Using the Carrier File · 2015-07-29 · * Note: In 2011, discontinue 90656 and use Q2035 – Q2039 ... HCPCS modifiers may also change in the course of a study, but much less likely

Using the Carrier File (FORMERLY CALLED THE PHYSICIAN/SUPPLIER PART B FILE)

Marshall McBean, M.D., M.Sc.

Director of ResDAC

University of Minnesota

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Capturing information on the CMS 1500

The important groups of Carrier File variables from the CMS 1500 form

Claim “Header” or “Fixed Portion” variables. The

“header” portion of CMS 1500 form, including the

diagnoses. Called “Base Claim File” portion in

CCW/Buccaneer record layout.

- Note: The patient characteristics (demographics) which

were only in the CCW Beneficiary Summary File are now

in the CCW claims files, too.

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The important groups of Carrier File variables from the CMS 1500 form

Line Item variables. Those variables found in the

“Trailer” portion of the CMS 1500 form. Called

“Line File” portion in CCW/Buccaneer record

layout.

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Carrier File Data Dictionaries

CCW data dictionary:

http://www.ccwdata.org/data-

dictionaries/index.htm

Classic CMS Carrier file data dictionary:

http://www.resdac.org/cms-data/files/carrier-

rif/data-documentation

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http://www.ccwdata.org/data-dictionaries/index.htm




http://www.resdac.org/cms-data/files/carrier-rif/data-documentation








Useful variables in the Base Claim File portion of the Carrier File

Information about the beneficiary

- BENE_ID (Encrypted)

- Beneficiary demographics

» Date of birth

» Gender

» Race/ethnicity

- Beneficiary place of residence

» State, county and zip code

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Useful variables in the Line File portion of the Carrier File

Information about the claim

- Claim From Date

- Claim Through Date

- Claim Payment Amount

- Claim Diagnosis Codes

» occurs up to 8 times (starting with 2007 data)

» uses ICD-9-CM codes – ICD-10 is coming October 2014

» diagnosis of XX000 = a laboratory test

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Carrier File Diagnoses

“By rule”, there should be no “rule-outs”

Diagnoses that are found in the line items are

truly also in the claim file portion of the record

Determination of co-morbidities is an issue as

discussed by Beth in her presentation of MedPAR

file

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Note: a line item or Line File portion may occur up

to 13 times on one claim

- No longer a “count variable”

Line Diagnosis Code

- It can be any of the up to 8 possible diagnoses in the

claim file portion of the Carrier File

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3 variables useful for linking Carrier claims to MedPAR hospital or to outpatient claims

1. Line Place of Service Code

2 and 3. Dates of service (Line First Expense Date and Line Last Expense Date)

Reasons to link the claims:

1. to sum the amount reimbursed for care,

2. to “validate” the occurrence of a procedure 3. to avoid duplicate counting of cases or procedures

4. Others?

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Examples of line place of service codes

11 = Office

12 = Home

21 = Inpatient hospital

22 = Outpatient hospital

23 = Emergency room - hospital

24 = Ambulatory surgical center

31 = Skilled nursing facility

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Additional examples of line place of service codes

32 = Nursing facility

33 = Custodial care facility

34 = Hospice

35 = Adult living care facilities (ALCF) (eff. NYD –

added 12/3/97)

41 = Ambulance - land

42 = Ambulance - air or water

50 = Federally qualified health centers

(eff. 10/1/93)

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More useful variables in the Line File portion of the Carrier File

Line Healthcare Common Procedure Coding

System (HCPCS) Code

Line HCPCS Initial Modifier Code

Line HCPCS Second Modifier Code

Line HCPCS Third Modifier Code

Line HCPCS Fourth Modifier Code

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HCPCS: Healthcare Common Procedure Coding System Codes

Level 1 - 5 position numeric codes -- are CPT (Current

Procedural Terminology) Codes of American Medical

Association

- e.g., 99201 Office or other outpatient visit for the

evaluation and management of new patient

Level 2 - 5 position alpha-numeric codes

- e.g., J0540 Injection, penicillin G benzathine and

penicillin G procaine, up to 1,200,000 units

Level 3 - 5 position alpha-numeric codes beginning with W,

X, Y or Z

- Note: XX000 as a diagnosis = a laboratory service

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Examples of Level 1 HCPCS or CPT codes

00100 -01999 Anesthesia

10040 - 69990 Surgery

70010 - 79999 Radiology

80049 - 89399 Pathology and Laboratory

90281 - 99199 Medicine

99201 - 99499 Evaluation and Management

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HCPCS – Issues for researchers (1)

1. What is actually included in a Evaluation and

Management (E&M) visit?

Codes 99201 - 99499

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HCPCS - Examples of level 2 codes

A0000 - A0999 Transportation Services including

Ambulance

A4000 - A8999 Medical and Surgical Supplies

A9000 - A9999 Administrative, Miscellaneous and

Investigational

B4000 - B9999 Enteral and parenteral therapy

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HCPCS - More examples of level 2

A4253 - Blood Glucose or reagent strips for home

blood glucose monitoring- per 50

A4259 - Lancets -box of 100

A2000 - Manipulation of spine by chiropractor

A0344 - Ambulance services, ALS, non-

emergency, no specialized ALS

plus ---- lots of other ambulance

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HCPCS - examples of level 1 & level 2 preventive services codes

Preventive services

- Influenza vaccine 90654, 90656 or 90658*

- Influenza vaccine administration G0008

- Pneumococcal polysac. vaccine 90732

- Pneumococcal vaccine administration G0009

- Fecal occult blood test G0238 or G0107

- Flexible sigmoidoscopy G0104

- Colonoscopy G0105

* Note: In 2011, discontinue 90656 and use Q2035 – Q2039

for split-virus vaccine….. pay attention. Things keep changing .

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Changes in HCPCS

Level 1 and Level 2 HCPCS may change annually

Level 3 HCPCS may change more frequently

CMS is making an effort to eliminate Level 3

HCPCS

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HCPCS - Level 3 codes

Repeat definition : 5 position alpha-numeric codes

beginning with W, X, Y or Z

Source = the MACs (Medicare Administrative

Contractors

CMS is really planning to eliminate

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HCPCS Modifiers

2 Position codes

Level 1 - numeric

- e.g., 21 - Prolonged Evaluation and Management

Services

- 26 - Professional Component

Level 2 - alpha or alpha-numeric

- TC - Technical Component

- LT = left, RT = right

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HCPCS Modifiers

Level 3 – formerly from Carriers, now from MACs

HCPCS modifiers may also change in the course of

a study, but much less likely

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Approximately 10,000 HCPCS codes

What’s a poor researcher to do?

HCPCS Line NCH BETOS Code

Useful for Aggregating

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BETOS codes – line NCH BETOS code

M1A = Office visits - new

M1B = Office visits - established

M2A = Hospital visit - initial

M2B = Hospital visit - subsequent

M2C = Hospital visit - critical care

M3 = Emergency room visit

M4A = Home visit

M4B = Nursing home visit

M5A = Specialist - pathology

M5B = Specialist - psychiatry

M5C = Specialist - opthamology

M5D = Specialist - other

M6 = Consultations

P0 = Anesthesia

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Physician services and amount Medicare paid for them by, BETOS code

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BETOS Code Services Amount Paid

M1A = Office visits - new 12,063,567 $729,435,905

M1B = Office visits - estab 175,981,446 $5,854,022,879

M2A = Hospital visit - initial 9,084,444 $915,516,580

M2B = Hospital visit - subs 82,434,957 $3,572,740,464

M2C = Hospital visit - critical care2,616,542 $302,633,080

M3 = Emergency room visit 15,135,564 $1,061,258,401

M4A = Home visit 1,531,304 $97,078,383

M4B = Nursing home visit 19,766,584 $720,985,090

M5A = Specialist - pathology 16,926,656 $673,411,742

M5B = Specialist - psychiatry 17,229,471 $654,250,877

M5C = Specialist - opthamology 21,782,022 $1,007,691,689

M5D = Specialist - other 9,641,201 $127,907,388


Line Allowed Charge Amount - the charges allowed

by CMS

Line NCH Payment Amount - the amount paid by

CMS

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Relationship between line allowed charge amount and line NCH payment amount

NCH Payment Amount generally 80% of Line NCH

Allowed Charge Amount. WHY?

For laboratory services the two values are the

same. WHY?

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Don’t over count the count.

- Carrier Line Miles/Time/Units/Services (MTUS) count

- Carrier Line Miles/Time/Units/Services indicator code

- Did the beneficiary use 40 ambulances?

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MTUS Indicator Code Values

0 = Values reported as zero (no allowed activities)

1 = Transportation (ambulance) miles

2 = Anesthesia time units

3 = Services

4 = Oxygen units

5 = Units of blood

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Information about the provider of service:

- Carrier Line Performing PIN Number

- Carrier Line Performing UPIN Number

- Line CMS Provider Specialty Code

- Carrier Line Performing NPI (National Provider

Identification Number)

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Provider of service information

The provider had to submit a PIN (Provider

Identification Number) on the CMS 1500 claim

The Carrier picked a UPIN (Unique Physician

Identification Number) for that PIN

CMS added the Provider Specialty based on the

UPIN

PIN, UPIN, AND PROVIDER SPECIALTY – THE OLD STORY

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National Provider Identification Number – NPI - and its implementation

In 2006 CMS started requiring the use NPI for providers in in billing using the CMS 1500 form

Electronic submission of claims - Through 1/2/ 06 – NPI not accepted

- 2/3/06 – 10/1/06 – NPI accepted, but only if UPIN is also reported

- 10/2/06 – 5/22/07 – NPI or UPIN accepted; encourage both to speed payment

- 5/23/07 and after – NPI must be submitted; No UPIN

Paper submission of claims - All of 2006 NPI not accepted; no place on claim

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NPI and UPIN use in 2006

Percent of Physician-related Carrier Line Items with

NPI and/or UPIN in 2006

All of 2006 After October 1st

NPI only 0.02 0.05

UPIN only 97.05 92.72

Both 1.65 5.53

Neither 1.28 1.81

MINIMAL IMPACT OF NPI

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Percent of physician-related Carrier line items with NPI and/or UPIN July through

Dec., 2007

Neither 0.42

UPIN only 12.35

NPI only 5.30

Both NPI and UPIN 81.93

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NPI implementation – Summary of the new story

Minimal impact on the 2006 data files, but major

conversion by second half of 2007. Still need to

work with UPINs for those 2 years.

2008 and 2009 only have NPI.

Use the TAX_NUM variable which has replaced the

PIN to identify the entity that is paid for the Part B

service.

Specialty code now derived by CMS from NPI.

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Line CMS Provider Specialty Codes

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Gynecology (osteopaths only)(discontinued 5/92 use code 16)

10 = Gastroenterology

11 = Internal medicine

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More line CMS provider specialty codes

40 = Hand surgery

41 = Optometry (revised 10/93 to mean optometrist)

42 = Certified nurse midwife (eff 1/87)

43 = CRNA, anesthesia assistant (eff 1/87)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology (eff 5/92)

47 = Independent Diagnostic Testing Facility (IDTF) (eff. 6/98)

48 = Podiatry

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Examples of uses of the Carrier File

Counting services provided by physicians and

others

Identifying cohorts of persons with chronic

diseases (Next presentation)

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Counting services provided by physicians and other Part B providers

Example: Mammography

How many women received a mammogram in 200X? Example is pre-2007.

How do you define mammography – all??; DX??; screening?? What HCPCS codes do you use?

Why use the Carrier file?

Would you need to use additional files? Any additional codes?

Do you want to count mammograms, or women tested?

What are you worried about in getting an accurate count?

- Too few???, or Too many???

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Mammography HCPCS pre-2007

- Mammography - unilateral 76090

- Mammography - bilateral 76091

- Mammography - screening 76092

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Claims for Mammogram, by Type of Mammogram, Female Medicare Beneficiaries, 1999-2001

(RESIDENTS OF SEER AREAS WITHOUT BREAST CANCER)

Type of

Type of

Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount

File Outpatient Outpatient using both Carrier only

Unilateral - Dx 2,279 1,388 3,667 2,474 1,388

Bilateral - Dx 6,578 3,282 9,860 7,444 3,282

Screening 18,237 10,204 28,441 19,190 10,204

Total claims 27,094 14,874 41,968 29,108 14,874

Total persons 25,359 13,994 39,353 26,112 13,241 753

Source of Data

Number of Claims(Black) or Persons (Red)

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Claims for Mammogram, Female Medicare Beneficiaries, 1999-2001

(Residents of SEER Areas without breast cancer)

Type of

Mammogram Carrier File Outpatient Carrier + Carrier or Overcount Undercount

File Outpatient Outpatient using both Carrier only

Unilateral - Dx

Bilateral - Dx

Screening

Total claims 27,094 14,874 41,968 29,108 14,874

Total persons 25,359 13,994 39,353 26,112 13,241 753

Number of Claims or Persons

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Claims for Mammogram, female Medicare beneficiaries, 1999-2001

(Residents of SEER areas without cancer)

Type of

Mammogram Overcount % Overcount Undercount % of Total if

counting both Carrier only used Carrier only

Unilateral - Dx

Bilateral - Dx

Screening

Total claims 14,874 0.35

Total persons 13,241 50.7 753 0.97

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Using 5% or 100% Carrier File

5% sample verses 100%

You cannot receive 100% national Carrier File

But you may need the 100% Carrier File to have enough power to study smaller geographic areas

May have 100% selected by demographics, diagnoses, procedures, etc. Barb will talk about tomorrow.

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Documents

Using the Carrier File · 2015-07-29 · * Note: In 2011, discontinue 90656 and use Q2035 – Q2039 ... HCPCS modifiers may also change in the course of a study, but much less likely