Information Bulletin, December 2007


ASC X12-837 Format Required January 1, 2008
CPT4/HCPCS Code required on Ambulatory Surgery Claims Effective January 1, 2008
SPARCS Edit Updates
Happy Holidays

ASC X12-837 Format Required January 1, 2008

Effective January 1, 2008, SPARCS will no longer accept Inpatient, Ambulatory Surgery and Emergency Department data submissions in UDS Version 5/6 format. All data submissions after December 31, 2007 MUST be transmitted to SPARCS through the NYSDOH Health Provider Network (HPN) in the ASC X12-837 electronic format.

If you are having trouble transitioning to the new format by this deadline, there are resources available to assist you. The SPARCS-837 PC application can help your facility transition to the ASC X12-837 format. The application allows data, in the current UDS Version 5/6 format, to be imported and then exported in the ASC X12-837 format for submission to SPARCS. This application is available for download from the Health Provider Network (HPN):   https://commerce.health.state.ny.us/hpn/ctrldocs/subsparc/request837.html.

If you have any questions, or would like help using the SPARCS-837 PC application, please contact the SPARCS Administrative Unit immediately at (518) 473-8144 or at sparcs@health.state.ny.us.

CPT4/HCPCS Code required on Ambulatory Surgery Claims Effective January 1, 2008

In the November 26 SPARCS Bulletin we announced that we are no longer collecting/editing for Principal Procedure (ICD-9-CM) Code reporting on Outpatient discharges. However, we neglected to state that at least one CPT4/HCPCS code will be required for Ambulatory Surgery Claims effective January 1, 2008. To clarify, if an outpatient claim is defined as Ambulatory Surgery (no ED revenue code reported), then the procedure time, operating physician and at least one CPT4/HCPCS code are required.

SPARCS Edit Updates

To be consistent with national codes, as defined by the National Uniform Bill Committee (NUBC) and the ASC X12-837 Standards Committee, SPARCS has made the following changes. Please see the SPARCS Input Data Dictionary (http://nyhealth.gov/statistics/sparcs/sysdoc/elements_837/index.htm) for complete descriptions.

  • Present on Admission Indicator
    Two new codes will be added effective 12/1/2007 for reporting with the other diagnosis data elements (not the principal diagnosis data element) for all discharges:

    • New Codes
      1 or blank= Exempt from POA Reporting for selected ICD-9-CM codes

      The list of exempt codes is available on the ICD-9-CM Guidelines manual at:   www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.

      Please note that the placement of this data element is dependent upon the version of the X12-837 format that you are using. If you are using the 4010/4010A1 version (as prescribed by CMS for Medicare claims), this data element is reported in the K3 segment of the 2300 loop, data element K301. If you are using the 4050 version (as preferred by SPARCS), then you must report this data element in the segment HI segment of 2300 loop, data element 1073. Currently, SPARCS will be editing and accepting the POA indicator in either version of X12-837.

  • Source of Payment
    The following new codes have been added effective 10/1/2007:
    • 11= Other Non-Federal Program
      14= Exclusive Provider Organization (EPO)
      15= Indemnity Insurance

  • Patient Discharge Status
    Effective 1/1/2008 the following changes will occur:
    • New Code
      70= Discharged/transferred to another type of health care institution not defined elsewhere in this code list.

    • Code Refined
      05= (redefined -effective 10/1/07) Discharged/transferred to a designated Cancer Center or Children's hospital

    • Codes Deleted
      90, 91

  • Source of Admission now called Point of Origin
    Effective 10/1/2007 the following code changes were made, see Table I below for details on code changes.
    • New Codes
      E= Transfer from Ambulatory Surgery
      • Inpatient:  The patient was admitted to this facility as a transfer from an ambulatory surgery center.
        Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services from an ambulatory surgery center.

      F= Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in a Hospice Program
      • Inpatient:  The patient was admitted to this facility as a transfer from a hospice.
        Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services from a hospice.

    • New codes for Newborn
      5=Born Inside this Hospital
      6=Born Outside of this Hospital

    • Discontinued Codes for Newborn
      1,2,3,4

TABLE 1

Updated Codes for Source of Admission now called Point of Origin

The National Uniform Billing Committee's (NUBC) updated and revised code list is now designed to focus on patient's place or point of origin rather than the source of a physician order or referral. Following is an overview of the changes.

Code Old Definition New Definition Effective 10/1/2007 Changes
Source of Referral Point of Origin
1 Physician Referral
The patient was admitted to this facility upon the recommendation of his or her personal physician.
Non-Health Care Facility Point of Origin
Inpatient:  The patient was admitted to this facility upon an order of a physician.
Outpatient:  The patient presents to this facility with an order from a physician for services or seeks scheduled services for which an order is not required (e.g. mammography). Includes non-emergent self-referrals.
Facility Part of Definition Change.
2 Clinic Referral
The patient was admitted to this facility upon recommendation of the facility's clinic physician.
Clinic
Inpatient:  The patient was referred to this facility as a transfer from a freestanding or non-freestanding clinic.
Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services.
Definition Improved.
3 HMO Referral
The patient was admitted to this facility upon recommendation of a health maintenance organization physician.
Reserved for assignment by the NUBC. Discontinued effective 10/1/2007.
4 Transfer from a Hospital (Different Facility)
Inpatient:  The patient was admitted to this facility as a hospital transfer from a different acute care facility where he or she was an inpatient.
Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) a different acute care facility.
Transfer from a Hospital (Different Facility)
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.
Value remains the same. Definition Improved.
5 Transfer from a SNF
The patient was admitted to this facility as a transfer from a skilled nursing facility where he or she was an inpatient.
Transfer from a SNF or ICF
Inpatient:  The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.
Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services for a SNF or ICF where he or she was a resident.
NOTE:  NYS no longer uses ICF determination.
Value remains the same. Definition Improved.
6 Transfer from Another Health Care Facility
The patient was admitted to this facility as a transfer from a health care facility other than an acute care facility or a skilled nursing facility. This includes transfers from nursing homes and long term care facilities and skilled nursing facility patients that are at a non-skilled level of care.
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 was referred to this facility for services by (a physician of) another health care facility not defined elsewhere in this code list where he or she was an inpatient or outpatient.
Value remains the same. Definition Improved.
7 Emergency Room
The patient was admitted to this facility upon recommendation of the facility's emergency room physician.
Emergency Room
Inpatient:  The patient was admitted to this facility after receiving services in this facility's emergency department.
Outpatient:  The patient received unscheduled services in this facility's emergency department and discharged without an inpatient admission. Includes self-referrals in emergency situations that require immediate medical attention.
Excludes:  Patients who came to the emergency room from another health care facility.
Value remains the same. Definition Improved-note added.
8 Court/Law Enforcement
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.
Court/Law Enforcement
Outpatient:  The patient was referred 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.
Outpatient definition added.
9 Information Not Available
The means by which the patient was admitted to this hospital was not known.
Information Not Available
The means by which the patient was admitted to this hospital was not known.
Value remains the same.
A Transfer from a Rural Primary Care Hospital
The patient was admitted to this facility as a transfer from a Rural Primary Care Hospital (RPCH) where he or she was an inpatient.
Discontinued effective 10/1/2007.
D Transfer from Hospital Inpatient in the Same Facility Resulting in a Separate Claim to the Payer
The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.
Transfer from One Distinct Unit of the Hospital to another Distinct Unit of the Same 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.
Title Change. Outpatient definition added.
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 was referred to this facility for outpatient or referenced diagnostic services from an ambulatory surgery center.
New
F Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in a Hospice Program
Inpatient:  The patient was admitted to this facility as a transfer from a hospice.
Outpatient:  The patient was referred to this facility for outpatient or referenced diagnostic services from a hospice.
New

If the Type of Admission is a Newborn, "4", the following coding scheme must be used for Source of Admission now called Point of Origin:

CODE STRUCTURE FOR NEWBORN

Code

Old Definition
New Definition Effective 10/1/2007
Changes
Source of Referral Point of Origin
1 Normal Delivery
A baby delivered without complications.
Discontinued effective 10/1/07.
2 Premature Delivery
A baby delivered with time and/or weight factors qualifying it for premature status.
Discontinued effective 10/1/07.
3 Sick Baby
A baby delivered with medical complications other than those relating to premature status.
Discontinued effective 10/1/07.
4 Extramural Birth
A newborn born in a non-sterile environment.
Discontinued effective 10/1/07.
5 Born Inside of this Hospital
A baby born inside of this Hospital.
New
6 Born Outside of this Hospital
A baby born outside of this Hospital.
New


Happy Holidays

The entire SPARCS staff would like to wish everyone a happy and healthy holiday season. The past year has brought many challenges to all of us as we transition to the new X12-837 file format. We want to assure you that we are committed to helping you make this transition.