This guide explains how individual fields need to be formatted in the Audit Worksheet and how we check each different data element for accuracy and completeness.
| Data Field | Applies To | What It Means | What We Check | Example |
| Encounter ID | All claim types | A unique number that identifies this specific claim or patient visit. | Letters and numbers are both allowed, in any combination. We make sure this number isn't used more than once for the same client. | 3292779, 2427792 4223DIC4 |
| Encounter or Claim ID | All claim types | A number that identifies the specific person whose work is being reviewed on this claim. | Letters and numbers are both allowed, in any combination. We make sure this number isn't used more than once for the same client. | JN5035228433 |
| Patient Name | All claim types | The patient's first, middle, and last name. | Letters are allowed, along with commas and periods (for names like "Jr." or "O'Brien"). Numbers are not allowed. | Jane M. Doe |
| Patient ID | All claim types | The number the facility uses internally to uniquely identify this patient. | Letters and numbers are both allowed, in any combination. We make sure this number isn't used more than once for the same client. | 784512 |
| Patient DOB | All claim types | The patient's birth date. | Must be entered in the format mm/dd/yyyy and must fall before today's date. | mm/dd/yyyy |
| Patient Gender | All claim types | The patient's recorded gender. | Letters only. Must be one of the accepted values: F (female), M (male), N (non-binary), or U (unknown/unspecified). | F, M, N, U |
| Patient Control Number | Facility claims | A short code (up to 24 characters) the facility uses to track the patient's billing record. | Letters and numbers are both allowed, up to 24 characters total. | 204938201 |
| Medical or Health Record Number | Facility claims | A short code (up to 24 characters) the facility uses to track the patient's medical chart. | Letters and numbers are both allowed, up to 24 characters total. | MR00123456 |
| Document Control Number | Facility claims | A code (up to 26 characters) that links supporting documents to this visit. | Letters and numbers are both allowed, up to 26 characters total. | DC0987654321 |
| Treatment Authorization Code | Facility claims | The approval/authorization code issued for the treatment (up to 25 characters). | Letters and numbers are both allowed, up to 25 characters total. | AUTH20239981 |
| Provider NPI or ID | All claim types | The ID number of a healthcare provider named on the claim. This requirement applies to every provider role referenced on a claim, including the rendering, referring, operating, billing, and pay-to provider. This can be their national provider ID or the facility's own internal ID. | Letters and numbers are both allowed, up to 12 characters total; either type of ID is fine, so no further check is applied. | 1023456789 |
| Provider Name | All claim types | The first, middle, and last name of a provider named on the claim. This requirement applies to every provider role referenced on a claim, including the rendering, referring, operating, billing, and pay-to provider. | Letters are allowed, along with commas and periods. Numbers are not allowed. | John A. Smith |
| Rendering Provider Credentials | All claim types | The provider's professional credentials or license type (e.g., RN, MD, CPC). | Letters and numbers are both allowed. No automatic check is applied. | MD, CPC |
| Rendering Provider Specialty | All claim types | The provider's area of medical expertise. | Letters only. Must match an approved list of recognized specialties. | Cardiology |
| Rendering Provider Region | All claim types | An internal field showing which region the person being reviewed is associated with. | Letters and numbers are both allowed. No automatic check is applied. | Southeast |
| Rendering Provider Department | All claim types | The department within the facility associated with this visit. | Letters and numbers are both allowed. No automatic check is applied. | Radiology |
| Rendering Provider Practice | All claim types | An internal field identifying the practice location where the service was performed. | Letters and numbers are both allowed. No automatic check is applied. | Main Street Clinic |
| Rendering Provider Organization | All claim types | An internal field identifying the larger organization the person being reviewed belongs to. | Letters and numbers are both allowed. No automatic check is applied. | Acme Health Group |
| Coder ID | All claim types | The number identifying the coder who originally coded the claim. | Letters and numbers are both allowed, up to 12 characters total; either type of ID is fine, so no further check is applied. | C4021 |
| Coder First, Middle and Last Name | All claim types | The first, middle, and last name of the coder who coded the claim. | Letters are allowed, along with commas and periods. Numbers are not allowed. | Patricia L. Nguyen |
| TOB | Facility claims | A short code that tells us the type of bill and care setting being billed (for example, inpatient vs. outpatient). | Numbers only. Must be a 4-digit number matching an approved list of codes. | 0113, 0711, 0201 |
| Admit Date | Facility claims | The date the patient was admitted to the hospital. | Must be entered in the format mm/dd/yyyy, must be a valid date, and cannot be in the future. | mm/dd/yyyy |
| Admit Hour | Facility claims | The time of day the patient was admitted to the hospital. | Must be entered in the format hh:mm followed by AM or PM, and must be a valid time. | hh,mm,xm |
| Discharge Date | Facility claims | The date the patient left the hospital. | Must be entered in the format mm/dd/yyyy, must be a valid date, cannot be in the future, and must be on or after the admission date. | mm/dd/yyyy |
| Discharge Hour | Facility claims | The time of day the patient was discharged from the hospital. | Must be entered in the format hh:mm followed by AM or PM, and must be a valid time. | hh,mm,xm |
| Statement From & Through Date | Facility claims | The first and last date covered by this invoice. | Must be entered in the format mm/dd/yyyy. The start date must be on or after the admission date, and the end date must be on or before the discharge date. | mm/dd/yyyy - mm/dd/yyyy |
| Admission Type | Facility claims | A code describing how urgent this admission was (for example, emergency vs. planned). | Numbers only. Must be a valid code, for the date of service. | 1, 4 |
| Admission Source | Facility claims | A code describing where the patient was coming from when admitted (for example, another facility or a physician referral). | Numbers only. Must be a valid code, for the date of service. | 1, 4, 8 |
| Discharge Status | Facility claims | A code describing where the patient went after being discharged (for example, home or another facility). | Numbers only. Must be a valid code, for the date of service. | 62, 83 |
| POA Indicators | Facility claims | A flag for each diagnosis showing whether that condition was already present when the patient was admitted. Y = yes, present at admission; N = not present at admission; U = not enough documentation to tell; W = provider couldn't determine; 1 = not reported/not used. | Letters or the number 1 are allowed. Must be one of the accepted single-character values. | Y, N, U |
| Accident State | Professional claims | The two-letter abbreviation for the state where the patient was injured (for accident-related claims). | Letters only. Must be a valid two-letter state abbreviation. | CA, TX, VA |
| Occurrence Code | Facility claims | A code noting a specific event or circumstance related to the claim. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | 20, 27, A1 |
| Occurrence Date | Facility claims | The date associated with the special circumstance noted above. | Must be entered in the format mm/dd/yyyy and must fall before the current date. | mm/dd/yyyy |
| Occurrence Span Code | Facility claims | A code noting a circumstance that spans a period of time rather than a single date. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | M4, 70, 81 |
| Occurrence Span From & Through Date | Facility claims | The start and end dates for the circumstance noted above. | Must be entered in the format mm/dd/yyyy and must be a valid date range that falls before the current date. | mm/dd/yyyy - mm/dd/yyyy |
| Condition Codes | Facility claims | Codes describing conditions or circumstances connected to the patient's illness or injury. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | 90, AC, W5 |
| Value Code | Facility claims | A code that provides additional detail about the circumstances of the claim. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | 1, 17, 26 |
| Value Amount | Facility claims | The dollar amount associated with the claim detail code above. | Numbers only. Shown with a dollar sign and two decimal places. | $83,630.22 |
| Diagnosis Code | All claim types | A code describing the patient's illness, injury, condition, or circumstance. This requirement applies to every diagnosis code field on the claim, including the admitting diagnosis, the patient's visit reason, and the diagnosis code(s) for the encounter. | Letters and numbers are both allowed. Must start with a letter, be at least three characters, and follow standard formatting rules. | A00.0, P74.422, S82.099K |
| ICD-10 Procedure Codes | Facility claims | Code(s) describing procedures performed during the hospital stay. This requirement applies to both principle and secondary codes. | Letters and numbers are both allowed. Must be a valid code, for the date of service, found in our standard approved list. | 0X610ZZ, 0X6J0Z0, 0WWG4YZ |
| ICD-10 Procedure Date | Facility claims | The date a listed procedure was performed. This requirement applies to both principle and secondary code dates | Must be entered in the format mm/dd/yyyy and must be a valid date before today. | mm/dd/yyyy |
| Line DOS | All claim types | The date(s) a specific billed service was provided. | Must be entered in the format mm/dd/yyyy and must be a valid date before today. | mm/dd/yyyy |
| Revenue Code | Facility claims | A code identifying which department within the hospital provided the service. | Numbers only. Must be a valid code, for the date of service. | 0250, 0450, 0301 |
| Procedure Code | All claim types | The code describing the specific medical service, procedure, or product being billed. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | 11010, D0149, 9077F |
| Units or Quantity | All claim types | The number of units of the service or item being billed. | Numbers only. | 1, 3, 12 |
| Modifiers | All claim types | A short code that adds detail about special circumstances surrounding a procedure or service. | Letters and numbers are both allowed. Must be a valid code, for the date of service. | 23, QX, 59 |
| Charges, Line | All claim types | The amount charged for a specific billed service. | Numbers only. Shown with a dollar sign and two decimal places. | $83,630.22 |
| Paid, Line | All claim types | The amount paid for a specific billed service. | Numbers only. Shown with a dollar sign and two decimal places. | $233,246.88 |
| Charges, Claim Total | All claim types | The total charge amount for the entire claim. | Numbers only. Automatically calculated as the sum of all line-item charges and shown with a dollar sign. | $1,480,223.32 |
| Paid, Claim Total | All claim types | The total amount paid for the entire claim. | Numbers only. Automatically calculated as the sum of all line-item paid amounts. | $454,453.45 |
| PPS/DRG | Facility claims | A code that groups the hospital stay by diagnosis and treatment for payment purposes. | Letters and numbers are both allowed. Must start with a letter, with at least three characters required, and must be a valid code, for the date of service. | E10.9, E08.31, E09.3512 |
| Quadrant | Dental claims | A code identifying which area (quadrant) of the mouth the service was performed in. | Numbers only. Must be a valid code, for the date of service. | 00, 10, 40 |
| Tooth Number | Dental claims | The number (1–32) identifying which tooth the service was performed on. | Numbers only. Must be a valid code, for the date of service. | 4, 8, 21 |
| Tooth Surface | Dental claims | A code identifying which surface of the tooth the service was performed on. | Letters only (single character). Must be a valid code, for the date of service. | B, I, O |
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