Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part VI - Health Care Cost Containment Council › Chapter 913 - PAYOR DATA REPORTING REQUIREMENTS › Subchapter D - INTERPRETATIONS › Appendix A - PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM

Current through Register Vol. 54, No. 28, July 13, 2024
HOSPITAL/AMBULATORY SERVICE FACILITY PAYMENTS AND
					 PHYSICIAN PAYMENTS REPORTING MANUAL
HC-87-101
VOLUME B
TABLE OF CONTENTS
I.
Facility and Physician Payments
								Reporting Manual.
II.
Header Record Manual.
III.
Trailer Record Manual.
IV.
Tape Format for Facility and Physician
								Payments Reporting.
INDEX
DATA ELEMENT
								NAME
FIELD
								#
Certification/SSN/Health Insurance Claim
								Number
20
Date of Admission/Start of Care/Date of
								Service
6
Date of Discharge/End of Care/Last Date of
								Service
7
Identifier of Physician
10
Other Payments
15
Patient Control Number
17
Patient's Birthdate
4
Patient - Uniform Identification
3
Patient Relationship to Insured
19
Patient's Sex
5
Payor Group Number
16
Place of Service
2
Primary Payor Payments
14
Procedure Code
8
Procedure Coding Method Used
18
Record Type
1
Reserve Field
21
Total Charges
13
Type of Professional Service
11
Uniform Identifier of Health Care
								Facility
9
Units of Service
12
I. REPORTING MANUAL
FIELD: 1
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Record Type
DEFINITION:
Indicator distinguishing
								between the different types of records.
PROCEDURE:
1 = Facility payment record.
2 = Physician payment record.
3 = Continuing physician payment record. (When
								individual patient records contain more than one procedure/service, this field
								indicates that this record is a continuation of the previous record.)
4 = Continuing facility payment record. (When
								individual patient records contain more than one procedure/service, this field
								indicates that this record is a continuation of the previous record.)
5 = This record is a delivery which includes
								newborn payments.
FIELD SIZE:
1 field, 1 character
RECORD POSITION:
1
FORMAT:
Numeric
FIELD: 2
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Place of Service
DEFINITION:
Type of setting.
PROCEDURE:
1 = Hospital Inpatient
2 = Hospital Outpatient
3 = Other Ambulatory Service Facility
4 = Unknown
FIELD SIZE:
1 field, 1 character
RECORD POSITION:
2
FORMAT:
Numeric
FIELD: 3
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Uniform Patient I.D.
DEFINITION:
Patient's Social Security
								Number.
PROCEDURES:
Left justify. No dashes. If the
								patient's Social Security Number is unknown, fill this field with zeroes.
FIELD SIZE:
1 field, 9 characters.
RECORD POSITION:
3-11
FORMAT:
Numeric
REFERENCE:
UB-82, Item 2a.
FIELD: 4
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Patient's Birthdate.
DEFINITION:
The date of birth of the
								patient.
PROCEDURE:
MMDDYYYY. If full birthdate is
								unknown, place the patient's year of birth in this field. Right justify. No
								dashes.
FIELD SIZE:
1 field, 8 characters.
RECORD POSITION:
12-19
FORMAT:
Numeric
REFERENCE:
UB-82, Item 12 or HCFA 1500,
								Item 2
FIELD: 5
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Patient's Sex.
DEFINITION:
The sex of the patient as
								recorded at the date of admission, outpatient service, or start of care.
PROCEDURE:
M = Male or 1 = Male
F = Female 2 = Female
U = Unknown 3 = Unknown
M, F, U is the preferred method. Data submitted in
								the format of a 1, 2, or 3 will be converted to M, F, or U by the Council. Edit
								reports to data sources will contain M, F, U.
FIELD SIZE:
1 field, 1 character.
RECORD POSITION:
20
FORMAT:
Alphanumeric
REFERENCE:
UB-82, item 13 or HCFA 1500,
								item 5
FIELD: 6
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Date of Admission/Start of
								Care/First Date of Service
DEFINITION:
The date that the patient was
								admitted to the provider for inpatient care, outpatient services, start of care
								or the beginning date of the period covered by this bill.
PROCEDURE:
MMDDYY.
FIELD SIZE:
1 field, 6 characters.
RECORD POSITION:
21-26
FORMAT:
Numeric
REFERENCE:
UB-82, item 15 or HCFA 1500,
								item 20 (the first 6 characters of this field.)
FIELD: 7
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Date of Discharge/End of
								Care/Last Date of Service
DEFINITION:
The ending service date of the
								period covered by this bill or the date that the patient was discharged from
								the provider's care.
PROCEDURE:
MMDDYY.
FIELD SIZE:
1 field, 6 characters.
RECORD POSITION:
27-32
FORMAT:
Numeric
REFERENCE:
UB-82, item 22 (the last 6
								characters in this field.) or HCFA 1500, item 20 (the last 6 characters of this
								field.)
FIELD: 8
REQUIRED:
Physician Payments Reporting Only
								(Blank fill for Facility Payments Records.)
DATA ELEMENT:
Procedure Code
DEFINITION:
Surgical Procedure Code, if
								any. Other procedure codes when available.
PROCEDURE:
The code structure must be
								consistent with the information provided in field 18. This field is required if
								field 11 is equal to an 02 or 05. This field is optional if field 11 is equal
								to an 01, 03, or 04. Use ICD-9-CM, HCPCS or CPT-4 codes. Left justify. Use
								decimal. Blank fill right. If unknown, blank fill.
FIELD SIZE:
1 field, 9 characters
RECORD POSITION:
33-41
FORMAT:
Alphanumeric
REFERENCE:
UB-82, item 84 or HCFA 1500,
								item 24d
FIELD: 9
REQUIRED:
Facility Payments Reporting Only
								(Blank fill for Physician Payments Records.)
DATA ELEMENT:
Uniform Identifier for Health
								Care Facility
DEFINITION:
Medicaid Number, Federal Tax
								I.D. Number, or Medicare Number.
PROCEDURE:
Character 1: 1 or A = Medicaid
								Number 2 or B = Tax I.D. Number 3 or C = Medicare Number
Characters 2-11: Medicaid Number, Tax I.D. Number,
								or Medicare Number. Left justify.
The Medicaid Number is the preferred number. Data
								Sources using other numbering systems must provide the Council with a Facility
								I.D. Dictionary on tape according to a format approved by the Council. The
								facility I.D. dictionary must have one number for each separately licensed
								facility.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
42-52
FORMAT:
Alphanumeric
REFERENCE:
UB-82, item 6
FIELD: 10
REQUIRED:
Physician Payments Reporting Only
								(Blank fill for Facility Payments Records.)
DATA ELEMENT:
Identifier of Physician
DEFINITION:
PA State License Number, Social
								Security Number, or Tax I.D. of the Physician. Other Unique Provider Numbers
								may be acceptable, however, prior approval must be obtained from the Council.
PROCEDURE:
Character 1: 1 or A = PA State
								License 2 or B = S.S. Number 3 or C = Tax I.D. Number 4 or D = Unique Provider
								Number
Characters 2-10 = PA State License, S.S. Number,
								Tax I.D., Unique Provider Number
Characters 11-20 = Physician Last Name
Characters 21-22 = Physician First and Middle
								Initial
Left Justify, Blank fill. The Pa. State license
								number is the preferred number. Data sources using other numbering systems must
								provide the Council with a dictionary of physician I.D. numbers on tape
								according to a format approved by the Council. (The approved format is
								described in Appendix B.) The Physician I.D. dictionary must have one number
								for each separately licensed physician.
FIELD SIZE:
1 field, 22 characters
RECORD POSITION:
53-74
FORMAT:
Alphanumeric
REFERENCE:
HCFA 1500, item 33.
FIELD: 11
REQUIRED:
Physician Payments Reporting Only
								(Zero fill for Facility Payments Records.)
DATA ELEMENT:
Type of Professional Service
DEFINITION:
The type of service that the
								physician performed for which payment is expected.
PROCEDURE:
01 = Medical, Consulting,
								Psychiatric (Includes drug abuse and alcohol treatment.) 02 = Surgical,
								Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in
								Surgery
FIELD SIZE:
1 field, 2 characters
RECORD POSITION:
75-76
FORMAT:
Numeric
REFERENCE:
HCFA 1500, item 24c
FIELD: 12
REQUIRED:
Physician Payments Reporting Only
								(Zero fill for Facility Payments records.)
DATA ELEMENTS:
Units of Service
DEFINITION:
If available, enter the total
								number of identical procedures or services, such as hospital visits.
PROCEDURE:
Right justify. Fill with zeroes
								left.
FIELD SIZE:
1 field, 3 characters
RECORD POSITION:
77-79
FORMAT:
Numeric
REFERENCE:
HCFA 1500, item 24g
FIELD: 13
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Total Charges
DEFINITION:
Total charges pertaining to the
								current billing period as entered in the statement covers period.
PROCEDURES:
Facility total Charges = Place
								total charges as stated in the definition above. Physician total Charges =
								Place the total charge for the procedure or service indicated in fields 11 and
								8. When the physician/professional or facility has provided more than one
								procedure or service, more than one record should be provided. The multiple
								records should be indicated as follows:
1. In field 1, place the number 3 or 4 which
								indicates that this record is a continuation of the previous record.
2. Complete the following fields: a. 8 - Procedure
								Code b.11 - Type of Professional Service. c.13 - Total Charges d.14 - Primary
								Payor Payments e.15 - Other Payments
3. All other fields in this record should be
								duplicated depending upon the format of each field. Right justify. No decimal.
FIELD SIZE:
1 field, 8 characters Character
								1-6 = dollars Character 7-8 = cents
RECORD POSITIONS:
80-87
FORMAT:
Numeric
REFERENCE:
UB-82, item 53 (Last line of
								this field.) or HCFA 1500, item 24f
FIELD: 14
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Primary Payor Payments
DEFINITION:
Total of all payments made by
								the payor to the health care facility or professional for services rendered to
								the patient for the episode of illness indicated in fields 6 and 7.
PROCEDURE:
Facility payments = Place total
								Primary Payor Payments as stated in the definition above. Physician payments =
								Place the total Primary Payor Payments for the procedure or service indicated
								in fields 11 and 8. When the physician/professional or facility has provided
								more than one procedure or service, more than one record should be provided.
								The multiple records should be indicated as follows:
1. In field 1, place the number 3 or 4 which
								indicates that this record is a continuation of the previous record.
2. Complete the following fields: a. 8 - Procedure
								Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary
								Payor Payments e.15 - Other Payments
3. All other fields in this record should be
								duplicated depending upon the format of each field. Right justify. No decimal.
FIELD SIZE:
1 field, 8 characters Character
								1-6 = dollars Character 7-8 = cents
RECORD POSITION:
88-95
FORMAT:
Numeric
REFERENCE:
UB-82, item 55
FIELD: 15
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Other Payments
DEFINITION:
The sum of deductible amounts
								and co-pay amounts that are attributed to the patients responsibility or other
								secondary payors.
PROCEDURE:
Facility other payments = Place
								total of Other Payments as stated in the definition above. Physician other
								payments = Place the total of Other Payments for the procedure or service
								indicated in fields 11 and 8. When the physician/professional or facility has
								provided more than one procedure or service, more than one record should be
								provided. The multiple records should be indicated as follows:
1. In field 1, place the number 3 or 4 which
								indicates that this record is a continuation of the previous record.
2. Complete the following fields: a. 8 - Procedure
								Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary
								Payor Payments e.15 - Other Payments
3. All other fields in this record should be
								duplicated depending upon the format of each field. Right justify. No Decimal.
FIELD SIZE:
1 field 8 characters Character
								1-6 = dollars Character 7-8 = cents
RECORD POSITION:
96-103
FORMAT:
Numeric
FIELD: 16
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Payor Group Number
DEFINITION:
The identification number,
								control number, or code assigned by the carrier or plan administrator to
								identify the group under which the individual is covered.
PROCEDURE:
Left justify.
FIELD SIZE:
1 field, 17 characters
RECORD POSITION:
104-120
FORMAT:
Alphanumeric
REFERENCE:
UB-82, item 70 or HCFA 1500,
								item 8
FIELD: 17
REQUIRED:
Facility Payments Reporting Only
								(Blank fill for Physician Payments Records.)
DATA ELEMENT:
Patient Control Number
DEFINITION:
Patient's unique alphanumeric
								number assigned by the carrier to facilitate retrieval of individual case
								records and posting of the payment. This field is optional.
PROCEDURE:
Left justify.
FIELD SIZE:
1 field, 17 characters
RECORD POSITION:
121-137
FORMAT:
Alphanumeric
FIELD: 18
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Procedure Coding Method Used
DEFINITION:
An indicator that identifies
								the coding method used for procedure coding on this bill.
PROCEDURE:
1-3 = Reserved for state
								assignment 4 = CPT-4 5 = HCPCS (HCFA Common Procedure Coding System) 6-8 =
								Reserved for National assignment 9 = ICD-9-CM
FIELD SIZE:
1 field, 1 character
RECORD POSITION:
138
FORMAT:
Numeric
REFERENCE:
UB-82, item 82
FIELD: 19
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Patient's Relationship to
								Insured
DEFINITION:
A code indicating the
								relationship of the patient to the identified insured.
PROCEDURE:
Use coding as follows: 1 = Self
								2 = Spouse 3 = Child 4 = Other Right justify. Zero fill left.
FIELD SIZE:
1 field, 2 characters
RECORD POSITION:
139-140
FORMAT:
Numeric
REFERENCE:
UB-82, item 67 a or HCFA 1500,
								item 7
FIELD: 20
REQUIRED:
Facility and Physician Payments
								Reporting
DATA ELEMENT:
Certificate/Social Security
								Number/Health Insurance Claim/Identification Number.
DEFINITION:
Insured's unique identification
								number assigned by the payor organization.
PROCEDURE:
Left justify.
FIELD SIZE:
1 field, 16 characters
RECORD POSITION:
141-156
FORMAT:
Alphanumeric
REFERENCE:
UB-82, item 68 or HCFA 1500,
								item 6
FIELD: 21
DATA ELEMENT:
Reserve Field
DEFINITION:
To be reserved for future use
								by the Council.
FIELD SIZE:
1 field filler, 144 characters
RECORD POSITION:
157-300
FORMAT:
Alphanumeric
II. HEADER RECORD
FIELD: 1
DATA ELEMENT:
Data Source Identifier
DEFINITION:
Number identifying the data
								source. Third party payors - use your payor number.
PROCEDURE:
Left justify. Blank fill right.
FIELD SIZE:
1 field, 25 characters
RECORD POSITION:
1-25
FORMAT:
Alphanumeric
FIELD: 2
DATA ELEMENT:
Data Source Name/Address
DEFINITIONS:
Name and address of the data
								source.
PROCEDURE:
Left justify. Fill with blanks
								right. Space between lines of name and address.
FIELD SIZE:
1 field, 4 lines, 100
								characters
RECORD POSITION:
26-125
FORMAT:
Alphanumeric
FIELD: 3
DATA ELEMENT:
Period Covered First Day
DEFINITION:
The first day of the quarter
								from which the data provided on this tape was contained.
PROCEDURE:
MMDDYY.
FIELD SIZE:
1 field, 6 characters
RECORD POSITION:
126-131
FORMAT:
Numeric
FIELD: 4
DATA ELEMENT:
Period Covered Last Day
DEFINITION:
The last day of the quarter
								from which the data provided on this tape was contained.
PROCEDURE:
MMDDYY.
FIELD SIZE:
1 field, 6 characters
RECORD POSITION:
132-137
FORMAT:
Numeric
FIELD: 5
DATA ELEMENT:
Run Date
DEFINITION:
The date that the data source
								produced this tape.
PROCEDURE:
MMDDYY.
FIELD SIZE:
1 field, 6 characters
FIELD POSITION:
138-143
FORMAT:
Numeric
FIELD: 6
DATA ELEMENT:
Filler
FIELD SIZE:
1 field filler, 157 characters
RECORD POSITION:
144-300
FORMAT:
Alphanumeric
III. TRAILER RECORD
FIELD: 1
DATA ELEMENT:
Number of records on this
								tape.
DEFINITION:
Total number of records
								contained on this tape, not including the Header and Trailer Records. This
								number should count each multi-page as one record.
PROCEDURE:
Right justify.
FIELD SIZE:
1 field, 10 characters
RECORD POSITION:
1-10
FORMAT:
Numeric
FIELD: 2
DATA ELEMENT:
Number of Patients on This
								Tape.
DEFINITION:
Total number of patients
								contained on this tape.
PROCEDURE:
Right justify.
FIELD SIZE:
1 field, 10 characters
RECORD POSITION:
11-20
FORMAT:
Numeric
FIELD: 3
DATA ELEMENT:
Total Physician Charges
DEFINITION:
Total of all Physician Charges
								on this tape.
PROCEDURE:
Sum of all fields 13 (Total
								Charges) when field 1 is equal to 2. Right justify. The last two digits are for
								cents.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
21-31
FORMAT:
Numeric
FIELD: 4
DATA ELEMENT:
Total Facility Charges
DEFINITION:
Total of all Facility Charges
								on this tape.
PROCEDURE:
Sum of all fields 13 (Total
								Charges) when field 1 is equal to 1. Right justify. The last two digits are for
								cents.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
32-42
FORMAT:
Numeric
FIELD: 5
DATA ELEMENT:
Total Physician Payments
DEFINITION:
Total of all Physician Payments
								on this tape.
PROCEDURE:
Sum of all fields 14 (Primary
								Payor Payments) when field 1 is equal to 2. Right justify. The last two digits
								are for cents.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
43-53
FORMAT:
Numeric
FIELD: 6
DATA ELEMENT:
Total Facility Payments
DEFINITION:
Total of all Facility Payments
								on this tape.
PROCEDURE:
Sum of all fields 14 (Primary
								Payor Payments) when field 1 is equal to 1. Right justify. The last two digits
								are for cents.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
54-64
FORMAT:
Numeric
FIELD: 7
DATA ELEMENT:
Total Other Payments
								(Physician)
DEFINITION:
Total of all Other Payments to
								Physicians on this tape.
PROCEDURE:
Sum of all fields 15 (Other
								Payments) when field 1 is equal to 2. Right justify. The last two digits are
								for cents.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
65-75
FORMAT:
Numeric
FIELD: 8
DATA ELEMENT:
Total Other Payments
								(Facility)
DEFINITION:
Total of all Other Payments to
								Facilities on this tape.
PROCEDURE:
Sum of all fields 15 (Other
								Payments) when field 1 is equal to 1.
FIELD SIZE:
1 field, 11 characters
RECORD POSITION:
76-86
FORMAT:
Numeric
FIELD: 9
DATA ELEMENT:
Filler
FIELD SIZE:
1 field filler, 214 characters
RECORD POSITION:
87-300
FORMAT:
Alphanumeric
DATA ELEMENT
DATA ELEMENT
								DESCRIPTION
POSITION
PICTURE
FORMAT
FROM
TO
HEADER RECORD
1
Data Source Identifier
1
25
X(25)
Left justify. Blank fill right.
2
Data Source Name
26
125
X(100)
4 lines. 25 characters each.
3
Period Covered First
								Day
126
131
9(6)
MMDDYY.
4
Period Covered Last
								Day
132
137
9(6)
MMDDYY.
5
Run
								Date
138
143
9(6)
MMDDYY. Date that this tape
								was created.
6
Filler
144
300
X(157)
TAPE FORMAT FOR HOSPITAL/AMBULATORY SERVICE FACILITY
					 PAYMENTS AND PHYSICIAN PAYMENTS REPORTING MANUAL HC-87-101B
DATA ELEMENT
DATA ELEMENT
								DESCRIPTION
POSITION
PICTURE
FORMAT
FROM
TO
1
Record
								Type
1
9(1)
1 = Facility payments record. 2 = Physician
								payments record. 3 = Continuing physician payments record. 4 = Continuing
								facility payments record. 5 = Delivery/ newborn record.
2
Place of
								Service
2
9(1)
1 = Hospital Inpatient 2 = Hospital
								Outpatient 3 = Ambulatory Service Facility 4 = Unknown
3
Uniform Patient
								Identifier
3
11
9(9)
If unknown, zero fill.
4
Patient's Date of
								Birth
12
19
9(8)
MMDDYYYY. If the patient date
								of birth is unknown, place the patient's year of birth in this field. Right
								justify.
5
Patient's
								Sex
20
X(1)
M = Male, F = Female, U = Unknown 1 = Male,
								2 = Female, 3 = Unknown.
6
Date of Admission/ Start of Care/Date of
								Service
21
26
9(6)
MMDDYY.
7
Date of Discharge/ End of Care/Last Date
								of Service
27
32
9(6)
MMDDYY.
8
Procedure Code
33
41
X(9)
Procedure code. Left justify. Use decimal. See manual
								for instructions.
9
Uniform Identifier of Health Care
								Facility
42
52
X(11)
Left justify. Blank fill
								right.
10
Identifier of
								Physician
53
74
X(22)
Left justify. Blank
								fill. See Manual for instructions.
11
Type of Professional
								Service
75
76
9(2)
Type of service performed
								by the professional: 01 = Medical, Consulting, Psychiatric, (Including drug
								abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic,
								Radiologic 04 = Anesthetic 05 = Assisted in surgery
12
Units of
								Service
77
79
9(3)
Right justify. Fill with
								zeroes left.
13
Total Charges
80
87
9(8)
6 dollar characters, 2 cent characters. Right justify.
								No decimal.
14
Primary Payor
								Payments
88
95
9(8)
6 dollar characters, 2
								cent characters. Right justify. No decimal.
15
Other
								Payments
96
103
9(8)
6 dollar characters, 2
								cent characters. Right justify. No decimal.
16
Payor Group
								Number
104
120
X(17)
Left justify.
17
Patient Control
								Number
121
137
X(17)
Left justify.
18
Procedure Coding Method
								Used
138
9(1)
1 - 3 Reserved for state assignment. 4 =
								CPT-4 5 = HCPCS 6 - 8 = Reserved for national assignment. 9 = ICD-9-CM
19
Patient's Relation- ship to
								Insured
139
140
9(2)
Right justify. 1 = Self 2
								= Spouse 3 = Child 4 = Other
20
Certification/SSN/ Health Insurance
								Claim Number
141
156
X(16)
Left justify.
21
Reserve
								Field
157
300
X(144)
To be reserved for future
								use by the Council.
*All numeric fields should be
								initialized to 0, and alpha numeric fields initialized to blank, before writing
								data to tape. Therefore, these characters (or blanks) will remain in fields
								where data is missing.
DATA ELEMENT
DATA ELEMENT
								DESCRIPTION
POSITION
PICTURE
FORMAT
FROM
TO
TRAILER RECORD
1
Number of Records on This
								Tape
1
10
9(10)
Total Number of patient
								discharge records on this tape.
2
Number of Patients on This
								Tape
11
20
9(10)
Total number of patients on
								this tape.
3
Total Physician
								Charges
21
31
9(11)
Total of all physician
								charges on this tape.
4
Total Facility
								Charges
32
42
9(11)
Total of all facility
								charges on this tape.
5
Total Physician
								Payments
43
53
9(11)
Total of all physician
								payments on this tape.
6
Total Facility
								Payments
54
64
9(11)
Total of all facility
								payments on this tape.
7
Total Other Payments
								(Physician)
65
75
9(11)
Total of all physician
								other payments on this tape.
8
Total Other Payments
								(Facility)
76
86
9(11)
Total of all facility
								other payments on this tape.
9
Filler
87
300
9(214)