Format Specifications
For the
MHA DMS 10 1.00.08
Publish Date: April 5, 2016
This document is updated periodically. If you are not reading this
on the web but are instead reading a printed copy, please check
our web site to ensure that you have the latest copy.
Up-to-date information can be found at:
http://www.datakoala.com/resources.htm
You may also call Data Services at (877) 999-4653 for verification.
Table of Contents
Table of Contents
FILE STRUCTURE ................................................................................................................................................... 3
Header Record ....................................................................................................................................................... 4
Sample Record Layout .......................................................................................................................................... 5
DATA EXTRACTION RULES ................................................................................................................................ 6
PROCESSING FOR MIDB/MOSDB ........................................................................................................................ 7
Data Pull Process ................................................................................................................................................... 7
DICTIONARY OF DATA ELEMENT TERMS ....................................................................................................... 8
DATA ELEMENT SUMMARY TABLES ............................................................................................................... 9
Main Record ........................................................................................................................................................ 13
Revenue Records ................................................................................................................................................. 44
Diagnosis Records ............................................................................................................................................... 50
CPT Procedure Records....................................................................................................................................... 56
ICD Procedure Records ....................................................................................................................................... 64
Condition Code Records ...................................................................................................................................... 71
APPENDIX .............................................................................................................................................................. 75
Glossary of Terms ............................................................................................................................................... 75
Revision History ...................................................................................................................................................... 77
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
2
Data Extraction Rules
FILE STRUCTURE
The MHA DMS 10 is an XML-based relational delimited file format. The file is designed to allow multiple hospitals per
file, multiple discharge dates per file, multiple patient types (inpatient, outpatient or both) and an unlimited number of
revenue, procedure, diagnosis and condition codes per patient record. There are six record types that can be associated
with a single patient record:

Main record
The following record types are related to the main record, and should only be included if there is data of that
type. Do not include blank related records.





Revenue record
Diagnosis record
CPT Procedure record
ICD Procedure record
Condition Code record
Additionally each submission file is also required to have a single header record as the first line. (Header record details
on following page)
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
3
Header Record
Each submission file must begin with a fixed length header record. The header record consists of fields used to identify
the structure and format of the data submission.
Length
(Bytes)
2
15
Begin
End
1
3
2
17
Submission Type
1
18
18
Delimiter Character
Value
1
19
19
Field Name
Record Type
File Type
MA Record Count
9
20
28
RE Record Count
9
29
37
DX Record Count
9
38
46
CX Record Count
9
47
55
PX Record Count
9
56
64
CC Record Count
9
65
73
Special Handling
Code
5
74
78
Detail
This field identifies the header record and should always be set to ‘HE’
This field identifies the submission format and version. For MHA DMS
10 1.XX.XX submissions this should be formatted as follows:
Current Version: ‘MHA DMS10 10000’
This field identifies the submission type and should be set to the most
appropriate value of the following options:
 P = Production submission or the standard first time
transmission of MIDB/MOSDB data.
 R = Resubmit submission or the reissue or resubmission of
previously transmitted MIDB/MOSDB data.
 T = Test submission or a transmission for the sole purpose of
testing
Enter the respective value for the character that will be used as
delimiter or field separator value for the file submission records. The
following are accepted delimiter characters (see note below):
 1 = Comma (,)
 2 = Pipe (|)
 3 = Tilde (~)
 4 = Asterisk (*)
Note: Because commas are often included in the Patient Mailing
Address fields, they may cause confusion when used as a delimiter.
For this reason, the Pipe character is recommended as the delimiter.
The total number of main (MA) records in the submission file.
 Right justify, zero fill
The total number of revenue (RE) records in the submission file.
 Right justify, zero fill
The total number of diagnosis (DX) records in the submission file.
 Right justify, zero fill
The total number of CPT-4 procedure (CX) records in the submission
file.
 Right justify, zero fill
The total number of ICD procedure (PX) records in the submission file.
 Right justify, zero fill
The total number of condition code (CC) records in the submission
file.
 Right justify, zero fill
MHASC assigned code for special data mapping or handling.
 Zero fill (unless otherwise specified by MHASC)
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
4
Sample Record Layout
There is a one-to-many relationship between the main record and the diagnosis/revenue/procedure/condition code
records associated with an individual patient record. This relationship and data structure allows an unlimited number of
related records to be captured.
Records may be grouped in the submission file as displayed in the example above or organized by record type so that all
main records are grouped together followed by groups of revenue, diagnosis, CPT procedure, ICD procedure and
condition code records.
Sample - Records Grouped by Associated Patient Record
HEMHA DMS10 10000T200001267700007494900003812800006287000000596300000384100000
MA|10|123456|X000|1234567890|123456|||221133||2222|||||||MI||||||||||||||||||||||||||
RE|10|123456|X000|0260|||2|123.56
DX|10|123456|X000|10|0|R1932|Y
PX|10|444443|7654|9|1|2649|082315|1234567890|15623
CC|30|555444|X111|R1
CX|30|123321|2222|1|36415|021415|1234567891|1123555666|50|||
Sample – Records Grouped by Record Type
HEMHA DMS10 10000T200001267700007494900003812800006287000000596300000384100000
MA|10|222222222|X999|||||||||||||||||||||||||||||||||||||||10|I25110
MA|10|222222222|X999|||||||||||||||||||||||||||||||||||||||10|R1932
MA|10|444444444|X999|||||||||||||||||||||||||||||||||||||||9|4360
MA|10|444444444|X999|||||||||||||||||||||||||||||||||||||||9|25000
RE|10| 111111111|X999|0996||010513|1|23785.00
RE|10| 111111111|X999|0487||010513|2|14048.00
RE|10| 333333333|X999|0996||010513|1|237.85
RE|10| 444444444|X999|0487||010515|2|15203.00
DX|10|111111111|X999|9|1|3670|Y
DX|10|111111111|X999|7682|0|9|Y
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
5
DATA EXTRACTION RULES
The following rules apply when extracting data for the DMS 10 Format.



In order to identify and relate various records for a specific patient record the following fields must be present
and appropriately designated:
 Each record must begin with the appropriate Record Type (Field 1) designation.
 Each record must be designated with the appropriate Patient Type code (Field 2).
 Each record must include an appropriate Patient Control Number (Field 3).
ICD-9/ICD-10 procedure codes are required for Inpatient records.
CPT-4 codes are required for Outpatient records.

Inpatient records submitted:
 Include persons who are given acute care in a licensed inpatient bed.
 Include acute Psychiatric and Rehabilitation patients.
 Include Stillbirths. These records must be assigned a Patient Type code of “11” (Field 2).
 Include Hospice patients. These records must be assigned a Patient Type code of “12” (Field 2).
 If two or more Inpatient records are combined for payment purposes because of a readmission we ask that
you send each individual record and not the combined record. Submissions should reflect the total number
of discharges that take place during the specific timeframe which allows hospitals to assess needs and aids
in readmission projects being performed across the state.

Inpatient records not submitted:
 Exclude Swing Beds, Respite or Long Term Care patients such as Skilled Nursing Home Patients or Nursing
Home Patients living within the facility.
 Exclude Donor records (e.g., kidney donors).

Outpatient records submitted:
 Include all hospital Outpatient records.
 Include Observation patients. These records must be assigned a Patient Type code of “31” (Field 2).
 Include Outpatient Births. These records must be assigned a Patient Type code of “32” (Field 2).

Outpatient records not submitted:
 Exclude Dr. Office / Clinic Visits
 Exclude Professional Fees
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
6
Processing for MIDB/MOSDB
PROCESSING FOR MIDB/MOSDB
Data Pull Process
The MIDB/MOSDB data pull is done on a quarterly basis and MHASC works with a designated Data Contact person at
each facility to ensure complete and accurate data. The selection criteria consists of inpatient/outpatient discharges
for a specified date range (see Data Extraction Rules on previous page for details). The data collection process allows
facilities to submit both inpatient and outpatient records on the same file as long as the records’ Patient Type field is
properly coded (Field 2).
Each facility is free to establish a process that best suits their needs as long as it does not compromise the traditional
MIDB/MOSDB data collection process. There are several different approaches to coordinating the two processes.
Following is one model for structuring the process:




House the data-pull process within the IT department.
Establish a consistent naming convention for location and names of the data-pull files and educate users on
these conventions.
 Suggested file naming convention: Your 4-digit hospital ID, the date range and INP for inpatient, OUT for
outpatient or BTH for both inpatient and outpatient records.
All submission files must be of type .txt.
A copy of the pull for each quarter is sent to MHASC for MIDB/MOSDB per traditional communication
method.
Sample – Hospital ID 0001 submitting inpatient data
for January - June
00010106INP.txt
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
7
Dictionary of Data Element Terms
DICTIONARY OF DATA ELEMENT TERMS
Data Element Name: The name of the data element or field.
Status: Indicates the data element or field’s usage status.
Description: A detailed description of the data element or field.
Field Length: Size of the data element in bytes.
Format: Specifications as to how the data must be formatted.
Codes: The accepted code values for the field.
Instructions: Additional detailed instructions beyond the format specifications.
Reference: Indicates reference to other standard formats.
Comment: General comment section.
Field Update History: A history of the versions in which the field was updated.
Status Type
Reserved for Future Use
The date element is a required field that must be included on all records.
These are fields that MHA must have in order to process the data, and should
be available from the source systems of all hospitals.
The data element is a required if it can be obtained from the hospital’s source
systems with a reasonable amount of programming effort, and without the
cost of such programming being prohibitively high.
This is a placeholder for a data element that is expected to be used in the
future.
Not Applicable
The data element does not currently apply for this type of data submission.
R
Required
RP
Required if Present
F
N/A
Definition
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Summary Tables
DATA ELEMENT SUMMARY TABLES
Field
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
Main Record
Field Name
Record Type=MA
Patient Type
Patient Control Number
Facility ID - MHASC Assigned
Facility ID - National Provider Identifier (NPI)
Facility ID - Medicare Provider Number
Location Code
Place of Service
Patient Medical/Health Record Number
Filler
Patient SSN (Last 4)
Patient First Name
Patient Middle Name
Patient Last Name
Patient Mailing Address 1
Patient Mailing Address 2
Patient Mailing Address - City
Patient Mailing Address - State
Patient Zip Code
Patient Zip Code Extension
Patient Birth Date
Patient Sex
Patient Race
Patient Ethnicity
Patient Primary Language
Medical Record Number – Mother of Newborn
Birth Weight
Admission Date
Admission Time
Priority (Type) of Admission or Visit
Point of Origin for Admission or Visit
Source of Admission - Specific Facility (NPI)
Discharge Date
Discharge Time
Patient Discharge Status (Disposition)
Disposition of Patient - Specific Facility (NPI)
Principal Payer
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
Length
(Bytes)
2
2
20
4
10
6
4
2
24
20
4
30
30
30
40
30
30
2
5
4
8
1
1
1
3
24
4
8
4
1
1
10
8
4
2
10
2
Status
MIDB MOSDB
R
R
R
R
R
RP
F
F
R
F
RP
R
RP
R
RP
RP
RP
RP
R
RP
R
R
RP
RP
RP
RP
RP
R
RP
R
R
RP
R
RP
R
RP
R
R
R
R
R
R
RP
F
F
R
F
RP
R
RP
R
RP
RP
RP
RP
R
RP
R
R
RP
RP
RP
RP
RP
R
RP
RP
R
RP
R
RP
R
RP
R
UB-04
Field
3a
56
3b
8
8
8
9a
9a
9b
9c
9
9
10
11
81 B1
81 B1
81 B7
12
13
14
15
6
16
17
50A
9
Data Element Summary Tables
Field
No.
Main Record
Length
(Bytes)
Field Name
38
39
40
41
42
43
44
Secondary Payer
Referring Physician - NPI
Primary Care Physician - NPI
Attending Physician – NPI
Attending Physician - Legacy
Admitting Diagnosis Version
Admitting Diagnosis Code / Reason for Visit
2
10
10
10
10
2
7
Status
MIDB MOSDB
RP
RP
RP
RP
RP
RP
R
R
R
R
RP
RP
RP
RP
UB-04
Field
50B
78-79
76
69
The Revenue Records provide additional information related to a Main Record. Only include Revenue Records if data
of this type actually exists. Do not include blank Revenue Records.
Field
No.
1
2
3
4
5
6
7
8
9
Revenue Records
Field Name
Length
(Bytes)
2
2
20
4
4
14
8
7
10
Record Type=RE
Patient Type
Patient Control Number
Facility ID – MHASC Assigned
Revenue Code
HCPCS Rate
Service Date
Units of Service
Revenue Code Charges
Status
MIDB
R
R
R
R
R
RP
RP
RP
RP
MOSDB
R
R
R
R
R
RP
RP
RP
RP
UB-04
Field
3a
42
44
45
46
47
The Diagnosis Records provide additional information related to a Main Record. Only include Diagnosis Records if
data of this type actually exists. Do not include blank Diagnosis Records.
Field
No.
1
2
3
4
5
6
7
8
Diagnosis Records
Field Name
Record Type=DX
Patient Type
Patient Control Number
Facility ID – MHASC Assigned
Diagnosis Code Version
Is Principal Diagnosis
Diagnosis Code
Present on Admission (POA) Indicator –Diagnosis Code
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
Length
(Bytes)
2
2
20
4
2
1
7
1
Status
MIDB
R
R
R
R
R
R
R
R
MOSDB
R
R
R
R
R
R
R
N/A
UB-04
Field
3a
67 a-q
67 a-q
10
Data Element Summary Tables
The CPT Procedure Records provide additional information related to a Main Record. Only include CPT Procedure
Records if data of this type actually exists. Do not include blank CPT Procedure Records.
Field
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
CPT Procedure Records
Field Name
Record Type=CX
Patient Type
Patient Control Number
Facility ID – MHASC Assigned
Is Principal Procedure – CPT
Procedure - CPT
Date of Procedure - CPT
CPT Operating Physician - NPI
CPT Operating Physician - Legacy
HCPCS Modifier 1
HCPCS Modifier 2
HCPCS Modifier 3
HCPCS Modifier 4
Length
(Bytes)
2
2
20
4
1
5
8
10
10
2
2
2
2
Status
MIDB
R
R
R
R
R
R
R
RP
RP
RP
RP
RP
RP
MOSDB
R
R
R
R
R
R
R
RP
RP
RP
RP
RP
RP
UB-04
Field
3a
45
78-79
44
44
44
44
The ICD Procedure Records provide additional information related to a Main Record. Only include ICD Procedure
Records if data of this type actually exists. Do not include blank ICD Procedure Records.
Field
No.
1
2
3
4
5
6
7
8
9
10
ICD Procedure Records
Field Name
Record Type=PX
Patient Type
Patient Control Number
Facility ID – MHASC Assigned
Procedure Version
Is Principal Procedure – ICD
Procedure - ICD
Date of Procedure - ICD
ICD Operating Physician – NPI
ICD Operating Physician - Legacy
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
Length
(Bytes)
2
2
20
4
2
1
7
8
10
10
Status
MIDB
R
R
R
R
R
R
R
R
RP
RP
MOSDB
R
R
R
R
R
R
R
R
RP
RP
UB-04
Field
3a
74
45
77-79
11
Data Element Summary Tables
The Condition Code Records provide additional information related to a Main Record. Only include Condition Code
Records if data of this type actually exists. Do not include blank Condition Code Records.
Field
No.
1
2
3
4
5
Condition Code Records
Field Name
Record Type=CC
Patient Type
Patient Control Number
Facility ID – MHASC Assigned
Condition Code
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
Length
(Bytes)
2
2
20
4
2
Status
MIDB MOSDB
R
R
R
R
R
R
R
R
R
R
UB-04
Field
3a
18-28
12
Main Record
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Main Record
Field 1
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Record Type
Required for MIDB and MOSDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
MA = Main Record
Set Record Type = ‘MA’ for all Main Records.
MHASC Defined
Return to Main Record Summary Table
Main Record
Field 2
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Patient Type
Required for MIDB and MOSDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Comment
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 3
Patient Control Number
Required for MIDB and MOSDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 4
Facility ID – MHASC Assigned
Required for MIDB and MOSDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 5
Facility ID – National Provider Identifier (NPI)
Required for MIDB and MOSDB
The unique identification number assigned to the provider submitting the bill.
NPI is the national provider identifier.
10 bytes
Numeric
UB-04, Form Locator 56
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 6
Facility ID – Medicare Provider Number
Required if Present for MIDB and MOSDB
Hospital’s Medicare provider number as assigned by CMS.
6 bytes
Numeric
CMS Assigned
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 7
Location Code
Reserved for Future Use for MIDB and MOSDB
Code identifying the physical location of patient care
4 bytes
Numeric
TBD
MHASC Defined
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 8
Place of Service
Reserved for Future Use for MIDB and MOSDB
Setting indicator for the location where a service was provided.
2 bytes
Alphanumeric
CMS Place of Service Code Set
Enter the most appropriate service code from the list on the CMS Place of
Service Code set webpage.
CMS 1500 Field 24b
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 9
Patient Medical/Health Record Number
Required for MIDB and MOSDB
The number assigned to the patient’s medical/health record by the provider.
24 bytes
Alphanumeric
Leave blank if the patient’s medical record number is missing.
UB-04, Form Locator 03b
Return to Main Record Summary Table
Main Record
Field 10
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Filler
Reserved for Future Use for MIDB and MOSDB
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 11
Patient SSN (Last 4)
Required if Present for MIDB and MOSDB
Last four digits of the number as assigned to the patient by the Social Security
Administration.
4 bytes
Numeric
Valid characters: 0 through 9, no hyphens or spaces.
Leave blank if SSN is unknown.
Reference
Comment
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 12
Patient First Name
Required for MIDB and MOSDB
The first name of the patient.
30 bytes
Alphanumeric
UB-04, Form Locator 08
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 13
Patient Middle Name
Required if Present for MIDB and MOSDB
The middle name of the patient.
30 bytes
Alphanumeric
Enter the full middle name of patient if available.
UB-04, Form Locator 08
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
18
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 14
Patient Last Name
Required for MIDB and MOSDB
The last name of the patient.
30 bytes
Alphanumeric
UB-04, Form Locator 08
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 15
Patient Mailing Address 1
Required if Present for MIDB and MOSDB
First line of the patient’s mailing address.
40 bytes
Alphanumeric
Include only the first line of the patient’s mailing address.
Select the patient’s mailing address and not the guarantor address.
UB-04, Form Locator 09 a
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 16
Patient Mailing Address 2
Required if Present for MIDB and MOSDB
Second line of the patient’s mailing address.
30 bytes
Alphanumeric
Leave blank if not needed.
UB-04, Form Locator 09 a
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 17
Patient Mailing Address - City
Required if Present for MIDB and MOSDB
City associated with the patient’s mailing address.
30 bytes
Alphanumeric
UB-04, Form Locator 09 b
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 18
Patient Mailing Address – State
Required if Present for MIDB and MOSDB
State associated with the patient’s mailing address.
2 bytes
Alphanumeric
Use the two digit state abbreviation.
UB-04, Form Locator 09 c
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 19
Patient Zip Code
Required for MIDB and MOSDB
Patient zip code
5 bytes
Alphanumeric
00000 = Unknown
11111 = Foreign other than Canada
66666 = Sault Ste. Marie Canada
77777 = Sarnia Canada
88888 = Windsor Canada
99999 = All other Canada not above
1. Records of patients residing outside of the U.S. must have their postal
codes mapped to the numeric codes identified above.
2. Homeless patients should be assigned the zip code of the treating facility.
UB-04, Form Locator 09
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 20
Patient Zip Code Extension
Required if Present for MIDB and MOSDB
Zip Code Extension
4 bytes
Alphanumeric
Leave blank if unavailable.
UB-04, Form Locator 09
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Main Record
Field 21
Patient Birth Date
Required for MIDB and MOSDB
Date of birth of the patient
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
Infants that are born within the facility should have an admission date equal to
the date of birth.
UB-04, Form Locator 10
Return to Main Record Summary Table
Main Record
Field 22
Data Element
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Patient Sex
Required for MIDB and MOSDB
The sex of the patient as recorded at admission, outpatient service, or start of
care.
1 byte
Alphanumeric
F = Female
M = Male
U = Unknown
1. Must be a valid code
2. Sex must be valid for sex-specific diagnoses or procedures
UB-04, Form Locator 11
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Data Element Descriptions
Main Record
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Main Record
Field 23
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Patient Race
Required if Present for MIDB and MOSDB
The race of the patient
1 byte
Alphanumeric
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = White
5 = Other
6 = Unknown or Not Stated (Patient Declined)
7 = Native Hawaiian or other Pacific Islander
Hispanic is not considered a race. If your hospital system records Hispanic
under the race field, then:
1. Map Race to Code 6 (Unknown or Not Stated)
2. Map Ethnicity (Field 11) to Code 1 (Hispanic)
If your hospital system has both a race field and an ethnicity field, then
“Hispanic” should be recorded under Ethnicity (Field 11) and Race remains that
which was reported by the patient.
If the facility captures the Arabic population but does not capture a race for
these patients, please map them using the following conventions:
1. Map Race to Code 6 (Unknown or Not Stated)
2. Map Ethnicity (Field 11) to Code 4 (Arabic)
If your hospital system captures both a race and “Arabic”, then “Arabic” should
be recorded under Ethnicity (Field 11) and Race remains that which was
reported by the patient.
Meaningful Use; OMB 15; UB-04 Form Locator 81 B1
Race information should be based on self-identification of the patient. It
should not be based on the judgment of facility personnel.
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 24
Patient Ethnicity
Required if Present for MIDB and MOSDB
Ethnicity of the patient
1 byte
Alphanumeric
1 = Hispanic or Latino
2 = Not Hispanic or Latino or Arabic
3 = Unknown or Not Stated (Patient Declined)
4 = Arabic
Hispanic is considered an ethnicity, not a race. If your hospital system records
Hispanic under the race field, then:
1. Map Race (Field 10) to Code 6 (Unknown or Not Stated)
2. Map Ethnicity to Code 1 (Hispanic)
If your hospital system has both a race field and an ethnicity field, then
“Hispanic” should be recorded under Ethnicity and Race (Field 10) remains that
which was reported by the patient.
If the facility captures the Arabic population but does not capture a race for
these patients, please map them using the following conventions:
1. Map Race (Field 10) to Code 6 (Unknown or Not Stated)
2. Map Ethnicity to Code 4 (Arabic)
If your hospital system captures both a race and “Arabic”, then “Arabic” should
be recorded under Ethnicity and Race (Field 10) remains that which was
reported by the patient.
Meaningful Use; OMB 15; UB-04 Form Locator 81 B1
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 25
Patient Primary Language
Required if Present for MIDB and MOSDB
Preferred spoken language of the patient.
3 bytes
Alphanumeric
Below are some examples of supported language codes. For the complete
supported code list, see the “DMS 10 – Primary Language Reference”, available
online at http://www.datakoala.com/resources.htm
ENG = English
SPA = Spanish
ARA = Arabic
MIS = Uncoded languages
NC = Not Collected
UND = Undetermined
ZXX = No linguistic content; Not applicable
Do not leave this field blank. ‘NC’ should be entered if the patient’s preferred
language was not collected.
UB-04, Form Locator 81 B7
ISO 639-2 Language Code List
The ISO 639-2 Language Code List has 21 languages that have alternate codes
depending on whether the usage is for Bibliographic (B) or Terminology (T)
purposes. The DMS-10 specification only uses the B codes.
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 26
Medical Record Number – Mother of Newborn
Required if Present for MIDB and MOSDB
The medical record numbers of the newborn child’s mother which links the
newborn’s hospital stay and the mother’s stay.
24 bytes
Alphanumeric
If the mother is not admitted with the infant, report all nines.
The record must contain:
1. A valid newborn diagnosis code must be reported as the Principal
Diagnosis Code
2. Type of Admission used = 4
3. Source of Admission used = 5,6
4. Date of birth must equal admission date.
Reference
Comment
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
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Main Record
Field 27
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Birth Weight
Required if Present for MIDB and MOSDB
The weight (in grams) of a neonate at the time of delivery.
4 bytes
Numeric
Round to the nearest whole number
If the birth weight is completely unknown, enter 9999
Reference
Comment
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Main Record
Field 28
Admission Date
Required for MIDB and MOSDB
The start date for this episode of care. For inpatient services, this is the date of
admission. For outpatient services it is the date the episode of care began.
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
Cannot be:
1. A future date
2. Before the date of birth
3. After the date of discharge
UB-04, Form Locator 12
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 29
Admission Time
Required if Present for MIDB and MOSDB
The time of the patient admission
4 bytes
Alphanumeric
Use twenty four hour, military time format, removing the colon.
Leave blank if hour is unavailable
Enter 00 for minutes, if minutes are unavailable
Reference
Comment
Military
Standard Time Range
Time Range
0000-0059
12:00 midnight -12:59 a.m.
0100-0159
01:00-01:59 a.m.
0200-0259
02:00-02:59 a.m.
0300-0359
03:00-03:59 a.m.
0400-0459
04:00-04:59 a.m.
0500-0559
05:00-05:59 a.m.
0600-0659
06:00-06:59 a.m.
0700-0759
07:00-07:59 a.m.
0800-0859
08:00-08:59 a.m.
0900-0959
09:00-09:59 a.m.
1000-1059
10:00-10:59 a.m.
1100-1159
11:00-11:59 a.m.
1200-1259
12:00 noon -12:59 p.m.
1300-1359
01:00-01:59 p.m.
1400-1459
02:00-02:59 p.m.
1500-1559
03:00-03:59 p.m.
1600-1659
04:00-04:59 p.m.
1700-1759
05:00-05:59 p.m.
1800-1859
06:00-06:59 p.m.
1900-1959
07:00-07:59 p.m.
2000-2059
08:00-08:59 p.m.
2100-2159
09:00-09:59 p.m.
2200-2259
10:00-10:59 p.m.
2300-2359
11:00-11:59 p.m.
UB-04, Form Locator 13
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 30
Priority (Type) of Admission or Visit
Required for MIDB
Required if Present for MOSDB
A code indicating the priority of this admission/visit.
1 byte
Alphanumeric
1 = Emergency
The patient requires immediate medical intervention as a result of severe,
life threatening or potentially disabling conditions.
2 = Urgent
The patient requires immediate attention for the care and treatment of a
physical or mental disorder.
3 = Elective
The patient’s condition permits adequate time to schedule the services.
4 = Newborn
Use of this code necessitates the use of special Source of Admission/Point
of Origin Codes - see Field 31.
5 = Trauma Center
Visit to a trauma center/hospital as licensed or designated by the state or
local government authority authorized to do so, or as verified by the
American College of Surgeons and involving a trauma activation.
(6 - 8 Reserved for assignment by NUBC. Not valid for MIDB/MOSDB data
collection.)
9 = Information not available.
Outpatient: Leave this field blank if the facility does not track this information.
UB-04, Form Locator 14
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Main Record
Field 31
Point of Origin for Admission or Visit
Required for MIDB and MOSDB
A code indicating the point of patient origin for this admission or visit.
1 byte
Alphanumeric
1 = Non-Health Care Facility Point of Origin
Examples:
Includes patients coming from home or workplace and patients receiving
care at home (such as home health services).
Inpatient: The patient was admitted to this facility.
Outpatient: The patient presented for outpatient services.
2 = Clinic or Physician’s Office
Inpatient: The patient was admitted to this facility.
Outpatient: The patient presented to this facility for outpatient services.
(3 Reserved for assignment by the NUBC. (Discontinued effective 10/1/07.)
4 = Transfer from a Hospital (Different Facility)
Usage Note:
Excludes Transfers from Hospital
Inpatient in the Same Facility (See Code D).
Inpatient: The patient was admitted to this facility as a hospital transfer
from an acute care facility where he or she was an inpatient or
outpatient.
Outpatient: The patient was transferred to this facility as an outpatient
from an acute care facility.
5 = Transfer from a Skilled Nursing Facility (SNF), Intermediate Care Facility
(ICF), or Assisted Living Facility (ALF)
Inpatient: The patient was admitted to this facility as a transfer from a
SNF, ICF or ALF where he or she was a resident.
Outpatient: The patient presented to this facility for outpatient or
referenced diagnostic services from a SNF, ICF or ALF where he or she
was a resident.
6 = Transfer from another Health Care Facility
Inpatient: The patient was admitted to this facility as a transfer from
another type of health care facility not defined elsewhere in this code list.
Outpatient: The patient presented to this facility for services from
another health care facility not defined elsewhere in this code list.
8 = Court/Law Enforcement
Usage Note:
Includes transfers from incarceration facilities.
Inpatient: The patient was admitted to this facility upon the direction of
a court of law, or upon the request of a law enforcement agency
representative.
Outpatient: The patient presented to this facility upon the direction of a
court of law, or upon the request of a law enforcement agency
representative for outpatient or referenced diagnostic services.
Michigan Health & Hospital Association Service Corporation
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Data Element Descriptions
Main Record
Data Element Name
Main Record
Field 31
Point of Origin for Admission or Visit
9 = Information not Available
Inpatient: The patient’s Point of Origin is not known.
Outpatient: The patient’s Point of Origin is not known.
D = Transfer from One Distinct Unit of the Hospital to another Distinct Unit of
the Same Hospital Resulting in a Separate Claim to the Payer
Usage Note:
For purposes of this code, “Distinct Unit” is defined as a unique unit or
level of care at the hospital requiring the issuance of a separate claim to
the payer. Examples could include observation services, psychiatric units,
rehabilitation units, a unit in a critical access hospital, or a swing bed
located in an acute hospital.
Inpatient: The patient was admitted to this facility as a transfer from
hospital inpatient within this hospital resulting in a separate claim to the
payer.
Outpatient: The patient received outpatient services in this facility as a
transfer from within this hospital resulting in a separate claim to the
payer.
E = Transfer from Ambulatory Surgery Center
Inpatient: The patient was admitted to this facility as a transfer from an
ambulatory surgery center.
Outpatient: The patient presented to this facility for outpatient or
referenced diagnostic services from an ambulatory surgery center.
F = Transfer from a Hospice Facility.
Inpatient: The patient was admitted to this facility as a transfer from a
hospice facility.
Outpatient: The patient presented to this facility for outpatient or
referenced diagnostic services from a hospice facility.
(G-Z Reserved for assignment by the NUBC. Not valid for MIDB/MOSDB
data collection.)
Code Structure for Newborn (use if Admission Type code is equal to 4)
Instructions
Reference
Comment
1-4 Reserved for assignment by the NUBC. (Discontinued effective
10/1/07.)
5 = Born Inside this Hospital
6 = Born Outside of this Hospital
If Admission Type code = 4 (Newborn), then Point of Origin for Admission or
Visit must be equal to code 5 or 6. If the facility cannot submit an accurate
breakout for newborns using Admission Type of 4 (Newborn) and Codes 5 or 6
for this field, then the facility should assign the newborns with an Admission
Type (Field 30) of Code 4 (Newborn) and a Point of Origin for Admission or
Visit (this field) of Code 5 (Born Inside this Hospital).
UB-04, Form Locator 15
For outpatient records:
It is permissible but not recommended to have a large number of
“Information not Available” for Point of Origin for Admission or Visit.
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
Data Element Name
Main Record
Field 31
Point of Origin for Admission or Visit
During the 1400 testing phase, the Data Quality Representative will verify
with the Medical Records Department the inability to track this
information.
Given this factor, do not default the outpatient records to any category
for Point of Origin for Admission or Visit without first consulting with
MHASC.
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 32
Source of Admission – Specific Facility (NPI)
Required if Present for MIDB and MOSDB
The national provider identifier for the facility that transferred the patient to
your facility.
10 bytes
Numeric
CMS Assigned NPI
Must have a value if Point of Origin (field 31) has a value of 4 “Transfer from a
Hospital”
Reference
Comment
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Main Record
Field 33
Discharge Date
Required for MIDB and MOSDB
The date the patient was discharged from care, left against medical advice, or
expired during this stay.
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
Cannot be:
1. A future date
2. Before the date of admission
UB-04, Form Locator 06
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 34
Discharge Time
Required if Present for MIDB and MOSDB
The time of the patient discharge
4 bytes
Alphanumeric
Use twenty four hour, military time format, removing the colon.
Leave blank if hour is unavailable
Enter 00 for minutes, if minutes are unavailable
Reference
Comment
Military
Standard Time Range
Time Range
0000-0059
12:00 midnight -12:59 a.m.
0100-0159
01:00-01:59 a.m.
0200-0259
02:00-02:59 a.m.
0300-0359
03:00-03:59 a.m.
0400-0459
04:00-04:59 a.m.
0500-0559
05:00-05:59 a.m.
0600-0659
06:00-06:59 a.m.
0700-0759
07:00-07:59 a.m.
0800-0859
08:00-08:59 a.m.
0900-0959
09:00-09:59 a.m.
1000-1059
10:00-10:59 a.m.
1100-1159
11:00-11:59 a.m.
1200-1259
12:00 noon -12:59 p.m.
1300-1359
01:00-01:59 p.m.
1400-1459
02:00-02:59 p.m.
1500-1559
03:00-03:59 p.m.
1600-1659
04:00-04:59 p.m.
1700-1759
05:00-05:59 p.m.
1800-1859
06:00-06:59 p.m.
1900-1959
07:00-07:59 p.m.
2000-2059
08:00-08:59 p.m.
2100-2159
09:00-09:59 p.m.
2200-2259
10:00-10:59 p.m.
2300-2359
11:00-11:59 p.m.
UB-04, Form Locator 16
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Data Element Descriptions
Main Record
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Data Element Name
Status
Description
Field Length
Format
Codes
Main Record
Field 35
Patient Discharge Status (Disposition)
Required for MIDB and MOSDB
A code indicating the disposition or discharge status of the patient.
2 bytes
Alphanumeric
00 = Unknown (MHASC defined, not a standard UB-04 code)
01 = Discharged to Home or Self Care (Routine Discharge)
Usage Note:
Includes discharge to home; home on oxygen if DME only; any other
DME only; group home, foster care, independent living and other
residential care arrangements; outpatient programs, such as partial
hospitalization or outpatient chemical dependency programs.
02 = Discharged/transferred to a Short-Term General Hospital for Inpatient
Care
03 = Discharged/transferred to a Skilled Nursing Facility (SNF) with Medicare
Certification in Anticipation of Skilled Care
Usage Note:
Medicare – Indicates that the patient is discharged/transferred to a
Medicare certified nursing facility. For hospitals with an approved swing
bed arrangement, use Code 61- Swing Bed. For reporting other
discharges/transfers to nursing facilities see 04 and 64.
04 = Discharged/transferred to a Facility that Provides Custodial or Supportive
Care
Usage Note:
Includes intermediate care facilities (ICFs) if specifically designated at the
state level. Also used to designate patients that are
discharged/transferred to a nursing facility with neither Medicare nor
Medicaid certification and for discharges/transfers to Assisted Living
Facilities.
05 = Discharged/transferred to a Designated Cancer Center or Children’s
Hospital
Usage Note:
Transfers to non-designated cancer hospitals should use Code 02. A list
of (National Cancer Institute) Designated Cancer Centers can be found at
http://www.cancer.gov/researchandfunding/extramural/cancercenters.
06 = Discharged/transferred to Home Under Care of an Organized Home
Health Service Organization in Anticipation of Covered Skilled Care
Usage Note:
Report this code when the patient is discharged/transferred to home
with a written plan of care (tailored to the patient’s medical needs) for
home care services. Not used for home health services provided by a
DME supplier or from a home IV provider for home IV services.
07 = Left Against Medical Advice or Discontinued Care
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Data Element Descriptions
Main Record
Data Element Name
Main Record
Field 35
Patient Discharge Status (Disposition)
09 = Admitted as an Inpatient to this Hospital. Valid for outpatient only.
Usage Note:
For use only on Medicare outpatient claims. Applies only to those
Medicare outpatient services that begin greater than three days prior to
an admission.
20 = Expired
21 = Discharged/transferred to Court/Law Enforcement
Usage Note:
Includes transfers to incarceration facilities such as jail, prison or other
detention facilities.
30 = Still a Patient. Valid for MOSDB only. Not valid for MIDB data collection.
Usage Note:
Used when a patient is still within the same facility; typically used when
billing for leave of absence days or interim bills.
43 = Discharged/transferred to a Federal Health Care Facility
Usage Note:
Discharges and transfers to a government operated health facility such
as a Department of Defense hospital, a Veteran’s Administration hospital
or a Veteran’s Administration nursing facility. To be used whenever the
destination at discharge is a federal health care facility, whether the
patient lives there or not.
50 = Hospice – Home.
51 = Hospice – Medical Facility (Certified) Providing Hospice Level of Care.
61 = Discharged/transferred to a Hospital-Based Medicare Approved Swing
Bed
Usage Note:
Medicare – Used for reporting patients discharged/transferred to a SNF
level of care within the hospital’s approved swing bed arrangement.
62 = Discharged/transferred to an Inpatient Rehabilitation Facility (IRF)
including Rehabilitation Distinct Part Units of a Hospital
63 = Discharged/transferred to a Medicare Certified Long Term Care Hospital
(LTCH)
Usage Note:
For hospitals that meet the Medicare criteria for LTCH certification.
64 = Discharged/transferred to a Nursing Facility Certified under Medicaid but
not Certified under Medicare
65 = Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct
Part Unit of a Hospital
66 = Discharged/transferred to a Critical Access Hospital (CAH)
69=Discharged/Transferred to a Designated Disaster Alternate Care Site
(Effective 10/1/13)
70 = Discharged/transferred to another Type of Health Care Institution not
Defined Elsewhere in this Code List
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
Data Element Name
Main Record
Field 35
Patient Discharge Status (Disposition)
(81-95 = Discharge status codes identifying patients who are discharged with
a planned acute care hospital inpatient readmission)
(Effective 10/1/13)
81 = Discharged to Home or Self Care with a Planned Acute. Care Hospital
Inpatient Readmission
82=Discharged/Transferred to a Short Term General Hospital for Inpatient Care
with a Planned Acute Care Hospital Inpatient Readmission
83=Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare
Certification with a Planned Acute Care Hospital Inpatient Readmission
84=Discharged/Transferred to a Facility that Provides Custodial or Supportive
Care with a Planned Acute Care Hospital Inpatient Readmission
85=Discharged/transferred to a Designated Cancer Center or Children's
Hospital with a Planned Acute Care Hospital Inpatient Readmission
86=Discharged/Transferred to Home Under Care of Organized Home Health
Service Organization with a Planned Acute Care Hospital Inpatient
Readmission
87=Discharged/Transferred to Court/Law Enforcement with a Planned Acute
Care Hospital Inpatient Readmission
88=Discharged/Transferred to a Federal Health Care Facility with a Planned
Acute Care Hospital Inpatient Readmission
89=Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed
with a Planned Acute Care Hospital Inpatient Readmission
90=Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF)
including Rehabilitation Distinct Part Units of a Hospital with a Planned
Acute Care Hospital Inpatient Readmission
91=Discharged/Transferred to a Medicare Certified Long Term Care Hospital
(LTCH) with a Planned Acute Care Hospital Inpatient Readmission
92=Discharged/Transferred to a Nursing Facility Certified Under Medicaid but
not Certified Under Medicare with a Planned Acute Care Hospital
Inpatient Readmission
93=Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part
Unit of a Hospital with a Planned Acute Care Hospital Inpatient
Readmission
94=Discharged/Transferred To a Critical Access Hospital (CAH) with a Planned
Acute Care Hospital Inpatient Readmission
95=Discharged/Transferred to Another Type of Health Care Institution not
Defined Elsewhere in this Code List with a Planned Acute Care Hospital
Inpatient Readmission
Michigan Health & Hospital Association Service Corporation
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Data Element Descriptions
Main Record
Data Element Name
Instructions
Reference
Comment
Main Record
Field 35
Patient Discharge Status (Disposition)
For MIDB records:
A small number of codes equal to “00” (unknown) may occur. Care
should be taken to ensure this field is coded as accurately as possible.
For MOSDB records:
It is permissible but not recommended to have a large number of
“Unknown” or “Missing” for Patient Discharge Status. During 1400
testing, the Data Quality Representative will verify with the Medical
Records Department the inability to track this information. Given this
factor, do not default the outpatient records to any category for Patient
Discharge Status. It is preferable to have the elements missing from the
records rather than defaulted to an inappropriate category.
UB-04, Form Locator 17
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 36
Disposition of Patient – Specific Facility (NPI)
Required if Present for MIDB and MOSDB
The national provider identifier for the facility that patient is transferred to
from your facility.
10 bytes
Numeric
CMS Assigned NPI
Must have a value if Patient Discharge Status (field 35) has one of the following
values: 02, 82, 03, 83, 04, 84, 05, 85, 06, 86,43, 88, 62, 90, 63, 91, 64, 92, 65,
93, 66, 94, 70, 95
Reference
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
36
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Main Record
Field 37
Principal Payer
Required for MIDB and MOSDB
The carrier expected to pay the major portion of the patient’s bill.
2 bytes
Alphanumeric
(Non-Michigan hospitals see Comment)
Medicare/Medicaid Carrier Codes
01 = Medicare Fee For Service
30 = Medicare Managed Care Plans
31 = Medicare Type of Plan Unknown (contains both fee for service and
managed care plans)
02 = Medicaid Fee For Service
40 = Medicaid Managed Care Plans
41 = Medicaid Type of Plan Unknown (contains both fee for service and
managed care plans)
Other Traditional Carrier Codes
00 = Unknown
03 = Title V
04 = Other Government Source, exclude Mental Health and Corrections
contracts
05 = Workers Compensation
06 = Blue Cross Blue Shield, exclude HMO/PPO
07 = Other Commercial Insurance Company, exclude HMO/PPO
08 = Self Pay
09 = Managed Care (only used if not breaking out into Codes 11 - 22 below)
10 = No Charge
23 = State Mental Health Contract
24 = Other Mental Health Contract
25 = State Corrections
26 = Other Corrections
51 = Charity Care
52 = Auto Insurance
99 = Other (not covered above)
Categorized Managed Care Carrier
11 = Blue Cross Blue Shield HMO
12 = Other HMO 1
13 = Other HMO 2
14 = Other HMO 3
15 = Other HMO 4
16 = Other HMO 5 (See Instruction 4 below)
17 = Blue Cross Blue Shield PPO/PPA
18 = Other PPO/PPA 1
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Main Record
Data Element Name
Instructions
Reference
Comment
Main Record
Field 37
Principal Payer
19 = Other PPO/PPA 2
20 = Other PPO/PPA 3
21 = Other PPO/PPA 4
22 = Other PPO/PPA 5 (See Instruction 4 below)
Please note the following when mapping to these codes:
1. The categories of “Other HMO” or “PPO/PPA” (Codes 12-16, 18-22) are
hospital defined and will include all other managed care plans that are not
BCBS plans.
2. For those hospitals who do not define individual managed care plans, use
“09” to indicate some type of managed care plan. A hospital should not
use Code 09 and Codes 11-22.
3. If a hospital cannot break out Medicaid and Medicare plans into both
traditional Fee For Service contracts (Codes 01 & 02) and Managed Care
Contracts (30 & 40), a hospital should use Code 31- Medicare Type Of Plan
Unknown and Code 41 – Medicaid Type of Plan Unknown.
4. If a hospital is utilizing HMO or PPO/PPAs 1-4, use Other HMO or PPO/PPA
- 5 to indicate all remaining types of plans.
“Medicare can be listed as the primary, secondary, tertiary, or even lower
down on the list of payers.” Therefore, (effective with CMS version 2.5b) if any
portion of a patient’s bill has been paid by Medicare, even 1 cent, then it needs
to be identified as Medicare. For mapping purposes, check your primary and
secondary Pay Source values and if neither contains a Medicare code, then
examine all of your other pay sources and if any of them are Medicare, then
assign Secondary Pay Source (Field 38) as Medicare.
MHASC Defined Codes; UB-04 Form Locator 50 A
For non-Michigan hospitals it is acceptable to assign all records to one of the
following four codes:
00 = Unknown
31 = Medicare
41 = Medicaid
99 = Payment other than Medicare or Medicaid
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
38
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Main Record
Field 38
Secondary Payer
Required if Present for MIDB and MOSDB
The carrier designated by the patient responsible for any remaining amount
due for the visit.
2 bytes
Alphanumeric
(Non-Michigan hospitals see Comment)
Medicare/Medicaid Carrier Codes
01 = Medicare Fee For Service
30 = Medicare Managed Care Plans
31 = Medicare Type of Plan Unknown (contains both fee for service and
managed care plans)
02 = Medicaid Fee For Service
40 = Medicaid Managed Care Plans
41 = Medicaid Type of Plan Unknown (contains both fee for service and
managed care plans)
Other Traditional Carrier Codes
00 = Unknown
03 = Title V
04 = Other Government Source, exclude Mental Health and Corrections
contracts
05 = Workers Compensation
06 = Blue Cross Blue Shield, exclude HMO/PPO
07 = Other Commercial Insurance Company, exclude HMO/PPO
08 = Self Pay
09 = Managed Care (only used if not breaking out into Codes 11 - 22 below)
10 = No Charge
23 = State Mental Health Contract
24 = Other Mental Health Contract
25 = State Corrections
26 = Other Corrections
51 = Charity Care
52 = Auto Insurance
99 = Other (not covered above)
Categorized Managed Care Carrier
11 = Blue Cross Blue Shield HMO
12 = Other HMO 1
13 = Other HMO 2
14 = Other HMO 3
15 = Other HMO 4
16 = Other HMO 5 (See Instruction 4 under Principal Payer: Field 21)
17 = Blue Cross Blue Shield PPO/PPA
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
39
Data Element Descriptions
Main Record
Data Element Name
Instructions
Reference
Comment
Main Record
Field 38
Secondary Payer
18 = Other PPO/PPA 1
19 = Other PPO/PPA 2
20 = Other PPO/PPA 3
21 = Other PPO/PPA 4
22 = Other PPO/PPA 5 (See Instruction 4 under Principal Payer: (Field 37)
Follow the same detailed mapping instructions as noted under the Principal
Payer (Field 37). In addition, please note the following:
1. If there is an outstanding balance that the patient is responsible for, assign
“08 – Self Pay.”
2. If the hospital will not be billing either another insurance company or the
patient, assign “10 – No-Charge.”
MHASC Defined Codes; UB-04 Form Locator 50 B
For non-Michigan hospitals, it is acceptable to assign all records to one of the
following four codes:
00 = Unknown
31 = Medicare
41 = Medicaid
99 = Payment other than Medicare or Medicaid
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 39
Referring Physician – NPI
Required if Present for MIDB and MOSDB
The unique identification number assigned to the physician who referred the
patient for care. NPI is the national provider identifier.
10 bytes
Numeric
Use the physician’s 10 digit individual national provider identifier.
UB-04, Form Locator 78-79
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
40
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 40
Primary Care Physician – NPI
Required if Present for MIDB and MOSDB
Patient’s primary care physician. NPI is the national provider identifier.
10 bytes
Numeric
Use the physician’s 10 digit individual national provider identifier.
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 41
Attending Physician – NPI
Required for MIDB and MOSDB
The unique identification number assigned to the physician who has primary
responsibility for the patient’s medical care and treatment. NPI is the national
provider identifier.
10 bytes
Numeric
Use the physician’s 10 digit individual national provider identifier.
UB-04, Form Locator 76
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
41
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Main Record
Field 42
Attending Physician – Legacy
Required for MIDB and MOSDB
The hospital-assigned ID number of the physician who has primary
responsibility for the patient's medical care and treatment and/or the
physician who would normally be expected to certify and re-certify the medical
necessity of the service rendered.
10 bytes
Alphanumeric
Use the hospital-defined physician number.
UHDDS
 If the treatment is performed by a resident or physician assistant, record
the supervising physician's identification that authorized the treatment.
 If the physician number is larger than 10 characters, please consult with
Medical Records and the MIDB/MOSDB user to agree on a format for
uniquely identifying each physician. For example, if the facility has a 12digit physician number, truncating the ID to 10 digits may result in a nonunique ID. The outcome would be that the facility would no longer be able
to accurately query their data by physician ID.
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Main Record
Field 43
Admitting Diagnosis Version
Required if Present for MIDB and MOSDB
Version identifier for ICD codes
2 bytes
Alphanumeric
09 = ICD-9
10 = ICD-10
Use the appropriate code to identify whether the respective diagnosis code
record is utilizing ICD-9 or ICD-10 code sets.
Must not be left blank if Admitting Diagnosis / Reason for Visit (Field 44) exists.
Reference
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
42
Data Element Descriptions
Main Record
Return to Main Record Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Main Record
Field 44
Admitting Diagnosis Code / Reason for Visit
Required if Present for MIDB and MOSDB
Inpatient: ICD diagnosis code describing the patient’s diagnosis at the time of
admission.
Outpatient: ICD diagnosis code describing the patient’s reason for visit at the
time of outpatient registration.
7 bytes
Alphanumeric
Do not include decimals
Examples:
“99999” = 999.99
“V999 ” = V99.9
“
” = Unrecorded
ICD-9-CM, ICD-10-CM
Inpatient: UB-04, Form Locator 69
Outpatient: UB-04, Form Locator 70a
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
43
Revenue Records
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
44
Data Element Descriptions
Revenue Records
Return to Revenue Records Summary Table
The Revenue Records provide additional information related to a Main Record. Only include Revenue Records if data of
this type actually exists. Do not include blank Revenue Records.
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 1
Record Type=RE
Required for MIDB and MOSDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
RE = Revenue Records
Set Record Type = ‘RE’ for all Revenue Records.
MHASC Defined
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Revenue Records
Field 2
Patient Type
Required for MIDB and MOSDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
45
Data Element Descriptions
Revenue Record
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 3
Patient Control Number
Required for MIDB and MOSDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 4
Facility ID – MHASC Assigned
Required for MIDB and MOSDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
46
Data Element Descriptions
Revenue Record
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 5
Revenue Code
Required for MIDB and MOSDB
Code that identifies a specific accommodation, ancillary service or unique
billing calculations or arrangements.
4 bytes
Alphanumeric
UB-04 Form Locator 42
Return to Revenue Records Summary Table
Revenue Records
Field 6
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
HCPCS Rate
Required if Present for MIDB
Required if Present for MOSDB
The accommodation rate for inpatient bills; or the HCPCS procedure code
applicable to ancillary services and outpatient bills.
14 bytes
Alphanumeric
Inpatient
Required when a room & board revenue code is reported, expected to be a
dollar and cents value with a decimal.
Outpatient
Required for outpatient claims when an appropriate HCPCS procedure code
exists for this service line item. This is expected to be an (up to) 14 character
alphanumeric value, with the leftmost five characters being the HCPCS
procedure, and allowing for up to four two-character modifiers (with no
separation between procedure code and modifiers).
UB-04 Form Locator 44
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
47
Data Element Descriptions
Revenue Record
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Revenue Records
Field 7
Service Date
Required if Present for MIDB and MOSDB
The month, day and year that the service was provided.
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
1. Must be a valid date
2. Must not be after discharge date
3. If the date is not known, leave blank.
UB-04 Form Locator 45
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 8
Units of Service
Required if Present for MIDB and MOSDB
A quantitative measure of services rendered by revenue category to or for the
patient to include items such as number of accommodation days, miles, pints
of blood, renal dialysis treatments, etc.
7 bytes
Decimal
Enter total units charged
UB-04 Form Locator 46
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
48
Data Element Descriptions
Revenue Record
Return to Revenue Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Revenue Records
Field 9
Revenue Code Charges
Required if Present for MIDB and MOSDB
Charges for the respective revenue code.
10 bytes
Numeric
Always include cents and the decimal point.
Remove commas and dollar signs.
Examples:
“1234.56” = $1,234.56
“1234.00” = $1,234
If amount is greater than $9,999,999.99 enter 9999999.99
UB-04 Form Locator 47
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
49
Diagnosis Records
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
50
Data Element Descriptions
Diagnosis Records
Return to Diagnosis Records Summary Table
The Diagnosis Records provide additional information related to a Main Record. Only include Diagnosis Records if data
of this type actually exists. Do not include blank Diagnosis Records.
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Diagnosis Records
Field 1
Record Type=DX
Required for MIDB and MOSDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
DX = Diagnosis Records
Set Record Type = ‘DX’ for all Diagnosis Records.
MHASC Defined
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Diagnosis Records
Field 2
Patient Type
Required for MIDB and MOSDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from both the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
51
Data Element Descriptions
Diagnosis Record
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Diagnosis Records
Field 3
Patient Control Number
Required for MIDB and MOSDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Diagnosis Records
Field 4
Facility ID – MHASC Assigned
Required for MIDB and MOSDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
52
Data Element Descriptions
Diagnosis Records
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Diagnosis Records
Field 5
Diagnosis Code Version
Required for MIDB and MOSDB
Indicator used to identify the ICD code version
2 bytes
Alphanumeric
09 = ICD-9
10 = ICD-10
Use the appropriate code to identify whether the respective diagnosis code
record is utilizing ICD-9 or ICD-10 code sets.
Reference
Comment
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Diagnosis Records
Field 6
Is Principal Diagnosis
Required for MIDB and MOSDB
Indicator used to identify if the respective diagnosis code is the principal
diagnosis for the patient record.
1 byte
Numeric
1 = True
0 = False
Use ‘1’ to signify that this is the principal diagnosis for the patient record.
There should only be one principal diagnosis per patient record.
Reference
Comment
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
53
Data Element Descriptions
Diagnosis Records
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Diagnosis Records
Field 7
Diagnosis Code
Required for MIDB and MOSDB
The ICD diagnoses codes corresponding to all conditions that coexist at the
time of admission, that develop subsequently or that affect the treatment
received and/or length of stay. Exclude diagnoses that relate to an earlier
episode which have no bearing on the current hospital stay.
7 bytes
Alphanumeric
It is recommended that diagnoses be ranked in priority order, the highest in
importance first.
Do not include decimals.
Example:
“99999” = 999.99
ICD-9-CM, ICD-10-CM
1. A principal diagnosis must be recorded before a secondary diagnosis can
be recorded
2. Must be a valid ICD code for the period of admission.
3. If an “E” code is present, an injury diagnosis code must be present as the
Principal Diagnosis.
4. If the diagnosis is sex-specific, the patient’s sex must be consistent with the
ICD code.
5. If the diagnosis is age-specific, the patient’s age must be consistent with
the ICD code.
6. A secondary diagnosis is considered a duplicate if it is coded the same as
the Principal Diagnosis.
UB-04, Form Locator 67 A-Q, 72 a-c; UHDDS
It is recommended that you abstract as many diagnoses and procedure codes
as possible to facilitate an accurate DRG number assignment.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
54
Data Element Descriptions
Diagnosis Records
Return to Diagnosis Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Diagnosis Records
Field 8
Present on Admission (POA) Indicator –Diagnosis Code
Required for MIDB
N/A for MOSDB
The Present on Admission Indicator pertaining to the Diagnoses.
1 byte
Alphanumeric
Y = Yes; Present at the time of inpatient admission
N = No; Not present at the time of inpatient admission
U = No Information in the Record; The documentation is insufficient to
determine if the condition was present at the time of inpatient admission
W = Clinically Undetermined; Provider is unable to clinically determine
whether condition was present on admission or not
1/Blank = Exempt from POA reporting (See Instructions)
Usage Note:
1. The POA Indicator applies to the diagnosis codes for all claims involving
inpatient admissions to general acute care hospitals or other facilities
that are subject to a law or regulation mandating collection of present
on admission information.
2. Present on admission is defined as present at the time the order for
inpatient admission occurs – conditions that develop during an
outpatient encounter, including emergency department, observation,
or outpatient surgery, are considered as present on admission.
3. Issues relating to inconsistent, missing, conflicting or unclear
documentation must still be resolved by the provider.
Present on Admission Indicator Code for Exempt from POA Reporting = “1” for
UB-04 reporting effective 7/1/11; not for use on the 5010 837 which will
continue to be Not Populated (Blank).
UB-04, Form Locator 67 A-Q, 72 a-c
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
55
CPT Procedure Records
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
56
Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
The CPT Procedure Records provide additional information related to a Main Record. Only include CPT Procedure
Records if data of this type actually exists. Do not include blank CPT Procedure Records.
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 1
Record Type=CX
Required for MOSDB
Required for MIDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
CX = CPT Procedure Records
Set Record Type = ‘CX’ for all CPT Procedure Records.
MHASC Defined
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
CPT Procedure Records
Field 2
Patient Type
Required for MOSDB
Required for MIDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from both the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
57
Data Element Descriptions
CPT Procedure Records
Data Element Name
Comment
CPT Procedure Records
Field 2
Patient Type
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 3
Patient Control Number
Required for MOSDB
Required for MIDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 4
Facility ID – MHASC Assigned
Required for MOSDB
Required for MIDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
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Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
CPT Procedure Records
Field 5
Is Principal Procedure - CPT
Required for MOSDB
Required for MIDB
Indicator used to identify if the respective CPT Procedure code is the principal
procedure for the patient record.
1 byte
Numeric
1 = True
0 = False
User ‘1’ to signify that this is the principal CPT procedure for the patient
record. There should only be one principal CPT procedure per patient record.
Reference
Comment
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
CPT Procedure Records
Field 6
Procedure - CPT
Required for MOSDB
Required for MIDB
The CPT-4 procedure codes assigned to procedures performed.
5 bytes
Alphanumeric
It is recommended that procedures be ranked in priority order, the highest in
importance first.
CPT-4 Codes
1. A principal procedure must be recorded before a secondary procedure is
recorded.
2. Must be a valid CPT-4 code for the period of discharge.
Reference
Comment
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Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
CPT Procedure Records
Field 7
Date of Procedure-CPT
Required for MOSDB
Required for MIDB
The date of each procedure.
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
1. Must be a valid date
2. Must not be after discharge date
3. If the date is not known, leave blank.
UB-04, Form Locator 45
Each procedure should have a date recorded in the corresponding sub-item.
For example, the date for the procedure located in Field 6 should be recorded
in Field 7 of the CPT Procedure Record line.
If the date is not known, leave blank.
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 8
CPT Operating Physician – NPI
Required if Present for MOSDB
Required if Present for MIDB
The unique identification number assigned to the individual who performed
the procedure. NPI is the national provider identifier.
10 bytes
Numeric
UB-04, Form Locator 78-79
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Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 9
CPT Operating Physician – Legacy
Required if Present for MOSDB
Required if Present for MIDB
This field contains the hospital-assigned ID number of the physician who
performed the procedure.
10 bytes
Alphanumeric
Use the hospital-defined physician number.
UHDDS
 If the treatment is performed by a resident or physician assistant, record
the supervising physician’s identification that authorized the treatment.
 If the physician number is larger than 10 characters, please consult with
Medical Records and the MIDB/MOSDB user to agree on a format for
uniquely identifying each physician. For example, if the facility has a 12digit physician number, truncating the ID to 10 digits may result in a nonunique ID. The outcome would be that the facility would no longer be able
to accurately query their data by physician ID.
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 10
HCPCS Modifier 1
Required if Present for MOSDB
Required if Present for MIDB
Represent items, supply and non-physician services not covered by CPT-4
codes.
2 Bytes
Enter up to four HCPCS modifiers for each procedure code using fields 10-12
on the CPT procedure record
UB-04, Form Locator 44
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Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 11
HCPCS Modifier 2
Required if Present for MOSDB
Required if Present for MIDB
Represent items, supply and non-physician services not covered by CPT-4
codes.
2 Bytes
Enter up to four HCPCS modifiers for each procedure code using fields 10-12
on the CPT procedure record
UB-04, Form Locator 44
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 12
HCPCS Modifier 3
Required if Present for MOSDB
Required if Present for MIDB
Represent items, supply and non-physician services not covered by CPT-4
codes.
2 Bytes
Enter up to four HCPCS modifiers for each procedure code using fields 10-12
on the CPT procedure record
UB-04, Form Locator 44
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Data Element Descriptions
CPT Procedure Records
Return to CPT Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
CPT Procedure Records
Field 13
HCPCS Modifier 4
Required if Present for MOSDB
Required if Present for MIDB
Represent items, supply and non-physician services not covered by CPT-4
codes.
2 Bytes
Enter up to four HCPCS modifiers for each procedure code using fields 10-12
on the CPT procedure record
UB-04, Form Locator 44
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Data Element Descriptions
ICD Procedure Records
ICD Procedure Records
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
The ICD Procedure Records provide additional information related to a Main Record. Only include ICD Procedure
Records if data of this type actually exists. Do not include blank ICD Procedure Records.
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 1
Record Type=PX
Required for MIDB and MOSDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
PX = ICD Procedure Records
Set Record Type = ‘PX’ for all ICD Procedure Records.
MHASC Defined
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
ICD Procedure Records
Field 2
Patient Type
Required for MIDB and MOSDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from both the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Comment
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 3
Patient Control Number
Required for MIDB and MOSDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 4
Facility ID – MHASC Assigned
Required for MIDB and MOSDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
ICD Procedure Records
Field 5
Procedure Version
Required for MIDB and MOSDB
Indicator used to identify the ICD code version
2 bytes
Alphanumeric
09 = ICD-9
10 = ICD-10
Use the appropriate code to identify whether the respective procedure code
record is utilizing ICD-9 or ICD-10 code sets.
Reference
Comment
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
ICD Procedure Records
Field 6
Is Principal Procedure - ICD
Required for MIDB and MOSDB
Indicator used to identify if the respective ICD procedure code is the principal
ICD procedure for the patient record.
1 byte
Numeric
1 = True
0 = False
User ‘1’ to signify that this is the principal ICD procedure for the patient record.
There should only be one principal ICD Procedure per patient record.
Reference
Comment
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 7
Procedure - ICD
Required for MIDB
Required for MOSDB
The ICD procedure codes assigned to procedures performed.
7 bytes
Alphanumeric
Do not include decimals
It is recommended that procedures be ranked in priority order, the highest in
importance first.
Do not include decimals.
Example:
“9999” = 99.99
“
” = Unrecorded
ICD-9-CM, ICD-10-CM
1. A principal procedure must be recorded before a secondary procedure is
recorded.
2. Must be a valid ICD code for the period of admission.
3. If the procedure is sex-specific, the patient’s sex must be consistent with
the ICD code.
4. All O.R. procedure codes reported cannot be non-specific.
UB-04, Form Locator 74a-e; UHDDS
It is recommended that you abstract as many diagnoses and procedure codes
as possible to facilitate an accurate DRG number assignment.
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
ICD Procedure Records
Field 8
Date of Procedure- ICD
Required for MIDB and MOSDB
The date of each procedure.
8 bytes
Alphanumeric
MMDDYYYY = Month Day Year
Each of the components should be right justified, zero filled within the two
digits. For example, January 5, 2014 is recorded as 01052014.
Codes
Instructions
Reference
Comment
1. Must be a valid date
2. Must not be after discharge date
3. If the date is not known, leave blank.
UB-04, Form Locator 74, a-e
Each procedure should have a date recorded in the corresponding sub-item.
For example, the date for the procedure located in Field 7 should be recorded
in Field 8 of the individual ICD Procedure Record line.
If the date is not known, leave blank. .
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 9
ICD Operating Physician – NPI
Required if Present for MIDB and MOSDB
The unique identification number assigned to the individual who performed
the ICD procedure. NPI is the national provider identifier.
10 bytes
Numeric
UB-04, Form Locator 77-79
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Data Element Descriptions
ICD Procedure Records
Return to ICD Procedure Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
ICD Procedure Records
Field 10
ICD Operating Physician – Legacy
Required if Present for MIDB and MOSDB
This field contains the hospital-assigned ID number of the physician who
performed the ICD procedure.
10 bytes
Alphanumeric
Use the hospital-defined physician number.
UHDDS
 If the treatment is performed by a resident or physician assistant, record
the supervising physician’s identification that authorized the treatment.
 If the physician number is larger than 10 characters, please consult with
Medical Records and the MIDB/MOSDB user to agree on a format for
uniquely identifying each physician. For example, if the facility has a 12digit physician number, truncating the ID to 10 digits may result in a nonunique ID. The outcome would be that the facility would no longer be able
to accurately query their data by physician ID.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Condition Code Records
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Data Element Descriptions
Condition Code Records
Return to Condition Code Records Summary Table
The Condition Code Records provide additional information related to a Main Record. Only include Condition Code
Records if data of this type actually exists. Do not include blank Condition Code Records.
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Condition Code Records
Field 1
Record Type=CC
Required for MIDB and MOSDB
Alpha character used to identify the record type.
2 bytes
Alphanumeric
CC = Condition Code Records
Set Record Type = ‘CC’ for all Condition Code Records.
MHASC Defined
Return to Condition Code Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Condition Code Records
Field 2
Patient Type
Required for MIDB and MOSDB
Subset categorization of inpatient or outpatient
2 bytes
Alphanumeric
10 = Inpatient Records (not Stillbirth or Hospice)
11 = Inpatient Stillbirth Records
12 = Inpatient Hospice Records (See Instructions)
30 = Outpatient Records (not Observation or Birth)
31 = Outpatient Observation patient
 Not admitted as an inpatient.
 Patients placed in a holding pattern –
“watchful waiting”.
 May or may not have a principal procedure.
 May have come in for ambulatory surgery, but placed into observation
status and departed facility as an observation patient.
32 = Outpatient Birth – assign to both mom records and baby records.
CRITICAL NOTE FOR HOSPICE PATIENTS:
Hospice Patients are not included in the MIDB. Patient Type 12 is used to
identify and remove hospice records from both the MIDB. If this code is not
assigned to hospice patient records, these records will be retained for the
MIDB and the result will be inflated rates for both mortality and length of stay.
Reference
Comment
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MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Condition Code Records
Return to Condition Code Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Condition Code Records
Field 3
Patient Control Number
Required for MIDB and MOSDB
The patient’s unique identification number assigned by the provider. This
number is often referred to as a patient account number and is unique to a
specific occurrence of a hospital stay. This is not a patient’s medical record
number.
20 bytes
Alphanumeric
UB-04, Form Locator 03a
If your patient control number is larger than 20 digits, please consult with
Medical Records/Finance and MHASC Data Services to agree on a truncation
formula that results in unique keys.
Return to Condition Code Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Condition Code Records
Field 4
Facility ID – MHASC Assigned
Required for MIDB and MOSDB
The hospital identification number assigned by MHASC to the facility for
submission of data.
4 bytes
Alphanumeric
If you are unsure of your ID, contact Data Services at (877) 999-4653 to obtain
the correct ID.
MHASC Defined
If the hospital has a separate Ambulatory Surgery Center, please contact the
assigned Data Quality Representative to receive a separate Hospital ID number
for these patients.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
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Data Element Descriptions
Condition Code Records
Return to Condition Code Records Summary Table
Data Element Name
Status
Description
Field Length
Format
Codes
Instructions
Reference
Comment
Condition Code Records
Field 5
Condition Code
Required for MIDB and MOSDB
Condition codes identify certain provisions and circumstances in regards to a
particular bill.
2 bytes
Alphanumeric
Include each condition code captured on the patient record as an individual
condition code record in the submission.
UB-04 Form Locator 18-28
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Appendix
Glossary of Terms
APPENDIX
Glossary of Terms
Term
Ambulatory Care
Ambulatory Surgery Center
Ancillary
BCBSM
Carrier
CMS
CPT-4
Diagnostic Related Group
(DRG)
Emergency Room
Fee for Service
Form Locator
HBIPS
HCPCS
HMO
Home Health Agency or Service
Organization
Hospice
Inpatient
The Joint Commission
Long Term Care
MHA
Managed Care
Definition
Health care services provided on an outpatient basis, where no overnight stay in a
health care facility is required.
A facility where surgical procedures are performed on an outpatient basis. The
facility may be freestanding or affiliated with a hospital.
Diagnostic or therapeutic services, such as laboratory, radiology, pharmacy, and
physical therapy performed by non-nursing departments.
Blue Cross Blue Shield of Michigan as specified for the Participating Hospital
Agreement.
An organization acting as an insurer.
Centers for Medicare & Medicaid Services.
Stands for the Common Procedure Terminology system used for classifying
medical procedures. Commonly used for outpatient services. It is a 5-digit code
updated annually by the AMA.
A system for the classification of patients into groups based on the similarity of
diagnoses and treatments.
A hospital department or area with personnel and equipment for the care of acute
illness, trauma, or other conditions needing immediate medical attention.
The traditional practice of providers billing for each encounter or service rendered.
The data elements on the Uniform Bill Claim Form are commonly referred to as
Form Locators. Each is assigned a unique number by the National Uniform Billing
Committee (NUBC).
Hospital Based Inpatient Psychiatric Services
A coding system used for classifying medical procedures, developed by CMS. They
are 5 digit alphanumeric procedure codes.
Health Maintenance Organization is a managed care organization that provides
health services to enrolled individuals.
An agency that has health professionals who provide services in an individual's
place of residence to patients who require short or long term intervention by
health professionals due to an injury, illness, or disabling condition.
Caring for terminally ill patients either in their home or in a facility so the patient
can live as full a life as possible. These patients are not included in the
MIDB/MOSDB.
See section on DATA EXTRACTION RULES for definition.
Joint Commission on Accreditation of Healthcare Organizations.
Health, rehabilitative or personal services provided on a long-term basis for
people, who are unable to perform basic activities of daily living, like dressing or
bathing.
Michigan Health & Hospital Association
A method of health care delivery used by health organizations, such as HMOs, to
“Manage” or coordinate what it spends on health care by closely monitoring how
physicians and other medical professionals treat patients.
Michigan Health & Hospital Association Service Corporation
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Appendix
Glossary of Terms
Term
Medicaid
Definition
State and federally funded program that pays for medical services to low-income
residents who meet certain requirements.
Medicare
A federally funded program that pays for medical services to residents over age 65
and the permanently disabled.
See section on DATA EXTRACTION RULES for definition.
National Uniform Billing Committee
A type of health plan that features both the elements of fee-for-service and
managed care. The PPO contracts with networks of providers who agree to provide
services and be paid negotiated rates.
Designation given to the insurer that has first priority for payment of a claim.
Known as a PPS it is a price-based payment system where payment has been
determined prior to the actual rendering of treatment.
Surgical Care Improvement Project
Designation given to the insurer that has second priority for payment of a claim,
after the primary payer.
A facility primarily engaged in providing skilled nursing care that has an organized
professional staff of physicians and registered nurses. The record of a patient
admitted to a SNF unit of a hospital would not be included in the MIDB
submission. The record detailing their treatment from the acute care portion of
the hospital would be included in the MIDB submission.
Health services provided to patients who are not in an acute or severe state of
illness but who require more medical care than they would receive in a long-term
care setting. These patients would not be included in the MIDB/MOSDB
submissions.
State Uniform Billing Committee
The uniform billing standard under the control of the National Uniform Billing
Committee (NUBC) and the State Uniform Billing Committee (SUBC).
The Uniform Hospital Discharge Data Set promulgated by the Department of
Health and Human Services.
Outpatient
NUBC
PPO
Primary Payer
Prospective Payment System
SCIP
Secondary Payer
Skilled Nursing Facility (SNF)
Sub-acute Care
SUBC
UB-04
UHDDS
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Revision History
Revision History
MHA DMS 10 1.00.00
The original release of the MHA DMS 10 was published January 16, 2014
MHA DMS 10 1.00.01
The MHA DMS 10 1.00.01 was published on March 26, 2014. Following is a table of revisions made.
Record Type
Various
Header (HE)
NA
Main (MA)
Main (MA)
Main (MA)
Main (MA)
MHA DMS 10 1.00.01 – Revision History Table
Field Name
Location
Changes Made
Various
Various
Minor verbiage changes
Special Handling Code
Page 4
Changed special handling code end position to 78
Data Pull Process
Page 7
Changed required submission file type to .txt
Patient Medical/Health
Page 9 &
Changed field length to 24 bytes
Record Number
Page 21
Patient HIC Number
Page 9 &
Changed field length to 20 bytes
(Medicare ID/Health
Page 22
Insurance Claim Number)
Patient Mailing Address 1
Page 9 &
Changed field length to 40 bytes
Page 27
Patient Discharge Status
Pages 49-52 Added new code 69:
69=Discharged/Transferred to a designated disaster
alternate care
Changed language for following codes 81-95:
81 = Discharged to Home or Self Care with a Planned
Acute. Care Hospital Inpatient Readmission
82=Discharged/Transferred to a Short Term General
Hospital for Inpatient Care with a Planned
Acute Care Hospital Inpatient Readmission
83=Discharged/Transferred to a Skilled Nursing
Facility (SNF) with Medicare Certification with a
Planned Acute Care Hospital Inpatient
Readmission
84=Discharged/Transferred to a Facility that Provides
Custodial or Supportive Care with a Planned
Acute Care Hospital Inpatient Readmission
85=Discharged/transferred to a Designated Cancer
Center or Children's Hospital with a Planned
Acute Care Hospital Inpatient Readmission
86=Discharged/Transferred to Home under Care of
Organized Home Health Service Organization
with a Planned Acute Care Hospital Inpatient
Readmission
87=Discharged/Transferred to Court/Law
Enforcement with a Planned Acute Care
Hospital Inpatient Readmission
88=Discharged/Transferred to a Federal Health Care
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Revision History
Facility with a Planned Acute Care Hospital
Inpatient Readmission
89=Discharged/Transferred to a Hospital-based
Medicare Approved Swing Bed with a Planned
Acute Care Hospital Inpatient Readmission
90=Discharged/Transferred to an Inpatient
Rehabilitation Facility (IRF) including
Rehabilitation Distinct Part Units of a Hospital
with a Planned Acute Care Hospital Inpatient
Readmission
91=Discharged/Transferred to a Medicare Certified
Long Term Care Hospital (LTCH) with a Planned
Acute Care Hospital Inpatient Readmission
92=Discharged/Transferred to a Nursing Facility
Certified Under Medicaid but not Certified
Under Medicare with a Planned Acute Care
Hospital Inpatient Readmission
93=Discharged/Transferred to a Psychiatric Hospital
or Psychiatric Distinct Part Unit of a Hospital
with a Planned Acute Care Hospital Inpatient
Readmission
94=Discharged/Transferred To a Critical Access
Hospital (CAR) with a Planned Acute Care
Hospital Inpatient Readmission
95=Discharged/Transferred to Another Type of Health
Care Institution not Defined Elsewhere in this Code
List with a Planned Acute Care Hospital Inpatient
Readmission
Revenue (RE)
Units of Service
Page 73
Changed code 97 to code 87
Changed format to decimal
MHA DMS 10 1.00.02
The MHA DMS 10 1.00.02 was published on April 4, 2014. Following is a table of revisions made.
Record Type
Various
Main (MA)
Main (MA)
MHA DMS 10 1.00.02 – Revision History Table
Field Name
Location
Changes Made
Various
Various
Removed Submission Thresholds from all fields
Patient HIC Number
Page 9, Page Changed field status to Reserved for Future Use,
(Medicare ID/Health
22
removed instruction content.
Insurance Claim Number)
Medical Record Number –
Page 9, Page Changed field length to 24 bytes
Mother of newborn
38
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Revision History
MHA DMS 10 1.00.03
The MHA DMS 10 1.00.03 was published on April 17, 2014. Following is a table of revisions made.
Record Type
Various
Main
Main
Main
Main
Field Name
Various
MHA DMS 10 1.00.03 – Revision History Table
Location
Changes Made
Various
Field spacing and minor formatting changes
throughout document
Source of Admission –
Specific Facility (NPI)
Disposition of Patient –
Specific Facility (NPI)
Page 31
Disposition of Patient
Specific Facility (NPI)
Patient HIC Number
(Medicare ID/Health
Insurance Claim Number)
Page 37
Page 37
Page 16
(*Note this impacted the length of the document
and page references for earlier versions of the
document will no longer be accurate)
Changed field type to numeric
Added instructions that the field must have a value
when Patient Discharge Status contains one of the
following values: 02, 82, 03, 83, 04, 84, 05, 85, 06,
86,43, 88, 62, 90, 63, 91, 64, 92, 65, 93, 66, 94, 70,
95
Changed field type to numeric
Added the following instructions: “DO NOT
POPULATE THIS FIELD AT THIS TIME”
MHA DMS 10 1.00.04
The MHA DMS 10 1.00.04 was published on April 24, 2014. Following is a table of revisions made.
Record Type
Main
MHA DMS 10 1.00.04 – Revision History Table
Field Name
Location
Changes Made
Patient HIC Number
Page 9, 16
Removed Patient HIC Number (Medicare ID/Health
(Medicare ID/Health
Insurance Claim Number) and marked position as
Insurance Claim Number)
filler
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
79
Revision History
MHA DMS 10 1.00.05
The MHA DMS 10 1.00.05 was published on June 17, 2014. Following is a table of revisions made.
Record Type
Main
NA
MHA DMS 10 1.00.05 – Revision History Table
Field Name
Location
Changes Made
Place of Service
Page 9, 16
Changed Status from Required to Reserved for
Future Use
NA
Page 6
Added the following to Inpatient data extraction
rules:
If two or more Inpatient records are combined for
payment purposes because of a readmission we ask
that you send each individual record and not the
combined record. The MIDB should reflect the total
number of discharges that take place during the
specific timeframe which allows hospitals to assess
needs and aids in readmission projects being
performed across the state.
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
80
Revision History
MHA DMS 10 1.00.06
The MHA DMS 10 1.00.06 was published on October 2, 2014. Following is a table of revisions made.
Record Type
NA
NA
Main
Revenue
Revenue
Revenue
Diagnosis
Diagnosis
Diagnosis
CPT Procedure
ICD Procedure
ICD Procedure
Condition Code
MHA DMS 10 1.00.06 – Revision History Table
Location
Changes Made
Page 6
Data extraction rules were revised to emphasize the
inclusion and proper coding of stillbirths and
hospice patients
NA
Page 7
The data pull process was revised to emphasize the
inclusion of all inpatient/outpatient records
Patient Type
Page 13
Removed the comment and removed “Respite”
from the description of Patient Type 12
Patient Type
Page 46
Removed the comment and removed “Respite”
from the description of Patient Type 12
Revenue Code
Page 48
Expanded the description to match UB-04
Revenue Code Charges
Page 10, 50 Increased the length to 10. Changed the
instructions to require cents and the decimal point.
Patient Type
Page 52
Removed the comment and removed “Respite”
from the description of Patient Type 12
Diagnosis Code Version
Page 54
Changed code from 9 to 09 for ICD-9
Present on Admission
Page 56
Added Blank as an allowable code for Exempt.
(POA) Indicator –Diagnosis
Added instructions.
Code
Patient Type
Page 58
Removed the comment and removed “Respite”
from the description of Patient Type 12
Patient Type
Page 66
Removed the comment and removed “Respite”
from the description of Patient Type 12
Procedure Version
Page 68
Changed code from 9 to 09 for ICD-9
Patient Type
Page 73
Removed the comment and removed “Respite”
from the description of Patient Type 12
Field Name
NA
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
81
Revision History
MHA DMS 10 1.00.07
The MHA DMS 10 1.00.07 was published on December 15, 2015. Following is a table of revisions made.
MHA DMS 10 1.00.07 – Revision History Table
Record Type
Field Name
Location
Changes Made
NA
NA
Page 1
Corrected URL for online version of documentation
NA
NA
Page 3
Added verbiage below Main Record entry to
indicate that related record types should only be
included if they exist.
RE, DX, CX, PX, CC NA
Pages 46,
Added verbiage to the first page of each record type
52, 58, 66,
explanation, stating that related records should only
73
be included if they exist.
Header
Delimiter Character Value
Page 4
Added verbiage stating that MHA prefers pipe
delimiters over other delimiter options.
NA
NA
Page 5
Corrected sample record layout to match the
specification.
Added a header record to the sample.
NA
NA
Page 8
Removed the following Data Element Status Types :
P (Preferred), PP (Preferred if Present), O (Optional),
D (Discontinued)
Revised the definitions for R (Required) and RP
(Required if Present)
Various
Various
Various
Revised Status Types in the Data Element Summary
Tables and related fields.
MA
Patient Medical / Health
Page 17
Removed comment
Record Number
MA
Point of Origin for
Page 30
In the section “Code Structure for Newborn”,
Admission or Visit
removed codes: 7-9 – Reserved for Assignment by
NUBC
MA
Principal Payer
Page 38
Added new codes: 51 - Charity Care, 52 - Auto
Insurance
MA
Secondary Payer
Page 40
Added new codes: 51 – Charity Care, 52 – Auto
Insurance
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
82
Revision History
MHA DMS 10 1.00.08
The MHA DMS 10 1.00.08 was published on April 5, 2016. Following is a table of revisions made.
Record Type
MA
RE
MHA DMS 10 1.00.08 – Revision History Table
Field Name
Location
Changes Made
Patient Primary Language
Page 25
Reworked list of supported languages and examples
to better reference ISO 639-2 list.
Data Extraction Rules
Page 6
Removed definitions for MIDB and MOSDB since
they were being confused as part of the Data
Extraction Rules.
Data Extraction Rules
Page 6
Added Outpatient Exclusion block, listing Dr. Office/
Clinic Visits and Professional Fees as being excluded.
Data Pull Process
Page 7
Reworded sentence that mentions submitting all
Inpatient and Outpatient records, added reference
to Data Extraction Rules page.
Overall
Various
Change all occurrences of MODB to MOSDB, left
Outpatient alone since “Outpatient Surgical” didn’t
make sense in most contexts.
HCPCS Rate
Page 47
HCPCS Coding instructions – changed “CPT-4
Procedure” to “HCPCS Procedure” in the
instructions. Updated descriptions for both
Inpatient and Outpatient.
Data Pull Process
Page 7
Fixed typo – changed “A copy of pull” to “A copy of
the pull” (added word “the”)
Michigan Health & Hospital Association Service Corporation
MHA DMS 10 1.00.08 Specifications Published on 04/05/2016
83