Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 241 - UNIFORM REPORTING SYSTEM FOR HOSPITAL INPATIENT DATA SETS AND HOSPITAL OUTPATIENT DATA SETS › Appendix 590-241-B-2 - Maine Health Data Organization

Current through 2024-29, July 17, 2024
Inpatient Data Record Type 71 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7101
Record Type
NA
NA
IP7102
Sequence Number
NA
NA
IP7103
Patient Control Number
3A
837/2300/CLM/01
IP7104
Principal Diagnosis
67
837/2300/HI/ABK/01-2
IP7105
Present On Admission Indicator
67 (pos 8)
837/2300/HI/01-9
IP7106
Admitting Diagnosis
69
837/2300/HI/ABJ/01-2
IP7110
Principal Procedure Code
74
837/2300/HI/BBR/01-2
IP7111
Principal Procedure Date
74
837/2300/HI/D8/01-4
Inpatient Data Record Type 72 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04
Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7201
Record Type
NA
NA
IP7202
Sequence Number
NA
NA
IP7203
Patient Control Number
3A
837/2300/CLM/01
IP7204
Other Procedure Code - 1
74A
837/2300/HI/BBQ/01-2
IP7205
Other Procedure Date - 1
74A
837/2300/HI/D8/01-4
IP7206
Other Procedure Code - 2
74B
837/2300/HI/BBQ/02-2
IP7207
Other Procedure Date - 2
74B
837/2300/HI/D8/02-4
IP7208
Other Procedure Code - 3
74C
837/2300/HI/BBQ/03-2
IP7209
Other Procedure Date - 3
74C
837/2300/HI/D8/03-4
IP7210
Other Procedure Code - 4
74D
837/2300/HI/BBQ/04-2
IP7211
Other Procedure Date - 4
74D
837/2300/HI/D8/04-4
IP7212
Other Procedure Code - 5
74E
837/2300/HI/BBQ/05-2
IP7213
Other Procedure Date - 5
74E
837/2300/HI/D8/05-4
IP7214
Other Procedure Code - 6
NA
837/2300/HI/BBQ/06-2
IP7215
Other Procedure Date - 6
NA
837/2300/HI/D8/06-4
IP7216
Other Procedure Code - 7
NA
837/2300/HI/BBQ/07-2
IP7217
Other Procedure Date - 7
NA
837/2300/HI/D8/07-4
IP7218
Other Procedure Code - 8
NA
837/2300/HI/BBQ/08-2
IP7219
Other Procedure Date - 8
NA
837/2300/HI/D8/08-4
Inpatient Data Record Type 73 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04
Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7301
Record Type
NA
NA
IP7302
Sequence Number
NA
NA
IP7303
Patient Control Number
3A
837/2300/CLM/01
IP7304
External Cause of Injury Code - 1
72A
837/2300/HI/ABN/01-2
IP7305
Present On Admission Indicator - 1
72A (pos 8)
837/2300/HI/01-9
IP7306
External Cause of Injury Code - 2
72B
837/2300/HI/ABN/02-2
IP7307
Present On Admission Indicator - 2
72B (pos 8)
837/2300/HI/02-9
IP7308
External Cause of Injury Code - 3
72C
837/2300/HI/ABN/03-2
IP7309
Present On Admission Indicator - 3
72C (pos 8)
837/2300/HI/03-9
IP7310
External Cause of Injury Code - 4
NA
837/2300/HI/ABN/04-2
IP7311
Present On Admission Indicator - 4
NA
837/2300/HI/04-9
IP7312
External Cause of Injury Code - 5
NA
837/2300/HI/ABN/05-2
IP7313
Present On Admission Indicator - 5
NA
837/2300/HI/05-9
IP7314
External Cause of Injury Code - 6
NA
837/2300/HI/ABN/06-2
IP7315
Present On Admission Indicator - 6
NA
837/2300/HI/06-9
IP7316
External Cause of Injury Code - 7
NA
837/2300/HI/ABN/07-2
IP7317
Present On Admission Indicator - 7
NA
837/2300/HI/07-9
IP7318
External Cause of Injury Code - 8
NA
837/2300/HI/ABN/08-2
IP7319
Present On Admission Indicator - 8
NA
837/2300/HI/08-9
IP7320
External Cause of Injury Code - 9
NA
837/2300/HI/ABN/09-2
IP7321
Present On Admission Indicator - 9
NA
837/2300/HI/09-9
IP7322
External Cause of Injury Code - 10
NA
837/2300/HI/ABN/10-2
IP7323
Present On Admission Indicator - 10
NA
837/2300/HI/10-9
IP7324
External Cause of Injury Code - 11
NA
837/2300/HI/ABN/11-2
IP7325
Present On Admission Indicator - 11
NA
837/2300/HI/11-9
IP7326
External Cause of Injury Code - 12
NA
837/2300/HI/ABN/12-2
IP7327
Present On Admission Indicator - 12
NA
837/2300/HI/12-9
Inpatient Data Record Type 74 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04
Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP7401
Record Type
NA
NA
IP7402
Sequence Number
NA
NA
IP7403
Patient Control Number
3A
837/2300/CLM/01
IP7404
Other Diagnosis Code - 1
67A
837/2300/HI/ABF/01-2
IP7405
Present On Admission Indicator - 1
67A (pos 8)
837/2300/HI/01-9
IP7406
Other Diagnosis Code - 2
67B
837/2300/HI/ABF/02-2
IP7407
Present On Admission Indicator - 2
67B (pos 8)
837/2300/HI/02-9
IP7408
Other Diagnosis Code - 3
67C
837/2300/HI/ABF/03-2
IP7409
Present On Admission Indicator - 3
67C (pos 8)
837/2300/HI/03-9
IP7410
Other Diagnosis Code - 4
67D
837/2300/HI/ABF/04-2
IP7411
Present On Admission Indicator - 4
67D (pos 8)
837/2300/HI/04-9
IP7412
Other Diagnosis Code - 5
67E
837/2300/HI/ABF/05-2
IP7413
Present On Admission Indicator - 5
67E (pos 8)
837/2300/HI/05-9
IP7414
Other Diagnosis Code - 6
67F
837/2300/HI/ABF/06-2
IP7415
Present On Admission Indicator - 6
67F (pos 8)
837/2300/HI/06-9
IP7416
Other Diagnosis Code - 7
67G
837/2300/HI/ABF/07-2
IP7417
Present On Admission Indicator - 7
67G (pos 8)
837/2300/HI/07-9
IP7418
Other Diagnosis Code - 8
67H
837/2300/HI/ABF/08-2
IP7419
Present On Admission Indicator - 8
67H (pos 8)
837/2300/HI/08-9
IP7420
Other Diagnosis Code - 9
67I
837/2300/HI/ABF/09-2
IP7421
Present On Admission Indicator - 9
67I (pos 8)
837/2300/HI/09-9
IP7422
Other Diagnosis Code - 10
67J
837/2300/HI/ABF/10-2
IP7423
Present On Admission Indicator - 10
67J (pos 8)
837/2300/HI/10-9
IP7424
Other Diagnosis Code - 11
67K
837/2300/HI/ABF/11-2
IP7425
Present On Admission Indicator - 11
67K (pos 8)
837/2300/HI/11-9
IP7426
Other Diagnosis Code - 12
67L
837/2300/HI/ABF/12-2
IP7427
Present On Admission Indicator - 12
67L (pos 8)
837/2300/HI/12-9
Inpatient Data Record Type 80 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP8001
Record Type
NA
NA
IP8002
Sequence
NA
NA
IP8003
Patient Control Number
3A
837/2300/CLM/01
IP8004
Attending Provider NPI
76
837/2310A/NM1/71/1/XX/09
IP8005
Operating Physician NPI
77
837/2310B/NM1/72/1/XX/09
IP8006
Attending Provider Last Name
76
837/2310A/NM1/71/1/03
IP8007
Attending Provider First Name
76
837/2310A/NM1/71/1/04
IP8008
Attending Provider Middle Initial
76
837/2310A/NM1/71/1/05
IP8009
Operating Physician Last Name
77
837/2310B/NM1/72/1/03
IP8010
Operating Physician First Name
77
837/2310B/NM1/72/1/04
IP8011
Operating Physician Middle Initial
77
837/2310B/NM1/72/1/05
IP8012
Billing Provider NPI
56
837/2010AA/NM1/XX/09
IP9001
Record Type
NA
NA
IP9003
Patient Control Number
3A
837/2300/CLM/01
IP9004
Total Accommodation Charges - Revenue Centers
NA
This is the total of the SV2 segments except for
							 Revenue Code 0001
IP9005
Total Ancillary Charges - Revenue Centers
NA
This is the total of the SV2 segments except for
							 Revenue Code 0001
IP9901
Record Type
NA
NA
The record types in the file must be in the following
							 order:
Record Type 01 - Processor Data
Record Type 20 Sequence 01 - Patient Data
Record Type 30 Sequence 01 - Third Party Payer Data
							 Primary Payer
Record Type 30 Sequence 02-99 - Third Party Payer
							 Additional Payer(s) Required for payer(s) other than primary.
Record Type 40 - Claim Data
Record Type 61 - Services
Record Type 71 - ICD-10 CM Principal and Reason for
							 Visit Diagnosis Codes, ICD-10 PCS Principal Procedure Code
Record Type 72 - ICD-10 PCS Other Procedure
							 Codes
Record Type 73 - ICD-10 CM External Cause of Injury
							 Diagnosis Codes
Record Type 74 - ICD-10 CM Other Diagnosis
							 Information
Record Type 80 - Provider Data
Record Type 90 - Claim Control Screen
Record Type 99 - File Control
The individual claim begins with Record Type 20 and
							 ends with Record Type 90.
The patient control number must be the same on each
							 record type generated for a single patient record.
The medical record number should not be substituted
							 for the patient control number.
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP0101
Record Type
T
2
01
OP0102
MHDO-Assigned Hospital ID
T
6
Must be the MHDO-assigned, 6-digit hospital code,
							 left justified
OP0198
Filler
T
38
OP0103
Hospital Name
T
21
OP0104
Address
T
18
OP0105
City
T
15
OP0106
State
T
2
OP0107
Zip Code
T
9
OP0199
Filler
T
78
OP0108
Version
T
3
Leave blank