Attachment D - sample inpatient record 07/08/2011 VER 7.0 MARYLAND HSCRC INPATIENT CONFIDENTIAL FILE CONFIDENTIAL FILE LAYOUT (1216 CHARACTERS) RECORD NO. POSITION BYTES FIELD NAME -------- ----- ---------- 01-34 34 DISCHARGE KEY 01-06 6 PROVIDER NUMBER 07-17 11 MEDICAL RECORD NUMBER (STANDARDIZED) 18-19 2 ADMIT MONTH (MM) 20-21 2 ADMIT DATE (DD) 22-25 4 ADMIT YEAR (CCYY) 26-27 2 DISCHARGE MONTH (MM) 28-29 2 DISCHARGE DATE (DD) 30-33 4 DISCHARGE YEAR (CCYY) 34-34 1 RECORD TYPE 1 35-36 2 ADMIT HOUR 37-37 1 NATURE OF ADMISSION 1=DELIVERY 2=NEWBORN 3=EMERGENCY 4=URGENT 5=SCHEDULED 6=OTHER 8=REHABILITATION 9=UNKNOWN 0=CHRONIC 38-39 2 SOURCE OF ADMISSION 00=TRANSFERRED FROM ON-SITE ACUTE CARE UNIT TO REHAB UNIT 01=TRANSFERRED FOR ANOTHER HOSPITAL TO A SPECIALTY CENTER 02=TRANSFERRED FROM ANOTHER HOSPITAL FOR ANY OTHER REASON 03=TRANSFERRED FROM A NURSING HOME 04=TRANSFERRED FROM ANY OTHER INSTITUTION 05=ADMITTED FROM HOME 06=TRANSFERRED FROM LITHOTRIPSY FACILITY 07=TRANSFERRED FROM ON-SITE AMBULATORY OUTPATIENT SURGERY UNIT 08=TRANSFERRED FROM OFF-SITE AMBULATORY OUTPATIENT UNIT 09=UNKNOWN 10=NEWBORN 11=TRANS FROM ONSITE ACUTE CARE UNIT TO PSYCHE UNIT 12=ADMITTED FROM ON-SITE SUB-ACUTE FACILITY 13=ADMITTED FROM OTHER SUB-ACUTE FACILITY 20=Trans from on-site acute care unit to on-site rehabilitation unit 21=Trans from on-site rehabilitation unit to acute care unit 22=Trans from on-site rehabilitation unit to chronic unit 23=Trans from chronic unit to on-site rehabilitation unit 24=Trans from on-site acute care unit to chronic unit 25=Trans from on-site chronic unit to acute care unit 26=Trans from on-site acute care to on-site psychiatric unit 27=Trans from on-site psychiatric unit to acute care unit 28=Trans from on-site sub-acute unit to acute care unit 29=Admit within 72 hours from on-site ambulatory surgery unit with surgery 30=Newborn (patient born in hospital) 40=Admit from another acute general hospital to MIEMS-designated facility 41=Admit from another acute care hospital inpatient service for any reason 42=Admit from from rehab. hospital or unit of another acute care hospital 43=Admit from private psych. hospital or unit of another acute care hospital 44=Admit from a chronic hospital 45=Admit from other facility at which subacute services were provided 46=Admit within 72 hours from off-site amb. surg. / care of another facility 47=Admit from any other health institution (domiciliary, mental, halfway) 60=Admit from home, physician's office, noninstitutional source 61=Admit from a nursing home 99=Unknown 40-40 1 ADMIT FROM EMERGENCY ROOM 1=ADMITTED FROM EMERGENCY ROOM 7=NOT APPLICABLE 9=UNKNOWN 41-42 2 BIRTHDATE MONTH (MM) 43-44 2 BIRTHDATE DAY (DD) 45-48 4 BIRTHDATE YEAR (CCYY) 49-49 1 SEX 1=MALE 2=FEMALE 9=UNKNOWN 50-50 1 RACE 1=WHITE 2=AFRICAN AMERICAN 3=ASIAN OR PACIFIC ISLANDER 4=AMERICAN INDIAN/ ESKIMO/ALEUT 5=OTHER 6=BI-RACIAL 9=UNKNOWN 51-51 1 ETHNICITY 1=SPANISH/HISPANIC ORIGIN 2=NOT SPANISH/HISPANIC ORIGIN 9=UNKNOWN 52-52 1 MARTIAL STATUS 1=SINGLE 2=MARRIED 3=SEPARATED 4=DIVORCED 5=WIDOW/WIDOWER 9=UNKNOWN 53-54 2 AREA OF RESIDENCE COUNTY CODE 01=ALLEGANY 02=ANNE ARUNDEL 03=BALTIMORE COUNTY 04=CALVERT 05=CAROLINE 06=CARROLL 07=CECIL 08=CHARLES 09=DORCHESTER 10=FREDERICK 11=GARRETT 12=HARFORD 13=HOWARD 14=KENT 15=MONTGOMERY 16=PRINCE GEORGE'S 17=QUEEN ANNE'S 18=ST. MARY'S 19=SOMERSET 20=TALBOT 21=WASHINGTON 22=WICOMICO 23=WORCESTER 29=UNIDENTIFIED MARYLAND 30=BALTIMORE CITY (INDEPENDENT CITY) 39=DELAWARE 49=PENNSYLVANIA 59=WEST VIRGINIA 69=VIRGINIA 79=DISTRICT OF COLUMBIA 89=FOREIGN 98=OTHER STATES 99=UNIDENTIFIED 55-59 5 RESIDENCE ZIP CODE XXXXX ZIP CODE 77777 FOREIGN 99999 UNKNOWN 60-61 2 PRINCIPAL PAYER SOURCE 01=AETNA HEALTH PLANS 02=CAPITOLCARE (B/C-NCA) 03=CFS HEALTH GROUP 04=CHESAPEAKE HEALTH PLAN 05=CIGNA HEALTHCARE MID-ATL 06=COLUMBIA MEDICAL PLAN 07=DELMARVA HEALTH PLAN 08=HUMANA GROUP HEALTH PLAN 09=GWU HEALTH PLAN 10=HEALTHPLUS 11=KAISER PERMANENTE 12=MAMSI 13=TOTAL HEALTH CARE 14=U.S.HEALTHCARE 15=PRUDENTIAL HEALTH CARE 16=PRINCIPAL HEALTH CARE 17=PREFERRED HEALTH NETWORK 18=PHYSICIANS HEALTH PLAN 19=PRINCIPAL HEALTH DELAWARE 20=MARYLAND PHYSICIANS CARE 21=HELIX FAMILY HEALTH 22=JAI MEDICAL 23=PRIORITY PARTNERS 24=UNITED HEALTHCARE 25=NEW AMERICAN HEALTH 26=PRIME HEALTH 27=AMERICAID 29=OTHER HMO 00=Not Applicable 30=Aetna Health Plans 31=CareFirst (i.e., Blue Choice) 32=Cigna Healthcare of Mid-Atlantic 33=Coventry Health Plan of Delaware 34=Kaiser Permanente 35=MAMSI 36=United Healthcare 37=Other HMO/POS 42=Amerigroup 43=Coventry Health Plan of Delaware (Diamond Plan) 44=Helix Family Health 45=JAI Medical Group 46=Medicaid/Uninsured APS - Maryland (psychiatric payer) 47=Maryland Physicians Care 48=Priority Partners 49=United Healthcare (Americhoice) 50=Other Medicaid MCO/HMO 55=Aetna (Golden Choice) 56=ElderHealth 57=United Healthcare (Evercare) 58=Other Medicare HMO 65=Aetna 66=CareFirst - CFMI (Maryland) (PPO, POS, Blue Preferred, FEP) 67=CareFirst - GHMSI (DC) (PPO, POS, Blue Preferred, FEP) 68=CCN/First Health 69=Cigna 70=Employer Health Plan (EHP) 71=Fidelity Benefits Administrator 72=Great West One Plan 73=Kaiser Permanente 74=MAMSI (i.e., Alliance PPO and MAMSI Life and Health) 75=National Capital PPO (NCPPO) 76=Private Health Care Systems 77=Other Commercial, PPO, PPN, TPA 85=American Psychiatric Systems (APS) 86=Cigna Behavioral Health 87=ComPsych 88=Magellan 89=Managed Health Network 90=United Behavioral Health 91=Value Options 92=Other Behavioral Health 93=MD Health Insurance Plan (MHIP) EPO 94=MD Health Insurance Plan (MHIP) PPO 95=Tricare - examples: Health Net 96=Uniformed Services Family Health Plan (USFHP) 97=Other Miscellaneous Government Programs 99=Invalid 62-63 2 SECONDARY PAYER SOURCE 01=AETNA HEALTH PLANS 02=CAPITOLCARE (B/C-NCA) 03=CFS HEALTH GROUP 04=CHESAPEAKE HEALTH PLAN 05=CIGNA HEALTHCARE MID-ATL 06=COLUMBIA MEDICAL PLAN 07=DELMARVA HEALTH PLAN 08=HUMANA GROUP HEALTH PLAN 09=GWU HEALTH PLAN 10=HEALTHPLUS 11=KAISER PERMANENTE 12=MAMSI 13=TOTAL HEALTH CARE 14=U.S.HEALTHCARE 15=PRUDENTIAL HEALTH CARE 16=PRINCIPAL HEALTH CARE 17=PREFERRED HEALTH NETWORK 18=PHYSICIANS HEALTH PLAN 19=PRINCIPAL HEALTH DELAWARE 20=MARYLAND PHYSICIANS CARE 21=HELIX FAMILY HEALTH 22=JAI MEDICAL 23=PRIORITY PARTNERS 24=UNITED HEALTHCARE 25=NEW AMERICAN HEALTH 26=PRIME HEALTH 27=AMERICAID 29=OTHER HMO 00=Not Applicable 30=Aetna Health Plans 31=CareFirst (i.e., Blue Choice) 32=Cigna Healthcare of Mid-Atlantic 33=Coventry Health Plan of Delaware 34=Kaiser Permanente 35=MAMSI 36=United Healthcare 37=Other HMO/POS 42=Amerigroup 43=Coventry Health Plan of Delaware (Diamond Plan) 44=Helix Family Health 45=JAI Medical Group 46=Medicaid/Uninsured APS - Maryland (psychiatric payer) 47=Maryland Physicians Care 48=Priority Partners 49=United Healthcare (Americhoice) 50=Other Medicaid MCO/HMO 55=Aetna (Golden Choice) 56=ElderHealth 57=United Healthcare (Evercare) 58=Other Medicare HMO 65=Aetna 66=CareFirst - CFMI (Maryland) (PPO, POS, Blue Preferred, FEP) 67=CareFirst - GHMSI (DC) (PPO, POS, Blue Preferred, FEP) 68=CCN/First Health 69=Cigna 70=Employer Health Plan (EHP) 71=Fidelity Benefits Administrator 72=Great West One Plan 73=Kaiser Permanente 74=MAMSI (i.e., Alliance PPO and MAMSI Life and Health) 75=National Capital PPO (NCPPO) 76=Private Health Care Systems 77=Other Commercial, PPO, PPN, TPA 85=American Psychiatric Systems (APS) 86=Cigna Behavioral Health 87=ComPsych 88=Magellan 89=Managed Health Network 90=United Behavioral Health 91=Value Options 92=Other Behavioral Health 93=MD Health Insurance Plan (MHIP) EPO 94=MD Health Insurance Plan (MHIP) PPO 95=Tricare - examples: Health Net 96=Uniformed Services Family Health Plan (USFHP) 97=Other Miscellaneous Government Programs 99=Invalid 64-69 6 CENSUS TRACT 70-71 2 DISPOSITION OF PATIENT 01=HOME OR SELF CARE 02=DO NOT USE 03=HOME HEALTH CARE 04=DO NOT USE 05=ACUTE CARE GEN HOSP 06=OTHER HEALTH CARE FACILITY 07=DIED 08=LEFT AGAINST MEDICAL ADVICE 09=UNKNOWN 10=REHAB FACILITY 11=REHAB UNIT OF HOSP 12=ON-SITE DISTINCT REHAB UNIT 13=TRANS TO NURSING FAC 14=DISCHARGE TO ONSITE PSYCHE 15=DISCHARGE TO ONSITE SUB-ACUTE 16=DISCHARGE TO OTHER SUB-ACUTE FACILITY 20 To distinct on-site rehabilitation unit from acute care 21 To acute care unit from on-site rehabilitation unit 22 To chronic unit from on-site rehabilitation unit 23 To on-site rehabilitation unit from chronic care unit 24 To chronic unit from acute care unit 25 To acute care unit from chronic care unit 26 To on-site psychiatric unit from acute care unit 27 To acute care unit from on-site psychiatric unit 28 To on-site subacute 29 To on-site hospice 40 To another acute care hospital 41 To a rehabilitation hospital or rehab. unit of another hospital 42 To a psychiatric hospital or an off-site psych. unit of another hospital 43 To a chronic hospital 44 To a nursing facility 45 To a subacute facility 46 To other health care facility 60 To home or self-care 61 To home under the care of a home health agency 62 To nursing home 70 Expired 71 Left against medical advice 99 Unknown 72-74 3 ALTERNATIVE RATE METHOD ARM CODE 75-76 2 SOURCE OF PAYMENT EXPECTED PAYOR FOR MOST OF THIS BILL 01=MEDICARE 02=MEDICAID 03=TITLE V 04=BLUE CROSS OF MD 05=COMMERCIAL INSURANCE 06=OTHER GOVERNMENT PROGRAM 07=WORKMEN'S COMPENSATION 08=SELF PAY 09=CHARITY 10=OTHER 11=DONOR 12=HMO 13=MEDICAID (STATE ONLY) 14=MEDICAID HMO 15=MEDICARE HMO 16=BLUE CROSS (NCA) 17=BLUE CROSS OTHER 99=UNKNOWN 77-78 2 SECONDARY SOURCE OF PAYMENT SECONDARY PAYOR 01=MEDICARE 02=MEDICAID 03=TITLE V 04=BLUE CROSS OF MD 05=COMMERCIAL INSURANCE 06=OTHER GOVERNMENT PROGRAM 07=WORKMEN'S COMPENSATION 08=SELF PAY 09=CHARITY 10=OTHER 11=DONOR 12=HMO 13=MEDICAID (STATE ONLY) 14=MEDICAID HMO 15=MEDICARE HMO 16=BLUE CROSS (NCA) 17=BLUE CROSS OTHER 77=NOT APPLICABLE 99=UNKNOWN 79-84 6 ATTENDING PHYSICIAN XXXXXX PHYSICIAN NUMBER 999999 UNKNOWN 85-90 6 OPERATING PHYSICIAN XXXXXX PHYSICIAN NUMBER 777777 NOT APPLICABLE 999999 UNKNOWN 91-92 2 MAJOR SERVICE 01,B1=MEDICINE 02,B2=SURGERY 03,B3=OBSTETRICS 04,B4=NEWBORN 05,B5=PEDIATRIC 06,B6=PSYCHIATRIC 07,B7=OTHER 08,B8=REHABILITATION 09,B9,99=UNKNOWN B=SPACE 10=CHRONIC 93-94 2 TYPE OF DAILY SERVICE 01=ALL OTHER 02=SHOCK TRAUMA 03=ONCOLOGY 04=SKILLED NURSING CARE 05=INTERMEDIATE (CHRONIC) CARE 06=NEO-NATAL INTENSIVE CARE 07=BURN CARE 08=REHAB 09=CHRONIC 95-97 3 NON-PSYCHIATRIC DAYS 001-776 NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 98-100 3 PSYCHIATRIC DAYS 001-776 NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 101-101 1 READMISSION 1=YES 2=NO 102-104 3 MEDICAL/SURGICAL ICU DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 105-107 3 CORONARY CARE DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 108-110 3 BURN CARE DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 111-113 3 NEO-NATAL ICU DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 114-116 3 PEDIATRIC ICU DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 117-119 3 SHOCK TRAUMA DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 120-122 3 OTHER CARE DAYS XXX=NUMBER OF DAYS 777=NOT APPLICABLE 999=UNKNOWN 123-126 4 NEWBORN BIRTH WEIGHT XXXX=ACTUAL WEIGHT AT BIRTH IN GRAMS 7777=PATIENT NOT A NEWBORN 9999=UNKNOWN 127-128 2 UMD-SERVICE 129-129 1 FILLER 130-136 7 PRINCIPAL DIAGNOSIS 137-143 7 OTHER DIAGNOSIS1 144-150 7 OTHER DIAGNOSIS2 151-157 7 OTHER DIAGNOSIS3 158-164 7 OTHER DIAGNOSIS4 165-171 7 OTHER DIAGNOSIS5 172-178 7 OTHER DIAGNOSIS6 179-185 7 OTHER DIAGNOSIS7 186-192 7 OTHER DIAGNOSIS8 193-199 7 OTHER DIAGNOSIS9 200-206 7 OTHER DIAGNOSIS10 207-213 7 OTHER DIAGNOSIS11 214-220 7 OTHER DIAGNOSIS12 221-227 7 OTHER DIAGNOSIS13 228-234 7 OTHER DIAGNOSIS14 235-241 7 E-CODE XXXXXXX=ICD9-CM CODE BBBBBBB=NOT APPLICABLE bbbbbbb=SPACES 242-242 1 RESERVE FLAG 243-250 8 AMBULANCE RUN NUMBER (THRU 06/2011 ONLY) 251-257 7 PRINCIPAL PROCEDURE XXXXXXX=ICD9-CM CODE BBBBBBB=NOT APPLICABLE bbbbbbb=SPACES 258-265 8 PRINCIPAL PROCEDURE DATE 01-12=MONTH 77=NOT APPLICABLE 99=UNKNOWN 01-31=DAY 77=NOT APPLICABLE 99=UNKNOWN XXXX=YEAR 7777=NOT APPLICABLE 9999=UNKNOWN 266-272 7 OTHER PROCEDURE 2 XXXXXXX=ICD9-CM CODE BBBBBBB=NOT APPLICABLE bbbbbbb=SPACES 273-280 8 OTHER PROCEDURE DATE 2 01-12=MONTH 77=NOT APPLICABLE 99=UNKNOWN 01-31=DAY 77=NOT APPLICABLE 99=UNKNOWN XXXX=YEAR 7777=NOT APPLICABLE 9999=UNKNOWN 281-287 7 OTHER PROCEDURE 3 SAME AS OTHER PROCEDURE 1 288-295 8 OTHER PROCEDURE DATE 3 SAME AS OTHER PROCEDURE DATE 1 296-302 7 OTHER PROCEDURE 4 SAME AS OTHER PROCEDURE 1 303-310 8 OTHER PROCEDURE DATE 4 SAME AS OTHER PROCEDURE DATE 1 311-317 7 OTHER PROCEDURE 5 SAME AS OTHER PROCEDURE 1 318-325 8 OTHER PROCEDURE DATE 5 SAME AS OTHER PROCEDURE DATE 1 326-332 7 OTHER PROCEDURE 6 SAME AS OTHER PROCEDURE 1 333-340 8 OTHER PROCEDURE DATE 6 SAME AS OTHER PROCEDURE DATE 1 341-347 7 OTHER PROCEDURE 7 SAME AS OTHER PROCEDURE 1 348-355 8 OTHER PROCEDURE DATE 7 SAME AS OTHER PROCEDURE DATE 1 356-362 7 OTHER PROCEDURE 8 SAME AS OTHER PROCEDURE 1 363-370 8 OTHER PROCEDURE DATE 8 SAME AS OTHER PROCEDURE DATE 1 371-377 7 OTHER PROCEDURE 9 SAME AS OTHER PROCEDURE 1 378-385 8 OTHER PROCEDURE DATE 9 SAME AS OTHER PROCEDURE DATE 1 386-392 7 OTHER PROCEDURE 10 SAME AS OTHER PROCEDURE 1 393-400 8 OTHER PROCEDURE DATE 10 SAME AS OTHER PROCEDURE DATE 1 401-407 7 OTHER PROCEDURE 11 SAME AS OTHER PROCEDURE 1 408-415 8 OTHER PROCEDURE DATE 11 SAME AS OTHER PROCEDURE DATE 1 416-422 7 OTHER PROCEDURE 12 SAME AS OTHER PROCEDURE 1 423-429 7 OTHER PROCEDURE 13 SAME AS OTHER PROCEDURE 1 430-436 7 OTHER PROCEDURE 14 SAME AS OTHER PROCEDURE 1 437-443 7 OTHER PROCEDURE 15 SAME AS OTHER 444-444 1 REHABILITATION ADMISSION CLASS 1=INITIAL REHABILITATION 2=EVALUATION 3=READMISSION 4=UNPLANNED DISCHARGE 5=CONTINUING REHABILITATION 445-451 7 REHABILITATION IMPAIRMENT GROUP CODE 452-457 6 PROVIDER SPECIFIC ADMIT CODE 458-463 6 PROVIDER SPECIFIC DISCHARGE CODE 464-466 3 FILLER 467-468 2 CMS MDC CODE 469-471 3 CMS DRG CODE 472-500 29 FILLER 501-501 1 POA FOR PRIMARY DIAGNOSIS N Diagnosis Not Present on Admission U Diagnosis Insufficient Documentation to Determine W Diagnosis Unable to Clinically Determine E Diagnosis Exempt from Reporting 502-502 1 POA FOR OTHER DIAGNOSIS1 503-503 1 POA FOR OTHER DIAGNOSIS2 504-504 1 POA FOR OTHER DIAGNOSIS3 505-505 1 POA FOR OTHER DIAGNOSIS4 506-506 1 POA FOR OTHER DIAGNOSIS5 507-507 1 POA FOR OTHER DIAGNOSIS6 508-508 1 POA FOR OTHER DIAGNOSIS7 509-509 1 POA FOR OTHER DIAGNOSIS8 510-510 1 POA FOR OTHER DIAGNOSIS9 511-511 1 POA FOR OTHER DIAGNOSIS10 512-512 1 POA FOR OTHER DIAGNOSIS11 513-513 1 POA FOR OTHER DIAGNOSIS12 514-514 1 POA FOR OTHER DIAGNOSIS13 515-515 1 POA FOR OTHER DIAGNOSIS14 516-516 1 FILLER 517-517 1 ATTENDING PHYSICIAN FLAG 0=VALID PHYSICIAN NUMBER 1=INVALID PHYSICIAN NUMBER 518-523 6 ATTENDING PHYSICIAN GHOST NUMBER 524-524 1 OPERATING PHYSICIAN FLAG 0=VALID PHYSICIAN NUMBER 1=INVALID PHYSICIAN NUMBER 525-530 6 OPERATING PHYSICIAN GHOST NUMBER 531-533 3 AGE IN YEARS 534-538 5 AGE IN DAYS (IF AGE IN YEARS = 000) 539-541 3 LENGTH OF STAY 542-542 1 FILLER 543-543 1 METROPOLITAN CODE 0=NOT METROPOLITAN 1=BALTIMORE METROPOLITAN 2=WASHINGTON METROPOLITAN 544-544 1 TEACHING HOSPITAL CODE 0=NOT TEACHING 1=TEACHING 545-545 1 BED CAPACITY (HOSPITAL BED SIZE) 0=NOT OVER 400 BEDS 1=OVER 400 BEDS 546-546 1 PSRO AREA 1=WESTERN MARYLAND 2=BALTIMORE CITY 3=MONTGOMERY 4=PRINCE GEORGES 5=CENTRAL MARYLAND 6=SOUTHERN MARYLAND 7=DELMARVA 547-547 1 HSA (HEALTH STATIC AREA 1=CENTRAL MARYLAND GROUPED BY COUNTY) 2=EASTERN SHORE 3=SOUTHERN MARYLAND 4=WESTERN MARYLAND 5=MONTGOMERY COUNTY 548-548 1 ICG CODE 549-549 1 ADMIT DAY OF WEEK 550-550 1 DISCHARGE DAY OF WEEK 551-553 3 PREOP TIME FOR PRIMARY PROCEDURE 554-556 3 OTHER PREOP TIME 1 557-559 3 OTHER PREOP TIME 2 560-562 3 OTHER PREOP TIME 3 563-565 3 OTHER PREOP TIME 4 566-568 3 OTHER PREOP TIME 5 569-571 3 OTHER PREOP TIME 6 572-574 3 OTHER PREOP TIME 7 575-577 3 OTHER PREOP TIME 8 578-580 3 OTHER PREOP TIME 9 581-583 3 OTHER PREOP TIME 10 584-584 1 CLASS FOR PRIMARY PROCEDURE 585-585 1 CLASS FOR 1ST SECONDARY PROCEDURE 586-586 1 CLASS FOR 2ND SECONDARY PROCEDURE 587-587 1 CLASS FOR 3RD SECONDARY PROCEDURE 588-588 1 CLASS FOR 4TH SECONDARY PROCEDURE 589-589 1 CLASS FOR 5TH SECONDARY PROCEDURE 590-590 1 CLASS FOR 6TH SECONDARY PROCEDURE 591-591 1 CLASS FOR 7TH SECONDARY PROCEDURE 592-592 1 CLASS FOR 8TH SECONDARY PROCEDURE 593-593 1 CLASS FOR 9TH SECONDARY PROCEDURE 594-594 1 CLASS FOR 10TH SECONDARY PROCEDURE 595-595 1 CLASS FOR 11TH SECONDARY PROCEDURE 596-596 1 CLASS FOR 12TH SECONDARY PROCEDURE 597-597 1 CLASS FOR 13TH SECONDARY PROCEDURE 598-598 1 CLASS FOR 14TH SECONDARY PROCEDURE 599-607 9 DAILY ROOM & BED CHARGES IMPLIED DECIMAL POINT ON 608-616 9 OPERATING ROOM CHARGES ALL CHARGES 9999999V99 617-625 9 DRUGS CHARGES 626-634 9 RADIOLOGY CHARGES 635-643 9 LABORATORY CHARGES 644-652 9 SUPPLIES CHARGES 653-661 9 THERAPY CHARGES 662-670 9 OTHER CHARGES 671-679 9 TOTAL CHARGES 680-682 3 FILLER 683-691 9 IP Med/Surg Acute CHARGES 692-700 9 Coronary Care CHARGES 701-709 9 ICU CHARGES 710-718 9 Nursery CHARGES 719-727 9 Oncology CHARGES 728-736 9 SNF CHARGES 737-745 9 Psychiatric CHARGES 746-754 9 OR CHARGES 755-763 9 Drugs CHARGES 764-772 9 Radiology Diagnostic CHARGES 773-781 9 Radiation Therapy CHARGES 782-790 9 Nuclear Medicine CHARGES 791-799 9 CT CHARGES 800-808 9 MRI CHARGES 809-817 9 IVC CHARGES 818-826 9 Lab CHARGES 827-835 9 Supplies CHARGES 836-844 9 Respiratory Therapy CHARGES 845-853 9 PT CHARGES 854-862 9 OT CHARGES 863-871 9 Speech/Audiology CHARGES 872-880 9 Pulmonary Function CHARGES 881-889 9 Anesthesia CHARGES 890-898 9 Not Used 899-907 9 Emergency Room CHARGES 908-916 9 Clinic CHARGES 917-925 9 Freestanding Clinic CHARGES 926-934 9 Labor & Delivery CHARGES 935-943 9 EKG CHARGES 944-952 9 EEG CHARGES 953-961 9 OTHER CHARGES 962-970 9 TOTAL CHARGES 971-1000 30 FILLER 1001-1007 7 OTHER DIAGNOSIS15 1008-1014 7 OTHER DIAGNOSIS16 1015-1021 7 OTHER DIAGNOSIS17 1022-1028 7 OTHER DIAGNOSIS18 1029-1035 7 OTHER DIAGNOSIS19 1036-1042 7 OTHER DIAGNOSIS20 1043-1049 7 OTHER DIAGNOSIS21 1050-1056 7 OTHER DIAGNOSIS22 1057-1063 7 OTHER DIAGNOSIS23 1064-1070 7 OTHER DIAGNOSIS24 1071-1077 7 OTHER DIAGNOSIS25 1078-1084 7 OTHER DIAGNOSIS26 1085-1091 7 OTHER DIAGNOSIS27 1092-1098 7 OTHER DIAGNOSIS28 1099-1105 7 OTHER DIAGNOSIS29 1106-1106 1 POA FOR OTHER DIAGNOSIS 15 N Diagnosis Not Present on Admission U Diagnosis Insufficient Documentation to Determine W Diagnosis Unable to Clinically Determine E Diagnosis Exempt from Reporting 1107-1107 1 POA FOR OTHER DIAGNOSIS 16 1108-1108 1 POA FOR OTHER DIAGNOSIS 17 1109-1109 1 POA FOR OTHER DIAGNOSIS 18 1110-1110 1 POA FOR OTHER DIAGNOSIS 19 1111-1111 1 POA FOR OTHER DIAGNOSIS 20 1112-1112 1 POA FOR OTHER DIAGNOSIS 21 1113-1113 1 POA FOR OTHER DIAGNOSIS 22 1114-1114 1 POA FOR OTHER DIAGNOSIS 23 1115-1115 1 POA FOR OTHER DIAGNOSIS 24 1116-1116 1 POA FOR OTHER DIAGNOSIS 25 1117-1117 1 POA FOR OTHER DIAGNOSIS 26 1118-1118 1 POA FOR OTHER DIAGNOSIS 27 1119-1119 1 POA FOR OTHER DIAGNOSIS 28 1120-1120 1 POA FOR OTHER DIAGNOSIS 29 1121-1130 10 ATTENDING PHYSICIAN NPI NUMBER (07/2009+) 1131-1140 10 OPERATING PHYSICIAN NPI NUMBER (07/2009+) 1141-1151 11 MEDICAID ID NUMBER (07/2011+) 1152-1169 18 PATIENT ACCOUNT NUMBER (07/2011+) 1170-1180 11 MAIS AMBULANCE RUNSHEET NUMBER (07/2011+) 1170-1216 47 FILLER