STANDARD DATA DICTIONARY #46 -- INPATIENT CPT CODE FILE 3/24/25 PAGE 1
STORED IN ^DGCPT(46, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 5.3)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file is used to capture inpatient professional services for billing. Entries from this file are used on the CMS 1500. This
file can be used to capture billing information for observation visits The date and time of the professional service is used as a
unique identifier for the professional service.
CROSS
REFERENCED BY: CPT CODE(B), PTF(C)
INDEXED BY: CPT CODE & PTF & PRIMARY DIAGNOSIS & SECONDARY DIAGNOSIS 1 & SECONDARY DIAGNOSIS 2 & SECONDARY DIAGNOSIS 3 &
SECONDARY DIAGNOSIS 4 & SECONDARY DIAGNOSIS 5 & SECONDARY DIAGNOSIS 6 & SECONDARY DIAGNOSIS 7 & DELETE DATE (AICNC)
LAST MODIFIED: JUN 24,2020@12:14:04
46,.01 CPT CODE 0;1 POINTER TO CPT FILE (#81) (Required)
INPUT TRANSFORM: S DIC("S")="D EN6^DGPTFJC I 'DGER" D ^DIC K DIC S DIC=$G(DIE),X=+Y K:Y<0 X
LAST EDITED: APR 30, 2007
HELP-PROMPT: Enter the procedure, services or supplies using CPT or HCPCS
DESCRIPTION: This is the procedure, services, or supplies used for the patient. It is using the Healthcare
Common Procedure Coding System (HCPCS) or Common Procedure Terminology (CPT) code. This value
appears on the CMS 1500 in box 24d. The values in this field will be provided to the billing
package when the record is closed.
SCREEN: S DIC("S")="D EN6^DGPTFJC I 'DGER"
EXPLANATION: Allow only active CPT procedures
DELETE TEST: 1,0)= W *7,!,"USE DELETE OPTION TO DO LOGICAL DELETE"
CROSS-REFERENCE: 46^B
1)= S ^DGCPT(46,"B",$E(X,1,30),DA)=""
2)= K ^DGCPT(46,"B",$E(X,1,30),DA)
CROSS-REFERENCE: ^^TRIGGER^46^.02
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^DGCPT(46,D0,0)):^(0),1:"") S X=$P(Y(1),U,2),X=X S D
IU=X K Y S X=DIV S X="" S DIH=$G(^DGCPT(46,DIV(0),0)),DIV=X S $P(^(0),U,2)=DIV,DIH=46,DIG=.02 D ^DI
CR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^DGCPT(46,D0,0)):^(0),1:"") S X=$P(Y(1),U,2),X=X S D
IU=X K Y S X=DIV S X="" S DIH=$G(^DGCPT(46,DIV(0),0)),DIV=X S $P(^(0),U,2)=DIV,DIH=46,DIG=.02 D ^DI
CR
CREATE VALUE)= S X="@"
DELETE VALUE)= S X="@"
FIELD)= CPT MODIFIER 1
CROSS-REFERENCE: ^^TRIGGER^46^.03
1)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^DGCPT(46,D0,0)):^(0),1:"") S X=$P(Y(1),U,3),X=X S D
IU=X K Y S X="" S DIH=$G(^DGCPT(46,DIV(0),0)),DIV=X S $P(^(0),U,3)=DIV,DIH=46,DIG=.03 D ^DICR
2)= K DIV S DIV=X,D0=DA,DIV(0)=D0 S Y(1)=$S($D(^DGCPT(46,D0,0)):^(0),1:"") S X=$P(Y(1),U,3),X=X S D
IU=X K Y S X="" S DIH=$G(^DGCPT(46,DIV(0),0)),DIV=X S $P(^(0),U,3)=DIV,DIH=46,DIG=.03 D ^DICR
CREATE VALUE)= S X=""
DELETE VALUE)= S X=""
FIELD)= CPT MODIFIER 2
RECORD INDEXES: AICNC (#836)
46,.02 CPT MODIFIER 1 0;2 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM: S DIC("S")="I $$MODP^ICPTMOD($P(^DGCPT(46,DA,0),U),Y,""I"",DGPRD)>0,$P(^DGCPT(46,DA,0),U,3)'=Y" D ^
DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAR 31, 2005
HELP-PROMPT: Indicates that a service or procedure has been altered, but code unchanged.
DESCRIPTION: Used to indicate that a service or procedure has been altered by some specific circumstance but
without changing the definition or code.
SCREEN: S DIC("S")="I $$MODP^ICPTMOD($P(^DGCPT(46,DA,0),U),Y,""I"",DGPRD)>0,$P(^DGCPT(46,DA,0),U,3)'=Y"
EXPLANATION: ALLOW ONLY MODIFIERS VALID FOR THIS CPT
NOTES: TRIGGERED by the CPT CODE field of the INPATIENT CPT CODE File
46,.03 CPT MODIFIER 2 0;3 POINTER TO CPT MODIFIER FILE (#81.3)
INPUT TRANSFORM: S DIC("S")="I $$MODP^ICPTMOD($P(^DGCPT(46,DA,0),U),Y,""I"",DGPRD)>0,$P(^DGCPT(46,DA,0),U,2)'=Y" D ^
DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: MAR 31, 2005
HELP-PROMPT: Indicates that a service or procedure has been altered, but code UNCHANGED.
DESCRIPTION: Used to indicate that a service or procedure has been altered by some specific circumstance but not
changed definition or code.
SCREEN: S DIC("S")="I $$MODP^ICPTMOD($P(^DGCPT(46,DA,0),U),Y,""I"",DGPRD)>0,$P(^DGCPT(46,DA,0),U,2)'=Y"
EXPLANATION: ALLOW ONLY MODIFIERS VALID FOR THIS CPT
NOTES: TRIGGERED by the CPT CODE field of the INPATIENT CPT CODE File
46,.04 PRIMARY DIAGNOSIS 0;4 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select the primary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: The diagnosis code most directly related to the procedure code performed for this professional
service. This field must be entered for each CPT code entered. It appears in box 21 on the
CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.05 SECONDARY DIAGNOSIS 1 0;5 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.06 SECONDARY DIAGNOSIS 2 0;6 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.07 SECONDARY DIAGNOSIS 3 0;7 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.08 TREATED FOR SC CONDITION 0;8 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: The patient care must be Service Connected.
DESCRIPTION: Enter 'Y' if this applicant is service connected and the professional service is related to that
service connection. Otherwise enter 'N'. This field can only be entered if the service connection
information was entered in registration. See field .301 in file 2.
46,.09 TREATED FOR AO CONDITION 0;9 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: The Patient must have Agent Orange exposure indicated!
DESCRIPTION: The Agent Orange questions must be answered yes in registration before this field can be entered.
Enter 'Y' if this procedure is related to Agent Orange exposure based on the related diagnosis.
See field .32102 in file 2.
46,.1 TREATED FOR IR CONDITION 0;10 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: The Patient must have Ionizing Radiation exposure indicated!
DESCRIPTION: Enter 'Y' if the procedure performed is related to exposure to ionizing . Enter 'N' if the
procedure performed is unrelated to ionizing radiation. The ionizing radiation information must be
entered in registration before it can be entered here. See field .32111 in file 2.
46,.11 EXPOSED TO ENVIR CONTAMINANTS 0;11 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: The Patient must have Environment Contaminants exposure!
DESCRIPTION: Enter 'Y' if the procedure performed is related to exposure to environmental contamination. Enter
'N' if the procedure performed is unrelated to environmental contamination. This information must
be entered in Registration before it can be entered here. See field .322013 in file 2.
46,.12 TREATMENT FOR MST 0;12 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: Was the treatment related to Military Sexual Trauma.
DESCRIPTION: Enter 'Y' if the procedure performed is related to military sexual trauma. Enter 'N' if the
procedure performed is unrelated to military sexual trauma. This information must be entered in
registration first.
46,.13 TREATMENT FOR HEAD/NECK CA 0;13 SET (Required)
'1' FOR YES;
'0' FOR NO;
LAST EDITED: MAY 27, 2003
HELP-PROMPT: Was the treatment related to Head and/or Neck Cancer.
DESCRIPTION: Enter 'Y' if this procedure is related to treatment for head/neck cancer. Enter 'N' is the
procedure is unrelated to the patient's head/neck cancer.
46,.131 COMBAT VET 0;19 SET
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: FEB 24, 2004
HELP-PROMPT: Care is potentially related to military combat.
DESCRIPTION: Indiacte if the inpatient stay at this location is related to military service in combat and not
from cause other than military service in combat operations (congenital, developmental, pre-service
existing conditions, or conditions having specific and well-established etiology that began after
military combat service, i.e., bone fractures occuring after separation date, comon colds, ect).
This information can only be entered if the patient has CV status in Registration.
46,.14 CPT RECORD DATE/TIME 1;1 DATE (Required)
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JAN 22, 2004
HELP-PROMPT: Date and time the professional service occurred.
DESCRIPTION:
The date and time the professional service was performed. May not be exact. Must be unique.
46,.16 PTF 1;3 POINTER TO PTF FILE (#45) (Required)
LAST EDITED: MAY 13, 2003
HELP-PROMPT: Enter the inpatient episode to enter professional service for.
DESCRIPTION:
Pointer to the inpatient record in the PTF file (45).
CROSS-REFERENCE: 46^C
1)= S ^DGCPT(46,"C",$E(X,1,30),DA)=""
2)= K ^DGCPT(46,"C",$E(X,1,30),DA)
RECORD INDEXES: AICNC (#836)
46,.17 SOURCE 1;4 FREE TEXT
INPUT TRANSFORM: K:$L(X)>30!($L(X)<3) X
LAST EDITED: SEP 17, 2003
HELP-PROMPT: ENTER THE PACKAGE WHICH PROVIDED THE DATA.
DESCRIPTION: SOURCE is a string of text (3-30 character) identifying the source of the data or Examples of
SOURCE are: "LAB DATA". "RADIOLOGY DATA".
46,.18 USER 1;2 POINTER TO NEW PERSON FILE (#200)
LAST EDITED: SEP 17, 2003
HELP-PROMPT: ENTER THE USER WHO LAST EDITED THIS ENTRY.
DESCRIPTION: User who is responsible for add/edit/delete action on the encounter. Pointer to the New Person file
(200).
46,.2 QUANTITY 0;14 NUMBER
INPUT TRANSFORM: K:+X'=X!(X>99)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: JUN 19, 2003
HELP-PROMPT: Enter a number between 1 and 99 indicating how many times this procedure was done.
DESCRIPTION:
This is the number of times this procedure was done to the patient for one professional service.
46,.21 SECONDARY DIAGNOSIS 4 0;15 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.22 SECONDARY DIAGNOSIS 5 0;16 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.23 SECONDARY DIAGNOSIS 6 0;17 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,.24 SECONDARY DIAGNOSIS 7 0;18 POINTER TO ICD DIAGNOSIS FILE (#80)
INPUT TRANSFORM: D GETAPI^DGICDGT("DG PTF","DIAG",$G(PTF),"EN5")
LAST EDITED: JAN 23, 2017
HELP-PROMPT: Select a secondary diagnosis associated with the procedure performed on the CMS 1500.
DESCRIPTION: A secondary diagnosis related to the procedure performed for this professional service. This field
is optional. It appears in box 21 on the CMS-1500 and is associated with a procedure in box 24e.
NOTES: XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
RECORD INDEXES: AICNC (#836)
46,1 DELETE DATE 9;1 DATE
INPUT TRANSFORM: S %DT="ETXR" D ^%DT S X=Y K:Y<1 X
LAST EDITED: JUN 20, 2003
HELP-PROMPT: Enter the date that the CPT code was deleted from the professional service.
RECORD INDEXES: AICNC (#836)
FILES POINTED TO FIELDS
CPT (#81) CPT CODE (#.01)
CPT MODIFIER (#81.3) CPT MODIFIER 1 (#.02)
CPT MODIFIER 2 (#.03)
ICD DIAGNOSIS (#80) PRIMARY DIAGNOSIS (#.04)
SECONDARY DIAGNOSIS 1 (#.05)
SECONDARY DIAGNOSIS 2 (#.06)
SECONDARY DIAGNOSIS 3 (#.07)
SECONDARY DIAGNOSIS 4 (#.21)
SECONDARY DIAGNOSIS 5 (#.22)
SECONDARY DIAGNOSIS 6 (#.23)
SECONDARY DIAGNOSIS 7 (#.24)
NEW PERSON (#200) USER (#.18)
PTF (#45) PTF (#.16)
File #46
Record Indexes:
AICNC (#836) RECORD MUMPS IR ACTION
Short Descr: Notify packages of ICD diagnosis code change.
Description: This cross-reference will notify subscribing packages via protocol DG PTF ICD DIAGNOSIS NOTIFIER when an ICD
diagnosis code is added, edited or removed.
Set Logic: D NOTIFY^DGPTDD(.X1,.X2,.DA,46,"SERVICE46","SET")
Kill Logic: D NOTIFY^DGPTDD(.X1,.X2,.DA,46,"SERVICE46","KILL")
X(1): CPT CODE (46,.01) (forwards)
X(2): PTF (46,.16) (forwards)
X(3): PRIMARY DIAGNOSIS (46,.04) (forwards)
X(4): SECONDARY DIAGNOSIS 1 (46,.05) (forwards)
X(5): SECONDARY DIAGNOSIS 2 (46,.06) (forwards)
X(6): SECONDARY DIAGNOSIS 3 (46,.07) (forwards)
X(7): SECONDARY DIAGNOSIS 4 (46,.21) (forwards)
X(8): SECONDARY DIAGNOSIS 5 (46,.22) (forwards)
X(9): SECONDARY DIAGNOSIS 6 (46,.23) (forwards)
X(10): SECONDARY DIAGNOSIS 7 (46,.24) (forwards)
X(11): DELETE DATE (46,1) (forwards)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):