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Variable Definitions

Note

These definitions are scraped from ResDAC. Click on the header of a variable description to see the ResDAC page.

Claim Accountable Care Organization (ACO) Identification Number

  • Short SAS Name: ACO_ID_NUM
  • Long SAS Name: ACO_ID_NUM

Contained in

The field identifies the Accountable Care Organization (ACO) Identification Number.

Claim Attending Physician NPI Number

  • Short SAS Name: AT_NPI
  • Long SAS Name: AT_PHYSN_NPI

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient at_npi at_npi at_npi at_npi at_npi
Outpatient at_npi at_npi at_npi at_npi at_npi
Dataset 2008 2007 2006 2005 2004
Inpatient at_npi at_npi at_npi at_npi at_npi
Outpatient at_npi at_npi at_npi at_npi at_npi
Dataset 2003 2002 2001 2000 1999
Inpatient at_npi at_npi at_npi at_npi at_npi
Outpatient at_npi at_npi at_npi at_npi at_npi

Contained in

On an institutional claim, the national provider identifier (NPI) number assigned to uniquely identify the physician who has overall responsibility for the beneficiary's care and treatment.

NOTE: Effective May 2007, the NPI will be- come the national standard identifier for covered health care providers. NPIs will replace current OSCAR provider number, UPINs, NSC numbers, and local contractor provider identification numbers (PINs) on standard HIPPA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capability was there for the NCH to receive NPIs along with an existing legacy number (UPIN, PIN, OSCAR provider number, etc.)).

NOTE1: CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be available in the NCH. After the 5/07 NPI implementation, the standard system main- tainers will add the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider number and any currently issued UPINs. Effective May 2007, no NEW UPINs (legacy number) will be generated for NEW physicians (Part B and Outpatient claims), so there will only be NPIs sent in to the NCH for those physicians.

Claim Attending Physician Specialty Code

  • Short SAS Name: AT_PHYSN_SPCLTY_CD
  • Long SAS Name: AT_PHYSN_SPCLTY_CD

Contained in

This variable is the code used to identify the CMS specialty code corresponding to the attending physician.

Values

Code Code Value
00 Carrier wide
01 General practice
02 General Surgery
03 Allergy/immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family Practice
09 Interventional Pain Management (IPM) (eff. 4/1/03)
10 Gastroenterology
11 Internal Medicine
12 Osteopathic manipulative therapy
13 Neurology
14 Neurosurgery
15 Speech/language pathology
16 Obstetrics/gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral surgery (dentists only)
20 Orthopedic surgery
21 Cardiac Electrophysiology
22 Pathology
24 Plastic and reconstructive surgery
25 Physical medicine and rehabilitation
26 Psychiatry
27 General Psychiatry
28 Colorectal surgery (formerly proctology)
29 Pulmonary disease
30 Diagnostic radiology
31 Intensive cardiac rehabilitation
32 Anesthesiologist Assistants (eff. 4/1/03 - previously grouped with Certified Registered Nurse Anesthetists (CRNA))
33 Thoracic surgery
34 Urology
35 Chiropractic
36 Nuclear medicine
37 Pediatric medicine
38 Geriatric medicine
39 Nephrology
40 Hand surgery
41 Optometrist
42 Certified nurse midwife
43 Certified Registered Nurse Anesthetist (CRNA) (Anesthesiologist Assistants were removed from this specialty 4/1/03)
44 Infectious disease
45 Mammography screening center
46 Endocrinology
47 Independent Diagnostic Testing Facility (IDTF)
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) e
53 Medical supply company with certified prosthetist-orthotist (certified by American Board for Certification in Prosthetics and Orthotics)
54 Medical supply company for DMERC (and not included in 51-53)
55 Individual certified orthotist
56 Individual certified prosthetist
57 Individual certified prosthetist-orthotist
58 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 Association, Catholic Charities)
62 Psychologist (billing indepedently)
63 Portable X-ray supplier
64 Audiologist (billing independently)
65 Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
66 Rheumatology
67 Occupational therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
68 Clinical psychologist
69 Clinical laboratory (billing independently)
70 Multispecialty clinic or group practice
71 Registered Dietician/Nutrition Professional (eff. 1/1/02)
72 Pain Management (eff. 1/1/02)
73 Mass Immunization Roster Biller
74 Radiation Therapy Centers (prior to 4/2003 this included independent Diagnostic Testing Facilities (IDTF)
75 Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs -- eff. 4/1/03)
76 Peripheral vascular disease
77 Vascular surgery
78 Cardiac surgery
79 Addiction medicine
80 Licensed clinical social worker
81 Critical care (intensivists)
82 Hematology
83 Hematology/oncology
84 Preventative medicine
85 Maxillofacial surgery
86 Neuropsychiatry
87 All other suppliers (e.g. drug and department stores)
88 Unknown supplier/provider specialty
89 Certified clinical nurse specialist
90 Medical oncology
91 Surgical oncology
92 Radiation oncology
93 Emergency medicine
94 Interventional radiology
95 Competitive Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/01/06, known as Independent physiological laboratory
96 Optician
97 Physician assistant
98 Gynecologist/oncologist
99 Unknown physician specialty
A0 Hospital (DMERCs only)
A1 SNF (DMERCs only)
A2 Intermediate care nursing facility (DMERCs only)
A3 Nursing facility, other (DMERCs only)
A4 Home Health Agency (DMERCs only)
A5 Pharmacy (DMERC)
A6 Medical supply company with respiratory therapist (DMERCs only)
A7 Department store (DMERC)
A8 Grocery store (DMERC)
A9 Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities, eff. 1/2005)
B1 Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07)
B2 Pedorthic Personnel (eff. 10/2/07)
B3 Medical Supply Company with pedorthic personnel (eff. 10/2/07)
B4 Does not meet definition of health care provider (e.g., Rehabilitation agency, organ procurement organizations, histocompatibility labs) (eff. 10/2/07)
B5 Ocularist
C0 Sleep medicine
C1 Centralized flu
C2 Indirect payment procedure
C3 Interventional cardiology
C5 Dentist (off. 7/2016)

Claim Attending Physician UPIN Number

  • Short SAS Name: AT_UPIN
  • Long SAS Name: AT_PHYSN_UPIN

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient at_upin at_upin at_upin at_upin at_upin
Outpatient at_upin at_upin at_upin at_upin at_upin
Dataset 2008 2007 2006 2005 2004
Inpatient at_upin at_upin at_upin at_upin at_upin
Outpatient at_upin at_upin at_upin at_upin at_upin
Dataset 2003 2002 2001 2000 1999
Inpatient at_upin at_upin at_upin at_upin at_upin
Outpatient at_upin at_upin at_upin at_upin at_upin

Contained in

On an institutional claim, the unique 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).

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009.

Claim Diagnosis Code I

  • Short SAS Name: ICD_DGNS_CD1
  • Long SAS Name: ICD_DGNS_CD1

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd1 icd_dgns_cd1 icd_dgns_cd1 dgns_cd1
Inpatient icd_dgns_cd1 icd_dgns_cd1 icd_dgns_cd1 icd_dgns_cd1 dgnscd1
Outpatient icd_dgns_cd1 icd_dgns_cd1 icd_dgns_cd1 icd_dgns_cd1 dgnscd1
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd1 dgns_cd1 dgns_cd1 dgns_cd1 dgns_cd1
Inpatient dgnscd1 dgnscd1 dgnscd1 dgns_cd1 dgns_cd1
Outpatient dgnscd1 dgnscd1 dgnscd1 dgns_cd1 dgns_cd1
Dataset 2003 2002 2001 2000 1999
Carrier dgns_cd1 dgns_cd1 dgns_cd1 dgns_cd1 bdx1
Inpatient dgns_cd1 dgns_cd1 dgnscd1 dgnscd1 dgnscd1
Outpatient dgns_cd1 dgns_cd1 dgns_cd1 dgnscd1 dgnscd1

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code II

  • Short SAS Name: ICD_DGNS_CD2
  • Long SAS Name: ICD_DGNS_CD2

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd2 icd_dgns_cd2 icd_dgns_cd2 dgns_cd2
Inpatient icd_dgns_cd2 icd_dgns_cd2 icd_dgns_cd2 icd_dgns_cd2 dgnscd2
Outpatient icd_dgns_cd2 icd_dgns_cd2 icd_dgns_cd2 icd_dgns_cd2 dgnscd2
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd2 dgns_cd2 dgns_cd2 dgns_cd2 dgns_cd2
Inpatient dgnscd2 dgnscd2 dgnscd2 dgns_cd2 dgns_cd2
Outpatient dgnscd2 dgnscd2 dgnscd2 dgns_cd2 dgns_cd2
Dataset 2003 2002 2001 2000 1999
Carrier dgns_cd2 dgns_cd2 dgns_cd2 dgns_cd2 bdx2
Inpatient dgns_cd2 dgns_cd2 dgnscd2 dgnscd2 dgnscd2
Outpatient dgns_cd2 dgns_cd2 dgns_cd2 dgnscd2 dgnscd2

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code III

  • Short SAS Name: ICD_DGNS_CD3
  • Long SAS Name: ICD_DGNS_CD3

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd3 icd_dgns_cd3 icd_dgns_cd3 dgns_cd3
Inpatient icd_dgns_cd3 icd_dgns_cd3 icd_dgns_cd3 icd_dgns_cd3 dgnscd3
Outpatient icd_dgns_cd3 icd_dgns_cd3 icd_dgns_cd3 icd_dgns_cd3 dgnscd3
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd3 dgns_cd3 dgns_cd3 dgns_cd3 dgns_cd3
Inpatient dgnscd3 dgnscd3 dgnscd3 dgns_cd3 dgns_cd3
Outpatient dgnscd3 dgnscd3 dgnscd3 dgns_cd3 dgns_cd3
Dataset 2003 2002 2001 2000 1999
Carrier dgns_cd3 dgns_cd3 dgns_cd3 dgns_cd3 bdx3
Inpatient dgns_cd3 dgns_cd3 dgnscd3 dgnscd3 dgnscd3
Outpatient dgns_cd3 dgns_cd3 dgns_cd3 dgnscd3 dgnscd3

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code IV

  • Short SAS Name: ICD_DGNS_CD4
  • Long SAS Name: ICD_DGNS_CD4

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd4 icd_dgns_cd4 icd_dgns_cd4 dgns_cd4
Inpatient icd_dgns_cd4 icd_dgns_cd4 icd_dgns_cd4 icd_dgns_cd4 dgnscd4
Outpatient icd_dgns_cd4 icd_dgns_cd4 icd_dgns_cd4 icd_dgns_cd4 dgnscd4
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd4 dgns_cd4 dgns_cd4 dgns_cd4 dgns_cd4
Inpatient dgnscd4 dgnscd4 dgnscd4 dgns_cd4 dgns_cd4
Outpatient dgnscd4 dgnscd4 dgnscd4 dgns_cd4 dgns_cd4
Dataset 2003 2002 2001 2000 1999
Carrier dgns_cd4 dgns_cd4 dgns_cd4 dgns_cd4 bdx4
Inpatient dgns_cd4 dgns_cd4 dgnscd4 dgnscd4 dgnscd4
Outpatient dgns_cd4 dgns_cd4 dgns_cd4 dgnscd4 dgnscd4

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code IX

  • Short SAS Name: ICD_DGNS_CD9
  • Long SAS Name: ICD_DGNS_CD9

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd9 icd_dgns_cd9 icd_dgns_cd9
Inpatient icd_dgns_cd9 icd_dgns_cd9 icd_dgns_cd9 icd_dgns_cd9 dgnscd9
Outpatient icd_dgns_cd9 icd_dgns_cd9 icd_dgns_cd9 icd_dgns_cd9 dgnscd9
Dataset 2008 2007 2006 2005 2004
Carrier
Inpatient dgnscd9 dgnscd9 dgnscd9 dgns_cd9 dgns_cd9
Outpatient dgnscd9 dgnscd9 dgnscd9 dgns_cd9 dgns_cd9
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd9 dgns_cd9 dgnscd9 dgnscd9 dgnscd9
Outpatient dgns_cd9 dgns_cd9 dgns_cd9 dgnscd9 dgnscd9

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code V

  • Short SAS Name: ICD_DGNS_CD5
  • Long SAS Name: ICD_DGNS_CD5

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd5 icd_dgns_cd5 icd_dgns_cd5 dgns_cd5
Inpatient icd_dgns_cd5 icd_dgns_cd5 icd_dgns_cd5 icd_dgns_cd5 dgnscd5
Outpatient icd_dgns_cd5 icd_dgns_cd5 icd_dgns_cd5 icd_dgns_cd5 dgnscd5
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd5 dgns_cd5 dgns_cd5
Inpatient dgnscd5 dgnscd5 dgnscd5 dgns_cd5 dgns_cd5
Outpatient dgnscd5 dgnscd5 dgnscd5 dgns_cd5 dgns_cd5
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd5 dgns_cd5 dgnscd5 dgnscd5 dgnscd5
Outpatient dgns_cd5 dgns_cd5 dgns_cd5 dgnscd5 dgnscd5

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code VI

  • Short SAS Name: ICD_DGNS_CD6
  • Long SAS Name: ICD_DGNS_CD6

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd6 icd_dgns_cd6 icd_dgns_cd6 dgns_cd6
Inpatient icd_dgns_cd6 icd_dgns_cd6 icd_dgns_cd6 icd_dgns_cd6 dgnscd6
Outpatient icd_dgns_cd6 icd_dgns_cd6 icd_dgns_cd6 icd_dgns_cd6 dgnscd6
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd6 dgns_cd6 dgns_cd6
Inpatient dgnscd6 dgnscd6 dgnscd6 dgns_cd6 dgns_cd6
Outpatient dgnscd6 dgnscd6 dgnscd6 dgns_cd6 dgns_cd6
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd6 dgns_cd6 dgnscd6 dgnscd6 dgnscd6
Outpatient dgns_cd6 dgns_cd6 dgns_cd6 dgnscd6 dgnscd6

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code VII

  • Short SAS Name: ICD_DGNS_CD7
  • Long SAS Name: ICD_DGNS_CD7

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd7 icd_dgns_cd7 icd_dgns_cd7 dgns_cd7
Inpatient icd_dgns_cd7 icd_dgns_cd7 icd_dgns_cd7 icd_dgns_cd7 dgnscd7
Outpatient icd_dgns_cd7 icd_dgns_cd7 icd_dgns_cd7 icd_dgns_cd7 dgnscd7
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd7 dgns_cd7 dgns_cd7
Inpatient dgnscd7 dgnscd7 dgnscd7 dgns_cd7 dgns_cd7
Outpatient dgnscd7 dgnscd7 dgnscd7 dgns_cd7 dgns_cd7
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd7 dgns_cd7 dgnscd7 dgnscd7 dgnscd7
Outpatient dgns_cd7 dgns_cd7 dgns_cd7 dgnscd7 dgnscd7

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code VIII

  • Short SAS Name: ICD_DGNS_CD8
  • Long SAS Name: ICD_DGNS_CD8

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd8 icd_dgns_cd8 icd_dgns_cd8 dgns_cd8
Inpatient icd_dgns_cd8 icd_dgns_cd8 icd_dgns_cd8 icd_dgns_cd8 dgnscd8
Outpatient icd_dgns_cd8 icd_dgns_cd8 icd_dgns_cd8 icd_dgns_cd8 dgnscd8
Dataset 2008 2007 2006 2005 2004
Carrier dgns_cd8 dgns_cd8 dgns_cd8
Inpatient dgnscd8 dgnscd8 dgnscd8 dgns_cd8 dgns_cd8
Outpatient dgnscd8 dgnscd8 dgnscd8 dgns_cd8 dgns_cd8
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd8 dgns_cd8 dgnscd8 dgnscd8 dgnscd8
Outpatient dgns_cd8 dgns_cd8 dgns_cd8 dgnscd8 dgnscd8

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code X

  • Short SAS Name: ICD_DGNS_CD10
  • Long SAS Name: ICD_DGNS_CD10

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier icd_dgns_cd10 icd_dgns_cd10 icd_dgns_cd10
Inpatient icd_dgns_cd10 icd_dgns_cd10 icd_dgns_cd10 icd_dgns_cd10 dgnscd10
Outpatient icd_dgns_cd10 icd_dgns_cd10 icd_dgns_cd10 icd_dgns_cd10 dgnscd10
Dataset 2008 2007 2006 2005 2004
Carrier
Inpatient dgnscd10 dgnscd10 dgnscd10 dgns_cd10 dgns_cd10
Outpatient dgnscd10 dgnscd10 dgnscd10 dgns_cd10 dgns_cd10
Dataset 2003 2002 2001 2000 1999
Carrier
Inpatient dgns_cd10 dgns_cd10 dgnscd10 dgnscd10 dgnscd10
Outpatient dgns_cd10 dgns_cd10 dgns_cd10 dgnscd10 dgnscd10

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XI

  • Short SAS Name: ICD_DGNS_CD11
  • Long SAS Name: ICD_DGNS_CD11

Variable Names

Dataset 2013 2012 2011 2010
Carrier icd_dgns_cd11 icd_dgns_cd11 icd_dgns_cd11
Inpatient icd_dgns_cd11 icd_dgns_cd11 icd_dgns_cd11 icd_dgns_cd11
Outpatient icd_dgns_cd11 icd_dgns_cd11 icd_dgns_cd11 icd_dgns_cd11

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XII

  • Short SAS Name: ICD_DGNS_CD12
  • Long SAS Name: ICD_DGNS_CD12

Variable Names

Dataset 2013 2012 2011 2010
Carrier icd_dgns_cd12 icd_dgns_cd12 icd_dgns_cd12
Inpatient icd_dgns_cd12 icd_dgns_cd12 icd_dgns_cd12 icd_dgns_cd12
Outpatient icd_dgns_cd12 icd_dgns_cd12 icd_dgns_cd12 icd_dgns_cd12

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XIII

  • Short SAS Name: ICD_DGNS_CD13
  • Long SAS Name: ICD_DGNS_CD13

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd13 icd_dgns_cd13 icd_dgns_cd13 icd_dgns_cd13
Outpatient icd_dgns_cd13 icd_dgns_cd13 icd_dgns_cd13 icd_dgns_cd13

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XIV

  • Short SAS Name: ICD_DGNS_CD14
  • Long SAS Name: ICD_DGNS_CD14

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd14 icd_dgns_cd14 icd_dgns_cd14 icd_dgns_cd14
Outpatient icd_dgns_cd14 icd_dgns_cd14 icd_dgns_cd14 icd_dgns_cd14

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XIX

  • Short SAS Name: ICD_DGNS_CD19
  • Long SAS Name: ICD_DGNS_CD19

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd19 icd_dgns_cd19 icd_dgns_cd19 icd_dgns_cd19
Outpatient icd_dgns_cd19 icd_dgns_cd19 icd_dgns_cd19 icd_dgns_cd19

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XV

  • Short SAS Name: ICD_DGNS_CD15
  • Long SAS Name: ICD_DGNS_CD15

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd15 icd_dgns_cd15 icd_dgns_cd15 icd_dgns_cd15
Outpatient icd_dgns_cd15 icd_dgns_cd15 icd_dgns_cd15 icd_dgns_cd15

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XVI

  • Short SAS Name: ICD_DGNS_CD16
  • Long SAS Name: ICD_DGNS_CD16

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd16 icd_dgns_cd16 icd_dgns_cd16 icd_dgns_cd16
Outpatient icd_dgns_cd16 icd_dgns_cd16 icd_dgns_cd16 icd_dgns_cd16

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XVII

  • Short SAS Name: ICD_DGNS_CD17
  • Long SAS Name: ICD_DGNS_CD17

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd17 icd_dgns_cd17 icd_dgns_cd17 icd_dgns_cd17
Outpatient icd_dgns_cd17 icd_dgns_cd17 icd_dgns_cd17 icd_dgns_cd17

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XVIII

  • Short SAS Name: ICD_DGNS_CD18
  • Long SAS Name: ICD_DGNS_CD18

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd18 icd_dgns_cd18 icd_dgns_cd18 icd_dgns_cd18
Outpatient icd_dgns_cd18 icd_dgns_cd18 icd_dgns_cd18 icd_dgns_cd18

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XX

  • Short SAS Name: ICD_DGNS_CD20
  • Long SAS Name: ICD_DGNS_CD20

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd20 icd_dgns_cd20 icd_dgns_cd20 icd_dgns_cd20
Outpatient icd_dgns_cd20 icd_dgns_cd20 icd_dgns_cd20 icd_dgns_cd20

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XXI

  • Short SAS Name: ICD_DGNS_CD21
  • Long SAS Name: ICD_DGNS_CD21

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd21 icd_dgns_cd21 icd_dgns_cd21 icd_dgns_cd21
Outpatient icd_dgns_cd21 icd_dgns_cd21 icd_dgns_cd21 icd_dgns_cd21

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XXII

  • Short SAS Name: ICD_DGNS_CD22
  • Long SAS Name: ICD_DGNS_CD22

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd22 icd_dgns_cd22 icd_dgns_cd22 icd_dgns_cd22
Outpatient icd_dgns_cd22 icd_dgns_cd22 icd_dgns_cd22 icd_dgns_cd22

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XXIII

  • Short SAS Name: ICD_DGNS_CD23
  • Long SAS Name: ICD_DGNS_CD23

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd23 icd_dgns_cd23 icd_dgns_cd23 icd_dgns_cd23
Outpatient icd_dgns_cd23 icd_dgns_cd23 icd_dgns_cd23 icd_dgns_cd23

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XXIV

  • Short SAS Name: ICD_DGNS_CD24
  • Long SAS Name: ICD_DGNS_CD24

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd24 icd_dgns_cd24 icd_dgns_cd24 icd_dgns_cd24
Outpatient icd_dgns_cd24 icd_dgns_cd24 icd_dgns_cd24 icd_dgns_cd24

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis Code XXV

  • Short SAS Name: ICD_DGNS_CD25
  • Long SAS Name: ICD_DGNS_CD25

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_dgns_cd25 icd_dgns_cd25 icd_dgns_cd25 icd_dgns_cd25
Outpatient icd_dgns_cd25 icd_dgns_cd25 icd_dgns_cd25 icd_dgns_cd25

Contained in

The diagnosis 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP).

Claim Diagnosis E Code I

  • Short SAS Name: ICD_DGNS_E_CD1
  • Long SAS Name: ICD_DGNS_E_CD1

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse effect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code II

  • Short SAS Name: ICD_DGNS_E_CD2
  • Long SAS Name: ICD_DGNS_E_CD2

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code III

  • Short SAS Name: ICD_DGNS_E_CD3
  • Long SAS Name: ICD_DGNS_E_CD3

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code IV

  • Short SAS Name: ICD_DGNS_E_CD4
  • Long SAS Name: ICD_DGNS_E_CD4

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code IX

  • Short SAS Name: ICD_DGNS_E_CD9
  • Long SAS Name: ICD_DGNS_E_CD9

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code V

  • Short SAS Name: ICD_DGNS_E_CD5
  • Long SAS Name: ICD_DGNS_E_CD5

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code VI

  • Short SAS Name: ICD_DGNS_E_CD6
  • Long SAS Name: ICD_DGNS_E_CD6

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code VII

  • Short SAS Name: ICD_DGNS_E_CD7
  • Long SAS Name: ICD_DGNS_E_CD7

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code VIII

  • Short SAS Name: ICD_DGNS_E_CD8
  • Long SAS Name: ICD_DGNS_E_CD8

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code X

  • Short SAS Name: ICD_DGNS_E_CD10
  • Long SAS Name: ICD_DGNS_E_CD10

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code XI

  • Short SAS Name: ICD_DGNS_E_CD11
  • Long SAS Name: ICD_DGNS_E_CD11

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Diagnosis E Code XII

  • Short SAS Name: ICD_DGNS_E_CD12
  • Long SAS Name: ICD_DGNS_E_CD12

Contained in

Effective with Version J, the code used to identify the external cause of injury, poisoning, or other adverse affect.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accomodate the future implementation of ICD-10. During the Version 'J' conversion this field was populated throughout history.

Claim Facility Type Code

  • Short SAS Name: FAC_TYPE
  • Long SAS Name: CLM_FAC_TYPE_CD

Contained in

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.

Values

Code Code Value
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 (discontinued effective 10/1/05)
6 Intermediate care
7 Clinic or hospital-based renal dialysis facility
8 Special facility or ASC surgery
9 Reserved

Claim Frequency Code

  • Short SAS Name: FREQ_CD
  • Long SAS Name: CLM_FREQ_CD

Contained in

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.

Values

Code Code Value
0 Non-payment/zero claims
1 Admit thru discharge claim
2 Interim - first claim
3 Interim - continuing claim (not valid for PPS claims)
4 Interim - last claim (not valid for PPS claims)
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 election notice - used when hospice or Religious Nonmedical Health Care Institution is submitting the HCFA-1450 as an admission notice - hospice NOE only
B Hospice/Medicare Coordinated Care Demonstration/RNCHI - Termination/Revocation Notice - hospice NOE only (eff 9/93)
C Hospice change of provider notice - hospice NOE only (eff 9/93)
D Hospice/Medicare Coordinated Care Demonstration/RNHCI - void/cancel - hospice NOE only (eff 9/93)
E Hospice change of ownership - hospice NOE only (eff 1/97)
F Beneficiary initiated adjustment claim (eff 10/93)
G CWF generated adjustment claim (eff 10/93)
H CMS generated adjustment claim (eff 10/93)
I Misc adjustment claim (other than PRO or provider) - used to identify a debit adjustment initiated by CMS or an intermediary (other than QIO or Provider) - 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 Quality Improvement Organization (QIO) -- formerly Peer Review Organization (PRO)
X Special adjustment processing - used for QA editing (eff 8/92)
Z Hospital Encounter Data alternate submission (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.

Claim From Date

  • Short SAS Name: FROM_DT
  • Long SAS Name: CLM_FROM_DT

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier from_dt from_dt from_dt from_dt
Inpatient from_dt from_dt from_dt from_dt from_dt
Outpatient from_dt from_dt from_dt from_dt from_dt
Dataset 2008 2007 2006 2005 2004
Carrier from_dt from_dt from_dt sfromdt sfromdt
Inpatient from_dt from_dt from_dt sfromdt sfromdt
Outpatient from_dt from_dt from_dt sfromdt sfromdt
Dataset 2003 2002 2001 2000 1999
Carrier sfromdt sfromdt from_dt from_dt bfromdt
Inpatient sfromdt sfromdt from_dt from_dt from_dt
Outpatient sfromdt sfromdt sfromdt from_dt from_dt

Contained in

The first day on the billing statement covering services rendered to the bene- ficiary (a.k.a. 'Statement Covers From Date').

NOTE: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match.

Claim ID

  • Short SAS Name: CLM_ID
  • Long SAS Name: CLM_ID

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier clm_id clm_id clm_id clm_id
Inpatient clm_id clm_id clm_id clm_id clm_id
Outpatient clm_id clm_id clm_id clm_id clm_id
Dataset 2008 2007 2006 2005 2004
Carrier clm_id clm_id clm_id claimindex claimindex
Inpatient clm_id clm_id clm_id claimindex claimindex
Outpatient clm_id clm_id clm_id claimindex claimindex
Dataset 2003 2002 2001 2000 1999
Carrier claimindex claimindex carrcntl carrcntl bccn
Inpatient claimindex claimindex link_num link_num clm_cntl
Outpatient claimindex claimindex claimindex link_num link_num

Contained in

The Unique CCW indentifier for a base claim. Simple encryption applied for extracts. Non-encrypted if pulled directly from CCW Oracle.

Limitation

When pulled directly from CCW, this is a numeric column.

Claim Line Number

  • Short SAS Name: CLM_LN
  • Long SAS Name: CLM_LINE_NUM

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient clm_ln clm_ln clm_ln clm_ln clm_ln
Dataset 2008 2007 2006 2005 2004
Outpatient clm_ln clm_ln clm_ln cntrindex cntrindex
Dataset 2003 2002 2001
Outpatient cntrindex cntrindex cntrindex

Contained in

The claim line number for detail revenue or part B line.

Claim MCO Paid Switch

  • Short SAS Name: MCOPDSW
  • Long SAS Name: CLM_MCO_PD_SW

Contained in

A switch indicating whether or not a Managed Care Organization (MCO) has paid the provider for an institutional claim.

Limitation

DESCRIPTION : The MCO paid switch made consistent with criteria used to identify an inpatient encounter claim.

BACKGROUND : During the NCH Version 'I' conversion, history was populated with an NCH Claim Type Code that will identify the record as an inpatient encounter claim. When applying the CWF logic to identify an inpatient encounter claim, it was discovered that when all the criteria was met the MCO paid switch was sometimes a blank or '0' (reflecting that the MCO did not pay the provider).

CORRECTIVE ACTION : With the inception of the Version 'I' processing (7/00), if all the criteria for identifying an inpatient encounter claim is met but the MCO paid switch is a blank or '0' it is changed to a '1'. A patch code = '13' was applied to all claims back to 7/1/97 service year thru date.

Values

Code Code Value
1 MCO has paid the provider for a claim
BLANK or 0 MCO has not paid the provider for a claim

Claim Medical Record Number

  • Short SAS Name: CLM_MDCL_REC
  • Long SAS Name: CLM_MDCL_REC

Contained in

The number assigned by the provider to the beneficiary's medical record to assist in record retrieval.

Claim Medicare Non Payment Reason Code

  • Short SAS Name: NOPAY_CD
  • Long SAS Name: CLM_MDCR_NON_PMT_RSN_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient nopay_cd nopay_cd nopay_cd nopay_cd nopay_cd
Dataset 2008 2007 2006 2005 2004
Outpatient nopay_cd nopay_cd nopay_cd nopay_cd nopay_cd
Dataset 2003 2002 2001 2000 1999
Outpatient nopay_cd nopay_cd nopay_cd nopay_cd cancelcd

Contained in

The reason that no Medicare payment is made for services on an institutional claim.

NOTE1: This field was put on all institutional claim types but data did not start coming in on OP/HHA/Hospice until 4/1/02. Prior to 4/1/02, data only came in Inpatient/SNF claims.

NOTE2: Effective 4/1/02, this field was also expanded to two bytes to accommodate new values. The NCH Nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of code for the crosswalk.

NOTE3: Effective with Version 'J', the field has been expanded on the NCH claim to 2 bytes. With this expansion the NCH will no longer use the character values to represent the official two byte values being sent in by CWF since 4/2002.

During the Version 'J' conversion, all character values were converted to the two byte values.

NOTE4: These code values were not identified as part of the original CMS data documentation.  ResDAC has identified the values and has provided them for convenience.

Values

Valid Values effective 1/2011 (2-byte values are replacing the character values)

Code Code Value
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)
00 MSP cost avoided - COB Contractor
12 MSP cost avoided - BCBS Voluntary Agreements
13 MSP cost avoided - Office of Personnel Management
14 MSP cost avoided - Workman's Compensation (WC) Datamatch
15 MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) (eff. 4/2006)
16 MSP cost avoided - Liability Insurer VDSA (eff. 4/2006)
17 MSP cost avoided - No-Fault Insurer VDSA (eff. 4/2006)
18 MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement (eff. 4/2006)
19 SEE NOTE4: Coordination of Benefits Contractor 11119 (see CMS Change Request 7906 for identification of the contractor.)
21 MSP cost avoided - MIR Group Heqalth Plan (eff. 1/2009)
22 MSP cost avoided - MIR non-Group Health Plan (eff. 1/2009)
25 MSP cost avoided - Recovery Audit Contractor - California (eff. 10/2005)
26 MSP cost avoided - Recovery Audit Contractor - Florida (eff. 10/2005)
42 SEE NOTE4: Coordination of Benefits Contractor 11142 (see CMS Change Request 7906 for identification of the contractor.)
43 SEE NOTE4: Coordination of Benefits Contractor 11143 (see CMS Change Request 7906 for identification of the contractor.)

Effective 4/1/02, the Medicare nonpayment reason code was expanded to a 2-byte field. The NCH instituted a crosswalk from the 2-byte code to a 1-byte character code. Below are the character codes (found in NCH & NMUD). At some point, NMUD will carry the 2-byte code but NCH will continue to have the 1-byte character code.

Code Code Value
! MSP cost avoided - COB Contractor ('00' 2-byte code)
@ MSP cost avoided - BC/BS Voluntary Agreements ('12' 2-byte code)
# MSP cost avoided - Office of Personnel Management ('13' 2-byte code)
$ MSP cost avoided - Workman's Compensation (WC) Datamatch ('14' 2-byte code)
* MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) ('15' 2-byte code) (eff. 4/2006)
( MSP cost avoided - Liability Insurer VDSA ('16' 2-byte code) (eff. 4/2006)
) MSP cost avoided - No-Fault Insurer VDSA ('17' 2-byte code) (eff. 4/2006)
+ MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement ('18' 2-byte code) (eff. 4/2006)
< MSP cost avoided - MIR Group Health Plan ('21' 2-byte code) (eff. 1/2009)
> MSP cost avoided - MIR non-Group Health Plan ('22' 2-byte code) (eff. 1/2009)
% MSP cost avoided - Recovery Audit Contractor - California ('25' 2-byte code) (eff. 10/2005)
& MSP cost avoided - Recovery Audit Contractor - Florida ('26' 2-byte code) (eff. 10/2005)

Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - 3 day SNF waiver

  • Short SAS Name: CLM_NEXT_GNRTN_ACO_IND_4_CD
  • Long SAS Name: CLM_NEXT_GNRTN_ACO_IND_CD4

Contained in

The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

There are 5 of these ACO fields (CLM_NEXT_GNRTN_ACO_IND_CD1 -CLM_NEXT_GNRTN_ACO_IND_CD5).

Values

Code Code Value
0 Base record (no enhancements)
1 Population Based Payments (PBP)
2 Telehealth
3 Post Discharge Home Health Visits
4 3-Day SNF Waiver
5 Capitation

Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Capitation

  • Short SAS Name: CLM_NEXT_GNRTN_ACO_IND_5_CD
  • Long SAS Name: CLM_NEXT_GNRTN_ACO_IND_CD5

Contained in

The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

There are 5 of these ACO fields (CLM_NEXT_GNRTN_ACO_IND_CD1 -CLM_NEXT_GNRTN_ACO_IND_CD5).

Values

Code Code Value
0 Base record (no enhancements)
1 Population Based Payments (PBP)
2 Telehealth
3 Post Discharge Home Health Visits
4 3-Day SNF Waiver
5 Capitation

Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Population based payments (PBP)

  • Short SAS Name: CLM_NEXT_GNRTN_ACO_IND_1_CD
  • Long SAS Name: CLM_NEXT_GNRTN_ACO_IND_CD1

Contained in

The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

There are 5 of these ACO fields (CLM_NEXT_GNRTN_ACO_IND_CD1 -CLM_NEXT_GNRTN_ACO_IND_CD5).

Values

Code Code Value
0 Base record (no enhancements)
1 Population Based Payments (PBP)
2 Telehealth
3 Post Discharge Home Health Visits
4 3-Day SNF Waiver
5 Capitation

Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Post Discharge HH visits

  • Short SAS Name: CLM_NEXT_GNRTN_ACO_IND_3_CD
  • Long SAS Name: CLM_NEXT_GNRTN_ACO_IND_CD3

Contained in

The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

There are 5 of these ACO fields (CLM_NEXT_GNRTN_ACO_IND_CD1 -CLM_NEXT_GNRTN_ACO_IND_CD5).

Values

Code Code Value
0 Base record (no enhancements)
1 Population Based Payments (PBP)
2 Telehealth
3 Post Discharge Home Health Visits
4 3-Day SNF Waiver
5 Capitation

Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code - Telehealth

  • Short SAS Name: CLM_NEXT_GNRTN_ACO_IND_2_CD
  • Long SAS Name: CLM_NEXT_GNRTN_ACO_IND_CD2

Contained in

The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

There are 5 of these ACO fields (CLM_NEXT_GNRTN_ACO_IND_CD1 -CLM_NEXT_GNRTN_ACO_IND_CD5).

Values

Code Code Value
0 Base record (no enhancements)
1 Population Based Payments (PBP)
2 Telehealth
3 Post Discharge Home Health Visits
4 3-Day SNF Waiver
5 Capitation

Claim Occurrence Span Code

  • Short SAS Name: SPAN_CD
  • Long SAS Name: CLM_SPAN_CD

Contained in

The code that identifies a significant event relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a time period (span of dates).

Values

Code Code Value
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 (utilization charged) - 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 Provider Liability (non-utilization) (Payer code) - Eff 3/92, from/thru dates of period of non-covered care where bene is not charged with utilization, deductible, or coinsurance and provider is liable. Eff 9/93, non-covered period of care due to lack of medical necessity.
80 Prior Same-SNF Stay Dates for Payment Ban Purposes - the from/thru dates of a prior same-SNF stay indicating a patient resided in the SNF prior to, and if applicable, during a payment ban period up until their discharge to a hospital.
81-99 Reserved for state assignment
M0 QIO/UR approved stay dates - Eff 10/93, the first and last days that were approved where not all of the stay was approved.
M1 Provider Liability-No Utilization - from/thru dates of a period of non-covered care that is denied due to lack of medical necessity or custodial care for which the provider is liable. (eff. 10/01)
M2 Dates of Inpatient Respite Care - from/thru dates of a period of inpatient respite care for hospice patients. (eff. 10/00)
M3 ICF Level of Care - the from/thru dates of a period of intermediate level of care during an inpatient hospital stay.
M4 Residential Level of Care - the from/thru dates of a period of residential level of care during an inpatient hospital stay.

Claim Occurrence Span From Date

  • Short SAS Name: SPANFROM
  • Long SAS Name: CLM_SPAN_FROM_DT

Contained in

The from date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.

Claim Occurrence Span Through Date

  • Short SAS Name: SPANTHRU
  • Long SAS Name: CLM_SPAN_THRU_DT

Contained in

The thru date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.

Claim Operating Physician NPI Number

  • Short SAS Name: OP_NPI
  • Long SAS Name: OP_PHYSN_NPI

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient op_npi op_npi op_npi op_npi op_npi
Outpatient op_npi op_npi op_npi op_npi op_npi
Dataset 2008 2007 2006 2005 2004
Inpatient op_npi op_npi op_npi op_npi op_npi
Outpatient op_npi op_npi op_npi op_npi op_npi
Dataset 2003 2002 2001 2000 1999
Inpatient op_npi op_npi op_npi op_npi op_npi
Outpatient op_npi op_npi op_npi op_npi op_npi

Contained in

On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify the physician with the primary responsibility for performing the surgical procedure(s).

NOTE: Effective May 2007, the NPI will become the national standard identifier for covered health care providers. NPIs will replace the current OSCAR provider number, UPINs, NSC numbers, and local contractor provider identi- fication numbers (PINs) on standard HIPPA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capability was there for the NCH to receive NPIs along with an existing legacy number (UPIN, PIN, OSCAR provider number, etc.)).

NOTE1: CMS has determined that dual provider identifiers (old legacy number and new NPI) must be available in the NCH. After the 5/07 NPI implementation, the standard system maint- tainers will add the legacy number to the claim when its adjudicated. We will continue to re- ceive the OSCAR provider number and any currently issued UPINs. Effective May 2007, no NEW UPINs (legacy numbers) will be generated for NEW physicians (Part B and outpatient claims), so there will only be NPIs sent in to the NCH for those physicians.

Claim Operating Physician Specialty Code

  • Short SAS Name: OP_PHYSN_SPCLTY_CD
  • Long SAS Name: OP_PHYSN_SPCLTY_CD

Contained in

The code used to identify the CMS specialty code corresponding to the operating physician. The Affordable Care Act (ACA) provides for incentive payments for physicians and non-physician practitioners with specific primary specialty designations. In order to determine if the physician or non-physicians is eligible for the incentive payment, the specialty code, NPI and name must be carried on the claims. 

Values

Code Code Value
00 Carrier wide
01 General practice
02 General surgery
03 Allergy/immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family practice
09 Interventional Pain Management (IPM) (eff. 4/1/03)
10 Gastroenterology
11 Internal medicine
12 Osteopathic manipulative therapy
13 Neurology
14 Neurosurgery
15 Speech/language pathology
16 Obstetrics/gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral surgery (dentists only)
20 Orthopedic surgery
21 Cardiac Electrophysiology
22 Pathology
24 Plastic and reconstructive surgery
25 Physical medicine and rehabilitation
26 Psychiatry
27 General Psychiatry
28 Colorectal surgery (formerly proctology)
29 Pulmonary disease
30 Diagnostic radiology
31 Intensive cardiac rehabilitation
32 Anesthesiologist Assistants (eff. 4/1/03--previously grouped with Certified Registered Nurse Anesthetists (CRNA))
33 Thoracic surgery
34 Urology
35 Chiropractic
36 Nuclear medicine
37 Pediatric medicine
38 Geriatric medicine
39 Nephrology
40 Hand surgery
41 Optometrist
42 Certified nurse midwife
43 Certified Registered Nurse Anesthetist (CRNA) (Anesthesiologist Assistants were removed from this specialty 4/1/03)
44 Infectious disease
45 Mammography screening center
46 Endocrinology
47 Independent Diagnostic Testing Facility (IDTF)
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 prosthetics-orthotist (certified by American Board for Certification in Prosthetics and Orthotics)
54 Medical supply company for DMERC (and not included in 51-53)
55 Individual certified orthoptist
56 Individual certified prosthetist
57 Individual certified prosthetist-orthotist
58 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 Association, Catholic Charities)
62 Psychologist (billing independently)
63 Portable X-ray supplier
64 Audiologist (billing independently)
65 Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
66 Rheumatology
67 Occupational therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
68 Clinical laboratory (billing independently)
69 Clinical laboratory (billing independently)
70 Multispecialty clinic or group practice
71 Registered Dietician/Nutrition Professional (eff. 1/1/02)
72 Pain Management (eff. 1/1/02)
73 Mass Immunization Roster Biller
74 Radiation Therapy Centers (prior to 4/2003 this included independent Diagnostic Testing Facilities (IDTF))
75 Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs--eff. 4/1/03))
76 Peripheral vascular disease
77 Vascular surgery
78 Cardiac surgery
79 Addiction medicine
80 Licensed clinical social worker
81 Critical care (intensivists)
82 Hematology
83 Hematology/oncology
84 Preventive medicine
85 Maxillofacial surgery
86 Neuropsychiatry
87 All other suppliers (e.g. drug and department stores)
88 Unknown supplier/provider specialty
89 Certified clinical nurse specialist
90 Medical oncology
91 Surgical oncology
92 Radiation oncology
93 Emergency medicine
94 Interventional radiology
95 Competitive Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/10/06, known as Independent physiological laboratory
96 Optician
97 Physician assistant
98 Gynecologist/oncologist
99 Unknown physician specialty
A0 Hospital (DMERCs only)
A1 SNF (DMERCs only)
A2 Intermediate care nursing facility (DMERCs only)
A3 Nursing facility, other (DMERCs only)
A4 Home Health Agency (DMERCs only)
A5 Pharmacy (DMERC)
A6 Medical supply company with respiratory therapist (DMERCs only)
A7 Department store (DMERC)
A8 Grocery store (DMERC)
A9 Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities, eff. 1/2005)
B1 Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07)
B2 Pedorthic Personnel (eff. 10/2/07)
B3 Medical Supply Company with pedorthic personnel (eff. 10/2/07)
B4 Does not meet definition of health care provider (e.g., Rehabilitation agency, organ procurement organizations, histocompatibility labs) (eff. 10/2/07)
B5 Ocularist
C0 Sleep medicine
C1 Centralized flu
C2 Indirect payment procedure
C3 Interventional cardiology
C5 Dentist (eff. 7/2016)

Claim Operating Physician UPIN Number

  • Short SAS Name: OP_UPIN
  • Long SAS Name: OP_PHYSN_UPIN

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient op_upin op_upin op_upin op_upin op_upin
Outpatient op_upin op_upin op_upin op_upin op_upin
Dataset 2008 2007 2006 2005 2004
Inpatient op_upin op_upin op_upin op_upin op_upin
Outpatient op_upin op_upin op_upin op_upin op_upin
Dataset 2003 2002 2001 2000 1999
Inpatient op_upin op_upin op_upin op_upin op_upin
Outpatient op_upin op_upin op_upin op_upin op_upin

Contained in

On an institutional claim, the unique physician 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 surgi- cal procedure.

Claim Other Physician NPI Number

  • Short SAS Name: OT_NPI
  • Long SAS Name: OT_PHYSN_NPI

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient ot_npi ot_npi ot_npi ot_npi ot_npi
Outpatient ot_npi ot_npi ot_npi ot_npi ot_npi
Dataset 2008 2007 2006 2005 2004
Inpatient ot_npi ot_npi ot_npi ot_npi ot_npi
Outpatient ot_npi ot_npi ot_npi ot_npi ot_npi
Dataset 2003 2002 2001 2000 1999
Inpatient ot_npi ot_npi ot_npi ot_npi ot_npi
Outpatient ot_npi ot_npi ot_npi ot_npi ot_npi

Contained in

On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify the other physician associated with the institutiohal claim.

NOTE: Effective May 2007, the NPI will be- come the national standard identifier for covered health care providers. NPIs will replace current OSCAR provider number, UPINs, NSC numbers, and local contractor provider identification numbers (PINs) on standard HIPPA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capability was there for the NCH to receive NPIs along with an existing legacy number (UPIN, PIN, OSCAR provider number, etc.)).

NOTE1: CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be available in the NCH. After the 5/07 NPI implementation, the standard system main- tainers will add the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider number and any currently issued UPINs. Effective May 2007, no NEW UPINs (legacy number) will be generated for NEW physicians (Part B AND outpatient claims), so there will only be NPIs sent in to the NCH for those physicians.

Claim Other Physician Specialty Code

  • Short SAS Name: OT_PHYSN_SPCLTY_CD
  • Long SAS Name: OT_PHYSN_SPCLTY_CD

Contained in

The code used to identify the CMS specialty code corresponding to the other physician. 

The Affordable Care Act (ACA) provides for incentive payments for physicians and non-physician practitioners with specific primary specialty designations. In order to determine if the physician or non-physician is eligible for the incentive payment, the specialty code, NPI and name must be carried on the claims.

Values

Code Code Value
00 Carrier wide
01 General practice
02 General surgery
03 Allergy/immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family Practice
09 Interventional Pain Management (IPM) (eff. 4/1/03)
10 Gastroenterology
11 Internal medicine
12 Osteopathic manipulative therapy
13 Neurology
14 Neurosurgery
15 Speech/language pathology
16 Obstetrics/gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral surgery (dentists only)
20 Orthopedic surgery
21 Cardiac Electrophysiology
22 Pathology
24 Plastic and reconstructive surgery
25 Physical medicine and rehabilitation
26 Psychiatry
27 General Psychiatry
28 Colorectal surgery (formerly proctology)
29 Pulmonary disease
30 Diagnostic radiology
31 Intensive cardiac rehabilitation
32 Anesthesiologist Assistants (eff. 4/1/03--previously grouped with Certified Registered Nurse Anesthetists (CRNA))
33 Thoracic surgery
34 Urology
35 Chiropractic
36 Nuclear medicine
37 Pediatric medicine
38 Geriatric medicine
39 Nephrology
40 Hand surgery
41 Optometrist
42 Certified nurse midwife
43 Certified Registered Nurse Anesthetist (CRNA) (Anesthesiologist Assistants were removed from this specialty 4/1/03)
44 Infectious disease
45 Mammography screening center
46 Endocrinology
47 Independent Diagnostic Testing Facility (IDTF)
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 for DMERC (and not included in 51-53)
55 Individual certified orthotist
56 Individual certified prosthetist
57 Individual certified prosthetist-orthotist
58 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 Association, Catholic Charities)
62 Psychologist (billing independently)
63 Portable X-ray supplier
64 Audiologist (billing independently)
65 Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
66 Rheumatology
67 Occupational therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
68 Clinical psychologist
69 Clinical laboratory (billing independently)
70 Multispecialty clinic or group practice
71 Registered Dietician/Nutrition Professional (eff. 1/1/02)
72 Pain Management (eff. 1/1/02)
73 Mass Immunization Roster Biller
74 Radiation Therapy Centers (prior to 4/2003 this included Independent Diagnostic Testing Facilities (IDTF))
75 Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs -- eff. 4/1/03))
76 Peripheral vascular disease
77 Vascular surgery
78 Cardiac surgery
79 Addiction medicine
80 Licensed clinical social worker
81 Critical care (intensivists)
82 Hematology
83 Hematology/oncology
84 Preventive medicine
85 Maxillofacial surgery
86 Neuropsychiatry
87 All other suppliers (e.g. drug and department stores)
88 Unknown supplier/provider specialty
89 Certified clinical nurse specialist
90 Medical oncology
91 Surgical oncology
92 Radiation oncology
93 Emergency medicine
94 Interventional radiology
95 Competitive Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/01/06, known as Independent physiological laboratory
96 Optician
97 Physician assistnat
98 Gynecologist/oncologist
99 Unknown physician specialty
A0 Hospital (DMERCs only)
A1 SNF (DMERCs only)
A2 Intermediate care nursing facility (DMERCs only)
A3 Nursing facility, other (DMERCs only)
A5 Pharmacy (DMERC)
A6 Medical supply company with respiratory therapist (DMERCs only)
A7 Department store (DMERC)
A8 Grocery store (DMERC)
A9 Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities, eff. 1/2005)
B1 Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07)
B2 Pedorthic Personnel (eff. 10/2/07)
B3 Medical Supply Company with pedorthic personnel (eff. 10/2/07)
B4 Does not meet definition of health care provider (e.g., Rehabilitation agency, organ procurement organizations, histocompatibility labs) (eff. 10/2/07)
B5 Ocularist
C0 Sleep medicine
C1 Centralized flu
C2 Indirect payment procedure
C3 Interventional cardiology
C5 Dentist (eff. 7/2016)

Claim Other Physician UPIN Number

  • Short SAS Name: OT_UPIN
  • Long SAS Name: OT_PHYSN_UPIN

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient ot_upin ot_upin ot_upin ot_upin ot_upin
Outpatient ot_upin ot_upin ot_upin ot_upin ot_upin
Dataset 2008 2007 2006 2005 2004
Inpatient ot_upin ot_upin ot_upin ot_upin ot_upin
Outpatient ot_upin ot_upin ot_upin ot_upin ot_upin
Dataset 2003 2002 2001 2000 1999
Inpatient ot_upin ot_upin ot_upin ot_upin ot_upin
Outpatient ot_upin ot_upin ot_upin ot_upin ot_upin

Contained in

On an institutional claim, the unique physician identification number (UPIN) of the other physician associated with the institutional claim.

Claim Outpatient Beneficiary Payment Amount

  • Short SAS Name: BENEPMT
  • Long SAS Name: CLM_OP_BENE_PMT_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient benepmt benepmt benepmt benepmt benepmt
Dataset 2008 2007 2006 2005 2004
Outpatient benepmt benepmt benepmt benepmt benepmt
Dataset 2003 2002 2001 2000 1999
Outpatient benepmt benepmt benepmt benepmt benepmt

Contained in

Effective with Version H, the amount paid, from the Medicare trust fund, to the beneficiary for the services reported on the outpatient claim.

NOTE: 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.

Values

Code
XXX.XX

Claim Outpatient End Stage Renal Disease (ESRD) Method of Reimbursement Code

  • Short SAS Name: CLM_OP_ESRD_MTHD_CD
  • Long SAS Name: CLM_OP_ESRD_MTHD_CD

Contained in

This variable contains the code denoting the method of reimbursement selected by the beneficiary receiving End Stage Renal Disease (ESRD) services for home dialysis (i.e. whether home supplies are purchased through a facility or from a supplier.)

Values

Code Code Value
0 Not ESRD
1 Method 1 - Home supplies purchased through a facility
2 Method 2 - Home supplies purchased from a supplier

Claim Outpatient Provider Payment Amount

  • Short SAS Name: PRVDRPMT
  • Long SAS Name: CLM_OP_PRVDR_PMT_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient prvdrpmt prvdrpmt prvdrpmt prvdrpmt prvdrpmt
Dataset 2008 2007 2006 2005 2004
Outpatient prvdrpmt prvdrpmt prvdrpmt prvdrpmt prvdrpmt
Dataset 2003 2002 2001 2000 1999
Outpatient prvdrpmt prvdrpmt prvdrpmt prvdrpmt prvdrpmt

Contained in

Effective with Version H, the amount paid, from the Medicare trust fund, to the provider for the services reported on the outpatient claim.

NOTE: 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.

Claim Outpatient transaction type

  • Short SAS Name: CLM_OP_TRANS_TYPE_CD
  • Long SAS Name: CLM_OP_TRANS_TYPE_CD

Contained in

The code derived by CMS based on the type of bill and provider number to identify the outpatient transaction type.

Values

Code Code Value
A Outpatient Psychiatric Hospital
B Outpatient tuberculosis (TB) Hospital
C Outpatient General Care Hospital
D Outpatient Skilled Nursing Facility (SNF)
E Home Health Agency
F Comprehensive Health Care
G Clinical Rehab Agency
H Rural Health Clinic
I Satellite Dialysis Facility
J Limited Care Facility
O Christian Science SNF
1 Psychiatric Hospital Facility
2 TB Hospital Facility
3 General Care Hospital
4 Regular SNF
SPACES Home Health/Hospice

Claim Pricer Return Code

  • Short SAS Name: CLM_PRCR_RTRN_CD
  • Long SAS Name: CLM_PRCR_RTRN_CD

Contained in

The code used to identify various prospective payment system (PPS) payment adjustment types. This code identifies the payment return code or the error return code for every claim type calculated by the PRICER tool.

The payment return code identifies the type of payment calculated by the PRICER software.

Values

The meaning of the values varies by type of bill (TOB)
Inpatient Hospital Pricer Return Codes**
******TOB 11X*****
Inpatient Hospital Payment return codes:

Code Code Value
0 Paid normal DRG payment
1 Paid as a day outlier (Note: day outlier no longer being paid as of 10/1/97)
2 Paid as a cost outlier
3 Transfer paid on a per diem basis up to and including the full DRG
5 Transfer paid on a per diem basis up to and including the full DRG which also qualified for a cost outlier payment
6 Provider refused cost outlier
10 DRG is 209, 210, or 211 and post-acute transfer
12 Post-acute transfer with specific DRGs. The following DRG's: 14, 113, 236, 263, 264, 429, 483
14 Paid normal DRG payment with per diem days = or > GM ALOS
16 Paid as a cost outlier with per diem days = or > GM ALOS
nan Inpatient Hospital Error return codes:
51 No provider specific information found
52 Invalid MSA# in provider file
53 Waiver state - not calculated by PPS
54 DRG < 001 or > 511, or = 214, 215, 221, 222, 438, 456, 457, 458
55 Discharge date < provider effective start date or discharge date < MSA effective start date for PPS
56 Invalid length of stay
57 Review code invalid (Not 00, 03, 06, 07, 09)
58 Total charges not numeric
61 Lifetime reserve days not numeric or BILL-LTR-DAYS > 60
62 Invalid number of covered days
65 PAY-CODE not = A, B or C on provider specific file for capital
67 Cost outlier with LOS > covered days
nan Inpatient Rehab Facility (IRF) Pricer Return Codes
nan IRF Payment return codes:
0 Paid normal CMG payment without outlier
1 Paid normal CMG payment with outlier
2 Transfer paid on a per diem basis without outlier
3 Transfer paid on a per diem basis with outlier
4 Blended CMG payment -- ⅔ Federal PPS rate + ⅓ provider specific rate -- without outlier
5 Blended CMG payment -- ⅔ Federal PPS rate + ⅓ provider specific rate -- with outlier
6 Blended transfer payment -- ⅔ Federal PPS transfer rate + ⅓ provider specific rate -- without outlier
7 Blended transfer payment -- ⅔ Federal PPS transfer rate + ⅓ provider specific rate -- with outlier
10 Paid normal CMG payment with penalty without outlier
11 Paid normal CMG payment with penalty with outlier
12 Transfer paid on a per diem basis with penalty without outlier
13 Transfer paid on a per diem basis with penalty with outlier
14 Blended CMG payment -- ⅔ Federal PPS rate + ⅓ provider specific rate -- with penalty without outlier
15 Blended CMG payment -- ⅔ Federal PPS rate + ⅓ provider specific rate -- with penalty with outlier
16 Blended transfer payment -- ⅔ Federal PPS transfer rate + ⅓ provider specific rate -- with penalty without outlier
17 Blended transfer payment -- ⅔ Federal PPS transfer rate + ⅓ provider specific rate -- with penalty with outlier
nan IRF Error return codes:
50 Provider specific rate not numeric
51 Provider record terminated
52 Invalid wage index
53 Waiver state - not calculated by PPS
54 CMG on claim not found in table
55 Discharge date < provider effective start date or discharge date < MSA effective start date for PPS
56 Invalid length of stay
57 Provider specific rate zero when blended payment requested
58 Total covered charges not numeric
59 Provider specific record not found
60 MSA wage index record not found
61 Lifetime reserve days not numeric or BILL-LTR-DAYS > 60
62 Invalid number of covered days
65 Operating cost-to-charge ratio not numeric
67 Cost outlier with LOS > covered days or cost outlier threshold calculation
72 Invalid blend indicator (not 3 or 4)
73 Discharged before provider FY begin date
74 Provider FY begin date not in 2002
nan Long Term Care Hospital (LTCH) Pricer Return Codes
nan LTCH Payment return codes:
0 Normal DRG payment without outlier
1 Normal DRG payment with outlier
2 Short stay payment without outlier
3 Short stay payment with outlier
4 Blend year 1 - 80% facility rate plus 20% normal DRG payment without outlier
5 Blend year 1 - 80% facility rate plus 20% normal DRG payment with outlier
6 Blend year 1 - 80% facility rate plus 20% short stay payment without outlier
7 Blend year 1 - 80% facility rate plus 20% short stay payment with outlier
8 Blend year 2 - 60% facility rate plus 40% normal DRG payment without outlier
9 Blend year 2 - 60% facility rate plus 40% normal DRG payment with outlier
10 Blend year 2 - 60% facility rate plus 40% short stay payment without outlier
11 60% facility rate plus 40% short stay payment with outlier
12 Blend year 3 - 40% facility rate plus 60% normal DRG payment without outlier
13 Blend year 3 - 40% facility rate plus 60% normal DRG payment with outlier
14 Blend year 3 - 40% facility rate plus 60% short stay payment without outlier
15 Blend year 3 - 40% facility rate plus 60% short stay payment with outlier
16 Blend year 4 - 20% facility rate plus 80% normal DRG payment without outlier
17 Blend year 4 - 20% facility rate plus 80% normal DRG payment with outlier
18 Blend year 4 - 20% facility rate plus 80% short stay payment without outlier
19 Blend year 4 - 20% facility rate plus 80% short stay payment with outlier
nan LTCH Error return codes:
50 Provider specific rate not numeric
51 Provider record terminated
52 Invalid wage index
53 Waiver state - not calculated by PPS
54 DRG on claim not found in table
55 Discharge date < provider effective start date or discharge date < MSA effective start date for PPS
56 Invalid length of stay
57 Provider specific rate zero when blended payment requested
58 Total covered charges not numeric
59 Provider specific record not found
60 MSA wage index record not found
61 Lifetime reserve days not numeric or BILL-LTR-DAYS > 60
62 Invalid number of covered days
65 Operating cost-to-charge ratio not numeric
67 Cost outlier with LOS > covered days or cost outlier threshold calculation
72 Invalid blend indicator (not 1 thru 5)
73 Discharged before provider FY begin date
74 Provider FY begin date not in 2002
nan **SNF Pricer Return Codes**
nan ****TOB 21X****
nan SNF Payment return codes:
0 RUG III group rate returned SNF Error return codes:
20 Bad RUG code
30 Bad MSA code
40 Thru date < July 1, 1998 or invalid
50 Invalid Federal blend for that year
60 Invalid Federal blend
61 Federal blend = 0 and SNF thru date < January 1, 2000
nan **Hospice Pricer Return Codes***
nan **TOB 81X or 82X****
nan Hospice Payment Return Codes:
0 Home rate returned Hospice Error Return Codes:
10 Bad units
20 Bad units2 < 8
30 Bad MSA code
40 Bad hospice wage index from MSA file
50 Bad bene wage index from MSA file
51 Bad provider number
nan *Home Health Pricer Return Codes****
nan TOB 32X or 33X, DOS 10/1/2000 and after*
nan Home Health Payment Return Codes:
0 Final payment where no outlier applies
1 Final payment where outlier applies
3 Initial percentage payment, 0%
4 Initial percentage payment, 50%
5 Initial percentage payment, 60%
6 LUPA payment only
7 Final payment, SCIC
8 Final payment, SCIC with outlier
9 Final payment, PEP
11 Final payment, PEP with outlier
12 Final payment, SCIC within PEP
13 Final payment, SCIS within PEP with outlier
nan Home Health Error Return Codes:
10 Invalid TOB
15 Invalid PEP Days
16 Invalid HRG Days, >60
20 PEP indicator invalid
25 Med review indicator invalid
30 Invalid MSA code
35 Invalid Initial Payment Indicator
40 Dates < October 1, 2000 or invalid
70 Invalid HRG Code
75 No HRG present in 1st occurrence
80 Invalid Revenue code
85 No revenue code present on HH final claim/adjustment
nan **Outpatient PPS Pricer Return Codes**
nan Outpatient PPS Payment return codes:
1 Line processed to payment
20 Line processed but payment = 0 bene deductible = > adjusted payment
nan Outpatient PPS Error return codes:
30 Missing, deleted or invalid APC
38 Missing or invalid discount factor
40 Invalid service indicator passed by the OCE
41 Service indicator invalid for OPPS PRICER
42 APC = '00000' or (packaging flag = 1 or 2)
43 Payment indicator not = to 1 or 5 thru 9
44 Service indicator = 'H' but payment indicator not = to 6
45 Packaging flag not = to 0
46 Line item denial/reject flag not = to 0 or line item denial/reject flag = to 1 and (APC not = 0033 or 0034 or 0322 or 0323 or 0324 or 0325 or 0373 or 0374)) or line item action flag not = to 1
47 Line item action flag = 2 or 3
48 Payment adjustment flag not valid
49 Site of service flag not = to 0 or (APC 0033 is not on the claim and service indicator = 'P' or APC = 0322, 0325, 0373, 0374)
50 Wage index not located
51 Wage index equals zero
52 Provider specific file wage index reclassification code invalid or missing
53 Service from date not numeric or < 20000801
54 Service from date < provider effective date or service from date > provider termination date
nan End Stage Renal Disease (ESRD) Pricer Return Codes
nan ESRD Payment return codes:
0 ESRD PPS payment calculated
1 ESRD facility rate > zero
nan ESRD Error return codes:
50 ESRD facility rate not numeric
52 Provider type not = '40' or '41'
53 Special payment indicator not = '1' or blank
54 Date of birth not numeric or = zero
55 Patient weight not numeric or = zero
56 Patient height not numeric or = zero
57 Revenue center code not in range
58 Condition code not = '73' or '74' or blank
60 MSA wage adjusted rate record not found
98 Claim through date before 4/1/2005 or not numeric

Claim Principal Diagnosis Code

  • Short SAS Name: PRNCPAL_DGNS_CD
  • Long SAS Name: PRNCPAL_DGNS_CD

Variable Names

Dataset 2012 2011 2010 2009 2008
Carrier prncpal_dgns_cd prncpal_dgns_cd prncpal_dgns_cd dgns_cd1 dgns_cd1
Dataset 2007 2006 2005 2004 2003
Carrier dgns_cd1 dgns_cd1 pdgns_cd pdgns_cd pdgns_cd
Dataset 2002 2001 2000 1999
Carrier pdgns_cd pdgns_cd pdgns_cd pdgns_cd

Contained in

The diagnosis code identifying the diagnosis, 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.

NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

Claim Procedure Code I

  • Short SAS Name: ICD_PRCDR_CD1
  • Long SAS Name: ICD_PRCDR_CD1

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd1 icd_prcdr_cd1 icd_prcdr_cd1 icd_prcdr_cd1 prcdrcd1
Outpatient icd_prcdr_cd1 icd_prcdr_cd1 icd_prcdr_cd1 icd_prcdr_cd1 prcdrcd1
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd1 prcdrcd1 prcdrcd1 prcdr_cd1 prcdr_cd1
Outpatient prcdrcd1 prcdrcd1 prcdrcd1 prcdr_cd1 prcdr_cd1
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd1 prcdr_cd1 prcdrcd1 prcdrcd1 prcdrcd1
Outpatient prcdr_cd1 prcdr_cd1 prcdr_cd1 prcdrcd1 prcdrcd1

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code I Date

  • Short SAS Name: PRCDR_DT1
  • Long SAS Name: PRCDR_DT1

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt1 prcdr_dt1 prcdr_dt1 prcdr_dt1 prcdrdt1
Outpatient prcdr_dt1 prcdr_dt1 prcdr_dt1 prcdr_dt1 prcdrdt1
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt1 prcdrdt1 prcdrdt1 prcdr_dt1 prcdr_dt1
Outpatient prcdrdt1 prcdrdt1 prcdrdt1 prcdr_dt1 prcdr_dt1
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt1 prcdr_dt1 prcdrdt1 prcdr_dt1 prcdrdt1
Outpatient prcdr_dt1 prcdr_dt1 prcdr_dt1 prcdrdt1 prcdrdt1

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code II

  • Short SAS Name: ICD_PRCDR_CD2
  • Long SAS Name: ICD_PRCDR_CD2

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd2 icd_prcdr_cd2 icd_prcdr_cd2 icd_prcdr_cd2 prcdrcd2
Outpatient icd_prcdr_cd2 icd_prcdr_cd2 icd_prcdr_cd2 icd_prcdr_cd2 prcdrcd2
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd2 prcdrcd2 prcdrcd2 prcdr_cd2 prcdr_cd2
Outpatient prcdrcd2 prcdrcd2 prcdrcd2 prcdr_cd2 prcdr_cd2
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd2 prcdr_cd2 prcdrcd2 prcdrcd2 prcdrcd2
Outpatient prcdr_cd2 prcdr_cd2 prcdr_cd2 prcdrcd2 prcdrcd2

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code II Date

  • Short SAS Name: PRCDR_DT2
  • Long SAS Name: PRCDR_DT2

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt2 prcdr_dt2 prcdr_dt2 prcdr_dt2 prcdrdt2
Outpatient prcdr_dt2 prcdr_dt2 prcdr_dt2 prcdr_dt2 prcdrdt2
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt2 prcdrdt2 prcdrdt2 prcdr_dt2 prcdr_dt2
Outpatient prcdrdt2 prcdrdt2 prcdrdt2 prcdr_dt2 prcdr_dt2
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt2 prcdr_dt2 prcdrdt2 prcdr_dt2 prcdrdt2
Outpatient prcdr_dt2 prcdr_dt2 prcdr_dt2 prcdrdt2 prcdrdt2

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code III

  • Short SAS Name: ICD_PRCDR_CD3
  • Long SAS Name: ICD_PRCDR_CD3

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd3 icd_prcdr_cd3 icd_prcdr_cd3 icd_prcdr_cd3 prcdrcd3
Outpatient icd_prcdr_cd3 icd_prcdr_cd3 icd_prcdr_cd3 icd_prcdr_cd3 prcdrcd3
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd3 prcdrcd3 prcdrcd3 prcdr_cd3 prcdr_cd3
Outpatient prcdrcd3 prcdrcd3 prcdrcd3 prcdr_cd3 prcdr_cd3
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd3 prcdr_cd3 prcdrcd3 prcdrcd3 prcdrcd3
Outpatient prcdr_cd3 prcdr_cd3 prcdr_cd3 prcdrcd3 prcdrcd3

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code III Date

  • Short SAS Name: PRCDR_DT3
  • Long SAS Name: PRCDR_DT3

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt3 prcdr_dt3 prcdr_dt3 prcdr_dt3 prcdrdt3
Outpatient prcdr_dt3 prcdr_dt3 prcdr_dt3 prcdr_dt3 prcdrdt3
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt3 prcdrdt3 prcdrdt3 prcdr_dt3 prcdr_dt3
Outpatient prcdrdt3 prcdrdt3 prcdrdt3 prcdr_dt3 prcdr_dt3
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt3 prcdr_dt3 prcdrdt3 prcdr_dt3 prcdrdt3
Outpatient prcdr_dt3 prcdr_dt3 prcdr_dt3 prcdrdt3 prcdrdt3

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code IV

  • Short SAS Name: ICD_PRCDR_CD4
  • Long SAS Name: ICD_PRCDR_CD4

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd4 icd_prcdr_cd4 icd_prcdr_cd4 icd_prcdr_cd4 prcdrcd4
Outpatient icd_prcdr_cd4 icd_prcdr_cd4 icd_prcdr_cd4 icd_prcdr_cd4 prcdrcd4
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd4 prcdrcd4 prcdrcd4 prcdr_cd4 prcdr_cd4
Outpatient prcdrcd4 prcdrcd4 prcdrcd4 prcdr_cd4 prcdr_cd4
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd4 prcdr_cd4 prcdrcd4 prcdrcd4 prcdrcd4
Outpatient prcdr_cd4 prcdr_cd4 prcdr_cd4 prcdrcd4 prcdrcd4

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code IV Date

  • Short SAS Name: PRCDR_DT4
  • Long SAS Name: PRCDR_DT4

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt4 prcdr_dt4 prcdr_dt4 prcdr_dt4 prcdrdt4
Outpatient prcdr_dt4 prcdr_dt4 prcdr_dt4 prcdr_dt4 prcdrdt4
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt4 prcdrdt4 prcdrdt4 prcdr_dt4 prcdr_dt4
Outpatient prcdrdt4 prcdrdt4 prcdrdt4 prcdr_dt4 prcdr_dt4
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt4 prcdr_dt4 prcdrdt4 prcdr_dt4 prcdrdt4
Outpatient prcdr_dt4 prcdr_dt4 prcdr_dt4 prcdrdt4 prcdrdt4

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code IX

  • Short SAS Name: ICD_PRCDR_CD9
  • Long SAS Name: ICD_PRCDR_CD9

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd9 icd_prcdr_cd9 icd_prcdr_cd9 icd_prcdr_cd9
Outpatient icd_prcdr_cd9 icd_prcdr_cd9 icd_prcdr_cd9 icd_prcdr_cd9

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code IX Date

  • Short SAS Name: PRCDR_DT9
  • Long SAS Name: PRCDR_DT9

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt9 prcdr_dt9 prcdr_dt9 prcdr_dt9
Outpatient prcdr_dt9 prcdr_dt9 prcdr_dt9 prcdr_dt9

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code V

  • Short SAS Name: ICD_PRCDR_CD5
  • Long SAS Name: ICD_PRCDR_CD5

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd5 icd_prcdr_cd5 icd_prcdr_cd5 icd_prcdr_cd5 prcdrcd5
Outpatient icd_prcdr_cd5 icd_prcdr_cd5 icd_prcdr_cd5 icd_prcdr_cd5 prcdrcd5
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd5 prcdrcd5 prcdrcd5 prcdr_cd5 prcdr_cd5
Outpatient prcdrcd5 prcdrcd5 prcdrcd5 prcdr_cd5 prcdr_cd5
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd5 prcdr_cd5 prcdrcd5 prcdrcd5 prcdrcd5
Outpatient prcdr_cd5 prcdr_cd5 prcdr_cd5 prcdrcd5 prcdrcd5

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code V Date

  • Short SAS Name: PRCDR_DT5
  • Long SAS Name: PRCDR_DT5

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt5 prcdr_dt5 prcdr_dt5 prcdr_dt5 prcdrdt5
Outpatient prcdr_dt5 prcdr_dt5 prcdr_dt5 prcdr_dt5 prcdrdt5
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt5 prcdrdt5 prcdrdt5 prcdr_dt5 prcdr_dt5
Outpatient prcdrdt5 prcdrdt5 prcdrdt5 prcdr_dt5 prcdr_dt5
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt5 prcdr_dt5 prcdrdt5 prcdr_dt5 prcdrdt5
Outpatient prcdr_dt5 prcdr_dt5 prcdr_dt5 prcdrdt5 prcdrdt5

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code VI

  • Short SAS Name: ICD_PRCDR_CD6
  • Long SAS Name: ICD_PRCDR_CD6

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient icd_prcdr_cd6 icd_prcdr_cd6 icd_prcdr_cd6 icd_prcdr_cd6 prcdrcd6
Outpatient icd_prcdr_cd6 icd_prcdr_cd6 icd_prcdr_cd6 icd_prcdr_cd6 prcdrcd6
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrcd6 prcdrcd6 prcdrcd6 prcdr_cd6 prcdr_cd6
Outpatient prcdrcd6 prcdrcd6 prcdrcd6 prcdr_cd6 prcdr_cd6
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_cd6 prcdr_cd6 prcdrcd6 prcdrcd6 prcdrcd6
Outpatient prcdr_cd6 prcdr_cd6 prcdr_cd6 prcdrcd6 prcdrcd6

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code VI Date

  • Short SAS Name: PRCDR_DT6
  • Long SAS Name: PRCDR_DT6

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prcdr_dt6 prcdr_dt6 prcdr_dt6 prcdr_dt6 prcdrdt6
Outpatient prcdr_dt6 prcdr_dt6 prcdr_dt6 prcdr_dt6 prcdrdt6
Dataset 2008 2007 2006 2005 2004
Inpatient prcdrdt6 prcdrdt6 prcdrdt6 prcdr_dt6 prcdr_dt6
Outpatient prcdrdt6 prcdrdt6 prcdrdt6 prcdr_dt6 prcdr_dt6
Dataset 2003 2002 2001 2000 1999
Inpatient prcdr_dt6 prcdr_dt6 prcdrdt6 prcdr_dt6 prcdrdt6
Outpatient prcdr_dt6 prcdr_dt6 prcdr_dt6 prcdrdt6 prcdrdt6

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code VII

  • Short SAS Name: ICD_PRCDR_CD7
  • Long SAS Name: ICD_PRCDR_CD7

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd7 icd_prcdr_cd7 icd_prcdr_cd7 icd_prcdr_cd7
Outpatient icd_prcdr_cd7 icd_prcdr_cd7 icd_prcdr_cd7 icd_prcdr_cd7

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code VII Date

  • Short SAS Name: PRCDR_DT7
  • Long SAS Name: PRCDR_DT7

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt7 prcdr_dt7 prcdr_dt7 prcdr_dt7
Outpatient prcdr_dt7 prcdr_dt7 prcdr_dt7 prcdr_dt7

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code VIII

  • Short SAS Name: ICD_PRCDR_CD8
  • Long SAS Name: ICD_PRCDR_CD8

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd8 icd_prcdr_cd8 icd_prcdr_cd8 icd_prcdr_cd8
Outpatient icd_prcdr_cd8 icd_prcdr_cd8 icd_prcdr_cd8 icd_prcdr_cd8

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code VIII Date

  • Short SAS Name: PRCDR_DT8
  • Long SAS Name: PRCDR_DT8

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt8 prcdr_dt8 prcdr_dt8 prcdr_dt8
Outpatient prcdr_dt8 prcdr_dt8 prcdr_dt8 prcdr_dt8

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code X

  • Short SAS Name: ICD_PRCDR_CD10
  • Long SAS Name: ICD_PRCDR_CD10

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd10 icd_prcdr_cd10 icd_prcdr_cd10 icd_prcdr_cd10
Outpatient icd_prcdr_cd10 icd_prcdr_cd10 icd_prcdr_cd10 icd_prcdr_cd10

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code X Date

  • Short SAS Name: PRCDR_DT10
  • Long SAS Name: PRCDR_DT10

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt10 prcdr_dt10 prcdr_dt10 prcdr_dt10
Outpatient prcdr_dt10 prcdr_dt10 prcdr_dt10 prcdr_dt10

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XI

  • Short SAS Name: ICD_PRCDR_CD11
  • Long SAS Name: ICD_PRCDR_CD11

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd11 icd_prcdr_cd11 icd_prcdr_cd11 icd_prcdr_cd11
Outpatient icd_prcdr_cd11 icd_prcdr_cd11 icd_prcdr_cd11 icd_prcdr_cd11

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XI Date

  • Short SAS Name: PRCDR_DT11
  • Long SAS Name: PRCDR_DT11

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt11 prcdr_dt11 prcdr_dt11 prcdr_dt11
Outpatient prcdr_dt11 prcdr_dt11 prcdr_dt11 prcdr_dt11

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XII

  • Short SAS Name: ICD_PRCDR_CD12
  • Long SAS Name: ICD_PRCDR_CD12

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd12 icd_prcdr_cd12 icd_prcdr_cd12 icd_prcdr_cd12
Outpatient icd_prcdr_cd12 icd_prcdr_cd12 icd_prcdr_cd12 icd_prcdr_cd12

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XII Date

  • Short SAS Name: PRCDR_DT12
  • Long SAS Name: PRCDR_DT12

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt12 prcdr_dt12 prcdr_dt12 prcdr_dt12
Outpatient prcdr_dt12 prcdr_dt12 prcdr_dt12 prcdr_dt12

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XIII

  • Short SAS Name: ICD_PRCDR_CD13
  • Long SAS Name: ICD_PRCDR_CD13

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd13 icd_prcdr_cd13 icd_prcdr_cd13 icd_prcdr_cd13
Outpatient icd_prcdr_cd13 icd_prcdr_cd13 icd_prcdr_cd13 icd_prcdr_cd13

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XIII Date

  • Short SAS Name: PRCDR_DT13
  • Long SAS Name: PRCDR_DT13

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt13 prcdr_dt13 prcdr_dt13 prcdr_dt13
Outpatient prcdr_dt13 prcdr_dt13 prcdr_dt13 prcdr_dt13

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XIV

  • Short SAS Name: ICD_PRCDR_CD14
  • Long SAS Name: ICD_PRCDR_CD14

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd14 icd_prcdr_cd14 icd_prcdr_cd14 icd_prcdr_cd14
Outpatient icd_prcdr_cd14 icd_prcdr_cd14 icd_prcdr_cd14 icd_prcdr_cd14

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XIV Date

  • Short SAS Name: PRCDR_DT14
  • Long SAS Name: PRCDR_DT14

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt14 prcdr_dt14 prcdr_dt14 prcdr_dt14
Outpatient prcdr_dt14 prcdr_dt14 prcdr_dt14 prcdr_dt14

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XIX

  • Short SAS Name: ICD_PRCDR_CD19
  • Long SAS Name: ICD_PRCDR_CD19

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd19 icd_prcdr_cd19 icd_prcdr_cd19 icd_prcdr_cd19
Outpatient icd_prcdr_cd19 icd_prcdr_cd19 icd_prcdr_cd19 icd_prcdr_cd19

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XIX Date

  • Short SAS Name: PRCDR_DT19
  • Long SAS Name: PRCDR_DT19

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt19 prcdr_dt19 prcdr_dt19 prcdr_dt19
Outpatient prcdr_dt19 prcdr_dt19 prcdr_dt19 prcdr_dt19

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XV

  • Short SAS Name: ICD_PRCDR_CD15
  • Long SAS Name: ICD_PRCDR_CD15

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd15 icd_prcdr_cd15 icd_prcdr_cd15 icd_prcdr_cd15
Outpatient icd_prcdr_cd15 icd_prcdr_cd15 icd_prcdr_cd15 icd_prcdr_cd15

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XV Date

  • Short SAS Name: PRCDR_DT15
  • Long SAS Name: PRCDR_DT15

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt15 prcdr_dt15 prcdr_dt15 prcdr_dt15
Outpatient prcdr_dt15 prcdr_dt15 prcdr_dt15 prcdr_dt15

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XVI

  • Short SAS Name: ICD_PRCDR_CD16
  • Long SAS Name: ICD_PRCDR_CD16

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd16 icd_prcdr_cd16 icd_prcdr_cd16 icd_prcdr_cd16
Outpatient icd_prcdr_cd16 icd_prcdr_cd16 icd_prcdr_cd16 icd_prcdr_cd16

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XVI Date

  • Short SAS Name: PRCDR_DT16
  • Long SAS Name: PRCDR_DT16

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt16 prcdr_dt16 prcdr_dt16 prcdr_dt16
Outpatient prcdr_dt16 prcdr_dt16 prcdr_dt16 prcdr_dt16

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XVII

  • Short SAS Name: ICD_PRCDR_CD17
  • Long SAS Name: ICD_PRCDR_CD17

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd17 icd_prcdr_cd17 icd_prcdr_cd17 icd_prcdr_cd17
Outpatient icd_prcdr_cd17 icd_prcdr_cd17 icd_prcdr_cd17 icd_prcdr_cd17

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XVII Date

  • Short SAS Name: PRCDR_DT17
  • Long SAS Name: PRCDR_DT17

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt17 prcdr_dt17 prcdr_dt17 prcdr_dt17
Outpatient prcdr_dt17 prcdr_dt17 prcdr_dt17 prcdr_dt17

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XVIII

  • Short SAS Name: ICD_PRCDR_CD18
  • Long SAS Name: ICD_PRCDR_CD18

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd18 icd_prcdr_cd18 icd_prcdr_cd18 icd_prcdr_cd18
Outpatient icd_prcdr_cd18 icd_prcdr_cd18 icd_prcdr_cd18 icd_prcdr_cd18

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XVIII Date

  • Short SAS Name: PRCDR_DT18
  • Long SAS Name: PRCDR_DT18

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt18 prcdr_dt18 prcdr_dt18 prcdr_dt18
Outpatient prcdr_dt18 prcdr_dt18 prcdr_dt18 prcdr_dt18

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XX

  • Short SAS Name: ICD_PRCDR_CD20
  • Long SAS Name: ICD_PRCDR_CD20

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd20 icd_prcdr_cd20 icd_prcdr_cd20 icd_prcdr_cd20
Outpatient icd_prcdr_cd20 icd_prcdr_cd20 icd_prcdr_cd20 icd_prcdr_cd20

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XX Date

  • Short SAS Name: PRCDR_DT20
  • Long SAS Name: PRCDR_DT20

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt20 prcdr_dt20 prcdr_dt20 prcdr_dt20
Outpatient prcdr_dt20 prcdr_dt20 prcdr_dt20 prcdr_dt20

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XXI

  • Short SAS Name: ICD_PRCDR_CD21
  • Long SAS Name: ICD_PRCDR_CD21

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd21 icd_prcdr_cd21 icd_prcdr_cd21 icd_prcdr_cd21
Outpatient icd_prcdr_cd21 icd_prcdr_cd21 icd_prcdr_cd21 icd_prcdr_cd21

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XXI Date

  • Short SAS Name: PRCDR_DT21
  • Long SAS Name: PRCDR_DT21

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt21 prcdr_dt21 prcdr_dt21 prcdr_dt21
Outpatient prcdr_dt21 prcdr_dt21 prcdr_dt21 prcdr_dt21

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XXII

  • Short SAS Name: ICD_PRCDR_CD22
  • Long SAS Name: ICD_PRCDR_CD22

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd22 icd_prcdr_cd22 icd_prcdr_cd22 icd_prcdr_cd22
Outpatient icd_prcdr_cd22 icd_prcdr_cd22 icd_prcdr_cd22 icd_prcdr_cd22

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XXII Date

  • Short SAS Name: PRCDR_DT22
  • Long SAS Name: PRCDR_DT22

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt22 prcdr_dt22 prcdr_dt22 prcdr_dt22
Outpatient prcdr_dt22 prcdr_dt22 prcdr_dt22 prcdr_dt22

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XXIII

  • Short SAS Name: ICD_PRCDR_CD23
  • Long SAS Name: ICD_PRCDR_CD23

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd23 icd_prcdr_cd23 icd_prcdr_cd23 icd_prcdr_cd23
Outpatient icd_prcdr_cd23 icd_prcdr_cd23 icd_prcdr_cd23 icd_prcdr_cd23

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XXIII Date

  • Short SAS Name: PRCDR_DT23
  • Long SAS Name: PRCDR_DT23

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt23 prcdr_dt23 prcdr_dt23 prcdr_dt23
Outpatient prcdr_dt23 prcdr_dt23 prcdr_dt23 prcdr_dt23

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XXIV

  • Short SAS Name: ICD_PRCDR_CD24
  • Long SAS Name: ICD_PRCDR_CD24

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd24 icd_prcdr_cd24 icd_prcdr_cd24 icd_prcdr_cd24
Outpatient icd_prcdr_cd24 icd_prcdr_cd24 icd_prcdr_cd24 icd_prcdr_cd24

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XXIV Date

  • Short SAS Name: PRCDR_DT24
  • Long SAS Name: PRCDR_DT24

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt24 prcdr_dt24 prcdr_dt24 prcdr_dt24
Outpatient prcdr_dt24 prcdr_dt24 prcdr_dt24 prcdr_dt24

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Procedure Code XXV

  • Short SAS Name: ICD_PRCDR_CD25
  • Long SAS Name: ICD_PRCDR_CD25

Variable Names

Dataset 2013 2012 2011 2010
Inpatient icd_prcdr_cd25 icd_prcdr_cd25 icd_prcdr_cd25 icd_prcdr_cd25
Outpatient icd_prcdr_cd25 icd_prcdr_cd25 icd_prcdr_cd25 icd_prcdr_cd25

Contained in

The code that indicates the principal or other procedure performed during the period covered by the institutional claim.

NOTE: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on Outpatient claims. The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures. HCPCS/CPT codes were named as the standard code set for physician services and other health care services.

Claim Procedure Code XXV Date

  • Short SAS Name: PRCDR_DT25
  • Long SAS Name: PRCDR_DT25

Variable Names

Dataset 2013 2012 2011 2010
Inpatient prcdr_dt25 prcdr_dt25 prcdr_dt25 prcdr_dt25
Outpatient prcdr_dt25 prcdr_dt25 prcdr_dt25 prcdr_dt25

Contained in

On an institutional claim, the date on which the principal or other procedure was performed.

Claim Query Code

  • Short SAS Name: QUERY_CD
  • Long SAS Name: CLAIM_QUERY_CODE

Contained in

Code indicating the type of claim record being processed with respect to payment (debit/credit indicator; interim/final indicator).

Values

Code Code Value
1 Interim bill
3 Final bill
5 Debit adjustment

Claim Referring Physician NPI Number

  • Short SAS Name: RFR_PHYSN_NPI
  • Long SAS Name: RFRG_NPI

Contained in

The national provider identifier (NPI) number assigned to uniquely identify the referring physician.

Claim Referring Physician Specialty Code

  • Short SAS Name: RFR_PHYSN_SPCLTY_CD
  • Long SAS Name: RFRG_SPCLTY_CD

Contained in

The code used to identify the CMS specialty code of the referring physician/practitioner.

Values

CMS_PRVDR_SPCLTY_TB.txt

  • Short SAS Name: RLT_COND
  • Long SAS Name: CLM_RLT_COND_CD

Contained in

The code that indicates a condition relating to an institutional claim that may affect payer processing.

Values

For codes C1 THRU C7, NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).

Code Code Value
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
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 QIO approval services
D0 THRU W0 Change conditions
Code Code Value
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 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 laborator 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
30 Qualifying Clinical Trials - Non-research services provided to all patients, including managed care enrollees, enrolled in a Qualified Clinical Trial.
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 Continuing Care Not Related to Inpatient Admission - continuing care not related to the condition or diagnosis for which the beneficiary received inpatient hospital services (eff. 10/01)
43 Continuing Care Not Provided Within Prescribed Postdischarge Window - continuing care was related to the inpatient admission but the prescribed care was not provided within the post-discharge window (eff. 10/01)
44 Inpatient Admission Changed to Outpatient - For use on outpatient claims only, when the physician ordered inpatient services, but upon internal review performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria (eff. 4/1/04)
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 Product Replacement within Product Lifecycle-replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly (eff. 4/2006)
50 Product Replacement for Known Recall of a Product - Manufacturer or FDA has identified the product for recall and therefore replacement (eff. 4/2006)
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 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 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 pathology services were provided off site.
80 Home Dialysis - Nursing Facility - Home dialysis furnished in a SNF or nursing facility. (eff. 4/4/05)
81-99 Reserved for state assignment.
A0 Special Zip Code Reporting - five digit zip code of the location from which the beneficiary is initially placed on board the ambulance (eff. 9/01)
A0 CHAMPUS external partnership program special program indicator code (eff 10/93) (obsolete)
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/incest. Special program indicator code (eff 10/93)
A9 Second opinion surgery - Service requested to support second opinion on surgery. Part B deductible and coinsurance do not apply. Special program indicator code (eff 10/93)
AA Abortion Performed due to Rape (eff. 10/1/02)
AB Abortion Performed due to Incest (eff. 10/1/02)
AC Abortion Performed due to Serious Fetal Genetic Defect, Deformity or Abnormality (eff. 10/1/02)
AD Abortion Performed due to a Life Endangering Physical Condition Caused by, arising from or exacerbated by the Pregnancy itself (eff. 10/1/02)
AE Abortion Performed due to physical health of mother that is not life endangering (eff. 10/1/02)
AF Abortion Performed due to emotional/psychological health of mother (eff. 10/1/02)
AG Abortion performed due to social economic reasons (eff. 10/1/02)
AH Elective Abortion (eff. 10/1/02)
AI Sterilization (eff. 10/1/02)
AJ Payer Responsible for copayment (4/1/03)
AK Air Ambulance Required - For ambulance claims. Time needed to transport poses a threat. (eff. 10/16/03)
AL Specialized Treatment/bed Unavailable - For ambulance claims. Specialized treatment bed unavailable. Transported to alternate facility. (eff. 10/16/03)
AM Non-emergency Medically Necessary Stretcher Transport Required - For ambulance claims. Non-emergency medically necessary stretcher transport required. (eff. 10/16/03)
AN Preadmission Screening Not Required - person meets the criteria for an exemption from preadmission screening. (eff. 1/1/04)
B0 Medicare Coordinated Care Demonstration Program - patient is a participant in a Medicare Coordinated Care Demonstration (eff. 10/01)
B1 Beneficiary ineligible for demonstration program (eff. 1/02).
B2 Critical Access Hospital Ambulance Attestation - Attestation by CAH that it meets the criteria for exemption from the Ambulance Fee Schedule
B3 Pregnancy Indicator - Indicates the patient is pregnant. Required when mandated by law. (eff. 10/16/03)
B4 Admission Unrelated to Discharge - Admission unrelated to discharge on same day. This code is for discharges starting on January 1, 2004.
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 QIO/UR or intermediary and are fully approved including any day or cost outlier. (eff 10/93) NOTE: Beginning July 2005, this code is relevant to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C2 Automatic approval as billed based on focused review. (No longer used for Medicare) QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C3 Partial approval - The services provided for this billing period have been reviewed by the QIO/UR or intermediary and some portion has been denied (days or services). (eff 10/93) NOTE: Beginning July 2005, this code is relevant to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C4 Admission/services denied - Indicates that all of the services were denied by the QIO/UR. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C5 Postpayment review applicable - QIO/UR review to take place after payment. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C6 Admission preauthorization - The QIO/UR authorized this admission/service but has not reviewed the services provided. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C7 Extended authorization - the QIO has authorized these services for an extended length of time but has not reviewed the services provided. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X).
C8 Reserved for national assignment. QIO approval indicator services (eff 10/93)
C9 Reserved for national assignment. QIO 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/HIPPS Rate Code Change condition (eff 10/93)
D3 Second or subsequent interim PPS bill. Change condition (eff 10/93)
D4 Change in ICD-9-CM diagnosis and/or procedure code 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)
DR Disaster Relief (eff. 10/2005) - Code used to facilitate claims processing and track services and items provided to victims of Hurricane Katrina and any future disasters.
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).
H0 Delayed Filing, Statement of Intent Submitted -- statement of intent was submitted within the qualifying period to specifically identify the existence of another third party liability situation. (eff. 9/01)
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); but no claims transmitted until 2/98)
XX Transgender/Hermaphrodite Beneficiaries (eff. ½/07)
  • Short SAS Name: RLTCNDSQ
  • Long SAS Name: RLT_COND_CD_SEQ

Contained in

The sequence number of the related institutional condition code for normal forms layout used in CCW.

  • Short SAS Name: OCRNC_CD
  • Long SAS Name: CLM_RLT_OCRNC_CD

Contained in

The code that identifies a significant event relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a specific date.

Values

Code Code Value
01 THRU 09 Accident
10 THRU 19 Medical condition
20 THRU 39 Insurance related
40 THRU 69 Service related
A1-A3 Miscellaneous
Code Code Value
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 & SNF of the UR committee's finding that the admission or future stay was not medically necessary.
22 Active care ended - The date on which a covered level of care ended in a SNF or general hospital, or date active care ended in a psychiatric or tuberculosis hospital or date on which patient was released on a trial basis from a residential facility. Code is not required if code "21" is used.
23 Cancellation of Hospice benefits - The date the RHHI cancelled the hospice benefit. (eff. 10/00). NOTE: this will be different than the revocation of the hospice benefit by beneficiaries. 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 of Hospice Certification or Re-Certification -- code indicates the date of certification or recertification of the hospice benefit period, beginning with the first two initial benefit periods of 90 days each and the subsequent 60-day benefit periods. (eff. 9/01)
27 Date home health plan established or last reviewed - Code indicating the date a home health plan of treatment was established or last reviewed. (Obsolete) not used by hospital unless owner of facility
28 Date comprehensive outpatient rehabilitation plan established or last reviewed - 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. 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 Religious Nonmedical Health Care Institutions 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 Date of First Test for Pre-admission Testing - 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). (eff. 10/01)
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 Scheduled Date of Canceled Surgery - date which ambulatory surgery was scheduled. (eff. 9/01)
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 Date Cost Outlier Status Begins - code indicates that this is the first day the cost outlier threshold is reached. For Medicare purposes, a bene must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. (eff. 9/01)
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)
  • Short SAS Name: RLTOCRSQ
  • Long SAS Name: RLT_OCRNC_CD_SEQ

Contained in

The sequence number of the related institutional occurrence code for normal forms layout used in CCW.

  • Short SAS Name: OCRNCDT
  • Long SAS Name: CLM_RLT_OCRNC_DT

Contained in

The date associated with a significant event related to an institutional claim that may affect payer processing.

  • Short SAS Name: RLTSPNSQ
  • Long SAS Name: RLT_SPAN_CD_SEQ

Contained in

The sequence number of the related institutional span code for normal forms layout used in CCW.

  • Short SAS Name: RLTVALSQ
  • Long SAS Name: RLT_VAL_CD_SEQ

Contained in

The sequence number of the related institutional value code for normal forms layout used in CCW.

Claim Rendering Physician NPI Number

  • Short SAS Name: RNDRNG_PHYSN_NPI
  • Long SAS Name: CLM_RNDRNG_PHYSN_NPI_NUM

Variable Names

Dataset 2013 2012 2011 2010
Outpatient rndrng_physn_npi rndrng_physn_npi rndrng_physn_npi rndrng_physn_npi

Contained in

This variable is the National Provider Identifier (NPI) for the physician who rendered the services. NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009. 

CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be available in the NCH. After the 5/07 NPI implementation, the standard system maintainers will add the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider number and any currently issued UPINs. Effective May 2007, no new UPINs (legacy numbers) will be generated for new physicians (Part B and outpatient claims), so there will only be NPIs sent in to the NCH for those physicians.

Claim Rendering Physician Specialty Code

  • Short SAS Name: RNDRNG_PHYSN_SPCLTY_CD
  • Long SAS Name: CLM_RNDRNG_PHYSN_SPCLTY_CD

Contained in

The code used to identify the CMS specilty code of the rendering physician/practitioner. 

Values

Code Code Value
00 Carrier wide
01 General practice
02 General surgery
03 Allergy/immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family practice
09 Interventional Pain Management (IPM) (eff. 4/1/03)
10 Gastroenterology
11 Internal medicine
12 Osteopathic manipulative therapy
13 Neurology
14 Neurosurgery
15 Speech/language pathology
16 Obstetrics/gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral surgery (dentists only)
20 Orthopedic surgery
21 Cardiac Electrophysiology
22 Pathology
24 Plastic and reconstructive surgery
25 Physical medicine and rehabilitation
26 Physchiatry
27 General Psychiatry
28 Colorectal surgery (formerly proctology)
29 Pulmonary disease
30 Diagnostic radiology
31 Intensive cardiac rehabilitation
32 Anesthesiologist Assistants (eff. 4/1/03--previously grouped with Certified Registered Nurse Anesthetists (CRNA))
33 Thoracic surgery
34 Urology
35 Chiropractic
36 Nuclear medicine
37 Pediatric medicine
38 Geriatric medicine
39 Nephrology
40 Hand surgery
41 Optometrist
42 Certified nurse midwife
43 Certified Registered Nurse Anesthetist (CRNA) (Anesthesiologist Assistants were removed from this specialty 4/1/03)
44 Infectious disease
45 Mammography screening center
46 Endocrinology
47 Independent Diagnostic Testing Facility (IDTF)
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 for DMERC (and not included in 51-53)
55 Individual certified orthotist
56 Individual certified prosthetist
57 Individual certified prosthetist-orthotist
58 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 Association, Catholic Charities)
62 Psychologist (billing independently)
63 Portable X-ray supplier
64 Audiologist (billing independently)
65 Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
66 Rheumatology
67 Occupational therapist (private practice added 4/103) (independently practicing removed 4/1/03)
68 Clinical psychologist
69 Clinical laboratory (billing independently)
70 Multispecialty clinic or group practice
71 Registered Dietician/Nutrition Professional (eff.1/1/02)
72 Pain Management (eff. 1/1/02)
73 Mass Immunization Roster Biller
74 Radiation Therapy Centers (prior to 4/2003 this included Independent Diagnostic Testing Facilities (IDFT))
75 Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs--eff. 4//1/03))
76 Peripheral vascular disease
77 Vascular surgery
78 Cardiac surgery
79 Addiction medicine
80 Licensed clinical social worker
81 Critical care (intensivists)
82 Hematology
83 Hematology/oncology
84 Preventive medicine
85 Maxillofacial surgery
86 Neuropsychiatry
87 All other suppliers (e.g. drug and department stores)
88 Unknown supplier/provider specialty
89 Certified clinical nurse specialist
90 Medical oncology
91 Surgical oncology
92 Radiation oncology
93 Emergency medicine
94 Interventional radiology
95 Competitive Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/01/06, known as Independent physiological laboratory
96 Optician
97 Physician assistant
98 Gynecologist/oncologist
99 Unknown physician specialty
A0 Hospital (DMERCs only)
A1 SNF (DMERCs only)
A2 Intermediate care nursing facility (DMERCs only)
A3 Nursing facility, other (DMERCs only)
A4 Home Health Agency (DMERCs only)
A5 Pharmacy (DMERC)
A6 Medical supply company with respiratory therapist (DMERCs only)
A7 Department store (DMERC)
A8 Grocery store (DMERC)
A9 Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities, eff. 1/2005)
B1 Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07)
B2 Pedorthic Personnel (eff. 10/2/07)
B3 Medical Supply Company with pedorthic personnel (eff. 10/2/07)
B4 Does not meet definition of health care provider (e.g., Rehabilitation agency, organ procurement organizations, histocompatibility labs) (eff. 10/2/07)
B5 Ocularist
C0 Sleep medicine
C1 Centralized flu
C2 Indirect payment procedure
C3 Interventional cardiology
C5 Dentist (eff. 7/2016)

Claim Service Classification Type Code

  • Short SAS Name: TYPESRVC
  • Long SAS Name: CLM_SRVC_CLSFCTN_TYPE_CD

Contained in

The second digit of the type of bill (TOB2) submitted on an institutional claim record to indicate the classification of the type of service provided to the beneficiary.

Values

For facility type code 1 thru 6, and 9

Code Code Value
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) -- (Includes HHA medical and other health services not under a plan of treatment, hospital or SNF for diagnostic clinical laboratory services for "nonpatients," and referenced diagnostic services. For HHAs under PPS, indicates an osteoporo
5 Intermediate care - level I
6 Intermediate care - level II
7 Subacute Inpatient (revenue code 019X required) (formerly Intermediate care - level III) NOTE: 17X & 27X are discontinued effective 10/1/05.
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

Code Code Value
1 Rural Health Clinic (RHC)
2 Hospital based or independent renal dialysis facility
3 Free-standing provider based federally qualified health center (FQHC) (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

Code Code Value
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

Claim Service Location NPI Number

  • Short SAS Name: SRVC_LOC_NPI_NUM
  • Long SAS Name: SRVC_LOC_NPI_NUM

Contained in

The National Provider Identifier (NPI) of the location where the services were provided

This field was new in January 2014. It is null/missing for all years prior.

Claim Through Date

  • Short SAS Name: THRU_DT
  • Long SAS Name: CLM_THRU_DT

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier thru_dt thru_dt thru_dt thru_dt
Inpatient thru_dt thru_dt thru_dt thru_dt thru_dt
Inpatient thru_dt thru_dt thru_dt thru_dt thru_dt
Outpatient thru_dt thru_dt thru_dt thru_dt thru_dt
Dataset 2008 2007 2006 2005 2004
Carrier thru_dt thru_dt thru_dt sthrudt sthrudt
Inpatient thru_dt thru_dt thru_dt sthrudt sthrudt
Inpatient thru_dt thru_dt thru_dt srev_dt srev_dt
Outpatient thru_dt thru_dt thru_dt sthrudt sthrudt
Dataset 2003 2002 2001 2000 1999
Carrier sthrudt sthrudt thru_dt thru_dt bthrudt
Inpatient sthrudt sthrudt thru_dt thru_dt thru_dt
Inpatient srev_dt srev_dt rev_dt rev_dt rev_dt
Outpatient sthrudt sthrudt sthrudt thru_dt thru_dt

Contained in

The last day on the billing statement covering services rendered to the beneficiary (a.k.a 'Statement Covers Thru Date').

NOTE: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match.

Claim Total Charge Amount

  • Short SAS Name: TOT_CHRG
  • Long SAS Name: CLM_TOT_CHRG_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg
Outpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg
Dataset 2008 2007 2006 2005 2004
Inpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg
Outpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg
Dataset 2003 2002 2001 2000 1999
Inpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg
Outpatient tot_chrg tot_chrg tot_chrg tot_chrg tot_chrg

Contained in

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.

Limitation

DESCRIPTION : The total charge amount field in the fixed portion was truncated on outpatient, hospice and home health claims. BACKGROUND : For outpatient, hospice and home health claims, the total charge amount field in the fixed portion was truncated (the cents were dropped off; the decimal point was moved, making cents out of dollars) in the CWFMQA process beginning with data received from CWF ¼/99 through 5/14/99. The problem occurred when CWF increased the size of the field. CORRECTIVE ACTION : The CWFMQA front-end was fixed. The Nearline was patched during the quarterly merge in 7/99 for service years 1998 and 1999. The NCH_PACTCH_CD field will be populated with a value '11'. The 1998 and 1999 SAFs were corrected when finalized in 7/99. The patch involved moving the total charge amount in the revenue center trailer to the total charge amount field in the fixed portion, for records with NCH Daily Process Date ¼/99 - 5/14/99.

Values

Code
XXX.XX

Claim Treatment Authorization Number

  • Short SAS Name: CLM_TRTMT_AUTHRZTN_NUM
  • Long SAS Name: CLM_TRTMT_AUTHRZTN_NUM

Contained in

The number assigned by the medical reviewer and reported by the provider to identify the medical review (treatment authorization) action taken after review of the beneficiary's case. It designates that treatment covered by the bill has been authorized by the payer.

This number is used by the fiscal intermediary and the Peer Review Organization.

Values

Code
XXXXXXX

Claim Value Amount

  • Short SAS Name: VAL_AMT
  • Long SAS Name: CLM_VAL_AMT

Contained in

The amount related to the condition identified in the CLM_VAL_CD which was used by the intermediary to process the institutional claim.

Values

Code
XXX.XX

Claim Value Code

  • Short SAS Name: VAL_CD
  • Long SAS Name: CLM_VAL_CD

Contained in

The code indicating the value of a monetary condition which was used by the intermediary to process an institutional claim.

Values

Claim Value Table.txt

Claim service facility ZIP code (where service was provided)

  • Short SAS Name: CLM_SRVC_FAC_ZIP_CD
  • Long SAS Name: CLM_SRVC_FAC_ZIP_CD

Contained in

ZIP code where service was provided, as indicated on the claim.

Values

Code
XXXXXXXXX

County Code from Claim (SSA)

  • Short SAS Name: CNTY_CD
  • Long SAS Name: BENE_CNTY_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier cnty_cd cnty_cd cnty_cd cnty_cd
Inpatient cnty_cd cnty_cd cnty_cd cnty_cd cnty_cd
MedPAR cnty_cd cnty_cd cnty_cd cnty_cd cnty_cd
Outpatient cnty_cd cnty_cd cnty_cd cnty_cd cnty_cd
Dataset 2008 2007 2006 2005 2004
Carrier cnty_cd cnty_cd cnty_cd county county
Inpatient cnty_cd cnty_cd cnty_cd county county
MedPAR cnty_cd cnty_cd cnty_cd county county
Outpatient cnty_cd cnty_cd cnty_cd county county
Dataset 2003 2002 2001 2000 1999
Carrier county county cnty_cd cnty_cd bcounty
Inpatient county county cnty_cd cnty_cd cnty_cd
MedPAR county county mcounty mcounty mcounty
Outpatient county county county cnty_cd cnty_cd

Contained in

The SSA standard county code of a beneficiary's residence.

Date of Birth from Claim (Date)

  • Short SAS Name: DOB_DT
  • Long SAS Name: DOB_DT

Contained in

The beneficiary's date of birth.

Demo information text

  • Short SAS Name: DEMO_INFO_TXT
  • Long SAS Name: DEMO_INFO_TXT

Contained in

This is a text field that contains information related to the demonstration.For example, a claim involving a CHOICES demo id 05 would contain the MCO plan contract number in the first five positions of this text field.

When the Demo ID = 01 (RUGS) -- the text field will contain a 2, 3 or 4 to denote the RUGS phase. If RUGS phase is blank or not one of the above the text field will reflect 'INVALID'. NOTE: In Version 'G', RUGS phase was stored in redefined Claim Edit Group, 3rd occurrence, 4th position. Demo ID = 02 (Home Health demo) -- the text field will contain PROV#. When demo number not equal to 02 then text will reflect 'INVALID'. Demo ID = 03 (Telemedicine demo) -- text field will contain the HCPCS code. If the required HCPCS is not shown then the text field will reflect 'INVALID'. Demo ID = 04 (UMWA) -- text field will contain W0 denoting that condition code W0 was present. If condition code W0 not present then the text field will reflect 'INVALID'. Demo ID = 05 (CHOICES) -- the text field will contain the CHOICES plan number, if both of the following conditions are met: (1) CHOICES plan number present and PPS or Inpatient claim shows that 1st 3 positions of provider number as 210 and the admission date is within HMO effective/termination date; or non-PPS claim and the from date is within HMO effective/termination date and (2) CHOICES plan number matches the HMO plan number. If either condition is not met the text field will reflect 'INVALID CHOICES PLAN NUMBER'. When CHOICES plan number not present, text will reflect 'INVALID'. Demo ID = 15 (ESRD Managed Care) -- text field will contain the ESRD/MCO plan number. If ESRD/MCO plan number not present the field will reflect 'INVALID'. Demo ID = 38 (Physician Encounter Claims) -- text field will contain the MCO plan number. When MCO plan number not present the field will reflect 'INVALID'.

Demonstration number

  • Short SAS Name: DEMO_ID_NUM
  • Long SAS Name: DEMO_ID_NUM

Contained in

The number assigned to identify a CMS demonstration project.This field is also used to denote special processing (a.k.a. Special Processing Number, SPN).

Values

Code Code Value
1 Nursing Home Case-Mix and Quality: NHCMQ (RUGS) Demo – testing PPS for SNFs in 6 states, using a case-mix classification system based on resident characteristics and actual resources used. The claims carry a RUGS indicator and one or more revenue center codes in the 9,000 series.
2 National HHA Prospective Payment Demo -- testing PPS for HHAs in 5 states, using two alternate methods of paying HHAs: per visit by type of HHA visit and per episode of HH care.
3 Telemedicine Demo -- testing covering traditionally non-covered physician services for medical consultation furnished via two-way, interactive video systems (i.e. teleconsultation)in 4 states. The claims contain line items with 'QQ' HCPCS code.
4 United Mine Workers of America (UMWA) Managed Care Demo -- testing risk sharing for Part A services, paying special capitation rates for all UMWA beneficiaries residing in 13 designated counties in 3 states. Under the demo, UMWA will waive the 3-day qualifying hospital stay for a SNF admission. The claims contain TOB '18X','21X','28X' and '51X'; condition code = W0; claim MCO paid switch = not '0'; and MCO contract # = '90091'.
5 Medicare Choices (MCO encounter data) demo --testing expanding the type of Managed Care plans available and different payment methods at 16 MCOs in 9 states. The claims contain one of the specific MCO Plan Contract # assigned to the Choices Demo site. NOTE - this demonstration was terminated 12/31/2000.
6 Coronary Artery Bypass Graft (CABG) Demo --testing bundled payment (all-inclusive global pricing) for hospital + physician services related to CABG surgery in 7 hospitals in 7 states. The inpatient claims contain a DRG '106' or '107'. NOTE - this demonstration was terminated in 1998.
7 Virginia Cardiac Surgery Initiative (VCSI) (formerly referred to as Medicare Quality Partnerships Demo) -- this is a voluntary consortium of the cardiac surgery Medicare FFS Claims (Version K) Codebook 166 May 2017 physician groups and the non-Veterans Administration hospitals providing open heart surgical services in the Commonwealth of Virginia. The goal of the demo is to share data on quality and process innovations in an attempt to improve the care for all cardiac patients. The demonstration only affects those FIs that process claims from hospitals in Virginia and the carriers that process claims from physicians providing inpatient services at those hospitals. The hospitals will be reimbursed on a global payment basis for selected cardiac surgical diagnosis related groups (DRGs). The inpatient claims will contain a DRG '104', '105', '106', '107', '109'; the related physician/supplier claims will contain the claim payment denial reason code = 'D'. NOTE - The implementation date for this demonstration is 4/1/03.
8 Provider Partnership Demo -- testing per-case payment approaches for acute inpatient hospitalizations, making a lump-sum payment (combining the normal Part A PPS payment with the Part B allowed charges into a single fee schedule) to a Physician/Hospital Organization for all Part A and Part B services associated with a hospital admission. From 3 to 6 hospitals in the Northeast and Mid-Atlantic regions may participate in the demo.
15 ESRD Managed Care (MCO encounter data) -- testing open enrollment of ESRD beneficiaries and capitation rates adjusted for patient treatment needs at 3 MCOs in 3 States. The claims contain one of the specific MCO Plan Contract # assigned to the ESRD demo site.
30 Lung Volume Reduction Surgery (LVRS) or National Emphysema Treatment Trial (NETT) Clinical Study -- evaluating the effectiveness of LVRS and maximum medical therapy (including pulmonary rehab) for Medicare beneficiaries in last stages of emphysema at 18 hospitals nationally, in collaboration with NIH.
31 VA Pricing Special Processing (SPN) -- not really a demo but special request from VA due to court settlement; not Medicare services but VA inpatient and physician services submitted to FI 00400 and Carrier 00900 to obtain Medicare pricing -- NCH WILL PROCESS VA CLAIMS ANNOTATED WITH DEMO ID '31', BUT WILL NOT TRANSMIT TO HCFA (CMS) (not in Nearline File).
37 Medicare Coordinated Care Demonstration -- to test whether coordinated care services furnished to certain beneficiaries improves outcome of care and reduces Medicare expenditures under Part A and Part B. There will be at least 14 Coordinated Care Entities (CCEs). The selected entities will be assigned a provider number specifically for the demonstration services.
37 Medicare Disease Management (DMD) -- the purpose of this demonstration is to study the impact on costs and health outcomes of applying disease management services supplemented with coverage for prescription drugs for certain Medicare diagnosed, beneficiaries with advanced-stage congestive heart failure, diabetes, or coronary heart disease. Three demonstration sites will be used for this demonstration and it will last for 3 years. (Effective 4/1/2003).
38 Physician Encounter Claims - the purpose of this demo id is to identify the physician encounter claims being processed at the HCFA Data Center (HDC). This number will help EDS in making the claim go through the appropriate processing logic, which differs from that for fee-for-service. NOT IN NCH. NOTE - Effective October, 2000. Demo ids will not be assigned to Inpatient and Outpatient encounter claims.
39 Centralized Billing of Flu and PPV Claims -- The purpose of this demo is to facilitate the processing carrier, Trailblazers, paying flu and PPV claims based on payment localities. Providers will be giving the shots throughout the country and transmitting the claims to Trailblazers for processing. NOTE - Effective October, 2000 for carrier claims.
40 Payment of Physician and Non-physician Services in certain Indian Providers -- the purpose of this demo is to extend payment for services of physician and non-physician practitioners furnished in hospitals and ambulatory care clinics. Prior to the legislation change in BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and skilled nursing facilities. This change will allow payment for IHS, Tribe and Tribal Organization providers under the Medicare physician fee schedule. NOTE - Effective July 1, 2001 for institutional and carrier claims.
48 Medical Adult Day-Care Services -- the purpose of this demonstration is to provide, as part of the episode of care for home health services, medical adult day care services to Medicare beneficiaries as a substitute for a portion of home health services that would otherwise be provided in the beneficiaries home. This demo would last approx. 3 years in not more than 5 sites. Payment for each home health service episode of care will be set at 95% of the amount that would otherwise be paid for home health services provided entirely in the home. NOTE - Effective July 5, 2005 for HHA claims.
49 Hemodialysis
53 Extended Stay
54 ACE Demo
58 used to identify the Multi-payer Advanced Primary Care Practice (MAPCP) demonstration. (eff. 7/2/12)
59 ACO Pioneer Demonstration (eff. 1/2014)
61 CLM-CARE-IMPRVMT-MODEL-1
62 CLM-CARE-IMPRVMT-MODEL-2
63 CLM-CARE-IMPRVMT-MODEL-3
64 CLM-CARE-IMPRVMT-MODEL-4
65 rebilled claims due to auditor denials -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full because of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12)
66 rebilled claims due to provider self-audit after claim submission/payment -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full because of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12)
67 rebilled claims due to provider self-audit after the patient has been discharged, but prior to payment -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full because of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12)
68 NCH will not apply the 3-day hospital stay requirement when processing a SNF claim. (eff. 1/2014)
70 used for Electrical Workers Insurance Fund claims. (eff. 7/2/12)
74 unknown value
77 Shared Savings Program (eff. 10/2016)
78 Comprehensive Primary Care Plus (CPC+) (eff. 4/2017)

Demonstration sequence number

  • Short SAS Name: DEMO_ID_SQNC_NUM
  • Long SAS Name: DEMO_ID_SQNC_NUM

Contained in

The number of demonstration identification trailers present on the claim.

The demonstration sequence number is a sequential line number to distinguish distinct demonstration projects that affect the same claim.

Encrypted CCW Beneficiary ID

  • Short SAS Name: BENE_ID
  • Long SAS Name: BENE_ID

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier bene_id bene_id bene_id bene_id
Inpatient bene_id bene_id bene_id bene_id bene_id
MedPAR bene_id bene_id bene_id bene_id bene_id
Outpatient bene_id bene_id bene_id bene_id bene_id
Dataset 2008 2007 2006
Carrier bene_id bene_id bene_id
Inpatient bene_id bene_id bene_id
MedPAR bene_id bene_id bene_id
Outpatient bene_id bene_id bene_id

Contained in

The unique CCW indentifier for a beneficiary. The CCW assigns a unique beneficiary identification number to each individual who receives Medicare and/or Medicaid, and uses that number to identify an individual’s records in all CCW data files (e.g., Medicare claims, MAX claims, MDS assessment data). This number does not change during a beneficiary’s lifetime and each number is used only once. The BENE_ID is specific to the CCW and is not applicable to any other identification system or data source.

FI Claim Process Date

  • Short SAS Name: FI_CLM_PROC_DT
  • Long SAS Name: FI_CLM_PROC_DT

Contained in

The date the fiscal intermediary completes processing and releases the institutional claim to the CWF host.

FI Number

  • Short SAS Name: FI_NUM
  • Long SAS Name: FI_NUM

Contained in

The identification number assigned by CMS to a fiscal intermediary authorized to process institutional claim records. Effective October 2006, the Medicare Administrative Contractors (MACs) began replacing the existing fiscal intermediaries and started processing institu- tional claim records for states assigned to its jurisdiction. NOTE: The 5-position MAC number will be housed in the existing FI_NUM field. During the transition from an FI to a MAC the FI_NUM field could contain either a FI number or a MAC number. See the FI_NUM table of codes to identify the new MAC numbers and their effective dates.

Values

JURISDICTION 3 - Part A MACs

Code Code Value
10 Alabama BC - Alabama
11 Alabama BC - Iowa (replaced by MAC # 03401 -- see below)
20 Arkansas BC - Arkansas
21 Arkansas BC - Rhode Island
30 Arizona BC (replaced by MAC #03101 -- see below)
40 California BC (term. 12/00)
50 New Mexico BC/CO (term. 06/89)
60 Connecticut BC (term. 06/99)
70 Delaware BC - terminated 2/98
80 Florida BC (term. 03/88)
90 Florida BC
101 Georgia BC
121 Illinois - HCSC (term. 08/98)
123 Michigan - HCSC (term. 08/98)
130 Indiana BC/Administar Federal
131 Illinois - Administar
140 Iowa - Wellmark (term. 6/2000)
150 Kansas BC (term. 2008) (replaced with MAC # 05201 --see below)
160 Kentucky/Administar
180 Maine BC
181 Maine BC - Massachusetts
190 Maryland BC (term. 9/2005)
200 Massachusetts BC (term. 7/97)
210 Michigan BC (term. 9/94)
220 Minnesota BC (term. 07/99)
230 Mississippi BC
231 Mississippi BC/LA (term. 09/92)
232 Mississippi BC
241 Missouri BC (term. 9/92)
250 Montana BC (replaced by MAC #03201 -- see below)
260 Nebraska BC (term. 2007) (replaced with MAC # 05401 --see below)
270 New Hampshire BC
280 New Jersey BC (term. 8/2000)
290 New Mexico BC - terminated 11/95
308 New York - Empire BC
310 North Carolina BC (term. 01/02)
320 North Dakota BC - North Dakota (replaced with MAC # 03301 -- see below)
322 North Dakota BC - Washington & Alaska
323 North Dakota BC - Idaho, Oregon & Utah (replaced with MAC # 03501 --see below)
332 Ohio-Administar
340 Oklahoma BC (term. 2008) (replaced with MAC # 04301 --see below)
350 Oregon BC
351 Oregon BC/ID. (term. 09/88)
355 Oregon-CWF
362 Independence BC - terminated 8/97
363 Pennsylvania/Highmark - Veritus
366 Highmark (MD & DC) - Part A (eff. 10/2005)
370 Rhode Island BC
380 South Carolina BC - South Carolina
382 South Carolina BC - North Carolina
390 Tennessee BC
400 Texas BC
410 Utah BC (term. 09/00)
423 Virginia BC; Trigon (term. 08/99)
430 Washington/Alaska BC
450 Wisconsin BC - Wisconsin
452 Wisconsin BC - Michigan
453 Wisconsin BC - Virginia & West Virginia
454 Wisconsin BC - California
460 Wyoming BC (replaced by MAC # 03601 -- see below)
468 N Carolina BC/CPRTIVA
993 BC/BS Assoc.
17120 Hawaii Medical Service (term. 06/99)
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 NE - Mutual of Omaha
57400 Puerto Rico - Cooperativa
61000 Aetna (term. 06/97)
80883 Contractor ID for Inpatient & Outpatient Risk Adjustment Data (data not sent through CWF; but through Palmetto)

JURISDICTION 4 - Part A MACs

Code Code Value
3101 Arizona (eff. 10/1/2006) (replaces FI #00030)
3201 Montana (eff. 12/1/2006) (replaces FI #00250)
3301 N. Dakota (eff. 12/1/2006) (replaces FI #00320)
3401 S. Dakota (eff. 3/1/2007) (replaces FI #00011)
3501 Utah (eff. 12/1/2006) (replaces FI #00323)
3601 Wyoming (eff. 11/1/2006) (replaces FI #00460)

JURISDICTION 5 - Part A MACs

Code Code Value
4301 Oklahoma (eff. 3/1/2008) (replaces FI #00340)
Code Code Value
5201 Oklahoma (eff. 3/1/2008) (replaces FI #00150)
5401 Oklahoma (eff. 12/1/2007)(replaces FI #00260)

FI or MAC Claim Action Code

  • Short SAS Name: ACTIONCD
  • Long SAS Name: FI_CLM_ACTN_CD

Contained in

The type of action requested by the intermediary to be taken on an institutional claim.

Values

ResDAC note: the only values that are actually found in the CCW data are 1, 5, 8. The CMS value for code 3, referred to in code 5 is "Secondary debit adjustment - used only in credit/debit pairs (under HHPPS, would be the final claim or an adjustment on a LUPA)."

Code Code Value
1 Original debit action (includes non-adjustment RTI correction items) - it will always be a 1 in regular bills.
5 Force action code 3
8 Benefits refused (for inpatient bills, an 'R' nonpayment code must also be present

First Claim Diagnosis E Code

  • Short SAS Name: FST_DGNS_E_CD
  • Long SAS Name: FST_DGNS_E_CD

Contained in

The code used to identify the 1st external cause of injury, poisoning, or other adverse effect This diagnosis E code is also stored as the 1st occurrence of the diagnosis E code trailer.

NOTE: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10.

Gender Code from Claim

  • Short SAS Name: GNDR_CD
  • Long SAS Name: GNDR_CD

Contained in

The sex of a beneficiary.

Values

Code Code Value
1 Male
2 Female
0 Unknown

HCPCS Fourth Modifier Code

  • Short SAS Name: MDFR_CD4
  • Long SAS Name: HCPCS_4TH_MDFR_CD

Contained in

A fourth modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to make it more specific than the first, second,

This field is available only in the Hospital Outpatient data file (not other claim types).

HCPCS Third Modifier Code

  • Short SAS Name: MDFR_CD3
  • Long SAS Name: HCPCS_3RD_MDFR_CD

Contained in

A third modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to make it more specific than the first or second modifier codes to identify the revenue center or line item services for the claim.

NCH Beneficiary Blood Deductible Liability Amount

  • Short SAS Name: BLDDEDAM
  • Long SAS Name: NCH_BENE_BLOOD_DDCTBL_LBLTY_AM

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient blddedam blddedam blddedam blddedam blddedam
MedPAR blddedam blddedam blddedam blddedam blddedam
Outpatient blddedam blddedam blddedam blddedam blddedam
Dataset 2008 2007 2006 2005 2004
Inpatient blddedam blddedam blddedam blddedam blddedam
MedPAR blddedam blddedam blddedam blddedam blddedam
Outpatient blddedam blddedam blddedam blddedam blddedam
Dataset 2003 2002 2001 2000 1999
Inpatient blddedam blddedam blddedam blddedam blddedam
MedPAR blddedam blddedam mbldded mbldded mbldded
Outpatient blddedam blddedam blddedam blddedam blddedam

Contained in

The amount of money for which the intermediary determined the beneficiary is liable for the blood deductible.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT DERIVATION RULES: Based on the presence of value code equal to '06' move the corresponding value amount to NCH_BENE_BLOOD_DDCTBL_AMT.

Values

Code
XXX.XX

NCH Beneficiary Part B Coinsurance Amount

  • Short SAS Name: PTB_COIN
  • Long SAS Name: NCH_BENE_PTB_COINSRNC_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient ptb_coin ptb_coin ptb_coin ptb_coin ptb_coin
Dataset 2008 2007 2006 2005 2004
Outpatient ptb_coin ptb_coin ptb_coin ptb_coin ptb_coin
Dataset 2003 2002 2001 2000 1999
Outpatient ptb_coin ptb_coin ptb_coin ptb_coin ptb_coin

Contained in

The amount of money for which the intermediary has determined that the beneficiary is liable for Part B coinsurance on the institutional claim.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT

DERIVATION RULES (Effective 10/93): Based on the presence of value codes A2, B2 or C2 move the related value amount to the NCH_BENE_PTB_COINSRNC_AMT. *NOTE: Prior to 10/93, this field was present on the claim transmitted by CWF.

NCH Beneficiary Part B Deductible Amount

  • Short SAS Name: PTB_DED
  • Long SAS Name: NCH_BENE_PTB_DDCTBL_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient ptb_ded ptb_ded ptb_ded ptb_ded ptb_ded
Dataset 2008 2007 2006 2005 2004
Outpatient ptb_ded ptb_ded ptb_ded ptb_ded ptb_ded
Dataset 2003 2002 2001 2000 1999
Outpatient ptb_ded ptb_ded ptb_ded ptb_ded ptb_ded

Contained in

The amount of money for which the intermediary or carrier has determined that the beneficiary is liable for the Part B cash deductible on the claim.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT

DERIVATION RULES (Effective 10/93): Based on the presence of value codes A1, B1 or C1 move the related value amount to the NCH_BENE_PTB_DDCTBL_AMT. *NOTE: Prior to 10/93, this field was present on the claim transmitted by CWF.

NCH Blood Pints Furnished Quantity

  • Short SAS Name: BLDFRNSH
  • Long SAS Name: NCH_BLOOD_PNTS_FRNSHD_QTY

Contained in

Number of whole pints of blood furnished to the beneficiary, as reported on the carrier claim (non-DMERC).

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT

DERIVATION RULES: Based on the presence of value code equal to 37 move the related value amount to the NCH_BLOOD_PT_FRNSH_QTY.

NCH Claim Type Code

  • Short SAS Name: CLM_TYPE
  • Long SAS Name: NCH_CLM_TYPE_CD

Variable Names

Dataset 2012 2011 2010 2009 2008
Carrier clm_type clm_type clm_type clm_type clm_type
Dataset 2007 2006 2005 2004 2003
Carrier clm_type clm_type clm_type clm_type clm_type
Dataset 2002 2001 2000 1999
Carrier clm_type clm_type clm_type clm_type

Contained in

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 throughout 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).

NOTE3: Effective with Version 'J', 3 new code values have been added to include a type code for the Medicare Advantage claims (IME/GME, no-pay and paid as FFS). During the Version 'J' conversion, these type codes were populated throughout history.

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 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 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 (Medicare Advantage IME/GME CLAIMS - 10/1/05 - FORWARD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '0' 2. CLM_RLT_COND_CD = '04' & '69' 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 63 (HMO NO-PAY CLAIMS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED ON OR AFTER 10/6/08 1. CLM_THRU_DT ON OR AFTER 10/1/06 2. CLM_MCO_PD_SW = '1' 3. CLM_RLT_COND_CD = '04' 4. MCO_CNTRCT_NUM MCO_OPTN_CD = 'A', 'B' OR 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS 5. ZERO REIMBURSEMENT (CLM_PMT_AMT) SET CLM_TYPE_CD TO 63 (HMO NO-PAY CLAIMS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED PRIOR to 10/6/08 1. MCO_CNTRCT_NUM MCO_OPTN_CD = 'A', 'B' OR 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS 2. ZERO REIMBURSEMENT (CLM_PMT_AMT) SET CLM_TYPE_CD TO 64 (HMO CLAIMS PAID AS FFS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED PRIOR to 10/6/08 1. MCO_CNTRCT_NUM MCO_OPTN_CD = '1', '2' OR '4' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET CLM_TYPE_CD TO 64 (HMO CLAIMS PAID AS FFS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED on or after 10/6/08 1. CLM_RLT_COND_CD = '04' 2. MCO_CNTRCT_NUM MCO_OPTN_CD = '1', '2' OR '4' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS 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 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).

Values

Code Code Value
10 HHA claim
20 Non swing bed SNF claim
30 Swing bed SNF claim
40 Outpatient claim
50 Hospice claim
60 Inpatient claim
61 Inpatient 'Full-Encounter' claim
62 Medicare Advantage IME/GME claims
63 Medicare Advantage (no-pay) claims
64 Medicare Advantage (paid as FFS) claim
71 RIC O local carrier non-DMEPOS claim
72 RIC O local carrier DMEPOS claim
81 RIC M DMERC non-DMEPOS claim
82 RIC M DMERC DMEPOS claim

NCH Near Line Record Identification Code

  • Short SAS Name: RIC_CD
  • Long SAS Name: NCH_NEAR_LINE_REC_IDENT_CD

Contained in

A code defining the type of claim record being processed.

Values

Code Code Value
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)

NCH Primary Payer Claim Paid Amount*

  • Short SAS Name: PRPAYAMT
  • Long SAS Name: NCH_PRMRY_PYR_CLM_PD_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prpayamt prpayamt prpayamt prpayamt prpayamt
MedPAR prpayamt prpayamt prpayamt prpayamt prpayamt
Outpatient prpayamt prpayamt prpayamt prpayamt prpayamt
Dataset 2008 2007 2006 2005 2004
Inpatient prpayamt prpayamt prpayamt prpayamt prpayamt
MedPAR prpayamt prpayamt prpayamt prpayamt prpayamt
Outpatient prpayamt prpayamt prpayamt prpayamt prpayamt
Dataset 2003 2002 2001 2000 1999
Inpatient prpayamt prpayamt prpayamt prpayamt prpayamt
MedPAR prpayamt prpayamt mppamt mppamt mppamt
Outpatient prpayamt prpayamt prpayamt prpayamt prpayamt

Contained in

Effective with Version H, the amount of a payment made on behalf of a Medicare bene- ficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges on a non-institutional claim.

NOTE: During the Version H conversion, this field was populated with data throughout history (back to service year 1991) by summing up the line item primary payer amounts.

NCH Primary Payer Code

  • Short SAS Name: PRPAY_CD
  • Long SAS Name: NCH_PRMRY_PYR_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
MedPAR prpay_cd prpay_cd prpay_cd prpay_cd prpay_cd
Dataset 2008 2007 2006 2005 2004
MedPAR prpay_cd prpay_cd prpay_cd prpay_cd prpay_cd
Dataset 2003 2002 2001 2000 1999
MedPAR prpay_cd prpay_cd mppcde mppcde mppcde

Contained in

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.

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'

Values

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 supposed to be effective after 12/90, but may have been used prior to that date.)

Code Code Value
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)
Y Other secondary payer investigation shows Medicare as primary payer
Z Medicare is primary payer

NCH Professional Component Charge Amount

  • Short SAS Name: PCCHGAMT
  • Long SAS Name: NCH_PROFNL_CMPNT_CHRG_AMT

Contained in

This field is the amount of physician and other professional charges covered under Medicare Part B.

This variable is not populated for Home Health or Hospice claims. This field is used for CMS editing purposes and other internal processes (e.g. if computing interim payments, then these charges are deducted). The source of information for this field for institutional claims is the CLM_VAL_AMT (when the code = 04 or 05, it indicates a professional component charge amount). For Outpatient claims, this information is from the revenue center codes (when the code=096, 097 or 098*, then the REV_CNTR_TOT_CHRG_AMT indicates a professional component charge amount).

Values

Code
XXX.XX

NCH Provider State Code

  • Short SAS Name: PRSTATE
  • Long SAS Name: PRVDR_STATE_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient prstate prstate prstate prstate prstate
Outpatient prstate prstate prstate prstate prstate
Dataset 2008 2007 2006 2005 2004
Inpatient prstate prstate prstate prstate prstate
Outpatient prstate prstate prstate prstate prstate
Dataset 2003 2002 2001 2000 1999
Inpatient prstate prstate prstate prstate prstate
Outpatient prstate prstate prstate prstate prstate

Contained in

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).

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' OR '75' SET NCH_PRVDR_STATE_CD TO '05'. FOR PRVDR_NUM POS1-2 EQUAL '67' OR '74' SET NCH_PRVDR_STATE_CD TO '45'. FOR PRVDR_NUM POS1-2 EQUAL '68' OR '69' SET NCH_PRVDR_STATE_CD TO '10'. FOR PRVDR_NUM POS1-2 EQUAL '78' SET NCH_PRVDR_STATE_CD TO '14' FOR PRVDR_NUM POS1-2 EQUAL TO '76' SET NCH_PRVDR_STATE_CD TO '16' FOR PRVDR_NUM POS1-2 EQUAL '70' SET NCH_PRVDR_STATE_CD TO '17' FOR PRVDR_NUM POS1-2 EQUAL '71' SET NCH_PRVDR_STATE_CD TO '19' FOR PRVDR_NUMBER POS1-2 EQUAL '77' SET NCH_PRVDR_STATE_CD TO '24' FOR PRVDR_NUM POS1-2 EQUAL TO '72' SET NCH_PRVDR_STATE_CD TO '36' FOR PRVDR_NUM POS1-2 EQUAL TO '73' SET NCH_PRVDR_STATE_CD TO '39'

Values

Code Code Value
1 Alabama
2 Alaska
3 Arizona
4 Arkansas
5 California
6 Colorado
7 Connecticut
8 Delaware
9 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 California
56 Canada & Islands
57 Central America and West Indies
58 Europe
59 Mexico
60 Oceania
61 Philippines
62 South America
63 U.S. Possessions
64 American Samoa
65 Guam
66 Commonwealth of the Northern Marianas Islands
67 Texas
68 Florida (eff. 10/2005)
69 Florida (eff. 10/2005)
70 Kansas (eff. 10/2005)
71 Louisiana (eff. 10/2005)
72 Ohio (eff. 10/2005)
73 Pennsylvania (eff. 10/2005)
74 Texas (eff. 10/2005)
80 Maryland (eff. 8/2000)
97 Northern Marianas
98 Guam
99 With 000 county code is American Samoa; otherwise unknown

NCH Weekly Claim Processing Date

  • Short SAS Name: WKLY_DT
  • Long SAS Name: NCH_WKLY_PROC_DT

Contained in

The date the weekly NCH database load process cycle begins, during which the claim records are loaded into the Nearline file. This date will always be a Friday, although the claims will actually be appended to the database subsequent to the date.

Organization NPI Number

  • Short SAS Name: ORGNPINM
  • Long SAS Name: ORG_NPI_NUM

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm
Outpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm
Dataset 2008 2007 2006 2005 2004
Inpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm
Outpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm
Dataset 2003 2002 2001 2000 1999
Inpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm
Outpatient orgnpinm orgnpinm orgnpinm orgnpinm orgnpinm

Contained in

On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify the institutional provider certified by Medicare to provide services to the beneficiary.

NOTE: Effective May 2007, the NPI will be- come the national standard identifier for covered health care providers. NPIs will replace current OSCAR provider number, UPINs, NSC numbers, and local contractor provider identification numbers (PINs) on standard HIPPA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capability was there for the NCH to receive NPIs along with an existing legacy number (UPIN, PIN, OSCAR provider number, etc.)).

NOTE1: CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be available in the NCH. After the 5/07 NPI implelmentation, the standard system main- tainers will add the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider number and any currently issued UPINs. Effective May 2007, no NEW UPINs (legacy number) will be generated for NEW physicians (Part B and outpatient claims), so there will only be NPIs sent in to the NCH for those physicians.

Patient Discharge Status Code

  • Short SAS Name: STUS_CD
  • Long SAS Name: PTNT_DSCHRG_STUS_CD

Contained in

The code used to identify the status of the patient as of the CLM_THRU_DT.

Values

EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES POSITIONS 1 & 2 OF ANSI CODE

Code Code Value
0 Unknown Value (but present in data)
1 Discharged to home/self care (routine charge).
2 Discharged/transferred to other short term general hospital for inpatient care.
3 Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care -- (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.
4 Discharged/transferred to intermediate care facility (ICF).
5 Discharged/transferred to another type of institution for inpatient care (including distinct parts). NOTE: Effective 1/2005, psychiatric hospital or psychiatric distinct part unit of a hospital will no longer be identified by this code. New code is '65'
6 Discharged/transferred to home care of organized home health service organization.
7 Left against medical advice or discontinued care.
8 Discharged/transferred to home under care of a home IV drug therapy provider. (discontinued effective 10/1/05)
9 Admitted as an inpatient to this hospital (effective 3/1/91). In situations where a patient is admitted before midnight of the third day following the day of an outpatient service, the outpatient services are considered inpatient.
20 Expired (did not recover - Christian Science patient).
21 Discharged/transferred to Court/Law Enforcement
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)
43 Discharged/transferred to a federal hospital (eff. 10/1/03)
50 Hospice - home (eff. 10/96)
51 Hospice - medical facility (eff. 10/96)
61 Discharged/transferred within this institution to a hospital-based Medicare approved swing bed (eff. 9/01)
62 Discharged/transferred to an inpatient rehabilitation facility including distinct parts units of a hospital. (eff. 1/2002)
63 Discharged/transferred to a long term care hospitals. (eff. 1/2002)
64 Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare (eff. 10/2002)
65 Discharged/Transferred to a psychiatric hospital or psychiatric distinct unit of a hospital (these types of hospitals were pulled from patient/discharge status code '05' and given their own code). (eff. 1/2005).
66 Discharged/transferred to a Critical Access Hospital (CAH) (eff. 1/1/06)
69 Discharged/transferred to a designated disaster alternative care site (eff. 10/2013)
70 Discharged/transferred to another type of health care institution not defined elsewhere in code list.
71 Discharged/transferred/referred to another institution for outpatient services as specified by the discharge plan of care (eff. 9/01) (discontinued effective 10/1/05)
72 Discharged/transferred/referred to this institution for outpatient services as specified by the discharge plan of care (eff. 9/01) (discontinued effective 10/1/05)
81 Discharged to home or self-care with a planned acute care hospital readmission (eff. 10/2013)
82 Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission (eff. 10/2013)
83 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission (eff. 10/2013)
84 Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission (eff. 10/2013)
85 Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission (eff. 10/2013)
86 Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission (eff. 10/2013)
87 Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission (eff. 10/2013)
88 Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission (eff. 10/2013)
89 Discharged/transferred to a hospital-based Medicare approved swing bed with a planned acute care hospital inpatient readmission (eff. 10/2013)
90 Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission (eff. 10/2013)
91 Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission (eff. 10/2103)
92 Discharged/transferred to nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission (eff. 10/2013)
93 Discharged/transferred to a psychiatric hospital/distinct part unit of a hospital with a planned acute care hospital inpatient readmission (eff. 10/2013)
94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission (eff. 10/2013)
95 Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital inpatient readmission (eff. 10/2013)
Code Code Value
CO Contractual Obligations -- this group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments 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 adjustment 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.
Code Code Value
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 authorization number is missing, invalid, or does not apply to the billed services or provider.
16 Claim/service lacks information which is needed for 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 Compensation 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-certification 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 arrangement.
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 conjunction with a routine exam.
50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.
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.
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 completion 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.
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, Assessments, 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 alternative services were available, and should have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component 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 records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
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.

Provider Number

  • Short SAS Name: PROVIDER
  • Long SAS Name: PRVDR_NUM

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient provider provider provider provider provider
Outpatient provider provider provider provider provider
Dataset 2008 2007 2006 2005 2004
Inpatient provider provider provider provider provider
Outpatient provider provider provider provider provider
Dataset 2003 2002 2001 2000 1999
Inpatient provider provider provider provider provider
Outpatient provider provider provider provider provider

Contained in

The identification number of the institutional provider certified by Medicare to provide services to the beneficiary. NOTE: Effective October 1, 2007 the OSCAR Provider Number has been renamed the CMS Certification Number (CCN). The name was changed to avoid confusion with the National Provider Identifier (NPI). The CCN (OSCAR Provider Number) will continue to play a critical role in verifying that a provider has been Medicare certified and for what type of services.

Values

Provider Number Table.txt

Race Code from Claim

  • Short SAS Name: RACE_CD
  • Long SAS Name: BENE_RACE_CD

Contained in

The race of a beneficiary.

Values

Code Code Value
0 Unknown
1 White
2 Black
3 Other
4 Asian
5 Hispanic
6 North American Native

Reason for Visit Diagnosis Code I

  • Short SAS Name: RSN_VISIT_CD1
  • Long SAS Name: RSN_VISIT_CD1

Contained in

The diagnosis code used to identify the patient's reason for visit.

Reason for Visit Diagnosis Code II

  • Short SAS Name: RSN_VISIT_CD2
  • Long SAS Name: RSN_VISIT_CD2

Contained in

The diagnosis code used to identify the patient's reason for visit.

Reason for Visit Diagnosis Code III

  • Short SAS Name: RSN_VISIT_CD3
  • Long SAS Name: RSN_VISIT_CD3

Contained in

The diagnosis code used to identify the patient's reason for visit.

Rendering Physician Specialty Code

  • Short SAS Name: RNDRNG_PHYSN_SPCLTY_CD
  • Long SAS Name: REV_CNTR_PHYSN_SPCLTY_CD

Contained in

The code used to identify the CMS specilty code of the rendering physician/practitioner. 

(Revenue Center file)

Values

Code Code Value
00 Carrier wide
01 General practice
02 General surgery
03 Allergy/immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family practice
09 Interventional Pain Management (IPM) (eff. 4/1/03)
10 Gastroenterology
11 Internal medicine
12 Osteopathic manipulative therapy
13 Neurology
14 Neurosurgery
15 Speech/language pathology
16 Obstetrics/gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral surgery (dentists only)
20 Orthopedic surgery
21 Cardiac Electrophysiology
22 Pathology
24 Plastic and reconstructive surgery
25 Physical medicine and rehabilitation
26 Physchiatry
27 General Psychiatry
28 Colorectal surgery (formerly proctology)
29 Pulmonary disease
30 Diagnostic radiology
31 Intensive cardiac rehabilitation
32 Anesthesiologist Assistants (eff. 4/1/03--previously grouped with Certified Registered Nurse Anesthetists (CRNA))
33 Thoracic surgery
34 Urology
35 Chiropractic
36 Nuclear medicine
37 Pediatric medicine
38 Geriatric medicine
39 Nephrology
40 Hand surgery
41 Optometrist
42 Certified nurse midwife
43 Certified Registered Nurse Anesthetist (CRNA) (Anesthesiologist Assistants were removed from this specialty 4/1/03)
44 Infectious disease
45 Mammography screening center
46 Endocrinology
47 Independent Diagnostic Testing Facility (IDTF)
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 for DMERC (and not included in 51-53)
55 Individual certified orthotist
56 Individual certified prosthetist
57 Individual certified prosthetist-orthotist
58 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 Association, Catholic Charities)
62 Psychologist (billing independently)
63 Portable X-ray supplier
64 Audiologist (billing independently)
65 Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03)
66 Rheumatology
67 Occupational therapist (private practice added 4/103) (independently practicing removed 4/1/03)
68 Clinical psychologist
69 Clinical laboratory (billing independently)
70 Multispecialty clinic or group practice
71 Registered Dietician/Nutrition Professional (eff.1/1/02)
72 Pain Management (eff. 1/1/02)
73 Mass Immunization Roster Biller
74 Radiation Therapy Centers (prior to 4/2003 this included Independent Diagnostic Testing Facilities (IDFT))
75 Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs--eff. 4//1/03))
76 Peripheral vascular disease
77 Vascular surgery
78 Cardiac surgery
79 Addiction medicine
80 Licensed clinical social worker
81 Critical care (intensivists)
82 Hematology
83 Hematology/oncology
84 Preventive medicine
85 Maxillofacial surgery
86 Neuropsychiatry
87 All other suppliers (e.g. drug and department stores)
88 Unknown supplier/provider specialty
89 Certified clinical nurse specialist
90 Medical oncology
91 Surgical oncology
92 Radiation oncology
93 Emergency medicine
94 Interventional radiology
95 Competitive Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/01/06, known as Independent physiological laboratory
96 Optician
97 Physician assistant
98 Gynecologist/oncologist
99 Unknown physician specialty
A0 Hospital (DMERCs only)
A1 SNF (DMERCs only)
A2 Intermediate care nursing facility (DMERCs only)
A3 Nursing facility, other (DMERCs only)
A4 Home Health Agency (DMERCs only)
A5 Pharmacy (DMERC)
A6 Medical supply company with respiratory therapist (DMERCs only)
A7 Department store (DMERC)
A8 Grocery store (DMERC)
A9 Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities, eff. 1/2005)
B1 Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07)
B2 Pedorthic Personnel (eff. 10/2/07)
B3 Medical Supply Company with pedorthic personnel (eff. 10/2/07)
B4 Does not meet definition of health care provider (e.g., Rehabilitation agency, organ procurement organizations, histocompatibility labs) (eff. 10/2/07)
B5 Ocularist
C0 Sleep medicine
C1 Centralized flu
C2 Indirect payment procedure
C3 Interventional cardiology
C5 Dentist (eff. 7/2016)

Revenue Center 1st ANSI Code

  • Short SAS Name: REVANSI1
  • Long SAS Name: REV_CNTR_1ST_ANSI_CD

Contained in

The first code used to identify the detailed reason an adjustment was made (e.g. reason for denial or reducing payment).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: 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.

Values

*EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES* **POSITIONS 1 & 2 OF ANSI CODE***

Code Code Value
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 adjustment 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*

Code Code Value
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 authorization number is missing, invalid, or does not apply to the billed services or provider.
16 Claim/service lacks information which is needed for 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 Compensation 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 arrangement.
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 conjunction with a routine exam.
50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.
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
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.
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 alternative services were available, and should have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component 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 records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
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.

Revenue Center 1st Medicare Secondary Payer Paid Amount

  • Short SAS Name: REV_MSP1
  • Long SAS Name: REV_CNTR_1ST_MSP_PD_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_msp1 rev_msp1 rev_msp1 rev_msp1 rev_msp1
Dataset 2008 2007 2006 2005 2004
Outpatient rev_msp1 rev_msp1 rev_msp1 rev_msp1 rev_msp1
Dataset 2003 2002 2001 2000 1999
Outpatient rev_msp1 rev_msp1 rev_msp1 rvmsp1_ rvmsp1_

Contained in

Effective with Version 'I', the amount paid by the primary payer when the payer is primary to Medicare (Medicare is secondary).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code
XXX.XX

Revenue Center 2nd ANSI Code

  • Short SAS Name: REVANSI2
  • Long SAS Name: REV_CNTR_2ND_ANSI_CD

Contained in

The second code used to identify the detailed reason an adjustment was made (e.g. reason for denial or reducing payment).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: 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.

Revenue Center 2nd Medicare Secondary Payer Paid Amount

  • Short SAS Name: REV_MSP2
  • Long SAS Name: REV_CNTR_2ND_MSP_PD_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_msp2 rev_msp2 rev_msp2 rev_msp2 rev_msp2
Dataset 2008 2007 2006 2005 2004
Outpatient rev_msp2 rev_msp2 rev_msp2 rev_msp2 rev_msp2
Dataset 2003 2002 2001 2000 1999
Outpatient rev_msp2 rev_msp2 rev_msp2 rvmsp2_ rvmsp2_

Contained in

Effective with Version 'I', the amount paid by the secondary payer when two payers are primary to Medicare (Medicare is the tertiary payer).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code
XXX.XX

Revenue Center 3rd ANSI Code

  • Short SAS Name: REVANSI3
  • Long SAS Name: REV_CNTR_3RD_ANSI_CD

Contained in

The third code used to identify the detailed reason an adjustment was made (e.g. reason for denial or reducing payment).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: 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.

Revenue Center 4th ANSI Code

  • Short SAS Name: REVANSI4
  • Long SAS Name: REV_CNTR_4TH_ANSI_CD

Contained in

The fourth code used to identify the detailed reason an adjustment was made (e.g. reason for denial or reducing payment).

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: 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.

Revenue Center APC/HIPPS

  • Short SAS Name: APCHIPPS
  • Long SAS Name: REV_CNTR_APC_HIPPS_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient apchipps apchipps apchipps apchipps apchipps
Dataset 2008 2007 2006 2005 2004
Outpatient apchipps apchipps apchipps apchipps apchipps
Dataset 2003 2002 2001 2000 1999
Outpatient apchipps apchipps apchipps apcpps apcpps

Contained in

Effective with Version 'I', this field was created to house two pieces of data. The Ambulatory Payment Classification (APC) code and the HIPPS code. The APC is used to identify groupings of outpatient services. APC codes are used to calculate payment for services under OPPS. The APC is a four byte field. The HIPPS codes are used to identify patient classifications for SNFPPS, HHPPS and IRFPPS that will be used to calculate payment. The HIPPS code is a five byte field.

NOTE1: The APC field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: Under SNFPPS, HHPPS & IRFPPS, HIPPS codes are stored in the HCPCS field. **EXCEPTION: if a HHPPS HIPPS code is downcoded/upcoded the downcoded/ upcoded HIPPS will be stored in this field.

NOTE3: 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.

Values

REV_CNTR_APC_TB.txt

Revenue Center Beneficiary Payment Amount

  • Short SAS Name: RBENEPMT
  • Long SAS Name: REV_CNTR_BENE_PMT_AMT

Contained in

Effective with Version I, the amount paid to the beneficiary for the services reported on the line item.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Revenue Center Blood Deductible Amount

  • Short SAS Name: REVBLOOD
  • Long SAS Name: REV_CNTR_BLOOD_DDCTBL_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient revblood revblood revblood revblood revblood
Dataset 2008 2007 2006 2005 2004
Outpatient revblood revblood revblood revblood revblood
Dataset 2003 2002 2001 2000 1999
Outpatient revblood revblood revblood rvbld rvbld

Contained in

Effective with Version 'I', the amount of money for which the intermediary determined the beneficiary is liable for the blood deductible for the line item service.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Revenue Center Cash Deductible Amount

  • Short SAS Name: REVDCTBL

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient revdctbl revdctbl revdctbl revdctbl revdctbl
Dataset 2008 2007 2006 2005 2004
Outpatient revdctbl revdctbl revdctbl revdctbl revdctbl
Dataset 2003 2002 2001 2000 1999
Outpatient revdctbl revdctbl revdctbl rvdtbl rvdtbl

Contained in

Effective with Version 'I' the amount of cash deductible the beneficiary paid for the line item service.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Revenue Center Code

  • Short SAS Name: REV_CNTR
  • Long SAS Name: REV_CNTR

Variable Names

Dataset 2013 2012 2011 2010 2009
Inpatient rev_cntr rev_cntr rev_cntr rev_cntr rev_cntr
Outpatient rev_cntr rev_cntr rev_cntr rev_cntr rev_cntr
Dataset 2008 2007 2006 2005 2004
Inpatient rev_cntr rev_cntr rev_cntr rev_cntr rev_cntr
Outpatient rev_cntr rev_cntr rev_cntr rev_cntr rev_cntr
Dataset 2003 2002 2001 2000 1999
Inpatient rev_cntr rev_cntr rvcntr rvcntr rvcntr
Outpatient rev_cntr rev_cntr rev_cntr rvcntr rvcntr

Contained in

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.

Values

Revenue Center Table.txt

Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount

  • Short SAS Name: WAGEADJ
  • Long SAS Name: REV_CNTR_COINSRNC_WGE_ADJSTD_C

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient wageadj wageadj wageadj wageadj wageadj
Dataset 2008 2007 2006 2005 2004
Outpatient wageadj wageadj wageadj wageadj wageadj
Dataset 2003 2002 2001 2000 1999
Outpatient wageadj wageadj wageadj wgdj wgdj

Contained in

Effective with Version 'I', the amount of coinsurance applicable to the line item 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 is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. The above claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

NOTE2: 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.

NOTE3: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code
XXX.XX

Revenue Center Date

  • Short SAS Name: REV_DT
  • Long SAS Name: REV_CNTR_DT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_dt rev_dt rev_dt rev_dt rev_dt
Dataset 2008 2007 2006 2005 2004
Outpatient rev_dt rev_dt rev_dt srev_dt srev_dt
Dataset 2003 2002 2001 2000 1999
Outpatient srev_dt srev_dt srev_dt rev_dt rev_dt

Contained in

This is the date of service for the revenue center record. Source: CCW

Revenue Center Deductible Coinsurance Code

  • Short SAS Name: REVDEDCD
  • Long SAS Name: REV_CNTR_DDCTBL_COINSRNC_CD

Contained in

Code indicating whether the revenue center charges are subject to deductible and/or coinsurance

Values

For revenue center code 0001, the following MSP override values may be present:

Code Code Value
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)
Code Code Value
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)

Revenue Center Discount Indicator Code

  • Short SAS Name: DSCNTIND
  • Long SAS Name: REV_CNTR_DSCNT_IND_CD

Contained in

Effective with Version 'I', 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.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

NOTE3: VALUES D, U & T REPRESENT THE FOLLOWING: D = Discounting fraction (currently 0.5) U = Number of units T = Terminated procedure discount (currently 0.5)

Values

DISCOUNTING FORMULAS

Code Code Value
1 1.0
2 (1.0+Discounting fraction (0.5) (Number of units-1))/U
3 Terminated procedure discount (currently 0.5)/Number of units
4 (1+Discounting fraction (0.5))/Number of units
5 Discounting fraction (currently 0.5)
6 Terminated procedure discount (currently 0.5)*Discounting fraction (0.5)/Number of units
7 Discounting fraction (0.5)(1+Discounting fraction (0.5))/Number of units
8 2.0/Number of units

Revenue Center HCFA Common Procedure Coding System

  • Short SAS Name: HCPCS_CD
  • Long SAS Name: HCPCS_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Inpatient hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Outpatient hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Dataset 2008 2007 2006 2005 2004
Carrier hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Inpatient hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Outpatient hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd
Dataset 2003 2002 2001 2000 1999
Carrier hcpcs_cd hcpcs_cd hcpcs_cd hcpcs_cd bhcpcs
Inpatient hcpcs_cd hcpcs_cd hcpscd hcpscd hcpscd
Outpatient hcpcs_cd hcpcs_cd hcpcs_cd hcpscd hcpscd

Contained in

The Health Care Common Procedure Coding System (HCPCS) is a collection of codes that represent procedures, 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:

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 CMS/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, Fifth Edition (CDT-5).  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 CMS, the Health Insurance Association of 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.

HCPCS - General Information (CMS Website)

Revenue Center HCPCS Initial Modifier Code

  • Short SAS Name: MDFR_CD1
  • Long SAS Name: HCPCS_1ST_MDFR_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1
Outpatient mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1
Dataset 2008 2007 2006 2005 2004
Carrier mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1
Outpatient mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1
Dataset 2003 2002 2001 2000 1999
Carrier mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfr_cd1 bhmod1
Outpatient mdfr_cd1 mdfr_cd1 mdfr_cd1 mdfcd1_ mdfcd1_

Contained in

A first modifier to the HCPCS procedure code to enable a more specific procedure identification for the line item service on the noninstitutional claim.

Revenue Center HCPCS Second Modifier Code

  • Short SAS Name: MDFR_CD2
  • Long SAS Name: HCPCS_2ND_MDFR_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2
Outpatient mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2
Dataset 2008 2007 2006 2005 2004
Carrier mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2
Outpatient mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2
Dataset 2003 2002 2001 2000 1999
Carrier mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfr_cd2 bhmod2
Outpatient mdfr_cd2 mdfr_cd2 mdfr_cd2 mdfcd2_ mdfcd2_

Contained in

A second modifier to the HCPCS procedure code to make it more specific than the first modifier code to identify the line item procedures for this claim.

Revenue Center IDE

  • Short SAS Name: IDENDC
  • Long SAS Name: REV_CNTR_IDE_NDC_UPC_NUM

Contained in

This field may contain one of three types of identifiers: the National Drug Code (NDC), the Universal Product Code (UPC), or the number assigned by the Food and Drug Administered (FDA) to an investigational device (IDE) after the manufacturer has approval to conduct a clinical trial. 

The IDEs will have a revenue center code 0624. 

This field was renamed to eventually accomodate 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 accomodate either of the new fields (under Version 'H' it was X(7). 

Revenue Center NDC Quantity

  • Short SAS Name: REV_CNTR_NDC_QTY
  • Long SAS Name: REV_CNTR_NDC_QTY

Contained in

Effective with Version 'J', the quantity dispensed for the drug reflected on the revenue center line item.

Revenue Center NDC Quantity Qualifier Code

  • Short SAS Name: REV_CNTR_NDC_QTY_QLFR_CD
  • Long SAS Name: REV_CNTR_NDC_QTY_QLFR_CD

Contained in

Effective with Version 'J', the code used to indicate the unit of measurement for the drug that was administered.

Values

Code Code Value
F2 International Unit
GR Gram
ML Milliliter
UN Unit

Revenue Center Non-Covered Charge Amount

  • Short SAS Name: REV_NCVR
  • Long SAS Name: REV_CNTR_NCVRD_CHRG_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_ncvr rev_ncvr rev_ncvr rev_ncvr rev_ncvr
Dataset 2008 2007 2006 2000 1999
Outpatient rev_ncvr rev_ncvr rev_ncvr rvncvr rvncvr

Contained in

The charge amount related to a revenue center code for 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.

Values

Code
XXX.XX

Revenue Center Obligation to Accept As Full (OTAF) Payment Code

  • Short SAS Name: OTAF_1
  • Long SAS Name: REV_CNTR_OTAF_PMT_CD

Contained in

Effective with Version 'j' the code used to indicate that the provider was obligated to accept as full payment the amount re- ceived from the primary (or secondary) payer.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Revenue Center Packaging Indicator Code

  • Short SAS Name: PACKGIND
  • Long SAS Name: REV_CNTR_PACKG_IND_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient packgind packgind packgind packgind packgind
Dataset 2008 2007 2006 2005 2004
Outpatient packgind packgind packgind packgind packgind
Dataset 2003 2002 2001 2000 1999
Outpatient packgind packgind packgind pckgnd pckgnd

Contained in

Effective with Version 'I', the code used to identify those services that are packaged/ bundled with another service.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code Code Value
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
3 Artificial charges for surgical procedure (eff. 7/2004)

Revenue Center Patient Responsibility Payment

  • Short SAS Name: PTNTRESP
  • Long SAS Name: REV_CNTR_PTNT_RSPNSBLTY_PMT

Contained in

Effective with Version I, the amount paid by the beneficiary to the provider for the line item service.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

ANAMOLY: For dates of service August 1, 2000 to present, the OPPS revenue center fields are being processed differently by FISS and APASS (standard systems). For more information on OPPS data problems for this time period see the Limitations Appendix. The following is how each system is handling this field:

FISS: populating correctly (sum of coinsurance and deductible)

APASS: not populating this field

Currently, the following FI numbers are under the APASS system and all other FI numbers are under FISS. See FI_NUM table of codes for all FI numbers.

52280 -- Mutual of Omaha (until 6/1/2003) 00430 -- Washington/Alaska (until 11/1/2003) 00310 -- North Carolina BC (until 12/1/2003) 00370 -- Rhode Island (until 2/1/2004) 00270 -- New Hampshire/Vermont (until 3/1/2004) 00181 -- Maine/Massachusetts (until 5/1/2004)

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code
XXX.XX

Revenue Center Patient/Initial Visit Add-On Payment Amount (for initial wellness visit)

  • Short SAS Name: RC_PTNT_ADD_ON_PYMT_AMT
  • Long SAS Name: RC_PTNT_ADD_ON_PYMT_AMT

Contained in

This field is the revenue-center Patient Initial Visit Add-On Amount. This field represents a base rate increase factor of 1.3516 for new patient initial preventive physical examination (IPPE) and annual wellness visit.

This field is new in October 2014.This field only applies to Outpatient claims.

Values

Code
XXX.XX

Revenue Center Payment Method Indicator Code

  • Short SAS Name: PMTMTHD
  • Long SAS Name: REV_CNTR_PMT_MTHD_IND_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient pmtmthd pmtmthd pmtmthd pmtmthd pmtmthd
Dataset 2008 2007 2006 2005 2004
Outpatient pmtmthd pmtmthd pmtmthd pmtmthd pmtmthd
Dataset 2003 2002 2001 2000 1999
Outpatient pmtmthd pmtmthd pmtmthd pmtthd pmtthd

Contained in

Effective with Version 'I', the code used to 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.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

NOTE3: Effective 10/2005, this field will no longer represent the service indicator and the payment indicator. This field will now house the 2-byte payment indicator. The status indicator will be housed in a new field named: REV_CNTR_STUS_IND_CD.

Values

NOTE: Prior to 10/2005, this table contained the valid values for both the payment indicator and status indicator. Effective 10/2005, the payment indicator codes will remain in this table and the status indicator code values will be reflected in the new table: REV_CNTR_STUS_IND_TB. Both the payment indicator and status indicator values have been expanded to 2-btyes.

Code Code Value
1 Paid standard hospital OPPS amount (status indicators K, S,T,V,X)
2 Services not paid under OPPS (status indicator A, or no HCPCS code and not certain revenue center codes)
3 Not paid (status indicator M,W,Y,E) or not paid under OPPS (status indicator B,C & Z)
4 Paid at reasonable cost (status indicator F,L)
5 Additional payment for drug or biological (status indicator G)
6 Additional payment for device (status indicator H)
7 Additional payment for new drug or new biological (status indicator J)
8 Paid partial hospitalization per diem (status indicator P)
9 No additional payment, payment included in line items with APCs (status indicator N, or no HCPCS code and certain revenue center codes, or HCPCS codes G0176 (activity therapy), G0129 (occupational therapy) or G0177 (partial hospitalization program services)

**VALUES PRIOR TO 10/3/2005***** **Service Indicator**** **** 1st position *****

Code Code Value
A Services not paid under OPPS
C Inpatient procedure
E Noncovered items or services
F Corneal tissue 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 *****

Code Code Value
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 indicator 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)

Revenue Center Pricing Indicator Code

  • Short SAS Name: REV_CNTR_PRCNG_IND_CD
  • Long SAS Name: REV_PRICNG_IND_CD

Contained in

The code used to identify if there was a deviation from the standard method of calculating payment amount.

This field is populated for those claims that are required to process through the Outpatient PPS PRICER software. The type of bills (TOB) required to process through are: 12X,13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field. Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward. It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service. VALUES D, U & T REPRESENT THE FOLLOWING: D = Discounting fraction (currently 0.5) U = Number of units T = Terminated procedure discount (currently 0.5)

Values

Code Code Value
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. for the provider billed charges. NOTE: There is an exception for Critical Access Hospitals (provider numbers XX1300-XX1399) with reimbursement method 'J' (all-inclusive method) and dates of service on or after 7/1/01. In these situations, reimbursement for professional services (revenue codes 96X, 97X, 98X) is always at the fee schedule amount of logic is not applicable.
C Unlisted Rehabilitation Carrier Priced HCPCS
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 treats this HCPCS as a non-covered service. Reimbursement is calculated 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 reported 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. NOTE: The ESRD Pricing Indicator is used when processing the ESRD claim. The non-ESRD pricing indicator is used only for Inpatient claims as follows: valid Hemophilia HCPCS for inpatient claim only and code is summed to parameter rate.
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. Reimbursement is calculated either on a fee schedule, Medicare FFS Claims (Version K) Codebook 522 May 2017 provider submitted charges or the lesser of provider submitted, or the fee schedule depending on the category of DME.
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. This code will be automatically set by the system.
M A valid TENS HCPCS, Medical Review has approved the rental charge in excess of five months. This must be set by Medical Review. This must be set by Medical Review when approved for payment.
N Paid based on the fee amount for non ESRD TOB's. NOTE: Fee amount is paid regardless of charges.
Q Manual pricing
R A valid radiology HCPCS code and is subject to APC. 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 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.
U Valid ambulance HCPCS. A fee amount is present. The amount payable is a blended amount based on a percentage of the fee schedule and a percentage of the reasonable cost. The fee amount is subject to coinsurance and deductible.
X Unclassified drug as subject to manual pricing.

Revenue Center Provider Payment Amount

  • Short SAS Name: RPRVDPMT
  • Long SAS Name: REV_CNTR_PRVDR_PMT_AMT

Contained in

Effective with Version 'I', the amount paid to the provider for the services reported on the line item.

NOTE1: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

ANAMOLY: For dates of service August 1, 2000 to the present, the OPPS revenue center fields are being processed differently by FISS and APASS (standard systems). For more information on OPPS data problems for this time period see Limitations Appendix. The following is how each system handles this field:

FISS: populated correctly with provider payment amount

APASS: provider payment amount plus interest on 1st revenue center line (CMM will instruct APASS not to include interest)

Currently, the following FI numbers are under the APASS system and all other FI numbers are under FISS. See FI_NUM table of codes for all FI numbers. 52280 -- Mutual of Omaha (until 6/1/2003) 00430 -- Washington/Alaska (until 11/1/2003) 00310 -- North Carolina BC (until 12/1/2003) 00370 -- Rhode Island (until 2/1/2004) 00270 -- New Hampshire/Vermont (until 3/1/2004) 00181 -- Maine/Massachusetts (until 5/1/2004)

NOTE2: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Revenue Center Rate Amount

  • Short SAS Name: REV_RATE
  • Long SAS Name: REV_CNTR_RATE_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_rate rev_rate rev_rate rev_rate rev_rate
Dataset 2008 2007 2006 2005 2004
Outpatient rev_rate rev_rate rev_rate rev_rate rev_rate
Dataset 2003 2002 2001 2000 1999
Outpatient rev_rate rev_rate rev_rate rvrt rvrt

Contained in

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), CMS 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, CMS 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), CMS 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.

NOTE4: For IRF PPS claims (when revenue center code equals 0024), CMS has developed a PRICER to compute the rate based on the HIPPS/CMG (HIPPS code, stored in revenue center HCPCS code field).

Revenue Center Reduced Coinsurance Amount

  • Short SAS Name: RDCDCOIN
  • Long SAS Name: REV_CNTR_RDCD_COINSRNC_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rdcdcoin rdcdcoin rdcdcoin rdcdcoin rdcdcoin
Dataset 2008 2007 2006 2005 2004
Outpatient rdcdcoin rdcdcoin rdcdcoin rdcdcoin rdcdcoin
Dataset 2003 2002 2001 2000 1999
Outpatient rdcdcoin rdcdcoin rdcdcoin rdcdcn rdcdcn

Contained in

Effective with Version 'I', for all services 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: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

NOTE2: The reduced coinsurance amount cannot be lower than 20% of the payment rate for the APC line.

NOTE3: It has been discovered that this field may be populated with data on claims with dates of service prior to 7/00 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the new revenue center fields was that data would be populated on claims with dates of service 7/00 and forward. Data has been found in claims with dates of service prior to 7/00 because the Standard Systems have processed any claim coming in 7/00 and after, meeting the above criteria, through the Outpatient Code Editor (OCE) regardless of the dates of service.

Values

Code
XXX.XX

Revenue Center Rendering Physician NPI

  • Short SAS Name: RNDRNG_PHYSN_NPI
  • Long SAS Name: REV_CNTR_RNDRNG_PHYSN_NPI_NUM

Variable Names

Dataset 2013 2012 2011 2010
Outpatient rndrng_physn_npi rndrng_physn_npi rndrng_physn_npi rndrng_physn_npi

Contained in

Effective with Version 'J', the NPI of the rendering physician who performed the service.

Revenue Center Rendering Physician UPIN

  • Short SAS Name: RNDRNG_PHYSN_UPIN
  • Long SAS Name: RNDRNG_PHYSN_UPIN

Variable Names

Dataset 2013 2012 2011 2010
Outpatient rndrng_physn_upin rndrng_physn_upin rndrng_physn_upin rndrng_physn_upin

Contained in

Revenue Center Status Indicator Code

  • Short SAS Name: REVSTIND
  • Long SAS Name: REVSTIND

Contained in

Effective 10/3/2005 with the implementation of NCH/NMUD CR#2, the code used to identify the status of the line item service. This field along with the payment method indicator field is used to identify how the service was priced for payment.

NOTE1: This 2-byte indicator is being added due to an expansion of a field that currently exist on the revenue center trailer. The status indicator is currently the 1st position of the Revenue Center Payment Method Indicator Code. The payment method indicator code is being split into two 2-byte fields (payment indicator and status indicator). The expanded payment indicator will continue to be stored in the existing payment method indicator field. The split of the current payment method indicator field is due to the expansion of both pieces of date from 1-byte to 2-bytes.

NOTE2: This field is populated for those claims that are required to process through Outpatient PPS Pricer. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code 07 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services.

Values

Code Code Value
A Services not paid under OPPS
B Non-allowed item or service for OPPS
C Inpatient procedure
E Non-allowed item or service
F Corneal tissue acquisition and certain CRNA services
G Drug/bilogical pass-through
H Device pass-through
J New drug or new biological pass-through
K Non pass-through drug/biological, radiopharmaceutical agent, certain brachytherapy sources
L Flu/PPV vaccines
M Service not billable to FI
N Packaged incidental service
P Paid partial hospitalization per diem
Q1 STVX-packaged codes (effective 2009)
Q2 T-packaged codes (effective 2009)
Q3 May be paid through a composite APC-based on composite-specific criteria or separately through single code APCs when the criteria are not met (effective 2009)
R Blood and blood products APCs (effective 2009)
S Significant procedure not subject to multiple procedure discounting
T Significant procedure subject to multiple procedure discounting
U Brachytherapy source APCs for which separate payment is made (effective 2009)
V Medical visit to clinic or emergency department
W Invalid HCPCS or invalid revenue code with blank HCPCS
X Ancillary service
Y Non-implantable DME, Therapeutic shoes
Z Valid revenue with blank HCPCS and no other SI assigned

Revenue Center Therapy Cap Indicator 1 Code

  • Short SAS Name: THRPY_CAP_IND_CD1
  • Long SAS Name: THRPY_CAP_IND_CD1

Contained in

The field used to identify whether the claim line is subject to a therapy cap.

Details regarding the therapy cap can be found on the CMS website, under the Medicare therapy services web page (see, for example: here.)

Values

Code Code Value
A Hospital outpatient claims are subject to the therapy cap for this date of service (this indicator is used on institutional claims only).
B Critical Access Hospital outpatient claims are subject to the therapy cap for this date of service (this indicator will be used on institutional claims only). Note: Currently, Critical Access Hospital claims are not subject to any therapy cap policies. Indicator B is created here to prepare for possible future legislation to include these claims.
C The therapy cap exceptions process, as indicated by the submission of the KX modifier, no longer applies for this date of service (this indicator will be used on both institutional and professional claims).
D The $3,700 threshold for review therapy services no longer applies for this date of service (this indicator will be used on both institutional and professional claims).

Revenue Center Therapy Cap Indicator 2 Code

  • Short SAS Name: THRPY_CAP_IND_CD2
  • Long SAS Name: THRPY_CAP_IND_CD2

Contained in

The field used to identify whether the claim line is subject to a therapy cap.

Details regarding the therapy cap can be found on the CMS website, under the Medicare therapy services web page (see, for example: here.)

Values

Code Code Value
A Hospital outpatient claims are subject to the therapy cap for this date of service (this indicator is used on institutional claims only).
B Critical Access Hospital outpatient claims are subject to the therapy cap for this date of service (this indicator will be used on institutional claims only). Note: Currently, Critical Access Hospital claims are not subject to any therapy cap policies. Indicator B is created here to prepare for possible future legislation to include these claims.
C The therapy cap exceptions process, as indicated by the submission of the KX modifier, no longer applies for this date of service (this indicator will be used on both institutional and professional claims).
D The $3,700 threshold for review therapy services no longer applies for this date of service (this indicator will be used on both institutional and professional claims).

Revenue Center Total Charge Amount

  • Short SAS Name: REV_CHRG
  • Long SAS Name: REV_CNTR_TOT_CHRG_AMT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_chrg rev_chrg rev_chrg rev_chrg rev_chrg
Dataset 2008 2007 2006 2005 2004
Outpatient rev_chrg rev_chrg rev_chrg rev_chrg rev_chrg
Dataset 2003 2002 2001 2000 1999
Outpatient rev_chrg rev_chrg rev_chrg rvchrg rvchrg

Contained in

The total charges (covered and non-covered) for all 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).

(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 Inpatient Rehabilitation Facility (IFR) PPS, when the revenue center code = 0024, the total charges will be zero. For accommodation revenue codes (010X - 021X), total charges must equal the rate times the units.

(6) 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).

Limitation

DESCRIPTION : Multiple total charge '0001' revenue center codes appearing on outpatient, hospice and home health claim records. BACKGROUND : On outpatient, home health and hospice it appears that more than one '0001' revenue center code is showing up on the claims. The first total charge line adds the revenue center codes above it correctly; the problem exists below the first total charge line where garbage may be present due to the FI Standard System not clearing out fields before processing the next claim. We believe the error began with the change- over to a different claims processing contractor in 1/98. CORRECTIVE ACTION : CWF created an edit to reject mulitple '0001' revenue center codes, effective 6/28/99. EDG's CWFMQA process implemented an edit to drop any revenue center line items below the first total charge line. The NCH Nearline File, as well as the 1998 Standard Analytic Files (SAFs), have been patched/corrected to delete the multiple '0001' codes where present on any of the institutional claim types. Also, HCIS will be cor- recting the revenue center summaries during the next refresh. The NCH_PATCH_CD field will reflect a value '10'.

Values

Code
XXX.XX

Revenue Center Unit Count

  • Short SAS Name: REV_UNIT
  • Long SAS Name: REV_CNTR_UNIT_CNT

Variable Names

Dataset 2013 2012 2011 2010 2009
Outpatient rev_unit rev_unit rev_unit rev_unit rev_unit
Dataset 2008 2007 2006 2005 2004
Outpatient rev_unit rev_unit rev_unit rev_unit rev_unit
Dataset 2003 2002 2001 2000 1999
Outpatient rev_unit rev_unit rev_unit rvunt rvunt

Contained in

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.

Description of the different unit of service measures by revenue center code beginning on page 18: here

State Code from Claim (SSA)

  • Short SAS Name: STATE_CD
  • Long SAS Name: BENE_STATE_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier state_cd state_cd state_cd state_cd
Inpatient state_cd state_cd state_cd state_cd state_cd
MedPAR state_cd state_cd state_cd state_cd state_cd
Outpatient state_cd state_cd state_cd state_cd state_cd
Dataset 2008 2007 2006 2005 2004
Carrier state_cd state_cd state_cd state state
Inpatient state_cd state_cd state_cd state state
MedPAR state_cd state_cd state_cd state state
Outpatient state_cd state_cd state_cd state state
Dataset 2003 2002 2001 2000 1999
Carrier state state state_cd state_cd bstate
Inpatient state state state_cd state_cd state_cd
MedPAR state state mstate mstate mstate
Outpatient state state state state_cd state_cd

Contained in

The SSA standard state code of a beneficiary's residence.

Values

Code Code Value
1 Alabama
2 Alaska
3 Arizona
4 Arkansas
5 California
6 Colorado
7 Connecticut
8 Delaware
9 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
57 Central America and West Indies
58 Europe
59 Mexico
60 Oceania
61 Philippines
62 South America
63 U.S. Possessions
97 Saipan - MP
98 Guam
99 American Samoa

Zip Code of Residence from Claim

  • Short SAS Name: ZIP_CD
  • Long SAS Name: BENE_MLG_CNTCT_ZIP_CD

Variable Names

Dataset 2013 2012 2011 2010 2009
Carrier zip_cd zip_cd zip_cd zip_cd
Inpatient zip_cd zip_cd zip_cd zip_cd zip_cd
Outpatient zip_cd zip_cd zip_cd zip_cd zip_cd
Dataset 2008 2007 2006 2005 2004
Carrier zip_cd zip_cd zip_cd zipcode zipcode
Inpatient zip_cd zip_cd zip_cd zipcode zipcode
Outpatient zip_cd zip_cd zip_cd zipcode zipcode
Dataset 2003 2002 2001 2000 1999
Carrier zipcode zipcode bene_zip bene_zip bzip
Inpatient zipcode zipcode bene_zip bene_zip bene_zip
Outpatient zipcode zipcode zipcode bene_zip bene_zip

Contained in

The ZIP code of the mailing address where the beneficiary may be contacted.

ResDAC variable note: The zip code variable in the claims data appears as a 9-digit variable. However, the field only presents the 5-digit zip code followed by trailing zeros. For example, a zip code of 55455 would appear as 554550000 in the data.