20 CAR Part 54 — Inpatient Database Hospital Discharge Data Submittal Guide 2014

Chapter I

Subchapter B

Subpart 1

20 CAR § 54-101 Introduction {#sec-20-car-54-101 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-101}

20 CAR § 54-101. Introduction.

(a)(1) A statewide Hospital Discharge Data System (HDDS) is one of the most important tools for addressing a broad range of health policy issues.

(2) Acts 1995, No. 670, State Health Data Clearinghouse Act, Arkansas Code § 20-7-301 et seq., requires all hospitals licensed by the State of Arkansas to report information on inpatient discharges.

(b) In order to simplify the reporting process, the Arkansas HDDS is based on the United States Centers for Medicare and Medicaid Services UB-04 form.

(c)(1) In accordance, the Department of Health is required to collect, analyze, and disseminate selected healthcare data.

(2) This guide defines the data that hospitals will submit for the specific purpose of constructing the Hospital Discharge Data System.

(d)(1) The Health Statistics Branch can provide technical consultation and assistance.

(2) Initially, such consultation or assistance must necessarily be limited to activities that specifically enable the hospital to submit data that will meet the requirements.

(e) For further information, contact Betty Hicks, Manager of HDDS.

Department of Health Health Statistics Branch 4815 West Markham Little Rock, AR 72205 Phone: (800) 482-5400 ext. 2368 Fax: (501) 661-2544 Betty Hicks Betty.Hicks@arkansas.gov Phone: (501) 661-2867

20 CAR § 54-102 Data reporting source {#sec-20-car-54-102 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-102}

20 CAR § 54-102. Data reporting source.

(a)(1) All facilities operating and licensed as hospitals in the State of Arkansas by the Department of Health, Division of Health Facility Services, will report discharge data to the department for each patient admitted as an inpatient or with at least one (1) full day of stay (overnight).

(2)(A) Discharge data means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a single inpatient hospital stay.

(B) The consolidation of discharge data is a discharge data record.

(C) The formats are defined later in this guide.

(b)(1) For a patient with multiple discharges, submit one (1) discharge data record for each discharge.

(2) For a patient with multiple billing claims (refer to 20 CAR § 54-106(g), Multi-hospital submission), consolidate the multiple billings into one (1) discharge data record for submission after the patient’s discharge.

(3) A discharge data record is submitted for each discharge, not for each bill generated.

(4) The discharge data record should be submitted for the reporting period within which the discharge occurs.

(5) If a claim will not be submitted to a provider or carrier for collection (e.g., charitable service), a hospital discharge data record should still be submitted to the department, with the normal and customary charges, as if the claim was being submitted.

(6) All acute and intensive care discharges or deaths, including newborn discharges or deaths, should be reported.

(c)(1) A hospital may submit discharge data directly to the department, or may designate an intermediary, such as a commercial data clearinghouse.

(2) Use of an intermediary does not relieve the hospital from its reporting responsibility.

(d)(1) In order to facilitate communication and problem solving, each hospital should designate a person as contact.

(2) Please provide the office name, telephone number, job title, and name of the person assigned this responsibility.

20 CAR § 54-103 Confidentiality of data {#sec-20-car-54-103 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-103}

20 CAR § 54-103. Confidentiality of data.

(a)(1) Acts 1995, No. 670, State Health Data Clearinghouse Act, Arkansas Code § 20-7-301 et seq., provides for the strictest confidentiality of data and severe penalties for the violation of the State Health Data Clearinghouse Act.

(2) Any information collected from hospitals which identifies a patient, provider, institution, or health plan cannot be released without promulgation of rules by the State Board of Health in accordance with Acts 1995, No. 670, § 2(g) and (h).

(3) The Department of Health will only release data, except as allowed by law that has sufficiently masked these identities.

(b)(1) Since the department needs patient-specific information to complete our analyses, we will take every prudent action to ensure the confidentiality and security of the data submitted to us.

(2) Procedures include, but are not limited to:

(A) Physical security and monitoring;

(B) Access to the files by authorized personnel only;

(C) Passwords; and

(D) Encryption.

(3) Not all measures taken are documented or mentioned in this guide to further protect our data.

20 CAR § 54-104 Submittal schedule {#sec-20-car-54-104 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-104}

20 CAR § 54-104. Submittal schedule.

(a)(1) Discharge data records will be submitted to the Department of Health as specified below.

(2) The data to be submitted is based on the discharges occurring in a calendar quarter.

(3) If a patient has a bill generated during a quarter but has not yet been discharged by the end of the quarter, data for that stay should not be included in the quarter’s data.

(4) Deadlines for data submission are forty (40) days after the end of the quarter for the first through third quarters and sixty (60) days for the fourth quarter.

(b)(1)(A) While most hospitals will be submitting data directly to the department, some are utilizing third-party intermediaries.

(B) When using an intermediary, the reporting deadlines are still to be met.

(C) Refer to 20 CAR § 54-107(h), Intermediaries, for further details.

(2) Reporting schedule.

Patients’ date of discharge is: Discharge data must be received by: January 1 through March 31 QTR 1 – May 10th April 1 through June 30 QTR 2 – August 10th July 1 through September 30 QTR 3 – November 10th October 1 through December 31 QTR 4 – March 1st

(3) Request for extension.

(A) All hospitals will submit discharge data in a form consistent with the requirements unless an extension has been granted.

(B) Request for extension should be in writing or email and be directed to:

Department of Health Health Statistics Branch, Slot #H19 Hospital Discharge Data Section 4815 West Markham Street Little Rock, AR 72205 Phone: (501) 661-2867 Fax: (501) 661-2544 Email: Betty.Hicks@arkansas.gov

(C)(i) The Health Statistics Branch will review requests submitted to it for extensions to the reporting schedule requirement.

(ii) A request for an extension should be submitted at least ten (10) working days prior to the reporting deadline.

(iii)(a) Extensions may be granted for a maximum of twenty (20) calendar days.

(b) Additional twenty-day extensions must be requested separately.

(iv) Extensions may be granted when the hospital documents that unforeseen difficulties, such as technical problems, prevent compliance.

20 CAR § 54-105 Data errors and certification {#sec-20-car-54-105 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-105}

20 CAR § 54-105. Data errors and certification.

(a)(1) Hospitals will review the discharge data records prior to submission for accuracy and completeness.

(2) Correction of invalid records and validation of aggregate tabulation are the responsibility of the hospital.

(3) All hospitals will certify the data submitted for each quarter in the manner specified.

(b) Error correction.

(1)(A) Edits that indicate a high probability of error will be highlighted for review, comment, and correction when applicable.

(B) The invalid record will be printed in a simplified format providing:

(i) Record identification;

(ii) An indication or explanation of the error; and

(iii) Space to record corrections.

(C) The error report will be sent by fax or email to the attention of the individual designated to receive the correspondence at the hospital.

(D) The corrections made by the hospital are to be returned within seven (7) days of receipt to the Health Statistics Branch.

(2)(A) In the event one percent (1%) or more of the records for a quarter are indicated as having a high probability of error, the entire submittal may be rejected.

(B) A record is in error when one (1) or more required data elements are in error.

(3)(A) Notification of the rejection will:

(i) Accompany the error report; and

(ii) Be sent by fax or email to the attention of the individual designated to receive the correspondence at the hospital.

(B) After correction, the submittal is to be returned within seven (7) days of receipt to the Arkansas Center for Health Statistics.

(C) In some situations, the Hospital Discharge Data System staff will make corrections to the hospital’s submissions, based on information obtained from hospital staff and/or internal health department databases.

(D) When this is done, notice will be given to the hospital.

20 CAR § 54-106 Data submittal specifications {#sec-20-car-54-106 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-106}

20 CAR § 54-106. Data submittal specifications.

(a)(1) The preferred method of submitting data is via secure FTP.

(2) Alternate modes of transmission such as email or CD may be established by agreement with the Health Statistics Branch. (3) Data submittals not in compliance with media or format specifications will be rejected unless approval is obtained prior to the scheduled due date from the Health Statistics Branch.

(4) Data submittal on physical media should be mailed to:

Arkansas Department of Health Health Statistics Branch Hospital Discharge Data System 4815 West Markham Street, Slot H19 Little Rock, AR 72205'

(5) If you are submitting data for more than one (1) hospital on one (1) submission, the additional specifications found in subsection (h) of this section, Multi-hospital submission, must be followed.

(b) File compression.

(1) WinZip is the compression utility of choice by the Hospital Discharge Data System (HDDS).

(2) If a compression utility other than WinZip is used, the resulting file must be able to be unzipped by HDDS.

(3) Please contact an HDDS colleague prior to sending a file compressed with any compression software other than WinZip.

(c) File encryption.

(1) Encryption of data files sent as email attachments is required.

(2) Refer to subsection (e) of this section, email attachment submissions — secondary submittal format.

(d) File transfer protocol (FTP) – Primary submittal format, preferred.

(1)(A) The following specifications must be met when submitting data using the FTP:

(i) The secured web site is at: http://adhftp.arkansas.gov; and

(ii) Upload by accessing the secured website and inputting the user name and password.

(B) Please contact an HDDS colleague for the user name and password.

(2) Click “Browse” to search for the hospital data file.

(3)(A) Select the data file for quarter you wish to submit.

(B) Please note the data file name must be created in the following format, HHHHQNYYVN.dat, where:

(i) HHHH = four (4) letters for the hospital;

(ii) QN = quarter number;

(iii) YY = two (2) numbers for the year; and

(iv) VN = shipment number.

(C) HDDSQ114V1.dat will tell us Hospital Discharge Data Systems uploaded quarter 1 of 2014 one (1) time.

(D) If you do not know the four-letter code for the hospital (HHHH), please contact an HDDS colleague for that information.

(4) Click “Upload.”

(e) Email attachment submissions — Secondary submittal format. The following specifications must be met when submitting data by email attachment via the internet:

(1) Hospitals must encrypt the attachment containing the data, preferably utilizing the WinZip encryption function;

(2) The physical characteristics of the attached file must have the following attributes:

(A) Record length — Three hundred twenty-one (321) bytes, fixed (1450 format), three hundred sixty-one (361) bytes, fixed (1450Y2K format); and

(B) PC text file (ASCII), WinZip file, or self-extracting executable file, refer to subsection (b) of this section, file compression;

(3) Each email submission must include a general message that contains the following information:

(A) The description "HOSPITAL DISCHARGE DATA" in the subject field;

(B) Hospital’s name;

(C) Date of submittal as MM/DD/YY;

(D) Beginning and ending dates of the reporting period (e.g., 1/1/14 – 3/30/14); and

(E) The name and telephone number of the contact person; and

(4) Refer to subdivision (f)(3) of this section for filename.extension naming standard for the attached file.

(f) CD-ROM submittal specifications — Server down submittal. The following specifications must be met when submitting data on PC CDs:

(1) Hospitals will submit no more than one (1) CD per quarter;

(2)(A) The physical characteristics of the CD-ROM must have the following attributes:

(i) Record Length: Three hundred twenty-one (321) bytes, fixed (1450 format), three hundred sixty-one (361) bytes, fixed (1450Y2K format); and

(ii) ASCII, WinZip file, or self-extracting executable file.

(B) Self-extracting executable file must run on Windows XP or higher operating system.

(C) Source and target of WinZip or executable file must be ASCII.

(D) ASCII file must have a carriage return (CR) and line feed (LF) at the end of each data record;

(3)(A) All CDs must have an external label or accompanying data sheet containing the following information:

(i) The description: ‘HOSPITAL DISCHARGE DATA’;

(ii) Hospital’s name;

(iii) Date of submittal as MM/DD/YY;

(iv) Beginning and ending dates of the reporting period (e.g., 1/1/14 – 3/30/14);

(v) Number of records;

(vi) Record format (1450);

(vii) The name and telephone number of the contact person;

(viii) PC extension, ASCII, ZIP, or EXE (refer to subdivision (f)(4)(D) of this section); and

(ix) If encrypted, the description: ENCRYPTED (refer to subsection (c) of this section, file encryption).

(B) An example of the label for the case is as follows:

; and

(4) Use the following filename.extension file naming standard:

(A) The first two (2) positions of the filename will be the last two (2) digits of the calendar year;

(B) The next three (3) characters will be QTR;

(C) The last position must be the quarter from one (1) through four (4) that indicates the quarter of the calendar year of the data submitted; and

(D) The extension will be:

(i) TXT or DAT for a PC Text file;

(ii) ZIP for a file compressed with WinZip; or

(iii) EXE for a self-extracting file.

Example: 14QTR1.TXT - ASCII data file for the first quarter of 2014

(g) Multi-hospital submission.

(1) Data from more than one (1) hospital may be submitted on one (1) media submission as one (1) file per hospital.

(2) Change the following items on your external label or accompanying information sheet:

(A) If you are not a hospital, replace "Hospital:" with your company name;

(B) If you are a hospital or subsidiary of a hospital, replace "Hospital:" with "Agent:" and your hospital name;

(C) If multiple files are on the submission, replace "Total Record Count:" with "Number of Files:";

(D) The contact person and phone number should be that of the agent or company, not the hospital; and

(E)(i) If multiple files are placed on a CD, the filename.extension file-naming standard must change.

(ii) The last two (2) positions of the filename (follows QTR and quarter number) must be the file number provided.

(iii) In addition to the above changes, a list of hospitals on the medium must be provided, with:

(a) Tax ID;

(b) Number of records; and

(c) Hospital contact.

(h) Intermediaries.

(1)(A) Third-party intermediaries may be utilized by hospitals for the delivery of data to the Department of Health.

(B) To better manage data collection, intermediaries must be registered with the department.

(C) Additions and deletions to the intermediary's list of hospitals represented must be submitted at least ten (10) days prior to the department’s reporting due date.

(D) The intermediary must specify:

(i) Hospitals being represented;

(ii) Media;

(iii) Formats;

(iv) Contacts; and

(v) Length of contractual obligation.

(2) Editing intermediaries. The following additional requirements and information apply to intermediaries delivering edited data to the department:

(A) The data must not have an error rate greater than one percent (1%);

(B) Each hospital’s data must be submitted in a separate file; and

(C) Data may be submitted through the secure FTP server.

(3) Pass-through intermediaries. The following additional requirements and information apply to intermediaries delivering unedited data to the department:

(A) The data must not have an error rate greater than one percent (1%); and

(B) Each hospital’s data must be submitted in a separate file.

(4) Subject to change.

(A) Data submission methods are always under review.

(B) If implemented, all Arkansas hospitals will receive notice of the changes to be implemented.

History

• Codification Notes: "ASCII" means American Standard Code for Information Interchange."CD" means compact disc."CD-ROM" means compact disc, read-only memory."FTP" means file transfer protocol."HDDS" means hospital data discharge system."ID" means identification."PC" means personal computer. Authority: Arkansas Code § 20-7-305

20 CAR § 54-107 Data record formats {#sec-20-car-54-107 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-107}

20 CAR § 54-107. Data record formats.

(a) The accepted data record formats are the UB-04 1450 version 7 formats.

(1) This format has altered slightly.

(2) The definition specified for each data element is in general agreement with the definition in the UB-04 Users’ Manual.

(3) Hospitals using data sources other than uniform billing should evaluate definitions for agreement with the definitions specified in this guide and UB-04 Users’ Manual.

(4) Refer to 20 CAR § 54-108, exceptions to 1450 format, to identify possible changes to your current format.

(5) Each record must be followed by a carriage-return/line-feed sequence.

(b) UB-04 1450 record specification.

(1) The UB-04 1450 claim record is made up of a series of 321-character physical records and the 1450 Y2K claim record is made up of a series of 341-character physical records.

(2) Not all of the physical claim records are used in the HDDS, such as the Claim Request Data.

(3) Records not specified in the HDDS will be ignored if included in the submittal.

(4)(A) Fields not referenced in the record formats may contain information but will not be processed by computer programs.

(B) This also includes fields reserved for national use.

(5) The exact record sequence and format of the 1450 is used for the HDDS, when possible.

(6) A complete copy of the patient’s 1450 records would satisfy the requirements, with exceptions noted in 20 CAR § 54-108, exceptions to 1450 format.

(7) The physical records for each claim are divided into logical subsets as follows:

(8) The record layouts that follow will provide the following information:

(A) Record Name — The name of the data record;

(B) Record Type — Code indicating the type of record;

(C) Record Size — Physical length of record;

(D) Required Field Annotation — An asterisk, *, denotes the field is required and must contain data if applicable;

(E)(i) Field Number — Field number as specified on the UB-04 1450 version 7 file layout.

(ii) This number is not the Form Locator number found on the UB-04 1450 form;

(F) Field Name — Name generally used with the UB-04 1450 form;

(G)(i) Picture — This is the COBOL picture.

(ii) Pic X is initialized to blanks and Pic 9 is initialized to zeroes.

(iii) All money and date fields are Pic 9;

(H)(i) Field Specification — Indicates how the data field is justified.

(ii) L = Left justification and R = Right justification;

(I)(i) Position.

(ii) From = Leftmost position in the record (high order).

(iii) Thru = Rightmost position in the record (low order); and

(J) Form Locator — Number found on the UB-04 form and associated with the field in that location.

(c) 1450 and 1450Y2K — Record type 10 — Provider data.

(1) Only one (1) type 10 record is required per hospital per submittal.

(2) Only the first type 10 record and will be processed.

(3) This record type will be processed as a header record and a record type 95 will be processed as a trailer record.

(4) The records encapsulated between the first type 10 and 95 will be processed using the hospital specified on the type 10 record.

(5) If the Federal Tax Number is not unique to a facility or cost center, the Federal Tax Sub ID must be included.

(d) 1450 — Record Type 20 — Patient data.

(e) 1450Y2K — Record Type 20 — Patient data.

(f) 1450 and 1450Y2K — Record Type 27 — Department of Health specific data.

(g) 1450 and 1450Y2K — Record Types 30-31 — Third-party payer data.

(1)(A) The use of these record types for the HDDS is the same as the UB-04 claim.

(B) When reporting for HDDS, records may need to be consolidated and amounts accumulated by payer.

(C) Below are specifications and an example as taken from UB-04.

(2)(A) One (1) third-party payer record packet (record type 30) must appear in the bill record for each payer involved in the bill.

(B) Each third-party payer packet must contain a record type 30.

(C) However, each record type 30 may or may not have an associated record type 31, depending on the specific third-party payer data required by the particular payer.

Example: Medicare is primary, and the secondary payer requires the insured’s address.

(3) Because the sequence number of the type 31 record for the secondary payer matches the sequence number of the secondary payer’s type 30 record, it serves as a matching criterion for the specific third-party payer record packet.

(4) Sequence 01 represents the primary payer, sequence 02 represents the secondary payer, and sequence 03 represents the tertiary payer.

(5) 1450 and 1450Y2K — Record Type 30 — Third-party payer.

(6) 1450 and 1450Y2K — Record Type 31 — Third-party payer.

(h) 1450 and 1450Y2K — Record Type 50 — Inpatient accommodations data.

(1) The sequence number for record type 50 can go from 01 to 99, each such physical record containing four (4) accommodations, thus making provision for reporting up to three hundred ninety-six (396) accommodations on a single claim.

(2) Accommodation revenue codes: 100 through 21X.

(i) 1450 and 1450Y2K — Record Type 60 — Inpatient ancillary services data.

(1)(A)(i) The sequence number for record type 60 can go from 01 to 99.

(ii) Each such physical record contains up to three (3) inpatient ancillary service codes, thus making provision for reporting up to two hundred ninety-seven (297) inpatient ancillary services on a single claim.

(B) Payer and related information revenue codes — Codes 001 – 099.

(C) Inpatient ancillary services revenue codes — Codes 220 – 99x.

(2) Identical revenue codes should be combined and their charges added together for reporting purposes.

(j) Record Type 70 sequences 1, 2, and 3.

(1) Sequence 1 — 1450 and 1450Y2K — Medical data (Diagnosis and Present on Admission codes).

(2) Sequence 2 — 1450 and 1450Y2K — Medical data (Admitting Diagnosis and External Cause of Injury).

(3) Sequence 3 — 1450 — Medical data (Procedures).

(4) Sequence 3 — 1450Y2K — Medical data (Procedures).

(A) ICD coding is required for diagnosis.

(B) Do not report the decimal in the code.

(C) The ICD diagnosis codes are assigned a COBOL picture of X.

(k) 1450 and 1450Y2K — Record Type 80 – 8N — Physician data.

(l) 1450 and 1450Y2K — Record Type 95 — Provider Batch Control.

(1) Only one (1) type 10 and type 95 record is required per hospital per submittal.

(2) Record type 95 will be processed as a trailer record.

(3) The Federal Tax Number must match the type 10 record.

(4) The record type 10 will be processed as a header record.

(5) Federal Tax Sub ID must be the same as specified on the type 10 record.

(6) Number of Claims should be the number of discharges in the batch (number of type 20 records).

History

• Codification Notes: "CBOL" means common business oriented language."ICD" means International Classification of Diseases. Authority: Arkansas Code § 20-7-305

20 CAR § 54-108 Exceptions to 1450 format {#sec-20-car-54-108 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-108}

20 CAR § 54-108. Exceptions to 1450 format.

(a)(1) In general, the submittal is identical to the current UB-04 1450 version 7 format used.

(2) The differences are minor but nevertheless important.

(3) The most notable difference is the requirement for one (1) discharge record for one (1) patient, as opposed to the possibility of multiple claim records for one (1) patient.

(4) For discharges with multiple claim records, they should be consolidated into a single discharge, accumulating amounts where necessary (e.g., amounts by payer).

(b)(1) Only one type 10 is required per hospital per submittal.

(2)(A) Only the first type 10 record and type 95 record will be processed.

(B) All others will be ignored.

(3) A record type 10 will be processed as a header record and a record type 95 will be processed as a trailer record.

(c) In record type 20, Statement Covers Period Thru should be the discharge date.

(d) In record type 95, Federal Tax Sub ID must be the same as specified on the type 10 record.

(e) Number of Claims in record type 95 should be the number of discharges reported in the batch, after the batch equal to the number of type 20 records.

(f)(1) Record type 27 is not a record type used in the UB-04 claim.

(2) It contains data that:

(A) May come from other record types, such as Type of Bill;

(B) May be computable, such as Total Charges; or

(C) Should be found in your current databases, Patient Social Security Number for example.

20 CAR § 54-109 Use of multipage claims {#sec-20-car-54-109 omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR § 54-109}

20 CAR § 54-109. Use of multipage claims.

(a) All data except revenue code and charge fields should be duplicated on successive records.

(b) All available revenue and charge fields should be completely filled before using additional records.

(c) The 0001 revenue code:

(1) Should be the last entry on the last record for a multi-page claim; and

(2) Charge should be equal to the total charge for all pages.

20 CAR pt. 54, Appendix A Data Dictionary {#sec-20-car-pt.-54-appendix-a omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR pt. 54, Appendix A}

APPENDIX A DATA DICTIONARY The definition specified for each data element is in general agreement with the definition in the UB-04 Users’ Manual. Hospitals using existing UB-04 record formats should reference 20 CAR § 54-108, exceptions to 1450 format, for differences from the established UB-04 record formats. Hospitals using data sources other than uniform billing should evaluate their definitions for agreement with the definitions specified in this Guide and the UB-04 Users’ Manual. A1 The dictionary format that follows will provide the following information:

1. Data Element: The name of the data element
2. Char Type: Character type for the data element N = numeric A = alphanumeric
3. Char Length: Character length of data element. For fields with an implied decimal point, the first number is the total length, the second number is the length after the implied decimal point (e.g., ‘9, 2’ represents the COBOL picture clause 9(7)V99).
4. Data Reporting Requirement for the Data Element Level: Required = must be reported As available = must be present, if captured in your database
5. Definition: A definition of the data element
6. General Comments: These comments help to further define or explain the data Comments: elements and give permissible values for code and type data elements.
7. Edit: Minimal edits that will be performed on the data element; these edits should be performed by the hospital prior to submission.

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

Table 1. Definition Breakdown

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION Accommodation Rate N 9, 2 Required As available Record Type 50, positions 29-37 for Accommodation 1, positions 71- 79 for Accommodation 2 & positions 113-121 for Accommodation 3. DEFINITION Per-diem rate for related UB-04 accommodations revenue codes. GENERAL COMMENTS The rate should be right justified with leading zeroes. There is an implied decimal placed 2 positions from the right. EDIT If present, rate must be greater than zero. Admission Date N 6 or 8 Required As available Record Type 20, positions 174-179 for 1450 format or positions 174- 18 1 for 1450Y2K format. DEFINITION The start date for this episode of care. For inpatient services, this is the date of admission. GENERAL COMMENTS The admission date is to be entered as month, day, and year. The format is MMDDYY for 1450 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example, February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made, all dates must use this format. EDIT Admission date must be present and a valid date. The date cannot be before date of birth or be after ending date in Statement Covers Period. Admission Hour A 2 Required As available Record Type 20, positions 180-181 for 1450 format or positions 182- 18 3 for 1450Y2K format. DEFINITION The hour during which the patient was admitted for inpatient care. GENERAL COMMENTS Military time should be used to represent the hour of admission. If admitted between midnight and noon, use the values from 00 to 11; if admitted between noon and 11:59 pm, use the values from 12 to 23. Code Time – AM Code Time – PM 00 01 02 03 04 05 06 07 08 09 10 11 12:00 – 12:59 Midnight 01:00 – 01:59 02:00 – 02:59 03:00 – 03:59 04:00 – 04:59 05:00 – 05:59 06:00 – 06:59 07:00 – 07:59 08:00 – 08:59 09:00 – 09:59 10:00 – 10:59 11:00 – 11:59 12 13 14 15 16 17 18 19 20 21 22 23 12:00 – 12:59 Noon 01:00 – 01:59 02:00 – 02:59 03:00 – 03:59 04:00 – 04:59 05:00 – 05:59 06:00 – 06:59 07:00 – 07:59 08:00 – 08:59 09:00 – 09:59 10:00 – 10:59 11:00 – 11:59 EDIT Valid numeric value for the hour of admission or blank. Admitting Diagnosis Code A 8 Required As available Record Type 70, Sequence 2, positions 25-32 (1450 & 1450Y2K). DEFINITION The ICD diagnosis code provided at the time of admission as stated by the physician. GENERAL COMMENTS This field is to contain the appropriate ICD code without a decimal. All entries are to be left justified with spaces to the right to complete the field length. An external cause of injury code should not be recorded as the admitting diagnosis. EDIT An admitting diagnosis must be present and valid. When the admitting diagnosis is sex or age dependent, the age and sex must be consistent with the code entered. APGAR Score N 4 Required As available Record Type 27, positions 60-63. DEFINITION APGAR Score (1 minute & 5 minute) for a newborn. Zero fills if not a newborn. GENERAL COMMENTS Right justify the field with zeroes to the left to complete the field. Positions 60-61 should contain the one minute APGAR and 62-63 should contain the five minute APGAR (Example: 0809). EDIT If present, must be numeric.

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION Attending Provider Name A 25 Required As available Record Type 80, positions 91-115 DEFINITION The individual who has overall responsibility for the patient’s medical care and treatment reported in this claim. GENERAL COMMENTS Entered in the order of last name, first name and middle initial. Last name in positions 91-106, first name in positions 107- 114 and initial in position 115. EDIT None Attending Provider Identifier N 10 Required As available Record Type 80, positions 27-36 DEFINITION National Provider Identifier of the individual who has overall responsibility for the patient’s medical care and treatment reported via this claim. GENERAL COMMENTS This field is to be left justified with spaces to the right to complete the field. EDIT This field must contain a valid National Provider Identifier (NPI). Birth Weight N 4 Required As available Record Type 27, positions 40-43 DEFINITION Birth weight in grams for a newborn. Zero-fill if not a newborn. GENERAL COMMENTS Right justify the field with zeroes to the left to complete the field. EDIT Must be numeric. Diagnosis Related Group (DRG) N 4 Required As available Record 27, positions 64-67 DEFINITION The PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. This represents an inpatient classification scheme to categorize patients that are medically related with respect to diagnosis and treatment and who are statistically similar in their lengths of stay. GENERAL COMMENTS When DRG is unknown or not available use 9999. Right justified with leading spaces. EDIT A DRG if present, must be valid and consistent with sex and age. Discharge Hour A 2 Required As available Record Type 20, positions 196-197 for format 1450 or positions 202- 203 for format 1450Y2K. DEFINITION Hour that the patient was discharged from inpatient care. Required on inpatient claims with a Frequency Code of 1 or 4, except for Type of Bill 021x. GENERAL COMMENTS Military time should be used to represent the hour of discharge. If discharged between midnight and noon, use the values from 00 to 11; if discharged between noon and 11:59 pm, use the values from 12 to 23. Code Time – AM Code Time – PM 00 01 02 03 04 05 06 07 08 09 10 11 12:00 – 12:59 Midnight 01:00 – 01:59 02:00 – 02:59 03:00 – 03:59 04:00 – 04:59 05:00 – 05:59 06:00 – 06:59 07:00 – 07:59 08:00 – 08:59 09:00 – 09:59 10:00 – 10:59 11:00 – 11:59 12 13 14 15 16 17 18 19 20 21 22 23 12:00 – 12:59 Noon 01:00 – 01:59 02:00 – 02:59 03:00 – 03:59 04:00 – 04:59 05:00 – 05:59 06:00 – 06:59 07:00 – 07:59 08:00 – 08:59 09:00 – 09:59 10:00 – 10:59 11:00 – 11:59 EDIT Valid numeric value for the hour of discharge.

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION Employer Location A 44 Required As available Record Type 31, positions 111-154 DEFINITION The specific location represented by the address of the employer of the individual identified by the second of two entries in employment information data field. GENERAL COMMENTS This is to be the full and complete address of the employer of the individual. EDIT None Employer Name A 24 Required As available Record Type 31, positions 87-110 DEFINITION The name of the employer that might or does provide health care coverage for the individual identified by the first of two entries in the employment information data fields. GENERAL COMMENTS Enter the full and complete name of the employer providing health care coverage. EDIT None Employer ZIPCode A 9 Required As available Record Type 31, positions 146-154 DEFINITION The ZIPCode of the employer of the individual identified by the first of two entries in the employment information data fields. GENERAL COMMENTS None EDIT None Employment Status Code A 1 Required As available Record Type 30, position 146 DEFINITION A code used to define the employment status of the individual identified in the first of two employment information data fields. GENERAL COMMENTS This field contains the employment status of the person described in the first of two employment information data fields. The codes to be used are as follows: 1 Employed full time Definition: individual states that he/she is employed full time 2 Employed part time Definition: individual states that he/she is employed part time 3 Not employed Definition: individual states that he/she is not employed part time or full time 4 Self employed 5 Retired 6 On active military duty

9 Unknown Definition: individual’s employment status is unknown EDIT If an entry is present, it must be a valid code. External Cause of Injury Code

A 6 Required As available Record Type 70, Sequence 2, positions 33-40, 41-48, 49-56, 57-64, 65-72, 73-80, 81-88, 89-96, 97-104, 105-112 (1450 & 1450Y2K) DEFINITION The ICD code for the external cause of injury, poisoning or adverse effect.

DATA ELEMENT

CHAR

TYPE

CHAR LGTH

DATA

REPORTING

LEVEL

LOCATION

GENERAL

COMMENTS

Hospitals are to complete this field whenever there is a diagnosis of an injury, poisoning or adverse effect. The priorities for

recording an external cause of injury code are:

1. Principal diagnosis of an injury or poisoning
2. Other diagnosis of an injury
3. Other diagnosis with an external cause

All entries are to be left justified without a decimal.

EDIT Must be valid. When the diagnosis is sex or age dependent, the age and sex must be consistent with the code entered.

Federal Tax

Number (EIN)

N 10

Required

As available

Record Type 10, positions 8-17, Record Type 95, positions 3-12

DEFINITION

The number assigned to the provider by the Federal government for tax report purposes, also known as a Tax Identification

Number (TIN) or Employer Identification Number (EIN).

GENERAL

COMMENTS

None

EDIT None

Federal Tax Sub

ID

A 4

Required

As available

When Federal Tax

Number

is not unique

Record Type 10 position 18-21, Record Type 95 position 13-16

DEFINITION Four-position modifier to Federal Tax ID.

GENERAL

COMMENTS

Used by providers to identify their affiliated subsidiaries when the Federal Tax Number does not distinguish between

separate facilities or cost centers.

EDIT None

HCPCS /

Procedure

Code

A 5

Required

As available

Record Type 60, positions 29-343, 85-89, 141-145

DEFINITION

Procedure codes reported in record types identify services so that appropriate payment can be made. HCFA Common

Procedural Coding System (HCPCS) code is required for many specific types of outpatient services and a few inpatient

services. May include up to two modifiers.

GENERAL

COMMENTS

None

EDIT None

Health Plan ID N 10

Required

As available

Record Type 30, positions 30-39

DEFINITION The numbers used by the health plan to identify itself.

GENERAL

COMMENTS

None

EDIT None

Insured

Address

A 62

Required

As available

Record Type 31, positions 25-86

DEFINITION Insured’s current mailing address: Address Line 1, Address Line 2, City, State, Zip.

GENERAL

COMMENTS

None

EDIT None

Insurance

Group Number

A 17

Required

As available

Record Type 30, positions 80-96

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION DEFINITION The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered. GENERAL COMMENTS None EDIT None Insured’s Name A 30 Required As available Record Type 30, positions 111-140 DEFINITION The name of the individual in whose name the insurance is carried. GENERAL COMMENTS Enter the name of the insured individual in last name, first name, middle initial order. Titles such as Sir, Mr. or Dr. should not be recorded in this data field. Record hyphenated names with the hyphen as in Smith-Jones. To record suffix of a name, write the last name, leave a space then write the suffix, for example, Snyder III or Addams Jr. EDIT None Insured’s Unique ID A 19 Required As available Record Type 30, positions 40-58 DEFINITION Insured’s unique identification number assigned by the payer organization. Medicare purposes enter the patient’s Medicare HIC number as on the Health Insurance Card, Certificate of Award, Utilization Notice, Temporary Eligibility Notice, Hospital Transfer Form, or as reported by the Social Security Office. GENERAL COMMENTS The payer organization’s assigned identification number is to be entered in this field. It should be entered exactly as printed on the Insured’s proof of coverage. EDIT None Major Diagnostic Categories (MDC) A 2 Required As available Record Type 27, positions 68-69 DEFINITION The MDC is formed by dividing all possible principal diagnoses into 25 mutually exclusive diagnosis areas. GENERAL COMMENTS MDC 1 to MDC 23 is grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondaries) from the different body site categories. Patients assigned to MDC 25 (HIV Infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection. EDIT Must be a valid code.

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION MDC Code & Definition 0 = Ungroupable 1 = Nervous System 2 = Eye 3 = Ear, Nose, Mouth and Throat 4 = Respiratory System 5 = Circulatory System 6 = Digestive System 7 = Hepatobiliary System And Pancreas 8 = Musculoskeletal System And Connective Tissue 9 = Skin, Subcutaneous Tissue And Breast 10 = Endocrine, Nutritional And Metabolic System 11 = Kidney and Urinary Tract 12 = Male Reproductive System 13 = Female Reproductive System 14 = Pregnancy, Childbirth and Puerperium 15 = Newborn and Other Neonates( Prenatal Period) 16 = Blood and Blood Forming Organs and Immunological Disorder 17 = Myeloprolifeative DDs (Poorly Differentiated Neoplasm) 18 = Infectious and Parasitic DDs 19 = Mental Diseases and Disorders 20 = Alcohol/Drug Use or Induced Mental Disorders 21 = Injuries, Poison And Toxic Effect of Drugs 22 = Burns 23 = Factors Influencing Health Status 24 = Multiple Significant Trauma 25 = Human Immunodeficiency Virus Infections Medical Record Number A 17 Required As available Record Type 20, positions 198-214 for format 1450 or positions 204- 22 0 for format 1450Y2K. DEFINITION Number assigned to patient by hospital or other provider to assist in retrieval of medical records. GENERAL COMMENTS This number is assigned by the hospital for each patient. EDIT None National Provider Identifier (NPI) – Billing Provider A 13 Required As available Record Type 10, positions 22-34 DEFINITION The National Provider Identifier (NPI) is a ten-position identifier issued by Medicare. GENERAL COMMENTS The unique identification number assigned to the provider submitting the bill. EDIT Will be verified against Department of Health databases obtained from Medicare. Number of Claims N 6 Required As available Record Type 95, positions 25-30 DEFINITION The number of discharge submitted by a hospital for this submitted. Used to verify a complete submittal, no losses of data. GENERAL COMMENTS None EDIT Must be the total number of discharges for the hospital in the batch (type ‘20’records).

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION Operating Physician Name A 25 Required As available Record Type 80, positions 116-140 DEFINITION The name of the individual with the primary responsibility for performing the surgical procedure(s). GENERAL COMMENTS Entered in the order of last name, first name and middle initial. Last name in positions 1-16, first name in positions 17-24 and initial in position 25. EDIT None Operating Physician Identifier N 10 Required As available Record Type 80, Position 43-52 DEFINITION National Provider Identifier of the individual with primary responsibility for performing the surgical procedure(s). GENERAL COMMENTS Must be left justified in the field. EDIT This field must contain a valid license or assigned number according to ‘Physician Number Qualifying Code’. Other Diagnosis Code A 6 Required As available Record Type 70, Sequence 1, See Record Format 20 CAR § 54-107(j) for positions (1450 & 1450Y2K) DEFINITION ICD code describing other diagnoses corresponding to additional conditions that co-exist at the time of admission or develop subsequently, and which have an effect on the treatment received or the length of stay. GENERAL COMMENTS The first of twenty-nine additional diagnoses. This field must contain the ICD code without a decimal. EDIT If other diagnoses are present, they must be valid. When diagnosis is sex or age dependent, the age and sex must be consistent with the code entered. Other Physician Name A 25 Required As available Record Type 80, positions 141-165, 166-190 DEFINITION This is the name of a physician other than the attending physician as defined by the payer organization. GENERAL COMMENTS Entered in the order of last name, first name and middle initial. EDIT None Other Physician Identifier N 10 Required As available Record Type 80, positions 59-68, 75-84 DEFINITION This is the National Provider Identifier of a physician. GENERAL COMMENTS Must be left justified in the field. EDIT This field must contain a valid National Provider Number. Other Procedure Code a 7 Required As available Record Type 70, Sequence 3 , See Record Format 20 CAR § 54-107(j)(3) for 1450 positions & 6.9.4 for 1450Y2K positions

DEFINITION The code that identifies the other procedures performed during the patient’s hospital stay covered by this discharge record. This may include diagnostic or exploratory procedures.

DATA ELEMENT CHAR TYPE CHAR LGTH DATA REPORTING LEVEL LOCATION GENERAL COMMENTS Procedures that make for accurate DRG Categorization must be included. The coding method used must agree with the coding method used for the principal procedure. Entries must include all digits. It must be present. Enter the code left justified, without a decimal. EDIT If this field is present, there must be a principal procedure entered. Codes entered must be valid. When a procedure is gender-specific, the gender code entered in the record must be consistent. Other Procedure Date N 6 Required As available Record Type 70, Sequence 3, See Record Format 20 CAR § 54-107(j)(3) for 1450 positions & 6.9.4 for 1450Y2K positions DEFINITION Date that the procedure indicated by the related procedure code was performed. GENERAL COMMENTS None EDIT Must be a valid date. Patient Address A 62 Required As available Record Type 20, positions 88 – 173 (1450 & 1450Y2K) DEFINITION The address including postal ZIPcode of the patient, as defined by the payer organization. (Address line 1 & 2, City, State, & ZIPCode) GENERAL COMMENTS The order of the complete address if provided should be street number, apartment number, city, state and ZIPcode, left justified with spaces to the right to complete the field. The state must be the standard post office abbreviations (AR for Arkansas). If the nine digit ZIPcode is used, it must be entered in the form XXXXXYYYY where X’s are the five digit ZIPcode and the Y’s are the ZIPcode extension. If Street Address is not provided, the nine digit postal ZIPcode is required for a valid address. EDIT This field is edited for the presence of an address with a valid and complete postal ZIPcode.

Patient Control Number A 20 Required As available All Records, positions 5-24 except for Record Types 10 and 95 DEFINITION A patient’s unique alpha-numeric number assigned by the hospital to facilitate retrieval of individual discharge records, if editing or correction is required. GENERAL COMMENTS This number should not be the same as the Medical Record Number. This number will be used for reference in correspondence, problem solving or edit corrections. EDIT The number must be present and should be unique within a hospital. Patient’s Date of Birth N 8 Required As available Record Type 20, positions 77-84 (1450 & 1450Y2K) DEFINITION The date of birth of the patient in month day year order; year is 4 digits. GENERAL COMMENTS The date of birth must be present and recorded in an eight-digit format of month day year (MMDDYYYY). The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging form 01-31. The year is recorded as four digits ranging from 1800-2100. Each of the first two components (month, day) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 1982 is entered as 02071982. If the birth date is unknown, then the field must contain ‘00000000. ’For hospitals using the 1450 record format that began using a different date in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2001 format is entered 20010207. Where this change is made, all dates must use this format. EDIT This field is edited for the presence of a valid date and of a date that it is not equal to the current date. Age is calculated and used in the clinic code edit to identify age/diagnosis conflicts and invalid or unknown age. Patient’s Discharge Status N 2 Required As available Record Type 20, positions 194-195 for format 1450 or 200-201 positions for format 1450Y2K DEFINITION A code indicating patient status at the time of the discharge. It is the arrangement or event ending a patient’s stay in the hospital. GENERAL COMMENTS This is a two-character code. This should be the status at the time of discharge, the last ‘Patient Status’; this would invalidate any patient’s stay codes of 30-39. The patient’s status is coded as follows: 01 Definition: Discharged to Home or Self Care (Routine Discharge)-Includes discharges 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 Definition: Discharged/transferred to a Short-Term General Hospital for Inpatient Care 03 Definition: Discharge/transferred to Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care-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 Definition: Discharge/transferred to a facility that provides custodial or supportive care. 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 state designated Assisted Living Facilities. 05 Definition: Discharge/transferred to Designated Cancer Center or Children’s Hospital 06 Definition: Discharge/transferred to Home Under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care 07 Definition: Left Against Medical Advice or Discontinued Care 09 Definition: Admitted as an Inpatient to this Hospital-Use only with Medicare outpatient claims. Applies only to those Medicare outpatient services that begin greater than three days prior to an admission. 20 Definition: Expired 21 Definition: Discharged/transferred to Court/Law Enforcement – includes transfers to incarceration facilities such as jails, prison or other detention facilities. 30 Definition: Still a Patient in the Hospital- ***not a valid code 40 Definition: Expired at home- (hospice claims only)

41 Definition: Expired in a Medical Facility-hospital, skilled nursing facility, intermediate care facility, or freestanding hospice (hospice claims only) 42 Definition: Expired – Place Unknown (hospice claims only) 43 Definition: Discharge/transferred to a Federal Health Care Facility e.g. Department of Defense hospital, a VA hospital, or a VA nursing facility 50 Definition: Hospice – Home 51 Definition: Hospice – Medical Facility 61 Definition: Discharged/transferred to a hospital based (Medicare approved) swing bed- For Medicare discharges; use for reporting patients discharged/transferred to a SNF level of care within the hospital’s approved swing bed arrangement. 62 Definition: Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital 63 Definition: Discharged/transferred to a Long Term Care Hospital (LTCH) 64 Definition: Discharged/transferred to a Nursing Facility Certified under Medicaid but not Certified under Medicare 65 Definition: Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a hospital 66 Definition: Discharged/transferred to a Critical Access Hospital (CAH) 67-69 Reserved for Assignment by the NUBC 70 Definition: Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List. 71-99 Reserved for Assignment by the NUBC EDIT The patient status code must be present and a valid code as defined. A patient status code of 30 is not a valid code. *In situations where a patient is admitted before midnight of the third day following the day of an outpatient service, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier, such as observation following outpatient surgery, which results in admission. Patient’s Ethnicity A 1 Required As available Record Type 27, position 39 DEFINITION This item gives the ethnicity of the patient. The information is based on self-identification, and is to be obtained from the patient, a relative, or a friend. The hospital is not to categorize the patient based on observation or personnel judgment. GENERAL COMMENTS The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled. 1 Hispanic origin Definition: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. 2 Not of Hispanic Origin Definition: A person who is not classified in 1. 6 Unknown Definition: A person who chooses not to respond to the inquiry Blank Space The hospital made no effort to obtain the information. EDIT If the data field contains an entry, it must be a valid code combination. Patient’s Marital Status A 1 Required As available Record Type 20, position 85 (1 450 & 1450Y2K) DEFINITION The marital status of the patient at date of admission, or start of care. GENERAL COMMENTS The marital status of the patient is to be reported as a one character code whenever the information is recorded in the patient’s hospital record. The following codes apply:

S = M = X = D =

W = U = Space = Single Married Legally Separated Divorced

Widowed Unknown Not present in patient’s record EDIT This field is edited for a valid entry Patient’s Name A 31 Required As available Record Type 20, positions 25- 75 (1450 & 1450Y2K) DEFINITION The name of the patient in last, first and middle initial order. GENERAL COMMENTS Titles such as Sir, Msgr., and Dr. should not be recorded. Record hyphenated names with the hyphen, as in Smith-Jones. To record a suffix of a name, write the last name, leave a space, then write the suffix, for example: Snyder III or Addams Jr. EDIT The name will be edited for the presence of the last name and the first name. Patient’s Race A 1 Required As available Record Type 27, position 38 DEFINITION This item gives the race of the patient. GENERAL COMMENTS The patient may choose not to provide the information. If the patient chooses not to answer, the hospital should enter the code for unknown. If the hospital fails to request the information, the field should be space filled. 1 American Indian or Alaskan Native Definition: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. 2 Asian or Pacific Islander Definition: A person having origins in any of the original oriental peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa. 3 Black Definition: A person having origins in any of the black racial groups of Africa 4 White Definition: A person having origins in any of the original peoples of Europe, North Africa or the Middle East. 5 Other Definition: Any possible options not covered in the above categories. 6 Unknown Definition: A person who chooses not to answer the question. Blank Space Definition: The hospital made no effort to obtain the information. EDIT None Patient’s Relationship to Insured N 2 Required As available Record Type 30, positions 144-145 DEFINITION A code indicating the relationship, such as patient, spouse, child, etc., of the patient to the identified Insured person listed in the first of three Insured’s Name fields. GENERAL COMMENTS Enter the 2 digit code representing the patient’s relationship to the individual named. All codes are to be right justified with a leading 0, if needed. The following codes apply: 18 Patient is named insured Definition: Self-explanatory 01 Spouse Definition: Self-explanatory 19 Natural child/insured financially responsible Definition: Self-explanatory 43 Natural child/insured does not have financial responsibility Definition: Self-explanatory

17 Step Child Definition: Self-explanatory 10 Foster Child Definition: Self-explanatory 15 Ward of the Court Definition: Patient is ward of the insured as a result of a court order 20 Employee Definition: The patient is employed by the named insured. 21 Unknown Definition: The patient’s relationship to the named insured is unknown 22 Handicapped Dependent Definition: Dependent child whose coverage extends beyond normal termination age limits as a result of laws or agreements extending coverage. 39 Organ Donor Definition: Code is used in cases where bill is submitted for care given to organ donor where such care is paid by the receiving patient’s insurance coverage. 40 Cadaver Donor Definition: Code is used where bill is submitted for procedures performed on cadaver donor where such procedures are paid by the receiving patient’s insurance coverage. 05 Grandchild Definition: Self-explanatory 07 Niece or Nephew Definition: Self-explanatory 41 Injured Plaintiff Definition: Patient is claiming insurance as a result of injury covered by insured. 23 Sponsored Dependent Definition: Individual not normally covered by insurance coverage but coverage has been specially arranged to include relationships such as grandparent or former spouse that would require further investigation by the payer. 24 Minor Dependent of a Minor Dependent Definition: Code is used where patient is a minor and a dependent of another minor who in turn is a dependent, although not a child of the insured. 32 Mother Definition: Self-explanatory 33 Father Definition: Self-explanatory 04 Grandparent Definition: Self-explanatory 29 Significant Other 36 Emancipated Minor 53 Life Partner G8 Other Relationship EDIT A code must be present and valid if Insured’s Name is entered. Patient’s Sex A 1 Required As available Record Type 20, position 76 (1450 & 1450Y2K) DEFINITION The gender of the patient as recorded at date of admission. GENERAL COMMENTS This is a one-character code. The sex is to be reported as male, female or unknown using the following coding: M =Male F = Female U = Unknown EDIT A valid code must be present. The gender of the patient is checked for consistency with diagnosis and procedure codes. The edit is to identify gender diagnosis conflicts and invalid or unknown gender. Patient Social Security Number N 10 Required As available Record Type 27, positions 28-37 DEFINITION The social security number of the patient receiving inpatient care GENERAL COMMENTS For 1450 submissions, this field is to be right justified, with zeroes to the left to complete the field. The format of SSN is 0123456789 without hyphens. If the patient is a newborn, use the mother’s SSN. If a patient does not have a social security number, fill with zeroes. EDIT The field is edited for a valid entry. Physician Identifier Code A 2 Required As available Record Type 80, positions 25-26 DEFINITION The type of Physician Number being submitted. Applies to all Physician Numbers for a single hospital discharge.

GENERAL COMMENTS Use the code NI for National Provider Identifier (NPI).

EDIT Must be a valid NPI. Point of Origin for Admission or Visit a 1 Required As available Record Type 20, position 87 DEFINITION A code indicating the point of patient origin for this admission or visit.

Code Structure for all Admission Types (excluding Newborns (Type 4)) 1 Non-Health Care Facility Point of Origin Definition: The patient was admitted to this facility. Example: include patients coming from home or workplace.

2 Clinic Definition: The patient was admitted to this facility as a transfer from a freestanding or non-freestanding clinic. 3 Reserved for assignment by NUBC Definition: 4 Transfer from a Hospital Definition: 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. 5 Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) Definition: The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident. 6 Transfer from another Health Care Facility Definition: The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list. 7 Reserved for assignment by NUBC

8 Court/Law Enforcement Definition: 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. 9 Information not available Definition: The means by which the patient was admitted to this hospital is not known. D Inpatient transfers within the same facility Definition: The patient was transferred from a separate unit of a hospital to another unit of the same hospital which results in separate claim to the payers. E Transfer from Ambulatory Surgery Center Definition: The patient was admitted to this facility as a transfer from an ambulatory surgery center. F

Transfer from Hospice

Definition: The patient was admitted to this facility as a transfer from hospice. Code Structure for Newborn If Priority of Admission is a 4, the following codes apply: 1-4 Reserved for assignment by the NUBC. 5 Definition: A baby born inside this Hospital. 6 Definition: A baby born outside of this Hospital. 7-9 Reserved for assignment by the NUBC. EDIT The code must be present and valid and agree with the Priority of Admission code entered. Present on Admission (POA) N 1 Required As available Record Type 70, Sequence 1, See Record Format 20 CAR § 54-107(j)(1) for positions DEFINITION The POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. There are five reporting options: Y Yes – present at the time of inpatient admission N No – not present at the time of inpatient admission U No information in the record W Clinically undetermined 1 Exempt from POA reporting

GENERAL COMMENTS None EDIT Must be a valid code.

Principal Diagnosis Code A 6 Required As available Record Type 70, Sequence 1, positions 25-31 DEFINITION The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient for care. An ICD code describes the principal disease. GENERAL COMMENTS This field is to contain the appropriate ICD code without a decimal. All entries are to be left justified with spaces to the right to complete the field length. An external cause of injury code should not be recorded as the principal diagnosis. EDIT A principal diagnosis must be present and valid. When the principal diagnosis is sex or age dependent, the age and sex must be consistent with the code entered. Principal Procedure Code A 7 Required As available Record Type 70, Sequence 3, position 25-32 (1450 & 1450Y2K) DEFINITION The code that identifies the principal procedure performed during the hospital stay covered by this discharge data record. The principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or is necessary as a result of complications. The principal procedure is that procedure most related to the principal diagnosis. GENERAL COMMENTS The coding method used should be ICD code. If some other coding method is used, Procedure Coding Method Used field must indicate the coding method. Enter the code left justified without a decimal. EDIT This field must be present if other procedures are reported and be a valid code. When a procedure is sex-specific, the sex code entered in the record must be consistent. Principal Procedure Date N 6 or 8 Required As available Record Type 70, Sequence 3, positions 33- 38 for format 1450 or positions 33-40 for format 1450Y2K. DEFINITION The date on which the principal procedure described on the bill was performed. GENERAL COMMENTS None EDIT Must be a valid date falling between admission and discharge dates. Procedure Coding Method Used N 1 Required As available Record Type 70, Sequence 3, position 321 for format 1450 or 361 for format 1450Y2K. DEFINITION An indicator that identifies the coding method used for procedure coding. GENERAL COMMENTS Enter appropriate code from the list: 4 CPT – 4 5 HCPCS (HCFA Common Procedure Coding Systems) 9 ICD – 9 – CM 0 ICD-10-CM EDIT This field must agree with the coding method used to code procedures. Priority of Admission or Visit A 1 Required As available Record Type 20, positions 86 DEFINITION A code indicating priority of the admission/visit. GENERAL COMMENTS This is a one-digit code ranging from 1 – 4, or may be 9. The code structure is as follows. 1 Emergency Definition: The patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. 2 Urgent Definition: The patient requires immediate attention for the care and treatment of a physical or mental disorder 3 Elective Definition: The patient’s condition permits adequate time to schedule the availability of a suitable accommodation. 4 Newborn Definition: Use of this code necessitates the use of special Source of Admission codes; see Point of Origin for Admission. 5 Trauma Definition: Visit to a trauma center/hospital as licensed or designated by state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving trauma activation.

9 Information not available Definition: Information was not collected or was not available. EDIT The field must be present and be a valid code 1 – 4 5 or 9. If the code is entered 4 (newborn), the Point of Origin for Admission codes will be checked for consistency as well as the date of birth and diagnosis. Provider Address A 50 Required As available Record Type 10, positions 126-175 DEFINITION Complete mailing address to which the provider correspondence is to be sent for the correction and acknowledgment of discharge data. Street address or box number, city, state and ZIPcode are required. GENERAL COMMENTS None EDIT All address fields must be present. Provider (Hospital) Data ID A 4 Required As available Record Type 10, positions 122-125 DEFINITION A four letter hospital identification code that is assigned to each hospital. GENERAL COMMENTS None EDIT A Data ID must be Present, Valid and Consistent with each hospital Provider Name A 25 Required As available Record Type 10, positions 97-121 DEFINITION The name of the hospital submitting the record. GENERAL COMMENTS The hospital’s name is entered in the first 25 character positions and must be the name as it is licensed by the Department of Health. EDIT The name must be present and match a name in a coding table. Provider Telephone Number N 10 Required As available Record Type 10, positions 87-96 DEFINITION Telephone number, including area code, at which the provider wishes to be contacted for correction and acknowledgment of discharge data. GENERAL COMMENTS None EDIT Must be present and numeric, cannot be all zeroes. Public Health Condition Code A 2 Required As available Record Type 27, positions 70-71, 72-73, 74- 75 , 76-77 DEFINITION Identify conditions related to public health reporting. GENERAL COMMENTS This 2 digit conditional code will have an initial digit of “P”. This code will be recorded in UB-04 Form Locator 18-28 or Form Locator 81 with a qualifying code of A1. Valid codes are as follows: p0 Reserved for Public Health Reporting P1 Do Not Resuscitate Order

Indicator that a DNR order was written at the time of, or within the first 24 hours of the patient’s admission to the hospital and is clearly documented in the patient’s medical record. P2-P6 Reserved for Public Health Data Reporting P7 Direct Inpatient Admission from Emergency Room

Code indicates that patient was admitted directly from this facility’s Emergency Room / Department. P8-PZ Reserved for Public Health Data Reporting EDIT Must be a valid code.

Record Type N 2 Required As available All Records, positions 1-2 DEFINITION The record format type indicator. GENERAL COMMENTS This field is used to specify each type of record. Use the following numbers: Record Type Code Record Name Record Type Code Record Name 01 Processor Data 20 Patient Data 02-04 Reserved for National Assignment 21 Noninsured Employment Information 05-09 Local Use 22 Unassigned State Form Locators 10 Provider Data 23-24 Reserved for National Assignment 11-14 Reserved for National Assignment 25-29 Local Use 15-19 Local Use

30-31 Third Party Payer Data 40 Claim Data TAN-Occurrence 32-33 Reserved for National Assignment 41 Claim Data Condition-Value 34 Authorization 42-44 Reserved for National Assignment 35-39 Local Use 45-49 Local Use

50

IP Accommodations Data 60 IP Ancillary Services Data 51-54 Reserved for National Assignment 61 Outpatient Procedures 55-59 Local Use 62-64 Reserved for National Assignment 65-69 Local Use

70 Medical Data 71 Plan of Treatment and Patient Information 80 Physician Data 72 Specific Services and Treatments 81 Pacemaker Registry Record 73 Plan of Treatment/Medial Update Narrative 82-84 Reserved for National Assignment 74 Patient Information 85-89 Local Use 75-78 Reserved for National Assignment

79 Local Use

90 Claim Control Screen 95 Provider Batch Control 91 Remarks (Overflow from RT 90) 96-98 Local Use 92-94 Reserved for National Assignment 99 File Control EDIT The number must be present and valid. Revenue Code n 4 Required As available Record Type 50, positions 25-28, 67-70, 109-112, 151-154 Record Type 60, positions 25-28, 81-84, 137-140 DEFINITION A four-digit code that identifies a specific accommodation, ancillary service or billing calculation.

GENERAL COMMENTS For every patient there must be at least one revenue service entered. There may be an entry representing the sum of all revenue services; this entry would have a revenue code of ‘0001.’ If the summed entry (‘0001’) is one of the entries, the revenue amount associated must equal ‘TOTAL CHARGE’ found on record type 27. EDIT This field must be present and contain a valid revenue code as defined in Revenue Codes and Units of Service section. Sequence Number N 2 Required As available Positions 3-4, as needed DEFINITION Sequential number from 01 to nn assigned to individual records within the same specific record type code to indicate the sequence of the physical record within the record type. Records 21 2n do not have a sequence number greater than 01. Records 01, 10, 90, 91, 95 and 99 do not have sequence numbers. The sequence numbers for record types 30, 31, 34, 80 and 81 are used as matching criteria to determine which type 30, type 31, type 34, type 80 and/or type 81 records are associated, like sequence numbers indicating the records are associated. GENERAL COMMENTS None EDIT Must be valid sequence number for record type. Source of Payment Code N 2 Required As available Record Type 30, position 25 DEFINITION A code indicating source of payment associated with this payer record. Note: These are based on the Public Health Data Standards Consortium, Source of Payment Typology, Version 5.0, October 2011. GENERAL COMMENTS Valid codes are as follows: 1 MEDICARE (Includes Medicare Managed, Non-Managed Care & Other ) 2 MEDICAID (Medicaid Managed Care, Non Managed Care Plan, SCHIP, Applicant, Out of State and Other) 3 OTHER GOVERNMENT – FEDERAL/STATE/LOCAL (Includes Departments of Defense & Veterans Affairs, Indian Health Service or Tribe, HRSA Program, Black Lung, State Government, Other Government & Other Federal) 4 DEPARTMENTS OF CORRECTIONS (Includes federal, state, and local) 5 PRIVATE HEALTH INSURANCE (Private Managed Care, Private Health Insurance – Indemnity ,Other non- specified Private Managed Care or Private Health Insurance – Indemnity, Organized Delivery System, Small Employer Purchasing Group, Other Private Insurance) 6 BLUE CROSS/BLUE SHIELD (BC Indemnity, BC Managed Care, BC Out of State, BC Unspecified, BC Other) 7 MANAGED CARE, UNSPECIFIED (HMO, PPO, POS, Other Managed Care- Unknown if public or private) 8 NO PAYMENT from an Organization/Agency/Program/Private Payer Listed (Self-pay, No Charge, Refusal to Pay/Bad Debt, Hill Burton Free Care, Research/Donor, No Payment- Other) 9 MISCELLANEOUS/OTHER (Foreign National, Other(Non-government), Disability Insurance, Long-term Care Insurance, Worker’s Compensation, Auto Insurance (no fault), Other specified (includes Hospice) , NoTypology Code available for payment source) EDIT Code must be present and valid. Statement Covers Period From N 6 or 8 Required As available Record Type 20, positions 182 – 187 on the 1450 On the 1450Y2K, positions 184-191 DEFINITION The beginning service date of the period on this bill. GENERAL COMMENTS The format is MMDDYY for 1450. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made, all dates must use this format. EDIT This date must be present and be valid. Statement Covers Period Thru n 6 or 8 Required As available Record Type 20, positions 188-193 on the 1450 On the 1450 Y2K, positions 188-193 DEFINITION The discharge date.

GENERAL COMMENTS The format is MMDDYY for 1450 record. The month is recorded as two digits ranging from 01-12. The day is recorded as two digits ranging from 01-31. The year is recorded as two digits ranging from 00 -99. Each of the three components (month, day, year) must be right justified within its two digits. Any unused space to the left must be zero filled. For example February 7, 2014 is entered as 020714 (1450). For hospitals using the 1450 record format that began using a different date format in 2000, the date must be given as CCYYMMDD. In this case, February 7, 2014 is entered 20140207. Where this change is made all dates must use this format. EDIT This date must be present and be valid. Total Charges N 10, 2 Required As available Record Type 27, positions 44-53 DEFINITION Total of charges for this inpatient hospital stay. GENERAL COMMENTS The total allows for an 8-digit dollar amount followed by 2 digits for cents (no decimal point). All entries are right justified. If the charge has no cent then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000 and a charge of $37.50 is entered as 3750. EDIT This field must be present and contain a value greater than 0 when any revenue code field is greater than 0. Total Charges by Revenue Code n 10, 2 Required As available Record Type 50, positions 42-51, 84-93, 126-135, 168-177 Record Type 60, positions 45-54, 101-110, 157-166 DEFINITION Total dollars and cents amount charged for the related revenue service entered. GENERAL COMMENTS The total allows for an 8-digit dollar amount followed by 2 digits for cents (no decimal point). All entries are right justified. If the charge has no cents, then the last two digits must be zero. For example, a charge of $500.00 is entered as 50000 and a charge of $37.50 is entered as 3750. EDIT This field must be present and contain a value greater than 0 when the associated revenue code field is greater than 0. Type of Bill A 3 Required As available Record Type 27, positions 25-27 DEFINITION A code indicating the specific type of bill (inpatient, outpatient, etc.). This three digit code requires 1 digit each, in the following sequence: 1. Type of facility, 2. Bill classification, and 3. Frequency GENERAL COMMENTS All positions must be fully coded. See UB-04 guidelines for codes and definitions. This code indicates the specific type of inpatient billing. EDIT None Units of Service (Service Units) N 7 Required As available If the revenue code needs units; see Revenue Codes and Units of Service Section Record Type 60, positions 38-44, 94-100, 150-156 DEFINITION A quantitative measure of services rendered, by revenue category to the patient. It includes such items as the number of scans, number of pints, number of treatments, number of visits, number of miles or number of sessions. GENERAL COMMENTS This number qualifies the revenue service. The presence of this code ensures that charges per revenue service are adjusted to a common base for comparison. Revenue Codes and Units of Service (refer to Appendix B) defines the appropriate units for each revenue code. EDIT The units of service must be present for those revenue services that require a unit; see Revenue Codes and Units of Service section.

this page has been left intentionally blank

20 CAR pt. 54, Appendix B Revenue Codes and Units of Service {#sec-20-car-pt.-54-appendix-b omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR pt. 54, Appendix B}

APPENDIX A REVENUE CODES AND UNITS OF SERVICE This section defines acceptable revenue codes representing services provided to a patient, and the unit of measure associated with each revenue service. Any codes not assigned are assumed to be non-applicable unless found in the NUBC’s published manual or addenda to this manual. Revenue Code A three-digit code that identifies a specific accommodation, ancillary service or billing calculation. The first two digits of the three-digit code indicate major category; the third digit, represented by ‘x’ in the codes, indicates a subcategory. Units of Service A quantitative measure of services rendered by revenue category to or for the patient, to include items such as number of accommodation days, miles, pints or treatments.

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

REVENUE CODES & UNITS OF SERVICE TABLE Data Element Description Breakdown

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 001 None Total Charges 01x Reserved for Internal Payer Use 02x None Health Insurance – Prospective Payment System 0 = Reserved 1 = Research 2 = Skilled Nursing Facility - PPS 3 = Home Health - PPS 4 = Inpatient Rehab Facility - PPS 03x to 09x Reserved 10x Days All inclusive rate – a flat fee charge incurred on either a daily basis or total stay basis for services rendered. Charge may cover room and board plus ancillary services or room and board only. 0 = All inclusive room and board plus ancillary 1 = All inclusive room and board 11x Days Room and board – private medical or general routine services for single bed rooms 0 = General Classification 1 = Medical/surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other 12x Days Room and board – semi-private (two beds) medical or general – routine service charges incurred for accommodations with two beds 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other 13x Days Semi-private – three and four beds – routine service charges incurred for accommodations with three and four beds 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other 14x Days Private deluxe – deluxe rooms are accommodations with amenities substantially in excess of those provided to other patients 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 15x Days Room and board – ward medical or general routine service charge for accommodations with five or more beds 0 = General classification 1 = Medical/Surgical/GYN 2 = OB 3 = Pediatric 4 = Psychiatric 5 = Hospice 6 = Detoxification 7 = Oncology 8 = Rehabilitation 9 = Other 16x Days Other room and board – any routine service charges for accommodations that cannot be included in the more specific revenue center codes 0 = General classification 4 = Sterile environment 7 = Self care 9 = Other 17x Days Nursery – charges for nursing care to newborn and premature infants in nurseries 0 = General classification 1 = Newborn – Level I 2 = Newborn – Level II 3 = Newborn – Level III 4 = Newborn – Level IV 9 = Other 18x Days Leave of absence – charges for holding a room while the patient is temporarily away from the provider 0 = General classification 1 = Reserved 2 = Patient convenience 3 = Therapeutic leave 4 = ICF/MR (any reason) 5 = Nursing home (for hospitalization) 9 = Other leave of absence 19x Days Subacute Care – Accommodations charges for subacute care to inpatients or skilled nursing facilities. 0 = Reserved Classification 1 = Subacute Care – Level I 2 = Subacute Care – Level II 3 = Subacute Care – Level III 4 = Subacute Care – Level IV 9 = Other Subacute Care 20x Days Intensive care – routine service charge for medical or surgical care provided to patients who require a more intensive level of care than is rendered in the general medical or surgical unit 0 = General classification 1 = Surgical 2 = Medical 3 = Pediatric 4 = Psychiatric 6 = Intermediate ICU 7 = Burn care 8 = Trauma 9 = Other intensive care 21x Days Coronary care – routine service charge for medical care provided to patients with coronary illness who require a more intensive level of care than is rendered in the more general medical care unit 0 = General classification 1 = Myocardial infarction 2 = Pulmonary care 3 = Heart transplant 4 = Intermediate ICU 9 = Other coronary care 22x None Special charges-charges incurred during an inpatient stay or on a daily basis for certain services 0 = General classification 1 = Admission charge 2 = Technical support charge 3 = U. R. service charge 4 = Late discharge, medically necessary 9 = Other special charges

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 23x None Incremental nursing charge rate – charge for nursing service assessed in addition to room and board 0 = General classification 1 = Nursery 2 = OB 3 = ICU (includes transitional care) 4 = CCU (includes transitional care) 5 = Hospice 9 = Other 24x None All inclusive ancillary – a flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 0 = General classification 9 = Other inclusive ancillary 25x None Pharmacy – charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist 0 = General classification 1 = Generic drug 2 = Non-generic drug 3 = Take home drug 4 = Drugs incident to other diagnostic services 5 = Drugs incident to radiology 6 = Experimental drug 7 = Non-prescription 8 = IV solutions 9 = Other pharmacy 26x None IV therapy – equipment charge or administration of intravenous solution by specially trained personnel to individuals requiring such treatment 0 = General classification 1 = Infusion pump 2 = IV therapy/pharmacy service 3 = IV therapy/drug/supply/delivery 4 = IV therapy/supplies 9 = Other IV therapy 27x Item Medical/surgical supplies and devices – charges for supply items required for patient care 0 = General classification 1 = Non-sterile supply 2 = Sterile supply 3 = Take home supplies 4 = Prosthetic/orthotic devices 5 = Pace maker 6 = Intraocular lens 7 = Oxygen take home 8 = Other implants 9 = Other supplies/devices 28x None Oncology – charges for the treatment of tumors and related diseases 0 = General classification 9 = Other oncology 29x Item Durable Medical Equipment (other than rental) charges for medical equipment that can withstand repeated use 0 = General classification 1 = Rental 2 = Purchase of new DME 3 = Purchase of used DME 4 = Supplies\drugs for DME effectiveness (HHA’s only) 9 = Other equipment 30x Test Laboratory – charges for the performance of diagnostic and routine clinical laboratory tests 0 = General classification 1 = Chemistry 2 = Immunology 3 = Renal patient (home) 4 = Non-routine dialysis 5 = Hematology 6 = Bacteriology and microbiology 7 = Urology 9 = Other laboratory

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 31x Test Laboratory pathological – charges for diagnostic and routine lab tests on tissue and culture 0 = General classification 1 = Cytology 2 = Histology 4 = Biopsy 9 = Other 32x Test Radiology diagnostic – charges for diagnostic radiology services provided for the examination and care of patients. Includes: taking, processing, examining and interpreting radiographs and fluorographs 0 = General classification 1 = Angiocardiography 2 = Arthrography 3 = Arteriography 4 = Chest x-ray 9 = Other 33x Test Radiology therapeutic – charges for therapeutic radiology services and chemotherapy required for care and treatment of patients. Includes therapy by injection or ingestion of radioactive substances 0 = General classification 1 = Chemotherapy injected 2 = Chemotherapy oral 3 = Radiation therapy 5 = Chemotherapy IV 9 = Other 34x Test Nuclear medicine – charges for procedures and tests performed by a radioisotope laboratory utilizing radioactive materials as required for diagnosis and treatment of patients 0 = General classification 1 = Diagnostic 2 = Therapeutic 3 = Diagnostic Radiopharmaceuticals 4 = Therapeutic Radiopharmaceuticals 9 = Other 35x Scan CT scan – charges for Computer Tomographic scans of the head and other parts of the body 0 = General classification 1 = Head scan 2 = Body scan 9 = Other CT scan 36x None Operating room services – charges for services provided by specifically trained nursing personnel who provide assistance to physicians in the performance of surgical and related procedures during and immediately following surgery 0 = General classification 1 = Minor surgery 2 = Organ transplant other than kidney 7 = Kidney transplant 9 = Other operating room services 37x None Anesthesia – charges for anesthesia services in the hospital 0 = General classification 1 = Anesthesia incident to RAD 2 = Anesthesia incident to other diagnostic services 4 = Acupuncture 9 = Other anesthesia 38x Pint Blood storage and processing – charges for the storage and processing of whole blood 0 = General classification 1 = Blood administration 2 = Whole blood 3 = Plasma 4 = Platelets 5 = Leucocytes 6 = Other components 7 = Other derivatives (cryoprecipitates) 9 = Other blood and blood components 39x Blood storage and processing – charges for the storage and processing of whole blood 0 = General classification 1 = Blood administration 2 = Processing and Storage 9 = Other blood handling

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 40x Test Other imaging services 0 = General classification 1 = Diagnostic mammography 2 = Ultrasound 3 = Screening mammography 4 = Positron Emission Tomography 9 = Other imaging services 41x Treatment Respiratory services – charges for administration of oxygen and certain potent drugs through inhalation or positive pressure and other forms of rehabilitative therapy, through measurement of inhaled and exhaled gases and analysis of blood, and evaluation of the patient’s ability to exchange oxygen and other gases 0 = General classification 2 = Inhalation services 3 = Hyper baric oxygen therapy 9 = Other respiratory services 42x Treatment Physical therapy – charges for therapeutic exercises, massage, and utilization of effective properties of light, heat, cold, water, electricity and assistive devices for diagnosis and rehabilitation of patients who have neuromuscular, orthopedic and other disabilities 0 = General classification 1 = Visit 2 = Hourly 3 = Group 4 = Evaluation or re-evaluation 9 = Other physical therapy 43x Treatment Occupational therapy – charges for teaching manual skills and independence in personal care to stimulate mental and emotional activity on the part of patients 0 = General classification 1 = Visit 2 = Hourly 3 = Group 4 = Evaluation or re-evaluation 9 = Other occupational therapy 44x Treatment Speech language pathology – charges for services provided to persons with impaired functional communications skills 0 = General classification 1 = Visit 2 = Hourly 3 = Group 4 = Evaluation or re-evaluation 9 = Other speech therapy 45x Visit Emergency room – charges for emergency room treatment to those ill and injured persons who require immediate unscheduled medical or surgical care 0 = General classification 1 = EMTALA emergency medical screening services 2 = ER beyond EMTALA screening 6 = Urgent care 9 = Other emergency room 46x Test Pulmonary function – charges for tests that measure inhaled and exhaled gases and analysis of blood, and for tests that evaluate the patient’s ability to exchange other gases 0 = General classification 9 = Other pulmonary function 47x Test Audiology – charges for the detection and management of communication handicaps centering in whole or in part on the hearing function 0 = General classification 1 = Diagnostic 2 = Treatment 9 = Other audiology 48x Test Cardiology – charges for cardiac procedures rendered in a separate unit within the hospital. Such procedures include, but are not limited to: heart catheterization, coronary angiography, Swan-Ganz catheterization and exercise stress test. 0 = General classification 1 = Cardiac cath lab 2 = Stress test 3 = Echo cardiology 9 = Other cardiology

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 49x None Ambulatory surgical care – charges for ambulatory surgery that are not covered by other categories 0 = General classification 9 = Other ambulatory surgical care 50x None Outpatient service- charges for services rendered to an outpatient who is admitted as an inpatient before midnight of the day following the date of service. 0 = General classification 9 = Other outpatient 51x Visit Clinic – charges for providing diagnostic, preventive, curative, rehabilitative and education services on a scheduled basis to an ambulatory patient 0 = General classification 1 = Chronic pain center 2 = Dental clinic 3 = Psychiatric clinic 4 = OB-GYN clinic 5 = Pediatric clinic 6 = Urgent care clinic 7 = Family practice 9 = Other clinic 52x Clinic Visit Freestanding Clinic provides a breakdown of some clinics that hospitals or third party payers may require 0 = General classification 1 = Rural health – clinic 2 = Rural health – home 3 = Family practice clinic 4 = Visit b Rurual Health Practitioner to a member in a covered Part A stay at SNF 5 = Visit Rural Health Clinic Practitioner to a member in a SNF 6 = Urgent care clinic 7 = Visiting Nurse Service 8 = Visit by Rural Health Clinic Practitioner to other non Rural Health Clinic Site 9 = Other free standing clinic 53x Visit Osteopathic services – charges for a structural evaluation of the cranium, entire cervical, dorsal and lumbar spine by a doctor of osteopathy 0 = General classification 1 = Osteopathic therapy 9 = Other osteopathic services 54x Mile/Item/Unit Ambulance – charges for ambulance service, usually on an unscheduled basis, to the ill and injured who require immediate medical attention 0 = General classification 1 = Supplies 2 = Medical transport 3 = Heart mobile 4 = Oxygen 5 = Air ambulance 6 = Neonatal ambulance services 7 = Pharmacy 8 = EKG transmission 9 = Other ambulance 55x Skilled Nursing Charges for nursing services that must be provided under the direct supervision of a licensed nurse to assure the safety of the patient and to achieve the medically desired result. This code may be used for nursing home services or a service charge for home health billing. 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other skilled nursing 56x Visit/Hour Medical social services such as counseling patients, intervening on behalf of patients, and interpreting problems of social situation rendered to patients on any basis. 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other medical social services

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 57x Home Health Aide/Visit/Hour Charges made by an HHA for personnel who are primarily responsible for the personal care of the patient 0 = General classification 1 = Visit charge 2 = Hourly charge 9 = Other home health aide 58x Other Visits/ Hour /Assess Code indicates the charge by an HHA for visits other than physical therapy, occupational therapy or speech therapy, which must be specifically identified. 0 = General classification 1 = Visit charge 2 = Hourly charge 3 = Assessment 9 = Other home health visits 59x Unit This revenue code is used by an HHA that bills (Home Health) on the basis of units of service. 0 = General classification

60x Oxygen Code indicates the charges by an HHA for (Home Health) oxygen equipment supplies or contents, excluding purchased equipment. If a beneficiary purchased a stationary oxygen system, and oxygen concentrator or portable equipment, current revenue code 292 or 293 applies. DME (other than oxygen systems) is billed under current revenue codes 291, 292 or 293. 0 = General classification 1 = Oxygen – state/equip/supply/ or content 2 = Oxygen – state/equip/supply under 1 LPM 3 = Oxygen – state/equip/ over 4 LPM 4 = Oxygen – portable add-on 9 = Oxygen – other 61x Test MRI – charges for Magnetic Resonance Imaging of the brain and other parts of the body. 0 = General classification 1 = MRI Brain/Brainstem 2 = MRI Spinal Cord/Spine 4 = MRI Other 5 = MRA – Head and Neck 6 = MRA – Lower Extremities 8 = MRA – Other 9 = Other MRT 62x Supplies Medicare/Surgical supplies – charges for supply items required for patient care. The category is an extension of code 27x for reporting additional breakdown where needed. Sub code 1 is for providers that cannot bill supplies used for radiology procedures under radiology. 1 = Supplies incident to radiology 2 = Supplies incident to other diagnostic services 3 = Surgical dressing 4 = Investigational device 63x Drugs Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist. 0 = General classification 1 = Single source drug 2 = Multiple source drug 3 = Restrictive prescription 4 = Erytropepoetin (EPO) - less than 10,000 units 5 = Erytropepoetin (EPO) - 10,000 or more units 6 = Drugs requiring detailed coding 7 = Self-administrable Drug

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 64x Home Therapy Services Charge for intravenous drug therapy services performed in the patient’s residence. For home IV providers the HCPCS code must be entered for all equipment, and all types of covered therapy. 0 = General classification 1 = Non-routine nursing, Central Line 2 = IV site care, central line 3 = IV start/change peripheral line 4 = Non-routine nursing, peripheral line 5 = Training patient/caregiver, central line 6 = Training, disabled patient, central line 7 = Training patient/caregiver, peripheral line 8 = Training, disabled patient, peripheral line 9 = Other IV therapy services 65x Day Hospice service – charges for hospice care services for a terminally ill patient if he/she elects these services in lieu of other services for the terminal condition 0 = General classification 1 = Routine home care 2 = Continuous home care 3 = Reserved 4 = Reserved 5 = Inpatient respite care 6 = General non-respite inpatient care 7 = Physician services 8 = Hospice Room and Board Nursing Facility 9 = Other hospice service 68x Activation Trauma Response – charges representing the activation of the trauma team 0 = No Used 1 = Level I Trauma 2 = Level II Trauma 3 = Level III Trauma 4 = Level IV Trauma 9 = Other Trauma Response 70x None Cast room – charges for services related to the application, maintenance and removal of casts 0= General classification

71x None Recovery room 0 = General classification

72x Labor Room / Delivery Room Labor room and delivery – charges Delivery Room for labor and delivery room services provided by specially trained nursing personnel to patients, including prenatal care during labor, assistance during delivery, postnatal care in the recovery room, and minor gynecological procedures if they are performed in the delivery suite. 0 = General classification 1 = Labor 2 = Delivery 3 = Circumcision 4 = Birthing center (unit is days) 9 = Other labor room and delivery 73x Test EKG/ECG (electrocardiogram) – charges for operation of specialized equipment to record electromotive variations in actions of the heart muscle on an electrocardiography for diagnosis of heart ailments 0 = General classification 1 = Holter monitor 2 = Telemetry 9 = Other EKG/ECG 74x Test EEG (electroencephalogram) – charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders 0 = General classification

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 75x Test Gastrointestinal services – procedure room charges for endoscopic procedures not performed in the operating room. 0 = General classification

76x None Treatment or observation room – charges for minor procedures performed outside the operating room 0 = General classification 1 = Treatment room 2 = Observation room 9 = Other Specialty Services 77x Preventative Care Services Charges for the administration of vaccines 0 = General classification 1 = Vaccine administration 9 = Other 78x None Telemedicine 0 = General Classification 79x None Lithotripsy – charges for the use of lithotripsy in the treatment of kidney stones 0 = General classification

80x Session Inpatient renal dialysis – a waste removal process performed in an inpatient setting that uses an artificial kidney when the body’s own kidneys have failed. The waste may be removed directly from the blood (hemodialysis) or indirectly from the abdominal covering and the tissue (peritoneal dialysis). 0 = General classification 1 = Inpatient hemodialysis 2 = Inpatient peritoneal 3 = Inpatient continuous ambulatory peritoneal dialysis 4 = Inpatient continuous cycling peritoneal dialysis 9 = Other inpatient dialysis 81x None Organ acquisition and storage costs 0 = General classification 1 = Living donor 2 = Cadaver donor 3 = Unknown donor 4 = Unsuccessful organ search – Donor Bank Charges 9 = Other organ acquisition 82x Hemodialysis Outpatient or Home Dialysis A waste removal performed in an outpatient or home setting necessary when the body’s own kidneys have failed. Waste is removed directly from the blood. 0 = General classification 1 = Hemodialysis/composite or other rate 2 = Home Supplies 3 = Home Equipment 4 = Home Maintenance 5 = Support services 9 = Other hemodialysis outpatient 83x Peritoneal Dialysis Outpatient or Home A waste removal process performed in an outpatient or home setting, necessary when the body’s own kidneys have failed. Waste is removed indirectly by flushing a special solution between the abdominal covering and the tissue. 0 = General classification 1 = Peritoneal/composite or other rate 2 = Home Supplies 3 = Home Equipment 4 = Maintenance 5 = Support services 9 = Other peritoneal dialysis 84x Continuous Ambulatory Peritoneal Dialysis (CAPD) Outpatient A continuous dialysis process performed in an outpatient or home setting, which uses the patient’s peritoneal membrane as a dialyzer. 0 = General classification 1 = CAPD/composite or other rate 2 = Home Supplies 3 = Home Equipment 4 = Maintenance 5 = Support services 9 = Other CAPD dialysis

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 85x Continuous Cycling Peritoneal Dialysis (CCPD) Outpatient A continuous dialysis process performed in an outpatient or home setting, which uses the patient’s peritoneal membrane as a dialyzer. 0 = General classification 1 = CCPD/composite or other rate 2 = Home Supplies 3 = Home Equipment 4 = Maintenance 5 = Support services 9 = Other CCPD dialysis 86x Tests Magneto encephalography (MEG) – Charges for operation of specialized medical equipment to measure the magnetic fields generated by brain activity 0 = General Classification 1 = MEG 87x Reserved 88x Session Miscellaneous dialysis – charges for dialysis services not identified elsewhere 0 = General classification 1 = Ultrafiltration 2 = Home Dialysis Aid Visit 9 = Other miscellaneous dialysis 89x Reserved 90x Visit Behavioral Health Treatments / Services 0 = General classification 1 = Electroshock treatment 2 = Milieu therapy 3 = Play therapy 4 = Activity therapy 5 = Intensive Outpatient Services – Psychiatric 6 = Intensive Outpatient Services - Clinical Dependency 7 = Community Behavioral Health Program 9 = Other 6 = Family therapy 91x Visit Behavioral Health Treatments /Services 1 = Rehabilitation 2 = Partial hospitalization – Less Intensive 3 = Partial Hospitalization - Intensive 4 = Individual therapy 5 = Group therapy 6 = Family therapy 7 = Biofeedback 8 = Testing 9 = Other Behavioral Health Treatments 92x Test Other diagnostic services 0 = General classification 1 = Peripheral vascular lab. 2 = Electromyelogram 3 = Pap smear 4 = Allergy test 5 = Pregnancy test 9 = Other diagnostic service

CODE UNIT DEFINITION SUBCATEGORY ‘x’ 94x Visit Other therapeutic services – charges for other therapeutic services not otherwise categorized 0 = General classification 1 = Recreational therapy 2 = Education or training 3 = Cardiac rehabilitation 4 = Drug rehabilitation 5 = Alcohol rehabilitation 6 = Routine complex medical equipment 7 = Ancillary complex medical equipment 8 = Pulmonary rehabilitation 9 = Other therapeutic services 96x None Professional fees – charges for medical professionals that the hospitals or third party payers require to be separately identified on the billing form 0 = General classification 1 = Psychiatric 2 = Ophthalmology 3 = MD anesthesiologist 4 = CRNA anesthetist 9 = Other professional fees 97x None Professional fees – continued 1 = Laboratory 2 = Radiology – diagnostic 3 = Radiology – therapeutic 4 = Radiology – nuclear medicine 5 = Operating room 6 = Respiratory therapy 7 = Physical therapy 8 = Occupational therapy 9 = Speech pathology 98x None Professional fees – continued 1 = Emergency room 2 = Outpatient services 3 = Clinic 4 = Medical; social services 5 = EKG 6 = EEG 7 = Hospital visit 8 = Consultation 9 = Private duty nurse 99x None Patient convenience items – charges for items that are generally considered by the third party payer to be strictly convenience items and as such, are not covered 0 = General classification 1 = Cafeteria/guest tray 2 = Private linen service 3 = Telephone/telegraph 4 = TV/radio 5 = Non-patient room rentals 6 = Late discharge charge 7 = Admission kits 8 = Beauty shop/barber 9 = Other convenience items 100x None Behavioral health Accommodations – charges for routine recommendations at specific health facilities 0 = General Classification 1 = Residential Treatment – Psychiatric 2 = Residential Treatment – Clinical Dependency 3 = Supervised Living 4 = Halfway House 5 = Group Home

20 CAR pt. 54, Appendix C Acronym Listing {#sec-20-car-pt.-54-appendix-c omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR pt. 54, Appendix C}

APPENDIX A ACRONYM LISTING

ACRONYM DESCRIPTION ADH Arkansas Department of Health ASCII PC Text File CAH Critical Access Hospital CAPD Continuous Ambulatory Peritoneal Dialysis CCPD Continuous Cycling Peritoneal Dialysis CD Compact Disk COBOL Common Business Oriented Language CPT Current Procedural Technology CR Carriage-return CT Computer Tomographic DAT PC Text File DCN Document Control Number DME Durable Medical Equipment DRG Diagnosis Related Group EEG Electroencephalogram EIN Employer Identification Number EKG/ECG Electrocardiogram EPO Erythropoetin alpha or Darbepoetin alpha FTP File Transfer Protocol HCFA Health Care Financing Administration HCPCS HCFA Common Procedural Coding System HDDS Hospital Discharge Data System HH Home Health HHA Home Health Agency HIPPA Health Insurance Portability and Accountability Act of 1996 ICD International Classification of Diseases ICF Intermediate Care Facility IRF Inpatient Rehabilitation Facility LF Line-feed LTCH Long Term Care Hospital MDC Major Diagnostic Categories MRI Magnetic Resonance Imaging NPI National Provider Identifier NUBC National Uniform Billing Committee PPS Perspective Payment System QTR Quarter RTC Residential Treatment Center SNF Skilled Nursing Facility TIN Tax Identification Number TOB Type of Bill TXT Text

UB Uniform Billing UPIN Universal Physician Identification Number ZIP Compressed file

20 CAR pt. 54, Appendix D References {#sec-20-car-pt.-54-appendix-d omnilex-key=us-ar-regs-official--title-20-part-54--20 CAR pt. 54, Appendix D}

APPENDIX A REFERENCES D1 RESOURCE LIST D2 RULES AND REGULATIONS PERTAINING TO HOSPITAL DISCHARGE DATA SYSTEM D3 ARKANSAS CODE – “STATE HEALTH DATA CLEARING HOUSE ACT” D4 UB-04

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

D1. RESOURCE LIST

Current Procedural Terminology Published by the American Medical Association; ISBN 3-89970-792-0. May be purchased from: Order Department Reference OP054194HA American Medical Association PO Box 10950 Chicago, IL 60610 (800) 621-8335 National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2013, Version 7.00, July 2013 Uniform Billing (UB-04) CMS Manual System, Pub100-04 Medicare Claims Processing, Transmittal 1104, November 3, 2006, Department of Health and Human Services, Centers for Medicare & Medicaid Services or www.cms.hhs.gov/transmittals/downloads/R1104CP.pdf HCFA Common Procedural Coding System (HCPCS) Published by the Centers for Medicare and Medicaid Service, (formerly HCFA) International Classification of Diseases, Ninth Edition (ICD-9) & Tenth Edition (ICD-10) Published by the Centers for Medicare and Medicaid Service, and the National Center for Health Statisti cs. The materials published by the Centers for Medicare and Medicaid Service may be purchased from: Government Printing Office U.S. Government Bookstore 710 North Capitol Street N.W. Washington, DC http://bookstore.gpo.gov/

Health Research and Educational Trust Disparities Toolkit

Authored by Hasnain-Wynia,R., Pierce, D., Haque, A., Hedges Greising, C., Prince, V., Reiter,j. (2007). hretdisparities.org. Some materials may also be purchased from large commercial bookstores and from medical office supply firms. These documents are also available for use by the general public at the Arkansas State Library and may be available from your local library by an interlibrary loan. Arkansas State Library Documents Service One Capitol Mall Little Rock, AR 72201 (501) 682-2326

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

D2. RULES AND REGULATIONS PERTAINING TO HOSPITAL DISCHARGE DATA SYSTEM

D3. ARKANSAS CODE – “STATE HEALTH DATA CLEARING HOUSE ACT”

Arkansas Code Annotated 20-7-301 et seq. 20-7-301. Title. This subchapter shall be entitled the "State Health Data Clearing House Act." History. Acts 1995, No. 670, § 1. 20-7-302. Purpose. The General Assembly finds that as a result of rising health care costs, the shortage of health professionals and health care services in many areas of the state, and the concerns expressed by care providers, consumers, third party payers, and others involved with planning for the provision of health care, there is an urgent need to understand patterns and trends in the availability, use, and costs of these services. Therefore, in order to establish an information base for patients, health professionals, and hospitals, to improve the appropriate and efficient usage of health care services, and to provide for appropriate protection for confidentiality and privacy, the Department of Health shall act as a state health data clearing house for the acquisition and dissemination of data from state agencies and other appropriate sources to carry out the purposes of this subchapter. History. Acts 1995, No. 670, § 2. 20-7-303. Collection and dissemination of health data. (a) The Director of the Department of Health shall, with the approval of the State Board of Health, compile and disseminate health data collected by the Department of Health. (b) The Department of Health, in consultation with advisory groups appointed by the director with representation from hospitals, outpatient surgery centers, health profession licensing boards, and other state agencies, should: (1)(A) Identify the most practical methods to collect, transmit, and share required health data as described in § 20-7-304; (B) Utilize, wherever practical, existing administrative databases and modalities of data collection to provide the required data; (C) Develop standards of accuracy, timeliness, economy, and efficiency for the provision of the data; and (D) Ensure confidentiality of data by enforcing appropriate rules and regulations. (2) In order to maximize limited resources and to prevent duplication of effort, the Department of Health may, when appropriate, consider contracting with private entities for the collection of data as set forth in this section subject to the provisions of this subchapter. (c)(1) All state agencies, including health profession licensing, certification, or registration boards and commissions, which collect, maintain, or distribute health data, including data relating to the Medicaid program, shall make available to the Department of Health such data as are necessary for the Department of Health to carry out its responsibilities as prescribed by this subchapter or such rules and regulations as may be adopted as provided in § 20-7-305. (2) If health data are already reported to another organization or governmental agency in the same manner, form, and content or in a manner, form, and content acceptable to the department, the director may obtain a copy of such data from said organization or agency, and no duplicative report need be submitted by the organization. (3) All hospitals and outpatient surgery centers licensed by the state shall submit information in a form and manner as prescribed by rules and regulations by the State Board of Health pursuant to § 20-7-305; however, if the same information is being collected by another state agency, the Department of Health shall obtain such data from the other state agency.

History. Acts 1995, No. 670, § 2. 20-7-304. Release of health data. The Director of the Department of Health shall be empowered to release data collected pursuant to this subchapter, except that data released shall not include any information which identifies or could be used to identify any individual patient, provider, institution, or health plan except as provided in § 20-7-305. History. Acts 1995, No. 670, § 2. 20-7-305. State Board of Health to prescribe rules and regulations - Data collected not subject to discovery. (a) The State Board of Health shall prescribe and enforce such rules and regulations as may be necessary to carry out the purpose of this subchapter, including the manner in which data are collected, maintained, compiled, and disseminated, and including such rules as may be necessary to promote and protect the confidentiality of data reported under this subchapter. (b) Provided further, that data collected under this subchapter which identifies, or could be used to identify, any individual patient, provider, institution, or health plan shall not be subject to discovery pursuant to the Arkansas Rules of Civil Procedure or the Freedom of Information Act of 1967, § 25-19-101 et seq. (c) The Department of Health and Human Services may, only for purposes of research and aggregate statistical reporting, provide data to the Arkansas Center for Health Improvement and the Agency for Healthcare Research and Quality for its Healthcare Cost and Utilization Project. The data shall be treated in a manner consistent with all state and federal privacy requirements, including, without limitation, the federal Health Insurance Portability and Accountability Act of 1996 privacy rule, specifically 45 C.F.R. § 164.512(i). Furthermore, any identifiable data provided, collected, or disseminated under this subsection shall not be subject to discovery pursuant to the Arkansas Rules of Civil Procedure or the Freedom of Information Act of 1967, § 25-19-101 et seq. (d) It shall be unlawful for the center to release any patient-identifying information to any nongovernmental third party. History. Acts 1995, No. 670, § 2. 20-7-306. Reports - Assistance. (a) The Director of the Department of Health shall prepare and submit a biennial report to the Governor and the House and Senate Interim Committees on Public Health, Welfare, and Labor or appropriate subcommittees thereof. (b) The Department of Health shall provide assistance to the House and Senate Interim Committees on Public Health, Welfare, and Labor or appropriate subcommittees thereof in the development of information necessary in the examination of health care issues. History. Acts 1995, No. 670, § 2; 1997, No. 179, § 22. 20-7-307. Penalties. (a)(1) Any person, firm, corporation, organization, or institution that violates any of the provisions of this subchapter or any rules and regulations promulgated hereunder regarding confidentiality of information shall be guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not less than one hundred dollars ($100) nor more than five hundred dollars ($500) or by imprisonment not exceeding one (1) month, or both. (2) Each day of violation shall constitute a separate offense. (b) Any person, firm, corporation, organization, or institution knowingly violating any of the provisions of this subchapter or any rules and regulations promulgated hereunder shall be guilty of a misdemeanor and, upon a

plea of guilty, a plea of nolo contendere, or conviction, shall be punished by a fine of not more than five hundred dollars ($500). (c)(1) Every person, firm, corporation, organization, or institution that violates any of the rules and regulations adopted by the State Board of Health or that violates any provision of this subchapter may be assessed a civil penalty by the board. (2) The penalty shall not exceed two hundred fifty dollars ($250) for each violation. (3) However, no civil penalty may be assessed until the person charged with the violation has been given the opportunity for a hearing on the violation pursuant to the Arkansas Administrative Procedure Act, § 25-15-201 et seq. History. Acts 1995, No. 670, § 3. 20-7-308. Repealer. All laws and parts of laws in conflict with this subchapter are hereby repealed, except that nothing herein shall be interpreted to repeal any provision which authorizes the Health Services Agency to gather such data as may be necessary to conduct permit of approval activities. History. Acts 1995, No. 670, § 6.

THIS PAGE HAS BEEN LEFT INTENTIONALLY BLANK

D3. UB-04