GLOBAL MAP DATA DICTIONARY #399 -- BILL/CLAIMS FILE 6/27/25 PAGE 1
STORED IN ^DGCR(399, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
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This file contains all of the information necessary to complete a Third Party billing form.
The entries in this file have matching entries in the Accounts Receivable file (430). The internal number in the AR file is the
same as the internal number in the BILL/CLAIMS file.
Per VHA Directive 10-93-142, this file definition should not be modified.
CROSS
REFERENCED BY: EVENT DATE(ABNDT), BILL CLASSIFICATION(ABT), PRIMARY BILL(AC), RATE TYPE(AD), ECME NUMBER(AECME),
STATUS DATE(AF), ECME NUMBER(AG), FORM TYPE(AH), UB-04 BILL CLASSIFICATION(AI), PRIMARY INSURANCE POLICY(AI11),
SECONDARY INSURANCE CARRIER(AI2), SECONDARY INSURANCE POLICY(AI21), TERTIARY INSURANCE CARRIER(AI3),
TERTIARY INSURANCE POLICY(AI31), FORM TYPE(AJ), LAST ELECTRONIC EXTRACT DATE(ALEX), RESPONSIBLE INSTITUTION(AML),
WHO'S RESPONSIBLE FOR BILL?(AML1), BILL PAYER CARRIER(AML2), STATUS(AOP), OP VISITS DATE(S)(AOPV),
DATE FIRST PRINTED(AP), DATE ENTERED(APD), AUTHORIZATION DATE(APD3), STATEMENT COVERS FROM(APDS),
EVENT DATE(APDT), MRA REQUESTED DATE(APM), PTF ENTRY NUMBER(APTF), OP VISITS DATE(S)(AREV1),
STATEMENT COVERS FROM(AREV2), STATEMENT COVERS TO(AREV3), BILL PAYER CARRIER(AREV4),
RESPONSIBLE INSTITUTION(AREV5), WHO'S RESPONSIBLE FOR BILL?(AREV6), FORM TYPE(AREV7), PROCEDURE(ASC1),
DIVISION(ASC11), PROCEDURE(ASC2), DIVISION(ASC21), PROCEDURES(ASD), PROCEDURE DATE(ASD1), STATUS(AST),
BILL NUMBER(B), PATIENT NAME(C), AUTO PROCESS(CAP), EVENT DATE(D), PRIMARY HPID EDIT DATE/TIME(E),
SECONDARY HPID EDIT DATE/TIME(F), TERTIARY HPID EDIT DATE/TIME(G)
INDEXED BY: DEFAULT DIVISION & NON-VA FACILITY & BILL PAYER POLICY & FORM TYPE (ABP), DENTAL TREATMENT PLAN ENTRY (ADT), PRIMARY
INSURANCE CARRIER & SECONDARY INSURANCE CARRIER & TERTIARY INSURANCE CARRIER & PATIENT NAME (AE), FORM TYPE (AK),
FORM TYPE (AL), BILL CHARGE TYPE (AM), PRIMARY INSURANCE CARRIER & SECONDARY INSURANCE CARRIER & TERTIARY INSURANCE
CARRIER & SECONDARY INSURANCE POLICY & PRIMARY INSURANCE POLICY & TERTIARY INSURANCE POLICY (AUPDID)
^DGCR(399,D0,0)= (#.01) BILL NUMBER [1F] ^ (#.02) PATIENT NAME [2P:2] ^ (#.03) EVENT DATE [3D] ^ (#.04) LOCATION OF CARE [4S] ^
==>(#.05) BILL CLASSIFICATION [5S] ^ (#.06) TIMEFRAME OF BILL [6S] ^ (#.07) RATE TYPE [7P:399.3] ^ (#.08) PTF ENTRY
==>NUMBER [8P:45] ^ (#.09) PROCEDURE CODING METHOD [9S] ^ ^ (#.11) WHO'S RESPONSIBLE FOR BILL? [11S] ^ ^ (#.13)
==>STATUS [13S] ^ (#.14) STATUS DATE [14D] ^ (#.15) BILL COPIED FROM [15P:399] ^ (#.16) NON-VA DISCHARGE DATE [16D]
==>^ (#.17) PRIMARY BILL [17P:399] ^ (#.18) SC AT TIME OF CARE [18F] ^ (#.19) FORM TYPE [19P:353] ^ (#.2) AUTO
==>[20S] ^ (#.21) CURRENT BILL PAYER SEQUENCE [21S] ^ (#.22) DEFAULT DIVISION [22P:40.8] ^ ^ (#.24) UB-04 LOCATION
==>OF CARE [24S] ^ (#.25) UB-04 BILL CLASSIFICATION [25P:399.1] ^ (#.26) UB-04 TIMEFRAME OF BILL [26S] ^ (#.27)
==>BILL CHARGE TYPE [27S] ^ (#.28) INITIAL DATE OF SERVICE [28D] ^
^DGCR(399,D0,C)= (#51) *CPT PROCEDURE CODE (1) [1P:81] ^ (#52) *CPT PROCEDURE CODE (2) [2P:81] ^ (#53) *CPT PROCEDURE CODE (3)
==>[3P:81] ^ (#54) *ICD PROCEDURE CODE (1) [4P:80.1] ^ (#55) *ICD PROCEDURE CODE (2) [5P:80.1] ^ (#56) *ICD
==>PROCEDURE CODE (3) [6P:80.1] ^ (#57) *HCFA PROCEDURE CODE (1) [7P:81] ^ (#58) *HCFA PROCEDURE CODE (2) [8P:81] ^
==>(#59) *HCFA PROCEDURE CODE (3) [9P:81] ^ (#60) OUTPATIENT DIAGNOSIS [10F] ^ (#61) *PROCDEDURE DATE (1) [11D] ^
==>(#62) *PROCEDURE DATE (2) [12D] ^ (#63) *PROCEDURE DATE (3) [13D] ^ ^ (#65) *ICD DIAGNOSIS CODE (2) [15P:80] ^
==>(#66) *ICD DIAGNOSIS CODE (3) [16P:80] ^ (#67) *ICD DIAGNOSIS CODE (4) [17P:80] ^ (#68) *ICD DIAGNOSIS CODE (5)
==>[18P:80] ^
^DGCR(399,D0,CC,0)=^399.04PA^^ (#40) CONDITION CODE
^DGCR(399,D0,CC,D1,0)= (#.01) CONDITION CODE [1P:399.1] ^
^DGCR(399,D0,CP,0)=^399.0304IVA^^ (#304) PROCEDURES
^DGCR(399,D0,CP,D1,0)= (#.01) PROCEDURES [1V] ^ (#1) PROCEDURE DATE [2D] ^ (#2) *ADDITIONAL PROCEDURE NAME [3F] ^ (#3) PRINT
==>ORDER [4N] ^ (#4) BASC BILLABLE [5S] ^ (#5) DIVISION [6P:40.8] ^ (#6) ASSOCIATED CLINIC [7P:44] ^ (#7)
==>*ASSOCIATED DIAGNOSIS [8P:80] ^ (#8) PLACE OF SERVICE [9P:353.1] ^ (#9) TYPE OF SERVICE [10P:353.2] ^
==>(#10) ASSOCIATED DIAGNOSIS (1) [11P:362.3] ^ (#11) ASSOCIATED DIAGNOSIS (2) [12P:362.3] ^ (#12) ASSOCIATED
==>DIAGNOSIS (3) [13P:362.3] ^ (#13) ASSOCIATED DIAGNOSIS (4) [14P:362.3] ^ (#14) *CPT MODIFIER [15P:81.3] ^
==>(#15) MINUTES [16N] ^ (#17) EMERGENCY PROCEDURE? [17S] ^ (#18) PROVIDER [18P:200] ^ (#19) PURCHASED COST
==>[19N] ^ (#20) OUTPATIENT ENCOUNTER [20P:409.68] ^ (#21) MILES [21N] ^ (#22) HOURS [22N] ^
^DGCR(399,D0,CP,D1,1)= (#70) ATTACHMENT CONTROL NUMBER [1F] ^ (#71) ATTACHMENT REPORT TYPE [2P:353.3] ^ (#72) ATTACHMENT REPORT
==>TRANS CODE [3S] ^ (#51) PROCEDURE DESCRIPTION [4F] ^ (#74) ADDITIONAL OB MINUTES [5N] ^ ^ (#53) NDC [7F]
==>^ (#54) UNITS [8N] ^
^DGCR(399,D0,CP,D1,2)= (#52) UNITS/BASIS OF MEASUREMENT [1S] ^ (#92) QUANTITY [2N] ^
^DGCR(399,D0,CP,D1,AUX)= (#50.01) *HCFA BOX 24K (LOCAL USE ONLY) [1F] ^ (#50.02) *LAST XRAY DATE [2D] ^ (#50.03) ATTENDING NOT
==>HOSPICE EMPLOYEE [3S] ^ (#50.04) *LEVEL OF SUBLUXATION [4F] ^ (#50.05) *CHIRO TREATMENT SERIES NUM [5N]
==>^ (#50.06) *CHIROPRACTIC QUANTITY [6N] ^ (#50.07) EPSDT FLAG [7S] ^ (#50.08) SERVICE LINE COMMENT [8F] ^
==>(#50.09) SERVICE LINE COMMENT QUALIFIER [9F] ^
^DGCR(399,D0,CP,D1,CMN)= (#23) CMN REQUIRED? [1S] ^ (#24) CMN FORM TYPE [2P:399.6] ^ (#24.01) CMN CERTIFICATION TYPE [3S] ^
==>(#24.02) CMN PATIENT HEIGHT (IN) [4N] ^ (#24.03) CMN PATIENT WEIGHT (LBS) [5N] ^ (#24.04) CMN MONTHS DME
==>EQUIP NEEDED [6N] ^ (#24.05) CMN DATE THERAPY STARTED [7D] ^ (#24.06) CMN LAST CERTIFICATION DATE [8D] ^
==>(#24.07) CMN RECERTIFICATION/REVISN DT [9D] ^ (#24.08) CMN REPLACEMENT ITEM? [10S] ^
^DGCR(399,D0,CP,D1,CMN-10126)= (#24.201) CMN SM BOWEL ABSORPTION DOC? [1S] ^ (#24.202) CMN ENTERAL NUTRITION BY TUBE? [2S] ^
==>(#24.203) CMN PROCEDURE A CALORIES [3N] ^ (#24.204) CMN PROCEDURE A [4P:81] ^ (#24.205) CMN METHOD
==>OF ADMINISTRATION [5S] ^ (#24.206) CMN DAYS PER WEEK ADMINISTERED [6N] ^ (#24.207) CMN SEVERE
==>MALABSORPTION DOC? [7S] ^ (#24.208) CMN AMINO ACID (ML/DAY) [8N] ^ (#24.209) CMN AMINO ACID
==>CONCENTRATION % [9N] ^ (#24.21) CMN AMINO ACID PROTEIN (GM/DY) [10N] ^ (#24.211) CMN DEXTROSE
==>(ML/DAY) [11N] ^ (#24.212) CMN DEXTROSE CONCENTRATE % [12N] ^ (#24.213) CMN LIPIDS (ML/DAY) [13N]
==>^ (#24.214) CMN ROUTE OF ADMINISTRATION [14S] ^ (#24.215) CMN LIPIDS (DAYS/WEEK) [15N] ^ (#24.216)
==>CMN LIPIDS CONCENTRATE % [16N] ^ (#24.217) CMN PARENTERAL/ENTERAL/BOTH [17S] ^ (#24.218) CMN
==>PROCEDURE B CALORIES [18N] ^ (#24.219) CMN PROCEDURE B [19P:81] ^
^DGCR(399,D0,CP,D1,CMN-484)= ^ (#24.102) CMN O2 SATURATION % [2N] ^ (#24.103) CMN DT LAST ABG PO2 AND O2 SAT [3D] ^ (#24.104)
==>CMN EDEMA DUE TO CHF PRESENT? [4S] ^ (#24.105) CMN COR PULMONARY HYPERTENSN? [5S] ^ (#24.106) CMN
==>HEMATOCRIT > 56%? [6S] ^ (#24.107) CMN PT CONDITION AT TEST TIME [7S] ^ (#24.108) CMN TEST
==>CONDITIONS [8S] ^ (#24.109) CMN PORTABLE O2 INDICATOR [9S] ^ (#24.11) CMN HIGHEST O2 FLOW RATE [10F]
==>^ (#24.111) CMN LAST 4 LPM ABG PO2 (MMHG) [11N] ^ ^ (#24.113) CMN LAST 4 LPM O2 SATURATION % [13N]
==>^ (#24.114) CMN DATE OF LAST 4 LPM TESTS [14D] ^ (#24.115) CMN EQUIPMENT/COST DESCRIPTION [15F] ^
==>(#24.1) CMN ABG PO2 (MMHG) [16N] ^
^DGCR(399,D0,CP,D1,DEN)= (#90.01) ORAL CAVITY DESIGNATION (1) [1S] ^ (#90.02) ORAL CAVITY DESIGNATION (2) [2S] ^ (#90.03) ORAL
==>CAVITY DESIGNATION (3) [3S] ^ (#90.04) ORAL CAVITY DESIGNATION (4) [4S] ^ (#90.05) ORAL CAVITY
==>DESIGNATION (5) [5S] ^ (#90.06) PROSTHESIS/CROWN/INLAY CODE [6S] ^ (#90.07) PRIOR PLACEMENT DATE
==>QUALIFIER [7S] ^ (#90.08) PRIOR PLACEMENT DATE [8D] ^ (#90.09) ORTHODONTIC BANDING DATE [9D] ^ (#90.1)
==>ORTHO BANDING REPLACEMENT DATE [10D] ^ (#90.11) TREATMENT START DATE [11D] ^ (#90.12) TREATMENT
==>COMPLETION DATE [12D] ^
^DGCR(399,D0,CP,D1,DEN1,0)=^399.30491PA^^ (#91) TOOTH INFORMATION
^DGCR(399,D0,CP,D1,DEN1,D2,0)= (#.01) TOOTH CODE [1P:356.022] ^ (#.02) TOOTH SURFACE (1) [2S] ^ (#.03) TOOTH SURFACE (2) [3S] ^
==>(#.04) TOOTH SURFACE (3) [4S] ^ (#.05) TOOTH SURFACE (4) [5S] ^ (#.06) TOOTH SURFACE (5) [6S] ^
==>(#.07) DENTAL TREATMENT PLAN ENTRY [7N] ^
^DGCR(399,D0,CP,D1,LNPRV,0)=^399.0404IS^^ (#60) LINE PROVIDER
^DGCR(399,D0,CP,D1,LNPRV,D2,0)= (#.01) LINE FUNCTION [1S] ^ (#.02) LINE PERFORMED BY [2V] ^ (#.03) CREDENTIALS [3F] ^ (#.04)
==>STATE [4P:5] ^ (#.05) PRIMARY INS CO ID NUMBER [5F] ^ (#.06) SECONDARY INS CO ID NUMBER [6F] ^
==>(#.07) TERTIARY INS CO ID NUMBER [7F] ^ (#.08) SPECIALTY [8F] ^ ^ ^ ^ (#.12) PRIM INS PROVIDER
==>ID TYPE [12P:355.97] ^ (#.13) SEC INS PROVIDER ID TYPE [13P:355.97] ^ (#.14) TERT INS PROVIDER ID
==>TYPE [14P:355.97] ^ (#.15) LINE TAXONOMY [15P:8932.1] ^
^DGCR(399,D0,CP,D1,MOD,0)=^399.30416IA^^ (#16) CPT MODIFIER SEQUENCE
^DGCR(399,D0,CP,D1,MOD,D2,0)= (#.01) CPT MODIFIER SEQUENCE [1N] ^ (#.02) CPT MODIFIER [2P:81.3] ^
^DGCR(399,D0,CV,0)=^399.047PA^^ (#47) VALUE CODE
^DGCR(399,D0,CV,D1,0)= (#.01) VALUE CODE [1P:399.1] ^ (#.02) VALUE [2F] ^
^DGCR(399,D0,D1,0)=^399.044PA^^ (#44) REASON(S) DISAPPROVED-INITIAL
^DGCR(399,D0,D1,D1,0)= (#.01) REASON(S) DISAPPROVED-INITIAL [1P:399.4] ^
^DGCR(399,D0,D2,0)=^399.045PA^^ (#45) REASON(S) DISAPPROVED-SECOND
^DGCR(399,D0,D2,D1,0)= (#.01) REASON(S) DISAPPROVED-SECOND [1P:399.4] ^
^DGCR(399,D0,DEN)= (#92) BANDING DATE [1D] ^ (#93) TREATMENT MONTHS COUNT [2N] ^ (#94) TREATMENT MONTHS REMAINING [3N] ^ (#95)
==>TREATMENT INDICATOR [4S] ^
^DGCR(399,D0,DEN1,0)=^399.096IA^^ (#96) TOOTH NUMBER
^DGCR(399,D0,DEN1,D1,0)= (#.01) TOOTH NUMBER [1N] ^ (#.02) STATUS CODE [2S] ^
^DGCR(399,D0,DEN2)= (#97) DENTAL CLAIM NOTE [1F] ^
^DGCR(399,D0,I1)= (#301) PRIMARY NODE [E1,240F] ^
^DGCR(399,D0,I17)= (#371) PRIMARY NODE 7 [E1,240F] ^
^DGCR(399,D0,I2)= (#302) SECONDARY NODE [E1,240F] ^
^DGCR(399,D0,I27)= (#372) SECONDARY NODE 7 [E1,240F] ^
^DGCR(399,D0,I3)= (#303) TERTIARY NODE [E1,240F] ^
^DGCR(399,D0,I37)= (#373) TERTIARY NODE 7 [E1,240F] ^
^DGCR(399,D0,M)= (#101) PRIMARY INSURANCE CARRIER [1P:36] ^ (#102) SECONDARY INSURANCE CARRIER [2P:36] ^ (#103) TERTIARY
==>INSURANCE CARRIER [3P:36] ^ (#104) MAILING ADDRESS NAME [4F] ^ (#105) MAILING ADDRESS STREET [5F] ^ (#106)
==>MAILING ADDRESS STREET2 [6F] ^ (#107) MAILING ADDRESS CITY [7F] ^ (#108) MAILING ADDRESS STATE [8P:5] ^ (#109)
==>MAILING ADDRESS ZIP CODE [9F] ^ (#110) *PATIENT SHORT MAILING ADDRESS [10F] ^ (#111) RESPONSIBLE INSTITUTION
==>[11P:4] ^ (#112) PRIMARY INSURANCE POLICY [12F] ^ (#113) SECONDARY INSURANCE POLICY [13F] ^ (#114) TERTIARY
==>INSURANCE POLICY [14F] ^
^DGCR(399,D0,M1)= (#121) MAILING ADDRESS STREET3 [1F] ^ (#122) PRIMARY PROVIDER # [2F] ^ (#123) SECONDARY PROVIDER # [3F] ^
==>(#124) TERTIARY PROVIDER # [4F] ^ (#125) PRIMARY BILL # [5P:399] ^ (#126) SECONDARY BILL # [6P:399] ^ (#127)
==>TERTIARY BILL # [7P:399] ^ (#460) ECME NUMBER [8F] ^ (#461) ECME APPROVAL [9F] ^ (#128) PRIMARY ID QUALIFIER
==>[10P:355.97] ^ (#129) SECONDARY ID QUALIFIER [11P:355.97] ^ (#130) TERTIARY ID QUALIFIER [12P:355.97] ^ (#471)
==>PRIMARY INSURANCE HPID [13N] ^ (#472) SECONDARY INSURANCE HPID [14N] ^ (#473) TERTIARY INSURANCE HPID [15N] ^
^DGCR(399,D0,M2)= (#140) PRIMARY PAYER-ALT ID TYPE [1P:355.98] ^ (#141) PRIMARY PAYER-ALT ID [2F] ^ (#142) SECONDARY PAYER-ALT ID
==>TYPE [3P:355.98] ^ (#143) SECONDARY PAYER-ALT ID [4F] ^ (#144) TERTIARY PAYER-ALT ID TYPE [5P:355.98] ^ (#145)
==>TERTIARY PAYER-ALT ID [6F] ^
^DGCR(399,D0,MP)= (#135) BILL PAYER CARRIER [1P:36] ^ (#136) BILL PAYER POLICY [2F] ^ (#474) PRIMARY HPID EDIT DATE/TIME [3D] ^
==>(#475) PRIMARY HPID CHANGES MADE BY [4P:200] ^ (#476) SECONDARY HPID EDIT DATE/TIME [5D] ^ (#477) SECONDARY
==>HPID CHANGES MADE BY [6P:200] ^ (#478) TERTIARY HPID EDIT DATE/TIME [7D] ^ (#479) TERTIARY HPID CHANGES MADE BY
==>[8P:200] ^
^DGCR(399,D0,OC,0)=^399.041IPA^^ (#41) OCCURRENCE CODE
^DGCR(399,D0,OC,D1,0)= (#.01) OCCURRENCE CODE [1P:399.1] ^ (#.02) DATE [2D] ^ (#.03) STATE [3P:5] ^ (#.04) END DATE [4D] ^
^DGCR(399,D0,OP,0)=^399.043DA^^ (#43) OP VISITS DATE(S)
^DGCR(399,D0,OP,D1,0)= (#.01) OP VISITS DATE(S) [1D] ^
^DGCR(399,D0,OT,0)=^399.048P^^ (#48) OTHER CARE
^DGCR(399,D0,OT,D1,0)= (#.01) OTHER CARE [1P:399.1] ^ (#.02) START DATE [2D] ^ (#.03) END DATE [3D] ^
^DGCR(399,D0,PRV,0)=^399.0222ISA^^ (#222) PROVIDER
^DGCR(399,D0,PRV,D1,0)= (#.01) FUNCTION [1S] ^ (#.02) PERFORMED BY [2V] ^ (#.03) CREDENTIALS [3F] ^ (#.04) STATE [4P:5] ^ (#.05)
==>PRIMARY INS CO ID NUMBER [5F] ^ (#.06) SECONDARY INS CO ID NUMBER [6F] ^ (#.07) TERTIARY INS CO ID NUMBER
==>[7F] ^ (#.08) SPECIALTY [8F] ^ (#.09) DELETE 2006 .09 [9P:355.96] ^ (#.1) DELETE 2006 .1 [10P:355.96] ^
==>(#.11) DELETE 2006 .11 [11P:355.96] ^ (#.12) PRIM INS PROVIDER ID TYPE [12P:355.97] ^ (#.13) SEC INS
==>PROVIDER ID TYPE [13P:355.97] ^ (#.14) TERT INS PROVIDER ID TYPE [14P:355.97] ^ (#.15) TAXONOMY
==>[15P:8932.1] ^
^DGCR(399,D0,PRV,D1,1)= (#1.01) DELETE 2006 1.01 [1P:355.96] ^ (#1.02) DELETE 2006 1.02 [2P:355.96] ^ (#1.03) DELETE 2006 1.03
==>[3P:355.96] ^
^DGCR(399,D0,R,0)=^399.046DA^^ (#46) RETURNED LOG DATE/TIME
^DGCR(399,D0,R,D1,0)= (#.01) LOG DATE/TIME [1D] ^ (#.02) USER [2P:200] ^ (#.03) RETURNED COMMENTS [3F] ^ (#.04) RETURN TO A/R?
==>[4F] ^
^DGCR(399,D0,RC,0)=^399.042IPA^^ (#42) REVENUE CODE
^DGCR(399,D0,RC,D1,0)= (#.01) REVENUE CODE [1P:399.2] ^ (#.02) CHARGES [2N] ^ (#.03) UNITS OF SERVICE [3N] ^ (#.04) TOTAL [4N] ^
==>(#.05) BEDSECTION [5P:399.1] ^ (#.06) PROCEDURE [6P:81] ^ (#.07) DIVISION [7P:40.8] ^ (#.08) AUTO [8S] ^
==>(#.09) NON-COVERED CHARGE [9N] ^ (#.1) TYPE [10S] ^ (#.11) ITEM [11N] ^ (#.12) COMPONENT [12S] ^ (#.13)
==>*UB92 FORM LOCATOR 49 [13F] ^ ^ (#.15) RX PROCEDURE [15F] ^ (#.16) MANUALLY EDITED [16S] ^
^DGCR(399,D0,S)= (#1) DATE ENTERED [1D] ^ (#2) ENTERED/EDITED BY [2P:200] ^ (#3) INITIAL REVIEW [3F] ^ (#4) INITIAL REVIEW DATE
==>[4D] ^ (#5) INITIAL REVIEWER [5P:200] ^ (#6) SECONDARY REVIEW [6F] ^ (#7) MRA REQUESTED DATE [7D] ^ (#8) MRA
==>REQUESTOR [8P:200] ^ (#9) AUTHORIZE BILL GENERATION? [9F] ^ (#10) AUTHORIZATION DATE [10D] ^ (#11) AUTHORIZER
==>[11P:200] ^ (#12) DATE FIRST PRINTED [12D] ^ (#13) FIRST PRINTED BY [13P:200] ^ (#14) DATE LAST PRINTED [14D] ^
==>(#15) LAST PRINTED BY [15P:200] ^ (#16) CANCEL BILL? [16F] ^ (#17) DATE BILL CANCELLED [17D] ^ (#18) BILL
==>CANCELLED BY [18P:200] ^ (#19) REASON CANCELLED [19F] ^ (#23) IS DUPLICATE? [20S] ^
^DGCR(399,D0,S1)= (#29) BILL CLONED TO [1P:399] ^ (#30) BILL CLONED FROM [2P:399] ^ (#31) DATE BILL CLONED [3D] ^ (#32) BILL
==>CLONED BY [4P:200] ^ (#33) REASON CLONED [5F] ^ (#34) AUTO PROCESSED FROM CLAIM [6P:399] ^ (#35) AUTO PROCESS
==>[7S] ^ (#36) AUTO PROCESS REASON [8P:350.8] ^ (#37) REMOVED FROM WORKLIST BY [9P:200] ^ (#37.1) ON TAS PCR?
==>[10S] ^
^DGCR(399,D0,TX)= (#20) LAST AUSTIN CONFIRM DATE [1D] ^ (#21) LAST ELECTRONIC EXTRACT DATE [2D] ^ (#22) MRA RECORDED DATE [3D] ^
==>^ (#24) CLAIM MRA STATUS [5S] ^ (#25) REQUEST AN MRA? [6F] ^ (#26) PRINTED VIA EDI? [7S] ^ (#27) FORCE CLAIM TO
==>PRINT [8S] ^ (#28) FORCE PRINT MRA SECONDARY [9S] ^ (#28.1) MRA REVIEW STATUS [10S] ^
^DGCR(399,D0,TXC,0)=^399.077DA^^ (#77) MRA REQUEST CLAIM COMMENTS
^DGCR(399,D0,TXC,D1,0)= (#.01) COMMENT ENTERED DATE [1D] ^ (#.02) COMMENT ENTERED BY [2P:200] ^
^DGCR(399,D0,TXC,D1,1,0)=^399.0771^^ (#.03) COMMENTS
^DGCR(399,D0,TXC,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^DGCR(399,D0,TXC2,0)=^399.078DA^^ (#78) EOB CLAIM COMMENTS
^DGCR(399,D0,TXC2,D1,0)= (#.01) EOB CLAIM COMMENTS [1D] ^ (#.02) COMMENT ENTERED BY [2P:200] ^
^DGCR(399,D0,TXC2,D1,1,0)=^399.0781^^ (#.03) COMMENTS
^DGCR(399,D0,TXC2,D1,1,D2,0)= (#.01) COMMENTS [1W] ^
^DGCR(399,D0,U)= (#151) STATEMENT COVERS FROM [1D] ^ (#152) STATEMENT COVERS TO [2D] ^ (#153) POWER OF ATTORNEY COMPLETED? [3F] ^
==>(#154) WHOSE EMPLOYMENT INFO.? [4S] ^ (#155) IS THIS A SENSITIVE RECORD? [5F] ^ (#156) ASSIGNMENT OF BENEFITS
==>[6F] ^ (#157) R.O.I. FORM(S) COMPLETED? [7F] ^ (#158) TYPE OF ADMISSION [8S] ^ (#159) SOURCE OF ADMISSION [9S] ^
==>(#160) ACCIDENT HOUR [10F] ^ (#161) DISCHARGE BEDSECTION [11P:399.1] ^ (#162) DISCHARGE STATUS [12P:399.1] ^
==>(#163) TREATMENT AUTHORIZATION CODE [13F] ^ (#164) BC/BS PROVIDER # [14F] ^ (#165) LENGTH OF STAY [15F] ^ (#166)
==>UNABLE TO WORK FROM [16D] ^ (#167) UNABLE TO WORK TO [17D] ^ (#168) *PLACE OF SERVICE [18P:353.1] ^ (#169) *TYPE
==>OF SERVICE [19P:353.2] ^ (#159.5) NON-PTF ADMISSION HOUR [20F] ^
^DGCR(399,D0,U1)= (#201) TOTAL CHARGES [1N] ^ (#202) OFFSET AMOUNT [2N] ^ (#203) OFFSET DESCRIPTION [3F] ^ (#204) *UB82 FORM
==>LOCATOR 2 [4F] ^ (#205) *FORM LOCATOR 9 [5F] ^ (#206) *FORM LOCATOR 27 [6F] ^ (#207) *FORM LOCATOR 45 [7F] ^
==>(#208) *BILL COMMENT [8F] ^ (#209) *FISCAL YEAR 1 [9F] ^ (#210) *FY 1 CHARGES [10N] ^ (#211) *FISCAL YEAR 2
==>[11F] ^ (#212) *FY 2 CHARGES [12N] ^ (#213) *FORM LOCATOR 92 [13F] ^ (#214) *FORM LOCATOR 93 [14F] ^ (#170) PPS
==>[15P:80.2] ^
^DGCR(399,D0,U2)= (#215) ADMITTING DIAGNOSIS [1P:80] ^ (#216) COVERED DAYS [2N] ^ (#217) NON-COVERED DAYS [3N] ^ (#218) PRIMARY
==>PRIOR PAYMENT [4N] ^ (#219) SECONDARY PRIOR PAYMENT [5N] ^ (#220) TERTIARY PRIOR PAYMENT [6N] ^ (#221)
==>CO-INSURANCE DAYS [7N] ^ (#230) SECONDARY AUTHORIZATION CODE [8F] ^ (#231) TERTIARY AUTHORIZATION CODE [9F] ^
==>(#232) NON-VA FACILITY [10P:355.93] ^ (#233) NON-VA CARE TYPE [11S] ^ (#234) NON-VA CARE ID # [12F] ^ (#235)
==>LAB CLIA NUMBER [13F] ^ (#236) HOMEBOUND [14S] ^ (#237) DATE LAST SEEN [15D] ^ (#238) SPECIAL PROGRAM INDICATOR
==>[16S] ^ (#239) PRIMARY EMC ID CARE UNIT [17F] ^ (#240) SECONDARY EMC ID CARE UNIT [18F] ^ (#241) TERTIARY EMC
==>ID CARE UNIT [19F] ^
^DGCR(399,D0,U3)= (#242) MAMMOGRAPHY CERT NUMBER [1F] ^ (#243) SERVICE FACILITY TAXONOMY [2P:8932.1] ^ (#244) NON-VA FACILITY
==>TAXONOMY [3P:8932.1] ^ (#245) LAST XRAY DATE [4D] ^ (#246) DATE OF INITIAL TREATMENT [5D] ^ (#247) DATE OF
==>ACUTE MANIFESTATION [6D] ^ (#248) PATIENT CONDITION CODE [7S] ^ (#249) PRV DIAGNOSIS (1) [8P:80] ^ (#250) PRV
==>DIAGNOSIS (2) [9P:80] ^ (#251) PRV DIAGNOSIS (3) [10P:80] ^ (#252) BILLING PROVIDER TAXONOMY [11P:8932.1] ^
^DGCR(399,D0,U4)= (#260) COB TOTAL NON-COVERED AMOUNT [1N] ^ (#261) PROPERTY/CASUALTY CLAIM NUMBER [2F] ^ (#262) PROP/CAS DATE OF
==>1ST CONTACT [3D] ^ (#263) DISABILITY START DATE [4D] ^ (#264) DISABILITY END DATE [5D] ^ ^ (#266) PRIMARY
==>SURGICAL PROC CODE [7P:81] ^ (#267) SECONDARY SURGICAL PROC CODE [8P:81] ^ (#268) PROPERTY/CASUALTY CONTACT
==>NAME [9F] ^ (#269) PROP/CAS COMMUNICATION NUMBER [10N] ^ (#269.1) PROP/CAS EXTENSION NUMBER [11N] ^ ^ (#282)
==>ASSUMED CARE DATE [13D] ^ (#283) RELINQUISHED CARE DATE [14D] ^
^DGCR(399,D0,U5)= ^ (#271) AMBULANCE P/U ADDRESS 1 [2F] ^ (#272) AMBULANCE P/U ADDRESS 2 [3F] ^ (#273) AMBULANCE P/U CITY [4F] ^
==>(#274) AMBULANCE P/U STATE [5P:5] ^ (#275) AMBULANCE P/U ZIP [6F] ^
^DGCR(399,D0,U6)= (#276) AMBULANCE D/O LOCATION [1F] ^ (#277) AMBULANCE D/O ADDRESS 1 [2F] ^ (#278) AMBULANCE D/O ADDRESS 2 [3F]
==>^ (#279) AMBULANCE D/O CITY [4F] ^ (#280) AMBULANCE D/O STATE [5P:5] ^ (#281) AMBULANCE D/O ZIP [6F] ^
^DGCR(399,D0,U7)= (#287) PATIENT WEIGHT (LB) [1N] ^ (#288) TRANSPORT REASON CODE [2P:353.4] ^ (#289) AMBULANCE TRANSPORT DISTANCE
==>[3N] ^ (#290) ROUND TRIP PURPOSE DESCRIPTION [4F] ^ (#291) STRETCHER PURPOSE DESCRIPTION [5F] ^
^DGCR(399,D0,U8)= (#284) ATTACHMENT CONTROL NUMBER [1F] ^ (#285) ATTACHMENT REPORT TYPE [2P:353.3] ^ (#286) ATTACHMENT REPORT
==>TRANS CODE [3S] ^
^DGCR(399,D0,U9,0)=^399.0292PA^^ (#292) AMBULANCE CONDITION INDICATOR
^DGCR(399,D0,U9,D1,0)= (#.01) AMBULANCE CONDITION INDICATOR [1P:353.5] ^
^DGCR(399,D0,UF2)= (#400) BLOCK 31 [1F] ^ ^ (#402) BILL REMARKS [3F] ^
^DGCR(399,D0,UF3)= ^ ^ ^ (#453) FORM LOCATOR 64A [4F] ^ (#454) FORM LOCATOR 64B [5F] ^ (#455) FORM LOCATOR 64C [6F] ^
^DGCR(399,D0,UF31)= (#457) *FORM LOCATOR 57 [1F] ^ (#458) *FORM LOCATOR 78 [2F] ^ (#459) FORM LOC 19-UNSPECIFIED DATA [3F] ^
^DGCR(399,D0,UF32)= (#253) PRIMARY REFERRAL NUMBER [1F] ^ (#254) SECONDARY REFERRAL NUMBER [2F] ^ (#255) TERTIARY REFERRAL NUMBER
==>[3F] ^ (#38) REMOVED FROM WORKLIST HOW [4S] ^ (#39) REMOVED FROM WORKLIST DATE [5D] ^
INPUT TEMPLATE(S):
^DIE(499)= IB MAIL
^DIE(502)= IB REVCODE EDIT
^DIE(508)= IB SCREEN1 Compiled: ^IBXS1
^DIE(1752)= IB SCREEN10 Compiled: ^IBXSA
^DIE(1753)= IB SCREEN102 Compiled: ^IBXSA2
^DIE(1754)= IB SCREEN10H Compiled: ^IBXSAH
^DIE(509)= IB SCREEN2 Compiled: ^IBXS2
^DIE(574)= IB SCREEN3 Compiled: ^IBXS3
^DIE(510)= IB SCREEN4 Compiled: ^IBXS4
^DIE(511)= IB SCREEN5 Compiled: ^IBXS5
^DIE(512)= IB SCREEN6 Compiled: ^IBXS6
^DIE(513)= IB SCREEN7 Compiled: ^IBXS7
^DIE(514)= IB SCREEN8 Compiled: ^IBXS8
^DIE(1755)= IB SCREEN9 Compiled: ^IBXS9
^DIE(506)= IB STATUS Compiled: ^IBXST
PRINT TEMPLATE(S):
^DIPT(241)= IB CLK PROD
^DIPT(1060)= IB CLK PROD HDR
SORT TEMPLATE(S):
^DIBT(124)= IB CLK PROD
FORM(S)/BLOCK(S):