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Back  RFI # 1479: 005010X223 - Admit Date

Formal vs. Informal Help Informal Formal

Submitter

Stacey Barber

Description

Does the 005010X223 guide require an admitting diagnosis code always be present when the claim contains an admit date?

My interpretation is that it does not because the UB04 manual requires an admit date for bill type 033X (Home Health), for example, but this bill type is designated as outpatient (OP) in the UB04 manual and only bill types 012X, 022X and inpatient claims (IP), with the exception of a few require IP bill types require an admitting diagnosis.

Response

No, each element must be evaluated separately.

The 837I recognizes the UB04 manual as the determinant for deciding if an element is required. This is based on the UB04 definition of "inpatient" and "outpatient". However, the UB04 manual's definition of "inpatient" and "outpatient" can be different, depending on the type of bill (Form Locator 04) and the data element being evaluated.

For example, the manual considers type of bill 033X (Home Health) as "outpatient" for most data elements, including Admitting Diagnosis. However, the manual considers type of bill 033X to be "inpatient" for the Admission Date element.

Section 1.12.6 of the 837I TR3 refers to these situations as "exceptions to the general rules". Exceptions like this one for Admission Date are recognized by the TR3 as defining the 837I data element requirements.

As a result, for type of bill 033X, the admitting diagnosis is not used, but the admission date is required.

We will consider enhancing the explanation of these exceptions in a future TR3.
Submission 12/16/2011
Status Date 3/16/2012
Status F - Final
Primary References
Document 005010X223
Section2