LAC 48:V.15127. Guide—Record Formats

A. The accepted data record formats are the UB-92 1450 version 4.1 format and the UB-92 1300 flat file format. The definition specified for each data element is in general agreement with the definition in the UB-92 Users Manual. Hospitals using data sources other than uniform billing should evaluate definitions for agreement with the definitions specified in this Guide and the UB-92 Users Manual. See §§15125 and 15127.B.3 to identify possible differences between standard referenced formats and requirements under this rule. 1. UB-92 1450 Version 4.1 Record Specification. The UB-92 1450 claim record is made up of a series of 192-character physical records, as listed in the Louisiana UB-92 Training Manual. Record Types not specified in the required data elements list are requested but are not required for submittal. 2. UB-92 1300 Record Specification. The UB-92 1300 flat file contains one record per discharge, except in the case of multi-page claims. However, the standard 1300 format does not contain some fields that are found on the 1450 format. The 1300 record format is included in §15127.A.2.c below. a. Use of Multi-Page Claims. All data except revenue code and charge fields should be duplicated on successive records. All available revenue and charge fields should be completely filled before using additional records. The last entry must be the Total Charge (001) Revenue Code and the Charge Amount must be the total of all previous entries. Any remaining revenue and charge fields must be blank or zero filled. No zero or space filled fields should precede the 001 entry. b. Exceptions to 1300 Format. Inclusion of the 1300 format as an accepted data format required the addition of data elements not found in the version currently used in Louisiana. The following fields indicate the locations for the additional data elements. Number | Field Name | Form Locator 10 | Admission Hour | FL18 14 | Medical Record Number | FL23 78 | Admitting Diagnosis | FL76 93 | Operating Physician Number | FL83 153 | Infant Birth Weight | (none) 154 | Infant APGAR Score | (none) 155 | Patient Race | (none) c. 1300 Discharge Record. The record layouts that follow will provide the following information. i. Record Number―Sequentially assigned record number (This is not the Form Locator). ii. Field Name—the name of the data element (field). iii. Picture—this is the COBOL picture. Pic X is initialized to blanks and Pic 9 is initialized to zeroes. All money and date fields are Pic 9. iv. Justification—indicates how the data field is justified (left or right). v. Start Position—leftmost position in the record. vi. End Position—rightmost position in the record. vii. Form Locator—this is the number found on the UB-92 paper form associated with the given field. Record Number | Field Name | Picture | Justif-ication | Start | End | Form Locator 1. | Patient Control Number | X(20) | L | 1 | 20 | FL03 2. | Type of Bill | 9(3) | R | 21 | 23 | FL04 3. | Federal Tax Number (EIN) | X(10) | L | 24 | 33 | FL05 4. | Statement Covers Period: FROM MMDDYYYY | 9(8) | R | 34 | 41 | FL06 5. | Statement Covers Period: TO MMDDYYYY | 9(8) | R | 42 | 49 | FL06 6. | Patient Address Zip Code | X(9) | L | 50 | 58 | FL13 7. | Patient Date of Birth MMDDYYYY | 9(8) | R | 59 | 66 | FL14 8. | Patient Sex | X(1) | L | 67 | FL15 9. | Admission Date | 9(8) | R | 68 | 75 | FL17 10. | Admission Hour | 9(2) | R | 76 | 77 | FL18 11. | Type of Admission | X(1) | L | 78 | FL19 12. | Source of Admission | X(1) | L | 79 | FL20 13. | Patient Status | 9(2) | R | 80 | 81 | FL22 14. | Medical Record Number | X(17) | L | 82 | 98 | FL23 15. | Revenue Code Line 1 | 9(4) | R | 99 | 102 | FL42 16. | Total Charges by Revenue 1 | S9(8)V99 | R | 103 | 112 | FL47 17. | Revenue Code Line 2 | 9(4) | R | 113 | 116 | FL42 18. | Total Charges by Revenue 2 | S9(8)V99 | R | 117 | 126 | FL47 19. | Revenue Code Line 3 | 9(4) | R | 127 | 130 | FL42 20. | Total Charges by Revenue 3 | S9(8)V99 | R | 131 | 140 | FL47 21. | Revenue Code Line 4 | 9(4) | R | 141 | 144 | FL42 22. | Total Charges by Revenue 4 | S9(8)V99 | R | 145 | 154 | FL47 23. | Revenue Code Line 5 | 9(4) | R | 155 | 158 | FL42 24. | Total Charges by Revenue 5 | S9(8)V99 | R | 159 | 168 | FL47 25. | Revenue Code Line 6 | 9(4) | R | 169 | 172 | FL42 26. | Total Charges by Revenue 6 | S9(8)V99 | R | 173 | 182 | FL47 27. | Revenue Code Line 7 | 9(4) | R | 183 | 186 | FL42 28. | Total Charges by Revenue 7 | S9(8)V99 | R | 187 | 196 | FL47 29. | Revenue Code Line 8 | 9(4) | R | 197 | 200 | FL42 30. | Total Charges by Revenue 8 | S9(8)V99 | R | 201 | 210 | FL47 31. | Revenue Code Line 9 | 9(4) | R | 211 | 214 | FL42 32. | Total Charges by Revenue 9 | S9(8)V99 | R | 215 | 224 | FL47 33. | Revenue Code Line 10 | 9(4) | R | 225 | 228 | FL42 34. | Total Charges by Revenue 10 | S9(8)V99 | R | 229 | 238 | FL47 35. | Revenue Code Line 11 | 9(4) | R | 239 | 242 | FL42 36. | Total Charges by Revenue 11 | S9(8)V99 | R | 243 | 252 | FL47 37. | Revenue Code Line 12 | 9(4) | R | 253 | 256 | FL42 38. | Total Charges by Revenue 12 | S9(8)V99 | R | 257 | 266 | FL47 39. | Revenue Code Line 13 | 9(4) | R | 267 | 270 | FL42 40. | Total Charges by Revenue 13 | S9(8)V99 | R | 271 | 280 | FL47 41. | Revenue Code Line 14 | 9(4) | R | 281 | 284 | FL42 42. | Total Charges by Revenue 14 | S9(8)V99 | R | 285 | 294 | FL47 43. | Revenue Code Line 15 | 9(4) | R | 295 | 298 | FL42 44. | Total Charges by Revenue 15 | S9(8)V99 | R | 299 | 308 | FL47 45. | 45 Revenue Code Line 16 | 9(4) | R | 309 | 312 | FL42 46. | Total Charges by Revenue 16 | S9(8)V99 | R | 313 | 322 | FL47 47. | Revenue Code Line 17 | 9(4) | R | 323 | 326 | FL42 48. | Total Charges by Revenue 17 | S9(8)V99 | R | 327 | 336 | FL47 49. | Revenue Code Line 18 | 9(4) | R | 337 | 340 | FL42 50. | Total Charges by Revenue 18 | S9(8)V99 | R | 341 | 350 | FL47 51. | Revenue Code Line 19 | 9(4) | R | 351 | 354 | FL42 52. | Total Charges by Revenue 19 | S9(8)V99 | R | 355 | 364 | FL47 53. | Revenue Code Line 20 | 9(4) | R | 365 | 368 | FL42 54. | Total Charges by Revenue 20 | S9(8)V99 | R | 369 | 378 | FL47 55. | Revenue Code Line 21 | 9(4) | R | 379 | 382 | FL42 56. | Total Charges by Revenue 21 | S9(8)V99 | R | 383 | 392 | FL47 57. | Revenue Code Line 22 | 9(4) | R | 393 | 396 | FL42 58. | Total Charges by Revenue 22 | S9(8)V99 | R | 397 | 406 | FL47 59. | Revenue Code Line 23 | 9(4) | R | 407 | 410 | FL42 60. | Total Charges by Revenue 23 | S9(8)V99 | R | 411 | 420 | FL47 61. | Filler | X(25) | 421 | 445 62. | First Provider Number (Payor) | X(13) | L | 446 | 458 | FL51A 63. | Patient's Relationship to Insured | X(2) | L | 459 | 460 | FL59A 64. | Certificate/SocSecNumber/Health Insurance Claim/ Identification Number | X(19) | L | 461 | 479 | FL60A 65. | Insurance Group Number | X(20) | L | 480 | 499 | FL62A 66. | Employment Status Code | X(1) | L | 500 | FL64 67. | Employer Name | X(24) | L | 501 | 524 | FL65 68. | Employer Zip Code | X(9) | L | 525 | 533 | FL66 (For Diagnosis and Procedure Codes (69-90)-omit decimal) 69. | Principal Diagnosis Code | X(6) | L | 534 | 539 | FL67 70. | Other Diagnosis Code 1 | X(6) | L | 540 | 545 | FL68 71. | Other Diagnosis Code 2 | X(6) | L | 546 | 551 | FL69 72. | Other Diagnosis Code 3 | X(6) | L | 552 | 557 | FL70 73. | Other Diagnosis Code 4 | X(6) | L | 558 | 563 | FL71 74. | Other Diagnosis Code 5 | X(6) | L | 564 | 569 | FL72 75. | Other Diagnosis Code 6 | X(6) | L | 570 | 575 | FL73 76. | Other Diagnosis Code 7 | X(6) | L | 576 | 581 | FL74 77. | Other Diagnosis Code 8 | X(6) | L | 582 | 587 | FL75 78. | Admitting Diagnosis | X(6) | L | 588 | 593 | FL76 79. | External Cause of Injury (E-Code) | X(6) | L | 594 | 599 | FL77 80. | Principal Procedure Code | X(7) | L | 600 | 606 | FL80 81. | Principal Procedure Date MMDDYY | 9(6) | R | 607 | 612 | FL80 82. | Other Procedure 1: Code | X(7) | L | 613 | 619 | FL81 83. | Other Procedure 1 : Date MMDDYY | 9(6) | R | 620 | 625 | FL81 84. | Other Procedure 2 : Code | X(7) | L | 626 | 632 | FL81 85. | Other Procedure 2 : Date MMDDYYYY | 9(6) | R | 633 | 638 | FL81 86. | Other Procedure 3 : Code | X(7) | L | 639 | 645 | FL81 87. | Other Procedure 3 : Date MMDDYY | 9(6) | R | 646 | 651 | FL81 88. | Other Procedure 4 : Code | X(7) | L | 652 | 658 | FL81 89. | Other Procedure 4 : DateMMDDYY | 9(6) | R | 659 | 664 | FL81 90. | Other Procedure 5 : Code | X(7) | L | 665 | 671 | FL81 91. | Other Procedure 5 : Date MMDDYY | 9(6) | R | 672 | 677 | FL81 92. | Attending Physician Number | X(22) | L | 678 | 699 | FL82 93. | Other Physician Number | X(22) | L | 700 | 721 | FL83 94. | Other Physician Number | X(22) | L | 722 | 743 | FL84 95. | Filler | X(2) | L | 744 | 745 96. | Century Flag Patient's DOB0=Birth Year 19001=Birth Year<1900 | 9(1) | R | 746 (Dates of Service-even numbers from 97-142; MMDDYY) 97. | Units of Service Line 1 | 9(7) | R | 747 | 753 | FL46 98. | Date of Service Line 1 | 9(6) | R | 754 | 759 | FL45 99. | Units of Service Line 2 | 9(7) | R | 760 | 766 | FL46 100. | Date of Service Line 2 | 9(6) | R | 767 | 772 | FL45 101. | Units of Service Line 3 | 9(7) | R | 773 | 779 | FL46 102. | Date of Service Line 3 | 9(6) | R | 780 | 785 | FL45 103. | Units of Service Line 4 | 9(7) | R | 786 | 792 | FL46 104. | Date of Service Line 4 | 9(6) | R | 793 | 798 | FL45 105. | Units of Service Line 5 | 9(7) | R | 799 | 805 | FL46 106. | Date of Service Line 5 | 9(6) | R | 806 | 811 | FL45 107. | Units of Service Line 6 | 9(7) | R | 812 | 818 | FL46 108. | Date of Service Line 6 | 9(6) | R | 819 | 824 | FL45 109. | Units of Service Line 7 | 9(7) | R | 825 | 831 | FL46 110. | Date of Service Line 7 | 9(6) | R | 832 | 837 | FL45 111. | Units of Service Line 8 | 9(7) | R | 838 | 844 | FL46 112. | Date of Service Line 8 | 9(6) | R | 845 | 850 | FL45 113. | Units of Service Line 9 | 9(7) | R | 851 | 857 | FL46 114. | Date of Service Line 9 | 9(6) | R | 858 | 863 | FL45 115. | Units of Service Line 10 | 9(7) | R | 864 | 870 | FL46 116. | Date of Service Line 10 | 9(6) | R | 871 | 876 | FL45 117. | Units of Service Line 11 | 9(7) | R | 877 | 883 | FL46 118. | Date of Service Line 11 | 9(6) | R | 884 | 889 | FL45 119. | Units of Service Line 12 | 9(7) | R | 890 | 896 | FL46 120. | Date of Service Line 12 | 9(6) | R | 897 | 902 | FL45 121. | Units of Service Line 13 | 9(7) | R | 903 | 909 | FL46 122. | Date of Service Line 13 | 9(6) | R | 910 | 915 | FL45 123. | Units of Service Line 14 | 9(7) | R | 916 | 922 | FL46 124. | Date of Service Line 14 | 9(6) | R | 923 | 928 | FL45 125. | Units of Service Line 15 | 9(7) | R | 929 | 935 | FL46 126. | Date of Service Line 15 | 9(6) | R | 936 | 941 | FL45 127. | Units of Service Line 16 | 9(7) | R | 942 | 948 | FL46 128. | Date of Service Line 16 | 9(6) | R | 949 | 954 | FL45 129. | Units of Service Line 17 | 9(7) | R | 955 | 961 | FL46 130. | Date of Service Line 17 | 9(6) | R | 962 | 967 | FL45 131. | Units of Service Line 18 | 9(7) | R | 968 | 974 | FL46 132. | Date of Service Line 18 | 9(6) | R | 975 | 980 | FL45 133. | Units of Service Line 19 | 9(7) | R | 981 | 987 | FL46 134. | Date of Service Line 19 | 9(6) | R | 988 | 993 | FL45 135. | Units of Service Line 20 | 9(7) | R | 994 | 1000 | FL46 136. | Date of Service Line 20 | 9(6) | R | 1001 | 1006 | FL45 137. | Units of Service Line 21 | 9(7) | R | 1007 | 1013 | FL46 138. | Date of Service Line 21 | 9(6) | R | 1014 | 1019 | FL45 139. | Units of Service Line 22 | 9(7) | R | 1020 | 1026 | FL46 140. | Date of Service Line 22 | 9(6) | R | 1027 | 1032 | FL45 141. | Units of Service Line 23 | 9(7) | R | 1033 | 1039 | FL46 142. | Date of Service Line 23 | 9(6) | R | 1040 | 1045 | FL45 143. | Filler | X(25) | L | 1046 | 1070 144. | Second Provider umber (Payor) | X(13) | L | 1071 | 1083 | FL51B 145. | Patient's Relationship to Insured | X(2) | L | 1084 | 1085 | FL59B 146. | Certificate/SocSecNumber/ Health Insurance Claim/ Identification Number | X(19) | L | 1086 | 1104 | FL60B 147. | Insurance Group Number | X(20) | L | 1105 | 1124 | FL62B 148. | Filler | X(25) | L | 1125 | 1149 149. | Third Provider Number (Payor) | X(13) | L | 1150 | 1162 | FL51C 150. | Patient's Relationship to Insured | X(2) | L | 1163 | 1164 | FL59C 151. | Certificate/SocSecNumber/ Health Insurance Claim/ Identification | X(19) | L | 1165 | 1183 | FL60C 152. | Insurance Group Number | X(20) | L | 1184 | 1203 | FL62C 153. | Infant Birth Weight (in grams) | 9(4) | R | 1204 | 1207 154. | Infant APGAR Score | 9(4) | R | 1208 | 1211 155. | Patient Race | 9(1) | R | 1212 156. | Primary Payor Code | X(2) | L | 1213 | 1214 | FL50A 157. | Second Payor Code | X(2) | L | 1215 | 1216 | FL50B 158. | Third Payor Code | X(2) | L | 1217 | 1218 | FL50C 159. | Medicaid Provider Number | X(12) | L | 1219 | 1230 | FL51 160. | Medicare Provider Number | X(12) | L | 1231 | 1242 | FL51 161. | Patient Social Security Number | X(9) | L | 1243 | 1251 | FL60 162. | Primary Payor Carrier ID Code | X(4) | L | 1252 | 1255 163. | Second Payor Carrier ID Code | X(4) | L | 1256 | 1259 164. | Third Payor Carrier ID Code | X(4) | L | 1260 | 1263 165. | Federal Tax Sub ID. | X(4) | L | 1264 | 1267 166. | Filler | X(2) | L | 1268 | 1269 167. | Filler | X(31) | L | 1270 | 1300