§ 912.81. Provider information.
A provider shall submit the following information annually on a form designed by the Council and in accordance with a submission schedule developed by the Council.
(1) Physicians on staff. A health care facility shall submit a listing of hospital-based and nonhospital-based physicians on the active, associate, courtesy and consulting medical staff. The listing shall include physician name, Pennsylvania license number and clinical specialty. The listing shall indicate whether the physician is Board-certified in the listed specialties.
(2) Medicare assignment. A physician shall indicate whether the physician accepts Medicare assignment as full payment for services.
(3) Medical Assistance participation. A physician shall indicate whether the physician is registered as a provider with the Commonwealth’s Medical Assistance Program. If the physician is registered, the number assigned by the Medical Assistance Program shall be listed.
(4) Accreditation, certification and licensure. A provider shall submit information concerning accreditation, certification and licensure of the facility by the Commonwealth; the Joint Commission on the Accreditation of Health Care Organizations, the American Osteopathic Association, or certified for Medicare Conditions of Participation; and the Commission on the Accreditation of Rehabilitation Facilities. The information shall include the accrediting/certifying/licensing agency, the type of accreditation/certification/licensure and the term, including the expiration date.
Source The provisions of this § 912.81 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.
APPENDIX A
Pennsylvania
Uniform Claims
and
Billing Form
Reporting Manual
HC-87-101 Volume A—Inpatient Data Reporting
Pennsylvania Health Care Cost
Containment Council
Harrisburg Transportation Center
Suite 208
4th and Chestnut Streets
Harrisburg, Pennsylvania 17101
(717) 232-6787
Purpose
The purpose of this manual is to provide data sources with the technical specifications necessary for data collection and data submissions to the Council. According to Act 89, the collection of health data by the Council will be used to facilitate the continuing provision of quality, cost-effective health services throughout the Commonwealth by providing data and information to the purchasers and consumers of health care on both cost and quality of health care services.
Volume A pertains to data submission formats for hospitals and ambulatory service facilities. The Council will collect the raw data from the various data sources, using some key matching data elements, merge the data to provide records per hospitalization or major ambulatory service visit.
Table of Contents
Index Hospital and Ambulatory Service Facility Reporting Manual Header Record Manual Trailer Record Manual Hospital and Ambulatory Service Facility Tape Format Appendices
Index by Data Element Name
Data Element Name Field # UB-92 Form Locater Admission Date 5 6 Admission Hour 40 18 Admission—Type of 26 19 Admission—Source of 27 20 Admitting Diagnosis 36 76 Certification/SSN/ Health Insurance Claim Number 29a—c 60 Discharge Date 6 6 Discharge Hour 41 21 Diagnosis Related Group (DRG) 24 2h E-Code 37 77 Employer Name 32a—c 65 Employment Status 34a—c 64 Estimated Amount Due 14g 55 Federal Tax ID 39 5 HCPCS/Rates 13a—w6 44 Hispanic/Latino Origin or Descent 35a 2i Non-Covered Charges 13a—w5 48 Patient Discharge Status 20 22 Patient Date of Birth 2 14 Patient Control Number 23 3 Patient—Uniform Identification 1 2a Patient Race 35b 2j Patient Relationship to Insured 28a—c 59 Patient Sex 3 15 Patient Zip Code 4 13 Payor Group Number 19 62 Payor Identification 14b 50 Physician Identification—Attending 11 82 Physician Identification—Operating 12 83 Physician Identification—Referring 38 82 Principal Diagnosis 7a 67 Principal Procedure Code and Date 8a, 8b 80 Prior Payments—Payor and Patient 14f 54 Procedure Coding Method Used 25 79 Provider Quality 21a 2d Provider Service Effectiveness 21b 2e Revenue Code 13a—w2 42 Reserve Field 21e HC4 Secondary Diagnosis 7b—i 68—75 Secondary Procedure Code and Date 9 81 Service Date 13a—w7 45 Total Charges 13a—w4 47 Type of Bill 22 4 Uniform Identifier of Health Care Facility 10 2b Uniform Identifier of Primary Payor 17 2c Units of Service 13a—w3 46 Unusual Occurrence—Nosocomial Infection 21c 2f Unusual Occurrence—Readmission 21d 29 Index by Field Number
Data Element Name Field # UB-92 Form Locater Patient—Uniform Identification 1 2a Patient Date of Birth 2 14 Patient Sex 3 15 Patient Zip Code 4 13 Admission Date 5 6 Discharge Date 6 6 Principal Diagnosis 7a 67 Secondary Diagnosis 7b—i 68—75 Principal Procedure Code and Date 8a, 8b 80 Secondary Procedure Code and Date 9 81 Uniform Identifier of Health Care Facility 10 2b Physician Identification—Attending 11 82 Physician Identification—Operating 12 83 Revenue Code 13a—w2 42 Units of Service 13a—w3 46 Total Charges 13a—w4 47 Non-Covered Charges 13a—w5 48 HCPCS/Rates 13a—w6 44 Service Date 13a—w7 45 Payor Identification 14b 50 Prior Payments—Payor and Patient 14f 54 Estimated Amount Due 14g 55 Uniform Identifier of Primary Payor 17 2c Payor Group Number 19 62 Patient Discharge Status 20 22 Provider Quality 21a 2d Provider Service Effectiveness 21b 2e Unusual Occurrence—Nosocomial Infection 21c 2f Unusual Occurrence—Readmission 21d 29 Reserve Field 21e Type of Bill 22 4 Patient Control Number 23 3 Diagnosis Related Group (DRG) 24 2h Procedure Coding Method Used 25 79 Admission—Type of 26 19 Admission—Source of 27 20 Patient Relationship to Insured 28a—c 59 Certification/SSN/Health Insurance Claim Number 29a—c 60 Employer Name 32a—c 65 Employment Status 34a—c 64 Hispanic/Latino Origin or Descent 35a 2i Patient Race 35b 2j Admitting Diagnosis 36 76 E-Code 37 77 Physician Identification—Referring 38 82 Federal Tax ID 39 5 Admission Hour 40 18 Discharge Hour 41 21
Hospital and Ambulatory Service Facility Reporting Manual
Field 1 Revised 3/25/88, 1/1/94 Data Element: Uniform Patient ID Definition: Patient’s Social Security Number Procedures: Right justify, no dashes. If the patient’s Social Security Number is unknown, fill this field with blanks after contacting the Department of Social Security in your area. Field Size: 1 field, 9 characters Record Position: 1—9 Format: Alphanumeric Reference: UB-92, Item 2a (Pos 1—9 of 29 character field, upper line) Field 2 Revised 4/1/90 Data Element: Patient Birthdate Definition: Date of birth of the patient Procedure: MMDDYYYY, No dashes Example: 01011992 Field Size: 1 field, 8 characters Record Position: 10—17 Format: Numeric Reference: UB-92, Item 14 Field 3 Data Element: Patient Sex Definition: The sex of the patient as recorded at the date of admission, outpatient service, or start of care. Procedure: M = Male F = Female U = Unknown Field Size: 1 field, 1 character Record Position: 18 Format: Alphanumeric Reference: UB-92, Item 15 Field 4 Revised 1/1/94 Data Element: Patient Zip Code Definition: Zip code of patient taken from the patient name and address field. Procedure: XXXXXYYYY Five character zip code with a four character extension. Facility should attempt to obtain the 4 character zip code extension, however, if the four character extension is unknown, fill with blanks. Left justify. Field Size: 1 field, 9 characters Record Position: 19—27 Format: Alphanumeric Reference: UB-92, Item 13 Field 5 Revised 4/1/90 Data Element: Date of Admission Definition: The date that the patient was admitted to the provider for inpatient care or start of care. Procedure: MMDDYYYY Example: 01011992 Field Size: 1 field, 8 characters Record Position: 28—35 Format: Numeric Reference: UB-92, Item 6 (taken from the ‘‘FROM’’ Date field) Field 6 Revised 4/1/90 Data Element: Date of Discharge Definition: Inpatient: The ending service date of patient care. The date that the patient was discharged from the provider’s care. Procedure: MMDDYYYY Example: 01011992 Field Size: 1 field, 8 characters Record Position: 36—43 Format: Numeric Reference: UB-92, Item 6, (taken from ‘‘Through’’ Date field) Field 7a Revised 7/1/88, 4/1/90, 1/1/94 Data Element: Principal Diagnosis Code Definition: The code describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing this hospitalization) that exists at the time of admission or discovered subsequently that has an effect on the length of stay. Procedure: Use ICD-9-CM codes. ‘‘V’’ codes are permitted. The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. Left justify. Fill with blanks right. The code structure must be consistent with the information provided in Fields 7b—i and 25. Field Size: 1 field, 6 characters Record Position: 48—53 Format: Alphanumeric Reference: UB-92, Item 67 Field 7b, c, d, e, f, g, h, i Revised 4/1/93, 1/1/94 Data Element: Secondary Diagnosis Codes Definition: The diagnoses codes corresponding to additional conditions that co-exist at the time of admission, or discovered subsequently, and which have an effect on the treatment received or the length of stay. Procedure: The code structure must be consistent with the coding used in Fields 7a, 25 and 30. The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. Use ICD-9-CM codes. Other diagnoses codes will permit the use of ICD-9-CM ‘‘V’’—codes where appropriate. (See Field 37—E-Code to determine other E-Code placement.) Left justify. Blank fill. Field Size: 8 fields, 6 characters Record Position: 7b 54—59 7f 78—83 7c 60—65 7g 84—89 7d 66—71 7h 90—95 7e 72—77 7i 96—101 Format: Alphanumeric Reference: UB-92, Items 68—75 Field 8a, 8b Revised 1/1/94 Data Element: Principal Procedure Code and Date Definition: The code that identifies the principal procedure performed during the period between admission and discharge and the date on which the principal procedure described was performed. Procedure: The code structure must be consistent with the information provided in Fields 9 and 25. Use ICD-9-CM codes unless the payor requires HCPCS or CPT-4. The reporting of the decimal between the second and third digits is unnecessary because it is implied. Left justify. Blank fill right. The date must be equal to or greater than admission date (Field 5) and equal to or less than discharge date (Field 6). Record date as MMDD Field Size: 2 fields, 5 character Procedure Code 4 character date Record Position: 8a 114—120 (Procedure Code) 8b 121—124 (Date) Format: Procedure Code = alphanumeric Date = numeric Reference: UB-92, Item 80 Field 9a1, 9a2, 9b2, 9c1, 9c2,
9d1, 9d2, 9e1, 9e2 Revised 3/25/88, 1/1/94Data Element: Secondary Procedure Codes and Dates Definitions: The codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. Procedure: The code structure must be consistent with the information provided in Fields 8 and 25. Use ICD-9-CM codes unless the payor requires HCPCS or CPT-4. Enter codes in descending order of importance. The reporting of the decimal between the second and third digits is unnecessary because it is implied. Left justify. Blank fill right. Record date as MMDD. Date must be equal to or greater than admission date (Field 5) and equal to or less than the discharge date (Field 6). Field Size: 5 fields, 7 character Procedure Code 4 character date Record Position: 9a1 125—131 (Procedure Code) 9d1 158—164 9a2 132—135 (Date) 9d2 165—168 9b1 136—142 (Procedure Code) 9e1 169—175 9b2 143—146 (Date) 9e2 176—179 9c1 147—153 (Procedure Code) 9c2 154—157 (Date) Format: Procedure Code = alphanumeric Date = numeric Reference: UB-92, Item 81a—e Field 10 Revised 4/1/90, 7/1/88 Data Element: Uniform Identifier for Health Care Facility. Definition: Number identifying the provider facility as developed and used by Medicaid. (See Appendix A.) If your unit is not listed in Appendix A, please contact the Council in writing and we will provide you with a Council assigned number for the unit. Procedure: Left justify. Blank fill right. Field Size: 1 field, 8 characters Record Position: 1751—1758 Format: Alphanumeric Reference: UB-92, Item 2b (Pos 10—17 of 29 character field, upper line) Field 11 Revised 3/25/88, 4/1/90 Data Element: Attending Physician ID Definition: The PA state license number of the physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient’s medical care and treatment. Procedure: Character 1—9 = PA State License Number Character 10—21 = Last Name Character 22—23 = First & Middle Initials Do not place the ‘‘PA’’ in the PA State License number in this field. Format as follows: MD123456L. Left justify. Blank fill right, if name unknown. Field Size: 1 field, 23 characters Record Position: 203—225 Format: Alphanumeric Reference: UB-92, Item 82 (lower line) Field 12 Revised 3/25/88, 4/1/90 Data Element: Operating Physician ID Definition: The PA state license number of the physician other than the attending physician who performed the principal procedure. Procedure: Character 1—9 = PA State License Number Character 10—21 = Last Name Character 22—23 = First & Middle Initials Do not place the ‘‘PA’’ in the PA State License Number in this field. Format as follows: MD123456L. If no procedure performed, leave blank. Left justify. Blank fill right, if name unknown. Field Size: 1 field, 23 characters Record Position: 226—248 Format: Alphanumeric Reference: UB-92, Item 83 (lower line) Field 13a2—13w2 Data Element: Revenue Code Definition: A code which identifies a specific accommodation, ancillary service or billing calculation. Procedure: See the table that indicates payers’ specific needs for detailed revenue code information. (See Appendix C.) (See Appendix G for instructions when there are more than 23 lines which would create the need for a second page.) Left justify. Line 23 will be 001 Field Size: 23 fields, 4 characters each Format: Alphanumeric Reference: UB-92, Item 42 Record Position: 13a2 249—252 13i2 633—636 13q2 1017—1020 13b2 297—300 13j2 681—684 13r2 1065—1068 13c2 345—348 13k2 730—732 13s2 1113—1116 13d2 393—396 13l2 777—780 13t2 1161—1164 13e2 441—444 13m2 825—828 13u2 1209—1212 13f2 489—492 13n2 873—876 13v2 1257—1260 13g2 537—540 13o2 921—924 13w2 1305—1308 13h2 585—588 13p2 969—972 Field 13a3—13w3 Revised 3/25/88 Data Element: Units of Service Definition: A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints of blood, or renal dialysis treatments, etc., according to Medicare definitions. Procedure: Right justify. Zero fill left. Last line fill with zeroes. (See Appendix C.) (See Appendix G for instructions when there are more than 23 lines which would create the need for a second page.) Field Size: 23 fields, 7 characters Format: Numeric Reference: UB-92, Item 46 Record Position: 13a3 270—276 13i3 654—660 13q3 1038—1044 13b3 318—324 13j3 702—708 13r3 1086—1092 13c3 366—372 13k3 750—756 13s3 1134—1140 13d3 414—420 13l3 798—804 13t3 1182—1188 13e3 462—468 13m3 846—852 13u3 1230—1236 13f3 510—516 13n3 894—900 13v3 1278—1284 13g3 558—564 13o3 942—948 13w3 1326—1332 13h3 606—612 13p3 990—996 Field 13a4—13w4 Revised 3/25/88, 1/1/94 Data Element: Total Charges (by Revenue Code Category) Definition: Total charges pertaining to the related revenue code for the current billing period as entered in the statement covers period. Procedures: Right justify. No decimal. Line 23 is the total of all charges in this column. (See Appendix G for instructions when there are more than 23 lines which would create the need for a second page.) Field Size: 23 fields, 10 characters each: Character 1 = credit {plus(+), minus(-), blank ( )} (If a blank is found, a + is assumed.) Character 2—8 = dollars fill with zeroes from credit character when applicable Character 9—10 = cents Format: Alphanumeric Reference: UB-92, Item 47 Record Position: 13a4 277—286 13i4 661—670 13q4 1045—1054 13b4 325—334 13j4 709—718 13r4 1093—1102 13c4 373—382 13k4 757—766 13s4 1141—1150 13d4 421—430 13l4 805—814 13t4 1189—1198 13e4 469—478 13m4 853—862 13u4 1237—1246 13f4 517—526 13n4 901—910 13v4 1285—1294 13g4 565—574 13o4 949—958 13w4 1333—1342 13h4 613—622 13p4 997—1006 Field 13a5—13w5 Revised 3/25/88, 1/1/94 Data Element: Non-Covered Charges (by Revenue Category) Definition: Those charges that are not covered by a payor for this patient pertaining to the related revenue code. Procedure: Right justify. No decimal. Line 23 will be the total of all Non-Covered Charges. (See Appendix G for instructions when there are more than 23 lines which would create the need for a second page.) Field Size: 23 fields, 10 characters each: Character 1 = credit {plus, (+), minus (-), blank ( )} (If a blank is found, a + is assumed.) Character 2—8 = dollars fill with zeroes from credit character when applicable Character 9—10 = cents Format: Alphanumeric Reference: UB-92, Item 48 Record Position: 13a5 287—296 13i5 671—680 13q5 1055—1064 13b5 335—344 13j5 719—728 13r5 1103—1112 13c5 383—392 13k5 767—776 13s5 1151—1160 13d5 431—440 13l5 815—824 13t5 1199—1208 13e5 479—488 13m5 863—872 13u5 1247—1256 13f5 527—536 13n5 911—920 13v5 1295—1304 13g5 575—584 13o5 959—968 13w5 1343—1352 13h5 623—632 13p5 1007—1016 Field 13a6—13w6 Revised 1/1/94 Data Element: HCPCS/Rates Definition: The accommodation rate for inpatient bills and the HCFA Common Procedure Coding System (HCPCS) applicable to ancillary services and outpatient bills. Procedure: Inpatient Bills: Accommodations must be entered in revenue code sequence. Dollar values reported in this field must include whole dollars and cents (NNNNNNNNN). When multiple rates exist for the same accommodation revenue code (e.g., semi-private room at $300 and $310), a separate revenue line should be used to report each rate, and the same revenue code should be reported on each line. Left justified for HCPCS. Right justified for rates. Field to be further developed. Until such time, fill this field with blanks. Field Size: 1 field, 23 lines, 9 positions Format: Alphanumeric Reference: UB-92, Item FL 44 Record Position: 13a6 253—261 13i6 637—645 13q6 1021—1029 13b6 301—309 13j6 685—693 13r6 1069—1077 13c6 349—357 13k6 733—741 13s6 1117—1125 13d6 397—405 13l6 781—789 13t6 1165—1173 13e6 445—453 13m6 829—837 13u6 1213—1221 13f6 493—501 13n6 877—885 13v6 1261—1269 13g6 541—549 13o6 925—933 13w6 1309—1317 13h6 589—597 13p6 973—981 Field 13a7—13w7 Revised 1/1/94 Data Element: Service Date Definition: Date that the indicated service was provided. Procedure: MMDDYYYY Field to be further developed. Until such time, fill this field with blanks. Field Size: 1 field, 23 lines, 8 positions Format: Alphanumeric Reference: UB-92, Item FL 45 Record Position: 13a7 262—269 13i7 646—653 13q7 1030—1037 13b7 310—317 13j7 694—701 13r7 1078—1085 13c7 358—365 13k7 742—749 13s7 1126—1133 13d7 406—413 13l7 790—797 13t7 1174—1181 13e7 454—461 13m7 838—845 13u7 1222—1229 13f7 493—501 13n7 886—893 13v7 1270—1277 13g7 541—549 13o7 934—941 13w7 1318—1325 13h7 598—605 13p7 982—989 Field 14b1, 14b2, 14b3 Revised 3/25/88, 7/1/88, 4/1/90, 1/1/94 Data Element: Payor Type and Identification Definition: Code identifying the type of payor organization and the name identifying the payor organization from which the provider might expect some payment for the bill. Procedure: Place primary payor in 14b1. {If this is a bill that will be paid by the patient (self-pay), place the word ‘‘self’’ in this line.} (Where the guarantor is different than the patient, the guarantor should be listed in 14b1. If the patient and the guarantor are the same, the word ‘‘self’’ should be used in 14b1) Place secondary payor in 14b2. Place tertiary payor in 14b3. The first two digits of this field indicate the payor type. The following coding scheme is to be used to determine the appropriate code. The first digit of the two digit code indicates the type of claims paying organization that will make payment. The second digit indicates the types of product offerings of those organizations.
First Digit Second Digit Medicare 1 Unknown/Other 0 Medicaid 2 HMO/PPO 5 Blue Cross 3 Health & Welfare Fund 6 Commercial 4 Workers’ Compensation 7 Patient Direct Bill 0 Auto 8 Employer Direct Bill 5 Association 9 Other Government 8 Unknown/Other 9 Facility should utilize best judgement when determining appropriate code. Codes for Champus, Black Lung, and U.S. Postal Service should be coded as 80 = other government. The following are the valid combinations of this two digit code. Any other codes will generate an error for invalid payor code. Patient Direct Bill 00 HMO/PPO 05 Medicare 10 HMO/PPO 15 Medicaid 20 HMO/PPO 25 Blue Cross 30 HMO/PPO 35 Union Health & Welfare Fund 36 Association 39 Commercial 40 HMO/PPO 45 Union Health & Welfare Fund 46 Workers’ Compensation 47 Auto 48 Association 49 Employer Direct Bill 50 HMO/PPO 55 Union Health & Welfare Fund 56 Workers’ Compensation 57 Association 59 Other Government 80 Cat Fund 88 State Workers Insurance Fund 87 Other Unknown 90 If the payor is unknown, place the word ‘‘unknown’’ in this field. If Medicare is entered in line 14b1, this indicates that the provider has developed for other insurance and has determined that Medicare is the primary payor. Left justify Payor Name. If Field 17, Uniform Identifier of Primary Payor is blank, this field must be filled. The Council will develop uniform numbers for these payers.
Field Size: 3 fields, 25 characters each Record Position: 14b1 1353—1354 Payor code 1355—1377 Payor Name 14b2 1378—1379 Payor code 1380—1402 Payor Name 14b3 1403—1404 Payor code 1405—1427 Payor Name Format: Alphanumeric Reference: UB-92, Item 50a, b, c Field 14f1, 14f2, 14f3, 14f4 Revised 3/25/88, 1/1/94 Data Element: Prior payments—Payor and Patient Definition: The amount the hospital has received toward payment of this bill prior to the billing date, by the indicated payor. Procedure: Right justify. No decimal. Place the amount paid by the patient in 14f4. 1 = A = Primary 2 = B = Secondary 3 = C = Tertiary 4 = P = Due from patient Field Size: 1 field, 4 lines, 10 characters each Character 1 = credit {plus (+), minus (-), blank ( )} (If a blank is found, a + is assumed.) Character 2—8 = dollars fill with zeroes from credit character when applicable Character 9—10 = cents Record Position: 14f1 1428—1437 14f2 1438—1447 14f3 1448—1457 14f4 1458—1467 Format: Alphanumeric Reference: UB-92, Item 54a, b, c, p Field 14g1, 14g2, 14g3, 14g4 Revised 3/25/88, 1/1/94 Data Element: Estimated Amount Due Definition: The amount estimated by the hospital to be due from the indicated payor (estimated responsibility less prior payments). Procedure: The Council will develop a methodology to apply to all hospitals. At the present time, fill with zeroes. Field Size: 1 field, 4 lines, 10 characters each. Character 1 = credit {plus (+), minus (-), blank ( )} (If a blank is found, a + is assumed.) Character 2—8 = dollars fill with zeroes from credit character when applicable Character 9—10 = cents Record Position: 14g1 1468—1477 14g2 1478—1487 14g3 1488—1497 14g4 1498—1507 Format: Alphanumeric Reference: UB-92, Item 55a, b, c, p Field 17 Revised 3/25/88, 7/1/88, 1/1/94 Data Element: Uniform Identifier of Primary Payers. Definition: NAIC Number. If number is not on the attached listing, the Health Care Cost Containment Council will assign a number based on the name in field 14b. (See Appendix D.) Procedure: If the NAIC number is unknown, this field may be blank. If this field is blank, Field 14b, Payor Identification, must be filled. The Council will develop numbers for those Payor numbers that are unknown. Left justify. Fill with blanks right. Field Size: 1 field, 7 characters Record Position: 1508—1514 Format: Alphanumeric Reference: UB-92, Item 2c (Pos 18—24 of 29 character field, upper line) Field 19a, b, c Revised 7/1/88, 1/1/94 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. Group number or policy number derived from Insurance Card as presented by the party responsible for the payment of this bill. Procedure: Left justify. A = Primary Payer B = Secondary Payer C = Tertiary Payer If the claim is a self-pay claim, place the word ‘‘self’’ in this field. Field Size: 3 lines, 17 characters Record Position: 19a 1524—1540 19b 1541—1557 19c 1558—1574 Format: Alphanumeric Reference: UB-92, Item 62 Field 20 Revised 1/1/94 Data Element: Patient Discharge Status Definition: A code indicating patient status as of the statement covers through date.
Procedure: Right justify Outpatient—zero fill 01 = Discharged to home or self care (routine discharge) 02 = Discharged/transferred to another short term general hospital for inpatient care 03 = Discharged/transferred to skilled nursing facility (SNF) 04 = Discharged/transferred to an intermediate care facility (ICF) 05 = Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 06 = Discharged/transferred to home under care of organized home health service organization 07 = Left against medical advice or discontinued care 08 = Discharged/transferred to home under care of a Home IV provider 09** = Admitted as an inpatient to this hospital 10—19 = Discharge to be defined at state level, if necessary 20 = Expired 21—29 = Expired to be defined at state level, if necessary 30 = Still patient or expected to return for outpatient services 31—39 = Still patient to be defined at state level, if necessary 40* = Expired at home 41* = Expired in a medical facility, e.g. hospital, SNF, ICF, or freestanding hospice 42* = Expired—place unknown 43—99 = Reserved for national assignment * For use only on Medicare claims for hospice care. ** For use only on Medicare outpatient claims.
Field Size: 1 field, 2 characters Record Position: 1575—1576 Format: Numeric Reference: UB-92, Item 22
Field 21a Revised 7/1/88, 6/21/03 Data Element: Provider Quality Definition: Provider quality consistent with section 6(d) of the act (35 P. S. § 449.6(d)) and with § 911.3 (relating to council adoption of methodology). Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. Field Size: 1 field, 1 character Record Position: 1577 Format: Alphanumeric Reference: UB-92, Item 2d (Pos 1 of 30 character field, lower line)
Field 21b Revised 7/1/88, 4/1/90, 6/21/03 Data Element: Provider Service Effectiveness Definition: Provider service effectiveness consistent with section 6(d) of the act (35 P. S. § 449.6(d)) and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. Field Size: 1 field, 1 character Record Position: 1578 Format: Alphanumeric Reference: UB-92, Item 2e (Pos 2 of 30 character field, lower line)
Field 21c Revised 4/1/90 Data Element: Unusual Occurrence Definition: Infections acquired while in the Hospital. Nosocomial infections are defined as those infections that are clinically manifested after 72 hours in the hospital, unless: 1. they are evident within 72 hours after admission and are related to a previous hospitalization; or 2. are related to a hospital procedure performed within the first 72 hours. The Council will develop a methodology to apply to all hospitals. Until that time, fill with blanks. Procedures: One digit code as follows: 1 = Urinary Tract 2 = Surgical Wound 3 = Respiratory Tract 4 = Intravenous 5 = Multiple Types 6 = Undetermined 7 = Other 8 = No nosocomial infection present 9 = Unknown Outpatient—Blank fill Field Size: 1 field, 1 character Record Position: 1579 Format: Alphanumeric Reference: UB-92, Item 2f (Pos 3 of 30 character field, lower line) Field 21d Revised 3/25/88 Data Element: Unusual Occurrence Definition: Patient readmission to the hospital, from a previous discharge, within 30 days. The Council will develop a methodology to apply to all hospitals. Until that time, fill with zeroes. Procedure: Right justify. Fill with the number of days since the previous admission. Field Size: 1 field, 2 characters Record Position: 1580—1581 Format: Numeric Reference: UB-92, Item 2g (Pos 4—5 of 30 character field, lower line) Field 21e Revised 4/1/90 Data Element: Reserve Field Definition: To be reserved for future use by the Council. Field Size: 1 field filler, 532 characters Record Position: 1769—2300 Format: Alphanumeric Field 22 Revised 4/1/90 Data Element: Type of bill Definition: A code indicating the specific type of bill (inpatient, outpatient, adjustments, voids, etc.)
Procedure: This three digit code requires 1 digit each, in the following sequence: 1. Type of facility 2. Bill classification When an outpatient bill is coded, the first and second digits must appear on the Council’s tape in the following possible combinations: 1st Digit: 2nd Digit: 1 3 1 9 7 3 7 9 7 1 8 3 8 9 3. Frequency All positions must be fully coded See Appendix E Field Size: 1 field, 3 characters Record Position: 1582—1584 Format: Alphanumeric Reference: UB-92, Item 4
Field 23 Revised 4/1/90, 1/1/94 Data Element: Patient Control Number Definition: Patient’s unique alphanumeric number assigned by the provider to facilitate retrieval of individual financial records and posting of the payment. Use your Patient Billing Account Number. Procedure: Right justify Field Size: 1 field, 20 characters Record Position: 1585—1604 Format: Alphanumeric Reference: UB-92, Item 3 Field 24 Revised 3/25/88, 4/1/90 Data Element: Diagnosis Related Group (DRG) Definition: The condition established after study as being chiefly responsible for this hospitalization. Classification of payment group based on diagnosis, age, treatment procedure, and discharge status. Procedure: Right justify with leading zeroes. Use the Medicare grouper in effect for each reporting period for DRG classification. If unknown, the Council will assign the DRG code. Field Size: 3 characters Record Position: 1605—1607 Format: Numeric Reference: UB-92, Item 2h (Pos 6—8 of 30 character field, lower line) Field 25 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: 1608 Format: Numeric Reference: UB-92, Item 79 Field 26 Revised 1/1/94 Data Element: Type of Admission Definition: A code indicating the priority of this admission
Procedure: Code structure: 1 = Emergency The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient is admitted through the emergency room. 2 = Urgent The patient requires immediate attention for the care and treatment of a physical or mental disorder. Generally the patient is admitted to the first available and suitable accommodation. 3 = Elective The patient’s condition permits adequate time to schedule the availability of a suitable accommodation. 4 = Newborn Use of this code necessitates the use of special Source of Admission Codes—see Field 27. 5—8 = Reserved for National assignment. Field Size: 1 field, 1 character Record Position: 1609 Format: Alphanumeric Reference: UB-92, Item 19
Field 27 Revised 1/1/94 Data Element: Source of Admission Definition: A code indicating the source of this admission. Procedure: Code structure (for Emergency, Elective or Other Type of Admission): 1 = Physician Referral Inpatient: The patient was admitted to this facility upon the recommendation of his or her personal physician. 2 = Clinic Referral Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s clinic physician. 3 = HMO Referral Inpatient: The patient was admitted to this facility upon the recommendation of a health maintenance organization physician. 4 = Transfer from a Hospital Inpatient: The patient was admitted to this facility as a transfer from a Hospital from an acute care facility where he or she was an inpatient. 5 = Transfer from a Skilled Nursing Facility Inpatient: The patient was admitted to this facility as a transfer from a skilled nursing facility where he or she was an inpatient. 6 = Transfer from another Health Care Facility Inpatient: The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility or a skilled nursing facility. This includes transfers from nursing homes, long term care facilities and skilled nursing facility patients that are at a non-skilled level of care. 7 = Emergency Room Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s emergency room physician. 8 = Court/LawEnforcement Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. A—Z Reserved for national assignment Code Structure (for Newborn): 1 = Normal Delivery A baby delivered without complications. 2 = Premature Delivery A baby delivered with time and/or weight factors qualifying it for premature status. 3 = Sick Baby A baby delivered with medical complications, other than those relating to premature status. 4 = Extramural Birth A newborn born in a non-sterile environment. 5—8 = Reserved for National assignment. Newborn coding structure must be used when the Type of Admissions (Field 26) code 4 Field Size: 1 Field, 1 character Record Position: 1610 Format: Alphanumeric Reference: UB-92, Item 20 Field 28a, b, c Data Element: Patient’s Relationship to Insured Definition: A code indicating the relationship of the patient to the identified insured. Procedure: A = Primary Payer B = Secondary Payer C = Tertiary Payer Right justify. (See Appendix F for code definitions) Field Size: 3 fields, 2 characters each Record Position: 28a 1611—1612 28b 1613—1614 28c 1615—1616 Format: Numeric Reference: UB-92, Item 59a, b, c Field 29a, b, c Revised 7/1/88, 4/1/90 Data Element: Certification/SSN/Health Insurance Claim Number Definition: Insured’s unique identification number assigned by the payer organization. Procedures: A = Primary Payer B = Secondary Payer C = Tertiary Payer Left justify. If the claim is a self-pay claim, place the word ‘‘self’’ in this field. Field Size: 3 fields, 19 characters each Record Position: 29a 1617—1635 29b 1636—1654 29c 1655—1673 Format: Alphanumeric Reference: UB-92, Item 60a b, c Field 32a, b, c Revised 3/25/88, 4/1/90 Data Element: Employer Name Definition: The name of the employer that might or does provide health care coverage for the individual who is responsible for the payment of this bill. Procedure: A = Primary Payer B = Secondary Payer C = Tertiary Payer Left justify. If the name of the employer is unknown, place the word ‘‘unknown’’ in this field. Field Size: 3 fields, 24 characters Record Position: 32a 1674—1697 32b 1698—1721 32c 1722—1745 Format: Alphanumeric Reference: UB-92, Item 65a, b, c Field 34a, b, c Revised 7/1/88, 4/1/90 Data Element: Employment Status Code Definition: A code used to define the employment status of the individual who is responsible for the payment of this bill. Procedure: A = Primary Payer B = Secondary Payer C = Tertiary Payer Code Structure: 1 Employed full time Individual states that he/she is employed full time. 2 Employed part time Individual states that he/she is employed part time. 3 Not Employed Individual states that he/she is not employed full time or part time. 4 Self Employed 5 Retired 6 On active Military Duty 7—8 Reserved for National Assignment 9 Unknown Individual’s employment status is unknown. Field Size: 3 fields, 1 character each Record Position: 34a 1746 34b 1747 34c 1748 Format: Numeric Reference: UB-92, Item 64a, b, c Field 35a Revised 4/1/93 Data Element: Hispanic/Latino Origin or Descent Definition: Hispanic/Latino Origin refers to people whose origins are from Spain, Mexico, or the Spanish speaking countries of Central or South America. Origin can be viewed as the ancestry, nationality, lineage, or country in which the person or his/her ancestors were born before their arrival in the United States Procedure: 1 = Yes, Patient is of Hispanic Origin or Descent 2 = No, Patient is not of Hispanic Origin or Descent Field Size: 1 field, 1 character Record Position: 1749 Format: Alphanumeric Reference: UB-92, Item 2i (Pos 9 of 30 character field, lower line) Field 35b Revised 3/25/88, 4/1/93 Data Element: Patient Race Definition: This code indicates the patient’s racial background. Procedure: Coding as follows: W = White B = Black A = Asian or Pacific Island I = Native American or Eskimo N = Other U = Unknown Field Size: 1 field, 1 character Record Position: 1750 Format: Alphanumeric Reference: UB-92, Item 2j (Pos 10 of 30 character field, lower line) Field 36 Revised 1/1/94 Data Element: Admitting Diagnosis Definition: The ICD-9-CM diagnosis code provided at the time of admission by the Attending Physician. Procedure: The ICD-9-CM diagnosis code describing the admitting diagnosis as a significant finding representing patient distress, an abnormal finding on examination, a possible diagnosis based on significant findings, a diagnosis established from a previous encounter or admission, an injury, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor. Report only one admitting diagnosis. This condition shall be determined based on the ICD-9-CM coding directives in Volumes I and II of the ICD-9-CM coding manuals and the official coding guidelines. The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. Left justify. Blank fill right. Field Size: 1 field, 6 characters Record Position: 102—107 Format: Alphanumeric Reference: UB-92, FL 76 Field 37 Revised 1/1/94 Data Element: E-Code—External Cause of Injury Code Definition: The ICD-9-CM code for the external cause of an injury, poisoning, or adverse effect. Procedure: Whenever there is a diagnosis of an injury, poisoning, or adverse effect, this field should be filled using the following priorities: 1. Principal diagnosis of an injury or poisoning; 2. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis;3. Other diagnosis with an external cause. The reporting of the decimal between the third and fourth digits is unnecessary because it is implied. The data contained in this field will also appear in the Diagnosis fields (7a—7i). Field Size: 1 field, 6 characters Record Position: 108—113 Format: Alphanumeric Reference: UB-92, FL 77 Field 38 Revised 1/1/94 Data Element: Referring Physician Definition: The PA State License Number of the physician who referred the patient to the Admitting Physician for care and/or treatment. Procedure: Character 1—9 = PA State License Number Character 10—21 = Last Name Character 22—23 = First & Middle Initial Do not place the ‘‘PA’’ in the PA State License Number in this field. Format as follows: MD123456L. Left justify. Blank fill right if name unknown. Field Size: 1 field, 23 character Record Position: 180—202 Format: Alphanumeric Reference: UB-92, Item 82 (upper line) Field 39 Revised 1/1/94 Data Element: Federal Tax ID Definition: The number assigned to the provider by the Federal Government for tax reports purposes. Also known as a tax identification number (TIN) or employer identification number (EIN) Procedure: Format: NN-NNNNNNN Left justify. Include hyphen. Field Size: 1 field, 10 character Record Position: 1759—1768 Format: Alphanumeric Reference: UB-92, Item 5 (lower line) Field 40 Revised 1/1/94 Data Element: Admission Hour Definition: The hour during which the patient was admitted for inpatient care.
Procedure: Code Structure: Code Time Code Time AM PM 00 12:00—12:59 12 12:00—12:59 Midnight Noon 01 01:00—01:59 13 01:00—01:59 02 02:00—02:59 14 02:00—02:59 03 03:00—03:59 15 03:00—03:59 04 04:00—04:59 16 04:00—04:59 05 05:00—05:59 17 05:00—05:59 06 06:00—06:59 18 06:00—06:59 07 07:00—07:59 19 07:00—07:59 08 08:00—08:59 20 08:00—08:59 09 09:00—09:59 21 09:00—09:59 10 10:00—10:59 22 10:00—10:59 11 11:00—11:59 23 11:00—11:59 99 Hour Unknown Right justify. (All positions fully coded) Field Size: 1 field, 2 positions Record Position: 44—45 Format: Numeric Reference: UB-92, Item 18 Field 41 Data Element: Discharge Hour Definition: Hour that the patient was discharged from inpatient care. Procedure: Code Structure: Code Time Code Time AM PM 00 12:00—12:59 12 12:00—12:59 Midnight Noon 01 01:00—1:59 13 01:00—01:59 02 02:00—2:59 14 02:00—02:59 03 03:00—03:59 15 03:00—03:59 04 04:00—04:59 16 04:00—04:59 05 05:00—05:59 17 05:00—05:59 06 06:00—06:59 18 06:00—06:59 07 07:00—07:59 19 07:00—07:59 08 08:00—08:59 20 08:00—08:59 09 09:00—09:59 21 09:00—09:59 10 10:00—10:59 22 10:00—10:59 11 11:00—11:59 23 11:00—11:59 99 Hour Unknown Right justify. (All positions fully coded) Field Size: 1 field, 2 positions Record Position: 46—47 Format: Numeric Reference: UB-92, Item 21
Header Record Manual
Field 1 Data Element: Data Source Identifier Definition: Number identifying the data source Hospitals—use your Medicaid ID Number (See Appendix A) Procedures: 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 Definition: Name and address of the data source
Procedure: Left justify. Fill with blanks right. Name = Position 26—50 Address 1 = Position 51—75 Address 2 = Position 76—100 City = Position 101—114 State = Position 115—116 Zip Code = Position 117—125 Field Size: 1 field, 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 Revised 4/1/90 Data Element: Filler Field Size: 1 field filler, 2129 characters Record Position: 170—2298 Format: Alphanumeric Field 7 Data Element: Inpatient/Outpatient Indicator Definition: Letter indicating whether the claims contained in this file are inpatient claims or outpatient claims. Procedure: I = Inpatient O = Outpatient Field Size: 1 field, 1 character Field Position: 144 Format: Alphanumeric Field 8 Data Element: Batch/Job/Run Number Definition: Number for the hospital’s use in identifying the tape. Procedure: Fill with the number that will identify this tape. Field Size: 1 field, 25 characters Field Position: 145—169 Format: Alphanumeric Field 9 Created 4/1/90 Data Element: Submission Type Definition: Code indicating whether this submission is an original submission, a resubmission of original data or a submission of correction data. Procedure: Place code as follows: O = Original Submission R = Resubmission of original data C = Correction data Field Size: 1 field, 1 character Record Position: 2299 Format: Alphanumeric Field 10 Revised 4/1/90 Data Element: Record Type Definitions: Code indicating this record to be a header record Procedure: H = Header Field Size: 1 field, 1 character Record Position: 2300 Format: Alphanumeric
Trailer Record Manual
Field 1 Revised 4/1/90 Data Element: Number of records on this tape Definition: Total number of records contained on this tape, not including the Header and Trailer Records. Procedure: Right justify. Field Size: 1 field, 10 characters Record Position: 1—10 Format: Numeric Field 2 Revised 4/1/90 Data Element: Number of Claims on this tape Definition: Total number of claims contained on this tape Procedure: Each record of a multi-page claim must be counted as one claim. Right justify. Field Size: 1 field, 10 characters Record Position: 11—20 Format: Numeric Field 3 Revised 4/1/90 Data Element: Filler Field Size: 1 field filler, 2268 characters Record Position: 32—2299 Format: Alphanumeric Field 4 Created 4/1/90, 1/1/94 Data Element: Total Dollars Definition: Total Dollars submitted on this tape Procedure: Characters 1—10 = dollars Characters 11—12 = cents Right justify. Zero fill left. No decimal Field Size: 1 field, 12 characters Record Position: 21—32 Format: Numeric Field 5 Created 4/1/90 Data Element: Record type Definition: Code indicating that this record is a trailer record Procedure: T = Trailer Field Size: 1 field, 1 character Record Position: 2300 Format: Alphanumeric
Hospital and Ambulatory Service Facility Tape Format
Data
ElementData 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/Address 26 125 X(100) Name = Position 26—50 Address 1 = Position 51—75 Address 2 = Position 76—100 City = Position 101—114 State = Position 115—116 Zip Code = Position 117—125 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. 7 Inpatient/Outpatient Indicator 144 X(1) I = Inpatient claims. O = Outpatient claims. 8 Batch/Job/RunNumber 145 169 X(25) For hospitals use in identifying the tape. 6 Filler 170 2298 X(2129) 9 Submission Type 2299 X(1) O = Original Submission R = Resubmission of original data C = Correction data 10 Record Type 2300 X(1) H = Header Record
Data
ElementData Element Description Position Picture Format* From To 1 Uniform Patient Identifier 1 9 X(9) If unknown, fill with blanks. Right justify. 2 Patient Date of Birth 10 17 9(8) MMDDYYYY 3 Patient Sex 18 X(1) M = Male, F = Female, U = Unknown 4 Patient Zip Code 19 27 X(9) XXXXXYYYY. The 9 or 5 character zip code of patient residence. Left justify. 5 Date of Admission 28 35 9(8) MMDDYYYY. Taken from Locator 15. 6 Date of Discharge 36 43 9(8) MMDDYYYY. Taken from the last 6 characters of Field 6 plus century.
*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
ElementData Element Description Position Picture Format From To 40 Admission Hour 44 45 9(2) See manual for instructions. 41 Discharge Hour 46 47 9(2) See manual for instructions. 7a Principal Diagnosis Code 48 53 X(6) Diagnosis code. Left justify. See manual for instructions. 7b Secondary Diagnosis Code 54 59 X(6) Diagnosis code. Left justify. See manual for instructions. 7c Secondary Diagnosis Code 60 65 X(6) Diagnosis code. Left justify. See manual for instructions. 7d Secondary Diagnosis Code 66 71 X(6) Diagnosis code. Left justify. See manual for instructions. 7e Secondary Diagnosis Code 72 77 X(6) Diagnosis code. Left justify. See manual for instructions. 7f Secondary Diagnosis Code 78 83 X(6) Diagnosis code. Left justify. See manual for instructions. 7g Secondary Diagnosis Code 84 89 X(6) Diagnosis code. Left justify. See manual for instructions. 7h Secondary Diagnosis Code 90 95 X(6) Diagnosis code. Left justify. See manual for instructions. 7i Secondary Diagnosis Code 96 101 X(6) Diagnosis code. Left justify. See manual for instructions. 36 Admitting Diagnosis Code 102 107 X(6) Diagnosis code. Left justify. See manual for instructions. 37 E-Code 108 113 X(6) Diagnosis code. Left justify. See manual for instructions. 8a Principal Procedure Code 114 120 X(7) Procedure code. Left justify. See manual for instructions. 8b Date 121 124 9(4) MMDD 9a1 Secondary Procedure Code 125 131 X(7) Procedure code. Left justify. See manual for instructions. 9a2 Date 132 135 9(4) MMDD 9b1 Secondary Procedure Code 136 142 X(7) Procedure code. Left justify. See manual for instructions. 9b2 Date 143 146 9(4) MMDD 9c1 Secondary Procedure Code 147 153 X(7) Procedure code. Left justify. See manual for instructions. 9c2 Date 154 157 9(4) MMDD 9d1 Secondary Procedure Code 158 164 X(7) Procedure code. Left justify. See manual for instructions. 9d2 Date 165 168 9(4) MMDD 9e1 Secondary Procedure Code 169 175 X(7) Procedure code. Left justify. See manual for instructions. 9e2 Date 176 179 9(4) MMDD 38 Referring Physician 180 202 X(23) Only PA State License Number should be used here. Character 1—9 = PA State License Number. Left justify. Blank fill right if name unknown. 11 Attending Physician ID 203 225 X(23) Only PA State License Number should be used here. Character 1—9 = PA State License Number. Left justify. Blank fill right if name unknown. 12 Operating Physician ID 226 248 X(23) Only PA State License Number should be used here. Character 1—9 = PA State License Number. Left justify. Blank fill right if name unknown. 13a2 Revenue Code 249 252 X(4) Left justify. See manual for code definitions. 13a6 HCPCS/Rate 253 261 9(9) Left justify for HCPCS. Right justify rate. 13a7 Service Date 262 269 9(8) MMDDYYYY 13a3 Units of Service 270 276 9(7) Right justify. Fill with zeroes left. 13a4 Total Charges 277 286 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit using a leading minus sign (-). Right justify. No decimal. 13a5 Non-Covered Charges 287 296 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit using a leading minus sign (-). Right justify. No decimal. 13b2 Revenue Code 297 300 X(4) Left justify. See manual for code definitions. 13b6 HCPCS/Rate 301 309 9(9) Left justify. See manual for code definitions. 13b7 Service Date 310 317 9(8) Left justify. See manual for code definitions. 13b3 Units of Service 318 324 9(7) Right justify. Fill with zeroes left. 13b4 Total Charges 325 334 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13b5 Non-Covered Charges 335 344 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13c2 Revenue Code 345 348 X(4) Left justify. See manual for code definitions. 13c6 HCPCS/Rate 349 357 9(9) Left justify. See manual for code definitions. 13c7 Service Date 358 365 9(8) Left justify. See manual for code definitions. 13c3 Units of Service 366 372 9(7) Right justify. Fill with zeroes left. 13c4 Total Charges 373 382 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13c5 Non-Covered Charges 383 392 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13d2 Revenue Code 393 396 X(4) Left justify. See manual for code definitions. 13d6 HCPCS/Rates 397 405 9(9) Left justify. See manual for code definitions. 13d7 Service Date 406 413 9(8) Left justify. See manual for code definitions. 13d3 Units of Service 414 420 9(7) Right justify. Fill with zeroes left. 13d4 Total Charges 421 430 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13d5 Non-Covered Charges 431 440 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13e2 Revenue Code 441 444 X(4) Left justify. See manual for code definitions. 13e6 HCPCS/Rates 445 453 9(9) Left justify. See manual for code definitions. 13e7 Service Date 454 461 9(8) Left justify. See manual for code definitions. 13e3 Units of Service 462 468 9(7) Right justify. Fill with zeroes left. 13e4 Total Charges 469 478 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13e5 Non-Covered Charges 479 488 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13f2 Revenue Code 489 492 X(4) Left justify. See manual for code definitions. 13f6 HCPCS/Rates 493 501 9(9) Left justify. See manual for code definitions. 13f7 Service Date 502 509 9(8) Left justify. See manual for code definitions. 13f3 Units of Service 510 516 9(7) Right justify. Fill with zeroes left. 13f4 Total Charges 517 526 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13f5 Non-Covered Charges 527 536 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13g2 Revenue Code 537 540 X(4) Left justify. See manual for code definitions. 13g6 HCPCS/Rates 541 549 9(9) Left justify. See manual for code definitions. 13g7 Service Date 550 557 9(8) Left justify. See manual for code definitions. 13g3 Units of Service 558 564 9(7) Right justify. Fill with zeroes left. 13g4 Total Charges 565 574 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13g5 Non-Covered Charges 575 584 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13h2 Revenue Code 585 588 X(4) Left justify. See manual for code definitions. 13h6 HCPCS/Rates 589 597 9(9) Left justify. See manual for code definitions. 13h7 Service Date 598 605 9(8) Left justify. See manual for code definitions. 13h3 Units of Service 606 612 9(7) Right justify. Fill with zeroes left. 13h4 Total Charges 613 622 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13h5 Non-Covered Charges 623 632 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13i2 Revenue Code 633 636 X(4) Left justify. See manual for code definitions. 13i6 HCPCS/Rates 637 645 9(9) Left justify. See manual for code definitions. 13i7 Service Date 646 653 9(8) Left justify. See manual for code definitions. 13i3 Units of Service 654 660 9(7) Right justify. Fill with zeroes left. 13i4 Total Charges 661 670 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13i5 Non-Covered Charges 671 680 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13j2 Revenue Code 681 684 X(4) Left justify. See manual for code definitions. 13j6 HCPCS/Rates 685 693 9(9) Left justify. See manual for code definitions. 13j7 Service Date 694 701 9(8) Left justify. See manual for code definitions. 13j3 Units of Service 702 708 9(7) Right justify. Fill with zeroes left. 13j4 Total Charges 709 718 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13j5 Non-Covered Charges 719 728 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13k2 Revenue Code 730 732 X(4) Left justify. See manual for code definitions. 13k6 HCPCS/Rates 733 741 9(9) Left justify. See manual for code definitions. 13k7 Service Date 742 749 9(8) Left justify. See manual for code definitions. 13k3 Units of Service 750 756 9(7) Right justify. Fill with zeroes left. 13k4 Total Charges 757 766 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13k5 Non-Covered Charges 767 776 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13l2 Revenue Code 777 780 X(4) Left justify. See manual for code definitions. 13l6 HCPCS/Rates 781 789 9(9) Left justify. See manual for code definitions. 13l7 Service Date 790 797 9(8) Left justify. See manual for code definitions. 13l3 Units of Service 798 804 9(7) Right justify. Fill with zeroes left. 13l4 Total Charges 805 814 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13l5 Non-Covered Charges 815 824 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13m2 Revenue Code 825 828 X(4) Left justify. See manual for code definitions. 13m6 HCPCS/Rates 829 837 9(9) Left justify. See manual for code definitions. 13m7 Service Date 838 845 9(8) Left justify. See manual for code definitions. 13m3 Units of Service 846 852 9(7) Right justify. Fill with zeroes left. 13m4 Total Charges 853 862 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13m5 Non-Covered Charges 863 872 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13n2 Revenue Code 873 876 X(4) Left justify. See manual for code definitions. 13n6 HCPCS/Rates 877 885 9(9) Left justify. See manual for code definitions. 13n7 Service Date 886 893 9(8) Left justify. See manual for code definitions. 13n3 Units of Service 894 900 9(7) Right justify. Fill with zeroes left. 13n4 Total Charges 901 910 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13n5 Non-Covered Charges 911 920 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13o2 Revenue Code 921 924 X(4) Left justify. See manual for code definitions. 13o6 HCPCS/Rates 925 933 9(9) Left justify. See manual for code definitions. 13o7 Service Date 934 941 9(8) Left justify. See manual for code definitions. 13o3 Units of Service 942 948 9(7) Right justify. Fill with zeroes left. 13o4 Total Charges 949 958 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13o5 Non-Covered Charges 959 968 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13p2 Revenue Code 969 972 X(4) Left justify. See manual for code definitions. 13p6 HCPCS/Rates 973 981 9(9) Left justify. See manual for code definitions. 13p7 Service Date 982 989 9(8) Left justify. See manual for code definitions. 13p3 Units of Service 990 996 9(7) Right justify. Fill with zeroes left. 13p4 Total Charges 997 1006 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13p5 Non-Covered Charges 1007 1016 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13q2 Revenue Code 1017 1020 X(4) Left justify. See manual for code definitions. 13q6 HCPCS/Rates 1021 1029 9(9) Left justify. See manual for code definitions. 13q7 Service Date 1030 1037 9(8) Left justify. See manual for code definitions. 13q3 Units of Service 1038 1044 9(7) Right justify. Fill with zeroes left. 13q4 Total Charges 1045 1054 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13q5 Non-Covered Charges 1055 1064 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13r2 Revenue Code 1065 1068 X(4) Left justify. See manual for code definitions. 13r6 HCPCS/Rates 1069 1077 9(9) Left justify. See manual for code definitions. 13r7 Service Date 1078 1085 9(8) Left justify. See manual for code definitions. 13r3 Units of Service 1086 1092 9(7) Right justify. Fill with zeroes left. 13r4 Total Charges 1093 1102 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13r5 Non-Covered Charges 1103 1112 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13s2 Revenue Code 1113 1116 X(4) Left justify. See manual for code definitions. 13s6 HCPCS/Rates 1117 1125 9(9) Left justify. See manual for code definitions. 13s7 Service Date 1126 1133 9(8) Left justify. See manual for code definitions. 13s3 Units of Service 1134 1140 9(7) Right justify. Fill with zeroes left. 13s4 Total Charges 1141 1150 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13s5 Non-Covered Charges 1151 1160 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13t2 Revenue Code 1161 1164 X(4) Left justify. See manual for code definitions. 13t6 HCPCS/Rates 1165 1173 9(9) Left justify. See manual for code definitions. 13t7 Service Date 1174 1181 9(8) Left justify. See manual for code definitions. 13t3 Units of Service 1182 1188 9(7) Right justify. Fill with zeroes left. 13t4 Total Charges 1189 1198 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13t5 Non-Covered Charges 1199 1208 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13u2 Revenue Code 1209 1212 X(4) Left justify. See manual for code definitions. 13u6 HCPCS/Rates 1213 1221 9(9) Left justify. See manual for code definitions. 13u7 Service Date 1222 1229 9(8) Left justify. See manual for code definitions. 13u3 Units of Service 1230 1236 9(7) Right justify. Fill with zeroes left. 13u4 Total Charges 1237 1246 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13u5 Non-Covered Charges 1247 1256 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13v2 Revenue Code 1257 1260 X(4) Left justify. See manual for code definitions. 13v6 HCPCS/Rates 1261 1269 9(9) Left justify. See manual for code definitions. 13v7 Service Date 1270 1277 9(8) Left justify. See manual for code definitions. 13v3 Units of Service 1278 1284 9(7) Right justify. Fill with zeroes left. 13v4 Total Charges 1285 1294 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13v5 Non-Covered Charges 1295 1304 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13w2 Revenue Code 1305 1308 X(4) 001. Unless it is a continuing record. 13w6 HCPCS/Rates 1309 1317 9(9) 001. Unless it is a continuing record. 13w7 Service Date 1318 1325 9(8) 001. Unless it is a continuing record. 13w3 Units of Service 1326 1332 9(7) Fill with blanks. 13w4 Total Charges 1333 1342 X(10) Total of all charges. 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 13w5 Non-Covered Charges 1343 1352 X(10) Total of all non-covered charges. 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 14b1 Payor Identification 1353 1377 X(25) Left justify. Blank fill right. See manual for code definitions. 14b2 Payor Identification 1378 1402 X(25) Left justify. Blank fill right. See manual for code definitions. 14b3 Payor Identification 1403 1427 X(25) Left justify. Blank fill right. See manual for code definitions. 14f1 Prior Payments—Payor and Patient 1428 1437 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 14f2 Prior Payments—Payor and Patient 1438 1447 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 14f3 Prior Payments—Payor and Patient 1448 1457 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 14f4 Prior Payments—Payor and Patient 1458 1467 X(10) 7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal. 14g1 Estimated Amount Due 1468 1477 X(10) Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks. 14g2 Estimated Amount Due 1478 1487 X(10) Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks. 14g3 Estimated Amount Due 1488 1497 X(10) Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks. 14g4 Estimated Amount Due 1498 1507 X(10) Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks. 17 Uniform Identifier of Primary Payor 1508 1514 X(7) Left justify. Fill with blanks right. 18 Zip Code of Facility 1515 1523 X(9) XXXXXYYYY. Left justify. 19a Payor Group Number 1524 1540 X(17) Left justify. 19b Payor Group Number 1541 1557 X(17) Left justify. 19c Payor Group Number 1558 1574 X(17) Left justify. 20 Patient Discharge Status 1575 1576 9(2) Right justify. See manual for definitions. 21a Provider Quality 1577 X(1) Provider quality consistent with section 6(d) of the act and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. 21b Provider Service Effectiveness 1578 X(1) Provider service effectiveness consistent with section 6(d) of the act and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. 21c Unusual Occurrence 1579 X(1) The Council will develop a methodology to apply to all hospitals. Until that time, fill with blanks. 21d Unusual Occurrence 1580 1581 9(2) The Council will develop a methodology to apply to all hospitals. Until that time, fill with zeroes. 22 Type of Bill 1582 1584 9(3) Right justify. See manual for code definitions. 23 Patient Control Number 1585 1604 X(20) Left justify. 24 Diagnosis Related Group (DRG) 1605 1607 9(3) See manual for instructions. 25 Procedure Coding Method Used 1608 9(1) 1—3 = Reserved for state assignment. 4 = CPT-4 5 = HCPCS 6—8 = Reserved for national assignment. 9 = ICD-9-CM 26 Type of Admission 1609 X(1) 1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn 5—8 = Reserved for National assignment. 9 = Information not available See manual for definitions. 27 Source of Admission 1610 X(1) 1 = Physician referral 2 = Clinic referral 3 = HMO referral 4 = Transfer from
hospital 5 = Transfer from
SNF 6 = Transfer from
another health
care facility 7 = Emergency
Room 8 = Court/Law
Enforcement 9 = Information
not available A—Z = Reserved
for
National
Assignment.
For Newborn admissions: 1 = Normal delivery 2 = Premature delivery 3 = Sick baby 4 = Extramural
birth 5—8 = Reserved
for National
assignment. 9 = Information
not available See manual for definitions.
28a Patient’s Relation- ship to Insured 1611 1612 9(2) Right justify. See manual for code definitions. 28b Patient’s Relation- ship to Insured 1613 1614 9(2) Right justify. See manual for code definitions. 28c Patient’s Relation- ship to Insured 1615 1616 9(2) Right justify. See manual for code definitions. 29a Certification/Social Security Number/ Health Insurance Claim Number 1617 1635 X(19) Left justify. 29b Certification/Social Security Number/ Health Insurance Claim Number 1636 1654 X(19) Left justify. 29c Certification/Social Security Number/ Health Insurance Claim Number 1655 1673 X(19) Left justify. 32a Employer Name 1674 1697 X(24) Left justify. 32b Employer Name 1698 1721 X(24) See manual for instructions. 32c Employer Name 1722 1745 X(24) See manual for instructions. 34a Employment Status 1746 9(1) 1 = Employed Full time 2 = Employed Part
time 3 = Not employed 4 = Self employed 5 = Retired 6 = On active
military
duty 7—8 = Reserved for
National
assignment. 9 = Unknown See manual for definitions.
34b Employment Status 1747 9(1) See manual for instructions. 34c Employment Status 1748 9(1) See manual for instructions. 35a Hispanic/Spanish Origin or Descent 1749 X(1) See manual for instructions. 35b Patient Race 1750 X(1) W = White B = Black A = Asian I = Native American
or Eskimo N = Other O = Unknown
10 Uniform Identifier for Health Care Facility 1751 1758 X(8) Left justify. Blank fill right. 39 Federal Tax ID 1759 1768 X(10) See manual for instructions. 21e Reserve Field 1769 2300 X(532) To be reserved for future use by the Council. 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. 4 Total Dollars 21 32 9(12) Total dollars on tape. 9 dollar characters and 2 cent characters. Right justify. No decimal. 3 Filler 33 2299 X(2267) 5 Record Type 2300 X(1) T = Trailer
Source The provisions of this Appendix A adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459; amended April 8, 1988, effective March 1, 1988, 18 Pa.B. 1607; amended May 11, 1990, effective May 12, 1990, and apply to second quarter 1990 submissions; amended February 11, 1994, effective January 1, 1994, 24 Pa.B. 840; amended June 20, 2003, effective June 21, 2003, 33 Pa.B. 2865. Immediately preceding text appears at serial pages (242570) to (242626).
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