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Sub-Field: 356.2216

Package: Integrated Billing

HCS REVIEW TRANSMISSION(#356.22)-->356.2216

Sub-Field: 356.2216


Information

Parent File Name Number Package
HCS REVIEW TRANSMISSION(#356.22) SERVICE LINE 356.2216 Integrated Billing

Details

Field # Name Loc Type Details
.01 SEQUENCE 0;1 NUMBER

  • 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)
.02 CERTIFICATION TYPE CODE 0;2 POINTER TO X12 278 CERTIFICATION TYPE CODE FILE (#356.002) X12 278 CERTIFICATION TYPE CODE(#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.
.03 SERVICE TYPE CODE 0;3 POINTER TO X12 271 SERVICE TYPE FILE (#365.013) X12 271 SERVICE TYPE(#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
.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.
.05 FACILITY TYPE 0;5 POINTER TO PLACE OF SERVICE FILE (#353.1) PLACE OF SERVICE(#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.
.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.
.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.
.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.
.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.
.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.
.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.
.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.
.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.
.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.
.15 REQUEST CATEGORY 0;15 POINTER TO X12 278 REQUEST CATEGORY FILE (#356.001) X12 278 REQUEST CATEGORY(#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.
.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.
.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.
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:  
1.02 PROCEDURE #1 1;2 VARIABLE POINTER CPT(#81)  ICD OPERATION/PROCEDURE(#80.1)  

  • 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.
1.03 PROCEDURE CODE #2 1;3 VARIABLE POINTER CPT(#81)  ICD OPERATION/PROCEDURE(#80.1)  

  • 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.
1.04 PROCEDURE MODIFIER #1 1;4 POINTER TO CPT MODIFIER FILE (#81.3) CPT MODIFIER(#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.
1.05 PROCEDURE MODIFIER #2 1;5 POINTER TO CPT MODIFIER FILE (#81.3) CPT MODIFIER(#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.
1.06 PROCEDURE MODIFIER #3 1;6 POINTER TO CPT MODIFIER FILE (#81.3) CPT MODIFIER(#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.
1.07 PROCEDURE MODIFIER #4 1;7 POINTER TO CPT MODIFIER FILE (#81.3) CPT MODIFIER(#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.
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.
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.
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.
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.
1.12 SERVICE LINE TYPE 1;12 SET
************************REQUIRED FIELD************************
  • '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.
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.
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.
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.
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.
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).
2.06 REVENUE CODE 2;6 POINTER TO REVENUE CODE FILE (#399.2) REVENUE CODE(#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.
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.
2.08 NURSING HOME STATUS 2;8 POINTER TO X12 278 NURSING HOME RESIDENTIAL STATUS FILE (#356.011) X12 278 NURSING HOME RESIDENTIAL STATUS(#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.
2.09 NURSING HOME LEVEL OF CARE 2;9 POINTER TO X12 278 NURSING HOME LEVEL OF CARE FILE (#356.019) X12 278 NURSING HOME LEVEL OF CARE(#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.
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 Designations #2, #3, #4 or #5.
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 Designations #1, #3, #4 or #5.
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 Designations #1, #2, #4 or #5.
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 Designations #1, #2, #3 or #5.
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 Designations #1, #2, #3 or #4.
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.
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.
4 TOOTH INFORMATION 4;0 POINTER Multiple #356.22164 356.22164

  • DESCRIPTION:  
    This multiple holds tooth information for the dental service line.
5.01 HCSD QUANTITY QUALIFIER 5;1 POINTER TO X12 271 QUANTITY QUALIFIER FILE (#365.016) X12 271 QUANTITY QUALIFIER(#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.
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.
5.03 HCSD UNITS OF MEASUREMENT 5;3 SET

  • 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.
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.
5.05 HCSD TIME PERIOD QUALIFIER 5;5 POINTER TO X12 271 TIME PERIOD QUALIFIER FILE (#365.015) X12 271 TIME PERIOD QUALIFIER(#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
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.
5.07 HCSD DELIVERY FREQUENCY 5;7 POINTER TO X12 271 DELIVERY FREQUENCY CODE FILE (#365.025) X12 271 DELIVERY FREQUENCY CODE(#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.
5.08 HCSD DELIVERY TIME PATTERN 5;8 POINTER TO X12 278 DELIVERY PATTERN TIME CODE FILE (#356.007) X12 278 DELIVERY PATTERN TIME CODE(#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.
6 ATTACHMENTS 6;0 POINTER Multiple #356.22166 356.22166

  • DESCRIPTION:  
    This multiple contains additional patient information (attachments) for service line level.
7 MESSAGE TEXT 7;0 WORD-PROCESSING #356.22167

  • DESCRIPTION:  
    An additional free text comment for this service line.
8 SERVICE PROVIDER 8;0 POINTER Multiple #356.22168 356.22168

  • DESCRIPTION:  
    This multiple holds data related to providers for this service line.
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.
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.
10 HI SEGMENTS 10;0 Multiple #356.2316 356.2316

  • LAST EDITED:  SEP 24, 2014
  • DESCRIPTION:  
    This multiple contains data for HI segments.
11.01 CERTIFICATION ACTION CODE 11;1 POINTER TO X12 278 CERTIFICATION ACTION CODES FILE (#356.02) X12 278 CERTIFICATION ACTION CODES(#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.
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
11.03 REVIEW DECISION REASON CODE 11;3 POINTER TO X12 278 HCS DECISION REASON CODES FILE (#356.021) X12 278 HCS DECISION REASON CODES(#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.
11.04 SECOND SURGICAL OPINION FLAG 11;4 SET

  • 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.
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).
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).
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