LAC 48:V.15125. Guide—Data Elements

A. Listed below are required and conditionally required data elements. Submission of any other data elements is optional; hospitals do not need to suppress or strip other elements appearing in their claims files. All elements submitted will be treated confidentially. 1. Required Data Elements. If a hospital is currently or temporarily unable to provide any of the data elements listed here, the hospital must apply for a waiver or extension, as detailed in §15119 of this rule. Data Element | Form Locator | 1300 Record Number | 1450 Data Element | Form Locator | 1300 Record Number | Record Type | Record Number Patient Control Number· assigned by Provider | 3 | 1 | 20 | 3 Type of Bill | 4 | 2 | 40 | 4 Federal Tax ID (Facility EIN)· with Sub ID Number if applicable | 5 | 3165 | 10 | 45 Statement Covers Period From | 6 | 4 | 20 | 19 Statement Covers Period Thru | 6 | 5 | 20 Patient Name | 12 | (none) | 20 | 4-6 Patient Address | 13 | 6(zip only) | 20 | 12-16 Patient Date of Birth | 14 | 7 | 20 | 8 Patient Sex | 15 | 8 | 20 | 7 Admission Date | 17 | 9 | 20 | 17 Type of Admission | 19 | 11 | 20 | 10 Source of Admission | 20 | 12 | 20 | 11 Patient Status at time of discharge | 22 | 13 | 20 | 21 Medical/Health Record Number | 23 | 14 | 20 | 25 Revenue Codes· Include all listed· Must be valid UB92 codes | 42 | Odd Number’s15-59 | 6050 | 4, 13, 14, 4, 11, 12, 13 Units of Service· Include all listed | 46 | Odd Number’s 97-141 | 60 | 8, 13, 14 Total Charges· Include all listed | 47 | Even Number’s 16-60 | 6050 | 97 Payor Classification· Include all listed· HCFA Payor ID number preferred | 50 | 156, 157, 158 | 30 | 5 Principal Diagnosis Code | 67 | 69 | 70 | 4 Other Diagnosis codes· Include all listed | 68-75 | 70-77 | 70 | 5-12 Admitting Diagnosis Code | 76 | 78 | 70 | 25 External cause of injury code (E-code)· Must contain data if possible | 77 | 79 | 70 | 26 Principal Procedure Code and Date | 80 | 80-81 | 70 | 13-14 Other Procedure Codes and Dates· Include all listed | 81 | 82-91 | 70 | 15-24 Attending Physician ID· State License Number | 82 | 92 | 80 | 5 Operating Physician Number· State License Number· Required if present | 83 | 93 | 80 | 6 Other Physician ID· State License Number· Required if present | 84 | 94 | 80 | 7-8 Patient Social Security Number | 60Only if insured | 161 | 22 | 5a Patient Race | none | 155 | 22 | 7a *Number of Claims | N/A | 95 | 6 *Record Type | N/A | all | 1 *Sequence Number | N/A | 21-70, 72, 80-81 | 2 a. Elements marked with an asterisk are required for submittals of the electronic 1450 only; they are included because they are essential to the 1450. b. The definitions of most data elements referred to in this rule can be found in the Louisiana UB-92 Users Manual referenced in §15109 of this rule. Hospitals using data sources other than uniform billing should evaluate their definitions for agreement with the definitions specified in this Guide and the Louisiana UB-92 Users Manual. The exceptions to referenced definitions are listed below. i. Patient’s Race—this alphanumeric one-character element contains race category information based on self-identification, which is to be obtained from the patient, a relative, or a friend. The hospital should not categorize the patient based on observation or personnel judgment. The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled. Code as follows: 1 = Native American or Alaskan Native: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. 2 = Asian or Pacific Islander: A person having origins in any of the peoples of the Far East, South East Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa. 3 = African American/Black: A person having origins in any of the black racial groups of Africa. 4 = Caucasian/White: A person having origins in any of the Caucasian peoples of Europe, North Africa, or the Middle East. 5 = Other: Any possible options not covered in the above categories. 6 = Unknown: A person who chooses not to answer the question. Blank Space: The hospital made no effort to obtain the information. ii. Patient Social Security Number—numeric, 10-character entry containing the Social Security Number of the patient receiving care. This field is to be right justified with zeroes to the left to complete the field. The format of SSN is 0123456789 without hyphens. If the patient is a newborn, use the mother’s SSN. If a patient does not have a social security number fill with zeroes. The field is edited for a valid entry. 2. Additional Data Elements Required if Available. These elements are required if the facility systematically collects the data in the ordinary course of operations as part of the facility’s standard operating procedures and that data is readily available for inclusion in the claim file. Date Element | Form Locator | 1300 Record Number | 1450 Date Element | Form Locator | 1300 Record Number | Record Type | Record Number Provider Name | 1 | (none) | 10 | 12 Provider Address· Must include zip code and city | 1 | (none) | 10 | 13-16 Marital Status | 16 | (none) | 20 | 9 Admission Hour | 18 | 10 | 20 | 18 Discharge Hour | 21 | 166 | 20 | 22 Provider Number | 51 | 62,144,149 | 30 | 24 Insured’s Name | 58 | (none) | 30 | 12-14 Patient’s Relationship to the Insured | 59 | 63, 145, 150 | 30 | 18 (Insured’s) Certificate/SSN/Health Insurance Claim/Identification Number | 60 | 64, 146, 151 | 30 | 7 Insured Group Name | 61 | (none) | 30 | 11 Insurance Group Number | 62 | 65, 147, 152 | 30 | 10 Treatment Authorization Code | 63 | (none) | 40 | 5-7 Employment Status Code | 64 | 66 | 30 | 19 Employer Name or EIN | 65 | 67 | 3121 | 94 Employer Location | 66 | 68(zip only) | 3121 | 10-135-8