CHAPTER 912. DATA REPORTING REQUIREMENTS

Subchap. Sec.

A.    GENERAL PROVISIONS … 912.1
B.    PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM SUBMISSION SCHEDULES … 912.21
C.    FINANCIAL REPORTING REQUIREMENTS … 912.61
D.    OTHER REQUIREMENTS … 912.81

Authority

   The provisions of this Chapter 912 issued under section 6 of the Health Care Cost Containment Act (35 P. S. §  449.6), unless otherwise noted.

Source

   The provisions of this Chapter 912 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459, unless otherwise noted.

Cross References

   This chapter cited in 28 Pa. Code §  915.51 (relating to procedures for access to Council data by data sources).

Subchapter A. GENERAL PROVISIONS


Sec.


912.1.    Legal base and purpose.
912.2.    Affected institutions.
912.3.    Definitions.

§ 912.1. Legal base and purpose.

 (a)  This chapter is promulgated by the Council under section 6 of the act (35 P. S. §  449.6).

 (b)  This chapter establishes submission schedules and formats for the collection of data from health care facilities specified in section 6 of the act.

Authority

   The provisions of this §  912.1 amended under section 5(b) of the Health Care Cost Containment Act (35 P. S. §  449.5(b)).

Source

   The provisions of this §  912.1 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 October 1, 1999, effective October 2, 1999, 29 Pa.B. 5093. Immediately preceding text appears at serial page (242559).

§ 912.2. Affected institutions.

 This chapter applies to health care facilities in this Commonwealth.

Source

   The provisions of this §  912.2 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

§ 912.3. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Act—The Health Care Cost Containment Act (35 P. S. § §  449.1—449.19).

   Additional data elements—Data, redefinitions of data or methodologies to calculate data to be added to the Pennsylvania Uniform Claims and Billing Form format.

   Ambulatory service facility—A facility licensed in this Commonwealth, not part of a hospital, which provides medical, diagnostic or surgical treatment to patients not requiring hospitalization. The term includes, but is not limited to, ambulatory surgical facilities, ambulatory imaging or diagnostic centers, birthing centers, free-standing emergency rooms and other facilities providing ambulatory care which charge a separate facility charge. The term does not include the offices of private physicians or dentists, whether for individual or group practices.

   Charge—The amount billed by a provider for specific goods or services provided to a patient, prior to adjustment for contractual allowances.

   Council—The Health Care Cost Containment Council.

   Covered services—Health care services or procedures connected with episodes of illness that require either inpatient hospital care or major ambulatory service, such as surgical, medical or major radiological procedures, including initial and follow-up outpatient services associated with the episode of illness before, during or after inpatient hospital care or major ambulatory service. The term does not include routine outpatient services connected with episodes of illness that do not require hospitalization or major ambulatory service.

   Data elements—Data identified by the Council to be submitted to the Council as part of the Pennsylvania Uniform Claims and Billing Form format.

   Executive Director—The Executive Director of the Council.

   General hospital—A hospital equipped and staffed for the treatment of medical or surgical conditions, or both, in the acute or chronic stages, on an inpatient basis of 24 or more hours. The term includes hospitals that treat children as their specialty.

   Health care facility—The term includes the following:

     (i)   A general or special hospital, including tuberculosis and psychiatric hospitals.

     (ii)   Ambulatory service facilities as defined in this section.

   Hospital—An institution, licensed in this Commonwealth, which is a general, tuberculosis, mental, chronic disease or other type of hospital, or kidney disease treatment center, whether profit or nonprofit, including those operated by an agency of State or local government.

   Major ambulatory service—Surgical or medical procedures, including diagnostic and therapeutic radiological procedures, commonly performed in hospitals or ambulatory service facilities, which are not of a type commonly performed or which cannot be safely performed in physicians’ offices and which require special facilities, such as operating rooms or suites or special equipment, such as fluoroscopic equipment or computed tomographic scanners, or a postprocedure recovery room or short term convalescent room.

   Pennsylvania Uniform Claims and Billing Form format—The Uniform Hospital Billing Form UB-82/HCFA-1450, and the HCFA 1500, or their successors, as developed by the National Uniform Billing Committee, with additional fields as necessary to provide the data in section 6(c) and (d) of the act (35 P. S. §  449.6(c) and (d)).

   Physician—An individual licensed under the laws of the Commonwealth to practice medicine and surgery within the scope of the Osteopathic Medical Practice Act (63 P. S. § §  271.1—271.18) or the Medical Practice Act of 1985 (63 P. S. § §  422.1—422.45).

   Provider—A hospital, ambulatory service facility or physician.

   Provider quality—The extent to which a provider renders care that, within the capabilities of modern medicine, obtains for patients medically acceptable health outcomes and prognoses, adjusted for patient severity, and treats patients compassionately and responsively.

   Provider service effectiveness—The effectiveness of services rendered by a provider, determined by measurement of the medical outcome of patients grouped by severity receiving those services.

   Raw data or data—Data collected by the Council under section 6 of the act in the form initially received.

   Region—A geographical area of contiguous counties formed to provide a basis for implementing data collection activities and reporting according to the following:

     (i)   Region 1 (Western Southwest)—Allegheny, Armstrong, Beaver, Fayette, Green, Washington and Westmoreland Counties.

     (ii)   Region 2 (Northwest)—Butler, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Potter, Venango and Warren Counties.

     (iii)   Region 3 (Eastern Southwest)—Bedford, Blair, Cambria, Indiana and Somerset Counties.

     (iv)   Region 4 (North Central)—Centre, Clinton, Columbia, Lycoming, Mifflin, Montour, Northumberland, Snyder, Tioga and Union Counties.

     (v)   Region 5 (South Central)—Adams, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Perry and York Counties.

     (vi)   Region 6 (Northeast)—Bradford, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Wayne and Wyoming Counties.

     (vii)   Region 7 (Eastern)—Berks, Carbon, Lehigh, Northampton and Schuylkill Counties.

     (viii)   Region 8 (Suburban Southeast)—Bucks, Chester, Delaware and Montgomery Counties.

     (ix)   Region 9 (Southeast—Philadelphia)—Philadelphia County.

   Short term procedure unit—A unit organized for the delivery of nonemergency surgical services to patients who do not remain in the hospital overnight.

   Special hospital—A hospital equipped and staffed for the treatment of disorders within the scope of specific medical specialties or for the treatment of limited classifications of diseases in their acute or chronic stages on an inpatient basis of 24 or more hours. The term includes psychiatric and rehabilitation hospitals.

   Specialty unit—A functional unit of a hospital that provides drug and alcohol rehabilitation, rehabilitative and psychiatric services.

Authority

   The provisions of this §  912.3 amended under section 5(b) of the Health Care Cost Containment Act (35 P. S. §  449.5(b)).

Source

   The provisions of this §  912.3 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 October 1, 1999, effective October 2, 1999, 29 Pa.B. 5093. Immediately preceding text appears at serial pages (242560) to (242562).

Subchapter B. PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM SUBMISSION SCHEDULES


GENERAL PROVISIONS

Sec.


912.21.    Required data elements.
912.22.    Data element submission schedules.
912.23.    Form of data submissions and release by Council.
912.24.    Frequency of data submissions.

EXCEPTIONS


912.31.    Principle.
912.32.    Requests for exceptions.
912.33.    Revocation of exceptions.

INTERPRETATIONS


912.41.    Definition for major ambulatory service.

GENERAL PROVISIONS


§ 912.21. Required data elements.

 (a)  A health care facility is required to submit the following data elements:

   (1)  Data elements specified in the act contained in Council Manual HC-87-101, Volume A. (See Appendix A.) A health care facility shall refer to Appendix A to determine specific data elements definitions and formats.

   (2)  Additional data elements, as defined in Appendix A:

     (i)   Unusual occurrences.

       (A)   Nosocomial infections.

       (B)   Readmissions.

     (ii)   Patient race.

 (b)  A hospital is required to submit the following additional data elements:

   (1)  Patient morbidity. A hospital shall refer to Council Manual HC-87-101, Volume A, Field 21b (See Appendix A) to determine formats.

   (2)  Patient severity. A hospital shall refer to Council Manual HC-87-101, Volume A, Field 21a (See Appendix A) to determine formats.

Source

   The provisions of the 912.21 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459; amended April 8, 1988, effective March 1, 1988, 18 Pa.B. 1607. Immediately preceding text appears at serial page (124980).

§ 912.22. Data element submission schedules.

 A health care facility shall submit data under the following schedules:

   (1)  General hospitals with more than 100 licensed beds.

     (i)   Inpatient data elements. A general hospital is required to submit data elements for inpatient discharges in the first quarter of 1988 by June 30, 1988, and thereafter, under §  912.24 (relating to frequency of data submissions).

     (ii)   Outpatient data elements. A general hospital is required to submit data elements for outpatient covered services by March 31, 1989, for discharges in the fourth quarter of 1988 and thereafter, under §  912.24.

     (iii)   Patient morbidity and patient severity data elements. A general hospital is required to submit data elements for patient morbidity and patient severity for inpatients admitted on or following the implementation date, excluding those in specialty units, in accordance with the following schedule:

       (A)   Region 5. Discharges in the second quarter of 1988 are due on or before September 30, 1988, and thereafter, under §  912.24.

       (B)   Region 7. Discharges in the third quarter of 1988 are due on or before December 31, 1988, and thereafter, under §  912.24.

       (C)   Region 1. Discharges in the fourth quarter of 1988 are due on or before March 31, 1989, and thereafter, under §  912.24.

       (D)   Regions 6 and 8. Discharges in the first quarter of 1989 are due on or before June 30, 1989, and thereafter, under §  912.24.

       (E)   Regions 2, 3 and 4. Discharges in the second quarter of 1989 are due on or before September 30, 1989, and thereafter, under §  912.24.

       (F)   Region 9. Discharges in the third quarter of 1989 are due on or before December 31, 1989, and thereafter, under §  912.24.

   (2)  General hospitals with 100 beds or less and other health care facilities. A general hospital with 100 beds or less or health care facility, excluding a health care facility identified in paragraph (1), are required to submit data elements for inpatient discharges and data elements for outpatient covered services rendered in the fourth quarter of 1988 by March 31, 1989, and thereafter, under §  912.24. The following schedule shall be used for patient morbidity and patient severity:

     (i)   For inpatient admissions beginning July 1, 1989, a general hospital in Regions 1, 2, 3, 4 and 5 shall submit data for discharges in the third quarter of 1989 on or before December 31, 1989, and thereafter, under §  912.24.

     (ii)   For inpatient admissions beginning October 1, 1989, a general hospital in Regions 6, 7, 8 and 9 shall submit data for discharges in the fourth quarter of 1989 on or before March 31, 1990, and thereafter, under §  912.24.

     (iii)   For inpatient admissions beginning January 1, 1990, special hospitals and specialty units shall submit data for discharges in the first quarter of 1990 on or before June 30, 1990, and thereafter, under §  912.24.

Source

   The provisions of this §  912.22 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 December 2, 1988, effective upon publication and applies retroactively to January 30, 1988, 18 Pa.B. 5351. Immediately preceding text appears at serial pages (127084) to (127085).

§ 912.23. Form of data submissions and release by Council.

 Data elements required to be submitted under this subchapter shall be submitted on nine-track labeled 1600 or 6250 BPI (density) tape or computer diskette approved by the Council, according to computer tape format specification contained in Appendix A.

Source

   The provisions of this §  912.23 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

§ 912.24. Frequency of data submissions.

 Data elements required to be submitted under this subchapter shall be submitted on a quarterly basis by the last day of the third month following the close of the quarter. Data elements for inpatient discharges and outpatient services rendered in calendar quarters ending March 31, June 30, September 30 and December 31, shall be submitted by June 30, September 30, December 31 and March 31.

Source

   The provisions of this §  912.24 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

Cross References

   This section cited in 28 Pa. Code §  912.22 (relating to data element submission schedules).

EXCEPTIONS


§ 912.31. Principle.

 The Council may, within its discretion and for good reason, grant exceptions to sections within this chapterwhen the policy and objectives of this chapter and the act are otherwise met.

Authority

   The provisions of this §  912.31 amended under section 5(b) of the Health Care Cost Containment Act (35 P. S. §  449.5(b)).

Source

   The provisions of this §  912.31 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 October 1, 1999, effective October 2, 1999, 29 Pa.B. 5094. Immediately preceding text appears at serial page (242565).

§ 912.32. Requests for exceptions.

 Requests for exceptions shall be made in writing addressed to the Executive Director. A request shall be specific to the section in this chapter to which the request applies and shall state in detail the reasons for the request. A request for an exception shall be received and deemed as complete 90 days prior to the appropriate submission date for which the request applies. The Council will act within 60 days of receipt of a complete request. A majority vote by the Council is necessary to grant an exception. Disapproval of the exception request at the Council level shall be deemed to represent disapproval of the request. Applicants will be notified in writing of the action taken by the Council.

Source

   The provisions of this §  912.32 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

§ 912.33. Revocation of exceptions.

 (a)  An exception granted under this chapter may be revoked by the Council. Notice of revocation will be in writing and will include the reason for the action of the Council and a specific date upon which the exception will be terminated.

 (b)  In revoking an exception, the Council will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the health care facility to come into compliance with this chapter. Failure by the facility to comply after the specified date may result in enforcement proceedings.

 (c)  If a facility wishes to request a reconsideration of a denial or revocation of an exception, it shall do so in writing within 30 days of receipt of the adverse notification.

Source

   The provisions of this §  912.33 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

INTERPRETATIONS


§ 912.41. Definition for major ambulatory service.

 (a)  The Council may issue interpretations of this subchapter which apply to the question of which major ambulatory services are considered to be covered services and submission and modifications to schedules of data pertaining to them.

 (b)  Interpretations issued under this section will be subject to modification by the Council in an adjudicative proceeding based on the particular facts and circumstances relevant to a service.

Source

   The provisions of this §  912.41 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

Subchapter C. FINANCIAL REPORTING REQUIREMENTS


Sec.


912.61.    Annual audited financial statements.
912.62.    Quarterly summary utilization and financial reports.
912.63.    Medicare cost reports and Medical Assistance Form 336.

§ 912.61. Annual audited financial statements.

 (a)  For fiscal years beginning January 1, 1988, and thereafter, a hospital and ambulatory service facility providing covered services shall file annual audited financial statements within 120 days after the close of the fiscal year.

 (b)  The financial statements shall be certified by an independent certified public accountant who shall render an opinion that the statements have been prepared in accordance with generally accepted accounting principles, and on the financial position, results of operations and changes in financial positions of the hospital as of and for the period then ended.

 (c)  The certified annual statements shall contain the following:

   (1)  A balance sheet detailing the assets, liabilities and net worth of the hospital or ambulatory service facility.

   (2)  A statement of revenue and expenses that fully discloses deductions from revenue according to contractual adjustments and other deductions.

   (3)  A statement of changes in financial position.

   (4)  Footnotes to financial statements.

 (d)  If more than one health care facility is operated by the reporting organization, the information required by this section shall be reported for each health care facility separately.

Source

   The provisions of this §  912.61 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

§ 912.62. Quarterly summary utilization and financial reports.

 (a)  A hospital and ambulatory care facility providing covered services shall compile data following instructions on report format HC-87-Q1 beginning May 1, 1988.

 (b)  Quarterly summary utilization and financial reports, due 45 days following each quarter, shall be sent to the Council beginning with the first quarter of 1988. Report formats shall follow the instructions and Form HC-87-Q1.

Source

   The provisions of this §  912.62 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

§ 912.63. Medicare cost reports and Medical Assistance Form 336.

 (a)  A provider is required to submit to the Council a copy of its Medicare cost report and Medical Assistance Form 336 at the time they are due to the Department of Welfare or the Health Care Financing Administration or within 120 days of the close of its fiscal year reporting period.

 (b)  A provider is required to submit the settled Medicare cost report and certified MA 336 Form within 30 days of the final settlement.

Source

   The provisions of this §  912.63 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459.

Subchapter D. OTHER REQUIREMENTS


Sec.


912.81.    Provider information.

§ 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 Date56
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 Birth2 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—Readmission21d 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 Date8a, 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—w548
HCPCS/Rates 13a—w6 44
Service Date13a—w7 45
Payor Identification 14b 50
Prior Payments—Payor and Patient14f 54
Estimated Amount Due 14g 55
Uniform Identifier of Primary Payor17 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 Field21e
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—Referring38 82
Federal Tax ID 39 5
Admission Hour40 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, 1/1/94

Data 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
Element
Data Element Description Position PictureFormat
FromTo
HEADER RECORD
1Data Source Identifier125X(25)Left justify. Blank fill right.
2Data Source Name/Address26125X(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
3Period Covered First Day1261319(6)MMDDYY
4Period Covered Last Day1321379(6)MMDDYY
5Run Date1381439(6)MMDDYY. Date that this tape was created.
7Inpatient/Outpatient Indicator144X(1)I = Inpatient claims. O = Outpatient claims.
8Batch/Job/RunNumber145169X(25)For hospitals use in identifying the tape.
6Filler1702298X(2129)
9Submission Type2299X(1)O = Original Submission R = Resubmission of original data C = Correction data
10 Record Type2300X(1)H = Header Record


Data
Element
Data Element Description Position PictureFormat*
FromTo
1Uniform Patient Identifier19X(9)If unknown, fill with blanks. Right justify.
2Patient Date of Birth10179(8)MMDDYYYY
3Patient Sex18X(1)M = Male, F = Female, U = Unknown
4Patient Zip Code1927X(9)XXXXXYYYY. The 9 or 5 character zip code of patient residence. Left justify.
5Date of Admission28359(8)MMDDYYYY. Taken from Locator 15.
6Date of Discharge36439(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
Element
Data Element Description Position PictureFormat
FromTo
40Admission Hour44459(2)See manual for instructions.
41Discharge Hour46479(2)See manual for instructions.
7aPrincipal Diagnosis Code4853X(6)Diagnosis code. Left justify. See manual for instructions.
7bSecondary Diagnosis Code5459X(6)Diagnosis code. Left justify. See manual for instructions.
7cSecondary Diagnosis Code6065X(6)Diagnosis code. Left justify. See manual for instructions.
7dSecondary Diagnosis Code6671X(6)Diagnosis code. Left justify. See manual for instructions.
7eSecondary Diagnosis Code7277X(6)Diagnosis code. Left justify. See manual for instructions.
7fSecondary Diagnosis Code7883X(6)Diagnosis code. Left justify. See manual for instructions.
7gSecondary Diagnosis Code8489X(6)Diagnosis code. Left justify. See manual for instructions.
7hSecondary Diagnosis Code9095X(6)Diagnosis code. Left justify. See manual for instructions.
7iSecondary Diagnosis Code96101X(6)Diagnosis code. Left justify. See manual for instructions.
36Admitting Diagnosis Code102107X(6)Diagnosis code. Left justify. See manual for instructions.
37E-Code108113X(6)Diagnosis code. Left justify. See manual for instructions.
8aPrincipal Procedure Code114120X(7)Procedure code. Left justify. See manual for instructions.
8bDate1211249(4)MMDD
9a1Secondary Procedure Code125131X(7)Procedure code. Left justify. See manual for instructions.
9a2Date1321359(4)MMDD
9b1Secondary Procedure Code136142X(7)Procedure code. Left justify. See manual for instructions.
9b2Date1431469(4)MMDD
9c1Secondary Procedure Code147153X(7)Procedure code. Left justify. See manual for instructions.
9c2Date1541579(4)MMDD
9d1Secondary Procedure Code158164X(7)Procedure code. Left justify. See manual for instructions.
9d2Date1651689(4)MMDD
9e1Secondary Procedure Code169175X(7)Procedure code. Left justify. See manual for instructions.
9e2Date1761799(4)MMDD
38Referring Physician180202X(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.
11Attending Physician ID203225X(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.
12Operating Physician ID226248X(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.
13a2Revenue Code249252X(4)Left justify. See manual for code definitions.
13a6HCPCS/Rate2532619(9)Left justify for HCPCS. Right justify rate.
13a7Service Date2622699(8)MMDDYYYY
13a3Units of Service2702769(7)Right justify. Fill with zeroes left.
13a4Total Charges277286X(10)7 dollar characters, 2 cent characters, and 1 character for credit using a leading minus sign (-). Right justify. No decimal.
13a5Non-Covered Charges287296X(10)7 dollar characters, 2 cent characters, and 1 character for credit using a leading minus sign (-). Right justify. No decimal.
13b2Revenue Code297300X(4)Left justify. See manual for code definitions.
13b6HCPCS/Rate3013099(9)Left justify. See manual for code definitions.
13b7Service Date3103179(8)Left justify. See manual for code definitions.
13b3Units of Service3183249(7)Right justify. Fill with zeroes left.
13b4Total Charges325334X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13b5Non-Covered Charges335344X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13c2Revenue Code345348X(4)Left justify. See manual for code definitions.
13c6HCPCS/Rate3493579(9)Left justify. See manual for code definitions.
13c7Service Date3583659(8)Left justify. See manual for code definitions.
13c3Units of Service3663729(7)Right justify. Fill with zeroes left.
13c4Total Charges373382X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13c5Non-Covered Charges383392X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13d2Revenue Code393396X(4)Left justify. See manual for code definitions.
13d6HCPCS/Rates3974059(9)Left justify. See manual for code definitions.
13d7Service Date4064139(8)Left justify. See manual for code definitions.
13d3Units of Service4144209(7)Right justify. Fill with zeroes left.
13d4Total Charges421430X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13d5Non-Covered Charges431440X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13e2Revenue Code441444X(4)Left justify. See manual for code definitions.
13e6HCPCS/Rates4454539(9)Left justify. See manual for code definitions.
13e7Service Date4544619(8)Left justify. See manual for code definitions.
13e3Units of Service4624689(7)Right justify. Fill with zeroes left.
13e4Total Charges469478X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13e5Non-Covered Charges479488X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13f2Revenue Code489492X(4)Left justify. See manual for code definitions.
13f6HCPCS/Rates4935019(9)Left justify. See manual for code definitions.
13f7Service Date5025099(8)Left justify. See manual for code definitions.
13f3Units of Service5105169(7)Right justify. Fill with zeroes left.
13f4Total Charges517526X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13f5Non-Covered Charges527536X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13g2Revenue Code537540X(4)Left justify. See manual for code definitions.
13g6HCPCS/Rates5415499(9)Left justify. See manual for code definitions.
13g7Service Date5505579(8)Left justify. See manual for code definitions.
13g3Units of Service5585649(7)Right justify. Fill with zeroes left.
13g4Total Charges565574X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13g5Non-Covered Charges575584X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13h2Revenue Code585588X(4)Left justify. See manual for code definitions.
13h6HCPCS/Rates5895979(9)Left justify. See manual for code definitions.
13h7Service Date5986059(8)Left justify. See manual for code definitions.
13h3Units of Service6066129(7)Right justify. Fill with zeroes left.
13h4Total Charges613622X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13h5Non-Covered Charges623632X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13i2Revenue Code633636X(4)Left justify. See manual for code definitions.
13i6HCPCS/Rates6376459(9)Left justify. See manual for code definitions.
13i7Service Date6466539(8)Left justify. See manual for code definitions.
13i3Units of Service6546609(7)Right justify. Fill with zeroes left.
13i4Total Charges661670X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13i5Non-Covered Charges671680X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13j2Revenue Code681684X(4)Left justify. See manual for code definitions.
13j6HCPCS/Rates6856939(9)Left justify. See manual for code definitions.
13j7Service Date6947019(8)Left justify. See manual for code definitions.
13j3Units of Service7027089(7)Right justify. Fill with zeroes left.
13j4Total Charges709718X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13j5Non-Covered Charges719728X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13k2Revenue Code730732X(4)Left justify. See manual for code definitions.
13k6HCPCS/Rates7337419(9)Left justify. See manual for code definitions.
13k7Service Date7427499(8)Left justify. See manual for code definitions.
13k3Units of Service7507569(7)Right justify. Fill with zeroes left.
13k4Total Charges757766X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13k5Non-Covered Charges767776X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13l2Revenue Code777780X(4)Left justify. See manual for code definitions.
13l6HCPCS/Rates7817899(9)Left justify. See manual for code definitions.
13l7Service Date7907979(8)Left justify. See manual for code definitions.
13l3Units of Service7988049(7)Right justify. Fill with zeroes left.
13l4Total Charges805814X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13l5Non-Covered Charges815824X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13m2Revenue Code825828X(4)Left justify. See manual for code definitions.
13m6HCPCS/Rates8298379(9)Left justify. See manual for code definitions.
13m7Service Date8388459(8)Left justify. See manual for code definitions.
13m3Units of Service8468529(7)Right justify. Fill with zeroes left.
13m4Total Charges853862X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13m5Non-Covered Charges863872X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13n2Revenue Code873876X(4)Left justify. See manual for code definitions.
13n6HCPCS/Rates8778859(9)Left justify. See manual for code definitions.
13n7Service Date8868939(8)Left justify. See manual for code definitions.
13n3Units of Service8949009(7)Right justify. Fill with zeroes left.
13n4Total Charges901910X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13n5Non-Covered Charges911920X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13o2Revenue Code921924X(4)Left justify. See manual for code definitions.
13o6HCPCS/Rates9259339(9)Left justify. See manual for code definitions.
13o7Service Date9349419(8)Left justify. See manual for code definitions.
13o3Units of Service9429489(7)Right justify. Fill with zeroes left.
13o4Total Charges949958X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13o5Non-Covered Charges959968X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13p2Revenue Code969972X(4)Left justify. See manual for code definitions.
13p6HCPCS/Rates9739819(9)Left justify. See manual for code definitions.
13p7Service Date9829899(8)Left justify. See manual for code definitions.
13p3Units of Service9909969(7)Right justify. Fill with zeroes left.
13p4Total Charges9971006X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13p5Non-Covered Charges10071016X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13q2Revenue Code10171020X(4)Left justify. See manual for code definitions.
13q6HCPCS/Rates102110299(9)Left justify. See manual for code definitions.
13q7Service Date103010379(8)Left justify. See manual for code definitions.
13q3Units of Service103810449(7)Right justify. Fill with zeroes left.
13q4Total Charges10451054X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13q5Non-Covered Charges10551064X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13r2Revenue Code10651068X(4)Left justify. See manual for code definitions.
13r6HCPCS/Rates106910779(9)Left justify. See manual for code definitions.
13r7Service Date107810859(8)Left justify. See manual for code definitions.
13r3Units of Service108610929(7)Right justify. Fill with zeroes left.
13r4Total Charges10931102X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13r5Non-Covered Charges11031112X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13s2Revenue Code11131116X(4)Left justify. See manual for code definitions.
13s6HCPCS/Rates111711259(9)Left justify. See manual for code definitions.
13s7Service Date112611339(8)Left justify. See manual for code definitions.
13s3Units of Service113411409(7)Right justify. Fill with zeroes left.
13s4Total Charges11411150X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13s5Non-Covered Charges11511160X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13t2Revenue Code11611164X(4)Left justify. See manual for code definitions.
13t6HCPCS/Rates116511739(9)Left justify. See manual for code definitions.
13t7Service Date117411819(8)Left justify. See manual for code definitions.
13t3Units of Service118211889(7)Right justify. Fill with zeroes left.
13t4Total Charges11891198X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13t5Non-Covered Charges11991208X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13u2Revenue Code12091212X(4)Left justify. See manual for code definitions.
13u6HCPCS/Rates121312219(9)Left justify. See manual for code definitions.
13u7Service Date122212299(8)Left justify. See manual for code definitions.
13u3Units of Service123012369(7)Right justify. Fill with zeroes left.
13u4Total Charges12371246X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13u5Non-Covered Charges12471256X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13v2Revenue Code12571260X(4)Left justify. See manual for code definitions.
13v6HCPCS/Rates126112699(9)Left justify. See manual for code definitions.
13v7Service Date127012779(8)Left justify. See manual for code definitions.
13v3Units of Service127812849(7)Right justify. Fill with zeroes left.
13v4Total Charges12851294X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13v5Non-Covered Charges12951304X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
13w2Revenue Code13051308X(4)001. Unless it is a continuing record.
13w6HCPCS/Rates130913179(9)001. Unless it is a continuing record.
13w7Service Date131813259(8)001. Unless it is a continuing record.
13w3Units of Service132613329(7)Fill with blanks.
13w4Total Charges13331342X(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.
13w5Non-Covered Charges13431352X(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.
14b1Payor Identification13531377X(25)Left justify. Blank fill right. See manual for code definitions.
14b2Payor Identification13781402X(25)Left justify. Blank fill right. See manual for code definitions.
14b3Payor Identification14031427X(25)Left justify. Blank fill right. See manual for code definitions.
14f1Prior Payments—Payor and Patient14281437X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
14f2Prior Payments—Payor and Patient14381447X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
14f3Prior Payments—Payor and Patient14481457X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
14f4Prior Payments—Payor and Patient14581467X(10)7 dollar characters, 2 cent characters, and 1 character for credit with a leading minus sign (-). Right justify. No decimal.
14g1Estimated Amount Due14681477X(10)Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks.
14g2Estimated Amount Due14781487X(10)Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks.
14g3Estimated Amount Due14881497X(10)Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks.
14g4Estimated Amount Due14981507X(10)Council will develop a methodology to apply to all hospitals. At the present time, fill with blanks.
17Uniform Identifier of Primary Payor15081514X(7)Left justify. Fill with blanks right.
18Zip Code of Facility15151523X(9)XXXXXYYYY. Left justify.
19aPayor Group Number15241540X(17)Left justify.
19bPayor Group Number15411557X(17)Left justify.
19cPayor Group Number15581574X(17)Left justify.
20Patient Discharge Status157515769(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 Effectiveness1578 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.
21cUnusual Occurrence1579X(1)The Council will develop a methodology to apply to all hospitals. Until that time, fill with blanks.
21dUnusual Occurrence158015819(2)The Council will develop a methodology to apply to all hospitals. Until that time, fill with zeroes.
22Type of Bill158215849(3)Right justify. See manual for code definitions.
23Patient Control Number15851604X(20)Left justify.
24Diagnosis Related Group (DRG)160516079(3)See manual for instructions.
25Procedure Coding Method Used16089(1)1—3 = Reserved for state assignment. 4 = CPT-4 5 = HCPCS 6—8 = Reserved for national assignment. 9 = ICD-9-CM
26Type of Admission1609X(1)1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn 5—8 = Reserved for National assignment. 9 = Information not available See manual for definitions.
27Source of Admission1610X(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.

28aPatient’s Relation- ship to Insured161116129(2)Right justify. See manual for code definitions.
28bPatient’s Relation- ship to Insured161316149(2)Right justify. See manual for code definitions.
28cPatient’s Relation- ship to Insured161516169(2)Right justify. See manual for code definitions.
29aCertification/Social Security Number/ Health Insurance Claim Number16171635X(19)Left justify.
29bCertification/Social Security Number/ Health Insurance Claim Number16361654X(19)Left justify.
29cCertification/Social Security Number/ Health Insurance Claim Number16551673X(19)Left justify.
32aEmployer Name16741697X(24)Left justify.
32bEmployer Name16981721X(24)See manual for instructions.
32cEmployer Name17221745X(24)See manual for instructions.
34aEmployment Status17469(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.

34bEmployment Status17479(1)See manual for instructions.
34cEmployment Status17489(1)See manual for instructions.
35aHispanic/Spanish Origin or Descent1749X(1)See manual for instructions.
35bPatient Race1750X(1)W = White B = Black A = Asian I = Native

  American

  or Eskimo N = Other O = Unknown

10Uniform Identifier for Health Care Facility17511758X(8)Left justify. Blank fill right.
39Federal Tax ID17591768X(10)See manual for instructions.
21e
Reserve Field17692300X(532)To be reserved for future use by the Council.
TRAILER RECORD
1Number of Records on This Tape1109(10)Total number of patient discharge records on this tape.
2Number of Patients on This Tape11209(10)Total number of patients on this tape.
4Total Dollars21329(12)Total dollars on tape. 9 dollar characters and 2 cent characters. Right justify. No decimal.
3Filler332299X(2267)
5Record Type2300X(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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