1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI Home Health Agency (HHA) REC VAR Fiscal intermediary Home Health Agency Limited Claim Record - Limited Data Data Set Standard View for version I of the NCH. Set Standard View The Limited Data Set Standard View supports the users of CMS data and provides the data in "text" ready format for easy conversion to ASCII text files. This file is also specifically processed to perform CMS standard encryption processes for identifiable and personal health information data fields. **** FI HHA Claim Fixed GROUP 188 1 188 Fixed portion of the fiscal intermediary Group - Limited Data claim record for the Limited Data Set Standard Set Standard View View of the Home Health Agency claim record for version I of the NCH Nearline File. 1. Record Length Count NUM 5 1 5 The length of the record. 5 DIGITS UNSIGNED 2. Record Number NUM 9 6 14 A sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. 3. Record Type NUM 2 15 16 Type of Record. CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 09 = Claim Value Group 10 = MCO Period Group 11 = NCH Edit Group 12 = NCH Patch Group 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE1: During the Version H conversion this field was populated with data through-out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. DB2 ALIAS: NCH_CLM_TYPE_CD SAS ALIAS: CLM_TYPE STANDARD ALIAS: UTLHHAI_NCH_CLM_TYPE_CD SYSTEM ALIAS: LTTYPE TITLE ALIAS: CLAIM_TYPE DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Beneficiary Birth Date NUM 8 22 29 The beneficiary's date of birth. For the Limited Data Set Standard View of the HHA files, the beneficiary's date of birth (age) is coded as a range. 8 DIGITS UNSIGNED DB2 ALIAS: BENE_BIRTH_DT SAS ALIAS: BENE_DOB STANDARD ALIAS: BENE_BIRTH_DT TITLE ALIAS: BENE_BIRTH_DATE EDIT-RULES FOR ENCRYPTED DATA: 0000000R WHERE R HAS ONE OF THE FOLLOWING VALUES. 0 = Unknown 1 = <65 2 = 65 Thru 69 3 = 70 Thru 74 4 = 75 Thru 79 5 = 80 Thru 84 6 = >84 SOURCE: CWF 7. Beneficiary Identification CHAR 2 30 31 The code identifying the type of relationship between an Code individual and a primary Social Security Administration (SSA) beneficiary or a primary Railroad Board (RRB) beneficiary. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ COMMON ALIAS: BIC DA3 ALIAS: BENE_IDENT_CODE DB2 ALIAS: BENE_IDENT_CD SAS ALIAS: BIC STANDARD ALIAS: BENE_IDENT_CD TITLE ALIAS: BIC EDIT-RULES: EDB REQUIRED FIELD CODES: REFER TO: BENE_IDENT_TB IN THE CODES APPENDIX SOURCE: SSA/RRB 8. Beneficiary Race Code CHAR 1 32 32 The race of a beneficiary. DA3 ALIAS: RACE_CODE DB2 ALIAS: BENE_RACE_CD SAS ALIAS: RACE STANDARD ALIAS: BENE_RACE_CD SYSTEM ALIAS: LTRACE TITLE ALIAS: RACE_CD CODES: 0 = Unknown 1 = White 2 = Black 3 = Other 4 = Asian 5 = Hispanic 6 = North American Native SOURCE: SSA 9. Beneficiary Residence SSA CHAR 3 33 35 The SSA standard county code of a beneficiary's residence. Standard County Code DA3 ALIAS: SSA_STANDARD_COUNTY_CODE DB2 ALIAS: BENE_SSA_CNTY_CD SAS ALIAS: CNTY_CD STANDARD ALIAS: BENE_RSDNC_SSA_STD_CNTY_CD TITLE ALIAS: BENE_COUNTY_CD EDIT-RULES: OPTIONAL: MAY BE BLANK SOURCE: SSA/EDB 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 10. Beneficiary Residence SSA CHAR 2 36 37 The SSA standard state code of a beneficiary's residence. Standard State Code DA3 ALIAS: SSA_STANDARD_STATE_CODE DB2 ALIAS: BENE_SSA_STATE_CD SAS ALIAS: STATE_CD STANDARD ALIAS: BENE_RSDNC_SSA_STD_STATE_CD TITLE ALIAS: BENE_STATE_CD EDIT-RULES: OPTIONAL: MAY BE BLANK CODES: REFER TO: GEO_SSA_STATE_TB IN THE CODES APPENDIX COMMENT: 1. Used in conjunction with a county code, as selection criteria for the determination of payment rates for HMO reimbursement. 2. Concerning individuals directly billable for Part B and/or Part A premiums, this element is used to determine if the beneficiary will receive a bill in English or Spanish. 3. Also used for special studies. SOURCE: SSA/EDB 11. Beneficiary Sex CHAR 1 38 38 The sex of a beneficiary. Identification Code COMMON ALIAS: SEX_CD DA3 ALIAS: SEX_CODE DB2 ALIAS: BENE_SEX_IDENT_CD SAS ALIAS: SEX STANDARD ALIAS: BENE_SEX_IDENT_CD SYSTEM ALIAS: LTSEX TITLE ALIAS: SEX_CD EDIT-RULES: REQUIRED FIELD CODES: 1 = Male 2 = Female 0 = Unknown SOURCE: SSA,RRB,EDB 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 12. Claim Attending Physician CHAR 6 39 44 On an institutional claim, the unique UPIN Number physician identification number (UPIN) of the physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the beneficiary's medical care and treatment (attending physician). This field is ENCRYPTED for the Limited Data Set Standard View of the HHA files. COMMON ALIAS: ATTENDING_PHYSICIAN_UPIN DB2 ALIAS: ATNDG_UPIN SAS ALIAS: AT_UPIN STANDARD ALIAS: CLM_ATNDG_PHYSN_UPIN_NUM TITLE ALIAS: ATTENDING_PHYSICIAN COMMENT: Prior to Version H this field was named: CLM_PRMRY_CARE_PHYSN_IDENT_NUM and contained 10 positions (6-position UPIN and 4-position physician surname). SOURCE: CWF 13. Claim Diagnosis E Code CHAR 5 45 49 Effective with Version H, the ICD-9-CM code used to identify the external cause of injury, poisoning, or other adverse affect. Redundantly this field is also stored as the last occurrence of the diagnosis trailer. NOTE: During the Version H conversion, the data in the last occurrence of the diagnosis trailer was used to populate history. DB2 ALIAS: CLM_DGNS_E_CD SAS ALIAS: DGNS_E STANDARD ALIAS: CLM_DGNS_E_CD TITLE ALIAS: DGNS_E_CD SOURCE: CWF 14. Claim Excepted/Nonexcepted CHAR 1 50 50 Effective with Version I, the code used to identify Medical Treatment Code whether or not the medical care or treatment received by a beneficiary, who has elected care from a Religious Nonmedical Health Care Institution (RNHCI), is excepted or nonexcepted. Excepted is medical care or treatment that is received involuntarily or is re- quired under Federal, State or local law. Nonexcepted is defined as medical care or treatment other than excepted. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ DB2 ALIAS: EXCPTD_NEXCPTD_CD SAS ALIAS: TRTMT_CD STANDARD ALIAS: CLM_EXCPTD_NEXCPTD_TRTMT_CD TITLE ALIAS: EXCPTD_NEXCPTD_CD CODES: 0 = No Entry 1 = Excepted 2 = Nonexcepted SOURCE: CWF 15. Claim Facility Type Code CHAR 1 51 51 The first digit of the type of bill (TOB1) submitted on an institutional claim used to identify the type of facility that provided care to the beneficiary. COMMON ALIAS: TOB1 DB2 ALIAS: CLM_FAC_TYPE_CD SAS ALIAS: FAC_TYPE STANDARD ALIAS: CLM_FAC_TYPE_CD TITLE ALIAS: TOB1 CODES: REFER TO: CLM_FAC_TYPE_TB IN THE CODES APPENDIX SOURCE: CWF 16. Claim Frequency Code CHAR 1 52 52 The third digit of the type of bill (TOB3) submitted on an institutional claim record to indicate the sequence of a claim in the beneficiary's current episode of care. COMMON ALIAS: TOB3 DB2 ALIAS: CLM_FREQ_CD SAS ALIAS: FREQ_CD STANDARD ALIAS: CLM_FREQ_CD SYSTEM ALIAS: LTFREQ TITLE ALIAS: FREQUENCY_CD CODES: REFER TO: CLM_FREQ_TB IN THE CODES APPENDIX SOURCE: CWF 17. Claim HHA Low Utilization CHAR 1 53 53 Effective with Version I, the code used to identify Payment Adjustment (LUPA) those Home Health PPS claims that have 4 visits Indicator Code or less in a 60-day episode. If an HHA provides 4 visits or less, they will be reimbursed based on a national standardized per visit rate instead of HHRGs. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces. DB2 ALIAS: HHA_LUPA_IND_CD SAS ALIAS: LUPAIND STANDARD ALIAS: CLM_HHA_LUPA_IND_CD TITLE ALIAS: HHA_TOT_VISITS CODES: L = LUPA Claim blank = Not a LUPA Claim SOURCE: CWF 18. Claim HHA Referral Code CHAR 1 54 54 Effective with Version 'I', the codes used to identify the means by which the beneficiary was referred for Home Health Services. NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces in this field. DB2 ALIAS: CLM_HHA_RFRL_CD SAS ALIAS: HHA_RFRL STANDARD ALIAS: CLM_HHA_RFRL_CD SYSTEM ALIAS: LTHRFRL TITLE ALIAS: HHA_REFERRAL_CODE CODES: REFER TO: CLM_HHA_RFRL_TB IN THE CODES APPENDIX SOURCE: CWF 19. Claim HHA Total Visit Count CHAR 4 55 58 Effective with Version H, the count of the number of HHA visits as derived by CWF. NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991) using the CWF derivation rule (units associated with revenue center codes 042X, 043X, 044X, 055X, 056X, 057X, 058X, and 059X. Value '999' will be displayed if the sum of the revenue center unit count equals or exceeds '999'. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE2: Effective 7/1/99, all HHA claims received with service from dates 7/1/99 and after will be processed as if the units field contains the 15 minute interval count; and each visit revenue code line item will be counted as ONE visit. This field is calculated correctly; but those users who derive the count themselves will have to revise their routine. NO LONGER IS THE COUNT DERIVED BY ADDING UP THE UNITS FIELDS ASSOCIATED WITH THE HHA VISIT REVENUE CODES. 3 DIGITS SIGNED DB2 ALIAS: HHA_TOT_VISIT_CNT SAS ALIAS: VISITCNT STANDARD ALIAS: CLM_HHA_TOT_VISIT_CNT TITLE ALIAS: HHA_TOT_VISITS EDIT-RULES +999 SOURCE: CWF *** Claim Locator Number Group GROUP 11 59 69 This number uniquely identifies the beneficiary in the NCH Nearline. STANDARD ALIAS: CLM_LCTR_NUM_GRP 20. Beneficiary Claim Account CHAR 9 59 67 The number identifying the primary beneficiary Number under the SSA or RRB programs submitted. This field is ENCRYPTED for the Limited Data Set Standard View of the HHA files. STANDARD ALIAS: BENE_CLM_ACNT_NUM SOURCE: SSA, RRB LIMITATIONS: RRB-issued numbers contain an overpunch in the first position that may appear as a plus zero or A-G. RRB-formatted numbers may cause matching problems on non-IBM machines. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 21. NCH Category Equatable CHAR 2 68 69 The code categorizing groups of BICs representing Beneficiary Identification representing similar relationships between Code the beneficiary and the primary wage earner. The equatable BIC module electronically The equatable BIC module electronially matches matches two records that contain different BICs where it is apparent that both are records for the same beneficiary. It validates the BIC and returns a base BIC under which to house the record in the National Claims History (NCH) databases. (All records for a beneficiary are stored under a single BIC.) For the Limited Data Set Standard View, this field contains the Beneficiary Identificaiton Code. (See Field #7 of the FI Home Health Agency Claim Fixed Group - Limited Data Set Standard View.) 22. Claim Medicare Non Payment CHAR 1 70 70 The reason that no Medicare payment is made for Reason Code services on an institutional claim. NOTE: Effective with Version I, this field was put on all institutional claim types. Prior to Version I, this field was present only on inpatient/SNF claims. DB2 ALIAS: MDCR_NPMT_RSN_CD SAS ALIAS: NOPAY_CD STANDARD ALIAS: CLM_MDCR_NPMT_RSN_CD SYSTEM ALIAS: LTNPMT TITLE ALIAS: NON_PAYMENT_REASON EDIT-RULES: OPTIONAL CODES: REFER TO: CLM_MDCR_NPMT_RSN_TB IN THE CODES APPENDIX SOURCE: CWF 23. Claim MCO Paid Switch CHAR 1 71 71 A switch indicating whether or not a Managed Care Organization (MCO) has paid the provider for an institutional claim. COBOL ALIAS: MCO_PD_IND DB2 ALIAS: CLM_MCO_PD_SW SAS ALIAS: MCOPDSW STANDARD ALIAS: CLM_MCO_PD_SW TITLE ALIAS: MCO_PAID_SW CODES: 1 = MCO has paid the provider for a claim Blank or 0 = MCO has not paid the provider 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ for a claim COMMENT: Prior to Version H this field was named: CLM_GHO_PD_SW. SOURCE: CWF 24. Claim Operating Physician CHAR 6 72 77 On an institutional claim, the unique physician UPIN Number identification number (UPIN) of the physician who performed the principal procedure. This element is used by the provider to identify the operating physician who performed the surgical procedure. This field is ENCRYPTED for the Limited Data Set Standard View of the HHA files. DB2 ALIAS: OPRTG_UPIN SAS ALIAS: OP_UPIN STANDARD ALIAS: CLM_OPRTG_PHYSN_UPIN_NUM TITLE ALIAS: OPRTG_UPIN COMMENT: Prior to Version H this field was named: CLM_PRNCPAL_PRCDR_PHYSN_NUM and contained 10 positions (6-position UPIN and 4-position physician surname. NOTE: For HHA and Hospice formats beginning with NCH weekly process date 10/3/97 this field was populated with data. HHA and Hospice claims processed prior to 10/3/97 will contain spaces. SOURCE: CWF 25. Claim Other Physician UPIN CHAR 6 78 83 On an institutional claim, the unique physician Number identification number (UPIN) of the other physician associated with the institutional claim. This field is ENCRYPTED for the Limited Data Set Standard View of the HHA files. DB2 ALIAS: OTHR_UPIN SAS ALIAS: OT_UPIN STANDARD ALIAS: CLM_OTHR_PHYSN_UPIN_NUM TITLE ALIAS: OTH_PHYSN_UPIN 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ COMMENT: Prior to Version H this field was named: CLM_OTHR_PHYSN_IDENT_NUM and contained 10 positions (6-position UPIN and 4-position other physician surname). NOTE: For HHA and Hospice formats beginning with NCH weekly process date 10/3/97 this field was populated with data. HHA and Hospice claims processed prior to 10/3/97 will contain spaces. SOURCE: CWF 26. Claim Payment Amount CHAR 13 84 96 Amount of payment made from the Medicare trust fund for the services covered by the claim record. Generally, the amount is calculated by the FI or carrier; and represents what was paid to the institutional provider, physician, or supplier, with the exceptions noted below. **NOTE: In some situations, a negative claim payment amount may be pre- sent; e.g., (1) when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or (2) when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.) Under IP PPS, inpatient hospital services are paid based on a predetermined rate per discharge, using the DRG patient classification system and the PRICER program. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (since 5/1/86), indirect medical education (since 10/1/88), total PPS capital (since 10/1/91). It does NOT include the pass thru amounts (i.e., capital-related costs, direct medical education costs, kidney acquisition costs, bad debts); or any beneficiary-paid amounts (i.e., deductibles and coinsurance); or any other payer reimbursement. Under SNF PPS, SNFs will classify beneficiaries using the patient classification system known as RUGS III. For the SNF PPS claim, the SNF PRICER will calculate/return the rate for each revenue center line item with revenue center code = '0022'; multiply the rate times the units count; and then sum the amount payable for all lines with revenue center code '0022' to determine the total claim payment amount. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ Under Outpatient PPS, the national ambulatory payment classification (APC) rate that is calculated for each APC group is the basis for determining the total payment. The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts. NOTE: There is no CWF edit check to validate that the revenue center Medicare payment amount equals the claim level Medicare payment amount. Under Home Health PPS, beneficiaries will be classified into an appropriate case mix category known as the Home Health Resource Group. A HIPPS code is then generated corresponding to the case mix category (HHRG). For the RAP, the PRICER will determine the payment amount appropriate to the HIPPS code by computing 60% (for first episode) or 50% (for subsequent episodes) of the case mix episode payment. The payment is then wage index adjusted. For the final claim, PRICER calculates 100% of the amount due, because the final claim is processed as an adjustment to the RAP, reversing the RAP payment in full. Although final claim will show 100% payment amount, the provider will actually receive the 40% or 50% payment. Exceptions: For claims involving demos and BBA encounter data, the amount reported in this field may not just represent the actual provider payment. For demo Ids '01','02','03','04' -- claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included. For demo Ids '05','15' -- encounter data 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO. For demo Ids '06','07','08' -- claims contain actual provider payment but represent a special negotiated bundled payment for both Part A and Part B services. To identify what the conventional provider Part A payment would have been, check value code = 'Y4'. The related noninstitutional (physician/supplier) claims contain what would have been paid had there been no demo. For BBA encounter data (non-demo) -- 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan. 9.2 DIGITS SIGNED 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ COMMON ALIAS: REIMBURSEMENT DB2 ALIAS: CLM_PMT_AMT SAS ALIAS: PMT_AMT STANDARD ALIAS: CLM_PMT_AMT TITLE ALIAS: REIMBURSEMENT EDIT-RULES: +9(9).99 COMMENT: Prior to Version H the size of this field was S9(7)V99. Also the noninstitutional claim records carried this field as a line item. Effective with Version H, this element is a claim level field across all claim types (and the line item field has been renamed.) SOURCE: CWF LIMITATIONS: Prior to 4/6/93, on inpatient, outpatient, and physician/supplier claims containing a CLM_DISP_CD of '02', the amount shown as the Medicare reimbursement does not take into consideration any CWF automatic adjustments (involving erroneous deductibles in most cases). In as many as 30% of the claims (30% IP, 15% OP, 5% PART B), the reimbursement reported on the claims may be over or under the actual Medicare payment amount. 27. Claim Principal Diagnosis CHAR 5 97 101 The ICD-9-CM diagnosis code identifying the diagnosis, Code condition, problem or other reason for the admission/encounter/visit shown in the medical record to be chiefly responsible for the services provided. NOTE: Effective with Version H, this data is also redundantly stored as the first occurrence of the diagnosis trailer. DB2 ALIAS: PRNCPAL_DGNS_CD SAS ALIAS: PDGNS_CD STANDARD ALIAS: CLM_PRNCPAL_DGNS_CD TITLE ALIAS: PRINCIPAL_DIAGNOSIS EDIT-RULES: ICD-9-CM SOURCE: CWF 28. Claim PPS Indicator Code CHAR 1 102 102 Effective with Version H, the code indicating whether or not the (1) claim is PPS and/or (2) the beneficiary is a deemed insured Medicare Qualified Government Employee (MQGE). 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: Beginning with NCH weekly process date 10/3/97 through 5/29/98, this field was pop- ulated with only the PPS indicator. Beginning with NCH weekly process date 6/5/98, this field was additionally populated with the deemed MQGE indicator. Claims processed prior to 10/3/97 will contain spaces. COBOL ALIAS: PPS_IND DB2 ALIAS: CLM_PPS_IND_CD SAS ALIAS: PPS_IND STANDARD ALIAS: CLM_PPS_IND_CD TITLE ALIAS: PPS_IND CODES: REFER TO: CLM_PPS_IND_TB IN THE CODES APPENDIX SOURCE: CWF 29. Claim Query Code CHAR 1 103 103 Code indicating the type of claim record being processed with respect to payment (debit/credit indicator; interim/final indicator). DB2 ALIAS: CLM_QUERY_CD SAS ALIAS: QUERY_CD STANDARD ALIAS: CLM_QUERY_CD TITLE ALIAS: QUERY_CD CODES: 0 = Credit adjustment 1 = Interim bill 2 = Home Health Agency (HHA) benefits exhausted (obsolete 7/98) 3 = Final bill 4 = Discharge notice (obsolete 7/98) 5 = Debit adjustment SOURCE: CWF 30. Claim Service CHAR 1 104 104 The second digit of the type of bill (TOB2) submitted on an Classification Type Code institutional claim record to indicate the classification of the type of service provided to the beneficiary. COMMON ALIAS: TOB2 DB2 ALIAS: SRVC_CLSFCTN_CD SAS ALIAS: TYPESRVC STANDARD ALIAS: CLM_SRVC_CLSFCTN_TYPE_CD TITLE ALIAS: TOB2 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: REFER TO: CLM_SRVC_CLSFCTN_TYPE_TB IN THE CODES APPENDIX SOURCE: CWF 31. Claim Through Date NUM 8 105 112 The last day on the billing statement covering services rendered to the beneficiary (a.k.a 'Statement Covers Thru Date'). For the Limited Data Set Standard View of the HHA files, the claim through date is coded as the quarter of the calendar year when the claim through date occurred. NOTE: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match. 8 DIGITS UNSIGNED DB2 ALIAS: CLM_THRU_DT SAS ALIAS: THRU_DT STANDARD ALIAS: CLM_THRU_DT TITLE ALIAS: THRU_DATE EDIT-RULES FOR ENCRYPTED DATA: YYYYQ000 WHERE Q IS ONE OF THE FOLLOWING VALUES. 1 = FIRST QUARTER OF THE CALENDAR YEAR 2 = SECOND QUARTER OF THE CALENDAR YEAR 3 = THIRD QUARTER OF THE CALENDAR YEAR 4 = FOURTH QUARTER OF THE CALENDAR YEAR SOURCE: CWF 32. Claim Total Charge Amount CHAR 13 113 125 Effective with Version G, the total charges for all services included on the institutional claim. This field is redundant with revenue center code 0001/total charges. 9.2 DIGITS SIGNED DB2 ALIAS: CLM_TOT_CHRG_AMT SAS ALIAS: TOT_CHRG STANDARD ALIAS: CLM_TOT_CHRG_AMT TITLE ALIAS: CLAIM_TOTAL_CHARGES EDIT-RULES: +9(9).99 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ COMMENT: Prior to Version H the size of this field was S9(7)V99. SOURCE: CWF 33. Claim Transaction Code CHAR 1 126 126 The code derived by CWF to indicate the type of claim submitted by an institutional provider. DB2 ALIAS: CLM_TRANS_CD SAS ALIAS: TRANS_CD STANDARD ALIAS: CLM_TRANS_CD SYSTEM ALIAS: LTCLTRAN TITLE ALIAS: TRANSACTION_CODE CODES: REFER TO: CLM_TRANS_TB IN THE CODES APPENDIX SOURCE: CWF 34. CWF Beneficiary Medicare CHAR 2 127 128 The CWF-derived reason for a beneficiary's Status Code entitlement to Medicare benefits, as of the reference date (CLM_THRU_DT). COBOL ALIAS: MSC COMMON ALIAS: MSC DB2 ALIAS: BENE_MDCR_STUS_CD SAS ALIAS: MS_CD STANDARD ALIAS: CWF_BENE_MDCR_STUS_CD SYSTEM ALIAS: LTMSC TITLE ALIAS: MSC DERIVATION: CWF derives MSC from the following: 1. Date of Birth 2. Claim Through Date 3. Original/Current Reasons for entitlement 4. ESRD Indicator 5. Beneficiary Claim Number DERIVATION: CWF derives MSC from the following: 1. Date of Birth 2. Claim Through Date 3. Original/Current Reasons for entitlement 4. ESRD Indicator 5. Beneficiary Claim Number Items 1,3,4,5 come from the CWF Beneficiary Master Record; item 2 comes from the FI/Carrier claim record. MSC is assigned as follows: 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ MSC OASI DIB ESRD AGE BIC ______ _____ _____ _____ _____ ______ 10 YES N/A NO 65 and over N/A 11 YES N/A YES 65 and over N/A 20 NO YES NO under 65 N/A 21 NO YES YES under 65 N/A 31 NO NO YES any age T. CODES: 10 = Aged without ESRD 11 = Aged with ESRD 20 = Disabled without ESRD 21 = Disabled with ESRD 31 = ESRD only COMMENT: Prior to Version H this field was named: BENE_MDCR_STUS_CD. The name has been changed to distinguish this CWF-derived field from the EDB-derived MSC (BENE_MDCR_STUS_CD). SOURCE: CWF 35. FI Claim Action Code CHAR 1 129 129 The type of action requested by the intermediary to be taken on an institutional claim. DB2 ALIAS: FI_CLM_ACTN_CD SAS ALIAS: ACTIONCD STANDARD ALIAS: FI_CLM_ACTN_CD TITLE ALIAS: ACTION_CD CODES: REFER TO: FI_CLM_ACTN_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: INTRMDRY_CLM_ACTN_CD. SOURCE: CWF 36. FI Number CHAR 5 130 134 The identification number assigned by CMS to a fiscal intermediary authorized to process institutional claim records. DB2 ALIAS: FI_NUM SAS ALIAS: FI_NUM STANDARD ALIAS: FI_NUM SYSTEM ALIAS: LTFI TITLE ALIAS: INTERMEDIARY 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: REFER TO: FI_NUM_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: FICARR_IDENT_NUM. SOURCE: CWF 37. FI Requested Claim Cancel CHAR 1 135 135 The reason that an intermediary requested cancelling Reason Code a previously submitted institutional claim. DB2 ALIAS: RQST_CNCL_RSN_CD SAS ALIAS: CANCELCD STANDARD ALIAS: FI_RQST_CLM_CNCL_RSN_CD TITLE ALIAS: CANCEL_CD CODES: REFER TO: FI_RQST_CLM_CNCL_RSN_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: INTRMDRY_RQST_CLM_CNCL_RSN_CD. SOURCE: CWF 38. HHA Claim Diagnosis NUM 2 136 137 The count of the number of diagnosis codes (both principal Code Count and other) reported on an HHA claim. The purpose of this count is to indicate how many claim diagnosis trailers are present. 2 DIGITS UNSIGNED DB2 ALIAS: HHA_DGNS_CD_CNT SAS ALIAS: HHDGNCNT STANDARD ALIAS: HHA_CLM_DGNS_CD_CNT EDIT-RULES: RANGE: 0 TO 10 COMMENT: Prior to Version H this field was named: CLM_OTHR_DGNS_CD_CNT and the principal was not included in the count. SOURCE: CWF 39. HHA Claim Related NUM 2 138 139 The count of the number of condition codes reported Condition Code Count on an HHA claim. The purpose of this count is to indicate how many condition code trailers are present. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 2 DIGITS UNSIGNED DB2 ALIAS: HHA_COND_CD_CNT SAS ALIAS: HHCONCNT STANDARD ALIAS: HHA_CLM_RLT_COND_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_COND_CD_CNT. SOURCE: CWF 40. HHA Claim Related NUM 2 140 141 The count of the number of occurrence codes reported Occurrence Code Count on an HHA claim. The purpose of this count is to indicate how many occurrence code trailers are present. 2 DIGITS UNSIGNED DB2 ALIAS: HHA_RLT_OCRNC_CNT SAS ALIAS: HHOCRCNT STANDARD ALIAS: HHA_CLM_RLT_OCRNC_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_OCRNC_CD_CNT. SOURCE: CWF 41. HHA Claim Value NUM 2 142 143 The count of the number of value codes reported Code Count on an HHA claim. The purpose of the count is to indicate how many value code trailers are present. 2 DIGITS UNSIGNED DB2 ALIAS: HHA_CLM_VAL_CD_CNT SAS ALIAS: HHVALCNT STANDARD ALIAS: HHA_CLM_VAL_CD_CNT EDIT-RULES: RANGE: 0 TO 36 COMMENT: Prior to Version H this field was named: CLM_VAL_CD_CNT. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SOURCE: CWF 42. HHA Revenue Center NUM 2 144 145 The count of the number of revenue codes Code Count reported on an HHA claim. The purpose of the count is to indicate how many revenue center trailers are present. 2 DIGITS UNSIGNED DB2 ALIAS: HHA_REV_CNTR_CD_CNT SAS ALIAS: HHREVCNT STANDARD ALIAS: HHA_REV_CNTR_CD_I_CNT EDIT-RULES: RANGE: 0 TO 45 COMMENT: Prior to Version H this field was named: CLM_REV_CNTR_CD_CNT. NOTE: During the Version 'I' conversion the number of occurrences changed to 45 (per segment - 450 total for claim). For claims prior to Version 'I' the number of occurrences was 58, but in the conversion we made all claims back to service year 1991 contain only 45 revenue center lines. It is possible that claims prior to 1991 will have 2 segments if they contained more than 45 revenue lines. SOURCE: CWF 43. NCH Beneficiary Discharge NUM 8 146 153 Effective with Version H, on an inpatient and Date HHA claim, the date the beneficiary was discharged from the facility or died (used for internal CWFMQA editing purposes.) For the Limited Data Set Standard View of the HHA files, the beneficiary's discharge date is coded as the quarter of the calendar year when the discharge occurred. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991.) 8 DIGITS UNSIGNED DB2 ALIAS: NCH_BENE_DSCHRG_DT SAS ALIAS: DSCHRGDT STANDARD ALIAS: NCH_BENE_DSCHRG_DT TITLE ALIAS: DISCHARGE_DT 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ EDIT-RULES FOR ENCRYPTED DATA: YYYYQ000 WHERE Q IS ONE OF THE FOLLOWING VALUES. 1 = FIRST QUARTER OF THE CALENDAR YEAR 2 = SECOND QUARTER OF THE CALENDAR YEAR 3 = THIRD QUARTER OF THE CALENDAR YEAR 4 = FOURTH QUARTER OF THE CALENDAR YEAR DERIVATION: DERIVED FROM: NCH_PTNT_STUS_IND_CD CLM_THRU_DT DERIVATION RULES: Based on the presence of patient discharge status code not equal to 30 (still patient), move the claim thru date to the NCH_BENE_DSCHRG_DT. SOURCE: NCH QA Process 44. NCH Near Line Record CHAR 1 154 154 A code defining the type of claim record being processed. Identification Code COMMON ALIAS: RIC DB2 ALIAS: NEAR_LINE_RIC_CD SAS ALIAS: RIC_CD STANDARD ALIAS: NCH_NEAR_LINE_RIC_CD TITLE ALIAS: RIC CODES: REFER TO: NCH_NEAR_LINE_RIC_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: RIC_CD. SOURCE: NCH 45. NCH Near-Line Record CHAR 1 155 155 The code indicating the record version of the Nearline file Version Code where the institutional, carrier or DMERC claims data are stored: DB2 ALIAS: NCH_REC_VRSN_CD SAS ALIAS: REC_LVL STANDARD ALIAS: NCH_NEAR_LINE_REC_VRSN_CD TITLE ALIAS: NCH_VERSION 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: A = Record format as of January 1991 B = Record format as of April 1991 C = Record format as of May 1991 D = Record format as of January 1992 E = Record format as of March 1992 F = Record format as of May 1992 G = Record format as of October 1993 H = Record format as of September 1998 I = Record format as of July 2000 46. NCH Payment and Edit Record CHAR 1 156 156 The code used for payment and editing purposes that Identification Code indicates the type of institutional claim record. DB2 ALIAS: PMT_EDIT_RIC_CD SAS ALIAS: PE_RIC STANDARD ALIAS: NCH_PMT_EDIT_RIC_CD TITLE ALIAS: NCH_PAYMENT_EDIT_RIC CODES: C = Inpatient hospital, SNF D = Outpatient E = Religious Nonmedical Health Care Institutions (eff. 8/00 Christian Science, prior to 7/00 F = Home Health Agency (HHA) G = Discharge notice (obsoleted 7/98) I = Hospice COMMENT: Prior to Version H this field was named: PMT_EDIT_RIC_CD. SOURCE: NCH QA Process 47. NCH Primary Payer Claim CHAR 13 157 169 The amount of a payment made on behalf of a Medicare Paid Amount beneficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges on an institutional, carrier, or DMERC claim. 9.2 DIGITS SIGNED DB2 ALIAS: PRMRY_PYR_PD_AMT SAS ALIAS: PRPAYAMT STANDARD ALIAS: NCH_PRMRY_PYR_CLM_PD_AMT TITLE ALIAS: PRIMARY_PAYER_AMOUNT EDIT-RULES: +9(9).99 COMMENT: Prior to Version H this field was named: BENE_PRMRY_PYR_CLM_PMT_AMT and the field size was S9(7)V99. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SOURCE: NCH 48. NCH Primary Payer Code CHAR 1 170 170 The code, on an institutional claim, specifying a federal non-Medicare program or other source that has primary responsibility for the payment of the Medicare beneficiary's health insurance bills. DB2 ALIAS: NCH_PRMRY_PYR_CD SAS ALIAS: PRPAY_CD STANDARD ALIAS: NCH_PRMRY_PYR_CD TITLE ALIAS: PRIMARY_PAYER_CD DERIVATION: DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT DERIVATION RULES SET NCH_PRMRY_PYR_CD TO 'A' WHERE THE CLM_VAL_CD = '12' SET NCH_PRMRY_PYR_CD TO 'B' WHERE THE CLM_VAL_CD = '13' SET NCH_PRMRY_PYR_CD TO 'C' WHERE THE CLM_VAL_CD = '16' and CLM_VAL_AMT is zeroes SET NCH_PRMRY_PYR_CD TO 'D' WHERE THE CLM_VAL_CD = '14' SET NCH_PRMRY_PYR_CD TO 'E' WHERE THE CLM_VAL_CD = '15' SET NCH_PRMRY_PYR_CD TO 'F' WHERE THE CLM_VAL_CD = '16' (CLM_VAL_AMT not equal to zeroes) SET NCH_PRMRY_PYR_CD TO 'G' WHERE THE CLM_VAL_CD = '43' SET NCH_PRMRY_PYR_CD TO 'H' WHERE THE CLM_VAL_CD = '41' SET NCH_PRMRY_PYR_CD TO 'I' WHERE THE CLM_VAL_CD = '42' SET NCH_PRMRY_PYR_CD TO 'L' (or prior to 4/97 set code to 'J') WHERE THE CLM_VAL_CD = '47' 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: REFER TO: BENE_PRMRY_PYR_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: BENE_PRMRY_PYR_CD. SOURCE: NCH 49. NCH Provider State Code CHAR 2 171 172 Effective with Version H, the two position SSA state code where provider facility is located. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS: NCH_PRVDR_STATE_CD SAS ALIAS: PRSTATE STANDARD ALIAS: NCH_PRVDR_STATE_CD TITLE ALIAS: PROVIDER_STATE_CD DERIVATION: DERIVED FROM: NCH PRVDR_NUM DERIVATION RULES: SET NCH_PRVDR_STATE_CD TO PRVDR_NUM POS1-2. FOR PRVDR_NUM POS1-2 EQUAL '55 SET NCH_PRVDR_STATE_CD TO '05'. FOR PRVDR_NUM POS1-2 EQUAL '67 SET NCH_PRVDR_STATE_CD TO '45'. FOR PRVDR_NUM POS1-2 EQUAL '68 SET NCH_PRVDR_STATE_CD TO '10'. CODES: REFER TO: GEO_SSA_STATE_TB IN THE CODES APPENDIX SOURCE: NCH 50. NCH Qualify Stay Through NUM 8 173 180 Effective with Version H, the ending date of Date the beneficiary's qualifying stay (used for internal CWFMQA editing purposes.) For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than 'A'. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ For the Limited Data Set Standard View of the HHA files, the beneficiary's qualifying stay through date is coded as the quarter of calendar year when the stay through date occurred. NOTE: During the Version H, conversion this field was populated with data throughout history (back to service year 1991). 8 DIGITS UNSIGNED DB2 ALIAS: QLFY_STAY_THRU_DT SAS ALIAS: QLFYTHRU STANDARD ALIAS: NCH_QLFY_STAY_THRU_DT TITLE ALIAS: QLFYG_STAY_THRU_DT EDIT-RULES FOR ENCRYPTED DATA: YYYYQ000 WHERE Q IS ONE OF THE FOLLOWING VALUES. 1 = FIRST QUARTER OF THE CALENDAR YEAR 2 = SECOND QUARTER OF THE CALENDAR YEAR 3 = THIRD QUARTER OF THE CALENDAR YEAR 4 = FOURTH QUARTER OF THE CALENDAR YEAR DERIVATION: DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_THRU_DT DERIVATION RULES: Based on the presence of occurrence code 70 move the related occurrence thru date to NCH_QLFY_STAY_THRU_DT. SOURCE: NCH QA Process 51. Patient Discharge Status CHAR 2 181 182 The code used to identify the status of the Code patient as of the CLM_THRU_DT. COMMON ALIAS: DISCHARGE_DESTINATION/PATIENT_STATUS DB2 ALIAS: PTNT_DSCHRG_STUS SAS ALIAS: STUS_CD STANDARD ALIAS: PTNT_DSCHRG_STUS_CD SYSTEM ALIAS: LTCLMST TITLE ALIAS: PTNT_DSCHRG_STUS_CD CODES: REFER TO: PTNT_DSCHRG_STUS_TB IN THE CODES APPENDIX 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ COMMENT: Prior to Version H this field was named: CLM_STUS_CD. SOURCE: CWF 52. Provider Number CHAR 6 183 188 The identification number of the institutional provider certified by Medicare to provide services to the beneficiary. DB2 ALIAS: PRVDR_NUM SAS ALIAS: PROVIDER STANDARD ALIAS: PRVDR_NUM TITLE ALIAS: PROVIDER_NUMBER CODES: REFER TO: PRVDR_NUM_TB IN THE CODES APPENDIX SOURCE: OSCAR *** DESY Trailer Group GROUP 50 189 238 DESY trailer 53. DESY System User CHAR 30 189 218 A user-defined field that holds the description of the request. For example, "Cross-referenced HICs". This field is blank for the Limited Data Set Standard View. STANDARD ALIAS: SYSTEM_USER 54. Filler CHAR 11 219 229 Filler This field is blank for the Limited Data Set Standard View. STANDARD ALIAS: FILLER 55. DESY Sort Key CHAR 9 230 238 This field contains the key to tie claims together for one beneficiary regardless of HICAN. This field is blank for the Limited Data Set Standard View. STANDARD ALIAS: DESY_SORT_KEY 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 ***************************************************************************************************************** C L A I M D I A G N O S I S G R O U P R E C O R D ***************************************************************************************************************** POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI HHA Claim GROUP 26 Claim Diagnosis Group Record for the Diagnosis Group Limited Data Set Standard View of the Record - Limited Data HHA version I NCH Nearline File. Set Standard View The number of claim diagnosis trailers is determined by the claim diagnosis code count. The principal diagnosis is the first occurrence. The 'E' code (ICD-9-CM code for the external cause of an injury, poisoning, or adverse affect) is stored as the last occurrence. The principal diagnosis and the 'E' code are also stored (redundantly) in the fixed record. NOTE: Prior to Version H this group was named: CLM_OTHR_DGNS_GRP and did not contain the CLM_PRNCPAL_DGNS_CD. OCCURS: UP TO 10 TIMES DEPENDING ON HHA_CLM_DGNS_CD_CNT STANDARD ALIAS: CLM_DGNS_GRP 1. Record Length Count NUM 5 1 5 The length of the Claim Diagnosis Group Record. 5 DIGITS UNSIGNED STANDARD ALIAS: DSY_VW_BYTE_CNT 2. Record Number NUM 9 6 14 A sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. STANDARD ALIAS: DSY_VW_REC_LNK_NUM 3. Record Type NUM 2 15 16 Type of Record. STANDARD ALIAS: DSY_VW_REC_TYPE CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 09 = Claim Value Group 10 = MCO Period Group 11 = NCH Edit Group 12 = NCH Patch Group 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. STANDARD ALIAS: DSY_VW_REC_SEQ 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data through- out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. STANDARD ALIAS: NCH_CLM_TYPE_CD DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Claim Diagnosis Code CHAR 5 22 26 The ICD-9-CM based code identifying the beneficiary's principal or other diagnosis (including E code). NOTE: Prior to Version H, the principal diagnosis code was not stored with the 'OTHER' diagnosis codes. During the Version H conversion the CLM_PRNCPAL_DGNS_CD was added as the first occurrence. DB2 ALIAS: CLM_DGNS_CD SAS ALIAS: DGNS_CD STANDARD ALIAS: CLM_DGNS_CD TITLE ALIAS: DIAGNOSIS 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ EDIT-RULES: ICD-9-CM COMMENT: Prior to Version H this field was named: CLM_OTHR_DGNS_CD. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 ***************************************************************************************************************** C L A I M R E L A T E D C O N D I T I O N G R O U P R E C O R D ***************************************************************************************************************** POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI HHA Claim GROUP 23 Claim Related Condition Group Record Related Condition Group for the Limited Data Set Standard View of the Record - Limited Data HHA version I NCH Nearline File. Set Standard View The number of claim related condition trailers is determined by the claim related condition code count. Effective 10/93, up to 30 occurrences can be reported on an institutional claim. Prior to 10/93, up to 10 occurrences could be reported. OCCURS: UP TO 30 TIMES DEPENDING ON HHA_CLM_RLT_COND_CD_CNT STANDARD ALIAS: CLM_RLT_COND_GRP 1. Record Length Count NUM 5 1 5 The length of the Claim Related Condition Group Record. 5 DIGITS UNSIGNED STANDARD ALIAS: DSY_VW_BYTE_CNT 2. Record Number NUM 9 6 14 A sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. STANDARD ALIAS: DSY_VW_REC_LNK_NUM 3. Record Type NUM 2 15 16 Type of Record. STANDARD ALIAS: DSY_VW_REC_TYPE CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 09 = Claim Value Group 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 10 = MCO Period Group 11 = NCH Edit Group 12 = NCH Patch Group 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. STANDARD ALIAS: DSY_VW_REC_SEQ 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data through- out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. STANDARD ALIAS: NCH_CLM_TYPE_CD DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Claim Related Condition CHAR 2 22 23 The code that indicates a condition relating to Code an institutional claim that may affect payer processing. DB2 ALIAS: CLM_RLT_COND_CD SAS ALIAS: RLT_COND STANDARD ALIAS: CLM_RLT_COND_CD SYSTEM ALIAS: LTCOND TITLE ALIAS: RELATED_CONDITION_CD CODES: 01 THRU 16 = Insurance related 17 THRU 30 = Special condition 31 THRU 35 = Student status codes which are required when a patient is a dependent child over 18 years old 36 THRU 45 = Accommodation 46 THRU 54 = CHAMPUS information 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 55 THRU 59 = Skilled nursing facility 60 THRU 70 = Prospective payment 71 THRU 99 = Renal dialysis setting A0 THRU B9 = Special program codes C0 THRU C9 = PRO approval services D0 THRU W0 = Change conditions CODES: REFER TO: CLM_RLT_COND_TB IN THE CODES APPENDIX SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 ***************************************************************************************************************** C L A I M R E L A T E D O C C U R R E N C E G R O U P R E C O R D ***************************************************************************************************************** POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI HHA Claim Related GROUP 31 Claim Related Occurrence Group Record Occurrence Group for the Limited Data Set Standard View of the Record - Limited Data HHA version I NCH Nearline File. Set Standard View The number of claim related occurrence trailers is determined by the claim related occurrence code count. Effective 10/93, up to 30 occurrences can be reported on an institutional claim. Prior to 10/93, up to 10 occurrences could be reported. OCCURS: UP TO 30 TIMES DEPENDING ON HHA_CLM_RLT_OCRNC_CD_CNT STANDARD ALIAS: CLM_RLT_OCRNC_GRP 1. Record Length Count NUM 5 1 5 The length of the Claim Related Occurrence Group. 5 DIGITS UNSIGNED STANDARD ALIAS: DSY_VW_BYTE_CNT 2. Record Number NUM 9 6 14 A sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. STANDARD ALIAS: DSY_VW_REC_LNK_NUM 3. Record Type NUM 2 15 16 Type of Record. STANDARD ALIAS: DSY_VW_REC_TYPE CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 09 = Claim Value Group 10 = MCO Period Group 11 = NCH Edit Group 12 = NCH Patch Group 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. STANDARD ALIAS: DSY_VW_REC_SEQ 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data through-out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. STANDARD ALIAS: NCH_CLM_TYPE_CD DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Claim Related Occurrence CHAR 2 22 23 The code that identifies a significant event Code relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a specific date. DB2 ALIAS: CLM_RLT_OCRNC_CD SAS ALIAS: OCRNC_CD STANDARD ALIAS: CLM_RLT_OCRNC_CD SYSTEM ALIAS: LTOCRNC TITLE ALIAS: OCCURRENCE_CD CODES: 01 THRU 09 = Accident 10 THRU 19 = Medical condition 20 THRU 39 = Insurance related 40 THRU 69 = Service related A1-A3 = Miscellaneous 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: REFER TO: CLM_RLT_OCRNC_TB IN THE CODES APPENDIX SOURCE: CWF 7. Claim Related Occurrence NUM 8 24 31 The date associated with a significant event Date related to an institutional claim that may affect payer processing. For the Limited Data Set Standard View of the HHA files, the claim related occurrence date is coded as the quarter of the calendar year when the related occurrence occurred. 8 DIGITS UNSIGNED DB2 ALIAS: CLM_RLT_OCRNC_DT SAS ALIAS: OCRNCDT STANDARD ALIAS: CLM_RLT_OCRNC_DT TITLE ALIAS: RLT_OCRNC_DT EDIT-RULES FOR ENCRYPTED DATA: YYYYQ000 WHERE Q IS ONE OF THE FOLLOWING VALUES. 1 = FIRST QUARTER OF THE CALENDAR YEAR 2 = SECOND QUARTER OF THE CALENDAR YEAR 3 = THIRD QUARTER OF THE CALENDAR YEAR 4 = FOURTH QUARTER OF THE CALENDAR YEAR SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 ****************************************************************************************************************** C L A I M V A L U E G R O U P R E C O R D ***************************************************************************************************************** POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI HHA Claim Value GROUP 36 Claim Value Group Record for the Group Record - Limited Data Set Standard View of the Limited Data Set HHA version I NCH Nearline File. Standard View The number of claim value data trailers present is determined by the claim value code count. Effective 10/93, up to 36 occurrences can be reported on an institutional claim. Prior to 10/93, up to 10 occurrences could be reported. OCCURS: UP TO 36 TIMES DEPENDING ON HHA_CLM_VAL_CD_CNT STANDARD ALIAS: CLM_VAL_GRP 1. Record Length Count NUM 5 1 5 The length of the Claim Value Group Record. 5 DIGITS UNSIGNED STANDARD ALIAS: DSY_VW_BYTE_CNT 2. Record Number NUM 9 6 14 A sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. STANDARD ALIAS: DSY_VW_REC_LNK_NUM 3. Record Type NUM 2 15 16 Type of Record. STANDARD ALIAS: DSY_VW_REC_TYPE CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 09 = Claim Value Group 10 = MCO Period Group 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 11 = NCH Edit Group 12 = NCH Patch Group 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. STANDARD ALIAS: DSY_VW_REC_SEQ 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data through- out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. SYSTEM ALIAS: NCH_CLM_TYPE_CD DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Claim Value Code CHAR 2 22 23 The code indicating the value of a monetary condition which was used by the intermediary to process an institutional claim. DB2 ALIAS: CLM_VAL_CD SAS ALIAS: VAL_CD STANDARD ALIAS: CLM_VAL_CD SYSTEM ALIAS: LTVALUE TITLE ALIAS: VALUE_CD CODES: REFER TO: CLM_VAL_TB IN THE CODES APPENDIX SOURCE: CWF 7. Claim Value Amount CHAR 13 24 36 The amount related to the condition identified in the CLM_VAL_CD which was used by the intermediary to process the institutional claim. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 9.2 DIGITS SIGNED DB2 ALIAS: CLM_VAL_AMT SAS ALIAS: VAL_AMT STANDARD ALIAS: CLM_VAL_AMT TITLE ALIAS: VALUE_AMOUNT EDIT-RULES: +9(9).99 SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 ***************************************************************************************************************** C L A I M R E V E N U E C E N T E R G R O U P R E C O R D ***************************************************************************************************************** POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ **** FI HHA Claim Revenue GROUP 262 Claim Revenue Center Group Record Center Group Record - for the Limited Data Set Standard View Limited Data Set of the HHA version I Nearline File. Standard View The number of claim revenue center group trailers present is determined by the claim revenue center code count. Effective 7/7/00, up to 450 occurrences may be reported for an institutional claim. The increase in the number of revenue center lines causes each claim to be broken out into records/segments (up to 10). Each record can have up to 45 occurrences of revenue center lines. Prior to 7/7/00, up to 58 occurrences may be reported on an institutional claim. Claims submitted prior to 10/93, contained up to 28 occurrences. OCCURS: UP TO 45 TIMES DEPENDING ON HHA_REV_CNTR_CD_I_CNT STANDARD ALIAS: CLM_REV_CNTR_GRP COMMENT: ****************** FOR SNF PPS ********************* The Balanced Budget Act modified how payment will be made for skilled nursing facility (SNF) services. Effective with cost reporting periods beginning on or after 7/1/98 (with all providers transitioning by 6/30/99, SNFs will be paid on a prospective payment system (PPS). SNFs will classify beneficiaries on the basis of residents' characteristics and resource needs, using the 44-group patient classification system known as Resource Utilization Groups (RUGS), Version III. Facilities will use information from the Minimum Data Set (MDS), Version 2.0, Resident Assessment Instrument (RAI) to classify residents into the RUG-III groups. ***************** FOR OUTPATIENT PPS *************** The Balanced Budget Act modified how payment will be made for hospital outpatient services, certain PTB services furnished to inpatients who have no PTA coverage, CMHCs, and limited services provided by CORFs, Home Health Agencies or to hospice patients for the treatment of a non-terminal illness. Imple- 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ mentation for Outpatient PPS (OPPS) will be effective for claims with dates of service on or after July 1, 2000. Payment for services under the OPPS system is calculated based on grouping outpatient services into ambulatory payment classifications (APC) groups. ************** FOR HOME HEALTH PPS *************** The Balanced Budget Act of 1997 mandated changes in payment and other provider requirements for home health. All home health agencies will be paid through a prospective payment system beginning October 1, 2000. Under Home Health PPS (HH PPS) the unit of payment will be a 60-day episode. Home Health Resources Groups (HHRGs), also called HRGs represented by HCFA HIPPS coding, will be the basis of payment for each episode; HHRGs will be produced through pubicly available Grouper software that will determine the appropriate HHRG when results of comprehensive assessments of the beneficiary (made incorporating the OASIS data set) are input or grouped in this software. 1. Record Length Count NUM 5 1 5 The length of the Claim Revenue Center Group Record. 5 DIGITS UNSIGNED STANDARD ALIAS: DSY_VW_BYTE_CNT 2. Record Number NUM 9 6 14 An sequentially assigned number for the claims included in the file. This number allows the user to link all of the records associated with one claim. STANDARD ALIAS: DSY_VW_REC_LNK_NUM 3. Record Type NUM 2 15 16 Type of Record. STANDARD ALIAS: DSY_VW_REC_TYPE CODES: 00 = Fixed/Main Group 01 = Carrier Line Group 02 = Claim Demonstration ID Group 03 = Claim Diagnosis Group 04 = Claim Health PlanID Group 05 = Claim Occurrence Span Group 06 = Claim Procedure Group 07 = Claim Related Condition Group 08 = Claim Related Occurrence Group 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 09 = Claim Value Group 10 = MCO Period Group 11 = NCH Edit Group 12 = NCH Patch Group 13 = DMERC Line Group 14 = Revenue Center Group 4. Claim Sequence Number NUM 3 17 19 A counter for records that consist of trailer information, such as claim line and revenue center data, which can occur multiple times for one claim. STANDARD ALIAS: DSY_VW_REC_SEQ 5. NCH Claim Type Code CHAR 2 20 21 The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data through- out history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). Placeholders for Physician and Outpatient encounters (available in NMUD) have also been added. STANDARD ALIAS: NCH_CLM_TYPE_CD DERIVATION: FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM INPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (HDC processing -- AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: From 7/1/97 to the start of HDC processing(?), abbreviated inpatient encounter claims are not available in NCH or NMUD. PHYSICIAN 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) CARR_NUM CLM_DEMO_ID_NUM OUTPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM OUTPATIENT 'ABBREVIATED' ENCOUNTER TYPE CODE DERIVED FROM: (AVAILABLE IN NMUD) FI_NUM CLM_FAC_TYPE_CD CLM_SRVC_CLSFCTN_TYPE_CD CLM_FREQ_CD DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 41 (OUTPATIENT 'FULL' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 42 (OUTPATIENT 'ABBREVIATED' ENCOUNTER CLAIMS -- AVAILABLE IN NMUD) 1. FI_NUM = 80881 2. CLM_FAC_TYPE_CD = '1' OR '8'; CLM_SRVC_ CLSFCTN_TYPE_CD = '2', '3' OR '4' & CLM_FREQ_CD = 'Z', 'Y' OR 'X' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (INPATIENT 'ABBREVIATED' ENCOUNTER CLAIM -- AVAILABLE IN NMUD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. FI_NUM = 80881 AND 2. CLM_FAC_TYPE_CD = '1'; CLM_SRVC_CLSFCTN_ TYPE_CD = '1'; CLM_FREQ_CD = 'Z' SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 73 (PHYSICIAN ENCOUNTER CLAIM-- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CARR_NUM = 80882 AND 2. CLM_DEMO_ID_NUM = 38 SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). CODES: REFER TO: NCH_CLM_TYPE_TB IN THE CODES APPENDIX SOURCE: NCH 6. Revenue Center Code CHAR 4 22 25 The provider-assigned revenue code for each cost center for which a separate charge is billed (type of accommodation or ancillary). A cost center is a division or unit within a hospital (e.g., radiology, emergency room, pathology). EXCEPTION: Revenue center code 0001 represents the total of all revenue centers included on the claim. COBOL ALIAS: REV_CD DB2 ALIAS: REV_CNTR_CD SAS ALIAS: REV_CNTR STANDARD ALIAS: REV_CNTR_CD SYSTEM ALIAS: LTRC TITLE ALIAS: REVENUE_CENTER_CD CODES: REFER TO: REV_CNTR_TB IN THE CODES APPENDIX SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 7. Revenue Center Date NUM 8 26 33 Effective with Version H, the date applicable to the service represented by the revenue center code. This field may be present on any of the institutional claim types. For home health claims the service date should be present on all bills with from date greater than 3/31/98. With the implementation of outpatient PPS, hospitals will be required to enter line item dates of service for all outpatient services which require a HCPCS. For the Limited Data Set Standard View of the HHA files, the date applicable to the service represented by the revenue center code is coded as the quarter of the calendar year when the service represented by the revenue center code occurred. NOTE1: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. NOTE2: When revenue center code equals '0022' (SNF PPS) and revenue center HCPCS code not equal to 'AAA00' (default for no assessment), date re- presents the MDS RAI assessment reference date. NOTE3: When revenue center code equals '0023' (HHPPS), the date on the initial claim (RAP) must represent the first date of service in the episode. The final claim will match the '0023' information submitted on the initial claim. The SCIC (significant change in condition) claims may show additional '0023' revenue lines in which the date represents the date of the first service under the revised plan of treatment. 8 DIGITS UNSIGNED DB2 ALIAS: REV_CNTR_DT SAS ALIAS: REV_DT STANDARD ALIAS: REV_CNTR_DT TITLE ALIAS: REV_CNTR_DATE EDIT-RULES FOR ENCRYPTED DATA: YYYYQ000 WHERE Q IS ONE OF THE FOLLOWING VALUES. 1 = FIRST QUARTER OF THE CALENDAR YEAR 2 = SECOND QUARTER OF THE CALENDAR YEAR 3 = THIRD QUARTER OF THE CALENDAR YEAR 4 = FOURTH QUARTER OF THE CALENDAR YEAR 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SOURCE: CWF 8. Revenue Center APC/HIPPS CHAR 5 34 38 Effective with Outpatient PPS (OPPS), the Ambulatory Code Payment Classification (APC) code used to identify groupings of outpatient services. APC codes are used to calculate payment for services under OPPS. Effective with Home Health PPS (HHPPS), this field will only be populated with a HIPPS code if the HIPPS code that is stored in the HCPCS field has been downcoded and the new code will be placed in this field. NOTE1: Under SNF PPS and HHPPS, HIPPS codes are stored in the HCPCS field. **EXCEPTION: if a HHPPS HIPPS code is downcoded the downcoded HIPPS will be stored in this field. NOTE2: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. DB2 ALIAS: REV_APC_HIPPS_CD SAS ALIAS: APCHIPPS STANDARD ALIAS: REV_CNTR_APC_HIPPS_CD SYSTEM ALIAS: LTAPC TITLE ALIAS: APC_HIPPS CODES: REFER TO: REV_CNTR_APC_TB IN THE CODES APPENDIX SOURCE: CWF 9. Revenue Center HCFA Common CHAR 5 39 43 HCFA's Common Procedure Coding System (HCPCS) Procedure Coding System is a collection of codes that represent procedures, Code supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs. The codes are divided into three levels, or groups, as described below: DB2 ALIAS: REV_CNTR_HCPCS_CD SAS ALIAS: HCPCS_CD STANDARD ALIAS: REV_CNTR_HCPCS_CD SYSTEM ALIAS: LTHIPPS TITLE ALIAS: HCPCS_CD 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ CODES: REFER TO: CLM_HIPPS_TB IN THE CODES APPENDIX COMMENT: Prior to Version H this field was named: HCPCS_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and non-institutional: LINE). NOTE: When revenue center code = '0022' (SNF PPS) or '0023' (HH PPS), this field contains the Health Insurance PPS (HIPPS) code. The HIPPS code for SNF PPS contains the rate code/assessment type that identifies (1) RUG-III group the beneficiary was classified into as of the RAI MDS assessment reference date and (2) the type of assessment for payment pur- poses. The HIPPS code for Home Health PPS identifies (1) the three case-mix dimensions of the HHRG system, clinical, functional and utilization, from which a beneficiary is assigned to one of the 80 HHRG categories and (2) it identifies whether or not the elements of the code were computed or derived. The HHRGs, represented by the HIPPS coding, will be the basis of payment for each episode. For both SNF PPS & HH PPS HIPPS values see CLM_HIPPS_TB. Level I Codes and descriptors copyrighted by the American Medical Association's Current Procedural Terminology, Fourth Edition (CPT-4). These are 5 position numeric codes representing physician and nonphysician services. **** Note: **** CPT-4 codes including both long and short descriptions shall be used in accordance with the HCFA/AMA agreement. Any other use violates the AMA copyright. Level II Includes codes and descriptors copyrighted by the American Dental Association's Current Dental Terminology, Second Edition (CDT-2). These are 5 position alpha-numeric codes comprising the D series. All other level II codes and descriptors are approved and maintained jointly by the alpha-numeric editorial panel (consisting of HCFA, the Health Insurance Association of 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ America, and the Blue Cross and Blue Shield Association). These are 5 position alpha- numeric codes representing primarily items and nonphysician services that are not represented in the level I codes. Level III Codes and descriptors developed by Medicare carriers for use at the local (carrier) level. These are 5 position alpha-numeric codes in the W, X, Y or Z series representing physician and nonphysician services that are not represented in the level I or level II codes. 10. Revenue Center HCPCS CHAR 2 44 45 A first modifier to the procedure code to enable a more Initial Modifier Code specific procedure identification for the claim. DB2 ALIAS: REV_HCPCS_MDFR_CD SAS ALIAS: MDFR_CD1 STANDARD ALIAS: REV_CNTR_HCPCS_INITL_MDFR_CD TITLE ALIAS: INITIAL_MODIFIER EDIT-RULES: Carrier Information File COMMENT: Prior to Version H this field was named: HCPCS_INITL_MDFR_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and non-institutional: LINE). SOURCE: CWF 11. Revenue Center HCPCS Second CHAR 2 46 47 A second modifier to the procedure code to make it more Modifier Code specific than the first modifier code to identify the procedures performed on the beneficiary for the claim. DB2 ALIAS: REV_HCPCS_2ND_CD SAS ALIAS: MDFR_CD2 STANDARD ALIAS: REV_CNTR_HCPCS_2ND_MDFR_CD TITLE ALIAS: SECOND_MODIFIER EDIT-RULES: CARRIER INFORMATION FILE COMMENT: Prior to Version H this field was named: HCPCS_2ND_MDFR_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and non-institutional: LINE). 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SOURCE: CWF 12. Revenue Center HCPCS Third CHAR 2 48 49 Effective with Version I, a third modifier to the Modifier Code procedure code to make it more specific than the second modifier code to identify the procedures performed on the beneficiary for the claim. DB2 ALIAS: REV_HCPCS_3RD_CD SAS ALIAS: MDFR_CD3 STANDARD ALIAS: REV_CNTR_HCPCS_3RD_MDFR_CD TITLE ALIAS: THIRD_MODIFIER EDIT-RULES: CARRIER INFORMATION FILE COMMENT: NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. SOURCE: CWF 13. Revenue Center HCPCS Fourth CHAR 2 50 51 Effective with Version I, a fourth modifier to the Modifier Code procedure code to make it more specific than the third modifier code to identify the procedures performed on the beneficiary for the claim. DB2 ALIAS: REV_HCPCS_4TH_CD SAS ALIAS: MDFR_CD4 STANDARD ALIAS: REV_CNTR_HCPCS_4TH_MDFR_CD TITLE ALIAS: FOURTH_MODIFIER EDIT-RULES: CARRIER INFORMATION FILE COMMENT: NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. SOURCE: CWF 14. Revenue Center HCPCS Fifth CHAR 2 52 53 Effective with Version I, a fifth modifier to the Modifier Code procedure code to make it more specific than the fourth modifier code to identify the procedures performed on the beneficiary for the claim. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ DB2 ALIAS: REV_HCPCS_5TH_CD SAS ALIAS: MDFR_CD5 STANDARD ALIAS: REV_CNTR_HCPCS_5TH_MDFR_CD TITLE ALIAS: FIFTH_MODIFIER EDIT-RULES: CARRIER INFORMATION FILE COMMENT: NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. SOURCE: CWF 15. Revenue Center Payment CHAR 2 54 55 Effective with Version 'I', the code used to Method Indicator Code identify how the service is priced for payment. This field is made up of two pieces of data, 1st position being the service indicator and the 2nd position being the payment indicator. NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. DB2 ALIAS: REV_PMT_MTHD_CD SAS ALIAS: PMTMTHD STANDARD ALIAS: REV_CNTR_PMT_MTHD_IND_CD SYSTEM ALIAS: LTPMTHD TITLE ALIAS: PMT_MTHD CODES: REFER TO: REV_CNTR_PMT_MTHD_IND_TB IN THE CODES APPENDIX SOURCE: CWF 16. Revenue Center Discount CHAR 1 56 56 Effective with Version 'I', for all services Indicator Code subject to Outpatient PPS, this code represents a factor that specifies the amount of any APC discount. The discounting factor is applied to a line item with a service indicator (part of the REV_CNTR_PMT_MTHD_IND_CD) of 'T'. The flag is applicable when more than one significant procedure is performed. **If there is no dis- counting the factor will be 1.0.** 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE1: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. DB2 ALIAS: REV_DSCNT_IND_CD SAS ALIAS: DSCNTIND STANDARD ALIAS: REV_CNTR_DSCNT_IND_CD SYSTEM ALIAS: LTDSCNT TITLE ALIAS: REV_CNTR_DSCNT_IND_CD CODES: *DISCOUNTING FORMULAS* 1 = 1.0 2 = (1.0+D(U-1))/U 3 = T/U 4 = (1+D)/U 5 = D 6 = TD/U 7 = D(1+D)/U 8 = 2.0/U SOURCE: CWF 17. Revenue Center Packaging CHAR 1 57 57 Effective with Version 'I', for all services Indicator Code subject to Outpatient PPS, the code used to identify those services that are packaged/ bundled with another service. NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. DB2 ALIAS: REV_PACKG_IND_CD SAS ALIAS: PACKGIND STANDARD ALIAS: REV_CNTR_PACKG_IND_CD SYSTEM ALIAS: LTPACKG TITLE ALIAS: REV_CNTR_PACKG_IND CODES: 0 = Not packaged 1 = Packaged service (service indicator N) 2 = Packaged as part of partial hospitalization per diem or daily mental health service per diem SOURCE: CWF 18. Revenue Center Pricing CHAR 2 58 59 Effective with Version 'I', the code used Indicator Code to identify if there was a deviation from the standard method of calculating payment amount. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. DB2 ALIAS: REV_PRICNG_IND_CD SAS ALIAS: PRICNG STANDARD ALIAS: REV_CNTR_PRICNG_IND_CD SYSTEM ALIAS: LTPRICNG TITLE ALIAS: REV_CNTR_PRICNG_IND CODES: REFER TO: REV_CNTR_PRICNG_IND_TB IN THE CODES APPENDIX SOURCE: CWF 19. Revenue Center Obligation CHAR 1 60 60 Effective with Version 'I' the code used to Accept As Full (OTAF) to indicate that the provider was obligated Payment Code to accept as full payment the amount re- ceived from the primary (or secondary) payer. NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. DB2 ALIAS: REV_OTAF1_IND_CD SAS ALIAS: OTAF_1 STANDARD ALIAS: REV_CNTR_OTAF_1_IND_CD TITLE ALIAS: REV_CNTR_OTAF_1_IND_CD EDIT-RULES: Y = provider is obligated to accept the payment as payment in full for the service. N or blank = provider is not obligated to accept the payment, or there is no payment by a prior payer. SOURCE: CWF 20. Revenue Center IDE, NDC, CHAR 24 61 84 Effective with Version H, the exemption number UPC Number assigned by the Food and Drug Administration (FDA) to an investigational device after a manufacturer has been approved by FDA to conduct a clinical trial on that device. HCFA established a new policy of covering certain IDE's which was implemented in claims processing on 10/1/96 (which is NCH weekly process 10/4/96) for service dates beginning 10/1/95. IDE's are always associated with revenue center code '0624'. 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ NOTE1: Prior to Version H a 'dummy' revenue center code '0624' trailer was created to store IDE's. The IDE number was housed in two fields: HCPCS code and HCPCS initial modifier; the second modifier contained the value 'ID'. There can be up to 7 distinct IDE numbers associated with an '0624' dummy trailer. During the Version H con- version IDE's were moved from the dummy '0624' trailer to this dedicated field. NOTE2: Effective with Version 'I', this field was renamed to eventually accommodate the National Drug Code (NDC) and the Universal Product Code (UPC). This field could contain either of these 3 fields (there would never be an instance where more than one would come in on a claim). The size of this field was expanded to X(24) to accommodate either of the new fields (under Version 'H' it was X(7). DATA ANAMOLY/LIMITATION: During an CWFMQA review an edit revealed the IDE was missing. The problem occurs in claim with an NCH weekly pro- cess dates of 6/9/00 through 9/8/00. During processing of the new format the program receives the IDE but then blanked out the data. DB2 ALIAS: IDE_NDC_UPC_NUM SAS ALIAS: IDENDC STANDARD ALIAS: REV_CNTR_IDE_NDC_UPC_NUM TITLE ALIAS: IDE_NDC_UPC SOURCE: CWF 21. Revenue Center Unit Count CHAR 8 85 92 A quantitative measure (unit) of the number of times the service or procedure being reported was performed according to the revenue center/HCPCS code definition as described on an institutional claim. Depending on type of service, units are measured by number of covered days in a particular accommodation, pints of blood, emergency room visits, clinic visits, dialysis treatments (sessions or days), outpatient therapy visits, and outpatient clinical diagnostic laboratory tests. NOTE1: When revenue center code = '0022' (SNF PPS) the unit count will reflect the number of covered days for each HIPPS code and, if applicable, the number of visits for each rehab therapy code. 7 DIGITS SIGNED 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ DB2 ALIAS: REV_CNTR_UNIT_CNT SAS ALIAS: REV_UNIT STANDARD ALIAS: REV_CNTR_UNIT_CNT TITLE ALIAS: UNITS EDIT-RULES: +9(7) SOURCE: CWF 22. Revenue Center Rate Amount CHAR 13 93 105 Charges relating to unit cost associated with the revenue center code. Exception (encounter data only): If plan (e.g. MCO) does not know the actual rate for the accommodations, $1 will be reported in the field. NOTE1: For SNF PPS claims (when revenue center code equals '0022'), HCFA has developed a SNF PRICER to compute the rate based on the provider supplied coding for the MDS RUGS III group and assessment type (HIPPS code, stored in revenue center HCPCS code field). NOTE2: For OP PPS claims, HCFA has developed a PRICER to compute the rate based on the Ambulatory Payment Classification (APC), discount factor, units of service and the wage index. NOTE3: Under HH PPS (when revenue center code equals '0023'), HCFA has developed a HHA PRICER to compute the rate. On the RAP, the rate is determined using the case mix weight associated with the HIPPS code, adjusting it for the wage index for the beneficiary's site of service, then multiplying the result by 60% or 50%, depending on whether or not the RAP is for a first episode. On the final claim, the HIPPS code could change the payment if the therapy threshold is not met, or partial episode payment (PEP) adjustment or a significant change in condition (SCIC) adjustment. In cases of SCICs, there will be more than one '0023' revenue center line, each representing the payment made at each case-mix level. 9.2 DIGITS SIGNED DB2 ALIAS: REV_CNTR_RATE_AMT SAS ALIAS: REV_RATE STANDARD ALIAS: REV_CNTR_RATE_AMT TITLE ALIAS: CHARGE_PER_UNIT EDIT-RULES: +9(9).99 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ EFFECTIVE-DATE: 10/01/1993 COMMENT: Prior to Version H the size of this field was: S9(7)V99. SOURCE: CWF 23. Revenue Center Blood CHAR 13 106 118 Effective with Version 'I', the amount of money Deductible Amount for which the intermediary determined the beneficiary is liable for the blood deductible for the line item service. NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_BLOOD_DDCTBL SAS ALIAS: REVBLOOD STANDARD ALIAS: REV_CNTR_BLOOD_DDCTBL_AMT TITLE ALIAS: BLOOD_DDCTBL_AMT EDIT-RULES: +9(9).99 SOURCE: CWF 24. Revenue Center Cash CHAR 13 119 131 Effective with Version 'I' the amount of cash Deductible Amount deductible the beneficiary paid for the line item service. NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_CASH_DDCTBL SAS ALIAS: REVDCTBL STANDARD ALIAS: REV_CNTR_CASH_DDCTBL_AMT TITLE ALIAS: CASH_DDCTBL EDIT-RULES: +9(9).99 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ SOURCE: CWF 25. Revenue Center CHAR 13 132 144 Effective with Version 'I', the amount of Coinsurance/Wage Adjusted coinsurance applicable to the line item Coinsurance Amount service defined by the revenue center and HCPCS codes. For those services subject to Outpatient PPS, the applicable coinsurance is wage adjusted. NOTE1: This field will have either a zero (for services for which coinsurance is not applicable), a regular coinsurance amount (calculated on either charges or a fee schedule) or if subject to OP PPS the national coinsurance amount will be wage adjusted. The wage adjusted coinsurance is based on the MSA where the provider is located or assigned as a result of a reclassification. NOTE2: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: ADJSTD_COINSRNC SAS ALIAS: WAGEADJ STANDARD ALIAS: REV_CNTR_WAGE_ADJSTD_COINS_AMT TITLE ALIAS: WAGE_ADJSTD_COINS EDIT-RULES: +9(9).99 SOURCE: CWF 26. Revenue Center Reduced CHAR 13 145 157 Effective with Version 'I', for all services Coinsurance Amount subject to Outpatient PPS, the amount of coinsurance applicable to the line for a particular service (HCPCS) for which the provider has elected to reduce the coinsurance amount. NOTE1: The reduced coinsurance amount cannot be lower than 20% of the payment rate for the APC line. NOTE2: Beginning with NCH weekly process date 8/18/00, this field will be populated with data. Claims processed prior to 8/18/00 will contain spaces in this field. 9.2 DIGITS SIGNED 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ DB2 ALIAS: RDCD_COINSRNC SAS ALIAS: RDCDCOIN STANDARD ALIAS: REV_CNTR_RDCD_COINS_AMT TITLE ALIAS: REDUCED_COINS EDIT-RULES: +9(9).99 SOURCE: CWF 27. Revenue Center 1st Medicare CHAR 13 158 170 Effective with Version 'I', the amount paid by Secondary Payer Paid the primary payer when the payer is primary to Amount Medicare (Medicare is secondary or tertiary). NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_MSP1_PD_AMT SAS ALIAS: REV_MSP1 STANDARD ALIAS: REV_CNTR_MSP1_PD_AMT TITLE ALIAS: MSP PAID AMOUNT EDIT-RULES: +9(9).99 SOURCE: CWF 28. Revenue Center 2nd Medicare CHAR 13 171 183 Effective with Version 'I', the amount paid by Secondary Payer Paid the secondary payer when two payers are primary Amount to Medicare (Medicare is the tertiary payer). NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_MSP2_PD_AMT SAS ALIAS: REV_MSP2 STANDARD ALIAS: REV_CNTR_MSP2_PD_AMT TITLE ALIAS: MSP PAID AMOUNT EDIT-RULES: +9(9).99 SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 29. Revenue Center Provider CHAR 13 184 196 Effective with Version 'I', the amount paid Payment Amount to the provider for the services reported on the line item. NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_PRVDR_PMT_AMT SAS ALIAS: RPRVDPMT STANDARD ALIAS: REV_CNTR_PRVDR_PMT_AMT TITLE ALIAS: REV_PRVDR_PMT EDIT-RULES: +9(9).99 SOURCE: CWF 30. Revenue Center Beneficiary CHAR 13 197 209 Effective with Version I, the amount paid Payment Amount to the beneficiary for the services reported on the line item. NOTE: Beginning with NCH weekly process date 7/7/00, this field will be populated with data. Claims processed prior to 7/7/00 will contain spaces in this field. 9.2 DIGITS SIGNED DB2 ALIAS: REV_BENE_PMT_AMT SAS ALIAS: RBENEPMT STANDARD ALIAS: REV_CNTR_BENE_PMT_AMT TITLE ALIAS: REV_BENE_PMT EDIT-RULES: +9(9).99 SOURCE: CWF 31. Revenue Center Patient CHAR 13 210 222 Effective with Version I, the amount paid Responsibility Payment by the beneficiary to the provider for the Amount line item service. NOTE: Beginning with NCH weekly process date 7/7/00 this field was populated with data. Claims processed prior to 7/7/00 will contain zeroes in this field. 9.2 DIGITS SIGNED 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ DB2 ALIAS: REV_PTNT_RESP_AMT SAS ALIAS: PTNTRESP STANDARD ALIAS: REV_CNTR_PTNT_RESP_PMT_AMT TITLE ALIAS: REV_PTNT_RESP EDIT-RULES: +9(9).99 SOURCE: CWF 32. Revenue Center Payment CHAR 13 223 235 Effective with Version 'I', the line item Amount Medicare payment amount for the specific revenue center. Under OP PPS, PRICER will compute the standard OPPS payment for a line item based on the payment APC. Under HH PPS, PRICER will compute/return a line item payment amount for the case-mixed, wage-index adjusted HIPPS code assigned to the '0023' revenue center line. The HIPPS code will be stored in the Revenue Center HCPCS code field. 9.2 DIGITS SIGNED COMMON ALIAS: REIMBURSEMENT DB2 ALIAS: REV_CNTR_PMT_AMT SAS ALIAS: REVPMT STANDARD ALIAS: REV_CNTR_PMT_AMT TITLE ALIAS: REIMBURSEMENT EDIT-RULES: +9(9).99 SOURCE: CWF 33. Revenue Center Total Charge CHAR 13 236 248 The total charges (covered and non-covered) for all Amount accommodations and services (related to the revenue code) for a billing period before reduction for the deductible and coinsurance amounts and before an adjustment for the cost of services provided. NOTE: For accommodation revenue center total charges must equal the rate times units (days). EXCEPTIONS: (1) For SNF RUGS demo claims only (9000 series revenue center codes), this field contains SNF customary accommodation charge, (ie., charges related to the accommodation revenue center code that would have been applicable if the provider had not been participating in the demo). 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ (2) For SNF PPS (non demo claims), when revenue center code = '0022', the total charges will be zero. (3) For Home Health PPS (RAPs), when revenue center code = '0023', the total charges will equal the dollar amount for the '0023' line. (4) For Home Health PPS (final claim), when revenue center code = '0023', the total charges will be the sum of the revenue center code lines (other than '0023'). (5) For encounter data, if the plan (e.g. MCO) does not know the actual charges for the accommodations the total charges will be $1 (rate) times units (days). 9.2 DIGITS SIGNED DB2 ALIAS: REV_TOT_CHRG_AMT SAS ALIAS: REV_CHRG STANDARD ALIAS: REV_CNTR_TOT_CHRG_AMT TITLE ALIAS: REVENUE_CENTER_CHARGES EDIT-RULES: +9(9).99 COMMENT: Prior to Version H the size of this field was: S9(7)V99. SOURCE: CWF 34. Revenue Center Non-Covered CHAR 13 249 261 The charge amount related to a revenue center code for Charge Amount services that are not covered by Medicare. NOTE: Prior to Version H the field size was S9(7)V99 and the element was only present on the Inpatient/SNF format. As of NCH weekly process date 10/3/97 this field was added to all institutional claim types. 9.2 DIGITS SIGNED DB2 ALIAS: REV_NCVR_CHRG_AMT SAS ALIAS: REV_NCVR STANDARD ALIAS: REV_CNTR_NCVR_CHRG_AMT TITLE ALIAS: REV_CENTER_NONCOVERED_CHARGES EDIT-RULES: +9(9).99 SOURCE: CWF 1 FI Home Health Agency Record - Limited Data Set Standard View -- 11/2005 POSITIONS NAME TYPE LENGTH BEG END CONTENTS --------------------------- ---- ------ --------- ------------------------------------------------------------ 35. Revenue Center Deductible CHAR 1 262 262 Code indicating whether the revenue center charges Coinsurance Code are subject to deductible and/or coinsurance. DB2 ALIAS: DDCTBL_COINSRNC_CD SAS ALIAS: REVDEDCD STANDARD ALIAS: REV_CNTR_DDCTBL_COINSRNC_CD TITLE ALIAS: REVENUE_CENTER_DEDUCTIBLE_CD CODES: REFER TO: REV_CNTR_DDCTBL_COINSRNC_TB IN THE CODES APPENDIX SOURCE: CWF 1 BENE_IDENT_TB Beneficiary Identification Code (BIC) Table ------------- ------------------------------------------- Social Security Administration: A = Primary claimant B = Aged wife, age 62 or over (1st claimant) B1 = Aged husband, age 62 or over (1st claimant) B2 = Young wife, with a child in her care (1st claimant) B3 = Aged wife (2nd claimant) B4 = Aged husband (2nd claimant) B5 = Young wife (2nd claimant) B6 = Divorced wife, age 62 or over (1st claimant) B7 = Young wife (3rd claimant) B8 = Aged wife (3rd claimant) B9 = Divorced wife (2nd claimant) BA = Aged wife (4th claimant) BD = Aged wife (5th claimant) BG = Aged husband (3rd claimant) BH = Aged husband (4th claimant) BJ = Aged husband (5th claimant) BK = Young wife (4th claimant) BL = Young wife (5th claimant) BN = Divorced wife (3rd claimant) BP = Divorced wife (4th claimant) BQ = Divorced wife (5th claimant) BR = Divorced husband (1st claimant) BT = Divorced husband (2nd claimant) BW = Young husband (2nd claimant) BY = Young husband (1st claimant) C1-C9,CA-CZ = Child (includes minor, student or disabled child) D = Aged widow, 60 or over (1st claimant) D1 = Aged widower, age 60 or over (1st claimant) D2 = Aged widow (2nd claimant) D3 = Aged widower (2nd claimant) D4 = Widow (remarried after attainment of age 60) (1st claimant) D5 = Widower (remarried after attainment of age 60) (1st claimant) D6 = Surviving divorced wife, age 60 or over (1st claimant) D7 = Surviving divorced wife (2nd claimant) D8 = Aged widow (3rd claimant) D9 = Remarried widow (2nd claimant) DA = Remarried widow (3rd claimant) DC = Surviving divorced husband (1st claimant) DD = Aged widow (4th claimant) DG = Aged widow (5th claimant) DH = Aged widower (3rd claimant) DJ = Aged widower (4th claimant) DK = Aged widower (5th claimant) DL = Remarried widow (4th claimant) DM = Surviving divorced husband (2nd claimant) DN = Remarried widow (5th claimant) 1 BENE_IDENT_TB Beneficiary Identification Code (BIC) Table ------------- ------------------------------------------- DP = Remarried widower (2nd claimant) DQ = Remarried widower (3rd claimant) DR = Remarried widower (4th claimant) DS = Surviving divorced husband (3rd claimant) DT = Remarried widower (5th claimant) DV = Surviving divorced wife (3rd claimant) DW = Surviving divorced wife (4th claimant) DX = Surviving divorced husband (4th claimant) DY = Surviving divorced wife (5th claimant) DZ = Surviving divorced husband (5th claimant) E = Mother (widow) (1st claimant) E1 = Surviving divorced mother (1st claimant) E2 = Mother (widow) (2nd claimant) E3 = Surviving divorced mother (2nd claimant) E4 = Father (widower) (1st claimant) E5 = Surviving divorced father (widower) (1st claimant) E6 = Father (widower) (2nd claimant) E7 = Mother (widow) (3rd claimant) E8 = Mother (widow) (4th claimant) E9 = Surviving divorced father (widower) (2nd claimant) EA = Mother (widow) (5th claimant) EB = Surviving divorced mother (3rd claimant) EC = Surviving divorced mother (4th claimant) ED = Surviving divorced mother (5th claimant EF = Father (widower) (3rd claimant) EG = Father (widower) (4th claimant) EH = Father (widower) (5th claimant) EJ = Surviving divorced father (3rd claimant) EK = Surviving divorced father (4th claimant) EM = Surviving divorced father (5th claimant) F1 = Father F2 = Mother F3 = Stepfather F4 = Stepmother F5 = Adopting father F6 = Adopting mother F7 = Second alleged father F8 = Second alleged mother J1 = Primary prouty entitled to HIB (less than 3 Q.C.) (general fund) J2 = Primary prouty entitled to HIB (over 2 Q.C.) (RSI trust fund) J3 = Primary prouty not entitled to HIB (less than 3 Q.C.) (general fund) J4 = Primary prouty not entitled to HIB 1 BENE_IDENT_TB Beneficiary Identification Code (BIC) Table ------------- ------------------------------------------- (over 2 Q.C.) (RSI trust fund) K1 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (1st claimant) K2 = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (1st claimant) K3 = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (1st claimant) K4 = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (1st claimant) K5 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (2nd claimant) K6 = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (2nd claimant) K7 = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (2nd claimant) K8 = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (2nd claimant) K9 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (3rd claimant) KA = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (3rd claimant) KB = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (3rd claimant) KC = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (3rd claimant) KD = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (4th claimant) KE = Prouty wife entitled to HIB (over 2 Q.C (4th claimant) KF = Prouty wife not entitled to HIB (less than 3 Q.C.)(4th claimant) KG = Prouty wife not entitled to HIB (over 2 Q.C.)(4th claimant) KH = Prouty wife entitled to HIB (less than 3 Q.C.)(5th claimant) KJ = Prouty wife entitled to HIB (over 2 Q.C.) (5th claimant) KL = Prouty wife not entitled to HIB (less than 3 Q.C.)(5th claimant) KM = Prouty wife not entitled to HIB (over 2 Q.C.) (5th claimant) M = Uninsured-not qualified for deemed HIB M1 = Uninsured-qualified but refused HIB T = Uninsured-entitled to HIB under deemed or renal provisions TA = MQGE (primary claimant) TB = MQGE aged spouse (first claimant) TC = MQGE disabled adult child (first claimant) TD = MQGE aged widow(er) (first claimant) TE = MQGE young widow(er) (first claimant) TF = MQGE parent (male) TG = MQGE aged spouse (second claimant) 1 BENE_IDENT_TB Beneficiary Identification Code (BIC) Table ------------- ------------------------------------------- TH = MQGE aged spouse (third claimant) TJ = MQGE aged spouse (fourth claimant) TK = MQGE aged spouse (fifth claimant) TL = MQGE aged widow(er) (second claimant) TM = MQGE aged widow(er) (third claimant) TN = MQGE aged widow(er) (fourth claimant) TP = MQGE aged widow(er) (fifth claimant) TQ = MQGE parent (female) TR = MQGE young widow(er) (second claimant) TS = MQGE young widow(er) (third claimant) TT = MQGE young widow(er) (fourth claimant) TU = MQGE young widow(er) (fifth claimant) TV = MQGE disabled widow(er) fifth claimant TW = MQGE disabled widow(er) first claimant TX = MQGE disabled widow(er) second claimant TY = MQGE disabled widow(er) third claimant TZ = MQGE disabled widow(er) fourth claimant T2-T9 = Disabled child (second to ninth claimant) W = Disabled widow, age 50 or over (1st claimant) W1 = Disabled widower, age 50 or over (1st claimant) W2 = Disabled widow (2nd claimant) W3 = Disabled widower (2nd claimant) W4 = Disabled widow (3rd claimant) W5 = Disabled widower (3rd claimant) W6 = Disabled surviving divorced wife (1st claimant) W7 = Disabled surviving divorced wife (2nd claimant) W8 = Disabled surviving divorced wife (3rd claimant) W9 = Disabled widow (4th claimant) WB = Disabled widower (4th claimant) WC = Disabled surviving divorced wife (4th claimant) WF = Disabled widow (5th claimant) WG = Disabled widower (5th claimant) WJ = Disabled surviving divorced wife (5th claimant) WR = Disabled surviving divorced husband (1st claimant) WT = Disabled surviving divorced husband (2nd claimant) Railroad Retirement Board: NOTE: Employee: a Medicare beneficiary who is still working or a worker who died before retirement Annuitant: a person who retired under the railroad retirement act on or after 03/01/37 Pensioner: a person who retired prior to 03/01/37 and was included in the railroad retirement act 1 BENE_IDENT_TB Beneficiary Identification Code (BIC) Table ------------- ------------------------------------------- 10 = Retirement - employee or annuitant 80 = RR pensioner (age or disability) 14 = Spouse of RR employee or annuitant (husband or wife) 84 = Spouse of RR pensioner 43 = Child of RR employee 13 = Child of RR annuitant 17 = Disabled adult child of RR annuitant 46 = Widow/widower of RR employee 16 = Widow/widower of RR annuitant 86 = Widow/widower of RR pensioner 43 = Widow of employee with a child in her care 13 = Widow of annuitant with a child in her care 83 = Widow of pensioner with a child in her care 45 = Parent of employee 15 = Parent of annuitant 85 = Parent of pensioner 11 = Survivor joint annuitant (reduced benefits taken to insure benefits for surviving spouse) 1 BENE_PRMRY_PYR_TB Beneficiary Primary Payer Table ----------------- ------------------------------- A = Working aged bene/spouse with employer group health plan (EGHP) B = End stage renal disease (ESRD) beneficiary in the 18 month coordination period with an employer group health plan C = Conditional payment by Medicare; future reimbursement expected D = Automobile no-fault (eff. 4/97; Prior to 3/94, also included any liability insurance) E = Workers' compensation F = Public Health Service or other federal agency (other than Dept. of Veterans Affairs) G = Working disabled bene (under age 65 with LGHP) H = Black Lung I = Dept. of Veterans Affairs J = Any liability insurance (eff. 3/94 - 3/97) L = Any liability insurance (eff. 4/97) (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) M = Override code: EGHP services involved (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) N = Override code: non-EGHP services involved (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) BLANK = Medicare is primary payer (not sure of effective date: in use 1/91, if not earlier) T = MSP cost avoided - IEQ contractor (eff. 7/96 carrier claims only) U = MSP cost avoided - HMO rate cell adjust- ment contractor (eff. 7/96 carrier claims only) V = MSP cost avoided - litigation settlement contractor (eff. 7/96 carrier claims only) X = MSP cost avoided override code (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) ***Prior to 12/90*** Y = Other secondary payer investigation shows Medicare as primary payer 1 BENE_PRMRY_PYR_TB Beneficiary Primary Payer Table ----------------- ------------------------------- Z = Medicare is primary payer NOTE: Values C, M, N, Y, Z and BLANK indicate Medicare is primary payer. (values Z and Y were used prior to 12/90. BLANK was suppose to be effective after 12/90, but may have been used prior to that date.) 1 BETOS_TB BETOS Table -------- ----------- M1A = Office visits - new M1B = Office visits - established M2A = Hospital visit - initial M2B = Hospital visit - subsequent M2C = Hospital visit - critical care M3 = Emergency room visit M4A = Home visit M4B = Nursing home visit M5A = Specialist - pathology M5B = Specialist - psychiatry M5C = Specialist - opthamology M5D = Specialist - other M6 = Consultations P0 = Anesthesia P1A = Major procedure - breast P1B = Major procedure - colectomy P1C = Major procedure - cholecystectomy P1D = Major procedure - turp P1E = Major procedure - hysterctomy P1F = Major procedure - explor/decompr/excisdisc P1G = Major procedure - Other P2A = Major procedure, cardiovascular-CABG P2B = Major procedure, cardiovascular-Aneurysm repair P2C = Major Procedure, cardiovascular-Thromboendarterectomy P2D = Major procedure, cardiovascualr-Coronary angioplasty (PTCA) P2E = Major procedure, cardiovascular-Pacemaker insertion P2F = Major procedure, cardiovascular-Other P3A = Major procedure, orthopedic - Hip fracture repair P3B = Major procedure, orthopedic - Hip replacement P3C = Major procedure, orthopedic - Knee replacement P3D = Major procedure, orthopedic - other P4A = Eye procedure - corneal transplant P4B = Eye procedure - cataract removal/lens insertion P4C = Eye procedure - retinal detachment P4D = Eye procedure - treatment P4E = Eye procedure - other P5A = Ambulatory procedures - skin P5B = Ambulatory procedures - musculoskeletal P5C = Ambulatory procedures - inguinal hernia repair P5D = Ambulatory procedures - lithotripsy P5E = Ambulatory procedures - other P6A = Minor procedures - skin P6B = Minor procedures - musculoskeletal P6C = Minor procedures - other (Medicare fee schedule) P6D = Minor procedures - other (non-Medicare fee schedule) P7A = Oncology - radiation therapy P7B = Oncology - other P8A = Endoscopy - arthroscopy P8B = Endoscopy - upper gastrointestinal P8C = Endoscopy - sigmoidoscopy P8D = Endoscopy - colonoscopy P8E = Endoscopy - cystoscopy P8F = Endoscopy - bronchoscopy P8G = Endoscopy - laparoscopic cholecystectomy P8H = Endoscopy - laryngoscopy P8I = Endoscopy - other P9A = Dialysis services 1 BETOS_TB BETOS Table -------- ----------- I1A = Standard imaging - chest I1B = Standard imaging - musculoskeletal I1C = Standard imaging - breast I1D = Standard imaging - contrast gastrointestinal I1E = Standard imaging - nuclear medicine I1F = Standard imaging - other I2A = Advanced imaging - CAT: head I2B = Advanced imaging - CAT: other I2C = Advanced imaging - MRI: brain I2D = Advanced imaging - MRI: other I3A = Echography - eye I3B = Echography - abdomen/pelvis I3C = Echography - heart I3D = Echography - carotid arteries I3E = Echography - prostate, transrectal I3F = Echography - other I4A = Imaging/procedure - heart including cardiac catheter I4B = Imaging/procedure - other T1A = Lab tests - routine venipuncture (non Medicare fee schedule) T1B = Lab tests - automated general profiles T1C = Lab tests - urinalysis T1D = Lab tests - blood counts T1E = Lab tests - glucose T1F = Lab tests - bacterial cultures T1G = Lab tests - other (Medicare fee schedule) T1H = Lab tests - other (non-Medicare fee schedule) T2A = Other tests - electrocardiograms T2B = Other tests - cardiovascular stress tests T2C = Other tests - EKG monitoring T2D = Other tests - other D1A = Medical/surgical supplies D1B = Hospital beds D1C = Oxygen and supplies D1D = Wheelchairs D1E = Other DME D1F = Orthotic devices O1A = Ambulance O1B = Chiropractic O1C = Enteral and parenteral O1D = Chemotherapy O1E = Other drugs O1F = Vision, hearing and speech services O1G = Influenza immunization Y1 = Other - Medicare fee schedule Y2 = Other - non-Medicare fee schedule Z1 = Local codes Z2 = Undefined codes 1 CARR_CLM_PMT_DNL_TB Carrier Claim Payment Denial Table ------------------- ---------------------------------- 0 = Denied 1 = Physician/supplier 2 = Beneficiary 3 = Both physician/supplier and beneficiary 4 = Hospital (hospital based physicians) 5 = Both hospital and beneficiary 6 = Group practice prepayment plan 7 = Other entries (e.g. Employer, union) 8 = Federally funded 9 = PA service A = Beneficiary under limitation of liability B = Physician/supplier under limitation of liability D = Denied due to demonstration involvement (eff. 5/97) E = MSP cost avoided IRS/SSA/HCFA Data Match (eff. 7/3/00) F = MSP cost avoided HMO Rate Cell (eff. 7/3/00) G = MSP cost avoided Litigation Settlement (eff. 7/3/00) H = MSP cost avoided Employer Voluntary Reporting (eff. 7/3/00) J = MSP cost avoided Insurer Voluntary Reporting (eff. 7/3/00) K = MSP cost avoided Initial Enrollment Questionnaire (eff. 7/3/00) P = Physician ownership denial (eff 3/92) Q = MSP cost avoided - (Contractor #88888) voluntary agreement (eff. 1/98) T = MSP cost avoided - IEQ contractor (eff. 7/96) (obsolete 6/30/00) U = MSP cost avoided - HMO rate cell adjustment (eff. 7/96) (obsolete 6/30/00) V = MSP cost avoided - litigation settlement (eff. 7/96) (obsolete 6/30/00) X = MSP cost avoided - generic Y = MSP cost avoided - IRS/SSA data match project (obsolete 6/30/00) 1 CARR_LINE_PRVDR_TYPE_TB Carrier Line Provider Type Table ----------------------- -------------------------------- For Physician/Supplier (RIC O) Claims: 0 = Clinics, groups, associations, partnerships, or other entities 1 = Physicians or suppliers reporting as solo practitioners 2 = Suppliers (other than sole proprietorship) 3 = Institutional provider 4 = Independent laboratories 5 = Clinics (multiple specialties) 6 = Groups (single specialty) 7 = Other entities For DMERC (RIC M) Claims - PRIOR TO VERSION H: 0 = Clinics, groups, associations, partnerships, or other entities for whom the carrier's own ID number has been assigned. 1 = Physicians or suppliers billing as solo practitioners for whom SSN's are shown in the physician ID code field. 2 = Physicians or suppliers billing as solo practitioners for whom the carrier's own physician ID code is shown. 3 = Suppliers (other than sole proprietorship) for whom EI numbers are used in coding the ID field. 4 = Suppliers (other than sole proprietorship) for whom the carrier's own code has been shown. 5 = Institutional providers and independent laboratories for whom EI numbers are used in coding the ID field. 6 = Institutional providers and independent laboratories for whom the carrier's own ID number is shown. 7 = Clinics, groups, associations, or partnerships for whom EI numbers are used in coding the ID field. 8 = Other entities for whom EI numbers are used in coding the ID field or proprietorship for whom EI numbers are used in coding the ID field. 1CARR_LINE_RDCD_PHYSN_ASTNT_TB Carrier Line Part B Reduced Physician Assistant Table ----------------------------- ----------------------------------------------------- BLANK = Adjustment situation (where CLM_DISP_CD equal 3) 0 = N/A 1 = 65% A) Physician assistants assisting in surgery B) Nurse midwives 2 = 75% A) Physician assistants performing services in a hospital (other than assisting surgery) B) Nurse practitioners and clinical nurse specialists performing services in rural areas C) Clinical social worker services 3 = 85% A) Physician assistant services for other than assisting surgery B) Nurse practitioners services 1 CARR_NUM_TB Carrier Number Table ----------- -------------------- 00510 = Alabama BS (eff. 1983) 00511 = Georgia - Alabama BS (eff. 1998) 00512 = Mississippi - Alabama BS (eff. 2000) 00520 = Arkansas BS (eff. 1983) 00521 = New Mexico - Arkansas BS (eff. 1998) 00522 = Oklahoma - Arkansas BS (eff. 1998) 00523 = Missouri - Arkansas BS (eff. 1999) 00528 = Louisianna - Arkansas BS (eff. 1984) 00542 = California BS (eff. 1983; term. 1996) 00550 = Colorado BS (eff. 1983; term. 1994) 00570 = Delaware - Pennsylvania BS (eff. 1983; term. 1997) 00580 = District of Columbia - Pennsylvania BS (eff. 1983; term. 1997) 00590 = Florida BS (eff. 1983) 00591 = Connecticut - Florida BS (eff. 2000) 00621 = Illinois BS - HCSC (eff. 1983; term. 1998) 00623 = Michigan - Illinois Blue Shield (eff. 1995) (term. 1998) 00630 = Indiana - Administar (eff. 1983) 00635 = DMERC-B (Administar Federal, Inc.) (eff. 1993) 00640 = Iowa - Wellmark, Inc. (eff. 1983; term. 1998) 00645 = Nebraska - Iowa BS (eff. 1985; term. 1987) 00650 = Kansas BS (eff. 1983) 00655 = Nebraska - Kansas BS (eff. 1988) 00660 = Kentucky - Administar (eff. 1983) 00690 = Maryland BS (eff. 1983; term. 1994) 00700 = Massachusetts BS (eff. 1983; term. 1997) 00710 = Michigan BS (eff. 1983; term. 1994) 00720 = Minnesota BS (eff. 1983; term. 1995) 00740 = Missouri - BS Kansas City (eff. 1983) 00751 = Montana BS (eff. 1983) 00770 = New Hampshire/Vermont Physician Services (eff. 1983; term. 1984) 00780 = New Hampshire/Vermont - Massachusetts BS (eff. 1985; term. 1997) 00801 = New York - Western BS (eff. 1983) 00803 = New York - Empire BS (eff. 1983) 00805 = New Jersey - Empire BS (eff. 3/99) 00811 = DMERC (A) - Western New York BS (eff. 2000) 00820 = North Dakota - North Dakota BS (eff. 1983) 00824 = Colorado - North Dakota BS (eff. 1995) 00825 = Wyoming - North Dakota BS (eff. 1990) 00826 = Iowa - North Dakota BS (eff. 1999) 00831 = Alaska - North Dakota BS (eff. 1998) 00832 = Arizona - North Dakota BS (eff. 1998) 00833 = Hawaii - North Dakota BS (eff. 1998) 00834 = Nevada - North Dakota BS (eff. 1998) 00835 = Oregon - North Dakota BS (eff. 1998) 00836 = Washington - North Dakota BS (eff. 1998) 00860 = New Jersey - Pennsylvania BS (eff. 1988; term. 1999) 00865 = Pennsylvania BS (eff. 1983) 00870 = Rhode Island BS (eff. 1983) 00880 = South Carolina BS (eff. 1983) 00882 = RRB - South Carolina PGBA (eff. 2000) 1 CARR_NUM_TB Carrier Number Table ----------- -------------------- 00885 = DMERC C - Palmetto (eff. 1993) 00900 = Texas BS (eff. 1983) 00901 = Maryland - Texas BS (eff. 1995) 00902 = Delaware - Texas BS (eff. 1998) 00903 = District of Columbia - Texas BS (eff. 1998) 00904 = Virginia - Texas BS (eff. 2000) 00910 = Utah BS (eff. 1983) 00951 = Wisconsin - Wisconsin Phy Svc (eff. 1983) 00952 = Illinois - Wisconsin Phy Svc (eff. 1999) 00953 = Michigan - Wisconsin Phy Svc (eff. 1999) 00954 = Minnesota - Wisconsin Phy Svc (eff. 2000) 00973 = Triple-S, Inc. - Puerto Rico (eff. 1983) 00974 = Triple-S, Inc. - Virgin Islands 01020 = Alaska - AETNA (eff. 1983; term. 1997) 01030 = Arizona - AETNA (eff. 1983; term. 1997) 01040 = Georgia - AETNA (eff. 1988; term. 1997) 01120 = Hawaii - AETNA (eff. 1983; term. 1997) 01290 = Nevada - AETNA (eff. 1983; term. 1997) 01360 = New Mexico - AETNA (eff. 1986; term. 1997) 01370 = Oklahoma - AETNA (eff. 1983; term. 1997) 01380 = Oregon - AETNA (eff. 1983; term. 1997 01390 = Washington - AETNA (eff. 1994; term. 1997) 02050 = California - TOLIC (eff. 1983) (term. 2000) 03070 = Connecticut General Life Insurance Co. (eff. 1983; term. 1985) 05130 = Idaho - Connecticut General (eff. 1983) 05320 = New Mexico - Equitable Insurance (eff. 1983; term. 1985) 05440 = Tennessee - Connecticut General (eff. 1983) 05530 = Wyoming - Equitable Insurance (eff. 1983) (term. 1989) 05535 = North Carolina - Connecticut General (eff. 1988) 05655 = DMERC-D - Connecticut General (eff. 1993) 10071 = Railroad Board Travelers (eff. 1983) (term. 2000) 10230 = Connecticut - Metra Health (eff. 1986) (term. 2000) 10240 = Minnesota - Metra Health (eff. 1983) (term. 2000) 10250 = Mississippi - Metra Health (eff. 1983) (term. 2000) 10490 = Virginia - Metra Health (eff. 1983) (term. 2000) 10555 = Travelers Insurance Co. (eff. 1993) (term. 2000) 11260 = Missouri - General American Life (eff. 1983; term. 1998) 14330 = New York - GHI (eff. 1983) 16360 = Ohio - Nationwide Insurance Co. 16510 = West Virginia - Nationwide Insurance Co. 21200 = Maine - BS of Massachusetts 31140 = California - National Heritage Ins. 31142 = Maine - National Heritage Ins. 31143 = Massachusetts - National Heritage Ins. 31144 = New Hampshire - National Heritage Ins. 31145 = Vermont - National Heritage Ins. 1 CARR_NUM_TB Carrier Number Table ----------- -------------------- 31146 = So. California - NHIC (eff. 2000) 1 CLM_BILL_TYPE_TB Claim Bill Type Table ---------------- --------------------- 11 = Hospital-inpatient (including Part A) 12 = Hospital-inpatient or home health visits (Part B only) 13 = Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) 14 = Hospital-other (Part B) 15 = Hospital-intermediate care - level I 16 = Hospital-intermediate care - level II 17 = Hospital-intermediate care - level III 18 = Hospital-swing beds 19 = Hospital-reserved for national assignment 21 = SNF-inpatient (including Part A) 22 = SNF-inpatient or home health visits (Part B only) 23 = SNF-outpatient (HHA-A also) 24 = SNF-other (Part B) 25 = SNF-intermediate care - level I 26 = SNF-intermediate care - level II 27 = SNF-intermediate care - level III 28 = SNF-swing beds 29 = SNF-reserved for national assignment 31 = HHA-inpatient (including Part A) 32 = HHA-inpatient or home health visits (Part B only) 33 = HHA-outpatient (HHA-A also) 34 = HHA-other (Part B) 35 = HHA-intermediate care - level I 36 = HHA-intermediate care - level II 37 = HHA-intermediate care - level III 38 = HHA-swing beds 39 = HHA-reserved for national assignment 41 = Religious Nonmedical Health Care Institution (RNHCI) hospital-inpatient (including Part A) (all references to Christian Science (CS) is obsolete eff. 8/00 and replaced with RNHCI) 42 = RNHCI hospital-inpatient or home health visits (Part B only) 43 = RNHCI hospital-outpatient (HHA-A also) 44 = RNHCI hospital-other (Part B) 45 = RNHCI hospital-intermediate care - level I 46 = RNHCI hospital-intermediate care - level II 47 = RNHCI hospital-intermediate care - level III 48 = RNHCI hospital-swing beds 49 = RNHCI hospital-reserved for national assignment 51 = CS extended care-inpatient (including Part A) OBSOLETE eff. 7/00 - implementation of Religious Nonmedical Health Care Institutions (RNHCI) 52 = RNHCI extended care-inpatient or home health visits (Part B only) (eff. 7/00); prior to 7/00 Christian Science (CS) 53 = RNHCI extended care-outpatient (HHA-A also) (eff. 7/00); prior to 7/00 referenced CS 54 = RNHCI extended care-other (Part B)(eff. 7/00); prior to 7/00 referenced CS 55 = RNHCI extended care-intermediate care - level I (eff. 7/00) prior to 7/00 referenced CS 56 = RNHCI extended care-intermediate care - level II (eff. 7/00) prior to 7/00 referenced CS 57 = RNHCI extended care-intermediate care - level III (eff. 7/00) prior to 7/00 referenced CS 58 = RNHCI extended care-swing beds (eff. 7/00) 1 CLM_BILL_TYPE_TB Claim Bill Type Table ---------------- --------------------- prior to 7/00 referenced CS 59 = RNHCI extended care-reserved for national assignment (eff. 7/00); prior to 7/00 referenced CS 61 = Intermediate care-inpatient (including Part A) 62 = Intermediate care-inpatient or home health visits (Part B only) 63 = Intermediate care-outpatient (HHA-A also) 64 = Intermediate care-other (Part B) 65 = Intermediate care-intermediate care - level I 66 = Intermediate care-intermediate care - level II 67 = Intermediate care-intermediate care - level III 68 = Intermediate care-swing beds 69 = Intermediate care-reserved for national assignment 71 = Clinic-rural health 72 = Clinic-hospital based or independent renal dialysis facility 73 = Clinic-independent provider based FQHC (eff 10/91) 74 = Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) 75 = Clinic-CORF 76 = Clinic-CMHC (eff 4/97) 77 = Clinic-reserved for national assignment 78 = Clinic-reserved for national assignment 79 = Clinic-other 81 = Special facility or ASC surgery-hospice (non-hospital based) 82 = Special facility or ASC surgery-hospice (hospital based) 83 = Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) 84 = Special facility or ASC surgery-freestanding birthing center 85 = Special facility or ASC surgery-rural primary care hospital (eff 86 = Special facility or ASC surgery-reserved for national use 87 = Special facility or ASC surgery-reserved for national use 88 = Special facility or ASC surgery-reserved for national use 89 = Special facility or ASC surgery-other 91 = Reserved-inpatient (including Part A) 92 = Reserved-inpatient or home health visits (Part B only) 93 = Reserved-outpatient (HHA-A also) 94 = Reserved-other (Part B) 95 = Reserved-intermediate care - level I 96 = Reserved-intermediate care - level II 97 = Reserved-intermediate care - level III 98 = Reserved-swing beds 99 = Reserved-reserved for national assignment 1 CLM_DISP_TB Claim Disposition Table ----------- ----------------------- 01 = Debit accepted 02 = Debit accepted (automatic adjustment) applicable through 4/4/93 03 = Cancel accepted 61 = *Conversion code: debit accepted 62 = *Conversion code: debit accepted (automatic adjustment) 63 = *Conversion code: cancel accepted *Used only during conversion period: 1/1/91 - 2/21/91 1 CLM_FAC_TYPE_TB Claim Facility Type Table --------------- ------------------------- 1 = Hospital 2 = Skilled nursing facility (SNF) 3 = Home health agency (HHA) 4 = Religious Nonmedical (Hospital) (eff. 8/1/00); prior to 8/00 referenced Christian Science (CS) 5 = Religious Nonmedical (Extended Care) (eff. 8/1/00); prior to 8/00 referenced CS 6 = Intermediate care 7 = Clinic or hospital-based renal dialysis facility 8 = Special facility or ASC surgery 9 = Reserved 1 CLM_FREQ_TB Claim Frequency Table ----------- --------------------- 0 = Non-payment/zero claims 1 = Admit thru discharge claim 2 = Interim - first claim 3 = Interim - continuing claim 4 = Interim - last claim 5 = Late charge(s) only claim 6 = Adjustment of prior claim 7 = Replacement of prior claim; eff 10/93, provider debit 8 = Void/cancel prior claim. eff 10/93, provider cancel 9 = Final claim -- used in an HH PPS episode to indicate the claim should be processed like debit/ credit adjustment to RAP (initial claim) (eff. 10/00) A = Admission notice - used when hospice is submitting the HCFA-1450 as an admission notice - hospice NOE only B = Hospice termination/revocation notice - hospice NOE only (eff 9/93) C = Hospice change of provider notice - hospice NOE only (eff 9/93) D = Hospice election void/cancel - hospice NOE only (eff 9/93) E = Hospice change of ownership - hospice NOE only (eff 1/97) F = Beneficiary initiated adjustment (eff 10/93) G = CWF generated adjustment (eff 10/93) H = HCFA generated adjustment (eff 10/93) I = Misc adjustment claim (other than PRO or provider) - used to identify a debit adjustment initiated by HCFA or an intermediary - eff 10/93, used to identify intermediary initiated adjustment only J = Other adjustment request (eff 10/93) K = OIG initiated adjustment (eff 10/93) M = MSP adjustment (eff 10/93) P = Adjustment required by peer review organization (PRO) X = Special adjustment processing - used for QA editing (eff 8/92) Z = Hospital Encounter Data alternate sub- mission (TOB '11Z') used for MCO enrollee hospital discharges 7/1/97-12/31/98; not stored in NCH. Exception: Problem in startup months may have resulted in this abbreviated UB-92 being erroneously stored in NCH. 1 CLM_HHA_RFRL_TB Claim Home Health Referral Table --------------- -------------------------------- 1 = Physician referral - The patient was admitted upon the recommendation of a personal physician. 2 = Clinic referral - The patient was admitted upon the recommendation of this facility's clinic physician. 3 = HMO referral - The patient was admitted upon the recommendation of an health maintenance organization (HMO) physician. 4 = Transfer from hospital - The patient was admitted as an inpatient transfer from an acute care facility. 5 = Transfer from a skilled nursing facility (SNF) - The patient was admitted as an inpatient transfer from a SNF. 6 = Transfer from another health care facility - The patient was admitted as a transfer from a health care facility other than an acute care facility or SNF. 7 = Emergency room - The patient was admitted upon the recommendation of this facility's emergency room physician. 8 = Court/law enforcement - The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative. 9 = Information not available - The means by which the patient was admitted is not known. A = Transfer from a Critical Access Hospital - patient was admitted/referred to this facility as a transfer from a Critical Access Hospital. B = Transfer from another HHA - Beneficiaries are permitted to transfer from one HHA to another unrelated HHA under HH PPS. (eff. 10/00) C = Readmission to same HHA - If a beneficiary is discharged from an HHA and then re- admitted within the original 60-day episode, the original episode must be closed early and a new once created. NOTE: the use of this code will permit the agency to send a new RAP allowing all claims to be accepted by Medicare. (eff. 10/00) 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- ******************* SNF PPS HIPPS ************************** ***************1st 3 positions (RUGS-III group)************** AAA = Default: No assessment BA1,BA2,BB1,BB2 = Behavior only problems (e.g., physical/verbal abuse) CA1,CA2,CB1,CB2 = Clinically-complex conditions CC1,CC2 (e.g., chemo, dialysis) IA1,IA2,IB1,IB2 = Impaired cognition (e.g., im- paired cognition (e.g., short- term memory) PA1,PA2,PB1,PB2 = Reduced physical functions PC1,PC2,PD1,PD2 PE1,PE2 RHA,RHB,RHC,RLA = Low/medium/high rehabilitation RLB,RMA,RMB,RMC RUA,RUB,RUC,RVA = Very high/ultra high rehabilita- RVB,RVC tion: highest level SE1,SE2,SE3 = Extensive services; e.g.; IV feed trach care SSA,SSB,SSC = Special care; e.g.; coma, burns ***********Positions 4 & 5 represent HIPPS modifier/******** *************** assessment type indicator ****************** 00 = No assessment completed 01 = Medicare 5-day full assessment/not an initial admission assessment 02 = Medicare 30-day full assessment 03 = Medicare 60-day full assessment 04 = Medicare 90-day full assessment 05 = Medicare Readmission/Return required assessment (eff. 10/2000) 07 = Medicare 14-day full or comprehensive assessment/ not an initial admission assessment 08 = Off-cycle Other Medicare Required Assessment (OMRA) 11 = Admission assessment AND Medicare 5-day (or readmission/ return) assessment 17 = Medicare 14-day required assessment AND initial admission assessment (eff. 10/2000) 18 = OMRA replacing Medicare 5-day required assessment (eff. 10/2000) 28 = OMRA replacing Medicare 30-day required assessment (eff. 10/2000) 30 = Off-cycle significant change assessment (outside assessment window) (eff. 10/2000) 31 = Significant change assessment replaces Medicare 5-day assessment (eff. 10/2000) 32 = Significant change assessment replaces Medicare 30-day assessment 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- 33 = Significant change assessment replaces Medicare 6--day assessment 34 = Significant change assessment replaces Medicare 90-day assessment 35 = Significant change assessment replaces a Medicare readmission/return assessment 37 = Significant change assessment replaces Medicare 14-day assessment 38 = OMRA replacing Medicare 60-day required assessment 40 = Off-cycle significant correction assessment of a prior assessment (outside assessment window) (eff. 10/2000) 41 = Significant correction of prior full assessment replaces a Medicare 5-day assessment 42 = Significant correction of prior full assessment replaces a Medicare 30-day assessment 43 = Significant correction of prior full assessment replaces a Medicare 60-day assessment 44 = Significant correction of prior full assessment replaces a Medicare 90-day assessment 45 = Significant correction of a prior assessment replaces a readmission/return assessment (eff. 10/2000) 47 = Significant correction of prior full assessment replaces a Medicare 14-day required assessment 48 = OMRA replacing Medicare 90-day required assessment 54 = Quarterly review assessment - Medicare 90-day full assessment 78 = OMRA replacing a Medicare 14-day assessment (eff. 10/2000) *************************************************************** *************************************************************** *************Claim Home Health PPS HIPPS Table**************** ************************* KEY ******************************** Position 1 = 'H' Position 2 = Clinical (A, B, C, D) Position 3 = Functional (E, F, G, H, I) Position 4 = Service (J, K, K, M) Position 5 = identifies which elements of the code were computed or derived: 1 = 2nd, 3rd, 4th positions computed 2 = 2nd position derived 3 = 3rd position derived 4 = 4th position derived 5 = 2nd & 3rd positions derived 6 = 3rd & 4th positions derived 7 = 2nd & 4th positions derived 8 = 2nd, 3rd, 4th positions derived *************************************************************** **HHRG = C0F0S0/Clinical = Min, Functional = Min, Service = Min** HAEJ1 HAEJ2 HAEJ3 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HAEJ4 HAEJ5 HAEJ6 HAEJ7 HAEJ8 **HHRG = C0F0S1/Clinical = Min, Functional = Min, Service = Low** HAEK1 HAEK2 HAEK3 HAEK4 HAEK5 HAEK6 HAEK7 HAEK8 **HHRG = C0F0S2/Clinical = Min, Functional = Min, Service = Mod** HAEL1 HAEL2 HAEL3 HAEL4 HAEL5 HAEL6 HAEL7 HAEL8 **HHRG = C0F0S3/Clinical = Min, Functional = Min, Service = High** HAEM1 HAEM2 HAEM3 HAEM4 HAEM5 HAEM6 HAEM7 HAEM8 **HHRG = C0F1S0/Clinical = Min, Functional = Low, Service = Min** HAFJ1 HAFJ2 HAFJ3 HAFJ4 HAFJ5 HAFJ6 HAFJ7 HAFJ8 **HHRG = C0F1S1/Clinical = Min, Functional = Low, Service = Low** HAFK1 HAFK2 HAFK3 HAFK4 HAFK5 HAFK6 HAFK7 HAFK8 **HHRG = C0F1S2/Clinical = Min, Functional = Low, Service = Mod** HAFL1 HAFL2 HAFL3 HAFL4 HAFL5 HAFL6 HAFL7 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HAFL8 **HHRG = C0F1S3/Clinical = Min, Functional = Low, Service = High** HAFM1 HAFM2 HAFM3 HAFM4 HAFM5 HAFM6 HAFM7 HAFM8 **HHRG = C0F2S0/Clinical = Min, Functional = Mod, Service = Min** HAGJ1 HAGJ2 HAGJ3 HAGJ4 HAGJ5 HAGJ6 HAGJ7 HAGJ8 **HHRG = C0F2S1/Clinical = Min, Functional = Mod, Service = Low** HAGK1 HAGK2 HAGK3 HAGK4 HAGK5 HAGK6 HAGK7 HAGK8 **HHRG = C0F2S2/Clinical = Min, Functional = Mod, Service = Mod** HAGL1 HAGL2 HAGL3 HAGL4 HAGL5 HAGL6 HAGL7 HAGL8 **HHRG = C0F2S3/Clinical = Min, Functional = Mod, Service = High** HAGM1 HAGM2 HAGM3 HAGM4 HAGM5 HAGM6 HAGM7 HAGM8 **HHRG = C0F3S0/Clinical = Min, Functional = High, Service = Min** HAHJ1 HAHJ2 HAHJ3 HAHJ4 HAHJ5 HAHJ6 HAHJ7 HAHJ8 **HHRG = C0F3S1/Clinical = Min, Functional = High, Service = Low** HAHK1 HAHK2 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HAHK3 HAHK4 HAHK5 HAHK6 HAHK7 HAHK8 **HHRG = C0F3S2/Clinical = Min, Functional = High, Service = Mod** HAHL1 HAHL2 HAHL3 HAHL4 HAHL5 HAHL6 HAHL7 HAHL8 **HHRG = C0F3S3/Clinical = Min, Functional = High, Service = High** HAHM1 HAHM2 HAHM3 HAHM4 HAHM5 HAHM6 HAHM7 HAHM8 **HHRG = C0F4S0/Clinical = Min, Functional = Max, Service = Min** HAIJ1 HAIJ2 HAIJ3 HAIJ4 HAIJ5 HAIJ6 HAIJ7 HAIJ8 **HHRG = C0F4S1/Clinical = Min, Functional = Max, Service = Low** HAIK1 HAIK2 HAIK3 HAIK4 HAIK5 HAIK6 HAIK7 HAIK8 **HHRG = C0F4S2/Clinical = Min, Functional = Max, Service = Mod** HAIL1 HAIL2 HAIL3 HAIL4 HAIL5 HAIL6 HAIL7 HAIL8 **HHRG = C0F4S3/Clinical = Min, Functional = Max, Service = High** HAIM1 HAIM2 HAIM3 HAIM4 HAIM5 HAIM6 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HAIM7 HAIM8 **HHRG = C1F0S0/Clinical = Low, Functional = Min, Service = Min** HBEJ1 HBEJ2 HBEJ3 HBEJ4 HBEJ5 HBEJ6 HBEJ7 HBEJ8 **HHRG = C1F0S1/Clinical = Low, Functional = Min, Service = Low** HBEK1 HBEK2 HBEK3 HBEK4 HBEK5 HBEK6 HBEK7 HBEK8 **HHRG = C1F0S2/Clinical = Low, Functional = Min, Service = Mod** HBEL1 HBEL2 HBEL3 HBEL4 HBEL5 HBEL6 HBEL7 HBEL8 **HHRG = C1F0S3/Clinical = Low, Functional = Min, Service = High** HBEM1 HBEM2 HBEM3 HBEM4 HBEM5 HBEM6 HBEM7 HBEM8 **HHRG = C1F1S0/Clinical = Low, Functional = Low, Service = Min** HBFJ1 HBFJ2 HBFJ3 HBFJ4 HBFJ5 HBFJ6 HBFJ7 HBFJ8 **HHRG = C1F1S1/Clinical = Low, Functional = Low, Service = Low** HBFK1 HBFK2 HBFK3 HBFK4 HBFK5 HBFK6 HBFK7 HBFK8 **HHRG = C1F1S2/Clinical = Low, Functional = Low, Service = Mod** HBFL1 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HBFL2 HBFL3 HBFL4 HBFL5 HBFL6 HBFL7 HBFL8 **HHRG = C1F1S3/Clinical = Low, Functional = Low, Service = High** HBFM1 HBFM2 HBFM3 HBFM4 HBFM5 HBFM6 HBFM7 HBFM8 **HHRG = C1F2S0/Clinical = Low, Functional = Mod, Service = Min** HBGJ1 HBGJ2 HBGJ3 HBGJ4 HBGJ5 HBGJ6 HBGJ7 HBGJ8 **HHRG = C1F2S1/Clinical = Low, Functional = Mod, Service = Low** HBGK1 HBGK2 HBGK3 HBGK4 HBGK5 HBGK6 HBGK7 HBGK8 **HHRG = C1F2S2/Clinical = Low, Functional = Mod, Service = Mod** HBGL1 HBGL2 HBGL3 HBGL4 HBGL5 HBGL6 HBGL7 HBGL8 **HHRG = C1F2S3/Clinical = Low, Functional = Mod, Service = High** HBGM1 HBGM2 HBGM3 HBGM4 HBGM5 HBGM6 HBGM7 HBGM8 **HHRG = C1F3S0/Clinical = Low, Functional = High, Service = Min** HBHJ1 HBHJ2 HBHJ3 HBHJ4 HBHJ5 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HBHJ6 HBHJ7 HBHJ8 **HHRG = C1F3S1/Clinical = Low, Functional = High, Service = Low** HBHK1 HBHK2 HBHK3 HBHK4 HBHK5 HBHK6 HBHK7 HBHK8 **HHRG = C1F3S2/Clinical = Low, Functional = High, Service = Mod** HBHL1 HBHL2 HBHL3 HBHL4 HBHL5 HBHL6 HBHL7 HBHL8 **HHRG = C1F3S3/Clinical = Low, Functional = High, Service = High** HBHM1 HBHM2 HBHM3 HBHM4 HBHM5 HBHM6 HBHM7 HBHM8 **HHRG = C1F4S0/Clinical = Low, Functional = Max, Service = Min** HBIJ1 HBIJ2 HBIJ3 HBIJ4 HBIJ5 HBIJ6 HBIJ7 HBIJ8 **HHRG = C1F4S1/Clinical = Low, Functional = Max, Service = Low** HBIK1 HBIK2 HBIK3 HBIK4 HBIK5 HBIK6 HBIK7 HBIK8 **HHRG = C1F4S2/Clinical = Low, Functional = Max, Service = Mod** HBIL1 HBIL2 HBIL3 HBIL4 HBIL5 HBIL6 HBIL7 HBIL8 **HHRG = C1F4S3/Clinical = Low, Functional = Max, Service = High** 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HBIM1 HBIM2 HBIM3 HBIM4 HBIM5 HBIM6 HBIM7 HBIM8 **HHRG = C2F0S0/Clinical = Mod, Functional = Min, Service = Min** HCEJ1 HCEJ2 HCEJ3 HCEJ4 HCEJ5 HCEJ6 HCEJ7 HCEJ8 **HHRG = C2F0S1/Clinical = Mod, Functional = Min, Service = Low** HCEK1 HCEK2 HCEK3 HCEK4 HCEK5 HCEK6 HCEK7 HCEK8 **HHRG = C2F0S2/Clinical = Mod, Functional = Min, Service = Mod** HCEL1 HCEL2 HCEL3 HCEL4 HCEL5 HCEL6 HCEL7 HCEL8 **HHRG = C2F0S3/Clinical = Mod, Functional = Min, Service = High** HCEM1 HCEM2 HCEM3 HCEM4 HCEM5 HCEM6 HCEM7 HCEM8 **HHRG = C2F1S0/Clinical = Mod, Functional = Low, Service = Min** HCFJ1 HCFJ2 HCFJ3 HCFJ4 HCFJ5 HCFJ6 HCFJ7 HCFJ8 **HHRG = C2F1S2/Clinical = Mod, Functional = Low, Service = Mod** HCFL1 HCFL2 HCFL3 HCFL4 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HCFL5 HCFL6 HCFL7 HCFL8 **HHRG = C2F1S3/Clinical = Mod, Functional = Low, Service = High** HCFM1 HCFM2 HCFM3 HCFM4 HCFM5 HCFM6 HCFM7 HCFM8 **HHRG = C2F2S0/Clinical = Mod, Functional = Mod, Service = Min** HCGJ1 HCGJ2 HCGJ3 HCGJ4 HCGJ5 HCGJ6 HCGJ7 HCGJ8 **HHRG = C2F2S1/Clinical = Mod, Functional = Mod, Service = Low** HCGK1 HCGK2 HCGK3 HCGK4 HCGK5 HCGK6 HCGK7 HCGK8 **HHRG = C2F2S2/Clinical = Mod, Functional = Mod, Service = Mod** HCGL1 HCGL2 HCGL3 HCGL4 HCGL5 HCGL6 HCGL7 HCGL8 **HHRG = C2F2S3/Clinical = Mod, Functional = Mod, Service = High** HCGM1 HCGM2 HCGM3 HCGM4 HCGM5 HCGM6 HCGM7 HCGM8 **HHRG = C2F3S0/Clinical = Mod, Functional = High, Service = Min** HCHJ1 HCHJ2 HCHJ3 HCHJ4 HCHJ5 HCHJ6 HCHJ7 HCHJ8 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- **HHRG = C2F3S1/Clinical = Mod, Functional = High, Service = Low** HCHK1 HCHK2 HCHK3 HCHK4 HCHK5 HCHK6 HCHK7 HCHK8 **HHRG = C2F3S2/Clinical = Mod, Functional = High, Service = Mod** HCHL1 HCHL2 HCHL3 HCHL4 HCHL5 HCHL6 HCHL7 HCHL8 **HHRG = C2F3S3/Clinical = Mod, Functional = High, Service = High** HCHM1 HCHM2 HCHM3 HCHM4 HCHM5 HCHM6 HCHM7 HCHM8 **HHRG = C2F4S0/Clinical = Mod, Functional = Max, Service = Min** HCIJ1 HCIJ2 HCIJ3 HCIJ4 HCIJ5 HCIJ6 HCIJ7 HCIJ8 **HHRG = C2F4S1/Clinical = Mod, Functional = Max, Service = Low** HCIK1 HCIK2 HCIK3 HCIK4 HCIK5 HCIK6 HCIK7 HCIK8 **HHRG = C2F4S2/Clinical = Mod, Functional = Max, Service = Mod** HCIL1 HCIL2 HCIL3 HCIL4 HCIL5 HCIL6 HCIL7 HCIL8 **HHRG = C2F4S3/Clinical = Mod, Functional = Max, Service = High** HCIM1 HCIM2 HCIM3 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HCIM4 HCIM5 HCIM6 HCIM7 HCIM8 **HHRG = C3F0S0/Clinical = High, Functional = Min, Service = Min** HDEJ1 HDEJ2 HDEJ3 HDEJ4 HDEJ5 HDEJ6 HDEJ7 HDEJ8 **HHRG = C3F0S1/Clinical = High, Functional = Min, Service = Low** HDEK1 HDEK2 HDEK3 HDEK4 HDEK5 HDEK6 HDEK7 HDEK8 **HHRG = C3F0S2/Clinical = High, Functional = Min, Service = Mod** HDEL1 HDEL2 HDEL3 HDEL4 HDEL5 HDEL6 HDEL7 HDEL8 **HHRG = C3F0S3/Clinical = High, Functional = Min, Service = High** HDEM1 HDEM2 HDEM3 HDEM4 HDEM5 HDEM6 HDEM7 HDEM8 **HHRG = C3F1S0/Clinical = High, Functional = Low, Service = Min** HDFJ1 HDFJ2 HDFJ3 HDFJ4 HDFJ5 HDFJ6 HDFJ7 HDFJ8 **HHRG = C3F1S1/Clinical = High, Functional = Low, Service = Low** HDFK1 HDFK2 HDFK3 HDFK4 HDFK5 HDFK6 HDFK7 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HDFK8 **HHRG = C3F1S2/Clinical = High, Functional = Low, Service = Mod** HDFL1 HDFL2 HDFL3 HDFL4 HDFL5 HDFL6 HDFL7 HDFL8 **HHRG = C3F1S3/Clinical = High, Functional = Low, Service = High** HDFM1 HDFM2 HDFM3 HDFM4 HDFM5 HDFM6 HDFM7 HDFM8 **HHRG = C3F2S0/Clinical = High, Functional = Mod, Service = Min** HDGJ1 HDGJ2 HDGJ3 HDGJ4 HDGJ5 HDGJ6 HDGJ7 HDGJ8 **HHRG = C3F2S1/Clinical = High, Functional = Mod, Service = Low** HDGK1 HDGK2 HDGK3 HDGK4 HDGK5 HDGK6 HDGK7 HDGK8 **HHRG = C3F2S2/Clinical = High, Functional = Mod, Service = Mod** HDGL1 HDGL2 HDGL3 HDGL4 HDGL5 HDGL6 HDGL7 HDGL8 **HHRG = C3F2S3/Clinical = High, Functional = Mod, Service = High** HDGM1 HDGM2 HDGM3 HDGM4 HDGM5 HDGM6 HDGM7 HDGM8 **HHRG = C3F3S0/Clinical = High, Functional = High, Service = Min** HDHJ1 HDHJ2 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HDHJ3 HDHJ4 HDHJ5 HDHJ6 HDHJ7 HDHJ8 **HHRG = C3F3S1/Clinical = High, Functional = High, Service = Low** HDHK1 HDHK2 HDHK3 HDHK4 HDHK5 HDHK6 HDHK7 HDHK8 **HHRG = C3F3S2/Clinical = High, Functional = High, Service = Mod** HDHL1 HDHL2 HDHL3 HDHL4 HDHL5 HDHL6 HDHL7 HDHL8 **HHRG = C3F3S3/Clinical = High, Functional = High, Service = High** HDHM1 HDHM2 HDHM3 HDHM4 HDHM5 HDHM6 HDHM7 HDHM8 **HHRG = C3F4S0/Clinical = High, Functional = Max, Service = Min** HDIJ1 HDIJ2 HDIJ3 HDIJ4 HDIJ5 HDIJ6 HDIJ7 HDIJ8 **HHRG = C3F4S1/Clinical = High, Functional = Max, Service = Low** HDIK1 HDIK2 HDIK3 HDIK4 HDIK5 HDIK6 HDIK7 HDIK8 **HHRG = C3F4S2/Clinical = High, Functional = Max, Service = Mod** HDIL1 HDIL2 HDIL3 HDIL4 HDIL5 HDIL6 1 CLM_HIPPS_TB Claim SNF & HHA Health Insurance PPS Table ------------ ------------------------------------------------- HDIL7 HDIL8 **HHRG = C3F4S3/Clinical = High, Functional = Max, Service = High** HDIM1 HDIM2 HDIM3 HDIM4 HDIM5 HDIM6 HDIM7 HDIM8 1 CLM_IP_ADMSN_TYPE_TB Claim Inpatient Admission Type Table -------------------- ------------------------------------ 0 = Blank 1 = Emergency - The patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room. 2 = Urgent - The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodation. 3 = Elective - The patient's condition permitted adequate time to schedule the availability of suitable accommodations. 4 = Newborn - Necessitates the use of special source of admission codes. 5 THRU 8 = Reserved. 9 = Unknown - Information not available. 1 CLM_MDCR_NPMT_RSN_TB Claim Medicare Non-Payment Reason Table -------------------- --------------------------------------- A = Covered worker's compensation (Obsolete) B = Benefit exhausted C = Custodial care - noncovered care (includes all 'beneficiary at fault' waiver cases) (Obsolete) E = HMO out-of-plan services not emergency or urgently needed (Obsolete) E = MSP cost avoided - IRS/SSA/HCFA Data Match (eff. 7/00) F = MSP cost avoid HMO Rate Cell (eff. 7/00) G = MSP cost avoided Litigation Settlement (eff. 7/00) H = MSP cost avoided Employer Voluntary Reporting (eff. 7/00) J = MSP cost avoid Insurer Voluntary Reporting (eff. 7/00) K = MSP cost avoid Initial Enrollment Questionnaire (eff. 7/00) N = All other reasons for nonpayment P = Payment requested Q = MSP cost avoided Voluntary Agreement (eff. 7/00) R = Benefits refused, or evidence not submitted T = MSP cost avoided - IEQ contractor (eff. 9/76) (obsolete 6/30/00) U = MSP cost avoided - HMO rate cell adjustment (eff. 9/76) (Obsolete 6/30/00) V = MSP cost avoided - litigation settlement (eff. 9/76) (Obsolete 6/30/00) W = Worker's compensation (Obsolete) X = MSP cost avoided - generic Y = MSP cost avoided - IRS/SSA data match project (obsolete 6/30/00) Z = Zero reimbursement RAPs -- zero reimbursement made due to medical review intervention or where provider specific zero payment has been determined. (effective with HHPPS - 10/00) 1 CLM_OCRNC_SPAN_TB Claim Occurrence Span Table ----------------- --------------------------- 70 = Eff 10/93, payer use only, the nonutilization from/thru dates for PPS-inlier stay where bene had exhausted all full/coinsurance days, but covered on cost report. SNF qualifying hospital stay from/thru dates 71 = Hospital prior stay dates - the from/ thru dates of any hospital stay that ended within 60 days of this hospital or SNF admission. 72 = First/last visit - the dates of the first and last visits occurring in this billing period if the dates are different from those in the statement covers period. 73 = Benefit eligibility period - the inclusive dates during which CHAMPUS medical benefits are available to a sponsor's bene as shown on the bene's ID card. 74 = Non-covered level of care - The from/ thru dates of a period at a noncovered level of care in an otherwise covered stay, excluding any period reported with occurrence span code 76, 77, or 79. 75 = The from/thru dates of SNF level of care during IP hospital stay. Shows PRO approval of patient remaining in hospital because SNF bed not available. not applicable to swing bed cases. PPS hospitals use in day outlier cases only. 76 = Patient liability - From/thru dates of period of noncovered care for which hospital may charge bene. The FI or PRO must have approved such charges in advance. patient must be notified in writing 3 days prior to noncovered period 77 = Provider liability - The from/thru dates of period of noncovered care for which the provider is liable. Eff 3/92, applies to provider liability where bene is charged with utilization and is liable for deductible/coinsurance 78 = SNF prior stay dates - The from/ thru dates of any SNF stay that ended within 60 days of this hospital or SNF admission. 79 = (Payer code) - Eff 3/92, from/thru dates of period of noncovered care where bene is not charged with utilization, deductible, or coinsurance. and provider is liable. Eff 9/93, noncovered period of care due to lack of medical necessity. 1 CLM_OCRNC_SPAN_TB Claim Occurrence Span Table ----------------- --------------------------- 80 - 99 = Reserved for state assignment M0 = PRO/UR approved stay dates - Eff 10/93, the first and last days that were approved where not all of the stay was approved. 1 CLM_PPS_IND_TB Claim PPS Indicator Table -------------- ------------------------- ***Effective NCH weekly process date 10/3/97 - 5/29/98*** 0 = not PPS bill (claim contains no PPS indicator) 2 = PPS bill ( claim contains PPS indicator) ***Effective NCH weekly process date 6/5/98*** 0 = not applicable (claim contains neither PPS nor deemed insured MQGE status indicators) 1 = Deemed insured MQGE (claim contains deemed insured MQGE indicator but not PPS indicator) 2 = PPS bill ( claim contains PPS indicator but no deemed insured MQGE status indicator) 3 = Both PPS and deemed insured MQGE (contains both PPS and deemed insured MQGE indicators) 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- 01 = Military service related - Medical condition incurred during military service. 02 = Employment related - Patient alleged that the medical condition causing this episode of care was due to environment/ events resulting from employment. 03 = Patient covered by insurance not reflected here - Indicates that patient or patient representative has stated that coverage may exist beyond that reflected on this bill. 04 = Health Maintenance Organization (HMO) enrollee - Medicare beneficiary is enrolled in an HMO. Eff 9/93, hospital must also expect to receive payment from HMO. 05 = Lien has been filed - Provider has filed legal claim for recovery of funds potentially due a patient as a result of legal action initiated by or on behalf of the patient. 06 = ESRD patient in 1st 18 months of entitlement covered by employer group health insurance - indicates Medicare may be secondary insurer. Eff 3/1/96, ESRD patient in 1st 30 months of entitlement covered by employer group health insurance. 07 = Treatment of nonterminal condition for hospice patient - The patient is a hospice enrollee, but the provider is not treating a terminal condition and is requesting Medicare reimbursement. 08 = Beneficiary would not provide information concerning other insurance coverage. 09 = Neither patient nor spouse is employed - Code indicates that in response to development questions, the patient and spouse have denied employment. 10 = Patient and/or spouse is employed but no EGHP coverage exists or (eff 9/93) other employer sponsored/provided health insurance covering patient. 11 = The disabled beneficiary and/or family member has no group coverage from a LGHP or (eff 9/93) other employer sponsored/provided health insurance covering patient. 12 = Payer code - Reserved for internal use only by third party payers. HCFA will assign as needed. Providers will not report them. 13 = Payer code - Reserved for internal use only by third party payers. HCFA will assign as needed. Providers will not report them. 14 = Payer code - Reserved for internal 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- use only by third party payers. HCFA will assign as needed. Providers will not report them. 15 = Clean claim (eff 10/92) 16 = SNF transition exemption - An exemption from the post-hospital requirement applies for this SNF stay or the qualifying stay dates are more than 30 days prior to the admission date 17 = Patient is over 100 years old - Code indicates that the patient was over 100 years old at the date of admission. 18 = Maiden name retained - A dependent spouse entitled to benefits who does not use her husband's last name. 19 = Child retains mother's name - A patient who is a dependent child entitled to CHAMPVA benefits that does not have father's last name. 20 = Bene requested billing - Provider realizes the services on this bill are at a noncovered level of care or otherwise excluded from coverage, but the bene has requested formal determination 21 = Billing for denial notice - The SNF or HHA realizes services are at a noncovered level of care or excluded, but requests a Medicare denial in order to bill medicaid or other insurer 22 = Patient on multiple drug regimen - A patient who is receiving multiple intravenous drugs while on home IV therapy 23 = Homecaregiver available - The patient has a caregiver available to assist him or her during self-administration of an intravenous drug 24 = Home IV patient also receiving HHA services - the patient is under care of HHA while receiving home IV drug therapy services 25 = Reserved for national assignment 26 = VA eligible patient chooses to receive services in Medicare certified facility rather than a VA facility (eff 3/92) 27 = Patient referred to a sole community hospital for a diagnostic laboratory test - (sole community hospital only). (eff 9/93) 28 = Patient and/or spouse's EGHP is secondary to Medicare - Qualifying EGHP for employers who have fewer than 20 employees. (eff 9/93) 29 = Disabled beneficiary and/or family member's LGHP is secondary to Medicare - Qualifying LGHP for employer having fewer than 100 full and part-time employees 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- 31 = Patient is student (full time - day) - Patient declares that he or she is enrolled as a full time day student. 32 = Patient is student (cooperative/work study program) 33 = Patient is student (full time - night) - Patient declares that he or she is enrolled as a full time night student. 34 = Patient is student (part time) - Patient declares that he or she is enrolled as a part time student. 36 = General care patient in a special unit - Patient is temporarily placed in special care unit bed because no general care beds were available. 37 = Ward accommodation is patient's request - Patient is assigned to ward accommodations at patient's request. 38 = Semi-private room not available - Indicates that either private or ward accommodations were assigned because semi-private accomodations were not available. 39 = Private room medically necessary - Patient needed a private room for medical reasons. 40 = Same day transfer - Patient transferred to another facility before midnight of the day of admission. 41 = Partial hospitalization - Eff 3/92, indicates claim is for partial hospitalization services. For OP services, this includes a variety of psych programs. 42 = Reserved for national assignment. 43 = Reserved for national assignment. 44 = Reserved for national assignment. 45 = Reserved for national assignment. 46 = Nonavailability statement on file for CHAMPUS claim for nonemergency IP care for CHAMPUS bene residing within the catchment area (usually a 40 mile radius) of a uniform services hospital. 47 = Reserved for CHAMPUS. 48 = Reserved for national assignment. 49 = Reserved for national assignment. 50 = Reserved for national assignment. 51 = Reserved for national assignment. 52 = Reserved for national assignment. 53 = Reserved for national assignment. 54 = Reserved for national assignment. 55 = SNF bed not available - The patient's SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available. 56 = Medical appropriateness - Patient's SNF admission was delayed more than 30 days after hospital discharge because 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- physical condition made it inappropriate to begin active care within that period 57 = SNF readmission - Patient previously received Medicare covered SNF care within 30 days of the current SNF admission. 58 = Payment of SNF claims for beneficiaries disenrolling from terminating M+C plans plans who have not met the 3-day hospital stay requirement (eff. 10/1/00) 59 = Reserved for national assignment. 60 = Operating cost day outlier - PRICER indicates this bill is length of stay outlier (PPS) 61 = Operating cost cost outlier - PRICER indicates this bill is a cost outlier (PPS) 62 = PIP bill - This bill is a periodic interim payment bill. 63 = PRO denial received before batch clearance report - The HCSSACL receipt date is used on PRO adjustment if the PRO's notification is before orig bill's acceptance report. (Payer only code eff 9/93) 64 = Other than clean claim - The claim is not a 'clean claim' 65 = Non-PPS code - The bill is not a prospective payment system bill. 66 = Outlier not claimed - Bill may meet the criteria for cost outlier, but the hospital did not claim the cost outlier (PPS) 67 = Beneficiary elects not to use LTR days 68 = Beneficiary elects to use LTR days 69 = Operating IME Payment Only - providers request for IME payment for each discharge of MCO enrollee, beginning 1/1/98, from teaching hospitals (facilities with approved medical residency training program); not stored in NCH. Exception: problem in startup year may have resulted in this special IME payment request being erroneously stored in NCH. If present, disregard claim as condition code '69' is not valid NCH claim. 70 = Self-administered EPO - Billing is for a home dialysis patient who self administers EPO. 71 = Full care in unit - Billing is for a patient who received staff assisted dialysis services in a hospital or renal dialysis facility. 72 = Self care in unit - Billing is for a patient who managed his own dialysis services without staff assistance in a hospital or renal dialysis facility. 73 = Self care training - Billing is for special dialysis services where the 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- patient and helper (if necessary) were learning to perform dialysis. 74 = Home - Billing is for a patient who received dialysis services at home. 75 = Home 100% reimbursement - (not to be used for services after 4/15/90) The billing is for home dialsis patient using a dialysis machine that was purchased under the 100% program. 76 = Back-up facility - Billing is for a patient who received dialysis services in a back-up facility. 77 = Provider accepts or is obligated/ required due to contractual agreement or law to accept payment by a primary payer as payment in full - Medicare pays nothing. 78 = New coverage not implemented by HMO - eff 3/92, indicates newly covered service under Medicare for which HMO does not pay. 79 = CORF services provided off site - Code indicates that physical therapy, occupational therapy, or speech path- ology services were provided off site. 80 - 99 = Reserved for state assignment. A0 = CHAMPUS external partnership program special program indicator code. (eff 10/93) A1 = EPSDT/CHAP - Early and periodic screening diagnosis and treatment special program indicator code. (eff 10/93) A2 = Physically handicapped children's program - Services provided receive special funding through Title 8 of the Social Security Act or the CHAMPUS program for the handicapped. (eff 10/93) A3 = Special federal funding - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A4 = Family planning - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A5 = Disability - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A6 = PPV/Medicare - Identifies that pneumococcal pneumonia 100% payment vaccine (PPV) services should be reimbursed under a special Medicare program provision. Special program indicator code (eff 10/93) A7 = Induced abortion to avoid danger to woman's life. Special program indicator code (eff 10/93) A8 = Induced abortion - Victim of rape/ 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- incest. Special program indicator code (eff 10/93) A9 = Second opinion surgery - Services requested to support second opinion on surgery. Part B deductible and coinsurance do not apply. Special program indicator code (eff 10/93) B0 = Special program indicator Reserved for national assignment. B1 = Special program indicator Reserved for national assignment. B2 = Special program indicator Reserved for national assignment. B3 = Special program indicator Reserved for national assignment. B4 = Special program indicator Reserved for national assignment. B5 = Special program indicator Reserved for national assignment. B6 = Special program indicator Reserved for national assignment. B7 = Special program indicator Reserved for national assignment. B8 = Special program indicator Reserved for national assignment. B9 = Special program indicator Reserved for national assignment. C0 = Reserved for national assignment. C1 = Approved as billed - The services provided for this billing period have been reviewed by the PRO/UR or intermediary and are fully approved including any day or cost outlier. (eff 10/93) C2 = Automatic approval as billed based on focused review. (No longer used for Medicare) PRO approval indicator services (eff 10/93) C3 = Partial approval - The services provided for this billing period have been reviewed by the PRO/UR or intermediary and some portion has been denied (days or services). (eff 10/93) C4 = Admission/services denied - Indicates that all of the services were denied by the PRO/UR. PRO approval indicator services (eff 10/93) C5 = Postpayment review applicable - PRO/UR review to take place after payment. PRO approval indicator services (eff 10/93) C6 = Admission preauthorization - The PRO/UR authorized this admission/ service but has not reviewed the services provided. PRO approval indicator services (eff 10/93) C7 = Extended authorization - the PRO has authorized these services for an extended length of time but has not reviewed the services provided. 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- PRO approval indicator services (eff 10/93) C8 = Reserved for national assignment. PRO approval indicator services (eff 10/93) C9 = Reserved for national assignment. PRO approval indicator services (eff 10/93) D0 = Changes to service dates. Change condition (eff 10/93) D1 = Changes in charges. Change condition (eff 10/93) D2 = Changes in revenue codes/HCPCS. Change condition (eff 10/93) D3 = Second or subsequent interim PPS bill. Change condition (eff 10/93) D4 = Change in grouper input (diagnosis and/or procedures are changed resulting in a different DRG). Change condition (eff 10/93) D5 = Cancel only to correct a beneficiary claim account number or provider identification number. change condition (eff 10/93) D6 = Cancel only to repay a duplicate payment or OIG overpayment (includes cancellation of an OP bill containing services required to be included on the IP bill). Change condition eff 10/93. D7 = Change to make Medicare the secondary payer. Change condition (eff 10/93) D8 = Change to make Medicare the primary payer. Change condition (eff 10/93) D9 = Any other change. Change condition (eff 10/93) E0 = Change in patient status. Change condition (eff 10/93) EY = National Emphysema Treatment Trial (NETT) or Lung Volume Reduction Surgery (LVRS) clinical study (eff. 11/97) G0 = Multiple medical visits occur on the same day in the same revenue center but visits are distinct and constitute independent visits (allows for payment under outpatient PPS -- eff. 7/3/00). M0 = All inclusive rate for outpatient services. (payer only code) M1 = Roster billed influenza virus vaccine. (payer only code) Eff 10/96, also includes pneumoccocal pneumonia vaccine (PPV) M2 = HH override code - home health total reimbursement exceeds the $150,000 cap or the number of total visits exceeds the 150 limitation. (eff 4/3/95) (payer only code) W0 = United Mine Workers of America (UMWA) SNF demonstration indicator (eff 1/97); 1 CLM_RLT_COND_TB Claim Related Condition Table --------------- ----------------------------- but no claims transmitted until 2/98) 1 CLM_RLT_OCRNC_TB Claim Related Occurrence Table ---------------- ------------------------------ 01 = Auto accident - The date of an auto accident. 02 = No-fault insurance involved, including auto accident/other - The date of an accident where the state has applicable no-fault liability laws, (i.e., legal basis for settlement without admission or proof of guilt). 03 = Accident/tort liability - The date of an accident resulting from a third party's action that may involve a civil court process in an attempt to require payment by the third party, other than no-fault liability. 04 = Accident/employment related - The date of an accident relating to the patient's employment. 05 = Other accident - The date of an accident not described by the codes 01 thru 04. 06 = Crime victim - Code indicating the date on which a medical condition resulted from alleged criminal action committed by one or more parties. 07 = Reserved for national assignment. 08 = Reserved for national assignment. 11 = Onset of symptoms/illness - The date the patient first became aware of symptoms/illness. 12 = Date of onset for a chronically dependent individual - Code indicates the date the patient/bene became a chronically dependent individual. 13 = Reserved for national assignment. 14 = Reserved for national assignment. 15 = Reserved for national assignment. 16 = Reserved for national assignment. 17 = Date outpatient occupational therapy plan established or last reviewed - Code indicating the date an occupational therapy plan was established or last reviewed (eff 3/93) 18 = Date of retirement (patient/bene) - Code indicates the date of retirement for the patient/bene. 19 = Date of retirement spouse - Code indicates the date of retirement for the patient's spouse. 20 = Guarantee of payment began - The date on which the provider began claiming Medicare payment under the guarantee of payment provision. 21 = UR notice received - Code indicating the date of receipt by the hospital of the UR committee's finding that the admission or future stay was not medically necessary. 22 = Active care ended - The date on which 1 CLM_RLT_OCRNC_TB Claim Related Occurrence Table ---------------- ------------------------------ a covered level of care ended in a SNF or general hospital, or date active care ended in a psychiatric or tuberculosis hospital. (For use by intermediary only) 23 = Reserved for national assignment (eff 10/93). Benefits exhausted - The last date for which benefits can be paid. (term 9/30/93; replaced by code A3) 24 = Date insurance denied - The date the insurer's denial of coverage was received by a higher priority payer. 25 = Date benefits terminated by primary payer - The date on which coverage (including worker's compensation benefits or no-fault coverage) is no longer available to the patient. 26 = Date skilled nursing facility (SNF) bed available - The date on which a SNF bed became available to a hospital inpatient who required only SNF level of care. 27 = Date home health plan established or last reviewed - Code indicating the date a home health plan of treatment was established or last reviewed. not used by hospital unless owner of facility 28 = Date comprehensive outpatient rehabi- litation plan established or last re- viewed - Code indicating the date a comprehensive outpatient rehabilitation plan was established or last reviewed. not used by hospital unless owner of facility 29 = Date OPT plan established or last reviewed - the date a plan of treatment was established for outpatient physical therapy. Not used by hospital unless owner of facility 30 = Date speech pathology plan treatment established or last reviewed - The date a speech pathology plan of treatment was established or last reviewed. Not used by hospital unless owner of facility 31 = Date bene notified of intent to bill (accommodations) - The date of the notice provided to the patient by the hospital stating that he no longer required a covered level of IP care. 32 = Date bene notified of intent to bill (procedures or treatment) - The date of the notice provided to the patient by the hospital stating requested care (diagnostic procedures or treatments) is not considered reasonable or necessary. 33 = First day of the Medicare coordination period for ESRD bene - During which Medicare benefits are secondary to benefits payable under an EGHP. 1 CLM_RLT_OCRNC_TB Claim Related Occurrence Table ---------------- ------------------------------ Required only for ESRD beneficiaries. 34 = Date of election of extended care facilities - The date the guest elected to receive extended care services (used by Christian Science Sanatoria only). 35 = Date treatment started for physical therapy - Code indicates the date services were initiated by the billing provider for physical therapy. 36 = Date of discharge for the IP hospital stay when patient received a transplant procedure - Hospital is billing for immunosuppressive drugs. 37 = The date of discharge for the IP hospital stay when patient received a noncovered transplant procedure - Hospital is billing for immunosuppresive drugs. 38 = Date treatment started for home IV therapy - Date the patient was first treated in his home for IV therapy. 39 = Date discharged on a continuous course of IV therapy - Date the patient was discharged from the hospital on a continuous course of IV therapy. 40 = Scheduled date of admission - The date on which a patient will be admitted as an inpatient to the hospital. (This code may only be used on an outpatient claim.) 41 = The date on which the first outpatient diagnostic test was performed as part of a pre-admission testing (PAT) program. This code may only be used if a date of admission was scheduled prior to the administration of the test(s). 42 = Date of discharge/termination of hospice care - for the final bill for hospice care. Eff 5/93, definition revised to apply only to date patient revoked hospice election. 43 = Reserved for national assignment. 44 = Date treatment started for occupational therapy - Code indicates the date services were initiated by the billing provider for occupational therapy. 45 = Date treatment started for speech therapy - Code indicates the date services were initiated by the billing provider for speech therapy. 46 = Date treatment started for cardiac rehabilitation - Code indicates the date services were initiated by the billing provider for cardiac rehabilitation. 47 = Noncovered Outlier Stay Began- code 1 CLM_RLT_OCRNC_TB Claim Related Occurrence Table ---------------- ------------------------------ indicates the date that cost outlier status began and no Medicare payment will be made because all benefits have been exhausted during the inlier stay or the beneficiary does not elect to use life time reserve days (to be implemented in 1999). 48 = Payer code - Code reserved for internal use only by third party payers. HCFA assigns as needed for your use. Providers will not report it. 49 = Payer code - Code reserved for internal use only by third party payers. HCFA assigns as needed for your use. Providers will not report it. 50 - 69 = Reserved for state assignment A1 = Birthdate, Insured A - The birthdate of the individual in whose name the insurance is carried. (Eff 10/93) A2 = Effective date, Insured A policy - A code indicating the first date insurance is in force. (eff 10/93) A3 = Benefits exhausted - Code indicating the last date for which benefits are available and after which no payment can be made to payer A. (eff 10/93) B1 = Birthdate, Insured B - The birthdate of the individual in whose name the insurance is carried. (eff 10/93) B2 = Effective date, Insured B policy - A code indicating the first date insurance is in force. (eff 10/93) B3 = Benefits exhausted - code indicating the last date for which benefits are available and after which no payment can be made to payer B. (eff 10/93) C1 = Birthdate, Insured C - The birthdate of the individual in whose name the insurance is carried. (eff 10/93) C2 = Effective date, Insured C policy - A code indicating the first date insurance is in force. (eff 10/93) C3 = Benefits exhausted - Code indicating the last date for which benefits are available and after which no payment can be made to payer C. (eff 10/93) 1 CLM_SRC_IP_ADMSN_TB Claim Source Of Inpatient Admission Table ------------------- ----------------------------------------- **For Inpatient/SNF Claims:** 0 = ANOMALY: invalid value, if present, translate to '9' 1 = Physician referral - The patient was admitted upon the recommendation of a personal physician. 2 = Clinic referral - The patient was admitted upon the recommendation of this facility's clinic physician. 3 = HMO referral - The patient was admitted upon the recommendation of an health maintenance organization (HMO) physician. 4 = Transfer from hospital - The patient was admitted as an inpatient transfer from an acute care facility. 5 = Transfer from a skilled nursing facility (SNF) - The patient was admitted as an inpatient transfer from a SNF. 6 = Transfer from another health care facility - The patient was admitted as a transfer from a health care facility other than an acute care facility or SNF. 7 = Emergency room - The patient was admitted upon the recommendation of this facility's emergency room physician. 8 = Court/law enforcement - The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative. 9 = Information not available - The means by which the patient was admitted is not known. A = Transfer from a Critical Access Hospital - patient was admitted/referred to this facility as a transfer from a Critical Access Hospital. --------------------------------------- **For Newborn Type of Admission** 1 = Normal delivery - A baby delivered with out complications. 2 = Premature delivery - A baby delivered with time and/or weight factors qualifying it for premature status. 3 = Sick baby - A baby delivered with medical complications, other than those relating to premature status. 4 = Extramural birth - A baby delivered in a nonsterile environment. 5-8 = Reserved for national assignment. 1 CLM_SRC_IP_ADMSN_TB Claim Source Of Inpatient Admission Table ------------------- ----------------------------------------- 9 = Information not available. 1 CLM_SRVC_CLSFCTN_TYPE_TB Claim Service Classification Type Table ------------------------ --------------------------------------- For facility type code 1 thru 6, and 9 1 = Inpatient (including Part A) 2 = Hospital based or Inpatient (Part B only) or home health visits under Part B 3 = Outpatient (HHA-A also) 4 = Other (Part B) 5 = Intermediate care - level I 6 = Intermediate care - level II 7 = Subacute Inpatient (formerly Intermediate care - level III) 8 = Swing beds (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement) 9 = Reserved for national assignment For facility type code 7 1 = Rural health 2 = Hospital based or independent renal dialysis facility 3 = Free-standing provider based federally qualified health center (eff 10/91) 4 = Other Rehabilitation Facility (ORF) and Community Mental Health Center (CMHC) (eff 10/91 - 3/97); ORF only (eff. 4/97) 5 = Comprehensive Rehabilitation Center (CORF) 6 = Community Mental Health Center (CMHC) (eff 4/97) 7-8 = Reserved for national assignment 9 = Other For facility type code 8 1 = Hospice (non-hospital based) 2 = Hospice (hospital based) 3 = Ambulatory surgical center in hospital outpatient department 4 = Freestanding birthing center 5 = Critical Access Hospital (eff. 10/99) formerly Rural primary care hospital (eff. 10/94) 6-8 = Reserved for national use 9 = Other 1 CLM_TRANS_TB Claim Transaction Table ------------ ----------------------- 0 = Religious NonMedical Health Care Institutions (RNHCI) bill (prior to 8/00, Christian Science bill), SNF bill, or state buy-in 1 = Psychiatric hospital facility bill or dummy psychiatric 2 = Tuberculosis hospital facility bill 3 = General care hospital facility bill or dummy LRD 4 = Regular SNF bill 5 = Home health agency bill (HHA) 6 = Outpatient hospital bill C = CORF bill - type of OP bill in the HHA bill format (obsoleted 7/98) H = Hospice bill 1 CLM_VAL_TB Claim Value Table ---------- ----------------- 04 = Inpatient professional component charges which are combined billed - For use only by some all inclusive rate hospitals. (Eff 9/93) 05 = Professional component included in charges and also billed separately to carrier - For use on Medicare and Medicaid bills if the state requests this information. 06 = Medicare blood deductible - Total cash blood deductible (Part A blood deductible). 07 = Medicare cash deductible (term 9/30/93) reserved for national assignment. (eff 10/93) 08 = Medicare Part A lifetime reserve amount in first calendar year - Lifetime reserve amount charged in the year of admission. (not stored in NCH until 2/93) 09 = Medicare Part A coinsurance amount in the first calendar year - Coinsurance amount charged in the year of admission. (not stored in NCH until 2/93) 10 = Medicare Part A lifetime reserve amount in the second calendar year - Lifetime reserve amount charged in the year of discharge where the bill spans two calendar years. (not stored in NCH until 2/93) 11 = Medicare Part A coinsurance amount in the second calendar year - Coinsurance amount charged in the year of discharge where the bill spans two calendar years (not stored in NCH until 2/93) 12 = Amount is that portion of higher priority EGHP insurance payment made on behalf of aged bene provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional Medicare payment. 13 = Amount is that portion of higher priority EGHP insurance payment made on behalf of ESRD bene provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment. 14 = That portion of payment from higher priority no fault auto/other liability insurance made on behalf of bene provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional payment 15 = That portion of a payment from a higher priority WC plan made on behalf of a bene that the provider applied to 1 CLM_VAL_TB Claim Value Table ---------- ----------------- Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment. 16 = That portion of a payment from higher priority PHS or other federal agency made on behalf of a bene the provider applied to Medicare covered services on this bill. Six zeroes indicate provider claimed conditional Medicare payment. 17 = Operating Outlier amount - Providers do not report this. For payer internal use only. Indicates the amount of day or cost outlier payment to be made. (Do not include any PPS capital outlier payment in this entry). 18 = Operating Disproportionate share amount - Providers do not report this. For payer internal use only. Indicates the disproportionate share amount applicable to the bill. Use the amount provided by the disproportionate share field in PRICER. (Do not include any PPS capital DSH adjust- ment in this entry). 19 = Operating Indirect medical education amount - Providers do not report this. For payer internal use only. Indicates the indirect medical education amount applicable to the bill. (Do not include PPS capital IME adjustment in this entry). 20 = Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount. (used 10/1/91 - 3/1/92 for provider reporting. Payer only code eff 9/93.) 21 = Catastrophic - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 22 = Surplus - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 23 = Recurring monthly income - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 24 = Medicaid rate code - Medicaid - Eligibility requirements to be determined at state level. (Medicaid specific/deleted 9/93) 31 = Patient liability amount - Amount shown is that which you or the PRO approved to charge the bene for noncovered accommodations, diagnostic procedures or treatments. 37 = Pints of blood furnished - Total number of pints of whole blood or units 1 CLM_VAL_TB Claim Value Table ---------- ----------------- of packed red cells furnished to the patient. (eff 10/93) 38 = Blood deductible pints - The number of unreplaced pints of whole blood or units of packed red cells furnished for which the patient is responsible. (eff 10/93) 39 = Pints of blood replaced - The total number of pints of whole blood or units of packed red cells furnished to the patient that have been replaced by or on behalf of the patient. (eff 10/93) 40 = New coverage not implemented by HMO - amount shown is for inpatient charges covered by HMO (eff 3/92). (use this code when the bill includes inpatient charges for newly covered services which are not paid by HMO.) 41 = Amount is that portion of a payment from higher priority BL program made on behalf of bene the provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment. 42 = Amount is that portion of a payment from higher priority VA made on behalf of bene the provider applied to Medicare covered services on this bill. Six zeroes indicate the provider claimed conditional Medicare payment. 43 = Disabled bene under age 65 with LGHP - Amount is that portion of a payment from a higher priority LGHP made on behalf of a disabled Medicare bene the provider applied to Medicare covered services on this bill. 44 = Amount provider agreed to accept from primary payer when amount less than charges but more than payment received - When a lesser amount is received and the received amount is less than charges, a Medicare secondary payment is due. 46 = Number of grace days - Following the date of the PRO/UR determination, this is the number of days determined by the PRO/UR to be necessary to arrange for the patient's post-discharge care. (eff 10/93) 47 = Any liability insurance - Amount is that portion from a higher priority liability insurance made on behalf of Medicare bene the provider is applying to Medicare covered services on this bill. (Eff 9/93) 48 = Hemoglobin reading - The latest 1 CLM_VAL_TB Claim Value Table ---------- ----------------- hemoglobin reading taken during this billing cycle. 49 = Latest hematocrit reading taken during billing cycle - Usually reported in two pos. (a percentage) to left of the dollar/cent delimiter. if provided with a a decimal, use the 3rd pos. to right of the delimiter for the third digit. 50 = Physical therapy visits - Indicates the number of physical therapy visits from onset (at billing provider) through this billing period. 51 = Occupational therapy visits - Indicates the number of occupational therapy visits from onset (at the billing provider) through this billing period. 52 = Speech therapy visits - Indicates the number of speech therapy visits from onset (at billing provider) through this billing period. 53 = Cardiac rehabilitation - Indicates the number of cardiac rehabilitation visits from onset (at billing provider) through this billing period. 54 = Reserved for national assignment. 55 = Reserved for national assignment. 56 = Hours skilled nursing provided - The number of hours skilled nursing provided during the billing period. Count only hours spent in the home. 57 = Home health visit hours - The number of home health aide services provided during the billing period. Count only the hours spent in the home. 58 = Arterial blood gas - Arterial blood gas value at beginning of each reporting period for oxygen therapy. This value or value 59 will be required on the initial bill for oxygen therapy and on the fourth month's bill. 59 = Oxygen saturation - Oxygen saturation at the beginning of each reporting period for oxygen therapy. This value or value 58 will be required on the initial bill for oxygen therapy and on the fourth month's bill. 60 = HHA branch MSA - MSA in which HHA branch is located. 61 = Location of HHA service or hospice service - the balanced budget act (BBA) requires that the geographic location of where the service was provided be furnished instead of the geographic location of the provider. (eff. 10/1/97) 62 = Number of Part A home health visits accrued during a period of continuous 1 CLM_VAL_TB Claim Value Table ---------- ----------------- care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 63 = Number of Part B home health visits accrued during a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 64 = Amount of home health payments attributed to the Part A trust fund in a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 65 = Amount of home health payments attributed to the Part B trust fund in a period of continuous care - necessitated by the change in payment basis under HH PPS (eff. 10/00) 66 = Reserved for national assignment. 67 = Peritoneal dialysis - The number of hours of peritoneal dialysis provided during the billing period (only the hours spent in the home). (eff. 10/97) 68 = EPO drug - Number of units of EPO administered relating to the billing period. 69 = Reserved for national assignment 70 = Interest amount - (Providers do not report this.) Report the amount applied to this bill. 71 = Funding of ESRD networks - (Providers do not report this.) Report the amount the Medicare payment was reduced to help fund the ESRD networks. 72 = Flat rate surgery charge - Code indicates the amount of the charge for outpatient surgery where the hospital has such a charging structure. 73 = Drug deductible - (For internal use by third party payers only). Report the amount of the drug deductible to be applied to the claim. 74 = Drug coinsurance - (For internal use by third party payers only). Report the amount of drug coinsurance to be applied to the claim. 75 = Gramm/Rudman/Hollings - (Providers do not report this.) Report the amount of the sequestration applied to this bill. 76 = Report provider's percentage of billed charges interim rate during billing period. Applies to OP hospital, SNF and HHA claims where interim rate is applicable. Report to left of dollar/cents delimiter. (TP payers internal use only) 77 = Payer code - This codes is set aside for payer use only. Providers do not report these codes. 1 CLM_VAL_TB Claim Value Table ---------- ----------------- 78 = Payer code - This codes is set aside for payer use only. Providers do not report these codes. 79 = Payer code - This code is set aside for payer use only. Providers do not report these codes. 80 - 99 = Reserved for state assignment. A1 = Deductible Payer A - The amount assumed by the provider to be applied to the patient's deductible amount involving the indicated payer. (eff 10/93) - Prior value 07 A2 = Coinsurance Payer A - The amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer. (eff 10/93) A4 = Self-administered drugs administered in an emergency situation - Ordinarily the only noncovered self-administered drug paid for under Medicare in an emergency situation is insulin administered to a patient in a diabetic coma. (eff 7/97) B1 = Deductible Payer B - The amount assumed by the provider to be applied to the patient's deductible amount involving the indicated payer. (eff 10/93) - Prior value 07 B2 = Coinsurance Payer B - the amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer. (eff 10/93) C1 = Deductible Payer C - The amount assumed by the provider to be applied to the patient's deductible amount involving the indicated payer. (eff 10/93) - Prior value 07 C2 = Coinsurance Payer C - The amount assumed by the provider to be applied to the patient's Part B coinsurance amount involving the indicated payer. (eff 10/93) Y1 = Part A demo payment - Portion of the payment designated as reimbursement for Part A services per the ORD contract. No deductible or coinsurance has been applied. (eff. 5/97) Y2 = Part B demo payment - Portion of the payment designated as reimbursement for Part B services for the ORD contract. No deductible or coinsurance has been applied. (eff. 5/97) Y3 = Part B coinsurance - Amount of Part B coinsurance applied by the intermediary to this demo claim. (eff. 5/97) Y4 = Conventional provider Part A payment - Amount Medicare would have reimbursed the provider for Part A services if there had been no demo. (eff. 5/97) 1 CTGRY_EQTBL_BENE_IDENT_TB Category Equatable Beneficiary Identification Code (BIC) Table ------------------------- -------------------------------------------------------------- NCH BIC SSA Categories ------- -------------- A = A;J1;J2;J3;J4;M;M1;T;TA B = B;B2;B6;D;D4;D6;E;E1;K1;K2;K3;K4;W;W6; TB(F);TD(F);TE(F);TW(F) B1 = B1;BR;BY;D1;D5;DC;E4;E5;W1;WR;TB(M) TD(M);TE(M);TW(M) B3 = B3;B5;B9;D2;D7;D9;E2;E3;K5;K6;K7;K8;W2 W7;TG(F);TL(F);TR(F);TX(F) B4 = B4;BT;BW;D3;DM;DP;E6;E9;W3;WT;TG(M) TL(M);TR(M);TX(M) B8 = B8;B7;BN;D8;DA;DV;E7;EB;K9;KA;KB;KC;W4 W8;TH(F);TM(F);TS(F);TY(F) BA = BA;BK;BP;DD;DL;DW;E8;EC;KD;KE;KF;KG;W9 WC;TJ(F);TN(F);TT(F);TZ(F) BD = BD;BL;BQ;DG;DN;DY;EA;ED;KH;KJ;KL;KM;WF WJ;TK(F);TP(F);TU(F);TV(F) BG = BG;DH;DQ;DS;EF;EJ;W5;TH(M);TM(M);TS(M) TY(M) BH = BH;DJ;DR;DX;EG;EK;WB;TJ(M);TN(M);TT(M) TZ(M) BJ = BJ;DK;DT;DZ;EH;EM;WG;TK(M);TP(M);TU(M) TV(M) C1 = C1;TC C2 = C2;T2 C3 = C3;T3 C4 = C4;T4 C5 = C5;T5 C6 = C6;T6 C7 = C7;T7 C8 = C8;T8 C9 = C9;T9 F1 = F1;TF F2 = F2;TQ F3-F8 = Equatable only to itself (e.g., F3 IS equatable to F3) CA-CZ = Equatable only to itself. (e.g., CA is only equatable to CA) --------------------------------------- RRB Categories 10 = 10 11 = 11 13 = 13;17 14 = 14;16 15 = 15 43 = 43 45 = 45 46 = 46 80 = 80 83 = 83 84 = 84;86 85 = 85 1 DMERC_LINE_SCRN_RSLT_IND_TB DMERC Line Screen Result Indicator Table --------------------------- ---------------------------------------- A = Denied for lack of medical necessity; highest level of review was automated level I review B = Reduced (partially denied) for lack of medical necessity; highest level of review was automated level I review C = Denied as statutorily noncovered; highest level of review was automated level I review D = Reserved for future use E = Paid after automated level I review F = Denied for lack of medical necessity; highest level of review was manual level I review G = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level I review H = Denied as statutorily noncovered; highest level of review was manual level I review I = Denied for coding/unbundling reasons; highest level of review was manual level I review J = Paid after manual level I review K = Denied for lack of medical necessity; highest level of review was manual level II review L = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level II review M = Denied as statutorily noncovered; highest level of review was manual level II review N = Denied for coding/unbundling reasons; highest level of review was manual level II review O = Paid after manual level II review P = Denied for lack of medical necessity; highest level of review was manual level III review Q = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level III review R = Denied as statutorily noncovered; highest level of review was manual level III review S = Denied for coding/unbundling reasons; highest level of review was manual level III review T = Paid after manual level III review 1 DMERC_LINE_SUPLR_TYPE_TB DMERC Line Supplier Type Table ------------------------ ------------------------------ 0 = Clinics, groups, associations, partnerships, or other entities for whom the carrier's own ID number has been assigned. 1 = Physicians or suppliers billing as solo practitioners for whom SSN's are shown in the physician ID code field. 2 = Physicians or suppliers billing as solo practitioners for whom the carrier's own physician ID code is shown. 3 = Suppliers (other than sole proprietorship) for whom EI numbers are used in coding the ID field. 4 = Suppliers (other than sole proprietorship) for whom the carrier's own code has been shown. 5 = Institutional providers and independent laboratories for whom EI numbers are used in coding the ID field. 6 = Institutional providers and independent laboratories for whom the carrier's own ID number is shown. 7 = Clinics, groups, associations, or partnerships for whom EI numbers are used in coding the ID field. 8 = Other entities for whom EI numbers are used in coding the ID field or proprietorship for whom EI numbers are used in coding the ID field. 1 DRG_OUTLIER_STAY_TB Diagnosis Related Group Outlier Patient Stay Table ------------------- -------------------------------------------------- 0 = No outlier 1 = Day outlier (condition code 60) 2 = Cost outlier, (condition code 61) *** Non-PPS Only *** 6 = Valid diagnosis related groups (DRG) received from the intermediary 7 = HCFA developed DRG 8 = HCFA developed DRG using patient status code 9 = Not groupable 1 FI_CLM_ACTN_TB Fiscal Intermediary Claim Action Table -------------- -------------------------------------- 1 = Original debit action (includes non- adjustment RTI correction items) - it will always be a 1 in regular bills. 2 = Cancel by credit adjustment - used only in credit/debit pairs (under HHPPS, updates the RAP). 3 = Secondary debit adjustment - used only in credit/debit pairs (under HHPPS, would be the final claim or an adjustment on a LUPA). 4 = Cancel only adjustment (under HHPPS, RAP/final claim/LUPA). 5 = Force action code 3 6 = Force action code 2 8 = Benefits refused (for inpatient bills, an 'R' nonpayment code must also be present 9 = Payment requested (used on bills that replace previously-submitted benefits- refused bills, action code 8. In such cases a debit/credit pair is not re- quired. For inpatient bills, a 'P' should be entered in the nonpayment code.) 1 FI_NUM_TB Fiscal Intermediary Number Table --------- -------------------------------- 00010 = Alabama BC 00020 = Arkansas BC 00030 = Arizona BC 00040 = California BC (term. 12/00) 00050 = New Mexico BC/CO 00060 = Connecticut BC 00070 = Delaware BC - terminated 2/98 00080 = Florida BC 00090 = Florida BC 00101 = Georgia BC 00121 = Illinois - HCSC 00123 = Michigan - HCSC 00130 = Indiana BC/Administar Federal 00131 = Illinois - Administar 00140 = Iowa - Wellmark (term. 6/2000) 00150 = Kansas BC 00160 = Kentucky/Administar 00180 = Maine BC 00181 = Maine BC - Massachusetts 00190 = Maryland BC 00200 = Massachusetts BC - terminated 7/97 00210 = Michigan BC - terminated 9/94 00220 = Minnesota BC 00230 = Mississippi BC 00231 = Mississippi BC/LA 00232 = Mississippi BC 00241 = Missouri BC - terminated 9/92 00250 = Montana BC 00260 = Nebraska BC 00270 = New Hampshire/VT BC 00280 = New Jersey BC (term. 8/2000) 00290 = New Mexico BC - terminated 11/95 00308 = Empire BC 00310 = North Carolina BC 00320 = North Dakota BC 00332 = Community Mutual Ins Co; Ohio-Administar 00340 = Oklahoma BC 00350 = Oregon BC 00351 = Oregon BC/ID. 00355 = Oregon-CWF 00362 = Independence BC - terminated 8/97 00363 = Veritus, Inc (PITTS) 00370 = Rhode Island BC 00380 = South Carolina BC 00390 = Tennessee BC 00400 = Texas BC 00410 = Utah BC 00423 = Virginia BC; Trigon 00430 = Washington/Alaska BC 00450 = Wisconsin BC 00452 = Michigan - Wisconsin BC 00454 = United Government Services - Wisconsin BC (eff. 12/00) 00460 = Wyoming BC 00468 = N Carolina BC/CPRTIVA 00993 = BC/BS Assoc. 17120 = Hawaii Medical Service 1 FI_NUM_TB Fiscal Intermediary Number Table --------- -------------------------------- 50333 = Travelers; Connecticut United Healthcare (terminated - date unknown) 51051 = Aetna California - terminated 6/97 51070 = Aetna Connecticut - terminated 6/97 51100 = Aetna Florida - terminated 6/97 51140 = Aetna Illinois - terminated 6/97 51390 = Aetna Pennsylvania - terminated 6/97 52280 = Mutual of Omaha 57400 = Cooperative, San Juan, PR 61000 = Aetna 1 FI_RQST_CLM_CNCL_RSN_TB Claim Cancel Reason Code Table ----------------------- ------------------------------ C = Coverage Transfer D = Duplicate Billing H = Other or blank L = Combining two beneficiary master records P = Plan Transfer S = Scramble ************For Action Code 4 ******************* *********Effective with HHPPS - 10/00************ A = RAP/Final claim/LUPA is cancelled by Interme- diary. Does not delete episode. Do not set cancellation indicator. B = RAP/Final claim/LUPA is cancelled by Interme- diary. Does not delete episode. Set cancellation indicator to 1. E = RAP/Final claim/LUPA is cancelled by Interme- diary. Remove episode. F = RAP/Final claim/LUPA is cancelled by Provider. Remove episode. 1 GEO_SSA_STATE_TB State Table ---------------- ----------- 01 = Alabama 02 = Alaska 03 = Arizona 04 = Arkansas 05 = California 06 = Colorado 07 = Connecticut 08 = Delaware 09 = District of Columbia 10 = Florida 11 = Georgia 12 = Hawaii 13 = Idaho 14 = Illinois 15 = Indiana 16 = Iowa 17 = Kansas 18 = Kentucky 19 = Louisiana 20 = Maine 21 = Maryland 22 = Massachusetts 23 = Michigan 24 = Minnesota 25 = Mississippi 26 = Missouri 27 = Montana 28 = Nebraska 29 = Nevada 30 = New Hampshire 31 = New Jersey 32 = New Mexico 33 = New York 34 = North Carolina 35 = North Dakota 36 = Ohio 37 = Oklahoma 38 = Oregon 39 = Pennsylvania 40 = Puerto Rico 41 = Rhode Island 42 = South Carolina 43 = South Dakota 44 = Tennessee 45 = Texas 46 = Utah 47 = Vermont 48 = Virgin Islands 49 = Virginia 50 = Washington 51 = West Virginia 52 = Wisconsin 53 = Wyoming 54 = Africa 55 = Asia 56 = Canada & Islands 57 = Central America and West Indies 1 GEO_SSA_STATE_TB State Table ---------------- ----------- 58 = Europe 59 = Mexico 60 = Oceania 61 = Philippines 62 = South America 63 = U.S. Possessions 64 = American Samoa 65 = Guam 66 = Saipan 97 = Northern Marianas 98 = Guam 99 = With 000 county code is American Samoa; otherwise unknown 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- **Prior to 5/92** 01 = General practice 02 = General surgery 03 = Allergy (revised 10/91 to mean allergy/ immunology) 04 = Otology, laryngology, rhinology revised 10/91 to mean otolaryngology) 05 = Anesthesiology 06 = Cardiovascular disease (revised 10/91 to mean cardiology) 07 = Dermatology 08 = Family practice 09 = Gynecology--osteopaths only (deleted 10/91; changed to '16') 10 = Gastroenterology 11 = Internal medicine 12 = Manipulative therapy (osteopaths only) (revised 10/91 to mean osteopathic manipulative therapy) 13 = Neurology 14 = Neurological surgery (revised 10/91 to mean neurosurgery) 15 = Obstetrics--osteopaths only (deleted 10/91; changed to '16') 16 = OB-gynecology 17 = Ophthalmology, otology, laryngology rhinology--osteopaths only (deleted 10/91; changed to '18' if physicians practice is more than 50% ophthalmology or to '04' if physician's practice is more than 50% otolaryngology. If practice is 50/50, choose specialty with greater allowed charges. 18 = Ophthalmology 19 = Oral surgery (dentists only) 20 = Orthopedic surgery 21 = Pathologic anatomy, clinical pathology- osteopaths only (deleted 10/91; changed to '22') 22 = Pathology 23 = Peripheral vascular disease or surgery (deleted 10/91; changed to '76') 24 = Plastic surgery (revised to mean plastic and reconstructive surgery). 25 = Physical medicine and rehabilitation 26 = Psychiatry 27 = Psychiatry, neurology (osteopaths only) (deleted 10/91; changed to '86') 28 = Proctology (revised 10/91 to mean colorectal surgery). 29 = Pulmonary disease 30 = Radiology (revised 10/91 to mean diagnostic radiology) 31 = Roentgenology, radiology (osteopaths) (deleted 10/91; changed to '30') 32 = Radiation therapy--osteopaths (deleted 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- 10/91; changed to '92') 33 = Thoracic surgery 34 = Urology 35 = Chiropractor, licensed (revised 10/91 to mean chiropractic) 36 = Nuclear medicine 37 = Pediatrics (revised 10/91 to mean pediatric medicine) 38 = Geriatrics (revised 10/91 to mean geriatric medicine) 39 = Nephrology 40 = Hand surgery 41 = Optometrist - services related to condition of aphakia (revised 10/91 to mean optometrist) 42 = Certified nurse midwife (added 7/88) 43 = Certified registered nurse anesthetist (revised 10/91 to mean CRNA, anesthesia assistant) 44 = Infectious disease 46 = Endocrinology (added 10/91) 48 = Podiatry - surgery chiropody (revised 10/91 to mean podiatry) 49 = Miscellaneous (include ASCS) 51 = Medical supply company with C.O. certification (certified orthotist - certified by American Board for Certification in Prosthetics and Orthotics. 52 = Medical supply company with C.P. certification (certified prosthetist - certified by American Board for Certification in Prosthetics and Orthotics). 53 = Medical supply company with C.P.O. certification (certified prosthetist - orthotist - certified by American Board for Certification in Prosthetics and Orthotics). 54 = Medical supply company not included in 51, 52, or 53. 55 = Individual certified orthotist 56 = Individual certified prosthetist 57 = Individual certified prosthetist - orthotist 58 = Individuals not included in 55,56 or 57 59 = Ambulance service supplier (e.g. private ambulance companies, funeral homes, etc.) 60 = Public health or welfare agencies (federal, state, and local) 61 = Voluntary health or charitable agencies (e.g. National Cancer Society, National Heart Association, Catholic Charities) 62 = Psychologist--billing independently 63 = Portable X-ray supplier--billing independently (revised 10/91 to mean portable X-ray supplier) 64 = Audiologist (billing independently) 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- 65 = Physical therapist (independent practice) 66 = Rheumatology (added 10/91) 67 = Occupational therapist--independent practice 68 = Clinical psychologist 69 = Independent laboratory--billing independently (revised 10/91 to mean independent clinical laboratory -- billing independently) 70 = Clinic or other group practice, except Group Practice Prepayment Plan (GPPP) 71 = Group Practice Prepayment Plan - diagnostic X-ray (do not use after 1/92) 72 = Group Practice Prepayment Plan - diagnostic laboratory (do not use after 1/92) 73 = Group Practice Prepayment Plan - physiotherapy (do not use after 1/92) 74 = Group Practice Prepayment Plan - occupational therapy (do not use after 1/92) 75 = Group Practice Prepayment Plan - other medical care (do not use after 1/92) 76 = Peripheral vascular disease (added 10/91) 77 = Vascular surgery (added 10/91) 78 = Cardiac surgery (added 10/91) 79 = Addiction medicine (added 10/91) 8O = Clinical social worker (1991) 81 = Critical care-intensivists (added 10/91) 82 = Ophthalmology, cataracts specialty (added 10/91; used only until 5/92) 83 = Hematology/oncology (added 10/91) 84 = Preventive medicine (added 10/91) 85 = Maxillofacial surgery (added 10/91) 86 = Neuropsychiatry (added 10/91) 87 = All other (e.g. drug and department stores) (revised 10/91 to mean all other suppliers) 88 = Unknown (revised 10/91 to mean physician assistant) 90 = Medical oncology (added 10/91) 91 = Surgical oncology (added 10/91) 92 = Radiation oncology (added 10/91) 93 = Emergency medicine (added 10/91) 94 = Interventional radiology (added 10/91) 95 = Independent physiological laboratory (added 10/91) 96 = Unknown physician specialty (added 10/91) 99 = Unknown--incl. social worker's psychiatric services (revised 10/91 to mean unknown supplier/provider) --------------------------------------- **Effective 5/92** 00 = Carrier wide 01 = General practice 02 = General surgery 03 = Allergy/immunology 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- 04 = Otolaryngology 05 = Anesthesiology 06 = Cardiology 07 = Dermatology 08 = Family practice 09 = Gynecology (osteopaths only) (discontinued 5/92 use code 16) 10 = Gastroenterology 11 = Internal medicine 12 = Osteopathic manipulative therapy 13 = Neurology 14 = Neurosurgery 15 = Obstetrics (osteopaths only) (discontinued 5/92 use code 16) 16 = Obstetrics/gynecology 17 = Ophthalmology, otology, laryngology, rhinology (osteopaths only) (discontinued 5/92 use codes 18 or 04 depending on percentage of practice) 18 = Ophthalmology 19 = Oral surgery (dentists only) 20 = Orthopedic surgery 21 = Pathologic anatomy, clinical pathology (osteopaths only) (discontinued 5/92 use code 22) 22 = Pathology 23 = Peripheral vascular disease, medical or surgical (osteopaths only) (discontinued 5/92 use code 76) 24 = Plastic and reconstructive surgery 25 = Physical medicine and rehabilitation 26 = Psychiatry 27 = Psychiatry, neurology (osteopaths only) (discontinued 5/92 use code 86) 28 = Colorectal surgery (formerly proctology) 29 = Pulmonary disease 30 = Diagnostic radiology 31 = Roentgenology, radiology (osteopaths only) (discontinued 5/92 use code 30) 32 = Radiation therapy (osteopaths only) (discontinued 5/92 use code 92) 33 = Thoracic surgery 34 = Urology 35 = Chiropractic 36 = Nuclear medicine 37 = Pediatric medicine 38 = Geriatric medicine 39 = Nephrology 40 = Hand surgery 41 = Optometry (revised 10/93 to mean optometrist) 42 = Certified nurse midwife (eff 1/87) 43 = Crna, anesthesia assistant (eff 1/87) 44 = Infectious disease 45 = Mammography screening center 46 = Endocrinology (eff 5/92) 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- 47 = Independent Diagnostic Testing Facility (IDTF) (eff. 6/98) 48 = Podiatry 49 = Ambulatory surgical center (formerly miscellaneous) 50 = Nurse practitioner 51 = Medical supply company with certified orthotist (certified by American Board for Certification in Prosthetics And Orthotics) 52 = Medical supply company with certified prosthetist (certified by American Board for Certification In Prosthetics And Orthotics) 53 = Medical supply company with certified prosthetist-orthotist (certified by American Board for Certification in Prosthetics and Orthotics) 54 = Medical supply company not included in 51, 52, or 53. (Revised 10/93 to mean medical supply company for DMERC) 55 = Individual certified orthotist 56 = Individual certified prosthetist 57 = Individual certified prosthetist- orthotist 58 = Individuals not included in 55, 56, or 57 (revised 10/93 to mean medical supply company with registered pharmacist) 59 = Ambulance service supplier, e.G., private ambulance companies, funeral homes, etc. 60 = Public health or welfare agencies (federal, state, and local) 61 = Voluntary health or charitable agencies (e.G., National Cancer Society, National Heart Associiation, Catholic Charities) 62 = Psychologist (billing independently) 63 = Portable X-ray supplier 64 = Audiologist (billing independently) 65 = Physical therapist (independently practicing) 66 = Rheumatology (eff 5/92) Note: during 93/94 DMERC also used this to mean medical supply company with respiratory therapist 67 = Occupational therapist (independently practicing) 68 = Clinical psychologist 69 = Clinical laboratory (billing independently) 70 = Multispecialty clinic or group practice 71 = Diagnostic X-ray (GPPP) (not to be assigned after 5/92) 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- 72 = Diagnostic laboratory (GPPP) (not to be assigned after 5/92) 73 = Physiotherapy (GPPP) (not to be assigned after 5/92) 74 = Occupational therapy (GPPP) (not to be assigned after 5/92) 75 = Other medical care (GPPP) (not to assigned after 5/92) 76 = Peripheral vascular disease (eff 5/92) 77 = Vascular surgery (eff 5/92) 78 = Cardiac surgery (eff 5/92) 79 = Addiction medicine (eff 5/92) 80 = Licensed clinical social worker 81 = Critical care (intensivists) (eff 5/92) 82 = Hematology (eff 5/92) 83 = Hematology/oncology (eff 5/92) 84 = Preventive medicine (eff 5/92) 85 = Maxillofacial surgery (eff 5/92) 86 = Neuropsychiatry (eff 5/92) 87 = All other suppliers (e.g. drug and department stores) (note: DMERC used 87 to mean department store from 10/93 through 9/94; recoded eff 10/94 to A7; NCH cross-walked DMERC reported 87 to A7. 88 = Unknown supplier/provider specialty (note: DMERC used 87 to mean grocery store from 10/93 - 9/94; recoded eff 10/94 to A8; NCH cross-walked DMERC reported 88 to A8. 89 = Certified clinical nurse specialist 90 = Medical oncology (eff 5/92) 91 = Surgical oncology (eff 5/92) 92 = Radiation oncology (eff 5/92) 93 = Emergency medicine (eff 5/92) 94 = Interventional radiology (eff 5/92) 95 = Independent physiological laboratory (eff 5/92) 96 = Optician (eff 10/93) 97 = Physician assistant (eff 5/92) 98 = Gynecologist/oncologist (eff 10/94) 99 = Unknown physician specialty A0 = Hospital (eff 10/93) (DMERCs only) A1 = SNF (eff 10/93) (DMERCs only) A2 = Intermediate care nursing facility (eff 10/93) (DMERCs only) A3 = Nursing facility, other (eff 10/93) (DMERCs only) A4 = HHA (eff 10/93) (DMERCs only) A5 = Pharmacy (eff 10/93) (DMERCs only) A6 = Medical supply company with respiratory therapist (eff 10/93) (DMERCs only) A7 = Department store (for DMERC use: eff 10/94, but cross-walked from code 87 eff 10/93) A8 = Grocery store (for DMERC use: eff 10/94, but cross-walked from 1 HCFA_PRVDR_SPCLTY_TB HCFA Provider Specialty Table -------------------- ----------------------------- code 88 eff 10/93) 1 HCFA_TYPE_SRVC_TB HCFA Type of Service Table ----------------- -------------------------- 1 = Medical care 2 = Surgery 3 = Consultation 4 = Diagnostic radiology 5 = Diagnostic laboratory 6 = Therapeutic radiology 7 = Anesthesia 8 = Assistant at surgery 9 = Other medical items or services 0 = Whole blood only eff 01/96, whole blood or packed red cells before 01/96 A = Used durable medical equipment (DME) B = High risk screening mammography (obsolete 1/1/98) C = Low risk screening mammography (obsolete 1/1/98) D = Ambulance (eff 04/95) E = Enteral/parenteral nutrients/supplies (eff 04/95) F = Ambulatory surgical center (facility usage for surgical services) G = Immunosuppressive drugs H = Hospice services (discontinued 01/95) I = Purchase of DME (installment basis) (discontinued 04/95) J = Diabetic shoes (eff 04/95) K = Hearing items and services (eff 04/95) L = ESRD supplies (eff 04/95) (renal supplier in the home before 04/95) M = Monthly capitation payment for dialysis N = Kidney donor P = Lump sum purchase of DME, prosthetics, orthotics Q = Vision items or services R = Rental of DME S = Surgical dressings or other medical supplies (eff 04/95) T = Psychological therapy (term. 12/31/97) outpatient mental health limitation (eff. 1/1/98) U = Occupational therapy V = Pneumococcal/flu vaccine (eff 01/96), Pneumococcal/flu/hepatitis B vaccine (eff 04/95-12/95), Pneumococcal only before 04/95 W = Physical therapy Y = Second opinion on elective surgery (obsoleted 1/97) Z = Third opinion on elective surgery (obsoleted 1/97) 1 LINE_ADDTNL_CLM_DCMTN_IND_TB Line Additional Claim Documentation Indicator Table ---------------------------- --------------------------------------------------- 0 = No additional documentation 1 = Additional documentation submitted for non-DME EMC claim 2 = CMN/prescription/other documentation submitted which justifies medical necessity 3 = Prior authorization obtained and approved 4 = Prior authorization requested but not approved 5 = CMN/prescription/other documentation submitted but did not justify medical necessity 6 = CMN/prescription/other documentation submitted and approved after prior authorization rejected 7 = Recertification CMN/prescription/other documentation 1 LINE_PLC_SRVC_TB Line Place Of Service Table ---------------- --------------------------- **Prior To 1/92** 1 = Office 2 = Home 3 = Inpatient hospital 4 = SNF 5 = Outpatient hospital 6 = Independent lab 7 = Other 8 = Independent kidney disease treatment center 9 = Ambulatory A = Ambulance service H = Hospice M = Mental health, rural mental health N = Nursing home R = Rural codes --------------------------------------- **Effective 1/92** 11 = Office 12 = Home 21 = Inpatient hospital 22 = Outpatient hospital 23 = Emergency room - hospital 24 = Ambulatory surgical center 25 = Birthing center 26 = Military treatment facility 31 = Skilled nursing facility 32 = Nursing facility 33 = Custodial care facility 34 = Hospice 35 = Adult living care facilities (ALCF) (eff. NYD - added 12/3/97) 41 = Ambulance - land 42 = Ambulance - air or water 50 = Federally qualified health centers (eff. 10/1/93) 51 = Inpatient psychiatric facility 52 = Psychiatric facility partial hospitalization 53 = Community mental health center 54 = Intermediate care facility/mentally retarded 55 = Residential substance abuse treatment facility 56 = Psychiatric residential treatment center 60 = Mass immunizations center (eff. 9/1/97) 61 = Comprehensive inpatient rehabilitation facility 62 = Comprehensive outpatient rehabilitation facility 65 = End stage renal disease treatment facility 71 = State or local public health clinic 72 = Rural health clinic 81 = Independent laboratory 1 LINE_PLC_SRVC_TB Line Place Of Service Table ---------------- --------------------------- 99 = Other unlisted facility 1 LINE_PMT_IND_TB Line Payment Indicator Table --------------- ---------------------------- 1 = Actual charge 2 = Customary charge 3 = Prevailing charge (adjusted, unadjusted gap fill, etc) 4 = Other (ASC fees, radiology and outpatient limits, and non-payment because of denial. 5 = Lab fee schedule 6 = Physician fee schedule - full fee schedule amount 7 = Physician fee schedule - transition 8 = Clinical psychologist fee schedule 9 = DME and prosthetics/orthotics fee schedules (eff. 4/97) 1 LINE_PRCSG_IND_TB Line Processing Indicator Table ----------------- ------------------------------- A = Allowed B = Benefits exhausted C = Noncovered care D = Denied (existed prior to 1991; from BMAD) I = Invalid data L = CLIA (eff 9/92) M = Multiple submittal--duplicate line item N = Medically unnecessary O = Other P = Physician ownership denial (eff 3/92) Q = MSP cost avoided (contractor #88888) - voluntary agreement (eff. 1/98) R = Reprocessed--adjustments based on subsequent reprocessing of claim S = Secondary payer T = MSP cost avoided - IEQ contractor (eff. 7/76) U = MSP cost avoided - HMO rate cell adjustment (eff. 7/96) V = MSP cost avoided - litigation settlement (eff. 7/96) X = MSP cost avoided - generic Y = MSP cost avoided - IRS/SSA data match project Z = Bundled test, no payment (eff. 1/1/98) 1 LINE_PRVDR_PRTCPTG_IND_TB Line Provider Participating Indicator Table ------------------------- ------------------------------------------- 1 = Participating 2 = All or some covered and allowed expenses applied to deductible Participating 3 = Assignment accepted/non-participating 4 = Assignment not accepted/non-participating 5 = Assignment accepted but all or some covered and allowed expenses applied to deductible Non-participating. 6 = Assignment not accepted and all covered and allowed expenses applied to deductible non-participating. 7 = Participating provider not accepting assignment. 1 NCH_CLM_TYPE_TB NCH Claim Type Table --------------- -------------------- 10 = HHA claim 20 = Non swing bed SNF claim 30 = Swing bed SNF claim 40 = Outpatient claim 41 = Outpatient 'Full-Encounter' claim (available in NMUD) 42 = Outpatient 'Abbreviated-Encounter' claim (available in NMUD) 50 = Hospice claim 60 = Inpatient claim 61 = Inpatient 'Full-Encounter' claim 62 = Inpatient 'Abbreviated-Encounter claim (available in NMUD) 71 = RIC O local carrier non-DMEPOS claim 72 = RIC O local carrier DMEPOS claim 73 = Physician 'Full-Encounter' claim (available in NMUD) 81 = RIC M DMERC non-DMEPOS claim 82 = RIC M DMERC DMEPOS claim 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- A0X1 = (C) PHYSICIAN-SUPPLIER ZIP CODE A000 = (C) REIMB > $100,000 OR UNITS > 150 A002 = (C) CLAIM IDENTIFIER (CAN) A003 = (C) BENEFICIARY IDENTIFICATION (BIC) A004 = (C) PATIENT SURNAME BLANK A005 = (C) PATIENT 1ST INITIAL NOT-ALPHABETIC A006 = (C) DATE OF BIRTH IS NOT NUMERIC A007 = (C) INVALID GENDER (0, 1, 2) A008 = (C) INVALID QUERY-CODE (WAS CORRECTED) A025 = (C) FOR OV 4, TOB MUST = 13,83,85,73 A1X1 = (C) PERCENT ALLOWED INDICATOR A1X2 = (C) DT>97273,DG1=7611,DG<>103,163,1589 A1X3 = (C) DT>96365,DIAG=V725 A1X4 = (C) INVALID DIAGNOSTIC CODES C050 = (U) HOSPICE - SPELL VALUE INVALID D102 = (C) DME DATE OF BIRTH INVALID D2X2 = (C) DME SCREEN SAVINGS INVALID D2X3 = (C) DME SCREEN RESULT INVALID D2X4 = (C) DME DECISION IND INVALID D2X5 = (C) DME WAIVER OF PROV LIAB INVALID D3X1 = (C) DME NATIONAL DRUG CODE INVALID D4X1 = (C) DME BENE RESIDNC STATE CODE INVALID D4X2 = (C) DME OUT OF DMERC SERVICE AREA D4X3 = (C) DME STATE CODE INVALID D5X1 = (C) TOS INVALID FOR DME HCPCS D5X2 = (C) DME HCPCS NOC & NOC DESCRIP MISSING D5X3 = (C) DME INVALID USE OF MS MODIFIER D5X4 = (C) TOS9 NDC REQD WHEN HCPCS OMITTED D5X5 = (C) TOS9 NDC REQD FOR Q0127-130 HCPCS D5X6 = (C) TOS9 NDC/DIAGNOSIS CODE INVALID D6X1 = (C) DME SUPPLIER NUMBER MISSING D7X1 = (C) DME PURCHASE ALLOWABLE INVALID D919 = (C) CAPPED/PEN PUMPS,NUM OF SRVCS > 1 D921 = (C) SHOE HCPC W/O MOD RT,LT REQ U=2/4/6 XXXX = (D) SYS DUPL: HOST/BATCH/QUERY-CODE Y001 = (C) HCPCS R0075/UNITS>1/SERVICES=1 Y002 = (C) HCPCS R0075/UNITS=1/SERVICES>1 Y003 = (C) HCPCS R0075/UNITS=SERVICES Y010 = (C) TOB=13X/14X AND T.C.>$7,500 Y011 = (C) INP CLAIM/REIM > $75,000 Z001 = (C) RVNU 820-859 REQ COND CODE 71-76 Z002 = (C) CC M2 PRESENT/REIMB > $150,000 Z003 = (C) CC M2 PRESENT/UNITS > 150 Z004 = (C) CC M2 PRESENT/UNITS & REIM < MAX Z005 = (C) REIMB>99999 AND REIMB<150000 Z006 = (C) UNITS>99 AND UNITS<150 Z237 = (E) HOSPICE OVERLAP - DATE ZERO 0011 = (C) ACTION CODE INVALID 0013 = (C) CABG/PCOE AND INVALID ADMIT DATE 0014 = (C) DEMO NUM NOT=01-06,08,15,31 0015 = (C) ESRD PLAN BUT DEMO ID NOT = 15 0016 = (C) INVALID VA CLAIM 0017 = (C) DEMO=31,TOB<>11 OR SPEC<>08 0018 = (C) DEMO=31,ACT CD<>1/5 OR ENT CD<>1/5 0020 = (C) CANCEL ONLY CODE INVALID 0021 = (C) DEMO COUNT > 1 0301 = (C) INVALID HI CLAIM NUMBER 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 0302 = (C) BENE IDEN CDE (BIC) INVAL OR BLK 04A1 = (C) PATIENT SURNAME BLANK (PHYS/SUP) 04B1 = (C) PATIENT 1ST INITIAL NOT-ALPHABETIC 0401 = (C) BILL TYPE/PROVIDER INVALID 0402 = (C) BILL TYPE/REV CODE/PROVR RANGE 0406 = (C) MAMMOGRAPHY WITH NO HCPCS 76092 0407 = (C) RESPITE CARE BILL TYPE 34X,NO REV 66 0408 = (C) REV CODE 403 /TYPE 71X/ PROV3800-974 0410 = (C) IMMUNO DRUG OCCR-36,NO REV-25 OR 636 0412 = (C) BILL TYPE XX5 HAS ACCOM. REV. CODES 0413 = (C) CABG/PCOE BUT TOB = HHA,OUT,HOS 0414 = (C) VALU CD 61,MSA AMOUNT MISSING 0415 = (C) HOME HEALTH INCORRECT ALPHA RIC 05X4 = (C) UPIN REQUIRED FOR TYPE-OF-SERVICE 05X5 = (C) UPIN REQUIRED FOR DME HCPCS 0501 = (C) UNIQUE PHY IDEN. (UPIN) BLANK 0502 = (C) UNIQUE PHY IDEN. (UPIN) INVALID 0601 = (C) GENDER INVALID 0701 = (C) CONTRACTOR INVALID CARRIER/ETC 0702 = (C) PROVIDER NUMBER INCONSISTANT 0703 = (C) MAMMOGRAPHY FOR NOT FEMALE 0704 = (C) INVALID CONT FOR CABG DEMO 0705 = (C) INVALID CONT FOR PCOE DEMO 0901 = (C) INVALID DISP CODE OF 02 0902 = (C) INVALID DISP CODE OF SPACES 0903 = (C) INVALID DISP CODE 1001 = (C) PROF REVIEW/ACT CODE/BILL TYPE 13X2 = (C) MULTIPLE ITEMS FOR SAME SERVICE 1301 = (C) LINE COUNT NOT NUMERIC OR > 13 1302 = (C) RECORD LENGTH INVALID 1401 = (C) INVALID MEDICARE STATUS CODE 1501 = (C) ADMIT DATE/ENTRY CODE INVALID 1502 = (C) ADMIT DATE > STAY FROM DATE 1503 = (C) ADMIT DATE INVALID WITH THRU DATE 1504 = (C) ADM/FROM/THRU DATE > TODAYS DATE 1505 = (C) HCPCS W SERVICE DATES > 09-30-94 1601 = (C) INVESTIGATION IND INVALID 1701 = (C) SPLIT IND INVALID 1801 = (C) PAY-DENY CODE INVALID 1802 = (C) HEADER AMT AND NOT DENIED CLAIM 1803 = (C) MSP COST AVD/ALL MSP LI NOT SAME 1901 = (C) AB CROSSOVER IND INVALID 2001 = (C) HOSPICE OVERRIDE INVALID 2101 = (C) HMO-OVERRIDE/PATIENT-STAT INVALID 2102 = (C) FROM/THRU DATE OR KRON/PAT STAT 2201 = (C) FROM/THRU DATE OR HCPCS YR INVAL 2202 = (C) STAY-FROM DATE > THRU-DATE 2203 = (C) THRU DATE INVALID 2204 = (C) FROM DATE BEFORE EFFECTIVE DATE 2205 = (C) DATE YEARS DIFFERENT ON OUTPAT 2207 = (C) MAMMOGRAPHY BEFORE 1991 2301 = (C) DOCUMENT CNTL OR UTIL DYS INVALID 2302 = (C) COVERED DAYS INVALID OR INCONSIST 2303 = (C) COST REPORT DAYS > ACCOMIDATION 2304 = (C) UTIL DAYS = ZERO ON PATIENT BILL 2305 = (C) UTIL DAYS = INCONSISTENCIES 2306 = (C) UTIL DYS/NOPAY/REIMB INCONSISTENT 2307 = (C) COND=40,UTL DYS >0/VAL CDE A1,08,09 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 2308 = (C) NOPAY = R WHEN UTIL DAYS = ZERO 2401 = (C) NON-UTIL DAYS INVALID 2501 = (C) CLAIM RCV DT OR COINSURANCE INVAL 2502 = (C) COIN+LR>UTIL DAYS/RCPT DTE>CUR DTE 2503 = (C) COIN/TR TYP/UTIL DYS/RCPT DTE>PD/DEN 2504 = (C) COINSURANCE AMOUNT EXCESSIVE 2505 = (C) COINSURANCE RATE > ALLOWED AMOUNT 2506 = (C) COINSURANCE DAYS/AMOUNT INCONSIST 2507 = (C) COIN+LR DAYS > TOTAL DAYS FOR YR 2508 = (C) COINSURANCE DAYS INVALID FOR TRAN 2601 = (C) CLAIM PAID DT INVALID OR LIFE RES 2602 = (C) LR-DYS, NO VAL 08,10/PD/DEN>CUR+27 2603 = (C) LIFE RESERVE > RATE FOR CAL YEAR 2604 = (C) PPS BILL, NO DAY OUTLIER 2605 = (C) LIFE RESERVE RATE > DAILY RATE AVR. 28XA = (C) UTIL DAYS > FROM TO BENEF EXH 28XB = (C) BENEFITS EXH DATE > FROM DATE 28XC = (C) BENEFITS EXH DATE/INVALID TRANS TYPE 28XD = (C) OCCUR 23 WITH SPAN 70 ON INPAT HOSP 28XE = (C) MULTI BENE EXH DATE (OCCR A3,B3,C3) 28XF = (C) ACE DATE ON SNF (NOPAY =B, C, N, W) 28XG = (C) SPAN CD 70+4+6+9 NOT = NONUTIL DAYS 28XM = (C) OCC CD 42 DATE NOT = SRVCE THRU DTE 28XN = (C) INVALID OCC CODE 28X0 = (C) BENE EXH DATE OUTSIDE SERVICE DATES 28X1 = (C) OCCUR DATE INVALID 28X2 = (C) OCCUR = 20 AND TRANS = 4 28X3 = (C) OCCUR 20 DATE < ADMIT DATE 28X4 = (C) OCCUR 20 DATE > ADMIT + 12 28X5 = (C) OCCUR 20 AND ADMIT NOT = FROM 28X6 = (C) OCCUR 20 DATE < BENE EXH DATE 28X7 = (C) OCCUR 20 DATE+UTIL-COIN>COVERAGE 28X8 = (C) OCCUR 22 DATE < FROM OR > THRU 28X9 = (C) UTIL > FROM - THRU LESS NCOV 33X1 = (C) QUAL STAY DATES INVALID (SPAN=70) 33X2 = (C) QS FROM DATE NOT < THRU (SPAN=70) 33X3 = (C) QS DAYS/ADMISSION ARE INVALID 33X4 = (C) QS THRU DATE > ADMIT DATE (SPAN=70) 33X5 = (C) SPAN 70 INVALID FOR DATE OF SERVICE 33X6 = (C) TOB=18/21/28/51,COND=WO,HMO<>90091 33X7 = (C) TOB<>18/21/28/51,COND=WO 33X8 = (C) TOB=18/21/28/51,CO=WO,ADM DT<97001 33X9 = (C) TOB=32X SPAN 70 OR OCCR BO PRESENT 34X2 = (C) DEMO ID = 04 AND COND WO NOT SHOWN 3401 = (C) DEMO ID = 04 AND RIC NOT = 1 35X1 = (C) 60, 61, 66 & NON-PPS / 65 & PPS 35X2 = (C) COND = 60 OR 61 AND NO VALU 17 35X3 = (C) PRO APPROVAL COND C3,C7 REQ SPAN M0 36X1 = (C) SURG DATE < STAY FROM/ > STAY THRU 3701 = (C) ASSIGN CODE INVALID 3705 = (C) 1ST CHAR OF IDE# IS NOT ALPHA 3706 = (C) INVALID IDE NUMBER-NOT IN FILE 3710 = (C) NUM OF IDE# > REV 0624 3715 = (C) NUM OF IDE# < REV 0624 3720 = (C) IDE AND LINE ITEM NUMBER > 2 3801 = (C) AMT BENE PD INVALID 4001 = (C) BLOOD PINTS FURNISHED INVALID 4002 = (C) BLOOD FURNISHED/REPLACED INVALID 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 4003 = (C) BLOOD FURNISHED/VERIFIED/DEDUCT 4201 = (C) BLOOD PINTS UNREPLACED INVALID 4202 = (C) BLOOD PINTS UNREPLACED/BLOOD DED 4203 = (C) INVALID CPO PROVIDER NUMBER 4301 = (C) BLOOD DEDUCTABLE INVALID 4302 = (C) BLOOD DEDUCT/FURNISHED PINTS 4303 = (C) BLOOD DEDUCT > UNREPLACED BLOOD 4304 = (C) BLOOD DEDUCT > 3 - REPLACED 4501 = (C) PRIMARY DIAGNOSIS INVALID 46XA = (C) MSP VET AND VET AT MEDICARE 46XB = (C) MULTIPLE COIN VALU CODES (A2,B2,C2) 46XC = (C) COIN VALUE (A2,B2,C2) ON INP/SNF 46XG = (C) VALU CODE 20 INVALID 46XN = (C) VALUE CODE 37,38,39 INVALID 46XO = (C) VALUE CDE 38>0/VAL CDE 06 MISSNG 46XP = (C) BLD UNREP VS REV CDS AND/OR UNITS 46XQ = (C) VALUE CDE 37=39 AND 38 IS PRESENT 46XR = (C) BLD FIELDS VS REV CDE 380,381,382 46XS = (C) VALU CODE 39, AND 37 IS NOT PRESENT 46XT = (C) CABG/PCOE,VC<>Y1,Y2,Y3,Y4,VA NOT>0 46X1 = (C) VALUE AMOUNT INVALID 46X2 = (C) VALU 06 AND BLD-DED-PTS IS ZERO 46X3 = (C) VALU 06 AND TTL-CHGS=NC-CHGS(001) 46X4 = (C) VALU (A1,B1,C1): AMT > DEDUCT 46X5 = (C) DEDUCT VALUE (A1,B1,C1) ON SNF BILL 46X6 = (C) VALU 17 AND NO COND CODE 60 OR 61 46X7 = (C) OUTLIER(VAL 17) > REIMB + VAL6-16 46X8 = (C) MULTI CASH DED VALU CODES (A1,B1,C1) 46X9 = (C) DEMO ID=03,REQUIRED HCPCS NOT SHOWN 4600 = (C) CAPITAL TOTAL NOT = CAP VALUES 4601 = (C) CABG/PCOE, MSP CODE PRESENT 4603 = (C) DEMO ID = 03 AND RIC NOT=6,7 4901 = (C) PCOE/CABG,DEN CD NOT D 4902 = (C) PCOE/CABG BUT DME 50X1 = (C) RVCD=54,TOB<>13,23,32,33,34,83,85 50X2 = (C) REV CD=054X,MOD NOT = QM,QN 5051 = (E) EDB: NOMATCH ON 3 CHARACTERISTICS 5052 = (E) EDB: NOMATCH ON MASTER-ID RECORD 5053 = (E) EDB: NOMATCH ON CLAIM-NUMBER 51XA = (C) HCPCS EYEWARE & REV CODE NOT 274 51XC = (C) HCPCS REQUIRES DIAG CODE OF CANCER 51XD = (C) HCPCS REQUIRES UNITS > ZERO 51XE = (C) HCPCS REQUIRES REVENUE CODE 636 51XF = (C) INV BILL TYP/ANTI-CAN DRUG HCPCS 51XG = (C) HCPCS REQUIRES DIAG OF HEMOPHILL1A 51XH = (C) TOB 21X/P82=2/3/4;REV CD<9001,>9044 51XI = (C) TOB 21X/P82<>2/3/4:REV CD>8999<9045 51XJ = (C) TOB 21X/REV CD: SVC-FROM DT INVALID 51XK = (C) TOB 21X/P82=2/3/4,REV CD = NNX 51XL = (C) REV 0762/UNT>48,TOB NOT=12,13,85,83 51XM = (C) 21X,RC>9041/<9045,RC<>4/234 51XN = (C) 21X,RC>9032/<9042,RC<>4/234 51XP = (C) HHA RC DATE OF SRVC MISSING 51XQ = (C) NO RC 0636 OR DTE INVALID 51XR = (C) DEMO ID=01,RIC NOT=2 51XS = (C) DEMO ID=01,RUGS<>2,3,4 OR BILL<>21 51X0 = (C) REV CENTER CODE INVALID 51X1 = (C) REV CODE CHECK 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 51X2 = (C) REV CODE INCOMPATIBLE BILL TYPE 51X3 = (C) UNITS MUST BE > 0 51X4 = (C) INP:CHGS/YR-RATE,ETC; OUTP:PSYCH>YR 51X5 = (C) REVENUE NON-COVERED > TOTAL CHRGE 51X6 = (C) REV TOTAL CHARGES EQUAL ZERO 51X7 = (C) REV CDE 403 WTH NO BILL 14 23 71 85 51X8 = (C) MAMMOGRAPHY SUBMISSION INVALID 51X9 = (C) HCPCS/REV CODE/BILL TYPE 5100 = (U) TRANSITION SPELL / SNF 5160 = (U) LATE CHG HSP BILL STAY DAYS > 0 5166 = (U) PROVIDER NE TO 1ST WORK PRVDR 5167 = (U) PROVIDER 1 NE 2: FROM DT < START DT 5169 = (U) PROVIDER NE TO WORK PROVIDER 5177 = (U) PROVIDER NE TO WORK PROVIDER 5178 = (U) HOSPICE BILL THRU < DOLBA 5181 = (U) HOSP BILL OCCR 27 DISCREPANCY 5200 = (E) ENTITLEMENT EFFECTIVE DATE 5201 = (U) HOSP DATE DIFFERENCE NE 60 OR 90 5202 = (E) ENTITLEMENT HOSPICE EFFECTIVE DATE 5202 = (U) HOSPICE TRAILER ERROR 5203 = (E) ENTITLEMENT HOSPICE PERIODS 5203 = (U) HOSPICE START DATE ERROR 5204 = (U) HOSPICE DATE DIFFERENCE NE 90 5205 = (U) HOSPICE DATE DISCREPANCY 5206 = (U) HOSPICE DATE DISCREPANCY 5207 = (U) HOSPICE THRU > TERM DATE 2ND 5208 = (U) HOSPICE PERIOD NUMBER BLANK 5209 = (U) HOSPICE DATE DISCREPANCY 5210 = (E) ENTITLEMENT FRM/TRU/END DATES 5211 = (E) ENTITLEMENT DATE DEATH/THRU 5212 = (E) ENTITLEMENT DATE DEATH/THRU 5213 = (E) ENTITLEMENT DATE DEATH MBR 5220 = (E) ENTITLEMENT FROM/EFF DATES 5225 = (E) ENT INP PPS SPAN 70 DATES 5232 = (E) ENTL HMO NO HMO OVERRIDE CDE 5233 = (E) ENTITLEMENT HMO PERIODS 5234 = (E) ENTITLEMENT HMO NUMBER NEEDED 5235 = (E) ENTITLEMENT HMO HOSP+NO CC07 5236 = (E) ENTITLEMENT HMO HOSP + CC07 5237 = (E) ENTITLEMENT HOSP OVERLAP 5238 = (U) HOSPICE CLAIM OVERLAP > 90 5239 = (U) HOSPICE CLAIM OVERLAP > 60 524Z = (E) HOSP OVERLAP NO OVD NO DEMO 5240 = (U) HOSPICE DAYS STAY+USED > 90 5241 = (U) HOSPICE DAYS STAY+USED > 60 5242 = (C) INVALID CARRIER FOR RRB 5243 = (C) HMO=90091,INVALID SERVICE DTE 5244 = (E) DEMO CABG/PCOE MISSING ENTL 5245 = (C) INVALID CARRIER FOR NON RRB 525Z = (E) HMO/HOSP 6/7 NO OVD NO DEMO 5250 = (U) HOSPICE DOEBA/DOLBA 5255 = (U) HOSPICE DAYS USED 5256 = (U) HOSPICE DAYS USED > 999 526Y = (E) HMO/HOSP DEMO 5/15 REIMB > 0 526Z = (E) HMO/HOSP DEMO 5/15 REIMB = 0 527Y = (E) HMO/HOSP DEMO OVD=1 REIMB > 0 527Z = (E) HMO/HOSP DEMO OVD=1 REIMB = 0 5299 = (U) HOSPICE PERIOD NUMBER ERROR 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 5320 = (U) BILL > DOEBA AND IND-1 = 2 5350 = (U) HOSPICE DOEBA/DOLBA SECONDARY 5355 = (U) HOSPICE DAYS USED SECONDARY 5378 = (C) SERVICE DATE < AGE 50 5399 = (U) HOSPICE PERIOD NUM MATCH 5410 = (U) INPAT DEDUCTABLE 5425 = (U) PART B DEDUCTABLE CHECK 5430 = (U) PART B DEDUCTABLE CHECK 5450 = (U) PART B COMPARE MED EXPENSE 5460 = (U) PART B COMPARE MED EXPENSE 5499 = (U) MED EXPENSE TRAILER MISSING 5500 = (U) FULL DAYS/SNF-HOSP FULL DAYS 5510 = (U) COIN DAYS/SNF COIN DAYS 5515 = (U) FULL DAYS/COIN DAYS 5516 = (U) SNF FULL DAYS/SNF COIN DAYS 5520 = (U) LIFE RESERVE DAYS 5530 = (U) UTIL DAYS/LIFE PSYCH DAYS 5540 = (U) HH VISITS NE AFT PT B TRLR 5550 = (E) SNF LESS THAN PT A EFF DATE 5600 = (D) LOGICAL DUPE, COVERED 5601 = (D) LOGICAL DUPE, QRY-CDE, RIC 123 5602 = (D) LOGICAL DUPE, PANDE C, E OR I 5603 = (D) LOGICAL DUPE, COVERED 5605 = (D) POSS DUPE, OUTPAT REIMB 5606 = (D) POSS DUPE, HOME HEALTH COVERED U 5623 = (U) NON-PAY CODE IS P 57X1 = (C) PROVIDER SPECIALITY CODE INVALID 57X2 = (C) PHYS THERAPY/PROVIDER SPEC INVAL 57X3 = (C) PLACE/TYPE/SPECIALTY/REIMB IND 57X4 = (C) SPECIALTY CODE VS. HCPCS INVALID 5700 = (U) LINKED TO THREE SPELLS 5701 = (C) DEMO ID=02,RIC NOT = 5 5702 = (C) DEMO ID=02,INVALID PROVIDER NUM 58X1 = (C) PROVIDER TYPE INVALID 58X9 = (C) TYPE OF SERVICE INVALID 5802 = (C) REIMB > $150,000 5803 = (C) UNITS/VISITS > 150 5804 = (C) UNITS/VISITS > 99 59XA = (C) PROST ORTH HCPCS/FROM DATE 59XB = (C) HCPCS/FROM DATE/TYPE P OR I 59XC = (C) HCPCS Q0036,37,42,43,46/FROM DATE 59XD = (C) HCPCS Q0038-41/FROM DATE/TYPE 59XE = (C) HCPCS/MAMMOGRAPHY-RISK/ DIAGNOSIS 59XG = (C) CAPPED/FREQ-MAINT/PROST HCPCS 59XH = (C) HCPCS E0620/TYPE/DATE 59XI = (C) HCPCS E0627-9/ DATE < 1991 59XL = (C) HCPCS 00104 - TOS/POS 59X1 = (C) INVALID HCPCS/TOS COMBINATION 59X2 = (C) ASC IND/TYPE OF SERVICE INVALID 59X3 = (C) TOS INVALID TO MODIFIER 59X4 = (C) KIDNEY DONOR/TYPE/PLACE/REIMB 59X5 = (C) MAMMOGRAPHY FOR MALE 59X6 = (C) DRUG AND NON DRUG BILL LINE ITEMS 59X7 = (C) CAPPED-HCPCS/FROM DATE 59X8 = (C) FREQUENTLY MAINTAINED HCPCS 59X9 = (C) HCPCS E1220/FROM DATE/TYPE IS R 5901 = (U) ERROR CODE OF Q 60X1 = (C) ASSIGN IND INVALID 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 6000 = (U) ADJUSTMENT BILL SPELL DATA 6020 = (U) CURRENT SPELL DOEBA < 1990 6030 = (U) ADJUSTMENT BILL SPELL DATA 6035 = (U) ADJUSTMENT BILL THRU DTE/DOLBA 61X1 = (C) PAY PROCESS IND INVALID 61X2 = (C) DENIED CLAIM/NO DENIED LINE 61X3 = (C) PAY PROCESS IND/ALLOWED CHARGES 61X4 = (C) RATE MISSING OR NON-NUMERIC 6100 = (C) REV 0001 NOT PRESENT ON CLAIM 6101 = (C) REV COMPUTED CHARGES NOT=TOTAL 6102 = (C) REV COMPUTED NON-COVERED/NON-COV 6103 = (C) REV TOTAL CHARGES < PRIMARY PAYER 62XA = (C) PSYC OT PT/REIM/TYPE 62X1 = (C) DME/DATE/100% OR INVAL REIMB IND 62X6 = (C) RAD PATH/PLACE/TYPE/DATE/DED 62X8 = (C) KIDNEY DONO/TYPE/100% 62X9 = (C) PNEUM VACCINE/TYPE/100% 6201 = (C) TOTAL DEDUCT > CHARGES/NON-COV 6203 = (U) HOSPICE ADJUSTMENT PERIOD/DATE 6204 = (U) HOSPICE ADJUSTMENT THRU>DOLBA 6260 = (U) HOSPICE ADJUSTMENT STAY DAYS 6261 = (U) HOSPICE ADJUSTMENT DAYS USED 6265 = (U) HOSPICE ADJUSTMENT DAYS USED 6269 = (U) HOSPICE ADJUSTMENT PERIOD# (MAIN) 63X1 = (C) DEDUCT IND INVALID 63X2 = (C) DED/HCFA COINS IN PCOE/CABG 6365 = (U) HOSPICE ADJUSTMENT SECONDARY DAYS 6369 = (U) HOSPICE ADJUSTMENT PERIOD# (SECOND) 64X1 = (C) PROVIDER IND INVALID 6430 = (U) PART B DEDUCTABLE CHECK 65X1 = (C) PAYSCREEN IND INVALID 66?? = (D) POSS DUPE, CR/DB, DOC-ID 66XX = (D) POSS DUPE, CR/DB, DOC-ID 66X1 = (C) UNITS AMOUNT INVALID 66X2 = (C) UNITS IND > 0; AMT NOT VALID 66X3 = (C) UNITS IND = 0; AMT > 0 66X4 = (C) MT INDICATOR/AMOUNT 6600 = (U) ADJUSTMENT BILL FULL DAYS 6610 = (U) ADJUSTMENT BILL COIN DAYS 6620 = (U) ADJUSTMENT BILL LIFE RESERVE 6630 = (U) ADJUSTMENT BILL LIFE PSYCH DYS 67X1 = (C) UNITS INDICATOR INVALID 67X2 = (C) CHG ALLOWED > 0; UNITS IND = 0 67X3 = (C) TOS/HCPCS=ANEST, MTU IND NOT = 2 67X4 = (C) HCPCS = AMBULANCE, MTU IND NOT = 1 67X6 = (C) INVALID PROC FOR MT IND 2, ANEST 67X7 = (C) INVALID UNITS IND WITH TOS OF BLOOD 67X8 = (C) INVALID PROC FOR MT IND 4, OXYGEN 6700 = (U) ADJUSTMENT BILL FULL/SNF DAYS 6710 = (U) ADJUSTMENT BILL COIN/SNF DAYS 68X1 = (C) INVALID HCPCS CODE 68X2 = (C) MAMMOGRAPY/DATE/PROC NOT 76092 68X3 = (C) TYPE OF SERVICE = G /PROC CODE 68X4 = (C) HCPCS NOT VALID FOR SERVICE DATE 68X5 = (C) MODIFIER NOT VALID FOR HCPCS, ETC 68X6 = (C) TYPE SERVICE INVALID FOR HCPCS, ETC 68X7 = (C) ZX MOD REQ FOR THER SHOES/INS/MOD. 68X8 = (C) LINE ITEM INCORRECT OR DATE INVAL. 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 69XA = (C) MODIFIER NOT VALID FOR HCPCS/GLOBAL 69X3 = (C) PROC CODE MOD = LL / TYPE = R 69X6 = (C) PROC CODE MOD/NOT CAPPED 69X8 = (C) SPEC CODE NURSE PRACT, MOD INVAL 6901 = (C) KRON IND AND UTIL DYS EQUALS ZERO 6902 = (C) KRON IND AND NO-PAY CODE B OR N 6903 = (C) KRON IND AND INPATIENT DEDUCT = 0 6904 = (C) KRON IND AND TRANS CODE IS 4 6910 = (C) REV CODES ON HOME HEALTH 6911 = (C) REV CODE 274 ON OUTPAT AND HH ONLY 6912 = (C) REV CODE INVAL FOR PROSTH AND ORTHO 6913 = (C) REV CODE INVAL FOR OXYGEN 6914 = (C) REV CODE INVAL FOR DME 6915 = (C) PURCHASE OF RENT DME INVAL ON DATES 6916 = (C) PURCHASE OF RENT DME INVAL ON DATES 6917 = (C) PURCHASE OF LIFT CHAIR INVAL > 91000 6918 = (C) HCPCS INVALID ON DATE RANGES 6919 = (C) DME OXYGEN ON HH INVAL BEFORE 7/1/89 6920 = (C) HCPCS INVAL ON REV 270/BILL 32-33 6921 = (C) HCPCS ON REV CODE 272 BILL TYPE 83X 6922 = (C) HCPCS ON BILL TYPE 83X -NOT REV 274 6923 = (C) RENTAL OF DME CUSTOMIZE AND REV 291 6924 = (C) INVAL MODIFIER FOR CAPPED RENTAL 6925 = (C) HCPCS ALLOWED ON BILL TYPES 32X-34X 6929 = (U) ADJUSTMENT BILL LIFE RESERVE 6930 = (U) ADJUSTMENT BILL LIFE PSYCH DYS 7000 = (U) INVALID DOEBA/DOLBA 7002 = (U) LESS THAN 60/61 BETWEEN SPELLS 7010 = (E) TOB 85X/ELECTN PRD: COND CD 07 REQD 71X1 = (C) SUBMITTED CHARGES INVALID 71X2 = (C) MAMMOGRPY/PROC CODE MOD TC,26/CHG 72X1 = (C) ALLOWED CHGS INVALID 72X2 = (C) ALLOWED/SUBMITTED CHARGES/TYPE 72X3 = (C) DENIED LINE/ALLOWED CHARGES 73X1 = (C) SS NUMBER INVALID 73X2 = (C) CARRIER ASSIGNED PROV NUM MISSING 74X1 = (C) LOCALITY CODE INVAL FOR CONTRACT 76X1 = (C) PL OF SER INVAL ON MAMMOGRAPHY BILL 77X1 = (C) PLACE OF SERVICE INVALID 77X2 = (C) PHYS THERAPY/PLACE 77X3 = (C) PHYS THERAPY/SPECIALTY/TYPE 77X4 = (C) ASC/TYPE/PLACE/REIMB IND/DED IND 77X6 = (C) TOS=F, PL OF SER NOT = 24 7701 = (C) INCORRECT MODIFIER 7777 = (D) POSS DUPE, PART B DOC-ID 78XA = (C) MAMMOGRAPHY BEFORE 1991 78X1 = (C) THRU DATE INVALID 78X3 = (C) FROM DATE GREATER THAN THRU DATE 78X4 = (C) FROM DATE > RCVD DATE/PAY-DENY 78X5 = (C) FROM DATE > PAID DATE/TYPE/100% 78X7 = (C) LAB EDIT/TYPE/100%/FROM DATE 79X3 = (C) THRU DATE>RECD DATE/NOT DENIED 79X4 = (C) THRU DATE>PAID DATE/NOT DENIED 8000 = (U) MAIN & 2NDARY DOEBA < 01/01/90 8028 = (E) NO ENTITLEMENT 8029 = (U) HH BEFORE PERIOD NOT PRESENT 8030 = (U) HH BILL VISITS > PT A REMAINING 8031 = (U) HH PT A REMAINING > 0 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 8032 = (U) HH DOLBA+59 NOT GT FROM-DATE 8050 = (U) HH QUALIFYING INDICATOR = 1 8051 = (U) HH # VISITS NE AFT PT B APPLIED 8052 = (U) HH # VISITS NE AFT TRAILER 8053 = (U) HH BENEFIT PERIOD NOT PRESENT 8054 = (U) HH DOEBA/DOLBA NOT > 0 8060 = (U) HH QUALIFYING INDICATOR NE 1 8061 = (U) HH DATE NE DOLBA IN AFT TRLR 8062 = (U) HH NE PT-A VISITS REMAINING 81X1 = (C) NUM OF SERVICES INVALID 83X1 = (C) DIAGNOSIS INVALID 8301 = (C) HCPCS/GENDER DIAGNOSIS 8302 = (C) HCPCS G0101 V-CODE/SEX CODE 8304 = (C) BILL TYPE INVALID FOR G0123/4 84X1 = (C) PAP SMEAR/DIAGNOSIS/GENDER/PROC 84X2 = (C) INVALID DME START DATE 84X3 = (C) INVALID DME START DATE W/HCPCS 84X4 = (C) HCPCS G0101 V-CODE/SEX CODE 84X5 = (C) HCPCS CODE WITH INV DIAG CODE 86X8 = (C) CLIA REQUIRES NON-WAIVER HCPCS 88XX = (D) POSS DUPE, DOC-ID,UNITS,ENT,ALWD 9000 = (U) DOEBA/DOLBA CALC 9005 = (U) FULL/COINS HOSP DAYS CALC 9010 = (U) FULL/COINS SNF DAYS CALC 9015 = (U) LIFE RESERVE DAYS CALC 9020 = (U) LIFE PSYCH DAYS CALC 9030 = (U) INPAT DEDUCTABLE CALC 9040 = (U) DATA INDICATOR 1 SET 9050 = (U) DATA INDICATOR 2 SET 91X1 = (C) PATIENT REIMB/PAY-DENY CODE 92X1 = (C) PATIENT REIMB INVALID 92X2 = (C) PROVIDER REIMB INVALID 92X3 = (C) LINE DENIED/PATIENT-PROV REIMB 92X4 = (C) MSP CODE/AMT/DATE/ALLOWED CHARGES 92X5 = (C) CHARGES/REIMB AMT NOT CONSISTANT 92X7 = (C) REIMB/PAY-DENY INCONSISTANT 9201 = (C) UPIN REF NAME OR INITIAL MISSING 9202 = (C) UPIN REF FIRST 3 CHAR INVALID 9203 = (C) UPIN REF LAST 3 CHAR NOT NUMERIC 93X1 = (C) CASH DEDUCTABLE INVALID 93X2 = (C) DEDUCT INDICATOR/CASH DEDUCTIBLE 93X3 = (C) DENIED LINE/CASH DEDUCTIBLE 93X4 = (C) FROM DATE/CASH DEDUCTIBLE 93X5 = (C) TYPE/CASH DEDUCTIBLE/ALLOWED CHGS 9300 = (C) UPIN OTHER, NOT PRESENT 9301 = (C) UPIN NME MIS/DED TOT LI>0 FR DEN CLM 9302 = (C) UPIN OPERATING, FIRST 3 NOT NUMERIC 9303 = (C) UPIN L 3 CH NT NUM/DED TOT LI>YR DED 94A1 = (C) NON-COVERED FROM DATE INVALID 94A2 = (C) NON-COVERED FROM > THRU DATE 94A3 = (C) NON-COVERED THRU DATE INVALID 94A4 = (C) NON-COVERED THRU DATE > ADMIT 94A5 = (C) NON-COVERED THRU DATE/ADMIT DATE 94C1 = (C) PR-PSYCH DAYS INVALID 94C3 = (C) PR-PSYCH DAYS > PROVIDER LIMIT 94F1 = (C) REIMBURSEMENT AMOUNT INVALID 94F2 = (C) REIMBURSE AMT NOT 0 FOR HMO PAID 94G1 = (C) NO-PAY CODE INVALID 1 NCH_EDIT_TB NCH EDIT TABLE ----------- -------------- 94G2 = (C) NO-PAY CODE SPACE/NON-COVERD=TOTL 94G3 = (C) NO-PAY/PROVIDER INCONSISTANT 94G4 = (C) NO PAY CODE = R & REIMB PRESENT 94X1 = (C) BLOOD LIMIT INVALID 94X2 = (C) TYPE/BLOOD DEDUCTIBLE 94X3 = (C) TYPE/DATE/LIMIT AMOUNT 94X4 = (C) BLOOD DED/TYPE/NUMBER OF SERVICES 94X5 = (C) BLOOD/MSP CODE/COMPUTED LINE MAX 9401 = (C) BLOOD DEDUCTIBLE AMT > 3 9402 = (C) BLOOD FURNISHED > DEDUCTIBLE 9403 = (C) DATE OF BIRTH MISSING ON PRO-PAY 9404 = (C) INVALID GENDER CODE ON PRO-PAY 9407 = (C) INVALID DRG NUMBER 9408 = (C) INVALID DRG NUMBER (GLOBAL) 9409 = (C) HCFA DRG<>DRG ON BILL 9410 = (C) CABG/PCOE,INVALID DRG 95X1 = (C) MSP CODE G/DATE BEFORE 1/1/87 95X2 = (C) MSP AMOUNT APPLIED INVALID 95X3 = (C) MSP AMOUNT APPLIED > SUB CHARGES 95X4 = (C) MSP PRIMARY PAY/AMOUNT/CODE/DATE 95X5 = (C) MSP CODE = G/DATE BEFORE 1987 95X6 = (C) MSP CODE = X AND NOT AVOIDED 95X7 = (C) MSP CODE VALID, CABG/PCOE 96X1 = (C) OTHER AMOUNTS INVALID 96X2 = (C) OTHER AMOUNTS > PAT-PROV REIMB 97X1 = (C) OTHER AMOUNTS INDICATOR INVALID 97X2 = (C) GRUDMAN SW/GRUDMAN AMT NOT > 0 98X1 = (C) COINSURANCE INVALID 98X3 = (C) MSP CODE/TYPE/COIN AMT/ALLOW/CSH 98X4 = (C) DATE/MSP/TYPE/CASH DED/ALLOW/COI 98X5 = (C) DATE/ALLOW/CASH DED/REIMB/MSP/TYP 99XX = (D) POSS DUPE, PART B DOC-ID 9901 = (C) REV CODE INVALID OR TRAILER CNT=0 9902 = (C) ACCOMMODATION DAYS/FROM/THRU DATE 9903 = (C) NO CLINIC VISITS FOR RHC 9904 = (C) INCOMPATIBLE DATES/CLAIM TYPE 991X = (C) NO DATE OF SERVICE 9910 = (C) EDIT 9910 (NEW) 9911 = (C) BLOOD VERIFIED INVALID 9920 = (C) EDIT 9920 (NEW) 9930 = (C) EDIT 9930 (NEW) 9931 = (C) OUTPAT COINSURANCE VALUES 9933 = (C) RATE EXCEDES MAMMOGRAPHY LIMIT 9940 = (C) EDIT 9940 (NEW) 9942 = (C) EDIT 9942 (NEW) 9944 = (C) STAY FROM>97273,DIAG<>V103,163,7612 9945 = (C) SERVICE DATE < 98001 9946 = (C) INVALID DIAGNOSIS CODE 9947 = (C) INVALID DIAGNOSIS CODE 9948 = (C) STAY FROM>96365,DIAG=V725 9960 = (C) MED CHOICE BUT HMO DATA MISSING 9965 = (C) HMO PRESENT BUT MED CHOICE MISSING 9968 = (C) MED CHOICE NOT= HMO PLAN NUMBER 1 NCH_IP_PRO_APRVL_TYPE_TB NCH Inpatient Peer Review Organization Approval Type Table ------------------------ ---------------------------------------------------------- 1 = Approved by the PRO as billed - Code indicates that the claim has been reviewed by the PRO and has been fully approved including any day or cost outliers. 2 = Automatic approval - Does not apply to Medicare claim. 3 = Partial approval - Code indicates the bill has been reviewed by the PRO, and some portion (days or services) has been denied. The from/thru dates of the approved portion of the stay, excluding grace days and any period at a noncovered level of care are shown on the bill. 4 = Admission denied - Code indicates the patient's need for inpatient services was reviewed upon admission and the PRO found that the stay was not medically necessary. 5 = Post payment review - Code indicates that any medical review will be completed after the claim is paid. The bill may be a day outlier, part of the sample review, or may not be reviewed. 6 = Pre-admission authorization - Pre- admission authorization obtained, but services not reviewed by the PRO. 7 THRU 9 = Reserved. 1 NCH_NEAR_LINE_RIC_TB NCH Near-Line Record Identification Code Table -------------------- ---------------------------------------------- O = Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services) V = Part A institutional claim record (inpatient (IP), skilled nursing facility (SNF), christian science (CS), home health agency (HHA), or hospice) W = Part B institutional claim record (outpatient (OP), HHA) U = Both Part A and B institutional home health agency (HHA) claim records -- due to HHPPS and HHA A/B split. (effective 10/00) M = Part B DMEPOS claim record (processed by DME Regional Carrier) (effective 10/93) 1 NCH_PATCH_TB NCH Patch Table ------------ --------------- 01 = RRB Category Equatable BIC - changed (all claim types) -- applied during the Nearline 'G' conversion to claims with NCH weekly process date before 3/91. Prior to Version 'H', patch indicator stored in redefined Claim Edit Group, 3rd occurrence, position 2. 02 = Claim Transaction Code made consistent with NCH payment/edit RIC code (OP and HHA) -- effective 3/94, CWFMQA began patch. During 'H' conversion, patch applied to claims with NCH weekly process date prior to 3/94. Prior to version 'H', patch indicator stored in redefined Claim Edit Group, 4th occurrence, position 1. 03 = Garbage/nonnumeric Claim Total Charge Amount set to zeroes (Instnl) -- during the Version 'G' conversion, error occurred in the deriva- tion of this field where the claim was missing revenue center code = '0001'. In 1994, patch was applied to the OP and HHA SAFs only. (This SAF patch indicator was stored in the redefined Claim Edit Group, 4th occurrence, position 2). During the 'H' ocnversion, patch applied to Nearline claims where garbage or nonnumeric values. 04 = Incorrect bene residence SSA standard county code '999' changed (all claim types) -- applied during the Nearline 'G' conversion and ongoing through 4/21/94, calling EQSTZIP routine to claims with NCH weekly process date prior to 4/22/94. Prior to Version 'H' patch indicator stored in redefined Claim Edit Group, 3rd occurrence, position 4. 05 = Wrong century bene birth date corrected (all claim types) -- applied during Nearline 'H' conversion to all history where century greater than 1700 and less than 1850; if century less than 1700, zeroes moved. 06 = Inconsistent CWF bene medicare status code made consistent with age (all claim types) -- applied during Nearline 'H' conversion to all history and patched ongoing. Bene age is calculated to determine the correct value; if greater than 64, 1st position MSC ='1'; if less than 65, 1st position MSC = '2'. 07 = Missing CWF bene mediare status code derived (all claim types) -- applied during Nearline 'H' conversion to all history and patched ongoing, except claims with unknown DOB and/ or Claim From Date='0' (left blank). Bene age is calculated to determine missing value; if greater than 64, MSC='10'; if less than 65, MSC = '20'. 08 = Invalid NCH primary payer code set to blanks (Instnl) -- applied during Version 'H' con- version to claims with NCH weekly process date 10/1/93-10/30/95, where MSP values = 1 NCH_PATCH_TB NCH Patch Table ------------ --------------- invalid '0', '1', '2', '3' or '4' (caused by erroneous logic in HCFA program code, which was corrected on 11/1/95). 09 = Zero CWF claim accretion date replaced with NCH weekly process date (all claim types) -- applied during Version 'H' conversion to Instnl and DMERC claims; applied during Version 'G' conversion to non-institutional (non-DMERC) claims. Prior to Version 'H', patch indicator stored in redefined claim edit group, 3rd occurrence, position 1. 10 = Multiple Revenue Center 0001 (Outpatient, HHA and Hospice) -- patch applied to 1998 & 1999 Nearline and SAFs to delete any revenue codes that followed the first '0001' revenue center code. The edit was applied across all institutional claim types, including Inpatient/ SNF (the problem was only found with OP/HHA/ Hospice claims). The problem was corrected 6/25/99. 11 = Truncated claim total charge amount in the fixed portion replaced with the total charge amount in the revenue center 0001 amount field -- service years 1998 & 1999 patched during quarterly merge. The 1998 & 1999 SAFs were corrected when finalized in 7/99. The patch was done for records with NCH Daily Process Date 1/4/99 - 5/14/99. 12 = Missing claim-level HHA Total Visit Count -- service years 1998, 1999 & 2000 patch applied during Version 'I' conversion of both the Nearline and SAFs. Problem occurs in those claims recovered during the missing claims effort. 13 = Inconsistent Claim MCO Paid Switch made consistent with criteria used to identify an inpatient encounter claim -- if MCO paid switch equal to blank or '0' and ALL conditions are met to indicate an inpatient encounter claim (bene enrolled in a risk MCO during the service period), change the switch to a '1'. The patch was applied during the Version 'I' conversion, for claims back to 7/1/97 service thru date. 1 NCH_STATE_SGMT_TB NCH State Segment Table ----------------- ----------------------- 01 = Alabama 02 = Alaska 03 = Arizona 04 = Arkansas 05 = California 06 = Colorado 07 = Connecticut 08 = Delaware 09 = District of Columbia 10 = Florida 11 = Georgia 12 = Hawaii 13 = Idaho 14 = Illinois 15 = Indiana 16 = Iowa 17 = Kansas 18 = Kentucky 19 = Louisiana 20 = Maine 21 = Maryland 22 = Massachusetts 23 = Michigan 24 = Minnesota 25 = Mississippi 26 = Missouri 27 = Montana 28 = Nebraska 29 = Nevada 30 = New Hampshire 31 = New Jersey 32 = New Mexico 33 = New York 34 = North Carolina 35 = North Dakota 36 = Ohio 37 = Oklahoma 38 = Oregon 39 = Pennsylvania 40 = Puerto Rico 41 = Rhode Island 42 = South Carolina 43 = South Dakota 44 = Tennesee 45 = Texas 46 = Utah 47 = Vermont 48 = Virgin Islands 49 = Virginia 50 = Washington 51 = West Virginia 52 = Wisconsin 53 = Wyoming 54 = Africa 55 = Asia 56 = Canada 57 = Central America & West Indies 1 NCH_STATE_SGMT_TB NCH State Segment Table ----------------- ----------------------- 58 = Europe 59 = Mexico 60 = Oceania 61 = Philippines 62 = South America 63 = US Possessions 97 = Saipan - MP 98 = Guam 99 = American Samoa 1 PRVDR_NUM_TB Provider Number Table ------------ --------------------- - First two positions are the GEO SSA State Code. Exception: 55 = California 67 = Texas 68 = Florida - Positions 3 and sometimes 4 are used as a category identifier. The remaining positions are serial numbers. The following blocks of numbers are reserved for the facilities indicated (NOTE: may have different meanings dependent on the Type of Bill (TOB): 0001-0879 Short-term (general and specialty) hospitals where TOB = 11X; ESRD clinic where TOB = 72X 0880-0899 Reserved for hospitals participating in ORD demonstration projects where TOB = 11X; ESRD clinic where TOB = 72X 0900-0999 Multiple hospital component in a medical complex (numbers retired) where TOB = 11X; ESRD clinic where TOB = 72X 1000-1199 Reserved for future use 1200-1224 Alcohol/drug hospitals (excluded from PPS-numbers retired) where TOB = 11X; ESRD clinic where TOB = 72X 1225-1299 Medical assistance facilities (Montana project); ESRD clinic where TOB = 72X 1300-1399 Rural Primary Care Hospital (RCPH) - eff. 10/97 changed to Critical Access Hospitals (CAH) 1400-1499 Continuation of 4900-4999 series (CMHC) 1500-1799 Hospices 1800-1989 Federally Qualified Health Centers (FQHC) where TOB = 73X; SNF (IP PTB) where TOB = 22X; HHA where TOB = 32X, 33X, 34X 1990-1999 Christian Science Sanatoria (hospital services) 2000-2299 Long-term hospitals (excluded from PPS) 2300-2499 Chronic renal disease facilities (hospital based) 2500-2899 Non-hospital renal disease treatment centers 2900-2999 Independent special purpose renal dialysis facility (1) 3000-3024 Formerly tuberculosis hospitals (numbers retired) 3025-3099 Rehabilitation hospitals (excluded from PPS) 3100-3199 Continuation of Subunits of Nonprofit and Proprietary Home Health Agencies (7300-7399) Series (3) (eff. 4/96) 3200-3299 Continuation of 4800-4899 series (CORF) 1 PRVDR_NUM_TB Provider Number Table ------------ --------------------- 3300-3399 Children's hospitals (excluded from PPS) where TOB = 11X; ESRD clinic where TOB = 72X 3400-3499 Continuation of rural health clinics (provider-based) (3975-3999) 3500-3699 Renal disease treatment centers (hospital satellites) 3700-3799 Hospital based special purpose renal dialysis facility (1) 3800-3974 Rural health clinics (free-standing) 3975-3999 Rural health clinics (provider-based) 4000-4499 Psychiatric hospitals (excluded from PPS) 4500-4599 Comprehensive Outpatient Rehabilitation Facilities (CORF) 4600-4799 Community Mental Health Centers (CMHC); 9/30/91 - 3/31/97 used for clinic OPT where TOB = 74X 4800-4899 Continuation of 4500-4599 series (CORF) (eff. 10/95) 4900-4999 Continuation of 4600-4799 series (CMHC) (eff. 10/95); 9/30/91 - 3/31/97 used for clinic OPT where TOB = 74X 5000-6499 Skilled Nursing Facilities 6500-6989 CMHC / Outpatient physical therapy services where TOB = 74X; CORF where TOB = 75X 6990-6999 Christian Science Sanatoria (skilled nursing services) 7000-7299 Home Health Agencies (HHA) (2) 7300-7399 Subunits of 'nonprofit' and 'proprietary' Home Health Agencies (3) 7400-7799 Continuation of 7000-7299 series 7800-7999 Subunits of state and local governmental Home Health Agencies (3) 8000-8499 Continuation of 7400-7799 series (HHA) 8500-8899 Continuation of rural health center (provider based) (3400-3499) 8900-8999 Continuation of rural health center (free-standing) (3800-3974) 9000-9499 Continuation of 8000-8499 series (HHA) (eff. 10/95) 9500-9999 Reserved for future use (eff. 8/1/98) NOTE: 10/95-7/98 this series was assigned to HHA's but rescinded - no HHA's were ever assigned a number from this series. Exception: P001-P999 Organ procurement organization (1) These facilities (SPRDFS) will be assigned the same provider number whenever they are recertified. (2) The 6400-6499 series of provider numbers in Iowa (16), South Dakota (43) and Texas (45) 1 PRVDR_NUM_TB Provider Number Table ------------ --------------------- have been used in reducing acute care costs (RACC) experiments. (3) In Virginia (49), the series 7100-7299 has been reserved for statewide subunit components of the Virginia state home health agencies. (4) Parent agency must have a number in the 7000-7299, 7400-7799 or 8000-8499 series. NOTE: There is a special numbering system for units of hospitals that are excluded from prospective payment system (PPS) and hospitals with SNF swing-bed designation. An alpha character in the third position of the provider number identifies the type of unit or swing-bed designation as follows: S = Psychiatric unit (excluded from PPS) T = Rehabilitation unit (excluded from PPS) U = Short term/acute care swing-bed hospital V = Alcohol drug unit (prior to 10/87 only) W = Long term SNF swing-bed hospital (eff 3/91) Y = Rehab hospital swing-bed (eff 9/92) Z = Rural primary care swing-bed hospital There is also a special numbering system for assigning emergency hospital identification numbers (non participating hospitals). The sixth position of the provider number is as follows: E = Non-federal emergency hospital F = Federal emergency hospital 1 PTNT_DSCHRG_STUS_TB Patient Discharge Status Table ------------------- ------------------------------ 01 = Discharged to home/self care (routine charge). 02 = Discharged/transferred to other short term general hospital for inpatient care. 03 = Discharged/transferred to skilled nursing facility (SNF) - (For hospitals with an approved swing bed arrangement, use Code 61 - swing bed. For reporting discharges/transfers to a non-certified SNF, the hospital must use Code 04 - ICF. 04 = Discharged/transferred to intermediate care facility (ICF). 05 = Discharged/transferred to another type of institution for inpatient care (including distinct parts). 06 = Discharged/transferred to home care of organized home health service organization. 07 = Left against medical advice or discontinued care. 08 = Discharged/transferred to home under care of a home IV drug therapy provider. 09 = Admitted as an inpatient to this hospital (effective 3/1/91). In situa- tions where a patient is admitted before midnight of the third day following the day of an outpatient service, the out- patient services are considered inpatient. 20 = Expired (did not recover - Christian Science patient). 30 = Still patient. 40 = Expired at home (hospice claims only) 41 = Expired in a medical facility such as hospital, SNF, ICF, or freestanding hospice. (Hospice claims only) 42 = Expired - place unknown (Hospice claims only) 50 = Hospice - home (eff. 10/96) 51 = Hospice - medical facility (eff. 10/96) 61 = Discharged/transferred within this insti- tution to a hospital-based Medicare approved swing bed (to be implemented in 1999) 71 = Discharged/transferred/referred to another institution for outpatient services as specified by the discharge plan of care (to be implemented in 1999). 72 = Discharged/transferred/referred to this institution for outpatient services as specified by the discharge plan of care (to be implemented in 1999). 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ *******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES******* **************POSITIONS 1 & 2 OF ANSI CODE*************** CO = Contractual Obligations -- this group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, re- sulted in an adjustment. Generally, these adjust- ments are considered a write-off for the provider and are not billed to the patient. CR = Corrections and Reversals -- this group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim. OA = Other Adjustments -- this group code should be used when no other group code applies to the adjustment. PI = Payer Initiated Reductions -- this group code should be used when, in the opinion of the payer, the adjust- ment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR = Patient Responsibility -- this group should be used when the adjustment represents an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments. ***********Claim Adjustment Reason Codes*************** ***********POSITIONS 3 through 5 of ANSI CODE********** 1 = Deductible Amount 2 = Coinsurance Amount 3 = Co-pay Amount 4 = The procedure code is inconsistent with the modifier used or a required modifier is missing. 5 = The procedure code/bill type is inconsistent with the place of service. 6 = The procedure code is inconsistent with the patient's age. 7 = The procedure code is inconsistent with the patient's gender. 8 = The procedure code is inconsistent with the provider type. 9 = The diagnosis is inconsistent with the patient's age. 10 = The diagnosis is inconsistent with the patient's gender. 11 = The diagnosis is inconsistent with the procedure. 12 = The diagnosis is inconsistent with the provider type. 13 = the date of death precedes the date of service. 14 = The date of birth follows the date of service. 15 = Claim/service adjusted because the submitted auth- orization number is missing, invalid, or does not apply to the billed services or provider. 16 = Claim/service lacks information which is needed for 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ adjudication. 17 = Claim/service adjusted because requested information was not provided or was insufficient/incomplete. 18 = Duplicate claim/service. 19 = Claim denied because this is a work-related injury/ illness and thus the liability of the Worker's Com- pensation Carrier. 20 = Claim denied because this injury/illness is covered by the liability carrier. 21 = Claim denied because this injury/illness is the liability of the no-fault carrier. 22 = Claim adjusted because this care may be covered by another payer per coordination of benefits. 23 = Claim adjusted because charges have been paid by another payer. 24 = Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. 25 = Payment denied. Your Stop loss deductible has not been met. 26 = Expenses incurred prior to coverage. 27 = Expenses incurred after coverage terminated. 28 = Coverage not in effect at the time the service was provided. 29 = The time limit for filing has expired. 30 = Claim/service adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 31 = Claim denied as patient cannot be identified as our insured. 32 = Our records indicate that this dependent is not an eligible dependent as defined. 33 = Claim denied. Insured has no dependent coverage. 34 = Claim denied. Insured has no coverage for newborns. 35 = Benefit maximum has been reached. 36 = Balance does not exceed copayment amount. 37 = Balance does not exceed deductible amount. 38 = Services not provided or authorized by designated (network) providers. 39 = Services denied at the time authorization/pre-certi- fication was requested. 40 = Charges do not meet qualifications for emergency/urgent care. 41 = Discount agreed to in Preferred Provider contract. 42 = Charges exceed our fee schedule or maximum allowable amount. 43 = Gramm-Rudman reduction. 44 = Prompt-pay discount. 45 = Charges exceed your contracted/legislated fee arrange- ment. 46 = This (these) service(s) is(are) not covered. 47 = This (these) diagnosis(es) is(are) not covered, missing, or are invalid. 48 = This (these) procedure(s) is(are) not covered. 49 = These are non-covered services because this is a routine exam or screening procedure done in conjunc- tion with a routine exam. 50 = These are non-covered services because this is not deemed a 'medical necessity' by the payer. 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ 51 = These are non-covered services because this a pre- existing condition. 52 = The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. 53 = Services by an immediate relative or a member of the same household are not covered. 54 = Multiple physicians/assistants are not covered in this case. 55 = Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer. 56 = Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by payer. 57 = Claim/service adjusted because the payer deems the information submitted does not support this level of service, this many services, this length of service, or this dosage. 58 = Claim/service adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. 59 = Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. 60 = Charges for outpatient services with the proximity to inpatient services are not covered. 61 = Charges adjusted as penalty for failure to obtain second surgical opinion. 62 = Claim/service denied/reduced for absence of, or exceeded, precertification/authorization. 63 = Correction to a prior claim. INACTIVE 64 = Denial reversed per Medical Review. INACTIVE 65 = Procedure code was incorrect. This payment reflects the correct code. INACTIVE 66 = Blood Deductible. 67 = Lifetime reserve days. INACTIVE 68 = DRG weight. INACTIVE 69 = Day outlier amount. 70 = Cost outlier amount. 71 = Primary Payer amount. 72 = Coinsurance day. INACTIVE 73 = Administrative days. INACTIVE 74 = Indirect Medical Education Adjustment. 75 = Direct Medical Education Adjustment. 76 = Disproportionate Share Adjustment. 77 = Covered days. INACTIVE 78 = Non-covered days/room charge adjustment. 79 = Cost report days. INACTIVE 80 = Outlier days. INACTIVE 81 = Discharges. INACTIVE 82 = PIP days. INACTIVE 83 = Total visits. INACTIVE 84 = Capital adjustments. INACTIVE 85 = Interest amount. INACTIVE 86 = Statutory adjustment. INACTIVE 87 = Transfer amounts. 88 = Adjustment amount represents collection against receivable created in prior overpayment. 89 = Professional fees removed from charges. 90 = Ingredient cost adjustment. 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ 91 = Dispensing fee adjustment. 92 = Claim paid in full. INACTIVE 93 = No claim level adjustment. INACTIVE 94 = Process in excess of charges. 95 = Benefits adjusted. Plan procedures not followed. 96 = Non-covered charges. 97 = Payment is included in allowance for another service/procedure. 98 = The hospital must file the Medicare claim for this inpatient non-physician service. INACTIVE 99 = Medicare Secondary Payer Adjustment Amount. INACTIVE 100 = Payment made to patient/insured/responsible party. 101 = Predetermination: anticipated payment upon comple- tion of services or claim ajudication. 102 = Major medical adjustment. 103 = Provider promotional discount (i.e. Senior citizen discount). 104 = Managed care withholding. 105 = Tax withholding. 106 = Patient payment option/election not in effect. 107 = Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim. 108 = Claim/service reduced because rent/purchase guidelines were not met. 109 = Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 110 = Billing date predates service date. 111 = Not covered unless the provider accepts assignment. 112 = Claim/service adjusted as not furnished directly to the patient and/or not documented. 113 = Claim denied because service/procedure was provided outside the United States or as a result of war. 114 = Procedure/product not approved by the Food and Drug Administration. 115 = Claim/service adjusted as procedure postponed or canceled. 116 = Claim/service denied. The advance indemnification notice signed by the patient did not comply with requirements. 117 = Claim/service adjusted because transportation is only covered to the closest facility that can provide the necessary care. 118 = Charges reduced for ESRD network support. 119 = Benefit maximum for this time period has been reached. 120 = Patient is covered by a managed care plan. INACTIVE 121 = Indemnification adjustment. 122 = Psychiatric reduction. 123 = Payer refund due to overpayment. INACTIVE 124 = Payer refund amount - not our patient. INACTIVE 125 = Claim/service adjusted due to a submission/billing error(s). 126 = Deductible - Major Medical. 127 = Coinsurance - Major Medical. 128 = Newborn's services are covered in the mother's allowance. 129 = Claim denied - prior processing information appears incorrect. 130 = Paper claim submission fee. 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ 131 = Claim specific negotiated discount. 132 = Prearranged demonstration project adjustment. 133 = The disposition of this claim/service is pending further review. 134 = Technical fees removed from charges. 135 = Claim denied. Interim bills cannot be processed. 136 = Claim adjusted. Plan procedures of a prior payer were not followed. 137 = Payment/Reduction for Regulatory Surcharges, Assess- ments, Allowances or Health Related Taxes. 138 = Claim/service denied. Appeal procedures not followed or time limits not met. 139 = Contracted funding agreement - subscriber is employed by the provider of services. 140 = Patient/Insured health identification number and name do not match. 141 = Claim adjustment because the claim spans eligible and ineligible periods of coverage. 142 = Claim adjusted by the monthly Medicaid patient liability amount. A0 = Patient refund amount A1 = Claim denied charges. A2 = Contractual adjustment. A3 = Medicare Secondary Payer liability met. INACTIVE A4 = Medicare Claim PPS Capital Day Outlier Amount. A5 = Medicare Claim PPS Capital Cost Outlier Amount. A6 = Prior hospitalization or 30 day transfer requirement not met. A7 = Presumptive Payment Adjustment. A8 = Claim denied; ungroupable DRG. B1 = Non-covered visits. B2 = Covered visits. INACTIVE B3 = Covered charges. INACTIVE B4 = Late filing penalty. B5 = Claim/service adjusted because coverage/program guidelines were not met or were exceeded. B6 = This service/procedure is adjusted when performed/ billed by this type of provider, by this type of facility, or by a provider of this specialty. B7 = This provider was not certified/eligible to be paid for this procedure/service on this date of service. B8 = Claim/service not covered/reduced because alter- native services were available, and should have been utilized. B9 = Services not covered because the patient is en- rolled in a Hospice. B10 = Allowed amount has been reduced because a com- ponent of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. B11 = The claim/service has been transferred to the proper payer/processor for processing. Claim/ service not covered by this payer/processor. B12 = Services not documented in patients' medical re- cords. B13 = Previously paid. Payment for this claim/service may have been provided in a previous payment. 1 REV_CNTR_ANSI_TB Revenue Center ANSI Code Table ---------------- ------------------------------ B14 = Claim/service denied because only one visit or consultation per physician per day is covered. B15 = Claim/service adjusted because this procedure/ service is not paid separately. B16 = Claim/service adjusted because 'New Patient' qualifications were not met. B17 = Claim/service adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B18 = Claim/service denied because this procedure code/ modifier was invalid on the date of service or claim submission. B19 = Claim/service adjusted because of the finding of a Review Organization. INACTIVE B20 = Charges adjusted because procedure/service was partially or fully furnished by another provider. B21 = The charges were reduced because the service/care was partially furnished by another physician. INACTIVE B22 = This claim/service is adjusted based on the diagnosis. B23 = Claim/service denied because this provider has failed an aspect of a proficiency testing program. W1 = Workers Compensation State Fee Schedule Adjustment. 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0001 = Photochemotherapy 0002 = Fine needle Biopsy/Aspiration 0003 = Bone Marrow Biopsy/Aspiration 0004 = Level I Needle Biopsy/ Aspiration Except Bone Marrow 0005 = Level II Needle Biopsy /Aspiration Except Bone Marrow 0006 = Level I Incision & Drainage 0007 = Level II Incision & Drainage 0008 = Level III Incision & Drainage 0009 = Nail Procedures 0010 = Level I Destruction of Lesion 0011 = Level II Destruction of Lesion 0012 = Level I Debridement & Destruction 0013 = Level II Debridement & Destruction 0014 = Level III Debridement & Destruction 0015 = Level IV Debridement & Destruction 0016 = Level V Debridement & Destruction 0017 = Level VI Debridement & Destruction 0018 = Biopsy Skin, Subcutaneous Tissue or Mucous Membrane 0019 = Level I Excision/ Biopsy 0020 = Level II Excision/ Biopsy 0021 = Level III Excision/ Biopsy 0022 = Level IV Excision/ Biopsy 0023 = Exploration Penetrating Wound 0024 = Level I Skin Repair 0025 = Level II Skin Repair 0026 = Level III Skin Repair 0027 = Level IV Skin Repair 0029 = Incision/Excision Breast 0030 = Breast Reconstruction/Mastectomy 0031 = Hyperbaric Oxygen 0032 = Placement Transvenous Catheters/Arterial Cutdown 0033 = Partial Hospitalization 0040 = Arthrocentesis & Ligament/Tendon Injection 0041 = Arthroscopy 0042 = Arthroscopically-Aided Procedures 0043 = Closed Treatment Fracture Finger/Toe/Trunk 0044 = Closed Treatment Fracture/Dislocation Except Finger/Toe/Trunk 0045 = Bone/Joint Manipulation Under Anesthesia 0046 = Open/Percutaneous Treatment Fracture or Dislocation 0047 = Arthroplasty without Prosthesis 0048 = Arthroplasty with Prosthesis 0049 = Level I Musculoskeletal Procedures Except Hand and Foot 0050 = Level II Musculoskeletal Procedures Except Hand and Foot 0051 = Level III Musculoskeletal Procedures Except Hand and Foot 0052 = Level IV Musculoskeletal Procedures Except Hand and Foot 0053 = Level I Hand Musculoskeletal Procedures 0054 = Level II Hand Musculoskeletal Procedures 0055 = Level I Foot Musculoskeletal Procedures 0056 = Level II Foot Musculoskeletal Procedures 0057 = Bunion Procedures 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0058 = Level I Strapping and Cast Application 0059 = Level II Strapping and Cast Application 0060 = Manipulation Therapy 0070 = Thoracentesis/Lavage Procedures 0071 = Level I Endoscopy Upper Airway 0072 = Level II Endoscopy Upper Airway 0073 = Level III Endoscopy Upper Airway 0074 = Level IV Endoscopy Upper Airway 0075 = Level V Endoscopy Upper Airway 0076 = Endoscopy Lower Airway 0077 = Level I Pulmonary Treatment 0078 = Level II Pulmonary Treatment 0079 = Ventilation Initiation and Management 0080 = Diagnostic Cardiac Catheterization 0081 = Non-Coronary Angioplasty or Atherectomy 0082 = Coronary Atherectomy 0083 = Coronary Angiosplasty 0084 = Level I Electrophysiologic Evaluation 0085 = Level II Electrophysiologic Evaluation 0086 = Ablate Heart Dysrhythm Focus 0087 = Cardiac Electrophysiologic Recording/Mapping 0088 = Thrombectomy 0089 = Level I Implantation/Removal/Revision of Pacemaker, AICD Vascular Device 0090 = Level II Implantation/Removal/Revision of Pacemaker, AICD Vascular Device 0091 = Level I Vascular Ligation 0092 = Level II Vascular Ligation 0093 = Vascular Repair/Fistula Construction 0094 = Resuscitation and Cardioversion 0095 = Cardiac Rehabilitation 0096 = Non-Invasive Vascular Studies 0097 = Cardiovascular Stress Test 0098 = Injection of Sclerosing Solution 0099 = Continuous Cardiac Monitoring 0100 = Continuous ECG 0101 = Tilt Table Evaluation 0102 = Electronic Analysis of Pacemakers/other Devices 0109 = Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant 0110 = Transfusion 0111 = Blood Product Exchange 0112 = Extracorporeal Photopheresis 0113 = Excision Lymphatic System 0114 = Thyroid/Lymphadenectomy Procedures 0116 = Chemotherapy Administration by Other Technique Except Infusion 0117 = Chemotherapy Administration by Infusion Only 0118 = Chemotherapy Administration by Both Infusion and Other Technique 0120 = Infusion Therapy Except Chemotherapy 0121 = Level I Tube changes and Repositioning 0122 = Level II Tube changes and Repositioning 0123 = Level III Tube changes and Repositioning 0130 = Level I Laparoscopy 0131 = Level II Laparoscopy 0132 = Level III Laparoscopy 0140 = Esophageal Dilation without Endoscopy 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0141 = Upper GI Procedures 0142 = Small Intestine Endoscopy 0143 = Lower GI Endoscopy 0144 = Diagnostic Anoscopy 0145 = Therapeutic Anoscopy 0146 = Level I Sigmoidoscopy 0147 = Level II Sigmoidoscopy 0148 = Level I Anal/Rectal Procedure 0149 = Level II Anal/Rectal Procedure 0150 = Level III Anal/Rectal Procedure 0151 = Endoscopic Retrograde Cholangio-Pancreatography (ERCP) 0152 = Percutaneous Biliary Endoscopic Procedures 0153 = Peritoneal and Abdominal Procedures 0154 = Hernia/Hydrocele Procedures 0157 = Colorectal Cancer Screening: Barium Enema (Not subject to National coinsurance) 0158 = Colorectal Cancer Screening: Colonoscopy Not subject to National coinsurance. Minimum unadjusted coinsurance is 25% of the payment rate. Payment rate is lower of the HOPD payment rate or the Ambulatory Surgical Center payment. 0159 = Colorectal Cancer Screening: Flexible Sigmoidoscopy Not subject to National coinsurance. Minimum unadjusted coinsurance is 25% of the payment rate. Payment rate is lower of the HOPD payment rate or the Ambulatory Surgical Center payment. 0160 = Level I Cystourethroscopy and other Genitourinary Procedures 0161 = Level II Cystourethroscopy and other Genitourinary Procedures 0162 = Level III Cystourethroscopy and other Genitourinary Procedures 0163 = Level IV Cystourethroscopy and other Genitourinary Procedures 0164 = Level I Urinary and Anal Procedures 0165 = Level II Urinary and Anal Procedures 0166 = Level I Urethral Procedures 0167 = Level II Urethral Procedures 0168 = Level III Urethral Procedures 0169 = Lithotripsy 0170 = Dialysis for Other Than ESRD Patients 0180 = Circumcision 0181 = Penile Procedures 0182 = Insertion of Penile Prosthesis 0183 = Testes/Epididymis Procedures 0184 = Prostate Biopsy 0190 = Surgical Hysteroscopy 0191 = Level I Female Reproductive Procedures 0192 = Level II Female Reproductive Procedures 0193 = Level III Female Reproductive Procedures 0194 = Level IV Female Reproductive Procedures 0195 = Level V Female Reproductive Procedures 0196 = Dilatation & Curettage 0197 = Infertility Procedures 0198 = Pregnancy and Neonatal Care Procedures 0199 = Vaginal Delivery 0200 = Therapeutic Abortion 0201 = Spontaneous Abortion 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0210 = Spinal Tap 0211 = Level I Nervous System Injections 0212 = Level II Nervous System Injections 0213 = Extended EEG Studies and Sleep Studies 0214 = Electroencephalogram 0215 = Level I Nerve and Muscle Tests 0216 = Level II Nerve and Muscle Tests 0217 = Level III Nerve and Muscle Tests 0220 = Level I Nerve Procedures 0221 = Level II Nerve Procedures 0222 = Implantation of Neurological Device 0223 = Level I Revision/Removal Neurological Device 0224 = Level II Revision/Removal Neurological Device 0225 = Implantation of Neurostimulator Electrodes 0230 = Level I Eye Tests 0231 = Level II Eye Tests 0232 = Level I Anterior Segment Eye 0233 = Level II Anterior Segment Eye 0234 = Level III Anterior Segment Eye Procedures 0235 = Level I Posterior Segment Eye Procedures 0236 = Level II Posterior Segment Eye Procedures 0237 = Level III Posterior Segment Eye Procedures 0238 = Level I Repair and Plastic Eye Procedures 0239 = Level II Repair and Plastic Eye Procedures 0240 = Level III Repair and Plastic Eye Procedures 0241 = Level IV Repair and Plastic Eye Procedures 0242 = Level V Repair and Plastic Eye Procedures 0243 = Strabismus/Muscle Procedures 0244 = Corneal Transplant 0245 = Cataract Procedures without IOL Insert 0246 = Cataract Procedures with IOL Insert 0247 = Laser Eye Procedures Except Retinal 0248 = Laser Retinal Procedures 0250 = Nasal Cauterization/Packing 0251 = Level I ENT Procedures 0252 = Level II ENT Procedures 0253 = Level III ENT Procedures 0254 = Level IV ENT Procedures 0256 = Level V ENT Procedures 0257 = Implantation of Cochlear Device 0258 = Tonsil and Adenoid Procedures 0260 = Level I Plain Film Except Teeth 0261 = Level II Plain Film Except Teeth Including Bone Density Measurement 0262 = Plain Film of Teeth 0263 = Level I Miscellaneous Radiology Procedures 0264 = Level II Miscellaneous Radiology Procedures 0265 = Level I Diagnostic Ultrasound Except Vascular 0266 = Level II Diagnostic Ultrasound Except Vascular 0267 = Vascular Ultrasound 0268 = Guidance Under Ultrasound 0269 = Echocardiogram Except Transesophageal 0270 = Transesophageal Echocardiogram 0271 = Mammography 0272 = Level I Fluoroscopy 0273 = Level II Fluoroscopy 0274 = Myelography 0275 = Arthrography 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0276 = Level I Digestive Radiology 0277 = Level II Digestive Radiology 0278 = Diagnostic Urography 0279 = Level I Diagnostic Angiography and Venography Except Extremity 0280 = Level II Diagnostic Angiography and Venography Except Extremity 0281 = Venography of Extremity 0282 = Level I Computerized Axial Tomography 0283 = Level II Computerized Axial Tomography 0284 = Magnetic Resonance Imaging 0285 = Positron Emission Tomography (PET) 0286 = Myocardial Scans 0290 = Standard Non-Imaging Nuclear Medicine 0291 = Level I Diagnostic Nuclear Medicine Excluding Myocardial Scans 0292 = Level II Diagnostic Nuclear Medicine Excluding Myocardial Scans 0294 = Level I Therapeutic Nuclear Medicine 0295 = Level II Therapeutic Nuclear Medicine 0296 = Level I Therapeutic Radiologic Procedures 0297 = Level II Therapeutic Radiologic Procedures 0300 = Level I Radiation Therapy 0301 = Level II Radiation Therapy 0302 = Level III Radiation Therapy 0303 = Treatment Device Construction 0304 = Level I Therapeutic Radiation Treatment Preparation 0305 = Level II Therapeutic Radiation Treatment Preparation 0310 = Level III Therapeutic Radiation Treatment Preparation 0311 = Radiation Physics Services 0312 = Radioelement Applications 0313 = Brachytherapy 0314 = Hyperthermic Therapies 0320 = Electroconvulsive Therapy 0321 = Biofeedback and Other Training 0322 = Brief Individual Psychotherapy 0323 = Extended Individual Psychotherapy 0324 = Family Psychotherapy 0325 = Group Psychotherapy 0330 = Dental Procedures 0340 = Minor Ancillary Procedures 0341 = Immunology Tests 0342 = Level I Pathology 0343 = Level II Pathology 0344 = Level III Pathology 0354 = Administration of Influenza Vaccine (Not subject to national coinsurance) 0355 = Level I Immunizations 0356 = Level II Immunizations 0357 = Level III Immunizations 0358 = Level IV Immunizations 0359 = Injections 0360 = Level I Alimentary Tests 0361 = Level II Alimentary Tests 0362 = Fitting of Vision Aids 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0363 = Otorhinolaryngologic Function Tests 0364 = Level I Audiometry 0365 = Level II Audiometry 0366 = Electrocardiogram (ECG) 0367 = Level I Pulmonary Test 0368 = Level II Pulmonary Test 0369 = Level III Pulmonary Test 0370 = Allergy Tests 0371 = Allergy Injections 0372 = Therapeutic Phlebotomy 0373 = Neuropsychological Testing 0374 = Monitoring Psychiatric Drugs 0600 = Low Level Clinic Visits 0601 = Mid Level Clinic Visits 0602 = High Level Clinic Visits 0603 = Interdisciplinary Team Conference 0610 = Low Level Emergency Visits 0611 = Mid Level Emergency Visits 0612 = High Level Emergency Visits 0620 = Critical Care 0701 = Strontium (eligible for pass-through payments) 0702 = Samariam (eligible for pass-through payments) 0704 = Satumomab Pendetide (eligible for pass-through payments) 0705 = Tc99 Tetrofosmin (eligible for pass-through payments) 0725 = Leucovorin Calcium (eligible for pass-through payments) 0726 = Dexrazoxane Hydrochloride (eligible for pass-) through payments) 0727 = Injection, Etidronate Disodium (eligible for pass-through payments) 0728 = Filgrastim (G-CSF) (eligible for pass-through payments) 0730 = Pamidronate Disodium (eligible for pass-through payments) 0731 = Sargramostim (GM-CSF) (eligible for pass-through payments) 0732 = Mesna (eligible for pass-through payments) 0733 = Epoetin Alpha (eligible for pass-through) payments) 0750 = Dolasetron Mesylate 10 mg (eligible for pass- through payments) 0754 = Metoclopramide HCL (eligible for pass-through payments) 0755 = Thiethylperazine Maleate (eligible for pass-through payments) 0761 = Oral Substitute for IV Antiemtic (eligible for pass- through payments) 0762 = Dronabinol (elibible for pass-through payments) 0763 = Dolasetron Mesylate 100 mg Oral (eligible for pass-through payments) 0764 = Granisetron HCL, 100 mcg (eligible for pass- through payments) 0765 = Granisetron HCL, 1mg Oral (eligible for pass- through payments) 0768 = Ondansetron Hydrochloride per 1 mg Injection (eligible for pass-through payments) 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0769 = Ondansetron Hydrochloride 8 mg oral (eligible for pass-through payments) 0800 = Leuprolide Acetate per 3.75 mg (eligible for pass-through payments) 0801 = Cyclophosphamide (eligible for pass-through payments) 0802 = Etoposide (eligible for pass-through payments) 0803 = Melphalan (eligible for pass-through payments) 0807 = Aldesleukin single use vial (eligible for pass- through payments) 0809 = BCG (Intravesical) one vial (eligible for pass- through payments) 0810 = Goserelin Acetate Implant, per 3.6 mg (eligible for pass-through payments) 0811 = Carboplatin 50 mg (eligible for pass-through payments) 0812 = Carmustine 100 mg (eligible for pass-through payments) 0813 = Cisplatin 10 mg (eligible for pass-through payments) 0814 = Asparaginase, 10,000 units (eligible for pass- through payments) 0815 = Cyclophosphamide 100 mg (eligible for pass- through payments) 0816 = Cyclophosphamide, Lyophilized 100 mg (eligible for pass-through payments) 0817 = Cytrabine 100 mg (eligible for pass-through payments) 0818 = Dactinomycin 0.5 mg (eligible for pass-through payments) 0819 = Dacarbazine 100 mg (eligible for pass-through payments) 0820 = Daunorubicin HCI 10 mg (eligible for pass-through payments) 0821 = Daunorubicin Citrate, Liposomal Formulation, 10 mg (eligible for pass-through payments) 0822 = Diethylstibestrol Diphosphate 250 mg (eligible for pass-through payments) 0823 = Docetaxel 20 mg (eligible for pass-through payments) 0824 = Etoposide 10 mg (eligible for pass-through payments) 0826 = Methotrexate Oral 2.5 mg (eligible for pass-through payments) 0827 = Floxuridine 500 mg (eligible for pass-through payments) 0828 = Gemcitabine HCL 200 mg (eligibile for pass- through payments) 0830 = Irinotecan 20 mg (eligible for pass-through payments) 0831 = Ifosfamide per 1 gram (eligible for pass-through payments) 0832 = Idarubicin Hydrochloride 5 mg (eligible for pass- through payments) 0833 = Interferon Alfacon-1, Recombinant, 1 mcg (eligible for pass-through payments) 0834 = Interferon, Alfa-2A, Recombinant 3 million units (eligible for pass-through payments) 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0836 = Interferon, Alfa-2B, Recombinant, 1 million units (eligible for pass-through payments) 0838 = Interferon, Gamma 1-B, 3 million units (eligible for pass-through payments) 0839 = Mechlorethamine HCI 10 mg (eligible for pass-through payments) 0840 = Melphalan HCI 50 mg (eligible for pass- through payments) 0841 = Methotrexate Sodium 5 mg (eligible for pass- through payments) 0842 = Fludarabine Phosphate 50 mg (eligible for pass- through payments) 0843 = Pegaspargase per single dose vial (eligible for pass-through payments) 0844 = Pentostatin 10 mg (eligible for pass-through payments) 0847 = Doxorubicin HCL 10 mg (eligible for pass-through payments) 0849 = Rituximab, 100 mg (eligible for pass-through payments) 0850 = Streptozocin 1 gm (eligible for pass-through payments) 0851 = Thiotepa 15 mg (eligible for pass-through pay- ments) 0852 = Topotecan 4 mg (eligible for pass-through payments) 0853 = Vinblastine Sulfate 1 mg (eligible for pass-through payments) 0854 = Vincristine Sulfate 1 mg (eligible for pass-through payments) 0855 = Vinorelbine Tartrate per 10 mg (eligible for pass- through payments) 0856 = Porfimer Sodium 75 mg (eligible for pass-through payments) 0857 = Bleomycin Sulfate 15 units (eligible for pass-through payments) 0858 = Cladribine, 1mg (eligible for pass-through payments) 0859 = Fluorouracil (eligible for pass-through payments) 0860 = Plicamycin 2.5 mg (eligible for pass-through payments) 0861 = Leuprolide Acetate 1 mg (eligible for pass-through payments) 0862 = Mitomycin, 5mg (eligible for pass-through payments) 0863 = Paclitaxel, 30mg (eligible for pass-through payments) 0864 = Mitoxantrone HCl, per 5mg (eligible for pass-through payments) 0865 = Interferon alfa-N3, 250,000 IU (eligible for pass- through payments) 0884 = Rho (D) Immune Globulin, Human one dose pack (eligible for pass-through payments) 0886 = Azathioprine, 50 mg oral (Not subject to national coinsurance) 0887 = Azathioprine, Parenteral 100 mg, 20 ml each injection (Not subject to national coinsurance) 0888 = Cyclosporine, Oral 100 mg (Not subject to national coinsurance) 0889 = Cyclosporine, Parenteral (Not subject to national coinsurance) 0890 = Lymphocyte Immune Globulin 50 mg/ ml, 5 ml each (Not subject to national coinsurance) 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0891 = Tacrolimus per 1 mg oral (Not subject to national coinsurance) 0892 = Daclizumab, Parenteral, 25 mg (eligible for pass-through payments) 0900 = Injection, Alglucerase per 10 units (eligible for pass-through payments) 0901 = Alpha I, Proteinase Inhibitor, Human per 10mg (eligible for pass-through payments) 0902 = Botulinum Toxin, Type A per unit (eligible for pass-through payments) 0903 = CMV Immune Globulin (eligible for pass-through payments) 0905 = Immune Globulin per 500 mg (eligible for pass-through payments) 0906 = RSV Immune Globulin (eligible for pass-through payments) 0907 = Ganciclovir Sodium 500 mg injection (Not subject to national coinsurance) 0908 = Tetanus Immune Globulin, Human, up to 250 units (Not subject to national coinsurance) 0909 = Interferon Beta - 1a 33 mcg (eligible for pass- through payments) 0910 = Interferon Beta - 1b 0.25 mg (eligible for pass- through payments) 0911 = Streptokinase per 250,000 iu (Not subject to national coinsurance) 0913 = Ganciclovir 4.5 mg, Implant (eligible for pass- through payments) 0914 = Reteplase, 37.6 mg (Two Single Use Vials) (Not subject to national coinsurance) 0915 = Alteplase recombinant, 10mg (Not subject to national coinsurance) 0916 = Imiglucerase per unit (eligible for pass-through payments) 0917 = Dipyridamole, 10mg / Adenosine 6MG (Not subject to national coinsurance) 0918 = Brachytherapy Seeds, Any type, Each (eligible for pass-through payments) 0925 = Factor VIII (Antihemophilic Factor, Human) per iu (eligible for pass-through payments) 0926 = Factor VIII (Antihemophilic Factor, Porcine) per iu (eligible for pass-through payments) 0927 = Factor VIII (Antihemophilic Factor, Recombinant) per iu (eligible for pass-through payments) 0928 = Factor IX, Complex (eligible for pass-through payments) 0929 = Other Hemophilia Clotting Factors per iu (eligible for pass-through payments) 0930 = Antithrombin III (Human) per iu (eligible for pass- through payments) 0931 = Factor IX (Antihemophilic Factor, Purified, Non- Recombinant) (eligible for pass-through payments) 0932 = Factor IX (Antihemophilic Factor, Recombinant) (eligible for pass-through payments) 0949 = Plasma, Pooled Multiple Donor, Solvent/Detergent Treated, Frozen (not subject to national coinsurance) 0950 = Blood (Whole) For Transfusion (not subject to national coinsurance) 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ 0952 = Cryoprecipitate (not subject to national coinsurance) 0953 = Fibrinogen Unit (not subject to national coinsurance) 0954 = Leukocyte Poor Blood (not subject to national coinsurance) 0955 = Plasma, Fresh Frozen (not subject to national coinsurance) 0956 = Plasma Protein Fraction (not subject to national coinsurance) 0957 = Platelet Concentrate (not subject to national coinsurance) 0958 = Platelet Rich Plasma (not subject to national coinsurance) 0959 = Red Blood Cells (not subject to national coinsurance) 0960 = Washed Red Blood Cells (not subject to national coinsurance) 0961 = Infusion, Albumin (Human) 5%, 500 ml (not subject to national coinsurance) 0962 = Infusion, Albumin (Human) 25%, 50 ml (not subject to national coinsurance) 0970 = New Technology - Level I ($0 - $50) (not subject to national coinsurance) 0971 = New Technology - Level II ($50 - $100) (not subject to national coinsurance) 0972 = New Technology - Level III ($100 - $200) (not subject to national coinsurance) 0973 = New Technology - Level IV ($200 - $300) (not subject to national coinsurance) 0974 = New Technology - Level V ($300 - $500) (not subject to national coinsurance) 0975 = New Technology - Level VI ($500 - $750) (not subject to national coinsurance) 0976 = New Technology - Level VII ($750 - $1000) (not subject to national coinsurance) 0977 = New Technology - Level VIII ($1000 - $1250) (not subject to national coinsurance) 0978 = New Technology - Level IX ($1250 - $1500) (not subject to national coinsurance) 0979 = New Technology - Level X ($1500 - $1750) (not subject to national coinsurance) 0980 = New Technology - Level XI ($1750 - $2000) (not subject to national coinsurance) 0981 = New Technology - Level XII ($2000 - $2500) (not subject to national coinsurance) 0982 = New Technology - Level XIII ($2500 - $3500) (not subject to national coinsurance) 0983 = New Technology - Level XIV ($3500 - $5000) (not subject to national coinsurance) 0984 = New Technology - Level XV ($5000 - $6000) (not subject to national coinsurance) 7000 = Amifostine, 500 mg (eligible for pass-through payments) 7001 = Amphotericin B lipid complex, 50 mg, Inj (eligible for pass-through payments) 7002 = Clonidine, HCl, 1 MG (eligible for pass- through payments) 7003 = Epoprostenol, 0.5 MG, inj (eligible for pass- through payments) 7004 = Immune globulin intravenous human 5g, inj 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ (eligible for pass-through payments) 7005 = Gonadorelin hcI, 100 mcg (eligible for pass- through payments) 7007 = Milrinone lacetate, per 5 ml, inj (not subject to national coinsurance) 7010 = Morphine sulfate concentrate (preservative free) per 10 mg (eligible for pass-through payments) 7011 = Oprelevekin, inj, 5 mg (eligible for pass-through payments) 7012 = Pentamidine isethionate, 300 mg (eligible for pass-through payments) 7014 = Fentanyl citrate, inj, up to 2 ml (eligible for pass-through payments) 7015 = Busulfan, oral 2 mg (eligible for pass-through payments) 7019 = Aprotinin, 10,000 kiu (eligible for pass-through payments) 7021 = Baclofen, intrathecal, 50 mcg (eligible for pass- through payments) 7022 = Elliotts B Solution, per ml (eligible for pass- through payments) 7023 = Treatment for bladder calculi, I.e. Renacidin per 500 ml (eligible for pass-through payments) 7024 = Corticorelin ovine triflutate, 0.1 mg (eligible for pass-through payments) 7025 = Digoxin immune FAB (Ovine), 10 mg (eligible for pass-through payments) 7026 = Ethanolamine oleate, 1000 ml (eligible for pass-through payments) 7027 = Fomepizole, 1.5 G (eligible for pass-through payments) 7028 = Fosphenytoin, 50 mg (eligible for pass-through payments) 7029 = Glatiramer acetate, 25 mg (eligible for pass-through payments) 7030 = Hemin, 1 mg (eligible for pass-through payments) 7031 = Octreotide Acetate, 500 mcg (eligible for pass-through payments) 7032 = Sermorelin acetate, 0.5 mg (eligible for pass-through payments) 7033 = Somatrem, 5 mg (eligible for pass-through payments) 7034 = Somatropin, 1 mg (eligible for pass-through payments) 7035 = Teniposide, 50 mg (eligible for pass-through payments) 7036 = Urokinase, inj, IV, 250,000 I.U. (not subject to national coinsurance) 7037 = Urofollitropin, 75 I.U. (eligible for pass-through payments) 7038 = Muromonab-CD3, 5 mg (eligible for pass-through payments) 7039 = Pegademase bovine inj 25 I.U. (eligible for pass-through payments) 7040 = Pentastarch 10% inj, 100 ml (eligible for pass-through payments) 7041 = Tirofiban HCL, 0.5 mg 1 REV_CNTR_APC_TB Revenue Center Ambulatory Payment Classification (APC) --------------- ------------------------------------------------------ (not subject to national coinsurance) 7042 = Capecitabine, oral 150 mg (eligible for pass-through payments) 7043 = Infliximab, 10 MG (eligible for pass-through payments) 7045 = Trimetrexate Glucoronate (eligible for pass- through payments) 7046 = Doxorubicin Hcl Liposome (eligible for pass- through payments) 1 REV_CNTR_DDCTBL_COINSRNC_TB Revenue Center Deductible Coinsurance Code --------------------------- ------------------------------------------ 0 = Charges are subject to deductible and coinsurance 1 = Charges are not subject to deductible 2 = Charges are not subject to coinsurance 3 = Charges are not subject to deductible or coinsurance 4 = No charge or units associated with this revenue center code. (For multiple HCPCS per single revenue center code) For revenue center code 0001, the following MSP override values may be present: M = Override code; EGHP services involved (eff 12/90 for non-institutional claims; 10/93 for institutional claims) N = Override code; non-EGHP services involved (eff 12/90 for non-institutional claims; 10/93 for institutional claims) X = Override code: MSP cost avoided (eff 12/90 for non-institutional claims; 10/93 for institutional claims) 1 REV_CNTR_PMT_MTHD_IND_TB Revenue Center Payment Method Indicator Table ------------------------ --------------------------------------------- **********Service Indicator************** ********** 1st position ***************** A = Services not paid under OPPS C = Inpatient procedure E = Noncovered items or services F = Corneal issue acquistion G = Current drug or biological pass-through H = Device pass-through J = New drug or new biological pass-through N = Packaged incidental service P = Partial hospitalization services S = Significant procedure not subject to multiple procedure discounting T = Significant procedure subject to multiple procedure discounting V = Medical visit to clinic or emergency department X = Ancillary service **********Payment Indicator************** ********** 2nd position ***************** 1 = Paid standard hospital OPPS amount (service indicators S,T,V,X) 2 = Services not paid under OPPS (service indicator A, or no HCPCS code and not certain revenue center codes) 3 = Not paid (service indicators C & E) 4 = Acquisition cost paid (service indica- tor F) 5 = Additional payment for current drug or biological (service indicator G) 6 = Additional payment for device (service indicator H) 7 = Additional payment for new drug or new biological (service indicator J) 8 = Paid partial hospitalization per diem (service indicator P) 9 = No additional payment, payment included in line items with APCs (service indicator N, or no HCPCS code and certain revenue center codes, or HCPCS codes Q0082 (activity therapy), G0129 (occupational therapy) or G0172 (partial hospitalization training) 1 REV_CNTR_PRICNG_IND_TB Revenue Center Pricing Indicator Table ---------------------- -------------------------------------- A = A valid HCPCS code not subject to a fee schedule payment. Reimbursement is calculated on provider submitted charges. B = A valid HCPCS code subject to the fee schedule payment. Reimbursement is the lesser of provider submitted charges or the fee schedule amount. D = a valid radiology HCPCS code subject to the Radiology Pricer and the rate is reflected as zeroes on the HCPCS file and cost report. The Radiology Pricer treates this HCPCS as a non-covered service. Reimbursement is cal- culated on provider submitted charges. E = A valid ASC HCPCS code subject to the ASC Pricer. The rate is reflected as zeroes on the HCPCS file. The ASC Pricer determines the ASC payment rate and is re- ported on the cost report. F = A valid ESRD HCPCS code subject to the parameter rate. Reimbursement is the lesser of provider submitted charges or the fee schedule amount for non-dialysis HCPCS. Reimbursement is calculated on the provider file rates for dialysis HCPCS. G = A valid HCPCS, code is subject to a fee schedule, but the rate is no longer present on the HCPCS file. Reimbursement is calculated on provider submitted charges. H = A valid DME HCPCS, code is subject to a fee schedule. The rates are reflected under the DME segment. Reim- bursement is calculated either on a fee schedule, pro- vider submitted charges or the lesser of provider submitted, or the fee schedule depending o the cate- gory. I = A valid DME category 5 HCPCS, HCPCS is not found on the DME history record, but a match was found on HIC, category and generic code. Claim must be reviewed by Medical Review before payment can be calculated. J = A valid DME HCPCS, no DME history is present, and a prescription is required before delivery. Claim must be reviewed by Medical Review. K = A valid DME HCPCS, prescribed has been reviewed, and fee schedule payment is approved as prescription was present before delivery. L = A valid TENS HCPCS, rental period is six months or greater and must be reviewed by Medical Review. M = A valid TENS HCPCS, Medical Review has approved the rental charge in excess of five months. R = A valid radiology HCPCS code and is subject to the Radiology Pricer. The rate is reported on the cost report. Reimbursement is calculated on provider submitted charges. S = Valid influenza/PPV HCPCS. A fee amount is not applicable. The amount payable is present in the covered charge field. This amount is not subject to the coinsurance and deductible. This charge is subject to the provider's reimbursement rate. T = Valid HCPCS. A fee amount is present. The amount payable should be the lower of the billed charge or 1 REV_CNTR_PRICNG_IND_TB Revenue Center Pricing Indicator Table ---------------------- -------------------------------------- fee amount. The system should compute the fee amount by multiplying the covered units times the rate. The fee amount is not subject to coinsurance and deductible or provider's reimbursement rate. 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0001 = Total charge 0022 = SNF claim paid under PPS submitted as TOB 21X, effective for cost reporting periods begin- ning on or after 7/1/98 (dates of service after 6/30/98). NOTE: This code may appear multiple times on a claim to identify different HIPPS Rate Code/assessment periods. 0023 = Home Health services paid under PPS submitted as TOB 32X and 33X, effective 10/00. This code may appear multiple times on a claim to identify different HIPPS/Home Health Resource Groups (HRG). 0100 = All inclusive rate-room and board plus ancillary 0101 = All inclusive rate-room and board 0110 = Private medical or general-general classification 0111 = Private medical or general-medical/surgical/GYN 0112 = Private medical or general-OB 0113 = Private medical or general-pediatric 0114 = Private medical or general-psychiatric 0115 = Private medical or general-hospice 0116 = Private medical or general-detoxification 0117 = Private medical or general-oncology 0118 = Private medical or general-rehabilitation 0119 = Private medical or general-other 0120 = Semi-private 2 bed (medical or general) general classification 0121 = Semi-private 2 bed (medical or general) medical/surgical/GYN 0122 = Semi-private 2 bed (medical or general)-OB 0123 = Semi-private 2 bed (medical or general)-pediatric 0124 = Semi-private 2 bed (medical or general)-psychiatric 0125 = Semi-private 2 bed (medical or general)-hospice 0126 = Semi-private 2 bed (medical or general) detoxification 0127 = Semi-private 2 bed (medical or general)-oncology 0128 = Semi-private 2 bed (medical or general) rehabilitation 0129 = Semi-private 2 bed (medical or general)-other 0130 = Semi-private 3 and 4 beds-general classification 0131 = Semi-private 3 and 4 beds-medical/surgical/GYN 0132 = Semi-private 3 and 4 beds-OB 0133 = Semi-private 3 and 4 beds-pediatric 0134 = Semi-private 3 and 4 beds-psychiatric 0135 = Semi-private 3 and 4 beds-hospice 0136 = Semi-private 3 and 4 beds-detoxification 0137 = Semi-private 3 and 4 beds-oncology 0138 = Semi_private 3 and 4 beds-rehabilitation 0139 = Semi-private 3 and 4 beds-other 0140 = Private (deluxe)-general classification 0141 = Private (deluxe)-medical/surgical/GYN 0142 = Private (deluxe)-OB 0143 = Private (deluxe)-pediatric 0144 = Private (deluxe)-psychiatric 0145 = Private (deluxe)-hospice 0146 = Private (deluxe)-detoxification 0147 = Private (deluxe)-oncology 0148 = Private (deluxe)-rehabilitation 0149 = Private (deluxe)-other 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0150 = Room&Board ward (medical or general) general classification 0151 = Room&Board ward (medical or general) medical/surgical/GYN 0152 = Room&Board ward (medical or general)-OB 0153 = Room&Board ward (medical or general)-pediatric 0154 = Room&Board ward (medical or general)-psychiatric 0155 = Room&Board ward (medical or general)-hospice 0156 = Room&Board ward (medical or general)-detoxification 0157 = Room&Board ward (medical or general)-oncology 0158 = Room&Board ward (medical or general)-rehabilitation 0159 = Room&Board ward (medical or general)-other 0160 = Other Room&Board-general classification 0164 = Other Room&Board-sterile environment 0167 = Other Room&Board-self care 0169 = Other Room&Board-other 0170 = Nursery-general classification 0171 = Nursery-newborn level I (routine) 0172 = Nursery-premature newborn-level II (continuing care) 0173 = Nursery-newborn-level III (intermediate care) (eff 10/96) 0174 = Nursery-newborn-level IV (intensive care) (eff 10/96) 0175 = Nursery-neonatal ICU (obsolete eff 10/96) 0179 = Nursery-other 0180 = Leave of absence-general classification 0182 = Leave of absence-patient convenience charges billable 0183 = Leave of absence-therapeutic leave 0184 = Leave of absence-ICF mentally retarded-any reason 0185 = Leave of absence-nursing home (hospitalization) 0189 = Leave of absence-other leave of absence 0190 = Subacute care - general classification (eff. 10/97) 0191 = Subacute care - level I (eff. 10/97) 0192 = Subacute care - level II (eff. 10/97) 0193 = Subacute care - level III (eff. 10/97) 0194 = Subacute care - level IV (eff. 10/97) 0199 = Subacute care - other (eff 10/97) 0200 = Intensive care-general classification 0201 = Intensive care-surgical 0202 = Intensive care-medical 0203 = Intensive care-pediatric 0204 = Intensive care-psychiatric 0206 = Intensive care-post ICU; redefined as intermediate ICU (eff 10/96) 0207 = Intensive care-burn care 0208 = Intensive care-trauma 0209 = Intensive care-other intensive care 0210 = Coronary care-general classification 0211 = Coronary care-myocardial infraction 0212 = Coronary care-pulmonary care 0213 = Coronary care-heart transplant 0214 = Coronary care-post CCU; redefined as intermediate CCU (eff 10/96) 0219 = Coronary care-other coronary care 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0220 = Special charges-general classification 0221 = Special charges-admission charge 0222 = Special charges-technical support charge 0223 = Special charges-UR service charge 0224 = Special charges-late discharge, medically necessary 0229 = Special charges-other special charges 0230 = Incremental nursing charge rate-general classification 0231 = Incremental nursing charge rate-nursery 0232 = Incremental nursing charge rate-OB 0233 = Incremental nursing charge rate-ICU (include transitional care) 0234 = Incremental nursing charge rate-CCU (include transitional care) 0235 = Incremental nursing charge rate-hospice 0239 = Incremental nursing charge rate-other 0240 = All inclusive ancillary-general classification 0241 = All inclusive ancillary-basic 0242 = All inclusive ancillary-comprehensive 0243 = All inclusive ancillary-specialty 0249 = All inclusive ancillary-other inclusive ancillary 0250 = Pharmacy-general classification 0251 = Pharmacy-generic drugs 0252 = Pharmacy-nongeneric drugs 0253 = Pharmacy-take home drugs 0254 = Pharmacy-drugs incident to other diagnostic service- subject to payment limit 0255 = Pharmacy-drugs incident to radiology- subject to payment limit 0256 = Pharmacy-experimental drugs 0257 = Pharmacy-non-prescription 0258 = Pharmacy-IV solutions 0259 = Pharmacy-other pharmacy 0260 = IV therapy-general classification 0261 = IV therapy-infusion pump 0262 = IV therapy-pharmacy services (eff 10/94) 0263 = IV therapy-drug supply/delivery (eff 10/94) 0264 = IV therapy-supplies (eff 10/94) 0269 = IV therapy-other IV therapy 0270 = Medical/surgical supplies-general classification (also see 062X) 0271 = Medical/surgical supplies-nonsterile supply 0272 = Medical/surgical supplies-sterile supply 0273 = Medical/surgical supplies-take home supplies 0274 = Medical/surgical supplies-prosthetic/orthotic devices 0275 = Medical/surgical supplies-pace maker 0276 = Medical/surgical supplies-intraocular lens 0277 = Medical/surgical supplies-oxygen-take home 0278 = Medical/surgical supplies-other implants 0279 = Medical/surgical supplies-other devices 0280 = Oncology-general classification 0289 = Oncology-other oncology 0290 = DME (other than renal)-general classification 0291 = DME (other than renal)-rental 0292 = DME (other than renal)-purchase of new DME 0293 = DME (other than renal)-purchase of used DME 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0294 = DME (other than renal)-related to and listed as DME 0299 = DME (other than renal)-other 0300 = Laboratory-general classification 0301 = Laboratory-chemistry 0302 = Laboratory-immunology 0303 = Laboratory-renal patient (home) 0304 = Laboratory-non-routine dialysis 0305 = Laboratory-hematology 0306 = Laboratory-bacteriology & microbiology 0307 = Laboratory-urology 0309 = Laboratory-other laboratory 0310 = Laboratory pathological-general classification 0311 = Laboratory pathological-cytology 0312 = Laboratory pathological-histology 0314 = Laboratory pathological-biopsy 0319 = Laboratory pathological-other 0320 = Radiology diagnostic-general classification 0321 = Radiology diagnostic-angiocardiography 0322 = Radiology diagnostic-arthrography 0323 = Radiology diagnostic-arteriography 0324 = Radiology diagnostic-chest X-ray 0329 = Radiology diagnostic-other 0330 = Radiology therapeutic-general classification 0331 = Radiology therapeutic-chemotherapy injected 0332 = Radiology therapeutic-chemotherapy oral 0333 = Radiology therapeutic-radiation therapy 0335 = Radiology therapeutic-chemotherapy IV 0339 = Radiology therapeutic-other 0340 = Nuclear medicine-general classification 0341 = Nuclear medicine-diagnostic 0342 = Nuclear medicine-therapeutic 0349 = Nuclear medicine-other 0350 = Computed tomographic (CT) scan-general classification 0351 = CT scan-head scan 0352 = CT scan-body scan 0359 = CT scan-other CT scans 0360 = Operating room services-general classification 0361 = Operating room services-minor surgery 0362 = Operating room services-organ transplant, other than kidney 0367 = Operating room services-kidney transplant 0369 = Operating room services-other operating room services 0370 = Anesthesia-general classification 0371 = Anesthesia-incident to RAD and subject to the payment limit 0372 = Anesthesia-incident to other diagnostic service and subject to the payment limit 0374 = Anesthesia-acupuncture 0379 = Anesthesia-other anesthesia 0380 = Blood-general classification 0381 = Blood-packed red cells 0382 = Blood-whole blood 0383 = Blood-plasma 0384 = Blood-platelets 0385 = Blood-leukocytes 0386 = Blood-other components 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0387 = Blood-other derivatives (cryopricipatates) 0389 = Blood-other blood 0390 = Blood storage and processing-general classification 0391 = Blood storage and processing-blood administration 0399 = Blood storage and processing-other 0400 = Other imaging services-general classification 0401 = Other imaging services-diagnostic mammography 0402 = Other imaging services-ultrasound 0403 = Other imaging services-screening mammography (eff 1/1/91) 0404 = Other imaging services-positron emission tomography (eff 10/94) 0409 = Other imaging services-other 0410 = Respiratory services-general classification 0412 = Respiratory services-inhalation services 0413 = Respiratory services-hyperbaric oxygen therapy 0419 = Respiratory services-other 0420 = Physical therapy-general classification 0421 = Physical therapy-visit charge 0422 = Physical therapy-hourly charge 0423 = Physical therapy-group rate 0424 = Physical therapy-evaluation or re-evaluation 0429 = Physical therapy-other 0430 = Occupational therapy-general classification 0431 = Occupational therapy-visit charge 0432 = Occupational therapy-hourly charge 0433 = Occupational therapy-group rate 0434 = Occupational therapy-evaluation or re-evaluation 0439 = Occupational therapy-other (may include restorative therapy) 0440 = Speech language pathology-general classification 0441 = Speech language pathology-visit charge 0442 = Speech language pathology-hourly charge 0443 = Speech language pathology-group rate 0444 = Speech language pathology-evaluation or re-evaluation 0449 = Speech language pathology-other 0450 = Emergency room-general classification 0451 = Emergency room-emtala emergency medical screening services (eff 10/96) 0452 = Emergency room-ER beyond emtala screening (eff 10/96) 0456 = Emergency room-urgent care (eff 10/96) 0459 = Emergency room-other 0460 = Pulmonary function-general classification 0469 = Pulmonary function-other 0470 = Audiology-general classification 0471 = Audiology-diagnostic 0472 = Audiology-treatment 0479 = Audiology-other 0480 = Cardiology-general classification 0481 = Cardiology-cardiac cath lab 0482 = Cardiology-stress test 0483 = Cardiology-Echocardiology 0489 = Cardiology-other 0490 = Ambulatory surgical care-general classification 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0499 = Ambulatory surgical care-other 0500 = Outpatient services-general classification (deleted 9/93) 0509 = Outpatient services-other (deleted 9/93) 0510 = Clinic-general classification 0511 = Clinic-chronic pain center 0512 = Clinic-dental center 0513 = Clinic-psychiatric 0514 = Clinic-OB-GYN 0515 = Clinic-pediatric 0516 = Clinic-urgent care clinic (eff 10/96) 0517 = Clinic-family practice clinic (eff 10/96) 0519 = Clinic-other 0520 = Free-standing clinic-general classification 0521 = Free-standing clinic-rural health clinic 0522 = Free-standing clinic-rural health home 0523 = Free-standing clinic-family practice 0526 = Free-standing clinic-urgent care (eff 10/96) 0529 = Free-standing clinic-other 0530 = Osteopathic services-general classification 0531 = Osteopathic services-osteopathic therapy 0539 = Osteopathic services-other 0540 = Ambulance-general classification 0541 = Ambulance-supplies 0542 = Ambulance-medical transport 0543 = Ambulance-heart mobile 0544 = Ambulance-oxygen 0545 = Ambulance-air ambulance 0546 = Ambulance-neo-natal ambulance 0547 = Ambulance-pharmacy 0548 = Ambulance-telephone transmission EKG 0549 = Ambulance-other 0550 = Skilled nursing-general classification 0551 = Skilled nursing-visit charge 0552 = Skilled nursing-hourly charge 0559 = Skilled nursing-other 0560 = Medical social services-general classification 0561 = Medical social services-visit charge 0562 = Medical social services-hourly charges 0569 = Medical social services-other 0570 = Home health aid (home health)-general classification 0571 = Home health aid (home health)-visit charge 0572 = Home health aid (home health)-hourly charge 0579 = Home health aid (home health)-other 0580 = Other visits (home health)-general classification (under HHPPS, not allowed as covered charges) 0581 = Other visits (home health)-visit charge (under HHPPS, not allowed as covered charges) 0582 = Other visits (home health)-hourly charge (under HHPPS, not allowed as covered charges) 0589 = Other visits (home health)-other (under HHPPS, not allowed as covered charges) 0590 = Units of service (home health)-general classification (under HHPPS, not allowed as covered charges) 0599 = Units of service (home health)-other 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- (under HHPPS, not allowed as covered charges) 0600 = Oxygen-general classification 0601 = Oxygen-stat or port equip/supply or count 0602 = Oxygen-stat/equip/under 1 LPM 0603 = Oxygen-stat/equip/over 4 LPM 0604 = Oxygen-stat/equip/portable add-on 0610 = Magnetic resonance technology (MRT)-general classification 0611 = MRT/MRI-brain (including brainstem) 0612 = MRT/MRI-spinal cord (including spine) 0614 = MRT/MRI-other 0615 = MRT/MRA-Head and Neck 0616 = MRT/MRA-Lower Extremities 0618 = MRT/MRA-other 0619 = MRT/Other MRI 0621 = Medical/surgical supplies-incident to radiology- subject to the payment limit - extension of 027X 0622 = Medical/surgical supplies-incident to other diagnostic service-subject to the payment limit - extension of 027X 0623 = Medical/surgical supplies-surgical dressings (eff 1/95) - extension of 027X 0624 = Medical/surgical supplies-medical investigational devices and procedures with FDA approved IDE's (eff 10/96) - extension of 027X 0630 = Drugs requiring specific identification-general classification 0631 = Drugs requiring specific identification-single drug source (eff 9/93) 0632 = Drugs requiring specific identification-multiple drug source (eff 9/93) 0633 = Drugs requiring specific identification-restrictive prescription (eff 9/93) 0634 = Drugs requiring specific identification-EPO under 10,000 units 0635 = Drugs requiring specific identification-EPO 10,000 units or more 0636 = Drugs requiring specific identification-detailed coding (eff 3/92) 0637 = Self-administered drugs administered in an emergency situation - not requiring detailed coding 0640 = Home IV therapy-general classification (eff 10/94) 0641 = Home IV therapy-nonroutine nursing (eff 10/94) 0642 = Home IV therapy-IV site care, central line (eff 10/94) 0643 = Home IV therapy-IV start/change peripheral line (eff 10/94) 0644 = Home IV therapy-nonroutine nursing, peripheral line (eff 10/94) 0645 = Home IV therapy-train patient/caregiver, central line (eff 10/94) 0646 = Home IV therapy-train disabled patient, central line (eff 10/94) 0647 = Home IV therapy-train patient/caregiver, peripheral line (eff 10/94) 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0648 = Home IV therapy-train disabled patient, peripheral line (eff 10/94) 0649 = Home IV therapy-other IV therapy services (eff 10/94) 0650 = Hospice services-general classification 0651 = Hospice services-routine home care 0652 = Hospice services-continuous home care-1/2 0655 = Hospice services-inpatient care 0656 = Hospice services-general inpatient care (non-respite) 0657 = Hospice services-physician services 0659 = Hospice services-other 0660 = Respite care (HHA)-general classification (eff 9/93) 0661 = Respite care (HHA)-hourly charge/skilled nursing (eff 9/93) 0662 = Respite care (HHA)-hourly charge/home health aide/ homemaker (eff 9/93) 0670 = OP special residence charges - general classification 0671 = OP special residence charges - hospital based 0672 = OP special residence charges - contracted 0679 = OP special residence charges - other special residence charges 0700 = Cast room-general classification 0709 = Cast room-other 0710 = Recovery room-general classification 0719 = Recovery room-other 0720 = Labor room/delivery-general classification 0721 = Labor room/delivery-labor 0722 = Labor room/delivery-delivery 0723 = Labor room/delivery-circumcision 0724 = Labor room/delivery-birthing center 0729 = Labor room/delivery-other 0730 = EKG/ECG-general classification 0731 = EKG/ECG-Holter moniter 0732 = EKG/ECG-telemetry (include fetal monitering until 9/93) 0739 = EKG/ECG-other 0740 = EEG-general classification 0749 = EEG (electroencephalogram)-other 0750 = Gastro-intestinal services-general classification 0759 = Gastro-intestinal services-other 0760 = Treatment or observation room-general classification 0761 = Treatment or observation room-treatment room (eff 9/93) 0762 = Treatment or observation room-observation room (eff 9/93) 0769 = Treatment or observation room-other 0770 = Preventative care services-general classification (eff 10/94) 0771 = Preventative care services-vaccine administration (eff 10/94) 0779 = Preventative care services-other (eff 10/94) 0780 = Telemedicine - general classification (eff 10/97) 0789 = Telemedicine - telemedicine (eff 10/97) 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0790 = Lithotripsy-general classification 0799 = Lithotripsy-other 0800 = Inpatient renal dialysis-general classification 0801 = Inpatient renal dialysis-inpatient hemodialysis 0802 = Inpatient renal dialysis-inpatient peritoneal (non-CAPD) 0803 = Inpatient renal dialysis-inpatient CAPD 0804 = Inpatient renal dialysis-inpatient CCPD 0809 = Inpatient renal dialysis-other inpatient dialysis 0810 = Organ acquisition-general classification 0811 = Organ acquisition-living donor (eff 10/94); prior to 10/94, defined as living donor kidney 0812 = Organ acquisition-cadaver donor (eff 10/94); prior to 10/94, defined as cadaver donor kidney 0813 = Organ acquisition-unknown donor (eff 10/94) prior to 10/94, defined as unknown donor kidney 0814 = Organ acquisition - unsuccessful organ search- donor bank charges (eff 10/94); prior to 10/94, defined as other kidney acquisition 0815 = Organ acquisition-cadaver donor-heart (obsolete, eff 10/94) 0816 = Organ acquisition-other heart acquisition (obsolete, eff 10/94) 0817 = Organ acquisition-donor-liver (obsolete, eff 10/94) 0819 = Organ acquisition-other donor (eff 10/94); prior to 10/94, defined as other 0820 = Hemodialysis OP or home dialysis-general classification 0821 = Hemodialysis OP or home dialysis-hemodialysis- composite or other rate 0822 = Hemodialysis OP or home dialysis-home supplies 0823 = Hemodialysis OP or home dialysis-home equipment 0824 = Hemodialysis OP or home dialysis-maintenance/100% 0825 = Hemodialysis OP or home dialysis-support services 0829 = Hemodialysis OP or home dialysis-other 0830 = Peritoneal dialysis OP or home-general classification 0831 = Peritoneal dialysis OP or home-peritoneal- composite or other rate 0832 = Peritoneal dialysis OP or home-home supplies 0833 = Peritoneal dialysis OP or home-home equipment 0834 = Peritoneal dialysis OP or home-maintenance/100% 0835 = Peritoneal dialysis OP or home-support services 0839 = Peritoneal dialysis OP or home-other 0840 = CAPD outpatient-general classification 0841 = CAPD outpatient-CAPD/composite or other rate 0842 = CAPD outpatient-home supplies 0843 = CAPD outpatient-home equipment 0844 = CAPD outpatient-maintenance/100% 0845 = CAPD outpatient-support services 0849 = CAPD outpatient-other 0850 = CCPD outpatient-general classification 0851 = CCPD outpatient-CCPD/composite or other rate 0852 = CCPD outpatient-home supplies 0853 = CCPD outpatient-home equipment 0854 = CCPD outpatient-maintenance/100% 0855 = CCPD outpatient-support services 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0859 = CCPD outpatient-other 0880 = Miscellaneous dialysis-general classification 0881 = Miscellaneous dialysis-ultrafiltration 0882 = Miscellaneous dialysis-home dialysis aide visit (eff 9/93) 0889 = Miscellaneous dialysis-other 0890 = Other donor bank-general classification; changed to reserved for national assignment (eff 4/94) 0891 = Other donor bank-bone; changed to reserved for national assignment (eff 4/94) 0892 = Other donor bank-organ (other than kidney); changed to reserved for national assignment (eff 4/94) 0893 = Other donor bank-skin; changed to reserved for national assignment (eff 4/94) 0899 = Other donor bank-other; changed to reserved for national assignment (eff 4/94) 0900 = Psychiatric/psychological treatments-general classification 0901 = Psychiatric/psychological treatments-electroshock treatment 0902 = Psychiatric/psychological treatments-milieu therapy 0903 = Psychiatric/psychological treatments-play therapy 0904 = Psychiatric/psychological treatments-activity therapy (eff 4/94) 0909 = Psychiatric/psychological treatments-other 0910 = Psychiatric/psychological services-general classification 0911 = Psychiatric/psychological services-rehabilitation 0912 = Psychiatric/psychological services-day care- redefined 10/97 to less Intensive 0913 = Psychiatric/psychological services-night care redefined 10/97 to Intensive 0914 = Psychiatric/psychological services-individual therapy 0915 = Psychiatric/psychological services-group therapy 0916 = Psychiatric/psychological services-family therapy 0917 = Psychiatric/psychological services-biofeedback 0918 = Psychiatric/psychological services-testing 0919 = Psychiatric/psychological services-other 0920 = Other diagnostic services-general classification 0921 = Other diagnostic services-peripheral vascular lab 0922 = Other diagnostic services-electromyelogram 0923 = Other diagnostic services-pap smear 0924 = Other diagnostic services-allergy test 0925 = Other diagnostic services-pregnancy test 0929 = Other diagnostic services-other 0940 = Other therapeutic services-general classification 0941 = Other therapeutic services-recreational therapy 0942 = Other therapeutic services-education/training (include diabetes diet training) 0943 = Other therapeutic services-cardiac rehabilitation 0944 = Other therapeutic services-drug rehabilitation 0945 = Other therapeutic services-alcohol rehabilitation 0946 = Other therapeutic services-routine complex medical equipment 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- 0947 = Other therapeutic services-ancillary complex medical equipment (eff 3/92) 0949 = Other therapeutic services-other 0951 = Professional Fees-athletic training 0952 = Professional Fees-kinesiotherapy 0960 = Professional fees-general classification 0961 = Professional fees-psychiatric 0962 = Professional fees-ophthalmology 0963 = Professional fees-anesthesiologist (MD) 0964 = Professional fees-anesthetist (CRNA) 0969 = Professional fees-other 0971 = Professional fees-laboratory 0972 = Professional fees-radiology diagnostic 0973 = Professional fees-radiology therapeutic 0974 = Professional fees-nuclear medicine 0975 = Professional fees-operating room 0976 = Professional fees-respiratory therapy 0977 = Professional fees-physical therapy 0978 = Professional fees-occupational therapy 0979 = Professional fees-speech pathology 0981 = Professional fees-emergency room 0982 = Professional fees-outpatient services 0983 = Professional fees-clinic 0984 = Professional fees-medical social services 0985 = Professional fees-EKG 0986 = Professional fees-EEG 0987 = Professional fees-hospital visit 0988 = Professional fees-consultation 0989 = Professional fees-private duty nurse 0990 = Patient convenience items-general classification 0991 = Patient convenience items-cafeteria/guest tray 0992 = Patient convenience items-private linen service 0993 = Patient convenience items-telephone/telegraph 0994 = Patient convenience items-tv/radio 0995 = Patient convenience items-nonpatient room rentals 0996 = Patient convenience items-late discharge charge 0997 = Patient convenience items-admission kits 0998 = Patient convenience items-beauty shop/barber 0999 = Patient convenience items-other NOTE: Following Revenue Codes reported for NHCMQ (RUGS) demo claims effective 2/96. 9000 = RUGS-no MDS assessment available 9001 = Reduced physical functions- RUGS PA1/ADL index of 4-5 9002 = Reduced physical functions- RUGS PA2/ADL index of 4-5 9003 = Reduced physical functions- RUGS PB1/ADL index of 6-8 9004 = Reduced physical functions- RUGS PB2/ADL index of 6-8 9005 = Reduced physical functions- RUGS PC1/ADL index of 9-10 9006 = Reduced physical functions- RUGS PC2/ADL index of 9-10 9007 = Reduced physical functions- 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- RUGS PD1/ADL index of 11-15 9008 = Reduced physical functions- RUGS PD2/ADL index of 11-15 9009 = Reduced physical functions- RUGS PE1/ADL index of 16-18 9010 = Reduced physical functions- RUGS PE2/ADL index of 16-18 9011 = Behavior only problems- RUGS BA1/ADL index of 4-5 9012 = Behavior only problems- RUGS BA2/ADL index of 4-5 9013 = Behavior only problems- RUGS BB1/ADL index of 6-10 9014 = Behavior only problems- RUGS BB2/ADL index of 6-10 9015 = Impaired cognition- RUGS IA1/ADL index of 4-5 9016 = Impaired cognition- RUGS IA2/ADL index of 4-5 9017 = Impaired cognition- RUGS IB1/ADL index of 6-10 9018 = Impaired cognition- RUGS IB2/ADL index of 6-10 9019 = Clinically complex- RUGS CA1/ADL index of 4-5 9020 = Clinically complex- RUGS CA2/ADL index of 4-5d 9021 = Clinically complex- RUGS CB1/ADL index of 6-10 9022 = Clinically complex- RUGS CB2/ADL index of 6-10d 9023 = Clinically complex- RUGS CC1/ADL index of 11-16 9024 = Clinically complex- RUGS CC2/ADL index of 11-16d 9025 = Clinically complex- RUGS CD1/ADL index of 17-18 9026 = Clinically complex- RUGS CD2/ADL index of 17-18d 9027 = Special care- RUGS SSA/ADL index of 7-13 9028 = Special care- RUGS SSB/ADL index of 14-16 9029 = Special care- RUGS SSC/ADL index of 17-18 9030 = Extensive services- RUGS SE1/1 procedure 9031 = Extensive services- RUGS SE2/2 procedures 9032 = Extensive services- RUGS SE3/3 procedures 9033 = Low rehabilitation- RUGS RLA/ADL index of 4-11 9034 = Low rehabilitation- RUGS RLB/ADL index of 12-18 9035 = Medium rehabilitation- RUGS RMA/ADL index of 4-7 9036 = Medium rehabilitation- 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- RUGS RMB/ADL index of 8-15 9037 = Medium rehabilitation- RUGS RMC/ADL index of 16-18 9038 = High rehabilitation- RUGS RHA/ADL index of 4-7 9039 = High rehabilitation- RUGS RHB/ADL index of 8-11 9040 = High rehabilitation- RUGS RHC/ADL index of 12-14 9041 = High rehabilitation- RUGS RHD/ADL index of 15-18 9042 = Very high rehabilitation- RUGS RVA/ADL index of 4-7 9043 = Very high rehabilitation- RUGS RVB/ADL index of 8-13 9044 = Very high rehabilitation- RUGS RVC/ADL index of 14-18 ***Changes effective for providers entering*** **RUGS Demo Phase III as of 1/1/97 or later** 9019 = Clinically complex- RUGS CA1/ADL index of 11 9020 = Clinically complex- RUGS CA2/ADL index of 11D 9021 = Clinically complex- RUGS CB1/ADL index of 12-16 9022 = Clinically complex- RUGS CB2/ADL index of 12-16D 9023 = Clinically complex- RUGS CC1/ADL index of 17-18 9024 = Clinically complex- RUGS CC2/ADL index of 17-18D 9025 = Special care- RUGS SSA/ADL index of 14 9026 = Special care- RUGS SSB/ADL index of 15-16 9027 = Special care- RUGS SSC/ADL index of 17-18 9028 = Extensive services- RUGS SE1/ADL index 7-18/1 procedure 9029 = Extensive services- RUGS SE2/ADL index 7-18/2 procedures 9030 = Extensive services- RUGS SE3/ADL index 7-18/3 procedures 9031 = Low rehabilitation- RUGS RLA/ADL index of 4-13 9032 = Low rehabilitation- RUGS RLB/ADL index of 14-18 9033 = Medium rehabilitation- RUGS RMA/ADL index of 4-7 9034 = Medium rehabilitation- RUGS RMB/ADL index of 8-14 9035 = Medium rehabilitation- RUGS RMC/ADL index of 15-18 9036 = High rehabilitation- RUGS RHA/ADL index of 4-7 9037 = High rehabilitation- 1 REV_CNTR_TB Revenue Center Table ----------- -------------------- RUGS RHB/ADL index of 8-12 9038 = High rehabilitation- RUGS RHC/ADL index of 13-18 9039 = Very High rehabilitation- RUGS RVA/ADL index of 4-8 9040 = Very high rehabilitation- RUGS RVB/ADL index of 9-15 9041 = Very high rehabilitation- RUGS RVC/ADL index of 16 9042 = Very high rehabilitation- RUGS RUA/ADL index of 4-8 9043 = Very high rehabilitation- RUGS RUB/ADL index of 9-15 9044 = Ultra high rehabilitation- RUGS RUC/ADL index of 16-18