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Data Element Name:  Outpatient Ancillary Total Charges
Format-Length:  N - 10 Required For:  AS, ED
Effective Date:  1/1/94 Revision Date:  May 2008

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element


Version 4050R 2400 SV203 782 Outpatient Ancillary Total Charges

Paper Form Locator Code Qualifier
Institutional - UB-04 47 N/A


The charges for Outpatient ancillary services incurred by 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.

Codes and Values:

  1. The amount must be entered in dollars and cents.

    Example:  $125.24 would be entered as: 125.24

  2. If this field is not applicable it must be blank.

Edit Applications:

  1. If Outpatient Ancillary Revenue Codes 0001 through 0099 are reported, any associated charges are NOT included in Outpatient Ancillary Total Charges.

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

  3. Outpatient Ancillary Total Charges must be equal to or greater than the corresponding Outpatient Ancillary Total Non-Covered Charges.

  4. SPARCS allows a maximum of 200 Ancillaries.
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