Medicare Financial Management Manual 
Chapter 9  Provider Statistical & Reimbursement Report 
 
 
Table of Contents 
(Rev. 321, 08-09-19) 
 
Transmittals for Chapter 9 
 
10  Provider Statistical and Reimbursement System 
20  Intermediary Use of PS&R System Reports in Cost Settlement Process 
  20.1  Provider Summary Report 
  20.2  Payment Reconciliation Report 
30  Description of Reports Available from Standard PS&R System 
  30.1  Payment Reconciliation Report 
  30.2  Provider Summary Report 
  30.3  DRG Summary Report 
40  Corrections to Individual Records 
50  The PS&R System Data Elements 10  Provider Statistical and Reimbursement System 
(Rev. 27, 12-19-03) 
 
The CMS provides each intermediary a standard Provider Statistical and Reimbursement System (PS&R) to 
interface with billing form CMS-1450. This system provides reports to be used in developing and auditing 
provider cost reports and related data accumulation operations. Providers also must use the reports in 
preparing cost reports, and must be able to explain any variances between the PS&R report and the cost 
report. 
 
Systems user reference manuals and software are distributed centrally. Updates to the program are prepared 
and released as needed. Implement and operate the system in accordance with the following guidelines. The 
intermediary shall establish procedures to integrate provider FY data collected prior to PS&R 
implementation.  Additional information related to the PS&R reporting system can be found in the PS&R 
Users Guide. 
 
20  Intermediary Use of PS&R System Reports in Cost Settlement Process 
(Rev. 27, 12-19-03) 
 
20.1  Provider Summary Report 
(Rev. 60, Issued: 11-26-04, Effective: 10-01-04, Implementation: 01-24-05) 
 
Guidelines for provider/intermediary use of the year-to-date PS&R provider summary reports are contained 
in 10.1 and 90 of Chapter 8 of this manual. 
 
20.2  Payment Reconciliation Report 
(Rev. 60, Issued: 11-26-04, Effective: 10-01-04, Implementation: 01-24-05) 
 
The payment reconciliation report provides detailed data that supports the provider summary report. See 
10.1 of Chapter 8 of this manual for instructions on the use of this report. 
 
30  Description of Reports Available from Standard PS&R System 
(Rev. 27, 12-19-03) 
 
Two types of reports are produced from the PS&R system. The first consist of statistical reports showing 
claim activity. These can be used for accounting and audit purposes regarding provider remittance. They are 
the main output and purpose of the PS&R system. The second shows the results of processing and are used 
for operations control and monitoring of the flow of data through the PS&R system. They include error 
reports, table listings, and results of updates and systems messages from data center staff. They also provide 
a detailed audit trail of the data. They are explained in the table maintenance and file maintenance sections 
of the PS&R User Reference manual. 
 
All reports produced from the PS&R system list a program ID and run date. The program ID is a unique 
number that identifies the program that produced the report. The run date shows the specific date that the 
report was produced. These fields are for informational purposes only in the event of possible problems. 
 
Statistical reports produced are: 
 
  Payment Reconciliation Report 
  Provider Summary Report 
  DRG Summary Report (Optional) 
 
30.1  Payment Reconciliation Report 
(Rev. 27, 12-19-03) 
  This report shows in detail claims accepted by the PS&R system with totals by provider within report type. 
All claims processed by the PS&R system will be reflected on this report. It can serve as an audit trail for 
claims activities and for comparison to the summary report. 
 
FREQUENCY:  Upon request. 
 
30.2  Provider Summary Reports 
(Rev. 27, 12-19-03) 
 
Summarizes claim data and other information by revenue code required for cost report settlement and CMS 
reporting purposes. Time periods included on this report are specified by the user. 
 
FREQUENCY: Upon request. 
 
REPORT TYPES: A report is generated for each type. These report types are based on the first two digits 
of the Bill Type code on the provider's claim form (CMS-1450). Report claims which cannot be mapped to 
one of the report types are shown under "UNKNOWN REPORT TYPE." 
 
Listed below are all known PS&R report types. 
 
11A  Inpatient  Part A (MSP- Supplements report type 110. 
LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
11I  Inpatient  Part A Managed  Supplements report type 118. 
Care (MSP-LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
11J  Inpatient  PPS Interim Bills  Supplements report type 119. 
(MSP-LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
11K  Inpatient Rehab  PPS Interim  Summarizes Inpatient Part A hospital services 
Bills  reimbursed under the Inpatient Rehabilitation 
Facility PPS payment system that have been 
billed on an interim basis (bill frequency code 
of 2 or 3). 
11R  Inpatient Rehabilitation  Part  Summarizes Inpatient Part A hospital services 
A  reimbursed under the Inpatient Rehabilitation 
Facility PPS payment system. 
110  Inpatient  Part A  Summarizes Inpatient Part A hospital services. 
Includes services reimbursed under cost, 
TEFRA and Inpatient PPS payment systems. 
118  Inpatient  Part A Managed  Summarizes services billed under Part A for 
Care  Medicare managed care patients for purposes 
of receiving reimbursement for DGME and 
IME. 
119  Inpatient  PPS Interim Bills  Summarizes Inpatient Part A hospital services 
reimbursed under the Inpatient PPS payment 
system that have been billed on an interim 
basis (bill frequency code of 2 or 3).  12A  Inpatient  Part B (MSP- Supplements report type 120. 
LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
12C  Inpatient  Part B VAC  Supplements report type 122. 
(MSP-LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
12F  Inpatient  Part B Fee  Supplements report type. 
Reimbursed (MSP-LCC)   
For providers on PIP (Part A) the interim 
payments included on the cost report will be 
adjusted by the MSP-LCC amounts. 
12P  Inpatient Part B OPPS  Captures data from all lines of a claim that 
were paid under OPPS including lines paid as 
APC services packaged with them. Effective 
with services 8/1/00 and after. 
12Z  Ambulance Blend Effective  Summarizes hospital outpatient ambulance 
4/01/02  services reimbursed under the ambulance fee 
schedule blended payment, which is effective 
for services provided On/after April 1, 2002. 
120  Inpatient  Part B  Accumulates data for services normally 
covered under Part A that have become 
covered under Part B. For reimbursement 
purposes, Inpatient Part B and Outpatient Part 
B are combined on the cost report. 
122  Inpatient  Part B VAC  Accumulates data applicable to vaccine 
services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
125  Inpatient  Part B Fee  Shows covered charges and reimbursement by 
Reimbursed  revenue code for fee reimbursed services (for 
patients who have exhausted Part A benefits). 
13A  Outpatient  All Other (MSP- Supplements report type 130. 
LCC) 
13B  Outpatient  Renal (MSP- Supplements report type 131. 
LCC) 
13C  Outpatient  Part B 100%  Supplements report type 132. 
(MSP-LCC) 
13F  Outpatient  Fee Reimbursed  Supplements report type 135. Covered charges 
(MSP-LCC)  and reimbursement are shown by revenue 
code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level. 
13G  O/P Other Diag. & Fee  Supplements report type 136. 
Schedule After 9/90(MSP-
LCC) 
13H  O/P Other Diag. & Fee  Supplements report type 137. 
Schedule. Before 10/90(MSP-
LCC)  13I  O/P Radiology & Fee  Supplements report type 138. 
Schedule After 9/89 (MSP-
LCC) 
13J  O/P Rad & Fee Sch Pre 10/89  Supplements report type 139. 
Or After 12/90(MSP-LCC) 
13P  Outpatient  OPPS  Captures data from all lines of a claim that 
were paid under OPPS including lines paid as 
APC services packaged with them. Effective 
with services 8/1/00 and after. 
13Z  Ambulance Blend Effective  Summarizes hospital outpatient ambulance 
04/01/02  services reimbursed under the ambulance fee 
schedule blended payment, which is effective 
for services provided on/after April 1, 2002. 
130  Outpatient  All  Summarizes hospital outpatient data 
Other/Ambulance  reimbursed on a reasonable cost basis, for all 
services other than diagnostic (see 136), 
radiology (see 139) and ASC (see 831) 
services. Also summarizes laboratory services 
reimbursed on a fee schedule in a 
supplemental report. 
131  Outpatient  Renal  Displays outpatient hospital ESRD service for 
services prior to April 1, 1990. 
132  Outpatient  Part B 100%  Accumulates data applicable to vaccine 
services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
135  Outpatient Fee Reimbursed  Shows covered charges and reimbursement by 
revenue code for fee reimbursed services 
(Hospital Outpatient setting). 
136  O/P Other Diag. & Fee  Summarizes all outpatient other diagnostic 
Schedule After 9/90  services reimbursed in part based on a fee 
schedule. 
137  O/P Other Diag. & Fee  Summarizes all outpatient other diagnostic 
Schedule Before 10/90  services reimbursed in part based on a fee 
schedule. 
138  Outpatient Radiology & Fee  Summarizes outpatient radiology services 
Schedule After 9/89  reimbursed based on a fee schedule. 
139  O/P Rad & Fee Sch Pre 10/89  Summarizes outpatient radiology services 
And/Or After 12/90  reimbursed based on a fee schedule. 
14A  Outpatient / Other (MSP- Supplements report type 140. 
LCC) 
14C  Outpatient/Other Vaccines  Supplements report type 142. This report 
(MSP-LCC)  accumulates data applicable to vaccine 
services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
14F  Outpatient/Other  Supplements report type 145. 
Mammography (MSP-LCC) 
14P  Outpatient/Other  OPPS  Captures data from all lines of a claim that 
were paid under OPPS including lines paid as 
APC services packaged with them. Effective 
with services 8/1/00 and after. 
140  Outpatient/ Other  All Other  Summarizes hospital other Part B data (bill 
type 14x) reimbursed on a reasonable cost 
basis.  142  Vaccines  Accumulates data applicable to vaccine 
services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
145  Outpatient/Other  Shows covered charges and reimbursement by 
Mammography/ Fee  revenue code for fee reimbursed services. 
Reimbursed 
18A  Swing Bed (MSP-LCC)  Supplements report type 180. 
180  Swing Bed  Summarizes Swing Bed hospital services. A 
supplement to this report accumulates data by 
RUG category. 
21A  SNF -Inpatient  Part A  Supplements report type 210. 
(MSP-LCC) 
210  SNF -Inpatient  Part A  Summarizes SNF Inpatient  Part A services. 
22A  SNF -Inpatient  Part B 100%  Supplements report type 220. 
(MSP-LCC) 
22C  SNF  Inpatient  Part B  Supplements report type 222. 
100% VAC (MSP-LCC) 
22F  SNF-Inpatient  Fee  Supplements report type 225. Covered charges 
Reimbursed (MSP-LCC)  and reimbursement are shown by revenue 
code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level. 
22P  SNF-Outpatient-OPPS  Captures data from all lines of a claim that 
(Condition Code 07  were paid under OPPS including lines paid as 
W/Cast/Splint/Ant)  APC services packaged with them. Effective 
with services 8/1/00 and after. 
22Z  Ambulance Blend effective  Summarizes skilled nursing facility, outpatient 
04/02/02  ambulance services reimbursed under the 
ambulance fee schedule blended payment, 
which is effective for services provided 
on/after April 1, 2002. 
220  SNF -Inpatient  Part B 100%  Summarizes SNF Inpatient  Part B services. 
222  SNF -Inpatient  Part B 100%  Accumulates data applicable to vaccine 
VAC  services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
225  SNF -Inpatient  Fee  Shows covered charges and reimbursement by 
Reimbursed  revenue code for fee reimbursed services. 
23A  SNF  Outpatient (MSP- Supplements report type 230. 
LCC) 
23C  SNF  Outpatient VAC  Supplements report type 232. 
(MSP-LCC) 
23F  SNF  Outpatient Fee  Supplements report type 235. Covered charges 
Reimbursed (MSP-LCC)  and reimbursement are shown by revenue 
code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level. 
23P  SNF-Outpatient-OPPS  Captures data from all lines of a claim that 
(Condition Code 07  were paid under OPPS including lines paid as 
W/Cast/Splint/Ant)  APC services packaged with them.  Effective 
with services 8/1/00 and after.  23Z  Ambulance Blend effective  Summarizes skilled nursing facility, outpatient 
04/02/02  ambulance services reimbursed under the 
ambulance fee schedule blended payment, 
which is effective for services provided 
on/after April 1, 2002. 
230  SNF  Outpatient  Summarizes SNF outpatient services. 
232  SNF  Outpatient VAC.  Accumulates data applicable to vaccine 
services reimbursed based on 100% of 
reasonable cost. Data on this report is used to 
complete the cost report. 
235  SNF  Outpatient Fee  Shows covered charges and reimbursement by 
Reimbursed  revenue code for fee reimbursed services. 
24P  SNF-Outpatient-OPPS  Captures data from all lines of a claim that 
(Condition Code 07  were paid under OPPS including lines paid as 
W/Cast/Splint/Ant)  APC services packaged with them. Effective 
with services 8/1/00 and after. 
32C  Home Health  (MSP-LCC)  OD44203 report number under report type 
32A: Summarizes the Part B claims with a 
plan of treatment that are subject to MSP-LCC 
limitation. Services included on this report are 
typically not subject to deductible or 
coinsurance. Report was previously used in 
cost reports ending prior to October 1, 2000, 
and then only if the provider was reimbursed 
under PIP method. 
 
D45300 report number (which corresponds to 
the OD44203 report): Summarizes visits and 
census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 32A is NOT needed for cost 
reporting purposes. 
32M  Home Health  (MSP-LCC)  Supplements report type 329. 
320  Home Health  Part B  OD44203 report number under report type 
320: Summarizes data included on home 
health Part B claims with a plan of treatment 
prior to implementation of home health PPS 
(October 1, 2000). Services included on this 
report are typically not subject to deductibles 
or coinsurance. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 320 is NOT needed for cost 
reporting purposes. 
322  Home Health  Part B   Summarizes Medicare Part B Requests for 
Anticipated Payments (RAPs) activity. The 
RAPs are not used in the cost report.  329  Home Health  Part B  OD44203 report number under report type 
Episode  329: Summarizes data included on Part B 
home health prospective payments episodes 
covered under a signed plan of treatment. Part 
B home health data is broken out into different 
episodic units. Services included on this report 
are typically not subject to deductibles or 
coinsurance. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 329 is NOT needed for cost 
reporting purposes. 
33A  Home Health  Part A (MSP- OD44203 report number under report type 
LCC)  33A: Summarizes the Part A claims with a 
plan of treatment that is subject to MSP-LCC 
limitation. Services included on this report are 
typically not subject to deductible or 
coinsurance. Report was previously used in 
cost reports ending prior to October 1, 2000, 
and then only if the provider was reimbursed 
under PIP method. 
 
OD45300 report number (which corresponds 
to the OD44203 report):  Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 33A is NOT needed for cost 
reporting purposes. 
33M  Home Health  Part A (MSP- Supplements report type 339. 
LCC) 
330  Home Health  Part  OD44203 report number under report type 
330: Summarizes data included on home 
health Part A claims with a plan of treatment 
prior to implementation of home health PPS 
(October 1 2000). 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 330 is NOT needed for cost 
reporting purposes. 
332  Home Health  Part A  Summarizes Medicare Part A Requests for 
Anticipated Payments (RAPs) activity. The 
RAPs are not used in the cost report.  339  Home Health  Part A  OD44203 report number under report type 
Episode  339: Summarizes data included on Part A 
home health prospective payment episodes 
covered under a signed plan of treatment. Part 
A home health data is broken out into different 
episodic units. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 339 is NOT needed for cost 
reporting purposes. 
34A  Home Health  Part B (MSP- Summarizes the Part B claims not under a plan 
LCC)  of treatment that is subject to MSP-LCC 
limitation. Data found in this report are subject 
to coinsurance and deductible. 
34P  HHA Outpatient-OPPS (Not  Summarizes the Part B claims data not under a 
Hhpps)  signed plan of care that are reimbursed under 
Outpatient PPS. Used in cost reports prior to 
starting date of 10/1/00. 
340  Home Health  Part B. (w/o a  Summarizes data included on Part B claims 
plan of treatment)  without a signed plan of treatment. Services 
included on this report are typically subject to 
deductibles or coinsurance. 
342  Home Health  Part B   Summarizes Part B vaccine claim data that is 
Vaccine  not reimbursed under OPPS. 
345  Home Health  Part B   Summarizes the Part B therapy claims data 
Rehab  that was furnished on and after 1/1/99 and not 
under a signed plan of care. 
399  Home Health  Part A And  Summarizes the home health episode data 
Part B Episode  from the 329 Home Health Part B Episode 
report and the 339 Home Health Part A 
Episode report. 
410  Christian Science  Inpatient  Summarizes the Medicare days, discharges, 
 Part A  charges, deductibles, coinsurance and net 
reimbursement for a reporting period.  
Christian Science facilities typically have 
relatively low Medicare utilization and the 
majority of their charges are for routine 
inpatient care. 
71A  Clinic  Rural Health (MSP- Supplements report type 710. 
LCC) 
71C  Clinic  Rural Health  100%  Supplements report type 712. 
(MSP-LCC) 
71P  Clinic-Rural Health-OPPS  Captures data from all lines that were paid 
(Condition Code 07)  under OPPS including lines paid as ASC 
services packaged with them.  Effective with 
services 8/1/00 and after. 
710  Clinic  Rural Health  Summarizes data for rural health clinic 
services (bill type 71x) paid based on an all-
inclusive rate. 
712  Clinic  Rural Health  VAC  Summarizes vaccine services provided by 
rural health clinics.  72A  Hosp. Based Or Ind. Renal  Supplements report type 720. 
Dialysis Center (MSP-LCC) 
72C  Free Standing Renal Dialysis  Supplements report type 722. 
100%  VAC (MSP-LCC) 
720  Hosp. Based Or Independent.  Summarizes data for renal dialysis centers 
Renal Dialysis Center  (bill type 72x) paid based on an all-inclusive 
rate. 
722  Free Standing Renal Dialysis  Summarizes vaccine services provided by 
100%  VAC  Free Standing Renal Dialysis centers. 
73A  FQHC (MSP-LCC)  Supplements report type 730. 
73C  FQHC-100% (MSP-LCC)  Supplements report type 732. 
73P  FQHC-OPPS (Condition  Captures data from all lines of a claim that 
Code 07)  were paid under OPPS including lines paid as 
APC services packaged with them.  Effective 
with services 8/1/00 and after. 
730  FQHC  Summarizes data for Federally Qualified 
Health Clinic services (bill type 73x) paid 
based on an all-inclusive rate. 
732  FQHC-VAC  Summarizes vaccine services provided by 
FQHC facilities. 
74A  Rehabilitation Facility (MSP- Supplements report type 740. 
LCC) 
74C  Rehabilitation Facility-100%  Supplements report type 742. 
(MSP-LCC) 
74F  Rehabilitation Facility-Fee  Supplements report type 745. 
Reimbursed (MSP-LCC) 
74P  Rehabilitation Facility-OPPS  Captures data from all lines of a claim that 
(Condition Code 07)  were paid under OPPS including lines paid as 
APC services packaged with them.  Effective 
with services 8/1/00 and after. 
740  Rehabilitation Facility  Shows cost reimbursed data, if any, by 
accommodation and ancillary service revenue 
codes. Captures lines of claims paid under the 
cost-reimbursed method for Outpatient Rehab 
facilities-mainly services prior to 1/1/99. This 
report is used to determine whether a provider 
has either Low Utilization or No Medicare 
Business for cost reporting. 
 
No cost report is required for reporting periods 
ending on or after July 1, 2003 [CMS Flash 
Report  dated May 9, 2003]. 
742  Rehabilitation Facility-VAC  Summarizes vaccine services provided by 
CORF facilities. 
745  Rehabilitation Facility-Fee  Shows covered charges and reimbursement by 
Reimbursed  revenue code for fee reimbursed services. 
75A  CORF (MSP-LCC)  Supplements report type 750. 
75C  CORF-100% (MSP-LCC)  Supplements report type 752. 
75F  CORF-Fee Reimbursed  Supplements report type 755. Covered charges 
(MSP-LCC)  and reimbursement are shown by revenue 
code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level.  75P  CORF-OPPS  Captures data from all lines of a claim that 
were paid under OPPS including lines paid as 
APC services packaged with them.  Effective 
with services 8/1/00 and after. 
750  CORF  Shows cost reimbursed data, if any, by 
accommodation and ancillary service revenue 
codes. Captures lines of claims paid under the 
cost-reimbursed method for Comprehensive 
Rehab Facilities mainly services prior to 
1/1/99. This report is used to determine 
whether a provider has either Low Utilization 
or No Medicare Business for cost reporting. ] 
No cost report is required for reporting periods 
ending on or after April 1, 2001 [CMS Flash 
Report  dated May 9, 2003]. 
752  CORF-VAC  Summarizes vaccine services provided by 
CORF facilities. 
755  CORF-Fee Reimbursed  Shows covered charges and reimbursement by 
revenue code for fee reimbursed services. 
76A  Community Mental Health  Supplements report type 760. 
Center (MSP-LCC) 
76C  Community Mental Health  Supplements report type 762. 
Center-100% (MSP-LCC) 
76F  Community Mental Health  Supplements report type 765. Covered charges 
Center-Fee Reimbursement  and reimbursement are shown by revenue 
(MSP-LCC)  code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level. 
76P  CMHC-OPPS  Captures data from all lines of a claim that 
were paid under OPPS including lines paid as 
APC services packaged with them. Effective 
with services 8/1/00 and after. 
760  Community Mental Health  Captures lines of claims paid under the cost-
Center  reimbursed method for Community Health 
Centers  mainly services prior to 8/1/00. 
762  Community Mental Health  Summarizes vaccine services provided by 
Center-VAC  Community Health Centers. 
765  Community Mental Health  Shows covered charges and reimbursement by 
Center-Fee Reimbursed  revenue code for fee reimbursed services. 
81A  Hospice  Non-Hospital  OD44203 report number under report type 
Based (MSP-LCC)  81A: Summarizes the Non-Hospital based 
(Free Standing) Hospice claims that are 
subject to MSP-LCC limitation. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 81A is informational only. 
81P  Hospice  Non-Hospital  Captures data from all lines of a claim that 
Based OPPS (Condition  were paid under OPPS including lines paid as 
Code 07)  APC services packaged with them.  Effective 
with services 8/1/00 and after.  810  Hospice  Non-Hospital  OD44203 report number under report type 
Based  810: Summarizes the Non-Hospital based 
(Free Standing) hospice claim data. May be 
used in cost report. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 810 is informational only. 
82A  Hospice  Hospital Based  OD44203 report number under report type 
(MSP-LCC)  82A: Summarizes the Hospital (provider) 
based Hospice claims that are subject to the 
MSP-LCC limitation. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 82A is informational only. 
82P  Hospice  Hospital Based- Captures data from all lines of a claim that 
OPPS (Condition Code 07)  were paid under OPPS including lines paid as 
APC services packaged with them.  Effective 
with services 8/1/00 and after. 
820  Hospice  Hospital Based  OD44203 report number under report type 
820: Summarizes the Hospital (provider) 
based Hospice claim data. May be used in cost 
report. 
 
OD45300 report number (which corresponds 
to the OD44203 report): Summarizes visits 
and census per metropolitan statistical area 
(MSA). The OD45300 report number under 
report type 820 is informational only. 
83A  ASC And ASC Fee Schedule  Supplements report type 830. 
(MSP-LCC) 
83B  ASC And ASC Fee Schedule  Supplements report type 831. 
After 12/90 (MSP-LCC) 
830  ASC And ASC Fee Schedule  Summarizes all outpatient ambulatory surgical 
services reimbursed in part based on HCPCS. 
831  ASC And ASC Fee Schedule  Summarizes all outpatient ambulatory surgical 
After 12/90  services reimbursed in part based on HCPCS. 
85A  CAH (MSP-LCC)  Supplements report type 850. 
85C  CAH-100% (MSP-LCC)  Supplements report type 852. 
85F  CAH-Fee  Supplements report type 855. Covered charges 
Reimbursed/Mammography  and reimbursement are shown by revenue 
(MSP-LCC)  code for fee reimbursed services. Data also 
represents MSP claims paid on Lower of Cost 
or Charges (LCC) and considered settled at 
the claim level. 
85Z  CAH Ambulance Blend  Summarizes critical access hospital, outpatient 
Effective 04/01/02  ambulance services reimbursed under the fee 
schedule blended payment, which is effective 
for services provided on/after April 1, 2002.  850  CAH  Summarizes data for critical access hospital 
services (bill type 85x) reimbursed on a cost 
basis. 
852  CAH-VAC  Summarizes vaccine services provided by 
critical access hospitals reimbursed on a 
reasonable cost basis. 
855  CAH-Fee  Shows covered charges and reimbursement by 
Reimbursed/Mammography  revenue code for fee reimbursed services. 
998  Hospital Outpatient  Part B  Summarizes, by revenue code and report type, 
the information that is printed on the various 
outpatient report types. This report cannot be 
used to complete the cost report. 
999  All Report Types For  MSA/Beneficiary Census/Rev Visits report: 
Provider  Summarizes the visits and census per 
metropolitan statistical area (MSA). The 
OD45300 report number under report type 999 
for Home Health Agencies is used for cost 
reporting periods ending before October 1, 
2000. 
 
The OD45300 report number under report 
type 999 for hospice providers is 
informational only. 
OD  DRG Summary Report  Summarizes PPS data by DRGs.  It is optional 
44215  and requested on demand. 
 
NOTE:  In all cases other than outpatient, the report type ties directly to the type of bill entered on the claim 
(CMS-1450). For outpatient bills, the distinction is broken out further to identify the bills as All Other, Part 
B 100 percent, renal bills, and ASC. 
 
30.3  DRG Summary Report 
(Rev. 27, 12-19-03) 
 
This report for PPS is a supplement to the provider summary report and is an optional report that is produced 
upon request when a provider summary report is produced for any given provider. The report is a summary 
of prospective payment data broken out and summarized by DRG code. 
 
40  Corrections to Individual Records 
(Rev. 27, 12-19-03) 
 
The PS&R system allows corrections of total charges and/or units, days/visits, revenue codes within a 
provider and changes to covered amounts on the provider summary report. The following data are required 
to make adjustments. 
 
INDIVIDUAL RECORDS 
 
Item  Enter 
1.  Request Date  Today's Date 
2.  Submitted By  Your Name 
3.  Provider  The provider to be adjusted. 
Number  4.  Report Type  The report type of the provider to be adjusted. 
5.  Paid Date  The remittance date for the claim(s) being adjusted. 
6.  Thru Date  The thru date of service for the claim(s) being adjusted. 
7.  DRG Code  For prospective payment providers, the DRG code under 
which the change was made. For other providers leave blank. 
8.  Add to Revenue  The revenue code to receive the new amounts. 
Code 
9.  Subtract  from  The revenue code from where amounts should be subtracted. 
Revenue Code 
10.  Days (Visits)  Number of days/visits to be adjusted between the revenue 
codes specified. 
11.  Charges  Dollar amounts to be adjusted. 
 
The PS&R system processes adjustments with a frequency code of 7 (cancel) and 8 (reissue). Other types of 
adjustments, e.g., credits and debits, PRO adjustments, cannot be handled by this system. Prepare an 
interface program that will convert the adjustments to frequency codes 7 or 8 in order to process PRO 
debit/credit adjustments and maintain the data in the PS&R system for cost settlement. 
 
50  The PS&R System Data Elements 
(Rev. 321, Issued: 08-09-2019, Effective: 01-01-20, Implementation: 01-06-20) 
 
Maintain the following data elements from the FISS paid claim file. The PS&R system shall reflect updated 
FISS changes to the paid claim file fields. 
This section contains a crosswalk of data elements used in the FI paid claims file and the PS&R detail files. 
The crosswalk is presented below. It contains the current FISS paid claim record and shows how it 
crosswalks to the PS&R detail file. 
 
Cross Walk of Data Elements in FI Paid Claims file and PS&R Detail File 
 
FI Paid Claim File  PS&R Detail Record File  Comments 
FSSCPDCL-NO  C-DETL-HICAN   
FSSCPDCL-NO  C-DETL2-HICAN  Via C-DETL-HICAN 
FSSCPDCL-PAT-LAST-NM  C-DETL-BENE-LNAME   
FSSCPDCL-PAT-FIRST-NM  C-DETL-BENE-INIT1   
FSSCPDCL-PAT-FIRST-INIT  C-DETL-BENE-INIT1   
FSSCPDCL-PAT-MIDL-INIT  C-DETL-BENE-INIT2   
FSSCPDCL-PAT-LAST-NM  C-2DETL-BENE-LNAME  Via C-BENE-LNAME 
FSSCPDCL-PAT-FIRST-NM  C-2DETL-BENE-INIT1  Via C-BENE-INIT1 
FSSCPDCL-PAT-FIRST-INIT  C-2DETL-BENE-INIT1  Via C-BENE-INIT1 
FSSCPDCL-PAT-MIDL-INIT  C-2DETL-BENE-INIT2  Via C-BENE-INIT2 
FSSCPDCL-DCN  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-PLAN-CD  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-JULIAN  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-YR  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-JUL-DT  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-BTCH-NBR-X  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-BTCH-NBR  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-CLM-SEQ-NBR  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-SPLIT-CD  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-ORIG-CD  C-DETL-ICN  C-DETL-KEY  FSSCPDCL-DCN-FUTURE  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-FUTURE2  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN-SITE-ID  C-DETL-ICN  C-DETL-KEY 
FSSCPDCL-DCN  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-PLAN-CD  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-JULIAN  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-YR  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY  FI Paid Claim File  PS&R Detail Record File  Comments 
FSSCPDCL-DCN-JUL-DT  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-BTCH-NBR-X  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-BTCH-NBR  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-CLM-SEQ-NBR  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-SPLIT-CD  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-ORIG-CD  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-FUTURE  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-FUTURE2  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-DCN-SITE-ID  C-DETL2-ICN  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-MEDA-PROV-ID  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-STATE-CD  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-ID  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-TYP-FACIL-CD  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-2  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-EMER-IND  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-PROV-DEPT-ID  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-MEDA-PROV-FILLER  C-DETL-PROV  C-DETL-KEY 
FSSCPDCL-MEDA-PROV-ID  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-STATE-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-ID  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-TYP-FACIL-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-2  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-EMER-IND  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PROV-DEPT-ID  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-MEDA-PROV-FILLER  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-OTHER-SUMMARY-  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
DATA 
FSSCPDCL-BILL-TYP-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-BILL-CATEGORY  C-DETL-RPT-TYPE  C-DETL-KEY 
FSSCPDCL-LOB-CD  C-DETL-RPT-TYPE  C-DETL-KEY 
FSSCPDCL-SERV-TYP-CD  C-DETL-RPT-TYPE  C-DETL-KEY 
88 PDCL-INP-CLAIM VALUES '11'  C-DETL-RPT-TYPE  C-DETL-KEY; COBOL condition name 
'18' '21' '28' '33' '32' '41' '51' '81' '82' 
88 PDCL-HH-CLAIM VALUES '32'  C-DETL-RPT-TYPE  C-DETL-KEY; COBOL condition name 
'81' '82' 
88 PDCL-HH-PPS-CLAIM VALUES  C-DETL-RPT-TYPE  C-DETL-KEY; COBOL condition name 
'32' '33' 
88 PDCL-SNF-CLAIM VALUES '18'  C-DETL-RPT-TYPE  C-DETL-KEY; COBOL condition name 
'21' '28' 
88 PDCL-OUTP-CLAIM VALUES '12  C-DETL-RPT-TYPE  C-DETL-KEY; COBOL condition name 
'13' '14''22' '23' '24' '34' '42' '43' '44' '52' 
'53' '54' '71' '72' '73' '74' '75' '76' '83' '85' 
FSSCPDCL-FREQ-CD  C-DETL-FREQ-CD  C-DETL-KEY (If I or P, make 7) 
FSSCPDCL-BILL-TYP-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-BILL-CATEGORY  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-LOB-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-SERV-TYP-CD  C-DETL2-PROV  C-DETL2-KEY via C-DETL-KEY 
88 PDCL-INP-CLAIM VALUES '11'  C-DETL2-PROV  C-DETL2-KEY; COBOL condition name 
'18' '21' '28' '33' '32' '41' '51' '81' '82' 
88 PDCL-HH-CLAIM VALUES '32'  C-DETL2-PROV  C-DETL2-KEY; COBOL condition name 
'81' '82' 
88 PDCL-HH-PPS-CLAIM VALUES  C-DETL2-PROV  C-DETL2-KEY; COBOL condition name  FI Paid Claim File  PS&R Detail Record File  Comments 
'32' '33'     
88 PDCL-SNF-CLAIM VALUES '18'  C-DETL2-PROV  C-DETL2-KEY; COBOL condition name 
'21' '28' 
88 PDCL-OUTP-CLAIM VALUES '12  C-DETL2-PROV  C-DETL2-KEY; COBOL condition name 
'13' '14''22' '23' '24' '34' '42' '43' '44' '52' 
'53' '54' '71' '72' '73' '74' '75' '76' '83' '85' 
FSSCPDCL-FREQ-CD  C-DETL2-PROV  C-DETL2-KEY (If I or P, make 7.) via C- 
DETL-KEY 
FSSCPDCL-FREQ-CD  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY 
RPT-CLASS 
88 PDCL-FINAL-BILL VALUES '1' '4  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
'5' '9'  RPT-CLASS 
88 PDCL-INTERIM-BILL VALUES '2 C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
'3'  RPT-CLASS 
88 PDCL-NO-PAY-BILL VALUE '0'  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
RPT-CLASS 
88 PDCL-DEBIT-ADJ VALUE '7'  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
RPT-CLASS 
88 PDCL-CREDIT-ADJ VALUE '8'  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
RPT-CLASS 
88 PDCL-CANCEL-BILL VALUE '8'  C-DETL-RPT-TYPE VIA W-  C-DETL-KEY; COBOL condition name 
'F' 'G' 'H' 'I' 'J' 'K' 'M'  RPT-CLASS 
FSSCPDCL-RECD-DT-CYMD  C-DETL-RECEIPT-DT   
FSSCPDCL-PAID-DT-CYMD  C-DETL-RMT-DATE  C-DETL-KEY 
FSSCPDCL-PAID-DT-CC  C-DETL-RMT-DATE  C-DETL-KEY 
FSSCPDCL-PAID-DT  C-DETL-RMT-DATE  C-DETL-KEY 
FSSCPDCL-PAID-YR  C-DETL-RMT-DATE  C-DETL-KEY via C-DETL-KEY 
FSSCPDCL-PAID-MO  C-DETL-RMT-DATE  C-DETL-KEY 
FSSCPDCL-PAID-DY  C-DETL-RMT-DATE  C-DETL-KEY 
FSSCPDCL-PAID-DT-CYMD  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-DT-CC  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-DT  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-YR  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-MO  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-DY  C-DETL2-RMT-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAID-DT-CYMD  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-PAID-DT-CC  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-PAID-DT  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-PAID-YR  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-PAID-MO  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-PAID-DY  C-DETL-FILE-DATE  C-DETL-KEY; MD400500 
FSSCPDCL-STMT-COV-FROM-DT-  C-DETL-FROM-DATE   
CYMD 
FSSCPDCL-STMT-COV-FROM-DT-  C-DETL-FROM-DATE   
CC 
FSSCPDCL-STMT-COV-FROM-DT  C-DETL-FROM-DATE   
FSSCPDCL-STMT-COV-FROM-YR  C-DETL-FROM-DATE   
FSSCPDCL-STMT-COV-FROM-MO  C-DETL-FROM-DATE   
FSSCPDCL-STMT-COV-FROM-DY  C-DETL-FROM-DATE   
FSSCPDCL-STMT-COV-FROM-DT-  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE 
CYMD 
FSSCPDCL-STMT-COV-FROM-DT-  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE  FI Paid Claim File  PS&R Detail Record File  Comments 
CC     
FSSCPDCL-STMT-COV-FROM-DT  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE 
FSSCPDCL-STMT-COV-FROM-YR  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE 
FSSCPDCL-STMT-COV-FROM-MO  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE 
FSSCPDCL-STMT-COV-FROM-DY  C-DETL2-FROM-DATE  Via C-DETL-FROM-DATE 
FSSCPDCL-STMT-COV-TO-DT-  C-DETL-THRU-DATE  C-DETL-KEY 
CYMD 
FSSCPDCL-STMT-COV-TO-DT-CC  C-DETL-THRU-DATE  C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-DT  C-DETL-THRU-DATE  C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-YR  C-DETL-THRU-DATE  C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-MO  C-DETL-THRU-DATE  C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-DY  C-DETL-THRU-DATE  C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-DT-  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
CYMD 
FSSCPDCL-STMT-COV-TO-DT-CC  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-DT  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-YR  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-MO  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-STMT-COV-TO-DY  C-DETL2-THRU-DATE  C-DETL2-KEY via C-DETL-KEY 
FSSCPDCL-PAT-MED-REC-NO  C-DETL-PCN   
FSSCPDCL-DRG-CD  C-DETL-DRG-CODE   
FSSCPDCL-CANC-ADJ-CD  C-DETL-CANCEL-ADJ   
FSSCPDCL-MEDICAL-RECORD-NO  C-DETL-PCN   
FSSCPDCL-PIP-IND  C-DETL-PIP-IND  In MD400600: 
 
IF FSSCPDCL-PIP-IND = 'Y' 
MOVE 'Y' TO C-DETL-PIP-IND 
FSSCPDCL-HH-SPLIT-IND  C-DETL-HH-SPLIT-IND   
FSSCPDCL-PATIENT-STATUS  C-DETL-PAT-STATUS   
FSSCPDCL-PATIENT-STATUS  C-DETL2-PAT-STATUS  Via C-DETL-PAT-STATUS 
FSSCPDCL-PATIENT-STATUS  C-DETL-PATIENT-ST   
FSSCPDCL-COV-DY-CNT  C-DETL-TRANS-DAYS   
FSSCPDCL-FED-PORTION  C-DETL-FED-SPEC-PMT   
FSSCPDCL-PPS-PAYMENT  C-DETL2-PPS-PAYMENT   
FSSCPDCL-DRG-WEIGHT  C-DETL-CAP-DRG-WT   
FSSCPDCL-DSCHG-FRCTN  C-DETL-CAP-DSCHG-FR   
FSSCPDCL-DRG-WT-FRCTN  C-DETL-DRGWT-FR   
FSSCPDCL-CAP-TOT-PAY  C-DETL-CAPTL-PMT  C-DETL-CAPTL-PMT redefines C-DETL- 
ESRD-NETWORK 
FSSCPDCL-CAP-FSP  C-DETL-CAP-FSP   
FSSCPDCL-CAP-DSH-ADJ  C-DETL-CAP-DSH-ADJ   
FSSCPDCL-CAP2-B-FSP  C-DETL-CAP-B-FSP   
FSSCPDCL-CAP-HSP  C-DETL-CAP-HSP   
FSSCPDCL-CAP-OLD-HARM  C-DETL-CAP-OLD-HARM  
FSSCPDCL-CAP-IME-ADJ  C-DETL-CAP-IME-ADJ   
FSSCPDCL-PPS-RTC  C-DETL-PRICER-RTC   
FSSCPDCL-COIN-DAYS-1ST-YR  C-DETL-COIN-DAYS   
FSSCPDCL-CAP-OUTLIER  C-DETL-CAP-OUTLIER   
FSSCPDCL-CAP2-B-OUTLIER  C-DETL-CAP-B-OUTLIE   
FSSCPDCL-OUTLIER-DYS  C-DETL-OUTLIER-DAYS   
FSSCPDCL-HOSP-PORTION  C-DETL-HOS-SPEC-PMT   
FSSCPDCL-CAPI-EXCEPTIONS  C-DETL-CAP-EXCPTONS   
  FI Paid Claim File  PS&R Detail Record File  Comments 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-VALUE-AMT-9 in MD400600 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-0-CASH-DEDUCT in MD400700 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-0-CASH-DEDUCT in MD400701 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-0-CASH-DEDUCT in MD400710 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-DEDUCTIBLE via W-O-CASH- 
DEDUCT in MD400700 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-DEDUCTIBLE via W-O-CASH- 
DEDUCT in MD400701 
FSSCPDCL-VAL-AMT  C-DETL-CASH-DEDUCT  Via W-DEDUCTIBLE via W-O-CASH- 
DEDUCT in MD400710 
FSSCPDCL-VAL-AMT  C-DETL-SRVC-MSAE  Field is set in this portion of MD400600: 
MSAE-RTN 
IF W-VALUE-AMT (3:3) = '099' 
MOVE W-VALUE-AMT (6:2) TO C- 
DETL-SRVC-MSAE (3:2) 
ELSE 
IF W-VALUE-AMT (3:2) = '99' 
MOVE W-VALUE-AMT (5:3) TO C- 
DETL-SRVC-MSAE (3:3) 
ELSE 
IF W-VALUE-AMT (7:1) > '5' 
MOVE W-VALUE-AMT (3:5) TO C 
DETL-SRVC-MSAE 
ELSE 
MOVE W-VALUE-AMT (4:4) TO C 
DETL-SRVC-MSAE. 
MSAE-RTN-EXIT 
EXIT 
FSSCPDCL-REIMB-PROV-AMT  C-DETL-NET-REIMB   
FSSCPDCL-REIMB-PROV-AMT  C-DETL-TRANS-PMT  C-DETL-TRANS-PMT = FSSCPDCL- 
REIMB-PROV-AMT - W-OUT-EIMB-AMT 
FSSCPDCL-HCPC-CD-X  C-DETL-HCPCS-CD  Via W-DETL-HCPCS-TRL.W-DETL- 
HCPCS-CD via W-HCPCS-CD 
in MD400600 
FSSCPDCL-HCPC-MODIFIERS  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-HCPC-MODIFIER  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-HCPC-MODIFIER2  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-HCPC-MODIFIER3  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-HCPC-MODIFIER4  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-HCPC-MODIFIER5  C-DETL-ASC-HCPCMODS  Via W-DETL-HCPCS-MODS via W- 
HCPCS-MODIFIERS in MD400600 
FSSCPDCL-ASC-PERCENT  C-DETL-ASC-PCT-IND  Via W-ASC-TRL.WAT-PCT-IND via W- 
ASCC-PERCENT in MD400600 
FSSCPDCL-ASC-GRP  C-DETL-ASC-GRP-CD  Via W-ASC-TRL.WAT-GRP-CD via W- 
ASC-GROUP in MD400600 
FSSCPDCL-PRICER-IND  C-DETL2-PRICER-IND   
FSSCPDCL-OPPS-PRICR-LINE-RTC  C-DETL2-PRICER-LINE-RT C 
FSSCPDCL-REV-CD  C-DETL-HCPCS-REV  Via W-HCPCS-TRL.W-DETL-HCPCS-REV  FI Paid Claim File  PS&R Detail Record File  Comments 
    via W-REVENUE-CD in MD400600 
FSSCPDCL-REV-CD  C-DETL-REV-CD  Via W-DETL-REV-CD via W-REVENUE- 
CD in MD400600. 
88 FSSCPDCL-FEE-SCHEDULE-  C-DETL-REV-CD  COBOL condition name 
REV-CD VALUES 0274, 0300 THRU 
0319, 0403 
88 PDCL-FEE-SCHEDULE-REV-CD  C-DETL-REV-CD  COBOL condition name 
VALUES 0274, 0300 THRU 0319, 
0403 
FSSCPDCL-REV-CD-X redefines  C-DETL-REV-CD   
FSSCPDCL-REV-CD 
FSSCPDCL-REV-SERV-UNIT-CNT  C-DETL-HCPCS-UNITS  Via W-HCPCS-TRL.W-DETL-HCPCS- 
PIC 9(07)  UNITS via W-UNITS in MD400600 
FSSCPDCL-REV-SERV-UNIT-CNT  C-DETL-REV-UNITS  Via W-DETL-REV-UNITS via W-UNITS in 
PIC 9(07)  MD400600 
FSSCPDCL-REV-SERV-RATE  C-DETL-HCPCS-REIMB  Via W-RATE in MD400600 
FSSCPDCL-RAD-PRICER-AMT-X     
FSSCPDCL-RAD-PRICER-AMT  C-DETL-HCPCS-REIMB  Via W-RATE via W-RAD-PRICER-AMT in 
MD400600 
FSSCPDCL-RAD-PRICER-AMT  C-DETL2-APC-GROSS-PMT  Via W-RATE via W-RAD-PRICER-AMT in 
MD400600 
FSSCPDCL-REV-TOT-CHRG-AMT  C-DETL-REV-CHG  Via W-DETL-REV-CHG via W-SERV- 
CHARGES in MD400600 
FSSCPDCL-REV-TOT-CHRG-AMT  C-DETL-TOT-COV-CHG  Via W-DETL-REV-CHRG via W-SERV- 
CHARGES 
FSSCPDCL-REV-COV-CHRG-AMT  C-DETL-HCPCS-REIMB  Via W-RATE in MD400600 
FSSCPDCL-REV-COV-CHRG-AMT  C-DETL2-REV-COV-CHG-  
AMT 
FSSCPDCL-REV-TOT-CHRG-AMT  C-DETL-TOT-COV-CHG  Via W-DETL-REV-CHRG via W-SERV- 
CHARGES 
FSSCPDCL-REV-COV-CHRG-AMT  C-DETL-REV-CHG  Via W-DETL-REV-CHG via W-SERV- 
CHARGES in MD400600 
FSSCPDCL-REV-NCOV-CHRG-AM T C-DETL-REV-CHG  Via W-RATE via W-I-SERV-NCOV- 
CHARGES in MD400600 
FSSCPDCL-REV-NCOV-CHRG-AM T C-DETL-HCPCS-REIMB  Via W-RATE via W-I-SERV-NCOV- 
CHARGES in MD400600 
FSSCPDCL-REV-TOT-CHRG-AMT  C-DETL-HCPCS-BLDCHG  Via W-DETL-REV-CHG via W-SERV- 
CHARGES in MD400600 
FSSCPDCL-REV-COV-CHRG-AMT  C-DETL-HCPCS-BLDCHG  Via W-DETL-REV-CHG via W-SERV- 
CHARGES in MD400600 
FSSCPDCL-REV-NCOV-CHRG-AM T C-DETL-HCPCS-BLDCHG  Via W-RATE via W-I-SERV-NCOV- 
CHARGES in MD400600 
FSSCPDCL-WAGE-ADJ-COIN-LINE  C-DETL2-WGE-ADJ-   
COIN-LINE 
FSSCPDCL-REDUCED-COIN-LINE  C-DETL2-REDU-COIN-LINE  
FSSCPDCL-PROV-REIMB-LINE  C-DETL2-PROV-REIMB-   
LINE 
FSSCPDCL-PAT-CASH-DED-LINE  C-DETL2-PAT-CASH-DED-  
LINE 
FSSCPDCL-PSY-ESRD-BLD-HEMO  C-DETL2-PSY-ESRD-BLD-  
HEMO 
FSSCPDCL-APC-HCPCS-PROC  C-DETL2-APC-HCPCS-PRO C 
FSSCPDCL-APC-SERV-IND  C-DETL-APC-SERV-IND  Via W-DETL-REV-TRL.W-DETL-APC-  FI Paid Claim File  PS&R Detail Record File  Comments 
    SERV-IND via W-APC-SERV-IND 
in MD400600 
FSSCPDCL-APC-SERV-IND  C-DETL2-APC-SERV-IND  Via W-DETL-REV-TRL.W-DETL-APC- 
SERV-IND via W-APC-SERV-IND 
in MD400600 
FSSCPDCL-SITE-OF-SERV-INC-  C-DETL-APC-SERV-IND  Via W-DETL-REV-TRL.W-DETL-APC- 
FLAG redefines FSSCPDCL-APC-  SERV-IND via W-APC-SERV-IND 
SERV-IND  in MD400600 
FSSCPDCL-APC-PAYMENT-IND  C-DETL2-APC-PMT-IND   
FSSCPDCL-APC-DISC-FCTR  C-DETL2-APC-DISC-FCTR  
FSSCPDCL-APC-DEN-REJ  C-DETL2-APC-DEN-REJ   
FSSCPDCL-APC-PKG-FLAG  C-DETL2-APC-PKG-FLAG  
FSSCPDCL-APC-PAY-ADJ-FLAG  C-DETL2-APC-PAY-ADJ-   
FLG 
FSSCPDCL-APC-TOB-INCL  C-DETL2-APC-TOB-INCL   
FSSCPDCL-APC-ACTION-FLAG  C-DETL2-APC-ACTION-   
FLAG 
FSSCPDCL-ORIG-HCPC-CD  C-DETL2-ORIG-HCPC-CD   
FSSCPDCL-ORIG-HCPC-IND  C-DETL2-ORIG-HCPC-IND  
FSSCPDCL-HH-HRG-WGTS  C-DETL-HIPPS-WGT  Via W-DETL-REV-TRL.W-DETL-HIPPS- 
WGT via W-HIPPS-WGT in MD400600 
FSSCPDCL-LINES-FUTURE3 PIC  C-DETL-HIPPS-APC  Via W-DETL-REV-TRL.W-DETL-HIPPS- 
X(22)  APC via W-HIPPS-APC via WS-HOLD- 
HIPPS via WS-FUTURE.W-HCPC in 
MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-SORT-BYTE  1 or 2; set in MD400600 
FSSCPDCL-VAL-AMT  C-DETL-IND-MDED-PMT  Via W-MED-ED-PMT 
FSSCPDCL-DRG-REIMB-AMT  C-DETL-ASCPRICE-AMT  Via W-ASC-PRICE-AMT in MD400700 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-SEC-LIAB-PMT  Computed in MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-SEC-LIAB-PMT  Computed in MD400502 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-MSP-RED-IND  Via W-MSP-REDUCED-IND set in 
REDUCE-MSP procedure in MD400700 
  C-DETL-BLOOD-DEDUCT  Via W-VALUE-AMT-9 
  C-DETL-VAL62  Via W-VALUE-AMT-9 
  C-DETL-VAL63  Via W-VALUE-AMT-9 
  C-DETL-VAL64  Via W-VALUE-AMT-9 
  C-DETL-VAL65  Via W-VALUE-AMT-9 
  C-DETL-DSH-PMT  Via W-VALUE-AMT-9 
  C-DETL-INTEREST-PMT  Via W-VALUE-AMT-9 
  C-DETL-ESRD-NETWORK  Via W-VALUE-AMT-9 
  C-DETL-SEQ-AMT  Via W-VALUE-AMT-9 
  C-DETL-FEE-MSP  Via W-VALUE-AMT-9 
  C-DETL-FEE-SEQ  Via W-VALUE-AMT-9 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-NPI  Field is not referenced by any programs 
NO IDENTIFIABLE FIELD IN PCR  C-DETL2-NPI  C-DETL2-KEY via C-DETL-KEY 
  C-DETL-LIFE-DAYS  Via W-LR-DAY-TOT in MD400600; see W- 
LR-DAY-TOT in this crosswalk. 
  C-DETL-COINSURANCE  Via W-O-COINSURANCE 
FSSCPDCL-PATIENT-STATUS  C-DETL-BNFT-EXH-IND  In MD400600: 
 
IF FSSCPDCL-PATIENT-STATUS = '30' 
MOVE 'S' TO C-DETL-BNFT-EXH-IND  FI Paid Claim File  PS&R Detail Record File  Comments 
  C-DETL-TOT-COV-CHG   
  C-DETL-OUT-DAYS-PMT  Via W-OUT-REIMB-AMT 
  W-OUT-REIMB-AMT  Via W-OUT-REIMB-AMT 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-TRANS-PMT  IF W-OUT-REIMB = 'Y' AND W-OUT- 
TYPE = 'C' 
COMPUTE C-DETL-TRANS-PMT = 
FSSCPDCL-REIMB-PROV-AMT - 
W-OUT-REIMB-AMT 
ELSE 
COMPUTE C-DETL-TRANS-PMT = 
FSSCPDCL-REIMB-PROV-AMT. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-HCPC-TOTREIM   
  C-DETL-HCPC-TOT-CHG  ADD W-DETL-HCPCS-BLDCHG TO C- 
DETL-HCPC-TOT-CHG 
  C-DETL-HH-DME-COINS  Redefines C-DETL-ASCPRICE-AMT and is 
not used in MD400600. Used in MD400502 
and MD400501 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-ICN-IND  MOVE 'I' TO C-DETL-ICN-IND appears to 
be the only reference to this field in 
MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-GROSSUP-IND  IF (C-DETL-THRU-DATE (1:4) = '1992' 
OR '1993') AND 
(C-DETL-GROSSUP-IND NOT = 'G') 
AND 
(C-DETL-RPT-TYPE = '136' OR '137' 
OR '138' OR '139') 
PERFORM  GROSSUP-CHECK 
MOVE 'G' TO C-DETL-GROSSUP-IND. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-FEE-RED-IND  C-DETL-FEE-RED-IND is not referenced in 
MD400600. Set to 'Y' in M400502. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-ORIG-THRU-CT  The only reference to this field in MD400600 
is this statement: 
 
IF C-DETL-THRU-DATE = C-PDTE- 
START (W-SUB) 
MOVE 1 TO C-DETL-ORIG-THRU-CT 
MOVE C-DETL-THRU-DATE TO C- 
DETL-ORIG-THRU-DATE (1) 
SUBTRACT 1 FROM W-SUB 
MOVE C-PROV-PD-END (W-SUB) TO 
C-DETL-THRU-DATE 
MOVE 2 TO W-SUB. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-SPLIT-CT  The sole apparent use of this field in 
MD400600 occurs here: 
 
SPLIT-RTN. 
IF W-SPLIT-TYPE (W-SUB) NOT = 
SPACES 
ADD 1 TO C-DETL-SPLIT-CT 
MOVE W-SPLIT-TYPE (W-SUB) TO 
C-DETL-SPLIT-IND (C-DETL- 
SPLIT-CT) 
SPLIT-RTN-EXIT. 
EXIT.  FI Paid Claim File  PS&R Detail Record File  Comments 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-REV-TRL-CT  C-DETL-REV-TRL-CT is an index, used in 
the context of this statement in MD400600: 
MOVE W-DETL-REV-TRL TO C-DETL- 
REV-TRL (C-DETL-REV-TRL-CT) 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-HCPCS-TRL-CT  IF W-ASC-PRICE-AMT > 
MOVE W-DETL-HCPCS-TRL TO 
C-DETL-HCPCS-TRL (C-DETL-HCPCS- 
TRL-CT) 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-OPPS-GEN-IND  Field is set in this portion of MD400600: 
 
IF W-OPPS-CLAIM = 'Y' OR W-OCEFLG1 
N = 'Y' 
OR (FSSCPDCL-STMT-COV-FROM-DT- 
CYMD > '20000731' AND 
(PDCL-OUTP-CLAIM AND (W-BILL- 
TYPE72X-SW NOT = 'Y') 
AND (FSSCPDCL-PAID-DT-CYMD > 
'20000611'))) 
MOVE 'Y' TO C-DETL-OPPS-GEN- 
IND. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-ORIG-THRU-DATE  Field is set in this portion of MD400600: 
 
ORIG-THRU-RTN. 
IF C-DETL-THRU-DATE = C-PDTE- 
START (W-SUB) 
MOVE 1 TO C-DETL-ORIG-THRU-CT 
MOVE C-DETL-THRU-DATE TO C- 
DETL-ORIG-THRU-DATE (1) 
SUBTRACT 1 FROM W-SUB 
MOVE C-PROV-PD-END (W-SUB) TO 
C-DETL-THRU-DATE 
MOVE 2 TO W-SUB. 
ORIG-THRU-RTN-EXIT. 
EXIT. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-SPLIT-IND  Field is set in this portion of MD400600: 
 
SPLIT-RTN. 
IF W-SPLIT-TYPE (W-SUB) NOT = 
SPACES 
ADD 1 TO C-DETL-SPLIT-CT 
MOVE W-SPLIT-TYPE (W-SUB) TO 
C-DETL-SPLIT-IND (C-DETL-SPLIT- 
CT) 
SPLIT-RTN-EXIT. 
EXIT. 
NO IDENTIFIABLE FIELD IN PCR  W-NCOV-UNITS  IF W-UNITS > 0 
COMPUTE W-UNIT-CHG = W-SERV- 
CHARGES / W-UNITS 
COMPUTE W-COV-UNITS = W-COV- 
CHG / W-UNIT-CHG 
COMPUTE W-NCOV-UNITS = W-I- 
SERV-NCOV-CHARGES / W-UNIT-CHG. 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-REV-NCV-IND  Set via W-DETL-REV-NCV-IND via 
program logic.  FI Paid Claim File  PS&R Detail Record File  Comments 
NO IDENTIFIABLE FIELD IN PCR  W-LR-DAYS-TOT  COMPUTE W-LR-DAYS-TOT = 
(FSSCPDCL-LIFE-DY-CNT + 
FSSCPDCL-LTR-DAYS-2ND-YR). 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-FULL-DAYS  IF FSSCPDCL-CST-REP-DYS > 0 OR (W- 
SEC-LIAB = 'R' OR 'Y') 
COMPUTE C-DETL-FULL-DAYS = 
FSSCPDCL-CST-REP-DYS - 
FSSCPDCL-COIN-DAYS-1ST-YR - W- 
LR-DAYS-TOT 
ELSE 
COMPUTE C-DETL-FULL-DAYS = 
FSSCPDCL-COV-DY-CNT - 
FSSCPDCL-COIN-DAYS-1ST-YR  W- 
LR-DAYS-TOT. 
W-ASC-TRL  C-DETL-ASC-TRL  See the 2 constituent fields in this structure: C 
DETL-ASC-GRP-CD and C-DELT-ASC- 
PCT-IND 
  C-DETL-CAP-TRL  See the 13 constituent fields in this structure 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-FREE-BYTES   
NO IDENTIFIABLE FIELD IN PCR  C-DETL-FREE-BYTE   
NO IDENTIFIABLE FIELD IN PCR  C-DETL-FREE-BYTE-CT   
NO IDENTIFIABLE FIELD IN PCR  C-DETL-CAP-TRL-CT  Set to zero and incremented in MD400600 
  C-DETL-OUT-COST-PMT  Via W-OUT-REIMB-AMT in MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-ASC-TRL-CT  Set to zero and incremented in MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-VAL-AMT  Via W-VALUE-AMT-9 in MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-VAL-CNT  Set to zero and incremented in MD400600 
NO IDENTIFIABLE FIELD IN PCR  C-DETL-CLM-NCV-IND   
NO IDENTIFIABLE FIELD IN PCR  C-DETL-GROSS-APC  Set to zero only in MD400600 
  C-DETL-VAL64  Via W-VALUE-AMT-9 
  C-DETL-VAL65  Via W-VALUE-AMT-9 
  C-DETL2-FREQ-CD  C-DETL2-KEY via C-DETL-KEY 
NO IDENTIFIABLE FIELD IN PCR  C-DETL2-SORT-BYTE  C-DETL2-KEY via C-DETL-KEY; then set 
to '2 
NO IDENTIFIABLE FIELD IN PCR  C-DETL2-OPPS-TRL-CT  Via C-DETL-HCPCS-TRL-CT 
NO IDENTIFIABLE FIELD IN PCR  C-DETL2-OPPS-TRL  Container of recurring structures containing: 
C-DETL2-APC-HCPCS-PROC 
C-DETL2-APC-PMT-APC 
C-DETL2-PRICER-LINE-RTC 
C-DETL2-PRICER-IND 
C-DETL2-APC-ACTION-FLAG 
C-DETL2-APC-GROSS-PMT 
C-DETL2-PROV-REIMB-LINE 
C-DETL2-APC-SERV-IND 
C-DETL2-APC-TOB-INCL 
C-DETL2-APC-PMT-IND 
C-DETL2-APC-DISC-FCTR 
C-DETL2-APC-DEN-REJ 
C-DETL2-APC-PKG-FLAG 
C-DETL2-APC-PAY-ADJ-FLG 
C-DETL2-REV-COV-CHG-AMT 
C-DETL2-REDU-COIN-LINE 
C-DETL2-WGE-ADJ-COIN-LINE 
C-DETL2-PSY-ESRD-BLD-HEMO  FI Paid Claim File  PS&R Detail Record File  Comments 
    C-DETL2-PAT-CASH-DED-LINE 
C-DETL2-ORIG-HCPC-CD 
C-DETL2-ORIG-HCPC-IND 
  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R321FM 08/09/2019 The Fiscal Intermediary Shared System (FISS)  01/06/2020 11359 
Submission of Copybook Files to the Provider 
and Statistical Reimbursement (PS&R) System  
R60FM  11/26/2004 Revised Instructions on Contractor Procedures  01/24/2005 3492 
for Provider Audit and the Provider Statistical 
and Reimbursement Report (PSRR) 
R27FM  12/19/2003 Provider Statistical and Reimbursement System  01/05/2004 2902 
R09FM  08/30/2002 Initial Publication of Chapter  N/A  N/A 
Back to top of chapter