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Slide 1 March 31, 2005 Texas Health Care Information Collection THCIC 837 Claim Technical Discussion.

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Presentation on theme: "Slide 1 March 31, 2005 Texas Health Care Information Collection THCIC 837 Claim Technical Discussion."— Presentation transcript:

1 Slide 1 March 31, 2005 Texas Health Care Information Collection THCIC 837 Claim Technical Discussion

2 2 Slide 2 Texas Health Care Information Collection Agenda Terminology UB92 verses Control Structure THCIC 837 Example

3 3 Slide 3 Texas Health Care Information Collection Terminology UB92 Batches of claims Multiple physical records per claim. 837 Transaction sets 1 or more physical records per transaction set

4 4 Slide 4 Texas Health Care Information Collection Terminology UB92 Each record contains logically related data elements. 837 Segments one or more related data elements Loops one or more segments (groups of semantically related segments)

5 5 Slide 5 Texas Health Care Information Collection Terminology UB92 Fixed length fields and records Every data element that can be reported has a place. Know exactly where to look for each data element. 837 Variable length fields and records Data elements do not have specific locations in a record. Identifiers used to locate data element.

6 6 Slide 6 Texas Health Care Information Collection UB92 versus 837 Patient Data Name, address, city, state, zip, birth date UB92 Record: Loop: 2010CA Segments: NM1, N3, N4, DMG

7 7 Slide 7 Texas Health Care Information Collection UB92 versus 837 UB92 20 WEISS RON 33 characters 837 NM1*QC*1*WEISS*RON* 19 characters Patient Last Name Patient First Name

8 8 Slide 8 Texas Health Care Information Collection UB92 versus WEISS RON NM1*QC*1*WEISS*RON* First Name Patient Last Name Name Segment Person Record Type Seq No Last Name First Name

9 9 Slide 9 Texas Health Care Information Collection File Control Structure ISA (Interchange Header) only one per file GS (Functional Group start) multiple per submission used for a group of similar transaction sets ST (Transaction Start) used to identify the type of transaction multiple per GS …Transaction Segments claim data SE (Transaction End) one for each ST used for balancing transaction set GE (Functional Group End) one for each GS used for balancing functional group IEA (Interchange End) one per submission used for balancing submission

10 10 Slide 10 Texas Health Care Information Collection Use example to Describe segments Their usage Key data elements Issues found during test review Spaces in this example are represented by ^ for clarity. Building A Submission

11 11 Slide 11 Texas Health Care Information Collection One submission from EL GRANDE SUBMITTER, Submitter ID = SUB000 Submitting for one hospital, TEXAS STATE HOSPITAL, THCIC ID = Submission includes two claims admission through discharge claims one where the subscriber is the patient, and one where the patient is the son of the subscriber. One submission from EL GRANDE SUBMITTER, Submitter ID = SUB000 Submitting for one hospital, TEXAS STATE HOSPITAL, THCIC ID = Submission includes two claims admission through discharge claims one where the subscriber is the patient, and one where the patient is the son of the subscriber. Case

12 12 Slide 12 Texas Health Care Information Collection ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ* SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455* U*00401* *0*T*:~ GS functional group ST transaction set SE GE IEA*1* ~ ISA and IEA segments wrap the submission. ISA segment is only segment that is fixed length. All positions within each data element must be filled. Interchange Control Header - Trailer

13 13 Slide 13 Texas Health Care Information Collection 1 ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ* SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917* *U*00401* *0*T*:~ 1 The character in position 4 (first element separator) defines the element separator to be used throughout the entire interchange. 2 Submitter ID assigned by CCS. 3 Receiver ID – ensures that claims are intended for THCIC. 4 Date for this submission. 5 Time for this submission. Interchange Control Header - Trailer

14 14 Slide 14 Texas Health Care Information Collection 1 ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ* SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917* *U*00401* *0*T*:~ 6 Interchange control number – unique to this submission. Must match element IEA02 in the IEA segment. 7 Identifies submission as Test or Production 8 Component element separator – : will be used to separate components within elements. 9 Defines the segment terminator to be used throughout the entire interchange. Interchange Control Header - Trailer

15 15 Slide 15 Texas Health Care Information Collection ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ* YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~ GS functional group ST transaction set SE GE 1 2 IEA*1* ~ 1 Number of functional groups in submission. 2 Interchange control number – unique to this submission. Must match element ISA13 in the ISA segment. Interchange Control Header - Trailer

16 16 Slide 16 Texas Health Care Information Collection ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ* YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~ GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~ ST transaction set SE GE*1*22~ IEA*1* ~ GS and GE segments wrap one or more transaction sets of like transactions. Identifies the version of the EDI standard used. Functional Group

17 17 Slide 17 Texas Health Care Information Collection GS*HC*SUB000*YTH837* *1455*22*X* X096A1~ 1 Submitter ID assigned by CCS. 2 Receiver ID – ensures that claims are intended for THCIC. 3 Date for this functional group. 4 Time for this functional group. 5 Group control number – unique to this functional group. Must match element GE02 in the GE segment. Functional Group Header - Trailer

18 18 Slide 18 Texas Health Care Information Collection GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~ 1 2 GE*1*22~ 1 Number of transaction sets in group. 2 Group control number – unique to this submission. Must match element GS06 in the GS segment. Functional Group Header - Trailer

19 19 Slide 19 Texas Health Care Information Collection ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ* YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~ GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~ ST*837*3333~ SE*10*3333~ GE*1*22~ IEA*1* ~ ST and SE segments wrap the data segments that comprise the claims for the transaction. Transaction Set

20 20 Slide 20 Texas Health Care Information Collection 1 2 ST*837*3333~ 3 4 SE*10*3333~ claims are being reported in this transaction set. 2 Transaction set control number – unique to this transaction set. Must match element SE02 in the SE segment. 3 Number of segments in this set, including ST and SE segments. 4 Transaction Set control number – unique to this transaction set. Must match element ST02 in the ST segment. Transaction Set Header - Trailer

21 21 Slide 21 Texas Health Care Information Collection Transmission ST*837*3333~ BHT*0019*00*5* *1455*CH~ 5 REF*87*004010X96DA1~ 1 Describes hierarchical application structure. 2 Transaction set reference ID. 3 Date transaction was created. 4 Time transaction was created. 5 Identifies transaction as production or test and which version of the EDI standard is used.

22 22 Slide 22 Texas Health Care Information Collection Transmission Submitter and Receiver ST*837*3333~ BHT*0019*00*5* *1455*CH~ REF*87*004010X96DA1~ NM1*41*2*El Grande Submitter*****46*SUB000~ NM1*40*2*THCIC*****46*YTH837~ Data segments identifying submitter and receiver.

23 23 Slide 23 Texas Health Care Information Collection Submitter & Receiver ST*837*3333~ BHT*0019*00*5* *1455*CH~ REF*87*004010X96DA1~ NM1*41*2*El Grande Submitter*****46*SUB000~ NM1*40*2*THCIC*****46*YTH837~ 1 Identifies segment as for submitter 2 Submitter Name 3 THCIC Submitter ID. 4 Identifies segment as for receiver 5 THCIC – receiver name 6 Receiver identifier

24 24 Slide 24 Texas Health Care Information Collection Billing / Pay-To Provider ST*837*3333~ BHT*0019*00*5* *1455*CH~ REF*87*004010X96DA1~ NM1*41*2*El Grande Submitter*****46*SUB000~ N1*40*2*THCIC*****46*YTH837~ HL*1**20*1~ PRV*BI*ZZ~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ REF*1J*000116~ Goal with these segments is to identify the service provider.

25 25 Slide 25 Texas Health Care Information Collection HLs HL*1**20*1~ HL*2*1*22*1~ HL*3*2*23*0~ HL*4*1*22*0~ HL segments identify levels of detail information using a hierarchical structures. HLs used in our example: 1 Provider 2 Subscriber 3 Patient 4 Subscriber

26 26 Slide 26 Texas Health Care Information Collection HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber The first HL in transaction set is for the provider. 1 HL ID 2 No parent HL 3 Characteristic - 20 – information source 4 Subordinate HLs follow

27 27 Slide 27 Texas Health Care Information Collection HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber The second HL in transaction set is for the subscriber. 1 HL ID is one more than previous HL 2 Parent HL is the provider 3 Characteristic - 22 Subscriber 4 Subordinate HLs follow

28 28 Slide 28 Texas Health Care Information Collection HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber 3 rd HL in transaction set is for the patient. 1ID of HL is one more than previous HL 2Parent HL is that of subscriber 3Characteristic - 23 – patient 4 No subordinate HLs follow

29 29 Slide 29 Texas Health Care Information Collection HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber 4 th HL in transaction set is for the next subscriber. 1ID of HL is one more than the previous HL 2Parent HL is the provider 3Characteristic - 22 subscriber 4 No subordinate HLs follow

30 30 Slide 30 Texas Health Care Information Collection Billing / Pay-To Provider HL*1**20*1~ PRV*BI*ZZ~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ REF*1J*000116~ Starts the Billing Provider Hierarchical Level 1 The first HL ID number is 1 2 There is no parent HL as this is the first. 3 Code defining characteristics of the HL level 20 – information source 4 Child code indicator – 1 indicates that there are HLs that are subordinate to this HL.

31 31 Slide 31 Texas Health Care Information Collection Billing / Pay-To Provider HL*1**20*1~ 1 PRV*BI~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ REF*1J*000116~ Identifies which of the reported providers is the service provider. 1 Options are BI (billing) and PT (pay-to). If the service provider is not the billing provider or the pay-to provider, then there is no PRV segment and the service provider is reported in the 2310E segments within the claim.

32 32 Slide 32 Texas Health Care Information Collection Billing / Pay-To Provider HL*1**20*1~ PRV*BI~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ REF*1J*000116~ Segment names billing provider. 1 Identifies the segment as being for the billing provider. 2 This is the only place that the provider name is reported. 3 EIN of the billing provider. Must match EIN in THCIC Provider Database. Contact Dee Shaw at to verify

33 33 Slide 33 Texas Health Care Information Collection Billing / Pay-To Provider HL*1**20*1~ PRV*BI~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ 1 2 N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ REF*1J*000116~ 1 Line one of the street address of the provider. 2 Line two of the street address of the provider. 3 City of the provider. 4 State of the provider. 5 Zip code of the provider. 1 st 15 characters of address line 1 are used to validate provider.

34 34 Slide 34 Texas Health Care Information Collection Billing / Pay-To Provider HL*1**20*1~ PRV*BI~ NM1*85*2*TEXAS STATE HOSPITAL*****24* ~ N3*4901 W. 49 ST*SUITE 660~ N4*AUSTIN*TX*78751~ 1 REF*1J*000116~ THCIC hospital identifier. 1 The THCIC 6-digit hospital ID. Replaces the 3-digit alphanumeric THCIC facility ID used in the UB92. Same as record 10, field 10 of the UB92T

35 35 Slide 35 Texas Health Care Information Collection Subscriber – Primary Payer HL*2*1*22*1~ SBR*P********CI~ NM1*PR*2*ALWAYS PAYS CLAIM*****PI*HH4504~ HL and subordinate segments describing the subscriber of a claim where the subscriber is not the patient.

36 36 Slide 36 Texas Health Care Information Collection Subscriber – Primary Payer HL*2*1*22*1~ SBR*P********CI~ NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~ HL segment for subscriber with a subordinate HL for patient 1 HL ID number 2 ID of parent HL 3 HL level code – 22 for subscriber 4 Child code – 1 subordinate HL follows

37 37 Slide 37 Texas Health Care Information Collection Subscriber – Primary Payer HL*2*1*22*1~ SBR*P********CI~ NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~ Identifies payer source of claim. 1 Primary payer code. 2 Indicates that subscriber is not the patient. 3 Commercial insurance.

38 38 Slide 38 Texas Health Care Information Collection Subscriber – Primary Payer HL*2*1*22*1~ SBR*P********CI~ NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~ 1 Payer name 2 Payer ID qualifier 3 Payer ID In the situation where there is not insurance, then if self pay:payer name = SELF PAY, payer ID = SELF indigent:payer name = INDIGENT, payer ID = INDIGENT charity:payer name = CHARITY, payer ID = CHARITY, and unknown: payer name = UNKNOWN, payer ID = UNKNOWN.

39 39 Slide 39 Texas Health Care Information Collection Patient Info HL*3*2*23*0~ PAT*19~ NM1*QC*1*WEISS*NATE~ N3*P O BOX 001~ N4*AUSTIN*TX*78701~ DMG*D8* *M**4~ REF*SY* ~ Patient name, identifiers, demographics.

40 40 Slide 40 Texas Health Care Information Collection Patient Info HL*3*2*23*0~ 5 PAT*19~ NM1*QC*1*WEISS*NATE~ N3*P O BOX 001~ N4*AUSTIN*TX*78701~ DMG*D8* *M**4~ REF*SY* ~ HL segment for patient that is subordinate to the previous subscriber 1 HL ID number 2 ID of parent HL 3 HL level code – dependent 4 Child code – no subordinate HLs follow 5 Identifies patients relationship to insured.

41 41 Slide 41 Texas Health Care Information Collection Patient Info HL*3*2*23*0~ PAT*19~ 1 2 NM1*QC*1*WEISS*NATE~ 3 N3*P O BOX 001~ N4*AUSTIN*TX*78701~ DMG*D8* *M**4~ REF*SY* ~ 1 Patient last name 2 Patient first name 3 Line one of the street address of the patient 4 City 5 State 6 Zip Code

42 42 Slide 42 Texas Health Care Information Collection Patient Info HL*3*2*23*0~ PAT*19~ NM1*QC*1*WEISS*NATE~ N3*P O BOX 001~ N4*AUSTIN*TX*78701~ DMG*D8* *M**4~ 4 REF*SY* ~ 1 Patient birth date 2 Gender 3 Race 4 Patient social security number. – Use SY qualifier. – Use for patients without social security numbers, who refuse to provide the number, or are covered by 42 USC 290dd-2 and 42 CFR Part 2.1.

43 43 Slide 43 Texas Health Care Information Collection Claim Info CLM*100381* ***11:A:1~ DTP*096*TM*1045~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*187~ NTE*UPI*2~ Claim details: including admission, diagnosis and treatment data.

44 44 Slide 44 Texas Health Care Information Collection Claim Info CLM*100381* ***11:A:1~ DTP*096*TM*1045~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*187~ NTE*UPI*2~ 1 Patient account number (patient control number). 2 Total claim charges 3 Facility code 4 Claim frequency code

45 45 Slide 45 Texas Health Care Information Collection Claim Dates CLM*100381* ***11:A:1~ 1 DTP*096*TM*1045~ 2 DTP*434*RD8* ~ 3 DTP*435*DT* ~ CL1*3*2*01~ REF*EA*187~ NTE*UPI*2~ 1 Discharge time – hhmm format. 2 Statement dates in a range. 3 Admission date and time - ccyymmddhhmm.

46 46 Slide 46 Texas Health Care Information Collection Claim Codes CLM*100381* ***11:A:1~ DTP*096*TM*1045~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ 4 REF*EA*187~ 5 NTE*UPI*2~ 1 Admission type 2 Admission source 3 Patient status 4 Medical record number 5 Patient ethnicity

47 47 Slide 47 Texas Health Care Information Collection Diagnoses, E-Codes, Treatment Codes NTE*UPI*2~ HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ All reported using HI segment. Identifiers are key to defining field values. Can mix and match but best kept in order.

48 48 Slide 48 Texas Health Care Information Collection Principal, Admitting Diagnoses, E-Codes HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for principal diagnosis 2 Principal diagnosis 3 Identifier for admitting diagnosis 4 Admitting diagnosis 5 Identifier for external cause of injury 6 E-code 7 Identifier for external cause of injury 8 E-Code

49 49 Slide 49 Texas Health Care Information Collection Other Diagnoses HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for other diagnosis 2 Diagnosis code 3 Identifier for other diagnosis 4 Diagnosis code

50 50 Slide 50 Texas Health Care Information Collection Principal Procedure HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for principal procedure 2 Principal procedure code 3 Qualifier for date type 4 Principal procedure date

51 51 Slide 51 Texas Health Care Information Collection Other Procedure HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853:D8: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for ICD code2 Other procedure code 3 Qualifier for date type4 Other procedure date 5 Identifier for HCPCS code6 Other procedure code 7 Qualifier for date type 8 Other procedure date

52 52 Slide 52 Texas Health Care Information Collection Occurrence Span HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853:D8: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for occurrence span 2 Occurrence span code 3 Qualifier for date type 4 Date range associated with occurrence span code

53 53 Slide 53 Texas Health Care Information Collection Occurrence HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853:D8: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ HI*BG*17~ 1 Identifier for occurrence code 2 Occurrence code 3 Qualifier for date type 4 Date associated with occurrence code

54 54 Slide 54 Texas Health Care Information Collection Occurrence HI*BK:486*BJ:486*BN:E2021*BN:E2022~ HI*BF:49121*BF:4019~ HI*BR:10012:D8: ~ HI*BQ:4001:D8: *BO:8853:D8: ~ HI*BI:71:RD8: ~ HI*BH:06:D8: ~ HI*BE:01:::307.65~ 4 5 HI*BG*17~ 1 Identifier for value code 2 Value code 3 Amount 4 Identifier for condition code 5 Condition code

55 55 Slide 55 Texas Health Care Information Collection Practitioners NM1*71*1*RICKSHAW*ROBERT~ REF*1G*C12321~ NM1*72*1*SHAW*RICK~ REF*0B*C3926~ Attending and operating practitioners Validate against license number/ UPIN first three characters of last name first character of first name.

56 56 Slide 56 Texas Health Care Information Collection Practitioners NM1*71*1*RICKSHAW*ROBERT~ 4 5 REF*1G*C12321~ NM1*72*1*SHAW*RICK~ REF*0B*C3926~ 1 Identifier for attending practitioner 2 Last name 3 First name 4 Qualifier for UPIN 5 UPIN

57 57 Slide 57 Texas Health Care Information Collection Practitioners NM1*71*1*RICKSHAW*ROBERT~ REF*1G*C12321~ NM1*72*1*SHAW*RICK~ 4 5 REF*0B*C3926~ 1 Identifier for operating practitioner 2 Last name 3 First name 4 Qualifier for state license 5 State license

58 58 Slide 58 Texas Health Care Information Collection Other Subscriber - Payer 1 2 SBR*S********ZZ~ NM1*PR*2*CHARITY*****PI*CHARITY~ 1 Secondary subscriber 2 Payer source 3 Payer name 4 Payer ID qualifier 5 Payer ID In the situation where there is not insurance, then if self pay:payer name = SELF PAY, payer ID = SELF indigent:payer name = INDIGENT, payer ID = INDIGENT charity:payer name = CHARITY, payer ID = CHARITY, and unknown: payer name = UNKNOWN, payer ID = UNKNOWN.

59 59 Slide 59 Texas Health Care Information Collection Service Lines LX*1~ SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~ LX*2~ SV2*0271**6.30*UN*1~ LX*3~ SV2*0258**285.80*UN*8~ Each service is preceded by a line number (LX) Sum of charges in service lines must equal the total charges in the CLM segment. No 0001 revenue code.

60 60 Slide 60 Texas Health Care Information Collection Service Lines 1 LX*1~ SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~ LX*2~ SV2*0271**6.30*UN*1~ LX*3~ SV2*0258**285.80*UN*8~ 1 line number beginning with 1 and incremented by 1 2 Revenue Code 3 Revenue Procedure Code Qualifier 4 Revenue Procedure Code Revenue Procedure Code Modifiers

61 61 Slide 61 Texas Health Care Information Collection Service Lines 1 LX*1~ SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~ LX*2~ SV2*0271**6.30*UN*1~ LX*3~ SV2*0258**285.80*UN*8~ 9 Charge amount 10 Unit code 11 Quantity 12 Unit rate 13 Non-covered amount

62 62 Slide 62 Texas Health Care Information Collection Subscriber is Patient Claim HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~ N3*54 TRAILS END~ N4*AUSTIN*TX*78755~ DMG*D8* *M**4~ REF*SY* ~ NM1*PR*2*MEDICARE PART A*****PI*HH300~ HL segment for subscriber where subscriber is the patient 1 HL ID number 2 ID of parent HL 3 HL level code – 22 for subscriber 4 Child code – no subordinate HL follows

63 63 Slide 63 Texas Health Care Information Collection Subscriber HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~ N3*54 TRAILS END~ N4*AUSTIN*TX*78755~ DMG*D8* *M**4~ REF*SY* ~ NM1*PR*2*MEDICARE PART A*****PI*HH300~ SBR identifies payer source of claim. 1 Primary payer 2 Subscriber is the patient 3 Payer source

64 64 Slide 64 Texas Health Care Information Collection Patient Info HL*4*1*22*0~ SBR*P*18*******MA~ 1 2 NM1*IL*1*SMITH*JOSEPH~ 3 N3*54 TRAILS END~ N4*AUSTIN*TX*78755~ DMG*D8* *M**4~ REF*SY* ~ NM1*PR*2*MEDICARE PART A*****PI*HH300~ 1 Patient last name 2 Patient first name 3 Line 1 - Street Address 4 City 5 State 6 Zip.

65 65 Slide 65 Texas Health Care Information Collection Patient Info HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~ N3*54 TRAILS END~ N4*AUSTIN*TX*78755~ DMG*D8* *M**4~ 4 REF*SY* ~ NM1*PR*2*MEDICARE PART A*****PI*HH300~ 1 Patient birth date 2 Gender 3 Race 4 Social security number

66 66 Slide 66 Texas Health Care Information Collection Primary Payer HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~ N3*54 TRAILS END~ N4*AUSTIN*TX*78755~ DMG*D8* *M**4~ REF*SY* ~ 1 2 NM1*PR*2*MEDICARE PART A*****PI*HH300~ 1 Payer name 2 Payer ID

67 67 Slide 67 Texas Health Care Information Collection Claim Info CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*MRN2211~ NTE*UPI*2~ Claim details: including admission, diagnosis and treatment data.

68 68 Slide 68 Texas Health Care Information Collection Claim Info CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*MRN2211~ NTE*UPI*2~ 1 Patient account number (patient control number). 2 Total claim charges 3 Bill Type

69 69 Slide 69 Texas Health Care Information Collection Discharge Time CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*MRN2211~ NTE*UPI*2~ 1 Identifies DTP as for discharge data. 2 Qualifies next element as time in format of hhmm. 3 Discharge time.

70 70 Slide 70 Texas Health Care Information Collection Statement Dates CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*MRN2211~ NTE*UPI*2~ 1 Identifies DTP as for statement dates. 2 Qualifies next element as being a date range. 3 Statement dates.

71 71 Slide 71 Texas Health Care Information Collection Admission Date and Time CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ REF*EA*MRN2211~ NTE*UPI*2~ 1 Identifies DTP as for admission date and time. 2 Qualifies next element as being a date/time combination. 3 Admission date and admission time (hhmm).

72 72 Slide 72 Texas Health Care Information Collection Claim Codes CLM*PAN1043*400***11:A:1~ DTP*096*TM*0900~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*3*2*01~ 4 REF*EA*MRN2211~ 5 NTE*UPI*2~ 1 Admission type 2 Admission source 3 Patient status (discharge status) 4 Medical record number 5 Ethnicity of patient.

73 73 Slide 73 Texas Health Care Information Collection HI Segments Diagnoses, E-Codes, Treatment Codes NTE*UPI*2~ HI*BK:100*BJ:100~ All reported using HI segment. Qualifier is key to defining field values.

74 74 Slide 74 Texas Health Care Information Collection Principal, Admitting Diagnoses, E-Codes HI*BK:100*BJ:100~ 1 Identifier for principal diagnosis 2 Principal diagnosis 3 Identifier for admitting diagnosis 4 Admitting diagnosis

75 75 Slide 75 Texas Health Care Information Collection Practitioners NM1*71*1*RICHARDS*SAM~ REF*1G*C96522~ REF*0B*C9312~ Attending practitioners Validate against license number/ UPIN first three characters of last name first character of first name.

76 76 Slide 76 Texas Health Care Information Collection Practitioners NM1*71*1*RICHARDS*SAM~ 4 5 REF*1G*C96522~ 6 7 REF*0B*C9312~ 1 Identifier for attending practitioner 2 Last name 3 First name 4 Identifier for UPIN 5 UPIN 6 Identifier for state license 7 State license

77 77 Slide 77 Texas Health Care Information Collection Other Subscriber - Payer SBR*S********BL~ NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~ SBR*T********CI~ NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~ Secondary and tertiary subscriber - payers. Only secondary subscriber - payer will be used.

78 78 Slide 78 Texas Health Care Information Collection Other Subscriber - Payer 1 2 SBR*S********BL~ 3 4 NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~ SBR*T********CI~ NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~ 1 Identifier for secondary subscriber 2 Payer source code 3 Payer name 4 Payer ID

79 79 Slide 79 Texas Health Care Information Collection Service Lines LX*1~ SV2*0120**1000*DA*2*500.00~ Each service is preceded by a line number (LX) Sum of charges in service lines must equal the total charges in the CLM segment. No 0001 revenue code.

80 80 Slide 80 Texas Health Care Information Collection Questions ? Ron Weiss Bruce Burns 6453


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