Data Element

1. Hospital identifier.*
Enter the six-digit Medicare provider number or a number assigned by the board or its designee.

2. Attending physician identifier.
Enter the nationally assigned physician identification number, either the Uniform Physician Identification Number (UPIN) or National Provider Identifier (NPI) as approved by the board for the physician assigned as the attending physician for an inpatient.

3. Other physician identifier.
Enter the nationally assigned physician identification number, either the Uniform Physician Identification Number (UPIN) or National Provider Identifier (NPI) as approved by the board for the physician identified as the operating physician for the principal procedure reported.

4. Payor identifier.

5. Employer identifier.

6. Patient identifier.*
Enter the nine-digit social security number of the patient. If a social security number has not been assigned, leave blank. The nine-digit social security number is not required for patients under four years of age.

7a. Patient sex.

7b. Race code.*
If an inpatient hospital collects information regarding the choices listed below, the appropriate one-digit code reflecting the race of the patient should be entered. If a hospital only collects information for categories 0, 1, or 2, then the appropriate code should be entered from those three selections.

0 = White

1 = Black

2 = Other

3 = Asian

4 = American Indian

5 = White Hispanic

6 = Black Hispanic

7c. Date of birth.

7d. Street address, city or county, and zip code.

7e. Employment status code.

7f. Patient status (i.e., discharge).
Inpatient codes only.

7g. Birth weight (for infants).*
Enter the birth weight of newborns in grams.

8a. Admission type.

8b. Admission source.

8c. Admission date.

8d. Admission hour.

8e. Admission diagnosis code.

9a. Discharge date.
Only enter date of discharge.

10. Principal diagnosis code.
Enter secondary diagnoses (up to eight).
In addition, include diagnoses recorded in the comments section for DX6-DX9.

11. External cause of injury code (E-code).
Record all external cause of injury codes in secondary diagnoses position after recording all treated secondary diagnoses.

12. Co-morbid conditions existing but not treated.

13. Principal procedure code and date.
Enter other procedures and dates (up to five). In addition, include procedures recorded in the comments section for PX4-PX6.

14. Revenue code (up to 23).
Units of service (up to 23).
Units of service charges (up to 23).

15. Total charges (by revenue code category or by HCPCS code).
(R.C. Code 001 is for total charges. See page 47-1.)

Table 1

Data Element

1. Provider Number
Enter the Medicare Provider Number

2. Provider NPI

3. Patient Control Number

4. Discharge Date
Discharge Statement Covers Period Through Date in MMDDYYYY format

5. Patient Zip Code
Zip Code of Patient Address

6. Patient Date of Birth
Date in MMDDYYYY format

7.Patient Sex
M, F, or U

8. Admission Date and Hour
Date in MMDDYYYY format, hour of admission in military time

9. Admission Type

10. Admission Source

11. Patient Discharge Status

12. Medical Record Number

13. Revenue Center Code (up to 22)

14. Revenue Center Units (up to 22)

15. Revenue Center Charges (up to 22)
Dollars and cents with an implied decimal

16. Total Charges
Dollars and cents with an implied decimal. If greater than $999,999.99, then use 99999999

17. Payor Identifier (up to 3)
Enter the Board of Health approved payor designation, which will be the nationally assigned payor ID, its successor, or English description of the payor

18. Patient Relationship to Insured A

19. Patient Social Security Number (SSN)
Enter the nine-digit social security number of the patient. If a social security number has not been assigned, leave blank. The nine-digit social security number is not required for patients under four years of age

20. Employment Status Code
Use the following codes
1 = Employed Full Time
2 = Employed Part Time
3 = Not Employed
4 = Self-employed
5 = Retired
6 = On Active Military Duty
9 = Unknown

21. Employer Identifier
Enter the federally approved EIN, or employer name

22. Principal Diagnosis Code
Codes set ICD-10 or their successors, omit decimal; eighth character is the Present On Admission value (Y, N, U, W, or 1)

23. Other Diagnosis Code (up to 17)
Codes set ICD-10 or their successors, omit decimal; eighth character is the Present On Admission value (Y, N, U, W, or 1)

24. Admitting Diagnosis Code
Codes set ICD-10 or their successors, omit decimal, eighth character is the Present On Admission value (Y, N, U, W, or 1)

25. External Cause of Injury Code (up to 3)
Codes set ICD-10 or their successors, omit decimal; eighth character is the Present On Admission value (Y, N, U, W, or 1)

26. Principal Procedure Code
Codes set ICD-10 or their successors, omit decimal

27. Principal Procedure Date
Date in MMDDYY format

28. Other Procedure Codes (up to 5)
Codes set ICD-10 or their successors, omit decimal

29. Other Procedure Dates (up to 5)
Date in MMDDYY format

30. Attending Physician
Physician's Individual NPI

31. Operating Physician
Physician's Individual NPI

32. Other Physician Provider (up to 2)
Physician's Individual NPI

33. Infant Birth Weight (in grams)

34. Patient Race
Use the following codes:
0 = White
1 = Black
2 = Other, specified
3 = Asian
4 = American Indian
5 = Hispanic - White
6 = Hispanic - Black
9 = Unknown, not recorded

35. Patient Street Address
Enter the valid patent's residence street number and street name. Do not include P.O. Box numbers

36. Patient City or County
Enter the valid patient's complete City or County of residence

37. Patient Legal Status
Enter the legal status of a psychiatric admission:
1 = § 16.1-338 Parental admission of minors younger than 14 and nonobjecting minors 14 years of age or older
2 = § 16.1-339 Parental admission of objecting minor 14 years of age or older
3 = § 16.1-340.1 Involuntary temporary detention order of a minor
4 = § 16.1-345 Involuntary commitment of a minor
5 = § 37.2-805 Voluntary admission of an adult
6 = § 37.2-809 Involuntary temporary detention order of an adult
7 = § 37.2-904 Sexually violent predator