Input and Output Parameter Blocks User’s Guide - C Platform...Fixed and Variable Length Output...

Input & Output Parameter Blocks User’s Guide

C/Windows® Platform

V2107.00Last Updated: July 6, 2021 2:36 pm

Input & Output Parameter Block’s User’s Guide

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Table of ContentsTable of ContentsSummary of Data Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6ECB [ezg_cntl_block] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14PCB1 [patient_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32PCB2.CCD [cah_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49PCB2.ICD [ip_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PCB2.OCD [op_claim_data]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53PCB2.PCD [phys_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PCB2.RCD [rehab_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57PCB2.SCD [snf_claim_data] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63DX [dx_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64OP [op_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68LINE [line_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70GOB1.APC [apc_grpr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74GOB1.APG [apg_grpr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76GOB1.CMG [cmg_grpr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78GOB1.DRG [drg_grpr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83GOB1.RUG [rug_grpr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88GOB2.APC [apc_grpr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89GOB2.APG [apg_grpr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93GOB2.CMG [cmg_grpr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96GOB2.DRG [drg_grpr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97GOB2.RUG [rug_grpr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98GOB3.DRG [drg_grpr_output_dx] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99GOB4.DRG [drg_grpr_output_op] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101POB1.APC [apc_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102POB1.APG [apg_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111POB1.CAH [cah_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115POB1.CMG [cmg_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116POB1.DRG [drg_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119POB1.PP1 [phys_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138POB1.RUG [rug_prcr_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139POB2.APC [apc_prcr_output_entry]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140POB2.APG [apg_prcr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150POB2.CAH [cah_prcr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158POB2.PP1 [phys_prcr_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161


POB2.RUG [rug_prcr_output_entry]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164POB3.ESRD [esrd_prcr_block3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165EEB1 [ezedit_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167EEB2 [ezedit_id_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168EEB3 [ezedit_msg_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169EEB4 [ezedit_rtn_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170MEB1 [mce_editor_block1]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172MEB.DX [mce_dx_edits]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174MEB.OP [mce_op_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177MEB4 [mce_edit_summary] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178LEB1 [lcd_edit_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179LEB.OP [lcd_op_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180LEB.URL [lcd_op_url] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182AEB1 [ace_edit_block1_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183AEB.DX [ace_dx_edits_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189AEB.OP [ace_op_edits_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190AEB4 [ace_edit_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201AEB5 [ace_edit_summary] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203PWS1.APC [apchopd_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204PWS1.ASC [asc_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206PWS1.ESRD [esrd_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207PWS1.HCFA [hcfa_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211PWS1.LTC [ltc_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217PWS1.NY [ny_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221PWS1.PROF [prof_prcr_worksheet1]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224PWS1.APG [apg_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225PWS1.APR [apr_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226PWS1.DRG [drg_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227PWS1.HHA [hha_prcr_worksheet1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228OOB2 [opt_output_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229MOB1 [map_output_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230PATHS [ezg_paths] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232OOB1 [opt_output_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233GOB5.APC [apc_grpr_output_entry_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234GOB5.APG [apg_grpr_output_entry_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235GOB5.RUG [rug_grpr_output_entry_01] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236


MOB2.DX [map_dx_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237MOB3.OP [map_op_entry] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238PEB1 [pe_edit_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239PEB2 [pe_dx_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241PEB3 [pe_op_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242CAB1.EDC [edc_analyzer_block1]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244CAB1.EAM [eam_analyzer_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246CAB2.EDC [edc_analyzer_block2]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248CAB2.EAM [eam_analyzer_block2] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249CAB3.EDC [edc_analyzer_block3]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250CAB3.EAM [eam_analyzer_block3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251ECB2 [ezg_cntl_block2] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252PWS2.ASC [asc_prcr_worksheet2] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253PWS2.APG [apg_prcr_worksheet2] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254PWS2.HHA [hha_prcr_worksheet2] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255PWS3.APG [apg_prcr_worksheet3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256PWS3.HHA [hha_prcr_worksheet3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257PWS4.APR [apr_prcr_worksheet4] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258PWS4.DRG [drg_prcr_worksheet4] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259PWS4.HHA [hha_prcr_worksheet4] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260OEB1 [outpatient_edit_block1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261OEB2 [outpatient_dx_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263OEB3 [outpatient_op_edits] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266


Summary of Data StructuresThe input and output data structures used for processing by the EASYGroup™ Optimizer are listed in the following table. The EASYGroup™ structures listed below are also defined in the optcntl.h header file that is included in the distribution.

Table 0-1: Input and Output Data Structures

Data Structures Length OP Codes

01 11 12 14 15 16 18Master Control Structure

ECB [ezg_cntl_block] Fixed Both Both Both Both Both Both BothECB2 [ezg_cntl_block2] Fixed Both Both Both Both Both Both BothDemographic Input Structures

PCB1 [patient_claim_data] Fixed In In In In In In InPCB2.CCD [cah_claim_data] Fixed In In In InPCB2.ICD [ip_claim_data] Fixed In In In In In InPCB2.OCD [op_claim_data] Fixed In In In In In InPCB2.RCD [rehab_claim_data] Fixed In In In In InPCB2.PCD [phys_claim_data] Fixed In In InPCB2.SCD [snf_claim_data] Fixed In In In InClinical Data Structures

DX [dx_entry] numdx In In In In In In InOP [op_entry] numop In

(D,E, P, H, M)In In In In In

LINE [line_entry] numhcpcs In (E,C,O,T, N, Y)

In In In In In

Fixed Length Grouper Output Structures

GOB1.DRG [drg_grpr_block1] Fixed Out In Out Out OutGOB1.APG [apg_grpr_block1] Fixed Out In Out Out OutGOB1.APC [apc_grpr_block1] Fixed Out In Out Out OutGOB1.CMG [cmg_grpr_block1] Fixed Out In Out Out OutGOB1.RUG [rug_grpr_block1] Fixed Out In Out Out OutVariable Length Grouper Output Structures

GOB2.APG [apg_grpr_output_entry] numhcpcs Out In Out Out OutGOB2.APC [apc_grpr_output_entry] numhcpcs Out In Out Out OutGOB2.RUG [rug_grpr_output_entry] numhcpcs Out In Out Out OutGOB3.DRG [drg_grpr_output_dx] numdx Out In Out Out OutGOB4.DRG [drg_grpr_output_op] numop Out In Out Out OutGOB5.APG [apg_grpr_output_entry_01]

numhcpcs Out In Out Out Out


GOB5.APC [apc_grpr_output_entry_01]


GOB5.RUG [rug_grpr_output_entry_01]


Fixed Length Pricer Output Structures

POB1.DRG [drg_prcr_block1] Fixed Out Out Out OutPOB1.APG [apg_prcr_block1] Fixed Out Out Out OutPOB1.APC [apc_prcr_block1] Fixed Out Out Out OutPOB1.CAH [cah_prcr_block1] Fixed Out Out Out OutPOB1.CMG [cmg_prcr_block1] Fixed Out Out Out OutPOB1.RUG [rug_prcr_block1] Fixed Out Out Out OutPOB1.PP1 [phys_prcr_block1] Fixed Out Out OutVariable Length Pricer Output Structures

POB2.APG [apg_prcr_output_entry] numhcpcs Out Out OutPOB2.APC [apc_prcr_output_entry] numhcpcs Out Out OutPOB2.CAH [cah_prcr_output_entry] numhcpcs Out Out OutPOB2.RUG [rug_prcr_output_entry] numhcpcs Out Out OutPOB3.ESRD [esrd_prcr_block3] numhcpcs Out Out OutPOB2.PP1 [phys_prcr_ouput_entry] numhcpcs Out OutFixed and Variable Length Output Structures for EASYEdit™

EEB1 [ezedit_block1] Fixed Out (E) OutEEB2 [ezedit_id_entry] maxeeb2 Out (E) OutEEB3 [ezedit_msg_entry] maxeeb2 Out (E) OutEEB4 [ezedit_rtn_entry] maxeeb2 Out (E) OutFixed and Variable Length Output Structures for DSC Editor

MEB1 [mce_editor_block1] Fixed Out (D, P, H, MI)

Out

MEB.DX [mce_dx_edits] numdx Out (D, P, H, MI)

Out

MEB.OP [mce_op_edits] numop Out(D, P, H, MI)

Out

MEB4 [mce_edit_summary] Fixed Out (D, P, H, MI)

Out

Fixed and Variable Length Output Structures for LCD Editor

LEB1 [lcd_edit_block1] Fixed Out (L) OutLEB.OP [lcd_op_edits] numhcpcs Out (L) OutLEB.URL [lcd_op_url] numhcpcs Out (L) OutFixed and Variable Length Output Structures for ACE

AEB1 [ace_edit_block1_01] Fixed Out (C, CAH, O, T, N)

Out



01 11 12 14 15 16 18


AEB.DX [ace_dx_edits_01] numdx Out (C, CAH, O, T, N)

Out

AEB.OP [ace_op_edits_01] numhcpcs Out (C, CAH, O, T, N)

Out In Out Out

AEB4 [ace_edit_entry] maxcci Out (C, CAH, O, T, N)

Out

AEB5 [ace_edit_summary] Fixed Out (C, CAH, O, T, N)

Out

Fixed and Variable Length Output Structures for Physician Editor

PEB1 [pe_edit_block1] Fixed Out (Y) OutPEB2 [pe_dx_edits] numdx Out (Y) OutPEB3 [pe_op_edits] numhcpcs Out (Y) In OutFixed and Variable Length Output Structures for Medicaid Outpatient Editor

OEB1 [outpatient_edit_block1] Fixed Out (MO) OutOEB2 [outpatient_dx_edits] numdx Out (MO) OutOEB3 [outpatient_op_edits] numhcpcs Out (MO) In OutFixed and Variable Length Analyzer Output Structures

CAB1 [edc_analyzer_block1] Fixed Out Out Out Out Out OutCAB2 [edc_analyzer_block2] numdx Out Out Out Out Out OutCAB3 [edc_analyzer_block3] numhcpcs Out Out Out Out Out OutCAB1 [eam_analyzer_block1] Fixed Out Out Out Out Out OutCAB2 [eam_analyzer_block2] numdx Out Out Out Out Out OutCAB3 [eam_analyzer_block3] numhcpcs Out Out Out Out Out OutPayer-Specific Reimbursement Worksheet Structures

PWS1.APC [apchopd_prcr_worksheet1]

Fixed Out Out Out Out

PWS1.HCFA [hcfa_prcr_worksheet1] Fixed Out Out Out OutPWS1.NY [ny_prcr_worksheet1] Fixed Out Out Out OutPWS1.ESRD [esrd_prcr_worksheet1] Fixed Out Out Out OutPWS1.LTC [ltc_prcr_worksheet1] Fixed Out Out Out OutPWS1.PROF [prof_prcr_worksheet1]^ Fixed Out Out Out OutPWS1.ASC [asc_prcr_worksheet1] Fixed Out Out Out OutPWS1.APG [apg_prcr_worksheet1] Fixed Out Out Out OutPWS1.APR [apr_prcr_worksheet1] Fixed Out Out Out OutPWS1.DRG [drg_prcr_worksheet1] Fixed Out Out Out OutPWS1.HHA [hha_prcr_worksheet1] Fixed Out Out Out OutPWS2.ASC [asc_prcr_worksheet2] numhcpcs Out Out Out OutPWS2.APG [apg_prcr_worksheet2] numhcpcs Out Out Out OutPWS2.HHA [hha_prcr_worksheet2] numhcpcs Out Out Out Out



01 11 12 14 15 16 18


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

Letters contained in () represent Edit Requests (edit_req; edit_req2) as defined in the ECB [ezg_cntl_block] structure. The Edit Request defines which Editor(s) are to be invoked. Some Editor input and output fields are specific to the Editor being called. The In or Out indicate which Editor requires this

PWS3.APG [apg_prcr_worksheet3] numhcpcs Out Out Out OutPWS3.HHA [hha_prcr_worksheet3] numhcpcs Out Out Out OutPWS4.APR [apr_prcr_worksheet4] maxpws4 Out Out Out OutPWS4.DRG [drg_prcr_worksheet4] maxpws4 Out Out Out OutPWS4.HHA [hha_prcr_worksheet4] maxpws4 Out Out Out OutFixed and Variable Length Optimizer Output Structures

OOB1 [opt_output_block1] Fixed Out Out Out Out Out OutOOB2 [opt_output_entry] numdx OutFixed and Variable Length Mapper Output Structures

MOB1 [map_output_block1] Fixed Out Out Out OutMOB2 [map_dx_entry]Note: ICD-10 Mapper and Alternate ICD-10 Mapper Only.

numdx Out Out Out Out

MOB3 [map_op_entry]Note: ICD-10 Mapper and Alternate ICD-10 Mapper Only.

numop Out Out Out Out

EASYGroup™ Path Structure

PATHS [ezg_paths] Fixed In In In In In In In



01 11 12 14 15 16 18

Legend: In = Required input OP Codes: 01 = Analyze/Edit In = Required input and optional output 11 = Analyze/GroupOut = Output 12 = Analyze/PriceBoth = Input and output 14 = Model

15 = Analyze/Group/Price16 = Anlayze/Edit/Group/

Price17 = Map only18 = Analyze only


structure for input or output. Blank values indicate that the structure is required for all Editors. For example, lcd_edit_block1 is only returned if there was an Edit Request of 1 in position 81.

0.1 EASYGroup™ Server Input/Output Blocks Order

Edit Requests: C = CCICAH = CAH Method IIC, O = OCE with edit pairs returnedD = DSCE = EASYEdit™H = HACL = LCDMI = Medicaid InpatientMO = Medicaid OutpatientN = Non-OCEO = OCEP = POAT = TRICAREY = Physician

Table 0-2: EASYGroup™ Server Input/Output Blocks Order

Server Input / Output Blocks OrderECB [ezg_cntl_block]PCB1 [patient_claim_data]PCB2 PCB2.CCD [cah_claim_data] PCB2.ICD [ip_claim_data] PCB2.OCD [op_claim_data] PCB2.RCD [rehab_claim_data] PCB2.PCD [phys_claim_data] PCB2.SCD [snf_claim_data]DX [dx_entry]OP [op_entry]LINE [line_entry]GOB1 GOB1.APC [apc_grpr_block1] GOB1.APG [apg_grpr_block1] GOB1.CMG [cmg_grpr_block1] GOB1.DRG [drg_grpr_block1] GOB1.RUG [rug_grpr_block1]


GOB2 GOB2.APC [apc_grpr_output_entry] GOB2.APG [apg_grpr_output_entry] GOB2.CMG [cmg_grpr_output_entry] GOB2.DRG [drg_grpr_output_entry] GOB2.RUG [rug_grpr_output_entry]GOB3.DRG [drg_grpr_output_dx]GOB4.DRG [drg_grpr_output_op]POB1 POB1.APC [apc_prcr_block1] POB1.APG [apg_prcr_block1] POB1.CAH [cah_prcr_block1] POB1.CMG [cmg_prcr_block1] POB1.DRG [drg_prcr_block1] POB1.PP1 [phys_prcr_block1] POB1.RUG [rug_prcr_block1]POB2 POB2.APC [apc_prcr_output_entry] POB2.APG [apg_prcr_output_entry] POB2.CAH [cah_prcr_output_entry] POB2.PP1 [phys_prcr_output_entry] POB2.RUG [rug_prcr_output_entry]POB3.ESRD [esrd_prcr_block3]EEB1 [ezedit_block1]EEB2 [ezedit_id_entry]EEB3 [ezedit_msg_entry]EEB4 [ezedit_rtn_entry]MEB1 [mce_editor_block1]MEB.DX [mce_dx_edits]MEB.OP [mce_op_edits]MEB4 [mce_edit_summary]LEB1 [lcd_edit_block1]LEB.OP [lcd_op_edits]LEB.URL [lcd_op_url]AEB1 [ace_edit_block1_01]AEB.DX [ace_dx_edits_01]AEB.OP [ace_op_edits_01]AEB4 [ace_edit_entry]AEB5 [ace_edit_summary]PWS1


Server Input / Output Blocks Order


PWS1.APC [apchopd_prcr_worksheet1] PWS1.ASC [asc_prcr_worksheet1] PWS1.ESRD [esrd_prcr_worksheet1] PWS1.HCFA [hcfa_prcr_worksheet1] PWS1.LTC [ltc_prcr_worksheet1] PWS1.NY [ny_prcr_worksheet1] PWS1.PROF [prof_prcr_worksheet1] PWS1.DRG [drg_prcr_worksheet1] PWS1.HHA [hha_prcr_worksheet1]OOB2 [opt_output_entry]MOB1 [map_output_block1]PATHS [ezg_paths]RESERVEDRESERVEDRESERVEDRESERVEDOOB1 [opt_output_block1]GOB5 GOB5.APC [apc_grpr_output_entry_01] GOB5.APG [apg_grpr_output_entry_01] GOB5.RUG [rug_grpr_output_entry_01]MOB2.DX [map_dx_entry]MOB3.OP [map_op_entry]RESERVEDPEB1 [pe_edit_block1]PEB2 [pe_dx_edits]PEB3 [pe_op_edits]CAB1 CAB1 [edc_analyzer_block1] CAB1 [eam_analyzer_block1]CAB2 CAB2 [edc_analyzer_block2] CAB2 [eam_analyzer_block2]CAB3 CAB3 [edc_analyzer_block3] CAB3 [eam_analyzer_block3]ECB2 [ezg_cntl_block2]PWS2 PWS2.ASC [asc_prcr_worksheet2] PWS2.APG [apg_prcr_worksheet2]




PWS2.HHA [hha_prcr_worksheet2]PWS3 PWS3.APG [apg_prcr_worksheet3] PWS3.HHA [hha_prcr_worksheet3]PWS4 PWS4.APR [apr_prcr_worksheet4] PWS4.DRG [drg_prcr_worksheet4] PWS4.HHA [hha_prcr_worksheet4]OEB1 [outpatient_edit_block1]OEB2 [outpatient_dx_edits]OEB3 [outpatient_op_edits]RESERVED




ECB [ezg_cntl_block] Table A-1: ECB [ezg_cntl_block]: Fixed length input or output fields for all EASYGroup™ processing

Field Description Variable Name Format Position NotesOptimizer Return Code

NoteThis field is no longer utilized and has been replaced by the Optimizer Return Code (opt_rtn_code) field located in the OOB1 [opt_output_block1] structure.

opt_rtn_code 9(2) 1 - 2 00 = Reserved

Optimizer Structure Release

opt_release X(1) 3 Reserved

Classification Type classification X(3) 4 - 6 APC = Ambulatory Payment Classification (APC) or Ambulatory Surgery Category (ASC) (starting January 01, 2008)

APG = Ambulatory Patient Group (APG) or Ambulatory Surgery Category (ASC) (prior to January 01, 2008)

CAH = CAH Method IICMG = Case Mix Group (CMG for IRF)DRG = Diagnosis Related Group (DRG)RUG = SNF Patient Driven Payment Model (PDPM)

(starting October 01, 2019) or Resource Utilization Groups (RUGs) (prior to October 01, 2019)

PHY = PhysicianOptimizer Reserved rtn_rsvd X(4) 7 - 10 ReservedOperation Code 1 opcode1 X(2) 11 - 12 01 = Analyze/Edit*

02 - 10 = Reserved11 = Analyze/Group*12 = Analyze/Price* (assumes case-mix measure

already assigned)13 = Reserved14 = Model15 = Analyze/Group/Price*16 = Analyze/Edit/Group/Price*17 = Map only18 = Analyze only*R1 = Retrieve payer filesO1 = Open filesC1 = Close files

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

Operation Code 2 opcode2 X(2) 13 - 14 Reserved


Operation Code 3 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 (opcode1) with a value of 01 (Edit Only), or with a value of 16 (Edit, Group, and Price).

Operation Code 4 opcode4 X(2) 17 - 18 Reserved

Table A-1: ECB [ezg_cntl_block]: Fixed length input or output fields for all EASYGroup™ processing

Field Description Variable Name Format Position Notes


Patient Type pattype X(2) 19 - 20 Arizona Medicaid, California Medicaid, Colorado Medicaid, Florida Medicaid, DRG Pro, Georgia Medicaid, Illinois Medicaid APR, Illinois Medicaid, Indiana Medicaid APR, Indiana Medicaid, Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Louisiana Medicaid, Massachusetts Medicaid, Medicaid APR Pro, Medicare Inpatient, Medicare IPF, Medicare LTC, Medicare SNF, Michigan Medicaid APR, Michigan Medicaid, Minnesota Medicaid, Mississippi Medicaid, Nebraska Medicaid APR, Nebraska Medicaid, New Jersey Medicaid APR, New Jersey Medicaid, New Mexico Medicaid, New York Medicaid APR, North Carolina Medicaid, North Carolina Worker’s Compensation, Ohio Medicaid APR, Ohio Medicaid, Pennsylvania Medicaid, Rhode Island Medicaid, South Carolina Medicaid, Texas Medicaid, TRICARE/CHAMPUS, Virginia Medicaid APR, Virginia Medicaid, Washington HCA, Washington DC Medicaid, Washington Medicaid APR, Washington Medicaid, Wisconsin Medicaid, Wisconsin Medicaid APR, Wisconsin Medicaid:01 = Inpatient

Alabama BCBS APG, APC Pro, ASC Pro, Colorado Medicaid APG, Florida Medicaid APG, Illinois Medicaid APG, Iowa Medicaid APC, Massachusetts Medicaid APG, Medicaid APG Pro, Medicare OPPS, Medicare ASC, Medicare ESRD, Medicare FQHC, Medicare HHA, Medicare Hospice, Michigan Medicaid APC, Michigan Medicaid ASC, New Mexico Medicaid APC, New York Medicaid APG, Ohio Medicaid APG, TRICARE APC, Virginia Medicaid APG, Virginia Medicaid ASC, Washington DC Medicaid APG, Washington Medicaid APG, Wisconsin Medicaid APG: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)




ICD-9/ICD-10 Mapping Flag

map_flag 9(1) 21 0 = No mapping1 = Standard mapping2 = State-specific mapping

NoteThis flag should always be set to zero for processing requests that involve the APR-DRG Grouper.

State-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 option_flag 9(1) 22 AP-DRG V14 Grouper:0 = Otherwise1 = Use the New York version of AP-DRG Grouper

Grouper Type grpr_type X(2) 23 - 24 01 = Medicare DRG02 = AP-DRG03 = TRICARE/CHAMPUS DRG04 = Reserved05 = Reserved06 = Wisconsin Medicaid DRG07 = North Carolina Medicaid DRG08 = Ohio Medicaid DRG10 = All Patient Refined (APR-DRG)11 = 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 FQHC40 = ICD-10 Wisconsin Medicaid DRG46 = New Mexico Medicaid APC51 = Reserved53 = Reserved54 = Reserved55 = Medicare APC56 = Reserved57 = Medicare ASC (effective January 01, 2008)59 = Medicare ASC (prior to January 01, 2008)60 = Medicare ESRD61 = APG62 = Medicare HHA HHRG (prior to January 01, 2020)63 = TRICARE APC66 = Medicare CAH Method II67 = Medicare Hospice90 = Medicare IRF CMG

NoteOnly required if rate files are not being utilized.

Grouper Type Reserved grpr_type_rsvd X(2) 25 - 26 Reserved




Grouper Version Number

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.”

APG Grouper:This field will equal the 2 digits that follow the decimal of the EAPG Version number (e.g., if the EAPG Version is “3.14,” set this field to “14”).


Grouper Version Reserved

grpr_vers_rsvd 9(4) 29 - 32 Reserved




Pricer Type prcr_type X(2) 33 - 34 Patient Type 1 - Inpatient:A = Medicare DRGE = Hospital-Specific Cost Reduction FactorF = ReservedG = TRICAREH = New Jersey MedicaidI = Pennsylvania MedicaidJ = Illinois MedicaidL = Reserved for DRG-Specific Cost Reduction Factorm = Washington HCA Case-BasedN = North Carolina Medicaidn = Washington HCA Non Case-BasedO = North Carolina State Employees/Worker’s

Compensationo = Reservedp = Virginia Medicaid & Virginia Medicaid APRP = Wisconsin MedicaidQ = First Tiered Per Diemq = Michigan Medicaid & Michigan Medicaid APR R = Second Tiered Per Diemr = Indiana Medicaid & Indiana Medicaid APRS = Multi-Pricer/DRG ProT = Texas Medicaidt = Analysis DRGu = ProfilerV = Washington Medicaidv = Medicare LTC19 = Medicare IPF20 = Georgia Medicaid21= Nebraska Medicaid23 = New Mexico Medicaid24 = Kentucky Medicaid25 = New York Medicaid APR26 = Pennsylvania Medicaid APR27 = Ohio Medicaid APR28 = Nebraska Medicaid APR29 = Illinois Medicaid APR30 = Florida Medicaid APR31 = California Medicaid32 = Kansas Medicaid33 = South Carolina Medicaid34 = Arizona Medicaid36 = Washington Medicaid APR42 = Medicaid APR Pro43 = Iowa Medicaid

continued below...




Pricer Type<continued>

prcr_type X(2) 33 - 34 Patient Type 2 - Outpatient:a = Reservedb = Reservedd = Reserved for Cost Reduction Factore = Reservedh = Medicare APC-HOPDi = Contract APCk = Reserved37 = Washington Medicaid APG38 = Illinois Medicaid APG39 = Medicare FQHC40 = Wisconsin Medicaid APG41 = Virginia Medicaid APG44 = Medicaid APG Pro45 = Enhanced New York Medicaid APG46 = New Mexico Medicaid APC55= Medicare ASC60= Medicare ESRD61= New York Medicaid APG62 = Medicare HHA63 = TRICARE APC64 = 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 prcr_type_rsvd X(2) 35 - 36 ReservedEditor Type edtr_type X(2) 37 - 38 ReservedEditor Type Reserved edtr_type_rsvd X(2) 39 - 40 ReservedEditor Version Number edtr_vers 9(2) 41 - 42 ReservedEditor Release edtr_rel X(1) 43 ReservedEditor Version Reserved

edtr_vers_rsvd X(3) 44 - 46 Reserved

Norms Type norms_type X(29) 47 - 75 Reserved




Editor Requests edit_req 9(10) 76 77787980

8182

838485

1 = Request DSC edits1 = Request EASYEdit™ edits 1 = Request CCI edits (for ASC and APG)1 = Request OCE edits (for FQHC)1 = Request OCE edits with CCI edit pairs returned (for

APC, ESRD, HHA, Hospice, and SNF)1 = Request LCD/NCD edits1 = Request non-OPPS OCE edits (for Maryland and

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

1 = Request POA edits1 = Request HAC edits1 = Request TRICARE OCE edits (for TRICARE APC)


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

Editor Requests 2 edit_req2 X(10) 86

8788

89909192939495

1 = Request physician edits, MUEs applied based on taxonomy

1 = Request Medicaid inpatient edits1 = Request physician edits, max of DME and

Practitioner MUE applied1 = Request Medicaid outpatient edits1 = Request CAH Method II edits1 = Reserved1 = Reserved1 = Reserved1 = Reserved1 = Reserved


Editor Reserved rsvd_req3 X(10) 96 - 105 ReservedEditor Reserved rsvd_req4 X(10) 106 - 115 ReservedKey Type 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 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 hac_override_id X(10) 137 - 146 DSC Editor, AP-DRG Grouper, APR-DRG Grouper, Medicare DRG Grouper, CHAMPUS/TRICARE Grouper, and Wisconsin DRG Grouper:Unique key used by the DSC Editor or DRG Grouper to determine what Hospital Acquired Conditions (HACs) should be applied to this facility.


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

TRICARE APC Editor:1 = TRICARE APC Editor was run and results are

available0 = Otherwise

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

available0 = Otherwise

CCI Edit Bypass bypass_cci_edits 9(1) 149 APG Payment Systems:0 = Do not apply CCI/MUE edits to reimbursement1= Apply CCI/MUE edits to reimbursement


Flag Reserved flag_rsvd 9(8) 150 - 157 ReservedRetrieve Payer pyr_lookup_sw X(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 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 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. - npi_used- taxonomy_used- facility_used- paysrc_used

Patient Type Retrieved pyr_pattype X(1) 189 ReservedPatient Type Extension pyr_pattype_rsvd X(1) 190 ReservedSequence Number Retrieved

pyr_eseq 9(4) 191 - 194 Output field used for EASYGroup™ processing.

Effective Date Retrieved

pyr_edate 9(8) 195 - 202 Output field used for EASYGroup™ processing.




Extended Structure Switch

ext_blk_sw X(1) 203 1 = Enable

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


Mapping Override ID map_override_id X(20) 224 - 243 ICD-10 Mapper:Unique key used to invoke override functionality that allows you to override the mapping rules for a particular ICD-10 diagnosis or procedure code.


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


Mapper Type map_type X(2) 246 - 247 ICD-10 Mapper & Alternate ICD-10 Mapper:02 = ICD-10 Mapper03 = Alternate ICD-10 Mapper


Mapper Type Reserved map_type_rsvd X(2) 248 - 249 ReservedICD-9 or ICD-10 Coding Classification

code_class X(2) 250 - 251 00 = ICD-9 coded claim01 = ICD-10 coded claim

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




Closed Rate Record Switch

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 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

bwgt_option X(1) 256 APR-DRG Grouper:1 = Entered in the birth weight field only.2 = Coded with diagnosis only.3 = Entered or coded with diagnosis.4 = Entered or coded with cross-check between entered

and coded birth weights to determine if a match or a conflict exists.

5 = Coded with diagnosis only, default of 2500 grams used if birth weight not coded.

6 = Entered or coded with diagnosis, default of 2500 grams used if birth weight not entered or coded.

7 = Entered or coded with cross-check between entered and coded birth weights to determine if a match or conflict exists, default of 2500 grams used if birth weight not entered or coded.


Discharge APR-DRG Option

disch_drg_option X(1) 257 APR-DRG Grouper:Provides the ability to compute the APR-DRG, Severity of Illness (SOI), and Risk of Mortality (ROM) considering POA indicators with APR-DRG complication of care codes.

0 = Compute excluding only non-POA complication of care codes

1 = Compute excluding all complication of care codes





HAC Version hac_version 9(3) 258 - 260 APR-DRG Grouper:The version of the Hospital Acquired Conditions (HACs) to use with HAC-adjusted APR-DRG grouping.

The HAC version should be entered as follows:Version 31 would be entered as “310.”


State CCI 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

MOE:Blank (default) = National Medicaid CCI/MUEU2 = National Medicaid CCI/MUE





User Key user_key X(3) 263 - 265 APG Payment Systems:The state-specific APG grouping rules to utilize.

Alabama BCBS APG= AL3Colorado Medicaid APG = CO1Florida Medicaid APG = FL1Illinois Medicaid APG = IL1 Nebraska Medicaid APG = NE1New York Medicaid APG = Blank or NY1Enhanced New York Medicaid APG = Blank or NY1Massachusetts Medicaid APG = MA1Ohio Medicaid APG = OH1Virginia Medicaid APG = VA1Virginia Medicaid ASC = VA4Washington Medicaid APG = WA1 Washington DC Medicaid APG = DC1Wisconsin Medicaid APG = WI1

APR-DRG Payment Systems:The state-specific APR pricing rules to utilize.

Colorado Medicaid = CO2Florida Medicaid = FL2Indiana Medicaid APR = IN2Louisiana Medicaid = LA2Massachusetts Medicaid = MA2Minnesota Medicaid = MN2Mississippi Medicaid = MS2New Jersey Medicaid APR = NJ2Rhode Island Medicaid = RI2Virginia Medicaid APR = VA2Washington DC Medicaid = DC2Wisconsin Medicaid APR = WI2


Apply CCI/MUE Edits line_bypass X(1) 266 APG Payment Systems:0 = Don’t exclude lines from APG grouping that are

returned from ACE with CCI and/or MUE edits1 = Exclude lines from APG grouping that are returned

from ACE with CCI and/or MUE edits2 = Exclude lines from APG grouping that are returned

from ACE with CCI edits only3 = Exclude lines from APG grouping that are returned

from ACE with MUE edits only





Function Return Code func_rtn_code X(2) 267 - 268 01 = No hospital rate calculator record07 = Error calling the Grouper control program08 = Error calling the Pricer control program12 = 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 = Error creating log file20 = Invalid or missing taxonomy21 = Non-zero return code from TRICARE APC Editor22 = Non-zero return code from Physician Editor25 = Non-zero return code from MOE26 = Non-zero return code from CAH Method II Editor62 = Closed or inactive rate record70 = Configuration record error87 = Program cannot be loaded88 = Initialization error 94 = Invalid dates95 = Parameter errorR1 = Invalid patient type

ICD-9 Grouper Routing Flag

icd9_routing 9(1) 269 ICD-10 Medicare DRG, ICD-10 TRICARE DRG, and ICD-10 Wisconsin Medicaid 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 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, the ACE Override ID (ace_override_id) field will be utilized.





Version Qualifier vers_qual X(1) 290 APR-DRG Grouper:Used to request the ICD-9 version of the APR-DRG V31 and V32 Groupers.

0 = ICD-10 Grouper (default)9 = ICD-9 Grouper


Analyzer Type analyzer_type X(2) 291 - 292 00 = No Analyzer01 = EDC Analyzer™02 = E&M Analyzer Pro


Analyzer Type Reserved

analyzer_type_rsvd X(2) 293 - 294 Reserved

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


Analyzer Version Reserved

analyzer_vers_rsvd 9(4) 297 - 300 Reserved

E&M Analyzer Pro/EDC Analyzer™ Starting Visit Level Option

start_lvl_option[] 9(1)occurs 5 times

301 - 305 EDC Analyzer™ & 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/EDC Analyzer™ Visit Level Change Option

lvl_change_option 9(1) 306 EDC Analyzer™ & 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/EDC Analyzer™ Action

edc_action 9(1) 307 EDC Analyzer™ & 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 required2 = 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 (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

override_req 9(10) 308

309310311312313314315316317

0 = EDC Analyzer™ options in the Configuration File take precedence

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

ReservedReservedReservedReservedReservedReservedReservedReservedReserved

Facility Type facility_type X(2) 318 - 319 Florida Medicaid APG, Ohio Medicaid APG, & Virginia Medicaid ASC:00 = All others01 = ASC


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




Log Request log_req X(1) 327 0 = Log file not requested1 = Log file requested

Instructions for setting this field:Step 1: Set this switch to 1.Step 2: Process the claim you wish to log.Step 3: Set this switch to 0.

NoteThis option is designed for use with a single claim, or a small set of claims. It should not be set to 1 for all claims processing, as the log file(s) will grow rapidly in size and processing speed may be affected.

Medicaid Outpatient Editor Flag

moe_flag 9(1) 328 Output field.

MOE:0 = Otherwise1 = Medicaid Outpatient Editor was run and results are

availableMedicaid APC Override ID

mcd_override_id X(20) 329 - 348 The Medicaid APC Override ID invokes override functionality. This override functionality allows the user to override the Payment Status Indicator for a particular procedure code.


Reimbursement Date reimbdate X(1) 349 Used to identify which claim date should be used for reimbursement calculations. The following options are available:- A = From or Admission Date- D = Thru or Discharge Date


E&M Analyzer Pro Audit or Adjudication Indicator

aa_ind 9(1) 350 Reserved

Filler X(50) 351 - 400




PCB1 [patient_claim_data]Table B-1: PCB1 [patient_claim_data]: Fixed length input fields for all EASYGroup™ processing

Field Description Variable Name Format Position NotesProvider Identifier 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

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 Discharge Without Cost Outlier Payments for HHC Hospitals

04 = New Jersey Medicaid and New Jersey Medicaid APR Reimbursement Pricing Rules and Variables

05 = Texas Medicaid Reimbursement Pricing Rules and Variables

06 = Georgia Medicaid Reimbursement Pricing Rules and Variables

07= Illinois Medicaid APR and Illinois Medicaid APG Reimbursement Pricing Rules and Variables

08 = Indiana Medicaid Managed Care APR Reimbursement Pricing Rules and Variables, w/o Hospital Assessment Fee (HAF)

09 = Medicare Reimbursement Pricing Rules and Variables

10 = New York Medicaid APG Reimbursement Pricing Rules and Variables, Medicaid Managed Care

11 = New York Medicaid APG Worker’s Compensation13 = New York No Fault14 = New York Medicaid Managed Care (MMC),

Excluding Medicaid Rebasing per Discharge Without Cost Outlier Payments for HHC Hospitals

15 = New York Medicaid Fee-for-Service (FFS) (APR-DRG only)

16 = New York Medicaid Managed Care (MMC), Including Medicaid Rebasing per Discharge With Cost Outlier Payments for Health and Hospital Corporation (HHC) Hospitals

18 = Florida Medicaid APG and Florida Medicaid APR Reimbursement Pricing Rules and Variables

20 = New York Medicaid APG Reimbursement Pricing Rules and Variables, Fee for Service

21 = New Mexico Medicaid and New Mexico Medicaid APC Reimbursement Pricing Rules and Variables, Fee-for-Service (FFS)

22 = New Mexico Medicaid and New Mexico Medicaid APC Reimbursement Pricing Rules and Variables, Medicaid Managed Care

continued below...


Payer ID or Contract Code<continued>

paysrc X(13) 17 - 29 23 = Washington Medicaid APG and Washington Medicaid APR Reimbursement Pricing Rules and Variables

26 = South Carolina Medicaid Reimbursement Pricing Rules and Variables

28 = Indiana Medicaid Managed Care APR Reimbursement Pricing Rules and Variables, w/ Hospital Assessment Fee (HAF)

30 = Arizona Medicaid Reimbursement Pricing Rules and Variables

31 = North Carolina Medicaid Reimbursement Pricing Rules and Variables

32 = Minnesota Medicaid APR Reimbursement Pricing Rules and Variables

40 = Michigan Medicaid APC and Michigan Medicaid APR Reimbursement Pricing Rules and Variables

41 = Rhode Island Medicaid APR Reimbursement Pricing Rules and Variables

45 = Nebraska Medicaid Managed Care APR and Nebraska Medicaid APG Reimbursement Pricing Rules and Variables

49 = California Medicaid Reimbursement Pricing Rules and Variables

50 = Ohio Medicaid APG and Ohio Medicaid APR Reimbursement Pricing Rules and Variables

51 = Ohio Medicaid APG and Ohio Medicaid APR Reimbursement Pricing Rules and Variables for MyCare Base Rates

55 = Virginia Medicaid APR and Virginia Medicaid APG Reimbursement Pricing Rules and Variables

56 = Virginia Medicaid ASC Reimbursement Pricing Rules and Variables

61 + 62 = Pennsylvania Medicaid APR Reimbursement Pricing Rules and Variables

65 = Colorado Medicaid APR and Colorado Medicaid APG Reimbursement Pricing Rules and Variables

70 = Wisconsin Medicaid, Wisconsin Medicaid APR, and Wisconsin Medicaid APG Reimbursement Pricing Rules and Variables

Table B-1: PCB1 [patient_claim_data]: Fixed length input fields for all EASYGroup™ processing



Payer ID or Contract Code<continued>

paysrc X(13) 17 - 29 77 = Iowa Medicaid Reimbursement Pricing Rules and Variables

78 = Iowa Medicaid Reimbursement Pricing Rules and Variables With Rate Floors

NoteFor Iowa Medicaid and Iowa Medicaid APC, Payer ID 78 was closed as of October 01, 2018.

80 = Kentucky Medicaid Reimbursement Pricing Rules and Variables

87 = Washington DC Medicaid and Washington DC Medicaid APG Reimbursement Pricing Rules and Variables

88 = Massachusetts Medicaid APR Reimbursement Pricing Rules and Variables

89 = Mississippi Medicaid Reimbursement Pricing Rules and Variables

90 = Michigan Medicaid ASC Reimbursement Pricing Rules and Variables

91 = Louisiana Medicaid Reimbursement Pricing Rules and Variables

95 = Utah Medicaid APC Reimbursement Pricing Rules and Variables

100 = Kansas Medicaid DRG Reimbursement Pricing Rules and Variables

110 = Montana Medicaid Reimbursement Pricing Rules and Variables

9960 = TRICARE APC Reimbursement Pricing Rules, in conjunction with the 3M™ TRICARE Outpatient Pricer Tables and TRICARE DRG Reimbursement Pricing Rules and Variables

From or Admission Date from_date 9(8) 30 - 37 UB-04 FL06. The first date of service on the claim. YYYYMMDD, where:

YYYY = year including century MM = month; 01-12DD = day; 01-31

Thru or Discharge Date thru_date 9(8) 38 - 45 UB-04 FL06. The last date of service on the claim. YYYYMMDD, where:


If still a patient, set equal to today’s date.Effective Date 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:


Set equal to From or Thru Date based on pricing rules.




Date of Birth birth_date X(8) 54 - 61 UB-04 FL10. 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 age_flag X(2) 62 - 63 ReservedAge in Years 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 from_date and 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.

Sex 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- I = Invalid

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

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

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

Filler filler_01 X(6) 108 - 113 ReservedNumber of Diagnosis Codes

numdx 9(3) 114 - 116 Count of ICD-9-CM or ICD-10-CM diagnosis codes (number of DX [dx_entry] occurrences). Required if diagnosis codes are being passed to any EASYGroup™ products.




Number of Procedure Codes

numop 9(3) 117 - 119 Count of ICD-9-CM or ICD-10-PCS procedure codes (number of OP [op_entry] occurrences). Required if procedure codes are being passed to any EASYGroup™ products.

Number of Procedure Codes

numhcpcs 9(3) 120 - 122 Count of claim lines submitted (number of LINE [line_entry] occurrences) with or without HCPCS procedure codes. Required if claim lines are being passed to any EASYGroup™ products.




Discharge Disposition 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 01, 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 01, 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 01, 2003)50 = Hospice, home51 = Hospice, certified medical facility61 = Discharged/transferred to swing bed, hospital-based

and Medicare-approved (valid beginning with October 01, 2001)

62 = Discharged/transferred to inpatient rehabilitation facility or unit (valid beginning January 01, 2002)

63 = Discharged/transferred to long term care hospital, Medicare-certified (valid beginning January 01, 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 01, 2004)

66 = Discharged/transferred to critical access hospital (valid beginning January 01, 2006)

69 = Discharged/transferred to a designated disaster alternative care site (effective October 01, 2013)

70 = Discharged/transferred to another type of health care institution not defined elsewhere in this code list (valid beginning April 01, 2008)

71 = Outpatient services, another facility (valid October 01, 2001 through September 30, 2003)

72 = Outpatient services, this facility (valid October 01, 2001 through September 30, 2003)

continued below...




Discharge Disposition<continued>

dstat 9(2) 123 - 124 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

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 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 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 (admit_date) is <= the From Date (from_date), set equal to the Thru Date (thru_date) – the From Date (from_date). Set equal to 0001 when the Thru Date (thru_date) is the same as the From Date (from_date).

If the Admit Date (admit_date) is > the From Date (from_date), set equal to the Thru Date (thru_date) – the Admit Date (admit_date). Set equal to 0001 when the Thru Date (thru_date) is the same as the Admit Date (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 (thru_date) – the From Date (from_date) + 1.

Medicare SNF (Part A):If the Discharge Disposition (dstat) = 30 (Still a Patient), set equal to the Thru Date (thru_date) – the From Date (from_date) plus one day. Otherwise, set equal to the Thru Date (thru_date) – the From Date (from_date) (do not include the day of discharge).

Filler filler_02 X(17) 139 - 155 ReservedUB-04 Occurrence Codes

occur_code X(2) occurs 8 times

156 - 171 UB-04 FL31-34. Occurrence codes.

UB-04 Occurrence Dates

occur_date 9(8) occurs 8 times

172 - 235 UB-04 FL31-34. Occurrence dates.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Filler filler_03 X(20) 236 - 255 ReservedUB-04 Occurrence Span Codes

span_code X(2) occurs 4 times

256 - 263 UB-04 FL35-36. Occurrence span codes.

UB-04 Occurrence Span Date #1

span_date1 9(8) occurs 4 times

264 - 295 UB-04 FL35-36. Occurrence span date 1.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31




UB-04 Occurrence Span Date #2

span_date2 9(8) occurs 4 times

296 - 327 UB-04 FL35-36. Occurrence span date 2.YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Filler filler_04 X(108) 328 - 435 ReservedUB-04 Admit Source admsource X(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 filler_05 X(1) 438 ReservedMaximum Number of CCI Errors to be Returned

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 (Method I and Method II), 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 filler_06 X(1) 442 Reserved




Acceptable Level of Error

accept_if 9(2) 443 - 444 ACE, CAH Method II Editor, and Physician Editor:Level of error that is considered 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 and will be rejected with Editor Return Code 10 (Final Disposition Exceeds Maximum Acceptable Level of Error). To price every line without an error, set to 06. To price clean claims only, set to 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

NoteTRICARE APC does not utilize acceptable level of 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 filler_07 X(5) 445 - 449Physician ID phys_id X(16) 450 - 465 Physician identifier. For facility claims only.Coder ID coder_id X(20) 466 - 485 HIM professional identifier who assigned the codes to this

case.UB-04 Bill Type billtype X(4) 486 - 489 UB-04 FL4. Bill Type consists of 3-character category

plus frequency.




Exclusion Criteria 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 filler_08 X(8) 491 - 498UB-04 Condition Codes 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

Filler filler_09 X(16) 523 - 538




UB-04 Value Code valcode X(2) occurs 12 times

539 - 562 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 = 61 = 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

UB-04 Value Amount valamt 9(10) occurs 12 times

563 - 682 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).





Maximum Number of EASYEdit™ Errors to be Returned

maxeeb2 9(3) 768 - 770 Maximum number of EASYEdit™ error messages to be returned for a single claim.

Filler filler_11 X(20) 771 - 790UB-04 Admission Type admit_type X(1) 791 UB-04 FL14. Patient admission or visit type.Filler filler_12 X(1) 792Admission Diagnosis Type

admit_dx_type X(3) 793 - 795 Reserved

Admission Diagnosis admit_dx X(10) 796 - 805 UB-04 FL69. The diagnosis at the time of admission.National Provider Identifier (NPI)

npi X(10) 806 - 815 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 taxonomy X(10) 816 - 825 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 hospital315D00000X = Hospice, inpatient (others per 837 definitions)

UB-04 Treatment Authorization Code

tx_authcode X(30) 826 - 855 UB-04 FL63.

UB-04 Admission/Start of Care Date

admit_date 9(8) 856 - 863 UB-04 FL12. YYYYMMDD, where:YYYY = year; including centuryMM = month; 01 - 12DD = day; 01 - 31

Paper Claim Flag paper_flag 9(1) 864 0 = Claim being processed is an electronic claim1 = Claim being processed is a paper claim



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



Health Plan Identifier (HPID)

hplan_id 9(10) 865 - 874 UB-04 FL51. Health Plan Identifier (HPID).

Organization Identifier org_id X(100) 875 - 974 ReservedContent Version content_vers X(12) 975 - 986 ReservedMaximum Number of Occurrences of the PWS4 Structure

maxpws4 9(3) 987 - 989 IPF Pricer & Medicaid APR Pro Pricer:Maximum number of occurrences of the PWS4 structure to be returned for a single claim.

Taxpayer Identification Number (TIN)

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

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

New UB-04 Occurrence Codes

occur_code_ext X(2)occurs 24 times

2001 - 2048

UB-04 FL31-34. Occurrence codes.

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

New UB-04 Occurrence Dates

occur_date_ext 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

span_code_ext X(2) occurs 24 times

2241 - 2288

UB-04 FL35-36. Occurrence span codes.


New UB-04 Occurrence Span Date #1

span_date1_ext 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

span_date2_ext 9(8) occurs 24 times

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

condcd_ext X(2) occurs 24 times

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 valcode_ext X(2) occurs 24 times

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

valamt_ext 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(1992) 3009 - 5000




PCB2.CCD [cah_claim_data]Table C-1: PCB2.CCD [cah_claim_data]: Fixed length CAH Method II input fields

Field Description Variable Name Format Position NotesZip Code zipcode 9(5) 1 - 5 UB-04 FL01. Billing provider zip code (first five digits)Zip Code Suffix zipsuffix 9(4) 6 - 9 UB-04 FL01. Billing provider zip code suffix (last four

digits)Bonus Payment/Adjustment Override

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

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 rend_npi X(10) 12 - 21 UB-04 FL78-79. Rendering provider National Provider

Identifier (NPI).Rendering Taxonomy rend_taxonomy X(10) 22 - 31 Rendering provider taxonomy code.Filler X(969) 32 - 1000


PCB2.ICD [ip_claim_data]Table D-1: PCB2.ICD [ip_claim_data]: Fixed length inpatient input fields

Field Description Variable Name Format Position NotesAge in Days on Admission

aage_ days 9(3) 1 - 3 AP-DRG, APR-DRG, ICD-10 TRICARE DRG, North Carolina Medicaid V24 and prior Groupers, Illinois Medicaid Pricer (legacy and APR), and Texas Medicaid Pricer: 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 or Pricer types.

Age in Days on Discharge

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

AP-DRG, APR-DRG, North Carolina Medicaid, 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.

Wisconsin Medicaid Grouper: Set equal to the patient’s length of stay. Required for neonates.

Alternate Level of Care Days

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, New Jersey Medicaid APR, & New York Medicaid APR: Set equal to the number of alternate level of care (ALC) days utilized by the patient.

Florida Medicaid, Kansas Medicaid, Medicare LTC, & 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.

Birth Weight in Grams 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 (valamt) field with Value Code 54 (valcode). Right justified, zero-filled. If not applicable, set to 0000.

APR-DRG and AP-DRG Groupers: 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 pat_drg 9(5) 15 - 19 APR-DRG/DRG is required as input when records are submitted for a Price Only call (opcode1 = 12). Set this field only when making a Price Only call.

Filler filler_01 X(2) 20 - 21Data Version Number 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.

Wisconsin Medicaid Grouper: Required for Group Only (opcode1 = 11) requests if the claim Thru Date (thru_date) is not provided.

ICD-9 Mapper 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 (eff_date) (if specified) or the Thru Date (thru_date).

Facility Type factype X(2) 26 - 27 Wisconsin Medicaid Grouper (prior to V25):1 = Milwaukee County Health Center2 = Institution for Mental Disease (IMD)3 = Medicare Psychiatric Exempt Unit4 = All other hospitals

NoteIf no value is provided this field will default to a value of 4.

County county X(3) 28 - 30 Wisconsin Medicaid Grouper (prior to V25):.1 = Milwaukee county2 = Non-Milwaukee county

NoteIf no value is provided this field will default to a value of 0.

Nursery Level nurslev 9(1) 31 Michigan Medicaid & Michigan Medicaid APR Pricer:0 = Patient not treated in accredited neonatal intensive

care unit3 = Patient received Level 3 nursery care (claim contains

UB-04 Revenue Code 0173)4 = Patient received Level 4 nursery care (claim contains

UB-04 Revenue Code 0174)Distinct Part Unit psycunit 9(1) 32 Reserved

Table D-1: PCB2.ICD [ip_claim_data]: Fixed length inpatient input fields



HMO Risk Flag 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 sameday 9(1) 34 Reserved.Readmission readmit 9(1) 35 Reserved.Special Unit special 9(1) 36 Reserved.Special Unit Flag #2 special2 9(1) 37 Reserved.Grouper Option Flag grpopt 9(1) 38 AP-DRG V14 Grouper:

Set this field to “1” to indicate thatthe New York modifications to the Version 14 AP-DRGGrouper should be invoked. When this option is set,Version 14.1, rather than Version 14 will be invoked.


Days on Mechanical Ventilation

dmv 9(3) 39 - 41 APR-DRG Grouper: Days on mechanical ventilation, if available.

Filler X(959) 42 - 1000

Table D-1: PCB2.ICD [ip_claim_data]: Fixed length inpatient input fields



PCB2.OCD [op_claim_data]Table E-1: PCB2.OCD [op_claim_data]: Fixed length outpatient input fields

Field Description Variable Name Format Position NotesTraditional Medicare Switch

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

Filler filler_01 X(32) 2 - 33 ReservedPatient Deductible deductible 9(8)v9(2) 34 - 43 APC-HOPD:

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

Filler filler_02 X(7) 44 - 50 ReservedState Key state_key X(2) 51 - 52 ReservedPayer Key payer_key X(14) 53 - 66 ReservedPhysician Referral Flag mdrefer X(1) 67 Contract APC:

0 or blank = Not referred by a qualified medical professional

1 = Referred by a qualified medical professionalFiller filler_03 X(20) 68 - 87 ReservedUB-04 Reason for Visit Diagnoses

rfvdx X(10) occurs 3 times

88 - 117 UB-04 FL70A. UB-04 Reason for visit diagnoses.

UB-04 Reason for Visit Diagnoses Type

rfvdx_type X(3) occurs 3 times

118 - 126 Reserved

Onset Date 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

state X(2) 135 - 136 V01 EDC Analyzer™:UB-04 FL01.

MD = Maryland

NoteAll billing provider state abbreviations should be submitted in all uppercase.

Zip Code zipcode 9(5) 137 - 141 Enhanced New York Medicaid APG Pricer:Five digit numeric zip code.

Zip Code Suffix zip_suffix 9(4) 142 - 145 Enhanced New York Medicaid APG Pricer:Four digit numeric zip code suffix.

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

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

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 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(843) 158 - 1000

Table E-1: PCB2.OCD [op_claim_data]: Fixed length outpatient input fields



PCB2.PCD [phys_claim_data]Table F-1: PCB2.PCD [phys_claim_data]: Fixed length Physician input fields

Field Description Variable Name Format Position NotesService Facility NPI serv_npi X(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

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

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 Provider Zip Code

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

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

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

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:


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


Bonus Payment/MACRA QPP Adjustment Override

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

amb_pat_count 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

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

Sanction/Preclusion Return Code Override

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(952) 49 -

1000

Table F-1: PCB2.PCD [phys_claim_data]: Fixed length Physician input fields



PCB2.RCD [rehab_claim_data]Table G-1: PCB2.RCD [rehab_claim_data]: Fixed length IRF input fields

Field Description Variable Name Format Position NotesAssessment Transmission Date

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

interpt 9(1) 9 1 = Patient left facility for treatment; stay was interrupted0 = No interruption

Admission Impairment Grouper Code

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 19 - 24


FIM Admission Motor Score – Total

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

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. Admission Motor Scores

motor_score 9(2) occurs 12 times

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 follows:

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

Admission Motor Score– Self Care, Grooming

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

Admission Motor Score– Self Care, Bathing

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

Table G-1: PCB2.RCD [rehab_claim_data]: Fixed length IRF input fields



Admission Motor Score– Self Care, Dressing,

Upper Body

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

Admission Motor Score– Self Care, Dressing,

Lower Body

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

Admission Motor Score– Self Care, Toileting

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

Admission Motor Score– Sphincter Control,

Bladder Management

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

Admission Motor Score– Sphincter Control,Bowel Management

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

Admission Motor Score– Transfers, Bed, Chair,

Wheelchair

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

Admission Motor Score– Transfers, Toilet

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

Admission Motor Score– Locomotion, Walk/

Wheelchair

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

Admission Motor Score– Locomotion, Stairs

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

Modifier for Admission Motor Score – Locomotion, Walk/Wheelchair

fim39L_mod X(1) 55 Optional modifier for IRF-PAI field 39L. Valid values are:

W = WalkC = WheelchairB = Both

NoteDoes not affect CMG assignment.

Individual Admission Cognitive Score

cogn_score 9(2) occurs 5 times

56 - 65 Effective October 01, 2019. 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

cogn_score 9(2) 56 - 57 IRF-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

cogn_score 9(2) 58 - 59 IRF-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

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


Cognition, ProblemSolving

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


Cognition, Memory

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

Modifier for Admission Cognitive Score – Communication, Comprehension

fim39N_mod X(1) 66 Optional Modifier for IRF-PAI field 39N. Valid values are:

A = AuditoryV = VisualB = Both


Modifier for Admission Cognitive Score – Communication, Expression

fim39O_mod X(1) 67 Optional Modifier for IRF-PAI field 39O. Valid values are:

V = VocalN = Non-vocalB = Both


Admission Motor Score 2 - Total

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

cogn2 9(3)v9(3) 74 - 79 Reserved




Admission Motor Scores 2

motor_score_2 9(2) occurs 24 times

80 - 127 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

- Eatingmotor_score_2 9(2) 80 - 81 IRF-PAI GG0130A1. Valid values range from 00 to 07, 09,

10, and 88.Admission Motor Score

- Oral Hygienemotor_score_2 9(2) 82 - 83 IRF-PAI GG0130B1. Valid values range from 00 to 07, 09,

10, and 88.Admission Motor Score

- Toileting Hygienemotor_score_2 9(2) 84 - 85 IRF-PAI GG0130C1. Valid values range from 00 to 07, 09,

10, and 88.




Admission Motor Score- Shower Bathe Self

motor_score_2 9(2) 86 - 87 IRF-PAI GG0130E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Upper-Body Dressing

motor_score_2 9(2) 88 - 89 IRF-PAI GG0130F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Lower-Body Dressing

motor_score_2 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

motor_score_2 9(2) 92 - 93 IRF-PAI GG0130H1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Sit to Lying

motor_score_2 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

motor_score_2 9(2) 96 - 97 IRF-PAI GG0170C1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Sit to Stand

motor_score_2 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

motor_score_2 9(2) 100 - 101 IRF-PAI GG0170E1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Toilet Transfer

motor_score_2 9(2) 102 - 103 IRF-PAI GG0170F1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Walk 10 Feet

motor_score_2 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

motor_score_2 9(2) 106 - 107 IRF-PAI GG0170J1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Walk 150 Feet

motor_score_2 9(2) 108 - 109 IRF-PAI GG0170K1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- One Step Curb

motor_score_2 9(2) 110 - 111 IRF-PAI GG0170M1. Valid values range from 00 to 07, 09, 10, and 88.

Admission Motor Score- Bladder Continence

motor_score_2 9(2) 112 - 113 IRF-PAI H0350. Valid values range include 00 to 05, and 09.

Admission Motor Score- Bowel Continence

motor_score_2 9(2) 114 - 115 IRF-PAI H0400. Valid values range include 00 to 03, and 09.

Reserved motor_score_2 9(2) 116 - 117 Reserved for future use.Reserved motor_score_2 9(2) 118 - 119 Reserved for future use.Reserved motor_score_2 9(2) 120 - 121 Reserved for future use.Reserved motor_score_2 9(2) 122 - 123 Reserved for future use.Reserved motor_score_2 9(2) 124 - 125 Reserved for future use.Reserved motor_score_2 9(2) 126 - 127 Reserved for future use.

Filler X(873) 128 - 1000




PCB2.SCD [snf_claim_data]Table H-1: PCB2.SCD [snf_claim_data]: Fixed length SNF input fields

Field Description Variable Name Format Position NotesTraditional Medicare Switch

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

Filler X(999) 2 - 1000


DX [dx_entry]Table I-1: DX [dx_entry]: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Code 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 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 narray 9(1) 14 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

APR-DRG Grouper:0 = Not used1 = 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

ctier X(1) 15 Output field. IRF Grouper:Comorbidity tier for diagnosis code.

A = Not a comorbidity, or comorbidity excluded for RICB = Tier 1 comorbidity (high cost)C = Tier 2 comorbidity (medium cost)D = Tier 3 comorbidity (low cost)

Table I-1: DX [dx_entry]: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (occurs numdx times)



Present on Admission (POA) Indicator

poa X(1) 16 Input field.

UB-04 FL67 and FL67A-Q. Indicator that this condition was present at the time of admission. Required in uppercase.

Washington Medicaid & Washington Medicaid APR: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)

Blank = Unreported/not used (Exempt from POA reporting)

All Others: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 (POA) Bypassed

poa_bypassed 9(1) 17 Output field.

MS-DRG, TRICARE DRG, Wisconsin Medicaid, North Carolina Medicaid 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

Illinois Medicaid (prior to July 1, 2014):1 = This code is a HAC-designated condition that was not

present on admission0 = Otherwise

APR-DRG (except for New York Medicaid): 2 = Code is excluded from HAC-adjusted grouping0 = Otherwise

APR-DRG (for New York Medicaid only): 1 = This code is a Never Event that was not present on

admission2 = Code is excluded from HAC-adjusted grouping0 = Otherwise

Filler X(71) 18 - 88Diagnosis Code Reserved

reserved_dx X(10) 89 - 98 Reserved field for ICD-9-CM code Mapper processing.




OP [op_entry]Table J-1: OP [op_entry]: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (occurs numop times)

Field Description Variable Name Format Position NotesProcedure Code 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 type X(3) 11 - 13 Input field.ICD-9 Procedure:BR = First ICD-9 procedureBQ = Other ICD-9 procedure

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

Procedure Date 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

narray 9(1) 22 Output field.

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

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

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

assignment

All Other DRG Groupers: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

pm_ narray 9(1) 23 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:

Output field.

Identifies procedures not generally related to the submitted diagnosis codes.

0 = Code is associated with one or more diagnosis codes1 = Procedure is not usually performed for any of the

submitted diagnosis codes

NoteNot returned for ICD-10.

Filler X(65) 24 - 88Procedure Code Reserved

reserved_op X(10) 89 - 98 Reserved field for ICD-9-CM code Mapper processing.

Table J-1: OP [op_entry]: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (occurs numop times)



LINE [line_entry]Note

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 K-1: LINE [line_entry]: Variable length HCPCS procedure input fields (occurs numhcpcs times)

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

code where applicable. Left-justified, blank filled.Modifiers mod X(2)

occurs 5 times

9 - 18 UB-04 FL44. 1500.24D. Modifiers 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.

Units 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 charges 9(8)v9(2) 26 - 35 UB-04 FL47 and 48. 1500.24F. Total covered charges for this procedure (individual covered charges multiplied by units).

Date of Service 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 rev 9(4) 44 - 47 UB-04 FL42. Revenue code.User Area user X(12) 48 - 59 Reserved


Line Override 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)

TRICARE APC:0 = OCE line item denial is not ignored.1 = OCE line item denial is ignored.2 = External line item denial. Line item is denied even if no

OCE edits4 = External line item adjustment. Technical charge rules

apply.8 = Inpatient only procedure on Supplemental Health Care

Program (SHCP) claim.9 = Line is bypassed by the OCE.

Provider ID provider X(8) 61 - 68 ReservedUnits Reserved units_rsvd 9(15) 69 - 83 ReservedNational Drug Code (NDC)

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 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).

NoteTRICARE APC does not utilize this functionality at this time, although Optum has developed this capability in the TRICARE APC Payment System, starting with the V1108 release.

Place of Service 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: http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

Rendering Provider NPI 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

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/

CAH Method II:Line-level rendering provider taxonomy.



http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html






Status Code 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

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

px_fp_ind 9(1) 132 E&M Analyzer Pro:0 = Code came from practitioner claim1 = Code came from facility claim

Specialty Code 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) and/or taxonomy code(s) on the claim.

Filler X(66) 135 - 200




GOB1.APC [apc_grpr_block1]Table L-1: GOB1.APC [apc_grpr_block1]: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields

Field Description Variable Name Format Position NotesGrouper Return Code grpr_rtn_code X(2) 1 - 2 Standard Return Codes:

00 = No errors found62 = Closed or inactive rate record87 = Program cannot be loaded

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

group78 = Error reading HHA PDGM Reader file

ESRD:None

Grouper Return Code Reserved

grpr_rtn_rsvd X(8) 3 - 10 Reserved

Grouper Type grpr_type X(2) 11 - 12 24 = Medicare HHA PDGM (effective January 01, 2020)55 = Medicare APC56 = Reserved57 = Medicare ASC (effective January 01, 2008)60 = Medicare ESRD62 = Medicare HHA HHRG (prior to January 01, 2020)

Grouper Type Reserved grpr_type_rsvd X(2) 13 - 14 ReservedGrouper Version grpr_vers 9(2) 15 - 16 Grouper version number.Grouper Version Reserved


Patient or Visit Type pattype X(1) 21 APC:0 = Undetermined1 = Significant procedure3 = Medical visit4 = Medical visit resulting in surgery


APC Status Code 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

alt_hhrg X(4) 23 - 26 HHA HHRG:Alternate HHRG.

HHA PDGM:First four positions of the alternate PDGM.

Alternate HHRG/PDGM Flag

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

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

nrs X(1) 32 HHA HHRG:Non-routine supplies code.

HHA PDGM:Fifth position of the PDGM.

Treatment Authorization Code Validity Flag

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

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

PDGM pdgm X(5) 39 - 43 HHA PDGM:PDGM

Filler X(957) 44 - 1000

Table L-1: GOB1.APC [apc_grpr_block1]: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields



GOB1.APG [apg_grpr_block1]Table M-1: GOB1.APG [apg_grpr_block1]: Fixed length APG Grouper output fields

Field Description Variable Name Format Position NotesGrouper Return Code grpr_rtn_code X(2) 1 - 2 00 = No errors found

01 = No claim lines submitted 02 = No principal diagnosis submitted 03 = Invalid or inconsistent from/thru or service dates 04 = Error return from database29 = Error reading Grouper file30 = Error writing to database60 = Cannot load external software61 = All other errors returned from external software62 = Closed or inactive rate record65 = Invalid certificate (3M™ GPCS only)66 = Invalid URL (3M™ GPCS only)67 = All other errors returned from GPCS (3M™ GPCS

only)80 = Invalid content version (3M™ GPCS only)87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory



Grouper Type grpr_type X(2) 11 - 12 51 = Reserved53 = Reserved54 = Reserved61 = APG

Grouper Type Reserved grpr_type_rsvd X(2) 13 - 14 ReservedGrouper Version grpr_vers 9(2) 15 - 16 Grouper version number. This field will equal the 2 digits

that follow the decimal of the EAPG Version number (e.g., if the EAPG Version is “3.14”, this field will be set to “14”).

Grouper Version Reserved


Patient or Visit Type pattype X(1) 21 ReservedAPG Status Code stat 9(1) 22 ReservedMedical APG Assigned mapg 9(5) 23 - 27 ReservedMedical APG Error Flag mapg_err X(2) 28 - 29 ReservedMedical APG Category mapg_cat X(2) 30 - 31 ReservedAPG SSF mapg_ssf X(6) 32 - 37 ReservedNumber of Visits num_visits 9(3) 38 - 40 Total number of visits on claim.ICD-10 APG SSF mapg_ssf_01 X(10) 41 - 50 Reserved


Emergency Room (ER) Payment Reduction Flag

er_reduc 9(1) 51 Virginia Medicaid APG:If an ER claim contains procedure codes 99281 - 99284 and the principal diagnosis code is on the Preventable Emergency Room List, a value of 1 will be returned in this field.

0 = Do not apply ER payment reduction1 = Apply ER payment reduction

Filler X(949) 52 - 1000

Table M-1: GOB1.APG [apg_grpr_block1]: Fixed length APG Grouper output fields



GOB1.CMG [cmg_grpr_block1]Table N-1: GOB1.CMG [cmg_grpr_block1]: Fixed length IRF Grouper output fields


01 = No CMG match02 = No HIPPS code on the claim03 = Reserved04 = Reserved05 = 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

range 24 = 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 range39 = Total cognitive score, admission, out of range62 = Closed or inactive rate record87 = Program cannot be loaded


Grouper Reserved grpr_rtn_rsvd X(8) 3 - 10 ReservedGrouper Type grpr_type X(2) 11 - 12 90 = Medicare IRF CMGGrouper Type Reserved grpr_type_rsvd X(2) 13 - 14 ReservedGrouper Version grpr_vers 9(2) 15 - 16 Grouper version number.Grouper Version Reserved


Rehabilitation Impairment Category

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

cmg 9(4) 23 - 26 Clinically-related CMG.

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

HIPPS Code 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

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

Table N-1: GOB1.CMG [cmg_grpr_block1]: Fixed length IRF Grouper output fields



Admission Motor Score – Calculated

motor_out 9(3) 38 - 40 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 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 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

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

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

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 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 cogn_flag field.





FIM Admission Cognitive Score Flag

cogn_flag 9(1) 45 0 = FIM Admission Cognitive Score was not calculated1 = FIM Admission Cognitive Score was calculated

Returned only if assessment data was provided.Admission Motor Score 2 – Calculated

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 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 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

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 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 cogn_flag field.

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

comorbid_01 X(10) 58 - 67 Comorbidity code that is at the highest comorbidity tier for the case.




Second ICD-10 Comorbidity Code Used for HIPPS Assignment

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(923) 78 - 1000




GOB1.DRG [drg_grpr_block1]Table O-1: GOB1.DRG [drg_grpr_block1]: Fixed length Inpatient Grouper output fields

Field Description Variable Name Format Position NotesGrouper Return Code grpr_rtn_code X(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 found87 = Program cannot be loaded62 = Closed or inactive rate record

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

All Patient Refined (APR-DRG):03 = Invalid age in years or age in days on admission 08 = Invalid mapping15 = Invalid birthweight in grams16 = Conflicting birth weights18 = Invalid discharge age 28 = Invalid data60 = Cannot load external software 61 = All other errors from external software65 = Invalid certificate (3M™ GPCS only)66 = Invalid URL (3M™ GPCS only)80 = Invalid content version (3M™ GPCS only)

Medicare DRG:06 = Illogical principal diagnosis (PDX)

North Carolina Medicaid 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

continued below...


Grouper Return Code grpr_rtn_code X(2) 1 - 2 Wisconsin Medicaid DRG:03 = Invalid age in years or age in days on admission06 = Illogical principal diagnosis (PDX)19 = Invalid length of stay21 = Invalid admission source

ICD-10 Wisconsin Medicaid DRG:03 = Invalid age in years or age in days on admission19 = Invalid length of stay21 = Invalid admission source

Grouper Reserved grpr_rtn_rsvd X(8) 3 - 10 ReservedGrouper Type grpr_type X(2) 11 - 12 01 = Medicare DRG

02 = All Patient (AP-DRG)03 = TRICARE/CHAMPUS DRG05 = Reserved06 = Wisconsin Medicaid DRG07 = North Carolina Medicaid DRG08 = Ohio Medicaid DRG10 = All Patient Refined (APR-DRG)11 = ICD-10 Medicare DRG12 = ICD-10 TRICARE DRG40 = ICD-10 Wisconsin Medicaid DRG



Major Diagnostic Category (MDC)

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

Diagnostic Related Group (DRG)

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

All Patient Refined DRGs (APR-DRGs): Consists of a 4-digit DRG and a 1-digit severity indicator. The severity indicators are as follows:0 = Not applicable 1 = Minor 2 = Moderate 3 = Major 4 = Extreme

Illinois Medicaid (prior to July 1, 2014): DRG will be modified if the patient was a neonate in DRGs 385, 386, 387, or 389 and the patient was treated in a Level III perinatal center. The DRG will be modified by the Illinois Pricer and returned in this field.

O.R. Procedures Needed for DRG Assignment

op X(7)occurs 3 times

28 - 48 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First three operating room procedures that influenced DRG assignment. May be blank.

Table O-1: GOB1.DRG [drg_grpr_block1]: Fixed length Inpatient Grouper output fields



Non-O.R. Procedures nor X(7)occurs 2 times

49 - 62 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First and second non-operating room procedures that influenced DRG assignment. May be blank.

Complication/Comorbidity Diagnosis

cc X(6) 63 - 68 Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG: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.

Diagnoses That Influenced DRG Assignment

dx X(6) occurs 3 times

69 - 86 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First three diagnoses (other than principal) that influenced DRG assignment. May be blank.

Trauma Flag 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

Congenital Malformation Flag

nyscmr 9(1) 88 AP-DRG: Congenital Malformation Flag. New York 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 2

Severity of Illness soi X(1) 89 APR-DRG: Severity level:0 = Not applicable1 = Minor2 = Moderate3 = Major4 = Extreme

Severity Filler soi_filler X(1) 90 ReservedRisk of Mortality rom X(1) 91 APR-DRG:

Risk of mortality:0 = Not applicable1 = Minor2 = Moderate3 = Major4 = Extreme

Mortality Filler rom_filler X(1) 92 Reserved




Number of MCCs num_mcc 9(3) 93 - 95 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:Number of major complications/comorbidities on the claim not excluded by the principal diagnosis.

Number of CCs num_cc 9(3) 96 - 98 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:Number of complications/comorbidities on the claim not excluded by the principal diagnosis.

Alternate DRG alt_drg 9(5) 99 - 103 Alternate DRG that would have been assigned if all conditions had been present on admission.

O.R. Procedure op_01 X(10)Occurs 3 times

104 - 133 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First three operating room procedures that influenced DRG assignment. May be blank.

Non-O.R. Procedure nor_01 X(10)Occurs 2 times

134 - 153 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First and second non-operating room procedures that influenced DRG assignment. May be blank.

Complication/Comorbidity Diagnosis

cc_01 X(10) 154 - 163 Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG: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.

Diagnosis dx_01 X(10)Occurs 3 times

164 - 193 AP-DRG, Medicare DRG, North Carolina Medicaid DRG, Ohio Medicaid DRG, TRICARE/CHAMPUS DRG, and Wisconsin Medicaid DRG:First three diagnoses (other than principal) that influenced DRG assignment. May be blank.

Admission DRG admit_drg 9(5) 194 - 198 APR-DRG:The admission DRG is derived based on the information known about the patient at the time of admission. This DRG is not used to calculate payment. Consists of a 4-digit admission DRG and a 1-digit severity indicator. The severity indicators are as follows:

0 = Not Applicable1 = Minor2 = Moderate3 = Major4 = Extreme




Admission SOI admit_soi X(1) 199 APR-DRG: Severity of illness level based on admission DRG:0 = Not applicable1 = Minor2 = Moderate3 = Major4 = Extreme

Admission Severity Filler

admit_soi_filler X(1) 200 Reserved

Admission ROM admit_rom X(1) 201 APR-DRG: Risk of mortality based on admission DRG:0 = Not applicable1 = Minor2 = Moderate3 = Major4 = Extreme

Admission Mortality Filler

admit_rom_filler X(1) 202 Reserved

Filler X(798) 203 - 1000




GOB1.RUG [rug_grpr_block1]Table P-1: GOB1.RUG [rug_grpr_block1]: Fixed length RUG Reader and SNF Reader output fields


02 = No HIPPS code on claim62 = Closed or inactive rate record87 = Program cannot be loaded



Grouper Type grpr_type X(2) 11 - 12 22 = Medicare SNF RUG (prior to October 01, 2019)23 = Medicare SNF Reader (effective October 01, 2019)



Filler X(980) 21 - 1000


GOB2.APC [apc_grpr_output_entry]Table Q-1: GOB2.APC [apc_grpr_output_entry]: Variable length ACE, APC Grouper, ASC Grouper, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesAPC proc 9(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 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 Editor:00 = No errors found01 = Invalid procedure code02 = Procedure not valid for service date03 = Procedure is valid for dates with pending editing and/



Payment Status Indicator

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 APCJ2 = 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 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 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

continued below...

Table Q-1: GOB2.APC [apc_grpr_output_entry]: Variable length ACE, APC Grouper, ASC Grouper, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader output fields (occurs numhcpcs times)



Payment Status Indicator<continued>

h_paystat X(2) 8 - 9 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 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 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 weightZ2 = Radiology service; OPPS weightZ3 = Radiology service; MPFS non-facility PE RVUsYY = Service not covered by Medicare for free-standing

ASCs

CAH Method II Editor: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

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

covservind 9(1) 11 ASC:0 = Service is not separately payable under the ASC PPS1 = Service is separately payable under the ASC PPS

Filler X(21) 12 - 32




GOB2.APG [apg_grpr_output_entry]Table R-1: GOB2.APG [apg_grpr_output_entry]: Variable length APG Grouper output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesAPG proc 9(5) 1 - 5 The final APG for each claim line used in pricing.APG Type type X(2) 6 - 7 01 = Per Diem

02 = Significant Procedure03 = Medical Visit04 = Ancillary05 = Incidental06 = Drug07 = DME08 = Unassigned (Final error APG = 993 or 999)21 = Physical therapy & rehabilitation procedure22 = Behavioral health & counseling procedure23 = Dental procedure24 = Radiologic procedure25 = Diagnostic or therapeutic procedure

APG Category cat X(2) 8 - 9 01 - 99 depending upon APG assigned.

Values are specific to each APG version. APG Consolidation Flag cons 9(1) 10 0 = APG is not consolidated

1 = APG is consolidated for similarity to other APG2 = APG is consolidated for clinical reasons

APG Packaging Flag pack 9(1) 11 0 = APG is not packaged1 = APG is packaged into a procedure or medical visit

Ambulatory Surgery Category

asc 9(2) 12 - 13 Reserved

ASC Grouper Return Code

asc_rc 9(2) 14 - 15 Reserved

Bilateral Discount Flag bidisc 9(1) 16 0 = Not subject to bilateral discounting2 = Subject to surgical bilateral discounting3 = Subject to non-surgical bilateral discounting


Unassigned Flag err 9(2) 17 - 18 Reason line grouped to error APG 999.

00 = Line item assigned01 = Line item denied based on agency defined edit (CCI,

MUE)02 = Inpatient procedure03 = Invalid procedure code04 = Not used by APGs05 = Invalid diagnosis for medical visit06 = External cause of injury diagnosis not appropriate for

medical visit assignment07 = Non-covered care or settings 08 = Invalid date cannot be used (invalid or out of range)09 = Invalid procedure, cannot be blank10 = Direct per diem code without qualifying principal

diagnosis11 = Observation code G0378 reported without an

encounter/observation referral (APG 492) on same day

12 = Encounter/observation referral (APG 492) reported without observation code G0378

13 = Gender unknown or invalid for medical gender-specific APG

14 = Home management15 = User option for direct per diem assignment off16 = APG assignment condition not met17 = Never event modifier present18 = Observation units of service does not match

specifications19 = Patient age not reported for preventative medicine

visit20 = Add-on code assignment to inpatient21 = Incorrect or invalid diagnosis pointer for multiple

medical visit option22 = Incorrect or invalid linked diagnosis for multiple

medical visit option23 = Revenue code only line

Medical Visit Diagnosis/SSF

med_dx X(6) 19 - 24 Identifies the diagnosis used to assign a Medical APG or Signs Symptoms and Findings (SSF) APG. This field is only populated when a Medical Visit APG or SSF APG is assigned to this service date and is applicable to this visit.

Multiple Procedure Discounting Flag

mspd 9(1) 25 0 = Not eligible for multiple procedure discounting1 = Eligible for multiple procedure discounting

Repeat Ancillary Discounting Flag

repanc 9(1) 26 0 = Not subject to repeat ancillary service discounting1 = Subject to repeat ancillary service discounting

Terminated Procedure Discounting Flag

term 9(1) 27 0 = Not subject to terminated procedure discounting1 = Subject to terminated procedure discounting

Table R-1: GOB2.APG [apg_grpr_output_entry]: Variable length APG Grouper output fields (occurs numhcpcs times)



Line Item Action Flag Used

actflg 9(2) 28 - 29 00 = Line item is included in Grouper logic01 = Line item is ignored by Grouper logic30 = Code excluded from grouping and editing - pending

final grouping assignment31 = External NCCI edit present32 = External MUE edit present33 = External NCCI and MUE edit present35 = Non-covered revenue code present36 = Non-covered procedure code present37 = Same claim as invalid diagnosis code which causes

all services to be denied38 = Same day as line which causes all other services to

be denied39 = Revenue code requires HCPCS code40 = Invalid revenue code41 = Invalid modifier42 = Blank revenue code43 = Same claim as HCPCS reported without a revenue

code which causes all services to be denied44 = Same claim as line which causes all other services to

be denied45 = Same claim as non-allowed or invalid bill type which

causes all services to be denied46 = Same claim as invalid patient sex which causes all

services to be denied47 = Multi-day claim lacking revenue code 450 or 762

causes all services to be denied48 = Behavioral health detail line49 = Behavioral health reporting requirements not met50 = Service limit exceeded52 = Reference lab service non-covered53 = Medical policy non-covered54 = Invalid procedure code55 = Observation hours reporting issue56 = COVID-19 vaccine reporting requirements not met57 = COVID-19 vaccine administration reporting

requirements not metLine Item 340B Discount Flag

disc_340b 9(1) 30 0 = No 340B discount applies1 = 340B discount applies

Line Item Device Modifier Discounting Flag

device_mod 9(1) 31 Reserved

Line Item Preventive Service Flag

prevent_svc 9(1) 32 0 = Not a preventive service1 = Preventive service

Table R-1: GOB2.APG [apg_grpr_output_entry]: Variable length APG Grouper output fields (occurs numhcpcs times)



GOB2.CMG [cmg_grpr_output_entry]Table S-1: GOB2.CMG [cmg_grpr_output_entry]: Variable length IRF Grouper output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesReserved X(32) 1 - 32 Reserved


GOB2.DRG [drg_grpr_output_entry]Table T-1: GOB2.DRG [drg_grpr_output_entry]: Variable length inpatient Grouper output fields (occurs numhcpcs times)



GOB2.RUG [rug_grpr_output_entry]Table U-1: GOB2.RUG [rug_grpr_output_entry]: Variable length RUG Reader and SNF Reader output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesHIPPS hipps X(5) 1 - 5 Health Insurance Prospective Payment CodeRUG rug X(5) 6 - 10 Resource Utilization GroupGrouper Return Code 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.DRG [drg_grpr_output_dx]Table V-1: GOB3.DRG [drg_grpr_output_dx]: Variable length diagnosis return fields (occurs numdx times)

Field Description Variable Name Format Position NotesSeverity of Illness Indicator

soi_indicator 9(1) 1 APR-DRG: Identifies diagnoses that contribute to the Severity of Illness (SOI) classification for the claim.1 = Diagnosis contributes to SOI0 = Otherwise

Severity of Illness soi X(1) 2 APR-DRG: Severity of illness.0 = Not applicable1 = Minor 2 = Moderate 3 = Major 4 = ExtremeP = Code used as principal diagnosisX = Code excluded for severity considerationC = Excluded Complication of Care D = Duplicate secondary diagnosisBlank = Diagnosis was not recognized or (if HAC functionality was not requested) SOI not evaluated or (if HAC functionality was requested) indicates code is identified as a HAC so excluded from HAC-adjusted processing.

Severity Filler soi_filler X(1) 3 ReservedRisk of Mortality Indicator

rom_indicator 9(1) 4 APR-DRG: Identifies diagnoses that contribute to the Risk of Mortality (ROM) index for the claim.1 = Diagnosis contributes to ROM0 = Otherwise

Risk of Mortality rom X(1) 5 APR-DRG: Risk of mortality:0 = Not applicable1 = Minor2 = Moderate3 = Major4 = ExtremeP = Code used as principal diagnosisX = Code excluded for mortality considerationC = Excluded Complication of Care D = Duplicate secondary diagnosisBlank = Diagnosis was not recognized or ROM not requested (or if HAC functionality was requested indicates code is identified as a HAC so excluded from HAC-adjusted processing).

Mortality Filler rom_filler X(1) 6 ReservedUnrelated CC unrelated_cc 9(1) 7 Reserved


Diagnosis Grouper Flag (output)

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

APR-DRG Grouper:0 = Not used1 = 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

Table V-1: GOB3.DRG [drg_grpr_output_dx]: Variable length diagnosis return fields (occurs numdx times)



GOB4.DRG [drg_grpr_output_op]Table W-1: GOB4.DRG [drg_grpr_output_op]: Variable length ICD-9-CM or ICD-10-PCS procedure return fields (occurs numop times)

Field Description Variable Name Format Position NotesSeverity of Illness Indicator

soi_indicator 9(1) 1 APR-DRG: Identifies procedures that contribute to the Severity of Illness (SOI) classification for the claim.1 = Procedure contributes to SOI0 = Otherwise

Severity of Illness Filler soi_filler X(2) 2 - 3 ReservedRisk of Mortality Indicator

rom_indicator 9(1) 4 APR-DRG: Identifies procedures that contribute to the Risk of Mortality (ROM) index for the claim.1 = Procedure contributes to ROM0 = Otherwise

Risk of Mortality Filler rom_filler X(2) 5 - 6 ReservedDRG Procedure Indicator (output)

narray 9(3) 7 - 9 Output field.

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

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

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

assignment

All Other DRG Groupers: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.APC [apc_prcr_block1]Table X-1: POB1.APC [apc_prcr_block1]: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields

Field Description Variable Name Format Position NotesPricer Return Code prcr_rtn_code X(2) 1 - 2 Standard Return Codes:

00 = No errors found01 = No hospital rate calculator record03 = Pricer type not licensed62 = Closed or inactive rate record70 = Configuration record error72 = Hospital rate calculator record not

found74 = No weights75 = Extended hospital rate calculator

record not found82 = Error reading hospital rate calculator

file83 = Error reading rate file84 = Error reading fee schedule file85 = Error reading the extended hospital

rate calculator file86 = Error reading the code table file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid dates95 = Parameter passing error98 = Invalid outpatient classification

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 therapy54 = Biosimilar HCPCS reported without

biosimilar modifier

Contract APC:22 = Denial claim25 = Invalid partial hospitalization claim26 = Reserved for credit/adjustment claim41 = Invalid billing of therapy services42 = Invalid billing of device credit

continued below...


Pricer Return Code<continued>

prcr_rtn_code X(2) 1 - 2 Contract ASC:37 = Invalid billing of codes for cardiac

resynchronization therapy54 = Biosimilar HCPCS reported without

biosimilar modifier

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 tests

38 = 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 type23 = Invalid service date, from-thru dates, or

admission date30 = 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 data39 = Claim from date is prior to HHA

Medicare participation/certification40 = 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

combinationcontinued below...

Table X-1: POB1.APC [apc_prcr_block1]: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields




prcr_rtn_code X(2) 1 - 2 56 = 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

New Mexico Medicaid APC:08 = Zero-divide error22 = Denial claim99 = No covered revenue code on claim

TRICARE APC:60 = Cannot load external software61 = All other errors from external software65 = Invalid certificate (3M™ GPCS only)66 = Invalid URL (3M™ GPCS only)80 = Invalid content version (3M™ GPCS

only)Pricer Return Code Reserved prcr_rtn_rsvd X(8) 3 - 10 Reserved Pricer Type prcr_type X(2) 11 - 12 d = Reserved for cost reduction factor

h = Medicare APC-HOPDi = Contract APC39 = Medicare FQHC46 = New Mexico Medicaid APC55 = Medicare ASC60 = Medicare ESRD62 = Medicare HHA63 = TRICARE APC64 = Contract ASC67 = Medicare Hospice

Pricer Type Reserved prcr_type_rsvd X(2) 13 - 14 ReservedBase Reimbursement base_pay 9(8)v9(2) 15 - 24 Total reimbursement for this claim.Patient Co-Payment 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 addon 9(8)v9(2) 35 - 44 APC-HOPD, Contract APC, ESRD, and TRICARE APC: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 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 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

transcor 9(8)v9(2) 65 - 74 APC-HOPD: Estimated transitional corridor/hold harmless payment for this claim.

TRICARE APC: Total transitional payment for this claim.

Claim Deductible clm_deduct 9(8)v9(2) 75 - 84 APC-HOPD:Patient deductible applied to this claim.

Total Reimbursement tot_reimb 9(8)v9(2) 85 - 94 Total anticipated payment.APC-HOPD:base_pay + copay + addon + transcor + clm_deduct

ASC, Contract ASC, and FQHC:base_pay + copay

Contract APC:base_pay + copay + addon + transcor

ESRD and HHA:base_pay + copay + addon

Hospice:base_pay + addon

New Mexico Medicaid APC:base_pay

TRICARE APC:base_pay + addon + transcor




Outlier Flag outflag 9(1) 95 APC-HOPD, Contract APC, ESRD, and TRICARE APC:1 = Claim contains outlier add-on0 = Otherwise

Base Rate Flag baserate_flag 9(1) 96 Contract APC:1 = Base * APC weight pricing appliesOtherwise, APC-based rates are used.

Cost Reduction Factor crf 9(1)v9(5) 97 - 102 APC-HOPD and Contract APC:Outpatient cost reduction factor

Rural Flag 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 rcc 9(1)v9(5) 104 - 109 APC-HOPD and Contract APC:Outpatient ratio of costs-to-charges.

Mark-Up/Discount Factor markup 9(1)v9(4) 110 - 114 Mark-up or discount applied to total reimbursement.




Pricing Method Indicator 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 alt_reimb 9(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

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 comrbd_cat 9(2) 137 - 138 ESRD:Comorbidity category associated with monthly bill:00 = No comorbidity adjustment01 = GI bleed02 = Pneumonia03 = Pericarditis04 = Myelodyspastic syndrome05 = Sickle cell anemia06 = Monoclina gammopathy

Quality Flag quality_flag 9(2) 139 - 140 ESRD:0 = Quality reporting requirements met1 = Quality reporting requirements not met

Dialysis PPS Payment with Facility Adjustment Only

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

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

Age Factor - Composite agefactor 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 agefactor_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

avg_pertreat 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

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

Body Mass Index (BMI) bmi 9(3)v9(4) 192 - 198 ESRD: BMI of patient.

Body Mass Index (BMI) Factor bmifactor 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

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

Body Surface Area (BSA) bsa 9(1)v9(4) 210 - 214 ESRD:BSA of patient.

Body Surface Area (BSA) Factor - Composite

bsafactor 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

bsafactor_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 bundle_agefactor 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

bundle_bmifactor 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

bundle_bsafactor 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 comrbd_factor 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

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

NDC Dispensing Fee dispense_fee 9(2)v9(2) 254 - 257 ESRD:Dispensing fee for oral-only drugs with an injectable equivalent.

Fixed Dollar Loss Amount 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 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

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

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

Dialysis Payment - Composite 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 (ext_blk_sw) in the ECB [ezg_cntl_block] needs to be = 1 for all fields beyond position 300.

Cost Outlier Threshold 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

totpred_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

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

Core Based Statistical Area (CBSA)

cbsa X(5) 331 - 335 ESRD:Core Based Statistical Area (CBSA).

Return Code Override Flag rc_over 9(1) 336 ESRD:0 = Do not override Return Codes 04, 05,

and 381 = Override Return Codes 04, 05, and 38

Rural Adjustment Factor 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

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 rap_reduction 9(8)v9(2) 349 - 358 HHA:The amount the total payment has been reduced by due to an untimely RAP submission.

Alternate RAP Penalty Amount alt_rap_reduction 9(8)v9(2) 359 - 368 HHA:The amount the alternate total payment has been reduced by due to an untimely RAP submission.

Filler X(632) 369 - 1000




POB1.APG [apg_prcr_block1]Table Y-1: POB1.APG [apg_prcr_block1]: Fixed length APG Pricer output fields


00 = No errors found01 = No hospital rate calculator record03 = Pricer type not licensed10 = Reserved11 = Reserved23 = Invalid service date, from-thru dates, or admission

date62 = Closed or inactive rate record70 = Configuration record error75 = Extended hospital rate calculator record not found83 = Error reading rate file84 = Error reading fee schedule file85 = Error reading extended hospital rate calculator file86 = Error reading code table file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid dates95 = Parameter passing error98 = Invalid outpatient classification

Additional Pricer-Specific Return Codes: Alabama BCBS APG:None

Colorado Medicaid APG and Florida Medicaid APG:22 = Denial claim

Enhanced New York Medicaid APG:09 = Missing or invalid rate file record12 = Missing rate code13 = Invalid rate code79 = Error reading rate code table80 = Error reading zip code table96 = Invalid billing of service for rate code

Nebraska Medicaid APG:22 = Denial claim

New York Medicaid APG:09 = Case not priced 12 = Missing rate code 13 = Invalid rate code continued below...



prcr_rtn_code X(2) 1 - 2 Illinois Medicaid APG:47 = No APL code found 48 = Patient reason for visit diagnosis not found 52 = Invalid billing of ER, observation, or psychiatric

service

Massachusetts Medicaid APG:22 = Denial claim

Ohio Medicaid APG:None

Virginia Medicaid APG and Virginia Medicaid ASC:22 = Denial claim

Washington DC Medicaid APG:22 = Denial claim

Washington Medicaid APG:None

Wisconsin Medicaid APG:27 = Wrong procedure performed

Pricer Return Code Reserved

pricer_rtn_rvsd X(8) 3 - 10 Reserved

Pricer Type prcr_type X(2) 11 - 12 a = Reservedb = Reservede = Reservedk = Reserved37 = Washington Medicaid APG38 = Illinois Medicaid APG40 = Wisconsin Medicaid APG41 = Virginia Medicaid APG44 = Medicaid APG Pro45 = Enhanced New York Medicaid APG61 = New York Medicaid APG

Pricer Type Reserved prcr_type_rsvd X(2) 13 - 14 ReservedBase APG Reimbursement

base_rate 9(8)v9(2) 15 - 24 Total APG portion of reimbursement.

Total Add-On Payment addon 9(8)v9(2) 25 - 34 Florida Medicaid APG:Total automatic rate enhancement supplemental payment.

Illinois Medicaid APG & Massachusetts Medicaid APG:Total cost outlier add-on payment for this claim.

Table Y-1: POB1.APG [apg_prcr_block1]: Fixed length APG Pricer output fields



Total APG Reimbursement

tot_reimb 9(8)v9(2) 35 - 44 Total APG reimbursement for this case.

Enhanced New York Medicaid APG and New York Medicaid APG: (base_rate + capital + tot_exist).

Alabama BCBS APG, Colorado Medicaid APG, Ohio Medicaid APG, Nebraska Medicaid APG, Virginia Medicaid APG, Virginia Medicaid ASC, Washington DC Medicaid APG, Washington Medicaid APG, & Wisconsin Medicaid APG: (base_rate)

Florida Medicaid APG, Illinois Medicaid APG, & Massachusetts Medicaid APG:(base_rate + addon)

Outlier Flag outflag 9(1) 45 Illinois Medicaid APG & Massachusetts Medicaid APG:Identifies claims containing an outlier add-on.0 = Otherwise1 = Claim contains outlier add-on

Medical APG Weight mapg_wgt 9(3)v9(5) 46 - 53 ReservedMedical APG Payment mapg_pay 9(8)v9(2) 54 - 63 ReservedStatewide Visit Expected Payment (SVEP)

svep 9(8)v9(2) 64 - 73 Reserved

Total ASC Payment asc_total 9(8)v9(2) 74 - 83 ReservedAdjusted Total ASC Payment

asc_adjtotal 9(8)v9(2) 84 - 93 Reserved

Cost Reduction Factor crf 9(1)v9(5) 94 - 99 Washington Medicaid APG:Weighted Cost-to-Charge (WCC) factor used to calculate reimbursement for this Critical Access Hospital (CAH) claim.

Capital Add-On capital 9(8)v9(2) 100 - 109 Enhanced New York Medicaid APG and New York Medicaid APG: Total capital add-on for this claim.

Blend Factor blend 9(1)v9(2) 110 - 112 Enhanced New York Medicaid APG and New York Medicaid APG: Blend factor (portion of APG payment applied to this claim).




Rate Code Indicator rcode 9(1) 113 Enhanced New York Medicaid APG and New York Medicaid APG: Payment rules applied to this claim, based on the APG rate code supplied on claim.

0 = Office of Alcohol and Substance Abuse (OASAS)1 = Hospital Outpatient Department (OPD)2 = Hospital Ambulatory Surgical Center (ASC)3 = Emergency Department/Room (ED)4 = Diagnostic and Treatment Center5 = Free-standing Ambulatory Surgical Center (ASC)6 = Clinic – Mental Retardation, Development Disability or

Traumatic Brain Injury (MR/DD/TBI)7 = Dental School8 = Renal Clinic9 = Mental Health Facility

Mark-Up/Discount Factor

markup 9(1)v9(4) 114 - 118 Mark-up or discount applied to each patient visit.

Total Existing Payment tot_exist 9(8)v9(2) 119 - 128 Enhanced New York Medicaid APG and New York Medicaid APG: Total payment for non-APG portion of visits on claim. Only applies to facility types subject to transitions.

State Pricing Indicator state_id X(2) 129 - 130 AL = Alabama BCBS APG pricing rulesCO = Colorado Medicaid APG pricing rulesDC = Washington DC Medicaid APG pricing rulesFL = Florida Medicaid APG pricing rulesIL = Illinois Medicaid APG pricing rulesMA = Massachusetts Medicaid APG pricing rulesNE = Nebraska Medicaid APG pricing rulesOH = Ohio Medicaid APG pricing rulesOS = Ohio Medicaid ASC pricing rulesOT = Other/user-defined pricing rulesVA = Virginia Medicaid APG and ASC pricing rules

Missing Ambulatory Procedures Listing (APL) Flag

aplflag 9(1) 131 Illinois Medicaid APG:0 = APL requirements met1 = Series APL code missing; clinical circumstances

should be reviewedFiller X(869) 132 -

1000




POB1.CAH [cah_prcr_block1]Table Z-1: POB1.CAH [cah_prcr_block1]: Fixed length CAH Method II Pricer output fields

Field Description Variable Name Format Position NotesPricer Return Code prcr_rtn_code X(2) 1 - 2 00 = No errors found

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 error72 = Hospital rate calculator record not

found81 = Error reading payers file82 = Error reading hospital rate calculator

file83 = Error reading rate file84 = Error reading fee schedule file86 = Error reading code table file87 = Program cannot be loaded88 = Initialization error89 = Memory error94 = Invalid dates95 = Parameter passing error

Pricer Return Code Reserved prcr_rtn_rsvd X(4) 3 - 6 ReservedPricer Return Code Type prcr_rtn_type X(1) 7 A = Return code from APC-HOPD Pricer

C = Return code from CAH Method II PricerP = Return code from Physician Pricer

Filler X(3) 8 - 10Pricer Type prcr_type X(2) 11 - 12 66 = CAH Method IIPricer Type Reserved prcr_type_rsvd X(2) 13 - 14 ReservedBase Reimbursement base_pay 9(8)v9(2) 15 - 24 Total Medicare payment for this claim.Patient Co-Payment copay 9(8)v9(2) 25 - 34 Total patient co-payment for this claim.Total Reimbursement tot_reimb 9(8)v9(2) 35 - 44 Total payment calculated as follows:

base_pay + copay + bonus_pay

Rural Flag rural X(1) 45 Rural indicator for ambulance pricing.B = Qualified rural area ZIP code for air and

ground ambulance servicesR = Rural ZIP code for air and ground

ambulance servicesEstimated Bonus Payment 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(945) 56 - 1000


POB1.CMG [cmg_prcr_block1]Table AA-1: POB1.CMG [cmg_prcr_block1]: Fixed length IRF Pricer output fields


01 = No hospital rate calculator record02 = No CMG rate record03 = Reserved04 = Invalid pricer type05 = Invalid or missing thrudate06 = 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 record70 = Configuration record error87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid dates95 = Parameter passing error


prcr_rtn_rsvd X(8) 3 - 10 Reserved

Pricer Type prcr_type X(2) 11 - 12 90 = Medicare IRFPricer Type Reserved prcr_type_rvsd X(2) 13 - 14 ReservedPayment Casemix Group

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 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

base 9(8)v9(2) 24 - 33 Base PPS reimbursement for the claim. Blend percentage, if applicable, has been applied.


Outlier Add-On addon 9(8)v9(2) 34 - 43 Outlier payment for the claim. Blend percentage, if applicable, has been applied.

Total PPS Payment 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

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 penalty 9(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 totreimb 9(8)v9(2) 74 - 83 Total reimbursement for the case. ppstot + factot - penalty

Payment Flag payflag 9(2) 84 - 85 00 = CMG-based case payment01 = Transfer 02 = Short stay case03 = Expired case

Cost Outlier Flag outflag 9(1) 86 0 = Not an outlier1 = Qualifies for a cost outlier payment

Transfer Flag trflag 9(2) 87 - 88 00 = Not a transfer01 = Paid using CMG-specific per diem02 = Payment capped at CMG payment rate

Blend Percentage 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.

Penalty Flag 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 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

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

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.

Table AA-1: POB1.CMG [cmg_prcr_block1]: Fixed length IRF Pricer output fields



Charges Used in Outlier Calculations

outchg 9(8)v9(2) 117 - 126 Charges used to determine applicable cost outlier payments.

Cost Outlier Threshold for Payment HIPPS Code

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

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(856) 145 - 1000

Table AA-1: POB1.CMG [cmg_prcr_block1]: Fixed length IRF Pricer output fields



POB1.DRG [drg_prcr_block1]Table AB-1: POB1.DRG [drg_prcr_block1]: Fixed length DRG Pricer output fields


00 = No errors found01 = No hospital rate calculator record02 = No DRG rate record10 = Reserved11 = Reserved12 = Reserved22 = Reserved23 = Reserved62 = Closed or inactive rate record70 = Configuration record error73 = Cannot retrieve rate record75 = Extended hospital rate calculator record not found83 = Error reading rate file85 = Error reading extended hospital rate calculator file86 = Error reading code table file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory95 = Parameter passing error

Additional Pricer-Specific Return Codes:Arizona Medicaid:07 = No DRG weights/rates available08 = Zero-divide error13 = Admit date equals discharge date21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim25 = Non-payment claim27 = Wrong procedure performed

California Medicaid:07 = No DRG weights/rates available08 = Zero-divide error25 = Non-payment claim27 = Wrong procedure performed28 = Invalid reimbursement configuration29 = Invalid rehabilitation claim

Colorado Medicaid:07 = No DRG weights/rates available08 = Zero-divide error16 = Invalid ALC days/interrupted days21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

continued below...



prcr_rtn_code X(2) 1 - 2 Florida Medicaid:07 = No DRG weights/rates available 08 = Zero-divide error16 = Invalid ALC days/interrupted days21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Georgia Medicaid: 21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Illinois Medicaid:06 = Invalid Indirect Medical Education Adjustment (IMEA)

of > 1.007 = No DRG weights/rates available 08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator27 = Wrong procedure performed46 = Invalid birthweight in grams

Illinois Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed46 = Invalid birthweight in grams

Indiana Medicaid:08 = Zero-divide error13 = Admit date equals discharge date21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Indiana Medicaid APR:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Iowa Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed28 = Invalid reimbursement configuration

continued below...

Table AB-1: POB1.DRG [drg_prcr_block1]: Fixed length DRG Pricer output fields




prcr_rtn_code X(2) 1 - 2 Kansas Medicaid:07 = No DRG weights/rates available16 = Invalid ALC days/interrupted days 21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed 30 = Neonate regroup

Kentucky Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 27 = Wrong procedure performed

Louisiana Medicaid:07 = No DRG weights/rates available21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim27 = Wrong procedure performed

Massachusetts Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Medicare Inpatient:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim27 = Wrong procedure performed

Medicare IPF: 08 = Zero-divide error16 = Invalid ALC days/interrupted days 17 = Number of ECT treatments not coded 18 = Invalid occurrence span date 19 = ECT units coded without appropriate procedure 25 = Non-payment claim27 = Wrong procedure performed

Medicare LTC:08 = Zero-divide error16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date 20 = Requested inpatient PPS rate information cannot be

found 25 = Non-payment claim27 = Wrong procedure performed

continued below...





prcr_rtn_code X(2) 1 - 2 Michigan Medicaid and Michigan Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed 38 = Invalid or missing required claims data 46 = Invalid birthweight in grams

Minnesota Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed46 = Invalid birthweight in grams94 = Invalid date

Mississippi Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Multi-Pricer/DRG Pro:08 = Zero-divide error14 = Invalid DRG pricing option 15 = Invalid tier start days 21 = Invalid Present on Admission (POA) indicator27 = Wrong procedure performed 28 = Invalid reimbursement configuration

Nebraska Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Nebraska Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim25 = Non-payment claim27 = Wrong procedure performed

New Jersey Medicaid:07 = No DRG weights/rates available16 = Invalid ALC days/interrupted days 18 = Invalid occurrence span date 21 = Invalid Present on Admission (POA) indicator

continued below...





prcr_rtn_code X(2) 1 - 2 New Jersey Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error16 = Invalid ALC days/interrupted days 21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed94 = Invalid date

New York Medicaid APR:08 = Zero-divide error 16 = Invalid ALC days/interrupted days18 = Invalid occurrence span date 21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim26 = Claim contains a never event or an adverse event

North Carolina Medicaid:08 = Zero-divide error13 = Admit date equals discharge date21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Ohio Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error 21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim27 = Wrong procedure performed

Pennsylvania Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim

Rhode Island Medicaid:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed 94 = Invalid date

South Carolina Medicaid:07 = No DRG weights/rates available08 = Zero-divide error 21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

continued below...





prcr_rtn_code X(2) 1 - 2 Texas Medicaid:08 = Zero-divide error 21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim25 = Non-payment claim 27 = Wrong procedure performed

TRICARE/CHAMPUS:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator 25 = Non-payment claim27 = Wrong procedure performed

Virginia Medicaid:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim27 = Wrong procedure performed

Virginia Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator24 = Non-covered claim 25 = Non-payment claim27 = Wrong procedure performed

Washington DC Medicaid:07 = No DRG weights/rates available08 = Zero-divide error13 = Admit date equals discharge date21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed94 = Invalid date

Washington Medicaid:08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator 25 = Non-payment claim27 = Wrong procedure performed

Washington Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed 38 = Invalid or missing required claims data46 = Invalid birthweight in grams

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

continued below...





prcr_rtn_code X(2) 1 - 2 Wisconsin Medicaid:21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed

Wisconsin Medicaid APR:07 = No DRG weights/rates available08 = Zero-divide error21 = Invalid Present on Admission (POA) indicator25 = Non-payment claim27 = Wrong procedure performed 46 = Invalid birth weight in grams

Filler prcr_rtn_rsvd X(8) 3 - 10 ReservedPricer Type prcr_type X(2) 11 - 12 Refer to the ECB [ezg_cntl_block] for a list of possible

values. Refer to the field labeled, Pricer Type.Filler prcr_type_rsvd X(2) 13 - 14 Reserved Base Reimbursement Rate

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

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

Alternate Level of Care Days Payments or Medicare Pass Thru Payment

alcpay 9(8)v9(2) 35 - 44 Florida Medicaid: Includes adjustment for non-covered days

Kentucky Medicaid: Payment for high volume per diem

Medicare Inpatient: Additional payment for pass-through expenses (passthru * los)

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

New Mexico Medicaid: Additional payment for pass-through capital expenses (cap_rate * markup)

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

Washington Medicaid: Additional payment for pass-through expenses

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




Outlier Type outflag 9(1) 55 1 = Not an outlier2 = Long stay outlier3 = Cost outlier4 = Short stay outlier5 = Transfer6 = Per diem reimbursement7 = Low cost outlier8 = Capped at billed charges9 = Cost and long stay outlier

Mean Length of Stay mlos 9(3)v9(4) 56 - 62 Iowa Medicaid, Kansas Medicaid, Kentucky Medicaid, Medicare Inpatient, Medicare LTC, Michigan Medicaid, Michigan Medicaid APR, Multi-Pricer/DRG Pro, New Jersey Medicaid, New Jersey Medicaid APR, North Carolina Medicaid, North Carolina State Employees/Worker’s Compensation Program, Ohio Medicaid APR, Pennsylvania Medicaid APR, and TRICARE/CHAMPUS:Geometric mean

Arizona Medicaid, California Medicaid, Colorado Medicaid, Florida Medicaid, Illinois Medicaid APR, Indiana Medicaid, Indiana Medicaid APR, Louisiana Medicaid, Massachusetts Medicaid, Minnesota Medicaid, Mississippi Medicaid, Nebraska Medicaid, Nebraska Medicaid APR, New York Medicaid APR, Rhode Island Medicaid, South Carolina Medicaid, Virginia Medicaid, Virginia Medicaid APR, Washington DC Medicaid, Washington Medicaid APR, and Wisconsin Medicaid APR:Arithmetic mean

Short Length of Stay Outlier Trim

ltrim 9(3) 63 - 65 Iowa Medicaid, Michigan Medicaid, Michigan Medicaid APR, North Carolina State Employees/Worker’s Compensation Program, Multi-Pricer/DRG Pro, and TRICARE/CHAMPUS:Low LOS trim used to identify short stay outliers.

Long Length of Stay Outlier Trim

htrim 9(3) 66 - 68 Colorado Medicaid, Illinois Medicaid, Iowa Medicaid, Kansas Medicaid, Medicare Inpatient, Michigan Medicaid, Michigan Medicaid APR, Multi-Pricer/DRG Pro, New Jersey Medicaid, New Jersey Medicaid APR, North Carolina Medicaid, North Carolina State Employees/Worker’s Compensation, Texas Medicaid, and TRICARE/CHAMPUS:High LOS trim used to identify long stay or day outliers.




Additional Mean Length of Stay

hmlos 9(3)v9(4) 69 - 75 Illinois Medicaid: Geometric mean LOS used to calculate the per diem rate for Illinois transfer-out cases and day/LOS outliers

Medicare Inpatient and Kentucky Medicaid: Arithmetic mean LOS

Medicare LTC: 5/6th of the geometric mean LOS

Multi-Pricer/DRG Pro: Average mean LOS

North Carolina Medicaid:Geometric mean (same value as mlos)

North Carolina State Employee/Worker’s Compensation: Arithmetic mean LOS used to calculate day/LOS outlier adjustments

Texas Medicaid: Arithmetic mean LOS used to calculate the per diem rate for transfers and day/LOS outliers

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

DRG Weight 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 pricing.




Per Diem Reimbursement

pdiem 9(8)v9(2) 84 - 93 Louisiana Medicaid:Inpatient psychiatric, rehabilitation, or post-acute care per diem rate applied to claim.

Medicare IPF: Per diem calculation before variable day adjustments.

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

Virginia Medicaid and Virginia Medicaid APR: Inpatient psychiatric or rehabilitation per diem rate applied to claim.

Washington DC Medicaid:Rehabilitation, psychiatric, or pediatric long term care hospital per diem rate applied to claim.

Washington 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

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

Washington 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

drg_paytype 9(1) 104 Medicare Inpatient and TRICARE/CHAMPUS:1 = Device was replaced or removed at reduced or no

cost.2 = 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 inrate 9(8)v9(2) 105 - 114 Medicare IPF: ECT payment

New Jersey Medicaid: Used in reimbursement prior to August 03, 2009 except for AIDS DRGs.

Multi-Pricer/DRG Pro: DRG base rate or case rate.




Low Per Diem or Low Cost Outlier Trim

ldiem 9(8)v9(2) 115 - 124 New Jersey Medicaid: Used to collect DRG-specific low per diem values prior to August 03, 2009.

Washington HCA Case-Based: Used to collect DRG-specific low charge thresholds.

Transfer Flag trflag 9(1) 125 Arizona Medicaid, California Medicaid, Colorado Medicaid, Florida Medicaid, Illinois Medicaid APR, Iowa Medicaid, Kansas Medicaid, Massachusetts Medicaid, Michigan Medicaid, Michigan Medicaid APR, Minnesota Medicaid, Mississippi Medicaid, Multi-Pricer/DRG Pro, Nebraska Medicaid, Nebraska Medicaid APR, New Jersey Medicaid, New Jersey Medicaid APR, New Mexico Medicaid, North Carolina Medicaid, Ohio Medicaid APR, Pennsylvania Medicaid APR, Rhode Island Medicaid, South Carolina Medicaid, Virginia Medicaid, Virginia Medicaid APR, Washington DC Medicaid, Washington HCA, Washington Medicaid APR, Washington Medicaid, and Wisconsin Medicaid APR:0 = Not reimbursed as a transfer1 = Standard transfer

Medicare Inpatient & 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

Kentucky Medicaid:0 = Not reimbursed as a transfer2 = Standard transfer after FY 19963 = Standard post-acute transfer after FY 19984 = Special post-acute transfer after FY 1998




Pricing Method Indicator

method 9(2) 126 - 127 Arizona Medicaid:00 = Standard DRG processing01 = Outlier02 = Transfer03 = Interim claim paid per diem04 = DRG exempt hospital per diem payment

California Medicaid:00 = Standard DRG processing01 = Interim claim02 = Rehabilitation claim03 = Transfer04 = Transfer and high cost outlier05 = Low cost outlier06 = High cost outlier07 = Capped at billed charges08 = Transfer and low cost outlier

Colorado Medicaid:00 = Standard DRG processing02 = Transfer05 = Capped reimbursement at charges09 = Long stay outlier

Florida Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Policy adjusted DRG weight05 = Payment capped at total charges

Georgia Medicaid:00 = Standard DRG processing01 = CCR excluded DRG

Illinois Medicaid APR:00 = Standard DRG processing01 = Burn and Trauma DRG02 = Perinatal DRG03 = Perinatal and transfer exempt DRG04 = Transplant DRG05 = Capped reimbursement at charges06 = Per-diem methodology

Indiana Medicaid APR:00 = Standard DRG processing01 = High cost outlier02 = Transfer05 = Payment capped at total charges07 = Per diem payment

Iowa Medicaid:00 = Standard DRG processing

continued below...




Pricing Method Indicator<continued>

method 9(2) 126 - 127 Kansas Medicaid:00 = Standard DRG processing02 = Standard with cost outlier03 = Standard with day outlier04 = Prorated DRG payment12 = Transfer15 = Payment capped at total charges

Louisiana Medicaid:00 = Standard DRG processing01 = High cost outlier07 = Per diem payment08 = Capped at cost

Massachusetts Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer

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 & Michigan Medicaid APR:00 = Standard DRG processing01 = Percent of charge pricing06 = Short stay99 = Standard MS-DRG processing

continued below...





method 9(2) 126 - 127 Minnesota Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Policy adjusted DRG weight

Mississippi Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Policy adjusted DRG weight04 = Interim claim06 = Low cost outlier

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

Nebraska Medicaid:00 = Standard DRG processing01 = Stable DRG03 = Psychiatric DRG04 = Rehabilitation DRG05 = Unstable/low volume DRG06 = Transplant DRG

Nebraska Medicaid APR:01 = Standard DRG processing03 = Psychiatric DRG04 = Rehabilitation DRG06 = Transplant DRG

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

continued below...





method 9(2) 126 - 127 New Jersey Medicaid APR:00 = Standard DRG processing 01 = High cost outlier02 = Transfer09 = Long stay outlier10 = High cost and long stay outlier11 = Low cost and long stay outlier13 = Same day discharge

New Mexico Medicaid:00 = Standard DRG processing 01 = Flagged for medical necessity review

New York Medicaid APR:00 = Standard DRG processing 01 = Flagged for Never Event02 = GME payment

North Carolina Medicaid:00 = Standard DRG processing01 = Psychiatric per diem payment02 = Rehabilitation per diem payment03 = Standard DRG processing with LARC

Ohio Medicaid APR:00 = Standard APR-DRG processing01 = Tracheostomy APR-DRGs02 = Neonate APR-DRGs03 = Organ acquisition charges APR-DRGs04 = Organ acquisition costs APR-DRG05 = Non-covered claim APR-DRG06 = Still a patient

Pennsylvania Medicaid APR:01 = Standard DRG processing02 = DRG-based case payment outlier 06 = Psychiatric, substance abuse or rehabilitation DRG12 = Transfer

Rhode Island Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Interim claim per diem04 = Transfer and high cost outlier05 = Payment capped at total charges07 = Per diem payment09 = Long stay outlier

South Carolina Medicaid:00 = Standard DRG processing01 = Transfer02 = One day stay pricing03 = Same day stay pricing

continued below...





method 9(2) 126 - 127 Texas Medicaid:01 = Adult obstetric delivery services99 = Standard DRG processing

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

Virginia Medicaid:00 = Standard DRG processing01 = High cost outlier 02 = Transfer03 = Rehabilitation per diem04 = Psychiatric per diem

Virginia Medicaid APR:00 = Standard DRG processing01 = High cost outlier 02 = Transfer07 = Per diem payment

Washington DC Medicaid:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Policy adjusted DRG weight04 = Interim claim06 = Low cost outlier07 = Per diem payment

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

continued below...





method 9(2) 126 - 127 Washington Medicaid APR:00 = Standard DRG processing01 = Rehabilitation DRG02 = Psychiatric DRG08 = Other, paid RCC14 = Critical access hospital15 = Bariatric surgery16 = Chemical Using Pregnant (CUP) women17 = Administrative days18 = Certified Public Expenditure (CPE) facility19 = Reimbursement capped at charges20 = Detox DRG21 = Transfer22 = Outlier23 = Long term acute care facility24 = Administrative days with pharmaceuticals

Washington Medicaid:00 = Standard DRG processing01 = Rehabilitation DRG02 = Psychiatric DRG03 = Substance abuse DRG04 = Exempt neonate DRG (Prior to August 1, 2007)05 = AIDS DRG06 = Normal newborn DRG07 = Delivery DRG08 = Other, paid RCC09 = Burn DRG10 = Medical DRG11 = Surgical DRG12 = Neonate per diem14 = Critical access hospital15 = Bariatric surgery16 = Chemically Using Pregnant (CUP) women17 = Administrative days 18 = Certified Public Expenditure (CPE) facility

Wisconsin Medicaid APR:00 = Standard DRG processing01 = High cost outlier02 = Transfer03 = Policy adjusted DRG weight05 = Payment capped at total charges




Percent of Charges Value

percent 9(1)v9(5) 128 - 133 Medicare IPF: Comorbidity factor applied for adjustment.

Washington HCA: Percentage of covered charges used to calculate reimbursement.

Washington Medicaid: Percentage of covered charges used to calculate reimbursement for this Critical Access Hospital (CAH), transplant, and cost outlier claim.

Washington Medicaid APR:Weighted Cost-to-Charge (WCC) factor used to calculate reimbursement for this CAH claim.

Multi-Pricer/DRG Pro: Percentage of charges to calculate reimbursement.

Default Pricing Method Utilized

default_method 9(1) 134 Reserved

Indirect Medical Education (IME) Payment

oime 9(8)v9(2) 135 - 144 Medicare IPF:Operating IME payment.

TRICARE/CHAMPUS:IME payment.

Operating Disproportionate Hospital (DSH) Payment

rsvd_odsh 9(8)v9(2) 145 - 154 Reserved

Capital Indirect Medical Education (IME) Payment

rsvd_cime 9(8)v9(2) 155 - 164 Reserved

Capital Disproportionate Hospital (DSH) Payment

rsvd_cdsh 9(8)v9(2) 165 - 174 Reserved

Cost Reduction Factor crf 9(1)v9(5) 175 - 180 Multi-Pricer/DRG Pro:Cost reduction factor

Reimbursement DRG reimb_drg 9(5) 181 - 185 APR-DRG/DRG used by the Pricer to determine claim reimbursement.




State Pricing Indicator state_id X(2) 186 - 187 CO = Colorado Medicaid APR pricing rulesDC = Washington DC Medicaid pricing rulesFL = Florida Medicaid APR pricing rulesIN = Indiana Medicaid APR pricing rulesIH = Indiana Medicaid APR pricing rules with Hospital

Assessment Fees (HAF)LA = Louisiana Medicaid APR managed care pricing rulesLF = Louisiana Medicaid APR Fee-for-Service pricing

rulesMA = Massachusetts Medicaid APR pricing rulesMN = Minnesota Medicaid APR pricing rulesMS = Mississippi Medicaid APR pricing rulesNJ = New Jersey Medicaid APR pricing rulesWI = Wisconsin Medicaid APR pricing rulesOT = Other/user-defined pricing rulesRI = Rhode Island Medicaid APR pricing rulesVA = Virginia Medicaid APR pricing rules

Adjusted DRG Weight adj_wgt 9(3)v9(5) 188 - 195 Kentucky Medicaid and Medicare DRG:Adjusted DRG weight used to calculate the operating payment amount for discharges for an individual diagnosed with COVID-19 (Coronavirus).

Medicaid APR Pro:DRG-specific weight adjusted by all applicable policy adjustors, utilized for pricing.

Michigan Medicaid APR, New Mexico Medicaid, North Carolina Medicaid, Ohio Medicaid APR, and Washington Medicaid APR:DRG-specific weight utilized for pricing.

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(805) 196 - 1000




POB1.PP1 [phys_prcr_block1]Table AC-1: POB1.PP1 [phys_prcr_block1]: Fixed length Physician Pricer output fields


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 error81 = Error reading physician factor file82 = Error reading physician rate calculator file84 = Error reading fee schedule file86 = Error reading code table file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid dates95 = Parameter passing error



Pricer Type prcr_type X(2) 11 - 12 65 = Medicare PhysicianPricer Type Reserved prcr_type_rsvd X(2) 13 - 14 ReservedPayment base_pay 9(8)v9(2) 15 - 24 Total Medicare reimbursement for this claim.Co-Payment copay 9(8)v9(2) 25 - 34 Total patient co-payment amount for this claim.Estimated Bonus Payment

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 tot_reimb 9(8)v9(2) 45 - 54 Total reimbursement for this claim, calculated as

follows: base_pay + bonus_pay + copay

Rural Flag 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


POB1.RUG [rug_prcr_block1]Table AD-1: POB1.RUG [rug_prcr_block1]: Fixed length SNF Pricer output fields


03 = Pricer type not licensed18 = Invalid occurrence span date21 = Invalid bill type (not 018X, 021X, 022X, or 023X)22 = Denial claim23 = Service date invalid or out of range25 = Non-payment claim26 = Total units exceed patient’s length of stay (Part A

only)38 = Invalid or missing required claims data40 = Claim spans calendar year (Part B only)41 = Invalid billing of therapy services (Part B only)62 = Closed or inactive rate record70 = Configuration record error72 = Hospital rate calculator record not found74 = No weights81 = Error reading payers file82 = Error reading hospital rate calculator file83 = Error reading rate file84 = Error reading fee schedule file86 = Error reading code table file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid dates95 = Parameter passing error

Pricer Return Code Reserved Extension


Pricer Type prcr_type X(2) 11 - 12 22 = Medicare SNFPricer Type Reserved prcr_type_rsvd X(2) 13 - 14 ReservedTotal Reimbursement total 9(8)v9(2) 15 - 24 Total patient reimbursementTotal Part A Prospective Payment

ppstotal 9(8)v9(2) 25 - 34 Total Part A reimbursement

AIDS Adjustment Factor aidsfactor 9(1)v9(4) 35 - 39 Part A adjustment factor applied to reimbursement when an AIDS diagnosis code is present.

Mark-up/Discount Factor

markup 9(1)v9(4) 40 - 44 Mark-up or discount applied to total reimbursement.

Total Part B Third-party Payment

totpay 9(8)v9(2) 45 - 54 Total Part B reimbursement for this claim minus patient coinsurance.

Total Part B Co-payment

totcopay 9(8)v9(2) 55 - 64 Total Part B patient coinsurance for this claim.

Filler X(936) 65 - 1000


POB2.APC [apc_prcr_output_entry]Table AE-1: POB2.APC [apc_prcr_output_entry]: Variable length APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesPayment Status Indicator

paystat X(2) 1 - 2 Left-justified.

APC-HOPD, Contract APC, and TRICARE 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

outpatient claimC = Inpatient service, not paid under OPPSE1 = Non-allowed item or service (APC-HOPD and

Contract APC)E1 = Items and services that are not covered by TRICARE

(TRICARE APC)E2 = Items and services for which pricing information and

claims data are not available (APC-HOPD and Contract APC)

F = 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 APC J2 = Hospital Part B services that may be paid through a

Comprehensive APC (APC-HOPD and Contract APC)

J2 = Hospital outpatient department services that may be paid through a Comprehensive APC (TRICARE APC)

K = Non pass-through drugs and non-implantable biologicals, including therapeutic radiopharmaceuticals

continued below...



paystat X(2) 1 - 2 KM = Drug/biological fee schedule item (Contract APC - legacy)

KN = Drug/biological fee schedule itemKX = 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 multiple T = Procedure or service, multiple reduction appliesTB = TRICARE reimbursement not allowed (TRICARE

APC only)U = 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 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 = Unclassified drug/biological; contractor-pricedL1 = Influenza/pneumococcal vaccine; packaged service/

item, no separate paymentcontinued below...

Table AE-1: POB2.APC [apc_prcr_output_entry]: Variable length APC-HOPD, ASC, Contract APC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields (occurs numhcpcs times)



Payment Status Indicator <continued>

paystat X(2) 1 - 2 L6 = 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 RVUsZZ = Services paid at contracted rate

New Mexico Medicaid APC:A = Services paid under fee schedule or other


outpatient claimC = Inpatient service, not paid under OPPS E = Non-covered service, not paid under OPPSF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH = Pass-through device categories K = Non pass-through drugs and non-implantable



M = Service not billable to the FI/MACN = Packaged/incidental service Q1 = STV - packaged servicesQ2 = T - packaged servicesQ3 = Services that may be paid through a Composite APC R = Blood and blood productsS = Procedure or service, not discounted when multipleT = Procedure or service, multiple reduction appliesU = Brachytherapy sourcesV = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and invalid revenue

codeX = Ancillary service Y = Non-implantable DMEZ = Valid revenue code, blank HCPCS, no other status

indicator assignedPayment Status Indicator Reserved

paystat_rsvd X(1) 3 Reserved




APC or Fee Rate 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, HHA, and New Mexico Medicaid APC: 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.

TRICARE APC: Payment rate before adjustments, where available.

Weight wgt 9(3)v9(5) 14 - 21 HHA:Weight associated with this HHRG.

Discount Factor disc 9(1)v9(4) 22 - 26 APC-HOPD, Contract APC, ASC, Contract ASC, Hospice, New Mexico Medicaid APC, and TRICARE APC:Discount, if any, applied to the reimbursement calculation.

Total Payment 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, Hospice, New Mexico Medicaid APC, and TRICARE APC:Total line payment.

Co-Payment 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 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

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

li_outpay 9(8)v9(2) 67 - 76 APC-HOPD, Contract APC, ESRD, Hospice, and TRICARE APC:Line item outlier payment.

Hospice:Service Intensity Add-On (SIA) payment for this line.

Reallocated Surgical Procedure Charges

stcharges 9(8)v9(2) 77 - 86 APC-HOPD, Contract APC, and TRICARE 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 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

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

continued below...





pret 9(2) 87 - 88 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

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 pricingcontinued below...





pret 9(2) 87 - 88 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

New Mexico Medicaid 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 type09 = Packaged service11 = Invalid units for this modifier29 = Paid by report/manually priced30 = Line bypassed from claims processing43 = Not enough information for pricing50 = Invalid observation billing

TRICARE APC:04 = Not covered or not covered under OPPS09 = Packaged service13 = Zip code missing or invalid (ambulance fee schedule

service only)26 = Manually priced by TRICARE

Reserved line_chg 9(8)v9(2) 89 - 98 ReservedMultiple Procedure Discount Indicator

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 transpay 9(8)v9(2) 100 - 109 TRICARE APC: Transitional payment

Reimbursement APC reimb_proc 9(5) 110 - 114 Contract ASC:APC used by the Contract ASC Pricer to determine reimbursement.

Reimbursement ASC Covered Services Indicator

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





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 units16 = Payment based on IRC rate, non-covered units17 = Payment based on GIP rate, non-covered units18 = Payment based on the fee schedule with discount

appliedcontinued below...





method 9(2) 116 - 117 New Mexico Medicaid APC:00 = No payment01 = Payment based on fee rate02 = Vaccine for children, no payment04 = Payment based on fee rate with bilateral adjustment06 = Payment based on fee rate with discount and

hospital adjustment07 = Payment based on fee rate with bilateral adjustment

and hospital adjustment08 = Payment based on fee rate with discount, bilateral

adjustment, and hospital adjustment10 = Payment based on charges with hospital adjustment11 = Payment based on fee rate with hospital adjustment14 = Observation payment with reduced units and hospital

adjustment15 = Observation payment with hospital adjustment

Extended Weight wgt_ext 9(4)v9(5) 118 - 126 APC-HOPD and Contract APC:Extended weight associated with this APC.

Carrier Used for Pricing

carrier X(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 feetype 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.APG [apg_prcr_output_entry]Table AF-1: POB2.APG [apg_prcr_output_entry]: Variable length APG Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesProcedure APG (PAPG) Type

type X(2) 1 - 2 Enhanced New York Medicaid APG and New York Medicaid APG: Reserved for future use. Refer to the type field located in the GOB2.APG [apg_grpr_output_entry] structure instead.

Alabama BCBS APG, Colorado Medicaid APG, Illinois Medicaid APG, Florida Medicaid APG, Massachusetts Medicaid APG, Nebraska Medicaid APG, Ohio Medicaid APG, Virginia Medicaid APG, Virginia Medicaid ASC, Washington DC Medicaid APG, Washington Medicaid APG, and Wisconsin Medicaid APG:01 = Per diem02 = Significant procedure03 = Medical visit04 = Ancillary 05 = Incidental06 = Drug07 = DME 08 = Unassigned (final error APG = 993 or 999) 21 = Physical therapy & rehabilitation procedure22 = Mental health & counseling procedure23 = Dental procedure24 = Radiologic procedure25 = Diagnostic significant procedure

APG Weight wgt 9(3)v9(5) 3 - 10 Washington Medicaid APG:Relative weight for the corresponding APG.

Enhanced New York Medicaid APG and New York Medicaid APG: Relative weight for the corresponding APG. For services with a procedure-specific weight, this value will be returned in this field instead of the APG relative weight.

APG Discount Factor pfac 9(1)v9(4) 11 - 15 Discount, if any, applied to the reimbursement calculation for the corresponding APG.

APG Payment pay 9(8)v9(2) 16 - 25 Payment for the corresponding APG.Payment Packaging Flag

pack 9(1) 26 0 = APG is not packaged1 = APG is packaged

NoteThe Pricer may modify the original Grouper packaging flags. This field reflects the packaging flags actually used for payment purposes.


Payment Consolidation Flag

cons 9(1) 27 0 = APG is not consolidated1 = APG is consolidated

NoteThe Pricer may modify the original Grouper consolidation flags. This field reflects the consolidation flags actually used for payment purposes.

ASC Discount Factor asc_discount 9(1)v9(4) 28 - 32 ReservedASC Payment Amount asc_ascpay 9(8)v9(2) 33 - 42 ReservedFee Schedule Rate rate 9(8)v9(2) 43 - 52 Massachusetts Medicaid APG, Ohio Medicaid APG,

Virginia Medicaid APG & Virginia Medicaid ASC:Fee schedule rate.

Table AF-1: POB2.APG [apg_prcr_output_entry]: Variable length APG Pricer output fields (occurs numhcpcs times)



Pricer Return Code pret 9(2) 53 - 54 Standard Return Codes:00 = No errors found01 = No available APG/fee schedule rate record09 = Packaged service10 = Line item rejection from Editor20 = Consolidated service29 = Non-covered service

Additional Pricer-Specific Return Codes:Alabama BCBS APG:06 = Missing or invalid fee schedule type

Colorado Medicaid APG:06 = Missing or invalid fee schedule type 07 = Paid by report/manually priced16 = Never event32 = Service did not meet minimum required units or

service exceeded maximum allowed units

Enhanced New York Medicaid APG:02 = Visit consists of all Never Pay or stand alone03 = Service is Never Pay05 = Alternate payment may be available06 = Missing or invalid fee schedule type 08 = Invalid modifier pair09 = Packaged service10 = Line item rejection from editor11 = No payment per New York Medicaid ancillary policy12 = Payment reduction per New York Medicaid ancillary

policy (information only)14 = Invalid observation billing15 = Telehealth facility fee invalid16 = Never event17 = Invalid billing of off-site services 18 = Diagnosis and procedure conflict19 = Missing or invalid modifier for pricing20 = Consolidated service32 = Service did not meet minimum required units or


Florida Medicaid APG:16 = Never event

Illinois Medicaid APG:16 = Never event23 = Non-covered revenue code

Nebraska Medicaid APG:06 = Missing or invalid fee schedule type continued below...





pret 9(2) 53 - 54 New York Medicaid APG:02 = Visit consists of all Never Pay or stand alone03 = Service is Never Pay04 = Invalid ambulatory surgical center claim05 = Carve-out service06 = Missing or invalid fee schedule type 08 = Invalid modifier pair11 = No payment per New York Medicaid ancillary policy12 = Payment reduction per New York Medicaid ancillary

policy (information only)13 = No facility rate available14 = Invalid observation billing15 = Telehealth facility fee invalid16 = Never event17 = Invalid billing of off-site services 18 = Diagnosis and procedure conflict19 = Missing or invalid modifier for pricing30 = Service exceeded maximum number of allowed units

Massachusetts Medicaid APG:06 = Missing or invalid fee schedule type 07 = Paid by report/manually priced16 = Never event38 = Payment bundled with other AMCC test

Ohio Medicaid APG:06 = Missing or invalid fee schedule type 14 = Invalid observation billing16 = Never event25 = Improper billing of drugs31 = Service not paid on independently billed claim33 = Invalid or missing claims data

Virginia Medicaid APG: 06 = Missing or invalid fee schedule type 16 = Never event32 = Service did not meet minimum required units or


Virginia Medicaid ASC:06 = Missing or invalid fee schedule type 16 = Never event

Washington DC Medicaid APG:16 = Never event32 = Service did not meet minimum required units or


continued below...





pret 9(2) 53 - 54 Washington Medicaid APG:06 = Missing or invalid fee schedule type

Wisconsin Medicaid APG:06 = Missing or invalid fee schedule type




Payment Method Indicator

method 9(2) 55 - 56 Standard Payment Method Indicators:01 = Full payment02 = Consolidated03 = Subject to discounting04 = Packaged05 = No payment06 = Bilateral07 = Discounted bilateral

Additional Pricer Specific Payment Method Indicators:

Alabama BCBS APG:09 = Paid via fee schedule

Colorado Medicaid APG:09 = Paid via fee schedule10 = Capped at charges

Enhanced New York Medicaid APG:09 = Paid via fee schedule10 = Capped at charges13 = Admin only14 = Paid greater of charges or fee schedule

Florida Medicaid APG:None

Illinois Medicaid APG:None

Nebraska Medicaid APG:09 = Paid via fee schedule10 = Capped at charges

New York Medicaid APG:08 = Stand-alone09 = Subject to discounting plus modifier adjustment10 = Admin only11 = Capped at charges12 = Paid via fee schedule13 = Paid greater of charges or fee schedule amount14 = Paid as multiple E&M service

Massachusetts Medicaid APG:09 = Paid via fee schedule10 = Capped at charges16 = Service paid as AMCC test

continued below...




Payment Method Indicator<continued>

method 9(2) 55 - 56 Ohio Medicaid APG:09 = Paid via fee schedule10 = Capped at charges11 = Percent of cost12 = Paid via fee schedule, zero rate13 = Flat rate payment

Virginia Medicaid APG:09 = Paid via fee schedule

Virginia Medicaid ASC:09 = Paid via fee schedule

Washington DC Medicaid APG:None

Washington Medicaid APG:08 = Percent of charges09 = Paid via fee schedule10 = Capped at charges15 = Paid billed charges

Wisconsin Medicaid APG:08 = Percent of charges09 = Paid via fee schedule10 = Capped at charges

Units Paid p_units 9(7) 57 - 63 Units paid for service.Add-On Payment addon 9(8)v9(2) 64 - 73 Florida Medicaid APG:

Per service automatic rate enhancement supplemental payment.

Illinois Medicaid APG & Massachusetts Medicaid APG:Cost outlier add-on payment.

Enhanced New York Medicaid APG and New York Medicaid APG: Capital add-on payment, if applicable to service.

Adjusted Weight adj_wgt 9(3)v9(5) 74 - 81 Washington Medicaid APG: Adjusted weight after discounting for corresponding APG.

Enhanced New York Medicaid APG and New York Medicaid APG: Adjusted weight after discounting for corresponding APG or service with a procedure-specific weight. For services with a procedure-specific weight, the discounted procedure-specific weight will be returned in this field.

Stand Alone Flag stndaln 9(1) 82 Enhanced New York Medicaid APG and New York Medicaid APG: 0 = Not Subject to stand-alone payment logic1 = Subject to stand-alone payment logic




Never Pay Flag nvrpay 9(1) 83 Enhanced New York Medicaid APG and New York Medicaid APG: 0 = Not subject to Never Pay logic1 = Subject to Never Pay logic

Visit Existing Payment exist 9(8)v9(2) 84 - 93 Enhanced New York Medicaid APG and New York Medicaid APG: Non-APG portion of payment for this service. Only applicable for facilities subject to transitions.

ASC Covered Service asccov 9(1) 94 Enhanced New York Medicaid APG and New York Medicaid APG:0 = Service is not on the New York Medicaid approved

ASC list1 = Service is on the New York Medicaid approved ASC

listUnits Paid p_units_01 9(15) 95 - 109 ReservedAPG Extended Weight wgt_ext 9(3)v9(6) 110 - 118 Alabama BCBS APG, Colorado Medicaid APG, Florida

Medicaid APG, Illinois Medicaid APG, Massachusetts Medicaid APG, Nebraska Medicaid APG, Ohio Medicaid APG, Virginia Medicaid APG, Virginia Medicaid ASC, Washington DC Medicaid APG, Washington Medicaid APG, and Wisconsin Medicaid APG:Relative weight for the corresponding APG.

Enhanced New York Medicaid APG and New York Medicaid APG: Relative weight for the corresponding APG. For services with a procedure-specific weight, this value will be returned in this field instead of the APG relative weight.

Adjusted Extended Weight

adj_wgt_ext 9(3)v9(6) 119 - 127 Alabama BCBS APG, Colorado Medicaid APG, Florida Medicaid APG, Illinois Medicaid APG, Massachusetts Medicaid APG, Nebraska Medicaid APG, Ohio Medicaid APG, Virginia Medicaid APG, Virginia Medicaid ASC, Washington DC Medicaid APG, Washington Medicaid APG, and Wisconsin Medicaid APG:Adjusted weight after discounting for corresponding APG.

Enhanced New York Medicaid APG and New York Medicaid APG: Adjusted weight after discounting for corresponding APG or service with a procedure-specific weight. For services with a procedure-specific weight, the discounted procedure-specific weight will be returned in this field.

Filler X(73) 128 - 200




POB2.CAH [cah_prcr_output_entry]Table AG-1: POB2.CAH [cah_prcr_output_entry]: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesPricing Method Indicator

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 line_rtn_code X(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 pay 9(8)v9(2) 5 - 14 Medicare payment for this procedure code.Co-Payment copay 9(8)v9(2) 15 - 24 Patient co-payment for this procedure code.Estimated Bonus Payment

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 totpay 9(8)v9(2) 35 - 44 Total payment for this procedure code calculated asfollows:pay + copay + bonus_pay

Fee Schedule Rate fsrate 9(8)v9(2) 45 - 54 Fee schedule rate used to price this procedure code.Fee Schedule Type feetype X(1) 55 Fee schedule methodology used to price this procedure

code.

A = AmbulanceL = Clinical LaboratoryN = NationalP = PhysicianX = Other (user-defined)


Facility/Non-Facility Rate Flag

facility_flag 9(1) 56 This field indicates whether the facility or non-facility ratewas used to price this practitioner service.

1 = Facility rate used2 = Non-facility rate used

Specialty Code Used for Pricing

spec_code X(2) 57 - 58 The 2-digit Medicare Specialty Code used to price thispractitioner 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/Discount Factor

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.


markup 9(1)v9(4) 64 - 68 Mark-up or discount applied to the payment for thisprocedure code.

Carrier Used for Pricing

carrier X(12) 69 - 80 The carrier/locality used to price this procedure code.

Bilateral Flag bilat_flag 9(1) 81 0 = Not bilateral1 = Conditionally bilateral procedure, payment adjusted3 = Independently bilateral procedure, payment adjusted

Multiple Procedure Discount Flag

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

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

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 AG-1: POB2.CAH [cah_prcr_output_entry]: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)


https://www.cms.gov/manuals/downloads/clm104c26.pdf


Status Code 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 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



Filler X(106) 95 - 200

Table AG-1: POB2.CAH [cah_prcr_output_entry]: Variable length CAH Method II Pricer output fields (occurs numhcpcs times)



POB2.PP1 [phys_prcr_output_entry]Table AH-1: POB2.PP1 [phys_prcr_output_entry]: Variable length Physician Pricer output fields, repeated numhcpcs times

Field Description Variable Name Format Position NotesPricer Return Code line_rtn_code X(2) 1 - 2 00 = No errors found

01 = No available APC/fee schedule rate04 = Not covered06 = 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 pay 9(8)v9(2) 3 - 12 Medicare reimbursement for this procedure code.Co-Payment copay 9(8)v9(2) 13 - 22 Patient co-payment amount for this procedure code.Estimated Bonus Payment

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 totpay 9(8)v9(2) 33 - 42 Total reimbursement for this procedure code calculated as follows:pay + bonus_pay + copay

Fee Schedule Rate fsrate 9(8)v9(2) 43 - 52 Fee schedule rate used to price this procedure code.


Fee Schedule Type feetype 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 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


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

facility_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

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

Carrier Used for Pricing 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.

Table AH-1: POB2.PP1 [phys_prcr_output_entry]: Variable length Physician Pricer output fields, repeated numhcpcs times


https://www.cms.gov/manuals/downloads/clm104c26.pdf


Percentage of the Fee Schedule Rate Paid

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

markup 9(1)v9(4) 77 - 81 Mark-up or discount applied to the reimbursement for this procedure code.

Bilateral Flag bilat_flag 9(1) 82 1 = Conditionally bilateral procedure, payment adjusted3 = Independently bilateral procedure, payment adjusted

Multiple Procedure Discounting Flag

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 qual_adjust_flag X(1) 84 0 = No quality adjustment

1 = Payment increased by quality adjustment2 = Payment decreased by quality adjustment

Total Payment Without Quality Adjustment

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 AH-1: POB2.PP1 [phys_prcr_output_entry]: Variable length Physician Pricer output fields, repeated numhcpcs times



POB2.RUG [rug_prcr_output_entry]Table AI-1: POB2.RUG [rug_prcr_output_entry]: Variable length SNF Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesLine Level Return Code line_rtn_code 9(2) 1 - 2 00 = No errors found

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 rug X(5) 3 - 7 Resource Utilization Group (RUG)RUG Rate rugrate 9(8)v9(2) 8 - 17 Per diem payment rate for RUGAdjusted RUG Rate or Fee Schedule Rate

adjrugrate 9(8)v9(2) 18 - 27 Part A:Adjusted per diem payment rate for RUG.

Part B:Fee schedule rate.

Total Line Payment totlinepay 9(8)v9(2) 28 - 37 Payment for this line.Third-Party Payment pay 9(8)v9(2) 38 - 47 Payment for line minus patient coinsurance.Co-Payment copay 9(8)v9(2) 48 - 57 Total patient coinsurance for this line.Fee Schedule Type feetype X(1) 58 Fee schedule methodology used to price this procedure

code.A = Ambulance D = 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

vpd_day_num 9(3) 59 - 61 The day number for Variable Per Diem (VPD).

Unadjusted HIPPS Code Rate

hippsrate 9(8)v9(2) 62 - 71 Unadjusted rate for the HIPPS code.

Filler X(129) 72 - 200


POB3.ESRD [esrd_prcr_block3]Note

The Extended Structure Switch (ext_blk_sw) in the ECB [ezg_cntl_block] needs to be = 1 for all fields in this structure.

Table AJ-1: POB3.ESRD [esrd_prcr_block3]: Variable length ESRD Pricer output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesChildren’s Modality Factor modality_factor 9(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

modality_factor_sep 9(1)v9(5) 7 - 12 Separately payable portion of the modality adjustment utilized for the cost outlier calculation.

NDC Reimbursement Indicator

ndc_reimb_ind 9(1) 13 Indicates that the service is a former Part D drug with an injectable equivalent.

NDC Reimbursement Amount - Separately Payable

ndc_reimb_sep 9(8)v9(2) 14 - 23 Amount of former Part D drug utilized for cost outlier calculation.

Dialysis Onset Factor onsetfactor 9(1)v9(5) 24 - 29 Onset adjustment utilized for the bundled prospective payment of this dialysis service for services dates on or after January 1, 2011.

Dialysis Onset Factor - Separately Payable

onsetfactor_sep 9(1)v9(5) 30 - 35 Separately payable portion of the onset adjustment utilized for cost outlier calculation.

Total ESRD PPS Casemix Adjustment

patrate 9(1)v9(5) 36 - 41 Patient case-mix adjustment utilized for this dialysis service for service dates on or after January 1, 2011.

Total ESRD PPS Casemix Adjustment - Separately Payable

patrate_sep 9(1)v9(5) 42 - 47 Separately payable portion of patient case-mix adjustment utilized for determining the predicted MAP for the cost outlier calculation.

Payment Separately Payable Outside of ESRD PPS

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 predicted_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

tot_dialysis_adjrate 9(8)v9(2) 68 - 77 Prospective payment dialysis amount prior to blending or user mark-up or discount.

Training Adjustment Rate training_adj 9(8)v9(2) 78 - 87 Prospective payment training amount.Composite Dialysis Payment

old_dialysis_pay 9(8)v9(2) 88 - 97 Composite payment dialysis amount.

Composite Methodology - Separately Payable

oldmethodology_sep 9(8)v9(2) 98 - 107 Separately payable amount.


Quality Reduction Factor 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 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

Table AJ-1: POB3.ESRD [esrd_prcr_block3]: Variable length ESRD Pricer output fields (occurs numhcpcs times)



EEB1 [ezedit_block1]Table AK-1: EEB1 [ezdit_block1]: Fixed length EASYEdit™ output fields

Field Description Variable Name Format Position NotesEditor Return Code edtr_rtn_code X(2) 1 - 2 00 = Record edited

02 = Error reading Standard Edit (edtrule) files03 = Error reading Standard Audit (hsscats) files04 = Error reading User Edit (usrrule) files05 = Error reading User Audit (ctsrule) files87 = Program cannot be loaded

Editor Reserved edtr_rtn_rsvd X(5) 3 - 7 ReservedTotal EASYEdit™ Errors

edtr_ttl 9(3) 8 - 10 Sum of all EASYEdit™ errors for this claim.

Editor Type edtr_type X(2) 11 - 12 ReservedEditor Subtype edtr_type_rsvd X(2) 13 - 14 ReservedEditor Version edtr_vers 9(2) 15 - 16 ReservedEditor Reserved edtr_vers_rsvd X(4) 17 - 20 ReservedFiller X(15) 21 - 35


EEB2 [ezedit_id_entry]Table AL-1: EEB2 [ezedit_id_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times)

Field Description Variable Name Format Position NotesEdit ID editid 9(9) 1 - 9 EASYEdit™ identifierMessage ID msgid 9(9) 10 - 18 Edit message identifierTable ID tbl_id X(1) 19 Input table the code is located in (i.e. the type of code).Table Position tbl_pos 9(3) 20 - 22 Code's position in the input table.Filler X(36) 23 - 58


EEB3 [ezedit_msg_entry]Table AM-1: EEB3 [ezedit_msg_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times)

Field Description Variable Name Format Position NotesEdit Message msg X(255) 1 - 255 EASYEdit™ description


EEB4 [ezedit_rtn_entry]Table AN-1: EEB4 [ezedit_rtn_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times)

Field Description Variable Name Format Position NotesLook-for Field Name look_id X(12) 1 - 12 Look-for field nameLook-for Field Position look_from X(20) 13 - 32 Position of look-for fieldLook-for Field Value look_pos 9(3) 33 - 35 Value of look-for fieldEdit Category category X(12) 36 - 47 01 = Diagnosis code sequenced incorrectly

03 = Assign single diagnosis code rather than multiple codes

04 = Assign single ICD-10-PCS code rather than multiple codes

05 = Assign single HCPCS code rather than multiple codes

06 = Do not report diagnosis codes together unless clinically appropriate

07 = Do not report ICD-10-PCS codes together unless a distinct service

08 = Do not report HCPCS codes together unless a distinct service

09 = Do not assign diagnosis and ICD-10-PCS codes together

10 = 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>

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 Severity edit_lvl X(12) 48 - 59 EASYEdit™ assigns an edit severity level of Critical to all edits.

Reserved look_start X(20) 60 - 79 ReservedFiller X(25) 80 - 104

Table AN-1: EEB4 [ezedit_rtn_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times)



MEB1 [mce_editor_block1]Table AO-1: MEB1 [mce_editor_block1]: Fixed length output fields from Date-Sensitive Code (DSC) Editor

Field Description Variable Name Format Position NotesEditor Return Code edtr_rtn_code X(2) 1 - 2 01 = Insufficient memory

02 = General processing error05 = Error opening Editor file(s)07 = Error reading Editor file(s)10 = HAC Editor not found16 = Invalid ALC days/interrupted days 18 = Invalid occurrence span date 87 = Program cannot be loaded88 = Initialization error

Editor Return Code Extension

edtr_rtn_rsvd X(4) 3 - 6 Reserved

Editor Version edtr_vers 9(2) 7 - 8 Current version of the DSC Editor.Editor Version Reserved


Demographic Error Count

demo_errcnt 9(4) 11 - 14 Number of demographic errors returned.

Age Edit demo_age 9(1) 15 0 = No error1 = Age invalid (not in range 0-124)

Sex Edit demo_sex 9(1) 16 0 = No error1 = Sex invalid (not 1, 2, M or F)

Discharge Disposition Edit

demo_dstat 9(1) 17 0 = No error1 = Invalid discharge disposition/patient status

Birthweight Edit demo_bwt 9(1) 18 0 = No error1 = Invalid birth weight (not zero, not 9999, not in range

100-9000 grams)Filler demo_filler X(57) 19 - 75 ReservedDiagnosis Error Count dx_errcnt 9(4) 76 - 79 Number of diagnosis errors returned.Principal Diagnosis Errors

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

diagnosisPrincipal Diagnosis/ Surgery Edit

dx_pdx_surg 9(1) 81 0 = No error1 = Principal diagnosis suggests surgery

Admit Diagnosis E-Code/Manifestation Code

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 dx_filler X(58) 83 - 140 ReservedProcedure Error Count op_errcnt 9(4) 141 - 144 Number of procedure errors returned.


Nonspecific Procedure Edit

op_nonspec 9(1) 145 0 = No error1 = All O.R. procedures coded are nonspecific

Bilateral Coding Edit op_bilat 9(1) 146 0 = No bilateral procedures present1 = Two or more different joint procedures are present

Filler op_filler X(59) 147 - 205Invalid Admit Diagnosis Code

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 date5 = Invalid code for dates, unnecessary 4th, 5th, 6th, or

7th digit6 = Invalid code for dates, missing 4th, 5th, 6th, or 7th digit

Admit Diagnosis Age/Sex

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

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 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 12 and 55 years4 = Code is for adults only, but patient age is less than 15

yearsAdmit Diagnosis Filler admdx_filler X(43) 210 - 252 ReservedTotal Number of Errors toterr 9(4) 253 - 256 Total number of errors returned.Filler X(144) 257 - 400

Table AO-1: MEB1 [mce_editor_block1]: Fixed length output fields from Date-Sensitive Code (DSC) Editor



MEB.DX [mce_dx_edits]Table AP-1: MEB.DX [mce_dx_edits]: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Invalid 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 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 date5 = Invalid code for dates, unnecessary 4th, 5th, 6th, or


Duplicate Diagnosis Flag

dupdx 9(1) 2 0 = Not duplicate code1 = Code is duplicate of principal diagnosis

Age/Sex Diagnosis Flag 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

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

dupsecdx 9(1) 5 0 = Not duplicate code1 = Code is duplicate of another secondary diagnosis

Diagnosis Suggests Surgery

dxsurg X(1) 6 Reserved

Present on Admission Flag

poa_invalid 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

haceligible 9(2) 8 - 9 00 = Code is not subject to HAC01 = Code is HAC eligible; another CC/MCC is present

(DRG may not be affected)02 = Code is HAC eligible; but is not a CC/MCC (DRG

may not be affected)03 = Code is HAC eligible; no other CC/MCC is present

(DRG may be affected)


CC/MCC Indicator ccmccind 9(1) 10 0 = Not a CC or MCC for DRG assignment1 = CC for DRG assignment2 = MCC for 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

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 obesity0012 = Surgical Site Infection (SSI) following certain

orthopedic procedures0013 = Surgical Site Infection (SSI) following Cardiac

Implantable Electronic Device (CIED)0014 = Iatrogenic pneumothorax with venous

catheterization9999 = Hospital Acquired Condition (HAC)

Wrong Procedure Performed

wrongpx 9(1) 15 0 = No error1 = Code indicates that a wrong procedure has been

performedPrincipal Diagnosis Errors

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

diagnosisAdmit Diagnosis E-Code/Manifestation Code

dx_admem 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

Table AP-1: MEB.DX [mce_dx_edits]: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (occurs numdx times)



Age Edit Indicator 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 09 and 64 years4 = Code is for adults only, but patient age is less than 15

yearsFiller X(32) 19 - 50

Table AP-1: MEB.DX [mce_dx_edits]: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (occurs numdx times)



MEB.OP [mce_op_edits]Table AQ-1: MEB.OP [mce_op_edits]: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from Date-Sensitive Code Editor (occurs numop times)

Field Description Variable Name Format Position NotesInvalid Procedure Edit Indicator

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 date5 = Invalid code for dates, unnecessary 4th, 5th, 6th, or


Sex Conflict Edit Indicator

sex 9(1) 2 0 = No error1 = Sex conflict, patient sex and procedure are

inconsistentNon-Covered Edit Indicator

ncbiop 9(1) 3 0 = No error1 = Non-covered procedure2 = Open biopsy code3 = Limited coverage procedure

Bilateral Code Indicator bicode 9(1) 4 0 = Not a bilateral procedure code1 = Bilateral procedure code

Closed Biopsy Code clsdbiop X(7) 5 - 11 When procedure code is an open biopsy, this is the corresponding closed biopsy code.

Operating Room Indicator

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

pilos X(1) 13 0 = No error1 = Length of stay and procedure are inconsistent

Questionable Obstetric Admission Indicator

qobadm X(1) 14 0 = No error1 = Questionable obstetric admission for this

procedure codeFiller X(36) 15 - 50


MEB4 [mce_edit_summary]Table AR-1: MEB4 [mce_edit_summary]: Fixed length error summary output fields from Date-Sensitive Code Editor

Field Description Variable Name Format Position NotesTotal Errors ttl 9(4) 1 - 4 Total errors for this claim.Error Code errcd 9(9)

Occurs 999 times

5 - 8995 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 errctr 9(3) Occurs 999 times

8996 - 11992

Number of times error code is returned.

Filler X(38) 11993 - 12030


LEB1 [lcd_edit_block1]Table AS-1: LEB1 [lcd_edit_block1]: Fixed length LCD Editor return fields

Field Description Variable Name Format Position NotesLCD Editor Return Code

edtr_rtn_code X(2) 1 - 2 01 = Cannot open codes.dat file02 = Cannot open pairs.dat file03 = Cannot open index.dat file04 = Cannot open ap.dat file05 = Cannot open sd.dat file06 = Cannot open fi.dat file07 = Invalid from or thru date08 = Policy in pairs.dat file has no matching entry in the

index.dat file09 = Provider ID not found on fi.dat file and no default is

defined10 = I/O initialization error13 = No edits available for the fiscal intermediary, carrier

or MAC associated with this provider ID14 = Cannot open stdx.dat file16 = Cannot open mac.dat file17 = No matching MAC record found18 = Number of diagnoses < 187 = Program cannot be loaded

Editor Reserved edtr_rtn_rsvd X(8) 3 - 10 ReservedTotal Claim Lines with Errors

toterr 9(3) 11 - 13 Total lines on this claim with one or more LCD/NCD edits. Valid values range from 000 to 999.

Fiscal Intermediary, Carrier or MAC

fi X(2) 14 - 15 Code identifying the Fiscal Intermediary (FI)/MAC Part A or carrier/MAC Part B responsible for this provider.

Statutorily-Denied Diagnosis Flag

stdeny 9(1) 16 0 = Claim does not contain CMS statutorily-denied diagnosis

1 = Claim contains CMS statutorily-denied diagnosisStatutorily-Denied Diagnosis Code

stdenydx X(6) 17 - 22 ICD-9-CM diagnosis code on statutorily-denied list.

Key Type Flag key_type X(1) 23 Identifies which provider ID was used to determine the fiscal intermediary, carrier or MAC: 0 = Facility identifier, legacy1 = National provider identifier (NPI)2 = Default fiscal intermediary, carrier, or MAC selected

ICD-9 or ICD-10 Statutorily-Denied Diagnosis Code

stdenydx_01 X(10) 24 - 33 ICD-9-CM or ICD-10-CM diagnosis code on statutorily-denied list.

Filler X(967) 34 - 1000


LEB.OP [lcd_op_edits]Table AT-1: LEB.OP [lcd_op_edits]: Variable length LCD Editor return fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesSummary opsum 9(2) 1 - 2 Count of errors for this line item. Code Valid Flag valid 9(1) 3 0 = Code is valid

1 = Code is not currently valid2 = Code is not valid for service date

Valid/Non-Covered Flag noncov 9(1) 4 0 = Code is valid1 = Code is not currently covered by Medicare2 = Code is not covered by Medicare based on statutory

exclusionNo Diagnosis Flag nodx 9(1) 5 0 = Code has supporting diagnosis codes

1 = Code does not have a supporting diagnosis codeAge Flag age 9(1) 6 0 = Code does not violate age constraints

1 = Code violates age constraints2 = There are age requirements but claim has no age

Sex Flag sex 9(1) 7 0 = Code does not violate sex constraints1 = Code violates sex constraints2 = There are sex requirements but no valid sex on this

claimNo Accompanying Procedure

ap 9(1) 8 0 = Code is not missing an appropriate accompanying procedure

1 = Code is missing an appropriate accompanying procedure

No Supporting Diagnosis

sd 9(1) 9 0 = Code is not missing an appropriate secondary diagnosis

1 = Code is missing an appropriate secondary diagnosisPolicy Description policy_name X(100) 10 - 109 Policy number or description associated with the LCD or

NCD. If opsum = 0, this field may be blank. Policy Original Effective Date

orig_effdate 9(8) 110 - 117 Date on which this policy became effective. If opsum = 0, this field may be zeros.

Last Update Date most_effdate 9(8) 118 - 125 Date on which this policy was last updated. If opsum = 0, this field may be zeros.

Frequency Warning Flag

freq_flag 9(1) 126 0 = Code does not have frequency restrictions1 = Code has frequency restrictions

Frequency freq 9(3) 127 - 129 The number of times a service can be performed for a given frequency span (freq_span) and frequency unit (freq_unit).

Example: Service can be performed 5 times every 2 months.

freq = 5freq_span = 2freq_unit = M


Frequency Span freq_span 9(3) 130 - 132 The span of a frequency unit (freq_unit).



Frequency Unit freq_unit X(1) 133 The unit of measurement for frequency (freq) and frequency span (freq_span).

Valid Values:D = Day(s)W = Week(s)M = MonthY = Year(s)L = LifetimeC = Course of Treatment



Broad Diagnostic Flag bd_flag 9(1) 134 0 = Procedure code is not broad diagnostic1 = Procedure code is broad diagnostic; clinical

circumstances should be reviewedPayment Status Indicator

paystat X(2) 135 - 136 Medicare APC Payment Status Indicator. Refer to h_paystat located in the GOB2.APC [apc_grpr_output_entry] for further information.

Filler X(13) 137 - 149

Table AT-1: LEB.OP [lcd_op_edits]: Variable length LCD Editor return fields (occurs numhcpcs times)



LEB.URL [lcd_op_url]Table AU-1: LEB.URL [lcd_op_url]: Variable length line-level LCD Editor return fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesPolicy Identifier policy_id X(10) 1 - 10 Policy identifier associated with the LCD or NCD. If opsum

= 0, this field may be blank.Policy URL url X(200) 11 - 210 URL for the web document describing this policy. If opsum

= 0, this field may be blank.


AEB1 [ace_edit_block1_01]Table AV-1: AEB1 [ace_edit_block1_01]: Fixed length ACE, CAH Method II Editor, and TRICARE APC Editor output fields

Field Description Variable Name Format Position NotesEditor Return Code edtr_rtn_code X(2) 1 - 2 Standard Return Codes:

00 = No errors found05 = Number of procedures < 109 = Number of diagnoses < 187 = Program cannot be loaded88 = Initialization error89 = Error allocating memory95 = Parameter error

Additional Editor-Specific Return Codes:ACE:02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error06 = Claim spans > 365 days07 = Reserved10 = Final disposition exceeds maximum acceptable level

of error11 = MUE File Open or I/O Error

CAH Method II:02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error06 = Claim spans > 365 days10 = Final disposition exceeds maximum acceptable level

of error11 = MUE File Open or I/O Error/Edit cannot be found on

code file13 = Code pair file open or I/O error

TRICARE APC:08 = Unsupported bill type11 = Claim dates outside of Grouper version12 = Invalid date60 = Cannot load external software 61 = All other errors from external software65 = Invalid certificate (3M™ GPCS only)66 = Invalid URL (3M™ GPCS only)88 = Invalid content version (3M™ GPCS only)

Editor Reserved edtr_rtn_rsvd X(4) 3 - 6 Reserved


Editor Version edtr_vers 9(2) 7 - 8 ACE and CAH Method II: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.

TRICARE APC:Editor version number applicable to this claim. This number is the last two digits of the calendar year plus one, i.e. 10 is for calendar year 2009.

Editor Release Version edtr_rel X(1) 9 ACE and CAH Method II:Editor release version number applicable to this claim. There are three or four versions a year. Values range from 1 to 4.

TRICARE APC:Editor release version number applicable to this claim. There are four versions a year. Values rage from 0 to 3.

ACE Version Reserved edtr_vers_rsvd X(3) 10 - 12 ReservedEditor Return Code Type

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 edtr_filler X(19) 14 - 32Number of Claim Errors num_claimerr 9(3) 33 - 35 Number of claim level errors returned.Number of DiagnosisErrors

num_dxerr 9(3) 36 - 38 Number of diagnosis errors returned.

Number of Procedure Errors

num_operr 9(3) 39 - 41 Number of procedure errors returned.

Number of CCI Errors num_ccierr 9(3) 42 - 44 Number of CCI edit pairs returned. Returned with an Edit Request (edit_req) for CCI editing or with an edit request for OCE editing with CCI code pairs.

NoteThis number may be greater than maxccierr.

Number of Reason for Visit Diagnosis Errors

num_admdxerr 9(2) 45 - 46 Number of reason for visit diagnosis errors returned.

Total Number of Errors toterr 9(4) 47 - 50 Total number of errors identified for this patient visit.(num_claimerr + num_dxerr + num_operr)

Notenum_ccierr is not included in this total.

Table AV-1: AEB1 [ace_edit_block1_01]: Fixed length ACE, CAH Method II Editor, and TRICARE APC Editor output fields



Highest Reason for Visit Diagnosis Disposition

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

final_disp 9(2) 53 - 54 Overall disposition of claim, incorporating claim, diagnosis, and procedure edits.

ACE and CAH Method II: 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

TRICARE APC:00 = Claim contains no edits01 = Claim contains edits for line item denial only02 = Multiple-day claim with one or more days denied03 = Claim denied, suspended, or single-day claim with all

line items denied, with post-payment edits04 = Claim denied, suspended, or single-day claim with all

line items denied, with pre-payment edits05 = Claim denied, suspended, or single-day claim with all

line items denied, with both post- and pre-payment edits

08 = Claim contains proprietary edits only09 = Claim suspended with all line items suspended

(TRICARE contractor to determine payment and may request additional information. Submit claim as is)

10 = Only edits present are for line item denial, with only MUE edits present

11 = Only edits present are for line item denial OCE edit(s) and MUE edit(s)

12 = Multiple-day claim and one or more days with OCE line denial edit(s) and MUE edit(s)

13 = Claim denied, or suspended, or single day claim with all line items denied, with only post-payment edits and MUE edit(s)

14 = Claim denied, or suspended, or single day claim with all line items denied, with only pre-payment OCE edit(s) and MUE edit(s)

15 = Claim denied, or suspended, or single day claim with all line items denied, with both post-payment and pre-payment OCE edit(s) and MUE edit(s)

18 = Only edits present are proprietary edits and MUE edit(s)

19 = Claim suspended with at least one line item suspended and MUE edit(s)

20 = Only edits present are MUE edit(s)




OCE Error Disposition oce_disp 9(1) occurs 6 times

55 - 60 ACE and CAH Method II:Claim disposition flag array: one flag for each disposition as listed under final_disp. A “1” in any position indicates that one or more errors were identified on the claim with the matching disposition. For example, 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 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 diagnosis00118 = Invalid bill type00119 = Invalid claims processing receipt date

TRICARE APC:00000 = No errors found00023 = Invalid From-Thru dates00024 = Date out of OCE range00025 = Invalid age00026 = Invalid sex00027 = Only incidental services reported00029 = Partial hospitalization services, non-mental-

health diagnosis00031 = Partial hospitalization claim without partial

hospitalization HCPCS or partial hospitalization HCPCS without partial hospitalization bill type

00046 = Partial hospitalization condition code invalid for this bill type

00098 = Other TRICARE edit00109 = Code first diagnosis present without mental

health diagnosis as the first secondary diagnosisReason for Visit Diagnosis Errors

admdxerr 9(5) occurs 3 times

136 - 150 ACE and TRICARE APC:00000 = No errors found00001 = Invalid admit diagnosis00002 = Admit diagnosis/age conflict00003 = Admit diagnosis/sex conflict




Payer Value Code valcode X(2) occurs 10 times

151 - 170 TRICARE APC:Payer specific value code.

QN = First APC device offsetQO = Second APC device offsetQQ = Terminated procedure with pass-through device OR

condition for device credit presentQR = First APC pass-through drug or biological offsetQS = Second APC pass-through drug or biological offsetQT = Third APC pass-through drug or biological offsetQU = Condition for device credit present

Payer Value Code Amount

valamt 9(10) occurs 10 times

171 - 270 TRICARE APC:Payer specific value code amount.

Filler X(730) 271 - 1000




AEB.DX [ace_dx_edits_01]Table AW-1: AEB.DX [ace_dx_edits_01]: Variable length ACE, CAH Method II Editor, and TRICARE APC Editor output fields for ICD-9-CM or ICD-10-CM diagnosis edits (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Code Type type X(3) 1 - 3 ReservedHighest Diagnosis Disposition

disp 9(2) 4 - 5 ACE and CAH Method II:The highest diagnosis disposition.00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

Number of Errors Recorded for this Diagnosis

numerr 9(2) 6 - 7 Number of diagnosis errors returned.

Admit Diagnosis Errors admdxerr 9(5) 8 - 12 ReservedDiagnosis Errors errors 9(5)

occurs 5 times

13 - 37 ACE and CAH Method II: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 diagnosis

TRICARE APC:00000 = No errors found 00001 = Invalid diagnosis 00002 = Diagnosis/age conflict 00003 = Diagnosis/sex conflict00005 = E-code as reason for visit00098 = Other TRICARE edit00113 = Supplementary or additional code not allowed as

principal diagnosisFiller X(18) 38 - 55


AEB.OP [ace_op_edits_01]Table AX-1: AEB.OP [ace_op_edits_01]: Fixed length ACE, CAH Method II Editor, and TRICARE APC Editor output fields for HCPCS procedures and claim line edits (occurs numhcpcs times)

Field Description Variable Name Format Position NotesAPC apc 9(5) 1 - 5 Ambulatory Payment ClassificationHighest Procedure Disposition

disp 9(2) 6 - 7 ACE and CAH Method II:00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

TRICARE APC:00 = Claim contains no edits01 = Claim contains edits for line item denial only

Procedure Validity Indicator

valid 9(2) 8 - 9 ACE and CAH Method II: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/


TRICARE APC:00 = Procedure is valid for dates01 = Procedure not valid, or not valid for service date

Number of Procedure Errors Recorded

num_err 9(2) 10 - 11 The number of edits returned for each claim line.


Procedure Errors error 9(5) occurs 15 times

12 - 86 ACE and CAH Method II: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 one00038 = 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 claim

continued below...

Table AX-1: AEB.OP [ace_op_edits_01]: Fixed length ACE, CAH Method II Editor, and TRICARE APC Editor output fields for HCPCS procedures and claim line edits (occurs numhcpcs times)



Procedure Errors<continued>

error 9(5) occurs 15 times

12 - 86 00053 = Codes G0378 and G0379 only allowed with bill type 13x

00055 = 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 allowed00061 = 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 code00089 = FQHC claim lacks required qualifying visit code

continued below...






12 - 86 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)

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 line00103 = 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 provider99999 = Line item denial from external Editor

continued below...






12 - 86 TRICARE APC:00000 = No error00006 = Invalid procedure code00007 = Procedure and age conflict00008 = Procedure and sex conflict00009 = Non-covered for reasons other than statute00012 = Questionable covered service00015 = Units exceed maximum (MUE)00017 = Inappropriate specification of bilateral procedure00018 = Inpatient procedure00019 = Mutually exclusive procedure that is not allowed

by NCCI even if appropriate modifier is present00020 = 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 date00027 = Incidental services reported only00028 = Code not recognized by TRICARE; alternate

code for same service may be available00030 = Insufficient partial hospitalization services00032 = Partial hospitalization HCPCS without partial

hospitalization revenue codes, or partial hospitalization revenue codes without partial hospitalization HCPCS codes

00035 = Only mental health education and training services are provided

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

00039 = Mutually exclusive procedure 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 G0 or modifier 27

00044 = Observation revenue code on line item with non-observation HCPCS code

00045 = Inpatient separate procedures not paid when accompanied by another type T procedure on same day or type J1 procedure on claim

00047 = Service is not separately payable00048 = Revenue center requires HCPCS code00049 = Other edit causing denial of all services on this

date00051 = Multiple maternity observations without condition

code G0 or modifier 27

continued below...






12 - 86 00053 = Codes G0378 and G0379 only allowed with bill type 13x

00054 = Multiple codes for the same service00055 = Non-reportable for site of service00058 = G0379 only allowed with G037800062 = Code not recognized by TRICARE APC;

alternate code for same service may be available00063 = OT (occupational therapy) code only billed on

partial hospitalization claims00064 = AT (activity therapy) service not payable outside

the partial hospitalization program00065 = Revenue code not recognized by TRICARE00066 = Code requires manual pricing00067 = Service provided prior to FDA approval or the

Morbidity and Mortality Weekly Report (MMWR) publication date for vaccines

00068 = Service provided prior to date of National Coverage Determination (NCD) approval

00069 = Service provided outside approval period00070 = CA modifier requires patient discharge status

indicating expired or transferred 00071 = Claim lacks required device code00072 = Not billable to TRICARE00074 = 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 code00078 = Claim lacks required radiolabeled product00080 = 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) 00084 = Claim lacks required principal code00085 = Claim lacks required device code or required

procedure code00087 = Claim contains skin substitute application

procedure code without appropriate skin substitute procedure code

00092 = Device-intensive procedure code billed without device code

00093 = Corneal tissue processing reported without cornea transplant procedure


00096 = Partial hospitalization interim claim from and through dates must span more than 4 days (deactivated)

00097 = Partial hospitalization services are required to be billed weekly (deactivated)

continued below...






12 - 86 00098 = Claim with pass-through device lacks required procedure or other TRICARE edit

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

00102 = Modifier pairing not allowed on the same line00103 = Modifier reported prior to FDA approval date

(deactivated)00105 = Claim reported with pass-through device prior to

FDA approval for the procedure00109 = Code first diagnosis present without mental

health diagnosis as the first secondary diagnosis00110 = Service provided prior to initial marketing date00900 = Multiple maternity observations without Condition

Code G0 or Modifier 2700901 = Partial hospitalization claim without partial

hospital HCPCS, or partial hospital HCPCS without PH Condition Code

00902 = Partial hospitalization HCPCS without PH Revenue Codes, or partial hospital Revenue Codes without PH HCPCS codes

00903 = Service on same day as an edit which causes all other services to be denied

00904 = TRICARE reimbursement not allowed for CPT®/ HCPCS code submitted

00905 = Code submitted prior to HIPAA effective date00906 = Multiple IOP codes or other partial hospitalization

codes not allowed on IOP claims00907 = Methadone treatment service only allowed once

per week02002 = HCPCS total units for date of service exceeds

Medically Unlikely Edit maximum. Appropriate modifiers considered

02012 = HCPCS units for line item exceed Medically Unlikely Edit maximum. Appropriate modifiers not considered

02022 = HCPCS units for line item exceed Medically Unlikely Edit maximum. Units reported in excess of the maximum are denied




Payment Status Indicator

paystat X(2) 87 - 88 ACE:A = Services paid under fee schedule or other


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

clams data are not availableF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-through H = Pass-through device categoriesJ1 = Hospital Part B services paid through a

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




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 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

continued below...





paystat X(2) 87 - 88 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



TRICARE APC:A = Services paid under fee schedule or other

prospectively determined rateB = More appropriate code required for TRICARE APCC = Inpatient service, not paid under TRICARE APCE1 = Items and services that are not covered by TRICAREF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH = Pass-through device categoriesJ1 = Hospital outpatient department services paid through

a Comprehensive APC J2 = Hospital outpatient department services that may be

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


N = 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 = Significant procedure, not subject to discounting T = Significant procedure, subject to discounting U = Brachytherapy sourcescontinue below...





paystat X(2) 87 - 88 V = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and invalid revenue

codeX = Ancillary service (prior to January 1, 2015)Z = Valid revenue code, blank HCPCS, no other status

indicator assignedTB = TRICARE reimbursement not allowed

Community Mental Health Center (CMHC) Indicator

paystat2 X(1) 89 ACE:P = Packaging indicator for services to be included in a

mental health or partial hospitalization per diemblank = Not applicable

Bilateral Modifier Flag (From ACE Edits)

bilatop 9(1) 90 ACE and CAH Method II:0 = Unknown or not applicable1 = Conditionally bilateral2 = Inherently bilateral3 = Independently bilateral9 = Not bilateral

Discount discount 9(1) 91 ACE and TRICARE APC:0, 1-9: These discount flags are used by the Pricer to determine payment for this procedure.

Maximum Units maxunits 9(15) 92 - 106 ACE and CAH Method II: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 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 pkgflag 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)

TRICARE APC:0 = Not packaged1 = Packaged service3 = Surgical charges are less than $1.014 = Packaged as part of drug administration APC payment

Composite Line Number

comp_line 9(3) 123 - 125 ACE and TRICARE APC:Line number containing the Composite APC or Comprehensive APC for this service.




Pricing Adjustment Flag adjflag 9(2) 126 - 127 TRICARE APC:00 = No payment adjustment05 = Manually priced by TRICARE07 = Item provided without cost to provider08 = Item provided with partial credit to provider11 = Multiple service units reduced to one by OCE

processing, payment based on a single payment rate12 = Offset for first device pass-through13 = Offset for second device pass-through14 = NEMA payment reduction on CT scan 16 = Terminated procedure with pass-through device17 = Condition for device credit present18 = Offset for first pass-through drug or biological19 = Offset for second pass-through drug or biological20 = Offset for third pass-through drug or biological 21 = Payment reduction on film x-ray22 = Payment reduction for x-rays taken with computed

radiography technology90 = Inpatient only procedure for Medicare-TRICARE dual

eligible beneficiaryProfessional Services Flag

proflag 9(1) 128 Reserved

MUE Adjudication Indicator

mai 9(1) 129 ACE and CAH Method II: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_entry]Table AY-1: AEB4 [ace_edit_entry]: Variable length OCE/CCI edit output fields (occurs num_ccierr times)

Field Description Variable Name Format Position NotesFirst Procedure Code op1 X(7) 1 - 7 ACE and CAH Method II:

First HCPCS procedure code plus one optional modifier.First Claim Line Pointer op1_line 9(3) 8 - 10 ACE and CAH Method II:

Line number of line containing first procedure code.Filler op1_filler X(5) 11 - 15Second Procedure Code

op2 X(7) 16 - 22 ACE and CAH Method II:Second HCPCS procedure code plus one optional modifier.

Second Claim Line Pointer

op2_line 9(3) 23 - 25 ACE and CAH Method II:Line number of line containing second procedure code.

Filler op2_filler X(5) 26 - 30Error Code errnum 9(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 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 edit2 = 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 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 context


Filler X(36) 36 - 71

Table AY-1: AEB4 [ace_edit_entry]: Variable length OCE/CCI edit output fields (occurs num_ccierr times)



AEB5 [ace_edit_summary]Table AZ-1: AEB5 [ace_edit_summary]: Fixed length ACE and CAH Method II Editor error summary output fields

Field Description Variable Name Format Position NotesCCI Edit Summary ces_ttl 9(4) 1 - 4 ACE and CAH Method II:

Total CCI edits.CCI Error Code ces_errcd 9(9)

occurs 999 times

5 - 8995 ACE and CAH Method II:CCI edit identifier.

CCI Error Count ces_errctr 9(3) occurs 999 times

8996 - 11992 ACE and CAH Method II:Number of occurrences of this CCI edit.

Filler ces_filler X(38) 11993 - 12030OCE Edit Summary oes_ttl 9(4) 12031 - 12034 ACE and CAH Method II:

Total OCE edits.OCE Error Code oes_errcd 9(9)

occurs 999 times

12035 - 21025 ACE and CAH Method II:OCE edit identifier.

OCE Error Count oes_errctr 9(3)occurs 999 times

21026 - 24022 ACE and CAH Method II:Number of occurrences of this OCE edit.

Filler oes_filler X(38) 24023 - 24060


PWS1.APC [apchopd_prcr_worksheet1]Table BA-1: PWS1.APC [apchopd_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the APC-HOPD Pricer

Field Description Variable Name Format Position NotesWage Index wi 9(1)v9(5) 1 - 6 Wage indexLabor-Related Portion labor 9(1)v9(5) 7 - 12 Labor-related portionRural Adjustment Factor

rural_fact 9(1)v9(4) 13 - 17 Rural adjustment factor

RCC rcc 9(1)v9(5) 18 - 23 Ratio of Cost-to-Charges (RCC)Outlier Fixed Cost Threshold

outlier_thresh 9(8)v9(2) 24 - 33 Outlier fixed cost threshold

DMEPOS Location/Carrier Code

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

labcarrier X(12) 46 - 57 Lab location/carrier code.


Physician Fee Schedule Location/Carrier Code

rehcarrier X(12) 58 - 69 Physician fee schedule location/carrier code.


Facility Type fac_type 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

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

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 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

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

mamcarrier 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

othcarrier X(12) 117 - 128 Other location/carrier code used for pricing services from a user-created non-Medicare fee schedule.



discount 9(1)v9(4) 129 - 133 The mark-up/discount factor applied to the total payment for each claim line.

OPPS Exempt Factor 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

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

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 BA-1: PWS1.APC [apchopd_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the APC-HOPD Pricer



PWS1.ASC [asc_prcr_worksheet1]Table BB-1: PWS1.ASC [asc_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the ASC Pricer

Field Description Variable Name Format Position NotesQuality Reduction Factor

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 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 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 theMedicare inpatient and outpatient payment systems.

Percentage Payment Flag

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

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

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 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

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

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

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

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.ESRD [esrd_prcr_worksheet1]Table BC-1: PWS1.ESRD [esrd_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the ESRD Pricer

Field Description Variable Name Format Position NotesLabor Portion (PPS) lportion_pps_ws 9(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)

nlpercent_pps_ws 9(8)v9(5) 11 - 23 Percentage of ESRD PPS payment that is not considered labor related.

Non-Labor Portion (PPS)

nlportion_pps_ws 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

wabr_pps_ws 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

ar_session_ws 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)

pmap_ws 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

cmp_map_ws 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

pos_map_ws 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

imp_pmap_ws 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

imp_pmap_ws_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

diff_map_ws 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

diff_map_ws_s 9(1) 117 Indicates if the Differential of Predicted and Imputed MAP field has a positive or negative value:


Blended Outlier Payment

blend_out_pay_ws 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

blend_out_pay_ws_s 9(1) 128 Indicates if the Blended Outlier Payment field has a positive or negative value.


Per Dialysis Session Final Outlier Payment

fop_per_session_ws 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

homeadj_ws 9(1)v9(6) 139 - 145 Adjustment factor for patients that receive CAPD or CCPD at home.

Dialysis Onset Factor onset_factor_ws 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

onset_factor_sep_ws 9(1)v9(5) 152 - 157 Onset adjustment factor for separately payable items for outlier consideration.

Labor-Related Percentage (PPS)

bundle_ls_ws 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) bundle_wi_ws 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 factype_ws 9(2) 169 - 170 01 = Hospital-based ESRD facility02 = Independent ESRD facility

Total PPS Training Adjustments

training_adj_total_ws 9(8)v9(2) 171 - 180 Total adjustment factor for patients receiving training services.

Unadjusted PPS Rate base_rate_ws 9(8)v9(2) 181 - 190 The bundled Medicare ESRD Payment System base rate applicable for both adult and pediatric ESRD patients.

Table BC-1: PWS1.ESRD [esrd_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the ESRD Pricer



Quality Reduction Factor

qualredfact_ws 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 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

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

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

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)

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 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 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 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 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 Addon Factor 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

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

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

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.HCFA [hcfa_prcr_worksheet1]Table BD-1: PWS1.HCFA [hcfa_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Medicare DRG Pricer

Field Description Variable Name Format Position NotesTransfer Exceptions Flag

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

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.)

baser 9(8)v9(2) 3 - 12 Reserved

Capital PPS Reimbursement (with low volume adj.)

tcapaddon 9(8)v9(2) 13 - 22 Reserved

Total PPS Reimbursement, Capital and Non-Capital (with low volume adj.)

totbase 9(8)v9(2) 23 - 32 Reserved

Inlier DRG Rate Before Add-on for Old Capital

init_drgrate 9(8)v9(2) 33 - 42 Reserved

Patient Apportionment of Old Capital Costs

cappatold 9(8)v9(2) 43 - 52 Reserved

Outlier Days outl_days 9(4) 53 - 56 Outlier DaysArithmetic Mean LOS new_mlos 9(3)v9(4) 57 - 63 Arithmetic Mean LOSFederal Wage-Adjusted Rate

fwa 9(8)v9(2) 64 - 73 Federal wage-adjusted rate

Marginal Cost Factor mcf 9(1)v9(2) 74 - 76 Marginal Cost FactorFederal Portion fp 9(1)v9(2) 77 - 79 Federal PortionCombined Operating IME and DSH Factors

comb_op_fac 9(1)v9(9) 80 - 89 Combined Operating IME and DSH Factors

Capital-Adjusted Federal Rate

capadjfrate 9(8)v9(2) 90 - 99 Capital-Adjusted Federal Rate

Capital Federal Portion capfedportion 9(1)v9(4) 100 - 104 Capital Federal PortionCombined Capital IME and DSH Factors

comb_cap_fac 9(1)v9(9) 105 - 114 Combined Capital IME and DSH Factors

Operating Cost-to-Charge Ratio

rcc 9(1)v9(4) 115 - 119 Operating Cost-to-Charge Ratio

Capital Cost-to-Charge Ratio

caprcc 9(1)v9(4) 120 - 124 Capital Cost-to-Charge Ratio

True Costs truecost 9(8)v9(2) 125 - 134 True CostsLOS for Threshold Calculations

costol_mlos 9(4)v9(1) 135 - 139 Reserved


Cost Outlier Factor cof 9(1)v9(2) 140 - 142 ReservedStandard Cost Outlier Threshold

cot 9(8)v9(2) 143 - 152 Cost outlier threshold which includes the operating and capital threshold.

Federal Labor Portion flp 9(1)v9(4) 153 - 157 Federal Labor PortionWage Index wi 9(1)v9(4) 158 - 162 Wage IndexGeographic Adjustment Factor

capgeofac 9(1)v9(4) 163 - 167 Geographic Adjustment Factor

Large Urban Adjustment Factor

caplgurbfac 9(1)v9(4) 168 - 172 Large Urban Adjustment Factor

Total Cost Outlier Threshold

threshold 9(8)v9(2) 173 - 182 Total Cost Outlier Threshold

Operating Cost Threshold

opthresh 9(8)v9(2) 183 - 192 Operating Cost Threshold

Capital Cost Threshold capthresh 9(8)v9(2) 193 - 202 Capital Cost ThresholdLOS for Transfer Calculations

tlos 9(4)v9(1) 203 - 207 LOS for Transfer Calculations

Transfer Per Diem Rate

trperdiem 9(8)v9(2) 208 - 217 Transfer Per Diem Rate

Operating Inlier Payment Due to IME (with low volume adj.)

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.)

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.)

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.)

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.)

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.)

newtech 9(6)v9(2) 268 - 275 New technology add-on payment including applicable low volume adjustments.

Medicare+Choice Reduction Factor

hmoreduc 9(1)v9(2) 276 - 278 Medicare+Choice reduction factor applied to IME and DME.

Transfer Adjustment Factor

xfer_base_adj 9(1)v9(4) 279 - 283 Transfer adjustment factor applied to base rate and outlier threshold.

Capital Cost of Living Adjustment Factor

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.)

costaddon_cap 9(8)v9(2) 289 - 298 The capital portion of the outlier add-on payment including applicable low volume adjustments.

Table BD-1: PWS1.HCFA [hcfa_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Medicare DRG Pricer



SCH/MDH Add-On(with low volume adj.)

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.)

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.)

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.)

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.)

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.)

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.)

tot_oper_amt 9(8)v9(2) 359 - 368 The total operating payment (inlier and outlier) calculated as follows:o_fsp + o_hsp + o_outlr + o_dsh + o_ime

Capital Inlier Payment (without DSH, IME, or low volume adj.)

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.)

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.)

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.)

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.)

tot_capi_amt 9(8)v9(2) 409 - 418 The total capital payment (inlier and outlier) calculated as follows:c_fsp + c_outlr + c_dsh + c_ime + c_old_hh + c_except

Medicare Advantage Hospital Specific Rate (without low volume adj.)

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.)

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.)

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 low_vol_amt 9(8)v9(2) 449 - 458 Low volume add-on payment amount.




Hold Harmless Payment

c_old_hh 9(8)v9(2) 459 - 468 Reserved

Capital Exceptions Payment

c_except 9(8)v9(2) 469 - 478 Reserved

Readmission Payment Adjustment Factor

o_rpaf 9(1)v9(4) 479 - 483 The provider specific readmission payment adjustment factor.

Readmission Payment Amount

o_rpaf_amt 9(8)v9(2) 484 - 493 Readmission payment reduction amount.

SCH Legacy Calculation Flag

sch_legacy 9(1) 494 SCH Legacy Calculation Flag

Value Based Purchasing (VBP) Adjustment Factor

o_vbp_adj 9(1)v9(11) 495 - 506 The provider-specific VBP factor.

Value Based Purchasing (VBP) Payment Amount

o_vbp_amt 9(8)v9(2) 507 - 516 The VBP payment amount.

Value Based Purchasing (VBP) Amount Sign

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

uncomp_dsh 9(8)v9(2) 518 - 527 An additional per claim add-on payment added to DSH claims.

DSH Reduction Factor dshreduc 9(1)v9(4) 528 - 532 Operating DSH reduction factor.Operating Medical Education (IME) Factor

op_ime_fac 9(1)v9(9) 533 - 542 The provider-specific Operating Indirect Medical Education (IME) Factor.

Capital Indirect Medical Education (IME) Factor

cap_ime_fac 9(1)v9(9) 543 - 552 The provider-specific Capital IME Factor.

Operating Disproportionate Share Hospital (DSH) Factor

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

cap_dsh_fac 9(1)v9(4) 558 - 562 The provider-specific Capital DSH Factor.

Low Volume Adjustment Factor

low_vol_fac 9(1)v9(6) 563 - 569 The provider-specific Low Volume Factor.

True Operating Costs trueopcost 9(8)v9(2) 570 - 579 The portion of true costs attributable to operating expenses.

True Capital Costs 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

uncomp_dshlow 9(8)v9(2) 590 - 599 The provider-specific Uncompensated DSH Amount including applicable low volume adjustments.




HAC Reduction Factor hac_fac 9(1)v9(4) 600 - 604 The provider specific HAC reduction factor.HAC Reduction Amount hac_amt 9(8)v9(2) 605 - 614 The HAC reduction payment amount.Blood Clotting Factor Add-On Payment

hemoadd 9(8)v9(2) 615 - 624 The blood clotting factor add-on payment.

Total Covered Charges 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 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

dmepassthru 9(8)v9(2) 645 - 654 Direct Medical Education (DME) pass through payment amount.

Allogeneic Stem Cell Per Diem Pass Through Amount

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

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)

nl 9(4)v9(2) 678 - 683 The national labor-related operating ASA.

National Non-Labor-Related ASA

nnl 9(4)v9(2) 684 - 689 The national non-labor-related operating ASA.

Cost of Living Adjustment (COLA)

(Alaska and Hawaii)

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

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

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

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

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 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 ptype X(2) 726 - 727 Medicare provider type (from the Inpatient Acute Care Provider-Specific File (PSF)).

Percentage of Operating Costs

opcotper 9(8)v9(8) 728 - 743 Used to calculate the operating cost outlier threshold.

Percentage of Capital Costs

capcotper 9(8)v9(8) 744 - 759 Used to calculate the capital cost outlier threshold.

Capital Standard Federal Rate

capstfrate 9(8)v9(2) 760 - 769 The national capital standard federal payment rate.

Hospital-Specific Rate (HSP) for SCHs/MDHs

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

fsp_rate 9(8)v9(2) 780 - 789 Federal-specific rate for SCHs/MDHs used in the operating HSP calculation.

SCH/MDH Factor 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)

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.LTC [ltc_prcr_worksheet1]Table BE-1: PWS1.LTC [ltc_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the LTC Pricer

Field Description Variable Name Format Position NotesSite Neutral Base Payment

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

base_rate_standard 9(8)v9(2) 11 - 20 Base payment under the standard federal payment methodology.


Site Neutral High Cost Outlier Add-On

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

addon_standard 9(8)v9(2) 31 - 40 Cost outlier add-on payment under the standard federal payment methodology.


Adjusted Length of Stay

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 cost 9(8)v9(2) 44 - 53 Total cost of the claim.Total Charges * Ratio of Cost to Charges

Site Neutral Indicator 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

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

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 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 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

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 ipps_blend 9(8)v9(2) 97 - 106 Used in calculations for Short Stay Outlier. IPPS Rate * (1- Blend Percentage)

IPPS Per Diem ipps_per_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 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 ltc_blend 9(8)v9(2) 127 - 136 Used in calculations for Short Stay Outlier. Short Stay Per Diem * Blend Percentage

Short Stay Base 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 BE-1: PWS1.LTC [ltc_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the LTC Pricer



Short Stay Blend 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 short_pdiem 9(8)v9(2) 157 - 166 Used in calculation 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

thresh_neutral 9(8)v9(4) 167 - 178 Used in calculation for High Cost Outlier on Site Neutral claims. Base Rate (Site Neutral) + Fixed Loss Amount (Site Neutral)

Budget Neutrality Offset

bn 9(1)v9(5) 179 - 184 Budget Neutrality Offset.

Cost of Living Adjustment for Alaska and Hawaii

cola 9(1)v9(4) 185 - 189 LTC cost-of-living adjustment.

Percentage of Cost Outlier Paid (Site Neutral)

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

frate 9(5)v9(2) 195 - 201 Unadjusted federal prospective payment.

Labor Related Share lrs 9(1)v9(5) 202 - 207 LTC labor-related share.

Markup/Discount markup 9(1)v9(4) 208 - 212 Markup/discount.

Site Neutral Percentage of Claim

snpct 9(1)v9(2) 213 - 215 Percentage of claim that is paid via site neutral payment method.

Wage Index wi 9(1)v9(4) 216 - 220 LTC wage index.

Non Labor Related Share

non_lrs 9(1)v9(5) 221 - 226 LTC non-labor-related share.1 – Labor Related Share

Short Stay Cost 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

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

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 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.NY [ny_prcr_worksheet1]Table BF-1: PWS1.NY [ny_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the New York Medicaid APR Pricer

Field Description Variable Name Format Position NotesTransfer Exceptions Flag

trflag 9(1) 1 Reserved

Payment Exceptions Flag

exflag 9(1) 2 Reserved

Blended Casemix Neutral Rate/Discharge or, as appropriate, the “Top 20 DRG Rate”

brate 9(8)v9(2) 3 - 12 Reserved

Malpractice Insurance Cost

mic 9(8)v9(2) 13 - 22 Reserved

Uncovered BC/MD Services

bnc 9(8)v9(2) 23 - 32 Reserved

Adjusted Blended Rate Plus Malpractice/Case

adjrate 9(8)v9(2) 33 - 42 Reserved

Capital Add-On cap 9(8)v9(2) 43 - 52 ReservedInlier DRG Rate (with capital) before Add-On and Markup

init_drgrate 9(8)v9(2) 53 - 62 Reserved

Bad Debt/Charity Care Percent

bdp v9(4) 63 - 66 Reserved

Primary Health Service Allowance

phsa v9(5) 67 - 71 Reserved

Financially Distressed Facility Allowance

fda v9(5) 72 - 76 Reserved

Physician Malpractice Add-On

pmi 9(8)v9(2) 77 - 86 Reserved

SPARCS Allowable Amount

saa 9(8)v9(2) 87 - 96 Reserved

Payment Rate Conversion Factor

cmf 9(1)v9(4) 97 - 101 Reserved

Self-Pay Markup omf 9(1)v9(4) 102 - 106 ReservedAlternate Level of Care Days Rate

alc 9(8)v9(2) 107 - 116 Reserved

Discount discount 9(1)v9(5) 117 - 122 ReservedGroup Specific Cost g 9(8)v9(2) 123 - 132 ReservedHospital Blend Factor blend 9(1)v9(2) 133 - 135 ReservedLong Stay Outlier Daily Rate

los_pdiem 9(8)v9(2) 136 - 145 Reserved

Outlier Days outl_days 9(4) 146 - 149 ReservedCost-to-Charge Converter Factor

rcc 9(1)v9(6) 150 - 156 Cost-to-Charge Converter Factor


Operating Prospective Rate Adjustment

opadj 9(8)v9(2) 157 - 166 Reserved

Capital Prospective Rate Adjustment

cdadj 9(8)v9(2) 167 - 176 Reserved

Neutralizing Case Mix Index

ncmi 9(1)v9(4) 177 - 181 Reserved

Cost Outlier Threshold for the Case

cost_thresh 9(8)v9(2) 182 - 191 Reserved

Short Stay Outlier, Transfer, or Long Stay Outlier Adjustment Factor

adj_fact 9(1)v9(2) 192 - 194 Reserved

Short Stay Outlier/Transfer Per Diem

init_perdiem 9(8)v9(2) 195 - 204 Reserved

Filler X(7) 205 - 211Spinal Implant Payment spinal_pay 9(8)v9(2) 212 - 221 Total spinal implant payment.Spinal Implant Charges spinal_charge 9(8)v9(2) 222 - 231 The total of line-level charges for all lines with revenue

code 0278.Alternate Level of Care Days Used

alcdayused 9(3) 232 - 234 Alternate Level of Care Days Used

Alternate Level of Care Days Charges

alccharges 9(8)v9(2) 235 - 244 The total of line-level charges for all lines with revenue codes 0190, 0191, 0192, 0193, 0194, or 0199.

Alternate Level of Care Days Payment

alcpay 9(8)v9(2) 245 - 254 The total alternate level of care payment (alcdayused multiplied by the hospital alternate level of care per diem rate).

Per-Discharge Add-On Payment

discharge 9(8)v9(2) 255 - 264 The total of hospital capital, non-comparable, transition, and direct medical education (if applicable) add-on amounts per discharge.

Base Rate for Transfer Calculation

xfer_base 9(8)v9(2) 265 - 274 Equal to the inlier, used to calculate the xfer_perdiem.

Transfer Payment xfer 9(8)v9(2) 275 - 284 If transfer payment is made, payment is equal to xfer_perdiem.

Transfer Payment Factor

xfer_factor 9(1)v9(4) 285 - 289 Hospital transfer payment factor.

Transfer Per-Diem xfer_perdiem 9(8)v9(2) 290 - 299 The transfer per diem is calculated as follows:

(((xfer_base / mlos)* (1+xfer_factor)+cap_perdiem)*alos)+dme

Where mlos is the DRG-specific mean length of stay, dme is the hospital direct medical education, and cap_perdiem is the hospital capital per-diem.

NoteOnly include dme in this calculation if applicable.

Table BF-1: PWS1.NY [ny_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the New York Medicaid APR Pricer



Outlier Payment outlier 9(8)v9(2) 300 - 309 When cost is greater than threshold, the outlier payment is calculated as follows:

(cost – threshold) * mcf

Where mcf is the hospital marginal cost factor.Outlier Cost cost 9(8)v9(2) 310 - 319 The outlier cost is calculated as follows:

(Total Charges - alccharges - spinal_charge) * rcc

Adjusted Length of Stay alos 9(3) 320 - 322 The adjusted length of stay is calculated as follows:

Length of Stay - alcdayused

Outlier Threshold threshold 9(8)v9(2) 323 - 332 The outlier threshold is calculated as follows:

DRG-specific Cost Outlier Threshold * Hospital Wage Equalization Factor

Inlier Base Rate inlier 9(8)v9(2) 333 - 342 The inlier base rate is calculated as follows:

DRG Weight * Hospital Base Rate * Hospital Wage Equalization Factor * (1 + Hospital Indirect Medical Education (IME) Factor)

NoteOnly include (1 + IME) in this calculation if applicable.

Elective Delivery Adjustment

elect_del 9(1)v9(4) 343 - 347 Payment adjustment used if condition code 82 is reported without an acceptable diagnosis code.

Filler X(653) 348 - 1000

Table BF-1: PWS1.NY [ny_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the New York Medicaid APR Pricer



PWS1.PROF [prof_prcr_worksheet1]Table BG-1: PWS1.PROF [prof_prcr_worksheet1]: Payer-Specific Reimbursement Worksheet Variables for APS-DRG Profiler

Field Description Variable Name Format Position NotesMLOS mlos 9(3)v9(4) 1 - 7 ReservedWeight weight 9(3)v9(5) 8 - 15 ReservedMean LOS for this APS-DRG for Facility

meanlos 9(3)v9(4) 16 - 22 Reserved

Mean Charges for this APS-DRG for Facility

meanchg 9(8)v9(2) 23 - 32 Reserved

LOS based Weight losweight 9(3)v9(5) 33 - 40 ReservedCHG based Weight chgweight 9(3)v9(5) 41 - 48 ReservedExpected LOS element1 9(3)v9(1) 49 - 52 ReservedPercentile LOS Probability

element2 9(3)v9(1) 53 - 56 Reserved

Probability LOS Exceeds Days


Amount of Days for which the LOS has a Particular Probability


Expected Charges element5 9(8)v9(2) 65 - 74 ReservedRelative Charges Percentage

element6 9(5) 75 - 79 Reserved

Percentile CHG Probability


Probability that Charges Exceed Dollar Amount


Dollar Amount for which the Charges have a Particular Probability


Percent of the Average Charge that has a Particular Probability

element10 9(5) 98 - 102 Reserved

Absolute LOS los_absolute 9(3)v9(2) 103 - 107 ReservedAbsolute Charges chg_absolute 9(8)v9(2) 108 - 117 ReservedLOS Probability Threshold

los_pval 9(3) 118 - 120 Reserved

CHG Probability Threshold

chg_pval 9(3) 121 - 123 Reserved

Y Axis Maximum for LOS Graph

los_yaxis 9(3) 124 - 126 Reserved

Y Axis Maximum for CHG Graph

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

Filler X(864) 137 - 1000


PWS1.APG [apg_prcr_worksheet1]Table BH-1: PWS1.APG [apg_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, New York Medicaid APG Pricer

Field Description Variable Name Format Position NotesClaim Level Worksheet Variables

text X(500) 1 - 500

Filler X(500) 501 - 1000


PWS1.APR [apr_prcr_worksheet1]Table BI-1: PWS1.APR [apr_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Medicaid APR Pro Pricer


text X(500) 1 - 500

Filler X(500) 501 - 1000


PWS1.DRG [drg_prcr_worksheet1]Table BJ-1: PWS1.DRG [drg_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the IPF Pricer


text X(500) 1 - 500

Filler X(500) 501 - 1000


PWS1.HHA [hha_prcr_worksheet1]Table BK-1: PWS1.HHA [hha_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the HHA Pricer

Field Description Variable Name Format Position NotesDescription of Payment Calculation in Words

text X(500) 1 - 500

Filler X(500) 501 - 1000


OOB2 [opt_output_entry]Table BL-1: OOB2 [opt_output_entry]: Variable length Optimizer output structure, occurs numdx times

Field Description Variable Name Format Position NotesDiagnosis Number for Principal Diagnosis

dx X(10) 1 - 10 Number of diagnosis that has been “swapped” with the principal diagnosis.

Optimizer MDC mdc 9(2) 11 - 12 MDC assigned when the “swapped” diagnosis is treated as principal.

Optimizer DRG drg 9(5) 13 - 17 DRG assigned when the “swapped” diagnosis is treated as the principal diagnosis.

Optimizer Base Rate base 9(8)v9(2) 18 - 27 Base or inlier reimbursementOptimizer Add-on addon 9(8)v9(2) 28 - 37 Outlier add-onOptimizer ALC Add-on alcpay 9(8)v9(2) 38 - 47 Payment for alternate level of care daysOptimizer Total Reimbursement

total 9(8)v9(2) 48 - 57 Total reimbursement for this “swapped” DRG

Optimizer Outlier Type outflag 9(1) 58 Reason for outlier add-onOptimizer Transfer Flag trflag 9(1) 59 Reason for the patient’s transferOptimizer DRG Weight weight 9(3)v9(5) 60 - 67 Weight for the “swapped” DRGOptimizer Grouper Return Code

grpr_rtn_code 9(2) 68 - 69 DRG Grouper Return Code

Optimizer Pricer Return Code

prcr_rtn_code 9(2) 70 - 71 Pricer Return Code

Optimizer Return Code opt_rtn_code 9(2) 72 - 73 Optimizer Return Code


MOB1 [map_output_block1]Table BM-1: MOB1 [map_output_block1]: Fixed length Mapper output fields

Field Description Variable Name Format Position NotesMapper Return Code map_rtn_code X(2) 1 - 2 Standard Return Codes:

02 = Target version cannot be determined87 = Program cannot be loaded89 = Memory allocation error95 = Parameter error

ICD-10 Mapper:01 = Cannot determine coding version (ICD-9 or ICD-10)

for claim05 = Mapping data file open or I/O error06 = Mapping override file open or I/O error

Alternate ICD-10 Mapper:03 = Source version does not match coding version08 = Mapping between code version and Grouper version

is not supported23 = Mapping between code version and HAC version is

not supported28 = Invalid data60 = Cannot load external software61 = All other errors from external software65 = Invalid certificate (3M™ GPCS only)66 = Invalid URL (3M™ GPCS only)88 = Invalid content version (3M™ GPCS only)

Mapper Return Reserved

map_rtn_rsvd X(8) 3 - 10 Reserved

Mapper Type map_type X(2) 11 - 12 02 = ICD-10 Mapper 03 = Alternate ICD-10 Mapper

Mapper Type Reserved map_type_rsvd X(2) 13 - 14 ReservedMapper Version Number

map_vers 9(2) 15 - 16 Reserved

Mapper Version Reserved

map_vers_rsvd 9(4) 17 - 20 Reserved

Code Type code_type X(2) 21 - 22 Coding classification of target mapped codes.

00 = ICD-901 = ICD-10

Source Version source_vers 9(2) 23 - 24 Source version of ICD-9 or ICD-10 codes passed in on claim.

Target Version target_vers 9(2) 25 - 26 Target version of ICD-9 or ICD-10 codes passed in on claim.

Direction direction X(2) 27 - 28 Indicates whether the Mapper performed backward or forward mapping based upon the source and target versions.

00 = Backward01 = Forward


Total Number of Diagnosis (DX) Mapping Errors

num_dxerr 9(3) 29 -31 ICD-10 Mapper & Alternate ICD-10 Mapper:Number of mapping errors recorded for the diagnosis codes on the claim.

Total Number of Procedure (OP) Mapping Errors

num_operr 9(3) 32 - 34 ICD-10 Mapper & Alternate ICD-10 Mapper:Number of mapping errors recorded for the procedure codes on the claim.

Filler X(366) 35 - 400

Table BM-1: MOB1 [map_output_block1]: Fixed length Mapper output fields



PATHS [ezg_paths]Table BN-1: PATHS [ezg_paths]: Fixed length input fields for all EASYGroup™ processing

Field Description Variable Name Format Position NotesSystem Path system X(256) 1 - 256 Submit only if data files reside in a location other than the

location defined on install. If Rate Path or User Path is not defined, the program will look in this location for all data files. Supply the fully qualified path including the drive letter.

NoteFor optimal performance, the path supplied should be located on the same server as the EASYGroup™ Optimizer that is processing the claim. In other words, the EASYGroup™ components and data files being used to process a single claim should be located on one server and should not be spread across multiple servers.

Rate Path rates X(256) 257 - 512 Submit only if rate files (e.g., medcalc, rate, payors) reside in a location other than the location defined on install or the System path. Supply the fully qualified path including the drive letter.


User Path user X(256) 513 - 768 Submit only if product files (i.e., ACE required files aceedit, oceedit and cciedit) reside in a location other than the location defined on install or the System path. Supply the fully qualified path including the drive letter.



OOB1 [opt_output_block1]Table BO-1: OOB1 [opt_output_block1]: Fixed Length Optimizer Output Structure

Field Description Variable Name Format Position NotesOptimizer Return Code opt_rtn_code X(2) 1 - 2 00 = No errors found

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 Program

(mdlcntl)20 = Memory Allocation Control Program (ezgmem)

cannot be loaded21 = Non-zero return code from the TRICARE APC Editor22 = Non-zero return code from Physician Editor23 = Non-zero return code from Analyzer24 = Non-zero return code from Log Control Program

(logcntl)25 = Non-zero return code from Medicaid Outpatient

Editor26 = Non-zero return code from CAH Method II Editor88 = Initialization error89 = Memory error90 = Invalid request (invalid opcode1)95 = Parameter error96 = Reserved97 = Reserved98 = Reserved99 = Reserved

Optimizer Return Code Reserved

opt_rtn_rsvd X(8) 3 - 10 Reserved



GOB5.APC [apc_grpr_output_entry_01]Table BP-1: GOB5.APC [apc_grpr_output_entry_01]: Variable length APC Grouper output fields (occurs numhcpcs times)



GOB5.APG [apg_grpr_output_entry_01]Table BQ-1: GOB5.APG [apg_grpr_output_entry_01]: Variable length APG Grouper output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesICD-10 Medical APG Diagnosis

med_dx X(10) 1 - 10 Identifies the diagnosis used to assign a Medical APG or Signs Symptoms and Findings (SSF) APG. This field is only populated when a Medical Visit APG or SSF APG is assigned to this service date and is applicable to this visit.

Line Item Visit ID visit_id 9(3) 11 - 13 Identifier (ID) is determined based on the admit/discharge date for each procedure code on the claim.

Preliminary APG supproc 9(5) 14 - 18 The preliminary APG for each claim line. This APG is not used for pricing. Please refer to the APG (proc) field.

Filler X(182) 19 - 200


GOB5.RUG [rug_grpr_output_entry_01]Table BR-1: GOB5.RUG [rug_grpr_output_entry_01]: Variable length RUG Reader output fields (occurs numhcpcs times)



MOB2.DX [map_dx_entry]Table BS-1: MOB2.DX [map_dx_entry]: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from the Mapper (occurs numdx times)

Field Description Variable Name Format Position NotesReturn Code rc X(2) 1 - 2 00 = Mapping, if needed occurred with no errors

02 = No mapping can occur for this diagnosis code

Number of Diagnosis (DX) Codes

numdx 9(2) 3 - 4 Number of target mapped codes for claims processing.

Code Type 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 diagnosis

Code code X(10)occurs 10 times

35 - 134 Target mapped codes for claims processing.

Filler X(16) 135 - 150


MOB3.OP [map_op_entry]Table BT-1: MOB3.OP [map_op_entry]: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from the Mapper (occurs numop times)

Field Description Variable Name Format Position NotesReturn Code 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

numop 9(2) 3 - 4 Number of target mapped codes for claims processing.

Code Type 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 ABR = First ICD-10 procedure ABQ = Other ICD-10 procedure

Code code X(10)occurs 10 times

35 - 134 Target mapped codes for claims processing.

Filler X(16) 135 - 150


PEB1 [pe_edit_block1]Table BU-1: PEB1 [pe_edit_block1]: Fixed length Physician Editor output fields

Field Description Variable Name Format Position NotesEditor Return Code edtr_rtn_code X(2) 1 - 2 00 = No errors found

02 = Code file open or I/O error03 = CCI edit file open or I/O error05 = Number of procedures < 109 = Number of diagnoses < 110 = Final disposition exceeds maximum acceptable

level of error11 = Edit cannot be found on code file12 = MUE file open or I/O error13 = Code pair file open or I/O error87 = Program cannot be loaded

Editor Reserved edtr_rtn_rsvd X(4) 3 - 6 ReservedEditor Version 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 edtr_rel X(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


Filler X(20) 13 -32Number of Claim Edits num_claimerr 9(3) 33 - 35 Number of claim-level edits returned.Number of Diagnosis Edits

num_dxerr 9(3) 36 - 38 Number of diagnosis edits returned.

Number of Procedure Edits

num_operr 9(3) 39 - 41 Number of procedure edits returned.

Total Number of Edits num_toterr 9(3) 42 - 44 Total number of edits identified for this claim, calculated as follows: num_claimerr + num_dxerr + num_operr


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

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

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 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 BU-1: PEB1 [pe_edit_block1]: Fixed length Physician Editor output fields



PEB2 [pe_dx_edits]Table BV-1: PEB2 [pe_dx_edits]: Variable length diagnosis output fields from the Physician Editor, repeated numdx times

Field Description Variable Name Format Position NotesDiagnosis Code Type type X(3) 1 - 3 ReservedHighest Diagnosis Edit Disposition

disp 9(2) 4 - 5 Highest edit disposition for this diagnosis 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 Diagnosis

numerr 9(2) 6 - 7 Number of edits returned for this diagnosis code.

Diagnosis Edits 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 [pe_op_edits]Table BW-1: PEB3 [pe_op_edits]: Variable length procedure output fields from the Physician Editor (repeated numhcpcs times)

Field Description Variable Name Format Position NotesHighest Procedure Edit Disposition

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

numerr 9(2) 3 - 4 Number of edits returned for this procedure code.

Procedure Errors 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



00018 = Claim lacks required primary procedure code00020 = Item or service not allowed with Modifier CS00021 = COVID-19 lab add-on code reported without

required primary procedureMaximum Units maxunits 9(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

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 cci_type 9(2) 102 - 103 01 = Do not code services essential to procedure02 = Code is a CPT® separate procedure 03 = Code only the more extensive procedure for the

same site04 = With and without codes should not be used

together05 = Anesthesia should not be reported separately

when administered by the operating physician 06 = Do not code lab services separately; code lab

panel07 = Report code for completed service only 08 = 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

together 12 = Codes indicate mutually exclusive services13 = Codes indicate sex conflict

Status Code scode X(1) 104 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


MUE Adjudication Indicator

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)


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 BW-1: PEB3 [pe_op_edits]: Variable length procedure output fields from the Physician Editor (repeated numhcpcs times)



CAB1.EDC [edc_analyzer_block1]Table BX-1: CAB1.EDC [edc_analyzer_block1]: Fixed length EDC Analyzer™ claim level output fields

Field Description Variable Name Format Position NotesAnalyzer Return Code analyzer_rtn_code X(2) 1 - 2 01 = Exclusion file I/O error

02 = Standard costs file I/O error03 = Extended costs file I/O error04 = Patient complexity costs file I/O error05 = Exclusion file not found06 = Diagnosis risk file not found07 = Visit level complexity claim file not found08 = Visit level complexity diagnosis file not found84 = Cannot open communication connection85 = Unable to write claim to the log file87 = Program cannot be loaded

Analyzer Return Code Extension

analyzer_rtn_code2 X(2) 3 - 4 Reserved

Analyzer Return Status

analyzer_rtn_status X(2) 5 - 6 Reserved

Analyzer Reserved analyzer_rsvd X(4) 7 - 10 ReservedAnalyzer Type analyzer_type X(2) 11 - 12 00 = No Analyzer

01 = EDC Analyzer™02 = E&M Analyzer Pro

Analyzer Type Reserved


Analyzer Version analyzer_vers 9(2) 15 - 16 Two digit version number of the Analyzer.Analyzer Version Reserved


Filler X(20) 21 - 40 ReservedAnalyzer Error error X(2) 41 - 42 01 = Claim length of stay is invalid or greater than

two days02 = No emergency department visit on this claim03 = More than one emergency department visit

on this claim04 = No/invalid/ambiguous gender on this claim05 = Claim excluded based on patient age06 = Claim excluded based on diagnosis code07 = PSCA could not be assigned to this claim08 = Claim excluded based on discharge

disposition09 = Claim excluded based on procedure code10 = Claim excluded based on revenue code15 = Claim excluded based on gender mismatch

Submitted Visit Level start_visit_lvl 9(1) 43 Visit level submitted on the claim to be processed by the EDC Analyzer™.

Calculated Visit Level end_visit_lvl 9(1) 44 The final visit level after any adjustments have been made.


Submitted Procedure Code

start_hcpcs X(7) 45 - 51 Procedure code submitted on the claim to be processed by the EDC Analyzer™.

Calculated Procedure Code

end_hcpcs X(7) 52 - 58 The final procedure code after any adjustments have been made.

Proportional Standard Cost Allocation (PSCA)

final_psca 9(1) 59 The final PSCA assigned to this claim taking into consideration all the reason for visit diagnosis codes, age, and gender of the patient.

Reason for Visit Diagnosis PSCA

rfvdx_psca[] 9(1)occurs 3 times

60 - 62 The PSCA assigned to each reason for visit code taking into consideration the age and gender of the patient.

NoteValues are only output in this field if the reason for visit codes are submitted in the UB-04 Reason for Visit Diagnoses field located in the PCB2.OCD [op_claim_data] structure.

Category om_cat[] 9(2)occurs 10 times

63 - 82 An array of the diagnostic test categories found on the claim. For example: if the claim contains categories 01 and 03, this field will be set to: 01000300000000000000.

01 = Laboratory tests02 = X-ray tests (film)03 = EKG/RT/other diagnostic tests04 = CT/MRI/ultrasound tests

Proportional Standard Cost Allocation (PSCA) Weight

psca_weight 9(5) 83 - 87 The final PSCA weight for this claim, based on all of the reason for visit diagnosis codes, as well as the patient's age and sex.

Category Weights om_weight[] 9(5) occurs 10 times

88 - 137 The weight for each diagnostic category found on this claim, based on all line-level procedure codes representing the ancillary services ordered for the patient.

Patient Complexity Weight

comp_weight 9(5) 138 - 142

The final patient complexity weight for this claim, based on the principal diagnosis, all secondary diagnosis codes, and all external cause of injury diagnosis codes.

Total Weight tot_weight 9(5) 143 - 147

The total weight used to assign the final visit level.

The total weight equals the sum of the PSCA, OM category, and patient complexity weights.

Filler X(853) 148 - 1000

Table BX-1: CAB1.EDC [edc_analyzer_block1]: Fixed length EDC Analyzer™ claim level output fields



CAB1.EAM [eam_analyzer_block1]Table BY-1: CAB1.EAM [eam_analyzer_block1]: Fixed length E&M Analyzer Pro claim level output fields

Field Description Variable Name Format Position NotesAnalyzer Return Code analyzer_rtn_code X(2) 1 - 2 05 = Exclusion file not found

06 = Diagnosis risk file not found07 = Visit level complexity claim file not found08 = Visit level complexity diagnosis file not found84 = Cannot open communication connection85 = Unable to write claim to the log file87 = Program cannot be loaded

Analyzer Return Code Extension

analyzer_rtn_code2 X(2) 3 - 4 Reserved

Analyzer Return Status

analyzer_rtn_status X(2) 5 - 6 Reserved

Analyzer Reserved analyzer_rsvd X(4) 7 - 10 ReservedAnalyzer Type analyzer_type X(2) 11 - 12 00 = No Analyzer

02 = E&M Analyzer ProAnalyzer Type Reserved


Analyzer Version analyzer_vers 9(2) 15 - 16 Two digit version number of the Analyzer.Analyzer Version Reserved


Filler X(20) 21 - 40 ReservedAnalyzer Error 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 claim15 = Claim excluded based on gender mismatch

Submitted Visit Level start_visit_lvl 9(1) 43 Visit level submitted on the claim to be processed by the E&M Analyzer Pro.

Calculated Visit Level end_visit_lvl 9(1) 44 The final visit level after any adjustments have been made.


Submitted Procedure Code

start_hcpcs X(7) 45 - 51 Procedure code submitted on the claim to be processed by the E&M Analyzer Pro.

Calculated Procedure Code

end_hcpcs X(7) 52 - 58 The final procedure code after any adjustments have been made.

Step 1 Scenario Number

step1_num 9(4) 59 - 62 Optum-defined scenario number.

Step 1 Scenario Text step1_txt X(200) 63 - 262 Text which describes this scenario.Number of Diagnosis Codes With Visit Complexity

step4_count 9(3) 263 - 265

Number of diagnosis codes that contributed to the complexity of the visit.

Weight of Diagnosis Codes With Highest Risk

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

step3_weight 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

step4_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 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 BY-1: CAB1.EAM [eam_analyzer_block1]: Fixed length E&M Analyzer Pro claim level output fields



CAB2.EDC [edc_analyzer_block2]Table BZ-1: CAB2.EDC [edc_analyzer_block2]: Variable length EDC Analyzer™ diagnosis level output fields (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Proportional Standard Cost Allocation (PSCA)

psca 9(1) 1 The PSCA assigned to this diagnosis code taking into consideration the age and gender of the patient.

Diagnosis Complexity Indicator

complexity_ind 9(1) 2 0 = Diagnosis code does not increase the complexity of the visit

1 = Diagnosis code increases the complexity of the visit

Filler X(53) 3 - 55 Reserved


CAB2.EAM [eam_analyzer_block2]Table CA-1: CAB2.EAM [eam_analyzer_block2]: Variable length E&M Analyzer Pro diagnosis level output fields (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Code Step 1 and 2 Indicator

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

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.EDC [edc_analyzer_block3]Table CB-1: CAB3.EDC [edc_analyzer_block3]: Variable length EDC Analyzer™ procedure line-level output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesFinal Procedure Code hcpcs X(7) 1 - 7 Final procedure code after any adjustments have been

made to the emergency department visit code.Method Indicator method 9(2) 8 - 9 00 = Emergency department visit level unchanged

01 = Emergency department visit level decreased02 = Emergency department visit level increased

Category om_cat 9(2) 10 - 11 Diagnostic test category assigned to this procedure code:

00 = Not a diagnostic test01 = Laboratory tests02 = X-ray tests (film)03 = EKG/RT/other diagnostic tests04 = CT/MRI/ultrasound tests

Filler X(139) 12 - 150


CAB3.EAM [eam_analyzer_block3]Table CC-1: CAB3.EAM [eam_analyzer_block3]: Variable length E&M Analyzer Pro procedure line-level output fields (occurs numhcpcs times)

Field Description Variable Name Format Position NotesFinal Procedure Code hcpcs X(7) 1 - 7 Final procedure code after any adjustments have

been made to the visit code.Method Indicator method 9(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


ECB2 [ezg_cntl_block2] Table CD-1: ECB2 [ezg_cntl_block2]: Fixed length input or output fields for all EASYGroup™ processing

Field Description Variable Name Format Position NotesNational Provider Identifier (NPI) Used for Processing

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

taxonomy_used X(10) 11 - 20 Refer to above

Facility ID Used for Processing

facility_used X(16) 21 - 36 Refer to above

Payer ID Used for Processing

paysrc_used X(13) 37 - 49 Refer to above

Filler X(951) 50 - 1000


PWS2.ASC [asc_prcr_worksheet2]Table CE-1: PWS2.ASC [asc_prcr_worksheet2]: Payer-specific reimbursement worksheet variables for the ASC Pricer (occurs numhcpcs times)

Field Description Variable Name Format Position NotesFee Schedule Rate feerate 9(8)v9(3) 1 - 11 Unadjusted fee schedule rate.Code Pair Reduction Factor

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 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

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)

wage_adj_rate 9(8)v9(2) 38 - 47 Wage adjusted base rate (prior to discounting).

Percent of Charges pct_charges 9(8)v9(2) 48 - 57 Percent of total covered charges used for cost outlier calculations.

Adjusted Rate 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

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

chrgs_rate 9(8)v9(2) 78 - 87 Applicable to Payment Status Indicators that do not qualify for multiple procedure discounting.

Highest Paid Line high_pay_flag X(1) 88 Blank = Default (not highest paid line)Y = Highest paid line

Discounted Rate disc_fs_rate 9(8)v9(2) 89 - 98 Discounted rate after multiple procedure discounting has been applied.

Discounted Rate Flag disc_flag 9(1) 99 0 = Default1 = Rate has been discounted

Final Adjusted Rate final_adj_rate 9(8)v9(2) 100 - 109 Final rate after any adjustments.ASC Coverage Factor asrcov 9(1)v9(4) 110 - 119 Coverage factor for the claim line.ASC Coinsurance Factor

asrcoins 9(1)v9(4) 120 - 124 Co-payment for the claim line.

Final Line Total line_total 9(8)v9(2) 125 - 134 Final total line reimbursement.Filler X(61) 135 - 195


PWS2.APG [apg_prcr_worksheet2]Table CF-1: PWS2.APG [apg_prcr_worksheet2]: Variable length Payer-specific line-level reimbursement worksheet variables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, New York Medicaid APG Pricer (occurs numhcpcs times)

Field Description Variable Name Format Position NotesDescription of Payment Variables in Numbers

total X(129) 1 - 129


PWS2.HHA [hha_prcr_worksheet2]Table CG-1: PWS2.HHA [hha_prcr_worksheet2]: Payer-specific reimbursement worksheet variables for the HHA Pricer (occurs numhcpcs times)

Field Description Variable Name Format Position NotesDescription of Payment Calculation Total in Numbers

total X(129) 1 - 129


PWS3.APG [apg_prcr_worksheet3]Table CH-1: PWS3.APG [apg_prcr_worksheet3]: Variable length Payer-specific line-level reimbursement worksheet variables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, and New York Medicaid APG Pricer (occurs numhcpcs times)

Field Description Variable Name Format Position NotesDescription of Payment Calculations in Words

text X(332) 1 - 332

Description of Payment Calculations in Numbers

calc X(180) 333 - 512

Description of Payment Calculation Totals in Numbers

total X(188) 513 - 700


PWS3.HHA [hha_prcr_worksheet3]Table CI-1: PWS3.HHA [hha_prcr_worksheet3]: Payer-specific reimbursement worksheet variables for the HHA Pricer (occurs numhcpcs times)

Field Description Variable Name Format Position NotesDescription of Payment Calculation in Words

text X(332) 1 - 332

Description of Payment Calculation in Numbers

calc X(180) 333 - 512

Description of Payment Calculation Total in Numbers

total X(188) 513 - 700


PWS4.APR [apr_prcr_worksheet4]Table CJ-1: PWS4.APR [apr_prcr_worksheet4]: Variable length Payer-specific reimbursement worksheet variables for the Medicaid APR Pro Pricer (occurs maxpws4 times)

Field Description Variable Name Format Position NotesType of Payment Calculation

cat X(250) 1 - 250

Description of Payment Calculation in Words

text X(400) 251 - 650


calc X(290) 651 - 940


total X(60) 941 - 1000


PWS4.DRG [drg_prcr_worksheet4]Table CK-1: PWS4.DRG [drg_prcr_worksheet4]: Variable length Payer-specific reimbursement worksheet variables for the IPF Pricer (occurs maxpws4 times)


cat X(250) 1 - 250


text X(400) 251 - 650


calc X(290) 651 - 940


total X(60) 941 - 1000


PWS4.HHA [hha_prcr_worksheet4]Table CL-1: PWS4.HHA [hha_prcr_worksheet4]: Payer-specific reimbursement worksheet variables for the HHA Pricer (occurs maxpws4 times)


cat X(250) 1 - 250


text X(400) 251 - 650


calc X(290) 651 - 940


total X(60) 941 - 1000


OEB1 [outpatient_edit_block1]Table CM-1: OEB1 [outpatient_edit_block1]: Fixed length Medicaid Outpatient Editor (MOE) output fields

Field Description Variable Name Format Position NotesEditor Return Code edtr_rtn_code X(2) 1 - 2 02 = Code file open or I/O error

03 = CCI edit file open or I/O error05 = Number of procedures < 109 = Number of diagnoses < 110 = Final disposition exceeds maximum acceptable level

of error11 = MUE file open or I/O error12 = Edit cannot be found on code file

Editor Reserved edtr_rtn_rsvd X(4) 3 - 6 ReservedEditor Version 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., 19 is for calendar year 2019).

Editor Release Version edtr_rel 9(1) 9 Editor release version number applicable to this claim. There are three or four versions a year. Values range from 1 to 4.

Editor Version Reserved


Filler X(20) 13 - 32Number of Claim Errors num_claimerr 9(3) 33 - 35 Number of claim-level edits returned.Number of DiagnosisErrors

num_dxerr 9(3) 36 - 38 Number of diagnosis edits returned.

Number of Procedure Errors

num_operr 9(3) 39 - 41 Number of procedure edits returned.

Total Number of Errors num_toterr 9(3) 42 - 44 Total number of edits identified for this claim, calculated as follows:(num_claimerr + num_dxerr + num_operr)


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 correction


Error Dispositions moe_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 = ReservedFlag 6 = Reserved

For example, 011000 would indicate that the claim contains edits that would result in line item denials and claim suspension.

Highest Claim Error Disposition

disp 9(2) 53 - 54 Highest claim-level edit disposition.

00 = No errors found 01 = Claim contains line item rejections02 = Claim contains line item denials03 = Claim suspension 04 = Claim Returned to Provider (RTP) for correction

Claim Errors claimerr 9(5) occurs 15 times

55 - 129 00001 = Invalid date00002 = Date out of range00003 = Invalid age00004 = Invalid sex

Filler X(871) 130 - 1000

Table CM-1: OEB1 [outpatient_edit_block1]: Fixed length Medicaid Outpatient Editor (MOE) output fields



OEB2 [outpatient_dx_edits]Table CN-1: OEB2 [outpatient_dx_edits]: Variable length Medicaid Outpatient Editor (MOE) output fields for ICD-10-CM diagnosis edits (occurs numdx times)

Field Description Variable Name Format Position NotesDiagnosis Code Type type X(3) 1 - 3 ReservedHighest Diagnosis Disposition

disp 9(2) 4 - 5 Highest edit disposition for this diagnosis code.


Number of Errors for this Diagnosis

numerr 9(2) 6 - 7 Number of edits returned for this diagnosis code.

Diagnosis Errors errors 9(5) occurs 5 times

8 - 32 00005 = Invalid diagnosis code00006 = Diagnosis and age conflict00007 = Diagnosis and sex conflict00015 = Supplementary or additional code not allowed as

principal diagnosisFiller X(23) 33 - 55


OEB3 [outpatient_op_edits]Table CO-1: OEB3 [outpatient_op_edits]: Variable length Medicaid Outpatient Editor (MOE) line-level output fields for HCPCS procedures and claim line edits (occurs numhcpcs times)

Field Description Variable Name Format Position NotesHighest Procedure Disposition

disp 9(2) 1 - 2 Highest edit disposition for this procedure code.



valid 9(2) 3 - 4 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 Errors for This Procedure

numerr 9(2) 5 - 6 Number of edits returned for this procedure code.

Procedure Errors errors 9(5)occurs 15 times

7 - 81 00001 = Invalid date00008 = Invalid procedure code00009 = Invalid revenue code00010 = Invalid modifier00011 = Procedure and sex conflict00012 = Medically Unlikely Edit (MUE)00013 = Code 2 of a code pair that is not allowed by NCCI

even if appropriate modifier is present00014 = Code 2 of a code pair that would be allowed by

NCCI if appropriate modifier were presentMaximum Units maxunits 9(15) 82 - 96 Maximum allowable units for this procedure code as

dictated by the Medicaid MUEs. If no maximum has been defined for this procedure code, this field will default to zero.

Column 1 Code for CCI Edit

column1 X(7) 97 - 103 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 cci_type 9(3) 104 - 106 915 = Column 1/column 2 correct coding edits


Procedure Payment Status

paystat X(2) 107 - 108 A = Services paid under fee schedule or other prospectively determined rate

B = Service not allowed under OPPS on hospital outpatient claim

C = Inpatient service, not paid under OPPS E1 = Non-allowed item or serviceE2 = Items and services for which pricing information and

clams data are not availableF = Corneal, CRNA and Hepatitis BG = Drug/biological pass-throughH = Pass-through device categories J1 = Hospital Part B services paid through a

Comprehensive APCJ2 = Hospital Part B services that may be paid through a




M = Service not billable to the FI/MACN = Packaged/incidental service P = Partial hospitalization serviceQ1 = STV - packaged servicesQ2 = T - packaged servicesQ3 = Services that may be paid through a Composite APC Q4 = Conditionally packaged laboratory servicesR = Blood and blood productsS = Procedure or service, not discounted when multipleT = Procedure or service, multiple reduction appliesU = Brachytherapy sourcesV = Clinic or emergency department visitW = Invalid HCPCS, or blank HCPCS and invalid revenue

codeY = Non-implantable DMEZ = Valid revenue code, blank HCPCS, no other status

indicator assignedBilateral Modifier Flag bilatop 9(1) 109 0 = Unknown or not applicable

1 = Conditionally bilateral2 = Inherently bilateral3 = Independently bilateral 9 = Not bilateral

Filler X(41) 110 - 150

Table CO-1: OEB3 [outpatient_op_edits]: Variable length Medicaid Outpatient Editor (MOE) line-level output fields for HCPCS procedures and claim line edits (occurs numhcpcs times)



List of TablesInput and Output Data Structures 6

EASYGroup™ Server Input/Output Blocks Order 10

ECB [ezg_cntl_block]: Fixed length input or output fields for all EASYGroup™ processing 14

PCB1 [patient_claim_data]: Fixed length input fields for all EASYGroup™ pro-cessing 32

PCB2.CCD [cah_claim_data]: Fixed length CAH Method II input fields 49

PCB2.ICD [ip_claim_data]: Fixed length inpatient input fields 50

PCB2.OCD [op_claim_data]: Fixed length outpatient input fields 53

PCB2.PCD [phys_claim_data]: Fixed length Physician input fields 55

PCB2.RCD [rehab_claim_data]: Fixed length IRF input fields 57

PCB2.SCD [snf_claim_data]: Fixed length SNF input fields 63

DX [dx_entry]: Variable length input and output fields for ICD-9-CM or ICD-10-CM diagnoses (occurs numdx times) 64

OP [op_entry]: Variable length input and output fields for inpatient ICD-9-CM or ICD-10-PCS procedures (occurs numop times) 68

LINE [line_entry]: Variable length HCPCS procedure input fields (occurs num-hcpcs times) 70

GOB1.APC [apc_grpr_block1]: Fixed length APC Grouper, ASC Grouper, HHA HHRG Reader, HHA PDGM Reader, and ESRD Reader output fields 74

GOB1.APG [apg_grpr_block1]: Fixed length APG Grouper output fields 76

GOB1.CMG [cmg_grpr_block1]: Fixed length IRF Grouper output fields 78

GOB1.DRG [drg_grpr_block1]: Fixed length Inpatient Grouper output fields 83

GOB1.RUG [rug_grpr_block1]: Fixed length RUG Reader and SNF Reader output fields 88

GOB2.APC [apc_grpr_output_entry]: Variable length ACE, APC Grouper, ASC Grouper, CAH Method II Editor, HHA HHRG Grouper, and ESRD Reader out-


put fields (occurs numhcpcs times) 89

GOB2.APG [apg_grpr_output_entry]: Variable length APG Grouper output fields (occurs numhcpcs times) 93

GOB2.CMG [cmg_grpr_output_entry]: Variable length IRF Grouper output fields (occurs numhcpcs times) 96

GOB2.DRG [drg_grpr_output_entry]: Variable length inpatient Grouper output fields (occurs numhcpcs times) 97

GOB2.RUG [rug_grpr_output_entry]: Variable length RUG Reader and SNF Reader output fields (occurs numhcpcs times) 98

GOB3.DRG [drg_grpr_output_dx]: Variable length diagnosis return fields (oc-curs numdx times) 99

GOB4.DRG [drg_grpr_output_op]: Variable length ICD-9-CM or ICD-10-PCS procedure return fields (occurs numop times) 101

POB1.APC [apc_prcr_block1]: Fixed length APC-HOPD, Contract APC, ASC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields 102

POB1.APG [apg_prcr_block1]: Fixed length APG Pricer output fields 111

POB1.CAH [cah_prcr_block1]: Fixed length CAH Method II Pricer output fields 115

POB1.CMG [cmg_prcr_block1]: Fixed length IRF Pricer output fields 116

POB1.DRG [drg_prcr_block1]: Fixed length DRG Pricer output fields 119

POB1.PP1 [phys_prcr_block1]: Fixed length Physician Pricer output fields 138

POB1.RUG [rug_prcr_block1]: Fixed length SNF Pricer output fields 139

POB2.APC [apc_prcr_output_entry]: Variable length APC-HOPD, ASC, Con-tract APC, Contract ASC, ESRD, FQHC, HHA, Hospice, New Mexico Medicaid APC, and TRICARE APC Pricer output fields (occurs numhcpcs times) 140

POB2.APG [apg_prcr_output_entry]: Variable length APG Pricer output fields (occurs numhcpcs times) 150

POB2.CAH [cah_prcr_output_entry]: Variable length CAH Method II Pricer out-put fields (occurs numhcpcs times) 158


POB2.PP1 [phys_prcr_output_entry]: Variable length Physician Pricer output fields, repeated numhcpcs times 161

POB2.RUG [rug_prcr_output_entry]: Variable length SNF Pricer output fields (occurs numhcpcs times) 164

POB3.ESRD [esrd_prcr_block3]: Variable length ESRD Pricer output fields (occurs numhcpcs times) 165

EEB1 [ezdit_block1]: Fixed length EASYEdit™ output fields 167

EEB2 [ezedit_id_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times) 168

EEB3 [ezedit_msg_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times) 169

EEB4 [ezedit_rtn_entry]: Variable length EASYEdit™ output fields (occurs up to maxeeb2 times) 170

MEB1 [mce_editor_block1]: Fixed length output fields from Date-Sensitive Code (DSC) Editor 172

MEB.DX [mce_dx_edits]: Variable length ICD-9-CM or ICD-10-CM diagnosis output fields from Date-Sensitive Code Editor (occurs numdx times) 174

MEB.OP [mce_op_edits]: Variable length ICD-9-CM or ICD-10-PCS procedure output fields from Date-Sensitive Code Editor (occurs numop times) 177

MEB4 [mce_edit_summary]: Fixed length error summary output fields from Date-Sensitive Code Editor 178

LEB1 [lcd_edit_block1]: Fixed length LCD Editor return fields 179

LEB.OP [lcd_op_edits]: Variable length LCD Editor return fields (occurs numh-cpcs times) 180

LEB.URL [lcd_op_url]: Variable length line-level LCD Editor return fields (oc-curs numhcpcs times) 182

AEB1 [ace_edit_block1_01]: Fixed length ACE, CAH Method II Editor, and TRICARE APC Editor output fields 183

AEB.DX [ace_dx_edits_01]: Variable length ACE, CAH Method II Editor, and TRICARE APC Editor output fields for ICD-9-CM or ICD-10-CM diagnosis edits (occurs numdx times) 189


AEB.OP [ace_op_edits_01]: Fixed length ACE, CAH Method II Editor, and TRI-CARE APC Editor output fields for HCPCS procedures and claim line edits (oc-curs numhcpcs times) 190

AEB4 [ace_edit_entry]: Variable length OCE/CCI edit output fields (occurs num_ccierr times) 201

AEB5 [ace_edit_summary]: Fixed length ACE and CAH Method II Editor error summary output fields 203

PWS1.APC [apchopd_prcr_worksheet1]: Payer-specific reimbursement work-sheet variables for the APC-HOPD Pricer 204

PWS1.ASC [asc_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the ASC Pricer 206

PWS1.ESRD [esrd_prcr_worksheet1]: Payer-specific reimbursement work-sheet variables for the ESRD Pricer 207

PWS1.HCFA [hcfa_prcr_worksheet1]: Payer-specific reimbursement work-sheet variables for the Medicare DRG Pricer 211

PWS1.LTC [ltc_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the LTC Pricer 217

PWS1.NY [ny_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the New York Medicaid APR Pricer 221

PWS1.PROF [prof_prcr_worksheet1]: Payer-Specific Reimbursement Work-sheet Variables for APS-DRG Profiler 224

PWS1.APG [apg_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, New York Medicaid APG Pricer 225

PWS1.APR [apr_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the Medicaid APR Pro Pricer 226

PWS1.DRG [drg_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the IPF Pricer 227

PWS1.HHA [hha_prcr_worksheet1]: Payer-specific reimbursement worksheet variables for the HHA Pricer 228

OOB2 [opt_output_entry]: Variable length Optimizer output structure, occurs numdx times 229


MOB1 [map_output_block1]: Fixed length Mapper output fields 230

PATHS [ezg_paths]: Fixed length in-put fields for all EASYGroup™ pro-cessing 232

OOB1 [opt_output_block1]: Fixed Length Optimizer Output Structure 233

GOB5.APC [apc_grpr_output_en-try_01]: Variable length APC Grouper output fields (occurs numhcpcs times) 234

GOB5.APG [apg_grpr_output_en-try_01]: Variable length APG Grouper output fields (occurs numhcpcs times) 235

GOB5.RUG [rug_grpr_output_en-try_01]: Variable length RUG Reader output fields (occurs numhcpcs times) 236

MOB2.DX [map_dx_entry]: Variable length ICD-9-CM or ICD-10-CM diag-nosis output fields from the Mapper (occurs numdx times) 237

MOB3.OP [map_op_entry]: Variable length ICD-9-CM or ICD-10-PCS pro-cedure output fields from the Mapper (occurs numop times) 238

PEB1 [pe_edit_block1]: Fixed length Physician Editor output fields 239

PEB2 [pe_dx_edits]: Variable length diagnosis output fields from the Phy-sician Editor, repeated numdx times 241

PEB3 [pe_op_edits]: Variable length procedure output fields from the Phy-sician Editor (repeated numhcpcs

times) 242

CAB1.EDC [edc_analyzer_block1]: Fixed length EDC Analyzer™ claim level output fields 244

CAB1.EAM [eam_analyzer_block1]: Fixed length E&M Analyzer Pro claim level output fields 246

CAB2.EDC [edc_analyzer_block2]: Variable length EDC Analyzer™ di-agnosis level output fields (occurs numdx times) 248

CAB2.EAM [eam_analyzer_block2]: Variable length E&M Analyzer Pro di-agnosis level output fields (occurs numdx times) 249

CAB3.EDC [edc_analyzer_block3]: Variable length EDC Analyzer™ pro-cedure line-level output fields (occurs numhcpcs times) 250

CAB3.EAM [eam_analyzer_block3]: Variable length E&M Analyzer Pro procedure line-level output fields (oc-curs numhcpcs times) 251

ECB2 [ezg_cntl_block2]: Fixed length input or output fields for all EASYGroup™ processing 252

PWS2.ASC [asc_prcr_worksheet2]: Payer-specific reimbursement work-sheet variables for the ASC Pricer (occurs numhcpcs times) 253

PWS2.APG [apg_prcr_worksheet2]: Variable length Payer-specific line-level reimbursement worksheet vari-ables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, New York Medicaid APG Pricer (occurs numhcpcs times) 254


PWS2.HHA [hha_prcr_worksheet2]: Payer-specific reimbursement work-sheet variables for the HHA Pricer (occurs numhcpcs times) 255

PWS3.APG [apg_prcr_worksheet3]: Variable length Payer-specific line-level reimbursement worksheet vari-ables for the Enhanced New York Medicaid APG Pricer, Medicaid APG Pro Pricer, and New York Medicaid APG Pricer (occurs numhcpcs times) 256

PWS3.HHA [hha_prcr_worksheet3]: Payer-specific reimbursement work-sheet variables for the HHA Pricer (occurs numhcpcs times) 257

PWS4.APR [apr_prcr_worksheet4]: Variable length Payer-specific reim-bursement worksheet variables for the Medicaid APR Pro Pricer (occurs maxpws4 times) 258

PWS4.DRG [drg_prcr_worksheet4]: Variable length Payer-specific reim-bursement worksheet variables for the IPF Pricer (occurs maxpws4 times) 259

PWS4.HHA [hha_prcr_worksheet4]: Payer-specific reimbursement work-sheet variables for the HHA Pricer (occurs maxpws4 times) 260

OEB1 [outpatient_edit_block1]: Fixed length Medicaid Outpatient Ed-itor (MOE) output fields 261

OEB2 [outpatient_dx_edits]: Variable length Medicaid Outpatient Editor (MOE) output fields for ICD-10-CM diagnosis edits (occurs numdx times) 263

OEB3 [outpatient_op_edits]: Variable

length Medicaid Outpatient Editor (MOE) line-level output fields for HCPCS procedures and claim line edits (occurs numhcpcs times) 264

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