22 Reversal of previous payment Not our claim, forwarded to additional 23 payer(s) Predetermination Pricing Only - no 25 payment Required when External MC094 = External Source 8 - Report the diagnostic code assigned 002 and Admitting Code Admitting MC 40 11/8/12 International varchar[7] by provider that supported admission MC036 = 98% A1 Diagnosis Source 8 Diagnosis Code Classification of into the inpatient setting. 11, 18, 21, - Text Diseases 28, 41, 65, 66, 84, 86, or 89 External Codes External Source 8 - ICD Diagnostic Report the external injury code for Code MC 41 E-Code 11/8/12 International varchar[7] External Injury patient when appropriate to the All 3% C Source 8 Classification of Code claim. - Text Diseases External Codes External Source 8 - Principal Code ICD Primary Report the Primary ICD Diagnosis MC 42 11/8/12 International varchar[7] All 99% A0 Diagnosis Source 8 Diagnosis Code Code here. Classification of - Text Diseases External Codes External Other Source 8 - Report the Secondary ICD Diagnosis Code ICD Secondary MC 43 Diagnosis 11/8/12 International varchar[7] Code here. If not applicable do not All 70% B Source 8 Diagnosis Code - 1 Classification of report any value here. - Text Diseases External Codes External Other Source 8 - Other ICD Diagnosis Code - 2. If not Code ICD Other MC 44 Diagnosis 11/8/12 International varchar[7] applicable do not report any value All 24% B Source 8 Diagnosis Code - 2 Classification of here. - Text Diseases
22 Reversal of previous payment 23 Not our claim, forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment MC 40 Admitting Diagnosis 11/8/12 External Code Source 8 - Text External Source 8 - International Classification of Diseases varchar[7] Admitting Diagnosis Code Report the diagnostic code assigned by provider that supported admission into the inpatient setting. Required when MC094 = 002 and MC036 = 11, 18, 21, 28, 41, 65, 66, 84, 86, or 89 98% A1 MC 41 E-Code 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Diagnostic External Injury Code Report the external injury code for patient when appropriate to the claim. All 3% C MC 42 Principal Diagnosis 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Primary Diagnosis Code Report the Primary ICD Diagnosis Code here. All 99% A0 MC 43 Other Diagnosis - 1 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Secondary Diagnosis Code Report the Secondary ICD Diagnosis Code here. If not applicable do not report any value here. All 70% B MC 44 Other Diagnosis - 2 11/8/12 External Code Source 8 - Text External Codes Source 8 - International Classification of Diseases varchar[7] ICD Other Diagnosis Code Other ICD Diagnosis Code - 2. If not applicable do not report any value here. All 24% B
apcd-medical-claim-file-submission-guide.docx