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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.

113 ICD-10 Recodes

• Short SAS Name: ICD_CODE_113

Contained in

• Master Beneficiary Summary File

This field groups (or recodes) the NDI ICD-10 code cause of death into 113 categories.

Addtional information regarding these categories can be found on the CDC website (see here and here.)

Available for 1999-2008. Researchers wishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

1^st Occrrnce of Alzheimer's Dsease and Rltd Disorders or Senile Dementia

• Short SAS Name: ALZHDMTE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

358 ICD-10 Recodes

• Short SAS Name: ICD_CODE_358

Contained in

• Master Beneficiary Summary File

This field groups (or recodes) the NDI ICD-10 code cause of death into 358 categories.

Additional information regarding these categories can be found on the CDC website (see here and here.)

Available for 1999-2008. Researchers wishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

5-digit ZIP code for beneficiary

• Short SAS Name: ZIP_CD
• Long SAS Name: 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

• Master Beneficiary Summary File

This field specifies the zip code identified as the beneficiary mailing address.

In some cases, the code may not be the actual state where the beneficiary resides. CMS obtains the mailing address used for cash benefits or the mailing address used for other purposes (for example, premium billing) from Social Security Administration (SSA) and Railroad Retirement Board (RRB) Beneficiary Record Systems.

Values

Code
5-digit zip

ADHD and Other Conduct Disorders - Medicare Only Claims

• Short SAS Name: ACP_MEDICARE

Contained in

• Master Beneficiary Summary File

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For ADHD and other conduct disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

ADHD and Other Conduct Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: ACP_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the attention deficit hyperactivity disorder (ADHD) or other conduct disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Acquired Hypothyroidism End Year Flag

• Short SAS Name: HYPOTH

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for acquired hypothyroidism as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For acquired hypothyroidism, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims with an acquired hypothyroidism code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Acquired Hypothyroidism First Ever Occurrence Date

• Short SAS Name: HYPOTH_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) acquired hypothyroidism indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Acquired Hypothyroidism Mid Year Flag

• Short SAS Name: HYPOTH_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for acquired hypothyroidism on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For acquired hypothyroidism, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims with an acquired hypothyroidism code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Acute Inpatient Beneficiary Payments

• Short SAS Name: ACUTE_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of Medicare coinsurance and deductible payments in the acute inpatient hospital setting for the year. The total acute hospitalization beneficiary payments are calculated as the sum of the beneficiary deductible amount and coinsurance amount (variables called NCH_BENE_IP_DDCTBL_AMT and NCH_BENE_PTA_COINSRNC_LBLTY_AM) for all acute inpatient claims where the CLM_PMT_AMT >= 0.

Acute inpatient claims are a subset of the claims in the IP data file consisting of data from both acute hospitals and critical access hospitals (CAH). These facilities are those where either the 3^rd digit of the provider number (SAS variable PRVDR_NUM) = 0 or the 3^rd and 4^th digits of PRVDR_NUM = 13.

There are 2 cost/use categories from the IP data files: Acute and OIP.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a CMS publication called "Your Medicare Benefits", which explains the deductibles and coinsurance amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Acute Inpatient Covered Days

• Short SAS Name: ACUTE_COV_DAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of Medicare covered days in the acute inpatient hospital setting for the year. This variable equals the sum of the CLM_UTLZTN_DAY_CNT variables on the source claims.

Acute inpatient hospital claims are a subset of the claims in the IP data file consisting of data from both acute hospitals and critical access hospitals (CAH). These facilities are those where either the 3^rd digit of the provider number (SAS variable PRVDR_NUM) = 0 or the 3^rd and 4^th digits of PRVDR_NUM = 13.

We consider fully-covered days, days where the beneficiary was liable for coinsurance, and lifetime reserve days to all be Medicare-covered days. Non-covered days, leave of absence days, and the day of discharge or death are not included.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Acute Inpatient Medicare Payments

• Short SAS Name: ACUTE_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of the Medicare claim payment amounts (CLM_PMT_AMT from each claim) in the acute inpatient hospital setting for a given year. To obtain the total acute hospital Medicare payments, take this variable and add in the annual per diem payment amount (ACUTE_MDCR_PMT + ACUTE_PERDIEM_AMT).

Acute inpatient hospital claims are a subset of the claims in the IP data file consisting of data from both acute hospitals and critical access hospitals (CAH). These facilities are those where either the 3^rd digit of the provider number (SAS variable PRVDR_NUM) = 0 or the 3^rd and 4^th digits of PRVDR_NUM = 13.

ACUTE_PERDIEM_PMT must be added to this field to obtain the total acute hospital Medicare payments for the year. The annual per diem variable was new in 2010; it will always be null/missing in earlier files.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Acute Inpatient Stays

• Short SAS Name: ACUTE_STAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of acute inpatient hospital stays (unique admissions, which may span more than one facility) for the year. An acute inpatient stay is defined as a set of one or more consecutive acute inpatient hospital claims where the beneficiary is only discharged on the most recent claim in the set. If a beneficiary is transferred to a different provider, the acute stay is continued even if there is a discharge date on the claim from which the beneficiary was transferred.

The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year.

Acute inpatient hospital claims are a subset of the claims in the IP data file consisting of data from both acute hospitals and critical access hospitals (CAH). These facilities are those where either the 3^rd digit of the provider number (SAS variable PRVDR_NUM) = 0 or the 3^rd and 4^th digits of PRVDR_NUM = 13.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

Acute Myocardial Infarction End-of-Year Flag

• Short SAS Name: AMI

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Acute Myocardial Infarction Mid-Year Flag

• Short SAS Name: AMIM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Age of beneficiary at end of year

• Short SAS Name: AGE
• Long SAS Name: AGE_AT_END_REF_YR

Contained in

• Master Beneficiary Summary File

This is the beneficiary’s age, expressed in years and calculated as of the end of the calendar year, or, for beneficiaries that died during the year, age as of the date of death

CCW calculates this variable.

Values

MAXIMUM AGE IS 115

CCW calculates this variable.

Code
Maximum age is 115

Alzheimer's Disease End-of-Year Flag

• Short SAS Name: ALZH

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Alzheimer's Disease Mid-Year Flag

• Short SAS Name: ALZHM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Alzheimer's Disease and Rltd Disorders or Senile Dementia EOY Flag

• Short SAS Name: ALZHDMTA

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Alzheimer's Disease and Rltd Disorders or Senile Dementia Mid-Year Flag

• Short SAS Name: ALZHDMTM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Ambulatory Surgery Center Beneficiary Payments

• Short SAS Name: ASC_BENE_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the sum of coinsurance and deductible payments in the part B ambulatory surgery center (ASC) setting for a given year.  The total beneficiary payment is calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for all relevant lines. ASC claims are a subset of the claims in the Part B Carrier data file.  The ASC claims are identified by the claim lines where the LINE_CMS_TYPE_SRVC_CD ='F'.   "

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Ambulatory Surgery Center Events

• Short SAS Name: ASC_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events in the part B ambulatory surgery center (ASC) setting for a given year. An event is defined as each line item that contains an ASC service.ASC claims are a subset of the claims in the Part B Carrier data file. The ASC claims are identified by the claim lines where the LINE_CMS_TYPE_SRVC_CD ='F'.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Ambulatory Surgery Center Medicare Payments

• Short SAS Name: ASC_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments in the part B ambulatory surgery center (ASC) setting for a given year.   ASC claims are a subset of the claims in the Part B Carrier data file.  The ASC claims are identified by the claim lines where the LINE_CMS_TYPE_SRVC_CD ='F'.  The total ASC Medicare Payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S').

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Anemia End Year Flag

• Short SAS Name: ANEMIA

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for anemia as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For anemia, beneficiaries must have at least one inpatient, SNF, home health, Part B institutional, or Part B non-institutional (carrier) claim with an anemia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Anemia First Ever Occurrence Date

• Short SAS Name: ANEMIA_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) anemia indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Anemia Mid Year Flag

• Short SAS Name: ANEMIA_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for anemia on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For anemia, beneficiaries must have at least one inpatient, SNF, home health, Part B institutional, or Part B non-institutional (carrier) claim with an anemia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Anesthesia Beneficiary Payments

• Short SAS Name: ANES_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for part B anesthesia services (ANES) for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines. ANES claims are a subset of the claims, and a subset of procedures in the Part B Carrier data file. ANES claims are defined as those with a line BETOS code (`BETOS_CD) where the first 2 digits = “P0” and theCARR_LINE_MTUS_CD=2`.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Anesthesia Events

• Short SAS Name: ANES_EVENTS

Contained in

• Master Beneficiary Summary File

"This variable is the count of events for part B anesthesia services (ANES) for a given year. ANES claims are a subset of the claims, and a subset of procedures in the Part B Carrier data file.   ANES claims are defined as those with a line BETOS code (BETOS_CD) where the first 2 digits = “P0” and the CARR_LINE_MTUS_CD=2.

An event is defined as each line item that contains the relevant service."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E &M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Anesthesia Medicare Payments

• Short SAS Name: ANES_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for part B anesthesia services (ANES) for a given year.  ANES claims are a subset of the claims, and a subset of procedures in the Part B Carrier data file.   ANES claims are defined as those with a line BETOS code (`BETOS_CD) where the first 2 digits = “P0” and theCARR_LINE_MTUS_CD=2`.

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Anxiety Disorders - Medicare Only Claims

• Short SAS Name: ANXI_MEDICARE

Contained in

• Master Beneficiary Summary File

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For anxiety disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Anxiety Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: ANXI_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the anxiety disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Asthma End Year Flag

• Short SAS Name: ASTHMA

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for asthma as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For asthma, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims with an asthma code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Asthma First Ever Occurrence Date

• Short SAS Name: ASTHMA_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) asthma indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Asthma Mid Year Flag

• Short SAS Name: ASTHMA_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for asthma on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For asthma, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims with an asthma code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Atrial Fibrillation End-of-Year Flag

• Short SAS Name: ATRIALFB

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Atrial Fibrillation Mid-Year Flag

• Short SAS Name: ATRIALFM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Autism Spectrum Disorders - Medicare Only Claims

• Short SAS Name: AUTISM_MEDICARE

Contained in

• Master Beneficiary Summary File

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For autism spectrum disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Autism Spectrum Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: AUTISM_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the autism spectrum disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Beneficiary Identification Number

• Short 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

• MedPAR RIF

Beneficiary Identification Number for this data request

Beneficiary LRD Used Count

• Short SAS Name: LRD_USE
• Long SAS Name: BENE_LRD_USED_CNT

Contained in

• Inpatient RIF

The number of lifetime reserve days that the beneficiary has elected to use during the period covered by the institutional claim. Under Medicare, each beneficiary has a one-time reserve of sixty additional days of inpatient hospital coverage that can be used after 90 days of inpatient care have been provided in a single benefit period. This count is used to subtract from the total number of lifetime reserve days that a beneficiary has available.

Beneficiary Race Code

• Short SAS Name: RACE
• Long SAS Name: BENE_RACE_CD

Contained in

• Master Beneficiary Summary File

The race of the beneficiary.

Values

Code	Code Value
0	UNKNOWN
1	WHITE
2	BLACK
3	OTHER
4	ASIAN
5	HISPANIC
6	NORTH AMERICAN NATIVE

Beneficiary Total Coinsurance Days Count

• Short SAS Name: COIN_DAY
• Long SAS Name: BENE_TOT_COINSRNC_DAYS_CNT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The count of the total number of coinsurance days involved with the beneficiary's stay in a facility.

Beneficiary date of birth

• Short SAS Name: BENE_DOB
• Long SAS Name: BENE_BIRTH_DT

Contained in

• Master Beneficiary Summary File

This is the beneficiary's date of birth.

Values

Code
MM/DD/YYYY

Beneficiary's Hospice Period Count

• Short SAS Name: HOSPCPRD
• Long SAS Name: BENE_HOSPC_PRD_CNT

Contained in

• Hospice RIF

The count of the number of hospice period trailers present for the beneficiary's record. Prior to BBA a beneficiary was entitled to a maximum of 4 hospice benefit periods that may be elected in lieu of standard Part A hospital benefits. The BBA changed the hospice benefit to the following: 2 initial 90 day periods followed by an unlimited number of 60 day periods (effective 8/5/97).

NOTE: CWF stopped populating the hospice period count field in October 2008 and then in December 2011 began populating it again.

Values

Code	Code Value
1	1st 90-day period
2	2nd 90-day period
3	60-day period (3 or greater periods)

Benign Prostatic Hyperplasia End Year Flag

• Short SAS Name: HYPERP

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for benign prostatic hyperplasia as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For benign prostatic hyperplasia, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a benign prostatic hyperplasia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Benign Prostatic Hyperplasia First Ever Occurrence Date

• Short SAS Name: HYPERP_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) hyperlipidemia indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Benign Prostatic Hyperplasia Mid Year Flag

• Short SAS Name: HYPERP_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for benign prostatic hyperplasia on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For benign prostatic hyperplasia, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a benign prostatic hyperplasia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Bipolar Disorder - Medicare Only Claims

• Short SAS Name: BIPL_MEDICARE

Contained in

• Master Beneficiary Summary File

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For bipolar disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Bipolar Disorder First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: BIPL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the bipolar disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Breast Cancer End-of-Year Flag

• Short SAS Name: CNCRBRST

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For breast cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart with a breast cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Breast Cancer Mid-Year Flag

• Short SAS Name: CNCRBRSM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For breast cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart with a breast cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

CPO Organization NPI Number

• Short SAS Name: CPO_ORG_NPI_NUM
• Long SAS Name: CPO_ORG_NPI_NUM

Contained in

• Carrier RIF

The National Provider Identifier(NPI) number of the Home Health Agency (HHA) or Hospice rendering Medicare services during the period the physician is providing care plan oversight (CPO).  

The purpose of this field is to ensure compliance with the CPO requirement that the beneficiary must be receiving covered HHA or Hospice services during the billing period. There can only be one CPO provider number per claim, and no other services but CPO physician services are to be reported on the claim. This field is only present on the non-DMERC processed carrier claim. 

Care Plan Oversight (CPO) Provider Number

• Short SAS Name: CPO_PRVDR_NUM
• Long SAS Name: CPO_PRVDR_NUM

Contained in

• Carrier RIF

The National Provider Identifier (NPI) number of the Home Health Agency (HHA) or Hospice rendering Medicare services during the period the physician is providing care plan oversight (CPO).

The purpose of this field is to ensure compliance with the CPO requirement that the beneficiary must be receiving covered HHA or Hospice services during the billing period. There can be only one CPO provider number per claim, and no other services but CPO physician services are to be reported on the claim. This field is only present on the non-DMERC processed carrier claim.

Carrier Claim Beneficiary Paid Amount

• Short SAS Name: CLM_BENE_PD_AMT
• Long SAS Name: CLM_BENE_PD_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The amount paid by the beneficiary for the non-institutional Part B (carrier, or DMERC) claim.

Values

Code
XXX.XX

Carrier Claim Billing NPI Number

• Short SAS Name: CARR_CLM_BLG_NPI_NUM
• Long SAS Name: CARR_CLM_BLG_NPI_NUM

Contained in

• Carrier RIF

The CMS National Provider Identifier (NPI) number assigned to the billing provider

Carrier Claim Cash Deductible Applied Amount*

• Short SAS Name: DEDAPPLY
• Long SAS Name: CARR_CLM_CASH_DDCTBL_APLD_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the amount of the cash deductible as submitted on the 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.

Carrier Claim Entry Code

• Short SAS Name: ENTRY_CD
• Long SAS Name: CARR_CLM_ENTRY_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Carrier-generated code describing whether the Part B claim is an original debit, full credit, or replacement debit.

Carrier Claim HCPCS Year Code

• Short SAS Name: HCPCS_YR
• Long SAS Name: CARR_CLM_HCPCS_YR_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	hcpcs_yr	hcpcs_yr	hcpcs_yr	hcpcs_yr	hcpcs_yr

Dataset	2007	2006	2005	2004	2003
Carrier	hcpcs_yr	hcpcs_yr	hcpcs_yr	hcpcs_yr	hcpcs_yr

Dataset	2002	2001	2000	1999
Carrier	hcpcs_yr	hcpcs_yr	hcpcs_yr	hcpcs_yr

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the terminal digit of HCPCS version used to code the 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.

Carrier Claim Payment Denial Code

• Short SAS Name: PMTDNLCD
• Long SAS Name: CARR_CLM_PMT_DNL_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	pmtdnlcd	pmtdnlcd	pmtdnlcd	pmtdnlcd	pmtdnlcd

Dataset	2007	2006	2005	2004	2003
Carrier	pmtdnlcd	pmtdnlcd	pmtdnlcd	pmtdnlcd	pmtdnlcd

Dataset	2002	2001	2000
Carrier	pmtdnlcd	pmtdnlcd	pmtdnlcd

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code on a noninstitutional claim indicating to whom payment was made or if the claim was denied.

NOTE1: Effective with Version 'J', the field has been expanded on the NCH record to 2 bytes, With this expansion, the NCH will no longer use the character values to represent the official two byte values sent in by CWF since 4/2002. During the Version J conversion, all character values were converted to the two byte values.

NOTE2: Effective 4/1/02, this field was 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.

Values

Carrier Claim Payment Denial Table.txt

Carrier Claim Primary Payer Paid Amount*

• Short SAS Name: PRPAYAMT
• Long SAS Name: CARR_CLM_PRMRY_PYR_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

• Durable Medical Equipment RIF
• Carrier RIF

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.

Carrier Claim Provider Assignment Indicator Switch

• Short SAS Name: ASGMNTCD
• Long SAS Name: CARR_CLM_PRVDR_ASGNMT_IND_SW

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

A switch indicating whether or not the provider accepts assignment for the noninstitutional claim.

Values

Code	Code Value
A	Assigned claim
N	Non-assigned claim

Carrier Claim Referring PIN Number

• Short SAS Name: RFR_PRFL
• Long SAS Name: CARR_CLM_RFRNG_PIN_NUM

Contained in

• Carrier RIF

Carrier-assigned identification (profiling) number of the physician who referred the beneficiary to the physician that performed the Part B services.

Carrier Claim Referring Physician NPI Number

• Short SAS Name: RFR_NPI
• Long SAS Name: RFR_PHYSN_NPI

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	rfr_npi	rfr_npi	rfr_npi	rfr_npi	rfr_npi

Dataset	2007	2006	2005	2004	2003
Carrier	rfr_npi	rfr_npi	rfr_npi	rfr_npi	rfr_npi

Dataset	2002	2001	2000
Carrier	rfr_npi	rfr_npi	rfr_npi

Contained in

• Carrier RIF

The national provider identifier (NPI) number of the physician who referred the beneficiary to the physician who performed the Part B services.

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 on 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 re- ceive 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.

Carrier Claim Referring Physician UPIN Number

• Short SAS Name: RFR_UPIN
• Long SAS Name: RFR_PHYSN_UPIN

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	rfr_upin	rfr_upin	rfr_upin	rfr_upin	rfr_upin

Dataset	2007	2006	2005	2004	2003
Carrier	rfr_upin	rfr_upin	rfr_upin	rfr_upin	rfr_upin

Dataset	2002	2001	2000	1999
Carrier	rfr_upin	rfr_upin	rfr_upin	brfrupin

Contained in

• Carrier RIF

The unique physician identification number (UPIN) of the physician who referred the beneficiary to the physician who performed the Part B services.

Carrier Line Anesthesia Unit Count

• Short SAS Name: CARR_LINE_ANSTHSA_UNIT_CNT
• Long SAS Name: CARR_LINE_ASNTHSA_UNIT_CNT

Contained in

• Carrier RIF

The base number of units assigned to the line item anesthesia procedure on the carrier claim (non-DMERC).

Carrier Line Clinical Lab Charge Amount

• Short SAS Name: CARR_LINE_CL_CHRG_AMT
• Long SAS Name: CARR_LINE_CL_CHRG_AMT

Contained in

• Carrier RIF

Clinical lab charge amount on the Carrier line.

Carrier Line HPSA/Scarcity Indicator Code

• Short SAS Name: HPSASCCD
• Long SAS Name: HPSA_SCRCTY_IND_CD

Contained in

• Carrier RIF

Effective 10/3/2005 with the implementation of NCH/ NMUD CR#2, the code used to track health professional shortage area (HPSA) and physician scarcity bonus payments on carrier claims.

NOTE: Prior to 10/3/2005, claims contained a modifier code to indicate the bonus payment. A 'QU' represented a HPSA bonus payment and an 'AR' represented a scarcity bonus payment. As of 1/1/2005, the modifiers were no longer being reported by the provider. NCH & NMUD were not ready to accept the new field until 10/3/2005.

Values

Code	Code Value
1	HPSA
2	Scarcity
3	Both
Space	Not applicable

Carrier Line Miles/Time/Units/Services Count

• Short SAS Name: MTUS_CNT
• Long SAS Name: CARR_LINE_MTUS_CNT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	mtus_cnt	mtus_cnt	mtus_cnt	mtus_cnt	mtus_cnt

Dataset	2007	2006	2005	2004	2003
Carrier	mtus_cnt	mtus_cnt	mtus_cnt	mtus_cnt	mtus_cnt

Dataset	2002	2001	2000	1999
Carrier	mtus_cnt	mtus_cnt	mtus_cnt	bmturei

Contained in

The count of the total units associated with services needing unit reporting such as transportation, miles, anesthesia time units, number of services, volume of oxygen or blood units. This is a line item field on the carrier claim (non-DMERC) and is used for both allowed and denied services.

NOTE: For anesthesia (MTUS Indicator = 2) this field should be reported in time unit intervals, i.e. 15 minute interals or fraction thereof. It appears that some carriers are reporting minutes instead of time units.

Carrier Line Miles/Time/Units/Services Indicator Code

• Short SAS Name: MTUS_IND
• Long SAS Name: CARR_LINE_MTUS_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	mtus_ind	mtus_ind	mtus_ind	mtus_ind	mtus_ind

Dataset	2007	2006	2005	2004	2003
Carrier	mtus_ind	mtus_ind	mtus_ind	mtus_ind	mtus_ind

Dataset	2002	2001	2000	1999
Carrier	mtus_ind	mtus_ind	mtus_ind	bmtuind

Contained in

Code indicating the units associated with services needing unit reporting on the line item for the carrier claim (non-DMERC).

Values

Code	Code Value
0	Values reported as zero (no allowed activities)
1	Transportation (ambulance) miles
2	Anesthesia time units
3	Services
4	Oxygen units
5	Units of blood
6	Anesthesia base and time units (prior to 1991; from BMAD)

Carrier Line Performing Group NPI Number

• Short SAS Name: PRGRPNPI
• Long SAS Name: ORG_NPI_NUM

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prgrpnpi	prgrpnpi	prgrpnpi	prgrpnpi	prgrpnpi

Dataset	2007	2006	2005	2004	2003
Carrier	prgrpnpi	prgrpnpi	prgrpnpi	prgrpnpi	prgrpnpi

Dataset	2002	2001	2000
Carrier	prgrpnpi	prgrpnpi	prgrpnpi

Contained in

• Carrier RIF

The National Provider Identifier (NPI) of the group practice, where the performing physician is part of that group.

NOTE: Effective May 2007, the NPI will become the national standard identifier for covered health care providers. NPIs will replace the current legacy numbers (UPINs, PINs, etc.) on the 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.

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 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.

Carrier Line Performing NPI Number

• Short SAS Name: PRFNPI
• Long SAS Name: PRF_PHYSN_NPI

Contained in

• Carrier RIF

A placeholder field (effective with Version H) for storing the NPI assigned to the performing provider.

Carrier Line Performing PIN Number

• Short SAS Name: PRF_PRFL
• Long SAS Name: CARR_PRFRNG_PIN_NUM

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prf_prfl	prf_prfl	prf_prfl	prf_prfl	prf_prfl

Dataset	2007	2006	2005	2004	2003
Carrier	prf_prfl	prf_prfl	prf_prfl	prf_prfl	prf_prfl

Dataset	2002	2001	2000	1999
Carrier	prf_prfl	prf_prfl	prf_prfl	bcpppn

Contained in

• Carrier RIF

The profiling identification number (PIN) of the physiciansupplier (assigned by the carrier) who performed the service for this line item on the carrier claim (non-DMERC).

Carrier Line Performing Provider ZIP Code

• Short SAS Name: PROVZIP
• Long SAS Name: PRVDR_ZIP

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	provzip	provzip	provzip	provzip	provzip

Dataset	2007	2006	2005	2004	2003
Carrier	provzip	provzip	provzip	provzip	provzip

Dataset	2002	2001	2000	1999
Carrier	provzip	provzip	provzip	bppzip

Contained in

• Carrier RIF

The ZIP code of the physician/supplier who performed the Part B service for this line item on the carrier claim (non-DMERC).

Carrier Line Performing UPIN Number

• Short SAS Name: PRF_UPIN
• Long SAS Name: PRF_PHYSN_UPIN

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prf_upin	prf_upin	prf_upin	prf_upin	prf_upin

Dataset	2007	2006	2005	2004	2003
Carrier	prf_upin	prf_upin	prf_upin	prf_upin	prf_upin

Dataset	2002	2001	2000	1999
Carrier	prf_upin	prf_upin	prf_upin	blnppun

Contained in

• Carrier RIF

The unique physician identification number (UPIN) of the physician who performed the service for this line item on the carrier claim (non-DMERC).

Limitation

REFER TO : CARR_LINE_PRFRMG_UPIN_LIM

Carrier Line Pricing Locality Code

• Short SAS Name: LCLTY_CD
• Long SAS Name: CARR_LINE_PRCNG_LCLTY_CD

Contained in

• Carrier RIF

Code denoting the carrier-specific locality used for pricing the service for this line item on the carrier claim (non-DMERC).

Carrier Line Provider Type Code

• Short SAS Name: PRV_TYPE
• Long SAS Name: CARR_LINE_PRVDR_TYPE_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prv_type	prv_type	prv_type	prv_type	prv_type

Dataset	2007	2006	2005	2004	2003
Carrier	prv_type	prv_type	prv_type	prv_type	prv_type

Dataset	2002	2001	2000	1999
Carrier	prv_type	prv_type	prv_type	bprvtyp

Contained in

• Carrier RIF

Code identifying the type of provider furnishing the service for this line item on the carrier claim (non-DMERC).

Values

For Physician/Supplier (RIC O) Claims:

Code	Code Value
0	Clinics, groups, associations, partnerships, or other entities
1	Physicians or suppliers reporting as solo practitioners
2	Suppliers (other than sole proprietorship)
3	Institutional provider
4	Independent laboratories
5	Clinics (multiple specialties)
6	Groups (single specialty)
7	Other entities

For DMERC (RIC M) Claims - PRIOR TO VERSION H:

Code	Code Value
0	Clinics, groups, associations, partnerships, or other entities for whom the carrier's own ID number has been assigned.
1	Physicians or suppliers billing as solo practitioners for whom SSN's are shown in the physician ID code field.
2	Physicians or suppliers billing as solo practitioners for whom the carrier's own physician ID code is shown.
3	Suppliers (other than sole proprietorship) for whom EI numbers are used in coding the ID field.
4	Suppliers (other than sole proprietorship) for whom the carrier's own code has been shown.
5	Institutional providers and independent laboratories for whom EI numbers are used in coding the ID field.
6	Institutional providers and independent laboratories for whom the carrier's own ID number is shown.
7	Clinics, groups, associations, or partnerships for whom EI numbers are used in coding the ID field.
8	Other entities for whom EI numbers are used in coding the ID field or proprietorship for whom EI numbers are used in coding the ID field.

Carrier Line RX Number

• Short SAS Name: CARRXNUM
• Long SAS Name: CARR_LINE_RX_NUM

Contained in

• Carrier RIF

The number used to identify the prescrip- tion order number for drugs and biologicals purchased through the competitive acquisition program (CAP).

NOTE1: MMA required the implementation of a competative acquisition program (CAP) for Part B drugs and biologicals not paid on a cost or PPS basis. Physicians will be given a choice between buying and billing these drugs under the average sales price (ASP) or obtaining these drugs from an approved CAP vendor. The prescription number is needed to identify which claims were submitted for CAP drugs and their administration.

NOTE2: Eventhough this field was implemented with NCH/NMUD CR#2, data will not be coming in until 1/1/2006.The number used to identify the prescrip- tion order number for drugs and biologicals purchased through the competitive acquisition program (CAP). NOTE1: MMA required the implementation of a competative acquisition program (CAP) for Part B drugs and biologicals not paid on a cost or PPS basis. Physicians will be given a choice between buying and billing these drugs under the average sales price (ASP) or obtaining these drugs from an approved CAP vendor. The prescription number is needed to identify which claims were submitted for CAP drugs and their administration. NOTE2: Eventhough this field was implemented with NCH/NMUD CR#2, data will not be coming in until 1/1/2006.

Limitation

REFER TO : CARR_LINE_RX_NUM_LIM

Carrier Line Reduced Payment Physician Assistant Code

• Short SAS Name: ASTNT_CD
• Long SAS Name: CARR_LINE_RDCD_PMT_PHYS_ASTN_C

Contained in

• Carrier RIF

Effective 1/92, the code on the carrier (non-DMERC) line item that identifies claims that have been paid a reduced fee schedule amount (65%, 75% or 85%) because a physician's assistant performed the services.

Values

Code	Code Value
BLANK	Adjustment situation (where CLM_DISP_CD equal 3)
0	nan
1	65% A) Physician assistants assisting in surgery B) Nurse midwives
2	75% A) Physician assistants performing services in a hospital (other than assisting surgery) B) Nurse practitioners and clinical nurse specialists performing services in rural areas C) Clinical social worker services
3	85% A) Physician assistant services for other than assisting surgery B) Nurse practitioners services

Carrier Number

• Short SAS Name: CARR_NUM
• Long SAS Name: CARR_NUM

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The identification number assigned by CMS to a carrier authorized to process claims from a physician or supplier. Effective July 2006, the Medicare Administrative Contractors (MACs) began replacing the existing carriers and started processing physician or supplier claim records for states assigned to its jurisdiction.

NOTE: The 5-position MAC number will be housed in the existing CARR_NUM field. During the transi- tion from a carrier to a MAC the CARR_NUM field could contain either a Carrier number or a MAC number. See the CARR_NUM table of codes to identify the new MAC numbers and their effective dates.

Values

Carrier Number-MAC Table.txt

Cataract End-of-Year Flag

• Short SAS Name: CATARACT

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Cataract Mid-Year Flag

• Short SAS Name: CATARCTM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Cerebral Palsy End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: CERPAL_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for cerebral palsy as of the end of the calendar year.

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For cerebral palsy, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Cerebral Palsy First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: CERPAL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the cerebral palsy indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Chronic Kidney Disease End-of-Year Flag

• Short SAS Name: CHRNKIDN

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Chronic Kidney Disease Mid-Year Flag

• Short SAS Name: CHRNKDNM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Chronic Obstructive Pulmonary Disease End-of-Year Flag

• Short SAS Name: COPD

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Chronic Obstructive Pulmonary Disease Mid-Year Flag

• Short SAS Name: COPDM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Claim Accountable Care Organization (ACO) Identification Number

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Carrier RIF

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

Claim Admission Date

• Short SAS Name: ADMSN_DT
• Long SAS Name: CLM_ADMSN_DT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

On an institutional claim, the date the beneficiary was admitted to the hospital, skilled nursing facility, or christian science sanitorium.

Claim Admitting Diagnosis Code

• Short SAS Name: ADMTG_DGNS_CD
• Long SAS Name: ADMTG_DGNS_CD

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

A diagnosis code on the institutional claim indicating the beneficiary's initial diagnosis at admission.

NOTE1: Effective 1/1/2004 with the implementa- tion of NCH/NMUD CR#1, the admitting diagnosis (also known as reason for patient visit) was added to the Outpatient claim. This data was stored in positions 572-576 (FILLER) until the implementation of NCH/NMUD CR#2. Prior to 1/1/2004, this field was only present on inpatient claims.

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

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Base Operating DRG Amount

• Short SAS Name: CLM_BASE_OPRTG_DRG_AMT
• Long SAS Name: CLM_BASE_OPRTG_DRG_AMT

Contained in

• Inpatient RIF

The amount of the wage-adjusted DRG operating payment plus the technology add-on payment.

This variable was new in 2011. It is populated only for Inpatient claims.

Claim Bundled Adjustment Payment Amount

• Short SAS Name: CLM_BNDLD_ADJSTMT_PMT_AMT
• Long SAS Name: CLM_BNDLD_ADJSTMT_PMT_AMT

Contained in

• Inpatient RIF

This field represents the amount the claim was reduced for those hospitals participating in Model 1 of the Bundled Payments for Care Improvement initiative (BPCI, Model 1).

The hospital must be participating in the Model 1 of the Bundled Payments for Care Improvement initiative (refer to CLM_CARE_IMPRVMT_MODEL_CD1). The percentage of the discount that this amount represents is in the field called CLM_BNDLD_MODEL_1_DSCNT_PCT. This field was new in 2013, and is null/missing for all previous years.

Values

Code
XXX.XX

Claim Bundled Model 1 Discount Percent

• Short SAS Name: CLM_BNDLD_MODEL_1_DSCNT_PCT
• Long SAS Name: CLM_BNDLD_MODEL_1_DSCNT_PCT

Contained in

• Inpatient RIF

This field identifies the discount percentage which will be applied to payment for all participating hospitals' DRG over the lifetime of the Bundled Payments for Care Improvement initiative (BPCI, Model 1).

The hospital must be participating in the Model 1 of the BPCI (refer to CLM_CARE_IMPRVMT_MODEL_CD1). The dollar amount of the payment reduction for the service is in the field called CLM_BNDLD_ADJSTMT_PMT_AMT. This field was new in 2013, and is null/missing for all previous years.

Values

Code
X.XX

Claim Care Improvement Model 1 Code (bundled payment)

• Short SAS Name: CLM_CARE_IMPRVMT_MODEL_CD1
• Long SAS Name: CLM_CARE_IMPRVMT_MODEL_CD1

Contained in

• Inpatient RIF

This code is used to identify that the care improvement model 1 is being used for bundling payments. The initiative if referred to as the Bundled Payments for Care Improvement initiative (BPCI, Model 1).

There are 4 of these Care Improvement Model fields (CLM_CARE_IMPRVMT_MODEL_CD1-CLM_CARE_IMPRVMT_MODEL_CD4). This field was new in 2013, and is null/missing for all previous years.

Values

Code	Code Value
61	Care Improvement Model 1 is used
Null/missing	nan

Claim Care Improvement Model 2 Code

• Short SAS Name: CLM_CARE_IMPRVMT_MODEL_CD2
• Long SAS Name: CLM_CARE_IMPRVMT_MODEL_CD2

Contained in

• Inpatient RIF

This code is used to identify that the care improvement model 2 is being used for payments.

There are 4 of these Care Improvement Model fields (CLM_CARE_IMPRVMT_MODEL_CD1-CLM_CARE_IMPRVMT_MODEL_CD4). This field was new in 2013, and is null/missing for all previous years.

Values

Code	Code Value
62	Care Improvement Model 2 is used
Null/missing	nan

Claim Care Improvement Model 3 Code

• Short SAS Name: CLM_CARE_IMPRVMT_MODEL_CD3
• Long SAS Name: CLM_CARE_IMPRVMT_MODEL_CD3

Contained in

• Inpatient RIF

This code is used to identify that the care improvement model 3 is being used for payments. 

There are 4 of these Care Improvement Model fields (CLM_CARE_IMPRVMT_MODEL_CD1-CLM_CARE_IMPRVMT_MODEL_CD4). This field was new in 2013, and is null/missing for all previous years.

Values

Code	Code Value
63	Care Improvement Model 3 is used
Null/missing	nan

Claim Care Improvement Model 4 Code

• Short SAS Name: CLM_CARE_IMPRVMT_MODEL_CD4
• Long SAS Name: CLM_CARE_IMPRVMT_MODEL_CD4

Contained in

• Inpatient RIF

This code is used to identify that the care improvement model 4 is being used for payments.

There are 4 of these Care Improvement Model fields (CLM_CARE_IMPRVMT_MODEL_CD1-CLM_CARE_IMPRVMT_MODEL_CD4). This field was new in 2013, and is null/missing for all previous years.

Values

Code	Code Value
64	Care Improvement Model 4 is used
Null/missing	nan

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 I Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW1
• Long SAS Name: CLM_POA_IND_SW1

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Limitation

DESCRIPTION : DESCRIPTION: Missing present on admission (POA) indicators on the NCH claims. BACKGROUND : A problem has been discovered with the Inpatient claims received from CWF from July 6, 2009 through October 4, 2009. The claims received during this timeperiod have no POA indicators. The problem was a result of a defect in the conversion code used by CWF to convert the new 5010 record format back to the 4010 format for the NCH. The reason CWF was converting the claims to the 4010 format was because they implemented the 5010 format beginning in July 2009 but the NCH is still using the 4010 until ⅓/2011. CORRECTIVE ACTION: CWF will be sending in adjustment claims to correct the problem. The claims will come into the NCH the week of December 19, 2009. There were approximately 3 million claims missing the POA indicator.CLM_POA_IND_CD_LIM

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).
Blank	Identifies diagnosis codes that are exempt from the POA reporting requirements (replaces the '1'). NOTE: NCH/NMUD will carry a '0' in place of a blank.

Claim Diagnosis Code I Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD1
• Long SAS Name: ICD_DGNS_VRSN_CD1

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1
Inpatient	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1
Outpatient	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1	icd_dgns_vrsn_cd1

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW2
• Long SAS Name: CLM_POA_IND_SW2

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code II Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD2
• Long SAS Name: ICD_DGNS_VRSN_CD2

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2
Inpatient	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2
Outpatient	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2	icd_dgns_vrsn_cd2

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW3
• Long SAS Name: CLM_POA_IND_SW3

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code III Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD3

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3
Inpatient	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3
Outpatient	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3	icd_dgns_vrsn_cd3

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW4
• Long SAS Name: CLM_POA_IND_SW4

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code IV Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD4

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4
Inpatient	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4
Outpatient	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4	icd_dgns_vrsn_cd4

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW9
• Long SAS Name: CLM_POA_IND_SW9

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code IX Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD9

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9
Inpatient	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9
Outpatient	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9	icd_dgns_vrsn_cd9

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW5
• Long SAS Name: CLM_POA_IND_SW5

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code V Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD5

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5
Inpatient	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5
Outpatient	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5	icd_dgns_vrsn_cd5

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW6
• Long SAS Name: CLM_POA_IND_SW6

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code VI Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD6

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6
Inpatient	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6
Outpatient	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6	icd_dgns_vrsn_cd6

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW7
• Long SAS Name: CLM_POA_IND_SW7

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -exempt from POA reporting. This code is equivalent to a blank on the UB-04, however, blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1'.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code VII Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD7

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7
Inpatient	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7
Outpatient	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7	icd_dgns_vrsn_cd7

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW8
• Long SAS Name: CLM_POA_IND_SW8

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code VIII Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD8

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8
Inpatient	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8
Outpatient	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8	icd_dgns_vrsn_cd8

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW10
• Long SAS Name: CLM_POA_IND_SW10

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code X Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD10

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10
Inpatient	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10
Outpatient	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10	icd_dgns_vrsn_cd10

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW11
• Long SAS Name: CLM_POA_IND_SW11

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code XI Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD11

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11
Inpatient	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11
Outpatient	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11	icd_dgns_vrsn_cd11

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW12
• Long SAS Name: CLM_POA_IND_SW12

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Code XII Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: ICD_DGNS_VRSN_CD12

Variable Names

Dataset	2013	2012	2011	2010
Carrier		icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12
Inpatient	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12
Outpatient	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12	icd_dgns_vrsn_cd12

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have bee expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW13
• Long SAS Name: CLM_POA_IND_SW13

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW14
• Long SAS Name: CLM_POA_IND_SW14

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW19
• Long SAS Name: CLM_POA_IND_SW19

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW15
• Long SAS Name: CLM_POA_IND_SW15

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW16
• Long SAS Name: CLM_POA_IND_SW16

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW17
• Long SAS Name: CLM_POA_IND_SW17

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW18
• Long SAS Name: CLM_POA_IND_SW18

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW20
• Long SAS Name: CLM_POA_IND_SW20

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW21
• Long SAS Name: CLM_POA_IND_SW21

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW22
• Long SAS Name: CLM_POA_IND_SW22

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW23
• Long SAS Name: CLM_POA_IND_SW23

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW24
• Long SAS Name: CLM_POA_IND_SW24

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM POA IND SW25
• Long SAS Name: CLM_POA_IND_SW25

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code I

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 I Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW1
• Long SAS Name: CLM_E_POA_IND_SW1

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code II

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 II Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW2
• Long SAS Name: CLM_E_POA_IND_SW2

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code III

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW3
• Long SAS Name: CLM_E_POA_IND_SW3

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code IV

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW4
• Long SAS Name: CLM_E_POA_IND_SW4

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code IX

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW9
• Long SAS Name: CLM_E_POA_IND_SW9

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code V

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW5
• Long SAS Name: CLM_E_POA_IND_SW5

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code VI

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW6
• Long SAS Name: CLM_E_POA_IND_SW6

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code VII

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW7
• Long SAS Name: CLM_E_POA_IND_SW7

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code VIII

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW8
• Long SAS Name: CLM_E_POA_IND_SW8

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code X

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW10
• Long SAS Name: CLM_E_POA_IND_SW10

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code XI

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW11
• Long SAS Name: CLM_E_POA_IND_SW11

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis E Code XII

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Diagnosis Present on Admission Indicator Code

• Short SAS Name: CLM E POA IND SW12
• Long SAS Name: CLM_E_POA_IND_SW12

Contained in

• Inpatient RIF

Effective with Version 'J', the code used to identify the present on admission(POA) indicator code associated with the diagnosis codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).

Claim Diagnosis Related Group Code

• Short SAS Name: DRG_CD
• Long SAS Name: CLM_DRG_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd

Dataset	2008	2007	2006	2005	2004
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd

Dataset	2003	2002	2001	2000	1999
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	mdrg	mdrg	mdrg

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The diagnostic related group to which a hospital claim belongs for prospective payment purposes.

Claim Diagnosis Related Group Outlier Stay Code

• Short SAS Name: OUTLR_CD
• Long SAS Name: CLM_DRG_OUTLIER_STAY_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	outlr_cd	outlr_cd	outlr_cd	outlr_cd	outlr_cd

Dataset	2008	2007	2006	2005	2004
MedPAR	outlr_cd	outlr_cd	outlr_cd	outlr_cd	outlr_cd

Dataset	2003	2002	2001	2000	1999
MedPAR	outlr_cd	outlr_cd	moutlier	moutlier	moutlier

Contained in

• Inpatient RIF

On an institutional claim, the code that indicates the beneficiary stay under the prospective payment system which, although classified into a specific diagnosis related group, has an unusually long length (day outlier) or exceptionally high cost (cost outlier).

Values

Non-PPS Only

Code	Code Value
0	No outlier
1	Day outlier (condition code 60)
2	Cost outlier, (condition code 61)

Code	Code Value
6	Valid diagnosis related groups (DRG) received from the intermediary
7	CMS developed DRG
8	CMS developed DRG using patient status code
9	Not groupable

Claim Disposition Code

• Short SAS Name: DISP_CD
• Long SAS Name: CLM_DISP_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Code indicating the disposition or outcome of the processing of the claim record.

Values

Code	Code Value
1	Debit accepted
2	Debit accepted (automatic adjustment) applicable through 4/4/93
3	Cancel accepted
61	Conversion code used only during conversion period - 1/1/91 - 2/21/91: debit accepted
62	Conversion code used only during conversion period - 1/1/91 - 2/21/91: debit accepted (automatic adjustment)
63	Conversion code used only during conversion period - 1/1/91 - 2/21/91: cancel accepted

Claim Electronic Health Record (EHR) Payment Adjustment Amount

• Short SAS Name: EHR_PYMT_ADJSTMT_AMT
• Long SAS Name: EHR_PYMT_ADJSTMT_AMT

Contained in

• Inpatient RIF

The claims adjustment payment amount for Hospitals that are not meaningful users of certified Electronic Health Record (EHR) technology.

This field was new in 2012, and is null/missing for all previous years.

Values

Code
XXX.XX

Claim Electronic Health Records (EHR) Program Reduction Indicator Switch

• Short SAS Name: EHR_PGM_RDCTN_IND_SW
• Long SAS Name: EHR_PGM_RDCTN_IND_SW

Contained in

• Inpatient RIF

This field is a switch that identifies which hospitals are Electronic Health Records(EHR) meaningful users, and distinguishes hospitals that will have a payment penalty for not being meaningful users.

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

Values

Code	Code Value
Y	hospital is subject to a reduction under the EHR program
Blank	not applicable

Claim Facility Type Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Final Standard Payment Amount

• Short SAS Name: FINL_STD_AMT
• Long SAS Name: FINL_STD_AMT

Contained in

• Inpatient RIF

This amount further adjusts the standard Medicare Payment amount (field called PPS_STD_VAL_PYMT_AMT) by applying additional standardization requirements (e.g. sequestration).

This amount is never used for payments. It is used for comparisons across different regions of the country for the value-based purchasing initiatives and for research. It is a standard Medicare payment amount, without the geographical payment adjustments and some of the other add-on payments that actually go to the hospitals.

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

Values

Code
XX.XX

Claim Frequency Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Full Standard Payment Amount

• Short SAS Name: CLM_FULL_STD_PYMT_AMT
• Long SAS Name: CLM_FULL_STD_PYMT_AMT

Contained in

• Inpatient RIF

This variable is the standard payment amount for long-term care hospitals (LTCH) under the Medicare prospective payment system (PPS), which is based on the MS-LTC-DRG.    

This amount does not include any applicable outlier payment amount.

Applies only to Inpatient (LTCH) claims. This field is new in October 2015. For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT, CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount field.

Values

Code
XXX.XX

Claim HHA Care Start Date

• Short SAS Name: HHSTRTDT
• Long SAS Name: CLM_ADMSN_DT

Contained in

• Home Health Agency RIF

Effective with Version H, the date care started for the HHA services reported on the institutional claim with a from date greater than 3/31/98. The Balanced Budget Act (BBA) required that this field be present on all HHA claims.

NOTE1: Beginning with NCH weekly process date 4/3/98, this field was populated with data. Claims processed prior to 4/3/98 will contain zeroes in this field.

NOTE2: Effective with Version 'I', the start of care date will be moved from the 1^st eight positions of the Claim Treatment Authorization Number. Prior to Version 'I' this date was moved from Occurrence Code 27 date field.

Data Variable Alert: The Claim HHA Care Start Date variable (CLM_ADMSN_DT) is often missing in the 2011-2012 claims. CMS has since corrected the issue for 2013 onward. However, CMS has no plans to fix the 2011-2012 claims.

Claim HHA Low Utilization Payment Adjustment (LUPA) Indicator Code

• Short SAS Name: LUPAIND
• Long SAS Name: CLM_HHA_LUPA_IND_CD

Contained in

• Home Health Agency RIF

Effective with Version I, the code used to identify those Home Health PPS claims that have 4 visits or less in a 60-day episode. If an HHA provides 4 visits or less, they will be reimbursed based on a national standardized per visit rate instead of HHRGs.

NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces.

Limitation

REFER TO : HHA_PPS_LUPA_IND_CD_LIM

Values

Code	Code Value
L	LUPA claim
BLANK	Not a LUPA claim

Claim HHA Referral Code

• Short SAS Name: HHA_RFRL
• Long SAS Name: CLM_HHA_RFRL_CD

Contained in

• Home Health Agency RIF

Effective with Version 'I', the code used to identify the means by which the beneficiary was referred for Home Health services. NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces in this field.

Limitation

REFER TO : HHA_RFRL_CD_LIM

Values

Code	Code Value
1	Physician referral - The patient was admitted upon the recommendation of a personal physician.
2	Clinic referral - The patient was admitted upon the recommendation of this facility's clinic physician.
3	HMO referral - The patient was admitted upon the recommendation of an health maintenance organization (HMO) physician.
4	Transfer from hospital - The patient was admitted as an inpatient transfer from an acute care facility.
5	Transfer from a skilled nursing facility (SNF) - The patient was admitted as an inpatient transfer from a SNF.
6	Transfer from another health care facility - The patient was admitted as a transfer from a health care facility other than an acute care facility or SNF.
7	Emergency room - The patient was admitted upon the recommendation of this facility's emergency room physician.
8	Court/law enforcement - The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative.
9	Information not available - The means by which the patient was admitted is not known.
A	Transfer from a Critical Access Hospital - patient was admitted/referred to this facility as a transfer from a Critical Access Hospital.
B	Transfer from another HHA - Beneficiaries are permitted to transfer from one HHA to another unrelated HHA under HH PPS. (eff. 10/00)
C	Readmission to same HHA - If a beneficiary is discharged from an HHA and then readmitted within the original 60-day episode, the original episode must be closed early and a new one created. NOTE: the use of this code will permit the agency to send a new RAP allowing all claims to be accepted by Medicare. (eff. 10/00)

Claim HHA Total Visit Count

• Short SAS Name: VISITCNT
• Long SAS Name: CLM_HHA_TOT_VISIT_CNT

Contained in

• Home Health Agency RIF

Effective with Version H, the count of the number of HHA visits as derived by CWF.

NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991) using the CWF derivation rule (units associated with revenue center codes 042X, 043X, 044X, 055X, 056X, 057X, 058X and 059X. Value 999 will be displayed if the sum of the revenue center unit count equals or exceeds 999.

NOTE2: Effective 7/1/99, all HHA claims received with service from dates 7/1/99 and after will be processed as if the units field contains the 15 minute interval count; and each visit revenue code line item will be counted as ONE visit. This field is calculated correctly; but those users who derive the count themselves they will have to revise their routine. NO LONGER IS THE COUNT DERIVED BY ADDING UP THE UNITS FIELDS ASSOCIATED WITH THE HHA VISIT REVENUE CODES.

Limitation

REFER TO : HHA_TOT_VISIT_CNT_LIM

Claim HRR Adjustment Percent

• Short SAS Name: CLM_HRR_ADJSTMT_PCT
• Long SAS Name: CLM_HRR_ADJSTMT_PCT

Contained in

• Inpatient RIF

Under the Hospital Readmissions Reduction (HRR) Program, the amount used to identify the readmission adjustment factor that will be applied.

The ACA (Section 3025) requires CMS to reduce payments to subsection (d) Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions. There is a variable that indicates whether the hospital was excluded from the HRR program (see CLM_HRR_PRTCPNT_IND_CD). This percentage reduction is applied to the base operating DRG amount(defined as the wage-adjusted DRG payment plus new technology add-on payments).

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

The actual dollar amount of the adjustment that applied to the claim is found in the variable called CLM_HRR_ADJSTMT_PMT_AMT.

This initiative began in 4^th Quarter of 2012 (i.e., beginning of Federal fiscal year 13).

This field was new in 2012, and is null/missing for all previous years.

Values

Code
X.XXXX

Claim Hospice Start Date

• Short SAS Name: HSPCSTRT
• Long SAS Name: CLM_HOSPC_START_DT_ID

Contained in

• Hospice RIF

On an institutional claim, the date the beneficiary was admitted to the hospice.

Claim Hospital Acquired Condition (HAC) Program Reduction Indicator Switch

• Short SAS Name: HAC_PGM_RDCTN_IND_SW
• Long SAS Name: HAC_PGM_RDCTN_IND_SW

Contained in

• Inpatient RIF

This field is a switch that identifies hospitals subject to a Hospital Acquired Conditions (HAC) reduction of what they would otherwise be paid under the inpatient prospective payment system (IPPS).

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

For details on the CMS hospital readmission reduction program see the CMS website: here

Values

Code	Code Value
Y	hospital subject to a reduction under the HAC Reduction Program
N	hospital is not subject to a reduction under the HAC Reduction Program

Claim Hospital Readmission Reduction (HRR) Adjustment Payment Amount

• Short SAS Name: CLM_HRR_ADJSTMT_PMT_AMT
• Long SAS Name: CLM_HRR_ADJSTMT_PMT_AMT

Contained in

• Inpatient RIF

This field represents the Hospital Readmission Reduction (HRR) Program Payment Amount. The amount is the reduction to the claim for a readmission. SHORT

The ACA (Section 3025) requires CMS to reduce payments to subsection (d) Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.

There is a variable that indicates whether the hospital was excluded from the HRR program (see CLM_HRR_PRTCPNT_IND_CD). This percentage reduction is applied to the base operating DRG amount(defined as the wage-adjusted DRG payment plus new technology add-on payments). Additional information is available on the CMS "Hospital Value-Based Purchasing" website. This amount is based on a percent (CLM_HRR_ADJSTMT_PCT).

This initiative began in 4^th Quarter of 2012 (i.e., beginning of Federal fiscal year 13).

This field was new in 2012, and is null/missing for all previous years.

Values

Code
XXX.XX (may be a negative value)

Claim Hospital Readmission Reduction (HRR) Participant Indicator Code

• Short SAS Name: CLM_HRR_PRTCPNT_IND_CD
• Long SAS Name: CLM_HRR_PRTCPNT_IND_CD

Contained in

• Inpatient RIF

This field is the code used to identify whether the hospital is participating in the Hospital Readmissions Reduction (HRR) program.

The ACA (Section 3025) requires CMS to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

This initiative began in 4^th Quarter of 2012 (i.e., beginning of Federal fiscal year 13).

This field was new in 2012, and is null/missing for all previous years.

Values

Code	Code Value
0	Not participating
1	Participating and not equal to 1.0000
2	Participating and equal to 1.0000
Null/missing	Not participating

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Inpatient Admission Type Code

• Short SAS Name: TYPE_ADM
• Long SAS Name: CLM_IP_ADMSN_TYPE_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	type_adm	type_adm	type_adm	type_adm	type_adm

Dataset	2008	2007	2006	2005	2004
MedPAR	type_adm	type_adm	type_adm	type_adm	type_adm

Dataset	2003	2002	2001	2000	1999
MedPAR	type_adm	type_adm	madmtype	madmtype	madmtype

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The code indicating the type and priority of an inpatient admission associated with the service on an intermediary submitted claim.

Values

Code	Code Value
0	Blank
1	Emergency - The patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.
2	Urgent - The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodation.
3	Elective - The patient's condition permitted adequate time to schedule the availability of suitable accommodations.
4	Newborn - Necessitates the use of special source of admission codes.
5	Trauma Center - visits to a trauma center/hospital as licensed or designated by the State or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation.
6 THRU 8	Reserved
9	Unknown - Information not available.

Claim Inpatient Low Volume Payment Amount

• Short SAS Name: CLM_IP_LOW_VOL_PMT_AMT
• Long SAS Name: CLM_IP_LOW_VOL_PMT_AMT

Contained in

• Inpatient RIF

This is the amount field used to identify a payment adjustment given to hospitals to account for the higher costs per discharge for low income hospitals under the Inpatient Prospective Payment System (IPPS).

Payment adjustment for low income IPPS hospitals. This field was new in 2011.

Values

Code
XXX.XX

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Model 4 Readmission Indicator Code

• Short SAS Name: CLM_MODEL_4_READMSN_IND_CD
• Long SAS Name: CLM_MODEL_4_READMSN_IND_CD

Contained in

• Inpatient RIF

This field identifies the method of payment of a claim billed within 30 days of a Model 4 Bundled Payments for Care Improvement (BPCI) admission.

Bundling payment for services that patients receive across a single episode of care, such as heart bypass surgery or a hip replacement, is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients. Under the Model 4 BPCI pilot, CMS will reimburse qualified acute care hospitals a blended payment for hospital inpatient care and physician services connected with a single episode of care. This will occur in association with inpatient hospital claims that the BPCI participating hospital will bill to their jurisdictional A/B MAC as type of bill 11X claims.

Values

Code	Code Value
1	claim is related readmission to a Model 4 BPCI claim and shall pay IME, DSH, and Capital Only.
2	two Model 4 BPCI claims within 30 days of each other, first claim in episode shall process as it would in the absence of Model 4 BPCI.
3	two Model 4 BPCI claims within 30 days of each other, this is the second claim in the episode and paid as Model 4.
Null/missing	not a BPCI claim

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Carrier RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Carrier RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Carrier RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Carrier RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Carrier RIF

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 Non Utilization Days Count

• Short SAS Name: NUTILDAY
• Long SAS Name: CLM_NON_UTLZTN_DAYS_CNT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

On an institutional claim, the number of days of care that are not chargeable to Medicare facility utilization.

Claim Occurrence Span Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

• Outpatient RIF

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 PPS Capital DRG Weight Number

• Short SAS Name: DRGWTAMT
• Long SAS Name: CLM_PPS_CPTL_DRG_WT_NUM

Contained in

• Inpatient RIF

Effective 3/2/92, the number used to determine a transfer adjusted case mix index for capital PPS. The number is determined by multiplying the DRG weight times the discharge fraction.

Limitation

DESCRIPTION : Field erroneously blanked out on segments 2-10. BACKGROUND : During the Version 'I' conversion of all service years (1991-6/30/00) the following field was erroneously blanked out on segments 2-10.During the Version 'I' planning process, it was decided that all codes, dates, numbers, names and percent fields would be populated on all segments of a claim; but amount, counts, and quantities would be zeroed out on segments 2-10 to eliminate the risk of overstating values. CORRECTIVE ACTION : This data can not be recovered.

Claim PPS Capital Disproportionate Share Amount

• Short SAS Name: DISP_SHR
• Long SAS Name: CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	disp_shr	disp_shr	disp_shr	disp_shr	disp_shr

Dataset	2008	2007	2006	2005	2004
MedPAR	disp_shr	disp_shr	disp_shr	disp_shr	disp_shr

Dataset	2003	2002	2001	2000	1999
MedPAR	disp_shr	disp_shr	mdprpamt	mdprpamt	mdprpamt

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, the amount of disproportionate share (rate reflecting indigent population served) portion of the PPS payment for capital.

Claim PPS Capital Exception Amount

• Short SAS Name: CPTL_EXP
• Long SAS Name: CLM_PPS_CPTL_EXCPTN_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, the capital PPS amount of exception payments provided for hospitals with inordinately high levels of capital obligations. Exception payments expire at the end of the 10-year transition period.

Values

Code
XXX.XX

Claim PPS Capital FSP Amount

• Short SAS Name: CPTL_FSP
• Long SAS Name: CLM_PPS_CPTL_FSP_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, the amount of the federal specific portion of the PPS payment for capital.

Values

Code
XXX.XX

Claim PPS Capital IME Amount

• Short SAS Name: IME_AMT
• Long SAS Name: CLM_PPS_CPTL_IME_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	ime_amt	ime_amt	ime_amt	ime_amt	ime_amt

Dataset	2008	2007	2006	2005	2004
MedPAR	ime_amt	ime_amt	ime_amt	ime_amt	ime_amt

Dataset	2003	2002	2001	2000	1999
MedPAR	ime_amt	ime_amt	mtotime	mtotime	mtotime

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, the amount of the indirect medical education (IME) (reimbursable amount for teaching hospitals only; an added amount passed by Congress to augment normal PPS payments for teaching hospitals to compensate them for higher patient costs resulting from medical education programs for interns and residents) portion of the PPS payment for capital.

Claim PPS Capital Outlier Amount

• Short SAS Name: CPTLOUTL
• Long SAS Name: CLM_PPS_CPTL_OUTLIER_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, the amount of the outlier portion of the PPS payment for capital.

Values

Code
XXX.XX

Claim PPS Indicator Code

• Short SAS Name: PPS_IND
• Long SAS Name: CLM_PPS_IND_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	pps_ind	pps_ind	pps_ind	pps_ind	pps_ind

Dataset	2008	2007	2006	2005	2004
MedPAR	pps_ind	pps_ind	pps_ind	pps_ind	pps_ind

Dataset	2003	2002	2001	2000	1999
MedPAR	pps_ind	pps_ind	mpps	mpps	mpps

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF
• Home Health Agency RIF

Effective with Version H, the code indicating whether or not the (1) claim is PPS and/or (2) the beneficiary is a deemed insured Medicare Qualified Government Employee (MQGE).

NOTE: Beginning with NCH weekly process date 10/3/97 through 5/29/98, this field was pop- ulated with only the PPS indicator. Beginning with NCH weekly process date 6/5/98, this field was additionally populated with the deemed MQGE indicator. Claims processed prior to 10/3/97 will contain spaces.

Values

Effective NCH weekly process date 10/3/97 - 5/29/98

Code	Code Value
0	not PPS bill (claim contains no PPS indicator)
2	PPS bill ( claim contains PPS indicator)

Effective NCH weekly process date 6/5/98

Code	Code Value
0	not applicable (claim contains neither PPS nor deemed insured MQGE status indicators)
1	Deemed insured MQGE (claim contains deemed insured MQGE indicator but not PPS indicator)
2	PPS bill ( claim contains PPS indicator but no deemed insured MQGE status indicator)
3	Both PPS and deemed insured MQGE (contains both PPS and deemed insured MQGE indicators)

Claim PPS Old Capital Hold Harmless Amount

• Short SAS Name: HLDHRMLS
• Long SAS Name: CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective 3/2/92, this amount is the hold harmless amount payable for old capital as computed by PRICER for providers with a payment code equal to 'A'. The hold harmless amount-old capital is 100 percent of the reasonable costs of old capital for sole community sole community hospitals, or 85 percent of the reasonable costs associated with old capital for all other hospitals, plus a payment for new capital.

Claim Pass Thru Per Diem Amount

• Short SAS Name: PER_DIEM
• Long SAS Name: CLM_PASS_THRU_PER_DIEM_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	per_diem	per_diem	per_diem	per_diem	per_diem

Dataset	2008	2007	2006	2005	2004
Inpatient	per_diem	per_diem	per_diem	per_diem	per_diem

Dataset	2003	2002	2001	2000	1999
Inpatient	per_diem	per_diem	per_diem	per_diem	per_diem

Contained in

• Inpatient RIF

The amount of the established reimbursable costs for the current year divided by the estimated Medicare days for the current year (all PPS claims), as calculated by the FI and reim- bursement staff. Items reimbursed as a pass through include capital-related costs; direct medical education costs; kidney acquisition costs for hospitals approved as RTCs; and bad debts (per Provider Reimbursement Manual, Part 1, Section 2405.2). **Note: Pass throughs are not included in the Claim Payment Amount.

Claim Payment Amount

• Short SAS Name: PMT_AMT
• Long SAS Name: CLM_PMT_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	mintreim	mintreim	mintreim
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Contained in

Amount of payment made from the Medicare trust fund for the services covered by the claim record. Generally, the amount is calculated by the FI or carrier; and represents what was paid to the institutional provider, physician, or supplier, with the exceptions noted below. **NOTE: In some situations, a negative claim payment amount may be pre- sent; e.g., (1) when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or (2) when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.)

Under IP PPS, inpatient hospital services are paid based on a predetermined rate per discharge, using the DRG patient classification system and the PRICER program. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (since 5/1/86), indirect medical education (since 10/1/88), total PPS capital (since 10/1/91). After 4/1/03, the payment amount could also include a "new technology" add-on amount. It does NOT include the pass-thru amounts (i.e., capital- related costs, direct medical education costs, kidney acquisition costs, bad debts); or any beneficiary-paid amounts (i.e., deductibles and coinsurance); or any any other payer reimbursement.

Under IRFPPS, inpatient rehabilitation services are paid based on a predetermined rate per discharge, using the Case Mix Group (CMG) classification system and the PRICER program. From the CMG on the IRF PPS claim, payment is based on a standard payment amount for operating and capital cost for that facility (including routine and ancillary services). The payment is adjusted for wage, the % of low-income patients (LIP), locality, transfers, interrupted stays, short stay cases, deaths, and high cost outliers. Some or all of these adjustments could apply. The CMG payment does NOT include certain pass- through costs (i.e. bad debts, approved education activities); beneficiary-paid amounts, other payer reim- bursement,and other services outside of the scope of PPS.

Under LTCH PPS, long term care hospital services are paid based on a predetermined rate per discharge based on the DRG and the PRICER program. Payments are based on a single standard Federal rate for both inpatient operating and capital-related costs (including routine and ancillary services), but do NOT include certain pass-through costs (i.e. bad debts, direct medical education, new technologies and blood clotting factors). Adjustments to the payment may occur due to short-stay outliers, interrupted stays, high cost outliers, wage index, and cost of living adjust- ments.

Under SNF PPS, SNFs will classify beneficiaries using the patient classification system known as RUGS III. For the SNF PPS claim, the SNF PRICER will calculate/return the rate for each revenue center line item with revenue center code = 0022; multiply the rate times the units count; and then sum the amount payable for all lines with revenue center code 0022 to determine the total claim payment amount.

Under Outpatient PPS, the national ambulatory payment classification (APC) rate that is calculated for each APC group is the basis for determining the total claim payment. The payment amount also includes the outlier payment and interest.

Under Home Health PPS, beneficiaries will be classified into an appropriate case mix category known as the Home Health Resource Group. A HIPPS code is then generated corresponding to the case mix category (HHRG).

For the RAP, the PRICER will determine the payment amount appropriate to the HIPPS code by computing 60% (for first episode) or 50% (for subsequent episodes) of the case mix episode payment. The payment is then wage index adjusted.

For the final claim, PRICER calculates 100% of the amount due, because the final claim is processed as an adjustment to the RAP, reversing the RAP payment in full. Although final claim will show 100% payment amount, the provider will actually receive the 40% or 50% payment. The payment may also include outlier payments.

Exceptions: For claims involving demos and BBA encounter data, the amount reported in this field may not just represent the actual provider payment.

For demo Ids 01,02,03,04 -- claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included.

For demo Ids 05,15 -- encounter data 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO.

For demo Ids 06,07,08 -- claims contain actual provider payment but represent a special negotiated bundled payment for both Part A and Part B services. To identify what the conventional provider Part A payment would have been, check value code = Y4. The related noninstitutional (physician/supplier) claims contain what would have been paid had there been no demo.

For BBA encounter data (non-demo) -- 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan.

Limitation

Prior to 4/6/93, on inpatient, outpatient, and physician/supplier claims containing a CLM_DISP_CD of '02', the amount shown as the Medicare reimbursement does not take into consideration any CWF automatic adjustments (involving erroneous deductibles in most cases). In as many as 30% of the claims (30% IP, 15% OP, 5% PART B), the reimbursement reported on the claims may be over or under the actual Medicare payment amount.

REFER TO : PMT_AMT_EXCEDG_CHRG_AMT_LIM

Claim Pricer Return Code

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

Contained in

• Outpatient RIF
• Inpatient RIF
• Hospice RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Values

CMS_PRVDR_SPCLTY_TB.txt

Claim Related Condition Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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)

Claim Related Condition Code Sequence

• Short SAS Name: RLTCNDSQ
• Long SAS Name: RLT_COND_CD_SEQ

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Claim Related Occurrence Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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)

Claim Related Occurrence Code Sequence

• Short SAS Name: RLTOCRSQ
• Long SAS Name: RLT_OCRNC_CD_SEQ

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Claim Related Occurrence Date

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Claim Related Span Code Sequence

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Claim Related Value Code Sequence

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Short Stay Outlier (SSO) Standard Payment Amount

• Short SAS Name: CLM_SS_OUTLIER_STD_PYMT_AMT
• Long SAS Name: CLM_SS_OUTLIER_STD_PYMT_AMT

Contained in

• Inpatient RIF

This variable is the standard payment amount for long-term care hospitals (LTCH) under the Medicare prospective payment system (PPS), which is based on the MS-LTC-DRG with the short stay outlier (SSO) adjustment.   

This amount does not include any other applicable outlier payment amount.

Applies only to Inpatient (LTCH) claims. This field is new in October 2015.

For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT, CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount field.

Values

Code
XXX.XX

Claim Site Neutral Payment Based on Cost Amount

• Short SAS Name: CLM_SITE_NTRL_PYMT_CST_AMT
• Long SAS Name: CLM_SITE_NTRL_PYMT_CST_AMT

Contained in

• Inpatient RIF

Under the Long Term Care Hospital (LTCH) prospective payment system (PPS), the payment amount based on estimated cost of the case.

Applies only to Inpatient (LTCH) claims. This field is new in October 2015. For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT, CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount field.

Values

Code
XXX.XX

Claim Site Neutral Payment Based on inpatient prospective payment system (IPPS) Amounts

• Short SAS Name: CLM_SITE_NTRL_PYMT_IPPS_AMT
• Long SAS Name: CLM_SITE_NTRL_PYMT_IPPS_AMT

Contained in

• Inpatient RIF

Under the Long Term Care Hospital (LTCH) prospective payment system (PPS), the payment amount based on the inpatient prospective payment system (IPPS) comparable amount. This amount does not include any applicable outlier payment amount.

Applies only to Inpatient (LTCH) claims. This field is new in October 2015. For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT, CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount field.

Values

Code
XXX.XX

Claim Source Inpatient Admission Code

• Short SAS Name: SRC_ADMS
• Long SAS Name: CLM_SRC_IP_ADMSN_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	src_adms	src_adms	src_adms	src_adms	src_adms

Dataset	2008	2007	2006	2005	2004
MedPAR	src_adms	src_adms	src_adms	src_adms	src_adms

Dataset	2003	2002	2001	2000	1999
MedPAR	src_adms	src_adms	madmsrce	madmsrce	madmsrce

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The code indicating the source of the referral for the admission or visit.

Values

For Inpatient/SNF Claims:

Code	Code Value
0	ANOMALY: invalid value, if present, translate to '9'
1	Non-Health Care Facility Point of Origin (Physician Referral) - The patient was admitted to this facility upon an order of a physician.
2	Clinic referral - The patient was admitted upon the recommendation of this facility's clinic physician.
3	HMO referral - Reserved for national assignment. (eff. 3/08) Prior to 3/08, HMO referral - The patient was admitted upon the recommendation of a health maintenance organization (HMO) physician.
4	Transfer from hospital (Different Facility) - The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient.
5	Transfer from a skilled nursing facility (SNF) or Intermediate Care Facility (ICF) - The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.
6	Transfer from another health care facility - The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list where he or she was an inpatient.
7	Emergency room - The patient was admitted to this facility after receiving services in this facility's emergency room department. (Obsolete - eff. 7/1/10)
8	Court/law enforcement - The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative.
9	Information not available - The means by which the patient was admitted is not known.
A	Reserved for National Assignment. (eff. 3/08) Prior to 3/08 defined as: Transfer from a Critical Access Hospital - patient was admitted/referred to this facility as a transfer from a Critical Access Hospital.
B	Transfer from Another Home Health Agency - The patient was admitted to this home health agency as a transfer from another home health agency. (Discontinued July 1, 2010- See Condition Code 47)
C	Readmission to Same Home Health Agency - The patient was readmitted to this home health agency within the same home health episode period. (Discontinued July 1, 2010)
D	Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer - The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.
E	Transfer from Ambulatory Surgical Center - The patient was admitted to this facility as a transfer from an ambulatory surgery center. (eff. 10/1/2007)
F	Transfer from Hospice and is under a Hospice Plan of Care or Enrolled in a Hospice Program - The patient was admitted to this facility as a transfer from a hospice. (eff. 10/1/2007)

For Newborn Type of Admission:

Code	Code Value
1	Normal delivery - A baby delivered without complications. (Obsolete eff. 10/1/07)
2	Premature delivery - A baby delivered with time and/or weight factors qualifying it for premature status. (Obsolete eff. 10/1/07)
3	Sick baby - A baby delivered with medical complications, other than those relating to premature status. (Obsolete eff. 10/1/07)
4	Extramural birth - A baby delivered in a non-sterile environment. (Obsolete eff. 10/1/07)
5	Born Inside this Hospital (eff. 10/1/07)
6	Born Outside of This Hospital (eff. 10/1/07)
7-9	Reserved for national assignment.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Total PPS Capital Amount

• Short SAS Name: PPS_CPTL
• Long SAS Name: CLM_TOT_PPS_CPTL_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	pps_cptl	pps_cptl	pps_cptl	pps_cptl	pps_cptl

Dataset	2008	2007	2006	2005	2004
MedPAR	pps_cptl	pps_cptl	pps_cptl	pps_cptl	pps_cptl

Dataset	2003	2002	2001	2000	1999
MedPAR	pps_cptl	pps_cptl	mppscamt	mppscamt	mppscamt

Contained in

• Inpatient RIF

The total amount that is payable for capital PPS for the claim. This is the sum of the capital hospital specific portion, federal specific portion, outlier portion, disproportionate share portion, indirect medical education portion, exception payments, and hold harmless payments.

Values

Code
XXX.XX

Claim Treatment Authorization Number

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF

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 Uncompensated Care Payment Amount

• Short SAS Name: CLM_UNCOMPD_CARE_PMT_AMT
• Long SAS Name: CLM_UNCOMPD_CARE_PMT_AMT

Contained in

• Inpatient RIF

This field identifies the payment for disproportionate share hospitals (DSH).  It represents the uncompensated care amount of the payment.

This field applies only to inpatient claims. These payments were authorized as part of Section 3133 of the Affordable Care Act (ACA).

Values

Code
XXX.XX

Claim Utilization Day Count

• Short SAS Name: UTIL_DAY
• Long SAS Name: CLM_UTLZTN_DAY_CNT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	util_day	util_day	util_day	util_day	util_day

Dataset	2008	2007	2006	2005	2004
Inpatient	util_day	util_day	util_day	util_day	util_day

Dataset	2003	2002	2001	2000	1999
Inpatient	util_day	util_day	util_day	util_day	util_day

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF
• Hospice RIF

On an institutional claim, the number of covered days of care that are chargeable to Medicare facility utilization that includes full days, coinsurance days, and lifetime reserve days. It excludes any days classified as non-covered, leave of absence days, and the day of discharge or death.

Claim VBP Adjustment Percent

• Short SAS Name: CLM_VBP_ADJSTMT_PCT
• Long SAS Name: CLM_VBP_ADJSTMT_PCT

Contained in

• Inpatient RIF

Under the Hospital Value Based Purchasing (HVBP) program, an adjustment is made to the base operating DRG amount for certain Inpatient Prospective Payment System (IPPS) hospitals - based on their Total Performance Score (TPS).

This initiative began in 4^th Quarter of 2013 (i.e., beginning of Federal fiscal year 14 [FY14]).

This field was new in 2013, and is null/missing for all previous years. The HVBP applies only to subsection (d) IPPS hospitals. There is a variable that indicates whether the hospital was excluded from HVBP (see CLM_VBP_PRTCPNT_IND_CD). This percentage reduction is applied to the base operating DRG amount, depending on their TPS (which is the Value Based Purchasing Score), as required by the Affordable Care Act (ACA). The percentages change each FY.

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

The actual dollar amount of the adjustment that applied to the claim is found in the variable called CLM_VBP_ADJSTMT_PMT_AMT.

Values

Code
X.XX

Claim Value Amount

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Based Purchasing Adjustment Payment Amount

• Short SAS Name: CLM_VBP_ADJSTMT_PMT_AMT
• Long SAS Name: CLM_VBP_ADJSTMT_PMT_AMT

Contained in

• Inpatient RIF

Under the Hospital Value Based Purchasing (HVBP) program, an adjustment is made to the base operating DRG amount for certain Inpatient Prospective Payment System (IPPS) hospitals - based on their Total Performance Score (TPS).

This initiative began in 4^th Quarter of 2013 (i.e., beginning of Federal fiscal year 14 [FY14]).

This field was new in 2013, and is null/missing for all previous years. The HVBP applies only to subsection (d) IPPS hospitals. There is a variable that indicates whether the hospital was excluded from HVBP (see CLM_VBP_PRTCPNT_IND_CD). This percentage reduction is applied to the base operating DRG amount, depending on their TPS (which is the Value Based Purchasing Score), as required by the Affordable Care Act (ACA). The percentages change each FY.

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

The actual dollar amount of the adjustment that applied to the claim is found in the variable called CLM_VBP_ADJSTMT_PMT_AMT.

Values

Code
X.XX

Claim Value Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Value-Based Purchasing (VBP) Participant Indicator Code

• Short SAS Name: CLM_VBP_PRTCPNT_IND_CD
• Long SAS Name: CLM_VBP_PRTCPNT_IND_CD

Contained in

• Inpatient RIF

This field is the code used to identify a reason a hospital is excluded from the Hospital Value Based Purchasing (HVBP) program.

The ACA (Section 3001) excludes from the HVBP hospitals that meet certain conditions. Additional information is available on the CMS "Hospital Value-Based Purchasing" website. This initiative began in 4^th Quarter of 2013 (i.e., beginning of Federal fiscal year 14). This field was new in 2013, and is null/missing for all previous years.

Values

Code	Code Value
Y	Participating in Hospital Value Based Purchasing
N	Not participating in Hospital Value Based Purchasing
Null/missing	same as 'N'

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF

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

Values

Code
XXXXXXXXX

Clinical Laboratory Improvement Amendments monitored laboratory number

• Short SAS Name: CARR_LINE_CLIA_LAB_NUM
• Long SAS Name: CARR_LINE_CLIA_LAB_NUM

Contained in

• Carrier RIF

The identification number assigned to the clinical laboratory providing services for the line item on the carrier claim (non-DMERC).

Clinical Trial Number

• Short SAS Name: CCLTRNUM
• Long SAS Name: CLM_CLNCL_TRIL_NUM

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective September 1, 2008 with the implementation of CR#3, the number used to identify all items and services provided to a beneficiary during their participation in a clinical trial.

NOTE: CMS is requesting the clinical trial number be voluntarily reported. The number is assigned by the National Library of Medicine (NLM) Clinical Trials Data Bank when a new study is registered.

Colorectal Cancer End-of-Year Flag

• Short SAS Name: CNCRCLRC

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for colorectal cancer as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For colorectal cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims at least one day apart, with a colorectal cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Colorectal Cancer Mid-Year Flag

• Short SAS Name: CNCRCLRM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

County Code for Beneficiary (SSA code)

• Short SAS Name: CNTY_CD
• Long SAS Name: COUNTY_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

• Master Beneficiary Summary File

This code specifies the Social Security Administration (SSA) code fopuyypr the county of identified through the benficiary mailing address.

Each state has a series of codes beginning with '000' for each county within that state. Certain cities within that state have their own code. County codes must be combined with state codes in order to locate the specific county. The coding system is the SSA system, not the Federal Information Processing Standard (FIPS).

In some cases, the code may not be the actual county where the beneficairy resides. CMS obtains the mailing address used for cash benefits or the mailing address used for other purposes (for example, premium billing) from Social Security Administration (SSA) and Railroad Retirement Board (RRB) Beneficiary Record Systems.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

Current Beneficiary Identification Code

• Short SAS Name: CRNT_BIC
• Long SAS Name: CRNT_BIC_CD

Contained in

• Master Beneficiary Summary File

The current beneficiary identification code (BIC) specifies the basis of the beneficiary's elgibility for cash payment programs, mainly Social Security. When the individual qualifies under another person's account (for example, as a spouse or child), the code identifies the type of relationship between the individual and primary beneficiary.

Values

Beneficiary Identification Code (BIC) Table.txt

Current Reason for Entitlement Code

• Short SAS Name: CREC
• Long SAS Name: ENTLMT_RSN_CURR

Contained in

• Master Beneficiary Summary File

Current reason for Medicare entitlement.

Values

This variable indicates how the beneficiary currently qualifies for Medicare.

The current reason for entitlement can differ from the original reason that a beneficiary qualified for Medicare (see the OREC variable).

CMS obtains this information from the Social Security Administration (SSA) and Railroad Retirement Board (RRB) record systems.

Code	Code Value
0	Old Age and Survivors Insurance (OASI)
1	Disability Insurance Benefits (DIB)
2	End-stage Renal Disease (ESRD)
3	Both DIB and ESRD

Cystic Fibrosis and Other Metabolic Developmental Disorders End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: CYSFIB_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for cystic fibrosis and other metabolic developmental disorders as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For cystic fibrosis and other metabolic developmental disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Cystic Fibrosis and Other Metabolic Developmental Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: CYSFIB_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the cystic fibrosis and other metabolic developmental disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

DMERC Claim Ordering Physician NPI Number

• Short SAS Name: RFR_NPI
• Long SAS Name: RFR_PHYSN_NPI

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	rfr_npi	rfr_npi	rfr_npi	rfr_npi	rfr_npi

Dataset	2007	2006	2005	2004	2003
Carrier	rfr_npi	rfr_npi	rfr_npi	rfr_npi	rfr_npi

Dataset	2002	2001	2000
Carrier	rfr_npi	rfr_npi	rfr_npi

Contained in

• Durable Medical Equipment RIF

A placeholder field (effective with Version H) for storing the NPI assigned to the physician ordering the Part B services/DMEPOS item.

DMERC Claim Ordering Physician UPIN Number

• Short SAS Name: RFR_UPIN
• Long SAS Name: RFR_PHYSN_UPIN

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	rfr_upin	rfr_upin	rfr_upin	rfr_upin	rfr_upin

Dataset	2007	2006	2005	2004	2003
Carrier	rfr_upin	rfr_upin	rfr_upin	rfr_upin	rfr_upin

Dataset	2002	2001	2000	1999
Carrier	rfr_upin	rfr_upin	rfr_upin	brfrupin

Contained in

• Durable Medical Equipment RIF

Effective with Version G, the unique physician identification number (UPIN) of the physician ordering the Part B services/DMEPOS item.

DMERC Line HCPCS Fourth Modifier Code

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

Contained in

• Durable Medical Equipment RIF

Prior to Version H this field was named: HCPCS_4TH_MDFR_CD.

DMERC Line HCPCS Third Modifier Code

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

Contained in

• Durable Medical Equipment RIF

Prior to Version H this field was named: HCPCS_3RD_MDFR_CD.

DMERC Line Item Supplier NPI Number

• Short SAS Name: SUP_NPI
• Long SAS Name: PRVDR_NPI

Contained in

• Durable Medical Equipment RIF

The National Provider Identifier (NPI) assigned to the supplier of the Part B service/DMEPOS line item.

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

NOTE1: CMS has determined that dual provider identifiers (legacy numbers and NPIs) must be available on the NCH. After the 5/07 NPI implementation, the standard system maintainers will add the legacy number to the claim when it is adjudicated. Effective May 2007, no NEW UPINs will be generated for NEW physicians (Part B and Outpatient claims) so there will only be NPIs sent in to the NCH for those phy- sicians.

DMERC Line Miles/Time/Units/Services Count

• Short SAS Name: DME_UNIT
• Long SAS Name: DMERC_LINE_MTUS_CNT

Contained in

The count of the total units associated with the DMERC line item service needing unit reporting, including number of services, volume of oxygen and drug dose.

DMERC Line Miles/Time/Units/Services Indicator Code

• Short SAS Name: UNIT_IND
• Long SAS Name: DMERC_LINE_MTUS_CD

Contained in

Code indicating the units associated with services needing unit reporting on the line item for the DMERC service. 

Values

Code	Code Value
0	Values reported as zero
1	(rarely used)
2	(rarely used)
3	Number of services
4	Oxygen volume units
6	Drug dosage (valid 2004 and earlier) - Since early 1994 this value has incorrectly been placed on DMERC claims. The DMERCs were overriding the MTUS indicator with a '6' if the claim was submitted with an NDC code. NOTE: This problem has been corrected - no date on when the correction became effective.

DMERC Line Pricing State Code

• Short SAS Name: PRCNG_ST
• Long SAS Name: DMERC_LINE_PRCNG_STATE_CD

Contained in

• Durable Medical Equipment RIF

Prior to Version H this field was named: CWFB_DME_PRCNG_STATE_CD.

Values

State Table.txt

DMERC Line Provider State Code

• Short SAS Name: PRVSTATE
• Long SAS Name: PRVDR_STATE_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prvstate	prvstate	prvstate	prvstate	prvstate

Dataset	2007	2006	2005	2004	2003
Carrier	prvstate	prvstate	prvstate	prvstate	prvstate

Dataset	2002	2001	2000	1999
Carrier	prvstate	prvstate	prvstate	prvstate

Contained in

• Durable Medical Equipment RIF

Effective with Version H, the two-digit numeric social security administration (SSA) state code where provider or facility is located.

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Values

State Table.txt

DMERC Line Screen Savings Amount

• Short SAS Name: SCRNSVGS
• Long SAS Name: DMERC_LINE_SCRN_SVGS_AMT

Contained in

• Durable Medical Equipment RIF

Prior to Version H this field was named: CWFB_DME_SCRN_SVGS_AMT and the field size was S9(5)V99.

Values

Code
XXX.XX

DMERC Line Supplier Provider Number

• Short SAS Name: SUPLRNUM
• Long SAS Name: PRVDR_NUM

Contained in

• Durable Medical Equipment RIF

Effective with Version 'G', billing number assigned to the supplier of the Part B service/DMEPOS by the National Supplier Clearinghouse, as reported on the line item for the DMERC claim.

Different types of identifiers may be used.Refer to the variable called DMERC_LINE_SUPPLR_TYPE_CD to determine the type used for each line.

DMERC Line Supplier Type Code

• Short SAS Name: SUP_TYPE
• Long SAS Name: DMERC_LINE_SUPPLR_TYPE_CD

Contained in

• Durable Medical Equipment RIF

Prior to Version H this field on the DMERC claim was named: CWFB_PRVDR_TYPE_CD.

Values

Code	Code Value
0	Clinics, groups, associations, partnerships, or other entities for whom the carrier's own ID number has been assigned.
1	Physicians or suppliers billing as solo practitioners for who SSN's are shown in the physician ID code field.
2	Physicians or suppliers billing as solo practitioners for who the carrier's own physician ID code is shown.
3	Suppliers (other than sole proprietorship) or whom employer identification (EI) numbers are used in coding the ID field.
4	Suppliers (other than sole proprietorship) for who the carrier's own code has been shown.
5	Institutional providers and independent laboratories for whom employer identification (EI) numbers are used in coding the ID field.
6	Institutional providers and independent laboratories for whom the carrier's own ID number is shown.
7	Clinics, groups, associations, or partnerships for whom employer identification (EI) numbers are used in coding the ID field.
8	Other entities for whom employer identification (EI) numbers are used in coding the ID field or proprietorship for whom EI numbers are used in coding the ID field.

Date of Birth from Claim (Date)

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

The beneficiary's date of birth.

Date of Death

• Short SAS Name: DEATH_DT
• Long SAS Name: DEATH_DT

Contained in

This field indicates the date of death of the enrollee according to the MAX PS, or if the person was dually enrolled in Medicare, the date of death from Medicare administrative data.

Formatted as YYYYMMDD

Demo information text

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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, 3^rd occurrence, 4^th 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 1^st 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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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.

Depression End-of-Year Flag

• Short SAS Name: DEPRESSN

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Depression Mid-Year Flag

• Short SAS Name: DEPRSSNM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Diabetes End-of-Year Flag

• Short SAS Name: DIABETES

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Diabetes Mid-Year Flag

• Short SAS Name: DIABTESM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Dialysis Beneficiary Payments

• Short SAS Name: DIALYS_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for Part B dialysis services (primarily the professional component since treatments are covered in hospital outpatient) for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Dialysis Events

• Short SAS Name: DIALYS_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for Part B dialysis services (primarily the professional component since treatments are covered in hospital outpatient) for a given year. An event is defined as each line item that contains the relevant service. Dialysis claims are a subset of the claims, and a subset of procedures in the Part B Carrier data file. Dialysis claims are defined as those with a line BETOS code (BETOS_CD) where the first 2 digits =P9.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Dialysis Medicare Payments

• Short SAS Name: DIALYS_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for Part B dialysis services (primarily the professional component since treatments are covered in hospital outpatient) for a given year.  Dialysis claims are a subset of the claims, and a subset of procedures in the Part B Carrier data file. Dialysis claims are defined as those with a line BETOS code (`BETOS_CD) where the first 2 digits =P9`.  

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Durable Medical Equipment Beneficiary Payments

• Short SAS Name: DME_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for part B durable medical equipment (DME) for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Claims for DME are a subset of the claims in the Part B Carrier and DME data files. These claims are defined as those with a line BETOS code (`BETOS_CD) where the first three digits are (D1A,D1B,D1C,D1D,D1E, orD1F`.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Durable Medical Equipment Events

• Short SAS Name: DME_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events in the part B durable medical equipment (DME) for a given year. An event is defined as each line item that contains the relevant service.

Claims for DME are a subset of the claims in the Part B Carrier and DME data files. These claims are defined as those with a line BETOS code (BETOS_CD) where the first three digits are (D1A,D1B,D1C,D1D,D1E, or D1F).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Durable Medical Equipment Medicare Payments

• Short SAS Name: DME_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for part B durable medical equipment (DME) for a given year. Claims for DME are a subset of the claims in the Part B Carrier and DME data files.

These claims are defined as those with a line BETOS code (`BETOS_CD) where the first three digits are (D1A,D1B,D1C,D1D,D1E, orD1F). The total Medicare payments are calculated as the sum ofLINE_NCH_PMT_AMTwhere theLINE_PRCSG_IND_CD` was ('A','R', or 'S') - for all relevant lines.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Master Beneficiary Summary File
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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.

End-stage Renal Disease (ESRD) Indicator

• Short SAS Name: ESRD_IND
• Long SAS Name: ESRD_IND

Contained in

• Master Beneficiary Summary File

This field specifies whether a beneficiary is entitled to Medicare benefits due to end stage renal disease (ESRD).

CMS obtains this information from the Social Security Administration (SSA) record system.

Values

Code	Code Value
Y	The beneficiary has ESRD
0	The beneficiary does not have ESRD

Endometrial Cancer End-of-Year Flag

• Short SAS Name: CNCRENDM

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for endometrial cancer as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For endometrial cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with an endometrial cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Endometrial Cancer Mid-Year Flag

• Short SAS Name: CNCENDMM

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for endometrial cancer on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For endometrial cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with an endometrial cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Enhanced Medicare 5% Sample Indicator

• Short SAS Name: EFIVEPCT
• Long SAS Name: ENHANCED_FIVE_PERCENT_FLAG

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was ever included in the CCW 5% sample for any year (1999+).

This enhanced 5% sample is broader than the annual 5% sample (variable that was previously called FIVE_PERCENT_FLAG; currently called SAMPLE_GROUP - when value =01 or 04) because it includes all beneficiaries who were ever part of the 5% sample but had a HIC change that was not part of the sample. The "enhanced" indicator variable allows for longitudinal study of the 5% sample (i.e., once in, always in). CCW creates the 5% sample using standard CMS processes. The 5% random sample consists of people who had a Medicare beneficiary Health Insurance Claim number (HIC) equal to the Claim Account Number (CAN) plus Beneficiary Identity Code (BIC) (HIC=CAN+BIC) where the last two digits of the CAN are in the set {05, 20, 45, 70, 95}.

Values

Code	Code Value
Y	Yes, included in enhanced 5% sample
nan	Not included in enhanced 5% sample

Epilepsy End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: EPILEP_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for epilepsy as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For epilepsy, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Epilepsy First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: EPILEP_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the epilepsy indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Equated BIC

• Short SAS Name: EQ_BIC

Contained in

• MedPAR RIF

The code categorizing groups of BICs representing similar relationships between the beneficiary and primary wage earner.

NOTE: The equatable BIC module electronically matches two records that contain different BICs where it is apparent both are records for the same beneficiary. It validates the BIC and returns a base BIC under which to house the record in the National Claims History (NCH) databases. (All records for a beneficiary are stored under a single BIC).

Values

Code	Code Value
nan	SSA Categories
A	A;J1;J2;J3;J4;M;M1;T;TA
B	B;B2;B6;D;D4;D6;E;E1;K1;K2;K3;K4;W;W6;TB (F);TD (F);TE (F);TW (F)
B1	B1;BR;BY;D1;D5;DC;E4;E5;W1;WR;TB (M);TD (M);TE (M);TW (M)
B3	B3;B5;B9;D2;D7;D9;E2;E3;K5;K6;K7;K8;W2;W7;TG (F);TL (F);TR (F);TX (F)
B4	B4;BT;BW;D3;DM;DP;E6;E9;W3;WT;TG (M);TL (M);TR (M);TX (M)
B8	B8;B7;BN;D8;DA;DV;E7;EB;K9;KA;KB;KC;W4;W8;TH (F);TM (F);TS (F);TY (F)
BA	BA;BK;BP;DD;DL;DW;E8;EC;KD;KE;KF;KG;W9;WC;TJ (F);TN (F);TT (F);TZ (F)
BD	BD;BL;BQ;DG;DN;DY;EA;ED;KH;KJ;KL;KM;WF;WF;TK (F);TP (F);TU (F);TV (F)
BG	BG;DH;DQ;DS;EF;EJ;W5;TH (M);TM (M);TS (M);TY (M)
BH	BH;DJ;DR;DX;EG;EK;WB;TJ (M);TN (M);TT (M);TZ (M)
BJ	BJ;DK;DT;DZ;EH;EM;WG;TK (M);TP (M);TU (M);TV (M)
C1	C1;TC
C2	C2;T2
C3	C3;T3
C4	C4;T4
C5	C5;T5
C6	C6;T6
C7	C7;T7
C8	C8;T8
C9	C9;T9
F1	F1;TF
F2	F2;TQ
F3-F8	Equatable only to itself (e.g., F3 is equatable to F3)
CA-CZ	Equatable only to itself (e.g., CA is only equatable to CA)
nan	RRB Categories
10	10
11	11
13	13;17
14	14;16
15	15
43	43
45	45
46	46
80	80
83	83
84	84;86
85	85

Evaluation and Management Beneficiary Payments

• Short SAS Name: EM_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for the part B evaluation and management (E&M) services for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

E & M claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician claims. The E & M claims are defined as those with a line BETOS code (`BETOS_CD) where the first digit ='M' (but is not M1A or M1B – which are categorized as physician office care in this file – seePHYS_MDCR_PMT`).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Evaluation and Management Events

• Short SAS Name: EM_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events for the part B evaluation and management (E&M) services for a given year. An event is defined as each line item that contains the relevant service.

E & M claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician claims. The E & M claims are defined as those with a line BETOS code (BETOS_CD) where the first digit ='M' (but is not M1A or M1B – which are categorized as physician office care in this file – see PHYS_MDCR_PMT).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Evaluation and Management Medicare Payments

• Short SAS Name: EM_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for the part B evaluation and management (E&M) services for a given year. E & M claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician claims.   The E & M claims are defined as those with a line BETOS code (`BETOS_CD) where the first digit ='M' (but is not M1A or M1B – which are categorized as physician office care in this file – seePHYS_MDCR_PMT`).

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

FI Claim Process Date

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF

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

Fibromyalgia, Chronic Pain and Fatigue End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: FIBRO_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for fibromyalgia, chronic pain and fatigue as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For fibromyalgia, chronic pain and fatigue, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Fibromyalgia, Chronic Pain and Fatigue First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: FIBRO_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the fibromyalgia, chronic pain and fatigue indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Claim Diagnosis E Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

First Occurrence of Acute Myocardial Infarction

• Short SAS Name: AMIE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Alzheimer's Disease

• Short SAS Name: ALZHE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Atrial Fibrillation

• Short SAS Name: ATRIALFE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Breast Cancer

• Short SAS Name: CNCRBRSE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Occurrence of Cataract

• Short SAS Name: CATARCTE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Chronic Kidney Disease

• Short SAS Name: CHRNKDNE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Chronic Obstructive Pulmonary Disease

• Short SAS Name: COPDE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Colorectal Cancer

• Short SAS Name: CNCRCLRE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Occurrence of Depression

• Short SAS Name: DEPRSSNE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Diabetes

• Short SAS Name: DIABTESE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Endometrial Cancer

• Short SAS Name: CNCENDME

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) endometrial cancer indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Occurrence of Glaucoma

• Short SAS Name: GLAUCMAE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Heart Failure

• Short SAS Name: CHFE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Hip/Pelvic Fracture

• Short SAS Name: HIPFRACE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Ischemic Heart Disease

• Short SAS Name: ISCHMCHE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Lung Cancer

• Short SAS Name: CNCRLNGE

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) lung cancer indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Occurrence of Osteoporosis

• Short SAS Name: OSTEOPRE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

First Occurrence of Prostate Cancer

• Short SAS Name: CNCRPRSE

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) prostate cancer indicator. The variable will be blank for beneficiaries that have never had the condition.

First Occurrence of Rheumatoid Arthritis / Osteoarthritis

• Short SAS Name: RA_OA_E

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW)rheumatoid arthritis/osteoarthritis indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

First Occurrence of Stroke / Transient Ischemic Attack

• Short SAS Name: STRKTIAE

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Gender Code from Claim

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

The sex of a beneficiary.

Values

Code	Code Value
1	Male
2	Female
0	Unknown

Glaucoma End-of-Year Flag

• Short SAS Name: GLAUCOMA

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Glaucoma Mid-Year Flag

• Short SAS Name: GLAUCMAM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

HCPCS Fourth Modifier Code

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

Contained in

• Outpatient RIF

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 Initial Modifier Code

• Short SAS Name: MDFR_CD1

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

• Skilled Nursing Facility RIF

A first modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to enable a more specific procedure identification for the revenue center or line item service for the claim.

HCPCS Second Modifier Code

• Short SAS Name: MDFR_CD2

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

• Skilled Nursing Facility RIF

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

HCPCS Third Modifier Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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.

HMO Coverage Count

• Short SAS Name: HMO_MO
• Long SAS Name: BENE_HMO_CVRAGE_TOT_MONS

Contained in

• Master Beneficiary Summary File

Total number of months of HMO coverage.

This variable counts the number of months during the year that the beneficiary received their Part A and Part B benefits through a managed care plan (i.e., a Medicare Advantage [MA] plan) instead of the traditional fee-for-service (FFS) program. Any month where the HMO indicator variable (HMOINDXX) was anything other than a 0 (not a member of an HMO) or a 4 (FFS particpant in a case or disease management demonstration project) is counted as a MA month.

HMO Indicator - April

• Short SAS Name: HMOIND04
• Long SAS Name: HMO_IND_04

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - August

• Short SAS Name: HMOIND08
• Long SAS Name: HMO_IND_08

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - December

• Short SAS Name: HMOIND12
• Long SAS Name: HMO_IND_12

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - February

• Short SAS Name: HMOIND02
• Long SAS Name: HMO_IND_02

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - January

• Short SAS Name: HMOIND01
• Long SAS Name: HMO_IND_01

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - July

• Short SAS Name: HMOIND07
• Long SAS Name: HMO_IND_07

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - June

• Short SAS Name: HMOIND06
• Long SAS Name: HMO_IND_06

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - March

• Short SAS Name: HMOIND03
• Long SAS Name: HMO_IND_03

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - May

• Short SAS Name: HMOIND05
• Long SAS Name: HMO_IND_05

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - November

• Short SAS Name: HMOIND11
• Long SAS Name: HMO_IND_11

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - October

• Short SAS Name: HMOIND10
• Long SAS Name: HMO_IND_10

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

HMO Indicator - September

• Short SAS Name: HMOIND09
• Long SAS Name: HMO_IND_09

Contained in

• Master Beneficiary Summary File

Historically, most Medicare managed care plans have been health maintenance organizations (HMOs), hence the name of the variable. This variable indicates whether the beneficiary was enrolled in a Medicare Advantage (MA) plan during a given month. The 01 through 12 at the end of the variable name correspond with the month (i.e., 01 is January and 12 is December).

Values

Code	Code Value
0	Not a member of an HMO
1	Non-lock-in, CMS to process provider claims
2	Non-lock-in, group health organization (GHO; MA plan) to process in plan Part A and in area Part B claims
4	Fee-for-service participant in case or disease management demonstration project
5	Not in documentation
A	Lock-in, CMS to process provider claims
B	Lock-in, GHO to process in plan Part A and in area Part B claims
C	Lock-in, GHO to process all provider claims

Health Care 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

• Durable Medical Equipment RIF
• Carrier RIF

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.

In the Institutional Claim Revenue Center Files, this variable can indicate the specific case-mix grouping that Medicare used to pay for skilled nursing facility (SNF), home health, or inpatient rehabilitation facility (IRF) services (see Note 2 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 non-physician services.

** Note 1: ** 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 non-physician services that are not represented in the level I codes.

Level III

Codes and descriptors developed by Medicare carriers (currently known as Medicare Administrative Contractors; MACs) for use at the local (MAC) level. These are 5-position alpha-numeric codes in the W, X, Y or Z series representing physician and non-physician services that are not represented in the level I or level II codes.

** Note 2: **

This field may contain information regarding case-mix grouping that Medicare used to pay for SNF, home health, or IRF services. These groupings are sometimes known as Health Insurance Prospective Payment System (HIPPS) codes. This field will contain a HIPPS code if the revenue center code (REV_CNTR) equals 0022 for SNF care, 0023 for home health, or 0024 for IRF care. For home health claims, please also see the revenue center APC/HIPPS code variable (`REV_CNTR_APC_HIPPS_CD`).

Heart Failure End-of-Year Flag

• Short SAS Name: CHF

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Heart Failure Mid-Year Flag

• Short SAS Name: CHFM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Hematocrit/Hemoglobin Test Results

• Short SAS Name: HCTHGBRS
• Long SAS Name: LINE_HCT_HGB_RSLT_NUM

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective September 1, 2008, with the implementation of CR#3, the number used to identify the most recent hematocrit or hemoglobin reading on the noninstitutional claim.

NOTE: The hematocrit/hemoglobin test result field is a redefined field. The field is being defined as X(3) and redefined as numeric (99V9). A numeric test on the alphanumeric field is needed. Whenever a user wants to use the field they must test the alphanumeric field for numerics and if it is numeric then the 99V9 definition would be used. The older data will cause an abend if trying to process numeric data with characters.

Hematocrit/Hemoglobin Test Type Code

• Short SAS Name: HCTHGBTP
• Long SAS Name: LINE_HCT_HGB_TYPE_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective September 1, 2008 with the implementation of CR#3, the code used to identify which reading is reflected in the hematocrit/hemoglobin result number field on the noninstitutional claim.

Values

Code	Code Value
R1	Hemoglobin Test
R2	Hematocrit Test

Hip/Pelvic Fracture End-of-Year Flag

• Short SAS Name: HIPFRAC

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Hip/Pelvic Fracture Mid-Year Flag

• Short SAS Name: HIPFRACM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Home Health Medicare Payments

• Short SAS Name: HH_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments in the home health (HH) setting for a given year.  Calculated as the sum of CLM_PMT_AMT for all HH claims where the CLM_PMT_AMT >= 0.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Home Health Visits

• Short SAS Name: HH_VISITS

Contained in

• Master Beneficiary Summary File

This variable is the count of home health (HH) visits for a given year.  The CCW variable CLM_HHA_TOT_VISIT_CNT is used to obtain this variable. 

The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year.

Hospice Covered Days

• Short SAS Name: HOS_COV_DAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of Medicare covered days in the hospice setting for a given year. This variable equals the sum of the CLM_UTLZTN_DAY_CNT variables on the source claims.

We consider fully-covered days, days where the beneficiary was liable for coinsurance, and lifetime reserve days to all be Medicare-covered days. Non-covered days, leave of absence days, and the day of discharge or death are not included.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Hospice Medicare Payments

• Short SAS Name: HOS_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments in the hospice setting for a given year.  The total Medicare payments is calculated as the sum of CLM_PMT_AMT for all hospice claims where the CLM_PMT_AMT >= 0.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Hospice Stays

• Short SAS Name: HOS_STAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of stays (unique admissions, which may span more than one facility) in the hospice setting for a given year.  A hospice stay is defined as a set of one or more consecutive hospice claims where the beneficiary is only discharged on the most recent claim in the set.

The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year.

Hospital Outpatient Beneficiary Payments

• Short SAS Name: HOP_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of Medicare coinsurance and deductible payments in the hospital outpatient setting for a given year. Calculated as the sum of DED_AMT and COIN_AMT for all HOP claims where the CLM_PMT_AMT >= 0.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a CMS publication called "Your Medicare Benefits", which explains the deductibles and coinsurance amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Hospital Outpatient Emergency Room Visits

• Short SAS Name: HOP_ER_VISITS

Contained in

• Master Beneficiary Summary File

This variable is the count of unique emergency department revenue center dates (as a proxy for an ED visit) in the hospital outpatient data file for a given year.  Revenue centers indicating Emergency Room use were (0450, 0451, 0452, 0456, or 0459). 

Note that additional ED revenue centers are found in the inpatient data files – if the ED visit resulted in an IP admission at the same facility.

There are 2 variables that contain counts of ER visits in different settings: this variable and the Inpatient ER (IP_ER_VISITS)

Hospital Outpatient Medicare Payments

• Short SAS Name: HOP_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments in the hospital outpatient setting for a given year.  Calculated as the sum of CLM_PMT_AMT for all HOP claims where the CLM_PMT_AMT >= 0.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Hospital Outpatient Visits

• Short SAS Name: HOP_VISITS

Contained in

• Master Beneficiary Summary File

This variable is the count of unique revenue center dates (as a proxy for visits) in the hospital outpatient setting for a given year. 

The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year.

ER visits in the HOP setting are counted in this variable (also see HOP_ER_VISITS).

Hospital Readmissions

• Short SAS Name: READMISSIONS

Contained in

• Master Beneficiary Summary File

This variable is the count of hospital readmissions in the acute inpatient setting for a given year.  The CLM_FROM_DT for the original admission must have been in the year of the data file, however it was permissible for the readmission claim to have occurred in January of the following year.  A beneficiary is considered to be readmitted when they have an acute inpatient stay with a discharge status that is not expired (DSCHRG_STUS≠20) or left against medical advice (DSCHRG_STUS≠07) within 30 days of a previous acute inpatient stay with a discharge status that is also not expired or left against medical advice.

All hospital stays during the year, including readmissions, are counted in the ACUTE_STAYS variable. Similarly, all acute hospital inpatient payments including payments for readmissions are included in the ACUTE_* payment variables.

Human Immunodeficiency Virus and/or Acquired Immunodeficiency Syndrome (HIV/AIDS) End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: HIVAIDS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for human immunodeficiency virus and/or acquired immunodeficiency syndrom (HIV/AIDS) as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For human immunodeficiency virus and/or acquired immunodeficiency syndrom (HIV/AIDS), beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Human Immunodeficiency Virus and/or Acquired Immunodeficiency Syndrome (HIV/AIDS) First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: HIVAIDS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the human immunodeficiency virus and/or acquired immunodeficiency syndrom (HIV/AIDS) indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Hyperlipidemia End Year Flag

• Short SAS Name: HYPERL

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for hyperlipidemia as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For hyperlipidemia, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a hyperlipidemia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Hyperlipidemia First Ever Occurrence Date

• Short SAS Name: HYPERL_EVER

Contained in

• Master Beneficiary Summary File

This code specifies the first calendar year, month, and day in which the beneficiary met the chronic condition algorithm criteria.  The earliest possible value is 1999MMDD.

Hyperlipidemia Mid Year Flag

• Short SAS Name: HYPERL_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for hyperlipidemia on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For hyperlipidemia, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a hyperlipidemia code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Hypertension End Year Flag

• Short SAS Name: HYPERT

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for hypertension (high blood pressure) as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For hypertension, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a hypertension code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Hypertension First Ever Occurrence Date

• Short SAS Name: HYPERT_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the chronic condition data warehouse (CCW) hypertension (high blood pressure) indicator. The variable will be blank for beneficiaries that have never had the condition

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Hypertension Mid Year Flag

• Short SAS Name: HYPERT_MID

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for hypertension (high blood pressure) on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For hypertension, beneficiaries must have at least one inpatient, SNF, or home health claim, or two Part B (institutional or non-institutional) claims, with a hypertension code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

ICD-10 Code

• Short SAS Name: ICD_CODE

Contained in

• Master Beneficiary Summary File

This field identifies only those codes associated with cause of death.

All ICD-10 codes begin with an alpha character followed by two or three digits. NDI results do not include decimals in the cause of death codes. The decimal is implied between the second and third digits for ICD-10 codes.

Available for 1999-2008. Researchers whishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

ICD-10 Title

• Short SAS Name: ICD_TITLE

Contained in

• Master Beneficiary Summary File

This field is the narrative description of the ICD-10 code value.

Available for 1999-2008. Researchers wishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

Imaging Beneficiary Payments

• Short SAS Name: IMG_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for imaging services (IMG) for a given year. The total beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Claims for imaging procedures are a subset of the claims, and a subset of procedures in the Part B Carrier and DME data files. These imaging claims are defined as those with a line BETOS code (`BETOS_CD) where the first digit =I (except forI1E, orI1F` – which are considered Part B drugs).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Imaging Events

• Short SAS Name: IMG_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events for imaging services (IMG) for a given year. An event is defined as each line item that contains the relevant service. Claims for imaging procedures are a subset of the claims, and a subset of procedures in the Part B Carrier and DME data files.

These imaging claims are defined as those with a line BETOS code (BETOS_CD) where the first digit =I (except for I1E, or I1F – which are considered Part B drugs).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Imaging Medicare Payments

• Short SAS Name: IMG_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for imaging services (IMG) for a given year.  Claims for imaging procedures are a subset of the claims, and a subset of procedures in the Part B Carrier and DME data files. These imaging claims are defined as those with a line BETOS code (`BETOS_CD) where the first digit =I (except forI1E, orI1F` – which are considered Part B drugs).

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Inpatient Emergency Room Visits

• Short SAS Name: IP_ER_VISITS

Contained in

• Master Beneficiary Summary File

This variable is the count of emergency department claims in the inpatient setting for a given year.  The revenue centers indicating Emergency Room use were (0450, 0451, 0452, 0456, 0459).

Note that additional ED revenue centers are found in the HOP data files – if the ED visit did not result in an IP admission at the same facility. See the variable HOP_ER_VISITS within this data file).

There are 2 variables that contain counts of ER visits in different settings: this variable and the Hospital Outpatient ER (HOP_ER_VISITS)

Intellectual Disabilities and Related Conditions End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: INTDIS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for intellectual disabilities and related conditions as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For intellectual disabilities and related conditions, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Intellectual Disabilities and Related Conditions First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: INTDIS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the intellectual disabilities and related conditions indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Ischemic Heart Disease End-of-Year Flag

• Short SAS Name: ISCHMCHT

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Ischemic Heart Disease Mid-Year Flag

• Short SAS Name: ISCHMCHM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Learning Disabilities End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: LEADIS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for learning disabilities as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For learning disabilities, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Learning Disabilities First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: LEADIS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the learning disabilities indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Leukemias and Lymphomas End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: LEUKLYMPH_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for leukemias and lymphomas as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For leukemias and lymphomas, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Leukemias and Lymphomas First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: LEUKLYMPH_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the leukemias and lymphomas indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Line Allowed Charge Amount

• Short SAS Name: LALOWCHG
• Long SAS Name: LINE_ALOWD_CHRG_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	lalowchg	lalowchg	lalowchg	lalowchg	lalowchg

Dataset	2007	2006	2005	2004	2003
Carrier	lalowchg	lalowchg	lalowchg	lalowchg	lalowchg

Dataset	2002	2001	2000	1999
Carrier	lalowchg	lalowchg	lalowchg	ballow

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The amount of allowed charges for the line item service on the noninstitutional claim. This charge is used to compute pay to providers or reimbursement to beneficiaries. **NOTE: The

Note1: The amount includes beneficiary-paid amounts (i.e., deductible and coinsurance).

Note2: The allowed charge is determined by the lower of three charges: prevailing, customary or actual.

Line Beneficiary Part B Deductible Amount

• Short SAS Name: LDEDAMT
• Long SAS Name: LINE_BENE_PTB_DDCTBL_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	ldedamt	ldedamt	ldedamt	ldedamt	ldedamt

Dataset	2007	2006	2005	2004	2003
Carrier	ldedamt	ldedamt	ldedamt	ldedamt	ldedamt

Dataset	2002	2001	2000	1999
Carrier	ldedamt	ldedamt	ldedamt	blnbded

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The amount of money for which the carrier has determined that the beneficiary is liable for the Part B cash deductible for the line item service on the noninstitutional claim.

Line Beneficiary Payment Amount

• Short SAS Name: LBENPMT
• Long SAS Name: LINE_BENE_PMT_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the payment (reim- bursement) made to the beneficiary related to the line item service on the noninstitu- tional 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.

Line Beneficiary Primary Payer Code

• Short SAS Name: LPRPAYCD
• Long SAS Name: LINE_BENE_PRMRY_PYR_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code specifying a federal non-Medicare program or other source that has primary responsibility for the payment of the Medicare beneficiary's medical bills relating to the line item service on the noninstitutional claim.

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)

Prior to 12/90

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

Line Beneficiary Primary Payer Paid Amount

• Short SAS Name: LPRPDAMT
• Long SAS Name: LINE_BENE_PRMRY_PYR_PD_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	lprpdamt	lprpdamt	lprpdamt	lprpdamt	lprpdamt

Dataset	2007	2006	2005	2004	2003
Carrier	lprpdamt	lprpdamt	lprpdamt	lprpdamt	lprpdamt

Dataset	2002	2001	2000	1999
Carrier	lprpdamt	lprpdamt	lprpdamt	PRPAYAMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges for to the line ITEM SERVICE ON THE NONINSTITUTIONAL.

Line Coinsurance Amount

• Short SAS Name: COINAMT
• Long SAS Name: LINE_COINSRNC_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	coinamt	coinamt	coinamt	coinamt	coinamt

Dataset	2007	2006	2005	2004	2003
Carrier	coinamt	coinamt	coinamt	coinamt	coinamt

Dataset	2002	2001	2000	1999
Carrier	coinamt	coinamt	coinamt	COINAMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the beneficiary coinsurance liability amount for this line item service on the noninstitutional 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.

Line DME Purchase Price Amount

• Short SAS Name: DME_PURC
• Long SAS Name: LINE_DME_PRCHS_PRICE_AMT

Contained in

• Durable Medical Equipment RIF

Effective 5/92, the amount representing the lower of fee schedule for purchase of new or used DME, or actual charge. In case of rental DME, this amount represents the purchase cap; rental payments can only be made until the cap is met. This line item field is applicable to non-institutional claims involving DME, prosthetic, orthotic and supply items, immunosuppressive drugs, pen, ESRD and oxygen items referred to as DMEPOS.

Values

Code
XXX.XX

Line Diagnosis Code

• Short SAS Name: LINE_ICD_DGNS_CD
• Long SAS Name: LINE_ICD_DGNS_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	line_icd_dgns_cd	line_icd_dgns_cd	line_icd_dgns_cd	linedgns	linedgns

Dataset	2007	2006	2005	2004	2003
Carrier	linedgns	linedgns	linedgns	linedgns	linedgns

Dataset	2002	2001	2000	1999
Carrier	linedgns	linedgns	linedgns	blndx

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code indicating the diagnosis supporting this line item procedure/service on the noninstitutional claim.

Line Diagnosis Code Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: LINE_ICD_DGNS_VRSN_CD
• Long SAS Name: LINE_ICD_DGNS_VRSN_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have been expanded to accomodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

Line First Expense Date

• Short SAS Name: EXPNSDT1
• Long SAS Name: LINE_1ST_EXPNS_DT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	expnsdt1	expnsdt1	expnsdt1	expnsdt1	expnsdt1

Dataset	2007	2006	2005	2004	2003
Carrier	expnsdt1	expnsdt1	sexpndt1	sexpndt1	sexpndt1

Dataset	2002	2001	2000	1999
Carrier	sexpndt1	expnsdt1	expnsdt1	bexpdt1

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Beginning date (1^st expense) for this line item service on the noninstitutional claim.

Line HCFA Provider Specialty Code

• Short SAS Name: HCFASPCL
• Long SAS Name: PRVDR_SPCLTY

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	hcfaspcl	hcfaspcl	hcfaspcl	hcfaspcl	hcfaspcl

Dataset	2007	2006	2005	2004	2003
Carrier	hcfaspcl	hcfaspcl	hcfaspcl	hcfaspcl	hcfaspcl

Dataset	2002	2001	2000	1999
Carrier	hcfaspcl	hcfaspcl	hcfaspcl	bspec

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

CMS specialty code used for pricing the line item service on the noninstitutional claim.

Values

HCFA Provider Specialty Table.txt

Line HCFA Type Service Code

• Short SAS Name: TYPSRVCB
• Long SAS Name: LINE_CMS_TYPE_SRVC_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	typsrvcb	typsrvcb	typsrvcb	typsrvcb	typsrvcb

Dataset	2007	2006	2005	2004	2003
Carrier	typsrvcb	typsrvcb	typsrvcb	typsrvcb	typsrvcb

Dataset	2002	2001	2000	1999
Carrier	typsrvcb	typsrvcb	typsrvcb	btos

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Code indicating the type of service, as defined in the CMS Medicare Carrier Manual, for this line item on the non-institutional claim.

Values

CMS Type of Service Table.txt

Line 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

• Durable Medical Equipment RIF
• Carrier RIF

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

Line 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

• Durable Medical Equipment RIF
• Carrier RIF

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.

Line Last Expense Date

• Short SAS Name: EXPNSDT2
• Long SAS Name: LINE_LAST_EXPNS_DT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	expnsdt2	expnsdt2	expnsdt2	expnsdt2	expnsdt2

Dataset	2007	2006	2005	2004	2003
Carrier	expnsdt2	expnsdt2	sexpndt2	sexpndt2	sexpndt2

Dataset	2002	2001	2000	1999
Carrier	sexpndt2	expnsdt2	expnsdt2	bexpdt2

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The ending date (last expense) for the line item service on the noninstitutional claim.

Line NCH BETOS Code

• Short SAS Name: BETOS
• Long SAS Name: BETOS_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	betos	betos	betos	betos	betos

Dataset	2007	2006	2005	2004	2003
Carrier	betos	betos	betos	betos	betos

Dataset	2002	2001	2000	1999
Carrier	betos	betos	betos	betos

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the Berenson-Eggers type of service (BETOS) for the procedure code based on generally agreed upon clinically meaningful groupings of procedures and services. This field is included as a line item on the noninstitutional claim.

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Derivation

Match the HCPCS on the claim to the HCPCS on the HCPCS Master File to obtain the BETOS code.

Values

BETOS Table.txt

Line NCH Payment Amount

• Short SAS Name: LINEPMT
• Long SAS Name: LINE_NCH_PMT_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	linepmt	linepmt	linepmt	linepmt	linepmt

Dataset	2007	2006	2005	2004	2003
Carrier	linepmt	linepmt	linepmt	linepmt	linepmt

Dataset	2002	2001	2000	1999
Carrier	linepmt	linepmt	linepmt	bpaymt

Contained in

Amount of payment made from the trust funds (after deductible and coinsurance amounts have been paid) for the line item service on the non- institutional claim.

Line NCH Provider State Code

• Short SAS Name: PRVSTATE
• Long SAS Name: PRVDR_STATE_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	prvstate	prvstate	prvstate	prvstate	prvstate

Dataset	2007	2006	2005	2004	2003
Carrier	prvstate	prvstate	prvstate	prvstate	prvstate

Dataset	2002	2001	2000	1999
Carrier	prvstate	prvstate	prvstate	prvstate

Contained in

• Carrier RIF

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: CARR_LINE_PRFRMG_PRVDR_ZIP_CD

DERIVATION RULES: Use the first three positions of the provider zip code to derive the LINE_NCH_PRVDR_STATE_CD from a crosswalk file. Where a match is not achieved this field will be blank.

Values

State Table.txt

Line National Drug Code

• Short SAS Name: LNNDCCD
• Long SAS Name: LINE_NDC_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective 1/1/94 on the DMERC claim, the National Drug Code identifying the oral anti-cancer drugs. Effective with Version H, this line item field was added as a placeholder on the carrier claim.

Line Other Applied Amount for 1^st Code

• Short SAS Name: LINE_OTHR_APLD_AMT1
• Long SAS Name: LINE_OTHR_APLD_AMT1

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 2^nd Code

• Short SAS Name: LINE_OTHR_APLD_AMT2
• Long SAS Name: LINE_OTHR_APLD_AMT2

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 3^rd Code

• Short SAS Name: LINE_OTHR_APLD_AMT3
• Long SAS Name: LINE_OTHR_APLD_AMT3

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 4^th Code

• Short SAS Name: LINE_OTHR_APLD_AMT4
• Long SAS Name: LINE_OTHR_APLD_AMT4

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 5^th Code

• Short SAS Name: LINE_OTHR_APLD_AMT5
• Long SAS Name: LINE_OTHR_APLD_AMT5

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 6^th Code

• Short SAS Name: LINE_OTHR_APLD_AMT6
• Long SAS Name: LINE_OTHR_APLD_AMT6

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Amount for 7^th Code

• Short SAS Name: LINE_OTHR_APLD_AMT7
• Long SAS Name: LINE_OTHR_APLD_AMT7

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The field used to identify amounts that were used to adjust the amount payable when processing the line item.

See the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field. There are up to 7 of these line applied amount fields (LINE_OTHR_APLD_AMT1 - LINE_OTHR_APLD_AMT7).

Values

Code
XXX.XX

Line Other Applied Indicator 1^st Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD1
• Long SAS Name: LINE_OTHR_APLD_IND_CD1

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 2^nd Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD2
• Long SAS Name: LINE_OTHER_APLD_IND_CD2

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 3^rd Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD3
• Long SAS Name: LINE_OTHR_APLD_IND_CD3

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 4^th Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD4
• Long SAS Name: LINE_OTHR_APLD_IND_CD4

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 5^th Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD5
• Long SAS Name: LINE_OTHR_APLD_IND_CD5

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 6^th Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD6
• Long SAS Name: LINE_OTHR_APLD_IND_CD6

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Other Applied Indicator 7^th Code

• Short SAS Name: LINE_OTHR_APLD_IND_CD7
• Long SAS Name: LINE_OTHR_APLD_IND_CD7

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code used to identify the reason the claim payment amount was adjusted during claims processing.

See the associated amounts in the LINE_OTHR_APLD_AMT{#} field. There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1 - LINE_OTHR_APLD_IND_CD7).

Values

LINE_OTHR_APLD_IND_CD_TB.txt

Line Payment 80%/100% Code

• Short SAS Name: PMTINDSW
• Long SAS Name: LINE_PMT_80_100_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code indicating that the amount shown in the payment field on the noninstitutional line item represents either 80% or 100% of the allowed charges less any deductible, or 100% limitation of liability only.

Line Place Of Service Code

• Short SAS Name: PLCSRVC
• Long SAS Name: LINE_PLACE_OF_SRVC_CD

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	plcsrvc	plcsrvc	plcsrvc	plcsrvc	plcsrvc

Dataset	2007	2006	2005	2004	2003
Carrier	plcsrvc	plcsrvc	plcsrvc	plcsrvc	plcsrvc

Dataset	2002	2001	2000	1999
Carrier	plcsrvc	plcsrvc	plcsrvc	bplacsv

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code indicating the place of service, as defined in the Medicare Carrier Manual, for this line item on the noninstitutional claim.

Values

List obtained from [here](https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html) Place of Service Table.txt

Line Place of Service (POS) Physician Zip Code

• Short SAS Name: PHYSN_ZIP_CD
• Long SAS Name: PHYSN_ZIP_CD

Contained in

• Carrier RIF

The 9-digit zip code for the primary practice/business location of the physician receiving the payment or other transfer of value.

Line Primary Payer Allowed Charge Amount

• Short SAS Name: PRPYALOW
• Long SAS Name: LINE_PRMRY_ALOWD_CHRG_AMT

Contained in

• Durable Medical Equipment RIF

Effective with Version H, the primary payer allowed charge amount for the line item service on the noninstitutional claim. 

If there is a primary payer other than Medicare, there may be an allowed payment for the provider; if so, this field is populated. 

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.

Line Processing Indicator Code

• Short SAS Name: PRCNGIND
• Long SAS Name: LINE_PRCSG_IND_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The code on a noninstitutional claim indicating to whom payment was made or if the claim was denied.

NOTE1: Effective with Version 'J', the field has been expanded on the NCH record to 2 bytes, With this expansion, the NCH will no longer use the character values to represent the official two byte values sent in by CWF since 4/2002. During the Version J conversion, all character values were converted to the two byte values.

NOTE2: Effective 4/1/02, this field was 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.

Values

Line Processing Indicator Table.txt

Line Provider Participating Indicator Code

• Short SAS Name: PRTCPTG
• Long SAS Name: PRTCPTNG_IND_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Code indicating whether or not a provider is participating or accepting assignment for this line item service on the noninstitutional claim.

Values

Code	Code Value
1	Participating
2	All or some covered and allowed expenses applied to deductible Participating
3	Assignment accepted/non-participating
4	Assignment not accepted/non-participating
5	Assignment accepted but all or some covered and allowed expenses applied to deductible Non-participating.
6	Assignment not accepted and all covered and allowed expenses applied to deductible non-participating.
7	Participating provider not accepting assignment.

Line Provider Payment Amount

• Short SAS Name: LPRVPMT
• Long SAS Name: LINE_PRVDR_PMT_AMT

Contained in

Effective with Version H, the payment made to the provider for the line item service on the noninstitutional 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.

Line Provider Tax Number

• Short SAS Name: TAX_NUM
• Long SAS Name: TAX_NUM

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	tax_num	tax_num	tax_num	tax_num	tax_num

Dataset	2007	2006	2005	2004	2003
Carrier	tax_num	tax_num	tax_num	tax_num	tax_num

Dataset	2002	2001	2000	1999
Carrier	tax_num	tax_num	tax_num	bprovid

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Social security number or employee identification number of physician/supplier used to identify to whom payment is made for the line item service on the noninstitutional claim.

Line Service Count

• Short SAS Name: SRVC_CNT
• Long SAS Name: LINE_SRVC_CNT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	srvc_cnt	srvc_cnt	srvc_cnt	srvc_cnt	srvc_cnt

Dataset	2007	2006	2005	2004	2003
Carrier	srvc_cnt	srvc_cnt	srvc_cnt	srvc_cnt	srvc_cnt

Dataset	2002	2001	2000	1999
Carrier	srvc_cnt	srvc_cnt	srvc_cnt	bsrvct

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The count of the total number of services processed for the line item on the non-institutional claim.

Line Service Deductible Indicator Switch

• Short SAS Name: DED_SW
• Long SAS Name: LINE_SERVICE_DEDUCTIBLE

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Switch indicating whether or not the line item service on the noninstitutional claim is subject to a deductible.

Values

Code	Code Value
0	SERVICE SUBJECT TO DEDUCTIBLE
1	SERVICE NOT SUBJECT TO DEDUCTIBLE

Line Submitted Charge Amount

• Short SAS Name: LSBMTCHG
• Long SAS Name: LINE_SBMTD_CHRG_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	lsbmtchg	lsbmtchg	lsbmtchg	lsbmtchg	lsbmtchg

Dataset	2007	2006	2005	2004	2003
Carrier	lsbmtchg	lsbmtchg	lsbmtchg	lsbmtchg	lsbmtchg

Dataset	2002	2001	2000	1999
Carrier	lsbmtchg	lsbmtchg	lsbmtchg	bsubchg

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

The amount of submitted charges for the line item service on the noninstitutional claim.

Line Therapy cap Indicator 1 Code

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

Contained in

• Carrier RIF

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 o

Line Therapy cap Indicator 2 Code

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

Contained in

• Carrier RIF

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 o

Line Therapy cap Indicator 3 Code

• Short SAS Name: THRPY_CAP_IND_CD3
• Long SAS Name: THRPY_CAP_IND_CD3

Contained in

• Carrier RIF

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 o

Line Therapy cap Indicator 4 Code

• Short SAS Name: THRPY_CAP_IND_CD4
• Long SAS Name: THRPY_CAP_IND_CD4

Contained in

• Carrier RIF

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 o

Line Therapy cap Indicator 5 Code

• Short SAS Name: THRPY_CAP_IND_CD5
• Long SAS Name: THRPY_CAP_IND_CD5

Contained in

• Carrier RIF

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 o

Liver Disease Cirrhosis and Other Liver Conditions (excluding Hepatitis) End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: LIVER_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for liver disease, cirrhosis and other liver conditions (excluding hepatitis) as of the end of the calendar year.

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Liver Disease, Cirrhosis and Other Liver Conditions (excluding Hepatitis) First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: LIVER_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the liver disease, cirrhosis and other liver conditions (excluding hepatitis) indicator.The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Lung Cancer End-of-Year Flag

• Short SAS Name: CNCRLUNG

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for lung cancer as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For lung cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with a lung cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Lung Cancer Mid-Year Flag

• Short SAS Name: CNCRLNGM

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for lung cancer on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For lung cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with a lung cancer code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

MEDPAR Active Cross Reference Indicator

• Short SAS Name: ACTV_XREF_IND

Contained in

• MedPAR RIF

Specifies whether the HI claim number originated from a cross-reference.

Values

Code	Code Value
X	Cross-Reference
A	Active

MEDPAR Admission Date

• Short SAS Name: ADMSNDT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	admsndt	admsndt	admsndt	admsndt	admsndt

Dataset	2008	2007	2006	2005	2004
MedPAR	admsndt	admsndt	admsndt	sadmsndt	sadmsndt

Dataset	2003	2002	2001	2000	1999
MedPAR	sadmsndt	sadmsndt	madmdte	madmdte	madmdte

Contained in

• MedPAR RIF

The date the beneficiary was admitted for Inpatient care or the date that care started.

NOTE: This field comes from the admission date that is present on the first claim record included in the stay.

MEDPAR Admission Day Code

• Short SAS Name: ADMSNDAY

Contained in

• MedPAR RIF

The code indicating the day of the week on which the beneficiary was admitted to a facility.

Derivation

This field is derived from the admission date that is present on the first claim record included in the stay.

Values

Code	Code Value
1	Sunday
2	Monday
3	Tuesday
4	Wednesday
5	Thursday
6	Friday
7	Saturday

MEDPAR Admission Death Day Count

• Short SAS Name: DEATHDAY

Contained in

• MedPAR RIF

The count of the number of days from the date the beneficiary was admitted to a facility to the beneficiary's date of death (DOD).

Derivation

This field is derived by counting the number of days between the MEDPAR admission date (the admission date present on the first claim record included in the stay) and MEDPAR beneficiary death date (the death date present on the enrollment database, which is accessed prior to creation of the quarterly MEDPAR file).

Limitation

DESCRIPTION : MEDPAR Admission Death Day Count calculated incorrectly, on both the 3/00 and 6/00 MEDPAR updates. BACKGROUND : Both the 3/00 and 6/00 MEDPAR updates incorrectly calculated the mortality days; i.e., days between the admission date and the beneficiary date of death. Users of the regular unencrypted MEDPAR file, this is not a problem, as the count can be calculated using the admission date and the date of death. The problem is with the encrypted file (the expanded modified MEDPAR) because the fields needed to calculate the mortality days are ranged. CORRECTIVE ACTION : The problem was corrected with the 12/00 MEDPAR update. NOTE: For users of the expanded modified MEDPAR file who needs the mortality days, the 12/00 update of the FY1999 file can be given as a replacement. SOURCE: CONTACT : OIS/EDG/DMUDD

MEDPAR Admitting Diagnosis Code

• Short SAS Name: AD_DGNS

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	ad_dgns	ad_dgns	ad_dgns	ad_dgns	ad_dgns

Dataset	2008	2007	2006	2005	2004
MedPAR	ad_dgns	ad_dgns	ad_dgns	ad_dgns	ad_dgns

Dataset	2003	2002	2001	2000	1999
MedPAR	ad_dgns	ad_dgns	mdiag0	mdiag0	mdiag0

Contained in

• MedPAR RIF

The ICD-9-CM code indicating the beneficiary's initial diagnosis at the time of admission.

NOTE: This field comes from the admitting diagnosis code that is present on the last claim record included in the stay.

MEDPAR Admitting Diagnosis Version Code

• Short SAS Name: ADMTG_DGNS_VRSN_CD

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have been expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

MEDPAR All Accommodations Total Charge Amount

• Short SAS Name: ACMDTNS

Contained in

• MedPAR RIF

The total charge amount (rounded to whole dollars) for all accommodations (routine hospital room and board charges for general care, coronary care and/or intensive care units) related to a beneficiary's stay.

Derivation

This field is the sum of MEDPAR private room charge amounts, MEDPAR semiprivate room charge amount, MEDPAR ward charge amount, MEDPAR intensive care charge amount, and MEDPAR coronary care charge amount (i.e., the accumulation of the revenue center total charge amount associated with revenue center codes 0100 - 0219 from all claim records included in the stay).

MEDPAR Ambulance Charge Amount

• Short SAS Name: AMBLNC

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for ambulance services related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 054x from all claim records included in the stay.

MEDPAR Anesthesia Charge Amount

• Short SAS Name: ANSTHSA

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for anesthesia services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 037X from all claim records included in the stay.

MEDPAR Base Operating DRG Amount

• Short SAS Name: BASE_OPRTG_DRG_AMT

Contained in

• MedPAR RIF

The sum of the claim base operating DRG amounts reported on the claims that comprise the stay. The base operating DRG amount used to identify the wage-adjusted DRG operating payment plus the new technology add-on payment.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the Claim Base Operating DRG amount (CLM-BASE-OPRTG-DRG-AMT) that is present on any of the claim records included in the stay (i.e. the sum of the claim base operating DRG amounts reported on the claims that comprise the stay).

MEDPAR Beneficiary Age Count

• Short SAS Name: AGE_CNT

Contained in

• MedPAR RIF

The beneficiary’s age as of date of admission.

NOTE: This field is derived by subtracting the bene date of birth from the admission date, present on the first claim record included in the stay. Exception: If the resulting age is 64, and the MSC = 10 or 11, the age is changed to 65.

MEDPAR Beneficiary Blood Deductible Liability Amount

• Short SAS Name: BLDDEDAM

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

• MedPAR RIF

The amount of money (rounded to whole dollars) identified as the beneficiary's liability for the blood deductible for the stay.

Derivation

This field is derived by accumulating the beneficiary blood deductible liability amount that is present on any of the claim records included in the stay (i.e., the sum of the blood deductibles reported on the claims that comprise the stay).

Limitation

DESCRIPTION : It was discovered that the blood deductible amounts were incorrect on the Old MEDPAR Files. BACKGROUND : Users of the MEDPAR data were comparing money amounts and counts present on the new MEDPAR file (created 6/95 using NCH Nearline File as the source) to that reported on the old MEDPAR File (created 3/95 and prior from claims from the Medicare Quality Assurance System) for Fiscal Year 1994. They discovered that the blood deductible amount on the new MEDPAR was greater than that of the old MEDPAR.

During NCH's investigation it was determined that the old 500-character MEDPAR incorrectly used a different field to report the blood deductible; specifically the noncovered charges derived from blood use Revenue Center codes 0380-0389. The new program correctly used the NCH field, BENE_BLOOD_DDCTBL_LBLTY_AMT, which is derived from a value code (CLM_VAL_AMT associated with CLM_VAL_CD = '6').

It is believed that all MEDPAR files created prior to 6/95 in the 500 character version are affected. MEDPAR 500 was first available with calendar year and fiscal year 9/91 updates for year 1987 forward.

NOTE: This anamoly also impacts the DRG Price Amount on the old MEDPAR file because it is calculated from a number of fields including the blood deductible.

MEDPAR Beneficiary Death Date

• Short SAS Name: DEATHDT

Contained in

• MedPAR RIF

The date the beneficiary died.

Derivation

This field comes from the beneficiary death date, if present on the enrollment database, which is accessed prior to creation of the quarterly MEDPAR file.

Limitation

DESCRIPTION : The Date of Death on the MEDPAR files were not up-to-date for four cycles. BACKGROUND : The MEDPAR process pulls in 10 segments of the HISKEW file, to get the date of death. The HISKEW file names were changed with no notification the change was being made. Because of this, MEDPAR kept using the HISKEW that was created in June 2000. The incomplete MEDPAR cycles are: 12/2000, 3/2001, 6/2001 and 9/2001 (9/2000 MEDPAR was not run). CORRECTIVE ACTION : Since this anamoly causes no major problem to the prime user of this data, a rerun will not take place. NOTE: The 12/01 quarterly update will access up-to-date information.

MEDPAR Beneficiary Death Date Verified Code

• Short SAS Name: DEATHCD

Contained in

• MedPAR RIF

The code indicating whether the beneficiary's date of death has been verified or originated from a claim record.

Derivation

This field is derived from the enrollment database's beneficiary source death date code, or from the presence of a claim status code = '20' (expired) on the last claim record included in the stay.

MEDPAR Beneficiary Discharge Status Code

• Short SAS Name: DSCHRGCD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	dschrgcd	dschrgcd	dschrgcd	dschrgcd	dschrgcd

Dataset	2008	2007	2006	2005	2004
MedPAR	dschrgcd	dschrgcd	dschrgcd	dschrgcd	dschrgcd

Dataset	2003	2002	2001	2000	1999
MedPAR	dschrgcd	dschrgcd	mdistat	mdistat	mdistat

Contained in

• MedPAR RIF

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

Derivation

This field is derived from the claim status code that is present on the last claim record included in the stay.

Values

Code	Code Value
A	Discharged alive (claim status code other than 20 or 30)
B	Discharged dead
C	Still a patient

MEDPAR Beneficiary Identification Code

• Short SAS Name: BIC

Contained in

• MedPAR RIF

The BIC reported on the first claim record included in the stay, representing the values existing on the CWF beneficiary master record on the date the CWF host site processed the claim.

MEDPAR Beneficiary Inpatient Deductible Liability Amount

• Short SAS Name: DED_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	mpded	mpded	mpded

Contained in

• MedPAR RIF

The amount of money (rounded to whole dollars) identified as the beneficiary's liability for the Inpatient deductible for the stay.

Derivation

This field is derived by accumulating the beneficiary Inpatient deductible amount that is present on any of the claim records included in the stay (i.e., the sum of the Inpatient deductibles reported on the claims that comprise the stay).

MEDPAR Beneficiary LRD Used Count

• Short SAS Name: LRD_USE

Contained in

• MedPAR RIF

The count of the number of lifetime reserve days (LRD) used by the beneficiary for this stay.

Derivation

This field is derived by accumulating the lifetime reserve days used count that is present on any of the claim records included in the stay (i.e., the sum of LRD reported on the claims that comprise the stay).

MEDPAR Beneficiary Mailing Contact Zip Code

• Short SAS Name: BENE_ZIP

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	bene_zip	bene_zip	bene_zip	bene_zip	bene_zip

Dataset	2008	2007	2006	2005	2004
MedPAR	bene_zip	bene_zip	bene_zip	zipcode	zipcode

Dataset	2003	2002	2001	2000	1999
MedPAR	zipcode	zipcode	mzip	mzip	mzip

Contained in

• MedPAR RIF

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

NOTE: This field comes from the zip code that is present on the first claim record included in the stay.

MEDPAR Beneficiary Medicare Benefit Exhausted Date

• Short SAS Name: EXHST_DT

Contained in

• MedPAR RIF

The last date for which the beneficiary had Medicare coverage. This field is completed only where benefits were exhausted before the discharge date and during the period covered by stay.

Derivation

This field comes from the highest benefits exhausted date that is present on the claim records included in the stay.

MEDPAR Beneficiary Medicare Status Code

• Short SAS Name: MS_CD

Contained in

• MedPAR RIF

The CWF-derived reason for a beneficiary’s entitlement to Medicare benefits, as of the reference date.

Derivation

CWF derives MSC from the following: 1. Date of birth 2. Claim through date 3. Original/Current reasons for entitlement 4. ESRD indicator 5. Beneficiary claim number Items 1,3,4,5 come from the CWF beneficiary master record; Item 2 comes from the FI/Carrier claim record. MSC is assigned as follows: MSC OASI DIB ESRD AGE BIC 10 YES N/A NO 65 AND OVER N/A 11 YES N/A YES 65 AND OVER N/A 20 NO YES NO UNDER 65 N/A 21 NO YES YES UNDER 65 N/A 31 NO NO YES ANY AGE T.

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

MEDPAR Beneficiary Part A Coinsurance Liability Amount

• Short SAS Name: COIN_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	mcoinamt	mcoinamt	mcoinamt

Contained in

• MedPAR RIF

The amount of money (rounded to whole dollars) identified as the beneficiary's liability for part A coinsurance for the stay.

Derivation

This field is derived by accumulating the beneficiary's part a coinsurance liability amount that is present on any of the claim records included in the stay (i.e., the sum of coinsurance amounts reported on the claims that comprise the stay).

MEDPAR Beneficiary Primary Payer Amount

• Short SAS Name: PRPAYAMT

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

• MedPAR RIF

The amount of payment (rounded to whole dollars) made on behalf of the beneficiary by a primary payer other than Medicare, which has been applied to the covered Medicare charges for the stay.

Derivation

This field is derived by accumulating the beneficiary primary payer payment amount that is present on any of the claim records included in the stay (i.e., the sum of the primary payer amounts reported on the claims that comprise the stay).

MEDPAR Beneficiary Primary Payer Code

• Short SAS Name: PRPAY_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

• MedPAR RIF

The code indicating the type of payer who has primary responsibility for the payment of the Medicare beneficiary's claims related to the stay.

Derivation

This field comes from the primary payer code that is present on the first claim record included in the stay.

Values

Code	Code Value
A	Working aged bene/spouse with eghp
B	ESRD bene in 18-month coordination period with eghp
C	Conditional Medicare payment; future reimbursement expected
D	Auto no-fault or any liability insurance
E	Worker's compensation
F	Phs or other federal agency (other than dept of veterans affairs)
G	Working disabled
H	Black lung
I	Dept of veterans affairs
J	Any liability insurance
Z/Blank	Medicare is primary payer

MEDPAR Beneficiary Race Code

• Short SAS Name: RACE

Contained in

• MedPAR RIF

The race of the beneficiary.

NOTE: This field comes from the race code that is present on the first claim record included in the stay.

Values

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

MEDPAR Beneficiary Residence SSA Standard County Code

• Short SAS Name: 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

• MedPAR RIF

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

NOTE: This field comes from the state code that is present on the first claim record included in the stay.

MEDPAR Beneficiary Residence SSA Standard State Code

• Short SAS Name: 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

• MedPAR RIF

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

NOTE: This field comes from the state code that is present on the first claim record included in the stay.

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	Tennesee
45	Texas
46	Utah
47	Vermont
48	Virgin Islands
49	Virginia
50	Washington
51	West Virginia
52	Wisconsin
53	Wyoming
54	Africa
55	Asia
56	Canada
57	Central America & West Indies
58	Europe
59	Mexico
60	Oceania
61	Philippines
62	South America
63	U.S. Possessions
97	Saipan - MP
98	Guam
99	American Samoa

MEDPAR Beneficiary Sex Code

• Short SAS Name: SEX

Contained in

• MedPAR RIF

The sex of a beneficiary.

NOTE: This field comes from the sex code that is present on the first claim record included in the stay.

Values

Code	Code Value
0	Unknown
2	Female
1	Male

MEDPAR Beneficiary Total Coinsurance Day Count

• Short SAS Name: COIN_DAY

Contained in

• MedPAR RIF

The count of the total number of coinsurance days involved with the beneficiary's stay in a facility. For Inpatient services, the beneficiary is liable for a daily coinsurance amount after the 60^th day and before the 91^st day in a single spell of illness; for SNF services, the beneficiary is liable for a daily coinsurance amount after the 20^th day and before the 101^st day in a single spell of illness.

Derivation

This field is derived by accumulating the coinsurance day count that is present on any of the claim records included in the stay (i.e., the sum of coinsurance days reported on the claims that comprise the stay).

MEDPAR Blood Administration Charge Amount

• Short SAS Name: BLDADMIN

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for blood storage and processing related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 039x from all claim records included in the stay.

MEDPAR Blood Charge Amount

• Short SAS Name: BLOODAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for blood provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 038x from all claim records included in the stay.

MEDPAR Blood Pints Furnished Quantity

• Short SAS Name: BLDFRNSH

Contained in

• MedPAR RIF

The quantity of blood (number of whole pints) furnished to the beneficiary during the stay.

Note: this includes blood pints replaced as well as not replaced.

Derivation

This field is derived by accumulating the blood pints furnished quantity from all claim records included in the stay.

MEDPAR Bundled Model Discount Percent

• Short SAS Name: BNDLD_MODEL_DSCNT_PCT

Contained in

• MedPAR RIF

The field used to identify the discount percentage that will be applied to the payment for all the hospitals' DRG over the lifetime of the initiative. The hospital must be participating in the Model 1 Bundled Payments for Care Improvement initiative.

Derivation

This field comes from the Claim Bundled Model Discount (CLM-BNDLD-MODEL-1-DSCNT-PCT) that is present on the last record included in the stay.

MEDPAR Cardiac Catheterization Amount

• Short SAS Name: CRDC_CATHRZTN_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the cardiac catheterization services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0481' from all claim records included in the stay.

MEDPAR Cardiology Charge Amount

• Short SAS Name: CRDLGY

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for cardiology services and electrocardiogram(s) provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 048X and 073X from all claim records included in the stay.

MEDPAR Care Improvement Model Code

• Short SAS Name: CARE_IMPRVMT_MODEL_{x}_CD

Contained in

• MedPAR RIF

The code used to identify that the care improvement model is being used for bundling payments. The valid value for care improvement model 1 is 61. The valid value for care improvement model 2 is 62. The valid value for care improvement model 3 is 63. The valid value for care improvement model 4 is 64. The value is also reflected in the demonstration trailer.

Derivation

This field comes from the Claim Care Improvement Model (CLM-CARE-IMPRVMT-MODEL-{x}-CD) code that is present on the first claim record included in the stay. If there is no Claim Care Improve Model code on the 1^st claim then take the first found code on a the other claims that make up the stay.

MEDPAR Case or Control Record

• Short SAS Name: SLCT_RSN_CD

Contained in

• MedPAR RIF

Specifies whether this record is a case or control record.

MEDPAR Claim Patient Relationship Code

• Short SAS Name: CLM_PTNT_RLTNSHP_CD

Contained in

• MedPAR RIF

The code used to identify the patient relationship to the beneficiary.

Derivation

This field comes from the patient relationship code (CLM-PTNT-RLTNSHP-CD) that is present on the first claim record included in the stay. If there is no patient relationship code on the 1^st claim then take the first found code on any of the other claims that make up the stay.

MEDPAR Claim Present on Admission Diagnosis Code Count

• Short SAS Name: POA_DGNS_CD_CNT

Contained in

• MedPAR RIF

Effective with Version 'J', the count of the number of Present on Admission (POA) codes reported on the Inpatient/SNF claim. The purpose of this count is to indicate how many claim POA diagnosis trailers are present.

MEDPAR Claim Present on Admission Diagnosis E Code Count

• Short SAS Name: POA_DGNS_E_CD_CNT

Contained in

• MedPAR RIF

Effective with Version 'J', the count of the number of Present on Admission (POA) codes associated with the diagnosis E codes reported on the Inpatient/SNF claim. The purpose of this count is to indicate how many claim POA diagnosis E trailers are present.

MEDPAR Clinic Visit Charge Amount

• Short SAS Name: CLNC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for clinic visits (e.g., visits to chronic pain or dental centers or to clinics providing psychiatric, ob-gyn, pediatric services) related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 051x from all claim records included in the stay.

MEDPAR Coronary Care Charge Amount

• Short SAS Name: CRNRYAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for coronary care accommodations related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with accommodation revenue center code 021X from all claim records included in the stay.

MEDPAR Coronary Care Day Count

• Short SAS Name: MCCCNT

Contained in

• MedPAR RIF

The count of the number of coronary care days used by the beneficiary for the stay.

Derivation

This field is derived by accumulating the revenue center unit count associated with accommodation revenue center code 021x (all six subcategories) from all claim records included in the stay.

Limitation

There is approximately a 20% error rate in the revenue center code category 0214 due to coders misunderstanding the term 'post ccu' as including any day after a ccustay rather than just days in a step-down/lower case version of a ccu. 'Post' was removed from the revenue center code 0214 description, effective 10/1/96 (12/96 MEDPAR update). 0214 Is now defined as 'intermediate ccu'.

MEDPAR Coronary Care Indicator Code

• Short SAS Name: CRNRY_CD

Contained in

• MedPAR RIF

The code indicating that the beneficiary has spent time under coronary care during the stay. It also specifies the type of coronary care unit.

Derivation

This field is derived by checking for the presence of coronary care revenue center codes (listed below) on any of the claim records included in the stay. If more than one of the revenue center codes listed below are included on these claims, the code with the highest revenue center total charge amount is used.

Limitation

There is approximately a 20% error rate in the revenue center code category 0214 due to coders misunderstanding the term 'post CCU' as including any day after a CCU stay rather than just days in a step-down/lower case version of a CCU. 'Post' was removed from the revenue center code 0214 description, effective 10/1/96 (12/96 MEDPAR update). 0214 Is now defined as 'intermediate CCU'.

Values

Code	Code Value
Blank	No coronary care indication
0	General (revenue code 0210)
1	Myocardial (revenue code 0211)
2	Pulmonary care (revenue code 0212)
3	Heart transplant (revenue code 0213)
4	Intermediate CCU (revenue code 0214)
9	Other Coronary Care (revenue code 0219)

MEDPAR Covered Level Care Thru Date

• Short SAS Name: CVRLVLDT

Contained in

• MedPAR RIF

The date on which a covered level of care ended in a SNF.

Derivation

This field comes from the date associated with occurrence code = 22 if present on any of the claims included in the stay. If multiple dates, the highest date is used. This field is only applicable to SNF claims.

MEDPAR Credit Received Replaced Device Switch

• Short SAS Name: CRED_RCVD_RPLCD_DVC_SW

Contained in

• MedPAR RIF

The switch used to identify whether the provider received a credit from the Manufacturer for a replaced medical device.

Derivation

If any claim that comprises the Stay has a value code (CLM-VAL-CD) equal to 'FD' populate the MEDPAR Credit Received from Manufacturer for Replaced Medical Device Switch with a 'Y'. If no 'FD' value code, populate field with an 'N'.

MEDPAR DME Charge Amount

• Short SAS Name: DME_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for DME (purchase of new DME and rentals) related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 0290, 0291, 0292, and 0294 - 0299 from all claim records included in the stay.

MEDPAR DRG Code

• Short SAS Name: DRG_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd

Dataset	2008	2007	2006	2005	2004
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd

Dataset	2003	2002	2001	2000	1999
Inpatient	drg_cd	drg_cd	drg_cd	drg_cd	drg_cd
MedPAR	drg_cd	drg_cd	mdrg	mdrg	mdrg

Contained in

• MedPAR RIF

The code indicating the DRG to which the claims that comprise the stay belong for payment purposes.

Derivation

This field comes from the actual DRG code that is present on the last claim record included in the stay. Exception: If the DRG code is not present (e.g., claims from Maryland and PPS-exempt hospital units do not have a DRG), a valid DRG is obtained using the grouper software and is moved to this field.

MEDPAR DRG Outlier Approved Payment Amount

• Short SAS Name: OUTLRAMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	outlramt	outlramt	outlramt	outlramt	outlramt

Dataset	2008	2007	2006	2005	2004
MedPAR	outlramt	outlramt	outlramt	outlramt	outlramt

Dataset	2003	2002	2001	2000	1999
MedPAR	outlramt	outlramt	moutamt	moutamt	moutamt

Contained in

• MedPAR RIF

The amount of additional payment (rounded to whole dollars) approved due to an outlier situation over the DRG allowance for the stay.

Derivation

This field is derived by accumulating the DRG outlier approved payment amount (value code = 17 amount) that is present on any of the claim records included in the stay (i.e., the sum of outlier amounts reported on the claims that comprise the stay).

MEDPAR DRG Price Amount

• Short SAS Name: DRGPRICE

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	drgprice	drgprice	drgprice	drgprice	drgprice

Dataset	2008	2007	2006	2005	2004
MedPAR	drgprice	drgprice	drgprice	drgprice	drgprice

Dataset	2003	2002	2001	2000	1999
MedPAR	drgprice	drgprice	mdrgpric	mdrgpric	mdrgpric

Contained in

• MedPAR RIF

The amount (called the 'DRG price' for purposes of MEDPAR analysis) that would have been paid if no deductibles, coinsurance, primary payers, or outliers were involved (rounded to whole dollars).

Derivation

This field is derived by accumulating the following amounts: MEDPAR Medicare payment amount, MEDPAR beneficiary primary payer payment amount, MEDPAR beneficiary coinsurance liability amount, MEDPAR beneficiary Inpatient deductible liability amount, MEDPAR beneficiary blood deductible amount; and then subtracting from the sum the MEDPAR DRG outlier approved payment amount.

Limitation

DESCRIPTION : IT WAS DISCOVERED THAT THE DRG PRICE AMOUNT WSA INCORRECT ON THE OLD MEDPAR FILES. BACKGROUND : Users of the MEDPAR data were comparing money amounts and counts present on the new MEDPAR file (created 6/95 using NCH Nearline File as the source) to that reported on the old MEDPAR File (created 3/95 and prior from claims from the Medicare Quality Assurance System) for Fiscal Year 1994. They discovered that the DRG price amount on the new MEDPAR contained incorrect amounts.

NOTE: This anamoly occurs because the DRG price amount is calculated from a number of fields including the blood deductible amount, which was discovered to be populated incorrectly.

During NCH's investigation it was determined that the old 500-character MEDPAR incorrectly used a different field to report the blood deductible; specifically the noncovered charges derived from blood use Revenue Center codes 0380-0389. The new program correctly used the NCH field, BENE_BLOOD_DDCTBL_LBLTY_AMT, which is derived from a value code (CLM_VAL_AMT associated with CLM_VAL_CD = '6').

It is believed that all MEDPAR files created prior to 6/95 in the 500 character version were affected. MEDPAR 500 was first available with calendar year and fiscal year 9/91 updates for year 1987 forward.

MEDPAR DRG/Outlier Stay Code

• Short SAS Name: OUTLR_CD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	outlr_cd	outlr_cd	outlr_cd	outlr_cd	outlr_cd

Dataset	2008	2007	2006	2005	2004
MedPAR	outlr_cd	outlr_cd	outlr_cd	outlr_cd	outlr_cd

Dataset	2003	2002	2001	2000	1999
MedPAR	outlr_cd	outlr_cd	moutlier	moutlier	moutlier

Contained in

• MedPAR RIF

The code identifying (1) for PPS providers if the stay has an unusually long length (day outlier) or high cost (cost outlier); or (2) for non-PPS providers the source for developing the DRG.

Derivation

This field is the actual DRG outlier stay code that is present on the last claim record included in the stay.

Values

Applicable to PPS providers:

Code	Code Value
0	No Outlier
1	Day Outlier
2	Cost Outlier

Applicable to Non-PPS Providers:

Code	Code Value
6	Valid DRG Received From Intermediary
7	HCFA-Developed DRG
8	HCFA-Developed DRG Using Claim Status Code
9	Not Groupable

MEDPAR Departmental Total Charge Amount

• Short SAS Name: DPRTMNTL

Contained in

• MedPAR RIF

The total charge amount (rounded to whole dollars) for all ancillary departments (other than routine room and board, CCU, and ICU) related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 0220 - 0999 from all claim records included in the stay (i.e., the sum of charges for all revenue centers other than accommodations 0100 - 0219).

MEDPAR Diagnosis Code

• Short SAS Name: DGNSCD{x}

Contained in

• MedPAR RIF

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).

Derivation

This field is the actual principal diagnosis code (1^st occurrence) or one of up to 9 other diagnosis codes that are present on the last claim record included in the stay.

MEDPAR Diagnosis Code Count

• Short SAS Name: DGNSCNT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	dgnscnt	dgnscnt	dgnscnt	dgnscnt	dgnscnt

Dataset	2008	2007	2006	2005	2004
MedPAR	dgnscnt	dgnscnt	dgnscnt	dgnscnt	dgnscnt

Dataset	2003	2002	2001	2000	1999
MedPAR	dgnscnt	dgnscnt	mdiagnum	mdiagnum	mdiagnum

Contained in

• MedPAR RIF

The count of the number of diagnosis codes included in the stay.

Derivation

This field is derived by adding '1' to the count of the other diagnosis codes reported on the last claim record included in the stay. The '1' represents the principal diagnosis code, which is reported separately from the other diagnosis.

MEDPAR Diagnosis Code POA Array

• Short SAS Name: DGNS_POA

Contained in

• MedPAR RIF

Diagnosis code POA array.

Derivation

This field is the actual principal diagnosis code (1^st occurrence) or one of up to 9 other diagnosis codes that are present on the last claim record included in the stay.

MEDPAR Diagnosis E Code Count

• Short SAS Name: DGNS_E_CD_CNT

Contained in

• MedPAR RIF

Effective with Version 'J', the count of the number of diagnosis E codes reported on the Inpatient/SNF claim. The purpose of this count is to indicate how many diagnosis E trailers are present.

MEDPAR Diagnosis E Code Present on Admission Indicator

• Short SAS Name: POA_DGNS_E_{x}_IND_CD

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to identify the Present on Admission (POA) indicator code associated with the diagnosis E codes.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).
Blank	Identifies diagnosis codes that are exempt from the POA reporting requirements (replaces the '1'). NOTE: NCH/NMUD will carry a '0' in place of a blank.

MEDPAR Diagnosis E Version Code

• Short SAS Name: DGNS_E_VRSN_CD_{x}

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

MEDPAR Diagnosis Present on Admission Indicator Code

• Short SAS Name: POA_DGNS_{x}_IND_CD

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to identify the Present on Admission (POA) indicator code associated with the diagnosis codes (principal and secondary). The present on admission indicators for the diagnosis E codes are stored in the present on admission diagnosis E trailer.

Values

Code	Code Value
Y	Diagnosis was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'Y' for the POA Indicator.
N	Diagnosis was not present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'N' for the POA Indicator.
U	Documentation is insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as 'U' for the POA Indicator.
W	Clinically undetermined. Provider is unable to clinically determine whether condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as 'W' for the POA Indicator.
1	Unreported/not used -- exempt from POA reporting -- This code is equivalent to a blank pn the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as '1' for the POA Indicator. The '1' POA Indicator should not be applied to any codes on the HAC list.
Z	Denotes the end of the POA indicators (terminated 1/2011).
X	Denotes the end of the POA indicators in special data processing situations that may be identified by CMS in the future (terminated 1/2011).
Blank	Identifies diagnosis codes that are exempt from the POA reporting requirements (replaces the '1'). NOTE: NCH/NMUD will carry a '0' in place of a blank.

MEDPAR Diagnosis Version Code

• Short SAS Name: DGNS_VRSN_CD_{x}

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10.

MEDPAR Discharge Date

• Short SAS Name: DSCHRGDT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	dschrgdt	dschrgdt	dschrgdt	dschrgdt	dschrgdt

Dataset	2008	2007	2006	2005	2004
MedPAR	dschrgdt	dschrgdt	dschrgdt	sdschrgdt	sdschrgdt

Dataset	2003	2002	2001	2000	1999
MedPAR	sdschrgdt	sdschrgdt	mdisdte	mdisdte	mdisdte

Contained in

• MedPAR RIF

The date on which the beneficiary was discharged or died.

NOTE: This field comes from the highest claim thru date that is present on the claim records included in the stay, where the claim status code is other than 30 (still patient)on the last claim record included in the stay. Inpatient claims will always have a discharge date; SNF claims could have a zero date.

MEDPAR Discharge Destination Code

• Short SAS Name: DSTNTNCD

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	dstntncd	dstntncd	dstntncd	dstntncd	dstntncd

Dataset	2008	2007	2006	2005	2004
MedPAR	dstntncd	dstntncd	dstntncd	dstntncd	dstntncd

Dataset	2003	2002	2001	2000	1999
MedPAR	dstntncd	dstntncd	mdisdest	mdisdest	mdisdest

Contained in

• MedPAR RIF

The code primarily indicating the destination of the beneficiary upon discharge from a facility; also denotes death or SNF/still patient situations.

Derivation

This field comes from the claim status code that is present on the last claim record included in the stay.

Values

Code	Code Value
70	Discharged/transferred to another type of health care institution not defined elsewhere in code list

MEDPAR ESRD Condition Code

• Short SAS Name: ESRD_CD

Contained in

• MedPAR RIF

The code indicating if the beneficiary had an ESRD condition reported during the stay.

Derivation

This field is derived by checking for condition codes 70 - 76 on any of the claim records included in the stay.

MEDPAR ESRD Revenue Setting Charge Amount

• Short SAS Name: ESRDSETG

Contained in

• MedPAR RIF

The code indicating the type of dialysis received by the beneficiary during the stay. Up to 5 2-position codes may be present.

Derivation

This field is derived from the presence of the dialysis revenue center codes listed below on any of the claim records included in the stay.

MEDPAR ESRD Setting Indicator Code

• Short SAS Name: ESRDSTG{x}

Contained in

• MedPAR RIF

The code indicating the type of dialysis received by the beneficiary during the stay. Up to 5 2-position codes may be present.

Derivation

This field is derived from the presence of the dialysis revenue center codes listed below on any of the claim records included in the stay.

Values

Medpar_ESRD_SETG_IND_TB.txt

MEDPAR Emergency Room Charge Amount

• Short SAS Name: ER_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	er_amt	er_amt	er_amt	er_amt	er_amt

Dataset	2008	2007	2006	2005	2004
MedPAR	er_amt	er_amt	er_amt	er_amt	er_amt

Dataset	2003	2002	2001	2000	1999
MedPAR	er_amt	er_amt	merchg	merchg	merchg

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for emergency room services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 045X from all claim records included in the stay.

MEDPAR Fiscal Intermediary/Carrier Identification Number

• Short SAS Name: FICARR

Contained in

• MedPAR RIF

The identification of the intermediary processing the beneficiary's claims related to the stay.

NOTE: This field comes from the intermediary number that is present on the first claim record included in the stay.

MEDPAR GHO Paid Code

• Short SAS Name: GHOPDCD

Contained in

• MedPAR RIF

The code indicating whether or not a GHO has paid the provider for the claim(s).

NOTE: This field comes from the GHO-paid indicator that is present on the first claim record included in the stay.

Values

Code	Code Value
1	GHO has paid the provider
0 or Blank	GHO has not paid the provider

MEDPAR HRR Adjustment Percent

• Short SAS Name: HRR_ADJSTMT_PCT

Contained in

• MedPAR RIF

Under the Hospital Readmission Reduction (HRR) Program, the percent used to identify the readmission adjustment factor that will be applied in determining a subsection (d) hospital's operating IPPS payment amount in accordance with Section 3025 of the Affordable Care Act (ACA).

Derivation

This field comes from the Claim HRR Adjustment Percent (CLM-HRR-ADJSTMT-PCT) that is present on the last claim record included in the stay.

MEDPAR HRR Participant Indicator Code

• Short SAS Name: HRR_PRTCPNT_IND_CD

Contained in

• MedPAR RIF

The code used to identify whether the facility is participating in the Hospital Readmission Reduction Program.

Derivation

This field comes from the Claim HRR Participant Indicator code (CLM-HRR-PRTCPNT-IND-CD) that is present on the first claim record included in the stay. If there is no Claim HRR Participant Indicator code on the first claim then take the first found code on any of the other claims that make up the stay.

MEDPAR Incident to Other Diagnostic Services Amount

• Short SAS Name: INCDNT_DGNSTC_SRVCS_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical supplies incident to other diagnostic services related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0622' from all claim records included in the stay.

MEDPAR Incident to Radiology Amount

• Short SAS Name: INCDNT_RDLGY_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical supplies incident to radiology related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0621' from all claim records included in the stay.

MEDPAR Indirect Medical Education (IME) Amount

• Short SAS Name: IME_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	ime_amt	ime_amt	ime_amt	ime_amt	ime_amt

Dataset	2008	2007	2006	2005	2004
MedPAR	ime_amt	ime_amt	ime_amt	ime_amt	ime_amt

Dataset	2003	2002	2001	2000	1999
MedPAR	ime_amt	ime_amt	mtotime	mtotime	mtotime

Contained in

• MedPAR RIF

The amount of additional payment (rounded to whole dollars) made to teaching hospitals for IME for the stay.

Derivation

This field is derived by accumulating the value amount associated with value code = 19 that is present on any of the claim records included in the stay (i.e., the sum of IME amounts - value code 19 amounts - reported on the claims that comprise the stay).

MEDPAR Informational Encounter Indicator Switch

• Short SAS Name: INFRMTL_ENCTR_IND_SW

Contained in

• MedPAR RIF

The switch used to identify if a beneficiary is enrolled in a Managed Care Organization.

Derivation

If any claim that comprises the Stay has a condition code (CLM RLT COND CD) equal to '04' populate the MEDPAR Informational Encounter Switch with a 'Y'. If no '04' condition code, populate field with an 'N'.

MEDPAR Inhalation Therapy Charge Amount

• Short SAS Name: INHLTAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for inhalation therapy services (respiratory and pulmonary function) provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 041x and 046x from all claim records included in the stay.

MEDPAR Inpatient Admission Type Code

• Short SAS Name: TYPE_ADM

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	type_adm	type_adm	type_adm	type_adm	type_adm

Dataset	2008	2007	2006	2005	2004
MedPAR	type_adm	type_adm	type_adm	type_adm	type_adm

Dataset	2003	2002	2001	2000	1999
MedPAR	type_adm	type_adm	madmtype	madmtype	madmtype

Contained in

• MedPAR RIF

The code indicating the type and priority of the beneficiary's admission to a facility for the Inpatient hospital stay.

Derivation

This field comes from the Inpatient admission type code that is present on the last claim record included in the stay.

Values

Code	Code Value
0	Blank
1	Emergency - The patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.
2	Urgent - The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available and suitable accommodation.
3	Elective - The patient's condition permitted adequate time to schedule the availability of suitable accommodations.
4	Newborn - Necessitates the use of special source of admission codes.
5	Trauma Center - visits to a trauma center/hospital as licensed or designated by the State or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation.
6 THRU 8	Reserved
9	Unknown - Information not available.

MEDPAR Inpatient Disproportionate Share Amount

• Short SAS Name: DISP_SHR

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	disp_shr	disp_shr	disp_shr	disp_shr	disp_shr

Dataset	2008	2007	2006	2005	2004
MedPAR	disp_shr	disp_shr	disp_shr	disp_shr	disp_shr

Dataset	2003	2002	2001	2000	1999
MedPAR	disp_shr	disp_shr	mdprpamt	mdprpamt	mdprpamt

Contained in

• MedPAR RIF

The amount paid over the DRG amount (rounded to whole dollars) for the disproportionate share hospital for the stay.

Derivation

This field is derived by accumulating the value amount associated with value code = 18 that is present on any of the claim records included in the stay (i.e., the sum of value code 18 amounts reported on the claims that comprise the stay).

MEDPAR Inpatient Low Volume Payment Amount

• Short SAS Name: IP_LOW_VOL_PYMT_AMT

Contained in

• MedPAR RIF

The amount field used to identify a payment adjustment given to hospitals to account for the higher costs per discharge for low income hospitals under the Inpatient Prospective Payment System (IPPS).

Derivation

This field is derived by accumulating the IP Low Volume Amount that is present on any of the claim records included in the stay (i.e. the sum of the low volume amounts re-ported on the claims that comprise the stay).

MEDPAR Intensive Care Charge Amount

• Short SAS Name: ICAREAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for intensive care accommodations related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with accommodation revenue center code 020x from all claim records included in the stay.

MEDPAR Intensive Care Day Count

• Short SAS Name: ICARECNT

Contained in

• MedPAR RIF

The count of the number of intensive care days used by the beneficiary for the stay.

Derivation

This field is derived by accumulating the revenue center unit count associated with accommodation revenue center codes 020X (all 9 subcategories) from all claims included in the stay.

Limitation

There is approximately a 20% error rate in the revenue center code category 0206 due to coders misunderstanding the term 'post ICU' as including any day after an ICU stay rather than just days in a step-down/lower case version of an ICU. 'Post' was removed from the revenue center code 0206 description, effective 10/1/96 (12/96 MEDPAR update). 0206 Is now defined as 'intermediate ICU'.

MEDPAR Intensive Care Unit (ICU) Indicator Code

• Short SAS Name: ICUINDCD

Contained in

• MedPAR RIF

The code indicating that the beneficiary has spent time under intensive care during the stay. It also specifies the type of ICU.

Derivation

This field is derived by checking for the presence of icu revenue center codes (listed below) on any of the claim records included in the stay. If more than one of the revenue center codes listed below are included on these claims, the code with the highest revenue center total charge amount is used.

Limitation

There is approximately a 20% error rate in the revenue center code category 0206 due to coders misunderstanding the term 'post ICU' as including any day after an ICU stay rather than just days in a step-down/lower case version of an ICU. 'Post' was removed from the revenue center code 0206 description, effective 10/1/96 (12/96 MEDPAR update). 0206 Is now defined as 'intermediate ICU'.

Values

Code	Code Value
0	General (revenue center 0200)
1	Surgical (revenue center 0201)
2	Medical (revenue center 0202)
3	Pediatric (revenue center 0203)
4	Psychiatric (revenue center 0204)
6	Intermediate IOU; (revenue center 0209) prior to 12/96 update was 'post ICU'
7	Burn care (revenue center 0207)
8	Trauma (revenue center 0208)
9	Other intensive care (revenue code 0209)

MEDPAR Internal Use (By IPSB) Code

• Short SAS Name: IPSBCD

Contained in

• MedPAR RIF

Limited availability; for internal use only. Where not available, this field will contain zeroes.

MEDPAR Internal Use File Date Code

• Short SAS Name: FILDTCD

Contained in

• MedPAR RIF

Limited availability; for internal use only to to identify fiscal year/calendar year segments. Where not available, this field will contain a zero.

MEDPAR Internal Use SSI Data

• Short SAS Name: INTRNL_USE_SSI_DATA

Contained in

• MedPAR RIF

Internal use SSI data.

MEDPAR Internal Use SSI Day Count

• Short SAS Name: SSIDAY

Contained in

• MedPAR RIF

Internal use SSI Day count.

MEDPAR Internal Use SSI Indicator Code

• Short SAS Name: SSICD

Contained in

• MedPAR RIF

Internal use SSI Indicator code.

MEDPAR Internal Use Sample Size Code

• Short SAS Name: SMPLSIZE

Contained in

• MedPAR RIF

Limited availability; for internal use only to identify the MEDPAR sample size: 20% (HIC 9^th digit = 0, 5); 20% (HIC 9^th digit = 4, 8; 60% (remainder). Where not available, this field will contain a zero.

MEDPAR Intraocular Lens Amount

• Short SAS Name: INTRAOCULAR_LENS_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical intraocular lens supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0276' from all claim records included in the stay.

MEDPAR Investigational Device Amount

• Short SAS Name: INVSTGTNL_DVC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical investigational devices supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0624' from all claim records included in the stay.

MEDPAR Laboratory Charge Amount

• Short SAS Name: LAB_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for laboratory costs related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 030x, 031x, 074x, and 075x from all claim records included in the stay.

MEDPAR Latest Claim Accretion Date

• Short SAS Name: ACRTNDT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	acrtndt	acrtndt	acrtndt	acrtndt	acrtndt

Dataset	2008	2007	2006	2005	2004
MedPAR	acrtndt	acrtndt	acrtndt	sacrtndt	sacrtndt

Dataset	2003	2002	2001	2000	1999
MedPAR	sacrtndt	sacrtndt	maccrdte	maccrdte	maccrdte

Contained in

• MedPAR RIF

The date the latest claim record included in the stay was accreted (posted/processed) to the beneficiary master record at the CWF host.

Derivation

This field comes from the highest accretion date that is present on the claim records included in the stay.

MEDPAR Length of Stay Day Count

• Short SAS Name: LOSCNT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	loscnt	loscnt	loscnt	loscnt	loscnt

Dataset	2008	2007	2006	2005	2004
MedPAR	loscnt	loscnt	loscnt	loscnt	loscnt

Dataset	2003	2002	2001	2000	1999
MedPAR	loscnt	loscnt	mlos	mlos	mlos

Contained in

• MedPAR RIF

The count in days of the total length of a beneficiary's stay in a hospital or SNF.

Derivation

This field is derived by subtracting the date of discharge (or thru date in SNF cases where beneficiary is still a patient) from the date of admission. If difference is '0,' the value becomes a '1.'

MEDPAR Lithotripsy Charge Amount

• Short SAS Name: LTHTRPSY

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for lithotripsy services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 079X from all claim records included in the stay.

MEDPAR MA Teaching Indicator Switch

• Short SAS Name: MA_TCHING_IND_SW

Contained in

• MedPAR RIF

The code used to identify whether the claim contains any request for supplemental IME/DGME/N&AH payment.

Derivation

If any claim that comprises the Stay has a condition code (CLM-RLT-COND-CD) equal to '69' populate the MEDPAR MA Teaching Indicator Switch with a 'Y'. If no '69' condition code, populate field with an 'N'.

MEDPAR MRI Charge Amount

• Short SAS Name: MRI_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for MRI services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center 061x from all claim records included in the stay.

MEDPAR Medical Surgical Dressing Amount

• Short SAS Name: MDCL_SRGCL_DRSNG_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical dressing supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV CNTR CD) '0623' from all claim records included in the stay.

MEDPAR Medical Surgical General Amount

• Short SAS Name: MDCL_SRGCL_GNRL_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical general supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV CNTR CD) '0270' from all claim records included in the stay.

MEDPAR Medical Surgical Miscellaneous Amount

• Short SAS Name: MDCL_SRGCL_MISC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical miscellaneous supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0620', '0625', '0626', '0627', '0628' & '0629' from all claim records included in the stay.

MEDPAR Medical Surgical Non-Sterile Supplies Amount

• Short SAS Name: MDCL_SRGCL_NSTRL_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical nonsterile supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0271' from all claim records included in the stay.

MEDPAR Medical Surgical Pacemaker Amount

• Short SAS Name: MDCL_SRGCL_PCMKR_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical pacemaker supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0275' from all claim records included in the stay.

MEDPAR Medical Surgical Sterile Supplies Amount

• Short SAS Name: MDCL_SRGCL_STRL_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical sterile supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRGAMT) associated with revenue center code (REV-CNTRCD) '0272' from all claim records included in the stay.

MEDPAR Medical/Surgical Supplies Charge Amount

• Short SAS Name: SUPLYAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for medical/surgical supplies related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 027x and 062x from all claim records included in the stay.

MEDPAR Medicare Payment Amount

• Short SAS Name: PMT_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt
MedPAR	pmt_amt	pmt_amt	mintreim	mintreim	mintreim
Outpatient	pmt_amt	pmt_amt	pmt_amt	pmt_amt	pmt_amt

Contained in

• MedPAR RIF

Amount of payment made from the Medicare trust fund for the services covered by the claim record. Generally, the amount is calculated by the fi; and represents what was paid to the institutional provider, with the exceptions noted below.

NOTE: In some situations, a negative claim payment amount may be present; e.g., (1) when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or (2) when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.)

Under IP PPS, Inpatient hospital services are paid based on a predetermined rate per discharge, using the DRG patient classification system and the pricer program. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (since 05/1/86), in- direct medical education (since 10/1/88), total PPS capital (since 10/1/91). It does not include the pass thru amounts (i.e., capital-related costs, direct medical education costs, kidney acquisition costs, bad debts); or any beneficiary-paid amounts (i.e., deductibles and coinsurance); or any other payer reimbursement.

Under SNF PPS, SNFs will classify beneficiaries using the patient classification system known as rugs III. For the SNF PPS claim, the SNF pricer will calculate/return the rate for each revenue center line item with revenue center code = 0022; multiply the rate times the units count; and then sum the amount payable for all lines with revenue center code 0022 to determine the total claim payment amount.

Exceptions: For claims involving demos and BBA encounter data, the amount reported in this field May not just represent the actual provider payment.

For demo ids 01,02,03,04 -- claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included.

For demo ids 05,15 -- encounter data 'claims'contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO.

For demo ids 06,07,08 -- claims contain actual provider payment but represent a special negotiated bundled payment for both part a and part B services. To identify what the conventional provider part a payment would have been, check value code = y4.

For BBA encounter data (non-demo) -- 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan.

Derivation

This field is derived by accumulating the payment amount that is present on all of the claim records included in the stay (i.e, the sum of payment (reimbursement) reported on the claims that comprise the stay).

MEDPAR NCH Claim Type Code

• Short SAS Name: CLM_TYPE

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

• MedPAR RIF

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

Values

In the data element NCH_CLM_TYPE_CD (derivation rules) the numbers for these claim types need to be changed - dictionary reflects 61 for all three.

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

MEDPAR New Technology Add On Amount

• Short SAS Name: NEW_TCHNLGY_ADD_ON_AMT

Contained in

• MedPAR RIF

The amount of payments made for discharges involving approved new technologies. If the total covered costs of the discharge exceeds the DRG payment for the case (including adjustments for IME and disproportionate share hospitals (DSH) but excluding outlier payments) an add-on amount is made indicating a new technology was used in the treatment of the beneficiary.

Derivation

This field is derived by accumulating the amount field (CLM-VAL-AMT) found in the value code trailer for value code (CLM-VAL-CD) equal to '77' for any claim records included in the stay.

MEDPAR Observation Switch

• Short SAS Name: OBSRVTN_SW

Contained in

• MedPAR RIF

The switch used to identify whether the claim involves treatment or observation in an observation room.

Derivation

If any claim that comprises the Stay has a revenue center code (REV-CNTR-CD) equal to '0762' populate the MEDPAR Observation Switch with a 'Y'. If no '0762' revenue center code populate field with an 'N'.

MEDPAR Occupational Therapy Charge Amount

• Short SAS Name: OCPTLAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for occupational therapy services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 043x from all claims records included in the stay.

MEDPAR Operating Hospital Amount

• Short SAS Name: OPRTG_HSP_AMT

Contained in

• MedPAR RIF

The sum of the claim operating HSP amounts reported on the claims that comprise the stay. The operating HSP amount is used to identify the difference between the HSP rate payment (updated HSP x DRG weight) and the federal rate payment (includes DSH, IME, outliers, etc. as applicable) when HSP rate payment exceeds Federal rate payment (otherwise $0).

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9).

Derivation

This field is derived by accumulating the Claim Operating HSP Amount (CLM_OPRTG_HSP_AMT) that is present on any of the claim records included in the stay (i.e. the sum of the claim operating HSP amounts reported on the claims that comprise the stay).

MEDPAR Operating Room Amount

• Short SAS Name: OPRTG_ROOM_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the operating room services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0360', '0361', '0362', '0363', '0364', '0365', '0366', '0367', '0368', '0369', '0710', '0711', '0712', '0713', '0714', '0715', '0717', '0718' & '0719' from all claim records included in the stay.

MEDPAR Operating Room Charge Amount

• Short SAS Name: OROOMAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the operating room, recovery room, and labor room delivery used by the beneficiary during the stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 036X, 071X, and 072X from all claim records included in the stay.

MEDPAR Operating Room Labor and Delivery Amount

• Short SAS Name: OR_LABOR_DLVRY_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the labor room/delivery services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0720', '0721', '0722', '0723', '0724', '0725', '0726', '0727', '0728' & '0729' from all claim records included in the stay.

MEDPAR Organ Acquisition Charge Amount

• Short SAS Name: ORGNAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for organ acquisition or other donor bank services related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 081x and 089x from all claim records included in the stay.

MEDPAR Organ Acquisition Indicator Code

• Short SAS Name: ORGNCD

Contained in

• MedPAR RIF

The code indicating the type of organ acquisition received by the beneficiary during the stay.

Derivation

This field is derived by checking for the presence of the organ acquisition indicator revenue center codes listed below on any of the claim records included in the stay.

Values

Code	Code Value
K1	General classification (revenue code 0810)
K2	Living donor kidney (revenue code 0811)
K3	Cadaver donor kidney (revenue code 0812)
K4	Unknown donor kidney (revenue code 0813)
K5	Other kidney acquisition (revenue code 0814)
H1	Cadaver donor heart (revenue code 0815)
H2	Other heart acquisition (revenue code 0816)
L1	Donor liver (revenue code 0817)
01	Other organ acquisition (revenue code 0819)
02	General acquisition (revenue code 0890)
B1	Bone donor bank (revenue code 0891)
03	Organ donor bank other than kidney (revenue code 0892)
S1	Skin donor bank (revenue code 0893)
04	Other donor bank (revenue code 0899)
BLANK	No organ acquisition indication

MEDPAR Other Implants Amount

• Short SAS Name: OTHR_IMPLANTS_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical other implant supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0278' from all claim records included in the stay.

MEDPAR Other Service Charge Amount

• Short SAS Name: OTHRAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for other services (revenue centers that do not fit into other categories) related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with the 'other' revenue center codes from all claim records included in the stay. The 'other' codes include 0002-0099, 022x, 023x, 024x, 052x, 053x, 055x - 060x, 064x - 070x, 076x - 078x, 090x - 095x, and 099x. (Some of these codes are not yet assigned.)

MEDPAR Other Supplies Device Amount

• Short SAS Name: OTHR_SUPLIES_DVC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical other devices supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0279' from all claim records included in the stay.

MEDPAR Outlier Day Count

• Short SAS Name: OUTLRDAY

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	outlrday	outlrday	outlrday	outlrday	outlrday

Dataset	2008	2007	2006	2005	2004
MedPAR	outlrday	outlrday	outlrday	outlrday	outlrday

Dataset	2003	2002	2001	2000	1999
MedPAR	outlrday	outlrday	moutdys2	moutdys2	moutdys2

Contained in

• MedPAR RIF

The count of the number of days paid as outliers (either a day or cost outlier) under PPS beyond the DRG threshold.

Derivation

This field is derived by checking the MEDPAR utilization day count against the DRG threshold table (DRG weightsfile).

MEDPAR Outpatient Service Charge Amount

• Short SAS Name: OPSRVC

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for outpatient services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 049x and 050x from all claim records included in the stay.

MEDPAR Outpatient Services Indicator Code

• Short SAS Name: OPSRVCCD

Contained in

• MedPAR RIF

The code indicating whether or not the beneficiary has received outpatient services, ambulatory surgical care, or both.

Derivation

This field is derived by checking for the presence of the outpatient services revenue center codes listed below on any of the claim records included in the stay.

Values

Code	Code Value
0	No outpatient services/ambulatory surgical care (revenue code other than 049X, 050X)
1	Outpatient services (revenue code 050X)
2	Ambulatory surgical care (revenue code 049X)
3	Outpatient services and ambulatory surgical care (revenue codes 049X and 050X)

MEDPAR Oxygen Take Home Amount

• Short SAS Name: OXYGN_TAKE_HOME_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical oxygen take home supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0277' from all claim records included in the stay.

MEDPAR PPS Indicator Code

• Short SAS Name: PPS_IND

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	pps_ind	pps_ind	pps_ind	pps_ind	pps_ind

Dataset	2008	2007	2006	2005	2004
MedPAR	pps_ind	pps_ind	pps_ind	pps_ind	pps_ind

Dataset	2003	2002	2001	2000	1999
MedPAR	pps_ind	pps_ind	mpps	mpps	mpps

Contained in

• MedPAR RIF

The code indicating whether or not the facility is being paid under the prospective payment system (PPS).

Derivation

If the condition code not equal 65 on all of the claims included in the stay and the third position of the provider number is numeric set MEDPAR_PPS_IND_CD to 2 (PPS). Otherwise set it to 0 (Non PPS.)

Values

Code	Code Value
0	Non PPS
2	PPS

MEDPAR Pharmacy Charge Amount

• Short SAS Name: PHRMCAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for pharmaceutical costs related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 025x, 026x, and 063x from all claims records included in the stay.

MEDPAR Pharmacy Indicator Code

• Short SAS Name: PHRMCYCD

Contained in

• MedPAR RIF

The code indicating whether or not the beneficiary received drugs during the stay. It also specifies the type of drugs.

Derivation

This field is derived by checking for the presence of drug-specific revenue center codes (listed below) on any of the claim records included in the stay.

Values

Code	Code Value
0	No drugs (revenue code other than those listed below)
1	General drugs and/pr IV therapy (revenue code 025x, 026x)
2	Erythropoietin (epoetin: revenue code 0630, 0635, 0637, 0639)
3	Blood clotting drugs (revenue code 0636)
4	General drugs and/or IV therapy; and epoetin (combination of values 1 and 2)
5	General drugs and/or IV therapy; and blood clotting drugs (combination of values 1 and 3)

MEDPAR Physical Therapy Charge Amount

• Short SAS Name: PHYTHAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for physical therapy services provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 042x from all claims records included in the stay.

MEDPAR Private Room Charge Amount

• Short SAS Name: PRVTAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for private room accommodations related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 011x and 014x from all claim records included in the stay.

Exception for SNF rugs demo effective 3/96 SNF update: this field is derived from revenue center codes in the 9033-9044 series.

MEDPAR Private Room Day Count

• Short SAS Name: PRVTDAY

Contained in

• MedPAR RIF

The count of the number of private room days used by the beneficiary for the stay.

Derivation

This field is derived by accumulating the revenue center unit count associated with accommodation revenue center codes 011x and 014x from all claim records included in the stay. Exception for SNF rugs demo effective 3/96 SNF update: field is derived from revenue center codes in the 9033-9044 series.

MEDPAR Product Replacement for known Recall of Product Switch

• Short SAS Name: PROD_RPLCMT_RCLL_SW

Contained in

• MedPAR RIF

The switch used to identify whether a claim involves the replacement of a product as a result of the Manufacturer or FDA having identified the product for recall and therefore a replacement.

Derivation

If any claim that comprises the Stay has a Condition code (CLM-RLT-COND-CD) equal to '50' populate the MEDPAR Product Replacement Recall Switch with a 'Y'. If no '50' condition code, populate field with an 'N'.

MEDPAR Product Replacement within Product Lifecycle Switch

• Short SAS Name: PROD_RPLCMT_LIFECYC_SW

Contained in

• MedPAR RIF

The switch used to identify whether a claim involves the replacement of a product earlier than the anticipated lifecycle due to an indication the product is not functioning properly.

Derivation

If any claim that comprises the Stay has a condition code (CLM-RLT-COND-CD) equal to '49' populate the MEDPAR Product Replacement within Product Lifecycle Switch with a 'Y'. If no '49' condition code, populate field with an 'N'.

MEDPAR Professional Fees Charge Amount

• Short SAS Name: PROFFEES

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for professional fees related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 096x, 097x, and 098x from all claims records included in the stay.

MEDPAR Prosthetic Orthotic Amount

• Short SAS Name: PRSTHTC_ORTHTC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical prosthetic/orthotic supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center code (REV-CNTR-CD) '0274' from all claim records included in the stay.

MEDPAR Provider Number

• Short SAS Name: PRVDRNUM

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	prvdrnum	prvdrnum	prvdrnum	prvdrnum	prvdrnum

Dataset	2008	2007	2006	2005	2004
MedPAR	prvdrnum	prvdrnum	prvdrnum	prvnumgrp	prvnumgrp

Dataset	2003	2002	2001	2000	1999
MedPAR	prvnumgrp	prvnumgrp	mprovno	mprovno	mprovno

Contained in

• MedPAR RIF

MEDPAR provider number.

Values

Provider Number Table.txt

MEDPAR Provider Number Special Unit Code

• Short SAS Name: SPCLUNIT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	spclunit	spclunit	spclunit	spclunit	spclunit

Dataset	2008	2007	2006	2005	2004
MedPAR	spclunit	spclunit	spclunit	spclunit	spclunit

Dataset	2003	2002	2001	2000	1999
MedPAR	spclunit	spclunit	mfaclty	mfaclty	mfaclty

Contained in

• MedPAR RIF

The code identifying the special numbering system for units of hospitals that are excluded from PPS or hospitals with SNF swing-bed designation.

Derivation

If the third position of the provider number from the first claim record included in the stay equals 'M', 'R', 'S', 'T', 'U', 'W', 'Y' OR 'Z', it is moved to this field, otherwise it is blank.

Values

Code	Code Value
M	PPS-exempt psychiatric unit in CAH
R	PPS-exempt rehabilitation unit in CAH
S	PPS-exempt psychiatric unit
T	PPS-exempt rehabilitation unit
U	Swing-bed short-term/acute care hospital
W	Swing-bed long-term hospital
Y	Swing-bed rehabilitation hospital
Z	Swing-bed rural primary care hospital; eff 10/97 changed to critical access hospitals
Blanks	Not PPS-exempt or swing-bed designation

MEDPAR Radiology CT Scan Amount

• Short SAS Name: RDLGY_CT_SCAN_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the Computed Tomographic (CT) services related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0350', '0351', '0352', '0353', '0354', '0355', '0356', 0357', '0358' & '0359' from all claim records included in the stay.

MEDPAR Radiology CT Scan Indicator Switch

• Short SAS Name: CTSCANSW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology computed tomographic (CT) scan services during the stay.

Derivation

This field is derived by checking for revenue center code 035X on any of the claim records included in the stay.

Values

Code	Code Value
0	No radiology CT scan (revenue code not 035X)
1	Yes radiology CT scan (revenue code 035X)

MEDPAR Radiology Charge Amount

• Short SAS Name: RDLGYAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for radiology costs (including oncology, excluding MRI) related to a beneficiary's stay.

Derivation

This field is derived by accumulating revenue center total charge amount associated with revenue center codes 028x, 032x, 033x, 034x, 035x, and 040x from all claim records included in the stay.

MEDPAR Radiology Diagnostic Amount

• Short SAS Name: RDLGY_DGNSTC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the radiology diagnostic services related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0320', '0321', '0322','0323', '0324', '0325', '0326', 0327', '0328' & '0329' from all claim records included in the stay.

MEDPAR Radiology Diagnostic Indicator Switch

• Short SAS Name: DGNSTCSW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology diagnostic services during the stay.

Derivation

This field is derived by checking for revenue center code 032x on any of the claim records included in the stay.

Values

Code	Code Value
0	No radiology-diagnostic (revenue code not 032x)
1	Yes radiology-diagnostic (revenue code 032x)

MEDPAR Radiology Nuclear Medicine Amount

• Short SAS Name: RDLGY_NUCLR_MDCN_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the nuclear medicine services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0340', '0341', '0342', '0343', '0344', '0345', '0346', '0347', '0348' & '0349' from all claim records included in the stay.

MEDPAR Radiology Nuclear Medicine Indicator Switch

• Short SAS Name: NUCLR_SW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology nuclear medicine services during the stay.

Derivation

This field is derived by checking for revenue center code 034x on any of the claim records included in the stay.

Values

Code	Code Value
0	No nuclear medicine (revenue code not 034x)
1	Yes nuclear medicine (revenue code 034x)

MEDPAR Radiology Oncology Amount

• Short SAS Name: RDLGY_ONCOLOGY_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the oncology services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0280', '0281', '0282', '0283', '0284', '0285', '0286', '0287', '0288' & '0289' from all claim records included in the stay.

MEDPAR Radiology Oncology Indicator Switch

• Short SAS Name: ONCLGYSW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology oncology services during the stay.

Derivation

This field is derived by checking for revenue center code 028X on any of the claim records included in the stay.

Values

Code	Code Value
0	No radiology-oncology (revenue code not 028x)
1	Yes radiology-oncology (revenue code 028x)

MEDPAR Radiology Other Imaging Amount

• Short SAS Name: RDLGY_OTHR_IMGNG_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the radiology other imaging services related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0400', '0401', '0402', '0403', '0404', '0405', '0406', '0407', '0408' & '0409' from all claim records included in the stay.

MEDPAR Radiology Other Imaging Indicator Switch

• Short SAS Name: IMGNG_SW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology other imaging services during the stay.

Derivation

This field is derived by checking for revenue center code 040X on any of the claim records included in the stay.

Values

Code	Code Value
0	No other imaging services (revenue code not 040x)
1	Yes other imaging services (revenue code 040x)

MEDPAR Radiology Therapeutic Amount

• Short SAS Name: RDLGY_THRPTC_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the radiology therapeutic services/supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9)

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRG-AMT) associated with revenue center codes (REV-CNTR-CD) '0330', '0331', '0332', '0333', '0334', '0335', '0336', '0337', '0338' & '0339' from all claim records included in the stay.

MEDPAR Radiology Therapeutic Indicator Switch

• Short SAS Name: THRPTCSW

Contained in

• MedPAR RIF

The switch indicating whether or not the beneficiary received radiology therapeutic services during the stay.

Derivation

This field is derived by checking for revenue center code 033X on any of the claim records included in the stay.

Values

Code	Code Value
0	No radiology-therapeutic (revenue code not 033X)
1	Yes radiology-therapeutic (revenue code 033X)

MEDPAR SNF Qualification From Date

• Short SAS Name: QLFYFROM

Contained in

• MedPAR RIF

The beginning date of the beneficiary's qualifying stay. For Inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to the qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'a', or at least three days in a row if the source of admission is other than an 'a'.

Derivation

This field comes from occurrence span code = 70 and related occurrence span from date, if present on any of the claim records included in the stay. If more than one record has an occurrence span code = 70, with different span dates, the date from the last claim record included in the stay is used.

MEDPAR SNF Qualification Through Date

• Short SAS Name: QLFYTHRU

Contained in

• MedPAR RIF

The ending date of the beneficiary's qualifying stay. For Inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to the qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than an 'A'.

Derivation

This field comes from the occurrence span code = 70 and related occurrence span thru date, if present on any of the claims included in the stay. If more than one record has an occurrence span code = 70, with different span dates, the date from the last claim record included in the stay is used.

MEDPAR Semi-Private Room Charge Amount

• Short SAS Name: SPRVTAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for semi-private room accommodations related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center codes 010x, 012x, 013x, and 016x - 019x from all claim records included in the stay.

Exception for SNF rugs demo effective 03/96 SNF update: field is derived from revenue center codes in the 9019-9032 series.

MEDPAR Semiprivate Room Day Count

• Short SAS Name: SPRVTDAY

Contained in

• MedPAR RIF

The count of the number of semi-private room days used by the beneficiary for the stay.

Derivation

This field is derived by accumulating the revenue center unit count associated with accommodation revenue center codes 010X, 012X, 013X, 016X - 019X from all claim records included in the stay.

MEDPAR Short Stay/Long Stay/SNF Indicator Code

• Short SAS Name: SSLSSNF

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	sslssnf	sslssnf	sslssnf	sslssnf	sslssnf

Dataset	2008	2007	2006	2005	2004
MedPAR	sslssnf	sslssnf	sslssnf	sslssnf	sslssnf

Dataset	2003	2002	2001	2000	1999
MedPAR	sslssnf	sslssnf	mstay	mstay	mstay

Contained in

• MedPAR RIF

The code indicating whether the stay is a short stay, long stay, or SNF.

Derivation

This field is derived from the third position of the provider number that is present on the first claim record included in the stay.

Values

Code	Code Value
N	SNF Stay (Prvdr3 = 5, 6, U, W, Y, or Z)
S	Short-Stay (Prvdr3 = 0, M, R, S, T)
L	Long-Stay (All Others)

MEDPAR Source Inpatient Admission Code

• Short SAS Name: SRC_ADMS

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	src_adms	src_adms	src_adms	src_adms	src_adms

Dataset	2008	2007	2006	2005	2004
MedPAR	src_adms	src_adms	src_adms	src_adms	src_adms

Dataset	2003	2002	2001	2000	1999
MedPAR	src_adms	src_adms	madmsrce	madmsrce	madmsrce

Contained in

• MedPAR RIF

The code indicating the source of the beneficiary's admission to an Inpatient facility or, for newborn admission, the type of delivery.

Derivation

This field comes from the source Inpatient admission code that is present on the last claim record included in the stay.

Values

For Inpatient/SNF Claims:

Code	Code Value
0	ANOMALY: invalid value, if present, translate to '9'
1	Non-Health Care Facility Point of Origin (Physician Referral) - The patient was admitted to this facility upon an order of a physician.
2	Clinical referral - The patient was admitted upon the recommendation of this facility's clinic physician.
3	HMO referral - Reserved for national assignment. (eff. 3/08) Prior to 3/08, HMO referral - The patient was admitted upon the recommendation of a health maintenance organization (HMO) physician.
4	Transfer from hospital (Different Facility) - The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient.
5	Transfer from a skilled nursing facility (SNF) or Intermediate Care Facility (ICF) - The patient was admitted to this facility as a transfer from a SNF or ICF where he or she was a resident.
6	Transfer from another health care facility - The patient was admitted to this facility as a transfer from another type of health care facility not defined elsewhere in this code list where he or she was an inpatient.
7	Emergency room - The patient was admitted to this facility after receiving services in this facility's emergency room department. (Obsolete - eff. 7/1/10)
8	Court/law enforcement - The patient was admitted upon the direction of a court of law or upon the request of a law enforcement agency's representative. Includes transfers from incarceration facilities.
9	Information not available - The means by which the patient was admitted is not known.
A	Reserved for National Assignment. (eff. 3/08) Prior to 3/08 defined as: Transfer from a Critical Access Hospital - patient was admitted/referred to this facility as a transfer from a Critical Access Hospital.
B	Transfer from Another Home Health Agency - The patient was admitted to this home health agency as a transfer from another home health agency. (Discontinued July 1, 2010 - See Condition Code 47)
C	Readmission to Same Home Health Agency - The patient was readmitted to this home health agency within the same home health episode period. (Discontinued July 1, 2010)
D	Transfer from hospital inpatient in the same facility resulting in a separate claim to the payer - The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.
E	Transfer from Ambulatory Surgery Center - The patient was admitted to this facility as a transfer from an ambulatory surgery center. (eff. 10/1/2007)
F	Transfer from Hospice and is under a Hospice Plan of Care or Enrolled in a Hospice Program - The patient was admitted to this facility as a transfer from a hospice. (eff. 10/1/2007)

For Newborn Type of Admission:

Code	Code Value
1	Normal delivery - A baby delivered without complications. (Obsolete eff. 10/1/07)
2	Premature delivery - A baby delivered with time and/or weight factors qualifying it for premature status. (Obsolete eff. 10/1/07)
3	Sick baby - A baby delivered with medical complications, other than those relating to premature status. (Obsolete eff. 10/1/07)
4	Extramural birth - A baby delivered in a non-sterile environment. (Obsolete eff. 10/1/07)
5	Born Inside this Hospital (eff. 10/1/07)
6	Born Outside of This Hospital (eff. 10/1/07)
7-9	Reserved for national assignment.

MEDPAR Speech Pathology Charge Amount

• Short SAS Name: SPCH_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for speech pathology services (speech, language, audiology) provided during the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 044x and 047x from all claim records included in the stay.

MEDPAR Stay Final Action Claims Count

• Short SAS Name: FACLMCNT

Contained in

• MedPAR RIF

The count of the number of claim records (final action) included in the stay.

Derivation

This field is derived by counting the number of final action claims used to create the stay.

MEDPAR Surgical Procedure Code

• Short SAS Name: PRCDRCD{x}

Contained in

• MedPAR RIF

The ICD-9-CM code identifying the principal or other surgical procedure performed during the beneficiary's stay. This element is part of the MEDPAR surgical procedure group. It may occur up to 25 times.

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

Derivation

This field is the actual principal surgical procedure code (1^st occurrence) or one of up to 24 other surgical procedure codes that may be present on the last claim record included in the stay.

MEDPAR Surgical Procedure Code Count

• Short SAS Name: PRCDRCNT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	prcdrcnt	prcdrcnt	prcdrcnt	prcdrcnt	prcdrcnt

Dataset	2008	2007	2006	2005	2004
MedPAR	prcdrcnt	prcdrcnt	prcdrcnt	prcdrcnt	prcdrcnt

Dataset	2003	2002	2001	2000	1999
MedPAR	prcdrcnt	prcdrcnt	msurgnum	msurgnum	msurgnum

Contained in

• MedPAR RIF

The count of the number of surgical procedure codes included in the stay.

Derivation

This field is derived by counting the procedure codes that are reported on the last claim record included in the stay.

MEDPAR Surgical Procedure Indicator Switch

• Short SAS Name: PRCDRSW

Contained in

• MedPAR RIF

The switch indicating whether or not there were any surgical procedures performed during the beneficiary's stay.

Derivation

This field is derived by checking for the presence of procedure codes on the last claim record included in the stay.

Values

Code	Code Value
0	No surgery indicated
1	Yes surgery indicated

MEDPAR Surgical Procedure Performed Date

• Short SAS Name: PRCDRDT{x}

Contained in

• MedPAR RIF

The date on which the icd-9-cm surgical procedure was performed during the beneficiary's stay. This element is part of the MEDPAR surgical procedure group. It can occur up to 25 times.

Derivation

This field is the actual date associated with the principal or one of up to 24 other surgical procedure codes that is present on the last claim record included in the stay.

MEDPAR Surgical Procedure Performed Date Count

• Short SAS Name: PRCDTCNT

Contained in

• MedPAR RIF

The count of the number of dates associated with the surgical procedures included in the stay.

Derivation

This field is derived by counting the surgical procedures dates that are reported on the last claim record included in the stay.

MEDPAR Surgical Procedure Version Code

• Short SAS Name: SRGCL_PRCDR_VRSN_CD_{x}

Contained in

• MedPAR RIF

Effective with Version 'J', the code used to indicate if the surgical procedure code is ICD-9 or ICD-10.

MEDPAR Take Home Amount

• Short SAS Name: TAKE_HOME_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for the medical/surgical take home supplies related to the beneficiary's stay.

NOTE: Effective with MEDPAR2000 expansion, all amount fields were expanded from S9(7) to S9(9).

Derivation

This field is derived by accumulating the revenue center total charge amount (REV-CNTR-TOT-CHRGAMT) associated with revenue center code (REV-CNTRCD) '0273' from all claim records included in the stay.

MEDPAR Total Charge Amount

• Short SAS Name: TOTCHRG

Contained in

• MedPAR RIF

The total amount (rounded to whole dollars) of all charges (covered and non-covered) for all services provided to the beneficiary for the stay.

Derivation

This field is derived by accumulating the total charge amount from all claim records included in the stay (i.e., the sum of total charges reported on the claims that comprise the stay).

MEDPAR Total Covered Charge Amount

• Short SAS Name: CVRCHRG

Contained in

• MedPAR RIF

The portion of the total charges amount (rounded to wholedollars) that is covered by Medicare for the stay.

Derivation

This field is derived by calculating the covered charges from all claim records included in the stay (i.e.,subtract the revenue center non-covered charge amount from the revenue center total charge amount for revenue center code = 0001 that is reported on the claims that comprise the stay; sum the results). Exception: if there exists an erroneous condition relative to revenue center code 0001, the calculation will be made for each revenue center code included on the claims that comprise the stay with the results summed to create the total.

MEDPAR Total PPS Capital Amount

• Short SAS Name: PPS_CPTL

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	pps_cptl	pps_cptl	pps_cptl	pps_cptl	pps_cptl

Dataset	2008	2007	2006	2005	2004
MedPAR	pps_cptl	pps_cptl	pps_cptl	pps_cptl	pps_cptl

Dataset	2003	2002	2001	2000	1999
MedPAR	pps_cptl	pps_cptl	mppscamt	mppscamt	mppscamt

Contained in

• MedPAR RIF

The total amount (rounded to whole dollars) that is payable for capital PPS (e.g., reimbursement for depreciation, rent, certain interest, real estate taxes for hospital buildings/equipment subject to PPS).

Derivation

This field is derived by accumulating the total PPS capital amount that is present on any of the claim records included in the stay (i.e., the sum of total PPS capital amounts reported on the claims that comprise the stay).

MEDPAR Total Pass Through Amount

• Short SAS Name: PASSTHRU

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	passthru	passthru	passthru	passthru	passthru

Dataset	2008	2007	2006	2005	2004
MedPAR	passthru	passthru	passthru	passthru	passthru

Dataset	2003	2002	2001	2000	1999
MedPAR	passthru	passthru	mbtpdiem	mbtpdiem	mbtpdiem

Contained in

• MedPAR RIF

The total of all claim pass through amounts (rounded to whole dollars) for the stay.

Derivation

This field is derived by multiplying the pass thru per diem amount that is present on the last claim record included in the stay times the MEDPAR utilization day count (the sum of the utilization (covered) days reported on the claims that comprise the stay).

MEDPAR Transplant Indicator Code

• Short SAS Name: TRNSPLNT

Contained in

• MedPAR RIF

The code indicating whether or not the beneficiary received a organ transplant during the stay.

Derivation

This field is derived by checking for the presence of the transplant revenue center code (listed below) on any of the claim records included in the stay.

Values

Code	Code Value
0	No organ or kidney transplant (revenue code not 0362 or 0367)
2	Organ transplant other than kidney (revenue code 0362)
7	Kidney transplant (revenue code 0367)

MEDPAR Used DME Charge Amount

• Short SAS Name: UDME_AMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for used DME (purchase of used DME) related to the beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 0293 from all claim records included in the stay.

MEDPAR Utilization Day Count

• Short SAS Name: UTIL_DAY

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	util_day	util_day	util_day	util_day	util_day

Dataset	2008	2007	2006	2005	2004
Inpatient	util_day	util_day	util_day	util_day	util_day

Dataset	2003	2002	2001	2000	1999
Inpatient	util_day	util_day	util_day	util_day	util_day

Contained in

• MedPAR RIF

The count of the number of covered days of care that are chargeable to Medicare utilization for the stay.

Derivation

This field is derived by accumulating the utilization day count that is present on any of the claim records included in the stay (i.e., the sum of utilization days reported on the claims that comprise the stay).

MEDPAR VBP Adjustment Percent

• Short SAS Name: VBP_ADJSTMT_PCT

Contained in

• MedPAR RIF

Under the Hospital Value Based Purchasing (HVBP) program, the percent used to identify an adjustment made to certain subsection (d) IPPS hospital's base operating DRG amount, in accordance with their Total Performance Score (TPS) as required by the Affordable Care Act (ACA). This is the Value Based Purchasing Score.

Derivation

This field comes from the Claim VBP Adjustment Percent (CLM-VBP-CLM-ADJSTMT-PCT) that is present on the last claim record included in the stay.

MEDPAR VBP Participant Indicator Code

• Short SAS Name: VBP_PRTCPNT_IND_CD

Contained in

• MedPAR RIF

The code used to identify a reason a hospital is excluded from the Hospital Value Based Purchasing (HVBP) program. The ACA (Section 3001) excludes from HVBP program hospitals that meet certain conditions.

Derivation

This field comes from the Claim VBP Participant Indicator code (CLM-VBP-PRTCPNT-IND-CD) that is present on the first claim record included in the stay. If there is no Claim VBP Participant Indicator code on the first claim then take the first found code on any of the other claims that make up the stay.

MEDPAR Ward Charge Amount

• Short SAS Name: WARDAMT

Contained in

• MedPAR RIF

The charge amount (rounded to whole dollars) for ward accommodations related to a beneficiary's stay.

Derivation

This field is derived by accumulating the revenue center total charge amount associated with revenue center code 015x from all claim records included in the stay.

Exception for SNF rugs demo effective 03/96 SNF update: this field is derived from revenue center codes in the 9000-9018 series.

MEDPAR Ward Day Count

• Short SAS Name: WARDDAY

Contained in

• MedPAR RIF

The count of the number of ward days used by the beneficiary for the stay.

Derivation

This field is derived by accumulating the revenue center unit count associated with accommodation revenue center code 015x from all claim records included in the stay.

Exception for SNF rugs demo eff 3/96 SNF update: field is derived from revenue center codes in the 9000-9018 series.

MEDPAR Warning Indicators Code

• Short SAS Name: WRNGCD

Contained in

• MedPAR RIF

The codes (commonly called warning indicators) specifying detailed billing information obtained from the claims analyzed for the stay process. The purpose of these codes is to provide additional information for the MEDPAR user; i.e., let the user know whether or not the stay included adjustments, a single claim or multiple claims, any error conditions, etc.

Derivation

This field is packed. Each of the digits identify a specific item of interest to users of the MEDPAR file. Warning indicators 1 and 6, and the first two values of indicator 8, are set early in the process – while processing all claims through the final action algorithm, prior to the creation of the stay record. The other indicators are derived from the claims remaining after the final action processing, which are used to created the stay record.

Values

MEDPAR Warning Indicators Code Table.txt

MEDPAR Year of Record

• Short SAS Name: MEDPAR_YR_NUM

Contained in

• MedPAR RIF

Year of the MedPAR Record.

Major Depressive Affective Disorder End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: DEPSN_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for major depressive affective disorder as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For major depressive affective disorder, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Major Depressive Affective Disorder First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: DEPSN_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the major depressive affective disorder indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

MedPAR ID Number

• Short SAS Name: MEDPARID

Contained in

• MedPAR RIF

Unique key for MEDPAR claim.

Medicare Coverage Start Date

• Short SAS Name: COVSTART
• Long SAS Name: COVSTART

Contained in

• Master Beneficiary Summary File

This variable is the date when the beneficiary first became eligible for Medicare coverage (Part A or Part B).

Historic date of 1^st Medicare coverage (may be prior to 1999, which is the earliest claim files available through CCW)

Historic date of 1^st Medicare coverage (may be prior to 1999, which is the earliest claim files available through CCW)

Medicare Entitlement/Buy-In Indicator - April

• Short SAS Name: BUYIN04
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_04

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - August

• Short SAS Name: BUYIN08
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_08

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - December

• Short SAS Name: BUYIN12
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_12

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - February

• Short SAS Name: BUYIN02
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_02

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - January

• Short SAS Name: BUYIN01
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_01

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - July

• Short SAS Name: BUYIN07
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_07

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - June

• Short SAS Name: BUYIN06
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_06

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - March

• Short SAS Name: BUYIN03
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_03

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - May

• Short SAS Name: BUYIN05
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_05

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - November

• Short SAS Name: BUYIN11
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_11

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part C state buy-in

Medicare Entitlement/Buy-In Indicator - October

• Short SAS Name: BUYIN10
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_10

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Entitlement/Buy-In Indicator - September

• Short SAS Name: BUYIN09
• Long SAS Name: MDCR_ENTLMT_BUYIN_IND_09

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was entitled to Part A, Part B, or both for a given month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). The variable also indicates whether the beneficiary’s state of residence paid his/her monthly premium for Part B coverage (and Part A if necessary). State Medicaid programs can pay those premiums for certain dual eligibles; this action is called “buying in” and so this variable is the “buy-in code.”

Values

Code	Code Value
0	Not entitled
1	Part A only
2	Part B only
3	Part A and Part B
A	Part A state buy-in
B	Part B state buy-in
C	Part A and Part B state buy-in

Medicare Sample Group Indicator

• Short SAS Name: SAMPLE_GROUP
• Long SAS Name: SAMPLE_GROUP

Contained in

• Master Beneficiary Summary File

Medicare 1, 5, or 20% strict sample group indicator.

CCW creates the sample values using standard CMS processes to identify the random 1, 5, 15, and 20 percent samples of Medicare beneficiaries. The sample groups are based on a random 20 percent sample that is split into three mutually exclusive groups of 1 percent, 4 percent, and 15 percent. To use the 1 percent sample, specify that SAMPLE_GRP equals “01”. To use the 5 percent sample, specify that SAMPLE_GRP equals “01” or “04”. To use the 15 percent sample, specify that SAMPLE_GRP equals “15”. To use the 20 percent sample, specify that SAMPLE_GRP equals “01”, “04”, or “15”. Beneficiaries are assigned to sample groups each year based on the last two digits of their Medicare Claim Account Numbers (CANs). Since CANs can change over time (e.g., in the case of remarriage), new beneficiaries are becoming eligible for Medicare, and existing beneficiaries are dying, the sample is cross-sectional. There is no guarantee that the exact same beneficiaries are represented in the same sample group from one year to the next (i.e., this is the strict sampling).

Values

Code
01, 04, 15, null/missing (not included in 20% sample for the year)

Medicare Status Code - April

• Short SAS Name: MDCR_STUS_CD_04
• Long SAS Name: MDCR_STATUS_CODE_04

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in April.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - August

• Short SAS Name: MDCR_STUS_CD_08
• Long SAS Name: MDCR_STATUS_CODE_08

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in August.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - December

• Short SAS Name: MDCR_STUS_CD_12
• Long SAS Name: MDCR_STATUS_CODE_12

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in December.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - February

• Short SAS Name: MDCR_STUS_CD_02
• Long SAS Name: MDCR_STATUS_CODE_02

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in February.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - January

• Short SAS Name: MDCR_STUS_CD_01
• Long SAS Name: MDCR_STATUS_CODE_01

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in January.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - July

• Short SAS Name: MDCR_STUS_CD_07
• Long SAS Name: MDCR_STATUS_CODE_07

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in July.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - June

• Short SAS Name: MDCR_STUS_CD_06
• Long SAS Name: MDCR_STATUS_CODE_06

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in June.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - March

• Short SAS Name: MDCR_STUS_CD_03
• Long SAS Name: MDCR_STATUS_CODE_03

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in March.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - May

• Short SAS Name: MDCR_STUS_CD_05
• Long SAS Name: MDCR_STATUS_CODE_05

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in May.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - November

• Short SAS Name: MDCR_STUS_CD_11
• Long SAS Name: MDCR_STATUS_CODE_11

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in November.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - October

• Short SAS Name: MDCR_STUS_CD_10
• Long SAS Name: MDCR_STATUS_CODE_10

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in October.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare Status Code - September

• Short SAS Name: MDCR_STUS_CD_09
• Long SAS Name: MDCR_STATUS_CODE_09

Contained in

• Master Beneficiary Summary File

This variable indicates how a beneficiary currently qualifies for Medicare - in September.

Analysts can use this variable to quickly distinguish between the aged, disabled, and ESRD populations. This field is coded from age, original reason for entitlement, current reason for entitlement and ESRD indicator contained in the enrollment data base at CMS. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
10	Aged without ESRD
11	Aged with ESRD
20	Disabled without ESRD
21	Disabled with ESRD
31	ESRD only

Medicare-Medicaid dual eligibility code - April

• Short SAS Name: DUAL_04
• Long SAS Name: DUAL_STUS_CD_04

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (April).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - August

• Short SAS Name: DUAL_08
• Long SAS Name: DUAL_STUS_CD_08

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (August).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - December

• Short SAS Name: DUAL_12
• Long SAS Name: DUAL_STUS_CD_12

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (December).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - February

• Short SAS Name: DUAL_02
• Long SAS Name: DUAL_STUS_CD_02

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (February).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - January

• Short SAS Name: DUAL_01
• Long SAS Name: DUAL_STUS_CD_01

Contained in

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (January).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - July

• Short SAS Name: DUAL_07
• Long SAS Name: DUAL_STUS_CD_07

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (July).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - June

• Short SAS Name: DUAL_06
• Long SAS Name: DUAL_STUS_CD_06

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (June).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - March

• Short SAS Name: DUAL_03
• Long SAS Name: DUAL_STUS_CD_03

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (March).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - May

• Short SAS Name: DUAL_05
• Long SAS Name: DUAL_STUS_CD_05

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (May).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - November

• Short SAS Name: DUAL_11
• Long SAS Name: DUAL_STUS_CD_11

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (November).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - October

• Short SAS Name: DUAL_10
• Long SAS Name: DUAL_STUS_CD_10

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (October).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Medicare-Medicaid dual eligibility code - September

• Short SAS Name: DUAL_09
• Long SAS Name: DUAL_STUS_CD_09

Contained in

• Master Beneficiary Summary File

This variable indicates whether the beneficiary was eligible for both Medicare and Medicaid in a given month (September).

The original source for this variable is the State Medicare Modernization Act (MMA) files that states submit to CMS. Those files are considered the “gold standard” for identifying dual eligibles because the information in them is used to determine the level of Medicare Part D low-income subsidies. Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. CMS generally considers beneficiaries to be full duals if they have values of 02, 04, or 08, and to be partial duals if they have values of 01, 03, 05, or 06. Partial duals sometimes divided into the QMB-only population (01) and all other partial duals (03, 05, or 06). There are CMS Chronic Conditions Data Warehouse (CCW) – Codebook Master Beneficiary Summary File (MBSF) with Medicare Part A, B, C & D May 2017 – Version 1.0 Page 56 of 225 different ways to classify dually eligible beneficiaries. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles". There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
**	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'XX' for 2006-2009)
nan	Non-Medicaid
00	Not Medicare enrolled for the month
01	Qualified Medicare Beneficiary (QMB)-only
02	QMB and full Medicaid coverage, including prescription drugs
03	Specified Low-Income Medicare Beneficiary (SLMB)-only
04	SLMB and full Medicaid coverage, including prescription drugs
05	Qualified Disabled Working Individual (QDWI)
06	Qualifying individuals (QI)
08	Other dual eligible (not QMB, SLMB, QWDI, or QI) with full Medicaid coverage, including prescription drugs
09	Other dual eligible, but without Medicaid coverage
99	Unknown

Migraine and other Chronic Headache End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: MIGRAINE_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for migraine and other chronic headache as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For migraine and other chronic headache, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Migraine and other Chronic Headache First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: MIGRAINE_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the migraine and other chronic headache indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Mobility Impairments End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: MOBIMP_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for mobility impairments as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For mobility impairments, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Mobility Impairments First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: MOBIMP_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the mobility impairments indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Months of Dual Eligibility

• Short SAS Name: DUAL_MO
• Long SAS Name: DUAL_ELGBL_MONS

Contained in

• Master Beneficiary Summary File

This variable is the number of months during the year that the beneficiary was dually eligible (i.e., he/she was also eligible for Medicaid benefits).

CCW derived this variable by counting the number of months where the beneficiary had dual eligibility (DUAL_STUS_CD_XX not equal to 00 or '**'). There are different ways to classify dually eligible beneficiaries - in terms of whether he/she is enrolled in full or partial benefits. Additional information regarding various ways to identify dually enrolled populations, refer to a CCW Technical Guidance document entitled: "Options in Determining Dual Eligibles"

Values

Code
The value in this field is between '00' through '12'.

Months of Part D Coverage

• Short SAS Name: PTD_MO
• Long SAS Name: PTD_PLAN_CVRG_MONS

Contained in

• Master Beneficiary Summary File

This variable is the number of months during the year that the beneficiary had Medicare Part D coverage. CCW derives this variable by counting the number of months where the beneficiary had Part D coverage.

A Part D covered month is one where the first value of the monthly PTD_CNTRCT_ID_XX variable equaled H, R, S, or E or the value was X followed by 4 alphanumeric characters.

Values

Code
The value in this field is between '00' through '12'.

Months of Retiree Drug Subsidy Coverage

• Short SAS Name: RDS_MO
• Long SAS Name: RDS_CVRG_MONS

Contained in

• Master Beneficiary Summary File

This variable is the number of months during the year that the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS). CCW derives this variable by counting the number of months where the beneficiary had retiree drug subsidy.

A month of RDS is when the RDS_IND_XX for the month = Y. Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans.

Values

Code
The value in this field is between '00' through '12'.

Multiple Sclerosis and Transverse Myelitis End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: MULSCL_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for multiple sclerosis and transverse myelitis as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For multiple sclerosis and transverse myelitis, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Multiple Sclerosis and Transverse Myelitis First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: MULSCL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the multiple sclerosis and transverse myelitis indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Muscular Dystrophy End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: MUSDYS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for muscular dystrophy as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For muscular dystrophy, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Muscular Dystrophy First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: MUSDYS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the muscular dystrophy indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

NCH Active or Covered Level Care Thru Date

• Short SAS Name: CARETHRU
• Long SAS Name: NCH_ACTV_OR_CVRD_LVL_CARE_THRU

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The date on a claim for which the covered level of care ended in a general hospital or the active care ended in a psychiatric/TB hospital.

Derivation

DERIVED FROM: CLM_RLT_OCRNC_CD CLM_RLT_OCRNC_DT

DERIVATION RULES: Based on the presence of occurrence code 22 move the related occurrence date to NCH_ACTV_CVR_LVL_CARE_THRU_DT.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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 Discharge Date

• Short SAS Name: DSCHRGDT

Variable Names

Dataset	2013	2012	2011	2010	2009
MedPAR	dschrgdt	dschrgdt	dschrgdt	dschrgdt	dschrgdt

Dataset	2008	2007	2006	2005	2004
MedPAR	dschrgdt	dschrgdt	dschrgdt	sdschrgdt	sdschrgdt

Dataset	2003	2002	2001	2000	1999
MedPAR	sdschrgdt	sdschrgdt	mdisdte	mdisdte	mdisdte

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF
• Hospice RIF

On an inpatient or Home Health claim, the date the beneficiary was discharged from the facility, or died.

Date matches the "thru" date on the claim (CLM_THRU_DT). When there is a discharge date, the discharge status code (PTNT_DSCHRG_STUS_CD) indicates the final disposition of the patient after discharge.

Derivation

DERIVED FROM: NCH_PTNT_STUS_IND_CD CLM_THRU_DT

DERIVATION RULES: Based on the presence of patient discharge status code not equal to 30 (still patient), move the claim thru date to the NCH_BENE_DSCHRG_DT.

NCH Beneficiary Inpatient Deductible Amount

• Short SAS Name: DED_AMT
• Long SAS Name: NCH_BENE_IP_DDCTBL_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	ded_amt	ded_amt	ded_amt	ded_amt	ded_amt
MedPAR	ded_amt	ded_amt	mpded	mpded	mpded

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The amount of the deductible the beneficiary paid for inpatient services, as originally submitted on the institutional claim.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT DERIVATION RULES: Based on the presence of value code equal to A1, B1, or C1 move the corresponding value amount to the NCH_BENE_IP_DDCTBL_AMT.

Values

Code
XXX.XX

NCH Beneficiary Medicare Benefits Exhausted Date

• Short SAS Name: EXHST_DT
• Long SAS Name: NCH_BENE_MDCR_BNFTS_EXHTD_DT_I

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

The last date for which the beneficiary has Medicare coverage. This is completed only where where benefits were exhausted before the date of discharge and during the billing period covered by this institutional claim.

Derivation

DERIVED FROM: CLM_RLT_OCRNC_CD CLM_RLT_OCRNC_DT

DERIVATION RULES (Effective 10/93): Based on the presence of occurrence code A3, B3 or C3 move the related occurrence date to NCH_MDCR_BNFT_EXHST_DT. *NOTE: Prior to 10/93, the date associated with occurrence code 23 was moved to this field.

NCH Beneficiary Part A Coinsurance Liability Amount

• Short SAS Name: COIN_AMT
• Long SAS Name: NCH_BENE_PTA_COINSRNC_LBLTY_AM

Variable Names

Dataset	2013	2012	2011	2010	2009
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt

Dataset	2008	2007	2006	2005	2004
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt

Dataset	2003	2002	2001	2000	1999
Inpatient	coin_amt	coin_amt	coin_amt	coin_amt	coin_amt
MedPAR	coin_amt	coin_amt	mcoinamt	mcoinamt	mcoinamt

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

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

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT DERIVATION RULES: Based on the presence of value code equal to 8, 9, 10 or 11 move the corresponding value amount to the NCH_BENE_IP_PTA_COINSRC_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

• Outpatient RIF

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

• Outpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF

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 Carrier Claim Allowed Charge Amount*

• Short SAS Name: ALOWCHRG
• Long SAS Name: NCH_CARR_CLM_ALOWD_AMT

Variable Names

Dataset	2012	2011	2010	2009	2008
Carrier	alowchrg	alowchrg	alowchrg	alowchrg	alowchrg

Dataset	2007	2006	2005	2004	2003
Carrier	alowchrg	alowchrg	alowchrg	alowchrg	alowchrg

Dataset	2002	2001	2000	1999
Carrier	alowchrg	alowchrg	alowchrg	alowchrg

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the total allowed charges on the claim (the sum of line item allowed charges).

NOTE1: The amount includes beneficiary-paid amounts (i.e., deductible and coinsurance).

NOTE2: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

NCH Carrier Claim Submitted Charge Amount*

• Short SAS Name: SBMTCHRG
• Long SAS Name: NCH_CARR_CLM_SBMTD_CHRG_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the total submitted charges on the claim (the sum of line item submitted charges).

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

NCH Claim Beneficiary Payment Amount*

• Short SAS Name: BENE_PMT
• Long SAS Name: NCH_CLM_BENE_PMT_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the total payments made to the beneficiary for this claim (sum of line payment amounts to the beneficiary.)

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.

NCH Claim Provider Payment Amount*

• Short SAS Name: PROV_PMT
• Long SAS Name: NCH_CLM_PRVDR_PMT_AMT

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version H, the total payments made to the provider for this claim (sum of line item provider payment amounts.) 

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.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 DRG Outlier Approved Payment Amount

• Short SAS Name: OUTLRPMT
• Long SAS Name: NCH_DRG_OUTLIER_APRVD_PMT_AMT

Contained in

• Inpatient RIF

On an institutional claim, the additional payment amount approved by the Peer Review Organization due to an outlier situation for a beneficiary's stay under the prospective payment system, which has been classified into a specific diagnosis related group.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT

DERIVATION RULES: Based on the presence of value code equal to 17 move the related amount to NCH_DRG_OUTLIER_APRV_PMT_AMT.

NCH Inpatient Noncovered Charge Amount

• Short SAS Name: NCCHGAMT
• Long SAS Name: NCH_IP_NCVRD_CHRG_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective with Version H, the noncovered charges for all accommodations and services, reported on an inpatient claim (used for internal CWFMQA editing purposes).

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Derivation

DERIVED FROM: REV_CNTR_CD REV_CNTR_NCVR_CHRG_AMT

DERVIATION RULES: Based on the presence of revenue center code equal to 0001 move the related noncovered charge amount to NCH_IP_NCOV_CHRG_AMT.

Values

Code
XXX.XX

NCH Inpatient Total Deduction Amount

• Short SAS Name: TDEDAMT
• Long SAS Name: NCH_IP_TOT_DDCTN_AMT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective with Version H, the total Part A deductions reported on the Inpatient claim (used for internal CWFMQA editing purposes).

NOTE: During the Version H conversion this field was populated with data throughout history (back to 1991), but the derivation rule applied was in- complete for claims processed prior to 10/93. Disregard any data present in this field on claims with NCH weekly process date earlier than 10/93.

Derivation

DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT

DERIVATION RULES (Effective 10/93): Accumulate the value amounts associated with value codes equal to 06, 08 thru 11 and A1, B1 or C1 and move to IP_TOT_DDCTN_AMT. NOTE: Value codes 08-11 did not exist in the NCH prior to 2/93; values codes A1, B1, C1 did not exist prior to 10/93.

Values

Code
XXX.XX

NCH Near Line Record Identification Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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 Patient Status Indicator Code

• Short SAS Name: PTNTSTUS
• Long SAS Name: NCH_PTNT_STATUS_IND_CD

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF
• Hospice RIF

Effective with Version H, the code on an inpatient/SNF and Hospice claim, indicating whether the beneficiary was discharged, died or still a patient (used for internal CWFMQA editing purposes.)

NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991).

Derivation

DERIVED FROM: NCH PTNT_DSCHRG_STUS_CD DERIVATION RULES: SET NCH_PTNT_STUS_IND_CD TO 'A' WHERE THE PTNT_DSCHRG_STUS_CD NOT EQUAL TO '20'- '30' OR '40' - '42'. SET NCH_PTNT_STUS_IND_CD TO 'B' WHERE THE PTNT_DSCHRG_STUS_CD EQUAL TO '20'- '29' OR '40' - '42'. SET NCH_PTNT_STUS_IND_CD TO 'C' WHERE THE PTNT_DSCHRG_STUS_CD EQUAL TO '30'

Values

Code	Code Value
A	Discharged
B	Died
C	Still patient

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Inpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Qualified Stay From Date

• Short SAS Name: QLFYFROM

Contained in

• Skilled Nursing Facility RIF

Effective with Version H, the beginning date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes). For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than 'A'.

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Derivation

DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_FROM_DT

DERIVATION RULES: Based on the presence of occurrence code 70 move the related occurrence from date to NCH_QLFY_STAY_FROM_DT.

NCH Qualify Stay Through Date

• Short SAS Name: QLFYTHRU

Contained in

• Skilled Nursing Facility RIF

Effective with Version H, the ending date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes.) For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than 'A'.

NOTE: During the Version H, conversion this field was populated with data throughout history (back to service year 1991).

Derivation

DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_THRU_DT

DERIVATION RULES: Based on the presence of occurrence code 70 move the related occurrence thru date to NCH_QLFY_STAY_THRU_DT.

NCH Verified Noncovered Stay From Date

• Short SAS Name: NCOVFROM
• Long SAS Name: NCH_VRFD_NCVRD_STAY_FROM_DT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective with Version H, the beginning date of the beneficiary's noncovered stay (used for internal CWFMQA editing purposes.)

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Derivation

DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_FROM_DT

DERIVATION RULES: Based on the presence of occurrence code 74, 76, 77 or 79 move the related occurrence from date to NCH_VRFY_NCOV_STAY_FROM_DT.

NCH Verified Noncovered Stay Through Date

• Short SAS Name: NCOVTHRU
• Long SAS Name: NCH_VRFD_NCVRD_STAY_THRU_DT

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF

Effective with Version H, the ending date of the beneficiary's noncovered stay (used for internal CWFMQA editing purposes.)

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

Derivation

DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_THRU_DT

DERIVATION RULES: Based on the presence of occurrence code 74, 76, 77 or 79 move the related occurrence thru date to NCH_VRFY_NCOV_STAY_THRU_DT.

NCH Weekly Claim Processing Date

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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.

NDI Date of Death

• Short SAS Name: NDI_DOD
• Long SAS Name: NDI_DOD

Contained in

• Master Beneficiary Summary File

This field indicates that an enrollee's date of death has been verified as the exact date of becoming deceased, according to a death certificate.

Formatted as YYYYMMDD

NDI Death Certificate Number

• Short SAS Name: DEATH_CERT_NUM

Contained in

• Master Beneficiary Summary File

This field represents the death certificate number of the beneficiary.

Numbers are not unique across years.

Available for 1999-2008/ Rsearchers wishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

NDI Entity Axis Cause of Death - Condition

• Short SAS Name: ENTITY_COND_1 (through ENTITY_COND_8)

Contained in

• Master Beneficiary Summary File

This field identifies the first eight underlying causes of death codes as listed by the certifier of death (formatted but not audited).

Values

Each condition takes 7 positions in the record Position1: Part/line number on certificate

Code	Code Value
1	Part I, line 1 (a)
2	Part I, line 2 (b)
3	Part I, line 3 ©
4	Part I, line 4 (d)
5	Part I, line 5 (e)
6	Part II

Position 2: Sequence of condition within part/line Code range:1-7

Position 3-6: Condition code (See ICD-9 or ICD-10 codes) Whenever there is a 4-position code, there is always an implied decimal after the 3^rd position.

Position 7: Nature of Injury flag (only for ICD-9 codes)

Code	Code Value
1	the code in positions 3-6 is a Nature of Injury ICD-9 code
0	all other codes

NDI Record Axis Cause of Death - Condition

• Short SAS Name: RECORD_COND_1 (through RECORD_COND_8)

Contained in

• Master Beneficiary Summary File

This field identifies the first eight underlying causes of death codes as edited and audited by National Center for Health Statistics (NCHS).

Values

Each condition takes 5 positions in the record.

Positions 1-4: Condition Code (See ICD-9 or ICD-10 codes)
Note: Whenever there is a 4-position code, there is always an implied decimal after the 3^rd position.

Position 5: Nature of Injury Flag (only for ICD-9 codes)

Code	Code Value
1	the code in position 1-4 is a Nature of Injury ICD-9 code
0	all other codes

NDI State of Death

• Short SAS Name: NDI_STATE_DEATH_CD

Contained in

• Master Beneficiary Summary File

This field identifies the state where the beneficiary death occurred.

Values

Centers for Disease Control and Prevention (CDC) National Death Index (NDI)

Recoded to SSA codes by CCW.

Available for 1999-2008. Researchers wishing to obtain this NDI segment of the MBSF must obtain an additional approval beyond the CMS DUA.

Code	Code Value
1	Alabama
2	Alaska
3	Arizona
4	Arkansas
5	California
6	Colorado
7	Connecticut
8	Delaware
9	District of Colombia
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 Virgina
52	Wisconsin
53	Wyoming

Obesity End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: OBESITY_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for obesity as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For obesity, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Obesity First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: OBESITY_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the obesity indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Operating Disproportionate Share Amount*

• Short SAS Name: DSH_OP
• Long SAS Name: DSH_OP_CLM_VAL_AMT

Contained in

• Inpatient RIF

Derived value created on extract from Claim value amount where value code = 18.

Values

Code
XXX.XX

Operating Indirect Medical Education (IME) Amount*

• Short SAS Name: IME_OP
• Long SAS Name: IME_OP_CLM_VAL_AMT

Contained in

• Inpatient RIF

Derived value created on extract from Claim value amount where value code = 19.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• MedPAR RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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.

Original Reason for Entitlement Code

• Short SAS Name: OREC
• Long SAS Name: ENTLMT_RSN_ORIG

Contained in

• Master Beneficiary Summary File

Original reason for Medicare entitlement.

Values

CMS obtains this information from the Social Security Administration (SSA) and Railroad Retirement Board (RRB) record systems.

Code	Code Value
0	OLD AGE AND SURVIVORS INSURANCE (OASI)
1	DISABILITY INSURANCE BENEFITS (DIB)
2	ESRD
3	BOTH DIB AND ESRD

Osteoporosis End-of-Year Flag

• Short SAS Name: OSTEOPRS

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Osteoporosis Mid-Year Flag

• Short SAS Name: OSTEOPRM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Other Developmental Delays End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: OTHDEL_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for other developmental delays as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For other developmental delays, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Other Developmental Delays First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: OTHDEL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the other developmental delays indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Other Inpatient Beneficiary Payments

• Short SAS Name: OIP_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of Medicare coinsurance and deductible payments in the non-acute inpatient hospital setting for the year. The total “other” inpatient (OIP) beneficiary payments are calculated as the sum of NCH_BENE_IP_DDCTBL_AMT and NCH_BENE_PTA_COINSRNC_LBLTY_AM for all relevant claims where the CLM_PMT_AMT >= 0.

These OIP claims are a subset of the claims in the IP data file consisting of data from IP settings such as long-term care hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, and other types of IP facilities such as children’s hospitals or cancer centers.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a CMS publication called "Your Medicare Benefits", which explains the deductibles and coinsurance amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Other Inpatient Covered Days

• Short SAS Name: OIP_COV_DAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of covered days in the non-acute inpatient setting for a given year.  The CCW variable CLM_UTLZTN_DAY_CNT is used to obtain this variable.   These “other” inpatient (OIP) claims are a subset of the claims in the IP data file consisting of data from IP settings such as long-term care hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, and other types of IP facilities such as children’s hospitals or cancer centers.

We consider fully-covered days, days where the beneficiary was liable for coinsurance, and lifetime reserve days to all be Medicare-covered days. Non-covered days, leave of absence days, and the day of discharge or death are not included.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Other Inpatient Medicare Payments

• Short SAS Name: OIP_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of the Medicare claim payment amounts (CLM_PMT_AMT from each claim) in the other inpatient (OIP) settings for a given year. To obtain the total OIP Medicare payments, take this variable and add in the annual per diem payment amount (OIP_MDCR_PMT + OIP_PERDIEM_AMT). .

These OIP claims are a subset of the claims in the IP data file consisting of data from IP settings such as long-term care hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, and other types of IP facilities such as children’s hospitals or cancer centers.

There are 2 cost/use categories from the IP data files: Acute and the OIP.

OIP_PERDIEM_PMT must be added to this field to obtain the total Medicare payments. The annual per diem variable was new in 2010; it will always be null/missing in earlier files.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a CMS publication called "Your Medicare Benefits", which explains the deductibles and coinsurance amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Other Inpatient Stays

• Short SAS Name: OIP_STAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of hospital stays (unique admissions, which may span more than one facility) in the non-acute inpatient setting for a given year.  A non-acute inpatient stay is defined as a set of one or more consecutive non-acute inpatient claims where the beneficiary is only discharged on the most recent claim in the set.  The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year. These “other” inpatient (OIP) claims are a subset of the claims in the IP data file consisting of data from IP settings such as long-term care hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, and other types of IP facilities such as children’s hospitals or cancer centers.

There are 2 cost/use categories from the IP data files: Acute and the OIP

Other Part B Carrier Beneficiary Payments

• Short SAS Name: OTHC_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments from Part B Carrier and DME claims which appear in settings other than the 10 specific categories which are part of this file for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Claims for other carrier/DME claims are a subset of the claims in the Part B Carrier and DME data files. Types of services which may have been summarized in this other carrier category (OTHC) include ambulance, chiropractor, chemotherapy, vision, hearing and speech services, etc.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Other Part B Carrier Events

• Short SAS Name: OTHC_EVENTS

Contained in

• Master Beneficiary Summary File

"This variable is the count of events in the part B other setting for a given year, which includes Part B Carrier and DME claims which appear in settings other than the 10 specific categories which are part of this file for a given year.  Claims for other carrier/DME claims are a subset of the claims in the Part B Carrier and DME data files.  Types of services which may have been summarized in this other carrier category (OTHC) include ambulance, chiropractor, chemotherapy, vision, hearing and speech services, etc.

An event is defined as each line item that contains the relevant service."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Other Part B Carrier Medicare Payments

• Short SAS Name: OTHC_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments from Part B Carrier and DME claims which appear in settings other than the 10 specific categories which are part of this file for a given year.  Claims for other carrier/DME claims are a subset of the claims in the Part B Carrier and DME data files.  Types of services which may have been summarized in this other carrier category (OTHC) include ambulance, chiropractor, chemotherapy, vision, hearing and speech services, etc.

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Other Procedures Beneficiary Payments

• Short SAS Name: OPROC_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for services considered part B other procedures (i.e., not anesthesia or dialysis) for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Claims for other procedures are a subset of the claims in the Part B Carrier data file. These other procedure claims are defined as those with a line BETOS code (`BETOS_CD) where the first 2 digits are (P1,P2,P3,P4,P5,P6,P7, orP8`).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Other Procedures Events

• Short SAS Name: OPROC_EVENTS

Contained in

• Master Beneficiary Summary File

"This variable is the count of events for part B other procedures for a given year. Claims for other procedures are a subset of the claims in the Part B Carrier data file. These other procedure claims are defined as those with a line BETOS code (BETOS_CD) where the first 2 digits are (P1,P2,P3,P4,P5,P6,P7, or P8).

An event is defined as each line item that contains the relevant service."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Other Procedures Medicare Payments

• Short SAS Name: OPROC_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for services considered part B other procedures (i.e., not anesthesia or dialysis) for a given year. Claims for other procedures are a subset of the claims, and a subset of procedures in the Part B Carrier data file. These other procedure claims are defined as those with a line BETOS code (`BETOS_CD) where the first 2 digits are (P1,P2,P3,P4,P5,P6,P7, orP8). The total Medicare payments are calculated as the sum ofLINE_NCH_PMT_AMTwhere theLINE_PRCSG_IND_CD` was ('A','R', or 'S') - for all relevant lines.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part A Months Count

• Short SAS Name: A_MO_CNT
• Long SAS Name: BENE_HI_CVRAGE_TOT_MONS

Contained in

• Master Beneficiary Summary File

Months of Part A coverage

This variable is the number of months during the year that the beneficiary had Medicare Part A coverage. (This is sometimes referred to as health insurance coverage - or Medicare HI coverage).

Derivation

CCW derives this variable by counting the number of months where the beneficiary had Part A coverage (i.e., the BUYINXX variable equaled 1, A, 3, or C).

Values

Code
0-12

Part A Termination Code

• Short SAS Name: A_TRM_CD
• Long SAS Name: BENE_PTA_TRMNTN_CD

Contained in

• Master Beneficiary Summary File

This code Specifies the reason Part A entitlement was terminated.

Values

Code	Code Value
0	Not terminated
1	Dead
2	Non-payment of premium
3	Voluntary withdrawl
9	Other termination

Part B Drug Beneficiary Payments

• Short SAS Name: PTB_DRUG_BENE_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the sum of coinsurance and deductible payments for part B drugs for a given year. Part B drug claims are a subset of the claims in the Part B Carrier and DME data files. The Part B drug claims are identified by BETOS codes (CCW variable `BETOS_CDwith values ofD1G,O1D,O1E,O1G,I1E, orI1F`).

The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.  "

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Drug Events

• Short SAS Name: PTB_DRUG_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events in the part B drug setting for a given year.  Part B drug claims are a subset of the claims in the Part B Carrier and DME data files. The Part B drug claims are identified by BETOS codes (CCW variable BETOS_CD with values of D1G,O1D,O1E,O1G,I1E, or I1F).  An event is defined as each line item that contains the relevant service.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Drug Medicare Payments

• Short SAS Name: PTB_DRUG_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for Part B drugs for a given year. Part B drug claims are a subset of the claims in the Part B Carrier and DME data files.  The Part B drug claims are identified by BETOS codes (CCW variable `BETOS_CDwith values ofD1G,O1D,O1E,O1G,I1E, orI1F`). 

Total Part B drug payments are calculated as sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S')."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Months Count

• Short SAS Name: B_MO_CNT
• Long SAS Name: BENE_SMI_CVRAGE_TOT_MONS

Contained in

• Master Beneficiary Summary File

Months of Part B coverage

This variable is the number of months during the year that the beneficiary had Medicare Part B coverage. (This is sometimes referred to as supplemental medical insurance coverage - or SMI coverage.) CCW derives this variable by counting the number of months where the beneficiary had Part B coverage (i.e., the BUYINXX variable equaled 2, B, 3, or C).

Values

Code
0-12

Part B Physician Beneficiary Payments

• Short SAS Name: PHYS_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for the part B physician office services (PHYS) for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Physician office claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician evaluation and management claims (note that E&M are tabulated separately in this data file). The PHYS claims are defined as those with a line BETOS code (`BETOS_CD) where the first three digits =M1A or M1B (the remainder of physician services which occur in different settings appear inEM_MDCR_PMT`).

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Physician Events

• Short SAS Name: PHYS_EVENTS

Contained in

• Master Beneficiary Summary File

"This variable is the count of events in the part B physician office services (PHYS) for a given year. Physician office claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician evaluation and management claims (note that E&M are tabulated separately in this data file).   The PHYS claims are defined as those with a line BETOS code (BETOS_CD) where the first three digits =M1A or M1B (the remainder of physician services which occur in different settings appear in  EM_MDCR_PMT).

An event is defined as each line item that contains the relevant service."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Physician Medicare Payments

• Short SAS Name: PHYS_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments for the part B physician office services (PHYS) for a given year. Physician office claims are a subset of the claims in the Part B Carrier and DME data files, and a subset of physician evaluation and management claims (note that E&M are tabulated separately in this data file).

The physician claims are defined as those with a line BETOS code (BETOS`_CD`) where the first 3 digits = M1A or M1B (note that all otherBETOS_CD that begin with "M" are categorized as other evluation & managment services in this file – see EM_MDCR_PMT). The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Part B Termination Code

• Short SAS Name: B_TRM_CD
• Long SAS Name: BENE_PTB_TRMNTN_CD

Contained in

• Master Beneficiary Summary File

This code specifies the reason Part B entitlement was terminated.

Values

Code	Code Value
0	Not terminated
1	Dead
2	Non-payment of premium
3	Voluntary withdrawl
9	Other termination

Part C Contract Number - April

• Short SAS Name: PTC_CNTRCT_ID_04
• Long SAS Name: PTC_CNTRCT_ID_04

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (April).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - August

• Short SAS Name: PTC_CNTRCT_ID_08
• Long SAS Name: PTC_CNTRCT_ID_08

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (August).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - December

• Short SAS Name: PTC_CNTRCT_ID_12
• Long SAS Name: PTC_CNTRCT_ID_12

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (December).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - February

• Short SAS Name: PTC_CNTRCT_ID_02
• Long SAS Name: PTC_CNTRCT_ID_02

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (February).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - January

• Short SAS Name: PTC_CNTRCT_ID_01
• Long SAS Name: PTC_CNTRCT_ID_01

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (January).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month.

You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - July

• Short SAS Name: PTC_CNTRCT_ID_07
• Long SAS Name: PTC_CNTRCT_ID_07

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (July).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - June

• Short SAS Name: PTC_CNTRCT_ID_06
• Long SAS Name: PTC_CNTRCT_ID_06

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (June).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - March

• Short SAS Name: PTC_CNTRCT_ID_03
• Long SAS Name: PTC_CNTRCT_ID_03

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (March).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - May

• Short SAS Name: PTC_CNTRCT_ID_05
• Long SAS Name: PTC_CNTRCT_ID_05

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (May).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - November

• Short SAS Name: PTC_CNTRCT_ID_11
• Long SAS Name: PTC_CNTRCT_ID_11

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (November).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - October

• Short SAS Name: PTC_CNTRCT_ID_10
• Long SAS Name: PTC_CNTRCT_ID_10

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (October).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C Contract Number - September

• Short SAS Name: PTC_CNTRCT_ID_09
• Long SAS Name: PTC_CNTRCT_ID_09

Contained in

• Master Beneficiary Summary File

This variable is the Medicare Part C contract number for the beneficiary’s Medicare Advantage (MA) plan for a given month (September).CMS assigns an identifier to each contract that a managed care plan has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Part C PBP Number - April

• Short SAS Name: PTC_PBP_ID_04
• Long SAS Name: PTC_PBP_ID_04

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (April).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - August

• Short SAS Name: PTC_PBP_ID_08
• Long SAS Name: PTC_PBP_ID_08

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (August).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - December

• Short SAS Name: PTC_PBP_ID_12
• Long SAS Name: PTC_PBP_ID_12

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (December).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - February

• Short SAS Name: PTC_PBP_ID_02
• Long SAS Name: PTC_PBP_ID_02

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (February).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - January

• Short SAS Name: PTC_PBP_ID_01
• Long SAS Name: PTC_PBP_ID_01

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (January).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - July

• Short SAS Name: PTC_PBP_ID_07
• Long SAS Name: PTC_PBP_ID_07

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (July).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - June

• Short SAS Name: PTC_PBP_ID_06
• Long SAS Name: PTC_PBP_ID_06

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (June).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - March

• Short SAS Name: PTC_PBP_ID_03
• Long SAS Name: PTC_PBP_ID_03

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (March).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - May

• Short SAS Name: PTC_PBP_ID_05
• Long SAS Name: PTC_PBP_ID_05

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (May).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - November

• Short SAS Name: PTC_PBP_ID_11
• Long SAS Name: PTC_PBP_ID_11

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (November).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - October

• Short SAS Name: PTC_PBP_ID_10
• Long SAS Name: PTC_PBP_ID_10

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (October).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C PBP Number - September

• Short SAS Name: PTC_PBP_ID_09
• Long SAS Name: PTC_PBP_ID_09

Contained in

• Master Beneficiary Summary File

The variable is the Medicare Part C plan benefit package (PBP) for the beneficiary’s Medicare Advantage (MA) plan for a given month (September).CMS assigns an identifier to each PBP within a contract that a Part C plan sponsor has with CMS.

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. You need to know both the Part C contract number (PTC_CNTRCT_ID_XX) and plan benefit package (PBP) in order to identify the specific plan in which a beneficiary was enrolled. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
3-digit alphanumeric that can include leading zeros.

Part C Plan Type Code - April

• Short SAS Name: PTC_PLAN_TYPE_CD_04
• Long SAS Name: PTC_PLAN_TYPE_CD_04

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (April).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - August

• Short SAS Name: PTC_PLAN_TYPE_CD_08
• Long SAS Name: PTC_PLAN_TYPE_CD_08

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (August).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - December

• Short SAS Name: PTC_PLAN_TYPE_CD_12
• Long SAS Name: PTC_PLAN_TYPE_CD_12

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (December).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - February

• Short SAS Name: PTC_PLAN_TYPE_CD_02
• Long SAS Name: PTC_PLAN_TYPE_CD_02

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (February).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - January

• Short SAS Name: PTC_PLAN_TYPE_CD_01
• Long SAS Name: PTC_PLAN_TYPE_CD_01

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (January).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - July

• Short SAS Name: PTC_PLAN_TYPE_CD_07
• Long SAS Name: PTC_PLAN_TYPE_CD_07

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (July).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - June

• Short SAS Name: PTC_PLAN_TYPE_CD_06
• Long SAS Name: PTC_PLAN_TYPE_CD_06

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (June).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - March

• Short SAS Name: PTC_PLAN_TYPE_CD_03
• Long SAS Name: PTC_PLAN_TYPE_CD_03

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (March).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - May

• Short SAS Name: PTC_PLAN_TYPE_CD_05
• Long SAS Name: PTC_PLAN_TYPE_CD_05

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (May).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - November

• Short SAS Name: PTC_PLAN_TYPE_CD_11
• Long SAS Name: PTC_PLAN_TYPE_CD_11

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (November).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - October

• Short SAS Name: PTC_PLAN_TYPE_CD_10
• Long SAS Name: PTC_PLAN_TYPE_CD_10

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (October).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part C Plan Type Code - September

• Short SAS Name: PTC_PLAN_TYPE_CD_09
• Long SAS Name: PTC_PLAN_TYPE_CD_09

Contained in

• Master Beneficiary Summary File

This variable is the type of Medicare Part C plan for the beneficiary for a given month (September).

If the beneficiary was not enrolled in a managed care plan for a given month, this variable will be null/missing for that month. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Part C Plan Type Code.txt

Part D Beneficiary Payments

• Short SAS Name: PTD_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the dollar amount that the beneficiary paid for all PDEs for a given year, without being reimbursed by a third party. The amount includes all copayments, coinsurance, deductible, or other patient payment amounts, and comes directly from the source Prescription Drug Events (PDEs).

The total beneficiary payments are calculated as the sum of three CCW variables: patient pay amount (PTNT_PAY_AMT), other troop amount (OTHER_TROOP_AMT), and patient liability reduction due to other payer amount (PLRO_AMT) for Part D drugs for the relevant PDEs.

This amount contributes to a beneficiary's true out-of-pocket (TrOOP) costs, but only if it is for a Part D-covered drug (i.e., spending on non-covered drugs does not count toward the TrOOP amount).

Note that another PDE variable called the low-income cost sharing (LIS) amount (variable name LICS_AMT), indicates the amount paid by Part D low-income subsidy for the PDE. Although this is sometimes considered a beneficiary payment (since it is made on behalf of a beneficiary), we have included the LIS payments in the Part D Medicare Payment amount (see variable called PTD_MDCR_PMT).

The value will be null if the beneficiary was not enrolled in Part D or did not use any Part D drugs during the year.

Part D Contract Number - April

• Short SAS Name: PTDCNTRCT04
• Long SAS Name: PTD_CNTRCT_ID_04

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (April). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - August

• Short SAS Name: PTDCNTRCT08
• Long SAS Name: PTD_CNTRCT_ID_08

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (August). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - December

• Short SAS Name: PTDCNTRCT12
• Long SAS Name: PTD_CNTRCT_ID_12

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (December). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - February

• Short SAS Name: PTDCNTRCT02
• Long SAS Name: PTD_CNTRCT_ID_02

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (February). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - January

• Short SAS Name: PTDCNTRCT01
• Long SAS Name: PTD_CNTRCT_ID_01

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (January). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - July

• Short SAS Name: PTDCNTRCT07
• Long SAS Name: PTD_CNTRCT_ID_07

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (July). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - June

• Short SAS Name: PTDCNTRCT06
• Long SAS Name: PTD_CNTRCT_ID_06

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (June). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - May

• Short SAS Name: PTDCNTRCT05
• Long SAS Name: PTD_CNTRCT_ID_05

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (May). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - November

• Short SAS Name: PTDCNTRCT11
• Long SAS Name: PTD_CNTRCT_ID_11

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (November). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - October

• Short SAS Name: PTDCNTRCT10
• Long SAS Name: PTD_CNTRCT_ID_10

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (October). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Contract Number - September

• Short SAS Name: PTDCNTRCT09
• Long SAS Name: PTD_CNTRCT_ID_09

Contained in

• Master Beneficiary Summary File

This variable is the Part D contract number for the beneficiary’s Part D plan for a given month (September). CMS assigns an identifier to each contract that a Part D plan has with CMS.

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D). If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Values

The first character of the contract ID is a letter that indicates the type of plan (for July 2009 and later, when X is followed by additional numbers/characters, it indicates Part D enrollment; for 2006-2009 the 'X' appeared without any other digits and indicated the beneficiary was not enrolled in Part D).

If the beneficiary did not have a Part D plan for a given month, this variable will have a value of X, N, 0, or *, or be null/missing for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled contract number.

For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules.

There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

You need to know both the Part D contract number and plan benefit package (PTD_PBP_ID_XX) in order to identify the specific plan in which a beneficiary was enrolled.

Code	Code Value
E	Employer direct plan (starting January 2007)
H	Managed care organizations other than a regional PPO (i.e., local MA-PDs, 1876 cost plans, Program of All-Inclusive Care for the Elderly (PACE) plans, private fee-for-service plans, or demonstration organization plans)
R	Regional preferred provider organization (PPO)
S	Stand-alone prescription drug plan (PDP)
X	Limited Income Newly Eligible Transition plan (LINET, starting July 2009)
N	Not Part D Enrolled
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Events

• Short SAS Name: PTD_EVENTS

Contained in

• Master Beneficiary Summary File

This variable is the count of events for Part D drugs for a given year (i.e., a unique count of the PDE_IDs). An event is a dispensed (filled) drug prescription that appears in the Prescription Drug Event (PDE) file.

The value will be null if the beneficiary was not enrolled in Part D or did not use any Part D drugs during the year.

PDEs consist of highly variable days supply of the medication. We also create a derived variable that counts a standard 30 day supply of a filled Part D prescription (see PTD_FILL_CNT).

Part D Fill Count

• Short SAS Name: PTD_FILL_CNT

Contained in

• Master Beneficiary Summary File

Part D prescribing events consist of highly variable days supply of the medication.  This derived variable creates a standard 30 days supply of a filled Part D prescription, and counts this as a “fill”.   The Part D fill count does not indicate the number of different drugs the person is using, only the total months covered by a medication (e.g., if a patient is receiving a full year supply of a medication, whether this occurs in one transaction or 12 monthly transactions, the fill count = 12; if the patient is taking three such medications, the fill count=36).  

The value will be null if the beneficiary was not enrolled in Part D or did not use any Part D drugs during the year.

We also calaculate the acutal number of prescription drug fill events for Part D drugs for a given year (i.e., a unique count of the PDE_IDs); see variable PTD_EVENTS.

Part D Medicare Payments

• Short SAS Name: PTD_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the dollar amount that the Part D plan covered for all covered drugs for a given year. The variable is calculated as the sum of the plan payments for covered PDEs (CVRD_D_PLAN_PD_AMT) and the low income cost sharing subsidy amount (LICS_AMT) during the year.

This variable does not include all costs to Medicare for the Part D benefit; it does not include non-covered drugs (PDE variable called NCVRD_PLAN_PD_AMT) also does not consider include any applicable rebate amounts or other discounts).

Plans may choose to provide enhanced benefits that pay for some non-covered drugs.

The value will be null if the beneficiary was not enrolled in Part D or did not use any Part D drugs during the year.

Part D PBP Number - April

• Short SAS Name: PTDPBPID04
• Long SAS Name: PTD_PBP_ID_04

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (April). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - August

• Short SAS Name: PTDPBPID08
• Long SAS Name: PTD_PBP_ID_08

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (August). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - December

• Short SAS Name: PTDPBPID12
• Long SAS Name: PTD_PBP_ID_12

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (December). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - February

• Short SAS Name: PTDPBPID02
• Long SAS Name: PTD_PBP_ID_02

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (February). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - January

• Short SAS Name: PTDPBPID01
• Long SAS Name: PTD_PBP_ID_01

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (January). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - July

• Short SAS Name: PTDPBPID07
• Long SAS Name: PTD_PBP_ID_07

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (July). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - June

• Short SAS Name: PTDPBPID06
• Long SAS Name: PTD_PBP_ID_06

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (June). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - March

• Short SAS Name: PTDPBPID03
• Long SAS Name: PTD_PBP_ID_03

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (March). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - May

• Short SAS Name: PTDPBPID05
• Long SAS Name: PTD_PBP_ID_05

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (May). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - November

• Short SAS Name: PTDPBPID11
• Long SAS Name: PTD_PBP_ID_11

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (November). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - October

• Short SAS Name: PTDPBPID10
• Long SAS Name: PTD_PBP_ID_10

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (October). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D PBP Number - September

• Short SAS Name: PTDPBPID09
• Long SAS Name: PTD_PBP_ID_09

Contained in

• Master Beneficiary Summary File

The variable is the Part D plan benefit package (PBP) for the beneficiary’s Part D plan for a given month (September). CMS assigns an identifier to each PBP within a contract that a Part D plan sponsor has with CMS.

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates the final, reconciled PBP number. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know both the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package in order to identify the specific plan in which a beneficiary was enrolled.

Values

Code
3-digit alphanumeric that can include leading zeros.

Part D Retiree Drug Subsidy Indicator - April

• Short SAS Name: RDSIND04
• Long SAS Name: RDS_IND_04

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (April).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - August

• Short SAS Name: RDSIND08
• Long SAS Name: RDS_IND_08

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (August).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - December

• Short SAS Name: RDSIND12
• Long SAS Name: RDS_IND_12

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (December).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - February

• Short SAS Name: RDSIND02
• Long SAS Name: RDS_IND_02

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (February).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - January

• Short SAS Name: RDSIND01
• Long SAS Name: RDS_IND_01

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (January).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - July

• Short SAS Name: RDSIND07
• Long SAS Name: RDS_IND_07

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (July).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - June

• Short SAS Name: RDSIND06
• Long SAS Name: RDS_IND_06

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (June).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - March

• Short SAS Name: RDSIND03
• Long SAS Name: RDS_IND_03

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (March).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - May

• Short SAS Name: RDSIND05
• Long SAS Name: RDS_IND_05

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (May).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - November

• Short SAS Name: RDSIND11
• Long SAS Name: RDS_IND_11

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (November).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - October

• Short SAS Name: RDSIND10
• Long SAS Name: RDS_IND_10

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (October).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Retiree Drug Subsidy Indicator - September

• Short SAS Name: RDSIND09
• Long SAS Name: RDS_IND_09

Contained in

• Master Beneficiary Summary File

This variable indicates if the beneficiary was enrolled in an employer-sponsored prescription drug plan that qualified for Part D’s retiree drug subsidy (RDS) for a given month (September).

Some employers offer prescription drug plans to their retirees, and Part D pays a subsidy to plans that offer coverage that is equivalent to (or better than) conventional Part D benefits. CMS does not collect PDEs for beneficiaries that are enrolled in RDS-eligible plans. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code	Code Value
Y	Employer subsidized for the retired beneficiary
N	No employer subsidization for the retired beneficiary
0	Not Medicare enrolled for the month
*	Enrolled in Medicare A and/or B, but no Part D enrollment data for the beneficiary. (This status was indicated as 'X' for 2006-2009)

Part D Segment Number - April

• Short SAS Name: SGMTID04
• Long SAS Name: PTD_SGMT_ID_04

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (April).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - August

• Short SAS Name: SGMTID08
• Long SAS Name: PTD_SGMT_ID_08

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (August).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - December

• Short SAS Name: SGMTID12
• Long SAS Name: PTD_SGMT_ID_12

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (December).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - February

• Short SAS Name: SGMTID02
• Long SAS Name: PTD_SGMT_ID_02

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (February).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - January

• Short SAS Name: SGMTID01
• Long SAS Name: PTD_SGMT_ID_01

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (January).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - July

• Short SAS Name: SGMTID07
• Long SAS Name: PTD_SGMT_ID_07

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (July).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - June

• Short SAS Name: SGMTID06
• Long SAS Name: PTD_SGMT_ID_06

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (June).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - March

• Short SAS Name: SGMTID03
• Long SAS Name: PTD_SGMT_ID_03

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (March).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - May

• Short SAS Name: SGMTID05
• Long SAS Name: PTD_SGMT_ID_05

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (May).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - November

• Short SAS Name: SGMTID11
• Long SAS Name: PTD_SGMT_ID_11

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (November).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - October

• Short SAS Name: SGMTID10
• Long SAS Name: PTD_SGMT_ID_10

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (October).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Segment Number - September

• Short SAS Name: SGMTID09
• Long SAS Name: PTD_SGMT_ID_09

Contained in

• Master Beneficiary Summary File

This variable is the segment number that CMS assigns to identify a geographic market segment or subdivision of a Part D plan; the segment number allows you to determine the market area covered by the plan. The variable describes the market segment for a given month (September).

If the beneficiary did not have a Part D plan for a given month, this variable will have null/missing value for that month. If the beneficiary changed plans during the year, the value indicates market segment identifier for the final, reconciled PBP. For 2006 - 2012, this variable was always encrypted to comply with CMS privacy rules. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December). You need to know the Part D contract number (PTD_CNTRCT_ID_XX) and plan benefit package (PTD_PBP_ID_XX) in order to determine the geographic market areas where the particular PBP was offered. Premiums may vary by market segment.

Values

Code
Null/missing or a 3-digit numeric value that includes leading zeros.

Part D Total Prescription Costs

• Short SAS Name: PTD_TOTAL_RX_CST

Contained in

• Master Beneficiary Summary File

This variable is the gross drug cost (TOT_RX_CST_AMT) of all Part D drugs for a given year. This value includes the ingredient cost, dispensing fee, sales tax (if applicable), and vaccine administration fee (if any, 2010+ only).

This is the price paid for the drug at the point of sale (i.e., the pharmacy counter), and it does not include any rebates or discounts that the drug manufacturer provides directly to the Part D plan sponsor.

The value will be null if the beneficiary was not enrolled in Part D or did not use any Part D drugs during the year.

Part D low-income cost share group code - April

• Short SAS Name: CSTSHR04
• Long SAS Name: CST_SHR_GRP_CD_04

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (April). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - August

• Short SAS Name: CSTSHR08
• Long SAS Name: CST_SHR_GRP_CD_08

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (August). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - December

• Short SAS Name: CSTSHR12
• Long SAS Name: CST_SHR_GRP_CD_12

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (December). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - February

• Short SAS Name: CSTSHR02
• Long SAS Name: CST_SHR_GRP_CD_02

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (February). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - January

• Short SAS Name: CSTSHR01
• Long SAS Name: CST_SHR_GRP_CD_01

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (January). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - July

• Short SAS Name: CSTSHR07
• Long SAS Name: CST_SHR_GRP_CD_07

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (July). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - June

• Short SAS Name: CSTSHR06
• Long SAS Name: CST_SHR_GRP_CD_06

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (June). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - March

• Short SAS Name: CSTSHR03
• Long SAS Name: CST_SHR_GRP_CD_03

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (March). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - May

• Short SAS Name: CSTSHR05
• Long SAS Name: CST_SHR_GRP_CD_05

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (May). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - November

• Short SAS Name: CSTSHR11
• Long SAS Name: CST_SHR_GRP_CD_11

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (November). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - October

• Short SAS Name: CSTSHR10
• Long SAS Name: CST_SHR_GRP_CD_10

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (October). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Part D low-income cost share group code - September

• Short SAS Name: CSTSHR09
• Long SAS Name: CST_SHR_GRP_CD_09

Contained in

• Master Beneficiary Summary File

This variable indicates the beneficiary’s Part D low-income subsidy cost sharing group for a given month (September). The Part D benefit requires enrollees to pay both premiums and cost-sharing, but the program also has a low-income subsidy (LIS) that covers some or all of those costs for certain low-income individuals, including deductibles and cost-sharing during the coverage gap.

CMS identifies beneficiaries with fully-subsidized Part D coverage by looking for individuals that have a 01, 02, or 03 for the month. Other beneficiaries who are eligible for the LIS but do not receive a full subsidy have a 04, 05, 06, 07, or 08. The remaining values indicate that the individual is not eligible for subsidized Part D coverage. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December)

Values

Part D low-income cost share group code .txt

Patient Discharge Status Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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.

Peripheral Vascular Disease End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: PVD_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for peripheral vascular disease as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For peripheral vascular disease, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Peripheral Vascular Disease First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: PVD_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the peripheral vascular disease indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Personality Disorders End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: PSDS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for personality disorders as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For personality disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Personality Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: PSDS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the personality disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Post-Traumatic Stress Disorder End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: PTRA_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for post-traumatic stress disorder as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For post-traumatic stress disorder, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Post-Traumatic Stress Disorder First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: PTRA_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the post-traumatic stress disorder indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Pressure Ulcers and Chronic Ulcers End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: ULCERS_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for pressure ulcers and chronic ulcers as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For pressure ulcers and chronic ulcers, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Pressure Ulcers and Chronic Ulcers First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: ULCERS_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the pressure ulcers and chronic ulcers indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Primary Claim Diagnosis Code Diagnosis Version Code (ICD-9 or ICD-10)

• Short SAS Name: PRNCPAL_DGNS_VRSN_CD
• Long SAS Name: PRNCPAL_DGNS_VRSN_CD

Contained in

• Durable Medical Equipment RIF
• Carrier RIF

Effective with Version 'J', the code used to indicate if the diagnosis is ICD-9 or ICD-10.

NOTE: With 5010, the diagnosis and procedure codes have been expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013.

Values

Code	Code Value
9	ICD-9
0	ICD-10

Prostate Cancer End-of-Year Flag

• Short SAS Name: CNCRPRST

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for prostate cancer as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For prostate cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with a prostate cancer code, on any diagnosis, within the last year. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Prostate Cancer Mid-Year Flag

• Short SAS Name: CNCRPRSM

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for prostate cancer on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For prostate cancer, beneficiaries must have at least one inpatient or SNF claim, or two Part B (institutional or non-institutional) claims that are at least one day apart, with a prostate cancer code, on any diagnosis, within the last year. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

Reference Year

• Short SAS Name: RFRNC_YR
• Long SAS Name: BEN_ENROLLMT_REF_YR

Contained in

• Master Beneficiary Summary File

This field indicates the reference year of the enrollment data. NOTE: The data files are partitioned into calendar year files.

Rendering Physician Specialty Code

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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)

Research Triangle Institute (RTI) Race Code

• Short SAS Name: RTI_RACE_CD
• Long SAS Name: RTI_RACE_CD

Contained in

• Master Beneficiary Summary File

Beneficiary race code (modified using RTI algorithm). Enhanced race/ethnicity designation based on first and last name algorithms.

Values

This variable is created by taking the beneficiary race code that has historically been used by the Social Security Administration (and is in turn used in CMS’s enrollment data base) and applying an algorithm that identifies more beneficiaries as Hispanic or Asian. This algorithm was developed by the Research Triangle Institute (RTI) and is thus often referred to as the “RTI race code”. The algorithm classifies beneficiaries as Hispanic or Asian if their SSA race code equals 4 (Asian) or 5 (Hispanic), or if they have a first or last name that RTI determined was likely Hispanic or Asian in origin.

The variable also incorporates CCW enhancements that reduce the number of beneficiaries with missing information.

Code	Code Value
0	UNKNOWN
1	NON-HISPANIC WHITE
2	BLACK (OR AFRICAN-AMERICAN)
3	OTHER
4	ASIAN/PACIFIC ISLANDER
5	HISPANIC
6	AMERICAN INDIAN / ALASKA NATIVE

Revenue Center (Medicare) Provider Payment Amount

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

Contained in

• Home Health Agency RIF

The amount Medicare paid for the services reported on the revenue center record.This field is rarely populated for Part A claims due to per-diem or DRG payments; the claim payment amounts should be used instead.For Hospital Outpatient services (also called Institutional Outpatient claims, which consist of claim type [variable called NCH_CLM_TYPE_CD]= 40), this variable can be summed across all revenue center lines for the claim to obtain the total Medicare claim payment amount.

This field is populated for those claims that are required to process through 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. Additional information regarding claim versus revenue-line level payments can be found in a CCW Technical Guidance document entitled: "Getting Started with Medicare Administrative Data."

Revenue Center 1^st ANSI Code

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

Contained in

• Outpatient RIF
• Home Health Agency RIF

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 1^st 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

• Outpatient RIF

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 2^nd ANSI Code

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

Contained in

• Outpatient RIF

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 2^nd 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

• Outpatient RIF

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 3^rd ANSI Code

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

Contained in

• Outpatient RIF

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 4^th ANSI Code

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

Contained in

• Outpatient RIF

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

• Outpatient RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Hospice RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF

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

• Outpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF

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 IDE, NDC, or UPC Number

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

Contained in

• Skilled Nursing Facility RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 Administration (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 accommodate the National Drug Code (NDC) and the Universal Product Code (UPC). This field could contain either of these 3 fields (there would never be an instance where more than one would come in on a claim). The size of this field was expanded to X(24) to accommodate either of the new fields (under Version 'H' it was X(7).

Revenue Center NDC Quantity

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

Contained in

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF

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

• Outpatient RIF

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

• Outpatient RIF

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 Responsibility Payment Amount

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

Contained in

• Home Health Agency RIF

The amount paid by the beneficiary to the provider for the line item service. 

NOTE: This field is populated for those claims that are required to process through Outpatient PPS 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. 

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

• Outpatient RIF

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 Amount

• Short SAS Name: REVPMT
• Long SAS Name: REV_CNTR_PMT_AMT_AMT

Variable Names

Dataset	2013	2012	2011	2010	2009
Outpatient	revpmt	revpmt	revpmt	revpmt	revpmt

Dataset	2008	2007	2006	2005	2004
Outpatient	revpmt	revpmt	revpmt	revpmt	revpmt

Dataset	2003	2002	2001	2000	1999
Outpatient	revpmt	revpmt	revpmt	revpmt	revpmt

Contained in

Effective with Version 'I', the line item Medicare payment amount for the specific revenue center.

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: this field contains provider reimbursement.

APASS: provider payment amount plus coinsurance and deductible (should not include coinsurance and deductible). Users should rely on provider payment amount field for the trust fund payment.

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 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

• Outpatient RIF
• Home Health Agency RIF

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, 1^st position being the service indicator and the 2^nd 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**** **** 1^st 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**** **** 2^nd 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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF
• Hospice RIF

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 1^st 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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Outpatient RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

Revenue Center Status Indicator Code

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

Contained in

• Outpatient RIF
• Hospice RIF
• Home Health Agency RIF

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 1^st 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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF

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

Rheumatoid Arthritis / Osteoarthritis End-of-Year Flag

• Short SAS Name: RA_OA

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the chronic condition data warehouse (CCW) criteria for rheumatoid arthritis/osteoarthritis as of the end of the calendar year.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For rheumatoid arthritis/osteoarthritis, beneficiaries must have at least two inpatient, SNF, home health, or Part B (institutional or non-institutional) claims that are at least one day apart with a rheumatoid arthritis/osteoarthritis code in any position during the 2-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient fee-for-service (FFS) coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Rheumatoid Arthritis / Osteoarthritis Mid-Year Flag

• Short SAS Name: RA_OA_M

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For rheumatoid arthritis/osteoarthritis, beneficiaries must have at least two inpatient, SNF, home health, or Part B (institutional or non-institutional) claims that are at least one day apart with a rheumatoid arthritis/osteoarthritis code in any position during the 2-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Schizophrenia End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: SCHI_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for schizophrenia as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For schizophrenia, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Schizophrenia First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: SCHI_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the schizophrenia indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Schizophrenia and Other Psychotic Disorders End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: SCHIOT_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for schizophrenia and other psychotic disorders as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For schizophrenia and other psychotic disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Schizophrenia and Other Psychotic Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: SCHIOT_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the schizophrenia and other psychotic disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Sensory - Blindness and Visual Impairment End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: VISUAL_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for sensory (blindness and visual) impairment as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For sensory (blindness and visual) impairment, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Sensory - Blindness and Visual Impairment First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: VISUAL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the sensory (blindness and visual) impairment indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Sensory - Deafness and Hearing Impairment End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: HEARIM_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for a sensory (deafness and hearing) impairment as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For sensory (deafness and hearing) impairment, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Sensory - Deafness and Hearing Impairment First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: HEARIM_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for a sensory (deafness and hearing) impairment. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Sex

• Short SAS Name: SEX
• Long SAS Name: SEX_IDENT_CD

Contained in

• Master Beneficiary Summary File

This variable indicates the sex of the beneficiary.

Values

Code	Code Value
0	UNKNOWN
1	MALE
2	FEMALE

Skilled Nursing Facility Beneficiary Payments

• Short SAS Name: SNF_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of Medicare coinsurance and deductible payments in the skilled nursing facility (SNF) setting for a given year.  The total beneficiary payment is calculated as the sum of DED_AMT and COIN_AMT for all SNF claims where the CLM_PMT_AMT >= 0.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a CMS publication called "Your Medicare Benefits", which explains the deductibles and coinsurance amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Skilled Nursing Facility Covered Days

• Short SAS Name: SNF_COV_DAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of Medicare covered days in the skilled nursing facility (SNF) setting for the year. This variable equals the sum of the CLM_UTLZTN_DAY_CNT variables on the source claims.

We consider fully-covered days, days where the beneficiary was liable for coinsurance, and lifetime reserve days to all be Medicare-covered days. Non-covered days, leave of absence days, and the day of discharge or death are not included.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Skilled Nursing Facility Medicare Payments

• Short SAS Name: SNF_MDCR_PMT

Contained in

• Master Beneficiary Summary File

This variable is the total Medicare payments in the skilled nursing facility (SNF) setting for a given year.  The total Medicare payments for SNF are calculated as the sum of CLM_PMT_AMT for all SNF claims where the CLM_PMT_AMT >= 0.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics” (see: here.)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (see the list of MLN publications at: here)

Skilled Nursing Facility Stays

• Short SAS Name: SNF_STAYS

Contained in

• Master Beneficiary Summary File

This variable is the count of skilled nursing facility setting (SNF) stays (unique admissions, which may span more than one facility) for a given year.  A SNF stay is defined as a set of one or more consecutive skilled nursing facility claims where the beneficiary is only discharged on the most recent claim in the set.

The CLM_FROM_DT for the first claim associated with the stay must have been in the year of the data file, however it was permissible for the CLM_THRU_DT to have occurred in January of the following year.

Source of enrollment data

• Short SAS Name: ENRL_SRC
• Long SAS Name: ENRL_SRC

Contained in

• Master Beneficiary Summary File

This variable indicates the source of enrollment data.

The Centers for Medicare & Medicaid Services (CMS) has updated the Medicare enrollment source data for the Master Beneficiary Summary File (MBSF). As of March 2017, the MBSF includes Medicare enrollment information from the CMS Common Medicare Environment (CME) rather than the CMS Enrollment Database (EDB). Data from the two sources was nearly identical. The CME improves the identification of Medicare Part B enrollment and also allows for more timely release of the MBSF. The universe of beneficiaries in the CME versus the EDB version of the MBSF are only slightly different.

Values

Code	Code Value
EDB	Enrollment Database
CME	Common Medicare Environment

Spina Bifida and Other Congenital Anomalies of the Nervous System End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: SPIBIF_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for spina bifida and other congenital anomalies of the nervous system as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For spina bifida and other congenital anomalies of the nervous system, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Spina Bifida and Other Congenital Anomalies of the Nervous System First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: SPIBIF_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the spina bifida and other congenital anomalies of the nervous system indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Spinal Cord Injury End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: SPIINJ_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for spinal cord injury as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For spinal cord injury, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Spinal Cord Injury First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: SPIINJ_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the spinal cord injury indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Standard Payment Amount

• Short SAS Name: PPS_STD_VAL_PYMT_AMT
• Long SAS Name: PPS_STD_VAL_PYMT_AMT

Contained in

• Inpatient RIF

This amount identifies the standardized Medicare payment amount.

This is the standardized amount as determined by PRICER software output. This amount is never used for payments. It is used for comparisons across different regions of the country for the value-based purchasing initiatives and for research. It is a standard amount, without the geographical payment adjustments and some of the other add-on payments that actually go to the hospitals.

This field is new in October 2014. This field only applies to Inpatient claims. Note that an additional field is available that further adjusts the standard Medicare Payment amount by applying additional standardization requirements (e.g. sequestration).

Refer to variable called the final standardized amount (FINL_STD_AMT).

Values

Code
XXX.XX

State Buy-In Coverage Count

• Short SAS Name: BUYIN_MO
• Long SAS Name: BENE_STATE_BUYIN_TOT_MONS

Contained in

• Master Beneficiary Summary File

Total number of months of state buy-in.

This variable counts the total number of months during the year when the beneficiary premium was paid by the state. State Medicaid programs can pay Medicare premiums for certain dual eligibles (i.e., for beneficiaries also enrolled in a state Medicaid program); this action is called “buying in” and so this variable is the “buy-in code.” Any month where the BUYINXX variable was: A (Part A state buy-in), B (Part B state buy-in), or C(Part A and Part B state buy-in) is counted.

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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

State and county FIPS code - April

• Short SAS Name: STATE_CNTY_FIPS_CD_04
• Long SAS Name: STATE_CNTY_FIPS_CD_04

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in April.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - August

• Short SAS Name: STATE_CNTY_FIPS_CD_08
• Long SAS Name: STATE_CNTY_FIPS_CD_08

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in August.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - December

• Short SAS Name: STATE_CNTY_FIPS_CD_12
• Long SAS Name: STATE_CNTY_FIPS_CD_12

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in December.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - February

• Short SAS Name: STATE_CNTY_FIPS_CD_02
• Long SAS Name: STATE_CNTY_FIPS_CD_02

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in February.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - January

• Short SAS Name: STATE_CNTY_FIPS_CD_01
• Long SAS Name: STATE_CNTY_FIPS_CD_01

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in January.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - July

• Short SAS Name: STATE_CNTY_FIPS_CD_07
• Long SAS Name: STATE_CNTY_FIPS_CD_07

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in July.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - June

• Short SAS Name: STATE_CNTY_FIPS_CD_06
• Long SAS Name: STATE_CNTY_FIPS_CD_06

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in June.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - March

• Short SAS Name: STATE_CNTY_FIPS_CD_03
• Long SAS Name: STATE_CNTY_FIPS_CD_03

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in March.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - May

• Short SAS Name: STATE_CNTY_FIPS_CD_05
• Long SAS Name: STATE_CNTY_FIPS_CD_05

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in May.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - November

• Short SAS Name: STATE_CNTY_FIPS_CD_11
• Long SAS Name: STATE_CNTY_FIPS_CD_11

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in November.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - October

• Short SAS Name: STATE_CNTY_FIPS_CD_10
• Long SAS Name: STATE_CNTY_FIPS_CD_10

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in October.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State and county FIPS code - September

• Short SAS Name: STATE_CNTY_FIPS_CD_09
• Long SAS Name: STATE_CNTY_FIPS_CD_09

Contained in

• Master Beneficiary Summary File

This field specifies the monthly the concatenated state/county Federal Information Processing Standard (FIPS) code for the beneficiary - in September.

The first 2 digits specify the state; the last 3 digits specify the county. This variable is derived by taking the SSA state/county code on record for the beneficiary in the CMS enrollment database and linking it to the corresponding FIPS state/county code. There are 12 monthly variables - where the 01 through 12 at the end of the variable name correspond with the month (e.g., 01 is January and 12 is December).

Values

Code
5-digit numeric value, which can include leading zeros, or null (if there is no crosswalk from the SSA code to the FIPS code)

State code for beneficiary (SSA code)

• Short SAS Name: STATE_CD
• Long SAS Name: STATE_CODE

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

• Master Beneficiary Summary File

The social security administration (SSA) standard 2-digit state code of a beneficiary's residence.

ResDAC data variable alert:Invalid beneficiary resident state codes are being sent to CMS from SSA.    -SSA has not identified a timeframe for resolution but the two agencies are addressing the issue.    -CMS notes the invalid codes as: 67, 68, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 96 and 97.    - ResDAC is aware that redundant code values exist in the table:        -64, 99 resolve to American Samoa;        -65, 98 resolve to Guam;        -66, 97 resolve to Northern Marianas. As noted above, 97 is an invalid code.

Values

State SSA codes_GDIT_05182017.txt

Stroke / Transient Ischemic Attack End-of-Year Flag

• Short SAS Name: STRKETIA

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria within the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For stroke/TIA, beneficiaries must have at least one inpatient claim or two Part B (institutional or non-institutional) claims with a stroke/TIA code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Stroke / Transient Ischemic Attack Mid-Year Flag

• Short SAS Name: STRKTIAM

Contained in

• Master Beneficiary Summary File

This code specifies whether the beneficiary met the chronic condition algorithm criteria on July 1 of the specified reference period.

Values

The CCW’s chronic condition flags require beneficiaries to satisfy both claims criteria (a minimum number/type of claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (FFS Part A and Part B coverage during the entire specified time period). For stroke/TIA, beneficiaries must have at least one inpatient claim or two Part B (institutional or non-institutional) claims with a stroke/TIA code in any position during the 1-year reference period. The CCW’s criteria were developed after reviewing validated algorithms from the research literature and criteria used by other federal data sources. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Neither claims nor coverage met
1	Claims met, coverage not met
2	Claims not met, coverage met
3	Claims and coverage met

Tests Beneficiary Payments

• Short SAS Name: TEST_BENE_PMT

Contained in

• Master Beneficiary Summary File

This variable is the sum of coinsurance and deductible payments for part B tests for a given year. The total Beneficiary payments are calculated as the sum of LINE_COINSRNC_AMT + LINE_BENE_PTB_DDCTBL_AMT for the relevant lines.

Claims for tests are a subset of the claims in the Part B Carrier data file. These claims are defined as those with a line BETOS code (`BETOS_CD`) where the first digit =T.

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Tests Events

• Short SAS Name: TEST_EVENTS

Contained in

• Master Beneficiary Summary File

"This variable is the count of events in for part B tests for a given year.  Claims for tests are a subset of the claims in the Part B Carrier data file. These claims are defined as those with a line BETOS code (BETOS_CD) where the first digit =T.

An event is defined as each line item that contains the relevant service."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Anesthesia, Part B Drug, Physician, E & M, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Tests Medicare Payments

• Short SAS Name: TEST_MDCR_PMT

Contained in

• Master Beneficiary Summary File

"This variable is the total Medicare payments for part B tests for a given year.  Claims for tests are a subset of the claims in the Part B Carrier data file. These claims are defined as those with a line BETOS code (`BETOS_CD`) where the first digit =T.

The total Medicare payments are calculated as the sum of LINE_NCH_PMT_AMT where the LINE_PRCSG_IND_CD was ('A','R', or 'S') - for all relevant lines."

There are 11 cost/use categories from the Carrier Part B and DME data files – the ASC, Part B Drug, Physician, E &M, anesthesia, dialysis, imaging, tests, other procedures, DME and other carrier claims.

Tobacco Use Disorders End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: TOBA_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for tobacco use disorders as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE: For tobacco use disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Tobacco Use Disorders First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: TOBA_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the tobacco use disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Traumatic Brain Injury and Nonpsychotic Mental Disorders due to Brain Damage End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: BRAINJ_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for traumatic brain injury and nonpsychotic mental disorders as of the end of the calendar year.

Values

The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

For traumatic brain injury and nonpsychotic mental disorders, beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Traumatic Brain Injury and Nonpsychotic Mental Disorders due to Brain Damage First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: BRAINJ_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the traumatic brain injury and nonpsychotic mental disorders indicator. The variable will be blank for beneficiaries that have never had the condition.

The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

Valid Date of Death Switch

• Short SAS Name: V_DOD_SW
• Long SAS Name: VALID_DEATH_DT_SW

Contained in

This variable indicates whether a beneficiary's day of death has been verified by the Social Security Administration (SSA) or the Railroad Retirement Board (RRB).

Values

The date of death of the beneficiary is contained in the BENE_DEATH_DT variable; many of these dates of death are not confirmed.

Code	Code Value
Null	Default
V	Valid death date

Viral Hepatitis (General) End-of-Year Indicator - Medicare Only Claims

• Short SAS Name: HEPVIRAL_MEDICARE

Contained in

• Master Beneficiary Summary File

This variable indicates whether a beneficiary met the condition criteria for viral hepatitis (general) as of the end of the calendar year.

NOTE: The condition variable requires beneficiaries to satisfy both claims criteria (a minimum number/type of Medicare claims that have the proper diagnosis codes and occurred within a specified time period) and coverage criteria (Medicare FFS Part A and Part B coverage during the entire specified time period).

NOTE1: For viral hepatitis (general), beneficiaries must have at least one Medicare inpatient claim or two other non-drug claims of any service type with a related code in any position during the 2-year reference period. You can find more detailed information on the criteria on the CCW website: here

Values

Code	Code Value
0	Beneficiary did not meet claims criteria or have sufficient FFS coverage
1	Beneficiary met claims criteria but did not have sufficient FFS coverage
2	Beneficiary did not meet claims criteria but had sufficient FFS coverage
3	Beneficiary met claims criteria and had sufficient FFS coverage

Viral Hepatitis (General) First Ever Occurrence Date - Medicare Only Claims

• Short SAS Name: HEPVIRAL_MEDICARE_EVER

Contained in

• Master Beneficiary Summary File

This variable shows the date when the beneficiary first met the criteria for the viral hepatitis (general) indicator. The variable will be blank for beneficiaries that have never had the condition.

NOTE: The earliest possible date for anyone in the CCW is January 1, 1999. If the beneficiary became eligible for Medicare after that, the earliest possible date will be some time after his/her coverage start date (i.e., the COVSTART variable in the Beneficiary File).

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

• Skilled Nursing Facility RIF
• Outpatient RIF
• Inpatient RIF
• Hospice RIF
• Home Health Agency RIF
• Durable Medical Equipment RIF
• Carrier RIF

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.