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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 5.3
Institutional Edit Requirements (ELN 200 - 299)
Revision:  C-21, January 31, 2019
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 =
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
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 2.8.
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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