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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 5.4
Institutional Edit Requirements (ELN 300 - 399)
Revision:  C-36, April 15, 2020
ELEMENT NAME:  PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (1-300)
1  PATIENT AGE IS CALCULATED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND DATE OF ADMISSION.
VALIDITY EDITS
1-300-01V
IF FILING DATE PRIOR TO 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM).
1-300-02V
IF FILING DATE ON OR AFTER 10/01/2004
THEN VALUE IN POSITIONS 1-7 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
1-300-03V
POA INDICATOR (POSITION 8 OF THE PRINCIPAL DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
1-300-01R
IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =
799.9
ICD-9-CM OR
R69
ICD-10-CM OR
R99
ICD-10-CM
THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
1
MEDICAID
1-300-02R
IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
AND PERSON SEX (PATIENT) = MALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
G
DIAGNOSIS/PROCEDURE CODE FOR FEMALE: SEX INDICATES MALE
1-300-03R
IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
AND PERSON SEX (PATIENT) = FEMALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
H
DIAGNOSIS/PROCEDURE CODE FOR MALE: SEX INDICATES FEMALE
1-300-05R
IF OP/NSP CODE IS CESAREAN SECTION OR REMOVAL OF FETUS (74.0-74.2, 74.4-74.99, 10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10A00ZZ, 10A03ZZ, 10A04ZZ, 10A08ZZ, 10A07Z6, 10A07ZW, 10A07ZX, OR 10A07ZZ)
THEN PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) MUST BE 640-676 OR O09.00-O77.9, O82, OR O85-O9A.53.
1-300-06R
IF OP/NSP CODE IS ECTOPIC PREGNANCY (74.3, 10D27ZZ, 10D28ZZ, 10T20ZZ, 10T23ZZ, OR 10T24ZZ)
THEN PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) MUST BE 633.0-633.9 OR O00.0-O00.9.
1-300-07R
IF TYPE OF INSTITUTION =
72
RTC
AND AMOUNT ALLOWED (TOTAL) > 0
THEN PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) MUST =
290-316 (MENTAL HEALTH, ICD-9-CM) OR
F01- F99 (MENTAL HEALTH, ICD-10-CM)
1-300-09R
IF TYPE OF INSTITUTION =
72
RTC
AND AMOUNT ALLOWED (TOTAL) > 0
THEN PATIENT AGE1 MUST BE < 21
UNLESS ENROLLMENT/HEALTH PLAN CODE =
SR
SHCP-MTF REFERRED CARE
ELEMENT NAME:  SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR OCCURRENCES 1-24 (1-305 THROUGH 1-328)
1  XXX EQUALS ELN (305 THROUGH 328) FOR EACH OCCURRENCE OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR.
VALIDITY EDITS
1-XXX-01V1
IF FILING DATE PRIOR TO 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE IF PRESENT OR BLANK FILLED
1-XXX-0V1
IF FILLING DATE ON OR AFTER 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE OR BLANK FILLED
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
1-XXX-03V1
ALL OCCURRENCES OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR.
1-XXX-04V1
POA INDICATOR (POSITION 8 OF THE SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
1-XXX-01R1
IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
AND PERSON SEX (PATIENT) = MALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
G
DIAGNOSIS/PROCEDURE CODE FOR FEMALE: SEX INDICATES MALE
1-XXX-02R1
IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
AND PERSON SEX (PATIENT) = FEMALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
H
DIAGNOSIS/PROCEDURE CODE FOR MALE: SEX INDICATES FEMALE
ELEMENT NAME:  PRINCIPAL OPERATION/NON-SURGICAL PROCEDURE CODE (OP/NSP) (1-345)
VALIDITY EDITS
1-345-01V
IF FILING DATE IS PRIOR TO 10/01/2004
THEN VALUE MUST BE A VALID ICD OP/NSP CODE IF PRESENT OR BLANK FILLED
1-345-02V
IF FILING DATE IS ON OR AFTER 10/01/2004
THEN VALUE MUST BE A VALID ICD OP/NSP CODE IF PRESENT OR BLANK FILLED
AND ADMISSION DATE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP
OR BEGIN DATE OF CARE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP REFERENCE TABLE
OR END DATE OF CARE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP REFERENCE TABLE
Relational Edits
NONE
ELEMENT NAME:  SECONDARY OPERATION/NON/SURGICAL PROCEDURE CODE OCCURRENCES 1-24 (1-350 THROUGH 1-373)
1  XXX EQUALS ELN (350 THROUGH 373) FOR EACH OCCURRENCE OF SECONDARY OPERATION/NON-SURGICAL PROCEDURE CODE.
VALIDITY EDITS
1-XXX-01V1
IF FILING DATE IS PRIOR TO 10/01/2004
THEN VALUE MUST BE A VALID ICD OP/NSP CODE IF PRESENT OR BLANK FILLED
1-XXX-02V1
IF FILING DATE IS ON OR AFTER 10/01/2004
THEN VALUE MUST BE VALID ICD OP/NSP CODE IF PRESENT OR BLANK FILLED
AND ADMISSION DATE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP
OR BEGIN DATE OF CARE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP REFERENCE TABLE
OR END DATE OF CARE MUST BE ON OR AFTER THE OP/NSP EFFECTIVE DATE AND NOT LATER THAN THE OP/NSP TERMINATION DATE ON THE ICD OP/NSP REFERENCE TABLE
1-XXX-03V1
ALL OCCURRENCES OF SECONDARY OP/NSP CODE FIELD MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SECONDARY OP/NSP CODE.
Relational Edits
NONE
ELEMENT NAME:  TED RECORD CORRECTION INDICATOR (1-374)
VALIDITY EDITS
1-374-01V
VALUE MUST BE BLANK.
Relational Edits
NONE
ELEMENT NAME:  TOTAL OCCURRENCE/LINE ITEM COUNT (1-375)
VALIDITY EDITS
1-375-01V
VALUE MUST BE IN RANGE 001-450.
AND MUST EQUAL THE PHYSICAL COUNT OF THE DETAIL LINE ITEMS ON THE TED RECORD
1-375-02V
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 TOTAL OCCURRENCE/LINE ITEM COUNT MUST BE ≥ TOTAL OCCURRENCE/LINE ITEM COUNT FROM DHA DATABASE
Relational Edits
NONE
ELEMENT NAME:  AMOUNT NETWORK PROVIDER DISCOUNT (1-377)
VALIDITY EDITS
1-377-01V
MUST BE NUMERIC AND ≥ ZERO
Relational Edits
1-377-01R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA OR
O
ZERO GOVERNMENT TED RECORD DUE TO 100% OHI
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
1-377-02R
IF PROVIDER NETWORK STATUS INDICATOR =
2
NON-NETWORK PROVIDER
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
1-377-03R
IF REGION INDICATOR =
b
BLANK
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
ELEMENT NAME:  ADJUSTMENT SEQUENCE NUMBER (1-378)
VALIDITY EDITS
1-378-01V
MUST BE NUMERIC
Relational Edits
1-378-01R
IF TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)
1-378-02R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION
THEN ADJUSTMENT SEQUENCE NUMBER MUST BE ONE GREATER THAN THE CURRENT VALUE IN THE TED DATABASE
1-378-03R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)
ELEMENT NAME:  SCH DRG NUMBER (1-379)
VALIDITY EDITS
1-379-01V
MUST BE A VALID DRG NUMBER OR BLANK-FILLED.
Relational Edits
1-379-01R
IF SCH DRG CALCULATION > 0
THEN SCH DRG NUMBER MUST NOT BE BLANK
ELEMENT NAME:  OCCURRENCE/LINE ITEM NUMBER (1-380)
VALIDITY EDITS
1-380-01V
EACH VALUE MUST BE NUMERIC.
1-380-02V
OCCURRENCE/LINE ITEM NUMBER MUST BE CODED FOR EACH NUMBER OF OCCURRENCES SPECIFIED BY THE TOTAL OCCURRENCE/LINE ITEM COUNT.
1-380-03V
OCCURRENCE/LINE ITEM NUMBER MUST BE REPORTED IN ASCENDING CONSECUTIVE ORDER.
Relational Edits
NONE
ELEMENT NAME:  REVENUE CODE (1-385)
VALIDITY EDITS
1-385-01V
VALUE MUST BE A VALID REVENUE CODE.
UNLESS ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTING IN Addendum G, Figure 2.G-1 OR Figure 2.G-2
Note:  THE FOLLOWING VALID OUTPATIENT REVENUE CODES ARE ALLOWED ON AN INSTITUTIONAL TED RECORD ONLY WHEN BEING DENIED
049X, 051X-054X, 0630-0635, 064X, 0661, 0662, 082X-085X, 0882, AND 310X.
1-385-02V
FIRST DETAILED LINE MUST CONTAIN REVENUE CODE 0001.
Relational Edits
1-385-01R
ONLY ONE OCCURRENCE OF REVENUE CODE MUST = 0001.
1-385-02R
AT LEAST ONE OCCURRENCE OF REVENUE CODE FOR ROOM ACCOMMODATION CHARGES MUST = 010X-021X OR 0724 OR 100X
UNLESS ONE OCCURRENCE OF OVERRIDE CODE =
Y
NEWBORN IN MOTHER’S ROOM WITHOUT NURSERY CHARGES
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
11
HOSPICE
OR ANY OCCURRENCE OF REVENUE CODE =
0023
HHA PPS
OR AMOUNT ALLOWED (TOTAL) = ZERO
1-385-03R
IF PRICING RATE CODE =
H
TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
I
TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR
J
TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR
DD
DISCOUNTED DRG
THEN PROFESSIONAL SERVICE REVENUE CODES = 0901, 0914-0918, OR 096X-098X
AND AQUISITION OF BODY PARTS (081X) MUST BE DENIED.
1-385-04R
IF ANY REVENUE CODE = 0723
THEN PERSON SEX (PATIENT) MUST = MALE.
1-385-05R
IF ANY REVENUE CODE = 072X BUT NOT 0723
THEN PERSON SEX (PATIENT) MUST = FEMALE
1-385-06R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION
THEN REVENUE CODES MUST OCCUR IN THE SAME ORDER
AND ON THE SAME OCCURRENCE/LINE ITEM NUMBER AS DHA DATABASE.
1-385-07R
IF REVENUE CODE =
0022
SNF CHARGE
THEN ADMISSION DATE ≥ 08/01/2003
AND TYPE OF INSTITUTION MUST =
76
SNF
AND HIPPS CODE ≠ BLANK
UNLESS PATIENT AGE IS < 10 YEARS OF AGE ON DATE OF ADMISSION
1-385-09R
IF ANY REVENUE CODE =
0650
GENERAL CLASSIFICATION OR
0651
ROUTINE HOME CARE OR
0652
CONTINUOUS HOME CARE OR
0655
INPATIENT RESPITE CARE OR
0656
GENERAL INPATIENT CARE - NON-RESPITE OR
0657
PHYSICIAN SERVICES OR
0659
OTHER HOSPICE
THEN TYPE OF INSTITUTION MUST =
78
NON-HOSPITAL BASED HOSPICE OR
79
HOSPITAL BASED HOSPICE
UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-385-11R
IF REVENUE CODE =
0023
HHA PPS
AND BEGIN DATE OF CARE ≥ 06/01/2004
THEN TYPE OF INSTIUTION MUST =
70
HHA
ELEMENT NAME:  UNITS OF SERVICE BY REVENUE CODE (1-390)
VALIDITY EDITS
1-390-01V
VALUE MUST BE SIGNED NUMERIC, 0 TO 9,999,999.
UNLESS TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN VALUE MUST BE SIGNED NUMERIC, -9,999,999 TO 9,999,999
Relational Edits
1-390-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN UNITS OF SERVICE BY REVENUE CODE MUST BE > ZERO FOR ALL OCCURRENCES/LINE ITEMS
EXCLUDING REVENUE CODE 0001 AND 0023.
1-390-02R
IF UNITS OF SERVICE BY REVENUE CODE = 0
AND TYPE OF SUBMISSION ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN TOTAL CHARGE BY REVENUE CODE MUST ALSO = 0 (FOR THAT OCCURRENCE/LINE ITEM)
EXCEPT FOR REVENUE CODE 0001 OR 0022
1-390-03R
IF UNITS OF SERVICE BY REVENUE CODE > 0
AND TYPE OF SUBMISSION ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN TOTAL CHARGE BY REVENUE CODE MUST ALSO > 0 (FOR THAT OCCURRENCE/LINE ITEM)
UNLESS REVENUE CODE =
0022
SNF PPS OR
0023
HHA PPS OR
0024
REHAB PPS OR
0180
GENERAL CLASSIFICATION OR
0182
PATIENT CONVENIENCE OR
0183
THERAPEUTIC LEAVE OR
0184
RESERVED (EFFECTIVE 04/01/2004) OR
0185
HOSPITALIZATION OR
0189
OTHER LEAVE OF ABSENCE
OR THE OCCURRENCE/LINE ITEM CONTAINS AN ADJUSTMENT/DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
1-390-04R
IF REVENUE CODE = 0001
THEN UNITS OF SERVICE BY REVENUE CODE MUST = ZERO.
ELEMENT NAME:  TOTAL CHARGE BY REVENUE CODE (1-395)
VALIDITY EDITS
1-395-01V
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN MUST BE - 999,999.99 TO 999,999.99
UNLESS REVENUE CODE = 0001
THEN MUST BE - 9,999,999.99 TO 9,999,999.99
ELSE MUST BE 0 TO 999,999.99
UNLESS REVENUE CODE = 0001
THEN MUST BE 0 TO 9,999,999.99
Relational Edits
1-395-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN TOTAL CHARGE BY REVENUE CODE MUST BE > ZERO ON EACH OCCURRENCE/LINE ITEM (EXCLUDING REVENUE CODE 0001, 0022, 0023, 0024, 0180, 0182, 0183, 0184, 0185, AND 0189)
1-395-02R
THE SUM OF ALL TOTAL CHARGE BY REVENUE CODE FOR REVENUE CODES OTHER THAN 0001 MUST EQUAL THE TOTAL CHARGE BY REVENUE CODE FOR REVENUE CODE 0001.
- END -

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