Section IV - Data Dictionary

To assist medical data providers in automating their Medical Data Call reporting systems, the alphabetized Data Dictionary in this section provides metadata such as data element descriptions and reporting format associated with the data elements in the Medical Data Call Record Layout. Refer to the Record Layouts section of this manual.

Accident Date
Field No.:	9
Position(s):	53-60
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date the claimant was injured.
Reporting Requirement:	Report the date the claimant was injured. The Accident Date must be the same as or after Policy Effective Date (Positions 24-31), and before or the same as Service Date (Positions 129-136) or Service From Date (Positions 137-144) and Service to Date (145-152). In the case of occupational disease or cumulative injury, use the last day that the claimant worked without the disability or the last day of coverage, whichever is earlier. The Accident Date must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Amount Charged by Provider
Field No.:	18
Position(s):	186-196
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	11
Format:	N 11, this field must be right justified and left zero-filled. There is an implied decimal between positions 194 and 195. If the reported amount does not include digits after the decimal, add 00 to the right of the reported amount. For example: • $123.45 is reported as 00000012345 • $123 is reported as 00000012300
Definition:	The total amount per line billed for the medical service by the service provider.
Reporting Requirement:	Report the total amount per line that was billed by the service provider for the applicable line. This amount is reported prior to any adjustments but includes corrections. If a change to the Amount Charged by Provider occurs to a previously reported record, submit a replacement transaction, Transaction Code 03 (Positions 44-45), and report the current cumulative amount (original amount plus or minus changes) for the applicable line. Note: This field should never be a negative value since the total amount charged rather than the change in charged dollars is to be reported. For information on changes to an amount field, refer to Record Replacements and Cancellations in the Reporting Rules section of this manual.

Bill Identification Number
Field No.:	11
Position(s):	69-98
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	30
Format:	A/N 30, exclude non-ASCII characters. This field must be left justified and contain blanks in all spaces to the right of the last character if the Bill Identification Number is less than 30 bytes.
Definition:	A unique number assigned to each bill by the administering entity.
Reporting Requirement:	Report the unique number assigned to the bill that corresponds to this transaction.

Birth Year
Field No.:	8
Position(s):	49-52
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	4
Format:	CCYY
Definition:	The actual or estimated (accident year minus claimant age) year the claimant was born.
Reporting Requirement:	Report the year the claimant was born. The Birth Year must be before Accident Date (Positions 53-60).

Carrier Code
Field No.:	1 (Transaction) and 6 (Key Field Change)
Position(s):	1–5 (Transaction) and 46–50 (Key Field Change)
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	5
Format:	N 5
Definition:	The carrier code assigned to the carrier by NCCI.
Reporting Requirement:	Report the 5-digit NCCI assigned Carrier Code. Do not report the NCCI Group ID or NAIC Carrier Code. The Carrier Code must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Claim Number Identifier
Field No.:	4 (Transaction) and 9 (Key Field Change)
Position(s):	32-43 (Transaction) and 77–88 (Key Field Change)
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	12
Format:	A/N 12, letters A–Z and numbers 0–9 only (if the Claim Number Identifier is less than 12 bytes, this field must be left justified, and blanks in all spaces to the right of the last character).
Definition:	A set of alphanumeric characters that uniquely identify the claim (letters A–Z and numbers 0–9 only).
Reporting Requirement:	Report the unique set of numbers and/or letters that identify the specific claim that the bill applies to. For the purpose of this requirement, unique means that each time a medical service is provided and billed for a specific claim, the same claim number is reflected on each bill. The Claim Number Identifier must match the Unit Statistical data claim number reported for this claim. For older claims where the claim number has changed since reporting the unit statistical data, report the Claim Number Identifier that identifies the claim in your system today. This number must be used consistently for all future reporting of the claim transactions. The Claim Number Identifier can neither be all zeros nor all blanks nor a combination of zeros and blanks. The Claim Number Identifier must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Claimant Gender Code
Field No.:	7
Position(s):	48
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	1
Format:	A/N
Definition:	A code that corresponds to the claimant’s gender.
Reporting Requirement:	Report the code that corresponds to the claimant's gender. Leave blank - if unknown.

Code	Description
1	Male
2	Female
3	Other

Jurisdiction State Code
Field No.:	6
Position(s):	46-47
Class:	Numeric (N) - Field contains only numeric characters
Bytes:	2
Format:	N 2, Date field is to be right justified and left zero-filled.
Definition:	The code that corresponds to the governing jurisdiction that would administer the claim and whose statutes will apply to the claim adjustment process.
Reporting Requirement:	Report the code that corresponds to the state under whose Workers Compensation Act or Employers Liability Act the claimant's benefits are being paid or Federal Act (Jurisdiction State Code 59.) Report the code the corresponds to the state workers compensation law, the employers liability law, or the federal law under which the claimant’s benefits are being paid. The Jurisdiction State Code must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.
Note:	When the jurisdiction state is Pennsylvania, all qualifying medical transactions for that state must be reported even when the compliance state (IAIABC State Compliance Code) is not an applicable state. For example, a medical service is provided to a claimant whose benefits are being paid under the Pennsylvania Workers Compensation Act. However, reimbursement for the medical service was determined under California medical billing requirements. Medical transactions for this claimant would be reportable under the Medical Data Call.

Jurisdiction	State Code
Pennsylvania	37
Federal Act (USL&HW)	59

Line Identification Number
Field No.:	12
Position(s):	99-128
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	30
Format:	A/N 30, exclude non-ASCII characters. This field must be left justified and contain blanks in all spaces to the right of the last character if the Line Identification Number is less than 30 bytes.
Definition:	A unique number that the administering entity assigns to each line associated with the Bill Identification Number (Positions 69-98).
Reporting Requirement:	Report the unique number assigned to the line associated with the Bill Identification Number (Positions 69-98) and for which this record applies.

Network Service Code
Field No.:	25
Position(s):	274
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	1
Format:	A
Definition:	A code that indicates whether the medical service is provided through a provider network.
Reporting Requirement:	Report the code that indicates whether the service is provided through a provider network regardless of whether a network discount was applied.

Code	Description
B	Pharmacy Benefit Manager
H	HMO – the medical service provider belongs to a Health Maintenance Organization agreement
N	No Agreement – the medical service provider does not belong to a provider network
P	Participation Agreement – the medical service provider is part of an agreement that is not an HMO or PPO
Y	PPO Agreement – the medical service provider belongs to a Preferred Provider Organization agreement

Paid Amount
Field No.:	19
Position(s):	197-207
Class:	Numeric (N) - Field contains only numeric characters
Bytes:	11
Format:	N 11, this field must be right justified and left zero-filled. There is an implied decimal between positions 205 and 206. If the reported amount does not include digits after the decimal, add 00 to the right of the reported amount. For example: • $123.45 is reported as 00000012345 • $123 is reported as 00000012300
Definition:	The amount on the bill (line) paid by the coverage provider for the medical service. For information on changes to an amount field, refer to Record Replacements and Cancellations in the Reporting Rules section of this manual.
Reporting Requirement:	Report the total amount that was paid by the coverage provider for the applicable line. If a change to the Paid Amount occurs to a previously reported record, submit a replacement transaction, Transaction Code 03 (Positions 44-45), and report the current cumulative amount (original amount plus or minus changes) for the applicable line.
Note:	This field should never be a negative value since the total amount paid rather than the change in paid dollars is to be reported.

Paid Procedure Code
Field No.:	16
Position(s):	153-177
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	25
Format:	A/N Varies, format according to the requirements for the code list used. Refer to the Procedure Code List Type table in the Reporting Requirement for this field.
Definition:	A code from the jurisdiction-approved code table that identifies the procedure associated with the reimbursement.
Reporting Requirement:	Report the Paid Procedure Code from the jurisdiction-approved code table (refer to the Procedure Code List Type table within this description) that corresponds to the Line Identification Number (Positions 99–128) as it relates to the reimbursement reported in Paid Amount (Positions 197–207). The Paid Procedure Code must be populated with correct code values, including leading zeros. When a procedure code is reported without leading zeros, that code may be edited as invalid or may match values from other codes sets. For example, if the leading zero is not reported on Hospital Revenue Code 0116 – Room & Board – Private (One Bed), the resulting value appears to be DRG Code 116 – Intraocular Procedures with CC/MCC. Incorrect reporting impacts the pricing of legislative reform. If the bill reflects a procedure code other than the procedure code associated with the reimbursement, report the Paid Procedure Code associated with the reimbursement in this field and the billed procedure code in the Secondary Procedure Code field (Positions 290–314). Refer to Paid Procedure Code Reporting section of this manual. Revenue codes provide only broad classifications; therefore, they should only be reported as a Paid Procedure Code when no other code was used to determine the reimbursement (i.e., CPT®, CDT, HCPCS, DRG or NDC.) The Pennsylvania Workers’ Compensation Act was amended by House Bill 1846 (passed during calendar year 2014) and the amended regulations state that: “A physician seeking reimbursement for drugs dispensed by a physician shall include the original manufacturer’s National Drug Code (NDC) number, as assigned by the Food and Drug Administration, on the bills and reports required under this section. In no event may a physician seek reimbursement in excess of [110] percent of the AWP [Average Wholesale Price] of the drugs dispensed by a physician as determined by reference to the original manufacturer’s NDC number. A repackaged NDC number may not be used and will not be considered the original manufacturer’s NDC number…” Based on this regulation, data submitters should report the original (underlying) NDC code as the Paid Procedure Code and the repackaged NDC code as the Secondary Procedure Code (Positions 290–314).

Procedure Code List Type
Code List Type*	Code Length (Bytes)	Description/Formatting
CPT® -Current Procedural Terminology	5	• Codes are either 5 numbers or 4 numbers followed by a single alpha character • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
CDT-Current Dental Terminology	5	• Codes are either 5 numbers or a single alpha character followed by 4 numbers • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
HCPCS-Healthcare Common Procedure Coding System	5	• Codes are either 5 numbers or a single alpha character followed by 4 numbers • Level 1 uses the CPT® codes while level 2 adds alphanumeric codes for other services such as ambulance or prosthetics • Left justify and blank-fill all spaces to the right of the last number or character when less than 25 bytes • Must include leading zeros when part of the code**
NDC-National Drug Codes	10 or 11	• 11-byte HIPAA (Health Insurance Portability and Accountability Act) standard codes or 10-byte FDA (Food and Drug Administration) codes • Left justify and blank-fill all spaces to the right of the last number • Do not include dashes • Must include leading zeros when part of the code**
Drug Dispensing Fees	n/a	• No dispensing fee in Pennsylvania. Retail pharmacies, fee for service providers or Part B providers (physicians) are reimbursed at 110% of the AWP and there is no dispensing fee.
Compound Drugs	11	• In Pennsylvania, compound drugs shall be billed by listing each drug included in the compound and separately calculating the charge for each drug, using national drug codes (NDC). Calculate reimbursement for each ingredient of compound drugs using national drug codes (NDC) listed line-by-line on the CMS 1500 bill. Each ingredient is reimbursed at 110% of the AWP. • Left justify and blank-fill Positions 164-177
DRG-Diagnostic Related Group	3	• Numeric codes classify procedures into related groups for inpatient services • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code** • Report the DRG code version as authorized in the state workers’ compensation fee schedule regulations. For Pennsylvania, as indicated in the regulations, the DRG Grouper was frozen for purposes of workers’ compensation inpatient claims. Medicare Grouper 12 was the version in effect on December 31, 1994 and will remain the authorized grouper for all inpatient workers’ comp medical claims. All DRG-charged admissions must be cross walked by the provider to a Grouper 12 DRG.
Revenue Codes	4	• Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
State-Specific	Varied	• Byte length dependent on state rules • Left justify and blank-fill all spaces to the right of the last number or character when less than 25 bytes • Must include leading zeros when part of the code**
NCCI Proprietary – Per Diem	8	• Report as PER-DIEM • Capitalize and include dash • Left justify and blank-fill Positions 161-177 • Refer to Section V – Reporting Rules Part F – Per Diem Hospital Charges for instructions on using this code
NCCI Proprietary – Medical Marijuana – Reimbursement to injured worker (claimant)	5	• Report as MM001 • Left justify and blank-fill Positions 158-177 • Refer to Section V – Reporting Rules, Part H- Medical Marijuana Data Reporting for instructions on using this code.
NCCI Proprietary – Medical Marijuana – Reimbursement directly to dispensary	5	• Report as MM002 • Left justify and blank-fill Positions 158-177 • Refer to Section V – Reporting Rules, Part H- Medical Marijuana Data Reporting for instructions on using this code.

*Report a DRG code as the Paid Procedure Code if it is the basis of reimbursement; otherwise, report the CPT®, CDT, HCPCS, or NDC code.

**If converting codes from a system that does not store leading zeros, ensure that the leading zero(s) is inserted correctly. For example, if the system stores 360 for Revenue Code 0360, then insert one zero to the left of the 3 bytes when reporting to the PCRB.

Paid Procedure Code Modifier(s)
Field No.:	17
Position(s):	178-185
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	8 – First Paid Procedure Code Modifier (4), Second Paid Procedure Code Modifier (4)
Format:	First Paid Procedure Code Modifier – A/N 4 (Positions 178-181), left justified and blank-filled to the right of the last number or character when the First Paid Procedure Code Modifier(s) is less than 4 bytes.
	Second Paid Procedure Code Modifier – A/N 4 (Positions 182-185), left justified and blank-filled to the right of the last number or character when the Second Paid Procedure Code Modifier(s) is less than 4 bytes.
	If only one Paid Procedure Code Modifier applies, report in Positions 178-181 and leave Positions 182-185 blank.
Definition:	A code from the jurisdiction-approved code table that identifies the unique circumstances related to the Paid Procedure Code (Positions 153-177) when the circumstance alters a procedure or service but does not change the Paid Procedure Code or its definition.
Reporting Requirement:	Report the Paid Procedure Code Modifier(s) related to the Paid Procedure Code (Positions 153-177). If there are more than two modifiers, report only the modifier(s) that impacts the reimbursement.

Place of Service Code
Field No.:	27
Position(s):	282-289
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	8
Format:	A/N 8, this field must be left justified and blank-filled to right of the last number or character when the Place of Service Code is less than 8 bytes. Include leading zeros when part of the code. If converting codes from a system that does not store leading zeros, ensure that the leading zero(s) is inserted correctly. For example, if the system stores 9 for a code that is listed as 09 on the code list, insert a zero to the left of the 9 when reporting to the PCRB.
Definition:	A code that indicates where the medical service was performed.
Reporting Requirement:	Report the Place of Service Code from the Place of Service list that indicates where the medical service was performed. Do not report Place of Service Code 99 (Other Place of Service) when the place of service is unavailable. Instead, leave this field blank. For facility and hospital services, the Place of Service Crosswalk was developed to provide a mapping of the Type of Bill code to the Place of Service code. Refer to the Place of Service Crosswalk in the Appendix.

Place of Service*
Code	Description	Code	Description
01	Pharmacy	33	Custodial Care Facility
02	Telehealth Provided Other than in Patient's Home	34	Hospice
03	School	35-40	Unassigned – Not valid for PA
04	Homeless Shelter	41	Ambulance-Land
05	Indian Health Service-Free Standing Facility	42	Ambulance-Air or Water
06	Indian Health Service Provider-Based Facility	43-48	Unassigned – Not valid for PA
07	Tribal 638 Free-Standing Facility	49	Independent Clinic
08	Tribal 638 Provider-Based Facility	50	Federally Qualified Health Center
09	Prison-Correctional Facility	51	Inpatient Psychiatric Facility
10	Telehealth Provided in Patient's Home	52	Psychiatric Facility-Partial Hospitalization
11	Office	53	Community Mental Health Center
12	Home	54	Intermediate Care Facility/Mentally Retarded
13	Assisted Living Facility	55	Residential Substance Abuse Treatment Facility
14	Group Home	56	Psychiatric Residential Treatment Center
15	Mobile Unit	57	Non-Residential Substance Abuse Treatment Facility
16	Temporary Lodging	58	Non-Residential Opioid Treatment Facility
17	Walk-In Retail Health Clinic	59	Unassigned – Not valid for PA
18	Place of Employment - Worksite	60	Mass Immunization Center
19	Off-Campus Outpatient Hospital	61	Comprehensive Inpatient Rehabilitation Facility
20	Urgent Care Facility	62	Comprehensive Outpatient Rehabilitation Facility
21	Inpatient Hospital	63-64	Unassigned – Not valid for PA
22	On-Campus Outpatient Hospital	65	End-Stage Renal Disease Treatment Facility
23	Emergency Room-Hospital	66-70	Unassigned – Not valid for PA
24	Ambulatory Surgical Center	71	Public Health Clinic
25	Birthing Center	72	Rural Health Clinic
26	Military Treatment Facility	73-80	Unassigned – Not valid for PA
27-30	Unassigned – Not valid for PA	81	Independent Laboratory
31	Skilled Nursing Facility	82-98	Unassigned – Not valid for PA
32	Nursing Facility	99	Other Place of Service
		DS	Dispensary**

*Source: Centers for Medicare & Medicaid Services (www.cms.hhs.gov).  The codes listed are valid as of the guidebook issue date.  New codes approved by CMS are valid by definition.

**This is an NCCI-assigned value.   CMS does not currently provide a code for dispensary.

Policy Effective Date
Field No.:	3 (Transaction) and 8 (Key Field Change)
Position(s):	24-31 (Transaction) and 69–76 (Key Field Change)
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date the policy under which the claim occurred became effective.
Reporting Requirement:	Report the effective date that corresponds to the date shown on the policy Information Page or to endorsements attached. The Policy Effective Date reported must be before or the same as Accident Date (Positions 53-60). The Policy Effective Date must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields. Report the policy effective date applicable at the time of the claim. Do not report the policy inception date. Medical Data Manager (MDM) will accept policy effective dates between 19700101 (January 1, 1970) and current calendar date plus two (2) years.

Policy Number Identifier
Field No.:	2 (Transaction) and 7 (Key Field Change)
Position(s):	6-23 (Transaction) and 51–68 (Key Field Change)
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	18
Format:	A/N 18, letters A–Z and numbers 0–9 only (if the Policy Number Identifier is less than 18 bytes, this field must be left justified, and blanks in all spaces to the right of the last character).
Definition:	The unique set of numbers and/or letters that identify the policy under which the claim occurred (letters A–Z and numbers 0–9 only).
Reporting Requirement:	Report the unique set of numbers and/or letters that identify the policy under which the claim occurred. The Policy Number Identifier must be consistently reported across all PCRB data types for the life of the claim. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields. Policy Number Identifier must match the Unit Statistical data Policy Number Identifier, reported for this claim, including any prefixes or suffixes. The Policy Number Identifier can neither be all zeros nor all blanks nor a combination or zeros and blanks.

Previous Carrier Code
Field No.:	1 (Key Field Change)
Position(s):	1–5 (Key Field Change)
Class:	Numeric (N)—Field contains only numeric characters
Bytes:	5
Format:	N5
Definition:	The previously reported Carrier Code (assigned to the carrier by NCCI) of the record being changed by the Key Field Change record.
Reporting Requirement:	Report the previously reported Carrier Code whether or not it is being changed by the Key Field Change record. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Previous Claim Number Identifier
Field No.:	4 (Key Field Change)
Position(s):	32–43 (Key Field Change)
Class:	Alphanumeric (AN)—Field contains alphabetic and numeric characters
Bytes:	12
Format:	A/N 12, letters A–Z and numbers 0–9 only (if the Claim Number Identifier is less than 12 bytes, this field must be left justified and have blanks in all spaces to the right of the last character).
Definition:	The previously reported Claim Number Identifier of the record being changed by the Key Field Change record. The Claim Number Identifier is the unique set of numbers and/or letters that identify the specific claim that the report/transaction applies to.
Reporting Requirement:	Report the previously reported Claim Number Identifier whether or not it is being changed by the Key Field Change record. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Previous Policy Effective Date
Field No.:	3 (Key Field Change)
Position(s):	24–31 (Key Field Change)
Class:	Numeric (N)—Field contains only numeric characters
Bytes:	8
Format:	YYYYMMDD
Definition:	The previously reported Policy Effective Date of the record being changed by the Key Field Change record. The Policy Effective Date is the date that the policy under which the claim occurred became effective.
Reporting Requirement:	Report the previously reported Policy Effective Date whether or not it is being changed by the Key Field Change record. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Previous Policy Number Identifier
Field No.:	2 (Key Field Change)
Position(s):	6–23 (Key Field Change)
Class:	Alphanumeric (AN)—Field contains alphabetic and numeric characters
Bytes:	18
Format:	A/N 18, letters A–Z and numbers 0–9 only (if the Policy Number Identifier is less than 18 bytes, this field must be left justified and have blanks in all spaces to the right of the last character).
Definition:	The previously reported Policy Number Identifier of the record being changed by the Key Field Change record. The Policy Number Identifier is the unique set of numbers and/or letters that Previous Policy Number Identifier identify the policy under which the claim occurred.
Reporting Requirement:	Report the previously reported Policy Number Identifier whether or not it is being changed by the Key Field Change record. Refer to Section II, Part D - Key Fields for more information on the consistent reporting of multi-data type fields.

Primary ICD Diagnostic Code
Field No.:	20
Position(s):	208-221
Class:	Alphanumeric (AN)—Field contains alphabetic and numeric characters
Bytes:	14
Format:	A/N 14, this field must be left justified and contain blanks in all spaces to the right of the last character if the Primary ICD Diagnostic Code is less than 14 bytes. Additional formatting rules include (see example): • Report zeros only when part of the code • Capitalize alphabetic characters • Report the decimal only if the code contains characters (including zero) to the right of the decimal
Definition:	A code that identifies the primary diagnosis associated with the medical service rendered.
Reporting Requirement:	Report the NCHS (National Center for Health Statistics) or CMS (Centers for Medicare & Medicaid Services) ICD code that identifies the primary diagnosis associated with the medical service rendered.
Note:	•If converting codes from a system that does not store a decimal, ensure that the decimal is inserted correctly (not always in the 4th position). For example, 7999 may be 079.99 or 799.9. •For ICD-9 codes, if the code starts with an E, then the decimal is reported in the fifth position; if it starts with a V, then the decimal is reported in the fourth position. If there is no leading alpha character, then report the decimal at the fourth position if the length of the code is four characters or more. •For ICD-10 codes, the decimal point is reported in the 4th position (regardless of the leading alpha character.) If the ICD-10 code is only 3 characters, do not report a decimal. •If converting codes from a system that does not store leading zeros, ensure that the leading zero(s) is inserted correctly. For example, if 5.9 is listed as 005.9 on the code list, insert two zeros to the left of the 5.
Note:	PCRB accepts both ICD-9 and ICD-10 codes in this field as of January 1, 2014.
Note:	PCRB does not recognize ICD-9 code 999.9 (complication of medical care not elsewhere classified) as a valid code.

If ICD Diagnostic Code is…	Then valid format is (“_” indicates a space)…
942	942_ _ _ _ _ _ _ _ _ _ _
942.	942_ _ _ _ _ _ _ _ _ _ _
942.0	942.0 _ _ _ _ _ _ _ _ _
372.61	372.61_ _ _ _ _ _ _ _
043.9	043.9_ _ _ _ _ _ _ _ _
005.9	005.9_ _ _ _ _ _ _ _ _
E111	E111_ _ _ _ _ _ _ _ _ _
S42	S42_ _ _ _ _ _ _ _ _ _ _
S42.	S42_ _ _ _ _ _ _ _ _ _ _
S42.0	S42.0_ _ _ _ _ _ _ _ _
S42.001D	S42.001D_ _ _ _ _ _

Provider Identification Number
Field No.:	23
Position(s):	256-270
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	15
Format:	A/N 15, this field must be left justified and contain blanks in all spaces to the right of the last character if the Provider Identification Number is less than 15 bytes.
Definition:	A number that uniquely identifies the medical/service provider.
Reporting Requirement:	Report the National Provider Identification (NPI) Number assigned by the National Plan and Provider Enumeration System (NPPES) that uniquely identifies the medical/service provider that performed the service. Refer to the NPI Registry (npiregistry.cms.hhs.gov/search) directory of all active and deactivated NPI records or the downloadable file containing active and deactivated NPI records linked on the same site. Note: For facility bills, report the National Provider Identification Number for the service facility. For example, if a line item of a hospital bill indicates that a Registered Physical Therapist provided therapy to a claimant as an employee of the hospital, report the hospital’s NPI number. For hospitals billing from a centralized location, report the National Provider Identification Number of the service facility. For pharmacy and DME (Durable Medical Equipment), report the dispensing provider. For billing houses, report the NPI of the medical provider for whom the billing house is submitting the bill. When the NPI is not assigned to a service provider, report the Federal Employer Identification Number (FEIN) of the service provider. PCRB considers a PBM (Pharmacy Benefit Management) company to be a billing house.

Provider Postal (ZIP) Code
Field No.:	24
Position(s):	271-273
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	3
Format:	A/N 3
Definition:	The code assigned by the postal service (USPS or other) to the medical/service provider address where the service was performed.
Reporting Requirement:	Report only the first three digits/characters of the postal (ZIP) code for the medical/service provider address where the service was performed. In states where the postal (ZIP) code impacts the reimbursement, report the postal (ZIP) code associated with the reimbursement. The 3-digit Provider Postal (ZIP) Code may be reported but is not required if the Provider Postal (ZIP+4) Code (Field 29) is reported. If the service facility or dispensing pharmacy ZIP Code is unavailable, report only the first three digits of the postal (ZIP) code of the provider’s billing address unless it is a billing house. When the billing address is a billing house and the postal (ZIP) code for the medical/service provider address where the service was performed is not available, leave this field blank.
Note:	PCRB considers a PBM (Pharmacy Benefit Management) company to be a billing house. PCRB expects that a PBM will have the dispensing pharmacy ZIP Code.

Provider Postal (ZIP+4) Code
Field No.:	29
Position(s):	315-323
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	9
Format:	A/N 9, this field must be left justified and contain blanks in all spaces to the right of the last character if the Provider Postal (ZIP+4) Code is less than 9 bytes.
Definition:	The standard 5-digit Zone Improvement Plan (ZIP) code with the appended 4-digit code (ZIP+4) assigned by the postal service (USPS or other) to the medical/service provider address where the service was performed.
Reporting Requirement:	Report the standard 5-digit Zone Improvement Plan (ZIP) code with the appended 4-digit code (ZIP+4) for the medical/service provider address where the service was performed. If the 9-digit ZIP Code is known, report the 9-digit ZIP Code. If only the standard 5-digit ZIP Code is known, report the 5-digit ZIP Code. If the service facility or dispensing pharmacy ZIP Code is unavailable, report only the Postal (ZIP+4) Code of the provider’s billing address unless it is a billing house. When the billing address is a billing house and the ZIP+4 Code for the medical/service provider address where the service was performed is not available, leave this field blank.
Note:	PCRB considers a PBM (Pharmacy Benefit Management) company to be a billing house. PCRB expects that a PBM will have the dispensing pharmacy ZIP Code.

Provider Taxonomy Code
Field No.:	22
Position(s):	236-255
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	20
Format:	A/N 20, this field must be left justified and contain blanks in all spaces to the right of the last character if the Provider Type Code is less than 20 bytes.
Definition:	A taxonomy code that identifies the type of provider that billed for and is being paid for the medical service.
Reporting Requirement:	Report the taxonomy code that identifies the type of provider that billed for and is being paid for the medical service. For example, if a line item of a hospital bill indicates that a Registered Physical Therapist provided therapy to a claimant as an employee of the hospital, report the Provider Taxonomy Code associated with the hospital. Or, if an Orthopedic Surgeon provides surgical services to a claimant through a surgical center, but the surgeon bills for the service, report the Provider Taxonomy Code associated with the surgeon. Use the Provider Taxonomy list of standard codes maintained by the National Uniform Claim Committee Code Subcommittee (available at www.nucc.org or The Washington Publishing Company).
Note:	When determining the Provider Taxonomy Code based on the Provider Identification Number, use the source for the Provider Identification Number as indicated in Section III – Record Layouts of this manual.
Note:	In cases where a billing house bills the payer, report the Provider Taxonomy Code associated with the medical service provider – for whom the billing house is submitting the bill. PCRB considers a PBM (Pharmacy Benefit Management) company to be a billing house.

Quantity/Number of Units Per Procedure Code
Field No.:	26
Position(s):	275-281
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	7
Format:	N 7, rounded up to the nearest whole number. Do not report a decimal. This field must be right justified and left zero-filled.
Definition:	The number of units of service performed or the quantity of drugs dispensed.
Reporting Requirement:	Report the number of units of service performed or the quantity of drugs dispensed that are related to the Paid Procedure Code. (Positions 153-177). Use the base quantity specified by the applicable procedure code to determine the quantity or number to report.

Example: Base size/amount as specified by applicable procedure code

• Supplies – The Paid Procedure Code reported is for surgical gloves. The code specifies that the base quantity is a pair of gloves. For this example, if one pair were used, 0000001 would be reported in this field.
• Physical or Occupational Therapy – The Paid Procedure Code specifies that one unit is equal to a base amount of time and that a base amount of time is equal to 15 minutes. For this example, if the therapy were for 15 minutes, the time would be reported as 0000001.

Note: Additional time spent in therapy is often designated with a distinct procedure code.

For Paid Procedure Codes related to medications, the quantity/units depend on the type of drug.

• For tablets, capsules, suppositories, non-filled syringes, etc., report the actual number of the drug provided. For example, a bottle of 30 pills would be reported as 0000030.
• For liquids, suspensions, solutions, creams, ointments, bulk powders, etc., dispensed in standard packages, report the units as specified by the Procedure Code. For example, a cream is dispensed in a standard tube, which is defined as a unit by the Procedure Code.  Report 00000001 (one tube).
• For liquids, suspensions, solutions, creams, ointments, bulk powders, etc., that are not dispensed in standard packages, report the amount provided in its standard unit of measurement (e.g., milliliters, grams, ounces). For example, codeine cough syrup dispensed by a pharmacist into a four-ounce bottle would be reported as 00000004.

For Paid Procedure Codes related to anesthesia, the quantity/units are reported in minutes. For example, if 220 minutes of anesthesia was provided, report 0000220 in this field.

Secondary ICD Diagnostic Code
Field No.:	21
Position(s):	222-235
Class:	Alphanumeric (AN)—Field contains alphabetic and numeric characters
Bytes:	14
Format:	A/N 14, this field must be left justified and contain blanks in all spaces to the right of the last character if the Secondary ICD Diagnostic Code is less than 14 bytes. Additional formatting rules include (see example): • Report zeros only when part of the code • Capitalize alphabetic characters • Report the decimal only if the code contains characters (including zero) to the right of the decimal
Definition:	A code that identifies the secondary diagnosis associated with the medical service rendered.
Reporting Requirement:	Report the NCHS (National Center for Health Statistics) or CMS (Centers for Medicare & Medicaid Services) ICD code that identifies the secondary diagnosis associated with the medical service rendered.
Note:	•If converting codes from a system that does not store a decimal, ensure that the decimal is inserted correctly (not always in the 4th position). For example, 7999 may be 079.99 or 799.9. •For ICD-9 codes, if the code starts with an E, then the decimal is reported in the fifth position; if it starts with a V, then the decimal is reported in the fourth position. If there is no leading alpha character, then report the decimal at the fourth position if the length of the code is four characters or more. •For ICD-10 codes, the decimal point is reported in the 4th position (regardless of the leading alpha character.) If the ICD-10 code is only 3 characters, do not report a decimal. •If converting codes from a system that does not store leading zeros, ensure that the leading zero(s) is inserted correctly. For example, if 5.9 is listed as 005.9 on the code list, insert two zeros to the left of the 5.
Note:	PCRB accepts both ICD-9 and ICD-10 codes in this field as of January 1, 2014.
Note:	PCRB does not recognize ICD-9 code 999.9 (complication of medical care not elsewhere classified) as a valid code.
Note:	Leave blank if a secondary diagnosis has not been identified.

If ICD Diagnostic Code is…	Then valid format is (“_” indicates a space)…
942	942_ _ _ _ _ _ _ _ _ _ _
942.	942_ _ _ _ _ _ _ _ _ _ _
942.0	942.0 _ _ _ _ _ _ _ _ _
372.61	372.61_ _ _ _ _ _ _ _
043.9	043.9_ _ _ _ _ _ _ _ _
005.9	005.9_ _ _ _ _ _ _ _ _
E111	E111_ _ _ _ _ _ _ _ _ _
S42	S42_ _ _ _ _ _ _ _ _ _ _
S42.	S42_ _ _ _ _ _ _ _ _ _ _
S42.0	S42.0_ _ _ _ _ _ _ _ _
S42.001D	S42.001D_ _ _ _ _ _

Secondary Procedure Code
Field No.:	28
Position(s):	290-314
Class:	Alphanumeric (AN) – Field contains alphabetic and numeric characters
Bytes:	25
Format:	A/N 25, format according to the requirements for the code list used. Refer to the Procedure Code List Type table in the Reporting Requirement for this field.
Definition:	A code from the jurisdiction-approved code table that identifies the billed procedure.
Reporting Requirement:	Report the Secondary Procedure Code from the jurisdiction-approved code table (refer to the Procedure Code List Type table within this description) if the bill reflects a procedure code other than the procedure code associated with the reimbursement. For example, an ambulatory surgery center bills for a facility fee using a CPT® code. However, the reimbursement is determined by assigning an APC code. The CPT® code is reported in this field, and the APC code, which is associated with the reimbursement, is reported as the Paid Procedure Code (Positions 153–177). Leave blank - if the secondary procedure code is the same as the Paid Procedure Code (Positions 153–177). Refer to Paid Procedure Code Reporting section of this manual for additional instructions and examples. The Secondary Procedure Code must be populated with correct code values, including leading zeros. When a procedure code is reported without leading zeros, that code may be edited as invalid or may match values from other code sets. For example, if the leading zero is not reported on Hospital Revenue Code 0116 – Room & Board – Private (One Bed), the resulting value appears to be DRG Code 116 – Intraocular Procedures with CC/MCC. Incorrect reporting impacts the pricing of legislative reform. Revenue codes provide only broad classifications; therefore, they should only be reported as a Paid Procedure Code when no other code was used to determine the reimbursement (i.e., CPT®, CDT, HCPCS, DRG or NDC.) The Pennsylvania Workers’ Compensation Act was amended by House Bill 1846 (passed during calendar year 2014) and the amended regulations state that: “A physician seeking reimbursement for drugs dispensed by a physician shall include the original manufacturer’s National Drug Code (NDC) number, as assigned by the Food and Drug Administration, on the bills and reports required under this section. In no event may a physician seek reimbursement in excess of [110] percent of the AWP [Average Wholesale Price] of the drugs dispensed by a physician as determined by reference to the original manufacturer’s NDC number. A repackaged NDC number may not be used and will not be considered the original manufacturer’s NDC number…” Based on this regulation, data submitters should report the original (underlying) NDC code as the Paid Procedure Code and the repackaged NDC code as the Secondary Procedure Code (Positions 290–314).

Procedure Code List Type
Code List Type*	Code Length (Bytes)	Description/Formatting
CPT® -Current Procedural Terminology	5	• Codes are either 5 numbers or 4 numbers followed by a single alpha character • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
CDT-Current Dental Terminology	5	• Codes are either 5 numbers or a single alpha character followed by 4 numbers • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
HCPCS-Healthcare Common Procedure Coding System	5	• Codes are either 5 numbers or a single alpha character followed by 4 numbers • Level 1 uses the CPT® codes while level 2 adds alphanumeric codes for other services such as ambulance or prosthetics • Left justify and blank-fill all spaces to the right of the last number or character when less than 25 bytes • Must include leading zeros when part of the code**
NDC-National Drug Codes	10 or 11	• 11-byte HIPAA (Health Insurance Portability and Accountability Act) standard codes or 10-byte FDA (Food and Drug Administration) codes • Left justify and blank-fill all spaces to the right of the last number • Do not include dashes • Must include leading zeros when part of the code**
DRG-Diagnostic Related Group	3	• Numeric codes classify procedures into related groups for inpatient services • Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code** • Report the DRG code version as authorized in the state workers’ compensation fee schedule regulations. For Pennsylvania, as indicated in the regulations, the DRG Grouper was frozen for purposes of workers’ compensation inpatient claims. Medicare Grouper 12 was the version in effect on December 31, 1994 and will remain the authorized grouper for all inpatient workers’ comp medical claims. All DRG-charged admissions must be cross walked by the provider to a Grouper 12 DRG.
Revenue Codes	4	• Left justify and blank-fill all spaces to the right of the last number • Must include leading zeros when part of the code**
State-Specific	Varied	• Byte length dependent on state rules • Left justify and blank-fill all spaces to the right of the last number or character when less than 25 bytes • Must include leading zeros when part of the code**

*Report a DRG code as the Paid Procedure Code if it is the basis of reimbursement; otherwise, report the CPT®, CDT, HCPCS, or NDC code.

**If converting codes from a system that does not store leading zeros, ensure that the leading zero(s) is inserted correctly. For example, if the system stores 360 for Revenue Code 0360, then insert one zero to the left of the 3 bytes when reporting to the PCRB.

Service Date
Field No.:	13
Position(s):	129-136
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date when the medical provider performed the service.
Reporting Requirement:	Report the date the service related to Line Identification Number (Positions 99-129) was performed. If an in-patient hospital payment spanning multiple days was made and the specific service date (line item) detail is unavailable, zero-fill this field and report in Service From Date (Positions 137–144) and Service To Date (Positions 145–152). Service Date must be the same as or after Accident Date (Positions 53-60).

Example: Bill spans multiple days—line item detail is available

A claimant receives 30 minutes* of physical therapy on January 8, 10, 15, and 17, 2008. The four services are listed as separate lines (Line Identification Number 1 through 4). Report four records, one for each line. For each record, report the individual date the service was performed in the Service Date field (Positions 129-136). There will only be one date reported for each record. In this example, the Service From Date and Service To Date fields will be zero-filled.

Bill ID (69-98)	Line ID (99-128)	Paid Procedure Code (153-177)	Service Date (129-136)	Quantity/#Units (275-281)
1001	1	0422	20080108	0000002
1001	2	0422	20080110	0000002
1001	3	0422	20080115	0000002
1001	4	0422	20080117	0000002

*For Paid Procedure Codes which specify each 15-minute segment as 1 unit, then each 30 minutes of physical therapy is reported as 2 units.

Service From Date
Field No.:	14
Position(s):	137-144
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date when services were initiated.
Reporting Requirement:	Use this field for the starting date of service if an in-patient hospital payment spanning multiple days was made and the specific service date (line item) detail is unavailable. In all other cases, zero-fill this field and report the date of service in Service Date (Positions 129–136). This field is the first date of a date range and must be accompanied by a Service To Date (Positions 145-152). Service From Date must be the same as or after Accident Date (Positions 53-60). Service From Date must not equal Service To Date.

Service To Date
Field No.:	15
Position(s):	145-152
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date when services were terminated.
Reporting Requirement:	Use this field for the ending date of service if an in-patient hospital payment spanning multiple days was made and the specific service date (line item) detail is unavailable. In all other cases, zero-fill this field and report the date of service in Service Date (Positions 129–136).This field is the last date of a date range and must be accompanied by a Service From Date (Positions 137–144). Service To Date must be after Service From Date (Positions 137–144). Service To Date must not equal Service From Date.

Transaction Code
Field No.:	5
Position(s):	44-45
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	2
Format:	N 2, Data field is to be right justified and left zero-filled.
Definition:	A code that identifies the type of transaction that the record represents.
Reporting Requirement:	Report the code that identifies the type of transaction of the record being submitted.
Note:	An Original (01) must be in the same submission or on the PCRB’s database before a Cancellation (02) or a Replacement (03) can be submitted.

Code	Description
01	Original – the initial report of the record to the PCRB. Only one original (Transaction Code 01) may be submitted for a given transaction.
02	Cancellation – cancels (deletes) a previously submitted (Transaction Code 01 or 03) record.
03	Replacement – replaces (changes) a previously submitted (Transaction Code 01 or 03) record.
04	Key Field Change – revises key field values previously submitted in a (Transaction 01 or 03) record (only used for key field change record.)

Transaction Date
Field No.:	10
Position(s):	61-68
Class:	Numeric (N) – Field contains only numeric characters
Bytes:	8
Format:	CCYYMMDD
Definition:	The date the information in the transaction was processed as established by the original source of the data. Original source of the data is defined as the entity initially responsible for administering the medical bill(s). This may be an insurer, TPA Bill Review vendor, Pharmacy Benefit Manager, or other entity that is responsible for medical claim management.
Reporting Requirement:	Report the date corresponding to the Transaction Code (Positions 44-45) of the record being submitted.

If Transaction Code is…	Then report…
01- Original	The date the information was originally processed by the administering entity. For example: A medical service was performed on 01/15/2008. The medical service provider submitted the bill to a third-party administrator, which processed and paid the bill on 01/21/2008. The medical data provider reports the original transaction to the PCRB with its 1st quarter submission on 04/01/2008. The Transaction Date for this original record is 01/21/2008 (reported as 20080121).
02- Cancellation	The date the cancellation was performed in the system of the administering entity.
03- Replacement	The date that the information was changed or corrected in the system of the administering entity. For example: Using the same scenario as described in the example for 01-Original, the administering entity discovers an error on the bill and corrects it in its system on 05/1/2008. The medical data provider reports the replacement transaction to the PCRB with its 2nd Quarter submission on 07/01/2008. The Transaction Date for this replacement record is 05/01/2008 (reported as 20080501).