APPENDIX A

DATA DICTIONARY

The definition specified for each data element is in general agreement with the definition in the UB-04 Users' Manual. Hospitals using existing UB-04 record formats should reference 20 CAR § 54-108, exceptions to 1450 format, for differences from the established UB-04 record formats. Hospitals using data sources other than uniform billing should evaluate their definitions for agreement with the definitions specified in this Guide and the UB-04 Users' Manual.

A1 The dictionary format that follows will provide the following information:

1. Data Element: The name of the data element

2. Char Type: Character type for the data element N = numeric A = alphanumeric

3. Char Length: Character length of data element. For fields with an implied decimal point, the first number is the total length, the second number is the length after the implied decimal point (e.g., '9, 2' represents the COBOL picture clause 9(7)V99).

4. Data Reporting Requirement for the Data Element Level: Required = must be reported As available = must be present, if captured in your database

5. Definition: A definition of the data element

6. General Comments: These comments help to further define or explain the data Comments: elements and give permissible values for code and type data elements.

7. Edit: Minimal edits that will be performed on the data element; these edits should be performed by the hospital prior to submission.

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

Table 1. Definition Breakdown

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
Accommodation Rate	N	9, 2	☑ Required ☐ As available	Record Type 50, positions 29-37 for Accommodation 1, positions 71-79 for Accommodation 2 & positions 113-121 for Accommodation 3.
DEFINITION	Per-diem rate for related UB-04 accommodations revenue codes.
GENERAL COMMENTS	The rate should be right justified with leading zeroes. There is an implied decimal placed 2 positions from the right.
EDIT	If present, rate must be greater than zero.
Admission Date	N	6 or 8	☑ Required ☐ As available	Record Type 20, positions 174-179 for 1450 format or positions 174-181 for 1450Y2K format.
DEFINITION	The start date for this episode of care. For inpatient services, this is the date of admission.
GENERAL COMMENTS	The admission date is to be entered as month, day, and year. The format is MMDDYY for 1450 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example, February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made, all dates must use this format.
EDIT	Admission date must be present and a valid date. The date cannot be before date of birth or be after ending date in Statement Covers Period.
Admission Hour	A	2	☑ Required ☐ As available	Record Type 20, positions 180-181 for 1450 format or positions 182-183 for 1450Y2K format.
DEFINITION	The hour during which the patient was admitted for inpatient care.
GENERAL COMMENTS	Military time should be used to represent the hour of admission. If admitted between midnight and noon, use the values from 00 to 11; if admitted between noon and 11:59 pm, use the values from 12 to 23.
	Code	Time – AM	Code	Time – PM
	00	12:00 – 12:59	12	12:00 – 12:59 Noon
	01	Midnight	13	01:00 – 01:59
	02	01:00 – 01:59	14	02:00 – 02:59
	03	02:00 – 02:59	15	03:00 – 03:59
	04	03:00 – 03:59	16	04:00 – 04:59
	05	04:00 – 04:59	17	05:00 – 05:59
	06	05:00 – 05:59	18	06:00 – 06:59
	07	06:00 – 06:59	19	07:00 – 07:59
	08	07:00 – 07:59	20	08:00 – 08:59
	09	08:00 – 08:59	21	09:00 – 09:59
	10	09:00 – 09:59	22	10:00 – 10:59
	11	10:00 – 10:59	23	11:00 – 11:59
		11:00 – 11:59
EDIT	Valid numeric value for the hour of admission or blank.
Admitting Diagnosis Code	A	8	☑ Required ☐ As available	Record Type 70, Sequence 2, positions 25-32 (1450 & 1450Y2K).
DEFINITION	The ICD diagnosis code provided at the time of admission as stated by the physician.
GENERAL COMMENTS	This field is to contain the appropriate ICD code without a decimal. All entries are to be left justified with spaces to the right to complete the field length. An external cause of injury code should not be recorded as the admitting diagnosis.
EDIT	An admitting diagnosis must be present and valid. When the admitting diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
APGAR Score	N	4	☑ Required ☐ As available	Record Type 27, positions 60-63.
DEFINITION	APGAR Score (1 minute & 5 minute) for a newborn. Zero fills if not a newborn.
GENERAL COMMENTS	Right justify the field with zeroes to the left to complete the field. Positions 60-61 should contain the one minute APGAR and 62-63 should contain the five minute APGAR (Example: 0809).
EDIT	If present, must be numeric.

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
Attending Provider Name	A	25	☑ Required ☐ As available	Record Type 80, positions 91-115
DEFINITION	The individual who has overall responsibility for the patient's medical care and treatment reported in this claim.
GENERAL COMMENTS	Entered in the order of last name, first name and middle initial. Last name in positions 91-106, first name in positions 107-114 and initial in position 115.
EDIT	None
Attending Provider Identifier	N	10	☑ Required ☐ As available	Record Type 80, positions 27-36
DEFINITION	National Provider Identifier of the individual who has overall responsibility for the patient's medical care and treatment reported via this claim.
GENERAL COMMENTS	This field is to be left justified with spaces to the right to complete the field.
EDIT	This field must contain a valid National Provider Identifier (NPI).
Birth Weight	N	4	☑ Required ☐ As available	Record Type 27, positions 40-43
DEFINITION	Birth weight in grams for a newborn. Zero-fill if not a newborn.
GENERAL COMMENTS	Right justify the field with zeroes to the left to complete the field.
EDIT	Must be numeric.
Diagnosis Related Group (DRG)	N	4	☐ Required ☑ As available	Record 27, positions 64-67
DEFINITION	The PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. This represents an inpatient classification scheme to categorize patients that are medically related with respect to diagnosis and treatment and who are statistically similar in their lengths of stay.
GENERAL COMMENTS	When DRG is unknown or not available use 9999. Right justified with leading spaces.
EDIT	A DRG if present, must be valid and consistent with sex and age.
Discharge Hour	A	2	☑ Required ☐ As available	Record Type 20, positions 196-197 for format 1450 or positions 202-203 for format 1450Y2K.
DEFINITION	Hour that the patient was discharged from inpatient care. Required on inpatient claims with a Frequency Code of 1 or 4, except for Type of Bill 021x.
GENERAL COMMENTS	Military time should be used to represent the hour of discharge. If discharged between midnight and noon, use the values from 00 to 11; if discharged between noon and 11:59 pm, use the values from 12 to 23.
	Code	Time – AM	Code	Time – PM
	00	12:00 – 12:59	12	12:00 – 12:59 Noon
	01	Midnight	13	01:00 – 01:59
	02	01:00 – 01:59	14	02:00 – 02:59
	03	02:00 – 02:59	15	03:00 – 03:59
	04	03:00 – 03:59	16	04:00 – 04:59
	05	04:00 – 04:59	17	05:00 – 05:59
	06	05:00 – 05:59	18	06:00 – 06:59
	07	06:00 – 06:59	19	07:00 – 07:59
	08	07:00 – 07:59	20	08:00 – 08:59
	09	08:00 – 08:59	21	09:00 – 09:59
	10	09:00 – 09:59	22	10:00 – 10:59
	11	10:00 – 10:59	23	11:00 – 11:59
EDIT	Valid numeric value for the hour of discharge.

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
Employer Location	A	44	☐ Required ☑ As available	Record Type 31, positions 111-154
DEFINITION	The specific location represented by the address of the employer of the individual identified by the second of two entries in employment information data field.
GENERAL COMMENTS	This is to be the full and complete address of the employer of the individual.
EDIT	None
Employer Name	A	24	☐ Required ☑ As available	Record Type 31, positions 87-110
DEFINITION	The name of the employer that might or does provide health care coverage for the individual identified by the first of two entries in the employment information data fields.
GENERAL COMMENTS	Enter the full and complete name of the employer providing health care coverage.
EDIT	None
Employer ZIPCode	A	9	☐ Required ☑ As available	Record Type 31, positions 146-154
DEFINITION	The ZIPCode of the employer of the individual identified by the first of two entries in the employment information data fields.
GENERAL COMMENTS	None
EDIT	None
Employment Status Code	A	1	☐ Required ☑ As available	Record Type 30, position 146
DEFINITION	A code used to define the employment status of the individual identified in the first of two employment information data fields.
GENERAL COMMENTS	This field contains the employment status of the person described in the first of two employment information data fields. The codes to be used are as follows:
	1	Employed full time	Definition: individual states that he/she is employed full time
	2	Employed part time	Definition: individual states that he/she is employed part time
	3	Not employed	Definition: individual states that he/she is not employed part time or full time
	4	Self employed
	5	Retired
	6	On active military duty
	9	Unknown	Definition: individual's employment status is unknown
EDIT	If an entry is present, it must be a valid code.
External Cause of Injury Code	A	6	☑ Required ☐ As available	Record Type 70, Sequence 2, positions 33-40, 41-48, 49-56, 57-64, 65-72, 73-80, 81-88, 89-96, 97-104, 105-112 (1450 & 1450Y2K)
DEFINITION	The ICD code for the external cause of injury, poisoning or adverse effect.

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
GENERAL COMMENTS	Hospitals are to complete this field whenever there is a diagnosis of an injury, poisoning or adverse effect. The priorities for recording an external cause of injury code are: a. Principal diagnosis of an injury or poisoning b. Other diagnosis of an injury c. Other diagnosis with an external cause All entries are to be left justified without a decimal.
EDIT	Must be valid. When the diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Federal Tax Number (EIN)	N	10	☑ Required ☐ As available	Record Type 10, positions 8-17, Record Type 95, positions 3-12
DEFINITION	The number assigned to the provider by the Federal government for tax report purposes, also known as a Tax Identification Number (TIN) or Employer Identification Number (EIN).
GENERAL COMMENTS	None
EDIT	None
Federal Tax Sub ID	A	4	☑ Required ☐ As available When Federal Tax Number is not unique	Record Type 10 position 18-21, Record Type 95 position 13-16
DEFINITION	Four-position modifier to Federal Tax ID.
GENERAL COMMENTS	Used by providers to identify their affiliated subsidiaries when the Federal Tax Number does not distinguish between separate facilities or cost centers.
EDIT	None
HCPCS / Procedure Code	A	5	☐ Required ☑ As available	Record Type 60, positions 29-34, 85-89, 141-145
DEFINITION	Procedure codes reported in record types identify services so that appropriate payment can be made. HCFA Common Procedural Coding System (HCPCS) code is required for many specific types of outpatient services and a few inpatient services. May include up to two modifiers.
GENERAL COMMENTS	None
EDIT	None
Health Plan ID	N	10	☑ Required ☐ As available	Record Type 30, positions 30-39
DEFINITION	The numbers used by the health plan to identify itself.
GENERAL COMMENTS	None
EDIT	None
Insured Address	A	62	☐ Required ☑ As available	Record Type 31, positions 25-86
DEFINITION	Insured's current mailing address: Address Line 1, Address Line 2, City, State, Zip.
GENERAL COMMENTS	None
EDIT	None
Insurance Group Number	A	17	☐ Required ☑ As available	Record Type 30, positions 80-96

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
DEFINITION	The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered.
GENERAL COMMENTS	None
EDIT	None
Insured's Name	A	30	☐ Required ☑ As available	Record Type 30, positions 111-140
DEFINITION	The name of the individual in whose name the insurance is carried.
GENERAL COMMENTS	Enter the name of the insured individual in last name, first name, middle initial order. Titles such as Sir, Mr. or Dr. should not be recorded in this data field. Record hyphenated names with the hyphen as in Smith-Jones. To record suffix of a name, write the last name, leave a space then write the suffix, for example, Snyder III or Addams Jr.
EDIT	None
Insured's Unique ID	A	19	☑ Required ☐ As available	Record Type 30, positions 40-58
DEFINITION	Insured's unique identification number assigned by the payer organization. Medicare purposes enter the patient's Medicare HIC number as on the Health Insurance Card, Certificate of Award, Utilization Notice, Temporary Eligibility Notice, Hospital Transfer Form, or as reported by the Social Security Office.
GENERAL COMMENTS	The payer organization's assigned identification number is to be entered in this field. It should be entered exactly as printed on the Insured's proof of coverage.
EDIT	None
Major Diagnostic Categories (MDC)	A	2	☐ Required ☑ As available	Record Type 27, positions 68-69
DEFINITION	The MDC is formed by dividing all possible principal diagnoses into 25 mutually exclusive diagnosis areas.
GENERAL COMMENTS	MDC 1 to MDC 23 is grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondaries) from the different body site categories. Patients assigned to MDC 25 (HIV Infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection.
EDIT	Must be a valid code.

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
MDC Code & Definition	0 = Ungroupable 1 = Nervous System 2 = Eye 3 = Ear, Nose, Mouth and Throat 4 = Respiratory System 5 = Circulatory System 6 = Digestive System 7 = Hepatobiliary System And Pancreas 8 = Musculoskeletal System And Connective Tissue 9 = Skin, Subcutaneous Tissue And Breast 10 = Endocrine, Nutritional And Metabolic System 11 = Kidney and Urinary Tract 12 = Male Reproductive System 13 = Female Reproductive System 14 = Pregnancy, Childbirth and Puerperium 15 = Newborn and Other Neonates( Prenatal Period) 16 = Blood and Blood Forming Organs and Immunological Disorder 17 = Myeloproliferative DDs (Poorly Differentiated Neoplasm) 18 = Infectious and Parasitic DDs 19 = Mental Diseases and Disorders 20 = Alcohol/Drug Use or Induced Mental Disorders 21 = Injuries, Poison And Toxic Effect of Drugs 22 = Burns 23 = Factors Influencing Health Status 24 = Multiple Significant Trauma 25 = Human Immunodeficiency Virus Infections
Medical Record Number	A	17	☑ Required ☐ As available	Record Type 20, positions 198-214 for format 1450 or positions 204-220 for format 1450Y2K.
DEFINITION	Number assigned to patient by hospital or other provider to assist in retrieval of medical records.
GENERAL COMMENTS	This number is assigned by the hospital for each patient.
EDIT	None
National Provider Identifier (NPI) – Billing Provider	A	13	☑ Required ☐ As available	Record Type 10, positions 22-34
DEFINITION	The National Provider Identifier (NPI) is a ten-position identifier issued by Medicare.
GENERAL COMMENTS	The unique identification number assigned to the provider submitting the bill.
EDIT	Will be verified against Department of Health databases obtained from Medicare.
Number of Claims	N	6	☑ Required ☐ As available	Record Type 95, positions 25-30
DEFINITION	The number of discharge submitted by a hospital for this submitted. Used to verify a complete submittal, no losses of data.
GENERAL COMMENTS	None
EDIT	Must be the total number of discharges for the hospital in the batch (type '20'records).

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
Operating Physician Name	A	25	☐ Required ☑ As available	Record Type 80, positions 116-140
DEFINITION	The name of the individual with the primary responsibility for performing the surgical procedure(s).
GENERAL COMMENTS	Entered in the order of last name, first name and middle initial. Last name in positions 1-16, first name in positions 17-24 and initial in position 25.
EDIT	None
Operating Physician Identifier	N	10	☑ Required ☐ As available	Record Type 80, Position 43-52
DEFINITION	National Provider Identifier of the individual with primary responsibility for performing the surgical procedure(s).
GENERAL COMMENTS	Must be left justified in the field.
EDIT	This field must contain a valid license or assigned number according to 'Physician Number Qualifying Code'.
Other Diagnosis Code	A	6	☑ Required ☐ As available	Record Type 70, Sequence 1, See Record Format 20 CAR § 54-107(j) for positions (1450 & 1450Y2K)
DEFINITION	ICD code describing other diagnoses corresponding to additional conditions that co-exist at the time of admission or develop subsequently, and which have an effect on the treatment received or the length of stay.
GENERAL COMMENTS	The first of twenty-nine additional diagnoses. This field must contain the ICD code without a decimal.
EDIT	If other diagnoses are present, they must be valid. When diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Other Physician Name	A	25	☐ Required ☑ As available	Record Type 80, positions 141-165, 166-190
DEFINITION	This is the name of a physician other than the attending physician as defined by the payer organization.
GENERAL COMMENTS	Entered in the order of last name, first name and middle initial.
EDIT	None
Other Physician Identifier	N	10	☑ Required ☐ As available	Record Type 80, positions 59-68, 75-84
DEFINITION	This is the National Provider Identifier of a physician.
GENERAL COMMENTS	Must be left justified in the field.
EDIT	This field must contain a valid National Provider Number.
Other Procedure Code	a	7	☑ Required ☐ As available	Record Type 70, Sequence 3, See Record Format 20 CAR § 54-107(j)(3) for 1450 positions & 6.9.4 for 1450Y2K positions
DEFINITION	The code that identifies the other procedures performed during the patient's hospital stay covered by this discharge record. This may include diagnostic or exploratory procedures.

DATA ELEMENT	CHAR TYPE	CHAR LGTH	DATA REPORTING LEVEL	LOCATION
GENERAL COMMENTS	Procedures that make for accurate DRG Categorization must be included. The coding method used must agree with the coding method used for the principal procedure. Entries must include all digits. It must be present. Enter the code left justified, without a decimal.
EDIT	If this field is present, there must be a principal procedure entered. Codes entered must be valid. When a procedure is gender-specific, the gender code entered in the record must be consistent.
Other Procedure Date	N	6	☑ Required ☐ As available	Record Type 70, Sequence 3, See Record Format 20 CAR § 54-107(j)(3) for 1450 positions & 6.9.4 for 1450Y2K positions
DEFINITION	Date that the procedure indicated by the related procedure code was performed.
GENERAL COMMENTS	None
EDIT	Must be a valid date.
Patient Address	A	62	☑ Required ☐ As available	Record Type 20, positions 88 – 173 (1450 & 1450Y2K)
DEFINITION	The address including postal ZIPcode of the patient, as defined by the payer organization. (Address line 1 & 2, City, State, & ZIPCode)
GENERAL COMMENTS	The order of the complete address if provided should be street number, apartment number, city, state and ZIPcode, left justified with spaces to the right to complete the field. The state must be the standard post office abbreviations (AR for Arkansas). If the nine digit ZIPcode is used, it must be entered in the form XXXXXXXXXX where X's are the five digit ZIPcode and the Y's are the ZIPcode extension. If Street Address is not provided, the nine digit postal ZIPcode is required for a valid address.
EDIT	This field is edited for the presence of an address with a valid and complete postal ZIPcode.

Patient Control Number	A	20	☑ Required ☐ As available	All Records, positions 5-24 except for Record Types 10 and 95
DEFINITION	A patient's unique alpha-numeric number assigned by the hospital to facilitate retrieval of individual discharge records, if editing or correction is required.
GENERAL COMMENTS	This number should not be the same as the Medical Record Number. This number will be used for reference in correspondence, problem solving or edit corrections.
EDIT	The number must be present and should be unique within a hospital.
Patient's Date of Birth	N	8	☑ Required ☐ As available	Record Type 20, positions 77-84 (1450 & 1450Y2K)
DEFINITION	The date of birth of the patient in month day year order; year is 4 digits.
GENERAL COMMENTS	The date of birth must be present and recorded in an eight-digit format of month day year (MMDDYYYY). The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as four digits ranging from 1800-2100. Each of the first two components (month, day) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 1982 is entered as 02071982. If the birth date is unknown, then the field must contain '00000000. For hospitals using the 1450 record format that began using a different date in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2001 format is entered 20010207. Where this change is made, all dates must use this format.
EDIT	This field is edited for the presence of a valid date and of a date that it is not equal to the current date. Age is calculated and used in the clinic code edit to identify age/diagnosis conflicts and invalid or unknown age.
Patient's Discharge Status	N	2	☑ Required ☐ As available	Record Type 20, positions 194-195 for format 1450 or 200-201 positions for format 1450Y2K
DEFINITION	A code indicating patient status at the time of the discharge. It is the arrangement or event ending a patient's stay in the hospital.
GENERAL COMMENTS	This is a two-character code. This should be the status at the time of discharge, the last 'Patient Status'; this would invalidate any patient's stay codes of 30-39. The patient's status is coded as follows:
	01	Definition: Discharged to Home or Self Care (Routine Discharge)-Includes discharges to home; home on oxygen if DME only; any other DME only; group home, foster care, independent living and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs.
	02	Definition: Discharged/transferred to a Short-Term General Hospital for Inpatient Care
	03	Definition: Discharge/transferred to Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care-Indicates that the patient is discharged/transferred to a Medicare certified nursing facility. For hospitals with an approved swing bed arrangement, use Code 61-Swing Bed. For reporting other discharges/transfers to nursing facilities see 04 and 64.
	04	Definition: Discharge/transferred to a facility that provides custodial or supportive care. Includes intermediate care facilities (ICFs) if specifically designated at the state level. Also, used to designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to state designated Assisted Living Facilities.
	05	Definition: Discharge/transferred to Designated Cancer Center or Children's Hospital
	06	Definition: Discharge/transferred to Home Under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care
	07	Definition: Left Against Medical Advice or Discontinued Care
	09	Definition: Admitted as an Inpatient to this Hospital-Use only with Medicare outpatient claims. Applies only to those Medicare outpatient services that begin greater than three days prior to an admission.
	20	Definition: Expired
	21	Definition: Discharged/transferred to Court/Law Enforcement – includes transfers to incarceration facilities such as jails, prison or other detention facilities.
	30	Definition: Still a Patient in the Hospital- *not a valid code
	40	Definition: Expired at home- (hospice claims only)

	41	Definition: Expired in a Medical Facility-hospital, skilled nursing facility, intermediate care facility, or freestanding hospice (hospice claims only)
	42	Definition: Expired – Place Unknown (hospice claims only)
	43	Definition: Discharge/transferred to a Federal Health Care Facility e.g. Department of Defense hospital, a VA hospital, or a VA nursing facility
	50	Definition: Hospice – Home
	51	Definition: Hospice – Medical Facility
	61	Definition: Discharged/transferred to a hospital based (Medicare approved) swing bed- For Medicare discharges; use for reporting patients discharged/transferred to a SNF level of care within the hospital's approved swing bed arrangement.
	62	Definition: Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital
	63	Definition: Discharged/transferred to a Long Term Care Hospital (LTCH)
	64	Definition: Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare
	65	Definition: Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a hospital
	66	Definition: Discharged/transferred to a Critical Access Hospital (CAH)
	67-69	Reserved for Assignment by the NUBC
	70	Definition: Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List.
	71-99	Reserved for Assignment by the NUBC
EDIT	The patient status code must be present and a valid code as defined. A patient status code of 30 is not a valid code. *In situations where a patient is admitted before midnight of the third day following the day of an outpatient service, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier, such as observation following outpatient surgery, which results in admission.
Patient's Ethnicity	A	1	☑ Required ☐ As available	Record Type 27, position 39
DEFINITION	This item gives the ethnicity of the patient. The information is based on self-identification, and is to be obtained from the patient, a relative, or a friend. The hospital is not to categorize the patient based on observation or personnel judgment.
GENERAL COMMENTS	The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled.
	1	Hispanic origin	Definition: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
	2	Not of Hispanic Origin	Definition: A person who is not classified in 1.
	6	Unknown	Definition: A person who chooses not to respond to the inquiry
	Blank Space	The hospital made no effort to obtain the information.
EDIT	If the data field contains an entry, it must be a valid code combination.
Patient's Marital Status	A	1	☐ Required ☑ As available	Record Type 20, position 85 (1450 & 1450Y2K)
DEFINITION	The marital status of the patient at date of admission, or start of care.
GENERAL COMMENTS	The marital status of the patient is to be reported as a one character code whenever the information is recorded in the patient's hospital record. The following codes apply:

	S =	Single
	M =	Married
	X =	Legally Separated
	D =	Divorced
	W =	Widowed
	U =	Unknown
	Space =	Not present in patient's record
EDIT	This field is edited for a valid entry
Patient's Name	A	31	☑ Required ☐ As available	Record Type 20, positions 25- 75 (1450 & 1450Y2K)
DEFINITION	The name of the patient in last, first and middle initial order.
GENERAL COMMENTS	Titles such as Sir, Msgr., and Dr. should not be recorded. Record hyphenated names with the hyphen, as in Smith-Jones. To record a suffix of a name, write the last name, leave a space, then write the suffix, for example: Snyder III or Addams Jr.
EDIT	The name will be edited for the presence of the last name and the first name.
Patient's Race	A	1	☑ Required ☐ As available	Record Type 27, position 38
DEFINITION	This item gives the race of the patient.
GENERAL COMMENTS	The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled.
	1	American Indian or Alaskan Native	Definition: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.
	2	Asian or Pacific Islander	Definition: A person having origins in any of the original oriental peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa.
	3	Black	Definition: A person having origins in any of the black racial groups of Africa
	4	White	Definition: A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
	5	Other	Definition: Any possible options not covered in the above categories.
	6	Unknown	Definition: A person who chooses not to answer the question.
	Blank Space		Definition: The hospital made no effort to obtain the information.
EDIT	None
Patient's Relationship to Insured	N	2	☐ Required ☑ As available	Record Type 30, positions 144-145
DEFINITION	A code indicating the relationship, such as patient, spouse, child, etc., of the patient to the identified Insured person listed in the first of three Insured's Name fields.
GENERAL COMMENTS	Enter the 2 digit code representing the patient's relationship to the individual named. All codes are to be right justified with a leading 0, if needed. The following codes apply:
	18	Patient is named insured	Definition: Self-explanatory
	01	Spouse	Definition: Self-explanatory
	19	Natural child/insured financially responsible	Definition: Self-explanatory
	43	Natural child/insured does not have financial responsibility	Definition: Self-explanatory

	17	Step Child	Definition: Self-explanatory
	10	Foster Child	Definition: Self-explanatory
	15	Ward of the Court	Definition: Patient is ward of the insured as a result of a court order
	20	Employee	Definition: The patient is employed by the named insured.
	21	Unknown	Definition: The patient's relationship to the named insured is unknown
	22	Handicapped Dependent	Definition: Dependent child whose coverage extends beyond normal termination age limits as a result of laws or agreements extending coverage.
	39	Organ Donor	Definition: Code is used in cases where bill is submitted for care given to organ donor where such care is paid by the receiving patient's insurance coverage.
	40	Cadaver Donor	Definition: Code is used where bill is submitted for procedures performed on cadaver donor where such procedures are paid by the receiving patient's insurance coverage.
	05	Grandchild	Definition: Self-explanatory
	07	Niece or Nephew	Definition: Self-explanatory
	41	Injured Plaintiff	Definition: Patient is claiming insurance as a result of injury covered by insured.
	23	Sponsored Dependent	Definition: Individual not normally covered by insurance coverage but coverage has been specially arranged to include relationships such as grandparent or former spouse that would require further investigation by the payer.
	24	Minor Dependent of a Minor Dependent	Definition: Code is used where patient is a minor and a dependent of another minor who in turn is a dependent, although not a child of the insured.
	32	Mother	Definition: Self-explanatory
	33	Father	Definition: Self-explanatory
	04	Grandparent	Definition: Self-explanatory
	29	Significant Other
	36	Emancipated Minor
	53	Life Partner
	G8	Other Relationship
EDIT	A code must be present and valid if Insured's Name is entered.
Patient's Sex	A	1	☑ Required ☐ As available	Record Type 20, position 76 (1450 & 1450Y2K)
DEFINITION	The gender of the patient as recorded at date of admission.
GENERAL COMMENTS	This is a one-character code. The sex is to be reported as male, female or unknown using the following coding: M = Male F = Female U = Unknown
EDIT	A valid code must be present. The gender of the patient is checked for consistency with diagnosis and procedure codes. The edit is to identify gender diagnosis conflicts and invalid or unknown gender.
Patient Social Security Number	N	10	☑ Required ☐ As available	Record Type 27, positions 28-37
DEFINITION	The social security number of the patient receiving inpatient care
GENERAL COMMENTS	For 1450 submissions, this field is to be right justified, with zeroes to the left to complete the field. The format of SSN is 0123456789 without hyphens. If the patient is a newborn, use the mother's SSN. If a patient does not have a social security number, fill with zeroes.
EDIT	The field is edited for a valid entry.
Physician Identifier Code	A	2	☑ Required ☐ As available	Record Type 80, positions 25-26
DEFINITION	The type of Physician Number being submitted. Applies to all Physician Numbers for a single hospital discharge.

GENERAL COMMENTS	Use the code NI for National Provider Identifier (NPI).
EDIT	Must be a valid NPI.
Point of Origin for Admission or Visit	a	1	☑ Required ☐ As available	Record Type 20, position 87
DEFINITION	A code indicating the point of patient origin for this admission or visit.
	Code Structure for all Admission Types (excluding Newborns (Type 4))
	1	Non-Health Care Facility Point of Origin	Definition: The patient was admitted to this facility. Example: include patients coming from home or workplace.
	2	Clinic	Definition: The patient was admitted to this facility as a transfer from a freestanding or non-freestanding clinic.
	3	Reserved for assignment by NUBC	Definition:
	4	Transfer from a Hospital	Definition: The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient or outpatient.
	5	Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)	Definition: The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.
	6	Transfer from another Health Care Facility	Definition: The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list.
	7	Reserved for assignment by NUBC
	8	Court/Law Enforcement	Definition: 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.
	9	Information not available	Definition: The means by which the patient was admitted to this hospital is not known.
	D	Inpatient transfers within the same facility	Definition: The patient was transferred from a separate unit of a hospital to another unit of the same hospital which results in separate claim to the payers.
	E	Transfer from Ambulatory Surgery Center	Definition: The patient was admitted to this facility as a transfer from an ambulatory surgery center.
	F	Transfer from Hospice	Definition: The patient was admitted to this facility as a transfer from hospice.
	Code Structure for Newborn If Priority of Admission is a 4, the following codes apply:
	1-4	Reserved for assignment by the NUBC.
	5	Definition: A baby born inside this Hospital.
	6	Definition: A baby born outside of this Hospital.
	7-9	Reserved for assignment by the NUBC.
EDIT	The code must be present and valid and agree with the Priority of Admission code entered.
Present on Admission (POA)	N	1	☑ Required ☐ As available	Record Type 70, Sequence 1, See Record Format 20 CAR § 54-107(j)(1) for positions
DEFINITION	The POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. There are five reporting options:
	Y	Yes – present at the time of inpatient admission
	N	No – not present at the time of inpatient admission
	U	No information in the record
	W	Clinically undetermined
	1	Exempt from POA reporting

GENERAL COMMENTS	None
EDIT	Must be a valid code.

Principal Diagnosis Code	A	6	☑ Required ☐ As available	Record Type 70, Sequence 1, positions 25-31
DEFINITION	The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient for care. An ICD code describes the principal disease.
GENERAL COMMENTS	This field is to contain the appropriate ICD code without a decimal. All entries are to be left justified with spaces to the right to complete the field length. An external cause of injury code should not be recorded as the principal diagnosis.
EDIT	A principal diagnosis must be present and valid. When the principal diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.
Principal Procedure Code	A	7	☑ Required ☐ As available	Record Type 70, Sequence 3, position 25-32 (1450 & 1450Y2K)
DEFINITION	The code that identifies the principal procedure performed during the hospital stay covered by this discharge data record. The principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or is necessary as a result of complications. The principal procedure is that procedure most related to the principal diagnosis.
GENERAL COMMENTS	The coding method used should be ICD code. If some other coding method is used, Procedure Coding Method Used field must indicate the coding method. Enter the code left justified without a decimal.
EDIT	This field must be present if other procedures are reported and be a valid code. When a procedure is sex-specific, the sex code entered in the record must be consistent.
Principal Procedure Date	N	6 or 8	☑ Required ☐ As available	Record Type 70, Sequence 3, positions 33-38 for format 1450 or positions 33-40 for format 1450Y2K.
DEFINITION	The date on which the principal procedure described on the bill was performed.
GENERAL COMMENTS	None
EDIT	Must be a valid date falling between admission and discharge dates.
Procedure Coding Method Used	N	1	☑ Required ☐ As available	Record Type 70, Sequence 3, position -321 for format 1450 or 361 for format 1450Y2K.
DEFINITION	An indicator that identifies the coding method used for procedure coding.
GENERAL COMMENTS	Enter appropriate code from the list:
	4	CPT – 4
	5	HCPCS (HCFA Common Procedure Coding Systems)
	9	ICD – 9 – CM
	0	ICD-10-CM
EDIT	This field must agree with the coding method used to code procedures.
Priority of Admission or Visit	A	1	☑ Required ☐ As available	Record Type 20, positions 86
DEFINITION	A code indicating priority of the admission/visit.
GENERAL COMMENTS	This is a one-digit code ranging from 1 – 4, or may be 9. The code structure is as follows.
	1	Emergency	Definition: The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions.
	2	Urgent	Definition: The patient requires immediate attention for the care and treatment of a physical or mental disorder
	3	Elective	Definition: The patient's condition permits adequate time to schedule the availability of a suitable accommodation.
	4	Newborn	Definition: Use of this code necessitates the use of special Source of Admission codes; see Point of Origin for Admission.
	5	Trauma	Definition: Visit to a trauma center/hospital as licensed or designated by state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving trauma activation.

	9	Information not available	Definition: Information was not collected or was not available.
EDIT	The field must be present and be a valid code 1 – 4-5 or 9. If the code is entered 4 (newborn), the Point of Origin for Admission codes will be checked for consistency as well as the date of birth and diagnosis.
Provider Address	A	50	☑ Required ☐ As available	Record Type 10, positions 126-175
DEFINITION	Complete mailing address to which the provider correspondence is to be sent for the correction and acknowledgment of discharge data. Street address or box number, city, state and ZIPcode are required.
GENERAL COMMENTS	None
EDIT	All address fields must be present.
Provider (Hospital) Data ID	A	4	☑ Required ☐ As available	Record Type 10, positions 122-125
DEFINITION	A four letter hospital identification code that is assigned to each hospital.
GENERAL COMMENTS	None
EDIT	A Data ID must be Present, Valid and Consistent with each hospital
Provider Name	A	25	☑ Required ☐ As available	Record Type 10, positions 97-121
DEFINITION	The name of the hospital submitting the record.
GENERAL COMMENTS	The hospital's name is entered in the first 25 character positions and must be the name as it is licensed by the Department of Health.
EDIT	The name must be present and match a name in a coding table.
Provider Telephone Number	N	10	☑ Required ☐ As available	Record Type 10, positions 87-96
DEFINITION	Telephone number, including area code, at which the provider wishes to be contacted for correction and acknowledgment of discharge data.
GENERAL COMMENTS	None
EDIT	Must be present and numeric, cannot be all zeroes.
Public Health Condition Code	A	2	☑ Required ☐ As available	Record Type 27, positions 70-71, 72-73, 74-75, 76-77
DEFINITION	Identify conditions related to public health reporting.
GENERAL COMMENTS	This 2 digit conditional code will have an initial digit of 'P'. This code will be recorded in UB-04 Form Locator 18-28 or Form Locator 81 with a qualifying code of A1. Valid codes are as follows:
	p0	Reserved for Public Health Reporting
		Do Not Resuscitate Order
	P1	Indicator that a DNR order was written at the time of, or within the first 24 hours of the patient's admission to the hospital and is clearly documented in the patient's medical record.
	P2-P6	Reserved for Public Health Data Reporting
		Direct Inpatient Admission from Emergency Room
	P7	Code indicates that patient was admitted directly from this facility's Emergency Room / Department.
	P8-PZ	Reserved for Public Health Data Reporting
EDIT	Must be a valid code.

Record Type	N	2	☑ Required ☐ As available	All Records, positions 1-2
DEFINITION	The record format type indicator.
GENERAL COMMENTS	This field is used to specify each type of record. Use the following numbers:
Record Type Code	Record Name	Record Type Code	Record Name
01	Processor Data	20	Patient Data
02-04	Reserved for National Assignment	21	Noninsured Employment Information
05-09	Local Use	22	Unassigned State Form Locators
10	Provider Data	23-24	Reserved for National Assignment
11-14	Reserved for National Assignment	25-29	Local Use
15-19	Local Use
30-31	Third Party Payer Data	40	Claim Data TAN-Occurrence
32-33	Reserved for National Assignment	41	Claim Data Condition-Value
34	Authorization	42-44	Reserved for National Assignment
35-39	Local Use	45-49	Local Use
50	IP Accommodations Data	60	IP Ancillary Services Data
51-54	Reserved for National Assignment	61	Outpatient Procedures
55-59	Local Use	62-64	Reserved for National Assignment
		65-69	Local Use
70	Medical Data
71	Plan of Treatment and Patient Information	80	Physician Data
72	Specific Services and Treatments	81	Pacemaker Registry Record
73	Plan of Treatment/Medial Update Narrative	82-84	Reserved for National Assignment
74	Patient Information	85-89	Local Use
75-78	Reserved for National Assignment
79	Local Use
90	Claim Control Screen	95	Provider Batch Control
91	Remarks (Overflow from RT 90)	96-98	Local Use
92-94	Reserved for National Assignment	99	File Control
EDIT	The number must be present and valid.
Revenue Code	n	4	☑ Required ☐ As available	Record Type 50, positions 25-28, 67-70, 109-112, 151-154 Record Type 60, positions 25-28, 81-84, 137-140
DEFINITION	A four-digit code that identifies a specific accommodation, ancillary service or billing calculation.

GENERAL COMMENTS	For every patient there must be at least one revenue service entered. There may be an entry representing the sum of all revenue services; this entry would have a revenue code of '0001.' If the summed entry ('0001') is one of the entries, the revenue amount associated must equal 'TOTAL CHARGE' found on record type 27.
EDIT	This field must be present and contain a valid revenue code as defined in Revenue Codes and Units of Service section.
Sequence Number	N	2	☑ Required ☐ As available	Positions 3-4, as needed
DEFINITION	Sequential number from 01 to nn assigned to individual records within the same specific record type code to indicate the sequence of the physical record within the record type. Records 21 2n do not have a sequence number greater than 01. Records 01, 10, 90, 91, 95 and 99 do not have sequence numbers. The sequence numbers for record types 30, 31, 34, 80 and 81 are used as matching criteria to determine which type 30, type 31, type 34, type 80 and/or type 81 records are associated, like sequence numbers indicating the records are associated.
GENERAL COMMENTS	None
EDIT	Must be valid sequence number for record type.
Source of Payment Code	N	2	☑ Required ☐ As available	Record Type 30, position 25
DEFINITION	A code indicating source of payment associated with this payer record. Note: These are based on the Public Health Data Standards Consortium, Source of Payment Typology, Version 5.0, October 2011.
GENERAL COMMENTS	Valid codes are as follows:
	1	MEDICARE (Includes Medicare Managed, Non-Managed Care & Other )
	2	MEDICAID (Medicaid Managed Care, Non Managed Care Plan, SCHIP, Applicant, Out of State and Other)
	3	OTHER GOVERNMENT – FEDERAL/STATE/LOCAL (Includes Departments of Defense & Veterans Affairs, Indian Health Service or Tribe, HRSA Program, Black Lung, State Government, Other Government & Other Federal)
	4	DEPARTMENTS OF CORRECTIONS (Includes federal, state, and local)
	5	PRIVATE HEALTH INSURANCE (Private Managed Care, Private Health Insurance – Indemnity ,Other non-specified Private Managed Care or Private Health Insurance – Indemnity, Organized Delivery System, Small Employer Purchasing Group, Other Private Insurance)
	6	BLUE CROSS/BLUE SHIELD (BC Indemnity, BC Managed Care, BC Out of State, BC Unspecified, BC Other)
	7	MANAGED CARE, UNSPECIFIED (HMO, PPO, POS, Other Managed Care- Unknown if public or private)
	8	NO PAYMENT from an Organization/Agency/Program/Private Payer Listed (Self-pay, No Charge, Refusal to Pay/Bad Debt, Hill Burton Free Care, Research/Donor, No Payment- Other)
	9	MISCELLANEOUS/OTHER (Foreign National, Other(Non-government), Disability Insurance, Long-term Care Insurance, Worker's Compensation, Auto Insurance (no fault), Other specified (includes Hospice) , NoTypology Code available for payment source)
EDIT	Code must be present and valid.
Statement Covers Period From	N	6 or 8	☑ Required ☐ As available	Record Type 20, positions 182 – 187 on the 1450 On the 1450Y2K, positions 184-191
DEFINITION	The beginning service date of the period on this bill.
GENERAL COMMENTS	The format is MMDDYY for 1450. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made, all dates must use this format.
EDIT	This date must be present and be valid.
Statement Covers Period Thru	n	6 or 8	☑ Required ☐ As available	Record Type 20, positions 188-193 on the 1450 On the 1450 Y2K, positions 188-193
DEFINITION	The discharge date.

GENERAL COMMENTS	The format is MMDDYY for 1450 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made all dates must use this format.
EDIT	This date must be present and be valid.
Total Charges	N	10, 2	☑ Required ☐ As available	Record Type 27, positions 44-53
DEFINITION	Total of charges for this inpatient hospital stay.
GENERAL COMMENTS	The total allows for an 8-digit dollar amount followed by 2 digits for cents (no decimal point). All entries are right justified. If the charge has no cent then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000 and a charge of $37.50 is entered as 3750.
EDIT	This field must be present and contain a value greater than 0 when any revenue code field is greater than 0.
Total Charges by Revenue Code	n	10, 2	☑ Required ☐ As available	Record Type 50, positions 42-51, 84-93, 126-135, 168-177 Record Type 60, positions 45-54, 101-110, 157-166
DEFINITION	Total dollars and cents amount charged for the related revenue service entered.
GENERAL COMMENTS	The total allows for an 8-digit dollar amount followed by 2 digits for cents (no decimal point). All entries are right justified. If the charge has no cents, then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000 and a charge of $37.50 is entered as 3750.
EDIT	This field must be present and contain a value greater than 0 when the associated revenue code field is greater than 0.
Type of Bill	A	3	☑ Required ☐ As available	Record Type 27, positions 25-27
DEFINITION	A code indicating the specific type of bill (inpatient, outpatient, etc.). This three digit code requires 1 digit each, in the following sequence: 1. Type of facility, 2. Bill classification, and 3. Frequency
GENERAL COMMENTS	All positions must be fully coded. See UB-04 guidelines for codes and definitions. This code indicates the specific type of inpatient billing.
EDIT	None
Units of Service (Service Units)	N	7	☑ Required ☐ As available If the revenue code needs units; see Revenue Codes and Units of Service Section	Record Type 60, positions 38-44, 94-100, 150-156
DEFINITION	A quantitative measure of services rendered, by revenue category to the patient. It includes such items as the number of scans, number of pints, number of treatments, number of visits, number of miles or number of sessions.
GENERAL COMMENTS	This number qualifies the revenue service. The presence of this code ensures that charges per revenue service are adjusted to a common base for comparison. Revenue Codes and Units of Service (refer to Appendix B) defines the appropriate units for each revenue code.
EDIT	The units of service must be present for those revenue services that require a unit; see Revenue Codes and Units of Service section.

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