Medicare Frequently Asked Questions

1. How does Medicare work?
2. What is a claim?
3. How are claims paid?
4. What is a final action claim?
5. Who are the Medicare beneficiaries?
6. What is not covered by Medicare?
7. What kind of data can I get from HCFA?
8. What types of files are there (categories)?
9. What are Research Identifiable Files (RIFs)?
10. What are Public Use Files: Beneficiary Encrypted Files (BEFs)?
11. What are Public Use Files: Public Use Files (PUFs) ?
12. Why would I want to use Medicare data for my research?
13. What are some limitations of Medicare data I need to consider?
14. What are some limitations of each category of files?
15. What are the advantages of each category of files?
16. What are the files contained under theses categories (BEFs and RIFs only)?
17. How do I find articles that use Medicare data?
18. How does the Privacy Act affect my access to Medicare data?
19. Why are there people under age 65 in my Medicare dataset?
20. Can I identify the referring physician for an inpatient stay using the Inpatient claims?
21. Can I identify the attending physician for an inpatient stay using the Inpatient claims?
    21a. Can I identify the operating/performing physician for an inpatient stay using the Inpatient claims?
22. Are prescriptions covered?
23. Can I study drugs?
24. Is insulin covered?
25. How much do files cost?
26. What factors influence the cost of files?
27. Why aren’t Research Identifiable Files (RIFs) in the Public Use Files (PUFs) catalog?
28. Is there any reason I would need a Public Use File (PUF) if I already have a Beneficiary Encrypted File (BEF) or Research Identifiable File (RIF)?
29. What’s the difference between the Inpatient SAF and the MedPAR files?
30. If I need to choose between MedPAR and the inpatient SAF, which would you recommend?
31. If I want outpatient data, what do I ask for?
32. What is the difference between Part B Physician/Supplier data and Outpatient data?
33. Why isn’t the residence information (e.g. county code) found in the denominator file and claims files completely in agreement when I link them?
34. How are the 5% samples selected?
35. How do I link Medicare data with my data?
36. What’s a HIC?
37. What’s a BIC?
38. What happens when a wife becomes a widow?
39. What is BIC equating?
40. Does BIC equating cost extra? Do I have to ask for it?
41. How do I link Medicare datasets?
42. Do HICs ever change?
43. How common is changing HICs?
44. What do I do about it?
45. What is cross-referencing?
46. For longitudinal or retrospective studies, what do I need to consider?
47. How much will the data cost me to acquire?
48. Where can I get a PUFs catalog?
49. Can I get the data at a discounted price?
50. How are costs determined?
51. I’m on a very tight budget - are there any data that are free or very low-cost?
52. What’s the difference between a variable length file and a fixed length-multiple linked file?
53. Can I study denials?
54. How do I study a particular condition/disease?
55. Can I perform county-level analysis with SAF data? I see that variable is optional.
56. What is the smallest level of detail not blanked/encrypted in a Beneficiary Encrypted File (BEF)?
57. Can I get a 100% (National) Physician/Supplier Part B file?
58. Will I be able to find all claims for an individual within one BEF/am I able to link beneficiaries across BEFs?
59. Can I access data dictionaries?
60. Can I figure out Medicare data without taking a training class?
61. What kind of training courses are offered and when are they offered?
62. What steps do I need to take to request RIFs?
63. Are there any sample protocols I can look at?
64. What’s a benefit period?
65. When does coinsurance kick in?
66. What are lifetime reserve days?
67. Is MedPAR one file?
68. What does MedicareGuru do?
69. What doesn’t MedicareGuru do?
70. Can you do analysis for me?
71. Do you have data there?
72. Can you send/email me some data?
73. What are carriers?
74. What are Fiscal Intermediaries (FIs)?
75. What are the final action algorithms for Institutional claims?
76. What are the final action algorithms for Non-Institutional claims?
77. How do I identify ALLOWED & DENIED Non-Institutional (Part B) Claims?
78. How do I identify ALLOWED & DENIED Non-Institutional (Part B) Line Items (Specific Services)?
79. How is Medicare reimbursement calculated for physicians?
80. How can I identify the different Institutional provider types?
81. Where can I go for more information?
82. How are Unique Physician Identification Numbers (UPIN) allocated based on the Physician Credential Codes?
83. How are physician services identified?
84. Under which circumstances are line item trailers for physician services excluded?
85. What business rules apply when processing physician claims data?
86. How can Non-Institutional Type of Services (TOS) be determined?
87. How are non-physician specialties identified?
88. Under what circumstances are line item trailers for non-physician specialties excluded?
89. Which business rules apply when processing non-physician specialties

Medicare is a public-private partnership. It is run by the Centers for Medicare and Medicaid Services(CMS-previously HCFA) within the Department of Health and Human Services. Much of the day-to-day work is done by intermediaries (for Part A) and carriers (for Part B). These are generally commercial insurers.

There are two parts of the Medicare program:

Part A - Hospital Insurance (HI)

Part A helps to cover the costs of hospital, skilled nursing facility, home health and hospice care. Part A benefits are provided automatically to all individuals who are eligible. Part A is financed primarily by payroll taxes based on covered work, both before and after one becomes eligible for benefits.

• Deductible of $764 per each Benefit Period (1998)
• Copayment of $191 a day for the 61^st through the 90th day, per Benefit Period (1998)

Part B – Supplementary Medical Insurance (SMI)

Part B helps to cover the costs of physician and outpatient services.

While Part B coverage is optional, 95 percent of those eligible choose to participate in Part B. At the time of Medicare eligibility, individuals will be given the option to enroll in Part B or decline it. Those who decline Part B, but choose to join later, may be subject to higher premiums.

Part B is financed by monthly premiums from those who enroll (about one-fourth of Part B expenses), and by the general revenues of the federal government (about three-fourths of Part B expenses).

• Deductible of $100 per year (1998)
• Monthly Premium of $ 43.80 (1998)
• Copayment is 20 percent of Medicare allowable charge

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2. What is a claim?

Request for reimbursement providers submit to insurance companies for services rendered. It includes the description of services and diagnoses.

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3. How are claims paid?

CMS(previously HCFA) contracts with private insurance companies in the states to process claims and make Medicare payments. These insurance companies are known as intermediaries and carriers. Hospital charges for Medicare beneficiaries are billed by the hospital to the intermediary that pays them. Intermediaries handle claims for Part A services.

Doctors and other suppliers of medical services covered under Part B submit charges directly to a Medicare carrier by "taking assignment." Carriers handle claims for Part B services. The doctor or supplier will receive the portion of the bill paid by Medicare and will bill a beneficiary only for the $100 deductible, and if applicable, a 20% copayment. Doctors and other suppliers who take assignment may not charge more than the amount allowed by the Medicare fee schedule.

Even if the doctor does not take assignment, he or she must send the claim to the Medicare carrier for the beneficiary. Medicare will pay the beneficiary the portion of the bill that is allowable and then they will pay the doctor or supplier directly. Some charges may be higher than the allowable Medicare charge, but the doctor cannot charge more than 15% above the amount allowed by the Medicare fee schedule.

CMS sends a notice to Medicare beneficiaries each time action is taken on carrier processed claims. This notice is called an explanation of Medicare benefits or an EOMB. The EOMB provides you with a record of services received and the status of any Part B deductible.

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4. What is a final action claim?

Non-rejected claim. Claim for which a payment has been made. All disputes have been resolved, and details clarified.

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5. Who are the Medicare beneficiaries?

To be eligible for Medicare, one must be a U.S. citizen living in the U.S. or a foreign national who has applied for legal residency and has lived in the U.S. for a minimum of five years.

There are four categories of Medicare eligibility:

• Social Security/Railroad Retiree: Persons aged 65 or older who are eligible for Social Security or Railroad Retirement benefits. Medicare Part A is automatic and Part B is optional. Medicare Part A becomes available at age 65. For Medicare Part B enrollment can occur three months before, during the month of, and up to three months after a qualified individual’s 65^th birthday.

• Social Security Disability/ESRD Recipients: People under age 65 who meet the eligibility criteria for Social Security Disability can qualify for Medicare. However, individuals must first be entitled to Social Security benefits for 24 successive months in order to get Medicare. Thereafter, Medicare Part A is automatic and Part B is optional. In addition, individuals with End Stage Renal Disease (ESRD) are also eligible for Medicare.

• Voluntary Enrollee:  Persons age 65 or older who are not qualified for Social Security can purchase Medicare coverage. A person who buys Medicare has the option of purchasing both Medicare Part A and Part B, or only Part B.

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6. What is not covered by Medicare?

Although Medicare provides coverage for a wide range of acute services there are many gaps in its coverage. In addition, there are a number of cost sharing requirements for Medicare beneficiaries. The gaps in coverage and required cost-sharing translate into direct out-of-pocket expenses for Medicare beneficiaries (hence, no claim records), unless they have supplemental insurance coverage, known as medigap insurance.

PART A-Hospital Insurance

• Hospital Deductible: One deductible is charged per hospital admission ($764 in 1998). Readmission within a 60-day period does not trigger another deductible.
• Hospital Coinsurance: From the 61^st day to the 90^th day of hospitalization, beneficiaries are the responsible for ¼ of the hospital deductible ($191 in 1998); from the 91^st through the 150^th day of hospitalization, coinsurance equals ½ of the hospital deductible ($382 in 1998).
• Hospital Coverage Beyond 150 Days: Medicare does not pay for hospital coverage beyond 150 days.
• Skilled Nursing Facility (SNF) coinsurance: Daily coinsurance for the twenty-first through one-hundredth day of SNF care ($95.50 in 1998).
• SNF Care Beyond 100 Days: Medicare does not pay for SNF care beyond 100 days.
• Home Health Care: To qualify for Medicare home health coverage, a physician must certify that the care is medically necessary and that the beneficiary is homebound and in need of only intermittent or part-time skilled care. Medicare does not pay for daily home health care services beyond 2-3 weeks.
• Inpatient Psychiatric Care: Medicare does not pay for inpatient psychiatric care beyond 190 days.
• Long-term Custodial Care: Medicare does not pay for nursing home care, adult day care or respite care.
• Medical Care Outside the U.S.: Medicare does not pay for medical care outside of the U.S. except for certain limited services furnished in Canada and Mexico.

PART B-Medical Insurance

• Deductible: $100 annual deductible. Beneficiaries must pay the first $100 of cost of Part B services each year.
• Coinsurance: Twenty percent coinsurance for approved Part B services. (For example, if Medicare approves $100 for an office visit, the beneficiary coinsurance will be $20.).
• Balanced Billing: Physicians who do not agree to accept Medicare's approved reimbursement (these are known as non-participating physicians) may charge beneficiaries up to 15% above the Medicare fee schedule amount.
• Outpatient Prescription Drugs: Beneficiaries generally must pay for all outpatient prescription drug costs.
• Preventive Care Services: Routine physical exams, routine foot care, and most immunizations are not covered.
• Routine Eye Exams or the Cost of Hearing Aids and Eyeglasses are not covered.
• Cosmetic Surgery is generally not covered.

Complete coverage info. can be found at: http://www.cms.hhs.gov

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7. What kind of data can I get from CMS?

CMS(previously HCFA) is a medical insurance company. Therefore, the data available are claims and records of services paid for.

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8. What types of files are there (categories)?

• Research Identifiable Files (RIFs)
• Public Use Files (PUFs)
• Beneficiary Encrypted Files (BEFs)
• Public Use Files (PUFs)

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9. What are Research Identifiable Files (RIFs)?

Research Identifiable Files (RIFs) contain person-specific data on Medicare providers, beneficiaries, and recipients including individual identifiers such as UPIN (Universal Physician ID Number), name, or social security number, or other elements that would permit the identity of a beneficiary or physician to be deduced (e.g., date of birth, age, race,sex, residence, ZIP code). Data with beneficiary or physician identifiers are subject to the Privacy Act and other Federal government rules and regulations. As such, the information is confidential and is to be used only for reasons compatible with the purpose(s) for which the data are collected. CMS(previously HCFA) employs strict security measures to safeguard individual privacy.

CMS data release policies seek to ensure that files containing physician and/or beneficiary identifiers are used only when necessary and in accordance with disclosure provisions of the Privacy Act. Researchers need to submit a written request, study plan or protocols, evidence of funding, and Data User Agreements (DUA) to CMS for review. If CMS approves the data file releasing, researchers need to pay the cost incurred in the processing of data. This means the researchers need to have the significant resources to obtain these data files.

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10. What are Public Use Files: Beneficiary Encrypted Files (BEFs)?

CMS(previously HCFA) creates the BEFs by encrypting/blanking/ranging all identifiers from the associated RIFs. Both BEFs and RIFs have the same record unit, same year available, same file updating schedule, and similar data structure (except for the encrypted variables). CMS requires that appropriate order form, signed DUA, and fees be sent before releasing the BEFs. Compared with RIFs, BEFS are similar in price, but easier to obtain than RIFs. Four types of BEFs can be obtained from CMS: SAFs, Expanded Modified MedPAR Files, Physician/Supplier Part B File, and the Denominator record.

Beneficiary-encrypted SAFs for inpatient, outpatient, HHA, SNF, and Hospice are available in three different versions: 5%, 100%, and State. The 5% sample is created based on selecting records with 05, 20, 45, 70, or 95 in position 8 and 9 of the HIC number. Provider numbers and beneficiary claim numbers are encrypted in the 5% files to protect the privacy of individuals. In the 100% and State file, the provider number is encrypted and the beneficiary claim number is blocked out. For Beneficiary-encrypted DME SAF, only 5% is available. For Beneficiary-encrypted Physician/Supplier Part B File, 5% and State are available.

Beneficiary-encrypted Expanded Modified MedPAR files contain records for 100% of Medicare beneficiaries who used hospital inpatient services or SNF services. The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the six position Medicare billing number. Three Beneficiary-encrypted Expanded Modified MedPAR files are available: MedPAR National, MedPAR State, MedPAR SNF.

The PUFs catalog details which variables have been blanked/encrypted.

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11. What are Public Use Files: Public Use Files (PUFs) ?

Public Use Files are aggregated data that for most instances are not covered by the Privacy Act as there is no beneficiary- or physician-level data in these files. Some of the files are summarizations of information found in the Research Identifiable Files and some contain information that cannot be derived from any other source. For a complete description of these files, download a PUFs catalog at : http://www.cms.hhs.gov/researchers/statsdata.asp . Under the header "Public Use Data Files (PUFs)" you’ll see a subheader to"Download a PUFs catalog."

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12. Why would I want to use Medicare data for my research?

There are many strengths associated with Medicare data:

• Population-based
• Large sample sizes allow ability to detect rare events
• Not subject to recall bias
• Linkage of beneficiaries across years (for longitudinal studies) and datasets is possible

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13. What are some limitations of Medicare data I need to consider?

There are several limitations of Medicare data:

• In general, the exclusion of persons under age 65
• The exclusion of individuals over 65 not enrolled in Medicare
• Exclusion of claims paid by a source other than Medicare
• Data (variables) were collected for the purpose of making healthcare payments, not for research

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14. What are some limitations of each category of files?

RIFs:

• must go through the most rigorous process to obtain the data

BEFs:

• a lot of information is encrypted – zip codes blank, lowest level of cross-sectional analysis would be the county level
• not cross-referenced

PUFs:

• No patient-or physician- level data

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15. What are the advantages of each category of files?

RIFs:

• all variables are present – can do zip code level analysis

BEFs:

• easier to obtain than RIFs – easier to find prices

PUFs:

• least expensive – some can be downloaded for free from CMS’s website
• some contain information that cannot be derived from a BEF or PUF

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16. What are the files contained under theses categories (BEFs and RIFs only)?

Denominator Record

The Denominator Record contains some basic demographic and enrollment information about each beneficiary enrolled during a calendar year.

Standard Analytic Files (SAFs) – Part A & Part B – Claims data

The Standard Analytical Files (SAFs) are generated by processing the National Claims History (NCH) file’s raw claims through final action algorithms that match the original claim with adjusted claims to resolve any adjustments. SAFs are available for each institutional claim type (inpatient, outpatient, SNF, hospice, or HHA) from 1989 onward. Non-institutional Part-B physician/supplier SAFs are available beginning with 1991 for 100% laboratory services, 100% DME, and a 5% beneficiary sample (contains all final action claims submitted for the 5% of beneficiaries included in sample). The record unit of SAFs is the final action claim. The files are annual and are produced quarterly.

Stay Records File (MedPAR) – stay level data

The Medicare Provider Analysis and Review (MedPAR) file contains inpatient hospital and SNF final action stay records. Each MedPAR record represents a stay in an inpatient hospital or SNF. A "stay" record summarizes all services rendered to a beneficiary from the time of admission to a facility through discharge. Each MedPAR record may represent one claim or multiple claims, depending on the length of a beneficiary's stay and the amount of inpatient services used throughout the stay. Prior to June 1995, MedPAR was created from claims from the Medicare Assurance System. Since June 1995, the inpatient and SNF claims from the NCH file became the source for the MedPAR file. The record unit of MedPAR file is the hospital or SNF stay. Annual MedPAR files, identified by the file update date, are available for fiscal years and calendar years 1984 forward.

National Claims History (NCH) Files

The purpose of the National Claims History (NCH) files is to house all processed institutional and non-institutional claims data from the Common Working File (CWF). The NCH file contains every claim submitted, including all adjustments and interim claims. Institutional data are available beginning in 1988, and complete physician/supplier data are available beginning in 1991. Although the CWF file was not adopted until 1991, claim records from prior years were reformatted into NCH structure and used to populate 1986 to 1990 NCH files. Since NCH files include all adjustment claims and interim claims, the researchers must create decision rules and write algorithms to account for claim adjustments when analyzing this file. As an aside, the NCH files are the only files that provide access to 100 percent of physician/supplier claims data. The record unit for NCH file is the claim. The file is updated monthly and annually.

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17. How do I find articles that use Medicare data?

You could start at: http://www.cms.hhs.gov/researchers/statsdata.asp

Another great place to start is Medline or Healthstar if you have access. Keywords suggestions to start your search: "Medicare" or "claims."

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18. How does the Privacy Act affect my access to Medicare data?

CMS(previously HCFA) data release policies seek to ensure that files containing physician and/or beneficiary identifiers are used only when necessary and in accordance with disclosure provisions of the Privacy Act. Researchers need to submit a written request, study plan or protocols, evidence of funding, and Data User Agreements (DUA) to CMS for review. CMS will then approve or reject the data file release.

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19. Why are there people under age 65 in my Medicare dataset?

There are other ways to become eligible for Medicare besides turning 65. See "Who are the Medicare beneficiaries?"

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20. Can I identify the referring physician for an inpatient stay using the Inpatient claims?

Not reliably: The Inpatient claims have changed format and content over the past 4 years. The current Inpatient claims data contain the field called "Attending UPIN". The current definition for this field requires the provider (hospital) to report the following:

The unique identification physician number (UPIN) of the physician who would normally be expected to certify and re-certify the medical necessity of the services rendered and/or who has primary responsibility for the beneficiary's care and treatment. This may or may not be the "Referring Physician". This data field is not stored in the MedPAR.

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21. Can I identify the attending physician for an inpatient stay using the Inpatient claims?

Yes. This is a field found on the inpatient SAF filled in by the provider and recorded on the UB92. The attending physician may also be the referring physician. See FAQ 20 above. This data field is not stored in the MedPAR

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21A. Can I identify the operating/performing physician for an inpatient stay using the Inpatient claims?

Yes. This is a field found on the inpatient SAF filled in by the provider and recorded on the UB92. The operating physician may also be the same as the attending physician.

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22. Are prescriptions covered?

Medicines given in an inpatient setting are paid for by Medicare. Prescriptions given to outpatients are not covered.

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23. Can I study drugs?

Unless they are prescribed during an inpatient stay, drug prescriptions are not covered by Medicare and hence could not be studied. Also, during inpatient stays, very few, if any, prescriptions are coded. However, the Medicare Beneficiary Survey (MCBS) includes self-reported information about a beneficiary’s drug utilization and may be adequate for your needs. More information on this survey can be found at: http://cms.hhs.gov/mcbs/default.asp

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24. Is insulin covered?

No. See "Are prescriptions covered?".

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25. How much do files cost?

The Public Use Files catalog contains prices for PUFs and BEFs. You can submit a formal request for a cost estimate for any RIFs you are interested in obtaining.

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26. What factors influence the cost of files?

• Submission of finder files
• Cross-referencing
• Number of years of data desired
• Size of cohort

All of these factors influence processing time, which is directly related to cost.

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27. Why aren’t Research Identifiable Files (RIFs) in the Public Use Files (PUFs) catalog?

There is more involved in the process of obtaining RIFs than can be dealt with using a catalog order form. See "How does the Privacy Act affect my access to Medicare data?".

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28. Is there any reason I would need a Public Use File (PUF) if I already have a Beneficiary Encrypted File (BEF) or Research Identifiable File (RIF)?

Yes. Some files provide unique information not found in a BEF or RIF (e.g., Provider of Services files) and others are summary files with limited variables that save work and are easier to work with.

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29. What’s the difference between the Inpatient SAF and the MedPAR files?

The unit of analysis for the inpatient SAFs is a claim and for the MedPAR it is a stay (a stay may have several claims). With some manipulation, you can turn an inpatient SAF into a MedPAR.

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30. If I need to choose between MedPAR and the inpatient SAF, which would you recommend?

It depends. For short stay hospitals, it is estimated that 95% of stays have only one claim associated with them. For long stay hospitals, there are approximately 1.2 claims per stay. Hence, the unit of analysis is virtually the same between the two files. The format they come in may be a factor in your decision. The typical format of the inpatient SAF is as a fixed block multiple linked file. This means there is a fixed (flat) portion of the file and normalized trailers that can be linked to them. The fixed file and trailers are all fixed block and are easier to read in for most platforms. The MedPAR, although it is one file, usually comes packed and is variable length, a more difficult format to read in. As far as the information contained in them, the SAF has more detail information, including attending physician. So, the answer is that it depends on your needs.

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31. If I want outpatient data, what do I ask for?

Both the Outpatient file and the Physician/Supplier Part B data files.

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32. What is the difference between Part B Physician/Supplier data and Outpatient data?

The Physician/Supplier data contain 1500 form claims related to services performed by physicians (non-institutional). The Outpatient file contains UB-92 claims related to institutional services.

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33. Why isn’t the residence information (e.g. county code) found in the denominator file and claims files completely in agreement when I link them?

In the claims files, the residence information is recorded at the time of treatment. In the Denominator file, the information is current as of the time the file is finalized. Hence, if a beneficiary moves between treatment and the time the Denominator file is finalized, residence information between the files will not match.

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34. How are the 5% samples selected?

The 5% beneficiary sample is created based on selecting records with 05, 20, 45, 70, or 95 in position 8 and 9 of the Health Insurance Claim (HIC) number.

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35. How do I link Medicare data with my data?

You need to submit what’s called a "finder file" to CMS(previously HCFA). This contains the identifying information of the individuals in your study that CMS will use to match cases in their datafiles. The identifying information can be either Health Insurance Claim numbers (HICs), SSNs, or the combination of name, date of birth, and sex.

If you submit HICs, this is called a finder file. This is CMS' unique identifier of beneficiaries and you can be assured that the cases you obtain using the finder file will be the same individuals in your data.

If you submit SSNs, CMS will perform a numeric search and give you a list of beneficiaries that have the same SSN. Then, because SSN is not always a unique identifier, you select the cases that match your patient sample.

Finally, if you have only name, date of birth, and sex of the members of your dataset, you can request an alpha search. Using several search algorithms, scores up to 127 are assigned to each potential match. You will receive a partial vital statistics file containing the individuals having the highest match score for each name, DOB and sex you submitted. Using this information, you will hopefully be able to identify the cases that are in your sample.

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36. What’s a HIC?

An acronym for Health Insurance Claim number, a HIC is an unique identifier of a beneficiary. It usually consists of the nine-digit social security number (SSN) and two-character code (BIC) that stores the relationship between the beneficiary and the primary holder of the associated SSN. There are exceptions, though. For former railroad employees, the HIC could be their railroad board number. It is also called the HICAN (High Can) or HICBIC (HICK BICK).

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37. What’s a BIC?

Short for the Beneficiary Identity Code, it is a two-digit alpha-numeric code that tells the relationship between the patient and the primary beneficiary.

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38. What happens when a wife becomes a widow?

Her BIC will change. It will no longer be the code for wife, but instead will be for widow, if she was in fact drawing social security benefits through her husband’s SSN.

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39. What is BIC equating?

A HIC is a unique identifier, but an individual may change HICs throughout their life. One way of doing this is if the BIC changes (e.g. person may go from spouse to widow), so BIC equating is the way of identifying several HICs as belonging to the same individual.

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40. Does BIC equating cost extra? Do I have to ask for it?

No, it is automatic and free.

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41. How do I link Medicare datasets?

Research Identifiable Files (RIFs) and 5% Beneficiary Encrypted Files (BEFs) can be linked by the Health Insurance Claim (HIC) number, the unique identifier CMS(previously HCFA) assigns to a beneficiary. The HIC is encrypted in the BEF, but it is a systematic encryption, allowing for linking of claims to one beneficiary. However, HICs can change, and BEFs have not been cross-referenced (see "What is cross-referencing?").

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42. Do HICs ever change?

Yes. A few examples:

• A widow determines she could be drawing better benefits as a widow instead of based on her own work history. In order to do this, she needs to change her SSN to that of her late husband. This would result in her receiving a new HIC also.
• Someone has been fraudulently using a beneficiary’s SSN. To protect themselves, the beneficiary has to change their SSN, and hence their HIC.
• A railroad employee had been drawing benefits based on their SSN, but realized their benefits would be better based on their designation as a former railroad employee. The HIC would then change to the railroad number, but the SSN would remain unchanged.

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43. How common is changing HICs?

It is estimated that 1-3% of beneficiaries change HICs in a given year.

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44. What do I do about it?

When a researcher intends to identify all claims for a beneficiary or link beneficiaries across datasets, cross-referencing is necessary. You must ask for cross-referencing at the time of processing of a data request.

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45. What is cross-referencing?

Cross-referencing is the act of tracking an individual’s various HICs across time, resulting in the ability to link their claims despite the fact that their unique identifier, the HIC, has changed.

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46. For longitudinal or retrospective studies, what do I need to consider?

• Are the same data available in the same format over all the years of my study?
• If I need to link beneficiaries across years/datasets, have I asked for cross-referencing?
• Is the event/procedure I am interested in coded the same across all the years?
• Is the event/procedure I am interested in studying treated in the same setting across all the years (e.g. has it always been dealt with in a outpatient setting?)?
• Has the event/procedure been covered by Medicare in all the years I’m interested in (e.g. colo-rectal screening was not covered until just recently)?

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47. How much will the data cost me to acquire?

For BEFs and PUFs, a catalog is available (See "Where can I get a PUFs catalog?"). For RIFs, a written request for a cost estimate can be submitted to CMS(previously HCFA).

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48. Where can I get a PUFs catalog?

Go to: http://www.cms.hhs.gov/researchers/statsdata.asp Under the header: "Public Use Data Files (PUFs)" you’ll see a subheader "Download a PUFs catalog."

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49. Can I get the data at a discounted price?

No. There are computational costs involved in fulfilling a data request that CMS(previously HCFA) needs to recover. CMS is required to obtain compensation for its costs incurred in the processing of data.

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50. How are costs determined?

• The number of records in the finder file
• The number of records searched
• The method of retrieval
• Other factors that impact resources

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51. I’m on a very tight budget - are there any data that are free or very low-cost?

There are some Public Use Files (PUFs) available for downloading at CMS' web site (http://www.cms.hhs.gov/researchers/statsdata.asp ) and those PUFs available through the catalog only are generally low-cost (range between $150 - $2000/year).

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52. What’s the difference between a variable length file and a fixed length-multiple linked file?

Variable length files are intended for use on a mainframe and fixed length multiple linked files are intended for non-mainframe systems.

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53. Can I study denials?

Although the National Claims History (NCH) file stores claims before they’ve been resolved, some claims may not even make it to CMS(previously HCFA) because they are filtered through a carrier/fiscal intermediary first. Of the final action claim files, only the Physician/Supplier Part B contains any record of denial.

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54. How do I study a particular condition/disease?

DRGs as well as ICD-9 codes (used in Part A datafiles) and HCPCs (Health Care Procedure Codes – used in Physician/Supplier Part B file and outpatient SAF) are captured in CMS(previously HCFA) files. You would have to go to those manuals to determine which codes are needed, as well as determine the setting in which the condition is treated (e.g., inpatient) in order to be able to request the appropriate file(s) and cases. Refer to the Data Compendium and Statistical Supplement.

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55. Can I perform county-level analysis with SAF data? I see that variable is optional.

Although it is optional, it is very rarely missing/invalid (less than .01% are unavailable).

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56. What is the smallest level of detail not blanked/encrypted in a Beneficiary Encrypted File (BEF)?

County.

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57. Can I get a 100% (National) Physician/Supplier Part B file?

No, that file is not available. The file is simply too large. It is estimated to be several hundred gigabytes.

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58. Will I be able to find all claims for an individual within one BEF/am I able to link beneficiaries across BEFs?

In the 100% BEF files, HIC is blanked out. This means there is no way of connecting claims/linking datasets. In the 5% sample, however, the HIC is systematically encrypted. In this case, for at least 97% of these cases, yes, you can find all their claims or link beneficiaries across files. But, the BEFs have not been cross-referenced. If a beneficiary changes their HIC midway through a year and receives care using both HICs, there is no way of linking those episodes to that one beneficiary.

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59. Can I access data dictionaries?

Yes, we can send them to you. We hope they will be online someday soon.

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60. Can I figure out Medicare data without taking a training class?

Yes, but it will be more difficult.

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61.What kind of training courses are offered and when are they offered?

At this time a short seminar is offered that is aimed at those completely unfamiliar with Medicare data. It introduces researchers to the kinds of research that can be conducted with Medicare data.

A half-day course is also being offered. It’s computer-based and is aimed at researchers who want to look at Medicare data and begin manipulating it.

The next courses will be at the CCQE meeting in October (http://www.ccqe.com/resdac.htm) .

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62. What steps do I need to take to request RIFs?

The following should be submitted to CMS(previously HCFA):

A written request that contains the following:

• The purpose for which the data are needed
• A description of the methodology
• Delineation of data requirements
• Criteria for data selection or searches

Study plan or protocol that does the following:

• Elaborates on the purpose for which the data will be used and outline the scientific methodology that will be used to perform the project

Evidence of funding

Data use agreement (DUA)

CMS will then determine the whether the following is true:

• The purpose cannot reasonably be accomplished unless the record is provided in individually identifiable form
• The purpose is of sufficient importance to warrant the effect and/or risk on the privacy of the individual
• There is reasonable probability that the objective for the use would be accomplished

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63. Are there any sample protocols I can look at?

Yes, we can send them to you.

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64. What’s a benefit period? (from http://www.cms.hhs.gov)

Coverage for care in hospitals and skilled nursing facilities is measured in "benefit periods." In each benefit period, there are limits to the number of days Medicare will help pay for inpatient hospital and skilled nursing facility care. Once the limit is exceeded, the beneficiary is responsible for all charges for each additional day of care.

A benefit period begins the day of admission to a hospital. It ends when the beneficiary has been out of a hospital or skilled nursing facility for 60 straight days, including the day of discharge. It also ends for those in a skilled nursing facility who have not received skilled nursing care for 60 straight days.

Once a benefit period has ended, a new benefit period begins and hospital and skilled nursing facility benefits are renewed. There is no limit to the total number of benefit periods.

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65. When does coinsurance kick in?

61^st –90^th day of inpatient treatment during a benefit period.

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66. What are lifetime reserve days?

60 non-renewable days that can be used over and above the 90 covered days of hospitalization during a benefit period. For instance, if a person stays in the hospital 95 days during a benefit period, he/she has only 55 lifetime reserve days left.

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67. Is MedPAR one file?

No. There are three MedPAR files: Long-Stay Hospital, Short-Stay Hospital, and Skilled Nursing Facility (SNF). You must request the ones you want.

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68.What does MedicareGuru do?

MedicareGuru provides assistance to researchers in the non-profit sector, private sector, university settings, and some government sites who wish to use Medicare/Medicaid data for their research. Based on a description of their study, we will help them understand what kind of data is available to help them answer their research questions.

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69. What doesn’t MedicareGuru do?

We will asssist in designing a study for a researcher, but we will not provide them with any data.

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70. Can you do analysis for me?

We can provide a limited amount of analysis services.

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71. Do you have data there?

No.

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72. Can you send/email me some data?

Even if we had access to data, due to privacy/security issues we would not be able to disseminate it to researchers electronically or any other way.

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73. What are carriers?

They handle Part B claims. Doctors and other suppliers of medical services covered under Part B submit charges directly to a Medicare carrier by "taking assignment." Carriers handle claims for Part B services. The doctor or supplier will receive the portion of the bill paid by Medicare and will only bill the individual for the $100 deductible, and if applicable, a 20% copayment.

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74. What are Fiscal Intermediaries (FIs)?

They handle Part A claims. Hospital charges for Medicare beneficiaries are billed by the hospital to the intermediary that pays them.

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75. What are the final action algorithms for Institutional claims?

You can view the final action algorithms for Institutional claims right here on the MedicareGuru site.

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76. What are the final action algorithms for Non-Institutional claims?

You can view the final action algorithms for Non-Institutional claims right here on the MedicareGuru site.

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77.  How do I identify ALLOWED & DENIED Non-Institutional (Part B) Claims?

ALLOWED CLAIMS are identified by checking the Carrier Claim Payment Denial Code in the fixed portion of the record for the values of '1' through '9' or 'A' or 'B'.

DENIED CLAIMS are identified by checking the Carrier Claim Payment Denial Code in the fixed portion of the record for the values of '0', 'D', 'P', 'T', 'U', 'V', 'X' or 'Y'.

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78. How do I identify ALLOWED & DENIED Non-Institutional (Part B) Line Items (Specific Services)?

ALLOWED LINE ITEMS are identified as follows:

(1) Line processing Indicator Code is equal to 'A'

(2) Line processing Indicator Code is equal to 'R' or 'S' and the Line Allowed Charge Amount greater than ‘0’.

DENIED LINE ITEMS are identified as follows:

(1)  Line Processing Indicator Code is equal to 'B', 'C', 'D', 'I', 'L', 'M', 'N', 'O', 'P', 'T', 'U', 'V', 'X', 'Y', 'Z'

(2)   Line Processing Indicator Code is equal to 'R' or 'S' and the Line Allowed Charge Amount are equal to’ 0’.

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79. How is Medicare reimbursement calculated for physicians?

There are a number of considerations when attempting to determine Medicare payment to physicians. The following identifies these and the methods of reimbursement calculation:

• WHEN MEDICARE IS THE PRIMARY PAYER

• Participating provider/assigned claims: (See the codes defined in the element called ‘Line participating Indicator code’ in the Physician/Supplier record specifications.

(FEE SCHEDULE (ALLOWED CHARGE) - DEDUCTIBLE) * .80 = PAYMENT

DEDUCTIBLE & COINSURANCE (20%) MAY BE PAID BY EITHER A SECONDARY (MEDIGAP PLAN) OR THE BENEFICIARY.

• Non-Participating provider/assigned claims: (See the codes defined in the element called ‘Line participating Indicator code’ in the Physician/Supplier record specifications.

(FEE SCHEDULE * .95) - (DEDUCTIBLE) * .80 = PAYMENT

• Non-Participating provider/unassigned claims: (See the codes defined in the element called ‘Line participating Indicator code’ in the Physician/Supplier record specifications.

(FEE SCHEDULE * .95) - (DEDUCTIBLE) * .80 = PAYMENT BUT NON-PARTICIPATING/UNASSIGNED CLAIMS CAN CHARGE THE BENEFICIARY UP TO 115% THE (FEE SCHEDULE* .95). SOME STATES HAVE LOWER LIMITS, e.g., NYC is 105%.

DEDUCTIBLE AND COINSURANCE MAY BE PAID BY EITHER A SECONDARY (MEDIGAP PLAN) OR THE BENEFICIARY.

• WHEN MEDICARE IS SECONDARY PAYER

1. Working Aged (MSP Code = A, B, G) – Medicare will pay the lower of the two based on the calculations below:

A. Calculate MSP involvement reimbursement;

FEE SCHEDULE (ALLOWED CHARGE) – OTHER PAYER REIMBURSEMENT = MSP REIMBURSEMENT

B. Calculate the normal Medicare primary reimbursement:

(FEE SCHEDULE - DEDUCTIBLE) * .80 = NORMAL REIMBURSEMENT

(MEDICARE WILL PAY THE LOWER OF THE TWO).

2. Not working Aged (MSP Code not equal to A, B, G) – e.g., auto no fault, black lung, VA, etc.:

MEDICARE FEE SCHEDULE (ALLOWED CHARGE) – OTHER PAYER AMOUNTS- CASH DEDUCTIBLE) * .80 = MEDICARE REIMBURSEMENT

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80. How can I identify the different Institutional provider types?

See the following table:

Institutional Provider Ranges and Groupings - By Range Code

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81. Where can I go for more information?

Try these Web sites:

http://www.cms.hhs.gov

http://www.aarp.org/monthly/medicare/thefacts.htm

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82. How are Unique Physician Identification Numbers (UPIN) allocated based on the Physician Credential Codes?

The UPIN is a unique identifier assigned to each non-institutional provider of health care services.

UPIN are assigned as follows:

1. Physicians (Medical Doctors) begin with A - M
2. Limited License Practitioners, e.g., Chiropractors, Dentist, etc, begin with T - V
3. Non-Physician Practitioners, e.g., Anesthesia Assistants, Physician Assistants, Clinical Nurse Practitioners, etc, are assigned P -S
4. Group Entities, e.g., Ambulance, Independent Physiological Lab, etc, are assigned W - Y
5. See below for the applicable Credential Codes:

AA = Anesthesia Assistant
AMB = Ambulance Service Supplier
ASC = Ambulatory Surgical Center
AU = Audiologist
CH = Chiropractor
CNA = Certified Nurse Anesthetist
CNM = Certified Nurse Midwife
CNS = Certified Clinical Nurse Specialist
CP = Clinical Psychologist
CSW = Clinical Social Worker
DDM = Doctor of Dental Medicine
DDS = Doctor of Dental Surgery
DO = Doctor of Osteopathy
DPM = Podiatrist
FNP = Family Nurse Practitioner
GRP = Group
IDF = Independent Diagnostic Facility
IPL = Independent Physiological Lab
LAB = Laboratory
MD = Medical Doctor
MSC = Mammography Screening Center
NP = Nurse Practitioner
OD = Doctor of Optometry
OT = Occupational Therapist
PA = Physician Assistant
PHS = Public Health Service
PSY = Psychologist
PT = Physical Therapist
PXS = Portable XRay Supplier
RNA = Certified Registered Nurse
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83. How are physician services identified?

Physician Services are identified by checking Line HCFA Provider Specialty Code for the values of 00 through 41, 44, 46, 48, 66, 70, 76 through 79, 81 through 86, 90 through 94, 98 or 99. If the trailer has been identified as a Physician Service by the Line HCFA Specialty Code, but the Line HCPCS Code is not numeric the trailer is dropped.

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84 Under which circumstances are line item trailers for physician services excluded?

In order not to overstate the episode of care counts, line item trailers are excluded if they meet any of the following conditions.

1. General:

           If  the Line Item has been denied (see Medicare FAQ # 78 for this definition)

2. Surgical claims:

a. If either the Line HCPCS Initial Modifier Code or Line HCPCS Second Modifier Code is a '55' (Postoperative Management) or '56' (Preoperative Management).

b. If either the Line HCPCS Initial Modifier Code or Line HCPCS Second Modifier Code contained a value of '62' (Two Surgeons), only the first line item (record) of the claim is kept, subsequent occurrences of '62' for the same claim are dropped.

                    c. If the Line HCFA Type of Service Code contains a value of '8' (Assistant Surgeon).

3. Radiology and Clinical Lab claims:

1. If either the Line HCPCS Initial Modifier Code or Line HCPCS Second Modifier Code is a 'TC' (Technical Component).

4. Miscellaneous claims:

1. If the Line HCFA Type of Service contains a value of 'F' (ASC Facility Charge). This is the charge of the Ambulatory Surgical Center (ASC) as the place of service.
2. If the HCPC code is DME (uses a HCFA defined procedure to identify DME HCPC Codes) and the Carrier Line MTUS Indicator Code is not ‘3' (a service). This will eliminate DME records that have a Physician Specialty but are not classified as a service (such as Oxygen units).

Note: If counting services by HCPCS Codes, B. above would not apply, and should not be used.

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85. What business rules apply when processing physician claims data?

1. If the HCPC is between 00100 and 01999 (Anesthesia) then the Line Service Count is set to 1. This corrects any potential mis-coding on the part of the carriers by substituting time units in place of the number of services. This applies to all years.

2. If the HCPC is between 95000-95199, 97110-97750, or 90780-97799 and the Line Service Count is > than 1, then the Line Service Count is set to 1. These codes have been identified as having been mis-coded in past years by the carriers.

3. If the HCPC is between 77419-77430 and the Line Service Count is ‘5', then the Line Service count is set to 1. These codes have been identified as having been mis-coded in past years by the carriers.

4. If Line Allowed Charge Amount is equal to ‘0' then the Line Service Count is set to 0.

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86. How can Non-Institutional Type of Services (TOS) be determined?

There are two TOS codes: the BERENSON-EGGERS TOS (BETOS) codes and the HCFA TOS codes. These are explained and defined as follows:

1. Determination of categories by BETOS Codes: General Categories (see below for detail)

(1) Clinical Laboratories: T1A through T1H

(2) Durable Medical Equipment :    D1A through D1F

(3) Anesthesia: PO

(4) Ambulance: O1A

(5) Physician: All Other BETOS Codes

THE FOLLOWING ARE THE BERENSON-EGGERS TYPE OF SERVICE (BETOS) CODES FOR EACH HEALTH CARE FINANCING ADMINISTRATION COMMON PROCEDURE

CODING SYSTEM (HCPCS) PROCEDURE CODE.

THE BETOS CODING SYSTEM WAS DEVELOPED PRIMARILY FOR ANALYZING THE GROWTH IN MEDICARE EXPENDITURES. THE CODING SYSTEM COVERS ALL HCPCS CODES; ASSIGNS A HCPCS CODE TO ONLY ONE BETOS CODE; CONSISTS OF READILY UNDERSTOOD CLINICAL CATEGORIES (AS OPPOSED TO STATISTICAL OR FINANCIAL CATEGORIES); CONSISTS OF CATEGORIES THAT PERMIT OBJECTIVE ASSIGNMENT; IS STABLE OVER TIME; AND IS RELATIVELY IMMUNE TO MINOR CHANGES IN TECHNOLOGY

OR PRACTICE PATTERNS.

BELOW ARE THE BETOS CODES AND DESCRIPTIONS:

(1) EVALUATION AND MANAGEMENT .

M1A OFFICE VISITS - NEW

M1B OFFICE VISITS - ESTABLISHED

M2A HOSPITAL VISIT - INITIAL

M2B HOSPITAL VISIT - SUBSEQUENT

M2C HOSPITAL VISIT - CRITICAL CARE

M3 EMERGENCY ROOM VISIT

M4A HOME VISIT

M4B NURSING HOME VISIT

M5A SPECIALIST - PATHOLOGY

M5B SPECIALIST - PSYCHIATRY

M5C SPECIALIST - OPHTHALMOLOGY

M5D SPECIALIST - OTHER

M6 CONSULTATIONS

(2) PROCEDURES

P0 ANESTHESIA

P1A MAJOR PROCEDURE - BREAST

P1B MAJOR PROCEDURE - COLECTOMY

P1C MAJOR PROCEDURE - CHOLECYSTECTOMY

P1D MAJOR PROCEDURE - TURP

P1E MAJOR PROCEDURE - HYSTERECTOMY

P1F MAJOR PROCEDURE - EXPLOR/DECOMPR/EXCISDISC

P1G MAJOR PROCEDURE - OTHER

P2A MAJOR PROCEDURE, CARDIOVASCULAR - CABG

P2B MAJOR PROCEDURE, CARDIOVASCULAR - ANEURYSM REPAIR

P2C MAJOR PROCEDURE, CARDIOVASCULAR - THROMBOENDARTERECTOMY

P2D MAJOR PROCEDURE, CARDIOVASCULAR - CORONARY ANGIOPLASTY(PTCA)

P2E MAJOR PROCEDURE, CARDIOVASCULAR - PACEMAKER INSERTION

P2F MAJOR PROCEDURE, CARDIOVASCULAR - OTHER

P3A MAJOR PROCEDURE, ORTHOPEDIC - HIP FRACTURE REPAIR

P3B MAJOR PROCEDURE, ORTHOPEDIC - HIP REPLACEMENT

P3C MAJOR PROCEDURE, ORTHOPEDIC - KNEE REPLACEMENT

P3D MAJOR PROCEDURE, ORTHOPEDIC - OTHER

P4A EYE PROCEDURE - CORNEAL TRANSPLANT

P4B EYE PROCEDURE - CATARACT REMOVAL/LENS INSERTION

P4C EYE PROCEDURE - RETINAL DETACHMENT

P4D EYE PROCEDURE - TREATMENT OF RETINAL LESIONS

P4E EYE PROCEDURE - OTHER

P5A AMBULATORY PROCEDURES - SKIN

P5B AMBULATORY PROCEDURES - MUSCULOSKELETAL

P5C AMBULATORY PROCEDURES - INGUINAL HERNIA REPAIR

P5D AMBULATORY PROCEDURES - LITHOTRIPSY

P5E AMBULATORY PROCEDURES - OTHER

P6A MINOR PROCEDURES - SKIN

P6B MINOR PROCEDURES - MUSCULOSKELETAL

P6C MINOR PROCEDURES - OTHER (MEDICARE FEE SCHEDULE)

P6D MINOR PROCEDURES - OTHER (NON-MEDICARE FEE SCHEDULE)

P7A ONCOLOGY - RADIATION THERAPY

P7B ONCOLOGY - OTHER

P8A ENDOSCOPY - ARTHROSCOPY

P8B ENDOSCOPY - UPPER GASTROINTESTINAL

P8C ENDOSCOPY - SIGMOIDOSCOPY

P8D ENDOSCOPY - COLONOSCOPY

P8E ENDOSCOPY - CYSTOSCOPY

P8F ENDOSCOPY - BRONCHOSCOPY

P8G ENDOSCOPY - LAPAROSCOPIC CHOLECYSTECTOMY

P8H ENDOSCOPY - LARYNGOSCOPY

P8I ENDOSCOPY - OTHER

P9A DIALYSIS SERVICES (MEDICARE FEE SCHEDULE)

P9B DIALYSIS SERVICES (NON-MEDICARE FEE SCHEDULE)

(3) IMAGING

I1A STANDARD IMAGING - CHEST

I1B STANDARD IMAGING - MUSCULOSKELETAL

I1C STANDARD IMAGING - BREAST

I1D STANDARD IMAGING - CONTRAST GASTROINTESTINAL

I1E STANDARD IMAGING - NUCLEAR MEDICINE

I1F STANDARD IMAGING - OTHER

I2A ADVANCED IMAGING - CAT: HEAD

I2B ADVANCED IMAGING - CAT: OTHER

I2C ADVANCED IMAGING - MRI: BRAIN

I2D ADVANCED IMAGING - MRI: OTHER

I3A ECHOGRAPHY - EYE

I3B ECHOGRAPHY - ABDOMEN/PELVIS

I3C ECHOGRAPHY - HEART

I3D ECHOGRAPHY - CAROTID ARTERIES

I3E ECHOGRAPHY - PROSTATE, TRANSRECTAL

I3F ECHOGRAPHY - OTHER

I4A IMAGING/PROCEDURE - HEART,INCLUDING CARDIAC CATHETERIZATION

I4B IMAGING/PROCEDURE - OTHER

(4) TESTS

T1A LAB TESTS - ROUTINE VENIPUNCTURE (NON MEDICARE FEE SCHEDULE)

T1B LAB TESTS - AUTOMATED GENERAL PROFILES

T1C LAB TESTS - URINALYSIS

T1D LAB TESTS - BLOOD COUNTS

T1E LAB TESTS - GLUCOSE

T1F LAB TESTS - BACTERIAL CULTURES

T1G LAB TESTS - OTHER (MEDICARE FEE SCHEDULE)

T1H LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE)

T2A OTHER TESTS - ELECTROCARDIOGRAMS

T2B OTHER TESTS - CARDIOVASCULAR STRESS TESTS

T2C OTHER TESTS - EKG MONITORING

T2D OTHER TESTS - OTHER

(5) DURABLE MEDICAL EQUIPMENT

D1A MEDICAL/SURGICAL SUPPLIES

D1B HOSPITAL BEDS

D1C OXYGEN AND SUPPLIES

D1D WHEELCHAIRS

D1E OTHER DME

D1F ORTHOTIC DEVICES

(6) OTHER

O1A AMBULANCE

O1B CHIROPRACTIC

O1C ENTERAL AND PARENTERAL

O1D CHEMOTHERAPY

O1E OTHER DRUGS

O1F VISION, HEARING AND SPEECH SERVICES

O1G INFLUENZA IMMUNIZATION

(7) EXCEPTIONS/UNCLASSIFIED

Y1 OTHER - MEDICARE FEE SCHEDULE

Y2 OTHER - NON-MEDICARE FEE SCHEDULE

Z1 LOCAL CODES

Z2 UNDEFINED CODES

2. THE CMS-DEFINED TOS CODES, ASSIGNED BY THE PART B CARRIERS, DESCRIBE THE PARTICULAR KIND(S) OF SERVICE REPRESENTED BY THE PROCEDURE. BELOW ARE THE TOS CODES AND DESCRIPTIONS:

1-MEDICAL CARE

2-SURGERY

3-CONSULTATION

4-DIAGNOSTIC RADIOLOGY

5-DIAGNOSTIC LABORATORY

6-THERAPEUTIC RADIOLOGY

7-ANESTHESIA

8-ASSISTANT AT SURGERY

9-OTHER MEDICAL ITEMS OR SERVICES

0-WHOLE BLOOD

A-USED DURABLE MEDICAL EQUIPMENT (DME)

B-HIGH RISK SCREENING MAMMOGRAPHY

C-LOW RISK SCREENING MAMMOGRAPHY

D-AMBULANCE

E-ENTERAL/PARENTERAL NUTRIENTS/SUPPLIES

F-AMBULATORY SURGICAL CENTER (FACILITY USAGE FOR SURGICAL SERVICES)

G-IMMUNOSUPPRESSIVE DRUGS

H-HOSPICE

J-DIABETIC SHOES

K-HEARING ITEMS AND SERVICES

L-ESRD SUPPLIES

M-MONTHLY CAPITATION PAYMENT FOR DIALYSIS

N-KIDNEY DONOR

P-LUMP SUM PURCHASE OF DME, PROSTHETICS, ORTHOTICS

Q-VISION ITEMS OR SERVICES

R-RENTAL OF DME

S-SURGICAL DRESSINGS OR OTHER MEDICAL SUPPLIES

T-PSYCHOLOGICAL THERAPY

U-OCCUPATIONAL THERAPY

V-PNEUMOCOCCAL/FLU VACCINE

W-PHYSICAL THERAPY

Y-SECOND OPINION ON ELECTIVE SURGERY

Z-THIRD OPINION ON ELECTIVE SURGERY

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87. How are non-physician specialties identified?

Non-Physician services are identified by checking the Line HCFA Provider Specialty Code for all Specialties except for Physician Specialties of 00 through 41, 44, 46, 48, 66, 70, 76 through 79, 81 through 86, 90 through 94, 98 or 99.

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88. Under what circumstances are line item trailers for non-physician specialties excluded?

Records are excluded if any of the following conditions are met:

1. If the Line Item has been denied (see FAQ 78 for this definition).
2. If the Line HCPCS Code is 'G0008' (Administration of Influenza Virus Vaccine) or '90724' (Influenza Virus Vaccine). These codes are eliminated due to the skewing of the statistics when they are present in the data, primarily in Public Health/Welfare Agencies.
3. If the Line NCH BETOS code is between 'D1A' and 'D1F'. This is to eliminate Durable Medical Equipment from the analysis.
4. If Line HCFA Type of Service Code contains a value of '8' (Assistant Surgeon). Applies for Surgical HCPCS only. This condition should not occur for Non-Physician services.
5. If Line HCFA Type of Service contains a value of 'F' (ASC Facility Charge). This is the charge of the Ambulatory Surgical Center (ASC) as the place of service.

Note: Items (2) and (3) above are rules that may or may not be appropriate for other applications using Part B data. If counting services by HCPCS Codes items (4) and (5) above would not apply, and should not be used.

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89. Which business rules apply when processing non-physician specialties?

1. If the HCPCS Code is between 00100 and 01999, 95000 and 95199, 97110 and 97750, or 90780 and 97799, then the Line Service Count is set to ‘1.’ These HCPCS Codes should not appear in Non-Physician services.

2. If the HCPCS is between 77419 and 77430 and the services count is equal to ‘5', then the Line Service Count is set to '1'. These HCPCS Codes should not appear in Non-Physician services.

3. If the Line Item is denied the Allowed Charge Amount and the Line Service Count is set to '0'.

4. Previous to 1995, no Ambulance Extra Mileage HCPCS Codes were in effect. In 1995, Codes A0380, A0390 and A0888 were established to depict Extra Mileage Ambulance Services.

5. The following corrects mis-coding by the Carriers for the periods 1991-1994 for Ambulance data:

1. HCPC A0010 - If Line Service Count > 2 Move 1 to Line Service Count
2. HCPC A0020 - Move 1 to Line Service Count
3. HCPC A0021 - Move 1 to Line Service Count
4. HCPC A0040 - move 1 to Line Service Count
5. HCPC A0080 - Move 1 to Line Service Count
6. HCPC A0090 - Move 1 to Line Service Count
7. HCPC A0150 - If Line Service Count > 2 move 1 to Line Service Count
8. HCPC A0160 - Move 1 to Line Service Count
9. HCPC A0220 - Move 1 to Line Service Count
10. HCPC A0221 - Move 1 to Line Service Count
11. HCPC A0222 - If Line Service Count > 2 Move 1 to Line Service Count
12. HCPC A0223 - If Line Service Count > 2 move 1 to Line Service Count

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