# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.001 | number | 11 | This field contains the IFN of the PTF record. | |||
.01 | patient(+) | 0;1 | POINTER | 2 | B | This field contains a pointer to the patient file (#2). This is the patient that the PTF data has been entered for. |
2 | admission date(+) | 0;2 | DATE-TIME | AF | This is the date of admission described by the PTF record. | |
2.1 | internal admission # | COMPUTED | IFN assigned to the admission date/time for this particular record. | |||
2.2 | ward at discharge | COMPUTED | This field contains the ward at the time of discharge. | |||
3 | facility(+) | 0;3 | NUMERIC | Facility from which this veteran was discharged. | ||
4 | fee basis | 0;4 | SET OF CODES | 1:FEE BASIS | This field indicated if the PTF record is a FEE basis record. A '1' in this field indicates a FEE basis record. | |
5 | suffix | 0;5 | FREE TEXT | This field contains the suffix of the medical center if not indicated in the facility number. | ||
6 | status | 0;6 | SET OF CODES | 0:Open 1:Closed 2:Released 3:Transmitted | AS | This field indicates the current status of the PTF record. |
7 | closed out by | 0;7 | POINTER | 200 | This field contains a pointer to the New Person File. The field indicates who closed out the PTF record. | |
7.1 | close out file | 0;9 | POINTER | 45.84 | File reference containing all PTF records that have been closed out. | |
7.2 | close out date | COMPUTED | This field contains the date the PTF record was closed out. | |||
7.3 | release date | COMPUTED | This field contains the date the PTF record was released. | |||
7.4 | transmission date | COMPUTED | This field contains the date the PTF record was transmitted. | |||
8 | first closed out at | 0;8 | DATE-TIME | This field contains the date the PTF record was first closed out. | ||
9 | drg | COMPUTED | This field contains the DRG for the episode of care described by the PTF record. | |||
10 | means test indicator(+) | 0;10 | SET OF CODES | AS:SERVICE CONNECTED AN:NSC MT COPAY EXEMPT B:CAT B C:MT COPAY REQUIRED N:NON VET X:NOT APPLICABLE U:NOT DONE/COMPLETED G:GMT COPAY REQUIRED | AMT | This field contains the Means Test Indicator. |
11 | type of record(+) | 0;11 | SET OF CODES | 1:PTF 2:CENSUS | This field indicates what type of record this is represents. As of 8/90 there are only two types, PTF and census. It is important to note that before MAS v4.7 this field did not exist and all records were PTF records. If sites have developed reports, they will need to screen on this field for the PTF record. (A PTF record has an internal value of 1 and a census record has a value of 2.) | |
12 | corresponding ptf record | 0;12 | POINTER | 45 | ACENSUS | This field is only filled in for census type of records. It points to the PTF record that was used to create the census record. A census record is an extract of information from the parent PTF record for activities that occurred during the census time period. |
13 | census date | 0;13 | POINTER | 45.86 | This field is only filled in for census records and it points back to a PTF CENSUS DATE file entry. | |
20 | source of admission | 101;1 | POINTER | 45.1 | This field contains the source of admission of the veteran, or where he was admitted to the hospital from, i.e. community, other facility, etc. | |
20.1 | admitting eligibility | 101;8 | POINTER | 8 | This field contains the Admitting Eligibility associated with this inpatient stay. | |
21 | *transfering facility | 101;2 | POINTER | 45.2 | Old version no longer used | |
21.1 | transferring facility | 101;5 | NUMERIC | Facility number of the facility that the veteran was transferred to the hospital from. | ||
21.2 | transferring suffix | 101;6 | FREE TEXT | The suffix assigned to the facility (if applicable) the veteran was transferred to the hospital from, i.e. 9AA = Nursing Home. | ||
22 | source of payment | 101;3 | SET OF CODES | 1:CONTRACT-PUBLIC&PRIV 2:SHARING 3:CONTRACT-MILT&FED AGENCY 4:PAID UNAUTH | The field contains the source of payment for this patient for Non-VA hospitals only. | |
23 | category of beneficiary | 101;4 | POINTER | 45.82 | Category of beneficiary. This field through cross reference sets Category of beneficiary field in patient file which is used for Amis 358 | |
30 | cpt record date/time | C;0 | MULTIPLE | 45.06 | ||
40 | 401 | S;0 | MULTIPLE | 45.01 | Multiple containing information on the PTF 401 screen relating to surgical procedures and operations. | |
45.01 | procedure 1 | 401P;1 | POINTER | 80.1 | This is a procedure performed during this episode of care. | |
45.02 | procedure 2 | 401P;2 | POINTER | 80.1 | This is a procedure performed during this episode of care. | |
45.03 | procedure 3 | 401P;3 | POINTER | 80.1 | This is a procedure performed during this episode of care. | |
45.04 | procedure 4 | 401P;4 | POINTER | 80.1 | This is a procedure performed during this episode of care. | |
45.05 | procedure 5 | 401P;5 | POINTER | 80.1 | This is a procedure performed during this episode of care. | |
50 | 501 | M;0 | MULTIPLE | 45.02 | 501 movements | |
60 | 601 | P;0 | MULTIPLE | 45.05 | 601 movements. | |
70 | discharge date | 70;1 | DATE-TIME | ADS | For census records, this field holds the census date associated with the record, not the admission's discharge date. | |
71 | discharge specialty | 70;2 | POINTER | 42.4 | This field contains the bedsection this patient was discharged from. | |
72 | type of disposition | 70;3 | SET OF CODES | 1:REGULAR 2:NBC OR WHILE ASIH 3:EXPIRATION 6 MONTH LIMIT 4:IRREGULAR 5:TRANSFER 6:DEATH WITH AUTOPSY 7:DEATH WITHOUT AUTOPSY | This field contains the type of disposition for this patient for this episode of care. | |
72.1 | discharge status | 70;14 | SET OF CODES | 1:BED OCCUPANT 2:ON PASS 3:ON LEAVE 4:ASIH | This field contains the discharge status for the patient during this episode of care. | |
73 | outpatient treatment | 70;4 | SET OF CODES | 1:YES 3:NO | This field indicates if the veteran was referred for outpatient treatment following an episode of hospital care. | |
74 | va auspices | 70;5 | SET OF CODES | 1:YES 2:NO | If outpatient care indicated, is it under VA auspices? Is the VA paying for this care or is the veteran being seen at a VA facility? | |
75 | place of disposition | 70;6 | POINTER | 45.6 | Enter place of disposition..where is the veteran being discharged to? | |
76 | *receiving facility | 70;7 | POINTER | 45.2 | Discontinued after version 3.3 | |
76.1 | receiving facility | 70;12 | NUMERIC | Facility number of the facility that the veteran is being transferred to from hospital. | ||
76.2 | receiving suffix | 70;13 | FREE TEXT | Suffix of receiving facility, i.e. 9AA for nursing home. | ||
77 | asih days | 70;8 | NUMERIC | Number of days patient was Absent Sick in Hospital during this episode of care (pertains to NHCU/DOM patients only). | ||
78 | c&p status | 70;9 | SET OF CODES | 1:COMP/SC COND >10% 2:NON-COMP/SC COND<10% 3:COMP/SC (+10%) NO MED CARE 4:NON-COMP(-10%) SC NO MED CARE-VA PENSION 5:VA PENSION-NO SC COND 6:NON-COMP(-10%) SC NO MED CARE NO PENSION 7:NO PENSION-NO SC 8:NON-VET | Compensation and Pension status (synoymous with eligibility). | |
79 | principal diagnosis | 70;10 | POINTER | 80 | This field contains the diagnosis responsible for the patient's greatest length of stay. | |
79.1 | provider | 70;15 | POINTER | 200 | The primary physician responsible for this patient's episode of care. | |
79.16 | secondary diagnosis 1 | 70;16 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.17 | secondary diagnosis 2 | 70;17 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.18 | secondary diagnosis 3 | 70;18 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.19 | secondary diagnosis 4 | 70;19 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.2 | provider ssn | COMPUTED | Social Security number of primary care physician. | |||
79.201 | secondary diagnosis 5 | 70;20 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.21 | secondary diagnosis 6 | 70;21 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.22 | secondary diagnosis 7 | 70;22 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.23 | secondary diagnosis 8 | 70;23 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24 | secondary diagnosis 9 | 70;24 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.241 | secondary diagnosis 10 | 71;1 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. | |
79.242 | secondary diagnosis 11 | 71;2 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. | |
79.243 | secondary diagnosis 12 | 71;3 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. | |
79.244 | secondary diagnosis 13 | 71;4 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. | |
79.245 | secondary diagnosis 14 | 71;5 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.246 | secondary diagnosis 15 | 71;6 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.247 | secondary diagnosis 16 | 71;7 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.248 | secondary diagnosis 17 | 71;8 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.249 | secondary diagnosis 18 | 71;9 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.2491 | secondary diagnosis 19 | 71;10 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24911 | secondary diagnosis 20 | 71;11 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24912 | secondary diagnosis 21 | 71;12 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24913 | secondary diagnosis 22 | 71;13 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24914 | secondary diagnosis 23 | 71;14 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.24915 | secondary diagnosis 24 | 71;15 | POINTER | 80 | This field contains a diagnosis for the patient during this episode of care. This diagnosis is used in the calculation of the DRG. | |
79.25 | treated for sc condition | 70;25 | SET OF CODES | 1:YES 2:NO | ||
79.26 | treated for ao condition | 70;26 | BOOLEAN | Y:YES N:NO | ||
79.27 | treated for ir condition | 70;27 | BOOLEAN | Y:YES N:NO | ||
79.28 | exposed to sw asia conditions | 70;28 | BOOLEAN | Y:YES N:NO | ||
79.29 | treatment for mst | 70;29 | BOOLEAN | Y:YES N:NO | Was the treatment related to Military Sexual Trauma. | |
79.3 | treatment for head/neck ca | 70;30 | BOOLEAN | Y:YES N:NO | Was the treatment related to Head and/or Neck Cancer. | |
79.31 | potentially related to combat | 70;31 | BOOLEAN | Y:YES N:NO | Indicate if inpatient stay at this location may be related to military service in combat and not from cause other than military service in combat operations (congenital, developmental, pre-service existing conditions, or conditions having specific and well-established etiology that began after military combat service, i.e. bone fractures occuring after separation date, common colds, etc). This information is copied from the movement records. | |
79.32 | treatment for shad | 70;32 | BOOLEAN | Y:YES N:NO | Was the treatment related to Project 112/SHAD. Project 112/SHAD was the name of the overall program for both shipboard and land-based biological and chemical testing that was conducted by the United States (U.S.) military between 1962 and 1973. Project SHAD (Shipboard Hazard and Defense) was the shipboard portion of these tests. | |
80 | principal diagnosis pre 1986 | 70;11 | POINTER | 80 | This field contains the diagnosis responsible for the patient being admitted to the medical center. This field is not used in the calculation of the DRG. This field is no longer used. | |
82.01 | poa principal diagnosis | 82;1 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for the Principal
Diagnosis. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.02 | poa secondary diagnosis 1 | 82;2 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 1. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.03 | poa secondary diagnosis 2 | 82;3 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 2. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.04 | poa secondary diagnosis 3 | 82;4 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 3. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.05 | poa secondary diagnosis 4 | 82;5 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 4. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.06 | poa secondary diagnosis 5 | 82;6 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 5. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.07 | poa secondary diagnosis 6 | 82;7 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 6. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.08 | poa secondary diagnosis 7 | 82;8 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 7. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.09 | poa secondary diagnosis 8 | 82;9 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 8. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.1 | poa secondary diagnosis 9 | 82;10 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 9. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.11 | poa secondary diagnosis 10 | 82;11 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 10. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.12 | poa secondary diagnosis 11 | 82;12 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 11. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.13 | poa secondary diagnosis 12 | 82;13 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 12. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.14 | poa secondary diagnosis 13 | 82;14 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 13. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.15 | poa secondary diagnosis 14 | 82;15 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 14. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.16 | poa secondary diagnosis 15 | 82;16 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 15. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.17 | poa secondary diagnosis 16 | 82;17 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 16. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.18 | poa secondary diagnosis 17 | 82;18 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 17. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.19 | poa secondary diagnosis 18 | 82;19 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 18. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.2 | poa secondary diagnosis 19 | 82;20 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 19. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.21 | poa secondary diagnosis 20 | 82;21 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 20. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.22 | poa secondary diagnosis 21 | 82;22 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 21. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.23 | poa secondary diagnosis 22 | 82;23 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 22. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.24 | poa secondary diagnosis 23 | 82;24 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 23. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
82.25 | poa secondary diagnosis 24 | 82;25 | SET OF CODES | Y:Present on Admission N:Not Present on Admission U:Insufficient Docum to Present on Admission W:Can't Determine if Present on Admission | This is the Present on Admission (POA) indicator for Secondary
Diagnosis 24. One of the following values should be assigned in
accordance with the official coding guidelines:
Y = present on the time of inpatient admission;
N = not present on the time of inpatient admission;
U = documentation is insufficient to determine if condition is
present on admission;
W = provider is unable to clinically determine whether condition
was present on admission or not
"" = null, no POA entered, user pressed | |
99 | terminal digit | COMPUTED | Computed field to determine the last four digits of the SSN | |||
100 | coding clerk | 1;0 | MULTIPLE | 45.03 | Multiple contains information on the coding clerk who worked on the PTF record for this episode of care. | |
101.07 | income | 101;7 | NUMERIC | This field contains the patient's income as reported for the MEANS TEST if applicable or the income is calculated from fields in the PATIENT file (#2). | ||
200 | census year | CEN;0 | MULTIPLE | 45.04 | Multiple containing information on the census year | |
300.01 | kidney source | 300;1 | SET OF CODES | 1:Live Donor 2:Cadaver | This field will indicate where the transplanted organ was received from. | |
300.02 | suicide/self inflict indicator | 300;2 | SET OF CODES | 1:Attempted Suicide 2:Accomplished Suicide 3:Self Inflicted Injury | This field will indicated if a suicide was attempted or accomplished. | |
300.03 | legionnaire's disease | 300;3 | SET OF CODES | 1:Yes 2:No | This field will indicated the patient was treated for Legionnaire's Disease. | |
300.04 | substance abuse | 300;4 | POINTER | 45.61 | Select type of substance abused by the patient. | |
300.05 | psychiatry class. severity | 300;5 | SET OF CODES | 0:INADEQUATE INFORMATION OR NO CHANGE IN CONDITION 1:NONE 2:MILD 3:MODERATE 4:SEVERE 5:EXTREME 6:CATASTROPHIC | Enter a one-digit rating from 0 (inadequate information/unchanged) through 6 (catastrophic). This field contains a rating indicating maximal stress. | |
300.06 | current functional assessment | 300;6 | NUMERIC | CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OR HURTING SELF OR OTHER OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH | ||
300.07 | high level psych class | 300;7 | NUMERIC | CODE TERMINOLOGY 90 TO 81 ABSENT OR MINIMAL SYMPTOMS 80 TO 71 IF SYMPTOMS ARE PRESENT, THEY ARE TRANSIENT AND EXPECTABLE REACTIONS TO PSYCHOSOCIAL STRESSORS 70 TO 61 SOME MILD SYMPTOMS OR SOME DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 60 TO 51 MODERATE SYMPTOMS OR MODERATE DIFFICULTY IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 50 TO 41 SERIOUS SYMPTOMS OR SERIOUS IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR SCHOOL FUNCTIONING 40 TO 31 SOME IMPAIRMENT IN REALITY TESTING OR COMMUNICATION OR MAJOR IMPAIRMENT IN SEVERAL AREAS, SUCH AS SCHOOL, FAMILY RELATIONS, JUDGEMENT, THINKING OR MOOD 30 TO 21 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION OR JUDGEMENT OR INABILITY TO FUNCTION IN ALMOST ALL AREAS 20 TO 11 SOME DANGER OF HURTING SELF OR OTHERS OR OCCASIONALLY FAILS TO MAINTAIN MINIMAL PERSONAL HYGIENE OR GROSS IMPAIRMENT IN COMMUNICATION 10 TO 1 PERSISTENT DANGER OF SEVERELY HURTING SELF OR OTHERS OR PERSISTENT INABILITY TO MAINTAIN MINIMAL PERSONAL HYGIENE OR SERIOUS SUICIDAL ACT WITH CLEAR EXPECTATIONS OF DEATH | ||
535 | 535 | 535;0 | MULTIPLE | 45.0535 | This multiple contains all the ward specialty movements of a patient that occur during the admission. If a patient changed wards but the specialty of the two wards are the same then no entry in this multiple is created. |