Specifications For the MHA DMS 10 1.00.10 Publish Date: 11/20/2017 This document is updated periodically. If you are not reading this on the web but are instead reading a printed copy, please check our web site to ensure that you have the latest copy. Up-to-date information can be found at: http://www.datakoala.com/resources.htm You may also call Data Services at (877) 999-4653 for verification.
Table of Contents Table of Contents FILE STRUCTURE... 3 Header Record... 4 Sample Record Layout... 5 DATA EXTRACTION RULES... 6 PROCESSING FOR MIDB/MOSDB... 7 Data Pull Process... 7 DICTIONARY OF DATA ELEMENT TERMS... 8 DATA ELEMENT SUMMARY TABLES... 9... 13 Revenue Records... 44 Diagnosis Records... 50 CPT Procedure Records... 56 ICD Procedure Records... 64 Condition Code Records... 71 APPENDIX... 75 Glossary of Terms... 75 Revision History... 77 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 2
Data Extraction Rules FILE STRUCTURE The MHA DMS 10 is an XML-based relational delimited file format. The file is designed to allow multiple hospitals per file, multiple discharge dates per file, multiple patient types (inpatient, outpatient or both) and an unlimited number of revenue, procedure, diagnosis and condition codes per patient record. There are six record types that can be associated with a single patient record: Main record The following record types are related to the main record, and should only be included if there is data of that type. Do not include blank related records. Revenue record Diagnosis record CPT Procedure record ICD Procedure record Condition Code record Additionally each submission file is also required to have a single header record as the first line. (Header record details on following page) MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 3
Header Record Each submission file must begin with a fixed length header record. The header record consists of fields used to identify the structure and format of the data submission. Field Name Length Begin End (Bytes) Detail Record Type 2 1 2 This field identifies the header record and should always be set to HE File Type 15 3 17 This field identifies the submission format and version. For MHA DMS 10 1.XX.XX submissions this should be formatted as follows: Current Version: MHA DMS10 10000 Submission Type 1 18 18 This field identifies the submission type and should be set to the most appropriate value of the following options: P = Production submission or the standard first time transmission of MIDB/MOSDB data. R = Resubmit submission or the reissue or resubmission of previously transmitted MIDB/MOSDB data. T = Test submission or a transmission for the sole purpose of Delimiter Character Value testing 1 19 19 Enter the respective value for the character that will be used as delimiter or field separator value for the file submission records. The following are accepted delimiter characters (see note below): 1 = Comma (,) 2 = Pipe ( ) 3 = Tilde (~) 4 = Asterisk (*) Note: Because commas are often included in the Patient Mailing Address fields, they may cause confusion when used as a delimiter. For this reason, the Pipe character is recommended as the delimiter. MA Record Count 9 20 28 The total number of main (MA) records in the submission file. Right justify, zero fill RE Record Count 9 29 37 The total number of revenue (RE) records in the submission file. Right justify, zero fill DX Record Count 9 38 46 The total number of diagnosis (DX) records in the submission file. Right justify, zero fill CX Record Count 9 47 55 The total number of CPT-4 procedure (CX) records in the submission file. Right justify, zero fill PX Record Count 9 56 64 The total number of ICD procedure (PX) records in the submission file. Right justify, zero fill CC Record Count 9 65 73 The total number of condition code (CC) records in the submission file. Special Handling Code Right justify, zero fill 5 74 78 MHASC assigned code for special data mapping or handling. Zero fill (unless otherwise specified by MHASC) MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 4
Sample Record Layout There is a one-to-many relationship between the main record and the diagnosis/revenue/procedure/condition code records associated with an individual patient record. This relationship and data structure allows an unlimited number of related records to be captured. Records may be grouped in the submission file as displayed in the example above or organized by record type so that all main records are grouped together followed by groups of revenue, diagnosis, CPT procedure, ICD procedure and condition code records. Sample - Records Grouped by Associated Patient Record HEMHA DMS10 10000T200001267700007494900003812800006287000000596300000384100000 MA 10 123456 X000 1234567890 123456 221133 2222 MI RE 10 123456 X000 0260 2 123.56 DX 10 123456 X000 10 0 R1932 Y PX 10 444443 7654 9 1 2649 082315 1234567890 15623 CC 30 555444 X111 R1 CX 30 123321 2222 1 36415 021415 1234567891 1123555666 50 Sample Records Grouped by Record Type HEMHA DMS10 10000T200001267700007494900003812800006287000000596300000384100000 MA 10 222222222 X999 10 I25110 MA 10 222222222 X999 10 R1932 MA 10 444444444 X999 9 4360 MA 10 444444444 X999 9 25000 RE 10 111111111 X999 0996 010513 1 23785.00 RE 10 111111111 X999 0487 010513 2 14048.00 RE 10 333333333 X999 0996 010513 1 237.85 RE 10 444444444 X999 0487 010515 2 15203.00 DX 10 111111111 X999 9 1 3670 Y DX 10 111111111 X999 7682 0 9 Y MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 5
DATA EXTRACTION RULES The following rules apply when extracting data for the DMS 10. In order to identify and relate various records for a specific patient record the following fields must be present and appropriately designated: Each record must begin with the appropriate Record Type (Field 1) designation. Each record must be designated with the appropriate Patient Type code (Field 2). Each record must include an appropriate Patient Control Number (Field 3). ICD-9/ICD-10 procedure codes are required for Inpatient records. CPT-4 codes are required for Outpatient records. Inpatient records submitted: Include persons who are given acute care in a licensed inpatient bed. Include acute Psychiatric and Rehabilitation patients. Include Stillbirths. These records must be assigned a Patient Type code of 11 (Field 2). Include Hospice patients. These records must be assigned a Patient Type code of 12 (Field 2). If two or more Inpatient records are combined for payment purposes because of a readmission we ask that you send each individual record and not the combined record. Submissions should reflect the total number of discharges that take place during the specific timeframe which allows hospitals to assess needs and aids in readmission projects being performed across the state. Inpatient records not submitted: Exclude Swing Beds, Respite or Long Term Care patients such as Skilled Nursing Home Patients or Nursing Home Patients living within the facility. Exclude Donor records (e.g., kidney donors). Outpatient records submitted: Include all hospital Outpatient records. Include Observation patients. These records must be assigned a Patient Type code of 31 (Field 2). Include Outpatient Births. These records must be assigned a Patient Type code of 32 (Field 2). Outpatient records not submitted: Exclude Dr. Office / Clinic Visits / Urgent Care Visits Exclude Professional Fees Exclude Ambulance Services MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 6
Processing for MIDB/MOSDB PROCESSING FOR MIDB/MOSDB Data Pull Process The MIDB/MOSDB data pull is done on a quarterly basis and MHASC works with a designated Data Contact person at each facility to ensure complete and accurate data. The selection criteria consists of inpatient/outpatient discharges for a specified date range (see Data Extraction Rules on previous page for details). The data collection process allows facilities to submit both inpatient and outpatient records on the same file as long as the records Patient Type field is properly coded (Field 2). Each facility is free to establish a process that best suits their needs as long as it does not compromise the traditional MIDB/MOSDB data collection process. There are several different approaches to coordinating the two processes. Following is one model for structuring the process: House the data-pull process within the IT department. Establish a consistent naming convention for location and names of the data-pull files and educate users on these conventions. Suggested file naming convention: Your 4-digit hospital ID, the date range and INP for inpatient, OUT for outpatient or BTH for both inpatient and outpatient records. All submission files must be of type.txt. A copy of the pull for each quarter is sent to MHASC for MIDB/MOSDB per traditional communication method. Sample Hospital ID 0001 submitting inpatient data for January - June 00010106INP.txt MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 7
DICTIONARY OF DATA ELEMENT TERMS : The name of the data element or field. : Indicates the data element or field s usage status. : A detailed description of the data element or field. : Size of the data element in bytes. : Specifications as to how the data must be formatted. : The accepted code values for the field. : Additional detailed instructions beyond the format specifications. : Indicates reference to other standard formats. : General comment section. Field Update History: A history of the versions in which the field was updated. R RP F Type Required Required if Present Reserved for Future Use Definition Dictionary of Data Element Terms The date element is a required field that must be included on all records. These are fields that MHA must have in order to process the data, and should be available from the source systems of all hospitals. The data element is a required if it can be obtained from the hospital s source systems with a reasonable amount of programming effort, and without the cost of such programming being prohibitively high. This is a placeholder for a data element that is expected to be used in the future. N/A Not Applicable The data element does not currently apply for this type of data submission. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 8
DATA ELEMENT SUMMARY TABLES Data Element Summary Tables Field No. Field Name Length (Bytes) Inpatient Outpatient 1 Record Type=MA 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID - MHASC Assigned 4 R R 5 Facility ID - National Provider Identifier (NPI) 10 R R 56 6 Facility ID - Medicare Provider Number 6 RP RP 7 Location Code 4 F F 8 Place of Service 2 F F 9 Patient Medical/Health Record Number 24 R R 3b 10 Filler 20 F F 11 Patient SSN (Last 4) 4 RP RP 12 Patient First Name 30 R R 8 13 Patient Middle Name 30 RP RP 8 14 Patient Last Name 30 R R 8 15 Patient Mailing Address 1 40 RP RP 9a 16 Patient Mailing Address 2 30 RP RP 9a 17 Patient Mailing Address - City 30 RP RP 9b 18 Patient Mailing Address - State 2 RP RP 9c 19 Patient Zip Code 5 R R 9 20 Patient Zip Code Extension 4 RP RP 9 21 Patient Birth Date 8 R R 10 22 Patient Sex 1 R R 11 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 9 UB-04 Field 23 Patient Race 1 RP RP 81 B1 24 Patient Ethnicity 1 RP RP 81 B1 25 Patient Primary Language 3 RP RP 81 B7 26 Medical Record Number Mother of Newborn 24 RP RP 27 Birth Weight 4 RP RP 28 Admission Date 8 R R 12 29 Admission Time 4 RP RP 13 30 Priority (Type) of Admission or Visit 1 R RP 14 31 Point of Origin for Admission or Visit 1 R R 15 32 Source of Admission - Specific Facility (NPI) 10 RP RP 33 Discharge Date 8 R R 6 34 Discharge Time 4 RP RP 16 35 Patient Discharge (Disposition) 2 R R 17 36 Disposition of Patient - Specific Facility (NPI) 10 RP RP 37 Principal Payer 2 R R 50A
Field No. Data Element Summary Tables Length (Bytes) Field Name Inpatient Outpatient 38 Secondary Payer 2 RP RP 50B 39 Referring Physician - NPI 10 RP RP 78-79 40 Primary Care Physician - NPI 10 RP RP 41 Attending Physician NPI 10 R R 76 42 Attending Physician - Legacy 10 R R 43 Admitting Diagnosis Version 2 RP RP 44 Admitting Diagnosis Code / Reason for Visit 7 RP RP 69 The Revenue Records provide additional information related to a. Only include Revenue Records if data of this type actually exists. Do not include blank Revenue Records. UB-04 Field Field No. Revenue Records Length (Bytes) Field Name Inpatient Outpatient 1 Record Type=RE 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID MHASC Assigned 4 R R 5 Revenue Code 4 R R 42 6 HCPCS Rate 14 RP RP 44 7 Service Date 8 RP RP 45 8 Units of Service 7 RP RP 46 9 Revenue Code Charges 10 RP RP 47 The Diagnosis Records provide additional information related to a. Only include Diagnosis Records if data of this type actually exists. Do not include blank Diagnosis Records. UB-04 Field Field No. Diagnosis Records Length (Bytes) Field Name Inpatient Outpatient 1 Record Type=DX 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID MHASC Assigned 4 R R 5 Diagnosis Code Version 2 R R 6 Is Principal Diagnosis 1 R R UB-04 Field 7 Diagnosis Code 7 R R 67 a-q 8 Present on Admission (POA) Indicator Diagnosis Code 1 R N/A 67 a-q MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 10
Data Element Summary Tables The CPT Procedure Records provide additional information related to a. Only include CPT Procedure Records if data of this type actually exists. Do not include blank CPT Procedure Records. Field No. CPT Procedure Records Length (Bytes) Field Name Inpatient Outpatient 1 Record Type=CX 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID MHASC Assigned 4 R R 5 Is Principal Procedure CPT 1 R R 6 Procedure - CPT 5 R R 7 Date of Procedure - CPT 8 R R 45 UB-04 Field 8 CPT Operating Physician - NPI 10 RP RP 78-79 9 CPT Operating Physician - Legacy 10 RP RP 10 HCPCS Modifier 1 2 RP RP 44 11 HCPCS Modifier 2 2 RP RP 44 12 HCPCS Modifier 3 2 RP RP 44 13 HCPCS Modifier 4 2 RP RP 44 The ICD Procedure Records provide additional information related to a. Only include ICD Procedure Records if data of this type actually exists. Do not include blank ICD Procedure Records. Field No. ICD Procedure Records Length (Bytes) Field Name Inpatient Outpatient 1 Record Type=PX 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID MHASC Assigned 4 R R 5 Procedure Version 2 R R 6 Is Principal Procedure ICD 1 R R 7 Procedure - ICD 7 R R 74 8 Date of Procedure - ICD 8 R R 45 UB-04 Field 9 ICD Operating Physician NPI 10 RP RP 77-79 10 ICD Operating Physician - Legacy 10 RP RP MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 11
Data Element Summary Tables The Condition Code Records provide additional information related to a. Only include Condition Code Records if data of this type actually exists. Do not include blank Condition Code Records. Field No. Condition Code Records Length (Bytes) Field Name Inpatient Outpatient 1 Record Type=CC 2 R R 2 Patient Type 2 R R 3 Patient Control Number 20 R R 3a 4 Facility ID MHASC Assigned 4 R R UB-04 Field 5 Condition Code 2 R R 18-28 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 12
MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 13
Data Element s Return to Summary Table Field 1 Record Type Required for MIDB and MOSDB Alpha character used to identify the record type. 2 bytes MA = Set Record Type = MA for all s. MHASC Defined Return to Summary Table Field 2 Patient Type Required for MIDB and MOSDB Subset categorization of inpatient or outpatient 2 bytes 10 = Inpatient Records (not Stillbirth or Hospice) 11 = Inpatient Stillbirth Records 12 = Inpatient Hospice Records 30 = Outpatient Records (not Observation or Birth) 31 = Outpatient Observation patient Not admitted as an inpatient. Patients placed in a holding pattern watchful waiting. May or may not have a principal procedure. May have come in for ambulatory surgery, but placed into observation status and departed facility as an observation patient. 32 = Outpatient Birth assign to both mom records and baby records. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 14
Data Element s Return to Summary Table Field 3 Patient Control Number Required for MIDB and MOSDB The patient s unique identification number assigned by the provider. This number is often referred to as a patient account number and is unique to a specific occurrence of a hospital stay. This is not a patient s medical record number. 20 bytes UB-04, Form Locator 03a If your patient control number is larger than 20 digits, please consult with Medical Records/Finance and MHASC Data Services to agree on a truncation formula that results in unique keys. Return to Summary Table Field 4 Facility ID MHASC Assigned Required for MIDB and MOSDB The hospital identification number assigned by MHASC to the facility for submission of data. 4 bytes If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain the correct ID. MHASC Defined If the hospital has a separate Ambulatory Surgery Center, please contact the assigned Data Quality Representative to receive a separate Hospital ID number for these patients. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 15
Data Element s Return to Summary Table Field 5 Facility ID National Provider Identifier (NPI) Required for MIDB and MOSDB The unique identification number assigned to the provider submitting the bill. NPI is the national provider identifier. 10 bytes Numeric UB-04, Form Locator 56 Return to Summary Table Field 6 Facility ID Medicare Provider Number Required if Present for MIDB and MOSDB Hospital s Medicare provider number as assigned by CMS. 6 bytes Numeric CMS Assigned Return to Summary Table Field 7 Location Code Reserved for Future Use for MIDB and MOSDB Code identifying the physical location of patient care 4 bytes Numeric TBD MHASC Defined MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 16
Data Element s Return to Summary Table Field 8 Place of Service Reserved for Future Use for MIDB and MOSDB Setting indicator for the location where a service was provided. 2 bytes CMS Place of Service Code Set Enter the most appropriate service code from the list on the CMS Place of Service Code set webpage. CMS 1500 Field 24b Return to Summary Table Field 9 Patient Medical/Health Record Number Required for MIDB and MOSDB The number assigned to the patient s medical/health record by the provider. 24 bytes plus hyphens/dashes (-) Leave blank if the patient s medical record number is missing. UB-04, Form Locator 03b Return to Summary Table Field 10 Filler Reserved for Future Use for MIDB and MOSDB MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 17
Data Element s Return to Summary Table Field 11 Patient SSN (Last 4) Required if Present for MIDB and MOSDB Last four digits of the number as assigned to the patient by the Social Security Administration. 4 bytes Numeric Valid characters: 0 through 9, no hyphens or spaces. Leave blank if SSN is unknown. Field 12 Patient First Name Required for MIDB and MOSDB The first name of the patient. 30 bytes UB-04, Form Locator 08 Return to Summary Table Field 13 Patient Middle Name Required if Present for MIDB and MOSDB The middle name of the patient. 30 bytes Enter the full middle name of patient if available. UB-04, Form Locator 08 Return to Summary Table MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 18
Data Element s Return to Summary Table Field 14 Patient Last Name Required for MIDB and MOSDB The last name of the patient. 30 bytes UB-04, Form Locator 08 Return to Summary Table Field 15 Patient Mailing Address 1 Required if Present for MIDB and MOSDB First line of the patient s mailing address. 40 bytes Include only the first line of the patient s mailing address. Select the patient s mailing address and not the guarantor address. UB-04, Form Locator 09 a Field 16 Patient Mailing Address 2 Required if Present for MIDB and MOSDB Second line of the patient s mailing address. 30 bytes Leave blank if not needed. UB-04, Form Locator 09 a Return to Summary Table MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 19
Data Element s Return to Summary Table Field 17 Patient Mailing Address - City Required if Present for MIDB and MOSDB City associated with the patient s mailing address. 30 bytes UB-04, Form Locator 09 b Return to Summary Table Field 18 Patient Mailing Address State Required if Present for MIDB and MOSDB State associated with the patient s mailing address. 2 bytes Use the two digit state abbreviation. UB-04, Form Locator 09 c MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 20
UB-04, Form Locator 09 Data Element s Return to Summary Table Field 19 Patient Zip Code Required for MIDB and MOSDB Patient zip code 5 bytes 00000 = Unknown 11111 = Foreign other than Canada 66666 = Sault Ste. Marie Canada 77777 = Sarnia Canada 88888 = Windsor Canada 99999 = All other Canada not above 1. Records of patients residing outside of the U.S. must have their postal codes mapped to the numeric codes identified above. 2. Homeless patients should be assigned the zip code of the treating facility. Field 20 Patient Zip Code Extension Required if Present for MIDB and MOSDB Zip Code Extension 4 bytes Leave blank if unavailable. UB-04, Form Locator 09 Return to Summary Table MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 21
Data Element s Return to Summary Table Field 21 Patient Birth Date Required for MIDB and MOSDB Date of birth of the patient 8 bytes MMDDYYYY = Month Day Year UB-04, Form Locator 10 Each of the components should be right justified, zero filled within the two digits. For example, January 5, 2014 is recorded as 01052014. Infants that are born within the facility should have an admission date equal to the date of birth. Data Element UB-04, Form Locator 11 Return to Summary Table Field 22 Patient Sex Required for MIDB and MOSDB The sex of the patient as recorded at admission, outpatient service, or start of care. 1 byte F = Female M = Male U = Unknown 1. Must be a valid code 2. Sex must be valid for sex-specific diagnoses or procedures MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 22
Data Element s Return to Summary Table Field 23 Patient Race Required if Present for MIDB and MOSDB The race of the patient 1 byte 1 = American Indian or Alaska Native 2 = Asian 3 = Black or African American 4 = White 5 = Other 6 = Unknown or Not Stated (Patient Declined) 7 = Native Hawaiian or other Pacific Islander Hispanic is not considered a race. If your hospital system records Hispanic under the race field, then: 1. Map Race to Code 6 (Unknown or Not Stated) 2. Map Ethnicity (Field 24) to Code 1 (Hispanic or Latino) If your hospital system has both a race field and an ethnicity field, then Hispanic or Latino should be recorded under Ethnicity (Field 24) and Race remains that which was reported by the patient. If the facility captures the Arabic population but does not capture a race for these patients, please map them using the following conventions: 1. Map Race to Code 6 (Unknown or Not Stated) 2. Map Ethnicity (Field 24) to Code 4 (Arabic) If your hospital system captures both a race and Arabic, then Arabic should be recorded under Ethnicity (Field 24) and Race remains that which was reported by the patient. Meaningful Use; OMB 15; UB-04 Form Locator 81 B1 Race information should be based on self-identification of the patient. It should not be based on the judgment of facility personnel. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 23
Data Element s Return to Summary Table Field 24 Patient Ethnicity Required if Present for MIDB and MOSDB Ethnicity of the patient 1 byte 1 = Hispanic or Latino 2 = Not Hispanic or Latino or Arabic 3 = Unknown or Not Stated (Patient Declined) 4 = Arabic Hispanic is considered an ethnicity, not a race. If your hospital system records Hispanic under the race field, then: 1. Map Race (Field 23) to Code 6 (Unknown or Not Stated) 2. Map Ethnicity to Code 1 (Hispanic or Latino) If your hospital system has both a race field and an ethnicity field, then Hispanic or Latino should be recorded under Ethnicity and Race (Field 23) remains that which was reported by the patient. If the facility captures the Arabic population but does not capture a race for these patients, please map them using the following conventions: 1. Map Race (Field 23) to Code 6 (Unknown or Not Stated) 2. Map Ethnicity to Code 4 (Arabic) If your hospital system captures both a race and Arabic, then Arabic should be recorded under Ethnicity and Race (Field 23) remains that which was reported by the patient. Meaningful Use; OMB 15; UB-04 Form Locator 81 B1 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 24
Data Element s Return to Summary Table Field 25 Patient Primary Language Required if Present for MIDB and MOSDB Preferred spoken language of the patient. 3 bytes Below are some examples of supported language codes. For the complete supported code list, see the DMS 10 Primary Language, available online at http://www.datakoala.com/resources.htm ENG = English SPA = Spanish ARA = Arabic MIS = Uncoded languages NC = Not Collected UND = Undetermined ZXX = No linguistic content; Not applicable Do not leave this field blank. NC should be entered if the patient s preferred language was not collected. UB-04, Form Locator 81 B7 ISO 639-2 Language Code List The ISO 639-2 Language Code List has 21 languages that have alternate codes depending on whether the usage is for Bibliographic (B) or Terminology (T) purposes. The DMS-10 specification only uses the B codes. Return to Summary Table Field 26 Medical Record Number Mother of Newborn Required if Present for MIDB and MOSDB The medical record numbers of the newborn child s mother which links the newborn s hospital stay and the mother s stay. 24 bytes plus hyphens/dashes (-) If the mother is not admitted with the infant, report all nines. The record must contain: 1. A valid newborn diagnosis code must be reported as the Principal Diagnosis Code 2. Type of Admission used = 4 3. Source of Admission used = 5,6 4. Date of birth must equal admission date. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 25
Data Element s Return to Summary Table Field 27 Birth Weight Required if Present for MIDB and MOSDB The weight (in grams) of a neonate at the time of delivery. 4 bytes Numeric Round to the nearest whole number If the birth weight is completely unknown, enter 9999 Return to Summary Table Field 28 Admission Date Required for MIDB and MOSDB The start date for this episode of care. For inpatient services, this is the date of admission. For outpatient services it is the date the episode of care began. 8 bytes MMDDYYYY = Month Day Year Each of the components should be right justified, zero filled within the two digits. For example, January 5, 2014 is recorded as 01052014. Cannot be: 1. A future date 2. Before the date of birth 3. After the date of discharge UB-04, Form Locator 12 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 26
Data Element s Return to Summary Table Field 29 Admission Time Required if Present for MIDB and MOSDB The time of the patient admission 4 bytes Use twenty four hour, military time format, removing the colon. Leave blank if hour is unavailable Enter 00 for minutes, if minutes are unavailable Military Standard Time Range Time Range 0000-0059 12:00 midnight -12:59 a.m. 0100-0159 01:00-01:59 a.m. 0200-0259 02:00-02:59 a.m. 0300-0359 03:00-03:59 a.m. 0400-0459 04:00-04:59 a.m. 0500-0559 05:00-05:59 a.m. 0600-0659 06:00-06:59 a.m. 0700-0759 07:00-07:59 a.m. 0800-0859 08:00-08:59 a.m. 0900-0959 09:00-09:59 a.m. 1000-1059 10:00-10:59 a.m. 1100-1159 11:00-11:59 a.m. 1200-1259 12:00 noon -12:59 p.m. 1300-1359 01:00-01:59 p.m. 1400-1459 02:00-02:59 p.m. 1500-1559 03:00-03:59 p.m. 1600-1659 04:00-04:59 p.m. 1700-1759 05:00-05:59 p.m. 1800-1859 06:00-06:59 p.m. 1900-1959 07:00-07:59 p.m. 2000-2059 08:00-08:59 p.m. 2100-2159 09:00-09:59 p.m. 2200-2259 10:00-10:59 p.m. 2300-2359 11:00-11:59 p.m. UB-04, Form Locator 13 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 27
Data Element s Return to Summary Table Field 30 Priority (Type) of Admission or Visit Required for MIDB Required if Present for MOSDB A code indicating the priority of this admission/visit. 1 byte 1 = Emergency The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. 2 = Urgent The patient requires immediate attention for the care and treatment of a physical or mental disorder. 3 = Elective The patient s condition permits adequate time to schedule the services. 4 = Newborn Use of this code necessitates the use of special Source of Admission/Point of Origin - see Field 31. 5 = Trauma Center Visit to a trauma center/hospital as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. (6-8 Reserved for assignment by NUBC. Not valid for MIDB/MOSDB data collection.) 9 = Information not available. Outpatient: Leave this field blank if the facility does not track this information. UB-04, Form Locator 14 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 28
Data Element s Return to Summary Table Field 31 Point of Origin for Admission or Visit Required for MIDB and MOSDB A code indicating the point of patient origin for this admission or visit. 1 byte 1 = Non-Health Care Facility Point of Origin Examples: Includes patients coming from home or workplace and patients receiving care at home (such as home health services). Inpatient: The patient was admitted to this facility. Outpatient: The patient presented for outpatient services. 2 = Clinic or Physician s Office Inpatient: The patient was admitted to this facility. Outpatient: The patient presented to this facility for outpatient services. (3 Reserved for assignment by the NUBC. (Discontinued effective 10/1/07.) 4 = Transfer from a Hospital (Different Facility) Usage Note: Excludes Transfers from Hospital Inpatient in the Same Facility (See Code D). Inpatient: The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient or outpatient. Outpatient: The patient was transferred to this facility as an outpatient from an acute care facility. 5 = Transfer from a Skilled Nursing Facility (SNF), Assisted Living Facility (ALF), Intermediate Care Facility (ICF), or other Nursing Facility (NF). Inpatient: The patient was admitted to this facility as a transfer from a SNF, ALF, ICF or other NF where he or she was a resident. Outpatient: The patient presented to this facility for outpatient or referenced diagnostic services from a SNF, ALF, ICF, or other NF where he or she was a resident. 6 = Transfer from another Health Care Facility Inpatient: The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list. Outpatient: The patient presented to this facility for services from another health care facility not defined elsewhere in this code list. 8 = Court/Law Enforcement Usage Note: Includes transfers from incarceration facilities. Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. Outpatient: The patient presented to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 29
Data Element s Field 31 Point of Origin for Admission or Visit 9 = Information not Available Inpatient: The patient s Point of Origin is not known. Outpatient: The patient s Point of Origin is not known. D = Transfer from One Distinct Unit of the Hospital to another Distinct Unit of the Same Hospital Resulting in a Separate Claim to the Payer Usage Note: For purposes of this code, Distinct Unit is defined as a unique unit or level of care at the hospital requiring the issuance of a separate claim to the payer. Examples could include observation services, psychiatric units, rehabilitation units, a unit in a critical access hospital, or a swing bed located in an acute hospital. Inpatient: The patient was admitted to this facility as a transfer from hospital inpatient within this hospital resulting in a separate claim to the payer. Outpatient: The patient received outpatient services in this facility as a transfer from within this hospital resulting in a separate claim to the payer. E = Transfer from Ambulatory Surgery Center Inpatient: The patient was admitted to this facility as a transfer from an ambulatory surgery center. Outpatient: The patient presented to this facility for outpatient or referenced diagnostic services from an ambulatory surgery center. F = Transfer from a Hospice Facility. Inpatient: The patient was admitted to this facility as a transfer from a hospice facility. Outpatient: The patient presented to this facility for outpatient or referenced diagnostic services from a hospice facility. (G-Z Reserved for assignment by the NUBC. Not valid for MIDB/MOSDB data collection.) Code Structure for Newborn (use if Admission Type code is equal to 4) 1-4 Reserved for assignment by the NUBC. (Discontinued effective 10/1/07.) 5 = Born Inside this Hospital 6 = Born Outside of this Hospital If Admission Type code = 4 (Newborn), then Point of Origin for Admission or Visit must be equal to code 5 or 6. If the facility cannot submit an accurate breakout for newborns using Admission Type of 4 (Newborn) and 5 or 6 for this field, then the facility should assign the newborns with an Admission Type (Field 30) of Code 4 (Newborn) and a Point of Origin for Admission or Visit (this field) of Code 5 (Born Inside this Hospital). UB-04, Form Locator 15 For outpatient records: It is permissible but not recommended to have a large number of Information not Available for Point of Origin for Admission or Visit. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 30
Data Element s Field 31 Point of Origin for Admission or Visit During the 1400 testing phase, the Data Quality Representative will verify with the Medical Records Department the inability to track this information. Given this factor, do not default the outpatient records to any category for Point of Origin for Admission or Visit without first consulting with MHASC. Return to Summary Table Field 32 Source of Admission Specific Facility (NPI) Required if Present for MIDB and MOSDB The national provider identifier for the facility that transferred the patient to your facility. 10 bytes Numeric CMS Assigned NPI Must have a value if Point of Origin (field 31) has a value of 4 Transfer from a Hospital Return to Summary Table Field 33 Discharge Date Required for MIDB and MOSDB The date the patient was discharged from care, left against medical advice, or expired during this stay. 8 bytes MMDDYYYY = Month Day Year Each of the components should be right justified, zero filled within the two digits. For example, January 5, 2014 is recorded as 01052014. Cannot be: 1. A future date 2. Before the date of admission UB-04, Form Locator 06 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 31
Data Element s Return to Summary Table Field 34 Discharge Time Required if Present for MIDB and MOSDB The time of the patient discharge 4 bytes Use twenty four hour, military time format, removing the colon. Leave blank if hour is unavailable Enter 00 for minutes, if minutes are unavailable Military Standard Time Range Time Range 0000-0059 12:00 midnight -12:59 a.m. 0100-0159 01:00-01:59 a.m. 0200-0259 02:00-02:59 a.m. 0300-0359 03:00-03:59 a.m. 0400-0459 04:00-04:59 a.m. 0500-0559 05:00-05:59 a.m. 0600-0659 06:00-06:59 a.m. 0700-0759 07:00-07:59 a.m. 0800-0859 08:00-08:59 a.m. 0900-0959 09:00-09:59 a.m. 1000-1059 10:00-10:59 a.m. 1100-1159 11:00-11:59 a.m. 1200-1259 12:00 noon -12:59 p.m. 1300-1359 01:00-01:59 p.m. 1400-1459 02:00-02:59 p.m. 1500-1559 03:00-03:59 p.m. 1600-1659 04:00-04:59 p.m. 1700-1759 05:00-05:59 p.m. 1800-1859 06:00-06:59 p.m. 1900-1959 07:00-07:59 p.m. 2000-2059 08:00-08:59 p.m. 2100-2159 09:00-09:59 p.m. 2200-2259 10:00-10:59 p.m. 2300-2359 11:00-11:59 p.m. UB-04, Form Locator 16 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 32
Data Element s Return to Summary Table Field 35 Patient Discharge (Disposition) Required for MIDB and MOSDB A code indicating the disposition or discharge status of the patient. 2 bytes 00 = Unknown (MHASC defined, not a standard UB-04 code) 01 = Discharged to Home or Self Care (Routine Discharge) Usage Note: Includes discharge to home; home on oxygen if DME only; any other DME only; group home, foster care, independent living and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs. 02 = Discharged/transferred to a Short-Term General Hospital for Inpatient Care 03 = Discharged/transferred to a Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care Usage Note: Medicare Indicates that the patient is discharged/transferred to a Medicare certified nursing facility. For hospitals with an approved swing bed arrangement, use Code 61- Swing Bed. For reporting other discharges/transfers to nursing facilities see 04 and 64. 04 = Discharged/transferred to a Facility that Provides Custodial or Supportive Care Usage Note: Includes intermediate care facilities (ICFs) if specifically designated at the state level. Also used to designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to Assisted Living Facilities. 05 = Discharged/transferred to a Designated Cancer Center or Children s Hospital Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list of (National Cancer Institute) Designated Cancer Centers can be found at http://www.cancer.gov/researchandfunding/extramural/cancercenters. 06 = Discharged/transferred to Home Under Care of an Organized Home Health Service Organization in Anticipation of Covered Skilled Care Usage Note: Report this code when the patient is discharged/transferred to home with a written plan of care (tailored to the patient s medical needs) for home care services. Not used for home health services provided by a DME supplier or from a home IV provider for home IV services. 07 = Left Against Medical Advice or Discontinued Care MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 33
Field 35 Patient Discharge (Disposition) Data Element s 09 = Admitted as an Inpatient to this Hospital. Valid for outpatient only. Usage Note: For use only on Medicare outpatient claims. Applies only to those Medicare outpatient services that begin greater than three days prior to an admission. 20 = Expired 21 = Discharged/transferred to Court/Law Enforcement Usage Note: Includes transfers to incarceration facilities such as jail, prison or other detention facilities. 30 = Still a Patient. Valid for MOSDB only. Not valid for MIDB data collection. Usage Note: Used when a patient is still within the same facility; typically used when billing for leave of absence days or interim bills. 41 = Expired in a Medical Facility (e.g. hospital, SNF, ICF, or freestanding Hospice). Usage Note: For use only on Medicare and TRICARE claims for hospice care. 43 = Discharged/transferred to a Federal Health Care Facility Usage Note: Discharges and transfers to a government operated health facility such as a Department of Defense hospital, a Veteran s Administration hospital or a Veteran s Administration nursing facility. To be used whenever the destination at discharge is a federal health care facility, whether the patient lives there or not. 50 = Hospice Home. 51 = Hospice Medical Facility (Certified) Providing Hospice Level of Care. 61 = Discharged/transferred to a Hospital-Based Medicare Approved Swing Bed Usage Note: Medicare Used for reporting patients discharged/transferred to a SNF level of care within the hospital s approved swing bed arrangement. 62 = Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital 63 = Discharged/transferred to a Medicare Certified Long Term Care Hospital (LTCH) Usage Note: For hospitals that meet the Medicare criteria for LTCH certification. 64 = Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare 65 = Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital 66 = Discharged/transferred to a Critical Access Hospital (CAH) MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 34
Data Element s Field 35 Patient Discharge (Disposition) 69=Discharged/Transferred to a Designated Disaster Alternate Care Site (Effective 10/1/13) 70 = Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List (81-95 = Discharge status codes identifying patients who are discharged with a planned acute care hospital inpatient readmission) (Effective 10/1/13) 81 = Discharged to Home or Self Care with a Planned Acute. Care Hospital Inpatient Readmission 82=Discharged/Transferred to a Short Term General Hospital for Inpatient Care with a Planned Acute Care Hospital Inpatient Readmission 83=Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare Certification with a Planned Acute Care Hospital Inpatient Readmission 84=Discharged/Transferred to a Facility that Provides Custodial or Supportive Care with a Planned Acute Care Hospital Inpatient Readmission 85=Discharged/transferred to a Designated Cancer Center or Children's Hospital with a Planned Acute Care Hospital Inpatient Readmission 86=Discharged/Transferred to Home Under Care of Organized Home Health Service Organization with a Planned Acute Care Hospital Inpatient Readmission 87=Discharged/Transferred to Court/Law Enforcement with a Planned Acute Care Hospital Inpatient Readmission 88=Discharged/Transferred to a Federal Health Care Facility with a Planned Acute Care Hospital Inpatient Readmission 89=Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed with a Planned Acute Care Hospital Inpatient Readmission 90=Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital with a Planned Acute Care Hospital Inpatient Readmission 91=Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH) with a Planned Acute Care Hospital Inpatient Readmission 92=Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not Certified Under Medicare with a Planned Acute Care Hospital Inpatient Readmission 93=Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital with a Planned Acute Care Hospital Inpatient Readmission 94=Discharged/Transferred To a Critical Access Hospital (CAH) with a Planned Acute Care Hospital Inpatient Readmission 95=Discharged/Transferred to Another Type of Health Care Institution not Defined Elsewhere in this Code List with a Planned Acute Care Hospital Inpatient Readmission MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 35
Field 35 Patient Discharge (Disposition) Data Element s For MIDB records: A small number of codes equal to 00 (unknown) may occur. Care should be taken to ensure this field is coded as accurately as possible. For MOSDB records: It is permissible but not recommended to have a large number of Unknown or Missing for Patient Discharge. During 1400 testing, the Data Quality Representative will verify with the Medical Records Department the inability to track this information. Given this factor, do not default the outpatient records to any category for Patient Discharge. It is preferable to have the elements missing from the records rather than defaulted to an inappropriate category. UB-04, Form Locator 17 Return to Summary Table Field 36 Disposition of Patient Specific Facility (NPI) Required if Present for MIDB and MOSDB The national provider identifier for the facility that patient is transferred to from your facility. 10 bytes Numeric CMS Assigned NPI Must have a value if Patient Discharge (field 35) has one of the following values: 02, 82, 03, 83, 04, 84, 05, 85, 06, 86,43, 88, 62, 90, 63, 91, 64, 92, 65, 93, 66, 94, 70, 95 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 36
Data Element s Return to Summary Table Field 37 Principal Payer Required for MIDB and MOSDB The carrier expected to pay the major portion of the patient s bill. 2 bytes (Non-Michigan hospitals see ) Medicare/Medicaid Carrier 01 = Medicare Fee For Service 30 = Medicare Managed Care Plans 31 = Medicare Type of Plan Unknown (contains both fee for service and managed care plans) 02 = Medicaid Fee For Service 40 = Medicaid Managed Care Plans 41 = Medicaid Type of Plan Unknown (contains both fee for service and managed care plans) Other Traditional Carrier 00 = Unknown 03 = Title V 04 = Other Government Source, exclude Mental Health and Corrections contracts 05 = Workers Compensation 06 = Blue Cross Blue Shield, exclude HMO/PPO 07 = Other Commercial Insurance Company, exclude HMO/PPO 08 = Self Pay 09 = Managed Care (only used if not breaking out into 11-22 below) 10 = No Charge 23 = State Mental Health Contract 24 = Other Mental Health Contract 25 = State Corrections 26 = Other Corrections 51 = Charity Care 52 = Auto Insurance 99 = Other (not covered above) Categorized Managed Care Carrier 11 = Blue Cross Blue Shield HMO 12 = Other HMO 1 13 = Other HMO 2 14 = Other HMO 3 15 = Other HMO 4 16 = Other HMO 5 (See Instruction 4 below) 17 = Blue Cross Blue Shield PPO/PPA 18 = Other PPO/PPA 1 MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 37
Data Element s Field 37 Principal Payer 19 = Other PPO/PPA 2 20 = Other PPO/PPA 3 21 = Other PPO/PPA 4 22 = Other PPO/PPA 5 (See Instruction 4 below) Please note the following when mapping to these codes: 1. The categories of Other HMO or PPO/PPA ( 12-16, 18-22) are hospital defined and will include all other managed care plans that are not BCBS plans. 2. For those hospitals who do not define individual managed care plans, use 09 to indicate some type of managed care plan. A hospital should not use Code 09 and 11-22. 3. If a hospital cannot break out Medicaid and Medicare plans into both traditional Fee For Service contracts ( 01 & 02) and Managed Care Contracts (30 & 40), a hospital should use Code 31- Medicare Type Of Plan Unknown and Code 41 Medicaid Type of Plan Unknown. 4. If a hospital is utilizing HMO or PPO/PPAs 1-4, use Other HMO or PPO/PPA - 5 to indicate all remaining types of plans. MHASC Defined ; UB-04 Form Locator 50 A For non-michigan hospitals it is acceptable to assign all records to one of the following four codes: 00 = Unknown 31 = Medicare 41 = Medicaid 99 = Payment other than Medicare or Medicaid MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 38
Data Element s Return to Summary Table Field 38 Secondary Payer Required if Present for MIDB and MOSDB The carrier designated by the patient responsible for any remaining amount due for the visit. 2 bytes (Non-Michigan hospitals see ) Medicare/Medicaid Carrier 01 = Medicare Fee For Service 30 = Medicare Managed Care Plans 31 = Medicare Type of Plan Unknown (contains both fee for service and managed care plans) 02 = Medicaid Fee For Service 40 = Medicaid Managed Care Plans 41 = Medicaid Type of Plan Unknown (contains both fee for service and managed care plans) Other Traditional Carrier 00 = Unknown 03 = Title V 04 = Other Government Source, exclude Mental Health and Corrections contracts 05 = Workers Compensation 06 = Blue Cross Blue Shield, exclude HMO/PPO 07 = Other Commercial Insurance Company, exclude HMO/PPO 08 = Self Pay 09 = Managed Care (only used if not breaking out into 11-22 below) 10 = No Charge 23 = State Mental Health Contract 24 = Other Mental Health Contract 25 = State Corrections 26 = Other Corrections 51 = Charity Care 52 = Auto Insurance 99 = Other (not covered above) Categorized Managed Care Carrier 11 = Blue Cross Blue Shield HMO 12 = Other HMO 1 13 = Other HMO 2 14 = Other HMO 3 15 = Other HMO 4 16 = Other HMO 5 (See Instruction 4 under Principal Payer: Field 21) 17 = Blue Cross Blue Shield PPO/PPA MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 39
Data Element s Field 38 Secondary Payer 18 = Other PPO/PPA 1 19 = Other PPO/PPA 2 20 = Other PPO/PPA 3 21 = Other PPO/PPA 4 22 = Other PPO/PPA 5 (See Instruction 4 under Principal Payer: (Field 37) Follow the same detailed mapping instructions as noted under the Principal Payer (Field 37). In addition, please note the following: 1. If there is an outstanding balance that the patient is responsible for, assign 08 Self Pay. 2. If the hospital will not be billing either another insurance company or the patient, assign 10 No-Charge. MHASC Defined ; UB-04 Form Locator 50 B For non-michigan hospitals, it is acceptable to assign all records to one of the following four codes: 00 = Unknown 31 = Medicare 41 = Medicaid 99 = Payment other than Medicare or Medicaid UB-04, Form Locator 78-79 Return to Summary Table Field 39 Referring Physician NPI Required if Present for MIDB and MOSDB The unique identification number assigned to the physician who referred the patient for care. NPI is the national provider identifier. 10 bytes Numeric Use the physician s 10 digit individual national provider identifier. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 40
Data Element s Return to Summary Table Field 40 Primary Care Physician NPI Required if Present for MIDB and MOSDB Patient s primary care physician. NPI is the national provider identifier. 10 bytes Numeric Use the physician s 10 digit individual national provider identifier. UB-04, Form Locator 76 Return to Summary Table Field 41 Attending Physician NPI Required for MIDB and MOSDB The unique identification number assigned to the physician who has primary responsibility for the patient s medical care and treatment. NPI is the national provider identifier. 10 bytes Numeric Use the physician s 10 digit individual national provider identifier. MHA DMS 10 1.00.10 Specifications Published on 11/20/2017 41