IBACCWLRURREV2 ;EDE/TAZ - ACC (Automated Community Care) Claims - ADDITIONAL REVIEW SCREEN FOR RUR (cont'd); 12-SEP-2023 ; 12-SEP-2023
;;2.0;INTEGRATED BILLING;**770**;21-MAR-94;Build 119
;;Per VA Directive 6402, this routine should not be modified.
Q
;THIS ROUTINE ALLOWS THE USER TO VIEW THE X12 ENCOUNTER IN READABLE FORMAT.
;
MIA ;Inpatient Adjudication Information
N CODE
S CODE=$P(DATA,D,2) I $L(CODE) D SET("Covered Days or Visits Count",(CODE))
S CODE=$P(DATA,D,3) I $L(CODE) D SET("HCPCS Payable Amount",$$DOL(CODE))
S CODE=$P(DATA,D,4) I $L(CODE) D SET("Lifetime Psychiatric Days Count",CODE)
S CODE=$P(DATA,D,5) I $L(CODE) D SET("Claim DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,6) I $L(CODE) D SET("Claim Payment Remark Code",CODE)
S CODE=$P(DATA,D,7) I $L(CODE) D SET("Claim Disproportionate Share Amount",$$DOL(CODE))
S CODE=$P(DATA,D,8) I $L(CODE) D SET("Claim MSP Pass-through Amount",$$DOL(CODE))
S CODE=$P(DATA,D,9) I $L(CODE) D SET("Claim PPS Capital Amount",$$DOL(CODE))
S CODE=$P(DATA,D,10) I $L(CODE) D SET("PPS-Capital FSP DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,11) I $L(CODE) D SET("PPS-Capital HSP DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,12) I $L(CODE) D SET("PPS-Capital DSH DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,13) I $L(CODE) D SET("Old Capital Amount",$$DOL(CODE))
S CODE=$P(DATA,D,14) I $L(CODE) D SET("PPS-Capital IME Amount",$$DOL(CODE))
S CODE=$P(DATA,D,15) I $L(CODE) D SET("PPS-Operating Hospital Specific DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,16) I $L(CODE) D SET("Cost Report Day Count",CODE)
S CODE=$P(DATA,D,17) I $L(CODE) D SET("PPS-Operating Federal Specific DRG Amount",$$DOL(CODE))
S CODE=$P(DATA,D,18) I $L(CODE) D SET("Claim PPS Capital Outlier Amount",$$DOL(CODE))
S CODE=$P(DATA,D,19) I $L(CODE) D SET("Claim Indirect Teaching Amount",$$DOL(CODE))
S CODE=$P(DATA,D,20) I $L(CODE) D SET("Non-Payable Professional Component Amount",$$DOL(CODE))
S CODE=$P(DATA,D,21) I $L(CODE) D SET("Claim Payment Remark Code",CODE)
S CODE=$P(DATA,D,22) I $L(CODE) D SET(,CODE)
S CODE=$P(DATA,D,23) I $L(CODE) D SET(,CODE)
S CODE=$P(DATA,D,24) I $L(CODE) D SET(,CODE)
S CODE=$P(DATA,D,25) I $L(CODE) D SET("PPS-Capital Exception Amount",CODE)
Q
;
NM1 ;Process NM1 record
N CODE,NAME,STOP
S STOP=0
S CODE=$P(DATA,D,2) D I 'STOP D SET(CODE,,1,1)
. I CODE=40 S CODE="Receiver" Q
. I CODE=41 S CODE="Submitter" Q
. I CODE=45 S CODE="Ambulance Drop Off Location" Q
. I CODE=71 S CODE="Attending Physician" Q
. I CODE=72 S CODE="Operating Physician" Q
. I CODE=77 D Q
.. ;I $P(DATA,D,9)="XX",$P(DATA,D,10)=$G(^TMP("IBACCWLRURREV",$J,"BP NPI")) S STOP=1 Q ;eBILL-5440;WCJ;GRAY build
.. S CODE="Service Location"
. I CODE=82 S CODE="Rendering Provider" Q
. I CODE=85 D Q
.. I $P(DATA,D,9)="XX" S ^TMP("IBACCWLRURREV",$J,"BP NPI")=$P(DATA,D,10)
.. S CODE="Billing Provider"
. I CODE=87 S CODE="Pay to Provider" Q
. I CODE="DD" S CODE="Assistant Surgeon" Q
. I CODE="DK" S CODE="Ordering Physician" Q
. I CODE="DN" S CODE="Referring Provider" Q
. I CODE="DQ" S CODE="Supervising Physician" Q
. I CODE="IL" S CODE="Insured or Subscriber" Q
. I CODE="P3" S CODE="Primary Care Provider" Q
. I CODE="PE" S CODE="Payee" Q
. I CODE="PR" S CODE="Payer" Q
. I CODE="PW" S CODE="Ambulance Pickup Address" Q
. I CODE="QB" S CODE="Purchase Service Provider" Q
. I CODE="QC" S CODE="Patient" Q
. I CODE="ZZ" S CODE="Other Operating Physician" Q
I STOP Q
I CODE?1"Ambulance".E Q
S NAME=$S($P(DATA,D,3)=1:$$NAME(DATA),1:$P(DATA,D,4))
I $L(NAME) D SET("Name",NAME)
S CODE=$P(DATA,D,9),LINE=$P(DATA,D,10) I CODE'="" D D SET(CODE,LINE)
. I CODE="46" S CODE="Electronic Transmitter ID # (ETIN)" Q
. I CODE="II" S CODE="Unique Health ID" Q
. I CODE="MI" S CODE="Member ID Number" Q
. I CODE="PI" S CODE="Payor Identification" Q
. I CODE="XV" S CODE="CMS Plan ID" Q
. I CODE="XX" S CODE="CMS National Provider Identifier" Q
Q
;
PWK ;Claim Supplimental
N CODE
S CODE=$P(DATA,D,2) D D SET("Attachment Report Type Code",CODE)
. I CODE="03" S CODE="Report Justifying Treatment Beyond Utilization Guidelines" Q
. I CODE="04" S CODE="Drugs Administered" Q
. I CODE="05" S CODE="Treatment Diagnosis" Q
. I CODE="06" S CODE="Initial Assessment" Q
. I CODE="07" S CODE="Functional Goals" Q
. I CODE="08" S CODE="Plan of Treatment" Q
. I CODE="09" S CODE="Progress Report" Q
. I CODE=10 S CODE="Continued Treatment" Q
. I CODE=11 S CODE="Chemical Analysis" Q
. I CODE=13 S CODE="Certified Test Result" Q
. I CODE=15 S CODE="Justification for Admission" Q
. I CODE=21 S CODE="Recovery Plan" Q
. I CODE="A3" S CODE="Allergies/Sensitivity Plan" Q
. I CODE="A4" S CODE="Autopsy Report" Q
. I CODE="AM" S CODE="Ambulance Certification" Q
. I CODE="AS" S CODE="Admission Summary" Q
. I CODE="B2" S CODE="Prescription" Q
. I CODE="B3" S CODE="Physician Order" Q
. I CODE="B4" S CODE="Referral Form" Q
. I CODE="BR" S CODE="Benchmark Testing Results" Q
. I CODE="BS" S CODE="Baseline" Q
. I CODE="BT" S CODE="Blanket Test Results" Q
. I CODE="CB" S CODE="Chiropractic Justification" Q
. I CODE="CK" S CODE="Consent Form(s)" Q
. I CODE="CT" S CODE="Certification" Q
. I CODE="D2" S CODE="Drug Profile Document" Q
. I CODE="DA" S CODE="Dental Models" Q
. I CODE="DB" S CODE="Durable Medical Equipment Prescription" Q
. I CODE="DG" S CODE="Diagnostic Report" Q
. I CODE="DJ" S CODE="Discharge Monitoring Report" Q
. I CODE="DS" S CODE="Discharge Summary" Q
. I CODE="EB" S CODE="Explanation of Benefits" Q
. I CODE="HC" S CODE="Health Certificate" Q
. I CODE="HR" S CODE="Health Clinic Records" Q
. I CODE="I5" S CODE="Immunization Record" Q
. I CODE="IR" S CODE="State School Immunization Record" Q
. I CODE="LA" S CODE="Lab Results" Q
. I CODE="M1" S CODE="Medical Record Attachment" Q
. I CODE="MT" S CODE="Models" Q
. I CODE="NN" S CODE="Nursing NotesNursing Notes" Q
. I CODE="OB" S CODE="Operative Note" Q
. I CODE="OC" S CODE="Oxygen Content Averaging Report" Q
. I CODE="OD" S CODE="Orders and Treatment Documents" Q
. I CODE="OE" S CODE="Objective Physical Exam Document" Q
. I CODE="OX" S CODE="Oxygen Therapy Certification" Q
. I CODE="OZ" S CODE="Support Data for Claim" Q
. I CODE="P4" S CODE="Pathology Report" Q
. I CODE="P5" S CODE="Patient Medical History Document" Q
. I CODE="PE" S CODE="Parenteral or Enteral Certification" Q
. I CODE="P6" S CODE="Periodontal Charts" Q
. I CODE="PN" S CODE="Physicall Therapy Notes" Q
. I CODE="PO" S CODE="Prosthetics or Orthotic Certification" Q
. I CODE="PQ" S CODE="Peramedical Results" Q
. I CODE="PY" S CODE="Physician's Report" Q
. I CODE="PZ" S CODE="Physical Therapy Certification" Q
. I CODE="RB" S CODE="Radiology Films" Q
. I CODE="RR" S CODE="Radiology Reports" Q
. I CODE="RT" S CODE="Report of Tests ad Analysis" Q
. I CODE="RX" S CODE="Renewable Oxygen Content Averaging Report" Q
. I CODE="SG" S CODE="Symptoms Document" Q
. I CODE="V5" S CODE="Death Notification" Q
. I CODE="XP" S CODE="Photographs" Q
S CODE=$P(DATA,D,3) D D SET("Attachment Transmission Code",CODE)
. I CODE="AA" S CODE="Available on Request at Provider Site" Q
. I CODE="AB" S CODE="Previous Submitted to Payer" Q
. I CODE="AD" S CODE="Certification Included in this Claim" Q
. I CODE="AF" S CODE="Narrative Segment Included in this Claim" Q
. I CODE="AG" S CODE="No Documentation is Required." Q
. I CODE="BM" S CODE="By Mail" Q
. I CODE="EL" S CODE="Electronically Only" Q
. I CODE="EM" S CODE="E-mail" Q
. I CODE="FT" S CODE="File Transfer" Q
. I CODE="FX" S CODE="By Fax" Q
. I CODE="NS" S CODE="Not Specified" Q
S CODE=$P(DATA,D,6) I CODE'="" D D SET("Identification Code Qualifier",CODE)
. I CODE="AC" S CODE="Attachment Control Number" Q
I $P(DATA,D,7)'="" D SET("Attachment Control Number",$P(DATA,D,7))
Q
;
REF ;Display Reference Segment
N CODE,LINE
S CODE=$P(DATA,D,2),LINE=$P(DATA,D,3) D D SET(CODE,LINE)
. I CODE="BT" S CODE="Immunization Bactch Number" Q
. I CODE="D9" S CODE="Value Added Network Trace Number" Q
. I CODE="EA" S CODE="Medical Record Number" Q
. I CODE="EI" S CODE="Tax Identification #",LINE=$E($P(DATA,D,3),1,2)_"-"_$E($P(DATA,D,3),3,$L($P(DATA,D,3))) Q
. I CODE="EW" S CODE="Mammography Certification Number" Q
. I CODE="FY" S CODE="Claim Office #" Q
. I CODE="F4" S CODE="Facility Certification Number" Q
. I CODE="F5" S CODE="Medicare Version Code",LINE=$S($P(DATA,D,3)="Y":4081,1:"Regular crossover") Q
. I CODE="F8" S CODE="Payer Claim Control Number" Q
. I CODE="G1" S CODE="Prior Authorization Number" Q
. I CODE="G2" S CODE="Provider Secondary Identifier" Q
. I CODE="G3" S CODE="Predetermination of Benefits Identifier" Q
. I CODE="G4" S CODE="Peer Review Authorization Number" Q
. I CODE="LU" S CODE="Location Number" Q
. I CODE="LX" S CODE="Investigational Device Exemption Identifier" Q
. I CODE="NF" S CODE="NAIC Code" Q
. I CODE="P4" S CODE="Demonstration Project Identifier" Q
. I CODE="SY" S CODE="Social Security Number",LINE=$E($P(DATA,D,3),1,3)_"-"_$E($P(DATA,D,3),4,5)_"-"_$E($P(DATA,D,3),6,9) Q
. I CODE="T4" S CODE="Claim Adjustment Indicator" Q
. I CODE="VY" S CODE="Link Sequence Number" Q
. I CODE="XZ" S CODE="Pharmacy Prescription Number" Q
. I CODE="X4" S CODE="Clinical Laboratory Improvement Amendment Number" Q
. I CODE="Y4" S CODE="Agency Claim Number" Q
. I CODE="0B" S CODE="State License #" Q
. I CODE="1G" S CODE="Provider UPIN" Q
. I CODE="1J" S CODE="Care Plan Oversight Number" Q
. I CODE="1W" S CODE="Member ID Number" Q
. I CODE="2U" S CODE="Payer Identification #" Q
. I CODE="4N" S CODE="Service Authorization Exception Code" D Q
.. I LINE=1 S LINE="Immediate/Urgent Care" Q
.. I LINE=2 S LINE="Services Rendered in a Rectoactive Period" Q
.. I LINE=3 S LINE="Emergency Care" Q
.. I LINE=4 S LINE="Client has Temporary Medicaid" Q
.. I LINE=5 S LINE="Request from County for Second Opinion to Determine if Receipient Can Work" Q
.. I LINE=6 S LINE="Request for Override Pending" Q
.. I LINE=7 S LINE="Special Handling"
. I CODE="6R" S CODE="Provider Control Number" Q
. I CODE="9A" S CODE="Repriced Claim Reference Number" Q
. I CODE="9B" S CODE="Repriced Line Item Reference Number" Q
. I CODE="9C" S CODE="Adjusted Repriced Claim Reference Number" Q
. I CODE="9D" S CODE="Adjusted Repriced Line Item Reference Number" Q
. I CODE="9F" S CODE="Referral Number"
S CODE=$P(DATA,D,5) I $L(CODE) D D SET(CODE,LINE)
. S LINE=$P(CODE,D1,2)
. I $P(CODE,D1,1)="2U" S CODE="Other Payer Primary Identifier" Q
Q
;
SBR ;Display Subscriber Segment
N CODE
S SBR=SBR+1 I SBR>1 D SET("Other Subscriber Information",,1,1)
S CODE=$P(DATA,D,2)
D SET("Payer Responsibility",$S(CODE="T":"Tertiary",CODE="S":"Secondary",CODE="P":"Primary",1:"Other"))
S CODE=$P(DATA,D,3) D D SET("Relationship",CODE)
. I CODE="01" S CODE="Spouse" Q
. I CODE=18 S CODE="Self" Q
. I CODE=19 S CODE="Child" Q
. I CODE=20 S CODE="Employee" Q
. I CODE=21 S CODE="Unknown" Q
. I CODE=39 S CODE="Organ Donor" Q
. I CODE=40 S CODE="Cadaver Donor" Q
. I CODE=53 S CODE="Life Partner" Q
. I CODE="G8" S CODE="Other Relationship" Q
S CODE=$P(DATA,D,4) I $L(CODE) D SET("Group Number",CODE)
S CODE=$P(DATA,D,5) I $L(CODE) D SET("Group Name",CODE)
S CODE=$P(DATA,D,6) I CODE'="" D D SET("Type of Insurance",CODE)
. I CODE=12 S CODE="Medicare Secondary or Spouse Employer Group Health" Q
. I CODE=13 S CODE="Medicare Secondary with Spouse Emplyer Group Health" Q
. I CODE=14 S CODE="Medicare Secondary, No Fault Insurance as primary" Q
. I CODE=15 S CODE="Medicare Secondary, Worker's Compensation" Q
. I CODE=16 S CODE="Medicare Secondary, Public Health Service" Q
. I CODE=41 S CODE="Medicare Secondary Black Lung" Q
. I CODE=42 S CODE="Medicare Secondary Veterans Administration" Q
. I CODE=43 S CODE="Medicare Secondary Disabled Beneficiary" Q
. I CODE=47 S CODE="Medicare Secondary, Other Liability Insurance Primary" Q
S CODE=$P(DATA,D,10) D D SET("Type of Plan",CODE)
. I CODE=11 S CODE="Other Non-Federal programs" Q
. I CODE=12 S CODE="Preferred Provide Organization (PPO)" Q
. I CODE=13 S CODE="Point of Service (POS)" Q
. I CODE=14 S CODE="Exclusive Provider Organization (EPO)" Q
. I CODE=15 S CODE="Indemnity Insurance" Q
. I CODE=16 S CODE="Health Maintenance Organization (HMO) Medicare Risk" Q
. I CODE=17 S CODE="Dental Maintenance Organization" Q
. I CODE="AM" S CODE="Automobile Medical" Q
. I CODE="BL" S CODE="Blue Cross/Blue Shield" Q
. I CODE="CH" S CODE="Champus" Q
. I CODE="CI" S CODE="Commercial Insurance" Q
. I CODE="DS" S CODE="Disability" Q
. I CODE="FI" S CODE="Federal Employees Program" Q
. I CODE="HM" S CODE="Health Maintenance Organization" Q
. I CODE="LM" S CODE="Liability Medical" Q
. I CODE="MA" S CODE="Medicare Part A" Q
. I CODE="MB" S CODE="Medicare Part B" Q
. I CODE="MC" S CODE="Medicaid" Q
. I CODE="OF" S CODE="Medicare Part D" Q
. I CODE="TV" S CODE="Title V" Q
. I CODE="VA" S CODE="Veterans Affairs Plan" Q
. I CODE="WC" S CODE="Worker Compensation Health Claim" Q
. I CODE="ZZ" S CODE="Mutually Defined/Unknown" Q
Q
;
DATE(DATE,TYPE) ;Format Date/Time
N D1
S TYPE=$G(TYPE,"D8")
I TYPE="TM" S D1=DATE G DATEQ
I TYPE="D8"!(TYPE="DT") D G DATEQ
. S D1=$$FMTE^XLFDT($$HL7TFM^XLFDT($E(DATE,1,8)),1)
. I TYPE="DT" S D1=D1_" "_$E(DATE,9,12)
S D1=$$FMTE^XLFDT($$HL7TFM^XLFDT($P(DATE,"-",1),1))_"-"_$$FMTE^XLFDT($$HL7TFM^XLFDT($P(DATE,"-",2),1))
DATEQ ;
Q D1
;
DOL(DATA) ;Format Dollars
S DATA="$"_$FN(DATA,",",2)
Q DATA
;
NAME(DATA) ;Format Person Name
N LAST,FIRST,MI,SUF
S LAST=$P(DATA,D,4),FIRST=$P(DATA,D,5),MI=$P(DATA,D,6),SUF=$P(DATA,D,8)
Q LAST_$S($L(FIRST):", ",1:"")_FIRST_" "_$S($L(MI):MI_" ",1:"")_SUF
;
PHONE(NUM) ;Format phone number
Q "("_$E(NUM,1,3)_") "_$E(NUM,4,6)_"-"_$E(NUM,7,10)
;
YN(YN) ;Translate Yes/No element
Q $S(YN="W":"Not Applicable",YN="U":"Uknown",YN="Y":"Yes",1:"No")
;
ZIP(ZIP) ;Format Zip Code
Q $E(ZIP,1,5)_$S($L(ZIP>5):"-"_$E(ZIP,6,9),1:"")
;
SET(TITLE,VALUE,BLANK,HEADER) ;
D SET^IBACCWLRURREV($G(TITLE),$G(VALUE),$G(BLANK),$G(HEADER))
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HIBACCWLRURREV2 14362 printed May 25, 2026@12:10:07 Page 2
IBACCWLRURREV2 ;EDE/TAZ - ACC (Automated Community Care) Claims - ADDITIONAL REVIEW SCREEN FOR RUR (cont'd); 12-SEP-2023 ; 12-SEP-2023
+1 ;;2.0;INTEGRATED BILLING;**770**;21-MAR-94;Build 119
+2 ;;Per VA Directive 6402, this routine should not be modified.
+3 QUIT
+4 ;THIS ROUTINE ALLOWS THE USER TO VIEW THE X12 ENCOUNTER IN READABLE FORMAT.
+5 ;
MIA ;Inpatient Adjudication Information
+1 NEW CODE
+2 SET CODE=$PIECE(DATA,D,2)
IF $LENGTH(CODE)
DO SET("Covered Days or Visits Count",(CODE))
+3 SET CODE=$PIECE(DATA,D,3)
IF $LENGTH(CODE)
DO SET("HCPCS Payable Amount",$$DOL(CODE))
+4 SET CODE=$PIECE(DATA,D,4)
IF $LENGTH(CODE)
DO SET("Lifetime Psychiatric Days Count",CODE)
+5 SET CODE=$PIECE(DATA,D,5)
IF $LENGTH(CODE)
DO SET("Claim DRG Amount",$$DOL(CODE))
+6 SET CODE=$PIECE(DATA,D,6)
IF $LENGTH(CODE)
DO SET("Claim Payment Remark Code",CODE)
+7 SET CODE=$PIECE(DATA,D,7)
IF $LENGTH(CODE)
DO SET("Claim Disproportionate Share Amount",$$DOL(CODE))
+8 SET CODE=$PIECE(DATA,D,8)
IF $LENGTH(CODE)
DO SET("Claim MSP Pass-through Amount",$$DOL(CODE))
+9 SET CODE=$PIECE(DATA,D,9)
IF $LENGTH(CODE)
DO SET("Claim PPS Capital Amount",$$DOL(CODE))
+10 SET CODE=$PIECE(DATA,D,10)
IF $LENGTH(CODE)
DO SET("PPS-Capital FSP DRG Amount",$$DOL(CODE))
+11 SET CODE=$PIECE(DATA,D,11)
IF $LENGTH(CODE)
DO SET("PPS-Capital HSP DRG Amount",$$DOL(CODE))
+12 SET CODE=$PIECE(DATA,D,12)
IF $LENGTH(CODE)
DO SET("PPS-Capital DSH DRG Amount",$$DOL(CODE))
+13 SET CODE=$PIECE(DATA,D,13)
IF $LENGTH(CODE)
DO SET("Old Capital Amount",$$DOL(CODE))
+14 SET CODE=$PIECE(DATA,D,14)
IF $LENGTH(CODE)
DO SET("PPS-Capital IME Amount",$$DOL(CODE))
+15 SET CODE=$PIECE(DATA,D,15)
IF $LENGTH(CODE)
DO SET("PPS-Operating Hospital Specific DRG Amount",$$DOL(CODE))
+16 SET CODE=$PIECE(DATA,D,16)
IF $LENGTH(CODE)
DO SET("Cost Report Day Count",CODE)
+17 SET CODE=$PIECE(DATA,D,17)
IF $LENGTH(CODE)
DO SET("PPS-Operating Federal Specific DRG Amount",$$DOL(CODE))
+18 SET CODE=$PIECE(DATA,D,18)
IF $LENGTH(CODE)
DO SET("Claim PPS Capital Outlier Amount",$$DOL(CODE))
+19 SET CODE=$PIECE(DATA,D,19)
IF $LENGTH(CODE)
DO SET("Claim Indirect Teaching Amount",$$DOL(CODE))
+20 SET CODE=$PIECE(DATA,D,20)
IF $LENGTH(CODE)
DO SET("Non-Payable Professional Component Amount",$$DOL(CODE))
+21 SET CODE=$PIECE(DATA,D,21)
IF $LENGTH(CODE)
DO SET("Claim Payment Remark Code",CODE)
+22 SET CODE=$PIECE(DATA,D,22)
IF $LENGTH(CODE)
DO SET(,CODE)
+23 SET CODE=$PIECE(DATA,D,23)
IF $LENGTH(CODE)
DO SET(,CODE)
+24 SET CODE=$PIECE(DATA,D,24)
IF $LENGTH(CODE)
DO SET(,CODE)
+25 SET CODE=$PIECE(DATA,D,25)
IF $LENGTH(CODE)
DO SET("PPS-Capital Exception Amount",CODE)
+26 QUIT
+27 ;
NM1 ;Process NM1 record
+1 NEW CODE,NAME,STOP
+2 SET STOP=0
+3 SET CODE=$PIECE(DATA,D,2)
Begin DoDot:1
+4 IF CODE=40
SET CODE="Receiver"
QUIT
+5 IF CODE=41
SET CODE="Submitter"
QUIT
+6 IF CODE=45
SET CODE="Ambulance Drop Off Location"
QUIT
+7 IF CODE=71
SET CODE="Attending Physician"
QUIT
+8 IF CODE=72
SET CODE="Operating Physician"
QUIT
+9 IF CODE=77
Begin DoDot:2
+10 ;I $P(DATA,D,9)="XX",$P(DATA,D,10)=$G(^TMP("IBACCWLRURREV",$J,"BP NPI")) S STOP=1 Q ;eBILL-5440;WCJ;GRAY build
+11 SET CODE="Service Location"
End DoDot:2
QUIT
+12 IF CODE=82
SET CODE="Rendering Provider"
QUIT
+13 IF CODE=85
Begin DoDot:2
+14 IF $PIECE(DATA,D,9)="XX"
SET ^TMP("IBACCWLRURREV",$JOB,"BP NPI")=$PIECE(DATA,D,10)
+15 SET CODE="Billing Provider"
End DoDot:2
QUIT
+16 IF CODE=87
SET CODE="Pay to Provider"
QUIT
+17 IF CODE="DD"
SET CODE="Assistant Surgeon"
QUIT
+18 IF CODE="DK"
SET CODE="Ordering Physician"
QUIT
+19 IF CODE="DN"
SET CODE="Referring Provider"
QUIT
+20 IF CODE="DQ"
SET CODE="Supervising Physician"
QUIT
+21 IF CODE="IL"
SET CODE="Insured or Subscriber"
QUIT
+22 IF CODE="P3"
SET CODE="Primary Care Provider"
QUIT
+23 IF CODE="PE"
SET CODE="Payee"
QUIT
+24 IF CODE="PR"
SET CODE="Payer"
QUIT
+25 IF CODE="PW"
SET CODE="Ambulance Pickup Address"
QUIT
+26 IF CODE="QB"
SET CODE="Purchase Service Provider"
QUIT
+27 IF CODE="QC"
SET CODE="Patient"
QUIT
+28 IF CODE="ZZ"
SET CODE="Other Operating Physician"
QUIT
End DoDot:1
IF 'STOP
DO SET(CODE,,1,1)
+29 IF STOP
QUIT
+30 IF CODE?1"Ambulance".E
QUIT
+31 SET NAME=$SELECT($PIECE(DATA,D,3)=1:$$NAME(DATA),1:$PIECE(DATA,D,4))
+32 IF $LENGTH(NAME)
DO SET("Name",NAME)
+33 SET CODE=$PIECE(DATA,D,9)
SET LINE=$PIECE(DATA,D,10)
IF CODE'=""
Begin DoDot:1
+34 IF CODE="46"
SET CODE="Electronic Transmitter ID # (ETIN)"
QUIT
+35 IF CODE="II"
SET CODE="Unique Health ID"
QUIT
+36 IF CODE="MI"
SET CODE="Member ID Number"
QUIT
+37 IF CODE="PI"
SET CODE="Payor Identification"
QUIT
+38 IF CODE="XV"
SET CODE="CMS Plan ID"
QUIT
+39 IF CODE="XX"
SET CODE="CMS National Provider Identifier"
QUIT
End DoDot:1
DO SET(CODE,LINE)
+40 QUIT
+41 ;
PWK ;Claim Supplimental
+1 NEW CODE
+2 SET CODE=$PIECE(DATA,D,2)
Begin DoDot:1
+3 IF CODE="03"
SET CODE="Report Justifying Treatment Beyond Utilization Guidelines"
QUIT
+4 IF CODE="04"
SET CODE="Drugs Administered"
QUIT
+5 IF CODE="05"
SET CODE="Treatment Diagnosis"
QUIT
+6 IF CODE="06"
SET CODE="Initial Assessment"
QUIT
+7 IF CODE="07"
SET CODE="Functional Goals"
QUIT
+8 IF CODE="08"
SET CODE="Plan of Treatment"
QUIT
+9 IF CODE="09"
SET CODE="Progress Report"
QUIT
+10 IF CODE=10
SET CODE="Continued Treatment"
QUIT
+11 IF CODE=11
SET CODE="Chemical Analysis"
QUIT
+12 IF CODE=13
SET CODE="Certified Test Result"
QUIT
+13 IF CODE=15
SET CODE="Justification for Admission"
QUIT
+14 IF CODE=21
SET CODE="Recovery Plan"
QUIT
+15 IF CODE="A3"
SET CODE="Allergies/Sensitivity Plan"
QUIT
+16 IF CODE="A4"
SET CODE="Autopsy Report"
QUIT
+17 IF CODE="AM"
SET CODE="Ambulance Certification"
QUIT
+18 IF CODE="AS"
SET CODE="Admission Summary"
QUIT
+19 IF CODE="B2"
SET CODE="Prescription"
QUIT
+20 IF CODE="B3"
SET CODE="Physician Order"
QUIT
+21 IF CODE="B4"
SET CODE="Referral Form"
QUIT
+22 IF CODE="BR"
SET CODE="Benchmark Testing Results"
QUIT
+23 IF CODE="BS"
SET CODE="Baseline"
QUIT
+24 IF CODE="BT"
SET CODE="Blanket Test Results"
QUIT
+25 IF CODE="CB"
SET CODE="Chiropractic Justification"
QUIT
+26 IF CODE="CK"
SET CODE="Consent Form(s)"
QUIT
+27 IF CODE="CT"
SET CODE="Certification"
QUIT
+28 IF CODE="D2"
SET CODE="Drug Profile Document"
QUIT
+29 IF CODE="DA"
SET CODE="Dental Models"
QUIT
+30 IF CODE="DB"
SET CODE="Durable Medical Equipment Prescription"
QUIT
+31 IF CODE="DG"
SET CODE="Diagnostic Report"
QUIT
+32 IF CODE="DJ"
SET CODE="Discharge Monitoring Report"
QUIT
+33 IF CODE="DS"
SET CODE="Discharge Summary"
QUIT
+34 IF CODE="EB"
SET CODE="Explanation of Benefits"
QUIT
+35 IF CODE="HC"
SET CODE="Health Certificate"
QUIT
+36 IF CODE="HR"
SET CODE="Health Clinic Records"
QUIT
+37 IF CODE="I5"
SET CODE="Immunization Record"
QUIT
+38 IF CODE="IR"
SET CODE="State School Immunization Record"
QUIT
+39 IF CODE="LA"
SET CODE="Lab Results"
QUIT
+40 IF CODE="M1"
SET CODE="Medical Record Attachment"
QUIT
+41 IF CODE="MT"
SET CODE="Models"
QUIT
+42 IF CODE="NN"
SET CODE="Nursing NotesNursing Notes"
QUIT
+43 IF CODE="OB"
SET CODE="Operative Note"
QUIT
+44 IF CODE="OC"
SET CODE="Oxygen Content Averaging Report"
QUIT
+45 IF CODE="OD"
SET CODE="Orders and Treatment Documents"
QUIT
+46 IF CODE="OE"
SET CODE="Objective Physical Exam Document"
QUIT
+47 IF CODE="OX"
SET CODE="Oxygen Therapy Certification"
QUIT
+48 IF CODE="OZ"
SET CODE="Support Data for Claim"
QUIT
+49 IF CODE="P4"
SET CODE="Pathology Report"
QUIT
+50 IF CODE="P5"
SET CODE="Patient Medical History Document"
QUIT
+51 IF CODE="PE"
SET CODE="Parenteral or Enteral Certification"
QUIT
+52 IF CODE="P6"
SET CODE="Periodontal Charts"
QUIT
+53 IF CODE="PN"
SET CODE="Physicall Therapy Notes"
QUIT
+54 IF CODE="PO"
SET CODE="Prosthetics or Orthotic Certification"
QUIT
+55 IF CODE="PQ"
SET CODE="Peramedical Results"
QUIT
+56 IF CODE="PY"
SET CODE="Physician's Report"
QUIT
+57 IF CODE="PZ"
SET CODE="Physical Therapy Certification"
QUIT
+58 IF CODE="RB"
SET CODE="Radiology Films"
QUIT
+59 IF CODE="RR"
SET CODE="Radiology Reports"
QUIT
+60 IF CODE="RT"
SET CODE="Report of Tests ad Analysis"
QUIT
+61 IF CODE="RX"
SET CODE="Renewable Oxygen Content Averaging Report"
QUIT
+62 IF CODE="SG"
SET CODE="Symptoms Document"
QUIT
+63 IF CODE="V5"
SET CODE="Death Notification"
QUIT
+64 IF CODE="XP"
SET CODE="Photographs"
QUIT
End DoDot:1
DO SET("Attachment Report Type Code",CODE)
+65 SET CODE=$PIECE(DATA,D,3)
Begin DoDot:1
+66 IF CODE="AA"
SET CODE="Available on Request at Provider Site"
QUIT
+67 IF CODE="AB"
SET CODE="Previous Submitted to Payer"
QUIT
+68 IF CODE="AD"
SET CODE="Certification Included in this Claim"
QUIT
+69 IF CODE="AF"
SET CODE="Narrative Segment Included in this Claim"
QUIT
+70 IF CODE="AG"
SET CODE="No Documentation is Required."
QUIT
+71 IF CODE="BM"
SET CODE="By Mail"
QUIT
+72 IF CODE="EL"
SET CODE="Electronically Only"
QUIT
+73 IF CODE="EM"
SET CODE="E-mail"
QUIT
+74 IF CODE="FT"
SET CODE="File Transfer"
QUIT
+75 IF CODE="FX"
SET CODE="By Fax"
QUIT
+76 IF CODE="NS"
SET CODE="Not Specified"
QUIT
End DoDot:1
DO SET("Attachment Transmission Code",CODE)
+77 SET CODE=$PIECE(DATA,D,6)
IF CODE'=""
Begin DoDot:1
+78 IF CODE="AC"
SET CODE="Attachment Control Number"
QUIT
End DoDot:1
DO SET("Identification Code Qualifier",CODE)
+79 IF $PIECE(DATA,D,7)'=""
DO SET("Attachment Control Number",$PIECE(DATA,D,7))
+80 QUIT
+81 ;
REF ;Display Reference Segment
+1 NEW CODE,LINE
+2 SET CODE=$PIECE(DATA,D,2)
SET LINE=$PIECE(DATA,D,3)
Begin DoDot:1
+3 IF CODE="BT"
SET CODE="Immunization Bactch Number"
QUIT
+4 IF CODE="D9"
SET CODE="Value Added Network Trace Number"
QUIT
+5 IF CODE="EA"
SET CODE="Medical Record Number"
QUIT
+6 IF CODE="EI"
SET CODE="Tax Identification #"
SET LINE=$EXTRACT($PIECE(DATA,D,3),1,2)_"-"_$EXTRACT($PIECE(DATA,D,3),3,$LENGTH($PIECE(DATA,D,3)))
QUIT
+7 IF CODE="EW"
SET CODE="Mammography Certification Number"
QUIT
+8 IF CODE="FY"
SET CODE="Claim Office #"
QUIT
+9 IF CODE="F4"
SET CODE="Facility Certification Number"
QUIT
+10 IF CODE="F5"
SET CODE="Medicare Version Code"
SET LINE=$SELECT($PIECE(DATA,D,3)="Y":4081,1:"Regular crossover")
QUIT
+11 IF CODE="F8"
SET CODE="Payer Claim Control Number"
QUIT
+12 IF CODE="G1"
SET CODE="Prior Authorization Number"
QUIT
+13 IF CODE="G2"
SET CODE="Provider Secondary Identifier"
QUIT
+14 IF CODE="G3"
SET CODE="Predetermination of Benefits Identifier"
QUIT
+15 IF CODE="G4"
SET CODE="Peer Review Authorization Number"
QUIT
+16 IF CODE="LU"
SET CODE="Location Number"
QUIT
+17 IF CODE="LX"
SET CODE="Investigational Device Exemption Identifier"
QUIT
+18 IF CODE="NF"
SET CODE="NAIC Code"
QUIT
+19 IF CODE="P4"
SET CODE="Demonstration Project Identifier"
QUIT
+20 IF CODE="SY"
SET CODE="Social Security Number"
SET LINE=$EXTRACT($PIECE(DATA,D,3),1,3)_"-"_$EXTRACT($PIECE(DATA,D,3),4,5)_"-"_$EXTRACT($PIECE(DATA,D,3),6,9)
QUIT
+21 IF CODE="T4"
SET CODE="Claim Adjustment Indicator"
QUIT
+22 IF CODE="VY"
SET CODE="Link Sequence Number"
QUIT
+23 IF CODE="XZ"
SET CODE="Pharmacy Prescription Number"
QUIT
+24 IF CODE="X4"
SET CODE="Clinical Laboratory Improvement Amendment Number"
QUIT
+25 IF CODE="Y4"
SET CODE="Agency Claim Number"
QUIT
+26 IF CODE="0B"
SET CODE="State License #"
QUIT
+27 IF CODE="1G"
SET CODE="Provider UPIN"
QUIT
+28 IF CODE="1J"
SET CODE="Care Plan Oversight Number"
QUIT
+29 IF CODE="1W"
SET CODE="Member ID Number"
QUIT
+30 IF CODE="2U"
SET CODE="Payer Identification #"
QUIT
+31 IF CODE="4N"
SET CODE="Service Authorization Exception Code"
Begin DoDot:2
+32 IF LINE=1
SET LINE="Immediate/Urgent Care"
QUIT
+33 IF LINE=2
SET LINE="Services Rendered in a Rectoactive Period"
QUIT
+34 IF LINE=3
SET LINE="Emergency Care"
QUIT
+35 IF LINE=4
SET LINE="Client has Temporary Medicaid"
QUIT
+36 IF LINE=5
SET LINE="Request from County for Second Opinion to Determine if Receipient Can Work"
QUIT
+37 IF LINE=6
SET LINE="Request for Override Pending"
QUIT
+38 IF LINE=7
SET LINE="Special Handling"
End DoDot:2
QUIT
+39 IF CODE="6R"
SET CODE="Provider Control Number"
QUIT
+40 IF CODE="9A"
SET CODE="Repriced Claim Reference Number"
QUIT
+41 IF CODE="9B"
SET CODE="Repriced Line Item Reference Number"
QUIT
+42 IF CODE="9C"
SET CODE="Adjusted Repriced Claim Reference Number"
QUIT
+43 IF CODE="9D"
SET CODE="Adjusted Repriced Line Item Reference Number"
QUIT
+44 IF CODE="9F"
SET CODE="Referral Number"
End DoDot:1
DO SET(CODE,LINE)
+45 SET CODE=$PIECE(DATA,D,5)
IF $LENGTH(CODE)
Begin DoDot:1
+46 SET LINE=$PIECE(CODE,D1,2)
+47 IF $PIECE(CODE,D1,1)="2U"
SET CODE="Other Payer Primary Identifier"
QUIT
End DoDot:1
DO SET(CODE,LINE)
+48 QUIT
+49 ;
SBR ;Display Subscriber Segment
+1 NEW CODE
+2 SET SBR=SBR+1
IF SBR>1
DO SET("Other Subscriber Information",,1,1)
+3 SET CODE=$PIECE(DATA,D,2)
+4 DO SET("Payer Responsibility",$SELECT(CODE="T":"Tertiary",CODE="S":"Secondary",CODE="P":"Primary",1:"Other"))
+5 SET CODE=$PIECE(DATA,D,3)
Begin DoDot:1
+6 IF CODE="01"
SET CODE="Spouse"
QUIT
+7 IF CODE=18
SET CODE="Self"
QUIT
+8 IF CODE=19
SET CODE="Child"
QUIT
+9 IF CODE=20
SET CODE="Employee"
QUIT
+10 IF CODE=21
SET CODE="Unknown"
QUIT
+11 IF CODE=39
SET CODE="Organ Donor"
QUIT
+12 IF CODE=40
SET CODE="Cadaver Donor"
QUIT
+13 IF CODE=53
SET CODE="Life Partner"
QUIT
+14 IF CODE="G8"
SET CODE="Other Relationship"
QUIT
End DoDot:1
DO SET("Relationship",CODE)
+15 SET CODE=$PIECE(DATA,D,4)
IF $LENGTH(CODE)
DO SET("Group Number",CODE)
+16 SET CODE=$PIECE(DATA,D,5)
IF $LENGTH(CODE)
DO SET("Group Name",CODE)
+17 SET CODE=$PIECE(DATA,D,6)
IF CODE'=""
Begin DoDot:1
+18 IF CODE=12
SET CODE="Medicare Secondary or Spouse Employer Group Health"
QUIT
+19 IF CODE=13
SET CODE="Medicare Secondary with Spouse Emplyer Group Health"
QUIT
+20 IF CODE=14
SET CODE="Medicare Secondary, No Fault Insurance as primary"
QUIT
+21 IF CODE=15
SET CODE="Medicare Secondary, Worker's Compensation"
QUIT
+22 IF CODE=16
SET CODE="Medicare Secondary, Public Health Service"
QUIT
+23 IF CODE=41
SET CODE="Medicare Secondary Black Lung"
QUIT
+24 IF CODE=42
SET CODE="Medicare Secondary Veterans Administration"
QUIT
+25 IF CODE=43
SET CODE="Medicare Secondary Disabled Beneficiary"
QUIT
+26 IF CODE=47
SET CODE="Medicare Secondary, Other Liability Insurance Primary"
QUIT
End DoDot:1
DO SET("Type of Insurance",CODE)
+27 SET CODE=$PIECE(DATA,D,10)
Begin DoDot:1
+28 IF CODE=11
SET CODE="Other Non-Federal programs"
QUIT
+29 IF CODE=12
SET CODE="Preferred Provide Organization (PPO)"
QUIT
+30 IF CODE=13
SET CODE="Point of Service (POS)"
QUIT
+31 IF CODE=14
SET CODE="Exclusive Provider Organization (EPO)"
QUIT
+32 IF CODE=15
SET CODE="Indemnity Insurance"
QUIT
+33 IF CODE=16
SET CODE="Health Maintenance Organization (HMO) Medicare Risk"
QUIT
+34 IF CODE=17
SET CODE="Dental Maintenance Organization"
QUIT
+35 IF CODE="AM"
SET CODE="Automobile Medical"
QUIT
+36 IF CODE="BL"
SET CODE="Blue Cross/Blue Shield"
QUIT
+37 IF CODE="CH"
SET CODE="Champus"
QUIT
+38 IF CODE="CI"
SET CODE="Commercial Insurance"
QUIT
+39 IF CODE="DS"
SET CODE="Disability"
QUIT
+40 IF CODE="FI"
SET CODE="Federal Employees Program"
QUIT
+41 IF CODE="HM"
SET CODE="Health Maintenance Organization"
QUIT
+42 IF CODE="LM"
SET CODE="Liability Medical"
QUIT
+43 IF CODE="MA"
SET CODE="Medicare Part A"
QUIT
+44 IF CODE="MB"
SET CODE="Medicare Part B"
QUIT
+45 IF CODE="MC"
SET CODE="Medicaid"
QUIT
+46 IF CODE="OF"
SET CODE="Medicare Part D"
QUIT
+47 IF CODE="TV"
SET CODE="Title V"
QUIT
+48 IF CODE="VA"
SET CODE="Veterans Affairs Plan"
QUIT
+49 IF CODE="WC"
SET CODE="Worker Compensation Health Claim"
QUIT
+50 IF CODE="ZZ"
SET CODE="Mutually Defined/Unknown"
QUIT
End DoDot:1
DO SET("Type of Plan",CODE)
+51 QUIT
+52 ;
DATE(DATE,TYPE) ;Format Date/Time
+1 NEW D1
+2 SET TYPE=$GET(TYPE,"D8")
+3 IF TYPE="TM"
SET D1=DATE
GOTO DATEQ
+4 IF TYPE="D8"!(TYPE="DT")
Begin DoDot:1
+5 SET D1=$$FMTE^XLFDT($$HL7TFM^XLFDT($EXTRACT(DATE,1,8)),1)
+6 IF TYPE="DT"
SET D1=D1_" "_$EXTRACT(DATE,9,12)
End DoDot:1
GOTO DATEQ
+7 SET D1=$$FMTE^XLFDT($$HL7TFM^XLFDT($PIECE(DATE,"-",1),1))_"-"_$$FMTE^XLFDT($$HL7TFM^XLFDT($PIECE(DATE,"-",2),1))
DATEQ ;
+1 QUIT D1
+2 ;
DOL(DATA) ;Format Dollars
+1 SET DATA="$"_$FNUMBER(DATA,",",2)
+2 QUIT DATA
+3 ;
NAME(DATA) ;Format Person Name
+1 NEW LAST,FIRST,MI,SUF
+2 SET LAST=$PIECE(DATA,D,4)
SET FIRST=$PIECE(DATA,D,5)
SET MI=$PIECE(DATA,D,6)
SET SUF=$PIECE(DATA,D,8)
+3 QUIT LAST_$SELECT($LENGTH(FIRST):", ",1:"")_FIRST_" "_$SELECT($LENGTH(MI):MI_" ",1:"")_SUF
+4 ;
PHONE(NUM) ;Format phone number
+1 QUIT "("_$EXTRACT(NUM,1,3)_") "_$EXTRACT(NUM,4,6)_"-"_$EXTRACT(NUM,7,10)
+2 ;
YN(YN) ;Translate Yes/No element
+1 QUIT $SELECT(YN="W":"Not Applicable",YN="U":"Uknown",YN="Y":"Yes",1:"No")
+2 ;
ZIP(ZIP) ;Format Zip Code
+1 QUIT $EXTRACT(ZIP,1,5)_$SELECT($LENGTH(ZIP>5):"-"_$EXTRACT(ZIP,6,9),1:"")
+2 ;
SET(TITLE,VALUE,BLANK,HEADER) ;
+1 DO SET^IBACCWLRURREV($GET(TITLE),$GET(VALUE),$GET(BLANK),$GET(HEADER))
+2 QUIT
