IP0106 State 1 837/2010AA/N4/02 IP0107 Zip Code 1 837/2010AA/N4/03 IP0108 Version NA NA HIPAA Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Form Segment ID/Code Value/ Data Element # Data Element Name Locator Reference Designator IP2001 Record Type NA NA IP2003 Patient Control Number 3A 837/2300/CLM/01 IP2004 Patient Sex 11 837/2010CA/DMG/03 837/2010BA/DMG/03 IP2005 Patient Birth Date 10 837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02 IP2006 Priority (Type) of Admission or Visit 14 837/2300/CL1/01 IP2007 Point of Origin for Admission or Visit 15 837/2300/CL1/02 IP2008 Patient City 9B 837/2010CA/N4/01 837/2010BA/N4/01 IP2009 Patient State 9C 837/2010CA/N4/02 837/2010BA/N4/02 IP2010 Patient Zip Code 9D 837/2010CA/N4/03 837/2010BA/N4/03 IP2011 of Care Date 12 837/2300/DTP/435/DT/03
IP0106 State 1 837/2010AA/N4/02 IP0107 Zip Code 1 837/2010AA/N4/03 IP0108 Version NA NA Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP2001 Record Type NA NA IP2003 Patient Control Number 3A 837/2300/CLM/01 IP2004 Patient Sex 11 837/2010CA/DMG/03 837/2010BA/DMG/03 IP2005 Patient Birth Date 10 837/2010CA/DMG/D8/02 837/2010BA/DMG/D8/02 IP2006 Priority (Type) of Admission or Visit 14 837/2300/CL1/01 IP2007 Point of Origin for Admission or Visit 15 837/2300/CL1/02 IP2008 Patient City 9B 837/2010CA/N4/01 837/2010BA/N4/01 IP2009 Patient State 9C 837/2010CA/N4/02 837/2010BA/N4/02 IP2010 Patient Zip Code 9D 837/2010CA/N4/03 837/2010BA/N4/03 IP2011 of Care Date 12 837/2300/DTP/435/DT/03
Chapter%20241_20170907_v2.docx