Input and Output Parameter Blocks User’s Guide - COBOL ......Table 1-1: ECB-EZG-CNTL-BLOCK: Fixed length input or output fields for all EASYGroup processing (defined in hctrlblk.cpy)

Input & Output Parameter Blocks User’s Guide

COBOL Platform

V2107.00Last Updated: July 6, 2021 12:45 pm

Input & Output Parameter Block’s User’s Guide

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

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

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Optum | www.optum.com July 6, 2021 Page 3

Table of ContentsSummary of Data Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6ECB-EZG-CNTL-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10PCB1-PATIENT-CLAIM-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23PCB2-CCD-CAH-CLAIM-DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40PCB2-ICD-IP-CLAIM-DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41PCB2-OCD-OP-CLAIM-DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43PCB2-PCD-PHYS-CLAIM-DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45PCB2-RCD-REHAB-CLAIM-DATA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47PCB2-SCD-SNF-CLAIM-DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55DCB-DX-CODE-BLOCK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56OCB-OP-CODE-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59HCT-HCPCS-CODE-TBL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61MOB1-MAP-OUTPUT-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65GOB1-IG1-IP-GRPR-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66GOB1-OG1-OP-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70GOB1-OG2-OP-GRPR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71GOB1-RG1-REHAB-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74GOB1-SG1-SNF-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80GOB2-IG1-IP-GRPR-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81GOB2-OG1-OP-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82GOB2-OG2-OP-GRPR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83GOB2-RG1-REHAB-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87GOB2-SG1-SNF-GRPR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88GOB3-ID1-IP-DX-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89GOB4-IO1-IP-OP-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90POB1-CA1-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91POB1-EP1-ESRD-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93POB1-IP1-IP-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97POB1-OP1-OP-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106POB1-OP2-OP-PRCR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108POB1-PP1-PHYS-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116POB1-RP1-REHAB-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118POB1-SP1-SNF-PRCR-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121POB2-CA1-CAH2-PRCR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122POB2-EP1-ESRD-PRCR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125


POB2-IP1-IP-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127POB2-OP1-OP-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128POB2-OP2-OP-PRCR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129POB2-PP1-PHYS-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137POB2-RP1-REHAB-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140POB2-SP1-SNF-PRCR-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141POB3-EP1-ESRD-PRCR-BLOCK3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142OOB1-OPT-OUTPUT-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144OOB2-IO1-IP-OPT-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146OOB2-OO1-OP-OPT-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147MEB1-MCE-EDITOR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148MEB2-MCE-EDITOR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150MEB3-MCE-EDITOR-BLOCK3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153MEB4-MCE-EDITOR-BLOCK4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154EEB1-EZEDIT-EDITOR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155EEB2-EZEDIT-EDITOR-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156EEB3-EZEDIT-EDITOR-BLOCK3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157EEB4-EZEDIT-EDITOR-BLOCK4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158AEB1-ACE-EDIT-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160AEB2-ACE-EDIT-BLOCK2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164AEB3-ACE-EDIT-BLOCK3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165AEB4-ACE-EDIT-BLOCK4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172AEB5-ACE-EDIT-BLOCK5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174LEB1-LCD-EDIT-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175LEB2-LCD-EDIT-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176LEB3-LCD-EDIT-BLOCK3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177GOB5-OG1-OP-GRPR-BLOCK5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178GOB5-OG2-OP-GRPR-BLOCK5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179GOB5-SG1-SNF-GRPR-BLOCK5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180MOB2-MAP-OUTPUT-BLOCK2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181MOB3-MAP-OUTPUT-BLOCK3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182PEB1-PHY-EDIT-BLOCK1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183PEB2-PHY-EDIT-BLOCK2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185PEB3-PHY-EDIT-BLOCK3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186PWS1-Y1-WKSHT-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188PWS1-E1-WKSHT-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189


PWS1-HC-PRCR-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193PWS1-LT-WKSHT-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199PWS1-N2-WKSHT-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203PWS1-Y2-WKSHT-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204FRB-FUNC-RTN-BLOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206ECB2-EZG-CNTL-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207CAB1-EAM-BLOCK1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208CAB2-EAM-BLOCK2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210CAB3-EAM-BLOCK3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211PWS2-Y1-WKSHT-DATA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213


Summary of Data StructuresThe input and output data structures used for processing by the EASYGroup™ Optimizer are listed in the following table.

Table 0-1: Input and Output Data Structures

Data Structures Length OP Codes10 11 12 13 14 15 16 18

Master Control Structure

ECB-EZG-CNTL-BLOCK Fixed Both Both Both Both Both Both Both BothECB2-EZG-CNTL-BLOCK2 Fixed Both Both Both Both Both Both Both BothDemographic Input Structures

PCB1-PATIENT-CLAIM-BLOCK1 Fixed In In In In In In In InPCB2-PATIENT-CLAIM-BLOCK2 PCB2-CCD-CAH-CLAIM-DATA Fixed In In In In In In In PCB2-ICD-IP-CLAIM-DATA Fixed In In In In In In In

PCB2-OCD-OP-CLAIM-DATA Fixed In In In In In In In PCB2-RCD-REHAB-CLAIM-DATA Fixed In In In In In In PCB2-PCD-PHYS-CLAIM-DATA Fixed In In In In PCB2-SCD-SNF-CLAIM-DATA Fixed In In In In InClinical Data Structures

DCB-DX-CODE-BLOCK Variable In In In In In In In InOCB-OP-CODE-BLOCK Variable In In In In In In In

HCT-HCPCS-CODE-TBL Variable In In In In In In InFixed Length Grouper Output Structures

GOB1-GRPR-OUTPUT-BLOCK1 GOB1-IG1-IP-GRPR-BLOCK1 Fixed Out In Out Out Out Out GOB1-OG1-OP-GRPR-BLOCK1 Fixed Out In Out Out Out Out GOB1-OG2-OP-GRPR-BLOCK2 Fixed Out In Out Out Out Out GOB1-SG1-SNF-GRPR-BLOCK1 Fixed Out In Out Out Out Out GOB1-RG1-REHAB-GRPR-

BLOCK1Fixed Out In Out Out Out Out

Variable Length Grouper Output Structures

GOB2-GRPR-OUTPUT-BLOCK2 GOB2-IG1-IP-GRPR-BLOCK1 Variable Out In Out Out Out Out GOB2-OG1-OP-GRPR-BLOCK1 Variable Out In Out Out Out Out GOB2-OG2-OP-GRPR-BLOCK2 Variable Out In Out Out Out Out GOB2-SG1-SNF-GRPR-BLOCK1 Variable Out In Out Out Out Out GOB2-RG1-REHAB-GRPR-

BLOCK1Variable Out In Out Out Out Out

GOB3-GRPR-OUTPUT-BLOCK3 GOB3-ID1-IP-DX-BLOCK1 Variable Out In Out Out Out Out


GOB4-GRPR-OUTPUT-BLOCK4 GOB4-IO1-IP-OP-BLOCK1 Variable Out In Out Out Out OutFixed Length Pricer Output Structures

POB1-PRCR-OUTPUT-BLOCK1 POB1-CA1-PRCR-BLOCK1 Fixed Out Out Out Out POB1-IP1-IP-PRCR-BLOCK1 Fixed Out Out Out Out POB1-OP1-OP-PRCR-BLOCK1 Fixed Out Out Out Out POB1-OP2-OP-PRCR-BLOCK2 Fixed Out Out Out Out POB1-SP1-SNF-PRCR-BLOCK1 Fixed Out Out Out Out POB1-RP1-REHAB-PRCR-

BLOCK1Fixed Out Out Out Out

POB1-PP1-PHYS-PRCR-BLOCK1

Fixed Out Out Out

Variable Length Pricer Output Structures

POB2-PRCR-OUTPUT-BLOCK2 POB2-CA1-CAH2-PRCR-

BLOCK2Variable Out Out Out

POB2-IP1-IP-PRCR-BLOCK1 Variable Out Out Out POB2-OP1-OP-PRCR-BLOCK1 Variable Out Out Out POB2-OP2-OP-PRCR-BLOCK2 Variable Out Out Out POB2-SP1-SNF-PRCR-BLOCK1 Variable Out Out Out POB2-RP1-REHAB-PRCR-

BLOCK1Variable Out Out Out

POB2-PP1-PHYS-PRCR-BLOCK1

Variable Out Out

POB3-PRCR-OUTPUT-BLOCK3 Variable Out Out OutPOB3-EP1-ESRD-PRCR-BLOCK3

Variable Out Out Out

Fixed and Variable Length Output Structures for DSC Editor

MEB1-MCE-EDITOR-BLOCK1 Fixed Out OutMEB2-MCE-EDITOR-BLOCK2 Variable Out OutMEB3-MCE-EDITOR-BLOCK3 Variable Out OutMEB4-MCE-EDITOR-BLOCK4 Variable Out OutFixed and Variable Length Output Structures for EASYEdit™

EEB1-EZEDIT-EDITOR-BLOCK1 Fixed Out OutEEB2-EZEDIT-EDITOR-BLOCK2 Variable Out OutEEB3-EZEDIT-EDITOR-BLOCK3 Variable Out OutEEB4-EZEDIT-EDITOR-BLOCK4 Variable Out OutFixed and Variable Length Output Structures for ACE

AEB1-ACE-EDIT-BLOCK1 Fixed Out Out




AEB2-ACE-EDIT-BLOCK2 Variable Out OutAEB3-ACE-EDIT-BLOCK3 Variable Out Out In Out Out OutAEB4-ACE-EDIT-BLOCK4 Variable Out OutAEB5-ACE-EDIT-BLOCK5 Variable Out OutFixed and Variable Length Output Structures for LCD Editor

LEB1-LCD-EDIT-BLOCK1^ Fixed Out OutLEB2-LCD-EDIT-BLOCK2^ Variable Out OutLEB3-LCD-EDIT-BLOCK3^ Variable Out OutLEB4-LCD-EDIT-BLOCK4^ Variable Out OutFixed and Variable Length Output Structures for Physician Editor

PEB1-PHY-EDIT-BLOCK1 Fixed Out OutPEB2-PHY-EDIT-BLOCK2 Variable Out OutPEB3-PHY-EDIT-BLOCK3 Variable Out In OutFixed Length Analyzer Output Structures

CAB1-CLM-ANALYZER-BLOCK1 CAB1-EAM-BLOCK1 Fixed Out Out Out Out Out OutVariable Length Analyzer Output Structures

CAB2-CLM-ANALYZER-BLOCK2 CAB2-EAM-BLOCK2 Variable Out Out Out Out Out OutCAB3-CLM-ANALYZER-BLOCK3 CAB3-EAM-BLOCK3 Variable Out Out Out Out Out OutPayer-Specific Reimbursement Worksheet Structures

PWS1-E1-WKSHT-BLOCK Fixed Out Out Out OutPWS1-HC-PRCR-BLOCK1 Fixed Out Out Out OutPWS1-LT-WKSHT-BLOCK1 Fixed Out Out Out OutPWS1-N2-WKSHT-BLOCK Fixed Out Out Out OutPWS1-Y2-WKSHT-BLOCK Fixed Out Out Out OutPWS1-Y1-WKSHT-BLOCK Fixed Out Out Out OutPWS2-Y1-WKSHT-DATA Fixed Out Out Out OutFixed and Variable Length Output Structure for Mapper

MOB1-MAP-OUTPUT-BLOCK1 Fixed Out Out Out Out OutMOB2-MAP-OUTPUT-BLOCK2Note: ICD-10 Mapper Only.

Fixed Out Out Out Out Out

MOB3-MAP-OUTPUT-BLOCK3Note: ICD-10 Mapper Only.

Fixed Out Out Out Out Out

Fixed and Variable Length Optimizer Output Structures

OOB1-OPT-OUTPUT-BLOCK1 Fixed Out Out Out Out Out Out Out OutOOB2-OPT-OUTPUT-BLOCK2 Variable OOB2-IO1-IP-OPT-BLOCK1 Variable Out




NoteThe above structures listed with an ^ have been allocated for future expansion and may be used internally. These structures are not currently supported.

OOB2-IO2-IP-OPT-BLOCK2 Variable Out OOB2-OO1-OP-OPT-BLOCK1^ Variable Out



Table 0-1:

Legend: In = Input OP Codes: 10 = Analyze/Edit In = Input plus optional output 11 = Analyze/GroupOut = Output 12 = Analyze/PriceBoth = Input and output 13 = Model (using DRG weights only)

14 = Model15 = Analyze/Group/Price16 = Analyze/Edit/Group/Price17 = Map only18 = Analyze only


ECB-EZG-CNTL-BLOCKTable 1-1: ECB-EZG-CNTL-BLOCK: Fixed length input or output fields for all EASYGroup™ processing (defined in hctrlblk.cpy)

Field Description Variable Name Format Position NotesReserved ECB-RTN-RSVD X(10) 1 - 10Operation Code 1 ECB-OPCODE1 X(2) 11 - 12 01 = Analyze/Edit*

02 - 09 = Reserved10 = Analyze/Edit*11 = Analyze/Group*12 = Analyze/Price* (assumes case-mix measure

already assigned)13 = Model using DRG weights only14 = Model15 = Analyze/Group/Price*16 = Analyze/Edit/Group/Price*17 = Map only18 = Analyze only*

O1 = Open filesO2 = Open files when ECB-OPCODE1 = 13C1 = Close filesC2 = Close files when ECB-OPCODE1 = 13

R1 = Retrieve payer filesBR = Calculate base rate

Note*Analyzer output is only returned if a value greater than zero is passed in the Analyzer Type field.

Operation Code 2 ECB-OPCODE2 X(2) 13 - 14 ReservedOperation Code 3 ECB-OPCODE3 X(2) 15 - 16 ACE:

00 = All other requests01 = Group only with ACE

Set this field to 01 if your processing request includes ACE and you want to bypass all ACE Edits, but you want to apply all other ACE logic including APC and payment status assignment, discounting, and packaging.

To use the value of 01 your request must be for an outpatient claim and must also include Operation Code 1 (ECB-OPCODE1) with a value of 01 (Edit Only), or with a value of 16 (Edit, Group, and Price).

Operation Code 4 ECB-OPCODE4 X(2) 17 - 18 Reserved


Patient Type ECB-PATTYPE X(1) 19 DRG Pro, Medicare Inpatient, Medicare IPF, Medicare LTC, Medicare SNF, Michigan Medicaid, New Jersey Medicaid, TRICARE/CHAMPUS, Washington HCA:01 = Inpatient

APC Pro, ASC Pro, Medicare OPPS, Medicare ASC, Medicare CAH Method II, Medicare ESRD, Medicare FQHC, Medicare HHA, Medicare Hospice, Michigan Medicaid APC, New York Medicaid APG, TRICARE APC:02 = Outpatient

Medicare IRF:03 = Inpatient Rehabilitation Facility (IRF)

Medicare Physician:04 = Physician

Medicare CAH Method II:05 = CAH Method II

Medicare SNF:06 = Skilled Nursing Facility (SNF)

Reserved ECB-ESEQ-RSVD X(1) 20 ReservedICD-9/ICD-10 Mapping Flag

ECB-MAP-FLAG 9(1) 21 0 = No mapping 1 = Standard mapping2 = State-specific mapping

NoteState-specific mapping is only utilized with the following Groupers: Wisconsin Medicaid (prior to V33), Ohio Medicaid, and North Carolina Medicaid.

Only required if rate files are not being utilized.

Grouper Option Flag ECB-OPTION-FLAG 9(1) 22 AP-DRG V14 Grouper Only:0 = Otherwise1 = Use the New York version of AP-DRG Grouper

Table 1-1: ECB-EZG-CNTL-BLOCK: Fixed length input or output fields for all EASYGroup™ processing (defined in hctrlblk.cpy)

Field Description Variable Name Format Position Notes


Grouper Type ECB-GRPR-TYPE X(2) 23 - 24 01 = Medicare DRG02 = All Patient (AP-DRG)03 = TRICARE/CHAMPUS DRG11 = ICD-10 Medicare DRG12 = ICD-10 TRICARE DRG22 = Medicare SNF RUG (prior to October 01, 2019)23 = Medicare SNF Reader (effective October 01,

2019)24 = Medicare HHA PDGM (effective January 01,

2020)39 = Medicare FQHC52 = Reserved53 = Reserved55 = Medicare APC57 = Medicare ASC (effective January 01, 2008)59 = Medicare ASC (prior to January 01, 2008)60 = Medicare ESRD62 = Medicare HHA HHRG (prior to January 01,

2020)66 = Medicare CAH Method II67 = Medicare Hospice90 = Medicare IRF CMG

NoteOnly required if rate files are not being utilized.

Grouper Type Reserved ECB-GRPR-TYPE-RSVD

X(2) 25 - 26 Reserved

Grouper Version Number

ECB-GRPR-VERS 9(2) 27 - 28 Two-digit Grouper version number. For example, if the Grouper version equals 2 the format should be “02.” If the Grouper version equals 32 the format should be “32.”


Grouper Version Reserved

ECB-GRPR-VERS-RSVD

9(4) 29 - 32 Reserved




Pricer Type ECB-PRCR-TYPE X(2) 33 - 34 Patient Type 1 - Inpatient:01 = Medicare DRG02 = Reserved03 = TRICARE04 = New Jersey Medicaid05 = Pennsylvania Medicaid06 = Washington HCA case-based07 = Washington HCA non-case-based14 = Multi-Pricer/DRG Pro17 = Michigan Medicaid18 = Medicare Long Term Care19 = Medicare Inpatient Psychiatric

Patient Type 2 - Outpatient:39 = Medicare FQHC52 = Reserved54 = Reserved55 = Medicare ASC56 = Medicare APC-HOPD57 = Contract APC59 = Reserved60 = Medicare ESRD62 = Medicare HHA64 = Contract ASC67 = Medicare Hospice

Patient Type 3 - Inpatient Rehabilitation:90 = Medicare IRF

Patient Type 4 - Physician:65 = Medicare Physician

Patient Type 5 - CAH Method II:66 = Medicare CAH Method II

Patient Type 6 - Skilled Nursing:22 = Medicare SNF


Pricer Type Reserved ECB-PRCR-TYPE-RSVD


Editor Type ECB-EDTR-TYPE X(2) 37 - 38 ReservedEditor Type Reserved ECB-EDTR-TYPE-

RSVDX(2) 39 - 40 Reserved

Editor Version Number ECB-EDTR-VERS 9(2) 41 - 42 ReservedEditor Version Release ECB-EDTR-REL X(1) 43 ReservedEditor Version Reserved

ECB-EDTR-VERS-RSVD


Norms Type ECB-NORMS-TYPE X(29) 47 - 75 Reserved




Request for Date-Sensitive/MCE Editing

ECB-EDIT-MCE-SW 9(1) 76 0 = No edits requested1 = Request DSC edits


Request for EASYEdit™ editing

ECB-EDIT-EZ-SW 9(1) 77 0 = No edits requested1 = Request EASYEdit™ edits


Request for CCI Editing ECB-EDIT-CCI-SW 9(1) 78 0 = No edits requested1 = Request CCI edits (for ASC)


Refer to the EASYGroup™ User’s Guide for a list of default ACE edits.

Request for OCE Editing

ECB-EDIT-OCE-SW 9(1) 79 0 = No edits requested1 = Request OCE edits (for FQHC)



Request for OCE Editing with CCI Code Pairs

ECB-EDIT-OCE-CCI-SW

9(1) 80 0 = No edits requested1 = Request OCE edits with CCI edit pairs returned

(for APC, ESRD, HHA, Hospice, and SNF)



Request for LCD/NCD Editing

ECB-EDIT-LCD-SW 9(1) 81 0 = No edits requested1 = Request LCD/NCD edits





Request for Non-OPPS OCE Editing With CCI Code Pairs

ECB-EDIT-NOCE-SW

9(1) 82 0 = No edits requested1 = Request non-OPPS OCE edits (for Maryland

and Critical Access Hospitals (CAHs)) with CCI edit pairs returned



Request for POA Editing

ECB-EDIT-POA-SW 9(1) 83 0 = No edits requested1 = Request POA edits


Request for HAC Editing

ECB-EDIT-HAC-SW 9(1) 84 0 = No edits requested1 = Request HAC edits


Request for TRICARE APC Editing

ECB-EDIT-TRICARE-SW

9(1) 85 0 = No edits requested1 = Request TRICARE OCE edits


Request for Physician Editing

ECB-EDIT-PHYS-SW

9(1) 86 0 = No edits requested1 = Request physician edits, MUEs applied based

on taxonomy


Request for Medicaid Inpatient Editing

ECB-EDIT-MDCD-SW

9(1) 87 0 = No edits requested1 = Request Medicaid inpatient edits


Request for Physician Editing 2

ECB-EDIT-MAXMUE

9(1) 88 0 = No edits requested1 = Request physician edits, max of DME and

Practitioner MUE applied


Reserved ECB-EDIT-MOE 9(1) 89 Reserved




Request for CAH Method II Editing

ECB-EDIT-CAH2 9(1) 90 0 = No edits requested1 = Request CAH Method II edits


Filler 9(5) 91 - 95Editor Reserved ECB-RSVD-REQ3 9(10) 96 - 105 ReservedEditor Reserved ECB-RSVD-REQ4 9(10) 106 - 115 ReservedKey Type ECB-KEY-TYPE X(1) 116 Output field.

0 or blank = Legacy Provider ID used for rate lookup1 = NPI plus Taxonomy Code used for rate lookup

ACE Override ID ECB-ACE-OVERRIDE-ID

X(20) 117 - 136 ACE:The ACE Override ID invokes override functionality. This override functionality allows the user to turn particular ACE edits on or off.


HAC Override ID ECB-HAC-OVERRIDE-ID

X(10) 137 - 146 DSC Editor, AP-DRG Grouper, Medicare DRG Grouper, TRICARE/CHAMPUS Grouper, and Wisconsin DRG Grouper:Unique key used by the DSC Editor or DRG Grouper to determine what HACs should be applied to this facility.


Editor Flag ECB-ACE-FLAG 9(1) 147 Output field.ACE and CAH Method II:1 = ACE was run and results are available0 = Otherwise

DSC Flag ECB-DSC-FLAG 9(1) 148 Output field.1 = Date-Sensitive Code Editor was run and results

are available0 = Otherwise

CCI Edit Bypass ECB-BYPASS-CCI-EDITS

9(1) 149 Reserved

Flag Reserved ECB-FLAG-RSVD 9(8) 150 - 157 ReservedRetrieve Payer ECB-PYR-LOOKUP-

SWX(1) 158 1 = Lookup analyzing, editing, grouping, and

mapping rules in the rate files0 = Otherwise

NoteFor analyze only, analyze/edit only, map only, and analyze/group calls.




Alternate Rate Look-up ECB-PYR-ALTLOOK-SW

X(1) 159 Flag used to indicate that additional search(es) of the rate files should be performed if the initial search fails.

Medicare Physician:0 = Perform search of the rate files using NPI and

taxonomy. 1 = Perform search of the rate files using NPI and

taxonomy. If not found, perform second search of the rate files using NPI 9999999999 and taxonomy.

2 = Perform search of the rate files using NPI and taxonomy. If not found or closed/inactive rate record encountered, perform second search of the rate files using NPI 9999999999 and taxonomy.

All Other Patient Types: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.

Facility Retrieved ECB-PYR-FACILITY X(29) 160 - 188 Output field used for EASYGroup™ processing. The information returned in this field is also returned in the following ECB2 fields with more specificity. - ECB2-NPI-USED- ECB2-TAXONOMY-USED- ECB2-FACILITY-USED- ECB2-PAYSRC-USED




Patient Type Retrieved ECB-PYR-PATTYPE X(1) 189 Output field used for EASYGroup™ processing.Patient Type Extension ECB-PYR-ESEQ-

EXTX(1) 190 Reserved

Sequence Number Retrieved

ECB-PYR-ESEQ 9(4) 191 - 194 Output field used for EASYGroup™ processing.

Effective Date Retrieved

ECB-PYR-EDATE 9(8) 195 - 202 Output field used for EASYGroup™ processing.

Extended Structure Switch

ECB-EXT-BLK-SW X(1) 203 1 = Enable

ASC Override ID ECB-ASC-OVERRIDE-ID

X(20) 204 - 223 Used to identify the appropriate override pattern in the ASC Override file.


Mapping Override ID ECB-MAP-OVERRIDE-ID

X(20) 224 - 243 ICD-10 Mapper:Used to identify the appropriate override pattern in the Mapper override file.


Mapping Category ECB-MAP-CATEGORY

X(2) 244 - 245 ICD-10 Mapper:01 = CMS reimbursement02 = Optum premier pick03 = Wisconsin Medicaid-specific


Mapper Type ECB-MAPPER-TYPE

X(2) 246 - 247 ICD-10 Mapper:02 = ICD-10 Mapper

Mapper Type Reserved ECB-MAPPER-TYPE-RSVD

X(2) 248 - 249 Reserved

ICD-9 or ICD-10 Coding Classification

ECB-CODE-CLASS X(2) 250 - 251 00 = ICD-9 coded claim01 = ICD-10 coded claim

Mapper Target Version ECB-MAP-TARGET X(2) 252 - 253 ICD-10 Mapper:Target version for code mapping. If the Mapper Target Version number is different than the Grouper version and the ICD-10 Mapper has been licensed, diagnosis and procedure codes will be translated or mapped to the coding version supplied here (e.g., if the Mapper Target Version is 33, ICD-9-CM codes supplied will be translated to ICD-10-CM/PCS codes that are available for testing).




Closed Rate Record Switch

ECB-CLOSED-FAC-SW

X(1) 254 Flag used to identify that a rate record is closed. Refer to the EASYGroup™ User’s Guide for an explanation of why a rate record may be closed. Claims that utilize a closed rate record will receive Function Return Code 62 (Closed or Inactive Rate Record).

0 = Open1 = Closed


Physician Editor Flag ECB-PE-FLAG 9(1) 255 Physician Editor and CAH Method II Editor:Output field.1 = Physician Editor was run and results are

available0 = Physician Editor was not run

Birth Weight Option Selected

ECB-BWGT-OPTION

X(1) 256 Reserved

Discharge APR-DRG Option

ECB-DISCH-DRG-OPTION

X(1) 257 Reserved

HAC Version ECB-HAC-VERSION

9(3) 258 - 260 Reserved

State CCI ECB-STATECCI X(2) 261 - 262 Two character abbreviation to determine which CCI/MUE editing rules to apply.

ACE:Blank (default) = Medicare CCI/MUEDM = Medicare Durable Medical Equipment (DME)MI = Michigan Medicaid CCI/MUESD = South Dakota Medicaid CCI/MUEUS = Medicare CCI/MUEU2 = National Medicaid CCI/MUE

CAH Method II Editor:Blank (default) = Medicare CCI/MUEUS = Medicare CCI/MUE


User Key ECB-USER-KEY X(3) 263 - 265 ReservedApply CCI/MUE Edits ECB-LINE-BYPASS-

SWX(1) 266 Reserved

Function Return Code ECB-FUNC-RTN-RSVD

X(2) 267 - 268 Reserved




ICD-9 Grouper Routing Flag

ECB-ICD9-ROUTING

9(1) 269 ICD-10 Medicare DRG and ICD-10 TRICARE DRG Groupers:Used to automatically send ICD-9 claims that are configured to utilize an ICD-10 Grouper Version after V32 to the equivalent final ICD-9 Grouper Version.

For example, if this option is enabled, ICD-9 claims sent to the ICD-10 Medicare DRG V33 Grouper will be automatically routed to the ICD-9 Medicare DRG V32 Grouper.

0 = Do Not Enable Routing1 = Enable Routing


APC Override ID ECB-APC-OVERRIDE-ID

X(20) 270 - 289 ACE:The APC Override ID invokes override functionality. This override functionality allows the user to override APC, Payment Status Indicators, and maximum allowable units assignment for a particular procedure code.

If this field is left blank, th ACE Override ID (ECB-ACE-OVERRIDE-ID) field will be utilized.


Version Qualifier ECB-VERS-QUAL X(1) 290 ReservedAnalyzer Type ECB-ANLZ-TYPE X(2) 291 - 292 00 = No Analyzer

01 = Reserved02 = E&M Analyzer Pro


Analyzer Type Reserved

ECB-ANLZ-TYPE-RSVD

X(2) 293 - 294 Reserved

Analyzer Version ECB-ANLZ-VERS 9(2) 295 - 296 Two digit version number of the Analyzer.


Analyzer Version Reserved

ECB-ANLZ-VERS-RSVD

9(4) 297 - 300 Reserved




E&M Analyzer Pro Starting Visit Level Option

ECB-EDC-START-LVL

9(1)occurs 5 times

301 - 305 E&M Analyzer Pro:Array of indicators to identify the claim starting visit levels that should be processed by the Analyzer.

For example, to process only those claims with a starting visit level of 4 or 5, set this field to 00011.

To process all claims, set this field to 11111.


E&M Analyzer Pro Visit Level Change Option

ECB-EDC-CHANGE-LVL

9(1) 306 E&M Analyzer Pro:The number of visit level changes that should be processed by the Analyzer.

For example, to only process claims that have a visit level change of 2 or more levels, set this field to 2.

To process all visit level changes, set this field to 1.


E&M Analyzer Pro Action

ECB-EDC-ACTION 9(1) 307 E&M Analyzer Pro:0 = Return visit level recommendation only; visit

code required1 = Return visit level recommendation and apply

results to reimbursement (if applicable); visit code required

2 = Return visit level recommendation if visit level is decreased and apply results to reimbursement (if applicable); visit code required

3 = Return visit level recommendation only; visit code not required

NoteResults only apply to reimbursement if the Operation Code 1 (ECB-OPCODE1) field is set to a value that includes both analyzing and pricing.

Only required if rate files are not being utilized.

Configuration File Override Option

ECB-OVERRIDE-REQ

9(1) 308 0 = Analyzer options in the Configuration File take precedence

1 = Analyzer options in the EASYGroup™ control block structure take precedence

Filler 309 - 317 ReservedFacility Type ECB-FACILITY-

TYPEX(2) 318 - 319 Reserved

Rate File Version ECB-RATEFILE-VERS

X(7) 320 - 326 Output field. Version of the Optum-supplied rate file that was used to process this claim.




Log Request ECB-LOG-REQ X(1) 327 ReservedE&M Analyzer Pro Audit or Adjudication Indicator

ECB-AA-IND 9(1) 328 Reserved

Filler X(72) 329 - 400




PCB1-PATIENT-CLAIM-BLOCK1Table 2-1: PCB1-PATIENT-CLAIM-BLOCK1: Fixed length input fields for all EASYGroup™ processing (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesProvider Identifier PCB1-FACILITY X(16) 1 - 16 Facility or provider identifier (i.e., Medicare Provider

ID, TIN, or other identifier).

NoteSubmit NPI in NPI field.

Payer ID or Contract Code

PCB1-PAYSRC X(13) 17 - 29 Payer identifier or contract code. Required.

01 = New York Worker’s Compensation02 = New York Medicaid Managed Care (MMC),

including Medicaid Rebasing per Discharge04 = New Jersey Medicaid09 = Medicare Reimbursement Pricing Rules and

Variables13 = New York No Fault14 = New York Medicaid Managed Care (MMC),

excluding Medicaid Rebasing per Discharge15 = New York Medicaid Fee-for-Service (FFS)

(APR-DRG only)40 = Michigan Medicaid APC Reimbursement

Pricing Rules and Variables80 = Kentucky Medicaid Reimbursement Pricing

Rules and Variables90 = Michigan Medicaid ASC Reimbursement

Pricing Rules and Variables9960 = TRICARE DRG Reimbursement Pricing

Rules and VariablesFrom or Admission Date PCB1-FROM-DATE 9(8) 30 - 37 UB-04 FL06. The first date of service on the claim.

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

Thru or Discharge Date PCB1-THRU-DATE 9(8) 38 - 45 UB-04 FL06. The last date of service on the claim.YYYYMMDD, where:YYYY = year including centuryMM = month; 01 - 12DD = day; 01 - 31

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


Effective Date PCB1-EFF-DATE 9(8) 46 - 53 If provided, this date will be used to select the reimbursement variables used for pricing. If not provided, the From Date or the Thru Date will be used depending on the type of claim.YYYYMMDD, where:YYYY = year including centuryMM = month; 01 - 12DD = day; 01 - 31

Set equal to from or thru date based on pricing rules.Date of Birth PCB1-BIRTH-DATE 9(8) 54 - 61 UB-04 FL10. Not required if age is submitted.

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

For IRF, 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 Flag PCB1-AGE-FLAG X(2) 62 - 63 ReservedAge in Years PCB1-AGE 9(3) 64 - 66 Patient age in years. Required. Right-justified, zero-

filled.

Medicare IRF:Valid values are 000-140. If age is not available, set to blanks. Age will be calculated using PCB1-FROM-DATE and PCB1-BIRTH-DATE.

All Other:Valid values are 000-124.

NoteAge in Years must be passed in and will not be calculated by EASYGroup™ based upon other claims information. For IRF and ACE there may be some exceptions.

Table 2-1: PCB1-PATIENT-CLAIM-BLOCK1: Fixed length input fields for all EASYGroup™ processing (defined in hpclmblk.cpy)



Sex PCB1-SEX X(1) 67 UB-04 FL11. 1500.3. Patient sex/gender. Required.

Valid values are:- 0, 3, or U = Unknown- 1 or M = Male- 2 or F = Female

NoteA value of 0 is not accepted by the ICD-10 Medicare DRG Grouper or ICD-10 TRICARE Grouper. For these groupers, if sex is unknown, 3 or U should be submitted.

Medical Record Number

PCB1-MED-NUM X(20) 68 - 87 UB-04 FL03B. Optional field to uniquely identify patient.

Patient Control Number PCB1-CTR-NUM X(20) 88 - 107 UB-04 FL03A. Optional field to uniquely identify a patient account.

Filler X(6) 108 - 113Number of Diagnosis Codes

PCB1-DCT-NUMDX 9(3) 114 - 116 Count of ICD-9-CM or ICD-10-CM diagnosis codes (number of DCB-DX-CODE-BLOCK occurrences). Required if diagnosis codes are being passed to any EASYGroup™ products.

Number of Procedure Codes

PCB1-OCT-NUMOP 9(3) 117 - 119 Count of ICD-9-CM or ICD-10-PCS procedure codes (number of OCB-OP-CODE-BLOCK occurrences). Required if procedure codes are being passed to any EASYGroup™ products.

Number of HCPCS Codes

PCB1-HCT-NUMHCPCS

9(3) 120 - 122 Count of claim lines submitted (number of HCT-HCPCS-CODE-TBL occurrences) with or without HCPCS procedure codes. Required if claim lines are being passed to any EASYGroup™ products.




Discharge Disposition PCB1-DSTAT 9(2) 123 - 124 UB-04 FL17. Patient Discharge Status. Required.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 care05 = 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 patient40 = Expired at home (for hospice care only)41 = Expired in a medical facility (for hospice care

only)42 = Expired - place unknown (for hospice care only)43 = 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)

69 = Discharged/transferred to a designated disaster alternative care site (effective 10/1/2013)

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

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

continued below...




Discharge Disposition<continued>

PCB1-DSTAT 9(2) 123 - 124 72 = Outpatient services, this facility (valid October 1, 2001 through September 30, 2003)

81 = Discharged to Home or Self-Care With a Planned Acute Care Hospital Inpatient Readmission

82 = Discharged/Transferred to a Short Term General Hospital for Inpatient Care With a Planned Acute Care Hospital Inpatient Readmission

83 = Discharged/Transferred to a Skilled Nursing Facility (SNF) With Medicare Certification With a Planned Acute Care Hospital Inpatient Readmission

84 = Discharged/Transferred to a Facility That Provides Custodial or Supportive Care With a Planned Acute Care Hospital Inpatient Readmission

85 = Discharged/Transferred to a Designated Cancer Center or Children’s Hospital With a Planned Acute Care Hospital Inpatient Readmission

86 = Discharged/Transferred to Home Under Care of Organized Home Health Service Organization With a Planned Acute Care Hospital Inpatient Readmission

87 = Discharged/Transferred to Court/Law Enforcement With a Planned Acute Care Hospital Inpatient Readmission

88 = Discharged/Transferred to a Federal Health Care Facility With a Planned Acute Care Hospital Inpatient Readmission

89 = Discharged/Transferred to a Hospital-Based Medicare Approved Swing Bed With a Planned Acute Care Hospital Inpatient Readmission

90 = Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF) Including Rehabilitation Distinct Part Units of a Hospital With a Planned Acute Care Hospital Inpatient Readmission

91 = Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH) With a Planned Acute Care Hospital Inpatient Readmission

92 = Discharged/Transferred to a Nursing Facility Certified Under Medicaid But Not Certified Under Medicare with a Planned Acute Care Hospital Inpatient Readmission

93 = Discharged/Transferred to a Psychiatric Distinct Part Unit of a Hospital With a Planned Acute Care Hospital Inpatient Readmission

94 = Discharged/Transferred to a Critical Access Hospital (CAH) With a Planned Acute Care Hospital Inpatient Readmission

continued below...




Discharge Disposition<continued>

PCB1-DSTAT 9(2) 123 - 124 95 = Discharged/Transferred to Another Type of Health Care Institution Not Defined Elsewhere in This Code List With a Planned Acute Care Hospital Inpatient Readmission

Total Covered Charges PCB1-TOT-CHG 9(8)v9(2) 125 - 134 UB-04 FL47-48. Report Total Covered Charges in this field which is calculated by subtracting the Non-Covered Charges (FL 48) from the Total Charges (FL 47).

Length of Stay PCB1-LOS 9(4) 135 - 138 Length of stay in days. Right-justified, zero-filled. Required. Valid values range from 0001 to 9999.

Medicare Inpatient:If the Admit Date (PCB1-ADMIT-DATE) is <= the From Date (PCB1-FROM-DATE), set equal to the Thru Date (PCB1-THRU-DATE) - the From Date (PCB1-FROM-DATE). Set equal to 0001 when the Thru Date (PCB1-THRU-DATE) is the same as the From Date (PCB1-FROM-DATE).

If the Admit Date (PCB1-ADMIT-DATE) is > the From Date (PCB1-FROM-DATE), set equal to the Thru Date (PCB1-THRU-DATE) - the Admit Date (PCB1-ADMIT-DATE). Set equal to 0001 when the Thru Date (PCB1-THRU-DATE) is the same as the Admit Date (PCB1-ADMIT-DATE).

NoteFor interim claims, set to the number of days in the billing period.

Medicare Outpatient/CAH Method II/HHA/Hospice/Physician:Set equal to the Thru Date (PCB1-THRU-DATE) - the From Date (PCB1-FROM-DATE) + 1.

Medicare SNF (Part A):If the Discharge Disposition (PCB1-DSTAT) = 30 (Still a Patient), set equal to the Thru Date (PCB1-THRU-DATE) – the From Date (PCB1-FROM-DATE) plus one day. Otherwise, set equal to the Thru Date (PCB1-THRU-DATE) – the From Date (PCB1-FROM-DATE) (do not include the day of discharge).

Filler X(17) 139 - 155UB-04 Occurrence Array

PCB1-OCCURENCE

X(10)occurs 8 times

156 - 235 Array of UB-04 occurrence codes and dates.

Occurrence Code PCB1-OCCUR-CODE

X(2) UB-04 FL31-34. Occurrence codes.




Occurrence Date PCB1-OCCUR-DATE

9(8) UB-04 FL31-34. Occurrence dates.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Filler X(20) 236 - 255UB-04 Occurrence Span Array

PCB1-OCCURENCE-SPAN

X(18) occurs 4 times

256 - 327 Array of UB-04 occurrence span codes and dates.

Occurrence Span Code

PCB1-SPAN-CODE X(2) UB-04 FL35-36. Occurrence span codes.

Occurrence Span From Date

PCB1-SPAN-DATE1 9(8) UB-04 FL35-36. Occurrence span date 1.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Occurrence Span Thru Date

PCB1-SPAN-DATE2 9(8) UB-04 FL35-36. Occurrence span date 2.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Filler X(108) 328 - 435 ReservedUB-04 Admit Source PCB1-

ADMSOURCEX(2) 436 - 437 UB-04 FL15. Source of referral for admission or visit.

For numeric admit sources this field should be right-aligned and zero filled. For admit sources that contain letters only this field should be left-aligned and blank filled. For example, if the Admit Source equals A it should be passed as follows: “A “.

01 = Non-healthcare facility point of origin02 = Clinic or physician's office03 = Health Maintenance Organization (HMO)

referral (prior to October 01, 2007) 04 = Transfer from a hospital 05 = Transfer from a Skilled Nursing Facility (SNF) 06 = Transfer from another health care facility 07 = Emergency room (prior to July 01, 2010)08 = Court/law enforcement 09 = Information Not Available A = Transfer from Critical Access Hospital (CAH)

(prior to October 01, 2007)B = Transfer from another Home Health Agency

(HHA) (prior to July 01, 2010) C = Re-admission to same HHA (prior to July 01,

2010)D = Transfer from hospital inpatient in same facility

resulting in separate claimG = Transferred from a designated disaster

Alternative Care Site (ACS)Filler X(1) 438 Reserved




Maximum Number of CCI Pairs

PCB1-MAXCCIERR 9(3) 439 - 441 Maximum number of OCE/CCI or CCI code pairs to be returned for a single claim. Optional for any claims subject to CCI edits, including APC, ASC, CAH, ESRD, HHA, Maryland hospital, and SNF claims.

NoteIf space or throughput is no constraint, set = 999. If space or throughput is a constraint, set to = 020 (minimum). If no CCI error details are desired, set = 000.

Filler X(1) 442 ReservedMaximum Acceptable Level of Error

PCB1-ACCEPT-IF 9(2) 443 - 444 ACE, CAH Method II Editor, and Physician Editor:(For ECB-OPCODE1 = 16 only) Level of error that will be acceptable to continue grouping and pricing. If a claim has a final disposition that is less than or equal to this value, the claim will be grouped and priced. Otherwise, the claim will not be grouped or priced. To price everything without an error, set = 06. To price clean claims only, set = 00.

00 = Price clean claims only01 = Price every line without an error if claim

contains line item rejection errors only02 = Price every line without an error if claim

contains line item denial and rejection errors only03 = Price every line without an error if claim

contains line item denial, line item rejection, and claim suspension errors only

04 = Price every line without an error if claim contains line item denial, line item rejection, claim suspension, and claim RTP errors only

05 = Price every line without an error if claim contains line item denial, line item rejection, claim suspension, claim RTP, and claim rejection errors only

06 = Price every line without an error

ACE (CCI Edit Only Calls):Level of error that will be acceptable to continue with pricing. If a claim has a final disposition that is less than or equal to this value, the claim will be sent for pricing and claim lines without errors will be eligible for payment. Otherwise, the claim will not be sent for pricing. To price every line item without an error, set = 02. To price clean claims only, set = 00.

Filler X(5) 445 - 449Physician ID PCB1-PHYS-ID X(16) 450 - 465 Physician identifier. For facility claims only.Coder ID PCB1-CODER-ID X(20) 466 - 485 HIM professional identifier who assigned the codes

to this case.




UB-04 Bill Type PCB1-BILLTYPE-CAT

X(3) 486 - 488 UB-04 FL4. Bill Type category.

UB-04 Bill Type Frequency

PCB1-BILLTYPE-FREQ

X(1) 489 UB-04 FL4. Bill Type frequency.

Exclusion Criteria PCB1-EX-CRITERIA 9(1) 490 Medicare LTC:0 = Otherwise1 = Admission to Long Term Care Hospital (LTCH)

was immediately preceded by discharge (on day of or day before admission to LTCH) from a Subsection (d) Hospital, and that stay did not include at least three days in the Intensive Care Unit (ICU) or Coronary Care Unit (CCU)

2 = Admission to LTCH was immediately preceded by discharge (on day of or day before admission to LTCH) from a Subsection (d) Hospital, and that stay included at least three days in the ICU or CCU

3 = Claim excluded from site neutral methodology for another reason

Filler X(8) 491 - 498UB-04 Condition Codes PCB1-CONDCD X(2)

occurs 12 times

499 - 522 UB-04 FL18-28. Condition codes.

For example:07 = Treatment of non-terminal condition for hospice

patient20 = Beneficiary requested billing21 = Billing for denial notice41 = Partial hospitalization47 = Transfer from another home health agency49 = Product replacement within product lifecycle50 = Product replacement for known recall of a

product59 = Non-primary ESRD facility70 = Self-administered anemia management drug71 = Full care in unit72 = Self care in unit73 = ESRD self care training74 = Home76 = Back-up in facility dialysis80 = Home dialysis – nursing facility81 = C-sections/inductions < 39 weeks - medical

necessity82 = C-sections/inductions < 39 weeks - elective83 = C-sections/inductions 39 weeks or greater84 = Dialysis for Acute Kidney Injury (AKI)87 = ESRD self care retrainingH3 = Reoccurrence of GI bleed comorbid categoryH4 = Reoccurrence of pneumonia comorbid

categoryH5 = Reoccurrence of pericarditis comorbid

categoryW2 = Duplicate of original bill




Reserved PCB1-CONDCD-RSVD

X(16) 523 - 538 Reserved

UB-04 Value Code Array

PCB1-VALUE X(12)occurs 12 times

539 - 682 Array of UB-04 value codes and amounts.

UB-04 Value Code PCB1-VALCODE X(2) UB-04 FL39-41. Value codes.

For example:A0 = ZIP code at point of pickup. Used for APC and

SNF ambulance fee schedule pricingFD = Credit received from the manufacturer for a

replaced medical deviceG8 = Facility where inpatient hospice service is

delivered24 = New York Medicaid rate code54 = Newborn birth weight in grams61 = Place of residence where service is furnished

(HHA and Hospice)75 = Prior covered days for interrupted stay (Payer

only85 = County where service is rendered




UB-04 Value Amount PCB1-VALAMT 9(10) UB-04 FL39-41. Leading digit should always be zero. Supply according to UB-04 conventions for the remaining 9 digits of this field.

For example:If value code = A0 (zip code at point of pickup), supply 5-digit zip code with three leading zeros and two trailing zeros (e.g., 0001234500).

If value code = FD (device credit), supply the actual credit received by the hospital from the device manufacturer. Entry should be an unsigned dollar amount.

If value code = G8 (facility where inpatient hospice service is delivered), supply the 2-digit or 5-digit CBSA with the appropriate number of leading zeros and two trailing zeros. For example: If the CBSA is 10, supply 0000001000. If the CBSA is 11020, supply 0001102000.

If value code = 24 (New York Medicaid rate code) supply valid rate code with four leading zeros and two trailing zeros (e.g., 0000143200 hospital clinic episode).

If value code = 54 (birth weight), supply birth weight in grams with two trailing zeros and the appropriate number of leading zeros (e.g., 0000250000 = 2500 grams).

If value code = 61 (place of residence where service is furnished (HHA and Hospice)), supply the 2-digit or 5-digit CBSA with the appropriate number of leading zeros and two trailing zeros. For example: If the CBSA is 10, supply 0000001000. If the CBSA is 11020, supply 0001102000.

If value code = 75 (prior covered days for interrupted stay), supply the number of days from the original IPF stay with two trailing zeros and the appropriate number of leading zeros (e.g., 0000000500 = 5 prior covered days).

Reserved PCB1-VALUE-RSVD X(76) 683 - 758 ReservedFiller X(20) 759 - 778UB-04 Admission Type PCB1-ADMIT-TYPE X(1) 779 UB-04 FL14. Patient admission or visit type.Reserved PCB1-ADMIT-TYPE-

RSVDX(1) 780 Reserved

Admission Diagnosis Type

PCB1-ADMIT-DX-TYPE

X(3) 781 - 783 Reserved

Admission Diagnosis PCB1-ADMIT-DX X(10) 784 - 793 UB-04 FL69. The diagnosis at the time of admission.




National Provider Identifier (NPI)

PCB1-NPI X(10) 794 - 803 UB-04 FL56. NPI.

Medicare Physician: 1500.33a. Billing provider National Provider Identifier (NPI).

If multiple NPIs and Taxonomies are provided on a claim, the following hierarchy will be applied to each claim line:(1) Rendering Provider NPI/Taxonomy(2) Service Facility NPI/Taxonomy(3) Billing Provider NPI/Taxonomy

Taxonomy Code PCB1-TAXONOMY X(10) 804 - 813 Taxonomy code.

Medicare Physician: 1500.33b. Billing provider taxonomy code.

The list of valid taxonomy codes is available at: http://www.wpc-edi.com/reference/

251G00000X = Hospice care, community based282N00000X = Short term general hospital282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital-based or freestanding renal

dialysis unit283X00000X = 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)315D00000X = Hospice, inpatient

UB-04 Treatment Authorization Code

PCB1-TX-AUTHCODE

X(30) 814 - 843 UB-04 FL63.

UB-04 Admission/Start of Care Date

PCB1-ADMIT-DATE 9(8) 844 - 851 UB-04 FL12. YYYYMMDD, where:YYYY = year; including centuryMM = month; 01 - 12DD = day; 01 - 31

Paper Claim Flag PCB1-PAPER-FLAG 9(1) 852 0 = Claim being processed is an electronic claim1 = Claim being processed is a paper claim

Health Plan Identifier (HPID)

PCB1-HPLAN-ID 9(10) 853 - 862 UB-04 FL51. Health Plan Identifier (HPID).

Organization Identifier PCB1-ORG-ID X(100) 863 - 962 ReservedContent Version PCB1-CONTENT-

VERSX(12) 963 - 974 Reserved

Reserved PCB1-RSVD-SYNC X(12) 975 - 986 Reserved



http://www.wpc-edi.com/reference/


Maximum Number of Occurrences of the PWS4 Structure

PCB1-MAXPWS4 9(3) 987 - 989 Reserved

Taxpayer Identification Number (TIN)

PCB1-TIN X(9) 990 - 998 Medicare Physician:1500.25. 837p Loop 2010AA, REF02. Billing Provider Tax Identification Number (TIN).

Medicare CAH Method II:UB-04 FL05 Federal Tax Number (also known as Tax Identification Number (TIN)).

NoteSupply all 9 digits including any leading or trailing zeros without dashes. For example: If the TIN is 001-12- 2333 or 00-1122333, supply 001122333 in this field.

Claims Processing Receipt Date

PCB1-RECEIPT-DATE

9(8) 999 - 1006 The date the claim was received.YYYYMMDD, where:YYYY = year including centuryMM = month; 01 - 12DD = day; 01 - 31

Filler X(993) 1007 - 1999

Expansion Flag PCB1-EXPANSION-FLAG

X(1) 2000 0 = Expanded PCB1 structure not being used1 = Expanded PCB1 structure being used

New UB-04 Occurrence Codes

PCB1-POT-OCCUR-CODE

X(2)occurs 24 times

2001 - 2048

UB-04 FL31-34. Occurrence codes.

NoteTo use this new field, the Expansion Flag (PCB1-EXPANSION-FLAG) field must be set to 1 (Expanded PCB1 structure being used).

New UB-04 Occurrence Dates

PCB1-POT-OCCUR-DATE

9(8)occurs 24 times

2049 - 2240

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


New UB-04 Occurrence Span Codes

PCB1-PST-SPAN-CODE


2241 - 2288

UB-04 FL35-36. Occurrence span codes.





New UB-04 Occurrence Span Date #1

PCB1-PST-SPAN-DATE1

9(8) occurs 24 times

2289 - 2480

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


New UB-04 Occurrence Span Date #2

PCB1-PST-SPAN-DATE2


2481 - 2672

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





New UB-04 Condition Codes

PCB1-PCT-CONDCD


2673 - 2720

UB-04 FL18-28. Condition codes.

For example:07 = Treatment of non-terminal condition for hospice

patient20 = Beneficiary requested billing21 = Billing for denial notice41 = Partial hospitalization47 = Transfer from another home health agency49 = Product replacement within product lifecycle50 = Product replacement for known recall of a

product59 = Non-primary ESRD facility70 = Self-administered anemia management drug71 = Full care in unit72 = Self care in unit73 = ESRD self care training74 = Home76 = Back-up in facility dialysis80 = Home dialysis – nursing facility81 = C-sections/inductions < 39 weeks - medical

necessity82 = C-sections/inductions < 39 weeks - elective83 = C-sections/inductions 39 weeks or greater84 = Dialysis for Acute Kidney Injury (AKI)87 = ESRD self care retrainingH3 = Reoccurrence of GI bleed comorbid categoryH4 = Reoccurrence of pneumonia comorbid

categoryH5 = Reoccurrence of pericarditis comorbid

categoryW2 = Duplicate of original bill





New UB-04 Value Code PCB1-PVT-VALCODE


2721 - 2768

UB-04 FL39-41. Value codes.

For example:A0 = ZIP code at point of pickup. Used for APC and

SNF ambulance fee schedule pricingFD = Credit received from the manufacturer for a

replaced medical deviceG8 = Facility where inpatient hospice service is

delivered24 = New York Medicaid rate code54 = Newborn birth weight in grams61 = Place of residence where service is furnished

(HHA and Hospice)75 = Prior covered days for interrupted stay (Payer

only)85 = County where service is rendered





New UB-04 Value Amount

PCB1-PVT-VALAMT 9(10) occurs 24 times

2769 - 3008

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

For example:If value code = A0 (zip code at point of pickup), supply 5-digit zip code with three leading zeros and two trailing zeros (e.g., 0001234500).

If value code = FD (device credit), supply the actual credit received by the hospital from the device manufacturer. Entry should be an unsigned dollar amount.

If value code = G8 (facility where inpatient hospice service is delivered), supply the 2-digit or 5-digit CBSA with the appropriate number of leading zeros and two trailing zeros. For example: If the CBSA is 10, supply 0000001000. If the CBSA is 11020, supply 0001102000.

If value code = 24 (New York Medicaid rate code) supply valid rate code with four leading zeros and two trailing zeros (e.g., 0000143200 hospital clinic episode).

If value code = 54 (birth weight), supply birth weight in grams with two trailing zeros and the appropriate number of leading zeros (e.g., 0000250000 = 2500 grams).

If value code = 61 (place of residence where service is furnished (HHA and Hospice)), supply the 2-digit or 5-digit CBSA with the appropriate number of leading zeros and two trailing zeros. For example: If the CBSA is 10, supply 0000001000. If the CBSA is 11020, supply 0001102000.

If value code = 75 (prior covered days for interrupted stay), supply the number of days from the original IPF stay with two trailing zeros and the appropriate number of leading zeros (e.g., 0000000500 = 5 prior covered days).


Filler X(2004) 3009 - 5012




PCB2-CCD-CAH-CLAIM-DATATable 3-1: PCB2-CCD-CAH-CLAIM-DATA: Fixed length CAH Method II input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesZip Code PCB2-CCD-

ZIPCODE9(5) 1 - 5 UB-04 FL01. Billing provider zip code (first five

digits)Zip Code Suffix PCB2-CCD-

ZIPSUFFIX 9(4) 6 - 9 UB-04 FL01. Billing provider zip code suffix (last four

digits)

Bonus Payment/Adjustment Override

PCB2-CCD-BONUS-OVERRIDE

9(1) 10 0 = Calculate bonus payments and MACRA Quality Payment Program (QPP) adjustments

1 = Bypass bonus payments for PCIP, primary care HPSA, HSIP program, mental health HPSA, EHR, PQRS, and val-based modifier only

2 = Bypass adjustments for MACRA QPP only3 = Bypass bonus payments for all bonus programs

and adjustments for MACRA QPPSanction/Preclusion Return Code Override

PCB2-CCD-SANCTION-OVERRIDE

9(1) 11 0 = Do not bypass Return Code 411 = Bypass Return Code 41 for providers that have

been sanctioned by the OIG2 = Bypass Return Code 41 for providers that have

been precluded3 = Bypass Return Code 41 for providers that have

been precluded and/or sanctioned by the OIGRendering NPI PCB2-CCD-REND-

NPIX(10) 12 - 21 UB-04 FL78-79. Rendering provider National

Provider Identifier (NPI).Rendering Taxonomy PCB2-CCD-REND-

TAXONOMYX(10) 22 - 31 Rendering provider taxonomy code.

Filler X(31969) 32 - 32000


PCB2-ICD-IP-CLAIM-DATATable 4-1: PCB2-ICD-IP-CLAIM-DATA: Fixed length inpatient input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesAge in Days on Admission

PCB2-ICD-AAGE-DAYS

9(3) 1 - 3 AP-DRG and TRICARE Groupers: Required for neonates. Calculate the age in days as the number of days between the birth date and the date of admission. Set to 000 if the date of birth equals the date of admission. Set to 999 if the patient’s age in years is greater than 000. Right-justified, zero-filled. Not required or utilized by other Grouper types.

Age in Days on Discharge

PCB2-ICD-DAGE-DAYS

9(3) 4 - 6 Grouper-specific input field, as detailed below.

AP-DRG and TRICARE Groupers: Required for neonates. Set to 999 if the patient’s age in years is greater than 000. Right-justified, zero-filled. Not required or utilized by other Grouper types.

Alternate Level of Care Days

PCB2-ICD-ALC-DAYS

9(4) 7 - 10 For any Pricers not detailed below, set this field to zeros. Right justified, zero-filled.

Multi-Pricer/DRG Pro, New Jersey Medicaid, and Kansas Medicaid: Set equal to the number of alternate level of care (ALC) days utilized by the patient.

Medicare LTC and Medicare IPF: This field should contain a count of inpatient days which were not medically necessary or non-covered. This value will be subtracted from the patient’s length of stay to determine the total number of medically necessary covered days.

Birthweight in Grams PCB2-ICD-BWGT 9(4) 11 - 14 Birth weight in grams. This field is only used if birth weight in grams is not reported in the Value Amount (PCB1-VALAMT) field with Value Code 54 (PCB1-VALCODE). Right justified, zero-filled. If not applicable, set to 0000.

AP-DRG Grouper: Required for all neonates. If birth weight in grams is not available, it can be imputed from recorded diagnosis codes. To impute birth weight from the patient’s diagnoses, set this input field to 9999. (Option to impute birth weight is only available beginning with V12 of these Groupers.)

Patient’s DRG PCB2-ICD-PAT-DRG

9(5) 15 - 19 DRG is required as input when records are submitted for a PriceOnly (ECB-OPCODE1 = 12). Set this field only when making a PriceOnly call.

Filler X(2) 20 - 21


Data Version Number PCB2-ICD-DATA-VERS

9(4) 22 - 25 Version number of the ICD-9-CM or ICD-10-CM/PCS code set used on the claim. Set this field when utilizing the below components only. Otherwise set to 0000. Right justified, zero-filled.

ICD-9 and ICD-10 Mapper: Used to determine whether the EASYGroup™ Mapper should be invoked. If the data version number is different than the Grouper version and the Mapper has been licensed, diagnosis and procedure codes will be translated or mapped prior to invoking Grouper logic. If set to zeros, the data version number will be calculated using the Effective Date (PCB1-EFF-DATE) (if specified) or the Thru Date (PCB1-THRU-DATE).

Facility Type PCB2-ICD-FACTYPE


County PCB2-ICD-COUNTY X(3) 28 - 30 ReservedNursery Level PCB2-ICD-

NURSLEV9(1) 31 Michigan Medicaid Pricer:

0 = Patient not treated in accredited neonatal intensive care unit

4 = Patient treated in accredited neonatal intensive care unit (claim contains UB-04 Revenue Code 0174 (Nursery Newborn - Level IV))

Distinct Part Unit PCB2-ICD-PSYCUNIT

9(1) 32 Reserved

HMO Risk Flag PCB2-ICD-HMO-RISK

9(1) 33 Medicare DRG Pricer:0 or Blank = Traditional Medicare pricing1 = HMO Risk/Medicare Advantage pricing applies

for this patient; SCHs will be paid the greater of the federal or hospital-specific rate

2 = HMO Risk/Medicare Advantage pricing applies for this patient; SCHs will be paid the federal rate


Same Day Admit PCB2-ICD-SAMEDAY

9(1) 34 Reserved

Readmission PCB2-ICD-READMIT

9(1) 35 Reserved

Special Unit PCB2-ICD-SPECIAL 9(1) 36 ReservedSpecial Unit Flag #2 PCB2-ICD-

SPECIAL29(1) 37 Reserved

Grouper Option Flag PCB2-ICD-GRPOPT 9(1) 38 ReservedDays on Mechanical Ventilation

PCB2-ICD-DMV 9(3) 39 - 41 Reserved

Filler X(31959) 42 - 32000

Table 4-1: PCB2-ICD-IP-CLAIM-DATA: Fixed length inpatient input fields (defined in hpclmblk.cpy)



PCB2-OCD-OP-CLAIM-DATATable 5-1: PCB2-OCD-OP-CLAIM-DATA: Fixed length outpatient input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesTraditional Medicare Switch

PCB2-OCD-TRADMED-SW

9(1) 1 APC-HOPD:0 = Apply Medicare Advantage requirements1 = Apply Medicare Fee-for-Service (FFS)

requirementsFiller FILLER-01 X(32) 2 - 33 ReservedPatient Deductible PCB2-OCD-

DEDUCTIBLE9(8)v9(2) 34 - 43 APC-HOPD:

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

ACE Report Request PCB2-OCD-ACE-REPORT

X(1) 44 Reserved

Filler X(6) 45 - 50State Key PCB2-OCD-STATE-

KEYX(2) 51 - 52 Reserved

Payer Key PCB2-OCD-PAYER-KEY


Physician Referral Flag PCB2-OCD-MDREFER

X(1) 67 Contract APC:0 or blank = Not referred by a qualified medical

professional1 = Referred by a qualified medical professional

Filler X(20) 68 - 87UB-04 Reason for Visit Diagnosis Array

PCB2-OCD-RFV X(13) occurs 3 times

88 - 126 UB-04 Reason for Visit diagnoses.

UB-04 Reason for Visit Diagnoses

PCB2-OCD-RFVDX X(10) UB-04 FL70A. UB-04 Reason for Visit diagnosis code.

UB-04 Reason For Visit Diagnosis Type

PCB2-OCD-RFVDX-TYPE

X(3) Reserved

Onset Date PCB2-OCD-ONSET 9(8) 127 - 134 ESRD:Set to dialysis date on Common Working File as provided on the CMS Form 2728 by the provider.

Billing Provider State Abbreviation

PCB2-OCD-STATE X(2) 135 - 136 Reserved

Zip Code PCB2-ZIPCODE-RSVD

9(5) 137 - 141 Reserved

Zip Code Suffix PCB2-ZIP-SUFFIX-RSVD

9(4) 142 - 145 Reserved

Request for Anticipated Payment (RAP)/Notice of Election (NOE) Exception

PCB2-OCD-EXCEPTION

9(1) 146 Medicare HHA & Medicare Hospice:Used to indicate if the late RAP/NOE is justified based on the documentation provided by the provider.0 = Not applicable or documentation insufficient to

justify late RAP/NOE1 = Documentation sufficient to justify late RAP/NOE


Prior Hospice Benefit Days

PCB2-OCD-PRIOR-DAYS

9(3) 147 - 149 Medicare Hospice:Number of days of prior hospice care. This field is only required if the hospice patient is discharged and readmitted to hospice care within 60 days of discharge.

RAP Receipt Date PCB2-OCD-RECEIPT-DATE

9(8) 150 - 157 Medicare HHA:The date that the RAP claim was received. In the case of a No-RAP LUPA enter 99999999.

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

Filler X(31843) 158 - 32000

Table 5-1: PCB2-OCD-OP-CLAIM-DATA: Fixed length outpatient input fields (defined in hpclmblk.cpy)



PCB2-PCD-PHYS-CLAIM-DATATable 6-1: PCB2-PCD-PHYS-CLAIM-DATA: Fixed length Physician input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesService Facility NPI PCB2-PCD-SERV-

NPIX(10) 1 - 10 1500. 32a. Service facility National Provider

Identifier (NPI). If multiple NPIs and Taxonomies are provided on a claim, the following hierarchy will be applied to each claim line:

(1) Rendering provider NPI/taxonomy(2) Service facility NPI/taxonomy(3) Billing provider NPI/taxonomy

Service Facility Taxonomy

PCB2-PCD-SERV-TAXONOMY

X(10) 11 - 20 1500. 32b. Service facility taxonomy code. The list of valid taxonomy codes is available at: http://www.wpc-edi.com/reference/

Service Facility Zip Code

PCB2-PCD-SERV-ZIPCODE

9(5) 21 - 25 1500. 32. Service facility 5-digit zip code. If multiple zip codes are provided on a claim, the following hierarchy will be applied to each claim line:

(1) If Place of Service (POS) is 12 (Home), service facility zip code is used.

(2) When an ambulance service is billed, an ambulance point of pickup zip code is required and will be used.

(3) Service facility zip code.(4) Billing provider zip code.

Billing Facility Zip Code PCB2-PCD-BILL-ZIPCODE

9(5) 26 - 30 1500. 33. Billing provider 5-digit zip code. If multiple zip codes are provided on a claim, the following hierarchy will be applied to each claim line:




Ambulance Point of Pickup ZIP Code

PCB2-PCD-AMB-ZIPCODE

9(5) 31 - 35 1500.23. Ambulance point of pickup 5-digit zip code. If multiple zip codes are provided on a claim, the following hierarchy will be applied to each claim line:






Service Facility Zip Code Suffix

PCB2-PCD-SERV-ZIPSUFFIX

9(4) 36 - 39 1500. 32. Service Facility 4-digit zip code suffix. This suffix is combined with the Service Facility Zip Code to create a 9-digit zip code. If multiple zip codes are provided on a claim, the following hierarchy will be applied to each claim line:


(2) If ambulance service, ambulance point of pickup zip code is used.


Billing Facility Zip Code Suffix

PCB2-PCD-BILL-ZIPSUFFIX

9(4) 40 - 43 1500. 33. Billing Facility 4-digit zip code suffix. This suffix is combined with the Billing Facility Zip Code to create a 9-digit zip code. If multiple zip codes are provided on a claim, the following hierarchy will be applied to each claim line:

(1) If Place of Service (POS) is 12 (Home), Service facility zip code is used.

(2) If ambulance service, ambulance point of pickup zip code is used.


Bonus Payment/MACRA QPP Adjustment Override

PCB2-PCD-BONUS-OVERRIDE

9(1) 44 0 = Calculate bonus payments and MACRA Quality Payment Program (QPP) adjustments

1 = Bypass bonus payments for PCIP, primary care HPSA, HSIP program, mental health HPSA, EHR, PQRS, and val-based modifier only

2 = Bypass adjustments for MACRA QPP only3 = Bypass bonus payments for all bonus programs

and adjustments for MACRA QPP

Number of Patients Transported in Ambulance

PCB2-PCD-AMB-NUMPAT

9(2) 45 - 46 Number of patients transported in an ambulance. If this number is greater than 1 and Modifier GM (Multiple Patients on One Ambulance Trip) is reported with the ambulance service, the payment for the ambulance service will be reduced.

Traditional Medicare Switch

PCB2-PCD-TRADMED-SW

9(1) 47 0 = Apply Medicare Advantage requirements1 = Apply Medicare Fee-for-Service (FFS)

requirementsSanction/Preclusion Return Code Override

PCB2-PCD-SANCTION-OVERRIDE

9(1) 48 0 = Do not bypass Return Code 411 = Bypass Return Code 41 for providers that have

been sanctioned by the OIG 2 = Bypass Return Code 41 for providers that have

been precluded3 = Bypass Return Code 41 for providers that have

been precluded and/or sanctioned by the OIGFiller X(31952) 49 - 32000

Table 6-1: PCB2-PCD-PHYS-CLAIM-DATA: Fixed length Physician input fields (defined in hpclmblk.cpy)



PCB2-RCD-REHAB-CLAIM-DATATable 7-1: PCB2-RCD-REHAB-CLAIM-DATA: Fixed length IRF input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesAssessment Transmission Date

PCB2-RCD-TDATE 9(8) 1 - 8 YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Date the final IRF-PAI assessments were transmitted to the CMS National Assessment Collection Database.

NoteBeginning January 1, 2011, per Medicare regulations, the Assessment Transmission Date must be passed into the Occurrence Date field, with an Occurrence Code of 50.

Program Interruption Flag

PCB2-RCD-INTERPT

9(1) 9 1 = Patient left facility for treatment; stay was interrupted

0 = No interruptionAdmission Impairment Grouper Code

PCB2-RCD-IGROUP

X(9) 10 - 18 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).

NoteIn the format described above you must include the decimal point.

Filler X(6) 19 - 24


FIM Admission Motor Score – Total

PCB2-RCD-MOTOR 9(2)v9(1) (refer to note)

25 - 27 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 zero, the IRF Grouper will calculate this 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 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

PCB2-RCD-COGN 9(3) 28 - 30 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 to 35.

If zero, the IRF Grouper will calculate this field.FIM Admission Motor Score

PCB2-RCD-IRF-MOTOR-SCORE


31 - 54 Effective prior to October 01, 2019. IRF-PAI fields 39A - 39M. Valid values for the Individual Admission Motor Score fields range from 00 to 07, with some exceptions, 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 “01”, except for 39J which defaults to “02”.

DETAILED FIM ADMISSION MOTOR SCORESAdmission Motor Score

– Self Care, EatingPCB2-RCD-IRF-FIM39A

9(2) 31 - 32 IFR-PAI field 39A. Valid values range from 00 to 07.

Admission Motor Score– Self Care, Grooming

PCB2-RCD-IRF-FIM39B

9(2) 33 - 34 IFR-PAI field 39B. Valid values range from 00 to 07.

Admission Motor Score– Self Care, Bathing

PCB2-RCD-IRF-FIM39C

9(2) 35 - 36 IFR-PAI field 39C. Valid values range from 00 to 07.

Table 7-1: PCB2-RCD-REHAB-CLAIM-DATA: Fixed length IRF input fields (defined in hpclmblk.cpy)



Admission Motor Score– Self Care, Dressing,

Upper Body

PCB2-RCD-IRF-FIM39D

9(2) 37 - 38 IFR-PAI field 39D. Valid values range from 00 to 07.

Admission Motor Score– Self Care, Dressing,

Lower Body

PCB2-RCD-IRF-FIM39E

9(2) 39 - 40 IFR-PAI field 39E. Valid values range from 00 to 07.

Admission Motor Score– Self Care, Toileting

PCB2-RCD-IRF-FIM39F

9(2) 41 - 42 IFR-PAI field 39F. Valid values range from 00 to 07.

Admission Motor Score– Sphincter Control,

Bladder Management

PCB2-RCD-IRF-FIM39G

9(2) 43 - 44 IFR-PAI field 39G. Valid values range from 01 to 07.

Admission Motor Score– Sphincter Control,Bowel Management

PCB2-RCD-IRF-FIM39H

9(2) 45 - 46 IFR-PAI field 39H. Valid values range from 01 to 07.

Admission Motor Score– Transfers, Bed, Chair,

Wheelchair

PCB2-RCD-IRF-FIM39I

9(2) 47 - 48 IFR-PAI field 39I. Valid values range from 00 to 07.

Admission Motor Score– Transfers, Toilet

PCB2-RCD-IRF-FIM39J

9(2) 49 - 50 IFR-PAI field 39J. Valid values range from 00 to 07.

Admission Motor Score– Locomotion, Walk/

Wheelchair

PCB2-RCD-IRF-FIM39L

9(2) 51 - 52 IFR-PAI field 39L. Valid values range from 00 to 07.

Admission Motor Score– Locomotion, Stairs

PCB2-RCD-IRF-FIM39M

9(2) 53 - 54 IFR-PAI field 39M. Valid values range from 00 to 07.

Modifier for Admission Motor Score – Locomotion, Walk/ Wheelchair

PCB2-RCD-IRF-FIM39L-MOD

X(1) 55 Optional modifier for IFR-PAI field 39L. Valid values are:

W = WalkC = WheelchairB = Both

NoteDoes not affect CMG assignment.

FIM Admission Cognitive Score

PCB2-RCD-IRF-COGN-SCORE

9(2) occurs 5 times

56 - 65 IRF-PAI fields 39N - 39R. 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 “01.”




DETAILED FIM ADMISSION COGNITIVE SCORESAdmission Cognitive

Score –Communication,Comprehension

PCB2-RCD-IRF-FIM39N

9(2) 56 - 57 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 CognitiveScore –

Communication,Expression

PCB2-RCD-IRF-FIM39O

9(2) 58 - 59 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 CognitiveScore – Social

Cognition, SocialInteraction

PCB2-RCD-IRF-FIM39P

9(2) 60 - 61 IFR-PAI field 39P. Valid values range from 01 to 07.


Cognition, ProblemSolving

PCB2-RCD-IRF-FIM39Q

9(2) 62 - 63 IFR-PAI field 39Q. Valid values range from 01 to 07.


Cognition, Memory

PCB2-RCD-IRF-FIM39R

9(2) 64 - 65 IFR-PAI field 39R. Valid values range from 01 to 07.

Modifier for Admission Cognitive Score – Communication, Comprehension

PCB2-RCD-IRF-FIM39N-MOD

X(1) 66 Optional Modifier for IFR-PAI field 39N. Valid values are:

A = AuditoryV = VisualB = Both


Modifier for Admission Cognitive Score – Communication, Expression

PCB2-RCD-IRF-FIM39O-MOD

X(1) 67 Optional Modifier for IFR-PAI field 39O. Valid values are:

V = VocalN = NonvocalB = Both





Admission Motor Score 2 - Total

PCB2-RCD-MOTOR2

9(3)v9(3) 68 - 73 Effective October 01, 2019, the total motor score calculated from IRF-PAI admission motor scores collected in fields GG0130A1 - GG0130C1, GG0130E1 -GG0130H1, GG0170B1 - GG0170F1, GG0170I1-GG0170K1,GG0170M1, H0350, and H0400.

When totaling individual IRF-PAI scores, values of 00, 07, 09, 10, and 88 default to "01", except for GG0170F1 which defaults to "02". Valid values range from 18 to 104. If zero, the IRF Grouper will calculate this field.

FIM Admission Cognitive Score

PCB2-RCD-COGN2 9(3)v9(3) 74 - 79 Reserved




Admission Motor Scores 2

PCB2-RCD-MOTOR-SCORE-2


80 - 127 Effective October 01, 2019. IRF-PAI components for self care (GG0130A1-GG0130C1 and GG0130E1- GG0130H1), mobility (GG0170B1-GG0170F1, GG0170I1- GG0170K1, and GG0170M1), bladder continence (H0350), and bowel continence (H0400).

Valid values for the Individual Admission Motor Score fields (GG0130A1 - GG0130C1, GG0130E1- GG0130H1, GG0170B1- GG0170F1, GG0170I1 - GG0170K1, GG0170M1) range from 00 to 06 as defined below: 00 = Not applicable01 = Dependent02 = Substantial/maximum assistance03 = Partial/moderate assistance04 = Supervision or touching assistance05 = Setup or clean-up assistance06 = Independent07 = Patient refused09 = Not applicable10 = Not attempted due to environmental limitations88 = Not attempted due to medical condition or

safety concerns

If a value of "00", “07”, “09”, “10”, or “88” is entered for self care or mobility motor scores, the IRF Grouper will treat it as "01", except for GG0170F1 which recodes to "02".

Valid values for the Individual Admission Motor Score range from 00 to 05 and 09 for bladder continence, 00 to 03, and 09 for bowel continence, as defined below:

00 = Always continent01 = Stress continence only02 = Incontinent less than daily03 = Incontinent daily04 = Always continent05 = No urine output09 = Not applicable

For field H0350, if a value of “00”, “01”, “02”, “03”, “04”, “05”, or “09” is entered, the IRF Grouper will treat it as a “04”, “04”, “03”, “02”, “01”, “04”, or “01” respectively. For field H0400, if a value of “00”, “01”, “02”, “03”, or “09” is entered, the IRF Grouper will treat it as an “04”, “03”, “02”, “01”, and “02” respectively.

DETAILED QUALITY INDICATOR MOTOR SCORESAdmission Motor Score

- EatingPCB2-RCD-MOTOR-SCORE-2

9(2) 80 - 81 IRF-PAI GG0130A1. Valid values range from 00 to 07, 09, 10, and 88.




Admission Motor Score- Oral Hygiene


9(2) 82 - 83 IRF-PAI GG0130B1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Toileting Hygiene


9(2) 84 - 85 IRF-PAI GG0130C1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Shower Bathe Self


9(2) 86 - 87 IRF-PAI GG0130E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Upper-Body Dressing


9(2) 88 - 89 IRF-PAI GG0130F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Lower-Body Dressing


9(2) 90 - 91 IRF-PAI GG0130G1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Putting On/Taking Off

Footwear


9(2) 92 - 93 IRF-PAI GG0130H1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Sit to Lying


9(2) 94 - 95 IRF-PAI GG0170B1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Lying to Sitting on Side

of Bed


9(2) 96 - 97 IRF-PAI GG0170C1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Sit to Stand


9(2) 98 - 99 IRF-PAI GG0170D1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Chair/Bed-to-Chair

Transfer


9(2) 100 - 101 IRF-PAI GG0170E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Toilet Transfer


9(2) 102 - 103 IRF-PAI GG0170F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Walk 10 Feet


9(2) 104 - 105 IRF-PAI GG0170I1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Walk 50 Feet With

Two Turns


9(2) 106 - 107 IRF-PAI GG0170I1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Walk 150 Feet


9(2) 108 - 109 IRF-PAI GG0170J1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- One Step Curb


9(2) 110 - 111 IRF-PAI GG0170K1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Bladder Continence


9(2) 112 - 113 IRF-PAI GG0170M1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Bowel Continence


9(2) 114 - 115 IRF-PAI H0350. Valid values range include 00 to 05, and 09.

Reserved PCB2-RCD-MOTOR-SCORE-2

9(2) 116 - 117 Reserved for future use.














Filler X(31873) 128 - 32000




PCB2-SCD-SNF-CLAIM-DATATable 8-1: PCB2-SCD-SNF-CLAIM-DATA: Fixed length SNF input fields (defined in hpclmblk.cpy)

Field Description Variable Name Format Position NotesTraditional Medicare Switch

PCB2-SCD-TRADMED-SW

9(1) 1 0 = Apply Medicare Advantage requirements1 = Apply Medicare Fee-for-Service (FFS)

requirementsFiller X(31999) 2 - 32000


DCB-DX-CODE-BLOCKTable 9-1: DCB-DX-CODE-BLOCK: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (defined in hdx2blk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesDiagnosis Code DCB-DX X(10) 1 - 10 Input field.

For facility claims, UB-04 FL 67, FL67 A-Q, FL 69, FL 70 a-c and for professional claims, 1500.21. For facility claims, 837i 2300-HI, and for professional claims, 837p 2300-HI.

ICD-9-CM or ICD-10-CM diagnosis codes. Codes should be contiguous (i.e., no gaps or blanks between codes). Principal diagnosis should be in the first position unless you are using the Diagnosis Code Type field. If the Code Type field is being used, the principal diagnosis can be in any position.

IRF Grouper: 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 DCB-DX-TYPE X(3) 11 - 13 Input field.

ICD-9 Diagnosis:BN = External Cause of Injury Diagnosis Code BK = Principal Diagnosis CodeBJ = Admitting Diagnosis CodePR = Reason for Visit Diagnosis CodeBF = Secondary Diagnosis Code

ICD-10 Diagnosis:ABN = External Cause of Injury Diagnosis CodeABK = Principal Diagnosis CodeABJ = Admitting Diagnosis CodeAPR = Reason for Visit Diagnosis CodeABF = Secondary Diagnosis Code


Diagnosis Grouper Flag DCB-DX-NARRAY 9(3) 14 - 16 Output field.

For inpatient DRG grouping only. Flag that shows how a diagnosis code was utilized by the Grouper.

AP-DRG Grouper:0 = Not used1 = Needed for DRG assignment2 = CC for PDX3 = CC for PDX, needed for DRG assignment4 = Non-traumatic major CC5 = Non-traumatic major CC, needed for DRG

assignment8 = Major CC9 = Major CC needed for DRG assignment

All Other DRG Groupers:0 = Not used1 = Needed for DRG assignment2 = CC for PDX3 = CC needed for DRG assignment4 = Major CC for PDX 5 = Major CC needed for DRG assignment

Comorbidity Tier for Input Diagnosis

DCB-CTIER X(1) 17 Output field.

IRF Grouper:Comorbidity tier for diagnosis code.

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)

Table 9-1: DCB-DX-CODE-BLOCK: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (defined in hdx2blk.cpy; occurs up to 999 times)



Present on Admission Indicator

DCB-POA X(1) 18 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 7/1/2012 and on paper claims on or after 7/1/2011)

Blank = Unreported/not used (Exempt from POA reporting on paper claims before 7/1/2011 and on electronic claims on or after 1/1/2011)

Present on Admission Bypassed

DCB-POA-BYPASSED

9(1) 19 Output field.

MS-DRG, TRICARE DRG, and AP-DRG V18, V23, V26, and V27: 1 = This code is eligible for bypass as a CC/MCC

during DRG assignment because it is a HAC-designated condition that was not present on admission

2 = This code was bypassed as a CC/MCC during DRG assignment because it is a HAC-designated condition that was not present on admission

0 = Otherwise

AP-DRG V26 (for New York Medicaid only):1 = This code is eligible for bypass during DRG

assignment as a Never Event that was not present on admission

2 = This code was bypassed during DRG assignment because it is a “Never Event” that was not present on admission

0 = OtherwiseFiller X(71) 20 - 90Diagnosis Code Reserved

DCB-RESERVED-DX

X(10) 91 - 100 Reserved field for ICD-9-CM code Mapper processing.

Table 9-1: DCB-DX-CODE-BLOCK: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (defined in hdx2blk.cpy; occurs up to 999 times)



OCB-OP-CODE-BLOCKTable 10-1: OCB-OP-CODE-BLOCK: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (defined in hop2blk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesProcedure Code OCB-OP X(10) 1 - 10 Input field. UB-04 FL 74.

ICD-9-CM or ICD-10-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).

Code Type OCB-OP-TYPE X(3) 11 - 13 Input field.

ICD-9 Procedure:BR = First ICD-9 procedure BQ = Other ICD-9 procedure

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

Procedure Date OCB-DATE 9(8) 14 - 21 Input field. UB-04 FL 74.

The date associated with each ICD-9-CM or ICD-10-PCS procedure code. Format: YYYYMMDD.

DRG Procedure Indicator

OCB-OP-NARRAY 9(3) 22 - 24 Output field.

For inpatient DRG grouping only. Flag that shows how each procedure code was utilized by the Grouper.

0 = Non-operating room procedure1 = Non-operating room procedure, needed for DRG

assignment2 = Qualifying non-operating room procedure3 = Qualifying non-operating room procedure,

needed for DRG assignment4 = Operating room procedure5 = Operating room procedure, needed for DRG

assignment6 = Qualifying operating room procedure7 = Qualifying operating room procedure, needed for

DRG assignment


Unrelated Procedure Indicator

OCB-PM-NARRAY 9(1) 25 AP-DRG, Medicare DRG, and TRICARE/CHAMPUS DRG:

Output field.

Identifies procedures not generally related to the submitted diagnosis codes.

0 = Code is associated with one or more procedure codes

1 = Procedure is not usually performed for any of the submitted diagnosis codes

NoteNot returned for ICD-10.

Filler X(65) 26 - 90Procedure Code Reserved

OCB-RESERVED-OP

X(10) 91 - 100 Reserved field for ICD-9-CM code Mapper processing.

Table 10-1: OCB-OP-CODE-BLOCK: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (defined in hop2blk.cpy; occurs up to 999 times)



HCT-HCPCS-CODE-TBLNote

Please note, clients should pass in fields that will be reported as “covered charges” on the claim (i.e., items that have non-zero total line charges in the UB-04 FL47/5010 2400:SV203 fields, after subtracting the non-covered charges in the UB-04 FL48 / 5010 2400:SV207 fields.

Table 11-1: HCT-HCPCS-CODE-TBL: Variable Length HCPCS Procedure Input Fields (defined in hhcpcblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesLock HCT-LOCK X(1) 1 ReservedHCPCS/HIPPS Code HCT-HCPCS X(7) 2 - 8 UB-04 FL44. 1500.24D. Level I or II HCPCS or

HIPPS code where applicable. Left-justified, blank-filled.

Modifier 1 HCT-MOD1 X(2) 9 - 10 UB-04 FL44. 1500.24D. First modifier for this procedure.

NoteModifiers must be entered in UPPERCASE format.

Up to five modifiers can be considered for editing and pricing. For services with more than four modifiers, do not submit Modifier 99 in the fourth modifier slot; instead provide the first two additional modifiers up to a total of five.

Modifier 2 HCT-MOD2 X(2) 11 - 12 UB-04 FL44. 1500.24D. Second modifier for this procedure.


Modifier 3 HCT-MOD3 X(2) 13 - 14 UB-04 FL44. 1500.24D. Third modifier for this procedure.


Modifier 4 HCT-MOD4 X(2) 15 - 16 UB-04 FL44. 1500.24D. Fourth modifier for this procedure.


Modifier 5 HCT-MOD5 X(2) 17 - 18 UB-04 FL44. 1500.24D. Fifth modifier for this procedure.



Units HCT-UNITS 9(7) 19 - 25 UB-04 FL46. 1500.24G. Number of billable days or units, as would be submitted on the facility or practitioner claim line for this item. For anesthesia services, enter the elapsed time in minutes. Separate payments may be received for each unit of service.

Charges HCT-CHARGES 9(8)v9(2) 26 - 35 UB-04 FL47 and 48. 1500.24F. Total covered charges for this procedure (individual covered charges times units).

Date of Service HCT-DATE 9(8) 36 - 43 UB-04 FL45. 1500.24A. From date of service for this procedure. YYYYMMDD, where: YYYY = year including century MM = month; 01 - 12 DD = day; 01 - 31

Revenue Code HCT-REV 9(4) 44 - 47 UB-04 FL42. Revenue code.User Area HCT-USER X(12) 48 - 59 ReservedLine Override HCT-OVERRIDE X(1) 60 APC-HOPD and CAH Method II:

1 = Reserved2 = External line item rejection/denial (ignore)3 = Reserved4 = Reserved5 = External line item rejection/denial (consider)

Physician:1 = External line item denial (ignore)2 = External line item denial (consider)

Provider ID Reserved HCT-PROVIDER-RSVD


Units Reserved HCT-UNITS-RSVD 9(15) 69 - 83 ReservedNational Drug Code (NDC)

HCT-NDC 9(11) 84 - 94 National Drug Code (NDC). The 11-digit NDC code is required. Optum software does not accept 10-digit NDC codes.

Inpatient and TRICARE/CHAMPUS: 837i, loop 2410, line 03. The NDC field is used to identify claims that contain certain new technologies eligible for an additional add-on payment.

ESRD: 837i, loop 2410, line 03. The NDC field is used to bill ESRD-related drugs that do not have a HCPCS code and were formerly covered under the Medicare Part D benefit.

Physician: NDC as reported on the 1500 claim form in field 24 (shaded)- without dashes.




Decimal Units HCT-DEC-UNITS 9(3) 95 - 97 APC-HOPD, CAH Method II, Contract APC, SNF, & Physician: If an ambulance trip is less than 100 miles, any fractional mileage for the ambulance trip should be reported in this field beginning January 1, 2011. This field is defined as the three digits following an implicit decimal (e.g., if an ambulance trip is 27.9 miles long, report the decimal units as “900” in this field).

Place of Service HCT-POS 9(2) 98 - 99 Physician:1500. 24B. The location where each item was used or procedure was performed. The list of valid Place of Service (POS) codes is available at: https://www.cms.gov/place-of-service-codes/20_Place_of_Service_Code_Set.asp

Rendering Provider NPI HCT-REND-NPI X(10) 100 - 109 Physician:1500. 24J (non-shaded). Rendering provider National Provider Identifier (NPI). If multiple NPIs and Taxonomies are provided on a claim, the following hierarchy will be applied to each claim line:

(1) Rendering provider NPI/taxonomy(2) Service facility NPI/taxonomy(3) Billing provider NPI/taxonomy

CAH Method II:UB-04 FL43. Line-level Rendering Provider NPI.

Rendering Provider Taxonomy

HCT-REND-TAX X(10) 110 - 119 Physician:1500. 24J (shaded). Rendering provider taxonomy code. The list of valid taxonomy codes is available at: http://www.wpc-edi.com/reference/



https://www.cms.gov/place-of-service-codes/20_Place_of_Service_Code_Set.asp



Status Code HCT-SCODE X(1) 120 Physician and CAH Method II:This field is optional for clients who are not using an Editor and are requesting pricing only:

A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from physician fee schedule by

regulationF = Deleted/discontinued codeG = Not valid for Medicare purposesH = Deleted modifierI = Not valid for Medicare purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/excluded codeQ = Therapy functional information code (used for

required reporting purposes only)R = Restricted coverageT = InjectionsX = Statutory exclusion

National Drug Code (NDC) Units

HCT-NDC-UNITS 9(8)v9(3) 121 - 131 Physician: NDC units as reported on the 1500 claim form in field 24 (shaded).

NoteAny values supplied after the decimal will be truncated for pricing.

Facility/Practitioner Indicator

HCT-PX-FP-IND 9(1) 132 E&M Analyzer Pro:0 = Code came from practitioner claim1 = Code came from facility claim

Specialty Code HCT-SPEC-CODE X(2) 133 - 134 Physician and CAH Method II:The specialty code of the practitioner.

This field is optional and if the specialty code is not provided in this field it will be derived from the NPI(s) or taxonomy code(s) on the claim.

Filler X(66) 135 - 200




MOB1-MAP-OUTPUT-BLOCK1Table 12-1: MOB1-MAP-OUTPUT-BLOCK1: Fixed length Mapper output fields (defined in hmapblk.cpy)

Field Description Variable Name Format Position NotesMapper Return Code MOB1-MAP-RTN-CODE X(2) 1 - 2 01 = Cannot determine coding version (ICD-9

or ICD-10) for claim02 = Target version cannot be determinedCL = Cannot load or open programIO = File I/O error (refer to MOB1-MAP-RTN-

CODE2 below)Mapper Return Code Extension

MOB1-MAP-RTN-CODE2 X(2) 3 - 4 01 = Error opening MAPFILE file02 = Error opening MAPRULE file

Mapper Return Status MOB1-MAP-RTN-STATUS X(2) 5 - 6 ReservedMapper Reserved MOB1-RSVD X(4) 7 - 10 ReservedMapper Type MOB1-MAP-TYPE X(2) 11 - 12 02 = ICD-10 MapperMapper Type Reserved MOB1-MAP-TYPE-RSVD X(2) 13 - 14 ReservedMapper Version MOB1-MAP-VERS 9(2) 15 - 16 ReservedMapper Version Reserved

MOB1-MAP-VERS-RSVD 9(4) 17 - 20 Reserved

Code Type MOB1-CODE-TYPEMOB1-CODE-ICD9

X(2) 21 - 22 Coding classification of target mapped codes.00 = ICD-901 = ICD-10

Mapper Source MOB1-SOURCE 9(2) 23 - 24 Source version of ICD-9 or ICD-10 codes passed in on claim

Mapper Target MOB1-TARGET 9(2) 25 - 26 Target version of ICD-9 or ICD-10 codes passed in on claim

Direction MOB1-DIRECTION X(2) 27 - 28 Indicates whether the ICD-10 Mapper performed backward or forward mapping based upon the source and target versions.00 = Backwards01 = Forwards

Number of Diagnosis (DX) Code Errors

MOB1-NUM-DXERR 9(3) 29 - 31 ICD-10 Mapper:Number of mapping errors recorded for the diagnosis codes on the claim.

Number of Procedure (OP) Errors

MOB1-NUM-OPERR 9(3) 32 - 34 ICD-10 Mapper:Number of mapping errors recorded for the procedure codes on the claim.

Filler X(366) 35 - 400


GOB1-IG1-IP-GRPR-BLOCK1Table 13-1: GOB1-IG1-IP-GRPR-BLOCK1: Fixed length inpatient Grouper output fields (defined in hgrpblk.cpy)

Field Description Variable Name Format Position NotesGrouper Return Code GOB1-GRPR-RTN-

CODEX(2) 1 - 2 Standard Return Codes:

00 = No errors found01 = Diagnosis cannot be used as principal02 = Record does not meet criteria for any DRG in

MDC, as indicated by the principal diagnosis 04 = Invalid sex05 = Invalid discharge status07 = Invalid principal diagnosis (PDX)23 = HAC Editor not found62 = Closed or inactive rate record87 = Program cannot be loaded90 =Invalid function code91 =Invalid Grouper type95 =Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to GOB1-GRPR-RTN-

CODE2 and GOB1-GRPR-RTN-STATUS below)

Additional Grouper Specific Return Codes:

All Patient (AP-DRG):03 = Invalid age in years or age in days on

admission15 = Invalid birthweight in grams16 = Conflicting birth weights17 = Non-specific birth weight as derived from

diagnosis codes18 = Invalid discharge age

Medicare DRG:06 = Illogical principal diagnosis (PDX)

TRICARE/CHAMPUS DRG and ICD-10 TRICARE DRG:03 = Invalid age in years or age in days on

admission06 = Illogical principal diagnosis (PDX)16 = Conflicting birth weights17 = Non-specific birth weight as derived from

diagnosis codes18 = Invalid age in days on admission

Grouper Return Code Extension

GOB1-GRPR-RTN-CODE2

X(2) 3 - 4 01 = Diagnosis file I/O error03 = Procedure file I/O error04 = CC exclusion file I/O error

Return Status GOB1-GRPR-RTN-STATUS

X(2) 5 - 6 File operation return status code. OS/Languagedependent.

Grouper Reserved GOB1-RSVD X(4) 7 - 10 Reserved


Grouper Type GOB1-GRPR-TYPE X(2) 11 - 12 01 = Medicare DRG02 = Reserved03 = TRICARE/CHAMPUS DRG11 = ICD-10 Medicare DRG12 = ICD-10 TRICARE DRG

Grouper Type Reserved GOB1-GRPR-TYPE-RSVD


Grouper Version GOB1-GRPR-VERS 9(2) 15 - 16 Grouper version number.Grouper Version Reserved

GOB1-GRPR-VERS-RSVD

9(4) 17 - 20 Reserved

MDC GOB1-IG1-MDC 9(2) 21 - 22 Major Diagnostic Category (MDC) number.Number of MDCs varies by Grouper type and version.

DRG GOB1-IG1-DRG 9(5) 23 - 27 Diagnosis Related Group (DRG) number. Number of DRGs varies by Grouper type and version. Right-justified, zero-filled.

First O.R. Procedure GOB1-IG1-OP1 X(7) 28 - 34 First operating room procedure that influenced DRG assignment. May be blank.

Second O.R. Procedure GOB1-IG1-OP2 X(7) 35 - 41 Second operating room procedure that influenced DRG assignment. May be blank.

Third O.R. Procedure GOB1-IG1-OP3 X(7) 42 - 48 Third operating room procedure that influenced DRG assignment. May be blank.

First Non-O.R. Procedures

GOB1-IG1-NOR1 X(7) 49 - 55 First non-operating room procedure that influenced DRG assignment. May be blank.

Second Non-O.R. Procedures

GOB1-IG1-NOR2 X(7) 56 - 62 Second non-operating room procedure that influenced DRG assignment. May be blank.

Complication/ Comorbidity Diagnosis

GOB1-IG1-CC X(6) 63 - 68 Diagnosis code that satisfied the Complication/ Comorbidity (CC) criteria and influenced DRG assignment. May contain either a non-major or major CC, as appropriate. May be blank.

AP-DRG: Diagnosis code that satisfied the non-major CC, major CC or non-traumatic major CC criteria.

First Diagnosis GOB1-IG1-DX1 X(6) 69 - 74 First diagnosis (other than principal) that influenced DRG assignment. May be blank.

Second Diagnosis GOB1-IG1-DX2 X(6) 75 - 80 Second diagnosis (other than principal) that influenced DRG assignment. May be blank.

Third Diagnosis GOB1-IG1-DX3 X(6) 81 - 86 Third diagnosis (other than principal) that influenced DRG assignment. May be blank.

Trauma Registry Flag GOB1-IG1-NYSTR 9(1) 87 AP-DRG: Used to flag patients who should be reported to the New York State Trauma Registry.

0 = Do not report patient1 = Patient should be reported

Table 13-1: GOB1-IG1-IP-GRPR-BLOCK1: Fixed length inpatient Grouper output fields (defined in hgrpblk.cpy)



Congenital Malformation Registry Flag

GOB1-IG1-NYSCMR

9(1) 88 AP-DRG: Congenital Malformation Flag. New York State reporting requirement.

0 = No congenital anomalies1 = 1 or more codes on congenital anomaly list 1

only2 = 1 or more codes on congenital anomaly list 2

only3 = 2 or more codes on congenital anomaly lists 1

and 2Filler X(4) 89 - 92Number of MCCs GOB1-IG1-NUM-

MCC9(3) 93 - 95 Number of major complications/comorbidities on the

claim not excluded by the principal diagnosis.Number of CCs GOB1-IG1-NUM-CC 9(3) 96 - 98 Number of complications/comorbidities on the claim

not excluded by the principal diagnosis.Alternate DRG GOB1-IG1-ALT-

DRG9(5) 99 - 103 Alternate DRG that would have been assigned if all

conditions had been present on admission.First O.R. Procedure GOB1-IG1-OP1-01 X(10) 104 - 113 First operating room procedure that influenced DRG

assignment. May be blank. Second O.R. Procedure GOB1-IG1-OP2-01 X(10) 114 - 123 Second operating room procedure that influenced

DRG assignment. May be blank. Third O.R. Procedure GOB1-IG1-OP3-01 X(10) 124 - 133 Third operating room procedure that influenced

DRG assignment. May be blank. First Non-O.R. Procedure

GOB1-IG1-NOR1-01 X(10) 134 - 143 First non-operating room procedure that influenced DRG assignment. May be blank.

Second Non-O.R. Procedure

GOB1-IG1-NOR2-01 X(10) 144 - 153 Second non-operating room procedure that influenced DRG assignment. May be blank.

Complication/Comorbidity Diagnosis

GOB1-IG1-CC-01 X(10) 154 - 163 Diagnosis code that satisfied the Complication/ Comorbidity (CC) criteria and influenced DRG assignment. May contain either a non-major or major CC, as appropriate. May be blank.

AP-DRG: Diagnosis code that satisfied the non-major CC, major CC or non-traumatic major CC criteria.

First Diagnosis GOB1-IG1-DX1-01 X(10) 164 - 173 First diagnosis (other than principal) that influenced DRG assignment. May be blank.

Second Diagnosis GOB1-IG1-DX2-01 X(10) 174 - 183 Second diagnosis (other than principal) that influenced DRG assignment. May be blank.

Third Diagnosis GOB1-IG1-DX3-01 X(10) 184 - 193 Third diagnosis (other than principal) that influenced DRG assignment. May be blank.

Admission DRG GOB1-IG1-ADM-DRG

9(5) 194 - 198 Reserved

Admission SOI GOB1-IG1-ADM-SOI

X(1) 199 Reserved

Admission Severity Filler

GOB1-IG1-ADM-SOI-FILLER

X(1) 200 Reserved




Admission ROM GOB1-IG1-ADM-ROM

X(1) 201 Reserved

Admission Mortality Filler

GOB1-IG1-ADM-ROM-FILLER

X(1) 202 Reserved

Filler X(31798) 203 - 32000




GOB1-OG1-OP-GRPR-BLOCK1Table 14-1: GOB1-OG1-OP-GRPR-BLOCK1: Fixed length APG Grouper output fields (defined in hgrpblk.cpy)


CODEX(2) 1 - 2 Reserved


GOB1-GRPR-RTN-CODE2

X(2) 3 - 4 Reserved


X(2) 5 - 6 Reserved

Grouper Reserved GOB1-RSVD X(4) 7 - 10 ReservedGrouper Type GOB1-GRPR-TYPE X(2) 11 - 12 ReservedGrouper Type Reserved GOB1-GRPR-TYPE-


Grouper Version GOB1-GRPR-VERS 9(2) 15 - 16 ReservedGrouper Version Reserved

GOB1-GRPR-VERS-RSVD

9(4) 17 - 20 Reserved

Patient or Visit Type GOB1-OG1-PATTYPE

X(1) 21 Reserved

APG Status Code GOB1-OG1-STAT 9(1) 22 ReservedMedical APG Assigned GOB1-OG1-MAPG 9(5) 23 - 27 ReservedMedical APG Error Flag GOB1-OG1-MAPG-

ERRX(2) 28 - 29 Reserved

Medical APG Category GOB1-OG1-MAPG-CAT


APG SSF GOB1-OG1-MAPG-SSF


Number of Visits GOB1-OG1-NUM-VISITS

9(3) 38 - 40 Reserved

ICD-10 APG SSF GOB1-OG1-MAPG-SSF-01


Filler X(31950) 51 - 32000


GOB1-OG2-OP-GRPR-BLOCK2Table 15-1: GOB1-OG2-OP-GRPR-BLOCK2: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields (defined in hgrpblk.cpy)



00 = No errors found62 = Closed or inactive rate record90 = Invalid function code91 = Invalid Grouper type95 = Invalid diagnosis or procedure countCL = Cannot load or open programIO = File I/O error (refer to GOB1-GRPR-RTN-CODE2 and GOB1-GRPR-RTN-STATUS below)

Additional Grouper Specific Return Codes:APC:None

ASC:None

HHA HHRG:01 = Invalid bill type 02 = Invalid number of HIPPS codes03 = Invalid HIPPS code 27 = Invalid or no treatment authorization code

provided

HHA PDGM:01 = Invalid bill type 02 = Invalid number of HIPPS codes03 = Invalid HIPPS code 31 = Principal diagnosis code not assigned to a

clinical group

ESRD:None


GOB1-GRPR-RTN-CODE2

X(2) 3 - 4 01 = Procedure file I/O error

HHA PDGM:01 = Procedure/HHA PDGM Reader file I/O error


X(2) 5 - 6 File operation return status code. OS/language dependent.

Grouper Reserved GOB1-RSVD X(4) 7 - 10 ReservedGrouper Type GOB1-GRPR-TYPE X(2) 11 - 12 24 = Medicare HHA PDGM (effective January 01,

2020)55 = Medicare APC57 = Medicare ASC (effective January 01, 2008)60 = Medicare ESRD62 = Medicare HHA HHRG (prior to January 01,

2020)





GOB1-GRPR-VERS-RSVD

9(4) 17 - 20

Patient or Visit Type GOB1-OG2-PATTYPE

X(1) 21 APC:0 = Undetermined1 = Significant procedure3 = Medical visit4 = Medical visit resulting in surgery

APC Status Code GOB1-OG2-STAT 9(1) 22 APC:0 = No errors found1 = Procedure APC error found on at least one or

multiple claim lines4 = No APCs assigned to case

ASC:0 = No errors found1 = Procedure APC error found on at least one or

multiple claim lines4 = Procedure APC errors found on all claim lines

Alternate HHRG/First Four Positions of Alternate PDGM

GOB1-OG2-ALT-HHRG

X(4) 23 - 26 HHA HHRG:Alternate home health resource group.

HHA PDGM:First four positions of the alternate PDGM.

Alternate HHRG/PDGM Flag

GOB1-OG2-ALT-FLAG

9(1) 27 HHA HHRG:0 = No alternate HHRG available1 = Alternate HHRG is available

HHA PDGM:0 = No alternate PDGM available 1 = Alternate PDGM is available 2 = No alternate PDGM available; Admit Date not

submitted on the claim3 = No alternate PDGM available; occurrence code

61 or 62 billed incorrectlyHHRG/First Four Positions of PDGM

GOB1-OG2-HHRG X(4) 28 - 31 HHA HHRG:Home health resource group.

HHA PDGM:First four positions of the PDGM.

Non-Routine Supplies (NRS)/Fifth Position of PDGM

GOB1-OG2-NRS X(1) 32 HHA HHRG:Non-routine supplies code.

HHA PDGM:Fifth position of the PDGM.

Table 15-1: GOB1-OG2-OP-GRPR-BLOCK2: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields (defined in hgrpblk.cpy)



Treatment Authorization Code Validity Flag

GOB1-OG2-TX-VALID-FLAG

9(1) 33 HHA HHRG:0 = Valid treatment authorization code provided1 = Invalid treatment authorization code provided2 = No treatment authorization code provided

Alternate PDGM GOB1-OG2-ALT-PDGM

X(5) 34 - 38 HHA PDGM:Alternate PDGM.

PDGM GOB1-OG2-PDGM X(5) 39 - 43 HHA PDGM:PDGM

Filler X(31957) 44 - 32000

Table 15-1: GOB1-OG2-OP-GRPR-BLOCK2: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields (defined in hgrpblk.cpy)



GOB1-RG1-REHAB-GRPR-BLOCK1Table 16-1: GOB1-RG1-REHAB-GRPR-BLOCK1: Fixed length IRF Grouper output fields (defined in hgrpblk.cpy)


CODEX(2) 1 - 2 00 = No errors found

01 = No CMG match02 = No HIPPS code on claim03 = Not used04 = Not used05 = Computed age is greater than 140 years 06 = Submitted age is invalid 07 = Birth date after 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 range14 = Self care, dressing, lower body (FIM39E,

admission value) is out of range15 = Self care, toileting (FIM39F, admission value) is

out of range16 = Sphincter control, bladder management

(FIM39G, admission value) is out of range17 = Sphincter control, bowel management

(FIM39H, admission value) is out of range18 = Transfers, bed, chair, wheelchair (FIM39I,

admission value) is out of range19 = Transfers, toilet (FIM39J, admission value) is

out of range20 = Locomotion, walk/wheelchair (FIM39L,

admission value) is out of range21 = Locomotion, stairs (FIM39M, admission value)

is out of range22 = Comprehension (FIM39N, admission value) is

out of range23 = Expression (FIM39O, admission value) is out of

range24 = Social interaction (FIM39P, admission value) is

out of range25 = Problem solving (FIM39Q, admission value) is

out of range26 = Memory (FIM39R, admission value) is out of

range27- 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 rangecontinued below...


Grouper Return Code<continued>

GOB1-GRPR-RTN-CODE

X(2) 1 - 2 39 = Total cognitive score, admission, out of range62 = Closed or inactive rate record90 = Invalid function code91 = Invalid Grouper type95-99 = ReservedCL = Cannot load or open programIO = File I/O error (refer to GOB1-GRPR-RTN-

CODE2 and GOB1-GRPR-RTN-STATUS below)


GOB1-GRPR-RTN-CODE2

X(2) 3 - 4 01 = Rehabilitation impairment category file I/O error02 = Case mix group file I/O error03 = Comorbidity diagnosis file I/O error

Grouper Return Status GOB1-GRPR-RTN-STATUS

X(2) 5 - 6 File operation status return code. O/S Language dependent.

Grouper Reserved GOB1-RSVD X(4) 7 - 10 ReservedGrouper Type GOB1-GRPR-TYPE X(2) 11 - 12 90 = Medicare IRF CMGGrouper Type Reserved GOB1-GRPR-TYPE-



GOB1-GRPR-VERS-RSVD

9(4) 17 - 20 Reserved

Rehabilitation Impairment Category

GOB1-RG1-RIC 9(2) 21 - 22 Rehabilitation Impairment Category (RIC). Used to identify orthopedic and non-orthopedic cases for pricing of claims for expired patients. Valid values range from 01 to 21.

Original/Clinical Case-Mix Group

GOB1-RG1-CMG 9(4) 23 - 26 Clinically-related CMG.

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

HIPPS Code GOB1-RG1-HIPPS X(5) 27 - 31 Health Insurance Prospective Payment System (HIPPS) code. Left-justified, blank-filled.

Format XYYYY, where:X = Comorbidity tierYYYY = “Original CMG”

Comorbidity Code Used for HIPPS Assignment

GOB1-RG1-COMORBID

X(6) 32 - 37 Diagnosis code with the highest comorbidity tier for the case.

Table 16-1: GOB1-RG1-REHAB-GRPR-BLOCK1: Fixed length IRF Grouper output fields (defined in hgrpblk.cpy)



Admission Motor Score – Calculated

GOB1-RG1-MOTOR-OUT

9(3) 38 - 40 Effective prior to October 01, 2019, the 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 PCB2-RCD-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 GOB1-RG1-MOTOR-FLAG field.

Returned only if assessment data was provided.

Effective October 01, 2019, the total motor score calculated from IRF-PAI admission motor scores collected in fields GG0130A1 - GG0130C1, GG0130E1 - GG0130H1, GG0170B1 - GG0170F1, GG0170I1, GG0170K1, GG0170M1, H0350, and H0400.

When totaling individual IRF-PAI scores, values of 00, 07, 09, 10, and 88 default to “01”, except for GG0170F1 which defaults to “02”. Valid values range from 18 to 104.



FIM Admission Motor Score Flag

GOB1-RG1-MOTOR-FLAG

9(1) 41 0 = FIM Admission Motor Score was not calculated1 = FIM Admission Motor Score was calculated





FIM Admission Cognitive Score – Calculated

GOB1-RG1-COGN-OUT

9(3) 42 - 44 Effective prior to October 01, 2019, the 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 to 35.

If input field PCB2-RCD-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 the GOB1-RG1-COGN-FLAG field.

Returned only if assessment data was provided.FIM Admission Cognitive Score Flag

GOB1-RG1-COGN-FLAG

9(1) 45 0 = FIM Admission Cognitive Score was not calculated

1 = FIM Admission Cognitive Score was calculated





Admission Motor Score 2 – Calculated

GOB1-RG1-MOTOR-OUT2

9(3)v9(3) 46 - 51 Effective prior to October 01, 2019, the 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 PCB2-RCD-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 GOB1-RG1-MOTOR-FLAG field.


Effective October 01, 2019, the total motor score calculated from IRF-PAI admission motor scores collected in fields GG0130A1 - GG0130C1, GG0130E1G - G0130H1, GG0170B1 - GG0170F1, GG0170I1 - GG0170K1, GG0170M1, H0350, and H0400.

When totaling individual IRF-PAI scores, values of 00, 07, 09, 10, and 88 default to "01", except for GG0170F1 which defaults to "02". Valid values range from 18 to 104.






FIM Admission Cognitive Score – Calculated

GOB1-RG1-COGN-OUT2

9(3)v9(3) 52 - 57 Effective prior to October 01, 2019, the 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 to 35.

If input field PCB2-RCD-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 the GOB1-RG1-COGN-FLAG field.

Returned only if assessment data was provided.ICD-10 Comorbidity Code used for HIPPS Assignment

GOB1-RG1-COMORBID-01

X(10) 58 - 67 Diagnosis code with the highest comorbidity tier for the case.

Second ICD-10 Comorbidity Code Used for HIPPS Assignment

GOB1-RG1-COMORBID-02

X(10) 68 - 77 Diagnosis code with the highest comorbidity tier for the case that is also part of an ICD-10 code pair.

Filler X(31923) 78 - 32000




GOB1-SG1-SNF-GRPR-BLOCK1Table 17-1: GOB1-SG1-SNF-GRPR-BLOCK1: Fixed length RUG Reader and SNF Reader output fields (defined in hgrpblk.cpy)



02 = No HIPPS code on claim62 = Closed or inactive rate record90 = Invalid function code91 = Invalid Grouper type95 = Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to GOB1-GRPR-RTN-

CODE2 and GOB1-GRPR-RTN-STATUS below)Grouper Return Code Extension

GOB1-GRPR-RTN-CODE2

X(2) 3 - 4 Reserved


X(2) 5 - 6 Reserved

Grouper Reserved GOB1-RSVD X(4) 7 - 10 ReservedGrouper Type GOB1-GRPR-TYPE X(2) 11 - 12 22 = Medicare SNF RUG (prior to October 01, 2019)

23 = Medicare SNF Reader (effective October 01, 2019)




GOB1-GRPR-VERS-RSVD

9(4) 17 - 20 Reserved

Filler X(31980) 21 - 200


GOB2-IG1-IP-GRPR-BLOCK1

Table 18-1: GOB2-IG1-IP-GRPR-BLOCK1: Variable length line-level inpatient Grouper output fields (defined in hgrpblk.cpy; reserved for future use)

Field Description Variable Name Format Position NotesReserved X(31968) 1 - 31968 Reserved


GOB2-OG1-OP-GRPR-BLOCK1Table 19-1: GOB2-OG1-OP-GRPR-BLOCK1: Variable length APG Grouper output fields (defined in hgrpblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesAPG GOB2-OG1-APG-

PROC9(5) 1 - 5 Reserved

APG Type GOB2-OG1-APG-TYPE

X(2) 6 - 7 Reserved

APG Category GOB2-OG1-APG-CAT

X(2) 8 - 9 Reserved

APG Consolidation Flag GOB2-OG1-APG-CONS

9(1) 10 Reserved

APG Packaging Flag GOB2-OG1-APG-PACK

9(1) 11 Reserved

Ambulatory Surgery Category

GOB2-OG1-APG-ASC

9(2) 12 - 13 Reserved

ASC Grouper Return Code

GOB2-OG1-APG-ASC-RC

9(2) 14 - 15 Reserved

Bilateral Discount Flag GOB2-OG1-APG-BIDISC

9(1) 16 Reserved

Unassigned Flag GOB2-OG1-APG-ERR

9(2) 17 - 18 Reserved

Medical Visit Diagnosis/SSF

GOB2-OG1-APG-MED-DX


Multiple Significant Procedure Discounting Flag

GOB2-OG1-APG-MSPD

9(1) 25 Reserved

Repeat Ancillary Discounting Flag

GOB2-OG1-APG-REPANC

9(1) 26 Reserved

Terminated Procedure Discounting Flag

GOB2-OG1-APG-TERM

9(1) 27 Reserved

Filler X(5) 28 - 32


GOB2-OG2-OP-GRPR-BLOCK2Table 20-1: GOB2-OG2-OP-GRPR-BLOCK2: Variable length APC Grouper, ASC Grouper, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesAPC GOB2-OG2-APC-

PROC9(5) 1 - 5 APC:

An APC is assigned to each non-blank procedure code with an H-PAYSTAT of G, H, J, J1, K, P, R, S, T, U, or V.

ASC: An APC is assigned to each non-blank procedure code with an H-PAYSTAT of A2, F4, G2, H2, H7, H8, J7, J8, K2, K7, L1, L6, N1, P2, P3, R2, YY, Z2, or Z3.

APC will be set to “00000” if the corresponding procedure code is invalid or not eligible for APC assignment

Procedure APC Error GOB2-OG2-APC-ERR

9(2) 6 - 7 APC/ASC:00 = No errors found01 = Invalid procedure code03 = Procedure is valid for dates with pending

editing and/or grouping information

ACE and CAH Method II:00 = No errors found01 = Invalid procedure code02 = Procedure not valid for service date03 = Procedure is valid for dates with pending

editing and/or grouping information


Hospital Payment Status

GOB2-OG2-APC-H-PAYSTAT

X(2) 8 - 9 APC:A = Services paid under fee schedule or other

prospectively determined rateB = Service not allowed under OPPS on hospital

outpatient claimC = Inpatient service, not paid under OPPSE1 = Non-allowed item or serviceE2 = Items and services for which pricing

information and claims data are not availableEL = Non-covered lab serviceF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH =Pass-through device categoriesJ1 = Hospital Part B services paid through a

Comprehensive APC J2 = Hospital Part B services that may be paid

through a Comprehensive APCK = Non pass-through drugs and non-implantable

biologicals, including therapeutic radiopharmaceuticals

L = Influenza virus or Pneumococcal Pneumonia Vaccine (PPV)

M = Service not billable to FI/MACN = Packaged/incidental serviceP = Partial hospitalization serviceQ1 = STV - packaged servicesQ2 = T - packaged servicesQ3 =Services that may be paid through a Composite

APCQ4 = Conditionally packaged laboratory servicesR = Blood and blood productsS = Procedure or service, not discounted when

multiple T = Procedure or service, multiple reduction appliesU = Brachytherapy sourcesV = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and invalid

revenue codeX = Ancillary service (prior to January 1, 2015)Y = Non-implantable DMEZ = Valid revenue code, blank HCPCS, no other

status indicator assigned

ASC:A2 = Surgical procedure; OPPS weightF4 = Corneal tissue acquisition, hepatitis B vaccine;

reasonable costG2 = Non office-based procedure; OPPS weightH2 = Brachytherapy source; OPPS rateH7 = Brachytherapy source; contractor rateH8 = Device-intensive procedure; adjusted rateJ7 = OPPS pass-through device; contractor rate

continued below...

Table 20-1: GOB2-OG2-OP-GRPR-BLOCK2: Variable length APC Grouper, ASC Grouper, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times)



Hospital Payment Status<continued>

GOB2-OG2-APC-H-PAYSTAT

X(2) 8 - 9 J8 = Device-intensive procedure; adjusted rateK2 = Drug/biological; OPPS rateK7 = Unclass drug/biological; contractor-pricedL1 = Influenza/pneumococcal vaccine; packaged

service/item, no separate paymentL6 = New tech intraocular lens; special paymentM5 = Quality measurement code used for reporting

purposes only; no payment madeN1 = Packaged service/item; no separate paymentP2 = Office-based procedure; OPPS weightP3 = Office-based procedure; MPFS RVUsR2 = Office-based procedure; OPPS weightYY = Service not covered by Medicare for free-

standing ASCsZ2 = Radiology service; OPPS weightZ3 = Radiology service; MPFS non-facility PE RVUs

CAH Method II:The status code for this practitioner service. The following values may be returned:A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician Fee Schedule by

regulationF = Deleted/ Discontinued codeG = Not valid for Medicare purposesH = Deleted modifierI = Not valid for Medicare purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/Excluded codeQ = Therapy functional information code (used for


NoteFor facility services, this field will be blank.

Partial Hospitalization Indicator

GOB2-OG2-APC-CMHCIND

X(1) 10 ACE:Blanks = Not a partial hospitalization serviceP = Partial hospitalization service

APC:0 = Not a partial hospitalization service1 = Partial hospitalization service




ASC Covered Services Indicator

GOB2-OG2-APC-COVSERVIND

9(1) 11 ASC:0 = Service is not separately payable under the ASC

PPS1 = Service is separately payable under the ASC

PPSFiller X(21) 12 - 32




GOB2-RG1-REHAB-GRPR-BLOCK1Table 21-1: GOB2-RG1-REHAB-GRPR-BLOCK1: Variable length IRF Grouper output fields (defined in hgrpblk.cpy; reserved for future use)



GOB2-SG1-SNF-GRPR-BLOCK1Table 22-1: GOB2-SG1-SNF-GRPR-BLOCK1: Variable length RUG Reader and SNF Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesHIPPS GOB2-SG1-HIPPS X(5) 1 - 5 Health Insurance Prospective Payment CodeRUG GOB2-SG1-RUG X(5) 6 - 10 Resource Utilization GroupGrouper Return Code GOB2-SG1-ERR X(2) 11 - 12 RUG Reader/SNF Reader line-level Return Code.

00 = No errors found01 = Invalid HIPPS code (Part A only)

Filler X(20) 13 - 32


GOB3-ID1-IP-DX-BLOCK1Table 23-1: GOB3-ID1-IP-DX-BLOCK1: Variable length diagnosis return fields (defined in hgrpblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesSeverity of Illness Indicator

GOB3-ID1-DX-SOI-IND

9(1) 1 Reserved

Severity of Illness GOB3-ID1-DX-SOI X(1) 2 ReservedSeverity Filler GOB3-ID1-DX-SOI-

RSVDX(1) 3 Reserved

Risk of Mortality Indicator

GOB3-ID1-DX-ROM-IND

9(1) 4 Reserved

Risk of Mortality GOB3-ID1-DX-ROM X(1) 5 ReservedMortality Filler GOB3-ID1-DX-

ROM-RSVDX(1) 6 Reserved

Unrelated CC GOB3-ID1-DX-UNRELATED-CC

9(1) 7 Reserved

Diagnosis Grouper Flag (output)

GOB3-ID1-DX-NARRAY

9(3) 8 - 10 Output field.

For inpatient DRG grouping only. Flag that shows how a diagnosis code was utilized by the Grouper.

AP-DRG Grouper:0 = Not used1 = Needed for DRG assignment2 = CC for PDX3 = CC for PDX, needed for DRG assignment4 = Non-traumatic major CC5 = Non-traumatic major CC, needed for DRG

assignment8 = Major CC9 = Major CC needed for DRG assignment

All Other DRG Groupers:0 = Not used1 = Needed for DRG assignment2 = CC for PDX3 = CC needed for DRG assignment4 = Major CC for PDX 5 =Major CC needed for DRG assignment

Filler X(22) 11 - 32


GOB4-IO1-IP-OP-BLOCK1Table 24-1: GOB4-IO1-IP-OP-BLOCK1: Variable length ICD-9-CM or ICD-10-PCS procedure return fields (defined in hgrpblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesSeverity of Illness Indicator

GOB4-IO1-OP-SOI-IND

9(1) 1 Reserved

SOI Filler GOB4-IO1-OP-SOI-RSVD

X(2) 2 - 3 Reserved

Risk of Mortality Indicator

GOB4-IO1-OP-ROM-IND

9(1) 4 Reserved

ROM Filler GOB4-IO1-OP-ROM-RSVD

X(2) 5 - 6 Reserved

DRG Procedure Indicator (output)

GOB4-IO1-OP-NARRAY

9(3) 7 - 9 Output field.

For inpatient DRG grouping only. Flag that shows how each procedure code was utilized by the Grouper.

0 = Non-operating room procedure1 = Non-operating room procedure, needed for DRG

assignment2 = Qualifying non-operating room procedure3 = Qualifying non-operating room procedure,

needed for DRG assignment4 = Operating room procedure5 = Operating room procedure, needed for DRG

assignment6 = Qualifying operating room procedure7 = Qualifying operating room procedure, needed for

DRG assignmentFiller X(23) 10 - 32


POB1-CA1-PRCR-BLOCK1Table 25-1: POB1-CA1-PRCR-BLOCK1: Fixed length CAH Method II Pricer output fields (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesPricer Return Code POB1-PRCR-RTN-


01 = No hospital rate calculator record21 = Invalid bill type22 = Denial claim23 = Invalid service date, from/thru dates, or

admission date41 = Invalid billing of therapy services44 = Invalid or missing zip code62 = Closed or inactive rate record70 = Configuration record error90 = Invalid function code91 = Invalid Pricer type94 = Invalid from/thru date relationship95 = Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-

CODE2 and POB1-PRCR-RTN-STATUS below)

Pricer Return Code Extension

POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No I/O errors01 = Hospital rate calculator file I/O error02 = APC weight/rate file I/O error03 = Fee schedule type file I/O error04 = Fee schedule rate file I/O error10 = Code table file I/O error11 = APC rate file I/O error

Return Status POB1-PRCR-RTN-STATUS


Pricer Return Code Type

POB1-PRCR-RTN-TYPE

X(1) 7 A = Return code from APC-HOPD PricerC = Return code from CAH Method II PricerP = Return code from Physician Pricer

Pricer Reserved POB1-RSVD X(3) 8 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 66 = CAH Method IIPricer Type Reserved POB1-PRCR-TYPE-


Base Reimbursement POB1-CA1-BASE-PAY

9(8)v9(2) 15 - 24 Total Medicare payment for this claim.

Patient Co-Payment POB1-CA1-COPAY 9(8)v9(2) 25 - 34 Total patient co-payment for this claim.Total Reimbursement POB1-CA1-TOT-

REIMB9(8)v9(2) 35 - 44 Total payment calculated as follows:

BASE-PAY + COPAY + BONUS-PAYRural Flag POB1-CA1-RURAL X(1) 45 Rural indicator for ambulance pricing.

B = Qualified rural area ZIP code for air and ground ambulance services

R = Rural ZIP code for air and ground ambulance services


Estimated Bonus Payment

POB1-CA1-BONUS-PAY

9(8)v9(2) 46 - 55 If requested by the user, this is the total estimated Health Professional Shortage Area (HPSA) payment for this claim.

Filler X(31945) 56 - 32000

Table 25-1: POB1-CA1-PRCR-BLOCK1: Fixed length CAH Method II Pricer output fields (defined in hprcblk.cpy)



POB1-EP1-ESRD-PRCR-BLOCK1Table 26-1: POB1-EP1-ESRD-PRCR-BLOCK1: Fixed length ESRD Pricer output fields (defined in hprcblk.cpy)



01 = No hospital rate calculator record04 = Invalid or missing value code/value amount05 = Invalid or missing modifier21 = Invalid bill type22 = Denial claim23 = Invalid service date, from-thru dates, or

admission date27 = Missing diagnosis code28 = Invalid case-mix adjustment29 = Attempted divide by zero36 = Incorrect billing of Automated Multi-Channel

Chemistry (AMCC) ESRD-related tests38 = Invalid or missing required claims data62 = Closed or inactive rate record85 = Error reading extended hospital rate calculator

file90 = Invalid function code91 = Invalid Pricer type94 = Invalid service date95 = Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-



POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No I/O errors01 = Hospital rate calculator file I/O error02 = Weight/rate file I/O error03 = Fee schedule type file I/O error04 = Fee schedule rate file I/O error05 = User fee schedule rate file I/O error (reserved)



Pricer Reserved POB1-RSVD X(4) 7 - 10 Reserved.Pricer Type POB1-PRCR-TYPE X(2) 11 - 12 60 = Medicare ESRDPricer Type Reserved POB1-PRCR-TYPE-

RSVDX(2) 13 - 14 Reserved.

Base Reimbursement POB1-EP1-BASE-PAY

9(8)v9(2) 15 - 24 Total reimbursement for this claim.

Patient Co-Payment POB1-EP1-COPAY 9(8)v9(2) 25 - 34 Total coinsurance for this claim.Outlier Payment POB1-EP1-ADDON 9(8)v9(2) 35 - 44 Total outlier payment for this claim. PPS Charges POB1-EP1-PPS-

CHARGES9(8)v9(2) 45 - 54 Reserved.

PPS Payment POB1-EP1-PPS-PAYMENT

9(8)v9(2) 55 - 64 Reserved.


Transitional Corridor/Hold Harmless Add-on

POB1-EP1-TRANSCOR

9(8)v9(2) 65 - 74 Reserved.

Claim Deductible POB1-EP1-CLM-DEDUCT

9(8)v9(2) 75 - 84 Reserved.

Total ESRD Reimbursement

POB1-EP1-TOT-REIMB

9(8)v9(2) 85 - 94 Total anticipated payment.BASE-PAY + COPAY + ADDON

Outlier Flag POB1-EP1-OUTFLAG

9(1) 95 1 = Claim contains outlier add-on0 = Otherwise

Base Rate Flag POB1-EP1-BASERATE-FLAG

9(1) 96 Reserved.

Cost Reduction Factor POB1-EP1-CRF-RSVD

9(1)v9(5) 97 - 102 Reserved.

Rural Flag POB1-EP1-RURAL-RSVD

X(1) 103 Reserved.

Outpatient RCC POB1-EP1-RCC 9(1)v9(5) 104 - 109 Reserved.Mark-up/Discount Factor

POB1-EP1-MARKUP

9(1)v9(4) 110 - 114 Mark-up or discount applied to total reimbursement.

Pricing Method POB1-EP1-METHOD

9(2) 115 - 116 Reserved.

Alternate Payment POB1-EP1-ALT-REIMB

9(8)v9(2) 117 - 126 Reserved.

Alternate Add-on (Outlier/LUPA Add-On) Payment

POB1-EP1-ALT-ADDON

9(8)v9(2) 127 - 136 Reserved.

Comorbidity Category POB1-EP1-COMRBD-CAT

9(2) 137 - 138 Comorbidity category associated with monthly bill:00 = No Comorbidity Adjustment01 = GI Bleed02 = Pneumonia03 = Pericarditis04 = Myelodysplastic Syndrome05 = Sickle Cell Aenemia06 = Monoclina Gammopathy

Quality Flag POB1-EP1-QUALITY-FLAG

9(2) 139 - 140 0 = Quality reporting requirements met1 = Quality reporting requirements not met

Dialysis PPS Payment with Facility Adjustment Only

POB1-EP1-ADJ-BASE

9(8)v9(2) 141 - 150 Adjusted base rate without patient-case mix adjustment.

Adjusted Outlier Services MAP

POB1-EP1-ADJ-MAP

9(8)v9(2) 151 - 160 Outlier services Medicare Anticipated Payment (MAP). Used for cost outlier calculation.

Age Factor - Composite POB1-EP1-AGEFACT

9(1)v9(4) 161 - 165 Age adjustment utilized for the composite payment of dialysis services prior to January 1, 2011.

Age Factor - Separately Payable

POB1-EP1-AGEFACT-SEP

9(1)v9(5) 166 - 171 Separately payable portion of bundled age adjustment utilized for cost outlier calculation.

Table 26-1: POB1-EP1-ESRD-PRCR-BLOCK1: Fixed length ESRD Pricer output fields (defined in hprcblk.cpy)



Average Imputed Separately Payable Services per Dialysis Treatment

POB1-EP1-AVG-PER-TREAT

9(8)v9(2) 172 - 181 Actual amount of formerly separately payable services per dialysis treatment on monthly bill.

Average Predicted Separately Payable Services per Dialysis Treatment

POB1-EP1-AVG-PER-TREAT-BLEND

9(8)v9(2) 182 - 191 Predicted amount of separately payable services per dialysis treatment on monthly bill.

Body Mass Index (BMI) POB1-EP1-BMI 9(3)v9(4) 192 - 198 BMI of patient.Body Mass Index (BMI) Factor

POB1-EP1-BMIFACT

9(1)v9(4) 199 - 203 BMI Factor for composite payment of dialysis services prior to January 1, 2011.

Body Mass Index (BMI) Factor - Separately Payable

POB1-EP1-BMIFACT-SEP

9(1)v9(5) 204 - 209 Separately payable portion of bundled BMI factor utilized for cost outlier calculation.

Body Surface Area (BSA)

POB1-EP1-BSA 9(1)v9(4) 210 - 214 BSA of patient.

Body Surface Area (BSA) Factor - Composite

POB1-EP1-BSAFACT

9(1)v9(4) 215 - 219 BSA utilized for the composite payment of dialysis services prior to January 1, 2011.

Body Surface Area (BSA) Factor - Separately Payable

POB1-EP1-BSAFACT-SEP

9(1)v9(5) 220 - 225 Separately payable portion of bundled BSA factor utilized for cost outlier calculation.

Age Factor - ESRD Bundled PPS

POB1-EP1-BUNDLE-AGEFACT

9(1)v9(4) 226 - 230 Age adjustment utilized for the bundled prospective payment of dialysis services on or after January 1, 2011.

Body Mass Index (BMI) Factor - ESRD Bundled PPS

POB1-EP1-BUNDLE-BMIFACT

9(1)v9(5) 231 - 236 BMI factor for the bundled prospective payment of dialysis services on or after January 1, 2011.

Body Surface Area (BSA) Factor - ESRD Bundled PPS

POB1-EP1-BUNDLE-BSAFACT

9(1)v9(4) 237 - 241 BSA factor for the bundled prospective payment of dialysis services on or after January 1, 2011.

Comorbidity Factor POB1-EP1-COMRBD-FACT

9(1)v9(5) 242 - 247 Comorbidity adjustment utilized for the prospective payment of dialysis services on or after January 1, 2011.

Comorbidity Factor - Separately Payable

POB1-EP1-COMRBD-FACT-SEP

9(1)v9(5) 248 - 253 Separately payable portion of comorbidity factor utilized for cost outlier calculation.

NDC Dispensing Fee POB1-EP1-DISPENSE-FEE

9(2)v9(2) 254 - 257 Dispensing fee for oral-only drugs with an injectable equivalent.

Fixed Dollar Loss Amount

POB1-EP1-FLOSS 9(8)v9(2) 258 - 267 Fixed dollar loss amount that is added to the predicted MAP to determine the cost outlier threshold.

Low Volume Adjustment POB1-EP1-LOW-VOL

9(1)v9(4) 268 - 272 Low volume adjustment utilized for the bundled prospective payment of dialysis services on or after January 1, 2011.

Low Volume Adjustment - Separately Payable

POB1-EP1-LOW-VOL-SEP

9(1)v9(4) 273 - 277 Separately payable portion of low volume factor utilized for cost outlier calculation.




Monthly Imputed ESRD outlier Services Amount

POB1-EP1-MONTHLY-SVCS-AMT

9(8)v9(2) 278 - 287 Total amount of formerly separately payable services utilized for the cost outlier calculation.

Dialysis Payment - Composite

POB1-EP1-TEMPRATE

9(8)v9(2) 288 - 297 Total composite payment without training or mark-up/discount adjustment for dialysis services prior to January 1, 2011.

NoteThe Extended Structure Switch (ECB-EXT-BLK-SW) in the ECB-EZG-CNTL-BLOCK needs to be = 1 for all fields beyond position 300.

Cost Outlier Threshold POB1-EP1-THRESHOLD

9(8)v9(2) 298 - 307 Predicted MAP plus fixed dollar loss amount that is utilized for the cost outlier calculation.

Total Predicted ESRD Outlier Payment

POB1-EP1-PREDICT-OUTL-MAP

9(8)v9(2) 308 - 317 Total predicted amount of separately payable services per dialysis treatment on monthly bill.

Geographic Adjustment - Composite

POB1-EP1-TOTWAGERATE

9(8)v9(2) 318 - 327 Composite dialysis payment with geographic adjustment only for dialysis services prior to January 1, 2011.

Number of Dialysis Line Items

POB1-EP1-LINE-DIALYSIS-COUNT

9(3) 328 - 330 Number of dialysis claim line items.

Core Based Statistical Area (CBSA)

POB1-EP1-CBSA X(5) 331 - 335 Core Based Statistical Area (CBSA).

Return Code Override Flag

POB1-EP1-RC-OVER

9(1) 336 0 = Do not override Return Codes 04, 05, and 381 = Override Return Codes 04, 05, and 38

Rural Adjustment Factor

POB1-EP1-RURAL-ADJ

9(1)v9(5) 337 - 342 Rural payment adjustment under the bundled Medicare ESRD Payment System, for adult ESRD beneficiaries utilizing ESRD facilities located in rural CBSAs (that are non-urban CBSAs).

Rural Adjustment Factor - Separately Billable

POB1-EP1-RURAL-ADJ-SEP

9(1)v9(5) 343 - 348 Separately billable rural payment adjustment for adult ESRD beneficiaries utilizing ESRD facilities located in rural CBSAs (that are non-urban CBSAs).

Filler X(31652) 349 - 32000




POB1-IP1-IP-PRCR-BLOCK1Table 27-1: POB1-IP1-IP-PRCR-BLOCK1: Fixed length Inpatient Pricer output fields (defined in hprcblk.cpy)



00 = No errors found01 = No hospital rate calculator record02 = No DRG rate record06 = Reserved09 = Reserved10 = Failure to locate a valid record during the config

lookup logic11 = Reserved12 = Reserved13 = Reserved22 = Reserved23 = Reserved62 = Closed or inactive rate record70 = Configuration record error73 = Cannot retrieve rate record90 = Invalid function code91 = Invalid Pricer type94 = Invalid from/thru date relationship95 = Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-


Medicare Inpatient:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim25 = Non-payment claim27 = Wrong procedure performed

Medicare IPF:08 = Zero-divide error16 = Invalid ALC days/interrupted days17 = Number of ECT treatments not coded18 = Invalid occurrence span date19 = ECT units coded without appropriate procedure25 = Non-payment claim27 = Wrong procedure performed

continued below...


Pricer Return Code<continued>

POB1-PRCR-RTN-CODE

X(2) 1 - 2 Medicare LTC:08 = Zero-divide error16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date20 = Requested inpatient PPS rate information

cannot be found25 = Non-payment claim27 = Wrong procedure performed

Michigan Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed38 = Invalid or missing required claims data46 = Invalid birth weight in grams

Multi Pricer/DRG Pro:08 = Zero-divide error14 = Invalid DRG pricing option15 = Invalid tier start days21 = Invalid Present on Admission (POA) indicator27 = Wrong procedure performed28 = Invalid reimbursement configuration

New Jersey Medicaid:07 = No DRG weights/rates available16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date21 = Invalid Present on Admission (POA) indicator

TRICARE/CHAMPUS:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Washington Health Care Authority (HCA):21 = Invalid Present on Admission (POA) indicator


POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No errors01 = Hospital Rate Calculator File I/O error02 = DRG Rate File I/O error05 = Extended Hospital Rate Calculator File I/O error 10 = Code Table File I/O error



Pricer Reserved POB1-RSVD X(4) 7 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 Refer to the ECB-EZG-CNTL-BLOCK for a list of

possible values. Refer to the field labeled, PricerType.

Pricer Type Reserved POB1-PRCR-TYPE-RSVD


Table 27-1: POB1-IP1-IP-PRCR-BLOCK1: Fixed length Inpatient Pricer output fields (defined in hprcblk.cpy)



Base Reimbursement Rate

POB1-IP1-BASE 9(8)v9(2) 15 - 24 Patient’s base level of reimbursement

Outlier Payments POB1-IP1-ADDON 9(8)v9(2) 25 - 34 Add-on amount for patients who qualify as cost or LOS outliers.

Alternate Level of Care Payment orPer Diem Pass-Through

POB1-IP1-ALCPAY 9(8)v9(2) 35 - 44 Medicare Inpatient: Additional payment for pass-through expenses (passthru * los)

New Jersey Medicaid:Payment for alternative level of care days when the length of stay exceeds the day outlier threshold.

New York Medicaid: Payment for the number of days a patient was at an alternative level of care

Total Reimbursement POB1-IP1-TOTAL 9(8)v9(2) 45 - 54 Total patient reimbursement(base + addon + alcpay)

Outlier Type POB1-IP1-OUTFLAG 9(1) 55 1 = Not an outlier2 = Long stay outlier3 = Cost outlier4 = Short stay outlier5 = Transfer6 = Per diem reimbursement

Mean Length of Stay POB1-IP1-MLOS 9(3)v9(4) 56 - 62 Medicare Inpatient, Multi-Pricer/DRG Pro, Medicare LTC, New Jersey Medicaid, Michigan Medicaid, Pennsylvania Medicaid, and TRICARE/CHAMPUS:Geometric mean

Short Length of Stay Outlier Trim

POB1-IP1-LTRIM 9(3) 63 - 65 Multi-Pricer/DRG Pro and TRICARE/CHAMPUS:Low LOS trim used to identify short stay outliers.

Long Length of Stay Outlier Trim

POB1-IP1-HTRIM 9(3) 66 - 68 Medicare Inpatient, Michigan Medicaid, Multi-Pricer/DRG Pro, New Jersey Medicaid, Pennsylvania Medicaid, and TRICARE/CHAMPUS:High LOS trim used to identify long stay or day outliers.

Additional Mean Length of Stay

POB1-IP1-HMLOS 9(3)v9(4) 69 - 75 Medicare Inpatient: Arithmetic mean length of stay

Medicare LTC: 5/6th of the geometric mean length of stay

Multi-Pricer/DRG Pro: Average mean LOS

TRICARE/CHAMPUS: Arithmetic mean LOS used to calculate the per diem rate for short LOS outliers




DRG Weight POB1-IP1-WGT 9(3)v9(5) 76 - 83 Medicare IPF:DRG-specific adjustment used to calculate the per diem

All Other DRG Pricers:DRG-specific weight utilized for patient pricing

Per Diem Reimbursement

POB1-IP1-PDIEM 9(8)v9(2) 84 - 93 Medicare IPF: Per diem calculation before variable day adjustments

Multi-Pricer/DRG Pro: Per diem rate applied to claim

Washington Health Care Authority (HCA): Inpatient psychiatric, substance abuse or rehabilitation per diem rate applied to first day of stay (Case-Based Pricer). All inclusive, medical DRG or surgical DRG operating cost per diem rate applied to claim (Non-Case-Based Pricer)

Tiered Per Diem Reimbursement

POB1-IP1-TDIEM 9(8)v9(2) 94 - 103 Multi-Pricer/DRG Pro:First tiered per diem rate applied to claim

Washington Health Care Authority (HCA): Inpatient psychiatric, substance abuse or rehabilitation per diem rate applied to day two and subsequent days of stay (Case-Based Pricer)

DRG-specific Pricing Rule

POB1-IP1-DRG-PAYTYPE

9(1) 104 Medicare Inpatient and TRICARE/CHAMPUS:1 = Device was replaced or removed at reduced or

no cost2 = Device was replaced or removed at reduced or

no cost and reimbursement has been impacted

Multi-Pricer/DRG Pro:1 = Base * DRG Weight2 = Case Rate3 = Cost Reduction Factor (CRF) or percent of

charges4 = Per diem5 = Tiered per diem6 = Case rate plus per diem7 = (Operating Base + Capital Base) * DRG Weight

Inlier Rate POB1-IP1-INRATE 9(8)v9(2) 105 - 114 Medicare IPF: ECT payment

New Jersey Medicaid: Used in reimbursement prior to August 3, 2009 except for AIDS DRGs

Multi-Pricer/DRG Pro: Used to calculate DRG base rate or case rate




Low Per Diem or Low Cost Outlier Trim

POB1-IP1-LDIEM 9(8)v9(2) 115 - 124 New Jersey Medicaid: Used to collect DRG-specific low per diem values prior to August 3, 2009

Multi-Pricer/DRG Pro: Used to calculate DRG base rate or case rate

Washington Health Care Authority (HCA) Case-Based: Used to collect DRG-specific low charge thresholds.

Transfer Flag POB1-IP1-TRFLAG 9(1) 125 Michigan Medicaid, Multi-Pricer/DRG Pro, New Jersey Medicaid, Pennsylvania Medicaid, and Washington Health Care Authority (HCA):0 = Not reimbursed as a transfer1 = Standard transfer

Medicare Inpatient and TRICARE/CHAMPUS:0 = Not reimbursed as a transfer1 = Standard transfer before FY 19962 = Standard transfer after FY 19963 = Standard post-acute transfer after FY 19984 = Special post-acute transfer after FY 1998




Pricing Method Indicator

POB1-IP1-METHOD 9(2) 126 - 127 Medicare Inpatient:00 = Pricing error encountered01 = Transfer exempt MS-DRG02 = Burn MS-DRGs03 = New technology MS-DRG04 = Error MS-DRG05 = Exempt facility critical access pricing06 = Exempt facility percent of charge pricing07 = SCH reimbursed using HSP rate - MA plans

only99 = Standard MS-DRG processing

Medicare IPF:00 = Standard DRG processing01 = Psychiatric DRG99 = Non-psychiatric DRG with secondary

psychiatric diagnosis code

Medicare LTC:00 = Standard federal01 = Site neutral, no blend02 = Site neutral, no blend, capped at cost03 = Site neutral, blend04 = Site neutral, blend, capped at cost05 = DPP adjustment applied

Michigan Medicaid:00 = Standard DRG processing01 = Percent of charge reimbursement02 = Neonatal DRG03 = Transfer exempt DRG04 = Three digit DRG age split05 = Two digit DRG age split06 = Short stay99 = Normal MS-DRG processing

Multi-Pricer/DRG Pro:01 = Standard DRG processing02 = DRG-specific rate03 = Per diem pricing04 = One day stay pricing05 = Case rate plus per diem pricing06 = Percent of charge pricing07 = Tiered per diem pricing08 = Reimbursement limited to percent of charges09 = Reimbursement increased to percent of charges10 = Operating and capital base rate pricing

continued below...




Pricing Method Indicator<continued>

POB1-IP1-METHOD 9(2) 126 - 127 New Jersey Medicaid:00 = Standard DRG processing 01 = Same day discharge02 = Transfer03 = Cost outlier05 = Transfer and cost outlier06 = Day outlier07 = Transfer and day outlier08 = Cost outlier and day outlier09 = Transfer, cost outlier and day outlier

New York Medicaid APR:00 = Standard DRG Processing01 = Flagged for Never Event02 = GME payment

Pennsylvania Medicaid:01 = Standard DRG processing 02 = Outlier06 = Psychiatric, substance abuse or rehabilitation

DRG12 = Transfer

TRICARE/CHAMPUS:00 = Standard DRG processing01 = Neonatal DRG excluding transfers02 = Burn DRG03 = Neonatal transfer DRG04 = Psychiatric DRG05 = Exempt facility critical access pricing06 = Exempt facility per diem pricing

Washington HCA:01 = DRG based case payment, inlier only02 = DRG based case payment outlier04 = Payment capped at full DRG payment05 = Non-DRG based, all-inclusive per diem06 = Percentage of covered charges07 = Non-DRG based, day-specific per diems08 = Per diems for medical and surgical DRGs 14 = Per diem, with outlier add-on15 = Payment capped at total charges




Percent of Charges Value

POB1-IP1-PERCENT

9(1)v9(5) 128 - 133 Percentage used to calculate reimbursement, when reimbursement is equal to a percentage of covered charges.

Medicare Inpatient Psychiatric: Comorbidity factor applied for adjustment.

Multi-Pricer/DRG Pro: Percentage of charges to calculate reimbursement.

Washington HCA: Percentage of covered charges used to calculate reimbursement.

Default Pricing Method Utilized

POB1-IP1-DEFAULT 9(1) 134 Reserved

Indirect Medical Education (IME) Payment

POB1-IP1-OIME 9(8)v9(2) 135 - 144 Medicare IPF:Operating IME payment.

TRICARE/CHAMPUS:IME payment.

Reserved for Disproportionate Hospital (DSH) Payment

POB1-IP1-RSVD-ODSH

9(8)v9(2) 145 - 154 Reserved

Reserved for Capital Indirect Medical Education (IME) Payment

POB1-IP1-RSVD-CIME

9(8)v9(2) 155 - 164 Reserved

Reserved for Capital Disproportionate Hospital (DSH) Payment

POB1-IP1-RSVD-CDSH

9(8)v9(2) 165 - 174 Reserved

Cost Reduction Factor POB1-IP1-RSVD-CRF

9(1)v9(5) 175 - 180 Reserved

Reimbursement DRG POB1-IP1-REIMB-DRG

9(5) 181 - 185 DRG used by the Pricer to determine claim reimbursement.

State Pricing Indicator POB1-IP1-STATE-ID X(2) 186 - 187 ReservedAdjusted DRG Weight POB1-IP1-ADJ-WGT 9(3)v9(5) 188 - 195 Medicare DRG:

Adjusted DRG weight used to calculate the operating payment amount for discharges for a patient diagnosed with COVID-19 (Coronavirus).

Multi-Pricer/DRG Pro:Adjusted DRG weight used to calculate reimbursement for discharges for an individual diagnosed with specified conditions.

TRICARE/CHAMPUS:Adjusted DRG weight used to calculate the payment for discharges for an individual diagnosed with COVID-19 (Coronavirus).




Filler X(31805) 196 - 32000




POB1-OP1-OP-PRCR-BLOCK1Table 28-1: POB1-OP1-OP-PRCR-BLOCK1: Fixed length APG Pricer output fields (defined in hprcblk.cpy)


CODEX(2) 1 - 2 Reserved


POB1-PRCR-RTN-CODE2

X(2) 3 - 4 Reserved


X(2) 5 - 6 Reserved

Pricer Reserved POB1-RSVD X(4) 7 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 52 = Reserved

54 = Reserved59 = Reserved37 = Reserved40 = Reserved38 = Reserved61 = Reserved



Base APG Reimbursement

POB1-OP1-APG-BASE-RATE

9(8)v9(2) 15 - 24 Reserved

Outlier Payment POB1-OP1-APG-ADDON

9(8)v9(2) 25 - 34 Reserved

Total APG Reimbursement

POB1-OP1-APG-TOT-REIMB

9(8)v9(2) 35 - 44 Reserved

Outlier Flag POB1-OP1-APG-OUTFLAG

9(1) 45 Reserved

Medical APG Weight POB1-OP1-MAPG-WGT

9(3)v9(5) 46 - 53 Reserved

Medical APG Payment POB1-OP1-MAPG-PAY

9(8)v9(2) 54 - 63 Reserved

Statewide Visit Expected Payment (SVEP)

POB1-OP1-APG-SVEP

9(8)v9(2) 64 - 73 Reserved

Total ASC Payment POB1-OP1-ASC-TOTAL

9(8)v9(2) 74 - 83 Reserved

Adjusted Total ASC Payment

POB1-OP1-ASC-ADJTOTAL

9(8)v9(2) 84 - 93 Reserved

Reserved POB1-OP1-APG-CRF-RSVD

9(1)v9(5) 94 - 99 Reserved

Markup/Discount Factor POB1-OP1-APG-MARKUP

9(1)v9(4) 100 - 104 Reserved

Capital Add-On POB1-OP1-APG-CAPITAL

9(8)v9(2) 105 - 114 Reserved

Blend Factor POB1-OP1-APG-BLEND

9(1)v9(2) 115 - 117 Reserved


Rate Code Indicator POB1-OP1-APG-RCODE

X(1) 118 Reserved

Total Existing Payment POB1-OP1-APG-TOTEXIST

9(8)v9(2) 119 - 128 Reserved

Filler X(31872) 129 - 32000

Table 28-1: POB1-OP1-OP-PRCR-BLOCK1: Fixed length APG Pricer output fields (defined in hprcblk.cpy)



POB1-OP2-OP-PRCR-BLOCK2Table 29-1: POB1-OP2-OP-PRCR-BLOCK2: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (defined in hprcblk.cpy)



00 = No errors found01 = No hospital rate calculator record23 = Invalid service date, from/thru dates, or

admission date62 = Closed or inactive rate record75 = Extended hospital rate calculator record not

found85 = Error reading the extended hospital rate

calculator file90 = Invalid function code91 = Invalid Pricer type94 = Invalid from/thru date relationship95 = Invalid diagnosis or procedure code countCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-


Additional Pricer-Specific Return CodesAPC-HOPD:22 = Denial claim25 = Invalid partial hospitalization claim26 = Reserved for credit/adjustment claim41 = Invalid billing of therapy services42 = Invalid billing of device credit

ASC:37 = Invalid billing of codes for cardiac

resynchronization therapy

Contract APC:22 = Denial claim25 = Invalid partial hospitalization claim26 = Reserved for credit/adjustment claim41 = Invalid billing of therapy services42 = Invalid billing of device credit

Contract ASC:37 = Invalid billing of codes for cardiac

resynchronization therapy54 = Biosimilar HCPCS reported without biosimilar

modifier

continued below...



POB1-PRCR-RTN-CODE

X(2) 1 - 2 ESRD:04 = Invalid or missing value code/value amount05 = Invalid or missing modifier21 = Invalid bill type22 = Denial claim27 = Missing diagnosis code28 = Invalid case-mix adjustment29 = Attempted divide by zero36 = Incorrect billing of Automated Multi-Channel

Chemistry (AMCC) ESRD-related tests38 = Invalid or missing required claims data51 = Claim does not contain any payable services

FQHC:21 = Invalid bill type 24 = Non-covered claim50 = Non-FQHC PPS claim (prior to October 01,

2020)51 = Claim does not contain any payable services

HHA:21 = Invalid bill type30 = Invalid home health/hospice claim dates31 = Invalid number of HIPPS codes32 = HIPPS code indicates NRS were provided, but

NRS not on claim (prior to January 01, 2020)33 = Invalid or missing CBSA34 = Final claim must have at least one visit-related

revenue code35 = No available HHRG/PDGM weight/rate38 = Invalid or missing required claims data40 = Claim spans calendar year (UB-04 Bill Type

034X only)41 = Invalid billing of therapy services53 = Invalid billing when no skilled service55 = Invalid therapy code and revenue code

combination56 = Invalid or missing FIPS code57 = HHA not eligible for RAP reimbursement

Hospice:18 = Invalid occurrence span date21 = Invalid bill type22 = Denial claim 23 = Invalid service date, from-thru dates, or

admission date30 = Invalid home health/hospice claim dates33 = Invalid or missing CBSA40 = Claim spans calendar year

Table 29-1: POB1-OP2-OP-PRCR-BLOCK2: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (defined in hprcblk.cpy)




POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No I/O errors01 = Hospital Rate Calculator File I/O error02 = APC weight/rate file I/O error03 = Fee schedule type file I/O error04 = Fee schedule rate file I/O error05 = Extended Hospital Rate Calculator File I/O

error 10 = Code table file I/O error11 = APC rate file I/O error



Pricer Reserved POB1-RSVD X(4) 7 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 39 = Medicare FQHC

55 = Medicare ASC56 = Medicare APC-HOPD57 = Contract APC60 = Medicare ESRD62 = Medicare HHA64 = Contract ASC67 = Medicare Hospice



Base Reimbursement POB1-OP2-APC-BASE-PAY

9(8)v9(2) 15 - 24 Total reimbursement for this claim.

Patient Co-Payment POB1-OP2-APC-COPAY

9(8)v9(2) 25 - 34 APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, HHA, and FQHC:Total coinsurance for this claim.

Outlier Payment POB1-OP2-APC-ADDON

9(8)v9(2) 35 - 44 APC-HOPD, Contract APC, and ESRD:Total outlier payment for this claim.

HHA:Total outlier or LUPA add-on payment for this claim.

Hospice:Total Service Intensity Add-On (SIA) payment for this claim.

PPS Charges POB1-OP2-APC-PPS-CHARGES

9(8)v9(2) 45 - 54 APC-HOPD and Contract APC:Total OPPS eligible charges for this claim. Used for Hold Harmless calculations (APC-HOPD Pricer only) and outlier calculations prior to April 01, 2002.

PPS Payment POB1-OP2-APC-PPS-PAYMENT

9(8)v9(2) 55 - 64 APC-HOPD and Contract APC:Total OPPS payments for this claim. Used for Hold Harmless calculations (APC-HOPD Pricer only) and outlier calculations prior to April 01, 2002.

Transitional Corridor/Hold Harmless Add-on

POB1-OP2-APC-TRANSCOR

9(8)v9(2) 65 - 74 APC-HOPD: Estimated transitional corridor/hold harmless payment for this claim.

Claim Deductible POB1-OP2-APC-CLM-DEDUCT

9(8)v9(2) 75 - 84 APC-HOPD:Patient deductible applied to this claim.




Total Reimbursement POB1-OP2-APC-TOT-REIMB

9(8)v9(2) 85 - 94 Total anticipated payment.

APC-HOPD:BASE-PAY + COPAY + ADDON + TRANSCOR + CLM-DEDUCT

Contract APC:BASE-PAY + COPAY + ADDON + TRANSCOR

ESRD and HHA:BASE-PAY + COPAY + ADDON

Hospice:BASE-PAY + ADDON

ASC, Contract ASC, and FQHC:BASE-PAY + COPAY

Outlier Flag POB1-OP2-APC-OUTFLAG

9(1) 95 APC-HOPD, Contract APC, and ESRD:1 = Claim contains outlier add-on0 = Otherwise

Base Rate Flag POB1-OP2-APC-BASERATE-FLAG

9(1) 96 Contract APC:1 = Base * APC weight pricing applies. Otherwise, APC-based rates are used.

Cost Reduction Factor POB1-OP2-APC-CRF-RSVD

9(1)v9(5) 97 - 102 APC-HOPD and Contract APC:Outpatient cost reduction factor.

Rural Flag POB1-OP2-APC-RURAL

X(1) 103 Rural indicator for ambulance, home health agency, and hospice pricing.

APC-HOPD and Contract APC:B = Qualified rural area ZIP code for air and ground

ambulance servicesR = Rural ZIP code for air and ground ambulance

services

HHA:H = High utilizationL = Low population densityO = All others

Hospice:R = Rural

Outpatient RCC POB1-OP2-APC-RCC

9(1)v9(5) 104 - 109 APC-HOPD and Contract APC:Outpatient ratio of costs-to-charges.

Mark-Up/Discount Factor

POB1-OP2-APC-MARKUP






POB1-OP2-APC-METHOD

9(2) 115 - 116 APC-HOPD:00 = Standard OPPS reimbursement05 = OPPS-exempt reimbursement (Critical Access

and Maryland hospitals)10 = Opioid Treatment Program (OTP)

reimbursement11 = Quality reporting reduction

Contract APC:00 = Standard OPPS reimbursement05 = OPPS-exempt reimbursement06 = Short stay reimbursement07 = Non-emergent Emergency Room (ER)

reduction08 = CAH reimbursement including the non-

emergent ER reduction09 = Non-participating provider non-emergent

reduction11 = Quality reporting reduction

HHA:20 = RAP payment - initial episode21 = LUPA payment only22 = LUPA payment, 1st episode add-on payment

applies23 = Final payment, PEP24 = Final payment, PEP with outlier25 = Final payment where no outlier applies26 = Final payment where outlier applies27 = Fee schedule payment28 = RAP payment - subsequent episode29 = Final Payment, PEP with outlier, units capped

for date of service30 = Final payment where outlier applies, units

capped for date of serviceAlternate Payment POB1-OP2-APC-

ALT-REIMB9(8)v9(2) 117 - 126 HHA:

Anticipated payment (BASE-PAY + COPAY) for this claim using the alternate HHRG and NRS code or the alternate PDGM.

Alternate Add-on (Outlier/LUPA Add-On) Payment

POB1-OP2-APC-ALT-ADDON

9(8)v9(2) 127 - 136 HHA:Anticipated outlier or LUPA add-on payment for this claim using the alternate HHRG and NRS code or the alternate PDGM.

Comorbidity Category POB1-OP2-APC-COMRBD-CAT

9(2) 137 - 138 ESRD:Comorbidity category associated with monthly bill:00 = No comorbidity adjustment01 = GI bleed02 = Pneumonia03 = Pericarditis04 = Myelodysplastic syndrome05 = Sickle cell anemia06 = Monoclina gammopathy




Quality Flag POB1-OP2-APC-QUALITY-FLAG

9(2) 139 - 140 ESRD:0 = Quality reporting requirements met1 = Quality reporting requirements not met

Dialysis PPS Payment with Facility Adjustment Only

POB1-OP2-APC-ADJ-BASE

9(8)v9(2) 141 - 150 ESRD:Adjusted base rate without patient-case mix adjustment.

Adjusted Outlier Services MAP

POB1-OP2-APC-ADJ-MAP

9(8)v9(2) 151 - 160 ESRD:Outlier services Medicare Anticipated Payment (MAP). Used for cost outlier calculation.

Age Factor - Composite POB1-OP2-APC-AGEFACT

9(1)v9(4) 161 - 165 ESRD:Age adjustment utilized for the composite payment of dialysis services prior to January 1, 2011.

Age Factor - Separately Payable

POB1-OP2-APC-AGEFACT-SEP

9(1)v9(5) 166 - 171 ESRD:Separately payable portion of bundled age adjustment utilized for cost outlier calculation.

Average Imputed Separately Payable Services per Dialysis Treatment

POB1-OP2-APC-AVG-PER-TREAT

9(8)v9(2) 172 - 181 ESRD:Actual amount of formerly separately payable services per dialysis treatment on monthly bill.

Average Predicted Separately Payable Services per Dialysis Treatment

POB1-OP2-APC-AVG-PER-TRT-BLEND

9(8)v9(2) 182 - 191 ESRD:Predicted amount of separately payable services per dialysis treatment on monthly bill.

Body Mass Index (BMI) POB1-OP2-APC-BMI

9(3)v9(4) 192 - 198 ESRD:BMI of patient.

Body Mass Index (BMI) Factor

POB1-OP2-APC-BMIFACT

9(1)v9(4) 199 - 203 ESRD:BMI factor for composite payment of dialysis services prior to January 1, 2011.

Body Mass Index (BMI) Factor - Separately Payable

POB1-OP2-APC-BMIFACT-SEP

9(1)v9(5) 204 - 209 ESRD:Separately payable portion of bundled BMI factor utilized for cost outlier calculation.

Body Surface Area (BSA)

POB1-OP2-APC-BSA

9(1)v9(4) 210 - 214 ESRD:BSA of patient.

Body Surface Area (BSA) Factor - Composite

POB1-OP2-APC-BSAFACT

9(1)v9(4) 215 - 219 ESRD: BSA utilized for the composite payment of dialysis services prior to January 1, 2011.

Body Surface Area (BSA) Factor - Separately Payable

POB1-OP2-APC-BSAFACT-SEP

9(1)v9(5) 220 - 225 ESRD:Separately payable portion of bundled BSA factor utilized for cost outlier calculation.

Age Factor - ESRD Bundled PPS

POB1-OP2-APC-BUNDLE-AGEFACT

9(1)v9(4) 226 - 230 ESRD:Age adjustment utilized for the bundled prospective payment of dialysis services on or after January 1, 2011.

Body Mass Index (BMI) Factor - ESRD Bundled PPS

POB1-OP2-APC-BUNDLE-BMIFACT

9(1)v9(5) 231 - 236 ESRD:BMI factor for the bundled prospective payment of dialysis services on or after January 1, 2011.




Body Surface Area (BSA) Factor - ESRD Bundled PPS

POB1-OP2-APC-BUNDLE-BSAFACT

9(1)v9(4) 237 - 241 ESRD:BSA factor for the bundled prospective payment of dialysis services on or after January 1, 2011.

Comorbidity Factor POB1-OP2-APC-COMRBD-FACT

9(1)v9(5) 242 - 247 ESRD:Comorbidity adjustment utilized for the prospective payment of dialysis services on or after January 1, 2011.

Comorbidity Factor - Separately Payable

POB1-OP2-APC-COMRBD-FACT-SEP

9(1)v9(5) 248 - 253 ESRD:Separately payable portion of comorbidity factor utilized for cost outlier calculation.

NDC Dispensing Fee POB1-OP2-APC-DISPENSE-FEE

9(2)v9(2) 254 - 257 ESRD:Dispensing fee for oral-only drugs with an injectable equivalent.

Fixed Dollar Loss Amount

POB1-OP2-APC-FLOSS

9(8)v9(2) 258 - 267 ESRD: Fixed dollar loss amount that is added to the predicted MAP to determine the cost outlier threshold.

Low Volume Adjustment POB1-OP2-APC-LOW-VOL

9(1)v9(4) 268 - 272 ESRD:Low volume adjustment utilized for the bundled prospective payment of dialysis services on or after January 1, 2011.

Low Volume Adjustment - Separately Payable

POB1-OP2-APC-LOW-VOL-SEP

9(1)v9(4) 273 - 277 ESRD: Separately payable portion of low volume factor utilized for cost outlier calculation.

Monthly Imputed ESRD outlier Services Amount

POB1-OP2-APC-MONTHLY-SVCS-AMT

9(8)v9(2) 278 - 287 ESRD:Total amount of formerly separately payable services utilized for the cost outlier calculation.

Dialysis Payment - Composite

POB1-OP2-APC-TEMPRATE

9(8)v9(2) 288 - 297 ESRD: Total composite payment without training or mark-up/discount adjustment for dialysis services prior to January 1, 2011.

NoteThe Extended Structure Switch (ECB-EXT-BLK-SW) in the ECB-EZG-CNTL-BLOCK needs to be = 1 for all fields beyond position 300.

Cost Outlier Threshold POB1-OP2-APC-THRESHOLD

9(8)v9(2) 298 - 307 ESRD: Predicted MAP plus fixed dollar loss amount that is utilized for the cost outlier calculation.

Total Predicted ESRD Outlier Payment

POB1-OP2-APC-PREDICT-OUTL-MAP

9(8)v9(2) 308 - 317 ESRD:Total predicted amount of separately payable services per dialysis treatment on monthly bill.




Geographic Adjustment - Composite

POB1-OP2-APC-TOTWAGERATE

9(8)v9(2) 318 - 327 ESRD: Composite dialysis payment with geographic adjustment only for dialysis services prior to January 1, 2011.

Number of Dialysis Line Items

POB1-OP2-LINE-DIALYSIS-COUNT

9(3) 328 - 330 ESRD:Number of dialysis claim line items.

Core Based Statistical Area (CBSA)

POB1-OP2-CBSA X(5) 331 - 335 ESRD:Core Based Statistical Area (CBSA).

Return Code Override Flag

POB1-OP2-RC-OVER

9(1) 336 ESRD:0 = Do not override Return Codes 04, 05, and 381 = Override Return Codes 04, 05, and 38


POB1-OP2-RURAL-ADJ

9(1)v9(5) 337 - 342 ESRD:Rural payment adjustment under the bundled Medicare ESRD Payment System, for adult ESRD beneficiaries utilizing ESRD facilities located in rural CBSAs (that are non-urban CBSAs).

Rural Adjustment Factor - Separately Billable

POB1-OP2-RURAL-ADJ-SEP

9(1)v9(5) 343 - 348 ESRD:Separately billable rural payment adjustment for adult ESRD beneficiaries utilizing ESRD facilities located in rural CBSAs (that are non-urban CBSAs).

RAP Penalty Amount POB1-OP2-RAP-REDUCTION

9(8)v9(2) 349 - 358 HHA:The amount reimbursement has been reduced by due to untimely RAP.

Alternate RAP Penalty Amount

POB1-OP2-ALT-RAP-REDUCTION

9(8)v9(2) 359 - 368 HHA:The amount alternate reimbursement has been reduced by due to untimely RAP.

Filler X(31632) 369 - 32000




POB1-PP1-PHYS-PRCR-BLOCK1Table 30-1: POB1-PP1-PHYS-PRCR-BLOCK1: Fixed length Physician Pricer output fields (defined in hprcblk.cpy)



23 = Invalid service date or from-thru dates41 = Invalid billing of therapy services42 = Invalid or missing place of service43 = Place of service not applicable for Medicare44 = Invalid or missing zip code62 = Closed or inactive rate record70 = Configuration record error 91 = Invalid Pricer type 94 = Invalid datesCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-

CODE2 below) Pricer Return Code Extension

POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No file I/O errors01 = Physician rate calculator file I/O error03 = Fee schedule type file I/O error04 = Fee schedule rate file I/O error07 = Configuration file I/O error09 = Extended fee schedule file I/O error10 = Physician code table file I/O error12 = Physician factor file I/O error


X(2) 5 - 6 File operation return status code. OS/Language dependent.

Pricer Reserved POB1-RSVD X(4) 7 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 65 = Medicare PhysicianPricer Type Reserved POB1-PRCR-TYPE-


Payment POB1-PP1-BASE-PAY

9(8)V9(2) 15 - 24 Total Medicare reimbursement for this claim.

Co-Payment POB1-PP1-COPAY 9(8)v9(2) 25 - 34 Total patient co-payment amount for this claim.Estimated Bonus Payment

POB1-PP1-BONUS-PAY

9(8)v9(2) 35 - 44 If requested by the user, this is the total estimated bonus (or incentive) payment amount for this claim including:- Health Professional Shortage Area (HPSA)

payments- Primary Care Incentive Payments (PCIP) (prior to

January 01, 2016)- HPSA Surgical Incentive Payments (HSIP) (prior

to January 01, 2016)Total Reimbursement POB1-PP1-TTL-

REIMB9(8)v9(2) 45 - 54 Total reimbursement for this claim, calculated as

follows:POB1-PP1-BASE-PAY + POB1-PP1-BONUS-PAY + POB1-PP1-COPAY


Rural Flag POB1-PP1-RURAL X(1) 55 Rural indicator associated with the ambulance point-of-pickup ZIP code. If no ambulance point-of-pickup ZIP code is provided for this claim, this field will default to a blank.

B = Qualified rural area ZIP code for air and ground ambulance services

R = Rural ZIP code for air and ground ambulance services

Filler X(945) 56 - 1000

Table 30-1: POB1-PP1-PHYS-PRCR-BLOCK1: Fixed length Physician Pricer output fields (defined in hprcblk.cpy)



POB1-RP1-REHAB-PRCR-BLOCK1Table 31-1: POB1-RP1-REHAB-PRCR-BLOCK1: Fixed length IRF Pricer output fields (defined in hprcblk.cpy)



01 = No hospital rate calculator record02 = No CMG rate record03 = Reserved for Pricer type not licensed04 = Invalid Pricer type05 = Reserved06 = LOS value required, must be > 007 = Length of stay inconsistent with claim from/thru

dates08 = Discharge status invalid/ missing09 = CMG/HIPPS code missing or invalid10 = RIC code invalid11 = CMG/HIPPS ALOS is missing; required for

transfer calculations16 = Invalid ALC days/interrupted days18 = Invalid occurrence date23 = Invalid service date or out of range25 = Non-payment claim27 = Wrong procedure performed45 = Assessment date is missing62 = Closed or inactive rate record90 = Invalid function code91 = Invalid Pricer type94 = Invalid dates95 - 99 = ReservedCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-



POB1-PRCR-RTN-CODE2

X(2) 3 - 4 00 = No I/O errors01 = Hospital Rate Calculator file I/O error02 = CMG rate file I/O error

Pricer File Status Code POB1-PRCR-RTN-STATUS


Pricer Reserved POB1-RSVD X(4) 7 - 10 Reserved.Pricer Type POB1-PRCR-TYPE X(2) 11 - 12 90 = Medicare IRFPricer Type Reserved POB1-PRCR-TYPE-

RSVDX(2) 13 - 14 Reserved.

Payment Casemix Group

POB1-RP1-PCMG 9(4) 15 - 18 Contains a payment-related CMG. The IRF Pricer may change the CMG assigned by the IRF CMG Grouper. The IRF 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 POB1-RP1-PHIPPS X(5) 19 - 23 Health Insurance Prospective Payment System (HIPPS) code. The IRF Pricer may change the HIPPS code assigned by the IRF CMG Grouper for short stays and expired cases.

Format XYYYY, where:X = Comorbidity tierYYYY = Payment CMG

Base PPS Payment Rate for the Case

POB1-RP1-BASE

9(8)v9(2) 24 - 33 Base PPS reimbursement for the claim. Blend percentage, if applicable, has been applied.

Outlier Add-on POB1-RP1-ADDON 9(8)v9(2) 34 - 43 Outlier payment for the claim. Blend percentage, if applicable, has been applied.

Total PPS Payment POB1-RP1-PPSTOT 9(8)v9(2) 44 - 53 Total PPS payment for the claim. Blend percentage, if applicable, has been applied.BASE + ADDON

Total Facility-Specific Payment

POB1-RP1-FACTOT 9(8)v9(2) 54 - 63 For historical claims prior to October 2002, IRF payments were a blend of the new PPS payment and the facility-specific pre-PPS TEFRA payment, and this field contained the anticipated facility-specific payment.

For current claims, this field will equal zero. Penalty Amount POB1-RP1-

PENALTY9(8)v9(2) 64 - 73 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 POB1-RP1-TOTREIMB

9(8)v9(2) 74 - 83 Total reimbursement for the case. PPSTOT + FACTOT – PENALTY

Payment Flag POB1-RP1-PAYFLAG

9(2) 84 - 85 00 = CMG-based case payment01 = Transfer 02 = Short stay case03 = Expired case

Cost Outlier Flag POB1-RP1-OUTFLAG

9(1) 86 0 = Not an outlier1 = Qualifies for a cost outlier payment

Transfer Flag POB1-RP1-TRFLAG 9(2) 87 - 88 00 = Not a transfer01 = Paid using CMG-specific per diem02 = Payment capped at CMG payment rate

Blend Percentage POB1-RP1-BLEND 9(1)v9(5) 89 - 94 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.

Table 31-1: POB1-RP1-REHAB-PRCR-BLOCK1: Fixed length IRF Pricer output fields (defined in hprcblk.cpy)



Penalty Flag POB1-RP1-PENFLAG

9(1) 95 0 = No penalties were applied to this claim1 = IRF-PAI assessment data was transmitted 28

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

Penalty Percentage POB1-RP1-PENPCT

9(1)v9(5) 96 - 101 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

POB1-RP1-PAYWGT

9(3)v9(5) 102 - 109 Relative weight for payment HIPPS code. Based on “payment CMG” and comorbidity tier.

HIPPS Code Average Length of Stay

POB1-RP1-PAYLOS 9(3)v9(4) 110 - 116 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

POB1-RP1-OUTCHG

9(8)v9(2) 117 - 126 Charges used to determine applicable cost outlier payments.

Cost Outlier Threshold for Payment HIPPS Code

POB1-RP1-FNTHRESH

9(8)v9(2) 127 - 136 Outlier threshold for this case. Equal to the CMG payment for the case, plus a facility-adjusted fixed outlier threshold.

Assessment Transmission Date

POB1-RP1-TDATE 9(8) 137 - 144 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.

Filler X(31856) 145 - 32000

Table 31-1: POB1-RP1-REHAB-PRCR-BLOCK1: Fixed length IRF Pricer output fields (defined in hprcblk.cpy)



POB1-SP1-SNF-PRCR-BLOCK1Table 32-1: POB1-SP1-SNF-PRCR-BLOCK1: Fixed length SNF Pricer output fields (defined in hprcblk.cpy)



01 = No hospital rate calculator record03 = Pricer type not licensed18 = Invalid occurrence span date21 = Invalid bill type (not 18x, 21x, 22x, or 23x)22 = Denial claim23 = Service date invalid or out of range25 = Non-payment claim26 = Total units exceed patient’s length of stay38 = Invalid or missing required claims data40 = Claim spans calendar year41 = Invalid billing of therapy services62 = Closed or inactive rate record72 = Hospital rate calculator record not found74 = No weights82 = Error reading hospital rate calculator file83 = Error reading rate file84 = Error reading fee schedule file88 = Initialization error94 = Invalid dates95 = Parameter passing errorCL = Cannot load or open programIO = File I/O error (refer to POB1-PRCR-RTN-

CODE2 and POB1-PRCR-RTN-STATUS below) Pricer Return Code Extension

POB1-PRCR-RTN-CODE2

X(2) 3 - 4 01 = Hospital rate calculator file I/O error10 = Code table file I/O error



Pricer Reserved POB1-RSVD X(4) 7 - 10 ReservedPricer Type POB1-PRCR-TYPE X(2) 11 - 12 22 = Medicare SNFPricer Type Reserved POB1-PRCR-TYPE-


Total Reimbursement POB1-SP1-TOTAL 9(8)v9(2) 15 - 24 Total patient reimbursement.Prospective Payment Total

POB1-SP1-PPSTOTAL

9(8)v9(2) 25 - 34 Total Part A reimbursement.

AIDS Adjustment Factor POB1-SP1-AIDSFACTOR

9(1)v9(4) 35 - 39 Part A adjustment factor applied to reimbursement when an AIDS diagnosis code is present.

Markup/Discount Factor POB1-SP1-MARKUP


Total Part B Third-party Payment

POB1-SP1-TOTPAY 9(8)v9(2) 45 - 54 Total Part B reimbursement for this claim minus patient coinsurance.

Total Part B Co-payment

POB1-SP1-TOTCOPAY

9(8)v9(2) 55 - 64 Total Part B patient coinsurance for this claim.

Filler X(31936) 65 - 32000


POB2-CA1-CAH2-PRCR-BLOCK2Table 33-1: POB2-CA1-CAH2-PRCR-BLOCK2: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesPricing Method Indicator

POB2-CA1-METHOD

9(2) 1 - 2 01 = Service paid at reasonable charge02 = Service paid charges03 = Service paid at fee schedule rate04 = Anesthesia service

Pricer Return Code POB2-CA1-RTN-CODE

9(8)V9(2) 3 - 4 00 = No errors found01 = No available APC/fee schedule rate record02 = Invalid HCPCS code04 = Not covered or not covered under OPPS06 = Missing/invalid fee schedule type08 = Invalid modifier for pricing10 = Line item denial or rejection from Editor11 = Invalid units for this modifier13 = ZIP code missing or invalid (ambulance fee

schedule service only)16 = Claim contains a never event25 = Improper billing of drugs29 = Paid by report30 = Line bypassed from claim processing31 = Invalid or missing taxonomy33 = Bundled service not separately payable34 = Service not payable35 = Service for reporting purposes only36 = Carrier priced service or restricted coverage37 = Missing or invalid status code39 = No physician rate calculator record40 = Attempted divide by zero41 = Provider subject to preclusion and/or OIG

sanction42 = Invalid or missing specialty code43 = Not enough information for pricing62 = Closed rate record

Total Payment POB2-CA1-PAY 9(8)V9(2) 5 - 14 Medicare payment for this procedure code.Co-Payment POB2-CA1-COPAY 9(8)V9(2) 15 - 24 Patient co-payment for this procedure code.Estimated Bonus Payment

POB2-CA1-BONUS-PAY

9(8)V9(2) 25 - 34 If requested by the user, this is the total estimated Health Professional Shortage Area (HPSA) payment for this procedure code.

Total Payment POB2-CA1-TOT-PAY

9(8)V9(2) 35 - 44 Total payment for this procedure code calculated asfollows:PAY + COPAY

Fee Schedule Rate POB2-CA1-FSRATE 9(8)V9(2) 45 - 54 Fee schedule rate used to price this procedure code.


Fee Schedule Type POB2-CA1-FSTYPE X(1) 55 Fee schedule methodology used to price this procedurecode.

A = AmbulanceL = Clinical LaboratoryN = NationalP = PhysicianX = Other (user-defined)

Facility/Non-Facility Rate Flag

POB2-CA1-FAC-FLAG

9(1) 56 This field indicates whether the facility or non-facility rate was used to price this practitioner service.

1 = Facility rate used2 = Non-facility rate used

Specialty Code Used for Pricing

POB2-CA1-SPEC-CODE

X(2) 57 - 58 The 2-digit Medicare Specialty Code used to price this practitioner service. A complete list of valid specialty codes is available in Sections 10.8.2 and 10.8.3 of Chapter 26 of the Medicare Claims Processing Manual which is available at:https://www.cms.gov/manuals/downloads/clm104c26.pdf

Percentage of the Fee Schedule Rate Paid

POB2-CA1-PERCENT

9(1)V9(4) 59 - 63 Percentage of the fee schedule rate paid for thispractitioner service or, if applicable, the discount factor applied to the total payment for this facility service.

Mark-up/Discount Factor

POB2-CA1-MARKUP

9(1)V9(4) 64 - 68 Mark-up or discount applied to the payment for thisprocedure code.

Carrier Used for Pricing POB2-CA1-CARRIER

X(12) 69 - 80 The carrier/locality used to price this procedure code.

Bilateral Flag POB2-CA1-BILAT-FLAG

9(1) 81 0 = Not bilateral1 = Conditionally bilateral procedure, payment

adjusted3 = Independently bilateral procedure, payment

adjustedMultiple Procedure Discount Flag

POB2-CA1-DISC-FLAG

9(1) 82 0 = No multiple procedure discounting1 = Multiple procedure discounting2 = Multiple endoscopic procedure discounting3 = Multiple procedure and multiple endoscopic

procedure discounting4 = Multiple diagnostic imaging procedure

discounting5 = Multiple therapy service discounting

Quality Adjustment Indicator

POB2-CA1-QUAL-ADJ-FLAG

X(1) 83 0 = No quality adjustment1 = Payment increased by quality adjustment2 = Payment decreased by quality adjustment

Total Payment Without Quality Adjustment

POB2-CA1-TOTPAY-NOQUAL

9(8)V9(2) 84 - 93 Total payment for this procedure code excluding any adjustments for HPSA bonus payments and CMS quality programs like MIPS.

Table 33-1: POB2-CA1-CAH2-PRCR-BLOCK2: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)


https://www.cms.gov/manuals/downloads/clm104c26.pdf


Status Code POB2-CA1-SCODE X(1) 94 The status code for this practitioner service. The following values may be returned:A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician Fee Schedule by




Filler X(106) 95 - 200

Table 33-1: POB2-CA1-CAH2-PRCR-BLOCK2: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)



POB2-EP1-ESRD-PRCR-BLOCK2Table 34-1: POB2-EP1-ESRD-PRCR-BLOCK2: Variable length ESRD Pricer output fields (defined in hprcblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesPayment Status POB2-EP1-

PAYSTATX(2) 1 - 2 Not used for ESRD.

Payment Status Reserved

POB2-EP1-PAYSTAT-RSVD

X(1) 3 Not used for ESRD.

APC or Fee Rate POB2-EP1-ADJRATE

9(8)v9(2) 4 - 13 Fee schedule rate for ESRD.

Weight POB2-EP1-WGT 9(3)v9(5) 14 - 21 Not used for ESRD.APC Discount Factor POB2-EP1-DISC 9(1)v9(4) 22 - 26 Not used for ESRD.Total Payment POB2-EP1-PAY 9(8)v9(2) 27 - 36 Total line payment for ESRD.Co-Payment POB2-EP1-COPAY 9(8)v9(2) 37 - 46 Patient coinsurance for this procedure, wage-

adjusted.Line Item Deductible POB2-EP1-LID 9(8)v9(2) 47 - 56 Not used for ESRD.Line Item Packaged Charges

POB2-EP1-PKGCHG

9(8)v9(2) 57 - 66 Not used for ESRD.

Line Item Outlier Payment

POB2-EP1-LI-OUTPAY

9(8)v9(2) 67 - 76 Line item outlier payment.

Reallocated Surgical Procedure Charges

POB2-EP1-STCHARGES


Pricer Return Code POB2-EP1-PRET 9(2) 87 - 88 00 = No errors found01 = No available APC/fee schedule rate06 = Missing or invalid fee schedule type08 = Invalid modifier for pricing10 = Line item denial or rejection from ACE edits15 = Invalid units for revenue code16 = Medically unlikely edit18 = Invalid units for modifier19 = Payment included in composite rate20 = Incorrect billing of Telehealth site fee21 = Item paid at a user-defined percent of charges22 = Contractor priced item requires additional setup

for reimbursement23 = Invalid revenue code for pricing24 = HCT/HGB exceeds monitoring threshold

without appropriate modifier41 = Improper billing of Modifier AY

Reserved for Line Item Total

POB2-EP1-LINE-CHG


Multiple Procedure Discount Indicator

POB2-EP1-MPD 9(1) 99 Not used for ESRD.

Transitional Payment POB2-EP1-TRANSPAY


Reimbursement APC POB2-EP1-REIMB-PROC

9(5) 110 - 114 Not used for ESRD.


Reimbursement ASC Covered Services Indicator

POB2-EP1-REIMB-COVSERVIND

9(1) 115 Not used for ESRD.

Filler X(85) 116 - 200

Table 34-1: POB2-EP1-ESRD-PRCR-BLOCK2: Variable length ESRD Pricer output fields (defined in hprcblk.cpy; occurs up to 999 times)



POB2-IP1-IP-PRCR-BLOCK1Note

This overlay is reserved for future use.

Table 35-1: POB2-IP1-IP-PRCR-BLOCK1: Line-level Inpatient Pricer output fields (defined in hprcblk.cpy; reserved for future use)



POB2-OP1-OP-PRCR-BLOCK1Table 36-1: POB2-OP1-OP-PRCR-BLOCK1: Variable length APG Pricer output fields (defined in hprcblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesProcedure APG (PAPG) Type

POB2-OP1-PAPG-TYPE

X(2) 1 - 2 Reserved

APG Weight POB2-OP1-PAPG-WGT

9(3)v9(5) 3 - 10 Reserved

APG Discount Factor POB2-OP1-PAPG-PFAC

9(1)v9(4) 11 - 15 Reserved

APG Payment POB2-OP1-PAPG-PAY

9(8)v9(2) 16 - 25 Reserved

Payment Packaging Flag

POB2-OP1-PAPG-PACK

9(1) 26 Reserved

Payment Consolidation Flag

POB2-OP1-PAPG-CONS

9(1) 27 Reserved

ASC Discount Factor POB2-OP1-PAPG-ASC-DISCOUNT

9(1)v9(4) 28 - 32 Reserved

ASC Payment Amount POB2-OP1-PAPG-ASC-ASCPAY

9(8)v9(2) 33 - 42 Reserved

Fee Schedule Rate POB2-OP1-PAPG-RATE

9(8)v9(2) 43 - 52 Reserved

Pricer Return Code POB2-OP1-PAPG-PRET

9(2) 53 - 54 Reserved

Payment Method Indicator

POB2-OP1-PAPG-METHOD

9(2) 55 - 56 Reserved

Units Paid POB2-OP1-PAPG-PUNITS

9(7) 57 - 63 Reserved

Add-On Payment POB2-OP1-PAPG-ADDON

9(8)v9(2) 64 - 73 Reserved

Adjusted Weight POB2-OP1-PAPG-ADJWGT

9(3)v9(5) 74 - 81 Reserved

Stand Alone Flag POB2-OP1-PAPG-STNDALN

9(1) 82 Reserved

Never Pay Flag POB2-OP1-PAPG-NVRPAY

9(1) 83 Reserved

Visit Existing Payment POB2-OP1-PAPG-EXIST

9(8)v9(2) 84 - 93 Reserved

ASC Covered Service POB2-OP1-PAPG-ASCCOV

9(1) 94 Reserved

Units Paid POB2-OP1-PAPG-PUNITS-01

9(15) 95 - 109 Reserved

Filler X(91) 110 - 200


POB2-OP2-OP-PRCR-BLOCK2Table 37-1: POB2-OP2-OP-PRCR-BLOCK2: Variable length APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesPayment Status Indicator

POB2-OP2-PAPC-PAYSTAT

X(2) 1 - 2 Left-justified.

APC-HOPD and Contract APC:A = Services paid under fee schedule or other

prospectively determined rateAA =Ambulance fee schedule itemAD =DMEPOS fee schedule itemAL = Clinical Laboratory fee schedule itemAM= Medicaid fee schedule itemAM= National fee schedule item (Contract APC -

legacy)AN = National fee schedule itemAP = Physician fee schedule itemAR = Physician fee schedule item (Contract APC -

legacy)AT = Physician fee schedule item, subject to

discountingAX =Other fee schedule itemB = Service not allowed under OPPS on hospital


information and claims data are not availableF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughGM = Drug/biological fee schedule item (Contract

APC - legacy)GN = Drug/biological fee schedule itemGX = Other fee schedule itemH = Pass-through device categoriesJ1 = Hospital Part B services paid through a

Comprehensive APCJ2 = Hospital Part B services that may be paid



KM = Drug/biological fee schedule item (Contract APC - legacy)

KN = Drug/biological fee schedule itemcontinued below...


Payment Status<continued>


X(2) 1 - 2 KX = Other fee schedule itemL = Influenza virus or pneumococcal pneumonia

vaccine (PPV)M = Service not billable to the FI/MACN = Packaged/incidental service, no additional

payment P = Partial hospitalization serviceQ1 =STV - packaged services Q2 =T - packaged servicesQ3 =Services that may be paid through a Composite

APCQ4 = Conditionally packaged laboratory servicesR = Blood and blood productsS = Procedure or service, not discounted when


revenue codeX = Ancillary service (prior to January 1, 2015)Y = Non-implantable DMEYD =DMEPOS fee schedule itemZ = Valid revenue code, blank HCPCS code, no

other status indicator assigned

ASC and Contract ASC:A2 = Surgical procedure; OPPS weightAX = Commercial significant covered service; wage-

adjusted (Contract ASC only)AZ = Commercial ancillary covered service; not

wage-adjusted (Contract ASC only)EX = Commercial non-covered service (Contract

ASC only)F4 = Corneal tissue acquisition, hepatitis B vaccine;

paid at reasonable costG2 = Non office-based procedure; OPPS weightH2 = Brachytherapy source; OPPS rateH7 = Brachytherapy source; Contractor rateH8 = Device-intensive procedure; adjusted rateJ7 = OPPS pass-through device; Contractor rateJ8 = Device-intensive procedure; adjusted rateK2 = Drug/biological; OPPS rateK7 = Unclass drug/biological; contractor-pricedL1 = Influenza/pneumococcal vaccine; packaged

service/item, no separate paymentL6 = New tech intraocular lens; special paymentcontinued below...

Table 37-1: POB2-OP2-OP-PRCR-BLOCK2: Variable length APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (occurs numhcpcs times)



Payment Status<continued>


X(2) 1 - 2 M5 = Quality measurement code used for reporting purposes only; no payment made

N1 = Packaged service/item; no separate paymentP2 = Office-based procedure; OPPS weightP3 = Office-based procedure; MPFS RVUsR2 = Office-based procedure; OPPS weightYY = Service not covered by Medicare in a free-

standing ASCZ2 = Radiology service; OPPS weightZ3 = Radiology service; MPFS non-facility PE RVUsZZ = Services paid at contracted rate

Payment Status Reserved

POB2-OP2-PAPC-PAYSTAT-RSVD

X(1) 3 Reserved

APC or Fee Rate POB2-OP2-PAPC-ADJRATE

9(8)v9(2) 4 - 13 APC-HOPD and Contract APC: Adjusted payment rate for the corresponding APC, after labor adjustment, before discounting.

ASC, Contract ASC, ESRD, and HHA: Fee schedule rate.

FQHC: FQHC-specific payment rate (including adjustments for the GAF and IPPE/AWV if applicable) or fee schedule rate.

Hospice:For hospice care services, this is the wage-adjusted per diem rate. For fee schedule items, this is the fee schedule rate.

Weight POB2-OP2-PAPC-WGT

9(3)v9(5) 14 - 21 HHA:Weight associated with this HHRG.

Discount Factor POB2-OP2-PAPC-DISC

9(1)v9(4) 22 - 26 APC-HOPD, Contract APC, ASC, Contract ASC, and Hospice:Discount, if any, applied to the reimbursement.

Total Payment POB2-OP2-PAPC-PAY

9(8)v9(2) 27 - 36 APC-HOPD and Contract APC:Medicare payment for the corresponding APC, wage-adjusted, after any applicable discount, not including coinsurance payment, not including any outlier payments, excluding any deductible allocated to this line (APC-HOPD only), and including any transitional pass-through payments.

ASC, Contract ASC, ESRD, FQHC, HHA, and Hospice:Total line payment.

Co-Payment POB2-OP2-PAPC-COPAY

9(8)v9(2) 37 - 46 APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, and HHA:Patient coinsurance for this line.

Line Item Deductible POB2-OP2-PAPC-LID

9(8)v9(2) 47 - 56 APC-HOPD:The portion of the claim deductible which was allocated to this claim line, if any.




Line Item Packaged Charges

POB2-OP2-PAPC-PKGCHG

9(8)v9(2) 57 - 66 APC-HOPD and Contract APC:Reallocated packaged charges (used for line item outlier calculations).

Line Item Outlier Payment

POB2-OP2-PAPC-LI-OUTPAY

9(8)v9(2) 67 - 76 APC-HOPD, Contract APC, and ESRD:Line item outlier payment.

Hospice:Service Intensity Add-On (SIA) payment for this line.

Reallocated Surgical Procedure Charges

POB2-OP2-PAPC-STCHARGES

9(8)v9(2) 77 - 86 APC-HOPD and Contract APC:Charges from all surgical procedures on the claim reallocated based on the percentage distribution of the APC payments for those items.

Pricer Return Code POB2-OP2-PAPC-PRET

9(2) 87 - 88 Standard Return Codes:00 = No errors found10 = Line item denial or rejection from Editor

Additional Pricer-Specific Return Codes:APC-HOPD:01 = No available APC/fee schedule rate record02 = Invalid HCPCS code03 = Invalid payment status from Grouper04 = Not covered or not covered under OPPS06 = Missing or invalid fee schedule type07 = Co-payment out of valid range08 = Invalid modifier for pricing09 = Packaged service11 = Invalid units for this modifier13 = Zip code missing or invalid (ambulance fee

schedule service only)25 = Improper billing of drugs 35 = Service for reporting purposes only36 = Therapy code without MPFS rate43 = Not enough information for pricing

Contract APC:01 = No available APC/fee schedule rate record02 = Invalid HCPCS code03 = Invalid payment status from Grouper04 = Not covered or not covered under OPPS06 = Missing or invalid fee schedule type08 = Invalid modifier for pricing09 = Packaged service11 = Invalid units for this modifier13 = Zip code missing or invalid (ambulance fee

schedule service only)28 = No available extended fee schedule rate29 = Paid by report/manually priced36 = Therapy code without MPFS rate43 = Not enough information for pricing

continued below...





POB2-OP2-PAPC-PRET

9(2) 87 - 88 ASC:01 = No available APC/fee schedule rate record02 = Invalid HCPCS code04 = Not covered or not covered under OPPS08 = Invalid modifier for pricing09 = Packaged service11 = Invalid units for this modifier14 = Device intensive procedure without device21 = Item paid at a user-defined percent of charges22 = Contractor priced item requires additional setup

for reimbursement35 = Service for reporting purposes only43 = Not enough information for pricing

Contract ASC:01 = No available APC/fee schedule rate record02 = Invalid HCPCS code04 = Not covered or not covered under OPPS08 = Invalid modifier for pricing09 = Packaged service11 = Invalid units for this modifier14 = Device intensive procedure without device21 = Item paid at a user-defined percent of charges22 = Contractor priced item requires additional setup

for reimbursement27 = Invalid ASCRULE file configuration35 = Service for reporting purposes only43 = Not enough information for pricing

ESRD:01 = No available APC/fee schedule rate record02 = Invalid HCPCS code06 = Missing or invalid fee schedule type08 = Invalid modifier for pricing09 = Packaged service15 = Invalid units for revenue code16 = Medically unlikely edit18 = Invalid units for modifier19 = Payment included in composite rate20 = Incorrect billing of Telehealth site fee21 = Item paid at a user-defined percent of charges22 = Contractor priced item requires additional setup

for reimbursement23 = Invalid revenue code for pricing24 = HCT/HGB exceeds monitoring threshold

without appropriate modifier (prior to January 01, 2020 only)

41 = Improper billing of modifier AY43 = Not enough information for pricing

continued below...





POB2-OP2-PAPC-PRET

9(2) 87 - 88 FQHC:04 = Not covered or not covered under OPPS06 = Missing or invalid fee schedule type09 = Packaged service20 = Incorrect billing of Telehealth site fee35 = Service for reporting purposes only43 = Not enough information for pricing49 = Payment code is not eligible for payment

HHA:01 = No available APC/fee schedule rate record08 = Invalid modifier for pricing22 = Contractor priced item requires additional setup

for reimbursement23 = Invalid revenue code for pricing25 = Improper billing of drugs 43 = Not enough information for pricing

Hospice:01 = No available APC/fee schedule rate record04 = Not covered or not covered under OPPS06 = Missing or invalid fee schedule type08 = Invalid modifier for pricing09 = Packaged service15 = Invalid units for revenue code43 = Not enough information for pricing

Reserved for Line Item Total

POB2-OP2-PAPC-LINE-CHG

9(8)v9(2) 89 - 98 Reserved

Multiple Procedure Discount Indicator

POB2-OP2-PAPC-MPD

9(1) 99 ASC and Contract ASC:0 = Procedure is not eligible for multiple procedure discounting1 = Procedure is eligible for multiple procedure discounting

Transitional Payment POB2-OPS-PAPC-TRANSPAY

9(8)v9(2) 100 - 109 Reserved

Reimbursement APC POB2-OP2-PAPC-REIMB-PROC

9(5) 110 - 114 Contract ASC:APC used by the Contract ASC Pricer to determine reimbursement.

Reimbursement ASC Covered Services Indicator

POB2-OP2-PAPC-REIMB-COVSERVIND

9(1) 115 Contract ASC:0 = Service is not separately payable under the ASC

Pro PPS1 = Service is separately payable under the ASC Pro

PPS





POB2-OP2-PAPC-METHOD

9(2) 116 - 117 ASC:01 = Payment based on ASC rate02 = Payment capped at percent of charges03 = Payment based on percent of charges04 = Payment based on charges

Contract ASC:01 = Payment based on ASC rate02 = Payment capped at percent of charges03 = Payment based on percent of charges04 = Payment based on charges05 = Payment based on ASC rate and maximum

allowable units

FQHC:00 = No payment01 = Payment based on PPS rate02 = Payment based on charges03 = Payment based on PPS rate with new patient/

IPPE/AWV adjustment04 = Payment based on PPS rate with preventive

service co-pay adjustment05 = Payment based on charges with preventive

service co-pay adjustment06 = Payment based on PPS rate with new patient/

IPPE/AWV adjustment and preventive service co-pay adjustment

07 = Payment based on line charges08 = Payment based on Telehealth site fee09 = Payment based on MPFS non-facility fee rate

Hospice:01 = Payment based on low RHC rate02 = Payment based on high RHC rate03 = Payment based on low and high RHC rate04 = Service Intensity add-on applied05 = Service Intensity add-on applied, units capped06 = Payment based on CHC rate07 = Payment based on high RHC rate, CHC < 32

units08 = Payment based on low RHC rate, CHC < 32

units09 = Payment based on IRC rate10 = Payment based on GIP rate11 = Payment based on the fee schedule 12 = Payment capped at charges13 = Payment based on low RHC rate, non-covered

units14 = Payment based on high RHC rate, non-covered

units15 = Payment based on low and high RHC rate,

non-covered unitscontinue below...




Pricing Method Indicator<continued>

POB2-OP2-PAPC-METHOD

9(2) 116 - 117 16 = Payment based on IRC rate, non-covered units17 = Payment based on GIP rate, non-covered units18 = Payment based on the fee schedule with

discount appliedExtended Weight POB2-OP2-PAPC-

WGT-EXT9(4)v9(5) 118 - 126 APC-HOPD and Contract APC:

Extended weight associated with this APC.Carrier Used for Pricing POB2-OP2-PAPC-

CARRIERX(12) 127 - 138 APC-HOPD:

The carrier/locality used to price this procedure code. A complete list of valid carrier/ locality codes is available in the Optum Fee Schedule Carriers Worksheet.

Fee Schedule Type POB2-OP2-PAPC-FSTYPE

X(2) 139 - 140 APC-HOPD:Fee schedule methodology used to price this procedure code.A = AmbulanceD = DMEPOSL = Clinical LaboratoryM = National (prior to January 01, 2017)N = NationalP = PhysicianR = Physician (prior to January 01, 2017)X = Other (user-defined)

Filler X(60) 141 - 200




POB2-PP1-PHYS-PRCR-BLOCK1Table 38-1: POB2-PP1-PHYS-PRCR-BLOCK1: Variable Length Physician Pricer output fields (defined in hprcblk.cpy, occurs 999 times)

Field Description Variable Name Format Position NotesPricer Return Code POB2-PP1-RTN-

CODE9(2) 1 - 2 00 = No errors found

04 = Not covered01 = No available APC/fee schedule rate06 = Missing or invalid fee schedule type08 = Invalid modifier for pricing10 = Line item denial or rejection from Editor11 = Invalid units for this modifier13 = Zip code missing or invalid (ambulance fee

schedule service only)16 = Claim contains a Never Event29 = Paid by report30 = Line bypassed from claims processing31 = Invalid or missing taxonomy32 = Pricing cannot be provided for this NDC33 = Bundled service not separately payable34 = Service not payable35 = Service for reporting purposes only36 = Carrier priced service or restricted coverage37 = Missing or invalid status code38 = Payment bundled with other AMCC test39 = No physician rate calculator record40 = Attempted divide by zero41 = Provider subject to preclusions and/or OIG

sanctions42 = Invalid or missing specialty code43 = Not enough information for pricing62 = Closed rate record

Payment POB2-PP1-PAY 9(8)v9(2) 3 - 12 Medicare reimbursement for this procedure code.Co-Payment POB2-PP1-COPAY 9(8)v9(2) 13 - 22 Patient co-payment amount for this procedure code.Estimated Bonus Payment

POB2-PP1-BONUS-PAY

9(8)v9(2) 23 - 32 If requested by the user, this is the estimated bonus (or incentive) payment amount for this procedure code including:- Health Professional Shortage Area (HPSA)

payments- Primary Care Incentive Payments (PCIP)- HPSA Surgical Incentive Payments (HSIP)

Total Payment POB2-PP1-TTLPAY 9(8)v9(2) 33 - 42 Total reimbursement for this procedure code calculated as follows:POB2-PP1-PAY + POB2-PP1-BONUS-PAY + POB2-PP1-COPAY

Fee Schedule Rate POB2-PP1-FSRATE 9(8)v9(2) 43 - 52 Fee schedule rate used to price this procedure code.


Fee Schedule Type POB2-PP1-FSTYPE X(1) 53 Fee schedule methodology used to price this procedure code.

A = AmbulanceD = DMEPOSL = Clinical LaboratoryM = National (prior to January 01, 2017)N = NationalP = PhysicianR = Physician (prior to January 01, 2017)X = Other (user-defined)

Status Code POB2-PP1-SCODE X(1) 54 A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician Fee Schedule by

regulationF = Deleted/Discontinued codeG = Not valid for Medicare purposesH = Deleted modifierI = Not valid for Medicare purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/excluded codeQ = Therapy functional information code (used for

required reporting purposes only) R = Restricted coverageT = InjectionsX = Statutory exclusion


POB2-PP1-METHOD

9(2) 55 - 56 01 = Service paid at reasonable charge02 = Service paid charges03 = Service paid at fee schedule rate04 = Anesthesia service05 = Service paid as AMCC test06 = Service paid at NDC rate

Facility/Non-Facility Rate Flag

POB2-PP1-FAC-FLAG

9(1) 57 This field indicates whether the facility or non-facility rate was used to price this physician procedure code based on Place of Service (POS).

1 = Facility rate used2 = Non-facility rate used

Specialty Code Used for Pricing

POB2-PP1-SPEC-CODE

X(2) 58 - 59 The 2-digit Medicare Specialty Code used to price this physician procedure code. A complete list of valid Specialty Codes is available in Sections 10.8.2 and 10.8.3 of Chapter 26 of the Medicare Claims Processing Manual which is available at: https://www.cms.gov/manuals/downloads/clm104c26.pdf

Table 38-1: POB2-PP1-PHYS-PRCR-BLOCK1: Variable Length Physician Pricer output fields (defined in hprcblk.cpy, occurs 999 times)


https://www.cms.gov/manuals/downloads/clm104c26.pdf


Carrier Used for Pricing POB2-PP1-CARRIER

X(12) 60 - 71 The carrier/locality used to price this procedure code based on the ZIP code. A complete list of valid carrier/locality codes is available in the Optum Fee Schedule Carriers Worksheet.

Percentage of the Fee Schedule Rate Paid

POB2-PP1-PERCENT

9(1)v9(4) 72 - 76 Percentage of the fee schedule rate paid for this procedure code. Percentage reflects cumulative adjustments made for one or more of the following:(1) Procedures performed bilaterally(2) Procedures performed by non-physician

practitioners (like Nurse Practitioners or Licensed Clinical Social Workers)

(3) Procedures performed as co-surgeries(4) Procedures performed by surgical assistants(5) Procedures for which the global care was split

between multiple practitionersMark-up/Discount Factor

POB2-PP1-MARKUP

9(1)v9(4) 77 - 81 Mark-up or discount applied to the reimbursement for this procedure code.

Bilateral Flag POB2-PP1-BILAT-FLAG

9(1) 82 1 = Conditionally bilateral procedure, payment adjusted

3 = Independently bilateral procedure, payment adjusted

Multiple Procedure Discounting Flag

POB2-PP1-DISC-FLAG

9(1) 83 0 = No multiple procedure discounting1 = Multiple procedure discounting 2 = Multiple endoscopic procedure discounting3 = Multiple procedure and multiple endoscopic

procedure discounting4 = Multiple diagnostic imaging procedure

discounting5 = Multiple therapy service discounting6 = Multiple diagnostic cardiovascular procedure

discounting7 = Multiple diagnostic ophthalmology procedure

discountingQuality Adjustment Flag POB2-PP1-QUAL-

ADJUST-FLAGX(1) 84 0 = No quality adjustment

1 = Payment increased by quality adjustment2 = Payment decreased by quality adjustment

Total Payment Without Quality Adjustment

POB2-PP1-TOTPAY-NOQUAL

9(8)v9(2) 85 - 94 Total reimbursement for this procedure code excluding any adjustments for bonus payments and CMS quality programs like MIPS.

Filler X(106) 95 - 200

Table 38-1: POB2-PP1-PHYS-PRCR-BLOCK1: Variable Length Physician Pricer output fields (defined in hprcblk.cpy, occurs 999 times)



POB2-RP1-REHAB-PRCR-BLOCK1Note


Table 39-1: POB2-RP1-REHAB-PRCR-BLOCK1: Variable Length IRF Pricer output fields (defined in hprcblk.cpy; reserved for future use)



POB2-SP1-SNF-PRCR-BLOCK1Table 40-1: POB2-SP1-SNF-PRCR-BLOCK1: Variable length SNF Pricer output fields (defined in hprcblk.cpy; occurs 999 times)

Field Description Variable Name Format Position NotesLine Level Return Code POB2-SP1-RTN-


01 = No RUG or HIPPS on this claim line02 = No rate available for RUG, HCPCS, or HIPPS

code04 = Invalid HIPPS code (Part A only)10 = Line item rejection from ACE (Part B only)13 = Zip code missing or invalid (Part B only)14 = Revenue code not covered under SNF Part B15 = Not covered16 = Invalid units for HIPPS code (Part A only) 35 = Service for reporting purposes only36 = Therapy code without MPFS rate (Part B only)43 = Not enough information for pricing

RUG POB2-SP1-RUG X(5) 3 - 7 Resource Utilization Group (RUG).RUG Rate POB2-SP1-

RUGRATE9(8)v9(2) 8 - 17 Per diem payment rate for RUG.

Adjusted RUG Rate or Fee Schedule Rate

POB2-SP1-ADJRUGRATE

9(8)v9(2) 18 - 27 Part A:Adjusted per diem payment rate for RUG.

Part B:Fee schedule rate.

Total Line Payment POB2-SP1-TOTLINEPAY

9(8)v9(2) 28 - 37 Payment for line.

Third-Party Payment POB2-SP1-PAY 9(8)v9(2) 38 - 47 Payment for line minus patient coinsurance.Co-Payment POB2-SP1-COPAY 9(8)v9(2) 48 - 57 Total patient coinsurance for this line.Fee Schedule Type POB2-SP1-

FEETYPEX(1) 58 Fee schedule methodology used to price this

procedure code.A = AmbulanceD = DMEPOSL = LaboratoryN = National rateP = PhysicianT = Therapy service subject to multiple procedure

payment reductionV = Vaccine paid at reasonable costX = Other fee schedule (user defined)

Variable Per Diem Day Number

POB2-SP1-VPD-DAY

9(3) 59 - 61 The day number for Variable Per Diem (VPD).

Unadjusted HIPPS Code Rate

POB2-SP1-HIPPSRATE

9(8)v9(2) 62 - 71 Unadjusted rate for the HIPPS code.

Filler X(129) 72 - 200


POB3-EP1-ESRD-PRCR-BLOCK3Note

The Extended Structure Switch (ECB-EXT-BLK-SW) in the ECB-EZG-CNTL-BLOCK needs to be = 1 for all fields in this structure.


Field Description Variable Name Format Position NotesChildren’s Modality Factor POB3-EP1-MODALITY-

FACT9(1)v9(5) 1 - 6 Modality adjustment for patients under the

age of 18 for this dialysis service for dates on or after January 1, 2011.

Children’s Modality Factor - Separately Payable

POB3-EP1-MODALITY-FACT-SEP

9(1)v9(5) 7 - 12 Separately payable portion of the modality adjustment utilized for the cost outlier calculation.

NDC Reimbursement Indicator

POB3-EP1-NDC-REIM-IND

9(1) 13 Indicates that the service is a former Part D drug with an injectable equivalent.

NDC Reimbursement Amount - Separately Payable

POB3-EP1-NDC-REIM-SEP

9(8)v9(2) 14 - 23 Amount of former Part D drug utilized for cost outlier calculation.

Dialysis Onset Factor POB3-EP1-ONSETFACT 9(1)v9(5) 24 - 29 Onset adjustment utilized for the bundled prospective payment of this dialysis service for service dates on or after January 1, 2011.

Dialysis Onset Factor - Separately Payable

POB3-EP1-ONSETFACT-SEP

9(1)v9(5) 30 - 35 Separately payable portion of the onset adjustment utilized for cost outlier calculation.

Total ESRD PPS Casemix Adjustment

POB3-EP1-PATRATE 9(1)v9(5) 36 - 41 Patient casemix adjustment utilized for this dialysis service for service dates on or after January 1, 2011.

Total ESRD PPS Casemix Adjustment - Separately Payable

POB3-EP1-PATRATE-SEP

9(1)v9(5) 42 - 47 Separately payable portion of patient casemix adjustment utilized for determining the predicted MAP for the cost outlier calculation.

Payment Separately Payable Outside of ESRD PPS

POB3-EP1-PAYMENT-SEP

9(8)v9(2) 48 - 57 Amount of service that is paid outside of the bundled ESRD Prospective Payment System.

Predicted Outlier Map POB3-EP1-PREDICT-OUTL-MAP

9(8)v9(2) 58 - 67 Predicted amount of separately payable services for this dialysis line.

Total ESRD PPS Payment Prior to Blending and Mark-up/Discount

POB3-EP1-TTL-DIAL-ADJ-RATET

9(8)v9(2) 68 - 77 Prospective payment dialysis amount prior to blending or user mark-up or discount.

Training Adjustment Rate POB3-EP1-TRAINING-ADJ

9(8)v9(2) 78 - 87 Prospective payment training amount.

Composite Dialysis Payment

POB3-EP1-OLD-DIAL-PAY

9(8)v9(2) 88 - 97 Composite payment dialysis amount.

Composite Methodology - Separately Payable

POB3-EP1-OLD-METHOD-SEP

9(8)v9(2) 98 - 107 Separately payable amount.


Quality Reduction Factor POB3-EP1-QUALREDFACT

9(1)v9(4) 108 - 112 Quality-related payment adjustment (based on Total Performance Score) for service dates on or after January 1, 2012.

Outlier Indicator POB3-EP1-HCPCS-OUTLIER-IND

9(1) 113 Indicates that the procedure code contributed to the calculation of the outlier payment.

0 = Does not contribute to outlier payment1 = Contributes to outlier payment

Filler X(87) 114 - 200




OOB1-OPT-OUTPUT-BLOCK1Table 42-1: OOB1-OPT-OUTPUT-BLOCK1: Fixed length Optimizer output fields (defined in hoptblk.cpy)

Field Description Variable Name Format Position NotesOptimizer Return Code OOB1-OPT-RTN-


04 = Error calling Analyzer Control Program (CAACNTL)

05 = 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 ACE15 = 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

Program22 = Non-zero return code from Physician Editor23 = Non-zero return code from Analyzer26 = Non-zero return code from CAH Method II

Editor90 = Invalid request (invalid OPCODE1)91 = Reserved92 = Reserved93 = Reserved94 = Reserved95 = Reserved96 = Reserved97 = Reserved98 = Reserved99 = ReservedCL = ReservedIO = Reserved

Optimizer Return Code Extension

OOB1-OPT-RTN-CODE2

X(2) 3 - 4 00 = No file errors found 01 = Reserved02 = Error on weight rate file03 = Reserved04 = Reserved05 = Reserved

File Status Return Code OOB1-OPT-RTN-STATUS

X(2) 5 - 6 File status return code. O/S dependent.


Optimizer Reserved OOB1-RSVD X(4) 7 - 10 ReservedFiller X(390) 11 - 400

Table 42-1: OOB1-OPT-OUTPUT-BLOCK1: Fixed length Optimizer output fields (defined in hoptblk.cpy)



OOB2-IO1-IP-OPT-BLOCK1Table 43-1: OOB2-IO1-IP-OPT-BLOCK1: Variable length Optimizer output structure (defined in hoptblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesDiagnosis Number for Principal Diagnosis

IOB2-IO1-DX X(10) 1 - 10 Number of diagnosis that has been “swapped” with the principal diagnosis.

Optimizer MDC IOB2-IO1-MDC 9(2) 11 - 12 MDC assigned when the “swapped” diagnosis is treated as principal.

Optimizer DRG IOB2-IO1-DRG 9(5) 13 - 17 DRG assigned when the “swapped” diagnosis is treated as the principal diagnosis.

Optimizer Base Rate IOB2-IO1-BASE 9(8)v9(2) 18 - 27 Base or inlier reimbursementOptimizer Add-on IOB2-IO1-ADDON 9(8)v9(2) 28 - 37 Outlier add-onOptimizer ALC Add-on

IOB2-IO1-ALCPAY 9(8)v9(2) 38 - 47 Payment for alternate level of care days

Optimizer Total Reimbursement

IOB2-IO1-TOTAL 9(8)v9(2) 48 - 57 Total reimbursement for this “swapped” DRG

Optimizer Outlier Type IOB2-IO1-OUTFLAG 9(1) 58 Reason for outlier add-onOptimizer Transfer Flag IOB2-IO1-TRFLAG 9(1) 59 Reason for the patient’s transferOptimizer DRG Weight IOB2-IO1-WEIGHT 9(3)v9(5) 60 - 67 Weight for the “swapped” DRGOptimizer Grouper Return Code

IOB2-IO1-GRPR-RTN

X(2) 68 - 69 DRG Grouper Return Code

Optimizer Pricer Return Code

IOB2-IO1-PRCR-RTN

X(2) 70 - 71 Pricer Return Code


OOB2-OO1-OP-OPT-BLOCK1Note


Table 44-1: OOB2-OO1-OP-OPT-BLOCK1: Variable length output fields from Outpatient modeling (defined in hoptblk.cpy; reserved for future use)



MEB1-MCE-EDITOR-BLOCK1Table 45-1: MEB1-MCE-EDITOR-BLOCK1: Fixed length output fields from Date-Sensitive Code (DSC) Editor (defined in hmceblk.cpy)

Field Description Variable Name Format Position NotesEditor Return Code MEB1-RTN-CODE X(2) 1 - 2 03 = Invalid number of DX/OP codes, exceeds max.

allowed16 = Invalid ALC days/interrupted days 18 = Invalid occurrence span date CL = Cannot load or open programIO = File I/O error

Editor Return Code Extension

MEB1-RTN-CODE2 X(2) 3 - 4 01 = Problem opening DXOP file02 = Reserved

Return Status MEB1-RTN-STATUS X(2) 5 - 6 File operation return status code. OS/language dependent.

Editor Version MEB1-EDTR-VERS 9(2) 7 - 8 Current version of the DSC Editor.Editor Reserved MEB1-RSVD X(2) 9 - 10 ReservedDemographic Error Count

MEB1-DEMO-ERRCNT

9(4) 11 - 14 Number of demographic errors returned.

Age Edit MEB1-DEMO-AGE 9(1) 15 0 = No error1 = Age invalid (not in range 0-124)

Sex Edit MEB1-DEMO-SEX 9(1) 16 0 = No error1 = Sex invalid (not 1, 2, M or F)

Discharge Disposition Edit

MEB1-DEMO-DSTAT

9(1) 17 0 = No error1 = Invalid discharge disposition/patient status

Birthweight Edit MEB1-DEMO-BWGT

9(1) 18 0 = No error1 = Invalid birth weight (not zero, not 9999, not in

range 100-9000 grams)Filler X(57) 19 - 75Diagnosis Error Count MEB1-DX-ERRCNT 9(4) 76 - 79 Number of diagnosis errors returned.Principal Diagnosis Errors

MEB1-DX-PDX 9(1) 80 0 = No error1 = E-code (ICD-9)/External Causes of Morbidity

Code (ICD-10) as principal diagnosis2 = Manifestation code as principal diagnosis3 = Nonspecific code as principal diagnosis4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis; requires

secondary diagnosisDiagnosis/Surgery Edit MEB1-DX-PDX-

SURG9(1) 81 Reserved

Admit Diagnosis E-Code/Manifestation Code

MEB1-DX-ADMEM 9(1) 82 0 = No error1 = E-code (ICD-9)/External Causes of Morbidity

Code (ICD-10) as admit diagnosis2 = Manifestation code as admit diagnosis

Filler X(58) 83 - 140Procedure Error Count MEB1-OP-ERRCNT 9(4) 141 - 144 Number of procedure errors returned.


Nonspecific Procedure Edit

MEB1-OP-NONSPEC

9(1) 145 0 = No error1 = All O.R. procedures coded are nonspecific

Bilateral Coding Edit MEB1-OP-BILAT 9(1) 146 0 = No bilateral procedures present1 = Two or more different joint procedures are

presentFiller X(59) 147 - 205Invalid Admit Diagnosis Code

MEB1-ADMDX-INVALID

9(1) 206 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

MEB1-ADMDX-AGESEX

9(1) 207 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 diagnosisAdmit Diagnosis Medicare as Secondary Payer Alert

MEB1-ADMDX-MSP 9(1) 208 0 = No error1 = Insurer may be secondary payer to auto

insurance, worker’s compensation, etc. (prior to October 01, 2001)

Age Edit Indicator MEB1-ADMDX-AGE-EDIT-IND

9(1) 209 0 = No error1 = Code is for newborns only, but patient age is

greater than zero years2 = Code is for pediatric patients only, but patient

age is greater than 17 years3 = Code is for maternity-aged patients only, but

patient age is not between 09 and 64 years4 = Code is for adults only, but patient age is less

than 15 yearsAdmit Diagnosis Filler MEB1-ADMDX-

FILLER-RSVDX(43) 210 - 252 Reserved

Total Number of Errors MEB1-TOTERR 9(4) 253 - 256 Total number of errors returned.Filler X(144) 257 - 400

Table 45-1: MEB1-MCE-EDITOR-BLOCK1: Fixed length output fields from Date-Sensitive Code (DSC) Editor (defined in hmceblk.cpy)



MEB2-MCE-EDITOR-BLOCK2Table 46-1: MEB2-MCE-EDITOR-BLOCK2: Variable Length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs 999 times)

Field Description Variable Name Format Position NotesDiagnosis Invalid MEB2-DX-INVALID 9(1) 1 0 = No error

1 = Code invalid, not found on table of valid ICD-9-CM/ICD-10-CM codes

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

3 = 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



Duplicate Diagnosis Flag

MEB2-DX-DUPDX 9(1) 2 0 = Not duplicate code1 = Code is duplicate of principal diagnosis

Age/Sex Diagnosis Flag MEB2-DX-AGESEX 9(1) 3 0 = No error1 = Age conflict, patient age and diagnosis are

inconsistent2 = Sex conflict, patient sex and diagnosis are

inconsistent3 = Age and sex conflict, patient age and sex are

inconsistent with the patient diagnosisMedicare as Secondary Payer

MEB2-DX-MSP 9(1) 4 0 = No error1 = Insurer may be secondary payer to Auto

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

Duplicate Secondary Diagnosis

MEB2-DX-DUPSECDX

9(1) 5 0 = Not duplicate code1 = Code is duplicate of another secondary

diagnosisPrincipal Diagnosis/ Surgery Edit Indicator

MEB2-DX-DXSURG X(1) 6 Reserved

Present on Admission Flag

MEB2-DX-POA 9(1) 7 0 = No error1 = POA indicator required but not submitted2 = POA indicator required but is not valid3 = POA indicator invalid for this exempt code on an

electronic claim4 = POA indicator invalid for this exempt code on a

paper claimHospital-Acquired Condition Eligibility/Impact

MEB2-DX-HAC-ELIGIBLE

9(2) 8 - 9 00 = Code is not subject to HAC01 = Code is HAC eligible; another CC/MCC is

present (MS-DRG may not be affected)02 = Code is HAC eligible, but is not a CC/MCC

(MS-DRG may not be affected)03 = Code is HAC eligible; no other CC/MCC is

present (MS-DRG may be affected)


CC/MCC Indicator MEB2-DX-CCMCCIND

9(1) 10 0 = Not a CC or MCC for Medicare MS-DRG assignment

1 = CC for Medicare MS-DRG assignment2 = MCC for Medicare MS-DRG assignment

NoteThese 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

MEB2-DX-HAC 9(4) 11 - 14 Hospital Acquired Condition (HAC) identified on this claim and not present on admission:0001 = Foreign object retained after surgery0002 = Air embolism0003 = Blood incompatibility0004 = Pressure ulcer stages III and IV 0005 = Falls and Trauma0006 = Catheter-associated Urinary Tract Infection

(UTI)0007 = Vascular catheter-associated infection0008 = Surgical Site Infection (SSI), mediastinitis,

following Coronary Artery Bypass Graft (CABG)0009 = Manifestations of poor glycemic control0010 = Deep vein thrombosis and pulmonary

embolism following certain orthopedic procedures

0011 = Surgical Site Infection (SSI) following bariatric surgery for obesity

0012 = Surgical Site Infection (SSI) following certain orthopedic procedures

0013 = Surgical Site Infection (SSI) following Cardiac Implantable Electronic Device (CIED)

0014 = Iatrogenic pneumothorax with venous catheterization

9999 = Hospital Acquired Condition (HAC)Wrong Procedure Performed

MEB2-DX-WRONGPX

9(1) 15 0 = No error1 = Code indicates that a wrong procedure has been

performedPrincipal Diagnosis Errors

MEB2-DX-PDX 9(1) 16 0 = No error1 = E-code (ICD-9)/external causes of comorbidity

code (ICD-10) as principal diagnosis2 = Manifestation code as principal diagnosis3 = Nonspecific code as principal diagnosis4 = Questionable admission5 = Unacceptable principal diagnosis6 = Unacceptable principal diagnosis; requires

secondary diagnosis

Table 46-1: MEB2-MCE-EDITOR-BLOCK2: Variable Length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs 999 times)



Admit Diagnosis E-Code/Manifestation Code

MEB2-DX-ADMDX-EM

9(1) 17 0 = No error1 = E-code (ICD-9)/external causes of comorbidity

code (ICD-10) as admit diagnosis2 = Manifestation code as admit diagnosis

Age Edit Indicator MEB2-DX-AGE-EDIT-IND

9(1) 18 0 = No error1 = Code is for newborns only, but patient age is

greater than zero years2 = Code is for pediatric patients only, but patient

age is greater than 17 years3 = Code is for maternity-aged patients only, but

patient age is not between 12 and 55 years4 = Code is for adults only, but patient age is less

than 15 yearsFiller X(32) 19 - 50

Table 46-1: MEB2-MCE-EDITOR-BLOCK2: Variable Length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs 999 times)



MEB3-MCE-EDITOR-BLOCK3Table 47-1: MEB3-MCE-EDITOR-BLOCK3: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesInvalid Procedure Edit Indicator

MEB3-OP-INVALID 9(1) 1 0 = No error1 = Code invalid, not found on table of valid ICD-9-

CM/ICD-10-PCS 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-PCS

table, but not valid for patient admission/discharge date



Sex Conflict Edit Indicator

MEB3-OP-SEX 9(1) 2 0 = No error1 = Sex conflict, patient sex and procedure are

inconsistentNon-Covered Edit Indicator

MEB3-OP-NCBIOP 9(1) 3 0 = No error1 = Non-covered procedure2 = Open biopsy code3 = Limited coverage procedure

Bilateral Code Indicator MEB3-OP-BICODE 9(1) 4 0 = Not a bilateral procedure code1 = Bilateral procedure code

Closed Biopsy Code MEB3-OP-CLSDBIOP

X(7) 5 - 11 When procedure code is an open biopsy, this is the corresponding closed biopsy code.

Operating Room Indicator

MEB3-OP-ORPROC X(1) 12 0 = Not typically performed in an operating room1 = Typically performed in an operating room

Procedure Inconsistent With Length of Stay Indicator

MEB3-OP-PILOS X(1) 13 0 = No error1 = Length of stay and procedure are inconsistent

Questionable Obstetric Admission Indicator

MEB3-OP-QOBADM

X(1) 14 0 = No error1 = Questionable obstetric admission for this

procedure code

Filler X(36) 15 - 50


MEB4-MCE-EDITOR-BLOCK4Table 48-1: MEB4-MCE-EDITOR-BLOCK4: Fixed length error summary output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy)

Field Description Variable Name Format Position NotesTotal Errors MEB4-MES-TTL 9(4) 1 - 4 Total errors for this claim.Error Summary Array MEB4-MES-ENTRY 9(12)

occurs 999 times

5 - 11992

Error Code MEB4-MES-ERRCD 9(9) 000000001 = Invalid DX000000002 = Invalid PX000000003 = Duplicate of PDX000000004 = Age Conflict000000005 = Sex Conflict000000006 = Manifestation as PDX000000007 = Non-Specific PDX000000008 = Questionable Admission000000009 = Unacceptable PDX000000010 = All Non-Specific O.R. PDX000000011 = Non-Covered Procedure000000012 = Open Biopsy Check000000013 = Bilateral Procedures000000014 = Invalid Age000000015 = Invalid Sex000000016 = Invalid Discharge Status000000017 = Limited Coverage000000018 = Invalid Birth Weight000000019 = External Causes of Morbidity Code as

PDX000000020 = Duplicate of Another SDX000000021 = External Causes of Morbidity Code as

Admit DX000000022 = Manifestation Code as Admit DX000000023 = Invalid POA Coding000000024 = Hospital-Acquired Condition (HAC) /

Health Care Acquired Condition (HCAC)

000000025 = Wrong Procedure Performed000000026 = Procedure Inconsistent with Length of

Stay000000027 = Questionable Obstetric Admission

Error Count MEB4-MES-ERRCTR

9(3) Number of times error code is returned.


EEB1-EZEDIT-EDITOR-BLOCK1Table 49-1: EEB1-EZEDIT-EDITOR-BLOCK1: Fixed length EASYEdit™ output fields (defined in hezdtblk.cpy)

Field Description Variable Name Format Position NotesEditor Return Code EEB1-RTN-CODE X(2) 1 - 2 00 = Record editedEASYEdit™ Return Code Extension

EEB1-RTN-CODE2 X(2) 3 - 4 00 = No I/O errors01 = DX/OP file I/O error02 = Edit Rule file I/O error

Return Status EEB1-RTN-STATUS X(2) 5 - 6 File operation return status code. OS/language-dependent.

Reserved EEB1-RSVD X(4) 7 - 10 ReservedEditor Type EEB1-EDTR-TYPE X(2) 11 - 12 ReservedEditor Subtype EEB1-EDTR-TYPE-


Editor Version EEB1-EDTR-VERS 9(2) 15 - 16 ReservedEditor Reserved EEB1-EDTR-VERS-

RSVD9(4) 17 - 20 Reserved

Filler X(15) 21 - 35


EEB2-EZEDIT-EDITOR-BLOCK2Table 50-1: EEB2-EZEDIT-EDITOR-BLOCK2: Variable length EASYEdit™ output fields (defined in hezdtblk.cpy; occurs up to 305 times)

Field Description Variable Name Format Position NotesTotal EASYEdit™ Errors

EEB2-EIE-TTL 9(3) 1 - 3 Sum of all EASYEdit™ errors for this claim.

EASYEdit™ Edit ID Array

EEB2-EIE-EDIT-ID-ENTRY

Occurs 305 times

4 - 17693

Edit ID EEB2-EIE-EDITID 9(9) EASYEdit™ IdentifierMessage ID EEB2-EIE-MSGID 9(9) Edit message identifierFiller X(40)

Filler X(289) 17694 - 17982



Field Description Variable Name Format Position NotesEASYEdit Message EEB3-EME-EDIT-

MSG-ENTRYOccurs 305 times

Edit description

EASYEdit™ Output Message

EEB3-EME-MSG X(255) 1 - 77775 Edit description

Filler X(147) 77776 - 77922



Field Description Variable Name Format Position NotesLook-for Field Name EEB4-ERE-LOOK-

IDX(12) 1 - 12 Look-for field name

Look-for Field Position EEB4-ERE-LOOK-FROM

X(20) 13 - 32 Position of look-for field

Look-for Field Value EEB4-ERE-LOOK-POS

9(3) 33 - 35 Value of look-for field

Edit Category EEB4-ERE-CATEGORY

X(12) 36 - 47 01 = Diagnosis code sequenced incorrectly03 = Assign single diagnosis code rather than

multiple codes04 = Assign single ICD-10-PCS code rather than

multiple codes05 = Assign single HCPCS code rather than multiple

codes06 = Do not report diagnosis codes together unless

clinically appropriate07 = Do not report ICD-10-PCS codes together

unless a distinct service08 = Do not report HCPCS codes together unless a

distinct service09 = Do not assign diagnosis and ICD-10-PCS

codes together10 = Do not assign diagnosis and HCPCS codes

together 14 = Assign diagnosis codes per guidelines and

classification instructions15 = Assign ICD-10-PCS codes per guidelines and

classification instructions16 = Assign HCPCS codes per guidelines and

classification instructions

continued below...


Edit Category <continued>

EEB4-ERE-CATEGORY

X(12) 36 - 47 24 = Questionable diagnosis code assignment on an inpatient case

25 = Do not report ICD-10-PCS add-on code without principal procedure code

26 = Do not report HCPCS add-on code without principal procedure code

27 = Incorrect code and modifier combination28 = Append modifier when appropriate29 = Diagnosis code conflicts with demographics30 = ICD-10-PCS code conflicts with demographics32 = HCPCS code conflicts with demographics33 = Duplicate ICD-10-PCS code not allowed34 = Duplicate HCPCS code not allowed35 = OPPS-related diagnosis edit36 = OPPS-related procedure edit37 = Other OPPS-related edit 38 = Medicare inpatient-related diagnosis edit39 = Medicare inpatient-related procedure edit41 = Other Medicare inpatient-related edit42 = RAC Issue43 = Hospital Acquired Condition (HAC) edit44 = Patient safety indicator45 = Patient quality indicator46 = Other regulatory audit issue48 = Excludes 1 Instructional Note49 = Code first instructional note50 = Use additional code or code also instructional

note98 = Other99 = Unassigned

Edit Level EEB4-ERE-EDIT-LVL

X(12) 48 - 59 EASYEdit™ assigns an edit severity level of Critical to all edits.

Reserved EEB4-ERE-LOOK-START


Filler X(25) 80 - 104

Table 52-1: EEB4-EZEDIT-EDITOR-BLOCK4: Variable length EASYEdit™ output fields (defined in hezdtblk.cpy; occurs up to 305 times)



AEB1-ACE-EDIT-BLOCK1Table 53-1: AEB1-ACE-EDIT-BLOCK1: Fixed length ACE and CAH Method II Editor output fields (defined in hace2blk.cpy)

Field Description Variable Name Format Position NotesEditor Return Code

AEB1-RTN-CODE X(2) 1 - 2 Standard Return Codes:00 = No errors found02 = Reserved03 = Reserved04 = Reserved07 = Reserved11 = Reserved

ACE:05 = Number of procedures < 106 = Claim spans > 365 days09 = Number of diagnoses < 110 = Final disposition exceeds maximum

acceptable level of errorCL = Cannot load or open programIO = File I/O error (refer to AEB1-RTN-CODE2

below)

CAH Method II:05 = Number of procedures < 106 = Claim spans > 365 days09 = Number of diagnoses < 110 = Final disposition exceeds maximum

acceptable level of errorCL = Cannot load or open programIO = File I/O error (refer to AEB1-RTN-CODE2

below)


ACE Return Code Extension

AEB1-RTN-CODE2 X(2) 3 - 4 ACE:00 = No file I/O errors01 = Error opening ACE code file02 = Error opening CCI pairs file03 = Error opening OCE/CCI pairs file04 = Error opening ACERULE file05 = Error opening APCRULE file06 = Error opening ACECCI2 file07 = Error opening ACEOCE2 file08 = Error opening ACCMI file09 = Error opening AOCEMI file10 = Error opening ACEMUE file11 = Error opening ACCISD file12 = Error opening AOCESD file

CAH Method II:00 = No file I/O errors01 = Error opening ACE code file/Error opening

code file02 = Error opening CCI pairs file/Error opening CCI

edit file03 = Error opening OCE/CCI pairs file/Error

opening MUE file04 = Error opening ACERULE file/Error opening

code pairs file05 = Error opening APCRULE file06 = Error opening ACECCI2 file07 = Error opening ACEOCE2 file10 = Error opening ACEMUE file

Return Status AEB1-RTN-STATUS X(2) 5 - 6 File operation return status code. OS/language dependent.

ACE Version AEB1-EDTR-VERS 9(2) 7 - 8 Editor version number applicable to this claim. This number is the last two digits of the calendar year, i.e. 05 is for calendar 2005.

ACE Release Version

AEB1-EDTR-REL X(1) 9 Editor release version number applicable to this claim. There are generally four versions a year. Values range from 1 to 4.

ACE Version Reserved

AEB1-EDTR-VERS-RSVD


Editor Return Code Type

AEB1-EDTR-RTN-TYPE

X(1) 13 CAH Method II:A = Return code from ACEC = Return code from CAH Method II EditorP = Return code from Physician Editor

Filler X(19) 14 - 32Number of Claim Errors

AEB1-NUM-CLAIMERR

9(3) 33 - 35 The number of claim-level errors returned.

Number of Diagnosis Errors

AEB1-NUM-DXERR 9(3) 36 - 38 The number of diagnosis errors returned.

Number of Procedure Errors

AEB1-NUM-OPERR 9(3) 39 - 41 The number of procedure errors returned.

Table 53-1: AEB1-ACE-EDIT-BLOCK1: Fixed length ACE and CAH Method II Editor output fields (defined in hace2blk.cpy)



Number of CCI Errors

AEB1-NUM-CCIERR 9(3) 42 - 44 The number of CCI edit pairs returned from ACE. Returned with a request for OCE editing with CCI code pairs (ECB-EDIT-OCE-CCI-SW) or with a request for CCI editing (ECB-EDIT-CCI-SW).

NoteThis number may be greater than PCB1-MAXCCIERR.

Number of Reason for Visit Diagnosis Errors

AEB1-NUM-ADMDXERR

9(2) 45 - 46 Number of reason for visit diagnosis errors returned.

Total Number of Errors

AEB1-TOTERR 9(4) 47 - 50 Total number of errors identified for this patient visit.(AEB1-NUM-CLAIMERR + AEB1-NUM-DXERR + AEB1-NUM-OPERR)

NoteAEB1-NUM-CCIERR is not included in this total.

Highest Reason for Visit Diagnosis Disposition

AEB1-ADMDX-DISP 9(2) 51 - 52 ACE:The highest reason for visit diagnosis disposition.00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspended04 = Claim returned to provider for correction (RTP)05 = Claim rejected06 = Claim denied

Overall Claim Disposition

AEB1-FINAL-DISP 9(2) 53 - 54 Overall disposition of claim, incorporating claim, diagnosis, and procedure edits.00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspended04 = Claim returned to provider for correction (RTP)05 = Claim rejected06 = Claim denied

OCE Error Disposition

AEB1-OCE-DISP 9(1) occurs 6 times

55 - 60 Claim disposition flag array: one flag for eachdisposition as listed under AEB1-FINAL-DISP. A “1” in any position indicates that one or more errors were identified on the claim with the matching disposition. For example, AEB1-OCE-DISP of “010011” indicates that the claim contains errors that would result in line item denials, claim rejection, and claim denial.




Claim Error Detail AEB1-CLAIMERR 9(5) occurs 15 times

61 - 135 ACE and CAH Method II:00000 = No errors found00010 = Condition code 2100023 = Invalid From-Thru dates00024 = Date out of OCE range00025 = Invalid age00026 = Invalid sex00027 = Only incidental services reported00029 = Partial hospitalization services, non-

mental-health diagnosis00030 = Insufficient partial hospitalization services00035 = Only mental health education and training

services are provided during one or more days00046 = Partial hospitalization condition code

invalid for this bill type00088 = FQHC payment code not reported for

FQHC claim00109 = Code first diagnosis present without

mental health diagnosis as the first secondary diagnosis

00118 = Invalid bill type00119 = Invalid claims processing receipt date

Reason for Visit Diagnosis Errors

AEB1-ADMDXERR 9(5) occurs 3 times

136 - 150 ACE:00000 = No errors found00001 = Invalid admit diagnosis00002 = Admit diagnosis/age conflict00003 = Admit diagnosis/sex conflict

Filler X(650) 151 - 800




AEB2-ACE-EDIT-BLOCK2Table 54-1: AEB2-ACE-EDIT-BLOCK2: Variable length ACE and CAH Method II Editor output fields for ICD-9-CM or ICD-10-CM diagnosis edits (defined in hace2blk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesDiagnosis Code Type AEB2-ADE-TYPE X(3) 1 - 3 ReservedHighest Diagnosis Disposition

AEB2-ADE-DISP 9(2) 4 - 5 The highest diagnosis disposition.00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

Number of Errors Recorded for this Diagnosis

AEB2-ADE-NUMERR

9(2) 6 - 7 Number of diagnosis errors returned.

Admit Diagnosis Errors AEB2-ADE-ADMDXERR

9(5) 8 - 12 Reserved

Diagnosis Errors AEB2-ADE-ERRORS

9(5) occurs 5 times

13 - 37 00000 = No errors found00001 = Invalid diagnosis00002 = Diagnosis/age conflict00003 = Diagnosis/sex conflict00005 = E-code as reason for visit00086 = Manifestation code not allowed as principal

diagnosis00113 = Supplementary or additional code not

allowed as principal diagnosisFiller X(18) 38 - 55


AEB3-ACE-EDIT-BLOCK3Table 55-1: AEB3-ACE-EDIT-BLOCK3: Variable length ACE and CAH Method II Editor output fields for HCPCS procedures and claim line edits (defined in hace2blk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesAPC AEB3-AOE-APC 9(5) 1 - 5 ReservedHighest Procedure Disposition

AEB3-AOE-DISP 9(2) 6 - 7 00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

Procedure Validity Indicator

AEB3-AOE-VALID 9(2) 8 - 9 00 = Procedure is valid for dates01 = Procedure not found in code table02 = Procedure not valid for service date03 = Procedure is valid for dates with pending

editing and/or grouping informationNumber of Procedure Errors Recorded

AEB3-AOE-NUM-ERR

9(2) 10 - 11 The number of edits returned for each claim line.


Procedure Errors AEB3-AOE-ERROR 9(5) occurs 15 times

12 - 86 00000 = No error00006 = Invalid procedure code00008 = Procedure and sex conflict00009 = Non-covered for reasons other than statute00011 = Service submitted for MAC review

(condition code 20)00012 = Questionable covered service00013 = Separate payment for services is not

provided by Medicare00015 = Units exceed maximum (MUE)00017 = Inappropriate specification of bilateral

procedure00018 = Inpatient procedure00020 = Code 2 of a code pair that is not allowed by

NCCI even if appropriate modifier is present00021 = Medical visit on same day as a type “T” or

“S” procedure without modifier 2500022 = Invalid modifier00023 = Invalid date00028 = Code not recognized by Medicare; alternate

code for same service may be available00030 = Insufficient partial hospitalization services 00037 = Terminated bilateral procedure, or

terminated procedure with units greater than one

00038 = Inconsistency between implanted device or administered substance and implantation or associated procedure

00040 = Code 2 of a code pair that would be allowed by NCCI if appropriate modifier were present

00041 = Invalid revenue code00042 = Multiple medical visits on same day with

same revenue code without condition code G000043 = Transfusion or blood product exchange

without specification of blood product00044 = Observation revenue code on line item with

non-observation HCPCS code00045 = Inpatient separate procedures not paid00047 = Service is not separately payable 00048 = Revenue center requires HCPCS code00049 = Service on same day as inpatient

procedure00050 = Non-covered based on statutory exclusion00051 = Observation code G0378 not allowed to be

reported more than once per claim00053 = Codes G0378 and G0379 only allowed with

bill type 13x00055 = Non-reportable for site of service00057 = E/M condition not met for observation and

line item date for code G0378 is 1/100058 = G0379 only allowed with G037800060 = Use of modifier CA with more than one

procedure not allowed

continued below...

Table 55-1: AEB3-ACE-EDIT-BLOCK3: Variable length ACE and CAH Method II Editor output fields for HCPCS procedures and claim line edits (defined in hace2blk.cpy; occurs up to 999 times)



Procedure Errors <continued>

AEB3-AOE-ERROR 9(5) occurs 15 times

12 - 86 00061 = Service can only be billed to the DMERC00062 = Code not recognized by OPPS; alternate

code for same service may be available00065 = Revenue code not recognized by Medicare00066 = Code requires manual pricing00067 = Service provided prior to FDA approval00068 = Service provided prior to date of National

Coverage Determination (NCD) approval00069 = Service provided outside approval period00070 = CA modifier requires patient discharge

status indicating expired or transferred 00071 = Claim lacks required device code00072 = Service not billable to the MAC00073 = Incorrect billing of blood and blood products00074 = Units greater than one for bilateral

procedure billed with modifier 5000075 = Incorrect billing of modifier FB or FC00076 = Trauma response critical care code without

revenue code 068x and CPT 9929100077 = Claim lacks allowed procedure code00079 = Incorrect billing of revenue code with

HCPCS code00080 = Mental health code not approved for partial

hospitalization program00081 = Mental health service not payable outside

the partial hospitalization program00082 = Charge exceeds token charge ($1.01)00083 = Service provided on or after effective date

of NCD non-coverage 00084 = Claim lacks required primary code00087 = Skin substitute application procedure

without appropriate skin substitute product code

00089 = FQHC claim lacks required qualifying visit code

00090 = Incorrect revenue code reported for FQHC payment code

00091 = Item or service not covered under FQHC PPS or Rural Health Clinic (RHC)

00092 = Device-intensive procedure code billed without device code

00093 = Corneal tissue processing reported without cornea transplant procedure

00094 = Biosimilar HCPCS reported without biosimilar modifier (deactivated)

00095 = Weekly partial hospitalization services require a minimum of 20 hours of service as evidenced in PHP plan of care

00096 = Partial hospitalization interim claim from and through dates must span more than 4 days (deactivated)

continued below...




Procedure Errors <continued>

AEB3-AOE-ERROR 9(5) occurs 15 times

12 - 86 00097 = Partial hospitalization services are required to be billed weekly (deactivated)

00098 = Claim with pass-through device lacks required procedure

00099 = Claim with pass-through or non-pass-through drug or biological lacks OPPS payable procedure

00100 = Claim for HSCT allogeneic transplantation lacks required revenue code line for donor acquisition services

00101 = Item or service with modifier PN not allowed under PFS

00102 = Modifier pairing not allowed on the same line

00103 = Modifier reported prior to FDA approval date (deactivated)

00104 = Service not eligible for all-inclusive rate00105 = Claim reported with pass-through device

prior to FDA approval for the procedure00106 = Add-on code reported without required

primary procedure code00110 = Service provided prior to initial marketing

date00111 = Service cost is duplicative; included in cost

of associated biological00112 = Information only service(s)00114 = Item or service not allowed with Modifier CS00115 = COVID-19 lab add-on code reported

without required primary procedure00116 = Opioid treatment program service not

payable outside the Opioid Treatment Program (OTP)

00117 = Token charge less than $1.01 billed by provider

99999 = Line item denial from external Editor




Procedure Payment Status

AEB3-AOE-PAYSTAT

X(2) 87 - 88 ACE:A = Services paid under fee schedule or other

prospectively determined rateB = Service not allowed under OPPS on hospital


information and clams data are not availableF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH = Pass-through device categoriesJ1 = Hospital Part B services paid through a

Comprehensive APCJ2 = Hospital Part B services that may be paid



L = Influenza virus or Pneumococcal Pneumonia Vaccine (PPV)

M = Service not billable to the FI/MACN = Packaged/incidental serviceP = Partial hospitalization serviceQ1 = STV - packaged servicesQ2 = T - packaged servicesQ3 = Services that may be paid through a

Composite APCQ4 = Conditionally packaged laboratory servicesR = Blood and blood productsS = Procedure or service, not discounted when


revenue codeX = Ancillary service (prior to January 1, 2015)Y = Non-implantable DMEZ = Valid revenue code, blank HCPCS, no other

status indicator assigned

CAH Method II:The status code for this practitioner service. The following values may be returned:A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician Fee Schedule by

regulationF = Deleted/ Discontinued codeG = Not valid for Medicare purposescontinue below...




Procedure Payment Status<continued>

AEB3-AOE-PAYSTAT

X(2) 87 - 88 H = Deleted modifierI = Not valid for Medicare purposesJ = Anesthesia serviceM = Measurement codeN = Non-covered serviceP = Bundled/Excluded codeQ = Therapy functional information code (used for



CMHC (Community Mental Health Center) Indicator

AEB3-AOE-PAYSTAT2

X(1) 89 ACE:P = Packaging indicator for services to be included

in a mental health or partial hospitalization per-diem

blank = Not applicableBilateral Modifier Flag (From ACE Edits)

AEB3-AOE-BILATOP

9(1) 90 0 = Unknown or not applicable1 = Conditionally bilateral2 = Inherently bilateral3 = Independently bilateral9 = Not bilateral

Discount AEB3-AOE-DISCOUNT

9(1) 91 ACE:0, 1-9These discount flags are used by the APC Pricer to determine payment for this procedure.

Maximum Units AEB3-AOE-MAXUNITS

9(15) 92 - 106 Maximum allowable units for this procedure if this claim is subject to the MUEs. If no maximum allowable units have been defined or if this claim is not subject to the MUEs, this field defaults to zero.

Paid Units AEB3-AOE-PDUNITS

9(15) 107 - 121 Number of units eligible for payment. May be reduced from submitted units due to drug administration unit limitations or because the code was recognized as a FQHC payment code.

Packaging Flag AEB3-AOE-PKGFLG

9(1) 122 ACE:0 = Not packaged1 = Packaged service2 = Packaged as part of partial hospitalization or

mental health per diem (prior to January 1, 2009)

3 = Surgical charges are less than $1.014 = Packaged as part of drug administration APC

payment5 = Paid or Packaged as part of Composite APC6 = Packaged as part of Comprehensive APC7 = Conditionally packaged (Payment Status

Indicator Q1, Q2, Q3 (limited circumstances), or Q4)




Composite Line Number

AEB3-AOE-COMPLINE

9(3) 123 - 125 ACE:Line number containing the Composite APC or Comprehensive APC to which this line is related.

Pricing Adjustment Flag AEB3-AOE-ADJFLAG

9(2) 126 - 127 Reserved

Professional Services Flag

AEB3-AOE-PROFLAG

9(1) 128 Reserved

MUE Adjudication Indicator

AEB3-AOE-MAI 9(1) 129 The type of Medically Unlikely Edit (MUE) that this procedure is subject to.

0 = No MUE edit or not applicable1 = Line level edit2 = Day level edit (policy)3 = Day level edit (clinical)

NoteThis field is only returned for claims that are subject to the MUE edits.

Filler X(21) 130 - 150




AEB4-ACE-EDIT-BLOCK4Table 56-1: AEB4-ACE-EDIT-BLOCK4: Variable length OCE/CCI edit output fields (defined in hace2blk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesFirst Procedure Code AEB4-AEE-OP1 X(7) 1 - 7 ACE and CAH Method II:

First HCPCS procedure code plus up to one optional modifiers.

First Claim Line Pointer AEB4-AEE-OP1-LINE

9(3) 8 - 10 ACE and CAH Method II:Line number of line containing first procedure code.

Filler X(5) 11 - 15Second Procedure Code

AEB4-AEE-OP2 X(7) 16 - 22 ACE and CAH Method II:Second HCPCS procedure code plus one optional modifier.

Second Claim Line Pointer

AEB4-AEE-OP2-LINE

9(3) 23 - 25 ACE and CAH Method II:Line number of line containing second procedure code.

Filler X(5) 26 - 30Error Code AEB4-AEE-

ERRNUM9(3) 31 - 33 ACE and CAH Method II:

OCE/CCI Edits:914 = Mutually exclusive procedures (prior to July

01, 2012)915 = Column 1/column 2 correct coding edits

ACE only:Full CCI Edits:901 = Standards of medical/surgical practice902 = CPT® separate procedure definition903 = More extensive procedure904 = “With” versus “without” services905 = Anesthesia included in surgical procedures906 = Laboratory panels907 = Sequential procedures908 = Standard preparation and monitoring

guidelines909 = CPT® coding manual instructions/guidelines910 = CPT® procedure code definition911 = Misuse of column 2 code with column 1 code912 = Mutually exclusive services913 = Designation of sex procedures

For further information on the above CCI Edits please refer to the EASYGroup™ User’s Guide.

Modifier Code AEB4-AEE-MODCODE

9(1) 34 ACE and CAH Method II:0 = Modifier will not affect edit1 = An OCE edit has been generated but an

appropriate modifier on code 1 or code 2 may affect this edit

2 = Code pair is accompanied by a modifier that is acceptable to the OCE but would not override the OCE/CCI edit according to standard coding practice


OCE Indicator AEB4-AEE-PPSIND 9(1) 35 ACE and CAH Method II:0 = Edit is used in the CCI but is not used in the

OCE1 = Edit is used in the CCI and is also used in the

OCE in mutually exclusive context2 = Edit is used in the CCI and is also used in the

OCE in comprehensive/component contextFiller X(36) 36 - 71

Table 56-1: AEB4-ACE-EDIT-BLOCK4: Variable length OCE/CCI edit output fields (defined in hace2blk.cpy; occurs up to 999 times)



AEB5-ACE-EDIT-BLOCK5Table 57-1: AEB5-ACE-EDIT-BLOCK5: Fixed length ACE and CAH Method II Editor error summary output fields (defined in hace2blk.cpy)

Field Description Variable Name Format Position NotesCCI Edit Summary AEB5-CES-TTL 9(4) 1 - 4 ACE and CAH Method II:

Total CCI edits.CCI Edit Array AEB5-CES-ENTRY 9(12)

occurs 999 times

5 - 11992

Error Code AEB5-CES-ERRCD 9(9) ACE and CAH Method II:CCI edit identifier.

Error Count AEB5-CES-ERRCTR

9(3) ACE and CAH Method II:Number of occurrences of this CCI edit.

OCE Edit Summary AEB5-OES-TTL 9(4) 11993 - 11996

ACE and CAH Method II:Total OCE edits.

OCE Edit Array AEB5-OES-ENTRY 9(12)occurs 999 times

11997 - 23984

Error Code AEB5-OES-ERRCD 9(9) ACE and CAH Method II:OCE edit identifier.

Error Count AEB5-OES-ERRCTR

9(3) ACE and CAH Method II:Number of occurrences of this OCE edit.


LEB1-LCD-EDIT-BLOCK1Table 58-1: LEB1-LCD-EDIT-BLOCK1: Fixed length LCD Editor return fields (defined in hlcdblk.cpy)

Field Description Variable Name Format Position NotesLCD Return Code LEB1-RTN-CODE X(2) 1 - 2 ReservedLCD Return Code Extension

LEB1-RTN-CODE2 X(2) 3 - 4 Reserved

LCD Return Status LEB1-RTN-STATUS X(2) 5 - 6 ReservedReserved LEB1-RSVD X(4) 7 - 10 ReservedTotal Number of Errors LEB1-TOTERR 9(3) 11 - 13 ReservedFI or Carrier LEB1-FI X(2) 14 - 15 ReservedStatutorily-Denied Diagnosis Flag

LEB1-STDENY 9(1) 16 Reserved

Statutorily-Denied Diagnosis Code

LEB1-STDENYDX X(6) 17 - 22 Reserved

Key Type LEB1-KEY-TYPE X(1) 23 ReservedICD-10 Statutorily-Denied Diagnosis Code

LEB1-STDENYDX-01


Filler X(31967) 34 - 32000


LEB2-LCD-EDIT-BLOCK2Table 59-1: LEB2-LCD-EDIT-BLOCK2: Variable length LCD Editor return fields (defined in hlcdblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesSummary LEB2-OPSUM 9(2) 1 - 2 ReservedCode Valid Flag LEB2-CODE-VALID 9(1) 3 ReservedValid/Non-Covered Flag LEB2-NONCOV 9(1) 4 ReservedNo Diagnosis Flag LEB2-NODX 9(1) 5 ReservedAge Flag LEB2-AGE 9(1) 6 ReservedSex Flag LEB2-SEX 9(1) 7 ReservedNo Accompanying Procedure

LEB2-AP 9(1) 8 Reserved

No Supporting Diagnosis

LEB2-SD 9(1) 9 Reserved

Policy Description LEB2-POLICY-NAME

X(100) 10 - 109 Reserved

Policy Original Effective Date

LEB2-ORIG-EFFDATE

9(8) 110 - 117 Reserved

Last Update Date LEB2-MOST-EFFDATE

9(8) 118 - 125 Reserved

Frequency Warning Flag

LEB2-FREQ-FLAG 9(1) 126 Reserved

Frequency LEB2-FREQUENCY 9(3) 127 - 129 ReservedFrequency Span LEB2-FREQ-SPAN 9(3) 130 - 132 ReservedFrequency Unit LEB2-FREQ-UNIT X(1) 133 ReservedBroad Diagnostic Flag LEB2-BD-FLAG 9(1) 134 ReservedFiller X(15) 135 - 149


LEB3-LCD-EDIT-BLOCK3Table 60-1: LEB3-LCD-EDIT-BLOCK3: Variable length line-level LCD Editor return fields (defined in hlcdblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesPolicy Identifier Description

LEB3-POLICY-ID X(10) 1 - 10 Reserved

Policy URL LEB3-URL X(200) 11 - 210 Reserved



Field Description Variable Name Format Position NotesICD-10 Medical APG Diagnosis

GOB5-OG1-APG-MED-DX

X(10) 1 -10 Reserved

Line Item Visit ID GOB5-OG1-APG-VISIT-ID

9(3) 11 - 13 Reserved

Filler X(188) 13 - 200





GOB5-SG1-SNF-GRPR-BLOCK5Table 63-1: GOB5-SG1-SNF-GRPR-BLOCK5: Variable length RUG Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times)



MOB2-MAP-OUTPUT-BLOCK2Table 64-1: MOB2-MAP-OUTPUT-BLOCK2: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from the Mapper (defined in hmapblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesReturn Code MOB2-MDE-RC X(2) 1 - 2 00 = Mapping, if needed

occurred with no errors02 = No mapping can

occur for this diagnosis code

Number of Diagnosis Codes

MOB2-MDE-NUMDX 9(2) 3 - 4 Number of target mapped codes for claims processing.

Mapped Diagnosis Codes Array

MOB2-MDE-DX-CODES

Code Type MOB2-MDE-TYPE X(3)occurs 10 times

5 -34 Type of code for target mapped codes.BK = Principal ICD-9

diagnosis BF = Other ICD-9

diagnosis ABK = Principal ICD-10

diagnosis ABF = Other ICD-10

diagnosis ABJ = Admit ICD-10

DiagnosisBJ = Admit ICD-9

diagnosisAPR = Reason for visit

ICD-10 diagnosisPR = Reason for visit ICD-

9 diagnosisCode MOB2-MDE-CODE X(10)

occurs 10 times35 - 134 Target mapped codes for

claims processing.Filler X(16) 135 - 150


MOB3-MAP-OUTPUT-BLOCK3 Table 65-1: MOB3-MAP-OUTPUT-BLOCK3: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from the Mapper (defined in hmapblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesReturn Code MOB3-MOE-RC X(2) 1 - 2 00 = Mapping, if needed occurred with no errors

02 = No mapping can occur for this procedure code

Number of Procedure (OP) Codes

MOB3-MOE-NUMOP

9(2) 3 - 4 Number of target mapped codes for claims processing.

Mapped Procedure Codes Array

MOB3-MOE-OP-CODES

Code Type MOB3-MOE-TYPE X(3)occurs 10 times

5 - 34 Type of code for target mapped codes.BR = First ICD-9 procedure BQ = Other ICD-9 procedure BBR = First ICD-10 procedure BBQ = Other ICD-10 procedure

Mapped Procedure Code

MOB3-MOE-CODE X(10)occurs 10 times

35 - 134 Target mapped codes for claims processing.

Filler X(16) 135 - 150


PEB1-PHY-EDIT-BLOCK1Table 66-1: PEB1-PHY-EDIT-BLOCK1: Fixed length Physician return fields (defined in hpebblk.cpy)

Field Description Variable Name Format Position NotesEditor Return Code PEB1-RTN-CODE X(2) 1 - 2 00 = No errors found

05 = Number of procedures < 109 = Number of diagnoses < 110 = Final disposition exceeds maximum acceptable

level of errorIO = File I/O error (refer to PEB1-RTN-CODE2)CL = Cannot load or open program

Editor Return Code Extension

PEB1-RTN-CODE2 X(2) 3 - 4 00 = No file I/O errors01 = Error opening code file02 = Error opening CCI edit file03 = Error opening MUE file04 = Error opening code pairs file

Return Status PEB1-RTN-STATUS X(2) 5 - 6 File operation return status code. OS/Language dependent.

Editor Version PEB1-EDTR-VERS 9(2) 7 - 8 The Physician Editor version number used to edit this claim. This number is the last 2 digits of the calendar year. For example, 12 is for Calendar Year (CY) 2012.

Editor Release Version PEB1-EDTR-REL 9(1) 9 The Physician Editor release number used to edit this claim. There are four versions a year; one for each quarter. For example, 1 is for the January release, 2 is for the April release, etc.

Editor Version Reserved

PEB1-EDTR-VERS-RSVD


Filler X(20) 13 - 32Number of Claim Edits PEB1-NUM-

CLAIMERR9(3) 33 - 35 Number of claim-level edits returned.

Number of Diagnosis Edits

PEB1-NUM-DXERR 9(3) 36 - 38 Number of diagnosis edits returned.

Number of Procedure Edits

PEB1-NUM-OPERR 9(3) 39 - 41 Number of procedure edits returned.

Total Number of Edits PEB1-NUM-TOTERR

9(3) 42 - 44 Total number of edits identified for this claim, calculated as follows:PEB1-NUM-CLAIMERR + PEB1-NUM-DXERR + PEB1-NUM-OPERR

Overall Claim Disposition

PEB1-FINAL-DISP 9(2) 45 - 46 Overall disposition of the claim, including claim-level, diagnosis, and procedure edits.00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denials03 = Claim suspension04 = Claim Returned to Provider (RTP) for correction05 = Claim rejection06 = Claim denial


Summary of All Claim Dispositions

PEB1-ALL-DISP 9(1)occurs 6 times

47 - 52 Claim disposition flag array; one flag for each disposition as listed below. The number 1 in any position indicates that one or more edits were identified on the claim with the matching disposition.

Flag 1 = Claim contains line item rejectionsFlag 2 = Claim contains line item denialsFlag 3 = Claim suspensionFlag 4 = Claim Returned to Provider (RTP) for correctionFlag 5 = Claim rejectionFlag 6 = Claim denial

For example, 010011 would indicate that the claim contains edits that would result in line item denials, claim rejection, and claim denial.

Highest Claim-Level Edit Disposition

PEB1-DISP 9(2) 53 - 54 Highest claim-level edit disposition.00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denials03 = Claim suspension04 = Claim Returned to Provider (RTP) for correction05 = Claim rejection06 = Claim denial

Claim-Level Edits PEB1-ERRORS 9(5)occurs 15 times

55 - 129 00001 = Invalid date00002 = Date out of range00003 = Invalid age00004 = Invalid sex

Filler X(871) 130 - 1000

Table 66-1: PEB1-PHY-EDIT-BLOCK1: Fixed length Physician return fields (defined in hpebblk.cpy)



PEB2-PHY-EDIT-BLOCK2Table 67-1: PEB2-PHY-EDIT-BLOCK2: Variable length diagnosis output fields from the Physician Editor (defined in hpebblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesDiagnosis Code Type PEB2-PDE-TYPE X(3) 1 - 3 ReservedHighest Diagnosis Edit Disposition

PEB2-PDE-DISP 9(2) 4 - 5 Highest edit disposition for this diagnosis code.00 = No errors found 01 = Claim contains line item rejections02 = Claim contains line item denials03 = Claim suspension 04 = Claim Returned to Provider (RTP) for

correction05 = Claim rejection06 = Claim denial

Number of Edits for This Diagnosis

PEB2-PDE-NUMERR

9(2) 6 - 7

Diagnosis Edits PEB2-PDE-ERRORS

9(5)occurs 5 times

8 - 32 00005 = Invalid diagnosis code00006 = Diagnosis and age conflict00007 = Diagnosis and sex conflict00008 = E-code as principal diagnosis00019 = Supplementary or additional code not

allowed as principal diagnosisFiller X(23) 33 - 55


PEB3-PHY-EDIT-BLOCK3Table 68-1: PEB3-PHY-EDIT-BLOCK3: Variable length procedure output fields from the Physician Editor (defined in hpebblk.cpy; occurs up to 999 times)

Field Description Variable Name Format Position NotesHighest Procedure Edit Disposition

PEB3-POE-DISP 9(2) 1 - 2 Highest edit disposition for this procedure code.00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denials03 = Claim suspension04 = Claim Returned to Provider (RTP) for correction05 = Claim rejection06 = Claim denial

Number of Edits for This Procedure

PEB3-POE-NUMERR

9(2) 3 - 4 Number of edits returned for this procedure code.

Procedure Errors PEB3-POE-ERRORS

9(5)occurs 15 times

5 - 79 00001 = Invalid date00009 = Invalid procedure code00010 = Procedure and sex conflict00011 = Medically Unlikely Edit (MUE)00012 = Invalid modifier00013 = Mutually exclusive procedure that is not

allowed by NCCI even if appropriate modifier is present (deactivated)

00014 = Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present (deactivated)

00015 = Code 2 of a code pair that is not allowed by NCCI even if appropriate modifier is present

00016 = Code 2 of a code pair that would be allowed by NCCI if appropriate modifier were present

00017 = Biosimilar HCPCS reported without biosimilar modifier (deactivated)

00018 = Claim lacks required primary procedure code

00020 = Item or service not allowed with Modifier CS00021 = COVID-19 lab add-on code reported

without required primary procedureMaximum Units PEB3-POE-

MAXUNITS9(15) 80 - 94 Maximum allowable units for this procedure code as

dictated by the Medicare Medically Unlikely Edits (MUEs). If no maximum has been defined for this procedure code, this field will default to zero.

Column 1 Code for Correct Coding Initiative (CCI) Edit

PEB3-POE-COLUMN1

X(7) 95 - 101 If a CCI edit has been returned for this procedure code, this field will contain the Column 2 procedure code for that CCI edit. If more than one CCI edit is returned for this procedure code, only the first Column 2 procedure code will be returned in this field.


CCI Edit Type PEB3-POE-CCI-TYPE

9(2) 102 - 103 01 = Do not code services essential to procedure02 = Code is a CPT® separate procedure03 = Code only the more extensive procedure for the

same site 04 = With and without codes should not be used

together05 = Anesthesia should not be reported separately

when administered by the operating physician06 = Do not code lab services separately; code lab

panel07 = Report code for completed service only08 = Do not code services integral to procedure09 = These codes should not be reported together

per CPT® coding guidelines10 = These codes should not be used together per

code definition11 = These services are not typically performed

together12 = Codes indicate mutually exclusive services13 = Codes indicate sex conflict

Status Code PEB3-POE-SCODE X(1) 104 A = Active codeB = Bundled codeC = Carriers price the codeD = Deleted codeE = Excluded from Physician Fee Schedule by



MUE Adjudication Indicator

PEB3-POE-MAI 9(1) 105 Indicates the type of Medically Unlikely Edit (MUE) that was applied to this claim line.

0 = No MUE Edit1 = Line Level Edit2 = Day Level Edit (policy)3 = Day Level Edit (clinical)

Procedure Validity Indicator

PEB3-POE-VALID 9(2) 106 - 107 00 = Procedure is valid for dates01 = Procedure not found in code table02 = Procedure not valid for service date03 = Procedure is valid for dates with pending

editing informationFiller X(43) 108 - 150

Table 68-1: PEB3-PHY-EDIT-BLOCK3: Variable length procedure output fields from the Physician Editor (defined in hpebblk.cpy; occurs up to 999 times)



PWS1-Y1-WKSHT-BLOCKTable 69-1: PWS1-Y1-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the ASC Pricer (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesQuality Reduction Factor

PWS1-Y1-QUAL-REDUCT

9(1)v9(4) 1 - 5 Two percent quality reduction that applies to all ASCs that have not submitted quality reporting data. This factor only applies to procedure codes that are assigned to a Payment Status Indicator of A2, G2, J8, P2, R2, or Z2.

Labor-Related Portion PWS1-Y1-LABOR 9(1)v9(5) 6 - 11 Percentage of free-standing ASC costs that are considered labor-related, as determined by Medicare. This portion of the ASC payment rate will be adjusted for local wage differences.

Wage Index PWS1-Y1-WI 9(1)v9(5) 12 - 17 Wage index that is used to adjust the labor-related portion of the ASC payment rates for local wage differences. This wage adjustment is based on the pre-reclassification Core-Based Statistical Area (CBSA) wage indices that are published for use under the Medicare inpatient and outpatient payment systems.

Percentage Payment Flag

PWS1-Y1-PPRFLG

9(1) 18 Option to allow services assigned to Payment Status Indicators J7 and K7 to be paid at the percent of line item charges, when the fee schedule rate for those services is set to $0.00.

Percentage Payment Rate

PWS1-Y1-PPR 9(1)v9(4) 19 - 23 Standard percentage used for payment calculations for services assigned to Payment Status Indicator J7 and K7 that have a rate of $0.00 in the fee schedule.

Percent of Charges Factor

PWS1-Y1-PAYPCT

9(1)v9(4) 24 - 28 This payment factor times the line item charges will determine the line item reimbursement for the claim.

Payment Limit Flag PWS1-Y1-PAYLIM 9(1) 29 Option to limit line item reimbursement for separately payable procedures to a specified percent of line item charges.

Multiple Procedure Discount Factor - First Procedure

PWS1-Y1-DISCOUNT1

9(1)v9(4) 30 - 34 Discount to be applied when calculating reimbursement for the first procedure with the highest expected payment. This discount applies only to surgical procedures eligible for multiple procedure discounting.

Multiple Procedure Discount Factor – All other Procedures

PWS1-Y1-DISCOUNT2

9(1)v9(4) 35 - 39 Discount to be applied when calculating reimbursement for all other surgical procedures with multiple procedure discounting status.

Discontinued Procedure Discount

PWS1-Y1-DMODPCT

9(1)v9(4) 40 - 44 The discount associated with procedures billed with Modifier 73 or 52 (i.e., procedures that were discontinued prior to completion).

Surgical Procedure Override

PWS1-Y1-SURG-PROC-OVR

X(1) 45 Option to price ancillary services only if there are novalid surgical procedures on the claim.

Filler X(910) 46 - 955


PWS1-E1-WKSHT-BLOCKTable 70-1: PWS1-E1-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the ESRD Pricer (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesLabor Portion (PPS) PWS1-E1-

LPORTION-PPS9(8)v9(2) 1 - 10 Wage adjusted labor portion of ESRD PPS payment.

Unadjusted PPS Rate * Labor Related Percentage (PPS) * Wage Index (PPS)

Non-Labor Related Percentage (PPS)

PWS1-E1-NLPERCENT-PPS

9(8)v9(5) 11 - 23 Percentage of ESRD PPS payment that is not considered labor related.

Non-Labor Portion (PPS)

PWS1-E1-NLPORTION-PPS

9(8)v9(2) 24 - 33 Non-labor portion of ESRD PPS payment.Unadjusted PPS Rate * Non-Labor Related Percentage (PPS)

PPS Wage Adjusted Base Rate

PWS1-E1-WABR-PPS

9(8)v9(2) 34 - 43 Wage adjusted base rate under the ESRD PPS.Labor Portion (PPS) + Non-Labor Portion (PPS)

Per Dialysis Session Adjusted Rate

PWS1-E1-AR-SESSION

9(8)v9(4) 44 - 55 Adjustment rate per dialysis session.PPS Wage Adjusted Base Rate *Age Factor *Body Surface Area (BSA) Factor *Body Mass Index (BMI) Factor *Dialysis Onset Factor *Comorbidity Factor *Low Volume Adjustment*Rural Adjustment Factor

Predicted Medicare Allowed Payment (MAP)

PWS1-E1-PMAP 9(8)v9(4) 56 - 67 Product of all applicable case-mix adjusters to be used with separately payable items eligible for outlier consideration.Age Factor (Sep)*Body Surface Area (BSA) Factor (Sep)*Body Mass Index (BMI) Factor (Sep) *Dialysis Onset Factor (Sep) *Comorbidity Factor (Sep)*Low Volume Adjustment (Sep)*Rural Adjustment Factor

Case-Mix Predicted MAP

PWS1-E1-CMP-MAP

9(8)v9(4) 68 - 79 Amount of the adjusted outlier services MAP (standard rate based on patient’s age) multiplied by the applicable case-mix adjusters.Adjusted Outlier Services MAP * Predicted Medicare Allowed Payment (MAP)

Predicted Outlier Services MAP

PWS1-E1-POS-MAP

9(8)v9(4) 80 - 91 Predicted outlier services MAP (used for outlier calculation).Case-Mix Predicted MAP + Fixed Loss Amount

Imputed Minus Predicted Outlier Services MAP

PWS1-E1-IMP-PMAP

9(8)v9(4) 92 - 103 Imputed minus predicted outlier services MAP.Average Imputed Separately Payable Services Per Dialysis Treatment - Predicted Outlier Services MAP

Imputed Minus Predicted Outlier Services MAP Sign

PWS1-E1-IMP-PMAP-S

9(1) 104 Indicates if the Imputed Minus Predicted Outlier Services MAP field has a positive or negative value.

0 = Negative number1 = Positive number or zero


Differential of Predicted and Imputed MAP

PWS1-E1-DIFF-MAP

9(8)v9(4) 105 - 116 Total outlier payment under the ESRD PPS before the blend.Imputed Minus Predicted Outlier Services MAP * Fixed Loss Sharing Percentage

Differential of Predicted & Imputed MAP Sign

PWS1-E1-DIFF-MAP-S

9(1) 117 Indicates if the Differential of Predicted and Imputed MAP field has a positive or negative value:


Blended Outlier Payment

PWS1-E1-BLEND-OUT-PAY

9(8)v9(2) 118 - 127 Total outlier payment under the blended ESRD PPS.Differential of Predicted & Imputed MAP * Bundled Blend Factor

Blended Outlier Payment Sign

PWS1-E1-BLEND-OUT-PAY-S

9(1) 128 Indicates if the Blended Outlier Payment field has a positive or negative value.


Per Dialysis Session Final Outlier Payment

PWS1-E1-FOP-PER-SESSION

9(8)v9(2) 129 - 138 Final outlier payment per dialysis session (prior to quality reduction).

Continuous Ambulatory Peritoneal Dialysis (CAPD)/Continuous Peritoneal Dialysis (CCPD) Adjustment Factor

PWS1-E1-HOMEADJ

9(1)v9(6) 139 - 145 Adjustment factor for patients that receive CAPD or CCPD at home.

Dialysis Onset Factor PWS1-E1-ONSET-FACTOR

9(1)v9(5) 146 - 151 Adjustment under the ESRD PPS for patients during their first four months of dialysis.

Separately Payable Dialysis Onset Factor

PWS1-E1-ONSET-FACTOR-SEP

9(1)v9(5) 152 - 157 Onset adjustment factor for separately payable items for outlier consideration.

Labor-Related Percentage (PPS)

PWS1-E1-BUNDLE-LS

9(1)v9(5) 158 - 163 The percentage of the bundled Medicare ESRD Payment System costs that are considered labor-related, as determined by Medicare. This portion of the ESRD payment rate will be adjusted for local wage differences.

Wage Index (PPS) PWS1-E1-BUNDLE-WI

9(1)v9(4) 164 - 168 This wage index is used to adjust the labor-related portion of the ESRD payment rates for local wage differences. This wage adjustment is based on the re-classification of Core-Based Statistical Area (CBSA) based wage indices.

Facility Type PWS1-E1-FACTYPE

9(2) 169 - 170 01 = Hospital-based ESRD facility02 = Independent ESRD facility

Total PPS Training Adjustments

PWS1-E1-TRAINING-ADJ-TOTAL

9(8)v9(2) 171 - 180 Total adjustment factor for patients receiving training services.

Unadjusted PPS Rate PWS1-E1-BASE-RATE

9(8)v9(2) 181 - 190 The bundled Medicare ESRD Payment System base rate applicable for both adult and pediatric ESRD patients.

Table 70-1: PWS1-E1-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the ESRD Pricer (defined in hprcblk.cpy)



Quality Reduction Factor

PWS1-E1-QUALREDFACT

9(1)v9(4) 191 - 195 Quality-related payment adjustment (based on Total Performance Score) for service dates on or after January 01, 2012.

Age as of Thru Date PWS1-E1-AGE-DOB

9(3) 196 - 198 Calculated age of the patient if the Birth Date is provided. Age is calculated as follows:

Age = (Thru Date - Birth Date) / 365

If the Birth Date is not provided, this field will contain the supplied age of the patient.

Transitional Drug Add-On Payment Adjustment (TDAPA) Amount

PWS1-E1-TDAPA-LINE

9(8)v9(2) 199 - 208 Additional payment for certain qualifying ESRD injectable or intravenous drugs and biologicals. This payment is added to the dialysis payment/co-payment calculated for each line prior to the QIP adjustment.

Fixed Loss Sharing Percentage

PWS1-E1-FLOSS-PCT

9(1)v9(4) 209 - 213 The amount of the cost outlier payment Medicare will pay to the dialysis facility for the excessive costs to treat the dialysis patient.

PPS Training Adjustment

PWS1-E1-TRAININGADJ

9(3)v9(2) 214 - 218 This adjustment factor will be wage adjusted and added to the ESRD payment for patients receiving training services by the renal dialysis facility.

CAPD Training (Composite Portion)

PWS1-E1-CAPDADJ

9(8)v9(2) 219 - 228 Self-dialysis and home dialysis training are programs that train ESRD patients and/or their helpers to perform self-dialysis in the ESRD facility or at home. This is the additional payment that is provided for training patients and/or their helpers on Hemodialysis, Peritoneal Dialysis, and Continuous Cycling Peritoneal Dialysis (CCPD).

Onset Adjustment PWS1-E1-ONSETADJ

9(1)v9(4) 229 - 233 The case-mix adjustment under the bundled Medicare ESRD Payment System for patients that have Medicare ESRD coverage during their first four months of dialysis.

Bundled Blend Factor PWS1-E1-BUNDLE-BLEND

9(1)v9(2) 234 - 236 The Medicare ESRD Payment System provides dialysis facilities a 4-year phase-in period under which they would receive a blend of payments under the prior composite payment system and the new Medicare ESRD Payment System. Select facilities have opted not to enter into the phase-in period. This is the percentage of the payment amount that is attributed to the new Medicare ESRD Payment System.

Labor-Related Portion PWS1-E1-LS 9(1)v9(5) 237 - 242 The percentage of ESRD costs that are considered labor-related, as determined by Medicare. This portion of the ESRD payment rate will be adjusted for local wage differences.




Wage Index PWS1-E1-WI 9(1)v9(4) 243 - 247 This wage index is used to adjust the labor-related portion of the ESRD payment rates for local wage differences. This wage adjustment is based on the pre-reclassification of CBSA-based wage indices that are published for use under the Medicare Inpatient and Outpatient Payment Systems.

Drug Add-on Factor PWS1-E1-DRUGFACT

9(1)v9(4) 248 - 252 Payments for separately billable ESRD drugs are provided to ESRD facilities in addition to dialysis composite payments. This additional payment is intended to account for the recent change from the Average Wholesale Price (AWP) payment methodology for drugs, to the Average Sales Price (ASP) payment methodology for drugs.

Budget Neutrality Factor

PWS1-E1-BNF 9(1)v9(6) 253 - 259 Factor applied to case-mix variables to maintain budget neutrality. Medicare has mandated that aggregate payments made to ESRD facilities be the same for each year. Therefore, any case-mix adjustments that are made to the ESRD payment system must be negated by the Budget Neutrality Factor.

Part D Blended Amount PWS1-E1-PART-D-BLEND

9(3)v9(2) 260 - 264 For purposes of the composite rate portion of the blended payment amount, an add-on will be added to the adjusted composite payment to account for ESRD related drugs and biologicals, that were previously separately paid under Part D and are now included in the Medicare ESRD Payment System.

Bundle Budget Neutrality Factor

PWS1-E1-BUNDLE-BNF

9(1)v9(6) 265 - 271 A reduction of payments to ESRD facilities in CY 2013 is finalized by a factor that is equal to 1 minus the ratio of the estimated payments under the bundled Medicare ESRD Payment System; where there is no transition to the total estimated payments or 0.0 percent.

Filler X(729) 272 - 1000




PWS1-HC-PRCR-BLOCK1Table 71-1: PWS1-HC-PRCR-BLOCK1: Payer-specific reimbursement worksheet variables for the Medicare DRG Pricer (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesTransfer Exceptions Flag

PWS1-HC-TRFLAG

9(1) 1 0 = Not reimbursed as a transfer1 = Standard transfer before FY 19962 = Standard transfer after FY 19963 = Standard post-acute transfer after FY 19984 = Special post-acute transfer after FY 1998

Payment Exceptions Flag

PWS1-HC-EXFLAG

9(1) 2 0 = Not a transfer or in a transfer-exempt DRG1 = Transfer reimbursed as a transfer2 = Transfer reimbursed as an inlier/cost outlier

Non-Capital PPS Base Reimbursement (with low volume adj.)

PWS1-HC-BASER 9(8)v9(2) 3 - 12 Reserved

Capital PPS Reimbursement (with low volume adj.)

PWS1-HC-TCAPADDON

9(8)v9(2) 13 - 22 Reserved

Total PPS Reimbursement, Capital and Non-Capital (with low volume adj.)

PWS1-HC-TOTBASE

9(8)v9(2) 23 - 32 Reserved

Inlier DRG Rate Before Add-on for Old Capital

PWS1-HC-INIT-DRGRATE

9(8)v9(2) 33 - 42 Reserved

Patient Apportionment of Old Capital Costs

PWS1-HC-CAPPATOLD

9(8)v9(2) 43 - 52 Reserved

Outlier Days PWS1-HC-OUTL-DAYS

9(4) 53 - 56 Outlier Days

Arithmetic Mean LOS PWS1-HC-NEW-MLOS

9(3)v9(4) 57 - 63 Arithmetic Mean LOS

Federal Wage-Adjusted Rate

PWS1-HC-FWA 9(8)v9(2) 64 - 73 Federal wage-adjusted rate

Marginal Cost Factor PWS1-HC-MCF 9(1)v9(2) 74 - 76 Marginal Cost FactorFederal Portion PWS1-HC-FP 9(1)v9(2) 77 - 79 Federal PortionCombined Operating IME and DSH Factors

PWS1-HC-COMB-OP-FAC

9(1)v9(9) 80 - 89 Combined Operating IME and DSH Factors

Capital-Adjusted Federal Rate

PWS1-HC-CAPADJFRATE

9(8)v9(2) 90 - 99 Capital-Adjusted Federal Rate

Capital Federal Portion PWS1-HC-CAPFEDPORTION

9(1)v9(4) 100 - 104 Capital Federal Portion

Combined Capital IME and DSH Factors

PWS1-HC-COMB-CAP-FAC

9(1)v9(9) 105 - 114 Combined Capital IME and DSH Factors

Operating Cost-to-Charge Ratio

PWS1-HC-RCC 9(1)v9(4) 115 - 119 Operating Cost-to-Charge Ratio

Capital Cost-to-Charge Ratio

PWS1-HC-CAPRCC

9(1)v9(4) 120 - 124 Capital Cost-to-Charge Ratio


True Costs PWS1-HC-TRUECOST

9(8)v9(2) 125 - 134 True Costs

LOS for Threshold Calculations

PWS1-HC-COSTOL-MLOS

9(4)v9(1) 135 - 139 Reserved

Cost Outlier Factor PWS1-HC-COF 9(1)v9(2) 140 - 142 ReservedStandard Cost Outlier Threshold

PWS1-HC-COT 9(8)v9(2) 143 - 152 Cost outlier threshold which includes the operating and capital threshold.

Federal Labor Portion PWS1-HC-FLP 9(1)v9(4) 153 - 157 Federal Labor PortionWage Index PWS1-HC-WI 9(1)v9(4) 158 - 162 Wage IndexGeographic Adjustment Factor

PWS1-HC-CAPGEOFAC

9(1)v9(4) 163 - 167 Geographic Adjustment Factor

Large Urban Adjustment Factor

PWS1-HC-CAPLGURBFAC

9(1)v9(4) 168 - 172 Large Urban Adjustment Factor

Total Cost Outlier Threshold

PWS1-HC-THRESHOLD

9(8)v9(2) 173 - 182 Total Cost Outlier Threshold

Operating Cost Threshold

PWS1-HC-OPTHRESH

9(8)v9(2) 183 - 192 Operating Cost Threshold

Capital Cost Threshold PWS1-HC-CAPTHRESH

9(8)v9(2) 193 - 202 Capital Cost Threshold

LOS for Transfer Calculations

PWS1-HC-TLOS 9(4)v9(1) 203 - 207 LOS for Transfer Calculations

Transfer Per Diem Rate

PWS1-HC-TRPERDIEM

9(8)v9(2) 208 - 217 Transfer Per Diem Rate

Operating Inlier Payment Due to IME (with low volume adj.)

PWS1-HC-OP-IMEA

9(8)v9(2) 218 - 227 The portion of the operating inlier payment due to IME including applicable low volume adjustments and HMO pricing reductions.

Operating Inlier Payment Due to DSH (with low volume adj.)

PWS1-HC-OP-DSH

9(8)v9(2) 228 - 237 The portion of the operating inlier payment due to DSH including applicable low volume adjustments.

Capital Inlier Payment due to IME (with low volume adj.)

PWS1-HC-CAP-IMEA

9(8)v9(2) 238 - 247 The portion of the capital inlier payment due to IME including applicable low volume adjustments.

Capital Inlier Payment Due to DSH (with low volume adj.)

PWS1-HC-CAP-DSH

9(8)v9(2) 248 - 257 The portion of the capital inlier payment due to DSH including applicable low volume adjustments.

Operating Portion of Outlier Add-on (with low volume adj.)

PWS1-HC-COSTADDON-OP

9(8)v9(2) 258 - 267 The operating portion of the outlier add-on payment including applicable low volume adjustments.

New Technology Add-on (with low volume adj.)

PWS1-HC-NEWTECH

9(6)v9(2) 268 - 275 New technology add-on payment including applicable low volume adjustments.

Medicare+Choice Reduction Factor

PWS1-HC-HMOREDUC

9(1)v9(2) 276 - 278 Medicare+Choice reduction factor applied to IME and DME.

Transfer Adjustment Factor

PWS1-HC-XFER-BASE-ADJ

9(1)v9(4) 279 - 283 Transfer adjustment factor applied to base rate and outlier threshold.

Table 71-1: PWS1-HC-PRCR-BLOCK1: Payer-specific reimbursement worksheet variables for the Medicare DRG Pricer (defined in hprcblk.cpy)



Capital Cost of Living Adjustment Factor

PWS1-HC-CAPCOLA

9(1)v9(4) 284 - 288 Capital Cost of Living Adjustment (CAPCOLA) factor applied to reimbursement calculations for hospitals in Hawaii and Alaska.

Capital Portion of Outlier Add-On (with low volume adj.)

PWS1-HC-COSTADDON-CAP

9(8)v9(2) 289 - 298 The capital portion of the outlier add-on payment including applicable low volume adjustments.

SCH/MDH Add-On(with low volume adj.)

PWS1-HC-SCH-ADDON

9(8)v9(2) 299 - 308 The SCH/MDH add-on payment including applicable low volume adjustments.

Operating Inlier Payment (without DSH, IME, or low volume adj.)

PWS1-HC-O-FSP 9(8)v9(2) 309 - 318 The operating portion of the inlier payment before adjustments for DSH, IME, and low volume are applied.

SCH/MDH Add-On (without low volume adj.)

PWS1-HC-O-HSP 9(8)v9(2) 319 - 328 The SCH/MDH add-on payment not including low volume adjustments.

Operating Portion of Outlier Add-On (without low volume adj.)

PWS1-HC-O-OUTLR

9(8)v9(2) 329 - 338 The operating portion of the outlier add-on payment not including low volume adjustments.

Operating Inlier Payment Due to DSH (without low volume adj.)

PWS1-HC-O-DSH 9(8)v9(2) 339 - 348 The portion of the operating inlier payment due to DSH not including low volume adjustments.

Operating Inlier Payment Due to IME (without low volume adj.)

PWS1-HC-O-IME 9(8)v9(2) 349 - 358 The portion of the operating inlier payment due to IME not including low volume adjustments.

Total Operating Payment (without low volume adj.)

PWS1-HC-TOT-OPER-AMT

9(8)v9(2) 359 - 368 The total operating payment (inlier and outlier) calculated as follows:

PWS1-HC-O-FSP + PWS1 - HC-O-OUTLR + PWS1-HC-O-DSH + PWS1-HC-O-IME

Capital Inlier Payment (without DSH, IME, or low volume adj.)

PWS1-HC-C-FSP 9(8)v9(2) 369 - 378 The capital portion of the inlier payment before adjustments for DSH, IME, and low volume are applied.

Capital Portion of Outlier Add-On (without low volume adj.)

PWS1-HC-C-OUTLR

9(8)v9(2) 379 - 388 The capital portion of the outlier add-on payment not including low volume adjustments.

Capital Inlier Payment Due to DSH (without low volume adj.)

PWS1-HC-C-DSH 9(8)v9(2) 389 - 398 The portion of the capital inlier payment due to DSH not including low volume adjustments.

Capital Inlier Payment Due to IME (without low volume adj.)

PWS1-HC-C-IME 9(8)v9(2) 399 - 408 The portion of the capital inlier payment due to IME not including low volume adjustments.

Total Capital Payment (without low volume adj.)

PWS1-HC-TOT-CAPI-AMT

9(8)v9(2) 409 - 418 The total capital payment (inlier and outlier) calculated as follows:

PWS1-HC-C-FSP + PWS1-HC-C-OUTLR + PWS1-HC-C-DSH + PWS1-HC-C-IME + PWS1-HC-C-OLD-HH + PWS1-HC-C-EXCEPT




Medicare Advantage Hospital Specific Rate (without low volume adj.)

PWS1-HC-MA-HSP

9(8)v9(2) 419 - 428 The hospital-specific payment not including low volume adjustments. Applicable for SCH and MDH Medicare Advantage claims only.

New Technology Add-On (without low volume adj.)

PWS1-HC-NEW-TECH-AMT

9(8)v9(2) 429 - 438 New technology add-on payment not including low volume adjustments.

Medicare Advantage Hospital Specific Rate(with low volume adj.)

PWS1-HC-MA-HSP-ADJ

9(8)v9(2) 439 - 448 The hospital-specific payment including applicable low volume adjustments. Applicable for SCH and MDH Medicare Advantage claims only.

Low Volume Payment PWS1-HC-LOWVOL-AMT

9(8)v9(2) 449 - 458 Low volume add-on payment amount.

Hold Harmless Payment

PWS1-HC-C-OLD-HH

9(8)v9(2) 459 - 468 Reserved

Capital Exceptions Payment

PWS1-HC-C-EXCEPT

9(8)v9(2) 469 - 478 Reserved

Readmission Payment Adjustment Factor

PWS1-HC-O-RPAF

9(1)v9(4) 479 - 483 The provider specific readmission payment adjustment factor.

Readmission Payment Amount

PWS1-HC-O-RPAF-AMT

9(8)v9(2) 484 - 493 Readmission payment reduction amount.

SCH Legacy Calculation Flag

PWS1-HC-SCH-LEGACY

9(1) 494 SCH Legacy Calculation Flag

Value Based Purchasing (VBP) Adjustment Factor

PWS1-HC-O-VBP-ADJ

9(1)v9(11) 495 - 506 The provider-specific VBP factor.

Value Based Purchasing (VBP) Payment Amount

PWS1-HC-O-VBP-AMT

9(1)v9(11) 507 - 516 The VBP payment amount.

Value Based Purchasing (VBP) Amount Sign

PWS1-HC-O-VBP-AMT-S

9(1) 517 Indicates if the VBP Payment Amount is positive or negative.

0 = Payment is increased by the VBP Payment Amount (hospital is rewarded)

1 = Payment is decreased by the VBP Payment Amount (hospital is penalized)

Uncompensated DSH Per Claim Amount

PWS1-HC-UNCOMP-DSH

9(8)v9(2) 518 - 527 An additional per claim add-on payment added to DSH claims.

DSH Reduction Factor PWS1-HC-DSHREDUC

9(1)v9(4) 528 - 532 Operating DSH reduction factor.

Operating Medical Education (IME) Factor

PWS1-HC-OP-IME-FAC

9(1)v9(9) 533 - 542 The provider-specific Operating Indirect Medical Education (IME) Factor.

Capital Indirect Medical Education (IME) Factor

PWS1-HC-CAP-IME-FAC

9(1)v9(9) 543 - 552 The provider-specific Capital IME Factor.

Operating Disproportionate Share Hospital (DSH) Factor

PWS1-HC-OP-DSH-FAC

9(1)v9(4) 553 - 557 The provider-specific Operating Hospital Disproportionate Share (DSH) Factor adjusted by the DSH Reduction Factor.




Capital Disproportionate Share Hospital (DSH) Factor

PWS1-HC-CAP-DSH-FAC

9(1)v9(4) 558 - 562 The provider-specific Capital DSH Factor.

Low Volume Adjustment Factor

PWS1-HC-LOW-VOL-FAC

9(1)v9(6) 563 - 569 The provider-specific Low Volume Factor.

True Operating Costs PWS1-HC-TRUEOPCOST

9(8)v9(2) 570 - 579 The portion of true costs attributable to operating expenses.

True Capital Costs PWS1-HC-TRUECAPCOST

9(8)v9(2) 580 - 589 The portion of true costs attributable to capital expenses.

Uncompensated Disproportionate Share Hospital (DSH) Per Claim Amount With Low Volume Adjustment

PWS1-HC-UNCOMP-DSHLOW

9(8)v9(2) 590 - 599 The provider-specific Uncompensated DSH Amount including applicable low volume adjustments.

HAC Reduction Factor PWS1-HC-HAC-FAC

9(1)v9(4) 600 - 604 The provider specific HAC reduction factor.

HAC Reduction Amount PWS1-HC-HAC-AMT

9(8)v9(2) 605 - 614 The HAC reduction payment amount.

Blood Clotting Factor Add-On Payment

PWS1-HC-HEMOADD

9(8)v9(2) 615 - 624 The blood clotting factor add-on payment.

Total Covered Charges PWS1-HC-TOT-CHG

9(8)v9(2) 625 - 634 The total covered charges used for cost outlier calculations. This is calculated as follows:

Total Charges - Organ Acquisition Charges - Blood Clotting Factor Charges

Pass Through Amount PWS1-HC-PASSTHRU

9(8)v9(2) 635 - 644 Medicare per diem pass through payment amount, including the Direct Medical Education (DME) Pass Through Amount and excluding the Allogeneic Stem Cell Per Diem Pass Through Amount.

Direct Medical Education (DME) Pass Through Amount

PWS1-HC-DME-PASSTHRU

9(8)v9(2) 645 - 654 Direct Medical Education (DME) pass through payment amount.

Allogeneic Stem Cell Per Diem Pass Through Amount

PWS1-HC-STEM-PASSTHRU

9(8)v9(2) 655 - 664 Allogeneic stem cell acquisition pass through amount.

Sole Community Hospital (SCH)/Medicare Dependant Hospital (MDH) Operating Costs Per Discharge

PWS1-HC-SCH-COST-DISC

9(8)v9(5) 665 - 677 For eligible SCHs, this field should is set to the hospital-specific rate based on the costs per discharge, adjusted to current dollars.

For eligible MDHs, this field is set to the hospital-specific rate based on the costs per discharge, adjusted to current dollars.

National Labor-Related Adjusted Standardized Amount (ASA)

PWS1-HC-NL 9(4)v9(2) 678 - 683 The national labor-related operating ASA.

National Non-Labor-Related ASA

PWS1-HC-NNL 9(4)v9(2) 684 - 689 The national non-labor-related operating ASA.




Cost of Living Adjustment (COLA)

(Alaska and Hawaii)

PWS1-HC-COLA 9(1)v9(4) 690 - 694 For hospitals in Alaska or Hawaii, this field is set to the applicable operating COLA factor.

Indirect Medical Education (IME) Adjustment Factor

PWS1-HC-IEA 9(1)v9(9) 695 - 704 This adjustment is intended to compensate hospitals for the indirect costs of providing medical education. This adjustment is applied to operating costs only.

Disproportionate Share Adjustment Factor

PWS1-HC-DSHARE

9(1)v9(4) 705 - 709 This adjustment factor is designed to take into account the special needs of hospitals that serve a disproportionate number of low-income patients or Medicare Part A beneficiaries. This disproportionate share factor is applied to operating costs only.

Capital Disproportionate Share Adjustment Factor

PWS1-HC-CAPDSHARE

9(1)v9(4) 710 - 714 This adjustment factor is designed to take into account the special needs of hospitals that treat a disproportionate share of low-income patients or Medicare Part A beneficiaries. This adjustment is applied to capital costs only.

Capital IME Adjustment Factor

PWS1-HC-CAPIMEA

9(1)v9(9) 715 - 724 This adjustment is intended to compensate hospitals for the indirect costs of providing medical education. This adjustment is applied to capital costs only.

Medicare Risk Flag PWS1-HC-RISK 9(1) 725 Indicates that the claim is from a Medicare Advantage (MA) plan. If the claim is from an MA plan, the costs of direct and indirect medical education and the costs of organ acquisition will be eliminated from reimbursement calculations.

Provider Type PWS1-HC-PTYPE X(2) 726 - 727 Medicare provider type (from the Inpatient Acute Care Provider-Specific File (PSF)).

Percentage of Operating Costs

PWS1-HC-OPCOTPER

9(8)v9(8) 728 - 743 Used to calculate the operating cost outlier threshold.

Percentage of Capital Costs

PWS1-HC-CAPCOTPER

9(8)v9(8) 744 - 759 Used to calculate the capital cost outlier threshold.

Capital Standard Federal Rate

PWS1-HC-CAPSTFRATE

9(8)v9(2) 760 - 769 The national capital standard federal payment rate.

Hospital-Specific Rate (HSP) for SCHs/MDHs

PWS1-HC-HSP-RATE

9(8)v9(2) 770 - 779 Hospital-specific rate for SCHs/MDHs used in the operating HSP calculation.

Federal-Specific Rate for SCHs/MDHs

PWS1-HC-FSP-RATE

9(8)v9(2) 780 - 789 Federal-specific rate for SCHs/MDHs used in the operating HSP calculation.

SCH/MDH Factor PWS1-HC-O-HSP-ADJ

9(1)v9(4) 790 - 794 Factor used in the operating HSP calculation for SCHs/MDHs.

New COVID-19 Treatments Add-On Payment (NCTAP)

PWS1-HC-NCTAP 9(8)v9(2) 795 - 804 Add-on payment applied to claims that include certain COVID-19 treatments.

Filler X(196) 805 - 1000




PWS1-LT-WKSHT-BLOCKTable 72-1: PWS1-LT-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the LTC Pricer (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesSite Neutral Base Payment

PWS1-LT-BASE-RATE-NEUTRAL

9(8)v9(2) 1 - 10 Base payment under the site neutral payment methodology.

NoteThe payment returned in this field is the amount prior to the application of any user-defined Mark-Up/Discount.

Standard Federal Base Payment

PWS1-LT-BASE-RATE-STANDARD

9(8)v9(2) 11 - 20 Base payment under the standard federal payment methodology.


Site Neutral High Cost Outlier Add-On

PWS1-LT-ADDON-NEUTRAL

9(8)v9(2) 21 - 30 Cost outlier add-on payment under the site neutral payment methodology.


Standard Federal High Cost Outlier Add-On

PWS1-LT-ADDON-STANDARD

9(8)v9(2) 31 - 40 Cost outlier add-on payment under the standard federal payment methodology.


Adjusted Length of Stay PWS1-LT-ADJLOS

9(3) 41 - 43 Patient length of stay after making adjustments for any leave of absence days.

This value is used when calculating payment for certain short-stay claims, if exempt from site-neutral pricing, and certain transfer claims, if paid under the site-neutral PPS-comparable methodology.

Cost PWS1-LT-COST 9(8)v9(2) 44 - 53 Total cost of the claim.Total Charges * Ratio of Cost to Charges

Site Neutral Indicator PWS1-LT-SITE-NEUTRAL

9(1) 54 Indicates if the claim is subject to site neutral reimbursement.0 = Excluded from site neutral payment1 = Site neutral payment applies


Adjusted Federal Rate PWS1-LT-ADJFRATE

9(8)v9(4) 55 - 66 Used to calculate standard federal payment for all claims in the site neutral blend period and for claims exempt from site-neutral payment. (Unadjusted Federal Prospective Payment Rate * Labor Related Share * Wage Index) + (Unadjusted Federal Prospective Payment Rate * COLA * Non-Labor Related Share)

Bipartisan Budget Act Reduction

PWS1-LT-BBA-REDUCTION

9(1)v9(4) 67 - 71 Used to calculate the Bipartisan Budget Act reduction for site neutral claims with discharge dates in Fiscal Years 2018-2026.

Blend Percentage PWS1-LT-BLEND 9(1)v9(4) 72 - 76 Used in calculations for short stay outlier claims.

If DRG’s short-stay outlier threshold is less than 25: Lesser of “1” or (claim’s adjusted length of stay / short stay outlier threshold)

If DRG’s short-stay outlier threshold is 25 or greater: Lesser of “1” or (adjusted length of stay / 25)

DRG Payment PWS1-LT-DRGPAY

9(8)v9(2) 77 - 86 Used in calculations for standard federal payment including short stay outlier claims.Adjusted Federal Rate * DRG weight

IPPS-Related Base Rate

PWS1-LT-IPPS-BASE

9(8)v9(2) 87 - 96 This field contains the IPPS Comparable Base Amount used in calculations for standard federal payment including short stay outlier claims and used to calculate the DPP Adjustment Amount. IPPS-equivalent Base Rate * IPPS-equivalent DRG weight

IPPS Blend PWS1-LT-IPPS-BLEND

9(8)v9(2) 97 - 106 Used in calculations for Short Stay Outlier. IPPS Rate * (1- Blend Percentage)

IPPS Per Diem PWS1-LT-IPPS-P-DIEM

9(8)v9(2) 107 - 116 Used in calculations for Short Stay Outlier. (IPPS-Related Base Rate/ IPPS-Equivalent DRG Mean Length of Stay) * Adjusted Length of Stay

IPPS Rate PWS1-LT-IPPS-RATE

9(8)v9(2) 117 - 126 Used in calculations for Short Stay Outlier. Lesser of IPPS-Related Base Rate or IPPS Per Diem

LTC Blend PWS1-LT-LTC-BLEND

9(8)v9(2) 127 - 136 Used in calculations for Short Stay Outlier. Short Stay Per Diem * Blend Percentage

Short Stay Base PWS1-LT-SHORT-BASE

9(8)v9(2) 137 - 146 Used in calculations for Short Stay Outlier.

If the claim’s Thru Date is equal to or greater than October 01, 2017:Short Stay Blend

If the claim's Thru Date is before October 01, 2017 and if the Short Stay Cost is greater than $0:Minimum of Short Stay Per Diem, Short Stay Cost and Short Stay Blend

Table 72-1: PWS1-LT-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the LTC Pricer (defined in hprcblk.cpy)



Short Stay Blend PWS1-LT-SHORT-BLEND

9(8)v9(2) 147 - 156 Used in calculations for Short Stay Outlier.

If the claim's Adjusted Length of Stay is less than or equal to the IPPS Comparable Additional Mean LOS: IPPS Rate

If the claim's Adjusted Length of Stay is greater than the IPPS Comparable Additional Mean LOS: IPPS Blend + LTC Blend

Short Stay Per Diem PWS1-LT-SHORT-PDIEM

9(8)v9(2) 157 - 166 Used in calculations for Short Stay Outlier. Percentage of Short Stay Outlier Paid for Per Diem * ((DRG Payment / Average Length of Stay) * Adjusted Length of Stay)

Site Neutral HCO Threshold

PWS1-LT-THRESH-NEUTRAL

9(8)v9(4) 167 - 178 Used in calculations for High Cost Outlier on Site Neutral claims. Base Rate (Site Neutral) + Fixed Loss Amount (Site Neutral)

Budget Neutrality Offset

PWS1-LT-BN 9(1)v9(5) 179 - 184 Budget Neutrality Offset.

Cost of Living Adjustment for Alaska and Hawaii

PWS1-LT-COLA 9(1)v9(4) 185 - 189 LTC cost-of-living adjustment.

Percentage of Cost Outlier Paid (Site Neutral)

PWS1-LT-COSTPCT-NEUTRAL

9(1)v9(4) 190 - 194 Percentage of the Cost Outlier Paid (Site Neutral). On Site Neutral claims, this field is used in the calculation of the High Cost Outlier Add-on (Site Neutral Portion) field.

Unadjusted Federal Prospective Payment Rate

PWS1-LT-FRATE 9(5)v9(2) 195 - 201 Unadjusted federal prospective payment.

Labor Related Share PWS1-LT-LRS 9(1)v9(5) 202 - 207 LTC labor-related share.

Markup/Discount PWS1-LT-MARKUP

9(1)v9(4) 208 - 212 Markup/discount.

Site Neutral Percentage of Claim

PWS1-LT-SNPCT

9(1)v9(2) 213 - 215 Percentage of claim that is paid via site neutral payment method.

Wage Index PWS1-LT-WI 9(1)v9(4) 216 - 220 LTC wage index.

Non Labor Related Share

PWS1-LT-NON-LRS

9(1)v9(5) 221 - 226 LTC non-labor-related share.1 – Labor Related Share

Short Stay Cost PWS1-LT-SHORT-COST

9(8)v9(2) 227 - 236 Used in calculations for Short Stay Outlier. Percentage of Short Stay Outlier Paid for Cost * Cost




Discharge Payment Percentage (DPP) Adjustment Amount

PWS1-LT-DPP-ADJ

9(8)v9(2) 237 - 246 LTCHs with a DPP of 50% or less are subject to a DPP payment adjustment. The DPP payment adjustment amount is equal to the IPPS comparable payment amount, including outlier payments, minus the payment that would have been made, including outlier payments, if the DPP was greater than 50%. The DPP payment adjustment amount is then added to the amount that would have been paid if the DPP was greater than 50%. If the DPP payment adjustment amount is negative, this means that the hospital will receive a lower payment. The following calculation is used for this adjustment:

DPP Adjustment Amount = (IPPS Comparable Base Amount + IPPS Comparable High Cost Outlier Amount) - (LTC PPS Base Amount + LTC PPS High Cost Outlier Amount)

Discharge Payment Percentage (DPP) Adjustment Sign

PWS1-LT-DPP-IND

9(1) 247 Identifies whether the value in the DPP Adjustment Amount field is positive or negative.

0 = Positive DPP adjustment amount1 = Negative DPP adjustment amount

IPPS Add-On PWS1-LT- IPPS-ADDON

9(8)v9(2) 248 - 257 This field contains the IPPS Comparable High Cost Outlier Amount used to calculate the DPP Adjustment Amount.

Filler X(743) 258 - 1000




PWS1-N2-WKSHT-BLOCKTable 73-1: PWS1-N2-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the New York Medicaid APR Pricer (defined in hprcblk.cpy)

Field Description Variable Name Format Position NotesFiller X(149) 1 - 149Cost-to-Charge Converter Factor

PWS1-N2-RCC 9(1)v9(6) 150 - 156 Reserved

Filler X(55) 157 - 211Spinal Implant Payment PWS1-N2-

SPINAL-PAY9(8)v9(2) 212 - 221 Reserved

Spinal Implant Charges PWS1-N2-SPINAL-CHARGE

9(8)v9(2) 222 - 231 Reserved

Alternate Level of Care Days Used

PWS1-N2-ALCDAYS-USED

9(3) 232 - 234 Reserved

Alternate Level of Care Days Charges

PWS1-N2-ALCCHARGES

9(8)v9(2) 235 - 244 Reserved

Alternate Level of Care Days Payment

PWS1-N2-ALCPAY

9(8)v9(2) 245 - 254 Reserved

Per-Discharge Add-On Payment

PWS1-N2-DISCHARGE

9(8)v9(2) 255 - 264 Reserved

Base Rate for Transfer Calculation

PWS1-N2-XFER-BASE

9(8)v9(2) 265 - 274 Reserved

Transfer Payment PWS1-N2-XFER 9(8)v9(2) 275 - 284 ReservedTransfer Payment Factor

PWS1-N2-XFER-FACTOR

9(1)v9(4) 285 - 289 Reserved

Transfer Per-Diem PWS1-N2-XFER-PERDIEM

9(8)v9(2) 290 - 299 Reserved

Outlier Payment PWS1-N2-OUTLIER

9(8)v9(2) 300 - 309 Reserved

Outlier Cost PWS1-N2-COST 9(8)v9(2) 310 - 319 ReservedAdjusted Length of Stay PWS1-N2-ALOS 9(3) 320 - 322 ReservedOutlier Threshold PWS1-N2-

THRESHOLD9(8)v9(2) 323 - 332 Reserved

Inlier Base Rate PWS1-N2-INLIER 9(8)v9(2) 333 - 342 Reserved

Elective Delivery Adjustment

PWS1-N2-ELECT-DEL

9(1)v9(4) 343 - 347 Reserved

Filler X(653) 348 - 1000


PWS1-Y2-WKSHT-BLOCKTable 74-1: PWS1-Y2-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the APC-HOPD Pricer

Field Description Variable Name Format Position NotesWage Index PWS1-Y2-WI 9(1)v9(5) 1 - 6 Wage indexLabor-Related Portion PWS1-Y2-

LABOR9(1)v9(5) 7 - 12 Labor-related portion


PWS1-Y2-RURAL-FACT

9(1)v9(4) 13 - 17 Rural adjustment factor

RCC PWS1-Y2-RCC 9(1)v9(5) 18 - 23 Ratio of Cost-to-Charges (RCC)Outlier Fixed Cost Threshold

PWS1-Y2-OUTLIER-THRESH

9(8)v9(2) 24 - 33 Outlier fixed cost threshold

DMEPOS Location/Carrier Code

PWS1-Y2-DMECARRIER

X(12) 34 - 45 DMEPOS location/carrier code.

NoteFor claims that span a calendar year, the carrier will reflect the From or Admission Date on the claim.

Lab Location/Carrier Code

PWS1-Y2-LABCARRIER

X(12) 46 - 57 Lab location/carrier code.


Physician Fee Schedule Location/Carrier Code

PWS1-Y2-REHCARRIER

X(12) 58 - 69 Physician fee schedule location/carrier code.


Facility Type PWS1-Y2-FACTYPE

9(2) 70 - 71 Type of facility:01 = Rural hospital with 100 beds or fewer or rural SCH02 = Cancer center03 = Children’s hospital04 = Rural hospital under 50 beds05 = OPPS exempt06 = Other SCH07 = Other rural hospital (not SCH)Otherwise, 00

Transitional Corridor Factor

PWS1-Y2-TRANSCSR

9(1)V9(2) 72 - 74 Factor used in the calculation of the hold harmless payment estimate.

Effective January 01, 2013, hold harmless adjustments apply to cancer centers and children’s hospitals only.

Transitional Corridor Multiplier

PWS1-Y2-TRANSMULT

9(1)v9(4) 75 - 79 Factor used in the calculation of the hold harmless payment estimate for per claim reimbursement.

Effective January 01, 2013, hold harmless adjustments apply to cancer centers and children’s hospitals only.


Fee Schedule Table PWS1-Y2-FSTABLE

X(13) 80 - 92 The fee schedule table used for pricing.

NoteFor claims that a span calendar year, the fee schedule table used for pricing will reflect the From or Admission Date on the claim.

Ambulance Location/Carrier Code

PWS1-Y2-AMBCARRIER

X(12) 93 - 104 Ambulance location/carrier. Code used for pricing. This code is determined based on the patient zip code at point of pickup (i.e., the Value Amount reported with Value Code A0).


National Location/Carrier Code

PWS1-Y2-NATLCARRIER

X(12) 105 - 116 National location/carrier code used for pricing services covered by a national fee schedule (for example: Parenteral/Enteral Nutrition (PEN) services and drugs/biologicals).


Other Location/Carrier Code

PWS1-Y2-OTHCARRIER

X(12) 117 - 128 Other location/carrier code used for pricing services from a user-created non-Medicare fee schedule.


Mark-up/Discount Factor

PWS1-Y2-DISCOUNT

9(1)v9(4) 129 - 133 The mark-up/discount factor applied to the total payment for each claim line.

OPPS Exempt Factor PWS1-Y2-EXEMPT-FACT

9(1)v9(4) 134 - 138 Factor used in the calculation of reimbursement for OPPS Exempt facilities.

Laboratory Ratio of Costs-to-Charges

PWS1-Y2-LABRCC

9(1)v9(5) 139 - 144 Factor used to calculate laboratory pricing for qualified rural hospitals with fewer than 50 beds (indicated by Facility Type = 04) (excluding CAHs).

1996 Ratio of Payment to Reasonable Costs

PWS1-Y2-RPC 9(1)v9(4) 145 - 149 The Medicare outpatient Ratio of Payment-to-Costs (RPC) from the Hospital 2552 Cost Report. Used to calculate hold harmless adjustments.

Filler X (851) 150 - 1000

Table 74-1: PWS1-Y2-WKSHT-BLOCK: Payer-specific reimbursement worksheet variables for the APC-HOPD Pricer



FRB-FUNC-RTN-BLOCKTable 75-1: FRB-FUNC-RTN-BLOCK: Fixed length interface function return fields (defined in hfuncblk.cpy)

Field Description Variable Name Format Position NotesFunction Return Code FRB-RTN-CODE X(2) 1 - 2 Return Codes from EDTCNTL program:

12 = Non-zero return code from DSC editor14 = Non-zero return code from ACE22 = Non-zero return code from Physician Editor26 = Non-zero return code from CAH Method II

Editor

Return Codes from MDLCNTL program:19 = Non-zero return code from Grouper or Pricer94 = Invalid dates

Return Codes from RTVPYR program:01 = No hospital rate calculator record10 = No historical rate record found19 = Grouping or pricing operation failed in the

model control program 20 = Invalid or missing taxonomy62 = Closed or inactive rate record70 = Configuration record error 94 = Invalid datesCL = Cannot load or open programIO = File I/O Error (refer to FRB-RTN-CODE2

below)Interface Function Return Code 2

FRB-RTN-CODE2 X(2) 3 - 4 00 = No file I/O errors01 = Error opening hospital rate file07 = Error opening configuration file

Interface Function Return Code Status

FRB-RTN-STATUS X(2) 5 - 6 File operation return status code. OS/language dependent.

Interface Function Reserved

FRB-RSVD X(4) 7 -10 Reserved

Filler X(200) 11 - 210


ECB2-EZG-CNTL-BLOCK2Table 76-1: ECB2-EZG-CNTL-BLOCK2: Fixed length input or output fields for all EASYGroup™ processing (defined in hctrlblk.cpy)

Field Description Variable Name Format Position NotesNational Provider Identifier (NPI) Used for Processing

ECB2-NPI-USED X(10) 1 - 10These three output fields provide information

about which facility identifier was used to process the claim. When multiple facility

identifiers (NPI, Facility ID, etc.) are submitted to EASYGroup™, only the identifier used in processing will be returned in these fields.

The Payer ID returned in this field was the Payer ID that was used to process this claim.

Taxonomy Code Used for Processing

ECB2-TAXONOMY-USED

X(10) 11 - 20 Refer to above

Facility ID Used for Processing

ECB2-FACILITY-USED


Payer ID Used for Processing

ECB2-PAYSRC-USED


Filler X(951) 50 - 1000


CAB1-EAM-BLOCK1Table 77-1: CAB1-EAM-BLOCK1: Fixed length E&M Analyzer Pro claim level output fields (defined in hcablk.cpy)

Field Description Variable Name Format Position NotesAnalyzer Return Code CAB1-ANLZ-RTN-

CODEX(2) 1 - 2 CL = Cannot load or open program

IO = File I/O error (refer to CAB1-ANLZ-RTN-CODE2 and CAB1-ANLZ-RTN-STATUS below)

IP = Socket communication errorAnalyzer Return Code Extension

CAB1-ANLZ-RTN-CODE2

X(2) 3 - 4 05 = Exclusion file I/O error06 = Diagnosis risk file I/O error07 = Visit level complexity claim file I/O error08 = Visit level complexity diagnosis file I/O error

Analyzer Return Status

CAB1-ANLZ-RTN-STATUS

X(2) 5 - 6 File operation or socket communication return status code. OS/language dependent.

Analyzer Reserved CAB1-ANLZ-RSVD X(4) 7 - 10 ReservedAnalyzer Type CAB1-ANLZ-TYPE X(2) 11 - 12 00 = No Analyzer

02 = E&M Analyzer ProAnalyzer Type Reserved

CAB1-ANLZ-TYPE-RSVD


Analyzer Version CAB1-ANLZ-VERS 9(2) 15 - 16 Two digit version number of the Analyzer.Analyzer Version Reserved

CAB1-ANLZ-VERS-RSVD

9(4) 17 - 20 Reserved

Filler X(20) 21 - 40 ReservedAnalyzer Error CAB1-EAM-ERROR X(2) 41 - 42 01 = Claim length of stay is invalid or greater than

2 days02 = No visit on this claim03 = More than one visit on this claim04 = Invalid, ambiguous, or no gender on this

claim05 = Claim excluded based on patient age06 = Claim excluded based on diagnosis code07 = There are no diagnosis codes on this claim

that are considered by the Analyzer 09 = Claim excluded based on procedure code11 = Claim excluded because minimum facility

claim data not provided12 = Claim excluded because high risk procedure

code was identified on the facility claim13 = Claim excluded because observation

services were identified on the facility claim14 = Claim excluded due to death or admission

identified on facility claimSubmitted Visit Level CAB1-EAM-START-

VISIT-LVL9(1) 43 Visit level submitted on the claim to be processed

by the E&M Analyzer Pro.Calculated Visit Level CAB1-EAM-END-

VISIT-LVL9(1) 44 The final visit level after any adjustments have

been made.


Submitted Procedure Code

CAB1-EAM-START-HCPCS

X(7) 45 - 51 Procedure code submitted on the claim to be processed by the E&M Analyzer Pro.

Calculated Procedure Code

CAB1-EAM-END-HCPCS

X(7) 52 - 58 The final procedure code after any adjustments have been made.

Step 1 Scenario Number

CAB1-EAM-STEP1-NUM

9(4) 59 - 62 Optum-defined scenario number.

Step 1 Scenario Text CAB1-EAM-STEP1-TXT

X(200) 63 - 262 Text which describes this scenario.

Number of Diagnosis Codes With Visit Complexity

CAB1-EAM-STEP4-CNT

9(3) 263 - 265

Number of diagnosis codes that contributed to the complexity of the visit.

Weight of Diagnosis Codes With Highest Risk

CAB1-EAM-STEP2-WEIGHT

9(5) 266 - 270

Weight of the diagnosis code found on the claim that represents the condition with the highest risk.

Weight of Diagnosis Codes With Second Highest Risk


9(5) 271 - 275

Weight of the diagnosis code found on the claim that represents the condition with the second highest risk.

Overall Visit Complexity Weight


9(5) 276 - 280

Weight for the total number of conditions on the claim that were determined to contribute complexity toward evaluation and management.

Total Weight CAB1-EAM-FINAL-WEIGHT

9(5) 281 - 285

Total weight used to assign the final visit level. The total weight equals the sum of the Weight of Diagnosis Code With Highest Risk, Weight of Diagnosis Code With Second Highest Risk, and the Overall Visit Complexity Weight.

Filler X(715) 286 - 1000

Table 77-1: CAB1-EAM-BLOCK1: Fixed length E&M Analyzer Pro claim level output fields (defined in hcablk.cpy)



CAB2-EAM-BLOCK2Table 78-1: CAB2-EAM-BLOCK2: Variable length E&M Analyzer Pro diagnosis level output fields (defined in hcablk.cpy, occurs 999 times)

Field Description Variable Name Format Position NotesDiagnosis Code Step 1 and 2 Indicator

CAB2-EAM-STEP-IND

9(1) 1 0 = Diagnosis code not used in Steps 1 and 21 = Diagnosis code used in Step 12 = Diagnosis code used in Step 2 (highest risk)3 = Diagnosis code used in Step 2 (second

highest risk)Diagnosis Code Step 3 Indicator

CAB2-EAM-STEP4-IND

9(1) 2 0 = Diagnosis code not used in Step 31 = Diagnosis code used in Step 3

Filler X(53) 3 - 55


CAB3-EAM-BLOCK3Table 79-1: CAB3-EAM-BLOCK3: Variable length E&M Analyzer Pro procedure line-level output fields (defined in hcablk.cpy, occurs 999 times)

Field Description Variable Name Format Position NotesFinal Procedure Code CAB3-EAM-HCPCS X(7) 1 - 7 Final procedure code after any adjustments have

been made to the visit code.Method Indicator CAB3-EAM-

METHOD9(2) 8 - 9 00 = Visit level unchanged

01 = Visit level decreased (passed facility claim criteria)

02 = Visit level increased (passed facility claim criteria)

03 = Visit level decreased (failed facility claim criteria)

04 = Visit level increased (failed facility claim criteria)

Filler X(141) 10 - 150


PWS2-Y1-WKSHT-DATATable 80-1: PWS2-Y1-WKSHT-DATA: Payer-specific reimbursement worksheet variables for the ASC Pricer (defined in hprcblk.cpy) (occurs PCB1-HCT-NUMHCPCS times)

Field Description Variable Name Format Position NotesFee Schedule Rate PWS2-Y1-

FEERATE9(8)v9(3) 1 - 11 Unadjusted fee schedule rate.

Code Pair Reduction Factor

PWS2-Y1-CPREDUCT

9(1)v9(5) 12 - 17 If this field is populated with a value < 1.00000, this value will be used for the wage adjusted rate calculation.

Device Offset Amount PWS2-Y1-OFFSET

9(8)v9(2) 18 - 27 If this field is populated with a non-zero value, this offset value will be used in the wage adjusted rate calculation.

Temporary Wage Adjusted Rate

PWS2-Y1-TEMP-WAGE-ADJ-RATE

9(8)v9(2) 28 - 37 This field will output the wage adjusted rate before the evaluation of wage adjusted rate vs. charges.

Wage Adjusted Rate (Prior to Discounting)

PWS2-Y1-WAGE-ADJ-RATE

9(8)v9(2) 38 - 47 Wage adjusted base rate (prior to discounting).

Percent of Charges PWS2-Y1-PCT-CHARGES

9(8)v9(2) 48 - 57 Percent of total covered charges used for cost outlier calculations.

Adjusted Rate PWS2-Y1-ADJ-RATE

9(8)v9(2) 58 - 67 This field will be output as the lesser of the adjusted rate or charges. If the charges are less, the charges will be output.

Temporary Adjusted Rate

PWS2-Y1-TEMP-ADJ-RATE

9(8)v9(2) 68 - 77 This field will be output as the lesser of the adjusted rate or charges. If the charges are less, the charges will be output.

Adjusted Rate Based on Charges

PWS2-Y1-CHRGS-RATE

9(8)v9(2) 78 - 87 Applicable to Payment Status Indicators that do not qualify for multiple procedure discounting.

Highest Paid Line PWS2-Y1-HIGH-PAY-FLAG

X(1) 88 Blank = Default (not highest paid line)Y = Highest paid line

Discounted Rate PWS2-Y1-DISC-FS-RATE

9(8)v9(2) 89 - 98 Discounted rate after multiple procedure discounting has been applied.

Discounted Rate Flag PWS2-Y1-DISC-FLAG

9(1) 99 0 = Default1 = Rate has been discounted

Final Adjusted Rate PWS2-Y1-FINAL-ADJ-RATE

9(8)v9(2) 100 - 109 Final rate after any adjustments.

ASC Coverage Factor PWS2-Y1-ASRCOV

9(1)v9(4) 110 - 119 Coverage factor for the claim line.

ASC Coinsurance Factor

PWS2-Y1-ASRCOINS

9(1)v9(4) 120 - 124 Co-payment for the claim line.

Final Line Total PWS2-Y1-LINE-TOTAL

9(8)v9(2) 125 - 134 Final total line reimbursement.

Filler X(62) 135 - 195


List of TablesInput and Output Data Structures 6

ECB-EZG-CNTL-BLOCK: Fixed length input or output fields for all EASYGroup™ processing (defined in hctrlblk.cpy) 10

PCB1-PATIENT-CLAIM-BLOCK1: Fixed length input fields for all EASYGroup™ processing (defined in hpclmblk.cpy) 23

PCB2-CCD-CAH-CLAIM-DATA: Fixed length CAH Method II input fields (de-fined in hpclmblk.cpy) 40

PCB2-ICD-IP-CLAIM-DATA: Fixed length inpatient input fields (defined in hp-clmblk.cpy) 41

PCB2-OCD-OP-CLAIM-DATA: Fixed length outpatient input fields (defined in hpclmblk.cpy) 43

PCB2-PCD-PHYS-CLAIM-DATA: Fixed length Physician input fields (defined in hpclmblk.cpy) 45

PCB2-RCD-REHAB-CLAIM-DATA: Fixed length IRF input fields (defined in hp-clmblk.cpy) 47

PCB2-SCD-SNF-CLAIM-DATA: Fixed length SNF input fields (defined in hp-clmblk.cpy) 55

DCB-DX-CODE-BLOCK: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (defined in hdx2blk.cpy; occurs up to 999 times) 56

OCB-OP-CODE-BLOCK: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (defined in hop2blk.cpy; occurs up to 999 times) 59

HCT-HCPCS-CODE-TBL: Variable Length HCPCS Procedure Input Fields (defined in hhcpcblk.cpy; occurs up to 999 times) 61

MOB1-MAP-OUTPUT-BLOCK1: Fixed length Mapper output fields (defined in hmapblk.cpy) 65

GOB1-IG1-IP-GRPR-BLOCK1: Fixed length inpatient Grouper output fields (defined in hgrpblk.cpy) 66

GOB1-OG1-OP-GRPR-BLOCK1: Fixed length APG Grouper output fields (de-fined in hgrpblk.cpy) 70


GOB1-OG2-OP-GRPR-BLOCK2: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields (de-fined in hgrpblk.cpy) 71

GOB1-RG1-REHAB-GRPR-BLOCK1: Fixed length IRF Grouper output fields (defined in hgrpblk.cpy) 74

GOB1-SG1-SNF-GRPR-BLOCK1: Fixed length RUG Reader and SNF Reader output fields (defined in hgrpblk.cpy) 80

GOB2-IG1-IP-GRPR-BLOCK1: Variable length line-level inpatient Grouper output fields (defined in hgrpblk.cpy; reserved for future use) 81

GOB2-OG1-OP-GRPR-BLOCK1: Variable length APG Grouper output fields (defined in hgrpblk.cpy; occurs up to 999 times) 82

GOB2-OG2-OP-GRPR-BLOCK2: Variable length APC Grouper, ASC Grou-per, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times) 83

GOB2-RG1-REHAB-GRPR-BLOCK1: Variable length IRF Grouper output fields (defined in hgrpblk.cpy; reserved for future use) 87

GOB2-SG1-SNF-GRPR-BLOCK1: Variable length RUG Reader and SNF Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times) 88

GOB3-ID1-IP-DX-BLOCK1: Variable length diagnosis return fields (defined in hgrpblk.cpy; occurs up to 999 times) 89

GOB4-IO1-IP-OP-BLOCK1: Variable length ICD-9-CM or ICD-10-PCS proce-dure return fields (defined in hgrpblk.cpy; occurs up to 999 times) 90

POB1-CA1-PRCR-BLOCK1: Fixed length CAH Method II Pricer output fields (defined in hprcblk.cpy) 91

POB1-EP1-ESRD-PRCR-BLOCK1: Fixed length ESRD Pricer output fields (defined in hprcblk.cpy) 93

POB1-IP1-IP-PRCR-BLOCK1: Fixed length Inpatient Pricer output fields (de-fined in hprcblk.cpy) 97

POB1-OP1-OP-PRCR-BLOCK1: Fixed length APG Pricer output fields (de-fined in hprcblk.cpy) 106

POB1-OP2-OP-PRCR-BLOCK2: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (de-fined in hprcblk.cpy) 108


POB1-PP1-PHYS-PRCR-BLOCK1: Fixed length Physician Pricer output fields (defined in hprcblk.cpy) 116

POB1-RP1-REHAB-PRCR-BLOCK1: Fixed length IRF Pricer output fields (de-fined in hprcblk.cpy) 118

POB1-SP1-SNF-PRCR-BLOCK1: Fixed length SNF Pricer output fields (de-fined in hprcblk.cpy) 121

POB2-CA1-CAH2-PRCR-BLOCK2: Variable length CAH Method II Pricer out-put fields (occurs numhcpcs times) 122

POB2-EP1-ESRD-PRCR-BLOCK2: Variable length ESRD Pricer output fields (defined in hprcblk.cpy; occurs up to 999 times) 125

POB2-IP1-IP-PRCR-BLOCK1: Line-level Inpatient Pricer output fields (defined in hprcblk.cpy; reserved for future use) 127

POB2-OP1-OP-PRCR-BLOCK1: Variable length APG Pricer output fields (de-fined in hprcblk.cpy; occurs up to 999 times) 128

POB2-OP2-OP-PRCR-BLOCK2: Variable length APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, FQHC, HHA, and Hospice Pricer output fields (oc-curs numhcpcs times) 129

POB2-PP1-PHYS-PRCR-BLOCK1: Variable Length Physician Pricer output fields (defined in hprcblk.cpy, occurs 999 times) 137

POB2-RP1-REHAB-PRCR-BLOCK1: Variable Length IRF Pricer output fields (defined in hprcblk.cpy; reserved for future use) 140

POB2-SP1-SNF-PRCR-BLOCK1: Variable length SNF Pricer output fields (de-fined in hprcblk.cpy; occurs 999 times) 141

POB3-EP1-ESRD-PRCR-BLOCK3: Variable length ESRD Pricer output fields (defined in hprcblk.cpy; occurs up to 999 times) 142

OOB1-OPT-OUTPUT-BLOCK1: Fixed length Optimizer output fields (defined in hoptblk.cpy) 144

OOB2-IO1-IP-OPT-BLOCK1: Variable length Optimizer output structure (de-fined in hoptblk.cpy; occurs up to 999 times) 146

OOB2-OO1-OP-OPT-BLOCK1: Variable length output fields from Outpatient modeling (defined in hoptblk.cpy; reserved for future use) 147

MEB1-MCE-EDITOR-BLOCK1: Fixed length output fields from Date-Sensitive


Code (DSC) Editor (defined in hmceblk.cpy) 148

MEB2-MCE-EDITOR-BLOCK2: Variable Length ICD-9-CM or ICD-10-CM di-agnosis output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs 999 times) 150

MEB3-MCE-EDITOR-BLOCK3: Variable length ICD-9-CM or ICD-10-PCS pro-cedure output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy; occurs up to 999 times) 153

MEB4-MCE-EDITOR-BLOCK4: Fixed length error summary output fields from Date-Sensitive Code Editor (defined in hmceblk.cpy) 154

EEB1-EZEDIT-EDITOR-BLOCK1: Fixed length EASYEdit™ output fields (de-fined in hezdtblk.cpy) 155

EEB2-EZEDIT-EDITOR-BLOCK2: Variable length EASYEdit™ output fields (defined in hezdtblk.cpy; occurs up to 305 times) 156



AEB1-ACE-EDIT-BLOCK1: Fixed length ACE and CAH Method II Editor output fields (defined in hace2blk.cpy) 160

AEB2-ACE-EDIT-BLOCK2: Variable length ACE and CAH Method II Editor output fields for ICD-9-CM or ICD-10-CM diagnosis edits (defined in hace2blk.cpy; occurs up to 999 times) 164

AEB3-ACE-EDIT-BLOCK3: Variable length ACE and CAH Method II Editor output fields for HCPCS procedures and claim line edits (defined in hace2blk.cpy; occurs up to 999 times) 165

AEB4-ACE-EDIT-BLOCK4: Variable length OCE/CCI edit output fields (de-fined in hace2blk.cpy; occurs up to 999 times) 172

AEB5-ACE-EDIT-BLOCK5: Fixed length ACE and CAH Method II Editor error summary output fields (defined in hace2blk.cpy) 174

LEB1-LCD-EDIT-BLOCK1: Fixed length LCD Editor return fields (defined in hl-cdblk.cpy) 175

LEB2-LCD-EDIT-BLOCK2: Variable length LCD Editor return fields (defined in hlcdblk.cpy; occurs up to 999 times) 176


LEB3-LCD-EDIT-BLOCK3: Variable length line-level LCD Editor return fields (defined in hlcdblk.cpy; occurs up to 999 times) 177



GOB5-SG1-SNF-GRPR-BLOCK5: Variable length RUG Reader output fields (defined in hgrpblk.cpy; occurs up to 999 times) 180

MOB2-MAP-OUTPUT-BLOCK2: Variable length ICD-9-CM or ICD-10-CM di-agnosis output fields from the Mapper (defined in hmapblk.cpy; occurs up to 999 times) 181

MOB3-MAP-OUTPUT-BLOCK3: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from the Mapper (defined in hmapblk.cpy; occurs up to 999 times) 182

PEB1-PHY-EDIT-BLOCK1: Fixed length Physician return fields (defined in hpebblk.cpy) 183

PEB2-PHY-EDIT-BLOCK2: Variable length diagnosis output fields from the Physician Editor (defined in hpebblk.cpy; occurs up to 999 times) 185

PEB3-PHY-EDIT-BLOCK3: Variable length procedure output fields from the Physician Editor (defined in hpebblk.cpy; occurs up to 999 times) 186

PWS1-Y1-WKSHT-BLOCK: Payer-specific reimbursement worksheet vari-ables for the ASC Pricer (defined in hprcblk.cpy) 188

PWS1-E1-WKSHT-BLOCK: Payer-specific reimbursement worksheet vari-ables for the ESRD Pricer (defined in hprcblk.cpy) 189

PWS1-HC-PRCR-BLOCK1: Payer-specific reimbursement worksheet vari-ables for the Medicare DRG Pricer (defined in hprcblk.cpy) 193

PWS1-LT-WKSHT-BLOCK: Payer-specific reimbursement worksheet vari-ables for the LTC Pricer (defined in hprcblk.cpy) 199

PWS1-N2-WKSHT-BLOCK: Payer-specific reimbursement worksheet vari-ables for the New York Medicaid APR Pricer (defined in hprcblk.cpy) 203

PWS1-Y2-WKSHT-BLOCK: Payer-specific reimbursement worksheet vari-ables for the APC-HOPD Pricer 204


FRB-FUNC-RTN-BLOCK: Fixed length interface function return fields (defined in hfuncblk.cpy) 206

ECB2-EZG-CNTL-BLOCK2: Fixed length input or output fields for all EASYGroup™ processing (defined in hctrlblk.cpy) 207

CAB1-EAM-BLOCK1: Fixed length E&M Analyzer Pro claim level output fields (defined in hcablk.cpy) 208

CAB2-EAM-BLOCK2: Variable length E&M Analyzer Pro diagnosis level output fields (defined in hca-blk.cpy, occurs 999 times) 210

CAB3-EAM-BLOCK3: Variable length E&M Analyzer Pro procedure line-level output fields (defined in hcablk.cpy, occurs 999 times) 211

PWS2-Y1-WKSHT-DATA: Payer-specific reimbursement worksheet variables for the ASC Pricer (defined in hprcblk.cpy) (occurs PCB1-HCT-NUMHCPCS times) 212

Documents

Input and Output Parameter Blocks User’s Guide - COBOL ......Table 1-1: ECB-EZG-CNTL-BLOCK: Fixed length input or output fields for all EASYGroup processing (defined in hctrlblk.cpy)