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Data Element Name:  Inpatient Ancillary Revenue Code
Format-Length:  N - 4 Required For:  IP
Effective Date:  1/1/94 Revision Date:  May 1994

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2400 SV201 234 Inpatient Ancillary Revenue Code

Paper Form Locator Code Qualifier
Institutional - UB-04 42 N/A

Definition:

The code which identifies the type of Inpatient ancillary service provided to the patient during the billing period.

Codes and Values:

  1. Must be a valid code in accordance with the UB Ancillary Revenue Codes in Appendix I.

Edit Applications:

  1. If revenue codes 0001 through 0099 are reported, the associated charges must NOT be included in the totals calculated for the Inpatient Ancillary Total Charges or Inpatient Ancillary Total Non-Covered Charges.

  2. If Inpatient Ancillary Revenue Code is entered, the associated Inpatient Ancillary Total Charges and Inpatient Ancillary Total Non-Covered Charges must also be reported.

  3. It is necessary to report at least one UB Accommodation or one Ancillary with each claim.

  4. SPARCS allows a maximum of 200 Ancillaries.
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