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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 2.7
Data Requirements - Institutional/Non-Institutional Record Data Elements (P)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-35, March 26, 2020
DATA ELEMENT DEFINITION
ELEMENT NAME:  PATIENT IDENTIFIER (DoD)
Notes And Special Instructions:
If person not on DEERS but claim is payable (i.e., Government liability), report all nines in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-095
2-080
1
1
Yes
Yes
Primary Picture (Format)
Ten (10) alphanumeric characters.
Definition
The identifier associated with a particular patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PATIENT STATUS
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
1-270
1
Yes
Primary Picture (Format)
Two (2) alphanumeric characters.
Definition
Code indicating patient status as of the end date of care on the TED record.
Code/Value Specifications
01
Discharged
02
Transferred
03
Discharged/transferred to SNF
04
Discharged/transferred to ICF
05
Discharged/transferred to another type of institution (including distinct parts of institutions) (definition not valid for discharges on or after 04/01/2008)
05
Discharged/transferred to a designated cancer center or children’s hospital (definition effective for discharges on or after 04/01/2008)
06
Discharged/transferred to home under care of organized home health service organization
07
Left against medical advice or discontinued care
08
Discharged/transferred to home under care of a home IV provider (not valid for discharges on or after 10/01/2005)
20
Expired (or did not recover - Christian Science Patient)
21
Discharged/transferred to court/law enforcement
30
Still patient (remaining)
40
Expired at home
41
Expired in a medical facility, such as a hospital, SNF, ICF, or freestanding hospice
42
Expired place unknown
43
Discharged/transferred to a federal health care facility
50
Discharged to Hospice - Home
51
Discharged to Hospice - Medical Facility
61
Discharged/transferred to a hospital-based Medicare approved swing bed
62
Discharged/transferred to an IRF including Rehabilitation Distinct Part Units of a hospital
63
Discharged/transferred to a LTC hospital
64
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
65
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
66
Discharged/transferred to a CAH
69
Discharged/transferred to a designated disaster alternative care site (Effective 10/01/2013)
70
Discharged/transferred to another type of health care institution not defined elsewhere in this code list (definition effective for discharges on or after 04/01/2008)
81
Discharged to home or self care with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
82
Discharged/transferred to a short-term general hospital for inpatient care with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
83
Discharged/transferred to a SNF with Medicare certification with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
84
Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
85
Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
86
Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
87
Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
88
Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
89
Discharged/transferred to a hospital-based Medicare approved swing bed with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
90
Discharged/transferred to an IRF including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission (Effective 10/01/2013)
91
Discharged/transferred to a Medicare certified LTC with a planned acute care hospital readmission (Effective 10/01/2013)
92
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital readmission (Effective 10/01/2013)
93
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital readmission (Effective 10/01/2013)
94
Discharged/transferred to a CAH with a planned acute care hospital readmission (Effective 10/01/2013)
95
Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital readmission (Effective 10/01/2013)
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PATIENT ZIP CODE
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-105
2-090
1
1
Yes
Yes
Primary Picture (Format)
Nine (9) alphanumeric characters.
Definition
U.S. Postal zip code or foreign country code for patient’s legal residence at the time service was rendered and must not be the zip code of a P.O. Box.
Code/Value Specifications
Must be a valid five or nine digit zip code. If only five digits, left justify and blank fill. If foreign country, must be three character foreign country code, left justify and blank fill. Refer to Addendum A.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PAY GRADE CODE (SPONSOR)
Notes And Special Instructions:
1  If the DEERS response does not return a PAY GRADE CODE (SPONSOR), report 00 in this field. If person not on DEERS but claim is payable (i.e., Government liability), report 00 in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-056
2-291
1
Up to 99
Yes1
Yes1
Primary Picture (Format)
Two (2) alphanumeric characters.
Definition
The code that represents the level of pay. (The combination of pay plan code and pay grade code represents the sponsor’s pay category.) Download field from DEERS.
Code/Value Specifications
00
Unknown
00 - ZZ
Used when pay plan is civil service
01
Used when pay plan is cadet
01 - 05
Used when pay plan is warrant office
01 - 09
Used when pay plan is enlisted
01 - 11
Used when pay plan is officer
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PAY PLAN CODE (SPONSOR)
Notes And Special Instructions:
1  If the DEERS response does not return a PAY PLAN CODE (SPONSOR), report ZZ in this field, left justify. If person not on DEERS but claim is payable (i.e., Government liability), report ZZ in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-057
2-292
1
Up to 99
Yes1
Yes1
Primary Picture (Format)
Five (5) alphanumeric characters.
Definition
The code that represents the type of pay category. (The combination of pay plan code and pay grade code represents the sponsor’s pay category.) Download field from DEERS.
Code/Value Specifications
For valid values refer to Addendum J.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PCM LOCATION DMIS-ID (ENROLLMENT) CODE
Notes And Special Instructions:
If not applicable blank fill.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-115
2-110
1
1
No
No
Primary Picture (Format)
Four (4) alphanumeric characters.
Definition
This code identifies and distinguishes MTF/eMSM/Clinic enrollments from network enrollments. The code designations vary based on type of Prime enrollment and begin work dates of new programs. The codes also vary based on the individual requirements of enrolling platforms used by the MCS regions. Download field from DEERS using PCM Enrolling Division DMIS-ID.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON BIRTH CALENDAR DATE (PATIENT)
Notes And Special Instructions:
1  Required if available on DEERS, if not available from DEERS report from the claim or report 19111111.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-085
2-070
1
1
Yes1
Yes1
Primary Picture (Format)
Eight (8) alphanumeric characters, YYYYMMDD.
Definition
The date when a human being was born. Download field from DEERS.
Code/Value Specifications
YYYY
4 digit calendar year
MM
2 digit calendar month
DD
2 digit calendar day
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON CADENCY NAME (PATIENT)
Notes And Special Instructions:
1  Required if available on DEERS, if not available from DEERS report from the claim or blank fill.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-079
2-064
1
1
Yes1
Yes1
Primary Picture (Format)
Ten (10) alphanumeric characters.
Definition
The cadency name (i.e., Sr., Jr., III, etc.) of the patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PERSON NAME (PATIENT)
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON FIRST NAME (PATIENT)
Notes And Special Instructions:
1  Required if available on DEERS; if not available from DEERS report from the claim or blank fill.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-077
2-062
1
1
Yes1
Yes1
Primary Picture (Format)
Twenty-five (25) alphanumeric characters.
Definition
First name of patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PERSON NAME (PATIENT)
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON IDENTIFIER (PATIENT)
Notes And Special Instructions:
If person not on DEERS but claim is payable (i.e., Government liability), report from the claim or report all nines in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-080
2-065
1
1
Yes
Yes
Primary Picture (Format)
Nine (9) alphanumeric characters.
Definition
The identifier that represents a human being. This attribute will usually contain the person’s SSN. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON IDENTIFIER (SPONSOR)
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-050
2-050
1
1
Yes
Yes
Primary Picture (Format)
Nine (9) alphanumeric characters.
Definition
The identifier that represents a person who is a sponsor. This attribute will usually contain the sponsor’s SSN. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON IDENTIFIER TYPE CODE (PATIENT)
Notes And Special Instructions:
If person not on DEERS but claim is payable (i.e., Government liability), report from the claim or report Z in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-081
2-066
1
1
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
The code that represents a specific kind of person identifier. Download field from DEERS.
Code/Value Specifications
D
Special nine digit code created for individuals (i.e., babies) who do not have or have not provided an SSN when the record is added to DEERS (dependents only).
F
Special nine digit code created for foreign military and nationals.
I
TIN
P
Special nine digit code created for U.S. military personnel from Service Numbers before the switch to SSNs.
R
Special nine digit code created for a DoD contractor who refused to give his or her SSN to RAPIDS. The associated PN_ID will begin with 99.
S
SSN
Z
Not applicable
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON IDENTIFIER TYPE CODE (SPONSOR)
Notes And Special Instructions:
If person not on DEERS but claim is payable (i.e., Government liability), report from the claim or report Z in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-051
2-051
1
1
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
The code that represents a specific kind of person identifier. Download field from DEERS.
Code/Value Specifications
D
Special nine digit code created for individuals (i.e., babies) who do not have or have not provided an SSN when the record is added to DEERS (dependents only).
F
Special nine digit code created for foreign military and nationals.
I
TIN
P
Special nine digit code created for U.S. military personnel from Service Numbers before the switch to SSNs.
R
Special nine digit code created for a DoD contractor who refused to give his or her SSN to RAPIDS. The associated PN_ID will begin with 99.
S
SSN
Z
Not applicable
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON LAST NAME (PATIENT)
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-076
2-061
1
1
Yes
Yes
Primary Picture (Format)
Thirty-five (35) alphanumeric characters.
Definition
Last name of patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PERSON NAME (PATIENT)
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON MIDDLE NAME (PATIENT)
Notes And Special Instructions:
1  Required if available on DEERS, if not available from DEERS report from the claim or blank fill.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-078
2-063
1
1
Yes1
Yes1
Primary Picture (Format)
Twenty-five (25) alphanumeric characters.
Definition
Middle name of patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PERSON NAME (PATIENT)
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON NAME (PATIENT)
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-075
2-060
1
1
Yes
Yes
Primary Picture (Format)
Group
Definition
Name of patient. Download field from DEERS.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
PERSON LAST NAME
PERSON FIRST NAME
PERSON MIDDLE NAME
PERSON CADENCY NAME
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PERSON SEX (PATIENT)
Notes And Special Instructions:
Use DEERS response if DEERS returns a value of F or M. If DEERS response is not F or M, the person sex should be reported based on claim information or patient history.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-100
2-085
1
1
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
Code defining sex of patient. Download field from DEERS.
Code/Value Specifications
F
Female
M
Male
Z
Unknown
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PHYSICIAN REFERRAL NUMBER
Notes And Special Instructions:
1  Required for all referred care (MTF/eMSM and Civilian PCM). If not applicable blank fill.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-270
1
Yes1
Primary Picture (Format)
Thirteen (13) alphanumeric characters.
Definition
The identifying number of the referring physician. This field will report the NPI or PROVIDER TAXPAYER NUMBER and PROVIDER SUB-IDENTIFIER as applicable.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PLACE OF SERVICE
Notes And Special Instructions:
This data element must be 19 for Mail Order Pharmacy (MOP).
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-275
Up to 99
Yes
Primary Picture (Format)
Two (2) alphanumeric characters.
Definition
Code to indicate where the health care was provided.
Code/Value Specifications
01
Pharmacy
02
Telehealth
03
School
04
Homeless Shelter
05
Indian Health Service (IHS) Freestanding Facility
06
Indian Health Service (IHS) Provider-based Facility
07
Tribal 638 Freestanding Facility
08
Tribal 638 Provider-based Facility
09
Prison-Correctional Facility
11
Office
12
Home
13
Assisted Living Facility
14
Group Home
15
Mobile Unit
16
Temporary Lodging
17
Walk-in Retail Health Clinic
18
Place of Employment Work-site
19
Pharmacy (Terminated 12/31/2015)
19
Off Campus-Outpatient Hospital
20
Urgent Care Facility
21
Inpatient Hospital
22
On Campus-Outpatient Hospital
23
Emergency Room - Hospital
24
Ambulatory Surgical Center (ASC)
25
Birthing Center
26
Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)
31
Skilled Nursing Facility (SNF)
32
Nursing Facility
33
Custodial Care Facility
34
Hospice
41
Ambulance - Land
42
Ambulance - Air or Water
49
Independent Clinic
50
Federally Qualified Health Center
51
Inpatient Psychiatric Facility
52
Psychiatric Facility Partial Hospitalization
53
Community Mental Health Center (CMHC)
54
Intermediate Care Facility/Mentally Retarded
55
Residential Substance Abuse Treatment Facility
56
Psychiatric Residential Treatment Center (RTC)
57
Non-Residential Substance Abuse Treatment Facility
60
Mass Immunization Center
61
Comprehensive Inpatient Rehabilitation Facility
62
Comprehensive Outpatient Rehabilitation Facility (CORF)
65
End Stage Renal Disease (ESRD) Treatment Facility
71
Public Health Clinic
72
Rural Health Clinic (RHC)
81
Independent Laboratory
99
Other Unlisted Facility
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  POINT OF ORIGIN
Notes And Special Instructions:
1  Use this coding structure when the TYPE OF ADMISSION = 4 (newborn).
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
1-260
1
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
Code indicating the source of the referral for this admission.
Code/Value Specifications
Source Of Admission Code
1
Physician Referral
The patient was admitted to this facility upon the recommendation of his or her personal physician. (Discontinued effective 10/01/2007.)
1
Non-Health Care Facility Point of Origin
The patient was admitted to this facility upon order of a physician or self-referral. (Effective 10/01/2007.)
2
Clinic Referral
The patient was admitted to this facility upon recommendation of this facility’s clinic physician.
3
HMO Referral
The patient was admitted to this facility as a transfer from a freestanding or non-freestanding clinic. Discontinued effective 10/01/2007.)
4
Transfer from a Hospital (Different Facility)
The patient was admitted to this facility as a hospital transfer from a different acute care facility where he or she was an inpatient.
5
Transfer from a SNF or ICF
The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.
6
Transfer from another Health Care Facility
The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list.
7
Emergency Room
The patient was admitted to this facility after receiving services in this facility’s emergency department. (Discontinued effective 07/01/2010).
8
Court/Law Enforcement
The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative.
9
Information Not Available
The means by which the patient was admitted to this hospital is not known.
A
Transfer from a CAH
The patient was admitted to this facility as a transfer from a CAH where he or she was an inpatient. (Discontinued effective 10/01/2007.)
B
Transfer from Another HHA
The patient was admitted to this HHA as a transfer from another HHA. (Discontinued effective 07/01/2010).
C
Readmission to the Same HHA
The patient was readmitted to this HHA within the existing 60 day payment. (Discontinued effective 07/01/2010).
D
Transfer from Hospital Inpatient in the same facility resulting in a separate claim to the payer
The patient was admitted to this facility as a transfer from Hospital Inpatient within this facility resulting in a separate claim to the payer.
E
Transfer from ASC
The patient was admitted to this facility as a transfer from an ASC. (Effective 10/01/2007.)
F
Transfer from Hospice and is under a Hospice Plan of Care or enrolled in a Hospice Program
The patient was admitted to this facility as a transfer from hospice. (Effective 10/01/2007.)
Code structure for newborn1
1
Normal Delivery
A baby delivered without complications. (Discontinued effective 10/01/2007.)
2
Premature Delivery
A baby delivered with time and/or weight factors qualifying it for premature status. (Discontinued effective 10/01/2007.)
3
Sick Baby
A baby delivered with medical complications, other than those relating to premature status. (Discontinued effective 10/01/2007.)
4
Extramural Birth
A newborn born in a non-sterile environment. (Discontinued effective 10/01/2007.)
5
Born Inside This Hospital
A baby born inside this hospital. (Effective 10/01/2007.)
6
Born Outside This Hospital
A baby born outside this hospital. (Effective 10/01/2007.)
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PRICING RATE CODE
Notes And Special Instructions:
1  Code 0 for all allowed drug charges.
2  Use Pricing Rate Code 1 (Priced Manually) for consultation procedures for which the allowable charge is limited to that for a Limited Initial Visit, New Patient.
To indicate that the hospital reimbursement was reduced by a full or partial credit a provider received for a replaced device, Special Processing Codes 49 or 50 should be used. See Section 2.8.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-190
2-325
1
Up to 99
Yes
Yes
Primary Picture (Format)
Two (2) alphanumeric characters.
Definition
Code indicating the pricing methodology used in determining the amount allowed for the service(s)/supplies. Left justify and blank fill.
Code/Value Specifications
Institutional code
b
No special rate
D
Discount rate agreement
H
TRICARE Diagnosis Related Group (DRG) reimbursement with Short Stay Outlier
I
TRICARE DRG reimbursement with Cost Outlier
J
TRICARE DRG reimbursement with No Outlier
K
Hospital-specific Psychiatric per diem rate
L
Region-specific Psychiatric per diem rate
P
Per diem rate
U
Supplemental Health Care Program (SHCP) claim or active duty member TPR claim paid outside normal limits
V
Medicare Reimbursement Rate
CA
Critical Access Hospital (CAH) Reimbursement
CI
CAH Inpatient Rehabilitation Facility (IRF) Reimbursement (Effective 10/01/2018)
CP
CAH Psychiatric Hospital per diem rate (Effective 10/01/2018)
CR
Cost-To-Charge Ratio (CCR) (Effective 01/01/2014)
DD
Discounted DRG
LT
Standard Long-Term Care Hospital (LTCH) Reimbursement (Effective 10/01/2018)
RF
TRICARE IRF Reimbursement (Effective 10/01/2018)
SN
Site-Neutral LTCH Reimbursement (Effective 10/01/2018)
nON-Institutional code
0
Pricing not applicable (denied service/supplies and allowed drugs)1
1
Priced Manually2
2
Prevailing charge (state)
3
Conversion amount (state)
4
Paid as billed
5
Paid on negotiated rate
A
National prevailing charge
B
National conversion factor
C
Ambulatory surgery facility payment rate
D
Discounted ambulatory surgery facility payment rate
E
Ambulatory surgery-paid as billed
F
Claim Auditing Software-added procedure, priced manually
G
Claim Auditing Software-added procedure, prevailing charge (State)
H
Claim Auditing Software-added procedure, conversion factor (Contractor)
I
Claim Auditing Software-added procedure, paid as billed
J
Claim Auditing Software-added procedure, paid on negotiated rate
N
Claim Auditing Software-added procedure, national prevailing charge
O
Claim Auditing Software-added procedure, national conversion factor
P
Claim Auditing Software-added procedure, ambulatory surgery facility payment rate
Q
Claim Auditing Software-added procedure, discounted ambulatory surgery facility payment rate
R
Claim Auditing Software-added procedure, ambulatory surgery-paid as billed
T
Claim Auditing Software-added procedure, allowed as billed but paid less than billed
U
SHCP or active duty member TPR claim paid outside normal limits
V
Medicare Reimbursement Rate
W
Priced over CMAC (Effective 09/27/2001)
BR
Blended Rate
CA
CAH Reimbursement
GG
Global Rate Agreement (used with corporate service providers only) (Effective 08/01/2003)
GP
Per Diem Rate Agreement (used with corporate service providers only) (Effective 08/01/2003)
LC
TRICARE Claim-added procedure, CMAC priced laboratory code
P1
OPPS
P2
OPPS with Cost Outlier
P3
OPPS with Discount
P5
Hospital-based Partial Hospitalization - paid as OPPS
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PROCESSING INFORMATION
DATA ELEMENT DEFINITION
ELEMENT NAME:  PRINCIPAL OPERATION/NON-SURGICAL PROCEDURE CODE
Notes And Special Instructions:
1  Required if one of the following Revenue Codes are present 036X or 072X.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
1-345
1
Yes1
Primary Picture (Format)
Seven (7) alphanumeric characters.
Definition
The code that identifies the principal procedure performed during the period reported on the TED record as submitted on the UB-04/UB-92.
Code/Value Specifications
Use the most current procedure code edition (ICD-9-CM or ICD-10-PCS) as directed by DHA. Must provide the most detailed code. Do not code the decimal point.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PRINCIPAL TREATMENT DIAGNOSIS/PRESENT ON ADMISSION (POA) INDICATOR
Notes And Special Instructions:
For MOP and Retail Pharmacy, if a more specific diagnosis code is not available, use ICD-9-CM 799.89 on or before September 30, 2015, and ICD-10-CM R68.89 on or after October 1, 2015.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-300
2-115
1
1
Yes
Yes
Primary Picture (Format)
Eight (8) alphanumeric characters.
Definition
Principal Treatment Diagnosis: The condition established, after study, to be the major cause for the patient to obtain medical care as submitted on the claim form or otherwise indicated by the provider.
POA Indicator: Diagnosis present at the time the order for inpatient admission occurs.
Code/Value Specifications
Principal Treatment Diagnosis (Positions 1 through 7): Use the most current diagnosis code edition (ICD-9-CM or ICD-10-CM), as directed by DHA. Must provide the most detailed code. Do not code the decimal point.
POA Indicator (Position 8):
Valid POA values are:
b
Not reported
1
Unreported/Not Used - Exempt from POA reporting
N
No - Not present at time of admission
U
Unknown - Documentation insufficient to determine if the condition was present at time of admission
W
Clinically Undetermined - The provider is unable to clinically determine if the condition was present at time of admission
Y
Yes - Present at time of admission
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROCEDURE CODE
Notes And Special Instructions:
For MOP report CPT procedure code 98800 for all drug prescriptions and CPT procedure code 99070 for all supplies. The first line item must report the information on the prescription and the second line item to report corresponding supplies that are issued such as alcohol pads, lancets, etc. The procedure code on the second occurrence/line item on MOP records must be CPT procedure code 99070.
For MOP and Retail Pharmacy Prior Authorizations and Medical Necessity Reviews report 000PA or 000MN.
For the list of the No Government Pay Procedure Codes that are excluded from TRICARE coverage and are not payable under TRICARE, refer to the No Government Pay Procedure Code list on DHA’s web site at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/No-Government-Pay-Procedure-Code-List.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-160
Up to 99
Yes
Primary Picture (Format)
Five (5) alphanumeric characters.
Definition
The code that identifies the procedure performed or describes the care received as submitted on the claim form.
Code/Value Specifications
Refer to Physician’s Current Procedure Terminology, 4th Edition1 (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) National Level II Medicare Codes or DHA approved codes (Addendum E, Figure 2.E-2). For Dental Services, use HCPC or ADA Dental procedure codes.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROCEDURE CODE MODIFIER
Notes And Special Instructions:
Can report from zero to four codes. Each occurrence consists of two characters left justified and blank-filled. Do not duplicate.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-165
4/Up to 99
No
Primary Picture (Format)
Four (4) occurrences of two (2) alphanumeric characters per occurrence/line item.
Definition
Two digit code which provides the means by which the health care professional can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. (Refer to Physician’s Current Procedure Terminology, 4th Edition, (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) National Level II Medicare Codes.)
Code/Value Specifications
Must be 21-27, 32, 33, 47, 50-59, 62, 63, 66, 73-82, 90-92, 95-97, 99, 0A-0P, 0Z, 1A-1J, 1Z, 2A-2O, 2Q-2T, 2Z, 3A-3I, 3K, 3Z, 4A-4U, 4Z, 5A-5O, 5Z, 6A-6F, 6Z, 7A-7F, 7Z, 8A-8C, 8P, 8Z, 9A-9D, 9L-9Q, 9Z, A1-A9, AA, AD-AK, AM, AO-AZ, BA, BL, BO-BR, BU, CA-CO, CQ-CT, DA, DE, DG-DJ, DN, DP, DR, DS, DX, E1-E4, EA-EE, EG-EJ, EM, EN, EP, ER-ET, EX, EY, F1-F9, FA-FC, FP, FX, FY, G0-G9, GA-GC, GE-GZ, H9, HA-HZ, ID, IE, IG-IJ, IN, IR, IS, IX, J1-J4, JA-JJ, JN, JP, JR, JS, JW, JX, K0-K4, KA-KZ, L1, LC, LD, LL, LM, LR-LT, M2, MA-MH, MR, MS, NB, ND, NE, NG-NJ, NN, NP, NR-NU, NX, P1-P6, PA-PE, PG, PI, PJ, PL-PP, PR-PT, PX, Q0-Q9, QA-QH, QJ-QZ, RA-RE, RG-RJ, RN, RP-RT, RX, SA-SN, SQ-SY, T1-T9, TA-TK, TL-TN, TP-TW, U1-U9, UA-UH, UJ-UK, UN, UP-US, V1-V3, V5-V9, VM, VP, X1-X5, XD, XE, XG-XJ, XN, XP, XR, XS, XU, or blank.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROCESSING INFORMATION
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
1-155
1
Yes
Primary Picture (Format)
Group
Definition
Field containing multiple elements that describe processing related to the TED record.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
OVERRIDE CODE
TYPE OF SUBMISSION
CA/NAS NUMBER
CA/NAS REASON FOR ISSUANCE
CA/NAS EXCEPTION REASON
SPECIAL PROCESSING CODE
PRICING RATE CODE
HEALTHCARE DELIVERY PROGRAM SPECIAL ENTITLEMENT CODE
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER INDIVIDUAL NPI NUMBER (TYPE 1)
Notes And Special Instructions:
1  Required for all “covered entities” that submit HIPAA-compliant standard electronic transactions in accordance with the TRICARE Operations Manual (TOM), Chapter 19, Section 4.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-225
Up to 99
Yes1
Primary Picture (Format)
Ten (10) alphanumeric characters.
Definition
Standard unique health identifier for individual providers, including but not limited to those (human beings) who provide care such as physicians, nurse practitioners, dentists, chiropractors, pharmacists, and physical therapists.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER NETWORK STATUS INDICATOR
Notes And Special Instructions:
This data element must be 1 for MOP.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-230
2-265
1
Up to 99
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
Code indicating whether the provider is a network or non-network provider.
Code/Value Specifications
1
Network Provider
2
Non-Network Provider
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER ORGANIZATIONAL NPI NUMBER (TYPE 2)
Notes And Special Instructions:
1  Required for all “covered entities” that submit HIPAA-compliant standard electronic transactions in accordance with the TOM, Chapter 20, Section 4.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-215
2-230
0
Up to 99
Yes1
Yes1
Primary Picture (Format)
Ten (10) alphanumeric characters.
Definition
Standard unique health identifier for organizational providers, including but not limited to non-person providers such as hospitals, HHAs, clinics, laboratories, suppliers of DME, pharmacies, and groups.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER PARTICIPATION INDICATOR
Notes And Special Instructions:
This data element must be Y for MOP.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-225
2-260
1
Up to 99
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
Code indicating whether or not the provider accepted assignment of benefits for services rendered.
Code/Value Specifications
N
No
Y
Yes
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER TAXONOMY (SPECIALTY)
Notes And Special Instructions:
This data element must be 183500000X for MOP and 333600000X for Retail Pharmacy.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-255
Up to 99
Yes
Primary Picture (Format)
Ten (10) alphanumeric characters.
Definition
Code describing the provider’s specialty.
Code/Value Specifications
Refer to http://www.wpc-edi.com/reference/ for Provider Specialty Codes. Refer to Addendum C, Figure 2.C-1 as a reference when assigning Provider Major Specialty Codes to Outpatient Hospital Non-Institutional TED records.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER STATE OR COUNTRY CODE
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-195
2-235
1
Up to 99
Yes
Yes
Primary Picture (Format)
Three (3) alphanumeric characters.
Definition
Code assigned to identify the state or foreign country in which the care was received. State Code must be left justified and blank fill to right.
Code/Value Specifications
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER SUB-IDENTIFIER
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-205
2-245
1
Up to 99
Yes
Yes
Primary Picture (Format)
Four (4) alphanumeric characters.
Definition
Identification number that uniquely identifies multiple providers using the same TIN.
Code/Value Specifications
Refer to Section 2.10, ELN 3-010.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER TAXPAYER NUMBER
Notes And Special Instructions:
Claims for care rendered by an EIA Tutor must be identified on the TED record using the billing ACSP Provider Taxpayer Number.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-200
2-240
1
Up to 99
Yes
Yes
Primary Picture (Format)
Nine (9) alphanumeric characters.
Definition
The IRS TIN assigned to the institution/provider supplying the care.
Code/Value Specifications
For institutions must be nine digit EIN. For individual providers, should be the nine digit EIN or SSN, if available. If not available, report the contractor-assigned number. (Refer to Section 2.10, ELN 3-005). Report all nines for transportation services.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  PROVIDER ZIP CODE
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-220
2-250
1
Up to 99
Yes
Yes
Primary Picture (Format)
Nine (9) alphanumeric characters.
Definition
Location of provider’s business office where care is usually provided.
Code/Value Specifications
Must be a valid five or nine digit zip code. If only five digits, left justify and blank fill. If a foreign country, must be three character foreign country code, left justify and blank fill. Refer to Addendum A.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
- END -

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