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Back  RFI # 1539: 837I/UB Manual Relationship

Formal vs. Informal Help Informal Formal

Submitter

Description

There are several situational rules and notes throughout the TR3’s predicated upon whether the claim is an inpatient and outpatient claim. Entities have come with varying interpretations as to how the determination of whether a claim is considered inpatient or outpatient. Is there a standard definition or guidance to help determine the appropriate application of the situational rules and TR3 Notes?

Response

This question is explicitly addressed in Section 1.12.6 of the TR3. It reads as follows: “The determination of what constitutes an Inpatient or Outpatient claim is defined in the external code set developed by the National Uniform Billing Committee in its Data Specifications Manual (UB Manual) beginning with UB-04. General guidelines are contained in the Type of Bill section of the UB Manual. Inpatient and Outpatient claims are distinguished by Type of Bill and other factors. Certain bill types are designated for inpatient use while others are designated for outpatient reporting. Exceptions to the general rules are documented with reference to the specific data elements affected.”

In effect, this means that implementers must use the UB Manual to interpret the situational rules in the TR3. Two points in particular should be understood:

1. The inpatient and outpatient classifications are not absolute for a claim. As explained in the UB manual, a single claim can be classified as inpatient when evaluating the particular situational rule for one data element, but will be considered outpatient when evaluating the situational rule for a different data element.
2. The classifications are not static. The derivation rules for inpatient and outpatient can change over time. This is why the rules are not explicitly embedded in the TR3 which does not change. The TR3 refers to the UB manual which is updated more frequently.
Submission 3/9/2012
Status Date 4/5/2012
Status F - Final
Primary References
Document 005010X223
SectionGuide