STANDARD DATA DICTIONARY #356.22 -- HCS REVIEW TRANSMISSION FILE 3/24/25 PAGE 1
STORED IN ^IBT(356.22, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains information related to Healthcare Services Review worklist and corresponding HL7 messages (message type 278).
DD ACCESS: @
RD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
POINTED TO BY: INQUIRY field (#.13) of the HCS REVIEW TRANSMISSION File (#356.22)
RESPONSE field (#.14) of the HCS REVIEW TRANSMISSION File (#356.22)
CROSS
REFERENCED BY: TRANSMISSION DATE/TIME(AC), DATE ENTERED(B), MESSAGE CONTROL ID(C), DATE MANUALLY REMOVED(F)
INDEXED BY: STATUS & DATE ENTERED (AD), PATIENT & EVENT DATE (D), INPATIENT / OUTPATIENT & INSURANCE POLICY & SOURCE & PATIENT
(E)
LAST MODIFIED: SEP 2,2016@13:49:11
356.22,.01 DATE ENTERED 0;1 DATE (Required)
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date and time, no range limit on date.
DESCRIPTION:
The date and time of when the entry was added to the file.
CROSS-REFERENCE: 356.22^B
1)= S ^IBT(356.22,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,"B",$E(X,1,30),DA)
RECORD INDEXES: AD (#459)
356.22,.02 PATIENT 0;2 POINTER TO PATIENT FILE (#2)
LAST EDITED: JAN 05, 2015
HELP-PROMPT: Enter a valid Patient.
DESCRIPTION:
The Patient of this transmission entry.
RECORD INDEXES: D (#470), E (#1215)
356.22,.03 INSURANCE POLICY 0;3 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>9999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 9999999, 0 decimal digits.
DESCRIPTION: This field contains the IEN of the PATIENT INSURANCE multiple (file 2, sub-file .312) this entry is
for.
RECORD INDEXES: E (#1215)
356.22,.04 INPATIENT / OUTPATIENT 0;4 SET
'I' FOR INPATIENT;
'O' FOR OUTPATIENT;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Patient Status.
DESCRIPTION:
The status of the patient - inpatient or outpatient.
RECORD INDEXES: E (#1215)
356.22,.05 WARD 0;5 POINTER TO WARD LOCATION FILE (#42)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ward location.
DESCRIPTION:
The Ward location for inpatients, null for outpatients.
356.22,.06 CLINIC 0;6 POINTER TO HOSPITAL LOCATION FILE (#44)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Clinic.
DESCRIPTION:
The Clinic for outpatients, null for inpatients.
356.22,.07 EVENT DATE 0;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>17!($L(X)<1) X
LAST EDITED: JUL 01, 2014
HELP-PROMPT: Answer must be 1-17 characters in length.
DESCRIPTION: Date of the event for this entry. Contains admission date/time (internal FM format) for inpatients
or appointment date/time (internal FM format) for outpatients. Can contain date range in [internal
FM date/time]-[internal FM date/time] format.
RECORD INDEXES: D (#470)
356.22,.08 STATUS 0;8 SET
'01' FOR IN PROGRESS;
'02' FOR AWAITING RESPONSE;
'03' FOR UNABLE TO SEND;
'04' FOR NEGATIVE RESPONSE RECEIVED;
'05' FOR POSITIVE RESPONSE RECEIVED;
'06' FOR MANUALLY REMOVED;
'07' FOR PENDING RESPONSE RECEIVED;
'08' FOR FLAGGED FOR NEXT REVIEW;
'0' FOR INITIAL ENTRY;
'09' FOR 215 INQ SENT;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Status Code.
DESCRIPTION:
The code describing current status of the entry.
RECORD INDEXES: AD (#459)
356.22,.09 MARKED 'IN PROGRESS' BY 0;9 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid user.
DESCRIPTION:
The User who marked this entry as "in progress".
356.22,.1 DATE MARKED 'IN PROGRESS' 0;10 DATE
INPUT TRANSFORM: S %DT="ESTR" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 07, 2015
HELP-PROMPT: Enter a valid date and time, no range limit on date.
DESCRIPTION:
The Date/time this entry was marked as 'in progress'.
356.22,.11 REQUESTED BY 0;11 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid User.
DESCRIPTION:
The name of the person who will be the Contact for any UMO questions.
356.22,.12 MESSAGE CONTROL ID 0;12 FREE TEXT
INPUT TRANSFORM: K:$L(X)>20!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-20 characters in length.
DESCRIPTION: This is the HL7 message control number that is generated at the time the HL7 message is created and
placed in the outgoing HL7 message queue.
CROSS-REFERENCE: 356.22^C
1)= S ^IBT(356.22,"C",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,"C",$E(X,1,30),DA)
3)= This index is used to link the response message to the original request or inquiry.
This cross reference is used to link the response messages with the corresponding request/inquiry
messages.
356.22,.13 INQUIRY 0;13 POINTER TO HCS REVIEW TRANSMISSION FILE (#356.22)
LAST EDITED: MAY 05, 2014
HELP-PROMPT: Select the inquiry this response corresponds to.
DESCRIPTION: This field contains the pointer to the 278 inquiry this response corresponds to. If this entry is
an inquiry, this field should be blank.
356.22,.14 RESPONSE 0;14 POINTER TO HCS REVIEW TRANSMISSION FILE (#356.22)
LAST EDITED: MAY 05, 2014
HELP-PROMPT: Select the response for this inquiry.
DESCRIPTION:
This field contains the pointer to the 278 response for this inquiry.
356.22,.15 TRANSMISSION DATE/TIME 0;15 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date and time, no range on date.
DESCRIPTION: This is the date and time response was received (if this entry is a response) or inquiry was sent
out (if this entry is an inquiry).
CROSS-REFERENCE: 356.22^AC
1)= S ^IBT(356.22,"AC",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,"AC",$E(X,1,30),DA)
Used to find HCS REVIEW TRANSMISSION entries by the date/time they were transmitted.
356.22,.16 SOURCE 0;16 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 30, 2014
HELP-PROMPT: Enter the date/time of the entry's associated appointment or the date of the entry's associated
admission.
DESCRIPTION: If the source of the event is an appointment, this is internal FileMan date/time of the
appointment. If the source of the event is an admission, this is the internal FileMan date of the
admission.
RECORD INDEXES: E (#1215)
356.22,.17 TICKLER 0;17 FREE TEXT
INPUT TRANSFORM: K:$L(X)>12!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'D' to delay review until time of discharge or enter a valid date.
DESCRIPTION: A value of 'D' will prevent this entry from being shown on the HCSR worklist until the admission
related to the entry has been discharged. The 'D' option is only valid for entries with an
Input/Output value of 'I'. Otherwise this is an internal FileMan date and the entry will begin to
appear on the worklist on this date.
356.22,.18 FROM RESPONSE 0;18 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>1)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 18, 2014
HELP-PROMPT: Enter 1 if the entry was created from the Response Worklist.
DESCRIPTION:
If the entry was created from the Response Worklist, the value of this field is 1.
356.22,.19 215 TRIGGERED 0;19 SET
'0' FOR NO;
'1' FOR YES;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 1 if a 215 transaction has been generated for this entry or 0 otherwise.
DESCRIPTION: A flag that determines if a 278X215 Inquiry transaction has been generated for this entry. This 215
version of the 278 transaction could have been generated manually or via the auto-trigger
controlled by the IB SITE PARAMETERS definition for auto trigger of 215 for appointments or
admissions.
356.22,.2 TRANSACTION TYPE 0;20 SET
'0' FOR X12 217 TRANSACTION;
'1' FOR X12 215 TRANSACTION;
'2' FOR X12 RESPONSE MESSAGE;
LAST EDITED: DEC 18, 2014
HELP-PROMPT: Enter 0 if the entry is a 217 transaction, 1 if the entry is a 215 transaction or 2 if the entry is
an X12 Response.
DESCRIPTION: This field value identifies the entry as either an X12 278X217 transaction, or an X12 278X215
transaction, or an X12 278 response.
356.22,.21 RESPONSE STATUS 0;21 SET
'0' FOR Not In-Progress;
'1' FOR In Progress;
LAST EDITED: DEC 18, 2014
HELP-PROMPT: Enter 1 to Mark the Response Entry as In progress or 0 to remove the In Progress mark.
DESCRIPTION: This field is set to 1 when a user marks the Response on the Response Worklist as In-Progress. It
is set to 0 when a user removes the In-Progress mark.
356.22,.22 DELETED RESPONSE 0;22 SET
'1' FOR DELETED;
LAST EDITED: FEB 18, 2015
HELP-PROMPT: Enter 1 to manually remove this response from the Response Worklist.
DESCRIPTION: Determines if a response entry was manually removed from the Response Worklist and should not be
displayed.
356.22,.23 DATE MANUALLY REMOVED 0;23 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: OCT 29, 2015
HELP-PROMPT: Enter the date/time the entry was manually removed (No range limit on date).
DESCRIPTION: The timestamp of when an entry was manually removed from the worklist. A manually removed entry
will no longer appear on the HCSR Worklist or the HCSR Response Worklist.
CROSS-REFERENCE: 356.22^F
1)= S ^IBT(356.22,"F",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,"F",$E(X,1,30),DA)
This cross reference will be used for the generation of the 278 Deletion Disposition Report.
356.22,.24 MANUALLY REMOVED BY 0;24 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: FEB 18, 2015
HELP-PROMPT: Enter a valid user.
DESCRIPTION:
The user who manually removed an entry from the HCSR Worklist or the HCSR Response Worklist.
356.22,.25 DELETE REASON 0;25 POINTER TO HCSR WORKLIST DELETE REASON CODE FILE (#356.023)
LAST EDITED: MAY 15, 2015
HELP-PROMPT: Enter one of the Delete Reason Codes on file.
DESCRIPTION: The Delete Reason Code is the reason for which the 278 request or inquiry was removed from the HCSR
Worklist.
356.22,.26 MANUAL 215 0;26 SET
'0' FOR NOT A MANUAL 215;
'1' FOR MANUAL 215;
LAST EDITED: SEP 21, 2015
HELP-PROMPT: Set value to 0 for 'non-manual' 278x215 or 1 for 'manual' 278x215 generation.
DESCRIPTION:
This flag is set automatically when a 278x215 Authorization Inquiry is generated manually.
356.22,.27 REQ FROM RESP 0;27 SET
'0' FOR NO REQUEST CREATED FROM RESPONSE;
'1' FOR REQUEST CREATED FROM THIS RESPONSE;
LAST EDITED: DEC 09, 2015
HELP-PROMPT: Select 1 if this 278 Response message has had a 278 Request generated from it. Otherwise, enter 0
to indicate no 278 Request message has been generated from this 278 Response message.
DESCRIPTION: This field indicates whether a request message was created from this response message. This is
required in order to prevent duplicate requests being generated from one response message.
356.22,1 COMMENTS 1;0 DATE Multiple #356.221 (Add New Entry without Asking)
DESCRIPTION:
User comments for this entry.
356.221,.01 DATE ENTERED 0;1 DATE
INPUT TRANSFORM: S %DT="ESTXR" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 07, 2015
HELP-PROMPT: Enter the date and time this comment was added, no range limit on date.
DESCRIPTION:
Date/time this comment was entered.
CROSS-REFERENCE: 356.221^B
1)= S ^IBT(356.22,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),1,"B",$E(X,1,30),DA)
356.221,.02 ENTERED BY 0;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: MAR 22, 2014
HELP-PROMPT: Select a user.
DESCRIPTION:
This field is the user who entered this comment.
356.221,.03 COMMENT 1;0 WORD-PROCESSING #356.231 (IGNORE "|")
DESCRIPTION:
Enter up to 250 characters of additional information related to this request.
LAST EDITED: MAR 22, 2014
HELP-PROMPT: Enter the comment text.
DESCRIPTION:
Comment text.
356.22,2.01 REQUEST CATEGORY 2;1 POINTER TO X12 278 REQUEST CATEGORY FILE (#356.001)
INPUT TRANSFORM: S DIC("S")="I $$REQCAT^IBTRH5C()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: REQUEST CATEGORY:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Request Type for this Patient Event review.
DESCRIPTION: The Request Type for this Patient Event review that is being submitted for approval (e.g. Admission
Review, Health Services Review, Individual or Specialty Care Review).
SCREEN: S DIC("S")="I $$REQCAT^IBTRH5C()"
EXPLANATION: Only allows Request Category that are valid for the status of the entry.
356.22,2.02 CERTIFICATION TYPE CODE 2;2 POINTER TO X12 278 CERTIFICATION TYPE CODE FILE (#356.002)
INPUT TRANSFORM: S DIC("S")="I $$CERTCD^IBTRH5C()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: CERTIFICATION TYPE CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Certification Type Code.
DESCRIPTION:
This is Certification Type of the HCSR Transmission entry.
SCREEN: S DIC("S")="I $$CERTCD^IBTRH5C()"
EXPLANATION: If a 278 Request is being created from a Response, 'I' is not a valid selection.
356.22,2.03 SERVICE TYPE CODE 2;3 POINTER TO X12 271 SERVICE TYPE FILE (#365.013)
INPUT TRANSFORM: S DIC("S")="I $$SVCTYPE^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: SERVICE TYPE CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Type.
DESCRIPTION:
The Service Type field is REQUIRED unless you plan to enter Service Detail information.
SCREEN: S DIC("S")="I $$SVCTYPE^IBTRH5I()"
EXPLANATION: Select a valid Service Type
356.22,2.04 FACILITY TYPE QUALIFIER 2;4 SET
'A' FOR Uniform Billing Claim Form Bill Type;
'B' FOR Place of Service Codes for Professional or Dental Services;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Location Qualifier code.
DESCRIPTION: The Service Location Qualifier field is REQUIRED unless you plan to enter Service Detail
information.
356.22,2.05 FACILITY TYPE 2;5 POINTER TO PLACE OF SERVICE FILE (#353.1)
OUTPUT TRANSFORM: FACILITY TYPE:NAME
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Location.
DESCRIPTION:
Select the Service Location where this patient event will be performed.
356.22,2.06 LOCATION OF CARE 2;6 SET
'1' FOR Hospital - Inpt or Opt (includes clinics);
'2' FOR Skilled Nursing (NHCU);
'3' FOR Home Health Agency;
'7' FOR Clinic (only independent/satellite);
'8' FOR Spec. Facility Hosp/Amb Surg Ctr;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Location of Care.
DESCRIPTION: This is location of care code for the 278 inquiry. This field is only populated if the FACILITY
TYPE QUALIFIER field is set to A.
356.22,2.07 BILL CLASSIFICATION 2;7 SET
'8' FOR Swingbed;
'1' FOR Inpatient (Medicare-A);
'2' FOR Humanit. Emerg. (Inpatient/Medicare-B);
'3' FOR Outpatient;
'4' FOR Humanit. Emerg. (Outpatient/ESRD);
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Bill Classification code.
DESCRIPTION: This is Bill Classification code for the 278 inquiry. This field is only populated if the FACILITY
TYPE QUALIFIER field is set to A.
356.22,2.08 RELATED CAUSES #1 2;8 SET
'AA' FOR Auto Accident;
'AP' FOR Another Party Responsible;
'EM' FOR Employment;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Related Cause. The entered Related Cause must not already be present in Related
Causes #2 or #3.
DESCRIPTION:
Select a cause related to this patient care event.
SCREEN: S DIC("S")="I $$RCAUSE^IBTRH5A(2.08)"
EXPLANATION: Only allows Related Causes that are not already present in in Related Causes #2 or #3.
356.22,2.09 RELATED CAUSES #2 2;9 SET
'AP' FOR Another Party Responsible;
'EM' FOR Employment;
LAST EDITED: JAN 27, 2015
HELP-PROMPT: Enter a valid Related Cause. The entered Related Cause must not already be present in Related
Causes #1 or #3.
DESCRIPTION:
Select a cause related to this patient care event.
SCREEN: S DIC("S")="I $$RCAUSE^IBTRH5A(2.09)"
EXPLANATION: Only allows Related Causes that are not already present in in Related Causes #1 or #3.
356.22,2.1 RELATED CAUSES #3 2;10 SET
'AP' FOR Another Party Responsible;
'EM' FOR Employment;
LAST EDITED: JAN 27, 2015
HELP-PROMPT: Enter a valid Related Cause. The entered Related Cause must not already be present in Related
Causes #1 or #2.
DESCRIPTION:
Select a cause related to this patient care event.
SCREEN: S DIC("S")="I $$RCAUSE^IBTRH5A(2.1)"
EXPLANATION: Only allows Related Causes that are not already present in in Related Causes #1 or #2.
356.22,2.11 STATE 2;11 POINTER TO STATE FILE (#5)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid state.
DESCRIPTION: The state in which the auto accident occurred. This is REQUIRED if the accident occurred out of
this state.
356.22,2.12 COUNTRY 2;12 POINTER TO COUNTRY CODE FILE (#779.004)
OUTPUT TRANSFORM: COUNTRY:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid country.
DESCRIPTION:
The country in which the auto accident occurred if outside the US.
356.22,2.13 LEVEL OF SERVICE 2;13 SET
'03' FOR Emergency;
'E' FOR Elective;
'U' FOR Urgent;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Level of Service.
DESCRIPTION:
The Level of Service if care is other than Routine. This is REQUIRED if this request is an Appeal.
356.22,2.14 CURRENT HEALTH CONDITION 2;14 POINTER TO X12 278 CURRENT HEALTH CONDITION CODE FILE (#356.003)
OUTPUT TRANSFORM: CURRENT HEALTH CONDITION:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter an optional Health Condition Code.
DESCRIPTION: The Health Condition Code is only entered if it is a factor in choosing services that are not
typical for the patient's diagnoses.
356.22,2.15 PROGNOSIS CODE 2;15 POINTER TO X12 278 PROGNOSIS CODE FILE (#356.004)
OUTPUT TRANSFORM: PROGNOSIS CODE:DESCRIPTION
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter an optional Prognosis Code.
DESCRIPTION: The Prognosis Code is only entered if it is a factor in choosing services that are not typical for
the patient's diagnoses.
356.22,2.16 RELEASE OF INFORMATION CODE 2;16 SET
'M' FOR Prov has Limited or Restricted Ability to Release Data Related to Clm;
'Y' FOR Prov has a Signed Statement Permitting Release of Medical Billing Data;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid ROI code.
DESCRIPTION:
The ROI code which determines how information of this patient event will be released.
356.22,2.17 DELAY REASON 2;17 POINTER TO X12 278 DELAY REASON CODE FILE (#356.005)
OUTPUT TRANSFORM: DELAY REASON:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Delay Reason.
DESCRIPTION: The Delay Reason code. This information is REQUIRED if this request is outside of the normal
timeframe for this UMO.
356.22,2.18 ACCIDENT DATE 2;18 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid date (no range limit).
DESCRIPTION:
Enter the date on which the accident occurred.
356.22,2.19 LAST MENSTRUAL PERIOD DATE 2;19 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid date (no range limit).
DESCRIPTION:
The Date of Last Menstrual Period if this request is related to pregnancy.
356.22,2.2 ESTIMATED DOB 2;20 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid estimated date of birth.
DESCRIPTION:
The Estimated Date of Birth if this request is related to an estimated date of birth (due date).
356.22,2.21 ILLNESS DATE 2;21 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: APR 08, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date when the current symptoms or illness first began.
356.22,2.22 DISCHARGE DATE 2;22 DATE
INPUT TRANSFORM: S %DT="ESTX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date and optional time of discharge for this patient.
DESCRIPTION:
The patient discharge date/time for the 278 inquiry. Time is optional.
356.22,2.23 CERTIFICATION ISSUE DATE 2;23 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Certification Issue Date.
DESCRIPTION:
The Certification Issue Date for this authorization.
356.22,2.24 CERTIFICATION EXPIRATION DATE 2;24 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Certification Expiration Date.
DESCRIPTION:
The authorization expiration date.
356.22,2.25 CERTIFICATION EFFECTIVE DATE 2;25 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Certification Effective Date.
DESCRIPTION:
The Certification Effective Date for the authorization provided.
356.22,2.26 CERT EFFECTIVE THRU DATE 2;26 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date for which the authorization is still in effect.
356.22,3 PATIENT DIAGNOSIS 3;0 POINTER Multiple #356.223 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains patient diagnosis codes for 278 inquiry.
356.223,.01 DIAGNOSIS TYPE 0;1 POINTER TO X12 278 DIAGNOSIS TYPE FILE (#356.006) (Multiply asked)
INPUT TRANSFORM: S DIC("S")="I $$DXTYPE^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: DIAGNOSIS TYPE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a REQUIRED Diagnosis Type Code.
DESCRIPTION:
The REQUIRED code that describes the Diagnosis Type.
SCREEN: S DIC("S")="I $$DXTYPE^IBTRH5H()"
EXPLANATION: Enter a valid Diagnosis Type.
CROSS-REFERENCE: 356.223^B
1)= S ^IBT(356.22,DA(1),3,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),3,"B",$E(X,1,30),DA)
356.223,.02 DIAGNOSIS CODE 0;2 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
80 1 I n ICD-10 Diagnosis
80.2 2 D n DRG Diagnosis
95.3 3 L n LOINC Diagnosis
SCREEN ON FILE 80: S DIC("S")="I $$DXCODE^IBTRH5A()"
SCREEN EXPLANATION: The selected Diagnosis must be valid for the selected Diagnosis Type and must not be a duplica
te.
SCREEN ON FILE 80.2: S DIC("S")="I $$DXCODE^IBTRH5A()"
SCREEN EXPLANATION: The selected Diagnosis must be valid for the selected Diagnosis Type and must not be a duplica
te.
LAST EDITED: NOV 23, 2015
HELP-PROMPT: Enter a valid Diagnosis Code.
DESCRIPTION:
The Diagnosis Code for the 278 inquiry.
356.223,.03 DIAGNOSIS DATE 0;3 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the optional date that the diagnosis was known.
DESCRIPTION:
The optional date of when the diagnosis was determined.
356.22,4.01 HCSD QUANTITY QUALIFIER 4;1 POINTER TO X12 271 QUANTITY QUALIFIER FILE (#365.016)
INPUT TRANSFORM: S DIC("S")="I $$HCSDQQ^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: HCSD QUANTITY QUALIFIER:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Quantity Qualifier.
DESCRIPTION: If the Certification Type is 4 - Extension, this is the number of additional visits. If the
Certification Type is S - Revised, it is the new total.
SCREEN: S DIC("S")="I $$HCSDQQ^IBTRH5H()"
EXPLANATION: Enter a valid Quantity Qualifier code.
356.22,4.02 HCSD SERVICE UNIT COUNT 4;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
The service unit count for the Health Care Services Delivery segment of the 278 inquiry.
356.22,4.03 HCSD UNITS OF MEASUREMENT 4;3 SET
'DA' FOR Days;
'MO' FOR Months;
'WK' FOR Weeks;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Units of Measurement code.
DESCRIPTION:
The Unit of Measurement for the Sample Selection Modulus.
356.22,4.04 HCSD SAMPLE SELECTION MODULUS 4;4 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<0)!(X?.E1"."3.N) X
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Type a number between 0 and 999, 2 decimal digits.
DESCRIPTION: Enter a number with up to 2 decimal points that represents the sampling frequency in terms of the
Unit of Measurement (e.g. 1.5 weeks).
356.22,4.05 HCSD TIME PERIOD QUALIFIER 4;5 POINTER TO X12 271 TIME PERIOD QUALIFIER FILE (#365.015)
INPUT TRANSFORM: S DIC("S")="I $$TIMEPDQ^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: HCSD TIME PERIOD QUALIFIER:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Time Period Qualifier.
DESCRIPTION: The Time Period Qualifier for the Period Count when patient events must be rendered within a
specific time frame.
SCREEN: S DIC("S")="I $$TIMEPDQ^IBTRH5I()"
EXPLANATION: Select a valid Time Period Qualifier
356.22,4.06 HCSD PERIOD COUNT 4;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 999, 0 decimal digits.
DESCRIPTION: Enter a whole number between 1 and 999 when patient events must be rendered within a specific time
frame.
356.22,4.07 HCSD DELIVERY FREQUENCY 4;7 POINTER TO X12 271 DELIVERY FREQUENCY CODE FILE (#365.025)
INPUT TRANSFORM: S DIC("S")="I $$HCSDFC^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 14, 2015
HELP-PROMPT: Enter a valid Delivery Frequency Code.
DESCRIPTION:
The Delivery Frequency Code when patient events must be rendered within a specific time frame.
SCREEN: S DIC("S")="I $$HCSDFC^IBTRH5H()"
EXPLANATION: The code identify a specific calendar delivery pattern.
356.22,4.08 HCSD DELIVERY TIME PATTERN 4;8 POINTER TO X12 278 DELIVERY PATTERN TIME CODE FILE (#356.007)
OUTPUT TRANSFORM: HCSD DELIVERY TIME PATTERN:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter an optional Delivery Pattern Time Code.
DESCRIPTION:
The optional Delivery Pattern Time Code of when the services will be provided.
356.22,4.09 AMBULANCE CERT. CONDITION 4;9 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if the Ambulance Cert. Condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Ambulance Certification Condition(s).
356.22,4.1 AMBULANCE CONDITION #1 4;10 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(4.1)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: AMBULANCE CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ambulance Certification Code. The entered code must not already be present in
Ambulance Conditions #2, #3, #4 or #5.
DESCRIPTION:
The first of 5 possible Ambulance Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(4.1)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Ambulance Certification.
356.22,4.11 AMBULANCE CONDITION #2 4;11 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(4.11)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: AMBULANCE CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ambulance Certification Code. The entered code must not already be present in
Ambulance Conditions #1, #3, #4 or #5.
DESCRIPTION:
The second of 5 possible Ambulance Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(4.11)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Ambulance Certification.
356.22,4.12 AMBULANCE CONDITION #3 4;12 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(4.12)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: AMBULANCE CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ambulance Certification Code. The entered code must not already be present in
Ambulance Conditions #1, #2, #4 or #5.
DESCRIPTION:
The third of 5 possible Ambulance Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(4.12)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Ambulance Certification.
356.22,4.13 AMBULANCE CONDITION #4 4;13 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(4.13)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: AMBULANCE CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ambulance Certification Code. The entered code must not already be present in
Ambulance Conditions #1, #2, #3 or #5.
DESCRIPTION:
The fourth of 5 possible Ambulance Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(4.13)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Ambulance Certification.
356.22,4.14 AMBULANCE CONDITION #5 4;14 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(4.14)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: AMBULANCE CONDITION #5:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Ambulance Certification Code. The entered code must not already be present in
Ambulance Conditions #1, #2, #3 or #4.
DESCRIPTION:
The fifth of 5 possible Ambulance Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(4.14)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Ambulance Certification.
356.22,5.01 CHIROPRACTIC CERT. CONDITION 5;1 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if Chiropractic Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Chiropractic Certification Condition(s).
356.22,5.02 CHIROPRACTIC CONDITION #1 5;2 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.02)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: CHIROPRACTIC CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Chiropracatic Certification Condition. The entered code must not already be present
in Chiropractic Conditions #2, #3, #4 or #5.
DESCRIPTION:
The first of 5 possible Chiropractic Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.02)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Chiropractic Certification.
356.22,5.03 CHIROPRACTIC CONDITION #2 5;3 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.03)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: CHIROPRACTIC CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Chiropractic Certification Condition. The entered code must not already be present in
Chiropractic Conditions #1, #3, #4 or #5.
DESCRIPTION:
The Second of 5 possible Chiropractic Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.03)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Chiropractic Certification.
356.22,5.04 CHIROPRACTIC CONDITION #3 5;4 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.04)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: CHIROPRACTIC CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Chiropractic Certification Condition. The entered code must not already be present in
Chiropractic Conditions #1, #2, #4 or #5.
DESCRIPTION:
The third of 5 possible Chiropractic Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.04)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Chiropractic Certification.
356.22,5.05 CHIROPRACTIC CONDITION #4 5;5 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.05)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: CHIROPRACTIC CONDITION #5:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Chiropractic Certification Condition. The entered code must not already be present in
Chiropractic Conditions #1, #2, #3 or #5.
DESCRIPTION:
The fourth of 5 possible Chiropractic Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.05)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Chiropractic Certification.
356.22,5.06 CHIROPRACTIC CONDITION #5 5;6 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.06)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: CHIROPRACTIC CONDITION #1:DESCRIPTION
LAST EDITED: APR 08, 2015
HELP-PROMPT: Enter a valid Chiropractic Certification Condition. The entered code must not already be present in
Chiropractic Conditions #1, #2, #3 or #4.
DESCRIPTION:
The fifth of 5 possible Chiropractic Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.06)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Chiropractic Certification.
356.22,5.07 DME CERT. CONDITION 5;7 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if the DME Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Durable Medical Equipment (DME) Certification Condition(s).
356.22,5.08 DME CONDITION #1 5;8 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.08)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: DME CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid DME Certification Condition. The entered code must not already be present in DME
Conditions #2, #3, #4 or #5.
DESCRIPTION:
The first of 5 possible DME Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.08)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for DME Certification.
356.22,5.09 DME CONDITION #2 5;9 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.09)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: DME CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid DME Certification Condition. The entered code must not already be present in DME
Conditions #1, #3, #4 or #5.
DESCRIPTION:
The second of 5 possible DME Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.09)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for DME Certification.
356.22,5.1 DME CONDITION #3 5;10 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.1)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: DME CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid DME Certification Condition. The entered code must not already be present in DME
Conditions #1, #2, #4 or #5.
DESCRIPTION:
The third of 5 possible DME Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.1)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for DME Certification.
356.22,5.11 DME CONDITION #4 5;11 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.11)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: DME CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid DME Certification Condition. The entered code must not already be present in DME
Certification Conditions #1, #2, #3 or #5.
DESCRIPTION:
The fourth of 5 possible DME Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.11)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for DME Certification.
356.22,5.12 DME CONDITION #5 5;12 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.12)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: DME CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid DME Certification Condition. The entered code must not already be present in DME
Conditions #1, #2, #3 or #4.
DESCRIPTION:
The fifth of 5 possible DME Certification Conditions.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.12)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for DME Certification.
356.22,5.13 OXYGEN CERT. CONDITION 5;13 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 'Y' if Oxygen Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Oxygen Therapy Certification condition(s).
356.22,5.14 OXYGEN CONDITION #1 5;14 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.14)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Certification Condition. The entered code must not already be present in
Oxygen Conditions #2, #3, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the need for Oxygen Therapy. You can enter up to
five Condition codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.14)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Oxygen Certification.
356.22,5.15 OXYGEN CONDITION #2 5;15 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.15)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Certification Condition. The entered code must not already be present in
Oxygen Conditions #1, #3, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the need for Oxygen Therapy. You can enter up to
five Condition codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.15)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Oxygen Certification.
356.22,5.16 OXYGEN CONDITION #3 5;16 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.16)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Certification Condition. The entered code must not already be present in
Oxygen Conditions #1, #2, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the need for Oxygen Therapy. You can enter up to
five Condition codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.16)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Oxygen Certification.
356.22,5.17 OXYGEN CONDITION #4 5;17 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.17)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Certification Condition. The entered code must not already be present in
Oxygen Conditions #1, #2, #3 or #5.
DESCRIPTION: The Cerfication Condition code that describes the need for Oxygen Therapy. You can enter up to
five Condition codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.17)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Oxygen Certification.
356.22,5.18 OXYGEN CONDITION #5 5;18 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(5.18)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN CONDITION #5:DESCRIPTION
LAST EDITED: FEB 18, 2015
HELP-PROMPT: Enter a valid Oxygen Certification Condition. The entered code must not already be present in
Oxygen Conditions #1, #2, #3 or #4.
DESCRIPTION: The Certification Condition code that describes the need for Oxygen Therapy. You can enter up to
five Condition codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(5.18)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Oxygen Certification.
356.22,6.01 FUNCT. LIMIT CERT. CONDITION 6;1 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if the Funct. Limit Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Functional Limitation Certification Condition(s).
356.22,6.02 FUNCT. LIMIT CONDITION #1 6;2 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.02)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: FUNCT. LIMIT CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Funct. Limit Certification Condition. The entered code must not already be present in
Funct Limit Conditions #2, #3, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the patient's Functional Limitations. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.02)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Functional Limits Certification.
356.22,6.03 FUNCT. LIMIT CONDITION #2 6;3 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.03)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: FUNCT. LIMIT CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Funct. Limit Certification Condition. The entered code must not already be present in
Funct. Limit Conditions #1, #3, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the patient's Functional Limitations. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.03)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Functional Limits Certification.
356.22,6.04 FUNCT. LIMIT CONDITION #3 6;4 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.04)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: FUNCT. LIMIT CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Funct. Limit Certification Condition. The entered code must not already be present in
Funct. Limit Conditions #1, #2, #4 or #5.
DESCRIPTION: The Certification Condition code that describes the patient's Functional Limitations. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.04)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Functional Limits Certification.
356.22,6.05 FUNCT. LIMIT CONDITION #4 6;5 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.05)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: FUNCT. LIMIT CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Funct. Limit Certification Condition. The entered code must not already be present in
Funct. Limit Conditions #1, #2, #3 or #5.
DESCRIPTION: The Certification Condition code that describes the patient's Functional Limitations. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.05)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Functional Limits Certification.
356.22,6.06 FUNCT. LIMIT CONDITION #5 6;6 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.06)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: FUNCT. LIMIT CONDITION #5:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Funct. Limit Certification Condition. The entered code must not already be present in
Funct. Limit Conditions #1, #2, #3 or #4.
DESCRIPTION: The Certification Condition code that describes the patient's Functional Limitations. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.06)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Functional Limits Certification.
356.22,6.07 ACTIVITIES CERT. CONDITION 6;7 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if the Activities Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Activities permitted certification condition(s).
356.22,6.08 ACTIVITIES CONDITION #1 6;8 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.08)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: ACTIVITIES CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Activities Certifcation Condition. The entered code must not already be present in
Activities Condditons #2, #3, #4 or #5.
DESCRIPTION: The Certification Condition Code that represents the defined patient activities permitted. You can
enter up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.08)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Activities Certification.
356.22,6.09 ACTIVITIES CONDITION #2 6;9 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.09)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: ACTIVITIES CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Activities Certification Condition. The entered code must not already be present in
Activities Conditions #1, #3, #4 or #5.
DESCRIPTION: The Certification Condition Code that represents the defined patient activities permitted. You can
add up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.09)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Activities Certification.
356.22,6.1 ACTIVITIES CONDITION #3 6;10 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.1)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: ACTIVITIES CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Activities Certifiction Condition. The entered code must not already be present in
Activities Conditions #1, #2, #4 or #5.
DESCRIPTION: The Certification Condition Code that represents the defined patient activities permitted. You can
add up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.1)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Activities Certification.
356.22,6.11 ACTIVITIES CONDITION #4 6;11 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.11)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: ACTIVITIES CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Activities Certification Condition. The entered code must not already be present in
Activities Conditions #1, #2, #3 or #5.
DESCRIPTION: The Certification Condition Code that represents the defined patient activities permitted. You can
add up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.11)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Activities Certification.
356.22,6.12 ACTIVITIES CONDITION #5 6;12 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.12)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: ACTIVITIES CONDITION #5:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Activities Certification Condition. The entered code must not already be present in
Activities Conditions #1, #2, #3 or #4.
DESCRIPTION: The Certification Condition Code that represents the defined patient activities permitted. You can
add up to five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.12)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Activities Certification.
356.22,6.13 MENTAL STATUS CERT. CONDITION 6;13 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'Y' if the Mental Status Cert. condition exists, or 'N' otherwise.
DESCRIPTION:
This field indicates existence of Mental Status Certification Condition(s).
356.22,6.14 MENTAL STATUS CONDITION #1 6;14 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.14)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: MENTAL STATUS CONDITION #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Mental Status Certification Condition. The entered code must not already be present
in Mental Status Conditions #2, #3, #4 or #5.
DESCRIPTION: The Certification Condition Code that represents the patient's mental status. You can add up to
five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.14)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Mental Status Certification.
356.22,6.15 MENTAL STATUS CONDITION #2 6;15 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.15)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: MENTAL STATUS CONDITION #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Mental Status Certification Condition. The entered code must not already be present
in Mental Status Conditions #1, #3, #4 or #5.
DESCRIPTION: The Certificaton Condition Code that represents the patient's mental status. You can add up to
five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.15)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Mental Status Certification.
356.22,6.16 MENTAL STATUS CONDITION #3 6;16 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.16)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: MENTAL STATUS CONDITION #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Mental Status Certification Condition. The entered code must not already be present
in Mental Status Conditions #1, #2, #4 or #5.
DESCRIPTION: The Certification Condition Code that represents the patient's mental status. You can add up to
five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.16)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Mental Status Certification.
356.22,6.17 MENTAL STATUS CONDITION #4 6;17 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.17)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: MENTAL STATUS CONDITION #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Mental Status Certification Condition. The entered code must not already be present
in Mental Status Conditions #1, #2, #3 or #5.
DESCRIPTION: The Certification Condition Code that represents the patient's mental status. You can add up to
five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.17)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Mental Status Certification.
356.22,6.18 MENTAL STATUS CONDITION #5 6;18 POINTER TO X12 278 CONDITION CODE FILE (#356.008)
INPUT TRANSFORM: S DIC("S")="I $$CERTCOND^IBTRH5A(6.18)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: MENTAL STATUS CONDITION #5:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Mental Status Certification Condition. The entered code must not already be present
in Mental Status Conditions #1, #2, #3 or #4.
DESCRIPTION: The Certification Condition Code that represents the patient's mental status. You can add up to
five Condition Codes.
SCREEN: S DIC("S")="I $$CERTCOND^IBTRH5A(6.18)"
EXPLANATION: Only allows X12 278 Condition Codes that are valid for Mental Status Certification.
356.22,7.01 ADMISSION TYPE 7;1 SET
'1' FOR Emergency;
'2' FOR Urgent;
'3' FOR Elective;
'4' FOR Newborn;
'5' FOR Trauma;
'9' FOR Information not available;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter an optional Admission Type.
DESCRIPTION:
The optional Admission Type that describes the type of inpatient admission.
356.22,7.02 ADMISSION SOURCE 7;2 POINTER TO X12 278 ADMISSION SOURCE FILE (#356.009)
OUTPUT TRANSFORM: ADMISSION SOURCE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter an optional Admission Source.
DESCRIPTION:
The an optional Admission Source that decribes the source of the inpatient admission.
356.22,7.03 PATIENT STATUS 7;3 POINTER TO X12 278 PATIENT STATUS FILE (#356.01)
OUTPUT TRANSFORM: PATIENT STATUS:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter an optional Patient Status.
DESCRIPTION:
The optional Patient Status which describes the current status of the patient.
356.22,7.04 NURSING HOME STATUS 7;4 POINTER TO X12 278 NURSING HOME RESIDENTIAL STATUS FILE (#356.011)
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a REQUIRED Nursing Home (SNF) Residential status.
DESCRIPTION: The Nursing Home (SNF) Residential status is required when the patient is currently in or eligible
for a nursing home.
356.22,7.05 TREATMENT SERIES NUMBER 7;5 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 21, 2014
HELP-PROMPT: Type a number between 0 and 999999999, 0 decimal digits.
DESCRIPTION: Enter a 1-9 digit whole number. This is REQUIRED when requesting certification for a specific
number in a series of treatments.
356.22,7.06 TREATMENT COUNT 7;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 21, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION: Enter a 1-15 digit number. This is REQUIRED when requesting certification for a specific number in
a series of treatments.
356.22,7.07 SUBLUXATION LEVEL CODE #1 7;7 POINTER TO X12 278 SUBLUXATION LEVEL CODE FILE (#356.012)
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid Subluxation Level Code.
DESCRIPTION:
The Subluxation Level code is REQUIRED if the treatment includes subluxation.
356.22,7.08 SUBLUXATION LEVEL CODE #2 7;8 POINTER TO X12 278 SUBLUXATION LEVEL CODE FILE (#356.012)
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid Subluxation Level Code.
DESCRIPTION:
The Subluxation Level code is REQUIRED if treatment includes subluxation.
356.22,7.09 PATIENT CONDITION CODE 7;9 SET
'A' FOR Acute Condition;
'C' FOR Chronic Condition;
'D' FOR Non-acute Condition;
'E' FOR Non-Life Threatening;
'F' FOR Routine;
'G' FOR Symptomatic;
'M' FOR Acute Manifestation of a Chronic Condition;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Patient Condition code.
DESCRIPTION:
The REQUIRED code that describes the current condition of the patient.
356.22,7.1 COMPLICATION INDICATOR 7;10 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter Y to indicate the existence of complications or N otherwise.
DESCRIPTION:
Determines whether or not complications indicators exist.
356.22,7.11 PAT. COND. DESCRIPTION LINE 1 7;11 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: NOV 21, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
Enter a 1-80 character, free text description of the patient's condition.
356.22,7.12 PAT. COND. DESCRIPTION LINE 2 7;12 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: NOV 21, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
Enter a 1-80 character, free text description of the patient's condition.
356.22,7.13 X-RAY AVAILABLE? 7;13 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter Y to indicate that there are related X-Rays available or N otherwise..
DESCRIPTION:
Determines wheter or not related X-Rays are available.
356.22,8.01 OXYGEN EQUIPMENT TYPE #1 8;1 POINTER TO X12 278 OXYGEN EQUIPMENT TYPE FILE (#356.013)
INPUT TRANSFORM: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.01)" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN EQUIPMENT TYPE #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Equipment type. The entered code must not already be present in Oxygen
Equipment Types #2 or #3.
DESCRIPTION:
Select the type of Oxygen Equipment. You can enter up to three Oxygen Equipment Types.
SCREEN: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.01)"
EXPLANATION: Only allows Oxygen Equipment Types that are not already present in in Oxygen Equipment Types #2 or
#3.
356.22,8.02 OXYGEN EQUIPMENT TYPE #2 8;2 POINTER TO X12 278 OXYGEN EQUIPMENT TYPE FILE (#356.013)
INPUT TRANSFORM: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.02)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN EQUIPMENT TYPE #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Equipment Type. The entered code must not already be present in Oxygen
Equipment Types #1 or #3.
DESCRIPTION:
Select the type of Oxygen Equipment. You can enter up to three Oxygen Equipment Types.
SCREEN: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.02)"
EXPLANATION: Only allows Oxygen Equipment Types that are not already present in in Oxygen Equipment Types #1 or
#3.
356.22,8.03 OXYGEN EQUIPMENT TYPE #3 8;3 POINTER TO X12 278 OXYGEN EQUIPMENT TYPE FILE (#356.013)
INPUT TRANSFORM: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.03)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: OXYGEN EQUIPMENT TYPE #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Equipment Type. The entered code must not already be present in Oxygen
Equipment Types #1 or #2.
DESCRIPTION:
Select the type of Oxygen Equipment. You can enter up to three Oxygen Equipment Types.
SCREEN: S DIC("S")="I $$OXYTTYPE^IBTRH5B(8.03)"
EXPLANATION: Only allows Oxygen Equipment Types that are not already present in in Oxygen Equipment Types #1 or
#2.
356.22,8.04 OXYGEN EQUIPMENT REASON 8;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
Enter an optional 1-80 character, free text description of why the oxygen equipment is needed.
356.22,8.05 OXYGEN FLOW RATE 8;5 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."3.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 2 decimal digits.
DESCRIPTION:
Enter a numeric value representing the Oxygen Flow rate in liters/minute.
356.22,8.06 DAILY OXYGEN USE COUNT 8;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 24, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
Enter a numeric value representing the number of times per day that the patient must use oxygen.
356.22,8.07 OXYGEN USE PERIOD HOUR COUNT 8;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 24, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
Enter a numeric value representing the number of hours per period of oxygen use.
356.22,8.08 RESPIRATORY THERAPIST ORDER 8;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: NOV 24, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
Enter a 1-80 character, free text description of special orders for the Respiratory Therapist.
356.22,9.01 ARTERIAL BLOOD GAS QUANTITY 9;1 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 24, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
Enter a numerical value representing Arterial Blood Gas Quantity.
356.22,9.02 OXYGEN SATURATION QUANTITY 9;2 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: NOV 24, 2014
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
Enter a numerical value representing Oxygen Saturation Quantity.
356.22,9.03 OXYGEN TEST CONDITION 9;3 POINTER TO X12 278 OXYGEN TEST CONDITION FILE (#356.014)
OUTPUT TRANSFORM: OXYGEN TEST CONDITION:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Test Condition.
DESCRIPTION:
The conditions under which the patient was tested.
356.22,9.04 OXYGEN TEST FINDINGS #1 9;4 POINTER TO X12 278 OXYGEN TEST FINDINGS FILE (#356.015)
INPUT TRANSFORM: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.04)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 22, 2015
HELP-PROMPT: Enter a valid Oxygen Test Findings. The entered code must not already be present in Oxygen Test
Findings #2 or #3.
DESCRIPTION:
The patient's Oxygen Test Findings. You can enter up to three findings.
SCREEN: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.04)"
EXPLANATION: Only allows Oxygen Test Finding Codes that are not already present in Oxygen Test Findings #2 or #3
.
356.22,9.05 OXYGEN TEST FINDINGS #2 9;5 POINTER TO X12 278 OXYGEN TEST FINDINGS FILE (#356.015)
INPUT TRANSFORM: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.05)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 12, 2015
HELP-PROMPT: Enter a valid Oxygen Test Findings. The entered code must not already be present in Oxygen Test
Findings #1 or #3.
DESCRIPTION:
The patient's Oxygen Test Findings. You can enter up to three findings.
SCREEN: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.05)"
EXPLANATION: Only allows Oxygen Test Finding Codes that are not already present in Oxygen Test Findings #1 or #3
.
356.22,9.06 OXYGEN TEST FINDINGS #3 9;6 POINTER TO X12 278 OXYGEN TEST FINDINGS FILE (#356.015)
INPUT TRANSFORM: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.06)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 22, 2015
HELP-PROMPT: Enter a valid Oxygen Test Findings. The entered code must not already be present in Oxygen Test
Findings #1 or #2.
DESCRIPTION:
The patient's Oxygen Test Findings. You can enter up to three findings.
SCREEN: S DIC("S")="I $$OXYTFIND^IBTRH5B(9.06)"
EXPLANATION: Only allows Oxygen Test Finding Codes that are not already present in Oxygen Test Findings #1 or #2
.
356.22,9.07 PORTABLE OXYGEN SYSTEM FLOW 9;7 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Type a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
Enter a numeric value representing the Flow Rate for portable oxygen in liter/minute.
356.22,9.08 OXYGEN DELIVERY SYSTEM 9;8 POINTER TO X12 278 OXYGEN DELIVERY SYSTEM CODE FILE (#356.016)
OUTPUT TRANSFORM: OXYGEN DELIVERY SYSTEM:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oxygen Delivery System Code.
DESCRIPTION:
The prescribed form of Oxygen Delivery.
356.22,10.01 HOME HEALTH START DATE 10;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date when the home health, private duty or nursing agency services started.
356.22,10.02 HOME HEALTH CERT. START 10;2 DATE
INPUT TRANSFORM: N %DT S %DT="EX" S:+$P($G(^IBT(356.22,DA,10)),U,3) %DT(0)=-$P($G(^IBT(356.22,DA,10)),U,3) D ^%DT S
X=Y K:X<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date when home health care will start.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^356.22^10.03
1)= Q
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X S Y(1)=$S($D(^IBT(356.22,D0,10)):^(10),1:"") S X=$P(Y(1)
,U,2)="" I X S X=DIV S Y(1)=$S($D(^IBT(356.22,D0,10)):^(10),1:"") S X=$P(Y(1),U,3),X=X S DIU=X K Y
S X="" X ^DD(356.22,10.02,1,1,2.4)
2.4)= S DIH=$G(^IBT(356.22,DIV(0),10)),DIV=X S $P(^(10),U,3)=DIV,DIH=356.22,DIG=10.03 D ^DICR
CREATE VALUE)= NO EFFECT
DELETE CONDITION)= HOME HEALTH CERT. START=""
DELETE VALUE)= @
FIELD)= #10.03
356.22,10.03 HOME HEALTH CERT. END 10;3 DATE
INPUT TRANSFORM: N %DT S %DT="EX",%DT(0)=$G(DG("10;2")) S:%DT(0)="" %DT(0)=$P($G(^IBT(356.22,DA,10)),U,2) D ^%DT S X
=Y K:X<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The Date when home health care will end.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the HOME HEALTH CERT. START field of the HCS REVIEW TRANSMISSION File
356.22,10.04 COVERED BY MEDICARE? 10;4 SET
'W' FOR Not applicable;
'Y' FOR Yes;
'N' FOR No;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Medicare Coverage Indicator Code.
DESCRIPTION:
The Medicare coverage indicator for the 278 inquiry.
356.22,10.05 SURGERY DATE 10;5 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION: The date on which surgery was performed. This date should be entered if there was a surgery
related to this home health care.
356.22,10.06 SURGICAL PROCEDURE CODE TYPE 10;6 SET
'HC' FOR CPT/HCPCS;
'ID' FOR ICD-9-CM;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Procedure Coding Method.
DESCRIPTION:
The Procedure Coding Method for the related surgical procedures.
356.22,10.07 SURGICAL PROCEDURE CODE 10;7 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
81 1 C n HCPCS procedure code
80.1 2 I n ICD-9 procedure code
SCREEN ON FILE 81: S DIC("S")="I $$PROC^IBTRH5B(10.07)"
SCREEN EXPLANATION: Restricts look-ups based on the Procedure Code Type.
SCREEN ON FILE 80.1: S DIC("S")="I $$PROC^IBTRH5B(10.07)"
SCREEN EXPLANATION: Restricts look-ups based upon the Procedure Code Type.
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a Surgical Procedure.
DESCRIPTION:
The Surgical Procedure associated with this home health care.
356.22,10.08 PHYSICIAN ORDER DATE 10;8 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date on which the physician issued verbal orders for the start of home health care.
356.22,10.09 LAST VISIT DATE 10;9 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date on which the patient was last seen by the physician.
356.22,10.1 PHYSICIAN CONTACT DATE 10;10 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The date on which the physician was last contacted by the home health services provider.
356.22,10.11 LAST ADMISSION START DATE 10;11 DATE
INPUT TRANSFORM: N %DT S %DT="EX" S:+$P($G(^IBT(356.22,DA,10)),U,12) %DT(0)=-$P($G(^IBT(356.22,DA,10)),U,12) D ^%DT
S X=Y K:X<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The Start Date of the last inpatient admission.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: ^^TRIGGER^356.22^10.12
1)= Q
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(0)=X S Y(1)=$S($D(^IBT(356.22,D0,10)):^(10),1:"") S X=$P(Y(1)
,U,11)="" I X S X=DIV S Y(1)=$S($D(^IBT(356.22,D0,10)):^(10),1:"") S X=$P(Y(1),U,12),X=X S DIU=X K
Y S X="" X ^DD(356.22,10.11,1,1,2.4)
2.4)= S DIH=$G(^IBT(356.22,DIV(0),10)),DIV=X S $P(^(10),U,12)=DIV,DIH=356.22,DIG=10.12 D ^DICR
CREATE VALUE)= NO EFFECT
DELETE CONDITION)= LAST ADMISSION START DATE=""
DELETE VALUE)= @
FIELD)= #10.12
356.22,10.12 LAST ADMISSION END DATE 10;12 DATE
INPUT TRANSFORM: N %DT S %DT="EX",%DT(0)=$G(DG("10;11")) S:%DT(0)="" %DT(0)=$P($G(^IBT(356.22,DA,10)),U,11) D ^%DT S
X=Y K:X<1 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The End Date of the last inpatient admission.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
TRIGGERED by the LAST ADMISSION START DATE field of the HCS REVIEW TRANSMISSION File
356.22,10.13 PATIENT LOCATION 10;13 POINTER TO X12 278 PATIENT LOCATION FILE (#356.017)
OUTPUT TRANSFORM: PATIENT LOCATION:DESCRIPTION
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Facility Type.
DESCRIPTION:
The Facility Type that represents the location of the patient's last inpatient admission.
356.22,11 ATTACHMENTS 11;0 POINTER Multiple #356.2211 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains additional patient information (attachments) for patient event level.
356.2211,.01 REPORT TYPE CODE 0;1 POINTER TO X12 278 REPORT TYPE CODE FILE (#356.018) (Multiply asked)
INPUT TRANSFORM: I $P($G(^IBT(356.22,DA(1),11,0)),"^",3)=10 K X
OUTPUT TRANSFORM: REPORT TYPE CODE:DESCRIPTION
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Report Type Code.
DESCRIPTION:
The Report Type code that describes the type of additional information available.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
CROSS-REFERENCE: 356.2211^B
1)= S ^IBT(356.22,DA(1),11,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),11,"B",$E(X,1,30),DA)
356.2211,.02 REPORT TRANSMISSION CODE 0;2 SET
'AA' FOR Available on request at provider site;
'BM' FOR By mail;
'EL' FOR Electronically only;
'EM' FOR E-mail;
'FX' FOR By fax;
'VO' FOR Voice;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Report Transmission Code.
DESCRIPTION:
The code which indicates the method by which the additional information will be delivered.
356.2211,.03 ATTACHMENT CONTROL NUMBER 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<2) X
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Answer must be 2-80 characters in length.
DESCRIPTION: This field is the number used to correctly identify the attachment. This identifier is REQUIRED
when the Delivery Method is BM, EL, EM or FX.
356.2211,.04 ATTACHMENT DESCRIPTION 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: JUL 01, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
This is a description of the attachment.
356.22,12 MESSAGE TEXT 12;0 WORD-PROCESSING #356.2212 (IGNORE "|")
DESCRIPTION:
This is a free form message for 278 inquiry.
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a free form message of up to 264 characters.
356.22,13 PATIENT EVENT PROVIDER 13;0 POINTER Multiple #356.2213 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds data related to patient event providers for 278 inquiry.
356.2213,.01 PROVIDER TYPE 0;1 POINTER TO X12 271 ENTITY IDENTIFIER CODE FILE (#365.022) (Multiply asked)
INPUT TRANSFORM: S DIC("S")="I $$PROVTYPE^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: PROVIDER TYPE:DESCRIPTION
LAST EDITED: FEB 20, 2015
HELP-PROMPT: Enter a valid Provider Type Qualifier.
DESCRIPTION:
This field indicates the type of provider.
SCREEN: S DIC("S")="I $$PROVTYPE^IBTRH5H()"
EXPLANATION: The code identifying an organization entity, a physical location, or an individual.
CROSS-REFERENCE: 356.2213^B
1)= S ^IBT(356.22,DA(1),13,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),13,"B",$E(X,1,30),DA)
356.2213,.02 PERSON / NON-PERSON 0;2 SET
'1' FOR Person;
'2' FOR Non-person;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter 1 if the provider is a person or 2 otherwise.
DESCRIPTION:
Determines whether or not the selected Provider is a Person or a Non-person (e.g. a Facility).
356.2213,.03 PROVIDER 0;3 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
200 1 V n VA providers
355.93 2 N n Non-VA providers
4 3 F n Institutions
SCREEN ON FILE 200: S DIC("S")="I $O(^(""USC1"",0)),+$P($$NPI^XUSNPI(""Individual_ID"",Y),U)>0"
SCREEN EXPLANATION: Enter a valid VA Provider with valid NPI
SCREEN ON FILE 355.93: S DIC("S")="I +$$NPIGET^IBCEP81(Y)>0"
SCREEN EXPLANATION: Enter a valid non-VA provider with valid NPI
SCREEN ON FILE 4: S DIC("S")="I +$P($$NPI^XUSNPI(""Organization_ID"",Y),U)>0"
SCREEN EXPLANATION: Enter a valid institution with valid NPI
LAST EDITED: FEB 24, 2016
HELP-PROMPT: Enter a valid Provider.
DESCRIPTION: The Health Care Services Provider. This field is REQUIRED for admission reviews or when there is
no primary ID available for the provider.
356.2213,.04 PER LOOP IDENTIFIER 0;4 POINTER TO X12 271 LOOP ID FILE (#365.027)
PER Loop Identifier
LAST EDITED: SEP 24, 2014
HELP-PROMPT: Select an X12 271 loop ID.
DESCRIPTION:
This is the PER Loop Identifier.
356.2213,.05 CONTACT FUNCTION CODE 0;5 FREE TEXT
Contact Function Code
INPUT TRANSFORM: K:$L(X)>2!($L(X)<2) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 2-character Contact Function Code (PER01).
DESCRIPTION:
The code identifying the major duty or responsibility of the person or group named.
356.2213,.06 CONTACT NAME 0;6 FREE TEXT
Contact Name
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-60 characters.
DESCRIPTION:
The name of the Contact.
TECHNICAL DESCR: Required when the response must be directed to a particular contact and when the name of the
entity to contact is not already defined or is different than the name within the prior name
segment (e.g., N1 or NM1).
356.2213,.07 COMMUNICATION NO. QUALIFIER-1 0;7 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-1
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-1.
TECHNICAL DESCR:
Required when PER02 is not valued in order to transmit a contact communication number.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.2213,.08 COMMUNICATION NO. QUALIFIER-2 0;8 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-2
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-2.
TECHNICAL DESCR:
Required when a telephone extension or multiple commmunication types are available.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.2213,.09 COMMUNICATION NO. QUALIFIER-3 0;9 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-3
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-3.
TECHNICAL DESCR:
Required when a telephone extension or multiple communication types are available.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.2213,1 CONTACT COMMUNICATION NUMBER-1 1;1 FREE TEXT
Contact Communication Number-1
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-250 character Communication Number (PER04).
DESCRIPTION:
The complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Required when PER02 is not valued to transmit a contact communication number.
356.2213,2 CONTACT COMMUNICATION NUMBER-2 2;1 FREE TEXT
Contact Communication Number-2
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-250 character Communication Number (PER06).
DESCRIPTION:
The complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Required when the telephone extension or multiple communication numbers are available.
356.2213,3 CONTACT COMMUNICATION NUMBER-3 3;1 FREE TEXT
Contact Communication Number-3
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-250 character Communication Number (PER08).
DESCRIPTION:
The complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Requied when the telephone extension or multiple communication numbers are available.
356.2213,4.01 NM1 LOOP IDENTIFIER 4;1 POINTER TO X12 271 LOOP ID FILE (#365.027)
NM1 Loop Identifier
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter an X12 271 Loop ID.
DESCRIPTION:
The Loop Identifier for the NM1 segment.
356.2213,4.02 ENTITY IDENTIFIER CODE 4;2 POINTER TO X12 271 ENTITY IDENTIFIER CODE FILE (#365.022)
Entity Identifier Code
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 2-3 character identifier code (NM101).
DESCRIPTION:
The code identifying an organizational entity, a physical location, property or an individual.
356.2213,4.03 ENTITY TYPE QUALIFIER 4;3 SET
Entity Type Qualifier
'1' FOR PERSON;
'2' FOR NON-PERSON ENTITY;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-digit code to qualify the Entity type (NM102).
DESCRIPTION:
The code qualifying the type of entity.
TECHNICAL DESCR:
NM102 qualifies NM103.
356.2213,4.04 CONTACT LAST OR COMPANY NAME 4;4 FREE TEXT
Contact Last or Company Name
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-60 characters.
DESCRIPTION:
The individual Last name or organizational name.
TECHNICAL DESCR:
Required when name information is used by the UMO to identify the requester.
356.2213,4.05 CONTACT FIRST NAME 4;5 FREE TEXT
Contact First Name
INPUT TRANSFORM: K:$L(X)>35!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-35 characters.
DESCRIPTION:
The individual first name.
TECHNICAL DESCR: Required when name information is used by the UMO to identify the requester and the requester is
a person.
356.2213,4.06 CONTACT MIDDLE NAME 4;6 FREE TEXT
Contact Middle Name
INPUT TRANSFORM: K:$L(X)>25!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-25 characters.
DESCRIPTION:
The individual middle name or initial.
TECHNICAL DESCR:
Required when NM104 is present and the middle name/initial of the person is known.
356.2213,4.07 CONTACT NAME SUFFIX 4;7 FREE TEXT
Contact Name Suffix
INPUT TRANSFORM: K:$L(X)>10!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-10 characters.
DESCRIPTION:
The suffix to individual name.
TECHNICAL DESCR: Required when NM104 is valued and the suffix of the individual's name is known; e.g., Sr., Jr.,
or III.
356.2213,4.08 IDENTIFICATION CODE QUALIFIER 4;8 POINTER TO X12 271 IDENTIFICATION QUALIFIER FILE (#365.023)
Identification Code Qualifier
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-2 characters for the Identification Code Qualifier (NM108).
DESCRIPTION:
The code designating the system/method of code structure used for Identification Code (67).
356.2213,4.09 IDENTIFICATION CODE 4;9 FREE TEXT
Identification Code
INPUT TRANSFORM: K:$L(X)>80!($L(X)<2) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 2-80 characters for the Identification Code (NM109).
DESCRIPTION:
The code identifying a party or other code.
356.2213,5 CONTACT ADDRESS LINE-1 5;1 FREE TEXT
Contact Address Line-1
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-55 characters.
DESCRIPTION:
The first line of the address information.
TECHNICAL DESCR:
Use this element for the first line of the requester's address.
356.2213,5.01 CONTACT ADDRESS LINE-2 5;2 FREE TEXT
Contact Address Line-2
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-55 characters.
DESCRIPTION:
The second line of the address information.
TECHNICAL DESCR:
Use this element for the second line of the requester's address.
356.2213,5.02 CONTACT CITY NAME 5;3 FREE TEXT
Contact City Name
INPUT TRANSFORM: K:$L(X)>30!($L(X)<2) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 2-30 characters.
DESCRIPTION:
Free-form text for city name.
TECHNICAL DESCR: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a
location.
356.2213,5.03 CONTACT STATE OR PROVINCE 5;4 POINTER TO STATE FILE (#5)
Contact State or Province
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid state or province.
DESCRIPTION:
The state or province of the contact.
TECHNICAL DESCR: Required when the address is in the United States of America, including its territories or
Canada.
356.2213,5.04 CONTACT ZIP CODE 5;5 FREE TEXT
Contact Zip Code
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 3-15 characters for the Zip Code (N403).
DESCRIPTION: The code defining international postal zone code excluding punctuation and blanks (zip code for
United States).
TECHNICAL DESCR: Required when the address is in the United States of America including its territories or Canada,
or when a postal code exists for the country in N404.
356.2213,5.05 CONTACT COUNTRY CODE 5;6 POINTER TO COUNTRY CODE FILE (#779.004)
Contact Country Code
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 2-3 characters.
DESCRIPTION:
The code identifying the country.
TECHNICAL DESCR:
Required when the address is outside the United States of America.
356.2213,5.06 CONTACT COUNTRY SUBDIVISION 5;7 FREE TEXT
Contact Country Subdivision Code
INPUT TRANSFORM: K:$L(X)>3!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-3 characters.
DESCRIPTION:
The code identifying the country subdivision.
TECHNICAL DESCR: Required when the address is not in the United States of America, including its territories, or
Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. Use the country subdivision codes from Part 2 of ISO 3166.
356.22,14 PATIENT EVENT TRANSPORT 14;0 SET Multiple #356.2214 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds data related to patient event transport information for 278 inquiry.
356.2214,.01 LOCATION TYPE 0;1 SET (Multiply asked)
'45' FOR Drop-off location;
'FS' FOR Final scheduled destination;
'ND' FOR Next destination;
'PW' FOR Pickup address;
'R3' FOR Next scheduled destination;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Location Type.
DESCRIPTION:
The Patient Event Transport code.
CROSS-REFERENCE: 356.2214^B
1)= S ^IBT(356.22,DA(1),14,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),14,"B",$E(X,1,30),DA)
356.2214,.02 LOCATION NAME 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-60 characters.
DESCRIPTION:
The name of the location.
356.2214,.03 ADDRESS LINE 1 0;3 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-55 characters.
DESCRIPTION:
The first line of the location address.
356.2214,.04 ADDRESS LINE 2 0;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>55!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-55 characters.
DESCRIPTION:
The second line of the location address.
356.2214,.05 CITY 0;5 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<2) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 2-30 characters.
DESCRIPTION:
The city of the location.
356.2214,.06 STATE / PROVINCE 0;6 POINTER TO STATE FILE (#5)
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Select state / province code.
DESCRIPTION:
The state or province of the location.
356.2214,.07 ZIP / POSTAL CODE 0;7 FREE TEXT
INPUT TRANSFORM: K:$L(X)>15!($L(X)<3) X
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Answer must be 3-15 characters in length.
DESCRIPTION:
Note: HIPAA is very intolerant of incomplete addresses, so this needs to be correct.
356.22,15 OTHER UMO 15;0 SET Multiple #356.2215 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds data related to patient event other UMO for 278 inquiry.
356.2215,.01 UMO TYPE 0;1 SET (Multiply asked)
'00' FOR Alternate insurer (commercial);
'CA' FOR Carrier (Medicare Part B);
'GG' FOR Intermediary (Medicare Part A);
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid UMO Qualifier.
DESCRIPTION:
The Utilizaton Managment Organization Qualifier.
CROSS-REFERENCE: 356.2215^B
1)= S ^IBT(356.22,DA(1),15,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),15,"B",$E(X,1,30),DA)
356.2215,.02 UMO NAME 0;2 POINTER TO INSURANCE COMPANY FILE (#36)
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid UMO Name.
DESCRIPTION: The name of the payer who previously denied this request. This is a REQUIRED field if the
request has been denied by another UMO.
356.2215,.03 UMO DENIAL REASON #1 0;3 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
INPUT TRANSFORM: S DIC("S")="I $$UDREASN^IBTRH5I(.03)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: UMO DENIAL REASON #1:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid UMO Denial Reason. The entered code must not already be present in Denial Reasons
#2, #3 or #4.
DESCRIPTION: The Denial Reason for which the request was previously denied. Up to 4 Denial Reasons are
allowed.
SCREEN: S DIC("S")="I $$UDREASN^IBTRH5I(.03)"
EXPLANATION: Select a valid UMO Denial Reason
356.2215,.04 UMO DENIAL REASON #2 0;4 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
INPUT TRANSFORM: S DIC("S")="I $$UDREASN^IBTRH5I(.04)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: UMO DENIAL REASON #2:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid UMO Denial Reason. The entered code must not already be present in Denial Reasons
#1, #3 or #4.
DESCRIPTION: The Denial Reason for which the request was previously denied. Up to 4 Denial Reasons are
allowed.
SCREEN: S DIC("S")="I $$UDREASN^IBTRH5I(.04)"
EXPLANATION: Select a valid UMO Denial Reason
356.2215,.05 UMO DENIAL REASON #3 0;5 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
INPUT TRANSFORM: S DIC("S")="I $$UDREASN^IBTRH5I(.05)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: UMO DENIAL REASON #3:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid UMO Denial Reason. The entered code must not already be present in Denial Reasons
#1, #2, or #4.
DESCRIPTION: The Denial Reason for which the request was previously denied. Up to 4 Denial Reasons are
allowed.
SCREEN: S DIC("S")="I $$UDREASN^IBTRH5I(.05)"
EXPLANATION: Select a valid UMO Denial Reason
356.2215,.06 UMO DENIAL REASON #4 0;6 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
INPUT TRANSFORM: S DIC("S")="I $$UDREASN^IBTRH5I(.06)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: UMO DENIAL REASON #4:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid UMO Denial Reason. The entered code must not already be present in Denial Reasons
#1, #2 or #3.
DESCRIPTION: The Denial Reason for which the request was previously denied. Up to 4 Denial Reasons are
allowed.
SCREEN: S DIC("S")="I $$UDREASN^IBTRH5I(.06)"
EXPLANATION: Select a valid UMO Denial Reason
356.2215,.07 UMO DENIAL DATE 0;7 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date.
DESCRIPTION:
The Date on which this request was previously denied.
356.22,16 SERVICE LINE 16;0 Multiple #356.2216 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds data related to each service line.
356.2216,.01 SEQUENCE 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>999999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 999999, 0 decimal digits.
DESCRIPTION:
The Sequence number for this service line.
CROSS-REFERENCE: 356.2216^B
1)= S ^IBT(356.22,DA(1),16,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),16,"B",$E(X,1,30),DA)
356.2216,.02 CERTIFICATION TYPE CODE 0;2 POINTER TO X12 278 CERTIFICATION TYPE CODE FILE (#356.002)
OUTPUT TRANSFORM: CERTIFICATION TYPE CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Certification Type code.
DESCRIPTION:
The Certification Type code for this service line.
356.2216,.03 SERVICE TYPE CODE 0;3 POINTER TO X12 271 SERVICE TYPE FILE (#365.013)
INPUT TRANSFORM: S DIC("S")="I $$SVCTYPE^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: SERVICE TYPE CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Type.
DESCRIPTION: The Service Type of the Service Line. Enter Service Line data ONLY if it differs from the
Patient Event data.
SCREEN: S DIC("S")="I $$SVCTYPE^IBTRH5I()"
EXPLANATION: Select a valid Service Type from the list
356.2216,.04 FACILITY TYPE QUALIFIER 0;4 SET
'A' FOR Uniform Billing Claim Form Bill Type;
'B' FOR Place of Service Codes for Professional or Dental Services;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Location Qualifier.
DESCRIPTION: The Service Location Qualifier of the Service Line. Enter Service Line data ONLY if it differs
from the Patient Event data.
356.2216,.05 FACILITY TYPE 0;5 POINTER TO PLACE OF SERVICE FILE (#353.1)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Facility Type code.
DESCRIPTION: The Facility Type code for this service line. This field is only populated if the FACILITY TYPE
QUALIFIER field for this service line is set to A.
356.2216,.06 LOCATION OF CARE 0;6 SET
'1' FOR Hospital - Inpt or Opt (includes clinics);
'2' FOR Skilled Nursing (NHCU);
'3' FOR Home Health Agency;
'7' FOR Clinic (only independent/satellite);
'8' FOR Spec. Facility Hosp/Amb Surg Ctr;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Location.
DESCRIPTION: The Service Location for this Service Line. Enter Service Line data ONLY if it differs from the
Patient Event data.
356.2216,.07 BILL CLASSIFICATION 0;7 SET
'8' FOR Swingbed;
'1' FOR Inpatient (Medicare-A);
'2' FOR Humanit. Emerg. (Inpatient/Medicare-B);
'3' FOR Outpatient;
'4' FOR Humanit. Emerg. (Outpatient/ESRD);
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Bill Classification.
DESCRIPTION: The Bill Classification code for this service line. This field is only populated if FACILITY
TYPE QUALIFIER field for this service line is set to B.
356.2216,.08 TRACE NUMBER 0;8 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
The trace number for this service line.
356.2216,.09 TRACE ASSIGNING ENTITY 0;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>10!($L(X)<10) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 10 characters in length.
DESCRIPTION:
The identifier of the trace assigning entity for this service line.
356.2216,.1 TRACE ASSIGNING ENTITY DESC. 0;10 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
The additional identifier of the trace assigning entity for this service line.
356.2216,.11 SERVICE DATE 0;11 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:X<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Date.
DESCRIPTION: The Service Date of this service line. Enter Service Line data ONLY if it differs from the
Patient Event data.
356.2216,.12 CERTIFICATION ISSUE DATE 0;12 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Date.
DESCRIPTION:
The date when the UMO issued the authorization.
356.2216,.13 CERTIFICATION EXPIRATION DATE 0;13 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Date.
DESCRIPTION:
The expiration date on which the authorization will expire.
356.2216,.14 CERTIFICATION EFFECTIVE DATE 0;14 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Date.
DESCRIPTION:
The effective date for this authorization.
356.2216,.15 REQUEST CATEGORY 0;15 POINTER TO X12 278 REQUEST CATEGORY FILE (#356.001)
INPUT TRANSFORM: S DIC("S")="I $$REQCAT^IBTRH5C(.15)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM: NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: FEB 02, 2015
HELP-PROMPT: Enter a valid Request Type code.
DESCRIPTION:
The Request Type for this Service Line.
SCREEN: S DIC("S")="I $$REQCAT^IBTRH5C(.15)"
EXPLANATION: Only allows Request Categories that are valid for a service line.
356.2216,.16 CERTIFICATION THRU DATE 0;16 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date.
DESCRIPTION: The certification effective through date, provided by a 278 Response message via X12 segment DTP
Certification Effective Date. Field DTP03 may contain a date range. The through date of this
date range is placed in this field.
356.2216,.17 SERVICE THRU DATE 0;17 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid date.
DESCRIPTION: The through date of service, as reported in a 278 Response message in the DTP Service Level 12
segment (Loop 2000F) in field DTP03 when DTP02 equals RD8.
356.2216,1.01 PROCEDURE CODE TYPE 1;1 SET
'HC' FOR CPT/HCPCS Code;
'N4' FOR NDC Code;
'ZZ' FOR ICD-10-PCS;
'AD' FOR CPT/HCPCS Dental Code;
LAST EDITED: DEC 23, 2015
HELP-PROMPT: Enter a valid Procedure Coding Method.
DESCRIPTION:
The Procedure Coding Method for the related procedure.
SCREEN: S DIC("S")="I $$PROCTYPE^IBTRH5B()"
EXPLANATION:
356.2216,1.02 PROCEDURE #1 1;2 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
81 1 C n HCPCS (CPT) Procedure Codes
80.1 2 I n ICD OPERATION/PROCEDURE
SCREEN ON FILE 81: S DIC("S")="I $$PROC^IBTRH5B(1.02)"
SCREEN EXPLANATION: Restricts look-ups based upon the Procedure Code Type.
SCREEN ON FILE 80.1: S DIC("S")="I $$PROC^IBTRH5B(1.02)"
SCREEN EXPLANATION: Restricts look-ups based upon the Procedure Code Type.
LAST EDITED: JAN 09, 2015
HELP-PROMPT: Enter a valid Procedure.
DESCRIPTION: The Procedure associated with this Service Line. You may enter a beginning Procedure code if you
want to enter a range of codes.
356.2216,1.03 PROCEDURE CODE #2 1;3 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
81 1 C n HCPCS (CPT) Procedure Codes
80.1 2 I n ICD OPERATION/PROCEDURE
SCREEN ON FILE 81: S DIC("S")="I $$PROC^IBTRH5B(1.03)"
SCREEN EXPLANATION: Restricts look-ups based upon the Procedure Code Type.
SCREEN ON FILE 80.1: S DIC("S")="I $$PROC^IBTRH5B(1.03)"
SCREEN EXPLANATION: Restricts look-ups based upon the Procedure Code Type.
LAST EDITED: JAN 09, 2015
HELP-PROMPT: Enter a valid Procedure Code (last in range).
DESCRIPTION: The Procedure associated with this Service Line. You may enter an ending Procedure code if you
want to enter a range of codes. All associated data will apply to the range of codes.
356.2216,1.04 PROCEDURE MODIFIER #1 1;4 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM: S DIC("S")="I $$PROCMOD^IBTRH5B(1.04)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Procedure Modifier. The entered code must not already be present in Procedure
Modifiers #2, #3 or #4.
DESCRIPTION: The Procedure Modifier used to further clarify the procedure. You can enter up to four
modifiers.
SCREEN: S DIC("S")="I $$PROCMOD^IBTRH5B(1.04)"
EXPLANATION: Only allows Procedure Modifier Codes that are not already present in in Procedure Modifiers #2, #3
or #4.
356.2216,1.05 PROCEDURE MODIFIER #2 1;5 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM:S DIC("S")="I $$PROCMOD^IBTRH5B(1.05)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Procedure Modifier. The entered code must not already be present in Procedure
Modifiers #1, #3 or #4.
DESCRIPTION:
The Procedure Modifier used to further clarify the procedure. You can enter up to four modifiers.
SCREEN: S DIC("S")="I $$PROCMOD^IBTRH5B(1.05)"
EXPLANATION: Only allows Procedure Modifier Codes that are not already present in in Procedure Modifiers #1, #3
or #4.
356.2216,1.06 PROCEDURE MODIFIER #3 1;6 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM:S DIC("S")="I $$PROCMOD^IBTRH5B(1.06)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Procedure Modifier. The entered code must not already be present on Procedure
Modifiers #1, #2 or #4.
DESCRIPTION:
The Procedure Modifier used to further clarify the procedure. You can enter up to four modifiers.
SCREEN: S DIC("S")="I $$PROCMOD^IBTRH5B(1.06)"
EXPLANATION: Only allows Procedure Modifier Codes that are not already present in in Procedure Modifiers #1, #2
or #4.
356.2216,1.07 PROCEDURE MODIFIER #4 1;7 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM:S DIC("S")="I $$PROCMOD^IBTRH5B(1.07)" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Procedure Modifier. The entered code must not already be present on Procedure
Modifiers #1, #2 or #3.
DESCRIPTION:
The Procedure Modifier used to further clarify the procedure. You can enter up to four modifiers.
SCREEN: S DIC("S")="I $$PROCMOD^IBTRH5B(1.07)"
EXPLANATION: Only allows Procedure Modifier Codes that are not already present in in Procedure Modifiers #1, #2
or #3.
356.2216,1.08 PROCEDURE DESCRIPTION 1;8 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: The 1-80 character, free text description of when a procedure is a NOC procedure, or, if Dental,
enter the Date of Initial Impression, Date of Initial Preparation Crown, Initial Preparation Tooth
Number or Initial Endodontic TX.
356.2216,1.09 SERVICE LINE AMOUNT 1;9 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>999999999999999)!(X<0) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a dollar amount between 0 and 999999999999999, 2 decimal digits.
DESCRIPTION:
The dollar amount associated with this service line.
356.2216,1.1 UNITS CODE 1;10 SET
'F2' FOR International unit;
'MJ' FOR Minutes;
'UN' FOR Unit;
'DA' FOR Days;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid Basis of Measurement code.
DESCRIPTION:
The Basis of Measurement for how many times a procedure is done.
SCREEN: S DIC("S")="I $$UNITS^IBTRH5H()"
EXPLANATION: 'F2' is used to indicate dosage amount for NDC code.
356.2216,1.11 UNIT COUNT 1;11 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>15)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: JAN 13, 2015
HELP-PROMPT: Enter a whole number between 1 and 15.
DESCRIPTION:
The number which indicates how many times this procedure was performed.
356.2216,1.12 SERVICE LINE TYPE 1;12 SET (Required)
'P' FOR Professional;
'I' FOR Institutional;
'D' FOR Dental;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Service Line Type Code.
DESCRIPTION:
This determines if this service line is for a professional, institutional, or dental service.
356.2216,2.01 DIAGNOSIS #1 2;1 SET
'1' FOR 1st Diagnosis;
'2' FOR 2nd Diagnosis;
'3' FOR 3rd Diagnosis;
'4' FOR 4th Diagnosis;
'5' FOR 5th Diagnosis;
'6' FOR 6th Diagnosis;
'7' FOR 7th Diagnosis;
'8' FOR 8th Diagnosis;
'9' FOR 9th Diagnosis;
'10' FOR 10th Diagnosis;
'11' FOR 11th Diagnosis;
'12' FOR 12th Diagnosis;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a number between 1 and 12 that corresponds to the appropriate Diagnosis Code Line.
DESCRIPTION: The diagnosis that is directly related to this procedure. You can link each procedure to a maximum
of four pointers.
SCREEN: S DIC("S")="I $$SLDXDUP^IBTRH5C(2.01)"
EXPLANATION: The selected Diagnosis must have already been entered in the entry's Diagnoses and must not already
be entered for Diagnosis #2, #3 or #4.
356.2216,2.02 DIAGNOSIS #2 2;2 SET
'1' FOR 1st Diagnosis;
'2' FOR 2nd Diagnosis;
'3' FOR 3rd Diagnosis;
'4' FOR 4th Diagnosis;
'5' FOR 5th Diagnosis;
'6' FOR 6th Diagnosis;
'7' FOR 7th Diagnosis;
'8' FOR 8th Diagnosis;
'9' FOR 9th Diagnosis;
'10' FOR 10th Diagnosis;
'11' FOR 11th Diagnosis;
'12' FOR 12th Diagnosis;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a number between 1 and 12 that corresponds to the appropriate Diagnosis Code Line.
DESCRIPTION: The diagnoses that is directly related to this procedure. You can link each procedure to a maximum
of four pointers.
SCREEN: S DIC("S")="I $$SLDXDUP^IBTRH5C(2.02)"
EXPLANATION: The selected Diagnosis must have already been entered in the entry's Diagnoses and must not already
be entered for Diagnosis #1, #3 or #4.
356.2216,2.03 DIAGNOSIS #3 2;3 SET
'1' FOR 1st Diagnosis;
'2' FOR 2nd Diagnosis;
'3' FOR 3rd Diagnosis;
'4' FOR 4th Diagnosis;
'5' FOR 5th Diagnosis;
'6' FOR 6th Diagnosis;
'7' FOR 7th Diagnosis;
'8' FOR 8th Diagnosis;
'9' FOR 9th Diagnosis;
'10' FOR 10th Diagnosis;
'11' FOR 11th Diagnosis;
'12' FOR 12th Diagnosis;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a number between 1 and 12 that corresponds to the appropriate Diagnosis Code Line.
DESCRIPTION: The diagnoses that is directly related to this procedure. You can link each procedure to a maximum
of four pointers.
SCREEN: S DIC("S")="I $$SLDXDUP^IBTRH5C(2.03)"
EXPLANATION: The selected Diagnosis must have already been entered in the entry's Diagnoses and must not already
be entered for Diagnosis #1, #2 or #4.
356.2216,2.04 DIAGNOSIS #4 2;4 SET
'1' FOR 1st Diagnosis;
'2' FOR 2nd Diagnosis;
'3' FOR 3rd Diagnosis;
'4' FOR 4th Diagnosis;
'5' FOR 5th Diagnosis;
'6' FOR 6th Diagnosis;
'7' FOR 7th Diagnosis;
'8' FOR 8th Diagnosis;
'9' FOR 9th Diagnosis;
'10' FOR 10th Diagnosis;
'11' FOR 11th Diagnosis;
'12' FOR 12th Diagnosis;
LAST EDITED: APR 13, 2015
HELP-PROMPT: Enter a number between 1 and 12 that corresponds to the appropriate Diagnosis Code Line.
DESCRIPTION: The diagnoses that is directly related to this procedure. You can link each procedure to a maximum
of four pointers.
SCREEN: S DIC("S")="I $$SLDXDUP^IBTRH5C(2.04)"
EXPLANATION: The selected Diagnosis must have already been entered in the entry's Diagnoses and must not already
be entered for Diagnosis #1, #2 or #3.
356.2216,2.05 EPSDT? 2;5 SET
'N' FOR No;
'Y' FOR Yes;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter Y if this procedure is associated with early and periodic screening for diagnosis and
treatment of children (EPSDT).
DESCRIPTION: Determines whether or not the selected procedure is associated with early and periodic screening
for diagnosis and treatment of children (EPSDT).
356.2216,2.06 REVENUE CODE 2;6 POINTER TO REVENUE CODE FILE (#399.2)
OUTPUT TRANSFORM:REVENUE CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Revenue Code.
DESCRIPTION: The Revenue Code for this service line if you are requesting approval based on a specific revenue
code. Enter Service Line data ONLY if it differs from the Patient Event data.
356.2216,2.07 RATE 2;7 NUMBER
INPUT TRANSFORM:S:X["$" X=$P(X,"$",2) K:X'?.N.1".".2N!(X>9999999999)!(X<0) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a dollar amount between 0 and 9999999999, 2 decimal digits.
DESCRIPTION: Enter the monetary amount of the per unit rate of the associated hospital accommodation revenue
code.
356.2216,2.08 NURSING HOME STATUS 2;8 POINTER TO X12 278 NURSING HOME RESIDENTIAL STATUS FILE (#356.011)
INPUT TRANSFORM:S DIC("S")="I $$NHOME^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM:NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid Nursing Home Status code.
DESCRIPTION: The REQUIRED Nursing Home (SNF) Residential status. Enter Service Line data ONLY if it differs
from the Patient Event data.
SCREEN: S DIC("S")="I $$NHOME^IBTRH5H()"
EXPLANATION: Valid codes specifying the status of a nursing home resident at the time of service.
356.2216,2.09 NURSING HOME LEVEL OF CARE 2;9 POINTER TO X12 278 NURSING HOME LEVEL OF CARE FILE (#356.019)
OUTPUT TRANSFORM:NURSING HOME LEVEL OF CARE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Nursing Home Level of Care code.
DESCRIPTION: The Level of Care provided by the Nursing Home. Enter Service Line data ONLY if it differs from the
Patient Event data.
356.2216,3.01 ORAL CAVITY DESIGNATION #1 3;1 SET
'00' FOR Entire Oral Cavity;
'01' FOR Maxillary Arch;
'02' FOR Mandibular Arch;
'10' FOR Upper Right Quadrant;
'20' FOR Upper Left Quadrant;
'30' FOR Lower Left Quadrant;
'40' FOR Lower Right Quadrant;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oral Cavity Designation code. The entered code must not already be present in Oral
Cavity Designations #2, #3, #4 or #5.
DESCRIPTION:
The first Oral Cavity Designation code. You can enter up to five codes.
SCREEN: S DIC("S")="I $$ORALCAV^IBTRH5B(3.01)"
EXPLANATION: Only allows Oral Cavity Designation Codes that are not already present in in Oral Cavity Designatio
ns #2, #3, #4 or #5.
356.2216,3.02 ORAL CAVITY DESIGNATION #2 3;2 SET
'00' FOR Entire Oral Cavity;
'01' FOR Maxillary Arch;
'02' FOR Mandibular Arch;
'10' FOR Upper Right Quadrant;
'20' FOR Upper Left Quadrant;
'30' FOR Lower Left Quadrant;
'40' FOR Lower Right Quadrant;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Oral Cavity Designation Code. The entered code must not already be present in Oral
Cavity Designations #1, #3, #4 or #5.
DESCRIPTION:
The second Oral Cavity Designation code. You can enter up to five codes.
SCREEN: S DIC("S")="I $$ORALCAV^IBTRH5B(3.02)"
EXPLANATION: Only allows Oral Cavity Designation Codes that are not already present in in Oral Cavity Designatio
ns #1, #3, #4 or #5.
356.2216,3.03 ORAL CAVITY DESIGNATION #3 3;3 SET
'00' FOR Entire Oral Cavity;
'01' FOR Maxillary Arch;
'02' FOR Mandibular Arch;
'10' FOR Upper Right Quadrant;
'20' FOR Upper Left Quadrant;
'30' FOR Lower Left Quadrant;
'40' FOR Lower Right Quadrant;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oral Cavity Designation Code. The entered code must not already be present in Oral
Cavity Designations #1, #2, #4 or #5.
DESCRIPTION:
The third Oral Cavity Designation code. You can enter up to five codes.
SCREEN: S DIC("S")="I $$ORALCAV^IBTRH5B(3.03)"
EXPLANATION: Only allows Oral Cavity Designation Codes that are not already present in in Oral Cavity Designatio
ns #1, #2, #4 or #5.
356.2216,3.04 ORAL CAVITY DESIGNATION #4 3;4 SET
'00' FOR Entire Oral Cavity;
'01' FOR Maxillary Arch;
'02' FOR Mandibular Arch;
'10' FOR Upper Right Quadrant;
'20' FOR Upper Left Quadrant;
'30' FOR Lower Left Quadrant;
'40' FOR Lower Right Quadrant;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid Oral Cavity Designation code. The entered code must not already be present in Oral
Cavity Designations #1, #2, #3 or #5.
DESCRIPTION:
The fourth Oral Cavity Designation code. You can enter up to five codes.
SCREEN: S DIC("S")="I $$ORALCAV^IBTRH5B(3.04)"
EXPLANATION: Only allows Oral Cavity Designation Codes that are not already present in in Oral Cavity Designatio
ns #1, #2, #3 or #5.
356.2216,3.05 ORAL CAVITY DESIGNATION #5 3;5 SET
'00' FOR Entire Oral Cavity;
'01' FOR Maxillary Arch;
'02' FOR Mandibular Arch;
'10' FOR Upper Right Quadrant;
'20' FOR Upper Left Quadrant;
'30' FOR Lower Left Quadrant;
'40' FOR Lower Right Quadrant;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Oral Cavity Designation code. The entered code must not already be present in Oral
Cavity Designations #1, #2, #3 or #4.
DESCRIPTION:
The fifth Oral Cavity Designation code. You can enter up to five codes.
SCREEN: S DIC("S")="I $$ORALCAV^IBTRH5B(3.05)"
EXPLANATION: Only allows Oral Cavity Designation Codes that are not already present in in Oral Cavity Designatio
ns #1, #2, #3 or #4.
356.2216,3.06 PLACEMENT STATUS 3;6 SET
'I' FOR Initial placement;
'R' FOR Replacement;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Placement Status code.
DESCRIPTION:
The code that indicates the placement status of the prosthetic.
356.2216,3.07 DENTAL WORK DESCRIPTION 3;7 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION: The free-form description of dental work for this service line. This field should be populated when
necessary to describe the reason for prosthesis, crown, or inlay replacement.
356.2216,4 TOOTH INFORMATION 4;0 POINTER Multiple #356.22164 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds tooth information for the dental service line.
356.22164,.01 TOOTH CODE 0;1 POINTER TO X12 278 DENTAL NUMBERING SYSTEM FILE (#356.022) (Multiply asked)
OUTPUT TRANSFORM:TOOTH CODE:DESCRIPTION
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Code.
DESCRIPTION:
The tooth that requires work.
CROSS-REFERENCE:356.22164^B
1)= S ^IBT(356.22,DA(2),16,DA(1),4,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(2),16,DA(1),4,"B",$E(X,1,30),DA)
356.22164,.02 TOOTH SURFACE #1 0;2 SET
'B' FOR Buccal;
'D' FOR Distal;
'F' FOR Facial;
'I' FOR Incisal;
'L' FOR Lingual;
'M' FOR Mesial;
'O' FOR Occlusal;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Surface code. The entered code must not already be present in Tooth Surfaces
#2, #3, #4 or #5.
DESCRIPTION: The code that best describes the area of the tooth that was treated. Up to five Tooth Surfaces
are allowed.
SCREEN: S DIC("S")="I $$TOOTHS^IBTRH5B(.02)"
EXPLANATION: Only allows Tooth Surface Codes that are not already present in Tooth Surfaces #2, #3, #4 or #5.
356.22164,.03 TOOTH SURFACE #2 0;3 SET
'B' FOR Buccal;
'D' FOR Distal;
'F' FOR Facial;
'I' FOR Incisal;
'L' FOR Lingual;
'M' FOR Mesial;
'O' FOR Occlusal;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Surface code. The entered code must not already be present in Tooth Surfaces
#1, #3, #4 or #5.
DESCRIPTION: The code that best describes the area of the tooth that was treated. Up to five Tooth Surfaces
are allowed.
SCREEN: S DIC("S")="I $$TOOTHS^IBTRH5B(.03)"
EXPLANATION: Only allows Tooth Surface Codes that are not already present in Tooth Surfaces #1, #3, #4 or #5.
356.22164,.04 TOOTH SURFACE #3 0;4 SET
'B' FOR Buccal;
'D' FOR Distal;
'F' FOR Facial;
'I' FOR Incisal;
'L' FOR Lingual;
'M' FOR Mesial;
'O' FOR Occlusal;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Surface code. The entered code must not already be present in Tooth Surfaces
#1, #2, #4 or #5.
DESCRIPTION: The code that best describes the area of the tooth that was treated. Up to five Tooth Surfaces
are allowed.
SCREEN: S DIC("S")="I $$TOOTHS^IBTRH5B(.04)"
EXPLANATION: Only allows Tooth Surface Codes that are not already present in Tooth Surfaces #1, #2, #4 or #5.
356.22164,.05 TOOTH SURFACE #4 0;5 SET
'B' FOR Buccal;
'D' FOR Distal;
'F' FOR Facial;
'I' FOR Incisal;
'L' FOR Lingual;
'M' FOR Mesial;
'O' FOR Occlusal;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Surface code. The entered code must not already be present in Tooth Surfaces
#1, #2, #3 or #5.
DESCRIPTION: The code that best describes the area of the tooth that was treated. Up to five Tooth Surfaces
are allowed.
SCREEN: S DIC("S")="I $$TOOTHS^IBTRH5B(.05)"
EXPLANATION: Only allows Tooth Surface Codes that are not already present in Tooth Surfaces #1, #2, #3 or #5.
356.22164,.06 TOOTH SURFACE #5 0;6 SET
'B' FOR Buccal;
'D' FOR Distal;
'F' FOR Facial;
'I' FOR Incisal;
'L' FOR Lingual;
'M' FOR Mesial;
'O' FOR Occlusal;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Tooth Surface code. The entered code must not already be present in Tooth Surfaces
#1, #2, #3 or #4.
DESCRIPTION: The code that best describes the area of the tooth that was treated. Up to five Tooth Surfaces
are allowed.
SCREEN: S DIC("S")="I $$TOOTHS^IBTRH5B(.06)"
EXPLANATION: Only allows Tooth Surface Codes that are not already present in Tooth Surfaces #1, #2, #3 or #4.
356.2216,5.01 HCSD QUANTITY QUALIFIER 5;1 POINTER TO X12 271 QUANTITY QUALIFIER FILE (#365.016)
INPUT TRANSFORM:S DIC("S")="I $$HCSDQQ^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid quantity qualifier for this service line.
DESCRIPTION:
The Health Care Services Delivery quantity qualifier for this service line.
SCREEN: S DIC("S")="I $$HCSDQQ^IBTRH5H()"
EXPLANATION: Enter a valid Quantity Qualifier Code.
356.2216,5.02 HCSD SERVICE UNIT COUNT 5;2 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>999999999999999)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a number between 0 and 999999999999999, 0 decimal digits.
DESCRIPTION:
The Health Care Services Delivery service unit count for this service line.
356.2216,5.03 HCSD UNITS OF MEASUREMENT 5;3 SET
'DA' FOR Days;
'MO' FOR Months;
'WK' FOR Weeks;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Units of Measurement code for this service line.
DESCRIPTION:
The Health Care Services Delivery Unit or Basis for Measurement code for this service line.
356.2216,5.04 HCSD SAMPLE SELECTION MODULUS 5;4 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>999)!(X<0)!(X?.E1"."3.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 0 and 999, 2 decimal digits.
DESCRIPTION:
The Health Care Services Delivery Sample Selection Modulus for this service line.
356.2216,5.05 HCSD TIME PERIOD QUALIFIER 5;5 POINTER TO X12 271 TIME PERIOD QUALIFIER FILE (#365.015)
INPUT TRANSFORM:S DIC("S")="I $$TIMEPDQ^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM:NOT EXECUTABLE!! -- SPECIFIER NEEDS AN "O"!
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Time Period Qualifier for this service line.
DESCRIPTION:
The Health Care Services Delivery Time Period Qualifier for this service line.
SCREEN: S DIC("S")="I $$TIMEPDQ^IBTRH5I()"
EXPLANATION: Select a valid Time Period Qualifier
356.2216,5.06 HCSD PERIOD COUNT 5;6 NUMBER
INPUT TRANSFORM:K:+X'=X!(X>999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 999, 0 decimal digits.
DESCRIPTION:
The Health Care Services Delivery Period Count for this service line.
356.2216,5.07 HCSD DELIVERY FREQUENCY 5;7 POINTER TO X12 271 DELIVERY FREQUENCY CODE FILE (#365.025)
INPUT TRANSFORM:S DIC("S")="I $$HCSDFC^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Delivery Frequency Code for this service line.
DESCRIPTION:
The Health Care Services Delivery Frequency code for this service line.
SCREEN: S DIC("S")="I $$HCSDFC^IBTRH5H()"
EXPLANATION: Enter a valid Delivery Frequency Code.
356.2216,5.08 HCSD DELIVERY TIME PATTERN 5;8 POINTER TO X12 278 DELIVERY PATTERN TIME CODE FILE (#356.007)
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Delivery Pattern Time Code for this service line.
DESCRIPTION:
The Health Care Services Delivery Pattern Time code for this service line.
356.2216,6 ATTACHMENTS 6;0 POINTER Multiple #356.22166 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains additional patient information (attachments) for service line level.
356.22166,.01 REPORT TYPE CODE 0;1 POINTER TO X12 278 REPORT TYPE CODE FILE (#356.018) (Multiply asked)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Report Type code.
DESCRIPTION:
The Report Type code for this service line.
CROSS-REFERENCE:356.22166^B
1)= S ^IBT(356.22,DA(2),16,DA(1),6,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(2),16,DA(1),6,"B",$E(X,1,30),DA)
356.22166,.02 REPORT TRANSMISSION CODE 0;2 SET
'AA' FOR Available on request at provider site;
'BM' FOR By mail;
'EL' FOR Electronically only;
'EM' FOR E-mail;
'FX' FOR By fax;
'VO' FOR Voice;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Report Transmission code.
DESCRIPTION:
The Report Transmission code for this service line.
356.22166,.03 ATTACHMENT CONTROL NUMBER 0;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<2) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 2-80 characters in length.
DESCRIPTION:
The Attachment Control Number for this service line.
356.22166,.04 ATTACHMENT DESCRIPTION 0;4 FREE TEXT
INPUT TRANSFORM:K:$L(X)>80!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-80 characters in length.
DESCRIPTION:
The description of attachment for this service line.
356.2216,7 MESSAGE TEXT 7;0 WORD-PROCESSING #356.22167 (IGNORE "|")
DESCRIPTION:
An additional free text comment for this service line.
LAST EDITED: DEC 31, 2014
DESCRIPTION:
The free text message associated with this service line.
356.2216,8 SERVICE PROVIDER 8;0 POINTER Multiple #356.22168 (Add New Entry without Asking)
DESCRIPTION:
This multiple holds data related to providers for this service line.
356.22168,.01 PROVIDER TYPE 0;1 POINTER TO X12 271 ENTITY IDENTIFIER CODE FILE (#365.022) (Multiply asked)
INPUT TRANSFORM:S DIC("S")="I $$SPROVTYP^IBTRH5H()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
OUTPUT TRANSFORM:PROVIDER TYPE:DESCRIPTION
LAST EDITED: FEB 20, 2015
HELP-PROMPT: Enter a valid Provider Type code.
DESCRIPTION:
The Provider Type (entity identifier code) for this service line.
SCREEN: S DIC("S")="I $$SPROVTYP^IBTRH5H()"
EXPLANATION: Enter a valid Provider Type.
CROSS-REFERENCE:356.22168^B
1)= S ^IBT(356.22,DA(2),16,DA(1),8,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(2),16,DA(1),8,"B",$E(X,1,30),DA)
356.22168,.02 PERSON / NON-PERSON 0;2 SET
'1' FOR Person;
'2' FOR Non-person;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter 1 if the selected Provider is a Person or N otherwise.
DESCRIPTION: Determines whether or not the selected Provider for this service line is a Person or a
Non-Person (e.g. a Facility).
356.22168,.03 PROVIDER 0;3 VARIABLE POINTER
FILE ORDER PREFIX LAYGO MESSAGE
200 1 V n VA providers
355.93 2 N n Non-VA providers
4 3 F n Institutions
SCREEN ON FILE 200: S DIC("S")="I $O(^(""USC1"",0)),+$P($$NPI^XUSNPI(""Individual_ID"",Y),U)>0"
SCREEN EXPLANATION: Enter a valid VA Provider with valid NPI
SCREEN ON FILE 355.93: S DIC("S")="I +$$NPIGET^IBCEP81(Y)>0"
SCREEN EXPLANATION: Enter a valid non-VA provider with valid NPI
SCREEN ON FILE 4: S DIC("S")="I +$P($$NPI^XUSNPI(""Organization_ID"",Y),U)>0"
SCREEN EXPLANATION: Enter a valid institution with valid NPI
LAST EDITED: FEB 23, 2016
HELP-PROMPT: Enter a valid Provider.
DESCRIPTION:
The Provider for this service line.
356.22168,.04 PER LOOP IDENTIFIER 0;4 POINTER TO X12 271 LOOP ID FILE (#365.027)
PER Loop Identifier
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Per Loop Identifier.
DESCRIPTION:
The PER Loop Identifier for this Service Line.
356.22168,.05 CONTACT FUNCTION CODE 0;5 FREE TEXT
Contact Function Code
INPUT TRANSFORM:K:$L(X)>2!($L(X)<2) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 2-character Contact Function Code (PER01).
DESCRIPTION:
The code identifying the major duty or responsibility of the person or group named.
356.22168,.06 CONTACT NAME 0;6 FREE TEXT
Contact Name
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 1-60 character free-form name (PER02).
DESCRIPTION:
The Free-form name of the Contact.
TECHNICAL DESCR:Required when the response must be directed to a particular contact and when the name of
the entity to contact is not already defined or is different than the name within the prior
name segment (e.g., N1 or NM1).
356.22168,.07 COMMUNICATION NO. QUALIFIER-1 0;7 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-1
INPUT TRANSFORM:S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Communication Qualifier code.
DESCRIPTION: The Communication Qualifier to identify what kind of reference the related Contact
Communication Number is.
TECHNICAL DESCR:
Required when PER02 is not valued in order to transmit a contact communication number.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.22168,.08 COMMUNICATION NO. QUALIFIER-2 0;8 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-2
INPUT TRANSFORM:S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Communication Qualifier code.
DESCRIPTION: The Communication Qualifier to identify what kind of reference the related Contact
Communication Number is.
TECHNICAL DESCR:
Required when a telephone extension or multiple communication types are available.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.22168,.09 COMMUNICATION NO. QUALIFIER-3 0;9 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
Communication Number Qualifier-3
INPUT TRANSFORM:S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a valid Communication Qualifier code.
DESCRIPTION: The Communication Qualifier to identify what kind of reference the related Contact
Communication Number is.
TECHNICAL DESCR:
Required when a telephone extension or multiple communicaton types are available.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.22168,1 CONTACT COMMUNICATION NUMBER-1 1;1 FREE TEXT
Contact Communication Number-1
INPUT TRANSFORM:K:$L(X)>250!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 1-250 character Communication Number (PER04).
DESCRIPTION:
The Complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Required when PER02 is not valued to transmit a contact communication number.
356.22168,2 CONTACT COMMUNICATION NUMBER-2 2;1 FREE TEXT
Contact Communication Number-2
INPUT TRANSFORM:K:$L(X)>250!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 1-250 character Communication Number (PER06).
DESCRIPTION:
The Complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Required when the telephone extension or multiple communication numbers are available.
356.22168,3 CONTACT COMMUNICATION NUMBER-3 3;1 FREE TEXT
Contact Communication Number-3
INPUT TRANSFORM:K:$L(X)>250!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 1-250 character Communication Number (PER08).
DESCRIPTION:
The Complete communications number including country or area code when applicable.
TECHNICAL DESCR:
Required when the telephone extension or multiple communication numbers are available.
356.22168,4.01 NM1 LOOP IDENTIFIER 4;1 POINTER TO X12 271 LOOP ID FILE (#365.027)
NM1 Loop Identifier
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid NM1 Loop Identifier code.
DESCRIPTION:
The NM1 Loop Identifier.
356.22168,4.02 ENTITY IDENTIFIER CODE 4;2 POINTER TO X12 271 ENTITY IDENTIFIER CODE FILE (#365.022)
Entity Identifier Code
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 2-3 character identifier code (NM101).
DESCRIPTION: The code identifying an organizational entity, a physical location, property or an
individual.
356.22168,4.03 ENTITY TYPE QUALIFIER 4;3 SET
Entity Type Qualifier
'1' FOR PERSON;
'2' FOR NON-PERSON ENTITY;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the 1-digit code to qualify the Entity Type (NM102).
DESCRIPTION:
The code qualifying the type of entity.
TECHNICAL DESCR:
NM102 qualifies NM103.
356.22168,4.04 CONTACT LAST OR COMPANY NAME 4;4 FREE TEXT
Contact Last or Company Name
INPUT TRANSFORM:K:$L(X)>60!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-60 characters for the Contact Last/Company Name (NM103).
DESCRIPTION:
The individual last name or organizational name.
TECHNICAL DESCR:
Required when name information is used by the UMO to identify the requester.
356.22168,4.05 CONTACT FIRST NAME 4;5 FREE TEXT
Contact First Name
INPUT TRANSFORM:K:$L(X)>35!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-35 characters for the Contact First Name (NM104).
DESCRIPTION:
The individual first name.
TECHNICAL DESCR:Required when name information is used by the UMO to identify the requester and the
requester is a person.
356.22168,4.06 CONTACT MIDDLE NAME 4;6 FREE TEXT
Contact Middle Name
INPUT TRANSFORM:K:$L(X)>25!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-25 characters for the Contact Middle Name (NM105).
DESCRIPTION:
The individual middle name or initial.
TECHNICAL DESCR:
Required when NM104 is present and the middle name/initial of the person is known.
356.22168,4.07 CONTACT NAME SUFFIX 4;7 FREE TEXT
Contact Name Suffix
INPUT TRANSFORM:K:$L(X)>10!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 1-10 characters for the Contact Name Suffix (NM107).
DESCRIPTION:
The Suffix to the individual name.
TECHNICAL DESCR:Required when NM104 is valued and the suffix of the individual's name is known; e.g., Sr.,
Jr., or III.
356.22168,4.08 IDENTIFICATION CODE QUALIFIER 4;8 POINTER TO X12 271 IDENTIFICATION QUALIFIER FILE (#365.023)
Identification Code Qualifier
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 1-2 characters for the Identification Code Qualifier (NM108).
DESCRIPTION:
The code designating the system/method of code structure used for Identification Code (67).
356.22168,4.09 IDENTIFICATION CODE 4;9 FREE TEXT
Identification Code
INPUT TRANSFORM:K:$L(X)>80!($L(X)<2) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 2-80 characters for the Identification Code (NM109).
DESCRIPTION:
The code identifying a party or other code.
356.22168,5 CONTACT ADDRESS LINE-1 5;1 FREE TEXT
Contact Address Line-1
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter 1-55 characters of Line 1 of Address (N301).
DESCRIPTION:
The first line of Address Information.
TECHNICAL DESCR:
Use this element for the first line of the requester's address.
356.22168,5.01 CONTACT ADDRESS LINE-2 5;2 FREE TEXT
Contact Address Line-2
INPUT TRANSFORM:K:$L(X)>55!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 1-55 characters of Line 2 of Address (N302).
DESCRIPTION:
The second line of Address Information.
TECHNICAL DESCR:
Use this element for the second line of the requester's address.
356.22168,5.02 CONTACT CITY NAME 5;3 FREE TEXT
Contact City Name
INPUT TRANSFORM:K:$L(X)>30!($L(X)<2) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 2-30 characters for the City Name (N401).
DESCRIPTION:
The Free-form text for the city name.
TECHNICAL DESCR:A combination of either N401 through N404, or N405 and N406 may be adequate to specify a
location.
356.22168,5.03 CONTACT STATE OR PROVINCE 5;4 POINTER TO STATE FILE (#5)
Contact State or Province
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 2 characters to identify the State or Province (N402).
DESCRIPTION:
The code (Standard or State/Province) as defined by the appropriate government agency.
TECHNICAL DESCR:Required when the address is in the United States of America, including its territories, or
Canada.
356.22168,5.04 CONTACT ZIP CODE 5;5 FREE TEXT
Contact Zip Code
INPUT TRANSFORM:K:$L(X)>15!($L(X)<3) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 3-15 characters for the Zip Code (N403).
DESCRIPTION: The code defining international postal zone code excluding punctuation and blanks (zip code
for United States).
TECHNICAL DESCR:Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404.
356.22168,5.05 CONTACT COUNTRY CODE 5;6 POINTER TO COUNTRY CODE FILE (#779.004)
Contact Country Code
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 2-3 characters for the Country Code (NM404).
DESCRIPTION:
The Code identifying the country.
TECHNICAL DESCR:
Required when the address is outside the United States of America.
356.22168,5.06 CONTACT COUNTRY SUBDIVISION 5;7 FREE TEXT
Contact Country Subdivision Code
INPUT TRANSFORM:K:$L(X)>3!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 1-3 characters for the Country Subdivision Code (NM407).
DESCRIPTION:
The code identifying the country subdivision.
TECHNICAL DESCR:Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but
not limited to states, provinces, cantons, etc. Use the country subdivision codes from Part
2 of ISO 3166.
356.2216,9.01 PREV. AUTHORIZATION # 9;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: Th Previous Authorization Number from the UMO that is associated with this service line.
Enter Service Line data ONLY if it differs from the Patient Event data.
356.2216,9.02 PREV. ADMIN. REFERENCE # 9;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: The previous Administrative Reference Number from the UMO that is associated with this
service line. Enter Service Line data ONLY if it differs from the Patient Event data.
356.2216,10 HI SEGMENTS 10;0 Multiple #356.2316 (Add New Entry without Asking)
LAST EDITED: SEP 24, 2014
DESCRIPTION:
This multiple contains data for HI segments.
356.2316,.01 HI SEQUENCE 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM:K:+X'=X!(X>12)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter a number between 1 and 12, 0 decimal digits.
DESCRIPTION:
The sequential number of the HI segment.
CROSS-REFERENCE:356.2316^B
1)= S ^IBT(356.22,DA(2),16,DA(1),10,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(2),16,DA(1),10,"B",$E(X,1,30),DA)
356.2316,.02 CODE LIST QUALIFIER CODE 0;2 POINTER TO X12 278 DIAGNOSIS TYPE FILE (#356.006)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the code for the Diagnosis Type.
DESCRIPTION:
The code identifying a specific industry code list.
356.2316,.03 INDUSTRY CODE 0;3 FREE TEXT
INPUT TRANSFORM:K:$L(X)>30!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-30 characters in length.
DESCRIPTION:
The code indicating a code from a specific industry code list.
TECHNICAL DESCR:The UMO can use each occurrence of the Health Care Code Information composite (C022) to
specify codes that identify the specific information that the UMO requires from the
provider to complete the medical review.
356.2316,.04 DATE 0;4 DATE
INPUT TRANSFORM:S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter the a valid date.
DESCRIPTION:
The Diagnosis Date for HI segment.
356.2216,11.01 CERTIFICATION ACTION CODE 11;1 POINTER TO X12 278 CERTIFICATION ACTION CODES FILE (#356.02)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be a valid X12 278 Certification Action Code.
DESCRIPTION:
The code indicating the type of action.
356.2216,11.02 REVIEW IDENTIFICATION NUMBER 11;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>50!($L(X)<1) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: The Reference information as defined for a particular Transaction Set or as specified by
the Reference Identification Qualifier.
TECHNICAL DESCR:HCR02 is the number assigned by the information source this this review outcome.
Required when HCR01 = A1 or A6
356.2216,11.03 REVIEW DECISION REASON CODE 11;3 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Answer must be a valid X12 278 HCS Decision Reason Code.
DESCRIPTION:
The code indicating a code from a specific industry code list.
TECHNICAL DESCR:HCR03 is the code assigned by the information source to identify the reason for the
health care service review outcome indicated in HCR01. See Code Source 886. Required
when HCR01=A3 or A4.
356.2216,11.04 SECOND SURGICAL OPINION FLAG 11;4 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Enter 'YES' to indicate that a second surgical opinion is required.
DESCRIPTION:
This field indicates whether a second surgical opinion is required.
TECHNICAL DESCR:HCR04 is the second surgical opinion indicator. A 'Y' value indicates a second surgical
opinion is required; an 'N' value indicates a second surgical opinion is not required for
this request.
356.2216,12.01 NDC CODE #1 12;1 FREE TEXT
INPUT TRANSFORM:K:$L(X)>13!($L(X)<13)!'(X?5N1"-"4N1"-"2N) X
LAST EDITED: JAN 12, 2015
HELP-PROMPT: Answer must be 13 characters in length.
DESCRIPTION:
Enter a National Drug Code in a 5-4-2 format (nnnnn-nnnn-nn).
TECHNICAL DESCR:The National Drug Code must be 13 characters in length and have a format of 5-4-2
(nnnnn-nnnn-nn).
356.2216,12.02 NDC CODE #2 12;2 FREE TEXT
INPUT TRANSFORM:K:$L(X)>13!($L(X)<13)!'(X?5N1"-"4N1"-"2N) X
LAST EDITED: JAN 12, 2015
HELP-PROMPT: Answer must be 13 characters in length.
DESCRIPTION:
Enter a National Drug Code in a 5-4-2 format (nnnnn-nnnn-nn).
TECHNICAL DESCR:The National Drug Code must be 13 characters in length and have a format of 5-4-2
(nnnnn-nnnn-nn).
356.22,17.01 PREV. AUTHORIZATION # 17;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: NOV 18, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION:
Enter the previous Authorization Number from the UMO that is associated with this patient event.
356.22,17.02 PREV. ADMIN. REFERENCE # 17;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: NOV 18, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: Enter the previous Administrative Reference Number from the UMO that is associated with this
patient event.
356.22,18.01 WEIGHT UNITS 18;1 SET
Weight Units
'KG' FOR KILOGRAM;
'LB' FOR POUND;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the Unit of Measurement Code for Weight (CR101).
DESCRIPTION: THE code specifying the units in which a value is being expressed, or manner in which a measurement
has been taken. (CR101)
TECHNICAL DESCR:
Required when CR102 (Patient Weight) is present.
356.22,18.02 PATIENT WEIGHT 18;2 NUMBER
Weight
INPUT TRANSFORM: K:+X'=X!(X>9999999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 9999999999, 0 decimal digits.
DESCRIPTION:
Enter the patient's weight in pounds.
TECHNICAL DESCR: Required when patient weight information is needed to justify the medical necessity of the level of
ambulance services.
356.22,18.03 AMBULANCE TRANSPORT CODE 18;3 SET
'I' FOR INITIAL TRIP;
'R' FOR RETURN TRIP;
'T' FOR TRANSFER TRIP;
'X' FOR ROUND TRIP;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter a valid Ambulance Transportation Code.
DESCRIPTION:
The type of ambulance transportation trip.
356.22,18.04 AMBULANCE TRANSPORT REASON 18;4 SET
'A' FOR NEAREST FACILITY;
'B' FOR PREFERRED PHYSICIAN;
'C' FOR NEARNESS OF FAMILY;
'D' FOR SPECIALIST OR SPECIAL EQUIP.;
'E' FOR REHABILITATION FACILITY;
'F' FOR RESIDENTIAL FACILITY;
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Select the most appropriate Ambulance Transport Reason.
DESCRIPTION:
Enter a code here to indicate the reason why the patient was transported to a particular location.
TECHNICAL DESCR:
Required when ambulance transport reason is required to determine medical necessity.
356.22,18.05 DISTANCE UNITS 18;5 SET
Distance Units
'DH' FOR MILES;
'DK' FOR KILOMETERS;
LAST EDITED: MAY 09, 2014
HELP-PROMPT: Enter the Unit of Measurement Code for Transport (CR105).
DESCRIPTION:
This field indicates the units of the value expressed in the field Transport Distance.
TECHNICAL DESCR:
Required when distance of transportation is known.
356.22,18.06 TRANSPORT DISTANCE 18;6 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>999999999999999)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Type a number between 1 and 999999999999999, 0 decimal digits.
DESCRIPTION:
This field represents the distance the patient was transported.
TECHNICAL DESCR:
Required when distance of transportation is known.
356.22,18.09 ROUND TRIP PURPOSE DESCRIPTION 18;9 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Enter a 1-80 character, free text description.
DESCRIPTION: The text entered here should explain why a round trip was needed. This field is REQUIRED when the
Transport Code is Round Trip.
TECHNICAL DESCR:
Required when CR103 (Ambulance Transport Code) equals 'X Round Trip'.
356.22,18.1 STRETCHER PURPOSE DESCRIPTION 18;10 FREE TEXT
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: NOV 19, 2014
HELP-PROMPT: Enter a 1-80 character, free text description.
DESCRIPTION:
The text entered here should explain why a stretcher was needed.
TECHNICAL DESCR:
Required when CR103 (Ambulance Transport Code) equals 'X Round Trip'.
356.22,19 UMO CONTACT NAME 19;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>60!($L(X)<1) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Answer must be 1-60 characters in length.
DESCRIPTION:
The name of the UMO contact person.
356.22,19.01 COMMUNICATION NO. QUALIFIER-1 19;2 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Select a Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-1.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To only select valid Communication Qualifiers.
356.22,19.02 COMMUNICATION NO. QUALIFIER-2 19;3 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Select a Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-2.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.22,19.03 COMMUNICATION NO. QUALIFIER-3 19;4 POINTER TO X12 271 CONTACT QUALIFIER FILE (#365.021)
INPUT TRANSFORM: S DIC("S")="I $$COMQUAL^IBTRH5I()" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: DEC 31, 2014
HELP-PROMPT: Select a Communication Qualifier.
DESCRIPTION: The value entered here identifies the type of number entered in the field Contact Communication
Number-3.
SCREEN: S DIC("S")="I $$COMQUAL^IBTRH5I()"
EXPLANATION: To screen for valid Communication Qualifiers.
356.22,20 CONTACT COMMUNICATION NUMBER-1 20;1 FREE TEXT
INPUT TRANSFORM: K:'$$CONTPH^IBTRH5C(20) X
LAST EDITED: FEB 04, 2015
HELP-PROMPT: Enter a valid Phone Number, Email or Phone Number Extension.
DESCRIPTION:
This is a 10 digit phone/FAX number (format: nnnnnnnnnn or nnn-nnn-nnnn) or an email/URL address.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
356.22,21 CONTACT COMMUNICATION NUMBER-2 21;1 FREE TEXT
INPUT TRANSFORM: K:'$$CONTPH^IBTRH5C(21) X
LAST EDITED: FEB 04, 2015
HELP-PROMPT: Enter a valid Phone Number, Email or Phone Number Extension.
DESCRIPTION:
This is a 10 digit phone/FAX number (format: nnnnnnnnnn or nnn-nnn-nnnn) or an email/URL address.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
356.22,22 CONTACT COMMUNICATION NUMBER-3 22;1 FREE TEXT
INPUT TRANSFORM: K:'$$CONTPH^IBTRH5C(22) X
LAST EDITED: FEB 04, 2015
HELP-PROMPT: Enter a valid Phone Number, Email or Phone Number Extension.
DESCRIPTION:
This is a 10 digit phone/FAX number (format: nnnnnnnnnn or nnn-nnn-nnnn) or an email/URL address.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
356.22,23 DELETE REASON NOTE 23;0 WORD-PROCESSING #356.2223 (IGNORE "|")
DESCRIPTION: This note is available to provide additional information pertaining to the removal of a 278
Request(217) or Inquiry(215) from the HCSR Worklist.
LAST EDITED: MAY 15, 2015
HELP-PROMPT: Please enter a note to describe the reason for removal from the HCSR Worklist.
DESCRIPTION:
This is the word processing note field for the Delete Reason.
356.22,101 AAA SEGMENTS 101;0 Multiple #356.22101 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains AAA segments data from 278 response.
356.22101,.01 AAA SEQUENCE 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: SEP 24, 2014
HELP-PROMPT: Type a number between 1 and 999, 0 decimal digits.
DESCRIPTION:
Sequential number of AAA segment.
CROSS-REFERENCE: 356.22101^B
1)= S ^IBT(356.22,DA(1),101,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),101,"B",$E(X,1,30),DA)
356.22101,.02 AAA LOOP IDENTIFIER 0;2 POINTER TO X12 271 LOOP ID FILE (#365.027)
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter an X12 271 Loop ID.
DESCRIPTION:
The loop identifier for the AAA segment.
356.22101,.03 VALID REQUEST INDICATOR 0;3 SET
Valid Request Indicator
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter Y to indicate that the 278 request is valid and the rejection is caused by something other
than errors in the request. Enter N to indicate an invalid request.
DESCRIPTION:
Determines if the 278 request is valid or or invalid.
TECHNICAL DESCR: AAA01 designates whether the request is valid or invalid. Code 'Y' indicates that the code is
valid; code 'N' indicates that the code is invalid.
356.22101,.04 REJECT REASON CODE 0;4 POINTER TO X12 271 ERROR CONDITION FILE (#365.017)
Reject Reason Code
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 2-digit Reason Code for Rejection (AAA04).
DESCRIPTION:
The code assigned by issuer to identify reason for rejection.
356.22101,.05 FOLLOW-UP ACTION CODE 0;5 POINTER TO X12 271 ERROR ACTION FILE (#365.018)
Follow-up Action Code
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-character code for the Follow-up Action (AAA04).
DESCRIPTION:
The code identifying follow-up actions allowed.
356.22101,1 FSC ERROR MESSAGE 1;1 FREE TEXT
INPUT TRANSFORM: K:$L(X)>250!($L(X)<1) X
LAST EDITED: MAY 12, 2014
HELP-PROMPT: Enter 1-250 characters for the FSC Error Message.
DESCRIPTION: This the field to store the FSC Error message that was not reported by the HCCH via the X12 AAA
segment.
356.22,103.01 CERTIFICATION ACTION CODE 103;1 POINTER TO X12 278 CERTIFICATION ACTION CODES FILE (#356.02)
LAST EDITED: NOV 13, 2014
HELP-PROMPT: Answer must be a valid X12 278 Certification Action Code.
DESCRIPTION:
Code indicating type of action.
356.22,103.02 REVIEW IDENTIFICATION NUMBER 103;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: JUL 07, 2014
HELP-PROMPT: Answer must be 1-50 characters in length.
DESCRIPTION: Reference information as defined for a particular Transaction Set or as specified by the Reference
Identification Qualifier.
TECHNICAL DESCR: HCR02 is the number assigned by the information source to this review outcome. Required when HCR02
equals A1, A2 or A6.
356.22,103.03 REVIEW DECISION REASON CODE 103;3 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021)
LAST EDITED: DEC 10, 2014
HELP-PROMPT: Answer must be a valid X12 278 HCS Decision Reason Code.
DESCRIPTION:
Code indicating a code from a specific industry code list.
TECHNICAL DESCR: HCR03 is the code assigned by the information source to identify the reason for the health care
service review outcome indicated in HCR01. See Code Source 886. Required when HCR01 equals A3 or
A4.
356.22,103.04 SECOND SURGICAL OPINION FLAG 103;4 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: SEP 24, 2014
HELP-PROMPT: Enter 'YES' if second surgical opinion is required, 'NO' otherwise.
DESCRIPTION:
This field should be set to 'YES' if second surgical opinion is required.
TECHNICAL DESCR: HCR04 is the second surgical opinion indicator. A 'Y' value indicates a second surgical opinion is
required; an 'N' value indicates a second surgical opinion is not required for this request.
356.22,105 TRN SEGMENTS 105;0 Multiple #356.22105 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains TRN segments data.
356.22105,.01 TRN SEQUENCE 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>999)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Type a number between 1 and 999, 0 decimal digits.
DESCRIPTION:
The sequential number of the TRN segment.
CROSS-REFERENCE: 356.22105^B
1)= S ^IBT(356.22,DA(1),105,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),105,"B",$E(X,1,30),DA)
356.22105,.02 TRN LOOP IDENTIFIER 0;2 POINTER TO X12 271 LOOP ID FILE (#365.027)
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter an X12 271 Loop ID.
DESCRIPTION:
The loop identifier for the TRN segment.
356.22105,.03 TRACE TYPE CODE 0;3 SET
Trace Type Code
'1' FOR CURRENT TRX TRACE NOS.;
'2' FOR REFERENCED TRX TRACE NOS.;
LAST EDITED: JAN 02, 2015
HELP-PROMPT: Enter the 1-2 character Transaction Trace Type Code (TRN01).
DESCRIPTION:
The code identifying which transaction is being referenced.
356.22105,.04 TRACE NUMBER 0;4 FREE TEXT
Reference Identification
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: MAY 09, 2014
HELP-PROMPT: Enter the 1-50 character Trace Number (TRN02).
DESCRIPTION: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier.
TECHNICAL DESCR:
TRN02 provides unique identification for the transaction.
356.22105,.05 TRACE ASSIGNING ENTITY ID 0;5 FREE TEXT
Originating Company Identifier
INPUT TRANSFORM: K:$L(X)>10!($L(X)<10) X
LAST EDITED: MAY 22, 2014
HELP-PROMPT: Enter a 10-character Trace Assigning Entity Identifier (TRN03).
DESCRIPTION: A unique identifier designating the company initiating the funds transfer instructions, business
transaction or assigning tracking reference identification.
TECHNICAL DESCR:
TRN03 identifies an organization.
356.22105,.06 TRACE ASSIGNING ENTITY ID-2 0;6 FREE TEXT
Additional Reference Identification
INPUT TRANSFORM: K:$L(X)>50!($L(X)<1) X
LAST EDITED: MAY 09, 2014
HELP-PROMPT: Enter 1-50 characters to further identify the organization (TRN04).
DESCRIPTION: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier.
TECHNICAL DESCR:
TRN04 identifies a further subdivision within the organization.
356.22,107 HI SEGMENTS 107;0 Multiple #356.22107 (Add New Entry without Asking)
DESCRIPTION:
This multiple contains data for HI segments.
356.22107,.01 HI SEQUENCE 0;1 NUMBER (Multiply asked)
INPUT TRANSFORM: K:+X'=X!(X>12)!(X<1)!(X?.E1"."1.N) X
LAST EDITED: SEP 24, 2014
HELP-PROMPT: Type a number between 1 and 12, 0 decimal digits.
DESCRIPTION:
This is a sequential number of the HI segment.
CROSS-REFERENCE: 356.22107^B
1)= S ^IBT(356.22,DA(1),107,"B",$E(X,1,30),DA)=""
2)= K ^IBT(356.22,DA(1),107,"B",$E(X,1,30),DA)
356.22107,.02 CODE LIST QUALIFIER CODE 0;2 POINTER TO X12 278 DIAGNOSIS TYPE FILE (#356.006)
Code List Qualifier Code
LAST EDITED: SEP 24, 2014
HELP-PROMPT: Enter 1-3 characters for the Code List Qualifier Code (HI##-1).
DESCRIPTION:
Code identifying a specific industry code list.
356.22107,.03 INDUSTRY CODE 0;3 FREE TEXT
Industry Code
INPUT TRANSFORM: K:$L(X)>30!($L(X)<1) X
LAST EDITED: MAY 22, 2014
HELP-PROMPT: Enter 1-30 characters for the Industry Code (HI##-2).
DESCRIPTION:
Code indicating a code from a specific industry code list.
TECHNICAL DESCR:
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
356.22107,.04 DATE 0;4 DATE
INPUT TRANSFORM: S %DT="E" D ^%DT S X=Y K:X<1 X
LAST EDITED: JAN 06, 2015
HELP-PROMPT: Enter a valid date (it may be imprecise).
DESCRIPTION:
This field contains diagnosis date (it may be imprecise) for the HI segment.
FILES POINTED TO FIELDS
COUNTRY CODE (#779.004) COUNTRY (#2.12)
PATIENT EVENT PROVIDER:CONTACT COUNTRY CODE (#5.05)
SERVICE PROVIDER:CONTACT COUNTRY CODE (#5.05)
CPT (#81) SURGICAL PROCEDURE CODE (#10.07)
CPT MODIFIER (#81.3) SERVICE LINE:PROCEDURE MODIFIER #1 (#1.04)
PROCEDURE MODIFIER #2 (#1.05)
PROCEDURE MODIFIER #3 (#1.06)
PROCEDURE MODIFIER #4 (#1.07)
HCS REVIEW TRANSMISSION (#356.22) INQUIRY (#.13)
RESPONSE (#.14)
HCSR WORKLIST DELETE REASON CO
(#356.023) DELETE REASON (#.25)
HOSPITAL LOCATION (#44) CLINIC (#.06)
ICD OPERATION/PROCEDURE (#80.1) SURGICAL PROCEDURE CODE (#10.07)
INSURANCE COMPANY (#36) OTHER UMO:UMO NAME (#.02)
NEW PERSON (#200) MARKED 'IN PROGRESS' BY (#.09)
REQUESTED BY (#.11)
MANUALLY REMOVED BY (#.24)
COMMENTS:ENTERED BY (#.02)
PATIENT (#2) PATIENT (#.02)
PLACE OF SERVICE (#353.1) FACILITY TYPE (#2.05)
SERVICE LINE:FACILITY TYPE (#.05)
REVENUE CODE (#399.2) SERVICE LINE:REVENUE CODE (#2.06)
STATE (#5) STATE (#2.11)
PATIENT EVENT PROVIDER:CONTACT STATE OR PROVINCE (#5.03)
PATIENT EVENT TRANSPORT:STATE / PROVINCE (#.06)
SERVICE PROVIDER:CONTACT STATE OR PROVINCE (#5.03)
WARD LOCATION (#42) WARD (#.05)
X12 271 CONTACT QUALIFIER
(#365.021) COMMUNICATION NO. QUALIFIER-1 (#19.01)
COMMUNICATION NO. QUALIFIER-2 (#19.02)
COMMUNICATION NO. QUALIFIER-3 (#19.03)
PATIENT EVENT PROVIDER:COMMUNICATION NO. QUALIFIER-1 (#.07)
COMMUNICATION NO. QUALIFIER-2 (#.08)
COMMUNICATION NO. QUALIFIER-3 (#.09)
SERVICE PROVIDER:COMMUNICATION NO. QUALIFIER-1 (#.07)
COMMUNICATION NO. QUALIFIER-2 (#.08)
COMMUNICATION NO. QUALIFIER-3 (#.09)
X12 271 DELIVERY FREQUENCY COD
(#365.025) HCSD DELIVERY FREQUENCY (#4.07)
SERVICE LINE:HCSD DELIVERY FREQUENCY (#5.07)
X12 271 ENTITY IDENTIFIER CODE
(#365.022) PATIENT EVENT PROVIDER:PROVIDER TYPE (#.01)
ENTITY IDENTIFIER CODE (#4.02)
SERVICE PROVIDER:PROVIDER TYPE (#.01)
ENTITY IDENTIFIER CODE (#4.02)
X12 271 ERROR ACTION (#365.018) AAA SEGMENTS:FOLLOW-UP ACTION CODE (#.05)
X12 271 ERROR CONDITION (#365.017) AAA SEGMENTS:REJECT REASON CODE (#.04)
X12 271 IDENTIFICATION QUALIFI
(#365.023) PATIENT EVENT PROVIDER:IDENTIFICATION CODE QUALIFIER (#4.08)
SERVICE PROVIDER:IDENTIFICATION CODE QUALIFIER (#4.08)
X12 271 LOOP ID (#365.027) AAA SEGMENTS:AAA LOOP IDENTIFIER (#.02)
TRN SEGMENTS:TRN LOOP IDENTIFIER (#.02)
PATIENT EVENT PROVIDER:PER LOOP IDENTIFIER (#.04)
NM1 LOOP IDENTIFIER (#4.01)
SERVICE PROVIDER:PER LOOP IDENTIFIER (#.04)
NM1 LOOP IDENTIFIER (#4.01)
X12 271 QUANTITY QUALIFIER
(#365.016) HCSD QUANTITY QUALIFIER (#4.01)
SERVICE LINE:HCSD QUANTITY QUALIFIER (#5.01)
X12 271 SERVICE TYPE (#365.013) SERVICE TYPE CODE (#2.03)
SERVICE LINE:SERVICE TYPE CODE (#.03)
X12 271 TIME PERIOD QUALIFIER
(#365.015) HCSD TIME PERIOD QUALIFIER (#4.05)
SERVICE LINE:HCSD TIME PERIOD QUALIFIER (#5.05)
X12 278 ADMISSION SOURCE
(#356.009) ADMISSION SOURCE (#7.02)
X12 278 CERTIFICATION ACTION C
(#356.02) CERTIFICATION ACTION CODE (#103.01)
SERVICE LINE:CERTIFICATION ACTION CODE (#11.01)
X12 278 CERTIFICATION TYPE COD
(#356.002) CERTIFICATION TYPE CODE (#2.02)
SERVICE LINE:CERTIFICATION TYPE CODE (#.02)
X12 278 CONDITION CODE (#356.008) AMBULANCE CONDITION #1 (#4.1)
AMBULANCE CONDITION #2 (#4.11)
AMBULANCE CONDITION #3 (#4.12)
AMBULANCE CONDITION #4 (#4.13)
AMBULANCE CONDITION #5 (#4.14)
CHIROPRACTIC CONDITION #1 (#5.02)
CHIROPRACTIC CONDITION #2 (#5.03)
CHIROPRACTIC CONDITION #3 (#5.04)
CHIROPRACTIC CONDITION #4 (#5.05)
CHIROPRACTIC CONDITION #5 (#5.06)
DME CONDITION #1 (#5.08)
DME CONDITION #2 (#5.09)
DME CONDITION #3 (#5.1)
DME CONDITION #4 (#5.11)
DME CONDITION #5 (#5.12)
OXYGEN CONDITION #1 (#5.14)
OXYGEN CONDITION #2 (#5.15)
OXYGEN CONDITION #3 (#5.16)
OXYGEN CONDITION #4 (#5.17)
OXYGEN CONDITION #5 (#5.18)
FUNCT. LIMIT CONDITION #1 (#6.02)
FUNCT. LIMIT CONDITION #2 (#6.03)
FUNCT. LIMIT CONDITION #3 (#6.04)
FUNCT. LIMIT CONDITION #4 (#6.05)
FUNCT. LIMIT CONDITION #5 (#6.06)
ACTIVITIES CONDITION #1 (#6.08)
ACTIVITIES CONDITION #2 (#6.09)
ACTIVITIES CONDITION #3 (#6.1)
ACTIVITIES CONDITION #4 (#6.11)
ACTIVITIES CONDITION #5 (#6.12)
MENTAL STATUS CONDITION #1 (#6.14)
MENTAL STATUS CONDITION #2 (#6.15)
MENTAL STATUS CONDITION #3 (#6.16)
MENTAL STATUS CONDITION #4 (#6.17)
MENTAL STATUS CONDITION #5 (#6.18)
X12 278 CURRENT HEALTH CONDITI
(#356.003) CURRENT HEALTH CONDITION (#2.14)
X12 278 DELAY REASON CODE
(#356.005) DELAY REASON (#2.17)
X12 278 DELIVERY PATTERN TIME
(#356.007) HCSD DELIVERY TIME PATTERN (#4.08)
SERVICE LINE:HCSD DELIVERY TIME PATTERN (#5.08)
X12 278 DENTAL NUMBERING SYSTE
(#356.022) TOOTH INFORMATION:TOOTH CODE (#.01)
X12 278 DIAGNOSIS TYPE (#356.006) HI SEGMENTS:CODE LIST QUALIFIER CODE (#.02)
PATIENT DIAGNOSIS:DIAGNOSIS TYPE (#.01)
HI SEGMENTS:CODE LIST QUALIFIER CODE (#.02)
X12 278 HCS DECISION REASON CO
(#356.021) REVIEW DECISION REASON CODE (#103.03)
OTHER UMO:UMO DENIAL REASON #1 (#.03)
UMO DENIAL REASON #2 (#.04)
UMO DENIAL REASON #3 (#.05)
UMO DENIAL REASON #4 (#.06)
SERVICE LINE:REVIEW DECISION REASON CODE (#11.03)
X12 278 NURSING HOME LEVEL OF
(#356.019) SERVICE LINE:NURSING HOME LEVEL OF CARE (#2.09)
X12 278 NURSING HOME RESIDENTI
(#356.011) NURSING HOME STATUS (#7.04)
SERVICE LINE:NURSING HOME STATUS (#2.08)
X12 278 OXYGEN DELIVERY SYSTEM
(#356.016) OXYGEN DELIVERY SYSTEM (#9.08)
X12 278 OXYGEN EQUIPMENT TYPE
(#356.013) OXYGEN EQUIPMENT TYPE #1 (#8.01)
OXYGEN EQUIPMENT TYPE #2 (#8.02)
OXYGEN EQUIPMENT TYPE #3 (#8.03)
X12 278 OXYGEN TEST CONDITION
(#356.014) OXYGEN TEST CONDITION (#9.03)
X12 278 OXYGEN TEST FINDINGS
(#356.015) OXYGEN TEST FINDINGS #1 (#9.04)
OXYGEN TEST FINDINGS #2 (#9.05)
OXYGEN TEST FINDINGS #3 (#9.06)
X12 278 PATIENT LOCATION
(#356.017) PATIENT LOCATION (#10.13)
X12 278 PATIENT STATUS (#356.01) PATIENT STATUS (#7.03)
X12 278 PROGNOSIS CODE (#356.004) PROGNOSIS CODE (#2.15)
X12 278 REPORT TYPE CODE
(#356.018) ATTACHMENTS:REPORT TYPE CODE (#.01)
ATTACHMENTS:REPORT TYPE CODE (#.01)
X12 278 REQUEST CATEGORY
(#356.001) REQUEST CATEGORY (#2.01)
SERVICE LINE:REQUEST CATEGORY (#.15)
X12 278 SUBLUXATION LEVEL CODE
(#356.012) SUBLUXATION LEVEL CODE #1 (#7.07)
SUBLUXATION LEVEL CODE #2 (#7.08)
File #356.22
Record Indexes:
AD (#459) RECORD MUMPS IR SORTING ONLY
Short Descr: Used to populate entries into the HCSR Worklist in a timely fashion
Set Logic: S ^IBT(356.22,"AD",+$E(X(1),1,2),$E(X(2),1,30),DA)=""
Kill Logic: K ^IBT(356.22,"AD",+$E(X(1),1,2),$E(X(2),1,30),DA)
Whole Kill: K ^IBT(356.22,"AD")
X(1): STATUS (356.22,.08) (Subscr 1) (Len 2) (forwards)
X(2): DATE ENTERED (356.22,.01) (Subscr 2) (Len 30) (forwards)
D (#470) RECORD REGULAR IR LOOKUP & SORTING
Short Descr: Patient and Admission Date Range
Description: Cross-reference index of Patient and Admission Date Range.
Set Logic: S ^IBT(356.22,"D",$E(X(1),1,30),$E(X(2),1,30),DA)=""
Kill Logic: K ^IBT(356.22,"D",$E(X(1),1,30),$E(X(2),1,30),DA)
Whole Kill: K ^IBT(356.22,"D")
X(1): PATIENT (356.22,.02) (Subscr 1) (Len 30) (forwards)
Lookup Prompt: PATIENT NAME
X(2): EVENT DATE (356.22,.07) (Subscr 2) (Len 30) (forwards)
Lookup Prompt: Appt/Adm
E (#1215) RECORD REGULAR IR LOOKUP & SORTING
Short Descr: Used to prevent creation of multiple events for the same source
Set Logic: S ^IBT(356.22,"E",$E(X(4),1,16),$E(X(1),1,1),$E(X(2),1,7),$E(X(3),1,16),DA)=""
Kill Logic: K ^IBT(356.22,"E",$E(X(4),1,16),$E(X(1),1,1),$E(X(2),1,7),$E(X(3),1,16),DA)
Whole Kill: K ^IBT(356.22,"E")
X(1): INPATIENT / OUTPATIENT (356.22,.04) (Subscr 2) (Len 1) (forwards)
X(2): INSURANCE POLICY (356.22,.03) (Subscr 3) (Len 7) (forwards)
X(3): SOURCE (356.22,.16) (Subscr 4) (Len 16) (forwards)
X(4): PATIENT (356.22,.02) (Subscr 1) (Len 16) (forwards)
INPUT TEMPLATE(S):
IB ADD/EDIT 278 MAR 02, 2016@12:49 USER #0
IB CREATE 278 REQUEST DEC 01, 2014@11:07 USER #0
Used to create/Edit a 278 request for a selected HCSR Worklist event
IB CREATE 278 REQUEST SHORT MAR 14, 2016@17:47 USER #0
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):