ECM Pro™ Inpatient Rehabilitation Facility (IRF) Web ... · application on any web-accessible platfo rm can request inpatient rehabilitation CMG assignment, and CMG-based pricing

V2004.00Last Updated: April 2, 2020 3:10 pm

ECM Pro™ Inpatient Rehabilitation Facility (IRF) Web Services User’s Guide

ECM Pro™ IRF Web Services User’s Guide

Published April 2, 2020 The format of this document is 8.5 x 11”

© 2020 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 severe 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 2019 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, © 2019 American Dental Association. All rights reserved.

Applicable FARS/DFARS Restrictions Apply to Government Use.

3M™ is a trademark of 3M™ Company. The 3M™ Grouper Plus System (3M™ GPS) with the 3M™ Enhanced Ambulatory Patient Grouping System (3M™ EAPGS) its logic are proprietary to 3M™ Company and are subject to the terms and conditions of the software licensing agreement between 3M™ and Optum.

© 2020, 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™ - Patent No. 10,417,382

Optum11000 Optum Circle

Eden Prairie, MN 55344

[email protected]

Op

Table of ContentsChapter 1: Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

About Optum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Prior Knowledge Assumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9The IRF Web Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9The Optimizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Alternate Rate Paths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16EASYGroup™ Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Rate Manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Hardware/Software Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Chapter 3: Installation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19General Description of Program Files. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Installing the Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Default Directory Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Testing the IRF Web Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Chapter 4: Integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Creating the IRF Rate Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Integrating the IRF Rate Files. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Configuring the FileReplace Web Service . . . . . . . . . . . . . . . . . . . . . . . . 32Preparing the Input Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Handling the Return Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Data Formatting Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Integrating the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Enabling Enhanced Web Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Chapter 5: CMGPrice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48CMGPrice Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CMGPrice Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CMGPrice Pricer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Chapter 6: CMGGroupPrice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54CMGGroupPrice Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55CMGGroupPrice Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56CMGGroupPrice Grouper Claim Responses . . . . . . . . . . . . . . . . . . . . . . 57CMGGroupPrice Grouper Line Responses . . . . . . . . . . . . . . . . . . . . . . . 61CMGGroupPrice Pricer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Chapter 7: CMGEditGroupPrice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65CMGEditGroupPrice Request. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66CMGEditGroupPrice Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67CMGEditGroupPrice Editor Claim Responses . . . . . . . . . . . . . . . . . . . . . 67CMGEditGroupPrice Editor Diagnosis Responses. . . . . . . . . . . . . . . . . . 70CMGEditGroupPrice Editor Procedure Responses . . . . . . . . . . . . . . . . . 72CMGEditGroupPrice Grouper Claim Responses . . . . . . . . . . . . . . . . . . . 74CMGEditGroupPrice Grouper Line Responses . . . . . . . . . . . . . . . . . . . . 78CMGEditGroupPrice Pricer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Chapter 8: CMGEdit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82CMGEdit Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

tum | www.optum.com April 2, 2020 Page 3

Op

CMGEdit Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84CMGEdit Editor Claim Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84CMGEdit Editor Diagnosis Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . 87CMGEdit Editor Procedure Responses . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Chapter 9: CMGEditMessages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91CMGEditMessages Requests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92CMGEditMessages Editor Claim Responses . . . . . . . . . . . . . . . . . . . . . . 93CMGEditMessages Editor Diagnosis Responses. . . . . . . . . . . . . . . . . . . 96CMGEditMessages Editor Procedure Responses . . . . . . . . . . . . . . . . . . 99

Chapter 10: CMGEditSummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100CMGEditSummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101CMGEditSummary Responses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101CMGEditSummary Editor Claim Responses . . . . . . . . . . . . . . . . . . . . . 102

Chapter 11: UB04_GetPayerList . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104UB04_GetPayerList Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105UB04_GetPayerList Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Chapter 12: UB04_GetGroupPriceRules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107UB04_GetGroupPriceRules Requests . . . . . . . . . . . . . . . . . . . . . . . . . . 108UB04_GetGroupPriceRules Responses. . . . . . . . . . . . . . . . . . . . . . . . . 110

Chapter 13: FileReplace Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112ReplaceFiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Chapter 14: Shared Structures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114CMGPatientInput . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Edit_Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120CMGLineInput. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121pcb2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Op_Entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127DX_Entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128gob1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130Optimizer Return Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Chapter 15: IRF Web Services Label Data File . . . . . . . . . . . . . . . . . . . . . . . . 136File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Description of Irfmsg Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142


Op

1 Overview

ECM Pro™ is an Enterprise Content Management (ECM) system for simplifying the complexities of Coding, Compliance, and Reimbursement Management (CCRM). With the multitude of regulatory content and its disparate and off-cycle release schedules, ECM Pro™ provides a valuable function by removing the heavy lifting associated with remaining current.

Through standard ECM practices, ECM Pro™:

• Aggregates content from multiple sources: The Centers for Medicare & Medicaid Services (CMS), The American Medical Association (AMA), Fiscal Intermediaries (FIs), etc.

• Syndicates content into reusable components such as technology components, online references, and publications.

• Deploys content in standards-based web services components, hyper-linked references (APC Assistant™, www.optum.com, Coding Clinic, CDGs, and CPT Assistant™) and other online publications.

1.1 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.

1.2 Contact Us

1.2.1 Corporate AddressOptum11000 Optum CircleEden Prairie, MN. 55344T 1 + (888) 445-8745www.optum.com


http://www.optuminsight.com

http://www.optum.com

Op

1.2.2 Need Assistance? Contact Optum Client ServicesWe welcome you as a valued client. Please contact Optum Client Services using one of the methods detailed below.

When opening a ticket with Optum Client Services 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.

When calling Optum Client Services 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.

Optum Client Services Phone: 800-999-DRGS (3747)

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.

After selecting Option 6 for Technical Support you will hear the following choices:

Email: Optum Client.Services

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.

1.2.3 Optum Client PortalFor access to announcements, user documentation, notices, release schedules, and much more please visit the Optum Client Portal.

Table 1-1: Technical Support Options

Option # Description

Option 1 For password reset, login issues, or expiration error.

Option 2 For all other issues.


mailto:[email protected]

https://optum.secure.force.com/CustomerPortal

Op

1.2.4 Found an Error in This User’s Guide?Please feel free to contact our EASYGroup™ Documentation Team with any errors you may have found within this user’s guide:

EASYGroup_Documentation

We welcome feedback from our clients.


mailto:[email protected]

Op

2 Introduction

This manual provides the technical information needed to install and use the ECM Pro™ IRF Web Service. Using this web service, a developer writing an application on any web-accessible platform can request inpatient rehabilitation CMG assignment, and CMG-based pricing.

The ECM Pro™ IRF Web Service is comprised of a series of methods written in Microsoft® C# and distributed to run on the Microsoft® .NET platform and on the Internet Information Server (IIS). Each method will accept the input data and reformat for submission to the EASYGroup™ Optimizer, which invokes the appropriate EASYGroup™ grouping, pricing, and editing components. Return data from the Optimizer is parsed and relevant fields are returned to the requesting operation.

This chapter contains the following sections:

• Prior Knowledge Assumed

• The IRF Web Service

• The Optimizer

• Alternate Rate Paths

• EASYGroup™ Components

• Rate Manager

• Hardware/Software Requirements


Op

2.1 Prior Knowledge AssumedThis manual assumes that the reader has a functional understanding of the following:

• Web Services architecture

• SOAP, XML, and HTML

• EASYGroup™ components and component architecture

The user’s guide also assumes familiarity with standard medical coding and prospective payment terminology. For a more comprehensive review of specific functions, please refer to the EASYGroup™ User’s Guide.

2.2 The IRF Web ServiceThe operations (methods) that comprise the IRF Web Service are:

• CMGPrice (refer to Chapter 5)

• CMGGroupPrice (refer to Chapter 6)

• CMGEditGroupPrice (refer to Chapter 7)

• CMGEdit (refer to Chapter 8)

• CMGEditMessages (refer to Chapter 9)

• CMGEditSummary (refer to Chapter 10)

• UB04_GetPayerList (refer to Chapter 11)

• UB04_GetGroupPriceRules (refer to Chapter 12)

• FileReplace Structures (refer to Chapter 13)

Input and output requirements for each operation are listed in the associated ASMX file: irf.asmx (supplied with your distribution) using Web Service Definition Language (WSDL). These requirements are also defined in separate sections within this manual.

2.2.1 Overview of CMGPrice Method The CMGPrice operation, available with the IRF Web Service, implements the Optimizer price only option for IRF processing. This method integrates CMG-based pricing within a single request. Input data includes basic demographic and claim data, variably occurring ICD-10-CM/PCS diagnosis and procedure codes and the CMG. Returned information includes base, add-on and total expected reimbursement, and additional pricing variables.

This operation invokes the Optimizer which reads the input patient or claim data, and identifies the facility, payer, reimbursement effective date, and the admit/discharge dates. Using this information, it reads the rate file data from Rate Manager (refer to the Rate Manager section below). It then calculates reimbursement (using the rate file data), and returns the combined results to the user.


Op

2.2.2 Overview of CMGGroupPrice MethodThe CMGGroupPrice method of the ECM Pro™ IRF Web Service implements the Optimizer combined group/price option for inpatient rehabilitation processing. This method integrates CMG assignment and CMG-based pricing within a single request. Input data should either include basic demographic and assessment data, plus variably occurring ICD-10-CM/PCS diagnosis codes or basic demographic and claim data (refer to note below). Returned information includes CMG, base, add-on and total expected reimbursement, and additional grouping and pricing variables.

NoteThe Grouper will search the claim lines for the HIPPS code supplied on the line with revenue code 0024, when the assessment data is not supplied. Assessment data includes impairment group, and motor scores. Refer to Chapter 6 for further details.

This operation employs one of two methods to invoke the Optimizer, which then invokes the appropriate Grouper type and version, and requests code mapping if appropriate:

1. Specify the Grouper type, Grouper version, and mapping request as input variables.

2. Allow the Optimizer to determine which Grouper to use, and whether to apply code mapping, based on information from the Rate File data maintained by Rate Manager.

If the method request includes input variables that specify the Grouper type and version, and the mapping request, the method then passes this information to the Optimizer, which then invokes the specified Grouper. If this information is not supplied as input, then the Optimizer reads the input patient or claim data and identifies the facility, payer, reimbursement effective date, and the admit/discharge dates. Using this information, it reads the rate file data from Rate Manager (refer to the Rate Manager section below), and identifies which Grouper type and version. It then invokes the appropriate Grouper, and returns the DRG to the user. If mapping is requested in the Rate Manager data files, then submitted ICD-10-CM/PCS diagnosis and procedure codes are translated into equivalent codes that will be acceptable to the designated Grouper.

CMGGroupPrice request and return fields are described in Chapter 6.

2.2.3 Overview of CMGEditGroupPrice MethodThe CMGEditGroupPrice method of the IRF Web Service implements the Optimizer combined edit/group/price option for inpatient rehabilitation processing. This method integrates DSC editing, CMG assignment and CMG-based pricing within a single request. Input data should either include basic demographic and assessment data, plus variably occurring ICD-10-CM/PCS diagnosis codes and procedure codes or basic demographic and claim data


Op

(refer to note below). Returned information includes DSC edits, CMG, base, add-on and total expected reimbursement, and additional grouping and pricing variables.

NoteThe Grouper will search the claim lines for the HIPPS code supplied on the line with Revenue Code 0024, when the assessment data is not supplied. Assessment data includes impairment group, and motor scores. Refer to Chapter 7 for further details.

This operation invokes the Optimizer which reads the input patient or claim data, and identifies the facility, payer, and admit/discharge dates. Using this information, it reads the rate file data from Rate Manager (refer to Rate Manager), and identifies which edits to apply, which Grouper type and version, and which Pricer to invoke. It then invokes the Editor for the requested edits, invokes the appropriate Grouper for CMG assignment, passes the CMG into the Pricer, calculates reimbursement (again using the Rate File data), and returns the combined results to the user. CMGEditGroupPrice request and return fields are described in Chapter 7.

2.2.4 Overview of CMG Edit, CMGEditMessages, and CMGEditSummary

The IRF Web Service editing operations utilize the EASYGroup™ Date-Sensitive Code (DSC) Editor. They are designed to evaluate the accuracy of ICD-10-CM/PCS diagnosis and procedure codes at the time health care services were delivered based on the patient’s dates of service or hospitalization. All current and previous ICD-10-CM/PCS codes, including code deletions and expansions, are supported. They identify codes that are invalid, are missing the required fourth, fifth, sixth, or seventh digits, contain unnecessary digits, are non-specific, or are vague. In addition, the appropriateness of codes for the patient’s age and sex are examined. All inpatient Medicare Code Edits (MCEs), as defined by the Centers for Medicare & Medicaid Services (CMS), are included within these methods.

Input to these methods includes basic demographic data and ICD-10-CM/PCS diagnosis and procedure codes. Returned information for the editing methods includes claim-level (demographic) errors, diagnosis (ICD-10-CM diagnosis code) errors, and procedure (ICD-10-CM/PCS procedure code) errors. The returned edits occur once for the demographic data elements, and are variably based on the size of the arrays of input diagnosis and procedure codes.

The CMGEdit operations require two reference files (dxopfile.dat, dxopi10.dat), which are included in the DSC Editor distribution. These files, which are flat ASCII data files, are updated once a year (every October) and may be updated once again during the year based on information that is published subsequent to the annual update. File updates are complete replacements.


Op

The IRF Web Service offers three methods for invoking DSC edits:

• CMGEdit

This method requires demographic and ICD-10-CM/PCS diagnosis and procedure codes as input, and return edits as one or two-byte codes. This method is designed for higher volume processing, or if editing results will be stored in a database or a data analysis package.

Request and return fields are described in Chapter 8.

• CMGEditMessages

This method operates the same as CMGEdit except that the errors are returned as text messages rather than as coded fields. This method is designed for individual claim editing where the results are preferred in explanatory text rather than coded output.


• CMGEditSummary

This method requires demographic and ICD-10-CM/PCS diagnosis and procedure codes as input, and returns error counts for each edit in the CMGEdit method.


2.2.5 Overview of UB04_GetPayerList MethodThe UB04_GetPayerList method provides a list of payers set up for a specified facility in the Rate Manager files. Input is a facility identifier, and output is a list of payer identifiers and descriptions.

UB04_GetPayerList request and return fields are described in Chapter 11.

2.2.6 Overview of UB04_GetGroupPriceRules MethodThe UB04_GetGroupPriceRules method of the IRF Web Service provides access to the grouping and pricing rules stored in the Rate Manager data files and referenced by the CMGGroupPrice method during the assignment of CMGs and the calculation of reimbursement. This operation invokes the Optimizer IO component to read the rate file data from Rate Manager. Input data includes facility ID, payer ID, admission date, and discharge date. Returned information includes the effective date of the most recent set of processing rules, along with the specified Grouper type, Grouper version, and Pricer type.

UB04_GetGroupPriceRules request and return fields are described in Chapter 12.


Op

2.2.7 Overview of the FileReplace Web ServiceThe FileReplace Web Service, available within the IRF Web Service, allows users to replace rate files without having to reset the Internet Information Server (IIS). Unlike other ECM Pro™ Web Services the FileReplace Web Service possesses a User Interface (UI), for ease of use and to foster an enhanced user experience.

Figure 2-1. FileReplace User Interface

For further information on the FileReplace UI and instructions on how to configure the FileReplace Web Service please refer to Chapter 4.

The FileReplace Web Service is utilized by the following three methods:

• ReplaceFiles - Replaces the files found in the New directory. This is the primary method of the FileReplace Web Service and is the method that will relocate all rate files the user wishes to replace.

• Query - Retrieves the file information for the files currently being used by the Optimizer (i.e., the IOCONTROL control program). This method will indicate which files are currently open and in use by the Optimizer. Files set to zero (0) will alert the user that the file is currently active.

• Search - Retrieves the file information for the files located in the New directory. This method indicates which files will be replaced by the


Op

FileReplace Web Service. The user will be able to see what files are out on the Server without connecting to the Server.

NoteFor a for further details on the layouts of the FileReplace Web Service methods please refer to Chapter 13.

The FileReplace Web Service Structure is illustrated below.


Op

Op

2.3 The OptimizerThe IRF Web Service uses a control program, the Optimizer (optcntl), which allows the web service methods to communicate with the various Optum EASYGroup™ components. The Optimizer invokes appropriate grouping, pricing, and editing logic based on a set of user-defined rules. The Optimizer works with these rules and an integrated collection of EASYGroup™ components to provide customized grouping, pricing, and modeling functions. The Grouper and Pricer programs and associated data files are licensed individually and are provided on separate distributions. The Optimizer is described more fully in the EASYGroup™ User’s Guide.

The user-defined rules for grouping and pricing are specific to a facility (i.e., hospital or provider), payer (i.e., line of business or provider contract) and period of time. These rules are stored in files which also contain data to drive the pricing functions.

2.4 Alternate Rate PathsThe IRF Web Service allows the customer to reference an alternate set of rate data, which can reside in a directory other than the default rate data directory, which is generally: C:\\inetpub\wwwroot\HSS\data. Each method requiring the use of rate data (the data files that are maintained using Rate Manager, referenced above) includes an optional input variable rate path for the full qualified directory path; where Rate Manager rate and configuration files are stored.

NotePlease note that the length of the “path” environment variable must be within the limits of the operating system being used; this can vary from 1024 and 2048 characters (depending on the version and service pack).


Op

2.5 EASYGroup™ ComponentsThe IRF Web Service invokes the Optimizer, which in turn invokes the appropriate EASYGroup™ components. These are separately licensed modules that implement CMG assignment (Groupers) and reimbursement calculations (Pricers). Each of the various EASYGroup™ components are managed by the Optimizer.

The relationships between the IRF Web Service methods and EASYGroup™ components are as follows:

• CMGPrice: This method utilizes the IRF Pricer and the rate data files from Rate Manager.

• CMGGroupPrice: This method utilizes the IRF Grouper, IRF Pricer, and the rate data files from Rate Manager.

• CMGEditGroupPrice: This method utilizes the DSC Editor, IRF Grouper, IRF Pricer, and the rate data files from Rate Manager.

• CMGEdit: This method utilizes the DSC Editor.

• CMGEditMessages: This method utilizes the DSC Editor.

• CMGEditSummary: This method utilizes the DSC Editor.

• UB04_GetGroupPriceRules: This method utilizes the EASYGroup™ control programs and the rate data files from Rate Manager.

• UB04_GetPayerList: This method utilizes the EASYGroup™ control programs and the rate data files from Rate Manager.

2.6 Rate ManagerThe Optimizer references external data files that contain processing rules for various facilities, payers, and effective dates. Inpatient rehabilitation data, editing, grouping, and pricing rules are stored in three data files: a Configuration File (config.dat), a Payer File (payirf.dat), and a Hospital Rate Calculator File (medirf.dat). These files are created and maintained using Rate Manager. Procedures for installing and using the Rate Manager are detailed in the Rate Manager Installation Guide and the Rate Manager User’s Guide.

Rate Manager provides a user friendly front-end to collect, edit, and maintain the facility and payer-specific variables required by the IRF Web Service pricing methods. This pricing data is stored in the config.dat, medirf.dat and payirf.dat files for inpatient rehabilitation processing. An additional file (rateirf.dat), with DRG-specific rate data such as weights and means, is required for pricing. This file is also created and maintained using Rate Manager.


Op

2.7 Hardware/Software RequirementsTo use the ECM Pro™ IRF Web Service, your operating environment must meet or exceed the following hardware and software requirements:

• Hardware

- Processor: 1GHz Pentium or equivalent (Minimum); 2.4GHz Dual Pentium (Recommended)

- RAM: 1GB (Minimum); 2GB or higher (Recommended)

- Hard Disk: 5 GB available space (Minimum); 10 GB available space (Recommended)

- Network Adapter: 100BASE-T (Minimum); 1000BASE-T (Recommended)

• Software

- Microsoft® Windows® Server 2008 (including R2) Service Pack 2 (SP2), 32-bit and 64-bit

- Microsoft® Windows® Server 2012 (including R2) Service Pack 2 (SP2), 64-bit

- Microsoft® Windows® Server 2016

- Microsoft® Windows® 7 Service Pack 1 (SP1), 64-bit

- Microsoft® .NET Framework V3.5 (Minimum); Microsoft® .NET Framework V4.6 Service Pack 1 (Recommended)

- Internet Information Services (IIS) V7.0, 7.5, 8.0, 8.5, and 10.0

NoteFor further information on installation requirements please refer to the EASYGroup™ Installation Guide.


Op

3 Installation


• General Description of Program Files

• Installing the Program

• Default Directory Structure

• Testing the IRF Web Service


Op

3.1 General Description of Program FilesThe IRF Web Service is comprised of a series of methods written in Microsoft® C# and distributed to run on the Microsoft® .NET platform and on Internet Information Server (IIS). These methods are distributed on a single distribution and loaded locally using an automated installation program. The Optimizer is included in the IRF Web Service distribution.

The individually licensed EASYGroup™ components (Groupers, Pricers, and Editors etc.) are distributed on separate distributions. These components are also loaded (after installing the IRF Web Service) using automated installation programs.

3.2 Installing the ProgramInstalling the IRF Web Service consists of the following tasks:

1. Installing the IRF Web Service.

2. Installing all licensed EASYGroup™ Grouping, Pricing, and Editing components.

3. If you are using any pricing methods, installing Rate Manager.

Details on completing these tasks are provided below.

3.2.1 Installing the IRF Web ServiceThe IRF Web Service installer (WS_IRF_Vnnnn.exe) will take users through the installation process and will prompt users to select a destination directory/folder for the methods (.asmx), the web service description file (.wsdl), the Optimizer (optcntl), and associated components.

NoteFor new installations, the IRF Web Service may be installed on drives other than the C: drive. Updates to previous installations, will re-install the IRF Web Service to the formerly identified location.

The steps below detail this installation process:

1. Download the IRF Web Service using the Optum Update Wizard or the Optum Client Portal. Double-click on the WS_IRF_Vnnnn.nn.exe file to invoke the installation sequence.

2. Install Shield will begin to prepare the wizard for the web service installation.

3. When the Install Shield is ready, the following Welcome screen will appear.



Op

Figure 3-1. Welcome Screen

4. Terminate the setup at anytime during the installation process by clicking on the Cancel button. To continue, click on the Next button to view the License Agreement.


Op

Figure 3-2. License Agreement Screen

5. To return to a previous step, simply click on the Back button at any time. Read the License Agreement completely. To continue with the setup process, select the I accept the license agreement, required to continue this install radio button and then select Next to agree with the terms specified.

6. Next, the Choose Destination Location screen will appear. To select a location other than the C: drive select the Browse button. Select Next when finished.

NoteThe Choose Destination Location screen will be displayed during new installations only.


Op

Figure 3-3. Choose Destination Location Screen

7. The Setup Status screen will now appear indicating the progress of the web service installation.


Op

Figure 3-4. Setup Status Screen: Installing Web Service Files

8. After installing the web service files, the Install Shield will then load the Microsoft® .NET framework which is required to run .NET-based web applications or services.


Op

Figure 3-5. Setup Status Screen: Configuring Virtual Directories

9. When the .NET framework has finished loading, the following screen will appear. Click on the Finish button to complete the installation/ setup process.


Op

Figure 3-6. Install Shield Wizard Complete Screen

NoteRefer to the Default Directory Structure section for details on the locations of all web service files.

3.2.2 Installing the Associated EASYGroup™ Component(s)Associated EASYGroup™ components are located on separate distributions. Follow the steps below for each EASYGroup™ component to be installed.

NoteAll associated EASYGroup™ component distributions MUST BE installed onthe machine that has the IRF Web Service installation.

1. Download the necessary EASYGroup™ components from the Optum Update Wizard or the Optum Client Portal.

2. Follow the on-screen prompts to complete the EASYGroup™ Server installation. The setup program will install the appropriate executables (*.dll) and data files in the folder containing the IRF Web Service.

3. When the installation process is complete, click Finish.



Op

3.2.3 Installing Rate ManagerRate Manager is supplied on a separate distribution to provide a means of defining and creating the payment systems that are used by the IRF Web Service.

1. Download Rate Manager from the Optum Update Wizard or from the Optum Client Portal.

2. Follow the on-screen prompts to complete the installation.

NoteIt is not necessary to load the Rate Manager program on the same machine that has the IRF Web Service installation. Typically, payment system files are copied to the IRF Web Service working directory after they have been created.

3. When the installation process is complete, click Finish.

4. Follow the instructions in the Rate Manager User’s Guide and Rate Manager Installation Guide to create the necessary payment systems, and then copy them to the working environment per the instructions detailed in Chapter 4.

NoteFor additional installation procedures for Rate Manager please refer to the Rate Manager Installation Guide.



Op

3.3 Default Directory StructureThe IRF Web Service components will be installed in the following directories (by default):

NoteUsers can select other install locations during the installation process.

C:\Inetpub\wwwroot\HSS\

\Data:This sub-directory contains all the data files required by the EASYGroup™ components including the data files utilized by the DSC Editor and also the data files built and exported by Rate Manager.

\Optimizer: This sub-directory contains the Optimizer and all the EASYGroup™ component executables for 32-bit.

\Optimizer64: This sub-directory contains the Optimizer and all the EASYGroup™ component executables for 64-bit.

\IRF: This sub-directory contains all of the IRF methods.

\FileReplace: This sub-directory contains the FileReplace Web Service.

\FileReplaceHelper: This sub-directory contains the FileReplace Helper .dll files which can be useful if multiple application pools are being utilized.

\FileReplaceUI: This sub-directory contains the files needed for the FileReplace Web Service User Interface (UI).

C:\Ratemgr: Rate Manager is installed in this directory.

NoteThe three directories listed above for the FileReplace Web Service will be assigned to the same application pool where the user’s current ECM Pro™ IRF Web Service is configured.


Op

3.4 Testing the IRF Web ServiceThe IRF Web Service distribution contains sample testing programs which accept patient data as input, and produce a basic listing of output fields. These programs can be used to validate your installation. The installation process will install all testing programs to the following directory path (by default):

C:\Inetpub\wwwroot\HSS\Testers

Before any testing, make sure to install the appropriate EASYGroup™ components, and load any Rate Manager data files into the appropriate web services Data directory, as specified above.

To test the UB04_GetGroupPriceRules or UB04_GetPayerList method, invoke the method directly (without use of a tester: //servername/hss/irf/irf.asmx). If the Rate Manager rate files are loaded correctly, if the facility and paysource identifiers are present, and a service date that matches the rules in the rate files is supplied, the UB04_GetGroupPriceRules method will return the processing rules for the applicable rate record. The UB04_GetPayerList method will return the payer numbers/names for the applicable facility. If input fields are incorrectly specified (i.e., data that will not match the rate data) or if the Rate Manager data files are not loaded properly, an error will be returned.

3.4.1 IRFTest ProgramTo run this sample tester, navigate to the following web address:

//servername/HSS/Testers/IRFTest/Test.aspx

Note“Servername” represents the name of the server on which the web service was installed.

To use this testing program to validate the CMGGroupPrice you must:

• Install at least one IRF Grouper

• Install at least one IRF Pricer

• Create a set of inpatient rehabilitation rate files (config.dat, payirf.dat, medirf.dat, rateirf.dat) which match your input test data.

To use this testing program to validate the CMGEditGroupPrice you must:

• Install the DSC Editor

• Install at least one IRF Grouper


• Create a set of inpatient rehabilitation rate files (config.dat, payirf.dat, medirf.dat, rateirf.dat) which match your input test data

To use this testing program to validate the CMGPrice you must:



Op

• Create a set of inpatient rehabilitation rate files (config.dat, payirf.dat, medirf.dat, rateirf.dat) which match your input test data.

To use this testing program to validate the CMGEdit, CMGEditMessages, and CMGEditSUmmary you must:

• Install the DSC Editor

3.4.2 Using the Test Program(s)If the calling program has been integrated with the web service(s), you can use these interactive testing programs to assist with validating your integration:

1. Create test cases, enter the patient claim data into the calling program, and invoke the web service.

2. Open the appropriate *.aspx file for the method(s) to be tested. Input the same claim data into the fields provided, and invoke the tester to provide results.

3. Compare the results from the tester to the results from the calling programs integration. Results should match exactly.


Op

4 Integration

After installing the IRF Web Service and any associated EASYGroup™ components, the calling application will need to be modified to invoke this service. Typically, integration of the IRF Web Service with a host application involves the following steps:

1. Create grouping/pricing rate files (using Rate Manager).

2. Move rate files to working environment.

3. Assemble the required input data.

4. Determine how to handle the return data.

5. Create the appropriate calls to the web service.


• Creating the IRF Rate Files

• Integrating the IRF Rate Files

• Configuring the FileReplace Web Service

• Preparing the Input Data

• Handling the Return Data

• Data Formatting Conventions

• Integrating the Service

• Enabling Enhanced Web Security


Op

4.1 Creating the IRF Rate FilesUse Rate Manager to create the following rate files:

• payirf.dat (Payer File)

• medirf.dat (Hospital Rate Calculator File)

• rateirf.dat (weights and means file)

• config.dat (Configuration File (including grouping, pricing, and editing rules))

Procedures for installing and using Rate Manager, and for exporting the rate files in the C/Windows® Optimizer format that is required for use with web services, are detailed in the Rate Manager User’s Guide and the Rate Manager Installation Guide.

4.2 Integrating the IRF Rate FilesAfter creating the rate files, copy them to the IRF Web Service Data directory on the designated web server. When default directories are specified during the installation process, this directory will be:

C:\Inetpub\wwwroot\HSS\Data

4.3 Configuring the FileReplace Web ServiceThe FileReplace Web Service can be used to allow the IRF rate files to be replaced on the web server without performing an IIS reset. Use of the FileReplace Web Service is optional. To use this Web Service, complete the following steps:

1. Manually create two folders named: New and Old in the \\inetpub\wwwroot\hss\Data directory (or other user-selected location where rate files are stored).

NoteThe above step only needs to be completed the first time that the FileReplace Web Service is utilized.

2. Copy the updated rate files into the New folder.

3. Access the FileReplace Web Service User Interface (UI) available at this location http://<servername>/HSS/FileReplaceUI/FileReplaceUI.aspx.


Op

Figure 4-1. FileReplace User Interface (UI)

4. Enter or Select the path that contains the currently in-use rate files that

you would to replace, by selecting the Browse button next to the Rate Path field or by using the Search Tree on the right-hand side of the screen.


Op

Figure 4-2. Search Tree

Figure 4-3. Enter Rate Path

5. Once a directory is selected, enter any notes in the Notes section that you would like to be saved in the FileReplace.log file. Notes will appear as shown below in the FileReplace.log file.

Figure 4-4. Example of Notes Shown in FileReplace.log File

6. Next, select the File Replace button; which will invoke the FileReplace Web Service.

7. The updated rate files will then be moved to the New directory into the directory specified on page 33.

8. The replaced files will be moved into the Old directory to preserve rate history.

9. The logging information will be displayed in the File Replace Log section of the screen. An example is shown below.


Op

Figure 4-5. File Replace Log Screen

10. A FileReplace.log file will also be created in the root Data directory.


Op

Figure 4-6. Example of FileReplace.log File

11. Once the All files replaced! message is displayed, the updated rate files are now available for claims processing.


Op

Figure 4-7. All Files Replaced Message in UI

4.4 Preparing the Input DataInpatient rehabilitation processing typically requires basic demographic and claim-related data including patient age or date of birth, patient sex, admission and discharge dates, discharge disposition, and total covered charges. In addition, impairment group and the individual cognitive and motor scores are required for CMG assignment. Users also have the ability to submit the HIPPS code containing the CMG on the service line, instead of supplying the impairment group, cognitive scores, and motor scores. Finally, all of the ICD-10-CM/PCS diagnosis codes and procedure codes available for the inpatient rehabilitation episode should be submitted to the service for accurate pricing.

Correct CMG-based processing requires that all inpatient rehabilitation services provided to the same patient during the hospital episode be included on a single claim. Split or interim bills, or multiple bills with overlapping claim spans, may not be priced correctly.

Typically, all the required data elements are present on a standard IRF claim.

4.5 Handling the Return DataThe returned information from the IRF Web Service will depend on the method invoked. Typically, the results may include CMG and pricing information. This information must be stored in data files or presented to the user via screens or reports.


Op

4.6 Data Formatting ConventionsThe following conventions are used for input and returned parameters for all ECM Pro™ Web Services:

4.6.1 Input Fields

NoteFor all input fields, all leading and trailing spaces are removed prior to any other action.

• Text. Any leading or trailing spaces will be removed. Maximum length provided below.

• Fixed length text. Text string, leading spaces removed, required length provided below. If required length is not provided, spaces will be added on the right.

• Numeric text. Treat as fixed length text. Leading zeros required. Required length provided below. All case-mix indicators (DRG, MDC, APC, APG, CMG) should be treated as numeric text. If required length is not provided, zeros will be added on the left.

• Integers. Numeric fields without decimals. Leading zeros not required. Maximum size provided below.

• Dollars. Leading zeros not required. Decimal not required. If no decimal is supplied, input is assumed to be in whole dollars. If decimal is supplied, zeros will be added on the right if necessary (e.g. 1.00, 1.50). Maximum size for all dollar fields is 9(8).99.

• Decimals. Leading zeros not required. Exact number of digits after the decimal is specified below. Maximum number of digits before the decimal is specified below. Decimal not required. If no decimal is supplied, decimal will be assumed based on field specifications below. If decimal is supplied, zeros will be added on the right if necessary.

• ICD-9-CM codes. Left-justified. Decimals not required but may be submitted. Maximum length is six bytes.

• ICD-10-CM codes. Left-justified. Decimals not required but may be submitted. Maximum length is eight bytes with decimal.

• ICD-10-PCS codes. Left-justified. Decimals not permitted. Maximum length is seven bytes.

• HCPCS or HIPPS codes. Five alphanumeric characters, no decimals.

• Dates. Eight digits, yyyymmdd format.

• Boolean. Numeric switch variable, 1=yes/true, 0=no/false.


Op

4.6.2 Output Fields• Text. Any leading or trailing spaces will be removed. Maximum length

provided below. A blank result will be returned as an empty string.

• Fixed length text. Text string, leading spaces removed.

• Numeric text. Treat as fixed length text. Leading zeros included. All case-mix indicators (DRG, MDC, APC, APG, CMG) will be treated as numeric text.

• Integers. Numeric fields without decimals. Leading zeros not included. Maximum size provided below. All error counts will be treated as integers.

• Dollars. The web service pricing operations will return dollar fields (marked here with a $$) without leading zeros, with explicit decimals, followed by two digits including any trailing zeros (e.g. 125.62 or 12.50 or 1250.00), and zero dollars will be returned as 0.00. Maximum size for all dollar fields is 9(8).99.

• Decimals. Leading zeros not required. Decimal will be included, plus the exact number of digits after the decimal, and up to the maximum number of digits before the decimal, as specified below.

• ICD-9-CM codes. Left justified. Decimals will be supplied. Maximum length is six bytes.

• ICD-10-CM codes. Left-justified. Decimals will be supplied. Maximum length is eight bytes.

• ICD-10-PCS codes. Left-justified. Maximum length is seven bytes.

• HCPCS or HIPPS codes. Five alphanumeric characters, no decimals.

• Error codes. These will be returned as fixed length numeric fields. Required length is supplied below.

• Error messages. These will be returned as text fields. Format of error messages includes the error code, a space, plus a text description. Error codes will be numeric text fields, with a required length specified below. For the descriptions, no maximum length is specified, but error descriptions are supplied below.

• Repeating error codes. For error arrays (claim level, admit diagnosis, diagnosis and procedure-related errors), only errors (non-zero entries) will be returned. The number of errors returned will equal the supplied error count. (For example, claim level errors can occur up to 15 times. If the claim level error count is 3, the returned data will include 3 non-zero entries but will not include 12 entries of zeros.

• Repeating error messages. For error message arrays (claim level, admit diagnosis, diagnosis and procedure-related errors), only errors (non-blank entries) will be returned. The number of errors returned will equal the supplied error count. (For example, claim level errors can occur up to 15


Op

times. If the claim level error count is 3, the returned data will include 3 messages only.)

• Negative numeric or decimal fields. These will be returned with an explicit negative sign (e.g. -450.25).

4.7 Integrating the ServiceIntegration of web services into a client application generally consists of the following steps. Note that this user’s guide assumes familiarity with the architecture and use of web services.

1. Discovering and Gathering Information about the Service. Browse to the IRF.asmx file in the \IRF folder (using default installation options, this will be C:\Inetpub\wwwroot\HSS\IRF. The HTML Description Page is displayed. This page provides the information required to request the web service and test the methods in the service. Select the Service Description on the page or navigate to *asmx/WSDL (with the appropriate address). An XML formatted file is displayed which describes the mechanism for providing the service to any client using SOAP or HTTP.

2. Generating a Proxy Class of the Service and Using the Created Proxy Class to Invoke an Available Service. To serialize and de-serialize SOAP messages for various transport protocols, create proxy or “stub” objects, using web application development tools that are specific to the appropriate application development and run-time environment.

3. Writing an Interface for the Web Service. Creating an instance of the generated proxy class provides access to all the methods of the IRF Web Service. The appropriate arguments have to be provided for each chosen operation, and each desired operation must be invoked. The results of the requested operation are returned to the client application and become available for further processing.

4.8 Enabling Enhanced Web SecurityIf you wish to enable Internet Information Services (IIS) Digest and Windows Authentication for the IRF Web Services and Web Services Tester you may do so by following the below instructions. Once these features are enabled, you will be prompted to log-in with a user name and password when launching the Web Services Tester. Once logged in, the same credentials will pass to the IRF Web Service. The Windows Authentication feature will allow you to be connected immediately to the Web Services Tester if you are already logged into Microsoft® Windows®.


Op

NoteThese instructions are optional, but Optum strongly suggests that they are implemented to fully secure the Tester.For further information on how to use the Tester please refer to Chapter 3.

1. Navigate to Start>Control Panel> Program and Features.

2. Select Turn Windows features on or off from the menu on the left-hand side of the screen.

Figure 4-8. Program and Features Screen

3. You should now see the Windows Features screen. In this screen, select the check box next to Internet Information Services (IIS) and expand the options, as shown below.


Op

Figure 4-9. Windows Features Screen

4. Check the boxes next to Basic Authentication, Digest Authentication, and Windows Authentication (if desired).

5. Select OK when complete.

6. Open the IIS Manager: Start>Control Panel>Administrative Tools>Internet Information Services (IIS).

7. Once you have the IIS Manager screen open, select Authentication from the main window.


Op

Figure 4-10. Authentication Option

8. You should now see the Authentication window.

Figure 4-11. Enable Digest Authentication for the Web Services Tester


Op

9. In this window enable Digest Authentication for the Web Services Tester as shown above.

10. Do the same for the IRF Web Service, as shown below.

Figure 4-12. Enable Digest Authentication for the IRF Web Services

11. Once Digest Authentication has been enabled for both the Web Services Tester and the IRF Web Service, you will be prompted for a user name and password once the Web Services Tester is launched.


Op

Figure 4-13. Log-in Dialog Box

12. Next, navigate back to the Authentication window and enable Windows Authentication (if desired) for the IRF Web Service, as shown below.


Op

Figure 4-14. Enable Windows Authentication for the IRF Web Services

13. Do the same for the Web Services Tester, as shown below.


Op

Figure 4-15. Enable Windows Authentication for the Web Services Tester

14. Once the above steps are completed, you will immediately be connected once you launch the Web Services Tester if you are already logged into Microsoft® Windows®. Your credentials will automatically pass from the Web Service Tester to the IRF Web Service.

NoteOnce the above features have been enabled you will need to re-start Windows® for them to take affect.


Op

5 CMGPrice

NoteAlthough most fields are designated as string variables, select fields are considered arrays of string variables, and are identified by the [ ] symbol at the end of the variable name. Also note that the variable formats listed in this chapter are the COBOL-type definitions which identify the maximum field length or precision required by the EASYGroup™ components. For web service requests, please conform to standard web service parameter passing conventions, the field definitions in the ASMX and WSDL files, and the input and output parameter data formatting conventions described in Chapter 4.


• CMGPrice Request

• CMGPrice Responses

• CMGPrice Pricer Responses


Op

5.1 CMGPrice RequestThe CMGPrice method has the following input structures:

• pcb1 (refer to Table 14-1 on page 115)


• gob1 (refer to Table 14-7 on page 130)

• diagnoses [ ]

• line [ ] (refer to Table 14-3 on page 121)

• Dx_Entry [ ] (refer to Table 14-6 on page 128)

Other input:

• rate_path

• user_path

Table 5-1: User Path and Rate Path

Field Description Format Variable Name Notes

Rate Path string rate_path Optional specification of directory containing alternate rate data. Supply the fully qualified rate path including drive letter.

User Path string user_path When defined, the User Path overrides the System Path. This path should be set when EASYGroup™ product files (e.g., dxopfile.dat, etc.) resides in a location that was not defined during the installation or within the System Path. The EASYGroup™ programs will utilize the product files residing at this User Path location.


Op

5.2 CMGPrice Responses

5.3 CMGPrice Pricer Responses

Table 5-2: CMGPrice Responses (CMGPriceResult)


Optimizer Return Code

NoteThis field is no longer utilized and has been replaced by the Optimizer Return Code field (opt_rtn_code).

9(2) optimizer_return_code

00 = Reserved

Table 5-3: CMGPrice Pricer Responses (CMGPriceResults)


Pricer Return Code X(2) pricer_return_code

00 = No errors encountered01 = No hospital rate calculator record02 = No CMG rate record03 = Reserved04 = Invalid pricer type05 = Invalid or missing thrudate06 = LOS value required, must be > 007 = LOS < (thrudate - fromdate) and non-

interrupted stay08 = Discharge status missing09 = CMG/HIPPS code missing or invalid10 = RIC code invalid11 = CMC/HIPPS ALOS is missing; required

for transfer calculations16 = Invalid ALC Days/Interrupted Days18 = Invalid Occurrence Span Date23 = Invalid service date or out of range25 = Non-Payment Claim27 = Wrong Procedure Performed45 = Assessment date is missing62 = Closed or inactive rate record87 = Program cannot be loaded

Pricer Type X(2) pricer_type 90 = Medicare IRF


Op

Payment Case-mix Group

9(4) payment_cmg Contains a payment-related CMG. The IRF PPS Pricer may change the CMG assigned by the Grouper. The Pricer assigns new CMGs for short stays and expired cases.

Generally (CMG < 5001), format is XXYY, where:XX = RICYY = Subgroup within RIC

Payment HIPPS Code

X(5) payment_hipps Health Insurance Prospective Payment System (HIPPS) code returned by the Pricer, in format XYYYY, where:X = Comorbidity tierYYYY = Payment CMG

Left-justified, blank-filled.

The Pricer may change the HIPPS code assigned by the Grouper for short stays and expired cases.

Base PPS Payment Rate for the Case

9(8)v9(2)

base_reimbursement

Base reimbursement for the claim under the IRF PPS. Blend percentage, if applicable, has been applied.

Outlier Add-on 9(8)v9(2)

outlier_addon Outlier payment for the claim. Blend percentage, if applicable, has been applied.

Total PPS Payment 9(8)v9(2)

pps_total Total PPS payment for the claim. Equal to (base + addon). Blend percentage, if applicable, has been applied.

Total Facility-Specific Payment

9(8)v9(2)

facility_payment For January 2002 through September 2002, IRF payments are a blend of the new PPS payment and the facility-specific pre-PPS TEFRA payment. This field shows the anticipated facility-specific payment for the claim.

Penalty Amount 9(8)v9(2)

penalty If IRF-PAI assessment data are transmitted 28 calendar days or more from the date of discharge (with the discharge date itself starting the counting sequence) a payment penalty is applied. Penalties apply to the IRF PPS portion of the payment only, and reduce the PPS payment by a specified percentage. This field contains the dollar amount of any applicable penalty.

Total Reimbursement 9(8)v9(2)

total_reimbursement

Total reimbursement for the case. Equal to (ppstot + factot - penalty)

Payment Flag 9(2) payment_flag 00 = CMG-based case payment 01 = Transfer 02 = Short stay case 03 = Expired case

Cost Outlier Flag 9(1) outlier_flag 0 = Not an outlier 1 = Qualifies for a cost outlier payment




Op

Transfer Flag 9(2) transfer_flag 00 = Not a transfer01 = Paid using CMG-specific per diem02 = Payment capped at CMG payment rate

Blend Percentage 9(1)v9(5)

blend_factor For January 2002 through September 2002, IRF payments are a blend of the new PPS payment and the facility-specific pre-PPS TEFRA payment. This field shows the percentage reimbursed under the new IRF PPS payment rules.

Format: 9(1)v9(5), with 1.00000 equals 100%.

Penalty Flag 9(1) penalty_flag 0 = No penalties were applied to this claim.1 = IRF-PAI assessment data were

transmitted 28 calendar days or more from the date of discharge (with the discharge date itself starting the counting sequence).

Penalty Percentage 9(1)v9(5)

penalty_percent If IRF-PAI assessment data are transmitted 28 calendar days or more from the date of discharge (with the discharge date itself starting the counting sequence) a payment penalty is applied. Penalties apply to the IRF PPS portion of the payment only, and reduce the PPS payment by a specified percentage. This field contains the percentage the facility was penalized.


HIPPS Weight Used for Payment

9(3)v9(5)

weight Relative weight for payment HIPPS code. Based on “payment CMG” and comorbidity tier.

HIPPS Code Average Length of Stay

9(3)v9(4)

average_length_of_stay

Average length of stay for payment HIPPS code. Based on “payment CMG” and comorbidity tier. Used to price transfer cases.

Charges Used in Outlier Calculations

9(8)v9(2)

outlier_charges Charges used to determine applicable cost outlier payments.

Cost Outlier Threshold for Payment HIPPS Code

9(8)v9(2)

outlier_threshold

Outlier threshold for this case. Equal to the CMG payment for the case, plus a facility-adjusted fixed outlier threshold.




Op

Assessment Transmission Date

9(8) tdate YYYYMMDDWhere: YYYY = Year including century MM = Month - 01-12 DD = Day - 01-31

Date the final IRF-PAI assessments were transmitted to the CMS National Assessment Collection Database. If IRF-PAI assessment data are transmitted 28 calendar days or more from the date of discharge (with the discharge date itself counting as day one) a payment penalty is applied.




Op

6 CMGGroupPrice



• CMGGroupPrice Request

• CMGGroupPrice Responses

• CMGGroupPrice Grouper Claim Responses

• CMGGroupPrice Grouper Line Responses

• CMGGroupPrice Pricer Responses


Op

6.1 CMGGroupPrice RequestThe CMGGroupPrice method has the following input structures:



• diagnoses [ ]

• line [ ] (refer to Table 14-3 on page 121)

• Dx_Entry [ ] (refer to Table 14-6 on page 128)

Other input:

• rate_path

• user_path






Op

6.2 CMGGroupPrice Responses

Table 6-2: CMGGroupPrice Responses (CMGGroupPriceResult)





00 = Reserved


Op

6.3 CMGGroupPrice Grouper Claim Responses

Table 6-3: CMGGroupPrice Grouper Claim Responses (CMGGroupClaimResults)


Grouper Return Code

X(2) grouper_return_code

00 = No errors01 = No CMG match02 = Not used03 = Not used04 = Not used05 = Computed age is greater than 140

years 06 = Submitted age is invalid 07 = Birth date before admission date/from

date08 = Invalid birth date09 = Invalid admission date/from date10 = Self care, eating (FIM39A, admission

value) is out of range11 = Self care, grooming (FIM39B,

admission value) is out of range12 = Self care, bathing (FIM39C, admission

value) is out of range13 = Self care, dressing, upper body

(FIM39D, admission value) is out of range

14 = Self care, dressing, lower body (FIM39E, admission value) is out of range

15 = Self care, toileting (FIM39F, admission value) is out of range

16 = Sphincter control, bladder management (FIM39G, admission value) is out of range

17 = Sphincter control, bowel management (FIM39H, admission value) is out of range

18 = Transfers, bed, chair, wheelchair (FIM39I, admission value) is out of range

19 = Transfers, toilet (FIM39J, admission value) is out of range

20 = Locomotion, walk/wheelchair (FIM39L, admission value) is out of range

continued below...


Op

Grouper Return Code<continued>


21 = Locomotion, stairs (FIM39M, admission value) is out of range

22 = Comprehension (FIM39N, admission value) is out of range

23 = Expression (FIM39O, admission value) is out of range

24 = Social interaction (FIM39P, admission value) is out of range

25 = Problem solving (FIM39Q, admission value) is out of range

26 = Memory (FIM39R, admission value) is out of range

27 - 35 = Not currently in use36 = One or More Admission Motor Scores

Out of Range37 = Impairment group code is invalid38 = Total motor score, admission, out of

range39 = Total cognitive score, admission, out of

range62 = Closed or inactive rate record87 = Program cannot be loaded

Grouper Type X(2) grouper_type 90 = Medicare IRF CMG

Grouper Version 9(2) grouper_version Two-digit Grouper version number.

Rehabilitation Impairment Category (RIC)

9(2) ric Required for IRF pricing to identify orthopedic and non-orthopedic cases for pricing of expired cases. Valid values range from 01 to 21.

Case-mix Group (CMG)

9(4) cmg Contains a clinically-related CMG. For Version 08 of the IRF Grouper, there are 87 clinically-related CMGs with valid values ranging from 0101 to 2102.

Format is XXYY, where:XX = RICYY = Subgroup within RIC

HIPPS code X(5) hipps Health Insurance Prospective Payment System (HIPPS) code, in format XYYYY, where: X = Comorbidity Tier YYYY = “Original CMG”


ICD-10 Comorbidity Code Used for HIPPS Assignment

X(10) comorbid_condition

First input comorbidity code that is at the highest comorbidity tier for the case.

Returned only if assessment data was provided.




Op

FIM Admission Motor Score – Calculated

9(3)v9(3) motor_out Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. (Note: IRF-PAI field 39K, “Transfers to Tub, Shower” is not currently used for CMG assignment). If input field “motor” is zero, IRF Grouper calculates and returns this field.

Note that when totaling individual IRF-PAI scores, values of “00” default to “01”, except for 39J which defaults to “02”.

To determine if this field was calculated or transferred directly from input, refer to the motor_flag field.


FIM Admission Motor Score Flag

9(1) motor_out_flag 0 = Contents of output field were transferred directly from input “motor” score field

1 = Total admission “motor” score was calculated


FIM Admission Cognitive Score – Calculated

9(3)v9(3) cognitive_out Sum of IRF-PAI fields 39N through 39R. If input “cogn” field is zero, IRF Grouper calculates and returns this field. Valid values range from 5 to 35. Note that when totaling individual IRF-PAI scores, values of “00” default to “01.”

To determine if this field was calculated or transferred directly from input, refer to the cogn_flag field.


FIM Admission Cognitive Score Flag

9(1) cognitive_out_flag

0 = Contents of output field were transferred directly from input “cogn” score field

1 = Total admission “cogn” score was calculated





Op

FIM Admission MotorScore – Calculated

9(3)v9(3) motor_out2 Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. When totaling individual IRF-PAI scores, values of “0” default to “1,” except for 39J which defaults to “2.” Valid values range from 12 to 84.

If input field motor is zero, the IRF Grouper will calculate and return this field. To determine if this field was calculated or transferred directly from input, refer to the motor_flag field.


NoteIRF-PAI field 39K (Transfers to Tub, Shower) is not currently used for CMG assignment.Prior to Version 4 of the IRF Grouper, this field should be entered as a 3-character field (999). For Version 4 and forward, this field will remain a 3-character numeric field but will now have an implied decimal for a tenth inaccuracy (99.9). For example, entering a value of 120 in this field would indicate that this claim has a total motor score of 12.0.

FIM AdmissionCognitive Score –Calculated

9(3)v9(3) cogn_out2 Total cognitive score calculated from IRF-PAI fields 39N through 39R. When totaling individual IRF-PAI scores, values of “0” default to “1”. Valid values range from 5 to35.

If input field cogn is zero, the IRF Grouper will calculate and return this field. To determine if this field was calculated or transferred directly from input, refer to thecogn_flag field.


ICD-10 ComorbidityCode used for HIPPSAssignment

X(10) comorbid_01 Comorbidity code that is at the highest comorbidity tier for the case. Returned only if assessment data was provided.




Op

6.4 CMGGroupPrice Grouper Line Responses

6.5 CMGGroupPrice Pricer Responses

Second ICD-10Comorbidity Code Used for HIPPS Assignment

X(10) comorbid_02 Diagnosis code with the highest comorbidity tier for the case that is also part of an ICD-10 code pair. Returned only if assessment data was provided.

Table 6-4: CMGGroupPrice Grouper Line Responses (CMGGroupLineResults [])


Comorbidity Tier for Input Diagnosis

X(1) comorbidity_tier For IRF EASYGroup™ only. For each input diagnosis, indication of comorbidity tier.

A = Not a comorbidity, or comorbidity excluded for RIC

B = Tier 1 comorbidity (high cost) C = Tier 2 comorbidity (medium cost) D = Tier 3 comorbidity (low cost)





Op

Table 6-5: CMGGroupPrice Pricer Responses (CMGPriceResults)





for transfer calculations16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date23 = Invalid service date or out of range25 = Non-payment claim27 = Wrong procedure performed45 = Assessment date is missing62 = Closed or inactive rate record87 = Program cannot be loaded





Payment HIPPS Code





9(8)v9(2)

base_reimbursement





Op




9(8)v9(2)





total_reimbursement













Op





9(3)v9(5)



9(3)v9(4)




9(8)v9(2)



9(8)v9(2)

outlier_threshold








Op

7 CMGEditGroupPrice



• CMGEditGroupPrice Request

• CMGEditGroupPrice Responses

• CMGEditGroupPrice Editor Claim Responses

• CMGEditGroupPrice Editor Diagnosis Responses

• CMGEditGroupPrice Editor Procedure Responses

• CMGEditGroupPrice Grouper Claim Responses

• CMGEditGroupPrice Grouper Line Responses

• CMGEditGroupPrice Pricer Responses


Op

7.1 CMGEditGroupPrice RequestThe CMGEditGroupPrice method has the following input structures:



• Dx_Entry (refer to Table 14-6 on page 128)

• Op_Entry (refer to Table 14-5 on page 127)

• line (refer to Table 14-3 on page 121)

• Edit_Request (refer to Table 14-2 on page 120)

Other input:

• rate_path

• user_path






Op

7.2 CMGEditGroupPrice Responses

7.3 CMGEditGroupPrice Editor Claim Responses

Table 7-2: CMGEditGroupPrice Responses (CMGEditGroupPriceResult)





00 = Reserved

Table 7-3: CMGEditGroupPrice Editor Claim Responses (EditResults)


Editor Return Code 9(2) editor_return_code

00 = No error01 = Insufficient memory02 = General processing error05 = Error opening edit table07 = Error reading edit table10 = HAC editor not found16 = Invalid ALC days/interrupted days 18 = Invalid occurrence span date87 = Program cannot be loaded

Editor Version 9(2) editor_version Reserved

Demographic Error Count

9(3) demographic_error_count

Count of total demographic errors encountered for the input record

Age Edit 9(1) demographic_age_invalid

0 = No error1 = Age invalid; not in range 0 - 124

Sex Edit 9(1) demographic_sex_invalid

0 = No error1 = Sex invalid; not 1 or 2, M or F

Discharge Disposition Edit

9(1) demographic_discharge_disposition_invalid

0 = No error1 = Invalid discharge disposition/patient

status

Birthweight Edit 9(1) demographic_birthweight_invalid

0 = No error1 = Invalid birthweight; not zero, not 9999,

not in range 100-9000 grams

Diagnosis Error Count

9(3) diagnosis_error_count

Count of total diagnosis errors encountered for the input record


Op

Principal Diagnosis Edit

9(1) principal_diagnosis_invalid

1 = E-code (ICD-9)/External Causes of Morbidity Code (ICD-10) as Principal Diagnosis

2 = Manifestation code as principal3 = Non-specific code as principal4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis;

requires secondary diagnosis

Principal Diagnosis/Surgery Edit

9(1) principal_diagnosis_suggests_surgery

0 = Not duplicate code1 = Principal diagnosis suggests surgery

Procedure Error Count

9(3) procedure_error_count

Count of total procedure errors encountered on the input record

Non-specific Procedure Edit

9(1) all_non_specific_procedures

0 = No error1 = All O.R. procedures coded are

nonspecific

Bilateral Coding Edit 9(1) multiple_bilateral_procedures

MDC 8 claims only.0 = No bilateral procedure present1 = Two or more different joint procedures

are present

Admit Diagnosis Invalid

9(1) admit_diagnosis_invalid

0 = No error1 = Code invalid; not found on table of valid

ICD-9-CM/ICD-10-CM codes2 = Invalid code, unnecessary 4th, 5th, 6th, or

7th digit3 = Invalid code, missing 4th, 5th, 6th, or 7th

digit4 = Code invalid; found on ICD-9-CM/ICD-

10-CM table, but not valid for patient’s admission/discharge date

5 = Invalid code for dates, unnecessary 4th, 5th, 6th, or 7th digit

6 = Invalid code for dates, missing 4th, 5th, 6th, or 7th digit

Admit Diagnosis Age/Sex

9(1) admit_diagnosis_age_sex_conflict

0 = No error1 = Age conflict; patient's age and

diagnosis are inconsistent2 = Sex conflict; patient's sex and diagnosis

are inconsistent3 = Age and sex conflict; patient's age and

sex are inconsistent with the patient's diagnosis

Admit Diagnosis Medicare as Secondary Payer Alert

9(1) admit_diagnosis_Medicare_secondary

0 = No error1 = Insurer may be secondary payer to Auto

Insurance, Workers’ Compensation, etc. (prior to October 1, 2001)

Admit Diagnosis Ecode/Manifestation Code

9(1) admit_diagnosis_Ecode_or_Manifestation_code

0 = No error1 = E-code as admit diagnosis2 = Manifestation code as admit diagnosis




Op

Total Number of Errors

9(4) toterr Total number of errors identified for this input record.

(demographic_error_count + diagnosis_error_count + procedure_error_count)




Op

7.4 CMGEditGroupPrice Editor Diagnosis Responses

Table 7-4: CMGEditGroupPrice Editor Diagnosis Responses (dscdxblk)


Invalid Diagnosis Edit 9(1) invalid 0 = No error1 = Code invalid; not found on table of valid



digit4 = Code invalid; found on ICD-9-CM/ICD




Duplicate of Principal Edit

9(1) duplicate_principal_diagnosis

0 = Not duplicate code1 = Code is duplicate of principal diagnosis

Age/Sex Diagnosis Edit

9(1) age_sex_conflict 0 = No error1 = Age conflict; patient's age and




Medicare as a Secondary Payer

9(1) medicare_secondary_payer

0 = No error1 = Insurer may be secondary payer to Auto Insurance, Workers' Compensation, etc.

Duplicate Secondary Edit

9(1) duplicate_secondary_diagnosis

0 = Not duplicate code1 = Code is duplicate of another secondary diagnosis

Present on Admission Edit

X(1) poa_invalid 0 = No errors1 = Present On Admission indicator

required but not submitted2 = Present On Admission indicator

required but is not valid3 = POA indicator invalid for this exempt

code on an electronic claim.4 = POA indicator invalid for this exempt

code on a paper claim.

Hospital-Acquired Condition Eligibility/Impact

9(1) haceligible 0 = Code is not subject to HAC1 = Code is HAC eligible; another CC/MCC

is present (DRG may not be affected)2 = Code is HAC eligible; but is not a CC/

MCC (DRG may not be affected)3 = Code is HAC eligible; no other CC/MCC

is present (DRG may be affected)


Op

Complication (CC) or Major Complication (MCC) Indicator

9(1) ccmccind 0 = Not a CC or MCC for DRG assignment1 = CC for DRG assignment2 = MCC for DRG assignment

Note: These indicators are based on Medicare's CC and MCC lists. During DRG assignment, certain codes on these lists are excluded by the Grouper as CCs or MCCs based on the principal diagnosis.

Hospital-Acquired Condition

9(4) hac Hospital Acquired Condition identified on this claim and not present on admission:0001 = Foreign Object Retained After

Surgery0002 = Air Embolism0003 = Blood Incompatibility0004 = Pressure Ulcer Stages III and IV0005 = Falls and Trauma0006 = Catheter-Associated Infection0007 = Vascular Catheter-Associated

Infection0008 = Surgical Site Infection, Mediastinitis

Following Coronary Artery Bypass Graft

0009 = Manifestations of Poor Glycemic Control

0010 = Deep Vein Thrombosis and Pulmonary. Embolism Following Certain Orthopedic Procedures

0011 = Surgical Site Infection Following Bariatric Surgery for Obesity

0012 = Surgical Site Infection Following Certain Orthopedic Procedures

0013 = Surgical Site Infection Following Cardiac Implantable Electronic Device

0014 = Iatrogenic Pneumothorax with Venous Catheterization

Present on Admission Bypassed

9(1) poa_bypassed MS-DRG (V26 or higher), TRICARE, Wisconsin Medicaid, APS-DRGs®, AP-DRG V18/V23/V24/V25/V26/V27, and APR-DRG:

1 = This code is eligible for bypass during DRG assignment because it is a HAC-designated condition/Never Event that was not present on admission.

2 = This code was bypassed during DRG assignment because it is a HAC-designated condition/Never Event that was not present on admission.

0 = Otherwise




Op

7.5 CMGEditGroupPrice Editor Procedure Responses

Wrong Procedure Flag

9(1) wrongpx 0 = No error1 = Code indicates that a wrong procedure

has been performed.

Diagnosis Type 9(3) type Reserved

Principal Diagnosis Errors

9(1) dx_pdx 1 = E-code (ICD-9)/External Causes of Morbidity Code (ICD-10) as Principal Diagnosis

2 = Manifestation code as principal3 = Nonspecific code as principal4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis;


Diagnosis/Surgery Edit

9(1) dx_pdx_surg Reserved

Admit Diagnosis E-Code/Manifestation Code

9(1) dx_admem 0 = No error1 = E-code as admit diagnosis2 = Manifestation code as admit diagnosis

Invalid Admit Diagnosis Code

9(1) admdx_invalid Reserved

Admit Diagnosis Sex/Age Edit

9(1) admdx_agesex Reserved

Medicare as Secondary Payer

9(1) admdx_msp Reserved

Table 7-5: CMGEditGroupPrice Editor Procedure Responses (dscopblk)


Invalid Procedure Edit Indicator

9(1) invalid 0 = No error1 = Code invalid; not found on table of

valid ICD-9-CM/ICD-10-CM codes2 = Invalid code, unnecessary 4th, 5th, 6th,

or 7th digit3 = Invalid code, missing 4th, 5th, 6th, or

7th digit4 = Code invalid; found on ICD-9-CM/

ICD-10-CM table, but not valid for patient’s admission/discharge date



Sex Conflict Edit Indicator

9(1) sex_conflict 0 = No error1 = Sex conflict; patient's sex and

procedure are inconsistent




Op

Non-Covered Edit Indicator

9(1) non_covered_or_open_biopsy

0 = Not “non-covered” and not an open biopsy

1 = Non covered procedure2 = Open biopsy code3 = Limited coverage procedure

Bilateral Code Edit 9(1) bilateral_code 0 = Not a bilateral procedure code1 = Bilateral procedure code

Closed Biopsy Code Indicator

X(7) closed_biopsy_code

Contains corresponding closed biopsy code when given procedure code is an open biopsy. Otherwise, it is blank.

Operating Room Indicator

9(1) operating_room_procedure

0 = Not typically performed in an operating room.

1 = Typically performed in an operating room

Procedure Inconsistent With Length of Stay Indicator

9(1) pilos 0 = No Error1 = Length of Stay and Procedure are

Inconsistent

Questionable Obstetric Admission Indicator

X(1) qobadm 0 = No error1 = Questionable obstetric admission

for this procedure

Table 7-5: CMGEditGroupPrice Editor Procedure Responses (dscopblk)



Op

7.6 CMGEditGroupPrice Grouper Claim Responses

Table 7-6: CMGEditGroupPrice Grouper Claim Responses (CMGGroupClaimResults)


Grouper Return Code

X(2) grouper_return_code 00 = No errors01 = No CMG match02 = Not used03 = Not used04 = Not used05 = Computed age is greater than 140














continued below...


Op


X(2) grouper_return_code 21 = Locomotion, stairs (FIM39M, admission value) is out of range






27 - 35 = Not currently in use36 = One or More Admission Motor Scores

Out of Range37 = Impairment group code is invalid38 = Total motor score, admission, out of



















Op


9(3)v9(3)

motor_out Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. (Note: IRF-PAI field 39K, “Transfers to Tub, Shower” is not currently used for CMG assignment). If input field “motor” is zero, IRF Grouper calculates and returns this field.









9(3)v9(3)

cognitive_out Sum of IRF-PAI fields 39N through 39R. If input “cogn” field is zero, IRF Grouper calculates and returns this field. Valid values range from 5 to 35. Note that when totaling individual IRF-PAI scores, values of “00” default to “01.”











Op


9(3)v9(3)

motor_out2 Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. When totaling individual IRF-PAIscores, values of “0” default to “1,” except for 39J which defaults to “2.” Valid values range from 12 to 84.





9(3)v9(3)

cogn_out2 Total cognitive score calculated from IRF-PAI fields 39N through 39R. When totaling individual IRF-PAI scores, values of “0” default to “1”. Valid values range from 5 to35.








Op

7.7 CMGEditGroupPrice Grouper Line Responses



Table 7-7: CMGEditGroupPrice Grouper Line Responses (CMGGroupLineResults)


Comorbidity Tier for Input Diagnosis

X(1) comorbidity_tier For IRF EASYGroup™ only. For each input diagnosis, indication of comorbidity tier.

A = Not a comorbidity, or comorbidity excluded for RIC

B = Tier 1 comorbidity (high cost) C = Tier 2 comorbidity (medium cost) D = Tier 3 comorbidity (low cost)





Op

7.8 CMGEditGroupPrice Pricer Responses

Table 7-8: CMGEditGroupPrice Pricer Responses (CMGPriceResults)





for transfer calculations16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date23 = Invalid service date or out of range25 = Non-payment claim27 = Wrong procedure performed45 = Assessment date is missing62 = Closed or inactive rate record87 = Program cannot be loaded





Payment HIPPS Code





9(8)v9(2)

base_reimbursement



Op






9(8)v9(2)





total_reimbursement













Op





9(3)v9(5)



9(3)v9(4)




9(8)v9(2)



9(8)v9(2)

outlier_threshold








Op

8 CMGEdit



• CMGEdit Requests

• CMGEdit Responses

• CMGEdit Editor Claim Responses

• CMGEdit Editor Diagnosis Responses

• CMGEdit Editor Procedure Responses


Op

8.1 CMGEdit RequestsThe CMGEdit method has the following input structures:






Other input:

• rate_path

• user_path






Op

8.2 CMGEdit Responses

8.3 CMGEdit Editor Claim Responses

Table 8-2: CMGEdit Responses (CMGEditResult)





00 = Reserved

Table 8-3: CMGEdit Editor Claim Responses (EditResults)








Age Edit 9(1) demographic_age_invalid


Sex Edit 9(1) demographic_sex_invalid


Discharge Disposition Edit

9(1) demographic_discharge_disposition_invalid

0 = No error1 = Invalid discharge disposition/patient

status

Birthweight Edit 9(1) demographic_birthweight_invalid

0 = No error1 = Invalid birthweight; not zero, not 9999,

not in range 100-9000 grams





Op




2 = Manifestation code as principal3 = Non-specific code as principal4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis;


Principal Diagnosis/Surgery Edit

9(1) principal_diagnosis_suggests_surgery





Non-specific Procedure Edit

9(1) all_non_specific_procedures

0 = No error1 = All O.R. procedures coded are

nonspecific

Bilateral Coding Edit 9(1) multiple_bilateral_procedures

MDC 8 claims only.0 = No bilateral procedure present1 = Two or more different joint procedures

are present

Admit Diagnosis Invalid









Admit Diagnosis Age/Sex

9(1) admit_diagnosis_age_sex_conflict

0 = No error1 = Age conflict; patient's age and




Admit Diagnosis Medicare as Secondary Payer Alert

9(1) admit_diagnosis_Medicare_secondary



Admit Diagnosis Ecode/Manifestation Code

9(1) admit_diagnosis_Ecode_or_Manifestation_code





Op







Op

8.4 CMGEdit Editor Diagnosis Responses

Table 8-4: CMGEdit Editor Diagnosis Responses (dscdxblk)


Invalid Diagnosis Edit 9(1) invalid 0 = No error1 = Code invalid; not found on table of valid







Duplicate of Principal Edit

9(1) duplicate_principal_diagnosis


Age/Sex Diagnosis Edit

9(1) age_sex_conflict 0 = No error1 = Age conflict; patient's age and




Medicare as a Secondary Payer

9(1) medicare_secondary_payer

0 = No error1 = Insurer may be secondary payer to Auto Insurance, Workers' Compensation, etc.

Duplicate Secondary Edit

9(1) duplicate_secondary_diagnosis

0 = Not duplicate code1 = Code is duplicate of another secondary diagnosis

Present on Admission Edit






Hospital-Acquired Condition Eligibility/Impact






Op










0010 = Deep Vein Thrombosis and Pulmonary. Embolism Following Certain Orthopedic Procedures









0 = Otherwise




Op


9(1) wrongpx 0 = No error1 = Code indicates that a wrong procedure has been performed.

Diagnosis Type 9(3) type Reserved


9(1) dx_pdx 1 = E-code (ICD-9)/External Causes of Morbidity Code (ICD-10) as Principal Diagnosis




9(1) dx_pdx_surg Reserved


9(1) dx_admem 0 = No error1 = E-code as admit diagnosis2 = Manifestation code as admit diagnosis


9(1) admdx_invalid Reserved


9(1) admdx_agesex Reserved

Medicare as Secondary Payer

9(1) admdx_msp Reserved




Op

8.5 CMGEdit Editor Procedure Responses

Table 8-5: CMGEdit Editor Procedure Responses (dscopblk)



9(1) invalid 0 = No error1 = Code invalid; not found on table of

valid ICD-9-CM/ICD-10-CM codes2 = Invalid code, unnecessary 4th, 5th, 6th,

or 7th digit3 = Invalid code, missing 4th, 5th, 6th, or

7th digit4 = Code invalid; found on ICD-9-CM/

ICD-10-CM table, but not valid for patient’s admission/discharge date



Sex Conflict Edit Indicator

9(1) sex_conflict 0 = No error1 = Sex conflict; patient's sex and


Non-Covered Edit Indicator

9(1) non_covered_or_open_biopsy


1 = Non covered procedure2 = Open biopsy code3 = Limited coverage procedure

Bilateral Code Edit 9(1) bilateral_code 0 = Not a bilateral procedure code1 = Bilateral procedure code

Closed Biopsy Code Indicator

X(7) closed_biopsy_code

Contains corresponding closed biopsy code when given procedure code is an open biopsy. Otherwise, it is blank.

Operating Room Indicator

9(1) operating_room_procedure

0 = Not typically performed in an operating

room.1 = Typically performed in an operating

room

Procedure Inconsistent With Length of Stay Indicator

9(1) pilos 0 = No Error1 = Length of Stay and Procedure are

Inconsistent

Questionable Obstetric Admission Indicator

X(1) qobadm 0 = No error1 = Questionable obstetric admission

for this procedure


Op

9 CMGEditMessages



• CMGEditMessages Requests

• CMGEditMessages Editor Claim Responses

• CMGEditMessages Editor Diagnosis Responses

• CMGEditMessages Editor Procedure Responses


Op

9.1 CMGEditMessages RequestsThe CMGEdit method has the following input structures:






Other input:

• rate_path

• user_path






Op

9.2 CMGEditMessages Editor Claim Responses

Table 9-2: CMGEditMessages Editor Claim Responses (CMGEditMessages)




9(2) CMGMessages_return_code

00 = Reserved







Age Message string demographic_age_invalid_message


Sex Message string demographic_sex_invalid_message


Discharge Disposition Message

string demographic_discharge_disposition_invalid_message

0 = No error1 = Invalid discharge disposition/patient status

Birthweight Message string demographic_birthweight_invalid_message

0 = No error1 = Invalid birthweight; not zero, not 9999, not

in range 100-9000 grams





Op




2 = Manifestation code as principal3 = Non-specific code as principal4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis; requires

secondary diagnosis

Principal Diagnosis Message

string principal_diagnosis_invalid_message


2 = Manifestation code as principal3 = Non-specific code as principal4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis; requires

secondary diagnosis

Principal Diagnosis/Surgery Message

string principal_diagnosis_suggests_surgery_message





Non-Specific Procedure Message

string all_non_specific_procedures_message

0 = No error1 = All O.R. procedures coded are nonspecific

Bilateral Coding Message

string multiple_bilateral_procedures_message

MDC 8 claims only.0 = No bilateral procedure present1 = Two or more different joint procedures are

present

Admit Diagnosis Invalid Edit



ICD-9-CM/ICD-10-CM codes2 = Invalid code, unnecessary 4th, 5th, 6th, or 7th

digit3 = Invalid code, missing 4th, 5th, 6th, or 7th digit4 = Code invalid; found on ICD-9-CM/ICD-10-

CM table, but not valid for patient’s admission/discharge date






Op

Admit Diagnosis Invalid Message

string admit_diagnosis_invalid_message


ICD-9-CM/ICD-10-CM codes2 = Invalid code, unnecessary 4th, 5th, 6th, or 7th

digit3 = Invalid code, missing 4th, 5th, 6th, or 7th digit4 = Code invalid; found on ICD-9-CM/ICD-10-

CM table, but not valid for patient’s admission/discharge date



Admit Diagnosis Age/Sex Message

string admit_diagnosis_age_sex_conflict_message

0 = No error1 = Age conflict; patient's age and diagnosis

are inconsistent2 = Sex conflict; patient's sex and diagnosis

are inconsistent3 = Age and sex conflict; patient's age and sex

are inconsistent with the patient's diagnosis

Admit Diagnosis Medicare as Secondary Payer Alert Message

string admit_diagnosis_Medicare_secondary_message



Admit Diagnosis Ecode/Manifestation Code Message

string admit_diagnosis_Ecode_or_Manifestation_code_message








Op

9.3 CMGEditMessages Editor Diagnosis Responses

Table 9-3: CMGEditMessages Editor Diagnosis Responses (dscdxblkmsg)


Invalid Diagnosis Edit 9(1) invalid 1 = Code invalid; not found on table of valid ICD-9-CM codes

2 = Invalid code, unnecessary 4th/5th digit3 = Invalid code missing 4th/5th digit4 = Code invalid; found on ICD-9-CM table,

but not valid for patient’s admission/discharge date

5 = Invalid code for dates, unnecessary 4th/5th digit

6 = Invalid code for dates, missing 4th/5th digit

Invalid Diagnosis Message

string invalid_message 1 = Code invalid; not found on table of valid ICD-9-CM codes

2 = Invalid code, unnecessary 4th/5th digit3 = Invalid code missing 4th/5th digit4 = Code invalid; found on ICD-9-CM table,

but not valid for patient’s admission/discharge date

5 = Invalid code for dates, unnecessary 4th/5th digit

6 = Invalid code for dates, missing 4th/5th digit

Duplicate of Principal Message

string duplicates_principal_diagnosis_message


Age/Sex Conflict Message

string age_sex_conflict_message

0 = No error1 = Age conflict; patient’s age and

diagnosis are inconsistent2 = Sex conflict; patient’s sex and diagnosis

are inconsistent3 = Age and sex conflict; patient’s age and

sex are inconsistent with the patient’s diagnosis

Medicare as Secondary Payer Message

string medicare_secondary_payer_message


Insurance, Workers’ Compensation, etc.

Duplicate Secondary Message

string duplicates_secondary_diagnosis_message

0 = Not duplicate code1 = Code is duplicate of another secondary

diagnosis


Op

Present On Admission Invalid






Hospital-Acquired Condition Eligibility














0010 = Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures








Op





0 = Otherwise


9(1) wrongpx 0 = No error1 = Code indicates that a wrong procedure

has been performed.

Diagnosis Type string type Reserved


string dx_pdx 1 = E-code (ICD-9)/External Causes of Morbidity Code (ICD-10) as Principal Diagnosis




string dx_pdx_surg Reserved


string dx_admem 0 = No error1 = E-code as admit diagnosis2 = Manifestation code as admit diagnosis


string admdx_invalid Reserved


string admdx_agesex Reserved




Op

9.4 CMGEditMessages Editor Procedure Responses

Table 9-4: CMGEditMessages Editor Procedure Responses (dscopblkmsg)



9(1) invalid 1 = Code invalid; not found on table of valid ICD-9-CM codes

2 = Invalid code, unnecessary 4th digit3 = Invalid code, missing 4th digit4 = Code invalid; found on ICD-9-CM

table, but not valid for patient’s admission/discharge date

5 = Invalid code for dates, unnecessary 4th digit

6 = Invalid code for dates, missing 4th digit

Invalid Procedure Message

string invalid_message 1 = Code invalid; not found on table of valid ICD-9-CM codes

2 = Invalid code, unnecessary 4th digit3 = Invalid code, missing 4th digit4 = Code invalid; found on ICD-9-CM

table, but not valid for patient’s admission/discharge date

5 = Invalid code for dates, unnecessary 4th digit

6 = Invalid code for dates, missing 4th digit

Sex Conflict Message

string sex_conflict_message

0 = No error1 = Sex conflict; patient’s sex and


Non-Covered Message

string non_covered_or_open_biopsy_message


1 = Non-covered procedure2 = Open biopsy code3 = Limited coverage procedure

Bilateral Code Message

string bilateral_code_message

0 = Not a bilateral procedure code1 = Bilateral procedure code

Closed Biopsy Code Message

string closed_biopsy_code_message

Contains corresponding closed biopsy code, when given procedure code is an open biopsy. Otherwise, it is blank.

Operating Room Indicator Message

string operating_room_procedure_message

0 = Not typically performed in an operating room.

1 = Typically performed in an operating room

Procedure Inconsistent With Length of Stay Indicator Message

string pilos_message 0 = No error1 = Length of Stay and Procedure are

Inconsistent

Questionable Obstetric Admission Indicator Message

string qobadm_messages 0 = No error1 = Questionable obstetric admission

for this procedure code


Op

10 CMGEditSummary



• CMGEditSummary

• CMGEditSummary Responses

• CMGEditSummary Editor Claim Responses


Op

10.1 CMGEditSummaryThe CMGEdit method has the following input structures:






Other input:

• rate_path

• user_path

10.2 CMGEditSummary Responses





Table 10-2: CMGEditSummary Responses (CMGEditSummaryResult)





00 = Reserved


Op

10.3 CMGEditSummary Editor Claim Responses



Editor Version 9(2) editor_version Reserved.

Total Errors 9(4) total_error_count

Total DSC/MCE errors for this claim.

Table 10-3: CMGEditSummary Editor Claim Responses (CMGErrors)


Error Number 9(3) error_number Medicare Code Edits:1 = Invalid DX2 = Invalid PX3 = Duplicate of PDX4 = Age conflict5 = Sex conflict6 = Manifestation as PDX7 = Non-specific PDX8 = Questionable admission9 = Unacceptable PDX10 = All non-specific O.R. PX11 = Non-covered procedure12 = Open biopsy check13 = Bilateral procedures14 = Invalid age15 = Invalid sex16 = Invalid discharge status17 = Limited coverage18 = Invalid birthweight19 = External Causes of Morbidity Code as

PDX20 = Duplicate of another SDX21= External Causes of Morbidity Code as

Admit DX22 = Manifestation Code as Admit DX23 = Present on Admission coding error24 = Hospital-Acquired Condition25 = Wrong Procedure Performed26 = Procedure Inconsistent With Length

of Stay

Table 10-2: CMGEditSummary Responses (CMGEditSummaryResult)



Op

Error Description string error_description Medicare Code Edits:1 = Invalid DX2 = Invalid PX3 = Duplicate of PDX4 = Age conflict5 = Sex conflict6 = Manifestation as PDX7 = Non-specific PDX8 = Questionable admission9 = Unacceptable PDX10 = All non-specific O.R. PX11 = Non-covered procedure12 = Open biopsy check13 = Bilateral procedures14 = Invalid age15 = Invalid sex16 = Invalid discharge status17 = Limited coverage18 = Invalid birthweight19 = External Causes of Morbidity Code as

PDX20 = Duplicate of another SDX21= External Causes of Morbidity Code as

Admit DX22 = Manifestation Code as Admit DX23 = Present on Admission coding error24 = Hospital-Acquired Condition25 = Wrong Procedure Performed26 = Procedure Inconsistent With Length

of Stay

Error Count 9(3) error_count The number of occurrences of the indicated edit.

Table 10-3: CMGEditSummary Editor Claim Responses (CMGErrors)



Op

11 UB04_GetPayerList



• UB04_GetPayerList Requests

• UB04_GetPayerList Responses


Op

11.1 UB04_GetPayerList Requests

Table 11-1: UB04_GetPayerList Requests


Provider Identifier X(16) facility_id Facility or provider identifier (i.e. Medicare Provider ID, TIN or other identifier). Submit NPI in NPI field.

National Provider ID X(10) national_provider_id

National Provider Identifier (NPI), including check digit.

Taxonomy Code X(10) taxonomy_code 282N00000X = Short term general hospital282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital based or

freestanding renal dialysis unit

283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct part unit282NC2000X = Children’s hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part unit275N00000X = Swing bed in short term

hospital(others per 837 definitions)

Alternate Rate Path string rate_path Optional specification of directory containing alternate rate data. Supply the fully qualified rate path including drive letter.

If no alternate rate path is supplied, the default location is: C:\\inetpub\wwwroot\HSS\data


Op

11.2 UB04_GetPayerList Responses

Table 11-2: UB04_GetPayerList Responses (PayerListResults)


Return Message 9(2) return_message 00 = No error71 = No paysource found for this NPI/

Facility81 = Payirf file error

Provider Identifier X(16) facility_id Facility or provider identifier (i.e. Medicare Provider ID, TIN or other identifier). Submit NPI in NPI field.

List of Payers PayerList [] Array of payer data

PayerID or Contract Code

X(13) payer_number Payer identifier or contract code.

Payer Name X(25) payer_name Description of the payer identifier or contract code.



Taxonomy Code X(10) taxonomy_code Taxonomy code associated with this NPI, if applicable.

Key Type string key_type Identifies the type of provider ID under which these rates are stored.1 = National Provider ID plus Taxonomy

Code used for rate lookup0 or blank = Legacy Provider ID used for

rate lookup


Op

12 UB04_GetGroupPriceRules



• UB04_GetGroupPriceRules Requests

• UB04_GetGroupPriceRules Responses


Op

12.1 UB04_GetGroupPriceRules RequestsThe UB04_GetGroupPriceRules method has the following input:

Table 12-1: UB04_GetGroupPriceRules Requests


Provider Identifier X(16) facility_id Facility or provider identifier (i.e., Medicare Provider ID, TIN, or other identifier). Submit NPI in NPI field.

Payer ID or Contract Code

X(13) payer_id Payer identifier or contract code.

From or Admission Date

9(8) admit_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Thru or Discharge Date

9(8) discharge_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

If still a patient set equal to today’s date.



Taxonomy Code X(10) taxonomy_code 282N00000X = Short term general hospital282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital based or

freestanding renal dialysis unit

283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct part

unit282NC2000X = Children’s hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part unit275N00000X = Swing bed in short term


Alternate Rate Path string rate_path Optional specification of directory containing alternate rate data. Supply the fully qualified rate path including drive letter.

If no alternate rate path is supplied, the default location is: C:\\inetpub\wwwroot\HSS\data


Op

Alternate Rate Look-up

X(1) pyr_altlook_sw Flag used to indicate that additional searches of the rate files should be performed if the initial search fails.

0 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

1 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided or not found, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

2 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

3 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

Table 12-1: UB04_GetGroupPriceRules Requests



Op

12.2 UB04_GetGroupPriceRules Responses

Table 12-2: UB04_GetGroupPriceRules Responses


Return Code 9(2) return_code 00 = No error01 = Error accessing payors file02 = Error accessing hospital rate file03 = Missing rate calculator record15 = Invalid from or thru date70 = Configuration record error71 = Payirf record not found72 = Medirf record not found81 = Payirf file error82 = Medirf file error

Effective Date 9(8) effective_date Note: Set equal to from or through date based on pricing rules.YYYYMMDD, where:

YYYY = year including century MM = month; 01-12DD = day; 01-31

Grouper Type Text grouper_type irf = Medicare Inpatient IRF CMG

Grouper Version 9(2) grouper_version Grouper version

Note: The IRF Web Service is only compatible with Versions 05 and higher of the IRF Grouper.


ICD-9 Mapping Flag X(1) mapping_flag Not applicable for Medicare IRF.

Rate Ownership X(1) rate_ownership Y = Facility and payer ID has its own set of rates/weights

N = Facility and payer ID has no rates/weights

L = Facility and payer ID has been linked to another facility identifier, payer identifier and/or effective date rate/weight information

Linked Facility ID X(16) linked_facility_id The facility identifier under which applicable rate information has been stored in the rate file.

Linked Payer ID X(13) linked_payer_id The payer identifier under which applicable rate information has been stored in the rate file.

Linked Effective Date 9(8) linked_effective_date

YYYYMMDD. The effective date under which applicable rate information has been stored in the rate file.

Classification Type X(3) classification_type

CMG = Case Mix Group for Inpatient Rehabilitation

Linked NPI X(10) linked_npi The National Provider Identifier under which applicable rate information has been stored in the rate file.


Op

Linked Taxonomy X(10) linked_taxonomy The taxonomy code associated with the linked National Provider ID, if applicable.

Key Type X(1) key_type Identifies the type of provider ID under which these rates are stored.1 = National Provider ID plus Taxonomy

Code used for rate lookup0 or blank = Legacy Provider ID used for

rate lookup

Editor Requests 9(10) edit_request Position: 1: 1 = DSC edits requested2: 0 = Reserved for EASYEdit request3: 1 = NCCI edits requested4: 1 = OCE edits requested5: 1 = OCE with CCI pairs edits requested6: 1 = LCD/NCD edits requested7: 1 = Non-OPPS OCE edits requested8: 1 = POA editing request9: 1 = HAC editing request10: 0 = Reserved for future expansion

Note: More than one edit type can be requested.

Short Grouper Type 9(2) short_grouper_type

90 = Medicare Inpatient IRF CMG

Facility Retrieved X(29) pyr_facility Unique facility identifier.

Effective Date Retrieved

9(8) pyr_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).

Rate File Version X(7) rf_vers Output field. Version of the rate file that was used to process a specific claim.

Table 12-2: UB04_GetGroupPriceRules Responses



Op

13 FileReplace Structures


• ReplaceFiles

• Query

• Search


Op

13.1 ReplaceFiles

13.2 Query

13.3 Search

Table 13-1: ReplaceFiles Layout


Path The directory name of where the file is located.

Force Direction (true/false) to the Optimizer (IOCNTRL) to not wait for all files to not be in use/open (Active = 0).

Table 13-2: Query Layout


Path The name of the directory where the file is located.

Name The file name.

Active Number of clients currently using the given file name.

Table 13-3: Search Layout


Path The directory where the file is located.

Name The file name.

Current Equals true if the file currently exists on the system.

New Equals true if the file currently exists in the New directory.


Op

14 Shared Structures

NoteAlthough most fields are designated as string variables, select fields are considered arrays of string variables, and are identified by the [] symbol at the end of the variable name. Also note that the variable formats listed in this chapter are the COBOL-type definitions which identify the maximum field length or precision required by the EASYGroup™ components. For web service requests, please conform to standard web service parameter passing conventions, the field definitions in the ASMX and WSDL files, and the input and output parameter data formatting conventions described in Chapter 4.


• CMGPatientInput

• Edit_Request

• CMGLineInput

• pcb2

• Op_Entry

• DX_Entry

• gob1

• Optimizer Return Data


Op

14.1 CMGPatientInput

Table 14-1: CMGPatientInput Structure


Provider Identifier string facility_id Facility or provider identifier (i.e. Medicare Provider ID, TIN or other identifier). Submit NPI in NPI field.

Payer Identifier or Contract Code

string payer_id Payer identifier or contract code. Required.

From or Admission Date

string from_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Thru or Discharge Date

string thru_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

If still a patient, set equal to today’s date.

Date of Birth string birthdate UB-04 FL10. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31.

For IRF EASYGroup™, a partial birth date may be provided. This partial birth date must contain at least a 4-digit year. Partial birth dates should be left-justified and blank-filled.

Age in Years string age Patient age in years. Required for all inpatient and outpatient processing. Valid values are 000-124.

For IRF EASYGroup™, valid values are 000-140. If age is not available, set to blanks. Age will be calculated using from_date and birth_date.

Sex string sex UB-04 FL11. Required for all inpatient and outpatient processing. Not used by IRF EASYGroup™.0 or U = Unknown1 or M = Male2 or F = Female

Medical Record Number

string medical_record_number

UB-04 FL03B. Optional field to uniquely identify patient.

Patient Control Number

string control_number UB-04 FL03A. Optional field to uniquely identify a patient account.

Reason for Visit Diagnosis

array reason_for_visit_diagnosis []

UB-04 FL70a. Reason for visit diagnoses, up to three ICD-9-CM/ICD-10-CM/PCS codes, for outpatient processing.


Op

Discharge Disposition

string discharge_disposition

UB-04 FL17. Patient Discharge Status.01 = Discharged to home or self care02 = Discharged/transferred to short-term

general hospital03 = Discharged/transferred to skilled

nursing facility, Medicare-certified04 = Discharged/transferred to a facility

that provides custodial or supportive care

05 = Discharged/transferred to designated cancer center or children's hospital (valid beginning October 1, 2007)

06 = Discharged/transferred to home health service organization

07 = Left against medical advice09 = Admitted as an inpatient (valid only

for Medicare outpatient claims)20 = Expired/died21 = Discharged/transferred to court/law

enforcement (valid beginning October 1, 2009)

30 = Still a patient43 = Discharged/transferred to federal

health care facility (valid beginning October 1, 2003)

50 = Hospice, home51 = Hospice, certified medical facility61 = Discharged/transferred to swing bed,

hospital-based and Medicare-approved (valid beginning with October 1, 2001)

62 = Discharged/transferred to inpatient rehabilitation facility or unit (valid beginning January 1, 2002)

63 = Discharged/transferred to long term care hospital, Medicare-certified (valid beginning January 1, 2002)

64 = Discharged/transferred to nursing facility, certified under Medicaid but not Medicare (valid beginning October 1, 2002)

65 = Discharged/transferred to psychiatric hospital or distinct part unit (valid beginning April 1, 2004)

66 = Discharged/transferred to critical access hospital (valid beginning January 1, 2006)

70 = Discharged/transferred to another type of health care institution not defined elsewhere in this code list (valid beginning April 1, 2008)

continued below...




Op

Discharge Disposition <continued>

string discharge_disposition

71 = Outpatient services, another facility (valid October 1, 2001 through September 30, 2003)

72 = Outpatient services, this facility (valid October 1, 2001 through September 30, 2003)

All-Patient (AP-DRG) Grouper:10 = Another hospital for neonatal

aftercare (Version 23 and prior)13 = Another hospital for tertiary aftercare

(Version 23 and prior)22 = Another hospital for neonatal

aftercare (Version 10 and prior)23 = Another hospital for tertiary aftercare

(Version 10 and prior)24 = Home, IV therapy (Version 10 and

prior)

Total Covered Charges

string total_charges UB-04 FL47-48. Subtract Non-covered charges (FL 48) from Total Charges (FL 47).

UB-04 Condition Codes

array of stringoccurs up to 24 times

condition_codes [] UB-04 FL18-28 condition codes.

Bill Type string billtype UB-04 FL4. UB-04 bill type consists of 3-character category plus frequency.

UB-04 Value Code array of stringoccurs up to 24 times

value_codes [] UB-04 FL39-41. Value codes.

UB-04 Value Amount array of stringoccurs up to 24 times

value_amounts [] UB-04 FL39-41. Leading digit should always be zero. Supply according to UB-04 conventions for the remaining 9 digits of this field.

Deductible string deductible Remaining Medicare outpatient deductible for this patient at the time of this visit.

Provider ZIP Code string provider_zip_code UB-04 FL01. Required for professional claims only.

National Provider Identifier

string national_provider_id

UB-04 FL56. National Provider ID, including check digit.




Op

Taxonomy Code string taxonomy_code If no taxonomy code is submitted, assume short term hospital.

282N00000X = Short term general hospital

282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital-based or free-

standing renal dialysis unit283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct part

unit282NC2000X = Children’s hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part

unit275N00000X = Swing bed in short term


Effective Date string eff_date Format is: YYYYMMDDWhere: YYYY = year including centuryMM = month: 01-12DD = day; 01-31

Set equal to from or thru date based on pricing rules.

Extended Structure Switch

string ext_blk_sw Enable new 5010 output structures and new 5010 block formats once all updated programs that reference these structures have been installed.1 = Enable

UB-04 Occurrence Codes

string occurs up to 24 times

occur_codes [] UB-04 FL31-34. Occurrence codes.

UB-04 Occurrence Dates

date occurs up to 24 times

occur_dates [] UB-04 FL31-34. Occurrence dates. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31

UB-04 Occurrence Span Codes

string occurs up to 24 times

span_codes [] UB-04 FL35-36. Occurrence span codes.

UB-04 Occurrence Span Date #1


span_dates1 [] UB-04 FL35-36. Occurrence span date 1. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31




Op

UB-04 Occurrence Span Date #2


span_dates2 [] UB-04 FL35-36. Occurrence span date 2. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31

ICD-9 or ICD-10 Coding Classification

X(2) code_class 00 = ICD-9 coded claim01 = ICD-10 coded claim

Paper Claim Flag 9(1) paper_flag 0 = Claim being processed is an electronic claim

1 = Claim being processed is a paper claim

Health Plan Identifier (HPID)

9(10) hplan_id UB-04 FL51. Health Plan Identifier (HPID).

Alternate Rate Look-up

X(1) pyr_altlook_sw Flag used to indicate that additional searches of the rate files should be performed if the initial search fails.

0 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

1 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided or not found, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

2 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

3 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.




Op

14.2 Edit_Request

Log Request X(1) log_req 0 = Log file (ezglog_yyyymmdd_seconds.txt) not requested

1 = Log file (ezglog_yyyymmdd_seconds.txt) requested

Instructions for setting this field:Step 1: Set this switch to 1.Step 2: Process the claim you wish to log.Step 3: Set this switch to 0.

NoteThis option is designed for use with a single claim, or a small set of claims. It should not be set to 1 for all claims processing, as the log file will grow rapidly in size and processing speed may be affected.

Start of Care Date 9(8) start_of_care_date

UB-04 FL12. YYYYMMDD, where:YYYY = year; including centuryMM = month; 01 - 12DD = day; 01 - 31

Table 14-2: Edit_Request Structure


MCE Request MCE boolean 1 = Performs all date-sensitive code edits including Medicare code edits, present on admission and hospital-acquired conditions

POA Request POA boolean 1 = Performs all present on admission coding edits

HAC Request HAC boolean 1 = Performs all Hospital-Acquired Condition (HAC) edits




Op

14.3 CMGLineInput

HAC Override ID Request

hac_override_id

string Unique key used by the Date-Sensitive Code (DSC) Editor to determine what Hospital-Acquired Conditions (HACs) should be applied to this facility. This identifier field may be set in the Rate Manager application to apply an edit pattern for a provider on a select effective-dated period. This allows the user to pass the HAC Override ID at the system level for the following scenarios: • The claim is utilizing a provider rate record that contains a blank value in the HAC Override ID (HAC ID) field in the Configuration record (config.dat). • The user has elected to pass in a non-blank value into the HAC Override ID field.

Table 14-3: CMGLineInput Repeating Structure


HCPCS Code string hcpcs_code UB-04 FL44. Level I or II HCPCS or HIPPS code where applicable. Left-justified.

Modifiers array of strings

modifiers [] UB-04 FL44. Optional modifiers.

Note: Modifiers must be entered in UPPERCASE format.

Units string units UB-04 FL46. Separate APC or APG payments may be received for each unit of service.

Charges string charges UB-04 FL47 and 48. Total covered charges for this procedure (individual covered charges times units).

Date date date UB-04 FL45. Service date for this procedure (YYYYMMDD). Required for all service lines effective January 1, 2005.

Note: For IRF, the service date reported with revenue code “0024” is the date the final IRF-PAI assessments were transmitted to the CMS National Assessment Collection Database.

Revenue Code string revenue_code UB-04 FL42. Revenue code.

ACE Override string ace_override Reserved

Table 14-2: Edit_Request Structure



Op

14.4 pcb2

Table 14-4: pcb2 Structure



tdate YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31


Program Interruption Flag

interpt 1 = Patient left facility for treatment; stay was interrupted

0 = No interruption

Admission Impairment Grouper Code

igroup The IRF impairment group code that best describes the patient’s primary reason for admission to the rehabilitation program.

Valid values will be a standard impairment group code in the format: xx.xxxx or the IRF-PAI electronic transmission format for this field: 00xx.xxxx (two zeros before impairment group code).

(must specify decimal point)

Etiologic Diagnosis edx Optional.The etiologic problem that led to the condition for which the patient is receiving rehabilitation.

ICD-9-CM/ICD-10-CM/PCS diagnosis code. Left-justified, blank- filled with no decimal points.


Op

FIM Admission Motor Score – Total

motor Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. (Note: IRF-PAI field 39K, “Transfers to Tub, Shower” is not currently used for CMG assignment). If zero, IRF Grouper will calculate and return value in the motor-out field in the output parameter section. Valid values range from 12 to 84. Note that when totaling individual IRF-PAI scores, values of “0” default to “1”, except for 39J which defaults to “02”.

Note: Prior to Version 4 of the IRF Grouper, this field should be entered as a 3-character field (999). For Version 4 and forward, this field will remain a 3-character numeric field but will now have an implied decimal for a tenth in accuracy (99.9). For example, entering a value of 120 in this field would indicate that this claim has a total motor score of 12.0.

FIM Admission Cognitive Score – Total

cogn Sum of IRF-PAI fields 39N through 39R. If zero, IRF Grouper will calculate and return value in the cogn-out field in the OUTPUT parameter section. Valid values range from 5 to 35. Note that when totaling individual IRF-PAI scores, values of “0” default to “1”.

Admission Motor Scores

motor_score IRF-PAI fields 39A – M. Valid values for the Individual Admission Motor Score fields range from 00 to 07 and are defined as follow:

00 = Activity does not occur01 = Total assistance02 = Maximal assistance03 = Moderate assistance04 = Minimal contact assistance05 = Supervision or setup06 = Modified independence07 = Complete independence

If a value of “00” is entered, the IRF Grouper will treat as an “01”, except for 39J which defaults to “02”.

DETAILED FIM ADMISSION MOTOR SCORES

Admission Motor Score – Self Care,

Eating

motor_score IFR-PAI field 39A. Valid values range from 00 to 07.


Grooming*

motor_score IFR-PAI field 39B. Valid values range from 00 to 07.




Op


Bathing

motor_score IFR-PAI field 39C. Valid values range from 00 to 07.


Dressing, Upper Body

motor_score IFR-PAI field 39D. Valid values range from 00 to 07.


Dressing, Lower Body

motor_score IFR-PAI field 39E. Valid values range from 00 to 07.


Toileting

motor_score IFR-PAI field 39F. Valid values range from 00 to 07.

Admission Motor Score – Sphincter

Control, Bladder Management

motor_score IFR-PAI field 39G. Valid values range from 01 to 07.

Admission Motor Score – Sphincter

Control, Bowel Management

motor_score IFR-PAI field 39H. Valid values range from 01 to 07.

Admission Motor Score – Transfers,

Bed, Chair, Wheelchair

motor_score IFR-PAI field 39I. Valid values range from 00 to 07.

Admission Motor Score – Transfers,

Toilet

motor_score IFR-PAI field 39J. Valid values range from 00 to 07.

Admission Motor Score – Locomotion,

Walk/ Wheelchair

motor_score IFR-PAI field 39L. Valid values range from 00 to 07.

Admission Motor Score – Locomotion,

Stairs

motor_score IFR-PAI field 39M. Valid values range from 00 to 07.

Modifier for Admission Motor Score – Locomotion, Walk/Wheelchair

fim39L_mod Optional modifier for IFR-PAI field 39L. Valid values are:W = WalkC = WheelchairB = Both

Does not affect CMG assignment.




Op

Individual Admission Cognitive Score

cogn_score IRF-PAI fields 39N – R. Valid values for the Individual Admission Cognitive Score fields generally range from 01 to 07, with some exceptions, and are defined as follows:

00 = Activity does not occur01 = Total assistance02 = Maximal prompting03 = Moderate prompting04 = Minimal prompting05 = Standby prompting06 = Modified independence07 = Complete independence

If a value of 00 is entered, the IRF Grouper will treat as an 01.

DETAILED FIM ADMISSION COGNITIVE SCORES

Admission Cognitive Score –

Communication, Comprehension

cogn_score IFR-PAI field 39N. Valid values range from 00 to 07 for Version 1.0 of the IRF Grouper (effective between January 1, 2001 and September 30, 2002). After October 1, 2002, the range of valid values became 01 to 07.

Admission Cognitive Score –

Communication, Expression

cogn_score IFR-PAI field 39O. Valid values range from 00 to 07 for Version 1.0 of the IRF Grouper (effective between January 1, 2001 and September 30, 2002). After October 1, 2002, the range of valid values became 01 to 07.

Admission Cognitive Score – Social

Cognition, Social Interaction

cogn_score IFR-PAI field 39P. Valid values range from 01 to 07.


Cognition, Problem Solving

cogn_score IFR-PAI field 39Q. Valid values range from 01 to 07.


Cognition, Memory

cogn_score IFR-PAI field 39R. Valid values range from 01 to 07.

Modifier for Admission Cognitive Score – Communication, Comprehension

fim39N_mod Optional Modifier for IFR-PAI field 39N. Valid values are:A = AuditoryV = VisualB = Both





Op

Modifier for Admission Cognitive Score – Communication, Expression

fim39O_mod Optional Modifier for IFR-PAI field 39O. Valid values are.V = VocalN = Non-vocalB = Both


AdmissionMotor Scores 2

motor_score_2 IRF-PAI componentsfor self care (GG0130A1- GG0130C1 andGG0130E1- GG0130H1), mobility (GG0170B1- GG0170F1,GG0170I1- GG0170K1, and GG0170M1), bladder continence (H0350), and bowel continence (H0400).Valid values for theIndividual AdmissionMotor Score fields(GG0130A1 - GG0130C1, GG0130E1- GG0130H1, GG0170B1- GG0170F1, GG0170I1 - GG0170K1, GG0170M1) range from 00 to 06.

DETAILED QUALITY INDICATOR MOTOR SCORES


Eating

string motor_score_2_SelfCare_A1

IRF-PAI GG0130A1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Oral

Hygiene

string motor_score_2_SelfCare_B1

IRF-PAI GG0130B1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Toilet

Hygiene

string motor_score_2_SelfCare_C1

IRF-PAI GG0130C1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Shower

Bathe Self

string motor_score_2_SelfCare_E1

IRF-PAI GG0130E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Upper Body

Dressing

string motor_score_2_SelfCare_F1

IRF-PAI GG0130F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Lower Body

Dressing

string motor_score_2_SelfCare_G1

IRF-PAI GG0130G1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Putting On/Taking Off Footwear

string motor_score_2_SelfCare_H1

IRF-PAI GG0130H1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score –Sit to Lying

string motor_score_2_SelfCare_B1

IRF-PAI GG0170B1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Lying to

Sitting on Side of Bed

string motor_score_2_Mobility_C1

IRF-PAI GG0170C1. Valid values range from 00 to 07, 09, 10, and 88.




Op

14.5 Op_Entry

Admission Motor Score – Sit to Stand

string motor_score_2_Mobility_D1

IRF-PAI GG0170D1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Chair/Bed-

to-Chair Transfer

string motor_score_2_Mobility_E1

IRF-PAI GG0170E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Toilet

Transfer

string motor_score_2_Mobility_F1

IRF-PAI GG0170F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Walk 10

Feet

string motor_score_2_Mobility_I1

IRF-PAI GG0170I1. Valid values range from 00 to 07, 09, 10, and 88.


Feet With Two Turns

string motor_score_2_Mobility_J1

IRF-PAI GG0170J1. Valid values range from 00 to 07, 09, 10, and 88.


Feet

string motor_score_2_Mobility_K1

IRF-PAI GG0170K1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – One Step

Curb

string motor_score_2_Mobility_M1

IRF-PAI GG0170M1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score – Bladder

Continence

string motor_score_2_Bladder

IRF-PAI H0350. Valid values range from 00 to 05, and 09.

Admission Motor Score – Bowel

Continence

string motor_score_2_Bowel

IRF-PAI H0400. Valid values range from 00 to 03, and 09.

FIM Admission Motor Score

motor2 Reserved

FIM Admission Cognitive Score

cogn2 Reserved

Table 14-5: Op_Entry Repeating Structure

Field Description

Variable Name

Format Notes

Procedure Code (input)

op X(10) Input field. ICD-9-CM or ICD-10-CM/PCS procedure code. Left-justified, blank-filled with no decimal points. Unused fields should be blank-filled. Codes should be contiguous, i.e., no gaps or blanks between codes.




Op

14.6 DX_Entry

Code Type (input)

type X(3) ICD-9 Procedure:BR = First ICD-9 procedureBQ = Other ICD-9 procedure

ICD-10 Procedure:BBR = First ICD-10 procedureBBQ = Other ICD-10 procedure

Table 14-5: Op_Entry Repeating Structure

Field Description

Variable Name

Format Notes

Table 14-6: Dx_Entry Repeating Structure

Field Description Variable Name

Format Notes

Diagnosis Code (input)

dx X(10) ICD-9-CM or ICD-10-CM diagnosis codes. Input field. Left-justified, blank-filled with no decimal points. Codes should be contiguous, i.e., no gaps or blanks between codes. Principal diagnosis should be in the first position.

For IRF EASYGroup™, specific patient conditions that are secondary in importance to the patient’s primary reason for admission to the rehabilitation program, as reflected in the Impairment Group Code. Do not code comorbid conditions that are identified on the day prior to discharge or the day of discharge.

Diagnosis Code Type (input)

type X(3) Input field. Reserved for ICD-10 implementation.BK = Principal ICD-9 diagnosisBF = Other ICD-9 diagnosisABK = Principal ICD-10 diagnosisABF = Other ICD-10 diagnosis


Op

Present on Admission Indicator (input)

poa X(1) Input field. UB-04 FL67 and FL67A-Q. Indicator that this condition was present at the time of admission. Required in uppercase.Y = Yes (Present at the time of inpatient

admission)N = No (Not present at the time of inpatient

admission)U = Unknown (Documentation is insufficient to

determine if the condition was present at the time of inpatient admission)

W = Clinically Undetermined (Provider is unable to clinically determine whether the condition was present at the time of inpatient admission)

1 = Unreported/Not used (Exempt from POA reporting on electronic claims before 6/30/2012)

Blank = Unreported/Not used (Exempt from POA reporting on paper claims and on electronic claims on or after 7/1/2012)

Table 14-6: Dx_Entry Repeating Structure

Field Description Variable Name

Format Notes


Op

14.7 gob1

Table 14-7: gob1 Structure


Grouper Return Code


00 = No errors01 = No CMG match02 = Not used03 = Not used04 = Not used05 = Computed age is greater than 140














continued below...


Op



21 = Locomotion, stairs (FIM39M, admission value) is out of range






27 - 36 = Not currently in use37 = Impairment group code is invalid38 = Total motor score, admission, out of



















Op


9(3)v9(3)

motor_out Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. (Note: IRF-PAI field 39K, “Transfers to Tub, Shower” is not currently used for CMG assignment). If input field “motor” is zero, IRF Grouper calculates and returns this field.









9(3)v9(3)

cognitive_out Sum of IRF-PAI fields 39N through 39R. If input “cogn” field is zero, IRF Grouper calculates and returns this field. Valid values range from 5 to 35. Note that when totaling individual IRF-PAI scores, values of “00” default to “01.”











Op


9(3)v9(3)

motor_out2 Total motor score calculated from IRF-PAI admission motor scores collected in fields 39A through 39M, excluding field 39K. When totaling individual IRF-PAI scores, values of “0” default to “1,” except for 39J which defaults to “2.” Valid values range from 12 to 84.





9(3)v9(3)

cogn_out2 Total cognitive score calculated from IRF-PAI fields 39N through 39R. When totaling individual IRF-PAI scores, values of “0” default to “1”. Valid values range from 5 to35.








Op

14.8 Optimizer Return Data



Table 14-8: Optimizer Return Data

Field Description Format Variable Name

Notes


X(2) opt_rtn_code 00 = No errors found05 = Error calling Mapper Control Program

(mapcntl)06 = Error calling Editor Control Program (edtcntl)07 = Error calling Grouper Control Program

(grpcntl)08 = Error calling Pricer Control Program (prccntl)09 = Error calling Retrieve Payer Control Program

(rtvpyr)10 = Error calling Model Control Program (mdlcntl)11 = Non-zero return code from Mapper12 = Non-zero return code from DSC Editor13 = Non-zero return code from EASYEdit™14 = Non-zero return code from ACE, or accept if

less than ACE DISP15 = Non-zero return code from Grouper16 = Non-zero return code from Pricer17 = Non-zero return code from LCD Editor18 = Non-zero return code from Retrieve Payer

Control Program (rtvpyr)19 = Non-zero return code from Model Control

Program20 = Memory Allocation Control Program

(ezgmem) cannot be loaded21 = Non-zero return code from the TRICARE

APC Editor22 = Non-zero return code from Physician Editor88 = Initialization error89 = Memory error90 = Invalid request (invalid opcode1)95 = Parameter error96 = Reserved97 = Reserved98 = Reserved99 = Reserved




Op

Function Return Code

9(2) func_rtn_code 01 = Error accessing rate files07 = GRPCNTL cannot be loaded08 = PRCCNTL cannot be loaded15 = Non-zero return code from the Grouper16 = Non-zero return code from the Pricer17 = Invalid patient type70 = Configuration record error87 = Program cannot be loaded88 = Initialization error94 = Invalid dates95 = Parameter error

Rate File Version X(7) rf_vers Output field. Version of the rate file that was used to process a specific claim.

Table 14-8: Optimizer Return Data

Field Description Format Variable Name

Notes


Op

15 IRF Web Services Label Data File

This chapter includes the following sections:

• File Layout

• Description of Irfmsg Values

tumInsight | www.optum.com April 2, 2020 Page 136

Op

15.1 File LayoutThe IRF Web Service uses an external data file (irfmsg.dat) to retrieve the labels for values that are output in the IRF Web Service. The layout is as follows:

NoteFor further information please refer to Table 15-2.

15.2 Description of Irfmsg ValuesBelow is the mapping of code type values to the fields that return them. In the irfmsg.dat file, these items will be sorted alphabetically. The Code Values in field 2 range from 1 digit to 5, and only these values should be returned for their respective Code Type values.

Table 15-1: Irfmsg.dat File Layout

Field Position Format Description

1 1 - 4 X(4) Code Type

2 5 - 9 X(5) Code Value

3 10 - 209 X(200) Description

4 210 - 250 X(144) Filler

Table 15-2: Code Type Values, Descriptions, and Web Service Infrastructure

Code Type Values

Description Corresponding IRF Web Service Field(s)

E01 Claim Level Editing Results

editor_return_code, 9(2)


error_number, 9(2)


demographic_age_invalid, 9(1)


demographic_sex_invalid, 9(1)


demographic_discharge_disposition_invalid, 9(1)


principal_diagnosis_invalid, 9(1)


principal_diagnosis_suggests_surgery, 9(1)


all_non_specific_procedures, 9(1)


multiple_bilateral_procedures, 9(1)


Op


admit_diagnosis_invalid, 9(1)


admit_diagnosis_age_sex_conflict, 9(1)


admit_diagnosis_Medicare_secondary, 9(1)


admit_diagnosis_Ecode_or_Manifestation_code, 9(1)

E16 Diagnosis Editing Results invalid, 9(1)

E17 Diagnosis Editing Results duplicates_principal_diagnosis, 9(1)

E18 Diagnosis Editing Results age_sex_conflict, 9(1)

E19 Diagnosis Editing Results medicare_secondary_payer, 9(1)

E20 Diagnosis Editing Results duplicates_secondary_diagnosis, 9(1)

E21 Diagnosis Editing Results poa_invalid, 9(1)

E22 Diagnosis Editing Results haceligible, 9(2)

E23 Diagnosis Editing Results ccmccind, 9(1)

E24 Diagnosis Editing Results hac, 9(4)

E25 Diagnosis Editing Results poa_bypassed, 9(1)

E26 Diagnosis Editing Results wrongpx, 9(1)

E27 Procedure Editing Results invalid, 9(1)

E28 Procedure Editing Results sex_conflict, 9(1)

E29 Procedure Editing Results non_covered_or_open_biopsy, 9(1)

E30 Procedure Editing Results bilateral_code, 9(1)

E31 Procedure Editing Results operating_room_procedure, 9(1)

E32 Procedure Editing Results pilos, 9(1)

G01 Group Claim Results grouper_return_code, 9(2)

O01 OOB1 Optimizer Return Code

opt_rtn_code, X(2)

O02 ECB Optimizer Return Code

optimizer_return_code, CMGMessages_return_code 9(2)

O03 Optimizer Results func_rtn_code, 9(2)

P01 Price Results pricer_return_code, 9(2)

Table 15-2: Code Type Values, Descriptions, and Web Service Infrastructure

Code Type Values

Description Corresponding IRF Web Service Field(s)


List of TablesTechnical Support Options 6

User Path and Rate Path 49

CMGPrice Responses (CMGPriceResult) 50

CMGPrice Pricer Responses (CMGPriceResults) 50


CMGGroupPrice Responses (CMGGroupPriceResult) 56

CMGGroupPrice Grouper Claim Responses (CMGGroupClaimResults) 57

CMGGroupPrice Grouper Line Responses (CMGGroupLineResults []) 61

CMGGroupPrice Pricer Responses (CMGPriceResults) 62


CMGEditGroupPrice Responses (CMGEditGroupPriceResult) 67

CMGEditGroupPrice Editor Claim Responses (EditResults) 67

CMGEditGroupPrice Editor Diagnosis Responses (dscdxblk) 70

CMGEditGroupPrice Editor Procedure Responses (dscopblk) 72

CMGEditGroupPrice Grouper Claim Responses (CMGGroupClaimResults) 74

CMGEditGroupPrice Grouper Line Responses (CMGGroupLineResults) 78

CMGEditGroupPrice Pricer Responses (CMGPriceResults) 79


CMGEdit Responses (CMGEditResult) 84

CMGEdit Editor Claim Responses (EditResults) 84

CMGEdit Editor Diagnosis Responses (dscdxblk) 87

CMGEdit Editor Procedure Responses (dscopblk) 90


Optum | www.optum.com April 2, 2020 Page 139

CMGEditMessages Editor Claim Responses (CMGEditMessages) 93

CMGEditMessages Editor Diagnosis Responses (dscdxblkmsg) 96

CMGEditMessages Editor Procedure Responses (dscopblkmsg) 99


CMGEditSummary Responses (CMGEditSummaryResult) 101

CMGEditSummary Editor Claim Responses (CMGErrors) 102

UB04_GetPayerList Requests 105

UB04_GetPayerList Responses (PayerListResults) 106

UB04_GetGroupPriceRules Requests 108

UB04_GetGroupPriceRules Responses 110

ReplaceFiles Layout 113

Query Layout 113

Search Layout 113

CMGPatientInput Structure 115

Edit_Request Structure 120

CMGLineInput Repeating Structure 121

pcb2 Structure 122

Op_Entry Repeating Structure 127

Dx_Entry Repeating Structure 128

gob1 Structure 130

Optimizer Return Data 134

Irfmsg.dat File Layout 137

Code Type Values, Descriptions, and Web Service Infrastructure 137




IndexCContact Optum 5Contact Us 5

Client Services 6Corporate Address 5

FFileReplace Structures 112GGuide Overview 5, 136

Documents

ECM Pro™ Inpatient Rehabilitation Facility (IRF) Web ... · application on any web-accessible platfo rm can request inpatient rehabilitation CMG assignment, and CMG-based pricing