C.M.R. 90, 590, ch. 241, app 590-241-C-2
Outpatient Data Record Type 71 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator |
OP7101 | Record Type | NA | NA | NA |
OP7102 | Sequence Number | NA | NA | NA |
OP7103 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP7104 | Principal Diagnosis | 67 | 21A | 837/2300/HI/ABK/01-2 |
OP7107 | Reason for Visit Diagnosis - 1 | 70A | NA | 837/2300/HI/APR/01-2 |
OP7108 | Reason for Visit Diagnosis - 2 | 70B | NA | 837/2300/HI/APR/02-2 |
OP7109 | Reason for Visit Diagnosis - 3 | 70C | NA | 837/2300/HI/APR/03-2 |
OP7110 | Principal Procedure Code | 74 | NA | 837/2300/HI/BBR/01-2 |
OP7111 | Principal Procedure Date | 74 | NA | 837/2300/HI/D8/01-4 |
Outpatient Data Record Type 72 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
OP7201 | Record Type | NA | NA | NA |
OP7202 | Sequence Number | NA | NA | NA |
OP7203 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP7204 | Other Procedure Code - 1 | 74A | NA | 837/2300/HI/BBQ/01-2 |
OP7205 | Other Procedure Date - 1 | 74A | NA | 837/2300/HI/D8/01-4 |
OP7206 | Other Procedure Code - 2 | 74B | NA | 837/2300/HI/BBQ/02-2 |
OP7207 | Other Procedure Date - 2 | 74B | NA | 837/2300/HI/D8/02-4 |
OP7208 | Other Procedure Code - 3 | 74C | NA | 837/2300/HI/BBQ/03-2 |
OP7209 | Other Procedure Date - 3 | 74C | NA | 837/2300/HI/D8/03-4 |
OP7210 | Other Procedure Code - 4 | 74D | NA | 837/2300/HI/BBQ/04-2 |
OP7211 | Other Procedure Date - 4 | 74D | NA | 837/2300/HI/D8/04-4 |
OP7212 | Other Procedure Code - 5 | 74E | NA | 837/2300/HI/BBQ/05-2 |
OP7213 | Other Procedure Date - 5 | 74E | NA | 837/2300/HI/D8/05-4 |
OP7214 | Other Procedure Code - 6 | NA | NA | 837/2300/HI/BBQ/06-2 |
OP7215 | Other Procedure Date - 6 | NA | NA | 837/2300/HI/D8/06-4 |
OP7216 | Other Procedure Code - 7 | NA | NA | 837/2300/HI/BBQ/07-2 |
OP7217 | Other Procedure Date - 7 | NA | NA | 837/2300/HI/D8/07-4 |
OP7218 | Other Procedure Code - 8 | NA | NA | 837/2300/HI/BBQ/08-2 |
OP7219 | Other Procedure Date - 8 | NA | NA | 837/2300/HI/D8/08-4 |
Outpatient Data Record Type 73 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
OP7301 | Record Type | NA | NA | NA |
OP7302 | Sequence Number | NA | NA | NA |
OP7303 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP7304 | External Cause of Injury - 1 | 72A | NA | 837/2300/HI/ABN/01-2 |
OP7306 | External Cause of Injury - 2 | 72B | NA | 837/2300/HI/ABN/02-2 |
OP7308 | External Cause of Injury - 3 | 72C | NA | 837/2300/HI/ABN/03-2 |
OP7310 | External Cause of Injury - 4 | NA | NA | 837/2300/HI/ABN/04-2 |
OP7312 | External Cause of Injury - 5 | NA | NA | 837/2300/HI/ABN/05-2 |
OP7314 | External Cause of Injury - 6 | NA | NA | 837/2300/HI/ABN/06-2 |
OP7316 | External Cause of Injury - 7 | NA | NA | 837/2300/HI/ABN/07-2 |
OP7318 | External Cause of Injury - 8 | NA | NA | 837/2300/HI/ABN/08-2 |
OP7320 | External Cause of Injury - 9 | NA | NA | 837/2300/HI/ABN/09-2 |
OP7322 | External Cause of Injury - 10 | NA | NA | 837/2300/HI/ABN/10-2 |
OP7324 | External Cause of Injury - 11 | NA | NA | 837/2300/HI/ABN/11-2 |
OP7326 | External Cause of Injury - 12 | NA | NA | 837/2300/HI/ABN/12-2 |
Outpatient Data Record Type 74 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator |
OP7401 | Record Type | NA | NA | NA |
OP7402 | Sequence Number | NA | NA | NA |
OP7403 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP7404 | Other Diagnosis Code - 1 | 67A | 21B | 837I/2300/HI/ABF/01-2 837P/2300/HI/ABF/02-2 |
OP7406 | Other Diagnosis Code - 2 | 67B | 21C | 837I/2300/HI/ABF/02-2 837P/2300/HI/ABF/03-2 |
OP7408 | Other Diagnosis Code - 3 | 67C | 21D | 837I/2300/HI/ABF/03-2 837P/2300/HI/ABF/04-2 |
OP7410 | Other Diagnosis Code - 4 | 67D | 21E | 837I/2300/HI/ABF/04-2 837P/2300/HI/ABF/05-2 |
OP7412 | Other Diagnosis Code - 5 | 67E | 21F | 837I/2300/HI/ABF/05-2 837P/2300/HI/ABF/06-2 |
OP7414 | Other Diagnosis Code - 6 | 67F | 21G | 837I/2300/HI/ABF/06-2 837P/2300/HI/ABF/07-2 |
OP7416 | Other Diagnosis Code - 7 | 67G | 21H | 837I/2300/HI/ABF/07-2 837P/2300/HI/ABF/08-2 |
OP7418 | Other Diagnosis Code - 8 | 67H | 21I | 837I/2300/HI/ABF/08-2 837P/2300/HI/ABF/09-2 |
OP7420 | Other Diagnosis Code - 9 | 67I | 21J | 837I/2300/HI/ABF/09-2 837P/2300/HI/ABF/10-2 |
OP7422 | Other Diagnosis Code - 10 | 67J | 21K | 837I/2300/HI/ABF/10-2 837P/2300/HI/ABF/11-2 |
OP7424 | Other Diagnosis Code - 11 | 67K | 21L | 837I/2300/HI/ABF/11-2 837P/2300/HI/ABF/12-2 |
OP7426 | Other Diagnosis Code - 12 | 67L | NA | 837I/2300/HI/ABF/12-2 |
Outpatient Data Record Type 80 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference Designator |
OP8001 | Record Type | NA | NA | NA |
OP8002 | Sequence | NA | NA | NA |
OP8003 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP8004 | Attending Provider NPI | 76 | NA | 837/2310A/NM1/71/1/XX/09 |
OP8005 | Operating Physician NPI | 77 | NA | 837/2310B/NM1/72/1/XX/09 |
OP8006 | Attending Provider Last Name | 76 | NA | 837/2310A/NM1/71/1/03 |
OP8007 | Attending Provider First Name | 76 | NA | 837/2310A/NM1/71/1/04 |
OP8008 | Attending Provider Middle Initial | 76 | NA | 837/2310A/NM1/71/1/05 |
OP8009 | Operating Physician Last Name | 77 | NA | 837/2310B/NM1/72/1/03 |
OP8010 | Operating Physician First Name | 77 | NA | 837/2310B/NM1/72/1/04 |
OP8011 | Operating Physician Middle Initial | 77 | NA | 837/2310B/NM1/72/1/05 |
OP8012 | Billing Provider NPI | 56 | NA | 837/2010AA/NM1/XX/09 |
OP9001 | Record Type | NA | NA | NA |
OP9003 | Patient Control Number | 3A | 26 | 837/2300/CLM/01 |
OP9004 | Total Ancillary Charges - Revenue Centers | NA | 28 | This is the total of the SV2 segments with the exception of Revenue Code 0001 |
Outpatient Data Record Type 99 Mapping to National Standards
Data Element # | Data Element Name | UB-04 Form Locator | CMS-1500 | HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator |
OP9901 | Record Type | NA | NA | NA |
C.M.R. 90, 590, ch. 241, app 590-241-C-2