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-C-2 - Maine Health Data Organization

Current through 2024-29, July 17, 2024
Outpatient Data Record Type 71 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/Segment ID/Code Value/Reference Designator
OP7101
Record Type
NA
NA
NA
OP7102
Sequence Number
NA
NA
NA
OP7103
Patient Control Number
3A
26
837/2300/CLM/01
OP7104
Principal Diagnosis
67
21A
837/2300/HI/ABK/01-2
OP7107
Reason for Visit Diagnosis - 1
70A
NA
837/2300/HI/APR/01-2
OP7108
Reason for Visit Diagnosis - 2
70B
NA
837/2300/HI/APR/02-2
OP7109
Reason for Visit Diagnosis - 3
70C
NA
837/2300/HI/APR/03-2
OP7110
Principal Procedure Code
74
NA
837/2300/HI/BBR/01-2
OP7111
Principal Procedure Date
74
NA
837/2300/HI/D8/01-4
Outpatient Data Record Type 72 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7201
Record Type
NA
NA
NA
OP7202
Sequence Number
NA
NA
NA
OP7203
Patient Control Number
3A
26
837/2300/CLM/01
OP7204
Other Procedure Code - 1
74A
NA
837/2300/HI/BBQ/01-2
OP7205
Other Procedure Date - 1
74A
NA
837/2300/HI/D8/01-4
OP7206
Other Procedure Code - 2
74B
NA
837/2300/HI/BBQ/02-2
OP7207
Other Procedure Date - 2
74B
NA
837/2300/HI/D8/02-4
OP7208
Other Procedure Code - 3
74C
NA
837/2300/HI/BBQ/03-2
OP7209
Other Procedure Date - 3
74C
NA
837/2300/HI/D8/03-4
OP7210
Other Procedure Code - 4
74D
NA
837/2300/HI/BBQ/04-2
OP7211
Other Procedure Date - 4
74D
NA
837/2300/HI/D8/04-4
OP7212
Other Procedure Code - 5
74E
NA
837/2300/HI/BBQ/05-2
OP7213
Other Procedure Date - 5
74E
NA
837/2300/HI/D8/05-4
OP7214
Other Procedure Code - 6
NA
NA
837/2300/HI/BBQ/06-2
OP7215
Other Procedure Date - 6
NA
NA
837/2300/HI/D8/06-4
OP7216
Other Procedure Code - 7
NA
NA
837/2300/HI/BBQ/07-2
OP7217
Other Procedure Date - 7
NA
NA
837/2300/HI/D8/07-4
OP7218
Other Procedure Code - 8
NA
NA
837/2300/HI/BBQ/08-2
OP7219
Other Procedure Date - 8
NA
NA
837/2300/HI/D8/08-4
Outpatient Data Record Type 73 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
OP7301
Record Type
NA
NA
NA
OP7302
Sequence Number
NA
NA
NA
OP7303
Patient Control Number
3A
26
837/2300/CLM/01
OP7304
External Cause of Injury - 1
72A
NA
837/2300/HI/ABN/01-2
OP7306
External Cause of Injury - 2
72B
NA
837/2300/HI/ABN/02-2
OP7308
External Cause of Injury - 3
72C
NA
837/2300/HI/ABN/03-2
OP7310
External Cause of Injury - 4
NA
NA
837/2300/HI/ABN/04-2
OP7312
External Cause of Injury - 5
NA
NA
837/2300/HI/ABN/05-2
OP7314
External Cause of Injury - 6
NA
NA
837/2300/HI/ABN/06-2
OP7316
External Cause of Injury - 7
NA
NA
837/2300/HI/ABN/07-2
OP7318
External Cause of Injury - 8
NA
NA
837/2300/HI/ABN/08-2
OP7320
External Cause of Injury - 9
NA
NA
837/2300/HI/ABN/09-2
OP7322
External Cause of Injury - 10
NA
NA
837/2300/HI/ABN/10-2
OP7324
External Cause of Injury - 11
NA
NA
837/2300/HI/ABN/11-2
OP7326
External Cause of Injury - 12
NA
NA
837/2300/HI/ABN/12-2
Outpatient Data Record Type 74 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/Segment ID/Code Value/Reference Designator
OP7401
Record Type
NA
NA
NA
OP7402
Sequence Number
NA
NA
NA
OP7403
Patient Control Number
3A
26
837/2300/CLM/01
OP7404
Other Diagnosis Code - 1
67A
21B
837I/2300/HI/ABF/01-2
837P/2300/HI/ABF/02-2
OP7406
Other Diagnosis Code - 2
67B
21C
837I/2300/HI/ABF/02-2
837P/2300/HI/ABF/03-2
OP7408
Other Diagnosis Code - 3
67C
21D
837I/2300/HI/ABF/03-2
837P/2300/HI/ABF/04-2
OP7410
Other Diagnosis Code - 4
67D
21E
837I/2300/HI/ABF/04-2
837P/2300/HI/ABF/05-2
OP7412
Other Diagnosis Code - 5
67E
21F
837I/2300/HI/ABF/05-2
837P/2300/HI/ABF/06-2
OP7414
Other Diagnosis Code - 6
67F
21G
837I/2300/HI/ABF/06-2
837P/2300/HI/ABF/07-2
OP7416
Other Diagnosis Code - 7
67G
21H
837I/2300/HI/ABF/07-2
837P/2300/HI/ABF/08-2
OP7418
Other Diagnosis Code - 8
67H
21I
837I/2300/HI/ABF/08-2
837P/2300/HI/ABF/09-2
OP7420
Other Diagnosis Code - 9
67I
21J
837I/2300/HI/ABF/09-2
837P/2300/HI/ABF/10-2
OP7422
Other Diagnosis Code - 10
67J
21K
837I/2300/HI/ABF/10-2
837P/2300/HI/ABF/11-2
OP7424
Other Diagnosis Code - 11
67K
21L
837I/2300/HI/ABF/11-2
837P/2300/HI/ABF/12-2
OP7426
Other Diagnosis Code - 12
67L
NA
837I/2300/HI/ABF/12-2
Outpatient Data Record Type 80 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/Segment ID/Code Value/Reference Designator
OP8001
Record Type
NA
NA
NA
OP8002
Sequence
NA
NA
NA
OP8003
Patient Control Number
3A
26
837/2300/CLM/01
OP8004
Attending Provider NPI
76
NA
837/2310A/NM1/71/1/XX/09
OP8005
Operating Physician NPI
77
NA
837/2310B/NM1/72/1/XX/09
OP8006
Attending Provider Last Name
76
NA
837/2310A/NM1/71/1/03
OP8007
Attending Provider First Name
76
NA
837/2310A/NM1/71/1/04
OP8008
Attending Provider Middle Initial
76
NA
837/2310A/NM1/71/1/05
OP8009
Operating Physician Last Name
77
NA
837/2310B/NM1/72/1/03
OP8010
Operating Physician First Name
77
NA
837/2310B/NM1/72/1/04
OP8011
Operating Physician Middle Initial
77
NA
837/2310B/NM1/72/1/05
OP8012
Billing Provider NPI
56
NA
837/2010AA/NM1/XX/09
OP9001
Record Type
NA
NA
NA
OP9003
Patient Control Number
3A
26
837/2300/CLM/01
OP9004
Total Ancillary Charges - Revenue Centers
NA
28
This is the total of the SV2 segments with the
							 exception of Revenue Code 0001
Outpatient Data Record Type 99 Mapping to National
				  Standards
Data Element #
Data Element Name
UB-04 Form Locator
CMS-1500
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
OP9901
Record Type
NA
NA
NA