THCIC Data Collection Healthcare Facility Procedures And Technical Specifications 5010 Inpatient and Outpatient Appendices Version 4.4 1/25/2021 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 1 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Table of Contents Appendix A1 VALID COUNTRY CODES ....................................................... 3 Appendix A2 DEFAULT OR MISSING DATA VALUES ................................... 10 Appendix A3 RACE AND ETHNICITY QUESTIONNAIRE DOCUMENTS ............ 13 Appendix A4 REVENUE CODE GROUPINGS FOR PUDF ............................... 17 Appendix A5 INPATIENT & OUTPATIENT AUDIT ID’S ................................. 19 Appendix A6 PAYER SOURCE CODING GUIDE .......................................... 54 Appendix A7 KEY DATA ELEMENTS FOR MATCHING INPATIENT CLAIMS ...... 59 Appendix A8 KEY DATA ELEMENTS FOR MATCHING OUTPATIENT CLAIMS ..... 60 Appendix A9 CHANGES MADE SINCE THE PREVIOUS VERSION(S) .............. 61 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 2 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Appendix A1 VALID COUNTRY CODES AND STATE CODES 1.1 Country Codes Code Short Name Code Short Name AD Andorra BN Brunei Darussalam AE United Arab Emirates BG Bulgaria AF Afghanistan BF Burkina Faso AX Aland Islands / Åland Islands BI Burundi AL Albania CV Cabo Verde DZ Algeria KH Cambodia AS American Samoa CM Cameroon AD Andorra CA Canada AO Angola KY Cayman Islands AI Anguilla CF Central African Republic AQ Antarctica TD Chad AG Antigua and Barbuda CL Chile AR Argentina CN China AM Armenia CX Christmas Island AW Aruba CC Cocos (Keeling) Islands AU Australia CO Colombia AT Austria KM Comoros AZ Azerbaijan CG Congo BS Bahamas Congo, the Democratic Republic of CD BH Bahrain the CK BD Bangladesh CR Costa Rica BB Barbados CI Cote d'Ivoire / Côte d'Ivoire BY Belarus HR Croatia BE Belgium CU Cuba BZ Belize CW Curacao / Curaçao BJ Benin CY Cyprus BM Bermuda CZ Czech Republic BT Bhutan DK Denmark BO Bolivia, Plurinational State of DJ Djibouti BQ Bonaire, Sint Eustatius and Saba DM Dominica BA Bosnia and Herzegovina DO Dominican Republic BW Botswana EC Ecuador BV Bouvet Island EG Egypt BR Brazil SV El Salvador IO British Indian Ocean Territory GQ Equatorial Guinea ER Eritrea 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 3 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Code Short Name Code Short Name EE Estonia MP Northern Mariana Islands ET Ethiopia NO Norway FK Falkland Islands (Malvinas) OM Oman FO Faroe Islands PK Pakistan FJ Fiji PW Palau FI Finland PS Palestine, State of FR France PA Panama GF French Guiana PG Papua New Guinea PF French Polynesia PY Paraguay TF French Southern Territories PE Peru GA Gabon PH Philippines GM Gambia PN Pitcairn GE Georgia PL Poland DE Germany PT Portugal GH Ghana PR Puerto Rico GI Gibraltar QA Qatar GR Greece RE Reunion! Réunion GL Greenland RO Romania GD Grenada RU Russian Federation GP Guadeloupe RW Rwanda GU Guam Saint Barthelemy / Saint BL FM Micronesia, Federated States of Barthélemy Saint Helena, Ascension and Tristan MD Moldova, Republic of SH MC Monaco da Cunha MN Mongolia KN Saint Kitts and Nevis ME Montenegro LC Saint Lucia MS Montserrat MF Saint Martin (French part) MA Morocco PM Saint Pierre and Miquelon MZ Mozambique VC Saint Vincent and the Grenadines MM Myanmar WS Samoa NA Namibia SM San Marino NR Nauru ST Sao Tome and Principe NP Nepal SA Saudi Arabia NL Netherlands SN Senegal NC New Caledonia RS Serbia NZ New Zealand SC Seychelles NI Nicaragua GT Guatemala NE Niger GG Guernsey NG Nigeria GN Guinea NU Niue GW Guinea-Bissau NF Norfolk Island GY Guyana 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 4 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Code Short Name Code Short Name HT Haiti MY Malaysia HM Heard Island and McDonald Islands MV Maldives VA Holy See (Vatican City State) ML Mali HN Honduras MT Malta HK Hong Kong MH Marshall Islands HU Hungary MQ Martinique IS Iceland MR Mauritania IN India MU Mauritius ID Indonesia YT Mayotte IR Iran, Islamic Republic of MX Mexico IQ Iraq SL Sierra Leone IE Ireland SG Singapore IM Isle of Man SX Sint Maarten (Dutch part) IL Israel SK Slovakia IT Italy SI Slovenia JM Jamaica SB Solomon Islands JP Japan SO Somalia JE Jersey ZA South Africa JO Jordan South Georgia and the South GS KZ Kazakhstan Sandwich Islands KE Kenya SS South Sudan KI Kiribati ES Spain Korea, Democratic People's LK Sri Lanka KP Republic of SD Sudan KR Korea, Republic of SR Suriname KW Kuwait SJ Svalbard and Jan Mayen KG Kyrgyzstan SZ Swaziland LA Lao People's Democratic Republic SE Sweden LV Latvia CH Switzerland LB Lebanon SY Syrian Arab Republic LS Lesotho TW Taiwan, Province of China LR Liberia TJ Tajikistan LY Libya TZ Tanzania, United Republic of LI Liechtenstein TH Thailand LT Lithuania TL Timor-Leste LU Luxembourg TG Togo MO Macao TK Tokelau Macedonia, the former Yugoslav MK TO Tonga Republic of TT Trinidad and Tobago MG Madagascar TN Tunisia MW Malawi TR Turkey 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 5 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Code Short Name TM Turkmenistan TC Turks and Caicos Islands TV Tuvalu UG Uganda UA Ukraine AE United Arab Emirates GB United Kingdom US United States United States Minor Outlying UM Islands UY Uruguay UZ Uzbekistan VU Vanuatu VE Venezuela, Bolivarian Republic of VN Viet Nam VG Virgin Islands, British VI Virgin Islands, U.S. WF Wallis and Futuna EH Western Sahara YE Yemen ZM Zambia ZW Zimbabwe 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 6 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual 1.2 United States Postal Service Two–Letter State and Possession Abbreviations Including Military States (from USPS.com) Abbreviation State/Possession AL ALABAMA AK ALASKA AS AMERICAN SAMOA AZ ARIZONA AR ARKANSAS CA CALIFORNIA CO COLORADO CT CONNECTICUT DE DELAWARE DC DISTRICT OF COLUMBIA FM FEDERATED STATES OF MICRONESIA FL FLORIDA GA GEORGIA GU GUAM HI HAWAII ID IDAHO IL ILLINOIS IN INDIANA IA IOWA KS KANSAS KY KENTUCKY LA LOUISIANA ME MAINE MH MARSHALL ISLANDS MD MARYLAND MA MASSACHUSETTS MI MICHIGAN MN MINNESOTA MS MISSISSIPPI MO MISSOURI MT MONTANA NE NEBRASKA NV NEVADA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NY NEW YORK 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 7 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Abbreviation State/Possession NC NORTH CAROLINA ND NORTH DAKOTA MP NORTHERN MARIANA ISLANDS OH OHIO OK OKLAHOMA OR OREGON PW PALAU PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VT VERMONT VI VIRGIN ISLANDS VA VIRGINIA WA WASHINGTON WV WEST VIRGINIA WI WISCONSIN WY WYOMING Abbreviation Military "State" AA Armed Forces Americas (except Canada) AE Armed Forces Europe, the Middle East, and Canada AP Armed Forces Pacific 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 8 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual 1.3 Canadian Provinces and Territories (from USPS.com) Abbreviation Canadian Province/Territory AB Alberta BC British Columbia MB Manitoba NB New Brunswick NL Newfoundland and Labrador NT Northwest Territories NS Nova Scotia NU Nunavut ON Ontario PE Prince Edward Island QC Quebec SK Saskatchewan YT Yukon 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 9 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual Appendix A2 DEFAULT OR MISSING DATA VALUES 2.1 Unknown Patient Address If the address of the patient is unknown, use the following: ANSI Loop.Data Segment Default Code or Information 2010AA or 2310E.N301 (Patient Address Line-1) Healthcare facility's street address 2010AA or 2310E.N302 (Patient Address Line-2) "Unknown" 2010AA or 2310E.N401 (Patient City) Healthcare facility's city 2010AA or 2310E.N402 (Patient State) TX 2010AA or 2310E.N403 (Patient ZIP) Healthcare facility’s ZIP code If the address of the patient is unknown, and in a Foreign Country (other than Canada), use the following: ANSI Loop.Data Segment Default Code or Information 2010BA or 2010CA.N402 (Patient State) FC or XX 2010BA or 2010CA.N403 (Patient ZIP) "00000" or "XXXXX" 2010BA or 2010CA.N404 (Patient Country) See appendices for Country Codes 2.2 Unknown Social Security Number If an SSN could not be obtained: ANSI Loop.Data Segment Default Code or Information 2010BA REF02 or 2300.K301 (Patient Social Spaces, Security Number) or 999999999 (if system requires an entry) 2.3 Unknown Date of Birth If a patient's date of birth is not known: ANSI Loop.Data Segment Default Code or Information 2010CA.DMG02 (Patient Birth Date) 19010101 = 01/01/1901 2.4 Unknown ZIP Code ANSI Loop.Data Segment Default Code or Information 2010BA or 2010CA.N403 (Patient ZIP) XXXXX OR 00000 5010_Inpatient_ and _Outpatient_ Appendices.docx Page 10 of 68 DSHS Publication # E25-12454-5010 Healthcare Facility Procedures and Technical Specifications Manual 2.5 Temporary Licenses If a practitioner does not have a state license, use the following: ANSI Loop.Data Segment Default Code or Information INPATIENT CLAIMS DATA TXTEMP OTHnnn 2310A or 2310B. NM109 (NPI) or REF02 (State RESnnn