Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part VI - Health Care Cost Containment Council › Chapter 911 - DATA SUBMISSION AND COLLECTION › Subchapter A - STATEMENT OF POLICY › Section 911.4 - Adoption of data elements to be reported to the Council

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Council adopted the data elements in
				  Table A and identified fields on the Pennsylvania Uniform Claims and Billing
				  Form format (see Table A).
(b) As
				  required by section 6 of the act (35 P. S. §
											449.6), the Council will promulgate rules and
				  regulations establishing technical specifications and schedules, and the
				  identification of data sources required to submit specific data elements to the
				  Council.
(c) The Council will
				  promulgate in the rules and regulations the following data elements:
(1) Field 21c, Unusual Occurrences-Nosocomial
				  infections.
(2) Field 21d, Unusual
				  Occurrences-Readmissions.
(3) Field
				  35, Patient Race.
TABLE A
PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM DATA
					 ELEMENTS
Field
Data
								Element
Definition
1
Uniform Patient
								Identifier
Patient's Social Security Number.
2
Patient Date of Birth
The date of
								birth of the patient.
3
Patient Sex
The sex of the
								patient as recorded at the date of admission, outpatient service, or start of
								care.
4
Patient Zip Code
Zip code of
								patient taken from the patient name and address field.
5
Date of Admission
The date that
								the patient was admitted to the provider for inpatient care, outpatient
								services or start of care.
6
Date of Discharge
The ending
								service date of patient care. The date that the patient was discharged from the
								provider's care.
7a
Principal Diagnosis
The code
								that identifies the principal diagnosis (i.e., the condition established after
								study to be chiefly responsible for causing this hospitalization) that exists
								at the time of admission or develops subsequently that has an effect on the
								length of stay.
7b, c, d, e
Secondary Diagnosis
The
								diagnosis code corresponding to additional conditions that co-exist at the time
								of admission, or develop subsequently, and which have an effect on the
								treatment received or the length of stay.
8a, b
Principal Procedure Code and
								Date
The code that identifies the principal procedure performed during
								the period between admission and discharge and the date on which the principal
								procedure described was performed.
9a1 through 9c2
Secondary
								Procedure
The code identifying the procedures other than the principal
								procedure, performed during the patient's stay and the dates on which the
								procedures (identified by the codes) were performed.
10
Uniform Identifier of Health Care
								Facility
Number identifying the provider facility as developed and used
								by Medicaid.
11
Attending Physician
								Identifier
The PA state license number of the physician who would
								normally be expected to certify and recertify the medical necessity of the
								services rendered and/or who has primary responsibility for the patient's
								medical care and treatment.
12
Operating Physician
								Identifier
The PA state license number of the physician other than the
								attending physician who performed the principal procedure.
13a1 through 13w1
Revenue
								Description
A narrative description of the related revenue categories
								included for a patient.
13a2 through 13w2
Revenue Code
A
								code which identifies a specific accommodation, ancillary service or billing
								calculation.
13a3 through 13w3
Units of
								Service
A quantitative measure of services rendered by revenue category
								to or for the patient to include items such as number of accommodation days,
								pints of blood, or renal dialysis treatments, etc.
13a4 through 13w4
Total
								Charges
Total charges pertaining to the related revenue code for the
								current billing period as entered in the statement covers period.
13a5 through 13w5
Noncovered
								Charges
Those charges that are not covered by a payor for this patient.
14a
Actual Payments to the Health Care
								Facility
Payments for services performed by the provider from the payor
								segregated according to Revenue Code.
14b
Payor Identification
Name and
								Pennsylvania Insurance Department number identifying each payor organization
								from which the provider might expect some payment for the bill.
14c
Deductible Amount
The amount
								assumed by the hospital to be applied to the patient's deductible amount
								involving the indicated payor.
14d
Co-Insurance Amount
The amount
								assumed by the hospital to be applied toward the patient's co-insurance amount
								involving the indicated payor.
14e
Estimated Responsibility
The
								amount estimated by the hospital to be paid by the indicated payor.
14f
Prior Payments-Payor and
								Patient
The amount the hospital has received toward payment of this
								bill prior to the billing date by the indicated payor.
14g
Estimated Amount Due
The amount
								estimated by the hospital to be due from the indicated payor (estimated
								responsibility less prior payments).
15a
Physician
								Identification
License number of the physician who charged the patient
								for a service related to an episode of illness for the period indicated in
								Fields 5 and 6.
15b
Type of Physician/ Professional
								Service
The type of service performed for which payment is expected.
15a3
Physician/ Professional Services
								Charge
Amount charged for services rendered to the patient for the
								procedure indicated in HCFA 1500, item 24d.
16
Physician/ Professional Services
								Payment
Payments received for services performed for the procedures
								indicated in Field 8a.
17
Uniform Identifier of Primary
								Payor
Pennsylvania Department of Insurance number. If the number is not
								available, the Health Care Cost Containment Council will assign a number based
								on the name in Field 14b.
18
Zip Code of Facility
XXXXXYYYY.
								Five character zip code with a four character extension. If the four character
								extension is unknown, fill with blanks.
19
Payor Group Number
The
								identification number, control number, or code assigned by the carrier or plan
								administrator to identify the group under which the individual is covered.
20
Patient Discharge Status
The
								status of the patient at discharge.
21c
Unusual Occurrence
Infections
								acquired while in the hospital. Nosocomial infections are defined as those
								infections that are clinically manifested after 72 hours in the hospital,
								unless: 1. They are evident within 72 hours after admission and are related to
								a previous hospitalization; 2. They are related to a hospital procedure
								performed within the first 72 hours.
21d
Unusual Occurrence
Patient
								readmission to the hospital within 30 days.
22
Type of Bill
A code indicating
								the specific type of bill (inpatient, outpatient, adjustments, voids, etc.)
23
Patient Control Number
Patient's
								unique alphanumeric number assigned by the provider to facilitate retrieval of
								individual case records and posting of the payment.
24
Diagnosis Related Group
								(DRG)
The condition established after study as being chiefly
								responsible for the admission of a patient to the hospital for care that exists
								at the time of admission or develops subsequently that has an effect on the
								length of stay.
25
Procedure Coding Method Used
An
								indicator that identifies the coding method used for procedure coding on this
								bill.
26
Type of Admission
A code
								indicating the priority of this admission.
27
Source of Admission
A code
								indicating the source of this admission.
28
Patient's Relationship to
								Insured
A code indicating the relationship of the patient to the
								identified insured.
29
Certificate/Social Security
								Number/Health Insurance Claim/ Identification Number
Insured's unique
								identification number assigned by the payor organization.
30
Principal and Other Diagnoses
								Descriptions
Narrative description of the principal diagnosis (i.e.,
								the condition established after study to be chiefly responsible for causing the
								hospitalization or use of hospital services) and other diagnoses.
31
Principal and Other Procedure
								Descriptions
A narrative description of the principal procedure (i.e.,
								the procedure that was performed for definitive treatment rather than the one
								performed for diagnostic or exploratory purposes or the procedure most related
								to the principal diagnosis) and other procedures. The principal procedure is to
								be shown first.
32
Employer Name
The name of the
								employer that might or does provide health care coverage for the individual
								identified in Field 33.
33
Employment Information
A code
								that indicates whether the employment information given in the related areas
								applies to an insured, the patient or the patient's spouse.
34
Employment Status Code
A code
								used to define the employment status of the individual identified in Field
								33.
35
Patient Race
This code indicates
								the patient's racial/ethnic background.
36
Reserve Field
To be reserved for
								future use by the Council.