C.M.R. 90, 590, ch. 241, app 590-241-B-2
Inpatient Data Record Type 71 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP7101 | Record Type | NA | NA |
IP7102 | Sequence Number | NA | NA |
IP7103 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP7104 | Principal Diagnosis | 67 | 837/2300/HI/ABK/01-2 |
IP7105 | Present On Admission Indicator | 67 (pos 8) | 837/2300/HI/01-9 |
IP7106 | Admitting Diagnosis | 69 | 837/2300/HI/ABJ/01-2 |
IP7110 | Principal Procedure Code | 74 | 837/2300/HI/BBR/01-2 |
IP7111 | Principal Procedure Date | 74 | 837/2300/HI/D8/01-4 |
Inpatient Data Record Type 72 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP7201 | Record Type | NA | NA |
IP7202 | Sequence Number | NA | NA |
IP7203 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP7204 | Other Procedure Code - 1 | 74A | 837/2300/HI/BBQ/01-2 |
IP7205 | Other Procedure Date - 1 | 74A | 837/2300/HI/D8/01-4 |
IP7206 | Other Procedure Code - 2 | 74B | 837/2300/HI/BBQ/02-2 |
IP7207 | Other Procedure Date - 2 | 74B | 837/2300/HI/D8/02-4 |
IP7208 | Other Procedure Code - 3 | 74C | 837/2300/HI/BBQ/03-2 |
IP7209 | Other Procedure Date - 3 | 74C | 837/2300/HI/D8/03-4 |
IP7210 | Other Procedure Code - 4 | 74D | 837/2300/HI/BBQ/04-2 |
IP7211 | Other Procedure Date - 4 | 74D | 837/2300/HI/D8/04-4 |
IP7212 | Other Procedure Code - 5 | 74E | 837/2300/HI/BBQ/05-2 |
IP7213 | Other Procedure Date - 5 | 74E | 837/2300/HI/D8/05-4 |
IP7214 | Other Procedure Code - 6 | NA | 837/2300/HI/BBQ/06-2 |
IP7215 | Other Procedure Date - 6 | NA | 837/2300/HI/D8/06-4 |
IP7216 | Other Procedure Code - 7 | NA | 837/2300/HI/BBQ/07-2 |
IP7217 | Other Procedure Date - 7 | NA | 837/2300/HI/D8/07-4 |
IP7218 | Other Procedure Code - 8 | NA | 837/2300/HI/BBQ/08-2 |
IP7219 | Other Procedure Date - 8 | NA | 837/2300/HI/D8/08-4 |
Inpatient Data Record Type 73 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP7301 | Record Type | NA | NA |
IP7302 | Sequence Number | NA | NA |
IP7303 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP7304 | External Cause of Injury Code - 1 | 72A | 837/2300/HI/ABN/01-2 |
IP7305 | Present On Admission Indicator - 1 | 72A (pos 8) | 837/2300/HI/01-9 |
IP7306 | External Cause of Injury Code - 2 | 72B | 837/2300/HI/ABN/02-2 |
IP7307 | Present On Admission Indicator - 2 | 72B (pos 8) | 837/2300/HI/02-9 |
IP7308 | External Cause of Injury Code - 3 | 72C | 837/2300/HI/ABN/03-2 |
IP7309 | Present On Admission Indicator - 3 | 72C (pos 8) | 837/2300/HI/03-9 |
IP7310 | External Cause of Injury Code - 4 | NA | 837/2300/HI/ABN/04-2 |
IP7311 | Present On Admission Indicator - 4 | NA | 837/2300/HI/04-9 |
IP7312 | External Cause of Injury Code - 5 | NA | 837/2300/HI/ABN/05-2 |
IP7313 | Present On Admission Indicator - 5 | NA | 837/2300/HI/05-9 |
IP7314 | External Cause of Injury Code - 6 | NA | 837/2300/HI/ABN/06-2 |
IP7315 | Present On Admission Indicator - 6 | NA | 837/2300/HI/06-9 |
IP7316 | External Cause of Injury Code - 7 | NA | 837/2300/HI/ABN/07-2 |
IP7317 | Present On Admission Indicator - 7 | NA | 837/2300/HI/07-9 |
IP7318 | External Cause of Injury Code - 8 | NA | 837/2300/HI/ABN/08-2 |
IP7319 | Present On Admission Indicator - 8 | NA | 837/2300/HI/08-9 |
IP7320 | External Cause of Injury Code - 9 | NA | 837/2300/HI/ABN/09-2 |
IP7321 | Present On Admission Indicator - 9 | NA | 837/2300/HI/09-9 |
IP7322 | External Cause of Injury Code - 10 | NA | 837/2300/HI/ABN/10-2 |
IP7323 | Present On Admission Indicator - 10 | NA | 837/2300/HI/10-9 |
IP7324 | External Cause of Injury Code - 11 | NA | 837/2300/HI/ABN/11-2 |
IP7325 | Present On Admission Indicator - 11 | NA | 837/2300/HI/11-9 |
IP7326 | External Cause of Injury Code - 12 | NA | 837/2300/HI/ABN/12-2 |
IP7327 | Present On Admission Indicator - 12 | NA | 837/2300/HI/12-9 |
Inpatient Data Record Type 74 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP7401 | Record Type | NA | NA |
IP7402 | Sequence Number | NA | NA |
IP7403 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP7404 | Other Diagnosis Code - 1 | 67A | 837/2300/HI/ABF/01-2 |
IP7405 | Present On Admission Indicator - 1 | 67A (pos 8) | 837/2300/HI/01-9 |
IP7406 | Other Diagnosis Code - 2 | 67B | 837/2300/HI/ABF/02-2 |
IP7407 | Present On Admission Indicator - 2 | 67B (pos 8) | 837/2300/HI/02-9 |
IP7408 | Other Diagnosis Code - 3 | 67C | 837/2300/HI/ABF/03-2 |
IP7409 | Present On Admission Indicator - 3 | 67C (pos 8) | 837/2300/HI/03-9 |
IP7410 | Other Diagnosis Code - 4 | 67D | 837/2300/HI/ABF/04-2 |
IP7411 | Present On Admission Indicator - 4 | 67D (pos 8) | 837/2300/HI/04-9 |
IP7412 | Other Diagnosis Code - 5 | 67E | 837/2300/HI/ABF/05-2 |
IP7413 | Present On Admission Indicator - 5 | 67E (pos 8) | 837/2300/HI/05-9 |
IP7414 | Other Diagnosis Code - 6 | 67F | 837/2300/HI/ABF/06-2 |
IP7415 | Present On Admission Indicator - 6 | 67F (pos 8) | 837/2300/HI/06-9 |
IP7416 | Other Diagnosis Code - 7 | 67G | 837/2300/HI/ABF/07-2 |
IP7417 | Present On Admission Indicator - 7 | 67G (pos 8) | 837/2300/HI/07-9 |
IP7418 | Other Diagnosis Code - 8 | 67H | 837/2300/HI/ABF/08-2 |
IP7419 | Present On Admission Indicator - 8 | 67H (pos 8) | 837/2300/HI/08-9 |
IP7420 | Other Diagnosis Code - 9 | 67I | 837/2300/HI/ABF/09-2 |
IP7421 | Present On Admission Indicator - 9 | 67I (pos 8) | 837/2300/HI/09-9 |
IP7422 | Other Diagnosis Code - 10 | 67J | 837/2300/HI/ABF/10-2 |
IP7423 | Present On Admission Indicator - 10 | 67J (pos 8) | 837/2300/HI/10-9 |
IP7424 | Other Diagnosis Code - 11 | 67K | 837/2300/HI/ABF/11-2 |
IP7425 | Present On Admission Indicator - 11 | 67K (pos 8) | 837/2300/HI/11-9 |
IP7426 | Other Diagnosis Code - 12 | 67L | 837/2300/HI/ABF/12-2 |
IP7427 | Present On Admission Indicator - 12 | 67L (pos 8) | 837/2300/HI/12-9 |
Inpatient Data Record Type 80 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
IP8001 | Record Type | NA | NA |
IP8002 | Sequence | NA | NA |
IP8003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP8004 | Attending Provider NPI | 76 | 837/2310A/NM1/71/1/XX/09 |
IP8005 | Operating Physician NPI | 77 | 837/2310B/NM1/72/1/XX/09 |
IP8006 | Attending Provider Last Name | 76 | 837/2310A/NM1/71/1/03 |
IP8007 | Attending Provider First Name | 76 | 837/2310A/NM1/71/1/04 |
IP8008 | Attending Provider Middle Initial | 76 | 837/2310A/NM1/71/1/05 |
IP8009 | Operating Physician Last Name | 77 | 837/2310B/NM1/72/1/03 |
IP8010 | Operating Physician First Name | 77 | 837/2310B/NM1/72/1/04 |
IP8011 | Operating Physician Middle Initial | 77 | 837/2310B/NM1/72/1/05 |
IP8012 | Billing Provider NPI | 56 | 837/2010AA/NM1/XX/09 |
IP9001 | Record Type | NA | NA |
IP9003 | Patient Control Number | 3A | 837/2300/CLM/01 |
IP9004 | Total Accommodation Charges - Revenue Centers | NA | This is the total of the SV2 segments except for Revenue Code 0001 |
IP9005 | Total Ancillary Charges - Revenue Centers | NA | This is the total of the SV2 segments except for Revenue Code 0001 |
IP9901 | Record Type | NA | NA |
The record types in the file must be in the following order: |
Record Type 01 - Processor Data |
Record Type 20 Sequence 01 - Patient Data |
Record Type 30 Sequence 01 - Third Party Payer Data Primary Payer |
Record Type 30 Sequence 02-99 - Third Party Payer Additional Payer(s) Required for payer(s) other than primary. |
Record Type 40 - Claim Data |
Record Type 61 - Services |
Record Type 71 - ICD-10 CM Principal and Reason for Visit Diagnosis Codes, ICD-10 PCS Principal Procedure Code |
Record Type 72 - ICD-10 PCS Other Procedure Codes |
Record Type 73 - ICD-10 CM External Cause of Injury Diagnosis Codes |
Record Type 74 - ICD-10 CM Other Diagnosis Information |
Record Type 80 - Provider Data |
Record Type 90 - Claim Control Screen |
Record Type 99 - File Control |
The individual claim begins with Record Type 20 and ends with Record Type 90. |
The patient control number must be the same on each record type generated for a single patient record. |
The medical record number should not be substituted for the patient control number. |
Data Element # | Data Element | Implementation Date for New Data Elements | Type | Length | Description/Codes/Sources |
OP0101 | Record Type | T | 2 | 01 | |
OP0102 | MHDO-Assigned Hospital ID | T | 6 | Must be the MHDO-assigned, 6-digit hospital code, left justified | |
OP0198 | Filler | T | 38 | ||
OP0103 | Hospital Name | T | 21 | ||
OP0104 | Address | T | 18 | ||
OP0105 | City | T | 15 | ||
OP0106 | State | T | 2 | ||
OP0107 | Zip Code | T | 9 | ||
OP0199 | Filler | T | 78 | ||
OP0108 | Version | T | 3 | Leave blank |
C.M.R. 90, 590, ch. 241, app 590-241-B-2