Core Health Data Elements: Report of the National Committee on Vital and Health Statistics. Core Health Data Elements


The following list of data elements contains those elements selected for the first iteration of this process. Consensus has been reached on definitions for the majority of these elements; for others, there is much agreement, but definitions must still be finalized; and for a third group, additional study and testing are needed. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Standard electronic formats are recommended to the extent that they have been developed

The Committee recognizes that this is an iterative process and has included in these recommendations several elements that have been proposed for standardization, even though no consensus currently exists concerning appropriate or feasible definitions. The description of the element indicates this present lack of agreement. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. The Committee encourages the Department and its partners to give high priority to conducting evaluation and testing on such elements and also seeks to alert organizations developing standards or data sets to leave place holders for their inclusion. In addition, a number of elements for which consensus is close, must be field tested to confirm their definitions and collectibility. A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element.

The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. Some recommendations in the area of mental health and substance abuse are included here. Other recommendations will be circulated for comment at a future time.



1. Personal/Unique Identifier 2/

2. Date of Birth

3. Gender

4. Race and Ethnicity

5. Residence

6. Marital Status

7. Living/Residential Arrangement 1/

8. Self-Reported Health Status 2/

9. Functional Status 2/

10. Years of Schooling

11. Patient's Relationship to Subscriber/Person Eligible for Entitlement

12. Current or Most Recent Occupation and Industry 2/

13. Type of Encounter 2/

14. Admission Date (inpatient)

15. Discharge Date (inpatient)

16. Date of Encounter (outpatient and physician services)

17. Facility Identification 1/

18. Type of Facility/Place of Encounter 1/

19. Health Care Practitioner Identification (outpatient) 1/

20. Provider Location or Address of Encounter (outpatient)

21. Attending Physician Identification (inpatient) 1/

22. Operating Clinician identification 1/

23. Health Care Practitioner Specialty 1/

24. Principal Diagnosis (inpatient)

25. Primary Diagnosis (inpatient)

26. Other Diagnoses (inpatient)

27. Qualifier for Other Diagnoses (inpatient)

28. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/

29. Diagnosis Chiefly Responsible for Services Provided (outpatient)

30. Other Diagnoses (outpatient)

31. External Cause of Injury

32. Birth Weight of Newborn

33. Principal Procedure (inpatient)

34. Other Procedures (inpatient)

35. Dates of Procedures (inpatient)

36. Procedures and Services (outpatient)

37. Medications Prescribed

38. Disposition of Patient (inpatient) 1/

39. Disposition (outpatient)

40. Patient's Expected Sources of Payment 1/

41. Injury Related to Employment

42. Total Billed Charges 1/

Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. A lack of footnote indicates that these elements are ready for implementation.

Person/Enrollment Data

The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. With the exception of the personal/unique identifier, they do not need to be collected at each encounter.

1. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes.

A. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.)

B. Numerical identifier

The personal/unique identifier is the element that is the most critical element to be collected uniformly. The NCVHS recommends the use of Social Security Number with a check item such as date of birth, while at the same time undertaking the study and evaluation needed to confirm this use or the recommendation of another identifier. More emphasis on the confidential use of SSN is essential. Standards groups should be consulted regarding setting criteria for recording of names.

Rationale and discussion

Without a universal unique identifier or a set of data items that can form a unique identifier, it will be impossible to link data across the myriad of healthcare locations and arrangements. In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." However, recent testimony has led the Committee to investigate this issue further, in light of perceived inadequacies of the SSN (e.g., lack of a check digit, multiple SSN's, etc.), particularly when used alone, and impediments (legal and otherwise) to its use. Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers.

New York State presented testimony that indicated that the last four digits of the SSN combined with the birth date were capable of linking data to a very high degree of probability. The State of California has tested the use of a series of data items that are readily known by individuals and which can be combined to link data. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. These data items include birth name, date of birth, place of birth, gender, and mother's first name. Seven confirmatory data items (including SSN) should also be collected when possible.

Those present at the November and December 1995 NCVHS regional meetings agreed that the establishment of a unique identifier is the most important core data item. A unique identifier such as the SSN in conjunction with at least one other data item or, alternatively, an identifier drawn from another distinct set of data items routinely collected presently would seem the most viable. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes.

Development of a unique identifier does not necessarily mean that the individual is identifiable to users. The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected.

2. Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. It will also serve as a quality check as the date of birth approaches the new century mark.

3. Gender As recommended by the UHDDS and the UACDS.

  1. Male
  2. Female
  3. Unknown/not stated

4. Race and Ethnicity - The collection of race and ethnicity have been recommended by the UHDDS and the UACDS, and these elements have a required definition for Federal data collection in Office of Management and Budget (OMB) Directive 15. The definition has been expanded slightly from the OMB requirement:

4A. Race

  1. American Indian/Eskimo/Aleut
  2. Asian or Pacific Islander (specify)
  3. Black
  4. White
  5. Other (specify)
  6. Unknown/not stated

4B. Ethnicity

  1. Hispanic Origin (specify)
  2. Other (specify)
  3. Unknown/not stated

It is recommended that this item be self-reported, not based on visual judgment or surnames. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin.

Rationale and discussion

The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. It remains unclear whether the modest health gains seen in low-income and racial/ethnic minority populations in the last thirty years will continue, considering the changes in the U.S. health care system. These data assist in the examination of disparities in stage of illness, care, and outcome, some of which have been documented in the past among racial and ethnic groups.

OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity.

The National Association of Health Data Organizations has also opposed such an inclusion. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. However, there is some evidence that the number of interracial marriages is accelerating.

5. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence..

Rationale and discussion

This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. The Subcommittee determined that residential street address has the advantage of enabling researchers to aggregate the data to any level of geographic detail (block, census tract, ZIP code, county, etc.) and is the best alternative to insure the availability of small area data. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Some thought needs to be given to completing this item for persons with no known residence or persons whose residence is outside of the United States. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data.

6. Marital Status - The following definitions, as recommended by the NCVHS, should be used.


A person currently married. Classify common law marriage as married.

  • A) living together
  • B) not living together

2. Never married

A person who has never been married or whose only marriages have been annulled.


A person widowed and not remarried.


A person divorced and not remarried.


A person legally separated.

6.Unknown/not stated

Rationale and discussion

The Committee recognizes that a person's social support system can be an important determinant of his or her health status, access to health care services, and use of services. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. It also may be required to verify benefits.

7. Living/Residential Arrangement - The following definitions are recommended by the NCVHS:

7A. Living Arrangement

  1. Alone
  2. With spouse
  3. With significant other/life partner
  4. With children
  5. With parent or guardian
  6. With relatives other than spouse, children, or parents
  7. With nonrelatives
  8. Unknown/not stated

Multiple responses to this item are possible. This element refers to living arrangements only. Marital status is discussed in element 6.

7B. Residential Arrangement

  1. Own home or apartment
  2. Residence where health, disability, or aging related services or supervision are available
  3. Other residential setting where no services are provided
  4. Nursing home or other health facility
  5. Other institutional setting (e.g. prison)
  6. Homeless or homeless shelter
  7. Unknown/not stated

Rationale and discussion

The usual living/residential arrangement of an individual is important for understanding the health status of the person as well as the person's follow-up needs when seen in a health care setting. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status.

A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. The Committee encourages the use of the above definition, while continuing to study and evaluate other residential categories, such as those used by the Bureau of the Census.

8. Self-Reported Health Status - There was much interest in documenting health status, one element that can precipitate the demand for health care and help determine the prognosis, although there was no consensus on how its definition should be standardized. A commonly used measure is the person's rating of his or her own general health, as in the five-category classification, "excellent, very good, good, fair, or poor." Used in the National Health Interview Survey and many other studies, this item has been shown to be predictive of morbidity, mortality, and future health care use, when collected in a general interview type of setting. This item would be collected at first clinical visit and periodically updated, at least annually. Additional evaluation and testing are needed on standardizing the health status element. At the present time, standards- setting organizations should assign place holder(s) for this element.

9. Functional Status - The functional status of a person is an increasingly important health measure that has been shown to be strongly related to medical care utilization rates. A number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. Self-report and clinician measurements are each valuable, and having both available is especially informative. Whichever method is used should be designated. Particular scales are more appropriate for measuring different functions or disabilities and should be selected on the basis of the needs of the patient population (such as, use of social functioning scales for those with mental disorders and substance abuse). Functional assessment scales must also be age-appropriate. At present, there is no widely recognized instrument for measuring the functional status of children. Periodicity of assessment also is an issue.

Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. Work on this topic is currently ongoing in the NCVHS Disability and Long-Term Care Statistics Subcommittee. It is possible that the description of functional status may entail more than a single measure, thus needing space for more than one measure and/or an additional element to document the scale used. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element.

10. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. For children under the age of 18, the mother's highest grade of schooling completed should be obtained.

Rationale and discussion

Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Years of schooling has been found to be highly predictive of health status and health care use.

Ideally, one would also collect income to more fully define socioeconomic status. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS.

11. Patient's Relationship to Subscriber/person eligible for entitlement -

D.Other (specify)

Rationale and discussion

This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes.

12. Current or Most Recent Occupation and Industry - This data item is very useful to track occupational diseases as well as to better define socioeconomic status. Standardized coding schemes, such as the Census Bureau's Alphabetical Listing of Occupation and Industry and the Standardized Occupation and Industry Coding (SOIC) software developed by the National Institute for Occupational Safety and Health, should be reviewed. In some situations, it is possible that a free-form narrative will be collected in place of the codes, to be coded at a later point.

The Committee feels that, over time, there will be increasing attention focused on this item and reaffirms its recommendations in the 1994 revisions to the UACDS that additional study and evaluation be conducted on the feasibility and utility of collecting and periodically updating information on a person's occupation and industry. In addition, the usefulness of both current/most recent occupation and industry as well as the addition of usual or longest held occupation and industry must be evaluated. All have significant value and could result in the collection of four separate data elements.

Encounter Data

The elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter.

13. Type of Encounter - This element is critical to the placement of an encounter of care within its correct location, i.e., hospital inpatient , outpatient, emergency department, observation, etc. However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. This term is one that needs study and evaluation before it can be implemented. However, a place holder for this element is recommended to the standards-setting organizations.

14. Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century.

15. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital. Four digits are recommended for the discharge year.

16. Date of Encounter (outpatient and physician services) - Year, month, and day of encounter, visit, or other health care encounter, as recommended by the UACDS and ANSI ASC X12. Each encounter generates a date of service that can be used to link encounters for the same patient over time. Grouping of similar services provided on different dates, as is often the case under batch billing, can be problematic if specificity of data elements is lost; the objective is to encourage identifying a unique date of record for each encounter. However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter.

17-23. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. The National Provider Identifier and National Provider File (NPI/NPF), currently under development by the Health Care Financing Administration (HCFA) and intended for implementation in 1997, could and should meet this need, if all providers are included. The NPI/NPF will provide a common means of uniquely identifying health care providers, including institutions, individuals, and group practices, both Medicare providers and those in other programs. Participation in the system will be voluntary for non-HCFA providers at first. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF.

The immediate goal of the NPI/NPF project is to support HCFA's Medicare Transaction System initiative by providing a single, universal method for enumerating the providers who serve Medicare beneficiaries. It will do so by assigning a unique identifier to each provider. In the future, the system will integrate non-HCFA subscribers. It is planned that enumeration of Medicare providers will begin in calendar year 1996. The draft systems requirement definition was issued in January, 1995. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. Items shown below with an asterisk (*) indicate that this type of information can be obtained from linking the NPI with the National Provider File and may not need separate collection. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included.

17. Facility Identification - The unique HCFA identifier as described above. This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. If the HCFA system does not have separate identification numbers for parts of a hospital (i.e., Emergency Department, Outpatient Department), an additional element (such as element 13) will need to be collected along with the facility ID to differentiate these settings. The Committee recommends that the HCFA identifier be adopted when completed.

18. Type of Facility/Place of Encounter.* As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. The Committee encourages the development of one taxonomy and will monitor progress.

19. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. There may be more than one health care provider identified:

A.The health care practitioner professionally responsible for the services, including ambulatory procedures, delivered to the patient (health care practitioner of record)
B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures

Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. The Committee recommends that the HCFA identifier be adopted when completed.

20. Location or Address of Encounter (outpatient) - The full address and Zip Code (nine digits preferred) for the location at which care was received from the health care practitioner of record (see 19A.). As recommended by the UACDS, address should be in sufficient detail (street name and number, city or town, county, State, and Zip Code) to allow for the computation of county and metropolitan statistical area.

21. Attending Physician Identification (inpatient) - The unique national identification number assigned to the clinician of record at discharge who is responsible for the discharge summary, as recommended by the 1992 UHDDS.

22. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS.

23. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use.

24. Principal Diagnosis (inpatient) - As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. The currently recommended coding instrument is the ICD-9-CM.

Rationale and discussion

Principal diagnosis is required by most systems for inpatient reporting. The Committee acknowledges that there are differences in coding guidelines for reporting diagnosis in inpatient and outpatient settings, and this may result in a lack of comparability in data between the two settings. It is recommended that convergence of these guidelines be investigated.

25. Primary Diagnosis (inpatient) - The diagnosis that is responsible for the majority of the care given to the patient or resources used in the care of the patient. The currently recommended coding instrument is the ICD-9-CM.

Rationale and discussion

The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Respondents have indicated a mixed use of this item for inpatients. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). The NCVHS notes that the Department of Veterans Affairs routinely collects this element, and thus approves the continued inclusion in this core list, pending a review of uses and users of this element.

26. Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. Conditions should be coded that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital or nursing home stay; or increased nursing care and/or monitoring. The currently recommended coding instrument is the ICD-9-CM.

27. Qualifier for Other Diagnoses (inpatient) - The following qualifier should be applied to each diagnosis coded under "other diagnoses," as was recommended in the 1992 revision of the UHDDS:

Onset prior to admission


Rationale and discussion

This element is currently being collected by California and New York hospital discharge data systems; there is an indication that use of this qualifier can contribute significantly to quality assurance monitoring, risk-adjusted outcome studies, and reimbursement strategies.

28-31. Ambulatory Conditions - The elements for ambulatory conditions contain information on the Patient's Stated Reason for Visit and the Problems, Diagnosis, or Assessment, both of which were recommended by the UACDS. The latter element, which describes all conditions requiring evaluation and/or treatment or management at the time of the encounter as designated by the health care practitioner, has been divided into two elements: 1) the diagnosis chiefly responsible for services provided, and 2) other diagnoses.

28. Patient's Stated Reason for Visit or Chief Complaint (outpatient) - Includes the patient's stated reason at the time of the encounter for seeking attention or care. This item attempts to define what actually motivated the patient to seek care and has utility for analyzing the demand for health care services, evaluating quality of care and performing risk adjustment. The NCVHS recommended this as an optional item in the UACDS but that high priority should be given to conducting additional study as to the feasibility, ease and practical utility of collecting the patient's reason for encounter, in as close to the patient's words as possible. There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. Additional evaluation and testing are warranted for this important information.

29-30. Problem, Diagnosis or Assessment (outpatient)

29. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. The currently recommended coding instrument is the ICD-9-CM.

Rationale and discussion

Information on all patient problems and diagnoses requiring attention at the encounter are needed to assess the quality of care delivered, to determine what types of health problems are being seen and treated in the different types of ambulatory care facilities, and for assessing the appropriateness of the setting used to perform the services. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. The instruction clarifies that only what is known to the highest level of specificity should be reported. In some instances this may be a symptom or an abnormal finding. Medicare and many other payers adhere to these guidelines. Some third party payers, however, have ignored the guidelines and required facilities and health care practitioners to report a diagnosis that justifies the performance of services being provided. This has resulted in inconsistent data found in many outpatient databases and has skewed patient outcome studies. It is anticipated that the introduction of ICD-10 will alleviate this problem. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored.

30. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). Condition(s) should be recorded to the highest documented level of specificity. The ICD-9-CM is the recommended coding convention.

Rationale and discussion

Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use.

31. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. The currently recommended coding instrument is the ICD- 9-CM. The priorities for recording an External Cause-of-Injury code (E-code) are:

  1. Principal diagnosis of an injury or poisoning
  2. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis.
  3. Other diagnosis with an external cause.

Rationale and discussion

The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. The information that this element provides on the causes of patients' injuries or adverse effects is considered essential for the development of intervention, prevention and control strategies. Compelling evidence presented by the Indian Health Service, states and nonprofit organizations demonstrates that effective intervention strategies can be implemented in response to available data on external causes of injury.

32. Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams.

Rationale and discussion

Birth weight of newborn is readily available in the medical record and has singular importance for risk-adjustment outcome studies and health policy development related to maternal and infant health.

33-35. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. A significant procedure is one that is:

  1. Surgical in nature, or
  2. Carries a procedural risk, or
  3. Carries an anesthetic risk, or
  4. Requires specialized training.

Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc.

33. Principal Procedure (inpatient)- As recommended by the UHDDS, the principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure. ICD-9-CM Vol. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care.

34. Other Procedures (inpatient) - All other procedures that meet the criteria described in element 33.

35. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure.

36. Procedures and Services (outpatient) - As recommended by the UACDS, describe all diagnostic procedures and services of any type including history, physical examination, laboratory, x-ray or radiograph, and others that are performed pertinent to the patient's reasons for the encounter; all therapeutic services performed at the time of the encounter; and all preventive services and procedures performed at the time of the encounter. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. The HCFA Common Procedure Coding System (HCPCS), based on CPT-4, is required for physician (ambulatory and inpatient), hospital outpatient department, and free-standing ambulatory surgical facility bills; however, NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible.

37. Medications Prescribed - Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code, dosage, strength, and total amount prescribed.

Rationale and discussion

The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. The Committee recognizes that not all providers are obtaining this detail, but it is anticipated that these data will be more frequently collected in the near future with the growth of computerized prescription information.

38. Disposition of Patient (inpatient) - As recommended by the UB 92 and as an expansion of the 1992-93 UHDDS data element:

1. Discharged Alive

A.Discharged to home or self care (routine discharge)
B.Discharged/transferred to another short term general hospital for inpatient care
C.Discharged/transferred to skilled nursing facility (SNF)
D.Discharged/transferred to an intermediate care facility (ICF)
E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution
F.Discharged/transferred to home under care of organized home health service organization
G.Discharged/transferred to home under care of a Home IV provider
H.Left against medical advice or discontinued care


3.Status not stated

Rationale and discussion

In addition to documenting whether the patient was discharged alive or died during the hospitalization, the patient disposition is an indicator of the patient's health status at the time of discharge and need for additional services.

39. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. Multiple responses are possible. At a minimum, the following classification is suggested:

  1. No follow-up planned (return if needed, PRN)
  2. Follow-up planned or scheduled
  3. Referred elsewhere (including to hospital)
  4. Expired

Rationale and discussion

The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers.

40. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment:

40A. Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill.

40B. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill.

  1. Self-pay
  2. Worker's Compensation
  3. Medicare
  4. Medicaid
  5. Maternal and Child Health
  6. Other government payments
  7. Blue Cross
  8. Insurance companies
  9. No charge (free, charity, special research, or teaching)
  10. Other
  11. Unknown/not stated

Rationale and discussion

The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. Source of payment categories, as recommended in the past, are no longer sufficient. The continuing expansion of types of payments and the combination of payments within groups is ever changing. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers.

HCFA is developing a new system, called the HCFA PAYERID project, which will assign a unique identifier to every payer of health care claims in the United States. Participation is voluntary, and HCFA, which is funding its development, has been working to get consensus about the kind of system that would be useful. The database will contain payer names, billing addresses and business information. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. Who will have access to the database for research purposes, and to what data, has yet to be determined. "Payers" are defined as public and private entities that have contract responsibility for health care payment.

Medicare decided a PAYERID was needed because of the difficulty its contractors were having in transferring claims to other insurance companies, due to incomplete information or multiple names for payers. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. They currently are not developing a system of categories to accompany the IDs. Such a system would be helpful to the extent that it is feasible in the current highly dynamic market.

Because the PAYERID system is still being developed, and because HCFA currently has no plans to categorize payers, the Committee recommends the current UHDDS categories while encouraging continued study and evaluation of categories used by other data collectors.

41. Injury Related to Employment - Yes, No.

Rationale and discussion

Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment. During the discussion on including External Cause of Injury in the 1994 revision to the UACDS, CDC and labor and business groups urged collection of whether or not an injury occurred at work or was work-related. This element is currently collected on the HCFA 1500 form.

42. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter.

Rationale and discussion

The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. This item already is collected by most state health data organizations collecting hospital discharge information and offers the only readily available information on the fiscal dimensions of care and the relative costs of different types of care. Although there is agreement that "payments" or "costs" are needed, most participants agreed that it is virtually impossible to collect these items consistently across time and locations. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. It might not be feasible to expect the record to be updated to include payment data when it becomes available. Therefore, billed charges should be collected, at a minimum.