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Data Element Name:  Outpatient Ancillary Revenue Code
Format-Length:  N - 4 Required For:  AS, ED
Effective Date:  1/1/94 Revision Date:  May 2008

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2400 SV201 234 Outpatient Ancillary Revenue Code

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

Definition:

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

It is necessary to report at least one Outpatient Ancillary with each claim. There must be at least one total and non-covered charge for all Outpatient ancillary codes reported except for the 036x, 045x, 048x, 049x, 051x, 052x, 075x, 076x or 079x categories. For these exceptions the total and non-covered charges may be rolled up to the first occurrence of the revenue code category with zero reported for subsequent occurrences on each claim.

Emergency Department Only:
It is necessary to report Ancillary Code 045x with each emergency department claim.

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 Outpatient Ancillary Total Charges or Outpatient Ancillary Total Non-Covered Charges.

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

  3. SPARCS allows a maximum of 200 Ancillaries.
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