INSTITUTIONAL/NON-INSTITUTIONAL RECORD DATA ELEMENTS (P)

Transcription

1 M, MAY 999 DATA REQUIREMENTS CHAPTER 2 SECTION 7 INSTITUTIONAL/NON-INSTITUTIONAL RECORD DATA ELEMENTS (P) PATIENT CO-INSURANCE Non PRIMARY PICTURE (FORMAT) Eight (8) signed numeric digits including two (2) decimal places. DEFINITION The amount of allowed charges that beneficiaries are required to pay under TRICARE. ALGORITHM For standard TRICARE program the co-insurance must be calculated in accordance with the TRICARE Reimbursement Manual, Chapter 2, Section. PATIENT COST-SHARE C-35, April 7, 2003

2 CHAPTER 2, SECTION M, MAY 999 PATIENT CO-PAYMENT Non PRIMARY PICTURE (FORMAT) Eight (8) signed numeric digits including two (2) decimal places. DEFINITION A fixed amount charged by the contractor that the beneficiary is liable for paying for covered services. ALGORITHM For standard TRICARE program, co-payment must be calculated in accordance with the TRICARE Reimbursement Manual, Chapter 2, Section. Co-payment must be calculated in accordance with established fees for service, if other than standard TRICARE program. PATIENT COST-SHARE 2 C-35, April 7, 2003

3 M, MAY 999 CHAPTER 2, SECTION 7 PATIENT COST-SHARE Non- PRIMARY PICTURE (FORMAT) Group DEFINITION ALGORITHM Two (2) element field reporting the amount of money the beneficiary is responsible for paying in connection with covered services, other than the annual fiscal year deductible and any disallowed amounts. PATIENT CO-INSURANCE PATIENT CO-PAYMENT 3 C-35, April 7, 2003

4 CHAPTER 2, SECTION M, MAY 999 PATIENT DATE OF BIRTH Non PRIMARY PICTURE (FORMAT) Eight (8) numeric characters, YYYYMMDD. DEFINITION Date of birth of patient. YYYY 4 digit calendar year MM 2 digit calendar month DD 2 digit calendar day ALGORITHM Download field from DEERS. For specific instructions, refer to Chapter 9 4 C-8, January, 2000

5 M, MAY 999 CHAPTER 2, SECTION 7 PATIENT NAME Non PRIMARY PICTURE (FORMAT) Twenty-seven (27) alphanumeric characters. DEFINITION Name of patient. Last name must be at least one () character, followed by a comma. ALGORITHM Download field from DEERS. For specific instructions, refer to Chapter 9 5 C-8, January, 2000

6 CHAPTER 2, SECTION M, MAY 999 PATIENT RELATIONSHIP TO SPONSOR Non PRIMARY PICTURE (FORMAT) One () alphanumeric character. DEFINITION Code that defines the relationship of the patient to the sponsor. b Sponsor C Child (includes adopted) or Step Child F Unremarried Widow(er) G Unmarried Widow(er) H Unmarried Former Spouse meeting 20/20/20 criteria L Parent-in-law (Terminated 0/6/2003) M Step Parent-In-Law (Terminated 0/6/2003) P Dependent Parent, Dependent Step Parent, Dependent Parent-in-law, Dependent Step Parent-in-law R Unremarried Former Spouse divorced on or after April, 985, meeting 20/20/5 criteria S Spouse T Unremarried Former Spouse U Step Parent (Terminated 0/6/2003) V Step Child (Terminated 0/6/2003) W X Y Z Ward (includes foster and preadoptive children) Other (includes good faith payments) Unremarried Former Spouse divorced prior to April, 985, meeting 20/20/5 criteria Unknown Download field from DEERS. For specific instructions, refer to Chapter 9. As of 0/6/2003, DEERS will no longer be supplying these codes. 6 C-4, September 4, 2003

7 M, MAY 999 CHAPTER 2, SECTION 7 PATIENT RELATIONSHIP TO SPONSOR (CONTINUED) ALGORITHM BENEFICIARY CATEGORY Download field from DEERS. For specific instructions, refer to Chapter 9. As of 0/6/2003, DEERS will no longer be supplying these codes. 7 C-4, September 4, 2003

8 CHAPTER 2, SECTION M, MAY 999 PATIENT SEX Non PRIMARY PICTURE (FORMAT) One () alphanumeric character. DEFINITION Code defining sex of patient. DEERS/Claim F Female M Male ALGORITHM Download field from DEERS. For specific instructions, refer to Chapter 9. 8 C-4, September 4, 2003

9 M, MAY 999 CHAPTER 2, SECTION 7 PATIENT SSN Non PRIMARY PICTURE (FORMAT) Nine (9) alphanumeric characters. DEFINITION Patient Social Security Number. If unknown, blank fill. ALGORITHM No No Optional. If entered, must be valid. 9 C-4, September 4, 2003

10 CHAPTER 2, SECTION M, MAY 999 PATIENT ZIP CODE Non PRIMARY PICTURE (FORMAT) Nine (9) alphanumeric characters. DEFINITION US Postal Zip Code or foreign country code for patient s legal residence at the time service was rendered and must not be the zip code of a P.O. Box. Valid 5 or 9 digit zip code. If only 5 digit, left justify and blank fill to right. If foreign country, must be 2 character foreign country code, left justified and blank filled. See Addendum A. ALGORITHM 0 C-4, September 4, 2003

11 M, MAY 999 CHAPTER 2, SECTION 7 PCM LOCATION DMIS-ID Non PRIMARY PICTURE (FORMAT) Four (4) alphanumeric characters. DEFINITION ALGORITHM No No This code identifies and distinguishes MTF/Clinic enrollments from network enrollments primarily for reporting on Enrollment Based Capitation (EBC). EBC became operational on 0/0/997. The code designations vary based on type of Prime enrollment and begin work dates of new programs such as TRICARE Prime Remote (TPR) which has an effective date of 0/0/999. The codes also vary based on the individual requirements of enrolling platforms used by the Managed Care Support regions. For detailed instructions on how this field is used turn to Chapter 9, Section 2. PCM LOCATION DMIS-ID CODE C-4, September 4, 2003

12 CHAPTER 2, SECTION M, MAY 999 PLACE OF SERVICE Non Up to 25 PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters. DEFINITION Code to indicate the location of provided health care. -Digit Place of Service codes Inpatient Hospital (Terminated 0/3/2000) 2 Outpatient Hospital (Terminated 0/3/2000) 3 Doctor s Office (Terminated 0/3/2000) 4 Patient s Home (Terminated 0/3/2000) 5 Day Care Facility (Terminated 0/3/2000) 6 Night Care Facility (Terminated 0/3/2000) 7 Nursing Home (Terminated 0/3/2000) 8 Skilled Nursing Facility/Extended Care Facility (Terminated 0/3/2000) 9 Ambulance (Terminated 0/3/2000) 0 Other Locations (Terminated 0/3/2000) A Independent Laboratory (Terminated 0/3/2000) B Ambulatory Surgical Center (Terminated 0/3/2000) C Residential Treatment Center (Terminated 0/3/2000) D Other Specialized Treatment Facility (e.g. Drug and Alcohol Treatment Facility, etc.) (Terminated 0/3/2000) E Birthing Center - Free Standing (Terminated 0/3/2000) F Independent Kidney Disease Treatment Center (Terminated 0/3/2000) Single digit codes were outdated in 992, when the 500 was modified. Adjustment/ cancellation for the one-digit codes are valid through /0/200, single-digit codes must be left justified and blank filled. 2 C-4, September 4, 2003

13 M, MAY 999 CHAPTER 2, SECTION 7 (CONTINUED) PLACE OF SERVICE (CONTINUED) G Pharmacy (Outpatient) - Drugs Only Ambulance (Terminated 0/3/2000) 2-digit Place Of Service codes for the revised HCFA versions. 00 Unassigned Office 2 Home 0; 3-9 Unassigned 2 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 20; Unassigned 3 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 30; Unassigned 4 Ambulance - Land 42 Ambulance - Air or Water 40; Unassigned 5 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility Single digit codes were outdated in 992, when the 500 was modified. Adjustment/ cancellation for the one-digit codes are valid through /0/200, single-digit codes must be left justified and blank filled. 3 C-4, September 4, 2003

14 CHAPTER 2, SECTION M, MAY Psychiatric Residential Treatment Center (CONTINUED) 50; Unassigned 6 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 60; 63; 64 Unassigned 65 End Stage Renal Disease Treatment Facility Unassigned 7 State or Local Public Health Clinic 72 Rural Health Clinic 70; Unassigned 8 Independent Laboratory 80; Unassigned 99 Other Unlisted Facility Unassigned ALGORITHM PLACE OF SERVICE (CONTINUED) Single digit codes were outdated in 992, when the 500 was modified. Adjustment/ cancellation for the one-digit codes are valid through /0/200, single-digit codes must be left justified and blank filled. 4 C-4, September 4, 2003

15 M, MAY 999 CHAPTER 2, SECTION 7 PRICING CODE Non Up to 25 PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters 2. DEFINITION The code indicating the contractor s pricing methodology used in determining the amount allowed for the service(s)/ supplies. 0 Pricing not applicable (denied service/ supplies and allowed drugs) Priced Manually 2 Prevailing charge (state) 3 Conversion factor(contractor) 4 Paid as billed 5 Paid on negotiated rate 6 Prevailing/conversion adjusted by the MEI - Primary Care 7 Prevailing/conversion adjusted by the MEI - Non-primary care, total charge subjected to MEI 8 Prevailing/conversion adjusted by the MEI - Non-primary care professional component only 9 Paid on surgical tier pricing (For use by CRI contractor only) A National prevailing charge B National conversion factor C Ambulatory surgery-facility payment rate. Code 0 for all allowed drug charges. Use Pricing Code (Priced Manually) for consultation procedures (procedure code* 906XX) for which the allowable charge is limited to that for a Limited Initial Visit, New Patient (procedure code* 9000). 2 When using single digit codes, left justify and blank fill. * CPT codes, descriptions and other data only are copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS Restrictions Apply to Government use. 5 C-50, April 30, 2004

16 CHAPTER 2, SECTION M, MAY 999 (CONTINUED) PRICING CODE (CONTINUED) D E F G H I J K L M N O P Discounted ambulatory surgery-facility payment rate. Ambulatory surgery-paid as billed. TRICARE Claimcheck-added procedure, priced manually TRICARE Claimcheck-added procedure, prevailing charge (state) TRICARE Claimcheck-added procedure, conversion factor (contractor) TRICARE Claimcheck-added procedure, paid as billed TRICARE Claimcheck-added procedure, paid on negotiated rate TRICARE Claimcheck-added procedure, prevailing/conversion adjusted by MEI - primary care TRICARE Claimcheck-added procedure, prevailing/conversion adjusted by the MEI - non-primary care, total charge subject to MEI TRICARE Claimcheck-added procedure, prevailing/conversion adjusted by the MEI - non-primary care professional component only TRICARE Claimcheck-added procedure, national prevailing charge TRICARE Claimcheck-added procedure, national conversion factor TRICARE Claimcheck-added procedure, ambulatory surgery-facility payment rate Code 0 for all allowed drug charges. Use Pricing Code (Priced Manually) for consultation procedures (procedure code* 906XX) for which the allowable charge is limited to that for a Limited Initial Visit, New Patient (procedure code* 9000). 2 When using single digit codes, left justify and blank fill. * CPT codes, descriptions and other data only are copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS Restrictions Apply to Government use. 6 C-50, April 30, 2004

17 M, MAY 999 CHAPTER 2, SECTION 7 (CONTINUED) PRICING CODE (CONTINUED) ALGORITHM Q R T U V W TRICARE Claimcheck-added procedure, discounted ambulatory surgery-facility payment rate TRICARE Claimcheck-added procedure, ambulatory surgery-paid as billed TRICARE Claimcheck-added procedure, allowed as billed but paid less than billed Medicare Reimbursement Used TRICARE Claim-added procedure, CMACpriced laboratory code Priced Over CMAC Code 0 for all allowed drug charges. Use Pricing Code (Priced Manually) for consultation procedures (procedure code* 906XX) for which the allowable charge is limited to that for a Limited Initial Visit, New Patient (procedure code* 9000). 2 When using single digit codes, left justify and blank fill. * CPT codes, descriptions and other data only are copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS Restrictions Apply to Government use. 7 C-50, April 30, 2004

18 CHAPTER 2, SECTION M, MAY 999 PRICING LOCALITY CODE Non PRIMARY PICTURE (FORMAT) Three (3) alphanumeric characters. DEFINITION The TRICARE assigned locality code for the physical location where the provider is physically located/or rendered the service. ALGORITHM For Internal Partnership claims and Resource Sharing claims, the locality code must be the location of the MTF where services were rendered. 8 C-4, September 4, 2003

19 M, MAY 999 CHAPTER 2, SECTION 7 PRICING PROFILE Non PRIMARY PICTURE (FORMAT) Two (2) alphanumeric digits. DEFINITION Number identifying the Pricing Profile used to determine the allowable charge. 88 = 88 Profile 0/0/987-0/3/ = 89 Profile 02/0/989-2/3/989 = Profile 0/0/990-03/3/ = 90 Profile 04/0/990-0/06/99 9 = 9 Profile 0/07/99-04/30/ = 92 Profile 05/0/992-02/28/ = 93 Profile 03/0/993-0/3/993 4 = 4 Profile /0/993-03/3/ = 94 Profile 04/0/994-2/3/994 5 = 5 Profile 0/0/995-02/28/ = 95 Profile 02/0/995-0/3/996 6 = 6 Profile 0/0/996-0/3/ = 96 Profile 02/0/996-2/3/996 7 = 7 Profile 0/0/997-02/28/ = 97 Profile 03/0/997-2/3/997 8 = 98 Profile 0/0/998-0/3/ = 98 Profile 02/0/998-07/3/ = 98 Profile 08/0/998-2/3/998 9 = 99 Profile 0/0/999-0/3/ = 99 Profile 02/0/999-0/3/2000 And if Second Byte Type of Service = 7 (Anesthesia) with an end of care between 0/0/999 and 03/3/2000 Required if Pricing Code 2, 3, 6, 7, 8, A or B. 9 C-4, September 4, 2003

20 CHAPTER 2, SECTION M, MAY 999 (CONTINUED) PRICING PROFILE (CONTINUED) ALGORITHM 00 = 00 Profile 02/0/2000-0/3/200 And if Second Byte Type of Service = 7 (Anesthesia) with an end of care 04/0/ = 0 Profile 02/0/200-0/3/ = 02 Profile 02/0/ /3/ = 03 Profile (04/0/ /29/2004) 04 = 04 Profile (03/0/ /99/9999) Required if Pricing Code 2, 3, 6, 7, 8, A or B. 20 C-49, February 9, 2004

21 M, MAY 999 CHAPTER 2, SECTION 7 PRINCIPAL OPERATION/NON-SURGICAL PROCEDURE CODE -340 PRIMARY PICTURE (FORMAT) Five (5) alphanumeric characters. DEFINITION The code that identifies the principal procedure performed during the period covered by this HCSR as coded on the UB- 82 or UB-92. Must limit to 4 of the 5 positions available. Use the most current procedure code edition as directed by TMA. Must provide the most detailed code. Must be left justified and blank filled. Do not code the decimal point which, for ICD-9- CM, is always assumed to follow the second position. Blank fill if not applicable. ALGORITHM Required if one of the following Revenue Codes are present 36X or 72X. 2 C-4, September 4, 2003

22 CHAPTER 2, SECTION M, MAY 999 PRINCIPAL TREATMENT DIAGNOSIS Non PRIMARY PICTURE (FORMAT) Six (6) alphanumeric characters. DEFINITION The condition established, after study, to be the major cause for the patient to obtain medical care as coded on the claim form or otherwise indicated by the provider. Must limit to 5 of the 6 positions available. Use the most current diagnosis code edition, as directed by TMA. Must provide the most detailed code. Left justify and blank fill. Do not code the decimal point, which for ICD-9-CM is always assumed to be following the third position. ALGORITHM 22 C-4, September 4, 2003

23 M, MAY 999 CHAPTER 2, SECTION 7 PROCEDURE CODE Non Up to 25 PRIMARY PICTURE (FORMAT) Five (5) alphanumeric characters. DEFINITION Code indicating the procedure which describes the care received. See Physician s Current Procedure Terminology (CPT-4), or HCPCS National Level II Medicare Codes or TMA approved codes (Figure 2-E-). ALGORITHM 23 C-4, September 4, 2003

24 CHAPTER 2, SECTION M, MAY 999 PROCEDURE CODE MODIFIER Non No PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters. DEFINITION Two digit code which provides the means by which the health care professional can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Must be 2-27, 32, 47, 50-59, 62, 63, 66, 73-82, 90, 9, 99, D, E, G, H, I, J, N, P, R, S, X, AA, AD, AH, AJ, AM, AP, AS - AV, A - A9, BA, BP, BQ, BR, BU, CC, EJ, EM, EP, ET, EY, E - E4, FA, FP, F - F9, GA - GC, GE, GG, GH, GJ, GK, GL, GM, GN, GO, GP, GQ, GT, GV, GW, GY, GZ, G - G9, HA - HZ, H9, JW, KA, KB, KH, KI, KJ, KM - KS, KX, KZ, K0 - K4, LC, LD, LL, LR, LS, LT, MS, MR, NR, NU, PL, P - P6, QA - QH, QJ - QQ, QS - QZ, Q2 - Q9, RC, RP - RT, SA - SH, SJ, SK, SL, ST - SV, TA, TC - TK, TL - TN, TP - TW, T - T9, UA - UH, UJ-UK, UN, UP- US, U - U9, VP, or blank. ALGORITHM Can report from 0 to 2 codes. Left justify and blank fill. When reporting more than one code, the more important code is to be reported first. Do not duplicate. 24 C-50, April 30, 2004

25 M, MAY 999 CHAPTER 2, SECTION 7 PROCEDURE TEXT IDENTIFIER Non PRIMARY PICTURE (FORMAT) One () alphanumeric character. DEFINITION Code identifying the edition number of the Physician s Current Procedure Terminology used in determining the procedure codes on the HCSR. 4 CPT-4, HCPCs (Levels I, II, and III) 8 ADA Dental Code ALGORITHM PROCESSING CODE 25 C-4, September 4, 2003

26 CHAPTER 2, SECTION M, MAY 999 PROCESSING CODE Non- PRIMARY PICTURE (FORMAT) Group DEFINITION ALGORITHM Field containing multiple elements that describe processing related to the HCSR. OVERRIDE TYPE OF SUBMISSION NAS EXCEPTION REASON HEALTH CARE PLAN CODE DIAGNOSIS EDITION IDENTIFIER PROCEDURE TEXT IDENTIFIER (NON-INSTITUTIONAL ONLY) REASON FOR ADJUSTMENT SPECIAL PROCESSING CODE SPECIAL RATE CODE Required if applicable to HCSR conditions. 26 C-4, September 4, 2003

27 M, MAY 999 CHAPTER 2, SECTION 7 PROGRAM INDICATOR Non PRIMARY PICTURE (FORMAT) One () alphanumeric character. DEFINITION Code identifying which TMA program the services being reported relate to. HCSR Non- HCSR I D Drug H Program for H Program for Persons with Persons with Disabilities Disabilities I (excluding D, H, and T) N Non- (excluding D, H, and T) T Dental (excluding D and H) ALGORITHM See the Chapter, Section 3 for further instructions. 27 C-4, September 4, 2003

28 CHAPTER 2, SECTION M, MAY 999 PROVIDER CONTRACT AFFILIATION CODE Non PRIMARY PICTURE (FORMAT) One () alphanumeric character. DEFINITION Code indicates whether the provider is under contract with the contractor. 0 Not applicable Contracted 2 Not Contracted 3 Contracted/Not Contracted 4 Active Duty - TPR 5 Non-Certified Providers (does not include sanctioned/suspended providers) (Effective 08/0/2003) ALGORITHM Codes, 2, and 3 apply only to at-risk contractors and subcontractors. All codes are irrespective of any Partnership Agreements. Report 0 if not an at-risk contractor. 28 C-4, September 4, 2003

29 M, MAY 999 CHAPTER 2, SECTION 7 PROVIDER SPECIALTY Non PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters. DEFINITION See Addendum C. ALGORITHM Code describing the provider s major specialty. 29 C-4, September 4, 2003

30 CHAPTER 2, SECTION M, MAY 999 PROVIDER PARTICIPATION INDICATOR Non PRIMARY PICTURE (FORMAT) One () alpha character. DEFINITION Code indicating whether or not the provider accepted assignment of benefits for services rendered. N No Y ALGORITHM 30 C-4, September 4, 2003

31 M, MAY 999 CHAPTER 2, SECTION 7 PROVIDER STATE OR COUNTRY CODE Non PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters. DEFINITION Code assigned to identify the state or foreign country in which the care was received. Addendum A and Addendum B. ALGORITHM 3 C-4, September 4, 2003

32 CHAPTER 2, SECTION M, MAY 999 PROVIDER SUB-IDENTIFIER Non PRIMARY PICTURE (FORMAT) Four (4) alphanumeric characters. DEFINITION Identification number that uniquely identifies multiple providers using the same Taxpayer Identification Number (TIN). Refer to ELN 3-00 for complete instructions. Assigned as per TMA instructions. Must be zero-filled if there are no multiple providers within the TIN. Refer to ELN 3-00 for complete instructions. ALGORITHM 32 C-4, September 4, 2003

33 M, MAY 999 CHAPTER 2, SECTION 7 PROVIDER TAXPAYER NUMBER Non PRIMARY PICTURE (FORMAT) Nine (9) alphanumeric characters. DEFINITION The IRS Taxpayer Identification Number (TIN) assigned to the institution/provider supplying the care. For institutions must be 9-digit Employer Identification Number (EIN). For individual providers should be the 9-digit EIN or SSN, if available. If not available, report the contractor-assigned number. (See Provider File data element Provider Taxpayer Number in the provider record for instructions). Report all nines for transportation services under Program for Persons with Disabilities and for Drug Program when the services are from a non-participating pharmacy. ALGORITHM 33 C-4, September 4, 2003

34 CHAPTER 2, SECTION M, MAY 999 PROVIDER ZIP CODE Non PRIMARY PICTURE (FORMAT) Nine (9) alphanumeric characters. DEFINITION Location of provider s business office where care is usually provided. Must be valid zip code or blank if a foreign country. If all 9- digits are not available, code 5 digits, left justify and blank fill. ALGORITHM First 5 digits are required. For professional claims: P.O. Box zip codes may be used if the care provided is radiology, pathology or anesthesiology. Enter the MTF zip code if the care is rendered by a Partnership provider in an MTF. Enter the beneficiary s zip code if the Program Indicator is D (Drug) and the pharmacy does not participate. 34 C-4, September 4, 2003