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-1 - Maine Health Data Organization

Current through 2024-29, July 17, 2024
Outpatient Data Submission Specifications Record Type
				  30 - Payer
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP2001
Record Type
T
2
20
OP2002
Filler (National Use)
T
2
OP2003
Patient Control Number
T
20
Assigned by the facility
OP2094
Filler
T
30
OP2004
Patient Sex
T
1
M = Male
F = Female
U = Unknown
OP2005
Patient Birth Date
T
8
CCYYMMDD
OP2095
Filler
T
2
OP2007
Point of Origin for Admission or
							 Visit
T
1
OP2096
Filler
T
30
OP2008
Patient City
T
15
OP2009
Patient State
T
2
OP2010
Patient Zip Code
T
9
As defined by US Postal Service Do not include
							 dashes
OP2011
Admission/Start of Care Date
T
8
CCYYMMDD
OP2097
Filler
T
2
OP2012
Statement Covers Period - From
T
8
The beginning service date for the period covered on
							 the record CCYYMMDD
OP2013
Statement Covers Period - Thru
T
8
The ending service date for the period covered on the
							 record CCYYMMDD
OP2014
Patient Discharge Status
T
2
OP2098
Filler
T
22
OP2015
Medical/Health Record Number
T
17
Assigned by the facility
OP2016
Race
March 1, 2007
T
1
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = Native Hawaiian or Other Pacific Islander
5 = White
6 = Other Race
7 = Patient Elected Not to Answer
8 = Unknown The code value "8" (Unknown), should be
							 used ONLY when patient answers unknown. Report only collected data. If not
							 available, leave blank.
OP2017
Ethnicity
March 1, 2007
T
1
1 = Hispanic or Latino
2 = Non-Hispanic or Non-Latino
7 = Patient Elected Not to Answer
8 = Unknown The code value "8" (Unknown), should be
							 used ONLY when patient answers unknown. Report only collected data. If not
							 available, leave blank.
OP2099
Filler
T
1
OP2018
Patient Country Code
January 1, 2018
T
2
Use ISO 3166-1 alpha-2 country codes. Refer to
							 Appendix A.
OP2019
Patient Last Name
January 1, 2018
T
60
OP2020
Patient First Name
January 1, 2018
T
35
OP2021
Patient Middle Name or Initial
January 1, 2018
T
25
OP2022
Patient Name Suffix
January 1, 2018
T
10
OP2023
Patient Address Line 1
January 1, 2018
T
55
OP2024
Patient Address Line 2
January 1, 2018
T
55
OP3001
Record Type
T
2
30
OP3002
Sequence Number
T
2
01 Primary Payer
02 - 99 Secondary Payer
OP3003
Patient Control Number
T
20
Assigned by the facility
OP3095
Filler
January 1, 2018
T
10
OP3005
Social Security Number
April 1, 2006
T
19
Do not include dashes For internal use only -
							 Required if collected
OP3097
Filler
January 1, 2018
T
26
OP3007
Insured's Group Number
April 1, 2006
T
17
For internal use only - Required if collected
OP3008
Insured's Unique Identifier
T
20
For internal use only - Required if collected
OP3099
Filler
T
1
OP3009
Payer Name
January 1, 2018
T
100
Full or unabbreviated payer name, not plan
							 name
OP4001
Record Type
T
2
40
OP4002
Sequence Number
T
2
01
OP4003
Patient Control Number
T
20
Assigned by the facility
OP4004
Type of Bill
T
3
Code indicating the specific type of institutional
							 bill.
OP4005
Location of Service
T
10
When Place of Service field OP4006 contains the
							 values 11, 17, 20, 22, 49, 50, 71, or 72 an encounter shall contain a Location
							 of Service code. The Location of Service code is internally created by the
							 Hospital and primarily for physician practices (primary care, specialty care
							 and clinics). Refer to section 2(A)(3).
OP4099
Filler
T
155
OP4006
Place of Service
January 1, 2018
T
2
CMS code identifying the entity/location where
							 professional service(s) were rendered.
Outpatient Data Submission Specifications Record Type
				  61 - Services
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP6101
Record Type
T
2
61
OP6102
Sequence Number
T
3
001 to 999
OP6103
Patient Control Number
T
20
Assigned by the facility
OP6190
Filler
T
2
OP6104
Revenue Center Code - 1
T
4
Code which identifies a specific ancillary service,
							 supplies, professional fees on billing calculation. Include leading
							 zeros.
OP6105
HCPCS Procedure Code - 1
T
5
Health Care Common Procedural Coding System (HCPCS)
							 This includes the CPT code of the American Medical Association
OP6106
Modifier - 1 (HCPCS & CPT-4) -
							 1
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6107
Modifier - 2 (HCPCS & CPT-4) -
							 1
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6108
Service Units - 1
N
7
A quantitative measure of services rendered by the
							 Revenue Center
OP6191
Filler
T
6
OP6109
Outpatient Total Charges - 1
N
10
Negative charges not accepted Two decimal places
							 implied
OP6192
Filler
T
10
OP6110
Service Date - 1
T
8
The date that the indicated outpatient service,
							 supplies, etc. were provided. Must be equal to or greater than statement covers
							 date "from" and less than or equal to statement covers date "thru".
							 CCYYMMDD
OP6193
Filler
T
1
OP6111
Revenue Center Code - 2
T
4
Code which identifies a specific ancillary service,
							 supplies, professional fees on billing calculation. Include leading
							 zeros.
OP6112
HCPCS Procedure Code - 2
T
5
Health Care Common Procedural Coding System (HCPCS)
							 This includes the CPT code of the American Medical Association
OP6113
Modifier - 1 (HCPCS & CPT-4) -
							 2
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6114
Modifier - 2 (HCPCS & CPT-4) -
							 2
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6115
Service Units - 2
N
7
A quantitative measure of services rendered by the
							 Revenue Center
OP6194
Filler
T
6
OP6116
Outpatient Total Charges - 2
N
10
Negative charges not accepted Two decimal places
							 implied
OP6195
Filler
T
10
OP6117
Service Date - 2
T
8
The date that the indicated outpatient service,
							 supplies, etc. were provided. Must be equal to or greater than statement covers
							 date "from" and less than or equal to statement covers date "thru"
							 CCYYMMDD
OP6196
Filler
T
1
OP6118
Revenue Center Code - 3
T
4
Code which identifies a specific ancillary service,
							 supplies, professional fees on billing calculation. Include leading
							 zeros.
OP6119
HCPCS Procedure Code - 3
T
5
Health Care Common Procedural Coding System (HCPCS)
							 This includes the CPT code of the American Medical Association
OP6120
Modifier - 1 (HCPCS & CPT-4) -
							 3
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6121
Modifier - 2 (HCPCS & CPT-4) -
							 3
T
2
Procedure modifier required when a modifier
							 clarifies/improves the reporting accuracy of the associated procedure
							 code
OP6122
Service Units - 3
N
7
A quantitative measure of services rendered by the
							 Revenue Center
OP6197
Filler
T
6
OP6123
Outpatient Total Charges - 3
N
10
Negative charges not accepted Two decimal places
							 implied
OP6198
Filler
T
10
OP6124
Service Date - 3
T
8
The date that the indicated outpatient service,
							 supplies, etc. were provided. Must be equal to or greater than statement covers
							 date "from" and less than or equal to statement covers date "thru"
							 CCYYMMDD
OP6199
Filler
T
1
OP6125
Place of Service - 1
January 1, 2020
T
2
CMS code identifying the entity/location where
							 professional service(s) were rendered, if different from POS code indicated in
							 OP4006
OP6126
Rendering Provider NPI - 1
January 1, 2020
T
16
National Provider Identifier for Rendering Provider,
							 the individual providing the service.
OP6127
Place of Service - 2
January 1, 2020
T
2
CMS code identifying the entity/location where
							 professional service(s) were rendered, if different from POS code indicated in
							 OP4006
OP6128
Rendering Provider NPI - 2
January 1, 2020
T
16
National Provider Identifier for Rendering Provider,
							 the individual providing the service.
OP6129
Place of Service - 3
January 1, 2020
T
2
CMS code identifying the entity/location where
							 professional service(s) were rendered, if different from POS code indicated in
							 OP4006
OP6130
Rendering Provider NPI - 3
January 1, 2020
T
16
National Provider Identifier for Rendering Provider,
							 the individual providing the service.
Sequence numbers go from 001 to 999 with 3 revenue centers on
				  each physical record makes it possible to have 2,997 revenue centers on a
				  single logical record. If revenue center code "0001" is utilized to report the
				  total of all the line item charges, it must be entered on the last revenue
				  center field. The value for revenue code 0001 must equal the total ancillary
				  charges reported on record type 90 and must equal the summation of all line
				  item charges reported on the logical record.
Outpatient Data Submission Specifications Record Type
				  71 - ICD-10 CM Principal and Reason for Visit Diagnosis Codes, ICD-10 PCS
				  Principal Procedure Code
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP7101
Record Type
10/1/2014
T
2
71
OP7102
Sequence Number
10/1/2014
T
2
01
OP7103
Patient Control Number
10/1/2014
T
20
Assigned by facility
OP7104
Principal Diagnosis
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7105
Filler
T
3
OP7106
Filler
T
10
OP7107
Reason for Visit Diagnosis - 1
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7108
Reason for Visit Diagnosis - 2
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7109
Reason for Visit Diagnosis - 3
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7110
Principal Procedure Code
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7111
Principal Procedure Date
10/1/2014
T
8
CCYYMMDD
Outpatient Data Submission Specifications Record Type
				  72 - ICD-10 PCS Other Procedure Codes
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
OP7201
Record Type
10/1/2014
T
2
72
OP7202
Sequence Number
10/1/2014
T
2
01 - 03
OP7203
Patient Control Number
10/1/2014
T
20
Assigned by facility
OP7204
Other Procedure Code - 1
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7205
Other Procedure Date - 1
10/1/2014
T
8
CCYYMMDD
OP7206
Other Procedure Code - 2
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7207
Other Procedure Date - 2
10/1/2014
T
8
CCYYMMDD
OP7208
Other Procedure Code - 3
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7209
Other Procedure Date - 3
10/1/2014
T
8
CCYYMMDD
OP7210
Other Procedure Code - 4
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7211
Other Procedure Date - 4
10/1/2014
T
8
CCYYMMDD
OP7212
Other Procedure Code - 5
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7213
Other Procedure Date - 5
10/1/2014
T
8
CCYYMMDD
OP7214
Other Procedure Code - 6
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7215
Other Procedure Date - 6
10/1/2014
T
8
CCYYMMDD
OP7216
Other Procedure Code - 7
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7217
Other Procedure Date - 7
10/1/2014
T
8
CCYYMMDD
OP7218
Other Procedure Code - 8
10/1/2014
T
10
If an organization or entity is using ICD-10- PCS for
							 outpatient claims, and only if applicable, please report here.
ICD-10 PCS - do not code decimal point - Left
							 Justified
OP7219
Other Procedure Date - 8
10/1/2014
T
8
CCYYMMDD
Record Type 73 - ICD-10 CM External Cause of Injury
				  Diagnosis Codes
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
OP7301
Record Type
10/1/2014
T
2
73
OP7302
Sequence Number
10/1/2014
T
2
01 - 02
OP7303
Patient Control Number
10/1/2014
T
20
Assigned by facility
OP7304
External Cause of Injury - 1
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7305
Filler
T
3
OP7306
External Cause of Injury - 2
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7307
Filler
T
3
OP7308
External Cause of Injury - 3
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7309
Filler
T
3
OP7310
External Cause of Injury - 4
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7311
Filler
T
3
OP7312
External Cause of Injury - 5
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7313
Filler
T
3
OP7314
External Cause of Injury - 6
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7315
Filler
T
3
OP7316
External Cause of Injury - 7
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7317
Filler
T
3
OP7318
External Cause of Injury - 8
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7319
Filler
T
3
OP7320
External Cause of Injury - 9
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7321
Filler
T
3
OP7322
External Cause of Injury - 10
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7323
Filler
T
3
OP7324
External Cause of Injury - 11
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7325
Filler
T
3
OP7326
External Cause of Injury - 12
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7327
Filler
T
3
Outpatient Data Submission Specifications Record Type
				  74 - ICD-10 CM Other Diagnosis Information
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
OP7401
Record Type
10/1/2014
T
2
74
OP7402
Sequence Number
10/1/2014
T
2
01 - 02
OP7403
Patient Control Number
10/1/2014
T
20
Assigned by facility
OP7404
Other Diagnosis Code - 1
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7405
Filler
T
3
OP7406
Other Diagnosis Code - 2
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7407
Filler
T
3
OP7408
Other Diagnosis Code - 3
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7409
Filler
T
3
OP7410
Other Diagnosis Code - 4
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7411
Filler
T
3
OP7412
Other Diagnosis Code - 5
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7413
Filler
T
3
OP7414
Other Diagnosis Code - 6
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7415
Filler
T
3
OP7416
Other Diagnosis Code - 7
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7417
Filler
T
3
OP7418
Other Diagnosis Code - 8
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7419
Filler
T
3
OP7420
Other Diagnosis Code - 9
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7421
Filler
T
3
OP7422
Other Diagnosis Code - 10
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7423
Filler
T
3
OP7424
Other Diagnosis Code - 11
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7425
Filler
T
3
OP7426
Other Diagnosis Code - 12
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
OP7427
Filler
T
3
Outpatient Data Submission Specifications Record Type
				  80 - Provider Data
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP8001
Record Type
T
2
80
OP8002
Sequence
T
2
01
OP8003
Patient Control Number
T
20
Assigned by the facility
OP8097
Filler
T
2
OP8004
Attending Provider NPI
T
16
NPI of Attending Provider; Attending provider is
							 located on UB-04
OP8005
Operating Physician NPI
T
16
NPI of Operating Physician; Operating physician is
							 located on UB-04.
OP8098
Filler
T
32
OP8006
Attending Provider Last Name
T
16
Cannot be blank if OP8004 is present on a
							 facility/institutional claim.
OP8007
Attending Provider First Name
T
8
Cannot be blank if OP8004 is present on a
							 facility/institutional claim.
OP8008
Attending Provider Middle Initial
T
1
OP8009
Operating Physician Last Name
T
16
Must be populated when OP8005 is populated.
OP8010
Operating Physician First Name
T
8
Cannot be blank if OP8005 is populated.
OP8011
Operating Physician Middle
							 Initial
T
1
OP8099
Filler
T
52
OP8012
Billing Provider NPI
T
16
National Provider Identifier assigned to the provider
							 submitting the bill.
Record Type 99 File Control
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
OP9001
Record Type
T
2
90
OP9002
Filler (National Use)
T
2
OP9003
Patient Control Number
T
20
Assigned by the facility
OP9098
Filler
T
40
OP9004
Total Ancillary Charges - Revenue
							 Centers
N
10
Must equal the sum of line item charges excluding
							 revenue center code 0001 if present. Two decimal positions implied
OP9099
Filler
T
118
OP9901
Record Type
T
2
99
OP9998
Filler
T
190
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
OP0101
Record Type
NA
NA
NA
OP0102
MHDO-Assigned Hospital ID
NA
NA
NA
OP0103
Hospital Name
1
33
837/2010AA/NM1/85/2/03
OP0104
Address
1
33
837/2010AA/N3/01
OP0105
City
1
33
837/2010AA/N4/01
OP0106
State
1
33
837/2010AA/N4/02
OP0107
Zip Code
1
33
837/2010AA/N4/03
OP0108
Version
NA
NA
NA
OP2001
Record Type
NA
NA
NA
OP2003
Patient Control Number
3A
26
837/2300/CLM/01
OP2004
Patient Sex
11
3
837/2010CA/DMG/03 or 837/2010BA/DMG/03
OP2005
Patient Birth Date
10
3
837/2010CA/DMG/D8/02 or 837/2010BA/DMG/D8/02
OP2007
Point of Origin for Admission or Visit
15
NA
837/2300/CL1/02
OP2008
Patient City
9B
5
837/2010CA/N4/01 or
837/2010BA/N4/01
OP2009
Patient State
9C
5
837/2010CA/N4/02
837/2010BA/N4/02
OP2010
Patient Zip Code
9D
5
837/2010CA/N4/03
837/2010BA/N4/03
OP2011
Admission/Start of Care Date
12
NA
837/2300/DTP/435/D8/03
OP2012
Statement Covers Period - From
6
24A
837I/2300/DTP/434/RD8/03
837P/2400/DTP/472/RD8/03
OP2013
Statement Covers Period - Thru
6
24A
837I/2300/DTP/434/RD8/03
837P/2400/DTP/472/RD8/03
OP2014
Patient Discharge Status
17
NA
837/2300/CL1/03
OP2015
Medical/Health Record Number
3B
NA
837/2300/REF/EA/02
OP2016
Race
NA
NA
837/2010CA/DMG/05
OP2017
Ethnicity
NA
NA
837/2010CA/DMG/05
OP2018
Patient Country Code
9E
NA
837/2010CA/N4/04
837/2010BA/N4/04
OP2019
Patient Last Name
8B
2
837/2010CA/NM1/QC/1/03
837/2010BA/NM1/IL/1/03
OP2020
Patient First Name
8B
2
837/2010CA/NM1/QC/1/04
837/2010BA/NM1/IL/1/04
OP2021
Patient Middle Name or Initial
8B
2
837/2010CA/NM1/QC/1/05
837/2010BA/NM1/IL/1/05
OP2022
Patient Name Suffix
8B
2
837/2010CA/NM1/QC/1/07
837/2010BA/NM1/IL/1/07
OP2023
Patient Address Line 1
9A
5
837/2010CA/N3/01
837/2010BA/N3/01
OP2024
Patient Address Line 2
9A
5
837/2010CA/N3/02
837/2010BA/N3/02
OP3001
Record Type
NA
NA
NA
OP3002
Sequence Number
NA
NA
837/2000B/SBR/01
OP3003
Patient Control Number
3A
26
837/2300/CLM/01
OP3005
Social Security Number
NA
NA
NA
OP3007
Insured's Group Number (Primary)
62A
11
837/2000B/SBR/P/03
Insured's Group Number (Secondary)
62B
9A
837/2320/SBR/S/03
OP3008
Insured's Unique Identifier (Primary)
60A
1A
837/2010BA/NM1/MI/09
Insured's Unique Identifier (Secondary)
60B
NA
837/2330A/NM1/MI/09
OP3009
Payer Name (Primary)
50A
Header/
Carrier Block
837/2010BB/NM1/PR/2/03
Payer Name (Secondary)
50B
Header/
Carrier Block
837/2330B/NM1/PR/2/03
OP4001
Record Type
NA
NA
NA
OP4002
Sequence Number
NA
NA
NA
OP4003
Patient Control Number
3A
26
837/2300/CLM/01
OP4004
Type of Bill
4
NA
837/2300/CLM/A/05-1
837/2300/CLM/05-3
OP4005
Location of Service
NA
NA
Hospital designated code when Place of Service field
							 OP4006 is 11, 17, 20, 22, 49, 50, 71 or 72. Primarily for physician practices
							 (primary care, specialty care and clinics).
OP4006
Place of Service
NA
24B
837/2300/CLM/05-1
OP6101
Record Type
NA
NA
NA
OP6102
Sequence Number
NA
NA
NA
OP6103
Patient Control Number
3A
26
837/2300/CLM/01
OP6104
Revenue Center Code - 1
42
NA
837/2400/SV2/01
OP6105
HCPCS Procedure Code - 1
44
24D-1
837I/2400/SV2/HC/02-2
837P/2400/SV1/HC/01-2
OP6106
Modifier - 1 (HCPCS & CPT-4) - 1
44
24D-1
837I/2400/SV2/HC/02-3
837P/2400/SV1/HC/01-3
OP6107
Modifier - 2 (HCPCS & CPT-4) - 1
44
24D-1
837I/2400/SV2/HC/02-4
837P/2400/SV1/HC/01-4
OP6108
Service Units - 1
46
24G-1
837I/2400/SV2/DA/05
837I/2400/SV2/UN/05
837P/2400/SV1/UN/04
OP6109
Outpatient Total Charges - 1
47
24F-1
837I/2400/SV2/03
837P/2400/SV1/02
OP6110
Service Date - 1
45
24A-1
837/2400/DTP/472/D8/03
OP6111
Revenue Center Code - 2
42
NA
837/2400/SV2/01
OP6112
HCPCS Procedure Code - 2
44
24D-2
837I/2400/SV2/HC/02-2
837P/2400/SV1/HC/01-2
OP6113
Modifier - 1 (HCPCS & CPT-4) - 2
44
24D-2
837I/2400/SV2/HC/02-3
837P/2400/SV1/HC/01-3
OP6114
Modifier - 2 (HCPCS & CPT-4) - 2
44
24D-2
837I/2400/SV2/HC/02-4
837P/2400/SV1/HC/01-4
OP6115
Service Units - 2
46
24G-2
837I/2400/SV2/DA/05
837I/2400/SV2/UN/05
837P/2400/SV1/UN/04
OP6116
Outpatient Total Charges - 2
47
24F-2
837I/2400/SV2/03
837P/2400/SV1/02
OP6117
Service Date - 2
45
24A-2
837/2400/DTP/472/D8/03
OP6118
Revenue Center Code - 3
42
NA
837/2400/SV2/01
OP6119
HCPCS Procedure Code - 3
44
24D-3
837I/2400/SV2/HC/02-2
837P/2400/SV1/HC/01-2
OP6120
Modifier - 1 (HCPCS & CPT-4) - 3
44
24D-3
837I/2400/SV2/HC/02-3
837P/2400/SV1/HC/01-3
OP6121
Modifier - 2 (HCPCS & CPT-4) - 3
44
24D-3
837I/2400/SV2/HC/02-4
837P/2400/SV1/HC/01-4
OP6122
Service Units - 3
46
24G-3
837I/2400/SV2/DA/05
837I/2400/SV2/UN/05
837P/2400/SV1/UN/04
OP6123
Outpatient Total Charges - 3
47
24F-3
837I/2400/SV2/03
837P/2400/SV1/02
OP6124
Service Date - 3
45
24A-3
837/2400/DTP/472/D8/03
OP6125
Place of Service - 1
NA
24B
837/2400/SV1/05
OP6126
Rendering Provider NPI - 1
NA
24J
837/2420A/NM1/XX/09;
837/2310B/NM1/XX/09
OP6127
Place of Service - 2
NA
24B
837/2400/SV1/05
OP6128
Rendering Provider NPI - 2
NA
24J
837/2420A/NM1/XX/09;
837/2310B/NM1/XX/09
OP6129
Place of Service - 3
NA
24B
837/2400/SV1/05
OP6130
Rendering Provider NPI - 3
NA
24J
837/2420A/NM1/XX/09;
837/2310B/NM1/XX/09