |
| FIELD: 12 | |
| REQUIRED: | Physician Payments Reporting Only (Zero fill for Facility Payments records.) |
| DATA ELEMENTS: | Units of Service |
| DEFINITION: | If available, enter the total number of identical procedures or services, such as hospital visits. |
| PROCEDURE: | Right justify. Fill with zeroes left. |
| FIELD SIZE: | 1 field, 3 characters |
| RECORD POSITION: | 77-79 |
| FORMAT: | Numeric |
| REFERENCE: | HCFA 1500, item 24g |
| FIELD: 13 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Total Charges |
| DEFINITION: | Total charges pertaining to the current billing period as entered in the statement covers period. |
| PROCEDURES: | Facility total Charges = Place total charges as stated in the definition above. Physician total Charges = Place the total charge for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows: |
| 1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record. | |
| 2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service. c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments | |
| 3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal. | |
| FIELD SIZE: | 1 field, 8 characters Character 1-6 = dollars Character 7-8 = cents |
| RECORD POSITIONS: | 80-87 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 53 (Last line of this field.) or HCFA 1500, item 24f |
| FIELD: 14 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Primary Payor Payments |
| DEFINITION: | Total of all payments made by the payor to the health care facility or professional for services rendered to the patient for the episode of illness indicated in fields 6 and 7. |
| PROCEDURE: | Facility payments = Place total Primary Payor Payments as stated in the definition above. Physician payments = Place the total Primary Payor Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows: |
| 1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record. | |
| 2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments | |
| 3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal. | |
| FIELD SIZE: | 1 field, 8 characters Character 1-6 = dollars Character 7-8 = cents |
| RECORD POSITION: | 88-95 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 55 |
| FIELD: 15 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Other Payments |
| DEFINITION: | The sum of deductible amounts and co-pay amounts that are attributed to the patients responsibility or other secondary payors. |
| PROCEDURE: | Facility other payments = Place total of Other Payments as stated in the definition above. Physician other payments = Place the total of Other Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows: |
| 1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record. | |
| 2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments | |
| 3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No Decimal. | |
| FIELD SIZE: | 1 field 8 characters Character 1-6 = dollars Character 7-8 = cents |
| RECORD POSITION: | 96-103 |
| FORMAT: | Numeric |
| FIELD: 16 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Payor Group Number |
| DEFINITION: | The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered. |
| PROCEDURE: | Left justify. |
| FIELD SIZE: | 1 field, 17 characters |
| RECORD POSITION: | 104-120 |
| FORMAT: | Alphanumeric |
| REFERENCE: | UB-82, item 70 or HCFA 1500, item 8 |
| FIELD: 17 | |
| REQUIRED: | Facility Payments Reporting Only (Blank fill for Physician Payments Records.) |
| DATA ELEMENT: | Patient Control Number |
| DEFINITION: | Patient's unique alphanumeric number assigned by the carrier to facilitate retrieval of individual case records and posting of the payment. This field is optional. |
| PROCEDURE: | Left justify. |
| FIELD SIZE: | 1 field, 17 characters |
| RECORD POSITION: | 121-137 |
| FORMAT: | Alphanumeric |
| FIELD: 18 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Procedure Coding Method Used |
| DEFINITION: | An indicator that identifies the coding method used for procedure coding on this bill. |
| PROCEDURE: | 1-3 = Reserved for state assignment 4 = CPT-4 5 = HCPCS (HCFA Common Procedure Coding System) 6-8 = Reserved for National assignment 9 = ICD-9-CM |
| FIELD SIZE: | 1 field, 1 character |
| RECORD POSITION: | 138 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 82 |
| FIELD: 19 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Patient's Relationship to Insured |
| DEFINITION: | A code indicating the relationship of the patient to the identified insured. |
| PROCEDURE: | Use coding as follows: 1 = Self 2 = Spouse 3 = Child 4 = Other Right justify. Zero fill left. |
| FIELD SIZE: | 1 field, 2 characters |
| RECORD POSITION: | 139-140 |
| FORMAT: | Numeric |
| REFERENCE: | UB-82, item 67 a or HCFA 1500, item 7 |
| FIELD: 20 | |
| REQUIRED: | Facility and Physician Payments Reporting |
| DATA ELEMENT: | Certificate/Social Security Number/Health Insurance Claim/Identification Number. |
| DEFINITION: | Insured's unique identification number assigned by the payor organization. |
| PROCEDURE: | Left justify. |
| FIELD SIZE: | 1 field, 16 characters |
| RECORD POSITION: | 141-156 |
| FORMAT: | Alphanumeric |
| REFERENCE: | UB-82, item 68 or HCFA 1500, item 6 |
| FIELD: 21 | |
| DATA ELEMENT: | Reserve Field |
| DEFINITION: | To be reserved for future use by the Council. |
| FIELD SIZE: | 1 field filler, 144 characters |
| RECORD POSITION: | 157-300 |
| FORMAT: | Alphanumeric |
| II. HEADER RECORD | |
| FIELD: 1 | |
| DATA ELEMENT: | Data Source Identifier |
| DEFINITION: | Number identifying the data source. Third party payors - use your payor number. |
| PROCEDURE: | Left justify. Blank fill right. |
| FIELD SIZE: | 1 field, 25 characters |
| RECORD POSITION: | 1-25 |
| FORMAT: | Alphanumeric |
| FIELD: 2 | |
| DATA ELEMENT: | Data Source Name/Address |
| DEFINITIONS: | Name and address of the data source. |
| PROCEDURE: | Left justify. Fill with blanks right. Space between lines of name and address. |
| FIELD SIZE: | 1 field, 4 lines, 100 characters |
| RECORD POSITION: | 26-125 |
| FORMAT: | Alphanumeric |
| FIELD: 3 | |
| DATA ELEMENT: | Period Covered First Day |
| DEFINITION: | The first day of the quarter from which the data provided on this tape was contained. |
| PROCEDURE: | MMDDYY. |
| FIELD SIZE: | 1 field, 6 characters |
| RECORD POSITION: | 126-131 |
| FORMAT: | Numeric |
| FIELD: 4 | |
| DATA ELEMENT: | Period Covered Last Day |
| DEFINITION: | The last day of the quarter from which the data provided on this tape was contained. |
| PROCEDURE: | MMDDYY. |
| FIELD SIZE: | 1 field, 6 characters |
| RECORD POSITION: | 132-137 |
| FORMAT: | Numeric |
| FIELD: 5 | |
| DATA ELEMENT: | Run Date |
| DEFINITION: | The date that the data source produced this tape. |
| PROCEDURE: | MMDDYY. |
| FIELD SIZE: | 1 field, 6 characters |
| FIELD POSITION: | 138-143 |
| FORMAT: | Numeric |
| FIELD: 6 | |
| DATA ELEMENT: | Filler |
| FIELD SIZE: | 1 field filler, 157 characters |
| RECORD POSITION: | 144-300 |
| FORMAT: | Alphanumeric |
| III. TRAILER RECORD | |
| FIELD: 1 | |
| DATA ELEMENT: | Number of records on this tape. |
| DEFINITION: | Total number of records contained on this tape, not including the Header and Trailer Records. This number should count each multi-page as one record. |
| PROCEDURE: | Right justify. |
| FIELD SIZE: | 1 field, 10 characters |
| RECORD POSITION: | 1-10 |
| FORMAT: | Numeric |
| FIELD: 2 | |
| DATA ELEMENT: | Number of Patients on This Tape. |
| DEFINITION: | Total number of patients contained on this tape. |
| PROCEDURE: | Right justify. |
| FIELD SIZE: | 1 field, 10 characters |
| RECORD POSITION: | 11-20 |
| FORMAT: | Numeric |
| FIELD: 3 | |
| DATA ELEMENT: | Total Physician Charges |
| DEFINITION: | Total of all Physician Charges on this tape. |
| PROCEDURE: | Sum of all fields 13 (Total Charges) when field 1 is equal to 2. Right justify. The last two digits are for cents. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 21-31 |
| FORMAT: | Numeric |
| FIELD: 4 | |
| DATA ELEMENT: | Total Facility Charges |
| DEFINITION: | Total of all Facility Charges on this tape. |
| PROCEDURE: | Sum of all fields 13 (Total Charges) when field 1 is equal to 1. Right justify. The last two digits are for cents. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 32-42 |
| FORMAT: | Numeric |
| FIELD: 5 | |
| DATA ELEMENT: | Total Physician Payments |
| DEFINITION: | Total of all Physician Payments on this tape. |
| PROCEDURE: | Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 43-53 |
| FORMAT: | Numeric |
| FIELD: 6 | |
| DATA ELEMENT: | Total Facility Payments |
| DEFINITION: | Total of all Facility Payments on this tape. |
| PROCEDURE: | Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 1. Right justify. The last two digits are for cents. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 54-64 |
| FORMAT: | Numeric |
| FIELD: 7 | |
| DATA ELEMENT: | Total Other Payments (Physician) |
| DEFINITION: | Total of all Other Payments to Physicians on this tape. |
| PROCEDURE: | Sum of all fields 15 (Other Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 65-75 |
| FORMAT: | Numeric |
| FIELD: 8 | |
| DATA ELEMENT: | Total Other Payments (Facility) |
| DEFINITION: | Total of all Other Payments to Facilities on this tape. |
| PROCEDURE: | Sum of all fields 15 (Other Payments) when field 1 is equal to 1. |
| FIELD SIZE: | 1 field, 11 characters |
| RECORD POSITION: | 76-86 |
| FORMAT: | Numeric |
| FIELD: 9 | |
| DATA ELEMENT: | Filler |
| FIELD SIZE: | 1 field filler, 214 characters |
| RECORD POSITION: | 87-300 |
| FORMAT: | Alphanumeric |
| DATA ELEMENT | DATA ELEMENT DESCRIPTION | POSITION | PICTURE | FORMAT | |
| FROM | TO | ||||
| HEADER RECORD | |||||
| 1 | Data Source Identifier | 1 | 25 | X(25) | Left justify. Blank fill right. |
| 2 | Data Source Name | 26 | 125 | X(100) | 4 lines. 25 characters each. |
| 3 | Period Covered First Day | 126 | 131 | 9(6) | MMDDYY. |
| 4 | Period Covered Last Day | 132 | 137 | 9(6) | MMDDYY. |
| 5 | Run Date | 138 | 143 | 9(6) | MMDDYY. Date that this tape was created. |
| 6 | Filler | 144 | 300 | X(157) | |
TAPE FORMAT FOR HOSPITAL/AMBULATORY SERVICE FACILITY PAYMENTS AND PHYSICIAN PAYMENTS REPORTING MANUAL HC-87-101B
| DATA ELEMENT | DATA ELEMENT DESCRIPTION | POSITION | PICTURE | FORMAT | |
| FROM | TO | ||||
| 1 | Record Type | 1 | 9(1) | 1 = Facility payments record. 2 = Physician payments record. 3 = Continuing physician payments record. 4 = Continuing facility payments record. 5 = Delivery/ newborn record. | |
| 2 | Place of Service | 2 | 9(1) | 1 = Hospital Inpatient 2 = Hospital Outpatient 3 = Ambulatory Service Facility 4 = Unknown | |
| 3 | Uniform Patient Identifier | 3 | 11 | 9(9) | If unknown, zero fill. |
| 4 | Patient's Date of Birth | 12 | 19 | 9(8) | MMDDYYYY. If the patient date of birth is unknown, place the patient's year of birth in this field. Right justify. |
| 5 | Patient's Sex | 20 | X(1) | M = Male, F = Female, U = Unknown 1 = Male, 2 = Female, 3 = Unknown. | |
| 6 | Date of Admission/ Start of Care/Date of Service | 21 | 26 | 9(6) | MMDDYY. |
| 7 | Date of Discharge/ End of Care/Last Date of Service | 27 | 32 | 9(6) | MMDDYY. |
| 8 | Procedure Code | 33 | 41 | X(9) | Procedure code. Left justify. Use decimal. See manual for instructions. |
| 9 | Uniform Identifier of Health Care Facility | 42 | 52 | X(11) | Left justify. Blank fill right. |
| 10 | Identifier of Physician | 53 | 74 | X(22) | Left justify. Blank fill. See Manual for instructions. |
| 11 | Type of Professional Service | 75 | 76 | 9(2) | Type of service performed by the professional: 01 = Medical, Consulting, Psychiatric, (Including drug abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in surgery |
| 12 | Units of Service | 77 | 79 | 9(3) | Right justify. Fill with zeroes left. |
| 13 | Total Charges | 80 | 87 | 9(8) | 6 dollar characters, 2 cent characters. Right justify. No decimal. |
| 14 | Primary Payor Payments | 88 | 95 | 9(8) | 6 dollar characters, 2 cent characters. Right justify. No decimal. |
| 15 | Other Payments | 96 | 103 | 9(8) | 6 dollar characters, 2 cent characters. Right justify. No decimal. |
| 16 | Payor Group Number | 104 | 120 | X(17) | Left justify. |
| 17 | Patient Control Number | 121 | 137 | X(17) | Left justify. |
| 18 | Procedure Coding Method Used | 138 | 9(1) | 1 - 3 Reserved for state assignment. 4 = CPT-4 5 = HCPCS 6 - 8 = Reserved for national assignment. 9 = ICD-9-CM | |
| 19 | Patient's Relation- ship to Insured | 139 | 140 | 9(2) | Right justify. 1 = Self 2 = Spouse 3 = Child 4 = Other |
| 20 | Certification/SSN/ Health Insurance Claim Number | 141 | 156 | X(16) | Left justify. |
| 21 | Reserve Field | 157 | 300 | X(144) | To be reserved for future use by the Council. |
| *All numeric fields should be initialized to 0, and alpha numeric fields initialized to blank, before writing data to tape. Therefore, these characters (or blanks) will remain in fields where data is missing. | |||||
| DATA ELEMENT | DATA ELEMENT DESCRIPTION | POSITION | PICTURE | FORMAT | |
| FROM | TO | ||||
| TRAILER RECORD | |||||
| 1 | Number of Records on This Tape | 1 | 10 | 9(10) | Total Number of patient discharge records on this tape. |
| 2 | Number of Patients on This Tape | 11 | 20 | 9(10) | Total number of patients on this tape. |
| 3 | Total Physician Charges | 21 | 31 | 9(11) | Total of all physician charges on this tape. |
| 4 | Total Facility Charges | 32 | 42 | 9(11) | Total of all facility charges on this tape. |
| 5 | Total Physician Payments | 43 | 53 | 9(11) | Total of all physician payments on this tape. |
| 6 | Total Facility Payments | 54 | 64 | 9(11) | Total of all facility payments on this tape. |
| 7 | Total Other Payments (Physician) | 65 | 75 | 9(11) | Total of all physician other payments on this tape. |
| 8 | Total Other Payments (Facility) | 76 | 86 | 9(11) | Total of all facility other payments on this tape. |
| 9 | Filler | 87 | 300 | 9(214) | |
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