Code

Title

Definition

01

Most Common Semi-Private Rate

To provide for the recording of hospital’s most common semi-private rate.

02

Hospital Has No Semi-Private Rooms

Entering this code requires $0.00 amount.

03

Reserved for national assignment

04

Inpatient Professional Component Charges Which Are Combined Billed

The sum of the inpatient professional component charges that are combined billed. Medicare uses this information in internal processes and also in the CMS notice of utilization sent to the patient to explain that Part B coinsurance applies to the professional component. (Used only by some all-inclusive rate hospitals.)

05

Professional Component Included in Charges and Also Billed Separately to Carrier

(Applies to Part B bills only.) Indicates that the charges shown are included in billed charges FL 47, but a separate billing for them will also be made to the carrier. For outpatient claims, these charges are excluded in determining the deductible and coinsurance due from the patient to avoid duplication when the carrier processes the bill for physician’s services. These charges are also deducted when computing interim payment.

The hospital uses this code also when outpatient treatment is for mental illness, and professional component charges are included in FL 47.

06

Medicare Part A and Part B Blood Deductible

The product of the number of un-replaced deductible pints of blood supplied times the charge per pint. If the charge per pint varies, the amount shown is the sum of the charges for each un-replaced pint furnished.

If all deductible pints have been replaced, this code is not to be used.

When the hospital gives a discount for un-replaced deductible blood, it shows charges after the discount is applied.

07

Reserved for National Assignment

08

Medicare Lifetime Reserve Amount in the First Calendar Year in Billing Period

The product of the number of lifetime reserve days used in the first calendar year of the billing period times the applicable lifetime reserve coinsurance rate. These are days used in the year of admission.

09

Medicare Coinsurance Amount in the First Calendar Year in Billing Period

The product of the number of coinsurance days used in the first calendar year of the billing period multiplied by the applicable coinsurance rate. These are days used in the year of admission. The provider may not use this code on Part B bills.

For Part B coinsurance use value codes A2, B2 and C2.

10

Medicare Lifetime Reserve Amount in the Second Calendar Year in Billing Period

The product of the number of lifetime reserve days used in the second calendar year of the billing period multiplied by the applicable lifetime reserve rate. The provider uses this code only on bills spanning 2 calendar years when lifetime reserve days were used in the year of discharge.

11

Medicare Coinsurance Amount in the Second Calendar Year in Billing Period

The product of the number of coinsurance days used in the second calendar year of the billing period times the applicable coinsurance rate. The provider uses this code only on bills spanning 2 calendar years when coinsurance days were used in the year of discharge. It may not use this code on Part B bills.

12

Working Aged Beneficiary Spouse With an EGHP

That portion of a higher priority EGHP payment made on behalf of an aged beneficiary that the provider is applying to covered Medicare charges on this bill. It enters six zeros (0000.00) in the amount field to claim a conditional payment because the EGHP has denied coverage. Where it received no payment or a reduced payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

13

ESRD Beneficiary in a Medicare Coordination Period With an EGHP

That portion of a higher priority EGHP payment made on behalf of an ESRD priority beneficiary that the provider is applying to covered Medicare charges on the bill. It enters six zeros (0000.00) in the amount field if it is claiming a conditional payment because the EGHP has denied coverage. Where it received no payment or a reduced payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

14

No-Fault, Including Auto/Other Insurance

That portion of a higher priority no-fault insurance payment, including auto/other insurance, made on behalf of a Medicare beneficiary, that the provider is applying to covered Medicare charges on this bill. It enters six zeros (0000.00) in the amount field if it is claiming a conditional payment because the other insurer has denied coverage or there has been a substantial delay in its payment. If it received no payment or a reduced no-fault payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

15

Worker’s Compensation (WC)

That portion of a higher priority WC insurance payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges on this bill. It enters six zeros (0000.00) in the amount field if it is claiming a conditional payment because there has been a substantial delay in its payment. Where the provider received no payment or a reduced payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

16

PHS, Other Federal Agency

That portion of a higher priority PHS or other Federal agency’s payment, made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges.

NOTE: A six zero value entry for Value Codes 12-16 indicates conditional Medicare payment requested (000000).

17

Operating Outlier Amount

(Not reported by providers.) The FI reports the amount of operating outlier payment made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code. It does not include any capital outlier payment in this entry.

18

Operating Disproportionate Share Amount

(Not reported by providers.) The FI reports the operating disproportionate share amount applicable. It uses the amount provided by the disproportionate share field in PRICER. It does not include any PPS capital DSH adjustment in this entry.

19

Operating Indirect Medical Education Amount

(Not reported by providers.) The FI reports operating indirect medical education amount applicable. It uses the amount provided by the indirect medical education field in PRICER. It does not include any PPS capital IME adjustment in this entry.

20

Payer Code

(For internal use by third party payers only.)

21

Catastrophic

Medicaid-eligibility requirements to be determined at State level.

22

Surplus

Medicaid-eligibility requirements to be determined at State level.

23

Recurring Monthly Income

Medicaid-eligibility requirements to be determined at State level.

24

Medicaid Rate Code

Medicaid-eligibility requirements to be determined at State level.

25

Offset to the Patient-Payment Amount – Prescription Drugs

Prescription drugs paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

26

Offset to the Patient-Payment Amount – Hearing and Ear Services

Hearing and ear services paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

27

Offset to the Patient-Payment Amount – Vision and Eye Services

Vision and eye services paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

28

Offset to the Patient-Payment Amount – Dental Services

Dental services paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

29

Offset to the Patient-Payment Amount – Chiropractic Services

Chiropractic Services paid for out of a long term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

31

Patient Liability Amount

The FI approved the provider charging the beneficiary the amount shown for non-covered accommodations, diagnostic procedures, or treatments.

32

Multiple Patient Ambulance Transport

If more than one patient is transported in a single ambulance trip, report the total number of patients transported.

33

Offset to the Patient-Payment Amount – Podiatric Services

Podiatric services paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

34

Offset to the Patient-Payment Amount – Other Medical Services

Other medical services paid for out of a long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

35

Offset to the Patient-Payment Amount – Health Insurance Premiums

Health insurance premiums paid for out of long-term care facility resident/patient’s funds in the billing period submitted (Statement Covers Period).

36

Reserved for national assignment.

37

Pints of Blood Furnished

The total number of pints of whole blood or units of packed red cells furnished, whether or not they were replaced. Blood is reported only in terms of complete pints rounded upwards, e.g., 1 1/4 pints is shown as 2 pints. This entry serves as a basis for counting pints towards the blood deductible.

38

Blood Deductible Pints

The number of un-replaced deductible pints of blood supplied. If all deductible pints furnished have been replaced, no entry is made.

39

Pints of Blood Replaced

The total number of pints of blood that were donated on the patient’s behalf. Where one pint is donated, one pint is considered replaced. If arrangements have been made for replacement, pints are shown as replaced. Where the hospital charges only for the blood processing and administration, (i.e., it does not charge a “replacement deposit fee” for un-replaced pints), the blood is considered replaced for purposes of this item. In such cases, all blood charges are shown under the 039X revenue code series (blood administration) or under the 030X revenue code series (laboratory).

40

New Coverage Not Implemented by Managed Care Plan

(For inpatient service only.) Inpatient charges covered by the Managed Care Plan. (The hospital uses this code when the bill includes inpatient charges for newly covered services that are not paid by the Managed Care Plan. It must also report condition codes 04 and 78.)

41

Black Lung (BL)

That portion of a higher priority BL payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges on this bill. It enters six zeros (0000.00) in the amount field if it is claiming a conditional payment because there has been a substantial delay in its payment. Where it received no payment or a reduced payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

42

Veterans Affairs (VA)

That portion of a higher priority VA payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on this bill.

43

Disabled Beneficiary Under Age 65 With LGHP

That portion of a higher priority LGHP payment made on behalf of a disabled beneficiary that it is applying to covered Medicare charges on this bill. The provider enters six zeros (0000.00) in the amount field, if it is claiming a conditional payment because the LGHP has denied coverage. Where it received no payment or a reduced payment because of failure to file a proper claim, it enters the amount that would have been payable had it filed a proper claim.

44

Amount Provider Agreed to Accept From Primary Payer When this Amount is Less than Charges but Higher than Payment Received

That portion that the provider was obligated or required to accept from a primary payer as payment in full when that amount is less than charges but higher than the amount actually received. A Medicare secondary payment is due.

45

Accident Hour

The hour when the accident occurred that necessitated medical treatment. Enter the appropriate code indicated below, right justified to the left of the dollar/cents delimiter.

46

Number of Grace Days

If a code “C3” or “C4” is in FL 24-30, indicating that the QIO has denied all or a portion of this billing period, the provider shows the number of days determined by the QIO to be covered while arrangements are made for the patient’s post discharge. The field contains one numeric digit.

47

Any Liability Insurance

That portion from a higher priority liability insurance paid on behalf of a Medicare beneficiary that the provider is applying to Medicare covered charges on this bill. It enters six zeros (0000.00) in the amount field if it is claiming a conditional payment because there has been a substantial delay in the other payer’s payment.

48

Hemoglobin Reading

The most recent hemoglobin reading taken before the start of this billing period. For patients just starting, use the most recent value prior to the onset of treatment. Whole numbers (i.e. two digits) are to be right justified to the left of the dollar/cents delimiter. Decimals (i.e. one digit) are to be reported to the right.

49

Hematocrit Reading

The most recent hematocrit reading taken before the start of this billing period. For patients just starting, use the most recent value prior to the onset of treatment. Whole numbers (i.e. two digits) are to be right justified to the left of the dollar/cents delimiter. Decimals (i.e. one digit) are to be reported to the right.

50

Physical Therapy Visits

The number of physical therapy visits from onset (at the billing provider) through this billing period.

51

Occupational Therapy Visits

The number of occupational therapy visits from onset (at the billing provider) through this billing period.

52

Speech Therapy Visits

The number of speech therapy visits from onset (at the billing provider) through this billing period.

53

Cardiac Rehabilitation Visits

The number of cardiac rehabilitation visits from onset (at the billing provider) through this billing period.

54

Newborn birth weight in grams

Actual birth weight or weight at time of admission for an extramural birth. Required on all claims with type f admission of 4 and on other claims as required by State law.

55

Eligibility Threshold for Charity Care

Code identifies the corresponding value amount at which a health care facility determines the eligibility threshold for charity care.

56

Skilled Nurse – Home Visit Hours (HHA only)

The number of hours of skilled nursing provided during the billing period. The provider counts only hours spent in the home. It excludes travel time. It reports in whole hours, right justified to the left of the dollars/cents delimiter. (Rounded to the nearest whole hour.)

57

Home Health Aide – Home Visit Hours (HHA only)

The number of hours of home health aide services provided during the billing period. The provider counts only hours spent in the home. It excludes travel time. It reports in whole hours, right justified to the left of the dollars/cents delimiter. (The number is rounded to the nearest whole hour.)

NOTE: Codes 50-57 represent the number of visits or hours of service provided. Entries for the number of visits are right justified from the dollars/cents delimiter:

58

Arterial Blood Gas (PO2/PA2)

Indicates arterial blood gas value at the beginning of each reporting period for oxygen therapy. This value or value 59 is required on the initial bill for oxygen therapy and on the fourth month’s bill. The provider reports right justified in the cents area. (See note following code 59 for an example.)

59

Oxygen Saturation (02 Sat/Oximetry)

Indicates oxygen saturation at the beginning of each reporting period for oxygen therapy. This value or value 58 is required on the initial bill for oxygen therapy and on fourth month’s bill. The hospital reports right justified in the cents area. (See note following this code for an example.)

60

HHA Branch MSA

The MSA in which HHA branch is located. (The HHA reports the MSA when its branch location is different than the HHA’s main location – It reports the MSA number in dollar portion of the form locator, right justified to the left of the dollar/cents delimiter.)

61

Location Where Service is Furnished (HHA and Hospice)

MSA number or Core Based Statistical Area (CBSA) number (or rural State code) of the location where the home health or hospice service is delivered. The HHA reports the number in dollar portion of the form locator right justified to the left of the dollar/cents delimiter.

For episodes in which the beneficiary’s site of service changes from one MSA to another within the episode period, HHAs should submit the MSA code corresponding to the site of service at the end of the episode on the claim.

62

HH Visits – Part A

(Internal Payer Use Only)

The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act.

63

HH Visits – Part B

Internal Payer Use Only)

The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act.

64

HH Reimbursement – Part A

(Internal Payer Use Only)

The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount. This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act.

65

HH Reimbursement – Part B

(Internal Payer Use Only)

The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount. This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by §1812(a)(3) of the Social Security Act.

66

Medicare Spend-down Amount

The dollar amount that was used to meet the recipient’s spend-down liability for this claim.

67

Peritoneal Dialysis

The number of hours of peritoneal dialysis provided during the billing period. The provider counts only the hours spent in the home, excluding travel time. It reports in whole hours, right justifying to the left of the dollar/cent delimiter. (Rounded to the nearest whole hour.)

68

Number of Units of EPO Provided During the Billing Period

Indicates the number of units of EPO administered and/or supplied relating to the billing period. The provider reports in whole units to the left of the dollar/cent delimiter. For example, 31,060 units are administered for the billing period.

69

State Charity Care Percent

Code indicates the percentage of charity care eligibility for the patient. Report the whole number right justified to the left of the dollar/cents delimiter and fractional amounts to the right.

70

Interest Amount

(For use by third party payers only.) The contractor reports the amount of interest applied to this Medicare claim.

71

Funding of ESRD Networks

(For third party payer use only.) The FI reports the amount the Medicare payment was reduced to help fund ESRD networks.

72

Flat Rate Surgery Charge

(For third party payer use only.) The standard charge for outpatient surgery where the provider has such a charging structure.

73-75

Payer Codes

(For use by third party payers only.)

76

Provider’s Interim Rate

(For third party payer internal use only.) Provider’s percentage of billed charges interim rate during this billing period. This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate is applicable. The contractor reports to the left of the dollar/cents delimiter.

77

Medicare New Technology Add-On Payment

Code indicates the amount of Medicare additional payment for new technology.

78-79

Payer Codes

Codes reserved for internal use only by third party payers. The CMS assigns as needed. Providers do not report payer codes.

80

Covered days

The number of days covered by the primary payer as qualified by the payer.

81

Non-Covered Days

Days of care not covered by the primary payer.

82

Co-insurance Days

The inpatient Medicare days occurring after the 60^th day and before the 91^st day or inpatient SNF/Swing Bed days occurring after the 20^th and before the 101^st day in a single spell of illness.

83

Lifetime Reserve Days

Under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services after using 90 days of inpatient hospital services during a spell of illness.

84-99

Reserved for national assignment.

A0

Special Zip Code Reporting

Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulance.

A1

Deductible Payer A

The amount the provider assumes will be applied to the patient’s deductible amount involving the indicated payer.

A2

Coinsurance Payer A

The amount the provider assumes will be applied toward the patient’s coinsurance amount involving the indicated payer.

For Medicare, use this code only for reporting Part B coinsurance amounts. For Part A coinsurance amounts use Value Codes 8-11.

A3

Estimated Responsibility Payer A

Amount the provider estimates will be paid by the indicated payer.

A4

Covered Self-Administrable Drugs – Emergency

The amount included in covered charges for self-administrable drugs administered to the patient in an emergency situation. (The only covered Medicare charges for an ordinarily non-covered, self-administered drug are for insulin administered to a patient in a diabetic coma. For use with Revenue Code 0637. See The Medicare Benefit Policy Manual).

A5

Covered Self-Administrable Drugs – Not Self-Administrable in Form and Situation Furnished to Patient

The amount included in covered charges for self-administrable drugs administered to the patient because the drug was not self-administrable in the form and situation in which it was furnished to the patient. For use with Revenue Code 0637.

A6

Covered Self-Administrable Drugs – Diagnostic Study and Other

The amount included in covered charges for self-administrable drugs administered to the patient because the drug was necessary for diagnostic study or other reasons (e.g., the drug is specifically covered by the payer). For use with Revenue Code 0637.

A7

Co-payment A

The amount assumed by the provider to be applied toward the patient’s co-payment amount involving the indicated payer.

A8

Patient Weight

Weight of patient in kilograms. Report this data only when the health plan has a predefined change in reimbursement that is affected by weight. For newborns, use Value Code 54. (Effective 1/01/05)

A9

Patient Height

Height of patient in centimeters. Report this data only when the health plan has a predefined change in reimbursement that is affected by height. (Effective 1/01/05)

AA

Regulatory Surcharges, Assessments, Allowances or Health Care Related Taxes Payer A

The amount of regulatory surcharges, assessments, allowances or health care related taxes pertaining to the indicated payer. Effective 10/16/2003

AB

Other Assessments or Allowances (e.g., Medical Education) Payer A

The amount of other assessments or allowances (e.g., medical education) pertaining to the indicated payer. Effective 10/16/2003

AC-B0

Reserved for national assignment.

B1

Deductible Payer B

The amount the provider assumes will be applied to the patient’s deductible amount involving the indicated payer.

B2

Coinsurance Payer B

The amount the provider assumes will be applied toward the patient’s coinsurance amount involving the indicated payer. For Part A coinsurance amounts use Value Codes 8-11.

B3

Estimated Responsibility Payer B

Amount the provider estimates will be paid by the indicated payer.

B4-B6

Reserved for national assignment

B7

Co-payment Payer B

The amount the provider assumes will be applied toward the patient’s co-payment amount involving the indicated payer.

B8-B9

Reserved for national assignment

BA

Regulatory Surcharges, Assessments, Allowances or HealthCare Related Taxes Payer B

The amount of regulatory surcharges, assessments, allowances or health care related taxes pertaining to the indicated payer. Effective 10/16/03

BB

Other Assessments or Allowances (e.g., Medical Education) Payer B

The amount of other assessments or allowances (e.g., medical education) pertaining to the indicated

BC-C0

Reserved for national assignment

C1

Deductible Payer C

The amount the provider assumes will be applied to the patient’s deductible amount involving the indicated payer. (NOTE: Medicare blood deductibles should be reported under Value Code 6.)

C2

Coinsurance Payer C

The amount the provider assumes will be applied toward the patient’s coinsurance amount involving the indicated payer. For Part A coinsurance amounts use Value Codes 8-11.

C3

Estimated Responsibility Payer C

Amount the provider estimates will be paid by the indicated payer.

C4-C6

Reserved for national assignment

C7

Co-payment Payer C

The amount the provider assumes is applied to the patient’s co-payment amount involving the indicated payer.

C8-C9

Reserved for national assignment

CA

Regulatory Surcharges, Assessments, Allowances or HealthCare Related Taxes Payer C

The amount of regulatory surcharges, assessments, allowances or health care related taxes pertaining to the indicated payer. Effective 10/16/03

CB

Other Assessments or Allowances (e.g., Medical Education) Payer C

The amount of other assessments or allowances (e.g., medical education) pertaining to the indicated payer. Effective 10/16/2003

CC-CZ

Reserved for national assignment

D0-D2

Reserved for national assignment

D3

Patient Estimated Responsibility

The amount estimated by the provider to be paid by the indicated patient

D4-DQ

Reserved for national assignment

DR

Reserved for disaster related code

DS-DZ

Reserved for national assignment

E0-Y0

Reserved for national assignment

Y1

Part A Demonstration Payment

This is the portion of the payment designated as reimbursement for Part A services under the demonstration. This amount is instead of the traditional prospective DRG payment (operating and capital) as well as any outlier payments that might have been applicable in the absence of the demonstration. No deductible or coinsurance has been applied. Payments for operating IME and DSH which are processed in the traditional manner are also not included in this amount.

Y2

Part B Demonstration Payment

This is the portion of the payment designated as reimbursement for Part B services under the demonstration. No deductible or coinsurance has been applied.

Y3

Part B Coinsurance

This is the amount of Part B coinsurance applied by the intermediary to this claim. For demonstration claims this will be a fixed copayment unique to each hospital and DRG (or DRG/procedure group).

Y4

Conventional Provider Payment Amount for Non-Demonstration Claims

This is the amount Medicare would have reimbursed the provider for Part A services if there had been no demonstration. This should include the prospective DRG payment (both capital as well as operational) as well as any outlier payment, which would be applicable. It does not include any pass through amounts such as that for direct medical education nor interim payments for operating IME and DSH.

Y5-ZZ

Reserved for national assignment