77 Ill. Adm. Code 1010.APPENDIX
A Uniform Inpatient Discharge Data
Section 1010.APPENDIX A Uniform Inpatient Discharge
Data
Data elements affected by
implementation of the ICD-10 coding scheme on October
1, 2013 (or as stipulated by CMMS) are noted when necessary and appropriate.
Detail Data
1. Hospital identifier
(federal tax identification number/Department assigned/NPI)
2. Patient account number
3. Discharge time (HH)
4. Patient zip code and
Plus 4
5. Patient birth date
(MMDDCCYY)
6. Patient sex
7. Admission date (MMDDYY)
and time (HH)
8. Type of admission
9. Source of admission
10. Patient discharge
status
11. Type
of bill
12. Total
patient charges and components of charges (by revenue code, units of service
and charges)
13. Primary payer ID and
health plan name
14. Secondary and tertiary
payer ID and health plan name (required when present)
15. Principal
and secondary diagnosis codes, when present (up to 25 per data record and up
to 50 with record pagination when necessary)
ICD-9 codes
required: current discharges through discharges of September
30, 2013 (or last date of CMMS acceptance of ICD-9 codes)
ICD-10 codes
required: discharges on and after October
1, 2013 (or first date of CMMS acceptance of ICD-10 codes)
16. Principal
and secondary procedure codes and dates (MMDDYY), when present (up to 25 per
data record and up to 50 with record pagination when necessary)
ICD-9 codes
required: current discharges through discharges of September
30, 2013 (or last date of CMMS acceptance of ICD-9 codes)
ICD-10 codes
required: discharges on and after October
1, 2013 (or first date of CMMS acceptance of ICD-10 codes)
17. Attending clinician ID
number/NPI
18. Other clinician ID
number/NPI (up to two required when present)
19. Patient race (according
to OMB guidelines)
20. Patient ethnicity
(according to OMB guidelines)
21. Patient
county code (five digits: state and county codes for Illinois and border state
residents (FIPS code))
22. Diagnosis present at
admission for each diagnosis
23. External cause of
injury codes (required when present)
ICD-9 Ecodes:
three required if available: current discharges through discharges of September 30, 2013 (or last date of CMMS acceptance of ICD-9 codes)
ICD-10 Ecodes:
eight required if available: discharges on and after October
1, 2013 (or first date of CMMS acceptance of ICD-10 codes)
24. Newborn birth weight
value code and birth weight in grams
25. Admitting diagnosis
code
ICD-9 code
required: current discharges through discharges of September
30, 2013 (or last date of CMMS acceptance of ICD-9 codes)
ICD-10 code
required: discharges on and after October
1, 2013 (or first date of CMMS acceptance of ICD-10 codes)
26. Do not resuscitate
indicator (entered in first 24 hours of stay)
27. Prior
stay occurrence code and prior stay from and through dates (required when
present)
28. Operating
clinician ID number/NPI (required when surgical procedures present as a
component of treatment)
29. Accident state
abbreviation (required when present)
30. Condition employment
related (required when present)
31. Accident
employment related occurrence code and date of accident (required when present)
32. Crime victim occurrence
code and date of crime (required when present)
33. Statement covers period
(from and through [discharge date] dates)
34. Insurance group numbers
(up to three required when present)
35. Page number and total
number of pages
36. Diagnoses code version
qualifier
ICD-9 indicator
required = 9: current discharges through discharges of September
30, 2013 (or last date of CMMS acceptance of ICD-9 codes)
ICD-10 indicator
required = 0: discharges on and after October
1, 2013 (or first date of CMMS acceptance of ICD-10 codes)
37. Condition
code indicating patient admitted directly from this facility's emergency
room/department
38. Patient name (first,
middle, last, suffix)
39. Patient
address (PO Box or street address, apartment number, city and state)
40. Unique
patient identifier based on the last four digits of patient Social Security
number
41. Primary
insured's unique identifier (beneficiary/policy #)
42. Any
element or service adopted for use by the the National Uniform Billing
Committee pursuant to Section 4-2(d)(14) of the Act. Elements or services
would be added as a submission requirement accompanied by sufficient
notification to all submitting facilities and health care systems. Notice
would be provided no less than 90 days in advance of the submission
requirement.