90-590 C.M.R. ch. 241 – Uniform Reporting System for Hospital Inpatient Data Sets and Hospital Outpatient Data Sets

90-590 MAINE HEALTH DATA ORGANIZATION
1. Chapter 241: UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETS

SUMMARY: This chapter contains the provisions for filing hospital inpatient data sets and hospital outpatient service data sets.

The provisions include:
1. Identification of the organizations required to report;
Establishment of requirements for the content, format, method, and time frame for filing hospital inpatient data and hospital outpatient service data;
1. Establishment of standards for the data reported; and
  Compliance provisions.
2. 1. Definitions
Unless the context indicates otherwise, the following words and phrases shall have the following meanings:
1. A. Attending Provider. Attending Provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim.
2. B. Billing Provider. Provider submitting the bill.
3. C. Designee. "Designee" means an entity with which the MHDO has entered into an arrangement under which the entity performs data collection, validation and management functions for the MHDO and is strictly prohibited from releasing information obtained in such a capacity if the information is not authorized for release by the MHDO.

D. Carrier. "Carrier" means an insurance company licensed in accordance with 24‑A M.R.S.A., including a health maintenance organization, a multiple employer welfare arrangement licensed pursuant to Title 24-A, chapter 81, a preferred provider organization, a fraternal benefit society, or a nonprofit hospital or medical service organization or health plan licensed pursuant to 24 M.R.S.A. An employer exempted from the applicability of 24-A M.R.S.A., chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) is not considered a carrier.

E. External Causes Codes. “External causes codes” in ICD-10 are codes designed to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition occurred (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event and the person’s status (e.g. civilian, military).
1. F. Hospital. "Hospital" means any acute care institution required to be licensed pursuant to 22 M.R.S.A., chapter 405.
2. G. Hospital Inpatient Data. "Hospital inpatient data" pertains to the information generated at the time of discharge which is associated with patients who are provided with room, board, and continuous nursing service based on a physician’s written order in an area of the hospital where patients generally stay more than twenty-four hours.
3. H. Hospital Outpatient Data. "Hospital outpatient data" pertains to the data generated for any patient visit that is not considered an inpatient admission, at any department of the hospital, regardless of its physical location. Hospital Outpatient Data also includes services provided by specialty groups or primary care practices when the hospital owns the data.
4. I. MHDO. "MHDO" means the Maine Health Data Organization.
5. J. M.R.S.A. “M.R.S.A.” means Maine Revised Statutes Annotated.
6. K. National Provider Identifier (NPI). The unique identification number assigned to the provider
7. L. Operating Physician. Operating Physician is the individual with the primary responsibility for performing the surgical procedures(s).
8. M. Rendering Provider. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care.
9. N. Third-party Administrator. “Third-party administrator” means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S.A., chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.
10. 2. Hospital Inpatient and Outpatient Service Data Sets Filing Description
Each hospital shall file with the MHDO or its designee a completed hospital inpatient data set and a completed hospital outpatient data set for every service provided to each patient. A completed hospital data set includes professional and facility services as defined in the appendices.

General Requirements
1. Codes

(a) Code Sources. The code sources listed and described in Appendix A are to be utilized with the inpatient and outpatient data file submissions.
1. (b) Specific and Unique Coding. Except for location of service codes and provider number, specific or unique coding systems shall not be permitted as part of the inpatient and outpatient data submissions.
  1. (c) External Cause Codes. External Cause Codes shall be assigned for all initial treatments of an injury, poisoning, or adverse effect of drugs. If a patient is transferred to another facility for continued treatment, this facility shall also assign the appropriate External Cause Code.

1. Definitions for Required Data Elements. Unless otherwise specified, the definitions for the required data elements described in Appendix B-1 and Appendix C-1 are the same as those provided in the most current National Uniform Billing Data Element Specifications as developed by the National Uniform Billing Committee and approved by the State of Maine Uniform Billing Committee.

(3) Inpatient Data Filing. Data for all inpatient services of the hospital must be submitted based on the discharge date and filed under the MHDO provider code assigned to that hospital.
1. (4) Outpatient Data Filing. Data for all outpatient services of the hospital and all services provided by specialty groups or primary care practices must be filed in one or more outpatient data streams under the MHDO provider code assigned to that hospital. Every encounter that is populated with a designated subset of Place of Service codes must include a Location of Service code, internally created by the Hospital. Also, each hospital shall submit annually an updated Location of Service crosswalk, which includes unique location of service code, full location name, address, city, state, and zip code for those locations only.
  1. (5) Adjustment Charges. Adjustment charges and negative values are not to be reported in inpatient and outpatient data sets. The adjustment charges are reconciled to the individual line item for which the adjustment applies.
2. B. Detailed File Specifications
  1. (1) Filled Fields. All fields shall be filled where applicable. Non-applicable text fields shall be space filled. Non-applicable numeric fields shall be zero filled and shall not include decimal points.
  2. (2) Position. All text fields are to be left justified. All numeric fields are to be right justified.
  3. (3) Individual Elements and Mapping. Individual data elements, data types, field lengths, and mapping locators (UB-04, CMS 1500, ANSI X12N 837) for each file type are presented in the following appendices:
3. (a) (i) Inpatient Data Specifications - Appendix B-1
  1. (ii) Inpatient Data Mapping to National Standards Formats - Appendix B-2
  2. (b) (i) Outpatient Data Specifications - Appendix C-1
    1. (ii) Outpatient Data Mapping to National Standards Formats - Appendix C-2
4. 3. Submission Requirements
5. A. File Format. The inpatient file and the outpatient file(s) are to be submitted to the MHDO or it designee as separate ASCII files with fixed length records. Each record shall be terminated with a carriage return line feed (ASCII 13, ASCII 10).
6. B. Filing Method. All data files must be encrypted using 256-bit AES (AES-256) encryption, prior to submission/uploading. This can be accomplished using various commercially available software packages. Data files shall be submitted via electronic transmission using the Secure Hypertext Transfer Protocol (HTTPS). E-mail attachments shall not be accepted.
7. C. File Editing. All data files must be processed through the MHDO designee’s system. Corrections must be applied to the data files before the data are transmitted.
8. D. Filing Specifications. Each hospital shall file all applicable data sets to the MHDO in accordance with the electronic specifications for submission of claims to Maine’s designated Medicare intermediary.
9. E. Filing Periods. Each inpatient discharge or outpatient service record must be filed no later than 90 days following the calendar quarter in which the discharge or service occurred.
10. F. Replacement of Data Files. No hospital may amend its data submission more than one year after the end of the quarter in which the discharge or outpatient service occurred unless it can be established by the hospital that exceptional circumstances occurred. Any resubmission of data after the elapse of the one year period must be approved by the MHDO.
11. G. Rejection of Files. Failure to conform to the requirements of subsections A, B, C or D of this section shall result in the rejection of the data file(s). Rejected files must be resubmitted in the appropriate corrected form to the MHDO within 15 days of notification.
12. 4. Standards for Data; Notification; Response
13. A. Standards. The MHDO shall evaluate each inpatient file and each outpatient file submission in accordance with the following standards:
  1. (1) The code for each data element identified in Appendices B-1 and C-1 shall be included within eligible values for the field;
  2. (2) Coding values indicating "data not available" "data unknown" or the equivalent shall not be used for individual data elements unless specified as an eligible value for the field;
  3. (3) Outpatient data sets shall have Current Procedural Terminology (CPT) Codes and Health Care Common Procedural Coding System (HCPCS) codes reported for specific revenue centers. The list of revenue centers requiring CPT and HCPCS codes shall be provided via the MHDO’s designee; and
14. (4) CPT and HCPCS codes shall be assigned to the correct revenue centers.
15. B. Notification. Upon completion of the evaluation, the MHDO or its designee shall promptly notify each hospital whose data sets do not satisfy the standards for any filing period. This notification shall identify the specific file and the data fields and elements that do not satisfy the standards.
16. C. Response. Each hospital notified under Subsection B shall respond within 32 days of the notification by making the required changes and resubmitting, if necessary, to satisfy the standards.
17. 5. Public Access
Information collected, processed and/or analyzed under this rule shall be subject to release to the public or retained as confidential information in accordance with 22 M.R.S.A. Sec. 8707 and Code of Maine Rules 90-590, Chapter 120: Release of Information to the Public, unless prohibited by state or federal law.
1. 6. Extension or Waiver to Data Submission Requirements
If a hospital, due to circumstances beyond its control, is temporarily unable to meet the terms and conditions of this chapter, a written request must be made to the Compliance Officer of the MHDO as soon as it is practicable after the hospital has determined that an extension or waiver is required. The written request shall include: the specific requirement to be extended or waived; an explanation of the cause; the methodology proposed to eliminate the necessity of the extension or waiver; and the time frame required to come into compliance. If the Compliance Officer does not approve the requested extension or waiver, the hospital making the request may submit a written request appealing the decision to the MHDO Board. The appeal shall be heard by the MHDO Board at the next regularly scheduled meeting following receipt of the request at the MHDO.
1. 7. Compliance
Failure to file, report, or correct in accordance with the provisions of this chapter may be considered a violation under 22 M.R.S.A. Sec. 8705-A and Code of Maine Rules 90-590, Chapter 100: Enforcement Procedures.

STATUTORY AUTHORITY:

22 M.R.S.A. §§ 8704 (4) and 8708

EFFECTIVE DATE:

May 2, 1990

AMENDED:

May 14, 1991

February 10, 1993

July 6, 1994

April 19, 1995

July 1, 1999

February 28, 2006

March 18, 2007 – filing 2007-95

April 15, 2009 – filing 2009-156

February 7, 2010 – filing 2010-23

May 21, 2011 – filing 2011-157

November 26, 2013 – filing 2013-289
1. November 22, 2015 – filing 2015-226
  October 31, 2017 – filing 2017-166
  December 22, 2019 – filing 2019-245
  November 15, 2021 – filing 2021-229

Accredited Standards Committee (ASC)

ASC X12N Electronic Data Interchange Transaction Set Implementation Guide

Health Care Claim: Institutional and Professional (837)

(Used for all Mapping of HIPAA Reference – Transaction Set/Loop/Segment Qualifier/Data Elements)

AVAILABLE FROM:

http://store.x12.org/store

Accredited Standards Committee

8300 Greensboro Drive, Suite 800

McLean, VA 22102

ABSTRACT: The data implementation guide provides standardized data requirements and content for all users of the ANSI ASC X12N 837 Health Care Claims transaction.

American Medical Association

Current Procedural Terminology (CPT) Codes

(MHDO Data Elements: OP6105, OP6106, OP6107, OP6112, OP6113, OP6114, OP6119, OP6120, OP6121)

SOURCE: Physicians' Current Procedural Terminology (CPT) Manual

AVAILABLE FROM:

https://www.ama-assn.org/

American Medical Association

AMA Plaza

330 N. Wabash Ave., Suite 39300

Chicago, IL 60611

ABSTRACT: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians in an outpatient setting.

International Country Codes

(MHDO Data Elements: IP2021, OP2018)

SOURCE: www.nationsonline.org/oneworld/country_code_list.htm

ABSTRACT: The ISO country codes are internationally recognized codes that designate each country and most of the dependent areas with a two- or three-letter combination or a numeric code.

National Uniform Billing Committee (NUBC)

National Uniform Billing Data Element Specifications as Developed by NUBC.

(All MHDO Data Elements except for the following: Diagnosis Codes, Procedure Codes, Payer Identification Number, Social Security Number, HCPCS Procedure Codes, HCPCS Procedure Modifiers, Race/Ethnicity, Present on Admission Indicator, Filler)

SOURCE: UB-04 Data Specifications Manual.

AVAILABLE FROM:

https://www.nubc.org/ub-04-products

National Uniform Billing Committee

American Hospital Association

155 N Wacker Drive

Chicago, IL 60606

ABSTRACT: This serves as the official source of information for institutional health care billing. It contains all billing conventions and codes, including form locators, data element descriptions, definitions, reporting requirements, field attributes, approval and effective dates, and revenue, condition, occurrence, and value codes.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

Ambulance Modifiers

(MHDO Data Element: OP6106, OP6107, OP6113, OP6114, OP6120, OP6121)

SOURCE: Medicare Claims Processing Manual

AVAILABLE FROM:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: Ambulance Modifiers are HCPCS modifier codes available for use with Ambulance services.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

Health Care Common Procedural Coding System

(MHDO Data Elements: OP6105, OP6106, OP6107, OP6112, OP6113, OP6114, OP6119, OP6120, OP6121)

SOURCE: Health Care Common Procedural Coding System

AVAILABLE FROM:

www.cms.gov/HCPCSReleaseCodeSets/

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

Center for Health Plans and Providers

7500 Security Boulevard

Baltimore, MD 21244‑1850

ABSTRACT: HCPCS is the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) coding scheme to group procedures performed for payment to providers.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

National Provider Identifier (NPI)

(MHDO Data Elements: OP6126, OP6128, OP6130, OP8004, OP8005, OP8012, IP8004, IP8005, IP8012)

SOURCE: National Plan and Provider Enumeration System (NPPES)

AVAILABLE FROM:

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244-1850

ABSTRACT: The Centers for Medicare and Medicaid Services developed the National Provider Identifier (NPI) as the standard, unique identifier for each health care provider under the Health Insurance Portability and Accountability Act of 1996 and the NPI Final Rule was implemented May 23, 2008.

United States Postal Service

States and Outlying Areas and Zip Codes of the U.S.

(MHDO Data Elements: IP0106, IP2009, OP0106, OP2009, IP0107, IP2010, OP0107, OP2010)

SOURCE: National Zip Code and Post Office Directory

The USPS Domestic Mail Manual

AVAILABLE FROM:

https://www.usps.com

U.S. Postal Service

National Information Data Center

P.O. Box 9408

Gaithersburg, MD 20898-9408

Or https://ribbs.usps.gov/index.cfm?page=address_manage_quality

Address Information Systems Products

National Customer Support Center

U.S. Postal Service

6060 Primacy Pkwy Ste 231

Memphis, TN 38119-5772

ABSTRACT: Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S. Microfiche AVAILABLE FROM: NTIS (same as address above). The Canadian Post Office lists the following as "official" codes for Canadian Provinces:

AB ‑ Alberta

BC ‑ British Columbia

MB ‑ Manitoba

NB ‑ New Brunswick

NF ‑ Newfoundland

NS ‑ Nova Scotia

NT ‑ North West Territories

ON ‑ Ontario

PE ‑ Prince Edward Island

PQ ‑ Quebec

SK ‑ Saskatchewan

YT – Yukon

The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two right-most digits identify a local delivery area. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes. The USPS Domestics Mail Manual includes information on the use of the new 11‑digit zip code.

World Health Organization (WHO)

International Classification of Diseases Clinical Modification (ICD‑10‑CM)

(MHDO Data Elements: IP7104, IP7106 IP7110, IP7204, IP7206, IP7208, IP7210, IP7212, IP7214, IP7216, IP7218, IP7304, IP7306, IP7308, IP7310, IP7312, IP7314, IP7316, IP7318, IP7320, IP7322, IP7324, IP7326, IP7404, IP7406, IP7408, IP7410, IP7412, IP7414, IP7416, IP7418, IP7420, IP7422, IP7424, IP7426, OP7104, OP7107, OP7108, OP7109, OP7110, OP7204, OP7206, OP7208, OP7210, OP7212, OP7214, OP7216, OP7218, OP7304, OP7306, OP7308, OP7310, OP7312, OP7314, OP7316, OP7318, OP7320, OP7322, OP7324, OP7326, OP7404, OP7406, OP7408, OP7410, OP7412, OP7414, OP7416, OP7418, OP7420, OP7422, OP7424, OP7426)

SOURCE: International Classification of Diseases, 10th Revision, Clinical Modification (ICD‑10-CM)

AVAILABLE FROM:

http://www.who.int/classifications/icd/en/

World Health Organization (WHO)

Regional Office for the Americas

525, 23rd Street, N.W.

Washington, DC 20037

USA

www.cdc.gov/nchs/icd/icd10cm.htm#9update

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA

30329-4027

ABSTRACT: The International Classification of Diseases, 10th Revision, is used to report medical diagnosis and inpatient procedures. ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

The record types in the file must be in the following order:

Record Type 01 - Processor Data

Record Type 20 - Sequence 01 - Patient Data

Record Type 30 - Sequence 01 - Third Party Payer Data Primary Payer

Record Type 30 - Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary.

Record Type 40 - Claim Data

Record Type 50 - IP Accommodations Data

Record Type 60 - IP Ancillary Services

Record Type 71 - ICD-10 CM Principal and Admitting Diagnosis Codes, ICD-10 PCS Principal Procedure Code

Record Type 72 - ICD-10 PCS Other Procedure Codes

Record Type 73 - ICD-10 CM External Cause of Injury Diagnosis Codes

Record Type 74 - ICD-10 CM Other Diagnosis Information

Record Type 80 - Provider Data

Record Type 90 - Claim Control Screen

Record Type 99 - File Control

The individual claim begins with Record Type 20 and ends with Record Type 90.

The patient control number must be the same on each record type generated for a single patient record.

The medical record number should not be substituted for the patient control number.

Data Element #	Data Element	Type	Length	Description/Codes/Sources
IP0101	Record Type	T	2	01
IP0102	MHDO-Assigned Hospital ID	T	6	Must be the MHDO-assigned, 6-digit hospital code, left justified
IP0198	Filler	T	38
IP0103	Hospital Name	T	21
IP0104	Address	T	18
IP0105	City	T	15
IP0106	State	T	2
IP0107	Zip Code	T	9
IP0199	Filler	T	78
IP0108	Version	T	3	leave blank

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
IP2001	Record Type		T	2	20
IP2002	Filler (National Use)		T	2
IP2003	Patient Control Number		T	20	Assigned by the facility
IP2095	Filler		T	30	Space filled
IP2004	Patient Sex		T	1	M = Male F = Female U = Unknown
IP2005	Patient Birth Date		T	8	CCYYMMDD
IP2096	Filler		T	1
IP2006	Priority (Type) of Admission or Visit		T	1
IP2007	Point of Origin for Admission or Visit		T	1
IP2097	Filler		T	30
IP2008	Patient City		T	15
IP2009	Patient State		T	2
IP2010	Patient Zip Code		T	9	As defined by US Postal Service Do not include dashes
IP2011	Admission/Start of Care Date		T	8	CCYYMMDD
IP2012	Admission Hour		T	2	Military Time - Range 00-23
IP2098	Filler		T	8
IP2013	Statement Covers Period - Thru		T	8	CCYYMMDD
IP2014	Patient Discharge Status		T	2
IP2015	Discharge Hour		T	2	Military Time - Range 00-23
IP2099	Filler		T	20
IP2016	Medical/Health Record Number		T	17	Assigned by the facility
IP2017	Race	March 1, 2007	T	1	1 = American Indian or Alaska Native 2 = Asian 3 = Black or African American 4 = Native Hawaiian or Other Pacific Islander 5 = White 6 = Other Race 7 = Patient Elected not to Answer 8 = Unknown The code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.
IP2018	Ethnicity	March 1, 2007	T	1	1 = Hispanic or Latino 2 = Non-Hispanic or Non-Latino 7 = Patient Elected not to Answer 8 = Unknown The code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.
IP2019	Filler		T	1
IP2020	Statement Covers Period – From	January 1, 2018	T	8	CCYYMMDD
IP2021	Patient Country Code	January 1, 2018	T	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.
IP2022	Patient Last Name	January 1, 2018	T	60
IP2023	Patient First Name	January 1, 2018	T	35
IP2024	Patient Middle Name or Initial	January 1, 2018	T	25
IP2025	Patient Name Suffix	January 1, 2018	T	10
IP2026	Patient Address Line 1	January 1, 2018	T	55
IP2027	Patient Address Line 2	January 1, 2018	T	55

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
IP3001	Record Type		T	2	30
IP3002	Sequence Number		T	2	01 Primary Payer 02 - 99 Secondary Payer
IP3003	Patient Control Number		T	20	Assigned by the facility
IP3095	Filler	January 1, 2018	T	10
IP3005	Social Security Number	April 1, 2006	T	19	Do not include the dashes For internal use only – Required if collected
IP3097	Filler	January 1, 2018	T	26
IP3007	Insured’s Group Number	April 1, 2006	T	17	For internal use only – Required if collected
IP3008	Insured’s Unique Identifier		T	20	Insurance policy or certificate ID
IP3099	Filler		T	1
IP3009	Payer Name	January 1, 2018	T	100	Full or unabbreviated payer name, not plan name

Data Element #	Data Element	Type	Length	Description/Codes/Sources
IP4001	Record Type	T	2	40
IP4002	Sequence Number	T	2	01
IP4003	Patient Control Number	T	20	Assigned by the facility
IP4004	Type of Bill	T	3	Code indicating the specific type of institutional bill
IP4099	Filler	T	165

Data Element #	Data Element	Type	Length	Description/Codes/Sources
IP5001	Record Type	T	2	50
IP5002	Sequence Number	T	3	001-999
IP5003	Patient Control Number	T	20	Assigned by the facility
IP5091	Filler	T	3
IP5004	Accommodations Revenue Code #1	T	4	Include leading zeros
IP5092	Filler	T	9
IP5005	Accommodations Service Units #1	N	4	Right Justified, leading zeros
IP5006	Accommodations Total Charges #1	T	10	Two decimal places implied
IP5093	Filler	T	14
IP5007	Accommodations Revenue Code #2	T	4	Include leading zeros
IP5094	Filler	T	9
IP5008	Accommodations Service Units #2	N	4	Right Justified, leading zeros
IP5009	Accommodations Total Charges #2	N	10	Two decimal places implied
IP5095	Filler	T	14
IP5010	Accommodations Revenue Code #3	T	4	Include leading zeros
IP5096	Filler	T	9
IP5011	Accommodations Service Units #3	N	4	Right Justified, leading zeros
IP5012	Accommodations Total Charges #3	N	10	Two decimal places implied
IP5097	Filler	T	14
IP5013	Accommodations Revenue Code #4	T	4	Include leading zeros
IP5098	Filler	T	9
IP5014	Accommodations Service Units #4	N	4	Right Justified, leading zeros
IP5015	Accommodations Total Charges #4	N	10	Two decimal places implied
IP5099	Filler	T	14

Data Element #	Data Element	Type	Length	Description/Codes/Sources
IP6001	Record Type	T	2	60
IP6002	Sequence Number	T	3	001 to 999
IP6003	Patient Control Number	T	20	Assigned by the facility
IP6093	Filler	T	2
IP6004	Inpatient Ancillary Revenue Code #1	T	4	Include leading zeros
IP6094	Filler	T	16
IP6005	Inpatient Ancillary Total Charges #1	N	10	Two decimal places implied
IP6095	Filler	T	25
IP6006	Inpatient Ancillary Revenue Code #2	T	4	Include leading zeros
IP6096	Filler	T	16
IP6007	Inpatient Ancillary Total Charges #2	N	10	Two decimal places implied
IP6097	Filler	T	25
IP6008	Inpatient Ancillary Revenue Code #3	T	4	Include leading zeros
IP6098	Filler	T	16
IP6009	Inpatient Ancillary Total Charge #3	N	10	Two decimal places implied
IP6099	Filler	T	25

Data Element #	Data Element	Implementation Date For New Data Elements	Type	Length	Description
IP7101	Record Type	10/1/2014	T	2	71
IP7102	Sequence Number	10/1/2014	T	2	01
IP7103	Patient Control Number	10/1/2014	T	20	Assigned by facility
IP7104	Principal Diagnosis	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7105	Present On Admission Indicator	10/1/2014	T	3	Standard POA code set - Left Justified
IP7106	Admitting Diagnosis	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7107	Filler		T	10
IP7108	Filler		T	10
IP7109	Filler		T	10
IP7110	Principal Procedure Code	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7111	Principal Procedure Date	10/1/2014	T	8	CCYYMMDD

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
IP7201	Record Type	10/1/2014	T	2	72
IP7202	Sequence Number	10/1/2014	T	2	01 - 03
IP7203	Patient Control Number	10/1/2014	T	20	Assigned by facility
IP7204	Other Procedure Code - 1	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7205	Other Procedure Date - 1	10/1/2014	T	8	CCYYMMDD
IP7206	Other Procedure Code - 2	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7207	Other Procedure Date - 2	10/1/2014	T	8	CCYYMMDD
IP7208	Other Procedure Code - 3	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7209	Other Procedure Date - 3	10/1/2014	T	8	CCYYMMDD
IP7210	Other Procedure Code - 4	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7211	Other Procedure Date - 4	10/1/2014	T	8	CCYYMMDD
IP7212	Other Procedure Code - 5	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7213	Other Procedure Date - 5	10/1/2014	T	8	CCYYMMDD
IP7214	Other Procedure Code - 6	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7215	Other Procedure Date - 6	10/1/2014	T	8	CCYYMMDD
IP7216	Other Procedure Code - 7	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7217	Other Procedure Date - 7	10/1/2014	T	8	CCYYMMDD
IP7218	Other Procedure Code - 8	10/1/2014	T	10	ICD-10 PCS - do not code decimal point - Left Justified
IP7219	Other Procedure Date - 8	10/1/2014	T	8	CCYYMMDD

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
IP7301	Record Type	10/1/2014	T	2	73
IP7302	Sequence Number	10/1/2014	T	2	01 - 02
IP7303	Patient Control Number	10/1/2014	T	20	Assigned by facility
IP7304	External Cause of Injury Code - 1	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7305	Present On Admission Indicator - 1	10/1/2014	T	3	Standard POA code set - Left Justified
IP7306	External Cause of Injury Code - 2	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7307	Present On Admission Indicator - 2	10/1/2014	T	3	Standard POA code set - Left Justified
IP7308	External Cause of Injury Code - 3	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7309	Present On Admission Indicator - 3	10/1/2014	T	3	Standard POA code set - Left Justified
IP7310	External Cause of Injury Code - 4	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7311	Present On Admission Indicator - 4	10/1/2014	T	3	Standard POA code set - Left Justified
IP7312	External Cause of Injury Code - 5	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7313	Present On Admission Indicator - 5	10/1/2014	T	3	Standard POA code set - Left Justified
IP7314	External Cause of Injury Code - 6	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7315	Present On Admission Indicator - 6	10/1/2014	T	3	Standard POA code set - Left Justified
IP7316	External Cause of Injury Code - 7	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7317	Present On Admission Indicator - 7	10/1/2014	T	3	Standard POA code set - Left Justified
IP7318	External Cause of Injury Code - 8	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7319	Present On Admission Indicator - 8	10/1/2014	T	3	Standard POA code set - Left Justified
IP7320	External Cause of Injury Code - 9	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7321	Present On Admission Indicator - 9	10/1/2014	T	3	Standard POA code set - Left Justified
IP7322	External Cause of Injury Code - 10	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7323	Present On Admission Indicator - 10	10/1/2014	T	3	Standard POA code set - Left Justified
IP7324	External Cause of Injury Code - 11	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7325	Present On Admission Indicator - 11	10/1/2014	T	3	Standard POA code set - Left Justified
IP7326	External Cause of Injury Code - 12	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7327	Present On Admission Indicator - 12	10/1/2014	T	3	Standard POA code set - Left Justified

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
IP7401	Record Type	10/1/2014	T	2	74
IP7402	Sequence Number	10/1/2014	T	2	01 - 02
IP7403	Patient Control Number	10/1/2014	T	20	Assigned by facility
IP7404	Other Diagnosis Code - 1	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7405	Present On Admission Indicator - 1	10/1/2014	T	3	Standard POA code set - Left Justified
IP7406	Other Diagnosis Code - 2	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7407	Present On Admission Indicator - 2	10/1/2014	T	3	Standard POA code set - Left Justified
IP7408	Other Diagnosis Code - 3	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7409	Present On Admission Indicator - 3	10/1/2014	T	3	Standard POA code set - Left Justified
IP7410	Other Diagnosis Code - 4	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7411	Present On Admission Indicator - 4	10/1/2014	T	3	Standard POA code set - Left Justified
IP7412	Other Diagnosis Code - 5	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7413	Present On Admission Indicator – 5	10/1/2014	T	3	Standard POA code set - Left Justified
IP7414	Other Diagnosis Code - 6	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7415	Present On Admission Indicator - 6	10/1/2014	T	3	Standard POA code set - Left Justified
IP7416	Other Diagnosis Code - 7	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7417	Present On Admission Indicator - 7	10/1/2014	T	3	Standard POA code set - Left Justified
IP7418	Other Diagnosis Code - 8	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7419	Present On Admission Indicator - 8	10/1/2014	T	3	Standard POA code set - Left Justified
IP7420	Other Diagnosis Code - 9	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7421	Present On Admission Indicator - 9	10/1/2014	T	3	Standard POA code set - Left Justified
IP7422	Other Diagnosis Code - 10	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7423	Present On Admission Indicator - 10	10/1/2014	T	3	Standard POA code set - Left Justified
IP7424	Other Diagnosis Code - 11	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7425	Present On Admission Indicator - 11	10/1/2014	T	3	Standard POA code set - Left Justified
IP7426	Other Diagnosis Code - 12	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
IP7427	Present On Admission Indicator - 12	10/1/2014	T	3	Standard POA code set - Left Justified

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
IP8001	Record Type		T	2	80
IP8002	Sequence		T	2	01
IP8003	Patient Control Number		T	20	Assigned by the facility
IP8097	Filler		T	2
IP8004	Attending Provider NPI	April 1, 2009	T	16	NPI of Attending Provider
IP8005	Operating Physician NPI	April 1, 2009	T	16	NPI of Operating Physician
IP8098	Filler		T	32
IP8006	Attending Provider Last Name		T	16	Cannot be blank
IP8007	Attending Provider First Name		T	8	Cannot be blank
IP8008	Attending Provider Middle Initial		T	1
IP8009	Operating Physician Last Name		T	16	Must be populated when IP8005 is populated.
IP8010	Operating Physician First Name		T	8	Cannot be blank if IP8005 is populated.
IP8011	Operating Physician Middle Initial		T	1
IP8099	Filler		T	52
IP8012	Billing Provider NPI		T	16	National Provider Identifier assigned to the provider submitting the bill.

Data Element #	Data Element	Type	Length	Description/Codes/Sources
IP9001	Record Type	T	2	90
IP9002	Filler (National Use)	T	2
IP9003	Patient Control Number	T	20	Assigned by the facility
IP9097	Filler	T	20
IP9004	Total Accommodation Charges – Revenue Centers	N	10	Must equal the sum of record type 50 revenue code data Two decimal places implied
IP9098	Filler	T	10
IP9005	Total Ancillary Charges – Revenue Centers	N	10	Must equal the sum of record type 60 revenue code data Two decimal places implied
IP9099	Filler	T	118

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
IP9901	Record Type		T	2	99
IP9999	Filler		T	190

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP0101	Record Type	NA	NA
IP0102	MHDO-Assigned Hospital ID	NA	NA
IP0103	Hospital Name	1	837/2010AA/NM1/85/2/03
IP0104	Address	1	837/2010AA/N3/01
IP0105	City	1	837/2010AA/N4/01
IP0106	State	1	837/2010AA/N4/02
IP0107	Zip Code	1	837/2010AA/N4/03
IP0108	Version	NA	NA

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP2001	Record Type	NA	NA
IP2003	Patient Control Number	3A	837/2300/CLM/01
IP2004	Patient Sex	11	837/2010CA/DMG/03 837/2010BA/DMG/03
IP2005	Patient Birth Date	10	837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02
IP2006	Priority (Type) of Admission or Visit	14	837/2300/CL1/01
IP2007	Point of Origin for Admission or Visit	15	837/2300/CL1/02
IP2008	Patient City	9B	837/2010CA/N4/01 837/2010BA/N4/01
IP2009	Patient State	9C	837/2010CA/N4/02 837/2010BA/N4/02
IP2010	Patient Zip Code	9D	837/2010CA/N4/03 837/2010BA/N4/03
IP2011	Admission/Start of Care Date	12	837/2300/DTP/435/DT/03
IP2012	Admission Hour	13	837/2300/DTP/435/DT/03
IP2013	Statement Covers Period Thru	6	837/2300/DTP/434/RD8/03
IP2014	Patient Discharge Status	17	837/2300/CL1/03
IP2015	Discharge Hour	16	837/2300/DTP/096/TM/03
IP2016	Medical/Health Record Number	3B	837/2300/REF/EA/02
IP2017	Race	NA	837/2010CA/DMG/05 837/2010BA/DMG/05
IP2018	Ethnicity	NA	837/2010CA/DMG/05 837/2010BA/DMG/05
IP2020	Statement Covers Period – From	6	837/2300/DTP/434/RD8/03
IP2021	Patient Country Code	9E	837/2010CA/N4/04 837/2010BA/N4/04
IP2022	Patient Last Name	8B	837/2010CA/NM1/QC/1/03 837/2010BA/NM1/IL/1/03
IP2023	Patient First Name	8B	837/2010CA/NM1/QC/1/04 837/2010BA/NM1/IL/1/04
IP2024	Patient Middle Name or Initial	8B	837/2010CA/NM1/QC/1/05 837/2010BA/NM1/IL/1/05
IP2025	Patient Name Suffix	8B	837/2010CA/NM1/QC/1/07 837/2010BA/NM1/IL/1/07
IP2026	Patient Address Line 1	9A	837/2010CA/N3/01 837/2010BA/N3/01
IP2027	Patient Address Line 2	9A	837/2010CA/N3/02 837/2010BA/N3/02

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP3001	Record Type	NA	NA
IP3002	Sequence Number	NA	837/2000B/SBR/01
IP3003	Patient Control Number	3A	837/2300/CLM/01
IP3005	Social Security Number	NA	NA
IP3007	Insured’s Group Number (Primary)	62A	837/2000B/SBR/P/03
	Insured’s Group Number (Secondary)	62B	837/2320A/SBR/S/03
IP3008	Insured’s Unique Identifier (Primary)	60A	837/2010BA/NM1/MI/09
	Insured’s Unique Identifier (Secondary)	60B	837/2330A/NM1/MI/09
IP3009	Payer Name (Primary)	50A	837/2010BB/NM1/PR/2/03
	Payer Name (Secondary)	50B	837/2330B/NM1/PR/2/03

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP4001	Record Type	NA	NA
IP4002	Sequence Number	NA	NA
IP4003	Patient Control Number	3A	837/2300/CLM/01
IP4004	Type of Bill	4	837/2300/CLM/05-1 837/2300/CLM/05-3

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP5001	Record Type	NA	NA
IP5002	Sequence Number	NA	NA
IP5003	Patient Control Number	3A	837/2300/CLM/01
IP5004	Accommodations Revenue Code - 1	42	837/2400/SV2/01
IP5005	Accommodations Service Units - 1	46	837/2400/SV2/DA/05
IP5006	Accommodations Total Charges - 1	47	837/2400/SV2/03
IP5007	Accommodations Revenue Code - 2	42	837/2400/SV2/01
IP5008	Accommodations Service Units - 2	46	837/2400/SV2/DA/05
IP5009	Accommodations Total Charges - 2	47	837/2400/SV2/03
IP5010	Accommodations Revenue Code - 3	42	837/2400/SV2/01
IP5011	Accommodations Service Units - 3	46	837/2400/SV2/DA/05
IP5012	Accommodations Total Charges - 3	47	837/2400/SV2/03
IP5013	Accommodations Revenue Code - 4	42	837/2400/SV2/01
IP5014	Accommodations Service Units - 4	46	837/2400/SV2/DA/05
IP5015	Accommodations Total Charges - 4	47	837/2400/SV2/03

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP6001	Record Type	NA	NA
IP6002	Sequence Number	NA	NA
IP6003	Patient Control Number	3A	837/2300/CLM/01
IP6004	Inpatient Ancillary Revenue Code - 1	42	837/2400/SV2/01
IP6005	Inpatient Ancillary Total Charges - 1	47	837/2400/SV2/03
IP6006	Inpatient Ancillary Revenue Code - 2	42	837/2400/SV2/01
IP6007	Inpatient Ancillary Total Charges - 2	47	837/2400/SV2/03
IP6008	Inpatient Ancillary Revenue Code - 3	42	837/2400/SV2/01
IP6009	Inpatient Ancillary Total Charges - 3	47	837/2400/SV2/03

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7101	Record Type	NA	NA
IP7102	Sequence Number	NA	NA
IP7103	Patient Control Number	3A	837/2300/CLM/01
IP7104	Principal Diagnosis	67	837/2300/HI/ABK/01-2
IP7105	Present On Admission Indicator	67 (pos 8)	837/2300/HI/01-9
IP7106	Admitting Diagnosis	69	837/2300/HI/ABJ/01-2
IP7110	Principal Procedure Code	74	837/2300/HI/BBR/01-2
IP7111	Principal Procedure Date	74	837/2300/HI/D8/01-4

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7201	Record Type	NA	NA
IP7202	Sequence Number	NA	NA
IP7203	Patient Control Number	3A	837/2300/CLM/01
IP7204	Other Procedure Code - 1	74A	837/2300/HI/BBQ/01-2
IP7205	Other Procedure Date - 1	74A	837/2300/HI/D8/01-4
IP7206	Other Procedure Code - 2	74B	837/2300/HI/BBQ/02-2
IP7207	Other Procedure Date - 2	74B	837/2300/HI/D8/02-4
IP7208	Other Procedure Code - 3	74C	837/2300/HI/BBQ/03-2
IP7209	Other Procedure Date - 3	74C	837/2300/HI/D8/03-4
IP7210	Other Procedure Code - 4	74D	837/2300/HI/BBQ/04-2
IP7211	Other Procedure Date - 4	74D	837/2300/HI/D8/04-4
IP7212	Other Procedure Code - 5	74E	837/2300/HI/BBQ/05-2
IP7213	Other Procedure Date - 5	74E	837/2300/HI/D8/05-4
IP7214	Other Procedure Code - 6	NA	837/2300/HI/BBQ/06-2
IP7215	Other Procedure Date - 6	NA	837/2300/HI/D8/06-4
IP7216	Other Procedure Code - 7	NA	837/2300/HI/BBQ/07-2
IP7217	Other Procedure Date - 7	NA	837/2300/HI/D8/07-4
IP7218	Other Procedure Code - 8	NA	837/2300/HI/BBQ/08-2
IP7219	Other Procedure Date - 8	NA	837/2300/HI/D8/08-4

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7301	Record Type	NA	NA
IP7302	Sequence Number	NA	NA
IP7303	Patient Control Number	3A	837/2300/CLM/01
IP7304	External Cause of Injury Code - 1	72A	837/2300/HI/ABN/01-2
IP7305	Present On Admission Indicator - 1	72A (pos 8)	837/2300/HI/01-9
IP7306	External Cause of Injury Code - 2	72B	837/2300/HI/ABN/02-2
IP7307	Present On Admission Indicator - 2	72B (pos 8)	837/2300/HI/02-9
IP7308	External Cause of Injury Code - 3	72C	837/2300/HI/ABN/03-2
IP7309	Present On Admission Indicator - 3	72C (pos 8)	837/2300/HI/03-9
IP7310	External Cause of Injury Code - 4	NA	837/2300/HI/ABN/04-2
IP7311	Present On Admission Indicator - 4	NA	837/2300/HI/04-9
IP7312	External Cause of Injury Code - 5	NA	837/2300/HI/ABN/05-2
IP7313	Present On Admission Indicator - 5	NA	837/2300/HI/05-9
IP7314	External Cause of Injury Code - 6	NA	837/2300/HI/ABN/06-2
IP7315	Present On Admission Indicator - 6	NA	837/2300/HI/06-9
IP7316	External Cause of Injury Code - 7	NA	837/2300/HI/ABN/07-2
IP7317	Present On Admission Indicator - 7	NA	837/2300/HI/07-9
IP7318	External Cause of Injury Code - 8	NA	837/2300/HI/ABN/08-2
IP7319	Present On Admission Indicator - 8	NA	837/2300/HI/08-9
IP7320	External Cause of Injury Code - 9	NA	837/2300/HI/ABN/09-2
IP7321	Present On Admission Indicator - 9	NA	837/2300/HI/09-9
IP7322	External Cause of Injury Code - 10	NA	837/2300/HI/ABN/10-2
IP7323	Present On Admission Indicator - 10	NA	837/2300/HI/10-9
IP7324	External Cause of Injury Code - 11	NA	837/2300/HI/ABN/11-2
IP7325	Present On Admission Indicator - 11	NA	837/2300/HI/11-9
IP7326	External Cause of Injury Code - 12	NA	837/2300/HI/ABN/12-2
IP7327	Present On Admission Indicator - 12	NA	837/2300/HI/12-9

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7401	Record Type	NA	NA
IP7402	Sequence Number	NA	NA
IP7403	Patient Control Number	3A	837/2300/CLM/01
IP7404	Other Diagnosis Code - 1	67A	837/2300/HI/ABF/01-2
IP7405	Present On Admission Indicator - 1	67A (pos 8)	837/2300/HI/01-9
IP7406	Other Diagnosis Code - 2	67B	837/2300/HI/ABF/02-2
IP7407	Present On Admission Indicator - 2	67B (pos 8)	837/2300/HI/02-9
IP7408	Other Diagnosis Code - 3	67C	837/2300/HI/ABF/03-2
IP7409	Present On Admission Indicator - 3	67C (pos 8)	837/2300/HI/03-9
IP7410	Other Diagnosis Code - 4	67D	837/2300/HI/ABF/04-2
IP7411	Present On Admission Indicator - 4	67D (pos 8)	837/2300/HI/04-9
IP7412	Other Diagnosis Code - 5	67E	837/2300/HI/ABF/05-2
IP7413	Present On Admission Indicator - 5	67E (pos 8)	837/2300/HI/05-9
IP7414	Other Diagnosis Code - 6	67F	837/2300/HI/ABF/06-2
IP7415	Present On Admission Indicator - 6	67F (pos 8)	837/2300/HI/06-9
IP7416	Other Diagnosis Code - 7	67G	837/2300/HI/ABF/07-2
IP7417	Present On Admission Indicator - 7	67G (pos 8)	837/2300/HI/07-9
IP7418	Other Diagnosis Code - 8	67H	837/2300/HI/ABF/08-2
IP7419	Present On Admission Indicator - 8	67H (pos 8)	837/2300/HI/08-9
IP7420	Other Diagnosis Code - 9	67I	837/2300/HI/ABF/09-2
IP7421	Present On Admission Indicator - 9	67I (pos 8)	837/2300/HI/09-9
IP7422	Other Diagnosis Code - 10	67J	837/2300/HI/ABF/10-2
IP7423	Present On Admission Indicator - 10	67J (pos 8)	837/2300/HI/10-9
IP7424	Other Diagnosis Code - 11	67K	837/2300/HI/ABF/11-2
IP7425	Present On Admission Indicator - 11	67K (pos 8)	837/2300/HI/11-9
IP7426	Other Diagnosis Code - 12	67L	837/2300/HI/ABF/12-2
IP7427	Present On Admission Indicator - 12	67L (pos 8)	837/2300/HI/12-9

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP8001	Record Type	NA	NA
IP8002	Sequence	NA	NA
IP8003	Patient Control Number	3A	837/2300/CLM/01
IP8004	Attending Provider NPI	76	837/2310A/NM1/71/1/XX/09
IP8005	Operating Physician NPI	77	837/2310B/NM1/72/1/XX/09
IP8006	Attending Provider Last Name	76	837/2310A/NM1/71/1/03
IP8007	Attending Provider First Name	76	837/2310A/NM1/71/1/04
IP8008	Attending Provider Middle Initial	76	837/2310A/NM1/71/1/05
IP8009	Operating Physician Last Name	77	837/2310B/NM1/72/1/03
IP8010	Operating Physician First Name	77	837/2310B/NM1/72/1/04
IP8011	Operating Physician Middle Initial	77	837/2310B/NM1/72/1/05
IP8012	Billing Provider NPI	56	837/2010AA/NM1/XX/09

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP9001	Record Type	NA	NA
IP9003	Patient Control Number	3A	837/2300/CLM/01
IP9004	Total Accommodation Charges - Revenue Centers	NA	This is the total of the SV2 segments except for Revenue Code 0001
IP9005	Total Ancillary Charges - Revenue Centers	NA	This is the total of the SV2 segments except for Revenue Code 0001

Data Element #	Data Element Name	UB-04 Form Locator	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
IP9901	Record Type	NA	NA

The record types in the file must be in the following order:

Record Type 01 – Processor Data

Record Type 20 Sequence 01 – Patient Data

Record Type 30 Sequence 01 – Third Party Payer Data Primary Payer

Record Type 30 Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary.

Record Type 40 – Claim Data

Record Type 61 – Services

Record Type 71 – ICD-10 CM Principal and Reason for Visit Diagnosis Codes, ICD-10 PCS Principal Procedure Code

Record Type 72 – ICD-10 PCS Other Procedure Codes

Record Type 73 – ICD-10 CM External Cause of Injury Diagnosis Codes

Record Type 74 – ICD-10 CM Other Diagnosis Information

Record Type 80 – Provider Data

Record Type 90 – Claim Control Screen

Record Type 99 – File Control

The individual claim begins with Record Type 20 and ends with Record Type 90.

The patient control number must be the same on each record type generated for a single patient record.

The medical record number should not be substituted for the patient control number.

Data Element #	Data Element	Type	Length	Description/Codes/Sources
OP0101	Record Type	T	2	01
OP0102	MHDO-Assigned Hospital ID	T	6	Must be the MHDO-assigned, 6-digit hospital code, left justified
OP0198	Filler	T	38
OP0103	Hospital Name	T	21
OP0104	Address	T	18
OP0105	City	T	15
OP0106	State	T	2
OP0107	Zip Code	T	9
OP0199	Filler	T	78
OP0108	Version	T	3	Leave blank

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP2001	Record Type		T	2	20
OP2002	Filler (National Use)		T	2
OP2003	Patient Control Number		T	20	Assigned by the facility
OP2094	Filler		T	30
OP2004	Patient Sex		T	1	M = Male F = Female U = Unknown
OP2005	Patient Birth Date		T	8	CCYYMMDD
OP2095	Filler		T	2
OP2007	Point of Origin for Admission or Visit		T	1
OP2096	Filler		T	30
OP2008	Patient City		T	15
OP2009	Patient State		T	2
OP2010	Patient Zip Code		T	9	As defined by US Postal Service Do not include dashes
OP2011	Admission/Start of Care Date		T	8	CCYYMMDD
OP2097	Filler		T	2
OP2012	Statement Covers Period – From		T	8	The beginning service date for the period covered on the record CCYYMMDD
OP2013	Statement Covers Period – Thru		T	8	The ending service date for the period covered on the record CCYYMMDD
OP2014	Patient Discharge Status		T	2
OP2098	Filler		T	22
OP2015	Medical/Health Record Number		T	17	Assigned by the facility
OP2016	Race	March 1, 2007	T	1	1 = American Indian or Alaska Native 2 = Asian 3 = Black or African American 4 = Native Hawaiian or Other Pacific Islander 5 = White 6 = Other Race 7 = Patient Elected Not to Answer 8 = Unknown The code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.
OP2017	Ethnicity	March 1, 2007	T	1	1 = Hispanic or Latino 2 = Non-Hispanic or Non-Latino 7 = Patient Elected Not to Answer 8 = Unknown The code value “8” (Unknown), should be used ONLY when patient answers unknown. Report only collected data. If not available, leave blank.
OP2099	Filler		T	1
OP2018	Patient Country Code	January 1, 2018	T	2	Use ISO 3166-1 alpha-2 country codes. Refer to Appendix A.
OP2019	Patient Last Name	January 1, 2018	T	60
OP2020	Patient First Name	January 1, 2018	T	35
OP2021	Patient Middle Name or Initial	January 1, 2018	T	25
OP2022	Patient Name Suffix	January 1, 2018	T	10
OP2023	Patient Address Line 1	January 1, 2018	T	55
OP2024	Patient Address Line 2	January 1, 2018	T	55

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP3001	Record Type		T	2	30
OP3002	Sequence Number		T	2	01 Primary Payer 02 - 99 Secondary Payer
OP3003	Patient Control Number		T	20	Assigned by the facility
OP3095	Filler	January 1, 2018	T	10
OP3005	Social Security Number	April 1, 2006	T	19	Do not include dashes For internal use only – Required if collected
OP3097	Filler	January 1, 2018	T	26
OP3007	Insured’s Group Number	April 1, 2006	T	17	For internal use only – Required if collected
OP3008	Insured’s Unique Identifier		T	20	For internal use only – Required if collected
OP3099	Filler		T	1
OP3009	Payer Name	January 1, 2018	T	100	Full or unabbreviated payer name, not plan name

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP4001	Record Type		T	2	40
OP4002	Sequence Number		T	2	01
OP4003	Patient Control Number		T	20	Assigned by the facility
OP4004	Type of Bill		T	3	Code indicating the specific type of institutional bill.
OP4005	Location of Service		T	10	When Place of Service field OP4006 contains the values 11, 17, 20, 22, 49, 50, 71, or 72 an encounter shall contain a Location of Service code. The Location of Service code is internally created by the Hospital and primarily for physician practices (primary care, specialty care and clinics). Refer to section 2(A)(3).
OP4099	Filler		T	155
OP4006	Place of Service	January 1, 2018	T	2	CMS code identifying the entity/location where professional service(s) were rendered.

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP6101	Record Type		T	2	61
OP6102	Sequence Number		T	3	001 to 999
OP6103	Patient Control Number		T	20	Assigned by the facility
OP6190	Filler		T	2
OP6104	Revenue Center Code - 1		T	4	Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.
OP6105	HCPCS Procedure Code - 1		T	5	Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association
OP6106	Modifier – 1 (HCPCS & CPT-4) - 1		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6107	Modifier – 2 (HCPCS & CPT-4) - 1		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6108	Service Units - 1		N	7	A quantitative measure of services rendered by the Revenue Center
OP6191	Filler		T	6
OP6109	Outpatient Total Charges - 1		N	10	Negative charges not accepted Two decimal places implied
OP6192	Filler		T	10
OP6110	Service Date - 1		T	8	The date that the indicated outpatient service, supplies, etc. were provided. Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru”. CCYYMMDD
OP6193	Filler		T	1
OP6111	Revenue Center Code - 2		T	4	Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.
OP6112	HCPCS Procedure Code - 2		T	5	Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association
OP6113	Modifier – 1 (HCPCS & CPT-4) - 2		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6114	Modifier – 2 (HCPCS & CPT-4) - 2		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6115	Service Units - 2		N	7	A quantitative measure of services rendered by the Revenue Center
OP6194	Filler		T	6
OP6116	Outpatient Total Charges - 2		N	10	Negative charges not accepted Two decimal places implied
OP6195	Filler		T	10
OP6117	Service Date - 2		T	8	The date that the indicated outpatient service, supplies, etc. were provided. Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru” CCYYMMDD
OP6196	Filler		T	1
OP6118	Revenue Center Code - 3		T	4	Code which identifies a specific ancillary service, supplies, professional fees on billing calculation. Include leading zeros.
OP6119	HCPCS Procedure Code - 3		T	5	Health Care Common Procedural Coding System (HCPCS) This includes the CPT code of the American Medical Association
OP6120	Modifier – 1 (HCPCS & CPT-4) - 3		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6121	Modifier – 2 (HCPCS & CPT-4) - 3		T	2	Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
OP6122	Service Units - 3		N	7	A quantitative measure of services rendered by the Revenue Center
OP6197	Filler		T	6
OP6123	Outpatient Total Charges - 3		N	10	Negative charges not accepted Two decimal places implied
OP6198	Filler		T	10
OP6124	Service Date - 3		T	8	The date that the indicated outpatient service, supplies, etc. were provided. Must be equal to or greater than statement covers date “from” and less than or equal to statement covers date “thru” CCYYMMDD
OP6199	Filler		T	1
OP6125	Place of Service - 1	January 1, 2020	T	2	CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006
OP6126	Rendering Provider NPI – 1	January 1, 2020	T	16	National Provider Identifier for Rendering Provider, the individual providing the service.
OP6127	Place of Service - 2	January 1, 2020	T	2	CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006
OP6128	Rendering Provider NPI - 2	January 1, 2020	T	16	National Provider Identifier for Rendering Provider, the individual providing the service.
OP6129	Place of Service - 3	January 1, 2020	T	2	CMS code identifying the entity/location where professional service(s) were rendered, if different from POS code indicated in OP4006
OP6130	Rendering Provider NPI - 3	January 1, 2020	T	16	National Provider Identifier for Rendering Provider, the individual providing the service.

Sequence numbers go from 001 to 999 with 3 revenue centers on each physical record makes it possible to have 2,997 revenue centers on a single logical record. If revenue center code “0001” is utilized to report the total of all the line item charges, it must be entered on the last revenue center field. The value for revenue code 0001 must equal the total ancillary charges reported on record type 90 and must equal the summation of all line item charges reported on the logical record.

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP7101	Record Type	10/1/2014	T	2	71
OP7102	Sequence Number	10/1/2014	T	2	01
OP7103	Patient Control Number	10/1/2014	T	20	Assigned by facility
OP7104	Principal Diagnosis	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7105	Filler		T	3
OP7106	Filler		T	10
OP7107	Reason for Visit Diagnosis - 1	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7108	Reason for Visit Diagnosis - 2	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7109	Reason for Visit Diagnosis - 3	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7110	Principal Procedure Code	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7111	Principal Procedure Date	10/1/2014	T	8	CCYYMMDD

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
OP7201	Record Type	10/1/2014	T	2	72
OP7202	Sequence Number	10/1/2014	T	2	01 - 03
OP7203	Patient Control Number	10/1/2014	T	20	Assigned by facility
OP7204	Other Procedure Code - 1	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7205	Other Procedure Date - 1	10/1/2014	T	8	CCYYMMDD
OP7206	Other Procedure Code - 2	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7207	Other Procedure Date - 2	10/1/2014	T	8	CCYYMMDD
OP7208	Other Procedure Code - 3	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7209	Other Procedure Date - 3	10/1/2014	T	8	CCYYMMDD
OP7210	Other Procedure Code - 4	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7211	Other Procedure Date - 4	10/1/2014	T	8	CCYYMMDD
OP7212	Other Procedure Code - 5	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7213	Other Procedure Date - 5	10/1/2014	T	8	CCYYMMDD
OP7214	Other Procedure Code - 6	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7215	Other Procedure Date - 6	10/1/2014	T	8	CCYYMMDD
OP7216	Other Procedure Code - 7	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7217	Other Procedure Date - 7	10/1/2014	T	8	CCYYMMDD
OP7218	Other Procedure Code - 8	10/1/2014	T	10	If an organization or entity is using ICD-10- PCS for outpatient claims, and only if applicable, please report here. ICD-10 PCS - do not code decimal point - Left Justified
OP7219	Other Procedure Date - 8	10/1/2014	T	8	CCYYMMDD

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
OP7301	Record Type	10/1/2014	T	2	73
OP7302	Sequence Number	10/1/2014	T	2	01 - 02
OP7303	Patient Control Number	10/1/2014	T	20	Assigned by facility
OP7304	External Cause of Injury - 1	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7305	Filler		T	3
OP7306	External Cause of Injury - 2	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7307	Filler		T	3
OP7308	External Cause of Injury - 3	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7309	Filler		T	3
OP7310	External Cause of Injury - 4	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7311	Filler		T	3
OP7312	External Cause of Injury - 5	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7313	Filler		T	3
OP7314	External Cause of Injury - 6	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7315	Filler		T	3
OP7316	External Cause of Injury - 7	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7317	Filler		T	3
OP7318	External Cause of Injury - 8	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7319	Filler		T	3
OP7320	External Cause of Injury - 9	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7321	Filler		T	3
OP7322	External Cause of Injury - 10	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7323	Filler		T	3
OP7324	External Cause of Injury - 11	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7325	Filler		T	3
OP7326	External Cause of Injury - 12	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7327	Filler		T	3

Data Element #	Data Element Name	Implementation Date For New Data Elements	Type	Length	Description
OP7401	Record Type	10/1/2014	T	2	74
OP7402	Sequence Number	10/1/2014	T	2	01 - 02
OP7403	Patient Control Number	10/1/2014	T	20	Assigned by facility
OP7404	Other Diagnosis Code - 1	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7405	Filler		T	3
OP7406	Other Diagnosis Code - 2	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7407	Filler		T	3
OP7408	Other Diagnosis Code - 3	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7409	Filler		T	3
OP7410	Other Diagnosis Code - 4	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7411	Filler		T	3
OP7412	Other Diagnosis Code - 5	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7413	Filler		T	3
OP7414	Other Diagnosis Code - 6	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7415	Filler		T	3
OP7416	Other Diagnosis Code - 7	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7417	Filler		T	3
OP7418	Other Diagnosis Code - 8	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7419	Filler		T	3
OP7420	Other Diagnosis Code - 9	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7421	Filler		T	3
OP7422	Other Diagnosis Code - 10	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7423	Filler		T	3
OP7424	Other Diagnosis Code - 11	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7425	Filler		T	3
OP7426	Other Diagnosis Code - 12	10/1/2014	T	10	ICD-10 CM - do not code decimal point - Left Justified
OP7427	Filler		T	3

Data Element #	Data Element	Type	Length	Description/Codes/Sources
OP8001	Record Type	T	2	80
OP8002	Sequence	T	2	01
OP8003	Patient Control Number	T	20	Assigned by the facility
OP8097	Filler	T	2
OP8004	Attending Provider NPI	T	16	NPI of Attending Provider; Attending provider is located on UB-04
OP8005	Operating Physician NPI	T	16	NPI of Operating Physician; Operating physician is located on UB-04.
OP8098	Filler	T	32
OP8006	Attending Provider Last Name	T	16	Cannot be blank if OP8004 is present on a facility/institutional claim.
OP8007	Attending Provider First Name	T	8	Cannot be blank if OP8004 is present on a facility/institutional claim.
OP8008	Attending Provider Middle Initial	T	1
OP8009	Operating Physician Last Name	T	16	Must be populated when OP8005 is populated.
OP8010	Operating Physician First Name	T	8	Cannot be blank if OP8005 is populated.
OP8011	Operating Physician Middle Initial	T	1
OP8099	Filler	T	52
OP8012	Billing Provider NPI	T	16	National Provider Identifier assigned to the provider submitting the bill.

Data Element #	Data Element	Type	Length	Description/Codes/Sources
OP9001	Record Type	T	2	90
OP9002	Filler (National Use)	T	2
OP9003	Patient Control Number	T	20	Assigned by the facility
OP9098	Filler	T	40
OP9004	Total Ancillary Charges - Revenue Centers	N	10	Must equal the sum of line item charges excluding revenue center code 0001 if present. Two decimal positions implied
OP9099	Filler	T	118

Data Element #	Data Element	Implementation Date for New Data Elements	Type	Length	Description/Codes/Sources
OP9901	Record Type		T	2	99
OP9998	Filler		T	190

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP0101	Record Type	NA	NA	NA
OP0102	MHDO-Assigned Hospital ID	NA	NA	NA
OP0103	Hospital Name	1	33	837/2010AA/NM1/85/2/03
OP0104	Address	1	33	837/2010AA/N3/01
OP0105	City	1	33	837/2010AA/N4/01
OP0106	State	1	33	837/2010AA/N4/02
OP0107	Zip Code	1	33	837/2010AA/N4/03
OP0108	Version	NA	NA	NA

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP2001	Record Type	NA	NA	NA
OP2003	Patient Control Number	3A	26	837/2300/CLM/01
OP2004	Patient Sex	11	3	837/2010CA/DMG/03 or 837/2010BA/DMG/03
OP2005	Patient Birth Date	10	3	837/2010CA/DMG/D8/02 or 837/2010BA/DMG/D8/02
OP2007	Point of Origin for Admission or Visit	15	NA	837/2300/CL1/02
OP2008	Patient City	9B	5	837/2010CA/N4/01 or 837/2010BA/N4/01
OP2009	Patient State	9C	5	837/2010CA/N4/02 837/2010BA/N4/02
OP2010	Patient Zip Code	9D	5	837/2010CA/N4/03 837/2010BA/N4/03
OP2011	Admission/Start of Care Date	12	NA	837/2300/DTP/435/D8/03
OP2012	Statement Covers Period - From	6	24A	837I/2300/DTP/434/RD8/03 837P/2400/DTP/472/RD8/03
OP2013	Statement Covers Period - Thru	6	24A	837I/2300/DTP/434/RD8/03 837P/2400/DTP/472/RD8/03
OP2014	Patient Discharge Status	17	NA	837/2300/CL1/03
OP2015	Medical/Health Record Number	3B	NA	837/2300/REF/EA/02
OP2016	Race	NA	NA	837/2010CA/DMG/05
OP2017	Ethnicity	NA	NA	837/2010CA/DMG/05
OP2018	Patient Country Code	9E	NA	837/2010CA/N4/04 837/2010BA/N4/04
OP2019	Patient Last Name	8B	2	837/2010CA/NM1/QC/1/03 837/2010BA/NM1/IL/1/03
OP2020	Patient First Name	8B	2	837/2010CA/NM1/QC/1/04 837/2010BA/NM1/IL/1/04
OP2021	Patient Middle Name or Initial	8B	2	837/2010CA/NM1/QC/1/05 837/2010BA/NM1/IL/1/05
OP2022	Patient Name Suffix	8B	2	837/2010CA/NM1/QC/1/07 837/2010BA/NM1/IL/1/07
OP2023	Patient Address Line 1	9A	5	837/2010CA/N3/01 837/2010BA/N3/01
OP2024	Patient Address Line 2	9A	5	837/2010CA/N3/02 837/2010BA/N3/02

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP3001	Record Type	NA	NA	NA
OP3002	Sequence Number	NA	NA	837/2000B/SBR/01
OP3003	Patient Control Number	3A	26	837/2300/CLM/01
OP3005	Social Security Number	NA	NA	NA
OP3007	Insured’s Group Number (Primary)	62A	11	837/2000B/SBR/P/03
	Insured’s Group Number (Secondary)	62B	9A	837/2320/SBR/S/03
OP3008	Insured’s Unique Identifier (Primary)	60A	1A	837/2010BA/NM1/MI/09
	Insured’s Unique Identifier (Secondary)	60B	NA	837/2330A/NM1/MI/09
OP3009	Payer Name (Primary)	50A	Header/ Carrier Block	837/2010BB/NM1/PR/2/03
	Payer Name (Secondary)	50B	Header/ Carrier Block	837/2330B/NM1/PR/2/03

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP4001	Record Type	NA	NA	NA
OP4002	Sequence Number	NA	NA	NA
OP4003	Patient Control Number	3A	26	837/2300/CLM/01
OP4004	Type of Bill	4	NA	837/2300/CLM/A/05-1 837/2300/CLM/05-3
OP4005	Location of Service	NA	NA	Hospital designated code when Place of Service field OP4006 is 11, 17, 20, 22, 49, 50, 71 or 72. Primarily for physician practices (primary care, specialty care and clinics).
OP4006	Place of Service	NA	24B	837/2300/CLM/05-1

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP6101	Record Type	NA	NA	NA
OP6102	Sequence Number	NA	NA	NA
OP6103	Patient Control Number	3A	26	837/2300/CLM/01
OP6104	Revenue Center Code - 1	42	NA	837/2400/SV2/01
OP6105	HCPCS Procedure Code - 1	44	24D-1	837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2
OP6106	Modifier - 1 (HCPCS & CPT-4) - 1	44	24D-1	837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3
OP6107	Modifier - 2 (HCPCS & CPT-4) - 1	44	24D-1	837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4
OP6108	Service Units - 1	46	24G-1	837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04
OP6109	Outpatient Total Charges - 1	47	24F-1	837I/2400/SV2/03 837P/2400/SV1/02
OP6110	Service Date - 1	45	24A-1	837/2400/DTP/472/D8/03
OP6111	Revenue Center Code - 2	42	NA	837/2400/SV2/01
OP6112	HCPCS Procedure Code - 2	44	24D-2	837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2
OP6113	Modifier - 1 (HCPCS & CPT-4) - 2	44	24D-2	837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3
OP6114	Modifier - 2 (HCPCS & CPT-4) - 2	44	24D-2	837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4
OP6115	Service Units - 2	46	24G-2	837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04
OP6116	Outpatient Total Charges - 2	47	24F-2	837I/2400/SV2/03 837P/2400/SV1/02
OP6117	Service Date - 2	45	24A-2	837/2400/DTP/472/D8/03
OP6118	Revenue Center Code - 3	42	NA	837/2400/SV2/01
OP6119	HCPCS Procedure Code - 3	44	24D-3	837I/2400/SV2/HC/02-2 837P/2400/SV1/HC/01-2
OP6120	Modifier - 1 (HCPCS & CPT-4) - 3	44	24D-3	837I/2400/SV2/HC/02-3 837P/2400/SV1/HC/01-3
OP6121	Modifier - 2 (HCPCS & CPT-4) - 3	44	24D-3	837I/2400/SV2/HC/02-4 837P/2400/SV1/HC/01-4
OP6122	Service Units - 3	46	24G-3	837I/2400/SV2/DA/05 837I/2400/SV2/UN/05 837P/2400/SV1/UN/04
OP6123	Outpatient Total Charges - 3	47	24F-3	837I/2400/SV2/03 837P/2400/SV1/02
OP6124	Service Date - 3	45	24A-3	837/2400/DTP/472/D8/03
OP6125	Place of Service - 1	NA	24B	837/2400/SV1/05
OP6126	Rendering Provider NPI - 1	NA	24J	837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09
OP6127	Place of Service - 2	NA	24B	837/2400/SV1/05
OP6128	Rendering Provider NPI - 2	NA	24J	837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09
OP6129	Place of Service - 3	NA	24B	837/2400/SV1/05
OP6130	Rendering Provider NPI - 3	NA	24J	837/2420A/NM1/XX/09; 837/2310B/NM1/XX/09

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7101	Record Type	NA	NA	NA
OP7102	Sequence Number	NA	NA	NA
OP7103	Patient Control Number	3A	26	837/2300/CLM/01
OP7104	Principal Diagnosis	67	21A	837/2300/HI/ABK/01-2
OP7107	Reason for Visit Diagnosis - 1	70A	NA	837/2300/HI/APR/01-2
OP7108	Reason for Visit Diagnosis - 2	70B	NA	837/2300/HI/APR/02-2
OP7109	Reason for Visit Diagnosis - 3	70C	NA	837/2300/HI/APR/03-2
OP7110	Principal Procedure Code	74	NA	837/2300/HI/BBR/01-2
OP7111	Principal Procedure Date	74	NA	837/2300/HI/D8/01-4

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7201	Record Type	NA	NA	NA
OP7202	Sequence Number	NA	NA	NA
OP7203	Patient Control Number	3A	26	837/2300/CLM/01
OP7204	Other Procedure Code - 1	74A	NA	837/2300/HI/BBQ/01-2
OP7205	Other Procedure Date - 1	74A	NA	837/2300/HI/D8/01-4
OP7206	Other Procedure Code - 2	74B	NA	837/2300/HI/BBQ/02-2
OP7207	Other Procedure Date - 2	74B	NA	837/2300/HI/D8/02-4
OP7208	Other Procedure Code - 3	74C	NA	837/2300/HI/BBQ/03-2
OP7209	Other Procedure Date - 3	74C	NA	837/2300/HI/D8/03-4
OP7210	Other Procedure Code - 4	74D	NA	837/2300/HI/BBQ/04-2
OP7211	Other Procedure Date - 4	74D	NA	837/2300/HI/D8/04-4
OP7212	Other Procedure Code - 5	74E	NA	837/2300/HI/BBQ/05-2
OP7213	Other Procedure Date - 5	74E	NA	837/2300/HI/D8/05-4
OP7214	Other Procedure Code - 6	NA	NA	837/2300/HI/BBQ/06-2
OP7215	Other Procedure Date - 6	NA	NA	837/2300/HI/D8/06-4
OP7216	Other Procedure Code - 7	NA	NA	837/2300/HI/BBQ/07-2
OP7217	Other Procedure Date - 7	NA	NA	837/2300/HI/D8/07-4
OP7218	Other Procedure Code - 8	NA	NA	837/2300/HI/BBQ/08-2
OP7219	Other Procedure Date - 8	NA	NA	837/2300/HI/D8/08-4

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7301	Record Type	NA	NA	NA
OP7302	Sequence Number	NA	NA	NA
OP7303	Patient Control Number	3A	26	837/2300/CLM/01
OP7304	External Cause of Injury - 1	72A	NA	837/2300/HI/ABN/01-2
OP7306	External Cause of Injury - 2	72B	NA	837/2300/HI/ABN/02-2
OP7308	External Cause of Injury - 3	72C	NA	837/2300/HI/ABN/03-2
OP7310	External Cause of Injury - 4	NA	NA	837/2300/HI/ABN/04-2
OP7312	External Cause of Injury - 5	NA	NA	837/2300/HI/ABN/05-2
OP7314	External Cause of Injury - 6	NA	NA	837/2300/HI/ABN/06-2
OP7316	External Cause of Injury - 7	NA	NA	837/2300/HI/ABN/07-2
OP7318	External Cause of Injury - 8	NA	NA	837/2300/HI/ABN/08-2
OP7320	External Cause of Injury - 9	NA	NA	837/2300/HI/ABN/09-2
OP7322	External Cause of Injury - 10	NA	NA	837/2300/HI/ABN/10-2
OP7324	External Cause of Injury - 11	NA	NA	837/2300/HI/ABN/11-2
OP7326	External Cause of Injury - 12	NA	NA	837/2300/HI/ABN/12-2

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7401	Record Type	NA	NA	NA
OP7402	Sequence Number	NA	NA	NA
OP7403	Patient Control Number	3A	26	837/2300/CLM/01
OP7404	Other Diagnosis Code - 1	67A	21B	837I/2300/HI/ABF/01-2 837P/2300/HI/ABF/02-2
OP7406	Other Diagnosis Code - 2	67B	21C	837I/2300/HI/ABF/02-2 837P/2300/HI/ABF/03-2
OP7408	Other Diagnosis Code - 3	67C	21D	837I/2300/HI/ABF/03-2 837P/2300/HI/ABF/04-2
OP7410	Other Diagnosis Code - 4	67D	21E	837I/2300/HI/ABF/04-2 837P/2300/HI/ABF/05-2
OP7412	Other Diagnosis Code - 5	67E	21F	837I/2300/HI/ABF/05-2 837P/2300/HI/ABF/06-2
OP7414	Other Diagnosis Code - 6	67F	21G	837I/2300/HI/ABF/06-2 837P/2300/HI/ABF/07-2
OP7416	Other Diagnosis Code - 7	67G	21H	837I/2300/HI/ABF/07-2 837P/2300/HI/ABF/08-2
OP7418	Other Diagnosis Code - 8	67H	21I	837I/2300/HI/ABF/08-2 837P/2300/HI/ABF/09-2
OP7420	Other Diagnosis Code - 9	67I	21J	837I/2300/HI/ABF/09-2 837P/2300/HI/ABF/10-2
OP7422	Other Diagnosis Code - 10	67J	21K	837I/2300/HI/ABF/10-2 837P/2300/HI/ABF/11-2
OP7424	Other Diagnosis Code - 11	67K	21L	837I/2300/HI/ABF/11-2 837P/2300/HI/ABF/12-2
OP7426	Other Diagnosis Code - 12	67L	NA	837I/2300/HI/ABF/12-2

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP8001	Record Type	NA	NA	NA
OP8002	Sequence	NA	NA	NA
OP8003	Patient Control Number	3A	26	837/2300/CLM/01
OP8004	Attending Provider NPI	76	NA	837/2310A/NM1/71/1/XX/09
OP8005	Operating Physician NPI	77	NA	837/2310B/NM1/72/1/XX/09
OP8006	Attending Provider Last Name	76	NA	837/2310A/NM1/71/1/03
OP8007	Attending Provider First Name	76	NA	837/2310A/NM1/71/1/04
OP8008	Attending Provider Middle Initial	76	NA	837/2310A/NM1/71/1/05
OP8009	Operating Physician Last Name	77	NA	837/2310B/NM1/72/1/03
OP8010	Operating Physician First Name	77	NA	837/2310B/NM1/72/1/04
OP8011	Operating Physician Middle Initial	77	NA	837/2310B/NM1/72/1/05
OP8012	Billing Provider NPI	56	NA	837/2010AA/NM1/XX/09

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP9001	Record Type	NA	NA	NA
OP9003	Patient Control Number	3A	26	837/2300/CLM/01
OP9004	Total Ancillary Charges - Revenue Centers	NA	28	This is the total of the SV2 segments with the exception of Revenue Code 0001

Data Element #	Data Element Name	UB-04 Form Locator	CMS-1500	HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator
OP9901	Record Type	NA	NA	NA