Ref	Id	Element Name	Req	Type	Min/Max	Usage
CR601	923	Prognosis Code Description: Code indicating physician's prognosis for the patient All valid standard codes are used.	M	ID	1/1	Required
CR602	373	Date Description: Date expressed as CCYYMMDD Industry: Service From Date Alias: Home Health Start Date	M	DT	8/8	Required
CR603	1250	Date Time Period Format Qualifier Description: Code indicating the date format, time format, or date and time format	C	ID	2/3	Situational

	CR604	1251	Date Time Period Description: Expression of a date, a time, or range of dates, times or dates and times Industry: Home Health Certification Period Required if duration of plan treatment period is known.	C	AN	1/35	Situational
	CR606	1073	Yes/No Condition or Response Code Description: Code indicating a Yes or No condition or response Industry: Skilled Nursing Facility Indicator	O	ID	1/1	Required

Code

Name

Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

Appeal - Standard

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

Cancel

Extension

Initial

Renewal

Revised

	CR609	373	Date Description: Date expressed as CCYYMMDD Industry: Surgery Date Alias: Related Surgery Date Required if home health care is related to a specific surgical procedure.	C	DT	8/8	Situational
	CR610	235	Product/Service ID Qualifier Description: Code identifying the type/source of the descriptive number used in Product/Service ID (234) Industry: Product or Service ID Qualifier Required if home health care is related to a specific surgical procedure.	C	ID	2/2	Situational

Code

Name

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA�s CPT codes are also level 1 HCPCS codes, they are reported under HC.

CODE SOURCE:

130: Health Care Financing Administration Common Procedural Coding System

International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE:

131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

CR611

1137

Medical Code Value
Description: Code value for describing a medical condition or procedure
Industry: Surgical Procedure Code
Alias: Related Surgical Procedure Code
Required if home health care is related to a specific surgical procedure.

1/15

Situational

CR612	373	Date Description: Date expressed as CCYYMMDD Industry: Physician Order Date Required if different from the date of the request.	O	DT	8/8	Situational
CR613	373	Date Description: Date expressed as CCYYMMDD Industry: Last Visit Date Required if known.	O	DT	8/8	Situational
CR614	373	Date Description: Date expressed as CCYYMMDD Industry: Physician Contact Date Required if known.	O	DT	8/8	Situational
CR615	1250	Date Time Period Format Qualifier Description: Code indicating the date format, time format, or date and time format Required if the patient had a recent inpatient stay.	C	ID	2/3	Situational

	CR616	1251	Date Time Period Description: Expression of a date, a time, or range of dates, times or dates and times Industry: Last Admission Period Required if the patient had a recent inpatient stay.	C	AN	1/35	Situational
	CR617	1384	Patient Location Code Description: Code identifying the location where patient is receiving medical treatment Industry: Patient Discharge Facility Type Code Required if the patient had a recent inpatient stay. All valid standard codes are used.	C	ID	1/1	Situational

1.	CR602 is the date covered home health services began.
2.	CR604 is the certification period covered by this plan of treatment.
3.	CR605 is the date of onset or exacerbation of the principal diagnosis.
4.	A "Y" value indicates patient is receiving care in a 1861J1 (skilled nursing) facility. An "N" value indicates patient is not receiving care in a 1861J1 facility. A "U" value indicates it is unknown whether or not the patient is receiving care in a 1861J1 facility.
5.	CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
6.	CR609 is date that the surgery identified in CR614 was performed.
7.	CR610 qualifies CR611.
8.	CR611 is the surgical procedure most relevant to the care being rendered.
9.	CR612 is the date the agency received the verbal orders from the physician for start of care.
10.	CR613 is the date that the patient was last seen by the physician.
11.	CR614 is the date of the home health agency's most recent contact with the physician.
12.	CR616 is the date range of the most recent inpatient stay.
13.	CR617 indicates the type of facility from which the patient was most recently discharged.
14.	CR618 is the date of onset or exacerbation of the first secondary diagnosis.
15.	CR619 is the date of onset or exacerbation of the second secondary diagnosis.
16.	CR620 is the date of onset or exacerbation of the third secondary diagnosis.
17.	CR621 is the date of onset or exacerbation of the fourth secondary diagnosis.

Notes:

1. Required on requests for certification of home health care, private duty nursing, or services by a nurses� agency.
2. Use the HI segment at the patient level in Loop 2000C or Loop 2000D for diagnosis and diagnosis dates related to requests for home health care.
3. Requests for home health care must include a principal diagnosis (HI01-1 = BK) and principal diagnosis date in the HI segment at the patient level in Loop 2000C or Loop 2000D.

Example:

CR6*7*19980601****N*N*I~

	Code	Name
	RD8	Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

	ExternalCodeList
	Name: 130
	Description: Health Care Financing Administration Common Procedural Coding System

	ExternalCodeList
	Name: 131
	Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

1.	P0304 - If either CR603,CR604 is present, then all are required
2.	P091011 - If either CR609,CR610,CR611 is present, then all are required
3.	P151617 - If either CR615,CR616,CR617 is present, then all are required