EASYGroup Technical Reference Guide...Optum | May 27, 2021 Page 8 1.3 Document Conventions This guide uses the following conventions: • Any screen fields, buttons, tabs, or other

EASYGroup™ Technical Reference Guide

V2108.01Last Updated: August 19, 2021 4:26 pm

EASYGroup™ Technical Reference Guide

Published August 2021The format of this document is 8.5 x 11”

© 2021 Optum.

All rights reserved.

This document is protected by copyright law and international treaties. Unauthorized reproduction or distribution of this document, or any portions of it, may result in sever civil and criminal penalties, and will be prosecuted to the maximum extent under the law.

CPT® codes, descriptions, and other CPT® materials obtain a copyright of 2020 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT®. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association.

Current Dental Terminology, © 2020 American Dental Association. All rights reserved.

Applicable FARS/DFARS Restrictions Apply to Government Use.

3M™ is a trademark of the 3M™ Company. The 3M™ Grouper Plus System (3M™ GPS) and the 3M™ Grouper Plus Content Services (GPCS) along with the 3M™ Enhanced Ambulatory Patient Grouping System (3M™ EAPGS) and it’s logic are proprietary to the 3M™ Company and are sub-ject to the terms and conditions of the software licensing agreement between 3M™ and Optum.

© 2021, American Hospital Association (AHA), Chicago, Illinois. Reproduced with permission. No portion of this publication may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.

Optum and the Optum logo are registered trademarks of Optum. All other brand or product names or trademarks are registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer.

EDC Analyzer™ - U.S. Patent No. 10,417,382

Optum11000 Optum Circle

Eden Prairie, MN 55344

[email protected]

Optum | www.optum.com August 19, 2021 Page 3

Table of ContentsChapter 1: Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Introduction to This Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Organization of This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Document Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8About Optum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 2: Optimizer Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Optimizer Return Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 3: Function Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Function Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Chapter 4: Analyzer Return Codes and Error Codes . . . . . . . . . . . . . . . . . . . . . 19Claim-Level Analyzer Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Claim-Level Analyzer Error Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Chapter 5: Editor Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ACE, CAH Method II Editor, and TRICARE APC Editor Return Codes . . 24DSC Editor Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27EASYEdit™ Editor Return Codes (C Only) . . . . . . . . . . . . . . . . . . . . . . . 29LCD Editor Return Codes (C Only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29MOE Return Codes (C Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Physician Editor Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Chapter 6: Grouper/Reader Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32APC and ASC Grouper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . 33APG Grouper Return Codes (C Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . 33DRG Grouper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35IRF Grouper Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42HHA HHRG/PDGM Reader Return Codes . . . . . . . . . . . . . . . . . . . . . . . . 44SNF Reader Return Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Chapter 7: Pricer Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Claim-Level Pricer Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Line-Level Pricer Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Chapter 8: Mapper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Claim-Level Mapper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Diagnosis-Level Mapper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . . 99Procedure-Level Mapper Return Codes . . . . . . . . . . . . . . . . . . . . . . . . . 100

Chapter 9: Troubleshooting & Logging in EASYGroup™. . . . . . . . . . . . . . . . . 101General EASYGroup™ Logging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Configuring Logging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105How to Resolve Return Code 60 and 61 . . . . . . . . . . . . . . . . . . . . . . . . 107Additional Logging for EASYGroup™ Server . . . . . . . . . . . . . . . . . . . . . 110Additional Logging for EASYGroup™ Web Service . . . . . . . . . . . . . . . . 115Additional Logging for Optum Exchange PPS (OEPPS) . . . . . . . . . . . . 117

Chapter 10: Hospital & Physician Rate Calculator File Key Fields. . . . . . . . . . 122C Platform Key Fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123COBOL Platform Key Fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Chapter 11: Medicare Hospital Rate Calculator File Layouts. . . . . . . . . . . . . . 128


Inpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130Outpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Physician Layouts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Chapter 12: Medicaid Hospital Rate Calculator File Layouts . . . . . . . . . . . . . . 178Inpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Outpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Chapter 13: Other Hospital Rate Calculator File Layouts. . . . . . . . . . . . . . . . . 209Inpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210Outpatient Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Chapter 14: Physician Factor File Layout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239C and COBOL Platform Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Chapter 15: Fee Schedule File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242Fee Schedule Data File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244Legacy Fee Schedule Data File Layout . . . . . . . . . . . . . . . . . . . . . . . . . 263

Chapter 16: Code Table Data File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . 265File Naming Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266Code Table Data File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Chapter 17: New York Medicaid APG Zip Code File Layout . . . . . . . . . . . . . . 307New York Medicaid APG Zip Code File Layout (C Platform Only) . . . . . 308

Chapter 18: Payers File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309File Naming Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310Payers File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Chapter 19: Configuration File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312File Naming Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313C Platform Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314COBOL Platform Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Chapter 20: Rate File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332File Naming Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333C Platform. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333COBOL Platform. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

Chapter 21: Rule File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382File Naming Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383APC Rule File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383ASC Rule File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386ACE Rule File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388Mapping Rule File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

Chapter 22: Editor File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393DSC Editor File Layouts (C and COBOL Platforms). . . . . . . . . . . . . . . . 394LCD Editor File Layouts (C Platform Only) . . . . . . . . . . . . . . . . . . . . . . . 400MOE File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408Physician Editor File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

Chapter 23: Reader File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419HHA PDGM V01 Reader File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . 420

Chapter 24: Analyzer File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421


EDC Analyzer™ File Layouts (C Platform Only). . . . . . . . . . . . . . . . . . . 422E&M Analyzer Pro File Layouts (C Platform Only) . . . . . . . . . . . . . . . . . 426

Chapter 25: Mapping Data File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 Mapping Data File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432

Chapter 26: Description File Layouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434DRG and MDC Grouper Description Files . . . . . . . . . . . . . . . . . . . . . . . 435APG Grouper Description File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436APC Grouper Description File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436

Chapter 27: Date-Sensitive Codes & Titles Files and Translation File Layouts 437Date-Sensitive Codes and Titles Overview . . . . . . . . . . . . . . . . . . . . . . 438Distinguishing Different Code Types . . . . . . . . . . . . . . . . . . . . . . . . . . . 439Identifying the Appropriate Code Value Record . . . . . . . . . . . . . . . . . . 439CPT® Copyright Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440ICD-9-CM, ICD-10-CM/PCS, and HCPCS Codes & Titles File Layouts. 440EASYGroup™ Translation File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449


1 Overview

This chapter provides an overview of this manual and how to contact Optum. It contains the following sections:

• Introduction to This Guide• Intended Audience• Organization of This Guide• Document Conventions• About Optum• Contact Us

- Corporate Address- Need Assistance? Contact Optum Client Care- Portal- Found an Error in This User’s Guide?


1.1 Introduction to This GuideThe EASYGroup™ Technical Reference Guide contains technical information to configure and analyze all EASYGroup™ components.

1.1.1 Intended AudienceThis guide is directed to:

- Information Technology Personnel- System Administrators

This guide assumes that the reader has a working knowledge of C and/or COBOL language syntax and file structures. All EASYGroup™ COBOL components utilize standard COBOL, using a compiler that conforms to INCITS/ISO/IEC 1989-2002 standard, “High” level specifications. The COBOL file types used are SEQUENTIAL and INDEXED.

1.2 Organization of This GuideTable 1-1: Guide Contents

Section DescriptionChapter 1, Overview Overview of Optum and of this user’s guideChapter 2, Optimizer Return Codes Listing of all EASYGroup™ Optimizer

Return CodesChapter 3, Function Return Codes Listing of all EASYGroup™ Function Return

CodesChapter 4, Analyzer Return Codes and Error Codes

Listing of all EASYGroup™ Analyzer Return Codes

Chapter 5, Editor Return Codes Listing of all EASYGroup™ Editor Return Codes

Chapter 6, Grouper/Reader Return Codes Listing of all EASYGroup™ Grouper Return Codes

Chapter 7, Pricer Return Codes Listing of all EASYGroup™ Pricer Return Codes

Chapter 8, Mapper Return Codes Listing of all EASYGroup™ Mapper Return Codes

Chapter 9, Troubleshooting & Logging in EASYGroup™

Troubleshooting and logging information for EASYGroup™

Chapter 10, Hospital & Physician Rate Calculator File Key Fields

Instructions on how to set up the hospital/provider rate calculator files, along with key fields

Chapter 11, Medicare Hospital Rate Calculator File Layouts

Listing of Medicare Rate Calculator File variables

Chapter 12, Medicaid Hospital Rate Calculator File Layouts

Listing of Medicaid Rate Calculator File variables


1.3 Document ConventionsThis guide uses the following conventions:

• Any screen fields, buttons, tabs, or other controls that you can manipulate are printed in bold type. Keys that you press on the keyboard are also printed in bold type. For example:- Press the Exit button.- Press the Enter key.

• Keyboard keys that you must press simultaneously are printed in bold type and separated by a plus (+) sign. For example:- Press Ctrl + C.

• Links embedded in the text that you can select to jump to another section are in orange. For example:- Mappers

• Field names for the C Platform and filenames are italicized. For example: - pricer_rtn_code- EASYGroup.exe

Chapter 13, Other Hospital Rate Calculator File Layouts

Listing of other Hospital Rate Calculator File variables

Chapter 14, Physician Factor File Layout Listing of Physician Factor File variablesChapter 15, Fee Schedule File Layouts Listing of Fee Schedule File variablesChapter 16, Code Table Data File Layouts Listing of Code Table Data File variablesChapter 17, New York Medicaid APG Zip Code File Layout

Listing of the New York Medicaid APG Zip Code File variables

Chapter 18, Payers File Layout Listing of Payers File variablesChapter 19, Configuration File Layouts Listing of Configuration File variablesChapter 20, Rate File Layouts Listing of Rate File variablesChapter 21, Rule File Layouts Listing of Rule File variablesChapter 22, Editor File Layouts Listing of Editor file variablesChapter 24, Analyzer File Layouts Listing of the data files and corresponding

variables utilized by the AnalyzerChapter 25, Mapping Data File Layouts Listing of the Mapping Data File variablesChapter 26, Description File Layouts Description of DRG, MDC, APG, and APC/

ASC Description FilesChapter 27, Date-Sensitive Codes & Titles Files and Translation File Layouts

Listing and descriptions of the Date-Sensitive Codes & Titles File(s), the Translation File variables

Index Quick reference index

Table 1-1: Guide Contents

Section Description


• Field names for the COBOL Platform are in all caps. For example: - PRCR-RTN-CODE

• Field Description titles are printed in bold type:- NICU Accreditation Indicator

• Legislation titles are italicized. For example:- Balanced Budget Act of 1997

1.4 About OptumOptum is a health services business dedicated to making the health system work better for everyone. At Optum, we help modernize the health ecosystem, by bringing inter-operable and connected technology, real-time information, streamlined administration and managed compliance, risk, and costs.

1.5 Contact Us1.5.1 Corporate Address

Optum11000 Optum CircleEden Prairie, MN. 55344T 1 + (888) 445-8745www.optum.com

1.5.2 Need Assistance? Contact Optum Client CareWe welcome you as a valued client. When opening a ticket with Optum Client Care you will be issued a ticket number. These ticket numbers correlate to individual issues. If you are experiencing multiple issues, it is recommended that you obtain individual ticket numbers.Please contact Optum Client Care using one of the methods detailed below:

• Navigating to the Optum Payment Integrity Software Support Portal• Sending an Email to Optum Client Care:

1. Include name and number and detailed description of product issue.2. Response time to email is generally within a few business hours.3. Service technician has ability to do prior research before calling back.

• Via the Optum Client Care Phone: 800-999-DRGS (3747)When calling Optum Client Care regarding a previously opened ticket, have your ticket number available. If you misplaced or did not receive a ticket number, please ask the technician to provide it to you.

http://www.optum.com

https://optumproductsupport.force.com/PISoftwareSupport/login?ec=302&startURL=%2FPISoftwareSupport%2Fs%2F

mailto:[email protected]


1. Calls are answered in the order that they are received. If there is a high call volume, calls are held in a queue until a technician becomes available.

2. Calls classified as an industry expert category (i.e., case and reimbursement, logic encoder, etc.) will be escalated to Optum experts.

3. Technicians are available 24/7.

1.5.3 PortalFor access to the latest release information, announcements, user documentation, release schedules, and much more please visit the Regulatory Portal.

1.5.4 Found an Error in This User’s Guide?Please feel free to contact our Optum PPS Product Suite Documentation Team with any errors you may have found within this document:Optum PPS_DocumentationWe welcome feedback from our clients.

mailto:[email protected]

https://clientportal.optum.com/content/regportal/login.html


2 Optimizer Return Codes

This chapter provides a list of all EASYGroup™ Optimizer Return Codes. For more information on the EASYGroup™ Optimizer please refer to the EASYGroup™ User’s Guide and the Input and Output Parameter Blocks User’s Guide. This chapter includes the following sections:

• Optimizer Return Code- OOB1 [opt_output_block1] and OOB1-OPT-OUTPUT-BLOCK1 Return

Codes


2.1 Optimizer Return Code2.1.1 OOB1 [opt_output_block1] and OOB1-OPT-OUTPUT-BLOCK1 Return Codes

Table 2-1: OOB1 [opt_output_block1] and OOB1-OPT-OUTPUT-BLOCK1 Return CodesReturn Code Short Description Long Description C or COBOL or Both00 No Errors Found There were no Optimizer errors found on the claim. Both04 Error Calling the

Analyzer Control Program

The Optimizer cannot find or locate the Analyzer Control Program (caacntl.c/.dll) that is required to process this record. The Analyzer Control Program should be stored in the same directory that contains the Optimizer control program.

C

05 Error Calling the Mapper Control Program

The Optimizer cannot find or load the Mapper Control Program (mapcntl.c/.dll/mapcntl.cob/cmapcntl.cob) that is required to process this record. The Mapper Control Program should be stored in the same directory that contains the Optimizer program.

Both

06 Error Calling the Editor Control Program

The Optimizer cannot find or load the Editor Control Program (edtcntl.c/.dll; edtcntl.cob/edtcntl.cob) that is required to process this record. The Editor Control Program should be stored in the same directory that contains the Optimizer program.

Both

07 Error Calling the Grouper Control Program

The Optimizer cannot find or load the Grouper Control Program (grpcntl.c/.dll; grpcntl.cob/grpcntl.cob) that is required to process this record. The Grouper Control Program should be stored in the same directory that contains the Optimizer program.

Both

08 Error Calling the Pricer Control Program

The Optimizer cannot find or load the Pricer Control Program (prccntl.c/.dll; prccntl.cob/prccntl.cob) that is required to process this record. The Pricer Control Program should be stored in the same directory that contains the Optimizer program.

Both

09 Error Calling the Retrieve Payer Program

The Optimizer cannot find or load the Retrieve Payer Program (rtvpyr.c/.dll; rtvpyr.cob/rtvpyr.cob) that is required to process this record. The Retrieve Payer Program should be stored in the same directory that contains the Optimizer program.

Both

10 Error Calling the Model Control Program

The Optimizer cannot find or load the Modeling Control Program (mdlcntl.c/.dll; mdlcntl.cob/mdlcntl.cob) that is required to process this record. The Modeling Control Program should be stored in the same directory that contains the Optimizer program.

Both

11 Non-Zero Return Code From Mapper

The Optimizer received a non-zero Return Code from the Mapper and cannot continue processing this case. Refer to the Mapper Return Codes section of this guide for further information.

Both


12 Non-Zero Return Code From the DSC Editor

The Optimizer received a non-zero Return Code from the Date-Sensitive Code (DSC) Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

13 Non-Zero Return Code From the EASYEdit™

The Optimizer received a non-zero Return Code from EASYEdit™ and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

14 Non-Zero Return Code From ACE

The Optimizer received a non-zero Return Code from the Ambulatory Code Editor™ (ACE) and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

15 Non-Zero Return Code From Grouper

The Optimizer received a non-zero Return Code from the Grouper and cannot continue processing this case. Refer to the Grouper/Reader Return Codes section of this guide for further information.

Both

16 Non-Zero Return Code From Pricer

The Optimizer received a non-zero Return Code from the Pricer and cannot continue processing this case. Refer to the Pricer Return Codes section of this guide for further information.

Both

17 Non-Zero Return Code From LCD Editor

The Optimizer received a non-zero Return Code from the LCD Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

18 Non-Zero Return Code From Retrieve Payer Program

The Optimizer received a non-zero Return Code from the Retrieve Payer Program and cannot continue processing this case. When Optimizer Return Code 18 is issued, a Function Return Code is also issued. Refer to the Function Return Codes section of this guide for further information.

Both

19 Non-Zero Return Code From Model Control Program

The Optimizer received a non-zero Return Code from the Modeling Control Program and cannot continue processing this case. When Optimizer Return Code 19 is issued, a Function Return Code is also issued. Refer to the Function Return Codes section of this guide for further information.

Both

20 EZGMEM Cannot Be Loaded

The Optimizer cannot find or load the EASYGroup™ Memory Allocation Program (ezgmem.c/.dll) that is required to process this record. The memory allocation program should be stored in the same directory that contains the Optimizer program.

C

21 Non-Zero Return Code from TRICARE APC Editor

The Optimizer received a non-zero Return Code from the TRICARE APC Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

22 Non-Zero Return Code From Physician Editor

The Optimizer received a non-zero Return Code from the Physician Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

Table 2-1: OOB1 [opt_output_block1] and OOB1-OPT-OUTPUT-BLOCK1 Return CodesReturn Code Short Description Long Description C or COBOL or Both


23 Non-Zero Return Code From Analyzer

The Optimizer received a non-zero Return Code from the Analyzer and cannot continue processing this case. Refer to the Analyzer Return Codes and Error Codes section of this guide for further information.

C

24 Non-Zero Return Code From Log Control Program

The Log File (logcntl.txt) cannot be created (due to a permissions issue, etc.), therefore the Logging Control Program (logcntl.c/.dll) will generate Optimizer Return Code 24, as well as Function Return Code 18. Refer to the Function Return Codes section for further information.

C

25 Non-Zero Return Code From MOE

The Optimizer received a non-zero Return Code from the MOE and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

26 Non-Zero Return Code From CAH Method II Editor

The Optimizer received a non-zero Return Code from the CAH Method II Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

87 Program Cannot Be Loaded

The control program cannot find or load the Optimizer program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found or the 3M™

GPS interfacing program (ezgps) cannot be found or loaded.

C

90 Invalid Request An invalid value in the Operation Code 1 (opcode1; ECB-OPCODE1) field was passed to the Optimizer.

Both

94 Invalid Dates Indicates one of the following conditions:- Effective Date on the claim is missing or not a valid

date.- From Date on the claim is missing or is not a valid

date.- Thru Date on the claim is missing or is not a valid

date.- From Date is after the Thru Date.

C

95 Parameter Error There is an error in the parameters being passed to EASYGroup™ and that one of the following is true:- Not enough memory has been allocated by the

calling program.- Memory has not been allocated by the calling

program for a required input or output structure.- The Extended Structure Switch (ext_blk_sw) field

located in the ECB [ezg_cntl_block] is not set to 1.

C

Table 2-1: OOB1 [opt_output_block1] and OOB1-OPT-OUTPUT-BLOCK1 Return CodesReturn Code Short Description Long Description C or COBOL or Both


3 Function Return Codes

This chapter provides a list of all EASYGroup™ Function Return Codes. This chapter includes the following sections:

• Function Return Codes- ECB [ezg_cntl_block] and FRB-FUNC-RTN-BLOCK Return Codes


3.1 Function Return Codes3.1.1 ECB [ezg_cntl_block] and FRB-FUNC-RTN-BLOCK Return Codes

Table 3-1: ECB [ezg_cntl_block] and FRB-FUNC-RTN-BLOCK Return CodesReturn Code Short Description Long Description C or COBOL or Both00 No Errors Found There were no errors found on the claim. Both01 No Hospital Rate

Calculator RecordThere is no Hospital Rate Calculator Record with a matching: - Hospital Number - Paysource Code- Patient TypeWhich has an Effective Date less than or equal to the Reimbursement Date passed to the Pricer.

Both

07 Error Calling the Grouper Control Program

The Optimizer cannot find or load the Grouper Control Program (grpcntl.c/.dll; grpcntl.cob/grpcntl.cob) that is required to process this record. The Grouper Control Program should be stored in the same directory that contains the Optimizer program.

C

08 Error Calling the Pricer Control Program

The Optimizer cannot find or load the Pricer Control Program (prccntl.c/.dll; prccntl.cob/prccntl.cob) that is required to process this record. The Pricer Control Program should be stored in the same directory that contains the Optimizer program.

C

10 No Historical Rate Record Found

The claim has an Effective Date prior to October 01, 2008 and no configuration record or historical hospital rate record was found.

COBOL

12 Non-Zero Return Code From the DSC Editor

The Optimizer received a non-zero Return Code from the Date-Sensitive Code (DSC) Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

13 Non-Zero Return Code From the EASYEdit™

The Optimizer received a non-zero Return Code from EASYEdit™ and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

14 Non-Zero Return Code From ACE

The Optimizer received a non-zero Return Code from the Ambulatory Code Editor™ (ACE) and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

15 Non-Zero Return Code From Grouper

The Optimizer received a non-zero Return Code from the Grouper and cannot continue processing this case. Refer to the Grouper/Reader Return Codes section of this guide for further information.

C

16 Non-Zero Return Code From Pricer

The Optimizer received a non-zero Return Code from the Pricer and cannot continue processing this case. Refer to the Pricer Return Codes section of this guide for further information.

C


17 Non-Zero Return Code From LCD Editor

The Optimizer received a non-zero Return Code from the LCD Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

18 Error Creating Log File The Log File (logcntl.txt) cannot be created (due to a permissions issue, etc.), therefore the Logging Control Program (logcntl.c/.dll) will generate Function Return Code 18, as well as Optimizer Return Code 24. Refer to the Optimizer Return Codes section for further information.

C

19 Grouping or Pricing Operation Failed in the Model Control Program

The Grouping or Pricing operation failed in the Modeling control program. Refer to the Grouper/Reader Return Codes and the Pricer Return Codes sections of this guide for further information.

COBOL

20 Invalid or Missing Taxonomy

The Retrieve Payer Control Program (rtvpyr; RTVPYR) lookup has failed due to a missing or invalid taxonomy code. Practitioner claims must include at least one valid taxonomy code.

Both

21 Non-Zero Return Code from TRICARE APC Editor

The Optimizer received a non-zero Return Code from the TRICARE APC Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

22 Non-Zero Return Code From Physician Editor

The Optimizer received a non-zero Return Code from the Physician Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

25 Non-Zero Return Code From MOE

The Optimizer received a non-zero Return Code from the MOE and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

C

26 Non-Zero Return Code From CAH Method II Editor

The Optimizer received a non-zero Return Code from the CAH Method II Editor and cannot continue processing this case. Refer to the Editor Return Codes section of this guide for further information.

Both

62 Closed or Inactive Rate Record

This facility is closed or inactive as indicated by the Closed Facility Switch in Rate Manager/the Configuration File.

Both

70 Configuration Record Error

The Configuration/hospital rate files are out of sync. Claim has an Effective Date on or after October 01, 2008 and the configuration record was not found, but a hospital rate record with an Effective Date on or after October 01, 2008 was found.

Both


The Pricer/Grouper Control program cannot find or load the Pricer/Grouper program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer program.

C

88 Initialization Error Check required components. C

Table 3-1: ECB [ezg_cntl_block] and FRB-FUNC-RTN-BLOCK Return CodesReturn Code Short Description Long Description C or COBOL or Both


89 Memory Error A memory allocation error has been found or the 3M™ GPS interfacing program (ezgps) cannot be found or loaded.

C

94 Invalid Dates Indicates one of the following conditions:- Effective Date on the claim is missing or not a valid

date.- From Date on the claim is missing or is not a valid

date.- Thru Date on the claim is missing or is not a valid

date.- From Date is after the Thru Date.

Both

95 Parameter Error There is an error in the parameters being passed to EASYGroup™ and that one of the following is true:- Not enough memory has been allocated by the




C

CL Cannot Load or Open Program

An error occurred during the opening or loading of the Retrieve Payer Control Program (rtvpyr; RTVPYR) or associated programs. Refer to the Interface Function Return Code Status (FRB-RTN-STATUS) field for further information.

COBOL

IO File I/O Error One or more of the rate files cannot be opened or closed. Refer to Interface Function Return Code 2 (FRB-RTN-CODE2) field for further information.

COBOL

R1 Invalid Patient Type The value provided in the Patient Type (pattype) field in the ECB [ezg_cntl_block] structure is invalid. Valid values are as follows:- 01 = Inpatient- 02 = Outpatient- 03 = IRF- 04 = Physician- 06 = SNF

C

Table 3-1: ECB [ezg_cntl_block] and FRB-FUNC-RTN-BLOCK Return CodesReturn Code Short Description Long Description C or COBOL or Both


4 Analyzer Return Codes and Error Codes

This chapter provides a list of all EASYGroup™ Analyzer Return Codes and Error Codes. For more information on EASYGroup™ Analyzers please refer to the EASYGroup™ User’s Guide. This chapter includes the following sections:

• Claim-Level Analyzer Return Codes• Claim-Level Analyzer Error Codes


4.1 Claim-Level Analyzer Return CodesIf one of the below Analyzer Return Codes is triggered, the claim will be rejected.

Table 4-1: Claim-Level Analyzer Return Codes

Return Code Short Description Long Description00 No Errors Found There were no errors found on the claim.01 Exclusion File Not

FoundEDC Analyzer™:The Exclusion File (comp0vvv.dat) is missing.

02 Standard Costs File Not Found

EDC Analyzer™:The Standard Costs File (comp1vvv.dat) is missing.

03 Extended Costs File Not Found

EDC Analyzer™:The Extended Costs File (comp2vvv.dat) is missing.

04 Patient Complexity Costs File Not Found

EDC Analyzer™:The Patient Complexity Costs File (comp3vvv.dat) is missing.

05 Exclusion File Not Found

E&M Analyzer Pro:The Exclusion File (excluvvv.dat) is missing.

06 Diagnosis Risk File Not Found

E&M Analyzer Pro:The Diagnosis Risk File (dxrskvvv.dat) is missing.

07 Visit Level Complexity Claim File Not Found

E&M Analyzer Pro:The Visit Level Complexity Claim File (vlccvvv.dat) is missing.

08 Visit Level Complexity Diagnosis File Not Found

E&M Analyzer Pro:The Visit Level Complexity Diagnosis File (vlcdvvv.dat) is missing.

84 Cannot Open Communication Connection

The Analyzer was unable to open the communications channel required to log claim data.

85 Unable to Write Claim to the Log File

The Analyzer was unable to successfully write claim data to the claim results text file. Several conditions could cause this which include insufficient permissions, a hardware error, or lack of disk space.

87 Program Cannot be Loaded

The Analyzer control program cannot find or load the Analyzer program that is required. The Analyzer control program should be stored in the same directory that contains the Optimizer program.

88 Initialization Error Check required components.89 Memory Error A memory allocation error has been found.


4.2 Claim-Level Analyzer Error CodesIf one of the below Analyzer Error Codes is returned, the claim will stop processing through the Analyzer (except as noted below), but will not be rejected.

Table 4-2: Claim-Level Analyzer Error Codes

Error Code Short Description Long Description00 No Errors Found There were no errors found on the claim.01 Claim Length of Stay is

Invalid or Greater Than Two Days

The claim spans greater than two days.

02 No Emergency Department Visit on This Claim

EDC Analyzer™:This claim does not include an emergency department visit code (e.g., 99281 – 99285/G0380 – G0384).

E&M Analyzer Pro:This claim does not include an emergency department visit code (e.g., 99281 – 99285).

03 More Than One Emergency Department Visit on This Claim

EDC Analyzer™:This claim includes more than one emergency department visit code (e.g., 99281 – 99285, G0380 – G0384).

E&M Analyzer Pro:This claim includes more than one emergency department visit code (e.g., 99281 – 99285).

04 Invalid, Ambiguous, or No Gender on This Claim

This claim meets one or more of the following criteria:- Gender for the patient was not billed- An invalid or unknown gender for the patient was

billed (i.e., something other than M, F, 1, or 2 was billed)

- Condition Code 45 (Ambiguous Gender Category) was billed (EDC Analyzer™ Only)

05 Claim Excluded Based on Patient Age

This claim meets one of the following criteria:- Patient was under the age of 2 years- Patient was over the age of 124 years (which is

considered invalid)06 Claim Excluded Based

on Diagnosis CodeThis claim includes a diagnosis code (e.g., Schizophrenia) which is excluded from claim processing.

07 There are No Diagnosis Codes on This Claim That are Considered by the Analyzer

EDC Analyzer™:This claim does not include any reason for visit diagnosis codes for which a weight has been established.

E&M Analyzer Pro:This claim does not include any diagnosis codes for which a risk has been established.


*This error code is for informational purposes only and will not stop processing through the Analyzer.

08 Claim Excluded Based on Discharge Disposition

EDC Analyzer™:This claim includes a Discharge Disposition other than 01 (Discharged to Home or Self Care), 07 (Left Against Medical Advice), or 81 (Discharged to Home or Self-Care With a Planned Acute Care Hospital Inpatient Readmission).

09 Claim Excluded Based on Procedure Code

This claim includes a procedure code which is excluded (e.g., critical care).

10 Claim Excluded Based on Revenue Code

EDC Analyzer™:This claim includes a revenue code which is excluded from claim processing.

11* Claim Excluded Because Minimum Facility Claim Data Was Not Provided

E&M Analyzer Pro:This claim does not contain the minimum facility claim data that is required. This includes the following:- UB-04 Bill Type- Discharge Disposition- At least one claim line with a procedure code or

revenue code

12* Claim Excluded Because a High Risk Procedure Code Was Identified on the Facility Claim

E&M Analyzer Pro:This facility claim includes a high risk procedure code which is excluded from claim processing.

13* Claim Excluded Because Observation Services Were Identified on the Facility Claim

E&M Analyzer Pro:This facility claim includes an observation service which is excluded from claim processing.

14* Claim Excluded Due to Death or Admission Identified on Facility Claim

E&M Analyzer Pro:This claim is excluded because either the patient died or was admitted to another health care setting. Therefore this claim is excluded from processing.

15 Claim Excluded Based on Gender Mismatch

EDC Analyzer™:This claim contains a mismatch between the Gender submitted on the claim and the reason for visit diagnosis code. For example, the claim for a Male patient has a diagnosis code of C55 (Malignant Neoplasm of Uterus, Part Unspecified).

Table 4-2: Claim-Level Analyzer Error Codes

Error Code Short Description Long Description


5 Editor Return Codes

This chapter provides a list of all EASYGroup™ Editor Return Codes. For more information on EASYGroup™ Editors please refer to the EASYGroup™ User’s Guide. This chapter includes the following sections:

• ACE, CAH Method II Editor, and TRICARE APC Editor Return Codes• DSC Editor Return Codes• EASYEdit™ Editor Return Codes (C Only)• LCD Editor Return Codes (C Only)• MOE Return Codes (C Only)• Physician Editor Return Codes


5.1 ACE, CAH Method II Editor, and TRICARE APC Editor Return Codes

Table 5-1: ACE, CAH Method II Editor, and TRICARE APC Editor Return Codes

Return Code Short Description Long Description C or COBOL or Both00 No Parameter or I/O

ErrorsThere were no errors found. TRICARE APC:

C

All Others:Both

02 Code File or Other I/O Error

ACE:Cannot find or open the code file (aceedit.dat).

CAH Method II Editor:Cannot find or open the code file (aceedit.dat or physedit.dat).

C

03 CCI Edit File Open or I/O Error

ACE:Cannot find or open one or more of the CCI Edit Files (cciedit.dat or cciedt2.dat).

CAH Method II Editor:Cannot find or open one or more of the CCI Edit Files (cciedit.dat, cciedt2.dat, or physcci.dat).

C

04 OCE/CCI Edit File Open or I/O Error

ACE and CAH Method II Editor:Cannot find or open one or more of the OCE/CCI Edit Files (ocecci.dat or ocecci2.dat).

C

05 Number of Procedures <1

There are no procedure codes on this claim. The input field Number of Procedure Codes (numhcpcs; PCB1-HCT-NUMHCPCS) must be greater than or equal to 1.

TRICARE APC:C

All Others:Both

06 Claims Spans > 365 Days

ACE and CAH Method II Editor:The claim length of stay ((Thru Date - From Date) + 1) is greater than 365 days.

Both

08 Unsupported Bill Type(3M™ GPS Only)

TRICARE APC Editor:The bill type on the claim is not a valid UB-04 bill type, or is otherwise not supported.

C

09 Number of Diagnoses < 1

There are no diagnosis codes on this claim. Number of Diagnosis Codes (numdx; PCB1-DCT-NUMDX) field must be greater than or equal to 1.

TRICARE APC:C

All Others:Both

10 Final Disposition Exceeds Maximum Acceptable Level of Error

ACE and CAH Method II Editor:Final claim disposition exceeds maximum acceptable level of error.

Both


11 ACE and CAH Method II Editor:MUE File Open or I/O Error

TRICARE APC:Claims Dates Outside of Grouper Version

ACE and CAH Method II Editor:Cannot find or open the MUE File (mue.dat).

TRICARE APC: Claim dates outside of Grouper version.

C

12 Invalid Date TRICARE APC:The date on a claim is missing or invalid.

C

13 Code Pair File Open or I/O Error

CAH Method II Editor:Cannot find or open the codepairs.dat file.

C

60 Cannot Load External Software

TRICARE APC:The 3M™ GPS was not installed or configured correctly.

C

61 All Other Errors From External Software

TRICARE APC:The 3M™ GPS returns an unexpected result or an exception is thrown.

C

65 Invalid Certificate TRICARE APC (3M™ GPCS only):The certificate needed for the 3M™ GPCS is not present or is invalid and/or when the required unique key needed for a Super Certificate(s) is not present or is invalid.

C

66 Invalid URL TRICARE APC (3M™ GPCS only):The values set in one of the following environment variables are missing or invalid: - GPCS_URL (i.e., the URL to send claim info to)- GPCS_STSURL (i.e., the URL to validate the

certificate)

C

80 Invalid Content Version TRICARE APC (3M™ GPCS only):An invalid content version (GPCS_ContentVersion) has been passed to the GPCS. This version is set either in an environment variable or in the HssSetup.ini file.

C


The Editor Control Program (edtcntl) cannot find or load the Editor program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.

NoteFor 3M™ GPCS users only, this Return Code might also be issued if the appropriate version of the Microsoft C++ redistributable and/or the appropriate version of OpenSSL is not installed. Please refer to the EASYGroup™ Installation Guide for a list of appropriate versions for these 3M™ GPCS software requirements.

C

88 Initialization Error Check required components. C


Return Code Short Description Long Description C or COBOL or Both


89 Memory Allocation Error A memory allocation error has been found or the 3M™ GPS interfacing program (ezgps) cannot be found or loaded.

C

95 Parameter Error There is an error in the parameters being passed toEASYGroup™ and that one of the following is true:- Not enough memory has been allocated by the


program for a required input or output structure.

C

IO File I/O Error ACE and CAH Method II Editor:One or more of the Editor data files cannot be opened or closed. Please refer to AEB1-RTN-CODE2 for details.

COBOL


ACE and CAH Method II Editor:An error occurred during the opening or loading of the Editor or associated programs.

COBOL




5.2 DSC Editor Return CodesTable 5-2: DSC Editor Return Codes

Return Code Short Description Long Description C or COBOL or Both00 No Error Found There were no errors found on the claim. Both01 Insufficient Memory C02 General Processing

ErrorC

03 Code Lookup Error, Code Not Found

C

03 Invalid Number of DX/OP Codes

Exceeds max allowed. COBOL

05 Error Opening Editor File(s)

The Editor is unable to open the ICD-10 Diagnosis and Procedure File (dxopfile.dat; dxopi10.dat).

C

07 Error Reading Editor File(s)

C

09 Maximum Error Code C10 HAC Editor Not Found C16 Invalid ALC Days/

Interrupted DaysThe number of non-covered/leave of absence days reported with UB-04 Occurrence Span Code 74 and UB-04 Occurrence Span Dates 1 and 2 is greater than or equal to the claim Length of Stay. This Return Code is only issued for claims with a Discharge Date greater than or equal to October 01, 2012 that are billed with a procedure code subject to DSC Edit 026.

Both

18 Invalid Occurrence Span Date

The UB-04 Occurrence Span Code 74 has been reported with an invalid UB-04 Occurrence Span Date 1 or 2, or a UB-04 Occurrence Span Date 2 that is before the UB-04 Occurrence Span Date 1. This Return Code is only issued for claims with a Discharge Date greater than or equal to October 01, 2012 that are billed with a procedure code subject to DSC Edit 026.

Both


The Editor Control Program cannot find or load the Editor program that is required. The Editor program should be stored in the same directory that contains the Optimizer program.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. C95 Parameter Error There is an error in the parameters being passed to

EASYGroup™ and that one of the following is true:- Not enough memory has been allocated by the




C

IO File I/O Error One or more of the DSC Editor data tables cannot be opened or closed. Please refer to MEB1-RTN-CODE2 and MEB1-RTN-STATUS for details.

COBOL



An error occurred during the opening or loading of the DSC Editor or associated programs.

COBOL

Table 5-2: DSC Editor Return Codes



5.3 EASYEdit™ Editor Return Codes (C Only)

5.4 LCD Editor Return Codes (C Only)

Table 5-3: EASYEdit™ Editor Return Codes

Return Code Short Description Long Description00 Record Edited

Table 5-4: LCD Editor Return Codes

Return Code Short Description Long Description00 No Errors Found There were no errors found on the claim.01 Cannot Open codes.dat File An error occurred during the opening or loading of the codes.dat file.02 Cannot Open i10pairs.dat File An error occurred during the opening or loading of the i10pairs.dat file.03 Cannot Open index.dat File An error occurred during the opening or loading of the index.dat file.04 Cannot Open ap.dat File An error occurred during the opening or loading of the ap.dat file.05 Cannot Open i10sd.dat File An error occurred during the opening or loading of the i10sd.dat file.06 Cannot Open fi.dat File An error occurred during the opening or loading of the fi.dat file.07 Invalid From or Thru Date08 Policy in i10pairs.dat File Has

No Matching Entry in the Index.dat File

The LCD or NCD policy cannot be found in the index.dat file.

09 Provider ID Not Found on Fi.dat File and No Default is Defined

The NPI and/or Facility ID cannot be found in the fi.dat file and no default MAC was defined.

10 I/O Initialization Error13 No Edits Available for the

Fiscal Intermediary, Carrier, or MAC Associated with This Provider ID

No LCD or NCD edits have been defined for this MAC.

14 Cannot Open i10stdx.dat File An error occurred during the opening or loading of the i10stdx.dat file.16 Cannot Open mac.dat File An error occurred during the opening or loading of the mac.dat file.17 No Matching MAC Record

FoundMAC ID cannot be found in the mac.dat file.

18 Number of Diagnoses < 1 There are no diagnosis on this claim.87 Program Cannot be Loaded The Editor Control program cannot find or load the Editor program that

is required. The Editor program should be stored in the same directory that contains the Optimizer program.



5.5 MOE Return Codes (C Only)

5.6 Physician Editor Return Codes

Table 5-5: MOE Return Codes

Return Code Short Description Long Description00 No Errors Found There were no errors found on the claim.02 Code File Open or I/O Error Cannot find or cannot open the MOE Code File (moeedit.dat).04 OCE/CCI Edit File Open or I/O

ErrorCannot find or cannot open the OCE/CCI Edit File (ocecci2.dat).

05 Number of Procedures < 1 The number of procedure codes (numhcpcs) must be greater than or equal to 1.

09 Number of Diagnoses < 1 The number of diagnosis codes (numdx) must be greater than or equal to 1.


Final claim disposition exceeds maximum acceptable level of error.

11 MUE File Open or I/O Error Cannot find or cannot open the MUE File (mue.dat)12 Edit Cannot be Found on Code

FileMOE cannot locate a requested edit (for the claim From Date) in the MOE Code Table File (moeedit.dat).

87 Program Cannot Be Loaded The Editor control program (edtcntl) cannot find or load the Editor program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.


Table 5-6: Physician Editor Return Codes


00 No Errors Found There were no errors found on the claim. Both02 Code File Open or I/O Error Cannot locate or open the code file

physedit.dat.C

03 CCI Edit File Open or I/O Error Cannot locate or open the CCI edit file physcci.dat.

C

05 Number of Procedures < 1 The input field Number of Procedure Codes (numhcpcs; PCB1-HCT-NUMHCPCS) must be greater than or equal to 1.

Both

09 Number of Diagnoses < 1 The input field Number of Diagnosis Codes (numdx; PCB1-DCT-NUMDX) must be greater than or equal to 1.

Both


Final claim disposition exceeds maximum acceptable level of error.

Both


11 Edit Cannot Be Found on Code File

Cannot locate a requested edit (for the claim from date) in the code file physedit.dat.

C

12 MUE File Open or I/O Error Cannot find or cannot open the mue.dat file. C

13 Code Pair File Open or I/O Error

Cannot find or cannot open the codepairs.dat file.

C

87 Program Cannot Be Loaded The Editor control program (edtcntl) cannot find or load the Editor program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. CIO File I/O Error One or more of the Editor data files cannot be

opened or closed. Please refer to PEB1-RTN-CODE2 and PEB1-RTN-STATUS for details.

COBOL

CL Cannot Load or Open Program An error occurred during the opening or loading of the Editor or associated programs.

COBOL

Table 5-6: Physician Editor Return Codes



6 Grouper/Reader Return Codes

This chapter provides a list of all EASYGroup™ Grouper/Reader Return Codes. For more information on EASYGroup™ Groupers please refer to the EASYGroup™ User’s Guide. This chapter includes the following sections:

• APC and ASC Grouper Return Codes• APG Grouper Return Codes (C Only)• DRG Grouper Return Codes• IRF Grouper Return Codes• HHA HHRG/PDGM Reader Return Codes• SNF Reader Return Codes

- Claim Level- Line Level


6.1 APC and ASC Grouper Return Codes

6.2 APG Grouper Return Codes (C Only)

Table 6-1: APC and ASC Grouper Return Codes

Return Code Short Description Long Description C or COBOL or Both00 No Errors Found There were no errors found on the claim. Both62 Closed or Inactive

Rate RecordThis facility is closed or inactive as indicated by the Closed Facility Switch in Rate Manager/the Configuration File.

Both


The Grouper control program cannot find or load the Grouper program or the Retrieve Payer Control Program (rtvpyr) that is required. These programs should be stored in the same directory that contains the Optimizer.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. C90 Invalid Function Code Claim contains an invalid Operation Code (ECB-

OPCODE1).COBOL

91 Invalid Grouper Type The Grouper Type is missing or is invalid. COBOL92 Invalid Patient Type The Patient Type is missing or is invalid. COBOL93 Invalid Function for

This Patient TypeCOBOL

94 Invalid From/Thru Date Relationship

The service dates on the claim are invalid. COBOL


An error occurred during the opening or loading of the Grouper or associated programs.

COBOL

IO File I/O Error One or more of the Grouper data files cannot be opened or closed. Please refer to GOB1-GRPR-RTN-CODE2 and GOB1-GRPR-RTN-STATUS for details.

COBOL

Table 6-2: APG Grouper Return Codes

Return Code Short Description Long Description00 No Errors Found There were no errors found on the claim.01 No Claim Lines Submitted Claim received, but no line-level information is present. 02 No Principal Diagnosis Code

SubmittedClaim did not include regulation information for EAPG processing.

03 Invalid or Inconsistent From/Thru or Service Dates

The Grouper will not process From/Thru dates as entered.

04 Error Acquiring Grouper Version/Payer Exceptions

A schedule is not found or the 3M™ payment database cannot be opened.

29 Error Reading eapgdata.dat File The APG Grouper Table (eapgdata.dat) cannot be found or read.30 Error Writing to Database 3M™ GPS only:

The payer exceptions and Grouper version that are passed to the APG Grouper are not written to the 3MPay folder.


56 Date Not Supported by Grouper Version

From Date is not supported by this EAPG Grouper version.

60 Cannot Load External Software The 3M™ GPS was not installed or configured correctly. 61 All Other Errors Returned from External

Software This error is returned when the 3M™ GPS returns an unexpected result or an exception is thrown.

62 Closed or Inactive Rate Record The Closed Facility Switch is set to 1 (Closed) in Rate Manager/the Configuration File.

65 Invalid Certificate 3M™ GPCS only:This error will occur when the certificate needed for the 3M™ GPCS is not present or is invalid and/or when the required unique key needed for a Super Certificate(s) is not present or is invalid.

66 Invalid URL 3M™ GPCS only:This error will occur when the values set in the 3M™ GPCS, GPCS_URL (i.e., the URL to send claim info to) and/or the GPCS_STSURL (i.e., the URL to validate the certificate) environmental variable or hsssetup.ini are missing or invalid.

67 All Other Errors Return From GPCS 3M™ GPCS only:This error will occur after a claim has been sent to the 3M™ GPCS and a maximum of 15 seconds has passed (by default). If this Return Code is triggered, the claim should be re-submitted. If this error is issued again, there may be an issue with the client’s Server clock.

The length of time to wait before issuing this Return Code is configurable by adjusting the GPCS_HTTPS_Timeout variable in the hsssetup.ini file or via the environment variable.

80 Invalid Content Version 3M™ GPCS only:An invalid content version (GPCS_ContentVersion) has been passed to the GPCS. This version is set either in an environment variable or in the HssSetup.ini file.

87 Program Cannot Be Loaded The Grouper Control Program (grpcntl) cannot find or load the Grouper program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.


88 Initialization Error Check required components.89 Memory Allocation Error A memory allocation error has been found or the 3M™ GPS

interfacing program (ezgps) cannot be found or loaded.94 Error Opening Grouper Table95 Parameter Error Check parameters.

Table 6-2: APG Grouper Return Codes

Return Code Short Description Long Description


6.3 DRG Grouper Return CodesTable 6-3: DRG Grouper Return Codes

Return Code

Short Description Long Description Example C or COBOL or Both

00 No Errors Found There were no errors found on the claim.

Both

01 Diagnosis Cannot Be Used as Principal

Principal diagnosis is valid but cannot be used as principal for purposes of the DRG assignment.

A claim with an external cause of injury code as the principal diagnosis will receive Return Code 01.

Example: Principal diagnosis W19.XXXA.

Both

02 Record Does Not Meet Criteria for Any DRG in MDC, as Indicated by Principal Diagnosis

Claim did not match any DRG in the MDC indicated by the principal diagnosis.

NoteNot returned for ICD-9 Medicare DRG and TRICARE/CHAMPUS DRG V28 through V32 Groupers.

A patient with sex = 1 (Male) and PDX = 650 would be grouped into MDC = 14.

A male patient should not have a PDX that would group him into MDC = 14 (Pregnancy, Childbirth, and Puerperium).

This patient’s record criteria did not match any DRG in the MDC indicated by the PDX.

Both

03 Invalid Age in Years or Age in Days on Admission

APR-DRG and TRICARE/CHAMPUS DRG:Age is not in the range 0 - 124.

AP-DRG:This Return Code may also indicate that age is non-numeric or less than 0.

An age greater than 125 years and a principal diagnosis of S06.6X0A.

Both

04 Invalid Sex The submitted gender for the patient is not male (1 or M), female (2 or F), or unknown (3 or U).

The claim with a gender of 0 (Undetermined).

Both

05 Invalid Discharge Status

Claim contains an invalid discharge status or is missing a discharge status.

The claim with a Discharge status of 00 and a principal diagnosis of Z38.00.

Both


06 Illogical PDX Medicare, TRICARE/CHAMPUS DRG, North Carolina Medicaid, Ohio Medicaid, and Wisconsin Medicaid:Principal diagnosis criteria matches DRG criteria whose DRG number is 470 or 999 and indicates illogical PDX.

NoteNot returned for ICD-10 DRG Groupers.

ICD-9 Example: PDX = 76509 (Extreme Immaturity 2500+g) is conflicting in nature. It is considered to be an illogical PDX and would group a newborn into MDC = 15. This is the only diagnosis code which generates this Return Code.

Both

07 Invalid PDX (PDX Not Found)

Principal diagnosis could not be found in the Grouper diagnosis table.

Claims with a principal diagnosis code which is invalid, or invalid for the claim discharge date, will generate Return Code 07.

Example: A principal diagnosis of 123 (ICD-9 or ICD-10).

Both

08 Invalid Mapping Ohio Medicaid:Diagnosis and procedure code mapping is required, but was not requested in the map_flag field.

APR-DRG:Inconsistency between the claim admit and discharge dates and the Grouper version requested.

C

Table 6-3: DRG Grouper Return Codes

Return Code



15 Invalid birth weight AP-DRG: Birth weight extracted from the patient record (in grams) was non-numeric or not in the Grouper’s range of minimum and maximum birth weight values.

APR-DRG: Also, no birth weight in grams is submitted and 1) no birth weight diagnosis codes are available to impute the birth weight, or 2) submitted birth weight diagnosis codes are conflicting.

Ohio Medicaid (C Only): A neonate claim with principal diagnosis 76500 and secondary diagnosis 27701 without a birth weight submitted will receive this Return Code.

NoteNot returned for Medicare DRG Grouper for ICD-9 or the ICD-10 Medicare DRG Grouper.

Certain Groupers require a birth weight to assign a DRG to neonatal claims. For these Groupers, a missing or invalid birth weight will generate Return Code 15.

Example: A neonatal claim with no birth weight and with principal diagnosis V3000 (ICD-9) or Z3800 (ICD-10).

For the Ohio Medicaid V15 Grouper only: a neonatal claim with no birth weight and with a principal diagnosis of 76500 and a secondary diagnosis code of 27701.

Both


Return Code



16 Conflicting birth weights

TRICARE/CHAMPUS DRG and ICD-10 TRICARE DRG: Birth weight categories were derived from available diagnosis codes. All codes indicated conflicting birth weight values.

AP-DRG: The birth weight category derived from available diagnosis codes conflicts with the birth weight (in grams) extracted from the patient record.

APR-DRG:The birth weight is invalid or conflicts with the gestational age as derived from the available diagnosis codes.

One of the following is true:

- Birth weight < 200 grams or > 7000 grams

- Gestational Age < 24 weeks and birth weight > 1249 grams

- Gestational Age = 24 weeks and birth weight > 1499 grams

- Gestational Age = 25 - 26 weeks and birth weight > 1999 grams

- Gestational Age = 27 - 28 weeks and birth weight > 2499 grams

- Gestational Age = 33 - 34 weeks and birth weight < 500 grams

- Gestational Age = 35 - 36 weeks and birth weight < 750 grams

- Gestational Age > 37 weeks and birth weight < 1000 grams

Example: A newborn claim (birth date equals admit date) with a principal diagnosis of V3000 (ICD-9) or Z3800 (ICD-10), with two secondary diagnosis codes of 76412 and 76418 (ICD-9) or P0508 and P0502 (ICD-10).

Example: A newborn claim (birth date equals admit date) with a birth weight of 1200 grams, a principal diagnosis of V3000 (ICD-9) and a secondary diagnosis of 76418.

NoteThe APR-DRGs can be configured with different birth weight reporting options. It is not possible to provide an example that will work for all configurations.

Both

17 Non-Specific birth weight

TRICARE/CHAMPUS DRG, ICD-10 TRICARE DRG. AP-DRG, and Wisconsin Medicaid: A birth weight category was derived using available diagnosis codes. birth weight was required for grouping and the only birth weight codes on the record indicated a non-specific birth weight.

A newborn claim (birth date equals admit date) with a principal diagnosis of V3000 (ICD-9) or Z38.00 (ICD-10), with a secondary diagnosis code of 76490 (ICD-9) or P05.9 (ICD-10).

Both


Return Code



18 Invalid Discharge Age

AP-DRG: Age in days on discharge was non-numeric or less than 0.

TRICARE/CHAMPUS DRG and ICD-10 TRICARE DRG: Age in days on admission was non-numeric or less than 0.

Both

19 Invalid Length of Stay

Length of stay was required for DRG assignment and was non-numeric or less than 0.

Both

20 Invalid Facility Type or County

Wisconsin Medicaid V24 and Previous:Either the facility type or county fields contained values not recognized by the Grouper.

C

21 Invalid Admission Source

Wisconsin Medicaid:Record admission source was not among the admission source values recognized by the Grouper.

C

22 Invalid Nursery Level

NoteThis Return Code is Reserved in COBOL

Ohio Medicaid V0805 and Previous: Nursery level was required for DRG assignment and was set to a value not recognized by the Grouper.

C


Return Code



23 HAC Editor Not Found

Hospital-Acquired Condition impact on DRG assignment has been requested, but the HAC Editor cannot be found.

APR-DRG:The Hospital-Acquired Condition impact on DRG assignment has beenrequested, but is not available due toone of the following:- The HAC Version is not valid for the

HAC Override ID.- Medicaid HCAC logic with a HAC

V28 was requested with a discharge date prior to July 01, 2011. Medicaid HCACs are only valid beginning with V28 for discharge dates on and after July 01, 2011.

- This is an ICD-10 claim with a HAC version other than versions 26.0 - 31.0.

NoteThis Return Code applies to all Groupers that allow HAC/HCAC assignment. Refer to the EASYGroup™ User’s Guide for further information.

Both

28 Invalid Data APR-DRG:Incorrect or missing required claims data.

C


APR-DRG:Refer to the Troubleshooting & Logging in EASYGroup™ section for more information on this Return Code.

C

61 All Other Errors From External Software

APR-DRG:Refer to the Troubleshooting & Logging in EASYGroup™ section for more information on this Return Code.

C


The Closed Facility Switch is set to 1 (Closed) in Rate Manager/the Configuration File.

Both


Return Code



65 Invalid Certificate

Note3M™ GPCS only.

APR-DRG Grouper:This error will occur when the certificate needed for the 3M™ GPCS is not present or is invalid and/or when the required unique key needed for a Super Certificate(s) is not present or is invalid.

C

66 Invalid URL


APR-DRG Grouper:This error will occur when the values set in the 3M™ GPCS, GPCS_URL (i.e., the URL to send claim info to) and/or the GPCS_STSURL (i.e., the URL to validate the certificate) environmental variables are missing or invalid.

C

80 APR-DRG Grouper:Invalid Content Version

APR-DRG Grouper (3M™ GPCS only):An invalid content version (GPCS_ContentVersion) has been passed to the GPCS. This version is set either in an environment variable or in the HssSetup.ini file.

C


The Grouper Control program (grpcntl) cannot find or load the Grouper program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.


Both

88 Initialization Error Check required components. C89 Memory Allocation

ErrorAPR-DRG:A memory allocation error has been found or the 3M™ GPS interfacing program (ezgps) cannot be found or loaded.

C


Return Code



6.4 IRF Grouper Return CodesTable 6-4: IRF Grouper Return Codes


00 No Errors Found There were no errors found on the claim. Both01 No CMG Match Both02 No HIPPS Code on the Claim Both03 Reserved Both04 Reserved Both05 Computed Age is Greater Than

140 Years Both

06 Submitted Age is Invalid Both07 Birth Date After Admission Date/

From DateBoth

08 Invalid Birth Date Both09 Invalid Admission Date/From Date Both10 Self Care, Eating (FIM39A,

Admission Value) is Out of RangeBoth

11 Self Care, Grooming (FIM39B, Admission Value) is Out of Range

Both

12 Self Care, Bathing (FIM39C, Admission Value) is Out of Range

Both

13 Self Care, Dressing, Upper Body (FIM39D, Admission Value) is Out of Range

Both

14 Self Care, Dressing, Lower Body (FIM39E, Admission Value) is Out of Range

Both

15 Self Care, Toileting (FIM39F, Admission Value) is Out of Range

Both

16 Sphincter Control, Bladder Management (FIM39G, Admission Value) is Out of Range

Both

17 Sphincter Control, Bowel Management (FIM39H, Admission Value) is Out of Range

Both

18 Transfers, Bed, Chair, Wheelchair (FIM39I, Admission Value) is Out of Range

Both

19 Transfers, Toilet (FIM39J, Admission Value) is Out of Range

Both

20 Locomotion, Walk/Wheelchair (FIM39L, Admission Value) is Out of Range

Both


21 Locomotion, Stairs (FIM39M, Admission Value) is Out of Range

Both

22 Comprehension (FIM39N, Admission Value) is Out of Range

Both

23 Expression (FIM39O, Admission Value) is Out of Range

Both

24 Social Interaction (FIM39P, Admission Value) is Out of Range

Both

25 Problem Solving (FIM39Q, Admission Value) is Out of Range

Both

26 Memory (FIM39R, Admission Value) is Out of Range

Both

27 Reserved Both28 Reserved Both29 Reserved Both30 Reserved Both31 Reserved Both32 Reserved Both33 Reserved Both34 Reserved Both35 Reserved Both36 One or More Admission Motor

Scores Out of RangeOne of the 18 submitted motor scores is out of range.

Both

37 Impairment Group Code is Invalid Both38 Total Motor Score, Admission, Out

of RangeBoth

39 Total Cognitive Score, Admission, Out of Range

Both


Both

87 Program Cannot Be Loaded The Grouper control program cannot find or load the Grouper program or the Retrieve Payer Control Program (rtvpyr) that is required. These programs should be stored in the same directory that contains the Optimizer program.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. C90 Invalid Function Code COBOL91 Invalid Grouper Type COBOL92 Invalid Patient Type COBOL93 Invalid Function for This Patient

TypeCOBOL

Table 6-4: IRF Grouper Return Codes



6.5 HHA HHRG/PDGM Reader Return Codes

94 Invalid From/Thru Date Relationship

COBOL

95 Reserved COBOL96 Reserved COBOL97 Reserved COBOL98 Reserved COBOL99 Reserved COBOLCL Cannot Load or Open Program An error occurred during the opening or loading of

the Grouper or associated programs.COBOL


COBOL

Table 6-5: HHA HHRG and PDGM Reader Return Codes


00 No Errors Found There were no errors found on the claim. Both01 Invalid Bill Type This Home Health claim has a UB-04 Bill Type other

than 0322, 0327, 0329, 032Q, 0332, 0337, 0339, 033Q, or 034X.

NoteEffective October 01, 2013, Home Health claims with UB-04 Bill Types 033X (where X = any value) are no longer payable.

Both

02 Invalid Number of HIPPS Codes This Home Health claim has a UB-04 Bill Type of 0322, 0332, 0327, 032Q, 0337, 0329, 0339, or 033Q and has either no claim lines with a HIPPS code and Revenue Code 0023 or has more than one claim line with a HIPPS code and Revenue Code 0023.


Both

Table 6-4: IRF Grouper Return Codes



03 Invalid HIPPS Code The HIPPS code submitted on this claim with Revenue Code 0023 is invalid.

Prior to January 01, 2020 (HHRG):Position one of the HIPPS code must be a 1, 2, 3, 4, or 5. Position two of the HIPPS code must be an A, B, or C. Position three of the HIPPS code must be an F, G, or H. Position four of the HIPPS code must be a K, L, M, N, or P. Position five of the HIPPS code must be an S, T, U, V, W, X, 1, 2, 3, 4, 5, or 6.

Effective January 01, 2020 (PDGM):Position one of the HIPPS code must be a 1, 2, 3, or 4. Position two of the HIPPS code must be an A, B, C, D, E, F, G, H, I, J, K, or L. Position three of the HIPPS code must be an A, B, or C. Position four of the HIPPS code must be a 1, 2, or 3. Position five of the HIPPS code must always be a 1.

Both

27 Invalid or No Treatment Authorization Code

HHA HHRG:This Home Health claim (UB-04 Bill Types 0322, 0327, 0329, 032Q, 0332, 0337, 0339, or 033Q) is either missing or has an invalid Treatment Authorization Code (TAC).


Both

31 Principal Diagnosis Code Not Assigned to a Clinical Group

HHA PDGM:The principal diagnosis code billed does not qualify for a clinical group. A different principal diagnosis code must be submitted or the claim will be denied.

Both


Both

78 Error Reading HHA PDGM Reader File

HHA PDGM:The Reader cannot find or load the PDGM Reader file.

Both

87 Program Cannot Be Loaded The Reader control program cannot find or load the Reader program or the Retrieve Payer Control Program (rtvpyr) that is required. These programs should be stored in the same directory that contains the Optimizer program.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. C

Table 6-5: HHA HHRG and PDGM Reader Return Codes



6.6 SNF Reader Return Codes6.6.1 Claim Level

6.6.2 Line Level

Table 6-6: Claim Level


00 No Errors Found There were no claim-level Grouper errors found on the claim.

Both

02 No HIPPS Code on Claim In order to be considered for reimbursement, SNF Part A (UB-04 Bill Type 018X or 021X) claim lines must be provided with both a HIPPS code and Revenue Code 0022. If no lines, on a submitted Part A claim are submitted with Revenue Code 0022, then a Return Code of 02 will be issued.

Both


Both

87 Program Cannot Be Loaded The Reader control program cannot find or load the Reader program or the Retrieve Payer Control Program (rtvpyr) that is required. These programs should be stored in the same directory that contains the Optimizer.

C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found. C90 Invalid Function Code Claim contains an invalid Operation Code (ECB-

OPCODE1).COBOL

91 Invalid Grouper Type The Grouper Type is missing or is invalid. COBOLCL Cannot Load or Open Program An error occurred during the opening or loading of the

Grouper or associated programs.COBOL


COBOL

Table 6-7: Line Level

Return Code Title Description C or COBOL or Both

00 No Errors Found There were no errors found on the claim line. Both01 Invalid HIPPS Code (Part A Only) The Part A claim line with Revenue Code 022

contains a missing or invalid HIPPS code.Both


7 Pricer Return Codes

This chapter provides a list of all EASYGroup™ Pricer Return Codes. For more information on EASYGroup™ Pricers please refer to the EASYGroup™ User’s Guide. This chapter includes the following sections:

• Claim-Level Pricer Return Codes• Line-Level Pricer Return Codes


7.1 Claim-Level Pricer Return CodesTable 7-1: Claim-Level Pricer Return Codes


00 No Errors Found There were no claim-level Pricer errors found on the claim. Both01 No Hospital Rate

Calculator RecordMedicare CAH Method II:The Pricer was unable to obtain a valid Hospital/Physician Rate Calculator record for this claim for one of the following reasons:- The Facility ID/NPI (with or without Taxonomy Code) and

Payer ID/Contract Code cannot be found with an Effective Date that is less than or equal to the From Date of this claim.

- The claim-level Rendering Provider Taxonomy Code is missing.

- This Facility ID/NPI (with or without Taxonomy Code), Payer ID/Contract Code, and Effective Date has been designated as closed or inactive.

- A Configuration record has been found for this Facility ID/NPI (with or without Taxonomy Code), Payer ID/Contract Code, and Effective Date, but no matching Hospital/Physician Rate Calculator record can be found.

All Other Pricers:The Pricer was unable to obtain a valid Rate Calculator record for this claim for the Facility ID/NPI (with or without Taxonomy Code) and Payer ID/Contract Code with an Effective Date that is less than or equal to the Reimbursement Date.

Both

02 No DRG/CMG Rate Record

The DRG/CMG rate record cannot be found. Both

03 Pricer Type Not Licensed

The EASYGroup™ Pricer is not licensed by client. Both

04 Medicare ESRD:Invalid or Missing Value Code/Value Amount

Medicare IRF:Invalid Pricer Type

Medicare ESRD:One or more of the following conditions are present:- The claim does not include a Kt/V reading (Value Code D5).- The claim does not include a hemoglobin reading (Value Code

48) or a Hematocrit reading (Value Code 49).- Erythropoiesis-Stimulating Agents (ESA) (e.g., EPO and/or

Aranesp) have been reported with hemoglobin and Hematocrit readings of 99.99 (No Reading).

NoteThis Return Code can be overridden for a given facility/paysource/effective date in Rate Manager with the Return Code Override Flag.

Medicare IRF:The Pricer Type is not 90 (Medicare IRF).

Both


05 Invalid or Missing Modifier

Medicare ESRD:One or more of the following modifier requirements have not been met:- Hemodialysis claims (Revenue Code 0821) must include a

route of access Modifier V5, V6, or V7 with the last reported Hemodialysis session on the claim.

- ESA drugs (Revenue Codes 634 or 635) and procedure code J0882 must be reported with a route of administration Modifier JA, JB, or JE.

- Hemodialysis claims (Revenue Code 0821) must include at least one session billed with one of the URR reading Modifiers G1, G2, G3, G4, G5, or G6.

- Iron injections administered via Dialysate (procedure codes J1443 or Q9976) must be billed with Modifier JE.


Both

06 LOS Value Required, Must be > 0

Medicare IRF:The length of stay is zero.

Both

07 No DRG Weights/Rates Available

Medicare IRF:Length of Stay Inconsistent With Claim From/Thru Dates

Arizona Medicaid, California Medicaid, Illinois Medicaid APR, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Medicaid APR Pro (for Colorado Medicaid, Florida Medicaid, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid APR, Rhode Island Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR), Michigan Medicaid APR, Nebraska Medicaid APR, New Jersey Medicaid, New Mexico Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, South Carolina Medicaid, and Washington Medicaid APR:DRG-specific weights/means or rates were not available for the patient’s assigned DRG. This error will occur if:- Users attempt to price claims for patients assigned to MS-

DRGs 0998 or 0999, claims for patients assigned to APR-DRGs 955 or 956, or claims for patients assigned to AP-DRGs 0470 and 0469.

- A patient is assigned to a DRG for which weights and means or inlier rates have not been established.

Medicare IRF:The submitted length of stay does not equal the length of stay calculated based on the claim admit date from date and the claim through-date.

Medicare IRF:Both

All Others:C

Table 7-1: Claim-Level Pricer Return Codes



08 Zero-Divide Error

Medicare IRF:Discharge Status Invalid/Missing

Arizona Medicaid, California Medicaid, Illinois Medicaid APR, Indiana Medicaid APR, Iowa Medicaid, Kentucky Medicaid, Medicaid APR Pro Pricer (for Colorado Medicaid, Florida Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid, Rhode Island Medicaid, Virginia Medicaid, Washington DC Medicaid, and Wisconsin Medicaid APR), Medicare LTC, Michigan Medicaid APR, Medicare Inpatient, Medicare IPF, Nebraska Medicaid APR, Multi-Pricer/DRG Pro, New York Medicaid APR, North Carolina Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, South Carolina Medicaid, Texas Medicaid, TRICARE/CHAMPUS, and Washington Medicaid APR:A divide by zero was attempted by the Pricer. Usually this occurs when the average length of stay is not available for the DRG that has been assigned to a transfer claim, or when a facility has both operating and capital RCCs (Ratio of Costs to Charges) set to zero.

New Mexico Medicaid APC:A divide by zero was attempted by the Pricer. Usually this occurs when the units submitted for a claim line subject to multiple procedure discounting was set to zero.

Medicare IRF:The discharge status code was not submitted, is zero, or is inconsistent with the submitted CMG.

Medicare LTC, Medicare Inpatient, Medicare IPF, and Medicare IRF:Both

All Others:C

09 Enhanced New York Medicaid APG:Missing or invalid Rate File Record

New York Medicaid APG:Case Not Priced

Medicare IRF:CMG/HIPPS Code Missing or Invalid

Enhanced New York Medicaid APG:The base rate is set to $0.00 in the rate files or the base rate is not found in the Enhanced New York Medicaid APG Rate File (rateny.dat).

New York Medicaid APG:The base rate is set to $0.00 in the rate files for the rate code billed on the claim.

Medicare IRF:One or more of the following conditions is present:- CMG/HIPPS code is missing.- First position of the HIPPS code (i.e., the comorbidity tier) is

invalid.

Medicare IRF: Both

All Others:C

11 CMG/HIPPS ALOS is Missing

Medicare IRF:The associated CMG rate record does not contain a valid (non-zero) average length of stay for the applicable comorbidity tier. This average length of stay is required for transfer pricing.

Both

12 Missing Rate Code Enhanced New York Medicaid APG and New York Medicaid APG:A rate code has not been submitted with Value Code 24 in the Value Amount field.

C




13 Admit Date Equals Discharge Date

Enhanced New York Medicaid APG and New York Medicaid APG:Invalid Rate Code

Arizona Medicaid, Medicaid APR Pro (for Washington DC Medicaid), and North Carolina Medicaid:The Discharge Date equals the Admit Date.

Enhanced New York Medicaid APG:The rate code is invalid.

New York Medicaid APG:One or more of the following conditions is present:- An invalid rate code was submitted for dates of service.- Rate code 1477, 1510, 1513, 1522, 1525, 1582, 1585, or 1591

is submitted on a claim with a patient age greater than or equal to 21 (prior to July 01, 2019).

C

14 Invalid DRG Pricing Option

Multi-Pricer/DRG Pro:The pricing option selected for the patient’s DRG is not valid. Users select one of six pricing options to be utilized with each DRG. Allowable pricing options are selected through the use of the DRG Pay Type on the DRG Rate file.

Both

15 Invalid Tier Start Days Multi-Pricer/DRG Pro:An invalid tier start date. When the Tiered Per Diem Pricing option is selected within the Contract Multi-Pricer, the starting day for tier 1 must be greater than zero. In addition, the starting day for each subsequent tier must be greater than the starting day for the previous tier. For example, the starting day for tier 3 must be after the staring day for tier 2.

Both

16 Invalid ALC Days/Interrupted Days

Kansas Medicaid, Medicaid APR Pro (for Colorado Medicaid, Florida Medicaid, New Jersey Medicaid), Medicare IPF, Medicare IRF, Medicare LTC, and New York Medicaid APR:The Alternate Level of Care (ALC) days or the number of interrupted days is greater than the length of stay on the claim. This could indicate an incorrect number of days were passed with Occurrence Span Code 74 or 75, Value Code 81, or the Alternate Level Of Care field (KS).

Medicare IPF, Medicare IRF, and Medicare LTC:Both

All Others:C

17 Number of ECT Treatments Not Coded

Medicare IPF:One or more of the following conditions is present:- Electroconvulsive Therapy (ECT) is not billed with Revenue

Code 0901 - Revenue Code 0901 is present with no units (i.e., number of

ECT treatments)

Both




18 Invalid Occurrence Span Date

Medicare Hospice, Medicare IPF, Medicare IRF, Medicare LTC, New Jersey Medicaid, and New York Medicaid APR:One of the following is present:- the Occurrence Span Date 1 is invalid- the Occurrence Span Date 2 is invalid- the Occurrence Span Date 1 is greater than the Occurrence

Span Date 2.

Medicare SNF:One of the following is present:- the Occurrence Span Date 1 is invalid- the Occurrence Span Date 2 is invalid- the Occurrence Span Date 1 is greater than the Occurrence

Span Date 2- the Admission Date or From Date is after the Occurrence

Span Date 1

New Jersey Medicaid and New York Medicaid APR:C

All Others:Both

19 ECT Units Coded Without Appropriate Procedure

Medicare IPF:ECT units are billed on a claim line with Revenue Code 0901 but procedure code GZB0ZZZ, GZB2ZZZ, or GZB4ZZZ was not billed on the same claim.

Both

20 Requested Inpatient PPS Rate Information Cannot be Found

Medicare LTC:There is no hospital rate record found for the supplied:- Inpatient Facility Identifier- Inpatient NPI/Taxonomy- Inpatient Payer ID

Both




21 Invalid Present on Admission (POA) Indicator

Medicare CAH Method II, Medicare ESRD, Medicare FQHC, Medicare Hospice, Medicare HHA, Medicare SNF, and TRICARE APC:Invalid Bill Type

Arizona Medicaid, Georgia Medicaid, Illinois Medicaid APR, Indiana Medicaid APR, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Medicaid APR Pro (for Colorado Medicaid, Florida Medicaid, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid, Rhode Island Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR), Medicare Inpatient, Multi-Pricer/DRG Pro, Michigan Medicaid APR, Nebraska Medicaid APR, New Jersey Medicaid, New York Medicaid APR, New Mexico Medicaid, North Carolina Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, South Carolina Medicaid, Texas Medicaid, TRICARE/CHAMPUS, Washington HCA, Washington Medicaid APR, and Wisconsin Medicaid:There is either a missing POA indicator or an invalid POA indicator on the claim.

Medicare CAH Method II:The claim does not contain a UB-04 Bill Type of 014X or 085X.

Medicare ESRD:The claim does not contain a UB-04 Bill Type of 072X.

Medicare FQHC:The claim does not contain a UB-04 Bill Type of 077X.

Medicare Hospice:The claim does not contain a UB-04 Bill Type of 0811, 0812, 0813, 0814, 0817, 0821, 0822, 0823, 0824, or 0827.

Medicare HHA:One or more of the following conditions are present:- This home health claim has a UB-04 Bill Type other than 0322,

0327, 0329, 032Q, 0332, 0337, 0339, 033Q, or 034X. - Condition Code 54 was incorrectly billed with a UB-04 Bill

Type of 0322 or 034X.

NoteEffective October 01, 2013, home health claims with UB-04 Bill Types 033X (where X = any value) are no longer payable.

Medicare SNF:The claim does not contain a UB-04 Bill Type of 018X, 021X, 022X, or 023X.

TRICARE APC:The claim does not contain a valid UB-04 Bill Type or the claim includes a Condition Code 41, with an inappropriate UB-04 Bill Type.

Medicare CAH Method II, Medicare Inpatient, Medicare ESRD, Medicare FQHC, Medicare Hospice, Medicare HHA, and Medicare SNF:Both

All Others:C




22 Denial Claim APC-HOPD, Contract APC/APC Pro, and Medicare CAH Method II:One or more of the following conditions are present:- Claim contains Condition Code 20 or 21 - Claim contains a UB-04 Bill Type ending with a last character

of zero. These types of claims are not eligible for reimbursement.

NoteFor Contract APC/APC Pro, this Return Code can be overridden for a given facility, paysource, or effective date in Rate Manager by utilizing the Claim Denial Override Flag.

New Mexico Medicaid APC and Medicaid APG Pro (for Colorado Medicaid, Florida Medicaid, Massachusetts Medicaid, Nebraska Medicaid, Virginia Medicaid, and Washington DC Medicaid APG):The claim contains a UB-04 Bill Type ending with a fourth character of zero. These types of claims are not eligible for reimbursement.

Medicare ESRD:One or more of the following conditions are present:- Claim does not contain Condition Code 59, 71, 72, 73, 74, 76,

80, 84, or 87 - Condition codes 73 and 74 are billed on the same claim- Claim contains dates in two different yearsEffective July 01, 2017:- Condition Code 87 and Condition Codes 71, 72, 73, 74, or 76

are billed on the same claim.

Medicare Hospice:One or more of the following conditions are present:- The claim contains an UB-04 Bill Type ending with a last

character of zero or eight. These types of claims are not eligible for reimbursement

- A claim needs to be submitted to the Fiscal Intermediary (FI) for denial verification (condition code 21) or review (condition code 20).

Medicare SNF:The claim contains one of the following:- A Thru Date of October 01, 2019 and a discharge status of 30

(Still a Patient).- A From Date before October 01, 2019 and a Thru Date after

October 01, 2019.

New Mexico Medicaid APC and Medicaid APG Pro: C

All Others:Both




23 APC-HOPD, APG Pricers, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare FQHC, Medicare HHA, Medicare Hospice, New Mexico Medicaid APC, and TRICARE APC:Invalid Service Date, From-Thru Dates, or Admission Date

Medicare IRF:Invalid Service Date orOut of Range

Medicare SNF (Part B claims only):Service Date Invalid or Out of Range

Medicare Physician:Invalid Service Date or From-Thru Dates

APC-HOPD, APG Pricers, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare FQHC, Medicare IRF, Medicare Physician, Medicare SNF (Part B claims only), New Mexico Medicaid APC, and TRICARE APC:One or more of the following conditions are present: - The From Date and/or Thru Date on the claim is missing or is

not a valid date. - The From Date is after the Thru Date. - Any individual service date is missing or is not a valid date (for

lines containing procedure codes only). - Any individual service date is outside the claim date range

(“From Date” to “Thru Date”).

NoteAPC-HOPD (COBOL Only) - If the Pricer is being used as a stand-alone product (so that the claims are not being pre-processed by ACE), it will accept only same-day claims (that is, the from date must equal the Thru date) unless the claim has a condition code 41 or a Bill Type of 076X.

Medicare IRF - Only applies to claim lines with HIPPS codes and UB-04 Revenue Code 0024.

Medicare HHA (prior to January 01, 2020 (HHRG)):One or more of the following conditions are present:- Any individual service date is missing or is not a valid date. A

valid service date is not required for a line billed with Revenue Code 027X (except 0274) or 0623 when the claim has a UB-04 Bill Type of 0322, 0327, 0329, 032Q, 0332, 0337, 0339, or 033Q.

- Any individual service date is outside the claim date range (From Date to Thru Date). A service date that is outside the claim date range is allowed on subsequent RAP claims (i.e., claims with a UB-04 Bill Type of 0322 or 0332 and an Admission Date that does not equal the From Date) as long as the service date is within 60 days of the From Date.

- Admission Date is greater than the From Date.


continued below...

APG Pricers, New Mexico Medicaid APC, and TRICARE APC:C

All Others:Both




23<continued>

APC-HOPD, APG Pricers, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare FQHC, Medicare HHA, Medicare Hospice, New Mexico Medicaid APC, and TRICARE APC:Invalid Service Date, From-Thru Dates, or Admission Date

Medicare IRF:Invalid Service Date orOut of Range

Medicare SNF:Service Date Invalid or Out of Range

Medicare Physician:Invalid Service Date or From-Thru Dates

Medicare HHA (on or after January 01, 2020 (PDGM)):- The From Date is before January 01, 2009.- Any individual service date is missing or is not a valid date. A

valid service date is not required for a line billed with Revenue Code 027X (except 0274) or 0623 when the claim has a UB-04 Bill Type of 0322, 0327, 0329, or 032Q.

- Any individual service date is outside the claim date range (From Date to Thru Date). A service date that is outside the claim range is allowed on subsequent RAP claims (i.e., claims with a UB-04 Bill Type of 0322 and an Admission Date that does not equal the From Date) as long as the service date is within 30 days of the From Date.

- Admission Date is greater than the From Date.

Medicare Hospice:One or more of the following conditions are present:- The Admission Date is greater than the From Date.- The From Date is before October 01, 2020.- The Date of Service is missing, invalid, prior to the From Date,

greater than the Thru Date.

APG Pricers, New Mexico Medicaid APC, and TRICARE APC:C

All Others:Both




24 DRG Pricers and Medicare FQHC:Non-Covered Claim

DRG Pricers:- Arizona Medicaid, Medicaid APR Pro (for Louisiana

Medicaid, Virginia Medicaid), Pennsylvania Medicaid APR, and Texas Medicaid:

Payment is requested for a non-covered DRG.- Kentucky Medicaid: Payment is requested for transplant DRGs 103, 480, 481, or 495 and either the Transplant Payment Maximum or the Transplant Payment Percentage in the Hospital Rate Calculator File is set to zero (no longer issued on or after October 01, 2015).- Medicare Inpatient:The claim contains a UB-04 Bill Type other than 0110 and also contains a non-covered procedure as determined by the Date-Sensitive Code (DSC) Editor. - Ohio Medicaid APR: Payment is requested for APR-DRG 772.- Nebraska Medicaid APR: Payment is requested for transplant APR-DRGs 001, 002, 006, 007, 008, or 440 on a claim paid by Managed Care payers.- New York Medicaid APR: Payment is requested for an elective early delivery claim and Condition Code 81, 82, or 83 have not been supplied to document medical necessity.

NoteFor New York Medicaid APR, this Return Code can be overridden for a given facility, paysource, or effective date in Rate Manager by utilizing the Return Code 24 Override option.

Medicare FQHC:The claim contains an UB-04 Bill Type of 0770.

Medicare APC, Medicare ASC, Medicare FQHC:Both

All Others:C




25 APC-HOPD and Contract APC/APC Pro:Invalid Partial Hospitalization Claim

DRG Pricers, Medicare IRF, and Medicare SNF:Non-Payment Claim

APC-HOPD and Contract APC/APC Pro:The partial hospitalization claim (Condition code 41 or UB-04 Bill Type 076X) was not processed with ACE, therefore cannot correctly be price.For a list of qualifying services, or a more comprehensive description of the requirements for a valid partial hospitalization claim, refer to the EASYGroup™ User’s Guide or APC Assistant™.

Arizona Medicaid, California Medicaid, Georgia Medicaid, Illinois Medicaid APR, Indiana Medicaid APR, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid APR, Medicaid APR Pro (for Colorado Medicaid, Florida Medicaid, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid, Rhode Island Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR), Michigan Medicaid APR, Medicare Inpatient, Medicare IPF, Medicare IRF, Medicare LTC, TRICARE/CHAMPUS, New Mexico Medicaid, New York Medicaid APR, Nebraska Medicaid APR, North Carolina Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, South Carolina Medicaid, Texas Medicaid, Wisconsin Medicaid, and Washington Medicaid APR:A non-payment claim with a UB-04 Bill Type of 0110.

In addition to the condition above, this Return Code may also indicate the following:Arizona Medicaid:- Claim has a Discharge Status Code of 30 and does not have a

UB-04 Bill Type of 0112, 0113, or 0117.- Claim has a Discharge Status Code of 30, a UB-04 Bill Type of

0112, 0113, or 0117 and a length of stay less than 30.- Claim has a UB-04 Bill Type of 0112 or 0113 and does not

have a Discharge Status Code of 30.California Medicaid:- This claim has a UB-04 Bill Type of 0110, 0114, or 0115.- This claim has a Discharge Status Code of 30 and does not

have a UB-04 Bill Type of 0112 or 0113. - This claim has a Discharge Status Code of 30, a UB-04 Bill

Type of 0112 or 0113, and a length of stay less than 30.- This claim has a UB-04 Bill Type of 0112 or 0113 and does not

have a Discharge Status Code of 30.Medicare SNF:Claim has a UB-04 Bill Type of 0210, 0220, 0230, or 0180.

APC-HOPD, Contract APC/APC Pro, Medicare Inpatient, Medicare IPF, Medicare IRF, Medicare LTC, and Medicare SNF:Both

All Others:C




26 APC-HOPD and Contract APC/APC Pro:Invalid Credit/Adjustments Claim

New York Medicaid APR:Claim Contains a Never Event or an Adverse Event

Medicare SNF:Total Units Exceed Patients Length of Stay (Part A Only)

APC-HOPD and Contract APC/APC Pro:This claim contains one or more line items billed with negatives units or charges and credit/adjustment bills are not accepted; Replacement bills should be submitted instead.

New York Medicaid APR:The claim contains a never event or an adverse event as indicated by Rate Code 2590 or 2591.

Medicare SNF:Part A claims only. Total units billed with revenue code 0022 exceeds the number of billable days on the claim by one or more days.

New York Medicaid APR:C

All Others:Both




27 Wrong Procedure Performed

Medicare ESRD:Missing Diagnosis Code

Arizona Medicaid, California Medicaid, Georgia Medicaid, Illinois Medicaid APR, Indiana Medicaid APR, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Medicaid APR Pro (for Colorado Medicaid, Florida Medicaid, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid, Rhode Island Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR), Medicare Inpatient, Medicare IPF, Medicare LTC, Michigan Medicaid APR, Multi-Pricer/DRG Pro, Nebraska Medicaid APR, New Mexico Medicaid, North Carolina Medicaid, Ohio Medicaid APR, South Carolina Medicaid, Texas Medicaid, TRICARE/CHAMPUS, Washington Medicaid APR, and Wisconsin Medicaid:The claim contains a diagnosis code that indicates that one of the following errors has occurred: - the wrong procedure has been performed- a procedure was performed on a patient not scheduled for

surgery- a procedure was performed on the wrong body part or wrong

side of body.

Medicare IRF:The claim contains a diagnosis code that indicates that a wrong procedure has been performed.

Wisconsin Medicaid APG:This claim contains one or more claim lines with Modifier PA, PB, or PC.

Medicare ESRD:One or more of the following are present:- The ESRD claim does not contain a principal diagnosis of

N18.6.- The AKI claim does not contain at least one of the following

diagnosis codes as principal or secondary diagnosis code: N17.0, N17.1, N17.2, N17.8, N17.9, T79.5XXA, T79.5XXD, T79.5XXS, or N99.0

Medicare ESRD, Medicare Inpatient, Medicare IPF, Medicare IRF, and Medicare LTC:Both

All Others:C




28 Invalid Reimbursement Configuration

Medicare ESRD:Invalid Case-Mix Adjustment

California Medicaid:One or more of the following is equal to zero:- hospital-specific cost-to-charge ratio- age adjustment factor- service adjustment factor- NICU adjustment factor- DRG assigned to the claim- hospital-specific marginal cost factor

Iowa Medicaid:The claim is from a CAH designated swing bed unit and was submitted with a UB-04 Bill Type other than 018X or 028X.

Multi-Pricer/DRG Pro:Both the minimum and maximum percent of charges reimbursement methodologies have been selected and the maximum percent of charges is less than the minimum percent of charges.

Medicare ESRD:One or more of the following conditions are present:- The claim contains a patient height greater than 300 cm (9.8

feet) or patient weight greater than 500 kg (1102 pounds) submitted with Value Codes A8 and A9

- The claim contains the Body Mass Index (BMI), age, Body Surface Area (BSA), comorbidity, onset, or modality factor is equal to 0.

California Medicaid and Iowa Medicaid:C

All Others:Both

29 California Medicaid:Invalid Rehabilitation Claim

Medicare ESRD:Attempted Divide by Zero

California Medicaid:The claim was assigned to a rehabilitation DRG, but no claim line with a rehabilitation room and board Revenue Code of 0118, 0128, 0138, or 0158 has been billed.

Medicare ESRD:A divide by zero was attempted by the Pricer. Usually this occurs when the average length of stay is not available for the DRG that has been assigned to a transfer claim, or when a facility has both operating and capital RCCs (Ratio of Costs to Charges) set to zero.

California Medicaid:C

Medicare ESRD:Both




30 Kansas Medicaid:Neonate Regroup

Medicare HHA and Medicare Hospice:Invalid Home Health/Hospice Claim Dates

Kansas Medicaid:The claim grouped to MS-DRG 789 with an adjusted length of stay (claim length of stay - ALC days) that is greater than or equal to three days. Per Kansas Medicaid, the Discharge Disposition should be changed to 01 and re-process the claim.

Medicare HHA (prior to January 01, 2020 (HHRG)):One or more of the following conditions are present:- The length of stay for this HHA claim is greater than 60 days. - The length of stay for this HHA Partial Episode Payment

(PEP) claim is greater than or equal to 60 days.Medicare HHA (on or after January 01, 2020 (PDGM)):One or more of the following conditions are present:- The length of stay for this HHA claim is greater than 30 days.- The length of stay for this HHA PEP claim is equal to 30 days

and the discharge disposition is 06.

Medicare Hospice:The claim’s From Date and Thru Date spans over a calendar month.

Kansas Medicaid:C

All Others:Both

31 Medicare HHA:Invalid Number of HIPPS Codes

Medicare HHA:The claim has a UB-04 Bill Type of 0322, 0332, 0327, 032Q, 0337, 0329, 0339, or 033Q and has no claim lines with a HIPPS code and Revenue Code 0023, or has more than one claim line with a HIPPS code and Revenue Code 0023.


Both

32 Medicare HHA HHRG:HIPPS Code Indicates NRS Were Provided, but NRS Not on Claim

Medicare HHA HHRG (prior to January 01, 2020):The claim has a UB-04 Bill Type of 0327, 0337, 0329, 032Q, 0339, or 033Q and a HIPPS code that indicates that non-routine supplies were provided during the episode, but does not have at least one non-routine supplies claim line with Revenue Code 027X or 0623.


Both




33 Medicare HHA and Medicare Hospice:Invalid or Missing CBSA

Medicare HHA:The Core Based Statistical Area (CBSA) is missing or an invalid CBSA has been provided on this Home Health claim in the UB-04 Value Amount field with UB- 04 Value Code 61.

Medicare Hospice:One or more of the following is present:- RHC (Revenue Code 0651) or CHC (Revenue Code 0652)

services are provided, but a CBSA has not been identified with UB-04 Value Code 61.

- IRC (Revenue Code 0655) or GIP (Revenue Code 0656) services are provided, but a CBSA has not been identified with UB-04 Value Code G8.

Both

34 Final Claim Must Have At Least One Visit-Related Revenue Code

Medicare HHA:The claim has a UB-04 Bill Type of 0327, 0329, 032Q, 0337, 0339, or 033Q and does not have at least one claim line with a valid Home Health visit. Valid Home Health visits are defined by the following procedure code and Revenue Code combinations:- Physical Therapy Visit: procedure codes G0151, G0157, or

G0159 and Revenue Code 042X.- Occupational Therapy Visit: procedure code G0152, G0158,

or G0160 and Revenue Code 043X. - Speech-Language Pathology Visit: procedure code G0153 or

G0161 and Revenue Code 044X. - Skilled Nursing Visit: procedure code G0154 (prior to January

01, 2016), G0162, G0163 (prior to January 01, 2017), or G0164 (prior to January 01, 2017), G0299, G0300 (on or after January 01, 2016), G0493, G0494, G0495, G0496 (on or after January 01, 2017) and Revenue Code 055X.

- Medical Social Services Visit: procedure code G0155 and Revenue Code 056X.

- Home Health Aid Visit: procedure code G0156 and Revenue Code 057X.


Both

35 No Available HHRG/PDGM Weight/Rate

Medicare HHA:A weight/rate record cannot be found for this particular facility ID, payer ID, effective date, and Home Health Resource Group (HHRG), Alternate HHRG, or Alternate PDGM.

Both

36 Medicare ESRD:Incorrect Billing of AMCC Test

Medicare ESRD (prior to April 04, 2015):Automated Multi-Channel Chemistry (AMCC) procedure code component codes must be billed separately. All panel procedure codes will be rejected by the ESRD Pricer.AMCC ESRD-related tests must be reported with Modifier CD, CE, or CF. If at least one of these three Modifiers is not reported for each of the AMCC ESRD-related tests billed on a claim, then the entire claim will be rejected.

Both




37 Invalid Billing of Codes for Cardiac Resynchronization Therapy

Medicare ASC and Contract ASC/ASC Pro:When billing services described by procedure codes 33225 and 33249 on the same date, please use procedure code G0448 in lieu of the two previously mentioned procedure codes.

NoteFor Contract ASC/ASC Pro, this Return Code can be overridden for a given facility/paysource/effective date in Rate Manager with the Apply Cardiac Resynch Therapy Logic Flag.

Both




38 Invalid or Missing Required Claims Data

Michigan Medicaid APR:A newborn claim with an UB-04 Admission Type of 4 that does not also include a UB-04 Admit Source of 5 or 6, effective January 01, 2015.

Washington Medicaid APR:One or more of the following conditions are present:- The Critical Access Hospital (CAH) or transplant claim has no

covered charges on the claim.- The claim contains regular acute care services plus

administrative days, and the number of administrative days billed with Revenue Code 0169 or 0191 is less than the total length of stay of the claim.

Medicare ESRD:One or more of the following billing requirements have not been met:- The date of the last Kt/V reading was not reported with

Occurrence Code 51, unless Value Code D5 was reported with Value Amount 8.88 or 9.99.

- Procedure code J0604 or J0606 is billed with Modifier AX but without Revenue Code 0636.


Medicare HHA:One of the following conditions are present:1. Incorrect billing of the location code Q5001, Q5002, or

Q5009. Every HHA claim with a UB-04 Bill Type 032X (excluding 0322) must contain at least one of these Q codes. These requirements are documented in the HHA chapter of the Medicare Claims Processing manual.

2. Possible LUPA claim conflict: Claims that involve all of the following are denied:

- The UB-04 Bill Type is 032X,- There are 4 or fewer covered visits (occurrences of revenue

codes 042x, 043x, 044x, 055x, 056x and 057x), - The Admission Date matches the From Date, - The first position of the HIPPS code is 1 or 2, - Condition code 47 is not present, and - There is no qualifying skilled service (at least one covered

occurrence of revenue codes 042x, 044x or 055x).3. If the RAP receipt date is after the Thru Date.4. If the RAP receipt date is 99999999 and it is not a LUPA

claim.continued below...

Michigan Medicaid APR and Washington Medicaid APR:C

All Others:Both



https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912


38 <continued>

Invalid or Missing Required Claims Data

Medicare SNF:The UB-04 Admission/Start of Care Date is either missing or invalid and the UB-04 Bill Type is not 0211, 0212, 0181, or 0182.

39 Claim From Date is Prior to HHA Medicare Participation/Certification

Medicare HHA:The From Date of this claim is before the Medicare participation/certification date for this HHA, which is equivalent to the date the HHA first became enrolled in Medicare.

Both

40 Medicare Hospice and Medicare HHA:Claim Spans Calendar Year

Medicare SNF:Claim Spans Calendar Year (Part B Only)

Medicare Hospice and Medicare HHA:The claim spans a calendar year. Claims are not allowed to cross the calendar year boundary (i.e., January 1st).

Medicare SNF:The SNF Part B claim (UB-04 Bill Type 022X or 023X) spans a calendar year. SNF Part B claims are not allowed to cross the calendar year boundary (i.e., January 1st).

Both

41 Invalid Billing of Therapy Services

APC-HOPD, Contract APC/APC Pro, Medicare CAH Method II, Medicare Physician, and Medicare SNF (Part B only):One or more of the following conditions are present:1. More than one therapy Modifier (GN, GO, or GP) on a single

claim line.2. One of the following therapy revenue codes is billed without

one of the below required therapy modifiers on a single claim line (excluding Medicare Physician):

- Revenue Code 042X billed without Modifier GP- Revenue Code 043X billed without Modifier GO- Revenue Code 044X billed without Modifier GN

3. All “always therapy” procedure codes that are not billed with the correct therapy Modifier (GN, GO, or GP) to identify the correct therapy discipline.

4. If traditional/FFS pricing has been requested, this Return Code will also be issued for claims where a therapy evaluation service is not accompanied by one of the functional limitation G-codes. If Medicare Advantage pricing has been requested, the requirement to provide a G-code with each therapy evaluation service is not enforced (prior to January 01, 2019).

5. A functional limitation G-code that is not reported with appropriate modifiers. Each G-code must be billed with one therapy Modifier (GN, GO, or GP) and one severity/complexity Modifier (CH, CI, CJ, CK, CL, CM, or CN) (prior to January 01, 2019).

continued below...

Both




41<continued>

Invalid Billing of Therapy Services

Medicare HHA:Individual procedures are identified as being provided under an outpatient rehabilitation plan of care when the services are billed with Modifiers GN, GO, or GP. Claims with UB-04 Bill Types 034X can only have one type of therapy Modifier (GN, GO, or GP) billed on a single claim line. In addition, claims with UB-04 Bill Types 034X that have claim lines billed with one of the below Revenue Codes must contain the required Modifier listed below. If a claim is not billed according to these guidelines, the HHA Pricer will issue this Return Code. - 042X with Modifier GP - 043X with Modifier GO- 044X with Modifier GN

NoteIn the above-listed revenue codes, X equals any value.

Both

42 APC-HOPD and Contract APC/APC Pro:Invalid Billing of Device Credit

Medicare Physician:Invalid or Missing Place of Service

APC-HOPD and Contract APC/APC Pro:The claim is billed with UB-04 Value Code FD without Condition Code 49 or 50 and/or without a UB-04 Value Amount.

Medicare Physician:One or more of the following conditions are present:- Place of Service (POS) code is missing or is not valid for one

or more claim lines- POS code is not the same for every claim line

Both

43 Place of Service Not Applicable for Medicare

Medicare Physician:The POS code provided for every claim line is either:- Not applicable for adjudication of Medicare claims (POS 05

(Indian Health Service Free-Standing Facility), POS 06 (Indian Health Service Provider-Based Facility), etc.)Or

- An unassigned POS code (POS 10 (Unassigned), etc.)

Both

44 Invalid or Missing Zip Code

Medicare CAH Method II:The billing provider zip code is missing or invalid.

Medicare Physician:One or more of the following conditions are present:- Service Facility Zip Code, Billing Provider Zip Code, and

Ambulance Point of Pickup Zip Code all have not been provided or are all invalid. At least one valid zip code must be provided for reimbursement calculations.

- POS code is 12 (Home) and a Service Facility Zip Code has not been provided. If services are provided in a patient's home, the zip code of the patient's home must be provided in the Service Facility Zip Code field.

- Service Facility Zip Code or Billing Provider Zip Code is not a valid zip code.

Both




45 Assessment Date is Missing

Medicare IRF:Occurrence Code 50 was not reported or Occurrence Code 50 was reported without occurrence date.

Both

46 Invalid Birth Weight in Grams

Illinois Medicaid APR and Washington Medicaid APR:The claim contains an age of 28 days or less on the date of admission, but UB-04 Value Code 54 with a UB-04 Value Amount are not reported on the claim.

Michigan Medicaid APR:The newborn claim does not contain an UB-04 Value Code of 54 with the birth weight in the UB-04 Value Amount field.

Medicaid APR Pro:The newborn claim does not include the birth weight (value Amount) reported with UB-04 Value Code 54.- Wisconsin Medicaid APR: Age of 14 days or less on the date

of admission.- Minnesota Medicaid: Age of 28 days or less on the date of

admission.

C

47 No APL Code Found Illinois Medicaid APG Pricer and Medicaid APG Pro (for Illinois Medicaid APG):The claim does not contain a valid Ambulatory Procedures Listing (APL) code (prior to July 01, 2020). Please refer to the Illinois Medicaid website for valid list of APL code.

NoteFor claims dated prior to January 01, 2019 (processed using the Illinois Medicaid APG Pricer), users can bypass this Return Code by setting the APL Return Code Override field to 1 (Bypass APL Requirements) in Rate Manager.

For claims dated on or after January 01, 2019 (processed using the Medicaid APG Pro Pricer), users can bypass this Return Code by removing Procedure Numbers 0005 (Claim Level Return Code 52 and 47: Invalid Billing of APL codes - Illinois Medicaid) and 0139 (Find APL Code/Revenue Pair - Illinois Medicaid) from the Illinois Procedure Array using the Procedure Editor functionality within Rate Manager.

C

48 Patient Reason for Visit Diagnosis Not Found

Illinois Medicaid APG Pricer and Medicaid APG Pro (for Illinois Medicaid APG):The claim does not contain a reason for visit diagnosis code and Revenue Code 045X, 0516, 0526, or 0762 was billed.

C

50 Non-FQHC PPS Claim Medicare FQHC:For claims dated prior to October 01, 2020: The claim contains Condition Code 65 (Non-PPS Claim) which indicates that the claim is not subject to the FQHC PPS.

Both



https://www.illinois.gov/hfs/MedicalProviders/MedicaidReimbursement/Pages/AmbulatoryProceduresListing.aspx


51 Claim Does Not Contain Payable Services

Medicare ESRD:This claim does not contain any payable services. Please refer to the line-level Pricer Return Code field to determine why each service is non-payable.

Medicare FQHC:This claim does not contain any payable services.

Both

52 Invalid Billing of ER, Observation, or Psychiatric Service

Illinois Medicaid APG Pricer and Medicaid APG Pro (for Illinois Medicaid APG):ER, Observation, psychiatric services must be billed using specific procedure code and revenue code combo. This claim does not meet those billing requirements. Refer to the Illinois Medicaid website for further details on billing requirements.

NoteFor claims dated prior to January 01, 2019 (processed using the Illinois Medicaid APG Pricer), users can bypass this Return Code by setting the APL Return Code Override field to 1 (Bypass APL Requirements) in Rate Manager.

For claims dated on or after January 01, 2019 (processed using the Medicaid APG Pro Pricer), users can bypass this Return Code by removing Procedure Numbers 0005 (Claim Level Return Code 52 and 47: Invalid Billing of APL codes - Illinois Medicaid) and 0139 (Find APL Code/Revenue Pair - Illinois Medicaid) from the Illinois Procedure Array using the Procedure Editor functionality within Rate Manager.

C

53 Invalid Billing When No Skilled Service

Medicare HHA:The claim contains all of the following conditions:- Condition Code 54 is not billed on the claim,- The UB-04 Bill Type is 0327, 0329, or 032Q,- The From Date is not equal to the Admit Date,- The claim does not contain any skilled home health visits

(Revenue Code 042X, 043X, 044X, or 055X), and- The claim contains other supportive services (at least one

covered occurrence of Revenue Code 056X or 057X).

Both

54 Biosimilar HCPCS Reported Without Biosimilar Modifier

Medicare ASC and Contract ASC/ASC Pro:The claim contains a biosimilar procedure code is reported without the required modifier (prior to April 01, 2018).

NoteFor Contract ASC/ASC Pro, this Return Code can be overridden for a given facility/paysource/effective date in Rate Manager with the Apply Bio-Similar Modifier Logic Flag.

Both






55 Invalid Therapy Code and Revenue Code Combination

Medicare HHA:Incorrect billing of HHA skilled services based on procedure code and revenue code requirements. These requirements involve effective-dated lists of skilled service G-codes and associated revenue codes for all physical therapy, occupational therapy, speech therapy, skilled nursing, Home Health aide, and social work services. These requirements are documented in the HHA chapter 10 of the Medicare Claims Processing manual.

Both

56 Invalid or Missing FIPS Code

Medicare HHA:Either no Federal Information Processing Standards (FIPS) state and county code or an invalid FIPS code has been provided on this Home Health claim in the UB-04 Value Amount field with UB- 04 Value Code 85.

Both

57 HHA Not Eligible for RAP Reimbursement

Medicare HHA (on or after January 01, 2020 (PDGM):Indicates one of the following conditions are found on UB-04 Bill Type 0322 claims:- The HHA was licensed by Medicare on or after January 01,

2019. These HHAs are not eligible for RAP reimbursement.- The date of service on the claim is on or after January 01,

2021.

NoteThis Return Code can be bypassed for a given facility/paysource/effective date in Rate Manager with the Return Code 57 Override option. The RAP claim will not receive reimbursement.

Both


TRICARE APC:The 3M™ GPS was not installed or configured correctly.

C

61 All Other Errors Returned From External Software

TRICARE APC:The 3M™ GPS returned an unexpected result or an exception is thrown.

C


The Rate Calculator record for this provider (as indicated by the Facility ID, or the NPI and Taxonomy), Payer ID/Contract Code, and Effective Date has been designated as closed or inactive.

Both

65 Invalid Certificate TRICARE APC:The certificate needed for the 3M™ GPCS is not present or is invalid and/or when the required unique key needed for a Super Certificate(s) is not present or is invalid.

C

66 Invalid URL TRICARE APC:The values set in the 3M™ GPCS, GPCS_URL (i.e., the URL to send claim info to) and/or the GPCS_STSURL (i.e., the URL to validate the certificate) environmental variables are missing or invalid.

C

70 Configuration Record Error

The Configuration File is out of sync with the Rate Calculator File. - Possible Solution: Re-export the rate files from Rate Manager. - Possible Solution: Verify you have copied over all rate files

exported from Rate Manager to your working environment.

C



https://www.cms.gov/index.php/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912


72 Hospital/Physician Rate Calculator Record Not Found

The rate record for this provider (as indicated by the Facility ID, or the NPI and Taxonomy), Payer ID/Contract Code, Effective Date cannot be found in Rate Calculator File.

C

73 Cannot Retrieve Rate Record

The record for this case-mix classification (i.e., DRG, APG, APC, etc.) and effective date cannot be found in the Rate File (i.e., rate.dat, wghtrate.dat, rateout.dat, etc).

Both

74 No Weights APC-HOPD:There are no APC rates for requested facility, payer ID, and effective date.

Medicare SNF:There are no RUG rates for the requested facility, payer ID, and effective date.

Both

75 Extended Hospital Rate Calculator Record Not Found

The rate record for the this provider (as indicated by the facility ID, or the NPI and taxonomy), payer ID, and effective date cannot be found in the applicable Extended Hospital Rate Calculator File.

Both

79 Error Reading Rate Code Table

Enhanced New York Medicaid APG:The Enhanced New York Medicaid APG Rate File (rateny.dat) cannot be read or opened.

C

80 Enhanced New York Medicaid APG:Error Reading Zip Code Table

TRICARE APC:Invalid Content Version

Enhanced New York Medicaid APG:The New York Medicaid APG Zip Code File (zipny.dat) cannot be read or opened.

TRICARE APC (3M™ GPCS only):An invalid content version (GPCS_ContentVersion) has been passed to the GPCS. This version is set either in an environment variable or in the HssSetup.ini file.

C

81 Medicare Physician and Medicare CAH Method II:Error Reading Physician Factor File

Medicare Physician and Medicare CAH Method II:The Physician Factor File (facphyyy.dat) cannot be read or open.

C

82 Error Reading Hospital/Physician Rate Calculator File

The applicable Rate Calculator File cannot be read or opened. C

83 Error Reading Rate File

The applicable rate file cannot be read or opened. C

84 Error Reading Fee Schedule File

The requested fee schedule file cannot be read or opened. C

85 Error Reading the Extended Hospital Rate Calculator File

The applicable Extended Hospital Rate Calculator File cannot be read or opened.

C

86 Error Reading Code Table File

The applicable Code Table File cannot be read or opened. C





The Pricer control program (prccntl) cannot find or load:- the Pricer program - the Retrieve Payer control program (rtvpyr)


C

88 Initialization Error Check required components. C89 Memory Error A memory allocation error has been found or the 3M™ GPS

interfacing program (ezgps) cannot be found or loaded.C

90 Invalid Function Code The Operation Code 1 (ECB-OPCODE1) is missing or invalid. COBOL91 Invalid Pricer Type The Pricer Type (ECB-PRCR-TYPE) is missing or is invalid. COBOL94 Invalid Dates Indicates one of the following conditions:

- Effective Date on the claim is missing or not a valid date.- From Date on the claim is missing or is not a valid date.- Thru Date on the claim is missing or is not a valid date.- From Date is after the Thru Date.

Both

95 Parameter Passing Error

Check parameters. C

96 Invalid Billing of Service for Rate Code

Enhanced New York Medicaid APG:One of the following conditions has not been met:- Rate code 1072, 1074, 1076, or 1078 is billed, but procedure

code H0038 is not billed.- A Severe Emotional Disturbance (SED) rate code is billed but

the age of the patient is greater than 21.

C

98 Invalid Outpatient Classification

APC-HOPD, Contract APC/APC Pro, Medicare ASC, Contract ASC/ASC Pro, Medicare ESRD, Medicare FQHC, Medicare HHA, New Mexico Medicaid APC, TRICARE APC, and all APG Pricers:The Classification Type submitted does not match the Classification Type determined based on the rate file lookup.

C

99 No Covered Revenue Code on Claim

New Mexico Medicaid APC:There is no covered revenue code on the claim.

C


An error occurred during the opening or loading of the Pricer or associated programs.

COBOL

IO File I/O Error One or more of the Pricer data files cannot be opened or closed. Please refer to POB1-PRCR-RTN-CODE2 and POB1-PRCR-RTN-STATUS for details.

COBOL




7.2 Line-Level Pricer Return CodesTable 7-2: Line-Level Pricer Return Codes


00 No Errors Found There were no errors found on the claim line. Both01 APC-HOPD, Contract APC/

APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare HHA, Medicare Hospice, Medicare Physician, New Mexico Medicaid APC, and APG Pricers: No Available APC/APG/Fee Schedule Rate Record

Medicare SNF:No HIPPS or RUG on This Claim Line

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare HHA, Medicare Physician, New Mexico Medicaid APC, and APG Pricers:Indicates one of the following conditions:1. The Pricer cannot locate a record in the Fee

Schedule file that has an effective date that is less than or equal to the service date with a matching:

- Procedure code- Carrier/locality- Modifier

2. The Pricer cannot locate a record that has an effective date that is less than or equal to the From/Thru Date with a matching:

- APC/APG- Facility ID- Payer ID

Medicare Hospice:The Pricer cannot locate a service billed with UB-04 Revenue Code 0657 in the Fee Schedule file that has an effective date that is less than or equal to the service date with a matching:


Medicare SNF:Indicates one of the following conditions:1. The Pricer cannot locate a record in the Fee

Schedule file that has an effective date that is less than or equal to the service date with a matching:


2. The Part A claim line contains Revenue Code 0022 and an invalid HIPPS or RUG.

APG Pricers and New Mexico Medicaid APC:C

All Others:Both


02 APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, New Mexico Medicaid APC:Invalid HCPCS Code

Enhanced New York Medicaid APG and New York Medicaid APG:Visit Consists of All Never Pay or Stand Alone

Medicare SNF:No Rate Available for RUG, HCPCS, or HIPPS Code

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, and New Mexico Medicaid APC:The procedure code on this claim line is invalid.

Medicare ESRD:The procedure code on this claim line is inappropriate:- Procedure code 90999 cannot be billed on Acute

Kidney Injury (AKI) claims, effective January 01, 2017.

- Procedure code G0491 can only be billed on AKI claims, effective January 01, 2017.

- Non-ESRD Erythropoietin Stimulating Agents (ESAs) cannot be billed on standard ESRD claims (UB-04 Bill Type 072X without Condition Code 84).

Enhanced New York Medicaid APG and New York Medicaid APG:New York has deemed a variety of services as Never Pay or Stand Alone. If all services for a given visit fall into these two categories, the Pricer returns a line-level Return Code of 02 for all stand alone services and a line-level Return Code of 03 for all never pay services.

Medicare SNF:Indicates one of the following conditions:- For Part A, the Pricer cannot locate a record that has

an effective date that is less than or equal to the Thru Date with a matching:

- RUG/HIPPS- Facility ID- Payer ID

- For Part B, 1. the claim line does not include a procedure

code. 2. the claim line contains a procedure code that

does not have a fee schedule rate, and either (1) the facility’s Reasonable Charge Factor and Reasonable Charge Co-Payment Factor are set to zero or (2) line-level charges are zero.

Enhanced New York Medicaid APG, New Mexico Medicaid APC, and New York Medicaid APG:C

All Others:Both

Table 7-2: Line-Level Pricer Return Codes



03 APC-HOPD, Contract APC/APC Pro, and New Mexico Medicaid APC:Invalid Payment Status From Grouper

Enhanced New York Medicaid APG and New York Medicaid APG: Service is Never Pay

APC-HOPD, Contract APC/APC Pro, and New Mexico Medicaid APC:The Payment Status Indicator for this service is invalid.

Enhanced New York Medicaid APG and New York Medicaid APG:New York have deemed a variety of services as Never Pay. If any service for a given visit falls into this category, the Pricer returns a line-level Return Code of 03 for that service.


All Others:Both




04 APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, New Mexico Medicaid APC, Medicare ASC, Medicare CAH Method II, Medicare FQHC, and Medicare Hospice:Not Covered or Not Covered Under OPPS

Medicare Physician:Not Covered

Medicare SNF:Invalid HIPPS Code (Part A Only)

New York Medicaid APG:Invalid Ambulatory Surgical Center Claim

APC-HOPD:Indicates one of the following conditions:- Service not in the CMS Ambulance Fee Schedule

that is billed with Revenue Code 054X.- Service is not covered under Medicare Part B

identified by a specific revenue code on a claim with a UB-04 Bill Type of 012X and without condition code W2.

- Service billed with a specific revenue code on a claim with a UB-04 Bill Type of 012X and condition code W2.

- Service is billed with Modifier PA, PB, or PC (indicating a surgical error).

- The procedure code on this claim line is invalid for the specified date of service.

- Service is assigned to Payment Status Indicator B, C, E, E1, E2, M, Q, Q1, Q2, Q3, Q4, W, or Z.

- Service is billed on a UB-04 Bill Type 076X claim and not assigned to Payment Status Indicator P or N.

- Medical visit under certain circumstance. - Kidney Disease Education service billed on a claim

originating from a non-rural facility. Contract APC/APC Pro:Indicates one of the following conditions:- Claim lines without a procedure code that are not

assigned to Payment Status Indicator N, F, or A and the Pricing Selection, Line Items Without HCPCS Codes field is not set to 1 (Package) or 2 (Use Specified Percent of Charges).

- The procedure code on this claim line is invalid for the specified date of service.

- Service is assigned to Payment Status Indicator W or Z.

- Service is billed on a UB-04 Bill Type 076X claim and not assigned to Payment Status Indicator P or N.

- The procedure code on this claim is not on the CMS Ambulance Fee Schedule, is billed with Revenue Code 054X, and the Ambulance Pricing Option is set to 1 (Apply Medicare Rules).

continued below...

New Mexico Medicaid APC and New York Medicaid APG:C

All Others:Both




04<continued>

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, New Mexico Medicaid APC, Medicare ASC, Medicare CAH Method II, Medicare FQHC, and Medicare Hospice:Not Covered or Not Covered Under OPPS




Contract ASC/ASC Pro:Indicates one of the following conditions:- Procedure Code V2785 (Processing, Preserving and

Transporting Corneal Tissue) is billed without a corneal transplant procedure code (i.e., 65710, 65730, 65750, 65755, or 65756).

- Service is billed with Modifier PA, PB, or PC (indicating a surgical error).

- Service is assigned to Payment Status Indicator YY or EX.

New Mexico Medicaid APC:Indicates one of the following conditions:- Service is billed with charges that are less than

$1.01.- Service is assigned to Payment Status Indicator B, C,

E, M, or Y.- Service is billed with Modifier PA, PB, or PC

(indicating a surgical error).

Medicare ASC: Indicates one of the following conditions: - Procedure Code V2785 (Processing, Preserving and

Transporting Corneal Tissue) is billed without a corneal transplant procedure code (i.e., 65710, 65730, 65750, 65755, or 65756).

- Service is assigned to Payment Status Indicator YY.- Service is billed with Modifier PA, PB, or PC

(indicating a surgical error).- Ancillary service (i.e., service assigned to Payment

Status Indicator F4, H7, J7, K2, K7, L1, L6, N1, Z2 or Z3) billed without a valid surgical procedure (i.e., service assigned to Payment Status Indicator A2, G2, H8, J8, P2, P3, or R2).

Medicare CAH Method II:Indicates one of the following conditions:- Service not in the CMS Ambulance Fee Schedule

that is billed with Revenue Code 054X.- Services billed with a Place of Service (POS) of 41 or

42 that are not on the Ambulance Fee Schedule.- Service is billed with Modifier PA, PB, or PC

(indicating a surgical error).- The procedure code on this claim line is invalid for

the specified date of service.- Service is assigned to Payment Status Indicator B, C,

E, E1, E2, M, Q, Q1, Q2, Q3, Q4, W, or Z.continued below...


All Others:Both




04<continued>

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, New Mexico Medicaid APC, Medicare ASC, Medicare CAH Method II, Medicare FQHC, and Medicare Hospice:Not Covered or Not Covered Under OPPS




- Medical visit under certain circumstance. - Kidney Disease Education service billed on a claim

originating from a non-rural facility.

Medicare FQHC:Service is billed with Modifier PA, PB, or PC (indicating a surgical error).

Medicare Hospice:Indicates one of the following conditions:- Services billed on dates of service that fall within the

span dates associated with UB-04 Occurrence Span Code 77 are not paid due to untimely NOE submission or untimely physician certification/recertification

- Kidney Disease Education service billed on a claim performed in a non-rural location.

Medicare Physician:Services billed with a Place of Service (POS) of 41 or 42 that are not on the Ambulance Fee Schedule.

Medicare SNF (Part A Only):The Part A claim line contains one of the following:- Revenue Code 0022 and a missing or invalid HIPPS

code.- Revenue Code 0022, the HIPPS code contains a Z,

the HIPPS code is not ZZZZZ, and the From Date is on or after October 01, 2019.

New York Medicaid APG (prior to July 01, 2010):New York has an official list of procedures that can be performed in an Ambulatory Surgical Center (ASC). If the visit does not contain at least one of these official procedures then the Pricer will return line-level Return Code 04 for every service on that visit.

NoteThis applies to ASC rate codes only.


All Others:Both

05 New York Medicaid APG:Carve-Out Service

Enhanced New York Medicaid APG:Alternate Payment May be Available

Enhanced New York Medicaid APG and New York Medicaid APG:This service is not paid under the APG reimbursement methodology and may be paid under an alternate payment methodology.

C




06 Missing/Invalid Fee Schedule Type

APC-HOPD, Contract APC/APC Pro, Enhanced New York Medicaid APG, Medicaid APG Pro (for Alabama BCBS APG, Colorado Medicaid APG, Massachusetts Medicaid APG, Nebraska Medicaid APG, Ohio Medicaid APG, Virginia Medicaid APG, and Virginia Medicaid ASC), Medicare CAH Method II, Medicare ESRD, Medicare Hospice, Medicare Physician, New Mexico Medicaid APC, New York Medicaid APG, Washington Medicaid APG, and Wisconsin Medicaid APG:This procedure code is included in the fee schedule with a missing or invalid Fee Schedule Type. The Pricer calculates fee schedule payments using all applicable fee schedules, plus a user-defined fee schedule. Each procedure code in the fee schedule must have a Fee Schedule Type to identify which fee schedule is used for pricing. For a list of valid Fee Schedule Types, please refer to the Fee Schedule File Layouts chapter of this guide.

Enhanced New York Medicaid APG, Medicaid APG Pro, New Mexico Medicaid APC, New York Medicaid APG, Washington Medicaid APG, and Wisconsin Medicaid APG:C

All Others:Both

07 APC-HOPD:Co-Payment Out of Valid Range

Medicaid APG Pro:Paid by Report/Manually Priced

APC-HOPD:The hospital has elected a co-payment amount for this APC that is higher than the national co-payment amount after wage-adjustment, higher than the inpatient Medicare deductible amount, or lower than the minimum co-payment amount after wage-adjustment, as defined by Medicare.

Medicaid APG Pro (for Colorado Medicaid APG and Massachusetts Medicaid APG):This service is to be paid by report/manually priced.

APC-HOPD:Both

All Others:C




08 Enhanced New York Medicaid APG and New York Medicaid APG:Invalid Modifier Pair

APC-HOPD, Contract APC/APC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare Hospice, Medicare HHA, and Medicare Physician:Invalid Modifier for Pricing

Enhanced New York Medicaid APG and New York Medicaid APG:This claim line contains both Modifier 52 and 73. Only one of these modifiers is allowed.

APC-HOPD:This claim-line contains one of the following: - Modifier GX, GY, or GZ- Modifier 50 along with Modifier 52 or 73

Contract APC/APC Pro:This claim-line contains one of the following:- Modifier GX, GY, or GZ- Modifier 50 along with Modifier 52 or 73- Modifier PA, PB, or PC (indicating a Never Event is

present)

NoteFor Contract APC/APC Pro, this Return Code can be overridden for a given facility/paysource/effective date in Rate Manager with the Apply Never Event Modifier Flag.

Medicare ASC:This claim-line contains one of the following:- Modifier GX, GY, or GZ- Modifier FB or FC along with Modifier 52 or 73- Modifier FB along with Modifier FC

Medicare CAH Method II:This claim-line contains one of the following: - Modifier GX, GY, or GZ- Modifier 50 along with Modifier 52 or 73- Both Modifier RT and LT. If the procedure was

performed bilaterally, it should be billed on two separate claim lines: one with the Modifier RT and one with the Modifier LT.

Medicare ESRD:This claim-line contains one of the following:- Epoetin Alfa and Darbepoetin Alfa will not be paid if

billed with both Modifier ED and Modifier EE without Condition Code 70 or 76.

- Modifier GX, GY, or GZ- Effective October 01, 2017, Modifier CG is billed with

procedure code 90999 and Revenue Code 0821 or 0881 without Condition Code 73 or 87.

continued below...

Enhanced New York Medicaid APG and New York Medicaid APG:C

All Others:Both




08<continued>

Enhanced New York Medicaid APG and New York Medicaid APG:Invalid Modifier Pair

APC-HOPD, Contract APC/APC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare Hospice, Medicare HHA, and Medicare Physician:Invalid Modifier for Pricing

Medicare HHA and Medicare Hospice:This claim line contains Modifier GX, GY, or GZ.

Medicare Physician:This claim-line contains one of the following:- Both Modifier RT and LT. If the procedure was

performed bilaterally, it should be billed on two separate claim lines: one with the Modifier RT and one with the Modifier LT.

- Modifier GX, GY, or GZ


All Others:Both

09 Packaged Service

NoteThis is not an error condition, but simply an explanation for why the line is being returned with zero payment.

APC-HOPD, APG Pricers, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare ESRD, Medicare FQHC, Medicare Hospice, and New Mexico Medicaid APC:No payment will be calculated for this service because the payment for this service is included in the payments for other services on the claim. If applicable the charges for this service may be included in other payment calculations (i.e., outlier calculations).


All Others:Both

10 Line Item Denial or Rejection From Editor

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare ESRD, Medicare HHA, Medicare Hospice, Medicare Physician, Medicare SNF (Part B Only), and New Mexico Medicaid APC:The claim was processed first by the Editor and the Editor has detected one or more errors for this claim line.

APG Pricers:This claim line meets one of the following criteria:- It is assigned to a Correct Coding Initiative (CCI) edit

and/or Medically Unlikely Edit (MUE).- It includes an invalid procedure code.- It is missing a procedure code, but includes a valid

revenue code that is allowed to be billed without a procedure code.

- It is missing both a revenue code and a procedure code.


All Others:Both




11 APC-HOPD, Contract ASC/ASC Pro, Contract APC/APC Pro, Medicare ASC, Medicare CAH Method II, Medicare Physician, and New Mexico Medicaid APC:Invalid Units for This Modifier

Enhanced New York Medicaid APG and New York Medicaid APG:No Payment per New York Medicaid Ancillary Policy

Contract ASC/ASC Pro and Medicare ASC: This claim line was billed with Modifier 52 or 73 and units greater than one.

APC-HOPD, Contract APC/APC Pro, and Medicare CAH Method II:This claim line was billed with Modifier 50, 52, or 73 and units greater than one.

Medicare Physician and New Mexico Medicaid APC:This claim line was billed with Modifier 50 and units greater than one.

Enhanced New York Medicaid APG and New York Medicaid APG:This claim line meets all of the following criteria:- Is assigned to an ancillary APG,- Is not packaged or is paid off the fee schedule, and- Is not billed with Modifier U6.


All Others:Both

12 Payment Reduction Per New York Medicaid Ancillary Policy (Information Only)

Enhanced New York Medicaid APG and New York Medicaid APG:This claim line meets all of the following criteria and, as such, a payment reduction is applied, per the APG Ancillary Policy:- Is assigned to an ancillary APG,- Is packaged,- Is not paid off the fee schedule, and- Is not billed with Modifier U6.

C

13 APC-HOPD, Contract APC/APC Pro, Medicare CAH Method II, and Medicare Physician:ZIP Code Missing or Invalid (Ambulance Fee Schedule Service Only)

Medicare SNF:Zip Code Missing or Invalid (Part B Only)

Enhanced New York Medicaid APG and New York Medicaid APG:No Facility Rate Available

APC-HOPD, Contract APC/APC Pro, Medicare CAH Method II, Medicare Physician, and Medicare SNF:For ambulance fee schedule pricing, a zip code must be entered indicating the point of pickup. Ambulance services occurring on a claim with no valid point of pickup zip code receive this Return Code.

Enhanced New York Medicaid APG and New York Medicaid APG:This claim line includes a vaccine code billed with Modifier SL, however the rate record for this facility/effective date does not have non-zero rate in the SL Modifier Rate field.


All Others:Both




14 Medicare ASC and Contract ASC/ASC Pro:Device Intensive Procedure Without Device

Enhanced New York Medicaid APG, New York Medicaid APG, Medicaid APG Pro, and Virginia Medicaid APG:Invalid Observation Billing

Medicare SNF:Revenue Code Not Covered Under SNF Part B

Medicare ASC and Contract ASC/ASC Pro:This claim does not contain a valid device code. A valid device code must be coded on the claim when a device-intensive procedure is coded with Modifier FB or FC.

Enhanced New York Medicaid APG and New York Medicaid APG:This claim line includes an observation service (procedure code G0378) billed with units less than 8 or without rate code 1402.

Medicaid APG Pro (for Ohio Medicaid APG):This claim line includes an observation service (procedure code G0378) billed with greater than 24 units in a single day or more than 48 consecutive units over a three day period.

Virginia Medicaid APG:This claim line includes an observation service (procedure code G0378) billed with less than 8 units or greater than 24 units.

Medicare SNF:This claim line includes an excluded revenue code billed on a UB-04 Bill Type 022X claim. Please refer to the EASYGroup™ User’s Guide (SNF Part B Revenue Code Exclusion table) for the list of excluded revenue codes.

Enhanced New York Medicaid APG, Medicaid APG Pro, New York Medicaid APG, and Virginia Medicaid APG:C

All Others:Both




15 Enhanced New York Medicaid APG and New York Medicaid APG:Telehealth Facility Fee Invalid

Medicare ESRD and Medicare Hospice:Invalid Units for Revenue Code

Medicare SNF:Not Covered

Enhanced New York Medicaid APG and New York Medicaid APG:The facility fee for Telehealth services is invalid. For procedure code Q3014, with a claim From Date greater than or equal to January 1, 2012, the procedure code Q3014 claim line will be paid only if other claim lines do not receive payment. If any other claim lines receive payment, Pricer Return Code 15 will be issued for the Telehealth claim line.

Medicare ESRD:Indicates one or more of the following conditions are present:- Epoetin Alfa is billed with Revenue Code 0634 and

units >= 100 (corresponds to 10,000 administered units).

- Epoetin Alfa is billed with Revenue Code 0635 and units < 100 (corresponds to 10,000 administered units).

- A claim line is billed with a dialysis Revenue Code and units >1.

- Procedure code Q5105 is billed with one of the appropriate revenue codes, but with inappropriate units for that revenue code.

Medicare Hospice:The claim line is billed with IRC Revenue Code 0655 and units are greater than 5 days.

Medicare SNF:The claim-line contains services billed with Revenue Code 054X and are not on the Ambulance Fee Schedule. These services will not be paid. Ambulance services are only reimbursed on UB-04 Bill Type 022X and 023X claims.


All Others:Both




16 Enhanced New York Medicaid APG, Illinois Medicaid APG Pricer, Medicaid APG Pro, and New York Medicaid APG:Never Event

Medicare ESRD:Medically Unlikely Edit

Medicare SNF:Invalid Units for HIPPS Code (Part A Only)

Medicare CAH Method II and Medicare Physician:Claim Contains a Never Event

Enhanced New York Medicaid APG, Illinois Medicaid APG Pricer, Medicaid APG Pro (for Colorado Medicaid APG, Florida Medicaid APG, Illinois Medicaid APG, Massachusetts Medicaid APG, Ohio Medicaid APG, Virginia Medicaid APG, Virginia Medicaid ASC, and Washington DC Medicaid APG), and New York Medicaid APG:Payment will be denied for claim lines billed with Modifiers PA, PB, or PC (indicating a surgical error).

Medicare ESRD:Indicates one of the following conditions:- Darbepoetin Alfa is billed with more than 1,200 units

(prior to July 01, 2017) or 1,500 units (effective July 01, 2017 - December 31, 2019).

- Epoetin Alfa is billed with more than 4,000 units (corresponds to 400,000 administered units) (prior to January 01, 2020).

Medicare SNF:A Part A claim line billed with Revenue Code 0022 contains a HIPPS code with a missing or invalid unit(s).

Medicare CAH Method II and Medicare Physician:Payment will be denied for claim lines billed with Modifiers PA, PB, or PC (indicating a Never Event is present).

Medicare ESRD, Medicare Physician, and Medicare SNF:Both

All Others:C




17 Enhanced New York Medicaid APG and New York Medicaid APG:Invalid Billing of Offsite Services

Enhanced New York Medicaid APG and New York Medicaid APG:Off-site services billing is invalid. Indicates one of the following conditions:- Effective Prior to January 01, 2013:Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2011, 90801, 90805, 90807, H2010, 90862, 90804, 90806, 90846, or 90847 and the age of the patient is less than or equal to 18.Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2011 and the age of the patient is greater than 18.- Effective January 01, 2013 - March 31, 2013:Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2010, H2011, 90791, 90792, 90832, 90833, 90834, 90836, 90846, 90847, or 90863 and the age of the patient is less than or equal to 18.Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2011 and the age of the patient is greater than 18.- Effective April 01, 2013:Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2010, H2011, 90791, 90792, 90832, 90833, 90834, 90836, 90846, or 90847 and the age of the patient is less than or equal to 18.Rate Code 1507, 1513, 1519, or 1525 has been billed with a procedure code other than H2011 and the age of the patient is greater than 18.- Effective July 01, 2019:Rate Code 1507 or 1519 has been billed with a procedure code other than H2010, H2011, 90791, 90792, 90832, 90833, 90834, 90836, 90846, or 90847 and the age of the patient is less than or equal to 18.Rate Code 1507 or 1519 has been billed with a procedure code other than H2011 and the age of the patient is greater than 18.

C




18 Enhanced New York Medicaid APG and New York Medicaid APG:Diagnosis and Procedure Code Conflict

Medicare ESRD:Invalid Units for Modifier

Enhanced New York Medicaid APG and New York Medicaid APG:Certain knee arthroscopy procedures are not payable with an osteoarthritis diagnosis unless an additional arthritis diagnosis is also supplied.Certain arthrocentesis procedures and associated medication codes are not covered when billed with a diagnosis of osteoarthritis.

Medicare ESRD:Automated Multi-Channel Chemistry (AMCC) procedure code component codes must have only one occurrence of a CD, CE, or CF Modifier on each line. The same AMCC procedure component code cannot be billed twice on the same service date with the same CD, CE, or CF Modifier unless Modifier 91 is also billed with at least one of the AMCC procedure component codes.

Enhanced New York Medicaid APG and New York Medicaid APG: C

All Others: Both

19 Enhanced New York Medicaid APG and New York Medicaid APG:Missing or Invalid Modifier for Pricing

Medicare ESRD:Payment Included in Composite Rate

Enhanced New York Medicaid APG and New York Medicaid APG:Indicates one of the following conditions:- A therapy code that is grouped to APG 270, APG 271, or APG 272 is not billed with an appropriate Modifier as follows:

APG 270: Modifiers GO, HN, or HO.APG 271: Modifiers GP, HN, or HO.APG 272: Modifiers GN, HN, or HO.

- A therapy code that is grouped to APG 270, APG 271, or APG 272 is billed with more than one appropriate Modifier as shown above.

- An identical therapy code that is grouped to APG 270, APG 271, or APG 272 that is billed with an identical Modifier with an episode rate code.

- An identical therapy code that is grouped to APG 270, APG 271, or APG 272 that is billed with an identical modifier, with a visit rate code on the same day of service.

Medicare ESRD:Automated Multi-Channel Chemistry (AMCC) service is not paid because less than 50% of these services are separately payable for the respective date of service.

Enhanced New York Medicaid APG and New York Medicaid APG: C

All Others: Both




20 APG Pricers:Consolidated Service

Medicare ESRD:Incorrect Billing of Telehealth Site Fee

Medicare FQHC:Incorrect Billing of Telehealth Site Fee

APG Pricers:Payment for this service is included in the APG payments for other services on this claim. Note that this is not an error condition, but simply an explanation for why the line is being returned with zero payment.

Medicare ESRD:Occurs when Telehealth originating site fee, procedure code Q3014, is billed incorrectly. Either an ineligible facility, an incorrect date of service (before 01/01/ 2009), an incorrect Revenue Code (not 078X) was used, or an AKI claim contains Telehealth (effective January 01, 2017).

Medicare FQHC:Telehealth originating site facility fee (procedure code Q3014) was not billed with Revenue Code 078X.

APG Pricers:C

All Others:Both

21 Items Paid at a User-Defined Percent of Charges

Medicare ASC and Contract ASC/ASC Pro:This service has been paid at a user-defined percent of charges. This is an informational Return Code and does not impact reimbursement.

Medicare ESRD:A service for which the ESRD fee schedule contains a rate of $0, and the applicable facility rate record has been configured to request percent-of-charge pricing for items with $0 fee schedule rates. This is an informational Return Code and does not impact reimbursement.

Both

22 Contractor Priced Item Requires Additional Setup for Reimbursement

Medicare ASC and Contract ASC/ASC Pro:This service has received zero reimbursement because it is a contractor priced item and it has not been configured to be paid. To have this service paid, refer to the EASYGroup™ User’s Guide.

Medicare ESRD:This service has received zero reimbursement because it is a contractor priced item and it has not been configured to be paid.

Medicare HHA:This service has received zero reimbursement because it is a contractor priced item and it has not been configured to be paid.

Both




23 Medicare ESRD and Medicare HHA:Invalid Revenue Code for Pricing

Illinois Medicaid APG Pricer and Medicaid APG Pro:Non-Covered Revenue Code

Medicare ESRD:1. Claim lines for EPO and Aranesp must be billed with

the proper Revenue Codes: - Revenue Code 0634 or 0635 must be used when

billing Epoetin Alfa (EPO).- Revenue Code 0636 must be used when billing

Darbepoetin Alfa (Aranesp). 2. Revenue Code 0250 or 0636 must be used when

billing a NDC code. 3. Revenue Code 0880 is no longer payable, after

January 01, 2011.4. Revenue Code 0821 and 0881 must be billed with

procedure code 90999.5. Revenue Code 082X, 083X, 084X, or 085X (where X

= 0 - 9) must be reported with procedure code G0491 on AKI claims, effective January 01, 2017 - September 30, 2018.

6. Revenue Code 082X, 083X, or 0881 must be reported with procedure code G0491 on AKI claims, effective October 01, 2018.

7. If procedure code Q5105 is billed without Revenue Code 0634 or 0635 it will receive line-level Pricer Return Code 23, effective July 01, 2018.

8. A non-ESRD Erythropoietin Stimulating Agent (ESA) was billed without Revenue Code 0636 on an Acute Kidney Injury (AKI) claim (UB-04 Bill Type 072X with Condition Code 84).

Medicare HHA:This claim line contains Revenue Code 058X or 059X (where X equals any value) or 0275, 0276, 0277, or 0278 with charges greater than zero. This claim line contains Revenue Code 0624.

Illinois Medicaid APG Pricer and Medicaid APG Pro (for Illinois Medicaid APG):This service was billed with a non-covered revenue code.

Illinois Medicaid APG Pricer and Medicaid APG Pro:C

All Others:Both

24 HCT/HGB Exceeds Monitoring Threshold Without Appropriate Modifier

Medicare ESRD:Prior to January 01, 2020, Epoetin Alfa and Darbepoetin Alfa will not be paid if billed without Modifier ED or EE if (1) the patient’s Hematocrit is greater than 39.0% and condition code 70 or 76 is not present, or (2) the patient’s hemoglobin is greater than 13.0g/dl and condition code 70 or 76 is not present.

Both




25 Improper Billing of Drugs APC-HOPD and Medicare CAH Method II:The Pricer will deny payment for drugs Epotein Alfa (procedure code Q4081 and J0887) and Darbepoetin Alfa (procedure code J0882) unless procedure code G0257 is also present on the claim. G0257 represents unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility. If a claim line is submitted with Q4081, J0887, J0890, or J0882 without an additional line containing G0257 the line will be rejected.

Medicaid APG Pro (for Ohio Medicaid APG):Indicates a pharmaceutical service was billed without Modifier UB and without a National Drug Code (NDC).

Medicare HHA:This claim contains injectable osteoporosis drugs that are not payable because the claim does not meet all of the following criteria: - The patient must be female- Diagnosis code 733.01 (ICD-9) or M81.0 (ICD-10)

must be present- The injectable osteoporosis drug must be billed with

Revenue Code 0636

Medicaid APG Pro:C

All Others:Both

26 Manually Priced by TRICARE C27 Invalid ASCRULE File

ConfigurationContract ASC/ASC Pro:The ASC Payment Status Indicator or Covered Services Indicator entered for this procedure code in the ascrule.dat file is invalid.

Both

28 No Available Extended Fee Schedule Rate

Contract APC/APC Pro: The Pricer cannot locate an extended fee schedule rate record with appropriate values in carrier and effective date for this service date and procedure code.

APG Pricers:The Pricer cannot locate an extended feeschedule rate record with appropriate values inthe carrier and effective date fields for this particularservice date.

NoteNot used by Illinois Medicaid APG, Medicaid APG Pro, New York Medicaid APG, Virginia Medicaid APG, and Washington Medicaid APG.

Medicare SNF:The Pricer cannot locate an extended fee schedule rate record with appropriate values in carrier and effective date for this particular service date and therapy code that is subject to discounting.

APG Pricers:C

All Others:Both




29 Contract APC/APC Pro, Iowa Medicaid APC, and New Mexico Medicaid APC:Paid by Report/Manually Priced

APG Pricers:Non-Covered Service

Medicare CAH Method II and Medicare Physician:Paid by Report

Contract APC/APC Pro:This procedure code may be paid subject to rules defined by the payer. Additional documentation must be submitted by the provider.

Iowa Medicaid APC:The procedure code has a Payment Type of MP or a Payment Type of NIP (Non-Inpatient Program) and an Iowa Fee Schedule of By Report.

New Mexico Medicaid APC:Procedure codes identified as OPPS NM Medicaid Price Review, OPPS NM Medicaid Special Revw, or OPPS NM Mcaid Price Revw on the New Mexico Fee Schedule with a rate of $0.00 will receive line-level Pricer Return Code 29.

APG Pricers:Medicaid has identified this service as non-covered.This Return Code will be issued on service lines that contain non-covered procedure codes, non-covered revenue codes, and/or revenue codes that are non-covered only when billed without a procedure code, as identified by the appropriate Medicaid agencies.

NoteFor Ohio Medicaid, this Return Code will also be issued on all other lines on the same date of service as a non-covered code.

Medicare CAH Method II and Medicare Physician:This surgical procedure has been performed by a team of surgeons (i.e., 3 or more surgeons of different specialties) as indicated by Modifier 66. Sufficient documentation must be provided to establish that a team was medically necessary and to allow for payment by report.

APG Pricers, Iowa Medicaid APC, and New Mexico Medicaid APC:C

All Others:Both

30 New York Medicaid APG:Service Exceeded Maximum Number of Allowed Units

Medicare CAH Method II, Medicare Physician, and New Mexico Medicaid APC:Line Bypassed From Claim Processing

New York Medicaid APG:The claim-line contains procedure code 99051 with more than one unit per day (effective January 01, 2015).

Medicare CAH Method II, Medicare Physician, and New Mexico Medicaid APC:This claim line has been denied or rejected by an external Editor (such as the Optum CES® Professional Editor or facility Editor). It has not been used for any reimbursement calculations.


All Others:Both




31 Medicaid APG Pro:Service Not Paid on Independently Billed Claim

Medicare CAH Method II and Medicare Physician:Invalid or Missing Taxonomy

Medicaid APG Pro (for Ohio Medicaid APG):Indicates Modifier UB was not billed with a principal procedure code on an independently billed claim.

Medicare CAH Method II and Medicare Physician:The Billing Provider Taxonomy, Service Facility Taxonomy, or Rendering Provider Taxonomy is missing or is not a valid Taxonomy.

Medicaid APG Pro:C

All Others:Both

32 Enhanced New York Medicaid APG and Medicaid APG Pro:Service Did Not Meet Minimum Required Units or Service Exceeded Maximum Allowed Units

Medicare Physician:Pricing Cannot be Provided for This NDC

Enhanced New York Medicaid APG and Medicaid APG Pro (for Colorado Medicaid APG, Virginia Medicaid APG, and Washington DC Medicaid APG):The procedure code was billed with less than the minimum required units or more than the maximum allowed units.

Medicare Physician:The Physician Pricer cannot locate a record in the Physician Date file (codephys.dat for C; code04.dat for COBOL) for this NDC that has an Effective Date that is less than or equal to the Service Date.

Enhanced New York Medicaid APG and Medicaid APG Pro:C

All Others:Both

33 Medicaid APG Pro:Invalid or Missing Claims Data

Medicare CAH Method II and Medicare Physician:Bundled Service Not Separately Payable

Medicaid APG Pro (for Ohio Medicaid APG):Behavior health reporting requirements were not met.

Medicare CAH Method II and Medicare Physician:Indicates one or more of the following conditions:- Service is assigned to a Status Code T or P and is

billed on the same Service Date as a service assigned to Status Code A. Payment for these services is bundled into the payment of the Status Code A service. Payment for these services will not be bundled if billed without a Status Code A service on the same Service Date.

- Service is assigned to a Status Code B. Payment for these services is always bundled into the payment for other not specified services.

- Conditionally bilateral service billed on two claim lines with the LT (Left Side) Modifier on one line and the RT (Right Side) Modifier on the other line. Payment for the LT Modifier line is bundled into the payment for the RT Modifier line.

- Service subject to endoscopic multiple procedure discounting. Payment for this line has been bundled into the payment for the related endoscopic procedure with the highest fee schedule rate on the same Service Date.

Medicaid APG Pro:C

All Others:Both




34 Service Not Payable Medicare CAH Method II and Medicare Physician:This service is assigned to one of the following non-payable Status Codes:- D = Deleted Code- F = Deleted/Discontinued Code- G = Not Valid for Medicare Purposes- H = Deleted Modifier- I = Not Valid for Medicare Purposes- N = Non-Covered Service

NoteThis Pricer Return Code may also be issued for Status Code A services that are billed with an assistant surgeon, co-surgeon, or team surgeon modifier which is not allowed for that service (based on the MPFS assistant surgeon, co-surgeon, or team surgeon indicator).

Both

35 Service for Reporting Purposes Only

Medicare FQHC:This service is used for reporting purposes only and is not payable. Services related to Influenza and PPV vaccines.

Medicare SNF:Used for reporting purposes only. No separate payment is made for this code. No payment will be made.

Medicare CAH Method II and Medicare Physician:This service is assigned to Status Code M. This service is used for quality reporting purposes only and is not payable.

Both




36 APC-HOPD and Contract APC/APC Pro:Therapy Code Without MPFS Rate

Medicare SNF:Therapy Code Without MPFS Rate (Part B Only)

Medicare CAH Method II and Medicare Physician:Carrier Priced Service or Restricted Coverage

APC-HOPD and Contract APC/APC Pro:Therapy procedure codes assigned to a Payment Status Indicator of A that are contractor priced or bundled under the MPFS.

Medicare CAH Method II:One or more of the following is present:- Therapy procedure codes assigned to a Payment

Status Indicator of A that are contractor priced or bundled under the MPFS.

- This service is assigned to Status Code C or R and a fee schedule rate has not been established for the service.

Medicare SNF:Therapy procedure codes that are contractor priced or bundled under the MPFS.

Medicare Physician:This service is assigned to Status Code C or R and a fee schedule rate has not been established for the service.

Both

37 Missing or Invalid Status Code Medicare CAH Method II and Medicare Physician:The status code assigned to this service is missing or is invalid. Valid status codes include:- A = Active Code- B = Bundled Code- C = Carriers Price the Code- D = Deleted Code- E = Excluded from Physician Fee Schedule by

Regulation- F = Deleted/Discontinued Code- G = Not Valid for Medicare Purposes- H = Deleted Modifier- I = Not Valid for Medicare Purposes- J = Anesthesia Service- M = Measurement Code- N = Non-Covered Service- P = Bundled/Excluded Code- R = Restricted Coverage- T = Injections- X = Statutory Exclusion

Both




38 Payment Bundled with Other AMCC Test

Medicaid APG Pro (for Massachusetts Medicaid APG):Payment for this Automated Multi-Channel Chemistry (AMCC) or clinical laboratory panel code has been bundled with the payment for the first AMCC or panel code on this Service Date.

Medicare Physician:Payment for this Automated Multi-Channel Chemistry (AMCC) or organ disease panel code has been bundled with the payment for the first AMCC or panel code on this Service Date.

Medicaid APG Pro:C

All Others:Both

39 No Physician Rate Calculator Record

Medicare CAH Method II and Medicare Physician:The Pricer cannot locate a record in the Physician Rate Calculator file (medphys.dat for C; hosp04.dat for COBOL) with a matching:- National Provider Identifier (NPI)- Taxonomy- Payer ID- Patient Type (COBOL only)That has an Effective Date that is less than or equal to the claim From Date.

Both

40 Attempted Divide by Zero Medicare CAH Method II and Medicare Physician:The Pricer cannot calculate reimbursement for this service assigned to a Status Code J because the variable Anesthesia Minutes has not been defined in the Physician Rate Calculator file (medphys.dat for C; hosp04.dat for COBOL) for this particular provider NPI, Taxonomy, Payer ID, and Effective Date.

Both

41 Improper Billing of Modifier AY

Medicare CAH Method II and Medicare Physician:Provider Subject to Preclusion and/or OIG Sanction

Medicare ESRD:- Occurs when Modifier AY is applied to a procedure

code that is on CMS’ Consolidated Billing List. CMS does not allow these procedure codes to be separately-payable. Effective January 01, 2012.

- AKI claims cannot be billed with Modifier AY, effective January 01, 2017.

- Procedure code Q5105 is not separately payable with or without Modifier AY and will receive line-level Pricer Return Code 41.

Medicare CAH Method II and Medicare Physician:This provider is on the CMS Preclusion List and/or has been sanctioned by the Office of Inspector General (OIG) as indicated in the Physician Rate Calculator File (medphys.dat; hosp04.dat).

Both

42 Invalid or Missing Specialty Code

Medicare CAH Method II and Medicare Physician:The specialty code assigned to this billing provider is missing or is invalid.

Both




43 Not Enough Information for Pricing

APC-HOPD, Contract APC/APC Pro, Contract ASC/ASC Pro, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare Hospice, Medicare HHA, New Mexico Medicaid APC, Medicare Physician, and Medicare SNF:Insufficient pricing information available for this service. For example, the Payment Status Indicator for the service is unknown.

Both

49 Payment Code is Not Eligible for Payment

Medicare FQHC:The FQHC payment code billed on the claim does not meet the criteria for payment.

Both

50 Invalid Observation Billing New Mexico Medicaid APC:Observation services billed with procedure code G0378 have been billed incorrectly. No more than 24 hours/units of observation service will be paid per day.

C

62 Closed Rate Record Medicare CAH Method II and Medicare Physician:A closed rate record is provided in either the Rendering or Service NPI/Taxonomy and that rate record is used for pricing. In addition, the alternate lookup switch is set to 0 or 1.

It is also possible for a 9999999999 record to be closed (if the taxonomy was discontinued), therefore this Return Code may also be triggered if the Alternate Lookup Switch is set to 1 and the Rendering or Service Taxonomy being used for pricing is no longer active.

Both




8 Mapper Return Codes

This chapter provides a list of all EASYGroup™ Mapper Return Codes. For more information on EASYGroup™ Mappers please refer to the EASYGroup™ User’s Guide. This chapter includes the following sections:

• Claim-Level Mapper Return Codes• Diagnosis-Level Mapper Return Codes• Procedure-Level Mapper Return Codes


8.1 Claim-Level Mapper Return CodesTable 8-1: Mapper Return Codes

Return Code Short Description Long Description C or COBOL or Both00 No Errors Found There were no claim-level Mapper errors found on the

claim.Both

01 Cannot Determine Coding Version (ICD-9 or ICD-10) for Claim

NoteICD-10 Mapper only.

Both

C only for the Alternate ICD-10 Mapper

02 Target Version Cannot Be Determined Note

ICD-10 Mapper and Alternate ICD-10 Mapper only.

Both


03 Source Version Does Not Match Coding Version

NoteAlternate ICD-10 Mapper only.

C

05 Mapping Data File Open or I/O Error Note

ICD-10 Mapper only.

C

06 Mapping Override File Open or I/O Error Note

ICD-10 Mapper only.

C

08 Mapping Between Code Version and Grouper Version Not Supported


C

23 Mapping Between Code Version and HAC Version Not Supported


C

28 Invalid Data Alternate ICD-10 Mapper:Incorrect or missing required claims data.

C


Alternate ICD-10 Mapper:The 3M™ GPS was not installed or configured correctly.

C

61 All Other Errors Returned from External Software

Alternate ICD-10 Mapper:The 3M™ GPS returns an unexpected result or an exception is thrown.

C

65 Invalid Certificate


Alternate ICD-10 Mapper:The certificate needed for the 3M™ GPCS is not present or is invalid and/or when the required unique key needed for a Super Certificate(s) is not present or is invalid.

C

66 Invalid URL


Alternate ICD-10 Mapper:The values set in the 3M™ GPCS, GPCS_URL (i.e., the URL to send claim info to) and/or the GPCS_STSURL (i.e., the URL to validate the certificate) environmental variables are missing or invalid.

C


8.2 Diagnosis-Level Mapper Return Codes


Alternate ICD-10 Mapper:The Mapper Control Program (mapcntl) cannot find or load the Mapper Program or the Retrieve Payer Control Program (rtvpyr) that are required. These programs should be stored in the same directory that contains the Optimizer.


C

88 Invalid Content Version

Alternate ICD-10 Mapper (3M™ GPCS only):An invalid content version (GPCS_ContentVersion) has been passed to the GPCS. This version is set either in an environment variable or in the HssSetup.ini file.

C

89 Memory Allocation Error

Alternate ICD-10 Mapper:A memory allocation error has been found or the 3M™ GPS interfacing program (ezgps) cannot be found or loaded.

C

95 Parameter Error NotePlease refer to the EASYGroup™ User’s Guide for Special Instructions for ICD-9 procedure code 0050 concerning further instruction relating to Return Code 95.

C


An error occurred during the opening or loading of the Mapper or associated programs.

COBOL

IO File I/O Error One or more of the Mapper data files cannot be opened or closed. Please refer to MOB1-MAP-RTN-CODE2 for details.

COBOL

Table 8-2: Diagnosis Code Level ICD-10 Mapper Return Codes

Return Code Short Description Long Description C or COBOL or Both00 Mapping, if Needed

Occurred with No Errors

NoteICD-10 Mapper and Alternate ICD-10 Mapper only.

Both


02 No Mapping Can Occur for This Diagnosis Code


Both


Table 8-1: Mapper Return Codes



8.3 Procedure-Level Mapper Return CodesTable 8-3: Procedure Code Level ICD-10 Mapper Return Codes

Return Code Short Description Long Description C or COBOL or Both00 Mapping, if Needed

Occurred with No Errors


Both


02 No Mapping Can Occur for This Procedure Code


Both



9 Troubleshooting & Logging in EASYGroup™

In this chapter you will find troubleshooting and logging techniques. These procedures will be useful when attempting to resolve an issue, or when calling Optum Client Care for assistance. Please refer to Chapter 1 for contact information for Optum Client Care. This chapter includes the following sections:

NoteFor information on logging for the EDC Analyzer™ please refer to the Implementation Plan Guide - EDC Analyzer™.

• General EASYGroup™ Logging- Logging Overview- Types of Logging

• Configuring Logging• How to Resolve Return Code 60 and 61• Additional Logging for EASYGroup™ Server

- The Three Types of Server Logging- Disable the ezgsrv-[YYYYMMDD].log

• Additional Logging for EASYGroup™ Web Service• Additional Logging for Optum Exchange PPS (OEPPS)

- OptumEPPS.log- OEPPSRemoteFileMover.log- <user-defined filename>.log- OptumEPPS.UI.log- OEPPS Troubleshooting


9.1 General EASYGroup™ LoggingNote

Before contacting Optum Client Care users should have the applicable log files available to assist in troubleshooting any issues.

9.1.1 Logging OverviewThe Log Control Program (logcntl/LOGCNTL) contains logging functionality for all EASYGroup™ components to assist in troubleshooting any undesired claims processing results. The user must enable logging, as it is not set by default.

NoteLogging may inhibit EASYGroup™ processing time and, as such, logging should only be enabled for troubleshooting purposes. Once troubleshooting is complete, logging should be immediately disabled.

9.1.2 Types of LoggingThere are three types of logging as described below:

• Log Control File- Manually Created Log Control File- Automatically Created Log Control File (C Platform Only)

• EASYGroup™ System Error Log File (C Platform Only)• 3M™ GPS Log File (C Platform Only)

9.1.2.1 Log Control FileThe Log Control File (logcntl.txt) includes all inputs sent to EASYGroup™, all outputs returned by EASYGroup™, and shows all EASYGroup™ components that were utilized along with their version numbers. The Log Control File can be created manually or automatically as described below.

Manually Created Log Control FileTo enable logging manually, you must create an empty text file named logcntl.txt with full read/write/modify permissions and place that file in one of the following locations:

• The directory indicated in the LogcntlFileName variable in the hsssetup.ini file (as shown below).

• The same directory as your EASYGroup™ components.• The Windows® directory.

To disable logging, simply delete or rename the logcntl.txt file.


The Log Control File will stop expanding once it reaches 1 GB. Once this limit has been reached a new log file will be created, and the original log file will be deleted along with all previously collected data. Clients can modify the 1 GB file limitation by modifying the LogcntlOutputFileSize setting in the hsssetup.ini file (as shown below).

Automatically Created Log Control File (C Platform Only)The Log Request (log_request) field located in the ECB [ezg_cntl_block] structure allows you to create a Log Control File on demand for a single claim.When this Log Request field is set to 1 (Log File (logcntl.txt) Requested), the log file will be created using the following naming convention: logcntl_[timestamp].txt (the time stamp will include the year, month, day, hours, minutes, and seconds).If the log file cannot be created (due to a permissions issue, etc.), then the Logging Control Program will generate Function Return Code 18 (Error Creating Log File) and Optimizer Return Code 24 (Non-Zero Return Code From Log Control Program (logcntl)).The location of the single claim log file is set as follows:

1. To the EzgClaimLogPath variable found under the [logcntl] heading in the hsssetup.ini file

2. If that variable is not found, then the path will be set to the LogcntlFileName variable found under the [logcntl] heading in the hsssetup.ini file

3. If both variables are not found, then the path will be set to the default path (C:\Windows)

9.1.2.2 EASYGroup™ System Error Log File (C Platform Only)The EASYGroup™ System Error Log File (ezgsyserr.txt) is used to log fatal EASYGroup™ errors. This log file contains the following information as shown below in Figure 9-1:

• Date/time the error was encountered.• The control program that logged the error.• The EASYGroup™ program (e.g., Editor, Analyzer, Grouper, Pricer,

Mapper, etc,) that returned the error.• All EASYGroup™ input and output data available when the error occurred.• Other error information.

To enable this log file, create an empty ezgsyserr.txt file in the path indicated by the EzgSysErrFileName variable found under the [logcntl] heading in the hsssetup.ini file (refer to Figure 9-2) or in the C:\Windows directory. Make sure to provide this log file with full read/write/modify permissions.

Figure 9-1. EASYGroup™ System Error Log File Example


NoteThe ezgsyserr.txt will not grow in size with each claim processed.

Figure 9-2. Location in hsssetup.ini File to Change Path for ezgsyserr.txt

9.1.2.3 3M™ GPS Log File (C Platform Only)The 3M™ GPS also includes troubleshooting logging. The 3M™ GPS log file (3MHIS.txt) shows all inputs to the 3M™ GPS and all outputs from the 3M™ GPS. Optum might request this log file from you when troubleshooting an issue with the 3M™ GPS. To enable this log file, locate the log4j.properties.save file which is installed with the 3M™ GPS in the following directory by default:


C:\Program Files\3mhis\gps\Rename this file to log4j.properties, open the file, and modify the path highlighted in yellow (refer to Figure 9-3) to the path of your choosing. Next, create an empty 3MHIS.txt file in the same path and provide the file with full read/write/modify permissions. To disable logging, do one of the following:

• Delete or rename the 3MHIS.txt file• Rename the log4j.properties file back to log4j.properties.save

Figure 9-3. log4j.properties.save File

9.2 Configuring LoggingYou can configure logging in may different ways using the hsssetup.ini file as described below (refer to Figure 9-4). The hsssetup.ini file contains a [logcntl] heading with the following variables:

• LogcntlFileName: The location of the logcntl.txt file to be used for logging.

• LogcntlOutputLevel: The level of logging to perform in the logcntl.txt file (refer to Table 9-1 for all available options). For most issues, Optum


recommends a LogcntlOutputLevel of 15. If utilizing the 3M™ GPCS, Optum recommends a LogcntlOutputLevel of 63.

• LogcntlOutputFileSize: The maximum size of the logcntl.txt file (in bytes). Once the file limit is reached, the log file is deleted and a new file is created. The default is 1000000 (1MB).

• EzgClaimLogPath: The location of the automatically created log file (logcntl_[timestamp].txt) to be used for logging.

• EzgSysErrFileName: The location of the ezgsyserr.txt file to be used for logging.

Table 9-1: LogcntlOutputLevel Level Descriptions

Output Level

Description

1 Logs the EASYGroup™ input and output structures.2 Logs summary information. This includes the version number of the.dll loaded.3 Logs output levels 1 and 2.4 Logs detail information. This can include file names of the .dat files.

7 Logs output levels 1, 2, and 4.8 Logs trace and debug statements.12 Logs the transaction times to and from the 3M™ GPCS and logs any errors returned by

the 3M™ GPCS.15 Logs output levels 7 and 8.16 Logs very verbose 3M™ GPCS information.32 Logs the message sent to/from the 3M™ GPCS.48 Logs output levels 16 and 32.63 Logs all output levels.


Figure 9-4. hsssetup.ini File Example

9.3 How to Resolve Return Code 60 and 61Return codes 60 and 61 are “catch-all” errors and, as such, logging must be used to determine the actual cause of the error. The sections below describe how to resolve some of the common causes of return codes 60 and 61. If you are unable to resolve the return code by reviewing the below sections, please collect the following information before contacting Optum Client Care for assistance:

- EASYGroup™ log file (logcntl.txt)- A copy of the config.xml file from the 3M™ GPS installation location

(i.e., C:\Program Files\3mhis\gps\)


- Open a command prompt and navigate to the 3M™ GPS installation location (i.e.,C:\Program Files\3mhis) and then execute the following command: dir /s. Next, copy the list of files returned by the command into a empty document or text file.

9.3.0.1 Return Code 61This catch all error occurs when the interface believes the 3M™ GPS is installed and working, but you have received an unexpected result from the 3M™ GPS or the 3M™ GPS has thrown an exception. If this occurs during claims processing, check the logcntl.txt log file for the following.

<grpr>_rtn_code=<61>, erc=2

NotePlease note that the above error can read as a Grouper, Pricer, or Editor Return Code. For example, grpr_rtn_code, prcr_rtn_code, or edtr_rtn_code.

The 3M™ GPS returns erc=2 (unknown error) when there is not enough space on the Java™ heap to process the claim. The 3M™ GPS erc=2 is more likely to occur with Web.Strat™ and the ECM Pro™ Web Services, since they use multiple threads for processing.The default Java™ heap size is 256 MB. EASYGroup™ clients are required to set the Java™ heap size to 100 MB (minimum) or higher. The following table shows typical Java™ heap requirements for the 3M™ GPS:

If you are receiving the above error, the size of the Java™ heap can be increased with the HSSJVMOPTION environment variable (refer to the EASYGroup™ Installation Guide on how to set this variable). It is recommended that the Java™ heap size be increased by increments of 15 MBs until the error is resolved.

ImportantChanging the Java™ heap size should be completed cautiously and in small increments. Changing the Java™ heap size also increases the possibility of Return Code 60 occurring as described below.

When the HSSJVMOPTION is set, the value of the environment variable is written to the log file.

9.3.0.2 Return Code 60

Table 9-2: Typical Java™ Heap Requirements for the 3M™ GPS

3M™ GPS Item Heap Memory Additional ThreadsEAPGs 100 MB 2 MBAPR 8 MB 1 MBOutpatient Payment (TRICARE)

9 MB 2 MB


This catch all error occurs when the interface cannot create a Java™ Virtual Machine (JVM) or 3M™ GPS object. Check the EASYGroup™ log file (logcntl.txt) for the following:

Unable to load jvm library, C:\Program Files\3mhis\gps\jre\bin\client\jvm.dll

EASYGroup™ was unable to load the JVM library. The only time this Return Code should be triggered, is when the jvm.dll file does not exist in the correct folder. The jvm.dll file is included as part of the 3M™ GPS. Verify the below:

• Verify that the 3M™ GPS wrapper and the 3M™ GPS have been installed correctly.

• Verify that the 3M™ GPS is not running on a workstation, which requires environment variables that need to be associated to a server with the 3M™ GPS.

• Check the location and version of the 3M™ GPS. • Verify that the batch testers work correctly.

If the above does not resolve the issue, please receive a copy of 3mhis\gps\config.xml and Windows\hsssetup.txt, and a recursive directory of the 3mhis folder.

Error occurred during initialization of VM Could not reserve enough space for object heap JNI_CreateJavaVM Failed, returned -4

This occurs when the interface is unable to create a JVM due to memory issues. When creating a JVM an adjoining section of virtual address space is needed for the Java™ heap. By default, the Java™ heap is 256 MB, but this can be changed with the HSSJVMOPTION as described in the How to Resolve Return Code 60 and 61 section above. If there is not a large enough section of virtual address space, creating the JVM will fail.If using Web.Strat™ or the ECM Pro™ Web Services, create separate pools for the Inpatient, Outpatient, and WebStratXML Web Services. This causes IIS to create a separate process for each pool, and each process will have more virtual address space available. The WebStratXML Web Service is a part of Web.Strat™, and is used by Web.Strat™ to process outpatient claims. Process Explorer can be used to determine what is running in each process (pool). If pools do not resolve this issue, follow the instructions in http://technet.microsoft.com/en-us/library/bb124810(EXCHG.65).aspx AND http://www.microsoft.com/whdc/system/platform/server/PAE/PAEmem.mspx for configuring Windows® to increase the amount of virtual address space available to each process from 2 GB to 3 GB.


ImportantThis is a system-wide setting and should be used cautiously.

To Enable the 3M™ GPS Interfacing Log File:Enabling the 3M™ GPS interfacing log file will expedite troubleshooting. Create a log file for the EASYGroup™ interface in the Windows® folder or current working directory. The log file should always be named: logcntl.txt.

NoteWeb.Strat™, the EASYGroup™ Web Service, and the ECM Pro™ Web Services run under the NETWORK SERVICE or <machine name>\ASPNET log-on in the logcntl.txt Properties>Security tab.

9.4 Additional Logging for EASYGroup™ ServerImportant

Please note that enabling logging will inhibit Server processing time. The Server includes optional data logging utilities to assist with troubleshooting issues.

Before contacting Optum Client Services users should have the applicable log files available to assist in troubleshooting any issues.

9.4.1 The Three Types of Server LoggingThere are three types of Server log files:

• ezgsrv-[YYYYMMDD].log • optsrv.txt• logcntl.txt

Each type of log file is explained in more detail below.

9.4.1.1 ezgsrv-[YYYYMMDD].log The ezgsrv-[YYYYMMDD].log files are generated by EZGsvr.exe, and their creation is enabled by default unless disabled by setting ServerLogging=False (for further information on disabling the ezgsrv-[YYYYMMDD].log please refer to Disable the ezgsrv-[YYYYMMDD].log section). The ezgsrv-[YYYMMDD].log files are located in the Server Data directory. Information displayed in the window log is identical to the log information contained in the ezgsrv-[YYYMMDD].log.There are two types of logging generated by the ezgsrv-[YYYMMDD].log files:

• Normal logging - Provides information about the communication between the EASYGroup™ Server and the calling application, as shown below in Figure 9-5.


NoteBytes in and bytes out are only displayed in this log file when the connection to the EASYGroup™ Server is closed.

• Detailed logging - In addition to the information in normal logging, detailed logging also includes the complete input from the calling application to the EASYGroup™ Server and the complete output from the EASYGroup™ Server to the calling application.

Figure 9-5. Normal Logging Example

To enable detailed logging, double-click anywhere in the Server window directly under the text Server On.


Figure 9-6. Enabling Detailed Logging

If detailed logging is enabled, a message will appear in the text box (as shown below).

Figure 9-7. Detailed Logging Enabled


Figure 9-8. Detailed Logging Results

To disable detailed logging, double-click again in the text box. An entry in the log will appear notifying the user that logging has been disabled.

9.4.1.2 Disable the ezgsrv-[YYYYMMDD].logSome users may wish to completely disable the ezgsrv-[YYYYMMDD].log file. In order to do this, users must insert the line ServerLogging=False into the HssSetup.ini file present in their environment under the [EASYGroup] heading, as shown in the example below.Adding the line ServerLogging=False will prevent the creation of any log files by the Server. In order to restore logging functionality, the line must be removed or updated to: ServerLogging=True.


Figure 9-9. Disable Logging

9.4.1.3 Optsrv.txtOptsrv.txt is generated by optsrv.dll. It will only be generated if the user creates an empty file named optsrv.txt. It is disabled by deleting or renaming the file. This file should be placed in the Data directory.The optsrv.txt log file shows several types of errors encountered by the EASYGroup™ Server. It will also display up to 409 bytes of every input claim and for each claim it will display the number of bytes received and returned by the EASYGroup™ Server.

9.4.1.4 Logcntl.txtLogcntl.txt is user-defined by creating an empty file with that name in the Server Data directory. If this file exists, the Optimizer will automatically log processing and error information. Be sure the log-on user ID has write access to the logcntl.txt file or the folder. To disable Optimizer logging, simply delete or rename the file. In an effort to enhance the Optimizer’s logging capabilities, functionality was added to the Log Control Program (logcntl; LOGCNTL) to allow all other Optimizer control programs to log their name and version number within the logcntl.txt file, if logging is enabled.Logcntl.txt contains logs for all EASYGroup™ components, including ECM Pro™ Web Services. This file can be extremely helpful when contacting Optum Client Services.


Figure 9-10. logcntl.txt Log File Example

9.5 Additional Logging for EASYGroup™ Web ServiceThe EASYGroup™ Web Service supports multiple types logging to aid in troubleshooting issues. There are two sets of EASYGroup™ Web Service log files, ezgws.log and ezgsystem.log, that are configured in the APISettings section of the appsettings.json file:

EzgwsLogLevel defines the detail of information written to ezgws.log. This logs transaction-level information (i.e., calculations, file reads, data-handling errors, and trace data in and out). This log level is optimal for troubleshooting transactions that fails at the EASYGroup™ Web Service layer.EzgSystemLogLevel defines the detail of information written to ezgsystem.log. This logs application-level information (i.e., system startup,

Table 9-3: List of Log Files

Setting File NameEzgSystemLogLevel \EZGWebService\EZGWebAPI\logs\ezgsystem.logEzgwsLogLevel \EZGWebService\EZGWebAPI\logs\ezgws.log


shutdown, activation of serializer settings, and detailed step-by-step transaction logs). This log level is optimal for troubleshooting complex multi-transactional requests that remain unresolved after reviewing ezgws.log. The log files feature a rolling archive. The EASYGroup™ Web Service will retain up to 7 archives plus the active file. The oldest archive is deleted when a new file is created. A new log file is created at either the start of a new day or when it reaches the maximum file size of 52MB.The values for these two log level entries is the level of entry that is written to these log levels:

- Trace = logs all the transaction that are made within the EASYGroup™ Web Service and information at all levels of logging. - Debug = logs detailed code level errors. Shows all below. - Warn (Default) = logs messages returned by the service that are considered warnings but still allow the results to return. - Error = logs messages returned by the service that are

considered errors and do not allow the full results to return.

9.5.1 How To Set Up Logging: 1. Navigate to the installation path (i.e.,

C:\Optum\EZGWebService\EZGWebAPI)2. Open the appsettings.json file within a text editor.

NoteIt is recommended to save a backup copy of the configuration file before making modifications (i.e., appsettings.json.bk).

3. Navigate to ApiSettings section update the EzgSystemLogLevel and EzgwsLogLevel to the appropriate level of logging as defined above.

4. Save the file. 5. Restart the application pool, web site, or IIS. 6. Re-run the claim producing the error. 7. View the log files to ensure the detail expected is present. If it is not, repeat the previous steps and increase the level of logging. 8. You can then either:


a. Edit the modified file back to Warn. b. Delete the modified file and rename the original file (i.e.,

appsettings.json.bk back to appsettings.json)

NoteRemember to restart Internet Information Services (IIS) and apply new settings.

9.5.1.1 Standard Output LoggingStandard output logging is a .NET Core standard log file that is designed to troubleshoot startup and configuration-level environment issues. The file name for the log file is stdout_Timstamp. This log file can be enabled and disabled by setting the stdoutLogEnabled value in the web.configg to true and false respectively. Per Microsoft® recommendation, this log should only be enabled in rare circumstances.

9.6 Additional Logging for Optum Exchange PPS (OEPPS)

In addition to file level logging, there are several useful session logs within OEPPS. These logs can be located in the root installation directory and the designated File Watch folder.

9.6.1 OptumEPPS.logThe OptumEPPS.log file is stored within the File Watch directory. Each time OEPPS processes file information it is written to this log file. Each new entry is appended onto existing entries to keep a running log. New log files are created each calendar day. The older logs are stored with their creation date (e.g., OptumEPPS_YYYYMMDD.log). The following is an example sequence of events:

• The date, time, and version are captured, along with how the Service was launched

• The current system CPU usage and memory available• The file was picked up for processing• Number of records• Time metrics once files have completed processing• When the Service or the application has started/stopped• EASYGroup™ Optimizer configuration file path• Logging of EASYGroup™ editing/grouping/pricing performed*• Grouper version and type*• Mapping flag*

https://docs.microsoft.com/en-us/aspnet/core/test/troubleshoot-azure-iis?view=aspnetcore-3.1


• EASYGroup™ Optimizer path*• Rate files path*• File Watcher path with files processed• Lines processed, claims per second• Errors*• File Watcher Service status

Important* Functionality for the legacy OPTDLL only.

Figure 9-11. OptumEPPS.log File Example

9.6.2 OEPPSRemoteFileMover.logThe OEPPSRemoteFileMover.log file is located in the root installation directory. This log file is written to each time the Windows® Service is called to pull a file from the RemoteFile directory. The following is an example sequence of events:

1. The date, time, and version are captured, along with how the Service was launched

2. Remote File Mover utility path3. Path to the status icons4. Verification of destination File Watch folder5. Connection attempt to the FTP server with specified credentials


6. Watch for trigger file pattern7. Move files to local File Watch folder for processing8. Loop or shutdown

9.6.3 <user-defined filename>.logWhen OEPPS processes a file, it will create a log for each file processed. It will place these logs in the File Watch>Debug folder. Log files are written with the name of the processed file. If a file of the same name is processed in the same File Watch folder, this log will be appended.The LogLevel setting determines the content that is logged to the <user-defined filename>.log file. The LogLevel values are shown below in Table 9-4.The default and recommended value is 0 (No Logging) and should only be adjusted for troubleshooting purposes. A LogLevel greater than 0 will write the information to the log file when applicable. The higher log level includes the previous log level information. For example, a LogLevel of 3 will log INFO, WARNING, and ERROR to the file.Due to the amount of information that is logged with higher log levels, OEPPS will only utilize values greater than 1 if the number of claims is equal to or less than 50. The log level will be reduced to a minimal debug logging after 50 claims, to prevent CPU, memory, and disk space overload. Additionally, if no ERROR or WARNING encounters are met and the LogLevel is 2 or less, the file will not be created.

9.6.4 OptumEPPS.UI.logThis log file has been created for future use. The OptumEPPS.UI.log file is written to the OEPPS program directory (i.e., C:\Optum\ExchangePPS).

9.6.5 OEPPS TroubleshootingUsers have the ability to view OEPPS errors in an output file. A Oepps structure is available and contains a OEPPS Return Code (oepps_return_code) field. The possible OEPPS Return Codes are listed

Table 9-4: LogLevels

LogLevel Information Logged

Status Details

0 No Logging N/A No Logging1 Error Failure OEPPS Processing Error2 Warning Success OEPPS Processing Warning

(Value Truncation)3 Info Success Data File Paths (System, User,

Rate)4 Detail Success Field-by-Field Value Mapping


below. Users can add the Oepps structure to their layout by using the Mapping Utility. Please refer to the Interfacing With EASYGroup™ Guide for further information. These error codes are exclusive to OPTXML processing.

Table 9-5: OEPPS Return Codes

Return Code Description0 No Error Found101 Database Access Error 301 Communication Error401 Exception1001 Sidebar Load Failed1002 Sidebar No XML File Name1003 Sidebar With Error1004 Sidebar Missing Attribute1005 Mapper Exception1006 Mapper Exception Unknown1101 Process No File1102 Process Exception1103 Process Cannot Open Stream1104 Process File Exception1105 Process Line Exception1106 Process Line Data String Overflow1107 Process Line Error Unknown C Block Found1108 Error Mapping File MUTEX1109 Error Truncation Occurred1110 Error Loading Mapping File1111 Error Invalid Mapping XML Content1112 Client Data Null1113 Map XML to EZG Error1114 Error Invalid Data String1115 Error Unknown C Block Found1116 Print XML Data Map1117 Error Output Data String Overflow1118 Error EZG Block Allocate1119 Error Unable to Load Optimizer1120 Error Calling Optimizer1121 Error Invalid Sidebar XML Content1122 Error Invalid XML File1123 Get Config String XML Parameter Error1124 Error Exception Caught in Mapper1125 Error Loading Data Dir


9.6.5.1 Helpful HintIt is helpful to have logging turned on during troubleshooting only. Otherwise, logging should be turned off to optimize the performance of OEPPS.

1138 Error NULL Character Encountered2001 Add Null Mapping to Output

Table 9-5: OEPPS Return Codes

Return Code Description


10 Hospital & Physician Rate Calculator File Key Fields

This chapter includes key fields for the Hospital/Physician Rate Calculator Files. The following sections are included:

• C Platform Key Fields• COBOL Platform Key Fields


10.1 C Platform Key FieldsPlease refer to the applicable Hospital/Physician Rate Calculator File chapters (e.g., Medicare, Medicaid, Other) for payer-specific rate calculator variables.

NoteIf using NPI and Taxonomy, use the format from the shaded gray fields in place of hospital/provider number and paysource code formats.

Table 10-1: C Key Fields

Field Description Variable Name Format Position NotesHospital/Provider Number pfac X(16) 1 - 16 Facility or provider identifier (i.e., Medicare

Provider ID, TIN, or other identifier).Paysource (Payer) Codefor list of valid paysource

psrc X(13) 17 - 29 Payer identifier or contract code.

NotePlease refer to the Input & Output Parameter Blocks User’s Guide for a list of valid values.

Hospital/Provider Number with NPI/Taxonomy

pfac X(20) 1 - 20 National Provider Identifier (NPI) with taxonomy code.

Paysource (Payer) Code with NPI/Taxonomy

psrc X(9) 21 - 29 Payer identifier or contract code.


Effective Date effdate 9(8) 30 - 37 The date on or after which the rate variables contained on this record should be used for calculating reimbursement. This field will be equal to either the beginning of the federal fiscal year or the beginning of the hospital's fiscal year (e.g. “20001001”).

YYYYMMDD, where:YYYY = year including centuryMM = month; 01-12DD = day; 01-31

Key Type key_type X(1) 38 0 or blank = Legacy Provider ID1 = NPI plus Taxonomy Code

Union of Payer-Specific Variables X(399) 39 - 437 Please refer to the applicable Hospital Rate Calculator File chapters (e.g., Medicare, Medicaid, Other) for more information on these payer-specific variables.

NMPRF/State Rate File Version version X(7) 438 - 444 Version of the Optum-supplied rate file when applicable.

Rate Manager. TAB Filename X(9) 445 - 453 The name of the case-mix (DRG, APC, APG, etc.) weight file that was loaded into Rate Manager for this rate record when applicable.

Filler X(4) 454 - 457


10.2 COBOL Platform Key FieldsPlease refer to the applicable Hospital/Physician Rate Calculator File chapters (e.g., Medicare, Medicaid, Other) for payer-specific rate calculator variables.

Weights/Rates, Owned/Shared havewt X(1) 458 Y = Rate record has its own case-mix weights. L = Rate record is sharing case-mix weights with another rate record.

Shared Weights/Rates, Facility ID ratefac X(16) 459 - 474 Facility or provider identifier that this rate record is sharing case-mix weights with when applicable.

Shared Weights/Rates, Payer ID ratepsrc X(13) 475 - 487 Payer identifier or contract code that this rate record is sharing case-mix weights with when applicable.

Shared Weights/Rates, Facility ID with NPI/Taxonomy

ratefac X(20) 459 - 478 NPI and taxonomy code that this rate record is sharing case-mix weights with when applicable.

Shared Weights/Rates, Payer ID with NPI/Taxonomy

ratepsrc X(9) 479 - 487 Payer identifier or contract code that this rate record is sharing case-mix weights with when applicable.

Shared Weights/Rates, Effective Date

rateeffdate 9(8) 488 - 495 The effective date that this rate record is sharing case-mix weights with when applicable.

Grouper Type grpr_type X(5) 496 - 500 Grouper type for this rate record.


Grouper Version grpr_vers 9(3) 501 - 503 Two-digit Grouper version for this rate record. For example, if the Grouper version equals 2 the format should be “02.” If the Grouper version equals 32 the format should be “32.”

Pricer/Payer Type pricer_type 9(2) 504 - 505 Pricer type for this rate record.


ICD-9/ICD-10 MappingFlag

icd9_map 9(1) 506 0 = No mapping1 = Code mapping2 = State-specific mapping

Edit Date edit_date X(1) 507 Used to identify which claim date should be used for reimbursement calculations.

A = From or Admission DateD = Thru or Discharge Date

Filler X(3) 508 - 510

Table 10-1: C Key Fields

Field Description Variable Name Format Position Notes


The following is the sort sequence for the COBOL Hospital/Physician Rate Calculator File:

1. Hospital/Provider Number (ascending)2. Paysource (Payer) Code (ascending)3. Patient Type (ascending)4. Effective Date (descending)

NoteIf using NPI and Taxonomy, use the format from the shaded gray fields in place of hospital/provider number and paysource code formats.

Table 10-2: COBOL Key Fields

Field Description Variable Name Format Position NotesHospital/Provider Number HRR-HOSP X(16) 1 - 16 Facility or provider identifier (i.e.,

Medicare Provider ID, TIN, or other identifier).

Paysource (Payer) Code HRR-PCODE X(13) 17 - 29 Payer identifier or contract code.



HRR-HOSP X(20) 1 - 20 National Provider Identifier (NPI) with taxonomy code.


HRR-PCODE X(9) 21 - 29 Payer identifier or contract code.


Patient Type HRR-PATTYPE X(1) 30 Please refer to the Input & Output Parameter Blocks User’s Guide for a list of valid values.

Patient Type Reserved HRR-PATTYPE-RSVD X(1) 31 ReservedEffective Date Sequence Code HRR-ESEQ 9(4) 32 - 35 Reserved for use by EASYGroup™.Effective Date HRR-EDATE The date on or after which the rate

variables contained on this record should be used for calculating reimbursement. This field will be equal to either the beginning of the federal fiscal year or the beginning of the hospital's fiscal year (e.g. “20001001”).

- Effective Century/Year HRR-EDATE-CCYY 9(4) 36 - 39 YYYY = year including century of the Effective Date

- Effective Month HRR-EDATE-MM 9(2) 40 - 41 MM = month of the Effective Date; 01 - 12


- Effective Day HRR-EDATE-DD 9(2) 42 - 43 DD = day of the Effective Date; 01 - 31

Filler for Effective Stop Date FILLER X(8) 44 - 51 ReservedPricer Type HRR-PRCR-TYPE X(2) 52 - 53 Pricer type for this rate record.


Filler HRR-PRCR-TYPE-RSVD

X(2) 54 - 55 Reserved

Grouper Type HRR-GRPR-TYPE X(2) 56 - 57 Grouper type for this rate record.


Filler HRR-GRPR-TYPE-RSVD


Grouper Version HRR-GRPR-VERS 9(2) 60 - 61 Two-digit Grouper version for this rate record. For example, if the Grouper version equals 2 the format should be “02.” If the Grouper version equals 32 the format should be “32.”

Filler HRR-GRPR-VERS-RSVD

9(4) 62 - 65 Reserved

Editor Type HRR-EDTR-TYPE X(2) 66 - 67 ReservedEditor Type Reserved HRR-EDTR-TYPE-RSVD X(2) 68 - 69 ReservedACE Version HRR-EDTR-VERS 9(2) 70 - 71 ReservedACE Version Release HRR-EDTR-REL X(1) 72 ReservedFiller HRR-EDTR-VERS-

RSVDX(3) 73 - 75 Reserved

ICD-9/ICD-10 MappingFlag

HRR-MAPPING 9(1) 76 0 = No mapping1 = Code mapping2 = State-specific mapping

Grouper Option HRR-GRPR-OPTION 9(1) 77 AP-DRG V14 Grouper:0 = Otherwise1 = Use the New York version of AP-DRG Grouper

Norms Type HRR-NORMS-TYPE X(29) 78 - 106 Facility/provider identifier/NPI and taxonomy code with a Payer identifier/contract code that this rate record is sharing case-mix weights with when applicable.




Effective Date HRR-NORMS-EFF-DATE

HRR-NORMS-CCYYHRR-NORMS-MMHRR-NORM-DD

9(4)9(2)9(2)

107 - 110111 - 112113 - 114

The effective date that this rate record is sharing case-mix weights with when applicable.- YYYY = year including century- MM = month; 01 - 12- DD = day; 01 - 31

Update Date HRR-RSVD-UPD-DATE X(8) 115 - 122 ReservedWeight Option HRR-RSVD-WEIGHT-

OPTIONX(1) 123 Reserved

ACE Override ID HRR-OVERRIDE-ID X(20) 124 - 143 The ACE Override ID invokes override functionality. This override functionality allows the user to turn particular ACE edits on or off.

Key Type HRR-KEY-TYPE X(1) 144 0 or blank = Legacy Provider ID1 = NPI plus Taxonomy Code

Filler X(106) 145 - 250 Reserved




11 Medicare Hospital Rate Calculator File Layouts

This chapter provides the layouts for Medicare Hospital Rate Calculator Files (C and COBOL). This chapter includes the following sections:

• Inpatient Layouts- C Platform

- Medicare Inpatient- Medicare IPF- Medicare IRF- Medicare LTC- Medicare SNF

- COBOL Platform- Medicare Inpatient- Medicare IPF- Medicare IRF- Medicare LTC- Medicare SNF

• Outpatient Layouts- C Platform

- Medicare APC-HOPD- Medicare ASC- Medicare CAH Method II- Medicare ESRD- Medicare FQHC- Medicare HHA- Medicare Hospice

- COBOL Platform- Medicare APC-HOPD- Medicare ASC- Medicare CAH Method II- Medicare ESRD- Medicare FQHC- Medicare HHA- Medicare Hospice


• Physician Layouts- C Platform- COBOL Platform


11.1 Inpatient Layouts11.1.1 C Platform

11.1.2.1 Medicare Inpatient

Table 11-1: Medicare Inpatient Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionRegional Labor-Related Adjusted Standardized Amount (ASA)

rl 9(4)v9(2) 39 - 44

Regional Non-Labor-Related ASA rnl 9(4)v9(2) 45 - 50National Labor-Related ASA nl 9(4)v9(2) 51 - 56National Non-Labor-Related ASA nnl 9(4)v9(2) 57 - 62Regional Portion rp 9(1)v9(2) 63 - 65Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 66 - 70Marginal Cost Factor: Burn Length of Stay (LOS)

bmcfl 9(1)v9(2) 71 - 73

Marginal Cost Factor: Burn Cost Outliers bmcfc 9(1)v9(2) 74 - 76Cost Outlier Threshold cot 9(5)v9(2) 77 - 83Cost Outlier Factor/Multiplier cof 9(1)v9(2) 84 - 86Federal Portion fp 9(1)v9(2) 87 - 89Hospital Base Year Costs byc 9(5)v9(2) 90 - 96Update Factor uf 9(1)v9(5) 97 - 102Wage Index wi 9(1)v9(4) 103 - 107Waiver waiver X(1) 108Provider Type ptype X(2) 109 - 110

9(1) 111Filler X(1) 112Case Mix Index cmi 9(1)v9(4) 113 - 117Federal Wage-adjusted Rate fwa 9(4)v9(2) 118 - 123Federal Non-Wage-adjusted Rate fnwa 9(2)v9(2) 124 - 129Federal Labor Portion flp 9(1)v9(4) 130 - 134Hospital Base Rate hrate 9(4)v9(2) 135 - 141Hospital Portion hport 9(1)v9(2) 142 - 144Non-Capital Base PPS Rate baser 9(5)v9(2) 145 - 151Cost of Living Adjustment (COLA) (Alaska and Hawaii)

cola 9(1)v9(4) 152 - 156

Disproportionate Share Hospital (DSH) Reduction Factor

dshreduc 9(1)v9(4) 157 - 161

Disproportionate Share Adjustment Factor dshare 9(1)v9(4) 162 - 166Standard Federal Rate capstfrate 9(4)v9(2) 167 - 172Geographic Adjustment Factor (GAF) capgeofac 9(1)v9(4) 173 - 177


Large Urban Adjustment Factor caplgurbfac 9(1)v9(4) 178 - 182Capital Disproportionate Share Adjustment Factor

capdshare 9(1)v9(4) 183 - 187

Puerto Rico GAF prgaf 9(1)v9(4) 188 - 192Capital RCC caprcc 9(1)v9(4) 193 - 197Base Year Allowable Capital Costs capbyrcost 9(4)v9(2) 198 - 203Transfer Adjustment to Discharges captradjdis 9(1)v9(4) 204 - 208Transfer-Adjusted Case-Mix Index captradjcmi 9(1)v9(4) 209 - 213Capital Update Factor capuf 9(1)v9(5) 214 - 219Exceptions Reduction Adjustment Factor capexcredfac 9(1)v9(4) 220 - 224Budget Neutrality Adjustment Factor capbnfac 9(1)v9(4) 225 - 229Current Year Medicare Discharges capcyrdis 9(6) 230 - 235Old Capital Costs capoldcosts 9(9) 236 - 244Old Capital Payment Percent capoldper 9(1)v9(2) 245 - 247Puerto Rico Standard Capital Rate prcapstfrate 9(4)v9(2) 248 - 253Puerto Rico Labor Portion prlp 9(1)v9(4) 254 - 258Capital Prospective Payment System (PPS) Reimbursement Rate

tcapaddon 9(5)v9(2) 259 - 265

Federal Portion of Capital Rate capfedportion 9(1)v9(4) 266 - 270Hospital Portion of Capital Rate caphblend 9(1)v9(2) 271 - 273Capital-adjusted Federal Rate capadjfrate 9(5)v9(2) 274 - 280Puerto Rico Wage Index prwi 9(1)v9(4) 281 - 285Total PPS Reimbursement (Capital + Non-Capital)

totbase 9(5)v9(2) 286 - 292

Marginal Cost Factor: LOS mcfl 9(1)v9(2) 293 - 295Marginal Cost Factor: Cost mcfcl 9(1)v9(2) 296 - 298Hospital-specific Capital Rate caphrate 9(5)v9(2) 299 - 305Patient Apportionment for Old Capital Cost cappatold 9(4)v9(2) 306 - 311Patient Apportionment for Exceptions Payment

capxcptn 9(4)v9(2) 312 - 317

Total Patient Apportionment Under Capital PPS

cappattot 9(4)v9(2) 318 - 323

Indirect Medical Education (IME) Adjustment Factor

iea 9(1)v9(9) 324 - 333

Capital IME Adjustment Factor capimea 9(1)v9(9) 334 - 343Markup/Discount Adjustment Factor markup 9(1)v9(5) 344 - 349Per Diem Pass-Through passthru 9(5)v9(2) 350 - 356Puerto Rico Capital Portion prcapportion 9(1)v9(2) 357 - 359Sole Community Hospital (SCH) Add-on (old) sch_addon 9(5)v9(2) 360 - 366Direct Medical Education (DME) Pass-through dmepassthru 9(4)v9(2) 367 - 372


Field Description Variable Name Format Position


Medicare Risk Flag risk 9(1) 373New Technology Procedure and Claim Factor techopfac 9(1)v9(2) 374 - 376New Technology Claim Cost Factor techcostfac 9(1)v9(2) 377 - 379PPS Waiver Factor waiver factor 9(1)v9(4) 380 - 384Low Volume Adjustment (old) lowvoladj 9(1)v9(4) 385 - 389Swing Bed Per Diem swingperdiem 9(8)v9(2) 390 - 399Low Volume Adjustment (new) lowvoladj_new 9(1)v9(6) 400 - 406Sole Community Hospital Add-On (new) sch_addon_new 9(8)v9(5) 407 - 419Sole Community Hospital Operating Costs Per Discharge

sch_cost_disc 9(8)v9(5) 420 - 432

Readmission Payment Adjustment Factor o_rpaf 9(1)v9(4) 433 - 437

Table 11-2: Medicare Inpatient Extended Hospital Rate Calculator Variables - medext.dat

Field Description Variable Name Format PositionHospital Number pfac X(16) 1 - 16Paysource (Payer) Code psrc X(13) 17 - 29Hospital Number with NPI/Taxonomy pfac X(20) 1 - 20Paysource (Payer) Code with NPI/Taxonomy psrc X(9) 21 - 29Effective Date eff_date 9(8) 30 - 37Patient Type pattype X(1) 38Sequence Number seqnum X(1) 39Value Based Purchasing Adjustment Factor (VBP Factor)

o_vbp_adj 9(1)v9(11) 40 - 51

Uncompensated DSH Per Claim Amount uncomp_dsh 9(8)v9(2) 52 - 61HAC Reduction Factor hac_fac 9(1)v9(4) 62 - 66Medicare Dependant Hospital (MDH) Factor mdh_fact 9(1)v9(4) 67 - 71Interest Adjustment Factor midnite_fact 9(1)v9(6) 72 - 78Antimicrobial New Technology Procedure and Claim Factor

antitechopfac 9(1)v9(2) 79 - 81

COVID-19 DRG Weight Factor covid_fact 9(1)v9(4) 82 - 86Allogeneic Stem Cell Per Diem Pass-Through stem_pasthru 9(8)v9(2) 87 - 96Federal Wage-Adjusted Rate (new) fwa_new 9(8)v9(2) 97 - 106Filler X(401) 107 - 507Pricer Type prcr_type X(2) 508 - 509 Key Type key_type X(1) 510




11.1.3.2 Medicare IPF

Table 11-3: Medicare IPF Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(7) 39 - 45Cost of Living Adjustment (COLA) (Alaska and Hawaii)

cola 9(1)v9(4) 46 - 50

Unadjusted Federal Prospective Payment Rate

fpdrate 9(8)v9(2) 51 - 60

Labor Related Share lrs 9(1)v9(5) 61 - 66Wage Index wi 9(1)v9(4) 67 - 71Fixed Loss Amount floss 9(8)v9(2) 72 - 81Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 82 - 86Teaching Adjustment Factor meduc 9(1)v9(4) 87 - 91Rural Adjustment Factor (old) rural 9(1)v9(2) 92 - 94ECT Payment Per Treatment ect 9(8)v9(2) 95 - 104Cost Factor for Days 1 - 9 costfact1 9(1)v9(2) 105 - 107Cost Factor for Days 10 + costfact2 9(1)v9(2) 108 - 110Markup/Discount Adjustment Factor markup 9(1)v9(4) 111 - 115Filler X(19) 116 - 134Age Factor [Array] agefact 9(1)v9(2)

occurs 9 times

135 - 161

Filler X(24) 162 - 185Variable Per Diem Factor [Array] perdiemfact 9(1)v9(2)

occurs 22 times

186 - 251

Filler X(24) 252 - 275Comorbidity Factor [Array] comrbfact 9(1)v9(2)

occurs 17 times

276 - 326

Interim Rate for Old Cost Base Method intrate 9(8)v9(2) 327 - 336Blend Factor blend 9(1)v9(2) 337 - 339Qualifying ED Facility qualed X(1) 340 - 340Qualifying ED Variable Per Diem Factor for Day 1

qualedfact 9(1)v9(2) 341 - 343

Teaching Adjustment Factor meduc_2 9(1)v9(7) 344 - 351Rural Adjustment Factor 2 (new) rural_2 9(1)v9(4) 352 - 356Filler X(81) 357 - 437


11.1.4.3 Medicare IRF

11.1.5.4 Medicare LTC

Table 11-4: Medicare IRF Rate Calculator Variables - medirf.dat

Field Description Variable Name Format PositionsReserved p_brate 9(8)v9(2) 39 - 48Labor-Related Percentage p_lp 9v9(6) 49 - 55Wage Index p_wi 9v9(6) 56 - 62Adjustment for Rural Location p_rural 9v9(6) 63 - 69Low Income Patient Adjustment p_lip 9v9(9) 70 - 79Ratio of Costs-to-Charges (For Cost Outlier Calculations)

p_rcc 9v9(6) 80 - 86

Marginal Cost Factor p_mcf 9v9(6) 87 - 93Cost Outlier Threshold p_thresh 9(8)v9(2) 94 - 103Federal Percentage of Blended Rate for Transition Period

p_fp 9v9(6) 104 - 110

Penalty Assessment Days p_pendays 9(3) 111 - 113Penalty Percentage p_penpct 9v9(6) 114 - 120Facility-Specific Payment Amount p_facamt 9(8)v9(2) 121 - 130Adjustment for Teaching p_teach 9v9(6) 131 - 137Markup/Discount Factor p_markup 9(1)v9(4) 138 - 142Hospital Quality Indicator p_qualind 9(1) 143Filler X(294) 144 - 437

Table 11-5: Medicare LTC Hospital Rate Calculator Variables - medcalc.dat


cola 9(1)v9(4) 46 - 50


frate 9(5)v9(2) 51 - 57

Labor-Related Share lrs 9(1)v9(5) 58 - 63Wage Index wi 9(1)v9(4) 64 - 68Budget Neutrality Offset bn 9(1)v9(5) 69 - 74Fixed Loss Amount (Standard Federal) floss 9(5)v9(2) 75 - 81Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 82 - 86Percentage of Cost Outlier Paid (Standard Federal)

costpct 9(1)v9(4) 87 - 91

Percentage of Short Stay Outlier Paid spctcost 9(1)v9(4) 92 - 96Phase-in Percentage phaseinpct 9(1)v9(2) 97 - 99


11.1.6.5 Medicare SNF

Facility Base Rate facrate 9(5)v9(2) 100 - 106Length of Stay Ratio Factor losfact 9(1)v9(2) 107 - 109Percentage of Short Stay Outlier Paid for Per Diem

spctdiem 9(1)v9(4) 110 - 114

Inpatient PPS Facility ipps_payid X(16) 115 - 130Inpatient PPS Payer ID ipps_paysrc X(13) 131 - 143Markup/Discount Adjustment Factor markup 9(1)v9(4) 144 - 148Fixed Loss Amount - Site Neutral floss_neutral 9(5)v9(2) 149 - 155Percentage of Cost Outlier Paid - Site Neutral costpct_neutral 9(1)v9(4) 156 - 160Site Neutral Percentage of Claim snpct 9(1)v9(2) 161 - 163Budget Neutrality Factor - Site Neutral bnf_neutral 9(1)v9(5) 164 - 169Bipartisan Budget Act Reduction Factor - Site Neutral

bba_reduction 9(1)v9(4) 170 - 174

Discharge Payment Percentage (DPP) Indicator0 = Not subject to DPP adjustment1 = Subject to DPP adjustment

dpp_flag 9(1) 175

Filler X(262) 176 - 437

Table 11-6: Medicare SNF Rate Calculator Variables - medsnf.dat

Field Description Variable Name Format PositionWage Index wi 9(1)v9(6) 39 - 45Labor Portion labor 9(1)v9(6) 46 - 52Rural Indicator rural X(1) 53Part A AIDS Adjustment aids_factor 9(1)v9(4) 54 - 58Mark-up/Discount Factor markup 9(1)v9(4) 59 - 63Part B Mark-up/Discount Factor markupb 9(1)v9(4) 64 - 68Reasonable Charge Factor rcc 9(1)v9(4) 69 - 73Reasonable Charge Co-payment Factor rcc_copay 9(1)v9(4) 74 - 78Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

fsind 9 (1) 79

Fee Schedule Table fstable X(13) 80 - 92Ambulance Coverage Factor ambcov 9(1)v9(4) 93 - 97Ambulance Coinsurance Factor ambcoins 9(1)v9(4) 98 - 102

Table 11-5: Medicare LTC Hospital Rate Calculator Variables - medcalc.dat



Ambulance Location/Carrier CodeFor Medicare pricing, Ambulance Carrier Code is based on patient ZIP code at point of pickup.

ambcarrier X(12) 103 - 114

DMEPOS Coverage Factor dmecov 9(1)v9(4) 115 - 119DMEPOS Coinsurance Factor dmecoins 9(1)v9(4) 120 - 124DMEPOS Location/Carrier Code dmecarrier X(12) 125 - 136Lab Coverage Factor labcov 9(1)v9(4) 137 - 141Lab Coinsurance Factor labcoins 9(1)v9(4) 142 - 146Lab Location/Carrier Code labcarrier X(12) 147 - 158National Coverage Factor mamcov 9(1)v9(4) 159 - 163National Coinsurance Factor mamcoins 9(1)v9(4) 164 - 168National Location/Carrier Code mamcarrier X(12) 169 - 180Physician Fee Schedule Coverage Factor rehcov 9(1)v9(4) 181 - 185Physician Fee Schedule Coinsurance Factor

rehcoins 9(1)v9(4) 186 - 190

Physician Fee Schedule Location/Carrier Code

rehcarrier X(12) 191 - 202

Other Coverage Factor othcov 9(1)v9(4) 203 - 207Other Coinsurance Factor othcoins 9(1)v9(4) 208 - 212Other Location/Carrier Code othcarrier X(12) 213 - 224Ambulance Rural Factor ambrural 9(1)v9(4) 225 - 229Ambulance Non-Rural Factor ambnonrural 9(1)v9(4) 230 - 234Vaccine Reasonable Charge Factor vrcf 9(1)v9(4) 235 - 239Extended Fee Schedule Table fsexttable X(13) 240 - 252Non-Emergency ESRD Ambulance Reduction Factor

esrd_reduc 9(1)v9(4) 253 - 257

Computed Tomography (CT) Reduction Factor

ct_reduc 9(1)v9(4) 258 - 262

DME Rural Indicator rural_ind 9(1) 263X-Ray With Film Reduction Factor fx_reduc 9(1)v9(4) 264 - 268Quality Reduction Factor (Part A) qrp_reduc_a 9(1)v9(4) 269 - 273Ambulance Base Rate Reduction - 2 Patients

amb_reduc2 9(1)v9(4) 274 - 278

Ambulance Base Rate Reduction - > 2 Patients

amb_reduc3 9(1)v9(4) 279 - 283

Traditional Medicare Switch0 = Apply Medicare Advantage

requirements1 = Apply Medicare Fee-for-Service (FFS)

requirements

tradmed_sw 9(1) 284

Computed Radiography Reduction Factor fy_reduc 9(1)v9(4) 285 - 289




Value-Based Purchasing (VBP) Adjustment Factor

vbp_adj 9(1)v9(11) 290 - 301

Urban Non-Case Mix Rate ncm_urban 9(8)v9(2) 302 - 311Rural Non-Case Mix Rate ncm_rural 9(8)v9(2) 312 - 321Filler X(116) 322 - 437




11.1.7 COBOL Platform11.1.8.1 Medicare Inpatient

Table 11-7: Medicare Inpatient COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionRegional Labor-Related ASA HCR-RL 9(8)v9(2) 251 - 260Regional Non-Labor-Related ASA HCR-RNL 9(8)v9(2) 261 - 270National Labor-Related ASA HCR-NL 9(8)v9(2) 271 - 280National Non-Labor-Related ASA HCR-NNL 9(8)v9(2) 281 - 290Regional Portion HCR-RP 9(1)v9(2) 291 - 293HCFA RCC HCR-RCC 9(1)v9(4) 294 - 298Marginal Cost Factor: Burn-LOS HCR-MCFBL 9(1)v9(2) 299 - 301Marginal Cost Factor: LOS HCR-MCFL 9(1)v9(2) 302 - 304Marginal Cost Factor: Cost HCR-MCFC 9(1)v9(2) 305 - 307Cost Outlier Threshold HCR-COT 9(8)v9(2) 308 - 317Cost Outlier Factor/Multiplier HCR-COF 9(1)v9(2) 318 - 320Federal Portion HCR-FP 9(1)v9(2) 321 - 323Wage Index HCR-WI 9(1)v9(4) 324 - 328Markup/Discount Factor HCR-MARKUP 9(1)v9(6) 329 - 335Pass-Through Amount HCR-PASS-THRU 9(8)v9(2) 336 - 345Federal Labor Portion HCR-FLP 9(1)v9(4) 346 - 350Disproportionate Share HCR-DSHARE 9(1)v9(4) 351 - 355Hospital Operating Base Year Costs HCR-BYC 9(8)v9(2) 356 - 365Operating Update Factor HCR-UF 9(1)v9(5) 366 - 371Operating Case Mix Index HCR-CMI 9(1)v9(4) 372 - 376Marginal Cost Factor: Burn-Cost HCR-MCFBC 9(1)v9(2) 377 - 379Standard Federal Rate HCR-CAPSTFRATE 9(8)v9(2) 380 - 389Geographic Adjustment Factor HCR-CAPGEOFAC 9(1)v9(4) 390 - 394Large Urban Adjustment Factor HCR-

CAPLGURBFAC9(1)v9(4) 395 - 399

Capital Disproportionate Share Adjustment Factor

HCR-CAPDSHARE 9(1)v9(4) 400 - 404

Disproportionate Share Reduction Factor HCR-DSHREDUC 9(1)v9(4) 405 - 409Capital RCC HCR-CAPRCC 9(1)v9(4) 410 - 414Base Year Allowable Cap Cost/Discharge HCR-CAPBYRCOST 9(8)v9(2) 415 - 424Transfer Adjustment to Discharges HCR-CAPTRADJDIS 9(1)v9(4) 425 - 429Transfer-Adjusted Case Mix Index HCR-CAPTRADJCMI 9(1)v9(4) 430 - 434Capital Update Factor HCR-CAPUF 9(1)v9(5) 435 - 440Exceptions Payment Adjustment Factor HCR-

CAPEXCREDFAC9(1)v9(4) 441 - 445


Budget Neutrality Adjustment Factor HCR-CAPBNFAC 9(1)v9(4) 446 - 450Current Year Medicare Discharges HCR-CAPCYRDIS 9(6) 451 - 456Old Capital Costs HCR-

CAPOLDCOSTS9(8)v9(2) 457 - 466

Old Capital Payment Percent HCR-CAPOLDPER 9(1)v9(2) 467 - 469Capital Federal Portion HCR-

CAPFEDPORTION9(1)v9(4) 470 - 474

Capital Hospital Portion HCR-CAPHBLEND 9(1)v9(2) 475 - 477Indirect Medical Education (IME) Adjustment Factor

HCR-IMEA 9(1)v9(9) 478 - 487

Capital IME Adjustment Factor HCR-CAPIMEA 9(1)v9(9) 488 - 497Prospective Payment System (PPS) Waiver HCR-WAIVER X(1) 498 - 498Provider Type HCR-PTYPE X(2) 499 - 500Operating Federal Rate HCR-FRATE 9(8)v9(2) 501 - 510Operating Federal Wage-Adjusted Rate HCR-FWA 9(8)v9(2) 511 - 520Operating Hospital Rate HCR-HRATE 9(8)v9(2) 521 - 530Operating Base PPS Rate HCR-BASER 9(8)v9(2) 531 - 540Capital-Adjusted Federal Rate HCR-CAPADJFRATE 9(8)v9(2) 541 - 550Capital Hospital Rate HCR-CAPHRATE 9(8)v9(2) 551 - 560Capital Base PPS Rate HCR-

TOTCAPADDON9(8)v9(2) 561 - 570

Patient Apportion, Old Capital Costs HCR-CAPPATOLD 9(8)v9(2) 571 - 580Total PPS Base Reimbursement Rate HCR-TOTBASE 9(8)v9(2) 581 - 590Puerto Rico Base Capital Reimbursement HCR-

PRCAPSTRATE9(8)v9(2) 591 - 600

Puerto Rico Geographic Adjustment Factor (GAF)

HCR-PRGAF 9(1)v9(4) 601 - 605

Puerto Rico Capital Portion HCR-PRCAPPORTION

9(1)v9(2) 606 - 608

Puerto Rico Wage Index HCR-PRWI 9(1)v9(4) 609 - 613Puerto Rico Federal Labor Portion HCR-PRLP 9(1)v9(4) 614 - 618Sole Community Hospital Add-On (old) HCR-SCH_ADDON 9(8)v9(2) 619 - 628Cost of Living Adjustment (COLA) (Hawaii and Alaska)

HCR-COLA 9(1)v9(4) 629 - 633

Capital Exceptions Payment HCR-CAPXCPTN 9(8)v9(2) 634 - 643Direct Medical Education Per-Diem Pass-Through (a component of the PASSTHRU field)

HCR-DMEPASSTHRU

9(8)v9(2) 644 - 653

Medicare Risk Flag HCR-RISK 9(1) 654New Technology Procedure and Claim Factor HCR-TECHOPFAC 9(1)v9(2) 655 - 657




New Technology Claim Cost Factor HCR-TECHCOSTFAC

9(1)v9(2) 658 - 660

Prospective Payment System (PPS) Waiver Factor

HCR-WAIVER FACTOR

9(1)v9(4) 661 - 665

Low Volume Adjustment (old) HCR-LOWVOLADJ 9(1)v9(4) 666 - 670Swing Bed Per Diem HCR-

SWINGPERDIEM9(8)v9(2) 671 - 680

Low Volume Adjustment (new) HCR-LOWVOLADJ-NEW

9(1)v9(6) 681 - 687

Sole Community Hospital Add-On (new) HCR-SCH-ADDON-NEW

9(8)v9(5) 688 - 700

Sole Community Hospital Operating Costs Per Discharge

HCR-SCH-COST-DISC

9(8)v9(5) 701 - 713

Readmission Payment Adjustment Factor HCR-RPAF 9(1)v9(4) 714 - 718SCH Legacy Calculation Flag HCR-SCH-LEGACY 9(1) 719Filler X(74) 720 - 793NMPRF Version HCR-VERSION X(7) 794 - 800

Table 11-8: Medicare Inpatient COBOL Extended Hospital Rate Calculator Variables - hospext.dat

Field Description Variable Name Format PositionHospital Number HER-HOSP X(16) 1 - 16Paysource (Payer) Code HER-PCODE X(13) 17 - 29Hospital Number with NPI HER-NPI X(10) 1 - 10Hospital Number with Taxonomy HER-TAXONOMY X(10) 11 - 20Paysource (Payer) Code with NPI/Taxonomy HER-PAYID X(9) 21 - 29Patient Type HER-PATTYPE X(1) 30Effective Date Sequence Code Extension HER-ESEQ-EXT X(1) 31Effective Date Sequence Code Extension (Set by Base Rate Calculator Program)

HER-ESEQ 9(4) 32 - 35

Effective Date of Rate Calculator Variables HER-EDATEEffective Century/Year HER-EDATE-

CCYY9(4) 36 - 39

Effective Month HER-EDATE-MM 9(2) 40 - 41Effective Day HER-EDATE-DD 9(2) 42 - 43Filler for Future Expansion (Stop Date) X(8) 44 - 51Value Based Purchasing Adjustment Factor (VBP Factor)

HCR0-O-VBP-ADJ

9(1)v9(11) 52 - 63

Uncompensated DSH Per Claim Amount HCR0-UNCOMP-DSH

9(8)v9(2) 64 - 73




11.1.9.2 Medicare IPF

HAC Reduction Factor HCR0-HAC-FAC 9(1)v9(4) 74 - 78Medicare Dependant Hospital (MDH) Factor HCR0-MDH-

FACT9(1)v9(4) 79 - 83

Interest Adjustment Factor HCR0-MIDNITE-FACT

9(1)v9(6) 84 - 90

Antimicrobial New Technology Procedure and Claim Factor

HCR0-ANTI-TECH-OP-FAC

9(1)v9(2) 91 - 93

COVID-19 DRG Weight Factor HCR0-COVID-FACT

9(1)v9(4) 94 - 98

Allogeneic Stem Cell Per Diem Pass-Through HCR0-STEM-PASSTHRU

9(8)v9(2) 99 - 108

Federal Wage-Adjusted Rate (new) HCR0-FWA-NEW 9(8)v9(2) 109 - 118Filler X(679) 119 - 797Pricer Type HCR0-PRCR-

TYPEX(2) 798 - 799

Key Type HCR0-KEY-TYPE X(1) 800

Table 11-9: Medicare IPF COBOL Rate Calculator Variables - hosprate.dat


P1R-COLA 9(1)v9(4)

261 - 265


P1R-FPDRATE 9(8)v9(2)

266 - 275

Labor Related Share P1R-LRS 9(1)v9(5)

276 - 281

Wage Index P1R-WI 9(1)v9(4)

282 - 286

Fixed Loss Amount P1R-FLOSS 9(8)v9(2)

287 - 296

Ratio of Cost-to-Charges P1R-RCC 9(1)v9(4)

297 - 301

Teaching Adjustment Factor P1R-MEDUC 9(1)v9(4)

302 - 306

Rural Adjustment Factor (old) P1R-RURAL 9(1)v9(2)

307 - 309

ECT Payment per Treatment P1R-ECT 9(8)v9(2)

310 - 319

Table 11-8: Medicare Inpatient COBOL Extended Hospital Rate Calculator Variables - hospext.dat



11.1.10.3 Medicare IRF

Cost Factor for Days 1 - 9 P1R-COSTFACT1 9(1)v9(2)

320 - 322

Cost Factor for Days 10 + P1R-COSTFACT2 9(1)v9(2)

323 - 325

Markup/Discount Factor P1R-MARKUP 9(1)v9(4)

326 - 330

Filler X(19) 331 - 349Age Factor - Array P1R-AGEFACT

3 characters 9 times9(1)v9(2)

350 - 376

Filler X(24) 377 - 400Variable Per Diem Factor - Array P1R-PERDIEMFACT


401 - 466

Filler X(24) 467 - 490Comorbidity Factor - Array P1R-COMRBFACT


491 - 541

Interim Rate for Old Cost-Based Method P1R-INTRATE 9(8)v9(2)

542 - 551

Blend Factor P1R-BLEND 9(1)v9(2)

552 - 554

Qualifying ED Facility P1R-QUALED X(1) 555 - 555Qualifying ED Variable Per Diem Factor - Day 1

P1R-QUALEDFACT 9(1)v9(2)

556 - 558

Teaching Adjustment Factor P1R-MEDUC-2 9(1)v9(7)

559 - 566

Rural Adjustment Factor 2 (new) P1R-RURAL-2 9(1)v9(4)

567 - 571

Filler X(222) 572 - 793NMPRF Version P1R-VERSION X(7) 794 - 800

Table 11-10: Medicare IRF COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionsReserved R1R-BRATE 9(8)v9(2) 251 - 260Labor-Related Percentage R1R-LP 9(1)v9(6) 261 - 267Wage Index R1R-WI 9(1)v9(6) 268 - 274Adjustment for Rural Location R1R-RURAL 9(1)v9(6) 275 - 281Low Income Patient Adjustment R1R-LIP 9(1)v9(9) 282 - 291Ratio of Costs-to-Charges (For Cost Outlier Calculations)

R1R-RCC 9(1)v9(6) 292 - 298

Marginal Cost Factor R1R-MCF 9(1)v9(6) 299 - 305

Table 11-9: Medicare IPF COBOL Rate Calculator Variables - hosprate.dat



11.1.11.4 Medicare LTC

Cost Outlier Threshold R1R-THRESH 9(8)v9(2) 306 - 315Federal Percentage of Blended Rate for Transition Period

R1R-FP 9(1)v9(6) 316 - 322

Penalty Assessment Days R1R-PENDAYS 9(3) 323 - 325Penalty Percentage R1R-PENPCT 9(1)v9(6) 326 - 332Facility-Specific Payment Amount R1R-FACAMT 9(8)v9(2) 333 - 342Teaching Adjustment R1R-TEACH 9(1)v9(6) 343 - 349Markup/Discount Factor R1R-MARKUP 9(1)v9(4) 350 - 354Hospital Quality Indicator R1R-QUALIND 9(1) 355Filler X(438) 356 - 793NMPRF Version RIR-VERSION X(7) 794 - 800

Table 11-11: Medicare LTC COBOL Hospital Rate Calculator Variables - hosprate.dat


LTR-COLA 9(1)v9(4) 261 - 265


LTR-FRATE 9(8)v9(2) 266 - 275

Labor-related Share LTR-LRS 9(1)v9(5) 276 - 281Wage Index LTR-WI 9(1)v9(4) 282 - 286Budget Neutrality Offset LTR-BN 9(1)v9(5) 287 - 292Fixed Loss Amount (Standard Federal) LTR-FLOSS 9(8)v9(2) 293 - 302Hospital Ratio of Cost-to-Charges LTR-RCC 9(1)v9(4) 303 - 307Percentage of Cost Outlier Paid (Standard Federal)

LTR-COSTPCT 9(1)v9(4) 308 - 312

Percentage of Short Stay Outlier Paid LTR--SPCTCOST 9(1)v9(4) 313 - 317Phase-in Percentage LTR-PHASEINPCT 9(1)v9(2) 318 - 320Facility-specific Rate LTR-FACRATE 9(8)v9(2) 321 - 330Length of Stay Ratio Factor LTR-LOSFACT 9(1)v9(2) 331 - 333Percentage of Short Stay Outlier Paid for Per Diem

LTR-SPCTDIEM 9(1)v9(4) 334 - 338

Inpatient PPS Facility LTR-IPPS-PAYID X(16) 339 - 354Inpatient PPS Payer ID LTR-IPPS-PAYSRC X(13) 355 - 367Markup/Discount Factor LTR-MARKUP 9(1)v9(4) 368 - 372Fixed Loss Amount - Site Neutral LTR-FLOSS-

NEUTRAL9(5)v9(2) 373 - 379

Table 11-10: Medicare IRF COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format Positions


11.1.12.5 Medicare SNF

Percentage of Cost Outlier Paid - Site Neutral

LTR-COSTPCT-NEUTRAL

9(1)v9(4) 380 - 384

Site Neutral Percentage of Claim LTR-SNPCT 9(1)v9(2) 385 - 387Budget Neutrality Factor - Site Neutral LTR-BNF-NEUTRAL 9(1)v9(5) 388 - 393Bipartisan Budget Act Reduction Factor - Site Neutral

LTR-BBA-REDUCTION

9(1)v9(4) 394 - 398

Discharge Payment Percentage (DPP) Indicator0 = Not subject to DPP adjustment1 = Subject to DPP adjustment

LTR-DPP-FLAG 9(1) 399

Filler X(394) 400 - 793NMPRF Version LTR-VERSION X(7) 794 - 800

Table 11-12: Medicare SNF COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionsWage Index S1R-WI 9(1)v9(6) 251 - 257Labor Portion S1R-LABOR 9(1)v9(6) 258 - 264Rural Indicator S1R-RURAL X(1) 265AIDS Adjustment Factor S1R-AIDS-FACTOR 9(1)v9(4) 266 -270Markup/Discount Factor S1R-MARKUP 9(1)v9(4) 271 - 275Part B Markup/Discount Factor S1R-MARKUPB 9v9(4) 276 - 280Pay Factor S1R-RCC 9v9(4) 281 - 285Co-Pay Factor S1R-RCC-COPAY 9v9(4) 286 - 290Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

S1R-FSIND 9(1) 291

Fee Schedule Table S1R-FSTABLE X(13) 292 - 304Ambulance Coverage Factor S1R-AMB-COV 9(1)v9(4) 305 - 309Ambulance Coinsurance Factor S1R-AMB-COINS 9(1)v9(4) 310 - 314Ambulance Location/Carrier CodeNOTE: For Medicare pricing, Ambulance Carrier Code is based on patient ZIP code at point of pickup.

S1R-AMB-CARRIER X(12) 315 - 326

DMEPOS Coverage Factor S1R-DME-COV 9(1)v9(4) 327 - 331DMEPOS Coinsurance Factor S1R-DME-COINS 9(1)v9(4) 332 - 336DMEPOS Location/Carrier Code S1R-DME-CARRIER X(12) 337 - 348Lab Coverage Factor S1R-LAB-COV 9(1)v9(4) 349 - 353Lab Coinsurance Factor S1R-LAB-COINS 9(1)v9(4) 354 - 358

Table 11-11: Medicare LTC COBOL Hospital Rate Calculator Variables - hosprate.dat



Lab Location/Carrier Code S1R-LAB-CARRIER X(12) 359 - 370National Coverage Factor S1R-MAM-COV 9(1)v9(4) 371 - 375National Coinsurance Factor S1R-MAM-COINS 9(1)v9(4) 376 - 380National Location/Carrier Code S1R-MAM-CARRIER X(12) 381 - 392Physician Fee Schedule Coverage Factor

S1R-REH-COV 9(1)v9(4) 393 - 397

Physician Fee Schedule Coinsurance Factor

S1R-REH-COINS 9(1)v9(4) 398 - 402


S1R-REH-CARRIER X(12) 403 - 414

Other Coverage Factor S1R-OTH-COV 9(1)v9(4) 415 - 419Other Coinsurance Factor S1R-OTH-COINS 9(1)v9(4) 420 - 424Other Location/Carrier Code S1R-OTH-CARRIER X(12) 425 - 436Ambulance Rural Factor S1R-AMBRURAL 9(1)v9(4) 437 - 441Ambulance Non-Rural Factor S1R-AMBNONRURAL 9(1)v9(4) 442 - 446Vaccine Reasonable Charge Factor S1R-VRCF 9(1)v9(4) 447 - 451Extended Fee Schedule Table S1R-FSEXTTABLE X(13) 452 - 464Non-Emergency ESRD Ambulance Reduction Factor

S1R-ESRD-REDUC 9(1)v9(4) 465 - 469

CT Reduction Factor S1R-CT-REDUC 9(1)v9(4) 470 - 474DME Rural Indicator S1R-RURAL-IND 9(1) 475X-Ray With Film Reduction Factor S1R-FX-REDUC 9(1)v9(4) 476 - 480Quality Reduction Factor (Part A) S1R-QRP-REDUC-A 9(1)v9(4) 481 - 485Ambulance Base Rate Reduction - 2 Patients

S1R-AMB-REDUC2 9(1)v9(4) 486 - 490


S1R-AMB-REDUC3 9(1)v9(4) 491 - 495


requirements1 = Apply Medicare Fee-for-Service

(FFS) requirements

S1R-TRADMED-SW 9(1) 496

Computed Radiography Reduction Factor

S1R-FY-REDUC 9(1)v9(4) 497 - 501


S1R-VBP-ADJ 9(1)v9(11) 502 - 513

Urban Non-Case Mix Rate S1R-NCM-URBAN 9(8)v9(2) 514 - 523Rural Non-Case Mix Rate S1R-NCM-RURAL 9(8)v9(2) 524 - 533Filler X(260) 534 - 793NMPRF Version S1R-VERSION X(7) 794 - 800

Table 11-12: Medicare SNF COBOL Rate Calculator Variables - hosprate.dat



11.2 Outpatient Layouts11.2.1 C Platform

11.2.2.1 Medicare APC-HOPD

Table 11-13: Medicare APC-HOPD Hospital Rate File Variables - medout.dat

Field Description Variable Name Position FormatLabor-related Portion labor 39 - 44 9(1)v9(5)Wage Index wi 45 - 50 9(1)v9(5)Facility Type 01 = Rural hospital with 100 beds or fewer or rural

Sole Community Hospital (SCH)02 = Cancer center03 = Children’s hospital04 = Rural hospital under 50 beds05 = OPPS exempt06 = Other SCH07 = Other rural hospital (Not SCH)08 = Free-standing non-residential opioid treatment

facilityOtherwise, 00

fac_type 51 - 52 9(2)

Multiple Procedure Discount Factor –For highest weighted procedure APC.

discount1 53 - 57 9(1)v9(4)

Multiple Procedure Discount Factor –For all other procedure APCs.

discount2 58 - 62 9(1)v9(4)

Filler 63 - 72 X(10)Discontinued Procedures Discount Factor dmodpct 73 - 77 9(1)v9(4)Outpatient Ratio of Costs-to-Charges rcc 78 - 83 9(1)v9(5)Inpatient Deductible Amount – Limit to total coinsurance for an individual APC

inpded 84 - 89 9(4)v9(2)

1996 Ratio of Payment to Reasonable Costs rpc 90 - 94 9(1)v9(4)Outlier Payment Percent outlier_pct 95 - 99 9(1)v9(4)Outlier Payment Factor outlier_fac 100 -

1049(1)v9(4)

Transitional Corridor 90% Factor 1 trans90_1 105 - 106

9(0)v9(2)

Transitional Corridor 90% Factor 2 trans90_2 107 - 108

9(0)v9(2)

Transitional Corridor 80% Factor 1 trans80_1 109 - 110 9(0)v9(2)Transitional Corridor 80% Factor 2 trans80_2 111 - 112 9(0)v9(2)Transitional Corridor 70% Factor 1 trans70_1 113 - 114 9(0)v9(2)Transitional Corridor 70% Factor 2 trans70_2 115 - 116 9(0)v9(2)Transitional Corridor Less Than 70% translt70 117 - 118 9(0)v9(2)Transitional Corridor Factor, Cancer Centers or Small Rural Facilities

transcsr 119 - 121 9(1)V9(2)


Transitional Corridor Multiplier transmult 122 - 126

9(1)v9(4)

Ambulance Rural Factor ambrural 127 - 131

9(1)v9(4)

Ambulance Non-Rural Factor ambnonrural 132 - 136

9(1)v9(4)

Hospital Quality Indicator hospqualind 137 X(1)Hospital Quality Reduction Factor qualredfact 138 -

1429(1)v9(4)

Filler 143 - 149

X(7)

Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

fsind 150 9(1)

Fee Schedule Table fstable 151 - 163

X(13)

Ambulance Coverage Factor ambcov 164 - 168

9(1)v9(4)

Ambulance Coinsurance Factor ambcoins 169 - 173

9(1)v9(4)

Ambulance Location/Carrier Code

NoteFor Medicare pricing, Ambulance Carrier Code is based on patient zip code at point of pickup.

ambcarrier 174 - 185

X(12)

DMEPOS Coverage Factor dmecov 186 - 190

9(1)v9(4)

DMEPOS Coinsurance Factor dmecoins 191 - 195

9(1)v9(4)

DMEPOS Location/Carrier Code dmecarrier 196 - 207

X(12)

Lab Coverage Factor labcov 208 - 212

9(1)v9(4)

Lab Coinsurance Factor labcoins 213 - 217

9(1)v9(4)

Lab Location/Carrier Code labcarrier 218 - 229

X(12)

National Coverage Factor mamcov 230 - 234

9(1)v9(4)

National Coinsurance Factor mamcoins 235 - 239

9(1)v9(4)

National Location/Carrier Code mamcarrier 240 - 251

X(12)


Field Description Variable Name Position Format


Physician Fee Schedule Coverage Factor rehcov 252 - 256

9(1)v9(4)

Physician Fee Schedule Coinsurance Factor rehcoins 257 - 261

9(1)v9(4)

Physician Fee Schedule Location/Carrier Code rehcarrier 262 - 273

X(12)

Other Coverage Factor othcov 274 - 278

9(1)v9(4)

Other Coinsurance Factor othcoins 279 - 283

9(1)v9(4)

Other Location/Carrier Code othcarrier 284 - 295

X(12)

APC Mapping Flag0 = Do not map HCPCS codes1 = Map HCPCS codes

apcmapflag 296 9(1)

Extended Fee Schedule Table fsexttable 297 - 309

X(13)

Sequester Factor sequest 310 - 314

Non-Emergency ESRD Ambulance Reduction Factor

esrd_reduc 315 - 319

9(1)v9(4)

Computed Tomography (CT) Reduction Factor ct_reduc 320 - 324

9(1)v9(4)

DME Rural Indicator0 = Non-Rural (Urban) Facility for DME Services1 = Rural Facility for DME Services

rural_ind 325 9(1)

X-Ray With Film Reduction Factor fx_reduc 326 - 330

9(1)v9(4)

Provider-Based Department (PBD) Reduction Factor (PN)

pn_reduc 331 - 335

9(1)v9(4)

Implantable Device RCC id_rcc 336 - 341

9(1)v9(5)

Traditional Medicare Switch0 = Apply Medicare Advantage Requirements 1 = Apply Medicare Fee-for-Service (FFS)

Requirements

tradmed_sw 342 9(1)

Ambulance Base Rate Reduction Factor - 2 Patients amb_reduc2 343 - 347

9(1)v9(4)

Ambulance Base Rate Reduction Factor -> 2 Patients

amb_reduc3 348 - 352

9(1)v9(4)

Computed Radiography Reduction Factor fy_reduc 353 - 357

9(1)v9(4)

PBD Reduction Factor (PO) po_reduc 358 - 362

9(1)v9(4)




11.2.3.2 Medicare ASC

Filler 363 - 371

X(9)

NMPRF Version nmprf_vers 372 - 378

X(7)

Pro-Rata Reduction Pass-Through Drug and Biologicals

prdrug 379 - 383

9(1)v9(4)

Pro-Rata Reduction Pass-Through Devices prdevice 384 - 388

9(1)v9(4)

Override ID override_id 389 - 408

X(20)

Total Reimbursement Discount Factor discount 409 - 413

9(1)v9(4)

Laboratory Ratio of Costs-to-Charges labrcc 414 - 419

9(1)v9(5)

OPPS Exempt Factor exempt_fact 420 - 424

9(1)v9(4)

Outlier Fixed Cost Threshold outlier_thresh 425 - 434

9(8)v9(2)

Reasonable Cost Factor rcost_fact 435 - 439

9(1)v9(4)

Rural Adjustment Factor rural_fact 440 - 444

9(1)v9(4)

Table 11-14: Medicare ASC Hospital Rate File Variables - medout.dat

Field Description Variable Name Position FormatLabor-Related Portion labor 39 - 44 9(1)v9(5

)Wage Index wi 45 - 50 9(1)v9(5

)Multiple Procedure Discount Factor - First Procedure discount1 51 - 55 9(1)v9(4

)Multiple Procedure Discount Factor - All Other Procedures

discount2 56 - 60 9(1)v9(4)

Discontinued Procedure Discount dmodpct 61 - 65 9(1)v9(4)

Percentage Payment Rate Flag pprflg 66 9(1)Percentage Payment Rate ppr 67 - 71 9(1)v9(4

)Markup/Discount Factor markup 72 - 76 9(1)v9(4

)Payment Limit Flag paylim 77 9(1)




11.2.4.3 Medicare CAH Method II

11.2.5.4 Medicare ESRD

Payment Limit Factor paypct 78 - 82 9(1)v9(4)


fsind 83 9(1)

Fee Schedule Table fstable 84 - 96 X(13)Coverage Factor asrcov 97 - 101 9(1)v9(4

)Coinsurance Factor asrcoins 102 -

1069(1)v9(4)

Fee Schedule Carrier asrcarrier 107 - 118 X(12)Other Coverage Factor othcov 119 - 123 9(1)v9(4

)Other Coinsurance Factor othcoins 124 -

1289(1)v9(4)

Other Fee Schedule Carrier othcarrier 129 - 140

X(12)

Quality Reduction Factor qual_reduct 141 - 145

9(1)v9(4)

Allow Payment for Ancillary Only Claims0 = Do not allow payment for ancillary only claims1 = Allow payment for ancillary only claims

surg_proc_ovr 146 X(1)

Filler 147 - 437

X(291)

Table 11-15: Medicare CAH Method II Rate Calculator Variables - medcah.dat

Field Description Variable Name Format PositionPractitioner Adjustment prac_adj 9(1)v9(4) 39 - 43Filler X(394) 44 - 437

Table 11-16: Medicare ESRD Rate Calculator Variables - medout.dat

Field Description Variable Name Format PositionCBSA Rate cbsarate 9(8)v9(2) 39 - 48MSA Wage Adjusted Rate adjmsarate 9(8)v9(2) 49 - 58MSA Add-On msafactor 9(1)v9(4) 59 - 63Labor-Related Portion ls 9(1)v9(5) 64 - 69Wage Index wi 9(1)v9(4) 70 - 74

Table 11-14: Medicare ASC Hospital Rate File Variables - medout.dat



Drug Add-on Factor drugfact 9(1)v9(4) 75 - 79Budget Neutrality Factor bnf 9(1)v9(6) 80 - 86Markup/Discount Factor markup 9(1)v9(4) 87 - 91Blend Factor blend 9(1)v9(2) 92 - 94Facility Type factype 9(2) 95 - 96Age Factor - array agefact [30]

5 characters6 times

9(1)v9(4) 97 - 126

Filler X(15) 127 - 141BMI Factor - array bmifact [15]

5 characters3 times

9(1)v9(4) 142 - 156

Filler X(15) 157 - 171Hemo, Peritoneal, or CCPD Training trainadj 9(8)v9(2) 172 - 181CAPD Training capdadj 9(8)v9(2) 182 - 191Home Dialysis Training for CAPD or CCPD homeadj 9(1)v9(6) 192 - 198Core-Based Statistical Area (CBSA) cbsa X(5) 199 - 203Filler X(16) 204 - 219Average BSA avgbsa 9(1)v9(4) 220 - 224BSA Exponent Increment bsaincr 9(1)v9(2) 225 - 227BSA Adjustment Factor bsaadj 9(1)v9(4) 228 - 232Pediatric BSA Adjustment pedbsa 9(1)v9(4) 233 - 237Reasonable Cost Factor factor 9(1)v9(4) 238 - 242Percentage Payment Rate Flag pprflg 9(1) 243Percentage Payment Factor ppr 9(1)v9(4) 244 - 248Dialysis Pay esrdcov 9(1)v9(4) 249 - 253Dialysis Co-Pay esrdcoins 9(1)v9(4) 254 - 258Fee Schedule Indicator:0 = No fee schedule pricing1 = Fee schedule pricing

fsind 9(1) 259

Fee Schedule Table fstable X(13) 260 - 272Lab Coverage Factor labcov 9(1)v9(4) 273 - 277Lab Coinsurance Factor labcoins 9(1)v9(4) 278 - 282Lab Fee Schedule Carrier labcarrier X(12) 283 - 294National Coverage Factor mamcov 9(1)v9(4) 295 - 299National Coinsurance Factor mamcoins 9(1)v9(4) 300 - 304National Fee Schedule Carrier mamcarrier X(12) 305 - 316Other Coverage Factor othcov 9(1)v9(4) 317 - 321Other Coinsurance Factor othcoins 9(1)v9(4) 322 - 326Other Fee Schedule Carrier othcarrier X(12) 327 - 338




Physician Coverage Factor rehcov 9(1)v9(4) 339 - 343Physician Coinsurance Factor rehcoins 9(1)v9(4) 344 - 348Physician Fee Schedule Carrier rehcarrier X(12) 349 - 360Eligible Telehealth Facility telehealth 9(1) 361DME Coverage Factor dmecov

9(1)v9(4)362 - 366

DME Coinsurance Factor dmecoins 9(1)v9(4)

367 - 371

DME Fee Schedule Carrier dmecarrier X(12) 372 - 383DME Rural Indicator rural_ind 9(1) 384Filler X(53) 385 - 437

Table 11-17: Medicare ESRD Extended Rate Calculator Variables - medext.dat

Field Description Variable Name Format PositionHospital Number pfac X(16) 1 - 16Paysource Code psrc X(13) 17 - 29Hospital Number with NPI/Taxonomy

pfac X(20) 1 - 20


psrc X(9) 21 - 29

Effective Date effdate 9(8) 30 - 37Patient Type pattype X(1) 38Filler X(1) 39 Adjusted Outlier Services MAP - Adult

adj_map_adlt 9(8)v9(2) 40 - 49

Adjusted Outlier Services MAP - Pediatric

adj_map_ped 9(8)v9(2) 50 - 59

Age Factor - Array - Separately Payable Services

agefact_sep [30] 6 characters, 5 times

9(1)v9(5) 60 - 89

Bundle Age Factor - Array bundle_ agefact[30] 6 characters, 5 times

9(1)v9(5) 90 - 119

Filler X(15) 120 - 134BMI Factor - Separately Payable Services

bmifactor_sep 9(1)v9(5) 135 - 140

Bundle BMI Factor bundle_bmifactor 9(1)v9(5) 141 - 146Bundle BSA Adjustment Factor

bundle_bsaadj 9(1)v9(4) 147 - 151

Bundle BSA Adjustment Factor - Separately Payable Services

bundle_bsaadj_sep 9(1)v9(5) 152 - 157

Bundle Average BSA bundle_avgbsa 9(1)v9(4) 158 - 162




Bundle Budget Neutrality Factor

bundle_bnf 9(1)v9(6) 163 - 169

Bundle Labor-Related Portion bundle_ls 9(1)v9(5) 170 - 175Bundle Wage Index bundle_wi 9(1)v9(4) 176 - 180Comorbidity Factor - Array comrbd_factor [36]

6 characters, 6 times9(1)v9(5) 181 - 216

Filler X(36) 217 - 252Comorbidity Factor - Array - Separately Payable Services

comrbd_factor_sep [36]6 characters, 6 times

9(1)v9(5) 253 - 288

Filler X(36) 289 - 324Drug Dispensing Fee dispense_fee 9(2)v9(2) 325 - 328Fixed Loss Dollar Amount - Adult

floss_adlt 9(8)v9(2) 329 - 338

Fixed Loss Dollar Amount - Pediatric

floss_ped 9(8)v9(2) 339 - 348

Fixed Loss Sharing Percentage

floss_pct 9(1)v9(4) 349 - 353

Low Volume Factor lvfac 9(1)v9(4) 354 - 358Low Volume - Separately Payable Services

lvfac_sep 9(1)v9(4) 359 - 363

Onset Adjustment onsetadj 9(1)v9(4) 364 - 368Onset Days onsetdays 9(3) 369 - 371Onset Factor - Separately Payable Services

onsetadj_sep 9(1)v9(5) 372 - 377

Pediatric PD < 13 ped_pd_13 9(1)v9(5) 378 - 383Pediatric PD < 13 - Separately Payable Services

ped_pd_13_sep 9(1)v9(5) 384 - 389

Pediatric PD > 13 ped_pd_17 9(1)v9(5) 390- 395Pediatric PD > 13 - Separately Payable Services

ped_pd_17_sep 9(1)v9(5) 396 - 401

Pediatric HD < 13 ped_hd_13 9(1)v9(5) 402 - 407Pediatric HD < 13 - Separately Payable Services

ped_hd_13_sep 9(1)v9(5) 408 - 413

Pediatric HD > 13 ped_hd_17 9(1)v9(5) 414 - 419Pediatric HD > 13 - Separately Payable Services

ped_hd_17_sep 9(1)v9(5) 420 - 425

PPS Training Adjustment trainingadj 9(3)v9(2) 426 - 430Unadjusted PPS Rate base_rate 9(8)v9(2) 431 - 440Part D Blended Amount part_d_blend 9(3)v9(2) 441 - 445Bundled Blend Factor bundle_blend 9(1)v9(2) 446 - 448Quality Reduction Factor qualredfact 9(1)v9(4) 449 - 453




11.2.6.5 Medicare FQHC

Extended Fee Schedule Table

fsexttable X(13) 454 - 466

Return Code Override0 = Do not override Return

Code 04, 05, and 381 = Override Return Code 04,

05, and 38

rc_over 9(1) 467

Rural Adjustment Factor rural_adj 9(1)v9(5) 468 - 473Rural Adjustment Factor - Separately Billable

rural_adj_sep 9(1)v9(5) 474 - 479

Filler X(28) 480 - 507Pricer Type prcr_type X(2) 508 - 509 Key Type key_type X(1) 510

Table 11-18: Medicare FQHC Rate Calculator Variables - medout.dat

Field Description Variable Name Position FormatGeographical Adjustment Factor (GAF) gaf 39 - 43 9(1)v9(4)Markup/Discount Factor markup 44 - 48 9(1)v9(4)IPPE/AWV Adjustment Factor ippeadjfact 49 - 53 9(1)v9(4)Telehealth Fee Schedule Rate

NoteNo longer utilized, as this rate is in the FQHC Fee Schedule Data Files.

telehealth 54 - 63 9(8)v9(2)

Base Rate baserate 64 - 73 9(8)v9(2)FQHC Coverage Factor fqhccov 74 - 78 9(1)v9(4)FQHC Coinsurance Factor fqhccoin 79 - 83 9(1)v9(4)Sequestration Reduction Factor sequest_reduc 84 - 88 9(1)v9(4)Chronic Care Management (CCM)/ Behavioral Health Integration (BHI) Payment Rate


ccmrate 89 - 98 9(8)v9(2)

Facility Type0 = All other FQHCs1 = Grandfathered tribal FQHCs

facility_type 99 9(1)




11.2.7.6 Medicare HHA

Collaborative Care Model (CoCM) Services Payment Rate


cocmrate 100 - 109 9(8)v9(2)

Fee Schedule Table fstable 110 - 112 X(13)Filler 113 - 122 X(10)National Carrier natcarrier 123 - 134 X(12)National Coverage Factor natcov 135 - 139 9(1)v9(4)National Coinsurance Factor natcoins 140 - 144 9(1)v9(4)Other Carrier othcarrier 145 - 156 X(12)Other Coverage Factor othcov 157 - 161 9(1)v9(4)Other Coinsurance Factor othcoins 162 - 166 9(1)v9(4)Filler 167 - 437 X(271)

Table 11-19: Medicare HHA Rate Calculator Variables - medout.dat

Field Description Variable Name Position FormatPhysical Therapy National Per Visit Rate - 042X rev_42_rate 39 - 48 9(8)v9(2)Occupational Therapy National Per Visit Rate - 043X

rev_43_rate 49 - 58 9(8)v9(2)

Speech-Language Pathology National Per Visit Rate - 044X

rev_44_rate 59 - 68 9(8)v9(2)

Skilled Nursing National Per Visit Rate - 055X rev_55_rate 69 - 78 9(8)v9(2)Medical Social Services National Per Visit Rate - 056X

rev_56_rate 79 - 88 9(8)v9(2)

Home Health Aide National Per Visit Rate - 057X

rev_57_rate 89 - 98 9(8)v9(2)

Federal Standard Episode Rate fed_rate 99 - 108 9(8)v9(2)Labor Portion labor 109 - 114 9(1)v9(5)LUPA Add-On Amount lupaaddon 115 - 124 9(8)v9(2)Outlier Fixed Loss Amount outlier 125 - 134 9(8)v9(2)Outlier Payment Percent outlier_pct 135 - 139 9(1)v9(4)Reasonable Cost Factor factor 140 - 144 9(1)v9(4)Percentage Payment Rate Flag pprflg 145 9(1)Percentage Payment Rate ppr 146 - 150 9(1)v9(4)Markup/Discount Factor markup 151 - 155 9(1)v9(4)Hospital Quality Indicator hospqualind 156 9(1)

Table 11-18: Medicare FQHC Rate Calculator Variables - medout.dat



Fee Schedule Indicator fsind 157 9(1)Fee Schedule Table fstable 158 - 170 X(13)Physician Coverage Factor rehcov 171 - 175 9(1)v9(4)Physician Coinsurance Factor rehcoins 176 - 180 9(1)v9(4)Physician Location/Carrier Code rehcarrier 181 - 192 X(12)National Coverage Factor mamcov 193 - 197 9(1)v9(4)National Coinsurance Factor mamcoins 198 - 202 9(1)v9(4)National Location/Carrier Code mamcarrier 203 - 214 X(12)Other Coverage Factor othcov 215 - 219 9(1)v9(4)Other Coinsurance Factor othcoins 220 - 224 9(1)v9(4)Other Location/Carrier Code othcarrier 225 - 236 X(12)Non-Routine Supplies Conversion Factor nrsfactor 237 - 246 9(8)v9(2)RAP Payment Percentage for Initial Episodes rap_init 247 - 251 9(1)v9(4)RAP Payment Percentage for Subsequent Episodes

rap_subs 252 - 256 9(1)v9(4)

Rural Add-On - All Other rural_addon 257 - 261 9(1)v9(4)Skilled Nursing (SN) LUPA Add-On Factor sn_addon 262 - 266 9(1)v9(4)Physical Therapy (PT) LUPA Add-On Factor pt_addon 267 - 271 9(1)v9(4)Speech Language Pathology (SLP) LUPA Add-On Factor

slp_addon 272 - 276 9(1)v9(4)

Physical Therapy Per Unit Rate rev_42_unit_rate 277 - 286 9(8)v9(2)Occupational Therapy Per Unit Rate rev_43_unit_rate 287 - 296 9(8)v9(2)Speech Language Pathology Per Unit Rate rev_44_unit_rate 297 - 306 9(8)v9(2)Skilled Nursing Per Unit Rate rev_55_unit_rate 307 - 316 9(8)v9(2)Medical Social Services Per Unit Rate rev_56_unit_rate 317 - 326 9(8)v9(2)Home Health Aide Per Unit Rate rev_57_unit_rate 327 - 336 9(8)v9(2)Value-Based Purchasing (VBP) Adjustment Factor

vbp_adj 337 - 342 9(1)v9(5)

Rural Add-On – High Utilization high_rural_addon 343 - 347 9(1)v9(4)Rural Add-On – Low Pop. Density low_rural_addon 348 - 352 9(1)v9(4)Transitional National 60-Day Episode Rate transitional_rate 353 - 362 9(8)v9(2)Transitional Outlier Fixed Loss Amount transitional_outlier 363 - 372 9(8)v9(2)HHA Not Eligible for RAP Reimbursement0 = HHA is eligible for RAP reimbursement1 = HHA is not eligible for RAP reimbursement

rap_exempt 373 9(1)

Return Code 57 Override0 = Do not bypass claim-level Pricer Return

Code 571 = Bypass claim-level Pricer Return Code 57

rc57_override 374 9(1)

Filler 375 - 437 X(63)

Table 11-19: Medicare HHA Rate Calculator Variables - medout.dat



11.2.8.7 Medicare Hospice

Table 11-20: Medicare Hospice Rate Calculator Variables - medout.dat

Field Description Variable Name Position FormatMark-up/Discount Factor markup 39 - 43 9(1)v9(4)Routine Home Care, Days 1 - 60 Labor Share high_rhc_lrate 44 - 53 9(8)v9(2)Routine Home Care, Days 1 - 60 Non-Labor Share high_rhc_nlrate 54 - 63 9(8)v9(2)

Routine Home Care, Days 61+ Labor Share low_rhc_lrate 64 - 73 9(8)v9(2)

Routine Home Care, Days 61+ Non- Labor Share low_rhc_nlrate 74 - 83 9(8)v9(2)Continuous Home Care Labor Share chc_lrate 84 - 93 9(8)v9(2)Continuous Home Care Non-Labor Share chc_nlrate 94 - 103 9(8)v9(2)Inpatient Respite Care Labor Share irc_lrate 104 - 113 9(8)v9(2)Inpatient Respite Care Non-Labor Share lrc_nlrate 114 - 123 9(8)v9(2)General Inpatient Care Labor Share gip_lrate 124 - 133 9(8)v9(2)General Inpatient Care Non-Labor Share gip_nlrate 134 - 143 9(8)v9(2)Fee Schedule Name fstable 144 - 156 X(13)National Carrier natcarrier 157 - 168 X(12)Physician Carrier physcarrier 169 - 180 X(12)Other Carrier othcarrier 181 - 192 X(12)Sequestor Factor sequest_reduc 193 - 197 9(1)v9(4)Filler 198 - 437 X(240)


11.2.9 COBOL Platform11.2.10.1 Medicare APC-HOPD

Table 11-21: Medicare APC-HOPD COBOL Hospital Rate File Variables - hosprate.dat

Field Description Variable Name Positions FormatLabor-Related Portion Y2R-LABOR 251 - 256 9(1)v9(5)Wage Index Y2R-WI 257 - 262 9(1)v9(5)Facility Type 01 = Rural hospital with 100 beds or fewer

or rural Sole Community Hospital (SCH)

02 = Cancer center03 = Children’s hospital04 = Rural hospital under 50 beds05 = OPPS exempt06 = Other SCH07 = Other rural hospital (Not SCH)08 = Free-standing non-residential opioid

treatment facilityOtherwise, 00

Y2R-FACILITY-TYPE 263 - 264 9(2)

Multiple Significant Procedure Payment Discount Factor - Factor for Highest Weighted Procedure

Y2R-DISCOUNT1 265 - 269 9(1)v9(4)

Multiple Significant Procedure Payment Discount Factor - Factor for all Other Procedures (Paystatus T)

Y2R-DISCOUNT2 270 - 274 9(1)v9(4)

Multiple Significant Procedure Payment Discount Filler Area

275 - 284 X(10)

Discontinued Procedure Payment Discount

Y2R-DMODPCT 285 - 289 9(1)v9(4)

Outpatient Ratio of Cost to Charges Y2R-RCC 290 - 295 9(1)v9(5)Inpatient Deductible Y2R-INPDED 296 - 305 9(8)v9(2)1996 Ratio of Payment to Charges Y2R-RPC 306 - 310 9(1)v9(4)Outlier Payment Percent Y2R-OUTLIER-PCT 311 - 315 9(1)v9(4)Outlier Payment Factor Y2R-OUTLIER-FAC 316 - 320 9(1)v9(4)Transitional Corridor 90% Factor 1 Y2R-TRANS90-1 321 - 322 v9(2)Transitional Corridor 90% Factor 2 Y2R-TRANS90-2 323 - 324 v9(2)Transitional Corridor 80% Factor 1 Y2R-TRANS80-1 325 - 326 v9(2)Transitional Corridor 80% Factor 2 Y2R-TRANS80-2 327 - 328 v9(2)Transitional Corridor 70% Factor 1 Y2R-TRANS70-1 329 - 330 v9(2)Transitional Corridor 70% Factor 2 Y2R-TRANS70-2 331 - 332 v9(2)Transitional Corridor Less Than 70% Y2R-TRANSLT70 333 - 334 v9(2)Transitional Corridor Factor, Cancer Centers or Small Rural Facilities

Y2R-TRANSCSR 335 - 337 9(1)v9(2)

Transitional Corridor Multiplier Y2R-TRANSMULT 338 - 342 9(1)v9(4)


Ambulance Rural Factor Y2R-AMBRURAL 343 - 347 9(1)v9(4)Ambulance Non-Rural Factor Y2R-AMBNONRURAL 348 - 352 9(1)v9(4)Hospital Quality Indicator Y2R-HOSPQUALIND 353 X(1)Hospital Quality Reduction Factor Y2R-QUALREDFACT 354 - 358 9(1)v9(4)Filler 359 - 365 X(7)Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

Y2R-FSIND 366 9(1)

Fee Schedule Table Y2R-FSTABLE 367 - 379 X(13)Ambulance Coverage Factor Y2R-AMBCOV 380 - 384 9(1)v9(4)Ambulance Coinsurance Factor Y2R-AMBCOINS 385 - 389 9(1)v9(4)Ambulance Location/Carrier Code


Y2R-AMBCARRIER 390 - 401 X(12)

DMEPOS Coverage Factor Y2R-DMECOV 402 - 406 9(1)v9(4)DMEPOS Coinsurance Factor Y2R-DMECOINS 407 - 411 9(1)v9(4)DMEPOS Location/Carrier Code Y2R-DMECARRIER 412 - 423 X(12)Lab Coverage Factor Y2R-LABCOV 424 - 428 9(1)v9(4)Lab Coinsurance Factor Y2R-LABCOINS 429 - 433 9(1)v9(4)Lab Location/Carrier Code Y2R-LABCARRIER 434 - 445 X(12)Mammography Coverage Factor Y2R-MAMCOV 446 - 450 9(1)v9(4)Mammography Coinsurance Factor Y2R-MAMCOINS 451 - 455 9(1)v9(4)Mammography Location/Carrier Code Y2R-MAMCARRIER 456 - 467 X(12)Rehabilitation Coverage Factor Y2R-REHCOV 468 - 472 9(1)v9(4)Rehabilitation Coinsurance Factor Y2R-REHCOINS 473 - 477 9(1)v9(4)Rehabilitation Location/Carrier Code Y2R-REHCARRIER 478 - 489 X(12)Other Coverage Factor Y2R-OTHCOV 490 - 494 9(1)v9(4)Other Coinsurance Factor Y2R-OTHCOINS 495 - 499 9(1)v9(4)Other Location/Carrier Code Y2R-OTHCARRIER 500 - 511 X(12)Pro-Rata Reduction for Pass-through Drugs and Biologicals

Y2R-PRDRUG 512 - 516 9(1)v9(4)

Pro-Rata Reduction Factor for Pass-through Devices

Y2R-PRDEVICE 517 - 521 9(1)v9(4)

Total Reimbursement Discount Factor Y2R-DISCOUNT 522 - 526 9(1)v9(4)Laboratory Ratio of Cost to Charges Y2R-LABRCC 527 - 532 9(1)v9(5)OPPS Exempt Factor Y2R-EXEMPT-FACT 533 - 537 9(1)v9(4)Outlier Fixed Cost Threshold Y2R-OUTLEIR-THRESH 538 - 547 9(8)v9(2)


Field Description Variable Name Positions Format


11.2.11.2 Medicare ASC

Reasonable Cost Factor Y2R-RCOST-FACT 548 - 552 9(1)v9(4)Rural Adjustment Factor Y2R-RURAL-FACT 553 - 557 9(1)v9(4)Extended Fee Schedule Table Y2R-FSEXTTABLE 558 - 570 X(13)Sequester Factor Y2R-SEQUEST 571 - 575 9(1)v(9)4Non-Emergency ESRD Ambulance Reduction Factor

Y2R-ESRD-REDUC 576 - 580 9(1)v9(4)

Computed (CT) Tomography Reduction Factor

Y2R-CT-REDUC 581 - 585 9(1)v9(4)

DME Rural Indicator0 = Non-Rural (Urban) Facility for DME

Services1 = Rural Facility for DME Services

Y2R-RURAL-IND 586 9(1)

X-Ray With Film Reduction Factor Y2R-FX-REDUC 587 - 591 9(1)v9(4)PBD Reduction Factor (PN) Y2R-PN-REDUC 592 - 596 9(1)v9(4)Implantable Device RCC Y2R-ID-RCC 597 - 602 9(1)v9(5)Traditional Medicare Switch0 = Apply Medicare Advantage

Requirements 1 = Apply Medicare Fee-for-Service (FFS)

Requirements

Y2R-TRADMED-SW 603 9(1)

Ambulance Base Rate Reduction Factor - 2 Patients

Y2R-AMB-REDUC2 604 - 608 9(1)v9(4)

Ambulance Base Rate Reduction Factor -> 2 Patients

Y2R-AMB-REDUC3 609 - 613 9(1)v9(4)

Computed Radiography Reduction Factor Y2R-FY-REDUC 614 - 618 9(1)v9(4)PBD Reduction Factor (PO) Y2R-PO-REDUC 619 - 623 9(1)v9(4)Filler 624 - 793 X(170)

Table 11-22: Medicare ASC Hospital Rate File Variables - hosprate.dat

Field Description Variable Name Format PositionLabor-Related Portion Y1R-LABOR 9v9(5) 251 - 256Wage Index Y1R-WI 9v9(5) 257 - 262Multiple Procedure Discount Factor - First Procedure

Y1R-DISCOUNT1 9(1)v9(4) 263 - 267

Multiple Procedure Discount Factor – All Other Procedures

Y1R-DISCOUNT2 9(1)v9(4) 268 - 272

Discontinued Procedure Discount Y1R-DMODPCT 9(1)v9(4) 273 - 277Payment Percentage Rate Flag Y1R-PPRFLG 9(1) 278Payment Percentage Rate Y1R-PPR 9(1)v9(4) 279 - 283


Field Description Variable Name Positions Format


11.2.12.3 Medicare CAH Method II

11.2.13.4 Medicare ESRD

Markup/Discount Factor Y1R-MARKUP 9(1)v9(4) 284 - 288Payment Limit Flag Y1R-PAYLIM 9(1) 289Payment Limit Factor Y1R-PAYPCT 9(1)v9(4) 290 - 294Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

Y1R-FSIND 9(1) 295

Fee Schedule Table Y1R-FSTABLE X(13) 296 - 308ASC Coverage Factor Y1R-ASRCOV 9(1)v9(4) 309 - 313ASC Coinsurance Factor Y1R-ASRCOINS 9(1)v9(4) 314 - 318ASC Fee Schedule Carrier Y1R-ASRCARRIER X(12) 319 - 330Other Coverage Factor Y1R-OTHCOV 9(1)v9(4) 331 - 335Other Coinsurance Factor Y1R-OTHCOINS 9(1)v9(4) 336 - 340Other Fee Schedule Carrier Y1R-OTHCARRIER X(12) 341 - 352Quality Reduction Factor Y1R-QUAL-

REDUCT9(1)v9(4) 353 - 357

Allow Payment for Ancillary Only Claims0 = Do not allow payment for ancillary only

claims1 = Allow payment for ancillary only claims

Y1R-SURG-PROC-OVR

X(1) 358

Filler X(435) 359 - 793NMPRF Version Y1R-VERSION X(7) 794 - 800

Table 11-23: Medicare CAH Method II COBOL Rate Calculator Variables - hosp05.dat

Field Description Variable Name Format PositionPractitioner Adjustment C2R-PRAC-ADJ 9(1)v9(4) 251 - 255Filler X(538) 256 - 793NMPRF Version C2R-VERSION X(7) 794 - 800

Table 11-24: Medicare ESRD COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionCBSA Rate E1R-CBSARATE 9(8)v9(2) 251 - 260MSA Wage Adjusted Rate E1R-ADJMSARATE 9(8)v9(2) 261 - 270MSA Add-On E1R-MSAFACTOR 9(1)v9(4) 271 - 275Labor-Related Portion E1R-LS 9(1)v9(5) 276 - 281

Table 11-22: Medicare ASC Hospital Rate File Variables - hosprate.dat



Wage Index E1R-WI 9(1)v9(4) 282 - 286Drug Add-on Factor E1R-DRUGFACT 9(1)v9(4) 287 - 291Budget Neutrality Factor E1R-BNF 9(1)v9(6) 292 - 298Mark-up/Discount Factor E1R-MARKUP 9(1)v9(4) 299 - 303Blend Factor E1R-BLEND 9(1)v9(2) 304 - 306Facility Type E1R-FACTYPE 9(2) 307 - 308Age Factor - Array E1R-AGEFACT [30]

5 characters,6 times

9(1)v9(4) 309 - 338

Filler X(15) 339 - 353BMI Factor - Array E1R-BMIFACT [15]

5 characters,3 times

9(1)v9(4) 354 - 368

Filler X(15) 369 - 383Hemo, Peritoneal, or CCPD Training E1R-TRAINADJ 9(8)v9(2) 384 - 393CAPD Training E1R-CAPDADJ 9(8)v9(2) 394 - 403Home Dialysis for CAPD or CCPD Factor E1R-HOMEADJ 9(1)v9(6) 404 - 410Core-Based Statistical Area (CBSA) E1R-CBSA X(5) 411 - 415Filler X(16) 416 - 431Average BSA E1R-AVGBSA 9(1)v9(4) 432 - 436BSA Exponent Increment E1R-BSAINCR 9(1)v9(2) 437 - 439BSA Adjustment Factor E1R-BSAADJ 9(1)v9(4) 440 - 444Pediatric BSA Adjustment E1R-PEDBSA 9(1)v9(4) 445 - 449Reasonable Cost Factor E1R-FACTOR 9(1)v9(4) 450 - 454Percentage Payment Rate Flag E1R-PPRFLG 9(1) 455 - 455Percentage Payment Rate E1R-PPR 9(1)v9(4) 456 - 460Dialysis Pay E1R-ESRDCOV 9(1)v9(4) 461 - 465Dialysis Co-pay E1R-ESRDCOINS 9(1)v9(4) 466 - 470Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

E1R-FSIND 9(1) 471 - 471

Fee Schedule Table E1R-FSTABLE X(13) 472 - 484Lab Coverage Factor E1R-LABCOV 9(1)v9(4) 485 - 489Lab Coinsurance Factor E1R-LABCOINS 9(1)v9(4) 490 - 494Lab Fee Schedule Carrier E1R-LABCARRIER X(12) 495 - 506National Coverage Factor E1R-MAMCOV 9(1)v9(4) 507 - 511National Coinsurance Factor E1R-MAMCOINS 9(1)v9(4) 512 - 516National Fee Schedule Carrier E1R-MAMCARRIER X(12) 517 - 528Other Coverage Factor E1R-OTHCOV 9(1)v9(4) 529 - 533Other Coinsurance Factor E1R-OTHCOINS 9(1)v9(4) 534 - 538




Other Fee Schedule Carrier E1R-OTHCARRIER X(12) 539 - 550Physician Coverage Factor E1R-REHCOV 9(1)v9(4) 551 - 555Physician Coinsurance Factor E1R-REHCOINS 9(1)v9(4) 556 - 560Physician Fee Schedule Carrier E1R-REHCARRIER X(12) 561 - 572Eligible Telehealth Facility E1R-TELEHEALTH 9(1) 573DME Coverage Factor E1R-DMECOV 9(1)v9(4) 574 - 578DME Coinsurance Factor E1R-DMECOINS

9(1)v9(4)579 - 583

DME Fee Schedule Carrier E1R-DMECARRIER X(12) 584 - 595DME Rural Indicator E1R-RURAL-IND 9(1) 596Filler X(197) 597 - 793NMPRF Version E1R-VERSION X(7) 794 - 800Pricer Type E1R-PRICER-TYPE X(2) 801 - 802Key Type E1R-KEY-TYPE X(1) 803

Table 11-25: Medicare ESRD Extended Rate Calculator Variables COBOL - hospext.dat

Field Description Variable Name Format PositionHospital Number HER-HOSP X(16) 1 - 16Paysource (Payer) Code HER-PCODE X(13) 17 - 29Hospital Number with NPI/Taxonomy HER-HOSP X(20) 1 - 20Paysource (Payer) Code with NPI/Taxonomy

HER-PCODE X(9) 21 - 29

Patient Type HER-PATTYPE X(1) 30Effective Date Sequence Code Extension

HER-ESEQ-EXT X(1) 31

Effective Date Sequence Code (Set by Base Rate Calculator Program)

HER-ESEQ 9(4) 32 - 35

Effective Date of Rate Calculator Variables

HER-EDATE

Effective Century/Year HER-EDATE-CCYY 9(4) 36 - 39 Effective Month HER-EDATE-MM 9(2) 40 - 41 Effective Day HER-EDATE-DD 9(2) 42 - 43Filler X(8) 44 - 51Adjusted Outlier Services MAP – Adult

E1R0-ADJ-MAP-ADLT 9(8)v9(2) 52 - 61

Adjusted Outlier Services MAP – Pediatric

E1R0-ADJ-MAP-PED 9(8)v9(2) 62 - 71




Age Factor –Array – Separately Payable Services

E1R0-SEP-AGEFACT [30]6 characters, 5 times

9(1)v9(4) 72 - 101

Bundle Age Factor –Array E1R0-BUNDLE- AGEFACT[30]6 characters, 5 times

9(1)v9(4) 102 - 131

Filler X(15) 132 - 146BMI Factor – Separately Payable Services

E1R0-BMIFACTOR-SEP

9(1)v9(5) 147 - 152

Bundle BMI Factor E1R0-BUNDLE-BMIFACTOR

9(1)v9(5) 153 - 158

Bundle BSA Adjustment Factor E1R0-BUNDLE-BSAADJ

9(1)v9(4) 159 - 163

Bundle BSA Adjustment Factor – Separately Payable Services

E1R0-BUNDLE-BSAADJ-SEP

9(1)v9(5) 164 - 169

Bundle Average E1R0-BSABUNDLE-AVGBSA

9(1)v9(4) 170 - 174

Bundle Budget Neutrality Factor E1R0-BUNDLE-BNF 9(1)v9(6) 175 - 181Bundle Labor-Related Portion E1R0-BUNDLE-LS 9(1)v9(5) 182 - 187Bundle Wage Index E1R0-BUNDLE-WI 9(1)v9(4) 188 - 192Comorbidity Factor – Array E1R0-COMRBD-

FACTOR [36] 6 characters, 6 times

9(1)v9(5) 193 - 228

Filler X(36) 229 - 264Comorbidity Factor – Array – Separately Payable Services

E1R0-COMRBD-FACTOR-SEP [36] 6 characters 6 times

9(1)v9(5) 265 - 300

Filler X(36) 301 - 336Drug Dispensing Fee E1R0-DISPENSE-FEE 9(2)v9(2) 337 - 340Fixed Loss Dollar Amount – Adult E1R0-FLOSS-ADLT 9(8)v9(2) 341 - 350Fixed Loss Dollar Amount – Pediatric E1R0-FLOSS-PED 9(8)v9(2) 351 - 360Fixed Loss Sharing Percentage E1R0-FLOSS-PCT 9(1)v9(4) 361 - 365Low Volume E1R0-LVFAC 9(1)v9(4) 366 - 370Low Volume – Separately Payable Services

E1R0-LVFAC-SEP 9(1)v9(4) 371 - 375

Onset Adjustment E1R0-ONSETADJ 9(1)v9(4) 376 - 380Onset Days E1R0-ONSETDAYS 9(3) 381 - 383Onset Factor – Separately Payable Services

E1R0-ONSETADJ-SEP 9(1)v9(5) 384 - 389

Pediatric PD < 13 E1R0-PED-PD-13 9(1)v9(5) 390 - 395Pediatric PD < 13 – Separately Payable Services

E1R0-PED-PD-13-SEP 9(1)v9(5) 396 - 401




11.2.14.5 Medicare FQHC

Pediatric PD > 13 E1R0-PED-PD-17 9(1)v9(5) 402 - 407Pediatric PD > 13 – Separately Payable Services

E1R0-PED-PD-17-SEP 9(1)v9(5) 408 - 413

Pediatric HD < 13 E1R0-PED-HD-13 9(1)v9(5) 414 - 419Pediatric HD < 13 – Separately Payable Services

E1R0-PED-HD-13-SEP 9(1)v9(5) 420 - 425

Pediatric HD > 13 E1R0-PED-HD-17 9(1)v9(5) 426 - 431Pediatric HD > 13 – Separately Payable Services

E1R0-PED-HD-17-SEP 9(1)v9(5) 432 - 437

PPS Training Adjustment E1R0-PPS-TRAININADJ

9(3)v9(2) 438 - 442

Unadjusted PPS Rate E1R0-BASE-RATE 9(8)v9(2) 443 - 452Part D Blended Amount E1R0-PART-D-BLEND 9(3)v9(2) 453 - 457Bundled Blend Factor E1R0-BUNDLE-BLEND 9(1)v9(2) 458 – 460Quality Reduction Factor E1R0-QUALREDFACT 9(1)v9(4) 461 - 465Extended Fee Schedule Table E1R0-FSEXTTABLE X(13) 466 - 478Return Code Override0 = Do not override Return Code 04,

05, and 381 = Override Return Code 04, 05,

and 38

E1R0-RC-OVER 9(1) 479

Rural Adjustment Factor E1R0-RURAL-ADJ 9(1)v9(5) 480 - 485Rural Adjustment Factor - Separately Billable

E1R0-RURAL-ADJ-SEP 9(1)v9(5) 486 - 491

Filler X(306) 492 - 797Pricer Type E1R0-PRCR-TYPE X(2) 798 - 799Key Type E1R0-KEY-TYPE X(1) 800

Table 11-26: Medicare FQHC COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Position FormatGeographical Adjustment Factor (GAF) FQ1-GAF 251 - 255 9(1)v9(4)Mark-up/Discount Factor FQ1-MARKUP 256 - 260 9(1)v9(4)IPPE/AWV Adjustment Factor FQ1-IPPEADJFACT 261 - 265 9(1)v9(4)Telehealth Fee Schedule Rate


FQ1-TELEHEALTH 266 - 275 9(8)v9(2)




11.2.15.6 Medicare HHA

Base Rate FQ1-BASERATE 276 - 285 9(8)v9(2)FQHC Coverage Factor FQ1-FQHCCOV 286 - 290 9(1)v9(4)FQHC Coinsurance Factor FQ1-FQHCCOIN 291 - 295 9(1)v9(4)Sequestration Reduction Factor FQ1-SEQUEST-

REDUC296 - 300 9(1)v9(4)

Chronic Care Management (CCM)/ Behavioral Health Integration (BHI) Payment Rate


FQ1-CCMRATE 301 - 310 9(8)v9(2)

Facility Type0 = All other FQHCs1 = Grandfathered tribal FQHCs

FQ1-FACILITYTYPE 311 9(1)

Collaborative Care Model (CoCM) Services Payment Rate


FQ1-COCMRATE 312 - 321 9(8)v9(2)

Fee Schedule Table FQ1-FSTABLE 322 - 334 X(13)National Carrier FQ1-NATCARRIER 335 - 346 X(12)National Coverage Factor FQ1-NATCOV 347 - 351 9(1)v9(4)National Coinsurance Factor FQ1-NATCOINS 352 - 356 9(1)v9(4)Other Carrier FQ1-OTHCARRIER 357 - 368 X(12)Other Coverage Factor FQ1-OTHCOV 369 - 373 9(1)v9(4)Other Coinsurance Factor FQ1-OTHCOINS 374 - 378 9(1)v9(4)Filler 379 - 793 X(415)NMPRF Version FQ1-VERSION 794 - 800 X(7)

Table 11-27: Medicare HHA COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Position FormatPhysical Therapy National Per Visit Rate - 042X

H1R-REV-42-RATE 251 - 260 9(8)v9(2)

Occupational Therapy National Per Visit Rate - 043X

H1R-REV-43-RATE 261 - 270 9(8)v9(2)

Speech-Language Pathology National Per Visit Rate - 044X

H1R-REV-44-RATE 271 - 280 9(8)v9(2)

Table 11-26: Medicare FQHC COBOL Rate Calculator Variables - hosprate.dat



Skilled Nursing National Per Visit Rate - 055X

H1R-REV-55-RATE 281 - 290 9(8)v9(2)

Medical Social Services National Per Visit Rate - 056X

H1R-REV-56-RATE 291 - 300 9(8)v9(2)

Home Health Aide National Per Visit Rate - 057X

H1R-REV-57-RATE 301 - 310 9(8)v9(2)

Federal Standard Episode Rate H1R-FED-RATE 311 - 320 9(8)v9(2)Labor Portion H1R-LABOR 321 - 326 9(1)v9(5)LUPA Add-On Amount H1R-LUPAADDON 327 - 336 9(8)v9(2)Outlier Fixed Loss Amount H1R-OUTLIER 337 - 346 9(8)v9(2)Outlier Payment Percent H1R-OUTLIER-PCT 347 - 351 9(1)v9(4)Reasonable Cost Factor H1R-FACTOR 352 - 356 9(1)v9(4)Percentage Payment Rate Flag H1R-PPRFLG 357 9(1)Percentage Payment Rate H1R-PPR 358 - 362 9(1)v9(4)Markup/Discount Factor H1R-MARKUP 363 - 367 9(1)v9(4)Hospital Quality Indicator H1R-HOSPQUALIND 368 9(1)Fee Schedule Indicator H1R-FSIND 369 9(1)Fee Schedule Table H1R-FSTABLE 370 - 382 X(13)Physician Coverage Factor H1R-REHCOV 383 - 387 9(1)v9(4)Physician Coinsurance Factor H1R-REHCOINS 388 - 392 9(1)v9(4)Physician Location/Carrier Code H1R-REHCARRIER 393 - 404 X(12)National Coverage Factor H1R-MAMCOV 405 - 409 9(1)v9(4)National Coinsurance Factor H1R-MAMCOINS 410 - 414 9(1)v9(4)National Location/Carrier Code H1R-MAMCARRIER 415 - 426 X(12)Other Coverage Factor H1R-OTHCOV 427 - 431 9(1)v9(4)Other Coinsurance Factor H1R-OTHCOINS 432 - 436 9(1)v9(4)Other Location/Carrier Code H1R-OTHCARRIER 437 - 448 X(12)Non-Routine Supplies Conversion Factor H1R-NRSFACTOR 449 - 458 9(8)v9(2)RAP Payment Percentage for Initial Episodes

H1R-RAP-INIT 459 - 463 9(1)v9(4)

RAP Payment Percentage for Subsequent Episodes

H1R-RAP-SUBS 464 - 468 9(1)v9(4)

Rural Add-On - All Other H1R-RURAL-ADDON 469 - 473 9(1)v9(4)Skilled Nursing (SN) LUPA Add-On Factor

H1R-SN-LUPA-ADDON 474 - 478 9(1)v9(4)

Physical Therapy (PT) LUPA Add-On Factor

H1R-PT-LUPA-ADDON 479 - 483 9(1)v9(4)

Speech Language Pathology (SLP) LUPA Add-On Factor

H1R-SLP-LUPA-ADDON

484 - 488 9(1)v9(4)

Physical Therapy Per Unit Rate H1R-REV42-UNIT-RATE

489 - 498 9(8)v9(2)




11.2.16.7 Medicare Hospice

Occupational Therapy Per Unit Rate H1R-REV43-UNIT-RATE

499 - 508 9(8)v9(2)

Speech Language Pathology Per Unit Rate

H1R-REV44-UNIT-RATE

509 - 518 9(8)v9(2)

Skilled Nursing Per Unit Rate H1R-REV55-UNIT-RATE

519 - 528 9(8)v9(2)

Medical Social Services Per Unit Rate H1R-REV56-UNIT-RATE

529 - 538 9(8)v9(2)

Home Health Aide Per Unit Rate H1R-REV57-UNIT-RATE

539 - 548 9(8)v9(2)


H1R-VBP-ADJ 549 - 554 9(1)v9(5)

Rural Add-On – High Utilization H1R-HIGH-RURAL-ADDON

555 - 559 9(1)v9(4)

Rural Add-On – Low Pop. Density H1R-LOW-RURAL-ADDON

560 - 564 9(1)v9(4)

Transitional National 60-Day Episode Rate

H1R-TRANSITIONAL-RATE

565 - 574 9(8)v9(2)

Transitional Outlier Fixed Loss Amount H1R-TRANSITIONAL-OUTLIER

575 - 584 9(8)v9(2)

HHA Not Eligible for RAP Reimbursement 0 = HHA is eligible for RAP

reimbursement1 = HHA is not eligible for RAP

reimbursement

H1R-RAP-EXEMPT 585 9(1)

Return Code 57 Override0 = Do not bypass claim-level Pricer

Return Code 571 = Bypass claim-level Pricer Return

Code 57

H1R-RC57-OVERRIDE 586 9(1)

Filler 587 - 793 X(207)NMPRF Version H1R-VERSION 794 - 800 X(7)

Table 11-28: Medicare Hospice COBOL Rate Calculator Variables - hosprate.dat

Field Description Variable Name Position FormatMark-up/Discount Factor HS1-MARKUP 251 - 255 9(1)v9(4)Routine Home Care, Days 1 - 60 Labor Share HS1-HIGH-

RHC-LRATE256 - 265 9(8)v9(2)

Routine Home Care, Days 1 - 60 Non-Labor Share HS1-HIGH-RHC-NLRATE

266 - 275 9(8)v9(2)




Routine Home Care, Days 61+ Labor Share HS1-LOW-RHC-LRATE

276 - 285 9(8)v9(2)

Routine Home Care, Days 61+ Non-Labor Share HS1-LOW-RHC-NLRATE

286 - 295 9(8)v9(2)

Continuous Home Care Labor Share HS1-CHC-LRATE

296 - 305 9(8)v9(2)

Continuous Home Care Non-Labor Share HS1-CHC-NLRATE

306 - 315 9(8)v9(2)

Inpatient Respite Care Labor Share HS1-IRC-LRATE 316 - 325 9(8)v9(2)Inpatient Respite Care Non-Labor Share HS1-IRC-

NLRATE326 - 335 9(8)v9(2)

General Inpatient Care Labor Share HS1-GIP-LRATE 336 - 345 9(8)v9(2)General Inpatient Care Non-Labor Share HS1-GIP-

NLRATE346 - 355 9(8)v9(2)

Fee Schedule Name HS1-FSTABLE 356 - 368 X(13)National Carrier HS1-

NATCARRIER369 - 380 X(12)

Physician Carrier HS1-PHYSCARRIER

381 - 392 X(12)

Other Carrier HS1-OTHCARRIER

393 - 404 X(12)

Sequestor Factor HS1-SEQUEST-REDUC

405 - 409 9(1)v9(4)

Filler 410 - 793 X(384)NMPRF Version VERSION 794 - 800 X(7)

Table 11-28: Medicare Hospice COBOL Rate Calculator Variables - hosprate.dat



11.3 Physician Layouts11.3.1 C Platform

11.3.2.1 Medicare Physician

Table 11-29: Medicare Physician Rate Calculator Variables - medphys.dat

Field Description Variable Name Format PositionConditional Bilateral Discount Factor bilat1 9(1)v9(4) 39 - 43Independent Bilateral Discount Factor bilat2 9(1)v9(4) 44 - 48Co-Surgery Discount Factor cosurg 9(1)v9(4) 49 - 53Assistant to Surgery Discount Factor astsurg 9(1)v9(4) 54 - 58Sanction/Preclusion Flag0 = Provider has not been sanctioned or

precluded1 = Provider has been sanctioned by the

OIG and is not eligible for Medicare reimbursement

2 = Provider has been precluded and is not eligible for Medicare reimbursement

3 = Provider has been precluded and/or sanctioned by the OIG and is not eligible for Medicare reimbursement

sanction 9(1) 59

Filler X(9) 60 - 68Multiple Surgical Procedure Discount Factor - Highest Paid Service

discount1 9(1)v9(4) 69 - 73

Multiple Surgical Procedure Discount Factor - Second through Fifth Highest Paid Services

discount2 9(1)v9(4) 74 - 78

Multiple Diagnostic Imaging Procedure Discount Factor - Technical Highest Paid Service

tcdisc1 9(1)v9(4) 79 - 83

Multiple Diagnostic Imaging Procedure Discount Factor - Technical Not Highest Paid Service

tcdisc2 9(1)v9(4) 84 - 88

Reasonable Charge Factor rcf 9(1)v9(4) 89 - 93Anesthesia Minutes (used for calculating Anesthesia Time Units)

anesthmin 9(4) 94 - 97

Monitored Anesthesia Reduction Factor anesthreduc 9(1)v9(4) 98 - 102Estimate Bonus Payments/Calculate MACRA QPP Adjustments0 = Do not estimate bonus payments/

calculate MACRA QPP adjustments for this provider

1 = Estimate bonus payments/calculate MACRA QPP adjustments for this provider

bonus_req 9(1) 103

Primary Care Health Professional Shortage Area (HPSA) Bonus Payment Factor

phpsa 9(1)v9(4) 104 - 108


Mental Health Professional Shortage Area (HPSA) Bonus Payment Factor

mhhpsa 9(1)v9(4) 109 - 113

HPSA Surgical Incentive Payment (HSIP) Factor

NoteThe HSIP program expired on December 31, 2015; therefore the HSIP Factor has been set to zero effective January 1, 2016.

hsip 9(1)v9(4) 114 - 118

Primary Care Incentive Payment (PCIP) Factor

NoteThe PCIP program expired on December 31, 2015; therefore the PCIP Factor has been set to zero effective January 1, 2016.

pcip 9(1)v9(4) 119 - 123

PCIP Eligibility1 = Provider is eligible for PCIP bonus

payments (i.e. primary care services accounted for 60% or more of the allowed Part B charges for this provider in a given time period)

0 = Provider is not eligible for PCIP bonus payments

NoteThe PCIP program expired on December 31, 2015; therefore the PCIP Eligibility field has been set to zero effective January 1, 2016.

pcip_elg 9(1) 124

Mental Health Limitation Factor mhlim 9(1)v9(4) 125 - 129Markup/Discount Adjustment Factor markup 9(1)v9(4) 130 - 134Fee Schedule Table fstable X(13) 135 - 147Extended Fee Schedule Table fsexttable X(13) 148 - 160Ambulance Coverage Factor ambcov 9(1)v9(4) 161 - 165Ambulance Coinsurance Factor ambcoins 9(1)v9(4) 166 - 170Filler X(15) 171 - 185DMEPOS Coverage Factor dmecov 9(1)v9(4) 186 - 190DMEPOS Coinsurance Factor dmecoins 9(1)v9(4) 191 - 195Lab Coverage Factor labcov 9(1)v9(4) 196 - 200Lab Coinsurance Factor labcoins 9(1)v9(4) 201 - 205National Coverage Factor natcov 9(1)v9(4) 206 - 210National Coinsurance Factor natcoins 9(1)v9(4) 211 - 215Physician Fee Schedule Coverage Factor pfscov 9(1)v9(4) 216 - 220




Physician Fee Schedule Coinsurance Factor pfscoins 9(1)v9(4) 221 - 225Other Coverage Factor othcov 9(1)v9(4) 226 - 230Other Coinsurance Factor othcoins 9(1)v9(4) 231 - 235Multiple Diagnostic Imaging Procedure Discount Factor – Professional Component - Highest Paid Service

pcdisc1 9(1)v9(4) 236 - 240

Multiple Diagnostic Imaging Procedure Discount Factor – Professional Component -Not Highest Paid Service

pcdisc2 9(1)v9(4) 241 - 245

Multiple Diagnostic Imaging Cardiovascular Procedure Discount Factor – Technical Component -Highest Paid Service

cvtcdisc1 9(1)v9(4) 246 - 250

Multiple Diagnostic Imaging Cardiovascular Procedure Discount Factor – Technical Component - Not Highest Paid Service

cvtcdisc2 9(1)9(4) 251 - 255

Multiple Diagnostic Imaging Opthalmology Procedure Discount Factor – Technical Component -Highest Paid Service

ophtcdisc1 9(1)v9(4) 256 - 260

Multiple Diagnostic Imaging Opthalmology Procedure Discount Factor – Technical Component - Not Highest Paid Service

ophtcdisc2 9(1)v9(4) 261 - 265


esrd_reduc 9(1)v9(4) 266 - 270

Electronic Health Record Adjustment Factor ehr 9(1)v9(4) 271- 275Physician Quality Reporting Adjustment Factor

pqrs 9(1)v9(4) 276 - 280

Value-Based Payment Modifier Adjustment Factor

val_based 9(1)v9(4) 281 - 285


cttcreduc 9(1)v9(4) 286 - 290

X-Ray With Film Reduction Factor fx_reduc 9(1)v9(4) 291 - 295Ambulance Base Rate Reduction Factor - 2 Patients

amb_reduc2 9(1)v9(4) 296 - 300

Ambulance Base Rate Reduction Factor - > 2 Patients

amb_reduc3 9(1)v9(4) 301 - 305

Traditional Medicare Switch0 = Apply Medicare Advantage requirements 1 = Apply Medicare Fee-for-Service (FFS)

requirements

tradmed_sw 9(1) 306

Specialty Code spec_code X(2) 307 - 308Computed Radiography Reduction Factor fy_reduc 9(1)v9(4) 309 - 313Sequestration Factor seq_factor 9(1)v9(4) 314 - 318Closed Rate Record Flag closed_fac 9(1) 319Factor File Name fac_table X(13) 320 - 332




11.3.3 COBOL Platform11.3.4.1 Medicare Physician

Bypass Charge Cap0 = Apply charge cap1 = Bypass charge cap

bypass_chargecap

9(1) 333

Filler X(104) 334 - 437NMPRF Version Number version X(7) 438 - 444Filler - Payer Specific X(13) 445 - 457Filler X(38) 458 - 495

Table 11-30: Medicare Physician COBOL Rate Calculator Variables - hosp04.dat

Field Description Variable Name Format PositionConditional Bilateral Discount Factor

P3R-BILAT1 9(1)v9(4) 251 - 255

Independent Bilateral Discount Factor

P3R-BILAT2 9(1)v9(4) 256 - 260

Co-Surgery Discount Factor P3R-COSURG 9(1)v9(4) 261 - 265Assistant to Surgery Discount Factor

P3R-ASTSURG 9(1)v9(4) 266 - 270

Sanction/Preclusion Flag0 = Provider has not been

sanctioned or precluded1 = Provider has been sanctioned

by the OIG and is not eligible for Medicare reimbursement

2 = Provider has been precluded and is not eligible for Medicare reimbursement

3 = Provider has been precluded and/or sanctioned by the OIG and is not eligible for Medicare reimbursement

P3R-SANCTION 9(1) 271

Filler X(9) 272 - 280Multiple Surgical Procedure Discount Factor - Highest Paid Service

P3R-DISCOUNT1 9(1)v9(4) 281 - 285

Multiple Surgical Procedure Discount Factor - Second through Fifth Highest Paid Services

P3R-DISCOUNT2 9(1)v9(4) 286 - 290

Multiple Diagnostic Imaging Procedure Discount Factor - Technical Highest Paid Service

P3R-TCDISC1 9(1)v9(4) 291 - 295




Multiple Diagnostic Imaging Procedure Discount Factor - Technical Not Highest Paid Service

P3R-TCDISC2 9(1)v9(4) 296 - 300

Reasonable Charge Factor P3R-RCF 9(1)v9(4) 301 - 305Anesthesia Minutes (used for calculating Anesthesia Time Units)

P3R-ANESTHMIN 9(4) 306 - 309

Monitored Anesthesia Reduction Factor

P3R-ANESTHRED 9(1)v9(4) 310 - 314

Estimate Bonus Payments/Calculate MACRA QPP Adjustments0 = Do not estimate bonus

payments/calculate MACRA QPP adjustments for this provider

1 = Estimate bonus payments/calculate MACRA QPP adjustments for this provider

P3R-BONUS-REQ 9(1) 315

Primary Care Health Professional Shortage Area (HPSA) Bonus Payment Factor

P3R-PHPSA 9(1)v9(4) 316 - 320

Mental Health Professional Shortage Area (HPSA) Bonus Payment Factor

P3R-MHHPSA 9(1)v9(4) 321 - 325

HPSA Surgical Incentive Payment (HSIP) Factor

NoteThe HSIP program expired on December 31, 2015; therefore the HSIP Factor has been set to zero effective January 1, 2016.

P3R-HSIP 9(1)v9(4) 326 - 330

Primary Care Incentive Payment (PCIP) Factor

NoteThe PCIP program expired on December 31, 2015; therefore the PCIP Factor has been set to zero effective January 1, 2016.

P3R-PCIP 9(1)v9(4) 331 - 335




PCIP Eligibility1 = Provider is eligible for PCIP

bonus payments (i.e. primary care services accounted for 60% or more of the allowed Part B charges for this provider in a given time period)

0 = Provider is not eligible for PCIP bonus payments

NoteThe PCIP program expired on December 31, 2015; therefore the PCIP Eligibility field has been set to zero effective January 1, 2016.

P3R-PCIP-ELG 9(1) 336

Mental Health Limitation Factor P3R-MHLIM 9(1)v9(4) 337 - 341Markup/Discount Adjustment Factor

P3R-MARKUP 9(1)v9(4) 342 - 346

Fee Schedule Table P3R-FS-TBL X(13) 347 - 359Extended Fee Schedule Table P3R-FSEXT-TBL X(13) 360 - 372Ambulance Coverage Factor P3R-AMB-COV 9(1)v9(4) 373 - 377Ambulance Coinsurance Factor P3R-AMB-COINS 9(1)v9(4) 378 - 382Multiple Diagnostic Imaging Procedure Discount Factor – Professional Highest Paid Service

P3R-PCDISC1 9(1)v9(4) 383 - 387

Multiple Diagnostic Imaging Procedure Discount Factor – Professional Not Highest Paid Service

P3R-PCDISC2 9(1)v9(4) 388 - 392

Filler X(5) 393 - 397DMEPOS Coverage Factor P3R-DME-COV 9(1)v9(4) 398 - 402DMEPOS Coinsurance Factor P3R-DME-COINS 9(1)v9(4) 403 - 407Lab Coverage Factor P3R-LAB-COV 9(1)v9(4) 408 - 412Lab Coinsurance Factor P3R-LAB-COINS 9(1)v9(4) 413 - 417National Coverage Factor P3R-NATL-COV 9(1)v9(4) 418 - 422National Coinsurance Factor P3R-NATL-COINS 9(1)v9(4) 423 - 427Physician Fee Schedule Coverage Factor

P3R-PFS-COV 9(1)v9(4) 428 - 432

Physician Fee Schedule Coinsurance Factor

P3R-PFS-COINS 9(1)v9(4) 433 - 437

Other Coverage Factor P3R-OTH-COV 9(1)v9(4) 438 - 442Other Coinsurance Factor P3R-OTH-COINS 9(1)v9(4) 443 - 447




Multiple Diagnostic Imaging Cardiovascular Procedure Discount Factor – Technical Component -Highest Paid Service

P3R-CVTCDISC1 9(1)v9(4) 448 - 452

Multiple Diagnostic Imaging Cardiovascular Procedure Discount Factor – Technical Component - Not Highest Paid Service

P3R-CVTCDISC2 9(1)v9(4) 453 - 457

Multiple Diagnostic Imaging Opthalmology Procedure Discount Factor – Technical Component -Highest Paid Service

P3R-OPHTCDISC1 9(1)v9(4) 458 - 462

Multiple Diagnostic Imaging Opthalmology Procedure Discount Factor – Technical Component - Not Highest Paid Service

P3R-OPHTCDISC2 9(1)v9(4) 463 - 467


P3R-ESRD-REDUC 9(1)v9(4) 468 - 472

Electronic Health Record Adjustment Factor

P3R-EHR 9(1)v9(4) 473 - 477

Physician Quality Reporting Adjustment Factor

P3R-PQRS 9(1)v9(4) 478 - 482

Value-Based Payment Modifier Adjustment Factor

P3R-VAL-BASED 9(1)v9(4) 483 - 487

CT Reduction Factor P3R-CTTCREDUC 9(1)v9(4) 488 - 492X-Ray With Film Reduction Factor P3R-FX-REDUC 9(1)v9(4) 493 - 497Ambulance Base Rate Reduction Factor - 2 Patients

P3R-AMB-REDUC2 9(1)v9(4) 498 - 502

Ambulance Base Rate Reduction Factor - > 2 Patients

P3R-AMB-REDUC3 9(1)v9(4) 503 - 507


requirements 1 = Apply Medicare Fee-for-

Service (FFS) requirements

P3R-TRADMED-SW 9(1) 508

Specialty Code P3R-SPEC-CODE X(2) 509 - 510Computed Radiography Reduction Factor

P3R-FY-REDUC 9(1)v9(4) 511 - 515

Sequestration Factor P3R-SEQ-FACTOR 9(1)v9(4) 516 - 520Closed Rate Record Flag P3R-CLOSED-FAC 9(1) 521Factor File Name P3R-FAC-TABLE X(13) 522 - 534Bypass Charge Cap0 = Apply charge cap1 = Bypass charge cap

P3R-BYPASS-CHARGECAP

9(1) 535




Filler X(258) 536 - 793NMPRF Version Number P3R-VERSION X(7) 794 - 800




12 Medicaid Hospital Rate Calculator File Layouts

This chapter provides the layouts for the Medicaid Hospital Rate Calculator Files. This chapter includes the following sections:


- Arizona Medicaid- California Medicaid- Florida Medicaid- Georgia Medicaid- Illinois Medicaid- Illinois Medicaid APR- Indiana Medicaid APR- Iowa Medicaid- Kansas Medicaid- Kentucky Medicaid- Michigan Medicaid APR- Nebraska Medicaid- Nebraska Medicaid APR- New Jersey Medicaid- New Mexico Medicaid- New York Medicaid APR- North Carolina Medicaid- Ohio Medicaid- Ohio Medicaid APR- Pennsylvania Medicaid- Pennsylvania Medicaid APR- South Carolina Medicaid- Texas Medicaid- Virginia Medicaid & Virginia Medicaid APR- Washington Healthcare Authority Case-Based- Washington Healthcare Authority Non Case-Based- Washington Medicaid- Washington Medicaid APR


- Wisconsin Medicaid- COBOL Platform

- New Jersey Medicaid- Pennsylvania Medicaid- Washington Healthcare Authority Case-Based- Washington Healthcare Authority Non Case-Based

• Outpatient Layouts- Illinois Medicaid APG- New Mexico Medicaid APC- New York Medicaid APG (effective October 01, 2019)- New York Medicaid APG (prior to October 01, 2019)- Virginia Medicaid APG- Washington Medicaid APG- Wisconsin Medicaid APG



12.1.2.1 Arizona Medicaid

12.1.3.2 California Medicaid

Table 12-1: Arizona Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionDRG Standardized Base Rate base 9(8)v9(2) 39 - 48Hospital-Specific Cost-to-Charge Ratio rcc 9(1)v9(4) 49 - 53Hold Harmless Adjustor Factor hold 9(1)v9(4) 54 - 58Markup/Discount Adjustment Factor markup 9(1)v9(4) 59 - 63Provider Payment Adjustor provadj 9(1)v9(4) 64 - 68Cost Outlier Threshold cot 9(8)v9(2) 69 - 78Age Cut-Off for Age Policy Adjustor cutage 9(3) 79 - 81Interim Claim Minimum Length of Stay icminlos 9(4) 82 - 85Interim Claim Per Diem Payment icpay 9(8)v9(2) 86 - 95Hospital Type0 = All Other1 = Long Term Acute Care2 = Rehabilitation3 = Psychiatric

type 9(1) 96

Long Term Acute Care Per Diem Amount ltpd 9(8)v9(2) 97 - 106Rehabilitation Per Diem Amount rpd 9(8)v9(2) 107 - 116Psychiatric Per Diem Amount pspd 9(8)v9(2) 117 - 126Outlier RCC outrcc 9(1)v9(5) 127 - 132Filler X(305) 133 - 437

Table 12-2: California Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionDRG Standardized Base Rate base 9(8)v9(2) 39 - 48Hospital-Specific Cost-to-Charge Ratio rcc 9(1)v9(5) 49 - 54Age Cut-Off For Age Policy Adjustor cutage 9(3) 55 - 57Case-Mix Adjustment Factor casemix 9(1)v9(5) 58 - 63Interim Day Threshold intday 9(4) 64 - 67Interim Claim Per Diem intdiem 9(8)v9(2) 68 - 771st Cost Outlier Threshold cot1 9(8)v9(2) 78 - 87


12.1.4.3 Florida Medicaid

2nd Cost Outlier Threshold

NoteEffective July 01, 2017, outlier payments are calculated using a single cost outlier threshold.

cot2 9(8)v9(2) 88 - 97

1st Marginal Cost Percentage mcf1 9(1)v9(5) 98 - 1032nd Marginal Cost Percentage

NoteEffective July 01, 2017, outlier payments are calculated using a single marginal cost percentage.

mcf2 9(1)v9(5) 104 - 109

Low Cost Outlier Threshold lowcot1 9(8)v9(2) 110 - 119Neonatal Intensive Care Unit nicu 9(1) 120Rehabilitation Per Diem Rules rehabrule 9(1) 121Rehabilitation Per Diem rehab 9(8)v9(2) 122 - 131Markup/Discount Adjustment Factor markup 9(1)v9(5) 132 - 137Obstetrics Policy Adjustor obadj 9(1)v9(4) 138 - 142Filler X(295) 143 - 437

Table 12-3: Florida Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionDRG Standardized Base Rate base 9(8)v9(2) 39 - 48Hospital-Specific Cost-to-Charge Ratio rcc 9(1)v9(5) 49 - 54Age Cut-Off For Age Policy Adjustor cutage 9(3) 55 - 57Case-Mix Adjustment Factor casemix 9(1)v9(5) 58 - 63Hospital Case-Mix hmix 9(1)v9(5) 64 - 69Hospital Category1 = All Other2 = Rural3 = LTAC4 = Medicaid Utilization and High Outlier

Payment

provcat 9(1) 70

Provider Adjustor provadj 9(1)v9(5) 71 - 76Hospital Average Per Discharge Self-Funded IGT Add-On Payment

sfitgf 9(8)v9(2) 77 - 86

Hospital Average Per Discharge Automatic IGT Add-On Payment

aitgf 9(8)v9(2) 97 - 106

Cost Outlier Threshold cot 9(8)v9(2) 97 - 106Marginal Cost Percentage mcf 9(1)v9(5) 107 - 112

Table 12-2: California Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.5.4 Georgia Medicaid

12.1.6.5 Illinois Medicaid

Markup/Discount Adjustment Factor markup 9(1)v9(5) 113 - 118Trauma Payment Percentage trauma 9(1)v9(4) 119 - 123Marginal Cost Factor 2 mcf2 9(1)v9(4) 124 -128Filler X(309) 129 - 437

Table 12-4: Georgia Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(7) 39 - 45Hospital Base Rate base 9(8)v9(2) 46 - 55Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 56 - 60Marginal Cost Factor mcf 9(1)v9(4) 61 - 65Transfer Payment Flag trans_flag X(1) 66Cost Outlier Payment Flag outl_flag X(1) 67Capital Add-On cappaddon 9(8)v9(2) 68 - 77Graduate Medical Education (GME) Add-On gmeaddon 9(8)v9(2) 78 - 87Markup/Discount Adjustment Factor markup 9(1)v9(5) 88 - 93Newborn Add-On newbornaddon 9(8)v9(2) 94 - 103Newborn Add-On for Rural Hospitals nwbrnruraladdon 9(8)v9(2) 104 - 113

Provider Payment Act Factor ppa_factor 9(1)v9(4) 114 - 118

Filler X(319) 119 - 437

Table 12-5: Illinois Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionTotal Base Rate blend 9(5)v9(2) 39 - 45Federal Rate fwa 9(5)v9(2) 46 - 52Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 53 - 57IME Adjustment Factor (must be 1.0 or greater; default to 1.0)

imea 9(1)v9(6) 58 - 64

Transfer-in Adjustment Factor transfac 9(1)v9(4) 65 - 69Marginal Cost Factor for LOS Outliers mcfl 9(1)v9(2) 70 - 72Hospital Specific Cost Outlier Threshold cot 9(5)v9(2) 73 - 79Cost Outlier Factor cof 9(1)v9(2) 80 - 82Marginal Cost Factor for Non-Burn Cost Outliers mcfc 9(1)v9(2) 83 - 85

Table 12-3: Florida Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.7.6 Illinois Medicaid APR

Marginal Cost Factor for Burns Cost Outliers mcfbc 9(1)v9(2) 86 - 88Capital Add-on cap 9(4)v9(2) 89 - 94Direct Medical Education Add-on meded 9(4)v9(2) 95 - 100Disproportionate Share Hospital Add-on dsh 9(4)v9(2) 101 - 106Medicaid High Volume Add-on mhva 9(4)v9(2) 107 - 112Non-Physician Anesthesia Add-on crna 9(4)v9(2) 113 - 118Level III Perinatal Center Indicator 0 = Hospital does not have center 1 = Hospital has Level III perinatal center

perinatal 9(1) 119

Medicaid Percentage Adjustment medpercent 9(8)v9(2) 120 - 129Mark-up/Discount Factor markup 9(1)v9(4) 130 - 134HAC Reduction Amount hacra 9(8)v9(2) 135 - 144Potentially Preventable Readmission (PPR) Reduction Factor

red_fact 9(1)v9(6) 145 - 151

Provider Rate Reductions (PRR) Factor prr_fact 9(1)v9(4) 152 - 156Filler X(281) 157 - 437

Table 12-6: Illinois Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFacility Type0 = All others1 = Level II, II+, or III perinatal hospital2 = Safety net hospital not designated as a

children’s hospital 3 = Meets the criteria for both facility types 1

& 2

fac_type 9(1) 39

Base Rate baserate 9(8)v9(2) 40 - 49Medicaid High Volume Add-On (MHVA) mhva 9(8)v9(2) 50 - 59Trauma Policy Adjustor trauma_adjustor 9(1)v9(4) 60 - 64Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 65 - 69Fixed Loss Threshold threshold 9(8)v9(2) 70 - 79SOI of 1 Adjustment Factor soi1_adjust_fact 9(1)v9(4) 80 - 84SOI of 2 Adjustment Factor soi2_adjust_fact 9(1)v9(4) 85 - 89SOI of 3 Adjustment Factor soi3_adjust_fact 9(1)v9(4) 90 - 94SOI of 4 Adjustment Factor soi4_adjust_fact 9(1)v9(4) 95 - 99Rate Reduction Factor rate_reduct_fact 9(1)v9(4) 100 - 104Potentially Preventable Readmission (PPR) Reduction Factor

ppr_fact 9(1)v9(4) 105 - 109

Markup/Discount Factor markup 9(1)v9(4) 110 - 114Safety Net Hospital Add-On snh_addon 9(8)v9(2) 115 - 124

Table 12-5: Illinois Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.8.7 Indiana Medicaid APR

12.1.9.8 Iowa Medicaid

Medicaid Percentage Adjustment mpa 9(8)v9(2) 125 - 134Filler X(303) 135 - 437

Table 12-7: Indiana Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate base 9(8)v9(2) 39 - 48Psychiatric Per Diem psychdiem 9(8)v9(2) 49 - 58Rehabilitation Per Diem rehabdiem 9(8)v9(2) 59 - 68Burn Per Diem burndiem 9(8)v9(2) 69 - 78Capital Per Diem capdiem 9(8)v9(2) 79 - 88Medical Education Per Diem meddiem 9(8)v9(2) 89 - 98Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 99 - 103Cost Outlier Threshold cot 9(8)v9(2) 104 - 113Marginal Cost Factor mcf 9(1)v9(2) 114 - 116Markup/Discount Adjustment Factor markup 9(1)v9(4) 117 - 121Lesser of Charges or Allowed Amount Flag 0 = Apply Lesser of Charges or Allowed Amount Logic1 = Do Not Apply Lesser of Charges or Allowed

Amount Logic

lesser_flg 9(1) 122

Filler X(315) 123 - 437

Table 12-8: Iowa Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variables Name Format PositionFacility Type0 = Acute care facility1 = Critical access hospital2 = Neonatal level 2 facility3 = Neonatal level 3 facility4 = Swing bed unit

fac_type 9(1) 39

Hospital Base Rate base 9(8)v9(2) 40 - 49Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(7) 50 - 57Markup/Discount Adjustment Factor markup 9(1)v9(5) 58 - 63Statewide Average DRG Rate statewide_base 9(8)v9(2) 64 - 73Cost Threshold cost_threshold 9(8)v9(2) 74 - 83Statewide Outlier Factor outlier_factor 9(1)v9(4) 84 - 88Marginal Cost Factor mcf 9(1)v9(4) 89 - 93

Table 12-6: Illinois Medicaid APR Hospital Rate Calculator Variables - medcalc.dat



12.1.10.9 Kansas Medicaid

12.1.11.10 Kentucky Medicaid

Long Stay Marginal Cost Factor long_mcf 9(1)v9(4) 94 - 98Short Stay Marginal Cost Factor short_mcf 9(1)v9(4) 99 - 103Swing Bed Per Diem swingbed_perdiem 9(8)v9(2) 104 - 113Filler X(324) 114 - 437

Table 12-9: Kansas Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFacility Type0 = Acute care facility1 = Border city children’s hospital

fac_type 9(1) 39

Hospital Base Rate base 9(8)v9(2) 40 - 49Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(7) 50 - 57Filler X(8) 58 - 65Cost Outlier Adjustment Factor cotadj 9(1)v9(2) 66 - 68Day Outlier Adjustment Factor dayadj 9(1)v9(2) 69 - 71Markup/Discount Adjustment Factor markup 9(1)v9(5) 72 - 77Graduate Medical Education (GME) Adjustment FactorCritical Access Hospital (CAH) Adjustment Factor

cah_adj 9(2)v9(4) 85 - 90

Extended Cost Outlier Adjustment Factor cotadj_ext 9(1)v9(4) 91 - 95Extended Day Outlier Adjustment Factor dayadj_ext 9(1)v9(4) 96 - 100Reduction Factor red_fact 9(1)v9(4) 101 - 105Filler X(332) 106 - 437

Table 12-10: Kentucky Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate base 9(8)v9(2) 39 - 48Operating Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 49 - 53Operating Indirect Medical Education (IME) Factor

ime 9(1)v9(9) 54 - 63

Capital IME Factor cime 9(1)v9(9) 64 - 73Marginal Cost Factor: Cost Outliers mcfc 9(1)v9(4) 74 - 78Markup/Discount Adjustment Factor markup 9(1)v9(4) 79 - 83Capital Base Rate cbase 9(8)v9(2) 84 - 93Capital Ratio of Cost-to-Charges (RCC) crcc 9(1)v9(4) 94 - 98

Table 12-8: Iowa Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variables Name Format Position


12.1.12.11 Michigan Medicaid APR

Critical Access Hospital Per Diem cahpd 9(8)v9(2) 99 - 108Psychiatric Per Diem psypd 9(8)v9(2) 109 - 118Rehabilitation Per Diem rehabpd 9(8)v9(2) 119 - 128Long Term Acute Care Hospital Per Diem ltcpd 9(8)v9(2) 129 - 138Cost Threshold cot 9(8)v9(2) 139 - 148Nursery Level No longer utilized, effective October 1, 2015.

nurslev X(1) 149

Facility Type: 00 = Acute care hospital 01 = Critical Access Hospital (CAH) 02 = Psychiatric hospital or Distinct Part Unit

(DPU) 03 = Rehabilitation hospital or DPU 04 = Long term acute care hospital

facttype X(2) 150 - 151

Medicaid High Volume Per Diem

NoteNo longer utilized, effective October 01, 2015.

hvpd 9(8)v9(2) 152 - 161

Transplant Payment Percentage


transpct 9(1)v9(4) 162 - 166

Transplant Payment Maximum


transmax 9(8)v9(2) 167 - 176

Marginal Cost Factor 2 mcfc2 9(1)v9(4) 177 - 181Kentucky Medicaid Adjustment Factor kadj 9(1)v9(4) 182 - 186COVID-19 DRG Weight Factor covid_fact 9(1)v9(4) 187 - 191Filler X(246) 192 - 437

Table 12-11: Michigan Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate hosp_rate 9(5)v9(2) 39 - 45Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 46 - 50Indirect Medical Education (IME) Adjustment Factor

ime_adjustor 9(1)v9(6) 51 - 57

Daily Rate Factor daily_rate_factor 9(1)v9(2) 58 - 60Max Cost Threshold max_cost_thresh 9(6)v9(2) 61 - 68

Table 12-10: Kentucky Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.13.12 Nebraska Medicaid

Cost Outlier Factor cost_outlier_factor 9(1)v9(2) 69 - 71NICU Accreditation Indicator nicu_ind 9(1) 72Hospital Capital Rate Per Discharge hosp_capital 9(5)v9(2) 73 - 79Markup/Discount Adjustment Factor hosp_markup 9(1)v9(5) 80 - 85Hospital Short Stay Rate hss_rate 9(8)v9(2) 86 - 95Filler X(342) 96 - 437

Table 12-12: Nebraska Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(7) 39 - 45Hospital Base Rate base 9(8)v9(2) 46 - 55Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 56 - 60Cost Outlier Threshold thresh 9(8)v9(2) 61 - 70 Marginal Cost Factor: Other mcf 9(1)v9(4) 71 - 75Marginal Cost Factor: Burns mcf_burn 9(1)v9(4) 76 - 80Capital Per Diem capital_diem 9(8)v9(2) 81 - 90Subspecialty Care Unit Flag subs_flag X(1) 91Direct Medical Education (DME) Add-On dme 9(8)v9(2) 92 - 101Indirect Medical Education (IME) Adjustment Factor

ime 9(1)v9(6) 102 - 108

Markup/Discount Adjustment Factor markup 9(1)v9(4) 109 - 113Psychiatric Per Diem: Tier 1 psych_diem 9(8)v9(2) 114 - 123Rehabilitation Per Diem rehab_diem 9(8)v9(2) 124 - 133Critical Access Cost-based Per Diem cah_diem 9(8)v9(2) 134 - 143Critical Access Facility Flag cah_flag X(1) 144Psychiatric Per Diem: Tier 2 psych_diem2 9(8)v9(2) 145 - 154Psychiatric Per Diem: Tier 3 psych_diem3 9(8)v9(2) 155 - 164Psychiatric Per Diem: Tier 4 psych_diem4 9(8)v9(2) 165 - 174RCC for Unstable DRGs rcc_unstable 9(1)v9(4) 175 - 179RCC for Transplant DRGs rcc_transplant 9(1)v9(4) 180 - 184DME Add-on for Unstable DRGs dme_unstable 9(8)v9(2) 185 - 194DME Add-on for Transplant DRGs dme_transplant 9(8)v9(2) 195 - 204Filler X(233) 205 - 437

Table 12-11: Michigan Medicaid APR Hospital Rate Calculator Variables - medcalc.dat



12.1.14.13 Nebraska Medicaid APR

12.1.15.14 New Jersey Medicaid

Table 12-13: Nebraska Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionPayer Type payer_type X(1) 39Filler X(6) 40 - 45Hospital Base Rate base 9(8)v9(2) 46 - 55Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 56 - 60Ratio of Cost-to-Charges: Transplants rcc_transplant 9(1)v9(4) 61 - 65Filler X(25) 66 - 90Marginal Cost Factor: Other mcf 9(1)v9(4) 91 - 95Marginal Cost Factor: Burns mcf_burn 9(1)v9(4) 96 - 100Capital Per Diem capital_diem 9(8)v9(2) 101 - 110Filler X(1) 111Direct Medical Education (DME) Add-On dme 9(8)v9(2) 112 - 121Indirect Medical Education (IME) Adjustment Factor

ime 9(1)v9(6) 122 - 128

Markup/Discount Adjustment Factor markup 9(1)v9(4) 129 - 133Psychiatric Per Diem: Tier 1 psych_diem 9(8)v9(2) 134 - 143Rehabilitation Per Diem rehab_diem 9(8)v9(2) 144 - 153Critical Access Cost-Based Per Diem cah_diem 9(8)v9(2) 154 - 163Critical Access Facility Flag cah_flag X(1) 164Psychiatric Per Diem: Tier 2 psych_diem2 9(8)v9(2) 165 - 174Psychiatric Per Diem: Tier 3 psych_diem3 9(8)v9(2) 175 - 184Psychiatric Per Diem: Tier 4 psych_diem4 9(8)v9(2) 185 - 194DME Add-on for Transplant DRGs dme_transplant 9(8)v9(2) 195 - 204Filler X(233) 205 - 437

Table 12-14: New Jersey Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller 9(217) 39 - 255Hospital Base Rate base_rate 9(8)v9(2) 256 - 265Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 266 - 270Marginal Cost Factor mcf 9(1)v9(4) 271 - 275Markup/Discount Factor markup 9(1)v9(4) 276 - 280Annual Nursing Facility Per Diem nfpd 9(8)v9(2) 281 - 290Ratio of Cost-to-Charges (RCC) - New rcc_new 9(1)v9(5) 291 - 296Critical Service Add-On Percentage cs_adj 9(1)v9(4) 297 - 301Filler X(136) 302 - 437


12.1.16.15 New Mexico Medicaid

12.1.17.16 New York Medicaid APR

Table 12-15: New Mexico Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(7) 39 - 45Hospital Base Rate base_rate 9(8)v9(2) 46 - 55Hospital Capital Rate cap_rate 9(8)v9(2) 56 - 65Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 66 - 70Marginal Cost Factor mcf 9(1)v9(4) 71 - 75Cost Outlier Threshold cot_thresh 9(8)v9(2) 76 - 85LOS Outlier Threshold los_thresh 9(3) 86 - 88Disproportionate Share Hospital Flag dsh_flag 9(1) 89Markup/Discount Adjustment Factor markup 9(1)v9(4) 90 - 94Outlier Flag out_flag 9(1) 95Transfer Flag trfer_flag 9(1) 96COVID-19 Adjustment for All Other Services covid_adj 9(1)v9(4) 97 - 101COVID-19 Adjustment for Intensive Care Unit (ICU) Services

covid_icu 9(1)v9(4) 102 - 106

Filler X(331) 107 - 437

Table 12-16: New York Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(7) 39 - 45Hospital Base Rate base_rate 9(8)v9(2) 46 - 55Capital and Non-Comparable Per Discharge Add-on

capital 9(8)v9(2) 56 - 65

Ratio Of Cost-to-Charges (RCC) (old) rcc 9(1)v9(4) 66 - 70Marginal Cost Factor mcf 9(1)v9(4) 71 - 75Direct Medical Education (DME) Per Discharge dme 9(8)v9(2) 76 - 85Wage Equalization Factor (WEF) wef 9(1)v9(4) 86 - 90Indirect Medical Education (IME) Factor ime 9(1)v9(8) 91 - 99Markup/Discount Adjustment Factor markup 9(1)v9(4) 100 - 104Non-Comparable Per Discharge Add-on noncomp 9(8)v9(2) 105 - 114Payment Type:1 = Medicaid managed care including rebasing2 = Workers’ compensation3 = No fault4 = Medicaid managed care excluding rebasing5 = Fee-for-service6 = Medicaid managed care including GME

payments

paytype 9(1) 115


12.1.18.17 North Carolina Medicaid

Return Code 24 Override0 = Do Not Override Return Code 241 = Override Return Code 24

override_rc24 9(1) 116

Pay Acute Care and Alternate Level of Care (ALC) Days Together0 = Do not pay acute care and ALC days together1 = Pay acute care and ALC days together

split_bill 9(1) 117

Filler X(1) 118Transfer Payment Factor xfer 9(1)v9(4) 119 - 123Transition Per Discharge Add-on transition 9(8)v9(2) 124 - 133Exempt Flag (Reserved) 1 = Exempt Pricing

exempt 9(1) 134

Exempt Per Diem Rate (Reserved) ex_perdiem 9(8)v9(2) 135 - 144SPARCS Allowable Amount sparcs 9(8)v9(2) 145 - 154Capital and Non-Comparable Per Diem cap_perdiem 9(8)v9(2) 155 - 164Alternate Level Of Care Per Diem Rate alcrate 9(8)v9(2) 165 - 174Ratio of Cost-to-Charges (new) rcc_new 9(1)v9(6) 175 - 181Cost Outlier Payment Flag0 = Cost outlier payment applied1 = Cost outlier payment not applied

costflag 9(1) 182

Spinal Implantable Device Percent imp_per 9(1)v9(4) 183 - 187Maximum Spinal Implantable Device Payment max_imp 9(8)v9(2) 188 - 197Spinal Implantable Device Payment Flag0 = Spinal implantable device payment not

requested1 = Spinal implantable device payment requested

imp_flag 9(1) 198

Elective Delivery Adjustment elect_del 9(1)v9(4) 199 - 203Negative Capital and Non-Comparable Per Discharge Add-on

neg_capital 9(8)v9(2) 204 - 213

Negative Capital and Non-Comparable Per Diem neg_cap_perdiem 9(8)v9(2) 214 - 223Filler X(214) 224 - 437

Table 12-17: North Carolina Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Unit Value unit 9(5)v9(2) 39 - 45Per Diem Rate (prior to December 1, 1995) per_diem 9(4)v9(2) 46 - 51Psychiatric Per Diem pd_psych 9(4)v9(2) 52 - 57Rehabilitation Per Diem pd_rehab 9(4)v9(2) 58 - 63Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 64 - 68

Table 12-16: New York Medicaid APR Hospital Rate Calculator Variables - medcalc.dat



12.1.19.18 Ohio Medicaid

Indirect Medical Education (IME) Adjustment Factor

imea 9(1)v9(6) 69 - 75

Direct Medical Education Adjustment (DME) Factor

meded 9(1)v9(6) 76 - 82

Disproportionate Share Adjustment Factor dshare 9(1)v9(6) 83 - 89Marginal Cost Factor: LOS Outliers mcfl 9(1)v9(2) 90 - 92Cost Outlier Threshold cot 9(5)v9(2) 93 - 99Marginal Cost Factor: Cost Outliers mcfc 9(1)v9(2) 100 - 102Markup/Discount Adjustment Factor markup 9(1)v9(4) 103 - 107Division of Medical Assistance Inpatient Reduction

dma_reduc 9(1)v9(4) 108 - 112

Facility Type0 = All others1 = Disproportionate Share Hospitals (DSHs)

fac_type 9(1) 113

Filler X(324) 114 - 437

Table 12-18: Ohio Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate base 9(6)v9(2) 39 - 46Capital Add-on capadd 9(6)v9(2) 47 - 54Medical Education Allowance edallow 9(6)v9(2) 55 - 62Hospital with High Percentage of Outliers (1 = yes)

outlhosp 9(1) 63

Hospital with High Percentage of Medicaid, General Assistance and Title V Days (1 = yes)

dshhosp 9(1) 64

Hospital with High Percentage of HIV Patients hivhosp 9(1) 65Length of Stay Outlier Percentage for Exceptions exc_los% 9(1)v9(4) 66 - 70Length of Stay Outlier Percentage for Non-exceptions

oth_los% 9(1)v9(4) 71 - 75

Cost Outlier Percentage for Exceptions exc_cost% 9(1)v9(4) 76 - 80Cost Outlier Percentage for Non-exceptions oth_cost% 9(1)v9(4) 81 - 85Cost Outlier Percentage for Babies baby_cost% 9(1)v9(4) 86 - 90Ratio of Cost-to-Charges (RCC) hosp_rcc 9(1)v9(6) 91 - 97Threshold for Excessive Costs threshold 9(6)v9(2) 98 - 105Markup/Discount Adjustment Factor markup 9(1)v9(5) 106 - 111Psychiatric Distinct Part Unit psycunit X(1) 112 - 112Nursery Level nurslev 9(1) 113 - 113Filler X(323) 114 - 437

Table 12-17: North Carolina Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.20.19 Ohio Medicaid APR

12.1.21.20 Pennsylvania Medicaid

12.1.22.21 Pennsylvania Medicaid APR

Table 12-19: Ohio Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate baserate 9(8)v9(2) 39 - 48Medical Education Rate mededrate 9(8)v9(2) 49 - 58Capital Rate capital 9(8)v9(2) 59 - 68Ratio of Cost-to-Charges rcc 9(1)v9(4) 69 - 73Outlier Threshold

Note: Major teaching (peer group 9), and children’s hospitals have a different Outlier Threshold than all other hospitals.

outthresh 9(8)v9(2) 74 - 83

Marginal Cost Factor mcf 9(1)v9(4) 84 - 88Mark-up/Discount Factor markup 9(1)v9(4) 89 - 93Facility Type fac_type 9(1) 94Filler X(343) 95 - 437

Table 12-20: Pennsylvania Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate pbaser 9(5)v9(2) 39 - 45Ratio of Cost-to-Charges (RCC) prcc 9(1)v9(4) 46 - 50Marginal Cost Factor: LOS Outliers pmcfl 9(1)v9(2) 51 - 53Marginal Cost Factor: Cost Outliers pmcfc 9(1)v9(2) 54 - 56Marginal Cost Factor: Transfers mcft 9(1)v9(4) 57 - 61Markup/Discount Adjustment Factor markup 9(1)v9(5) 62 - 67Filler X(370) 68 - 437

Table 12-21: Pennsylvania Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital DRG Base Rate base 9(8)v9(2) 39 - 48Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 49 - 53Markup/Discount Adjustment Factor markup 9(1)v9(5) 54 - 59Detox Flag detox 9(1) 60 Standard Outlier Percentage out_perc 9(1)v9(4) 61 - 65High Outlier Percentage highout_perc 9(1)v9(4) 66-70


12.1.23.22 South Carolina Medicaid

12.1.24.23 Texas Medicaid

Payment Type1 = Fee for Service2 = Managed Care

paytype 9(1) 71

Low-Cost Outlier Threshold l_threshold 9(8)v9(2) 72 - 81Filler X(356) 82 - 437

Table 12-22: South Carolina Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionDRG Discharge Rate baserate 9(8)v9(2) 39 – 48Ratio of Cost-to-Charges rcc 9(1)v9(4) 49 – 53Same Day Stay Factor sdsf 9(1)v9(4) 54 - 58Marginal Cost Factor mcf 9(1)v9(4) 59 – 63Mark-up/Discount Factor markup 9(1)v9(4) 64 – 68Filler X(369) 69 – 437

Table 12-23: Texas Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionStandard Dollar Amount sda 9(5)v9(2) 39 - 45LOS Cutoff for Transfer Calculations tlos 9(4) 46 - 49Marginal Cost Factor: LOS Outlier lmcf 9(1)v9(2) 50 - 52Marginal Cost Factor: Cost Outlier cmcf 9(1)v9(2) 53 - 55Cost Outlier Factor: Per Case Threshold dfactor 9(2)v9(2) 56 - 59Cost Outlier Factor: Universal Mean Threshold ufactor 9(2)v9(2) 60 - 63Cost Outlier Factor: Hospital Threshold hfactor 9(2)v9(2) 64 - 67Universal Mean umean 9(5)v9(2) 68 - 74Cost Outlier Reimbursement Rate rcc 9(1)v9(2) 75 - 77LoneSTAR Select I Discount discount 9(1)v9(2) 78 - 80Markup/Discount Adjustment Factor markup 9(1)v9(4) 81 - 85Potentially Preventable Readmission (PPR) Reduction Factor

red_fact 9(1)v9(4) 86 - 90

Hospital Type htype 9(1) 91Outlier Reduction Factor outlier_rf 9(1)v9(2) 92 - 94Children’s Hospital Adult Delivery SDA aobdel_sda 9(5)v9(2) 95 - 101

Table 12-21: Pennsylvania Medicaid APR Hospital Rate Calculator Variables - medcalc.dat



12.1.25.24 Virginia Medicaid & Virginia Medicaid APR

12.1.26.25 Washington Healthcare Authority Case-Based

Potentially Preventable Complications (PPC) Reduction Factor

ppc_fact 9(1)v9(4) 102 - 106

Neonatal Designation0 = Hospital does not have a neonatal level of

care designation1 = Hospital has a neonatal level of care

designation or is exempt from needing a neonatal level of care designation

nloc_flag 9(1) 107

Rural Hospital Delivery SDA rhdel_sda 9(8)v9(2) 108 - 117Filler X(320) 118 - 437

Table 12-24: Virginia Medicaid & Virginia Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionOperating Hospital Base Rate rate 9(5)v9(2) 39 - 45Wage Index wi 9(1)v9(5) 46 - 51Psychiatric Per Diem pd_psych 9(4)v9(2) 52 - 57Rehabilitation Per Diem pd_rehab 9(4)v9(2) 58 - 63Operating Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 64 - 68Capital Adjustment Factor capital 9(1)v9(6) 69 - 75DRG Adjustment Factor drgadjust 9(1)v9(6) 76 - 82Labor Portion labor 9(1)v9(6) 83 - 89Filler X(3) 90 - 92Cost Outlier Threshold cot 9(5)v9(2) 93 - 99Marginal Cost Factor: Cost Outlier mcfc 9(1)v9(2) 100-102Markup/Discount Adjustment Factor markup 9(1)v9(5) 103 - 108Filler X(329) 109 - 437

Table 12-25: Washington Healthcare Authority Case-Based Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(27) 39 - 65Labor Market Adjustment Factor lma 9(1)v9(4) 66 - 70Indirect Medical Education (IME) Adjustment Factor

ime 9(1)v9(4) 71 - 75

Disproportionate Share Hospital (DSH) Adjustment Factor

dsh 9(1)v9(4) 76 - 80

Table 12-23: Texas Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.27.26 Washington Healthcare Authority Non Case-Based

Uncompensated Care Percent unc 9(1)v9(4) 81 - 85Contribution to Margin, Plus Adjustment for the Effects of Recession

mrg 9(1)v9(4) 86 - 90

Physician Participation Bonus pbns 9(1)v9(4) 91 - 95Adjusted Direct Medical Education (DME) Cost Per Case Add-on

dmepc 9(4)v9(2) 96 - 101

Adjusted DME Cost Per Day Add-on dmepd 9(4)v9(2) 102 - 107CMI-adjusted Capital Cost Per Case cappc 9(4)v9(2) 108 - 113Capital Costs Per Day: Psychiatric cappdp 9(4)v9(2) 114 - 119Capital Cost Per Day: Substance Abuse cappds 9(4)v9(2) 120 - 125Capital Costs Per Day: Rehabilitation cappdr 9(4)v9(2) 126 - 131Effective Percent of Charges epoc 9(1)v9(4) 132 - 136Cost Outlier Factor/Multiplier factor 9(1)v9(2) 137 - 139Minimum Cost Outlier Threshold threshmin 9(5)v9(2) 140 - 146Operating Cost Per Diem, Day 1: Psychiatric pdp1 9(4)v9(2) 147 - 152Operating Cost Per Diem, Day 2+: Psychiatric pdp2 9(4)v9(2) 153 - 158Operating Cost Per Diem, Day 1: Substance Abuse

pdsa1 9(4)v9(2) 159 - 164

Operating Cost Per Diem, Day 2+: Substance Abuse

pdsa2 9(4)v9(2) 165 - 170

Operating Cost Per Diem, Day 1: Rehabilitation pdr 9(4)v9(2) 171 - 176Filler X(19) 177 - 195Operating Cost Per Diem, Day 2+: Rehabilitation pdr2 9(4)v9(2) 196 - 201Filler X(84) 202 - 285Base Rate for Per Case Payments pc 9(5)v9(2) 286 - 292Markup/Discount Adjustment Factor markup 9(1)v9(5) 293 - 298Filler X(139) 299 - 437

Table 12-26: Washington Healthcare Authority Non Case-Based Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(27) 39 - 65Payment Strategy to be Applied 01 = All inclusive per diem 02 = Per diems for medical/surgical DRGs 03 = Percent of charges

ex_paystrat 9(2) 66 - 67

Table 12-25: Washington Healthcare Authority Case-Based Hospital Rate Calculator Variables - medcalc.dat



All-Inclusive Operating Cost Per Diem - For Rural Hospitals, the rural hospital all-inclusive operating cost per diem. - For Children’s Hospitals, the hospital-specific all-inclusive operating cost per diem.

ex_pd 9(4)v9(2) 68 - 73

Operating Cost Per Diem for Medical DRGs - For Rural Hospitals, the rural hospital operating cost per diem for medical DRGs. - For Children’s Hospitals, the hospital-specific operating cost per diem for medical DRGs.

ex_pdmed 9(4)v9(2) 74 - 79

Operating Cost Per Diem for Surgical DRGs - For Rural Hospitals, the rural hospital operating cost per diem for surgical DRGs. - For Children’s Hospitals, the hospital-specific operating cost per diem for surgical DRGs.

ex_pdsurg 9(4)v9(2) 80-85

Effective Percent of Charges ex_epoc 9(1)v9(4) 86 - 90Capital Costs Per Day - For Rural Hospitals, the capital costs per day for rural hospitals. - For Children’s Hospitals, the hospital-specific mean capital costs per day.

ex_cappdall 9(4)v9(2) 91 - 96

Capital Costs Per Day for Medical DRGs - For Rural Hospitals, the capital costs per day for medical DRG cases in rural hospitals. - For Children’s Hospitals, the hospital-specific capital costs per day for medical DRG cases in the hospital.

ex_cappdmed 9(4)v9(2) 97 - 102

Capital Costs Per Day for Surgical DRGs - For Rural Hospitals, the capital costs per day for surgical DRG cases in rural hospitals. - For Children’s Hospitals, the hospital-specific capital costs per day for surgical DRG cases in the hospital

ex_cappdsurg 9(4)v9(2) 103 - 108

Adjusted Direct Medical Education Cost Per Day Add-on

ex_dmepd 9(4)v9(2) 109 - 114

Labor Market Adjustment Factor ex_lma 9(1)v9(4) 115 - 119Uncompensated Care Percent ex_unc 9(1)v9(4) 120 - 124Contribution to Margin, Plus Adjustment for the Effects of Recession

ex_mrg 9(1)v9(4) 125 - 129

Physician Participation Bonus ex_pbns 9(1)v9(4) 130 - 134Cost Outlier Policy Factor/Multiplier ex_factor 9(1)v9(2) 135 - 137Minimum Cost Outlier ex_threshmin 9(5)v9(2) 138 - 144Flag Indicating Payment Capped at Billed Charges

ex_limflag 9(1) 145

RCC for Transplant Cases ex_bmepoc 9(1)v9(4) 146 - 150Filler X(287) 151 - 437

Table 12-26: Washington Healthcare Authority Non Case-Based Hospital Rate Calculator Variables - medcalc.dat



12.1.28.27 Washington Medicaid

Table 12-27: Washington Medicaid Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate hbr 9(5)v9(2) 39 - 45Contracted Base Rate cbr 9(5)v9(2) 46 - 52Facility Type:M = Medicaid standard DRGC = Medicaid contractual DRGP = Some DRGs use contractual rate, others use

standard rateR = RCC reimbursement (DRG-excluded)A = Critical access hospital (CAH) B = Children’s hospitalD = Chemically-using pregnant (CUP) women certified hospitalE = Certified public expenditure (CPE) hospital

ft X(1) 53

Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 54- 58Outlier RCC Reduction Factor orrf 9(1)v9(2) 59 - 61Administrative Day Rate for LOS Outliers adr 9(4)v9(2) 62 - 67High Cost Trim hct 9(6)v9(2) 68 - 75High Cost Factor hcf 9(1)v9(2) 76 - 78Low Cost Trim lct 9(4)v9(2) 79 - 84Low Cost Factor lcf 9(1)v9(2) 85 - 87Length of Stay Age Cut-off 06 = Disproportionate share hospitals 01 = Other hospitals

lac 9(2) 88 - 89

Per Claim Add-on pcad 9(4)v9(2) 90 - 95Outpatient RCC orcc 9(1)v9(4) 96 - 100Markup/Discount Adjustment Factor markup 9(1)v9(5) 101 - 106High Cost Factor: Neonate hcfn 9(1)v9(4) 107 - 111Psychiatric Per Diem psychperdiem 9(8)v9(2) 112 - 121Rehabilitation Per Diem rehabperdiem 9(8)v9(2) 122 - 131Detoxification Per Diem detoxperdiem 9(8)v9(2) 132 - 141Medical Per Diem medperdiem 9(8)v9(2) 142 - 151Surgical Per Diem surghperdiem 9(8)v9(2) 152 - 161Neonatal Per Diem neonateperdiem 9(8)v9(2) 162 - 171Burn Per Diem burnperdiem 9(8)v9(2) 172 - 181Bariatric Case Rate for Hospital barperdiem 9(8)v9(2) 182 - 191Bariatric Flag (1 = hospital can bill for bariatric procedures)

barflg X(1) 192

CUP rate cuprate 9(8)v9(2) 193 - 202Critical Access Hospital inpatient rate cahip 9(1)v9(4) 203 - 207Federal Matching Assistance Percentage fmap 9(1)v9(4) 208 - 212Outlier Ratio of Cost to Charge Reduction Factor - Burns

orrf_burns 9(1)v9(2) 213 - 215


12.1.29.28 Washington Medicaid APR

Outlier Ratio of Cost to Charge Reduction Factor - Neonate

orrf_neonate 9(1)v9(4) 216 - 220

Outlier Ratio of Cost to Charge Reduction Factor orrf_new 9(1)v9(4) 221 - 225High-Cost Factor hcf_new 9(1)v9(4) 226 - 230Low-Cost Factor lcf_new 9(1)v9(4) 231 - 235Outlier Ratio of Cost to Charge Reduction Factor - Burns

orrf_burns_new 9(1)v9(4) 236 - 240

Filler X(197) 241 - 437

Table 12-28: Washington Medicaid APR Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionHospital Base Rate baserate 9(8)v9(2) 39 - 48Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 49 - 53Critical Access Hospital (CAH) Rate (Legacy)

cahip 9(1)v9(4) 54 - 58

Markup/Discount Adjustment Factor markup 9(1)v9(4) 59 - 63Cost Outlier Threshold cot 9(8)v9(2) 64 - 73Bariatric Case Rate Payment Amount barpay 9(8)v9(2) 74 - 83Hospital Type 0 = All other1 = Critical Access Hospital (CAH)2 = Certified Chemical-Using Pregnant

(CUP) facility3 = Certified Public Expenditure (CPE)

hospital4 = Long Term Acute Care

type 9(1) 84

Detox Per Diem Amount dpd 9(8)v9(2) 85 - 94Rehabilitation Per Diem Amount rpd 9(8)v9(2) 95 - 104Psychiatric Per Diem Amount pspd 9(8)v9(2) 105 - 114Federal Matching Assistance Percentage fmap 9(1)v9(4) 115 - 119Administrative Day Per Diem Rate adr 9(8)v9(2) 120 - 129Chemically Using Pregnant (CUP) Women

cuprate 9(8)v9(2) 130 - 139

Bariatric Flag barflag 9(1) 140LTAC Per Diem Rate ltacpd 9(8)v9(2) 141 - 150Newborn Screening Add-On newborn_add 9(8)v9(2) 151 - 160CAH Rate (New) cahip2 9(1)v9(5) 161 - 166

COVID-19 Adjustment Factor covid_adj 9(1)v9(4) 167 - 171Filler X(266) 172 - 437

Table 12-27: Washington Medicaid Hospital Rate Calculator Variables - medcalc.dat



12.1.30.29 Wisconsin Medicaid

* As adjusted for wages, indirect medical education, disproportionate share and adverse selection where applicable.

12.1.31 COBOL Platform12.1.32.1 New Jersey Medicaid

12.1.33.2 Pennsylvania Medicaid

Table 12-29: Wisconsin Medicaid Hospital Rate Calculator Variables - medcalc.dat


Hospital Base Rate * base 9(5)v9(2) 39 - 45

Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 46 - 50Cost Outlier Fixed Loss Threshold Amount cot 9(5)v9(2) 51 - 57Marginal Cost Factor: Non-Burns mcfc 9(1)v9(2) 58 - 60Marginal Cost Factor: Burns mcfbc 9(1)v9(2) 61 - 63Disproportionate Share Adjustment (DSH) Factor dshare 9(1)v9(6) 64 - 70Markup/Discount Factor discount 9(1)v9(4) 71 - 75 Filler X(362) 76 - 437

Table 12-30: New Jersey Medicaid COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionFiller 9(367) 124 - 490Hospital Base Rate NJR-BASE-RATE 9(8)v9(2) 491 - 500Ratio of Cost-to-Charges NJR-RCC 9(1)v9(4) 501 - 505Marginal Cost Factor NJR-MCF 9(1)v9(4) 506 - 510Markup/Discount Factor NJR-MARKUP 9(1)v9(4) 511 - 515Annual Nursing Facility Per Diem NJR-NFPD 9(8)v9(2) 516 - 525Ratio of Cost-to-Charges - New NJR-RCC-NEW 9(1)v9(5) 526 - 531Critical Service Add-On Percentage NJR-CS-ADJ 9(1)v9(4) 532 - 536Filler X(264) 537 - 800

Table 12-31: Pennsylvania Medicaid COBOL Hospital Rate Calculator Variables -hosprate.dat

Field Description Variable Name Format PositionHospital Payment Rate PAR-PBASER 9(8)v9(2) 251 - 260Ratio of Cost-to-Charges PAR-PRCC 9(1)v9(4) 261 - 265Marginal Cost Factor for LOS Outliers PAR-PMCFL 9(1)v9(4) 266 - 270


12.1.34.3 Washington Healthcare Authority Case-Based

Marginal Cost Factor for Cost Outliers PAR-PMCFC 9(1)v9(4) 271 - 275Marginal Cost Factor for Transfers PAR-MCFT 9(1)v9(4) 276 - 280Markup/Discount Adjustment Factor PAR-MARKUP 9(1)v9(5) 281 - 286Filler X(514) 287 - 800

Table 12-32: Washington Healthcare Authority Case-Based COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionLabor Market Adjustment Factor WCR-LMA 9(1)v9(4) 251 - 255Indirect Medical Education Factor WCR-IME 9(1)v9(4) 256 - 260Disproportionate Share Factor WCR-DSH 9(1)v9(4) 261 - 265Uncompensated Care Percent WCR-UNC 9(1)v9(4) 266 - 270Contribution to Margin/Recession WCR-MRG 9(1)v9(4) 271 - 275Physician Participation Bonus WCR-PBNS 9(1)v9(4) 276 - 280Adjusted DME/Case WCR-DMEPC 9(8)v9(2) 281 - 290Adjusted DME/Day WCR-DMEPD 9(8)v9(2) 291 - 300CMI-Adjusted Capital Cost Per Case WCR-CAPPC 9(8)v9(2) 301 - 310Capital Costs/Day for Psychiatric Cases WCR-CAPPDP 9(8)v9(2) 311 - 320Capital Cost/Day Substance Abuse WCR-CAPPDS 9(8)v9(2) 321 - 330Capital Costs/Day Rehabilitation WCR-CAPPDR 9(8)v9(2) 331 - 340Effective Percent of Charges WCR-EPOC 9(1)v9(4) 341 - 345Cost Outlier Policy Factor/Multiplier WCR-FACTOR 9(1)v9(2) 346 - 348Minimum Cost Outlier Threshold WCR-THRESHMIN 9(8)v9(2) 349 - 358Psych Operating Costs/Day-Day WCR-PDP1 9(8)v9(2) 359 - 368Psychiatric Operating Costs/Day-Day 2 WCR-PDP2 9(8)v9(2) 369 - 378Substance Abuse Operating Cost/Day-Day 1 WCR-PDSA1 9(8)v9(2) 379 - 388Substance Abuse Operating Cost/Day-Day 2 WCR-PDSA2 9(8)v9(2) 389 - 398Rehabilitation Operating Cost/Day WCR-PDR 9(8)v9(2) 399 - 408Reserved X(27) 409 - 435Rehabilitation Operating Cost Per Diem for Day Two and Beyond (January 1, 2000 and after)

WCR-PDR2 9(8)v9(2) 436 - 445

Filler X(90) 446 - 535Base Rate for Per Case Payments WCR-PC 9(8)v9(2) 536 - 545Markup/Discount Factor WCR-MARKUP 9(1)v9(5) 546 - 551Filler X(249) 552 - 800

Table 12-31: Pennsylvania Medicaid COBOL Hospital Rate Calculator Variables -hosprate.dat



12.1.35.4 Washington Healthcare Authority Non Case-Based

12.2 Outpatient Layouts12.2.1.1 Illinois Medicaid APG

Table 12-33: Washington Healthcare Authority Non Case-Based COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionPayment Strategy to be Applied WNR-PAYSTRAT 9(2) 251 - 252All-Inclusive Operating Cost Per Diem WNR-PD 9(8)v9(2) 253 - 262Operating Cost Per Diem for Medical DRGs WNR-PDMED 9(8)v9(2) 263 - 272Operating Cost Per Diem for Surgical DRGs WNR-PDSURG 9(8)v9(2) 273 - 282Effective Percentage of Charges WNR-EPOC 9(1)v9(4) 283 - 287Capital Costs Per Day WNR-CAPPDALL 9(8)v9(2) 288 - 297Capital Costs/Day for Medical DRGs WNR-CAPPDMED 9(8)v9(2) 298 - 307Capital Costs/Day for Surgical DRGs WNR-CAPPDSURG 9(8)v9(2) 308 - 317Adjusted DME Cost Per Day Add-on WNR-DMEPD 9(8)v9(2) 318 - 327Labor Market Adjustment Factor WNR-LMA 9(1)v9(4) 328 - 332Uncompensated Care Percent WNR-UNC 9(1)v9(4) 333 - 337Contribution to Margin/Recession WNR-MRG 9(1)v9(4) 338 - 342Physician Participation Bonus WNR-PBNS 9(1)v9(4) 343 - 347Cost Outlier Policy Factor/Multiplier WNR-FACTOR 9(1)v9(2) 348 - 350Minimum Cost Outlier Threshold WNR-THRESHMIN 9(8)v9(2) 351 - 360Flag Indicating Payment Capped at Billed Charges

WNR-LIMFLAG 9(1) 361 - 361

Cost-to-Charge Ratio for Transplant Cases WNR-BMEPOC 9(1)v9(4) 362 - 366Filler X(434) 367 - 800

Table 12-34: Illinois Medicaid APG Hospital Rate File Variables - medout.dat

Field Description Variable Name Format PositionProvider Specific Base Rate base_rate 9(8)v9(2) 39 - 48 Mark-up/Discount Factor markup 9(1)v9(4) 49 - 53First Significant Procedure Discount disc1 9(1)v9(4) 54 - 58Second Significant Procedure Discount disc2 9(1)v9(4) 59 - 63All Other Significant Procedure Discount disc3 9(1)v9(4) 64 - 68First Repeated Ancillary Discount ancdisc 9(1)v9(4) 69 - 73Terminated Procedure Discount termdisc 9(1)v9(4) 74 - 78Bi-lateral Procedure Discount bilatdisc 9(1)v9(4) 79 - 83Filler X(2) 84 - 85Second Repeated Ancillary Discount ancdisc2 9(1)v9(4) 86 - 90Third Repeated Ancillary Discount ancdisc3 9(1)v9(4) 91 - 95


12.2.2.2 New Mexico Medicaid APC

12.2.3.3 New York Medicaid APG (effective October 01, 2019)

Rate Reduction Factor rate_reduct_fact 9(1)v9(4) 96 - 100Ambulatory Procedures Listing (APL) Return Code Override0 = Do not bypass APL requirements1 = Bypass APL requirements

apl_rc_flag 9(1) 101

Operating Ratio of Cost-to-Charges (RCCs) oper_rcc 9(1)v9(4) 102 - 106Capital RCCs cap_rcc 9(1)v9(4) 107 - 111Fixed Loss Amount floss 9(8)v9(2) 112 - 121Outlier Eligibility Indicator

0 = Not eligible for cost outlier add-on payments

1 = Eligible for cost outlier add-on payments

out_elig 9(1) 122

Marginal Cost Factor mcf 9(1)v9(4) 123 - 127Filler X(310) 128 - 437

Table 12-35: New Mexico Medicaid APC Hospital Rate File Variables - medout.dat

Field Description Variable Name Format PositionMarkup/Discount Factor markup 9(1)v9(4) 39 - 43National Carrier natcarrier X(12) 44 - 55Other Carrier othcarrier X(12) 56 - 67Multiple Procedure Discount Factor 1 disc1 9(1)v9(4) 68 - 72Multiple Procedure Discount Factor 2 disc2 9(1)v9(4) 73 - 77Conditionally Bilateral Discount Factor cond_disc 9(1)v9(4) 78 - 82Independently Bilateral Discount Factor ind_disc 9(1)v9(4) 83 - 87Facility Type fac_type 9(2) 88 - 89Reduction Factor red_fact 9(1)v9(4) 90 - 94Pediatric Age pd_age 9(3) 95 - 97Fee Schedule Name fstable X(13) 98 - 110Adjustment Factor adj_fact 9(1)v9(5) 111 - 116Filler X(321) 117 - 437

Table 12-36: Enhanced New York Medicaid APG Rate File Variables - medout.dat (effective October 01, 2019)

Field Description Variable Name Format PositionHospital Number fac X(16) 1 - 16

Table 12-34: Illinois Medicaid APG Hospital Rate File Variables - medout.dat



Paysource Code psrc X(13) 17 - 29Locator Code loccode 9(2) 30 - 31Rate Code ratecode 9(6) 32 - 37Page Number pgnum 9(2) 38 - 39Effective Date effdate 9(8) 40 - 47Key Type keytype X(1) 48Base Rate base 9(8)v9(3) 49 - 59Capital Rate capital 9(8)v9(3) 60 - 70Filler X(30) 71 - 100

Table 12-37: New York Medicaid APG Hospital Rate File Variables - medout.dat (effective October 01, 2019)

Field Description Variable Name Format PositionLocator Code Flag locat_code_flag 9(1) 39Markup markup 9(1)v9(4) 40 - 44MSPD Discount 1 mspd_disc1 9(1)v9(4) 45 - 49MSPD Discount 2 mspd_disc2 9(1)v9(4) 50 - 54MSPD Discount 3 mspd_disc3 9(1)v9(4) 55 - 59Ancillary Discount 1 anc_disc1 9(1)v9(4) 60 - 64Ancillary Discount 2 anc_disc2 9(1)v9(4) 65 - 69Ancillary Discount 3 anc_disc3 9(1)v9(4) 70 - 74Terminated Discount term_disc 9(1)v9(4) 75 - 79Bilateral Discount bilat_disc 9(1)v9(4) 80 - 84340B Drug Discount drug_disc 9(1)v9(4) 85 - 89Language Other Than English Adjustment lang_adj 9(1)v9(4) 90 - 94HO/HN Modifier Adjustment mh_disc 9(1)v9(4) 95 - 99Mental Health U5 Adjustment Factor psych_disc 9(1)v9(4) 100 - 104Mental Health Adjustment 1 mh_adj1 9(1)v9(4) 105 - 109Mental Health Adjustment 2 mh_adj2 9(1)v9(4) 110 - 114Group Smoking Cessation Adjustment group_cess_adj 9(1)v9(4) 115 - 119Non Distinct Observation Bed Adjustment nondisc_obsadj 9(1)v9(4) 120 - 124Second Day Observation Adjustment obsadj 9(1)v9(4) 125 - 129Pediatric Psych Adjustment ped_psych_adj 9(1)v9(4) 130 - 134State Wide Base Rate stwide_base 9(8)v9(2) 135 - 144VFC Rate vfc_rate 9(3)v9(2) 145 - 149Vaccine Rate vac_rate 9(3)v9(2) 150 - 154Pediatric Age Cutoff doh_age 9(3) 155 - 157SED Pediatric Age Cutoff omh_age 9(3) 158 - 160

Table 12-36: Enhanced New York Medicaid APG Rate File Variables - medout.dat (effective October 01, 2019)



12.2.4.4 New York Medicaid APG (prior to October 01, 2019)

Fee Schedule Table fstable 9(3) 161 - 173National Carrier natcarrier X(12) 174 - 185Other Carrier othcarrier X(12) 186 - 197KP Modifier Adjustment opioid_adj 9(1)v9(4) 198 - 202Offsite Licensed Behavioral Health (LBHP) Practitioner Adjustment

lbhp_adj 9(1)v9(4) 203 - 207

Offsite LBHP Location Flag lbhp_facility 9(1) 208 Dental Telehealth Discount dental_disc 9(1)v9(4) 209 - 213Zip Code Lookup Flag0 = Single zip code lookup; if locator code

is appended, always use locator code1 = Loop through zip codes until locator

code/rate code match is found; if locator code is appended, always use locator code

lookup_bypass 9(1) 214

Filler X(223) 215 - 437

Table 12-38: New York Medicaid APG Hospital Rate File Variables - medout.dat (prior to October 01, 2019)

Field Description Variable Name Format PositionFacility Type factype 9(2) 39 - 40OPD Base Rate opd_base 9(8)v9(2) 41 - 50Non-APG Rate nonapg 9(8)v9(2) 51 - 60OPD Capital Add-On opd_capital 9(8)v9(2) 61 - 70Blend Factor blend 9(1)v9(2) 71 - 73Mark-up/Discount Factor markup 9(1)v9(4) 74 - 78Significant Procedure - First Weight Percent disc1 9(1)v9(4) 79 - 83Significant Procedure - Second Weight Percent

disc2 9(1)v9(4) 84 - 88

Significant Procedure - Third Weight Percent disc3 9(1)v9(4) 89 - 93Repeated Ancillary Discount ancdisc 9(1)v9(4) 94 - 98Terminated Procedure Discount termdisc 9(1)v9(4) 99 - 103Bilateral Procedure Discount bilatdisc 9(1)v9(4) 104 - 108ASC Base Rate asc_base 9(8)v9(2) 109 - 118ED Base Rate ed_base 9(8)v9(2) 119 - 128ASC Capital Add-On asc_capital 9(8)v9(2) 129 - 138ED Capital Add-On ed_capital 9(8)v9(2) 139 - 148DTC Base Rate dtc_base 9(8)v9(2) 149 – 158

Table 12-37: New York Medicaid APG Hospital Rate File Variables - medout.dat (effective October 01, 2019)



DTC Capital Add-On dtc_capital 9(8)v9(2) 159 – 168DTC Non-APG Rate dtc_nonapg 9(8)v9(2) 169 – 178Exception Base Rate exception_base 9(8)v9(2) 179 – 188Free-Standing ASC Base Rate fr_asc_base 9(8)v9(2) 189 – 198Free-Standing Capital Add-On fr_asc_capital 9(8)v9(2) 199 – 208Free-Standing Non-APG Rate fr_asc_nonapg 9(8)v9(2) 209 – 218Renal Base Rate renal_base 9(8)v9(2) 219 – 228Renal Capital Add-On renal_capital 9(8)v9(2) 229 – 238Renal Non-APG Rate renal_nonapg 9(8)v9(2) 239 – 248Dental Base Rate dental_base 9(8)v9(2) 249 – 258Dental Capital Add-On dental_capital 9(8)v9(2) 259 – 268Dental Non-APG Rate dental_nonapg 9(8)v9(2) 269 – 278Drug Discount drugdisc 9(1)v9(4) 279 - 283Language Adjustment lang_adj 9(1)v9(4) 284 - 288U5 Modifier Adjustment u5_mod 9(1)v9(4) 289 - 293HO/HN Modifier Adjustment hohn_mod 9(1)v9(4) 294 - 298Statewide Base Rate st_base 9(8)v9(2) 299 - 308Mental Health Adjustment 1 mh_adj1 9(1)v9(4) 309 - 313Mental Health Adjustment 2 mh_adj2 9(1)v9(4) 314 - 318HQ Modifier Adjustment hq_mod 9(1)v9(4) 319 - 323SL Modifier Rate sl_vac 9(8)v9(2) 324 - 333FB Modifier Rate fb_vac 9(8)v9(2) 334 - 343MH Hospital Base Rate mh_hosp_base 9(8)v9(2) 344 - 353MH Hospital Non-APG Rate mh_hosp_nonapg 9(8)v9(2) 354 - 363MH Hospital Capital Add-On mh_hosp_cap 9(8)v9(2) 364 - 373MH Non-Hospital Base Rate mh_nonhosp_base 9(8)v9(2) 374 - 383MH Non-Hospital Non-APG Rate mh_nonhosp_legacy 9(8)v9(2) 384 - 393MH Non-Hospital Capital Add-On mh_nonhosp_cap 9(8)v9(2) 394 - 403MH Blend Factor mh_blend 9(1)v9(2) 404 - 406Offsite Adjustment Factor off_adj 9(1)v9(4) 407 - 411Non-Discrete Observation Unit Adjustment nondis_obs_adj 9(1)v9(4) 412 - 416Second Day Observation Adjustment second_day_adj 9(1)v9(4) 417 - 421Pediatric Psychiatric Adjustment ped_psych_adj 9(1)v9(4) 422 - 426Second Repeated Ancillary Discount ancdisc2 9(1)v9(4) 427 - 431Third Repeated Ancillary Discount ancdisc3 9(1)v9(4) 432 - 436Filler X(1) 437

Table 12-38: New York Medicaid APG Hospital Rate File Variables - medout.dat (prior to October 01, 2019)



12.2.5.5 Virginia Medicaid APG

Table 12-39: New York Medicaid APG Extended Hospital Rate File Variables - medext.dat (prior to October 01, 2019)

Field Description Variable Name Format PositionHospital Number facility X(16) 1 - 16Paysource Code paysrc X(13) 17 - 29Effective Date eff_date 9(8) 30 - 37Patient Type pattype X(1) 38Sequence Number seqnum X(1) 39Fee Schedule Table fstable X(13) 40 - 52Extended Fee Schedule Table fsexttable X(13) 53 - 65National Carrier natcarrier X(12) 66 - 77Other Carrier othcarrier X(12) 78 - 89Fee Schedule Indicator rmfsind 9(1) 90OASAS Base Rate oas_hosp 9(8)v9(2) 91 - 100OASAS Capital Add-On oas_cap 9(8)v9(2) 101 - 110Free-Standing OASAS Base Rate oas_fs 9(8)v9(2) 111 - 120KP Modifier Adjustment kp_mod 9(1)v9(4) 121 - 125Multiple E&M Payment Amount mult_em 9(8)v9(2) 126 - 135Office for People With Developmental Disabilities (OPWDD) Base Rate

omrd_hosp 9(8)v9(2) 136 - 145

OPWDD Capital Add-On omrd_cap 9(8)v9(2) 146 - 155Free-Standing OPWDD Base Rate omrd_fs 9(8)v9(2) 156 - 165Free-Standing OPWDD Capital Add-On omrd_fs_cap 9(8)v9(2) 166 - 175OASAS Chemical Rehabilitation Base Rate

oas_hosp_rehab 9(8)v9(2) 176 - 185

OASAS Opioid Treatment Center Rate oas_hosp_otp 9(8)v9(2) 186 - 195Free-Standing OASAS Chemical Rehabilitation Rate

oas_fs_rehab 9(8)v9(2) 196 - 205

Free-Standing OASAS Opioid Treatment Center Rate

oas_fs_otp 9(8)v9(2) 206 - 215

Licensed Behavioral Health Practitioner (LBHP) Benefit Flag

lbhp_locflag 9(1) 216

OASAS Hospital Chemical Rehabilitation Capital Rate

oas_hosp_rehab_cap 9(8)v9(2) 217 - 226

Filler X(281) 227 - 507Pricer Type prcr_type X(2) 508 - 509Key Type key_type X(1) 510

Table 12-40: Virginia Medicaid APG Hospital Rate File Variables - medout.dat

Field Description Variable Name Format PositionProvider Specific Base Rate base_rate 9(8)v9(2) 39 - 48


12.2.6.6 Washington Medicaid APG

Mark-up/Discount Factor markup 9(1)v9(4) 49 - 53First Procedure Discount disc1 9(1)v9(4) 54 - 58Second Procedure Discount disc2 9(1)v9(4) 59 - 63All Other Procedures Discount disc3 9(1)v9(4) 64 - 68First Repeated Ancillary Discount ancdisc1 9(1)v9(4) 69 - 73Second Repeated Ancillary Discount ancdisc2 9(1)v9(4) 74 - 78Third Repeated Ancillary Discount ancdisc3 9(1)v9(4) 79 - 83Terminated Procedure Discount termdisc 9(1)v9(4) 84 - 88Bi-lateral Procedure Discount bilatdisc 9(1)v9(4) 89 - 93340B Drug Discount drugdisc 9(1)v9(4) 94 - 98Fee Schedule fstable X(13) 99 - 111Extended Fee Schedule fsexttable X(13) 112 - 124National Carrier natcarrier X(12) 125 - 136Other Carrier othcarrier X(12) 137 - 148Filler X(289) 149 - 437

Table 12-41: Washington Medicaid APG Hospital Rate File Variables - medout.dat

Field Description Variable Name Format PositionProvider Specific Base Rate base_rate 9(8)v9(2) 39 - 48 Mark-up/Discount Factor markup 9(1)v9(4) 49 - 53First Significant Procedure Discount

disc1 9(1)v9(4) 54 - 58

Second Significant Procedure Discount

disc2 9(1)v9(4) 59 - 63

All Other Significant Procedures Discount

disc3 9(1)v9(4) 64 - 68

First Repeated Ancillary Discount ancdisc 9(1)v9(4) 69 - 73Terminated Procedure Discount termdisc 9(1)v9(4) 74 - 78Bilateral Discount bilatdisc 9(1)v9(4) 79 - 83Hospital Type00 = All others01 = Sole Community Hospital

(SCH)02 = Critical Access Hospital

(CAH)03 = Non-CAH approved for

Diabetes education

type 9(2) 84 - 85

Pediatric Adjustment Factor pedadj 9(1)v9(4) 86 - 90Sole Community Hospital Adjustor schadj 9(1)v9(4) 91 - 95Pediatric Age Cutoff cutage 9(3) 96 - 98

Table 12-40: Virginia Medicaid APG Hospital Rate File Variables - medout.dat



12.2.7.7 Wisconsin Medicaid APG

Critical Access Payment Factor (Legacy)

cahip 9(1)v9(4) 99 - 103

Outpatient Ratio of Cost-to-Charges (RCCs)

out_rcc 9(1)v9(4) 104 - 108

Second Repeated Ancillary Discount

ancdisc2 9(1)v9(4) 109 - 113

Third Repeated Ancillary Discount ancdisc3 9(1)v9(4) 114 - 118Fee Schedule Table fstable X(13) 119 - 131Extended Fee Schedule Table fsexttable X(13) 132 - 144National Carrier natcarrier X(12) 145 - 156Other Carrier othcarrier X(12) 157 - 168Critical Access Payment Factor (New)

cahip2 9(1)v9(5) 169 - 174

Filler X(263) 175 - 437

Table 12-42: Wisconsin Medicaid APG Hospital Rate File Variables - medout.dat

Field Description Variable Name Format PositionProvider Specific Base Rate base_rate 9(8)v9(2) 39 - 48 Mark-up/Discount Factor markup 9(1)v9(4) 49 - 53First Procedure Discount disc1 9(1)v9(4) 54 - 58Second Procedure Discount disc2 9(1)v9(4) 59 - 63All Other Procedures Discount disc3 9(1)v9(4) 64 - 68First Repeated Ancillary Discount ancdisc1 9(1)v9(4) 69 - 73Second Repeated Ancillary Discount ancdisc2 9(1)v9(4) 74 - 78Terminated Procedure Discount termdisc 9(1)v9(4) 79 - 83Bi-lateral Procedure Discount bilatdisc 9(1)v9(4) 84 - 88Percent of Charge Factor pctchrg 9(1)v9(4) 89 - 93Third Repeated Ancillary Discount ancdisc3 9(1)v9(4) 94 - 98Second Percentage of Charge Factor pctchrg2 9(1)v9(4) 99 - 103Fee Schedule Table fstable X(13) 104 - 116Extended Fee Schedule Table fsexttable X(13) 117 - 129National Carrier natcarrier X(12) 130 - 141Other Carrier othcarrier X(12) 142 - 153Filler X(284) 154 - 437

Table 12-41: Washington Medicaid APG Hospital Rate File Variables - medout.dat



13 Other Hospital Rate Calculator File Layouts

This chapter provides the layouts for the “other” (i.e., Commercial) Hospital Rate Calculator File layouts (C and COBOL). This chapter includes the following sections:


- Contract Multi-Pricer/DRG Pro- Medicaid APR Pro- TRICARE/CHAMPUS

- COBOL Platform- Contract Multi-Pricer/DRG Pro- TRICARE/CHAMPUS

• Outpatient Layouts- C Platform

- Contract APC- Contract ASC- Medicaid APG Pro- TRICARE APC

- COBOL Platform- Contract APC- Contract ASC



13.1.2.1 Contract Multi-Pricer/DRG Pro

Table 13-1: Contract Multi-Pricer/DRG Pro Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionFiller X(71) 39 - 109Transfer Pricing Flag1 = Acute Care Transfers2 = Medicare Acute, Post-Acute, and Special

Post-Acute Care Transfers

special1 9(1) 110

Short Stay Pricing Flag special2 9(1) 111One Day Stay Pricing Flag special3 9(1) 112Outlier Pricing Flag1 = Combination Stop-Loss2 = First Dollar - Dollar Threshold (per diem rate)3 = First Dollar - Day Threshold (per diem rate)4 = First Dollar - Dollar Threshold (PPR to per

diem rate cap)5 = First Dollar - Dollar Threshold (PPR)6 = Second Dollar - Dollar Threshold (PPR)7 = Second Dollar - Day Threshold (per diem

rate)8 = Second Dollar - Day Threshold (per diem rate

- threshold based on average mlos)9 = Second Dollar - Standard DRG Cost Outlier

Threshold

special4 X(1) 113

Limit Reimbursement to a% of Charges Flag special5 9(1) 114Filler X(15) 115 - 129Overall Markup/Discount Flag special6 9(1) 130Markup/Discount Factor discount 9(1)v9(4) 131 - 135Short Stay Factor shortstayfactor 9(1)v9(4) 136 - 140Maximum Percent of Charge chargecapfactor 9(1)v9(4) 141 - 145Outlier Payment for Transfers Flag transoutflag 9(1) 146Transfer Factor transferfactor 9(1)v9(4) 147 - 151Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 152 - 156Base Factor for High Cost Outlier basefactor 9(1)v9(4) 157 -161Cost Factor for High Cost Outlier costfactor 9(1)v9(4) 162 - 166Charge Factor for High Cost Outlier chargefactor 9(1)v9(4) 167 - 171Cost Threshold for High Cost Outlier costthreshold 9(8)v9(2) 172 - 181Charge Threshold for High Cost Outlier chargethreshold 9(8)v9(2) 182 - 191Day Threshold for Outlier daythreshold 9(4) 192 - 195Per Diem for Outlier perdiem 9(8)v9(2) 196 - 205


13.1.3.2 Medicaid APR Pro

Negotiated Number of Days in Excess of DRG Mean Length of Stay for Outlier

adddays 9(4) 206 - 209

One Day Stay Rate onedaystayrate 9(8)v9(2) 210 - 219Minimum Percent of Charge minchargefactor 9(1)v9(4) 220 - 224One Day Stay Pricing Takes Precedence Over Transfer Pricing

onedayovertrans 9(1) 225

Never Reimburse Below a% of Charges Flag special7 9(1) 226Filler X(210) 227 - 436Extended Hospital Rate Calculator File in Use0 = Extended Hospital Rate Calculator File not

required1 = Extended Hospital Rate Calculator File

required

medext_sw X(1) 437

Reserved for Rate File Version version X(7) 438 - 444

Table 13-2: Contract Multi-Pricer/DRG Pro Extended Hospital Rate Calculator Variables - medext.dat

Field Description Variable Name Format PositionDRG Weight Factor drg_factor 9(1)v9(4) 40 - 44Diagnosis Code and Effective Date Array

- Diagnosis Code- Start Date- End Date

dx_codestart_dateend_date

X(10) (occurs 10 times)9(8)9(8)

45 - 304

Filler X(203) 305 - 507

Pricer Type prcr_type X(2) 508 - 509 Key Type key_type X(1) 510

Table 13-3: Medicaid APR Pro Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable name Format PositionState state_id X(2) 39 - 40Procedure Array proc_array X(4)

(occurs 50 times)

41 - 240

Hospital Base Rate base 9(8)v9(2) 241 - 250Ratio of Cost-to-Charges (RCCs) rcc 9(1)v9(4) 251 - 255Mark-up/Discount Factor markup 9(1)v9(4) 256 - 260Potentially Preventive Readmission (PPR) Factor ppr 9(1)v9(4) 261 - 265High Cost Fixed Outlier Threshold cot 9(8)v9(2) 266 - 275

Table 13-1: Contract Multi-Pricer/DRG Pro Hospital Rate Calculator Variables - medcalc.dat



Capital Add-On Payment capital 9(8)v9(2) 276 - 285Hospital Type00 = Standard reimbursement01 = Exempt from PPR adjustments02 = Eligible for policy adjustor03 = Eligible for policy adjustor with age limit04 = Exempt from transfer logic

type 9(2) 286 - 287

Malpractice Add-On Payment malprac 9(8)v9(2) 288 - 297Organ Acquisition Add-On Payment orgpay 9(8)v9(2) 298 - 307Marginal Cost Factor 1 mcf 9(1)v9(4) 308 - 312Medical Education Payment mededpay 9(8)v9(2) 313 - 322Interim Claim Threshold iclm_threshold 9(3) 323 - 325Interim Claim Per Diem iclm_perdiem 9(8)v9(2) 326 - 335Day Outlier Threshold mhls_threshold 9(3) 336 - 338Day Outlier Per Diem mhls_perdiem 9(8)v9(2) 339 - 348Policy Adjustor 1 pol_adj1 9(1)v9(4) 349 - 353Policy Adjustor 2 pol_adj2 9(1)v9(4) 354 - 358Policy Adjustor 3 pol_adj3 9(1)v9(4) 359 - 363Policy Adjustor 4 pol_adj4 9(1)v9(4) 364 - 368Policy Adjustor 5 pol_adj5 9(1)v9(4) 369 - 373Policy Adjustor 6 pol_adj6 9(1)v9(4) 374 - 378Age Limit cut_age 9(3) 379 - 381Marginal Cost Factor 2 mcf2 9(1)v9(4) 382 - 386Provider Adjustor prov_adj 9(1)v9(4) 387 - 391Birth Weight Age Limit bw_age_limit 9(2) 392 - 393Policy Add-On 1 pol_addon1 9(8)v9(2) 394 - 403Outlier Threshold 2 cot2 9(8)v9(2) 404 - 413Marginal Cost Factor 3 mcf3 9(1)v9(4) 414 - 418Potentially Preventable Readmission (PPR) Extended Factor

ppr_ext 9(1)v9(5) 419 - 424

Filler X(12) 425 - 436Extended Hospital Rate Calculator File in Use0 = Extended Hospital Rate Calculator File not

required1 = Extended Hospital Rate Calculator File required

medext_sw X(1) 437

Table 13-4: Medicaid APR Pro Extended Hospital Rate File - medext.dat

Field Description Variable Name Format PositionPer Diem Rate 1 perdiem1 9(4)v9(2) 40 - 45Per Diem Rate 2 perdiem2 9(4)v9(2) 46 - 51Labor Portion labor 9(1)v9(6) 52 - 58

Table 13-3: Medicaid APR Pro Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable name Format Position


13.1.4.3 TRICARE/CHAMPUS

Wage Index wi 9(1)v9(5) 59 - 64Adjustment Factor 1 adjustfactor1 9(1)v9(6) 65 - 71Capital Adjustment Factor capital_factor 9(1)v9(6) 72 - 78Per Diem Factor 3 perdiem3 9(4)v9(2) 79 - 84Case-Mix Factor casemix 9(1)v9(5) 85 - 90Extended Ratio of Cost-to-Charges (RCCs) rcc_ext 9(1)v9(6) 91 - 97High Cost Fixed Outlier Threshold 2 cot3 9(8)v9(2) 98 - 107Age Limit 2 cut_age2 9(3) 108 - 110Policy Add-On 2 pol_addon2 9(8)v9(2) 111 - 120Policy Add-On 3 pol_addon3 9(8)v9(2) 121 - 130Filler X(377) 131 - 507Pricer Type prcr_type X(2) 508 - 509 Key Type key_type X(1) 510

Table 13-5: TRICARE/CHAMPUS Hospital Rate Calculator Variables - medcalc.dat

Field Description Variable Name Format PositionLabor-related Adjusted Standardized Amount (ASA)

lrasa 9(4)v9(2) 39 - 44

Non-Labor-related ASA nlrasa 9(4)v9(2) 45 - 50Labor-Related Children’s Hospital Differential lrchd 9(4)v9(2) 51 - 56Non-Labor-related Children’s Hospital Differential nlrchd 9(4)v9(2) 57 - 62Wage Index wi 9(1)v9(4) 63 - 67Indirect Medical Education (IME) Adjustment imea 9(1)v9(6) 68 - 74Ratio of Cost-to-Charges (RCC) rcc 9(1)v9(4) 75 - 79Cost Outlier Threshold cot 9(5)v9(2) 80 - 86Children’s Hospital/Neonate Cost Outlier Threshold

cotcn 9(5)v9(2) 87 - 93

Cost Outlier Factor/Multiplier cof 9(1)v9(2) 94 - 96Short Stay Outlier Factor sof 9(1)v9(2) 97 - 99Neonate Transfer Factor ntf 9(1)v9(2) 100 - 102Marginal Cost Factor: LOS Outliers mcfl 9(1)v9(2) 103 - 105Marginal Cost Factor: Cost Outliers mcfc 9(1)v9(2) 106 - 108Marginal Cost Factor: Burns LOS Outliers mcfbl 9(1)v9(2) 109 - 111Marginal Cost Factor: Burns Cost Outliers mcfbc 9(1)v9(2) 112 - 114Marginal Cost Factor: Children’s Hospitals/Neonates

mcfn 9(1)v9(2) 115 - 117

National TRICARE Rate ncr 9(5)v9(2) 118 - 124

Table 13-4: Medicaid APR Pro Extended Hospital Rate File - medext.dat



13.1.5 COBOL Platform13.1.6.1 Contract Multi-Pricer/DRG Pro

Children’s Hospital/Neonatal Cost Outlier Adjustment

ccoladj 9(1)v9(4) 125 - 129

Operating Percent for Cost Outlier Threshold opcotper 9(1)v9(4) 130 - 134Labor Portion labor 9(1)v9(4) 135 - 139Filler X(5) 140 - 144TRICARE Hospital Base Rate baser 9(5)v9(2) 145 - 151Markup/Discount Adjustment Factor markup 9(1)v9(5) 152 - 157Psychiatric Per Diem pd_psych 9(8)v9(2) 158 - 167Psychiatric Distinct Part Unit psycunit X(1) 168Waiver waiver X(1) 169Waiver Factor waiver_factor 9(1)v9(4) 170 - 174COVID-19 DRG Weight Factor covid_fact 9(1)v9(4) 175 - 179Value-Based Purchasing (VBP) Adjustment Factor

vbp_adj 9(1)v9(11) 180 - 191

Traditional New Tech. Procedure and Claim Factor

techopfac 9(1)v9(2) 192 - 194

Alternative New Tech. Procedure and Claim Factor

alttechopfac 9(1)v9(2) 195 - 197

Filler X(247) 198 - 444

Table 13-6: Contract Multi-Pricer/DRG Pro COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionFiller X(71) 251 - 321Transfer Pricing Flag1 = Acute Care Transfers2 = Medicare Acute, Post-Acute, and

Special Post-Acute Care Transfers

MPR-SPECIAL1 9(1) 322

Short Stay Pricing Flag MPR-SPECIAL2 9(1) 323One Day Stay Pricing Flag MPR-SPECIAL3 9(1) 324

Table 13-5: TRICARE/CHAMPUS Hospital Rate Calculator Variables - medcalc.dat



Outlier Pricing Flag1 = Combination Stop-Loss2 = First Dollar - Dollar Threshold (per

diem rate)3 = First Dollar - Day Threshold (per diem

rate)4 = First Dollar - Dollar Threshold (PPR

to per diem rate cap)5 = First Dollar - Dollar Threshold (PPR)6 = Second Dollar - Dollar Threshold

(PPR)7 = Second Dollar - Day Threshold (per

diem rate)8 = Second Dollar - Day Threshold (per

diem rate - threshold based on average mlos)

MPR-SPECIAL4 X(1) 325

Limit Reimbursement to a% of Charges Flag


Ratio of Cost-to-Charges MPR-RCC 9(1)v9(4) 327 - 331Cost Threshold MPR-

COSTTHRESHOLD9(8)v9(2) 332 - 341

Overall Markup/Discount Flag MPR-SPECIAL6 9(1) 342Markup/Discount Factor MPR-DISCOUNT 9(1)v9(4) 343 - 347Base Factor for High Cost Outlier MPR-BASEFACTOR 9(1)v9(4) 348 - 352Cost Factor for High Cost Outlier MPR-COSTFACTOR 9(1)v9(4) 353 - 357Charge Factor for High Cost Outlier MPR-CHARGEFACTOR 9(1)v9(4) 358 - 362Charge Threshold for High Cost Outlier MPR-

CHARGETHRESHOLD9(8)v9(2) 363 - 372

Outlier Payment for Transfer Flag MPR-TRANSOUTFLAG 9(1) 373Transfer Factor MPR-

TRANSFERFACTOR9(1)v9(4) 374 - 378

Maximum Percent of Charge MPR-CHARGECAPFACTOR

9(1)v9(4) 379 - 383

Short Stay Factor MPR-SHORTSTAYFACTOR

9(1)v9(4) 384 - 388

Never Reimburse Below a% of Charges Flag


Day Threshold for Outlier MPR-DAYTHRESHOLD 9(4) 390 - 393Per Diem for Outlier MPR-PERDIEM 9(8)v9(2) 394 - 403Negotiated Number of Days in Excess of DRG Mean Length of Stay for Outlier

MPR-ADDDAYS 9(4) 404 - 407

One Day Stay Rate MPR-ONEDAYSTAYRATE

9(8)v9(2) 408 - 417

Minimum Percent of Charge MPR-MINCHARGEFACTOR

9(1)v9(4) 418 - 422




13.1.7.2 TRICARE/CHAMPUS

One Day Stay Pricing Takes Precedence Over Transfer Pricing

MPR-ONEDAYOVERTRANS

9(1) 423

Filler X(369) 424 - 792Extended Hospital Rate Calculator File in Use0 = Extended Hospital Rate Calculator

File not required1 = Extended Hospital Rate Calculator

File required

MPR-MEDEXT-SW X(1) 793

Reserved for Rate File Version MPR-VERSION X(7) 794 - 800

Table 13-7: Contract Multi-Pricer/DRG Pro Extended Hospital Rate Calculator Variables - hospext.dat

Field Description Variable Name Format PositionDRG Weight Factor MPR0-DRG-FACTOR 9(1)v9(4) 52 - 56Diagnosis Code and Effective Date Array

- Diagnosis Code- Start Date- End Date

MPR0-DX-CODEMPR0-START-DATEMPR0-END-DATE

X(10) (occurs 10 times)9(8)9(8)

57 - 316

Filler X(481) 317 - 797Pricer Type MPR0-PRCR-TYPE X(2) 798 - 799Key Type MPR0-KEY-TYPE X(1) 800

Table 13-8: TRICARE/CHAMPUS COBOL Hospital Rate Calculator Variables - hosprate.dat

Field Description Variable Name Format PositionASA – Labor-related CHR-LRASA 9(8)v9(2) 251 - 260ASA – Non-Labor-related CHR-NLRASA 9(8)v9(2) 261 - 270Children’s Differential/Labor-related CHR-LRCHD 9(8)v9(2) 271 - 280Children’s Differential/Non-Labor CHR-NLRCHD 9(8)v9(2) 281 - 290Wage Index CHR-CWI 9(1)v9(4) 291 - 295Indirect Education Adjustment CHR-CIMEA 9(1)v9(6) 296 - 302Cost-to-Charge Ratio CHR-CRCC 9(1)v9(4) 303 - 307Cost Outlier Threshold CHR-CCOT 9(8)v9(2) 308 - 317Children’s Hospital/Neonate Cost Outlier Threshold

CHR-CCOTCN 9(8)v9(2) 318 - 327

Cost Outlier Factor/Multiplier CHR-CCOF 9(1)v9(2) 328 - 330Short Stay Outlier Factor CHR-CSSOF 9(1)v9(2) 331 - 333




Neonate Transfer Factor CHR-CNTF 9(1)v9(2) 334 - 336Marginal Cost Factor: LOS CHR-CMCFL 9(1)v9(2) 337 - 339Marginal Cost Factor: Cost CHR-CMCFC 9(1)v9(2) 340 - 342Marginal Cost Factor: Burns - LOS CHR-CMCFBL 9(1)v9(2) 343 - 345MCF - Children’s Hospitals/Neonates CHR-CMCFCN 9(1)v9(2) 346 - 348Marginal Cost Factor: Burns - Cost CHR-CMCFBC 9(1)v9(2) 349 - 351COVID-19 DRG Weight Factor CHR-COVID-FACTOR 9(1)v9(4) 352 - 356Value-Based Purchasing (VBP) Adjustment Factor

CHR-VBP-FACTOR 9(1)v9(11) 357 - 368

Traditional New Tech. Procedure and Claim Factor

CHR-TECHOPFAC 9(1)v9(2) 369 - 371

Alternative New Tech. Procedure and Claim Factor

CHR-ALT-TECHOPFAC

9(1)v9(2) 372 - 374

Filler X(114) 375 - 488National TRICARE Rate CHR-NCR 9(8)v9(2) 489 - 498Hospital-Based TRICARE Rate CHR-HBCR 9(8)v9(2) 499 - 508Children’s Hospital/Neonatal Cost Outlier Adjustment

CHR-CCOLADJ 9(1)v9(4) 509 - 513

Operating Percent for Cost Outlier Threshold CHR-OPCOTPER 9(1)v9(4) 514 - 518Labor Portion CHR-LABOR 9(1)v9(4) 519 - 523Markup/Discount Adjustment Factor CHR-MARKUP 9(1)v9(5) 524 - 529Psychiatric Per Diem CHR-PD-PSYCH 9(8)v9(2) 530 - 539Psychiatric Distinct Part Unit CHR-PSYCUNIT X(1) 540Waiver CHR-WAIVER X(1) 541Waiver Factor CHR-WAIVER-

FACTOR9(1)v9(4) 542 - 546

Filler X(254) 547 - 800

Table 13-8: TRICARE/CHAMPUS COBOL Hospital Rate Calculator Variables - hosprate.dat



13.2 Outpatient Layouts13.2.1 C Platform

13.2.2.1 Contract APC

Table 13-9: Contract APC Hospital Rate File Variables - medout.dat

Field Description Variable Name Position FormatLabor-related Portion labor 39 - 44 9(1)v9(5)Wage Index wi 45 - 50 9(1)v9(5)Facility Type00 = All other hospitals05 = OPPS exempt (CAH) 08 = Non-participating hospital

fac_type 51 - 52 9(2)

Multiple Procedure Discount Factor –For highest weighted procedure APC.

discount1 53 - 57 9(1)v9(4)

Multiple Procedure Discount Factor –For second highest weighted procedure APC.

discount2 58 - 62 9(1)v9(4)

Multiple Procedure Discount Factor –For third highest weighted procedure APC.

discount3 63 - 67 9(1)v9(4)

Multiple Procedure Discount Factor –For all other procedure APCs.

discount4 68 - 72 9(1)v9(4)

Discontinued Procedures Discount Factor dmodpct 73 - 77 9(1)v9(4)Outpatient Ratio of Costs-to-Charges rcc 78 - 83 9(1)v9(5)Filler 84 - 94 X(11)Outlier Payment Percent outlier_pct 95 - 99 9(1)v9(4)Outlier Payment Factor outlier_fac 100 - 104 9(1)v9(4)Ambulance Rural Factor ambrural 105 - 109 9(1)v9(4)Ambulance Non-Rural Factor ambnonrural 110 - 114 9(1)v9(4)Hospital Quality Indicator hospqualind 115 X(1)Hospital Quality Reduction Factor qualredfact 116 - 120 9(1)v9(4)Filler 121 - 125 X(5)Claim Denial Override Flag0 = Do not override Return Code 221 = Override Return Code 22

clm_denial_override

126 9(1)

Payment Limit Flag – Limit payment to some percent of charges.0 = No1 = Yes

paylim 127 9(1)

Payment Limit Factor – Limit payment for each claim to this field times total charges.

paypct 128 - 132 9(1)v9(4)

Reserved for Co-Payment Limit Flag – Limit co-payment to some percent of charges.0 = No1 = Yes

copaylim 133 9(1)

Reserved for Co-Payment Limit Factor – Limit payment for each claim to this field times total charges.

copaypct 134 - 138 9(1)v9(4)


Base * Weight Pricing Flag0 = No (use APC Rates)1 = Yes (use BRATE * APC weights)

brflag 139 9(1)

Base Rate or Conversion Factor –Supply this field if BRFLAG = 1

brate 140 - 147 9(5)v9(3)

Fee Schedule Charge Limit Flag0 = Fee schedule items are priced at the fee schedule

rate1 = Fee schedule items are priced at the lesser of the

fee schedule rate or line item charge2 = Fee schedule items except for Payment Status

Indicator G and K items are priced at the lesser of the fee schedule rate or line item charge (default)

fschglim 148 9(1)

Discounting Option0 = Use Medicare discounting rules (default)1 = Use contract pricing discounts2 = Use Iowa Medicaid discounting rules

discoption 149 9(1)


fsind 150 9(1)

Fee Schedule Table fstable 151 - 163 X(13)Ambulance Coverage Factor ambcov 164 - 168 9(1)v9(4)Ambulance Coinsurance Factor ambcoins 169 - 173 9(1)v9(4)Ambulance Location/Carrier Code


ambcarrier 174 - 185 X(12)

DMEPOS Coverage Factor dmecov 186 - 190 9(1)v9(4)DMEPOS Coinsurance Factor dmecoins 191 - 195 9(1)v9(4)DMEPOS Location/Carrier Code dmecarrier 196 - 207 X(12)Lab Coverage Factor labcov 208 - 212 9(1)v9(4)Lab Coinsurance Factor labcoins 213 - 217 9(1)v9(4)Lab Location/Carrier Code labcarrier 218 - 229 X(12)National Coverage Factor mamcov 230 - 234 9(1)v9(4)National Coinsurance Factor mamcoins 235 - 239 9(1)v9(4)National Location/Carrier Code mamcarrier 240 - 251 X(12)Physician Fee Schedule Coverage Factor rehcov 252 - 256 9(1)v9(4)Physician Fee Schedule Coinsurance Factor rehcoins 257 - 261 9(1)v9(4)Physician Fee Schedule Location/Carrier Code rehcarrier 262 - 273 X(12)Other Coverage Factor othcov 274 - 278 9(1)v9(4)Other Coinsurance Factor othcoins 279 - 283 9(1)v9(4)Other Location/Carrier Code othcarrier 284 - 295 X(12)




APC Mapping Flag0 = Do not map HCPCS codes1 = Map HCPCS codes

apcmapflag 296 9(1)

Pricing Selection, Non-OPPS0 = Include Non-OPPS and Reasonable Cost under

Non-OPPS1 = Separate Reasonable Cost from Non-OPPS

psaf 297 9(1)

Payment Factor, Non-OPPS Items psafpayfact 298 - 302 9(1)v9(4)Co-Payment Factor, Non-OPPS Items psafcpyfact 303 - 307 9(1)v9(4)Filler 308 9(1)Payment Factor, Non-Covered Items psbepayfact 309 - 313 9(1)v9(4)Co-Payment Factor, Non-Covered Items psbecpyfact 314 - 318 9(1)v9(4)Filler 319 9(1)Payment Factor, Inpatient Items pscpayfact 320 - 324 9(1)v9(4)Co-Payment Factor, Inpatient Items psccpyfact 325 - 329 9(1)v9(4)Pricing Selection, Packaged Items/Paystatus N: 0 = Package according to Medicare rules1 = Use Contract fee schedule or pay percent of charge

psn 330 9(1)

Payment Factor, Packaged Items/Paystatus N psnpayfact 331 - 335 9(1)v9(4)Co-Payment Factor, Packaged Items/Paystatus N psncpyfact 336 - 340 9(1)v9(4)Pricing Selection, Line Items Without HCPCS Codes:0 = Medicare rules 1 = Package 2 = Use specified percent of charges

psrev 341 9(1)

Payment Factor, Line Items Without HCPCS Codes psrevpayfact 342 - 346 9(1)v9(4)Co-Payment Factor, Line Items Without HCPCS Codes psrevcpyfact 347 - 351 9(1)v9(4)Paystatus G Flag0 = Medicare rulesProcedure code is grouped to an APC and priced using an APC rate.1 = Percent of charge if no fee scheduleIf there is a fee schedule rate for the procedure code, pay via the fee schedule. If the item is not in the fee schedule, pay as a percent of line item charge.2 = Price using the fee schedule rate

psg 352 9(1)

Payment Factor, Paystatus G psgpayfact 353 - 357 9(1)v9(4)Co-Payment Factor, Paystatus G psgcpyfact 358 - 362 9(1)v9(4)Paystatus H Flag0 = Pay the same as other APCs (default)1 = Use Contract fee schedule or pay a percent of

charge

psh 363 9(1)

Payment Factor, Paystatus H pshpayfact 364 - 368 9(1)v9(4)Co-Payment Factor, Paystatus H pshcpyfact 369 - 373 9(1)v9(4)Bilateral Pricing Discount Factor –Default is 1.0000.

bilateral 374 - 378 9(1)v9(4)

Payment Factor, Reasonable Cost Items psflpayfact 379 - 383 9(1)v9(4)




Co-Payment Factor, Reasonable Cost Items psflcpyfact 384 - 388 9(1)v9(4)Override ID override_id 389 - 408 X(20)Total Reimbursement Mark-Up Factor discount 409 - 413 9(1)v9(4)Lab Panel/Multi-Channel Flag0 = Perform lab panel/multi-channel discounting

(default)1 = Do not perform lab panel/multi-channel discounting

labpnl 414 9(1)

Fee Schedule Mark-Up Flag Except Fee Type of Other0 = Apply mark-up factor1 = Do not apply mark-up factor

fee_markup 415 9(1)

Fee Schedule Mark-Up Flag for Fee Type of Other0 = Apply mark-up factor1 = Do not apply mark-up factor

fsother_markup 416 9(1)

Pay Status H Items Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

h_markup 417 9(1)

Pay Status G and K Items Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

gk_markup 418 9(1)

Pay Status J1, J2, R, S, T, V, and X Items Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

rstvx_markup 419 9(1)

Pay Status F and L Items Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

fl_markup 420 9(1)

All Other Payment Statuses Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

other_markup 421 9(1)

Outlier Add-On Items Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

out_markup 422 9(1)

Pay Status U Mark-Up Flag0 = Apply mark-up factor1 = Do not apply mark-up factor

u_markup 423 9(1)

Pricer Return Code 08 Override Flag1 = Override line-level Pricer Return Code 08 for

modifiers GX, GY, and GZ.

modovrflg 424 9(1)

Outlier Fixed Cost Threshold outlier_thresh 425 - 434 9(8)v9(2)Reserved for Reasonable Cost Factor rcost_fact 435 - 439 9(1)v9(4)Rural Adjustment Factor rural_fact 440 - 444 9(1)v9(4)

Table 13-10: Contract APC Extended Hospital Rate File Layout - medext.dat

Field Description Variable Name Position FormatHospital Number pfac 1 - 16 X(16)Paysource (Payer) Code psrc 17 - 29 X(13)




Hospital Number with NPI/Taxonomy pfac 1 - 20 X(20)Paysource (Payer) Code with NPI/Taxonomy psrc 21 - 29 X(9)Effective Date eff_date 30 - 37 9(8)Patient Type pattype 38 X(1)Sequence Number seqnum 39 X(1)Extended Fee Schedule Table fsexttable 40 - 52 X(13)Pay Lines with MUEs Flag0 = Do not pay lines with MUEs1 = Pay lines with MUEs up to the MUE maximum

mue_flag 53 9(1)

Apply Therapy Modifier and Revenue Code Logic Flag

0 = Do not apply Return Code 411 = Assign Return Code 41 for therapy billing errors

based on bill type and revenue code requirements2 = Assign Return Code 41 for therapy G-codes

without appropriate discipline and severity modifiers

3 = Assign Return Code 41 for bill type/revenue code restrictions and also for therapy G-codes without appropriate discipline and severity modifiers

4 = Apply Return Code 41 for therapy code without appropriate modifier

5 = Apply all Return Code 41 options

rc41_flag 54 9(1)

Non-Emergency ESRD Ambulance Reduction Factor esrd_reduc 55 - 59 9(1)v9(4)Bypass Fee Schedule Markup if Fee Schedule Payment Capped at Charges0 = Apply markup to line items whose fee schedule

payment has been capped at charges1 = Bypass markup for line items whose fee schedule

payment has been capped at charges

bypass_markup 60 9(1)

Apply Terminated Discounting to Non-Payment Status T Codes0 = Do not apply terminated discounts to eligible

services1 = Apply terminated discounting to eligible services

term_disc 61 9(1)

Apply Invalid Billing of Device Credit Logic0 = Do not assign Return Code 42 for claims with

invalid billing of device credits1 = Assign Return Code 42 to claims with invalid

billing of device credits

inval_device_flag 62 9(1)

Paystatus J1 Flag0 = Pay the same as other APCs (default)1 = Use contract fee schedule or pay a percent of

charge

psj1 63 9(1)

Payment Factor, Paystatus J1 psj1payfact 64 - 68 9(1)v9(4)Co-Payment Factor, Paystatus J1 psj1cpyfact 69 - 73 9(1)v9(4)




Apply Michigan Medicaid Short Stay Reimbursement Policy0 = Do not apply Michigan Medicaid Short Stay

Reimbursement Policy1 = Apply Michigan Medicaid Short Stay

Reimbursement Policy

short_stay 74 9(1)

Short Stay Rate hss_rate 75 - 84 9(8)v9(2)Apply Computed Tomography (CT) Reduction Factor0 = Do not apply CT Reduction Policy1 = Apply the CT Reduction Policy

modct_flag 85 9(1)

Computed Tomography (CT) Reduction Factor ct_reduc 86 - 90 9(1)v9(4)Apply Never Event Modifier Logic0 = Do not apply1 = Apply invalid modifier for pricing line-level Return

Code 08

nem_flag 91 9(1)

Non-Participating Provider Factor altprov_factor 92 - 96 9(1)v9(4)Apply X-Ray With Film Reduction Flag0 or blank = Do not apply x-ray with film reduction1 = Apply x-ray with film reduction

fx_flag 97 9(1)

X-Ray With Film Reduction Factor fx_reduc 98 - 102 9(1)v9(4)Fee Schedule Layout FlagCheck = Utilize new fee schedule layout (450 bytes)Do Not Check = Utilize legacy fee schedule layout

(38 bytes)

fs_flag 103 9(1)

Apply Non-Emergent Emergency Room (ER) Reduction Flag0 = Do not apply non-emergent ER reduction1 = Apply non-emergent ER reduction

er_flag 104 9(1)

Non-Emergent Qualified Physician Referral Factor mdrefer_factor 105 - 109 9(1)v9(4)

Non-Emergent No Qualified Physician Referral Factor

norefer_factor 110 - 114 9(1)v9(4)

DME Rural Indicator0 = Non-rural (urban) facility for DME services 1 = Rural facility for DME services

rural_ind 115 9(1)

Apply Provider-Based Department (PBD) Reduction Flag0 = Do not apply reduction factor1 = Apply PN reduction factor2 = Apply PO reduction factor3 = Apply both PN and PO reduction factors

pn_flag 116 9(1)

PBD Reduction Factor (PN) pn_reduc 117 - 121 9(1)v9(4)PBD Payment Factor (PN) pn_pay 122 - 126 9(1)v9(4)Ambulance Pricing Option0 = No change from previous methodology1 = Apply Medicare rules2 = Apply Michigan rules3 = Apply non-Medicare rules

amb_option 127 9(1)

Ambulance Base Rate Reduction - 2 Patients amb_reduc2 128 - 132 9(1)v9(4)




Ambulance Base Rate Reduction - > 2 Patients amb_reduc3 133 - 137 9(1)v9(4)Paystatus K Flag0 = Medicare rulesProcedure code is grouped to an APC and priced using an APC rate.1 = Percent of charge if no fee scheduleIf there is a fee schedule rate for the procedure code, pay via the fee schedule. If the item is not in the fee schedule, pay as a percent of line item charge.2 = Price using the fee schedule rate

psk 138 9(1)

Payment Factor, Paystatus K pskpayfact 139 - 143 9(1)v9(4)Co-Payment Factor, Paystatus K pskcpyfact 144 - 148 9(1)v9(4)Apply Computed Radiography Reduction Flag0 = Do not apply computed radiography reduction1 = Apply computed radiography reduction

fy_flag 149 9(1)

Computed Radiography Reduction Factor fy_reduc 150 - 154 9(1)v9(4)Therapy Bundling Flag0 = Do not deny bundled therapy services with line-

level Pricer Return Code 361 = Only deny bundled therapy services with line-

level Pricer Return Code 36 when a fee schedule rate is not established

2 = Deny all bundled therapy services with line-level Pricer Return Code 36

bundle_therapy 155 9(1)

PBD Reduction Factor (PO) po_reduc 156 - 160 9(1)v9(4)Fee Schedule Mark-Up Flag for Ambulance Fee Schedule Items1 = Bypass mark-up factor

fsamb_markup 161 9(1)

Fee Schedule Mark-Up Flag for DME Fee Schedule Items1 = Bypass mark-up factor

fsdme_markup 162 9(1)

Fee Schedule Mark-Up Flag for Lab Fee Schedule Items1 = Bypass mark-up factor

fslab_markup 163 9(1)

Fee Schedule Mark-Up Flag for National/ASP/Medicaid Fee Schedule Items1 = Bypass mark-up factor

fsnat_markup 164 9(1)

Fee Schedule Mark-Up Flag for Physician Fee Schedule Items1 = Bypass mark-up factor

fsphys_markup 165 9(1)

Filler 166 - 507 X(342)Pricer Type prcr_type 508 - 509 X(2)Key Type key_type 510 X(1)




13.2.3.2 Contract ASC

Table 13-11: Contract ASC Hospital Rate File Variables - medout.dat

Field Description Variable Name Position FormatLabor-Related Portion labor 39 - 44 9(1)v9(5)Wage Index wi 45 - 50 9(1)v9(5)Multiple Procedure Discount Factor - First Procedure discount1 51 - 55 9(1)v9(4)Multiple Procedure Discount Factor - All Other Procedures

discount4 56 - 60 9(1)v9(4)

Discontinued Procedure Discount dmodpct 61 - 65 9(1)v9(4)Percentage Payment Rate Flag pprflg 66 9(1)Percentage Payment Rate ppr 67 - 71 9(1)v9(4)Mark-up/Discount Factor markup 72 - 76 9(1)v9(4)Payment Limit Flag paylim 77 9(1)Payment Limit Factor paypct 78 - 82 9(1)v9(4)Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

fsind 83 9(1)

Fee Schedule Table fstable 84 - 96 X(13)Coverage Factor asrcov 97 - 101 9(1)v9(4)Coinsurance Factor asrcoins 102 - 106 9(1)v9(4)Fee Schedule Carrier asrcarrier 107 - 118 X(12)Other Coverage Factor othcov 119 - 123 9(1)v9(4)Other Coinsurance Factor othcoins 124 - 128 9(1)v9(4)Other Fee Schedule Carrier othcarrier 129 - 140 X(12)Payment Status A2 Items Mark-up Flag a2_markup 141 9(1)Payment Status AX Items Mark-up Flag ax_markup 142 9(1)Payment Status AZ Items Mark-up Flag az_markup 143 9(1)Payment Status F4 Items Mark-up Flag f4_markup 144 9(1)Payment Status G2 Items Mark-up Flag g2_markup 145 9(1)Payment Status H2 Items Mark-up Flag h2_markup 146 9(1)Payment Status H7 Items Mark-up Flag h7_markup 147 9(1)Payment Status H8 Items Mark-up Flag h8_markup 148 9(1)Payment Status J7 Items Mark-up Flag j7_markup 149 9(1)Payment Status J8 Items Mark-up Flag j8_markup 150 9(1)Payment Status K2 Items Mark-up Flag k2_markup 151 9(1)Payment Status K7 Items Mark-up Flag k7_markup 152 9(1)Payment Status L6 Items Mark-up Flag l6_markup 153 9(1)Payment Status P2 Items Mark-up Flag p2_markup 154 9(1)Payment Status P3 Items Mark-up Flag p3_markup 155 9(1)Payment Status R2 Items Mark-up Flag r2_markup 156 9(1)Payment Status Z2 Items Mark-up Flag z2_markup 157 9(1)


13.2.4.3 Medicaid APG Pro

Payment Status Z3 Items Mark-up Flag z3_markup 158 9(1)Cardiac Resynch. Therapy Logic Flag0 = Do not apply Return Code 371 = Apply Return Code 37

rc37_flag 159 9(1)

ASC Quality Reduction Factor qual_reduct 160 - 164 9(1)v9(4)Apply Bio-Similar Modifier Logic Flag0 = Do not apply Return Code 541 = Apply Return Code 54

rc54_flag 165 9(1)

Fee Schedule Layout Flag0 or Blank = Utilize legacy fee schedule layout (38 bytes) 1 = Utilize new fee schedule layout (450 bytes)

fs_flag 166 9(1)

Colonoscopy Payment Factor col_pay_fact 167 - 171 9(1)v9(4)Colonoscopy Co-Payment Factor col_copay_fact 172 - 176 9(1)v9(4)Pay Lines With MUEs0 = Do not pay lines with MUEs1 = Pay lines with MUEs up to the MUE maximum

mue_flag 177 9(1)

Multiple Procedure Discount Factor - Second Procedure discount2 178 - 182 9(1)v9(4)Multiple Procedure Discount Factor - Third Procedure discount3 183 - 187 9(1)v9(4)Filler 188 - 437 X(250)

Table 13-12: Medicaid APG Pro Hospital Rate Variables - medout.dat

Field Description Variable Name Format PositionState state_id X(2) 39 - 40Procedure Array proc_array X(4) (occurs

50 times)41 - 240

Provider Specific Base Rate base_rate 9(8)v9(2) 241 - 250Mark-Up/Discount Factor markup 9(1)v9(4) 251 - 255First Procedure Discount disc1 9(1)v9(4) 256 - 260Second Procedure Discount disc2 9(1)v9(4) 261 - 265All Other Procedures Discount disc3 9(1)v9(4) 266 - 270First Repeat Ancillary Discount ancdisc1 9(1)v9(4) 271 - 275Second Repeat Ancillary Discount ancdisc2 9(1)v9(4) 276 - 280Third Repeat Ancillary Discount ancdisc3 9(1)v9(4) 281 - 285Terminated Procedure Discount termdisc 9(1)v9(4) 286 - 290Bilateral Procedure Adjustment bilatdisc 9(1)v9(4) 291 - 295Ratio of Cost-to-Charges (RCCs) rcc 9(1)v9(4) 296 - 300Factor 1 factor1 9(1)v9(4) 301 - 305Rate 1 rate1 9(8)v9(4) 306 - 315Rate 2 rate2 9(8)v9(4) 316 - 325

Table 13-11: Contract ASC Hospital Rate File Variables - medout.dat



Facility Type facility_type 9(1) 326 Policy Adjustor 1 pol_adj1 9(1)v9(4) 327 - 331Policy Adjustor 2 pol_adj2 9(1)v9(4) 332 - 336Marginal Cost Factor mcf 9(1)v9(4) 337 - 341Cost Outlier Threshold threshold 9(8)v9(2) 342 - 351Age age 9(3) 352 - 354Add-On Payment add_on 9(8)v9(2) 355 - 364Ratio of Cost of Charges (RCCs) 2 rcc2 9(1)v9(4) 365 - 369Policy Adjustor 3 pol_adj3 9(1)v9(4) 370 - 374Policy Adjustor 4 pol_adj4 9(1)v9(4) 375 - 379Policy Adjustor 5 pol_adj5 9(1)v9(4) 380 - 384Filler X(2) 385 - 386Extended Hospital Rate Calculator File in Use0 = Extended Hospital Rate

Calculator File not required1 = Extended Hospital Rate

Calculator File required

medext_sw X(1) 387

Fee Schedule Table fstable X(13) 388 - 400Extended Fee Schedule Table fsexttable X(13) 401 - 413National Carrier natcarrier X(12) 414 - 425Other Carrier othcarrier X(12) 426 - 437State Rate File Version version X(7) 438 - 444

Table 13-13: Medicaid APG Pro Extended Hospital Rate File Layout - medext.dat

Field Description Variable Name Position FormatHospital Number facility 1 - 16 X(16)Paysource (Payer) Code paysrc 17 - 29 X(13)Effective Date eff_date 30 - 37 9(8)Patient Type pattype 38 X(1)Sequence Number seq_num 39 X(1)Add-On 2 add_on2 40 - 49 9(8)v9(2)Add-On 3 add_on3 50 - 59 9(8)v9(2)Alternate Weight st_weight 60 - 66 9(2)v9(5)Independently Bilateral Adjustment bilatdisc2 67 - 71 9(1)v9(4)Filler 72 - 507 X(436)

Pricer Type prcr_type 508 - 509

X(2)

Key Type key_type 510 X(1)

Table 13-12: Medicaid APG Pro Hospital Rate Variables - medout.dat



13.2.5.4 TRICARE APC

Table 13-14: TRICARE APC Hospital Rate Calculator Variables - medout.dat

Field Description Variable Name Position FormatIn Network Provider network 39 9(1)Markup markup 40 - 44 9(1)v9(4)User Key 1 user_key1 45 - 59 X(15)User Key 2 user_key2 60 - 74 X(15)Filler 75 - 437 X(363)NMPRF/State Rate File Version (when applicable, otherwise filler)

version 438 - 444 X(7)

Rate Manager .TAB Filename 445 - 453 X(9)Filler 454 - 457 X(4)Weights/Rates, Owned/Shared havewt 458 X(1)Shared Weights/Rates, Facility ID ratefac 459 - 474 X(16)Shared Weights/Rates, Payer ID ratepsrc 475 - 487 X(13)Shared Weights/Rates, Effective Date rateeffdate 488 - 495 9(8)Grouper Type: Set to __tri (i.e. double-space, tri) if this payer uses TRICARE APCs for payment.

grpr_type 496 - 500 X(5)

Grouper Version grpr_vers 501 - 503 9(3)Pricer/Payer Type – Character field, left-justified. Set to 63 for TRICARE APC Pricer

pricer_type 504 - 505 9(2)

ICD-9-CM Mapping Flag icd9_map 506 9(1)Edit Date edit_date 507 9(1)Filler 508 - 510 X(3)


13.2.6 COBOL Platform13.2.7.1 Contract APC

Table 13-15: Contract APC COBOL Hospital Rate File Variables - hosprate.dat

Field Description Variable Name Format PositionsLabor-Related Portion Y3R-LABOR 9(1)v9(5) 251 - 256Wage Index Y3R-WI 9(1)v9(5) 257 - 262Facility Type00 = All other hospitals05 = OPPS exempt (CAH) 08 = Non-participating hospital

Y3R-FACILITY-TYPE 9(2) 263 - 264

Multiple Significant Procedure Payment Discount Factor for Highest Weighted Procedure

Y3R-DISCOUNT1 9(1)v9(4) 265 - 269

Multiple Significant Procedure Payment Discount Factor for 2nd Highest Weighted Procedure.

Y3R-DISCOUNT2 9(1)v9(4) 270 - 274

Multiple Significant Procedure Payment Discount Factor for 3rd Highest Weighted Procedure.

Y3R-DISCOUNT3 9(1)v9(4) 275 - 279

Multiple Significant Procedure Payment Discount Factor for all other Procedures.

Y3R-DISCOUNT4 9(1)v9(4) 280 - 284

Discontinued Procedures Discount Factor Y3R-DMODPCT 9(1)v9(4) 285 - 289Outpatient Ratio of Costs to Charges Y3R-RCC 9(1)v9(5) 290 - 295Inpatient Deductible Y3R-INPDED 9(8)v9(2) 296 - 305Reserved for 1996 Ratio of Payment to Charges

9(1)v9(4) 306 - 310

Outlier Payment Percent Y3R-OUTLIER-PCT 9(1)v9(4) 311 - 315Outlier Payment Factor Y3R-OUTLIER-FAC 9(1)v9(4) 316 - 320Ambulance Rural Factor Y3R-AMBRURAL 9(1)v9(4) 321 - 325Ambulance Non-Rural Factor Y3R-AMBNONRURAL 9(1)v9(4) 326 - 330Hospital Quality Indicator Y3R-HOSPQUALIND X(1) 331Hospital Quality Reduction Factor Y3R-QUALREDFACT 9(1)v9(4) 332 - 336Filler X(5) 337 - 341Claim Denial Override Flag0 = Do not override Return Code 221 = Override Return Code 22

Y3R0-CLM-DENIAL-OVERRIDE

9(1) 342

Flag to Limit Payment to Some Percent of Charges (APC Contract Pricer Only)

Y3R-PAYLIM 9(1) 343

Payment Limit Factor (Limit Payment for Each Claim to this Field Times Total Charges) (APC Contract Pricer Only).

Y3R-PAYPCT 9(1)v9(4) 344 - 348

Flag to Limit Co-Payment to Some Percent of Charges (APC Contract Pricer Only)

Y3R-COPAYLIM 9(1) 349


Co-Payment Limit Factor (Limit Payment for Each Claim to this Field Times Total Charges (APC Contract Pricer Only)

Y3R-COPAYPCT 9(1)v9(4) 350 - 354

Use Base * Weight Pricing Y3R-BRFLAG 9(1) 355Base Rate or Conversion Factor. Y3R-BRATE 9(5)v9(3) 356 - 363Fee Schedule Charge Limit Flag0 = Fee schedule items are priced at the

fee schedule rate1 = Fee schedule items are priced at the

lesser of the fee schedule rate or line item charge

2 = Fee schedule items except for Payment Status Indicator G and K items are priced at the lesser of the fee schedule rate or line item charge (default)

Y3R-FSCHGLIM 9(1) 364

Discounting Option0 = Use Medicare discounting rules

(default)1 = Use contract pricing discounts2 = Use Iowa Medicaid discounting rules

Y3R-DISCOPTION 9(1) 365

Fee Schedule Indicator Y3R-FSIND 9(1) 366Fee Schedule Table Y3R-FSTABLE X(13) 367 - 379Ambulance Coverage Factor Y3R-AMBCOV 9(1)v9(4) 380 - 384Ambulance Coinsurance Factor Y3R-AMBCOINS 9(1)v9(4) 385 - 389Ambulance Location/Carrier Code Y3R-AMBCARRIER X(12) 390 - 401DMEPOS Coverage Factor Y3R-DMECOV 9(1)v9(4) 402 - 406DMEPOS Coinsurance Factor Y3R-DMECOINS 9(1)v9(4) 407 - 411DMEPOS Location/Carrier Code Y3R-DMECARRIER X(12) 412 - 423Lab Coverage Factor Y3R-LABCOV 9(1)v9(4) 424 - 428Lab Coinsurance Factor Y3R-LABCOINS 9(1)v9(4) 429 - 433Lab Location/Carrier Code Y3R-LABCARRIER X(12) 434 - 445National Coverage Factor Y3R-MAMCOV 9(1)v9(4) 446 - 450National Coinsurance Factor Y3R-MAMCOINS 9(1)v9(4) 451 - 455National Location/Carrier Code Y3R-MAMCARRIER X(12) 456 - 467Physician Fee Schedule Coverage Factor Y3R-REHCOV 9(1)v9(4) 468 - 472Physician Fee Schedule Coinsurance Factor

Y3R-REHCOINS 9(1)v9(4) 473 - 477


Y3R-REHCARRIER X(12) 478 - 489

Other Coverage Factor Y3R-OTHCOV 9(1)v9(4) 490 - 494Other Coinsurance Factor Y3R-OTHCOINS 9(1)v9(4) 495 - 499Other Location/Carrier Code Y3R-OTHCARRIER X(12) 500 - 511




Pricing Selection, Non-OPPS0 = Include Non-OPPS and Reasonable

Cost under Non-OPPS.1 = Separate Reasonable Cost from Non-

OPPS.

Y3R-PSAF 9(1) 512

Payment Factor for Non-OPPS Items (Paystatus A)

Y3R-PSAFPAYFACT 9(1)v9(4) 513 - 517

Co-Payment Factor for Non-OPPS Items Y3R-PSAFCPYFACT 9(1)v9(4) 518 -522Reserved Filler 9(1) 523Payment Factor for Non-Covered Items Y3R-PSBEPAYFACT 9(1)v9(4) 524 - 528Co-Payment Factor for Non-Covered Items

Y3R-PSBECPYFACT 9(1)v9(4) 529 - 533

Reserved Filler 9(1) 534Payment Factor for Inpatient Items Y3R-PSCPAYFACT 9(1)v9(4) 535 - 539Co-Payment Factor for Inpatient Items Y3R-PSCCPYFACT 9(1)v9(4) 540 - 544Pricing Selection for Packaged Items (Paystatus N)

Y3R-PSN 9(1) 545

Payment Factor for Packaged Items Y3R-PSNPAYFACT 9(1)v9(4) 546 - 550Co-Payment Factor for Packaged Items Y3R-PSNCPYFACT 9(1)v9(4) 551 - 555Pricing Selection for Line Items Without HCPCS Codes

Y3R-PSREV 9(1) 556

Payment Factor for Line Items Without HCPCS Codes

Y3R-PSREVPAYFACT 9(1)v9(4) 557 - 561

Co-Payment Factor for Line Items Without HCPCS Codes

Y3R-PSREVCPYFACT 9(1)v9(4) 562 - 566

Paystatus G Flag0 = Medicare rulesProcedure code is grouped to an APC and priced using an APC rate.1 = Percent of charge if no fee scheduleIf there is a fee schedule rate for the procedure code, pay via the fee schedule. If the item is not in the fee schedule, pay as a percent of line item charge.2 = Price using the fee schedule rate

Y3R-PSG 9(1) 567

Payment Factor for Paystatus G Y3R-PSGPAYFACT 9(1)v9(4) 568 - 572Co-Payment Factor for Paystatus G Y3R-PSGCPYFACT 9(1)v9(4) 573 - 577Paystatus H Flag Y3R-PSH 9(1) 578Payment Factor for Paystatus H Y3R-PSHPAYFACT 9(1)v9(4) 579 - 583Co-Payment Factor for Paystatus H Y3R-PSHCPYFACT 9(1)v9(4) 584 - 588Bilateral Pricing Discount Factor Default is 1.0000 (if left at zeros, Pricer will assume discount = 1.0000)

Y3R-BILATERAL 9(1)v9(4) 589 - 593

Total Reimbursement Discount Factor Y3R-DISCOUNT 9(1)v9(4) 594 - 598Fixed Outlier Threshold Y3R-OUTLIER THRESH 9(8)v9(2) 599 - 608




Payment Factor for Reasonable Cost Items

Y3R-PSFLPAYFACT 9(1)v9(4) 609 - 613

Co-Payment Factor, Reasonable Cost Items

Y3R-PSFLCPYFACT 9(1)v9(4) 614 - 618

Lab Panel /Multi-Channel Flag0 = Perform lab panel/multi-channel

discounting (default)1 = Do not perform lab panel/multi-

channel discounting

Y3R-LABPNL 9(1) 619

Fee Schedule Mark-Up Flag except Fee Type of Other0 = Apply mark-up factor1 = Do not apply mark-up factor

Y3R-FEE-MARKUP X(1) 620

Fee Schedule Mark-Up Flag for Fee Type of Other0 = Apply Mark-Up Factor1 = Do Not Apply Mark-Up Factor

Y3R-FSOTHER-MARKUP X(1) 621

Pay Status H Items Mark-Up Flag0 = Apply Mark-Up Factor1 = Do Not Apply Mark-Up Factor

Y3R-H-MARKUP X(1) 622

Pay Status G and K Items Mark-up Flag0 = Apply Mark-Up Factor1 = Do Not Apply Mark-Up Factor

Y3R-GK-MARKUP X(1) 623

Pay Status J1, J2, R, S, T, V, and X Items Mark-Up Flag0 = Apply Mark-Up Factor1 = Do not Apply Mark-Up Factor

Y3R-RSTVX-MARKUP X(1) 624

Pay Status F and L Items Mark-Up Flag0 = Apply Mark-Up Factor1 = Do Not Apply Mark-Up Factor

Y3R-FL-MARKUP X(1) 625

All Other Payment Statuses Mark-Up Flag0 = Apply Mark-Up Factor1 = Do not Apply Mark-Up Factor

Y3R-OTHER-MARKUP X(1) 626

Outlier Add-on Items Mark-Up Flag0 = Apply Mark-Up Factor1 = Do not Apply Mark-Up Factor

Y3R-OUT-MARKUP X(1) 627

Rural Adjustment Factor Y3R-RURAL-FACT 9(1)v9(4) 628 - 632Pay Status U Mark-Up Flag0 = Apply Mark-Up Factor1 = Do Not Apply Mark-Up Factor

Y3R-U-MARKUP X(1) 633

Pricer Return Code 08 Override Flag1 = Override Line-Level Pricer Return

Code 08 for Modifiers GX, GY, and GZ

Y3R-MODOVRFLG 9(1) 634





Table 13-16: Contract APC Extended COBOL Hospital Rate File Layout - hospext.dat

Field Description Variable Name Position FormatHospital Number HER-HOSP 1 - 16 X(16)Paysource (Payer) Code HER-PCODE 17 - 29 X(13)Hospital Number with NPI/Taxonomy HER-HOSP 1 - 10 X(10)Paysource (Payer) Code with NPI/Taxonomy

HER-PCODE 11 - 20 X(10)

Patient Type HER-PATTYPE 30 X(1)Effective Date Sequence Code Extension

HER-ESEQ-EXT 31 X(1)

Effective Date Sequence Code (Set by Base Rate Calculator Program)

HER-ESEQ 32 - 35 9(4)

Effective Date of Rate Calculator Variables

HER-EDATE

Effective Century/Year HER-EDATE-CCYY 36 - 39 9(4)Effective Month HER-EDATE-MM 40 - 41 9(2)Effective Day HER-EDATE-DD 42 - 43 9(2)Filler for Future Expansion (Stop Date) 44 - 51 X(8)Extended Fee Schedule Variable Y3R0-FSEXTTABLE 52 - 64 X(13)Pay Lines with MUEs Flag0 = Do not pay lines with MUEs1 = Pay lines with MUEs up to the MUE

maximum

Y3R0-MUE-FLAG 65 9(1)

Apply Therapy Modifier and Revenue Code Logic Flag0 = Do not apply Return Code 411 = Assign Return Code 41 for therapy

billing errors based on bill type and revenue code requirements

2 = Assign Return Code 41 for therapy G-codes without appropriate discipline and severity modifiers

3 = Assign Return Code 41 for bill type/revenue code restrictions and also for therapy G-codes without appropriate discipline and severity modifiers

4 = Apply Return Code 41 for therapy code without appropriate modifier

5 = Apply all Return Code 41 options

Y3R0-RC41-FLAG 66 9(1)


Y3R0-ESRD-REDUCE 67 - 71 9(1)v9(4)

Bypass Fee Schedule Markup if Fee Schedule Payment Capped at Charges0 = Apply markup to line items whose

fee schedule payment has been capped at charges

1 = Bypass markup for line items whose fee schedule payment has been capped at charges

Y3R0-BYPASS-CAP 72 9(1)


Apply Terminated Discounting to Non-Payment Status T Codes0 = Do not apply terminated discounts to

eligible services1 = Apply terminated discounting to

eligible services

Y3R0-TERM-DISC 73 9(1)

Apply Invalid Billing of Device Credit Logic0 = Do not assign Return Code 42 for

claims with invalid billing of device credits

1 = Assign Return Code 42 to claims with invalid billing of device credits

Y3R0-INVAL-DEVICE-FLAG 74 9(1)

Paystatus J1 Flag0 = Pay the same as other APCs

(default)1 = Use contract fee schedule or pay a

percent of charge

Y3R0-PSJ1 75 9(1)

Payment Factor, Paystatus J1 Y3R0-PSJ1PAYFACT 76 - 80 9(1)v9(4)Co-Payment Factor, Paystatus J1 Y3R0-PSJ1CPYFACT 81 - 85 9(1)v9(4)Apply Michigan Medicaid Short Stay Reimbursement Policy0 = Do not apply Michigan Medicaid

Short Stay Reimbursement Policy1 = Apply Michigan Medicaid Short Stay

Reimbursement Policy

Y3R0-SHORT-STAY 86 9(1)

Short Stay Rate Y3R0-HSS-RATE 87 - 96 9(8)v9(2)Apply Computed Tomography (CT) Reduction0 = Do not apply CT Reduction Policy1 = Apply the CT Reduction Policy

Y3R0-MODCT-FLAG 97 9(1)


Y3R0-CT-REDUC 98 - 102 9(1)v9(4)

Apply Never Event Modifier Logic0 = Do not apply1 = Apply invalid modifier for pricing line-

level Return Code 08

Y3R0-NEM-FLAG 103 9(1)

Non-Participating Provider Factor Y3R0-ALTPROV-FACTOR 104 -108 9(1)v9(4)Apply X-Ray With Film Reduction Flag0 or blank = Do not apply x-ray with film

reduction1 = Apply x-ray with film reduction

Y3R0-FX-FLAG 109 9(1)

X-Ray With Film Reduction Factor Y3R0-FX-REDUC 110 - 114 9(1)v9(4)Fee Schedule Layout FlagCheck = Utilize new fee schedule layout

(450 bytes)Do Not Check = Utilize legacy fee

schedule layout (41 bytes)

Y3R0-FS-FLAG 115 9(1)




Apply Non-Emergent Emergency Room (ER) Reduction Flag0 = Do not apply non-emergent ER

reduction1 = Apply non-emergent ER reduction

Y3R0-ER-FLAG 116 9(1)

Non-Emergent Qualified Physician Referral Factor

Y3R0-MD-REFER-FACTOR 117 - 121 9(1)v9(4)

Non-Emergent No Qualified Physician Referral Factor

Y3R0-MD-NOREFER-FACTOR

122 - 126 9(1)v9(4)

DME Rural Indicator0 = Non-rural (urban) facility for DME

services 1 = Rural facility for DME services

Y3R0-RURAL-IND 127 9(1)

Apply PBD Reduction Flag0 = Do not apply reduction factor1 = Apply PN reduction factor2 = Apply PO reduction factor3 = Apply both PN and PO reduction

factors

Y3R0-PN-FLAG 128 9(1)

PBD Reduction Factor (PN) Y3R0-PN-REDUC 129 - 133 9(1)v9(4)PBD Payment Factor (PN) Y3R0-PN-PAY 134 - 138 9(1)v9(4)Ambulance Pricing Option0 = No change from previous

methodology1 = Apply Medicare rules2 = Apply Michigan rules3 = Apply non-Medicare rules

Y3R0-AMB-OPTION 139 9(1)

Ambulance Base Rate Reduction - 2 Patients

Y3R0-AMB-REDUC2 140 - 144 9(1)v9(4)


Y3R0-AMB-REDUC3 145 - 149 9(1)v9(4)

Paystatus K Flag0 = Medicare rulesProcedure code is grouped to an APC and priced using an APC rate.1 = Percent of charge if no fee scheduleIf there is a fee schedule rate for the procedure code, pay via the fee schedule. If the item is not in the fee schedule, pay as a percent of line item charge.2 = Price using the fee schedule rate

Y3R0-PSK 150 9(1)

Payment Factor, Paystatus K Y3R0-PSKPAYFACT 151 - 155 9(1)v9(4)Co-Payment Factor, Paystatus K Y3R0-PSKCPYFACT 156 - 160 9(1)v9(4)




13.2.8.2 Contract ASC

Apply Computed Radiography Reduction Flag0 = Do not apply computed radiography

reduction1 = Apply computed radiography

reduction

Y3R0-FY-FLAG 161 9(1)

Computed Radiography Reduction Factor

Y3R0-FY-REDUC 162 - 166 9(1)v9(4)

Therapy Bundling Flag0 = Do not deny bundled therapy

services with line-level Pricer Return Code 36

1 = Only deny bundled therapy services with line-level Pricer Return Code 36 when a fee schedule rate is not established

2 = Deny all bundled therapy services with line-level Pricer Return Code 36

Y3R0-BUNDLE-THERAPY 167 9(1)

PBD Reduction Factor (PO) Y3R0-PO-REDUC 168 - 172 9(1)v9(4)Fee Schedule Mark-Up Flag for Ambulance Fee Schedule Items1 = Bypass mark-up factor

Y3R0-FSAMB-MARKUP 173 9(1)

Fee Schedule Mark-Up Flag for DME Fee Schedule Items1 = Bypass mark-up factor

Y3R0-FSDME-MARKUP 174 9(1)

Fee Schedule Mark-Up Flag for Lab Fee Schedule Items1 = Bypass mark-up factor

Y3R0-FSLAB-MARKUP 175 9(1)

Fee Schedule Mark-Up Flag for National/ASP/Medicaid Fee Schedule Items1 = Bypass mark-up factor

Y3R0-FSNAT-MARKUP 176 9(1)

Fee Schedule Mark-Up Flag for Physician Fee Schedule Items1 = Bypass mark-up factor

Y3R0-FSPHYS-MARKUP 177 9(1)

Filler 178 - 800 X(623)Pricer Type Y3R0-PRICER-TYPE 801 - 802 X(2)Key Type Y3R0-KEY-TYPE 803 X(1)

Table 13-17: Contract ASC COBOL Hospital Rate File Variables - hosprate.dat

Field Description Variable Name Format PositionLabor-Related Portion Y4R-LABOR 9v9(5) 251 - 256Wage Index Y4R-WI 9v9(5) 257 - 262




Multiple Procedure Discount Factor - First Procedure

Y4R-DISCOUNT1 9(1)v9(4) 263 - 267

Multiple Procedure Discount Factor – All Other Procedures

Y4R-DISCOUNT4 9(1)v9(4) 268 - 272

Discontinued Procedure Discount Y4R-DMODPCT 9(1)v9(4) 273 - 277Payment Percentage Rate Flag Y4R-PPRFLG 9(1) 278 - 278Payment percentage rate Y4R-PPR 9(1)v9(4) 279 - 283Markup/Discount Factor Y4R-MARKUP 9(1)v9(4) 284 - 288Payment Limit Flag Y4R-PAYLIM 9(1) 289 - 289Payment Limit Factor Y4R-PAYPCT 9(1)v9(4) 290 - 294Fee Schedule Indicator0 = No fee schedule pricing1 = Fee schedule pricing

Y4R-FSIND 9(1) 295 - 295

Fee Schedule Table Y4R-FSTABLE X(13) 296 - 308ASC Coverage Factor Y4R-ASRCOV 9(1)v9(4) 309 - 313ASC Coinsurance Factor Y4R-ASRCOINS 9(1)v9(4) 314 - 318ASC Fee Schedule Carrier Y4R-ASRCARRIER X(12) 319 - 330Other Coverage Factor Y4R-OTHCOV 9(1)v9(4) 331 - 335Other Coinsurance Factor Y4R-OTHCOINS 9(1)v9(4) 336 - 340Other Fee Schedule Carrier Y4R-OTHCARRIER X(12) 341 - 352Payment Status A2 Items Mark-up Flag Y4R-A2-MARKUP 9(1) 353Payment Status AX Items Mark-up Flag Y4R-AX-MARKUP 9(1) 354Payment Status AZ Items Mark-up Flag Y4R-AZ-MARKUP 9(1) 355Payment Status F4 Items Mark-up Flag Y4R-F4-MARKUP 9(1) 356Payment Status G2 Items Mark-up Flag Y4R-G2-MARKUP 9(1) 357Payment Status H2 Items Mark-up Flag Y4R-H2-MARKUP 9(1) 358Payment Status H7 Items Mark-up Flag Y4R-H7-MARKUP 9(1) 359Payment Status H8 Items Mark-up Flag Y4R-H8-MARKUP 9(1) 360Payment Status J7 Items Mark-up Flag Y4R-J7-MARKUP 9(1) 361Payment Status J8 Items Mark-up Flag Y4R-J8-MARKUP 9(1) 362Payment Status K2 Items Mark-up Flag Y4R-K2-MARKUP 9(1) 363Payment Status K7 Items Mark-up Flag Y4R-K7-MARKUP 9(1) 364Payment Status L6 Items Mark-up Flag Y4R-L6-MARKUP 9(1) 365Payment Status P2 Items Mark-up Flag Y4R-P2-MARKUP 9(1) 366Payment Status P3 Items Mark-up Flag Y4R-P3-MARKUP 9(1) 367Payment Status R2 Items Mark-up Flag Y4R-R2-MARKUP 9(1) 368Payment Status Z2 Items Mark-up Flag Y4R-Z2-MARKUP 9(1) 369Payment Status Z3 Items Mark-up Flag Y4R-Z3-MARKUP 9(1) 370Cardiac Resynch. Therapy Logic Flag0 = Do not apply Return Code 371 = Apply Return Code 37

Y4R-RC37-FLAG 9(1) 371




ASC Quality Reduction Factor Y4R-QUAL-REDUCT 9(1)v9(4) 372 - 376Apply Bio-Similar Modifier Logic Flag0 = Do not apply Return Code 541 = Apply Return Code 54

Y4R-RC54-FLAG 9(1) 377

Fee Schedule Layout Flag0 or Blank = Utilize legacy fee schedule layout

(38 bytes) 1 = Utilize new fee schedule layout (450 bytes)

Y4R-FS-FLAG 9(1) 378

Colonoscopy Payment Factor Y4R-COL-PAY-FACT 9(1)v9(4) 379 - 383Colonoscopy Co-Payment Factor Y4R-COL-COPAY-

FACT9(1)v9(4) 384 - 388

Pay Lines With MUEs0 = Do not pay lines with MUEs1 = Pay lines with MUEs up to the MUE

maximum

Y4R-MUE-FLAG 9(1) 389

Multiple Procedure Discount Factor - Second Procedure

Y4R-DISCOUNT2 9(1)v9(4) 390 - 394

Multiple Procedure Discount Factor - Third Procedure

Y4R-DISCOUNT3 9(1)v9(4) 395 - 399





14 Physician Factor File Layout

This chapter provides the layout for the Physician Factor File (C and COBOL). It includes the following section:

• C and COBOL Platform Layout


14.1 C and COBOL Platform LayoutTable 14-1: Physician Factor Variables - facphyyy.dat; fac09yy.dat

Field Description C Variable Name COBOL Variable Name

Format Position

Billing National Provider Identifier (NPI)

npi HFR-NPI X(10) 1 - 10

Paysource paysrc HFR-PAYSRC X(9) 11 - 19Tax Identification Number (TIN)

tin HFR-TIN X(9) 20 - 28

Sequence Number seq_nbr HFR-SEQ-NBR 9(4) 29 - 32Page Number pge_nbr HFR-PGE-NBR 9(2) 33 - 34Start Date startdate HFR-START-

DATE9(8) 35 - 42

End Date enddate HFR-END-DATE 9(8) 43 - 50C Pricer Type Reserved prcr_type_c HFR-PRCR-

TYPE-C-RSVDX(2) 51 - 52

COBOL Pricer Type Reserved

prcr_type_cbl HFR-PRCR-TYPE-CBL-RSVD

X(2) 53 - 54

Payment Factor pay_fac HFR-09-PAY-FAC 9(3)v9(6) 55 - 63Filler X(37) 64 - 100


15 Fee Schedule File Layouts

This chapter provides the layouts for the Fee Schedule Data Files (C and COBOL). This chapter includes the following sections:

• Overview- File Naming Conventions

• Fee Schedule Data File Layout- Medicaid APG Fee Schedule Data File Layout- APC-HOPD and Contract APC Fee Schedule Data File Layout- ESRD Fee Schedule Data File Layout- Physician Fee Schedule Data File Layout- SNF Fee Schedule Data File Layout- Legacy Fee Schedule Data File Layout


15.1 OverviewOptum supplies different types of Fee Schedule Files. The file for the calendar year is updated several times throughout the year and distributed separately on the Fee Schedule Data File distribution. Users can modify or import a Fee Schedule File through Rate Manager or create a user-specified file in the file layouts detailed below. Once a fee schedule has been modified, it should be renamed to prevent it from being overwritten by future updates from Optum. The Pricers used alone or with the Optimizer, can accept user-specified fee schedule file names that conform to the appropriate naming convention. When naming a user-specified file, keep in mind that the file name must (1) include fs, FS, or fee as the first letters of the file name (note that the Extended Fee Schedule file name should be prefixed with ex or EX), (2) not exceed eight (8) characters, and (3) not include spaces or non-alphanumeric characters (for example, fscnt12 or ex2011 are valid file names for the C Platform). Refer to the EASYGroup™ User’s Guide for further information. Beginning January 01, 2017, the Fee Schedule Data File will only contain data for a given year and for a specific payment system. During the course of the Fiscal Year (FY), updated/revised annual fee schedule files for each payment system may be released. The files will overlay the client's current fee schedule files for that year/payment system. Prior to the next Fiscal Year (FY), a new annual fee schedule file will be deployed. As was the case prior to January 01, 2017, the new file will only contain data for a given year and for a specific payment system. In order to determine if you need to load the new annual fee schedule file, please reference the figure below. If the distribution contains a file matching the listed naming scheme(s), then you will need to load the new annual fee schedule file.

Figure 15-1. Naming Schemes


For the data-only distribution of the fee schedule files, the JCL for defining/loading the new annual fee schedule file is named:

• MVSFSYY (z/OS)• VSEFSYY (z/VSE)

For the Pricer distributions, steps for defining/loading the new annual fee schedule file have been added to the existing JCL named:

• MVSCLDF/MVSCLLD (z/OS)• VSECLDF/VSECLLD (z/VSE)

NotePrior to January 01, 2017, the COBOL Fee Schedules contained only rates for the current year. If required, users can create a cumulative file for multiple years (refer to the COBOL directory within the distribution for a sample JCL).

15.1.1 File Naming ConventionsFee schedule file names are listed in the following tables, where yyyy or yy is replaced by the 4-digit or 2-digit calendar year, respectively.

Table 15-1: Fee Schedule File Names

Description C COBOL COBOL Fee Rate

COBOL Fee Type

Alabama BCBS APG

feealbcyy.dat N/A N/A N/A

APC-HOPD feeyyyy.dat fsr01yy.dat N/A N/AASC feeascyy.dat fsr02yy.dat N/A N/AColorado APG feecoyy.dat N/A N/A N/AContract APC feeyyyy.dat fsr01yy.dat N/A N/AContract ASC Legacy:

fsascyy.dat

New:feeascyy.dat

New:fsr02yy.dat

Legacy:fsr02.dat

Legacy:fst02.dat

Enhanced New York Medicaid APG

feenyyy.datfeenywyy.dat

N/A N/A N/A

ESRD feesrdyy.dat fsr05yy.dat N/A N/AFQHC feefqyy.dat fsr11yy.dat N/A N/AHHA feehhyy.dat fsr06yy.dat N/A N/AHospice feehspyy.dat fsr12yy.dat N/A N/AIowa Medicaid APC

feeiayy.dat fsr10yy.dat N/A N/A

Massachusetts Medicaid APG

feemayy.dat N/A N/A N/A


15.2 Fee Schedule Data File Layout15.2.1.1 Key FieldsKey fields are variables used across all applicable payment systems.

Michigan Medicaid APC

feemiyy.dat fsr08yy.dat N/A N/A

Michigan Medicaid ASC

feemiayy.dat fsr07yy.dat N/A N/A

Nebraska Medicaid APG

feeneyy.dat N/A N/A N/A

New Mexico Medicaid APC

feenmyy.dat N/A N/A N/A

Ohio Medicaid APG

feeohyy.dat N/A N/A N/A

Physician feephysyy.dat fsr09yy.dat N/A N/ASNF feesnfyy.dat fsr03yy.dat N/A N/AVirginia Medicaid APG

feevayy.dat N/A N/A N/A

Virginia Medicaid ASC

feevaasyy.dat N/A N/A N/A

Washington Medicaid APG

feewayy.dat N/A N/A N/A

Wisconsin Medicaid APG

feewiyy.dat N/A N/A N/A

Table 15-2: Legacy Extended Fee Schedule File Names

Description C COBOLContract APC exyyyy.dat fse01.dat

Table 15-1: Fee Schedule File Names

Description C COBOL COBOL Fee Rate

COBOL Fee Type

Table 15-3: Fee Schedule Data File Variables - Key Fields, C and COBOL

Field Description C Variable Name

COBOL Variable Name

Format Position Notes

HCPCS Code hcpcs FSR1-HCPCS-CODE

X(7) 1 - 7 HCPCS Level I or II code. No embedded spaces or decimals.

Location/Carrier carrier FSR1-CARRIER

X(12) 8 - 19 Identifies the carrier code for this payment rate.

Sequence Number seq_nbr FSR1-SEQ-NBR

9(4) 20 - 23 Begins at 1, varies based on carrier.


Page Number pge_nbr FSR1-PGE-NBR

9(2) 24 - 25 Reserved

Start Date startdate FSR1-START-DATE

9(8) 26 - 33 CCYYMMDD. Date on which this payment rate becomes effective. Generally, this will be January 1st of each calendar year.

End Date enddate FSR1-END-DATE

9(8) 34 - 41 00000000 = Code is still in effect

YYYYMMDD = End date for the record

Total Number of Modifiers

ttl_mods FSR1-TTL-MODS

9(1) 42 Total number of modifiers.

Modifiers modifiers FSR1-MODIFIERS

X(2) occurs 5 times

43 - 52 Where applicable, a HCPCS code can appear more than once in the table along with different modifiers, where the modifier results in a different payment.

Pricer Type (C Platform)

prcr_type_c FSR1-PRCR-TYPE-C

X(2) 53 - 54 Refer to the Input & Output Parameter Blocks User’s Guide for a detailed list.

Pricer Type (COBOL Platform)

prcr_type_cbl FSR1-PRCR-TYPE-CBL

X(2) 55 - 56 Refer to the Input & Output Parameter Blocks User’s Guide for a detailed list.

Fee Schedule Type type FSR1-TYPE X(2) 57 - 58 A = Ambulance fee scheduleD = DMEPOS fee scheduleL = Clinical laboratory fee

scheduleM = Medicaid fee scheduleN = National/ASP fee scheduleP = Physician fee scheduleS = ASC fee scheduleX = Other fee schedule (user-

defined)



COBOL Variable Name



Gap Fill Indicator gapfill FSR1-GAPFILL X(2) 59 - 60 APC-HOPD:Ambulance Services:1 = Ground transport2 = Air transport3 = Air mileage4 = Ground mileage

Physician Services:5 = Therapy service subject to

discounting9 = All other therapy services

ASC:Indicates whether a service is subject to multiple procedure discounting and/or the service is preventive and coinsurance is waived.

0 = Not subject to multiple procedure discounting

1 = Subject to multiple procedure discounting

2 = Coinsurance is waived for this preventive service

3 = Subject to multiple procedure discounting and coinsurance is waived for this preventive service

continued below...



COBOL Variable Name



Gap Fill Indicator <continued>

gapfill FSR1-GAPFILL X(2) 59 - 60 Contract APC:Ambulance Services:1 = Ground transport2 = Air transport3 = Air mileage4 = Ground mileage


discounting9 = All other therapy services

National/ASP:A = Anesthesia service

Other:B = Michigan Medicaid

ambulance mileage

ESRD:National/ASP:2 = Epoetin alfa Retacrit®3 = Drug subject to the

Transitional Drug Add-On Payment Adjustment (TDAPA)

5 = Epoetin alfa6 = Darbepoetin alfa8 = Blood9 = Non-ESRD Erythropoietin

Stimulating Agent (ESA)

FQHC:National/ASP:1 = Coinsurance based on

charges

HHA:National/ASP:1 = Osteoporosis drugs

continued below...



COBOL Variable Name



Gap Fill Indicator <continued>

gapfill FSR1-GAPFILL X(2) 59 - 60 Hospice:Physician Services:1 = Kidney Disease Education

Iowa Medicaid APC:Physician Services:5 = Therapy service subject to

discounting

National/ASP:A = Anesthesia

Michigan Medicaid APC:Physician Services:5 = Therapy service subject to

discounting

New Mexico Medicaid APC:1= Lab service2 = Vaccine for children3 = Observation service4 = Manual pricing

Physician:Ambulance Services:1 = Ground transport2 = Air transport3 = Air mileage4 = Ground mileage

DME Services:5 = Units not used in pricing6 = Pharmacy supply and

dispensing code

SNF:Ambulance Services:1 = Ground transport2 = Air transport3 = Air mileage4 = Ground mileage


discounting6 = Coinsurance is waived for

this preventive service



COBOL Variable Name



Rate 1 rate1 FSR1-RATE1 9(8)v9(3) 61 - 71 Contains the fee schedule rate for:

A = Urban ambulanceD = Urban DMEPOSL = Clinical laboratoryM = MedicaidN = National/ASPP = Facility physician S = ASC fee scheduleX = Other fee schedule (user-

defined)

Washington Medicaid APG: For services with a Special Payment Flag (spay_flag) of 4 (Paid Based on Age (Dental Procedure)), this is the fee schedule rate for patients age 21 and older. For all other services, this is the fee schedule rate for all patients.


A = Rural ambulance D = Rural DMEPOSM = MedicaidP = Non-facility physician

Washington Medicaid APG: For services with a Special Payment Flag (spay_flag) of 4 (Paid Based on Age (Dental Procedure)), this is the fee schedule rate for patients under the age of 21.


A = Super rural ambulanceP = Therapy services subject to

the MPPRRate 4 rate4 FSR1-RATE4 9(8)v9(3) 94 - 104 Contains the fee schedule rate

for:

A = Ground rural ambulance for 1 - 17 miles

Filler X(22) 105 - 126



COBOL Variable Name



NoteFields 171 - 450 are payment system-specific.

Multiple Fee Schedule Type Flag

multi_ftype FSR1-MULTIFLAG

9(1) 127 0 = This code only has one fee schedule type for the year

1 = This code changed fee schedule types for the year

Filler X(43) 128 - 170



COBOL Variable Name



15.2.2 Medicaid APG Fee Schedule Data File Layout

Table 15-4: Medicaid APG Fee Schedule Data File Variables

Field Description Variable Name Format Position NotesProcedure Weight weight 9(3)v9(6) 171 - 179 Enhanced New York

Medicaid APG:Relative weight for this procedure.

Procedure Discount Percent 1 disc1 9(1)v9(5) 180 - 185 Ohio Medicaid APG:The payment for this procedure will be discounted by this factor if units are billed that exceed the value shown in the Maximum Units field.

Washington Medicaid APG: The payment for this service will be discounted by this factor when the Special Payment Flag is set to 3.

Procedure Discount Percent 2 disc2 9(1)v9(5) 186 - 191 ReservedProcedure Discount Percent 3 disc3 9(1)v9(5) 192 - 197 ReservedMaximum Units maxunits 9(7) 198 - 204 Ohio Medicaid APG:

The number of units for which the service will be paid 100% and above which the service will be paid the discount shown in the Procedure Discount Percent 1 field.

Enhanced New York Medicaid APG and Washington Medicaid APG:The maximum payable units for this procedure code.


Fee Flag fee_flag 9(1) 205 This flag indicates if the procedure code is paid using a fee schedule rate, and, if so how it is paid using that rate.

Alabama BCBS APG, Colorado Medicaid APG, Enhanced New York Medicaid APG, Massachusetts Medicaid APG, Nebraska Medicaid APG, Virginia Medicaid ASC, Washington Medicaid APG, and Wisconsin Medicaid APG:0 = Price using procedure

weight1 = Price using fee

schedule rate (charge cap)

2 = Price using percent of charge

3 = Price using second percent of charge

4 = Price using greater of fee schedule rate or charges

5 = Price using fee schedule (no charge cap)

6 = Price using percent of cost with discounts

7 = Price using fee schedule rate with discounts (charge cap)

8 = Price using fee schedule rate with discounts (no charge cap)

continued below...




Fee Flag<continued>

fee_flag 9(1) 205 Ohio Medicaid APG:1 = Price using fee


2 = Price using fee schedule rate (charge cap, no packaging or consolidation)

6 = Price using percent of cost with discounts

7 = Price using fee schedule rate with discounts (charge cap)

8 = Price using fee schedule rate with discounts (no charge cap)

Virginia Medicaid APG:1 = Price using fee


2 = Price using fee schedule rate (charge cap, no packaging or consolidation)

5 = Price using fee schedule (no charge cap)

Units Flag units_flag 9(1) 206 Enhanced New York Medicaid APG:Apply the units of service in the payment calculation.

0 = Service units not used1 = Service units used2 = Top 25 drug




Special Payment Flag spay_flag 9(1) 207 This procedure code uses special payment logic.

Colorado Medicaid APG:1 = Manually priced3 = Long Acting Reversible

Contraceptive (LARC) device

Enhanced New York Medicaid APG:0 = No special payment

logic1 = Carve out2 = Payable incidental

procedure3 = Per-diem max units

payment logic4 = No capital add-on

procedure5 = No capital add-on

procedure and payable incidental procedure

8 = No payment

Ohio Medicaid APG:0 = No special payment

logic2 = Vaccine for Children

(VFC)3 = Long Acting Reversible

Contraceptive (LARC) device

Virginia Medicaid APG:0 = No special payment


(VFC) vaccine code, paid fee schedule if patient age < 19

3 = Long Acting Reversible Contraceptive (LARC) device

Virginia Medicaid ASC:0 = No special payment


(VFC) vaccine code, paid fee schedule if patient age < 19

continued below...




Special Payment Flag <continued>

spay_flag 9(1) 207 Washington Medicaid APG:0 = No special payment

logic1 = Procedure code paid

billed charges2 = Procedure code paid

percent of charge3 = Non-excepted off-

campus provider-based department reduction applied

4= Paid based on age (dental procedure)

Wisconsin Medicaid APG:0 = No special payment

logic2 = Procedure code paid

even if packaged by APG Grouper

Stand Alone Flag standalone_flag 9(1) 208 Enhanced New York Medicaid APG:This procedure will not be paid if billed without any other procedures on the same date of service (i.e., stand-alone).

0 = Not subject to stand-alone payment logic

1 = If stand-alone, pay zeroTransition Flag trans_flag 9(1) 209 Enhanced New York

Medicaid APG:Payment for this procedure code will be a blend of the APG payment and the previous non-APG payment.

0 = Not subject to blending1 = Subject to blending

AMCC Indicator amcc 9(1) 210 Massachusetts Medicaid APG:0 = Concept does not apply1 = Multi-channel service2 = Lab panel service3 = Lab panel service with

components not included in the AMCC bundling




15.2.3 APC-HOPD and Contract APC Fee Schedule Data File Layout

AMCC Component Count amcc_cnt 9(3) 211 - 213 Massachusetts Medicaid APG:Count of procedure codes that are included in the AMCC bundling for this lab panel code. For multichannel services, the count will always be 001.

Codes Not Included in AMCC Bundling

not_amcc X(5) occurs 3 times

214 - 228 Massachusetts Medicaid APG:Procedure code that is not included in the AMCC bundling for this lab panel code.

Filler X(222) 229 - 450

Table 15-5: APC-HOPD & Contract APC Fee Schedule Data File Variables, C and COBOL



Practice Expense RVU pe_rvu FSR1-FS1-PE-RVU

9(8)v9(5) 171 - 183 APC-HOPD and Contract APC:Non-facility PE RVU value. This value is used to determine the highest paid therapy service.

Anesthesia Base Units anth_base FSR1-FS1-ANTH-BASE

9(3) 184 - 186 Contract APC:Base units for this anesthesiaservice.

Alternate Pricing Flag alt_flag FSR1-FS1-ALT-FLAG

9(1) 187 Contract APC:Procedure codes are being processed using the followingmethodologies:

1 = Manually Priced2 = Maximum Fee

(lesser of the billed charges or fee schedule rate)

3 = Billed Charges




15.2.4 ESRD Fee Schedule Data File Layout

Co-Payment Waived Flag

copay_waived FSR1-FS1-COPAY-WAIVED

9(1) 188 APC-HOPD and Contract APC:Flag used to identify services that are not subject to co-payments.

0 = Co-Payment is Not Waived

1 = Co-Payment is Waived

Filler X(262) 189 - 450

Table 15-6: ESRD Fee Schedule Data File Variables, C and COBOL


COBOL Variable Name


ESRD Non-Separately Payable Flag

cb_flag FSR1-FS5-CB-FLAG

9(1) 171 This flag identifies services that will not be separately payable when billed with Modifier AY on an ESRD claim.

1 = Service is not separately payable when billed with Modifier AY on an ESRD claim

0 = OtherwiseOutlier Flag outlier_flag FSR1-FS5-

OUTLIER-FLAG

9(1) 172 Flag to identify services that contribute to outlier calculations.

0 = Procedure code is not outlier eligible

1 = Procedure code is outlier eligibleAKI Non-Separately Payable Flag

cb_flag2 FSR1-FS5-CB-FLAG2

9(1) 173 This flag identifies services that will not be separately payable when billed on an AKI claim.

1 = Service is not separately payable on an AKI claim

0 = OtherwiseFiller X(277) 174 - 450

Table 15-5: APC-HOPD & Contract APC Fee Schedule Data File Variables, C and COBOL




15.2.5 Physician Fee Schedule Data File Layout

Table 15-7: Physician Fee Schedule Data File Variables, C and COBOL


COBOL Variable Name


Practice Expense RVU

pe_rvu FSR1-FS9-PE-RVU

9(8)v9(5) 171 - 183 Non-facility PERVU value.

Status Code scode FSR1-FS9-SCODE

X(1) 184 Indicates whether the code is in the fee schedule and whether it is separately payable if the service is covered.

A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from physician fee

schedule by regulationF = Deleted/discontinued codeG = Not valid for Medicare purposesH = Deleted modifierI = Not valid for Medicare purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/excluded codeQ = Therapy functional information

code (used for required reporting purposes only)

R = Restricted coverageT = InjectionsX = Statutory exclusion

PC/TC Indicator pctc FSR1-FS9-PCTC

X(1) 185 0 = Physician service codes1 = Diagnostic tests for radiology

services2 = Professional component only

codes3 = Technical component only codes4 = Global test only codes5 = Incident to codes6 = Laboratory physician

interpretation codes7 = Physical therapy service, for

which payment may not be made8 = Physician interpretation codes9 = Not applicable


Global Surgery glob_surg FSR1-FS9-GLOB-SURG

X(3) 186 - 188 000 = Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.

010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.

continued below...Global Surgery glob_surg FSR1-FS9-

GLOB-SURGX(3) 186 - 188 090 = Major surgery with a 1-day

preoperative period and 90-day postoperative period included in the fee schedule amount.

MMM = Maternity codes; usual global period does not apply.

XXX = The global concept does not apply to this code.

YYY = The carrier is to determine whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing.

ZZZ = The code is related to another service and is always included in the global period of the other service.



COBOL Variable Name



MPPR Indicator mppr FSR1-FS9-MPPR

9(1) 189 0 = Not eligible for multiple procedure discounting

2 = Eligible for multiple procedure discounting

3 = Eligible for Endoscopy Discounting

4 = Professional/Technical Component (PC/TC) Eligible for Diagnostic Imaging Discounting

5 = Subject to 20% PE RVU Discount for Certain Therapy Services

6 = Eligible for Diagnostic Cardiovascular Procedure Discounting

7 = Eligible for Diagnostic Ophthalmology Procedure Discounting

9 = Concept does not applyBilateral Indicator bilat FSR1-FS9-

BILAT9(1) 190 Indicates services subject to bilateral

payment adjustments.

0 = Not bilateral1 = Conditionally bilateral2 = Inherently bilateral3 = Independently bilateral9 = Not applicable

Assistant to Surgery Indicator

astsurg FSR1-FS9-ASTSURG

9(1) 191 Indicates services where an assistant at surgery is never paid for per Medicare Claims Manual.

0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.

1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.

2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.

9 = Concept does not apply.



COBOL Variable Name



Co-Surgery Indicator cosurg FSR1-FS9-COSURG

9(1) 192 Indicates services for which two surgeons, each in a different specialty, may be paid.

0 = Co-surgeons not permitted for this procedure

1 = Co-surgeons could be paid, though supporting documentation is required to establish the medical necessity of two surgeons for the procedure

2 = Co-surgeons permitted and no documentation required if the two-specialty requirement is met

9 = Concept does not applyTeam Surgery Indicator

teamsurg FSR1-FS9-TEAMSURG

9(1) 193 Indicates services for which team surgeons may be paid.

0 = Team surgeons not permitted for this procedure.

1 = Team surgeons could be paid, though supporting documentation required to establish medical necessity of a team; pay by report.

2 = Team surgeons permitted; pay by report.

9 = Concept does not apply.Endoscopy Base Code

endo_base FSR1-FS9-ENDO-BASE

X(5) 194 - 198 Base code for this endoscopic procedure.

Filler 9(1) 199Anesthesia Flag anesthesia FSR1-FS9-

ANESTHESIA9(1) 200 1 = Anesthesia service does not have

time unitsAnesthesia Base Units

base_units FSR1-FS9-BASE-UNITS

9(3) 201 - 203 Base units for this anesthesia service.

Coinsurance Waiver Flag

coins_waived FSR1-FS9-COINS-WAIVED

9(1) 204 0 = Coinsurance not waived1 = Coinsurance waived2 = Coinsurance waived with

appropriate modifier3 = Coinsurance waived with

appropriate preventive service4 = Coinsurance waived; when billed

with a Prolonged Preventive Service (PPS), the PPS coinsurance will also be waived



COBOL Variable Name



Therapy Code Indicator

therapy FSR1-FS9-THERAPY

9(1) 205 1 = “Always therapy” code (non-facility rate in all circumstances)

2 = “Sometimes therapy” code (non-facility rate in some circumstances)

AMCC Indicator amcc FSR1-FS9-AMCC

9(1) 206 1 = Multi-channel service2 = Lab panel service3 = Lab panel service with

components not included in the AMCC bundling

0 = Concept does not applyAMCC Component Count

amcc_cnt FSR1-FS9-AMCC-CNT

9(3) 207 - 209 Count of procedure codes that are included in the AMCC bundling for this lab panel code. For multi-channel services, the count will always be 001.

Codes Not Included in AMCC Bundling

not_amcc FSR1-FS9-NOT-AMCC

X(5) 210 - 224 Procedure code that is not included in the AMCC bundling for this lab panel code.

Filler 9(1) 225OPPS Facility Fee Amount

fac_oppscap FSR1-FS9-FAC-OPPSCAP

9(8)v9(3) 226 - 236 Facility fee schedule rate that has been capped at the level of the OPPS Payment Amount mandated by Section 5102(b) of the DRA of 2005.

OPPS Non-Facility Fee Amount

nonfac_oppscap

FSR1-FS9-NONFAC-OPPSCAP

9(8)v9(3) 237 - 247 Non-facility fee schedule rate that has been capped at the level of the OPPS Payment Amount mandated by Section 5102(b) of the DRA of 2005.

Preoperative Percentage

preop FSR1-FS9-PREOP

9(1)v9(4) 248 - 252 Preoperative percentage of global fee.

Intraoperative Percentage

intraop FSR1-FS9-INTRAOP

9(1)v9(4) 253 - 257 Intraoperative percentage of global fee, including postoperative work in the hospital.

Postoperative Percentage

postop FSR1-FS9-POSTOP

9(1)v9(4) 258 - 262 Postoperative percentage of global fee for services provided in the office after hospital discharge.

Cardiovascular TC Code 1

cardio_tc1 FSR1-FS9-CARDIO-TC1

X(7) 263 - 269 First TC code associated with this global cardiovascular service.

Cardiovascular TC Code 2

cardio_tc2 FSR1-FS9-CARDIO-TC2

X(7) 270 - 276 Second TC code associated with this global cardiovascular service.

Filler X(174) 277 - 450



COBOL Variable Name



15.2.6 SNF Fee Schedule Data File Layout

15.3 Legacy Fee Schedule Data File LayoutNote

Applicable to Contract ASC only.

Table 15-8: SNF Fee Schedule Data File Variables, C and COBOL



Practice Expense RVU pe_rvu FSR1-FS3-PE-RVU

9(8)v9(5) 171 - 183 Non-facility PE RVU value.

Filler X(267) 184 - 450

Table 15-9: Legacy Fee Schedule Data File Variables, C and COBOL

Field Description

C Variable Name

COBOL Variable Name

Format CPosition

COBOL Position

Notes

HCPCS Code hcpcs HCPCS X(5) 1 - 5 4 - 8(1 - 3 is Filler)

HCPCS Level I or II code. No embedded spaces or decimals.

HCPCS Level II or CPT® code.

No embedded spaces or decimals.

Location/Carrier

carrier CARRIER X(12) 6 - 17 9 - 20 Identifies the carrier code for this payment rate.

This is set to “NATIONAL” for all ASC Fee Schedule services.

Effective Date effdate EFFDATE 9(8) 18 - 25 21 - 28 CCYYMMDD. Date on which this payment rate becomes effective. Generally, this will be January 1st of each calendar year.

Modifier modifier MODIFIER X(2) 26 - 27 29 - 30 Where applicable, a HCPCS code can appear more than once in the table along with different modifiers, where the modifier results in a different payment.

Fee Schedule Rate

feerate FEERATE 9(7)v9(2) 28 - 36 31 - 39 Fee Schedule Payment Rate applicable for this service.

Fee Schedule Type

type TYPE X(1) 37 40 Contract ASC:S = ASC fee scheduleX = Other fee schedule (user-

defined)


Gap Fill Indicator

gapfill GAPFILL X(1) 38 41 Contract ASC:Indicates whether a service is subject to multiple procedure discounting and/or the service is preventive and coinsurance is waived.

0 = Not subject to multiple procedure discounting.

1 = Subject to multiple procedure discounting.

2 = Coinsurance is waived for this preventive service.

3 = Subject to multiple procedure discounting and coinsurance is waived for this preventive service.

Table 15-9: Legacy Fee Schedule Data File Variables, C and COBOL

Field Description

C Variable Name

COBOL Variable Name

Format CPosition

COBOL Position

Notes


16 Code Table Data File Layouts

This chapter provides the layouts for the various Code Table Data Files (C and COBOL (when applicable)). This chapter includes the following sections:

• File Naming Conventions• Code Table Data File Layouts

- APC Code Table Data File Layout- ESRD Code Table Data File Layout- HHA Code Table Data File Layout- Hospice Code Table Data File Layout- Inpatient Code Table Data File Layout- Medicaid APG Pro Code Table Layout- New Mexico Medicaid APC Code Table Data File Layout- New York Medicaid APG Code Table Data File Layout- North Carolina Inpatient Code Table Data File Layout- Physician Code Table Data File Layout- Standard APG Code Table Data File Layout- Standard APR Code Table Data File Layout- SNF Code Table Data File Layout


16.1 File Naming ConventionsThe Code Table Data File names are listed below:

Table 16-1: Code Table Data File Names

Description FilenameC Platform

FilenameCOBOL Platform

APC Code Table Data File codeapc.dat code01.datESRD Code Table Data File codesrd.dat code05.datHHA Code Table Data File codehha.dat code06.datHospice Code Table Data File codehsp.dat code12.datInpatient Code Table Data File codedrg.dat codedrg.datMedicaid APG Pro Code Table:- Alabama BCBS APG Code Table Data File- Colorado Medicaid APG Code Table Data File- Florida Medicaid APG Code Table Data File- Illinois Medicaid APG Code Table Data File- Nebraska Medicaid APG Code Table Data File- Ohio Medicaid APG Code Table Data File- Virginia Medicaid APG Code Table Data File- Virginia Medicaid ASC Code Table Data File- Washington DC Medicaid APG Code Table Data

File

- codeal3.dat- codeco1.dat- codefl1.dat- codeil1.dat- codene1.dat- codeoh1.dat- codeva1.dat- codeva4.dat- codedc1.dat

New Mexico Medicaid APC Code Table Data File codenm1.datNew York Medicaid APG Code Table Data File codeny1.datNorth Carolina Inpatient Code Table Data File codenc2.datPhysician Code Table Data File codephys.dat code09.datStandard APG Code Table:- Illinois Medicaid APG Code Table Data File- New York Medicaid APG Code Table Data File

- codeil1.dat- codeny1.dat

Standard APR Code Table:- Colorado Inpatient Code Table Data File- Florida Inpatient Code Table Data File- Indiana Inpatient Code Table Data File- Louisiana Inpatient Code Table Data File- Massachusetts Inpatient Code Table Data File- Minnesota Inpatient Code Table Data File- Mississippi Inpatient Code Table Data File- New Jersey Inpatient Code Table Data File- Rhode Island Inpatient Code Table Data File- Virginia Inpatient Code Table Data File- Washington DC Inpatient Code Table Data File- Wisconsin Inpatient Code Table Data File

- codeco2.dat- codefl2.dat- codein2.dat- codela2.dat- codema2.dat- codemn2.dat- codems2.dat- codenj2.dat- coderi2.dat- codeva2.dat- codedc2.dat- codewi2.dat


SNF Code Table Data File codesnf.dat code03.dat

Table 16-1: Code Table Data File Names




16.2 Code Table Data File Layouts16.2.1 APC Code Table Data File Layout

Table 16-2: APC Code Table Data File Layout

Field Description

C Variable Name

COBOL Variable Name


Code Type codetype CTR-CODE-TYPE

X(1) 1 C = Procedure codeD = ICD-9-CM

diagnosis codeK = ICD-10-CM

diagnosis codeM = ModifierZ = Zip code

Code code CTR-CODE X(11) 2 - 12 Code value will be 5-digit zip code, 5 character procedure code, 7 character diagnosis code, or 2 character modifier.

Code Sequence seq CTR-SEQ 9(2) 13 - 14 Sequence number for this code record.

Start Date startdate CTR-START-DATE

9(8) 15 - 22 Date record is effective.

End Date enddate CTR-END-DATE


YYYYMMDD = End date for record

Ambulance Carrier/Locality

carrier CTR-01-CARRIER

X(12) 31 - 42 Identifies the Medicare Part B carrier number and pricing locality.


Ambulance Rural Indicator

amb_rural CTR-01-AMB-RURAL

X(1) 43 This flag indicates that the zip code is rural.

B = Qualified rural area zip code for air and ground ambulance services

R = Rural zip code for air and ground ambulance services

U = Rural zip code for ground ambulance services and qualified rural area zip code for air ambulance services

V = Qualified rural area zip code for ground ambulance services and rural zip code for air ambulance services

W = Rural zip code for ground ambulance services only

X = Rural zip code for air ambulance services only

Y = Qualified rural area zip code for ground ambulance services only (currently, not in use)

Z = Qualified rural area zip code for air ambulance services only

Blank = Not rural Device Offset dev_offset CTR-01-DEV-

OFFSET9(8)v9(2)

44 - 53 Procedure Code:Payment offset for device-intensive procedures.

Filler X(2) 54 - 55


Field Description

C Variable Name

COBOL Variable Name



Therapy Service Flag

therapyflag CTR-01-THERAPY-FLAG

9(1) 56 0 = All other 1 = Evaluative

therapy code, functional therapy code required

2 = Therapy code, no functional therapy code required

3 = Functional therapy code

4 = Therapy code without MPFS Rate, no functional therapy code required

Michigan Short Stay Flag

mssflag CTR-01-MSS-FLAG

9(1) 57 Contract APC:0 = All other diagnosis

codes1 = Diagnosis codes

subject to the Michigan short stay policy

Emergent Diagnosis Flag

erflag CTR-01-ER-FLAG

9(1) 58 Contract APC:0 = All other diagnosis

codes1 = Diagnosis codes

not subject to the Iowa Medicaid “non-emergent” ER reduction

Provider Based Department (PBD) Flag

pbd_flag CTR-01-PBD-FLAG

9(1) 59 APC-HOPD:0 = Not applicable1 = Not eligible for the

PN reduction2 = Eligible for the PO

reductionDeductible Waived Flag

deduct_waived CTR-01-DED-WV-FLAG

9(1) 60 APC-HOPD:0 = Do not waive

deductible1 = Waive deductible2 = Deductible waived

with Modifier CS


Field Description

C Variable Name

COBOL Variable Name



Coinsurance Waived Flag

coins_waived CTR-01-COINS-WV-FLAG

9(1) 61 APC-HOPD:0 = Do not waive

coinsurance1 = Waive

coinsurance2 = Coinsurance

waived with Modifier CS

Ambulance Flag amb_flag CTR-01-AMB-FLAG

9(1) 62 Contract APC & APC-HOPD:0 = Code is not in the

Ambulance Fee Schedule

1 = Code is in the Ambulance Fee Schedule

Offset Eligibility Flag

offset_elg CTR-01-OFFSET-ELG

9(1) 63 APC-HOPD:C = Procedure code

is eligible for contrast agent/skin product offsets

D = Procedure code is eligible for pass-through device offset

R = Procedure code is eligible for Radiopharmaceutical offsets

Edit Modifier edit_mod CTR-01-EDIT-MODS

X(2)occurs 5 times

64 - 73 Contract APC & APC-HOPD:Blank = Codes not

applicableGO = Occupational

speech therapy service

GN = Speech language pathology service

GP = Physical therapy service

Mammography Procedure Flag

mamm_flag CTR-01-MAMM-FLAG

9(1) 74 APC-HOPD:0 = All other

procedure codes1 = Mammography

codes


Field Description

C Variable Name

COBOL Variable Name



16.2.2 ESRD Code Table Data File Layout

Payment Adjustment Modifiers

pay_adj_mod CTR-01-PAY-ADJ-MODS

X(2)occurs 5 times

75 - 84 Contract APC & APC-HOPD:This field holds modifiers that can be used for a payment adjustment with the corresponding procedure code on the line:

CT = Services eligible for a reduction when billed with Modifier CT

FX= Services eligible for a reduction when billed with Modifier FX

FY = Services eligible for a reduction when billed with Modifier FY

Modifier Flag mod_flag CTR-01-MOD-FLAG

9(1) 85 APC-HOPD:0 = All others1 = Modifier indicates

COVID-19 testing-related service

Opioid Use Disorder Treatment Flag

oud_flag CTR-01-OUD-FLAG

9(1) 86 APC-HOPD:0 = All others1 = Opioid use

disorder treatment service

Filler X(164) 87 - 250

Table 16-3: ESRD Code Table Data File Layout

Field Description

C Variable Name COBOL Variable Name



X(1) 1 C = Procedure codeD = ICD-9-CM

diagnosis codeK = ICD-10-CM

diagnosis codeN = National Drug

Code (NDC)


Field Description

C Variable Name

COBOL Variable Name



Code code CTR-CODE X(11) 2 - 12 Code value will be a 5-digit procedure code, a 4 to 7 digit diagnosis code, or an 11-digit NDC value.

Code Sequence

codeseq CTR-SEQ 9(2) 13 - 14 Sequence number for this code record.






Vaccine Type vactype CTR-05-VAC-TYPE

9(1) 31 0 = Not a vaccine1 = Hepatitis B

vaccine2 = Hepatitis B

administration3 = Flu/PPV/COVID-

19 vaccine or monoclonal antibody

4 = Flu/PPV/COVID-19 vaccine or monoclonal antibody administration

NDC Mean Unit Cost

mean_unit_cost CTR-05-MEAN-UNIT-COST

9(8)v9(3) 32 - 42 National Drug Code (NDC) mean unit cost

Comorbidity Category

comrbd_cat CTR-05- COMRBD-CAT

9(2) 43 - 44 00 = Not a comorbidity code

01 = GI bleed02 = Pneumonia03 = Pericarditis04 = Myelodyspastic

syndrome05 = Sickle cell

anemia06 = Monclina

gammopathyFiller X(206) 45 - 250

Table 16-3: ESRD Code Table Data File Layout

Field Description

C Variable Name COBOL Variable Name



16.2.3 HHA Code Table Data File Layout

Table 16-4: HHA Code Table Data File Layout

Field Description

C Variable Name

COBOL Variable Name



X(1) 1 C = Procedure codeE = CBSAF = FIPS code

Code code CTR-CODE-TYPE

X(11) 2 - 12 Left justified. Code value will be a 5-digit procedure code, 5 digit CBSA code, or a 5 digit FIPS code.

Code Sequence




End Date enddate CTR-END-DATE 9(8) 23 - 30 00000000 = Code is still in effect.

YYYYMMDD = End date for record.

Wage Index wi CTR-06-WI 9(1)v9(4) 31 - 35 Wage index value associated to the CBSA.

Rural Indicator

ruralind CTR-06-RURAL-IND

9(1) 36 Code Type E (prior to January 01, 2019):0 = Non-rural CBSA1 = Rural CBSA

Code Type F (on or after January 01, 2019):0 = Non-rural1 = High utilization2 = Low population

density3 = All others

All Other Code Types:0 = All other records


16.2.4 Hospice Code Table Data File Layout

Vaccine Type vactype CTR-06-VAC-TYPE

9(1) 37 0 = Not a vaccine1 = Hepatitis B

vaccine3 = Flu/PPV/

COVID-19 vaccine or monoclonal antibody

Filler X(213) 38

Table 16-5: Hospice Code Table Date File Layout


COBOL Variable Name



X(1) 1 E = CBSAR = Revenue CodeM = Modifiers

Code code CTR-CODE X(11) 2 - 12 Code value will be 5 digit CBSA code, 4 digit revenue code, or a 2 character modifier.

Code Sequence codeseq CTR-SEQ 9(2) 13 - 14 Sequence number for this code record.




9(8) 23 - 30 00000000 = Code is still in effect.

YYYYMMDD = End date for record.

Care Type care_type CTR-12-CARE-TYPE

9(1) 31 Revenue Codes (Type R):1 = Routine Home Care

(RHC)2 = Continuous Home Care

(CHC)3 = Inpatient Respite (IRC)4 = General Inpatient (GIP)

Wage Index wi CTR-12-WI 9(1)v9(4)

32 - 36 CBSA Codes (Type E):Wage Index for CBSA

Rural Indicator rural_ind CTR-12-RURAL-IND

X(1) 37 CBSA Codes (Type E):R = CBSA is classified as

rural

Table 16-4: HHA Code Table Data File Layout

Field Description

C Variable Name

COBOL Variable Name



16.2.5 Inpatient Code Table Data File Layout

Modifier Flag mod_flag CTR-12-MOD-FLAG

9(1) 38 Modifiers (Type M):1 = Modifier indicates line is

non-coveredFiller X(212) 39 - 250

Table 16-6: Inpatient Code Table Data File Layout

Field Description

C Variable Name

COBOL Variable Name



X(1) 1 C = HCPCS/CPT® procedure code

D = ICD-9 diagnosis code

F = New technology family

K = ICD-10 diagnosis code

L = ICD-10 procedure code

N = National Drug Code (NDC)

P = ICD-9 procedure code

Code code CTR-CODE X(11) 2 - 12 Code value will be a 5-digit HCPCS/CPT® procedure code, 7-digit ICD-10 diagnosis code, 7-digit ICD-10 procedure code, 4-digit New Technology Family ID, or an 11-digit NDC value.

Code Sequence







Table 16-5: Hospice Code Table Date File Layout


COBOL Variable Name



Rate rate CTR-50-RATE

9(8)v9(3) 31 - 41 Payment rate

Blood Clotting Factor Flag

hemo_flag CTR-50-HEMO-FLAG

9(1) 42 0 = All others1 = Blood clotting

factorCOVID-19 Code Flag

covid19_flag CTR-50-COVID19-FLAG

9(1) 43 Medicare Inpatient and TRICARE/CHAMPUS:0 = All others1 = COVID-19 code

New Technology Family ID

newtech_family_id

CTR-50-NEWTECH-FAMILY-ID

9(4) 44 – 47 Medicare Inpatient and TRICARE/CHAMPUS:Unique 4-digit number assigned to each new technology.

Number of New Technology Lists for Family

newtech_num_lists

CTR-50-NEWTECH-NUM-LISTS

9(1) 48 Medicare Inpatient and TRICARE/CHAMPUS:Number of lists for new technology.

New Technology List Number for Code

newtech_list CTR-50-NEWTECH-LIST

9(1) 49 Medicare Inpatient and TRICARE/CHAMPUS:New technology list number for code.

New Technology Code Requirements

newtech_req CTR-50-NEWTECH-REQ

9(1) 50 Medicare Inpatient and TRICARE/CHAMPUS:1 = At least one code

from list is required to meet new technology criteria

2 = Codes on this list cause an exclusion from new technology


Field Description

C Variable Name

COBOL Variable Name



New Technology Type

newtech_type CTR-50-NEWTECH-TYPE

9(1) 51 Medicare Inpatient:1 = Traditional

pathway 2 = Alternative

pathway 3 = New COVID-19

Treatments Add-on Payment (NCTAP)

TRICARE/CHAMPUS:1 = Traditional

pathway 2 = Alternative

pathwayFiller X(199) 52 - 250


Field Description

C Variable Name

COBOL Variable Name



16.2.6 Medicaid APG Pro Code Table Layout

Table 16-7: Medicaid APG Pro Code Table Layout (C Platform Only)

Field Description C Variable Name Format Position NotesCode Type codetype X(1) 1 Alabama BCBS APG:

T = APG typeM = Modifier

Florida Medicaid APG:C = Procedure codeM = Modifier

Illinois Medicaid APG:A = APGC = Procedure codeR = Revenue code

Ohio Medicaid APG:A = APGC = Procedure codeM = ModifierR = Revenue code

Nebraska Medicaid APG:G = APG categoryT = APG type

Colorado Medicaid APG:A = APGC = Procedure codeM = Modifier

Virginia Medicaid APG:C = Procedure codeM = Modifier

Virginia Medicaid ASC:M = Modifier

Washington DC Medicaid APG:C = Procedure codeT = APG type


Code code X(11) 2 - 12 Alabama BCBS APG:Code value will be a 2 digit APG Type or 2 digit modifier.

Colorado Medicaid APG: Code value will be a 2 digit modifier, a 5 digit APG, or a 5 digit procedure code.

Florida Medicaid APG:Code value will be a 2 digit modifier.

Illinois Medicaid APG:Code value will either be a 5 digit APG, a 5 digit procedure code, or a 4 digit revenue code.

Ohio Medicaid APG:Code value will be a 5 digit procedure code, a 5 digit APG (for ASC claims), a 2 digit modifier, or a 4 digit revenue code.

Nebraska Medicaid APG:Code value will be 2 digit APG Type or APG Category.

Virginia Medicaid APG:Code value will be a 2 digit modifier or a 5 digit procedure code.

Virginia Medicaid ASC:Code value will be a 2 digit modifier.

Washington DC Medicaid APG:Code value will be a 2 digit APG type or a 5 digit procedure code.

Code Sequence codeseq 9(2) 13 - 14 Sequence number for this code record.

Start Date fromdate 9(8) 15 - 22 Date record is effective.


Field Description C Variable Name Format Position Notes


End Date thrudate 9(8) 23 - 30 00000000 = Code is still in effect


Adjustment Flag adj_flag 9(1) 31 Alabama BCBS APG:For APG Type 22:1 = This code is subject to

policy adjustment 1

For APG Type 21:2 = This code is subject to

policy adjustment 2

Colorado Medicaid APG:1 = This modifier is subject

to 340B drug discounting

2 = This code is subject to policy adjustment 2

Ohio Medicaid APG:1 = This code is subject to

policy adjustment 12 = This code is subject to


policy adjustment 3

Nebraska Medicaid APG:3 = This code is subject to



policy adjustment 5

Virginia Medicaid APG, & Virginia Medicaid ASC:1 = This modifier is subject

to 340B drug discounting




Cap at Charge Flag charge_flag 9(1) 32 Colorado Medicaid APG:0 = Procedure code is

included in the charge cap redistribution methodology

2 = Procedure code is excluded from charge cap redistribution methodology

Ohio Medicaid APG:0 = Procedure code should

not be capped at charges

1 = Procedure code should be capped at charges

Observation Flag obs_flag 9(1) 33 Ohio Medicaid APG:Used to identify observation services that are subject to special processing rules.

0 = Not an observation service

1 = Hourly observation2 = Observation visit

Revenue Code Flag revenue_flag 9(1) 34 Illinois Medicaid APG:0 = Covered revenue code1 = Non-covered revenue

code

Ohio Medicaid APG:Used to identify revenue codes that are paid via an alternate fee schedule rate.

2 = Revenue code paid the fee schedule rate in the Rate 2 field




Non-Covered HCPCS deniedhcpc 9(1) 35 Ohio Medicaid APG:Used to identify vaccine codes subject to certain policies.

0 = Otherwise1 = Vaccine code not paid if

billed with Modifier 52 or 73

2 = Vaccine code not paid if billed with Modifier 52 or 73 and not paid if age is greater than maximum

Minimum Units min_units 9(7) 36 - 42 Colorado Medicaid APG, Virginia Medicaid APG, & Washington DC Medicaid APG:The minimum number of units allowed for this procedure code.

Maximum Units max_units 9(7) 43 - 49 Colorado Medicaid APG, Virginia Medicaid APG, & Washington DC Medicaid APG:The maximum number of units allowed for this procedure code.

Modifier Flag mod_flag 9(1) 50 Alabama BCBS APG, Colorado Medicaid APG, Florida Medicaid APG, & Ohio Medicaid APG:Used to identify modifiers subject to payment denial.

0 = Modifier not subject to payment denial

1 = Modifier subject to payment denial

3 = Modifier indicates partial replacement




Outlier Flag outlier_flag 9(1) 51 Illinois Medicaid APG:Used to identify high cost device and drug APGs.

0 = Not eligible for outlier1 = Eligible for outlier

without revenue code requirements

2 = Eligible for outlier with revenue code requirements

APL Flag aplflag X(2) 52 - 53 Illinois Medicaid APG (prior to July 01, 2020):Used to identify APL procedure codes and APL revenue codes.

00 = Not an APL code01 = APL code02 = ER APL code 103 = ER APL code 204 = ER APL code 305 = Observation APL code

106 = Observation APL code

207 = Psychiatric clinic Type

A code08 = Psychiatric clinic Type

B code09 = Series-billable code

Payment Type special_pmt 9(1) 54 Ohio Medicaid APG:0 = No special payment1 = Paid case rate

Vagus Nerve Stimulator (VNS) Flag

vns_flag 9(1) 55 Florida Medicaid APG:0 = N/A1 = VNS device code2 = VNS insertion or full

replacement procedure code

3 = VNS partial replacement procedure code

Discount Flag discount_flag 9(1) 56 Washington DC Medicaid APG:0 = N/A1 = APG type discounted

with APG type 02 (Significant Procedure)

Filler X(194) 57 - 250




16.2.7 New Mexico Medicaid APC Code Table Data File Layout

16.2.8 New York Medicaid APG Code Table Data File Layout

Table 16-8: New Mexico Medicaid APC Code Table Data File Layout (C Platform Only)

Field Description

C Variable Name


Code Type codetype X(1) 1 R = Revenue CodeCode code X(11) 2 - 12 Code value will be a 4

digit revenue code value.

Code Sequence seq 9(2) 13 - 14 Sequence number for this code record.

Start Date startdate 9(8) 15 - 22 Date record is effective.End Date enddate 9(8) 23 - 30 00000000 = Code is still

in effectYYYYMMDD = End

date for recordCovered Revenue Code Flag

cov_rev X(1) 31 0 = Not covered1 = Covered

Revenue Code Type

rev_type X(1) 32 0 = All other revenue codes

1 = Packaged revenue codes

2 = Drug revenue codesFiller X(218) 33 - 250

Table 16-9: New York Medicaid APG Code Table Data File Layout (C Platform Only)

Field Description

C Variable Name


Code Type codetype X(1) 1 A = APG codesC = Procedure codesG = APG categoriesK = Diagnosis codesT = APG typesX = Rate codes

Code code X(11) 2 - 12 Code value will either be a 3-4 character APG, 5 character procedure code, 2 digit APG category, a 10 character diagnosis code, 2 character APG type, or a 6 character rate code.



Start Date fromdate 9(8) 15 - 22 Date record is effective.End Date thrudate 9(8) 23 - 30 99999999 = Code is still

in effectYYYYMMDD = End date

for recordSpecial Payment Flag

special_pmt 9(2) 31 - 32 01 = Arthroscopy code02 = Osteoarthritis policy

conflict code03 = LBHP non-covered

code04 = No discounting

code05 = Code subject to

pediatric psychiatric discounting

06 = Code subject to Telehealth billing policies

07 = Observation code08 = OASAS peer

services code09 = Code subject to

therapy modifier restrictions

10 = Severe Emotional Disturbance (SED) rate code

11 = Alternate discounting rate code

Offsite Service Flag

offsite 9(1) 33 Flag that identifies procedure codes that are eligible for reimbursement when provided in an off-site setting.

0 = Not eligible1 = Eligible pediatric

offsite services2 = Eligible offsite

servicesAlternate Payment Available Flag

altpay 9(1) 34 0 = Not on never pay list or alternate payment list

1 = Never pay procedure2 = Alternate payment

may be available


Field Description

C Variable Name



Opioid Treatment Flag

opiodtreat 9(1) 35 0 = Not applicable1 = Apply treatment

administration adjustments for all OASAS locations

2 = Apply treatment administration adjustments for opioid treatment OASAS locations only

Payment Modifiers

modifiers X(2) occurs 10 times

36 - 55 The modifiers that impact payment for an APG, procedure code, or APG type.

Rate Code Type rtype 9(1) 56 1 = Hospital Outpatient Department (OPD)

2 = Hospital Ambulatory Surgical Center (ASC)

3 = Emergency Department (ED)/room

4 = Diagnostic and Treatment Center (DTC)

5 = Free-standing Ambulatory Surgical Center (ASC)

6 = Clinic – Mental Retardation, Development Disability or Traumatic Brain Injury (MR/DD/TBI)

7 = Dental school8 = Renal clinic9 = Mental Health (MH)

Ancillary Policy Flag

anc_indicator 9(1) 57 Identifies the ancillary policy status for a rate code.0 = Ancillary policy is not

applicable1 = Ancillary policy is

applicable


Field Description

C Variable Name



16.2.9 North Carolina Inpatient Code Table Data File Layout

Licensed Behavioral Health Practitioner (LBHP) Flag

lbhpflag 9(1) 58 1 = Offsite licensed behavioral health practitioner rules apply

OASAS Flag oasasflag 9(1) 59 0 = Not an OASAS location

1 = Chemical dependence

2 = Opioid treatment center

3 = Rehabilitation center4 = Peer services

Dental Code Flag

dentalflag 9(1) 60 0 = Not a dental code1 = Dental Telehealth

code2 = Qualified dental code

for TelehealthFiller X(190) 61 - 250

Table 16-10: North Carolina Medicaid Code Table Data File Layout (C Platform Only)

Field Description Variable Name


Code Type codetype X(1) 1 C = LARC device codeG = DRGL = LARC procedure codeQ = Discharge status

Code code X(11) 2 - 12 Code value will either be a two character discharge status code, 5 character HCPCS code, or a 10 character ICD-10 procedure code.


Start Date fromdate 9(8) 15 - 22 Date record is effective.End Date thrudate 9(8) 23 - 30 00000000 = Code is still in

effectYYYYMMDD = End date for record


Field Description

C Variable Name



16.2.10 Physician Code Table Data File Layout

Long Acting Reversible Contraceptive (LARC) Flag

larc 9(1) 31 Identifies the LARC ICD-10 procedure code and LARC HCPCS code.

0 = Not a LARC code1 = LARC ICD-10 procedure

code2 = LARC HCPCS code

Transfer Flag transfer 9(1) 32 1 = Transfer discharge statusLARC DRG larc_drg 9(4) 33 - 36 LARC DRG that should be

assigned if a LARC insertion procedure and a LARC device are present and the claim is grouped to an obstetrics DRG.

Filler X(214) 37 - 250

Table 16-11: Physician Code Table Data File Layout

Field Description

C Variable Name

COBOL Variable Name



X(1) 1 P = Place of serviceS = Specialty codeT = TaxonomyZ = Zip codeN = NDCC = Procedure code

Code code CTR-CODE

X(11) 2 - 12 Code value will either be 2-digit place of service indicator, 10-digit taxonomy, 5 or 9 digit zip code, 11-digit NDC value, or 5 digit procedure code.

Code Sequence codeseq CTR-SEQ

9(2) 13 - 14 Sequence number for this code record.






Table 16-10: North Carolina Medicaid Code Table Data File Layout (C Platform Only)




Label label CTR-09-LABEL

X(40) 31 - 70 Label that describes Taxonomy value, place of service setting, carrier/locality, or NDC.

Specialty Code spec_code CTR-09-SPEC-CODE

X(2) 71 - 72 Taxonomy:The Medicare physician specialty code associated with this Taxonomy.

MPFS Payment Percentage

pfs_disc CTR-09-PFS-DISC

9(1)v9(4)

73 - 77 Taxonomy and Specialty Code:The Medicare payment percentage associated with this specialty code/taxonomy.

Facility Status facility_flag CTR-09-FAC-FLAG

9(1) 78 Place of Service:The facility/non-facility status associated with this place of service.

1 = Facility (use facility rate from PFS)

2 = Non-facility (use non-facility rate)

3 = Not applicable for Medicare claims processing (reject)


Field Description

C Variable Name

COBOL Variable Name



Rural Indicator rural CTR-09-RURAL

X(1) 79 Zip Code:This field corresponds to the rural flag in the CMS Zip Code File.

R = Rural zip code for air and ground ambulance services.

B = Qualified rural area zip code for air and ground ambulance services.

U = Rural zip code for ground ambulance services and qualified rural area zip code for air ambulance services.

V = Qualified rural area zip code for ground ambulance services and rural zip code for air ambulance services.

W = Rural zip code for ground ambulance services only.

X = Rural zip code for air ambulance services only.

Y = Qualified rural area zip code for ground ambulance services only.

Z = Qualified rural area zip code for air ambulance services only.

Blank = Not ruralHealth Professional Shortage Area (HPSA) Indicator

hpsa CTR-09-HPSA

9(1) 80 Zip Code:1 = Primary care physician

HPSA only2 = Mental health HPSA

only3 = Both primary care and

mental health HPSA0 = Otherwise

Ambulance Carrier

ambcarrier CTR-09-AMBCARRIER

X(12) 81 - 92 Zip Code:The ambulance fee schedule carrier for this zip code.


Field Description

C Variable Name

COBOL Variable Name



DME Carrier dmecarrier CTR-09-DMECARRIER

X(12) 93 - 104 Zip Code:The DME fee schedule carrier for this zip code.

Lab Carrier labcarrier CTR-09-LABCARRIER

X(12) 105 - 116 Zip Code:The clinical lab fee schedule carrier for this zip code.

National Carrier natcarrier CTR-09-NTLCARRIER

X(12) 117 - 128 Zip Code:The national fee schedule carrier for this zip code.

Physician Carrier pfscarrier CTR-09-PFSCARRIER

X(12) 129 - 140 Zip Code:The physician fee schedule carrier for this zip code.

Other Carrier othcarrier CTR-09-OTHCARRIER

X(12) 141 - 152 Zip Code:The other (user-defined) carrier for this zip code.

NDC Rate ndcrate CTR-09-NDC-RATE

9(8)v9(3)

153 - 163 NDC:The rate for this NDC.


Field Description

C Variable Name

COBOL Variable Name



Fee Schedule Types

sfeetypes CTR-09-SFEETYPES

X(1)occurs 6 times

164 - 169 Procedure Code:The list of possible fee schedule types for procedure codes that have multiple fee schedule types. If a procedure code does not have multiple fee schedule types, there will not be a record for that code in the Physician Code Table.

Possible Fee Schedule Types:A = Ambulance fee

scheduleD = DMEPOS fee

scheduleL = Clinical laboratory fee

scheduleM = National fee scheduleR = Physician fee

scheduleX = Other fee schedule

(user-defined)DME Rural Rate Indicator

dmerural CTR-09-DMERURAL

9(1) 170 Zip Code:0 = Not eligible for the

DME rural rate1 = Eligible for the DME

rural rateFiller X(2) 171 - 172 ReservedTherapy Flag therapy_flag CTR-

09-THERAPY-FLAG

9(1) 173 Procedure Code:0 = All others1 = Evaluative therapy

code (functional G-code is required)

2 = All other therapy codes (functional G-code is not required)

Edit Modifiers edit_mod CTR-09-EDIT-MODS

X(2)occurs 5 times

174 - 183 Procedure Code:GO = Occupational

speech therapyGN = Speech language

pathology serviceGP = Physical therapy

service


Field Description

C Variable Name

COBOL Variable Name




pay_adj_mod

CTR-09-PAY-ADJ-MOD

X(2) occurs 5 times

184 - 193 Procedure Code:This field holds modifiers that can be used for a payment adjustment with the corresponding procedure code on the line:




Filler X(57) 194 - 250


Field Description

C Variable Name

COBOL Variable Name



16.2.11 Standard APG Code Table Data File Layout

Table 16-12: Standard APG Code Table Data File Layout (C Platform Only)



Code Type codetype X(1) 1 Illinois Medicaid APG:C = Procedure codeR = Revenue code

New York Medicaid APG:C = Procedure codeD = Diagnosis code (ICD-9)K = Diagnosis code (ICD-10)X = Rate code

Code code X(11) 2 - 12 Illinois Medicaid APG:Code value will either be a 5 digit procedure code or a 4 digit Revenue Code.

New York Medicaid APG:Code value will either be a 5 digit procedure code, a 4 to 6 digit diagnosis code, or a 4 digit rate code.


Start Date fromdate 9(8) 15 - 22 Date record is effective.End Date thrudate 9(8) 23 - 30 00000000 = Code is still in

effectYYYYMMDD = End date for

recordArthroscopy Code arthrodx 9(1) 31 New York Medicaid APG:

Diagnosis Codes:0 = Not applicable 1 = 711.0 - 719.392 = 715.00 - 715.99

Osteoarthritis Code osteodx 9(1) 32 New York Medicaid APG:Diagnosis Codes:0 = Not an osteoarthritis

diagnosis code1 = Osteoarthritis diagnosis

code


Ambulatory Procedures Listing (APL) Code

apl X(1) 33 Illinois Medicaid APG:Procedure Codes:0 = Not an APL code1 = APL code2 = ER APL Code 13 = ER APL Code 24 = ER APL Code 35 = Observation APL Code 16 = Observation APL Code 27 = Psychiatric Clinic Type A

Code8 = Psychiatric Clinic Type B

CodeA = Series-billable procedure

codeNon-Covered Revenue Code

noncovrev 9(1) 34 Illinois Medicaid APG:Revenue Codes:0 = Covered revenue code1 = Non-covered revenue

codeASC Code asccode 9(1) 35 New York Medicaid APG:

Procedure Codes:0 = Not an ASC allowable

procedure code1 = ASC allowable procedure

codeRate Code Type ratecodetype 9(1) 36 New York Medicaid APG:

Rate Codes:0 = Office of Alcohol and

Substance Abuse (OASAS)

1 = Hospital Outpatient Department (OPD)

2 = Hospital Ambulatory Surgical Center (ASC)

3 = Emergency Department/Room (ED)

4 = Diagnostic and Treatment Center (DTC)

5 = Free-Standing Ambulatory Surgical Center (ASC)

6 = Clinic – Mental Retardation, Development Disability or Traumatic Brain Injury (MR/DD/TBI)

7 = Dental School8 = Renal Clinic9 = Mental Health (MH)





Episode Type episodetype 9(1) 37 New York Medicaid APG:Rate Codes:0 = Visit1 = Episode

Ancillary Policy ancillarypolicy 9(1) 38 New York Medicaid APG:Rate Codes:0 = Ancillary policy is not

applicable1 = Ancillary policy is

applicableCarve Out Code carveoutcode 9(1) 39 New York Medicaid APG:

Procedure Codes:0 = Non carve out code1 = Carve out code

Discount Policy Flag disc_pol 9(1) 40 New York Medicaid APG:Rate Codes:0 = Standard multiple

significant procedure discount policy applies

1 = Rate code not subject to multiple significant procedure discount policy for certain APGs

Revenue Code Flag rev_flag 9(1) 41 Illinois Medicaid APG:Revenue Codes:0 = Otherwise2 = ER revenue code 13 = ER revenue code 24 = ER revenue code 35 = Observation revenue

code 17 = Psychiatric clinic Type A

revenue code8 = Psychiatric clinic Type B

revenue code9 = Device revenue code

Osteoarthritis Procedure

osteocpt 9(1) 42 New York Medicaid APG:Procedure Codes:0 = Not an osteoarthritis

procedure code1 = Osteoarthritis procedure

codeMultiple E&M Policy Flag

em_pol 9(1) 43 New York Medicaid APG:Rate Codes:0 = Multiple E&M policy not

applicable1 = Multiple E&M policy

applicable





Mental Health or Substance Abuse Diagnosis Codes

mental_hlt 9(1) 44 New York Medicaid APG:Diagnosis Codes:0 = Not a mental health or

substance abuse diagnosis code

1 = Mental health or substance abuse diagnosis code

Blend Indicator blendind 9(1) 45 New York Medicaid APG:0 = Not a blend eligible rate

code1 = Blend eligible rate code

Extended Rate Code Type

ratecodeind 9(2) 46 - 47 New York Medicaid APG:00 = OASAS chemical

dependence01 = Hospital outpatient

department02 = Hospital ambulatory

surgical center03 = Emergency department/

room04 = Diagnostic and

Treatment Center05 =Free-standing

ambulatory surgical center

06 = Clinic, mental retardation, developmental disabilities, traumatic brain injury

07 = Dental school08 = Renal clinic09 = Mental health10 = OASAS opioid

treatment program11 = OASAS chemical rehab

Hospital Type Indicator

hospind 9(1) 48 New York Medicaid APG:0 = Hospital based1 = Free-standing

Non-Covered Licensed Behavioral Health Practitioner (LBHP) Service

LBHP_noncov

9(1) 49 New York Medicaid APG:0 = Covered service1 = Non-covered service

Serious Emotional Disturbance (SED) Eligible Rate Code

sed_code 9(1) 50 New York Medicaid APG:0 = Not a SED rate code1 = SED rate code





16.2.12 Standard APR Code Table Data File Layout

Capital Bypass Flag no_cap 9(1) 51 New York Medicaid APG:0 = Do not bypass capital

add-on rate code1 = Bypass capital add-on

rate codeFiller X(199) 52 - 250

Table 16-13: Standard APR Code Table Data Files Layout (C Platform Only)



Code Type codetype X(1) 1 Colorado Medicaid:B = UB-04 bill typeQ = Discharge statusU = UB-04 admit source

Florida Medicaid APR:B = UB-04 bill typeC = Procedure codeM = ModifierQ = Discharge status

Indiana Medicaid APR:B = UB-04 bill typeK = ICD-10-CM diagnosis

codeQ = Discharge statusU = UB-04 admit source

Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, and Virginia Medicaid APR:B = UB-04 bill typeQ = Discharge status

Louisiana Medicaid:B = UB-04 bill typeQ = Discharge statusR = Revenue codeY = Psychiatric day identifiercontinued below...





Code Type<continued>

codetype X(1) 1 New Jersey Medicaid APR:B = UB-04 bill typeQ = Discharge statusS = Occurrence span codeR = Revenue code

Rhode Island Medicaid:B = UB-04 bill typeO = Occurrence span codesQ = Discharge status

Washington DC Medicaid:B = UB-04 bill typeQ = Discharge status

Wisconsin Medicaid APR:B = UB-04 bill typeK = ICD-10-CM diagnosis

codeL = ICD-10-PCS procedure

codeQ = Discharge status

Code code X(11) 2 - 12 Code value will be one of the following:- Two digit discharge status

code- Two digit UB-04 admit

source - Two digit modifier- Two digit occurrence span

code- Four digit UB-04 Bill Type- Four digit psychiatric day

identifier- Four digit revenue code- Five digit CPT®/HCPCS

code- Ten digit ICD-10

procedure code or diagnosis code


Start Date fromdate 9(8) 15 - 22 YYYYMMDD = Date record is effective.

End Date thrudate 9(8) 23 - 30 YYYYMMDD = End date for record





Transfer Flag transfer 9(1) 31 Colorado Medicaid, Florida Medicaid, Indiana Medicaid APR, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid APR, Rhode Island Medicaid, Virginia Medicaid APR, and Wisconsin Medicaid APR:1 = Transfer discharge

status or admit source

Washington DC Medicaid:1 = Transfer discharge

status 2 = Transfer day payment

Non-Covered Bill Type

noncovbill 9(1) 32 Colorado Medicaid, Florida Medicaid, Indiana Medicaid APR, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, New Jersey Medicaid APR, Rhode Island Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR:1 = Non-covered bill type

Interim Discharge Status

interim 9(1) 33 Mississippi Medicaid, Rhode Island Medicaid, and Washington DC Medicaid:1 = Interim discharge status

Long Acting Reversible Contraceptive (LARC) Code Combination

larccode X(2) 34 - 35 Wisconsin Medicaid APR:Identifies the LARC procedure code and diagnosis code combinations.

K1 = Diagnosis code list 1K2 = Diagnosis code list 2L1 = Procedure code list 1L2 = Procedure code list 2





Diagnosis Flag dxflag 9(1) 36 Indiana Medicaid APR:0 = No special diagnosis

pricing1 = Not eligible for per diem

pricing when billed with DRG category 12

Psychiatric Length of Stay Factor

factor 9(1)v9(4) 37 - 41 Louisiana Medicaid:The day factor used to determine the cumulative adjustment for psychiatric per diem payments.

Span Code Flag spanflag 9(1) 42 New Jersey Medicaid APR:1 = Alternate Level of Care

(ALC) occurrence span code

Rhode Island Medicaid:2 = Partial eligibility claim

occurrence span codeRevenue Code Flag revflag 9(1) 43 Louisiana Medicaid:

2 = Revenue code paid per diem

New Jersey Medicaid APR:1 = ALC revenue code

Vagus Nerve Stimulator (VNS) Flag

vnsflag 9(1) 44 Florida Medicaid APR:0 = N/A1 = VNS device code2 = Modifier indicates partial

replacementExemption Flag exempt 9(1) 45 Washington DC Medicaid:

1 = Exempt from same day discharge denial

Filler X(205) 46 - 250





16.2.13 SNF Code Table Data File Layout

Table 16-14: SNF Code Table Data File Layout


COBOL Variable Name



X(1) 1 C = Procedure CodeZ = Zip Code

Code code CTR-CODE X(11) 2 - 12 Code value. Will be a 5-digit zip code or procedure code.

Code Sequence seq CTR-SEQ 9(2) 13 - 14 Sequence number for this code record.






Ambulance Carrier/Locality

carrier CTR-03-CARRIER

X(12) 31 - 42 Zip Code:Identifies the Medicare Part B carrier number and pricing locality.


Ambulance Rural Indicator

amb_rural CTR-03-AMB-RURAL

X(1) 43 Zip Code:This flag indicates that the zip code is rural:B = Qualified rural

area zip code for air and ground ambulance services

R = Rural zip code for air and ground ambulance services

U = Rural zip code for ground ambulance services and qualified rural area zip code for air ambulance services

V = Qualified rural area zip code for ground ambulance services and rural zip code for air ambulance services

W = Rural zip code for ground ambulance services only

X = Rural zip code for air ambulance services only

Y = Qualified rural area zip code for ground ambulance services only

Z = Qualified rural area zip code for air ambulance services only

Blank = Not ruralFiller X(11) 44 - 54



COBOL Variable Name



Vaccine Type vac_flag CTR-03-VAC-FLAG

9(1) 55 0 = All other codes2 = Flu/PPV/

Hepatitis B/ COVID-19 vaccine or monoclonal antibody

Therapy Flag therapy_flag CTR-03- THERAPY-FLAG

9(1) 56 0 = All other codes1 = Evaluate therapy

code, functional therapy code required

2 = Therapy code, no functional therapy code required

3 = Functional therapy code

4 = Therapy code without MPFS rate, no functional therapy code required

Ambulance Flag amb_flag CTR-03- AMB-FLAG

9(1) 57 0 = Code is not in the Ambulance Fee Schedule

1 = Code is in the Ambulance Fee Schedule

Edit Modifiers edit_mod CTR-03-EDIT-MODS

X(2) occurs 5 times

58 - 67 Blank = Codes not applicable

GO = Occupational speech therapy service

GN = Speech language pathology service

GP = Physical therapy service



COBOL Variable Name




pay_adj_mod CTR-03-PAY-ADJ-MOD

X(2) occurs 5 times

68 - 77 This field holdsmodifiers that can beused for a paymentadjustment with thecorrespondingprocedure code onthe line:




Filler X(173) 78 - 250



COBOL Variable Name



17 New York Medicaid APG Zip Code File Layout

This chapter provides the layout for the New York Medicaid APG Zip Code File. It includes the following section:

• New York Medicaid APG Zip Code File Layout (C Platform Only)


17.1 New York Medicaid APG Zip Code File Layout (C Platform Only)

Table 17-1: New York Medicaid APG Zip Code File Variables - zipny.dat



Hospital Number fac X(16) 1 - 16Paysource psrc X(13) 17 - 29Zip Code (with Zip Code Suffix)

zip 9(9) 30 - 38 The five digit zip code and the four digit zip code suffix of the service location.

Sequence Number seq X(2) 39 - 40 Code sequence number for this code record.

Effective Date effdate 9(8) 41 - 48End Date enddate 9(8) 49 - 56Locator Code loc 9(2) 57 - 58 The last two digits of the facility

ID represent the locator code.


18 Payers File Layout

This chapter provides the layout for the Payers File (C Only). This chapter includes the following sections:

NoteThe following data is not required by the EASYGroup™ Pricer, but is utilized by the Test Driver supplied with the distribution.

• File Naming Conventions• Payers File Layout


18.1 File Naming ConventionsThe Payers File (C Only) names are listed below:

18.2 Payers File Layout

Table 18-1: Payers File Names

Description FilenameInpatient Payers File payors.datOutpatient Payers File payout.datSNF Payers File paysnf.datCAH Method II Payers File paycah.datPhysician Payers File payphs.datIRF Payers File payirf.dat

Table 18-2: Payers File Variables - payors.dat, payout.dat, paysnf.dat, paycah.dat, payphs.dat, payirf.dat

Field Description Variable Name Format Position DescriptionHospital/Provider Number

pfac X(16) 1 - 16 Unique provider identifier. Contains the provider’s Medicare Provider Number.

Paysource Code psrc X(13) 17 - 29 Unique paysource or payer identifier.


pfac X(20) 1 - 20 Unique provider identifier. Contains the provider’s Medicare Provider Number or the National Provider ID and Taxonomy Code.

Paysource Code with NPI/Taxonomy

psrc X(9) 21 - 29 Unique paysource or payer identifier.

Care Setting payset X(2) 30 - 31 CA = CAH Method IIIN = InpatientOP = Outpatient

Facility Name dsc X(25) 32 - 56 Up to 25 characters of the provider name.

State abr X(5) 57 - 61 Abbreviation of the state where the provider is located.

Payer Type ptype X(2) 62 - 63 Refer to the ECB [ezg_cntl_block] in the Input and Output Parameter Blocks User’s Guide for the appropriate values for the prcr_type variable.

Filler X(31) 64 - 94


Reimbursement Date

reimbdate X(1) 95 D = Pricing utilizes discharge date

A = Pricing utilizes admission date

Payer Class pclass X(2) 96 - 97 This field is required by Optum and indicates the payer classification.

BC = Blue Cross/Blue ShieldCH = TRICARE/CHAMPUSHM = HMOIC = Insurance CompanyMD = MedicaidMR = MedicareNS = Not SpecifiedOT = OtherSP = Self payTC = TRICARE APCWC = Worker’s Compensation

Key Type key_type X(1) 98 1 = National Provider ID plus Taxonomy Code used for rate lookup

0 or blank = Legacy Provider ID used for rate lookup

Filler X(93) 99 - 191

Table 18-2: Payers File Variables - payors.dat, payout.dat, paysnf.dat, paycah.dat, payphs.dat, payirf.dat

Field Description Variable Name Format Position Description


19 Configuration File Layouts

This chapter provides the layouts for the Configuration File (C and COBOL). This file contains edit requests and other data that can be passed in the ECB structures or can be configured in Rate Manager. This chapter includes the following sections:

• File Naming Conventions• C Platform Layout• COBOL Platform Layout


19.1 File Naming ConventionsThe configuration file names are listed below:

Table 19-1: Configuration File Names



CAH Method II only cfgcah.dat cnfg05.datPhysician only cfgphys.dat cnfg04.datAll Other Payment Systems config.dat ezgconfg.dat


19.2 C Platform LayoutTable 19-2: Configuration File Variables (config.dat, cfgphys.dat, cfgcah.dat)


pfac X(16) 1 - 16 Unique provider identifier. Contains the provider’s Medicare Provider Number.



pfac X(20) 1 - 20 Unique provider identifier. Contains the provider’s Medicare Provider Number or the National Provider ID and Taxonomy Code.



Patient Type pattype X(2) 30 - 31 01 = Inpatient02 = Outpatient03 = IRF/Rehabilitation04 = Physician05 = CAH Method II06 = SNF/Skilled Nursing

Effective Date Sequence Code

eseq 9(4) 32 - 35 Reserved for use by the EASYGroup™ Pricer.

Effective Date of Rate Variables

effdate 9(8) 36 - 43 The date on or after which the rate variables contained on this record should be used for calculating reimbursement. This field will be equal to either the beginning of the federal fiscal year or the beginning of the provider's fiscal year (e.g. “20001001”).

Filler for Effective Stop Date (Future)

X(8) 44 - 51

Payer/Pricer Type pricer_type X(2) 52 - 53 Refer to the ECB [ezg_cntl_block] of the Input and Output Parameter Blocks User’s Guide for a list of acceptable values. Refer to the field labeled Pricer Type.

Payer Type Reserved

pricer_type_rsvd X(2) 54 - 55

Grouper Type grpr_type X(2) 56 - 57 Refer to the ECB [ezg_cntl_block] of the Input and Output Parameter Blocks User’s Guide for a list of acceptable values. Refer to the field labeled Grouper Type.

Grouper Type Reserved

grpr_type_rsvd X(2) 58 - 59


Grouper Version grpr_vers 9(2) 60 - 61 Set to the Grouper version number that is applicable for the effective date.

Grouper Version Reserved

grpr_vers_rsvd 9(4) 62 - 65 Reserved

Editor Type edtr_type X(2) 66 - 67 ReservedEditor Type Reserved

edtr_type_rsvd X(2) 68 - 69 Reserved

Editor Version edtr_vers 9(2) 70 - 71 ReservedEditor Release edtr_rel X(1) 72 ReservedEditor Version Reserved

edtr_vers_rsvd X(3) 73 - 75 Reserved

Editor Requests edit_req 9(10) 76777879808182838485

Refer to the edit_req field in the ECB [ezg_cntl_block] structure in the Input & Output Parameter Blocks User’s Guide for Editor Requests information.

Editor Requests 2 edit_req2 9(10) 86878889909192939495

Refer to the edit_req2 field in the ECB [ezg_cntl_block] structure in the Input & Output Parameter Blocks User’s Guide for Editor Requests information.

Editor Requests Reserved 3

rsvd_req3 X(10) 96 - 105 Reserved

Editor Requests Reserved 4

rsvd_req4 X(10) 106 - 115 Reserved

Mapping Flag icd9_map 9(1) 116 0 = No mapping1 = Code mapping2 = State-specific mapping

Grouper Option grpr_option 9(1) 117 Reserved Weight Option wgt_option X(1) 118 ReservedACE Override ID ace_override_id X(20) 119 - 138 ACE:

The ACE Override ID invokes override functionality. This override functionality allows the user to turn particular ACE edits on or off.

Table 19-2: Configuration File Variables (config.dat, cfgphys.dat, cfgcah.dat)



HAC Override ID hac_override_id X(10) 139 - 148 DSC Editor, AP-DRG Grouper, APR-DRG Grouper, Medicare DRG Grouper, CHAMPUS/TRICARE Grouper, and Wisconsin DRG Grouper:Unique key used by the DSC Editor or DRG Grouper to determine what HACs should be applied to this facility.

ACE Flag ace_flag 9(1) 149 ReservedDSC Flag dsc_flag 9(1) 150 ReservedFlag Reserved flag_rsvd 9(8) 151 - 158 ReservedKey Type key_type X(1) 159 1 = National Provider ID plus

Taxonomy Code used for rate lookup


Reimbursement Date

reimbdate X(1) 160 Used to identify which claim date should be used for reimbursement calculations. The following options are available:- A = From or Admission Date- D = Thru or Discharge Date

CCI Edit Bypass bypass_cci_edits 9(1) 161 APG Payment Systems:0 = Do not apply CCI/MUE

edits to reimbursement

NoteIndicates that the claim lines with CCI/MUE edits should not be included in the reimbursement.

1= Apply CCI/MUE edits to reimbursement

NoteIndicates that the claim lines with CCI/MUE edits should be included in the reimbursement.

State Key state_key X(2) 162 - 163Payer Key payer_key X(14) 164 - 177ASC Override ID asc_override_id X(20) 178 - 197 Used to identify the

appropriate override pattern in the ASC Override File.




Mapping Override ID map_override_id X(20) 198 - 217 ICD-10 Mapper:Used to identify the appropriate override pattern in the Mapper Override File.

Mapping Category map_category X(2) 218 - 219 ICD-10 Mapper:01 = CMS reimbursement02 = Optum premier pick03 = Wisconsin Medicaid-

specificMapper Type map_type X(2) 220 - 221 ICD-10 Mapper and Alternate

ICD-10 Mapper:02 = ICD-10 Mapper03 = Alternate ICD-10 Mapper

Closed Rate Record Switch

closed_fac_sw X(1) 222 Flag used to identify that a rate record is closed. Refer to the EASYGroup™ User’s Guide for an explanation of why a rate record may be closed. Claims that utilize a closed rate record will receive Function Return Code 62 (Closed or Inactive Rate Record).

0 = Open1 = Closed

Birth Weight Option Selected

bwgt_option X(1) 223 APR-DRG Grouper:1 = Entered in the birth weight

field only.2 = Coded with diagnosis only.3 = Entered or coded with

diagnosis.4 = Entered or coded with

cross-check between entered and coded birth weights to determine if a match or a conflict exists.

5 = Coded with diagnosis only, default of 2500 grams used if birth weight not coded.

6 = Entered or coded with diagnosis, default of 2500 grams used if birth weight not entered or coded.

7 = Entered or coded with cross-check between entered and coded birth weights to determine if a match or conflict exists, default of 2500 grams used if birth weight not entered or coded.




Discharge APR- DRG Option

disch_drg_option X(1) 224 APR-DRG Grouper:Provides the ability to compute the APR-DRG, Severity of Illness (SOI), and Risk of Mortality (ROM) considering POA indicators with APR-DRG complication of care codes. 0 = Compute excluding only

non-POA Complication of Care codes

1 = Compute excluding all Complication of Care codes

HAC Version hac_version 9(3) 225 - 227 APR-DRG Grouper: The version of the Hospital Acquired Conditions to use with HAC-adjusted APR-DRG grouping.

The HAC version should be entered as follows: Version 31 would be entered as “310.”

Sequester Flag sqr_flag X(1) 228 ReservedState CCI statecci X(2) 229 - 230 ACE:

Two character abbreviation to determine which CCI/MUE editing rules to apply.

Blank (default) = Medicare CCI/MUE

DM = Medicare Durable Medical Equipment (DME)

MI = Michigan Medicaid CCI/MUE

SD = South Dakota Medicaid CCI/MUE

US = Medicare CCI/MUEU2 = National Medicaid CCI/

MUE

CAH Method II Editor:Blank (default) = Medicare

CCI/MUEUS = Medicare CCI/MUE

MOE:U2 = National Medicaid CCI/

MUE




User Key user_key X(3) 231 - 233 APC Payment Systems:The state-specific APC grouping rules to utilize. - New Mexico Medicaid APC =

NM1

APG Payment Systems:The state-specific APG grouping rules to utilize. - Alabama BCBS APG = AL3- Colorado Medicaid APG =

CO1- Florida Medicaid APG = FL1- Illinois Medicaid APG = IL1 - Nebraska Medicaid APG =

NE1- New York Medicaid APG =

Blank or NY1 - Massachusetts Medicaid

APG = MA1- Ohio Medicaid APG = OH1- Virginia Medicaid APG = VA1 - Virginia Medicaid ASC = VA4- Washington DC Medicaid

APG = DC1- Washington Medicaid APG =

WA1 - Wisconsin Medicaid APG =

WI1

APR-DRG Payment Systems:The state-specific APR pricing rules to utilize.- Colorado Medicaid = CO2- Florida Medicaid = FL2- Indiana Medicaid APR = IN2- Louisiana Medicaid = LA2- Massachusetts Medicaid =

MA2- Minnesota Medicaid = MN2- Mississippi Medicaid = MS2

continued below...




User Key

<continued>

user_key X(3) 231 - 233 - New Jersey Medicaid = NJ2- Rhode Island Medicaid = RI2- Virginia Medicaid APR = VA2- Washington DC Medicaid =

DC2 - Wisconsin Medicaid APR =

WI2Apply CCI/MUE Edits

line_bypass X(1) 234 APG Payment Systems:0 = Don’t exclude lines from

APG grouping that are returned from ACE with CCI and/or MUE edits

1 = Exclude lines from APG grouping that are returned from ACE with CCI and MUE edits

2 = Exclude lines from APG grouping that are returned from ACE as CCI edits only

3 = Exclude lines from APG grouping that are returned from ACE as MUE edits only

ICD-9 Grouper Routing Flag

icd9_routing 9(1) 235 ICD-10 Medicare DRG, ICD-10 TRICARE DRG, and ICD-10 Wisconsin Medicaid Groupers:Used to automatically send ICD-9 claims that are configured to utilize an ICD-10 Grouper Version after V32 to the equivalent final ICD-9 Grouper Version.

For example, if this option is enabled, ICD-9 claims sent to the ICD-10 Medicare DRG V33 Grouper will be automatically routed to the ICD-9 Medicare DRG V32 Grouper.

0 = Do not enable routing1 = Enable routing




APC Override ID apc_override_id X(20) 236 - 255 ACE:The APC Override ID invokes override functionality. This override functionality allows the user to override APC, Payment Status Indicators, and maximum allowable units assignment for a particular procedure code.

If this field is left blank, the ACE Override ID (ace_override_id) field will be utilized.

Version Qualifier vers_qual X(1) 256 APR-DRG:Used to request the ICD-9 version of the APR-DRG V31 and V32 Groupers.

0 = ICD-10 Grouper (default)9 = ICD-9 Grouper

Analyzer Type analyzer_type X(2) 257 - 258 00 = No Analyzer01 = V01 EDC Analyzer™02 = E&M Analyzer Pro

Analyzer Type Reserved

analyzer_type_rsvd X(2) 259 - 260 Reserved

Analyzer Version analyzer_vers 9(2) 261 - 262 Two digit version number of the Analyzer.

Analyzer Version Reserved

analyzer_vers_rsvd 9(4) 263 - 266 Reserved

EDC Analyzer™/E&M Analyzer Pro Starting Visit Level Option

start_lvl_option[] 9(1) occurs 5 times

267 - 271 V01 EDC Analyzer™ and E&M Analyzer Pro:Array of indicators to identify the claim starting visit levels that should be processed by the V01 EDC Analyzer™/E&M Analyzer Pro.

For example, to process only those claims with a starting visit level of 4 or 5, set this field to 00011.

To process all claims, set this field to 11111.




EDC Analyzer™/E&M Analyzer Pro Visit Level Change Option

lvl_change_option 9(1) 272 V01 EDC Analyzer™ and E&M Analyzer Pro:The number of visit level changes that should be processed by the V01 EDC Analyzer™/E&M Analyzer Pro.

For example, to only process claims that have a visit level change of 2 or more levels, set this field to 2.

To process all visit level changes, set this field to 1.

EDC Analyzer™/ E&M Analyzer Pro Action

edc_action 9(1) 273 V01 EDC Analyzer™ and E&M Analyzer Pro:0 = Return visit level

recommendation only; visit code required

1 = Return visit level recommendation and apply results to reimbursement (if applicable); visit code required

2 = Return visit level recommendation if visit level is decreased and apply results to reimbursement (if applicable); visit code required

3 = Return visit level recommendation only; visit code not required

Facility Type facility_type X(2) 274 - 275 Florida Medicaid APG and Ohio Medicaid APG:00 = All others01 = ASC

Rate File Version rf_vers X(7) 276 - 282 Version of the rate file that was used to process a specific claim.

Medicaid APC Override ID

mcd_override_id X(20) 283 - 302 The Medicaid APC Override ID invokes override functionality. This override functionality allows the user to override the Payment Status Indicator for a particular procedure code.

Filler X(498) 303 - 800




19.3 COBOL Platform LayoutTable 19-3: COBOL Configuration File Variables (ezgconfg.dat, cnfg04.dat, cnfg05.dat)


ECR-HOSP X(16) 1 - 16 Unique provider identifier. Contains the provider’s Medicare Provider Number.

Paysource Code ECR-PCODE X(13) 17 - 29 Unique paysource or payer identifier. This field is set to 09 for all providers to represent Medicare for this version of the NMPRF.


ECR-HOSP X(20) 1 - 20 Unique provider identifier. Contains the provider’s Medicare Provider Number or the National Provider ID and Taxonomy Code.


ECR-PCODE X(9) 21 - 29 Unique paysource or payer identifier. This field is set to “09” for all providers to represent Medicare for this version of the NMPRF.

Patient Type ECR-PATTYPE X(1) 30 1 = Inpatient2 = Outpatient3 = IRF/Rehabilitation4 = Physician5 = CAH Method II6 = SNF/Skilled Nursing

Patient Type Reserved

ECR-PATTYPW-RSVD

X(1) 31

Effective Date Sequence Code

ECR-ESEQ 9(4) 32 - 35 Reserved for use by the EASYGroup™ Pricer.

Effective Date of Rate Variables Effective Century Effective Year Effective Month Effective Day

ECR-EDATEECR-CCYYECR-MMECR-DD

9(4)9(2)9(2)

36 - 3940 - 4142 - 43

The date on or after which the rate variables contained on this record should be used for calculating reimbursement. This field will be equal to either the beginning of the federal fiscal year or the beginning of the provider's fiscal year (e.g. 20001001).

Filler for Effective Stop Date (Future)

X(8) 44 - 51

Payer/Pricer Type ECR-PRCR-TYPE

X(2) 52 - 53 Refer to the ECB-EZG-CNTL-BLOCK of the Input and Output Parameter Blocks User’s Guide for a list of acceptable values. Refer to the field labeled Pricer Type.


Payer Type Reserved

ECR-PRCR-TYPE-RSVD


Grouper Type ECR-GRPR-TYPE

X(2) 56 - 57 Refer to the ECB-EZG-CNTL-BLOCK of the Input and Output Parameter Blocks User’s Guide for a list of acceptable values. Refer to the field labeled Grouper Type.

Grouper Type Reserved

ECR-GRPR-TYPE-RSVD


Grouper Version ECR-GRPR-VERS

9(2) 60 - 61 Set to the Grouper version number that is applicable to this effective date.

Grouper Version Reserved

ECR-GRPR-VERS-RSVD

9(4) 62 - 65 Reserved

Editor Type ECR-EDTR-TYPE


Editor Type Reserved

ECR-EDTR-TYPE-RSVD


Editor Version ECR-EDTR-VERS

9(2) 70 - 71 Reserved

Editor Release ECR-EDTR-REL X(1) 72 ReservedEditor Version Reserved

ECR-EDTR-VERS-RSVD


Request for Date-Sensitive/MCE Editing

ECR-EDIT-MCE-SW

9(1) 76 0 = No edits requested1 = Request Date-Sensitive/

MCE edits

NoteDSC/MCE settings in this file will override DSC/MCE requests made through the EDIT-MCE-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for EASYEdit™ Editing

ECR-EDIT-EZ-SW

9(1) 77 0 = No edits requested1 = Request EASYEdit™ edits

NoteEASYEdit™ settings in this file will override EASYEdit™ requests made through the EDIT-EZ-SW field in the ECB-EZG-CNTL-BLOCK structure.

Table 19-3: COBOL Configuration File Variables (ezgconfg.dat, cnfg04.dat, cnfg05.dat)



Request for CCI Editing

ECR-EDIT-CCI-SW

9(1) 78 0 = No edits requested1 = Request CCI edits (for

ASC)

NoteCCI settings in this file will override CCI requests made through the EDIT-CCI-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for OCE Editing

ECR-EDIT-OCE-SW

9(1) 79 0 = No edits requested1 = Request OCE edits (for

FQHC)

NoteOCE settings in this file will override OCE requests made through the EDIT-OCE-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for OCE/CCI Editing

ECR-EDIT-OCE-CCI-SW

9(1) 80 0 = No edits requested1 = Request OCE/CCI edits (for

APC, ESRD, HHA, and SNF)

NoteOCE/CCI settings in this file will override OCE/CCI requests made through the EDIT-OCE-CCI-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for LCD Editing

ECR-EDIT-LCD-SW

9(1) 81 0 = No edits requested1 = Request LCD edits

NoteLCD settings in this file will override LCD requests made through the EDIT-LCD-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for Non-OCE Editing With CCI Code Pairs

ECR-EDIT-NOCE-SW

9(1) 82 0 = No edits requested1 = Request non-OPPS OCE

edits (for Maryland and Critical Access Hospitals (CAHs)) with CCI edit pairs returned




Request for POA Editing

ECR-EDIT-POA-SW

9(1) 83 0 = No edits requested1 = Request POA edits

NotePOA settings in this file will override POA requests made through the EDIT-POA-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for HAC ECR-EDIT-HAC-SW

9(1) 84 0 = No edits requested1 = Request HAC edits

NoteHAC settings in this file will override HAC requests made through the EDIT-HAC-SW field in the ECB-EZG-CNTL-BLOCK structure.

Filler X(1) 85Request for Physician Editing

ECR-EDIT-PHYS-SW

9(1) 86 0 = No edits requested1 = Request physician edits, MUEs applied based on taxonomy

NotePhysician edit settings in this file will override Physician edit requests made through the EDIT-PHYS-SW field in the ECB-EZG-CNTL-BLOCK structure.

Request for Medicaid Inpatient Editing

ECR-EDIT-MDCD-SW

9(1) 87 0 = No edits requested1 = Request Medicaid inpatient

edits

NoteMedicaid inpatient settings in this file will override Medicaid inpatient requests made through the EDIT-MDCD-SW field in the ECB-EZG-CNTL-BLOCK structure.




Request for Physician Editing 2

ECR-EDIT-MAXMUE

9(1) 88 0 = No edits requested1 = Request physician edits, max of DME and practitioner MUE applied

NotePhysician edit settings in this file will override Physician edit requests made through the EDIT-MAXMUE field in the ECB-EZG-CNTL-BLOCK structure.

Reserved ECR-EDIT-MOE 9(1) 89 ReservedRequest for CAH Method II Editing

ECR-EDIT-CAH 9(1) 90 0 = No edits requested1 = Request CAH Method II

edits

NoteCAH Method II settings in this file will override OCE/CCI requests made through the EDIT-OCE-SW field in the ECB-EZG-CNTLBLOCK structure.

Filler X(25) 91 - 115ICD-9/ICD-10 Mapping Flag

ECR-MAPPING 9(1) 116 0 = No mapping 1 = Standard mapping2 = State-specific mapping

NoteState-specific mapping is only utilized with the following Groupers: Wisconsin Medicaid, Ohio Medicaid, and North Carolina Medicaid.

Grouper Option ECR-GRPR-OPTION

9(1) 117 Reserved

Weight Option ECR-WGT-OPTION

X(1) 118 Reserved

ACE Override ID ECR-ACE-OVERRIDE-ID

X(20) 119 - 138 ACE:The ACE Override ID invokes override functionality. This override functionality allows the user to turn particular ACE edits on or off.




HAC Override ID ECR-HAC-OVERRIDE-ID

X(10) 139 - 148 DSC Editor, AP-DRG Grouper, Medicare DRG Grouper, CHAMPUS/TRICARE Grouper, and Wisconsin DRG Grouper:Unique key used by the DSC Editor or DRG Grouper to determine what HACs should be applied to this facility.

ACE Flag ECR-ACE-FLAG 9(1) 149 ReservedDSC Flag ECR-DSC-FLAG 9(1) 150 ReservedFlag Reserved ECR-FLAG-

RSVD9(8) 151 - 158 Reserved

Key Type ECR-KEY-TYPE X(1) 159 1 = National Provider ID plus Taxonomy Code used for rate lookup


Reimbursement Date ECR-REIMBDATE

X(1) 160 Used to identify which claim date should be used for reimbursement calculations. The following options are available:- A = From or Admission Date- D = Thru or Discharge Date

CCI Edit Bypass ECR-BYPASS-CCI-EDITS

9(1) 161 Reserved

State Key ECR-STATE-KEY X(2) 162 - 163Payer Key ECR-PAYER-KEY X(14) 164 - 177ASC Override ID ECR-ASC-

OVERRIDE-IDX(20) 178 - 197 Used to identify the appropriate

override pattern in the ASC Override file.

Mapping Override ID ECR-MAP-OVERRIDE-ID

X(20) 198 - 217 ICD-10 Mapper:Used to identify the appropriate override pattern in the Mapper Override file

Mapping Category ECR-MAP-CATEGORY

X(2) 218 - 219 ICD-10 Mapper:01 = CMS reimbursement02 = Optum premier pick03 = Washington Medicaid-

specificMapper Type ECR-MAP-TYPE X(2) 220 - 221 ICD-10 Mapper:

02 = ICD-10 Mapper




Closed Rate Record Switch

ECR-CLOSED-FAC-SW

X(1) 222 Flag used to identify that a rate record is closed. Refer to the EASYGroup™ User’s Guide for an explanation of why a rate record may be closed. Claims that utilize a closed rate record will receive Function Return Code 62 (Closed or Inactive Rate Record).

0 = Open1 = Closed

Birth Weight Option Selected

ECR-BWGT-OPTION

X(1) 223 Reserved

Discharge APR-DRG Option

ECR-DISCH-DRG-OPTION

X(1) 224 Reserved

HAC Version ECR-HAC-VERSION

9(3) 225 - 227 Reserved

Sequester Flag ECR-SQR-FLAG X(1) 228 ReservedState CCI ECR-STATECCI X(2) 229 - 230 ACE:

Two character abbreviation to determine which CCI/MUE editing rules to apply.

Blank (default) = Medicare CCI/MUE

DM = Medicare Durable Medical Equipment (DME)

MI = Michigan Medicaid CCI/MUE

SD = South Dakota Medicaid CCI/MUE

US = Medicare CCI/MUEU2 = National Medicaid CCI/

MUE

CAH Method II Editor:Blank (default) = Medicare CCI/

MUEUS = Medicare CCI/MUE

User Key ECR-USER-KEY X(3) 231 - 233 ReservedApply CCI/MUE Edits ECR-LINE-

BYPASSX(1) 234 Reserved




ICD-9 Grouper Routing Flag

ECR-ICD9-ROUTING

9(1) 235 ICD-10 Medicare DRG, ICD-10 TRICARE DRG, and ICD-10 Wisconsin Medicaid Groupers:Used to automatically send ICD-9 claims that are configured to utilize an ICD-10 Grouper Version after V32 to the equivalent final ICD-9 Grouper Version.

For example, if this option is enabled, ICD-9 claims sent to the ICD-10 Medicare DRG V33 Grouper will be automatically routed to the ICD-9 Medicare DRG V32 Grouper.

0 = Do not enable routing1 = Enable routing

APC Override ID ECR-APC-OVERRIDE-ID

X(20) 236 - 255 ACE:The APC Override ID invokes override functionality. This override functionality allows the user to override APC, Payment Status Indicators, and maximum allowable units assignment for a particular procedure code.

If this field is left blank, the ACE Override ID (ECR-ACE-OVERRIDE-ID) field will be utilized.

Version Qualifier ECR-VERS-QUAL

X(1) 256 Reserved

Analyzer Type ECR-ANLZ-TYPE X(2) 257 - 258 ReservedAnalyzer Type Reserved

ECR-ANLZ-TYPE-RSVD

X(2) 259 - 260 Reserved

Analyzer Version ECR-ANLZ-VERS 9(2) 261 - 262 ReservedAnalyzer Version Reserved

ECR-ANLZ-VERS-RSVD

9(4) 263 - 266 Reserved

EDC Analyzer™/E&M Analyzer Pro Starting Visit Level Option

ECR-EDC-START-LVL

9(1) occurs 5 times

267 - 271 Reserved

EDC Analyzer™/E&M Analyzer Pro Visit Level Change Option

ECR-EDC-CHANGE-LVL

9(1) 272 Reserved




EDC Analyzer™/E&M Analyzer Pro Action

ECR-EDC-ACTION

9(1) 273 Reserved

Facility Type ECR-FACILITY-TYPE

X(2) 274 - 275 Reserved

Rate File Version ECR-RATEFILE-VERS

X(7) 276 - 282 Version of the rate file that was used to process a specific claim.





20 Rate File Layouts

This chapter provides the layouts for Rate Files (C and COBOL). This chapter includes the following sections:

• File Naming Conventions• C Platform

- APC Rate File Layout (prior to January 01, 2018)- APC Rate File Layout (on or after January 01, 2018)- APG Rate File Layout- DRG Rate File Layout- HHA Rate File Layout (prior to January 01, 2020)- HHA Rate File Layout (on or after January 01, 2020)- IRF CMG Rate File Layout- SNF RUG Rate File Layout (on or prior to October 01, 2019)- SNF Rate File Layout (after October 01, 2019)

• COBOL Platform- APC Rate File Layout (prior to January 01, 2018)- APC Rate File Layout (on or after January 01, 2018)- DRG Rate File Layout- HHA Rate File Layout (prior to January 01, 2020)- HHA Rate File Layout (on or after January 01, 2020)- IRF CMG Rate File Layout- SNF RUG Rate File Layout (on or prior to October 01, 2019)- SNF Rate File Layout (after October 01, 2019)


20.1 File Naming ConventionsThe file names of the specific Rate Files are listed below:

20.2 C Platform20.2.1 APC Rate File Layout (prior to January 01, 2018)

NoteNot applicable to Medicare ASC or Contract ASC pricing.

Table 20-1: Rate File Names



APC Rate File- prior to January 01, 2018- on or after January 01, 2018

rateout.datrateapc.dat

wghtrate.datwghtapc.dat

APG Rate File rateout.dat N/ADRG Rate File rate.dat wghtrate.datHHA Rate File rateout.dat wghtrate.datIRF CMG Rate File rateirf.dat wghtrate.datSNF Rate File- prior to October 01, 2019- on or after October 01, 2019

ratesnf.datratesnf2.dat

wghtrate.datwghtsnf.dat

Table 20-2: APC Rate File Variables - rateout.dat (prior to January 01, 2018)

Field Description Variable Name Format Position NotesHospital Number pfac X(16) 1 - 16Paysource (Payer) Code psrc X(13) 17 - 29Effective Date edate 9(8) 30 - 37 Day norms went into effect.

CCYYMMDD format, where:CC = CenturyYY = YearMM = MonthDD = Day

APC apc 9(4) 38 - 41APC/APG Weight weight 9(3)v9(5) 42 - 49 Weight associated with this

APC or APG if used with a base rate to calculate reimbursement.

APG Type (not used in APC pricing)

apgtype 9(2) 50 - 51

Non-Covered APG Flag noncover 9(1) 52 Not used in APC pricing.Packaging Flag package 9(2) 53 - 54Units of Service Pricing unitpric 9(1) 55 Not used in APC pricing.


APC Rate apc_rate 9(5)v9(2) 56 - 62 Base rate for this APC, before adjustments.

APC Payment Status hpaystat X(2) 63 - 64 APC Payment Status Indicators.

NoteFor a list of APC Payment Status Indicators, please refer to the Input & Output Parameter Blocks User’s Guide.

Reserved for APC Payment Status for ASC

ascpaystat X(1) 65

Reserved for IOL Flag iol_flag X(1) 66National Unadjusted Co-Payment

ntl_copay 9(4)v9(2) 67 - 72 APC-HOPD:National unadjusted coinsurance

Minimum Unadjusted Co-Payment

min_copay 9(4)v9(2) 73 - 78 APC-HOPD:Minimum unadjusted coinsurance

Hospital-Specific Unadjusted Co-Payment

hos_copay 9(4)v9(2) 79 - 84 APC-HOPD:Hospital-specific unadjusted coinsurance (must be greater than or equal to the minimum co-payment, and less than or equal to the national co-payment).




Coinsurance Flag coinsflag 9(1) 85 0 = Standard co-insurance rules

1 = Co-insurance is 25% of payment rate, hospital cannot reduce coinsurance

2 = Not subject to national coinsurance, hospital cannot reduce coinsurance

3 = Pass thru item, hospital cannot reduce coinsurance

4 = Item is eligible for outlier payment

5 = Device or procedure eligible for offset deduction (prior to January 01, 2017)

5 = Procedure eligible for offset deduction (on or after January 01, 2017)

6 = Procedure eligible for no-cost and reduced cost device offset deduction (Prior to January 01, 2017)

7 = New technology APC exempt from quality reporting reduction

8 = Pass thru item, contrast agent eligible for offset.

9 = Nuclear medicine procedure eligible for no-cost offset deduction

Program Payment Percentage

ppp 9(1)v9(6) 86 - 92 Program payment percentage, percent of line item payment paid by third party payer.

Medicare program payment percentage:((APC-RATE – NTL-COPAY) / APC-RATE)

Rank rank 9(5) 93 - 97 APC-HOPD:Ranking for allocation of deductible to individual claim lines.

Reserved for Recurring APG Flag

apg_recur 9(1) 98 Not used in APC pricing




20.2.2 APC Rate File Layout (on or after January 01, 2018)

APC Offset apc_offset 9(5)v9(2) 99 - 105 Unadjusted offset that is deducted from the payment for transitional pass-through items or from the payment for procedures with no-cost devices (prior to January 01, 2017).

Filler X(1) 106Rate Manager TAB Filename

X(9) 107 - 115

APC User Base Rate user_rate 9(5)v9(3) 116 - 123 Contract APC/APC Pro:User specified base rate/conversion factor. If the hospital base * weight pricing option is set to Yes and this field is set, the APC Rate = APC User Base Rate * APC Weight.

Filler 9(11) 124 - 134APC Policy Packaged Offset

apc_poloffset 9(8)v9(2) 135 - 144 Offset dollar amount to be deducted from radiopharmaceutical reimbursement where applicable.

APC Contrast Agent Offset

apc_caoffset 9(8)v9(2) 145 – 154 Offset dollar amount to be deducted from contrast agent reimbursement where applicable.

Filler 9(17) 155 - 171Key Type key_type X(1) 172Extended Weight weight_ext 9(4)v9(5) 173 - 181 Extended weight associated

with this APC if used with a base rate to calculate reimbursement.

Filler X(10) 182 - 191

Table 20-3: APC Rate File Variables - rateapc.dat (on or after January 01, 2018)

Field Description Variable Name Format Position NotesHospital Number pfac X(16) 1 - 16Paysource (Payer) Code psrc X(13) 17 - 29




Effective Date edate 9(8) 30 - 37 Day norms went into effect. CCYYMMDD format, where:

CC = CenturyYY = YearMM = MonthDD = Day

Reserved X(2) 38 - 39Reserved 9(1) 40APC apc 9(5) 41 - 45Page Number pge_nbr 9(2) 46 - 47NPI/Legacy Flag key_type X(1) 48 0 = Legacy

1 = NPIReserved 9(1) 49APC Weight weight 9(4)v9(5) 50 - 58 APC-HOPD:

Weight associated with this APC.

Contract APC/APC Pro:Weight associated with this APC if used with a base rate to calculate reimbursement.

APC Rate apc_rate 9(8)v9(2) 59 - 68 Base rate for this APC, before adjustments.

Reserved 9(1) 69APC Payment Status hpaystat X(2) 70 - 71 APC Payment Status

Indicators.


National Unadjusted Co-Payment

ntl_copay 9(8)v9(2) 72 - 81 APC-HOPD:National unadjusted coinsurance


min_copay 9(8)v9(2) 82 - 91 APC-HOPD:Minimum unadjusted coinsurance


hos_copay 9(8)v9(2) 92 - 101 APC-HOPD:Hospital-specific unadjusted coinsurance (must be greater than or equal to the minimum co-payment, and less than or equal to the national co-payment).




Coinsurance Flag coinsflag 9(2) 102 - 103 00 = Standard co-insurance rules

01 = Co-insurance is 25% of payment rate, hospital cannot reduce coinsurance









ppp 9(1)v9(6) 104 - 110 Program payment percentage, percent of line item payment paid by third party payer.


Reserved 9(1) 111Rank rank 9(5) 112 - 116 APC-HOPD:

Ranking for allocation of deductible to individual claim lines.

APC User Base Rate user_rate 9(8)v9(3) 117 - 127 Contract APC/APC Pro:User specified base rate/conversion factor. If the hospital base * weight pricing option is set to Yes and this field is set, the APC Rate = APC User Base Rate * APC Weight.

APC Policy Packaged Offset

apc_poloffset 9(8)v9(2) 128 - 137 Offset dollar amount to be deducted from radiopharmaceutical reimbursement where applicable.




20.2.3 APG Rate File Layout


apc_caoffset 9(8)v9(2) 138 - 147 Offset dollar amount to be deducted from contrast agent reimbursement where applicable.

Extended APC Weight weight_ext 9(6)v9(5) 148 - 158 Contract APC/APC Pro:Extended weight associated with this APC if used with a base rate to calculate reimbursement.

APC-HOPD and Contract APC (for Iowa APC):Reserved for future use.

Filler X(83) 159 - 241Rate Manager TAB Filename

ratemgr_rsvd X(9) 242 - 250

Table 20-4: APG Rate File Variables - rateout.dat

Field Description Variable Name Format Position NotesHospital/Provider Number

pfac X(16) 1 - 16

Paysource (Payer) Code

psrc X(13) 17 - 29


pfac X(20) 1 - 20


psrc X(9) 21 – 29

Effective Date effdate 9(8) 30 - 37 CCYYMMDD, where:CC = CenturyYY = YearMM = MonthDD = Day

APG apg 9(4) 38 - 41Filler X(1) 42 APG Weight weight 9(2)v9(5) 43 - 49APG Type apgtype 9(2) 50 - 51Non-Covered APG Flag

noncover 9(1) 52 0 = Covered1 = Non-covered

Packaging Flag package 9(2) 53 - 54 Reserved




Discount Exempt Flag

disc_exempt 9(1) 55 New York Medicaid APG:0 = Standard discounting

applies1 = Exempt from discounting

for certain rate codes2 = Alternate discounting

applies for certain rate codes

APC Rate apc_rate 9(5)v9(2) 56 - 62 ReservedAPC Pricing Type hpaystat X(2) 63 - 64 ReservedFiller X(1) 65IOL Flag (reserved) iol_flag X(1) 66 ReservedNational Co-Payment

ntl_copay 9(4)v9(2) 67 - 72 Reserved

Minimum Co-Payment

min-copay 9(4)v9(2) 73 - 78 Reserved

Hospital Co-Payment

hos-copay 9(4)v9(2) 79 - 84 Reserved

Coinsurance Flag coinsflag 9(1) 85 ReservedProgram Payment Percentage

ppp 9(1)v9(6) 86 - 92 Reserved

Deductible Ranking rank 9(5) 93 - 97 ReservedRecurring APG Flag

apg_recur 9(1) 98 Reserved

Pass-Through Offset

owr_apc_offset 9(5)v9(2) 99 - 105 Reserved

Filler X(1) 106File Name for .tab File (Rate Manager)

filename X(9) 107 - 115

Low Charge Threshold

apg_lchg 9(5)v9(2) 116 - 122 Reserved

High Charge Threshold

apg_hchg 9(5)v9(2) 123 - 129 Reserved

APG Percent of Charge

apg_poc 9(1)v9(2) 130 - 132 Reserved

Never Pay Flag nvrpay 9(1) 133 New York Medicaid APG:0 = Not a Never Pay APG1 = Never Pay APG

Stand Alone Flag stndaln 9(1) 134 New York Medicaid APG:0 = Not Stand Alone APG1 = Stand Alone APG




Special Payment Flag

special_pmt 9(1) 135 Illinois Medicaid APG:0 = Standard APG processing1 = High cost drug APG2 = High cost device APG

New York Medicaid APG:0 = Standard APG processing1 = Carve out2 = Payable incidental



procedure and payable incidental procedure

8 = No payment

Ohio Medicaid APG:0 = Standard APG processing1 = APG paid flat rate2 = Observation APG3 = APG paid off fee schedule

Washington Medicaid APG:0 = Standard APG processing2 = Pay percent of charges

Transition Flag transition 9(1) 136 New York Medicaid APG:0 = Not subject to transitional

blend1 = Subject to transitional

blendAPG Discount 1 apg_disc1 9(1)v9(5) 137 - 142 New York Medicaid APG:

Discount to be applied if service is highest weighted procedure.

APG Discount 2 apg_disc2 9(1)v9(5) 143 - 148 New York Medicaid APG:Discount to be applied if service is second highest weighted procedure.

APG Discount 3 apg_disc3 9(1)v9(5) 149 -154 New York Medicaid APG:Discount to be applied if service is third or higher weighted procedure.

APG Extended Weight

weight_ext 9(3)v9(6) 155 - 163 Extended field for relative weight for the corresponding APG.

Reserved mod_90 9(1) 164 Reserved for future use.Statewide Base Rate Flag

stwide_base 9(1) 165 New York Medicaid APG:0 = Does not receive

statewide base rate1 = Receives statewide base

rate




20.2.4 DRG Rate File Layout

Mental Health Adjustment Flag

mh_adj 9(1) 166 New York Medicaid APG:0 = Not eligible for Mental

Health Adjustment1 = Eligible for Mental Health

Adjustment 12 = Eligible for Mental Health

Adjustment 2Modifier U6 Flag mod_u6 9(1) 167 New York Medicaid APG:

0 = Not eligible for NY Ancillary Billing Policy

1 = Eligible for NY Ancillary Billing Policy

Modifier HQ Flag mod_hq 9(1) 168 New York Medicaid APG:0 = Not eligible for NY

Smoking Cessation Adjustment

1 = Eligible for NY Smoking Cessation Adjustment

Filler X(3) 169 - 171Key Type key_type X(1) 172 0 or Blank = Legacy Provider

ID used for rate lookup.1 = NPI plus taxonomy code

used for rate lookup.Filler X(19) 173 - 191

Table 20-5: DRG Rate File Variables - rate.dat



Hospital Number pfac X(16) 1 - 16 Hospital number for which the remaining information in the record applies.


Hospital Number with NPI Taxonomy

pfac X(20) 1 - 20 Unique hospital identifier. Contains the hospital’s National Provider Identifier (NPI) and Taxonomy Code.






Effective Date Norms Went into Effect - Century - Year - Month - Day

effdate

9(2)9(2)9(2)9(2)

30 - 37 The century, year, month, and day that these APR-DRG/DRG weights and norms went into effect.

DRG drg 9(4) 38 - 41 APR-DRG/DRG number.Filler filler1 9(1) 42Pricer-Specific Rate or Factor

rate 9(7)v9(2) 43 - 51 Used for Pricer-specific DRG/APR-DRG rates or factors.

North Carolina Medicaid, Georgia Medicaid, Kansas Medicaid, New Jersey Medicaid APR, New York Medicaid APR, Nebraska Medicaid APR, Ohio Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, South Carolina Medicaid, and Virginia Medicaid APR:Used to store DRG-specific cost outlier thresholds.

Kentucky Medicaid:Used to the store transplant acquisition payment rate.

Arizona Medicaid:Used to store the APR-DRG specific outlier marginal cost factor.

Multi-Pricer/DRG Pro and Pennsylvania Medicaid APR:Used to store the DRG base rate or case rate.

Weight weight 9(2)v9(5) 52 - 58 Weighting factor associated with the APR-DRG/DRG.

Medicare IPF:DRG-specific adjustment used to calculate the per diem.





Mean Length of Stay

mlos 9(3)v9(4) 59 - 65 Multi-Pricer/DRG Pro, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Medicare Inpatient, Medicare LTC, Michigan Medicaid, Michigan Medicaid APR, New Jersey Medicaid, New Jersey Medicaid APR, New York Medicaid APR, North Carolina Medicaid, Ohio Medicaid, Pennsylvania Medicaid, Pennsylvania Medicaid APR, TRICARE/CHAMPUS, Virginia Medicaid, and Washington Medicaid:Geometric mean

Arizona Medicaid, California Medicaid, Florida Medicaid, Illinois Medicaid APR, Indiana Medicaid APR, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, Nebraska Medicaid APR, Ohio Medicaid APR, Rhode Island Medicaid, South Carolina Medicaid, Virginia Medicaid APR, Washington DC Medicaid, and Wisconsin Medicaid APR:Arithmetic mean

Washington Medicaid APR:Rounded arithmetic mean

High Length of Stay Trim

cutoff 9(3) 66 - 68 Where applicable, used to identify long-stay outlier claims.

New Jersey Medicaid:AIDS DRGS only (DRGs 700-702, 704-705, 707-708, 710-714), the high length of stay trim should be zero-filled.

New Jersey Medicaid APR:Alternate Level of Care

Low Length of Stay Trim

lowcutoff 9(3) 69 - 71 Where applicable, used to identify short-stay outlier claims.

New Jersey Medicaid:AIDS DRGS only (DRGs 700-702, 704-705, 707-708, 710-714), the low length of stay trim should be zero-filled.





Low Per Diem loperdiem 9(5)v9(2) 72 - 78 Washington Health Care Authority (HCA):Used to collect DRG-specific low charge threshold.

New Jersey Medicaid:The DRG-specific low per diem.

Pennsylvania Medicaid APR: Low cost outlier percentage.

California Medicaid:Used for the NICU adjustment factor.

High Per Diem hiperdiem 9(5)v9(2) 79 - 85 Kansas Medicaid: DRG Daily Rate

New Mean Length of Stay or Service Adjustor

new_mlos 9(3)v9(4) 86 - 92 Multi-Pricer/DRG Pro, Kentucky Medicaid, Medicare Inpatient, Texas Medicaid, TRICARE/CHAMPUS, and Virginia Medicaid APR:Arithmetic mean

Medicare LTC:5/6th of the geometric mean

Illinois Medicaid and Pennsylvania Medicaid Day (LOS) Outliers and Transfer-Out Cases: Geometric mean

Arizona Medicaid and Florida Medicaid: Service adjustor

California Medicaid:Service adjustor or high acuity policy adjustor

Washington Medicaid APR: Marginal cost factor

Illinois Medicaid APR and Minnesota Medicaid: Policy adjustor

Michigan Medicaid APR: Alternate weight for Level 4 NICU





DRG Flag

New York Medicaid “Top 20 DRG” Indicator(prior to December 01, 2009)

Post-Acute Transfer DRG Flag

drgflag

(nytopdrg)

(xfr_flag)

9(1) 93 Multi-Pricer/DRG Pro, Kentucky Medicaid, Medicare Inpatient, and TRICARE/CHAMPUS:0 = DRG is not subject to post-

acute transfer pricing1 = DRG is subject to standard

post-acute transfer pricing2 = DRG is subject to special

post-acute transfer pricing

Florida Medicaid and Pennsylvania Medicaid APR:0 = Normal DRG (80%)1 = High cost DRG (100%)2 = Non-covered DRG (0%)

Florida Medicaid:0 = DRG not subject to special

neonate/pediatric outlier provisions (Marginal Cost Factor)

1 = DRG subject to special pediatric outlier provisions (Marginal Cost Factor 2)

2 = DRG subject to special neonate outlier provisions (Marginal Cost Factor 2)

Louisiana Medicaid:0 = DRG not subject to special

burn outlier provisions2 = DRG subject to special burn

outlier provisions

Washington Medicaid:0 = DRGs not subject to special

neonate/pediatric outlier provisions

1 = DRGs subject to special neonate/pediatric outlier provisions

Medical/Surgical Flag

msflag 9(1) 94 1 = Medical DRG2 = Surgical DRG





DRG Category drgcat 9(2) 95 - 96 Arizona Medicaid:00 = Normal DRG processing01 = Transfer exempt DRG02 = Non-covered DRG

California Medicaid:00 = Normal DRG processing01 = Rehabilitation DRG02 = Obstetrics DRG

Florida Medicaid:00 = Normal DRG processing06 = DRG considered for transfer13 = DRG not subject to DRG

policy adjustments

Georgia Medicaid:00 = Normal DRG processing01 = CCR excluded DRG02 = Rural newborn addon

eligible DRG03 = Rural newborn add-on

eligible DRG (CCR excluded)

Illinois Medicaid:00 = Normal DRG processing01 = Delivery DRG02 = Neonatal DRG (excluding

DRG 385-389)03 = Level III neonatal DRG

(DRGs 385-389 only)04 = Burn DRG05 = Psychiatric DRG

Illinois Medicaid APR:00 = Normal DRG processing01 = Burn and Trauma DRG 02 = Perinatal DRG03 = Perinatal transfer exempt

DRG04 = Transplant DRG05 = Normal Newborn

Indiana Medicaid APR:00 = Normal DRG processing06 = DRG exempt from transfer08 = DRG paid per diem 109 = DRG paid per diem 211 = DRG paid per diem 312 = DRG paid per diem 1 with

diagnosis requirements

continued below...





DRG Category<continued>

drgcat 9(2) 95 - 96 Iowa Medicaid:00 = Normal DRG processing01 = Neonatal DRG processing

Kentucky Medicaid:00 = Normal DRG processing02 = Psychiatric per diem03 = Transplant DRG (prior to

October 01, 2015)04 = Neonatal DRG (prior to

October 01, 2015)05 = Rehabilitation per diem06 = Transfer exempt DRG07 = Burn DRG

Louisiana Medicaid:00 = Normal DRG processing06 = Neonatal DRG exempt from

transfer08 = Psychiatric DRG09 = Rehabilitation DRG10 = Transplant DRG

Medicare Inpatient:00 = Normal DRG processing01 = Transfer exempt DRG02 = Burn DRG03 = New technology DRG04 = Error DRG99 = Normal DRG processing

Medicare IPF:00 = Normal DRG processing01 = Psychiatric DRG

Medicare LTC:00 = Normal DRG processing01 = Psychiatric or rehabilitation

DRGs

Michigan Medicaid APR:00 = Normal DRG processing01 = Bone marrow transplant

DRG02 = Neonatal DRG03 = Transfer exempt DRG04 = Three digit DRG age split05 = Two digit DRG age split06 = All other transplant DRG99 = Normal DRG processing

continued below...






drgcat 9(2) 95 - 96 Minnesota Medicaid:00 = Normal DRG processing01 = Obstetric DRGs (subject to

policy adjustor 1)02 = Pediatric DRGs (subject to

policy adjustor 2)03 = Mental health DRGs (subject

to policy adjustor 3)

Mississippi Medicaid:01 = Obstetrics and normal

newborn DRGs (subject to policy adjustor 1)

02 = Neonate DRGs (subject to policy adjustor 2)

03 = Mental health DRGs (subject to policy adjustors 3 and 4)

04 = Rehabilitation DRGs (subject to policy adjustor 5)

05 = Transplant DRGs (subject to policy adjustor 6)

Nebraska Medicaid:00 = Normal DRG processing01 = Neonate DRG02 = Burn DRG03 = Psychiatric DRG04 = Rehabilitation DRG05 = Unstable/low volume DRG06 = Transplant DRG

Nebraska Medicaid APR:00 = Normal DRG processing02 = Burn DRG03 = Psychiatric DRG04 = Rehabilitation DRG06 = Transplant DRG

New York Medicaid APR:00 = Normal DRG processing01 = Transfer exempt DRG02 = Eligible for spinal implant

payment DRG

North Carolina Medicaid:00 = Normal DRG processing01 = Psychiatric DRG02 = Rehabilitation DRG03 = Transfer exempt DRG04 = Obstetric DRG eligible for

LARC DRG reimbursement

continued below...






drgcat 9(2) 95 - 96 Ohio Medicaid:00 = Normal DRG processing01 = Neonatal DRG02 = HIV DRG

Ohio Medicaid APR:00 = Normal DRG processing01 = Tracheostomy DRGs (004

and 005)02 = Neonatal DRG (580 - 639)03 = Organ acquisition charges

DRGs (001, 002, and 006)04 = Organ acquisition costs

DRG (003 and 007)05 = Non-covered claim DRG

(772)

Pennsylvania Medicaid:00 = Normal DRG processing01 = Cost outlier eligible/transfer

exempt02 = Tracheostomy DRG03 = Special payment applies04 = Rehabilitation DRG

Pennsylvania Medicaid APR:00 = Normal DRG processing01 = Neonates 02 = Psychiatric/drug/

rehabilitation DRG03 = Transplant DRG04 = Burn DRG

Rhode Island Medicaid:00 = Normal DRG processing03 = Mental health DRG (subject

to policy adjustor 3 or 4)

South Carolina Medicaid:00 = Normal DRG processing01 = Normal delivery DRGs (541

and 560)02 = False labor DRG (565)03 = Normal newborn DRG (640)

Texas Medicaid:01 = Obstetrics delivery services

DRG99 = Normal DRG processing

continued below...






drgcat 9(2) 95 - 96 TRICARE/CHAMPUS:00 = Normal DRG processing01 = Neonatal DRGs excluding

transfer DRG02 = Burn DRG03 = Neonatal transfer DRG04 = Psychiatric DRG

Virginia Medicaid:00 = Normal DRG processing01 = Rehabilitation DRG02 = Psychiatric DRG03 = Exempt transplant DRG04 = Error DRG

Virginia Medicaid APR:00 = Normal DRG processing06 = DRG exempt from transfer08 = DRG paid per diem 109 = DRG paid per diem 210 = Exempt/transplant DRG

Washington HCA:00 = Normal DRG processing01 = Unit-specific rehabilitation

DRG02 = Psychiatric DRG03 = Substance abuse DRG04 = Rehabilitation DRG05 = Transplant DRG06 = Low volume DRG

Washington Medicaid:00 = Normal DRG processing01 = Rehabilitation DRG02 = Psychiatric DRG03 = Substance abuse DRG04 = Exempt neonate DRG (prior

to August 01,200705 = AIDS DRG (prior to August

01, 2007)06 = Normal newborn DRG (prior

to August 01, 2007) 07 = Delivery DRG (prior to

August 01, 2007)08 = Other, paid RCC09 = Burn DRG 10 = Medical DRG11 = Surgical DRG 12 = Neonate per diem

continued below...






drgcat 9(2) 95 - 96 Washington Medicaid APR:00 = Normal DRG processing01 = Rehabilitation DRG02 = Psychiatric DRG03 = Detox DRG04 = Transplant DRG05 = Neonatal DRG

Washington DC Medicaid:00 = Normal DRG processing01 = Neonate DRGs (subject to

policy adjustor 1)02 = Normal newborn DRGs

(subject to policy adjustor 2)03 = Pediatric mental health

DRGs (subject to policy adjustor 3 or 4)

04 = Pediatric miscellaneous DRGs (subject to policy adjustor 5)

05 = Pediatric respiratory DRGs (subject to policy adjustor 6)

Wisconsin Medicaid: 00 = Normal DRG processing 01 = Psychiatric DRG 02 = Burn DRG

Wisconsin Medicaid APR:00 = Normal DRG processing 01 = Neonate DRGs (subject to

policy adjustor 1)02 = Normal newborn DRGs

(subject to policy adjustor 2)04 = Transplant DRGs (subject to

policy adjustor 5)06 = Neonatal DRG exempt from

transfer07 = Long Acting Reversible

Contraceptive (LARC) add-on DRGs (subject to policy add-on 1)





Base Rate Flag brf X(1) 97 Massachusetts Medicaid:Identifies DRGs that are subject to the pediatric acute care payment adjustment.

0 = No adjustment1 = Apply pediatric acute care

base rate adjustment

Medicare Inpatient and TRICARE/CHAMPUS:Identifies MS-DRGs that are assigned based on an implantation of a device.

Washington Medicaid: Identifies DRGs that use a contractual base rate, instead of a standard base rate.

DRG-specific Cost Reduction Factor

drg_crf 9(1)v9(5) 98 - 103 Multi-Pricer/DRG Pro:DRG-specific cost reduction factor or percent of charges.

DRG-Specific Tiered Per Diem RatesRate 1Rate 2Rate 3Rate 4Rate 5

OR

DRG-Specific Base Rates

Operating Base Rate

DRG-Specific Base Rates

Capital Base Rate

drg_tier1drg_tier2drg_tier3drg_tier4drg_tier5

drg_tier1

drg_tier2

9(5)v9(2)9(5)v9(2)9(5)v9(2)9(5)v9(2)9(5)v9(2)

9(5)v9(2)

9(5)v9(2)

104 - 110111 - 117118 - 124125 - 131132 - 138

104 - 110

111 - 117

Multi-Pricer/DRG Pro:Used for DRG-specific tiered per diem pricing. For this type of pricing, five daily rates are allowed for each DRG. Each per diem rate is applied to a specific period of the patient’s hospital stay, beginning on a specified start-day.

OR

Used for DRG-specific capital base rates (operating base rate and capital base rates).

Used for DRG-specific base rates (operating base rate and capital base rates).





DRG-Specific Starting DaysDay 1Day 2Day 3Day 4Day 5

drg_day1drg_day2drg_day3drg_day4drg_day5

9(3)9(3)9(3)9(3)9(3)

139 - 141142 - 144145 - 147148 - 150151 - 153

Multi-Pricer/DRG Pro:Used for DRG-specific tiered per diem pricing. It indicates the day of the patient’s hospital stay on which the corresponding tiered per diem should begin to be applied. This rate will be applied until another tiered per diem rate becomes applicable.

For example, beginning on drg_day1, drg_tier1 will be applied. This rate will be applied until drg_day2. At this point in the hospital stay, drg_tier2 will be utilized.

DRG-Specific Payment Type/Rules

drgpaytype 9(2) 154 - 155 Multi-Pricer/DRG Pro:1 = Base * DRG weight2 = Case rate3 = Cost Reduction Factor (CRF)

or percent of charges4 = Per diem5 = Tiered per diem6 = Case rate plus per diem7 = (Operating base + capital

base) * DRG weightDRG-specific Per Diem Rate

drg_pdiem 9(5)v9(2) 156 - 162 Reserved

Rate Manager *.TAB filename

filename X(9) 163 - 171 Reserved for Rate Manager *.TAB file name.

Key Type key_type X(1) 172 1 = NPI plus taxonomy code used for rate lookup


Additional Mean Length of Stay

add_mlos 9(3)v9(4) 173 - 179 Medicare LTC:Contains the IPPS comparable threshold (IPPS ALOS + 1sd)

Arizona Medicaid, California Medicaid, and Florida Medicaid: Age adjustor

Washington Medicaid APR: Arithmetic mean

Michigan Medicaid APR:Alternate mean length of stay for Level 4 NICU





20.2.5 HHA Rate File Layout (prior to January 01, 2020)

Day Threshold daythreshold 9(4) 180 - 183 Multi-Pricer/DRG Pro:Day of stay after which the per diem rate is paid.

Michigan Medicaid APR: Alternate low trim for Level 4 NICU.

Filler X(8) 184 - 191

Table 20-6: HHA Rate File Variables - rateout.dat

Field Description Variable Name Format Position NotesHospital Number facility X(16) 1 - 16 Hospital number for which the

remaining information in the record applies.

Paysource Code paysrc X(13) 17 - 29 Unique paysource or payer identifier.

Hospital Number with NPI/Taxonomy

facility X(20) 1 - 20


paysrc X(9) 21 - 29

Effective Date eff_date 9(8) 30 - 37 CCYYMMDD, where:CC = CenturyYY = YearMM = MonthDD = Day

HHRG hhrg X(4) 38 - 41 HHRG number.Weight weight 9(3)v9(5) 42 - 49Reserved 9(8)v9(2) 50 - 59Reserved 9(8)v9(2) 60 - 69Reserved 9(8)v9(2) 70 - 79Reserved 9(8)v9(2) 80 - 89Reserved 9(8)v9(2) 90 - 99Reserved 9(8)v9(2) 100 - 109Non-Routine Medical Supplies Weight Severity Level 1

nrs_weight1 9(3)v9(5) 110 - 117

Non-Routine Medical Supplies Weight Severity Level 2

nrs_weight2 9(3)v9(5) 118 - 125





20.2.6 HHA Rate File Layout (on or after January 01, 2020)


nrs_weight3 9(3)v9(5) 126 - 133


nrs_weight4 9(3)v9(5) 134 - 141


nrs_weight5 9(3)v9(5) 142 - 149


nrs_weight6 9(3)v9(5) 150 - 157

Filler X(14) 158 - 171Key Type key_type X(1) 172Filler X(19) 173 - 191

Table 20-7: HHA Rate File Variables - ratehha.dat





Payer Type Reserved X(2) 30 - 39 ReservedPDGM Classification pdgm X(6) 40 - 45 PDGM classification (i.e.,

HIPPS code).Page Number pge_nbr 9(2) 46 - 47NPI/Legacy Flag key_type X(1) 48 0 = Legacy

1 = NPIWeight weight 9(3)v9(5) 49 - 56 Weight associated with this

PDGM (i.e., HIPPS code).LUPA Threshold lupathresh 9(3) 57 - 59Filler X(191) 60 - 250

Table 20-6: HHA Rate File Variables - rateout.dat



20.2.7 IRF CMG Rate File Layout

Table 20-8: CMG Rate File Variables - rateirf.dat

Field Description Variable Name Format Position NotesHospital Number c_hosp X(16) 1 - 16Paysource Code c_pcode X(13) 17 - 29Hospital Number with NPI/Taxonomy

c_hosp X(20) 1 - 20 Unique hospital identifier. Contains the hospital’s National Provider Identifier and Taxonomy Code.


c_pcode X(9) 21 - 29 Unique paysource or payer identifier.

Effective Date Norms Went into Effect - Century - Year - Month - Day

c_effdate

9(2)9(2)9(2)9(2)

30 - 37

30 - 3132 - 3334 - 3536 - 37

Date when Norms went into effect.

CMG c_cmg 9(4) 38 - 41 Contains one of 100 payment related CMGs. Valid values range from 0101 to 5104.

Generally (CMG < 5001), format is XXYY, where:

XX = RICYY = Subgroup within RIC

Filler X(1) 42Relative Weight With Tier 1 Comorbidity

c_weight1 9(3)v9(5) 43 - 50 Relative weight for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).

Relative Weight With Tier 2 Comorbidity

c_weight2 9(3)v9(5) 51 - 58 Relative weight for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


c_weight3 9(3)v9(5) 59 - 66 Relative weight for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Relative Weight With No Comorbidities

c_weight4 9(3)v9(5) 67 - 74 Relative weight for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidity (HIPPS comorbidity tier A).


Mean LOS With Tier 1 Comorbidity

c_alos1 9(3)v9(4) 75 - 81 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


c_alos2 9(3)v9(4) 82 - 88 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


c_alos3 9(3)v9(4) 89 - 95 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Mean LOS With No Comorbidities

c_alos4 9(3)v9(4) 96 - 102 Average length of stay for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidities (HIPPS comorbidity tier A).

Payment Rate With Tier 1 Comorbidity

c_rate1 9(8)v99 103 - 112 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


c_rate2 9(8)v99 113 - 122 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


c_rate3 9(8)v99 123 - 132 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Payment Rate With No Comorbidities

c_rate4 9(8)v99 133 - 142 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidities (HIPPS comorbidity tier A).




20.2.8 SNF RUG Rate File Layout (on or prior to October 01, 2019)

Payment Rate With Tier 1 ComorbidityWithout QualityReporting

c_noqual_rate1 9(6)v9(2) 143 - 150 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


c_noqual_rate2 9(6)v9(2) 151 - 158 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).

Filler X(4) 159 - 162Rate Manager *.TAB Filename

filename X(9) 163 - 171 Reserved for Rate Manager *.TAB file name.

Key Type key_type X(1) 172 1 = National Provider ID plus Taxonomy Code used for rate lookup



c_noqual_rate3 9(6)v9(2) 173 - 180 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Payment Rate With No ComorbiditiesWithout QualityReporting

c_noqual_rate4 9(6)v9(2) 181 - 188 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of no comorbidities (HIPPS comorbidity tier A).

Filler X(3) 189 - 191

Table 20-9: RUG Rate File Variables - ratesnf.dat







20.2.9 SNF Rate File Layout (after October 01, 2019)


RUG rug X(5) 38 - 42 RUG number.RUG Adjustment rug_adj 9(3)v9(5) 43 - 50Filler X(52) 51 - 102Urban Rate urban_rate 9(8)v9(2) 103 - 112Rural Rate rural_rate 9(8)v9(2) 113 - 122Filler X(69) 123 - 191

Table 20-10: SNF Rate File Variables - ratesnf2.dat

Field Description Variable Name Format Position NotesHospital Number pfac X(16) 1 - 16 Hospital number for which

the remaining information in the record applies.


Effective Date edate 9(8) 30 - 37 CCYYMMDD, where:CC = CenturyYY = YearMM = MonthDD = Day

Reserved X(2) 38 - 39HIPPS Character code X(6) 40 - 45Page Number pge_nbr 9(2) 46 - 47NPI/Legacy Flag key_type X(1) 48 0 = Legacy

1 = NPIPhysical Therapy Urban pt_urban 9(8)v9(2) 49 - 58 Physical therapy urban rate

Case-Mix Range:A-P, Z

Physical Therapy Rural pt_rural 9(8)v9(2) 59 - 68 Physical therapy rural rate


Occupational Therapy Urban

ot_urban 9(8)v9(2) 69 - 78 Occupational therapy urban rate


Table 20-9: RUG Rate File Variables - ratesnf.dat



Occupational Therapy Rural

ot_rural 9(8)v9(2) 79 - 88 Occupational therapy rural rate


Speech-Language Pathology Urban

slp_urban 9(8)v9(2) 89 - 98 Speech-language pathology urban rate

Case-Mix Range:A-L, Z

Speech-Language Pathology Rural

slp_rural 9(8)v9(2) 99 - 108 Speech-language pathology rural rate


Nursing Urban nrs_urban 9(8)v9(2) 109 - 118 Nursing urban rate

Case-Mix Range:A-Z

Nursing Rural nrs_rural 9(8)v9(2) 119 - 128 Nursing rural rate

Case-Mix Range:A-Z

Non-Therapy Ancillary Urban

nta_urban 9(8)v9(2) 129 - 138 Non-therapy ancillary urban rate

Case-Mix Range:A-F, Z

Non-Therapy Ancillary Rural

nta_rural 9(8)v9(2) 139 - 148 Non-therapy ancillary rural rate


Filler X(102) 149 - 250

Table 20-10: SNF Rate File Variables - ratesnf2.dat



20.3 COBOL Platform 20.3.1 APC Rate File Layout (prior to January 01, 2018)

NoteNot applicable to Medicare ASC or Contract ASC pricing.

* = Key Field

Table 20-11: COBOL APC Rate File Variables - wghtrate.dat (prior to January 01, 2018)

Field Description Variable Name Format Position NotesPayer Type WRR-PAYER-

TYPEX(2) 1 - 2 55 = APCs for ASC

56 = APCs for HOPD57 = Contract APC/APC Pro64 = Contract ASC

Payer Type Reserved *

WRR-PAYER-TYPE-RSVD

X(2) 3 - 4

Norms Type * WWR-NORMS-TYPE

X(29) 5 - 33 Zero-filled for APCs

Norms Effective Date*

WWR-EDATE

Century/Year WWR-EDATE-CCYY

9(2) 36 - 37 Century/Year norms went into effect

Month WWR-EDATE-MM

9(2) 38 - 39 Month norms went into effect

Day WWR-EDATE-DD

9(2) 40 - 41 Day norms went into effect

APC * WWR-CODE 9(5) 42 - 46Reserved for Stop Date

WWR-STOP-DATE

X(8) 47 - 54

APC Weight WWR-OWD-WGT

9(3)v9(5) 55 - 62 Weight associated with this APC if used with a base rate to calculate reimbursement.

APG Type WWR-OWD-APG-TYPE

9(2) 63 - 64 Not used by APC-HOPD Pricer

Non-Covered APG Flag

WRR-OWD-APG-NONCOVER

9(1) 65 Not used by APC-HOPD Pricer

Packaging Flag WWR-OWD-APG-PACKAGE

9(2) 66 - 67

Units of Service Pricing

WWR-OWD-APG-UNITPRIC


APC Rate WWR-OWD-APC-RATE

9(8)v9(2) 69 - 78 Published base rate for this APC, before adjustments


APC Payment Status

WWR-OWD-APC-HPAYSTAT

X(2) 79 - 80 APC Payment Status Indicators.


ASC Payment Indicator

WRR-OWD-ASC-PAYSTAT

X(1) 81 Reserved for ASC status

“IOL Flag, reserved”

WRR-OWD-IOL-FLAG

9(1) 82 Reserved for IOL flag


WRR-OWD-NTL-COPAY

9(8)v9(2) 83 - 92 APC-HOPD:National unadjusted coinsurance.


WRR-OWD-MIN-COPAY

9(8)v9(2) 93 - 102 APC-HOPD:Minimum unadjusted coinsurance.


WRR-OWD-HOS-COPAY

9(8)v9(2) 103 - 112 APC-HOPD:Hospital-specific unadjusted coinsurance (must be greater than or equal to the minimum co-payment, and less than or equal to the national co-payment).




Coinsurance Flag WRR-OWD-HOS-COINSFLAG

9(1) 113 0 = Standard co-insurance rules1 = Coinsurance is 25% of

payment rate, hospital cannot reduce coinsurance




5 = Device or procedure eligible for offset deduction (prior to January 01, 2017)


6 = Procedure eligible for no-cost and reduced cost device offset deduction (prior to January 01, 2017)





WRR-OWD-PPP

9(1)v9(6) 114 - 120 Program payment percentage, percent of line item payment paid by third party payer.


Rank WRR-OWD-RANK

9(5) 121 - 125 APC-HOPD:Ranking for allocation of deductible to individual claim lines.

Recurring APG Flag

WRR-OWD-APG-RECUR


APC Offset WRR-OWD-APC-OFFSET

9(8)v9(2) 127 - 136 Unadjusted offset that is deducted from the payment for transitional pass-through items or from the payment for procedures with no-cost devices (prior to January 01, 2017).




20.3.2 APC Rate File Layout (on or after January 01, 2018)

APC User Base Rate

WRR-OWD-APC-USER-RATE

9(5)v9(3) 137 - 144 Contract APC/APC Pro:User specified base rate/conversion factor. If the hospital “Base * Weight Pricing” option is set to “Yes” and this field is set, the APC Rate = APC User Base Rate * APC Weight.

Filler X(2) 145 - 146APC Policy Packaged Offset

WRR-OWD-APC-POLOFFSET

9(8)v9(2) 147 - 156 Offset dollar amount to be deducted from radiopharmaceutical reimbursement where applicable.


WRR-OWD-APC-CAOFFSET

9(8)v9(2) 157 - 166 Offset dollar amount to be deducted from contrast agent reimbursement where applicable.

Extended Weight WRR-OWD-APC-WEIGHT-EXT

9(4)v9(5) 167 - 175 Extended weight associated with this APC if used with a base rate to calculate reimbursement.

Filler X(75) 176 - 250

Table 20-12: COBOL APC Rate File Variables - wghtapc.dat (on or after January 01, 2018)

Field Description Variable Name Format Position NotesHospital Number WRR2-

NORMS-TYPEX(29) 1 - 29

Effective Date WRR2-EDATE Day norms went into effect. CCYYMMDD format, where:

CC = CenturyYY = YearMM = MonthDD = Day

Century/Year WRR2-EDATE-CCYY

9(4) 30 - 33 Century/Year norms went into effect

Month WRR2-EDATE-MM


Day WRR2-EDATE-DD


Reserved X(2) 38 - 39APC WRR2-CODE 9(6) 40 - 45Page Number WRR2-PGE-

NBR9(2) 46 - 47




NPI/Legacy Flag WRR2-ARD-KEY-TYPE

X(1) 48 0 = Legacy1 = NPI

Reserved 9(1) 49APC Weight WRR2-ARD-

WEIGHT9(5)v9(5) 50 - 58 APC-HOPD:

Weight associated with this APC.

Contract APC/APC Pro:Weight associated with this APC if used with a base rate to calculate reimbursement.

APC Rate WRR2-ARD-APC-RATE

9(8)v9(3) 59 - 68 Base rate for this APC, before adjustments.

Reserved 9(1) 69APC Payment Status WRR2-ARD-

APC-HPAYSTAT

X(2) 70 - 71 APC Payment Status Indicators.



WRR2-ARD-NTL-COPAY

9(8)v9(2) 72 - 81 APC-HOPD:National unadjusted coinsurance.


WRR2-ARD-MIN-COPAY

9(8)v9(2) 82 - 91 APC-HOPD:Minimum unadjusted coinsurance.


WRR2-ARD-HOS-COPAY

9(8)v9(2) 92 - 101 APC-HOPD:Hospital-specific unadjusted coinsurance (must be greater than or equal to the minimum co-payment, and less than or equal to the national co-payment).




Coinsurance Flag WRR2-ARD-COINSFLAG

9(2) 102 - 103 00 = Standard co-insurance rules

01 = Coinsurance is 25% of payment rate, hospital cannot reduce coinsurance









WRR2-ARD-PPP

9(1)v9(6) 104 - 110 Program payment percentage, percent of line item payment paid by third party payer.


Reserved 9(1) 111Rank WRR2-ARD-

RANK9(5) 112 - 116 APC-HOPD:

Ranking for allocation of deductible to individual claim lines.

APC User Base Rate WRR2-ARD-USER-RATE

9(8)v9(3) 117 - 127 Contract APC/APC Pro:User specified base rate/conversion factor. If the hospital “Base * Weight Pricing” option is set to “Yes” and this field is set, the APC Rate = APC User Base Rate * APC Weight.




20.3.3 DRG Rate File LayoutNote

* = Key Field

APC Policy Packaged Offset

WRR2-ARD-APC-POLOFFSET

9(8)v9(2) 128 - 137 Offset dollar amount to be deducted from radiopharmaceutical reimbursement where applicable.


WRR2-ARD-APC-CAOFFSET

9(8)v9(2) 138 - 147 Offset dollar amount to be deducted from contrast agent reimbursement where applicable.

Extended APC Weight WRR2-ARD-WEIGHT-EXT

9(6)v9(5) 148 - 158 Contract APC/APC Pro:Extended weight associated with this APC if used with a base rate to calculate reimbursement.

APC-HOPD:Reserved for future use.

Filler X(83) 159 - 241Rate Manager TAB Filename

WRR2-ARD-TAB-FILE

X(9) 242 - 250



Table 20-13: COBOL DRG Rate File Variables - wghtrate.dat

Field Description Variable Name Format Position NotesPayer Type* WRR-PAYER-

TYPEX(2) 1 - 2

Payer Type Reserved*

WRR-PAYER-TYPE-RSVD

X(2) 3 - 4

Norms Type* WRR-NORMS-TYPE

X(29) 5 - 33

Norms Effective Date*

WRR-EDATE

Effective Century/Year

WRR-EDATE-CCYY

9(4) 34 - 37 Century/year norms went into effect

Effective Month WRR-EDATE-MM 9(2) 38 - 39 Month norms went into effectEffective Day WRR-EDATE-DD 9(2) 40 - 41 Day norms went into effectDRG* WRR-CODE 9(5) 42 - 46Filler for Future Expansion

WRR-STOP-DATE 9(8) 47 - 54


Weight WRR-IWD-WGT 9(3)v9(5) 55 - 62 Medicare Inpatient, Michigan Medicaid, New York Medicaid, New Jersey Medicaid, Multi-Pricer/DRG Pro, Pennsylvania Medicaid, TRICARE, and Washington HCA Case-Based:DRG-specific weight

Medicare IPF:DRG-specific adjustments used to calculate the per diem.

Mean LOS WRR-IWD-MLOS 9(3)v9(4) 63 - 69 Medicare Inpatient, Medicare LTC, Multi-Pricer/DRG Pro, TRICARE/CHAMPUS, North Carolina Medicaid, New Jersey Medicaid, Washington HCA, and Pennsylvania Medicaid:Geometric mean

New York Medicaid:Arithmetic mean

High Length of Stay Trim

WRR-IWD-HTRIM 9(3) 70 - 72 Where applicable, used to identify long-stay outlier claims.

New Jersey Medicaid:AIDS DRGS only (DRGs 700-702, 704-705, 707-708, 710-714), the high length of stay trim should be zero-filled.

Low Length of Stay Trim

WRR-IWD-LTRIM 9(3) 73 - 75 Where applicable, used to identify short-stay outlier claims.

New Jersey Medicaid:AIDS DRGS only (DRGs 700-702, 704-705, 707-708, 710-714), the low length of stay trim should be zero-filled.

Inlier Rate WRR-IWD-INRATE 9(8)v9(2) 76 - 85 Used for user-defined DRG-specific rates.

Multi-Pricer/DRG Pro:DRG base rate or case rate.




Low Per Diem or Low Cost Outlier Trim

WRR-IWD-LDIEM 9(8)v9(2) 86 - 95 New Jersey Medicaid:The DRG-specific low per diem.

Washington HCA:The low charge threshold.

Pennsylvania Medicaid:The low cost outlier percentage.

High Per Diem WRR-IWD-HDIEM 9(8)v9(2) 96 - 105 ReservedDRG Category WRR-IWD-

EXCLDRG9(2) 106 - 107 Medicare Inpatient:

00 = Normal DRG processing (before FY 2008)

01 = Transfer exempt MS-DRG

02 = Burn MS-DRG03 = New technology MS-

DRG04 = Error MS-DRG99 = Standard MS-DRG

processing

Medicare IPF:00 = Normal DRG processing01 = Psychiatric DRG

Medicare LTC:00 = Normal DRG processing01 = Psychiatric or

rehabilitation DRGs

Michigan Medicaid:00 = Normal DRG processing

(before FY 2008)01 = Bone marrow transplant

DRG02 = Neonatal DRG03 = Transfer exempt DRG04 = Three-digit DRG age

split05 = Two-digit DRG age split06 = All other transplant DRG99 = Standard MS-DRG

processing

New York Medicaid APR:00 = Normal DRG processing01 = Transfer exempt02 = Eligible for spinal implant

payment

continued below...





WRR-IWD-EXCLDRG

9(2) 106 - 107 North Carolina Medicaid:00 = Normal DRG processing01 = Psychiatric DRG02 = Rehabilitation DRG

Pennsylvania Medicaid:00 = Normal DRG processing01 = Cost outlier eligible/

transfer exempt02 = Tracheostomy DRG03 = Special payment applies04 = Rehabilitation DRG

Pennsylvania Medicaid APR:00 = Normal DRG processing01 = Neonates02 = Psych/drug/rehab03 = Transplants04 = Burns

TRICARE/CHAMPUS:00 = Normal DRG processing01 = Neonatal DRG except

transfer DRG02 = Burns DRG03 = Neonatal transfer DRG04 = Psychiatric DRG

Washington HCA:00 = Normal DRG processing01 = Unit-specific

rehabilitation DRG02 = Psychiatric DRG03 = Substance abuse DRG04 = Rehabilitation DRG05 = Transplant DRG06 = Low Volume DRG

Medical/Surgical DRG Identification Flag

WRR-IWD-MSFLAG

9(1) 108 1 = Medical DRG2 = Surgical DRG





WRR-IWD-HMLOS 9(3)v9(4) 109 - 115 Medicare Inpatient and TRICARE/CHAMPUS: The arithmetic mean length of stay used for day outlier and short-stay calculations.

Pennsylvania Medicaid:The geometric mean used for day outliers and transfer-out calculations.

Multi-Pricer/DRG Pro:Average mean length of stay.

Medicare LTC:5/6th of the geometric mean.

DRG-specific Percent of Charges

WRR-IWD-DRG-EPOC

9(1)v9(4) 116 - 120 Reserved

DRG Flag WRR-IWD-NYTOPDRGorWRR-IWD-XFR-FLAG

9(1) 121 New York Medicaid:0 = DRG is not a Medicaid

“Top 20 DRG”1 = DRG is a Medicaid “Top

20 DRG”

Medicare, Multi-Pricer/DRG Pro, and TRICARE/CHAMPUS:0 = DRG is not subject to

post-acute transfer pricing

1 = DRG is subject to standard post-acute transfer pricing

2 = DRG is subject to special post-acute transfer pricing

Pennsylvania Medicaid APR:0 = Normal DRG1 = High cost DRG2 = Non-covered DRG

Base Rate Flag WRR-IWD-DRG-BRF

X(1) 122 Medicare Inpatient and TRICARE/CHAMPUS:Identifies MS-DRGs classified by the implantation of a device.

D = Classified by a deviceDRG-specific CRF WRR-IWD-DRG-

CRF9(1)v9(5) 123 - 128 Multi-Pricer/DRG Pro:

DRG-specific cost reduction factor or percentage of charges.




DRG-Specific Tiered Per Diem Rates:Rate 1

Rate 2

Rate 3

Rate 4

Rate 5

OR

DRG-Specific Operating and Capital Base Rates

Operating Base Rate

Capital Base Rate

WRR-IWD-DRG-TIER1WRR-IWD-DRG-TIER2WRR-IWD-DRG-TIER3WRR-IWD-DRG-TIER4WRR-IWD-DRG-TIER5

WRR-IWD-DRG-TIER1WRR-IWD-DRG-TIER2

9(8)v9(2)

9(8)v9(2)

9(8)v9(2)

9(8)v9(2)

9(8)v9(2)

9(8)v9(2)

9(8)v9(2)

129 - 138

139 - 148

149- 158

159 - 168

169 - 178

129 - 138

139 - 148

Multi-Pricer/DRG Pro:For DRG-specific tiered per diem pricing. For this type of pricing, five daily rates are allowed for each DRG. Each per diem rate is applied to a specific period of the patient’s hospital stay, beginning on a specified start-day.

OR

Used for DRG-specific capital base rates (operating base rate and capital base rates).

DRG-specific Starting Days:- Day #1

- Day #2

- Day #3

- Day #4

- Day #5

WRR-IWD-DRG-DAY1WRR-IWD-DRG-DAY2WRR-IWD-DRG-DAY3WRR-IWD-DRG-DAY4WRR-IWD-DRG-DAY5

9(3)

9(3)

9(3)

9(3)

9(3)

179 - 181

182 - 184

185 - 187

188 - 190

191 - 193

Multi-Pricer/DRG Pro:For DRG-specific tiered per diem pricing. It indicates the day of the patient’s hospital stay on which the corresponding tiered per diem should begin to be applied. This rate will be applied until another tiered per diem rate becomes applicable.

For example, beginning on DRG_DAY1, DRG_TIER1 will be applied. This rate will be applied until DRG_DAY2. At this point in the hospital stay, DRG_TIER2 will be utilized.

DRG-Specific Payment Type/Rules

WRR-IWD-DRGPAYTYPE

9(2) 194 - 195 Multi-Pricer/DRG Pro:1 = Base * DRG weight2 = Case rate3 = Cost Reduction Factor

(CRF) or percent of charges

4 = Per diem5 = Tiered per diem6 = Case rate plus per diem7 = (Operating base + capital

base) * DRG weight




20.3.4 HHA Rate File Layout (prior to January 01, 2020)


WRR-IWD-ADD-MLOS

9(3)v9(4) 196 - 202 Medicare LTC:Contains the IPPS comparable threshold (IPPS ALOS + 1sd).

Day Threshold WRR-IWD-DAYTHRESHOLD

9(4) 203 - 206 Multi-Pricer/DRG Pro:Day of stay after which the per diem rate is paid

Filler X(44) 207 - 250

Table 20-14: COBOL HHA Rate File Variables - wghtrate.dat

Field Description Variable Name Format Position NotesPayer Type PAYER-TYPE X(2) 1 - 2Payer Type Reserved PAYER-TYPE-

RSVDX(2) 3 - 4

Norms Type NORMS-TYPE X(29) 5 - 33Effective Date of NormsCentury/YearMonthDay

EDATEEDATE-CCYYEDATE-MMEDATE-DD

9(4)9(2)9(2)

34 - 3738 - 3940 - 41

CCYYMMDD, where:CC = CenturyYY = YearMM = MonthDD = Day

HHRG(NOTE: the fifth character will be blank-filled)

HHRG X(5) 42 - 46 HHRG number.

Reserved for Stop Date STOP-DATE X(8) 47 - 54Weight 9(8)v9(2) 55 - 62Reserved 9(8)v9(2) 63 - 72Reserved 9(8)v9(2) 73 - 82Reserved 9(8)v9(2) 83 - 92Reserved 9(8)v9(2) 93 - 102Reserved 9(8)v9(2) 103 - 112Reserved 9(8)v9(2) 113 - 122Non-Routine Medical Supplies Weight Severity Level 1

WRR-HAA-NRS-WEIGHT1

9(3)v9(5) 123 - 130


WRR-HAA-NRS-WEIGHT2

9(3)v9(5) 131 - 138


WRR-HAA-NRS-WEIGHT3

9(3)v9(5) 139 - 146




20.3.5 HHA Rate File Layout (on or after January 01, 2020)

20.3.6 IRF CMG Rate File Layout Note

* = Key Field


WRR-HAA-NRS-WEIGHT4

9(3)v9(5) 147 - 154


WRR-HAA-NRS-WEIGHT5

9(3)v9(5) 155 - 162


WRR-HAA-NRS-WEIGHT6

9(3)v9(5) 163 - 170

Filler X(80) 171 - 250

Table 20-15: COBOL HHA Rate File Variables - wghthha.dat

Field Description Variable Name Format Position NotesHospital Number NORMS-TYPE X(16) 1 - 16 Hospital number for which

the remaining information in the record applies.

Paysource Code NORMS-TYPE X(13) 17 - 29 Unique paysource or payer identifier.

Effective Date EDATEEDATE-CCYYEDATE-MMEDATE-DD

9(8)9(4)9(2)9(2)

30 - 3730 - 3334 - 3536 - 37

CCYYMMDD, where:CC = CenturyYY = YearMM = MonthDD = Day

Payer Type Reserved X(2) 38 -39 ReservedPDGM Classification PDGM X(6) 40 - 45 PDGM classification (i.e.,

HIPPS code).Page Number PGE-NBR X(2) 46 - 47NPI/Legacy Flag KEY-TYPE X(1) 48 0 = Legacy

1 = NPIWeight WEIGHT 9(3)v9(5) 49 - 56 Weight associated with

this PDGM (i.e., HIPPS code).

LUPA Threshold LUPATHRESH 9(3) 57 - 59Filler X(191) 60 - 250

Table 20-14: COBOL HHA Rate File Variables - wghtrate.dat



Table 20-16: COBOL CMG Rate File Variables - wghtrate.dat

Field Description Variable Name Format Position NotesPayor Type* WRR-PAYER-TYPE X(2) 1 - 2

WRR-PAYER-TYPE-RSVD

X(2) 3 - 4


X(29) 5 - 33

Effective Date Norms Went into Effect*

WRR-EDATE

- Century WRR-EDATE-CCYY 9(4) 34 - 37 Century and Year Norms Went into Effect

- Month WRR-EDATE-MM 9(2) 38 - 39 Month Norms Went into Effect

- Day WRR-EDATE-DD 9(2) 40 - 41 Day Norms Went into Effect

CMG WRR-RWD-CMG 9(5) 42 - 46 Contains one of 100 payment related CMGs. Valid values range from 0101 to 5104.

Generally (CMG < 5001), format is XXYY, where:XX = RICYY = Subgroup within RIC

Filler for Future Expansion

WRR-STOP-DATE 9(8) 47 - 54


WRR-RWD-WGT1 9(3)v9(5) 55 - 62 Relative weight for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


WRR-RWD-WGT2 9(3)v9(5) 63 - 70 Relative weight for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


WRR-RWD-WGT3 9(3)v9(5) 71 - 78 Relative weight for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Relative Weight With No Comorbidities

WRR-RWD-WGT4 9(3)v9(5) 79 - 86 Relative weight for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidity (HIPPS comorbidity tier A).



WRR-RWD-MLOS1 9(3)v9(4) 87 - 93 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


WRR-RWD-MLOS2 9(3)v9(4) 94 - 100 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


WRR-RWD-MLOS3 9(3)v9(4) 101 - 107 Average length of stay for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Mean LOS With No Comorbidities

WRR-RWD-MLOS4 9(3)v9(4) 108 - 114 Average length of stay for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidities (HIPPS comorbidity tier A).


WRR-RWD-RATE1 9(8)v9(2) 115 - 124 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).


WRR-RWD-RATE2 9(8)v9(2) 125 - 134 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).


WRR-RWD-RATE3 9(8)v9(2) 135 - 144 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).




Payment Rate With No Comorbidities

WRR-RWD-RATE4 9(8)v9(2) 145 - 154 Federal unadjusted payment rate for payment HIPPS code. Based on payment CMG and no comorbidities or excluded comorbidities (HIPPS comorbidity tier A).

Payment Rate With Tier 1 ComorbidityWith No QualityReporting

WRR-RWD-NOQUAL-RATE1

9(6)v9(2) 155 - 162 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a high cost comorbidity (HIPPS comorbidity tier B).



9(6)v9(2) 163 - 170 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a medium cost comorbidity (HIPPS comorbidity tier C).



9(6)v9(2) 171 - 178 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of a low cost comorbidity (HIPPS comorbidity tier D).

Payment Rate With No ComorbiditiesWithout QualityReporting


9(6)v9(2) 179 - 186 Federal adjusted payment rate for payment HIPPS code. Based on payment CMG and presence of no comorbidities (HIPPS comorbidity tier A).

Filler X(64) 187 - 250




20.3.7 SNF RUG Rate File Layout (on or prior to October 01, 2019)

Note* = Key Field

20.3.8 SNF Rate File Layout (after October 01, 2019) Note

* = Key Field

Table 20-17: COBOL RUG Rate File Variables - wghtrate.dat

Field Description Variable Name Format Position NotesPayor Type* WRR-PAYER-TYPE X(2) 1 - 2

WRR-PAYER-TYPE-RSVD

X(2) 3 - 4


X(29) 5 - 33

Effective Date Norms Went Into Effect*

WRR-EDATE

- Century WRR-EDATE-CCYY 9(4) 34 - 37 Century and year norms went into effect

- Month WRR-EDATE-MM 9(2) 38 - 39 Month norms went into effect - Day WRR-EDATE-DD 9(2) 40 - 41 Day norms went into effectWeight Rate Code WRR-CODE X(5) 42 - 46Filler WRR-STOP-DATE 9(8) 47 - 54 For future expansionRUG Adjustment WRR-RUG-ADJ 9(3)v9(5) 55 - 62Filler X(52) 63 - 114Urban Rate WRR-URBAN-RATE 9(8)v9(2) 115 - 124Rural Rate WRR-RURAL-RATE 9(8)v9(2) 125 - 134Filler X(116) 135 - 250

Table 20-18: SNF Rate File Variables - wghtsnf.dat

Field Description Variable Name Format Position NotesPayor Type* WRR2-

PAYER-TYPEX(2) 1 - 2

WRR2-PAYER-TYPE-RSVD

X(2) 3 - 4

Norms Type* WRR2-NORMS-TYPE

X(13) 17 - 29

Effective Date Norms Went Into Effect*

WRR2-EDATE


WRR2-EDATE-CCYY

9(4) 30 - 33 Century and year norms went into effect

WRR2-EDATE-MM


WRR2-EDATE-DD


Reserved X(2) 38 - 39HIPPS Character WRR2-CODE X(6) 40 - 45Page Number WRR2-PGE-

NBR9(2) 46 - 47

NPI/Legacy Flag WRR2-ARD-KEY-TYPE

X(1) 48 0 = Legacy1 = NPI

Physical Therapy Urban WRR2-SRD-PT-URBAN

9(8)v9(2) 49 - 58 Physical therapy urban rate


Physical Therapy Rural WRR2-SRD-PT-RURAL

9(8)v9(2) 59 - 68 Physical therapy rural rate


Occupational Therapy Urban

WRR2-SRD-OT-URBAN

9(8)v9(2) 69 - 78 Occupational therapy urban rate


Occupational Therapy Rural

WRR2-SRD-OT-RURAL

9(8)v9(2) 79 - 88 Occupational therapy rural rate


Speech-Language Pathology Urban

WRR2-SRD-SLP-URBAN

9(8)v9(2) 89 - 98 Speech-language pathology urban rate


Speech-Language Pathology Rural

WRR2-SRD-SLP-RURAL

9(8)v9(2) 99 - 108 Speech-language pathology rural rate


Nursing Urban WRR2-SRD-NRS-URBAN

9(8)v9(2) 109 - 118 Nursing urban rate

Case-Mix Range:A-Z

Nursing Rural WRR2-SRD-NRS-RURAL

9(8)v9(2) 119 - 128 Nursing rural rate

Case-Mix Range:A-Z




Non-Therapy Ancillary Urban

WRR2-SRD-NTA-URBAN

9(8)v9(2) 129 - 138 Non-therapy ancillary urban rate


Non-Therapy Ancillary Rural

WRR2-SRD-NTA-RURAL

9(8)v9(2) 139 - 148 Non-therapy ancillary rural rate


Filler X(102) 149 - 250




21 Rule File Layouts

This chapter provides the layouts for the Rule files (C and COBOL). This chapter includes the following sections:

• File Naming Conventions• APC Rule File

- Overview- APC Rule File Layout- Procedure-Level Edits

• ASC Rule File- Overview- ASC Rule File Layout

• ACE Rule File- Overview- Override ID- ACE Rule File Layout- Example File- Exceptions to Individual Edit Flags

• Mapping Rule File- Overview- Mapping Override ID- Mapping Override File Layout

• New Mexico Medicaid APC Rule File Layout


21.1 File Naming ConventionsThe Rule File names are listed below:

21.2 APC Rule FileNote

Applicable to Contract APC pricing only.

21.2.1 OverviewThe Contract APC option (available for contracted clients only) allows the user to deviate from Medicare OPPS APC assignments for a specified facility, paysource, and time period. The user can reassign APC, payment status, and the maximum allowed units for a particular procedure code during specified effective dates. Medicare rules will be applied to all procedure codes that the user does not reassign.The user-defined rules are maintained in Rate Manager. Rules can be created using this interactive tool and/or imported from text files. Rate Manager stores and maintains the rules. The rules are then exported to the APC Rule File (apcrule.dat) for use with ACE.The Contract APC rules are defined in the APC Rule File (apcrule.dat). Each row in the file contains an Override ID, HCPCS Code, APC, APC Payment Status, Maximum Units of Service and additional procedure-level information. The file layout and an example are detailed below.

21.2.2 APC Rule File Layout

Table 21-1: Rule File Names

Description FilenameAPC Rule File apcrule.datASC Rule File ascrule.datACE Rule File acerule.datMapping Rule File maprule.datNew Mexico Medicaid Rule File nmrule.dat

Table 21-2: APC Rule File Layout - apcrule.dat

Field Description

C Variable Name

COBOL Variable Name


Override ID override_id OVERRID-ID

X(20) 1 - 20 Maximum of 20 alphanumeric characters.

Code Type codetype CODETYPE X(1) 21 Always set to C.


HCPCS Code code CODE X(9) 22 - 30 HCPCS code, 5 bytes alphanumeric.

Code Sequence Number

codeseq CODESEQ 9(2) 31 - 32 Sequence number used to identify the number of entries for the same HCPCS code. Identify the entry with the most recent start date for the HCPCS code as 01, the second most recent start date as 02 etc.

Starting Date startdate STARTDATE

9(8) 33 - 40 Start Date. The format is YYYYMMDD (where YYYY equals the year, MM the month, and DD the day).

Ending Date enddate ENDDATE 9(8) 41 - 48 End Date. The format is YYYYMMDD. If no end date set to 00000000.

Original Effective Date

origindate ORIGINDATE

9(8) 49 - 56 Set equal to effective date of code (if unknown set to 20000801). The format is YYYYMMDD.

Further Qualifier Flag

furqual FURQUAL 9(1) 57 Set to 0.

OCE Effective Version

ocevfrom OCEVFROM

9(2) 58 - 59 Set to 00.

OCE End Version ocevthru OCEVTHRU 9(2) 60 - 61 Set to 00.Code Description desc DESC X(24) 62 - 85 Set equal to HCPCS code label. If

this field is not set, a blank label will be displayed in Modify HCPCS Rules utility. The label must not contain commas and be a maximum of 24 characters.

Sex Edit Indicator sex SEX X(1) 86 Set to blank.Age Edit Indicator Diagnoses

age AGE X(1) 87 Set to blank.

Minimum Age minage MINAGE 9(3) 88 - 90 Set to 000.Maximum Age maxage MAXAGE 9(3) 91 - 93 Set to 124.CCI Control ccicntl CCICNTL 9(1) 94 Set to 0.OCE CCI Control oceccicntl OCECCICN

TL9(1) 95 Set to 0.

Procedure Category

nuq NUQ X(1) 96 Set to blank.

Bilateral Procedure Indicator

bilatop BILATOP 9(1) 97 Set to 9.


Field Description

C Variable Name

COBOL Variable Name



APC apc APC 9(5) 98 - 102 This a 5-digit numeric field. An APC of 1 should be defined as 00001. If an APC is not applicable set to 00000.

APC Payment Status

hpaystat HPAYSTAT X(2) 103 - 104 APC Payment Status Indicator.


Reserved X(1) 105 ReservedMaximum Units of Service

units UNITS 9(7) 106 - 112 Maximum units to be used when applying Edit 015. If not applicable, set to seven (7) zeros, 0000000.

Utility Date apcdate APCDATE 9(8) 113 - 120 Zero FillUtility Rate apcrate APCRATE 9(8)v9(2) 121 - 130 Zero FillUtility Date2 apcdate2 APCDATE2 9(8) 131 - 138 Zero FillApproval Date Edit Number

dateeditno1 DATEEDITNO1

9(2) 139 - 140 Zero FillDefault = Blank

If the Approval Date Edit Number 2 field is set to zero, the Approval Date Edit Number field will be used.

Filler X(19) 141 - 159 ReservedApproval Date Edit Number 2

dateeditno2 DATEEDITNO2

9(3) 160 - 162 Zero FillDefault = Blank

If the Approval Date Edit Number 2 field is set to zero, the Approval Date Edit Number field will be used.

Filler X(5) 163 - 167 ReservedOCE Code Category

ocecat OCECAT 9(3) 168 - 170 Zero Fill

OCE Switch 1 - 30

ocesw1 OCESW1 9(30) 171 - 200 Zero Fill

Physician/ASC Units of Service

physunits PHYSUNITS

9(7) 201 - 207 Zero Fill

Reserved X(13) 208 - 220 Reserved


Field Description

C Variable Name

COBOL Variable Name



21.2.3 Procedure-Level EditsIf the user defines maximum allowable units for a specific procedure code, procedure codes with units that exceed this maximum will receive OCE Edit 015 (Service Unit Out of Range for Service/Medically Unlikely Edits (MUEs)). Line-level ACE edits are applied to the procedure code. Many of these edits are applied as a result of the APC and/or payment status associated with the procedure code. Therefore, when a user reassigns a procedure code APC and/or Payment Status Indicator, the ACE edits may no longer be applicable to this procedure code. When a procedure code is defined in the APC Rule File, only the age, sex, and CCI Edits are maintained, and the maximum units edit can be defined by the user. No other edits will be applied to this procedure code.

21.3 ASC Rule FileNote

Applicable to Contract ASC pricing only.

21.3.1 OverviewThe ASC Override rules are defined in the ASC Rule File (ascrule.dat). The file layout is detailed below. The ASC Rule File can be created via Rate Manager through the Rate Manager ASC Pro module.Each individual set of alternative grouping rules is uniquely identified by an Override ID. This Override ID is defined by the user to identify a set of user-defined grouping rules. During the grouping process, the Contract ASC user can request a particular set of alternate grouping rules in two ways:

1. The Override ID can be passed to the Contract ASC Pricer directly or indirectly via the Optimizer, in the ASC Override ID (asc_override_id; ECB-ASC-OVERRIDE-ID) field of the ECB [ezg_cntl_block]/ECB-EZG-CNTL-BLOCK structure.

2. The Contract ASC Pricer can retrieve the Override ID from the configuration file for a specified facility, payer, and effective date.

The Override ID is defined by the user and can be between one and twenty characters. The ID name is an alphanumeric field (i.e., can contain letters and/or numbers), however, it cannot contain non-alphanumeric characters (i.e., periods, dashes) or spaces.


21.3.2 ASC Rule File Layout

Table 21-3: ASC Rule File Variables - ascrule.dat



ASC Override ID asc_override_id ARR-OVERRIDE-ID

X(20) 1 - 20 Maximum of 20 alphanumeric characters.

Code Type code_type ARR-CODE-TYPE

X(1) 21 Always set to C.

C = Procedure CodeCode code ARR-

CODEX(9) 22 - 30

Sequence Number codeseq ARR-CODESEQ

9(2) 31 - 32

Start Date start_date ARR-START-DATE

9(8) 33 - 40 Start Date. The format is YYYYMMDD (where YYYY equals the year, MM the month, and DD the day).

End Date end_date ARR-END-DATE

9(8) 41 - 48 End Date. The format is YYYYMMDD. If no end date set to 00000000.

Payment Status Indicator

paystat ARR-PAYSTAT

X(2) 49 - 50 Payment Status Indicator.

NotePayment Status Indicators H8 and J8 cannot be utilized with the ASC Override functionality.

NoteFor a list of Payment Status Indicators, please refer to the Input & Output Parameter Blocks User’s Guide.

APC proc ARR-PROC

9(5) 51 - 55

Covered Services Indicator

covservind ARR-COVSERVIND

9(1) 56 0 = Not Covered 1 = Covered

Filler X(164) 57 - 220


21.4 ACE Rule File21.4.1 Overview

The ACE Override option allows the user to turn particular ACE edits ON or OFF for a specified facility and/or payer and time period. The user-defined rules are defined in the ACE Rule File (acerule.dat), which can be created and maintained in Rate Manager. For each edit, the user can request one of three override functions:

1. Always Apply the Edit2. Never Apply the Edit3. Apply the Edit Based on Medicare’s Rules

Medicare applies edits based on UB-04 Bill Type and UB-04 condition code. Medicare’s rules for which edits are applied for each UB-04 Bill Type are outlined in the Outpatient Code Editor Program Transmittal (formerly Program Memorandum) that Medicare publishes on a quarterly basis.Each row in the file contains an Override ID, an edit number, and an on/off flag. The on/off flag indicates that the edit is always on and will be applied even when Medicare would not apply the edit (due to UB-04 Bill Type), or always off and the edit will never be applied. All edits not in this file for a particular Override ID will default to Medicare rules. If you want an edit to be applied, it is recommended that you leave the edit out of the file. It is rarely necessary to turn an edit on. Turning an edit on disregards the edit matrix and can produce unintended results.

21.4.2 Override IDEach individual set of alternative editing rules is uniquely identified by an Override ID. This Override ID is defined by the user to identify a set of user-defined edit rules. During the editing process, the ACE user can request a particular set of alternate editing rules in two ways:

1. The Override ID can be passed to ACE directly or indirectly via the ace_override_id/ECB-ACE-OVERRIDE-ID field located in the ECB [ezg_cntl_block] structure for C and the ECB-EZG-CNTL-BLOCK structure for COBOL.

2. ACE can retrieve the Override ID from the Configuration File (config.dat; ezgconfg.dat) for a specified facility, payer, and effective date. The Configuration File can be adjusted manually or through Rate Manager to include the Override ID for a defined facility, payer, and effective date.

The Override ID is defined by the user and can be between one and twenty characters. The OVERRIDE ID name is an alphanumeric field (i.e., can contain letters and/or numbers), however it cannot contain non-alphanumeric characters (i.e., periods, dashes, or spaces).


21.4.3 ACE Rule File Layout

NoteThis file must be sorted by Edit Override ID then Edit Number. Edit Override ID + Edit Number combine to form the unique key for this file.

21.4.4 Example File

For claims that contain the Override ID ACEOverrideFacility1, OCE Edits 015 and 016 will never be applied; all other edits will be applied according to Medicare rules. Claims that are associated with an Override ID of January2004Edits will always be subject to edits 019, 020, 039, and 040.

NoteDescriptions for each OCE Edit are available in the EASYGroup™ User’s Guide.

Table 21-4: ACE Rule File Layout - acerule.dat

Field C Variable Name

COBOL Variable Name


Edit Override ID override_id EOR-OVRD-ID X(20) 1 - 20 Override ID defined by user for a set of override edits.

Edit Number ocenum EOR-OCENUM 9(3) 21 - 23 The number of the OCE Edit to be turned on or off for the Override ID. Edits that follow Medicare rules are not included in this file.

Filler X(1) 24 - 24On/Off Flag onoff EOR-

EDSWITCH9(1) 25 - 25 The flag that indicates that the Edit

should always be on or off. 0 = Off, never apply edit1 = On, always apply edit when

applicablefiller X(15) 26 - 40

Table 21-5: Example File Layout

ACEOverrideFacility1 015 0 (turn Edits 15 and 16 off, do all other Edits per Medicare)ACEOverrideFacility1 016 0January2004Edits 019 1 (turn Edits 19, 20, 39 and 40 always on)January2004Edits 020 1January2004Edits 039 1January2004Edits 040 1


21.4.5 Exceptions to Individual Edit FlagsWith the ACE Override logic, edits can be individually turned off except for certain edits that are grouped together or cannot be turned off. The following exceptions apply to the ACE override logic.

• Edits that cannot be turned off: 010, 023, and 024.• Inpatient edits: If OCE Edit 018 is turned off, OCE Edit 049 will not be

returned, as well. However, if OCE Edit 049 is turned off, OCE Edit 018 will continue to be returned.

• Partial hospitalization edits: OCE Edits 030, 031, 032, 033, and 034 should be treated as a group and handled consistently (i.e., if OCE Edit 030 is turned off, OCE Edits 031 - 034 should be turned off, as well).

• Observation edits: CMS pays for observation services only in specific limited circumstances. Prior to 2006, CMS implemented these requirements via OCE Edits 052, 053, 056, 057, and 058. Effective January 01, 2006, CMS has inactivated the observation OCE Edits 052 and 056. However, the underlying logic determining coverage of observation services remains intact.To implement CMS payment policy for observation services, leave OCE Edits 052, 053, 056, 057, and 058 on, per Medicare guidelines. To bypass CMS payment policy, and to calculate reimbursement for observation services coded with procedure codes G0378 and G0379, turn off OCE Edits 052, 053, 056, 057, and 058.

21.5 Mapping Rule File21.5.1 Overview

The Mapping Override ID is used to identify the appropriate override pattern in the Mapping Override File. This option allows the user to override the CMS ICD-10-CM/PCS to ICD-9-CM reimbursement mapping results.

21.5.2 Mapping Override IDEach individual set of alternative mapping rules is uniquely identified by a Mapping Override ID. This Mapping Override ID is defined by the user to identify a set of user-defined mapping rules. During the mapping process, the user can request a particular set of alternate mapping rules in two ways:

1. The Mapping Override ID can be passed to the ICD-10 Mapper directly or indirectly via the Optimizer, in the map_override_id/ECB-MAP-OVERRIDE-ID field of the ECB [ezg_cntl_block]/ECB-EZG-CNTL-BLOCK structure.

2. The ICD-10 Mapper can retrieve the Mapping Override ID from the configuration file for a specified facility, payer, and effective date.


The Configuration file can be adjusted through Rate Manager to include the Mapping Override ID for a defined facility, payer, and effective date.The Mapping Override ID can be between one and twenty characters. The ID name is an alphanumeric field (i.e., can contain letters and/or numbers), however it cannot contain non-alphanumeric characters (i.e., periods, dashes) or spaces.

21.5.3 Mapping Override FileThe Mapping Override ID rules are defined in the Mapping Override File. Each row in the file contains an Mapping Override ID, Mapping Category, Mapping Direction, Code Type, Source Code, Source Version, Target Version, Number of Target Codes, and Target (ICD-9 or ICD-10 diagnosis or procedure) Codes.The Mapping Override File can be manually created using a text editor in the file layout defined below, or in the Mapping Configuration utility within Rate Manager.

21.5.4 Mapping Override File Layout

Table 21-6: Mapping Override File Variables - maprule.dat


COBOL Variable Name


Mapping Override ID override_id MFR-OVERRIDE_ID

X(20) 1 - 20

Mapping Category category MFR-CATEGORY

X(2) 21 - 22 01 = CMS reimbursement02 = Optum premier pick03 - 99 = State-specific or

custom mappingsMapping Direction direction MFR-

DIRECTIONX(2) 23 - 24 F = Forward

B = BackwardCode Type code_type MFR-CODE-

TYPEX(2) 25 - 26 D = Diagnosis Code

P = Procedure CodeSource CodeICD-9 or ICD-10 Diagnosis or Procedure Code

code MFR-CODE X(10) 27 - 36

Filler X(10) 37 - 46Source Version source_vers MFR-SOURCE-

VERS9(2) 47 - 48 i.e., V28 = effective October

1, 2010Target Version target_vers MFR-TARGET-

VERS9(2) 49 - 50 i.e., V26 = effective October

1, 2008Number of Target Codes

target_codes_num

MFR-TARGET-CODES-NUM

9(2) 51 - 52

Target CodesICD-9 or ICD-10 Diagnosis or Procedure Codes

target_codes MFR-TARGET-CODES

X(10)occurs 10 times

53 - 152


21.5.5 New Mexico Medicaid APC Rule File Layout

Table 21-7: New Mexico Medicaid APC Rule File Layout - nmrule.dat

Field C Variable Name


Override ID override_id X(20) 1 - 20 Override ID defined by user for a set of override edits.

Code Type codetype X(1) 21 C = Procedure codeHCPCS Code code X(9) 22 - 30 HCPCS code, 5 bytes alphanumeric. Sequence Number

codeseq 9(2) 31 - 32 Code sequence number for this code record. Sort descending by date (most recent is 01).

Starting Date startdate 9(8) 33 - 40 Start Date. The format is YYYYMMDD (where YYYY equals the year, MM the month, and DD the day).

Ending Date enddate 9(8) 41 - 48 End Date. The format is YYYYMMDD. If no end date set to 00000000.


paystat X(2) 49 - 50 Please refer to the Input & Output Parameter Blocks User’s Guide for a list of applicable Payment Status Indicators.

Filler X(170) 51 - 220


22 Editor File Layouts

The following sections are included in this chapter:• DSC Editor File Layouts (C and COBOL Platforms)

- ICD-9-CM Diagnosis and Procedure File Layout- ICD-10-CM/PCS Diagnosis and Procedure File Layout

• LCD Editor File Layouts (C Platform Only)- Associated Procedure File Layout- HCPCS Code File Layout- Index File Layout- FI/Carrier/MAC Assignment File Layout- Customizing the LCD Editor- HCPCS/Diagnosis Pairs File Layout- Secondary Diagnosis File Layout- Statutory Denied Diagnosis File Layout- Frequency File Layout

• MOE File Layouts- Code Table File Layout- CCI Edit Table Layout- MUE Table File Layout

• Physician Editor File Layouts- CCI Edit Table Layout- Code Table File Layout- MUE Table File Layout- Code Pairs Table Layout


22.1 DSC Editor File Layouts (C and COBOL Platforms)22.1.1 ICD-9-CM Diagnosis and Procedure File Layout

Table 22-1: ICD-9-CM Diagnosis and Procedure File Variables - dxopfile.dat; mcedp02.dat


COBOL Variable Name


ICD-9-CM Code Type

ctype MDR-CODETYPE

X(1) 1 D = DiagnosisP = Procedure

ICD-9-CM Code code MDR-CODE

X(9) 2 - 10 ICD-9-CM diagnosis or procedure code. Left-justified; blank-filled


cseq MDR-CODESEQ

9(2) 11 - 12 Code sequence number for this code record

Starting Date startdate MDR-STARTDATE

9(8) 13 - 20 00000000 = Code never validYYYYMMDD = Effective date for this code

recordEnding Date enddate MDR-

ENDDATE

9(8) 21 - 28 00000000 = Code never valid or data for this code record is still in effect

YYYYMMDD = Termination date for this code record


origindate

MDR-ORIGINDATE

9(8) 29 - 36 00000000 = Code never validYYYYMMDD = Earliest effective date for this

code recordFurther Qualifier Flag

furq MDR-FURQUAL

9(1) 37 0 = Code does not require additional digit(s)1 = Code requires additional digit(s)

Code Description desc MDR-DESC

X(24) 38 - 61 ICD-9-CM code description

Filler X(1) 62Sex Edit Indicator sex MDR-

SEXX(1) 63 M = Code valid for males only

F = Code valid for females onlyBlank = Default

UHDDS Class –Procedures Only

class MDR-CLASS

9(1) 64 0 = Code never valid1 = Class 1 – most risk, resource intensive2 = Class 23 = Class 34 = Class 4 – least risk, resource intensive

Medicare MDC Number – Diagnoses Only

mdc MDR-MDC

9(2) 65 - 66 00 = Diagnosis code never valid or MDC 0 assigned by Grouper (E-codes)

01 - 25 = Valid Major Diagnostic Category (MDC) number

Medicare CC Indicator – Diagnoses Only

ccind MDR-CCIND

X(1) 67 Y = Diagnosis code is a Medicare CCM = Diagnosis Code is a Medicare Major CCBlank = Default


Medicare CC DRG Indicator –Diagnoses Only

cccode MDR-CCCODE

X(1) 68 Y = Code used alone groups to a Medicare DRG which would change in the presence of a secondary CC diagnosis.

Blank = DefaultAge Edit Indicator – Diagnoses Only

age MDR-AGE

X(1) 69 1 = Newborn, age = 02 = Pediatric, age = 0 - 173 = Maternity, age = 12-554 = Adult, age > 14Blank = Default

Principal Diagnosis Indicator – Flag 1

morv MDR-MORV

X(1) 70 M = ManifestationV = VagueBlank = Default


nuq MDR-NUQ

X(1) 71 N = Non-specific codeU = Unacceptable as principal diagnosisQ = Questionable as principal diagnosisBlank = Default

Secondary Payor Flag – Diagnoses Only

msp MDR-MSP

X(1) 72 2 = Insurer may be secondary PayorBlank = Default (prior to FY2002 only)

Surgery Indicator – Diagnoses Only

reqsur MDR-REQSURG

X(1) 73 1 = Principal diagnosis suggests surgeryBlank = Default

Secondary Diagnosis Indicator

reqsdx MDR-REQSEC

X(1) 74 1 = Principal diagnosis requires secondary diagnosis

Blank = DefaultNon-Specific Procedure Indicator –Procedures Only

nspec MDR-NSPEC

X(1) 75 N = Non-specific O.R. procedureBlank = Default

Biopsy Code Indicator – Procedures Only

biopsy MDR-BIOPSY

X(1) 76 O = Open biopsyC = Closed biopsyBlank = Default

Closed Biopsy Code – Procedures Only

clsdbps MDR-CLSDBIOPSY

X(7) 77 - 83 Closed biopsy code corresponding to the procedure in the code field if biopsy is set to “O”. Blank = Default



COBOL Variable Name



Procedure Indicator (Includes diagnosis exceptions)

ncind MDR-NCIND

X(1) 84 Diagnoses:Valid beginning October 01, 2004:1 = Matches PX value 12 = Not used3 = Not used4 = Matches PX value 3 (1 of 2) (diabetes)5 = Matches PX value 3 (2 of 2) (renal

complications)6 = Matches PX value 2 (multiple myeloma)7 = Not used8 = Clinical trial

Procedures:Valid beginning October 01, 2004:N = Unconditionally non-coveredL = Limited coverage1 = Select bone marrow transplant PXs

(autologous)2 = Select bone marrow transplant PXs

(allogenic)3 = Select pancreas transplant PXs4 = Percutaneous angioplasty 5 = Percutaneous shunt insertion6 = Spinal disk prosthesis and age >60

Valid beginning October 01, 2007:N = Unconditionally non-coveredL = Limited coverage1 = Select bone marrow transplant PXs


(allogenic)3 = Select pancreas transplant PXs4 = Percutaneous angioplasty (reserved)5 = Percutaneous shunt insertion (reserved)6 = Spinal disk prosthesis and age >607 = PTA of intracranial vessel(s)8 = Intracranial stent

Operating Room Indicator – Procedures Only

or MDR-ORIND

9(1) 85 0 = Grouper does not consider O.R. procedure.1 = Grouper considers O.R. procedure.

Code Position Edit Flag – Diagnoses Only

priflag MDR-PRIFLAG

X(1) 86 N = Code should not appear in the principal position

Blank = Default



COBOL Variable Name



22.1.2 ICD-10-CM/PCS Diagnosis and Procedure File Layout

Ambulatory Surgery Indicator Code – Procedures Only

Present on Admission Exempt Indicator

amsg

poa_exempt

MDR-AMSG

MDR-POA-EXEMPT

X(1)

X(1)

87

88

Reserved for future use

Y = Code is exempt from POA reporting Blank (default) = Code is not exempt from POA

reporting


Table 22-2: ICD-10-CM/PCS Diagnosis and Procedure File Variables - dxopi10.dat; mcedp01.dat


COBOL Variable Name


ICD-10-CM Code Type

ctype MDR-CODETYPE

X(1) 1 K = DiagnosisL = Procedure

ICD-10-CM Code code MDR-CODE

X(9) 2 - 10 ICD-10-CM diagnosis or procedure code. Left-justified; blank-filled


cseq MDR-CODESEQ

9(2) 11 - 12 Code sequence number for this code record

Starting Date startdate MDR-STARTDATE

9(8) 13 - 20 00000000 = Code never validYYYYMMDD = Effective date for this code

recordEnding Date enddate MDR-

ENDDATE

9(8) 21 - 28 00000000 = Code never valid or data for this code record is still in effect



origindate

MDR-ORIGINDATE

9(8) 29 - 36 00000000 = Code never validYYYYMMDD = Earliest effective date for this

code recordFurther Qualifier Flag

furq MDR-FURQUAL

9(1) 37 0 = Code does not require additional digit(s)1 = Code requires additional digit(s)

Code Description desc MDR-DESC

X(24) 38 - 61 ICD-10-CM code description

Filler X(1) 62



COBOL Variable Name



Sex Edit Indicator sex MDR-SEX

X(1) 63 M = Code valid for males onlyF = Code valid for females onlyBlank = Default

Filler X(1) 64Medicare MDC Number – Diagnoses Only

mdc MDR-MDC

9(2) 65 - 66 00 = Diagnosis code never valid or MDC 0 assigned by Grouper (E-codes)

01 - 25 = Valid Major Diagnostic Category (MDC) number

Medicare CC Indicator – Diagnoses Only

ccind MDR-CCIND

X(1) 67 Y = Diagnosis code is a Medicare CCM = Diagnosis Code is a Medicare Major CCBlank = Default

Filler X(1) 68Age Edit Indicator – Diagnoses Only

age MDR-AGE

X(1) 69 1 = Newborn, age = 02 = Pediatric, age = 0 - 173 = Maternity, age = 12-554 = Adult, age > 14Blank = Default


morv MDR-MORV

X(1) 70 M = ManifestationV = VagueBlank = Default


nuq MDR-NUQ

X(1) 71 U = Unacceptable as principal diagnosisQ = Questionable as principal diagnosisBlank = Default

Filler X(1) 72Surgery Indicator – Diagnoses Only

reqsurg MDR-REQSURG

X(1) 73 1 = Principal diagnosis suggests surgery Blank = Default

Secondary Diagnosis Indicator

reqsdx MDR-REQSDX

X(1) 74 1 = Principal diagnosis requires secondary diagnosis

Blank = DefaultFiller X(9) 75 - 83



COBOL Variable Name



Procedure Indicator (Includes diagnosis exceptions)

ncind MDR-NCIND

X(1) 84 Diagnoses:Q = Diagnoses that satisfy questionable

obstetric admission Edit 271 = Matches PX value 12 = Not used3 = Not used4 = Matches PX value 3 (1 of 2) (diabetes)5 = Not used6 = Matches PX value 2 (multiple myeloma)7 = Wrong procedure performed8 = Clinical trial

Procedures:N = Unconditionally non-coveredL = Limited coverageP = Kidney transplant limited coverage Q = Procedures subject to questionable

obstetric admission procedure Edit 27S = Procedures subject to procedure

inconsistent with length of stay edit 261 = Select bone marrow transplant PXs


(allogenic)3 = Select pancreas transplant PXs4 = Percutaneous angioplasty (reserved)5 = Percutaneous shunt insertion (reserved)6 = Spinal disk prosthesis and age >607 = PTA of intracranial vessel(s) (reserved)8 = Intracranial stent9 = Limited Coverage / Non-covered (unless

clinical trial)Operating Room Indicator – Procedures Only

or MDR-ORIND

9(1) 85 0 = Grouper does not consider O.R. procedure.1 = Grouper considers O.R. procedure.

Code Position Edit Flag – Diagnoses Only

priflag MDR-PRIFLAG

X(1) 86 N = Code should not appear in the principal position

Blank = DefaultAmbulatory Surgery Indicator Code – Procedures Only

Present on Admission Exempt Indicator

amsg

poa_exempt

MDR-ANSG

MDR-POA-EXEMPT

X(1)

X(1)

87

88

Reserved for future use

Y = Code is exempt from POA reporting Blank (default) = Code is not exempt from POA

reporting




COBOL Variable Name



22.2 LCD Editor File Layouts (C Platform Only)22.2.1 Associated Procedure File Layout

22.2.2 HCPCS Code File Layout

Table 22-3: Associated Procedure File Variables - ap.dat

Field Description Variable Name Format Position NotesFiscal Intermediary, Carrier, or MAC

fi X(2) 1 - 2 Code identifying the originating Fiscal Intermediary, carrier, or MAC for the LCD rules to be applied for this provider.

Policy Number policy_id X(10) 3 - 12 Policy ID plus optional suffix. Number uniquely identifying the associated LCD or NCD.

Effective Date effdate 9(8) 13 - 20 CCYYMMDD. Date on which the associated procedure code affiliated with this policy ID is effective.

Terminated Date termdate 9(8) 21 - 28 CCYYMMDD. Date on which the associated procedure code affiliated with this policy ID is terminated. If code is still effective, date will be 20491231.

HCPCS px X(7) 29 - 35 CPT® or HCPCS Level II code that must also be on the claim for this LCD/original HCPCS code associated with this policy ID number.

Filler X(6) 36 - 41

Table 22-4: HCPCS Code File Variables - codes.dat

Field Description Variable Name Format Position NotesHCPCS Code px X(7) 1 - 7 CPT® or HCPCS Level II CodeEffective Date effdate 9(8) 8 - 15 CCYYMMDD. Date on which code was

effective.Terminated Date termdate 9(8) 16 - 23 CCYYMMDD. Date on which code was

terminated. If code is still in effect, date will be 20491231.

Payment Status paystat X(2) 24 - 25 OPPS Payment Status Code.

NoteFor a list of OPPS Payment Status Codes, please refer to the Input & Output Parameter Blocks User’s Guide.

Non-Covered Flag noncovered 9(1) 26 0 = Eligible for coverage1 = Non-covered based on policy2 = Non-covered based on statutory exclusion


22.2.3 Index File Layout

Filler X(4) 27 - 30

Table 22-5: Index File Variables - index.dat



Policy Number policy_id X(10) 3 - 12 Policy ID plus optional suffix. Number uniquely identifying the LCD information tied to this procedure-diagnosis pair for this Fiscal Intermediary, carrier, or MAC.

Effective Date effdate 9(8) 13 - 20 CCYYMMDD. Date the policy is effective.

Terminated Date termdate 9(8) 21 - 28 CCYYMMDD. Date the policy is terminated. If policy is still in effect, date will be 20491231.

Sex sex X(1) 29 M = Patient must be maleF = Patient must be female

Otherwise, there is no sex requirement for this LCD.

Low Age Requirement

low_age 9(3) 30 - 32 Lowest valid age for this LCD. If there is no age requirement, value will be 000.

High Age Requirement

hi_age 9(3) 33 - 35 Highest valid age for this LCD. If there is no age requirement, value will be 999.

Associated Procedure Flag

ap X(1) 36 Y = There are associated procedure requirements for this LCD.

N = There are no associated procedure requirements for this LCD.

Secondary Diagnosis Flag

sd X(1) 37 Y = There are secondary diagnosis requirements for this LCD.

N = There are no secondary diagnosis requirements for this LCD.

Policy Name policy_name X(100) 38 - 137 Long description or name of LCD.Original Effective Date

origeff 9(8) 138 - 145

Reserved

Web Address url X(200) 146 - 345

Fully qualified link to the full LCD description on the World Wide Web.

Laboratory NCD Flag

lab_ncd_flag X(1) 346 0 = Policy is not a laboratory NCD1 = Policy is a laboratory NCD

Filler X(12) 347- 358

Table 22-4: HCPCS Code File Variables - codes.dat



22.2.4 FI/Carrier/MAC Assignment File Layout

As shipped, this file includes both FI, carrier, and MAC identifiers. There is one entry in this file for every Medicare provider number and NPI and its corresponding FI/MAC Part A. To invoke FI/MAC edits, the Provider Identifier field must contain the appropriate Medicare provider number or NPI. To invoke carrier/MAC Part B edits, the Provider Identifier field must contain the appropriate carrier/MAC identifier. All current FIs, carriers, and MACs are listed in the EASYGroup™ User’s Guide.A default entry can be created by adding a blank provider ID and the desired FI or carrier code as the first row in this file. Any incoming claim containing an identifier not found in this file will be assigned this default. Please refer to the EASYGroup™ User’s Guide for more details on customizing this file.

Table 22-6: FI/Carrier/MAC Assignment File Variables - fi.dat

Field Description Variable Name Format Position NotesProvider Identifier hosp X(16) 1 - 16 Hospital or physician identifier (i.e.

OSCAR number or NPI).Effective Date effdate 9(8) 17 - 24 CCYYMMDD. Date the Fiscal

Intermediary, carrier, or MAC is effective.

Terminated Date termdate 9(8) 25 - 32 CCYYMMDD. Date the Fiscal Intermediary, carrier, or MAC is terminated. If still in effect, date will be 20491231.

Fiscal Intermediary, Carrier or MAC Code

fi X(2) 33 - 34 Code identifying the originating Fiscal Intermediary, carrier, or MAC for the LCD/NCD rules to be applied for this provider.

Part A/Part B Indicator part_ind 9(1) 35 Code identifying whether a facility ID is assigned to a Part A or Part B rule set.1 = Part A2 = Part B

Table 22-7: FI/Carrier/MAC Assignment File Variables - mac.dat

Field Description Variable Name Format Position NotesFiscal Intermediary or Carrier

fi X(2) 1 - 2 Code identifying the originating MAC for the LCD Part A or Part B rules to be applied for this provider.

MAC Start Date mac_eff X(8) 3 - 10 Contract start date of 1st round MAC

MAC End Date mac_term X(8) 11 - 18 Contract end date of 1st round MAC


22.2.5 Customizing the LCD EditorThe LCD Editor as shipped is based on the following assumptions:

• Claims submitted to the Editor are facility-based claims and include the standard Medicare six-digit provider number or National Provider Identifier (NPI) used to identify the facility providing the care.

• The LCD rules in effect for each provider are those associated with the Medicare FI that is identified in the Medicare Provider Specific File (PSF).

If these two assumptions are not correct, the LCD Editor must be customized to select the correct edits for the facilities whose claims will be edited. This is accomplished by editing the fi.dat file, as follows.

22.2.6.1 Using the Default Fiscal Intermediary (Part A) Assignment The LCD Editor is shipped with a file fi.dat (or fi-new.dat) which contains the 6-digit Medicare provider number, as well as the National Provider Identifier (NPI) for every Medicare acute care hospital in the country, along with its associated FI. This file is based off available information in the Medicare PSF and the National Plan and Provider Enumeration System (NPPES). The format of this file is described above. To use the LCD Editor with claims that contain the Medicare provider or NPI number with the standard FI assignment for each Medicare acute care provider, this file does not need to be modified. For example, supply provider number “310001” to request the edits for the New Jersey FI – Riverbend. Refer to the EASYGroup™ User’s Guide for a list of FI codes.

NoteCMS has converted FIs into Medicare Administrative Contractors (MACs), as mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). MAC Part A identifiers have been added to the LCD Editor.

22.2.7.2 Using the Default Carrier (Part B) Assignment Also included in fi.dat is a set of default carrier codes. To edit physician claims rather than hospital claims, and apply edits based on a specific carrier, find the appropriate carrier ID in EASYGroup™ User’s Guide for the provider and supply this ID code as the carrier ID. For example, supply a facility number “35” to request the edits for the New Jersey Carrier – National Government Services.

MAC mac_id X(2) 19 - 20 MAC associated with this FI and provider

Filler X(30) 21 - 50

Table 22-7: FI/Carrier/MAC Assignment File Variables - mac.dat



22.2.8.3 Changing a Default Fiscal Intermediary Assignment To change the FI/MAC associated with a specific provider based on the provider’s Medicare ID or NPI, locate the row in the fi.dat that contains the default FI/MAC assignment and replace the value in the FI column. To change the FI/MAC associated with a specific provider effective as of a certain date, create a new row in fi.dat for the same provider ID or NPI, but with the appropriate starting date. Supply an appropriate termination date on the existing row. Make sure the date ranges do not overlap. Also make sure that ascending sort order has been maintained and that record lengths have been maintained. Refer to the above layout of the fi.dat file.

NoteA new version of fi.dat (fi-new.dat) will be included with each monthly update of the LCD/NCD data files. If you would like to update to the newest version of fi.dat, you must re-name the fi-new.dat file to fi.dat and replicate the appropriate user modifications to this file.

22.2.9.4 Adding a Default Fiscal Intermediary or Carrier Assignment A default FI, carrier, or MAC can be specified when the provider number on the claim is not found in the fi.dat file. To enable this default logic, insert a new row in the first line of the fi.dat file, leave the provider identifier blank and add the FI, carrier, or MAC in the appropriate position. After inserting a row, verify that ascending sort order has been maintained and that record lengths have been maintained. Refer to the above section for the file format of fi.dat.

22.2.10.5 Adding a Provider The fi.dat file can be customized with additional provider identifiers for MACs, carriers, FIs, and alternate FIs such as Mutual of Omaha. To do this, insert a row in the fi.dat file with a provider identifier and a valid FI, carrier, MAC or national code from the EASYGroup™ User’s Guide. After inserting a row, verify that ascending sort order has been maintained and that record lengths have been maintained.


22.2.11.6 Installing Changes to Fiscal Intermediary or Carrier Assignment The fi.dat file is updated monthly. If you would like to update to the newest version of fi.dat, you must rename the fi-new.dat file to fi.dat and replicate the appropriate user modifications to this file.

22.2.12 HCPCS/Diagnosis Pairs File Layout

Table 22-8: HCPCS/Diagnosis Pairs File Variables - i10pairs.dat



HCPCS px X(7) 3 - 9 CPT® or HCPCS Level II code.Effective Date effdate 9(8) 10 - 17 CCYYMMDD. Date on which

the HCPCS-diagnosis code pair is effective.

Terminated Date termdate 9(8) 18 - 25 CCYYMMDD. Date on which the HCPCS-diagnosis code pair is terminated. If code pair is still effective, date will be 20491231.

ICD-10-CM Diagnosis Code

dx 9(10) 26 - 35 ICD-10-CM diagnosis code which will support the HCPCS code under the LCD rules for this Fiscal Intermediary or carrier.

Policy Number policy_id X(10) 36 - 45 Policy ID plus optional suffix. Number uniquely identifying the NCD or LCD information tied to this HCPCS-diagnosis code pair for this Fiscal Intermediary, carrier, or MAC.

Diagnosis Support Flag

suppdxflag 9(1) 46 0 = Diagnosis code supports the medical necessity of the procedure code

1 = Diagnosis code does not support the medical necessity of the procedure code

Broad Diagnostic Flag

bd_flag 9(1) 47 0 = Procedure code is not broad diagnostic

1 = Procedure code is broad diagnostic; clinical circumstances should be reviewed


22.2.13 Secondary Diagnosis File Layout

22.2.14 Statutory Denied Diagnosis File Layout

Table 22-9: Secondary Diagnosis File Variables - i10sd.dat



Policy ID policy_id X(10) 3 - 12 Policy ID plus optional suffix. Number uniquely identifying the associated LCD or NCD.

Effective Date effdate 9(8) 13 - 20 CCYYMMDD. Date on which the secondary diagnosis code associated with this policy ID is effective.

Terminated Date termdate 9(8) 21 - 28 CCYYMMDD. Date on which the secondary diagnosis code associated with this policy ID is terminated. If code is still effective, date will be 20491231.

ICD-10-CM Diagnosis Code

dx 9(10) 29 - 38 ICD-10-CM diagnosis code that must also be on the claim with the original HCPCS code associated with this policy ID number for this LCD.

Filler X(3) 39 - 41

Table 22-10: Statutory Denied Diagnosis File Variables - i10stdx.dat

Field Description Variable Name Format Position NotesStatutory-Excluded Diagnosis Code

dx X(10) 1 - 10 ICD-10-CM diagnosis code on the CMS list of statutory denied diagnoses.

Effective Date effdate 9(8) 11 - 18 CCYYMMDD. Date on which statutorily denied diagnosis was added to the CMS list.

Terminated Date termdate 9(8) 19 - 26 CCYYMMDD. Date on which FI/carrier was terminated. If FI/carrier is not terminated, use a date of 20491231.

Statutorily Denied Flag

stdx 9(1) 27 0 = Code is not statutorily denied1 = Code is statutorily denied


22.2.15 Frequency File Layout

Table 22-11: Frequency File Variables - fq.dat



Fiscal Intermediary (FI) or Carrier

fi X(2) 1 - 2 Code identifying the originating MAC for the LCD Part A or Part B rules to be applied for this provider.

HCPCS Code px X(7) 3 - 9 CPT or HCPCS Level II code that must also be on the claim for this LCD, and the original HCPCS code associated with this policy ID.

Policy Number policy_id X(10) 10 - 19 Policy ID plus optional suffix. Number uniquely identifying the associated LCD or NCD.

Effective Date effdate 9(8) 20 - 27 CCYYMMD. Date on which frequency with this policy ID was effective.

Terminated Date termdate 9(8) 28 - 35 CCYYMMD. Date on which associated procedure associated with this policy ID was terminated.

If the FI is still active, this field will be set to 20491231.

Frequency freq 9(3) 36 - 38 The number of times a service can be performed for a given frequency span and frequency unit.

Example: “5” for 5 times per frequency unit and frequency span. 5 times every 2 months.

Frequency Span freq_span 9(3) 39 - 41 The span of a frequency unit.

Example: “2” for 2 times per frequency unit or 2 months.

Frequency Unit freq_unit X(1) 42 The unit of measurement for frequency and frequency span.

Example: “M” for Months.

Valid Values:D = Day(s)W = Week(s)M = MonthY = Year(s)L = LifetimeC = Course of Treatment

Filler X(21) 43 - 63


22.3 MOE File Layouts22.3.1 Code Table File Layout

Table 22-12: MOE Code Table File Variables - moeedit.dat

Field Description Variable Name Format Position NotesCode Type codetype X(1) 1 Space = Version record

C = CPT®/HCPCS procedure, or modifiers prefixed by 099

E = EditK = DiagnosisR = Revenue codes

Code code X(10) 2 - 11 Code value. Left justified, blank filled.Sequence Number codeseq 9(2) 12 - 13 Sequence number for this code record.Starting Date startdate 9(8) 14 - 21 YYYYMMDD = Effective date for this code

record.Ending Date enddate 9(8) 22 - 29 YYYYMMDD = Termination date for this code

record.Starting Version vfrom 9(2) 30 - 31 Serial starting version for this row, beginning

with 01 on January 01, 2019.Ending Version vthru 9(2) 32 - 33 Serial ending version for this row.Description desc X(24) 34 - 57 Abbreviated code description.Sex Edit Indicator sex X(1) 58 Diagnosis and Procedure Codes:

M = Code valid for males onlyF = Code valid for females only

Minimum Age minage 9(3) 59 - 61 Diagnosis Codes:Minimum acceptable age for this code.

Maximum Age maxage 9(3) 62 - 64 Diagnosis Codes:Maximum acceptable age for this code.

CCI Control ccicntl 9(1) 65 Procedure Codes: 0 = Not applicable1 = Code appears as code1 in CCI pairs2 = Code appears as code2 in CCI pairs3 = Code appears as code1 and code2 in CCI

pairsCategory cat 9(3) 66 - 68 Version:

Version numberEdit Switch 1 sw1 9(1) 69 Diagnosis Codes:

1 = Supplementary or Additional Code Not Allowed as Principal Diagnosis

Modifiers:1 = Modifier mitigates eligible CCI Edit pair

Procedure Codes:1 = Code lacks information required for editing

and/or grouping


Edit Disposition eddisp 9(2) 70 - 71 Edits:01 = Line item rejection02 = Line item denial03 = Claim suspension 04 = Claim Returned to Provider (RTP)

Payment Status paystat X(2) 72 - 73 Procedure Codes and Revenue Codes:A = Services paid under fee schedule or other

prospectively determined rateB = Service not allowed under OPPS on

hospital outpatient claimC = Inpatient service, not paid under OPPSE1 = Non-allowed item or serviceE2 = Items and services for which pricing

information and claims data are not available

F = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH = Pass-through device categoriesJ1 = Hospital Part B services paid through a

Comprehensive APCJ2 = Hospital Part B services that may be paid

through a Comprehensive APCK = Non pass-through drugs and non-

implantable biologicals, including therapeutic radiopharaceuticals

L = Influenza virus or Pneumococcal Pneumonia Vaccine (PPV)

M = Service not billable to the FI/MACN = Packaged/incidental serviceP = Partial hospitalization serviceQ1 = STV - packaged servicesQ2 = T - packaged servicesQ3 = Services that may be paid through a

Composite APCQ4 = Conditionally packaged laboratory

servicesR = Blood and blood productsS = Procedure or service, not discounted

when multipleT = Procedure or service, multiple reduction

appliesU = Brachytherapy sourcesV = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and

invalid revenue codeY = Non-implantable DMEZ = Valid revenue code, blank procedure

code, no other status indicator assigned




22.3.2 CCI Edit Table Layout

Bilateral Procedure Indicator

bilatop 9(1) 74 Procedure Codes:1 = Conditionally bilateral2 = Inherently bilateral 3 = Independently bilateral4 = Not bilateral

Edit Switch 2 sw2 9(1) 75 Modifiers:1 = Modifier Overrides MUEs

Filler X(175) 76 - 250

Table 22-13: Medicaid Outpatient Editor CCI Edit Table Variables - ocecci2.dat

Field Description Variable Name Format Position NotesProcedure Code 1 code1 X(5) 1 - 5 First procedure code.Reserved X(4) 6 - 9Procedure Code 2 code2 X(5) 10 - 14 Second procedure code.Reserved X(4) 15 - 18CCI Edit Sequence Number

edseq 9(2) 19 - 20 Sequence number for this code pair.

Start Date startdate 9(8) 21 - 28 YYYYMMDD = Effective date for this code record.

End Date enddate 9(8) 29 - 36 00000000 = Code never valid or data for this code record is still in effect.YYYYMMDD = Termination date for this code record.

Error Code errnum 9(3) 37 - 39 915 = Comprehensive/component proceduresPrior Policy pripol X(1) 40 ReservedModifier Code modcode 9(1) 41 0 = Modifier will not affect edit

1 = An appropriate modifier on code 1 or code 2 may affect this edit

OPPS Indicator oppsind 9(1) 42 0 = Edit is not used in OPPS (code pair is removed from relevant CMS CCI source data)

1 = Edit is used in OPPS in mutually exclusive context

2 = Edit is used in OPPS in comprehensive/component context




22.3.3 MUE Table File Layout

Table 22-14: Medicaid Outpatient Editor MUE Table Variables - mue.dat

Field Description Variable Name Format Position NotesState CCI statecci X(2) 1 - 2 Two character abbreviation to determine

which CCI/MUE editing rules to apply.

Blank (default) = National Medicare CCI/MUE

DM - Durable Medical Equipment (DME)US = National Medicare CCI/MUE U2 = National Medicaid CCI/MUE

NoteMOE only utilizes U2 = National Medicaid CCI/MUE.

MUE Category muecat 9(1) 3 Flag to identify if the record is an outpatient hospital or practitioner record.

0 = Outpatient hospital1 = Practitioner

NoteMOE only uses 0 = Outpatient hospital.

HCPCS Code code X(5) 4 - 8 Five digit HCPCS code.Reserved X(4) 9 - 12 Reserved for expanded HCPCS codes.Code Sequence Number

codeseq 9(4) 13 - 16 Code sequence number for this code record.

Start Date startdate 9(8) 17 - 24 Format = YYYYMMDDEnd Date enddate 9(8) 25 - 32 YYYYMMDDUnits of Service units X(7) 33 - 39 Maximum allowed units.MUE Adjudication Indicator

mai 9(1) 40 Indicates the type of MUE that should be applied to this procedure code.

0 = No MUE edit1 = Line-level edit2 = Day-level edit (policy)3 = Day-level edit (clinical)

NoteThis field is not used by MOE.

Filler X(10) 41 - 50


22.4 Physician Editor File Layouts22.4.1 CCI Edit Table Layout

Table 22-15: Physician Editor CCI Edit Table Variables - physcci.dat; phycci.dat


COBOL Variable Name


Column 1 Code code1 PER-CODE1 X(5) 1 - 5Reserved X(4) 6 - 9Column 2 Code code2 PER-CODE2 X(5) 10 - 14Reserved X(4) 15 - 18Sequence Number edseq PER-KSEQ 9(2) 19 - 20Start Date startdate PER-START-

DATE9(8) 21 - 28

End Date enddate PER-END-DATE

9(8) 29 - 36

Edit Flag edit_flag PER-EDIT-FLAG

9(1) 37 1 = Mutually exclusive procedure

2 = Comprehensive/component procedures


Edit Type edit_type PER-EDIT-TYPE

9(2) 38 - 39 01 = Do not code services essential to procedure

02 = Code is a CPT® separate procedure

03 = Code only the more extensive procedure for the same site

04 = With and without codes should not be used together

05 = Anesthesia should not be reported separately when administered by the operating physician

06 = Do not code lab services separately; code lab panel

07 = Report code for completed service only

08 = Do not code services integral to procedure

09 = These codes should not be reported together per CPT® coding guidelines

10 = These codes should not be used together per code definition

11 = These services are not typically performed together

12 = Codes indicate mutually exclusive services

13 = Codes indicate sex conflict

Modifier Code modcode PER-MODCODE

9(1) 40 0 = Modifier will not affect edit

1 = An appropriate modifier on code 1 or code 2 may affect this edit.



COBOL Variable Name



22.4.2 Code Table File Layout

Filler X(110) 41 - 150

Table 22-16: Physician Editor Code Table Variables - physedit.dat; phycode.dat


COBOL Variable Name


Code Type codetype PCR-CODE-TYPE

X(1) 1 Space = Version recordC = CPT®/HCPCS

procedure or modifier prefixed by 099

D = Diagnosis (ICD-9)E = EditK = Diagnosis (ICD-10)

Code code PCR-CODE X(10) 2 - 11 Code value. Left justified, blank filled.

Sequence Number codeseq PCR-CODESEQ

9(2) 12 - 13

Start Date startdate PCR-START-DATE

9(8) 14 - 21 YYYYMMDD

End Date enddate PCR-END-DATE

9(8) 22 - 29 YYYYMMDD


origindate PCR-ORIGIN-DATE

9(8) 30 - 37 YYYYMMDD

Further Qualifier Flag furqual PCR-FURQUAL

9(1) 38 Diagnosis Codes:0 = Code does not require

additional digit(s)1 = Code requires additional

digit(s)Starting Version vfrom PCR-VFROM 9(2) 39 - 40 Serial starting version for

this row, beginning with 01 on 01/01/2011.

Ending Version vthru PCR-VTHRU 9(2) 41 - 42 Serial ending version for this row.

Description desc PCR-DESC X(24) 43 - 66 Abbreviated code description.



COBOL Variable Name



Sex Edit Indicator sex PCR-SEX X(1) 67 Diagnosis and Procedure Codes:M = Code valid for males

onlyF = Code valid for females

onlyAge Edit Indicator age PCR-AGE X(1) 68 ReservedMinimum Age minage PCR-

MINAGE9(3) 69 - 71 Diagnosis and Procedure

Codes:Minimum acceptable age for this code.

Maximum Age maxage PCR-MAXAGE

9(3) 72 - 74 Diagnosis and Procedure Codes:Maximum acceptable age for this code.

CCI Control ccicntl PCR-CCI-CNTL

9(1) 75 Procedure Codes: 0 = Not applicable1 = Code appears as code1

in CCI pairs2 = Code appears as code2

in CCI pairs3 = Code appears as code1

and code2 in CCI pairsCategory cat PCR-CAT 9(3) 76 - 78 Version number.Medically Unlikely Edit Maximum

physunits PCR-PHYSUNITS

9(7) 79 - 85 Procedure Codes: This field is no longer used for maxunits. It has been replaced by the mue.dat file - refer to MUE file layout below.

Edit Switch 1 sw1 PCR-SW1 9(1) 86 Procedure Codes:2 = Code lacks information

required for editingModifiers:1 = Modifier mitigates

eligible CCI edit pairEdit Disposition edddisp PCR-

EDDDISP9(2) 87 - 88 Edits:

01 = Line item rejection02 = Line item denial03 = Claim suspension 04 = Claim RTP



COBOL Variable Name



Status Code scode PCR-SCODE X(1) 89 Status Codes:A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician

Fee Schedule by regulation

F = Deleted/discontinued code

G = Not valid for Medicare purposes

H = Deleted modifierI = Not valid for Medicare

purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/excluded codeQ = Therapy functional

information code R = Restricted coverageT = InjectionsX = Statutory exclusion

MUE Type muetype PCR-MUE-TYPE


Edit Switch 2 sw2 PCR-SW2 9(1) 92 Diagnosis Codes:1 = Supplementary or

additional code not allowed as principal diagnosis

Modifiers:1 = Modifier overrides MUEsProcedure Codes:1 = Procedure code eligible

to have the coinsurance waived with Modifier CS

Jurisdiction jurisdiction PCR-JURISDICTION

X(1) 93 Blank = Not applicableD = DME MAC jurisdictionJ = Joint DME MAC/local

carrier jurisdictionL = Local Part B carrier

jurisdictionFiller X(157) 94 - 250



COBOL Variable Name



22.4.3 MUE Table File Layout

Table 22-17: Physician Editor MUE Table Variables - mue.dat


COBOL Variable Name


State CCI statecci MRL-STATECCI

X(2) 1 - 2 Two character abbreviation to determine which CCI/MUE editing rules to apply.

Blank (default) = National Medicare CCI/MUE

DM - Durable Medical Equipment (DME)

US = National Medicare CCI/MUE

U2 = National Medicaid CCI/MUE

MUE Category muecat MRL-MUECAT

9(1) 3 Flag to identify if the record is an outpatient hospital or practitioner record.

0 = Outpatient hospital1 = Practitioner

HCPCS Code code MRL-CODE X(5) 4 - 8 Five digit HCPCS code.Reserved X(4) 9 - 12 Reserved for expanded

HCPCS codes.Code Sequence Number

codeseq MRL-CODESEQ

9(4) 13 - 16 Code sequence number for this code record.

Start Date startdate MRL-STARTDATE

9(8) 17 - 24 Format = YYYYMMDD

End Date enddate MRL-ENDDATE

9(8) 25 - 32 YYYYMMDD

Units of Service units MRL-UNITS X(7) 33 - 39 Maximum allowed units.MUE Adjudication Indicator

mai MRL-MAI 9(1) 40 Indicates the type of MUE that should be applied to this procedure code.

0 = No MUE edit1 = Line-level edit2 = Day-level edit (policy)3 = Day-level edit (clinical)

Filler X(10) 41 - 50


22.4.4 Code Pairs Table Layout

Table 22-18: Physician Editor Code Pairs Table Variables - codepair.dat


COBOL Variable Name


Code1 code1 CPR-CODE1

X(7) 1 - 7 Add-on code of a code pair.


code_seq CPR-CODE-SEQ

9(4) 8 - 11 Sequential number for this code pair.

Code2 code2 CPR-CODE2

X(7) 12 - 18 Primary code of a code pair.

Start Date startdate CPR-STARTDATE

9(8) 19 - 26 YYYYMMDD

End Date enddate CPR-ENDDATE

9(8) 27 - 34 YYYYMMDD

Code Pair Switch 1

sw1 CPR-SW1 X(1) 35 Identifies the type of add-on code pair:1 = NCCI add-on code pair2 = COVID-19 add-on code

pair


23 Reader File Layouts

This chapter provides the EASYGroup™ Reader (C and COBOL Platform) file layouts utilized for processing. The following sections are included in this chapter:

• HHA PDGM V01 Reader File Layout- HHA PDGM Reader File


23.1 HHA PDGM V01 Reader File Layout23.1.1 HHA PDGM Reader File

Table 23-1: HHA PDGM Reader File Variables - hhapdgm.dat



Code Type codetype DXTABLE-CODETYPE

X(1) 1 K = Diagnosis code

Code code DXTABLE-CODE X(11) 2 - 12 Left-justified. Code value will be a 10-digit diagnosis code.

Code Sequence codeseq DXTABLE-CODESEQ

9(2) 13 - 14 Code sequence number for this code record.

Start Date start DXTABLE-START 9(8) 15 - 22 Date record is effective.End Date end DXTABLE-END 9(8) 23 - 30 00000000 = Code never valid or data for this code

record is still in effect.YYYYMMDD = Termination date for this code

record.Clinical Grouping Value

clinical_grouping DXTABLE-CLINICAL-GROUPING

X(1) 31 Value A - L; Clinical group assigned to diagnosis code.

Sub-Chapter subchapter DXTABLE-SUBCHAPTER

X(7) 32 - 38 Sub-chapter of diagnosis code.

Sub-Group subgroup DXTABLE-SUBGROUP

X(20) 39 - 58 Sub-group of diagnosis code identifies comorbidity.

Primary Awarding Flag

primary_flag DXTABLE-PRIMARY-FLAG

9(1) 59 0 = Not a Primary Awarding diagnosis code1 = Primary Awarding diagnosis code

Filler X(191) 60 - 250


24 Analyzer File Layouts

The EASYGroup™ Analyzers utilize the below-listed data files for processing. This chapter includes the following sections:

• EDC Analyzer™ File Layouts (C Platform Only)- File Naming Conventions- Exclusion File Layout- Standard Costs File Layout- Extended Costs File Layout- Patient Complexity Costs File Layout- Client-Specific Exclusion File Layout

• E&M Analyzer Pro File Layouts (C Platform Only)- File Naming Conventions- Exclusion File Layout- Diagnosis Risk File Layout- Visit Level Complexity Claim File Layout- Visit Level Complexity Diagnosis File Layout


24.1 EDC Analyzer™ File Layouts (C Platform Only)24.1.1 File Naming Conventions

The EDC Analyzer™ file names are listed below (where vvv = the V01 EDC Analyzer™ version number).

24.1.2 Exclusion File LayoutThis file is used to exclude claims with certain diagnosis codes, revenue codes, certain ages, and certain discharge dispositions from being processed by the EDC Analyzer™.

Table 24-1: EDC Analyzer™ Data File Names

Description File NameExclusion File comp0vvv.datStandard Costs File comp1vvv.datExtended Costs File comp2vvv.datPatient Complexity Costs File comp3vvv.datClient-Specific Exclusion File usercomp.csv

Table 24-2: Exclusion File Layout (C Platform Only)



Code Type type X(1) 1 Blank = Version number

A = AgeK =ICD-10-CM

diagnosis codeQ = Discharge

dispositionR = Revenue code

Code code X(10) 2 - 11 Code value will be a 3 digit age, 7 digit diagnosis code, or a 4 digit revenue code.

Sequence Number seq_nbr 9(4) 12 - 15 Sequence number for this code record.

Start Date start_date 9(8) 16 - 23 Date record is effective.End Date end_date 9(8) 24 - 31 00000000 = Code is

still in effectYYYYMMDD = End

date for recordAge age 9(3) 32 - 34 Patient age that is

excluded from claim processing.


24.1.3 Standard Costs File LayoutThis file is used to assign each reason for visit diagnosis code on the claim to a Proportional Standard Cost Allocation (PSCA).

Discharge Disposition Array

dstat[] 9(2) occurs 10 times

35 - 54 Discharge disposition(s) that are not excluded from claim processing.

Filler X(190) 55 - 244Current EDC Analyzer™ Version

version X(6) 245 - 250 The current EDC Analyzer™ version number.

For example: 200602




Table 24-3: Standard Costs File Layout (C Platform Only)



Diagnosis Code dx X(10) 1 - 10 Reason for visit diagnosis code(s) found on the claim.


Start Date start_date 9(8) 15 - 22 Date record is effective.End Date end_date 9(8) 23 - 30 00000000 = Code is still in

effectYYYYMMDD = End date for

recordGender Category sex_cat X(2) 31 - 32 M = Male only

F = Female onlyMF = Male and female

Age Units age_units X(1) 33 Y = YearsLow Age low_age 9(3) 34 - 36 If there is no age restriction,

this field will be set to 000.High Age high_age 9(3) 37 - 39 If there is no age restriction,

this field will be set to 999.Proportional Standard Cost Allocation (PSCA)

psca 9(1) 40 Possible values are 1 - 5.

Filler X(210) 41 - 250


24.1.4 Extended Costs File LayoutThis file is used to assign each procedure code on the claim to a category.

24.1.5 Patient Complexity Costs File LayoutThis file is used to assign each principal and secondary diagnosis code on the claim to a complexity weight.

Table 24-4: Extended Costs File Layout (C Platform Only)



HCPCS Code hcpcs X(7) 1 - 7 Procedure code(s) found on the claim.


Start Date start_date 9(8) 12 - 19 Date record is effective.End Date end_date 9(8) 20 - 27 00000000 = Code is still in effect


Category om_cat 9(2) 28 - 29 01 = Laboratory tests02 = X-ray tests (film)03 = EKG/RT/other diagnostic

tests04 = CT/MRI/ultrasound tests

Filler X(221) 30 - 250

Table 24-5: Patient Complexity Costs File Layout (C Platform Only)



Diagnosis Code dx X(10) 1 - 10 Principal and secondary diagnosis code(s) found on the claim.



YYYYMMDD = End date for recordPatient Complexity Cost Weight

hcc_weight 9(5) 31 - 35 The complexity weightthat each principal and secondary diagnosis code has been assigned.

Filler X(215) 36 - 250


24.1.6 Client-Specific Exclusion File LayoutThis file is used to customize the COVID-19 diagnosis codes/HCPCS/CPT® codes, and observation HCPCS/CPT®/revenue codes that are excluded from analyzing.

Table 24-6: Client-Specific Exclusion File Layout (C Platform Only)

Field Name Length Format DescriptionCode Type 1 X(1) C = HCPCS/CPT® code

K = ICD-10-CM diagnosis codeR = Revenue code

Code 10 X(10) Code value will be a 3 digit age, 7 digit diagnosis code, or a 4 digit revenue code.

Start Date 8 9(8) Date record is effective.End Date 8 9(8) 00000000 = Code is still in effect



24.2 E&M Analyzer Pro File Layouts (C Platform Only)24.2.1 File Naming Conventions

The E&M Analyzer Pro file names are listed below (where vvv = the E&M Analyzer Pro version number).

24.2.2 Exclusion File LayoutThis file is used to exclude claims with certain revenue codes, diagnosis codes, procedure codes, certain ages, and certain discharge dispositions from being processed by the E&M Analyzer Pro. In addition, this file is also used to set the Analyzer version number in the savings log file.

Table 24-7: E&M Analyzer Pro Data File Names

Description File NameDiagnosis Risk File dxrskvvv.datExclusion File excluvvv.datVisit Level Complexity Claim File vlccvvv.datVisit Level Complexity Diagnosis File vlcdvvv.dat




Code Type type X(1) 1 Blank = Version numberA = AgeJ = Procedure code (facility)K = ICD-10-CM diagnosis codeQ = Discharge dispositionR = Revenue codeW = Procedure code

(practitioner)Code code X(10) 2 - 11 Code value will be a 3 digit age,

4 digit revenue code or discharge status code, 5 digit procedure code, or a 7 digit diagnosis code.




Age age 9(3) 32 - 34 Claims are excluded when the patient’s age is less than this amount.


24.2.3 Diagnosis Risk File LayoutThis file is used to assign each diagnosis code on the claim to a risk value.

Discharge Disposition Array

dstat[] 9(2) occurs 10 times

35 - 54 Dischargedisposition(s) that arenot excluded from claimprocessing.

Procedure or Revenue Code Exclusion Type for Facility

excl_type 9(1) 55 0 = Not a procedure code or revenue code exclusion

1 = High risk procedure code2 = Observation procedure code

or revenue code Filler X(189) 56 - 244 FillerCurrent E&M Analyzer Pro Version Number

version X(6) 245 - 250 The E&M Pro Analyzer version number.




Table 24-9: Diagnosis Risk File Layout (C Platform Only)



Diagnosis Code dx X(10) 1 - 10 ICD-10-CM diagnosis code(s) found on the claim.


Start Date start_date 9(8) 15 - 22 Date record is effective.

End Date end_date 9(8) 23 - 30 00000000 = Code is still in effectYYYYMMDD = End date for

recordGender Category sex_cat X(2) 31 - 32 The gender the record applies to.

M = Male onlyF = Female onlyMF = Male and female

Age Units age_units X(1) 33 Age in units.

Y = YearsLow Age low_age 9(3) 34 - 36 Lowest patient age which will be

evaluated for risk.

If there is no age restriction, this field will be set to 000.


24.2.4 Visit Level Complexity Claim File LayoutThis file is used to determine if a claim is strongly correlated to an encounter complexity evaluation and management for a higher level of risk.

High Age high_age 9(3) 37 - 39 Highest patient age which will be evaluated for risk.

If there is no age restriction, this field will be set to 999.

Chronic Condition/Admit Identifier

special_flag X(2) 40 - 41 If this diagnosis is not a chronic condition and is not likely to lead to an admission, this field will be set to all blanks.

A = Admission is likelyC = Chronic conditionAC = Chronic condition and

admission is likelyCC/MCC Indicator cc_ind X(1) 42 Indicates whether or not the

diagnosis code is a CC or MMC.

If this diagnosis is not a CC or MCC, this field will be set to a blank.

C = Complication or Comorbidity (CC)

M = Major Complication or Comorbidity (MCC)

Risk Value risk 9(3) 43 - 45 Risk value for this diagnosis code.

Filler X(205) 46 - 250

Table 24-9: Diagnosis Risk File Layout (C Platform Only)



Table 24-10: Visit Level Complexity Claim File Layout (C Platform Only)



Sequence Number seq_nbr 9(4) 1 - 4 Sequence number for this record.

Step 1 Scenario Number

step1_num 9(4) 5 - 8 Optum-defined scenario number.

Start Date start_date 9(8) 9 - 16 Date record is effective.

End Date end_date 9(8) 17 - 24 00000000 = Record is still in effect



Age Criteria age 9(3) 25 - 27 Age on the claim is greater than or equal to this value.

Gender Criteria sex X(2) 28 - 29 The gender on the claim is consistent with one of the following values:M = Male onlyF = Female onlyMF = Male and female

Number of Diagnosis Codes With Risk Criteria

num_dxrsk 9(3) 30 - 32 Number of diagnosis codes that must be found on the claim.

Number of Chronic Conditions Criteria

num_chron 9(3) 33 - 35 Number of chronic condition codes that must be found on this claim.

Number of MCCs Criteria

num_mcc 9(3) 36 - 38 Number of diagnosis codes that must be MCCs.

Number of CCs Criteria

num_cc 9(3) 39 - 41 Number of diagnosis codes that must be CCs.

Diagnosis Risk Criteria

dxrsk 9(3) 42 - 44 Risk amount that must be exceeded.

Principal Diagnosis Criteria

pdx_flag 9(3) 45 - 47 This claim must include a principal diagnosis code from the following lists:001 = Principal diagnosis code

list for scenario 1306002 = Principal diagnosis code


begins with S or R for scenario 501

Submitted Visit Level Criteria

start_visit_lvl 9(1) 48 This claim must have a submitted visit level equal to this value.

Calculated Visit Level end_visit_lvl 9(1) 49 This claim must include this visit level after the submitted visit level.

Risk Amount to Add add_risk 9(3) 50 - 52 Additional risk value to added to a non-risk value on the claim.

Step 1 Scenario Text step1_txt X(200) 53 - 252 Evaluates emergency department claims for text which describes this scenario.

Filler X(198) 253 - 450

Table 24-10: Visit Level Complexity Claim File Layout (C Platform Only)




24.2.5 Visit Level Complexity Diagnosis File LayoutThis file is used in conjunction with the Visit Level Complexity Claim File to determine if a diagnosis code is eligible for a higher level of risk.

Table 24-11: Visit Level Complexity Diagnosis File Layout (C Platform Only)



Diagnosis Code dx X(10) 1 - 10 ICD-10-CM diagnosis code(s)Sequence Number seq_nbr 9(4) 11 - 14 Sequence number for this

record.Start Date start_date 9(8) 15 - 22 Date record is effective.

End Date end_date 9(8) 23 - 30 00000000 = Record is still in effect


Principal Diagnosis Criteria

pdx_flag 9(3) 31 - 33 This claim must include a principal diagnosis code from the following lists:001 = Principal diagnosis code



begins with S or R for scenario 501

Filler X(217) 34 - 250


25 Mapping Data File Layouts

This chapter provides the layouts for the Mapping Data File (C and COBOL). This chapter includes the following sections:

• C Platform Layout• COBOL Platform Layout

NoteThis chapter contains information for use with the EASYGroup™ ICD-10 Mapper only.


25.1 Mapping Data File25.1.1 C Platform Layout

25.1.2 COBOL Platform Layout

Table 25-1: Mapping Data File Variables - mapfile.dat

Field Description Variable Name Format PositionMapping Override ID override_id X(20) 1 - 20Mapping Category01 = CMS reimbursement02 = Optum premier pick03 = Wisconsin Medicaid-specific04 - 99 = State-specific or custom

mappings

category X(2) 21 - 22

Mapping DirectionF = Forward mappingB = Backward mapping

direction X(2) 23 - 24

Code TypeD = Diagnosis codeP = Procedure code

code_type X(2) 25 - 26

Source CodeICD-9 or ICD-10 diagnosis or procedure code

code X(10) 27 - 36

Filler X(10) 37 - 46Source Version(e.g., V28 = effective October 1, 2010)

source_vers 9(2) 47 - 48

Target Version(e.g., V26 = effective October 1, 2008)

target_vers 9(2) 49 - 50

Number of Target Codes target_codes_num 9(2) 51 - 52Target Codes target_codes X(10)

occurs 10 times

53 - 152


Field Description Variable Name Format PositionMapping Override ID MFR-OVERRIDE-ID X(20) 1 - 20Mapping Category01 = CMS reimbursement02 = Optum premier pick03 = Wisconsin Medicaid-specific04- 99 = State-specific or custom

mappings

MFR-CATEGORY X(2) 21 - 22

Mapping DirectionF = Forward mappingB = Backward mapping

MFR-DIRECTION X(2) 23 - 24


Code TypeD = Diagnosis codeP = Procedure code

MFR-CODE-TYPE X(2) 25 - 26

Source CodeICD-9 or ICD-10 diagnosis or procedure code

MFR-CODE X(10) 27 - 36

Filler X(10) 37 - 46Source Version(e.g., V28 = effective October 1, 2010)

MFR-SOURCE-VERS

9(2) 47 - 48

Target Version(e.g, V26 = effective October 1, 2008)

MFR-TARGET-VERS 9(2) 49 - 50

Number of Target Codes MFR-TARGET-CODES-NUM

9(2) 51 - 52

Target Codes MFR-TARGET-CODES

X(10)occurs 10 times

53 - 152




26 Description File Layouts

This chapter provides the layouts for the DRG, MDC, APG, and APC Description Files (C and COBOL) used in EASYGroup™. This chapter includes the following sections:

• DRG and MDC Grouper Description Files• APG Grouper Description File• APC Grouper Description File


26.1 DRG and MDC Grouper Description FilesThe EASYGroup™ ICD-10 Medicare DRG Grouper, ICD-10 TRICARE DRG Grouper, and the APR-DRG Grouper distributions contain MDC and DRG description files. The MDC file contains the MDC number and English text for each of the MDCs. The DRG files contain a DRG number, corresponding MDC number, and English text for each of the DRGs.

Table 26-1: drglabel; drglmVV; drgltVV

C;COBOL Variable Names


drg_num; DRG-NUM

9(4) 1 - 4 DRG number. Right-justified, zero-filled.

mdc_num; MDC-NUM

9(2) 5 - 6 MDC number for this DRG. Right-justified, zero-filled. Equal to 00 if the DRG is eligible for assignment to multiple MDCs.

drg_desc; DRG-DESC

X(40) 7 - 46 Description or label for the DRG. Left-justified, blank-filled.

Table 26-2: mdclabel; mdclmVV

C;COBOL Variable Names


mdc_num; MDC-NUM

9(2) 1 - 2 MDC number. Right-justified, zero-filled.

drg_desc; MDC-DESC

X(40) 3 - 42 Description or label for the MDC. Left-justified, blank-filled.


26.2 APG Grouper Description FileThe APG Grouper distribution contains an APG Description File. This file contains an APG number and the English text for each of the APGs.The record layout for apglabel is:

26.3 APC Grouper Description FileThe APC Grouper distribution contains an APC Description File (apclabel; apclyVV). This file contains an APC number and the English text for each of the APCs.The record layout for apclabel, apclyVV (where VV = Grouper version number) is:

Table 26-3: apglabel

Variable Name Position Notesapg_num 1 - 3 APG number. Right-justified, zero-filled.apgdesc 4 - 80 Description or label for the APG. Left-justified, blank-

filled.

Table 26-4: apclabel; apclyVV

Field Description

Variable NameC; COBOL


APC apc_num;APC-NUM

9(4) 1 - 4 APC number. Right-justified, zero-filled.


paymentstatus;PAYMENTSTATUS

X(1) 5 Payment Status Indicator for this APC.

Filler 9(1) 6 Zero-filled.APC Description

apc_desc;APC-DESC

X(40) 7 - 46 Description or label for this APC. Left-justified, blank-filled.


27 Date-Sensitive Codes & Titles Files and Translation File Layouts

The following sections are included in this chapter:• Date-Sensitive Codes and Titles Overview• Distinguishing Different Code Types• Identifying the Appropriate Code Value Record • CPT® Copyright Notice• ICD-9-CM, ICD-10-CM/PCS, and HCPCS Codes & Titles File Layouts

- ICD-9-CM & HCPCS Layout- ICD-10-CM/PCS Layout

• EASYGroup™ Translation File- Retrieving Mapped CPT®-4 Codes- ICD-9-CM to HCPCS Level I (CPT®-4) Translation File Format


27.1 Date-Sensitive Codes and Titles OverviewThe EASYGroup™ Date-Sensitive Codes and Titles file(s) contain all current and previous codes, with accompanying short (abbreviated) and long (complete) titles or descriptions. Please note that as of January 01, 2011 dental services D codes are no longer included in the standard distribution file(s). The dental service D codes are available as part of the Date-Sensitive Codes & Titles HCPCS Plus file. Each code is tagged with a starting and ending date, which shows exactly when that particular code or version of the code was valid. Codes valid at the present time have an ending date of all zeros (00000000). Rubrics or code subparts, which have never been valid for coding, are identified with both a starting and ending date of zeros.With the Date-Sensitive Codes and Titles file(s), users can evaluate the accuracy of diagnosis and procedure codes at the time health care services were delivered (e.g., according to the patient’s dates of service or hospitalization). In addition, the appropriateness of a code for the patient’s age and sex can be examined. The complete contents of the Codes and Titles file can be found below.The Date-Sensitive Codes and Titles file(s) contains all current and previous codes, as well as all rubrics or code subparts. Please note that as of January 01, 2011 dental services D codes are no longer included in the standard distribution file(s). The dental service D codes are available as part of the Date-Sensitive Codes & Titles HCPCS Plus file. Each code record is tagged with a starting and ending date, which shows exactly when the information for that particular code value was valid. Codes valid at the present time have an ending date of all zeros (00000000). Rubrics or code subparts, which have never been valid for coding purposes, are identified with zeros for both the starting and ending date.Any particular code value may have more than one record in the Codes and Titles file(s). This will occur if there has been a change in a code description/title or if one of the associated informational fields (e.g., UHDDS class, Medicare MDC number, or Medicare CC Indicator) has been changed over time. Each record for the same code value will be assigned a unique starting and ending date, as well as a “code sequence number.” The most current record is assigned a “code sequence number” of “1,” the next most current record has a “code sequence number” of “2,” and so on.Note that in addition to a starting and ending date, each record in the Codes and Titles file(s) contains an “original effective date.” This field is particularly useful when there are multiple records for the same code value. This field indicates the earliest date upon which this particular code value was valid. The “original effective date” will be the same on all records for the same code value.


27.2 Distinguishing Different Code TypesEach record in the Codes and Titles file(s) begins with a one-byte field which identifies the “code type” of that record. ICD-9-CM diagnosis and procedure codes are identified by a “code type” of “D” and “P,” respectively. ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are identified by a “K” and “L,” respectively. CPT®-4 and HCPCS codes are identified by a “C” and “H.”

27.3 Identifying the Appropriate Code Value Record To effectively utilize the EASYGroup™ Codes and Titles file(s), users must be able to retrieve the appropriate record for the patient’s “code value” (i.e., ICD-9-CM, ICD-10-CM, ICD-10-PCS, or HCPCS/CPT® code) and “dates of service.” This is a two-step process. First, select those records which match the patient’s “code type” and “code value.” Then, compare the patient’s date of service to the “starting date” and “ending date” ranges of the selected Codes and Titles records. Select as a match the single record that meets the following two conditions:

• Has a “starting date” which is less than or equal to the patient’s date of service, and

• Has an “ending date” which is either greater than or equal to the patient’s date of service or is all zeros.

You may use the “code sequence number” field to simplify this process. For example, if you wish to look at only the most current Codes and Titles record for the code value, only retrieve the record which has a “code sequence number” of “1.”It is possible to find Codes and Titles records which match the patient’s “code type” and “code value,” but are inappropriate from a date perspective. That is, these records are in no “starting date” and “ending date” range on any record which includes the patient’s “dates of service.” This situation indicates that the “code value” being used for the patient is not appropriate for the indicated “dates of service.”


27.4 CPT® Copyright NoticeIf you have licensed the HCPCS/CPT® or the HCPCS Plus version of the Date-Sensitive Codes and Titles file, be aware that the initial records contain the required American Medical Association (AMA) CPT® copyright notice. In addition to being located at the physical beginning of the file, the records containing this copyright notice contain placeholders for formatting purposes in the following fields:

• Code Type• Code Value• Code Sequence Number

27.5 ICD-9-CM, ICD-10-CM/PCS, and HCPCS Codes & Titles File Layouts

NoteUnless indicated otherwise, a given field applies to all code types.

27.5.1 ICD-9-CM & HCPCS Layout

Table 27-1: ICD-9-CM & HCPCS Codes and Titles File Layout

Field Description FieldType

FieldLength

Position Notes

Code Type A 1 1 C = CPT® (HCPCS Level I and III) or modifier prefixed by 099

D = ICD-9-CM DiagnosisH = HCPCS Level IIP = ICD-9-CM ProcedureBlank = Default

Code Value AN 9 2 - 10 Contains either an ICD-9-CM, CPT®, or HCPCS code value, as indicated by the Code Type field. Left-justified; blank-filled.


N 2 11 - 12 Code sequence number for this code value.

Starting Date N 8 13 - 20 00000000 = Code never validYYYYMMDD = Effective date for this code

recordEnding Date N 8 21 - 28 00000000 = Code never valid or data for

this code record is still in effect


Original Effective Date N 8 29 - 36 00000000 = Code never validYYYYMMDD = Earliest effective date for

this code value


Further Qualifier Flag N 1 37 0 = Code does not require additional digit(s)

1 = Code requires additional digit(s)Zero-filled for HCPCS/CPT®

Short Code Description AN 24 38 - 61 Abbreviated code descriptionFiller A 1 62Sex Indicator A 1 63 M = Code valid for males only


UHDDS Class N 1 64 0 = Code never valid1 = Class 1, most risk, resource intensive2 = Class 23 = Class 34 = Class 4, least risk, resource intensiveZero-filled for HCPCS/CPT®

Medicare MDC Number

or

Ambulatory Surgery Category

N 2 65 - 66 ICD-9-CM Diagnosis Only:0 code never valid or MDC 0 assigned by

Grouper (E-codes)01-25 = Valid Major Diagnostic Category

(MDC) Number

CPT® Procedures Only:00 = Procedure code is not assigned to an

ASC 01-09 = Valid Ambulatory Surgery

Category (ASC)Medicare CC Indicator A 1 67 ICD-9-CM Diagnosis Only:

Y = Diagnosis code is a Medicare CCM = Diagnosis code is a Medicare MCCBlank = Default

Medicare CC DRG Indicator

A 1 68 ICD-9-CM Diagnosis Only:Y = Code used alone groups to a Medicare

DRG which would change in the presence of a secondary CC diagnosis.

Blank = DefaultAge Indicator AN 1 69 ICD-9-CM Diagnosis Only:

1 = Newborn, age = 02 = Pediatric, age = 0 - 173 = Maternity, age = 12-55 (prior to

October 01, 2019), 9-64 (effective October 01, 2019)

4 = Adult, age > 14Blank = Default

Principal Diagnosis Indicator - Flag 1

A 1 70 ICD-9-CM Diagnosis Only:M = ManifestationV = VagueBlank = Default



FieldLength

Position Notes



A 1 71 ICD-9-CM Diagnosis Only:N = Non-specific codeU = Unacceptable as principal diagnosisQ = Questionable as principal diagnosisBlank = Default

Filler AN 13 72 - 84Operating Room Indicator

N 1 85 ICD-9-CM Procedures Only:0 = Grouper does not consider O.R.

procedure1 = Grouper considers O.R. procedure.



FieldLength

Position Notes


APC Payment Status AN 2 86 - 87 HCPCS/CPT® Procedures Only:A = Services paid under fee schedule or

other prospectively determined rateB = Service not allowed under OPPS on

hospital outpatient claimC = Inpatient service, not paid under

OPPSE = Non-covered service, not paid under

OPPSF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughGN = Drug/biological fee schedule itemGM = Drug/biological fee schedule itemH = Pass-through device categories and

therapeutic radiopharaceuticalsJ = New drug/biological, transitional pass-

through payment (prior to April 1, 2002 only)

J1 = Hospital Part B services paid through a Comprehensive APC

K = Non-pass-through drugs and biologicals

KN = Drug/biological fee schedule itemKM = Drug/biological fee schedule itemL = Influenza virus or Pneumococcal

Pneumonia Vaccine (PPV)M = Service not billable to the FI/MACN = Packaged/incidental service, no

additional payment P = Partial hospitalization serviceQ = Packaged service subject to separate

payment based on payment criteria (prior to January 1, 2009 only)

Q1 = STV - packaged services Q2 = T - packaged servicesQ3 = Services that may be paid through a

composite APCR = Blood and blood productsS = Procedure or service, not discounted

when multiple T = Procedure or service, multiple

reduction appliesU = Brachytherapy sourcesV = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and

invalid revenue codeX = Ancillary service (prior to January 1,

2015)Y = Non-implantable DMEZ = Valid revenue code, blank HCPCS

code, no other status indicator assigned



FieldLength

Position Notes


27.5.2 ICD-10-CM/PCS Layout

Present On Admission Exempt Indicator

A 1 88 ICD-9-CM Diagnosis Only:Y = Code is exempt from POA reporting.Otherwise, POA reporting is required for this code beginning October 1, 2007.

Filler A 22 89-110 ReservedLong Code Description AN 255 111-365 Full code description

Table 27-2: ICD-10-CM/PCS Codes and Titles File Layout


FieldLength

Position Notes

Code Type A 1 1 K = ICD-10-CM DiagnosisL = ICD-10-PCS ProcedureBlank = Default

Code Value AN 9 2 - 10 Contains an ICD-10-CM or ICD-10-PCS value, as indicated by the Code Type field. Left-justified; blank-filled.


N 2 11 - 12 Code sequence number for this code value.

Starting Date N 8 13 - 20 00000000 = Code never validYYYYMMDD = Effective date for this code

recordEnding Date N 8 21 - 28 00000000 = Code never valid or data for

this code record is still in effect


Original Effective Date N 8 29 - 36 00000000 = Code never validYYYYMMDD = Earliest effective date for

this code valueFurther Qualifier Flag N 1 37 0 = Code does not require additional

digit(s)1 = Code requires additional digit(s)

Reserved AN 24 38 - 61 ReservedFiller AN 1 62Sex Indicator A 1 63 M = Code valid for males only


Reserved N 1 64 Reserved



FieldLength

Position Notes


Medicare MDC Number

N 2 65 - 66 ICD-10-CM Diagnosis Only:00 = Diagnosis code never valid or MDC 0

assigned by Grouper(V-Y codes)01-25 = Valid Major Diagnostic Category

(MDC) NumberMedicare CC Indicator A 1 67 ICD-10-CM Diagnosis Only:

Y = Diagnosis code is a Medicare CCM = Diagnosis code is a Medicare MCCBlank = Default

Reserved A 1 68 ReservedAge Indicator AN 1 69 ICD-10-CM Diagnosis Only:

1 = Newborn, age = 02 = Pediatric, age = 0 - 173 = Maternity, age = 12-55 (prior to

October 01, 2019), 9-64 (effective October 01, 2019)

4 = Adult, age > 14Blank = Default


A 1 70 ICD-10-CM Diagnosis Only:M = ManifestationBlank = Default


A 1 71 ICD-10-CM Diagnosis Only:U = Unacceptable as principal diagnosisQ = Questionable as principal diagnosisBlank = Default

Filler AN 13 72 - 84Operating Room Indicator

N 1 85 ICD-10-PCS Procedures Only:0 = Grouper does not consider O.R.

procedure1 = Grouper considers O.R. procedure.


A 1 86 ICD-10-CM Diagnosis Only:N = Code should not appear in the

principal positionBlank = Default

Reserved AN 1 87 ReservedPresent on Admission Exempt Indicator

A 1 88 ICD-10-CM Diagnosis Only:Y = Code is exempt from POA reporting.Otherwise, POA reporting is required forthis code.

Hospital Acquired Condition (HAC) Indicator

A 1 89 ICD-10-CM Diagnosis Only:1 = Code is a HACBlank = Code is not a HAC

Filler AN 21 90 - 110 ReservedShort Code Description AN 35 111 - 145 ICD-10-CM diagnosis and ICD-10-PCS

procedures only; Short code description.



FieldLength

Position Notes


27.6 EASYGroup™ Translation FileThe EASYGroup™ ICD-9-CM to HCPCS Level I (CPT®-4) Translation File contains all ICD-9-CM procedure codes valid since V15 (October 1, 1997) with suggested CPT®-4 code mappings. Each ICD-9-CM procedure code can have one or more mapped CPT®-4 codes in the Translation File. Each mapped code pair is identified by a time period value and a sequence number. The format and content of the Translation File can be found below. Installation instructions are included in the EASYGroup™ Installation Guide.With the Translation File, users can map an ICD-9-CM procedure code to the most reasonable CPT®-4 match at the time health care services were delivered (as determined by the patient's dates of service and the Map Period field contained in the Translation File). When multiple CPT®-4 matches are found for an ICD-9-CM code during the same time period, a sequence number of 001 identifies the most reasonable match.

27.6.1 Retrieving Mapped CPT®-4 CodesICD-9-CM procedure codes can have one or more mapped CPT®-4 codes in the Translation File. Each mapped code pair is identified by a time period value and a sequence number. If there is only one mapped CPT®-4 code for a given ICD-9-CM procedure code and time period, the sequence number will equal 001. For ICD-9-CM procedures with more than one mapped CPT®-4 code, the map record with sequence number 001 represents the best single code choice among the multiple maps. Other maps are arranged in ascending CPT®-4 code order beginning with sequence number 002.The time period used for retrieving map records (i.e., Map Period) is a three-digit number derived from the service date of the patient data. It is based upon the ICD-9-CM update cycle, which corresponds to the federal fiscal year. To calculate the time period for retrieving Translation File records, proceed as follows:

• Step 1. Subtract 1983 from the four-digit year value of the patient’s service date.

• Step 2. If the service month is October through December, add 1 to the Step 1 result. Otherwise, add a 0.

Medium Code Description

AN 70 146 - 215 ICD-10-CM diagnosis and ICD-10-PCS procedures only; Medium code description.

Long Code Description AN 255 216 - 470 ICD-10-CM diagnosis and ICD-10-PCS procedures only; Full code description.



FieldLength

Position Notes


• Step 3. If the service month is October through December, append a 0 to the Step 2 result. Otherwise, append a 1.

For example:The time period for 10/01/1998 would be 160:

1998 - 1983 = 15Add 1 for service month 10 through 12 = 16Append 0 for service month 10 through 12 = 160

The time period for 01/01/1999 would be 161:1999 - 1983 = 16Add 0 for service month 01 through 09 = 16Append 1 for service month 01 through 09 = 161

Use the calculated time period, ICD-9-CM four character procedure code, and sequence number 001 to locate the first (or only) CPT®-4 map for the input ICD-9-CM procedure code. If only a single, most representative, ICD-9-CM to CPT®-4 map is required, the sequence number can be left as a constant 001. To look at all possible ICD-9-CM to CPT®-4 matches, vary the sequence number by one until no further procedure code matches are found.

27.6.2 ICD-9-CM to HCPCS Level I (CPT®-4) Translation File Format

Table 27-3: Translation File Format

Field Description Format Position NotesMap Period 9(3) 1 - 3 Three digit code for the federal fiscal year/

quarters for which the map is in effect. The first two digits correspond to the Medicare Grouper version number (i.e., (service year – 1983) + (1 if service month >= 10)).

The third digit is 0 if the service month is in the 1st fiscal (4th calendar quarter), otherwise 1.

Examples:09/30/199815110/01/199916012/31/199816001/01/1999161

CM Code X(4) 4 - 7 Contains an ICD-9-CM procedure code value. Left-justified, blank-filled.


Sequence Number 9(3) 8 - 10 Sequential numbering of one or more CPT®-4 code mapping(s) within a ICD-9-CM code.For ICD-9-CM codes with more than one CPT®-4 mapping(s), sequence number 001 indicates the most reasonable code map.Sequence numbers 002 through N order the remaining code maps in ascending CPT®-4 code sequence.

CPT®-4 Code 9(5) 11 - 15 Contains a CPT®-4 code value.

Table 27-3: Translation File Format

Field Description Format Position Notes


IndexAAPC and ASC Hospital Rate CalculatorFile Layouts 128, 209

C Platform 130Contract APC 218Contract ASC 225Extended Hospital Rate File 218Medicare APC-HOPD 146Medicare ASC 149, 210

COBOL PlatformContract APC 229Contract ASC 236Extended Hospital Rate File 229Medicare APC-HOPD 158, 214Medicare ASC 160

APC Rule File Layouts 332CConfiguration File Layouts 312Contact Optum 9Contact Us 9

Corporate Address 9DDescription File Layouts 434

APG 436DRG and MDC 435

DRG Hospital Rate Calculator File Lay-outs 178

C PlatformContract Multi-Pricer 210Georgia Medicaid 182Illinois Medicaid 182Indiana Medicaid 184Kentucky Medicaid 185Medicare 130Medicare IPF 133Medicare LTC 134Michigan Medicaid 186Nebraska Medicaid 187New Jersey Medicaid 188New Mexico Medicaid 189New York Medicaid 189North Carolina Medicaid 190Ohio Medicaid 191Pennsylvania Medicaid 192Pennsylvania Medicaid APR-DRG 192, 193Texas Medicaid 193TRICARE 213Virginia Medicaid 194

Washington HCA Case-Based194Washington HCA Non-CaseBased 195Washington Medicaid 197Wisconsin Medicaid 199

COBOL Platform 199Contract Multi-Pricer 214Medicare 138Medicare IPF 141Medicare LTC 143New Jersey Medicaid 199Pennsylvania Medicaid 199TRICARE 216Washington HCA Case-Based200Washington HCA Non-CaseBased 201

EEditor Return Codes 23

ACE 24DSC 27EASYEdit (COBOL Only) 27LCD (C Only) 29, 30Physician 30

ESRD Hospital Rate Calculator File Lay-outs

C PlatformExtended Hospital Rate Calcula-tor File 151Extended Hospital Rate Calcula-tor file 161

FFee Schedule File Layouts 241

C Platform Layouts 244

Overview 242GGrouper Return Codes

APC and ASC 33APG 33DRG 35HHA Reader 44IRF 42SNF RUG Reader 46

Guide Overview 6, 11, 15, 19, 23, 47, 97Document Conventions 8Introduction to This Guide 7


Intended Audience 7Organization of This Guide 7

HHHA Hospital Rate Calculator File Lay-outs

C Platform Layout 134, 135, 155COBOL Platform Layout 142, 144,

166Hospital Rate Calculator Instructions

C Platform Key Fields 123COBOL Platform Key Fields 124

MMapper Return Codes 19, 97OOptimizer Return Codes 11, 15Overview 6

About Optum 9Contact Us 9Document Conventions 8Intro to this Guide 7Organization of this Guide 7

PPayers Block Table Layouts 309Physician Code Table Layouts 265Physician Rate Calculator File Layouts239, 307

C Platform 170, 240, 308COBOL Platform 173

Pricer Return Codes 47APC and ASC 48

SSNF RUG Rate File Layouts 421, 431TTRICARE APC Hospital Rate CalculatorFile Layouts

C Platform (Only) 228Troubleshooting and Logging 101Troubleshooting with EASYGroup and3M GPS

How to Resolve Error 60 108

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