TRICARE Manuals - Display Chap 2 Sect 5.3 (Change 63, Oct 18, 2022)

TRICARE Encounter Data (TED)

Chapter 2

Section 5.3

Institutional Edit Requirements (ELN 200 - 299)

Revision: C-53, September 8, 2021

ELEMENT NAME: PROVIDER TAXPAYER NUMBER (1-200)
1 ONLY THE FIRST FIVE DIGITS OF THE PROVIDER ZIP CODE ARE USED IN THE MATCH.
VALIDITY EDITS
1-200-01V	MUST BE NUMERIC
	OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE AND LAST SIX POSITIONS MUST BE NUMERIC)
	OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE AND FOURTH POSITION MUST BE = A AND LAST FIVE POSITIONS MUST BE NUMERIC)
Relational Edits
NO ERROR	IF ADJUSTMENT/DENIAL REASON CODE =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	THEN DO NOT CHECK PROVIDER FILE
NO ERRROR	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) OR
		RS	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
	THEN DO NOT CHECK PROVIDER FILE
NO ERROR	IF AMOUNT ALLOWED (TOTAL) ≤ ZERO
	THEN DO NOT CHECK PROVIDER FILE
1-200-02R	IF ANY OCCURRENCE OF OVERRIDE CODE =	NC	NON-CERTIFIED PROVIDER
	THEN THE NON-CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING: INSTITUTIONAL PROVIDER TAXPAYER NUMBER AND TYPE OF INSTITUTION AND PROVIDER ZIP CODE1 AND PROVIDER SUB-IDENTIFIER AND ACCEPTANCE AND TERMINATION DATES MUST = ZEROES AND PROVIDER CONTRACT AFFILIATION CODE MUST = 5 (NON-CERTIFIED PROVIDER)
	IF NO OCCURRENCE OF OVERRIDE CODE =	NC	NON-CERTIFIED PROVIDER
	THEN CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING: INSTITUTIONAL PROVIDER TAXPAYER NUMBER AND TYPE OF INSTITUTION AND PROVIDER ZIP CODE1 AND PROVIDER SUB-IDENTIFIER

ELEMENT NAME: PROVIDER SUB-IDENTIFIER (1-205)
VALIDITY EDITS
1-205-01V	MUST BE ALPHA OR NUMERIC--CANNOT BE BLANKS
Relational Edits
	NONE

ELEMENT NAME: SCH DRG CALCULATION (1-208)
VALIDITY EDITS
1-208-01V	MUST BE NUMERIC AND MUST BE ≥ ZERO
Relational Edits
1-208-01R	IF SCH DRG NUMBER IS NOT BLANK
	THEN SCH DRG CALCULATION MUST BE > ZERO

ELEMENT NAME: PROVIDER ORGANIZATIONAL NPI NUMBER (TYPE 2) (1-215)
VALIDITY EDITS
1-215-01V	MUST BE ALL BLANKS OR 10 DIGITS (MUST NOT BE ALL ZEROES)
1-215-02V	IF PROVIDER ORGANIZATIONAL NPI NUMBER IS ALL DIGITS
	THEN THE CHECK DIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
	NONE

ELEMENT NAME: PROVIDER ZIP CODE (1-220)
1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A.
VALIDITY EDITS
1-220-01V	MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS
	MUST BE A VALID ZIP CODE (BASED ON ADMISSION DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODE FILE OR
	MUST BE A THREE CHARACTER FOREIGN COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWED BY SIX BLANKS
Relational Edits
	NONE

ELEMENT NAME: PROVIDER PARTICIPATION INDICATOR (1-225)
VALIDITY EDITS
1-225-01V	MUST BE A VALID PROVIDER PARTICIPATION INDICATOR.
Relational Edits
	NONE

ELEMENT NAME: PROVIDER NETWORK STATUS INDICATOR (1-230)
VALIDITY EDITS
1-230-01V	MUST BE ONE OF THE FOLLOWING VALUES	1	NETWORK PROVIDER OR
		2	NON-NETWORK PROVIDER
Relational Edits
	NONE

ELEMENT NAME: TYPE OF INSTITUTION (1-235)
VALIDITY EDITS
1-235-01V	VALUE MUST BE A VALID TYPE OF INSTITUTION CODE.
Relational Edits
1-235-02R	IF PRICING RATE CODE =	K	HOSPITAL-SPECIFIC PSYCHIATRIC PER DIEM RATE OR
		L	REGION SPECIFIC PSYCHIATRIC PER DIEM RATE
	THEN TYPE OF INSTITUTION MUST =	22	PSYCHIATRIC HOSPITAL/UNIT OR
		52	CHILDREN’S PSYCHIATRIC HOSPITAL/UNIT
1-235-03R	IF TYPE OF INSTITUTION =	70	HHA
	AND BEGIN DATE OF CARE ≥ 06/01/2004
	THEN ONE OCCURRENCE OF REVENUE CODE MUST =	0023	HHA PPS
	UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-235-04R	IF TYPE OF INSTITUTION =	91	SCH
	AND ADMISSION DATE ≥ 01/01/2014
	AND AMOUNT ALLOWED (TOTAL) > 0
	THEN PRICING RATE CODE MUST =	V	MEDICARE REIMBURSEMENT RATE OR
		CR	CCR

ELEMENT NAME: CLAIM FORM TYPE/EMC INDICATOR (1-240)
VALIDITY EDITS
1-240-01V	VALUE MUST BE A VALID CLAIM FORM TYPE/EMC INDICATOR.
Relational Edits
	NONE

ELEMENT NAME: FREQUENCY CODE (1-250)
VALIDITY EDITS
1-250-01V	MUST BE A VALID FREQUENCY CODE
1-250-02V	IF DRG NUMBER IS NOT BLANK
	AND TYPE OF SUBMISSION =	A	ADJUSTMENT TO TED RECORD DATA OR
		C	COMPLETE CANCELLATION TO TED RECORD DATA OR
		I	INITIAL TED RECORD SUBMISSION OR
		O	ZERO PAYMENT TED RECORD DUE TO 100% OHI OR
		R	RESUBMISSION OF AN INITIAL TED RECORD
	AND FREQUENCY CODE =	2	INTERIM-INITIAL OR
		3	INTERIM-INTERIM OR
		4	INTERIM-FINAL
	THEN THE FREQUENCY CODE SUBMISSION MUST FOLLOW THE DIRECTIONS IN THE TABLE BELOW
	FREQUENCY CODE	PREVIOUS TED RECORD FREQUENCY CODE
	2	= 2 OR NO PREVIOUS TED RECORD
	3	= 2 OR 3 (PREVIOUS TED RECORD MUST EXIST)
	4	= 2, 3, OR 4 (PREVIOUS TED RECORD MUST EXIST)
Relational Edits
1-250-01R	IF PATIENT STATUS =	30	STILL A PATIENT
	AND AMOUNT ALLOWED (TOTAL) ≠ ZERO
	OR OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYER) OR
		FS	TFL (SECOND PAYER)
	THEN FREQUENCY CODE MUST =	2	INTERIM-INITIAL OR
		3	INTERIM-INTERIM
	UNLESS TYPE OF INSTITUTION =	70	HHA
	THEN FREQUENCY CODE MUST =	2	INTERIM-INITIAL OR
		3	INTERIM-INTERIM OR
		7	REPLACEMENT OF PRIOR CLAIM OR
		8	VOID/CANCEL OF PRIOR CLAIM OR
		9	FINAL CLAIM FOR HHA EPISODE
1-250-02R	IF PATIENT STATUS =	01	DISCHARGED OR
		02	TRANSFERRED OR
		20	EXPIRED
	THEN FREQUENCY CODE MUST =	0	NON-PAYMENT/ZERO CLAIM OR
		1	ADMIT THROUGH DISCHARGE OR
		4	INTERIM-FINAL OR
		5	LATE CHARGE(S) OR
		7	REPLACEMENT OF PRIOR CLAIM OR
		8	VOID/CANCELLATION OF PRIOR CLAIM OR
		9	FINAL CLAIM FOR HHA PPS EPISODE
1-250-03R	IF PRICING RATE CODE =	H	TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER
	THEN FREQUENCY CODE MUST =	1	ADMIT THROUGH DISCHARGE
1-250-05R	IF FREQUENCY CODE =	5	LATE CHARGE(S)
	THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO FOR ALL OCCURRENCE/LINE ITEMS

ELEMENT NAME: TYPE OF ADMISSION (1-255)
VALIDITY EDITS
1-255-01V	VALUE MUST BE A VALID TYPE OF ADMISSION CODE.
	UNLESS REVENUE CODE ON ANY OF THE OCCURRENCES/LINE ITEMS =	0023	HHA
	OR TYPE OF INSTITUTION =	70	HHA
	OR AMOUNT ALLOWED (TOTAL) = ZERO
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	11	HOSPICE
	THEN VALUE MUST BE BLANK OR A VALID TYPE OF ADMISSIONS CODE
Relational Edits
1-255-03R	IF TYPE OF ADMISSION =	4	NEWBORN
	AND ICD VERSION =	9	ICD-9
	AND POINT OF ORIGIN =	1	NORMAL DELIVERY OR
		2	PREMATURE DELIVERY OR
		4	EXTRAMURAL BIRTH OR
		5	BORN INSIDE THIS HOSPITAL OR
		6	BORN OUTSIDE THIS HOSPITAL
	THEN PRINCIPAL DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) MUST BE BETWEEN V30.0 AND V39.2.
1-255-04R	IF TYPE OF ADMISSION =	4	NEWBORN
	AND ICD VERSION =	0	ICD-10
	THEN POINT OF ORIGIN =	5	BORN INSIDE THIS HOSPITAL OR
		6	BORN OUTSIDE THIS HOSPITAL
	AND PRINCIPAL DIAGNOSIS/POA INDICATOR (POSITiONS 1-7) MUST BE BETWEEN Z38.00 AND Z38.8.

ELEMENT NAME: POINT OF ORIGIN (1-260)
VALIDITY EDITS
1-260-01V	VALUE MUST BE A VALID POINT OF ORIGIN.
Relational Edits
1-260-01R	IF TYPE OF ADMISSION =	4	NEWBORN
	THEN POINT OF ORIGIN MUST =	1	NORMAL DELIVERY (DISCONTINUED 10/01/2007) OR
		2	PREMATURE DELIVERY (DISCONTINUED 10/01/2007) OR
		3	SICK BABY (DISCONTINUED 10/01/2007) OR
		4	EXTRAMURAL BIRTH OR
		5	BORN INSIDE THIS HOSPITAL OR
		6	BORN OUTSIDE THIS HOSPITAL

ELEMENT NAME: ADMISSION DATE (1-265)
VALIDITY EDITS
1-265-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
1-265-01R	ADMISSION DATE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC)
1-265-02R	ADMISSION DATE MUST BE ≤ END DATE OF CARE
1-265-03R	IF FREQUENCY CODE =	1	ADMIT THROUGH DISCHARGE
	THEN ADMISSION DATE MUST BE ≥ BEGIN DATE OF CARE
	ELSE IF FREQUENCY CODE =	2	INTERIM-INITIAL
	AND TYPE OF INSTITUTION ≠	70	HHA
	THEN ADMISSION DATE MUST BE ≥ BEGIN DATE OF CARE
1-265-04R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN ADMISSION DATE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED

ELEMENT NAME: PATIENT STATUS (1-270)
VALIDITY EDITS
1-270-01V	VALUE MUST BE A VALID PATIENT STATUS CODE.
Relational Edits
1-270-01R	IF FREQUENCY CODE =	2	INTERIM-INITIAL OR
		3	INTERIM-INTERIM
	THEN PATIENT STATUS MUST =	30	STILL A PATIENT
1-270-03R	IF PRICING RATE CODE =	H	TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
		J	TRICARE DRG REIMBURSEMENT WITH NO OUTLIER
	THEN PATIENT STATUS MUST ≠	30	STILL A PATIENT

ELEMENT NAME: BEGIN DATE OF CARE (1-275)
1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).
VALIDITY EDITS
1-275-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
1-275-02V	BEGIN DATE OF CARE CANNOT BE < 01/01/1990.
1-275-03V	BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.
Relational Edits
1-275-02R	BEGIN DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC)
1-275-03R	BEGIN DATE OF CARE MUST BE ≥ PERSON BIRTH CALENDAR DATE (PATIENT)
1-275-05R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN BEGIN DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED
1-275-06R	PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR THIS BEGIN DATE OF CARE
	UNLESS AMOUNT ALLOWED (TOTAL) ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) OR
		RS	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
	THEN DO NOT CHECK PROVIDER FILE

ELEMENT NAME: END DATE OF CARE (1-280)
1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).
VALIDITY EDITS
1-280-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
1-280-02V	END DATE OF CARE CANNOT BE < 01/01/1990.
1-280-03V	END DATE OF CARE MUST BE ≥ BEGIN DATE OF CARE.
Relational Edits
1-280-01R	END DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC)
1-280-02R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN END DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED
1-280-03R	PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR THIS END DATE OF CARE
	UNLESS AMOUNT ALLOWED (TOTAL) ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) OR
		RS	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
	THEN DO NOT CHECK PROVIDER FILE

ELEMENT NAME: ADMINISTRATIVE CLIN (1-283)
VALIDITY EDITS
1-283-01V	MUST BE BLANKS.
Relational Edits
	REFER TO Section 8.1.

ELEMENT NAME: COVERED DAYS (1-285)
VALIDITY EDITS
1-285-01V	MUST BE NUMERIC.
1-285-02V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	11	HOSPICE
	OR TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	OR TYPE OF INSTITUTION =	78	NON-HOSPITAL BASED HOSPICE OR
		79	HOSPITAL BASED HOSPICE
	THEN BYPASS THIS EDIT
	ELSE IF AMOUNT ALLOWED (TOTAL) ≤ ZERO
	OR TYPE OF INSTITUTION =	70	HHA
	OR THE SUM OF UNITS OF SERVICE BY REVENUE CODE FOR REVENUE CODES THAT INDICATE THAT A ROOM WAS USED (010X-021X, OR 0724, OR 100X) = ZERO
	THEN COVERED DAYS MUST = ZERO
	ELSE IF FREQUENCY CODE =	3	INTERIM - INTERIM TED RECORD
	OR BEGIN DATE OF CARE = END DATE OF CARE
	THEN COVERDAYS MUST BE ≤ END DATE OF CARE - BEGIN DATE OF CARE + 1
	ELSE IF ADMISSION DATE = END DATE OF CARE
	THEN COVERED DAYS MUST BE ≤ 1
	ELSE IF FREQUENCY CODE =	1	ADMIT THRU DISCHARGE
	THEN COVERED DAYS MUST BE ≤ END DATE OF CARE - ADMISSION DATE
	ELSE IF FREQUENCY CODE =	2	INTERIM - INITIAL TED RECORD
	THEN COVERED DAYS MUST BE ≤ END DATE OF CARE - ADMISSION DATE + 1
	ELSE COVERED DAYS MUST BE ≤ END DATE OF CARE - BEGIN DATE OF CARE
Relational Edits
	NONE

ELEMENT NAME: DRG NUMBER (1-290)
VALIDITY EDITS
1-290-01V	MUST BE A VALID DRG NUMBER OR BLANK FILLED.
Relational Edits
1-290-01R	IF PRICING RATE CODE =	b	NO SPECIAL RATE CODE OR
		K	HOSPITAL-SPECIFIC PSYCHIATRIC PER DIEM RATE OR
		L	REGIONAL-SPECIFIC PSYCHIATRIC PER DIEM RATE OR
		P	PER DIEM RATE AGREEMENT OR
		CA	CAH REIMBURSEMENT OR
		CI	CAH IRF REIMBURSEMENT OR
		CP	CAH PSYCHIATRIC HOSPITAL PER DIEM RATE OR
		LT	STANDARD LTCH REIMBURSEMENT OR
		RF	TRICARE IRF REIMBURSEMENT OR
		SN	SITE-NEUTRAL LTCH REIMBURSEMENT
	THEN DRG NUMBER MUST = BLANK
1-290-02R	IF ANY OCCURRENCE OF OVERRIDE CODE =	Y	NEWBORN IN MOTHER’S ROOM WITHOUT NURSERY CHARGES
	THEN DRG NUMBER MUST = BLANK
1-290-31R	IF PRICING RATE CODE =	H	TRICARE/CHAMPUS DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
		I	TRICARE/CHAMPUS DRG REIMBURSEMENT WITH COST OUTLIER OR
		J	TRICARE/CHAMPUS DRG REIMBURSEMENT WITH NO OUTLIER OR
		S	HVBP ADJUSTMENT FACTOR OR
		CV	COVID-19 ADJUSTMENT FACTOR OR
		DD	DISCOUNTED DRG
	THEN DRG MUST NOT BE BLANK
	AND IF END DATE OF CARE < 10/01/2014
	THEN DATE OF ADMISSION MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE
	ELSE END DATE OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE

ELEMENT NAME: HIPPS CODE (1-292)
VALIDITY EDITS
1-292-01V	MUST BE VALID HIPPS CODES REFER TO Section 2.5 AND REFER TO CMS WEBSITE AT HTTPS://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FOR-SERVICE-PAYMENT/PROSPMEDICAREFEESVCPMTGEN/HIPPSCODES.
Relational Edits
1-292-01R	IF HIPPS CODE = BLANK
	THEN NO OCCURRENCE OF REVENUE CODE CAN =	0022	SNF OR
		0023	HHA PPS

ELEMENT NAME: ICD VERSION (1-293)
VALIDITY EDITS
1-293-01V	VALUE MUST BE A VALID ICD VERSION.
Relational Edits
NO ERROR	IF AMOUNT ALLOWED (TOTAL) = ZERO
1-293-02R	IF END DATE OF CARE ≥ 10/01/2015
	THEN ICD VERSION MUST BE	0	ICD-10
1-293-04R	IF END DATE OF CARE < 10/01/2015
	THEN ICD VERSION MUST BE	9	ICD-9

ELEMENT NAME: ADMISSION DIAGNOSIS (1-295)
VALIDITY EDITS
1-295-01V	IF FILING DATE IS PRIOR TO 10/01/2004
	THEN VALUE MUST BE VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1
	UNLESS REVENUE CODE ON ANY OF THE OCCURRENCES/LINE ITEMS =	0023	HHA
	THEN VALUE MUST BE BLANK OR A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1
1-295-02V	IF FILING DATE ON OR AFTER 10/01/2004
	THEN VALUE MUST BE VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM) AND V00-Y99.9 (ICD-10-CM).
	AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
	OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
	UNLESS REVENUE CODE ON ANY OF THE OCCURRENCES/LINE ITEMS =	0023	HHA
	OR TYPE OF INSTITUTION =	70	HHA
	OR AMOUNT ALLOWED (TOTAL) = ZERO
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	11	HOSPICE
	THEN VALUE MUST BE BLANK OR VALUE MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM) AND V00-Y99.9 (ICD-10-CM)
	AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
	OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
Relational Edits
	NONE

- END -

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