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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 5.3
InstitutionalEdit Requirements (ELN 200 - 299)
Revision:C-66, May 5, 2023
| ELEMENT NAME:PROVIDER TAXPAYER NUMBER (1-200) | |||
|---|---|---|---|
| 1ONLY THE FIRST FIVE DIGITSOF THE PROVIDER ZIP CODE ARE USED IN THE MATCH. | |||
| VALIDITYEDITS | |||
| 1-200-01V | MUST BE NUMERIC | ||
| OR (FIRST THREEPOSITIONS MUST BE A VALID STATE/COUNTRY CODE AND LASTSIX POSITIONS MUST BE NUMERIC) | |||
| OR (FIRST THREEPOSITIONS MUST BE A VALID STATE/COUNTRY CODE AND FOURTHPOSITION MUST BE = A AND LASTFIVE POSITIONS MUST BE NUMERIC) | |||
| RelationalEdits | |||
| NO ERROR | IF ADJUSTMENT/DENIAL REASONCODE = | 38 | SERVICES NOT PROVIDED OR AUTHORIZEDBY DESIGNATED (NETWORK) PROVIDERS OR |
| 52 | THE REFERRING/PRESCRIBING/RENDERINGPROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICEBILLED OR | ||
| B7 | THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLETO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE | ||
| THEN DO NOT CHECKPROVIDER FILE | |||
| NO ERRROR | IF ANY OCCURRENCE OF SPECIAL PROCESSINGCODE = | T | MEDICARE/TRICARE DUAL ENTITLEMENT(SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR |
| FG | TFL (FIRST PAYOR-NO TRICAREPROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR | ||
| FS | TFL (SECOND PAYOR) OR | ||
| RS | MEDICARE/TRICARE DUAL ENTITLEMENT(FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITSHAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 | ||
| THEN DO NOT CHECKPROVIDER FILE | |||
| NO ERROR | IF AMOUNT ALLOWED (TOTAL) ≤ZERO | ||
| THEN DO NOT CHECKPROVIDER FILE | |||
| 1-200-02R | IF ANY OCCURRENCE OF OVERRIDECODE = | NC | NON-CERTIFIED PROVIDER |
| THEN THE NON-CERTIFIEDPROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING: INSTITUTIONALPROVIDER TAXPAYER NUMBER AND TYPEOF INSTITUTION AND PROVIDER ZIPCODE1 AND PROVIDERSUB-IDENTIFIER AND ACCEPTANCEAND TERMINATION DATES MUST = ZEROES AND PROVIDERCONTRACT AFFILIATION CODE MUST = 5 (NON-CERTIFIED PROVIDER) | |||
| IF NO OCCURRENCE OF OVERRIDECODE = | NC | NON-CERTIFIED PROVIDER | |
| THEN CERTIFIEDPROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THEFOLLOWING: INSTITUTIONAL PROVIDER TAXPAYERNUMBER AND TYPE OF INSTITUTION AND PROVIDERZIP CODE1 AND PROVIDERSUB-IDENTIFIER | |||
| ELEMENT NAME:PROVIDER SUB-IDENTIFIER (1-205) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-205-01V | MUST BE ALPHA OR NUMERIC--CANNOTBE BLANKS | ||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:SCH DRG CALCULATION (1-208) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-208-01V | MUST BE NUMERIC AND MUST BE≥ ZERO | ||
| RelationalEdits | |||
| 1-208-01R | IF SCH DRG NUMBER IS NOT BLANK | ||
| THEN SCH DRG CALCULATIONMUST BE > ZERO | |||
| ELEMENT NAME:PROVIDER ORGANIZATIONAL NPINUMBER (TYPE 2) (1-215) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-215-01V | MUST BE ALL BLANKS OR 10DIGITS (MUST NOT BE ALL ZEROES) | ||
| 1-215-02V | IF PROVIDER ORGANIZATIONALNPI NUMBER IS ALL DIGITS | ||
| THEN THE CHECKDIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUSTEQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE”CHECK DIGIT ALGORITHM | |||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:PROVIDER ZIP CODE (1-220) | |||
|---|---|---|---|
| 1WHEN FOREIGN COUNTRY CODESARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A. | |||
| VALIDITYEDITS | |||
| 1-220-01V | MUST BE NINE DIGITS OR FIVEDIGITS WITH FOUR BLANKS | ||
| MUST BE A VALID ZIP CODE (BASEDON ADMISSION DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODEFILE OR | |||
| MUST BE A THREE CHARACTER FOREIGNCOUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWEDBY SIX BLANKS | |||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:PROVIDER PARTICIPATION INDICATOR(1-225) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-225-01V | MUST BE A VALID PROVIDER PARTICIPATIONINDICATOR. | ||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:PROVIDER NETWORK STATUS INDICATOR(1-230) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-230-01V | MUST BE ONE OF THE FOLLOWINGVALUES | 1 | NETWORK PROVIDER OR |
| 2 | NON-NETWORK PROVIDER | ||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:TYPE OF INSTITUTION (1-235) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-235-01V | VALUE MUST BE A VALID TYPEOF INSTITUTION CODE. | ||
| RelationalEdits | |||
| 1-235-02R | IF PRICING RATE CODE = | K | HOSPITAL-SPECIFIC PSYCHIATRICPER DIEM RATE OR |
| L | REGION SPECIFIC PSYCHIATRICPER DIEM RATE | ||
| THEN TYPE OF INSTITUTIONMUST = | 22 | PSYCHIATRIC HOSPITAL/UNIT OR | |
| 52 | CHILDREN’S PSYCHIATRIC HOSPITAL/UNIT | ||
| 1-235-03R | IF TYPE OF INSTITUTION = | 70 | HHA |
| AND BEGIN DATEOF CARE ≥ 06/01/2004 | |||
| THEN ONE OCCURRENCEOF REVENUE CODE MUST = | 0023 | HHA PPS | |
| UNLESS AMOUNTALLOWED (TOTAL) = ZERO | |||
| 1-235-04R | IF TYPE OF INSTITUTION = | 91 | SCH |
| AND ADMISSIONDATE ≥ 01/01/2014 | |||
| AND AMOUNT ALLOWED(TOTAL) > 0 | |||
| THEN PRICING RATECODE MUST = | V | MEDICARE REIMBURsem*nT RATE OR | |
| CR | CCR | ||
| ELEMENT NAME:CLAIM FORM TYPE/EMC INDICATOR(1-240) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-240-01V | VALUE MUST BE A VALID CLAIMFORM TYPE/EMC INDICATOR. | ||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:FREQUENCY CODE (1-250) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-250-01V | MUST BE A VALID FREQUENCY CODE | ||
| 1-250-02V | IF DRG NUMBER IS NOT BLANK | ||
| AND TYPE OF SUBMISSION= | A | ADJUSTMENT TO TED RECORD DATA OR | |
| C | COMPLETE CANCELLATION TO TEDRECORD DATA OR | ||
| I | INITIAL TED RECORD SUBMISSION OR | ||
| O | ZERO PAYMENT TED RECORD DUETO 100% OHI OR | ||
| R | RESUBMISSION OF AN INITIALTED RECORD | ||
| AND FREQUENCYCODE = | 2 | INTERIM-INITIAL OR | |
| 3 | INTERIM-INTERIM OR | ||
| 4 | INTERIM-FINAL | ||
| THEN THE FREQUENCYCODE SUBMISSION MUST FOLLOW THE DIRECTIONS IN THE TABLE BELOW | |||
| FREQUENCYCODE | PREVIOUS TED RECORD FREQUENCYCODE | ||
| 2 | = 2 OR NO PREVIOUSTED RECORD | ||
| 3 | = 2 OR 3 (PREVIOUSTED RECORD MUST EXIST) | ||
| 4 | = 2, 3, OR 4 (PREVIOUSTED RECORD MUST EXIST) | ||
| RelationalEdits | |||
| 1-250-01R | IF PATIENT STATUS = | 30 | STILL A PATIENT |
| AND AMOUNT ALLOWED(TOTAL) ≠ ZERO | |||
| OR OCCURRENCEOF SPECIAL PROCESSING CODE = | T | MEDICARE/TRICARE DUAL ENTITLEMENT(SECOND PAYER) OR | |
| FS | TFL (SECOND PAYER) | ||
| THEN FREQUENCYCODE MUST = | 2 | INTERIM-INITIAL OR | |
| 3 | INTERIM-INTERIM | ||
| UNLESS TYPE OFINSTITUTION = | 70 | HHA | |
| THEN FREQUENCYCODE MUST = | 2 | INTERIM-INITIAL OR | |
| 3 | INTERIM-INTERIM OR | ||
| 7 | REPLACEMENT OF PRIOR CLAIM OR | ||
| 8 | VOID/CANCEL OF PRIOR CLAIM OR | ||
| 9 | FINAL CLAIM FOR HHA EPISODE | ||
| 1-250-02R | IF PATIENT STATUS = | 01 | DISCHARGED OR |
| 02 | TRANSFERRED OR | ||
| 20 | EXPIRED | ||
| THEN FREQUENCYCODE MUST = | NON-PAYMENT/ZERO CLAIM OR | ||
| 1 | ADMIT THROUGH DISCHARGE OR | ||
| 4 | INTERIM-FINAL OR | ||
| 5 | LATE CHARGE(S) OR | ||
| 7 | REPLACEMENT OF PRIOR CLAIM OR | ||
| 8 | VOID/CANCELLATION OF PRIORCLAIM OR | ||
| 9 | FINAL CLAIM FOR HHA PPS EPISODE OR | ||
| A | ADMISSION/ELECTIONNOTICE OR | ||
| D | CANCELLATION OF ADMISSION/ELECTIONNOTICE | ||
| 1-250-03R | IF PRICING RATE CODE = | H | TRICARE DRG REIMBURsem*nT WITHSHORT STAY OUTLIER |
| THEN FREQUENCYCODE MUST = | 1 | ADMIT THROUGH DISCHARGE | |
| 1-250-05R | IF FREQUENCY CODE = | 5 | LATE CHARGE(S) |
| THEN AMOUNT ALLOWED(TOTAL) MUST = ZERO FOR ALL OCCURRENCE/LINE ITEMS | |||
| ELEMENT NAME:TYPE OF ADMISSION (1-255) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-255-01V | VALUE MUST BE A VALID TYPEOF ADMISSION CODE. | ||
| UNLESS REVENUECODE ON ANY OF THE OCCURRENCES/LINE ITEMS = | 0023 | HHA | |
| OR TYPE OF INSTITUTION= | 70 | HHA | |
| OR AMOUNT ALLOWED(TOTAL) = ZERO | |||
| OR ANY OCCURRENCEOF SPECIAL PROCESSING CODE = | 11 | HOSPICE | |
| THEN VALUE MUSTBE BLANK OR A VALID TYPE OF ADMISSIONS CODE | |||
| RelationalEdits | |||
| 1-255-03R | IF TYPE OF ADMISSION = | 4 | NEWBORN |
| AND ICD VERSION= | 9 | ICD-9 | |
| AND POINT OF ORIGIN= | 1 | NORMAL DELIVERY OR | |
| 2 | PREMATURE DELIVERY OR | ||
| 4 | EXTRAMURAL BIRTH OR | ||
| 5 | BORN INSIDE THIS HOSPITAL OR | ||
| 6 | BORN OUTSIDE THIS HOSPITAL | ||
| THEN PRINCIPALDIAGNOSIS/POA INDICATOR (POSITIONS 1-7) MUST BE BETWEEN V30.0 ANDV39.2. | |||
| 1-255-04R | IF TYPE OF ADMISSION = | 4 | NEWBORN |
| AND ICD VERSION= | ICD-10 | ||
| THEN POINT OFORIGIN = | 5 | BORN INSIDE THIS HOSPITAL OR | |
| 6 | BORN OUTSIDE THIS HOSPITAL | ||
| AND PRINCIPALDIAGNOSIS/POA INDICATOR (POSITiONS 1-7) MUST BE BETWEEN Z38.00 ANDZ38.8. | |||
| ELEMENT NAME:POINT OF ORIGIN (1-260) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-260-01V | VALUE MUST BE A VALID POINTOF ORIGIN. | ||
| RelationalEdits | |||
| 1-260-01R | IF TYPE OF ADMISSION = | 4 | NEWBORN |
| THEN POINT OFORIGIN MUST = | 1 | NORMAL DELIVERY (DISCONTINUED10/01/2007) OR | |
| 2 | PREMATURE DELIVERY (DISCONTINUED10/01/2007) OR | ||
| 3 | SICK BABY (DISCONTINUED 10/01/2007) OR | ||
| 4 | EXTRAMURAL BIRTH OR | ||
| 5 | BORN INSIDE THIS HOSPITAL OR | ||
| 6 | BORN OUTSIDE THIS HOSPITAL | ||
| ELEMENT NAME:ADMISSION DATE (1-265) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-265-01V | MUST BE A VALID GREGORIAN DATEAND CANNOT BE > DHA CURRENT SYSTEM DATE. | ||
| RelationalEdits | |||
| 1-265-01R | ADMISSION DATE MUST BE ≤ DATETED RECORD PROCESSED TO COMPLETION (PTC) | ||
| 1-265-02R | ADMISSION DATE MUST BE ≤ ENDDATE OF CARE | ||
| 1-265-03R | IF FREQUENCY CODE = | 1 | ADMIT THROUGH DISCHARGE |
| THEN ADMISSIONDATE MUST BE ≥ BEGIN DATE OF CARE | |||
| ELSE IF FREQUENCYCODE = | 2 | INTERIM-INITIAL | |
| AND TYPE OF INSTITUTION≠ | 70 | HHA | |
| THEN ADMISSIONDATE MUST BE ≥ BEGIN DATE OF CARE | |||
| 1-265-04R | IF TYPE OF SUBMISSION = | A | ADJUSTMENT OR |
| B | ADJUSTMENT OF NON-TED RECORD(HCSR) DATA OR | ||
| C | COMPLETE CANCELLATION OR | ||
| E | COMPLETE CANCELLATION OF NON-TEDRECORD (HCSR) DATA | ||
| THEN ADMISSIONDATE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED | |||
| ELEMENT NAME:PATIENT STATUS (1-270) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-270-01V | VALUE MUST BE A VALID PATIENTSTATUS CODE. | ||
| RelationalEdits | |||
| 1-270-01R | IF FREQUENCY CODE = | 2 | INTERIM-INITIAL OR |
| 3 | INTERIM-INTERIM | ||
| THEN PATIENT STATUSMUST = | 30 | STILL A PATIENT | |
| 1-270-03R | IF PRICING RATE CODE = | H | TRICARE DRG REIMBURsem*nT WITHSHORT STAY OUTLIER OR |
| J | TRICARE DRG REIMBURsem*nT WITHNO OUTLIER | ||
| THEN PATIENT STATUSMUST ≠ | 30 | STILL A PATIENT | |
| ELEMENT NAME:BEGIN DATE OF CARE (1-275) | |||
|---|---|---|---|
| 1“AUTHORIZED” RECORD ON PROVIDERFILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDERSUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDERACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE APROVIDER MATCH HAS BEEN OBTAINED (1-200-02R). | |||
| VALIDITYEDITS | |||
| 1-275-01V | MUST BE A VALID GREGORIAN DATEAND CANNOT BE > DHA CURRENT SYSTEM DATE. | ||
| 1-275-02V | BEGIN DATE OF CARE CANNOT BE< 01/01/1990. | ||
| 1-275-03V | BEGIN DATE OF CARE MUST BE≤ END DATE OF CARE. | ||
| RelationalEdits | |||
| 1-275-02R | BEGIN DATE OF CARE MUST BE≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC) | ||
| 1-275-03R | BEGIN DATE OF CARE MUST BE≥ PERSON BIRTH CALENDAR DATE (PATIENT) | ||
| 1-275-05R | IF TYPE OF SUBMISSION = | A | ADJUSTMENT OR |
| B | ADJUSTMENT TO NON-TED RECORD(HCSR) DATA OR | ||
| C | COMPLETE CANCELLATION OR | ||
| E | COMPLETE CANCELLATION OF NON-TEDRECORD (HCSR) DATA | ||
| THEN BEGIN DATEOF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED | |||
| 1-275-06R | PROVIDER MUST BE “AUTHORIZED”1 ONPROVIDER FILE FOR THIS BEGIN DATE OF CARE | ||
| UNLESS AMOUNTALLOWED (TOTAL) ≤ ZERO | |||
| OR ADJUSTMENT/DENIALREASON CODE = | 38 | SERVICES NOT PROVIDED OR AUTHORIZEDBY DESIGNATED (NETWORK) PROVIDERS OR | |
| 52 | THE REFERRING/PRESCRIBING/RENDERINGPROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICEBILLED OR | ||
| B7 | THIS PROVIDER WAS NOT CERTIFIEDELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE | ||
| OR ANY OCCURRENCEOF SPECIAL PROCESSING CODE = | T | MEDICARE/TRICARE DUAL ENTITLEMENT(SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR | |
| FG | TFL (FIRST PAYOR-NO TRICAREPROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR | ||
| FS | TFL (SECOND PAYOR) OR | ||
| RS | MEDICARE/TRICARE DUAL ENTITLEMENT(FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITSHAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 | ||
| THEN DO NOT CHECKPROVIDER FILE | |||
| ELEMENT NAME:END DATE OF CARE (1-280) | |||
|---|---|---|---|
| 1“AUTHORIZED” RECORD ON PROVIDERFILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDERSUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDERACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE APROVIDER MATCH HAS BEEN OBTAINED (1-200-02R). | |||
| VALIDITYEDITS | |||
| 1-280-01V | MUST BE A VALID GREGORIAN DATEAND CANNOT BE > DHA CURRENT SYSTEM DATE. | ||
| 1-280-02V | END DATE OF CARE CANNOT BE< 01/01/1990. | ||
| 1-280-03V | END DATE OF CARE MUST BE ≥BEGIN DATE OF CARE. | ||
| RelationalEdits | |||
| 1-280-01R | END DATE OF CARE MUST BE ≤DATE TED RECORD PROCESSED TO COMPLETION (PTC) | ||
| 1-280-02R | IF TYPE OF SUBMISSION = | A | ADJUSTMENT OR |
| B | ADJUSTMENT TO NON-TED RECORD(HCSR) DATA OR | ||
| C | COMPLETE CANCELLATION OR | ||
| E | COMPLETE CANCELLATION OF NON-TEDRECORD (HCSR) DATA | ||
| THEN END DATEOF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED | |||
| 1-280-03R | PROVIDER MUST BE “AUTHORIZED”1 ONPROVIDER FILE FOR THIS END DATE OF CARE | ||
| UNLESS AMOUNTALLOWED (TOTAL) ≤ ZERO | |||
| OR ADJUSTMENT/DENIALREASON CODE = | 38 | SERVICES NOT PROVIDED OR AUTHORIZEDBY DESIGNATED (NETWORK) PROVIDERS OR | |
| 52 | THE REFERRING/PRESCRIBING/RENDERINGPROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICEBILLED OR | ||
| B7 | THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLETO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE | ||
| OR ANY OCCURRENCEOF SPECIAL PROCESSING CODE = | T | MEDICARE/TRICARE DUAL ENTITLEMENT(SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR | |
| FG | TFL (FIRST PAYOR-NO TRICAREPROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR | ||
| FS | TFL (SECOND PAYOR) OR | ||
| RS | MEDICARE/TRICARE DUAL ENTITLEMENT(FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITSHAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 | ||
| THEN DO NOT CHECKPROVIDER FILE | |||
| ELEMENT NAME:ADMINISTRATIVE CLIN (1-283) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-283-01V | MUST BE BLANKS. | ||
| RelationalEdits | |||
| REFER TO Section 8.1. | |||
| ELEMENT NAME:COVERED DAYS (1-285) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-285-01V | MUST BE NUMERIC. | ||
| 1-285-02V | IF ANY OCCURRENCE OF SPECIAL PROCESSINGCODE = | 11 | HOSPICE |
| OR TYPE OF SUBMISSION= | B | ADJUSTMENT TO NON-TED RECORD(HCSR) DATA OR | |
| E | COMPLETE CANCELLATION OF NON-TEDRECORD (HCSR) DATA | ||
| OR TYPE OF INSTITUTION= | 78 | NON-HOSPITAL BASED HOSPICE OR | |
| 79 | HOSPITAL BASED HOSPICE | ||
| THEN BYPASS THISEDIT | |||
| ELSE IF AMOUNTALLOWED (TOTAL) ≤ ZERO | |||
| OR TYPE OF INSTITUTION= | 70 | HHA | |
| OR THE SUM OFUNITS OF SERVICE BY REVENUE CODE FOR REVENUE CODES THAT INDICATETHAT A ROOM WAS USED (010X-021X, OR 0724, OR 100X)= ZERO | |||
| THEN COVERED DAYSMUST = ZERO | |||
| ELSE IF FREQUENCYCODE = | 3 | INTERIM - INTERIM TED RECORD | |
| OR BEGIN DATEOF CARE = END DATE OF CARE | |||
| THEN COVERDAYSMUST BE ≤ END DATE OF CARE - BEGIN DATE OF CARE + 1 | |||
| ELSE IF ADMISSIONDATE = END DATE OF CARE | |||
| THEN COVERED DAYSMUST BE ≤ 1 | |||
| ELSE IF FREQUENCYCODE = | 1 | ADMIT THRU DISCHARGE | |
| THEN COVERED DAYSMUST BE ≤ END DATE OF CARE - ADMISSION DATE | |||
| ELSE IF FREQUENCYCODE = | 2 | INTERIM - INITIAL TED RECORD | |
| THEN COVERED DAYSMUST BE ≤ END DATE OF CARE - ADMISSION DATE + 1 | |||
| ELSE COVERED DAYSMUST BE ≤ END DATE OF CARE - BEGIN DATE OF CARE | |||
| RelationalEdits | |||
| NONE | |||
| ELEMENT NAME:DRG NUMBER (1-290) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-290-01V | MUST BE A VALID DRG NUMBER OR BLANKFILLED. | ||
| RelationalEdits | |||
| 1-290-01R | IF PRICING RATE CODE = | b | NO SPECIAL RATE CODE OR |
| K | HOSPITAL-SPECIFIC PSYCHIATRICPER DIEM RATE OR | ||
| L | REGIONAL-SPECIFIC PSYCHIATRICPER DIEM RATE OR | ||
| P | PER DIEM RATE AGREEMENT OR | ||
| CA | CAH REIMBURsem*nT OR | ||
| CI | CAH IRF REIMBURsem*nT OR | ||
| CP | CAH PSYCHIATRIC HOSPITAL PERDIEM RATE OR | ||
| LT | STANDARD LTCH REIMBURsem*nT OR | ||
| RF | TRICARE IRF REIMBURsem*nT OR | ||
| SN | SITE-NEUTRAL LTCH REIMBURsem*nT | ||
| THEN DRG NUMBERMUST = BLANK | |||
| 1-290-02R | IF ANY OCCURRENCE OF OVERRIDECODE = | Y | NEWBORN IN MOTHER’S ROOM WITHOUTNURSERY CHARGES |
| THEN DRG NUMBERMUST = BLANK | |||
| 1-290-31R | IF PRICING RATE CODE = | H | TRICARE/CHAMPUS DRG REIMBURsem*nTWITH SHORT STAY OUTLIER OR |
| I | TRICARE/CHAMPUS DRG REIMBURsem*nTWITH COST OUTLIER OR | ||
| J | TRICARE/CHAMPUS DRG REIMBURsem*nTWITH NO OUTLIER OR | ||
| S | HVBP ADJUSTMENT FACTOR OR | ||
| CV | COVID-19 ADJUSTMENT FACTOR OR | ||
| DD | DISCOUNTED DRG | ||
| THEN DRG MUSTNOT BE BLANK | |||
| AND IF END DATEOF CARE < 10/01/2014 | |||
| THEN DATE OF ADMISSIONMUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE | |||
| ELSE END DATEOF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATIONDATE | |||
| ELEMENT NAME:HIPPS CODE (1-292) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-292-01V | MUST BE VALID HIPPS CODES REFERTO Section 2.5 AND REFERTO CMS WEBSITE AT HTTPS://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FOR-SERVICE-PAYMENT/PROSPMEDICAREFEESVCPMTGEN/HIPPSCODES. | ||
| RelationalEdits | |||
| 1-292-01R | IF HIPPS CODE = BLANK | ||
| THEN NO OCCURRENCEOF REVENUE CODE CAN = | 0022 | SNF OR | |
| 0023 | HHA PPS | ||
| ELEMENT NAME:ICD VERSION (1-293) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-293-01V | VALUE MUST BE A VALID ICD VERSION. | ||
| RelationalEdits | |||
| NO ERROR | IF AMOUNT ALLOWED (TOTAL) =ZERO | ||
| 1-293-02R | IF END DATE OF CARE ≥ 10/01/2015 | ||
| THEN ICD VERSIONMUST BE | ICD-10 | ||
| 1-293-04R | IF END DATE OF CARE < 10/01/2015 | ||
| THEN ICD VERSIONMUST BE | 9 | ICD-9 | |
| ELEMENT NAME:ADMISSION DIAGNOSIS (1-295) | |||
|---|---|---|---|
| VALIDITYEDITS | |||
| 1-295-01V | IF FILING DATEIS PRIOR TO 10/01/2004 | ||
| THEN VALUE MUSTBE VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 | |||
| UNLESS REVENUECODE ON ANY OF THE OCCURRENCES/LINE ITEMS = | 0023 | HHA | |
| THEN VALUE MUSTBE BLANK OR A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 | |||
| 1-295-02V | IF FILING DATEON OR AFTER 10/01/2004 | ||
| THEN VALUE MUSTBE VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM)AND V00-Y99.9 (ICD-10-CM). | |||
| AND BEGIN DATEOF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVEDATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICDDIAGNOSIS REFERENCE TABLE | |||
| OR END DATE OFCARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATEAND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSISREFERENCE TABLE | |||
| UNLESS REVENUECODE ON ANY OF THE OCCURRENCES/LINE ITEMS = | 0023 | HHA | |
| OR TYPE OF INSTITUTION= | 70 | HHA | |
| OR AMOUNT ALLOWED(TOTAL) = ZERO | |||
| OR ANY OCCURRENCEOF SPECIAL PROCESSING CODE = | 11 | HOSPICE | |
| THEN VALUE MUSTBE BLANK OR VALUE MUST BE A VALID ICD DIAGNOSIS CODE,EXCLUDING E000.0-E999.1 (ICD-9-CM) AND V00-Y99.9 (ICD-10-CM) | |||
| AND BEGIN DATEOF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVEDATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICDDIAGNOSIS REFERENCE TABLE | |||
| OR END DATE OFCARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATEAND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSISREFERENCE TABLE | |||
| RelationalEdits | |||
| NONE | |||
- END -
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