February 28, 2006 – filing 2006-89 CORRECTION: May 24, 2006 – restored item in Appendix C-1 under ME012, “34 Other Adult” AMENDED: 15, 2009 – filing 2009-157 October 31, 2012 – filing 2012-295 May 27, 2014 – filing 2014-100 October 6, 2015 – filing 2015-183
Refer to Appendix A MC041 Principal Diagnosis 1/1/2003 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A Diagnosis – 1 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC043 Diagnosis – 2 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A Other Diagnosis – 3 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC045 Other Diagnosis – 4 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC046 Other Diagnosis – 5 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC047 Other Diagnosis – 6 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC048 Other Diagnosis – 7 4/1/2004 Text 5 ICD-9-CM Do not code decimal point. Refer to Appendix A MC049 Diagnosis 4/1/2004 Text 5 ICD-9-CM Do not code decimal
routinely change. If blank or not specified, populate with MC076 -- Billing Provider Number. MC093 Service Facility Location Country Code 2/1/2016 Text 2 Code US for United States MC094 Billing Provider Country Code 2/1/2016 Text 2 Code US for United States MC101 Subscriber Last Name 1/1/2010 Text 60 The subscriber last name MC102 Subscriber First Name 1/1/2010 Text 35 The subscriber first name MC103 Subscriber Middle Name 1/1/2010 Text 25 The subscriber middle name or initial MC104 Member Last Name 1/1/2010 Text 60 The member last name Member First Name 1/1/2010 Text 35 The member name MC106 Member Middle Name 1/1/2010 Text 25 The member middle name or initial MC107 Attending Provider Number 2/1/2016 Text 30 Payer assigned attending provider number. This number should be the identifier used by the payer for internal
External Cause of Injury - 20 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC245 Present On Admission Indicator - 20 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC246 External Cause of Injury - 21 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A Present On Admission Indicator - 21 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC248 External Cause of Injury - 22 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC249 Present On Admission Indicator - 22 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC250 External Cause of Injury - 23 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A Present On Admission Indicator - 23 10/1/2014 Text 1 Standard POA code set Refer to Appendix A External of Injury - 24 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A
Indicator – 4 MC262 Other Diagnosis – 5 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC263 Present On Admission Indicator – 5 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC264 Other Diagnosis – 6 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator – 6 10/1/2014 Text 1 Standard POA code set to Appendix A MC266 Other Diagnosis – 7 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC267 Present On Admission Indicator – 7 10/1/2014 Text 1 Standard POA code set to Appendix A MC268 Diagnosis – 8 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC269 Present On Admission Indicator – 8 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC270 Diagnosis 10/1/2004 Text 7 ICD-10-CM Do not code
– 9 decimal point. Refer to Appendix A MC271 Present On Admission Indicator – 9 10/1/2014 Text 1 Standard POA code set Refer to Appendix A Other Diagnosis – 10 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC273 Present On Admission Indicator – 10 10/1/2014 Text 1 Standard POA code set Refer to Appendix A Other Diagnosis – 11 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC275 Present On Admission Indicator – 11 10/1/2014 Text 1 Standard POA code set to Appendix A MC276 Diagnosis – 12 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC277 Present On Admission Indicator – 12 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC278 Other Diagnosis – 13 10/1/2004 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A
MC279 Present On Admission Indicator – 13 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC280 Other Diagnosis – 14 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator – 14 10/1/2014 Text 1 Standard POA code set to Appendix A MC282 Other Diagnosis – 15 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator – 15 10/1/2014 Text 1 Standard POA code set to Appendix A MC284 Other Diagnosis – 16 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC285 Present On Admission Indicator – 16 10/1/2014 Text 1 Standard POA code set to Appendix A MC286 Other Diagnosis – 17 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC287 Present On Admission Indicator – 17 10/1/2014 Text 1 Standard POA code set Refer to Appendix A
MC288 Other Diagnosis – 18 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A Present On Admission Indicator – 18 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC290 Other Diagnosis – 19 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC291 Present On Admission Indicator – 19 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC292 Diagnosis – 20 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC293 Present On Admission Indicator – 20 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC294 Other Diagnosis – 21 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator – 21 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC296 Other Diagnosis – 22 10/1/2014 Text 7 ICD-10-CM Do not code decimal
MC314 Procedure Code - 12 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. to Appendix A Other Procedure Code - 13 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC316 Other Procedure Code - 14 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC317 Other Procedure Code - 15 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC318 Other Procedure Code - 16 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC319 Other Procedure Code - 17 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A Other Procedure Code - 18 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC321 Other Procedure Code - 19 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A Other Procedure Code 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point.
Data Element Date Maximum # Data Element Name Effective Type Length Description/Codes/Sources DC001 Submitter 1/1/2003 Text 8 MHDO-assigned identifier of payer submitting claims data. Do not blank. DC002 Payer 7/1/2012 Text 8 MHDO-assigned code of the insurer/ underwriter in the case of coverage, or of the administrator in the case of self-funded coverage. Do not leave blank. DC003 Insurance Type/Product Code 1/1/2003 Text 2 Code identifying the type of insurance policy within a specific insurance program. to Appendix A DC004 Payer Claim Control Number 1/1/2003 Text 35 Must apply to entire claim and be unique within the payer's system Line Counter 4/1/2004 Number 4 Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. DC006 Insured Group or Policy Number 1/1/2003 Text 30 Group or policy number - not the number that uniquely identifies the subscriber DC007 Subscriber Social Security Number 1/1/2003 Text 9 Subscriber’s social security number Leave blank if unavailable. DC008 Plan Specific Contract Number 1/1/2003 Text 80 Plan assigned contract number Leave blank if contract number = subscriber’s social security number. DC009 Member Suffix or Sequence Number 1/1/2003 Text 20 Uniquely numbers the member within the contract DC010 Member Identification Code 1/1/2003 Text 50 Member’s social security number Leave blank if unavailable. Individual Relationship Code 1/1/2003 Text 2 Member's relationship to insured