(Medicare Claims Processing Manual)

13-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  14-Filler  X(01)  52 - 52  15- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   16-Filler  X(01)  60 - 60   50.2 - Institutional Claim Record Layout for the Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule  (Rev. 3350, Issued: 09- 11-15, Effective: 01 -01-16, Implementation: 01- 04-16)  This file contains services subject to national Floors and Ceilings under the DMEPOS Fee Schedules including Surgical Dressings.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label DMEPOS.   Record Length  - 60 Record Format  - FB Block Size  - 6000  Character Code  - EBCDIC  Sort Sequence  - Label, HCPCS Code, MOD, State   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-MOD  X(02)  6  7  3-MOD 2  X(02)  8  9  4-Fee Schedule Amt  9(05)V99  10  16  5-Filler  X(01)  17  6-Rural Fee Amt 9(05)v99  18  24  7-Filler  X(01)  25  8-Rural Fee indicator  X(01)  26- R = Rural Fee is present  9-Filler  X(04)  27-30  10-State  X(02)  31 - 32  11-Filler  X(05)  33 - 37  12-*Label*  X(3)  38 - 40 DME = Durable Medical Equipment (other than oxygen)  OXY = Oxygen  Data Element Name  Picture  Location  Comment  P/O = Prosthetic/Orthotic  S/D = Surgical Dressings  13-Filler  X(4)  41 - 44  14-*Pricing Change Indicator  X(1)  45 - 45 0 = No change to Update Fee Schedule Amount since previous release  1 = A change has occurred to the Update Fee Schedule Amount since the previous release.  NOTE:  In the initial release of the annual update, this field is initialized to >0 15-Filler  X(02)  46  47  16-Effective Date  X(08)  48  55 Update effective date (YYYYMMDD)  17-Filler  X(05)  56  60   50.3 - Institutional Claim Record Layout for the Outpatient Rehabilitation and CORF Services Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for outpatient rehabilitation and CORF services payment.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label ABSTR.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  Data Element Name  Picture  Location  Comment  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment. 5-Facility Fee  9(05)V99  12 - 22  6-Effective Date  X(08)  23 - 30 Update effective date  7- A/B MAC (B) Number  X(05)  31 - 35  8-Locality  X(02)  36 - 37  9-Filler  X(03)  38 - 40  10-Fee Indicator  X(1)  41 - 41 R = Rehab/Audiology function test/CORF services  11-Outpatient Hospital  X(1)  42 - 42 0 = Fee applicable in hospital outpatient setting  1 = Fee not applicable in hospital outpatient setting  12-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  13-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  14-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  15-Filler  X(01)  52 - 52  16- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   17-Filler  X(01)  60 - 60   50.4 - Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This section contains the record layout for the SNF extract for radiology Services, other diagnostic services, and other SNF services priced on the MPFS.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label SNF.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14 The SNF fee schedule amount is based on the non- facility rate which is the fee that physicians may receive if performing the service in the physicians office.  4-PCTC Indicator  X(01)  15 - 15  5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)  23 - 30 31 - 35 Update effective date  8-Locality  X(02)  36 - 37  9-Filler  X(05)  38 - 42  Data Element Name  Picture  Location  Comment  10-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  11-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  12-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  13-Filler  X(01)  52 - 52  14- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   15-Filler  X(01)  60 - 60   50.5 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  50.6  Physician Fee Schedule Payment Policy Indicator File Record Layout  (Rev.12326; Issued:10- 26-23; Effective: 01 -29-24; Implementation:01 -29-24)   When a Medicare beneficiary elects hospice services, hospices must complete the data elements  identified  below  for the Uniform  (Institutional Provider)  Bill (Form  CMS -1450)  or its electronic equivalent, which is a Notice of Election (NOE).   The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used for processing Method II CAH professional services with revenue codes 96X, 97X or 98X.     FIELD NAME & DESCRIPTION LENGTH & PIC Position  File Year  This field displays the effective year of the file.  4 Pic x(4)  1-4 HCPCS Code   This field represents the procedure code.   Each Current Procedural Terminology (CPT) code and alpha -numeric HCPCS codes that are currently returned on the MPFS supplemental file will be included when the MPFS Status Indicator is A, C, T, and some with R.  The standard sort for this field is blanks, alpha, and numeric in ascending order.  5 Pic x(5)  5-9 Modifier   For diagnostic tests, a blank in this field denotes the global service and the following modifiers identify the components:  26 = Professional component; and TC = Technical component.  For services other than those with a professional and/or technical component, a blank will appear in this field with one exception: the presence of CPT modifier -53 which indicates that separate Relative Value Units (RVUs) and a fee schedule amount have be en established for procedures which the physician terminated before completion.  This modifier is used only with colonoscopy code 45378 and screening colonoscopy codes G0105 and G0121.  Any other codes billed with modifier -53 are subject 2 Pic x(2)  10-11 FIELD NAME & DESCRIPTION LENGTH & PIC Position  to medical review and priced by individual consideration.  Modifier -53 = Discontinued Procedure -  Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure.  Due to extenuating circumstances, or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Code Status   This 1 position field provides the status of each code under the full fee schedule.  Each status code is explained in Pub. 100-04, Chapter 23, 30.2.2.  1 Pic x(1)  12 Global Surgery   This field provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service.   000 = Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.   010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative relative 3 Pic x(3)  13-15 FIELD NAME & DESCRIPTION LENGTH & PIC Position  values during a 10 -day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during this 10- day postoperative period generally not payable.   090 = Major surgery with a 1- day preoperative period and 90- day postoperative period included in the fee schedule payment amount.  MMM = Maternity codes; usual global period does not apply.   XXX = Global concept does not apply.  YYY = A/B MAC (A) determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing.  ZZZ = Code related to another service and is always included in the global period of the other service.  (NOTE: Physician work is associated with intra -service time and in some instances the post service time.)  Preoperative Percentage (Modifier 56)   This field contains the percentage (shown in decimal format) for the preoperative portion of the global package.  For example, 10 percent will be shown as 010000.  The total of the preoperative percentage, intraoperative percentage, and the postoperative p ercentage fields will 6 Pic 9v9(5)  16-21 FIELD NAME & DESCRIPTION LENGTH & PIC Position  usually equal one.  Any variance is slight and results from rounding. Intraoperative Percentage (Modifier 54)  This field contains the percentage (shown in decimal format) for the intraoperative portion of the global package including postoperative work in the hospital.  For example, 63 percent will be shown as 063000.  The total of the preoperative percentage, int raoperative percentage, and the postoperative percentage fields will usually equal one.  Any variance is slight and results from rounding. 6 Pic 9v9(5)  22-27 Postoperative Percentage (Modifier 55)