SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

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Data Element Names / Screen/Data Element Location / RequiredFor
Accommodations Days / Claim Information (Revenue Tab) Add/Update: enter Quantity then Add/Update. / IP
Accommodations Rate / Claim Information (Revenue Tab) Add/Update: enter Rate then Add/Update. / IP
Accommodations Total Charges / Claim Information (Revenue Tab) Add/Update: enter Total Charges in Amount then Add/Update. / IP
Accommodations Total Non-Covered Charges / Claim Information (Revenue Tab) Add/Update: enter Total Non-Covered Charges in Non-Covered then Add/Update. / IP
ADMISSION DATE/START OF CARE / Claim Information (General Tab):Admit/Start Date use arrow to select MMDDYYYY then Save. / AS, ED, IP
Admission Hour/Emergency Visit Hour / Claim Information (General Tab):Admit/Start DateHour use arrow to select time then Save. / AS, ED, IP
Admitting Diagnosis Code / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Type use arrow to select “Admit” then enter Diagnosis Code then Add/Update. / IP
AMI (Acute Myocardial Infarction) - Diastolic Blood Pressure on Arrival / Claim Information (AMI Elements Tab): enter 3-digit for Diastolic then Save. / ED, IP
AMI (Acute Myocardial Infarction) - Heart Rate on Arrival / Claim Information (AMI Elements Tab): enter 3-digit for Heart Rate on Arrival then Save. / ED, IP
AMI (Acute Myocardial Infarction) - Systolic Blood Pressure on Arrival / Claim Information (AMI Elements Tab): enter 3-digit for Systolic then Save. / ED, IP
ATTENDING/EMERGENCY DEPT PHYSICIAN 1 STATE LICENSE NUMBER / Claim Information (General Tab):Attending Physician License Type use arrow to select and enter License Number then Save. / ED, IP
Condition Information - Homeless Patients / Claim Information (Condition Codes Tab) Add/Update: enter “17” in Condition Code for Homeless Patients then Add/Update. / AS, ED, IP

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SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

Data Element Names / Screen/Data Element Location / RequiredFor
Condition Information - Non-US Resident Patients / Claims (Condition Codes Tab) Add/Update: enter “25” in Condition Codefor Non-US Resident Patient’s then Add/Update. / AS, ED, IP
Condition Information - Special Program (DIS) / Claim Information (Condition Codes Tab) Add/Update: enter “A5” for Condition Code (DIS) then Add/Update. / IP
Condition Information - Special Program (FP) / Claim Information (Condition Codes Tab) Add/Update: enter “A4” for Condition Code (FP) then Add/Update. / IP
Condition Information - Special Program (PHC) / Claim Information (Condition Codes Tab) Add/Update: enter “A2” for Condition Code (PHC) then Add/Update. / IP
Condition Information - Special Program (SFP) / Claim Information (Condition Codes Tab) Add/Update: enter “A3” for Condition Code (SFP) then Add/Update. / IP
Covered Days / Claim Information (General Tab):enter number of days inCovered Days then Save. / IP
Discharge Hour / Claim Information (General Tab):Through DateHour use arrow to select time then Save. / AS, ED, IP
Exempt Unit Indicator / Claim Information (General Tab):Exempt Unit use arrow to select then Save. / IP
Expected Principal Reimbursement / Claim Information (General Tab):Expected Payer: Primary use arrow to select then Save. / AS, ED, IP
Expected Reimbursement Other 1 / Claim Information (General Tab):Expected Payer: Other 1 use arrow to select then Save. / IP
Expected Reimbursement Other 2 / Claim Information (General Tab):Expected Payer: Other 2 use arrow to select then Save. / IP
External Cause-of-Injury Code / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Typeuse arrow to select “E-Code” and enter Diagnosis Code then Add/Update. / AS, ED, IP
File Sequence and Serial Number / Generated / AS, ED, IP

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SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

Data Element Names / Screen/Data Element Location / RequiredFor
Inpatient Ancillary Revenue Code / Claim Information (Revenue Tab)
Add/Update: enter Revenue Code then Add/Update. / IP
Inpatient Ancillary Total Charges / Claim Information (Revenue Tab) Add/Update: enter Total Charges in Amount then Add/Update. / IP
Inpatient Ancillary Total Non-Covered Charges / Claim Information (Revenue Tab) Add/Update: enter Total Non-Covered Charges in Non-Covered then Add/Update. / IP
MEDICAL RECORD NUMBER / Claim Information (General Tab):
enter Medical Record Num then Save. / AS, ED, IP
Method of Anesthesia Used / Claim Information (General Tab):
Anesthesia use arrow to select then Save. / AS, IP
MOTHER'S MEDICAL RECORD NUMBER FOR NEWBORN CHILD / Claim Information (General Tab):
enterMother’s MRNthen Save. / IP
New York State Patient Status or Disposition / Claim Information (General Tab) Add/Update: Patient Status use arrow to select then Save. / AS, ED, IP
Non-Covered Days / Claim Information (General Tab):enter number of days in Non-covered Days then Save. / IP
Occurrence Information - ACCIDENT RELATED Codes and DATES / Claim Information (Occurrence Dates Tab) Add/Update: enter Occurrence Code and Occurrence Date use arrow to select MMDDYYYY then Add/Update. / AS, ED, IP
OCCURRENCE SPAN INFORMATION - ALC AND LOA DATES / Claim Information (Occurrence Spans Tab) Add/Update: enter Occurrence Span Code,From Date use arrow to select MMDDYYYY and Through Date use arrow to select MMDDYYYY then Add/Update. / IP
OPERATING/EMERGENCY DEPARTMENT PHYSICIAN 2 STATE LICENSE NUMBER / Claim Information (General Tab):Operating Physician License Type use arrow to select and enter License Number then Save. / AS, ED, IP

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SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

Data Element Names / Screen/Data Element Location / RequiredFor
Other Diagnosis Code 1-14 / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Typeuse arrow to select “Other”and enterDiagnosis Code then Add/Update. / AS, ED, IP
OTHER/EMERGENCY DEPARTMENT PHYSICIAN 3 STATE LICENSE NUMBER / Claim Information (General Tab):Other Physician License Type use arrow to select and enter License Number then Save. / ED, IP
Other Procedure Code 1-14 / Claim Information (Procedures Tab) Add/Update: Procedure Type use arrow to select “Other” then enter Procedure Code then Add/Update. / IP
OTHER PROCEDURE DATE 1-14 / Claim Information (Procedures Tab) Add/Update: Procedure Date use arrow to select MMDDYYY then Add/Update. / IP
Outpatient Ancillary Revenue Code / Claim Information (Revenue Tab)
Add/Update: enter Revenue Code then Add/Update. / AS, ED
Outpatient Ancillary Total Charges / Claim Information (Revenue Tab) Add/Update: enter Total Charges in Amount then Add/Update. / AS, ED
Outpatient Ancillary Total Non-Covered Charges / Claim Information (Revenue Tab) Add/Update: enter Total Non-Covered Charges in Non-Covered then Add/Update. / AS, ED
PATIENT BIRTH DATE / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Date of Birth use arrow to select MMDDYYYY then Save. / AS, ED, IP
Patient City / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): enter City then Save. / AS, ED, IP
PATIENT CONTROL NUMBER / Claim Information (General Tab):
enter Patient Control Num then Save. / AS, ED, IP
Patient County Code / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): County use arrow to select then Save. / AS, ED, IP

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SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

Data Element Names / Screen/Data Element Location / RequiredFor
Patient Ethnicity / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Ethnicity use arrow to select then Save. / AS, ED, IP
Patient Postal Service Zip Code and EXTENSION CODE / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): enter 5-digit or 9-digit Zip Code then Save. / AS, ED, IP
Patient Race / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Race use arrow to select then Save. / AS, ED, IP
Patient Reason For Visit Code / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Type use arrow to select “Reason for Visit” and enter Diagnosis Code then Add/Update. / AS, ED
PATIENT RESIDENCE ADDRESS - ADDRESS LINE 1 / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Address1 enter street address then Save. / AS, ED, IP
PATIENT RESIDENCE ADDRESS - ADDRESS LINE 2 / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Address 2 enter apt# or leave blank then Save. / AS, ED, IP
Patient Sex / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): Sex use arrow to select then Save. / AS, ED, IP
Patient State / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): State use arrow to select then Save. / AS, ED, IP
Payer Identification Number / Claim Information (From Tool Bar II Subscriber Icon then Update Icon): enter 5-digit Payer IDthen Save; or
Claim Information (Secondary Payers Tab) Add/Update: enter 5-digit Payer ID then select Add/Update. / AS, ED, IP

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SPARCS-837 PC Application

Data Element Look-Up Reference

Revised: April 21, 2010

Data Element Names / Screen/Data Element Location / RequiredFor
Place-of-Injury Code / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Type use arrow to select “E-code”, and enter Diagnosis Code then Add/Update. / AS, ED, IP
Point of Origin / Source of Admission / Claim Information (General Tab):Originuse arrow to select Source of Admission then Save. / IP
POLICY NUMBER / Claim Information (From Tool Bar II Subscriber Icon then Update Icon): enter Policy Number then Save; or
Claim Information (Secondary Payers Tab) Add/Update: enter Policy Numberthen select Add/Update. / IP
Present on Admission Indicator / Claim Information (Diagnoses Tab) Add/Update: Present on Admission use arrow to select appropriate POA then Add/Update. / IP
Principal/Primary Diagnosis Code / Claim Information (Diagnoses Tab) Add/Update: Diagnosis Type use arrow to select “Principal” and enter Diagnoses Code then Add/Update. / AS, ED, IP
Principal Procedure Code / Claim Information (Procedures Tab) Add/Update: Procedure Type use arrow to select “Principal” then enter Procedure Code then Add/Update. / IP
PRINCIPAL PROCEDURE DATE / Claim Information (Procedures Tab) Add/Update: Procedure Date use arrow to select “MMDDYYYY” then Add/Update. / IP
Procedure Code - CPT-4 / HCPCS & Modifier 1 and 2 / Claim Information (Revenue Tab) Add/Update: Procedure Code enter CPT-4/HCPCS and Modifier 1 &Modifier 2 then Add/Update. / AS, ED
Procedure Time/Operating Room Time / Claim Information (General Tab):Procedure Time: use arrow to select Hours H and Mins MM then Save. / AS
Processing Date / Generated (Date of Export) / AS, ED, IP
Provider Identification Number / Select Facility from list (Update Icon): enter Provider ID (NPI) then Update. / AS, ED, IP
Data Element Names / Screen/Data Element Location / RequiredFor
Source of Admission / Point of Origin / Claim Information (General Tab):Originuse arrow to select Source of Admission then Save. / IP
Source of Payment Code/Claim Filing Indicator Code / Claim Information (From Tool Bar II Subscriber Icon then Update Icon): Payer Source use arrow to select then Save; or
Claim Information (Secondary Payers Tab) Add/Update: Payer Source use arrow to select then Add/Update. / AS, ED, IP
Source of Payment Typology I / Claim Information (General Tab):Source of Payment: Typology: I use arrow to select then Save. / AS, ED, IP
Source of Payment Typology II / Claim Information (General Tab):Source of Payment: Typology: II use arrow to select then Save. / AS, ED, IP
Source of Payment Typology III / Claim Information (General Tab):Source of Payment: Typology: III use arrow to select then Save. / AS, ED, IP
SPARCS Collector Code / From Tool Bar I Menu select
Options (Update Submitter Settings): enter 3-digit Collector Numberthen Update. / AS, ED, IP
SPARCS Identification Number / Select Facility from list (Add Icon): enter 5-digit SPARCS Facility ID (PFI) then Add. / AS, ED, IP
STATEMENT COVERS PERIOD - FROM DATE / Claim Information (General Tab):Admit/Start Date use arrow to select MMDDYY then Save. / AS, ED, IP
STATEMENT COVERS PERIOD - THRU DATE / Claim Information (General Tab):Through Date use arrow to select MMDDYY then Save. / AS, ED, IP
Submitter Name / From Tool Bar I Menu select Options (Update Submitter Settings): enter Submitter Name then Update. / AS, ED, IP
Test/Production Indicator / Export (Submission Type) / AS, ED, IP
Total Charges / Claim Information (General Tab):enter Total Chargesamount or press calculate button then Save. / AS, ED, IP
Type of Admission / Claim Information (General Tab):Claim Type use arrow to selectthen Save. / IP
Data Element Names / Screen/Data Element Location / RequiredFor
Type of Bill / Claim Information (General Tab):Bill Type use arrow to select then Save. / AS, ED, IP
UB Accommodation Code / Claim Information (Revenue Tab)
Add/Update: enter UB Accommodation Code in Revenue Codethen Add/Update. / IP
UNIQUE PERSONAL IDENTIFIER / Claim Information (From Tool Bar II select Patient/Subscriber Icon then Update Icon): enter Unique Personal Identifier then Save. / AS, ED, IP
Value Information - Accident Hour / Claim Information (Value Codes Tab) Add/Update: enter “45” in Value Code for Hour and 2-digit hour in Value Amount then Add/Update. / AS, ED
Value Information - Blood Furnished Code and Amount / Claim Information (Value Codes Tab) Add/Update: enter “37” in Value Code for Blood and number of pints furnished in Value Amount then Add/Update. / IP
Value Information - NEONATE BIRTH WEIGHT / Claim Information (Value Codes Tab) Add/Update: enter “54” in Value Code for Birth Weight and weight in Value Amount then Add/Update. / IP
Value Information - Surplus, Catastrophic, or Recurring Monthly Income Code and Amount / Claim Information (Value Codes Tab) Add/Update: enter “21” for Catastrophic, “22” for Surplus, or “23” for Recurring Monthly Income in Value Code and Value Amount then Add/Update. / IP
Value Information - Workers' Compensation/No Fault Indicator / Claim Information (Value Codes Tab) Add/Update: enter Value Code”15” for Worker’s Compor “14” for No Fault and Value Amount then Add/Update. / IP

NOTE:Bolded and UPPER CASE are IDENTIFYING DATA ELEMENTS[see "Data Protection Review Board (DPRB)].

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