Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part V - Preventive Health Services › Subpart 53 - State Center for Health Statistics › Chapter 151 - State Health Care Data Clearinghouse › Section V-15127 - Guide-Record Formats

Current through Register Vol. 50, No. 6, June 20, 2024
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 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
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
78
FL19
12.
Source of Admission
X(1)
L
79
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
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
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
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