References to other Chapters

6

• 6
  Chapter 6
  • 6.1 PURPOSE
  • 6.2 TRIGGER EVENTS AND MESSAGE DEFINITIONS
    • 6.2.1 Add and Update Patient Accounts (Event Code P01)
    • 6.2.2 Purge Patient Accounts (Event Code P02)
    • 6.2.3 Post Detail Financial Transactions (Event Code P03)
    • 6.2.4 Generate Bills and Accounts Receivable Statements (Event Code P04)
  • 6.3 MESSAGE SEGMENTS
    • 6.3.1 SEGMENT: ACC - ACCIDENT-
    • 6.3.2 DG1 - DIAGNOSIS-
    • 6.3.3 FT1 - FINANCIAL TRANSACTION-
    • 6.3.4 GT1 - GUARANTOR-
    • 6.3.5 IN1 - INSURANCE-
    • 6.3.6 NK1 - NEXT OF KIN-
    • 6.3.7 PR1 - PROCEDURES-
    • 6.3.8 UB1 - UB82 DATA-
  • 6.4 EXAMPLE TRANSACTIONS
    • 6.4.1 Create a Patient Billing/Accounts Receivable Record
    • 6.4.2 UB82 Information Updated from Utilization Review Department
    • 6.4.3 Diagnosis and DRG Assignment
  • 6.5 IMPLEMENTATION CONSIDERATIONS
  • 6.6 OUTSTANDING ISSUES

6
Chapter 6

6.1 PURPOSE

The Patient Accounting Message set provides for the entry and manipulation of: charge, payment, adjustment, demographic, insurance, and other related patient billing and accounts receivable information.
NOTE: This section of the HL7 specification deals with patient accounting interfaces. Future HL7 releases will include other systems in the Financial arena such as: payroll/personnel, general ledger, accounts payable, cost accounting, budgeting, etc. These systems will be presented in a separate finance section when appropriate.
The specification includes all data defined in the National Uniform Billing Data Element Specifications (as adapted by the National Uniform Billing Commission, May 21, 1982 and revised November 8, 1984). We have excluded state-specific coding and suggest that, where required, it be implemented in site-specific 'Z' segments. State-specific fields may be included in the specification at a later time. In addition, no attempt has been made to define data traditionally required for the proration of charges. The requirement for this is unique to a billing system and not a part of an interface.
It is recognized that a wide variety of billing and accounts receivable systems exist today. Therefore, in an effort to accommodate the needs of the most comprehensive systems, an extensive set of transaction segments has been defined.
Financial transactions can be sent between systems either in batches or on-line. As defined in Chapter II, multiple transactions may be grouped and sent through all file transfer media or programs when using the HL7 Encoding Rules.
This chapter defines the transactions at the seventh level, i.e., the abstract messages. Various schemes may be used to generate the actual characters that comprise the messages according to the communications environment. The HL7 Encoding Rules will be used where there is not a complete Presentation Layer. This is described in Chapter 1, "Relationship to Other Protocols." The examples included in this chapter were constructed using the HL7 Encoding Rules.

6.2 TRIGGER EVENTS AND MESSAGE DEFINITIONS

The triggering events that follow are served by the Detail Financial Transaction (DFT), Add/Change Billing Account (BAR) and General Acknowledgement (ACK) messages.
Each triggering event is listed below, along with the applicable form of the message exchange. The notation used to describe the sequence, optionality, and repetition of segments is described in Chapter II, "Format for Defining Abstract Messages."

6.2.1 Add and Update Patient Accounts (Event Code P01)

Data is sent from some application (usually a Registration or an ADT system) to the patient accounting system to establish an account for a patient's billing/accounts receivable record. Many of the segments associated with this event are optional. This optionality allows those systems needing these fields to set up transactions which fulfill their requirements yet satisfy the HL7 requirements. Sample event codes are in table 3.
BAR Add/Change Billing Account Chapter
MSH Message Header II
EVN Event Type III
PID Patient ID Information III
{[ PV1 ] Patient Visit III
[{ DG1 }] Patient Diagnosis VI
[{ PR1 }] Procedures VI
[{ GT1 }] Guarantor VI
[{ NK1 }] Next of Kin VI
[{ IN1 }] Insurance VI
[ACC] Accident Information VI
[UB1] Universal Bill Information VI
}
ACK General Acknowledgement Chapter
MSH Message Header II
MSA Message Acknowledgement II
[ ERR ] Error II
The error segment will indicate the fields that caused a transaction to be rejected.
The Set ID field in the IN1 records is used, in later updates, to link the new update to the original transaction.
The Set ID field in the insurance, diagnosis, and procedures segments will be set the first time these segments are sent and can be used in subsequent transactions to update them.
ACK General Acknowledgement Chapter
MSH Message Header II
MSA Message Acknowledgement II
[ ERR ] Error II
The error segment will indicate the fields that caused a transaction to be rejected.

6.2.2 Purge Patient Accounts (Event Code P02)

Generally, the elimination of all billing/accounts receivable records will be an internal function controlled by the financial system. However, on occasion, there is a need to correct an account, or series of accounts, which may require a notice of account deletion to be sent from another sub-system and processed by the financial system.
BAR Add/Change Billing Account Chapter
MSH Message Header II
EVN Event Type III
{ PID Patient ID Information III
[ PV1 ] Patient Visit III
}
The Set ID field in the insurance, diagnosis, and procedures segments will be used to identify the items to be deleted.
ACK General Acknowledgement Chapter
MSH Message Header II
MSA Message Acknowledgement II
[ ERR ] Error II
The error segment will indicate the fields that caused a transaction to be rejected.

6.2.3 Post Detail Financial Transactions (Event Code P03)

The Detail Financial Transaction is used to describe a financial transaction transmitted between systems, ie., to HIS for ancillary charges, ADT to HIS for patient deposits, etc.
DFT Detail Financial Transaction Chapter
MSH Message Header II
EVN Event Type III
PID Patient ID Information III
[ PV1 ] Patient Visit III
{[ FT1 ]} Financial Transaction VI
Special codes in the Event Type record are used for updating.
ACK General Acknowledgement Chapter
MSH Message Header II
MSA Message Acknowledgement II
[ ERR ] Error II
The error segment will indicate the fields that caused a transaction to be rejected.

6.2.4 Generate Bills and Accounts Receivable Statements (Event Code P04)

For patient accounting systems that support demand billing, the QRY/DSP transaction defined in Chapter V will provide the mechanism to request a copy of the bill for printing or viewing by the requesting system. (Note that this is a display-oriented response. That is why the associated messages are defined in Chapter V.)

6.3 MESSAGE SEGMENTS

6.3.1 SEGMENT: ACC - ACCIDENT-

The ACC segment contains patient information relative to an accident the patient has been involved in.

FIELD NOTES: ACC ACCIDENT

1. 00182 ACCIDENT DATE/TIME. Date/time of the accident.

2. 00184 ACCIDENT CODE. This code describes the type of accident patient was involved in. Refer to user defined table 0050 for valid entries.

3. 00185 ACCIDENT LOCATION. Location of accident.

6.3.2 DG1 - DIAGNOSIS-

The DG1 segment contains patient diagnosis information of various types. For example: Admitting, Current, Primary, final, etc. Coding methodologies are also defined.

FIELD NOTES: DG1 DIAGNOSIS

1. 00506 SET ID - DIAGNOSIS. A number that uniquely identifies the individual transaction for adding, deleting, and updating the diagnosis in the patient's record.

2. 00394 DIAGNOSIS CODING METHOD. ICD9 is the recommended coding methodology. Refer to table 0053 for valid entries.

3. 00293 DIAGNOSIS CODE. The diagnosis code assigned to this diagnosis. Refer to table 0051 for valid codes.

4. 00294 DIAGNOSIS DESCRIPTION. The description that best describes the diagnosis.

5. 00295 DIAGNOSIS DATE/TIME. The date/time the diagnosis was determined.

6. 00297 DIAGNOSIS/DRG TYPE. This code identifies the type of diagnosis being sent. Valid types could include: Admitting, Final, etc. Refer to user defined table 0052 for valid entries.

7. 00298 MAJOR DIAGNOSTIC CATEGORY. Refer to user defined table 0118 for valid entries.

8. 00299 DIAGNOSTIC RELATED GROUP. The DRG for the transaction. Interim DRG's could be determined for an encounter. Refer to table 0055 for valid entries.

9. 00373 DRG APPROVAL INDICATOR.

10. 00374 DRG GROUPER REVIEW CODE. Refer to table 0056 for valid entries.

11. 00375 OUTLIER TYPE. Refer to table 0083 for valid entries.

12. 00300 OUTLIER DAYS.

13. 00376 OUTLIER COST.

14. 00781 GROUPER VERSION AND TYPE. Grouper version and type.

6.3.3 FT1 - FINANCIAL TRANSACTION-

The FT1 segment contains detail data necessary to post charges, payments, adjustments, etc. to patient accounting records.

FIELD NOTES: FT1 FINANCIAL TRANSACTION

1. 00507 SET ID - FINANCIAL TRANSACTION. The number that uniquely identifies this transaction for the purpose of adding, changing, or deleting the transaction.

2. 00366 TRANSACTION ID. Number assigned by the sending system for control purposes. Can be returned by the receiving to identify errors.

3. 00503 TRANSACTION BATCH ID. A ID that uniquely identifies the batch to which this transaction belongs.

4. 00351 TRANSACTION DATE. Date of transaction. May be defaulted to today's date.

5. 00352 TRANSACTION POSTING DATE. The date the transaction was sent to the financial system for posting.

6. 00353 TRANSACTION TYPE. The code that identifies the type of transaction. e.g., charge, credit, payment, etc. Refer to table 0017 for valid entries.

7. 00354 TRANSACTION CODE. The code assigned by the institution for the purpose of uniquely identifying the transaction. Refer to table 0096 for valid entries.

8. 00356 TRANSACTION DESCRIPTION. The description of the transaction associated with the code entered in Transaction Code (above).

9. 00706 TRANSACTION DESCRIPTION - ALT. This is an alternate financial transaction description to be used on a site specific basis.

10. 00357 TRANSACTION QUANTITY. The quantity of items associated with this transaction.

11. 00358 TRANSACTION AMOUNT - EXTENDED. Amount of transaction. Amount field may be blank if the transaction is automatically priced. Total price for multiple items.

12. 00782 TRANSACTION AMOUNT - UNIT. Unit price of transaction. Price of a single item.

13. 00355 DEPARTMENT CODE. The department code which owns the transaction code described above. Refer to user defined table 49 for valid entries.

14. 00359 INSURANCE PLAN ID. ID of the primary insurance plan this transaction should be associated with. Refer to user defined table 0072 for valid codes.

15. 00360 INSURANCE AMOUNT. Amount to be posted to the insurance plan referenced above.

16. 00361 PATIENT LOCATION. Current patient location. For format, see Segment "PV1", field New Patient Location. Refer to user defined table 0079 for valid entries.

17. 00362 FEE SCHEDULE. This code is used to select the appropriate fee schedule to be used for this transaction posting.

18. 00363 PATIENT TYPE. This code is the type code assigned to the patient for this visit.

19. 00364 DIAGNOSIS CODE. ICD9-CM is assumed for all diagnosis codes. This diagnosis code is the most current diagnosis code assigned to the patient.

20. 00377 PERFORMED BY CODE. Composite number/name of the person/group which performed the test/procedure/transaction, etc.

21. 00783 ORDERED BY CODE. Composite number/name of person/group which performed the test/procedure/transaction, etc.

22. 00784 UNIT COST. Unit price of transaction. Price of a single item.

6.3.4 GT1 - GUARANTOR-

The GT1 segment contains Guarantor (e.g., person with financial responsibility for payment of a patient account) data for patient and insurance billing applications.

FIELD NOTES: GT1 GUARANTOR

1. 00321 SET ID - GUARANTOR. A number that uniquely identifies the transaction for the purpose of adding, changing, or deleting a transaction.

2. 00322 GUARANTOR NUMBER. A unique number assigned to the guarantor.

3. 00323 GUARANTOR NAME. The name of the guarantor. See Standard name format.

4. 00707 GUARANTOR SPOUSE NAME. Name of the guarantor's spouse. Refer to Chapter II for Person Name format.

5. 00324 GUARANTOR ADDRESS. The guarantor's address.

6. 00329 GUARANTOR PH. NUM.- HOME. The guarantor's home phone number.

7. 00330 GUARANTOR PH. NUM-BUSINESS. The guarantor's business phone number.

8. 00331 GUARANTOR DATE OF BIRTH. The guarantor's date of birth.

9. 00332 GUARANTOR SEX. Refer to SEX table for valid entries.

10. 00333 GUARANTOR TYPE. This code identifies the type of guarantor. e.g., Individual, institution, etc.

11. 00334 GUARANTOR RELATIONSHIP. This code identifies the relationship of guarantor with the patient. e.g., Parent, Child, etc.

12. 00335 GUARANTOR SSN. The guarantor's social security number.

13. 00338 GUARANTOR DATE - BEGIN. The date that the guarantor becomes responsible for the patient's account.

14. 00339 GUARANTOR DATE - END. The date that the guarantor stops being responsible for the patient's account.

15. 00340 GUARANTOR PRIORITY. A code used to determine the order the guarantors will be responsible for the patient's account.

16. 00341 GUARANTOR EMPLOYER NAME. The name of the guarantor's employer.

17. 00342 GUARANTOR EMPLOYER ADDRESS. The guarantor's employer's address.

18. 00347 GUARANTOR EMPLOY PHONE #. The guarantor's employer phone number. See Standard for format.

19. 00391 GUARANTOR EMPLOYEE ID NUM. The guarantor's employee number.

20. 00392 GUARANTOR EMPLOYMENT STATUS. A code that indicates the guarantor's employment status. e.g., Full Time, Part Time, Self Employed, etc.

6.3.5 IN1 - INSURANCE-

The IN1 segment contains insurance policy coverage information necessary to produce properly pro-rated and patient and insurance bills.

FIELD NOTES: IN1 INSURANCE

1. 00234 SET ID - INSURANCE. The set ID uniquely identifies this transaction for the purpose of adding, changing, or deleting the transaction.

2. 00378 INSURANCE PLAN ID. This code serves to uniquely identify the insurance plan. User defined table. To eliminate a plan, the plan could be sent with null values in each subsequent element. If the respective systems can support it, a null value can be sent in the plan field.

3. 00235 INSURANCE COMPANY ID. The code that serves to uniquely identify the insurance company.

4. 00236 INSURANCE COMPANY NAME. The name of the insurance company.

5. 00237 INSURANCE COMPANY ADDRESS. The address of the insurance company.

6. 00242 INSURANCE CO. CONTACT PERS. The name of the person who should be contacted at the insurance company.

7. 00243 INSURANCE CO PHONE NUMBER. The phone number of the insurance company.

8. 00248 GROUP NUMBER. The group number of the insured's insurance.

9. 00249 GROUP NAME. The group name of the insured's insurance.

10. 00250 INSURED'S GROUP EMP. ID. The group employer ID of the insured's insurance.

11. 00251 INSURED'S GROUP EMP. NAME. The group employer name of the insured's insurance.

12. 00252 PLAN EFFECTIVE DATE. The date that the insurance goes into effect.

13. 00253 PLAN EXPIRATION DATE. The last date of service that the insurance will cover or be responsible for.

14. 00254 AUTHORIZATION INFORMATION. Based on the type of insurance, some coverages require that an authorization number or code be obtained prior to all non emergency admissions and within 48 hours of an emergency admission. Insurance billing would not be permitted without this number. Date & source of authorization are sub-fields.

15. 00260 PLAN TYPE. A coding structure that identifies the various plan types.

16. 00261 NAME OF INSURED. The name of the insured person.

17. 00262 INSURED'S RELATIONSHIP TO PATIENT. A code that will identify the insured's relationship to the patient.

18. 00708 INSURED'S DATE OF BIRTH.

19. 00709 INSURED'S ADDRESS.

20. 00263 ASSIGNMENT OF BENEFITS. Has the insured agreed to assign the insurance benefits to the healthcare provider? If so, the insurance will pay the provider directly. Values are Y - Yes, N - No, Modified assignment.

21. 00264 COORDINATION OF BENEFITS. Does this insurance work in conjunction with other insurance plans or does it provide independent coverage and payment of benefits regardless of other insurance that might be available to the patient. Values are CO - coordination, IN - independent.

22. 00265 COORD OF BEN. PRIORITY. If the insurance works in conjunction with other insurance plans, is it considered a primary payor or secondary payor. Values are Y - yes; N - no.

23. 00266 NOTICE OF ADMISSION CODE. Does the insurance require a written notice of admission from the healthcare provider. Values are Y - yes; N - no.

24. 00267 NOTICE OF ADMISSION DATE. If a notice is required, this is the date that it was sent.

25. 00268 RPT OF ELIGIBILITY CODE. Does this insurance send a report indication that the patient is eligible for benefits and identifying what those benefits are. Values are Y - yes, N - No.

26. 00269 RPT OF ELIGIBILITY DATE. If a report of eligibility (ROE) was received, this indicates the date it was received.

27. 00270 RELEASE INFORMATION CODE. Can the healthcare provider release information about the patient, and what information can be released. Values are: Y - Yes, N - no, or user defined codes.

28. 00271 PRE-ADMIT CERT. (PAC). Pre-admission certification code. If the admission must be certified before the admission, this is the code associated with the admission.

29. 00272 VERIFICATION DATE. The date that the healthcare provider verified that the patient has the indicated benefits.

30. 00273 VERIFICATION BY. The person that verified the benefits.

31. 00277 TYPE OF AGREEMENT CODE. Used to further identify an insurance plan.

32. 00278 BILLING STATUS. Has the particular insurance been billed and if so, what type of bill.

33. 00280 LIFETIME RESERVE DAYS.

34. 00281 DELAY BEFORE L. R. DAY. Delay before lifetime reserve days.

35. 00282 COMPANY PLAN CODE. A facility defined table of codes used to uniquely identify an insurance plan. Optional information to further define data in field 3 of the IN1 segment.

36. 00283 POLICY NUMBER. The individual policy number of the insured.

37. 00284 POLICY DEDUCTIBLE. An amount specified by the insurance plan that is the responsibility of the guarantor.

38. 00285 POLICY LIMIT - AMOUNT. The maximum amount that the insurance policy will pay. In some cases, the limit may be for a single encounter.

39. 00286 POLICY LIMIT - DAYS. The maximum number of days that the insurance policy will cover.

40. 00287 ROOM RATE - SEMI-PRIVATE. The average room rate that the policy will cover.

41. 00288 ROOM RATE - PRIVATE. The maximum private room rate the policy will cover.

42. 00710 INSURED'S EMPLOYMENT STATUS. Refer to table 0066 for valid codes.

43. 00711 INSURED'S SEX. Refer to table 0001 for valid codes.

44. 00713 INSURED'S EMPLOYER ADDRESS.

6.3.6 NK1 - NEXT OF KIN-

The NK1 segment contains information about the patient's next of kin. Utilizing the SET ID field, multiple NT1 segments can be sent to patient accounts allowing for different types of next of
kin.

FIELD NOTES: NK1 NEXT OF KIN

1. 00712 SET ID - NEXT OF KIN. This field is used to uniquely identify the NK1 records for the purpose of adding, changing, or deleting records.

2. 00048 NEXT OF KIN NAME.

3. 00047 NEXT OF KIN RELATIONSHIP. This code indicates the next-of-kin relationship to the patient.

4. 00225 NEXT OF KIN - ADDRESS.

5. 00230 NEXT OF KIN - PHONE NUMBER.

6.3.7 PR1 - PROCEDURES-

The PR1 segment contains information relative to various types of procedures that can be performed on a patient. For example: Surgical, Nuclear Medicine, X-Ray with contrast, etc.

FIELD NOTES: PR1 PROCEDURES

1. 00304 SET ID - PROCEDURE. A unique number that is used to identify a transaction for the purpose of adding, changing or deleting entries.

2. 00393 PROCEDURE CODING METHOD.. The methodology used to assign a code to the procedure. CPT4 for example.

3. 00305 PROCEDURE CODE. The unique identifier assigned to the procedure.

4. 00306 PROCEDURE DESCRIPTION. The text description that describes the procedure.

5. 00307 PROCEDURE DATE/TIME. The date/time the procedure was performed.

6. 00309 PROCEDURE TYPE. An optional code that further defines the type of procedure.

7. 00310 PROCEDURE MINUTES. The length of time in whole minutes that the procedure took to complete.

8. 00311 ANESTHESIOLOGIST. The Anesthesiologist who administered the anesthesia.

9. 00313 ANESTHESIA CODE. The code that uniquely identifies the anesthesia used during the procedure.

10. 00314 ANESTHESIA MINUTES. The length of time in minutes that the anesthesia was administered.

11. 00315 SURGEON. The surgeon who performed the procedure.

12. 00318 RESIDENT CODE. The resident who was assigned responsibility for care.

13. 00317 CONSENT CODE. The code that identifies the type of consent that was obtained for permission to treat the patient.

6.3.8 UB1 - UB82 DATA-

The UB1 segment contains data necessary to complete UB82 bills. Only UB82 data elements that do not exist in other HL7 defined segments will appear in this segment. Patient name and Date of
Birth are required for UB82 billing, however, they are included in the PID segment and therefore do not appear here.

FIELD NOTES: UB1 UB82 DATA

1. 00459 SET ID - UB82. The number used to uniquely identify the transaction for the purpose of adding, changing, or deleting the entry.

2. 00279 BLOOD DEDUCTIBLE.

3. 00396 BLOOD FURN.-PINTS OF (40). The amount of blood furnished the patient for this visit. The (40) indicates the corresponding UB82 Data Element number.

4. 00397 BLOOD REPLACED-PINTS (41). UB82 Data Element 41.

5. 00398 BLOOD NOT RPLCD-PINTS(42). Blood not replaced. Measured in pints. UB82 Data Element 42

6. 00399 CO-INSURANCE DAYS (25). UB82 Data Element 25.

7. 00400 CONDITION CODE. Repeats 5 times. UB82 Data Elements (35), (36), (37), (38),and (39).

8. 00405 COVERED DAYS - (23). UB82 Data Element 23.

9. 00406 NON COVERED DAYS - (24). UB82 Data Element 24.

10. 00407 VALUE AMOUNT & CODE. Value code <component separator> value amount. This pair can repeat up to 8 times. (46A, 47A, 48A, 49A, 46B, 47B, 48B, and 49B).

11. 00424 NUMBER OF GRACE DAYS (90). UB82 Data Element 90.

12. 00425 SPEC. PROG. INDICATOR(44). Special program indicator. UB82 Data Element 44.

13. 00426 PSRO/UR APPROVAL IND. (87). PSRO/UR approval indicator. UB82 Data Element 87.

14. 00427 PSRO/UR APRVD STAY-FM(88). PSRO/UR approved stay date (from). UB82 Data Element 88.

15. 00428 PSRO/UR APRVD STAY-TO(89). PSRO/UR approved stay date (to). UB82 Data Element 89.

16. 00429 OCCURRENCE (28-32). Three subfields: Occurrence Code (ID), Occurrence To Date (DT) and Occurrence From Date (DT). This set of values can repeat up to 5 times. UB82 Data Elements 28-32.

17. 00435 OCCURRENCE SPAN (33). UB82 Data Element 33.

18. 00446 OCCURRENCE SPAN START DATE(33). Occurrence span start date. UB82 Data Element 33.

19. 00447 OCCUR. SPAN END DATE (33). Occurrence span end date. UB82 Data Element 33.

20. 00448 UB-82 LOCATOR 2.

21. 00449 UB-82 LOCATOR 9.

22. 00450 UB-82 LOCATOR 27.

23. 00451 UB-82 LOCATOR 45.

6.4 EXAMPLE TRANSACTIONS

6.4.1 Create a Patient Billing/Accounts Receivable Record

MSH|^~\|PATA||PATB||||BAR|MSG0010|P|2.1<CR>
EVN|001|198808220800<CR>
PID|||125976|JOHNSON^SAM^J||19471007|M|C|
8339 MORVEN RD^BALTIMORE^MD^21234^""||
(301)555-9876|||||125976011<CR>
GT1|001||JOHNSON^SAM^J|8339 MORVEN RD^BALTIMORE^MD^
21234^""||||||193-22-1876<CR>
NK1|JOHNSON^WILLIAM|F|522 MAIN ST^CUMBERLAND^MD
^28765^""|(301)555-2134<CR> IN1|001|A|A357|BCMD|||||
132987<CR>
A patient has been registered by the ADT system (PATA) and notification is sent to the Patient Billing system (PATB). The patient's name is Sam J. Johnson, a Male Caucasian, born on October 7, 1947. Living at 8339 Morven Rd, Baltimore, MD.
Mr. Johnson's patient number is 125976 and his billing number is 125976011. Mr. Johnson has provided his father's name and address as next of kin. Mr. Johnson is insured under plan id A357 with an insurance company known to both systems as BCMD.

6.4.2 UB82 Information Updated from Utilization Review Department

MSH|^~\|UREV||PATB||||BAR|MSG0018|P|VRS1.0<CR>
PID|||125976|JOHNSON^SAM^J||||||||||||125976011<CR>
UB1|1|5|3|1||1^36|||220|76|1|19880501|19880522<CR>
Utilization review sends data for Patient Billing to the Patient Accounting system. The patient's insurance program has a 1 pint deductible for blood, the patient received 5 pints of blood, and 3 pints were replaced, with 1 pint not yet replaced. There is a UB82 Condition code 1.
The patient has been assigned to a Special Unit because no general care beds are available (UB82 condition code 36). Additionally, the patient has been scheduled for out-patient pre-admission diagnostic services in preparation for a previously scheduled admission, the cost of these services is $220. The patient's services are related to a special program, defined by the Insurance Plan as plan 76.
The services provided for the period 05/01/88 through 05/22/88 are fully approved (PSRO/UR Approval Code 1), including any day or cost outlier.

6.4.3 Diagnosis and DRG Assignment

MSH|^~\|UREV||PATB||||BAR|MSG0018|P|VRS1.0<CR>
PID|||125976|JOHNSON^SAM^J||||||||||||125976011<CR>
DG1|001|I9|1550|MAL NEO LIVER, PRIMARY|19880501|DG<CR>
DG1|002||||19880501||DR||203|||DY|5<CR>
The first Diagnosis segment, contains the information that the patient has been diagnosed on May 1, as having a malignancy of the Hepatobiliary System or Pancreas (ICD9 code 1550). In the second segment, the patient hasbeen assigned a Diagnostic Related Group (DRG) of 203 (corresponding to the ICD9 code of 1550). Also, the patient has been approved for an additional 5 days (5 day outlier).
ID Codes used:
element 3.0 Diagnosis Coding Methodology I9 = ICD9
element 8.0 Diagnosis/DRG Type
DG = Diagnosis
DR = DRG
element 13.0 Outlier type
DY = Day Outlier

6.5 IMPLEMENTATION CONSIDERATIONS

The SET-ID used to be to identify whether or not a record was to be used for deletion, update, or cancellation. This was redundant since the event type indicates this fact. Consequently, the SET-ID is now only used to uniquely identify a segment.

6.6 OUTSTANDING ISSUES

1) Future releases of the HL7 specification will include other finance systems.
2) Implementors may submit state-specific segments for future releases of the specification.
3) SEND 1 DRG and up to 9 diagnosis codes per segment.