TRICARE Systems Manual 7950.4-M, April 2021
TRICARE Encounter Data (TED)
Chapter 2
Section 2.7
Data Requirements- Institutional/Non-Institutional Record Data Elements (P)
Copyright:CPT only © 2006 American MedicalAssociation (or such other date of publication of CPT).All Rights Reserved.
Revision:
| ELEMENT NAME:PATIENT IDENTIFIER (DoD) | |||
|---|---|---|---|
| Notes And Special Instructions: If person not on DEERS butclaim is payable (i.e., Government liability), report all ninesin this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-095 2-080 | 1 1 | Yes Yes |
| Primary Picture (Format) | Ten (10) alphanumeric characters. | ||
| Definition | The identifier associated witha particular patient. Download field from Defense Enrollment Eligibility ReportingSystem (DEERS). | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PATIENT STATUS | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional | 1-270 | 1 | Yes |
| Primary Picture (Format) | Two (2) alphanumeric characters. | ||
| Definition | Code indicating patient statusas of the end date of care on the TED record. | ||
| Code/Value Specifications | 01 | Discharged | |
| 02 | Transferred | ||
| 03 | Discharged/transferred to SkilledNursing Facility (SNF) | ||
| 04 | Discharged/transferred to IntermediateCare Facility (ICF) | ||
| 05 | Discharged/transferred to anothertype of institution (including distinct parts of institutions) (definitionnot valid for discharges on or after 04/01/2008) | ||
| 05 | Discharged/transferred to adesignated cancer center or children’s hospital (definition effectivefor discharges on or after 04/01/2008) | ||
| 06 | Discharged/transferred to homeunder care of organized home health service organization | ||
| 07 | Left against medical adviceor discontinued care | ||
| 08 | Discharged/transferred to homeunder care of a home IV provider (not valid for discharges on orafter 10/01/2005) | ||
| 20 | Expired (or did not recover- Christian Science Patient) | ||
| 21 | Discharged/transferred to court/lawenforcement | ||
| 30 | Still patient (remaining) | ||
| 40 | Expired at home | ||
| 41 | Expired in a medical facility,such as a hospital, SNF, ICF, or freestanding hospice | ||
| 42 | Expired place unknown | ||
| 43 | Discharged/transferred to afederal health care facility | ||
| 50 | Discharged to Hospice - Home | ||
| 51 | Discharged to Hospice - MedicalFacility | ||
| 61 | Discharged/transferred to ahospital-based Medicare approved swing bed | ||
| 62 | Discharged/transferred to anInpatient Rehabilitation Facility (IRF) including RehabilitationDistinct Part Units of a hospital | ||
| 63 | Discharged/transferred to aLong-Term Care Hospital (LTCH) | ||
| 64 | Discharged/transferred to anursing facility certified under Medicaid but not certified underMedicare | ||
| 65 | Discharged/transferred to apsychiatric hospital or psychiatric distinct part unit of a hospital | ||
| 66 | Discharged/transferred to aCritical Access Hospital (CAH) | ||
| 69 | Discharged/transferred to adesignated disaster alternative care site (Effective 10/01/2013) | ||
| 70 | Discharged/transferred to anothertype of health care institution not defined elsewhere in this codelist (definition effective for discharges on or after 04/01/2008) | ||
| 81 | Discharged to home or selfcare with a planned acute care hospital inpatient readmission (Effective10/01/2013) | ||
| 82 | Discharged/transferred to ashort-term general hospital for inpatient care with a planned acutecare hospital inpatient readmission (Effective 10/01/2013) | ||
| 83 | Discharged/transferred to aSNF with Medicare certification with a planned acute care hospitalinpatient readmission (Effective 10/01/2013) | ||
| 84 | Discharged/transferred to afacility that provides custodial or supportive care with a plannedacute care hospital inpatient readmission (Effective 10/01/2013) | ||
| 85 | Discharged/transferred to adesignated cancer center or children’s hospital with a planned acutecare hospital inpatient readmission (Effective 10/01/2013) | ||
| 86 | Discharged/transferred to homeunder care of organized home health service organization with aplanned acute care hospital inpatient readmission (Effective 10/01/2013) | ||
| 87 | Discharged/transferred to court/lawenforcement with a planned acute care hospital inpatient readmission(Effective 10/01/2013) | ||
| 88 | Discharged/transferred to afederal health care facility with a planned acute care hospitalinpatient readmission (Effective 10/01/2013) | ||
| 89 | Discharged/transferred to ahospital-based Medicare approved swing bed with a planned acutecare hospital inpatient readmission (Effective 10/01/2013) | ||
| 90 | Discharged/transferred to anIRF including rehabilitation distinct part units of a hospital witha planned acute care hospital inpatient readmission (Effective 10/01/2013) | ||
| 91 | Discharged/transferred to aMedicare certified LTC with a planned acute care hospital readmission(Effective 10/01/2013) | ||
| 92 | Discharged/transferred to anursing facility certified under Medicaid but not certified underMedicare with a planned acute care hospital readmission (Effective10/01/2013) | ||
| 93 | Discharged/transferred to apsychiatric hospital or psychiatric distinct part unit of a hospitalwith a planned acute care hospital readmission (Effective 10/01/2013) | ||
| 94 | Discharged/transferred to aCAH with a planned acute care hospital readmission (Effective 10/01/2013) | ||
| 95 | Discharged/transferred to anothertype of health care institution not defined elsewhere in this codelist with a planned acute care hospital readmission (Effective 10/01/2013) | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PATIENT ZIP CODE | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-105 2-090 | 1 1 | Yes Yes |
| Primary Picture (Format) | Nine (9) alphanumeric characters. | ||
| Definition | United States (US) postal ZIPcode or foreign country code for patient’s legal residence at thetime service was rendered and must not be the ZIP code of a P.O.Box. | ||
| Code/Value Specifications | Must be a valid five or ninedigit ZIP code. If only five digits, left justify and blank fill.If foreign country, must be three character foreign country code,left justify and blank fill. Refer to Addendum A. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PAY GRADE CODE (SPONSOR) | |||
|---|---|---|---|
| Notes And Special Instructions: 1If the DEERS response doesnot return a PAY GRADE CODE (SPONSOR), report 00 inthis field.If person not on DEERS but claim is payable (i.e., Government liability),report 00 in this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-056 2-291 | 1 Up to 99 | Yes1 Yes1 |
| Primary Picture (Format) | Two (2) alphanumeric characters. | ||
| Definition | The code that represents thelevel of pay. (The combination of pay plan code and pay grade code representsthe sponsor’s pay category.) Download field from DEERS. | ||
| Code/Value Specifications | 00 | Unknown | |
| 00 - ZZ | Used when pay plan is civilservice | ||
| 01 | Used when pay plan is cadet | ||
| 01 - 05 | Used when pay plan is warrantoffice | ||
| 01 - 09 | Used when pay plan is enlisted | ||
| 01 - 11 | Used when pay plan is officer | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PAY PLAN CODE (SPONSOR) | |||
|---|---|---|---|
| Notes And Special Instructions: 1If the DEERS response doesnot return a PAY PLAN CODE (SPONSOR), report ZZ inthis field, left justify.If person not on DEERS but claim is payable (i.e., Government liability),report ZZ in this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-057 2-292 | 1 Up to 99 | Yes1 Yes1 |
| Primary Picture (Format) | Five (5) alphanumeric characters. | ||
| Definition | The code that represents thetype of pay category. (The combination of pay plan code and paygrade code represents the sponsor’s pay category.) Download fieldfrom DEERS. | ||
| Code/Value Specifications | For valid values refer to Addendum J. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PCM LOCATION DMIS-ID (ENROLLMENT)CODE | |||
|---|---|---|---|
| Notes And Special Instructions: If not applicable blank fill. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-115 2-110 | 1 1 | No No |
| Primary Picture (Format) | Four (4) alphanumeric characters. | ||
| Definition | This code identifies and distinguishesMarket/Military Medical Treatment Facility (MTF)/clinic enrollmentsfrom network enrollments. The code designations vary based on typeof Prime enrollment and begin work dates of new programs. The codesalso vary based on the individual requirements of enrolling platformsused by the Managed Care Support (MCS) regions. Download field fromDEERS using Primary Care Manager (PCM) Enrolling Division DMIS-ID. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON BIRTH CALENDAR DATE(PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required if available on DEERS,if not available from DEERS report from the claim or report 19111111. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-085 2-070 | 1 1 | Yes1 Yes1 |
| Primary Picture (Format) | Eight (8) alphanumeric characters,YYYYMMDD. | ||
| Definition | The date when a human beingwas born. Download field from DEERS. | ||
| Code/Value Specifications | YYYY | 4 digit calendar year | |
| MM | 2 digit calendar month | ||
| DD | 2 digit calendar day | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON CADENCY NAME (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required if available on DEERS,if not available from DEERS report from the claim or blank fill. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-079 2-064 | 1 1 | Yes1 Yes1 |
| Primary Picture (Format) | Ten (10) alphanumeric characters. | ||
| Definition | The cadency name (i.e., Sr.,Jr., III, etc.) of the patient. Download field from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | PERSON NAME (PATIENT) | ||
| ELEMENT NAME:PERSON FIRST NAME (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required if available on DEERS;if not available from DEERS report from the claim or blank fill. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-077 2-062 | 1 1 | Yes1 Yes1 |
| Primary Picture (Format) | Twenty-five (25) alphanumericcharacters. | ||
| Definition | First name of patient. Downloadfield from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | PERSON NAME (PATIENT) | ||
| ELEMENT NAME:PERSON IDENTIFIER (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: If person not on DEERS butclaim is payable (i.e., Government liability), report from the claimor report all nines in this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-080 2-065 | 1 1 | Yes Yes |
| Primary Picture (Format) | Nine (9) alphanumeric characters. | ||
| Definition | The identifier that representsa human being. This attribute will usually contain the person’sSocial Security Number (SSN). Download field from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON IDENTIFIER (SPONSOR) | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-050 2-050 | 1 1 | Yes Yes |
| Primary Picture (Format) | Nine (9) alphanumeric characters. | ||
| Definition | The identifier that representsa person who is a sponsor. This attribute will usually contain thesponsor’s SSN. Download field from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON IDENTIFIER TYPE CODE(PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: If person not on DEERS butclaim is payable (i.e., Government liability), report from the claimor report Z in this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-081 2-066 | 1 1 | Yes Yes |
| Primary Picture (Format) | One (1) alphanumeric character. | ||
| Definition | The code that represents aspecific kind of person identifier. Download field from DEERS. | ||
| Code/Value Specifications | D | Special nine digit code createdfor individuals (i.e., babies) who do not have or have not providedan SSN when the record is added to DEERS (dependents only). | |
| F | Special nine digit code createdfor foreign military and nationals. | ||
| I | Taxpayer Identification Number(TIN) | ||
| P | Special nine digit code createdfor US military personnel from Service Numbers before the switchto SSNs. | ||
| R | Special nine digit code createdfor a Department of Defense (DoD) contractor who refused to givehis or her SSN to Real-Time Automated Personnel Identification System(RAPIDS. The associated PN_ID will begin with 99. | ||
| S | SSN | ||
| Z | Not applicable | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON IDENTIFIER TYPE CODE(SPONSOR) | |||
|---|---|---|---|
| Notes And Special Instructions: If person not on DEERS butclaim is payable (i.e., Government liability), report from the claimor report Z in this field. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-051 2-051 | 1 1 | Yes Yes |
| Primary Picture (Format) | One (1) alphanumeric character. | ||
| Definition | The code that represents aspecific kind of person identifier. Download field from DEERS. | ||
| Code/Value Specifications | D | Special nine digit code createdfor individuals (i.e., babies) who do not have or have not providedan SSN when the record is added to DEERS (dependents only). | |
| F | Special nine digit code createdfor foreign military and nationals. | ||
| I | TIN | ||
| P | Special nine digit code createdfor US military personnel from Service Numbers before the switchto SSNs. | ||
| R | Special nine digit code createdfor a DoD contractor who refused to give his or her SSN to RAPIDS.The associated PN_ID will begin with 99. | ||
| S | SSN | ||
| Z | Not applicable | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PERSON LAST NAME (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-076 2-061 | 1 1 | Yes Yes |
| Primary Picture (Format) | Thirty-five (35) alphanumericcharacters. | ||
| Definition | Last name of patient. Downloadfield from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | PERSON NAME (PATIENT) | ||
| ELEMENT NAME:PERSON MIDDLE NAME (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required if available on DEERS,if not available from DEERS report from the claim or blank fill. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-078 2-063 | 1 1 | Yes1 Yes1 |
| Primary Picture (Format) | Twenty-five (25) alphanumericcharacters. | ||
| Definition | Middle name of patient. Downloadfield from DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | PERSON NAME (PATIENT) | ||
| ELEMENT NAME:PERSON NAME (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-075 2-060 | 1 1 | Yes Yes |
| Primary Picture (Format) | Group | ||
| Definition | Name of patient. Download fieldfrom DEERS. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| PERSON LAST NAME PERSONFIRST NAME PERSON MIDDLE NAME PERSONCADENCY NAME | N/A | ||
| ELEMENT NAME:PERSON SEX (PATIENT) | |||
|---|---|---|---|
| Notes And Special Instructions: Use DEERS response if DEERSreturns a value of F or M. If DEERS responseis not F or M, the person sex should bereported based on claim information or patient history. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-100 2-085 | 1 1 | Yes Yes |
| Primary Picture (Format) | One (1) alphanumeric character. | ||
| Definition | Code defining sex of patient.Download field from DEERS. | ||
| Code/Value Specifications | F | Female | |
| M | Male | ||
| Z | Unknown | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PHYSICIAN REFERRAL NUMBER | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required for all referred care(Market/MTF and Civilian PCM). If not applicable blank fill. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Non-Institutional | 2-270 | 1 | Yes1 |
| Primary Picture (Format) | Thirteen (13) alphanumericcharacters. | ||
| Definition | The identifying number of thereferring physician. This field will report the National ProviderIdentifier (NPI) or PROVIDER TAXPAYER NUMBER and PROVIDER SUB-IDENTIFIERas applicable. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PLACE OF SERVICE | |||
|---|---|---|---|
| Notes And Special Instructions: This data element must be 19 forMail Order Pharmacy (MOP). | |||
| Records/Locator Numbers | |||
| Record Name | LOCATOR# | Occurrences | Required |
| Non-Institutional | 2-275 | Up to 99 | Yes |
| Primary Picture (Format) | Two (2) alphanumeric characters. | ||
| Definition | Code to indicate where thehealth care was provided. | ||
| Code/Value Specifications | 01 | Pharmacy | |
| 02 | Telehealth | ||
| 03 | School | ||
| 04 | Homeless Shelter | ||
| 05 | Indian Health Service (IHS)Freestanding Facility | ||
| 06 | IHS Provider-based Facility | ||
| 07 | Tribal 638 Freestanding Facility | ||
| 08 | Tribal 638 Provider-based Facility | ||
| 09 | Prison-Correctional Facility | ||
| 11 | Office | ||
| 12 | Home | ||
| 13 | Assisted Living Facility | ||
| 14 | Group Home | ||
| 15 | Mobile Unit | ||
| 16 | Temporary Lodging | ||
| 17 | Walk-in Retail Health Clinic | ||
| 18 | Place of Employment Work-site | ||
| 19 | Pharmacy (Terminated 12/31/2015) | ||
| 19 | Off Campus-Outpatient Hospital | ||
| 20 | Urgent Care Facility | ||
| 21 | Inpatient Hospital | ||
| 22 | On Campus-Outpatient Hospital | ||
| 23 | Emergency Room - Hospital | ||
| 24 | Ambulatory Surgical Center(ASC) | ||
| 25 | Birthing Center (BC) | ||
| 26 | Market/MTF | ||
| 31 | SNF | ||
| 32 | Nursing Facility | ||
| 33 | Custodial Care Facility | ||
| 34 | Hospice | ||
| 41 | Ambulance - Land | ||
| 42 | Ambulance - Air or Water | ||
| 49 | Independent Clinic | ||
| 50 | Federally Qualified HealthCenter | ||
| 51 | Inpatient Psychiatric Facility | ||
| 52 | Psychiatric Facility PartialHospitalization | ||
| 53 | Community Mental Health Center(CMHC) | ||
| 54 | ICF/Mentally Retarded | ||
| 55 | Residential Substance AbuseTreatment Facility | ||
| 56 | Psychiatric Residential TreatmentCenter (RTC) | ||
| 57 | Non-Residential Substance AbuseTreatment Facility | ||
| 60 | Mass Immunization Center | ||
| 61 | Comprehensive Inpatient RehabilitationFacility | ||
| 62 | Comprehensive Outpatient RehabilitationFacility (CORF) | ||
| 65 | End Stage Renal Disease (ESRD)Treatment Facility | ||
| 71 | Public Health Clinic | ||
| 72 | Rural Health Clinic (RHC) | ||
| 81 | Independent Laboratory | ||
| 99 | Other Unlisted Facility | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:POINT OF ORIGIN | ||||
|---|---|---|---|---|
| Notes And Special Instructions: 1Use this coding structure whenthe TYPE OF ADMISSION = 4 (newborn). | ||||
| Records/LocatorNumbers | ||||
| Record Name | Locator# | Occurrences | Required | |
| Institutional | 1-260 | 1 | Yes | |
| Primary Picture (Format) | One (1) alphanumeric character. | |||
| Definition | Code indicating the sourceof the referral for this admission. | |||
| Code/Value Specifications | SourceOf Admission Code | |||
| 1 | Physician Referral | The patient was admitted tothis facility upon the recommendation of his or her personal physician.(Discontinued effective 10/01/2007.) | ||
| 1 | Non-Health Care Facility Pointof Origin | The patient was admitted tothis facility upon order of a physician or self-referral. (Effective10/01/2007.) | ||
| 2 | Clinic Referral | The patient was admitted tothis facility upon recommendation of this facility’s clinic physician. | ||
| 3 | Health Maintenance Organization(HMO) Referral | The patient was admitted tothis facility as a transfer from a freestanding or non-freestandingclinic. Discontinued effective 10/01/2007.) | ||
| 4 | Transfer from a Hospital (Different Facility) | The patient was admitted tothis facility as a hospital transfer from a different acute carefacility where he or she was an inpatient. | ||
| 5 | Transfer from a SNF or ICF | The patient was admitted tothis facility as a transfer from a SNF or ICF where he or she wasa resident. | ||
| 6 | Transfer from another HealthCare Facility | The patient was admitted tothis facility as a transfer from another type of health care facilitynot defined elsewhere in this code list. | ||
| 7 | Emergency Room | The patient was admitted tothis facility after receiving services in this facility’s emergencydepartment. (Discontinued effective 07/01/2010). | ||
| 8 | Court/Law Enforcement | The patient was admitted tothis facility upon the direction of a court of law, or upon therequest of a law enforcement agency representative. | ||
| 9 | Information Not Available | The means by which the patientwas admitted to this hospital is not known. | ||
| A | Transfer from a CAH | The patient was admitted tothis facility as a transfer from a CAH where he or she was an inpatient.(Discontinued effective 10/01/2007.) | ||
| B | Transfer from Another HomeHealth Agency (HHA) | The patient was admitted tothis HHA as a transfer from another HHA. (Discontinued effective07/01/2010). | ||
| C | Readmission to the Same HHA | The patient was readmittedto this HHA within the existing 60 day payment. (Discontinued effective07/01/2010). | ||
| D | Transfer from Hospital Inpatientin the same facility resulting in a separate claim to the payer | The patient was admitted tothis facility as a transfer from Hospital Inpatient within thisfacility resulting in a separate claim to the payer. | ||
| E | Transfer from ASC | The patient was admitted tothis facility as a transfer from an ASC. (Effective 10/01/2007.) | ||
| F | Transfer from Hospice and isunder a Hospice Plan of Care or enrolled in a Hospice Program | The patient was admitted tothis facility as a transfer from hospice. (Effective 10/01/2007.) | ||
| Code structurefor newborn1 | ||||
| 1 | Normal Delivery | A baby delivered without complications.(Discontinued effective 10/01/2007.) | ||
| 2 | Premature Delivery | A baby delivered with timeand/or weight factors qualifying it for premature status. (Discontinuedeffective 10/01/2007.) | ||
| 3 | Sick Baby | A baby delivered with medicalcomplications, other than those relating to premature status. (Discontinuedeffective 10/01/2007.) | ||
| 4 | Extramural Birth | A newborn born in a non-sterileenvironment. (Discontinued effective 10/01/2007.) | ||
| 5 | Born Inside This Hospital | A baby born inside this hospital.(Effective 10/01/2007.) | ||
| 6 | Born Outside This Hospital | A baby born outside this hospital.(Effective 10/01/2007.) | ||
| Algorithm | N/A | |||
| Subordinate And/Or Group Elements | ||||
| Subordinate | Group | |||
| N/A | N/A | |||
| ELEMENT NAME:PRICING RATE CODE | |||
|---|---|---|---|
| Notes And Special Instructions: 1Code 0 for allallowed drug charges. 2Use Pricing Rate Code 1 (PricedManually) for consultation procedures for which the allowable chargeis limited to that for a Limited Initial Visit, New Patient. To indicate that the hospitalreimbursem*nt was reduced by a full or partial credit a providerreceived for a replaced device, Special Processing Codes 49 or 50 shouldbe used. See Section 2.8. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-190 2-325 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | Two (2) alphanumeric characters. | ||
| Definition | Code indicating the pricingmethodology used in determining the amount allowed for the service(s)/supplies.Left justify and blank fill. | ||
| Code/Value Specifications | Institutionalcode | ||
| b | No special rate | ||
| D | Discount rate agreement | ||
| H | TRICARE Diagnosis Related Group(DRG) reimbursem*nt with Short Stay Outlier | ||
| I | TRICARE DRG reimbursem*nt withCost Outlier | ||
| J | TRICARE DRG reimbursem*nt withNo Outlier | ||
| K | Hospital-specific Psychiatricper diem rate | ||
| L | Region-specific Psychiatricper diem rate | ||
| P | Per diem rate | ||
| S | HVBP Adjustment Factor | ||
| U | Supplemental Health Care Program(SHCP) claim or active duty member TRICARE Prime Remote (TPR) claimpaid outside normal limits | ||
| V | Medicare Reimbursem*nt Rate | ||
| CA | CAH Reimbursem*nt | ||
| CI | CAH IRF Reimbursem*nt (Effective10/01/2018) | ||
| CP | CAH Psychiatric Hospital perdiem rate (Effective 10/01/2018) | ||
| CR | Cost-To-Charge Ratio (CCR)(Effective 01/01/2014) | ||
| CV | COVID-19 Adjustment Factor | ||
| DD | Discounted DRG | ||
| LT | Standard LTCH Reimbursem*nt(Effective 10/01/2018) | ||
| RF | TRICARE IRF Reimbursem*nt (Effective10/01/2018) | ||
| SN | Site-Neutral LTCH Reimbursem*nt(Effective 10/01/2018) | ||
| NON-Institutionalcode | |||
| Pricing not applicable (deniedservice/supplies and allowed drugs)1 | |||
| 1 | Priced Manually2 | ||
| 2 | Prevailing charge (state) | ||
| 3 | Conversion amount (state) | ||
| 4 | Paid as billed | ||
| 5 | Paid on negotiated rate | ||
| A | National prevailing charge | ||
| B | National conversion factor | ||
| C | Ambulatory surgery facilitypayment rate | ||
| D | Discounted ambulatory surgeryfacility payment rate | ||
| E | Ambulatory surgery-paid asbilled | ||
| F | Claim Auditing Software-addedprocedure, priced manually | ||
| G | Claim Auditing Software-addedprocedure, prevailing charge (State) | ||
| H | Claim Auditing Software-addedprocedure, conversion factor (Contractor) | ||
| I | Claim Auditing Software-addedprocedure, paid as billed | ||
| J | Claim Auditing Software-addedprocedure, paid on negotiated rate | ||
| N | Claim Auditing Software-addedprocedure, national prevailing charge | ||
| O | Claim Auditing Software-addedprocedure, national conversion factor | ||
| P | Claim Auditing Software-addedprocedure, ambulatory surgery facility payment rate | ||
| Q | Claim Auditing Software-addedprocedure, discounted ambulatory surgery facility payment rate | ||
| R | Claim Auditing Software-addedprocedure, ambulatory surgery-paid as billed | ||
| S | HVBP Adjustment Factor | ||
| T | Claim Auditing Software-addedprocedure, allowed as billed but paid less than billed | ||
| U | SHCP or active duty memberTPR claim paid outside normal limits | ||
| V | Medicare Reimbursem*nt Rate | ||
| W | Priced over CHAMPUS MaximumAllowable Charge (CMAC) (Effective 09/27/2001) | ||
| BR | Blended Rate | ||
| CA | CAH Reimbursem*nt | ||
| GG | Global Rate Agreement (usedwith corporate service providers only) (Effective 08/01/2003) | ||
| GP | Per Diem Rate Agreement (usedwith corporate service providers only) (Effective 08/01/2003) | ||
| LC | TRICARE Claim-added procedure,CMAC priced laboratory code | ||
| P1 | Outpatient Prospective PaymentSystem (OPPS) | ||
| P2 | OPPS with Cost Outlier | ||
| P3 | OPPS with Discount | ||
| P5 | Hospital-based Partial Hospitalization- paid as OPPS | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | PROCESSING INFORMATION | ||
| ELEMENT NAME:PRINCIPAL OPERATION/NON-SURGICALPROCEDURE CODE | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required if one of the followingRevenue Codes are present 036X or 072X. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional | 1-345 | 1 | Yes1 |
| Primary Picture (Format) | Seven (7) alphanumeric characters. | ||
| Definition | The code that identifies theprincipal procedure performed during the period reported on theTED record as submitted on the UB-04/UB-92. | ||
| Code/Value Specifications | Use the most current procedurecode edition (International Classification of Diseases, 9th Revision, ClinicalModification (ICD-9-CM) or International Classification of Diseases,10th Revision, Procedure Coding System (ICD-10-PCS)) as directedby the Defense Health Agency (DHA). Must provide the most detailedcode. Do not code the decimal point. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PRINCIPAL TREATMENT DIAGNOSIS/PRESENTON ADMISSION (POA) INDICATOR | |||
|---|---|---|---|
| Notes And Special Instructions: For MOP and Retail Pharmacy,if a more specific diagnosis code is not available, use ICD-9-CM799.89 on or before September 30, 2015, and ICD-10-CM R68.89 onor after October 1, 2015. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-300 2-115 | 1 1 | Yes Yes |
| Primary Picture (Format) | Eight (8) alphanumeric characters. | ||
| Definition | Principal Treatment Diagnosis:The condition established, after study, to be the major cause forthe patient to obtain medical care as submitted on the claim formor otherwise indicated by the provider. | ||
| POA Indicator: Diagnosis presentat the time the order for inpatient admission occurs. | |||
| Code/Value Specifications | Principal Treatment Diagnosis(Positions 1 through 7): Use the most current diagnosis code edition (ICD-9-CMor ICD-10-CM), as directed by DHA. Must provide the most detailedcode. Do not code the decimal point. | ||
| POA Indicator (Position 8): | |||
| Valid POA values are: | |||
| b | Not reported | ||
| 1 | Unreported/Not Used - Exemptfrom POA reporting | ||
| N | No - Not present at time ofadmission | ||
| U | Unknown - Documentation insufficientto determine if the condition was present at time of admission | ||
| W | Clinically Undetermined - Theprovider is unable to clinically determine if the condition waspresent at time of admission | ||
| Y | Yes - Present at time of admission | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROCEDURE CODE | |||
|---|---|---|---|
| Notes And Special Instructions: For MOP report CPT code 98800for all drug prescriptions and CPT code 99070 for all supplies.The first line item must report the information on the prescriptionand the second line item to report corresponding supplies that areissued such as alcohol pads, lancets, etc. The procedure code onthe second occurrence/line item on MOP records must be CPT code99070. For MOP and Retail PharmacyPrior Authorizations and Medical Necessity Reviews report 000PA or 000MN. For the list of the No GovernmentPay Procedure Codes that are excluded from TRICARE coverage andare not payable under TRICARE, refer to the No Government Pay ProcedureCode list on DHA’s website at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursem*nt/No-Government-Pay-Procedure-Code-List. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Non-Institutional | 2-160 | Up to 99 | Yes |
| Primary Picture (Format) | Five (5) alphanumeric characters. | ||
| Definition | The code that identifies theprocedure performed or describes the care received as submittedon the claim form. | ||
| Code/Value Specifications | Refer to Physician’s CurrentProcedure Terminology, 4th Edition (CPT-4) or Healthcare Common ProcedureCoding System (HCPCS) National Level II Medicare Codes or DHA approvedcodes (Addendum E, Figure 2.E-2). For dental services,use HCPC or ADA Dental procedure codes. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROCEDURE CODE MODIFIER | |||
|---|---|---|---|
| Notes And Special Instructions: Can report from zero to fourcodes. Each occurrence consists of two characters left justifiedand blank-filled. Do not duplicate. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Non-Institutional | 2-165 | 4/Up to 99 | No |
| Primary Picture (Format) | Four (4) occurrences of two(2) alphanumeric characters per occurrence/line item. | ||
| Definition | Two digit code which providesthe means by which the health care professional can indicate thata service or procedure that has been performed has been alteredby some specific circ*mstance but not changed in its definitionor code. (Refer to Physician’s CPT-4 or HCPCS National Level IIMedicare Codes.) | ||
| Code/Value Specifications | Must be 21-27, 32, 33, 47,50-59, 62, 63, 66, 73-82, 90-92, 95-97, 99, 0A-0P, 0Z, 1A-1J, 1Z,2A-2O, 2Q-2T, 2Z, 3A-3I, 3K, 3Z, 4A-4U, 4Z, 5A-5O, 5Z, 6A-6F, 6Z,7A-7F, 7Z, 8A-8C, 8P, 8Z, 9A-9D, 9L-9Q, 9Z, A1-A9, AA, AD-AK, AM,AO-AZ, BA, BL, BO-BR, BU, CA-CO, CQ-CT, DA, DE, DG-DJ, DN, DP, DR,DS, DX, E1-E4, EA-EE, EG-EJ, EM, EN, EP, ER-ET, EX, EY, F1-F9, FA-FC,FP, FX, FY, G0-G9, GA-GC, GE-GZ, H9, HA-HZ, ID, IE, IG-IJ, IN, IR,IS, IX, J1-J5, JA-JJ, JN, JP, JR, JS, JW, JX, K0-K4, KA-KZ, L1,LC, LD, LL, LM, LR-LT, M2, MA-MH, MR, MS, NB, ND, NE, NG-NJ, NN,NP, NR-NU, NX, P1-P6, PA-PE, PG, PI, PJ, PL-PP, PR-PT, PX, Q0-Q9,QA-QH, QJ-QZ, RA-RE, RG-RJ, RN, RP-RT, RX, SA-SN, SQ-SY, T1-T9,TA-TK, TL-TN, TP-TW, U1-U9, UA-UH, UJ-UK, UN, UP-US, V1-V9, VM,VP, X1-X5, XD, XE, XG-XJ, XN, XP, XR, XS, XU, or blank. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROCESSING INFORMATION | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional | 1-155 | 1 | Yes |
| Primary Picture (Format) | Group | ||
| Definition | Field containing multiple elementsthat describe processing related to the TED record. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| OVERRIDE CODE TYPE OFSUBMISSION CA/NAS NUMBER CA/NASREASON FOR ISSUANCE CA/NAS EXCEPTION REASON SPECIALPROCESSING CODE PRICING RATE CODE HEALTHCAREDELIVERY PROGRAM SPECIAL ENTITLEMENT CODE | N/A | ||
| ELEMENT NAME:PROVIDER INDIVIDUAL NPI NUMBER(TYPE 1) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required for all “covered entities”that submit Health Insurance Portability and Accountability Act(HIPAA)-compliant standard electronic transactions in accordancewith the TRICARE Operations Manual (TOM), Chapter 19, Section 4. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Non-Institutional | 2-225 | Up to 99 | Yes1 |
| Primary Picture (Format) | Ten (10) alphanumeric characters. | ||
| Definition | Standard unique health identifierfor individual providers, including but not limited to those (human beings)who provide care such as physicians, nurse practitioners, dentists,chiropractors, pharmacists, and physical therapists. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER NETWORK STATUS INDICATOR | |||
|---|---|---|---|
| Notes And Special Instructions: This data element must be 1 forMOP. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-230 2-265 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | One (1) alphanumeric character. | ||
| Definition | Code indicating whether theprovider is a network or non-network provider. | ||
| Code/Value Specifications | 1 | Network Provider | |
| 2 | Non-Network Provider | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER ORGANIZATIONAL NPINUMBER (TYPE 2) | |||
|---|---|---|---|
| Notes And Special Instructions: 1Required for all “covered entities”that submit HIPAA-compliant standard electronic transactions inaccordance with the TOM, Chapter 20, Section 4. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-215 2-230 | Up to 99 | Yes1 Yes1 |
| Primary Picture (Format) | Ten (10) alphanumeric characters. | ||
| Definition | Standard unique health identifierfor organizational providers, including but not limited to, non-person providerssuch as hospitals, HHAs, clinics, laboratories, suppliers of DurableMedical Equipment (DME), pharmacies, and groups. | ||
| Code/Value Specifications | N/A | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER PARTICIPATION INDICATOR | |||
|---|---|---|---|
| Notes And Special Instructions: This data element must be Y forMOP. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-225 2-260 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | One (1) alphanumeric character. | ||
| Definition | Code indicating whether ornot the provider accepted assignment of benefits for services rendered. | ||
| Code/Value Specifications | N | No | |
| Y | Yes | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER TAXONOMY (SPECIALTY) | |||
|---|---|---|---|
| Notes And Special Instructions: This data element must be 183500000X forMOP and 333600000X for Retail Pharmacy. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Non-Institutional | 2-255 | Up to 99 | Yes |
| Primary Picture (Format) | Ten (10) alphanumeric characters. | ||
| Definition | Code describing the provider’sspecialty. | ||
| Code/Value Specifications | Refer to http://www.wpc-edi.com/reference/ forProvider Specialty Codes. Refer to Addendum C, Figure 2.C-1 as a reference whenassigning Provider Major Specialty Codes to Outpatient HospitalNon-Institutional TED records. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER STATE OR COUNTRY CODE | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-195 2-235 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | Three (3) alphanumeric characters. | ||
| Definition | Code assigned to identify thestate or foreign country in which the care was received. State Codemust be left justified and blank fill to right. | ||
| Code/Value Specifications | Addendums A and B. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER SUB-IDENTIFIER | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-205 2-245 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | Four (4) alphanumeric characters. | ||
| Definition | Identification number thatuniquely identifies multiple providers using the same TIN. | ||
| Code/Value Specifications | Refer to Section 2.10,ELN 3-010. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER TAXPAYER NUMBER | |||
|---|---|---|---|
| Notes And Special Instructions: Claims for care rendered byan Educational Interventions for Autism Spectrum Disorders (EIA)Tutor must be identified on the TED record using the billing AutismDemonstration Corporate Services Provider (ACSP) Provider TaxpayerNumber. | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-200 2-240 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | Nine (9) alphanumeric characters. | ||
| Definition | The IRS TIN assigned to theinstitution/provider supplying the care. | ||
| Code/Value Specifications | For institutions must be ninedigit Employer Identification Number (EIN). For individual providers, shouldbe the nine digit EIN or SSN, if available. If not available, reportthe contractor-assigned number. (Refer to Section 2.10,ELN 3-005). Report all nines for transportation services. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
| ELEMENT NAME:PROVIDER ZIP CODE | |||
|---|---|---|---|
| Notes And Special Instructions: N/A | |||
| Records/LocatorNumbers | |||
| Record Name | Locator# | Occurrences | Required |
| Institutional Non-Institutional | 1-220 2-250 | 1 Up to 99 | Yes Yes |
| Primary Picture (Format) | Nine (9) alphanumeric characters. | ||
| Definition | Location of provider’s businessoffice where care is usually provided. | ||
| Code/Value Specifications | Must be a valid five or ninedigit ZIP code. If only five digits, left justify and blank fill.If a foreign country, must be three character foreign country code,left justify and blank fill. Refer to Addendum A. | ||
| Algorithm | N/A | ||
| Subordinate And/Or Group Elements | |||
| Subordinate | Group | ||
| N/A | N/A | ||
- END -
