PART B MEDICARE FILES

The Part B Medicare Files contain data on the utilization of physician services and certain other medical services, equipment, and supplies covered by the Medicare SMI plan. Prior to the implementation of the CWF, physician and supplier claims data processed by carriers were submitted to CMS in the form of payment records. Payment records, however, did not include line item detail such as payment amount for each service. To supplement its physician/supplier utilization data, CMS required all carriers to submit four summary and sample files extracted from the complete history of the Medicare claims they processed. These four historic BMAD files included the following:

• BMAD Procedure File
• BMAD Prevailing Charge/Pricing File
• BMAD Provider File
• BMAD Beneficiary File

The BMAD files were derived from only those Medicare claims processed by Medicare carriers. Claims for home health services and outpatient hospital services, while also Part B benefit claims, were processed by FIs and hence were not included in the BMAD files. Physician/supplier services rendered to beneficiaries enrolled in Health Maintenance Organizations (HMOs) were also not included.

After 1990, annual carrier BMAD submissions were discontinued because complete physician/supplier claims data became available on a flow basis from the CWF. In addition, the BMAD Prevailing Charge/Pricing File became outdated with the implementation of the physician fee schedule, and fee schedules for clinical laboratory services and DME. As a result, the BMAD files have been superseded by files created from other data sources.

The following table lists the historic BMAD files and their successors:

The successors to the BMAD Procedure File and the BMAD Beneficiary File are created from CWF claims data. The successors to the BMAD Prevailing Charge/Pricing File are fee schedules containing pricing amounts for individual services. The successor to the BMAD Provider File, the Physician Sample File, is created from the NCH file.

Physician/Supplier Procedure Summary (PSPS) File

The PSPS Procedure File provides information on services used by Medicare beneficiaries during a calendar year. The information is provided at the procedure level.

File Creation

Each year, CMS produces the PSPS file using all the claims for physician and supplier services rendered to Medicare beneficiaries during the year and processed by the carrier through June 30 of the following year. Each carrier summarized the claims data (i.e., submitted and allowed charges) to the procedure code level. Every procedure code reported on a claim in a given year was represented in the PSPS File even if it occurred only once.

CMS receives submissions from carriers via CWF and creates a PSPS File once a year, generally six months after the end of the service year. CMS processes the files through a series of edit and validation programs. These programs included checks for valid codes and logical consistency between related data elements within each record. Records identified in the edit process as being incorrect but within acceptable tolerance levels are annotated as errant records and included in the file.

Since 1991, CMS has produced a Physician/Supplier Procedure Summary File from CWF claims data as a successor to the BMAD Procedure File.

File Maintenance

The PSPS is created on an annual basis. It is available as of July of the succeeding year. For example, 1998 incurred year is available in July of 1999.

File Structure and Usage

The PSPS File contains frequency and charge data for every procedure occurring on the Medicare claims processed by all carriers. Each PSPS File record represents a unique combination of the following:

• Carrier number
• HCPCS procedure code
• First modifier
• Second modifier
• Type of service
• Place of service
• Specialty
• Locality

The PSPS File provides information on the services used by Medicare beneficiaries at the local and national level, and the cost of these services to the SMI fund. Such information is crucial for the evaluation of the impact of alternative Medicare fee schedules and payment policies, and for Medicare utilization trend analyses and projections.

Data Structure and Usage

The PSPS File contains records representing unique combinations of carrier number, HCPCS code, first and second modifiers, type of service, place of service, specialty, and locality. The file includes one record for each combination occurring at least once in the combined claims of the reporting carriers. The more recent annual PSPS files contain approximately nine million records.

PSPS File records contain each of the data elements used to define a unique record (e.g., carrier number and type of service), as well as procedure frequency, and total charges submitted, allowed, and denied. Also included are the miles, time, units, or services for each procedure depending on the type of procedure. Records are sorted by locality, specialty code, type of service, place of service, and procedure and modifier codes.

Known data limitations at the individual data element level are described in detail in the Center for Health Plans and Providers (CHPP)-produced PSPS File Limitations document. This document includes year- and carrier-specific examples of errant records, and contains tables illustrating the amount and percentage of total allowed charges contained in errant records.

Methods of Access

A public use version of the PSPS File, described in the Public Use Files (PUFs) Data chapter, is available for purchase.

Data from the Physician/Supplier Procedure Summary File (created from CWF claims data), are available online at the HDC through the Part B Extract and Summary System (BESS). BESS provides three complete years of data plus the current year to date. This interactive system is designed to access and extract select physician/supplier summarized claims data and generate pre-formatted reports for the current and three prior years. BESS is open to all CMS HDC users.

Migration of Data

Since 1991, CMS has produced a Physician/Supplier Procedure Summary File using CWF claims data. The Physician/Supplier Procedure Summary File differs from the BMAD Procedure File in that it captures CWF data quarterly, is maintained and made available on a year-to-date basis, and contains the Medicare payment amount. The calendar year file is closed six months after the end of the service year (instead of the three-month lag allowed for the historic BMAD files). Data for the current calendar year and the three previous years are available through BESS.

Since the Physician/Supplier Procedure Summary File is created from daily submissions of CWF data, it is more current than the BMAD Procedure File. Year-to-date files are available one month after the close of each quarter. Full calendar year data are available by July of the following year.

List of Data Elements

A list of the data elements contained in the Physician/Supplier Procedure Summary File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Physician Sample File

The Physician Sample File contains final action claim line item-level data for services rendered to Medicare beneficiaries by a sample of physicians.

File Creation

The Unique Physician Identification Number (UPIN) Validation File is statistically analyzed for the random selection of the physicians and is based on the ending two digits of the UPIN in the Carrier Identification Number and Locality Code. The identified sample is extracted from the NCH file six months after the close of the calendar year. The Physician Sample File is created using all the physician line items extracted for the year and netted into final action. Because the data for this file come from the NCH, they have been subjected to the NCH Quality Assurance System (NCHQAS).

File Maintenance

The Physician Sample File is created eight to 12 months after the close of the calendar year.

File Structure and Usage

The Physician Sample File contains service information such as place and type of service, and charge and payment amounts. The files contain records for every service furnished to Medicare beneficiaries by a sample of physicians in a given year. Each Physician Sample File record contains data from one physician claim line item. The file is used for research.

Data Structure and Usage

The Physician Sample File is a sequential flat file that resides on robotic cartridge containing fixed-length records sorted in ascending order by HIC Number and Carrier Control Number. The file contains approximately 20 million records per year. The data are derived from all physician line items.

Methods of Access

The Physician Sample File is also available as a BEF and is described in the Beneficiary Encrypted Files Data chapter.

Migration of Data

With the implementation of the CWF, physician claims data became available to CMS (previously HCFA) on a flow basis. Annual carrier BMAD submissions and creation of the BMAD Provider File were discontinued after CMS received the 1990 data. The Physician Sample File was first created in 1991 and is the successor to the BMAD Provider File

List of Data Elements

A list of data elements contained in the file as well as brief definitions and coding schemes will be included in the future on the CMS web site at www.cms.hhs.gov.