TABLE_NAME,VERSION,COMMENTS
DATA_APC,APC,APC value
DATA_APC,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_APC,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_APC,DESCRIPTION,APC description
DATA_APC,STATUS_INDICATOR,Status indicator assigned to the APC
DATA_APC,PAYMENT_INDICATOR,Payment indicator assigned to the APC
DATA_APC,APC_PAYMENT,Payment amount of the APC
DATA_APC,MENTAL_HEALTH,"APC subject to Mental Health/Partial Hospitalization Program (MH/PHP) logic.
Values:
0 = not applicable
1 = applicable"
DATA_APC,ER_VISIT,"Emergency room visit and critical care APC subject to observation logic.
Values:
0 = not applicable
1 = applicable"
DATA_APC,DEVICE_OFFSET,APC's device offset amount prior to v54. Refer to OFFSET_CODEPAIRS table for device offset amounts after v53.
DATA_APC,COMP1_ID,"APC subject to composite APC processing.
Values:
0 = not applicable
1 = electrophysiology/ablation composite APC (v15.3)
2 = LDR prostate brachytherapy composite APC (v18.3)"
DATA_APC,COMP2_ID,"APC subject to observation composite APC processing prior to v62 (Note: EA&M composite levels I & II combined in v18.0).
Values:
0 = not applicable
1 = possible level II observation composite APC
2 = possible level I observation composite APC"
DATA_APC,COMP3_ID,"APC subject to multiple imaging composite APC processing.
Values:
0 = not applicable
1 = Ultrasound Composite
2 = CT and CTA without Contrast Composite
3 = CT and CTA with Contrast Composite
4 = MRI and MRA without Contrast Composite
5 = MRI and MRA with Contrast Composite"
DATA_APC,NUC_RAD_FB,"APC subject to nuclear medicine/radiopharm processing prior to v54.
Values:
0 = not applicable
1 = applicable"
DATA_APC,CAPC_SRS,"APC subject to comprehensive APC processing for Stereotactic Radiosurgery (SRS).
Values:
0 = not applicable
1 = applicable"
DATA_CAPC,HCPCS,CPT/HCPCS code value.
DATA_CAPC,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_CAPC,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_CAPC,RANK,Ranking of comprehensive APC procedures used to determine primary comprehensive APC procedure when multiple comprehensive APC procedures are present on a claim.
DATA_CAPC,COMPLEXITY_ADJUSTMENT,"Comprehensive APC procedure subject to complexity-adjusted logic when conditions present on claim.
Values:
0 = no complexity adjustment
1 = complexity adjustment applies"
DATA_DISCOUNT_FORMULA,DISCOUNT_KEY,"Discount key used to determine which discount formula to apply when discounting conditions present on claim.
Values: (Key descriptions) H = High, N = No, Y = Yes
HNN
HNY
HYN
HYY
NNN
NNY
NYN
NYY"
DATA_DISCOUNT_FORMULA,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DISCOUNT_FORMULA,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DISCOUNT_FORMULA,DISCOUNT_FORMULA,"Discount formula string.
Values:
221113
428813
333333
551113
958813"
DATA_DISCOUNT_FORMULA,DESCRIPTION,"Discount formula description.
Values:
HNN = Highest paying discount-applicable line; no modifier 52, 73, nor 50 is present; line is not an independent or conditional bilateral.
HNY = Highest paying discount-applicable line; no modifier 52 nor 73 is present; modifier 50 is present or the line is an independent or conditional bilateral.
HYN = Highest paying discount-applicable line; either modifier 52 or 73 is present; neither modifier 50 is present and line is not an independent or conditional bilateral.
HYY = Highest paying discount-applicable line; either modifier 52 or 73 is present; and modifier 50 is present or the line is an independent or conditional bilateral.
NNN = Non-highest paying discount-applicable line; no modifier 52, 73, nor 50 is present; line is not an independent or conditional bilateral.
NNY = Non-highest paying discount-applicable line; no modifier 52 nor 73 is present; modifier 50 is present or the line is an independent or conditional bilateral.
NYN = Non-highest paying discount-applicable line; either modifier 52 or 73 is present; neither modifier 50 present and line is not an independent or conditional bilateral.
NYY = Non-highest paying discount-applicable line; either modifier 52 or 73 is present; and modifier 50 is present or the line is an independent or conditional bilateral."
DATA_DX09,DIAGNOSIS,Diagnosis code
DATA_DX09,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DX09,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DX09,DESCRIPTION,Diagnosis code description
DATA_DX09,LO_AGE,"Lowest valid age for the diagnosis.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55 = maternity
15/124 = adult"
DATA_DX09,HI_AGE,"Highest valid age for the diagnosis.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55 = maternity
15/124 = adult"
DATA_DX09,SEX,"Sex restriction value for the diagnosis.
Values:
0 = not applicable
1 = male-only
2 = female-only"
DATA_DX09,EXTERNAL_CAUSE,"Diagnosis identified as an external cause of morbidity diagnosis.
Values:
0 = not applicable
1 = applicable"
DATA_DX09,MENTAL_HEALTH,"Diagnosis identified as a mental health diagnosis.
Values:
0 = not applicable
1 = applicable"
DATA_DX09,MANIFESTATION,"Diagnosis identified as a manifestation diagnosis (Edit 86).
Values:
0 = not applicable
1 = applicable"
DATA_DX09,CODE_FIRST,"Mental health diagnosis may be coded in first position of secondary diagnoses slots (Edit 109).
Values:
0 = not applicable
1 = applicable"
DATA_DX09,UNACCEPTABLE_PDX,"Diagnosis identified as an unacceptable principal diagnosis (Edit 113).
Values:
0 = not applicable
1 = applicable"
DATA_DX09,UNACCEPTABLE_PDX_EXCLUSION,"Diagnosis identified as being an unacceptable principal diagnosis exclusion (Edit 113) due to OPPS coding requirements.
Values:
0 = not applicable
1 = applicable"
DATA_DX10,DIAGNOSIS,Diagnosis code
DATA_DX10,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DX10,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_DX10,DESCRIPTION,Diagnosis code description
DATA_DX10,LO_AGE,"Lowest valid age for the diagnosis.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55, 9/64 (activated v18.3, 2019-10-01) = maternity
15/124 = adult"
DATA_DX10,HI_AGE,"Highest valid age for the diagnosis.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55, 9/64 (activated v18.3, 2019-10-01) = maternity
15/124 = adult"
DATA_DX10,SEX,"Sex restriction value for the diagnosis.
Values:
0 = not applicable
1 = male-only
2 = female-only"
DATA_DX10,EXTERNAL_CAUSE,"Diagnosis identified as an external cause of morbidity diagnosis.
Values:
0 = not applicable
1 = applicable"
DATA_DX10,MENTAL_HEALTH,"Diagnosis identified as a mental health diagnosis.
Values:
0 = not applicable
1 = applicable"
DATA_DX10,MANIFESTATION,"Diagnosis identified as a manifestation diagnosis (Edit 86).
Values:
0 = not applicable
1 = applicable"
DATA_DX10,CODE_FIRST,"Mental health diagnosis may be coded in first position of secondary diagnoses slots (Edit 109).
Values:
0 = not applicable
1 = applicable"
DATA_DX10,UNACCEPTABLE_PDX,"Diagnosis identified as an unacceptable principal diagnosis (Edit 113).
Values:
0 = not applicable
1 = applicable"
DATA_DX10,UNACCEPTABLE_PDX_EXCLUSION,"Diagnosis identified as being an unacceptable principal diagnosis exclusion (Edit 113) due to OPPS coding requirements.
Values:
0 = not applicable
1 = applicable"
DATA_EDIT_BYPASS,EDIT,Lists edits allowed by the Contractor Bypass functionality.
DATA_EDIT_BYPASS,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_EDIT_BYPASS,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_EDIT_BYPASS,LINE_BYPASS_REQUIRED,"Indicates whether the bypassed edit is located at the claim level or line level.
Values:
0 = Claim level edit
1 = Line level edit"
DATA_HCPCS,HCPCS,CPT/HCPCS code
DATA_HCPCS,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_HCPCS,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_HCPCS,DESCRIPTION,CPT/HCPCS description
DATA_HCPCS,APC,Default APC assignment for CPT/HCPCS.
DATA_HCPCS,LO_AGE,"Lowest valid age for the CPT/HCPCS.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55, 9/64 (activated v18.3, 2019-10-01) = maternity
15/124 = adult"
DATA_HCPCS,HI_AGE,"Highest valid age for the CPT/HCPCS.
Ranges (Low Age/High Age):
0/124 = all valid ages
0/0 = newborn
0/17= pediatric
12/55, 9/64 (activated v18.3, 2019-10-01) = maternity
15/124 = adult"
DATA_HCPCS,SEX,"Sex restriction value for the CPT/HCPCS.
Values:
0 = not applicable
1 = male-only
2 = female-only"
DATA_HCPCS,STATUS_INDICATOR,Default status indicator assigned to CPT/HCPCS.
DATA_HCPCS,PAYMENT_INDICATOR,Default payment indicator assigned to CPT/HCPCS.
DATA_HCPCS,QUESTIONABLE,"Questionable service (Edit 12).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NOT_RECOGNIZED_MCARE,Code not recognized by Medicare for outpatient claims; alternate code for same service may be available (Edit 28)
DATA_HCPCS,NOT_RECOGNIZED_OPPS,"Not recognized by OPPS (Edit 62).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NON_COVERED,"Non-covered service (Edit 9).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NON_REPORTABLE_SITE,"C-HCPCS codes only reportable for OPPS claims (Edit 55).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BILATERAL_CONDITIONAL,"Conditional bilateral code from Medicare physician fee schedule.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BILATERAL_INDEPENDENT,"Independent bilateral code from Medicare physician fee schedule.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BILATERAL_INHERENT,"Inherent bilateral code from Medicare physician fee schedule.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NCCI_CODE1,"Code 1 of code pair subject to NCCI PTP editing.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NCCI_CODE2,"Code 2 of code pair subject to NCCI PTP editing.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,VACCINE,"Vaccine services that may be paid for Home Health Agency (HHA) or Hospice claims under OPPS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ANTIGEN,"Antigens for allergen immunotherapy services that may be paid for Home Health Agency (HHA) or Hospice claims under OPPS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SPLINT,"Splint application services that may be paid for Home Health Agency (HHA) or Hospice claims under OPPS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CAST,"Cast application services that may be paid for Home Health Agency (HHA) or Hospice claims under OPPS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NEGATIVE_PRESSURE_WOUND_THERAPY,"NPWT services separately payable on Home Health Agency (HHA) claims with bill type 34x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SOMETIMES_THERAPY,"Wound care services that may be considered sometimes therapy and payable under fee schedule if performed by a therapist.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ACTIVITY_THERAPY,"Activity therapy service not payable outside of a partial hospitalization program (PHP).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OCCUPATIONAL_THERAPY,"Occupational therapy service only billable on partial hospitalization claims (PHP).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DEDUCTIBLE_NA,"Deductible is not applicable for CPT/HCPCS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DEDUCTIBLE_COINS_NA,"Deductible and Coinsurance are not applicable for CPT/HCPCS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,COINS_NA,"Coinsurance not applicable for CPT/HCPCS.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BLOOD_SERVICE,"Blood transfusion or exchange (Edit 43).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BLOOD_PRODUCT,"Blood product (Edit 43).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PACKED_RED_CELLS,"Packed red blood cells reported with revenue code 381 (Edit 79).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,WHOLE_BLOOD,"Whole blood reported with revenue code 382 (Edit 79).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,EDUCATIONAL,"Education and Training HCPCS (Edit 35).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OBSERVATION,"Observation CPT/HCPCS code requires revenue code 762 (Edit 44).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OBSERVATION_HOURLY,"Observation code requires the number of observation hours reported in the units of service field.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OBSERVATION_DIRECT_ADMIT,"Observation code for direct admission or referral to hospital observation.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OBSERVATION_HOSPITAL_ONLY,"Observation code can only be reported with bill type 13x or 85x (Edit 53).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,TRAUMA_REVENUE_CODE,"Revenue code 068x is required for trauma response critical care services (Edit 76).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,TRAUMA_CRITICAL_CARE,"Critical care services required to be reported with trauma response service (Edit 76).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CRITICAL_CARE_ANCILLARY,"Critical care ancillary service.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,STV_PACKAGED,"Code packaged when status indicator S, T, or V procedure present.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,T_PACKAGED,"Code packaged when status indicator T procedure present.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,HAS_DEV_REQ_PROC,"Device CPT/HCPCS that require a surgical implantation procedure code to be reported (Edit 77), v58.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SEPARATE_PROCEDURE,"Separate inpatient procedure (Edit 45).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,STATUTORY_EXCLUSION,"Statutory exclusion (Edit 50).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DMERC_BILLABLE_ONLY,"Billable to Durable Medical Equipment Regional Carrier (DMERC) only (Edit 61).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,UNCLASSIFIED_DRUG,"Unclassified Drug (Edit 66).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,RADIO_PHARM,"Radiolabeled product(s) required for nuclear medicine procedure, prior to v54.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NUCLEAR_MED,"Nuclear medicine procedure requires diagnostic radiopharmaceutical, prior to v54.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,MID_QUARTER_DATE_EDIT,"The mid-quarter date edit returned when conditions present on claim.
Values:
0 = not applicable
67 = Service provided prior to FDA approval
68 = Service provided prior to date of NCD approval
69 = Service provided outside approval period
83 = Service provided on or after effective date of NCD noncoverage
110 = Service provided prior to initial marketing date"
DATA_HCPCS,DATE_APPROVED,"The effective mid-quarter date of approval for FDA, National Coverage Determination (NCD), or initial marketing date.
Values:
0 = not applicable
YYYYMMDD = approval date for code"
DATA_HCPCS,DATE_TERMINATED,"The mid-quarter date when a code approval period becomes inactive.
Values:
0 = not applicable
YYYYMMDD = termination date for code"
DATA_HCPCS,NON_BILLABLE_MAC,"Not billable to MAC (Edit 72).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,HAS_DEVICE_PAIR1,"Surgical implantation procedure that requires a device CPT/HCPCS to be reported (Edit 71), prior to v58.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,HAS_DEVICE_PAIR2,"Surgical implantation procedure that may require a second device HCPCS to be reported (Edit 71), prior to v58.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PH_PRIMARY,"Primary partial hospitalization program (PHP) service (e.g. psychotherapy) subject to the partial hospitalization program logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PH_SERVICE,"Services applicable to the partial hospitalization program.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DAILY_MENTAL_HEALTH,"Mental health services that count towards the daily mental health service total.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,MH_NOT_PH,"Mental health service that is not payable under the partial hospitalization program (PHP) (Edit 80).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PH_NOT_MH,"Partial hospitalization service that is not payable on a mental health claim (Edit 81).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PH_DURATION,"Numeric value representing the duration of a partial hospitalization program (PHP) service that counts towards the weekly requirements for the partial hospitalization program (PHP) (Edit 95).
Values:
0 = 1 hour or not applicable
1 = 0.25 hour
2 = 0.5 hour
3 = 0.75 hour"
DATA_HCPCS,PH_ADDON,"Partial hospitalization program (PHP) add-on codes excluded from the PHP daily count and subject to editing (Edit 84).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,TOKEN_CHARGE_ONLY,"Radiolabeled product provided during an inpatient stay under Medicare Part B that may have a line item charge reported as $1.01 or less.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE_SG,"Skin substitute application procedure (v13.0-v14.3).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE,"Skin substitute product (v13.0-v14.3).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CAPC_EXCLUSION,"Code excluded from comprehensive APC packaging.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CAPC_SRS_PLAN_AND_PREP,"Stereotactic Radiosurgery planning and preparation procedure.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DEVICE_PROCEDURE,"Device-dependent procedure (Edit 92).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DEVICE,"Device for a device-dependent procedure (Edit 92).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE_SG_LO,"Low-cost skin substitute procedure (Edit 87).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE_LO,"Low-cost skin substitute product (Edit 87).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE_SG_HI,"High-cost skin substitute procedure (Edit 87).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,SKIN_SUBSTITUTE_HI,"High-cost skin substitute product (Edit 87).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,LAB_SERVICE,"Non-packaged laboratory service for bill type 14x (v62).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_PREVENTIVE,"FQHC PPS preventive service for bill type 77x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_FLU_PPV,"FQHC PPS influenza/PPV vaccine service for bill type 77x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_NON_COVERED,"FQHC PPS non-covered service for bill type 77x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_ADDON,"FQHC PPS mental health add-on service requires primary procedure code for bill type 77x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_PRIMARY,"FQHC PPS primary procedure service code not reported with mental health add-on service code for bill type 77x.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FQHC_CHRONIC_CARE,"FQHC Chronic Care Management code.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,RHC_MODIFIER_CONFLICT,"Not eligible for the all-inclusive rate under Rural Health Clinic (RHC).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BYPASS_E72_FQHC_RHC,"Not subject to edit 72 under FQHC and RHC.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,DEV_PROC_BYPASS,"Device codes that bypass edit 71 and 77 for dates prior to 8/13/2013.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CORNEA_TRANSPLANT,"Code may be paired with cornea tissue processing code (Edit 93).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,CORNEA_TISSUE_PROCESSING,"Cornea tissue processing code (Edit 93).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ADVANCED_CARE_PLANNING,"Advanced care planning code.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ANNUAL_WELLNESS_VISIT,"Medicare annual wellness visit code.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,TERMINATED_DEVICE_PROCEDURE,"Device intensive procedure may be subject to payment offset/credit for the following conditions: terminated procedure reported with modifier 73 or procedures subject to full or partial device credit due to the presence of condition code 49, 50 or 53.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PASSTHROUGH_DEVICE,"Pass-through device subject to payment offset for device procedure logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PASSTHROUGH_RADIOPHARM,"Pass-through radiopharmaceutical subject to payment offset for nuclear medicine procedure logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PASSTHROUGH_SKIN_PRODUCT,"Pass-through skin substitute product subject to payment offset for skin substitute implantation procedure logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PASSTHROUGH_CONTRAST,"Pass-through contrast agent subject to payment offset for radiological procedure logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,PASSTHROUGH_STRESS_AGENT,"Pass-through pharmacologic stress agent subject to payment offset for myocardial perfusion imaging procedure logic.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,NON_STANDARD_CT_SCAN,"Code may be reported with modifier CT for non-standard NEMA equipment.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,FILM_XRAY,"Film x-ray code subject to payment reduction when reported with applicable radiological modifier FX or FY.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ALLOGENEIC_TRANSPLANT,"Allogeneic transplant procedure (Edit 100).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BYPASS_E99,"Blood clotting factor excluded from edit (Edit 99).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,OVERRIDE_SECTION603,"Not subject to payment reduction under Section 603 requirements.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ADDON_TYPE1,"Type I add-on code (Edit 106).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ADDON_TYPE2,"Type II add-on code (Edit 107).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ADDON_TYPE3,"Type III add-on code (Edit 108).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BIOSIMILAR,"Biosimilar code required to be reported with an applicable manufacturer modifier.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BUNDLED_IN_BIOLOGICAL,"Cost of service bundled into cost of drug or biological (Edit 111).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,BYPASS_E92_MODIFIER,"Device procedure may bypass edit 92 if the appropriate modifier is present on the line.
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,ADDON_DRUG_ADMIN,"Drug administration add-on code (Edit 106).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,INFORMATION_ONLY,"Information-only service (Edit 112).
Values:
0 = not applicable
1 = applicable"
DATA_HCPCS,UNUSED,For future use
DATA_HCPCS,COINSURANCE_DEDUCTIBLE_WAIVER_ELIGIBLE,"Eligible for coinsurance deductible waiver if reported with modifier CS. Items that are not flagged as being eligible for coinsurance deductible waiver should not be reported with modifier CS (Edit 114).
Values:
0 = not applicable
1 = applicable"
DATA_MODIFIER,MODIFIER,Modifier value
DATA_MODIFIER,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_MODIFIER,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_MODIFIER,DESCRIPTION,Modifier description
DATA_MODIFIER,DATE_ACTIVATED,Mid-Quarter effective date of Modifier usage (YYYYMMDD).
DATA_MODIFIER,NCCI,"Codepair excluded from NCCI editing (Edit 20 and 40) if modifier present and bypass allowed (e.g. NCCI modifier indicator = 1).
Values:
0 = not applicable
1 = applicable"
DATA_MODIFIER,THERAPY,"Therapy modifier (e.g. Speech therapist, physical therapist) used in reporting therapy services.
Values:
0 = not applicable
1 = applicable"
DATA_MODIFIER,NON_DISCOUNT,"Modifier excludes lines from discounting.
Values:
0 = not applicable
1 = applicable"
DATA_MODIFIER,DIED_TRANSFERRED,"Modifier used to identify when a patient has died or was transferred (Edit 60).
Values:
0 = not applicable
1 = applicable"
DATA_MODIFIER,DEVICE_REQ_EXCLUSION,"Modifier identifies early termination of procedure for discounting or subject to terminated device procedure credit.
Values:
0 = not applicable
1 = applicable"
DATA_PAYMENT_INDICATOR,PAYMENT_INDICATOR,Payment indicator value
DATA_PAYMENT_INDICATOR,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_PAYMENT_INDICATOR,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_PAYMENT_INDICATOR,DESCRIPTION,Payment indicator description
DATA_REVENUE,REVENUE_CODE,Revenue center code
DATA_REVENUE,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_REVENUE,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_REVENUE,DESCRIPTION,Revenue code description
DATA_REVENUE,STATUS_INDICATOR,Assigned status indicator when no CPT/HCPCS is reported.
DATA_REVENUE,NOT_RECOGNIZED,"Revenue code not recognized by Medicare without an accompanying CPT/HCPCS (Edit 65).
Values:
0 = not applicable
1 = applicable"
DATA_REVENUE,THERAPY,"Revenue code used in reporting therapy services.
Values:
0 = not applicable
1 = applicable"
DATA_REVENUE,BYPASS_E48,"Revenue code bypasses edit 48 (revenue code requires CPT/HCPCS).
Values:
0 = not applicable
1 = applicable"
DATA_REVENUE,STATUTORY_EXCLUSION,"Revenue code subject to statutory exclusion without an accompanying CPT/HCPCS (Edit 50).
Values:
0 = not applicable
1 = applicable"
DATA_REVENUE,BUNDLED_IN_BIOLOGICAL,"Revenue code subject to ""bundled in biological"" logic without an accompanying CPT/HCPCS (Edit 111).
Values:
0 = not applicable
1 = applicable"
DATA_STATUS_INDICATOR,STATUS_INDICATOR,Status indicator value
DATA_STATUS_INDICATOR,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_STATUS_INDICATOR,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
DATA_STATUS_INDICATOR,DESCRIPTION,Status indicator description
MAP_ADDON_DRUG_ADMIN,ADDON,Drug administration add-on procedure code
MAP_ADDON_DRUG_ADMIN,ADDON_PRIMARY,Drug administration primary procedure code
MAP_ADDON_DRUG_ADMIN,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_DRUG_ADMIN,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE1,ADDON,Type I add-on procedure code
MAP_ADDON_TYPE1,ADDON_PRIMARY,Type I primary procedure code
MAP_ADDON_TYPE1,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE1,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE2,ADDON,Type II add-on procedure code
MAP_ADDON_TYPE2,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE2,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE3,ADDON,Type III add-on procedure code
MAP_ADDON_TYPE3,ADDON_PRIMARY,Type III primary procedure code
MAP_ADDON_TYPE3,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_ADDON_TYPE3,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_BIOSIMILAR,HCPCS,CPT/HCPCS code
MAP_BIOSIMILAR,MODIFIER,Modifier required for CPT/HCPCS reporting.
MAP_BIOSIMILAR,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_BIOSIMILAR,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CAPC,CODE1,1st CPT/HCPCS code of a complexity-adjusted code pair under comprehensive APCs
MAP_CAPC,CODE2,2nd CPT/HCPCS code of a complexity-adjusted code pair under comprehensive APCs
MAP_CAPC,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CAPC,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CAPC,APC,Comprehensive APC assignment for complexity-adjusted code pair
MAP_CODEPAIR,CODE1,1st CPT/HCPCS code of pair.
MAP_CODEPAIR,CODE2,2nd CPT/HCPCS code of pair.
MAP_CODEPAIR,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CODEPAIR,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CODEPAIR,DEVICE_PAIR1,"Procedure Code1 has a 1st required device Code2 (Edit 71 if an associated code2 is not present), v58.
Values:
0 = not applicable
1 = applicable"
MAP_CODEPAIR,DEVICE_PAIR2,"Procedure Code1 has a 2nd required device Code2 (Edit 71 if an associated code 2 is not present), v58.
Values:
0 = not applicable
1 = applicable"
MAP_CODEPAIR,DEV_REQ_PROC,"Device Code1 has a required procedure Code2 (Edit 77 if an associated code2 is not present), v58.
Values:
0 = not applicable
1 = applicable"
MAP_CODEPAIR,DEV_OFFSET_PAIR,"Code pair eligible for offset if reported with either modifer FC or FB, v54.
Values:
0 = not applicable
1 = applicable"
MAP_CODEPAIR,DEV_PROC_BYPASS,"Code pair bypasses code pair requirements for edits 71 and 77, v58.
Values:
0 = not applicable
1 = applicable"
MAP_COMPOSITE,HCPCS,CPT/HCPCS code
MAP_COMPOSITE,COMPOSITE_APC,Composite APC
MAP_COMPOSITE,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_COMPOSITE,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_COMPOSITE,LIST_TYPE,"Type of Composite list.
Values:
A = Imaging composite
B = EA&M composite for observation
C = Electrophysiology/Ablation composite"
MAP_CONFLICT_RHC,HCPCS,CPT/HCPCS code
MAP_CONFLICT_RHC,MODIFIER,Conflicting modifier if reported with CPT/HCPCS (column1)
MAP_CONFLICT_RHC,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_CONFLICT_RHC,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_FQHC_VISIT,CODE1,Code 1 of a FQHC qualifying visit code pair
MAP_FQHC_VISIT,CODE2,Code 2 of a FQHC qualifying visit code pair
MAP_FQHC_VISIT,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_FQHC_VISIT,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_MODIFIER_CONFLICT,MODIFIER1,Modifier1 required for CPT/HCPCS reporting (code 1 of modifier conflict)
MAP_MODIFIER_CONFLICT,MODIFIER2,Modifier2 required for CPT/HCPCS reporting (code 2 of modifier conflict)
MAP_MODIFIER_CONFLICT,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_MODIFIER_CONFLICT,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_NCCI,CODE1,Code 1 of a NCCI code pair
MAP_NCCI,CODE2,Code 2 of a NCCI code pair
MAP_NCCI,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_NCCI,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_NCCI,MOD_INDICATOR,"Indicates whether an appropriate modifier can be applied to suppress editing.
Values:
0 = modifier not allowed; services represented by code combination not paid separately
1 = modifier allowed; billed services may be justifiable for the code combination
9 = no longer an active NCCI edit; code combinations are billable; no modifier needed"
MAP_PH_ADDON,ADDON,Partial Hospitalization Program (PHP) Add-on Code (Edit 84).
MAP_PH_ADDON,ADDON_PRIMARY,Partial Hospitalization Program (PHP) Primary Procedure.
MAP_PH_ADDON,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_PH_ADDON,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_S603_OVERRIDE,HCPCS,Radiation treatment CPT/HCPCS subject to section 603 logic when reported with modifier PN.
MAP_S603_OVERRIDE,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_S603_OVERRIDE,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_S603_OVERRIDE,APC,APC assignment for radiation treatment CPT/HCPCS when subject to section 603 logic.
MAP_STATUS_PAYMENT,STATUS_INDICATOR,Status indicator (for internal use)
MAP_STATUS_PAYMENT,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_STATUS_PAYMENT,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
MAP_STATUS_PAYMENT,PAYMENT_INDICATOR,Default payment indicator assigned to status indicator (for internal use).
OFFSET_APC,GROUP_ID,"Group of pass-through items or services.
Values:
1 = Radiopharmaceutical
2 = Drug/Biological (Skin Product, Radiological Contrast, or Stress Agent)"
OFFSET_APC,LIST_ID,"Type of pass-through item or service.
Values:
1 = Radiopharmaceutical
2 = Skin Product
3 = Radiological Contrast
4 = Stress Agent"
OFFSET_APC,APC,Associated procedure APC for pairing with the pass-through item or service.
OFFSET_APC,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_APC,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_APC,AMOUNT,Amount of payment offset applied to pass-through item or service
OFFSET_CODEPAIR,LIST_ID,"Type of pass-through device.
Values:
1 = Device"
OFFSET_CODEPAIR,CODE1,1st CPT/HCPCS in pair
OFFSET_CODEPAIR,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_CODEPAIR,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_CODEPAIR,CODE2,2nd CPT/HCPCS in pair
OFFSET_CODEPAIR,AMOUNT,Offset amount applied to passthrough device when applicable.
OFFSET_CODEPAIR,DATE_ACTIVATED,Mid-quarter effective date (YYYYMMDD) of offset amount to be returned.
OFFSET_HCPCS,LIST_ID,"Type of pass-through device offset.
Values:
5 = Terminated Device Procedure (activated V18.0, 2017-01-01)"
OFFSET_HCPCS,HCPCS,Procedure code subject to possible device offset/credit.
OFFSET_HCPCS,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_HCPCS,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
OFFSET_HCPCS,AMOUNT,Amount of payment offset/credit applied to terminated device procedure.
PBT_CONTROL,PBT_INDEX,Identifies execution path by concept (for internal use)
PBT_CONTROL,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
PBT_CONTROL,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
PBT_CONTROL,DX_PROC_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,LINE_ITEM_DATE,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,APC_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,AGE_SEX_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,UNIT_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,MODIFIER_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,NCCI_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,PH_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,MH_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,APC_RETURN_BUF,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,REV_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,OPPS_EDITS,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,BILL_TYPE,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,HCPC,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,NON_MCARE,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,PROC_MOD,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,HCPC_REQ,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,OBSERVATION,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,OPPS_PROC,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,DME,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,DX_PROC_EDITS2,Identifies logic associated with excution path (for internal use)
PBT_CONTROL,REV_EDITS2,Identifies logic associated with excution path (for internal use)
PBT_MAP,ROW_ID,Identifies execution path by bill type (for internal use)
PBT_MAP,LO_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
PBT_MAP,HI_VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
PBT_MAP,RULE,Identifies additional execution path criteria (for internal use)
PBT_MAP,PBT_INDEX,Identifies execution path by bill type (for internal use)
PBT_MAP,LO_BILL,Identifies the lowest bill type involved in the concept (for internal use)
PBT_MAP,HI_BILL,Identifies the highest bill type involved in the concept (for internal use)
VERSION_RANGE,VERSION,Version signature (for internal use). Refer to VERSION_RANGE table to determine date.
VERSION_RANGE,DATE_STARTED,The first date of the given version (for internal use).
VERSION_RANGE,DATE_ENDED,The last date of the given version (for internal use).
VERSION_RANGE,VERSION_ID,String representation of the version (exposed externally).
