Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 1010 - HEALTH CARE DATA COLLECTION AND SUBMISSION CODE › Appendix C - Ambulatory Surgical Data Elements

Current through Register Vol. 48, No. 28, July 12, 2024
Data elements affected by implementation of ICD-10 coding
				scheme October 1, 2013 (or as stipulated by CMMS) are noted when necessary and
				appropriate.
Detail Data
1. Facility identifier (Federal tax identification
				number/Department assigned/NPI)
2. Surgical site identifier (Department
				assigned)
3. Patient account number
4. Patient zip code and Plus 4
5. Patient birth date (MMDDCCYY)
6. Patient sex
7. Date (MMDDYY) and time (HH) of visit
8. Time (HH) of discharge
9. Type of admission/visit
10. Source of admission/visit
11. Patient discharge status
12. Type of bill
13. Total patient charges and components of those
				charges (revenue codes, HCPCS codes with modifiers, date of service, units of
				service and charges)
14. Primary payer ID and health plan name
15. Secondary and tertiary payer ID and health plan
				name (required when present)
16. 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 revised CMMS acceptance of ICD-10
				codes)
17. 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); only the values of the CPT coding scheme will be
				accepted as procedure codes for outpatient data submissions
18. Attending clinician ID number/NPI
19. Operating clinician ID number/NPI
20. Other clinician ID number/NPI (up to 2 required
				when present)
21. Patient race (according to OMB
				guidelines)
22. Patient ethnicity (according to OMB
				guidelines)
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. Patient county code (5 digits: state and county
				codes for Illinois and border state residents (FIPS code))
25. Patient reason for visit (diagnosis codes up to
				three required when present)
26. Accident state abbreviation (required when
				present)
27. Condition employment related (required when
				present)
28. Accident employment related occurrence code and
				date of accident (required when present)
29. Crime victim occurrence code and date of crime
				(required when present)
30. Page number and total number of pages of this
				claim
31. Insurance group number (up to three required
				when present)
32. 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)
33. Statement covers period (from and through
				[discharge date] dates)
34. Patient name (first, middle, last,
				suffix)
35. Patient address (PO Box or street address,
				apartment number, city and state)
36. Unique patient identifier based on the last four
				digits of patient Social Security number
37. Primary insured's unique identifier
				(beneficiary/policy #)
38. Any element or service adopted for use by 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.