1. 1. Hospital identifier (federal tax identification number/Department assigned/NPI)
2. 2. Patient account number
3. 3. Discharge time (HH)
4. 4. Patient zip code and Plus 4
5. 5. Patient birth date (MMDDCCYY)
6. 6. Patient sex
7. 7. Admission date (MMDDYY) and time (HH)
8. 8. Type of admission
9. 9. Source of admission

10. 10. Patient discharge status

    1. 11. Type of bill

11. 12. Total patient charges and components of charges (by revenue code, units of service and charges)

    1. 13. Primary payer ID and health plan name

    2. 14. Secondary and tertiary payer ID and health plan name (required when present)

       1. 15. Principal and secondary diagnosis codes, when present (up to 25 per data record and up to 50 with record pagination when necessary)

          ICD-9 codes required: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)

          ICD-10 codes required: discharges on and after October 1, 2013 (or first date of CMMS acceptance of ICD-10 codes)

       2. 16. Principal and secondary procedure codes and dates (MMDDYY), when present (up to 25 per data record and up to 50 with record pagination when necessary)

          ICD-9 codes required: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)

          ICD-10 codes required: discharges on and after October 1, 2013 (or first date of CMMS acceptance of ICD-10 codes)

    3. 17. Attending clinician ID number/NPI
    4. 18. Other clinician ID number/NPI (up to two required when present)
    5. 19. Patient race (according to OMB guidelines)

    6. 20. Patient ethnicity (according to OMB guidelines)

       1. 21. Patient county code (five digits: state and county codes for Illinois and border state residents (FIPS code))
12. 22. Diagnosis present at admission for each diagnosis

13. 23. External cause of injury codes (required when present)

    ICD-9 Ecodes: three required if available: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)

    ICD-10 Ecodes: eight required if available: discharges on and after October 1, 2013 (or first date of CMMS acceptance of ICD-10 codes)

14. 24. Newborn birth weight value code and birth weight in grams

15. 25. Admitting diagnosis code

    ICD-9 code required: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)

    ICD-10 code required: discharges on and after October 1, 2013 (or first date of CMMS acceptance of ICD-10 codes)

16. 26. Do not resuscitate indicator (entered in first 24 hours of stay)

    1. 27. Prior stay occurrence code and prior stay from and through dates (required when present)
    2. 28. Operating clinician ID number/NPI (required when surgical procedures present as a component of treatment)
17. 29. Accident state abbreviation (required when present)

18. 30. Condition employment related (required when present)

    1. 31. Accident employment related occurrence code and date of accident (required when present)
19. 32. Crime victim occurrence code and date of crime (required when present)
20. 33. Statement covers period (from and through [discharge date] dates)
21. 34. Insurance group numbers (up to three required when present)
22. 35. Page number and total number of pages

23. 36. Diagnoses code version qualifier

    1. 37. Condition code indicating patient admitted directly from this facility's emergency room/department

    ICD-9 indicator required = 9: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)

    ICD-10 indicator required = 0: discharges on and after October 1, 2013 (or first date of CMMS acceptance of ICD-10 codes)

24. 38. Patient name (first, middle, last, suffix)

    1. 39. Patient address (PO Box or street address, apartment number, city and state)
    2. 40. Unique patient identifier based on the last four digits of patient Social Security number
    3. 41. Primary insured's unique identifier (beneficiary/policy #)
    4. 42. Any element or service adopted for use by the the National Uniform Billing Committee pursuant to Section 4-2(d)(14) of the Act. Elements or services would be added as a submission requirement accompanied by sufficient notification to all submitting facilities and health care systems. Notice would be provided no less than 90 days in advance of the submission requirement.

Data elements affected by implementation of the ICD-10 coding scheme on October 1, 2013 (or as stipulated by CMMS) are noted when necessary and appropriate.

Detail Data

(Source: Amended at 36 Ill. Reg. 8017, effective May 8, 2012)