evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Provider Specific File Data   Data Element  Title  1 National Provider Identifier (not a mandatory entry at this time)  2 Provider CMS Certification Number (CCN)  3 Effective Date  4 Fiscal Year Begin Date  5 Report Date  6 Termination Date  7 Waiver Indicator  Data Element  Title  9 Provider Type (must be 03 or 06) Effective July 1, 2006, 06 is no longer valid.  Contractors shall use 49.  12 Actual Geographic Reclassification -MSA (no longer applicable effective July 1, 2006)  17 Temporary Relief Indicator (For IPF PPS, code Y if there is an Emergency Department)  18 Federal PPS Blend Indicator (must be 1, 2, 3, or 4)  21 Case Mix Adjusted Cost Per Discharge/PPS Facility Specific Rate (This is determined using the same methodology that would be used to determine the interim payment per discharge under the TEFRA system if the IPF PPS were not being implemented.)  22 Cost of Living Adjustment (COLA)  23 Intern/Bed Ratio  25 Combined Capital and Operating Cost to Charge Ratio  33 Special Wage Indicator (should be set to 1 if there is a change to the wage index.)  35 Actual Geographic Location  Core -Based Statistical Area (CBSA) (required July 1, 2006)  38 Special Wage Index  48 New Hospital  63 Supplemental Wage Index  64 Supplemental Wage Index Indicator   Bill Data   National Provider Identifier  Covered Charges  Provider CMS Certification Number (CCN)  Discharge Date (or benefits exhaust date if present)  Patient Age  Other Diagnosis Codes  DRG  Other Procedure Codes  Length of Stay Indicator for Occurrence Code 31, A3, B3, or C3 to apply outlier to this bill.  Source of Admission  ECT Units  Patient Status Code  Claim Number  National Provider Identifier  Covered Charges   Indicator for Value Code75 to apply variable per diem adjustment to this bill.   Outputs   In addition to returning the above bill data inputs, Pricer will return the following:   Final Payment  National Non -Labor Rate  DRG/MS -DRG Adjusted Payment  Federal Rate  Federal Adjusted Payment  Budget Neutrality Rate  Outlier Adjusted Payment  Outlier Threshold  Comorbidity Adjusted Payment  Federal Per Diem Base Rate  Per Diem Adjusted Payment  Standardized Factor  Facility Adjusted Payment  Labor Share  Age Adjusted Payment  Non-Labor Share  Rural Adjusted Payment  COLA  Teaching Adjusted Payment  Day of Stay Adjustment  ED Adjusted Payment  Age Adjustment  ECT Adjusted Payment  Comorbidity Adjustment  Return Code  DRG Adjustment  MSA/CBSA  Rural Adjustment  Wage Index  ECT Adjustment  National Labor Rate  Blend Year Calculation Version
(Medicare Claims Processing Manual)
200 - Electronic Health Record (EHR) Incentive Payments  (Rev. 2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)  The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111- 5) provides incentive payments for acute care hospitals (subsection (d) hospitals) and critical access hospitals (CAHs) who are meaningful users of certified electronic health records (EHR) technology.  200.1 - Payment Calculation  (Rev.  2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)  A - Incentive Payment Calculation for Subsection (d) Hospitals   [Initial Amount] x [Medicare Share] x [Transition Factor]   o Initial Amount  equals $2,000,000 + [$200 per discharge for the 1,150th - 23,000th discharge]   o Medicare Share equals Medicare/(Total*Charges), whereas:   o Medicare equals [number of Inpatient Bed Days for Part A Beneficiaries] plus [number of Inpatient Bed Days for MA Beneficiaries]   o Total  equals [number of Total Inpatient Bed Days]   o Charges  equals [Total Charges minus Charges for Charity Care*] divided by [Total Charges]   o Transition Factor   Fiscal Year  Fiscal Year that Eligible Hospital First Receives the Incentive Payment   2011 2012 2013 2014 2015 2011 1.00     2012 0.75 1.00    2013 0.50 0.75 1.00   2014 0.25 0.50 0.75 0.75  2015  0.25 0.50 0.50 0.50 2016   0.25 0.25 0.25  B - Incentive Payment Calculation for Critical Access Hospitals (CAHs)   CAH Reasonable Cost x Medicare Share*   * See Medicare Share computation in sub -section A above.   200.2 - Submission of Informational Only Bills for Maryland Waiver Hospitals and Critical Access Hospitals (CAHs)  (Rev. 2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)
(Medicare Claims Processing Manual)
Acute care hospitals already submit informational only bills for purposes of including Part C days in the Disproportionate Share (DSH) calculations, as explained in Section 20.3 above.  However, Maryland waiver hospitals and CAHs do not currently submit informational only bills.  In order for CMS to capture Part C days for purposes of calculating EHR payments, Maryland waiver hospitals and CAHs must submit informational only claims to Medicare, effective for discharges October 1, 2010.  Informational only c laims are claims billed for patients enrolled in a Medicare Advantage (MA) Plan and contain a condition the following elements:    Covered 11X TOB (not 110)   Condition Code 04   Medicare is the primary payer   There is no MSP   Beneficiarys Medicare HICN   All other required claim elements
(Medicare Claims Processing Manual)
250.18 Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)  (Rev.  4153, Issued: 10- 26-18, Effective: 04 -01-19, Implementation: 04- 01-19) An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon- small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier  -53. (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388- 53, 45378- 53, G0105- 53 and G0121- 53. An incomplete c olonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one -half the value of the inputs for the codes. As such, instruct CAHs that elect Method II payment to use modifier  -53 to identify an incomplete screening colonoscopy (physician professional service(s) billed in revenue code 096X, 097X, and/or 098X).  CAH Method II shall be consistent with the guidelines outlined in PUB. 100- 04, chapter 12, section 30.1 and chapter 18, section 60.2.                          Addendum A - Provider Specific File  (Rev. 12234, Issued: 08-31-23, Effective: 10-01-2023, Implementation: 10-02-2023)   Data Element  File Position  Format  Title  Description  1 1-10 X(10)  National Provider Identifier (NPI)  Alpha -numeric 10 character  NPI number.  Data Element  File Position  Format  Title  Description
(Medicare Claims Processing Manual)
Data Element  File Position  Format  Title  Description  1 1-10 X(10)  National Provider Identifier (NPI)  Alpha -numeric 10 character  NPI number.  Data Element  File Position  Format  Title  Description   11-16 X(6)  Provider CMS Certification Number (CCN)  Alpha -numeric 6 character provider number.  Cross check to provider type.  Positions 3 and 4 of: Provider #  Provider Type  00-08 Blanks, 00, 07 -11, 13-17, 21-22; NOTE: 14 and 15 no longer valid, effective 10/1/12  12 18 13 23,37  20-22 02 30 04 33 05 40-44 03 50-64 32-34, 38  15-17 35 70-84, 90 -99 36 Codes for special units are in the third position of the provider CMS Certification Number (CCN) and should correspond to the appropriate provider type, as shown below ( NOTE:  SB = swing bed): Special Unit  Prov. Type  M - Psych unit in CAH  49 R  - Rehab unit in CAH  50 S - Psych Unit  49 T - Rehab Unit  50 U - SB for short -term hosp.  51 W - SB for LTCH  52 Y - SB for Rehab  53 Z - SB for CAHs  54  3 17-24 9(8) Effective Date  Must be numeric, CCYYMMDD.  This is the effective date of the provider's first PPS period, or for subsequent PPS periods, the effective date of a change to the PROV file.  If a termination date is present for this record, the effective date must be equal to or less than the termination date. Year: Greater than 82, but not greater than current year.  Month: 01-12 Day: 01 -31 Data Element  File Position  Format  Title  Description  4 25-32 9(8) Fiscal Year Beginning Date Must be numeric, CCYYMMDD.  Year: Greater than 81, but not greater than current year.  Month: 01-12 Day: 01-31 Must be updated annually to show the current year for providers receiving a blended payment based on their FY begin date.  Must be equal to or less than the effective date.  5 33-40 9(8) Report Date  Must be numeric, CCYYMMDD.  Date file created/run date of the PROV report for submittal to CMS CO.  6
(Medicare Claims Processing Manual)
41-48 9(8) Termination Date  Must be numeric, CCYYMMDD.  Termination Date in this context is the date on which the reporting MAC ceased servicing the provider. Must be zeros or contain a termination date.  Must be equal to or greater than the effective date.  If the provider is terminated or transferred to another MAC, a termination date is placed in the file to reflect the last date the provider was serviced by the outgoing MAC.  Likewise, if the provider identification number changes, the MAC must place a ter mination date in the PROV file transmitted to CO for the old provider identification number. 7 49 X(1)  Waiver Indicator  Enter a Y or N.  Y = waived (Provider is not under PPS). N = not waived (Provider is under PPS).  8 50-54 9(5) Intermediary Number  Assigned intermediary number.  9 55-56 X(2)  Provider Type  This identifies providers that require special handling.  Enter one of the following codes as appropriate. 00 or blanks = Short Term Facility 02 Long Term 03 Psychiatric 04 Rehabilitation Facility  05 Pediatric 06 Hospital Distinct Parts  Data Element  File Position  Format  Title  Description  (Provider type 06 is effective until July 1, 2006.  At that point, provider type 06 will no longer be used.  Instead, MACs will assign a hospital distinct part as one of the following provider types: 49, 50, 51, 52, 53, or 54) 07 Rural Referral Center  08 Indian Health Service 13 Cancer Facility  14 Medicare Dependent Hospital  (during cost reporting periods that began on or after April 1, 1990).  15 Medicare Dependent Hospital/Referral Center  (during cost reporting periods that began on or after April 1, 1990.  Invalid October 1, 1994 through September 30, 1997).   16 Re-based Sole Community Hospital 17 Re-based Sole Community Hospital/ Referral Center  18 Medical Assistance Facility  21 Essential Access Community Hospital 22 Essential Access Community Hospital/Referral Center  23 Rural Primary Care Hospital 32 Nursing Home Case Mix Quality Demo Project  Phase II  33 Nursing Home Case Mix Quality Demo Project  Phase III  Step 1  34 Reserved  35 Hospice 36 Home Health Agency  37 Critical Access Hospital  38 Skilled Nursing Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998 40 Hospital Based ESRD Facility  41 Independent ESRD Facility 42 Federally Qualified Health Centers  43 Religious Non-
(Medicare Claims Processing Manual)
Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998 40 Hospital Based ESRD Facility  41 Independent ESRD Facility 42 Federally Qualified Health Centers  43 Religious Non- Medical Health Care Institutions  44 Rural Health Clinics -Free Standing  Data Element  File Position  Format  Title  Description  45 Rural Health Clinics -Provider Based  46 Comprehensive Outpatient Rehab Facilities  47 Community Mental Health Centers 48 Outpatient Physical Therapy Services  49 Psychiatric Distinct Part 50 Rehabilitation Distinct Part 51 Short- Term Hospital  Swing Bed 52 Long- Term Care Hospital  Swing Bed 53 Rehabilitation Facility  Swing Bed 54 Critical Access Hospital  Swing Bed NOTE:  Provider Type values 49- 54 refer to special unit designations that are assigned to the third position of the provider CMS Certification Number (CCN) (See field #2 for a special unit- to-provider type cross -walk).  10 57 9(1) Current Census Division  Must be numeric (1 -9).  Enter the Census division to which the facility belongs for payment purposes.  When a facility is reclassified for the standardized amount, MACs must change the census division to reflect the new standardized amount location.  Valid codes a re: 1 New England 2 Middle Atlantic  3 South Atlantic  4 East North Central  5 East South Central 6 West North Central  7 West South Central  8 Mountain 9 Pacific  NOTE:  When a facility is reclassified for purposes of the standard amount, the MAC changes the census division to reflect the new standardized amount location.  11 58 X(1)  Change Code Wage Index Reclassification  Enter "Y" if hospital's wage index location has been reclassified for the year. Enter "N" if it has not been reclassified for the year.  Adjust annually.  12 59-62 X(4)  Actual Geographic Location - MSA  Enter the appropriate code for the MSA 0040-9965, or the rural area, (blank) (blank) 2 digit numeric State code such as Data Element  File Position  Format  Title  Description  _ _36 for Ohio, where the facility is physically located.  13 63-66 X(4)  Wage Index Location - MSA  Enter the appropriate code for the MSA, 0040-9965, or the rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the actual location MSA
(Medicare Claims Processing Manual)
rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the actual location MSA (field 13), if not reclassified.  Pricer will automatically default to the actual location MSA if this field is left blank.  14 67-70 X(4)  Standardized Amount MSA Location  Enter the appropriate code for the MSA, 0040-9965, or the rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified for standardized amount.  Leave blank or enter the actual location MSA (field 13) if not reclassified.  Pricer will automatically default to the actual location MSA if this field is left blank.  15 71-72 X(2)  Sole Community or Medicare Dependent Hospital  Base Year  Leave blank if not a sole community hospital (SCH) or a Medicare dependent hospital (MDH) effective with cost reporting periods that begin on or after April 1, 1990.  If an SCH or an MDH, show the base year for the operating hospital specific rate, the higher of either 82 or 87.  See 20.6 .  Must be completed for any SCH or MDH that operated in 82 or 87, even if the hospital will be paid at the Federal rate.   16
(Medicare Claims Processing Manual)
73 X(1)  Change Code for Lugar reclassification  Enter an "L" if the MSA has been reclassified for wage index purposes under 1886(d)(8)(B) of the Act.  These are also known as Lugar reclassifications, and apply to ASC-approved services provided on an outpatient basis when a hospital qualifies for payment under an alternate wage index MSA. Leave blank for hospitals if there has not been a Lugar reclassification.  Data Element  File Position  Format  Title  Description  17 74 X(1)  Temporary Relief Indicator  Enter a Y if this provider qualifies for a payment update under the temporary relief provision, otherwise leave blank. IPPS : Effective October 1, 2004, code a Y if the provider is considered low volume. IPF PPS : Effective January 1, 2005, code a Y if the acute facility where the unit is located has an Emergency Department or if the freestanding psych facility has an Emergency Department.  IRF PPS:  Effective October 1, 2005, code a Y for IRFs located in the state and county in Table 2 of the Addendum of the August 15, 2005 Federal Register (70 FR 47880).  The table can also be found at the following website:  www.cms.hhs.gov/InpatientRehabFacPPS/07DataFiles.asp#topOfPage LTCH PPS: Effective 04/21/16 through 12/31/16, code a Y for an LTCH that is a grandfathered HwH (hospitals that are described in  412.23(e)(2)(i) that currently meets the criteria of  412.22(f)); and is located in a rural area or is reclassified rural by meeting the provisions outlined in 412.103, as set forth in the regulations at 412.522(b)(4).  18 75 X(1)  Federal PPS Blend Indicator HH PPS:  For From dates before 1/1/2021:  Enter the value to indicate if normal percentage payments should be made on RAP and/or whether payment should be reduced under the Quality Reporting Program.  Valid values: 0 = Make normal percentage payment  1 = Pay 0% 2 = Make final payment reduced by 2% 3 = Make final payment reduced by
(Medicare Claims Processing Manual)
payments should be made on RAP and/or whether payment should be reduced under the Quality Reporting Program.  Valid values: 0 = Make normal percentage payment  1 = Pay 0% 2 = Make final payment reduced by 2% 3 = Make final payment reduced by 2%, pay RAPs at 0% NOTE: All new HHAs enrolled after January 1, 2019 must have this value set to 1 or 3 (no RAP payments).  For From dates on or after 1/1/2021: Enter the value to indicate whether Data Element  File Position  Format  Title  Description  payment should be reduced under the Quality Reporting Program.  Valid values: 0 = Make normal percentage payment  2 = Make final payment reduced by 2%
(Medicare Claims Processing Manual)
IRF PPS:  All IRFs are 100% Federal for cost reporting periods beginning on or after 10/01/2002. LTCH PPS:   For cost reporting periods beginning on or after 10/01/2002, enter the appropriate code for the blend ratio between federal and facility rates for the LTCH provider:    Federal %  Facility%  1 20 80 2 40 60 3 60 40 4 80 20 5 100 00  For LTCH cost reporting periods beginning on or after 10/01/2015 enter the appropriate code for the blend year representing 50% site neutral payment and 50 % standard payment.   6 Blend Year 1  (represents 50% site neutral payment and 50 % standard payment effective for all LTCH providers with cost reporting periods beginning on or after 10/01/2015 through 09/30/16)   7 - Blend Years 2 through 4  (represents 50% site neutral payment and 50 % standard payment effective for all LTCH providers with cost reporting periods beginning in FY 2017, FY 2018 or FY 2019   8 - Blank  Transition Blend no longer applies with cost reporting periods beginning in on or after 10/01/2019. Full Site Neutral payment   Data Element  File Position  Format  Title  Description  IPF PPS:  Enter the appropriate code for the blend ratio between federal and facility rates.  Effective for all IPF providers with cost reporting periods beginning on or after 1/1/2005.  Federal %  Facility%  1 25 75 2 50 50 3 75 25 4 100 00   19 76-77  9(2) State Code  Enter the 2 -digit state where the provider is located.  Enter only the first (lowest) code for a given state. For example, effective October 1, 2005, Florida has the following State Codes: 10, 68 and 69.  MACs shall enter a 10 for Floridas state code.  List of valid state codes is located in Pub. 100-07, Chapter 2, Section 2779A1.  20 78-80 X(3)  Filler  Blank.  21 81-87 9(5)V9(2)  Case Mix Adjusted Cost Per Discharge/PPS Facility Specific Rate
(Medicare Claims Processing Manual)
For PPS hospitals and waiver state non -excluded hospitals, enter the base year cost per discharge divided by the case mix index.  Enter zero for new providers.  See 20.1  for sole community and Medicare-dependent hospitals on or after 04/01/90. For inpatient PPS hospitals, verify if figure is greater than $10,000.  For LTCH, verify if figure is greater than $35,000.   22 88-91  9V9(3)   Cost of Living Adjustment (COLA)  Enter the COLA.  All hospitals except Alaska and Hawaii use 1.000. 23 92-96 9V9(4)  Intern/Beds Ratio  Enter the provider's intern/resident to bed ratio.  Calculate this by dividing the provider's full time equivalent residents by the number of available beds (as calculated in positions 97-101).  Do not include residents in anesthesiology who are employed t o replace anesthetists or those assigned to PPS excluded units.  Base the count upon the average number of full- time equivalent residents assigned to the hospital during the fiscal year.  Correct cases where there is reason to believe that Data Element  File Position  Format  Title  Description  the count is substantially in error for a particular facility.  The MAC is responsible for reviewing hospital records and making necessary changes in the count at the end of the cost reporting period. Enter zero for non-teaching hospitals. IPF PPS:  Enter the ratio of residents/interns to the hospitals average daily census.  24
(Medicare Claims Processing Manual)
97-101 9(5) Bed Size  Enter the number of adult hospital beds and pediatric beds available for lodging inpatient. Must be greater than zero.  (See the Provider Reimbursement Manual, 2405.3G.)  25 102-105 9V9(3)  Operating Cost to Charge Ratio  Derived from the latest settled cost report and corresponding charge data from the billing file.  Compute this amount by dividing the Medicare operating costs by Medicare covered charges.  Obtain Medicare operating costs from the Medicare cost repot form C MS-2552-96, Supplemental Worksheet D-1, Part II, Line 53.  Obtain Medicare covered charges from the MAC billing file, i.e., PS&R record.  For hospitals for which the MAC is unable to compute a reasonable cost- to-charge ratio, they use the appropriate urban or rural statewide average cost -to-charge ratio calculated annually by CMS and published in the " Federal Register."  These average ratios are used to calculate cost outlier payments for those hospitals where you compute cost- to-charge ratios that are not within the limits published in the "Federal Register."  For LTCH and IRF PPS, a combined operating and capital cost- to-charge ratio is entered here.  See below for a discussion of the use of more recent data for determining CCRs.  Data Element  File Position  Format  Title  Description  26 106-110  9V9(4)   Case Mix Index   The case mix index is used to compute positions 81-87 (field 21).  Zero- fill for all others.  In most cases, this is the case mix index that has been calculated and published by CMS for each hospital (based on 1981 cost and billing data) reflecting the relative cost of that hospital's mix of cases compared to the national average mix.  27 111-114 V9(4)  Supplemental Security Income Ratio