X12 837 Health Care Claim: Institutional (X223A3)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.
For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HC
- Health Care Claim (837)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X223A3
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 837
- Health Care Claim
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
- 005010X223A3
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
- The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0019
- Information Source, Subscriber, Dependent
Code identifying purpose of transaction set
- BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.
- 00
- Original
Original transmissions are transmissions which have never been sent to the receiver.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
- This field is limited to 30 characters.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
- This is the date that the original submitter created the claim file from their business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
- This is the time that the original submitter created the claim file from their business application system.
Code specifying the type of transaction
- CH
- Chargeable
Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.
Submitter Name
To supply the full name of an individual or organizational entity
- The submitter is the entity responsible for the creation and formatting of this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Medicare does not support the submission of foreign currency.
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement
Code identifying a party or other code
The MAC will reject an interchange (transmission) that is submitted with a
submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02.
Submitter EDI Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
The MAC will reject an interchange (transmission) that is not submitted with a valid Part A MAC code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Name
To supply the full name of an individual or organizational entity
- Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
- Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
- The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
- When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Billing Provider Address
To specify the location of the named party
- The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
Billing Provider City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Tax Identification
To specify identifying information
- This is the tax identification number (TIN) of the entity to be paid for the submitted services.
Code qualifying the Reference Identification
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Pay-to Address Name
To supply the full name of an individual or organizational entity
- Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
- The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
Pay-to Address - ADDRESS
To specify the location of the named party
Pay-To Address City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
- P
- Primary
- S
- Secondary
- T
- Tertiary
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
For Medicare, the subscriber is always the same as the patient.
- 18
- Self
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
Code identifying type of claim
For Medicare, the subscriber is always the same as the patient.
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- OF
- Other Federal Program
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Subscriber Name
To supply the full name of an individual or organizational entity
- In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
The MBI: must be 11 positions in the format of C A AN N A AN N A A N N
where “C” represents a constrained numeric 1 thru 9, “A” represents alphabetic character A – Z but excluding S, L, O, I, B, Z, “N” represents numeric 0 thru 9, and “AN” represents either “A” or “N”.
Subscriber Address
To specify the location of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Must not be a future date.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Property and Casualty Claim Number
To specify identifying information
- This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
- This segment is not a HIPAA requirement as of this writing.
- Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Name
To supply the full name of an individual or organizational entity
- This is the destination payer.
- For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Secondary Identification
To specify identifying information
- Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Information
To specify basic data about the claim
- The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
- For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Identifier used to track a claim from creation by the health care provider through payment
- The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
- When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
- The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- The Total Claim Charge Amount must be greater than or equal to zero.
- The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim.
When Medicare is primary payer, CLM02 must equal the sum of all SV203
service line charge amounts. When Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320
& 2430 CAS amounts and the 2320 AMT02 (AMT01= “D”).
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
Code indicating whether the provider accepts assignment
- Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
- A
- Assigned
Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. - B
- Assignment Accepted on Clinical Lab Services Only
Required when the provider accepts assignment for Clinical Lab Services only.
- C
- Not Assigned
Required when neither codes
A' norB' apply.
Code indicating a Yes or No condition or response
- CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Code indicating the reason why a request was delayed
Data submitted in CLM20 will not be used for processing
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 5
- Delay in Supplying Billing Forms
- 6
- Delay in Delivery of Custom-made Appliances
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
Admission Date/Hour
To specify any or all of a date, a time, or a time period
- Required on inpatient claims.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Selection of the appropriate qualifier is designated by the NUBC Billing Manual.
Must not be a future date.
- D8
- Date Expressed in Format CCYYMMDD
- DT
- Date and Time Expressed in Format CCYYMMDDHHMM
Expression of a date, a time, or range of dates, times or dates and times
Must be in format HHMM.MM
Date - Repricer Received Date
To specify any or all of a date, a time, or a time period
- Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Discharge Hour
To specify any or all of a date, a time, or a time period
- Required on all final inpatient claims. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- TM
- Time Expressed in Format HHMM
Expression of a date, a time, or range of dates, times or dates and times
Statement Dates
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 434
- Statement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same.
Expression of a date, a time, or range of dates, times or dates and times
Institutional Claim Code
To supply information specific to hospital claims
Code indicating the priority of this admission
Code indicating the source of this admission
Code indicating patient status as of the "statement covers through date"
Claim Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Only the first iteration of the PWK, at either the claim level and/or line
level, will be considered in the claim adjudication.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Patient Estimated Amount Due
To indicate the total monetary amount
- Required when the Patient Responsibility Amount is applicable to this claim.
If not required by this implementation guide, do not send.
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Auto Accident State
To specify identifying information
- Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in code source 22. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Values in this field must be valid codes found in code source 22.
Claim Identifier For Transmission Intermediaries
To specify identifying information
- Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
- Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Code qualifying the Reference Identification
- Number assigned by clearinghouse, van, etc.
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The value carried in this element is limited to a maximum of 20 positions.
Demonstration Project Identifier
To specify identifying information
- Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- P4
- Project Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Investigational Device Exemption Number
To specify identifying information
- Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- LX
- Qualified Products List
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Medical Record Number
To specify identifying information
- Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EA
- Medical Record Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- F8
- Original Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Peer Review Organization (PRO) Approval Number
To specify identifying information
- Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G4
- Peer Review Organization (PRO) Approval Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- Required when an authorization number is assigned by the payer or UMO
AND
the services on this claim were preauthorized.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND
a referral is involved.
If not required by this implementation guide, do not send. - Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Repriced Claim Number
To specify identifying information
- This information is specific to the destination payer reported in Loop ID-2010BB.
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Authorization Exception Code
To specify identifying information
- Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 4N
- Special Payment Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine
if Recipient Can Work
6 Request for Override Pending
7 Special Handling
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Billing Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send.
Claim Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
OR
Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services.
If not required by this implementation guide, do not send. - The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Code identifying the functional area or purpose for which the note applies
- ALG
- Allergies
- DCP
- Goals, Rehabilitation Potential, or Discharge Plans
- DGN
- Diagnosis Description
- DME
- Durable Medical Equipment (DME) and Supplies
- MED
- Medications
- NTR
- Nutritional Requirements
- ODT
- Orders for Disciplines and Treatments
- RHB
- Functional Limitations, Reason Homebound, or Both
- RLH
- Reasons Patient Leaves Home
- RNH
- Times and Reasons Patient Not at Home
- SET
- Unusual Home, Social Environment, or Both
- SFM
- Safety Measures
- SPT
- Supplementary Plan of Treatment
- UPI
- Updated Information
A free-form description to clarify the related data elements and their content
EPSDT Referral
To supply information on conditions
- Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- ZZ
- Mutually Defined
EPSDT Screening referral information.
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- The response answers the question: Was an EPSDT referral given to the patient?
- N
- No
If no, then choose "NU" in CRC03 indicating no referral given.
- Y
- Yes
Code indicating a condition
- The codes for CRC03 also can be used for CRC04 through CRC05.
- AV
- Available - Not Used
Patient refused referral.
- NU
- Not Used
This conditioner indicator must be used when the submitter answers "N" in CRC02.
- S2
- Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health problem.
- ST
- New Services Requested
Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Admitting Diagnosis
To supply information related to the delivery of health care
- Required when claim involves an inpatient admission.
If not required by this implementation guide, do not send.; - Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Condition Information
To supply information related to the delivery of health care
- Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Diagnosis Related Group (DRG) Information
To supply information related to the delivery of health care
- Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- DR
- Diagnosis Related Group (DRG)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
External Cause of Injury
To supply information related to the delivery of health care
- Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send.
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
- In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Occurrence Information
To supply information related to the delivery of health care
- Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BH
- Occurrence
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Occurrence Span Information
To supply information related to the delivery of health care
- Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BI
- Occurrence Span
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Other Diagnosis Information
To supply information related to the delivery of health care
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
- Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Other Procedure Information
To supply information related to the delivery of health care
- Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send.
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Patient's Reason For Visit
To supply information related to the delivery of health care
- Required when claim involves outpatient visits. If not required by this implementation guide, do not send.
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Principal Diagnosis
To supply information related to the delivery of health care
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating a Yes or No condition or response
- C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
- C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
- N
- No
- U
- Unknown
- W
- Not Applicable
- Y
- Yes
Principal Procedure Information
To supply information related to the delivery of health care
- Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send.
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BBR
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes
- CAH
- Advanced Billing Concepts (ABC) Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Treatment Code Information
To supply information related to the delivery of health care
- Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- TC
- Treatment Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Value Information
To supply information related to the delivery of health care
- Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BE
- Value
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Claim Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP06 is the approved DRG code.
- HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Monetary amount
- HCP07 is the approved DRG amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Identifying number for a product or service
- HCP08 is the approved revenue code.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- UN
- Unit
Numeric value of quantity
- HCP12 is the approved service units or inpatient days.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Attending Provider Name
To supply the full name of an individual or organizational entity
- Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send.
- The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim.
Code identifying an organizational entity, a physical location, property or an individual
- 71
- Attending Physician
When used, the term physician is any type of provider filling this role.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Attending Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Attending Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Operating Physician Name
To supply the full name of an individual or organizational entity
- Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send.
- The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 72
- Operating Physician
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Operating Physician Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Operating Physician Name
To supply the full name of an individual or organizational entity
- Required when another Operating Physician is involved. If not required by the implementation guide, do not send.
- The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician.
- This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- ZZ
- Mutually Defined
ZZ is used to indicate Other Operating Physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Suffix to individual name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Other Operating Physician Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim.
AND
When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
If not required by this implementation guide, do not send. - The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Location Name
To supply the full name of an individual or organizational entity
- Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
If not required by this implementation guide, do not send. - When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referring Provider Name
To supply the full name of an individual or organizational entity
- Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send.
- The Referring Provider is provider who sends the patient to another provider for services.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Other Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
- Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
- All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
The SBR must contain a different value in each iteration of the SBR01.
Each value may only be used one time per claim.
- A
- Payer Responsibility Four
- B
- Payer Responsibility Five
- C
- Payer Responsibility Six
- D
- Payer Responsibility Seven
- E
- Payer Responsibility Eight
- F
- Payer Responsibility Nine
- G
- Payer Responsibility Ten
- H
- Payer Responsibility Eleven
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown
This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
Code identifying type of claim
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MC
- Medicaid
- OF
- Other Federal Program
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Claim Level Adjustments
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
- Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
- Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
- Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
CAS segment must not be present when 2000B SBR01 = “P”
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Coordination of Benefits (COB) Payer Paid Amount
To indicate the total monetary amount
- Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
If not required by this implementation guide, do not send.;
Code to qualify amount
Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 = “D” must be present when 2000B SBR01 = “S”.
- D
- Payor Amount Paid
Monetary amount
- It is acceptable to show "0" as the amount paid.
- When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
Coordination of Benefits (COB) Total Non-Covered Amount
To indicate the total monetary amount
- Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
- When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send. - In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Other Insurance Coverage Information
To specify information associated with other health insurance coverage
- All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Code indicating a Yes or No condition or response
- OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This is a crosswalk from CLM08 when doing COB.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- This is a crosswalk from CLM09 when doing COB.
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Inpatient Adjudication Information
To provide claim-level data related to the adjudication of Medicare inpatient claims
- Required when inpatient adjudication information is reported in the remittance advice.
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.
Numeric value of quantity
- MIA01 is the covered days.
Numeric value of quantity
- MIA03 is the lifetime psychiatric days.
Monetary amount
- MIA04 is the Diagnosis Related Group (DRG) amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MIA05 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MIA06 is the disproportionate share amount.
Monetary amount
- MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.
Monetary amount
- MIA08 is the total Prospective Payment System (PPS) capital amount.
Monetary amount
- MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.
Monetary amount
- MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount.
Monetary amount
- MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.
Monetary amount
- MIA12 is the old capital amount.
Monetary amount
- MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.
Monetary amount
- MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
Numeric value of quantity
- MIA15 is the cost report days.
Monetary amount
- MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
Monetary amount
- MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
Monetary amount
- MIA18 is the indirect teaching amount.
Monetary amount
- MIA19 is the professional component amount billed but not payable.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MIA20 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MIA21 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MIA22 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MIA23 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MIA24 is the capital exception amount.
Outpatient Adjudication Information
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
- Required when outpatient adjudication information is reported in the remittance advice
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- MOA01 is the reimbursement rate.
Monetary amount
- MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA03 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA04 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA05 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA06 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA07 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MOA08 is the End Stage Renal Disease (ESRD) payment amount.
Monetary amount
- MOA09 is the professional component amount billed but not payable.
Other Subscriber Name
To supply the full name of an individual or organizational entity
- If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
- If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
Other Subscriber Address
To specify the location of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Other Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Must be 9 digits with no punctuation.
First 3 digits cannot be higher than “272”.
Digits 1-3, 4-5, and 6-9 cannot be zeros.
Other Payer Name
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
- When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
Other Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Other Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Claim Check or Remittance Date
To specify any or all of a date, a time, or a time period
- Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be future date.
Other Payer Claim Adjustment Indicator
To specify identifying information
- Required when the claim is being sent in the payer-to-payer COB model,
AND
the destination payer is secondary to the payer identified in this Loop ID-2330B,
AND
the payer identified in this Loop ID-2330B has re-adjudicated the claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- T4
- Signal Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Only allowed value is "Y".
Other Payer Claim Control Number
To specify identifying information
- Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer's Claim Control Number is available.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F8
- Original Reference Number
This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Prior Authorization Number
To specify identifying information
- Required when the payer identified in this loop has assigned a prior authorization number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referral Number
To specify identifying information
- Required when the payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Secondary Identifier
To specify identifying information
- Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the qualifier XV is reported in NM108 of this loop.
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Number
To reference a line number in a transaction set
- The LX functions as a line counter.
- The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
- LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Number assigned for differentiation within a transaction set
LX01 must be greater than zero and less than or equal to “449”. An individual claim with service lines greater than “449” will be rejected (However, the transmission of claims will be accepted, per HIPAA).
Institutional Service Line
To specify the service line item detail for a health care institution
Identifying number for a product or service
- SV201 is the revenue code.
- See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Required for outpatient claims when an appropriate procedure code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item.
If not required by this implementation guide, do not send.;
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
If A0427, A0428 (with a QL modifier in SV202-3, SV202-4, SV202-5, or SV202-6), A0425, A0429, A0430, A0431, A0432, A0433, A0434, A0435,
A0488, or A0436 (nonscheduled transportation claim) are the only codes present, 2310A NM1 must not be preset.
Otherwise, 2310A NM1 must be present.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Monetary amount
- SV203 is the submitted service line item amount.
- This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
- Zero "0" is an acceptable value for this element.
SV203 must be greater than zero. SV203’s decimal positions are limited to 0, 1, or 2.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- UN
- Unit
Numeric value of quantity
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SV205 must be greater than zero and less than or equal to “999,999.9”.
Must be 0 or 1 decimal position.
Monetary amount
- SV207 is a non-covered service amount.
Line Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- EM
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Date - Service Date
To specify any or all of a date, a time, or a time period
- Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day.
OR
Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written.
If not required by this implementation guide, do not send. - In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.
- In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written).
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date, except for type of bill 0322 after 1/1/2021
Adjusted Repriced Line Item Reference Number
To specify identifying information
- Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9D
- Adjusted Repriced Line Item Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Line Item Control Number
To specify identifying information
- Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
- The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
- Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Code qualifying the Reference Identification
- 6R
- Provider Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The maximum number of characters to be supported for this field is
30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
Repriced Line Item Reference Number
To specify identifying information
- Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9B
- Repriced Line Item Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Facility Tax Amount
To indicate the total monetary amount
- Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
- When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount.
Service Tax Amount
To indicate the total monetary amount
- Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
- When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount.
Third Party Organization Notes
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.
Line Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP06 is the approved DRG code.
- HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Monetary amount
- HCP07 is the approved DRG amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Identifying number for a product or service
- HCP08 is the approved revenue code.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.; - WK
- Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
Identifying number for a product or service
- HCP10 is the approved procedure code.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- UN
- Unit
Numeric value of quantity
- HCP12 is the approved service units or inpatient days.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Drug Identification
To specify basic item identification data
- Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400.
- Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
OR
Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
- N4
- National Drug Code in 5-4-2 Format
Identifying number for a product or service
Drug Quantity
To specify pricing information
Numeric value of quantity
CTP04 must be greater than “0” and less than or equal to “9,999,999.999”.
CTP04 is limited to up to 3 decimal positions.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- F2
- International Unit
- GR
- Gram
- ME
- Milligram
- ML
- Milliliter
- UN
- Unit
Prescription or Compound Drug Association Number
To specify identifying information
- In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
- Required when dispensing of the drug has been done with an assigned prescription number.
OR
Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
If not required by this implementation guide, do not send. - For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
Code qualifying the Reference Identification
- VY
- Link Sequence Number
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Operating Physician Name
To supply the full name of an individual or organizational entity
- Required when a surgical procedure code is listed on this claim.
AND
The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level).
If not required by this implementation guide, do not send. - The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
Code identifying an organizational entity, a physical location, property or an individual
- 72
- Operating Physician
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Operating Physician Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Other Operating Physician Name
To supply the full name of an individual or organizational entity
- Required when another Operating Physician is involved,
AND
The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level).
If not required by this implementation guide, do not send.;
Code identifying an organizational entity, a physical location, property or an individual
- ZZ
- Mutually Defined
ZZ is used to indicate Other Operating Physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Suffix to individual name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Other Operating Physician Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim.
AND
State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
AND
The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level).
If not required by this implementation guide, do not send. - The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Referring Provider Name
To supply the full name of an individual or organizational entity
- Required on an outpatient claim when the Referring Provider is different than the Attending Provider.
AND
The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level).
If not required by this implementation guide, do not send. - The Referring Provider is provider who sends the patient to another provider for services.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Referring Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Line Adjudication Information
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
- Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
- To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Code identifying a party or other code
- SVD01 is the payer identification code.
- This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
Monetary amount
- SVD02 is the amount paid for this service line.
- Zero "0" is an acceptable value for this element.
Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01).
If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Must be an integer (no decimals).
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- SVD04 is the revenue code.
Numeric value of quantity
- SVD05 is the paid units of service.
- This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Number assigned for differentiation within a transaction set
- SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
Line Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Line Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Remaining Patient Liability
To indicate the total monetary amount
- In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
- This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1a: Institutional Claim
GS*HC*SENDERGS*RECEIVERGS*20231031*014228*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93***14>A>1**A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
HI*BH>A1>D8>19261111*BH>A2>D8>19911101*BH>B1>D8>19261111*BH>B2>D8>19870101~
HI*BE>A2>>>15.31~
HI*BG>09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC>93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*000000001~
IEA*1*000000001~
Example 1b: Two Claims for the Same Provider
GS*HC*SENDERGS*RECEIVERGS*20231031*014255*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*20050630*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*1112223333~
NM1*40*2*TRICARE*****46*99999~
HL*1**20*1~
PRV*BI*PXC*282N00000X~
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
N3*225 MAIN STREET~
N4*ANYWHERE*PA*17111~
REF*EI*123456789~
HL*2*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*DOE*JOHN*T***MI*030005074~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19681111*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756048Q*89.95***13>A>1**C*Y*Y~
DTP*434*RD8*20050315-20050315~
CL1*1**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
NM1*71*1*JONES*JOHN*J***XX*1122334455~
REF*1G*U12345~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*20050315~
LX*2~
SV2*0730*HC>93010*76.56*UN*3~
DTP*472*D8*20050315~
HL*3*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*SMITH*JOE****MI*123405074~
N3*5 MAIN STREET~
N4*ANYWHERE*PA*17111~
DMG*D8*19621210*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756049Q*50***13>A>1**C*Y*Y~
DTP*434*RD8*20050401-20050401~
CL1*1**01~
HI*BK>30000~
NM1*71*1*JONES*JUDY*J***XX*9999999999~
PRV*AT*PXC*363LP0200N~
LX*1~
SV2*0300*HC>85087*50*UN*1~
DTP*472*D8*20050401~
SE*48*987654~
GE*1*000000001~
IEA*1*000000001~
Example 1c: PPO Repriced Claim
GS*HC*SENDERGS*RECEIVERGS*20231108*022053*000000001*X*005010X223A3~
ST*837*1002*005010X223A3~
BHT*0019*00*1002*20050721*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~
HL*1**20*1~
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
N3*592 NORTH ELM STREET~
N4*EDGEWOOD*AZ*860015590~
REF*EI*344232321~
HL*2*1*22*1~
SBR*P**46522567AW******CI~
NM1*IL*1*JONES*JENNY****MI*345U8423H~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19690731*F~
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~
CLM*456DFH43*237.5***13>A>1**A*Y*Y~
DTP*434*RD8*20050706-20050706~
DTP*435*DT*200507060800~
CL1*1*2*01~
AMT*F3*237.5~
REF*9A*09459034092~
REF*D9*04566877634343456~
HI*BK>38181~
HI*BF>38900~
HI*BH>11>D8>20050706~
HCP*03*182.88*54.62*123456789~
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
SBR*S*19**T&T PLUMBING COMPANY*****CI~
OI***Y***Y~
NM1*IL*1*JONES*GEORGE****MI*56454566~
NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~
LX*1~
SV2*0471*HC>92557*178*UN*1~
DTP*472*D8*20050706~
HCP*03*137.06*40.94~
LX*2~
SV2*0471*HC>92567*59.5*UN*1~
DTP*472*D8*20050706~
HCP*03*45.82*13.68~
SE*42*1002~
GE*1*000000001~
IEA*1*000000001~
Example 1d: Out of Network Repriced Claim
GS*HC*SENDERGS*RECEIVERGS*20231031*014349*000000001*X*005010X223A3~
ST*837*1024*005010X223A3~
BHT*0019*00*1024*20050711*1335*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
HL*1**20*1~
NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~
N3*3423 SMALL STREET~
N4*COLUMBUS*OH*432150000~
REF*EI*111002222~
HL*2*1*22*0~
SBR*P*18*34561W******CI~
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
N3*934 NORTH STREET~
N4*COLUMBUS*OH*432150000~
DMG*D8*19621015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~
CLM*W392-49141*14.84***13>A>1**A*Y*Y~
DTP*434*RD8*20050617-20050617~
DTP*435*DT*200506170800~
CL1*1*1*01~
AMT*F3*14.84~
REF*9A*459804390823~
REF*D9*32423466233~
HI*BK>53081~
HCP*00*0**333001234*********T1~
NM1*71*1*RIVERS*DAWN****XX*2244224455~
LX*1~
SV2*0301*HC>82270*14.84*UN*1~
DTP*472*D8*20050617~
SE*31*1024~
GE*1*000000001~
IEA*1*000000001~
Example 2a: Automobile Accident
GS*HC*SENDERGS*RECEIVERGS*20231108*022219*000000001*X*005010X223A3~
ST*837*557766*005010X223A3~
BHT*0019*00*0324*20051111*1800*CH~
NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~
PER*IC*KATE CASEY*TE*7152569877~
NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~
N3*1 CANTON ROAD~
N4*BROKEN FIELD*CA*99998~
REF*EI*737373737~
HL*2*1*22*1~
SBR*P********AM~
NM1*IL*1*HOWLING*HAL****MI*B999777791G~
NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~
CLM*67236695521*545***13>A>1**A*Y*Y~
DTP*434*RD8*20051031-20051101~
CL1*3*7*1~
REF*LU*CA~
HI*BK>8842~
HI*PR>8842~
HI*BN>E9750*BN>E9860~
NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~
LX*1~
SV2*0450*HC>98765*150*UN*1~
DTP*472*D8*20051031~
LX*2~
SV2*0360*HC>26591*75*UN*1~
DTP*472*D8*20051031~
LX*3~
SV2*0312*HC>86225*100*UN*2~
DTP*472*D8*20051031~
LX*4~
SV2*0360*HC>99283*220*UN*1~
DTP*472*D8*20051031~
SE*36*557766~
GE*1*000000001~
IEA*1*000000001~
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.