N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-2
(cf. § 400.18[b])
Uniform Bill Elements
SPARCS Hospital Identification Number
Patient Control Number (Admission Number)
Patient Sex
Patient Birthdate
Source of Admission
Admission Date/Start of Care Date
Admission Hour
Statement Covers From Date
Statement Covers Thru Date
Patient Status/Disposition
Discharge Hour
Medical Record Number
Discharge Date
Type of Alternate Care Required
Patient's Residence Address
Patient's Residence City, County, State, and Zip Code
Source of Payment Code
Policy Number
Insurance Group Number
Payor Covered Days
Payor Non-Covered Days
Provider Number
Payor Alternate Level of Care Days
Payor Leave of Absence Days
Accident Type
Accident Type Date
Blood Furnished
Blood Charge
Special Program--Disability
Special Program--Family Planning
Special Program--Physically Handicapped Children
Special Program--Special Funding Project
Surplus, Catastrophic, or Recurring Monthly Income Code
Surplus, Catastrophic, or Recurring Monthly Income Amount
Workers Compensation/No Fault Indicator
SPARCS Accommodation Code
Accommodation Rate
Accommodation Days
Accommodation Total Non-Covered Charges
Ancillary Revenue Code
Ancillary Total Charges
Ancillary Total Non-Covered Charges
Principal Procedure Code
Other Diagnosis Codes (14 occurrences)
Principal Procedure Code
Principal Procedure Date
Other Procedure Codes (14 occurrences)
Other Procedure Dates (14 occurrences)
Admitting Diagnosis Code
External Cause of Injury Code
Procedure Coding Method Used
State Attending Physician License Number
State Operating Physician License Number
State Other Physician License Number
DRG Billed
Type of Bill
N.Y. Comp. Codes R. & Regs. tit. 10, Appendices, app C-2