Home Health Billing

Physical Therapists (PT) must have a current, active license in accordance with the Colorado Physical Therapy Practice Act 

 Acute Home Health: All physical therapy services may be provided on pediatric and adult Home Health client and are billed using revenue code 420 on a per visit basis. No PAR is required. 

 Long-Term Home Health: Physical therapy is available to pediatric clients when prior authorized and deemed medically necessary. Physical therapy is reimbursed on a per visit basis using revenue code 421.

Occupational Therapists (OT) must have a current, active registration in accordance with the DORA Colorado Occupational Therapy Practice Act 

 Acute Home Health: All occupational therapy services may be provided to all Medicaid Home Health clients with a demonstrated need for speech therapy interventions. Occupational therapy services are reimbursed on per visit basis using revenue code 430. No PAR is required. 

 Long-Term Home Health: Occupational therapy is available to pediatric clients when prior authorized and deemed medically necessary. All Home Health speech therapy is reimbursed on a per visit basis using revenue code 431. 

Speech/Language Pathologists (SLP) who have a current, active certification from the American Speech-Language-Hearing Association (ASHA).  Acute Home Health: All speech therapy services may be provided to all Medicaid Home Health clients with a demonstrated need for speech therapy interventions. Speech therapy services are reimbursed on per visit basis using revenue code 440. No PAR is required.  Long-Term Home Health: Speech therapy is available to pediatric clients when prior authorized and deemed medically necessary. All Home Health speech therapy is reimbursed on a per visit basis using revenue code 441.

Reimbursable Home Health Services

The licensed and certified Class A Home Care shall not utilize staff that has been excluded from participation in federally funded health care programs by the US Department of Health and Human Services (HHS)/Office of Inspector General (OIG) and shall be in good standing with the Colorado Department of Regulatory Agencies (DORA) or other regulatory agency:

Registered Nurses (RN) and Licensed Practical Nurses (LPN) must have a current, active license in accordance with the DORA Colorado Nurse Practice Act at §12-38-111, C.R.S..

 Acute Home Health: All nursing services provided during the acute Home Health period shall be billed under revenue code 550. No PAR is required.

 Long-Term Home Health: Nursing services provided during Long-Term Home Health shall be billed using the appropriate revenue codes based on the purpose and complexity of the nursing visit. Standard, infrequent or complicated nursing visits may be billed using revenue code 551. Nursing visits that are uncomplicated in nature or visits that are uncomplicated with frequent revisits completed by the nurse shall be billed using revenue codes 590 and 599).

o Long-Term Home Health nursing visits for the sole purpose of assessing a client may be reimbursed for a limited time when managing, and reporting to the client’s physician on specific conditions and/or symptoms which are not stable. 

Certified Nurse Aides (CNA) must have a current, active license in accordance with the DORA Colorado Nurse Aide Practice Act at §12-38-111, C.R.S. 

 Acute Home Health: Skilled certified nurse aide visits are reimbursed based on the amount of time the CNA is providing skilled care to a client. If a certified nurse aide provides care for at least 15 minutes but not more than 60 minutes, the agency shall bill a basic unit with revenue code 570. For each every additional 30 minutes the certified nurse aide provides hands-on assistance to the client the agency may bill an extended CNA unit with revenue code 572. A unit of time that is less than 15 minutes shall not be reimbursable as a basic unit and at least 15 minutes must elapse before an agency may bill an extended unit. No PAR is required.

 Long-Term Home Health: Skilled certified nurse aide visits are reimbursed based on the amount of time the CNA is providing skilled care to a client. If a certified nurse aide care for at least 15 minutes but not more than 60 minutes, the agency shall bill a basic unit with revenue code 571. For each every additional 30 minutes the certified nurse aide provides hands-on assistance to the client the agency may bill an extended CNA unit with revenue code 579. A unit of time that is less than 15 minutes shall not be reimbursable as a basic unit and at least 15 minutes must elapse before an agency may bill an extended unit. 

Change of Provider Revisions

When a client in long-term home health changes providers during an active PAR certification, the receiving Home Health Providers shall complete a Change of Provider Form in order to transfer the client’s care from the previous provider to the receiving agency.

Once the receiving agency completes the Change of Provider form, the form must include the client’s signature to indicate that the client is in agreement with the change of provider request. The completed Change of Provider form must accompany a new Home Health PAR from the receiving agency. 

The agency must submit the Change of Provider form along with a new PAR to the authorizing agency. The new PAR start date should coincide with the first day that the new agency plans to provide LTHH care. The provider should not include dates for acute home health or any lapses in care between the last date of service provided by the previous home health agency and the receiving agency.

The previous provider’s PAR end date will be revised to match the information provided in the “last date of service” box, and a new PAR will be entered for the receiving agency. 

The Change of Provider letter authorizes Department’s fiscal agent to end the current PAR so the new Home Health PAR may be entered. Single Entry Points (SEPs) and Community Centered Boards (CCBs) must include the Case Management Agency’s (CMA) identification number on the PAR form.

If the receiving agency is unable to obtain the necessary PAR information from the previous agency, the receiving agency may call the Department’s fiscal agent at 1-800-237-0044 to find out whether there is a current Home Health PAR in the system. If a current PAR does exist, the Department’s fiscal agent will provide the name and phone number of the Home Health Agency who currently has the approved PAR, but will not be able to provide any of the details for the PAR. 

The receiving agency should contact the previous agency, when possible, and notify them that the client is transferring agencies and the effective date of the change. The Change of Provider Form is located on the Department’s website (colorado.gov/hcpf)

Providers Services

Forms. Home Health Agencies should not bill Long-Term Home Health services on another provider’s Long-Term Home Health PAR.

Batch Electronic Claims Submission

Batch billing refers to the electronic creation and transmission of several claims in a group. Batch billing systems usually extract information from an automated accounting or patient billing system to create a group of claim transactions. Claims may be transmitted from the provider's office or sent through a billing vendor or clearinghouse.

All batch claim submission software must be tested and approved by the Department’s fiscal agent.

Any entity sending electronic transactions through the fiscal agent’s Electronic Data Interchange (EDI) Gateway for processing where reports and responses will be delivered must complete an EDI enrollment package. This provides EDI Gateway the information necessary to assign a Logon Name, Logon ID, and Trading Partner ID, which are required to submit electronic transactions, including claims.

The X12N 837 Professional (837P), Institutional (837I), or Dental (837D) transaction data will be submitted to the EDI Gateway, which validates submission of American National Standards Institute (ANSI) X12N format(s). The TA1 Interchange Acknowledgement reports the syntactical analysis of the interchange header and trailer. If the data is corrupt or the trading partner relationship does not exist within the Medicaid Management Information System (MMIS), the interchange will reject and a TA1 along with the data will be forwarded to the State Healthcare Clearinghouse (SHCH) Technical Support for review and follow-up with the sender. An X12N 999 Functional Acknowledgement is generated when a file that has passed the header and trailer check passes through the SHCH.

If the file contains syntactical error(s), the segment(s) and element(s) where the error(s) occurred will be reported. After validation, the SHCH will then return the X12N 835 Remittance Advice containing information related to payees, payers, dollar amount, and payments. These X12N transactions will be returned to the Web Portal for retrieval by the trading partner, following the standard claims processing cycle.

NCH Patch Code

Variable Name : PTCHCD{x} where { x } ranges from 1 to 30  

Label:  NCH Patch Code

Effective with Version H, the code annotated to the claim indicating a patch was applied to the record during an NCH Nearline record conversion and/or during current processing. NOTE: Prior to Version H this field was located in the third and fourth occurrence of the CLM_EDIT_CD. DB2 ALIAS: NCH_PATCH_CD SAS ALIAS: PATCHCD STANDARD ALIAS: NCH_PATCH_CD TITLE ALIAS: NCH_PATCH CODES: REFER TO: NCH_PATCH_TB IN THE CODES APPENDIX SOURCE: NCH  

Variable Name : PTCHDT{x} where { x } ranges from 1 to 30

Label:  NCH Patch Applied Date

Effective with Version H, the date the NCH patch was applied to the claim. 8 DIGITS UNSIGNED DB2 ALIAS: NCH_PATCH_APPLY_DT SAS ALIAS: PATCHDT STANDARD ALIAS: NCH_PATCH_APPLY_DT TITLE ALIAS: NCH_PATCH_DT EDIT-RULES: YYYYMMDD SOURCE: NCH 

Variable Name : MCOIND{x} where { x } ranges from 1 to 2

Label:   NCH MCO Trailer Indicator Code

Effective with Version H, the code indicating the presence of a Managed Care Organization (MCO) trailer. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. COBOL ALIAS: MCO_IND DB2 ALIAS: MCO_TRLR_IND_CD SAS ALIAS: MCOIND STANDARD ALIAS: NCH_MCO_TRLR_IND_CD TITLE ALIAS: MCO_INDICATOR CODES: M = MCO trailer present SOURCE: NCH QA Process 

Variable Name : MCONUM{x} where { x } ranges from 1 to 2

Label:   MCO Contract Number

Effective with Version H, this field represents the plan contract number of the Managed Care Organization (MCO). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS: MCO_CNTRCT_NUM SAS ALIAS: MCONUM STANDARD ALIAS: MCO_CNTRCT_NUM TITLE ALIAS: MCO_NUM SOURCE: CWF

Variable Name : MCOOPTN{x} where { x } ranges from 1 to 2

Label:   MCO Option Code

Effective with Version H, the code indicating Managed Care Organization (MCO) lock-in enrollment status of the beneficiary. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS: MCO_OPTN_CD SAS ALIAS: MCOOPTN STANDARD ALIAS: MCO_OPTN_CD TITLE ALIAS: MCO_OPTION_CD CODES: *****For lock-in beneficiaries**** A = HCFA to process all provider bills B = MCO to process only in-plan C = MCO to process all Part A and Part B bills ***** For non-lock-in beneficiaries***** 1 = HCFA to process all provider bills 2 = MCO to process only in-plan Part A and Part B bills SOURCE: CWF  

Claim HHA Care Start Date

Variable Name :HHSTRTDT

Label :  Claim HHA Care Start Date

Effective with Version H, the date care started for the HHA services reported on the institutional claim with a from date greater than 3/31/98. The Balanced Budget Act (BBA) required that this field be present on all HHA claims. 

NOTE1: Beginning with NCH weekly process date 4/3/98, this field was populated with data. Claims processed prior to 4/3/98 will contain zeroes in this field. 

NOTE2: Effective with Version 'I', the start of care date will be moved from the 1st eight positions of the Claim Treatment Authorization Number. Prior to Version 'I' this date was moved from Occurrence Code 27 date field. 8 DIGITS UNSIGNED 

DB2 ALIAS: HHA_CARE_STRT_DT 

SAS ALIAS: HHSTRTDT 

STANDARD ALIAS: CLM_HHA_CARE_STRT_DT 

TITLE ALIAS: HHA_CARE_START_DT EDIT-RULES: YYYYMMDD 

SOURCE: CWF

Variable Name :   HHSTRTDT EDTND{x} where { x } ranges from 1 to 13

Label :  NCH Edit Trailer Indicator Code

Effective with Version H, the code indicating the presence of an NCH edit trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS: EDIT_TRLR_IND_CD SAS ALIAS: EDITIND STANDARD ALIAS: NCH_EDIT_TRLR_IND_CD CODES: 

E = Edit code trailer present SOURCE: NCH QA Process 

Variable Name :   EDITCD{x} where { x } ranges from 1 to 13

Label :  NCH Edit Code

The code annotated to the claim indicating the CWFMQA editing results so users will be aware of data deficiencies. NOTE: Prior to Version H only the highest priority code was stored. Beginning 11/98 up to 13 edit codes may be present. COMMON ALIAS: QA_ERROR_CODE DB2 ALIAS: NCH_EDIT_CD SAS ALIAS: EDIT_CD STANDARD ALIAS: NCH_EDIT_CD TITLE ALIAS: QA_ERROR_CD CODES: REFER TO: NCH_EDIT_TB IN THE CODES APPENDIX SOURCE: NCH QA EDIT PROCESS

Variable Name :   PTCHND{x} where { x } ranges from 1 to 30

Label :  NCH Patch Trailer Indicator Code

Effective with Version H, the code indicating the presence of an NCH patch trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS: PATCH_TRLR_IND_CD SAS ALIAS: PATCHIND STANDARD ALIAS: NCH_PATCH_TRLR_IND_CD CODES: P = Patch code trailer present SOURCE: NCH 

HHA Claim Occurrence Span Code Count

Variable Name : HHSPNCNT

Label :  HHA Claim Occurrence Span Code Count 

The count of the number of occurrence span codes reported on an HHA claim. The purpose of the count is to indicate how many span code trailers are present. 2 DIGITS UNSIGNED 

 DB2 ALIAS: HHA_OCRNC_SPAN_CNT 

 SAS ALIAS: HHSPNCNT 

 STANDARD ALIAS: HHA_CLM_OCRNC_SPAN_CD_CNT 

 COMMENT: Prior to Version H this field was named: CLM_OCRNC_SPAN_CD_CNT. 

 SOURCE: NCH  

Variable Name :HHVALCNT

Label :  HHA Claim Value Code Count

The count of the number of value codes reported on an HHA claim. The purpose of the count is to indicate how many value code trailers are present. 2 DIGITS UNSIGNED 

 DB2 ALIAS: HHA_CLM_VAL_CD_CNT 

 SAS ALIAS: HHVALCNT 

 STANDARD ALIAS: HHA_CLM_VAL_CD_CNT EDIT-RULES: RANGE: 0 TO 36 COMMENT: Prior to Version H this field was named: CLM_VAL_CD_CNT. 

 SOURCE: NCH 

Variable Name : HHREVCNT

Label :  HHA Revenue Center Code Count

The count of the number of revenue codes reported on an HHA claim. The purpose of the count is to indicate how many revenue center trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_REV_CNTR_CNT 

SAS ALIAS: HHREVCNT 

STANDARD ALIAS: HHA_REV_CNTR_CD_I_CNT 

EDIT-RULES: RANGE: 0 TO 45 

COMMENT: Prior to Version H this field was named: CLM_REV_CNTR_CD_CNT. 

NOTE: During the Version 'I' conversion the number of occurrences changed to 45 (per segment - 450 total for claim). For claims prior to Version 'I' the number of occurrences was 58. 

SOURCE: NCH 

Variable Name : LUPAIND

Label :  Claim HHA Low Utilization Payment Adjustment (LUPA) 

Effective with Version I, the code used to identify those Home Health PPS claims that have 4 visits or less in a 60- day episode. If an HHA provides 4 visits or less, they will be reimbursed based on a national standardized per visit rate instead of HHRGs. 

NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces. 

DB2 ALIAS: HHA_LUPA_IND_CD SAS ALIAS: LUPAIND 

STANDARD ALIAS: CLM_HHA_LUPA_IND_CD 

TITLE ALIAS: HHA_TOT_VISITS CODES: L = LUPA Claim blank = Not a LUPA claim SOURCE: CWF 

Variable Name : HHA_RFRL

Label :  Claim HHA Referral Code 

Effective with Version 'I', the code used to identify the means by which the beneficiary was referred for Home Health services.NOTE: Beginning 10/1/00, this field will be populated with data. Claims processed prior to 10/1/00 will contain spaces in this field. 

DB2 ALIAS: CLM_HHA_RFRL_CD SAS ALIAS: HHA_RFRL 

STANDARD ALIAS: CLM_HHA_RFRL_CD 

SYSTEM ALIAS: LTHRFRL TITLE ALIAS: HHA_REFERRAL_CODE 

SOURCE: CWF  

HHA Claim Demonstration ID Count

Variable Name : HHDEMCNT

Label :  HHA Claim Demonstration ID Count 

A placeholder field (effective with Version H) for storing the count of the number of Health PlanIDs reported on the HHA claim. The purpose of this count is to indicate how many Health PlanID trailers are present. NOTE: Prior to Version 'I' this field was named: HHA_CLM_PAYERID_CNT. 1 DIGIT UNSIGNED 

DB2 ALIAS: HHA_PLANID_CNT 

SAS ALIAS: HHPLANNT 

STANDARD ALIAS: HHA_CLM_HLTH_PLANID_CNT EDIT-RULES: RANGE: 0 TO 3 SOURCE: NCH 

Variable Name : HHDEMCNT

Label :  HHA Claim Demonstration ID Count

Effective with Version H, the count of the number of claim demonstration IDs reported on an HHA claim. The purpose of this count is to indicate how many claim demonstration trailers are present. NOTE: During the Version H conversion this field was populated with data where a demo was identifiable. 1 DIGIT UNSIGNED

 DB2 ALIAS: HHA_DEMO_ID_CNT 

SAS ALIAS: HHDEMCNT 

STANDARD ALIAS: HHA_CLM_DEMO_ID_CNT EDIT-RULES: RANGE: 0 TO 5 

SOURCE: NCH 

Variable Name : HHDGNCNT

Label :  HHA Claim Diagnosis Code Count

The count of the number of diagnosis codes (both principal and other) reported on an HHA claim. The purpose of this count is to indicate how many claim diagnosis trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_DGNS_CD_CNT 

SAS ALIAS: HHDGNCNT 

STANDARD ALIAS: HHA_CLM_DGNS_CD_CNT EDIT-RULES: RANGE: 0 TO 10 COMMENT: Prior to Version H this field was named: CLM_OTHR_DGNS_CD_CNT and the principal was not included in the count. 

 SOURCE: NCH

Variable Name : HHCONCNT

Label :  HHA Claim Related Condition Code Count

The count of the number of condition codes reported on an HHA claim. The purpose of this count is to indicate how condition code trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_COND_CD_CNT 

SAS ALIAS: HHCONCNT 

STANDARD ALIAS: HHA_CLM_RLT_COND_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_COND_CD_CNT. 

SOURCE: NCH 

Variable Name : HHOCRCNT

Label :  HHA Claim Related Occurrence Code Count

The count of the number of occurrence codes reported on an HHA claim. The purpose of this count is to indicate how many occurrence code trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_RLT_OCRNC_CNT SAS ALIAS: HHOCRCNT 

STANDARD ALIAS: HHA_CLM_RLT_OCRNC_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_OCRNC_CD_CNT. 

SOURCE: NCH 

Claim Total Charge Amount

Variable Name : TOT_CHRG

Label :  Claim Total Charge Amount

Effective with Version G, the total charges for all services included on the institutional claim.This field is redundant with revenue center code 0001/total charges. 9.2 DIGITS SIGNED 
DB2 ALIAS: CLM_TOT_CHRG_AMT 
SAS ALIAS: TOT_CHRG 
STANDARD ALIAS: CLM_TOT_CHRG_AMT 
TITLE ALIAS: CLAIM_TOTAL_CHARGES 
COMMENT: Prior to Version H the size of this field was S9(7)V99. 
SOURCE: CWF  

Variable Name : HHEDCNT

Label :  HHA NCH Edit Code Count

The count of the number of edit codes annotated to the HHA claim during the HCFA's CWFMQA process. The purpose of this count is to indicate how many claim edit trailers are present. 2 DIGITS UNSIGNED 
DB2 ALIAS: HHA_EDIT_CD_CNT 
SAS ALIAS: HHEDCNT 
STANDARD ALIAS: HHA_NCH_EDIT_CD_CNT 
COMMENT: Prior to Version H this field was named: CLM_EDIT_CD_CNT. 
SOURCE: NCH 

Variable Name : HHPATCNT

Label :  HHA NCH Patch Code Count

Effective with Version H, the count of the number of HCFA patch codes annotated to the home health claim during the Nearline maintenance process. The purpose of this count is to indicate how many NCH patch trailers are present. NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991). NOTE2: Effective with Version 'I' the number of possible occurrences was reduced to 30. Prior to Version 'I' the number of possible occurrences was 99. 2 
DIGITS UNSIGNED 
DB2 ALIAS: HHA_PATCH_CD_CNT 
SAS ALIAS: HHPATCNT 
STANDARD ALIAS: HHA_NCH_PATCH_CD_I_CNT SOURCE: NCH 

Variable Name : HHMCOCNT

Label :  HHA MCO Period Count

Effective with Version H, the count of the number of Managed Care Organization (MCO) periods reported on an home health agency claim. The purpose of this count is to indicate how many MCO period trailers are present. 
NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. 
Claims processed prior to 10/3/97 will contain zeroes in this field. 1 DIGIT UNSIGNED 
DB2 ALIAS: HHA_MCO_PRD_CNT 
SAS ALIAS: HHMCOCNT 
STANDARD ALIAS: HHA_MCO_PRD_CNT EDIT-RULES: RANGE: 0 TO 2 
SOURCE: NCH 

Variable Name : HHPLANNT

Label :   HHA Claim Health PlanID Count

A placeholder field (effective with Version H) for storing the count of the number of Health PlanIDs reported on the HHA claim. The purpose of this count is to indicate how many Health PlanID trailers are present. 
NOTE: Prior to Version 'I' this field was named: HHA_CLM_PAYERID_CNT. 1 DIGIT UNSIGNED 
DB2 ALIAS: HHA_PLANID_CNT 
SAS ALIAS: HHPLANNT 
STANDARD ALIAS: HHA_CLM_HLTH_PLANID_CNT EDIT-RULES: RANGE: 0 TO 3 
SOURCE: NCH 

Home Health Agency

Variable Name : AT_MDL

Label : Claim Attending Physician Middle Initial Name

Effective with Version H, the middle initial of the attending physician (used for internal editing purposes in HCFA's CWFMQA system.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. 
DB2 ALIAS: ATNDG_MI_NAME 
SAS ALIAS: AT_MDL 
STANDARD 
ALIAS: CLM_ATNDG_PHYSN_MDL_INITL_NAME 
TITLE ALIAS: ATNDG_PHYSN_MI 
SOURCE: CWF 

Variable Name : OP_UPIN

Label : Claim Operating Physician UPIN Number
On an institutional claim, the unique physician identification number (UPIN) of the physician who performed the principal procedure. This element is used by the provider to identify the operating physician who performed the surgical procedure. 
DB2 ALIAS: OPRTG_UPIN 
SAS ALIAS: OP_UPIN 
STANDARD ALIAS: CLM_OPRTG_PHYSN_UPIN_NUM 
TITLE ALIAS: OPRTG_UPIN 
COMMENT: Prior to Version H this field was named: CLM_PRNCPAL_PRCDR_PHYSN_NUM and contained 10 positions (6-position UPIN and 4-position physician surname. NOTE: For HHA and Hospice formats beginning with NCH weekly process date 10/3/97 this field was populated with data. HHA and Hospice claims processed prior to 10/3/97 will contain spaces. 
SOURCE: CWF 

Variable Name : OP_NPI

Label : Claim Operating Physician NPI Number

A placeholder field (effective with Version H) for storing the NPI assigned to the operating physician. 
DB2 ALIAS: OPRTG_NPI 
SAS ALIAS: OP_NPI 
STANDARD ALIAS: CLM_OPRTG_PHYSN_NPI_NUM 
TITLE ALIAS: OPRTG_NPI 
SOURCE: CWF 

Variable Name : OP_SRNM

Label : Claim Operating Physician Surname

Effective with Version H, the last name of the operating physician (used for internal editing purposes in HCFA's CWFMQA system.) NOTE: Beginning with the NCH weekly process date 10/3/97 this field was populated with data. 
Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS: OPRTG_SRNM 
SAS ALIAS: OP_SRNM 
STANDARD ALIAS: CLM_OPRTG_PHYSN_SRNM_NAME 
TITLE ALIAS: OPRTG_PHYSN_SURNAME 
SOURCE: CWF

Variable Name : OP_GVN

Label : Claim Operating Physician Given Name

Effective with Version H, the first name of the operating physician (used for internal editing purposes in HCFA's CWFMQA system.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. 
DB2 ALIAS: OPRTG_GVN_
NAME SAS ALIAS: OP_GVN 
STANDARD ALIAS: CLM_OPRTG_PHYSN_GVN_NAME TITLE ALIAS: OPRTG_PHYSN_FIRSTNAME 
SOURCE: CWF 

Variable Name : OP_MDL

Label : Claim Operating Physician Middle Initial Name

Effective with Version H, the middle initial of the operating physician (used for internal editing purposes in HCFA's CWFMQA system.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. 
DB2 ALIAS: OPRTG_MI_NAME 
SAS ALIAS: OP_MDL 
STANDARD ALIAS: CLM_OPRTG_PHYSN_MDL_INITL_NAME 
TITLE ALIAS: OPRTG_PHYSN_MI 
SOURCE: CWF 

NCH Provider State Code

Variable Name : PRSTATE

Label : NCH Provider State Code

Effective with Version H, the two position SSA state code where provider facility is located. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). 

DB2 ALIAS: NCH_PRVDR_STATE_CD 

SAS ALIAS: PRSTATE STANDARD ALIAS: NCH_PRVDR_STATE_CD 

TITLE ALIAS: PROVIDER_STATE_CD DERIVATION: DERIVED FROM: NCH PRVDR_NUM DERIVATION RULES: SET NCH_PRVDR_STATE_CD TO PRVDR_NUM POS1-2. FOR PRVDR_NUM POS1-2 EQUAL '55 SET NCH_PRVDR_STATE_CD TO '05'. FOR PRVDR_NUM POS1-2 EQUAL '67 SET NCH_PRVDR_STATE_CD TO '45'. FOR PRVDR_NUM POS1-2 EQUAL '68 SET NCH_PRVDR_STATE_CD TO '10'. 

CODES: REFER TO: GEO_SSA_STATE_TB IN THE CODES APPENDIX 

SOURCE: NCH  

Variable Name : ORGNPINM

Label : Organization NPI Number 

A placeholder field (effective with Version H) for storing the NPI assigned to the institutional provider. 

DB2 ALIAS: ORG_NPI_NUM 

SAS ALIAS: ORGNPINM

STANDARD ALIAS: ORG_NPI_NUM 

TITLE ALIAS: ORG_NPI 

SOURCE: CWF 

Variable Name : AT_UPIN

Label :Claim Attending Physician UPIN Number

On an institutional claim, the unique physician identification number (UPIN) of the physician who would normally be expected to certify and recertify the medical necessity of the services  rendered and/or who has primary responsibility for the beneficiary's medical care and treatment (attending physician). COMMON ALIAS: ATTENDING_PHYSICIAN_UPIN 

DB2 ALIAS: ATNDG_UPIN 

SAS ALIAS: AT_UPIN 

STANDARD ALIAS: CLM_ATNDG_PHYSN_UPIN_NUM 

TITLE ALIAS: ATTENDING_PHYSICIAN COMMENT: Prior to Version H this field was named: CLM_PRMRY_CARE_PHYSN_IDENT_NUM and contained 10 positions (6-position UPIN and 4-position physician surname). 

SOURCE: CWF  

Variable Name : AT_NPI

Label : Claim Attending Physician NPI Number

A placeholder field (effective with Version H) for storing the NPI assigned to the attending physician. 

COMMON ALIAS: ATTENDING_PHYSICIAN_NPI 

DB2 ALIAS: ATNDG_NPI SAS ALIAS: AT_NPI 

STANDARD ALIAS: CLM_ATNDG_PHYSN_NPI_NUM 

TITLE ALIAS: ATNDG_NPI 

SOURCE: CWF

Variable Name : AT_SRNM

Label :Claim Attending Physician Surname

Effective with Version H, the last name of the attending physician (used for internal editing purpose in HCFA's CWFMQA system.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS: ATNDG_SRNM 

SAS ALIAS: AT_SRNM 

STANDARD ALIAS: CLM_ATNDG_PHYSN_SRNM_NAME 

TITLE ALIAS: ANDG_PHYSN_SURNAME 

SOURCE: CWF 

Variable Name : AT_GVNNM

Label :Claim Attending Physician Given Name

Effective with Version H, the first name of the attending physician (used for internal editing purposes in HCFA's CWFMQA system). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. 

DB2 ALIAS: ATNDG_GVN_NAME 

SAS ALIAS: AT_GVNNM 

STANDARD ALIAS: CLM_ATNDG_PHYSN_GVN_NAME 

TITLE ALIAS: ATNDG_PHYSN_FIRSTNAME 

SOURCE: CWF  

NCH Primary Payer Claim Paid Amount

Variable Name : PRPAYAMT 

Label: NCH Primary Payer Claim Paid Amount  

The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than Medicare, that theprovider is applying to covered Medicare charges on an institutional, carrier, or DMERC claim. 9.2 DIGITS SIGNED 

DB2 ALIAS: PRMRY_PYR_PD_AMT 

SAS ALIAS: PRPAYAMT STANDARD ALIAS: NCH_PRMRY_PYR_CLM_PD_AMT

 TITLE ALIAS: PRIMARY_PAYER_AMOUNT EDIT-RULES: $$$$$$$$$CC 

COMMENT: Prior to Version H this field was named: BENE_PRMRY_PYR_CLM_PMT_AMT and the field size was S9(7)V99. 

SOURCE: NCH 

Variable Name : PRPAY_CD

Label:  NCH Primary Payer Code

The code, on an institutional claim, specifying a federal non-Medicare program or other source that has primary responsibility for the payment of the Medicare beneficiary's health insurance bills. 

DB2 ALIAS: NCH_PRMRY_PYR_CD 

SAS ALIAS: PRPAY_CD STANDARD ALIAS: NCH_PRMRY_PYR_CD 

TITLE ALIAS: PRIMARY_PAYER_CD DERIVATION: DERIVED FROM: CLM_VAL_CD CLM_VAL_AMT DERIVATION RULES SET NCH_PRMRY_PYR_CD TO 'A' WHERE THE CLM_VAL_CD = '12' SET NCH_PRMRY_PYR_CD TO 'B' WHERE THE CLM_VAL_CD = '13' SET NCH_PRMRY_PYR_CD TO 'C' WHERE THE CLM_VAL_CD = '16' and CLM_VAL_AMT is zeroes SET NCH_PRMRY_PYR_CD TO 'D' WHERE THE CLM_VAL_CD = '14' SET NCH_PRMRY_PYR_CD TO 'E' WHERE THE CLM_VAL_CD = '15' SET NCH_PRMRY_PYR_CD TO 'F' WHERE THE CLM_VAL_CD = '16' (CLM_VAL_AMT not equal to zeroes) SET NCH_PRMRY_PYR_CD TO 'G' WHERE THE CLM_VAL_CD = '43' SET NCH_PRMRY_PYR_CD TO 'H' WHERE THE CLM_VAL_CD = '41' SET NCH_PRMRY_PYR_CD TO 'I' WHERE THE CLM_VAL_CD = '42' SET NCH_PRMRY_PYR_CD TO 'L' (or prior to 4/97 set code to 'J') WHERE THE CLM_VAL_CD = '47' CODES: REFER TO: BENE_PRMRY_PYR_TB IN THE CODES APPENDIX

 COMMENT: Prior to Version H this field was named: BENE_PRMRY_PYR_CD. 

 SOURCE: NCH

Variable Name : CANCELCD

Label:  FI Requested Claim Cancel Reason Code

The reason that an intermediary requested cancelling a previously submitted institutional claim. DB2 ALIAS: RQST_CNCL_RSN_CD SAS ALIAS: CANCELCD 

STANDARD ALIAS: FI_RQST_CLM_CNCL_RSN_CD 

TITLE ALIAS: CANCEL_CD CODES: REFER TO: FI_RQST_CLM_CNCL_RSN_TB IN THE CODES APPENDIX 

COMMENT: Prior to Version H this field was named: INTRMDRY_RQST_CLM_CNCL_RSN_CD. 

SOURCE: CWF

Variable Name : ACTIONCD

Label: FI Claim Action Code

The type of action requested by the intermediary to be taken on an institutional claim. 

DB2 ALIAS: FI_CLM_ACTN_CD SAS ALIAS: ACTIONCD 

STANDARD ALIAS: FI_CLM_ACTN_CD TITLE ALIAS: ACTION_CD CODES: REFER TO: FI_CLM_ACTN_TB IN THE CODES APPENDIX

 COMMENT: Prior to Version H this field was named: INTRMDRY_CLM_ACTN_CD. 

SOURCE: CWF  

Variable Name : APRVL_DT

Label: FI Claim Process Date

The date the fiscal intermediary completes processing and releases the institutional claim to the CWF host. 8 DIGITS UNSIGNED 

DB2 ALIAS: FI_CLM_PROC_DT 

SAS ALIAS: APRVL_DT 

STANDARD ALIAS: FI_CLM_PROC_DT 

TITLE ALIAS: FI_PROCESS_DT EDIT-RULES: YYYYMMDD 

SOURCE: CWF 

Claim Patient First Initial Middle Name

Variable Name : MDL_INIT

Label :   Claim Patient First Initial Middle Name.

The first initial of the Medicare patient's middle name as reported by the provider on the claim. 

 NOTE1: Prior to Version H, this field was only present on the IP/SNF claim record. Effective with Version H, this field is present on all claim types. 

 NOTE2: For OP, HHA, Hospice and all Carrier claims, data was populated beginning with NCH  weekly process date 10/3/97. Claims processed prior to 10/3/97 will contain spaces in this field. COMMON ALIAS: PATIENT_MIDDLE_NAME 

DB2 ALIAS: 1ST_INITL_MDL_NAME 

SAS ALIAS: MDL_INIT 

STANDARD ALIAS: CLM_PTNT_1ST_INITL_MDL_NAME TITLE ALIAS: PATIENT_MIDDLE_INITIAL 

SOURCE: CWF 

Variable Name : CWFLOCCD

Label :   Beneficiary CWF Location Code

The code that identifies the Common Working File (CWF) location (the host site) where a beneficiary's Medicare utilization records are maintained. COMMON ALIAS: CWF_HOST 

DB2 ALIAS: BENE_CWF_LOC_CD 

SAS ALIAS: CWFLOCCD 

STANDARD ALIAS: BENE_CWF_LOC_CD 

SYSTEM ALIAS: LTCWFLOC 

TITLE ALIAS: CWF_HOST 

CODES: B = Mid-Atlantic 

C = Southwest 

D = Northeast 

E = Great Lakes 

F = Great Western 

G = Keystone 

H = Southeast 

I = South 

J = Pacific 

SOURCE: CWF

Variable Name : PDGNS_CD

Label :   Claim Principal Diagnosis Code

The ICD-9-CM diagnosis code identifying the diagnosis, condition, problem or other reason for the admission/encounter/visit shown in the medical record to chiefly responsible for the services provided. NOTE: Effective with Version H, this data is also redundantly stored as the first occurrence of the diagnosis trailer. 

DB2 ALIAS: PRNCPAL_DGNS_CD 

SAS ALIAS: PDGNS_CD 

STANDARD ALIAS: CLM_PRNCPAL_DGNS_CD 

TITLE ALIAS: PRINCIPAL_DIAGNOSIS EDIT-RULES: ICD-9-CM 

SOURCE: CWF

Variable Name : NOPAY_CD

Label :    Claim Medicare Non Payment Reason Code

The reason that no Medicare payment is made for services on an institutional claim. NOTE: Effective with Version I, this field was put on all institutional claim types. Prior to Version I, this field was present only on inpatient/SNF claims.

DB2 ALIAS: MDCR_NPMT_RSN_CD 

SAS ALIAS: NOPAY_CD 

STANDARD ALIAS: CLM_MDCR_NPMT_RSN_CD 

SYSTEM ALIAS: LTNPMT 

TITLE ALIAS: NON_PAYMENT_REASON EDIT-RULES: OPTIONAL 

CODES: REFER TO: CLM_MDCR_NPMT_RSN_TB IN THE CODES APPENDIX 

SOURCE: CWF   

Variable Name : TRTMT_CD

Label :    Claim Excepted/Nonexcepted Medical Treatment Code

Effective with Version I, the code used to identify whether or not the medical care or treatment received by a beneficiary, who has elected care from a Religious Nonmedical Health Care Institution (RNHCI), is excepted or nonexcepted. Excepted is medical care or treatment that is received involuntarily or is required under Federal, State or local law. Nonexcepted is defined as medical care or treatment other than excepted. 
DB2 ALIAS: EXCPTD_NEXCPTD_CD 
SAS ALIAS: TRTMT_CD 
STANDARD ALIAS: TITLE ALIAS: EXCPTD_NEXCPTD_CD 
CODES: 0 = No Entry 
1 = Excepted 2 = Nonexcepted
 SOURCE: CWF 

Variable Name : PMT_AMT

Label :    Claim Payment Amount
Amount of payment made from the Medicare trust fund for the services covered by the claim record. Generally, the amount is calculated by the FI or carrier; and represents what was paid to the institutional provider, physician, or supplier, with the exceptions noted below. **NOTE: In some situations, a negative claim payment amount may be present; e.g., (1) when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or (2) when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.) Under IP PPS, inpatient hospital services are paid based a predetermined rate per discharge, using the DRG patient classification system and the PRICER program. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (since 5/1/86), indirect medical education (since 10/1/88), total PPS capital (since 10/1/91). It does NOT include the pass thru amounts (i.e., capital-related costs, direct medical education costs, kidney acquisition costs, bad debts); or any beneficiary-paid amounts (i.e., deductibles and coinsurance); or any other payer reimbursement. Under SNF PPS, SNFs will classify beneficiaries using the patient classification system known as RUGS III. For the SNF PPS claim, the SNF PRICER will calculate/return the rate for each revenue center line item with revenue center code '0022'; multiply the rate times the units count; and then sum the amount payable for all lines with revenue center code '0022' to determine the total claim payment amount. Under Outpatient PPS, the national ambulatory payment classification (APC) rate that is calculated for each APC group is the basis for determining the total payment. The Medicare payment amount takes into account the wage adjustment and the beneficiary deductible and coinsurance amounts. NOTE: There is no CWF edit check to validate the revenue center Medicare payment amount equals the claim level Medicare payment amount. Under Home Health PPS, beneficiaries will be classified into an appropriate case mix category known as the Home Health Resource Group. A HIPPS code is then generated corresponding to the case mix category (HHRG). For the RAP, the PRICER will determine the payment appropriate to the HIPPS code by computing 60% (for first episode) or 50% (for subsequent episodes) of the case mix episode payment. The payment is then wage index For the final claim, PRICER calculates 100% of the amount due, because the final claim is processed as an adjustment to the RAP, reversing the RAP payment in full. Although final claim will show 100% payment amount, the provider actually receive the 40% or 50% payment. Exceptions: For claims involving demos and BBA data, the amount reported in this field may not just represent the actual provider payment. For demo Ids '01','02','03','04' -- claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included. For demo Ids '05','15' -- encounter data 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO. For demo Ids '06','07','08' -- claims contain actual provider payment but represent a special negotiated bundled payment for both Part A and Part B services. To identify what the conventional provider Part A payment would have been, check value code = 'Y4'. The related noninstitutional (physician/supplier) claims contain what would have been paid had there been no demo. For BBA encounter data (non-demo) -- 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan. 9.2 DIGITS SIGNED
 COMMON ALIAS: REIMBURSEMENT 
DB2 ALIAS: CLM_PMT_AMT SAS ALIAS: PMT_AMT 
STANDARD ALIAS: CLM_PMT_AMT
TITLE ALIAS: REIMBURSEMENT EDIT-RULES: $$$$$$$$$CC 
COMMENT: Prior to Version H the size of this field was S9(7)V99. Als the noninstitutional claim records carried this field as a l item. Effective with Version H, this element is a claim lev field across all claim types (and the line item field has be renamed.) SOURCE: CWF LIMITATIONS: Prior to 4/6/93, on inpatient, outpatient, and physician/supplier claims containing a CLM_DISP_CD of '02', the amount shown as the Medicare reimbursement does not take into consideration any CWF automatic adjustments (involving erroneous deductibles in most cases). In as many as 30% of the claims (30% IP, 15% OP, 5% PART B), the reimbursement reported on the claims may be over or under the actual Medicare payment amount.