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The claim line status codes identify the status of a specific detail claim line rather than the entire claim.
A switch indicating whether or not a Managed Care Organization (MCO) has paid the provider for an institutional claim.
The number assigned by the provider to the beneficiary's medical record to assist in record retrieval. The medical record number has special significance for chart review encounters. When the chart review’s purpose is to delete a diagnosis code from the claim, the medical record number should be ‘8’.
The number assigned by the provider to the beneficiary's medical record to assist in record retrieval.
On an institutional claim, the number of days of care that are not chargeable to Medicare facility utilization.
The reason that no Medicare payment is made for services on an institutional claim.
On an institutional claim, the number of covered days of care that are chargeable to Medicare facility utilization that includes full days, coinsurance days, and lifetime reserve days.
It excludes any days classified as non-covered, leave of absence days, and the day of discharge or death.
This field identifies the method of payment of a claim billed within 30 days of a Model 4 Bundled Payments for Care Improvement (BPCI) admission.
This field contains the "Net Reimbursement Amount" of what Medicare would have paid for Global Budget Services from a hospital participating in the particular model. If the claim only includes global services, the reimbursement amount (CLM_PMT_AMT) will reflect $0 (zero). If the claim includes global services and non-global services, the reimbursement amount will reflect the amount Medicare actually paid for the non-global services.
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
This field represents the benefit enhancement indicator that identifies these are Next Generation (NG) Accountable Care Organization (ACO) claims that qualify for specific claims processing edits.
This field represents the benefit enhancement indicator that identifies these are Next Generation (NG) Accountable Care Organization (ACO) claims that qualify for specific claims processing edits
This field represents the benefit enhancement indicator that identifies these are Next Generation (NG) Accountable Care Organization (ACO) claims that qualify for specific claims processing edits.
This field represents the benefit enhancement indicator that identifies these are Next Generation (NG) Accountable Care Organization (ACO) claims that qualify for specific claims processing edits.
This field represents the benefit enhancement indicator that identifies these are Next Generation (NG) Accountable Care Organization (ACO) claims that qualify for specific claims processing edits.
The field identifies the claims that qualify for specific claims processing edits related to benefit enhancement through the Next Generation (NG) Accountable Care Organization (ACO).
The unique number used to identify a unique claim.
The date the claim is no longer the latest action (including chart reviews that link to an original claim).
The code that identifies a significant event relating to an institutional claim that may affect payer processing.
These codes are claim-related occurrences that are related to a time period span of dates (variables called the CLM_SPAN_FROM_DT and CLM_SPAN_THRU_DT).
The code that identifies a significant event relating to an institutional claim that may affect payer processing.
These codes are claim-related occurrences that are related to a time period span of dates (variables called the CLM_SPAN_FROM_DT and CLM_SPAN_THRU_DT).
The from date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.
The first date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).
The from date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.
The first date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).
The thru date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.
The last date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).
The thru date of a period associated with an occurrence of a specific event relating to an institutional claim that may affect payer processing.
The last date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).
On an institutional encounter record, the National Provider Identifier (NPI) number assigned to uniquely identify the physician with the primary responsibility for performing the surgical procedure(s).
On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify the physician with the primary responsibility for performing the surgical procedure(s).
NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009.
The code used to identify the CMS specialty code corresponding to the operating physician. The Affordable Care Act (ACA) provides for incentive payments for physicians and non-physician practitioners with specific primary specialty designations. In order to determine if the physician or non-physicians is eligible for the incentive payment, the specialty code, NPI and name must be carried on the claims.
On an institutional claim, the unique physician identification number (UPIN) of the physician who performed the principal procedure. This element is used by the provider to identify the operating physician who performed the surgical procedure.
NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009.
The code used to identify the CMS specialty code of the rendering physician/practitioner.
This variable is the original intermediary control number (ICN) which is present on adjustment encounter, representing the ICN of the original transaction now being adjusted.
On an institutional claim or encounter record, the National Provider Identifier (NPI) number assigned to uniquely identify the other physician associated with the institutional claim.
On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify the other physician associated with the institutional claim.
NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009.
The code used to identify the CMS specialty code corresponding to the other physician.
On an institutional claim, the unique physician identification number (UPIN) of the other physician associated with the institutional claim.
NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never populated after 2009.
This variable contains the code denoting the method of reimbursement selected by the beneficiary receiving End Stage Renal Disease (ESRD) services for home dialysis (i.e. whether home supplies are purchased through a facility or from a supplier.)
The amount paid, from the Medicare trust fund, to the beneficiary for the services reported on the outpatient claim.
The code indicating the type and priority of an inpatient admission associated with the service on an intermediary submitted claim.
The amount paid, from the Medicare trust fund, to the provider for the services reported on the outpatient claim.
The code derived by CMS based on the type of bill and provider number to identify the outpatient transaction type.
Medicare establishes a daily payment amount to reimburse IPPS hospitals for certain “pass-through” expenses, such as capital-related costs, direct medical education costs, kidney acquisition costs for hospitals that are renal transplant centers, and bad debts. This variable is the daily payment rate for pass-through expenses. It is not included in the CLM_PMT_AMT field.
To determine the total of the pass-through payments for a hospitalization, this field should be multiplied by the claim Medicare utilization day count (CLM_UTLZTN_DAY_CNT). Then, total Medicare payments for a hospitalization claim can be determined by summing this product and the CLM_PMT_AMT field.
The code used to identify the patient relationship to the beneficiary.
The code indicating where the service was performed; the place of service.
Source: Medicare Advantage Organizations (MAOs)
The amount of disproportionate share (rate reflecting indigent population served) portion of the PPS payment for capital.
This is one component of the total amount that is payable for capital PPS for the claim. The total capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.
The number used to determine a transfer adjusted case mix index for capital, under the prospective payment system (PPS). The number is determined by multiplying the Diagnosis Related Group Code (DRG) weight times the discharge fraction.
Medicare assigns a weight to each DRG to reflect the average cost of caring for patients with the DRG compared to the average of all types of Medicare cases. This variable reflects the weight that is applied to the base payment amount.
The DRG weights in this variable reflect adjustments due to patient characteristics and factors related to the stay. For example, payments are reduced for certain short stay transfers or where patients are discharged to post-acute care. Therefore, for a given DRG, the weight in this field may vary.
The capital PPS amount of exception payments provided for hospitals with inordinately high levels of capital obligations. Exception payments expire at the end of the 10-year transition period.
This is one component of the total amount that is payable for capital PPS for the claim. The total capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.