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-1 - Maine Health Data Organization Inpatients Data Submission Specifications General

Current through 2024-29, July 17, 2024
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 50 - IP Accommodations Data
Record Type 60 - IP Ancillary Services
Record Type 71 - ICD-10 CM Principal and Admitting
							 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.
Record Type 01 - Processor Data
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
IP0101
Record Type
T
2
01
IP0102
MHDO-Assigned Hospital ID
T
6
Must be the MHDO-assigned, 6-digit hospital code,
							 left justified
IP0198
Filler
T
38
IP0103
Hospital Name
T
21
IP0104
Address
T
18
IP0105
City
T
15
IP0106
State
T
2
IP0107
Zip Code
T
9
IP0199
Filler
T
78
IP0108
Version
T
3
leave blank
IP2001
Record Type
T
2
20
IP2002
Filler (National Use)
T
2
IP2003
Patient Control Number
T
20
Assigned by the facility
IP2095
Filler
T
30
Space filled
IP2004
Patient Sex
T
1
M = Male
F = Female
U = Unknown
IP2005
Patient Birth Date
T
8
CCYYMMDD
IP2096
Filler
T
1
IP2006
Priority (Type) of Admission or
							 Visit
T
1
IP2007
Point of Origin for Admission or
							 Visit
T
1
IP2097
Filler
T
30
IP2008
Patient City
T
15
IP2009
Patient State
T
2
IP2010
Patient Zip Code
T
9
As defined by US Postal Service Do not include
							 dashes
IP2011
Admission/Start of Care Date
T
8
CCYYMMDD
IP2012
Admission Hour
T
2
Military Time - Range 00-23
IP2098
Filler
T
8
IP2013
Statement Covers Period - Thru
T
8
CCYYMMDD
IP2014
Patient Discharge Status
T
2
IP2015
Discharge Hour
T
2
Military Time - Range 00-23
IP2099
Filler
T
20
IP2016
Medical/Health Record Number
T
17
Assigned by the facility
IP2017
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.
IP2018
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.
IP2019
Filler
T
1
IP2020
Statement Covers Period - From
January 1, 2018
T
8
CCYYMMDD
IP2021
Patient Country Code
January 1, 2018
T
2
Use ISO 3166-1 alpha-2 country codes. Refer to
							 Appendix A.
IP2022
Patient Last Name
January 1, 2018
T
60
IP2023
Patient First Name
January 1, 2018
T
35
IP2024
Patient Middle Name or Initial
January 1, 2018
T
25
IP2025
Patient Name Suffix
January 1, 2018
T
10
IP2026
Patient Address Line 1
January 1, 2018
T
55
IP2027
Patient Address Line 2
January 1, 2018
T
55
IP3001
Record Type
T
2
30
IP3002
Sequence Number
T
2
01 Primary Payer
02 - 99 Secondary Payer
IP3003
Patient Control Number
T
20
Assigned by the facility
IP3095
Filler
January 1, 2018
T
10
IP3005
Social Security Number
April 1, 2006
T
19
Do not include the dashes For internal use only -
							 Required if collected
IP3097
Filler
January 1, 2018
T
26
IP3007
Insured's Group Number
April 1, 2006
T
17
For internal use only - Required if collected
IP3008
Insured's Unique Identifier
T
20
Insurance policy or certificate ID
IP3099
Filler
T
1
IP3009
Payer Name
January 1, 2018
T
100
Full or unabbreviated payer name, not plan
							 name
IP4001
Record Type
T
2
40
IP4002
Sequence Number
T
2
01
IP4003
Patient Control Number
T
20
Assigned by the facility
IP4004
Type of Bill
T
3
Code indicating the specific type of institutional
							 bill
IP4099
Filler
T
165
IP5001
Record Type
T
2
50
IP5002
Sequence Number
T
3
001-999
IP5003
Patient Control Number
T
20
Assigned by the facility
IP5091
Filler
T
3
IP5004
Accommodations Revenue Code #1
T
4
Include leading zeros
IP5092
Filler
T
9
IP5005
Accommodations Service Units #1
N
4
Right Justified, leading zeros
IP5006
Accommodations Total Charges #1
T
10
Two decimal places implied
IP5093
Filler
T
14
IP5007
Accommodations Revenue Code #2
T
4
Include leading zeros
IP5094
Filler
T
9
IP5008
Accommodations Service Units #2
N
4
Right Justified, leading zeros
IP5009
Accommodations Total Charges #2
N
10
Two decimal places implied
IP5095
Filler
T
14
IP5010
Accommodations Revenue Code #3
T
4
Include leading zeros
IP5096
Filler
T
9
IP5011
Accommodations Service Units #3
N
4
Right Justified, leading zeros
IP5012
Accommodations Total Charges #3
N
10
Two decimal places implied
IP5097
Filler
T
14
IP5013
Accommodations Revenue Code #4
T
4
Include leading zeros
IP5098
Filler
T
9
IP5014
Accommodations Service Units #4
N
4
Right Justified, leading zeros
IP5015
Accommodations Total Charges #4
N
10
Two decimal places implied
IP5099
Filler
T
14
Record Type 60 - IP Ancillary Services
				  Data
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
IP6001
Record Type
T
2
60
IP6002
Sequence Number
T
3
001 to 999
IP6003
Patient Control Number
T
20
Assigned by the facility
IP6093
Filler
T
2
IP6004
Inpatient Ancillary Revenue Code
							 #1
T
4
Include leading zeros
IP6094
Filler
T
16
IP6005
Inpatient Ancillary Total Charges
							 #1
N
10
Two decimal places implied
IP6095
Filler
T
25
IP6006
Inpatient Ancillary Revenue Code
							 #2
T
4
Include leading zeros
IP6096
Filler
T
16
IP6007
Inpatient Ancillary Total Charges
							 #2
N
10
Two decimal places implied
IP6097
Filler
T
25
IP6008
Inpatient Ancillary Revenue Code
							 #3
T
4
Include leading zeros
IP6098
Filler
T
16
IP6009
Inpatient Ancillary Total Charge
							 #3
N
10
Two decimal places implied
IP6099
Filler
T
25
Record Type 71 - ICD-10 CM Principal and Admitting
				  Diagnosis Codes, ICD-10 PCS Principal Procedure Code
Data Element #
Data Element
Implementation Date For New Data
							 Elements
Type
Length
Description
IP7101
Record Type
10/1/2014
T
2
71
IP7102
Sequence Number
10/1/2014
T
2
01
IP7103
Patient Control Number
10/1/2014
T
20
Assigned by facility
IP7104
Principal Diagnosis
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7105
Present On Admission Indicator
10/1/2014
T
3
Standard POA code set - Left Justified
IP7106
Admitting Diagnosis
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7107
Filler
T
10
IP7108
Filler
T
10
IP7109
Filler
T
10
IP7110
Principal Procedure Code
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7111
Principal Procedure Date
10/1/2014
T
8
CCYYMMDD
Record Type 72 - ICD-10 PCS Other Procedure
				  Codes
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
IP7201
Record Type
10/1/2014
T
2
72
IP7202
Sequence Number
10/1/2014
T
2
01 - 03
IP7203
Patient Control Number
10/1/2014
T
20
Assigned by facility
IP7204
Other Procedure Code - 1
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7205
Other Procedure Date - 1
10/1/2014
T
8
CCYYMMDD
IP7206
Other Procedure Code - 2
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7207
Other Procedure Date - 2
10/1/2014
T
8
CCYYMMDD
IP7208
Other Procedure Code - 3
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7209
Other Procedure Date - 3
10/1/2014
T
8
CCYYMMDD
IP7210
Other Procedure Code - 4
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7211
Other Procedure Date - 4
10/1/2014
T
8
CCYYMMDD
IP7212
Other Procedure Code - 5
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7213
Other Procedure Date - 5
10/1/2014
T
8
CCYYMMDD
IP7214
Other Procedure Code - 6
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7215
Other Procedure Date - 6
10/1/2014
T
8
CCYYMMDD
IP7216
Other Procedure Code - 7
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7217
Other Procedure Date - 7
10/1/2014
T
8
CCYYMMDD
IP7218
Other Procedure Code - 8
10/1/2014
T
10
ICD-10 PCS - do not code decimal point - Left
							 Justified
IP7219
Other Procedure Date - 8
10/1/2014
T
8
CCYYMMDD
Record Type 73 - ICD-10 CM Other Diagnosis Information
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
IP7301
Record Type
10/1/2014
T
2
73
IP7302
Sequence Number
10/1/2014
T
2
01 - 02
IP7303
Patient Control Number
10/1/2014
T
20
Assigned by facility
IP7304
External Cause of Injury Code - 1
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7305
Present On Admission Indicator -
							 1
10/1/2014
T
3
Standard POA code set - Left Justified
IP7306
External Cause of Injury Code - 2
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7307
Present On Admission Indicator -
							 2
10/1/2014
T
3
Standard POA code set - Left Justified
IP7308
External Cause of Injury Code - 3
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7309
Present On Admission Indicator -
							 3
10/1/2014
T
3
Standard POA code set - Left Justified
IP7310
External Cause of Injury Code - 4
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7311
Present On Admission Indicator -
							 4
10/1/2014
T
3
Standard POA code set - Left Justified
IP7312
External Cause of Injury Code - 5
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7313
Present On Admission Indicator -
							 5
10/1/2014
T
3
Standard POA code set - Left Justified
IP7314
External Cause of Injury Code - 6
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7315
Present On Admission Indicator -
							 6
10/1/2014
T
3
Standard POA code set - Left Justified
IP7316
External Cause of Injury Code - 7
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7317
Present On Admission Indicator -
							 7
10/1/2014
T
3
Standard POA code set - Left Justified
IP7318
External Cause of Injury Code - 8
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7319
Present On Admission Indicator -
							 8
10/1/2014
T
3
Standard POA code set - Left Justified
IP7320
External Cause of Injury Code - 9
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7321
Present On Admission Indicator -
							 9
10/1/2014
T
3
Standard POA code set - Left Justified
IP7322
External Cause of Injury Code -
							 10
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7323
Present On Admission Indicator -
							 10
10/1/2014
T
3
Standard POA code set - Left Justified
IP7324
External Cause of Injury Code -
							 11
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7325
Present On Admission Indicator -
							 11
10/1/2014
T
3
Standard POA code set - Left Justified
IP7326
External Cause of Injury Code -
							 12
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7327
Present On Admission Indicator -
							 12
10/1/2014
T
3
Standard POA code set - Left Justified
Record Type 74 - ICD-10 CM Other Diagnosis Information
Data Element #
Data Element Name
Implementation Date For New Data
							 Elements
Type
Length
Description
IP7401
Record Type
10/1/2014
T
2
74
IP7402
Sequence Number
10/1/2014
T
2
01 - 02
IP7403
Patient Control Number
10/1/2014
T
20
Assigned by facility
IP7404
Other Diagnosis Code - 1
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7405
Present On Admission Indicator -
							 1
10/1/2014
T
3
Standard POA code set - Left Justified
IP7406
Other Diagnosis Code - 2
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7407
Present On Admission Indicator -
							 2
10/1/2014
T
3
Standard POA code set - Left Justified
IP7408
Other Diagnosis Code - 3
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7409
Present On Admission Indicator -
							 3
10/1/2014
T
3
Standard POA code set - Left Justified
IP7410
Other Diagnosis Code - 4
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7411
Present On Admission Indicator -
							 4
10/1/2014
T
3
Standard POA code set - Left Justified
IP7412
Other Diagnosis Code - 5
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7413
Present On Admission Indicator -
							 5
10/1/2014
T
3
Standard POA code set - Left Justified
IP7414
Other Diagnosis Code - 6
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7415
Present On Admission Indicator -
							 6
10/1/2014
T
3
Standard POA code set - Left Justified
IP7416
Other Diagnosis Code - 7
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7417
Present On Admission Indicator -
							 7
10/1/2014
T
3
Standard POA code set - Left Justified
IP7418
Other Diagnosis Code - 8
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7419
Present On Admission Indicator -
							 8
10/1/2014
T
3
Standard POA code set - Left Justified
IP7420
Other Diagnosis Code - 9
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7421
Present On Admission Indicator -
							 9
10/1/2014
T
3
Standard POA code set - Left Justified
IP7422
Other Diagnosis Code - 10
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7423
Present On Admission Indicator -
							 10
10/1/2014
T
3
Standard POA code set - Left Justified
IP7424
Other Diagnosis Code - 11
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7425
Present On Admission Indicator -
							 11
10/1/2014
T
3
Standard POA code set - Left Justified
IP7426
Other Diagnosis Code - 12
10/1/2014
T
10
ICD-10 CM - do not code decimal point - Left
							 Justified
IP7427
Present On Admission Indicator -
							 12
10/1/2014
T
3
Standard POA code set - Left Justified
Record Type 80 - Provider Data
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
IP8001
Record Type
T
2
80
IP8002
Sequence
T
2
01
IP8003
Patient Control Number
T
20
Assigned by the facility
IP8097
Filler
T
2
IP8004
Attending Provider NPI
April 1, 2009
T
16
NPI of Attending Provider
IP8005
Operating Physician NPI
April 1, 2009
T
16
NPI of Operating Physician
IP8098
Filler
T
32
IP8006
Attending Provider Last Name
T
16
Cannot be blank
IP8007
Attending Provider First Name
T
8
Cannot be blank
IP8008
Attending Provider Middle Initial
T
1
IP8009
Operating Physician Last Name
T
16
Must be populated when IP8005 is populated.
IP8010
Operating Physician First Name
T
8
Cannot be blank if IP8005 is populated.
IP8011
Operating Physician Middle
							 Initial
T
1
IP8099
Filler
T
52
IP8012
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
IP9001
Record Type
T
2
90
IP9002
Filler (National Use)
T
2
IP9003
Patient Control Number
T
20
Assigned by the facility
IP9097
Filler
T
20
IP9004
Total Accommodation Charges - Revenue
							 Centers
N
10
Must equal the sum of record type 50 revenue code
							 data Two decimal places implied
IP9098
Filler
T
10
IP9005
Total Ancillary Charges - Revenue
							 Centers
N
10
Must equal the sum of record type 60 revenue code
							 data Two decimal places implied
IP9099
Filler
T
118
Inpatient Data Submission Specifications Record Type 99
				  - File Control
Data Element #
Data Element
Implementation Date for New Data
							 Elements
Type
Length
Description/Codes/Sources
IP9901
Record Type
T
2
99
IP9999
Filler
T
190
Data Element #
Data Element Name
UB-04 Form Locator
HIPAA Reference ASC X12N/005010A1 Transaction
							 Set/Loop/ Segment ID/Code Value/ Reference Designator
IP0101
Record Type
NA
NA
IP0102
MHDO-Assigned Hospital ID
NA
NA
IP0103
Hospital Name
1
837/2010AA/NM1/85/2/03
IP0104
Address
1
837/2010AA/N3/01
IP0105
City
1
837/2010AA/N4/01
IP0106
State
1
837/2010AA/N4/02
IP0107
Zip Code
1
837/2010AA/N4/03
IP0108
Version
NA
NA
IP2001
Record Type
NA
NA
IP2003
Patient Control Number
3A
837/2300/CLM/01
IP2004
Patient Sex
11
837/2010CA/DMG/03
837/2010BA/DMG/03
IP2005
Patient Birth Date
10
837/2010CA/DMG/D8/02
837/2010BA/DMG/D8/02
IP2006
Priority (Type) of Admission or Visit
14
837/2300/CL1/01
IP2007
Point of Origin for Admission or Visit
15
837/2300/CL1/02
IP2008
Patient City
9B
837/2010CA/N4/01
837/2010BA/N4/01
IP2009
Patient State
9C
837/2010CA/N4/02
837/2010BA/N4/02
IP2010
Patient Zip Code
9D
837/2010CA/N4/03
837/2010BA/N4/03
IP2011
Admission/Start of Care Date
12
837/2300/DTP/435/DT/03
IP2012
Admission Hour
13
837/2300/DTP/435/DT/03
IP2013
Statement Covers Period Thru
6
837/2300/DTP/434/RD8/03
IP2014
Patient Discharge Status
17
837/2300/CL1/03
IP2015
Discharge Hour
16
837/2300/DTP/096/TM/03
IP2016
Medical/Health Record Number
3B
837/2300/REF/EA/02
IP2017
Race
NA
837/2010CA/DMG/05
837/2010BA/DMG/05
IP2018
Ethnicity
NA
837/2010CA/DMG/05
837/2010BA/DMG/05
IP2020
Statement Covers Period - From
6
837/2300/DTP/434/RD8/03
IP2021
Patient Country Code
9E
837/2010CA/N4/04
837/2010BA/N4/04
IP2022
Patient Last Name
8B
837/2010CA/NM1/QC/1/03
837/2010BA/NM1/IL/1/03
IP2023
Patient First Name
8B
837/2010CA/NM1/QC/1/04
837/2010BA/NM1/IL/1/04
IP2024
Patient Middle Name or Initial
8B
837/2010CA/NM1/QC/1/05
837/2010BA/NM1/IL/1/05
IP2025
Patient Name Suffix
8B
837/2010CA/NM1/QC/1/07
837/2010BA/NM1/IL/1/07
IP2026
Patient Address Line 1
9A
837/2010CA/N3/01
837/2010BA/N3/01
IP2027
Patient Address Line 2
9A
837/2010CA/N3/02
837/2010BA/N3/02
IP3001
Record Type
NA
NA
IP3002
Sequence Number
NA
837/2000B/SBR/01
IP3003
Patient Control Number
3A
837/2300/CLM/01
IP3005
Social Security Number
NA
NA
IP3007
Insured's Group Number (Primary)
62A
837/2000B/SBR/P/03
Insured's Group Number (Secondary)
62B
837/2320A/SBR/S/03
IP3008
Insured's Unique Identifier (Primary)
60A
837/2010BA/NM1/MI/09
Insured's Unique Identifier (Secondary)
60B
837/2330A/NM1/MI/09
IP3009
Payer Name (Primary)
50A
837/2010BB/NM1/PR/2/03
Payer Name (Secondary)
50B
837/2330B/NM1/PR/2/03
IP4001
Record Type
NA
NA
IP4002
Sequence Number
NA
NA
IP4003
Patient Control Number
3A
837/2300/CLM/01
IP4004
Type of Bill
4
837/2300/CLM/05-1
837/2300/CLM/05-3
IP5001
Record Type
NA
NA
IP5002
Sequence Number
NA
NA
IP5003
Patient Control Number
3A
837/2300/CLM/01
IP5004
Accommodations Revenue Code - 1
42
837/2400/SV2/01
IP5005
Accommodations Service Units - 1
46
837/2400/SV2/DA/05
IP5006
Accommodations Total Charges - 1
47
837/2400/SV2/03
IP5007
Accommodations Revenue Code - 2
42
837/2400/SV2/01
IP5008
Accommodations Service Units - 2
46
837/2400/SV2/DA/05
IP5009
Accommodations Total Charges - 2
47
837/2400/SV2/03
IP5010
Accommodations Revenue Code - 3
42
837/2400/SV2/01
IP5011
Accommodations Service Units - 3
46
837/2400/SV2/DA/05
IP5012
Accommodations Total Charges - 3
47
837/2400/SV2/03
IP5013
Accommodations Revenue Code - 4
42
837/2400/SV2/01
IP5014
Accommodations Service Units - 4
46
837/2400/SV2/DA/05
IP5015
Accommodations Total Charges - 4
47
837/2400/SV2/03
IP6001
Record Type
NA
NA
IP6002
Sequence Number
NA
NA
IP6003
Patient Control Number
3A
837/2300/CLM/01
IP6004
Inpatient Ancillary Revenue Code - 1
42
837/2400/SV2/01
IP6005
Inpatient Ancillary Total Charges - 1
47
837/2400/SV2/03
IP6006
Inpatient Ancillary Revenue Code - 2
42
837/2400/SV2/01
IP6007
Inpatient Ancillary Total Charges - 2
47
837/2400/SV2/03
IP6008
Inpatient Ancillary Revenue Code - 3
42
837/2400/SV2/01
IP6009
Inpatient Ancillary Total Charges - 3
47
837/2400/SV2/03