X12-837 Input Data Element Table of Contents (Version 4050)

Additional mapping guidelines for HEADER and TRAILER information are available in the Inpatient and Outpatient 837 Addenda.

Select Data Element Name, Number for definitions, codes and values, and edit applications.
AS-Ambulatory Surgery, ED-Emergency Department and IP-Inpatient

NOTE:  Bolded and UPPER CASE are IDENTIFYING DATA ELEMENTS
See Data Protection Review Board (DPRB) or Appendix Z for details.

Segments Loops Names Required For
ISA HEADER Test/Production Indicator AS, ED, IP
BHT HEADER File Sequence and Serial Number AS, ED, IP
BHT HEADER Processing Date AS, ED, IP
NM1 1000A Submitter Name AS, ED, IP
NM1 1000A SPARCS Collector Code AS, ED, IP
NM1 2010AA Provider Identification Number AS, ED, IP
REF 2010AA SPARCS Identification Number AS, ED, IP
SBR 2000B, 2320 Claim Filing Indicator Code / Source of Payment Code AS, ED, IP
NM1 2010BA, 2010CA, 2330A POLICY NUMBER IP
N3 2010BA, 2010CA PATIENT RESIDENCE ADDRESS - ADDRESS LINE 1 AS, ED, IP
N3 2010BA, 2010CA PATIENT RESIDENCE ADDRESS - ADDRESS LINE 2 AS, ED, IP
N4 2010BA, 2010CA Patient City AS, ED, IP
N4 2010BA, 2010CA Patient State AS, ED, IP
N4 2010BA, 2010CA Patient Postal Service Zip Code and EXTENSION CODE AS, ED, IP
N4 2010BA, 2010CA Patient County Code AS, ED, IP
DMG 2010BA, 2010CA PATIENT BIRTH DATE AS, ED, IP
DMG 2010BA, 2010CA Patient Sex AS, ED, IP
DMG 2010BA, 2010CA Patient Race AS, ED, IP
DMG 2010BA, 2010CA Patient Ethnicity AS, ED, IP
REF 2010BA, 2010CA UNIQUE PERSONAL IDENTIFIER AS, ED, IP
NM1, REF 2010BC, 2330B Payer Identification Number AS, ED, IP
CLM 2300 PATIENT CONTROL NUMBER AS, ED, IP
CLM 2300 Total Charges AS, ED, IP
CLM 2300 Type of Bill AS, ED, IP
DTP 2300 Discharge Hour AS, ED, IP
DTP 2300 STATEMENT COVERS PERIOD - FROM DATE AS, ED, IP
DTP 2300 STATEMENT COVERS PERIOD - THRU DATE AS, ED, IP
DTP 2300 ADMISSION DATE/START OF CARE AS, ED, IP
DTP 2300 Admission Hour/Emergency Visit Hour AS, ED, IP
CL1 2300 Type of Admission IP
CL1 2300 Point of Origin / Source of Admission IP
CL1 2300 New York State Patient Status or Disposition AS, ED, IP
REF 2300 MEDICAL RECORD NUMBER AS, ED, IP
REF 2300 MOTHER'S MEDICAL RECORD NUMBER FOR NEWBORN CHILD IP
NTE 2300 Expected Principal Reimbursement AS, IP
NTE 2300 Expected Reimbursement Other 1 IP
NTE 2300 Expected Reimbursement Other 2 IP
NTE 2300 Method of Anesthesia Used AS, IP
NTE 2300 Exempt Unit Indicator IP
NTE 2300 Heart Rate on Arrival ED, IP
NTE 2300 Systolic Blood Pressure on Arrival ED, IP
NTE 2300 Diastolic Blood Pressure on Arrival ED, IP
NTE 2300 Procedure Time AS
NTE 2300 Source of Payment Typology I AS, ED, IP
NTE 2300 Source of Payment Typology II AS, ED, IP
NTE 2300 Source of Payment Typology III AS, ED, IP
HI 2300 Principal/Primary Diagnosis Code AS, ED, IP
HI 2300 Admitting Diagnosis Code IP
HI 2300 Patient Reason For Visit Code AS, ED
HI 2300 External Cause-of-Injury Code AS, ED, IP
HI 2300 Place-of-Injury Code AS, ED, IP
HI 2300 Other Diagnosis Code 1-14 AS, ED, IP
HI 2300 Present on Admission Indicator IP
HI 2300 Principal Procedure Code IP
HI 2300 PRINCIPAL PROCEDURE DATE IP
HI 2300 Other Procedure Code 1-14 IP
HI 2300 OTHER PROCEDURE DATE 1-14 IP
HI 2300 OCCURRENCE SPAN INFORMATION - ALC AND LOA DATES IP
HI 2300 Occurrence Information - ACCIDENT RELATED Codes and DATES AS, ED, IP
HI 2300 Value Information Group Definition
HI 2300 Workers' Compensation/No Fault Indicator IP
HI 2300 Surplus, Catastrophic, or Recurring Monthly Income Code and Amount IP
HI 2300 Blood Furnished Code and Amount IP
HI 2300 Accident Hour AS, ED
HI 2300 NEONATE BIRTH WEIGHT IP
HI 2300 Condition Information Group Definition
HI 2300 Homeless Patients AS, ED, IP
HI 2300 Non-US Resident Patients IP
HI 2300 Special Program (PHC) IP
HI 2300 Special Program (SFP) IP
HI 2300 Special Program (FP) IP
HI 2300 Special Program (DIS) IP
QTY 2300 Covered Days IP
QTY 2300 Non-Covered Days IP
REF 2310A ATTENDING/EMERGENCY DEPT PHYSICIAN 1 STATE LICENSE NUMBER ED, IP
REF 2310B OPERATING/EMERGENCY DEPARTMENT PHYSICIAN 2 STATE LICENSE NUMBER AS, ED, IP
REF 2310C OTHER/EMERGENCY DEPARTMENT PHYSICIAN 3 STATE LICENSE NUMBER ED, IP
SV2 2400 UB Accommodation Code IP
SV2 2400 Accommodations Total Charges IP
SV2 2400 Accommodations Days IP
SV2 2400 Accommodations Rate IP
SV2 2400 Accommodations Total Non-Covered Charges IP
SV2 2400 Inpatient Ancillary Revenue Code IP
SV2 2400 Inpatient Ancillary Total Charges IP
SV2 2400 Inpatient Ancillary Total Non-Covered Charges IP
SV2 2400 Outpatient Ancillary Revenue Code AS, ED
SV2 2400 Procedure Code - CPT-4 / HCPCS & Modifier 1 and 2 AS, ED
SV2 2400 Outpatient Ancillary Total Charges AS, ED
SV2 2400 Outpatient Ancillary Total Non-Covered Charges AS, ED