National Private Patient Claim Form Page 2
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1
2CODES FOR CLAIM FORM ITEMS*
4. DAY ONLY PROCEDURES AND OVERNIGHT STAY CERTIFICATION
ADMISSION CODES
ACCOMMODATION CODES
DISCHARGE CODES
(PLEASE TICK ( ) BELOW)
1
Admission Claim
1
Single Room
1
Discharged
2
Continuation Claim
2
Shared Room
2
Interim Claim
DATE OF SERVICE:
/
/
3
Unplanned Re-admission within
3
Shared Room+
3
Deceased
28 Days
4
Coronary Care
4
On Leave
4
Same Day
5
Intensive Care
5
Transfer to Another Hospital
Day Only Procedures – Certification
5
Transfer from Another Hospital
6
Other (eg HDU)
6
Early Discharge Program
Certificate for the purpose of paragraph (bj), Schedule 1, National Health Act, 1953
6
Other Re-admission
7
Neonatal
8
Nursing Home Type Patient
PAYMENT TYPE CODES
9
Rehabilitation Program
1
Per Diem
Overnight Stay Admission – Certification
10 Psychiatric Program
2
Case Payment
Certificate for the purpose of paragraph (bj), Schedule 1, National Health Act, 1953
11 Outreach/Hospital in the Home Care
3
Other__________________________
(Hospital to insert other payment type)
Note: Overnight Certificate only required when a Band 1 or a non-band specific Type B patient is
admitted as an Overnight Stay Patient
OTHER SERVICES CODES
INFANT / NEONATE WEIGHT
URGENCY OF ADMISSION CODES
1
Labour Ward
The admission weight rounded to the
1
Urgency status assigned – emergency
2
Theatre Fee
nearest gram.
2
Urgency status assigned – elective
I certify that this hospitalisation / overnight stay was necessary because of:
3
Pharmaceuticals
3
Urgency status not assigned
4
Nursery Fee
9
Not known / not reported
5
Disposables
The medical condition of the patient named overleaf, namely…
6
Prostheses
8
Allied Health Services
Other special circumstances, namely…
7
Other
MODE OF SEPARATION CODES
SOURCE OF REFERRAL CODES
TRANSFER CODES – TRANSFER IN OR
Please specify medical condition and / or other special circumstances:
1
Discharge / Transfer to an (other) Acute
The facility from which the patient was
TRANSFER OUT
Hospital
referred as follows:
U
Up Transfer: This / the next Hospital stay
2
Discharge / Transfer to a Nursing Home
0
Born in Hospital
is expected to be more resource intensive
3
Discharge / Transfer to an (other)
1
Admitted Patient Transferred from
than the next / previous hospital stay
Psychiatric Hospital
Another Hospital
D
Down Transfer: This / the next hospital
4
Discharge / Transfer to Other Health Care
2
Statistical Admission – Type Change
stay is expected to be less resource
Accommodation
4
From Accident/Emergency
intensive than the next / previous hospital
5
Statistical Discharge – Type Change
5
From Community Health Service
stay
6
Patient Left against Medical Advice
6
From Outpatients Department
L
Lateral Transfer: This / the next hospital
7
Statistical Discharge from Leave
7
From Nursing Home
stay is expected to be of similar resource
8
Died
8
By Outside Medical Practitioner
intensity as the next / previous hospital
9
To Home / Other
9
Other
stay
X
Unknown
CARE TYPE CODES
ICU HOURS
The type of service for which the patient was initially admitted:
The number of hours spent by the patient in one or more of the
Name of medical practitioner providing the professional treatment:
10 Acute Care
following:
20 Rehabilitation Care
ICU; CCU; Neonatal Intensive Care; Paediatric Intensive Care.
21 Rehabilitation Care Delivered in a Designated Unit
This does not include days spent in Special Care Nurseries or High
22 Rehabilitation Care According to a Designated Program
Dependency Units.
23 Rehabilitation Care is the Principal Clinical Intent
Name of authorised hospital health professional (where applicable):
30 Palliative Care
MV (MECHANICAL VENTILATION) HOURS
31 Palliative Care Delivered in a Designated Unit
The number of hours (rounded) for which the patient received
32 Palliative Care According to a Designated Program
mechanical ventilation in ICU during the episode.
33 Palliative Care is the Principal Clinical Intent
[Overnight certification may be provided by a professional employed by the hospital who is suitably
40 Geriatric Evaluation and Management
SAME DAY STATUS CODES
qualified to do so. (This applies only in the event that the treating practitioner is not physically
50 Psychogeriatric Care
0
Patient with a Valid Arrangement allowing for Overnight Stay for
60 Maintenance Care
Procedure normally performed on a Same Day Basis. (Please
available to certify the certificate. There is still a requirement for the hospital representative to
70 Newborn Care
complete Overnight Stay Certification)
consult and obtain ratification from the treating practitioner of the need for overnight hospital care)].
80 Other Admitted Patient Care
1
Same Day Patient
90 Organ Procurement - Posthumous
2
Overnight Patient (other than type 0 above)
100 Hospital Boarder
:
Date of Consultation
Time of Consultation
/
/
MENTAL HEALTH LEGAL STATUS CODES
INTER-HOSPITAL CONTRACTED PATIENT CODES
Certifying the Need for
(24hr)
1
Involuntary
1
Inter-Hospital contracted patient from public sector
Overnight Hospital Care:
2
Voluntary
2
Inter-Hospital contracted patient from private sector
3
Not permitted to be reported under legislative arrangements
3
Other
in the jurisdiction
9
Not reported
8
Not applicable
Signature of Treating Practitioner
(or Authorised Person
Barcode Area
where applicable)
Date:
/
/
* Based on Hospital Casemix Protocol data definitions published by the
Australian Government Department of Health & Ageing.
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