ADT Segments (HL7 Data Transmission Guide Appendix B)

BHS
Seq 1

Batch Header Segment

2.4 Len 1 DT ST Rep Element Name Batch Field Separator Sup Yes Description The character representing the separator between Segment ID and the first real field (BHS-2). Serves as the separator and defines the character to be used as a separator for the rest of the message. Recommended value is | (ASCII 124). Four characters in the following order: component separator, repetition separator, escape character and subcomponent separator. Recommended values are ^~\& (ASCII 94, 126, 92 and 38, respectively). Uniquely identifies the sending application. For RPMS sites, the value will be "RPMS"; for non-RPMS site, it will be the name of the application. Contains the address of one of several occurrences of the same application within the sending system. Uniquely identifies the receiving applications among all other applications. This will be "DW1." Identifies the receiving application among multiple instances of the application running on behalf of different organizations. Constant value is "IHS." Date export was run. Format CCYYMMDD. If the export runs over multiple days, this is the date the export started. In some applications of HL7, this field is used to implement security features. Its use is not yet further specified. This field can be used by the application processing the batch, and can have extra components if needed. For RPMS sites, this will be the batch log IEN from RPMS. This is a comment field not further defined in the HL7 protocol. For DW1 purposes, this will be the name of the exporting box's site. Uniquely identifies a particular batch concatenating the values of BHS-4 and BHS-9. This can be echoed back in BHS-12 if an answering batch is needed. This has a value only if the batch is repeated. It is the BHS11 value in the original batch that is being repeated. Comp 1

Version Number:

ST

Batch Encoding Characters

Yes

15

ST

Batch Sending Application

Yes

4 5

1 1

20 15

ST ST

Batch Sending Facility Batch Receiving Application

Yes Yes

20

ST

Batch Receiving Facility

Yes

26

TS

Batch Creation Date/Time

Yes

8 9

1 1

40 20

ST ST

Batch Security Batch Name/ID/Type

No Yes

10

80

ST

Batch Comment

Yes

11

20

ST

Batch Control ID

Yes

12

20

ST

Reference Batch Control ID

No

BHS Batch Header Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 1 of 45

BTS

Batch Trailer Segment

2.4 Len 10 80 100 DT ST ST NM Y Rep Element Name Batch Message Count Batch Comment Batch Totals Sup Yes Yes Yes Description

Version Number: Seq 1 2 3 Comp 1 1 1

BTS Batch Trailer Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 2 of 45

DG1
Seq 1

Diagnosis Segment
2.4 Len 2 DT SI Rep Element Name Set ID - DG1 Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. The first occurrence is considered the "primary" diagnosis. Comp 1

Version Number:

2 3

1 1

2 6

ID CE

Diagnosis Coding Method Diagnosis Code - DG1

No Yes Nationally recognized standard code set (http://www.cdc.gov/nchs/icd.htm)

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

40 26 2 250 250 1 2 250 3 12 4 2 250 3 1 26

ST TS IS CE CE ID IS CE NM CP ST ID XCN IS ID TS Y

Diagnosis Description Diagnosis Date/Time Diagnosis Type Major Diagnostic Category Diagnostic Related Group DRG Approval Indicator DRG Grouper Review Code Outlier Type Outlier Days Outlier Cost Grouper Version And Type Diagnosis Priority Diagnosing Clinician Diagnosis Classification Confidential Indicator Attestation Date/Time

No No No No No No No No No No No No No No No No

DG1 Diagnosis Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 3 of 45

EVN
Seq 1

Event Type Segment

2.4 Len 3 DT ID Rep Element Name Event Type Code Sup Yes Description Retained for backward compatibility only. IHS recommends using the second component of MSH-9 to transmit the event type code information. Duplicates MSH-7. Comp 1

Version Number:

2 3 4 5 6 7

1 1 1 1 1 1

26 26 3 250 26 180

TS TS IS XCN TS HD Y

Recorded Date/Time Date/Time Planned Event Event Reason Code Operator ID Event Occurred Event Facility

Yes No No No No No

EVN Event Type Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 4 of 45

IN1

Insurance Segment
2.4 Len 4 DT SI Rep Element Name Set ID - IN1 Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Sending application's Insurance Plan ID. Insurance company's EIN. LOOKUP: INSURANCE_CAT; Insurance Company Category. Insurance Company Name.

Version Number: Seq Comp 1 1

2 3 4

1 1 1 2

250 11 3 50 250 250 250 12 250 250 250 8 8 250 2 30 30 30 30 17

IS CX IS ST XAD XPN XTN ST XON CX XON DT DT CM IS IS ST ST ST IS Y Y Y Y Y Y Y Y Y

Insurance Plan ID Insurance Company ID Insurance Company Name

No Yes Yes Yes

5 6 7 8 9 10 11 12 13 14 15

1 1 1 1 1 1 1 1 1 1 1 2

Insurance Company Address Insurance Co Contact Person Insurance Co Phone Number Group Number Group Name Insured's Group Emp ID Insured's Group Emp Name Plan Effective Date Plan Expiration Date Authorization Information Plan Type

No No No Yes No No No Yes Yes No Yes Yes LOOKUP: STATE; Medicaid State Of Eligibility. Medicaid Plan Name. Last Name. First Name. Middle Initial or Name. This will be the applicable code for "relationship to insured" used by UB-92, a nationally recognized standard for electronic claims submission. Note that this code set is scheduled to change 10/16/2003. For Medicaid and Medicare this will be the eligibility date; for private insurance this will be the effective date. For Medicaid and Medicare this will be the eligibility end date; for private insurance this will be the expiration date.

16

1 2 3

Name Of Insured

Yes Yes Yes

17

Insured's Relationship To Patient

Yes

IN1 Insurance Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 5 of 45

IN1

Insurance Segment
2.4 Len 26 250 2 2 2 1 8 1 8 2 15 26 250 2 2 4 4 8 15 12 12 4 12 DT TS XAD IS IS ST ID DT ID DT IS ST TS XCN IS IS NM NM IS ST CP CP NM CP Y Y Rep Element Name Insured's Date Of Birth Insured's Address Assignment Of Benefits Coordination Of Benefits Coord Of Ben. Priority Notice Of Admission Flag Notice Of Admission Date Report Of Eligibility Flag Report Of Eligibility Date Release Information Code Pre-Admit Cert (PAC) Verification Date/Time Verification By Type Of Agreement Code Billing Status Lifetime Reserve Days Delay Before L.R. Day Company Plan Code Policy Number Policy Deductible Policy Limit - Amount Policy Limit - Days Room Rate - Semi-Private Sup No No No No No No No No No No No No No No No No No No No No No No No Description

Version Number: Seq Comp 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

IN1 Insurance Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 6 of 45

IN1

Insurance Segment
2.4 Len 12 250 1 250 2 8 2 DT CP CE IS XAD ST IS IS Y Rep Element Name Room Rate - Private Insured's Employment Status Insured's Administrative Sex Insured's Employer's Address Verification Status Prior Insurance Plan ID Coverage Type Sup No No No No No No Yes For Medicare and Railroad: A or B; for Medicaid: value must be 1 or 2 chars; not applicable for private. Description

Version Number: Seq Comp 41 42 43 44 45 46 47 1 1 1 1 1 1 1

48 49

1 1 2

2 30 3

IS CX CX Y

Handicap Insured's ID Number

No Yes Yes Policy Number. Prefix / Suffix.

IN1 Insurance Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 7 of 45

MSA
Seq 1

Message Acknowledgement Segment

2.4 Len 2 DT ID Rep Element Name Acknowledgment Code Sup Yes Description CA = Application Accept, CE = Application Error, CR = Application Reject. The message control ID of the original message sent by the sending system; allows the sending system to associate this response with the message for which it is intended. Comp 1

Version Number:

20

ST

Message Control ID

Yes

3 4 5 6

1 1 1 1

80 15 1 250

ST NM ID CE

Text Message Expected Sequence Number Delayed Acknowledgment Type Error Condition

No No No No

MSA Message Acknowledgement Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 8 of 45

MSH

Message Header Segment

2.4 Len 1 DT ST Rep Element Name Field Separator Sup Yes Description The separator between the Segment ID and the first real field (MSH-2). Serves as the separator and defines the character to be used as a separator for the rest of the message. Recommended value is | (ASCII 124). The four characters in the following order: component separator, repetition separator, escape characters and subcomponent separators. Recommended values are ^~\& (ASCII 94, 126, 92 and 38, respectively). Uniquely identifies the sending application. For RPMS sites, the value will be "RPMS"; for non-RPMS site, it will be the name of the application. Contains the address of one of several occurrences of the same application within the sending system. Uniquely identifies the receiving applications among all other applications within. This will be "DW1." Identifies the receiving application among multiple instances of the application running on behalf of different organizations. Constant value is "IHS." The date time the message was created; may be sent with or without seconds. Used to implement security features; not yet further specified. Message type (e.g., ADT for inbound messages). Trigger Event (e.g., A08 or A31). Uniquely identifies a particular message. Identifies the current status of the interface. Only the first component (DT=ID) is supported in DW1. Valid values: "D" = Debug "P" = Production "T" = Training. The HL7 Standard Version used; DW1 supports version 2.4. Not used with standard dictionary. Not used with standard dictionary. "AL" = Always Acknowledge "NE" = Never Acknowledge. "AL" = Always Acknowledge "NE" = Never Acknowledge. NV

Version Number: Seq Comp 1 1

ST

Encoding Characters

Yes

180

HD

Sending Application

Yes

4 5 6

1 1 1

180 180 180

HD HD HD

Sending Facility Receiving Application Receiving Facility

Yes Yes Yes

7 8 9

1 1 1 2

26 40 3 3 20 3

TS ST ID ID ST PT

Date/Time Of Message Security Message Type

Yes Yes Yes Yes

10 11

1 1

Message Control ID Processing ID

Yes Yes

12 13 14 15 16 17

1 1 1 1 1 1

60 15 180 2 2 3

VID NM ST ID ID ID

Version ID Sequence Number Continuation Pointer Accept Acknowledgment Type Application Acknowledgment Type Country Code

Yes No No Yes Yes No

MSH Message Header Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 9 of 45

MSH

Message Header Segment

2.4 Len 16 250 20 10 DT ID CE ID ID Y Rep Y Element Name Character Set Principal Language Of Message Alternate Character Set Handling Scheme Conformance Statement ID Sup No No No No Description NV NV NV NV

Version Number: Seq Comp 18 19 20 21 1 1 1 1

MSH Message Header Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 10 of 45

OBX-CPT
Seq 1

CPT Segment
2.4 Len 4 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "CPT" to indicate a CPT or HCPCS observation. Valid CPT or other HCPCS code.

Version Number: Comp 1

2 3 4 5

1 1 1 1

3 5

ST ST

Type of Result CPT Code

Yes Yes No

ST

CPT Quantity

Yes

OBX-CPT CPT Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 11 of 45

OBX-HF
Seq 1

Health Factor Segment

2.4 Len 4 DT ID Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "HF" to indicate a Health Factor observation. Health Factor Category. Health Factor Code. Health Factor Name. Health Factor Category Code. Comp 1

Version Number:

2 3

1 1 2 3

3 40 4 40 4

ST IS ST ST ST

Type of Result Health Factor

Yes Yes Yes Yes

Health Factor Category Code

Yes

OBX-HF Health Factor Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 12 of 45

OBX-LAB
Seq 1

Lab Segment
2.4 Len 2 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "LAB" to indicate a Lab observation. LOINC Code. Local Lab Test Name.

Version Number: Comp 1

2 3

1 1 2

3 10 40

ST IS ST

Type of Result Lab Test

Yes Yes Yes No

4 5 6 7

1 1 1 1 2 200 30 12 12 ST ST ST ST Lab Test Results Lab Test Units Reference Range

Yes Yes Yes Yes Unit of measure for this lab test. Reference Low. Reference High.

OBX-LAB Lab Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 13 of 45

OBX-MSR
Seq 1

Measurement Segment
2.4 Len 2 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "MSR" to indicate a Measurement observation. LOOKUP: CLINICAL_MEASURE Not supported by DW1. Measurement Value; formatting accepted is 999/999 for blood pressure; 999.9 for weight in pounds; 99.9 for height in inches.

Version Number: Comp 1

2 3 4 5

1 1 1 1

3 2 30 15

ST IS ST ST

Type of Result Clinical Measurement Code Clinical Measurement Type Measurement Value

Yes Yes No Yes

OBX-MSR Measurement Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 14 of 45

OBX-PED
Version Number: Seq Comp 1 1

Patient Education Segment

2.4 Len 2 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "PED" to indicate a CPT observation. LOOKUP: EDUCATION

2 3 4 5 6 7 8 9 10 11 12 13

1 1 1 1 1 1 1 1 1 1 1 1

3 12

ST IS

Type of Result Patient Education Code

Yes Yes No

IS

Patient Level of Understanding Code

Yes No No No No No No No

LOOKUP: EDUC_UNDERSTAND

NM

Patient Education Length of Education

Yes

Length of the education in minutes.

OBX-PED Patient Education Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 15 of 45

OBX-SKT
Seq 1

Skin Test Segment

2.4 Len 2 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "SKT" to indicate a CPT observation. LOOKUP: SKIN_TEST

Version Number: Comp 1

2 3 4 5

1 1 1 1 2

3 2

ST IS

Type of Result Skin Test Code

Yes No No

1 5

IS NM

Result/Reading

Yes Yes

LOOKUP: SKIN_TEST_RESULT Skin Test Reading. Numeric measurement of skin test result in mm.

OBX-SKT Skin Test Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 16 of 45

OBX-XAM
Seq 1

Exam Segment
2.4 Len 2 DT SI Rep Element Name Set ID Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Constant: "XAM" to indicate an Exam observation. LOOKUP: EXAM_IHS

Version Number: Comp 1

2 3

1 1

3 2

ST IS

Type of Result Exam Code

Yes Yes

OBX-XAM Exam Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 17 of 45

PID

Patient Identification Segment

2.4 Len 4 20 15 DT SI CX IS Rep Element Name Set ID - PID Patient ID Unique Registration Code (Patient ID) Sup Yes No Yes Not supported by DW1. 15-character unique identifier. The first 5-characters are the identifier agreed upon between the sending application and the National Data Warehouse. The remaining 10-characters contain the ID the sending application uses to uniquely identify this patient, right justified and left zero filled. (For example: XXXXX0000000001) 12-character alternate patient identifier. The first 6characters are the facility code where the patient's chart resides. The remaining 6-characters are the patient's chart number, right justified with leading zeroes. Last Name. First Name. Middle Initial or Name. Name suffix, such as Sr., Jr., III, etc. Title, such as Mr., Ms., Mrs., Miss, etc. Mother's Maiden Last Name. Mother's Maiden First Name. Mother's Maiden Middle Initial or Name. Date of Birth. GENDER (M = Male, F = Female, U = Unknown) Data is supported in Segment ZRL (element ZRL-6). Description

Version Number: Seq Comp 1 2 3 1 1 1

12

ST

Alternate Patient ID (Health Record Number)

Yes

1 2 3 4 5

30 30 30 10 10 30 30 30 8 1 250 250

ST ST ST ST ST ST ST ST DT IS XPN CE Y Y

Patient's Name

Yes Yes Yes Yes Yes

1 2 3

Mother's Maiden Name

No No No

7 8 9 10

1 1 1 1

Date of Birth Gender Patient Alias Race

Yes Yes No No

PID Patient Identification Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 18 of 45

PID

Patient Identification Segment

2.4 Len 50 50 30 2 10 DT ST ST ST IS ST ST IS 4 250 250 250 250 250 250 10 IS XTN XTN CE CE CE CX ST Y Y County Code Phone Number - Home Phone Number - Business Primary Language Marital Status Religion Patient Account Number SSN Number - Patient Rep Element Name Patient Address Sup Yes Yes Yes Yes Yes No No No No No No No No No Yes Patient's SSN without dashes; format 999999999. (If SSN is pseudo, 10th character is a "P".) Description Street Address. Additional Street Address. City. LOOKUP: STATE Zip or Postal Code; format 99999-9999. Country. County.

Version Number: Seq Comp 11 1 2 3 4 5 6 7 12 13 14 15 16 17 18 19 1 1 1 1 1 1 1 1

20 21 22 23 24 25 26 27

1 1 1 1 1 1 1 1

25 250 250 250 1 2 250 1

DLN CX CE ST ID NM CE BL Y Y Y

Driver's License Number - Patient Mother's Identifier Ethnic Group Birth Place Multiple Birth Indicator Birth Order Citizenship Veterans Military Status

No No No No No No No Yes "Y" =Patient is a person who has previously served in the US Military, otherwise "N." Data is supported in Segment ZP2 (element ZP2-14).

PID Patient Identification Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 19 of 45

PID

Patient Identification Segment

2.4 Len 250 8 1 1 20 26 40 250 250 80 250 DT CE DT ID ID IS TS HD CE CE ST CE Y Y Rep Element Name Nationality Patient Death Date and Time Patient Death Indicator Identity Unknown Indicator Identity Reliability Code Last Update Date/Time Last Update Facility Species Code Breed Code Strain Production Class Code Sup No Yes No No No No No No No No No Date only; time not supported by DW1. Description

Version Number: Seq Comp 28 29 30 31 32 33 34 35 36 37 38 1 1 1 1 1 1 1 1 1 1 1

PID Patient Identification Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 20 of 45

PR1

Procedure Segment
2.4 Len 2 DT SI Rep Element Name Set ID - PR1 Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on.

Version Number: Seq Comp 1 1

2 3 4 5 6 7 8 9 10 11

1 1 1 1 1 1 1 1 1 1 2

3 5 40 8 2 4 250 2 4 1 2 250 250 2 250 250 20 250

IS CE ST DT IS NM XCN IS NM IS IS XCN CE ID CE CE IS CE Y Y Y Y Y

Procedure Coding Method Procedure Code Procedure Description Procedure Date/Time Procedure Functional Type Procedure Minutes Anesthesiologist Anesthesia Code Anesthesia Minutes Surgeon

No Yes No Yes No No No No No Yes Yes LOOKUP: AFFILIATION; Provider Affiliation. LOOKUP: PROVIDER_DISC; Provider Discipline. Date only; time not supported by DW1. Nationally recognized standard code set (http://www.cdc.gov/nchs/icd.htm)

12 13 14 15 16 17 18

1 1 1 1 1 1 1

Procedure Practitioner Consent Code Procedure Priority Associated Diagnosis Code Procedure Code Modifier Procedure DRG Type Tissue Type Code

No No No No No No No

PR1 Procedure Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 21 of 45

PV1

Patient Visit Segment

2.4 Len 2 1 6 1 250 80 1 2 3 250 250 2 80 2 2 6 2 2 250 2 15 DT SI IS IS IS CX PL IS IS IS XCN XON IS PL IS IS IS IS IS XCN IS IS Y Y Y Y Referring Doctor Consulting Doctor Hospital Service Temporary Location Preadmit Test Indicator Re-admission Indicator Admit Source Ambulatory Status VIP Indicator Admitting Doctor Patient Type Unique Encounter Code (Visit Number) Rep Element Name Set ID - PV1 Patient Class Assigned Patient Location Admission Type Preadmit Number Prior Patient Location Attending Doctor Sup No No Yes Yes No No Yes Yes Yes No No Yes No No No No No No No No Yes 15-character unique identifier. The first 5-characters are the identifier agreed upon between the sending application and the National Data Warehouse. The remaining 10-characters contain the ID the sending application uses to uniquely identify this visit, right justified and left zero filled. (For example: XXXXX0000000001) LOOKUP: SERVICE LOOKUP: AFFILIATION; Attending Physician Code. LOOKUP: PROVIDER_DISC; Provider Discipline. Attending Physician Code; sending application value; sometimes initials. LOOKUP: FACILITY; Location of encounter for the visit. LOOKUP: ADMISSION Description DW1 supports only one occurrence per message, so SET ID is not applicable.

Version Number: Seq Comp 1 2 3 4 5 6 7 1 1 1 1 1 1 1 2 3 8 9 10 11 12 13 14 15 16 17 18 19 1 1 1 1 1 1 1 1 1 1 1 1

PV1 Patient Visit Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 22 of 45

PV1

Patient Visit Segment

2.4 Len 50 2 2 2 2 8 12 3 2 1 8 10 12 12 1 8 1 6 250 2 1 2 80 DT FC IS IS IS IS DT NM NM IS IS DT IS NM NM IS DT IS CM CE IS IS IS PL Y Y Y Y Rep Y Element Name Financial Class Charge Price Indicator Courtesy Code Credit Rating Contract Code Contract Effective Date Contract Amount Contract Period Interest Code Transfer to Bad Debt Code Transfer to Bad Debt Date Bad Debt Agency Code Bad Debt Transfer Amount Bad Debt Recovery Amount Delete Account Indicator Delete Account Date Discharge Disposition Discharged to Location Diet Type Servicing Facility Bed Status Account Status Pending Location Sup No No No No No No No No No No No No No No No No Yes Yes No No No No No LOOKUP: ER_DISPOS; Disposition on ER visits. LOOKUP: FACILITY; Facility patient was transferred to. Description

Version Number: Seq Comp 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

PV1 Patient Visit Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 23 of 45

PV1

Patient Visit Segment

2.4 Len 80 8 DT PL DT Rep Element Name Prior Temporary Location Admit Date/Time Sup No Yes Outpatient visit date or inpatient admission date. Date only; time not supported by DW1. Date only; time not supported by DW1. Description

Version Number: Seq Comp 43 44 1 1

45 46 47 48 49 50 51 52

1 1 1 1 1 1 1 1

8 12 12 12 12 250 1 250

DT NM NM NM NM CX IS XCN Y

Discharge Date/Time Current Patient Balance Total Charges Total Adjustments Total Payments Alternate Visit ID Visit Indicator Other Healthcare Provider

Yes No No No No No No No

PV1 Patient Visit Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 24 of 45

ZDN
Seq 1 2 3 4 5 6 7

IHS Dental Segment

2.4 Len 2 4 2 5 1 7 9 DT SI IS NM NM IS ST ST Rep Element Name ADA Sequence Number ADA Code # of Units ADA Code Fee Delivery Mode Dental Total Cost Dentists SSN Sup Yes Yes Yes Yes Yes Yes Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. LOOKUP: ADA Number of units for this ADA code. Fee for this coded service, rounded to nearest dollar. If multiple units are stated for this code entry, fee amount is the total for all units. DENTAL DELIVERY CODE (D = Direct, K = Contract) Rounded to the nearest dollar. 9999999. Dentist's SSN without dashes; format 999999999. Comp 1 1 1 1 1 1 1

Version Number:

ZDN IHS Dental Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 25 of 45

ZDP
Seq 1 2 3

IHS Dental Op Segment

2.4 Len 2 3 2 DT SI IS ST Rep Element Name Set ID Op Site Tooth Surface Sup Yes Yes Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. LOOKUP: DENTAL_OPSITE While there is a generally accepted set of codes, an insurer/facility may define the code set to be used. Supplying the code alone is ambiguous. There are five generally accepted surface definitions: m=mesial, d=distal, o=occlusal, l=lingual, and b=buccal. Comp 1 1 1

Version Number:

ZDP IHS Dental Op Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 26 of 45

ZDX
Seq 1 2 3 4 5 6 7

IHS Diagnosis Segment

2.4 Len 80 1 60 1 1 6 1 DT ST NM CE IS CE IS IS Rep Element Name Provider Narrative Stage Modifier Cause of DX First / Revisit Cause of Injury Place of Injury Sup No No No Yes No Yes Yes Nationally recognized standard code set (http://www.cdc.gov/nchs/icd.htm) LOOKUP: INJURY_PLACE LOOKUP: DX_CAUSE Description Comp 1 1 1 1 1 1 1

Version Number:

ZDX IHS Diagnosis Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 27 of 45

ZEN

IHS Encounter Segment

2.4 Len 1 1 1 1 8 8 8 1 1 15 1 15 1 10 1 10 1 10 1 10 1 10 1 DT BL BL BL BL DT DT DT BL ST ST ST ST BL ST BL ST BL ST BL ST BL ST BL Rep Element Name Medicaid Eligible on Visit Date Medicare Eligible on Visit Date Private Insurance Eligible on Visit Date HTN Documented Ever Date HTN Last Documented LMP Date LMP Noted Was An Ace Inhibitor Filled Urine Protein Test Urine Protein Value Microalbuminuria Test Microalbuminuria Value DM Nutrition Education Done HGB A1C Value Pap Lab Test Glucose Value HDL Cholesterol Test HDL Cholesterol Value LDL Cholesterol Test LDL Cholesterol Value Triglyceride Test Triglyceride Value PSA Lab Test Sup Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N." Date in CCYYMMDD format. Description "Y" or "N." "Y" or "N." "Y" or "N." "Y" or "N."

Version Number: Seq Comp 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

ZEN IHS Encounter Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 28 of 45

ZEN

IHS Encounter Segment

2.4 Len 1 2 DT BL NM Rep Element Name Fecal Occult Blood Lab # of Lab Tests Done Sup No Yes Description "Y" or "N." The cumulative total of lab tests for this visit.

Version Number: Seq Comp 24 25 1 1

ZEN IHS Encounter Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 29 of 45

ZHS
Seq 1

IHS Batch Header Segment

2.4 Len 8 DT DT Rep Element Name Export Begin Date Sup Yes Description Beginning export date. This is the first creation/modification date that is included in this export. Ending export date. This is the ending creation/modification date that is included in this export. Control number assigned to the export at the local level. A code designating the file type of the export (e.g. HL7 File = HL7) Processing options associated with an HL7 export file to indicate if it is an initial, re-export, or an incremental. For RPMS HL7 these would include GDW=INCR, RERX=RERN, DRE=DRE, Initial Load=INIT. An example of a value for the GDW option would be EXO^INCR. The version of the extract software that is being utilized by the exporting site Comp 1

Version Number:

2 3 4 5

1 1 1 1

8 6 4 30

DT ST ST ST

Export End Date Export Log Number Source File Type Code Export Options

Yes Yes Yes Yes

10

ST

Source File Version Number

Yes

ZHS IHS Batch Header Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 30 of 45

ZIM
Seq 1 2 3 4 5 6

IHS Immunization Segment

2.4 Len 2 3 3 3 2 1 DT SI ST ST ST ST ST Rep Element Name Set ID HL7 CVX Code HL7 MVX Code Imm Code - IHS Mod HL7 Imm Code - Old IHS Imm Dose Number Sup Yes Yes Yes Yes No Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. LOOKUP: HL7_IMMUN_CVX LOOKUP: HL7_IMMUN_MVX LOOKUP: HL7_IMMUNIZATION Proprietary code for immunizations used by IHS prior to version 7.0 of the RPMS Immunization Package. Comp 1 1 1 1 1 1

Version Number:

ZIM IHS Immunization Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 31 of 45

ZIN
Seq 1

IHS Third Party Billing Segment

2.4 Len 8 DT DT Rep Element Name Date of Last Mod of Any Third Party Field Sup Yes Description Last date that any of the Insurance Eligibility Fields changed, formatted CCYYMMDD. (Fields include: IN1-3, IN1-4, IN1-12, IN1-13, IN1-15, N1-16, IN1-17, IN1-47, IN1-49, ZIN-5, and ZIN-6.) Time associated with last date of any field change in Insurance Eligibility Fields, formatted HHMM, (associated to ZIN-1). Valid values: "A" = New "Y" = Modifications made "N" = No Modifications made. Comp 1

Version Number:

2 3 4 5

1 1 1 1

4 1 1 7

TM ST ST IS

Time of Last Mod of Any Third Party Field Any Third Party Field Mod Since Last Export Load Code Local Database ID for this Eligibility Record Date of Last Insurance Record Update

No Yes No Yes

Sending application ID for the Eligibility record (e.g., a sequentially assigned "row counter" that allows the system to store multiple pieces of information per patient/visit). Same as value in ZIN-1.

DT

No

ZIN IHS Third Party Billing Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 32 of 45

ZMD
Seq 1 2 3 4 5

IHS Medication Segment

2.4 Len 2 40 11 5 11 DT SI ST IS IS NM Rep Element Name Set ID Drug Name NDC Code VA Drug Class Medication Quantity Sup Yes Yes Yes Yes Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. Defined by the sending application. NDC-maintained code set, format without dashes 99999999999. LOOKUP: VA_DRUG_CLASS Medication Quantity, formatted as 9999999.999. Comp 1 1 1 1 1

Version Number:

ZMD IHS Medication Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 33 of 45

ZP2

IHS Patient Information Segment

2.4 Len 8 8 8 8 12 60 3 8 8 8 1 60 40 6 3 12 1 2 8 2 6 7 60 DT DT DT DT DT ST CE ID DT DT DT ST CE AD ST CE ST IS IS DT ID ST IS CE Rep Element Name Date Established Date of last Reg Update Med/RR Release Date Med/RR Release Revoked Date Tribal Enrollment Number CHS Tribal Affiliation Blood Type Date of Last Update Assign Benefits Obtained Date Assign Benefits Expired Date SSN Verification Status Reason for no SSN Birth Place Birth Certificate Number Tribe of Membership Tribe Quantum Indian Blood Quantum Classification/Beneficiary Current Residence Date State of Death Death Certificate Number Current Community Tribe Membership Verified Flag Sup Yes Yes No No No No No No No No Yes No No No Yes No Yes Yes Yes No No Yes No LOOKUP: COMMUNITY LOOKUP: BLOOD_QUANTUM LOOKUP: BENEF_CLASS LOOKUP: TRIBE RPMS-specific. Used to indicate the SSN has gone through SSA verification process. Description Date the record was established.

Version Number: Seq Comp 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

ZP2 IHS Patient Information Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 34 of 45

ZP2

IHS Patient Information Segment

2.4 Len 1 8 60 250 250 250 250 30 30 30 40 40 1 30 30 30 ST ST ST AD AD ST ST ST ST Father's Birth Place Mother's Birth Place Eligibility Mother's Name DT ID DT CE Rep Element Name Residence Verified Flag Date Eligibility Determined Eligible Minor Child Location of Home Additional Registration Info Remarks Alerts Father's Name Sup No No No No No No No Yes Yes Yes No No Yes Yes Yes Yes LOOKUP: SVC_ELIG Mother's Last Name. Mother's First Name. Mother's Middle Initial or Name. Father's Last Name. Father's First Name. Father's Middle Initial or Name. Description

Version Number: Seq Comp 24 25 26 27 28 29 30 31 1 1 1 1 1 1 1 1 2 3 32 33 34 35 1 1 1 1 2 3

ZP2 IHS Patient Information Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 35 of 45

ZPN
Seq 1 2 3

IHS PHN Segment

2.4 Len 2 2 1 DT SI IS IS Rep Element Name Set ID Sequence Number PHN Activity Code PHN Level of Intervention Sup No Yes Yes Description DW1 does not support multiple ZPN segments; therefore, sequence number is not applicable. LOOKUP: PHN_ACTIVITY LOOKUP: PHN_INTERV_LEVEL Comp 1 1 1

Version Number:

ZPN IHS PHN Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 36 of 45

ZPR
Seq 1 2 3 4 5 6 7 8 9

IHS Procedure Segment

2.4 Len 2 60 5 80 1 1 60 60 2 DT NM CE ST ST BL ID CE CE ST Rep Element Name No. of Units Operative Site Tooth Surface Provider Narrative Infection Anesthesia Administered ASA-PS Class CPT Code for ICD Procedure Dx Done For Sup No No No No Yes No No Yes Yes The sequence number of the diagnosis (Element DG1-1) for which the CPT procedure was performed, if applicable. This is used to link the diagnosis to this procedure (Segment ZPR). LOOKUP: PROV_X12_CLASS LOOKUP: PROV_X12_SPEC LOOKUP: PROVIDER_TYPE "Y" = Infection; otherwise "N." Covered in ZDP-3. Description Comp 1 1 1 1 1 1 1 1 1

Version Number:

10 11 12

1 1 1

2 5 2

IS ST ST

Procedure Provider Class Procedure Provider Specialty Procedure Provider Type

Yes Yes Yes

ZPR IHS Procedure Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 37 of 45

ZRB
Seq 1

IHS Base Registration Segment

2.4 Len 8 DT DT Rep Element Name Date of Last Mod of Any Base Reg Sup Yes Description Last date that any of the Base Registration Record Fields changed, formatted CCYYMMDD. (Fields include: PID-3, PID-7, PID-8, PID-19, PID-29, ZRB-2, ZRB-5, ZP2-11, ZP2-31, and ZP2-35.) Time associated with last date of any field change in Base Registration Record Fields, formatted HHMM, (associated to ZRB-1). Valid values are: "A" = New "Y" = Modifications made "N" = No Modifications made. Comp 1

Version Number:

2 3 4 5

1 1 1 1

4 1

TM ST ST

Time of Last Mod of Any Base Reg Any Base Reg Field Mod Since Last Export Load Code Cause of Death

Yes Yes No Yes

IS

Nationally recognized standard code set (http://www.cdc.gov/nchs/icd.htm)

ZRB IHS Base Registration Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 38 of 45

ZRC
Seq 1 2 3

IHS Chart Segment

2.4 Len 8 4 1 DT DT TM ST Rep Element Name Date of Last Mod of Any Chart Field Time of Last Mod of Any Chart Field Any Chart Reg Field Mod Since Last Export Load Code Local Database ID for this Chart Record Sup Yes No Yes Description Last date that any of the Chart Fields changed, formatted CCYYMMDD. (Fields include: ZRC-5, ZRC-6, ZRC-7, and ZRC-8.) Time associated with last date of any field change in Chart Fields, formatted HHMM, (associated to ZRC-1). Valid values: "A" = New "Y" = Modifications made "N" = No Modifications made. Note that this response applies to all records in this segment and not this one in particular. Comp 1 1 1

Version Number:

4 5

1 1

1 7

ST IS

No Yes Sending application ID for the Chart record (e.g., a sequentially assigned "row counter" that allows the system to store multiple pieces of information per patient/visit). LOOKUP: FACILITY; Facility code where the chart is located. Patient's Chart Number. STATUS (A = Active, D = Deleted, I = Inactive)

6 7 8

1 1 1

6 6 1

IS IS IS

Chart Facility Code Chart Number Chart Status

Yes Yes Yes

ZRC IHS Chart Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 39 of 45

ZRD
Seq 1

IHS Demographic State Segment

2.4 Len 8 DT DT Rep Element Name Date of Last Mod of Any Demo Reg Sup Yes Description Last date that any of the Patient Demographic Fields changed, formatted CCYYMMDD. (Fields include: PID-5, PID-11, PID-27, ZRD-5, ZRD-6, ZRD-7, ZRD-8, ZP2-15, ZP2-16, ZP2-18, ZP2-19, ZP2-22 and ZP2-34.) Time associated with last date of any field change in Patient Demographic Fields, formatted HHMM, (associated to ZRD-1). Valid values are: "A" = New "Y" = Modifications made "N" = No Modifications made. Comp 1

Version Number:

2 3 4 5

1 1 1 1

4 1 1 50

TM ST ST ST

Time of Last Mod of Any Demo Reg Any Demo Reg Field Mod Since Last Export Load Code Patient's Full Name

No Yes No Yes

If sending application does not store the patient's full name in separate first, last, and middle name fields, this is the full name prior to parsing for transmittal. Title, such as Mr., Ms., Mrs., Miss, etc. Name suffix, such as Sr., Jr., III, etc. Valid Values: "A" = Active "I" = Inactive. criteria. Determined by sending application's

6 7 8

1 1 1

5 5 1

ST ST BL

Patient's Title Patient's Name Suffix Reg Record Status Code

No No Yes

ZRD IHS Demographic State Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 40 of 45

ZRL
Seq 1 2 3

IHS Alias Segment

2.4 Len 8 4 1 DT DT TM ST Rep Element Name Date of Last Mod of Any Alias Field Time of Last Mod of Any Alias Field Any Alias Reg Field Mod Since Last Export Load Code Local Database ID for this Alias Sup Yes No Yes Description Last date that any of the Alias Fields changed, formatted CCYYMMDD. (Fields include: ZRL-5 and ZRL-6.) Time associated with last date of any field change in Alias Fields, formatted HHMM, (associated to ZRL-1). Valid values are: "A" = New "Y" = Modifications made "N" = No Modifications made. Note that this response applies to all records in this segment and not this one in particular. Comp 1 1 1

Version Number:

4 5

1 1

1 7

ST IS

No Yes Sending application ID for the Alias record (e.g., a sequentially assigned "row counter" that allows the system to store multiple pieces of information per patient/visit). Last Name. First Name. Middle Initial or Name. Name suffix, such as Sr., Jr., III, etc. Title, such as Mr., Ms., Mrs., Miss, etc.

1 2 3 4 5

30 30 30 10 10

ST ST ST ST ST

Alias Name

Yes Yes Yes Yes Yes

ZRL IHS Alias Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 41 of 45

ZTS
Seq 1 2 3 4 5

IHS Batch Trailer Segment

2.4 Len 10 10 10 10 10 DT NM NM NM NM NM Rep Element Name Total number of visits exported Total number of visits skipped Total number of visits in error Skipped visits due to DEMO,PATIENT # of discrete records Sup Yes Yes Yes Yes Yes Description The total number of visits that are contained in this export. RPMS-specific. Used to indicate the number of PCC visits that were reviewed but not exported because of errors OR did not meet the export criteria. RPMS-specific. Used to indicate the number of visits not exported due to errors. RPMS-specific. Used to indicate the number of visits skipped because they were for a patient whose name begins with DEMO,PATIENT. Total number of records in the export file. If there is one HL7 message for each patient registration record and encounter record in the export, then this number should equal the number of registration and encounter records exported plus 2 (for the header and trailer records). Comp 1 1 1 1 1

Version Number:

ZTS IHS Batch Trailer Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 42 of 45

ZV1

IHS Patient Visit Information Segment

2.4 Len 8 60 2 14 60 1 60 12 50 60 60 3 1 1 10 6 60 9 60 2 15 2 4 DT DT CE IS TS CE IS CE NM ST CE CE NM ID ID ST ST CE NM CE NM ST ST NM Rep Element Name Date Visit Created Third Party Billed Clinic Date Last Modified Walk In / Appointment Level of Service Eligibility Amount Billed Outside Location Admitting Service Discharge Service (not used) Number of Consults Medicare Release Assignment of Benefits CHS Purchase Order Number Authorizing Facility Code Pay Status Total Charges Stillborn Number of Visits Hospital Voucher Number Vendor Activity Time Sup Yes No Yes Yes No Yes No No No No No Yes No No Yes Yes No Yes No No No Yes Yes LOOKUP: PROVIDER_TYPE Total time in minutes. CHS cost for this visit, formatted as 999999.99. CHS Purchase Order Number LOOKUP: FACILITY; Authorizing Facility Code. LOOKUP: SERVICE_LEVEL LOOKUP: CLINIC Description Date visit record was created in CCYYMMDD format.

Version Number: Seq Comp 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 16 17 18 19 20 21 22 1 1 1 1 1 1 1

ZV1 IHS Patient Visit Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 43 of 45

ZV1

IHS Patient Visit Information Segment

2.4 Len 4 4 1 8 4 DT NM TS BL DT NM Rep Element Name Travel Time Visit Last Modified Time Delete Record Flag Visit Export Date Visit Export Time Sup Yes No Yes Yes No No 2 4 1 1 2 5 6 2 1 4 NM TM IS IS IS IS IS IS IS NM Number of RX's Time of Visit/Admission Day of Week of Visit/Admission Type Service Category Evaluation and Management CPT Cause of Death Discharge Service Discharge Type Length of Stay Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Nationally recognized standard code set (http://www.cdc.gov/nchs/icd.htm) LOOKUP: SERVICE LOOKUP: INP_DISPOS Length of stay in days. DAY OF WEEK (1 = Sunday, 2 = Monday, 3 = Tuesday, 4 = Wednesday, 5 = Thursday, 6 = Friday, 7 = Saturday) LOOKUP: SVC_TYPE LOOKUP: SVC_CATEGORY Number of medication prescriptions dispensed for this visit. Not used; data supported in ZV1-26 as a time stamp. "Y" = Record deleted, otherwise "N." Description Total time in minutes.

Version Number: Seq Comp 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

ZV1 IHS Patient Visit Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 44 of 45

ZVP
Seq 1

IHS Patient Provider Segment

2.4 Len 2 DT SI Rep Element Name Set ID Sequence Number Sup Yes Description For the first occurrence, the sequence number is 1; for the second occurrence, the sequence number is 2, and so on. The first occurrence is considered the "primary" provider. LOOKUP: AFFILIATION; Provider Affiliation. LOOKUP: PROVIDER_DISC; Provider Discipline. Provider Code Provider Classification Provider Specialty Provider Type Midwifery Yes Yes Yes Yes Yes Sending application's provider classification; typically initials. LOOKUP: PROV_X12_CLASS LOOKUP: PROV_X12_SPEC LOOKUP: PROV_X12_TYPE "Y" = Provider is a midwife, otherwise "N". Comp 1

Version Number:

1 2

1 2 3 2 5 2 1

ST ST IS IS IS IS BL

Provider Affiliation/Discipline

Yes

3 4 5 6 7

1 1 1 1 1

ZVP IHS Patient Provider Segment DA100 Official Product of Documatron for DW1 Date generated: 12/1/2009

Page 45 of 45