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Medicare Data to Calculate Your Primary Service Areas

Data for ACO Applicant Share Calculations

The following data is being made available to applicants to the Medicare Shared Savings Program (Shared Savings Program), in order to allow them to calculate their share of services in each applicable Primary Service Area ("PSA"), as described in the Federal Trade Commission/Department of Justice (FTC/DOJ) Proposed Antitrust Enforcement Policy Statement Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program ("Policy Statement").  The data is organized into the following files:

Physician File

These data sets include all physician fee-for-service claims for calendar year 2010 (1/1/2010-12/31/2010), 2011 (01/01/2011 – 12/31/2011) and CY 2012 (01/01/2012 – 12/31/2012). Claims selected for the data set contain at least one of the specialty codes on the Physician Specialty file available on this web page. Claims are final action and the line allowed charges are aggregated by the beneficiary zip code on the claim and summarized by specialty category. Please note specialties 01 – General Practice, 08 – Family Practice, 11 – Internal Medicine, and 38 – Geriatric Medicine, are combined into the Primary Care category and the summed line allowed charges under this category represent all of these specialties.

Inpatient Facility File

These data sets include all Inpatient fee-for-service claims for Fiscal Year 2010 (10/1/2009-9/30/2010), 2011 (01/01/2011 – 12/31/2011) and CY 2012 (01/01/2012 – 12/31/2012) and covers facilities paid under the Inpatient Prospective Payment System (IPPS), Critical Access Hospitals (CAHs), the Inpatient Rehabilitation Facility Prospective Payment System ( IRF), Inpatient Psychiatric Prospective Payment System (IPS), Long Term Care Hospital Prospective Payment System (LTCH), Indian Health Service Hospitals (IHS), Children's Hospitals (to extent for which the CMS has data available), Cancer Hospitals and TEFRA Hospitals. Claims are final action and total payments include the Medicare Claim payment amount, the Beneficiary Inpatient Deductible Amount, the Beneficiary Part A Coinsurance Liability Amount and the Beneficiary Blood Deductible Liability Amount. Payments are aggregated by the beneficiary zip code on the claim and are summarized for each Major Diagnostic Category (MDC).

Outpatient Facility File

These data sets include all outpatient fee for service claims for calendar year 2010 (1/1/2010-12/31/2010), 2011 (01/01/2011 – 12/31/2011) and CY 2012 (01/01/2012 – 12/31/2012) for facilities that include Ambulatory Surgical Centers (ASCs), Outpatient Prospective Payment Systems (OPPS) facilities, Critical Access Hospitals (CAHs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), End-Stage Renal Disease facilities (ESRD), Federally Qualified Health Centers (FQHCs), Outpatient Rehabilitation Facilities (ORFs) and Rural Health Clinics. Claims are final action and include any copayments and/or deductibles that apply. Medicare Payments (and line allowed charge amounts in the case of ASCs) are aggregated by the beneficiary zip code on the claim and are summarized for each Outpatient Category.

Each file contains an aggregate dollar amount, reflecting total Medicare payments or allowed charges including deductibles and co-insurance, for each zip code and each service category.  For physicians, a service is defined as the physician's primary specialty, as designated on the physician's Medicare Enrollment Application.  (If the physician's primary specialty is General Practice, Family Practice, Internal Medicine, or Geriatric Medicine, the service is defined as "Primary Care".)  For inpatient facilities, a service is a major diagnostic category ("MDC"), and for outpatient facilities, a service is an outpatient category.  Treatment codes for inpatient and outpatient services are assigned to the applicable categories in the following crosswalk files:

  • Crosswalk from Ambulatory Surgical Center (ASC) Healthcare
  • Common Procedure Coding System (HCPCS) codes to outpatient categories
  • Crosswalk from Ambulatory Payment Classifications (APCs) to outpatient categories
  • Crosswalk from diagnosis-related groups (DRGs) to Major Diagnostic Categories (MDCs)

For detailed instructions on using this data to calculate PSA shares, applicants should refer to the Policy Statement.

Please submit any questions to: aco_psa_questions@ftc.gov.