	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	CR601	923	Prognosis Code Description: Code indicating physician's prognosis for the patient Alias: Prognosis Indicator EMC v.6.0 Reference: Record Type 71 Field No. 18	M	ID	1/1	Required

	Code	Name
	1	Poor
	2	Guarded
	3	Fair
	4	Good
	5	Very Good
	6	Excellent
	7	Less than 6 Months to Live
	8	Terminal

	CR602	373	Date Description: Date expressed as CCYYMMDD Industry: Service From Date Alias: SOC Date EMC v.6.0 Reference: Record Type 71 Field No. 5 (MMDDYY)	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 Required on claims/encounters when a certification for Home Health Services was previously or is being submitted to the destination payer.	C	ID	2/3	Situational

Code

Name

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDD where CCYY is the numerical expression of the century CC and year YY, MM is the numerical expression of the month within the year, and DD is the numerical expression of the day within the year; the first occurrence of CCYYMMDD is the beginning date and the second occurrence is the ending date

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 Alias: Certification Period EMC v.6.0 Reference: Record Type 71 Field No. 6, 7 Required on claims/encounters when a certification for Home Health Services was previously or is being submitted to the destination payer.	C	AN	1/35	Situational
CR605	373	Date Description: Date expressed as CCYYMMDD Industry: Diagnosis Date Alias: Date of Onset or Exacerbation of Principal Diagnosis EMC v.6.0 Reference: Record Type 71 Field No. 8 (MMDDYY)	O	DT	8/8	Required
CR606	1073	Yes/No Condition or Response Code Description: Code indicating a Yes or No condition or response Industry: Skilled Nursing Facility Indicator Alias: Patient Receiving Care in 1861 (j) (1) Facility Indicator EMC v.6.0 Reference: Record Type 71 Field No. 27	O	ID	1/1	Required

CR607

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Medicare Coverage Indicator
Alias: Medicare Covered Indicator
EMC v.6.0 Reference: Record Type 71 Field No. 24

1/1

Required

CR608

1322

Certification Type Code
Description: Code indicating the type of certification
Alias: Certification Type Indicator
EMC v.6.0 Reference: Record Type 71 Field No. 28
Required on claims/encounters when a certification for Home Health Services was previously or is being submitted to the destination payer.

1/1

Required

	CR609	373	Date Description: Date expressed as CCYYMMDD Industry: Surgery Date Alias: Date Surgical Procedure Performed EMC v.6.0 Reference: Record Type 71 Field No. 10 (MMDDYY) This data element is required when a surgical procedure was performed on the patient.	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 This data element is required when a surgical procedure was performed on the patient.	C	ID	2/2	Situational

Code

Name

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

Description: HCFA coding scheme to group procedure(s) performed on an outpatient basis for payment to hospital under Medicare; primarily used for ambulatory surgical and other diagnostic departments

This code includes Current Procedural Terminology (CPT) and HCPCS coding.

CODE SOURCE:

130: Health Care Financing Administration Common Procedural Coding System

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

Description: The International Classification of Diseases, Clinical Modification, is designated for the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations, for data storage and retrieval; this is a procedure code

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
EMC v.6.0 Reference: Record Type 71 Field No. 9
This data element is required when a surgical procedure was performed on the patient.

1/15

Situational

CR612	373	Date Description: Date expressed as CCYYMMDD Industry: Physician Order Date Alias: Verbal SOC Date EMC v.6.0 Reference: Record Type 71 Field No. 19 (MMDDYY) This data element is required when the Provider has the Physician Order Date information on file.	O	DT	8/8	Situational
CR613	373	Date Description: Date expressed as CCYYMMDD Industry: Last Visit Date Alias: Date Physician Last Saw Patient EMC v.6.0 Reference: Record Type 71 Field No. 25 (MMDDYY) This data element is required when the Provider has the Last Visit Date information on file.	O	DT	8/8	Situational
CR614	373	Date Description: Date expressed as CCYYMMDD Industry: Physician Contact Date Alias: Date Last Contacted Physician EMC v.6.0 Reference: Record Type 71 Field No. 26 (MMDDYY) This data element is required when the Provider has the Physician Contact Date information on file.	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 This data element is required when a hospital admission occurred to the patient.	C	ID	2/3	Situational

Code

Name

RD8

	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 Alias: Admission Date and Discharge Date EMC v.6.0 Reference: Record Type 71 Field No. 29, 30 (MMDDYY) This data element is required when a hospital admission occurred to the patient.	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 Alias: Type of Facility EMC v.6.0 Reference: Record Type 71 Field No. 31	C	ID	1/1	Required

	Code	Name
	A	Acute Care Facility
	B	Boarding Home
	C	Hospice
	D	Intermediate Care Facility
	E	Long-term or Extended Care Facility
	F	Not Specified
	G	Nursing Home
	H	Sub-acute Care Facility
	L	Other Location
	M	Rehabilitation Facility
	O	Outpatient Facility
	R	Residential Treatment Facility
	S	Skilled Nursing Home
	T	Rest Home

CR618	373	Date Description: Date expressed as CCYYMMDD Industry: Diagnosis Date Alias: Date Secondary Diagnosis - 1 EMC v.6.0 Reference: Record Type 71 Field No. 11 This data element is required when a secondary diagnosis code is present on this claim.	O	DT	8/8	Situational
CR619	373	Date Description: Date expressed as CCYYMMDD Industry: Diagnosis Date Alias: Date Secondary Diagnosis - 2 EMC v.6.0 Reference: Record Type 71 Field No. 12 This data element is required when a second secondary diagnosis code is present on this claim.	O	DT	8/8	Situational
CR620	373	Date Description: Date expressed as CCYYMMDD Industry: Diagnosis Date Alias: Date Secondary Diagnosis - 3 EMC v.6.0 Reference: Record Type 71 Field No. 13 This data element is required when a third secondary diagnosis code is present on this claim.	O	DT	8/8	Situational
CR621	373	Date Description: Date expressed as CCYYMMDD Industry: Diagnosis Date Alias: Date Secondary Diagnosis - 4 EMC v.6.0 Reference: Record Type 71 Field No. 14 This data element is required when a fourth secondary diagnosis code is present on this claim.	O	DT	8/8	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.

	Code	Name
	I	Initial
	R	Renewal
	S	Revised

	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